Content uploaded by Moshe Farchi
Author content
All content in this area was uploaded by Moshe Farchi on Feb 04, 2022
Content may be subject to copyright.
BRIEF REPORT
The Effects of “Psychological Inoculation” Versus Ventilation on
the Mental Resilience of Israeli Citizens Under Continuous War
Stress
Moshe Farchi, PhD,* and Yori Gidron, PhD†‡
Abstract: Anxiety and hopelessness are common reactions of citizens
exposed to continuous war threats. Common interventions focus on support,
calming, and emotional ventilation, with few attempts to reduce people’s
cognitive barriers concerning active coping, which could increase their
resilience. This study tested the effects of psychological inoculation (PI),
which specifically aims to challenge such barriers, on the mental resilience of
Israeli citizens living in Sderot. Participants were randomly assigned to either
2 PI sessions or 2 ventilation sessions, provided over the phone. Anxiety,
helplessness, pessimism, and functioning were briefly assessed at baseline
and 1 week after interventions. No time, group, or group ⫻time interactions
were observed. However, a time ⫻group ⫻sex interaction emerged for
helplessness: Men benefited from the PI whereas women benefited from
ventilation, in reducing helplessness. Under chronic war stress, it seems
difficult to improve people’s resilience, although PI may be partly beneficial
for men. Further research is needed to test the effects of PI on mental
resilience.
Key Words: Psychological inoculation, continuous war threats, anxiety,
helplessness, Rwanda pessimism, ventilation, resilience.
(J Nerv Ment Dis 2010;198: 382–384)
Beyond injuries and mortality, civil victims of war and political
conflicts experience frequent levels of distress ranging, for
example, from 10.2% of Israeli medical staff in a bombarded
hospital with probable post-traumatic stress disorder (PTSD; Koren
et al., 2009), up to 54% to 62% of children in Ruanda with probable
PTSD (Neugebauer et al., 2009). Risk factors of war-related distress
include exposure to deaths and trauma severity (Neugebauer et al.,
2009), exposure to terror and the inability to estimate its duration
(Gidron et al., 2004), female gender (Neugebauer et al., 2009), and
being displaced and poor maternal functioning in children (Laor
et al., 2001).
Cognitive models of distress focus on exaggerated negative
appraisals of “neutral” events predicting future distress (e.g., Ehring
et al., 2008). One cognitive variable, namely coping self-efficacy,
was recently found to predict post-traumatic distress and to mediate
effects of negative cognitions on distress (Cieslak et al., 2008).
Coping self-efficacy needs to be targeted in interventions.
Despite these findings, many early interventions mainly pro-
vide support and calming, and enable people to ventilate their
emotions (e.g., Chemtob et al., 1997; Stallard et al., 2005; Weth-
ington et al., 2008). However, studies have not found much support
for the efficacy of ventilation-related interventions such as debrief-
ing (van Emmerik et al., 2002). Sharing one’s emotions may not
challenge cognitive barriers (e.g., low self-efficacy), prognostic in
future distress (Cieslak et al., 2008).
One method that challenges people’s beliefs and barriers is
“psychological inoculation” (PI), where people are exposed to chal-
lenging sentences, reflecting cognitive barriers impeding functioning
or adaptive behavior. In turn, they are guided to systematically
refute such sentences. PI was found to prevent unhealthy behaviors
in adolescents (e.g., smoking; Duryea et al., 1990; Evans, 1976).
However, to the best of our knowledge, the effects of PI on mental
health outcomes, and specifically on helping people under war
stress, have not been systematically examined.
The purpose of this study was to compare the effects of PI
versus emotional ventilation on citizens’ mental resilience, while
living under continuous threat in a war zone. PI was expected to
improve mental resilience better than ventilation, as the former is
thought to increase one’s coping self-efficacy. We also examined
whether gender moderated intervention effects, as previously found
in relation to psychological interventions in traumatic contexts (e.g.,
Gidron et al., 2007).
METHODS
The Context
Between 2001 and 2009, residents of the Town of Sderot, in
the southwest of Israel, near the Gaza strip, were attacked by
Qassam missiles from Gaza. These included nearly daily launches of
1 to 20 missiles, landing in open areas, houses, shops, and schools.
Residents had between 8 and 12 seconds after an alert to find
shelters. Higher levels of post-traumatic stress symptoms were
found among Sderot residents than in residents of nearby Kibbutzim
(Dekel and Nuttman-Shwartz, 2009).
Participants, Design, and Procedure
We sampled participants from the adult population of Sderot.
Participants had to be over the age of 18 and appearing in the Sderot
phone book. The study was approved by an ethics committee of the
Tel-Hai Academic College, North of Israel, and by the welfare
department of Sderot. A randomized controlled design was used.
Participants were randomly assigned either to ventilation or to PI.
After providing verbal consent, they provided baseline levels on
each of the measures of resilience (T1), underwent their allocated
intervention, and provided background information (T1). Approxi-
mately 1-week later (T2), they were asked the resilience measures
and once again underwent their allocated intervention. A week later
(T3) and a month after session 2 (T4), they were only reassessed.
Measures
Mental resilience was conceptualized as high levels of daily
functioning, and low levels of anxiety, helplessness, and pessimism.
To reduce burden on participants as much as possible, we used very
brief measures, because assessment took place during a local war.
*Department of the Stress and Trauma Studies, School of Social Work, Tel Hai
Academic College, Tel Hai, Israel; †Department of Behavior Medicine, Free
University of Brussels (VUB), Brussels, Belgium; and ‡Department of Orga-
nizational Behavior and Job Stress, IESEG, Lille, France.
Supported by Legacy Heritage Fund.
Send reprint requests to Moshe Farchi, PhD, Head of the Stress and Trauma
Studies, School of Social Work, Tel Hai Academic College, Tel Hai, Israel.
E-mail: moshefar@telhai.ac.il.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0022-3018/10/19805-0382
DOI: 10.1097/NMD.0b013e3181da4b67
The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010382 | www.jonmd.com
Background Information
This included participants’ age, sex, marital status, occupation,
and number of children. Stress or exposure information included esti-
mated closest distance from a missile hit, presence of a safety room at
home, and whether one’s house was hit during the last 8 years.
Mental Resilience
Daily functioning was assessed by a 1-item scale, asking “To
what extent did you succeed to carry out what you planned during
the last week?” (1, not at all; 10, succeeded to do everything).
Anxiety was assessed by asking participants “How do you evaluate
your level of anxiety at this moment (1, very low; 10, very high).
Previous intervention trials used similar single-item scales to assess
anxiety (e.g., Sneed et al., 2001). We used the hopelessness scale
(Everson et al., 1996) that includes 2 items; one assessing helpless-
ness, the inability to achieve one’s goals, and the other assessing
pessimism, lack of hope about the future. Each item was rated on a
1 to 10 scale (1, do not agree at all; 10, fully agree).
Interventions
Interventions were conducted over the phone, to reach a larger
population, and to be cost beneficial. Phone interventions have positive
effects on mental health outcomes (Mozer et al., 2008).
All interventions included 2 phone “sessions,” 1-week apart.
In the ventilation intervention, participants were asked their opinion
about the level of security in Sderot, how they cope with this
situation, and which things most help them cope with it. Counselors
responded emphatically and encouraged expression of thoughts and
feelings, while reinforcing participants’ actions. The ventilation
aimed to increase support, a buffer of the effects of missile exposure
on depressive symptoms in this context (Henrich and Shahar, 2008).
PI followed Duryea et al. (1990), by asking participants to
refute 6 “challenging sentences.” These reflected constructs from a
model of stress such as problem- and emotion-focused coping (Taylor
and Aspinwall, 1996), coping self-efficacy, and PTSD symptoms (e.g.,
avoidance and intrusions). Counselors provided feedback on partici-
pants’ refutations. In cases of insufficient refutation, counselors then
exaggerated the challenging sentence. An example of a challenging
sentence concerning negative appraisal and intrusions was as follows:
“Every sound you hear must be a siren”! Hearing and refuting chal-
lenging sentences reflected psychological immunization.
Statistical Analysis
After testing group equality, the main analysis was a mixed
design analysis of variance (ANOVA), where group was the be-
tween-subjects factor and time (baseline and postsession assess-
ment) was the within-subjects factor. In the ANOVA, we controlled
for any significant baseline differences. To reduce the statistical tests
and chances of a type 1 error, we focused here on baseline and
postsession 2 measures (T3) alone. The latter was chosen because it
reflected the end of intervention and included more participants than
T4 assessment.
RESULTS
Baseline Characteristics
Table 1 depicts scores of baseline and 1-week follow-up
resilience measures, per group. Concerning background data, be-
tween 2/3 and 3/4 of the sample included women or working people,
between 1/3 to half of the participants experienced a missile hitting
their house, approximately one-third had a security room in their
house, and over 71% lived with their husband/wife or partner. Mean
estimated closest distance of participants from a missile hit was
below 100 m, and the median was 20 m. Despite these figures and
the continuing fall of missiles during the study, participants’ mean
baseline daily functioning approached 7, on a 1 to 10 scale, indi-
cating relatively good functioning.
Correlations Between Baseline Dependent Variables
Scores on the helplessness item were positively significantly
correlated with pessimism (r⫽0.53, p⬍0.001) and anxiety (r⫽
0.212, p⬍0.01) and inversely correlated with daily functioning (r⫽
⫺0.302, p⬍0.001). Levels of pessimism were inversely correlated
with daily functioning (r⫽⫺0.147, p⬍0.05). Finally, levels of daily
functioning were significantly inversely correlated with levels of anxi-
ety (r⫽⫺0.247, p⬍0.001). These correlations provide support for the
construct validity of the single-item measures used.
Effects of Group and Gender on Outcomes
Because of the significant differences on baseline functioning,
percentages of houses hit and of working participants between
groups, ANOVA tests of main and interaction effects were done,
controlling for these 3 baseline background factors. There were no
significant time ⫻group interaction effects for helplessness 关F(1,63)
⫽0.21, p⫽0.65兴, pessimism 关F(1,63) ⫽0.07, p⫽0.80兴, daily
functioning 关F(1,64) ⫽1.15, p⫽0.29兴, or anxiety 关F(1,63) ⫽0.05,
p⫽0.83兴.
Considering gender as a moderator, a significant time ⫻
group ⫻sex interaction effect was observed in relation to helpless-
ness 关F(1,61) ⫽6.10, p⫽0.02兴. Paired t-tests then revealed that in
men, the PI led to reductions in helplessness over time 关t(11) ⫽2.24,
p⬍0.05兴, whereas ventilation did not lead to significant changes in
helplessness 关t(10) ⫽0.40, p⬎0.05兴. In contrast, in women, the PI
did not lead to significant reductions in helplessness 关t(22) ⫽0.42,
p⬎0.05兴, whereas the ventilation led to significant reductions in
helplessness over time 关t(21) ⫽2.57, p⬍0.05; see Fig. 1兴. There
were no time ⫻group x sex interactions for other outcomes
(all P⬎0.05).
DISCUSSION
This study compared 2 intervention methods aiming at in-
creasing mental resilience in Israeli citizens exposed to continuous
war threats. Mental resilience was operationalized by assessing
perceived helplessness, pessimism, daily functioning, and anxiety.
Two major findings were observed in this study. First, no changes
over time were observed in either intervention group on any study
outcome. Second, when considering gender as a selected moderator,
different intervention effects were observed: PI seemed to reduce
helplessness in men whereas structured ventilation seemed to reduce
helplessness in women. Thus, increasing the mental resilience of
TABLE 1. Means (SD) of Scores on Resilience Measures at
Baseline and 1-Week Postintervention per Group
Variable
Psychological
Inoculation Ventilation
Mean SD Mean SD
Helplessness: baseline 3.3 2.5 4.0 3.2
Helplessness: postintervention 2.7 2.4 3.0 2.7
Pessimism: baseline 3.7 3.4 3.7 3.3
Pessimism: postintervention 3.7 2.7 3.8 3.1
Daily functioning: baseline 7.6 2.9 6.1* 3.1
Daily functioning: postintervention 7.6 2.5 7.4 2.8
Anxiety: baseline 3.9 2.7 4.4 3.0
Anxiety: postintervention 3.2 2.7 3.2 2.7
SD indicates standard deviation.
*P⬍0.05, between groups.
The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010 Psychological Inoculation Versus Ventilation
© 2010 Lippincott Williams & Wilkins www.jonmd.com |383
people in the context of continuous war threats is not a trivial issue,
and background variables (e.g., gender) need to be considered as
possible moderators of the effects of psychological interventions.
The fact that neither intervention had a clear effect on most out-
comes, including a supporting ventilation intervention, also chal-
lenges current clinical practice and calls for doing further research.
These findings have implications for guiding policies in mental health
provided in the context of traumatic events (Hobfoll et al., 2007).
Sex emerged as a moderator, where PI was beneficial for men
and ventilation was beneficial for women, in relation to helplessness.
Sex has been found to moderate the effects of other forms of mental
health interventions (e.g., Gidron et al., 2007). Findings from neu-
roimaging research may shed some light on this interaction. One
study found that in response to a stressor, women exhibited greater
limbic activation, whereas men showed mainly frontal activation:
increased right and reduced left frontal activity (Wang et al., 2007).
It is possible that for women, ventilation, which includes support
and verbal expression, may calm an overactive limbic stress re-
sponse (Hariri et al., 2000). In men, the PI method, which relies on
logic and verbal processing, may increase primarily left prefrontal
activity (Goel et al., 2007), to possibly regulate their stress. Future
research needs to test these issues more in depth.
The similarity between the effects of the PI and ventilation can
be explained by the fact that both interventions include some compo-
nents from the 5 evidence-based therapeutic elements suggested by
Hobfoll et al. (2007). In PI, these may be enhancement of self-efficacy
and hope, whereas in ventilation, this may include calming, connect-
edness, and hope. These elements may be important in reducing
helplessness, but by different mechanisms in each gender. Future
studies should identify the specific populations who may benefit from
each of the methods used in this study and from their combination.
CONCLUSIONS
Our findings, though preliminary, support the need to test
intervention efforts for aiding people under such hardships. An
evidence-based approach can help prevent harm and increase tai-
lored benefits, supporting the aim of increasing mental resilience of
people in such circumstances most effectively.
ACKNOWLEDGMENTS
The authors thank the citizens of Sderot for their cooperation
and their counseling team—Noam Brillient, Inbal Tirer, Dorit Halp-
eren, Hadas Trager, and Inbal Tzach, from the Stress and Trauma
Study Program, School of Social Work, Tel-Hai Academic College,
Israel.
REFERENCES
Chemtob CM, Tomas S, Law W, Cremniter D (1997) Postdisaster psychosocial
intervention: A field study of the impact of debriefing on psychological distress.
Am J Psychiatry. 154:415– 417.
Cieslak R, Benight CC, Caden Lehman V (2008) Coping self-efficacy mediates
the effects of negative cognitions on posttraumatic distress. Behav Res Ther.
46:788 –798.
Dekel R, Nuttman-Shwartz O (2009) Posttraumatic stress and growth: The
contribution of cognitive appraisal and sense of belonging to the country.
Health Soc Work. 34:87–96.
Duryea EJ, Ransom MV, English G (1990) Psychological immunization: Theory,
research and current health behavior applications. Health Educ Q. 17:169–178.
Ehring T, Ehlers A, Glucksman E (2008) Do cognitive models help in predicting
the severity of posttraumatic stress disorder, phobia and depression after motor
vehicle accidents? A prospective longitudinal study. J Consult Clin Psychol.
76:219 –230.
Evans RI (1976) Smoking in children: Developing a social psychological strategy
of deterrence. Prev Med. 5:122–127.
Everson SA, Goldberg DE, Kaplan GA, Cohen RD, Pukkala E, Tuomilehto J,
Salonen JT (1996) Hopelessness and risk of mortality and incidence of
myocardial infarction and cancer. Psychosom Med. 58:113–121.
Gidron Y, Gal R, Givati G, Lauden A, Snir Y, Benjamin J (2007) Interactive
effects of memory structuring and gender in preventing posttraumatic stress
symptoms. J Nerv Ment Dis. 195:179 –182.
Gidron Y, Kaplan Y, Velt A, Shalem R (2004) Prevalence and moderators of
terror-related post-traumatic stress disorder symptoms in Israeli citizens. Isr
Med Assoc J. 6:425– 426.
Goel V, Tierney M, Sheesley L, Bartolo A, Vartanian O, Grafman J (2007)
Hemispheric specialization in human prefrontal cortex for resolving certain and
uncertain inferences. Cereb Cortex. 17:2245–2250.
Hariri AR, Bookheimer SY, Mazziotta JC (2000) Modulating emotional re-
sponses: Effects of a neocortical network on the limbic system. Neuroreport.
11:43– 48.
Henrich CC, Shahar G (2008) Social support buffers the effects of terrorism on
adolescent depression: Findings from Sderot, Israel. J Am Acad Child Adolesc
Psychiatry. 47:1073–1076.
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman
M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE,
Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM,
Ursano RJ (2007) Five essential elements of immediate and mid-term mass
trauma intervention: Empirical evidence. Psychiatry. 70:283–315.
Koren D, Caspi Y, Leiba R, Bloch D, Vexler B, Klein E (2009) Acute stress
reactions among medical and non-medical personnel in a general hospital under
missile attacks. Depress Anxiety. 26:123–128.
Laor N, Wolmer L, Cohen DJ (2001) Mothers’ functioning and children’s symptoms
5 years after a SCUD missile attack. Am J Psychiatry. 158:1020–1026.
Mozer E, Franklin B, Rose J (2008) Psychotherapeutic intervention by telephone.
Clin Interv Aging. 3:391–396.
Neugebauer R, Fisher PW, Turner JB, Yamabe S, Sarsfield JA, Stehling-Ariza T
(2009) Post-traumatic stress reactions among Rwandan children and adoles-
cents in the early aftermath of genocide. Int J Epidemiol. 38:1033–1045.
Sneed CD, Morisky DE, Rotheram-Borus MJ, Ebin VJ, Malotte CK (2001)
Patterns and predictors of adolescent alcohol, cigarette and marijuana use over
a six-month period. Addict Behav. 26:415– 423.
Stallard P, Simpson N, Anderson S, Carter T, Osborn C, Bush S (2005) An
evaluation of the FRIENDS program: A cognitive behavior therapy to promote
emotional resilience. Arch Dis Child. 90:1016 –1019.
Taylor SE, Aspinwall LG (1996) Mediating and moderating processes in psycho-
social stress: Appraisal, coping, resistance, and vulnerability. In H Kaplan (Ed),
Psychosocial Stress: Perspectives on Structure,Theory,Life-Course and Meth-
ods (pp 71–110). San Diego, CA: Academic Press.
van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM (2002) Single
session debriefing after psychological trauma: A meta-analysis. Lancet. 360:766–771.
Wang Y, Xue G, Chen C, Xue F, Dong Q (2007) Neural bases of asymmetric
language switching in second-language learners: An ER-fMRI study. Neuro-
Image. 35:862– 870.
Wethington HR, Hahn RA, Fuqua-Whitley DS, Sipe TA, Crosby AE, Johnson RL,
Liberman AM, Mos´cicki E, Price LN, Tuma FK, Kalra G, Chattopadhyay SK;
Task Force on Community Preventive Services (2008) The effectiveness of
interventions to reduce psychological harm from traumatic events among
children and adolescents: A systematic review. Am J Prev Med. 35:287–313.
FIGURE 1. Effects of time and group on helplessness by gender.
Farchi and Gidron The Journal of Nervous and Mental Disease • Volume 198, Number 5, May 2010
384 | www.jonmd.com © 2010 Lippincott Williams & Wilkins
