In recent years the question of coping and resiliency became more than just a theoretical or research issue but a crucial element in crisis intervention. With the growing numbers of ASR (Acute Stress Reaction) clients referred to immediate help following major critical incidents , in some cases in the ratio of 1:9 or 10 injured to emotionally affected, the question of how to assess coping on the one hand and what to focus on in mental first aid is a burning question.
In the past two decades I have managed supervised developed and trained hundreds of crisis intervention centres and teams and studied the amazing phenomena of the ability of individuals, families groups and communities to recover from disasters.
These studies and surveys never failed to amazed me and help me to admire the spirit of human kind.
This chapter will review some of the concepts related to coping and resiliency together with the results of our studies and my personal view and suggestions for an integrated model to approach major incidents.
Historical Overview of Stress and Coping - "The Survival Game"
Historically there were several theoretical attempts to describe the human code of survival. Some of these attempts tried to present an exclusive explanation, whilst others tried to highlight one aspect in relation to previous theories. One can deduce from these attempts six fundamental elements in explaining human survival. Freud (1933) stressed the affective world, both inner (i.e. unconscious) and overt, (projection and transference) and it is Freud who stated that early emotional experiences, conflicts and fixations determine the way a person meets the world. Often this unconscious part overrides the transactions of the real world.
His students and colleagues, Erikson (1963) and Adler, (1956) albeit from a different angle, highlighted the role of society and the social setting in the way a person meets the world, Adler in his theory of inferiority and the drive for power and Erikson in his eight stages of development
Jung, who was originally a student of Freud's emphasised the symbolic and archetypal element, imagination, "the culture heritage" and the fantastic inner and outer world. Jung also mentioned intuition as one of his types.
Other psychological theories have dismissed the whole idea of psyche and emotion and have attempted to describe the human behaviour in terms of stimulus and response. This has been called behaviourism, but we suggest that they should be called physiologist, because their theory suggests neuro-chemical chains of reactions result in behaviour (Pavlov 1927). Before long, the cognitive school found its own theory about the way a person meets the world and they phrased it "Its all in the mind", or cognitive processes with errors of thought or perception.
Last but not least we have the beliefand meaning stream, presented by Maslow and later developed into a psychological theory and psychotherapeutic approach by Victor Frankl (1963). Based on his extreme experiences of the Holocaust he founded the Logotherapy Movement.
We believe that these exclusive attempts to describe human psychic life have many disadvantages and that human psychic life is more complex than the theoretical attempts to describe it on one or two dimensions. In our approach we tend to relate to the six dimensions that in our experience underlie the coping style of the client: Belief and values, Affect (emotional), Social, Imaginative, Cognitive, and Physiological. We have named it BASIC - Ph. It is this multi-modal approach that suggests a combination between these elements in the unique coping style of each person.
Obviously, people react in more than one of these modes, and everyone has the potential to cope in all six modes, but each person develops his own special configuration. Most of us at different times have a preferred mode or modes of coping and will use this extensively. From hundreds of observations and interviews with people under stress (Lahad 1981,1984) it is apparent that each individual has a special way of coping and combining coping mechanisms.
In our research of coping mechanisms under stress (Lahad 1984, 1989), we have found different coping styles. There are those whose preferred mode of coping is cognitive-behavioural. The cognitive strategies include information gathering, problem solving, self navigation, internal conversation or lists of activities or preference. Another type will demonstrate an emotional or "affective" coping mode and will use expressions of emotion: crying, laughter or talking with someone about their experiences; or through non-verbal methods such as drawing, reading or writing.
A third type will opt for a social mode of coping, and receive support from belonging to a group, having a task, taking a role and being part of an organisation. A fourth will use imagination either to mask the brutal facts, by day-dreaming, pleasant thoughts, or divert their attention using guided imagery; or try and imagine additional solutions to the problem that go beyond the facts -improvisation. Type five will rely on belief and values to guide them through times of stress or crisis. Not only religious belief are meant here, political stands beliefs or feeling of mission (meaning) are also intended, the need for self-fulfilment and strong "self" expressions. "Ph" type people are those who mainly react and cope by using physical expressions together with body movement. Their methods for coping with stress are relaxation, desensitisation, physical exercise and activity. Expending energy is an important component in many modes of coping.
Resilience How does the personal BASIC Ph develop? One approach is through the studies of resilience. Resilience is defined as self-stabilising and overall healthy patterns of development which lead neither to a career of disordered behaviour (drugs, delinquency etc.) nor to manifest mental or psychosomatic syndromes. It is noteworthy that temporary oscillations of individual behaviour on the health - disorder spectrum under impact of an acute stressor are implied, but in the medium and long-term a remission of symptoms should occur. The individual degree of resilience is understood as being relative in so far as quantitative and qualitative variations cannot be ruled out (Koferl 1989). It is only in this decade that empirical psychology has begun to conceptualise resilience applying models which are based explicitly on the idea of healthy or adaptive development in the face of stressful influences, rather than by using derivatives of stress - disturbance models.
In retrospect, research into coping with stress has also produced decisive contributions. The primary appraisal category, "challenge" in Lazarus' stress model is particularly worthy of consideration (Folkman and Lazarus, 1988). The transformation of the trend towards negative pathogenic effects of a stressful life event through coping and reappraisal processes into a new homeostasis promoting psychological and physical health is of outstanding importance for resilience research. All most recent variations of mainline stress models have, since the mid-eighties, taken account not only of psycho-pathological syndromes but also of variables in psychological health and well being, (e.g. Lazarus et al 1984, Moos 1984).
Empirical research has gained many insights into factors and mechanisms which are important to the development of a resilient person - environment relationship. These findings can be redefined and categorised within the model of BASIC Ph.
- B, Ph The way of coping and managing a single stressor or multiple risk factors, the decisive question being whether a person merely reacts or also acts (e.g. Rutter, 1985).
- C, B A low tendency towards problem avoidance or fatalism (e.g. Losel et al., 1989).
- B, C Cognitions of self-efficacy and self esteem (e.g. Rutter 1985).
- A, S Availability of an emotionally stable and trustworthy person during early childhood (e.g. Brandt 1984).
- S Stable emotional relationships with and positive experience in social communication, with other (extra-familial) persons including a social support network of functional size, as well as satisfaction with the different types of support received.
- S, A, Ph Temperamental characteristics of a child which favour de-escalation and self-control in general as well as in acute crises but which also promote an overall uncomplicated child-parent relationship, even if both parents are in chronic discord (e.g. Chess and Thomas 1985).
- B, A, C The ability of the child to accept delay in gratification (e.g. Murphy 1987).
- I, C Curiosity, Motivation and joy in exploratory behaviour already as an infant, as well as motivation to observe and listen (e.g. Murphy 1987).
- C Higher IQ (e.g. Felsman and Valliant, 1987).
- B, I, C An open educational climate directed towards the acquisition of autonomy (e.g. Losel et al 1989).
- S Socially competent behaviour despite chronic stress; helpfulness; popularity with peers and taking on of responsibility for siblings and sometimes also for ill parents (e.g. Werner 1989).
- Ph Physical attractiveness, particularly in girls (e.g. Elder et al, 1986).
Thus we see that BASIC Ph can serve as a model for understanding coping and resilience.
Stressful situations become unbearable when they are prolonged and we are no longer capable, using the resources at our disposal, to be rid of or to lessen the stress. Under circumstances where repeated attempts do not avail, the situation could turn into a crisis. Many times a situation becomes a crisis because the individual uses "more of the same thing" to be rid of the stress. In other words, a person becomes set in the mould, using the same mode of coping endlessly, neither progressing nor changing anything. In this case the crisis stems from being stuck or from inflexibility. (On a primary prevention level our "multi-modal approach" aims to teach the individual a number of different options in order to gain flexibility in coping with stressful situations rather than reach a dead-end).
In crisis situations it is normal for people to feel bad, but they are not actually "ill", simply, their current distress is too hard for them to cope with. Hodgkinson (1991) suggests that up to 50% of the population exposed to disaster will be potential candidates for crisis intervention. From experience we have learned that some will stay for lengthy treatment, many will meet with us just a few times and a minority will have just one or two meetings. In short-term intervention during emergencies there is no time to develop prolonged contact or for taking long case histories.
BASIC Ph is a model to understand the strengths of the client and supply a framework which will enable the therapist to decide whether to suffice with crisis intervention or to introduce short-term psychotherapy.
Therefore, the task of the therapist in crisis intervention is to assess and help develop those useful behaviours as soon as possible. (Short-term intervention must identify as quickly as possible the client's mode of functioning and make decisions on the basis of the understanding of this situation.) The practical difference will be that in crisis intervention, the therapist will use what he found existing within the BASIC Ph and in short-term psychotherapy the therapist focuses on what is missing and on the negative coping aspects indicated.
Six Piece Storymaking - 6 PSM Our assessment tool is based on the use of bibliotherapy, a therapeutic technique which uses the story and storytelling in order to assist the individual to reach self-awareness and improve internal and external communication. The basic assumption of the instrument described is that it will not always be easy for the client (usually a child but possibly an adolescent or adult) to relate what has happened, especially in a time of distress, but when there is a need for a quick evaluation of modes of coping, so that intervention can begin, this instrument will be most useful. Thus our assumption is: to tell a projected story based on the elements of fairy tales and myth; we will see the way the self projects itself in organised reality in order to meet the world.
Thus we believe that this instrument somewhat answers the need for a quick assessment of coping modes with the objective of helping the therapist/helper reach an understanding and develop contact with the client based on the therapist's understanding of the client's language. We have found that this can be done in a very short period of time of training, through the use of our instrument.
Tools: Pencil, paper and eraser. Instructions given to the client are as follows: We are going to tell a story without words. What I mean is, you scribble or draw the story in any way you wish, following my instructions (questions). There is no need to worry about how nice the drawing is, or if it can be understood, you can always explain it. (Note - the story can be told in words).
a) Divide the page into six spaces in any way you want (but do not cut it).
b) Think of a main character - hero or heroine of any story, imaginary, legendary, film, show or simply make one up, think where this character lives and this will be the first picture.
c) The second picture will be the mission or task of that character. In every story or legend the main character has a task to fulfil. What is your hero/heroine's mission? That will be the second picture.
d) Third picture - who or what can help the main character, if at all?
e) Fourth picture - who or what obstacle stands in the way of his/her carrying out the mission/task?
f) Fifth picture - how will he/she cope with this obstacle?
g) Sixth picture - then what happened? Does it end or continue?
Those are the six parts of the story. Now with lines, shapes, symbols or drawings, compose your story. When you have finished you can explain it to me. (There are no time limits.) When the client tells his story the therapist must listen to it on several levels.
1) the tone in which the story is told,
2) the context of the story and its message, (themes),
3) finding the dominant coping modes of the story, (BASIC Ph).
Why do we ask these questions? M.L. von Franz (1987) the great researcher of fairy tales and stories from a Jungian approach has found that these six elements are always represented in fairy tales the world round. She quoted Jung as saying "It is in fairy tales that one can best study the comparative anatomy of the psyche" (p 11) and that the basic and maybe only archetype is that of the self reflected in many ways. Von Franz herself says that fairy tales are the purest and simplest expression of collective, unconscious psychic processes (p 1) and later, she states, "personally, I think that the most frequent way archetypal stories originate is through individual experiences" (p 16). Our assumption is that by telling a projected story based on elements of fairytale and myth, we may be able to see the way that the self projects itself in organised reality in order to meet the world.
Many think that detecting coping behaviour is only demonstrated in picture five, but this is not so. Each picture gives us information on coping modes. If, for example, the hero is a fairy, that gives a suggestion or hints at the use of imagination. The goal can be connected with values and beliefs. The help can be practical or imaginary, or maybe an inner belief. The obstacle can be social, imaginary, or very realistic and demanding of a solution. Coping can come in all kinds of ways and the conclusion can be emotional, intellectual, social or imaginary. Therefore it is important to pay attention and to determine the modes the individual does and does not utilise, and to begin the contact according to those lines.
The way in which we analyse the most developed coping mode/s is by counting the number of times each mode appeared, the one most frequently mentioned is the coping mode most used. The following examples are quoted verbatim and can appear somewhat confusing. The first example of six-piece storymaking is from a child in the third grade. He was referred because of social problems on a background of difficult parent- child relations. (In brackets appear the BASIC Ph initials).
Once upon a time there was a flower (C) and it was small (Ph). When it grew up (Ph) its mission was to get to another flower (S). He had an assistant (S, Ph) who raised him and he had a bow and arrow (C, I). The obstacles were a man (-S) with a gun and fire (Ph) which surrounded the flower. The man who looked after the flower (S) shot (Ph) the man (-S) with the gun and he also had a hose pipe (C), so the flower managed to get to the other flower (S) and in the end the good man (A) brought the two (Ph) flowers to his garden (C). I've also drawn his footsteps. (See picture 1).
Analysing his story according to BASIC Ph has led to the following: 4C, 6Ph, I, 4S, 2S-, A. The interview took the following lines: Q: Why did he decide that he wanted to go to this flower? A: Because he didn't want to be alone, he was the only flower, around him was desert, at first he thought that the grass was his friend, but when he grew up he noticed that he was different and alone. When they were fighting also the grass grew and this helped him, I mean that the grass can also help the man against the desert, but he still wants someone like him. Q: What did the flowers say to him? A: They said that they had waited a long time for him and it was boring without him. The flowers will be friends. Q: What will they feel if they separate? A: If they separate then he will feel sad, but then he'll go and look for another flower, but not in this area.
Second story, reported by a dramatherapy trainee, the story and analysis went as follows:
1. There was this man called Charlie and he doesn't like school and he got expelled a hundred years ago. There was this man Microchip and he's a spy for the enemy of Charlie but he disguises himself as Charlie's friend.
2. What he had to do is this; he tries to get a key because he's lost his front door key. He's lost it down there (points to drawing) at the other side of the sea. But they've added new weapons to stop him getting it.
3. The helper's called Marco and they try to stop (him ?), Marco and Charlie, with school dinners because Charlie did not like school dinners at this time. And the leader of the baddies is the Minotaur.
4. And what they do is: the helper goes up into the wall and Charlie goes up to the top of the wall and Marco sets alight a stick of dynamite and then he goes down to the next cannon and leaves another stick of dynamite. And then when they've exploded, Charlie jumps off in to the sea.
5. When he walks into the sea there's a school dinner thrower he didn't see and it chucks a school dinner into the sky and (just passes) lands just past the school dinner thrower. And the same thing happened to the helper.. And then the helper got a stick of dynamite and exploded a hole through the wall. And then at the end Microchip the spy, (because Charlie got the key and Microchip wasn't happy about it, as he was the spy), he shot Charlie.
1. C.A.I.S.C.S-. 2. C.Ph.C.Ph.C.(Ph-?)
3. S.C.S.I.C.A.C.S.I. 4. S.Ph.C.Ph.C.Ph.C.C.Ph.
5. Ph.I.C.Ph.I.Ph.Ph.C.S. 6. S.C.Ph.S.C.A.C.Ph-.
B...0 A...3 S...8, 1- I...5 C...17 Ph...11 1.5-
Chris has strong coping abilities in the cognitive area which is supported by his imagination and his feelings. A suggested approach would be information gathering and creative problem solving, finding solutions other than the obvious. The minus scores indicate conflict in both physical and social areas and suggests that Chris is having difficulties in his life and relationships. He does not have clear values about life as indicated by the lack of B in his story. The overtones to the story are action and violence. The themes are betrayal, hurting, killing, school is a bad place, school food is bad, you can't trust anyone, life is struggle and full of conflict. You can fight but in the end you lose. The enemy is hidden. Just when you think you've won, a disaster will get you.
Conflicts: Betrayal ... loyalty/friendship.
Hurting and killing ... nurturing and caring.
Trust ... distrust
Fight ... help
Deceit ... openness
Loss ... win/gain.
Dislike of food ... enjoyment of food.
Success/achievement ... failure
In clinical work we use "BASIC Ph" in capital and small letters. The capital letters represent the more dominant characteristics and modalities whilst small letters represent characteristics present in less intensity, or if we are not sure about the mode of operation, small letters. This should then be checked up by asking questions whilst investigating the story, or afterwards during work with the client. This method will be further discussed in a special article which will be devoted to a more statistical description of what is expected for each age group, which configurations there are and what they mean. In our clinical experience we have found many configurations of behaviour clusters which can be identified through the six-piece story techniques. Moreover, we have found that one can identify current conflicts which are causing difficulty, and possibly even the nub of some problem of which the individual is not even fully aware (marked by the minus sign). It is important to note that with this kind of diagnosis, partly verbal and partly non-verbal, one can identify coping resources and plan crisis intervention programmes accordingly.
So, it seems that with the aid of the structured story we can locate relatively quickly a person's coping resources and conflict areas.
Intervention Programmes as a Result of the Assessment of Coping Resources
Intervention programmes as a product of the location of coping resources are constructed from groups of techniques connected to the diagnosed mode of coping and configuration (see diagram 1). For example, in a case where we have identified that a person is more in the "B" mode, beliefs and values, and his main resources are techniques related to values clarification, then the most appropriate forms of intervention for this type of person will be activities encouraging the search for meaning such as Logotherapy, or techniques of value clarification and orders of preference.
In another case, where the assessment has shown the following configurations, "S" social, "C" cognitive and "I" imaginative, we can offer the following instruments: In the cognitive mode they include primarily, information gathering and problem solving. Since the person has been shown to have imaginative capabilities, ordinary problem solving is not enough for him, but improvisation, the ability to imagine solutions over and beyond the routine solution. This means developing resourcefulness and the ability to find alternative solutions, or in the words of Watzlawick et al (1979), "second degree solutions". In addition, since we are talking about someone in whom social facets of coping have been identified, solutions in the problem solving exercise can be directed towards social targets such as taking a new role or responsibility in a group or organisation.
Experience teaches us that within a relatively short time one can plan an initial intervention programme from which, either a longer term treatment programme will come about or a short intervention will suffice. There are other uses for the six-piece story, such as use of the story content itself. We will not expand in this article on those uses of the story, but will merely mention that by looking at the themes, subjects, conflicts and deliberations of the hero, one can check the stance and current emotional state of the storyteller. All this can be done on an interpretative or an analytical level, dynamically or with a Gestalt approach to allow the storyteller to identify with different parts of the story and thus clarify the special meaning of the story for the storyteller himself here and now.
In summary, we have found that the six-piece story can be multi-dimensional, not only in the location of coping resources, but also multi-faceted in the course of short-term crisis intervention therapy or longer term treatment in a dynamic setting.
Diagram 1 - Crisis Intervention According to BASIC Ph Model
The natural state is an
overlap of ME and the WORLD.
The connection is the way ME WORLD
the individual meets the
world through BASIC Ph.
Crisis - feeling that nothing
is working for me "I'm lost" etc. ME WORLD
The therapist identifies BASIC Ph
the language of the individual
and builds a BASIC Ph bridge
with the client. ME WORLD
If not possible - then move to
the forgotten language, i.e.
the language the client uses ME WORLD
least, that means psychotherapy
If successful then the process of
meeting the world starts again
to be followed by the natural ME WORLD
process of overlap.
Appendix 1 - BASIC Ph
Below are the major configurations of BASIC Ph and their interpretations.
B - Self-reliant, clear values, views and beliefs.
BC - Very rigid or concrete beliefs and opinions.
BA - Very sensitive beliefs and opinions, sometimes some imaginary beliefs.
BS - Social values.
A - Affect of all types.
(A-) - Aggressive feeling against the self and general destruction.
AS - Social emotion, (similar to BS) or social support.
AI - Emotions mixed with imaginary characters, frightening dragons monsters etc.
AC - An inclination to understand emotions by conceptualisation, occasionally also neutralisation or control of emotion by intellect.
S - Social, inclination to take a task upon oneself, to be in need of company, not necessarily for support but for a sense of purpose. A source of support in the social setting and in organisations.
SC - Socially aware and capable of solving problems, practical under conditions of stress.
SI - Social support from imaginary figures such as Superman.
(S-) - Feeling of alienation or rejection by society, hostility.
I - Broad imagination either in content or range.
IC - Improvisational ability based on factual knowledge.
(I-) - Morbid imagination.
C - Cognition, knowledge, organisation and thought, acting according to common sense with concrete tasks.
CPh - Concrete ways of thinking, action oriented.
(C-) - Apparent reason for activity but without logic, e.g. going to the seaside because its winter! Lack of reality testing.