Risk Factors are not Predictive Factors. Carl C. Bell, M.D

Risk Factors are not Predictive Factors Due to Protective Factors Carl C. Bell, M.D. C.E.O./President C Community i Mental M l Health H l h Council, ...
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Risk Factors are not Predictive Factors Due to Protective Factors Carl C. Bell, M.D. C.E.O./President

C Community i Mental M l Health H l h Council, C il Inc. I Professor Psychiatry and Public Health Director of Public & Community Psychiatry – Department of Psychiatry

University of Illinois at Chicago

Barriers to Cultural Dialogue Most American’s American s acknowledge progress towards the ideal America as "one Nation under y for all." God, with Justice and Liberty ¾ Further, for years the US has tried to be a gp pot," and consideration of "color blind," "melting the dynamics of culture, race and ethnicity have been selectively ignored by science. ¾ Accordingly, when the topic of cultural sensitivity or competence surfaces, individuals b become anxious, i d defensive, f i and d very rigid i id iin their perspectives. ¾

Barriers to Cultural Dialogue “Race Race constitutes a stubbornly resistant malady in the United States because of “the color line” a visible (and invisible) barrier that separates whites from nonwhites” (Pulera (2002) ¾ Racist policies occur at an organizational or group level and these policies are embedded in the operating contexts of particular organizations or institutions in such a way that racist assumptions may be difficult to recognize ( f (referred d to t as institutional i tit ti l racism) i ) -American A i Psychiatric Association, 2006. ¾

RACISM IN RESEARCH ¾ In

volume one, number one of the A American i J Journall off P Psychiatry hi t in i July 1921 Dr. Bevis noted ¾ "All Negroes have a fear of darkness, are careless,, credulous,, childlike,, easily amused, and sadness and p have little part p in his depression psychic make-up".

RACISM IN RESEARCH ¾ In

Kardiner and Ovesey's influential book "The Mark Of Oppression" ((1951)) it is noted the stress of racist discrimination had produced not merely an inerasable mark but a deformity of the Black man's psyche.

RACISM IN RESEARCH

¾Bell and Mehta (1980) published

Misdiagnosis of Blacks with ManicManic "Misdiagnosis Depressive illness" in the Journal of the National Medical Association illustrating the dynamics of how Blacks were thought p illness than Whites as to have less bipolar it was felt bipolar illness was a middle class disease.

Culture,, Race and Ethnicity y supplement to Dr. Satcher’s Surgeon General’s General s Report of Mental Health ¾ There

is very little published mental h l h research health h on cultural, l l racial i l and d ethnic issues in general ¾U.S. Department of Health and Human Services Services, 2001 ¾www. surgeongeneral.gov

Articles in Psychiatric Services about Racial/ Ethnic Groups by Decade (Bell & Williamson, 2002) 1628

1656

1656

1656

African Am

1600 1400

F r e q u e n c y

1380

Latinos

1200

Asians

1000

Native Am Alaska Nat

800

Multiethnic 600

Total T t l Race R Ethnicity

400 200 01 11 03

1 8 5 2 2 18

6 4 1 3 4 18

1950-59

1960-69

1970-79

15 6 2 4 1037

14 2 6 5 1138

0

1980-1989

1990-99

Est Total Articles

African-Based African Based Populations ¾ Pre-slavery

Africans in U.S. ¾ Africans in U.S. subjected to various degrees g of slavery y ¾ Recent African immigrants in U.S. ¾ Recent R t Af African i refugees f in i U U.S. S

Middle Class African African-Americans Americans Dual employment p y of husband and wife relying y g on the public sector for jobs (e.g., public post office)) schools, p ¾ 2 or less kids ¾ Continuity of employment ¾ Family functions are shared and not exclusively the prerogati prerogative e of the h husband sband or wife ife ¾ Egalitarian patterns of interaction ¾

Middle Class African African-Americans Americans ¾

Income is spent p on the home and children’s education

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Visit relatives relatives, hold membership in 1 or 2 social organizations

¾

At least 1 spouse is a college graduate

¾

Kids take music lessons, and are taught the value of work and thrift

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Active A ti involvement i l t iin community it affairs ff i is characteristic

Middle Class African-Americans African Americans Family members manifest the Puritan orientation towards work, success and selfreliance ¾ They identify with the goals of the American society ¾ They are achievement-oriented, upwardly mobile bil and d egalitarian lit i ¾ They immerse themselves in work and have little time for leisure ¾

Middle Class African African-Americans Americans

¾ Personal

p p y especially property, p y their residence, is a major symbol of success ¾ Education is highly valued ¾ They are the conformists

Working Class AfricanAmericans ¾

Struggle for survival that requires a group effort

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The number of kids is 5 or more

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Family size is a source of pride for the parents, especially the father

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Children are a contribution to society

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Work roles are semi-skilled

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Size of family is related to the early age of marriage

Working Class AfricanAmericans Cohesion comes from the joint effort to stave off adversity ¾ Parents are literate literate—most most completing grammar school and some high school drop outs; a few go past high school with some college ¾ They hope their kids get about the same education, but hope the smarter ones will go on to college and become a skilled manual worker, secretary, nurse, etc. ¾

Working Class AfricanAmericans ¾ Fathers

may hold 2 jobs ¾ They are long-term residents in their neighborhoods and are stable workers with a long work history with 1 employer ¾ Home ownership is a major goal for the family ¾ They y boast their children are g good and stay out of trouble with the police

Working Class AfricanAmericans ¾ Strong

moral sense that emphasized clean living ¾ There is little time for community activities ¾ Religion is important with church every Sunday ¾ They Th d do wellll b by th their i children hild if th there are no special problems, as their comprehension of psychological problems is limited

Working Class AfricanAmericans ¾ Cooperation C ti

iis necessary ffor survival i l so relationships are egalitarian; however, they then have their assigned roles (during (du g a ccrisis s s these ese roles o es ca can cchange) a ge) ¾ Husband decides about money, maintains the house; advises the boys ¾ Mother cooks and cleans; advises the girls

Working Class AfricanAmericans ¾

Many are working their way out of poverty –

As a result, there is little margin for error in finances or they will slip back into poverty

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About one third are up from poverty or down from middle class

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These are good examples of self-reliance in American society and they are the innovators, as they are ingenious for developing survival adaptations

Poor Class African-Americans African Americans Low income status forces them to make a number of necessary, clever and sometimes foolish arrangements to survive ¾ These arrangements representing a rebellion against i t common goals l and d conventional ti l ways of doing things in society ¾



E.g., extended households with several generations under 1 roof, taking in boarders or foster children for pay

Poor Class African African-Americans Americans Boyfriend and girlfriend relations assume parental functions while participants maintain their autonomy from marital bonds ¾ Morality is compromised for survival ¾ The Th struggle t l iis severe and d poor bl black k ffamilies ili learn to hope for little and expect less ¾ Parents love their children but seldom understand them ¾

Poor Class African African-Americans Americans Men and M d women are sexually ll iinvolved l db butt are afraid to entrust their futures to each other ¾ There is much disappointment—parents in broken homes sometimes have broken spirits ¾ Movement is constant ¾ Jobs, Jobs houses houses, communities communities, spouses spouses, girlfriends and boyfriends are constantly changed ¾

Poor Class African African-Americans Americans Unemployment is a constant specter ¾ Women do jobs that require few skills—e.g., maids ¾ Men do unskilled factory work ¾ Marriage occurs at an early age ¾ First children may y be born before the marriage g and other children come in rapid succession— so family y size can be above 6 ¾

Poor Class African African-Americans Americans With family size so large and funds so short short, escape behavior of drinking, drugs, gambling may increase ¾ Soon there is a break in the male/female relationship l ti hi and d another th ffailure il iis experienced i d ¾ Parents are grade school or high school drop outs ¾ Parents hold themselves up p to their children as failures ¾

Poor Class African African-Americans Americans They are admonished not to follow the pattern but there is little concrete effort at prevention ¾ There is fierce loyalty between mothers and their offspring ¾ Also, Al strong t b bonds d b between t b brothers th and d sisters helping each other develop, but the siblings ibli are also l struggling t li ¾ There is little participation in the community ¾

Poor Class African-Americans African Americans Religion is important for some families and for others, it is a delusion—reward system after death ¾ It’s hard to overcome poverty—if illness or unemployment don’t don t drain resources, resources then old age will ¾ They reject society as it has rejected them; it is usually passive but can become riotous ¾

Poor Class African African-Americans Americans ¾ Failure

and disappointment occur regularly ¾ They y have been g given little, and thus have not learned to receive ¾ They trust not and are uncommitted ¾ They are the rebels

ETHNOCENTRIC MONOCULTURALISM ¾

This aspect of Euro-American culture makes it difficult to appreciate cultural differences between different ethnic groups.

¾

This aspect of Euro-American culture makes it difficult to appreciate diversity within racial groups (Sue & Sue, 1999).

ETHNOCENTRIC MONOCULTURALISM ¾ An example is the food pyramid graphic recommended by the U. S. Department of Agriculture which has milk and dairy products as a consumer’s consumer s only source of calcium. ¾ Lactose actose intolerance to e a ce occurs occu s in: ¾ 70% of African Americans ¾ 90% of Asian Americans ¾ 74% of Native Americans ¾ 53% of Mexican Americans ¾ Only 15% of Whites are lactose intolerant

ETHNOCENTRIC MONOCULTURALISM ¾

Racially biased attitudes may implicitly affect provider decision-making, leading to denial of services for some populations or to inappropriate assessment and diagnosis which in turn leads to ineffective treatment (Miranda et al, 2002)

“Outline for Cultural Formulation Formulation” ¾

¾

Inquire about patients’ patients cultural identity to determine their ethnic or cultural reference group, language abilities, language use, and language preference Explore possible cultural explanations of the illness, including patients’ idioms of distress, the meaning and perceived severity of their symptoms in relation to the norms of the patients’ cultural reference group, and their cur cur-rent rent preferences for for, as well as past experiences with, professional and popular sources of care

PROCESS OF ACCULTURATION No contact ¾ Interaction ¾ Emerging differences ¾ Conflict comes to a head ¾ Stability in modes of acculturation ¾

MODES OF ACCULTURATION Assimilation - Relinquish original ethnic/cultural identity ¾ Integration - Maintain identity and incorporate majority identity ¾ Separation - Withdrawal from majority ¾ Segregation - Forced separation ¾ Marginalization - Lack of identity with both the original ethnic/cultural group and majority group ¾

Lifetime Prevalence of CIDI Disorders in Fresno and National Comorbidity Survey (NCS) (Vega, Kolody, Aguilar-Gaxiola et al., 1998) 50

Affective Disorders

P e r c e n t a g e

40

Anxiety Disorders

30

Any Substance abuse/ dependence Any Disorder

48.6

48.1

28.2

27.7 24.9

25

23.2

20

18.7

19.5

13

10

10.5 8 0 Immigrants

F r e s n o

U.S.-Born Mexican Americans

S t u d y

NCS-Total

12-Month Rates of Health Care Services Use by Mexican Americans with Mental Disorders (Vega, Kolody, Aguilar-Gaxiola & Catalano, 1999) 50

P e r c e n t a g e

Mental Health 40

General Medical Any Provider

37.5

30 28.1 24

20

18.4 15.4

10 0

11

11 9 11.9 8.8

4.6 Immigrant Mexican Americans

Native-Born Native Born Mexican Americans

Mexican American Total

LEVEL OF RACIAL IDENTITY Completely unaware of any other racial groups ¾ Vaguely aware of other racial groups ¾ Pro your racial group and anti other racial groups ¾ Embracing a “people are people” philosophy ¾ Embracing a “people are people” philosophy while recognizing there are racial identity, ethnic, and cultural differences ¾

Moderating Variables in Acculturation Type of acculturating group ¾ Refugee ¾Have stigmatic notions regarding mental illness ¾Have more pressing problems of lack of English skills, family separation, unemployment, limited funds, lack of transportation, insufficient child care. ¾Maybe misleadingly suspicious and paranoid ¾May present with somatic complaints ¾ May have PTSD confused with psychosis due to language barriers

Moderating Variables in Acculturation Type of acculturating group ¾ Immigrants ¾ Indigenous

people ¾ Native born ethnic minority ¾ Sojourners

CULTURAL COMPETENCE ¾ It

is not p possible for someone outside of the culture to be culturally competent p in that culture. ¾ It is possible to learn how to be culturally sensitive sensitive, in varying degrees, to different cultures.

RACISM,, TORTURE & TERRORISM ¾ Racism

is an abuse of human rights which is identical to,, supplementary pp y to, and complimentary to torture and terrorism.

¾ Torture

is the deliberate, systematic infliction f off physical and mental suffering for the purpose of forcing people to conform.

RACISM,, TORTURE & TERRORISM ¾ Terrorism is actual or threatened violence to g gain attention causing g people p p to exaggerate the strength of the terrorists and the importance p of their cause. ¾The purpose of terrorism is to destroy mental health and wellness.

¾Racism, torture, and terrorism all require the victim to be dehumanized and degraded.

Oppressed/Oppressor pp pp Relationships IIn any effective ff ti and d efficient ffi i t submissionb i i dominance system, it is critical for the oppressor to monopolize the perception of the victim. ¾ One is victimized in proportion to the quality of space, time, energy, and mobility that one must yield or has yielded to the oppressor. oppressor ¾ Conversely, the more one regains or commands control of these elements the less one is victimized. ¾

MICROINSULTS AND MICROAGGRESSIONS ¾ African-Americans

are subjected to daily minute insults and aggressions. ¾ Known as microinsults and microaggressions these offensive mechanisms are designed to operationall keep Blacks in the operationally inferior, dependent, helpless role.

MICROINSULTS AND MICROAGGRESSIONS ¾ These

mechanisms are nonverbal and kinetic and they are well suited to kinetic, control space, time, energy, and mobility of an African-American African American while at the same time producing feelings of degradation. degradation

MALCOLM ON RACISM ¾

“All of us have suffered, here in this country, political oppression at the hands of the white man, economic exploitation att the th hands h d off the th white hit man, and d social i l degradation at the hands of the white man Now, man. Now in speaking like this, this it does not mean we’re anti-white, but it does mean we we’re re anti-exploitation, anti exploitation, we we’re re antianti degradation, we’re anti-oppression. And if the white man doesn’t want us to be anti-him, let him stop oppressing and exploiting and degrading us.”

AFRICAN-AMERICAN CONFUSION ABOUT RACISM ¾ African-Americans

are confused about whether they are being tolerated or accepted p by y whites. ¾ There is confusion about the supportive efforts of individual whites versus the destructive action by whites as a collective collective.

AFRICAN-AMERICAN CONFUSION ABOUT RACISM ¾ The

third confusion is when, where, and how to resist oppression versus when, where, and how to accommodate it. ¾ The final confusion is whether an African-American’s locus of control is internal or external external.

Stress ¾ Stress

occurs when the body looses its physiological p y g or p psychological y g balance and strives to re-acquire its balance, e.g. exercise causes the body to get short of oxygen and the lungs increase their rates of respiration to catch up up.

Distress ¾ Distress

occurs when the body looses its physiological p y g or p psychological y g balance and to re-acquire balance the body must tax itself beyond its usual limits limits, but not beyond its capacity.

Traumatic Stress ¾ Traumatic

stress occurs when the body looses its p physiological y g or p psychological y g balance to such an extent that the reacquisition of body and mind balance is beyond its capacity.

1985 - Children (N = 536; Ages 7 to 15) % Witnessing g Violence SHOOTING

STABBING

40

30 20

26.3

30

10 0 SHOOTING

STABBING

1987 – 88 Children (N=997; (N 997; Ages10 – 19) % Witnessing Violence SHOOTING

STABBING

KILLING

50 40 30

39.4 34.6

20 23.5 10 0 SHOOTING

STABBING

KILLING

1987 – 88 Children (N=997; (N 997; Ages 10 to 19) % Victimized by Violence SHOT AT

KNIFE ATTACK

12 10 8

10.9

6 4 4.3

2 0 SHOT AT

KNIFE ATTACK

1994 Children (N=203; (N 203; Ages 13 to 18) % Witnessing Violence SHOOTING

STABBING

KILLING

70 60 50

60 6 60.6

40 30

45

43

STABBING

KILLING

20 10 0 SHOOTING

1994 Children (N=203; (N 203; Ages 13 to 18) % Experiencing Violence Shot at 50 45 40 35 30 25 20 15 10 5 0

Attacked with a knife

Beaten/Mugged

43

Shot at

8.6

8.5

Attacked with a knife

Beaten/Mugged

Categories of Adverse E Experiences i Psychological abuse ¾ Physical abuse ¾ Sexual abuse ¾ Violence against mother ¾ Living with household members who were substance abusers ¾ Living with household members who were mentally ill or suicidal ¾ Living with ex ex-offender offender household members. ¾

Results The most prevalent of the 7 categories of child exposure was substance abuse in the household (25.6%). ¾ The least p prevalent exposure p category g y was evidence of criminal behavior in the ( ) household (3.4%). ¾ More than half of respondents (52%) experienced > 1 category of adverse childhood exposure ¾ 6.2% 6 2% reported > 4 exposures exposures. ¾

Results ¾

Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none, had a: – 7.4 fold increase for alcoholism – 10.3 10 3 fold increase for drug abuse – 4.6 fold increase for depression – 12.2 12 2 ffold ld iincrease in i suicide i id attempts. tt t

Results ¾

Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none had a: – 2.2-fold increase in smoking – 2.2 2 2-fold fold increase in poor self-rated self rated health – 3.2-fold increase in > 50 sexual intercourse partners – 2.5-fold increase in sexually transmitted disease di

Results ¾ Persons P

who h experienced i d 4 or more categories of childhood exposure compared to those who had experienced p none had ¾a 2.2 fold increase in ischemic heart disease ¾A 1.9 fold increase cancer, ¾A 3 3.9 9 ffold ld iincrease in i chronic h i lung l disease (bronchitis and emphysema), ¾A 1.6 fold increase in skeletal fractures, ¾and a 2.4 fold increase in liver disease.

Remember Your Medical History ¾

An Infectious agent, g , a genetic g defect,, & a deficiency of an element – all risk factors that were predictive of poor mental health outcomes, now corrected by protective factors. –N Neurosyphilis hili used d to t b be responsible ibl for f half h lf of all inpatient psychiatric hospitalizations. – Phenylketonuria used to be a major cause of mental retardation. – Iodine deficiency y used to be a major j cause of mental retardation in the form of cretinism.

Trauma is Ubiquitous q ¾

¾

¾

¾

Bell & Jenkins (1985) found that 25% and 30% of innercity Chicago children, ages 7-15, had seen a shooting and stabbing, stabbing respectively. respectively Using structured telephone interviews in a national sample of 4,008 adult women, Resnick et al (1993) found a lifetime rate of exposure to any type of traumatic event of 69%. Kessler et al (The National Comorbidity Survey - 1995) 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. Breslau et al (1998) examined trauma exposure and the g of PTSD in a telephoned p community y sample p of diagnosis 2,181 individuals in the Detroit area and found that the lifetime prevalence of trauma exposure was 89.6%.

Exposure To A Traumatic Event Does Not Automatically y Put A p person On A Path To Develop p PTSD: The Importance of Protective Factors To Promote Resiliency ¾ Kessler et al (1995)found 8% of males and 20% of females ¾ Breslau et al (1992) found 10% of males and 14% of females who were exposed to trauma had a lifetime prevalence rate of PSTD) ¾ Exposure E to t a traumatic t ti stress t does d automatically t ti ll mean a victim of trauma is predisposed to develop p PTSD. ¾ Most people affected by a trauma event will adapt in a period of 3 – 6 months following trauma (Riggs et al, al 1995) and only a small proportion will develop long-term psychiatric disorders (Bryant, 2006; Bryant 2006).

Minimizing Effects Of Trauma ¾

¾

¾

24% of p posttraumatic stress at follow-up p is predicted by pre-trauma catastrophic appraisals about the future and one’s symptoms. M l d ti appraisals Maladaptive i l about b t themselves, th l rather th than maladaptive appraisals about the world or self-blame, self blame, contributes PTSD. Thus, self-oriented appraisals, e.g. having a lack of self-efficacy, contribute to the risk of getting PTSD after a traumatic exposure. – Bryant R & Guthrie RM. (2005) Factor for Posttraumatic Stress: A Study of Trainee Firefighters. Psychological Science, 16 (10), 749 – 752.

¾

Thus, turning learned helplessness into learned helpfulness is a protective factor against PTSD. – Bell CC. Cultivating Resiliency in Youth. Journal of Adolescent Health, Vol. 29: 375 - 381, 2001. http://www.giftfromwithin.org/pdf/carlbell.pdf

Principles p of Coping p g with Traumatic Stress ¾ Safety S f t

is i a priority. i it ¾ Symptom y p reduction using g medication. ¾ Education about traumatic stress manifests and how to cope or treat itit. ¾ Being able to tell the story in a safe, empathic interpersonal environment.

Principles p of Coping p g with Traumatic Stress Taking T ki a h holistic li ti h health lth approach h and d addressing issues of diet, exercise, humor, and d spirituality. i it lit ¾ Making sure that social networks, i.e., family and support groups, are in place. ¾ Being g able to find meaning g by y turning ga negative into a positive is also an essential part of the restorative p p process. ¾

Principles p of Coping p g with Traumatic Stress ¾Try y

to turn traumatic helplessness p into learned helpfulness

Child Welfare: CANS Psychiatric Symptoms Integrated Assessment Assessment, FY06 30 25

25.4

20 17.9

17.7

15

16.7

10 5 0 Trauma

Attach

Anger

Depress

% N 1375 N=1375

Risk of Symptoms & Strengths 2 STR STR S STR STR STR

Risk k Average e (z)

1.5 1

90th 75th 50th 25th 10th

Pctl Pctl Pctl Pctl Pctl

= = = = =

1.27 0.72 -0.01 -0.73 -1.38

05 0.5 0 -0.5 05 -1 -1.5 -2 -2

-1.5

-1

-0.5

0

0.5

1

1.5

Traumatic Experience Score (10,25,50,75,90 Pctl)

2

Suicide Prevention Protective Factors ¾ ¾ ¾ ¾

20% - 20,000/100,000 , , get g Major j Depression 8% - 8,000 , attempt p suicide 0.012% - 12/100,000 commit suicide Clearly, risk factors are not predictive factors due to protective factors factors.

Paradigm g Shift

“Risk Risk factors are not predictive factors due to p protective factors.”

CHARACTERISTICS OF RESILIENCY ¾ Cu Curiosity os ty

and a d intellectual te ectua mastery aste y ¾ Compassion - with detachment ¾ Ability to conceptualize ¾ Conviction of one's right to survive ¾ Ability to remember and invoke images of g good and sustaining g figures g ¾ Ability to be in touch with affects, not denying or suppressing major affects as they arise

CHARACTERISTICS OF RESILIENCY ¾ Goal

to live for ¾ Ability to attract and use support ¾ Vision of the possibility possibilit and desirability desirabilit of restoration civilized moral order ¾ The need and ability to help others ¾ An affective repertory ¾ Resourcefulness ¾ Altruism toward others

CHARACTERISTICS OF RESILIENCY

¾ Traumatic

Helplessness - Learned helpfulness ¾ Sense of Atman – True Self ¾ Kokoro (Heart) is an essential component in having resiliency - also known as "Indomitable Fighting Spirit“ ¾ Having a totem – An animal spirit that live inside ¾ Cultivating C lti ti Chi – Chinese Chi word d for f internal energy

Triadic Theory of Influence ¾ ¾ ¾ ¾

¾ ¾ ¾

¾

Sociological g theories of social control and social bonding (Akers et al., 1979; Elliott et al., 1985) Peer clustering (Oetting & Beauvais, 1986) Cultural identity (Oetting & Beauvais, 1990-91) Psychological theories of attitude change & b h i behavioral l prediction di ti (Fishbein (Fi hb i & Ajzen, Aj 1975; 1975 Ajzen, 1985) Personality development (Digman, (Digman 1990) Social learning (Akers et al., 1979; Bandura, 1977, 1986)) Integrative theories (Jessor & Jessor's, Problem Behavior Theory; Brook’s Family Interaction Th Theory, Hawkins’ H ki ’ Social S i l Development D l t Theory) Th ) See Petraitis, Flay and Miller (1995).

Cultural/ Attitudinal Stream

Social/ Normative Stream

Intrapersonal Stream

Community Psychiatry Protective Factor Field Principles ¾ ¾ ¾ ¾ ¾

Rebuilding the Village/Constructing Social Fabric Access to Modern Medical Technology gy Connectedness Social Skills Self Esteem – – – –

¾ ¾

Activities that create a sense of power Activities that create a sense of connectedness Activities that create a sense of models Activities that create a sense of uniqueness

Reestablish R t bli h the th Adult Ad lt Protective P t ti Shield Shi ld Minimize the Effects of Trauma

Photo by Aleta McLeod 2-29-08: Dr. Bell standing on 60ft cliff off Shipwreck beach in Kauai, Hawaii

Photo by Aleta McLeod 2-29-08: Dr. Bell jumping off a 60ft cliff off Shipwreck beach in Kauai, Hawaii

Fact ¾

One fifth of the U.S. adult population is One-fifth flourishing - the rest are “languishing in life. life.”

Positive emotions (i.e. emotional well-being) well being) ¾

Positive affect – Regularly cheerful, interested in life, in good spirits, p , happy, ppy, calm and peaceful, p , full of life.

¾

Avowed quality of life – Mostly or highly satisfied with life overall or in domains of life life.

Positive psychological functioning (i e psychological well-being) (i.e. ¾

Self-acceptance – Holds positive attitudes toward self, acknowledges, likes most parts of self, personality.

¾

Personal growth – Seeks See s challenges, c a e ges, has as insight s g t into to o own potential, feels a sense of continued development

Positive psychological functioning (i e psychological well-being) (i.e. ¾

Purpose in life – Finds Fi d own life lif h has di direction ti and d meaning. i

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Environmental mastery – E Exercises i ability bilit tto select, l t manage, and d mold ld personal environs to suit needs.

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Autonomy – Is guided by own, socially accepted, internal standards and values values.

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Positive relations with others – Has Has, or can form, form warm, warm trusting personal relationships

Positive social functioning (i.e., social well-being) well being) ¾

Social acceptance p – Holds positive attitudes toward, acknowledges, and is accepting of human differences

¾

Social actualization – Believes people, groups, and society have potential and can evolve or grow positively

¾

Social contribution – Sees own daily activities as useful to and valued by society and others.

Positive social functioning (i.e., social well-being) well being) ¾

Social coherence – Interested in society and social life and finds them meaningful and somewhat intelligible.

¾

Social integration – A sense of belonging to, and comfort and support from, a community.