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Resilience Informed Service Environments (RISE) ANTHONY SALERNO, PHD JAMES RODRIGUEZ, LCSW, PHD JANUARY 17, 2018
Agenda ‣ Understanding resilience ‣ The neurobiology of resilience ‣ Research on resilience ‣ Building Resilience
Poll Questions ‣ Please tell us who you are? A. Adult Mental Health Providers B. Child/Adolescent MH Providers C. Adult Care Manager D. Child/Adolescent Care Manager E. Substance Use Provider F. Supervisor G. Administrator H. Other
Understanding Resilience THE OTHER SIDE OF THE COIN FROM TRAUMA
Resilience “What’s predictable is preventable.” Robert Anda – Co-Investigator, ACEs Study
History ‣ Early worked focused on the individual – internal strengths that protect people against the negative effects of exposure to toxic stress (e.g. the resilient child – invulnerable, invincible) ‣ Picked up by MH researchers interested in the social determinants of health
Definition ‣ Resilience . A dynamic process reflecting positive adjustment despite significant risk or adversity (Luthar & Zigler, 1991; Garmezy, 1971; Rutter, 1987) ‣ Resilience is… • Context-based/Situational • Domain Specific • Fluctuates over time (fluid)
Resilience is not…? ‣ Competence ‣ Ego resiliency ‣ Grit
When has someone demonstrated resilience? 1. Resiliency - No signs of unhealthy coping response (disorder), despite exposure to Potentially Traumatizing Event (PTE) 2. Recovery – Improving coping response after unhealthy coping in response to PTE. 3. Prosperity – exceeds expectations and doing better than before exposure to PTE. Bonanno and Mancini, 2012
Three Levels of Protection Significant Individual others Strengths (Resources) (Assets) Resilience Systems and Culture (Resources)
Individual characteristics (Assets) ‣ Temperament ‣ Personality traits ‣ Ego resiliency ‣ Competence ‣ Grit ‣ Intelligence ‣ Future orientation ‣ Self-efficacy ‣ Self-esteem
Significant others (Resources) ‣ Family/Parenting • Attachment, • Parental/Caregiver monitoring/supervision, support ‣ Peers ‣ Mentors ‣ Extended family ‣ Social support
Systems support (Resources) ‣ Quality Systems • Schools – • Engaging services • Quality care • Evidence-based practice • Practice-based evidence ‣ Trauma Informed Systems • Safety • Connections • Emotional regulation
Cultural/Context Example ‣ Religion/Spirituality ‣ Ethnic/Racial Identity (Zimmerman et al., 1995) ‣ 5 Categories of Resilience in African American males impacted by poverty (Teti, et al., 2012): 1. Perseverance and refusing to quit despite challenges 2. A commitment to learning/growing from hardship 3. Using reflection and refocusing 4. Creating a positive and supportive environment 5. Drawing on religion/spirituality for strength
Cultural and Community Resilience ‣ First Nations research (Chandler and Lalonde, 1998) • Self government • Land claims • Education • Health services • Cultural facilities • Police and fire departments • Native Language ‣ Increases suicide rates by cumulative bands • 0 = 137.5/100,000 • 6 = 0.0/100,000
Recent Research and the Brain
Sinha et al., 2016
Neurobiology of Resilience Genetics Epigenetics Neurochemicals
Genetics
Epigenetics ‣ Biological mechanisms that will switch genes on and off (What happens around the gene): • Epigenetics control genes • Epigenetics is everywhere • Epigenetics makes us unique • Epigenetics is reversible or plastic
Epigenetic Factors ‣ Exposure to stress ‣ Environmental toxins ‣ Prenatal environment ‣ Diet ‣ Exercise ‣ Developmental (critical) periods ‣ Aging ‣ Virus/infection
Epigenetics and Stress 20 18 16 14 12 10 8 6 4 2 0 0 1 2 3 4-5 6 or more ACE Score
Neurochemicals Others HPA Axis Sympathetic NS CRH Norepinephrine Others Neuropeptide Y Cortisol Dopamine Galanin DHEA Serotonin BDNF ALLO
Basic Research on Resilience ‣ Resilience is a significant predictor of decrease in self- reported fatigue after MTBI (Losoi et al., 2014). ‣ Associated with healthy lifestyles, wellness: • Healthy eating, Exercise, Tobacco use (Wagnild 2015) • Fatigue (Losoi et al., 2014) ‣ Depression, Anxiety (Alena et al., 2014; Wagnild, 2015) ‣ Life satisfaction (Alena et al., 2014) ‣ Religiosity (Mosquito, 2015)
Outcomes of Resilience Based Intervention ‣ Self efficacy and personal functioning in people with severe mental Illness (Maxan et al., 2013) ‣ Decreased adolescent substance use (Hodder, et al., 2011) ‣ PTSD Symptoms and positive emotional health (Kent et al., 2011) ‣ Quality of life and self-concept for people with TIC D/O (Storch et al., 2012) ‣ Psychological, physiological and self-management for African Americans with Type II Diabetes (Steinhardt et al. 2015)
Components of RB Interventions ‣ All provide psycho-education on resilience ‣ Finding positive meaning in the context of disease – reframing disease (Steinhardt et al., 2015) ‣ Emotion regulation and social connectedness (Kent et al., 2011; Maxan et al., 2013). ‣ Storch et al., (2012): typical CBT components with focus on: (1) talking to others about tics, (2) responding to bullies, and (3) not limiting activities because of tics.
Research on Resilience in Children ‣ Therapeutic Foster Care can affect cortisol levels in children and adults (Fisher, 2016) ‣ Social Emotional Learning increases resilience: emotional control, goal setting, perspective taking, problem solving (Durlak et al., 2011) ‣ Treating maternal mental health and improving parenting helps (Goodman and Garber 2017) ‣ Individual characteristics (e.g. self-efficacy) at least one supportive adult relationship help overcome adversity (Werner and Smith, 2005)
What You Can Do
Ways of Building Resilience 1. Build on strengths – whether assets or resources 2. Increase protective factors 3. Reduce exposure to risk 4. Prevention: Primary, Secondary, Tertiary
Implications for the work in behavioral health services The bifocal lens of trauma and resilience • Assessing the severity and chronicity of a person’s risk exposure • Assessing comprehensive resiliency promoting personal and environmental factors
A practical and immediate clinical focus that aligns with building resilience ‣ Maintaining a very comprehensive and continual focus on personal strengths and opportunities to utilize the people, places and things in the person’s life that are reliable and helpful resources. ‣ Assisting clients to identify, engage and develop strong social bonds is critical.
What practitioners need to know ‣ Practitioners and service systems can strengthen a persons resilience (ability to more effectively manage the impact of highly stressful events in the past, present and future) ‣ In contexts of higher exposure to adversity, environmental factors may be more important to resilience than individual factors. ‣ Even maladaptive patterns of coping may be signs of resilience in challenging contexts.
Assessing Risk ‣ Age of initial exposure and duration of adversity ‣ Severity and duration of adverse events and conditions ‣ Number of adverse events experienced ‣ Current challenges and difficulties associated with adversity ‣ Cultural/familial/religious beliefs and values about: ◦ What constitutes an adverse event- what the term trauma means ◦ Why bad things happen to good people ( role of sin, punishment, forgiveness) ◦ How people are expected to deal with highly stressful life events (prayer, penance) ◦ Self disclosure to strangers, keeping or disclosing secrets ◦ Gender related expectations
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