RESILIENCE George S. Everly, Jr., PhD, ABPP

1
RESILIENCEGeorge S. Everly, Jr., PhD, ABPP 
Dept of Psychiatry and Behavioral Sciences, The
Johns Hopkins University School of MedicineThe
Johns Hopkins Center for Public Health
PreparednessThe Johns Hopkins Bloomberg School
of Public Healthgeverly_at_jhsph.edu
2
ObjectivesParticipants 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.

3
1. Johns HopkinsRESISTENCE, 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.
4
Johns HopkinsRESISTENCE, 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.
5
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

6
3. Group Crisis Intervention

• Debriefings (small group - interactive)
• Crisis Management Briefings (Large or small group
  - informational)
• Battle Mind (Informational and interactive)

7
Mechanisms of Action

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

8
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

9
ESSENTIAL CONCEPTS
10
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

11
Crisis Intervention Principles

• Proximity
• Immediacy
• Expectancy

12

• 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.

13
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

14
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.

15
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

16
CISM was found to be superior to acute-phase
psychotherapy, post 9/11.Psychotherapy tended
to increase symptoms of PTSD.
17
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

18
(No Transcript)
19
DysfunctionRed 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

20
Predicting Beyond Immediate Severity

• 1. Dose - response relationship with exposure
• 2. Peri-traumatic dissociation
• 3. Peri-traumatic belief one was going to die
• 4. Negative appraisal of symptoms
• 5. Physical injuries
• 6. Peri-traumatic panic
• 7. Psychogenic amnesia
• 8. Peri-traumatic depression, despair, numbing
• 9. History of significant mental illness
• 10. Significant loss

21
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.

22
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

23
Dr Everlys 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 dont 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.

24

• 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.
  Empathizeyou 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.

25
Resources

• geverly_at_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