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
1. Crisis intervention should be multi-
component in nature (British
Psychological Society, 1990)
2. 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
anger
anxiety
heroism
reconstruction
impact
shock
depression
despair
Phases of Disaster
(DHHS, 2004)
5
RESCUE 0-1 WK
RECOVERY 1-4 WKS
RETURN
2 WKS - 2 YRS
Pre-incident
IMPACT 0-48HRS
Phases of Disaster
(NIMH, 2002)
6
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
7
Critique and a Proposal
1. Do not include assessment
1.
2.
Of individuals
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
Assessment
Intervention
Evaluation
Enhance Resiliency
Assessment
Intervention
Evaluation
Speed Recovery
Assessment
Intervention
Evaluation
[Kaminsky, et al, (2005) RESISTENCE, REILENCE, RECOVERY, Johns Hopkins.
9
ADVANTAGES OF OUTCOMEDRIVEN 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
Assess
Resistance Intervene
Evaluate
Assess
Intervene
Evaluate
Persons
Assess
Intervene
Evaluate
Resilience
Assess
Intervene
Evaluate
Assess
Intervene
Evaluate
Assess
Intervene
Evaluate
Recovery
Assess
Intervene
Evaluate
Assess
Intervene
Evaluate
Assess
Intervene
Evaluate
14
The Johns Hopkins Perspectives
on Disaster Psychiatry
“RRR”
Concepts
DISEASE
DIMENSIONS
BEHAVIOR
LIFE STORY
What a person
“has”
“Who a person
is”
“What a person
does”
“What a person
encounters”
Hypotheses
Hypotheses
Hypotheses
Hypotheses
RESISTANCE
A person may have somatically-based
pathological conditions that
compromise his/her immunity to
stressors
A person may have certain
intellectual or personality traits
that affect (+ or -) his/her
immunity to stressors
A person may have drives, habits,
learned behaviors, etc that affect
(+ or -) his/her immunity to
stressors
A person may have life
encounters and resulting
assumptive systems that can
affect (+ or -) his/her immunity to
stressors*
RESILIENCE
A person’s capacity to rebound from
stressors, traumatic incidents, etc
may be impaired by acute and chronic
illness and disease (eg, via immunosuppression)
A person’s intelligence, problemsolving ability, extraversion,
optimism, etc can position
him/her to “spring back” from a
stressor faster than a person
without such traits
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
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
RECOVERY
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
A person’s recovery from a
disaster may be facilitated (or
impeded) by certain intellectual
and personality traits
A person’s recovery from a
disaster may be facilitated (or
impeded) by previously learned
behavioral tendencies, coping
skills, etc.
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
Key focus for
recovery
An identifiable abnormality of
structure or function
Vulnerability due to intellectual
sub-normality, unstable
introversion, and
affective/temperamental traits,
etc.
Maladaptive goal-directed and /or
learned behavior; return to
functioning
Psychological distress, anxiety,
demoralization, negative beliefs
about self efficacy
Key
intervention
for recovery
Cure by way of appropriate medical
treatment
Guidance and support
Increase, decrease, or extinguish
problem behavior
Recapitulation , rescripting, reframing, reconstrual, etc.
15
The Johns Hopkins Perspectives
on Disaster Psychiatry
DISEASE
DIMENSIONS
BEHAVIOR LIFE STORY
What a
person
has
Who a
person is
What a
person
does
What a
person
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
1. Assess vulnerabilities, knowledge,
beliefs and preparation of individuals
2. Assess quality of group
cohesion/social support/organizational
management
3. 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




Disaster Mental Health 101
Psychological 1st aide
Grief counseling
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
Group cohesion
Social support
Foster 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
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

33
“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

34
The dimensional paradigm
potential
provocation
response
The neurotic paradigm or emotive triad
temperamental
shyness
Low IQ
speech
requirement
anxiety symptoms
difficult
cognitive
task
demoralization,
with anxiety &
depressive
symptoms
35
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
decreased
discomfort
avoidance
of trauma-related
places & memories
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
37
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)...
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.
2.
3.
4.
5.
information (and rumor deterrence),
reassurance,
direction,
motivation, and
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 selfhindering 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
%
% with PTSD
Symptoms
30 %
25%-15%
?
W
3m
9m12m
Data from Rothbaum et al.,
1992
Years
50
Prevalence of Trauma and PTSD
in Men and Women in the US
100
91.9
90
79.6
Percent (%)
80
70
60
60.7
Trauma
PTSD
No PTSD
51.2
50
40
30
20.4
20
10
8.1
0
Men
Women
Kessler 1995
51
Rate of PTSD is Influenced by the
Nature of the Trauma
60
Trauma
PTSD
Percent (%)
50
40
30
20
10
0
Disaster
Kessler, 1995
Accident
Assault
Molestation
Combat*
Rape
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
100
PE
SIT
PE/SIT
WL
90
80
70
60
50
40
30
20
10
0
Post-Tx
Foa et al., 1999
6 Mo FU
Last Available FU
(M = 10.7 mos.)
54
Effect Size of PTSD Symptoms
Post-Rx Effect Sizes* of PE
vs SIT vs PE/SIT: PTSD
PE
SIT
SIT/PE
2
1.5
1
0.5
0
TOTAL
Reexp.
Arousal
*Effect size compared to wait-list group at posttreatment
Avoidance
Foa et al., 1999
PTSD Severity
PE VS PE and CR With Torture
Victims
45
40
35
30
25
20
15
10
5
0
PE
PE/CR
Pre
Post
FU
Paunovic & Ost, 2001
56
Study with Men and Women
Victims of Mixed Traumas
Treatments:

Exposure (PE)

Cognitive Restructuring (CR)

PE + CR

Relaxation Training
Treatment consisted of 10 sessions conducted
over 16 weeks
Marks et al.,
1998
57
Good End State Functioning
Post Treatment*
Perecent Responders
60
50
40
30
20
10
0
PE
SIT
PE/SIT
Foa et al., 1999
WL
PE
CR
R
Marks et al., 1998
* > 50% improved on PTSD; <7 BDI; <35
STAI-S
PE/CR
58
“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


Uninjured affected
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