Behavioral Health Leadership in a High-Risk Occupation

Occupational Health Psychology Summer InstituteOregon Healthy Workforce Center

Portland State UniversityJuly 2016

Amy B. Adler, Ph.D.Center for Military Psychiatry and Neuroscience

Walter Reed Army Institute of Research

Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the U.S. Army Medical Command or the Department of Defense

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PTSD

Source: Castro & Adler (2011) “Re-Conceptualizing PTSD” in Deployment Psychology

• Unexpected• Discrete• Unwanted

TraumaticEvent

• Freezing• Intensefear• Shutting

down

Reaction

• Maladaptive• Spread

acrossdifferentdimensions

Symptoms

• Social• Work• Family

Impairment

VictimModelofPTSD

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OccupationalHealthModelofPTSD

Source: Adapted from Castro & Adler (2011) “Re-Conceptualizing PTSD” in Deployment Psychology

• Adaptive• Maladaptive

Symptoms

• Expected• Consistent

withidentity• Multiple

Events

TraumaticEvent

• TrainingKicksIn

• “Autopilot”

Reaction

• Grief• Second

guessing• Anger• Risk-Taking• Moralinjury

Symptoms

• Functioningwithsymptoms

• Unmaskedpost-transition

Impairment

TrainingandPreparation Context MilitaryCulture

&Structure

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Leadership• Leadership correlated with better mental health

– Civilian contexts (Kelloway & Barling, 2010) – Peacekeeping (Bliese & Halverson, 1998)– Combat (Jones et al., 2012)

• General leadership skills– Relevant in many situations (Bliese & Britt, 2001)– Span transactional and transformational behaviors (Bass, 1990).

• Limitations– Relatively “blunt instrument” for addressing specific challenges– Harder to teach (Barker, 1997; Gunia et al., 2015)

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WRAIRGeneralLeadership

WRAIRItemsExhibitsclearthinkingandreasonableactionunderstress

Tellssoldierswhentheyhavedoneagoodjob

Triestolookgoodtohigher-upsbyassigningextramissionsordetailstosoldiers

Embarrasses soldiersinfrontofothers

Source:WRAIRitems:Bliese &Britt,2001;Castro&McGurk,2007

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Domain-SpecificLeadership

• Previous Research– Safety-specific leadership1

– Health-specific leadership2

– Family-supportive leadership3

• Measures– Behaviors that can be observed– Referent varies depending on context

GeneralLeadership Domain-SpecificLeadership

MentalHealth&Well-Being

1Source:Barling,Loughlin,&Kelloway (2002);2Source:Gurt,Schwennen,&Elke(2011);3Hammeretal.(2011)

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BehavioralHealthLeadershipDomains

• Sleep leadership• Combat Operational Stress

Control (COSC) leadership• Health-promoting leadership• Resilience training leadership• Emotion regulation leadership• Post-traumatic growth

leadership

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SleepLeadership

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61%

8%

25%21%

10%

31%

4%

41%

0%

10%

20%

30%

40%

50%

60%

70%

Soldiers Civilians

%ofP

opulation

HoursofSleepPerNight

ReportedHoursofSleepAmongSoldiersandCivilians

≤5 6 7 ≥8

SleepHours

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Sleep:Background• High-risk occupations and sleep problems

– 20-30% (Seelig et al., 2010)– 28.7-32.2% (J-MHAT-7)

• Sleep problems linked to – Performance problems (Wesensten et al., 2006)– Mistakes (LoPresti et al., in press; MHAT-9)– Affect dysregulation (van der Helm & Walker, 2012)– Mental health problems (Seelig et al., 2010; Wright et al., 2011)– Moral decision-making (Barnes et al., 2012)– Health risk behaviors (Luxton et al., 2011)

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SleepLeadershipImmediateLeaders

Often/AlwaysConsidersleep asanimportantplanningfactor 34.7%

EncourageServiceMemberstogetextrasleepbeforemissionsthatrequirelonghours

34.6%

EncourageServiceMemberstotrytogotosleepontime 29.8%

EncouragesServiceMemberstogetadequatesleep 25.6%

WorktoensureServiceMembershaveagoodsleepenvironment(quiet,dark,nottoohotorcold)

23.6%

Supporttheappropriateuseofprescriptionsleepmedication 16.5%

Discouragetheuseofcaffeineornicotinewithinseveralhoursbeforetryingtogotosleep

14.1%

EncourageSoldierstoreducesleepdistractionsbyusingearplugs,eye-masksorotherstrategies

10.8%

EncourageServiceMemberstonapwhenpossible* 8.5%

AsksServiceMembersabouttheirsleepinghabits 5.8%

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SleepLeadership:Peacekeeping• Survey of 623 US Soldiers deployed to Horn of Africa

(alpha = .90)

Rank GeneralLeadership

SleepLeadership

SleepQualityMoraleCohesion

Source:Gunia,Sipos,LoPresti &Adler,2015,MilitaryPsychology

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SleepLeadership:Combat• Survey of 619 US Soldiers deployed to Afghanistan (alpha

= .93)

Rank GeneralLeadership

SleepLeadership

SleepQuantityMoraleCohesion

Source:Gunia,Sipos,LoPresti &Adler,2015,MilPsych

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SleepLeadership:IndirectEffects• In both studies, indirect effect of sleep leadership

• Longitudinal study finding similar effects (Gunia et al., in prep)

(-.52***)

(.07+)

Sleep quality.10* -.51***

.02 DepressionSleep leadership

Bootstrap, CI = -.87 to -.27 (5000 iterations; Preacher & Hayes, 2004)

Source:Gunia,Sipos,LoPresti &Adler,2015,MilPsych

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BehavioralHealthLeadershipDomains

• Sleep leadership• Combat Operational Stress

Control (COSC) leadership• Health-promoting leadership• Resilience training leadership• Emotion regulation leadership• Post-traumatic growth

leadership

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COSCLeadership• Combat Operational

Stress Control (COSC) Leadership– COSC manual identifies a set

of leader behaviors designed to reduce or ameliorate combat stress reactions of subordinates

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COSCLeadership

Source: Adler, Saboe, Anderson, Sipos & Thomas (2014) Current Psychiatry Reports

Often/Always

PlatoonSergeant

PlatoonLeader

Does notjudgesoldierswhoseekbehavioralhealthhelp 53.4% 50.8%

Encouragessoldierstoseekhelpforstress-relatedproblems 47.7% 47.2%

Demonstratesconcernforhowfamiliesaredealingwithstress

48.0% 46.8%

Interveneswhenasoldierdisplaysstressreactionssuchasanxiety, depressionorotherbehavioralhealthproblem

45.2% 43.8%

Encouragessoldierstoexpressemotionsfollowinglossesandsetbacksduringdeployment

42.3% 42.3%

Remindssoldiersafterintenseexperiences thatweareheretoservewithhonor,mission,greaterpurpose

49.4% 49.4%

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COSCLeadership&MentalHealth

• 2,072 US Soldiers in Afghanistan (alpha = .91-.94)

Rank&Combat

Experiences

GeneralLeadership(NCO&PL)

COSC-SpecificLeadership

PCLAnxiety

DepressionComfort

talkingtoBHProvider

Source: Adler, Saboe, Anderson, Sipos & Thomas (2014) Current Psychiatry Reports

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COSCLeadership&Combat

17

27

37

47

Low High

PTSD

Sym

ptom

s(PC

L)

CombatExposure

COSCLeadershipBehaviors,CombatExposure,andPTSDSymptoms

LowCOSCLeadership HighCOSCLeadership

Note: Analysis controlled for rank and general leadership.Source: Adler, Saboe, Anderson, Sipos & Thomas (2014) Curr Psych Rep

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BehavioralHealthLeadershipDomains

• Sleep leadership• Combat Operational Stress

Control (COSC) leadership• Health-promoting

leadership• Resilience training leadership• Emotion regulation leadership• Post-traumatic growth

leadership

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Health-PromotingLeadershipThinkingaboutyourcurrentteam/unit,ratehowoftendoesyourleadership Often/AlwaysEmphasizemaintainingprofessionalstandards 74%

Emphasizetakingcareofyourselfphysically 63%

Emphasizetheimportanceofthemedicalmission 61%

Emphasizetakingcareofyourselfmentally 52%

Giveyoupositivefeedbackaboutyouraccomplishments 44%

Emphasizemaintainingcompassion 41%

Remindyoutotakeabreak/recharge 41%

Encourageyoutogetenoughsleep 37%

Giveyouspecificguidanceonhowtoimprove 35%

Reducetension intheteam/unitwhenemotionsrunhigh 34%

Source: Adler, Adrian, Hemphill, Scaro, Sipos, & Thomas, under review

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Health-PromotingLeadership&Burnout

• 344 medical staff deployed to Afghanistan (alpha = .95)

RankPTSD

SymptomsProfessionalStresssors

GeneralLeadership

Health-PromotingLeadership

Burnout(EmotionalExhaustion+Deperson-alization)

Source: Adler, Adrian, Hemphill, Scaro, Sipos, & Thomas, under review

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OperationUnitedAssistance• 498 Soldiers in Controlled Monitoring Areas (CMAs) • 21-Day CMA (quarantine)• 4 cohorts (MAR-MAY 2015)• Following 6-month deployment to Liberia in response to

Ebola outbreak

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CMA:Attitudes

Agree or Strongly Agree

19.7%

43.9%

30.0%

42.7%

52.5%

54.0%

63.5%

71.8%

0% 20% 40% 60% 80% 100%

Shouldbeapartofeverydeployment

Willhelpmetransitionhomemoreeasily

Isawasteoftime

Isagoodidea

Willhelpkeepourcommunitiessafe

Willhelpkeepourfamiliessafe

Isunderstandable

Willreduceanxietyinourcommunities

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% Often or Always

53.0%

58.4%

58.6%

62.5%

65.0%

65.4%

73.9%

74.1%

0% 20% 40% 60% 80% 100%

Giveyouspecificguidanceonhowtoimprove

Encourageyoutogetenoughsleep

Emphasizetheimportanceofthehumanitarianmission

Placecommandemphasisonimportanceofhealthmonitoringmeasures

Leadbyexamplebyusinghealthmonitoringmeasuresthemselves

Emphasizetakingcareofyourselfmentally

Emphasizemaintainingprofessionalstandards

Emphasizetakingcareofyourselfphysically

*

CMAVersionofHealth-PromotingLeadership

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Health-PromotingLeadershipinCMA

Rank General Leadership

Health-Promoting Leadership

DepressionAnxiety

Attitudes toward CMA

Source: Adler, Kim, Thomas & Sipos, in prep --Alpha = .97

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BehavioralHealthLeadershipDomains

• Sleep leadership• Combat Operational Stress

Control (COSC) leadership• Health-promoting leadership• Resilience training

leadership• Emotion regulation leadership• Post-traumatic growth

leadership

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ResilienceTrainingLeadership

ImmediateLeadersModerately/Quitea

Bit/A lotAttendresiliencetrainingactivities 64%

Emphasizetheimportanceofresilience trainingskills 62%

Refertoskillswhen talkingwithsoldiers 56%

Encouragesoldierstousetheskills 66%

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ValidationofResilienceTrainingLeadership

9%21%

35%

62%

0%

20%

40%

60%

80%

100%

Negative Justgoingthroughthemotions

Opentotheideaitmightbeuseful

Enthusiastic

%SoldiersA

gree

ingL

eade

rs

Attend

edResilien

ceTraining

SoldierPerceptionofLeaderAttitudetowardResilienceTraining

Figure1.SoldierPerceptionofLeaderAttitudesTowardResilienceTrainingandTraining

Attendance

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ResilienceTrainingLeadership&UnitClimate

• 2,181 Soldiers deployed to Afghanistan

Rank&Combat

Experiences

GeneralLeadership

ResilienceTraining

Leadership

PerceptionofTraining

UnitClimate

Source: Sims & Adler (in press) Parameters

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AdditionalBehavioralHealthLeadershipDomains

• Sleep leadership• Combat Operational Stress

Control (COSC) leadership• Health-promoting leadership• Resilience training leadership• Emotion regulation

leadership• Post-traumatic growth

leadership

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EmotionRegulationLeadership• 3,030 Soldiers surveyed in Afghanistan and Germany

(alpha = .86)

Often/Always

PlatoonSergeant

PlatoonLeader

Canpausewithoutimmediately reactinginemotionallychargedsituations.

36.3% 36.8%

Cancalmdownquicklyifhe/shegetsupset. 48.0% 46.3%

IsgoodatcalmingSoldiersdownwhentheygetangry.

41.7% 54.8%

IsgoodatacknowledgingwhenSoldiersaregoingthroughatoughtime.

46.7% 43.0%

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Leadershipvs.BHLeadership• Are domain-specific leadership behaviors all the same?

– Similar pattern for Platoon Leaders & Immediate Supervisors

SleepLeadership

COSCLeadership

ResilienceTrainingLeadership

EmotionRegulationLeadership

GeneralLeadership .35 .55 .28 .61

SleepLeadership .52 .40 .44COSCLeadership .43 .72ResilienceTrainingLeadership

.35

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Implications• Validates doctrine

– Sleep – COSC

• Training– Examine degree to which these skills are trainable– Assess efficacy of training in context

• Alternatives to Training– Over reliance of training as “The Answer”– Integrate into the culture– Consider role of “bystanders”– Train indirectly

• Work with Stakeholders

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ImplementationDirectTraining

TrainEmbeddedProvidersin“ConversationStarters”

IntegratedintoMasterResilience Training–Medicalcourse

Integrateinpre-commandcourse

TrainEmbeddedProvidersin“ConversationStarters”

GeneralLeadership

SleepLeadership

OperationalStressControl

Leadership

FamilySupportiveLeadership

ResilienceTraining

Leadership

HealthPromotingLeadership

Emotion

Regulation

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SleepLeadershipTraining

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FutureDirections• Complete analysis of behavioral health leadership scales

– Emotion regulation– Post-traumatic growth leadership (Wood et al.)

• Sleep leadership training studies– Army study with Behavioral Health Officers– Hammer study with National Guard– Navy study of sleep leadership – International interest (5-nation program)

• Explore emotion regulation leadership – Mindfulness leadership– Self-distancing techniques

• Consider small-team culture & other occupational groups

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ThankYou!

AmyAdler,PhDClinicalResearchPsychologistandSeniorConsultantCenterforMilitaryPsychiatryandNeuroscience

amy.b.adler.civ@mail.mil