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INDEX:
"Exposure To A Traumatic Event Does Not Automatically Put A Person On A Path To Develop PTSD:
The Importance of Protective Factors To Promote Resiliency."

by
Carl C. Bell, M.D.

ABSTRACT


This article presents a principle that is essential to building a wellness approach that uses public health prevention strategies to prevent Post Traumatic Stress Disorder (PTSD) and other psychiatric disorders that come from exposure to trauma. First, we learn that exposure to a traumatic stressor does not automatically put a person on a path to develop PTSD. Second, scientific documentation is provided that protective factors decrease the risk of being exposed to a traumatic stressor from generating PTSD or other disorders such as depression and suicidal or violent behavior. Finally, a theoretically-sound, evidence-based, common sense model is offered as a "directionally correct" way to ensure that at-risk populations obtain protective factors to prevent a potential traumatic stressor from generating poor health and mental health outcomes.

TRAUMATIC STRESS DOES NOT AUTOMATICALLY CAUSE PTSD



Using the American Psychiatric Association's Diagnostic and Statistical Manual, 3rd Edition - Revised1 criteria, which required that the traumatic stressor be outside the range of normal human experience, researchers in the National Comorbidity Survey found that more than one half of nearly 6,000 subjects, ages 15 - 54, had experienced a traumatic event during their lifetime and most people had experienced more than one 2. Using the same criteria, another research group 3 found that by age 18 years, more than two-fifths of youths in a community sample had been exposed to an event that was severe enough to qualify for a diagnosis of PTSD. Using structured telephone interviews in a national sample of 4,008 adult women, Resnick and colleagues 4 found a lifetime rate of exposure to any type of traumatic event of 69%. Finally, using the DSM-IV criteria Breslau and colleagues 5 examined trauma exposure and the diagnosis of PTSD in a telephoned community sample of 2,181 individuals in the Detroit area and found that the lifetime prevalence of trauma exposure was 89.6%.

As the estimated lifetime prevalence rate of PTSD ranges from 7.8% 2 to 20% 6 (Kessler et al found 8% of males and 20% of females 2 and Breslau et al 6 found 10% of males and 14% of females who were exposed to trauma had a lifetime prevalence rate of PSTD), it should be obvious that exposure to a traumatic stress does not automatically mean a victim of trauma is predisposed to develop PTSD 7. Most people affected by a trauma event will adapt in a period of 3 - 6 months following trauma 8 and only a small proportion will develop long-term psychiatric disorders 9, 10. Thus, as the Institute of Medicine's Report on Reducing Suicide: A National Imperative 11 and Dr. Satcher's Surgeon General's Report on Youth Violence 12 point out, risk factors are not predictive factors. Given this reality it would be helpful to identify people at risk for subsequent psychiatric disorders as prevention and early intervention could prevent the development of such disorders. A major reason for the development of Acute Stress Disorder in DSM - IV 13 was to attempt to identify acute stress reactions that were predictive of developing PTSD 14. Bryant points out 12 studies following motor vehicle accidents, brain injury, crime, typhoons, burns and cancer which reveal that while Acute Stress Disorder (ASD) is highly predictive of PTSD screening for ASD missed many people who will develop PTSD 10.

PROTECTIVE FACTORS
(see Table 2)
Psychological Protective Factors



Bell et al 15 outline protective factors as being largely biological (intellectual ability, personality/temperamental traits, and toughness), psychological (intrapsychic attributes - adaptive mechanisms such as ego resiliency, motivation, humor and hardiness and perceptions of self; emotional attributes - emotional well-being, life satisfaction, optimism, happiness, trust, dispositional optimism, dispositional hope; cognitive attributes - cognitive styles, causal attribution such as an internal locus of control and blame, world view or philosophy of life, and wisdom; spiritual attributes, and attributes of posttraumatic growth), social (interpersonal skills, interpersonal relationships, connectedness, and social support) and environmental (such as positive life events and socioeconomic status). Unfortunately, the study of protective factors and their role in mental health and wellness are poorly organized and originate from many different disciplines that all use different models and language.

Further, science has given minimal attention to protective factors as mental health fields tend to be rooted in deficit models instead of strength models. As Sartorius (former President of the World Psychiatric Association) 16 points out "psychiatry has to do with diseases as well as distress," thus "many psychiatrists will concentrate on the recognition and treatment of mental disorders." He concludes "Their (sic psychiatrists) interest in public health will be negligible and they will make no sustained effort to understand the intricate relationships between psychiatry and overall development nor draw guidelines for their own behaviour on the basis of such an analysis" 17. Accordingly, many psychiatrists live on a DSM - IV planet where your job is to make a diagnosis, offer treatment for the disease you have diagnosed, and submit a bill. Unfortunately, this creates a philosophy replete with deficit models, and many mental health professionals are skilled at filling out a problem list, but have difficulty filling out a strength list for patients they serve. This tendency to focus only on disease and deficits and to "catastrophize" 18 traumatic events has hampered the field's progress in developing strategies to prevent mental illnesses. This criticism is not to say that "deficit models" or models that only focus on disease don't have value, as they do have value. However, using a deficit model to diagnose and treat an observable mental illness should not also preclude developing strategies to keep them from manifesting their full clinical potential. Medicine has a history of developing efficacious and effective prevention strategies for what historically were thought to be mental illnesses, e.g. phenylketonuria (a cause of mental retardation and seizures that occurs due to a genetic lack of an enzyme that metabolizes phenylalanine which is prevented by restricting phenylalanine from the diet) or neurosyphilis (a infection of the brain causing confusion and disorientation prevented by identifying and treating primary syphilis infections). Thus, a public health model of psychiatry, which seeks to prevent mortality and morbidity from current mental disorders, like PTSD and Depression, is being developed in the 21st century.

The Community Mental Health Council's (CMHC) clinical work with traumatized individuals 19 suggests that repeated exposure to minimal or moderate stressors can build resilience 20. Accordingly, we have proposed Table 1 to model CMHC's understanding of how one verses repeated stressors and how mild or severe stressors interact. Studies are coming out that clarify the biological protective factors 21 and how to cultivate them. These results provide the first prospective evidence that moderately stressful early experiences strengthen socioemotional and neuroendocrine resistance to subsequent stressors 22. Studies are also coming out that suggest social fabric, community social control, and cohesion may also be protective of children's mental health and that these protective factors may be amenable to intervention (see rebuilding the village/constructing social fabric below) 21. John McKnight 22 at Northwestern University has done a great deal of advocating for this approach and Felton Earl's 23 group from Harvard has also shown that "collective efficacy" (a measure for social fabric) has been linked with healthier communities. Finally, studies are also starting to come out that focus on both risk and protective factors mediate psychological symptoms of adolescents facing continuing terrorism 24, and other traumas 27, 28.

PROTECTIVE FACTORS CAN PREVENT SUICIDE AND VIOLENCE



Resiliency, coping skills, and other protective factors can reduce the risk of suicide 29- 35. Suicide prevention research shows that social support and connectedness, including close relationships, sometimes represents part of a protective process that increases self-efficacy and thereby reduces suicidal behavior 36. Programs that promote protective factors, e.g., self-efficacy, interpersonal problem solving, self esteem, and social support reduce the risk for suicide 11. Further, by creating a sense of purpose and hope 37 - 39, a number of studies provide some evidence that spiritual protective factors (e.g., religious beliefs and spiritualism) may inoculate individuals against stressful life experiences 40 - 47. Strategies that include encouraging early mental health intervention and offering coordinated services among agencies, normalizing help-seeking behavior, and increasing protective factors, and effective coping skills have also been shown to reduce the risk for suicide 48. Normalizing help seeking behavior is a health behavior change that can be achieved by: 1) "rebuilding the village" with a goal to change social norms by creating social fabric that minimizes stigma, 2) ensuring that when seeking help the most technologically advanced methods will be available to help seekers, 3) ensuring that help seekers will be connected to people who will encourage their seeking help from appropriate sources, 4) teaching help seekers social skills necessary to obtain proper help, 5) giving help seekers a sense of self-esteem so they will not have their self-respect eroded by help-seeking behavior, 6) providing "adult protective shield" to make sure a caring other is protecting the health of the seeker, and 7) minimizing the trauma the health seeker may have experienced in the past (see the Community Psychiatry Protective Factor Field Principles below). Protective factor strategies have also been found useful in preventing risk factors from being predictive factors for violence 49 - 53 and psychiatric illness 54, 55.

PROTECTIVE FACTORS CAN PREVENT MENTAL ILLNESS AND PTSD



Protective factor strategies have also been found useful in preventing risk factors from being predictive factors for depression 54, and unhealthy weight control behavior, suicide attempts, low self-esteem and depression 53. More specifically, protective factors have been found to prevent stress-related disorders such as PTSD. Chemtob et al 55 developed a psychosocial intervention for post disaster trauma symptoms in elementary school children. These researchers did a community-wide, school-based screening of 4,258 public elementary school children in second through sixth grades who were exposed to a hurricane in Kauai. To test the effectiveness of the intervention, the children were randomly assigned to 1 of 3 consecutively treated groups each of which had to wait for their treatment. The researchers chose 248 children with the highest levels of psychological trauma symptoms and gave them four sessions of manual-guided psychotherapy (individual and group) consisting of four sessions: a) Safety and Happiness, b) Loss, Mobilizing Competence, c) Issues of Anger, d) and Ending and Going Forward. The post treatment group reported significant reductions in their self-reported symptoms and this reduction remained in effect when assessed a year later. Treated children had fewer trauma symptoms compared with untreated children. Thus, "school-based community-wide screening followed by psychosocial intervention seems to effectively identify and reduce children's disaster-related trauma symptoms and may facilitate psychological recovery." 55

We are in the 21st century and mental health is shifting paradigms that are essential to the continued well-being of the country. As we gain a better understanding of how genetics and environment interact, we are gathering more and more information how protective factors prevent risk factors from becoming predictive factors. We need an easy to understand, evidence-based model of how to build protective factors around at risk populations to prevent their risk factors from becoming predictive factors that are harbingers of poor health and mental health outcomes.

Community Psychiatry Protective Factor Field Principles



Using a theoretically, ecologically sound model of health behavior change - the Triadic Theory of Influence 56 (developed by incorporating several theoretically sound, well-researched health behavior change theories 57 - 64), Bell et al 65, developed seven community psychiatry protective factor field principles. The seven community psychiatry protective factor field principles are: 1) Rebuilding the village/Constructing social fabric, 2) Providing access to modern medical technology, 3) Improving bonding, attachment, & connectedness dynamics, 4) Improving self-esteem or self-respect (this task is achieved by providing individuals with opportunities to develop a sense of power, a sense of models, a sense of uniqueness and a sense of connectedness), 5) Increasing social skills of target recipients, 6) Reestablishing the adult protective shield and monitoring, and 7) Minimizing the effects of trauma (for a more complete description of these principles see http://www.giftfromwithin.org/html/cultivat.html 66). Bell 66 suggests that using these field principles, resiliency in youth can be cultivated.

Self Efficacy As A Protective Factor Against The Developing PTSD



As noted earlier, a major reason for the development of Acute Stress Disorder (ASD) in DSM - IV 13 was to attempt to identify acute stress reactions that were predictive of developing PTSD 14. While ASD is highly predictive of PTSD, screening for ASD missed many people who will develop PTSD 10. The main difference between the two diagnoses was the presence of dissociation during the traumatic stressor. The original hope was that by developing criteria for an acute stress disorder, it could predict the development of PTSD. At the Sidney E. Frank Conference on Early Psychological Intervention Following Mass Trauma: Present and Future Directions sponsored by New York Medical College, in Valhalla, New York, June 13, 2006, Dr. Richard Bryant, the originator of the Acute Stress Disorder (ASD) diagnosis in DSM - IV 13, reported ten years of research on ASD reveals that dissociation does not predict the risk for the development of PTSD. Thus, Dr. Bryant asserts ASD is not predictive of developing PTSD because many people develop PTSD without displaying ASD in initial month after trauma and many people who do not show initial dissociation can still develop PTSD. Further, he notes studies on children show the same pattern. Ergo, he insists the requirement that dissociation be present is limiting the prediction of PTSD. The overall severity of acute stress is currently best predictor of the development of PTSD, however, it is important to remember that "risk factors are not predictive factors due to protective factors."

Consistent with the notion that "risk factors are not predictive factors due to protective factors" is Dr. Bryant's prospective research that finds cognitive style predicts posttraumatic stress up to three years after trauma exposure 16. Specifically, 24% of posttraumatic stress at follow-up was predicted by pre-trauma catastrophic thinking. It turns out that catastrophic appraisals about the future and one's symptoms predict later PTSD. These findings are in accordance with cognitive models predicting a tendency to "catastrophize" about negative events is a risk factor for developing posttraumatic stress symptoms 16. Dr. Bryant notes participants' maladaptive appraisals about themselves, rather than maladaptive appraisals about the world or self-blame, contributed to posttraumatic stress. Thus, self-oriented appraisals, e.g. having a lack of self-efficacy, contribute to the risk of getting PTSD after a traumatic exposure. At the Sidney E. Frank Conference on Early Psychological Intervention Following Mass Trauma: Present and Future Directions, Dr. Bryant also reported that research is showing 33% of the risk for the development of PTSD is also dependent on the individual's lack of self-efficacy. For example, emergency personnel who experience stress reactions tend to be characterized by low self-efficacy 67. Thus, the suggestion is that activities that develop a sense of self-efficacy would be protective in the prevention of PTSD is well advised.

Putting this protective strategy in the language of the above Community Psychiatry Protective Factor Field Principles, we would call it "Improving self-esteem" as self-esteem is achieved by providing individuals with opportunities to develop a sense of power, a sense of models, a sense of uniqueness and a sense of connectedness 68. Based on the above research about "catastophizing" traumatic exposure outcomes and the importance of self-efficacy, individuals exposed to trauma need special emphasis on being helped to develop a sense of power. Individuals with a sense of power have competence to do what they must do to turn their sense of traumatic helplessness into learned helpfulness 66, 69. They also have the resources required to illustrate their competence, and have the opportunity to use their competence to influence important circumstances of their lives. Folk with a high sense of power believe they can do what they set out to do, and they feel confident they can handle, "by hook or by crook," the challenges ahead of them. A sense of power lets you feel you can get what you need to do what you have to do. Thus, self-efficacy or a sense of power allows a person to feel, for the most part, they are in charge of their own lives (after all everyone has to depend on others some of the time). People with a sense of power are not afraid, comfortable with responsibilities, and are not easily bullied.

We have evidence from Chemtob et al's research 55 that a sense of power and a sense of models can be cultivated in children and that these skills can protect them from traumatic exposure. So, why not flip the script? Why not be more strategic using the understanding that "risk factors are not predictive due to protective factors" and target people in risky contexts and who have already been traumatized, e.g. children who are in protective services, with strategies that will cultivate their resilience? Why not give people, especially children, resources to meet important objectives in their lives? Why not give people, especially children multiple ways to exercise a sense of power? Why not give people, especially children, to an opportunity to develop a sense of power and self-efficacy? The more skills people have and the more adept they are at using them, the more confident they can be in meeting new circumstances. We know that one of the strategies to minimize trauma is to turn traumatic helplessness into learned helpfulness 66, 69. We have models 70 and we are developing science to show, with good plans of action 71, the models work 72. Those of us who have the political will need to get busy and surround risky populations with protective factors - in the long run the nation will be stronger.

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Table One

 
MILD STRESS
SEVERE TRAUMATIC STRESS
Single
Nothing
PTSD
Multiple and Repeated
Resistance
Personality and Behavioral Problems


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Table Two
Psychological Protective Factors

Intrapsychic Protective Factors Emotional Protective Factors Cognitive Protective Factors Posttraumatic Growth Protective Factors Spiritual Protective Factors
Ego adaptive mechanisms (altruism, sublimation, suppression, humor, and anticipation) (Vaillant, 2000). Eudaimonia (Ryan & Frederick, 1997; Ryan & Deci, 2000). Explanatory Style (Abramson et al, 1978; Peterson, 2000). Trauma leading to religious transformation (Pargament,
1996).
Religious beliefs and
practices
(Koenig et al, 1999; Pargament et al, 1998; Park & Cohen, 1993; Stack and Lester, 1991).
Hardiness (Kobasa et al, 1982; Florian et al, 1995). Optimism (Peterson, 2000; Tedeschi & Calhoun, 1995; Thompson, 1985; Tennen & Affleck, 1998; Carver & Scheier, 1990; Seligman, 1991; Scheier & Carver, 1992; Gilham et al., 1995). Causal Attribution (Bulman & Wortman, 1977; Sullivan, 1956; Vaillant & Drake, 1985; Downey et al, 1990; Tennen & Affleck, 1990; Abrahamson et al, 1989;Janoff-Bulman, 1979; Tedeschi, 1999; Kottler, 1994)
Changes in self-perception
(Tedeschi, 1999; Silver et al, 1983; Tedeschi & Calhoun,1996).
Spirituality as a reason for living (Maris, 1981; Ellis & Smith, 1991).
Motivation (Ryan & Deci, 2000) Hope (hopefulness, learned industriousness, learned mastery, learned relevance, and leaned resourcefulness) (Zimmerman, 1990; Eisenberger, 1992; Volpicelli et al., 1983; Mackintosh, 1975; Rosenbaum & Jafee, 1983; Snyder, 1994). Internal locus of control (Luthar, 1991; Seligman, 1975; Murphy & Moriarty, 1976; Luthar, 1991; Werner, 1989). Changes in interpersonal relationships (Park et al, 1996; Tedeschi et al, 1988).
Religion as inoculation against depression and substance abuse
(Kendler et al, 1997;
Koenig et al, 1997;
Kennedy et al, 1996;
Koenig et al, 1998).
Perception of self (Tedeschi & Calhoun, 1996; Thomas et al., 1991; Gilbar & Dagan, 1995; Lund et al., 1993; Meichenbaum, 1985; Aldwin et al., 1994; Phifer & Norris, 1989; Wallerstein, 1986; Elder & C, 1989; Sledge et al., 1980; Collins et al., 1990; Curbow et al., 1993). Happiness (Harvey et al., 1987; McGloshen & O?Bryant, 1988; Siegel & Kuykendall, 1990; Ellison, 1991; McIntosh et al. 1993). Cognitive styles and processing (Tedeschi & Calhoun, 1995; Finke & Bettle, 1996; Strickland, 1989; Tedeschi, 1999; Silver et al, 1983; Creamer et al, 1992; Joseph et al, 1996; Nolen-Hoeksema et al, 1997). Changed philosophy of life (Silver et al, 1983; Affleck et al, 1985; Janoff-Bulman, 1992; Taylor & Brown, 1988). Religious activity decreasing suicide risk factors (Gorsuch, 1995; Koenig, 1994; Braam et al, 1997)
Trust (Sharma & Husain, 1992; Smith et al, 1988; Antonucci et al, 1997; Berkman, 1995; Blazer, 1982). Change in Philosophy of life or world view (Affleck et al, 1985; Taylor et al, 1984; Joseph et al, 1993; Thompson, 1985; Janoff-Bulman, 1992; Taylor & Brown, 1988).
Life Satisfaction Koivumaa-Honkanen, 2001). Wisdom (Tedeschi, 1999; Collins et al, 1990; Elder & Clipp, 1989; Lehman et al, 1993).


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Dr. Bell is President/C.E.O. of the Community Mental Health Council, Inc. and Foundation (www.thecouncil-online.org) in Chicago, Illinois. He is also a Professor of Psychiatry and Public Health at the University of Illinois at Chicago where he is also the Director of Public and Community. Dr. Bell is also the Principal Investigator of an NIMH R-01 grant - Using CHAMP to Prevent Youth HIV Risk in a South African Township. Dr. Bell is also the creator of the resiliency cultivating Chi Kung DVD - "Eight Pieces of Brocade" and his latest book is The Sanity of Survival: Reflections on Community Mental Health, published by Third World Press - both can be obtained at CMHC's website www.thecouncil-online.org. Dr. Bell is also a regular contributor to Clinical Psychiatry News and his monthly columns on "Prevention in Action" can be found at http://www.eclinicalpsychiatrynews.com/home


"Dr. Carl Bell painted this mural featuring his all time favorite superhero--Spider-Man. A special 1984 production between Marvel Comics & Prevent Child Abuse America created a Spider-Man comic book focusing on child abuse and it was revealed that Spider-Man had been abused. Dr. Bell believes Spider-Man is a poster superhero for risk factors are not predictive factors due to protective factors."


Other Articles:

Cultivating Resiliency in Youth
Cultivating Resiliency
Traumatic Stress and Children

Videos in which Dr. Bell appears:

PTSD In Children: Move In the Rhythm of the Child
When Helping Hurts: Sustaining Trauma Workers

 


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