Posttraumatic stress disorder (PTSD) is a highly prevalent disorder (lifetime prevalence range, 7.8–14 %), frequently co-occurring with depression [1]. Estimates suggest that 42–48 % of patients with PTSD also have a major depressive disorder (MDD) [2]. Furthermore, PTSD is just as highly associated with the development of other comorbid psychiatric disorders, addiction, dysfunctional health behavior, escalated levels of psychosocial disabilities, somatic complications, and frequent utilization of healthcare resources [3–5]. Despite the availability of evidence-based treatments, such as selective serotonin reuptake inhibitors as well as cognitive-behavioral therapy, outcomes feature just modest degrees of improvement, with more than 50 % of patients remaining refractory to treatment for MDD or PTSD [1].

The Beslan school hostage-taking (also known as the Beslan siege) began on 1 September 2004 when armed Chechen separatists took more than 1200 school children and adults hostage at School Number One in the town of Beslan in the Russian republic of North Ossetia. The siege left 331 people dead, including 186 children, and more than 700 people were injured.

Following the Beslan school hostage-taking , in addition to psychiatric and psychotherapeutic treatments, a number of psychosocial programs, under the auspices of the North Ossetian Ministry of Education, were offered to the child and youth survivors by staff of the local psychosocial education center “Doverie.” As anticipated, 2 years later, in spite of the wide range of therapeutic and psychosocial programs offered, a substantial quota of treated child and youth hostages remained psychologically and socially impaired, having a major impact on school performance and professional training. Following a systematic assessment of these impairments by teachers, a resilience enhancing program was designed as a second-line psychosocial and therapeutic intervention, realized, monitored, and evaluated.

The primary goal of the project was to offer an add-on intervention module for all children and youth hostages who were still suffering from psychological and functional impairments 2 years after the hostage-taking. Therapy refractory, comorbid mental health problems are mainly perpetuated by a perceived absence of control over the outcome of a situation (learned helplessness) [6], self-handicapping strategies in response to non-contingent success [7], and attributional biases (a sort of social cognitive bias that refers to systematic errors during evaluation of possible reasons for their own and others’ behaviors) [8]. With children and young people, very often their family members’ behavior may have a substantial sustaining influence either on their recovery or their continuous malfunctioning with regard to mental problems [9]. So it seemed to make sense to take these children and young people for a short time out of the family setting and to allow them to benefit from totally different social surroundings.

On this basis, we decided to offer weekly camps during official school holidays, so that nobody would miss any school lessons. In order to prevent additional regressive and destructive psychological effects on our target group, we opted against a mere mental healthcare perspective with trauma-focused interventions. This might have become a sort of self-fulfilling prophecy, blocking any recovery. Therefore, we selected resilience enhancement and development as the basis for our intervention. We hypothesized that the young people would benefit from enhancement of their emotional, mental, and social capacities to overcome the adversities they faced. Research has shown that building resilience among survivors of high-risk environments can help develop and maintain: social competence, empathy, caring, problem-solving skills, critical and creative thinking, task mastery, and a sense of purpose and social connectedness [10]. Problem-solving skills are a particularly strong predictor of improved resilience in children and young people in the long-term, as improved problem-solving skills can enhance the possibility that future life challenges will be resolved successfully [11–15].

Conceptually, our program was based on the developmental psychology perspective of resilience, first conceptualized by Luthar [16–20]. The basic definition of resilience is: “A dynamic process encompassing positive adaptation within the context of significant adversity. Implicit within this notion are two critical conditions: first, an exposure to significant threat or severe adversity, and secondly an achievement of positive adaptation despite major assaults on the developmental process” [16, 21]. Past research on psychological resilience has identified four key protective factors that can contribute to the development, support, and sustaining of resilience processes in children and young people; they are: (a) healthy attachments to related and unrelated older adults who provide them with support, encouragement, and guidance; (b) healthy and connected peer relationships; (c) effective problem-solving skills and coping strategies; and (d) community involvement, in support of the common good [15, 22–25]. These protective factors are interactive with resilience factors, as both help develop, and can later help sustain, resilience processes and trajectories [11].

Our goal was to design a program that incorporated these four protective factors for enhancing the development of resilience processes and to add some cognitive-behavioral elements to cope with learned helplessness, self-handicapping strategies and social biases. The approach was to combine sport activities and safety training with integrated, but hidden, therapeutic rehabilitation activities in a group setting. Specifically, the program provided: (a) medical first aid, cardiopulmonary resuscitation (CPR) , and lifesaving rescue techniques; (b) mountaineering and survival skills training; (c) alpine sport activities, such as skiing, climbing, and alpine hiking; and (d) informal arts, play and supportive discussion groups. The last element was primarily designed to offer participants assistance in sorting out emotions provoked by other program activities. These sessions were informal and primarily supportive in focus, with no special training offered to the therapists and no particular therapeutic approach or intervention emphasized. Individual support was administered in cases where a child’s behavior suggested that the daytime or evening activities provoked exacerbation of psychopathology. Psychologists then addressed the children’s experiences and emotions within the group.

It was anticipated that each of the listed components would foster resilience via multiple mechanisms . For example, the physical activities in the mountain wilderness were expected to build internal resilience though boosting confidence, supporting the experience of positive emotions, improving somatic health, and encouraging a climate of solidarity, both with peer participants and adult leaders. It is important to note that the actual outdoor activities and training were conducted by rescuers (emergency medical technicians and professional mountain guides) from the North Ossetian Search and Rescue Services, a department of the Russian Federal Ministry for Emergencies. All participating rescuers were professionals who had been involved in the liberation of hostages, and were thus considered as heroes by participants. All psychosocial therapists and psychologists were locals with university degrees and all attended specific courses for psycho-traumatology prior to participating in the camp. We then opened the camps to healthy and well-functioning children and young people, matched in age and gender. These integrated healthy peers and adults served as social role models. Last, but not least, mountains are a good location to be confronted with fears and anxiety. Comparable medical first aid and cardiopulmonary resuscitation training were strong triggers for hostage survivors to re-experience the traumatic event, learning to stand and not to avoid the situation and acquiring at the same time effective coping mechanisms, being empowered by their new skills to help any injured victims in the future. This also erased lingering feelings of guilt at having survived the tragedy and not having helped their deceased friends and family members enough.

For 3 years following the Beslan school hostage-taking, the Swiss Department of Development and Cooperation (SDC) fully financed a number of psychosocial programs under the auspices of the North Ossetian Ministry of Education. Already in December 2004 a fully functioning psychosocial center was operational and offered sports and play interventions for all children and young people of Beslan in individual or group settings, supplemented by counseling for parents. It included close cooperation with local schools, teachers, mental health professionals, hospitals, and the North Ossetian State Medical Academy, becoming a knowledge exchange platform and offering educational courses for professionals under the auspices of the North Ossetian Ministry of Health, which were accredited for professional recertification. Last, but not least, the North Ossetian Institute of Humanitarian and Social Research was helping to scientifically monitor the majority of these programs together with the Centre of Disaster and Military Psychiatry, University of Zurich, Switzerland. Local public health and social support systems were empowered by using only local professionals, involving them in drafting the program and training them according to the needs of the program. This created new jobs instead of letting them vanish and meant that all interventions could be applied on a medium- to long-term basis without any cultural or language barriers.