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An Evidence-Informed Model of Human Resistance, Resilience, and Recovery:

The Johns Hopkins' Outcome-Driven Paradigm for Disaster Mental Health
Services

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DOI: 10.1093/brief-treatment/mhl015

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 An Evidence-Informed Model of Human
Resistance, Resilience, and Recovery: The Johns
Hopkins’ Outcome-Driven Paradigm for
Disaster Mental Health Services

Michael Kaminsky, MD, MBA

O. Lee McCabe, PhD
Alan M. Langlieb, MD, MPH, MBA
George S. Everly Jr., PhD

In the past, psychological intervention subse- from the same type of assistance (National In-
quent to mass disasters/acts of terrorism has stitute of Mental Health [NIMH], 2002). In fact,
been characterized by reactive, event-specific only the minority of individuals exposed to
practices that all too often overlook the vari- traumatic events will require formalized in-
ability inherent in the temporal trajectory of tervention beyond perhaps information and
the human response to such events. In essence, reassurance (NIMH, 2002; United States
these so-called univariate crisis intervention Department of Health and Human Services,
models can trace their origins back to com- 1999). The challenge, therefore, becomes iden-
munity mental health initiatives (Decker & tifying those who require more structured
Stubblebine, 1972; Langsley, Machotka, & intervention from those who do not. This obser-
Flomenhaft, 1971; Parad & Parad, 1968), the vation has recently pushed ‘‘interventionists,’’
outpatient community psychiatry movements sometimes reluctantly, to now consider adding
(Caplan, 1961, 1964), as well as the ‘‘forward the skills of assessment and strategic planning
psychiatry’’ initiatives of the great World Wars to their therapies. The emerging model must
(Artiss, 1963; Kardiner, 1941; Salmon, 1919). therefore be one of a continuum of care in order
Given the original intent and design of these to accommodate the varied aspects and chal-
models, it is not surprising that they are not eas- lenges of disaster response.
ily transferable to the disaster mental health One potential framework that may assist di-
field. Although mass disasters and terrorism af- saster mental health interventionists to plan and
fect whole communities of individuals, all indi- structure such a revised therapeutic program
viduals in the community do not react the same is a framework that engages the concepts of re-
to such events. Stated another way, some (but sistance, resilience, and recovery. The impetus
not all) individuals exposed to a disaster will and foundation of this framework are based
need assistance and not everyone will benefit on a presentation to the Johns Hopkins Confer-
ence on Mental Health by Kaminsky (2003). In
From the Johns Hopkins University School of Medicine. that conference, Dr. Kaminsky discussed the
Contact author: Alan M. Langlieb, Assistant Professor.
E-mail: [email protected].
need for a paradigmatic shift away from previ-
doi:10.1093/brief-treatment/mhl015
ous disaster mental health practices that were
Advance Access publication December 7, 2006 (a) void of adequate assessment; (b) reactionary
ª The Author 2006. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:
[email protected].

1
KAMINSKY ET AL.

instead of proactive; (c) predicated upon one- interventions should be combined and se-
time, univariate, clinical interventions; (d) con- quenced in such a manner so as to yield the
founded by the quest for clinically appropriate most efficient and effective intervention possi-
outcomes; and (e) practiced in a morass of con- ble. The various combinations and permuta-
fusing acronyms in the absence of a standard tions that are actually utilized will be
nomenclature. In this paper we shall discuss determined by the unique demands of each crit-
the resistance, resilience, and recovery con- ical incident or disaster, and the unique
cepts and offer this strategic framework as a demands of each target population, as they arise
new, ‘‘evidence-informed’’ paradigm for ap- in real time. In addition, this intervention
proaching disaster mental health. model is applicable to a wide variety of settings
that have been previously identified as being at
risk for emotional crises in the workplace in
Resistance, Resilience, and Recovery as general, of which disasters form a subset cate-
a Strategic and Integrative Paradigm gory; these include hospitals, industrial and fi-
nancial organizations, educational institutions,
The resilience, resistance, and recovery formu- the military, transportation industries, govern-
lation represents an evidence-informed, out- ment buildings, and so forth (Heidel, 2003).
come-driven approach to critical incident and In this paper, we shall (a) briefly describe each
disaster management. Currently, this model is of the fundamental characteristics (resistance,
being developed at the Johns Hopkins Univer- resilience, and recovery) of this outcome-driven
sity and may be thought of as ‘‘The Johns approach, (b) provide the empirical evidence
Hopkins Perspectives Model of Disaster Mental that serves to support the principles contained
Health.’’ At its core, this perspectival model herein, and (c) provide psychological and socio-
assists in strategic planning by both consider- logical interventions that are suited to enhance
ing multiple intervention perspectives and sub- each component. In addition, we will provide
sequently aligning the tactical interventions training guidelines for mental health interven-
most suited to achieve the desired outcome, tionists and discuss an assessment technique that
that is, building resistance, enhancing resil- has been developed at the Johns Hopkins De-
ience, or facilitating the recovery of those partment of Psychiatry and Behavioral Sciences
affected by the disaster. This concept is consis- which has been the basis for the resistance, resil-
tent with the ‘‘integrative psychotherapeutic ience, and recovery paradigm (McHugh, 1992;
concepts’’ of Millon, Grossman, Meagher, McHugh & Slavney, 1983, 1998). It is important
Millon, and Everly (1999) wherein (a) potentiat- to note, however, that although each of the
ing pairings (using interacting combinations of components of the following ‘‘prescription’’ (re-
interventions so as to achieve an enhancing sistance, resilience, and recovery) is empirically
clinical effect), (b) catalytic sequences (sequen- supported, the prescription in its aggregate, pro-
tially combining tactical interventions in their grammatic form has not been empirically assessed.
most clinically useful ways), and (c) polythetic
selection (selecting the tactical interventions
as determined by the specific needs of each crit- Enhance Resistance and Foster
ical event or mass disaster/terrorism situation) Resiliency
are all utilized to create the intervention ap-
proach with the greatest potential for achieving In order for our community to defeat the
a successful outcome. Thus, specific disaster psychological reactions of terrorism, it is impor-

2 Brief Treatment and Crisis Intervention / 7:1 February 2007

 Evidence-Informed Model of Human Resistance, Resilience, and Recovery

tant that proactive steps be taken to prepare Meichenbaum, 1985; Schiraldi & Brown,
ourselves with the appropriate ‘‘psychological 2001, 2002; Seligman, Reivich, Jaycox, &
body armor’’ to foster self-efficacy. This, we Gillham, 1995).
believe, may be achieved by enhancing resis- 2. Fostering group cohesion and social
tance and promoting resilience of the target support. Social support has been shown to
populations. buffer stress (Flannery, 1990). The
Resistance refers to the ability of an individ- creation of group cohesion, with an
ual, a group, an organization, or even an entire underlying infrastructure for social
population to literally resist manifestations of support, may be useful (American
clinical distress, impairment, or dysfunction as- Psychological Association, 2004). An
sociated with critical incidents, terrorism, and essential element of fostering cohesion and
even mass disasters. Resistance may be thought support, we believe, will be effective risk
of as a form of psychological/behavioral immu- communications. Risk communication
nity to distress and dysfunction. should be designed to provide the
Historically, this element of disaster mental following five essential elements:
health response was conspicuous in its absence. information (and rumor deterrence),
More specifically, disaster mental health serv- reassurance, direction, motivation, and
ices were almost exclusively reactionary in a sense of connectedness.
nature. The notion of creating resistance 3. Fostering positive cognitions. Cognitive
represents a proactive step in emergency men- appraisals appear to be key determinants
tal health. Notions of ‘‘psychological immuniza- of stress (for a review, see Everly & Lating,
tion’’ and psychological body armor are 2002) and trauma (Ehlers & Clark, 2003).
engendered by the introduction of this inter- Positive cognitions appear to deter
vention to the preincident phase of the tempo- excessive stress and foster resilience
ral continuum. (Affleck & Tennen, 1996; Meichenbaum,
Resilience refers to the ability of an individ- 1985; Taylor, 1983; Tedeschi & Calhoun,
ual, a group, an organization, or even an entire 1996). Positive cognitions may include
population to rapidly and effectively rebound positive memories of those lost in war/
from psychological and/or behavioral perturba- terrorism and/or identification with
tions associated with critical incidents, terror- a noble motive, such as religion or
ism, and even mass disasters. nationalism.
Collectively, we believe that resistance and 4. Building self-efficacy and hardiness.
resilience may be facilitated by the following Building self-efficacy and hardiness is
empirically supported, quadratic, strategic for- important to enhancing resistance to stress
mulations that collectively may be seen to have and fostering resiliency. The primary
two ‘‘active ingredients’’: expectancy and expe- formulation that will serve as the basis for
rience. The four strategies are listed below. this notion resides in the work of Albert
Bandura (self-efficacy) and Kobasa, Maddi,
1. Providing realistic preparation. Setting and Kahn (1982).
appropriate expectations, developing Self-efficacy. Bandura’s (1997) work is
stress management and coping skills, and summarized in his magnum opus on self-
providing realistic preincident training efficacy and human agency. Bandura
may all serve to foster stress resistance defines the perception of self-efficacy as
(Hobfoll et al., 1991; Lating et al., 2003; the belief in one’s ability to organize and

Brief Treatment and Crisis Intervention / 7:1 February 2007 3

KAMINSKY ET AL.

execute the courses of action required to just such an example. As the perception of
achieve necessary and desired goals (see efficacy eroded, so did political support.
also Freud, 1911/1958). This perception Objective military success was
of control or influence, Bandura (p. 3) subordinated to the perception of a ‘‘war
points out, is an essential aspect of life that could never be won.’’ Therefore,
itself; ‘‘People guide their lives by their retreat became the only option.
beliefs of personal efficacy’’. He goes on ii. Vicarious experience. ‘‘Self-efficacy
to note: appraisals are also partly influenced by
People’ s beliefs in their efficacy have diverse vicarious experiences. Seeing or
effects. Such beliefs influence the courses of visualizing similar others perform
action people choose to pursue, how much ef- successfully can raise self-percepts of
fort they put forth in given endeavors, how efficacy in observers that they too possess
long they will persevere in the face of the capabilities to master comparable
obstacles and failures, their resilience to ad- activities . . . . By the same token,
versity, whether their thought patterns are observing that others to be of similarly
self-hindering or self-aiding, how much stress competence fail despite high efforts
and depression they experience in coping with lowers observers judgments of their own
taxing environmental demands, and the level capabilities and undermines their efforts’’
of accomplishments they realize’’ (p. 3). (Bandura, 1982, p. 399). Such modeling of
experience as described may be done in
Bandura (1977, 1982, 1997) has described four
vivo, in vitro, or symbolically.
sources that affect the perception of self-
efficacy and are particularly relevant in terms iii. Verbal persuasion and support. Verbal
of the resistance/resilience model. They are as persuasion comprises things such as
follows. suggestion, education, and
reinterpretation of exogenous,
i. Performance. ‘‘Enactive attainments environmental, or interoperative stimuli
provide the most influential source of so as to improve perceptions of self-
efficacy information. Successes raise efficacy. Such cognitive alterations may
efficacy appraisals, repeated failures be done by oneself or by another (e.g.,
lower them’’ (Bandura, 1982, pp. 26–27). a coach, a charismatic leader, or even
Bandura has also shown perceptions of a therapist).
self-efficacy to influence subsequent iv. Physiological/affective arousal. ‘‘People
performance, as well as autonomic rely partly on their state of physiological
nervous system activity. Though enactive arousal in judging their capabilities and
attainment appears to be the single most vulnerability to stress. Because unusually
powerful way of influencing perceptions high arousal usually debilitates
of self-efficacy, it is important to note that performance, individuals are more likely
attainment is in the eye of the beholder. to expect success when they are not beset
Objective success shows no favorable by aversive arousal. Fear reactions
impact on self-efficacy if the individual generate further fear through
perceives that success as ‘‘failure.’’ One anticipatory self-arousal . . . . People can
might argue that the experience of the rouse themselves to elevated levels of
United States in the Vietnam conflict is distress that produce the very

4 Brief Treatment and Crisis Intervention / 7:1 February 2007

 Evidence-Informed Model of Human Resistance, Resilience, and Recovery

dysfunctions they fear. Treatments that 5. identification with a higher ideal;

eliminate emotional arousal heighten 6. identification with a group to foster group
perceived efficacy with corresponding identity;
improvements in performance’’ (Bandura, 7. fostering impact and acute-phase task
1982, p. 28). Biofeedback and other orientations;
techniques that induce the relaxation 8. stress management training; and
response are useful interventions within 9. provision of family support.
this domain.
And specifically, to achieve resilience, the
Hardiness. Kobasa et al. (1982) focus on the
following measures need to be taken:
concept of hardiness, which they believe is an
insulating factor against stressors. Hardiness 1. assessment of need;
is characterized by the following: (a) the 2. effective leadership;
belief in one’s own agency or self-efficacy 3. sustaining a credible, accurate
(i.e., the ability to exert control over relevant information flow;
life events); (b) the tendency to see stressful 4. stress management;
events as ‘‘challenges’’ to be overcome and 5. establishment and utilization of social
opportunities for growth; and (c) a strong support networks;
commitment and sense of purpose. 6. fostering an acute-phase task orientation;
7. implementation of ‘‘psychological first
This notion of perceived personal efficacy
aid’’;
and hardiness is relevant to understanding in-
8. utilization of small-group crisis
dividual behavior, group behavior, and even
intervention for naturally occurring
the behavior of nations. Enhancing perceived
cohorts and families;
efficacy and hardiness is an essential and intrin-
9. pastoral crisis intervention and
sic process for combating terrorism because it
chaplaincy services; and
not only enhances effort and self-esteem but
10. psychological triage.
also contradicts the perception of helplessness
while at the same time conveying the perception
that the world is more controllable (i.e., safer).
Enhance the Recovery Process
Psychological and Social Interventions to
Enhance Resistance and Resiliency As we just discussed, resistance and resilience
are proactive steps needed to be taken to pre-
In order to achieve resistance and resilience,
pare our community for terrorism and mass dis-
certain mechanisms need to be put in place.
asters. Recovery, on the other hand, refers to the
Specifically, to achieve resistance and the true
ability of an individual, a group, an organiza-
sense of a prevention paradigm, the following
tion, or even an entire population to literally
measures need to be undertaken:
recover the ability to adaptively function, both
1. perception of credible and competent psychologically and behaviorally, in the wake
leadership; of a significant clinical distress, impairment, or
2. anticipatory guidance, setting appropriate dysfunction subsequent to critical incidents,
expectations; terrorism, and even mass disasters.
3. realistic training; However, similar to building resistance and
4. identification with a common purpose, resiliency, the essential building block to re-
goal; cover from terrorism and a mass disaster is

Brief Treatment and Crisis Intervention / 7:1 February 2007 5

KAMINSKY ET AL.

a populations’ ability in ‘‘regaining control provement. The dropout rates of individuals

over their emotional responses and place the participating in these studies is rather high.
trauma in the larger perspective of their lives In some recent randomized controlled trials,
as something that happened but that can be the dropout rates stand at about 25%. More-
expected to not recur if the individual is able over, on certain studies focused on post-
to retake charge of his or her life’’(van der Kolk, traumatic stress disorders, at the end of
McFarlane, & van der Hart, 2002). treatment, a subgroup of patients still meet di-
agnostic criteria for posttraumatic stress disor-
der (ranging from 35% to 47%) (Blanchard
Psychological and Social Interventions to
et al., 2003; Bryant, Moulds, Guthrie, Dang,
Enhance Recovery
& Nixon, 2003; Ehlers, 2004; Foa et al., 1999;
In order to enhance the recovery process, our Resick, Nishith, Weaver, Astin, & Feuer, 2002).
review of the research has illustrated that cog- With regard to therapy itself, current re-
nitive-behavioral psychotherapy (CBT) is one search has suggested that three fundamental
of the best methods to aid trauma victims. concepts must be addressed in psychotherapy
CBT combines the use of techniques from cog- to assist the recovery process.
nitive therapy and behavioral therapy. CBT is
based on the premise that cognition is a primary 1. Establish a sense of control.
determinant of behavior and mood. Thus, CBT Psychotherapy must establish a sense of
uses behavioral and verbal techniques to iden- safety and control from which the patient
tify and correct problematic thinking patterns can approach the memories related to the
that are at the root of dysfunctional behavior. A trauma (van der Kolk et al., 2002). Patients
complete review of the benefits, indications, need to learn to master and own their
and contraindications of CBT have been previ- experiences (Taylor, 1983; van der Kolk
ously defined and are beyond the scope of this et al., 2002) and reestablish a sense of
paper (Bryant & Harvey, 2000; Katz, Pellegrino, safety in their bodies and come to trust
Pandya, Ng, & DeLisi, 2002). Several acute trauma their own perception and feelings (van der
studies have established the benefits of CBT for Kolk et al., 2002).
trauma victims (Bryant, Harvey, Sackville, 2. Decondition fear. Psychotherapy must
Dang, & Basten, 1998; Bryant, Sacksville, Dang, also assist the patient in learning to
Moulds, & Guthrie, 1999; Difede, Apfeldory, decondition the fear and anxiety related to
Cloitre, Spielman, & Perry, 1997; Foa, Hearst, the traumatic memories themselves. To be
Ideda, & Perry, 1995; Frank et al., 1988). Cog- able to fully understand his/her current
nitive appraisals appear to be key determinants experiences, an individual must
of stress (for a review, see Everly & Lating, understand what happened to him/her in
2004) and trauma (Ehlers & Clark, 2003). Con- the past and accept the role he/she played
versely, positive cognitions appear to deter ex- in it (van der Kolk et al., 2002). Unless
cessive stress and foster resiliency (Affleck & individuals face their memories, they will
Tennen, 1996; Meichenbaum, 1985; Taylor, likely continue to react with self-blame for
1983; Tedeschi & Calhoun, 1996). Thus, cogni- failure to prevent the trauma. The clinical
tive as well as behavioral therapies appear to be usefulness of actively addressing
effective methods to enhance recovery. traumatic memories has been addressed in
However, it should be noted that despite several studies centered on combat
these successes of CBT, there is room for im- veterans (Boudewyns et al., 1990;

6 Brief Treatment and Crisis Intervention / 7:1 February 2007

 Evidence-Informed Model of Human Resistance, Resilience, and Recovery

Cooper & Clum, 1989; Keane et al., 1989; 3. skill in small-group crisis intervention
Peniston, 1986; Pitman et al., 1991). (;20 or less);
3. Reestablish integrity and control. Therapy 4. skill in large-group crisis/risk
should also help individuals by communications (;20 to ;300 or more);
reestablishing a feeling of personal and
integrity and control by addressing the 5. the ability to plan and implement an
way trauma victims make sense out of integrated, phasic multicomponent
their lives. Often, after a mass disaster, emergency mental health initiative
individuals need help to restructure residing within the confines of an overall
trauma-related cognitive schemes in order Incident Command System.
to ensure that they do not dominate their
Thus, training disaster mental health interven-
everyday existence. The work of Frank
tionists on how to apply the resistance, resilience,
and Frank (1991) reminds us as well that
recovery framework within these five core com-
the ‘‘remoralization’’ of a defeated
petencies is essential. And as a result, we believe it
individual and the provision of hope are
will lead to the application of an emergent psy-
central to all psychological and moral
chological and sociological intervention that is
helping relationships.
predicated upon selecting the most appropriate
intervention to correspond to the needs of the sit-
Training in Disaster Mental Health uation and target population (Center for Mental
Intervention Health, 2000; Everly & Langlieb, 2003; Everly &
Mitchell, 1999; NIMH, 2002; Professional
Understanding the terms resistance, resilience, Practice Board Working Party, 2002; Raphael,
and recovery and interventions needed to sup- 1986; Shalev et al., 2003; Ursano, McCarroll, &
port these concepts is only half the battle. The Fullerton, 2003; Myers, 1994; Myers, 2005).
other half is putting the theory to work. We
believe that as the perceived need for disaster A Comment on Assessment
mental health services grows, the need for
As one examines the five training competencies
training disaster mental health experts in
mentioned above, it becomes clear that assess-
how to build resistance and resilience and en-
ment is the ‘‘bedrock’’ competency of disaster
hance recovery in individuals and communities
mental health. More specifically, effective
will also emerge as an important issue.
clinical management of human responses to
Whether based upon a review of current
traumatic events should become a priority.
practices (Sheehan, Everly, & Langlieb, 2004)
However, until assessment is viewed as a core
or expert consensus (NIMH, 2002; Olson,
competency in the repertoire of disaster mental
2005), it can be argued that there exist ‘‘core
health specialists, it is difficult to conceive how
competencies’’ in disaster mental. Everly
individuals with different vulnerabilities can be
(2002) has argued that the core competencies
identified for the type and scope of interven-
may be thought of as follows:
tions they actually need to help foster resilience
1. assessment, especially the ability to and assist in an enhanced recovery. (The result
differentiate benign versus malignant of such perspectival assessment is a case concep-
psychological symptomatology; tualization that can inform triage, treatment,
2. skill in one-on-one crisis intervention and prognosis. Moreover, by revealing the
(face-to-face or telephonically); benefits and liabilities of singular forms of

Brief Treatment and Crisis Intervention / 7:1 February 2007 7

KAMINSKY ET AL.

assessment, the approach offers an intellectual program based on tactical proficiency and ef-
scaffolding upon which future clinical, scientific, fective strategic planning. This paper is
and educational efforts may be constructed. designed to educate readers about an inte-
That such advances might be applied to human- grated, multicomponent, intervention model
kind’s potentials for disaster resistance, resil- that addresses these issues. Unlike its predeces-
ience, and recovery across the lifespan is sors, the ‘‘perspectival’’ disaster mental health
both a professional opportunity and obligation model described herein is motivated by the mis-
in the permanently altered world that we now sion to achieve specific behavioral outcomes
inhabit.) A multiperspective approach to assess- constructed within an environment based on
ment has been developed at the Johns Hopkins a logical and temporal flow. The formulation
Department of Psychiatry and Behavioral Scien- of resistance, resilience, and recovery is not
ces (McHugh & Slavney, 1983, 1998) and has only a conceptual framework that may assist
been the backbone of the resistance, resilience, in advancing the field beyond an oversimpli-
and recovery paradigm. Briefly, the Hopkins’ fied, univariate disaster mental health response
‘‘perspectives’’ provide a framework for under- but also by focusing on clinically meaningful
standing the essential natures of and substrates outcome measurements it may lend itself more
underlying clinical disorders, trauma related readily to the type of evidenced-based research
and otherwise. Rather than adopt one worldview that is so desperately needed in the field of
for elucidating psychopathology, the Hopkins disaster mental health.
approach employs four distinct but overlapping
perspectives. Each of these assessment view-
points drives a set of exploratory propositions. Acknowledgments
The propositions address (a) what the person
Portions of this paper were previously published by
‘‘has’’ (biologically based disease and physical
the Johns Hopkins Center for Public Health
illness); (b) who a person ‘‘is’’ (graded dimen-
Preparedness. Conflicts of interest: None declared.
sions of temperament and disposition); (c) what
a person ‘‘does’’ (purposeful, goal-directed be-
havior); and (d) what a person has ‘‘encoun- References
tered’’ (his/her life story and the meaning that
has been given to those experiences). Individu- Affleck, G., & Tennen, H. (1996). Constructing
ally and collectively, these perspectives illuminate benefits from adversity: Adaptational significance
important aspects of personal vulnerability and and dispositional underpinnings. Journal of
symptom development. Through this approach, Personality, 64, 899–822.
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