RESILIENCE

George S. Everly, Jr., PhD, ABPP 

Dept of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine

The Johns Hopkins Center for Public Health Preparedness

The Johns Hopkins Bloomberg School of Public Health

geverly@jhsph.edu

Objectives:Participants will increase their

understanding of: 1. The JHU resistance, resilience,

recovery model 2. What returning military members need

to feel resilient. 3. How large and small group crisis

interventions foster resilience. 4. What clinicians can do. 5. What clinicians should NOT do.

1. Johns Hopkins’RESISTENCE, RESILIENCE, RECOVERY An outcome-driven continuum of care

Build Resistance Enhance Resiliency Speed Recovery Immunity Rebound Treatment/Rehab Kaminsky, et al, (2005) RESISTENCE, RESILIENCE, RECOVERY, Johns Hopkins.

Johns Hopkins’RESISTENCE, RESILIENCE, RECOVERY

Build Resistance Enhance Resiliency Speed Recovery Immunity Rebound Treatment/Rehab

Expectancy CBT, EMDR + Crisis Intervention Experience CISM

PFA Self-efficacy + Group cohesion Kaminsky, et al, (2007) RESISTENCE, RESILIENCE, RECOVERY, Brief Treatment & Crisis Intervention.

2. What do People Need? Honest, Reliable Information Interpersonal Support, a Sense of

Connectedness (UDT/SEAL) Confidence, Self-efficacy Faith in Leadership (“strength & honor”) Belief in Something Greater than

Themselves (Faith, Duty) Future Orientation

3. Group Crisis Intervention

Debriefings (small group - interactive) Crisis Management Briefings (Large or

small group - informational) Battle Mind (Informational and

interactive)

Mechanisms of Action Information Normalization De-stigmatization (Hoge) Fosters interpersonal support (Yalom) Exerts anti-demoralization effect (Frank) Peers communicate with unique ethos

LAW ENFORCEMENT BEST PRACTICES

(Sheehan, 2004, FBI Law Enforcement Bulletin) Peer-based intervention system, consisting of… Basic communication skills Assessment/ triage of benign vs. malignant

symptoms Chaplain services MH consultation/ support An integrated continuum of intervention services

ESSENTIAL CONCEPTS

Crisis Intervention A short-term helping process designed

to: Stabilize distress Mitigate distress Assess need for continued care Facilitate access to continued care, if

indicated NOT psychotherapy, nor a substitute for

Crisis Intervention Principles

Proximity Immediacy Expectancy

ARTISS (Military Medicine, 1963) Regarding war neurosis, removal of the soldier from the front “returned only five percent of such casualties to duty” (p. 1011).

The treatment principles of immediacy, proximity, & expectancy (PIE) were later applied and resulted in 70 to 80 percent of combat psychiatric casualties returning to duty.

Zahava Solomon Tested PIE with Israeli soldiers finding all

3 components active, but expectancy most useful

Re-tested 20 years later finding those who received PIE did better in post-military life than did those who did not receive PIE

Boscarino, et al., 2005, 2006, 2008

conducted a random prospective cohort study utilizing a sample of 1,681 New York at 1 year and 2 years after 9/11. Results indicate that brief workplace-based crisis interventions, (CISM), had a beneficial impact including reduced risks for binge drinking, alcohol dependence, PTSD symptoms, major depression, anxiety, and global impairment, compared with individuals who did not receive these interventions.

CISM: Integrative Crisis Intervention and Disaster

Mental Health(Everly & Mitchell, 2008)

Integrated multi-component intervention system

Utilizing the most effective intervention for the target population given the current challenge at hand

Most widely used model: Critical Incident Stress Management (CISM)

Used by United Nations

CISM was found to be superior to acute-phase

psychotherapy, post 9/11.

Psychotherapy tended to increase symptoms of

PTSD.

4. What Can Clinicians Do?

Normalize Triage Provide anticipatory guidance Reinforce importance of connectedness Foster future orientation Foster problem-solving approach to life Reinforce role of clinician as consultant Practice PFA

Dysfunction“Red Flags”

Dissociation Depersonalization Derealization

Depression and Guilt Survivor Guilt Psychogenic amnesia Persistent sleep

disturbance Panic Violent inclinations Psychosis

Reliance upon self-medication

Lack of social support Hyperarousal (severe

exaggerated startle response, explosive tirades)

Evidence of seizures Inability to function after

respite

Predicting Beyond Immediate Severity

1. Dose - response relationship with exposure2. Peri-traumatic dissociation3. Peri-traumatic belief one was going to die4. Negative appraisal of symptoms 5. Physical injuries6. Peri-traumatic panic7. Psychogenic amnesia8. Peri-traumatic depression, despair, numbing9. History of significant mental illness10. Significant loss

Crisis Intervention Triad(Everly & Mitchell, 2008)

Antidote for impulsivity:Slowing down the interaction (assuming medical stability and no other objective urgency); suggesting a delay in any actions which have lasting consequences;

Antidote for inability to understand consequences:Using the crisis communication techniques of summary and extrapolation paraphrasing to assist individuals in gaining insight into the consequences of actions and to see options; and

Antidote for hopelessness:A supportive, optimistic presence that corrects misconceptions, conveys both directly and indirectly a future orientation, hope; facilitation of access to continued care, if indicated (friends, family, EAP, MHP, etc.

5. What Clinicians Should Avoid

Traditional patient-focused psychotherapy Non-directive counseling Confrontation Fostering dependency/ transference reactions Paradoxical intention “I know how you feel” Fostering affective abreaction, unless other-

initiated

Dr Everly’s MHC Burnout Club 1. Be a perfectionist, never accept excellence. 2. Never exercise! 3. Remember, the glass is always half empty! 4. Eat as much “fast food” as possible; only

eat things that had faces (chickens don’t count--no lips). Never eat breakfast.

5. Blame all of your failures in life on your parents, your lack of friends, your coercive unethical money-grubbing outsourcing capitalistic boss, or the great right-wing conspiracy.

6. Accept responsibility for everything and everyone, all the time! You must make all veterans happy.

7. Engage in an endless process of controlling everything and everyone, especially those people/ things over which you have no actual control. Empathize…you must feel their pain.

8. Strive to sleep as little as possible! 9. Feel guilty when leaving the disaster at end

of deployment. NEVER take vacations, if forced to do so, feel guilty.

10.Seek out a routine: Sleep until you are hungry, eat until you are tired; use ETOH to relax, stimulants to get going.

Resources geverly@jhsph.edu Everly, GS, Jr. (2009), Resilient Child. NY:

DiaMedica. Everly, GS, Jr., etal. (2010). Resilient

Leadership. NY: DiaMedica. Everly, GS, Jr. & Mitchell, JT (2007).

Integrative Crisis Intervention and Disaster Mental Health. Ellicott City, MD: Chevron.

Everlybooks.com