Targeting Early Interventions for High-Risk Occupations

Transcription

1 Targeting Early Interventions for High-Risk Occupations Amy B. Adler, Ph.D. Center for Military Psychiatry and Neuroscience Walter Reed Army Institute of Research Australian Psychological Society Annual Conference Melbourne September 2016 Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the U.S. Army Medical Command or the Department of Defense

2 PTSD Traumatic Event Reaction Symptoms Impairment Victim Model of PTSD Unexpected Discrete Unwanted Freezing Intense fear Shutting down Maladaptive Spread across different dimensions Social Work Family Source: Castro & Adler (2011) Re-Conceptualizing PTSD in Deployment Psychology 2

3 Occupational Health Model of PTSD Symptoms Traumatic Event Reaction Symptoms Impairment Adaptive Maladaptive Expected Consistent with identity Multiple Events Training Kicks In Autopilot Grief Second guessing Anger Risk-Taking Moral injury Functioning with symptoms Unmasked posttransition Training and Preparation Context Military Culture & Structure Source: Adapted from Castro & Adler (2011) Re-Conceptualizing PTSD in Deployment Psychology 3

4 Typical Training Programs Universal One-size-fits-all Teach resilience skills Some evidence of efficacy Small effect sizes ( ) 4

5 Examples Post-deployment Battlemind (Adler et al., 2009; Castro et al., 2012; Mulligan et al., 2010) Pre-deployment mindfulness (Jha et al., 2008; Jha et al., 2015) Social resilience skills (Cacioppo et al., 2015) Performance skills at Basic Training (Adler et al., 2015) 5

6 Performance Skills: Example Mental Skills Foundation Attention Control Building Confidence Energy Management Goal Setting Imagery 6

7 Study Design Platoons randomly assigned to 8 hrs of Performance Psychology (ACEP) 8 hrs of Military History Randomization by Platoon 23 platoons assigned to ACEP (1,174 Soldiers) 24 platoons assigned to Military History (1,222 Soldiers) Source: Adler et al. (2015), J of Applied Psych 7

8 Training Evaluation *p<.05 I am satisfied with the Mental Fitness Training The Mental Fitness Training was interesting The Mental Fitness Training was relevant I learned a lot from the Mental Fitness Training The Mental Fitness training helped bring the platoon closer together The Mental Fitness training helped me during Basic Training The Mental Fitness training provided me with important information about the military* The Mental Fitness training will help me in the future The instructors for the Mental Fitness training understand what it is like to be in the military* Overall, the Drill Sergeants were supportive of the Mental Fitness training* The Mental Fitness training fit well with what the Drill Sergeant taught us* Source: Adler et al. (2015), J of Applied Psych ACEP Military History

9 Results (1 of 2) Results (1 of 2) Performance Psychology resulted in better Performance Basic Rifle Marksmanship Grouping Army Physical Fitness Test (APFT) diagnostic scores Slide to Victory Wall Hanger Cognitive skills Key covariates Sport history Gender Source: Adler et al. (2015), J of Applied Psych 9

10 No significant difference Victory Tower Confidence Climb Pre-NBC Chamber Anxiety Exploratory comparisons: Combat Life Saver Test Scores Behavioral Health Symptoms Graduation Status Results (2 of 2) Source: Adler et al. (2015), J of Applied Psych 10

11 Targeting Early Interventions and Boosting Effectiveness Leaders Individual 11

12 Leadership Leadership correlated with better mental health Civilian contexts (Kelloway & Barling, 2010) Peacekeeping (Bliese & Halverson, 1998) Combat (Jones et al., 2012) General leadership skills Relevant in many situations (Bliese & Britt, 2001) Span transactional & transformational behaviors (Bass, 1990) Limitations Relatively blunt instrument for addressing specific challenges Harder to teach (Barker, 1997; Gunia et al., 2015) 12

13 WRAIR General Leadership WRAIR Items Exhibits clear thinking and reasonable action under stress Tells soldiers when they have done a good job Tries to look good to higher-ups by assigning extra missions or details to soldiers Embarrasses soldiers in front of others Source: WRAIR items: Bliese & Britt, 2001; Castro & McGurk,

14 Domain-Specific Leadership Previous Research Safety-specific leadership 1 Health-specific leadership 2 Family-supportive leadership 3 Domain-Specific Leadership Mental Health & Well- Being Measures Behaviors that can be observed Referent varies depending on context Sources: 1 Barling, Loughlin, & Kelloway (2002); 2 Gurt, Schwennen, & Elke (2011); 3 Hammer et al. (2011) 14

15 Behavioral Health Leadership Domains Sleep leadership Combat Operational Stress Control (COSC) leadership Health-promoting leadership Resilience training leadership 15

16 Sleep Leadership 16

17 % of Population Sleep Hours 70% 60% Reported Hours of Sleep Among Soldiers and Civilians 61% % 40% 30% 20% 10% 0% 31% 25% 21% 10% 8% 4% Soldiers Civilians Hours of Sleep Per Night 41% 17

18 Sleep: Background High-risk occupations and sleep problems 20-30% (Seelig et al., 2010) % (J-MHAT-7) Sleep problems linked to Performance problems (Wesensten et al., 2006) Mistakes (LoPresti et al., in press; MHAT-9) Affect dysregulation (van der Helm & Walker, 2012) Mental health problems (Seelig et al., 2010; Wright et al., 2011) Moral decision-making (Barnes et al., 2012) Health risk behaviors (Luxton et al., 2011) 18

19 Sleep Leadership Immediate Leaders Often/Always Consider sleep as an important planning factor 34.7% Encourage Service Members to get extra sleep before missions that require long hours 34.6% Encourage Service Members to try to go to sleep on time 29.8% Encourages Service Members to get adequate sleep 25.6% Work to ensure Service Members have a good sleep environment (quiet, dark, not too hot or cold) 23.6% Support the appropriate use of prescription sleep medication 16.5% Discourage the use of caffeine or nicotine within several hours before trying to go to sleep Encourage Soldiers to reduce sleep distractions by using earplugs, eye-masks or other strategies 14.1% 10.8% Encourage Service Members to nap when possible* 8.5% Asks Service Members about their sleeping habits 5.8% 19

20 Sleep Leadership: Peacekeeping 623 US Soldiers deployed to Horn of Africa (alpha =.90) Rank General Leadership Sleep Leadership Sleep Quality Morale Cohesion Source: Gunia, Sipos, LoPresti & Adler (2015), Mil Psych 20

21 Sleep Leadership: Combat 619 US Soldiers deployed to Afghanistan (alpha =.93) Rank General Leadership Sleep Leadership Sleep Quantity Morale Cohesion Source: Gunia, Sipos, LoPresti & Adler (2015), Mil Psych 21

22 Behavioral Health Leadership Domains Sleep leadership Combat Operational Stress Control (COSC) leadership Health-promoting leadership Resilience training leadership 22

23 COSC Leadership Combat Operational Stress Control (COSC) Leadership COSC manual identifies a set of leader behaviors designed to reduce or ameliorate combat stress reactions of subordinates 23

24 COSC Leadership Does not judge soldiers who seek behavioral health help Encourages soldiers to seek help for stress-related problems Demonstrates concern for how families are dealing with stress Intervenes when a soldier displays stress reactions such as anxiety, depression or other behavioral health problem Encourages soldiers to express emotions following losses and setbacks during deployment Reminds soldiers after intense experiences that we are here to serve with honor, mission, greater purpose Source: Adler, Saboe, Anderson, Sipos & Thomas (2014) Current Psychiatry Reports Often/Always Platoon Sergeant Platoon Leader 53.4% 50.8% 47.7% 47.2% 48.0% 46.8% 45.2% 43.8% 42.3% 42.3% 49.4% 49.4% 24

25 COSC Leadership & Mental Health 2,072 US Soldiers in Afghanistan (alpha = ) PCL Rank & Combat Experiences General Leadership (NCO & PL) COSC- Specific Leadership Anxiety Depression Comfort talking to BH Provider Source: Adler, Saboe, Anderson, Sipos & Thomas (2014) Curr Psychiatry Rep 25

26 Behavioral Health Leadership Domains Sleep leadership Combat Operational Stress Control (COSC) leadership Health-promoting leadership Resilience training leadership 26

27 Health-Promoting Leadership Thinking about your current team/unit, rate how often does your leadership Often/Always Emphasize maintaining professional standards 74% Emphasize taking care of yourself physically 63% Emphasize the importance of the medical mission 61% Emphasize taking care of yourself mentally 52% Give you positive feedback about your accomplishments 44% Emphasize maintaining compassion 41% Remind you to take a break/recharge 41% Encourage you to get enough sleep 37% Give you specific guidance on how to improve 35% Reduce tension in the team/unit when emotions run high 34% Source: Adler, Adrian, Hemphill, Scaro, Sipos, & Thomas (in press), Mil Med 27

28 Health-Promoting Leadership & Burnout 344 US medical staff deployed to Afghanistan (alpha =.95) Rank PTSD Symptoms Professional Stresssors General Leadership Health- Promoting Leadership Burnout (Emotional Exhaustion + Depersonalization) Source: Adler, Adrian, Hemphill, Scaro, Sipos, & Thomas (in press) 28

29 Operation United Assistance 498 Soldiers in Controlled Monitoring Areas (CMAs) 21-Day CMA (quarantine) 4 cohorts (MAR-MAY 2015) Following 6-month deployment to Liberia in response to Ebola outbreak 29

30 CMA Version of Health-Promoting Leadership Emphasize taking care of yourself physically Emphasize maintaining professional standards Emphasize taking care of yourself mentally Lead by example by using health monitoring measures themselves Place command emphasis on importance of health monitoring Emphasize the importance of the humanitarian mission 65.4% 65.0% 62.5% 58.6% * 74.1% 73.9% Encourage you to get enough sleep Give you specific guidance on how to improve Source: Adler, Kim, Thomas & Sipos (in prep) 58.4% 53.0% 0% 20% 40% 60% 80% 100% % Often or Always 30

31 Health-Promoting Leadership in CMA Rank General Leadership Health- Promoting Leadership Depression Anxiety Attitudes toward CMA Source: Adler, Kim, Thomas & Sipos (in prep) 31

32 Behavioral Health Leadership Domains Sleep leadership Combat Operational Stress Control (COSC) leadership Health-promoting leadership Resilience training leadership 32

33 Resilience Training Leadership Immediate Leaders Moderately/Quite a Bit/A lot Attend resilience training activities 64% Emphasize the importance of resilience training skills 62% Refer to skills when talking with soldiers 56% Encourage soldiers to use the skills 66% Source: Sims & Adler (in press) Parameters 33

34 Resilience Training Leadership & Unit Climate 2,181 Soldiers deployed to Afghanistan Rank & Combat Experiences General Leadership Resilience Training Leadership Perception of Training Unit Climate Source: Sims & Adler (in press) Parameters 34

35 Behavioral Health: Implications Over reliance of training as The Answer Integrate into the culture Train indirectly Work with Stakeholders 35

36 Implementation Integrated into Master Resilience Training Medical course Health Promoting Leadership Sleep Leadership General Leadership Direct Training Operational Stress Control Leadership Train Embedded Providers in Conversation Starters Integrate in precommand course Resilience Training Leadership Emotion Regulation Family Supportive Leadership Train Embedded Providers in Conversation Starters 36

37 Sleep Leadership Training 37

38 Targeting Early Interventions and Boosting Effectiveness Leaders Individual 38

39 Stage Description Instructional Strategy Precontemplation Contemplation Preparation Action Maintenance No intention for change Starting to look at pros and cons Intends to act/ committed to change Actively working to change Has changed, prevent relapse Source: Mander et al. (2012); Prochaska & DiClemente (1983) Stages of Change Engage with information about need for change Provide personalized information about risks if no change, emphasize multiple benefits of change Emphasize what life would be like if changed, learn from people who have changed, Encourage them to work at reducing the cons Encourage seeking support, telling people about plan and thinking about how change would feel. Help create and implement specific action plan; set realistic goals Provide action-oriented planning to strengthen commitment and fight urge to slip back Provide support, positively address slips/relapses Employ reminder systems 39

40 Measure Pre-contemplation Contemplation / Preparation Action Maintenance I don t need resilience training (RC). Resilience training is a waste of time (RC). It is not worth my time talking about resilience training because everyone has problems (RC). I hope resilience training will help me understand myself better. I wish I had more ideas about how to improve my resilience. Resilience training might be useful to me. I am interested in resilience training so I can maintain my resilience. I have been practicing resilience skills. At times, I struggle with my resilience but I m working on it. I am working hard to improve my resilience. I am interested in increasing my resilience. I would like to prevent a decline in my resilience. 40

41 Categorization Alpha = % clustered tightly around the median (scale midpoint) 30.6% below the median 31.8% above the median Source: Sowden & Adler (2016) 41

42 Readiness Stage: Attitudes Is resiliency training having a positive impact on your unit? 80% *** 70% 60% 50% 40% yes no unsure 30% 20% 10% 0% Pre-contemplative Contemplative Preparation Action Source: Sowden & Adler (2016) 2 (4, 2701) = 42.31, p <.001, d =.52 (OR = 2.61) 42

43 Readiness Stage: Utility Composite measure: How much are you using the skills you ve learned in resilience training? 4 *** Pre-contemplation Contemplation Action Pre-contemplative Preparation Action Source: Sowden & Adler (2016) F (2, 1169) = 174, p <.001, d =

44 Readiness Stage: Health *** *** *** * *** Z- scores PTSD Symptoms Depression Symptoms Anxiety Symptoms Functional Impairment Anger and Aggression pre-contempation preparation action Source: Sowden & Adler (2016) 44

45 Readiness Stage: Implications Potential to match readiness stage with training material Move away from a one-size-fits-all approach Future research Identify mechanisms of change Disentangle stages vs. overall readiness Test group-level vs. individual-level construct Develop quick assessment tools to target training 45

46 Summary/Future Directions Training studies find small effect sizes Methods to enhance training Behavioral Health Leadership Matching Soldiers to the right training Future work Behavioral nudging Feedback on normative behavior Bystander interventions Small-team culture 46

47 Thank You! Amy Adler, PhD Clinical Research Psychologist and Senior Consultant Center for Military Psychiatry and Neuroscience 47