Resistance, Resilience & Recovery

1. Resistance, Resilience & Recovery Michael J. Kaminsky, M.D., MBA, George Everly, Ph.D., Alan Langlieb, M.D., Lee McCabe, Ph.D. Johns Hopkins University School of Medicine

2. Introduction • Crisis intervention should be multi-component in nature (British Psychological Society, 1990) • Early intervention includes a variety of interventions matched to the needs of the situation and the recipient populations along a continuum (NIMH, 2002; DHHS 2004)

3. Introduction Traditional models of disaster have emphasized temporal or phenomenological aspects

4. PHASES OF A DISASTERWarning Impact Heroic Disillusionment Reconstruction

5. Phases of Disaster(DHHS, 2004) anxiety anger heroism reconstruction impact shock depression despair

6. Phases of Disaster (NIMH, 2002) RESCUE 0-1 WK RECOVERY 1-4 WKS RETURN 2 WKS - 2 YRS Pre-incident IMPACT 0-48HRS

7. Critique and a Proposal • Traditional models tend to be: • Limiting—e.g. only some aspects of behavior or emotion • Inflexible • Event focused, not person, group or institution focused

8. Critique and a Proposal • Do not include assessment • Of individuals • Of organizations • Do not make predictions (hypotheses) that can be assessed post-event to establish effectiveness • Are reactionary, not proactive • Tend to propose one size fits all interventions, ignoring vulnerabilities An outcomes driven proposal: resistance/resilience/recovery (RRR)

9. RESISTENCE, RESILENCE, RECOVERY An outcome-driven continuum of careBuild Resistance Enhance Resiliency Speed RecoveryAssessment Assessment Assessment Intervention Intervention Intervention Evaluation Evaluation Evaluation[Kaminsky, et al, (2005) RESISTENCE, REILENCE, RECOVERY, Johns Hopkins.

10. ADVANTAGES OF OUTCOME-DRIVEN SYSTEM • DESCRIPTIVE - PHASES COLLECTIVELY DEFINE THE PHENOMENOLOGICAL PROGRESSION IN THE CONTINUUM OF CARE • TIME EPOCHS ARE RELATIVE, FLEXIBLE • PRESCRIPTIVE - EACH PHASE PRESCRIPTIVELY DEFINES ITS OWN RESPECTIVE OBJECTIVES, DESIRED OUTCOME • PRESCRIPTIVE NATURE LENDS ITSELF TO BEHAVIORAL EVALUATION

11. I. RESISTANCEIn the present context, the term resistancerefers to the ability of an individual, a group, an organization, or even an entire population, to literally resistmanifestations of clinical distress, impairment, or dysfunction associated with critical incidents, terrorism, and even mass disasters. Resistance may be thought of as a form of psychological/ behavioral immunity to distress and dysfunction.

12. II. RESILIENCEIn the present context, the term resilience refers to the ability of an individual, a group, an organization, or even an entire population, to rapidly and effectivelyrebound from psychological and/or behavioral perturbations associated with critical incidents, terrorism, and even mass disasters.

13. III. RECOVERYThe term recoveryrefers to the ability of an individual, a group, an organization, or even an entire population, to literally recover the abilityto adaptively function, both psychologically and behaviorally,in the wake of a significant clinical distress, impairment, or dysfunction subsequent to critical incidents, terrorism, and even mass disasters.

14. Tasks in the RRR Model Organizations/ Populations Groups Persons

15. The Johns Hopkins Perspectives on Disaster Psychiatry

16. The Johns Hopkins Perspectives on Disaster Psychiatry

17. The Johns Hopkins Perspectives on Disaster Psychiatry—Resistance Hypotheses

18. Resistance—Assessment • Assess vulnerabilities, knowledge, beliefs and preparation of individuals • Assess quality of group cohesion/social support/organizational management • Assess availability of credible leadership

19. New Orleans • Poverty, poor individual resources for transportation • Large addiction population • High community disability load: 65,000 disabled in population of 550,000

20. Resistance—InterventionSetting appropriate expectations, developing stress management and coping skills, and providing realistic pre-incident training may foster stress resistance (Lating, et al, 2003; Meichenbaum, 1985; Schiraldi & Brown, 2001, 2002; Seligman, Reivich, Jaycox, & Gillham, 1995; Chang, et al., 2004).

22. STATE OF MARYLAND DHMH:DISASTER MENTAL HEALTH VOLUNTEER CORPS TRAINING

23. Disaster Mental Health Training for the Spiritual Caregiver Supported by a Special Projects grant from the Maryland Department of Health and Mental Hygiene, and administered through the Maryland Hospital Association with funding from the Health Resources and Services Administration (HRSA).

24. Community Capacity Building • Faith appropriate • 4 ½ day sessions • Disaster Mental Health 101 • Psychological 1st aide • Grief counseling • Disaster planning

25. Build Resistance—Intervention The creation of group cohesion with an underlying infrastructure for social support may be useful (American Psychological Association, 2004).

26. Psychological Efforts to Build Resistance(APA, 2003) • Pre-incident, Pre-deployment • Group cohesion • Social support • Foster a sense of purpose

27. Build Resistance—Evaluation • Piper Alpha oil platform disaster—psychoprophylactic role of good organization and sensitive staff management (Alexander, BJP, 1993) • Preparation, interpersonal relationships, debriefing (Thompson and Solomon, Anxiety Research, 1991)

28. The Johns Hopkins Perspectives on Disaster Psychiatry—Resilience Hypotheses

29. “It is more important to know what sort of patient has a disease than what sort of disease a patient has”. William Osler

31. Traits Neuroticism— Assesses adjustment vs. emotional instability. Identifies individuals prone to psychological distress, unrealistic ideas, excessive cravings or urges, and maladaptive coping responses e.g. worrying, nervous versus calm, relaxed, unemotional

33. “Neuroticism” and Anxiety Disorders • Predisposing factor • Angst and Vollrath, 1991 – cohort of young adult males in Zurich – high “neuroticism” at 19 predicted onset of anxiety neurosis by age 36 • Krueger, 1999 – Dunedin sample - high “negative emotionality” in late adolescence predicted onset of anxiety disorders by early adulthood

34. “Neuroticism” and Anxiety Disorders • Predisposing factor • Bramsen et al., 2000 – U.N. peacekeepers in the former Yugoslavia – high predeployment “psychoneuroticism” was second only to traumatic event exposure in predicting PTSD symptoms • Fauerbach et al., 2000 – severe burn survivors – higher baseline neuroticism predicted onset of PTSD in the following year

35. The dimensional paradigm potential provocation response The neurotic paradigm or emotive triad temperamental shyness speech requirement anxiety symptoms demoralization, with anxiety & depressive symptoms difficult cognitive task Low IQ

36. A more complex example – interacting perspectives emotive paradigm personality vulnerabilities (e.g., neuroticism &/or introversion) disaster exposure anxiety, arousal, numbing, re-experiencing + behavioral perspective restriction of activities, impaired role functioning avoidance of trauma-related places & memories decreased discomfort

37. Psychological Efforts to Build Resilience (APA, 2003)—Intervention • During • Provide strong leadership • Work in teams, when possible • Sustain an information flow • Stay task oriented • Utilize on-scene support services • Remain vigilant for fatigue, distress, mistakes • Promote recovery between incidents

38. Enhance Resilience—Intervention • Acute Post-incident, Post Deployment • Provide information about event, • Provide information about normal behavioral reactions • Emphsize social support • Teach personal stress management, foster “self-efficacy” (Bandura, 1997) • Address “relationship” issues • Return to normal routines: diet, exercise • “Debriefings” or similar organization-based crisis interventions should be considered. Cathartic ventilation should be voluntary! • Utilize a phase sensitive disaster mental health system (Raphael, 1986; Everly & Mitchell, 1999)...

39. Enhance Resilience—Intervention Fostering group cohesion and interpersonal support Interpersonal support has been shown to buffer stress (Flannery, 1990). Group discussions, debriefings may be useful in enhancing cohesion, reducing distress, reducing maladaptive coping (NIMH, 2002, Tables 2-3)

40. Enhance Resilience—Intervention An essential element of fostering cohesion and support can be effective group communications. Communications should be designed to provide five essential elements:1. information (and rumor deterrence), 2. reassurance, 3. direction, 4. motivation, and5. a sense of connectedness.

41. Enhance Resilience—InterventionSelf-Efficacy “People guide their lives by their beliefs of personal efficacy” (Bandura, 1997, p. 3).

42. Enhance Resilience—Intervention Foster Self-Efficacy“People’ s beliefs in their efficacy…influence the courses of action people choose topursue, how much effort they put forth in given endeavors, how long they will persevere in the face of obstacles and failures, their resilience to adversity, whether their thought patterns are self-hindering or self-aiding, how much stress and depression they experience in coping with taxing environmental demands, and the level of accomplishments they realize” (Bandura, 1997, p.3).

43. Psychological First Aid • Stabilize • Assess and triage • Communicate • Connect SACC Model of Acute Psychological First Aid (Everly & Flynn, 2004)

44. Ørner’s TRACK system of responder resilience T—Talk about it but not beyond what you are ready to talk about R—Relax; do the things that normally relax you A—Activity; exercise, hobby, the active things that divert you. C—Control; re-establish everyday routine K—Kontemplate (Contemplate); don’t decide /conclude what it all means, wait and see.

45. Enhance Resilience—Evaluation Fostering positive cognitions.Cognitive appraisals appear to be key determinants of stress (see Everly& Lating, 2002, for a review) and trauma (Ehlers & Clark, 2003).Conversely, positive cognitions appears to deter excessive stress and foster resiliency (Affleck & Tennen, 1996; Meichenbaum, 1985; Taylor, 1983; Tedeschi & Calhoun, 1996).

46. Enhance Resilience—Evaluation LESSONS LEARNED FROM COMMUNITY MENTAL HEALTH • Early Psychological Intervention may reduce the need for more intensive psych services. (Langsley, Machotka, & Flomenhaft, 1971, Am J Psyc; Decker, & Stubblebine, 1972, Am J Psyc) • Early Psychological Intervention may mitigate acute distress . (Bordow & Porritt, 1979, Soc Sci & Med; Bunn & Clarke, 1979, Br. J Med. Psychol;Campfield & Hills, 2001, JTS; Everly, et al., 1999, Stress Med; Flannery & Everly, 2004, Aggression & Violent Beh.) • Early psychological Intervention may reduce ETOH use. (Deahl, et al, 2000, Br J Med Psychol)

47. Enhance Resilience—EvaluationThe Military Experience • Treat near the front (SALMON, NYMedJ, 1919). • “…Keep alive the [causal] relation between the symptoms and the traumatic event” [as opposed to attributing symptoms to weakness in character]” (KARDINER, Am. Hdbk. Psyc, 1959). • Importance of principles of immediacy, proximity, and expectancy—70%-80% return to duty (ARTISS, Military Medicine, 1963)

48. Enhance Resistance—Evaluation • SHALEV (1994, Debriefing Following Traumatic Exposure) Advocates the S.L.A. Marshall method of debriefing wherein groups of soldiers were encouraged to discuss events of combat shortly after the incidents themselves. He quotes Marshall, “Soldiers are eager to talk, their memory is good, they do so much better when together, in groups.” • SHALEV, PERI, ROGEL-FUCHS (1998, Military Med) Applied Marshall’s historical group debriefing 7 hours after combat exposure (n=39). Results indicated the debriefing was followed by a reduction in anxiety, improvement in self-efficacy, increased group cohesion.

49. The Johns Hopkins Perspectives on Disaster Psychiatry—Recovery Hypotheses

50. Recovery From PTSD After Rape 94% 47% 42% 30 % 25%-15% % with PTSD Symptoms ? 3m Years W 9m 12m Data from Rothbaum et al., 1992