Why is it that two boys from the same desperate, impoverished and dangerous neighborhood -- be it Watts, Bedford-Stuyvesant or downtown Detroit -- can turn out so differently? One is using drugs and committing petty crime by the age of 12, and in prison for a violent offense by 20; the other stays in school, attends college, gets married and finds employment?
Why is it that in wake disasters such as 9/11 and Katrina, some who were directly affected suffer terrible PTSD (post-traumatic stress disorder), depression, alcohol and drug abuse while others feel distress yet go about rebuilding their lives, families and communities? Why is it that some soldiers deployed, even for multiple tours, in Iraq and Afghanistan, develop severe psychological problems while others go about their lives and their missions and return home never forgetting but not impaired by the horrific exposure they have had?
Perhaps the best concept we have to explain such radically different responses to extraordinary, even life threatening, stress is called resilience. Resilience is a term that originates from physics and refers to the capacity of a substance to return to its original state after being subject to intense levels of pressure, heat or other external force. What a great term for human nature to adopt. It conveys a capacity to return to what was after experiencing trauma, tragedy, life threatening danger, persistent adversity or all of these profound and too often inescapable fates that humans encounter. Sometimes resilience is called adaptation, but resilience has a dynamic feeling to it, a sense that we all can tap into properties that enable us to rebound to where we were before misfortune, natural or manmade, strikes.
I had the privilege of recently participating in a small conference hosted by the Columbia University/Mailman School of Public Health, where Dr. Linda Fried is dean and Dr. Sandro Galea and Dr. Thomas D'Aunno are leaders in departments whose work focuses on the topic of the meeting, "Resilience in the Face of Adversity." (Disclosure: I hold my university faculty appointment at this school.) The Mailman School recognizes that a field of public mental health is emerging and that Columbia and its experts must aim to serve in a leadership position to advance public mental health. We all understand public health, with its honored traditions of reducing neonatal and maternal death and childhood infectious illnesses, containing diseases like tuberculosis, AIDS and avian flu, promoting nutrition and sanitation and in recent times focusing upon chronic illnesses like heart disease, diabetes and asthma.
But what too few people appreciate is that principles of public health apply to mental health: focus on a health problem with profound quality and/or duration of life consequences affecting large numbers of individuals; identify scientifically proven interventions that can be feasibly and effectively delivered to that population; mobilize a campaign to reduce the impact of that problem (which includes public education, community engagement and methods of prevention or treatment); and measure to see if what the campaign purports to be doing is being accomplished. The Columbia meeting was a needed step in establishing that resilience is central to improving the public mental health, much like immunity has achieved that status in public health.
We now have a sound scientific base about disaster and trauma. We know, for example, that in disasters the greater the degree of exposure to the horror and danger during and after an event the greater the risk of post-traumatic psychological disease. We know that supportive families and cohesive communities reduce the risk of developing mental disorders while fostering resilience.
Problem-solving help -- not merely emotionally expressive therapies -- that conveys a spirit of hope and belief that something can be done are what people need in the wake of catastrophe, acute or chronic. Belief in something bigger than oneself strengthens both individuals and families, and promotes recovery. Helping others helps. Seeking meaning, even in the darkest of moments (as documented by concentration and prisoner of war camp survivors), can be sustaining. And, very recently, we are discovering the neurobiological correlates of resilience.
A colleague, Dr. Glenn Saxe, discovered that children with severe burns given higher doses of morphine had fewer problems with post-traumatic symptoms, like low mood, anxiety and flashbacks. This finding that we can mitigate how brain neurotransmitters process and encode traumatic experiences has led the military to explore a similar approach in wounded soldiers and may be applicable in emergency rooms for victims of trauma, assault and rape.
Troubled and threatening communities are pervasive throughout the world. Natural disasters strike without regard to who will be affected or when. Man-made trauma such as war, domestic abuse, crime and violence, genocide and terrorism, are our contemporary demons. We are not on the cusp of eliminating these modern day plagues as we have with polio and smallpox. But we have a growing body of science and practice that informs us about how to prepare for disaster and trauma, how we must respond in its immediate aftermath, and how we can promote recovery in impacted individuals and communities. The core concept for policy and practice is resilience and its field of study is public mental health.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
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