1. Encouraging Natural Resilience for Child & Adolescent Mental Health
Presented April 23, 2003 at the Community Assessment and Intervention Center (CAIC)
Katherine Best, MSW, MPH

2. Objectives Defining Resiliency The Problems in Research
The Importance of Contextualizing our Understanding
Identify Predisposing Conditions that Contribute to Poor Outcomes
The Difference Between Protective Factors and Protective Processes

3. More Objectives Impacting External Protective Factors
Identify Resiliencies in those Who Have Overcome Adversities
Discuss Strategies that Foster Resiliency
Discuss the Ways Providers Perceive Resiliency

4. Understanding Resilience
Resilience is defined by Merriam-Webster Dictionary:
(1) “As the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress”;
(2) “An ability to recover from or adjust easily to misfortune or change” (1993).

5. Lack of Consensus in Resilience Research
A type of “phenomenon characterized by good outcomes in spite of serious threats to adaptation or development” (Ann Masten, 2001).
Ability to cope or recover equilibrium in the presence of stress and trauma utilizing protective factors that mediate the relationship between risk and competency (Smith & Carlson, 1997).

6. More Definitions
Resilience has come to mean both a set of behaviors (within cultural norms) and internal capacities (Gilgun, 1999).
Resiliencies are clusters of strength developed as one struggles against the effects of hardship… It is persistence in the face of adversity…It is a paradox of vulnerability and strength in the same person at the same time (Wolin, 2001).

7. More Terms Risk Factors Vulnerabilities Resilience Protective Factors
Definitional ambiguity for related terms :
Risk Factors
Vulnerabilities
Resilience
Protective Factors
Protective Processes
Has resulted in inconsistent sets of variables being used to study the trajectories of children growing up under adversity.
(Ungar, Boothroyd, Duque, & Le Blanc, 2003)

8. Tipping Point for Resilience Research
A PsychInfo Search demonstrates a new shift from medicalization to interest in resilience:
article
1985 – 3 articles
1990 – 47 articles
1995 – 67 articles
2000 – 141 articles
2002 – 126 articles

9. Why are there Problems in the Field
Foucault spoke of mental health, deviance, and disorder as things that those in power, “experts”, defined for others. To illustrate some historical trends and errors within mental illness:
Mental illness was punishment by God for disobedience
The insane needed to be chained or caged in Asylums to protect the public (we still criminalize our mentally ill)
Stories by female patients of sexual abuse were instead perceived by Freud as fantasies
The term sexual abuse only came into vogue in the early 1980’s before then survivors lacked a language to define abuse
Ever changing diagnostic categories
(Ungar, 2002)

10. Challenges in the Field
The way in which we define resilient or good outcomes not only changes from one decade to the next, it is arbitrary and often does not take into account social and cultural differences.
In Hong Kong: “obedience” versus “autonomy”
In Palestine: being a “freedom fighter” is good
In Halifax: escaping abuse by becoming a “street youth” is being a survivor
In USA: “running away” from abusive and multiple foster placements may be a sign of resilience
(Ungar, Boothroyd, Duque, & Le Blanc, 2003)

11. Survivors Pride : From a teen who remained silent for many hours each day…
“I’m boiling with rage, and yet I mustn't show it. I’d like to stamp my feet, scream, give mom a good shaking, cry, and I don’t know what else, because of the words, mocking looks, and accusations … I can’t let them see the wounds …they have caused, I couldn’t bear their sympathy…it would only make me scream all the more. If I talk everyone thinks I’m showing off, when I’m silent they think I’m ridiculous; rude if I answer, sly if I get a good idea, lazy if I’m tired, selfish if I eat a mouthful more than I should, stupid, cowardly, crafty…”

12. Adolescent Wellness: In the eye of the beholder
From The Promotion of Wellness in Children and Adolescents
(Cicchetti, Rappaport, Sandler & Weissberg, 2000)
“The residual of truncated life options in relation to oppression and poverty, limited resources, and the accelerated life course resulting from a foreshortened life expectancy intersect to shape the time perspectives, coping strategies, and locally defined successful adaptations. Physical survival, becomes a bottom line indicator of success.” (Pg. 379)

13. Competing Conceptions of Competence and Wellness
Differences in perceptions exist between and within:
Mainstream and dominant cultural codes
Inner-City Youth
Latinos
Asians
Blacks
Bicultural Youth
Haves and have nots
It is proposed that there are unnamed protective processes found in the lived experiences of others within contexts. This can only be found by giving power to minority voices through unique definitions of positive outcomes.

14. Methodological Issues with Resilience
Distinguishing between resilience and factors promoting or reducing resilience
Choosing sources of measures
Selecting scoring criteria to indicate resilience
Determine when to measure resilience
Determine adequate comparison group
Examine the stability of resilience over time

15. Risk and Protective Model
Theoretical Models
Outcomes Orientation
Risk and Protective Model
Main Effect Model
Additive Model
Postulates that protective factors increase the likelihood of a positive outcome (e.g. parenting qualities, intellectual functioning, SES, positive self perceptions) (Smith & Carlson, 1997).

16. Buffering Effect Model
Theoretical Models
Process Orientation
The Challenge Model
Interaction Model
Buffering Effect Model
Postulates that resilience is a constructive approach to hardship which is developed through compensatory experiences, analogous to building resistance to infection through immunization (Caprara & Rutter, 1995).

17. Protective Factors: Variables that modify a person’s response to risk:
Individual factors – average IQ, and the ability to illicit positive responses from others
Family – attachment with caregivers that promote trust and autonomy
Community factors – support systems with youth groups, church, or school

18. Protective Processes:
Successful engagement with risk that involves a change from risk to adaptation such as processes :
Reduce impact of risk exposure
Reduce or stop chain of events to minimize long term effects of exposure to stressors
Development of self-esteem and competence through adaptation
Turning point: where new opportunities are opened up

19. Predisposing Conditions & Negative Mediating Variables
Trauma/Abuse/Neglect/ or Witness
Consequences of Trauma
Fear of being bad, unwanted, unworthy,
Fear condition will occur again
Negative Mediators
Few opportunities to understand the meaning of exposure to trauma or abuse
Exposure to anti-social models of coping
Exposure to negative ways of attaining sense that self is good (e.g. drinking, rage, denigration of opposite sex, or the “other”)
Committing Acts of Violence
Poor coping behaviors

20. Predisposing Conditions & Positive Mediating Variables
Trauma/Abuse/Neglect/ or Witness
Consequences of Trauma
Fear of being bad, unwanted, unworthy,
Fear condition will occur again
Positive Mediators
Opportunities to understand the meaning of exposure to trauma or abuse
Exposure to pro-social models of coping
Exposure to positive ways of attaining sense that self is good
Not Committing Acts of Violence
Development of pro-social coping
(Jane Gilgun, 2002)

21. Designing Strategies for Prevention & Intervention
“Kids can walk around trouble if there is some place to walk to and someone to walk with.”
(Tito a Gang Member, quoted by McLaughlin, Irbv, & Langman, 1993)
Key Elements
Reduce Risk or Threat
Increase Resources
Focus on Process

22. Family Risk & Protective Factors From the Florida Alcohol & Drug Abuse Association
Family Risk Factors
Genetics
Family Conflict
Condoning Drug or Alcohol Use
Poor Monitoring
Inconsistent Discipline
Over/Under Involvement with Family
Family Protective Factors
Family Bonding
Good Parenting
Shared Responsibility
Clear Expectations
Quality Time

23. Individual Risk Factors
In the adult literature…
Cocaine/opiate users 10 Xs more likely to meet PTSD criteria.
Other drug use 4 Xs more likely to meet PTSD criteria (Cottler, et al., 1992).
Parent substance abuse directly predicts later substance abuse in adulthood (Stein, Leslie, Nyamathi, 2002).
Subjects experiencing 4 or more childhood adverse events were more likely to consider themselves alcoholics, and had used drugs (Felitti, et al., 2001).

24. Individual Risk Factors
In the adolescent literature…
One study found 19% of chemically dependent youth met criteria for PTSD (Deykin & Buka, 1997).
Females are 6Xs more likely to develop PTSD symptoms than males following exposure to violence (Fitzpatrick & Boldizar, 1993; Schwab-Stone et al., 1995).
A recent study found females with substance abuse issues scored higher for traumatic stress (Stevens, Murphy, McKnight, 2003).

25. A Model for Impacting External Protective Factors
Strong Connections to Individuals, Schools, or Community that have a Positive Influence
Competencies in Academics, Social Skills, Problem-Solving, and/or Recreation and Arts
Responsibility for the Well-being of Others/Giving or Helping Others (volunteerism or social interest)
High Expectations for Behavior and Performance
Hope and Optimism about the Future
(Best, Friedman, Jetson & Gaunt, 2003)

26. Changing Paradigms The Damage Model
Focuses on injuries of the past rather than living well in the present
Lures survivors into the Victim Trap
Instills feeling of being a walking time bomb
The Challenge Model
Builds on strengths
Breaks the chain by improving deliberately on their parent’s lifestyles
Seeks alternative mirrors
Establishes new routines and family rituals
(Wolin & Wolin, 1993)

27. How have you been resilient?
Think of a hardship, trauma, or loss you have experienced in the past…
Describe what you did to help yourself through the situation…

28. REFRAMING THE PAST Grief - loss of childhood
Comfort – secret is out no longer alone
Anger – due to suffering
Pride – completing something parent’s couldn’t have done
Loss – of love and acceptance
Courage – seeing the way your life has already improved
Fear – you will fall into your
parent’s patterns
Validation – someone acknowledged the wrongs
Shame – because of origins
Clarity – you know what needs to change to re-build your life

29. 7 Resiliencies: How we Overcome Adversities (Sybil Wolin, 2001)
Insight: Asking Tough Questions
Independence: Being your Own Person
Relationships: Connecting to People
Initiative: Taking Charge of Problems
Creativity: Using Imagination
Humor: Finding What’s Funny
Morality: Doing the Right Thing

30. Insight Damage Model: Intellectualization Challenge Model:
Sensing (early childhood) -
Detected patterns of behavior that spelled trouble
Knowing (adolescence) –
Labeled your family as troubled made effort to gather more information
Understanding (adulthood) –
Do you watch yourself in action accepting the role you play in your own difficulties

31. Insight: Forewarned is Forearmed
“I don’t know what the word ‘Mommy’ means…the hardcore truth is, my mother didn’t take care of us. She couldn’t cope with herself, let alone three daughters… I had to teach myself not to settle for less. My family hated that I spoke out…I want to break the cycle.”

32. Independence Damage Model: Fear of Intimacy Challenge Model:
Straying (early childhood) –
Distancing from painful family scenes to avoid being a messenger, whipping post, sexual object or confidant
Disengage (adolescence) –
Stepping out of the ‘parental orbit’ and becoming the commander of their own future
Separating (adulthood) –
Survivors stop looking to their families for satisfaction and aim to break the chain for future generations

33. Independence: A Delicate Negotiation
“I kept myself going by plotting my getaway and putting my plan in motion. I decided to leave after high school and work to support myself. When I was 14 I took my first job… I picked the brain of every adult I could…I was going to endure and leave the awful life with my family. I was going to be something they never dreamed of…”

34. Relationships Damage Model: Co-Dependency Challenge Model:
Connecting (early childhood) –
Attracting the attention of available adults
Recruiting (adolescence) –
Enlisting a friend, teacher, neighbor, or minister as parent substitute
Attaching (adulthood) –
The ability to form and keep mutually gratifying relationships with regard for the well-being of others as well as oneself

35. Relationships: The Search for Love
“I felt wonderful whenever it was time to cook because it also meant doing something that my parents had never encouraged in my thirteen years of living with them: bonding with other girls…” “At the group home… I met people who really cared about me, who accepted me without judgment, who gave me the love and attention I needed.”

36. Initiative Damage Model: Overachievement Challenge Model:
Exploring (early childhood) –
Conducting trial & error experiments, achieve a sense of effectiveness
Working (adolescence) –
Focused, organized, goal directed over a wide range of activities
Generating (adulthood) –
A lifelong attraction to generating projects that stretch the self and promote growth

37. Initiative: The Pleasure in Problems
At 7 he struggled to free himself from his mother’s psychotic delusions, at 15 he “broke” and was hospitalized… years later one of the most prominent theorists on rational thinking wrote –
“One of the direct consequences of my mother’s poor mental health was that I started to forego playing for serious work very early in childhood in order to take refuge in a private and non-fictitious world. I have always detested any departure from reality…” Jean Piaget

38. Creativity Damage Model: Useless Fantasy Challenge Model:
Playing (early childhood) -
Spending much of the time in imaginative play
Shaping (adolescence) –
Using art to express feelings in an undisguised form
Composing (adulthood) –
Artistic hobby or profession: creating compensates for pain of the past

39. Creativity: Building a New World on the Ruins of the Old
“ I came from ugliness. I’m horrified by ugliness. I feel compelled to make beauty…”“I chose writing to impose order on the chaos that was life with Mother…the brain is cunning in looking for ways to live when you’re ready to give up. On paper, I get to choose what happens, even if I have to wrestle every word to the ground with brute force, when I win the victory is sweeter than any other I can imagine.”

40. Humor Damage Model: Compulsive Clowning Challenge Model:
Playing (early childhood) –
Spending much of the time role playing to restore confidence
Shaping (adolescence) –
Using humor to transform family situation into something better
Laughing (adulthood) –
Seeing the absurd and awful and using humor to diffuse tension

41. Humor:Power to Reduce Something into Nothing
“I was born an accident, raised a burden, my mother was a prostitute, she got sloppy and conceived one night and so she had to take a ‘sabbatical’, after dropping me off on my widower grandfather who wanted me as much as an advanced-stage cancer I decided to get serious about being funny. “During manic episodes, my mother ran around the street in her nightgown. I lived in terror…when she was finally hospitalized I was relieved. I thought mental hospitals were places set up to give families a vacation…”

42. Morality Damage Model: Over Responsible Challenge Model:
Judging (early childhood) –
They know the rights and wrongs of their caregivers
Valuing (adolescence) –
Compassion, justice, loyalty, and fair play are critical, standing up against hypocrisy and cruelty
Serving (adulthood) –
Living a meaningful life, willing to risk self for ‘doing the right thing’

43. Morality:Holiness in an Unholy World
“The worst was the way my father would go after the younger kids who couldn’t defend themselves. He was a bully- a coward at heart. I felt I had to protect the little ones. It was a moral obligation, something any decent person would do.”
“Coming from the kind of home life I had, you never stop remembering that things could have been different. I certainly have my horrible days, but I also have an abiding sense of appreciation for what I have – a sense of indebtedness and obligation to repay.”

44. How providers Can Apply Resiliency Theories…
Awareness of Deficits and Illness based Vocabulary
Interventions Decreasing Risks and Increasing Protective Factors
Build Inner Strengths through Encouragement and Modeling
Honor the Struggle to be Strong

45. Individual Level Strategies From “Playing at Being Bad” by Michael Ungar
Strategy 1: Ask “what is true for you?” Help children become critical consumers of everyone’s values, including those of parents, peers or anyone who would have them believe their truth is the “Truth”.
Strategy 2: Encourage them to “shop around”. Youth may need to become part of a different peer groups if they are to discover who they really want to be.

46. Individual Level cont’d
Strategy 3: Celebrate Storytelling. Listen closely to the complex stories young people tell about themselves.
Strategy 4: Accept the Unusual. Acknowledge the identity a child or youth chooses. Find the positive aspects of that identity and show whatever acceptance is possible.
Strategy 5: Stop Blaming our Youth’s Peers. Youth are equal participants in creating their group identity.

47. Family Intervention Strategies
Develop interventions that foster self-determination in school-aged children by increasing a sense of self-efficacy and self-reliance
Develop intervention strategies that are empowering for children and families rather than punitive
Develop subsequent booster interventions
Children with MalTX may experience new difficulties as a function of developmental capacities

48. Fostering Resilience at Community Level
Prevent maltreatment through psycho- educational home-based outreach models
Prevention and reduction of sequelae associated with Mal TX through early provision of services
Find methods to reduce community violence
Develop interventions that foster self-determination in school-aged children by increasing a sense of self-efficacy and self-reliance
(Cicchett, Toth & Rogosch)

49. We can change the mental health outcomes of our nations children.
Why is this important…
Resilience and thriving reflects the noble side of the human experience…overcoming the odds, making something good out of something bad…
If we can reduce the burden of damage
Increase protective factors in the environment
And encourage insight and teach skills to children and families
We can change the mental health outcomes of our nations children.

50. There is a possibility of joy…”
“One discovers that destiny can be directed, that one does not have to remain in bondage to the first wax imprint made on childhood sensibilities. Once the deforming mirror has been smashed, there is a possibility of wholeness.
There is a possibility of joy…”
Anais Nin