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Disaster Mental Health Lessons Learned about Resiliency

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Disaster Mental Health  Lessons Learned about Resiliency Powered By Docstoc
					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



                                                 1
Introduction
w Crisis intervention should be multi-
  component in nature (British 
  Psychological Society, 1990)
w 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)

                                         2
Introduction

Traditional models of disaster have 
  emphasized temporal or 
  phenomenological aspects 




                                  3
   


PHASES OF A DISASTER




Warning     Impact      Heroic     Disillusionment     Reconstruction



                                                                        4
                               anxiety
                   anger

 heroism

                                         reconstruction

 impact



           shock                depression
                     despair

             Phases of Disaster
                (DHHS, 2004)
                                                          5
                RESCUE 0-1 WK




                       RECOVERY 1-4 WKS
                                             RETURN
Pre-incident                              2 WKS - 2 YRS


      IMPACT 0-48HRS


               Phases of Disaster 
               (NIMH, 2002)
                                                     6
Critique and a Proposal
w Traditional models tend to be:
  n   Limiting—e.g. only some aspects of behavior 
      or emotion
  n   Inflexible
  n   Event focused, not person, group or 
      institution focused




                                             7
Critique and a Proposal
1. Do not include assessment 
      1.   Of individuals
      2.   Of organizations
2. Do not make predictions (hypotheses) that can 
   be assessed post-event to establish effectiveness  
3. Are reactionary, not proactive
4. Tend to propose one size fits all interventions, 
   ignoring vulnerabilities

An outcomes driven proposal:
   resistance/resilience/recovery (RRR)
                                                8
RESISTENCE, RESILENCE,
RECOVERY
An outcome-driven continuum of care

 


Build Resistance        Enhance Resiliency        Speed Recovery
      Assessment                Assessment                Assessment
        Intervention              Intervention                       Intervention
        Evaluation                Evaluation                         Evaluation

[Kaminsky, et al, (2005) RESISTENCE, REILENCE, RECOVERY, Johns Hopkins. 
                                                                           9
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
                                    10
I. RESISTANCE
In the present context, the term resistance
refers to the ability of an individual, a group, an 
organization, or even an entire population, to 
literally resist manifestations 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.                                    11
II. RESILIENCE
In 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 effectively rebound from 
psychological and/or behavioral perturbations 
associated with critical incidents, terrorism, and 
even mass disasters. 




                                                  12
III. RECOVERY
The term recovery refers to the ability of an 
individual, a group, an organization, or even an 
entire population, to literally recover the
ability to 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. 


                                              13
Tasks in the RRR Model
             Organizations/
             Populations    Groups     Persons
           Assess         Assess      Assess
Resistance Intervene      Intervene   Intervene
           Evaluate       Evaluate    Evaluate
             Assess       Assess      Assess
Resilience   Intervene    Intervene   Intervene
             Evaluate     Evaluate    Evaluate
             Assess       Assess      Assess
Recovery     Intervene    Intervene   Intervene
             Evaluate     Evaluate    Evaluate
                                                  14
  The Johns Hopkins Perspectives
  on Disaster Psychiatry
                          DISEASE                              DIMENSIONS                              BEHAVIOR                              LIFE STORY
                     What a person                            “Who a person                       “What a person                          “What a person
                        “has”                                      is”                                does”                                encounters”
“RRR”                   Hypotheses                               Hypotheses                           Hypotheses                              Hypotheses
Concepts
RESISTANCE      A person may have somatically-based 
                pathological conditions that 
                                                           A person may have certain 
                                                           intellectual or personality traits 
                                                                                                 A person may have drives, habits, 
                                                                                                 learned behaviors, etc that affect 
                                                                                                                                        A person may have life encounters 
                                                                                                                                        and resulting assumptive systems 
                compromise his/her immunity to             that affect (+ or -) his/her          (+ or -) his/her immunity to           that can affect (+ or -) his/her 
                stressors                                  immunity to stressors                 stressors                              immunity to stressors*



RESILIENCE      A person’s capacity to rebound from 
                stressors, traumatic  incidents, etc 
                                                           A person’s intelligence, problem-
                                                           solving ability, extraversion, 
                                                                                                 A person’s learned responses to 
                                                                                                 external stressors, ie, one’s 
                                                                                                                                        A person’s psychosocial history 
                                                                                                                                        (eg, in the contexts of family, 
                may be impaired by acute and chronic       optimism, etc  can position           repertoire of active coping skills,    school, and job settings) and the 
                illness and disease (eg, via immuno-       him/her to “spring back” from a       in part, determine one’s resilience    resulting assumptions about the 
                suppression)                               stressor faster than a person         to such stressors                      value of interpersonal 
                                                           without such traits                                                          relationships as a personal 
                                                                                                                                        resource are  critical elements of 
                                                                                                                                        resilience

RECOVERY        A person’s recovery from a disaster 
                may be facilitated or impeded by the 
                                                           A person’s recovery from a 
                                                           disaster may be facilitated (or 
                                                                                                 A person’s recovery from a 
                                                                                                 disaster may be facilitated (or 
                                                                                                                                        A person’s recovery from a 
                                                                                                                                        disaster may be facilitated (or 
                absence (or existence) of a physical or    impeded) by certain intellectual      impeded) by previously learned         impeded) by prior life encounters, 
                mental illness/disease process             and personality traits                behavioral tendencies, coping          by the availability (or absence) of  
                                                                                                 skills, etc.                           close interpersonal relationships, 
                                                                                                                                        and be his/her sense of self 
                                                                                                                                        efficacy

Key focus for   An identifiable abnormality of 
                structure or function
                                                           Vulnerability due to intellectual 
                                                           sub-normality, unstable 
                                                                                                 Maladaptive goal-directed and /or 
                                                                                                 learned behavior; return to 
                                                                                                                                        Psychological distress, anxiety, 
                                                                                                                                        demoralization, negative beliefs 
recovery                                                   introversion, and 
                                                           affective/temperamental traits, 
                                                                                                 functioning                            about self efficacy

                                                           etc. 

Key             Cure by way of appropriate medical 
                treatment
                                                           Guidance and support                  Increase, decrease, or extinguish 
                                                                                                 problem behavior 
                                                                                                                                        Recapitulation , rescripting, re-
                                                                                                                                        framing, reconstrual, etc.
intervention
for recovery
                                                                                                                                                             15
The Johns Hopkins Perspectives 
on Disaster Psychiatry 

DISEASE   DIMENSIONS   BEHAVIOR LIFE STORY


What a    Who a        What a   What a
person    person is    person   person
has                    does     encounters




                                       16
The Johns Hopkins Perspectives on Disaster 
Psychiatry—Resistance Hypotheses
Disease      A person may have somatically-based 
             pathological conditions that compromise 
             his/her immunity to stressors.
Dimensions A person may have certain intellectual or 
             personality traits that affect (positively or 
             negatively) his/her immunity to stressors.
Behavior     A person may have drives, habits, learned 
             behaviors, etc  that affect (positively or 
             negatively) his/her immunity to stressors.
Life Story   A person may have life  encounters, and 
             resulting assumptive systems,  that can 
             affect (positively or negatively) his/her 
             immunity to stressors.                     17
Resistance—Assessment
w Assess vulnerabilities, knowledge, 
  beliefs and preparation of individuals
w Assess quality of group 
  cohesion/social support/organizational 
  management
w Assess availability of credible 
  leadership 

                                        18
New Orleans
  Poverty, poor individual resources for 
  transportation
  Large addiction population
  High community disability load:     
  65,000 disabled in population of 550,000



                                       19
Resistance—Intervention 

Setting 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).

                                                               20
21
STATE OF MARYLAND DHMH:

 DISASTER MENTAL HEALTH
VOLUNTEER CORPS TRAINING
                                        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).
Community Capacity Building
  Faith appropriate
  4 ½ day sessions
  n   Disaster Mental Health 101
  n   Psychological 1st aide
  n   Grief counseling 
  n   Disaster planning



                                   24
Build Resistance—Intervention 

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



                                   25
Psychological Efforts to Build    
Resistance (APA, 2003)

     Pre-incident, Pre-deployment
        wGroup cohesion
        wSocial support
        wFoster a sense of purpose




                                     26
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)

                                         27
   The Johns Hopkins Perspectives on Disaster 
   Psychiatry—Resilience Hypotheses
Disease        A person’s capacity to rebound from stressors, traumatic  
               incidents, etc may be impaired by acute and chronic 
               illness and disease (eg, via immuno-suppression). 
Dimensions A person’s intelligence, problem-solving ability, 
               extraversion, optimism, etc  can position him/her to 
               “spring back” from a stressor faster than a person 
               without such traits. 
Behavior       A person’s learned responses to external stressors, ie, 
               one’s repertoire of active coping skills, in part, determine 
               one’s resilience to such stressors. 
Life Story     A person’s psychosocial history (eg, in the contexts of 
               family, school, and job settings) and the resulting 
               assumptions about the value of interpersonal 
               relationships as a personal resource are  critical elements 
               of resilience.                                       28
“It is more important to know what sort 
  of patient has a disease than what sort 
  of disease a patient has”. 
 
                          William Osler 




                                        29
30
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




                                                  31
32
“Neuroticism” and Anxiety Disorders

      Predisposing factor
 nAngst and Vollrath, 1991 – cohort of young 
  adult males in Zurich – high “neuroticism” at 
  19 predicted onset of anxiety neurosis by age 
  36
 nKrueger, 1999 – Dunedin sample - high 
  “negative emotionality” in late adolescence 
  predicted onset of anxiety disorders by early 
  adulthood

                                               33
“Neuroticism” and Anxiety 
Disorders
      Predisposing factor
 nBramsen et al., 2000 – U.N. peacekeepers in 
  the former Yugoslavia – high predeployment 
  “psychoneuroticism” was second only to 
  traumatic event exposure in predicting PTSD 
  symptoms
 nFauerbach et al., 2000 – severe burn 
  survivors – higher baseline neuroticism 
  predicted onset of PTSD in the following year

                                              34
    The dimensional paradigm

 potential      provocation       response
The neurotic paradigm or emotive triad
temperamental     speech
                              anxiety symptoms
   shyness      requirement

                 difficult    demoralization,
                cognitive      with anxiety &
 Low IQ
                   task         depressive
                                symptoms
                                         35
          A more complex example – interacting
                     perspectives
                       emotive paradigm
    personality
  vulnerabilities            disaster           anxiety, arousal,
(e.g., neuroticism          exposure               numbing,
&/or introversion)                              re-experiencing



                     + behavioral perspective
     restriction                                 avoidance
    of activities,         decreased
                                             of trauma-related
   impaired role           discomfort
                                            places & memories
    functioning
Psychological Efforts to Build
Resilience (APA, 2003)—Intervention
        During 
        w Provide strong leadership
        w Work in teams, when possible
        w Sustain an information flow
        w Stay task oriented
        w Utilize on-scene support services
        w Remain vigilant  for fatigue, distress, 
          mistakes
        w Promote recovery between incidents

                                               37
Enhance Resilience—Intervention 
n   Acute Post-incident, Post Deployment
     w Provide information about event, 
     w Provide information about normal behavioral reactions
     w Emphsize social support
     w Teach personal stress management, foster “self-
       efficacy” (Bandura, 1997)
     w Address “relationship” issues
     w Return to normal routines: diet, exercise
     w “Debriefings” or similar organization-based crisis 
       interventions should be considered. Cathartic 
       ventilation should be voluntary!
     w Utilize a phase sensitive disaster mental health system 
       (Raphael, 1986; Everly & Mitchell, 1999)...
                                                        38
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)


                                                39
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, and
 5. a sense of connectedness.

                                           40
Enhance Resilience—Intervention
    Self-Efficacy 

   “People guide their lives by 
   their beliefs of personal 
   efficacy” 
  (Bandura, 1997, p. 3). 


                                   41
 
Enhance Resilience—Intervention 
Foster Self-Efficacy

 “People’ s beliefs in their efficacy…
influence the courses of action people choose to
pursue, 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).
                                              42
Psychological First Aid
    Stabilize
    Assess and triage
    Communicate
    Connect

SACC Model of Acute Psychological First Aid
(Everly & Flynn, 2004)

                                        43
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. 

                                             44
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).                                     45
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)


                                                                46
Enhance Resilience—Evaluation
 The 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)                                     47
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.    48
The Johns Hopkins Perspectives on Disaster 
Psychiatry—Recovery Hypotheses
Disease        A person’s recovery from a disaster may be 
               facilitated or impeded by the absence (or 
               existence) of a physical  or mental illness/disease 
               process.
Dimensions A person’s recovery from a disaster may be 
               facilitated (or impeded) by certain intellectual and 
               personality traits.
Behavior       A person’s recovery from a disaster may be 
               facilitated (or impeded) by previously learned 
               behavioral tendencies, coping skills, etc.
Life Story     A person’s recovery from a disaster may be 
               facilitated (or impeded) by prior life encounters, by 
               the availability (or absence) of  close interpersonal 
               relationships, and be his/her sense of self efficacy.
                                                               49
     Recovery From PTSD After Rape


                  94%



                    47%
                          42
                             30 %
                          %         25%-15%
% with PTSD                    ?
 Symptoms


              W    3m     9m12m       Years




Data from Rothbaum et al.,                    50
1992
Prevalence of Trauma and PTSD
 in Men and Women in the US




                           Kessler 1995
                                51
      Rate of PTSD is Influenced by the
            Nature of the Trauma




Kessler, 1995
                                          52
  Evidence of Traumatic 
  Damage to the brain
1. Left Hippocampal over-
   activity after trauma
2. Left Hippocampal 
   atrophy after trauma
3. Cell loss thought 
   secondary to excitatory 
   toxicity/apoptosis.
4. Psychological 
   event/exposure possibly 
   directly damaging the 
   brain
                              53
                             PE  Vs  SIT Vs  PE/SIT  Vs  
                             WL
Percent Patients with PTSD




                                   Post-Tx   6 Mo FU   Last Available FU
Foa et al., 1999
                                                          (M = 10.7 mos.)
                                                                   54
      Post-Rx Effect Sizes* of PE 
      vs SIT vs PE/SIT: PTSD




*Effect size compared to wait-list group at post-
                                                    Foa et al., 1999
treatment
PE VS PE and CR With Torture 
Victims




                   Paunovic & Ost, 2001
                                    56
 Study with Men and Women 
 Victims of Mixed Traumas
  Treatments:
   n   Exposure (PE)
   n   Cognitive Restructuring (CR)
   n   PE + CR
   n   Relaxation Training

Treatment consisted of 10 sessions conducted 
  over 16 weeks
                                      Marks et al.,
                                      1998       57
     Good End State Functioning 
     Post Treatment*




         PE   SIT    PE/SIT   WL   PE      CR   PE/CR        R
          Foa et al., 1999              Marks et al., 1998
*>50% improved on PTSD; <7 BDI; <35
                                                        58
STAI-S
“Worried well”
1.  Who came up with this designation?  
    Certainly not a mental health person.
2.  In standard medical culture-  a 
    PERJORATIVE (means hypochondria, 
     crock, someone without a serious 
    problem).
3.  Effect is to discount the very psychological  
      effects that are the purpose of terror 
                                           59
“Worried well”  (cont’d)

 1.  Stop using the term
 2.  Substitute 
   n   Uninjured affected
   n   Psychologically effected




                                  60
 A Lesson:
Never give in. Never give in. 
Never, never, never, never
-- in nothing, great or small, large or petty, never 
give in, except to convictions of honour and
good sense. Never yield to force. Never yield to 
the apparently overwhelming might of the enemy.

                              Winston Churchill,
                              October 29, 1941
                              Harrow School, England


                                                  61

				
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Jun Wang Jun Wang Dr
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