The concept of psychological resiliency or danger flexibility in the military

Transcription

1 AARMS Vol. 11, No. 1 (2012) MEDICINE The concept of psychological resiliency or danger flexibility in the military NÓRA URBÁN Military Hospital, Budapest, Hungary Nowadays, both in civilian and in military life, more and more attention is given to PTSD or the pathological conditions following traumatic events and to the possibilities of their prevention. It is of special importance that according to statistic data, the occurrence of PTSD after combat operations can exceed 20% (TAYLOR, 2008). The main focus of attention falls on figuring out the facts that are partially responsible for the appearance of individual vulnerability as well as for the flexible resistance. In my work my aim is to give a short overview of the concept and research of psychological resiliency, with special attention to its role in the military environment. Introduction The researching and filtering of risk factors is continuous at all levels of prevention. From the point of primary prevention it is important to measure the factors of vulnerability, especially in case of professions continuously facing dangerous situations, which can mean application of selective criteria. Several authors in their work research only the risk factors. If we want to summarise it, we can distinguish environmental, demographic, personal, psychiatric, cognitive, biological and genetic risk factors (WALD et al., 2006). Following the terrorist attack of 9/11 the American Psychological Association (APA) issued facts, data and publications in which they emphasised the importance of flexible resistance ability in connection with traumatic events. They established that the majority of individuals possess this ability and with its help they are able to cope with the highest levels of stress. APA defines that the flexible resistance ability is an adaptation process with which an individual is capable to deal successfully with a difficult life situation, an accident, tragedy, i.e., with the symptoms caused by distress (MANDSORF, 2008). The concept of resiliency first appeared in psychology of development when children s reaction was studied in extreme life situations. Later resiliency research was extended to population who, originating from the character of their professions, are participants of extreme or unusual situations, who have suffered or witnessed traumatic experiences (e.g. human suffering or death). This applies to Received: January 24, 2012 Address for correspondence: NÓRA URBÁN noraurban6@gmail.com

2 soldiers, police personnel, catastrophe rescuers, civilian rescue forces and aid organisation workers. In case of this especially endangered population the protective role of flexible resiliency is extremely important in reaction to stress and in psychopathology (WALD et al., 2006). The constructum of resiliency involves several factors, it is more than the coping ability of a person, however, there is no established and integrated concept yet. I would like to give a short overview of research of resiliency, its role in prevention, possibilities in development, concentrating to the area of the military. The concept of psychological resiliency Resiliency is a flexible resistance capability, or a reaction ability of a certain system, e.g. an individual, an organisation, or an ecosystem where it is possible to adapt successfully to very strong, continuous or even shocking external influence (BÉKÉS, 2002). The origin of the word comes from the Latin verb salire (jump): re-salire means to jump back, to move back, to move backward or forward, but not to break. This expression was originally taken from engineering physics. Hollig (BÉKÉS, 2002), one of the leading figures in the research of resiliency, was the one who introduced the paradox in the 70 s, which exists, on the one hand, in the ability to withstand, performance ability, permanency, staying power of a system and on the other hand, the difference between stability and change. According to this controversy, in the ecological literature there are two different definitions of resiliency. In the first definition resiliency is the measurement within which the system preserves its inner balance against influencing forces. In the second definition the notion of stability is paraphrased, the system reacts to the imbalancing force by reacting to the new influence in a flexible way. While the first definition focuses on the effectiveness, withstanding capacity, reliability of a system, the second one prefers stamina, persistency, adaptivity. Psychological resistance can be defined as a dynamic process when an individual adapts and fights positively against a traumatic experience. It is a two-dimensional constructum that, on the one hand, concentrates on exposition of difficult situations, on the other side, on the positive outcome of these difficult situations (LUTHAR, CICCHETTI, 2000). In psychology the research of resiliency developed mainly in the area of psychological development, later they moved on to research of influence of traumatic or extreme experiences on adults. In other words, how an individual is able to recover after such events, with pathology or without it. 126 AARMS 11(1) (2012)

3 Resiliency and trauma Nowadays more and more research deals with the healing process that follows traumatic experiences. While earlier the main focus was on pathology, risk factors, vulnerability, today the focus shifted on the fact that certain people do not become ill following a serious trauma, they do not develop post-traumatic stress disorders or any other mental illnesses and in a comparatively short period of time they are able to return to healthy lifestyle. There are several theories dealing with the resiliency concept but still there is no common definition. At the moment there are two approaches: one of them belongs to Bonnano, which is a narrow definition, the other one is of wider character. BONNANO (2004) focuses on a single short time trauma consequence. A flexible individual can go through short-time mental and physical disregulations, but later he/she is capable to continue personal and social tasks even have positive feelings. However, the disadvantage of the definition is that the difference between the notion of resiliency and the process of heeling is not clear enough, on the other hand, the definition concentrates on a single separate event and does not take into consideration the influence of chronic stress and multiple trauma. It is considered more like a static entity in its character and not a dynamic process that is able to develop and outer and inner factors can play role in its formation. In contrast with Bonnano s definition many researchers handle the notion of resiliency and healing as individual, well-separated construction. Among these definitions some describe stamina as a dynamic and context-dependent construction, which can be characterised by the lack of the side effects of stress, but also by the natural process of healing (CONNOR, DAVIDSON, 2003; KING et al., 1998, 1999; LUTHAR, CICCHETTI, 2000; WALD et al., 2006). Further differences may arise from the origin of the source of psychological resistance power. Some researchers distinguish sources within an individual, others, on the other hand, state that resiliency can originate from several sources, not only from the ones within an individual, so it is necessary to take into consideration psychological and dispositional characteristics, as well as family context (e.g. family and other supportive network). Generally each approach connects the notion of resiliency with other constructions, so this way with the notions of hardiness, thriving and posttraumatic growth. Hardiness as a personal feature, helps to avoid extreme stress (KOBASA et al., 1982). It involves three dimensions: the ability to recognise and identify the most important goals in our life, the belief that people are able to change the outcome of events and their circumstances, and the belief that people are able to learn from both their negative and positive experiences. A resilient person is more self-confident, he/she has more effective ways of coping and AARMS 11(1) (2012) 127

4 can benefit personally from social support. Strengthening weakens reaction to stress, it speeds up recovery and produces higher level of functioning following a traumatic experience (CARVER, 1988). This way it can improve the state of health, psychological well-being and develop social relationships. However, it is uncertain whether psychological strengthening is one dimensional or multidimensional and it is not proved how this notion is different in the concepts of hardiness and posttraumatic development. Its relationship with the processes of coping is also not clear enough (WALD et al., 2006). The notion of posttraumatic development has also been examined and used by many researchers (AFFLECK and TENNEN, 1996; FONTANA and ROSENHECK, 1998; TEDESCHI and CALHOUN, 2004; WALD et al., 2006), the concept is connected with personal growth following a traumatic experience and any other difficult life situation. Similarly to the notion of strengthening but contrary to resiliency refers to the aspect that compared the functional level prior to a trauma there is a higher level functioning in the time following a traumatic experience, and also the individual s schemes of behaviour with himself/herself and the world change, become more positive. At the same time the posttraumatic development has a certain feature of illusion and self-deception, e.g. the adaptive functioning follows the denial of the trauma. It can be seen that the constructum of resiliency is considerably underdeveloped and that it is very complex. There are other notions that denote similar aspects, however, a consensus is missing between the relationship of resiliency and other constructums. These factors cause the researchers to try to create conceptual model in connection with the definition of resiliency, in other words, to define those factors that play part in the development of resiliency, to support them by empiric means and make resiliency measurable. Research of extreme stress and trauma based resiliency in the military It was in the 80 s when empiric research of trauma and extreme stress based resiliency started. I want to mention one of the most endangered progression in this field, that is of soldiers. This research examines the protective influencing factors following combat situations from the point of development of psychopathology and this way, the appearance of posttraumatic stress disorder. The first work is connected to HENDIN and HAAS (1984), (WALD et al., 2006) which, from the point of methodology is not sufficient. 10 Vietnamese veterans were examined. These people did not develop PTSD and they showed positive adaptive attitude. The following characteristic features were established in their case: calmness in stressful situations, intellectual control, acceptance of fear, lack of extremely violent behaviour and self-pity in battle conditions. 128 AARMS 11(1) (2012)

5 SOLOMON and his colleagues (1988), (WALD et al., 2006) examined Israeli soldiers after the Lebanon war in In their studies they established that those soldiers who used problem-focused approach in difficult, traumatic situations, were less likely to develop PTSD. They examined the relationship between developing PTSD and coping, the place of control, social support in combat situations and events in the next two or three years with those soldiers who were suffering from stress reaction in combat situations during the war. Those who possessed inner self-control, problem solving focus and recognised social support, managed to heal much faster in two years and the intensity of PTSD was much lower. ELDER and CLIPP (1989), WALD et al. (2006), examined the growth of posttraumatic effects after traumatic experiences with veterans who participated both in WW2 and the Korean war. In their results they established that the battle stress can cause both pathological and positive signs of development. Among positive outcome the researchers established the following: coping with difficulties, self-discipline, interest, horizon widening. Negative consequences were the following: separation from the loved ones, being tense, loss of friends. In 1990 Capella and Motta (WALD et al., 2006) in their studies drew the attention to the difference between veterans suffering from PTSD and the healthy ones. Those who did not develop PTSD reached lower neuroticism points on the Eysenck Personality Questionnaire. It showed that in spite of difficult combat conditions they possessed sufficient spiritual strenght and resiliency. The place of control was also examined and they established that veterans who possessed inner control could structure their war experiences more successfully and they were less likely to develop PTSD. SUTKER and his colleagues (1995), WALD et al. (2006) examined the role of environment in psychological functioning in veterans of the Gulf war. Low levels of hardiness, limited commitment, lack of coping and lack of family cohesion were the introductory factors of PTSD development. They established that individual asnd environmental factors together modify or establish vulnerability in wartime stress. KING and his colleagues (1998, 1999), WALD et al. (2006) performed the most complex research of resiliency in military sphere. They examined the relationship between the risk factors existing before the war, wartime stress and resiliency following a traumatic event and healing. The pre-trauma factors were unstable family relationships, childhood antisocial behaviour, the factors of resiliency were hardiness and social support. Stronger existence of hardiness and social support considerably diminished the appearance of PTSD even with the same levels of pretraumatic and peritraumatic risk factors. AARMS 11(1) (2012) 129

6 I want to mention two studies in connection with the examination of Iraqi veterans. PIETRZAK and colleagues (2009) examined the influence of social support and resiliency in the case of Iraqi veterans from the point of view of the development of resiliency and PTSD. The measure of resiliency was compared to that of civilian patients. According to the examination the measure of resiliency was much higher in veterans, on the other hand, in case of veterans who developed PTSD or depression and the recognized social support was lower than that of healthy veterans. Demographic factors and the seriousness of the trauma was taken into consideration. GREEN and his colleagues (2010) examined the relationship between resiliency and psychological functioning in case of Iraqi veterans. The aim of their examination was to establish whether the exposition of the trauma and the development of PTSD is influenced by resiliency and whether the presence of resiliency is connected to psychological functioning in PTSD. The results showed the significance of interaction of trauma exposition and the resiliency. Those veterans who went through more intensive and stronger combat situations proved to be more resilient and it influenced them positively. Besides the diagnosis of PTSD, and in case of depression resiliency was a protective factor, similarly as in cases of suicide, problems with alcohol and physical health. To sum up, resiliency research in connection with traumatisation and posttraumatic effects emphasized mainly the identification of protective factors. Risk factors (either pretraumatic or connected with exposition) were examined as well how could they modify the protective factors that are present in resiliency. Studies proved that the examined protective factors were successful in the pathological defence in intensive combat stress. Resiliency and prevention in the military During the process of research of resiliency were found more and more proof that resiliency can be developed consequently in extreme stress situations and the negative effects of traumatisation can be avoided. I want to briefly introduce the resiliency development program of the US Army. American soldiers are continuously exposed to combat situations because they are deployed in territories (Iraq, Afghanistan), especially in the last decades, where there are constant conflicts, war, their lives are in constant danger, they witness their comrades, civilians, children dying. They are far from their loved ones and parallelly they have to deal with complex tasks characterised by extreme stress. They have to be, at the same time, combattants, conflict managing specialists, social workers, peacemakers. Suicide rate is very high among these soldiers. With soldiers returning 130 AARMS 11(1) (2012)

7 from Afghanistan and Iraq there are lots of cases of developing PTSD and other mental illnesses as well as alcohol problems. After 12 months of returning from Iraq, according to the research done by the Department of Psychiatry at the Walter Reed Arrmy Institute of Research, in case of returned soldiers 15% developed PTSD, 12% developed depression and 11.5% of them displayed symptoms of tenseness. 15% of them showed problems with alcohol, family and relationship problems. The question of psychological stigma is a big problem with the soldiers. 40 to 50% of those asked would not look for help, because they want to keep their jobs, they are afraid of considered weak and they do not expect any military awards for heroism. Due to organisational limitations, the soldiers do not know where to turn for help in case of a problem (CASTRO, HOGE, 2005; CASEY, 2011). The solution to this problem at first a training and filtering program can be that includes soldiers, commanders, civilians. With the help of this program it would be possible to reduce risks connected with combat activities, development of resiliency, preparation for combat events, as well as preparation for returning home and readjustment into the society. This is how the following three initiatives started (CASTRO, HOGE, 2005) P Development and testing of psychological preparedness in deployment (PRIDE) modul: It gives information about the effect of combat circumstances, situations of the mental health of a soldier, and those specific behavioral patterns with which soldiers and commanders are able to diminish the consequences of battle and deployment stressors. Part of this is also the readjustment into the society following the deployment and service. P Appreciation of the needs of units to provide mental hygiene support, if necessary, for the soldiers and the unit, based on their mental health and well being. P Psychological filtration to identify soldiers who experienced distress, and to provide help as soon as possible. Nowadays in the American forces there are more and more programs have been developed that are aimed at development of resiliency, the so called Comprehensive Soldier Fitness Program (CFS). This program started in the autumn of 2008, and it is a complex, comprehensive program for the stamina development for soldiers. Its main aim is the prevention of posttraumatic disorders (ASSOCIATION OF THE US ARMY, 2010). This prevention program tries to help both soldiers and their relatives, as well as civilians working in the military how to be able to stay healthy mentally and physically when facing difficult circumstances, including difficult combat situations, as well as staying away from the loved ones for longer periods of time. AARMS 11(1) (2012) 131

8 The context of the program is three following (CASEY, 2011): P Provision of information in connection with CFS as well as education of holistic approach and its representation, in other words, to try to develop resiliency in the following five dimensions physical, social, spiritual and familial. P The program includes several strategies, ranging from traditional classroom lessons to online tasks. P It is important that the program is individual orientated, from the age of 18 to 40, for privates and officers, for men and women, etc. The trainings are tailored to satisfy personal and individual needs. The program consists of four components: 1. Online self evaluation, identification of resiliency level. 2. Online self helping module, tailored to the previous evaluation and appreciation. 3. With the help of resiliency development training, to perform the actual training tailored to the level of a given unit. 4. Compulsory resiliency training for (future) leaders, commanders in officer training schools. To sum up, we can say that interventions aiming at the development of resiliency in the military emphasize the following: P they concentrate on competency, positive sources, strength and not on deficits P they try to establish the relationship between vulnerability and protective factors P the relationship between the individual and its surroundings is vitally important P the first step of each intervention is a thorough evaluation, filtration which supports practice. Conclusions Resiliency is a broad notion that in many areas of science means positive adaptation capabilities in any dynamic systems, in cases of extreme changes or threat. This danger flexibility is dynamic itself, because the same individual sometimes behaves maladaptive, sometimes in resilient manner. Masten (MASTEN et al., 2009) established four, well separable patterns of danger flexibility: P Resistance is a rational, balanced, adaptive behavior pattern shown by children who, in spite of their difficult circumstances, performed their development tasks according to the requirements of their age group. P Extrication a behavioral pattern when the adaptive form of behaviour of a certain individual temporarily stops due to a traumatic event but the individual returns to 132 AARMS 11(1) (2012)

9 the adequate level. This pattern is characteristic in the case of being exposed to continuous stress or at the times of unexpected catastrophes. P Normalisation happens when a child lives in unhealthy environment from the moment of birth and when escapes from this environment he/she gets into better circumstances. P Transformation is the type of flexible danger behaviour when as a consequence of a trauma the adaptive functions of a person change, this can be described as posttraumatic growth. These four types of resilient behaviour help to perform in each stage of the human development, this way we can count on protective function of resiliency throughout our entire cycle of life. References BÉKÉS Vera (2002): A reziliencia-jelenség, avagy az ökologizálódó tudományok tanulságai egy ökologizált episztemológia számára in: FORRAI Gábor, MARGITAY Tihamér (Eds): Tudomány és történet. Tanulmánykötet Fehér Márta tiszteletére, Typotex, Budapest. BONANNO, G. A. (2004): Loss, trauma and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, CARVER, C. S. (1988): Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54, CASEY, G. W. (2011): Comprehensive Soldier Fitness. A vision for psychological resilience in the U. S. Army. American Psychologist, 66(1), 1 3. CASTRO, C. A., HOGE, C. W. (2005): Building psychological resiliency and mitigating the risk of combat and deployment stressors faced by soldiers in: Strategies to Maintain Combat Readiness during Extended Deployments A Human Systems Approach. GREEN, K. T., CALHOUN, P. S., DENNIS, M. F. (2010): Exploration of the resilience construct in posttraumatic strss disorder severity and funcional correlates in military combat veterans who have served since September 11, Journal of Clinical Psychiatry, 71(7), KOBASA, S. C., MADDI, S. R., KAHN, S. (1982): Hardiness and health: A prospective study. Journal of Personality and Social Psychology, 42, LUTHAR, S. S., CICCHETTI, D. (2000): The construct of resilience: Implications for interventions and social policies. Development and Psychopathology, 12, MANSDORF, I. J. (2008): Psychological interventions following terrorist attacks. British medical Bulletin, 88, MASTEN, A. S., WRIGHT, M. O D. (2009): Resilience over lifespan: Developmental perspectives on resistance, recovery, and transformation in: REICH, J. W., ZAUTRA, A. J., HALL, J. S. (Eds): Handbook of adult resilience. Guilford Press, New York. PIETRZAK, R. H. JOHNSON, D. C., GOLDSTEIN, M. B. et al. (2009): Psychological resilience and postdeployment social support protect against traumatic stress and depressive symptoms in soldiers returning from Operations Enduring Freedom and Iraqi Freedom. Depression and Anxiety, 0, 1 7. TAYLOR, M. K., MARKHAM, A. E., REIS, J. P. et al. (2008): Physical fitness influences stress reactions to extreme military training. Military Medicine, 173(8), WALD, J., TAYLOR, S., ASMUNDSON, G. J. G. et al.: Literature Review of Concepts Psychological Resiliency. Defence R&D Canada, Toronto, AARMS 11(1) (2012) 133