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Psychology.EliteCME.com Page i Table of Contents

CE for Massachusetts Psychology All 20 Hrs ONLY Professionals $55 CHAPTER 1: AGING AND LONG-TERM CARE Page 1

The following sections provide a discussion of issues on the mental health needs of older Americans, including a demographic profile of the nation’s elderly population, the mental health problems that tend to be more prevalent among them, mental health and aging dilemmas that concern policy makers as well as service providers, and efforts to give Want more courses to heightened attention to these challenges and to provide programmatic and policy responses. choose from? Aging and Long-Term Care Final Exam Page 17

CHAPTER 2: BULLYING IN CHILDREN AND YOUTH Page 18 No problem!

Bullying in children and youth has become excessively widespread and aggressive in Here are just a few of our most the 21st century. Bullying behavior causes a harmful social, physical, psychological and popular courses: academic impact on personal well-being in very young children to older teenagers. And • Autism Spectrum Disorder in through their own actions and inaction of others who hold responsible roles, bullies learn Children that antisocial behavior and exerting control over others is acceptable and that it works. Bullying creates an atmosphere that is unhealthy for everyone. It interferes with child and • Couples Counseling youth development and can lead to suicide and school violence. • Elderly Mental Health: Bullying in Children and Youth Final Exam Page 36 Depression and Dementia • HIV and Mental Health CHAPTER 3: INDUSTRIAL/ORGANIZATIONAL PSYCHOLOGY Page 37 • Reflective Supervision in Infant Mental Health Practice Industrial and organizational psychologists address two main goals in their research and practice. The first is promoting effective job performance by employees, which ultimately • Understanding Trauma in leads to enhanced performance by the organization as a whole. The second goal is to Children contribute to human welfare by improving the health, safety, and well-being of employees. In effective organizations, employees are not only capable of performing their jobs well but are also healthy and well adjusted in the workplace. Visit Psychology.EliteCME.com Industrial/Organizational Psychology Final Exam Page 84 to view our entire course library and get your CE today! CHAPTER 4: THE RETURNING U.S. VETERAN OF MODERN WAR: BACKGROUND ISSUES, ASSESSMENT AND TREATMENT Page 85 PLUS... Lowest Price Guaranteed All soldiers are impacted by their experiences in war. For many, surviving the challenges of war can be rewarding, maturing, and growth-promoting (e.g., greater self-efficacy, A+ Rating from BBB enhanced identity and sense of purposefulness, pride, camaraderie, etc.). Conversely, Serving Professionals Since 1999 the demands, stressors, and conflicts of participation in war can also be traumatizing, spiritually and morally devastating, and transformative in potentially damaging ways, the impact of which can be manifest across the veteran’s lifespan. Elite The Returning U.S. Veteran of Modern War: Background Issues Continuing Education Assessment and Treatment Final Exam Page 101

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Page ii Psychology.EliteCME.com Chapter 1: Aging and Long-Term Care

3 CE Hours

By: Kathryn Brohl, MA, LMFT with Rene Ledford, MSW, LCSW, BCBA Reviewed and Edited by: Wade Lijewski, Ph.D.

Learning objectives This workshop is designed to help you: ŠŠ Assess barriers and strategies to the delivery of mental ŠŠ Summarize the reasons for the booming elderly population. health services to older adults. ŠŠ Recognize examples of various aging subgroups. ŠŠ Discuss key adaptive mechanisms used by older adults. ŠŠ Describe different types of stressors. ŠŠ Analyze the elements of psychosocial interventions in nursing homes.

Introduction The average life span of Americans has increased dramatically, 12.7 percent of the U.S. population, or about one in every eight and the population age 85 and over has grown and will continue persons. America’s older adult population will burgeon between to grow well into the next century. Old age is a lively and exciting the years 2010 and 2030, when the 76 million members of the time for many Americans, with the majority of older Americans “baby boom” generation born between 1946-1964 reach 65 years coping constructively with the many changes that accompany the of age. At that time, older persons will account for 20 percent of aging process. But too many of our elders struggle to cope with the nation’s people (USDHHS, 1999a). The interplay of mental difficult life situations or mental disorders that negatively affect health and aging issues, pointed out in the early 1970s by Butler their ability to participate fully in life. It is estimated that nearly and Lewis and others, may be expected to become even more 20 percent of the population aged 55 and older experience mental evident in the future (Butler and Lewis, 1973). disorders that are not part of “normal” aging (U.S. Department of Health and Human Services Administration, 2001). Based upon studies that examine the existing mental health needs of older Americans, it is reasonable to anticipate that the The cost of this loss of vitality to elders, their families, their upsurge in the number of older adults in this new century will caregivers, and our country is staggering. Moreover, there is ample be accompanied by an increased need for mental health and evidence that much of this suffering could be avoided if prevention supportive services tailored to this population. The challenges and treatment resources were more adequately delivered to older that mental health and aging policy makers and service providers Americans. A growing body of scientific research has highlighted are already facing and may expect to confront in the future can both the potentially disabling consequences of unrecognized or be readily identified. This course focuses upon major issues in untreated mental disorders in late life, and important advances in the field of mental health and aging; discusses efforts to address psychotherapy, medications, and other treatments. these issues; and identifies crucial challenges that must be confronted in the years ahead as well as strategies to meet them. When interventions are tailored to the age and health status of older individuals, a wide range of treatments is available for most The following sections provide a discussion of issues on the mental disorders and mental health problems experienced by mental health needs of older Americans, including a demographic older persons, interventions that can vastly improve the quality profile of the nation’s elderly population, the mental health of late life. Despite this progress, stigma, missed opportunities to problems that tend to be more prevalent among them, mental recognize and treat mental health problems in older persons, and health and aging dilemmas that concern policy makers as well as barriers to care remind us that there is still a great deal to do. service providers, and efforts to give heightened attention to these challenges and to provide programmatic and policy responses. Since 1900, the percentage of Americans age 65 and over has tripled. In 1998, they numbered 34.4 million and represented

Older Americans and their characteristics Older Americans are a diverse segment of our nation’s younger cohorts of older Americans also include more persons population. With the extension of longevity, the diversity of of minority ethnicity and races. These differences foreshadow the older persons in communities across the U.S. has become even variations that can be anticipated within the baby boom generation more apparent. Not only do the values, beliefs, and activities that began to turn 60 years old in 2006. (USDHHS, 2001). of the old-old appear to differ from those of the young-old,

Psychology.EliteCME.com Page 1 The following provides a brief description of the older adult eighth decade of life, with 50 percent of men married and population in the United States: 13 percent of women married at age 85-plus. Among older ●● Age. Older adults are often categorized by their age: young- Americans 85-plus, 42 percent of men were widowers and old (65-75), the old (75-85), and the old-old (85-plus). The 77 percent of women were widows. While only 4 percent older population itself is getting older. Persons 85 years of older men and 5 percent of older women had never and older comprise the most rapidly growing segment of married, all older persons who were alone because they were the U.S. population. Among those older Americans are widowed, divorced (7 percent), or unmarried were more apt centenarians, numbering 65,000 in the year 2000 (U.S. to live alone, to have a lower household income, and to have Bureau of the Census, 1996). fewer caregivers available to assist them (Federal Interagency Forum on Aging Related Statistics, 2000). While the extension of longevity among older Americans is ●● Minority status. Minority populations are expected to a result of public health and other successes, the incidence of represent 25 percent of the elderly population in 2030, up chronic illness and vulnerability to mental health conditions from 16 percent in 1998. Between 1998 and 2030, the white such as depression and Alzheimer’s disease tends to rise in population 65 years and over is expected to increase by 79 the later years of life. While suicide rates for persons 65 and percent, compared with 226 percent for older minorities, older are higher than for any other age group, the suicide including Hispanics (341 percent), African-Americans (130 rate for persons 85-plus is the highest of all, nearly twice the percent), American Indians, Native Alaskans and Aleuts overall national rate. According to the Centers for Disease (150 percent), and Asians and Pacific Islander Americans Control and Prevention, there are approximately 21 suicides (323 percent) (USDHHS, 1999b). per 100,000 persons among those 85 years of age and older (CDC, 1999). Minorities face additional stressors, such as higher rates ●● Gender. Most older persons, and especially the old and old- of poverty and greater health problems (Sanchez, 1992). old, are women. At 65-69 years of age, there are 118 women Despite this, access to health care is frequently frustrated by for every 100 men. At age 85-plus, there are 241 women for limited English proficiency and by the lack of availability every 100 men (USDHHS, 1999b). According to the U.S. of bilingual health care providers. In a number of minority Census Bureau, four out of every five Americans 100 years of groups, Westernized mental health treatment modalities that age and older are women (U.S. Bureau of the Census, 1999). tend to be dependent upon verbal inquiry, interaction, and Women on average live seven years longer than men and response do not appear to present a comfortable “fit” with are much more likely than older men to be widowed, to live their cultural beliefs and practices. Consequently, minority alone, to be institutionalized (Goldstein & Perkins, 1993), communities have consistently called for assistance and to receive a lower retirement income from all sources. from persons who are bilingual and bicultural. Where these are not available, there has been a call for mental Because they live longer, women are also likely to suffer health services provided by professionals who have an disproportionately from chronic disabilities and disorders, understanding and appreciation for their cultural values, including mental disorders. However, white men who are norms, and beliefs and are culturally competent. 85-plus account for the high suicide rate (65 per 100,000) ●● Income. A number of studies have identified poverty to persons in the elderly population (CDC, 1999). be a risk factor associated with mental illness (Bruce & McNamara, 1992; Cohen, 1989; Sanchez, 1992). For One sub-segment of the older adult population, older gay men individuals who are poor or who have limited incomes, the and lesbians, have not been a focus of most discussions about lack of adequate financial resources can seriously constrain aging and mental health. Yet, the challenges faced by gay men access to health and mental health services. and lesbians have become more widely known in recent years. Though there is a dearth of sound research on the mental While the economic status of older Americans has improved, health needs of gay, lesbian, and bisexual Americans, some there is wide disparity in the distribution of income, especially have suggested that these individuals may be at increased among subgroups within the elderly population (Siegel, 1996; risk for mental disorders and mental health problems U.S. Bureau of the Census, 1996). One of every six (17.0 because of exposure to societal stressors, such as prejudice, percent) older persons was poor (below poverty level) or stigmatization, and anti-gay violence (Dean et al, 2000). near-poor in 1998. (USDHHS, 1999b). Among older persons, women, African-Americans, persons living alone, very old Social support, which is an important element of mental persons, those living in rural areas, or those with a combination health for all older people, may be especially critical for of these characteristics tend to be at greater risk of poverty older people who are gay, lesbian, or bisexual (Dean et al, (Siegel, 1996). In fact, divorced African American women who 2000). Furthermore, access to health care may be limited are 65-74 years of age were among the poorest of the poor in because of concerns about health care providers’ sensitivity 1998, with a poverty rate of 47 percent (Federal Interagency to differences in sexual orientation (Solarz, 1999). Further Forum on Aging Related Statistics, 2000). research on the mental health needs of older gay, lesbian, ●● Living arrangements. Living arrangements are closely tied and bisexual Americans is needed. to income and, specifically, being at risk of poverty, poor ●● Marital status. The emotional and economic well-being of health status, and the unavailability of caregivers (Federal older Americans is strongly linked to their marital status. At Interagency Forum on Aging Related Statistics, 2000). In age 65-74, 79 percent of men and 55 percent of women were 1998, the majority (67 percent) of older Americans lived in married in 1998. These numbers decrease significantly in the

Page 2 Psychology.EliteCME.com the community in a family setting with spouses, children, older persons have at least one chronic condition and many siblings, relatives or nonrelatives; however, this proportion have multiple conditions, such as arthritis, hypertension, decreases with age. Almost one-third of those in the heart disease, cataracts, or diabetes. In 1994-1995, more than community lived alone and were more likely to be at risk 4.4 million (14 percent) had difficulty carrying out activities than those who lived within family settings. of daily living, such as bathing or eating, and 6.5 million (21 percent) had difficulty with activities such as shopping, While only a small percentage (4.2 percent or 1.43 million) of managing money, doing housework, or taking medication, older persons lived in nursing homes in 1996, this percentage many because of chronic disabling conditions.Although increases dramatically with age (USDHHS, 1999b). The poor physical health is a key risk factor for mental disorders majority of nursing home residents have mental disorders (Kramer et al, 1992), recent studies have established that all such as dementia, depression, or schizophrenia. Moreover, too often, symptoms of mental disorders escape detection a recent Supreme Court decision, Olmstead v. L.C., requires and treatment by health professionals who are treating states to provide community-based services for persons with older persons for physical ailments. Yet the prevalence of disabilities, including mental disorders, who would otherwise chronic conditions in the elderly population should be a be entitled to institutional services, provided that community cause for anticipating possible comorbidity.Understanding placement is appropriate, the affected persons do not oppose the relationships between physical and mental health is a such a plan, and the placement can be reasonably carried central task in the assessment and treatment of older persons out considering the resources of the state. Thus, mental by health care professionals (APA Working Group on the health services must be designed to fit the needs of persons Older Adult, 1998). Moreover, potential adverse effects of irrespective of their living arrangements. medications, and specifically of drug interaction effects, are ●● Physical health. The majority of older persons report that more likely among older persons, who tend as a group to use they are in good health compared with others their age (APA more prescription drugs, and should thus be a point of routine Working Group on the Older Adult, 1998). However, most inquiry by health care professionals.

Successful aging: Stressors and adaptations During the normal process of aging, older persons encounter and other psychosocial dilemmas. Frequently adding to stressors, such as retirement from a career or job, that may the emotional toll of bereavement is the need to also make trigger both appropriate and distorted emotional responses. practical decisions, such as where to live, what to do about However, exposure and adaptation to these stressors varies with the family home and possessions (Butler et al, 1998). Social each person’s economic resources, gender, ethnicity, level of roles may change, as can connections to friends, family, education, life experiences, and perception of the meaning of and community. Some persons may gain a new sense of the stressor itself. independence and competence (Lopata, 1979; Wortman and Silver, 1992) as they adapt to these losses and changes. Pearlin and Skaff (1995) view older persons as confronted with However, bereavement is a well-established risk factor for two main types of stressors: life events and chronic strain, and depression (Zisook & Shuchter, 1993; Zisook et al, 1994). their conceptualization is used in discussing these events. The life events thought to be the most stressful are those that are In addition to these unplanned life events, chronic strains may unscheduled or undesired unlike those that can be planned for, also impact the older adult (Pearlin & Skaff, 1995): such as a lack of an occupational role in retirement. As older ●● Strains related to their community or neighborhood persons confront undesired life events, there is an intricate of residence. Relocation may place an older person in balance of physical, social, and emotional forces, any one of an unfamiliar environment. If the person remains in his which can upset or involve the others. old neighborhood, the older person may feel separated from previous support networks because familiar The initial event or primary stressor may lead to secondary neighbors may no longer be there. A deteriorating or stressors such as those described below: changing neighborhood may be upsetting, and access to ●● Health-related events. Health events such as a fall or a heart transportation, convenience to shopping and medical care, attack have been found to have a more depressive effect and availability of a senior center or movie theater are all than many other types of events (Ensel, 1991; Murrell et al., amenities whose absence may constitute ambient stressors. 1988). For example, an elderly woman falls and breaks her Also, growing frailty may leave people feeling less able to hip, which necessitates hospitalization and surgery. Upon defend themselves against physical dangers. her return home, she finds that stress proliferates as she ●● Relationship strains. These strains may occur with family needs help with shopping and the maintenance of her home, members. Older people may experience disappointments experiences economic strain, and is unable to participate about their children’s situation in life, especially if they do in leisure activities. It may be difficult to distinguish the not coincide with their own values or desires. For example, depressive effects of acute health events from the chronic their children may not be raising their own children in a problems that result from these events. way that meets with the elder’s approval, or may not be ●● Loss of loved ones. The loss of relatives, friends, or a spouse supportive or respectful of the older person. Additionally, during the advanced years of life can result in loneliness, assuming caregiving responsibilities for a spouse may lead an increased sense of vulnerability, increased isolation, to secondary stressors, such as family conflicts, financial

Psychology.EliteCME.com Page 3 strains, or the loss of the caregiver’s identity. Finally, ●● Coping. Coping involves managing situations giving rise financial hardship and chronic health problems may create to stress, managing the meaning of these situations, and undesired dependency on others. managing the stresses resulting from these situations. Older ●● Strains in the older person’s immediate environment. persons tend to use “emotion-focused coping,” a strategy These are the ordinary logistical problems or “hassles” that that refers to managing the meaning of the situation or people face in their daily lives. Studies of the old-old who controlling the symptoms of stress rather than trying to are living independently have focused attention on this manage the stressful situation itself (Chiriboga, 1992; class of stressors (Barer, 1993). They include such ordinary Martin et al., 1992). Some of the stressors experienced by activities as getting out of the bathtub, managing the steps older people, such as frailty and chronic health problems, on a bus, seeing the fine print in a telephone book, changing are not easily modified by problem-solving; thus, older a light bulb, or removing trash for pickup. For people of persons may cope by reshaping the meaning of the situation advanced age, these activities may be major obstacles to be or restructuring their priorities. overcome each and every day. For example, an elderly woman who has painful arthritis Historically, our society has held ambivalent views of aging and and cannot tolerate the side effects of the medication is very of older persons. Among these are many persistent myths that disappointed that she can no longer play the piano. She may have resulted in the devaluation of the potential of older adults. choose to continue to enjoy music and to find satisfaction by For example, the myth that older adults are set in their ways coaching students. and incapable of learning, growth, and change does not take into account the fact that declines in some intellectual abilities Older persons also cope by universalizing their situation generally are not severe enough to cause problems in daily and comparing themselves with others, using family and living. More important, such a myth disregards determinations friends as reference points. This strategy helps them to see by researchers that the aging brain has the capacity to make new that hardships are not aimed solely at themselves, but also connections, absorb new data and thus acquire new skills (Rowe impact their peers. and Kahn, 1998). Furthermore, it disregards recent analyses that ●● Social support. Social support includes both concrete and suggest that creativity is not lost in old age (Cohen, 2000). emotional assistance provided by families, friends, neighbors, and volunteers or by acceptable private or governmental Yet another myth incorrectly suggests that lack of productivity organizations, including religious organizations and senior is associated with old age. It miscasts older people as no longer centers that have high levels of legitimacy within their capable of being productive on the job, of being socially community and their peer group. For example, older persons active, or of being creative. Instead, older adults are cast as may be active in church groups, supported by a circle of disengaged, declining, and disinterested in life. However, friends, or may receive concrete support in the form of most older people tend to remain actively concerned about homemaker or chore services and home-delivered meals their personal and community relationships and many are still when needed. employed (APA Working Group on the Older Adult, 1998; Butler et al, 1998; Rowe and Kahn, 1998). An extensive body of research has shown that social support is an important predictor of good physical and mental health, Acknowledging such myths is important for communities to life satisfaction, and reduced risk of institutionalization support the self esteem of older persons, their ability to live and among older adults (LaGory & Fitzpatrick, 1992; Forster work successfully, and their ability and motivation to maintain & Stoller, 1992; Sabin, 1993; and Steinbach, 1992). Social and improve the quality of their lives. Health, mental health, support may also buffer the adverse effects of various human services, and aging programs will be miscast if old age stressors common to aging (Feld & George, 1994; Krause & is perceived to be a time of inevitable isolation, decline and Borawski-Clark, 1994). Researchers point out, however, that decay. Thus, mental health and aging professionals must be the effectiveness of social support depends on the situation, attentive to their biases and stereotypes if they are to effectively the person, and his or her needs; thus, goodness-of-fit is serve older persons (Roff and Atherton, 1989). essential. Unneeded, unwanted, or the wrong type of support may reduce older persons’ independence or self-esteem Recent research helps to further debunk ageist stereotypes by (Pearlin & Skaff, 1995; Rowe and Kahn, 1998). revealing that older persons as a group cope and adapt well ●● Sense of control. Many older people are able to maintain a and tend to be very resilient. This resilience is comparable sense of mastery over the circumstances of their lives, and to and sometimes exceeds that of their younger counterparts this sense extends into late life as a resource important to (Foster, 1997). Older persons also appear to have the capacity well-being (Rodin, 1986). Those working with older persons for constructive change, even in the face of mental illness, can reinforce this sense of control by respecting their right to adversity, and chronic mental health problems (Cohen, 1988). make decisions or to initiate, withdraw, or terminate treatment (APA Working Group on the Older Adult, 1998). A sense of Whether older persons can face stressors, function well, and control has also been found to be an effective buffer mitigating maintain their well-being appears to depend upon the resources the impact of stressors (Cohen & Edwards, 1989; Krause that older persons possess and use. & Stryker, 1984). For example, in Alzheimer’s caregivers, Several key adaptive mechanisms used by older persons have a strong sense of mastery protects the caregiver against the been identified (Pearlin and Skaff, 1995): stressors arising in the daily care of the patient (Skaff, 1991).

Page 4 Psychology.EliteCME.com In their study of older persons who are functioning at a high This psychosocial perspective assures that we acknowledge the level, Rowe and Kahn (1998) found three characteristics that diversity of older persons and view each individual as having define successful aging: unique interactions with his or her environment. ●● Low risk of disease and disease-related disability. ●● High mental and physical function. Ideally, aging is a dynamic process in which an individual ●● Active engagement with life. confronts the stressors and challenges of later life not as a passive victim but as an actor drawing on resources developed over a And they found that successful aging is most fully represented lifetime. Even the impact of losses that may be irreversible, such by the combination of all three of these factors. However, Pearlin as those that involve personal health and the deaths of significant and Skaff (1995) remind us that the outcome of successful aging others, can be minimized by restructuring personal meaning, with must be examined not only in relation to the above three criteria, the availability and use of social supports, and a sense of mastery but also to the social, economic, and cultural conditions to over important circumstances of life (Pearlin & Skaff, 1995). which people are exposed as well as their adaptive mechanisms.

The mental health of older Americans Most older adults enjoy good mental health, but almost 20 percent found that just more than half felt confident in diagnosing of those who are 55 years and older experience specific mental depression, and only 35 percent felt confident in prescribing disorders that are not part of “normal” aging. The most common antidepressant medications to older people. (Callahan et al, 1992). disorders, in order of prevalence, are anxiety disorders, such as phobias and obsessive-compulsive disorder; severe cognitive Treatment also presents a number of challenges. Older people impairment, including Alzheimer’s disease; and mood disorders, metabolize medications differently because of physiological such as depression. Schizophrenia and personality disorders are changes, which may make them more vulnerable to side less common (USDHHS, 1999a). There are suggestions, however, effects of psychoactive medications. They are also likely to be that mental disorders in older adults are underreported. taking medications for other disorders, placing them at risk for unintended medication interactions. Older adults with cognitive One study, for example, estimates that 8-20 percent of older adults deficits may also have difficulty managing medications or in the community and up to 37 percent of those who receive remembering appointments (USDHHS, 1999). primary care experience symptoms of depression. It is particularly noteworthy that the rate of suicide, frequently a consequence of Psychosocial interventions can be an important component depression, is highest among older adults (Hoyert et al, 1999). of effective treatment, but lack of transportation may make it In addition, approximately two-thirds of those in nursing homes difficult to get to counseling appointments or support group suffer from mental disorders, including Alzheimer’s and related meetings. As noted earlier, there is convincing evidence that dementias (Burns et al, 1993). Older adults with mental illness depression and other mental disorders typically are unrecognized vary widely in the onset of their disorders. and thus fail to be treated by primary care providers.

Some have suffered from serious and persistent mental illness Efforts to prevent mental disorders among older adults have most of their adult life, while others have had periodic episodes also been inadequate. At this time, there is no national agenda of mental illness. A substantial number experience mental to promote mental health and prevent mental and behavioral health disorders or problems for the first time late in life; disorders (Center for Mental Health Services, 2000). Present problems are frequently exacerbated by bereavement or other knowledge about effective prevention techniques is not as losses, which tend to occur in old age. extensive as is our understanding of the diagnosis and treatment of mental disorders. Yet another variable is severity. Mental disorders can range from problematic to disabling to fatal. Clearly, then, treatment Preventing mental disorders before they occur requires some and prevention efforts must take into consideration the range understanding of their etiology, risk factors, pathogenesis, and of experiences and needs of older adults with mental disorders course (USDHHS, 1999). As noted in a 1994 Institute of Medicine to provide appropriate care for older persons at all points of the (IOM) report, the base of knowledge about prevention for some mental health continuum. But there are major barriers to overcome. disorders is considerably more advanced than for others (Mrazek For example, assessment and diagnosis of mental disorders in & Haggerty, 1994). Among older adults, for example, the largest older people can be particularly difficult (USDHHS, 1999). pool of primary prevention research focuses on depression that develops late in life (USDHHS, 1999). Moreover, there has been a Older people with mental disorders may present with history of disagreement within the mental health community about different symptoms than younger people emphasizing somatic how to define prevention (Mrazek & Haggerty, 1994). complaints rather than psychological troubles (USDHHS, 1999). In addition, it can be hard to determine whether certain Nonetheless, there has been a growing awareness that certain symptoms – like sleep disturbances – are indicative of mental psychosocial factors can heighten the risk of developing mental disorders or another health problem (Lebowitz et al, 1997). disorders or exacerbate them when they occur. Further research is needed on the prevention of mental disorders in older adults. Moreover, there is significant under-diagnosis of mental illness In addition, greater effort must be devoted to translating among primary care providers. A survey of primary care physicians research advances that have already been made into practice.

Psychology.EliteCME.com Page 5 Delivery of mental health services to older adults While there is strong evidence of the need for mental health persons themselves become more dependent, they may fear services of older persons, older adults have made limited use of a loss of control over their lives and thus become resistant these services (Demmler, 1998). It is estimated that only half to the idea that they may need help. of all older adults who acknowledge mental health problems ●● Access barriers. Access to services by older persons is actually are treated by either mental health professionals or thwarted in a number of ways. Affordable, accessible primary care physicians (Blazer et al, 1988). A very small transportation to services may be unavailable. For some percentage of older adults – less than 3 percent – report seeing older people, the cost of mental health treatment – mental health professionals for treatment. especially prescription drugs – may be too expensive.

This rate of utilization is lower than for any other adult age group Older persons who live alone are a particularly hard-to- (Lebowitz et al, 1997). Older Americans account for only 7 reach population. They may live in rural areas that do not percent of all inpatient services, 6 percent of community-based have adequate mental health services, or they may live near mental health services, and 9 percent of private psychiatric services but far from family members. They may not be able care, despite comprising 13 percent of the U.S. population to come to an office as a result of their physical frailty. (Persky, 1998). And in a study examining community mental health services and older persons, 40 percent of community The isolation of older adults means that outreach workers mental health providers identified non-health related services, who go into the home may be needed to build relationships such as transportation and home help services, as unmet needs, and provide day-to-day monitoring and support. Outreach suggesting that the comprehensive needs of these persons are activities may also involve approaching the family of the not being met (Estes et al, 1994). Unfortunately, individual and elder, but the only “family” may be neighbors or a service systemic barriers thwart the provision and receipt of adequate coordinator, for example, in a public housing project. care to older persons with mental health needs. ●● Funding issues. Typically, funding streams for aging and mental health are separate and limited. As in other fields The following are among the barriers most frequently noted of health and human services, the separation of funding in the literature (Birren, et al, 1992; Butler et al, 1998; Estes, streams can complicate efforts to collaborate and can result 1995; NCOA, 1999; Persky, 1998): in the fragmentation of services. Perhaps of greater concern ●● Stigma. Stigma surrounding the receipt of mental to most service providers, families, and older persons with health treatment affects older people disproportionately mental health problems is that current funding for both of (USDHHS, 1999a), and as a result, older adults and their these systems is not ample enough to cover the mental health family members often do not want to be identified with service needs of the elderly population. While Medicare the traditional mental health system. The stigmatization and Medicaid provide insurance coverage for older person’s of mental illness has deep, historical roots dating back to mental health needs, these benefits are limited. Descartes’ conceptualization of the separation of mind and ●● Lack of collaboration and coordination. The mental health body. During centuries past, the stigma surrounding mental and aging networks are separate and distinct in most state and illness was reinforced in both European and American local communities across the nation. Coordination issues are societies by fears about deviant, violent behaviors. thus as relevant in mental health and aging as in other fields of health and human services. Although interdisciplinary While considerable progress has been made to achieve practice and coordination have long been advocated, there increased scientific understanding of mental disorders, the has been a continuing need to emphasize their importance social meanings attached to mental illness and the treatment and to ensure that they occur. Interdisciplinary collaboration of most conditions continue to place the moral identity of the and the coordination of multiple services are especially individual at risk of degradation. Today’s older Americans essential in work with elders who are poor, have limited grew up during decades in which institutionalization in English proficiency, or physical health problems. asylums, electroshock treatments, and other treatment ●● Gaps in services. While the mental health system has tended approaches, understandably, were regarded with fear. to not serve older persons in quite the same proportion as Moreover, among older persons, who tend to be defined in children or adults, the aging network has tended, in relation large measure by their pre-retirement work roles and by any to mental health and aging, to serve primarily persons with ongoing community involvement, the possibility of becoming Alzheimer’s disease. Even when community-based service more vulnerable, falling victim to ageist perspectives, and providers have the capacity to respond to the mental health then being doubly jeopardized and demeaned can only raise concerns of older adults, they frequently are challenged by the specter of a loss of dignity and of place in society. the lack of adequate reimbursement and by the lack of a ●● Denial of problems. Anxiety, depression, memory loss, complement of staff needed to provide appropriate, culturally and dementia may complicate the ability of older persons to sensitive prevention and treatment services to minority elders recognize that they have a mental health problem for which and continuing care to those who are chronically mentally ill. they should seek help. However, mental health problems ●● Workforce issues. There are national shortages of health may also be denied. Health professionals, family members, and social service professional and paraprofessional and policy makers may internalize society’s negative personnel who have expertise in providing geriatric mental attitudes toward older persons and give superficial attention health care. Shortages across disciplines are sure to become to or be dismissive of their problems. Moreover, as older even more problematic as the population ages and the

Page 6 Psychology.EliteCME.com demand for specialized mental health services increase. For problems, few home health workers had any aging-related example, presently, there are 200-700 geropsychologists and education (Dawson & Santos, 2000). 2,425 board-certified geriatric psychiatrists. Thus, there is a critical need for training opportunities One promising trend has been noted. General psychiatrists for those entering and currently working in the area of are seeing a greater proportion of geriatric patients in mental health and aging. Surveys suggest that 53 percent of their practices. In 1996, 18 percent of psychiatrists had a graduate social work programs have no fieldwork faculty geriatric caseload in excess of 20 percent; this represented an in aging, and 21 percent have no classroom faculty (Dye, increase of 148 percent and 25 percent from 1982 and 1989 1993; Mellor and Solomon, 1992). And of 637 nursing respectively (Colenda et al, 1999). However, this does not baccalaureate programs, only about 14 percent have come close to meeting the projected need for at least 5,000 in required training content in gerontological nursing (Dye, each psychiatry and psychology specialty (Jeste et al, 1997). 1993; O’Neal, 1994). Barriers to education include a lack of trained faculty, lack of training sites, student and faculty Moreover, less than 5 percent of members of the National resistance, curricula that are too full, and a view of the Association of Social Workers identify their primary focus elderly as a low-priority population. of practice as aging (Gibelman & Schervish, 1997), and ●● Organized consumer support. At the state, local and only 15 percent of clients of direct service social workers national levels, there has been recent success in organizing in mental health are 60 years of age and older, although consumer groups that include older persons who are the proportion of elders estimated to have mental health consumers of mental health and substance abuse services, problems is 20-22 percent (Gatz & Smyer, 1992). their families, and advocates, but expansion of these efforts is needed. Although these important service delivery issues A survey of state home health associations found low to and the critical challenges mentioned at the outset of this moderate availability of home health aides who serve section continue to remain concerns, there have been strong, primarily older adults. Although many older adults in need though intermittent, efforts to give heightened attention to of home health services have complex physical and mental mental health and aging issues and to develop and provide programmatic and policy responses.

Community mental health services It is estimated that only half of older adults who acknowledge Services Administration’s (SAMHSA) Center for Mental Health mental health problems receive treatment from any health Services administers the CMHSBG. care provider, and only a fraction of those receive specialty mental health services. The specialty mental health services Each state has a state mental health authority whose mission system consists of private mental health providers funded is to oversee the public mental health system. To receive by private insurance and consumers, and publicly and CMHSBG funds, each state must have a comprehensive plan privately owned providers funded by states, counties, and to provide mental health services throughout the state. States municipalities. Institutional or facility-based mental health vary widely in the organization of their mental health service services include inpatient care (acute and long-term), residential delivery systems and in the degree to which these systems treatment centers, and therapeutic group homes. Community- interact with providers of other types of services, such as based services include outpatient psychotherapy, partial primary care, social services, and the aging network. hospitalization/day treatment, crisis services, case management, Access to community-based mental health services is and home-based and “wraparound” services. problematic for older people because of several factors, including Historically, public and private funding for adult mental health the growing reliance on managed care; the targeting of mental services was targeted toward intensive and costly institutional health services to specialized groups that exclude the elderly; care. In the last two decades, mainly because of court decisions and the emphasis public providers place on serving the severely restricting the institutionalization of adults with mental illness, chronically mentally ill. In addition, community mental health the service priorities have changed in favor of less intense organizations often lack staff trained in addressing non-mental community-based services. health medical needs, which are especially important for older adults. These organizations also tend not to see treatment of those Most mental health funding comes from state and local with cognitive impairments as part of their mission. governments, Medicaid, and private insurance. Publicly funded services are thought to be a “safety net” for those unable to afford Survey findings indicate that while older adults have a private insurance or to pay for services. The federal government tremendous need for services such as elder case management augments state and local funding through the Community Mental or psychiatric home care services, only a few states designate Health Services Block Grant (CMHSBG). The CMHSBG is a older adults as priority clients, and only a minority of the joint federal-state partnership that awards annual formula grants states address the mental health needs of the elderly through to the states to provide community-based mental health services specialized services for them. However, studies have also to adults with serious mental illness and children with serious shown that the use of specialized geriatric services and staff emotional disturbances. The Substance Abuse and Mental Health as well as partnerships between the aging and mental health systems can increase access to services for older persons.

Psychology.EliteCME.com Page 7 Primary and long-term care Primary care. When faced with a mental health problem, older Currently, there are three ongoing multi-site research efforts in persons frequently first turn to their primary care physician. the United States that are examining services to older persons More than half of older persons who receive mental health care with mental health problems in primary care settings. receive it from their primary care physician. Many reasons have been suggested for this pattern: Going to a primary care Long-term care. Various studies indicate a high prevalence physician does not carry the same stigma that specialty mental of mental illness in nursing homes. Dementia and depression health services do; insurance policies encourage use of primary appear to be the most common mental disorders in this setting. care; and primary care may be more convenient and accessible. However, most residents with mental disorders do not receive adequate treatment. While many older people prefer to receive mental health treatment in primary care settings, diagnosis and treatment of older persons’ Barriers to good treatment include: mental disorders in these settings are often inadequate. Many ●● A shortage of specialized mental health professionals primary care physicians receive inadequate training in mental trained in geriatrics. health. Physicians often attribute psychiatric symptoms either to ●● Lack of knowledge and inadequate training of nursing home changes expected with age or concomitant physical disorders and staff about mental health issues. sometimes inappropriately prescribe psychotropic medications. In ●● Lack of adequate Medicaid and Medicare reimbursement to addition, some physicians’ negative attitudes toward older people facilities to cover behavioral and mental health problems. appear to undermine their clinical effectiveness. ●● Difficulty obtaining the services of psychiatrists and other mental health professionals because of inadequate There are also system barriers to providing mental health care reimbursement policies. in the primary care setting. It is important to coordinate mental and physical health care, because consumers with emotional Thus, there is a great need to incorporate mental health care into problems can also have physical health problems. However, the basic structure of nursing home care and to make professional frequently this coordination does not occur. services available to patients and their families. Psychosocial interventions that can be used in nursing homes include individual, In response to these shortcomings, several models aimed at group, program, family-based and staff interventions. Each improving mental health services in primary care have been intervention focuses on helping the resident and the family adapt developed. These models call for either collaboration between to the nursing home environment, changing resident behaviors, mental health and primary care providers, or integration of improving quality of life, or enhancing staff and resident morale. mental health providers into the primary care setting.

Mental health services in long-term care facilities There is strong evidence of a high prevalence of mental illness nursing homes. These have been outlined by Lombardo et al in nursing homes (Lombardo et al,1996). One study found that (1996) in a descriptive summary of key policy issues. up to 88 percent of all nursing home residents exhibit mental health problems, including dementia (Smyer et al, 1994). These They include: individuals exhibit a wide range of symptoms, from delusions ●● A shortage of specialized mental health professionals and hallucinations to sadness and anger at their loss of privacy trained in geriatrics. and independence (Lombardo et al, 1996). Depression is a ●● Lack of knowledge among and inadequate training of major problem in long-term care facilities, with estimates nursing home staff about mental health issues. ranging from about 12 to 22.4 percent for major depression, and ●● Lack of adequate Medicaid and Medicare reimbursement to an additional 17 to 30 percent for minor depression (Burrows et facilities to cover behavioral and mental health problems. al, 1995; Katz et al, 1995). ●● Lack of adequate reimbursement to obtain the services of psychiatrists and other mental health professionals. A number of interventions can be used to address the mental health needs of the residents of nursing homes, but often they As continuing care retirement communities, assisted living are generally not made available. Thus, many residents do not facilities, and other types of living arrangements become more receive the mental health care they need (Burns et al, 1993; commonplace, attention will need to be given to ensuring that Shea et al, 1995). A 1994 study found that only 19 percent of residents of these facilities have access to mental health services. In nursing home residents with mental illness, excluding those addition, research is needed to determine types of interventions and with dementia, received mental health treatment at least once services that are most appropriate and effective in these settings. (Smyer et al, 1994). A wide range of psychosocial interventions is appropriate for Although there is a need to incorporate mental health care as a use in the nursing home. Smyer and Frysinger (1985) have basic component of nursing home care and to make professional categorized them as follows: services available to patients and their families, there are major ●● Individual interventions include interpersonal skill training, barriers to obtaining treatment for mental health conditions in psychotherapy, reality orientation, self-care training, or social interaction for the treatment of a specific resident.

Page 8 Psychology.EliteCME.com ●● Group interventions involve several patients and may use While program strategies that include mental health interventions interpersonal skill training, education and discussion, group are being implemented in some nursing homes, there is a paucity therapy, or socialization therapy. of outcome-oriented research on the effectiveness of such efforts. ●● Program interventions are not specific to one person or a Selected examples of innovative interventions that are in practice group, but rather impact many residents by focusing on the in facilities are described below (Lombardo et al, 1996): facility’s environment or its quality of life; for example, the ●● Mobile psychogeriatric teams. In one innovative model, therapeutic use of animals, social hours, reality orientation nursing homes in rural areas are supported through classes, activities programs, environmental stimulation, or state-funded mobile mental health intervention teams. A intergenerational programs. mobile psychogeriatric team consisting of a psychiatrist, a ●● Family-based interventions include in-service training psychiatric nurse, and a clinical social worker are available, with family members and staff, short-term counseling upon request, to 23 nursing and 28 residential care facilities groups for children of elderly parents, conjoint therapy in a rural catchment area. The team provides assessments, with elderly couples, preadmission groups, post-admission treatment services, and medication reviews for individuals counseling, group therapy, education and support programs, with mental illnesses or behavioral disturbances; works and information and counseling for caregivers of patients with staff on the development of care plans; and trains staff. with Alzheimer’s disease. The program is prevention-oriented, aims to avoid having ●● Staff interventions include weekly staff meetings; training psychiatric crises develop, and thus works to reduce the or workshops for staff; environmental alternatives to likelihood of admissions to acute hospital settings; increase social interactions among patients, staff, and family ●● In-facility mental health department. A mental health members; or a core group of administrators that focuses on department staffed by a psychiatric mental health clinical staff relations and attitudes. specialist was established within a facility. The specialist reviews psychotropic medications to ensure the appropriateness What mental health needs are addressed by psychosocial of the drugs, dosages, and times of administration; develops interventions in nursing homes? nursing interventions that can be used in addition to or in place Individual and group interventions can be used to help the of medications; and works closely with staff to suggest how resident adapt to the nursing home environment and to role behavioral problems can be addressed. changes. For example, residents can be helped to regain or ●● Preadmission screening and resident review (PASRR) maintain orientation to their surroundings, or with withdrawn agency collaboration with health department. The mental residents, increasing their social activities. Other similar health and public health systems and the aging network interventions can decrease specific problems or achieve specific collaborate on the implementation of PASRR, instituted by behaviors, such as social interaction. the Omnibus Budget Reconciliation Act of 1987 (OBRA). Some states have set up systems to use PASRR Level II Interventions also can be designed to prepare residents to return screening results to establish treatment plans to improve the to the community. Program interventions offer benefits and mental health care of residents. can help to improve quality of their lives. In a 10-state study, ethnographic researchers found that quality of life issues, such In one example, the PASRR screening agency sends the as dignity, independence, freedom of choice, self-image, and Department of Health a list, by nursing facility, of all a sense of purpose and privacy, were important to residents residents or prospective residents who received Level II (Teitelbaum, 1995). screening, are appropriate for admission, and need mental health services. Surveyors then spot check records of Family-based interventions usually focus on providing accurate residents to see whether they are receiving recommended information about the aging process and the specific difficulties mental health services. If residents are not receiving the troubling the resident, enabling family members to better services, facilities may be cited for deficiencies and may be understand their own reactions to the older adult’s impairments required to develop a plan of correction. and increasing the ability of caregivers to provide optimal care while continuing their own personal development. Finally, How effective are psychosocial interventions in nursing the purpose of staff interventions is to improve both staff and homes? resident morale and functioning. While there is no way to reverse the most common causes of dementia, research has shown that depression and anxiety in How are these interventions implemented? older persons with chronic diseases, including some forms of Mental health interventions can be implemented in the nursing dementia, usually can be treated successfully with medication home setting in a variety of ways. Because of the scarcity of and with various forms of psychotherapy and cognitive mental health professionals who work directly with residents, behavioral therapy (Burns, 1992; Fogel, 1993; Gallagher- consultation and education with staff are often utilized. There Thompson, 1994, Kamholz & Gottlieb, 1990). may be an arrangement with one or more mental health specialists who monitor and train the staff, consult with attending physicians, There are many studies that evaluate the various types of and help staff conduct assessments and develop individual care interventions. Examples of outcomes from studies that plans. Or there may be a senior nurse with knowledge and skill in examined individual, group, program, and staff interventions mental and behavioral areas who advises staff. are described in this section. In a five-year study, Haight et al (1998) followed 256 newly relocated nursing home residents who received individual interventions.

Psychology.EliteCME.com Page 9 Group members participated in “life review” activities conducted grounds. Children play onsite and mingle with residents for by a therapeutic listener on a one-to-one basis, while those in several hours most days as part of a day care program. the control groups received friendly visits. Life review is a form of reminiscence therapy, involving reciprocal acts of telling Three years after the project began in a nursing facility, staff found and listening. The listener helps the older person reframe and a 15 percent drop in the death rate compared to a nearby nursing integrate life periods and events. Controlling for the effects of facility that served as a control. Infection rates dropped by about adjustment over time, researchers found that at eight weeks, 50 percent. Staff turnover rates plunged by 26 percent, saving the experimental group members were significantly less depressed. facility the cost of recruiting and training nursing assistants, about At the end of the first year, there was significantly less depression $2,000 per individual. The average number of prescriptions per and hopelessness and greater psychological well-being and life resident fell to 3.01, compared to a national average of 5.60. And satisfaction in the life review groups compared to the control medication costs fell to less than 56 percent of the U.S. average groups. Researchers concluded that over time, life review can (Lombardo et al, 1996; Thomas, 1994; Vilbig, 1995). alleviate despair in frail elders newly admitted to a nursing home. Finally, Smith et al (1994) describe a geriatric mental health In a review of 29 studies that focus on improving the quality care training project that trained nurses and nursing personnel of life in nursing homes, Wieland et al (1995) included a group in rural long-term care facilities to care for residents with intervention (Moran & Gatz, 1987) that evaluated the effect of psychiatric and behavioral problems. A two-day train-the- task-oriented versus insight-oriented group therapy conducted trainer class covered six modules focused on mental health in two different groups on locus of control and life satisfaction. topics, including the causes of problem behaviors, management Results were compared with a wait-list group. Twelve weekly techniques, and the impact of the care providers’ feelings and sessions, each 75 minutes in length, were held with the residents. reactions. Geropsychiatric nurse specialists trained 43 nurse The task-oriented group improved on locus of control, active leaders, and then these leaders trained 520 staff in their own coping, striving for social desirability, and sense of well-being, facilities. Two-way interactive telecommunications techniques but not on trust. The insight group improved on locus of control were also used to reach leaders in rural facilities. and trust. However, trust decreased in the control group. The The nurse trainers viewed the program materials as relevant residents indicated they liked these groups, and there was less and user-friendly, while the trainees gave the overall quality of than 20 percent attrition in attendance. the program, its relevance, and usefulness high marks. There A new program model that has drawn considerable attention, was a significant increase in knowledge on the part of both the the Eden Alternative, provides a more humane habitat for trainers and trainees. And pre- to post-test attitude changes were residents of nursing facilities, using the companionship of overwhelmingly positive for the trainees. The leaders/trainers animals and other humans. For example, birds, dogs, cats, who had more positive attitudes to begin with showed a less rabbits, and even chinchillas are brought into the facility. dramatic pattern. Before the training program, many nurses Rooms and halls are filled with green hanging plants, and attributed residents’ problem behaviors to manipulation instead residents can plant vegetables and flowers in gardens on the of considering they could be the effect of impairments or feeling threatened. After the training, these attitudes improved.

Supportive services and health promotion This section describes a number of supportive services and ●● Mental health outreach programs offer early identification health promotion activities that may be helpful to older people and interventions to encourage access to services for high-risk with mental disorders and their families. In planning for the older adult populations. They offer assessment and referral to delivery of mental health services, it is clear that alternatives community treatment and support services. These programs to specialty mental health settings must be considered given strive to keep older persons in the community by providing the stigmatization of mental health services in the minds of supportive services that help to increase functioning. many older adults. Senior centers, congregate meal sites, and ●● Support groups and peer counseling programs provide other community settings that older people frequent and feel preventive interventions. Support groups have members who comfortable in may offer promising venues for the delivery of share similar problems and pool resources, gather information, mental health services to seniors. Hence, it is essential that the and offer mutual support. Peer counseling programs utilize aging network, the mental health system, and primary health care the skills and life experiences of older persons as peers to providers form partnerships to explore how to best marshal their enable others at risk to be supported and helped. Both of these various resources in the service of older persons’ mental health. interventions provide psychosocial support to older people facing life transitions, short-term crises, or chronic stressors. Among the services discussed are: ●● Caregiver programs, which offer a range of services for ●● Adult day services, group programs designed to respond to caregivers of frail elders such as respite care, support groups, the needs of functionally and cognitively impaired adults. care management, counseling, or home modifications. These These programs provide older adults with social interaction services can reduce caregiver stress and improve coping skills and health monitoring and also provide respite for caregivers. so that families can continue to provide care. ●● Health promotion and wellness programs, which focus ●● Respite care refers to a range of services that offer temporary on educating older adults about how to increase control relief to caregivers of frail elders, such as short periods of over and improve their mental health, nutrition, or physical companionship in the home or short stays in residential exercise. They seek to promote mental health and prevent settings. Respite programs can prevent or alleviate depression the onset of mental disorders and costly treatment. and burnout, delay the need for more costly care, and offer an

Page 10 Psychology.EliteCME.com opportunity for mental health outreach by bringing the family into short-term contact with formal care delivery systems.

Respite care Respite care refers to a wide range of services intended to give There are three models of respite care: temporary relief to caregivers of frail elders. This relief can be 1. In-home services. The most frequently requested and provided in a variety of ways, from use of volunteers providing utilized form of respite service is in-home respite care, short periods of companionship in the home to short stays in which can be provided by a volunteer, homemaker, home institutions. The only common element to these services is health aide, or a nurse. This type of care can include the intent of providing a rest for caregivers (Montgomery & assistance with housework, physical needs, or sitting with Kosloski, 1995). the older person. Most in-home programs provide services for a period of three to four hours, although some offer Informal care provided by family members is the main more extended overnight or weekend services. source of help for the majority of disabled elders living in the 2. Out-of-home respite. This type of respite can be provided community (USDHHS, 1998). What has been consistently in a group or institutional setting, such as a foster home, reported across studies are the constraints or restrictions of adult day care center, respite facility, nursing home, or this informal caregiving on time for leisure, social, or personal hospital. Institutional respite usually takes the form of activities. Overall, 55 percent of caregivers reported less time holiday or intermittent readmissions, and some facilities for other family members and for vacations, leisure time or require cumbersome medical exams or other assessments. hobbies (Tennstedt, 1999; National Alliance for Caregiving and The most common form of out-of-home respite is provided Alzheimer’s Association, 1999; McKinlay et al, 1995). This through adult day care centers, which are discussed in a personal time restriction is greater when the needs for care are separate section of this report. greater, as is true in dementia care. 3. Comprehensive care models. In comprehensive respite programs, the family is able to select from a variety of in- Respite care is an intervention that aims to alleviate some of the home or out-of-home respite options that offer differing levels pressures that can accompany caregiving. of care, according to the service that best fits their needs at the What mental health needs can respite care address? time. For example, in one respite program, family members Respite care is provided to benefit both caregivers and elders. are able to choose from three types of respite for a one-year For caregivers, respite programs can prevent or alleviate period: a short nursing home stay, adult day care, or in- depression and burnout by allowing time for the caregiver to home respite from a home health aide or visiting nurse. use in whatever way he or she determines is needed. This is Respite care is provided through a range of aging, public mental important for caregivers’ mental health and also enables older health, or social service agencies or private organizations. persons and their families to use community-based rather than Eligibility may be determined using income and diagnostic institutional services. criteria. Some private organizations serve a specific type of Research has indicated that the caregiver’s capacities and client, such as the Alzheimer’s patient and family. An example health may be as important in predicting institutionalization of how respite services can be organized and delivered includes as is the physical condition of the person receiving the care a joint endeavor between a health care agency and an area (McFall & Miller, 1992; Pruchno at al, 1990). Thus, a major agency on aging. These two organizations operate a service that force driving the development of respite has been the belief that provides homecare aides who offer companion, personal care, respite programs result in net savings to society by reducing or homemaker, or skilled care services. delaying the need for more costly forms of care. They also have facilities to provide overnight respite care, In addition, by bringing families at risk for mental health including supervision by a health care worker and participation problems into contact with formal care delivery systems, respite in day care activities if the respite stay exceeds one night. programs offer an opportunity for mental health outreach. Payment varies depending on whether the client is entitled to For example, the respite provider, after assessing the family coverage through Medicaid or a social service agency. situation, may be able to increase a family’s awareness of How effective is respite care? needed services available through the aging network – adult day In their beginning efforts to study respite, researchers have services, meals-on-wheels, or senior center activities – and to examined three outcomes: caregiver satisfaction, caregiver burden link family members with these services, if they are interested. or well-being, and institutionalization. While many studies show How is respite care implemented? modest but positive results, evidence on the effectiveness of respite There are many ways that respite care is provided and paid care is limited and inconsistent (Zarit et al, 1999). Researchers cite for. Respite care is among the services included in the newly the complexity of the issue as a reason for the mixed findings; for established National Family Caregiver Support Program example, variation in the levels, types, and quality of care as well under the Older Americans Act. Programs may vary along a as the characteristics of the elder and caregiver. Additional research continuum from low to high levels of care, and respite episodes is needed to come to definitive conclusions. may range from a few hours to stays of up to six weeks. Clients The most pervasive finding in the literature is that caregivers may use services as frequently as once or twice a week or as like respite programs and find them valuable, especially in- infrequently as once or twice a year. home respite care (Berry et al, 1991; Malone Beach et al, 1992;

Psychology.EliteCME.com Page 11 Montgomery and Kosloski, 1995; Zarit et al, 1999). Families they reach the point at which they are providing extensive care report benefits including relief from tasks, psychological and have identified themselves as caregivers. It is at this point that support, stimulation for the elder, and health assessments of the respite programs can be expected to have their greatest impact. older person that led to changes in medical routines. Finally, findings on whether respite care prevents or delays Concerns caregivers had about respite care centered on institutionalization are mixed. Some studies found that respite increased confusion and dependency of the elder, disruption had no impact on nursing home placement (Montgomery of home routines, and relinquishing responsibility and control; and Borgatta, 1985 and 1989; Montgomery and Kosloski, however, these problems are more frequently associated with 1995); however, another study found the greater the amount of out-of-home services, especially in hospital settings. Findings respite use, the less the probability of nursing home placement on caregiver burdens and well-being are inconsistent. Some (Kosloski and Montgomery, 1995). studies report no significant changes in either caregiver well- being or caregiver strain (Burdz et al, 1988; Deimling, 1991; Helping older adults with mental health needs requires attention Lawton et al, 1989; Knight et al 1993), while other studies to the body, mind, and spirit. The services described in this indicate a lessening of objective or subjective burden for the section can be a vital part of a holistic support system for caregiver (Kosloski and Montgomery, 1993; Montgomery and older people and their families, but could likely be even more Borgatta, 1985 and 1989). effective if the many systems involved (i.e. aging, health, and mental health) collaborated to coordinate care and form Montgomery and Kosloski (1999) examined the factors that partnerships with other community organizations. Finally, there influence caregivers’ utilization of respite care. They report that is a need to develop innovative models for delivering mental caregivers become most receptive to respite programs only when health outreach and care in alternative settings.

Medicare Medicare covers certain medical services and items in hospitals discussions about Medicare are likely to remain prominent on and other settings. Some are covered under Medicare Part A, the nation’s agenda in the years to come. and some are covered under Medicare Part B. As long as an individual has both Part A and Part B, these services and items Certain people younger than age 65 can qualify for Medicare, are covered regardless of whether he or she has the original too, including those who have disabilities and those who have Medicare plan, or belongs to a Medicare Advantage plan (like a permanent kidney failure or amyotrophic lateral sclerosis (Lou HMO or PPO). Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of Medicare is the nation’s health insurance program for Americans most long-term care services. age 65 and older, and for younger adults with permanent disabilities and people with end-stage renal disease, often referred to as ESRD. Medicare is financed by a portion of the payroll taxes paid Medicare does not provide complete coverage for all health care by workers and their employers. It also is financed in part by needs. Even though it pays for some preventive services and covers monthly premiums deducted from Social Security checks. The most medically necessary services, Medicare doesn’t pay for many Centers for Medicare and Medicaid Services is the agency in routine services such as annual physicals, or things like glasses, charge of the Medicare program, but an individual must apply hearing aids, or long-term care at home or in a nursing home. for Medicare at the local Social Security office.

The program helps to pay for many important health care Medicare has four parts: services, including hospitalizations, physician services, and a ●● Hospital insurance (Part A) helps pay for inpatient care in new prescription drug benefit. Individuals contribute payroll a hospital or skilled nursing facility (following a three-day taxes to Medicare throughout their working lives and generally hospital stay), some home health care and hospice care. become eligible for Medicare when they reach age 65, ●● Medical insurance (Part B) helps pay for doctors’ services regardless of their income or health status. and many other medical services and supplies that are not covered by hospital insurance. Comprising 13 percent of the federal budget and 19 percent of ●● Medicare Advantage (Part C) plans are available in many total national health expenditures in 2006, Medicare is often areas. People with Medicare Parts A and B can choose to a significant part of discussions about how to moderate the receive all of their health care services through one of the growth of both federal spending and health care spending in provider organizations under Part C. the U.S. With the dual challenges of providing needed and ●● Prescription drug coverage (Part D) helps pay for increasingly expensive medical care to an aging population medications doctors prescribe for treatment. and keeping the program financially secure for the future,

Medicare Part A Most people age 65 or older who are citizens or permanent helps cover hospice care and home health care. An individual residents of the United States are eligible for free Medicare must meet certain conditions to get these benefits. hospital insurance (Part A). Medicare Part A helps cover inpatient care in hospitals. This includes critical access hospitals and An individual is eligible at age 65 if he or she: skilled nursing facilities (not custodial or long-term care). It also ●● Receives or is eligible to receive Social Security benefits; or

Page 12 Psychology.EliteCME.com ●● Receives or is eligible to receive railroad retirement ●● Is the child or widow(er) age 50 or older, including a divorced benefits; or widow(er) of someone who has worked long enough in a ●● Is a spouse (living or deceased, including divorced spouses) government job where Medicare taxes were paid and so meets of someone who worked long enough in a government job the requirements of the Social Security disability program. where Medicare taxes were paid; or ●● Has permanent kidney failure and receives maintenance ●● Is the dependent parent of someone who worked long enough dialysis or a kidney transplant and: in a government job where Medicare taxes were paid. ○○ Is eligible for or receives monthly benefits under Social Security or the railroad retirement system. If an individual does not meet these requirements, he or she ○○ Has worked long enough in a Medicare-covered may be able to get Medicare hospital insurance by paying a government job. monthly premium. Usually, it is possible to sign up for this ○○ Is the child or spouse (including a divorced spouse) hospital insurance only during designated enrollment periods. of a worker (living or deceased) who has worked long enough under Social Security or in a Medicare-covered Before age 65, an individual is eligible for free Medicare government job. hospital insurance if he or she: ●● Has been entitled to Social Security disability benefits for Part A helps cover inpatient care in hospitals. This includes 24 months. critical access hospitals and skilled nursing facilities (not ●● Receives a disability pension from the railroad retirement custodial or long-term care). It also helps cover hospice care board and meets certain conditions. and home health care. It is important to meet certain conditions ●● Has Lou Gehrig’s disease (amyotrophic lateral sclerosis). to get these benefits. If an individual does not know for sure ●● Has worked long enough in a government job where whether he or she has Part A, it will show on the red, white, and Medicare taxes were paid and so meets the requirements of blue Medicare card. If an individual has Part A, “HOSPITAL the Social Security disability program. (PART A)” it is printed on the card.

Medicare Part B Part B helps cover medical services like doctors’ services, (Part A) can enroll in Medicare medical insurance (Part B) by outpatient care, and other medical services that Part A does paying a monthly premium. Some beneficiaries with higher not cover. Part B is optional. Part B helps pay for covered incomes will pay a higher monthly Part B premium. medical services and items when they are medically necessary. Part B also covers some preventive services. These include a If an individual is not eligible for free hospital insurance, he or one-time “Welcome to Medicare” physical exam, bone mass she can buy medical insurance, without having to buy hospital measurements, flu and pneumococcal shots, cardiovascular insurance, if the individual is age 65 or older and he or she is: screenings, cancer screenings, diabetes screenings, and more. ●● A U.S. citizen; or Anyone who is eligible for free Medicare hospital insurance ●● A lawfully admitted noncitizen who has lived in the U.S. for at least five years.

Medicare Part B and durable medical equipment Medicare Part B helps pay for durable medical equipment, such ●● One pair of eyeglasses with an intraocular lens after cataract as oxygen equipment, wheelchairs, walkers, and other medically surgery. necessary equipment that a doctor prescribes to use in the home. Other types of durable medical equipment covered by Medicare Medicare will not cover equipment, such as grab bars and include: humidifiers, that do not have a primary medical purpose, even ●● Arm, leg, back, and neck braces. though one may use them for reasons of safety or comfort. Medicare ●● Medical supplies, such as ostomy pouches, surgical pays for different kinds of durable medical equipment in different dressings, splints, and casts. ways. Some equipment must be rented; other equipment must be ●● Breast prostheses following a mastectomy. purchased. In some cases, an individual will need a “certificate of medical necessity” from the doctor for Medicare to pay.

Medicare Part C Medicare Advantage plans are run by private companies. They to the plan or going to certain hospitals to get services. This give more choices and sometimes extra benefits. These plans individual may also have to pay a monthly premium for the are still part of the Medicare Program and are also called Part extra benefits. Medicare pays a set amount of money for a C. They provide all of Part A (hospital) and Part B (medical) person’s care every month to these health plans. coverage. Some may also provide Part D (prescription drug) coverage. To join a Medicare Advantage Plan, an individual must have both Medicare Part A and Part B and live in the plan’s service area. The plan may have special rules that an individual needs to follow, such as seeing doctors that belong

Psychology.EliteCME.com Page 13 Medicare Part D Medicare offers prescription drug coverage for everyone with While Medicare Part D is a voluntary benefit, if an individual Medicare. This is called “Part D.” This coverage may help chooses NOT to enroll in a plan when first eligible AND does lower prescription drug costs and help protect against higher NOT have other drug coverage that is as good as or better than costs in the future. It can give a greater access to drugs that one Medicare’s (also known as ‘credible coverage’), he or she may can use to prevent complications of diseases and stay well. If an be charged a penalty if the decision to enroll at a later time individual joins a Medicare drug plan, he or she usually pays a is made. There are only certain times during the year that is monthly premium. Part D is optional. If this individual decides open enrollment. The penalty is 1 percent for every month of not to enroll in a Medicare drug plan when he or she is first eligibility for Part D when a person was not enrolled. eligible, there may be a penalty to pay when choosing to join later. These plans are run by insurance companies and other Medicare drug plans cover both generic and brand-name drugs, private companies approved by Medicare. but plans have rules about what drugs are covered in different drug categories. Most plans have a formulary, which is a Two methods to get Medicare prescription drug coverage are: list of drugs covered by the plan. This list must always meet 1. Join a Medicare prescription drug plan that adds drug Medicare’s minimum requirements, but in some situations, it coverage to the original Medicare plan, some Medicare cost can be changed by the plan during the year. Two such situations plans, some Medicare private fee-for-service plans, and are if a new generic version of a covered brand-name drug Medicare medical savings account plans. becomes available, or if new information shows a drug to be 2. Join a Medicare plan (like an HMO or PPO) that includes unsafe. In general, however, plans cannot stop or reduce the prescription drug coverage as part of the plan. An individual coverage of a drug a person is currently taking. If a formulary can get all Medicare coverage through these plans, change is made that affects an enrollee, the plan must let him or including prescription drugs. her know at least 60 days before a change takes place.

Both types of plans are called Medicare drug plans here. Like other insurance, Medicare prescription drug coverage will be there when help is needed with drug costs. Even if The Medicare Prescription Drug, Improvement, and Modernization an individual does not take a lot of prescription drugs now, Act of 2003 (also known as the MMA), was signed into law he or she still should consider joining a Medicare drug plan. on December 8, 2003. It created a voluntary prescription drug As individuals age, they usually still need prescription drugs insurance program through Medicare called “Medicare Prescription to stay healthy. Joining when first eligible means that an Drug Coverage” or “Medicare Part D” or “Medicare Rx.” individual will pay the lowest possible monthly premium. Every year (from November 15 to December 31), an enrollee This drug coverage is available to everyone who has Medicare, can switch to a different Medicare drug plan if needs change. regardless of income, health status, or how their prescriptions have been covered. Private companies provide the insurance An individual can join a Medicare drug plan from three months coverage. An individual chooses the drug plan and pays a before turning 65 to three months after turning 65 (called an monthly premium. If this individual has a limited income, he or initial enrollment period). Generally, if a person is disabled, he she may get extra help to cover prescription drugs for little or or she can join three months before and three months after the no cost. The amount of the monthly premium paid cannot cost 25th month of disability. The plan will notify the enrollee when more because of that person’s health condition or the number of coverage begins. prescriptions needed. In addition to a premium, one may also have to pay a deductible and a portion of the cost of the drugs.

Challenges in mental health and aging The following challenges will need to be addressed in the near ●● Financing mental health services. Federal, state, future by individuals who work with the elderly: and private funding streams are separate, may not be ●● Prevention and early intervention. Existing efforts generally coordinated, and tend to be less than adequate. focus on the diagnosis and treatment of illness rather than on ●● Collaboration. The delivery system encompasses a the early identification of high-risk individuals and families, variety of distinct care systems at both the institutional preventive measures, and the promotion of optimal health. and community levels: medical care, long-term care, ●● Public awareness and education. Stigma discourages mental health services, and aging network services. These older adults and their family members from acknowledging systems operate under different principles, and need to be mental health problems. It also discourages the pursuit of coordinated in order to best serve older people. treatment. Societal stereotypes and myths can hinder efforts ●● Access. Many mental health services for older adults are to diagnose and treat mental illness. consistently in short supply. Some older people do not ●● Workforce issues: shortages and need for education. recognize their own need for help or do not know how to There is an insufficient supply of trained professionals access the service delivery system. Most older adults could and paraprofessionals available to provide mental health access mental health care through their primary care physician, services to older people. Training opportunities for those but many health professionals are not adequately prepared to entering and currently working in the field must include identify or refer clients in need of mental health treatment. multidisciplinary cross-training. ●● Research. An expanded mental health and aging research agenda is needed to deepen our understanding of the

Page 14 Psychology.EliteCME.com biological, behavioral, social, and cultural factors that of these groups, and what types of mental health approaches prevent and cause disease, especially for at-risk and are most effective with minority elders. underserved populations. Research is needed in the areas of prevention, intervention, health services, and training. Addressing these challenges will require the concerted efforts ●● Consumer involvement. Consumer and family participation of all those working for better mental health of older persons in are essential in the care planning and treatment processes. both the public and private sectors, including social workers, Partnerships have begun to develop among consumers and policymakers, practitioners and service providers, researchers, family members, advocacy groups, and providers to plan and consumers and family members, and other advocates. develop mental health research, systems, and services. By taking advantage of the numerous efforts in mental health and ●● Needs of special populations. To provide competent aging that have been implemented and using them as a foundation assistance, mental health professionals serving special for crafting policies, programs, and research that will enhance the population groups such as racial and ethnic minorities must mental health of older persons and their families, we can address acquire adequate knowledge about the culture and values of the emerging crisis in geriatric mental health care, providing the these groups, how services can be tailored to meet the needs opportunity to work in partnership across services systems and disciplines to address the mental health needs of older adults.

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Consensus statement of the American Association directions. International Journal of Geriatric Psychiatry. 14, 165- 181. for Geriatric Psychiatry, Alzheimer’s Association, and the American Geriatrics Society. 98. Zisook, S. & Shuchter, S.R. (1993). Major depression associated with widowhood. American Journal of the American Medical Association, 278, 1363-1371. Journal of Geriatric Psychiatry, 1, 316-326. 79. Smith, M., Buckwalter, K., Garand, L., Mitchell, S., Albanese, M., & Kreiter, C. (1994). 99. Zisook, S., Shuchter, S.R, Irwin, M., Darko, D.F., Sledge, P., & Resovsky, K. (1994). Evaluation of a geriatric mental health training program for nursing personnel in rural long- Bereavement, depression, and immune function. Psychiatry Research, 52, 1-10. term care facilities. Issues in Mental Health Nursing, 15, 149-186. 100. Zylstra, R., & Steitz, J. (2000). Knowledge of late life depression and aging among primary 80. Smyer, M.A., Shea, D.G., & Streit, A. (1994). The provision and use of mental health care physicians. Aging & Mental Health, 4(1), 30-35. services in nursing homes. Results from the national medical expenditure survey. The American Journal of Public Health, 84, 284-287.

Aging and Long-Term Care Final Examination Select the best answer for each question and proceed to Psychology.EliteCME.com to complete your final examination.

1. While the extension of longevity among older Americans 4. A wide range of services intended to give temporary relief is a result of public health and other successes, the to caregivers of frail elders is called: incidence of chronic illness and vulnerability to mental a. Preventative care. health conditions also tends to rise in the later years of life , b. Respite care. including Alzheimer’s disease and: c. Diversion services. a. AIDS. d. Welfare services. b. Depression c. Pneumonia. 5. To provide competent assistance, mental health professionals d. Schizophrenia. serving special population groups such as racial and ethnic minorities must acquire adequate knowledge about which of 2. Managing situations giving rise to stress, managing the the following about these groups? meaning of those situations, and managing the stresses a. Culture and values. resulting from them is considered: b. Demographics. a. Coping. c. Characteristics. b. Resiliency. d. Therapeutic value. c. Restraint. d. Time management.

3. Interpersonal skill training, psychotherapy, reality orientation, self-care training, or social interaction are part of treatment of a specific resident for which of the following? a. Individual treatment. b. Group interventions. c. Psycho-social analysis. d. Individual interventions. PYMA03AL14

Page 16 Psychology.EliteCME.com Chapter 2: Bullying In Children And Youth

4 CE Hours

By: Kathryn Brohl, MA, LMFT and Rene Ledford, MSW, LCSW, BCBA Reviewed and Edited by: Wade Lijewski, Ph.D.

Learning objectives In this course, learners will be able to: ŠŠ Understand how to guide parents to protect their children ŠŠ Define bullying as it applies to children and youth. from bullies. ŠŠ Identify the characteristics of child and youth bullies. ŠŠ Understand that bullying is a worldwide problem. ŠŠ Understand the various forms of and settings where bullying ŠŠ Learn statistics that relate to bullying in children and youth occurs. within the United States. ŠŠ Identify the characteristic symptoms of a child or youth who ŠŠ Provide prevention and intervention information to assist is being bullied. children, youth and families when they’ve experienced bullying.

Introduction I shall remember and will never forget exhibiting perceived or true lesbian, gay, bisexual or Monday: my money was taken. transgender-related characteristics (Survey, 2008). Tuesday: names called. ●● Bullying occurs in all geographic regions and all types of Wednesday: my uniform torn, schools. It involves large numbers of children and youth Thursday: my body pouring with blood. from the United States in all socioeconomic backgrounds, in Friday: it’s ended. racial groups that have been studied and in areas of different Saturday: freedom… population density (urban, suburban and rural settings). Whereas social stereotypes may convey the impression that These words are from the final pages of a diary written by a certain ethnic or socioeconomic groups are more likely to 13-year-old boy, a victim of bullying who was found dead bully and perpetrate violence, research reveals no significant hanging from the banister railing at his home on the Sunday racial differences in the rates of bullying (Nasel, 2001). after he made his final entry (Taken from the book “Bullycide, ●● Most students report that when they are bullied, adults do Death at Playtime: An expose of Child Suicide Caused by not notice. Bullying,” Harper/Collins 2003). ●● In a 2001 study by Kaiser Foundation in conjunction with Nickelodeon TV network and Children Now, 86 percent Bullying in children and youth has become excessively of children ages 12-15 interviewed said they get teased or widespread and aggressive in the 21st century. Bullying bullied at school – making bullying more prevalent than behavior causes a harmful social, physical, psychological smoking, alcohol, drugs or sex among this age group. and academic impact on personal well-being in very young ●● According to the National Youth Violence Prevention children to older teenagers. And through their own actions and Resource Center, 30 percent of teens in the U.S. are inaction of others who hold responsible roles, bullies learn estimated to be involved in bullying in one way or another. that antisocial behavior and exerting control over others is ●● Victims are always vulnerable in some way. They are more acceptable and that it works. Bullying creates an atmosphere anxious and insecure than other students (Olweus, 1993). that is unhealthy for everyone. It interferes with child and youth ●● Bullying is a worldwide problem that ranges from England development and can lead to suicide and school violence. to Japan to New Zealand to British Columbia to South The pioneering work of Dan Olweus in Norway and Sweden as America. Bullying can affect victims far away because it well as other researchers has found that: now occurs through cyberspace, including through e-mail, ●● Children and youth in the United States are teased, cell phone texting, instant messaging, blogging and social threatened or tormented by bullies to the extent that 160,000 networking sites. students skip school each day. Until recently, and even now, the common thread in all countries ●● The most common forms of bullying in middle and high is that children are relentlessly and repeatedly bullied without school are related to physical appearance, disabilities, significant objections or outrage from responsible adults. perceived sexual orientation or gender expression, and

Psychology.EliteCME.com Page 17 The mental health professional’s responsibility The most horrifying and damaging effect of bullying is child or emotional well-being of victims, affecting them on many levels, adolescent suicide. Because suicidal ideation and suicide occurs including long-term psychological and physical wellbeing. among young bullying victims, it is essential for mental health providers to help caregivers to identify and intervene on behalf In addition, while mental health providers must pay attention to of their bullied children. It is also essential that mental health supporting children, youth and families when they experience professionals help caregivers to identify the key gatekeepers, bullying, it is also important for practitioners to facilitate those people who regularly encounter individuals or families in healing in bullies, the perpetrators, as well as in environments distress, and who can identify and refer children and youth at where bullying begins and thrives. risk for suicide. Key gatekeepers include teachers and school This course will define bullying and its effects on children, staff, school health personnel, clergy, natural community youth and families, as well as populations most vulnerable helpers, extended family and emergency health care personnel. to being bullied, and settings in which it most often occurs. While suicide is an outcome at the end of the bullying In addition, it will discuss interventions that mental health spectrum, bullying can also have a life-long effect on the professionals can use to prevent and heal bullying.

Bullying Bullying is a behavior linked to child development, relationship include the words “repeated,” “ongoing” and “exposed over formation and psychological well-being. Bullying is a learned time” in addition to intentionally inflicting or attempting to behavior. According to the American Psychological Association inflict injury or discomfort on another (Olweus, 2001). Bullying (APA), bullying is commonly characterized as aggressive intensity can range from mild to moderate to severe. In behavior that: addition, harm to the victim is not intentionally provoked by the ●● Is intended to cause distress or harm. victim himself. The various forms of bullying include: ●● Involves an imbalance of power or strength between the ●● Physical – hitting, kicking, shoving, spitting, hair pulling, aggressor and the victim. strangling and so on. ●● Commonly occurs repeatedly over time (APA, 2004). ●● Verbal – taunting, teasing, name calling, hate speech, threatening. In its 2004 Resolution on Bullying Among Children and Youth, ●● Emotional/relational – rejection or exclusion of others, the APA described bullying as taking many forms, including rumors, gossip, forcing others to do things. physical bullying; teasing or name-calling; social exclusion; ●● Sexual – unwanted hugs, punches, slaps or sexual jokes. peer sexual harassment; bullying about race, ethnicity, religion, ●● Cyber bullying – using Internet, e-mails, instant messaging, disability, sexual orientation and gender identity; and cyber text messages and social networking sites to taunt, tease, bullying. harass and spread rumors or gossip.

Bullying could also be defined as “actualized arrogance.” The bullying relationship affirms the power needs of the It is abusive behavior by one or more person(s) against a abuser and takes advantage of the vulnerability of the victim victim or victims. While bullying can be a direct attack such in a situation where lack of external support leaves the victim as teasing, taunting, threatening, stalking, name-calling, feeling isolated and exposed, and in which there are lasting hitting, making threats, coercion and stealing, it can also be consequences for the victim as a damaged self-concept. subtler through malicious gossiping, spreading rumors and intentional exclusion. All forms of bullying result in victims Bullies may work alone or in a group, and the becoming socially rejected and isolated because of physical or victim is usually isolated. Witnesses or psychological intimidation that occurs repeatedly over time to bystanders are frequently present and may feel create an ongoing pattern of harassment and abuse. paralyzed by their own sense of vulnerability to the bully (Ressenger, 2010). Bullying can occur As noted above, bullying is an imbalance in real or perceived power among peer groups, sibling groups or work that exists between the bully and the victim (U.S. Department groups. Or bullying can be random with bullies of Education, 2010). When defining bullying, other sources often not knowing their victims.

Power and bullying Webster’s New World College Dictionary (Macmillan, fourth Authors, Suellen and Paul Fried, in their book, “Bullies edition, 1999) provides various definitions of power. The and Victims: Helping Your Child Through the Schoolyard definition most closely associated with bullying states, “The Battlefield,” (New York: M. Evans and Company, Inc, 1996), ability to control others, sway, influence. Power denotes include six factors that further identify bullying: the inherent ability or the admitted right to rule, govern and 1. Intent to harm – The perpetrator finds pleasure in the taunting determine. Authority refers to the power, because of rank or office and continues even when the victim’s distress is obvious. to give commands, enforce obedience and make decisions.”

Page 18 Psychologogy.EliteCME.com 2. Intensity and duration – The teasing continues over a long 6. Consequences – The damage to self-concept is long lasting, period, and the degree of taunting is damaging to the self- and the impact on the victim leads to behavior marked by esteem of the victim. either withdrawal or aggression. 3. Power of the abuser – The abuser maintains power because of age, strength, size or gender. According to author Barbara Coloroso, children and youth who 4. Vulnerability of the victim – The victim is more sensitive bully look for potential targets and often search for potential to teasing, cannot adequately defend him- or herself and bystanders. Once targeted, the victim is depersonalized in some has physical or psychological qualities that make him or her way by the bully through taunts, ridicule and/or harassing more prone to vulnerability. physical behavior. The bullied child or youth moves away in 5. Lack of support – The victim feels isolated and exposed. fear and blames him- or herself for the attack. Often bystanders Often, the victim is afraid to report the abuse for fear of move away and feel helpless and afraid themselves. Feeling retaliation. emboldened, the bully escalates his actions toward the victim. Two types of bystanders may surface; those that move away from the victim and clear of the bully, and those that join forces with the bully.

Victims Victims of bullying are likely to be anxious, insecure, cautious, have been victims of parental or sibling bullying and simply have and suffer from low self-esteem, rarely defending themselves not learned how to self-nurture, assert themselves or regulate or retaliating when confronted by bullies. They may lack social their emotions when stressed. A child may never suffer from skills and, for many reasons, tend to be isolated. They may bullying until the family moves to a new school where the values appear physically, mentally, emotionally or sexually oriented and environment are dramatically different from what they’ve differently than their peers. Depending on their family dynamics, known. Because of new stressor, a child’s self-confidence can they may or may not have overly protective parents. They may plummet. Jackson is an example of such a child.

Jackson’s story Jackson was raised by his single mom in a small, rural she’d been the target for teasing because she had physically community in Upper Michigan. His classmates knew Jackson developed earlier than other girls. Noticing the girl paying all his life and were happy to play with this little boy who attention to Jackson prompted taunting from her bullies, and had a slight speech impediment. When Jackson was in the Jackson was drawn into her victimized world. In addition, they sixth grade, his mother met a man on a business trip and noticed Jackson’s speech and began to taunt him as well. subsequently moved Jackson to Detroit when she and the man were married. As time passed, Jackson became their target. Jackson was miserable and begged his mother to move back “home.” His Jackson was suddenly thrust into an environment where there mother, caught up in her new world and relationship, told were more children in his middle school class than there were her son to avoid these kids, and his stepfather told him to in his entire school up north. The kids dressed differently and stand his ground and learn to fight “like a man.” Jackson felt there was much confusion every time they changed classes psychologically abandoned by his caregivers, and the school during the school day. Sensing his wide-eyed, frightened officials were too busy with their “more urgent issues” to insecurity, a girl his age decided to help him. Unfortunately, address the bullying at Jackson’s school.

When children and youth are bullied Bullying causes negative psychosocial functioning in victims. ●● Withdraws from family and school activities. Problems that occur because of bullying (APA, 2004) include: ●● Is sad, sullen or angry after receiving a phone call or e-mail. ●● Lowered self-esteem. ●● Uses derogatory or demeaning language when talking about ●● Higher rates of depression. peers. ●● Anxiety. ●● Stops talking about peers and everyday activities. ●● Feelings of loneliness. ●● Disheveled, torn or missing clothing. ●● Suicidal ideation. ●● Physical injuries. ●● Higher rates of school absenteeism. ●● Unable to sleep, sleeps too much, or is exhausted.

A child may show few or many signs of bullying. For example, The victim feels helpless and can develop severe depression warning signs that a child is bullied at school include: and rage. He is angry at himself, at observers, and at adults ●● An abrupt lack of interest in school or refusal to go to school. who didn’t intervene as well as at the bully. He may suffer ●● Takes an unusual route to school. academically, develop psychosomatic complaints, withdraw ●● Suffers a drop in grades. from family and friends, and fantasize about revenge. ●● Few or no friends.

Psychology.EliteCME.com Page 19 A tragic story South Hadley, Mass., is a place where severe bullying ended followed her home, calling her offensive names while throwing in death for one young student in 2010. Nine students were a large drink in her direction. charged in connection with the death of Phoebe Prince, a 15-year-old teenager formerly from Ireland, who killed herself Surprisingly, students interviewed following her death didn’t after having been harassed by girls at her high school. Six of see her bullying as a serious problem, calling it “normal girl the bullies were charged with felonies and three more were also drama.” As the case drew nationwide attention and outrage, the charged, but as juveniles. question became, “Where were the adults?” The South Hadley High School principal said: “There were instances of name- Massachusetts district attorney Elizabeth Scheibel charged calling with Phoebe the week before she died. These were the group with “relationship aggression,” which included brought to our attention, and we dealt with those kids right three months of verbal insults and physical threats. Phoebe, away. We also talked to her, we had her working with a school with a history of depression, was also targeted electronically counselor, we talked to her mom.” (Pytel, 2010). This begs the on Facebook where she received messages urging her to kill question: Could the school have done anything else to prevent herself. In addition, the young victim was also targeted in the Phoebe’s suicide? library, hallways, shoved into lockers and taunted walking home from school. According to some students, teachers Experts remain divided on whether legal action was the right observed a few of the incidents. And on the day she died, the choice. They wonder whether children should be judged solely bullying was extremely intense when South Hadley students on group behavior, or did taking legal action finally bring the issue to light?

Bullying, trauma and post-traumatic stress disorder Bullying has been linked to creating trauma in children and on exposure to internal or external cues that symbolize or youth. And trauma can create acute stress disorder and in more resemble aspects of the traumatic event. severe cases post-traumatic stress disorder. The latter, known ●● Persistent avoidance of stimuli associated with the trauma as PTSD, is marked by clear physiological changes that occur and numbing of general responsiveness not present before because of exposure to life-threatening events and impairs the trauma including efforts to avoid thoughts or feelings physical, cognitive, social, emotional, self-regulation and of conversations associated with the trauma; avoiding relational daily functioning. Children and youth who may be activities, places or people that arouse recollections of the more vulnerable to acquire acute stress or post-traumatic stress trauma; inability to recall an important aspect of the trauma; disorders are likely to: markedly diminished interest or participation in significant ●● Have had prior vulnerability factors that included early activities; feeling detachment or estrangement from others; trauma, no functional social support, concurrent stress and and restricted range of affect. genetic makeup. ●● Persistent symptoms of increased arousal that include ●● Report greater perceived threat or danger, suffering, terror difficulty falling or staying asleep; irritability or outbursts and horror, or fear. of anger; difficulty concentrating; hyper-vigilance; and ●● Have exposure to social environments that promote self- exaggerated startle response (Brohl, 2008). hatred, shame, guilt and stigmatization. ●● Have experienced greater stressors with regard to Post-traumatic stress disorder and depression contribute to unpredictability, uncontrollability, sexual victimization, intense anxiety that prompts high-risk behaviors in children betrayal, and real or perceived responsibility. and youth. Both are often present in young victims of bullying. Suicide is an action taken at the end of the depression spectrum Indicators that bullied kids may have acquired acute stress and has been attempted by too many victims. When young or PTSD include: traumatized victims suffer from depression and bullying, ●● Persistently re-experiencing the trauma through images, they can become intensely distraught and hyper-reactive and thoughts, or perceptions as recurrent and intrusive distressing become more vulnerable to experiencing suicide ideation and recollections of the traumatic event; recurring distressing attempting suicide. Hyper-reactivity is one PTSD and acute dreams of the event; acting or feeling as if the traumatic event stress symptom. were recurring; intense psychological distress at exposure to internal or external cues that symbolize or resemble an Anthony is someone who at an early age developed post- aspect of the traumatic event; and physiological reactivity traumatic stress disorder and was also bullied.

Anthony Anthony suffered from emotional developmental disruptions he also grew more and more oppositional and was moved when he was removed from his home and placed in foster to other out-of-home placements. At age 12, he was obese, care because of sexual abuse by his mother’s boyfriend at age temperamental and sad. His mother’s parental rights had been 5. Anthony also suffered from learning disabilities and was terminated, and there was little hope of locating his biological frequently teased by his young schoolmates. As he grew older, father. Different case managers came in and out of his life, but

Page 20 Psychologogy.EliteCME.com he was moved to a therapeutic foster home where he met new youth beamed. The group was about to attack him on a Friday loving foster parents with grown children. At the same time, he afternoon when a teacher happened to see their suspicious was introduced to a young therapist who quickly diagnosed him activity in a secluded part of the gym. He was able to intercede with PTSD, and once again, Anthony became acquainted with before the boys could do real harm, but Anthony was devastated yet another mental health professional. by their behavior. He spent the weekend sleeping and eating. His foster parents were caught off guard by his depression and His new foster parents knew he was vulnerable at his new school lethargy, and especially when Anthony began to talk about because of his prior academic struggles and were prepared dying. They asked him if he intended to hurt himself, and the for handling Anthony’s explosive temper. It didn’t take long, boy replied that it had been on his mind for a while. “He just because bullies at school picked up on his vulnerability. They didn’t see the point.” If it had not been for his foster parents’ even devised a plan to pose as his friend and later verbally quick and insightful actions as well as his therapist’s intensive and physically harm him. For a brief week, they included intervention, Anthony might have attempted to take his life. him in their group and made him an “honorary member.” The

Different types of victims According to researcher Olweus, there are three types of Jim bullying victims: Jim, age 14, loves sports. He was always eager to join 1. Passive victims – Representing the largest group, passive a neighborhood game of touch football, but became victims do not directly provoke bullies; they may appear very upset when he lost a game or made a bad play. The to be physically or emotionally weaker and do not defend neighborhood kids would avoid Jim sometimes when they themselves. They may have few or no friends and can be set up a game simply because Jim often lost his temper overly protected by their parents. Heather is an example. when they were just trying to have fun. When Jim began his freshman year in high school, he joined the junior varsity Heather basketball team and was thrilled to practice, but got easily Heather was adopted at birth and cherished by her adoptive angered when he wasn’t thrown the ball or when he fouled parents. She was dressed in beautiful clothes and exposed out of the game. The other players soon excluded Jim from to many privileges, such as exotic vacations and learning their social activities and began to call him derogatory opportunities. As Heather grew older, she spent more time names while “accidentally” elbowing him during practices. in her parents’ company than she did playing with other children. They were overly cautious of Heather’s safety and 3. Bully-victims – These people represent a small percentage often worried when she was out of their purview. When of bullies and have experienced bullying themselves. They Heather became older, she asked her parents to take her are typically physically weaker than their bullies, but are out of private school and place her in public school. When stronger than those they bully. Mary is an example. she entered public school for the first time, at age 11, she asked some of the students where she could find the bottled Mary water machine and told some of her new “friends” about her Mary was the oldest of seven children and a surrogate family and the fun time they all had in France the previous mother to many of them, especially when her parents drank. summer. Her classmates soon erroneously labeled Heather She was also on the front line when it came to her father’s “a spoiled rich girl” and began to taunt her at school. temper, because she was the one he struck when he lost his Heather was surprised and hurt by their comments and temper. His size and strength overwhelmed Mary, while didn’t understand why she’d been targeted. She didn’t know her mother stood silently by when her husband went on a how to defend herself and simply remained silent during her rampage. Mary grew up being bullied by her father – the abuse. The taunts grew, and eventually Heather’s parents person who should have protected her. As they prepared to and school officials intervened when other students began to walk to the corner bar on Friday evenings, Mary’s parents throw food at her in the cafeteria. always directed her to watch her younger brothers and sisters. At age 12, she towered over the little ones and was 2. Provocative victims – These youths represent a smaller much stronger than her closest sibling. But instead of being group than passive victims and are actually aggressive sensitive to their needs, Mary simply used her strength and themselves, especially toward others who appear weaker power to bully them. When they needed help getting ready than they. They may lack anger management skills and are for bed, Mary slapped and shouted at them. She called them not liked by peers. They may react negatively to conflict or names and frightened them by saying she’d call the police losing. Jim is an example. to take them away if they didn’t behave.

Settings where bullying occurs High-risk areas for bullying are places where there is no adult Bullying occurs while children travel to and from school, but it is supervision, inadequate adult supervision or lack of structure most likely to happen on school property (Beane, 2008). Almost – areas where children have nothing to do or are free to do as 10 percent of students are bullied at school (Pawlik-Kienlen, they wish. 2007). Some of the school-related places include bus stops, bathrooms, buses, hallways, cafeterias, playgrounds, locker

Psychology.EliteCME.com Page 21 rooms, gyms, parking lots, stairwells, between buildings and psychological harm can occur on an even deeper level because even classrooms. Sports activities can set the stage for bullying the home is where children first learn to feel safe. to occur as well. While not discussed very openly, sports bullying occurs when violence, taunting and humiliation is often viewed In addition, children are bullied in their own neighborhoods as normal behavior and assigned as just a place where it’s okay where there is a lack of responsible adult supervision and to have a “competitive edge.” The adults in charge of school unsafe playing areas. Says Todd: “I hated my neighborhood. sports programs most often set the tone for bullying to occur. There were a bunch of kids that had been there long before I Sometimes these adults can contribute to bullying through their moved in and they all hung together cause their daddies had excessive aggressive behavior and unreasonable expectations of all hung together when they were young, too. It was like a their players. Coaches have been known to publicly humiliate fraternity for 10-year-olds, for god’s sake, and I was the new and verbally abuse their students, in addition to encouraging kid that never fit in. I remember one time they called me to their bullying behavior in their team members toward rival team fort, and when I climbed up in the tree, they all raced down the members. At the same time, parents overlook these behaviors and ladder and left me there all alone, calling me a loser.” encourage their kids to “suck it up.” Malls, theaters and other public places are settings where Factors that contribute to school bullying include: bullying also occurs. One latency age young woman reported: ●● No anti-bullying policy. “I was waiting for my sister to meet me at the food court at the ●● Crowded locker rooms. mall, and all of a sudden a group of about five boys around my ●● Inconsistent discipline. age sat down near my table. They began to laugh, and when I ●● Inconsistent behavior standards. turned around, they were making nasty gestures at me. I felt ●● High teacher turnover. humiliated and walked quickly to toward the mall bathroom. ●● Low staff morale. I could hear them laughing and shouting comments such as, ●● Narrow, isolated or unmonitored areas. ‘Look at that fat b. She’s asking for it.’” ●● Lack of policies that pertain to student transitions to and Adolescents are also bullied at the workplace, and the effects from class and before or after school. include loss of productivity and high absenteeism rates. Sara ●● Lack of support for students with special needs. said this: “I don’t know why the guys at work give me such ●● Public humiliation from adult supervisors. a hard time. I really need this job, and they goof off. When ●● Overlooking signs of bullying and discouraging disclosure I’m serious, they just make fun of me and call me all kinds of (Stephenson and Smith, 1994). names behind my boss’s back. I get so nervous before going to But victimization isn’t limited to schools. Siblings bully one work that sometimes I’ve had to call in sick. The problem is, I another, and the effects can be devastating as well, except that know they’d take it out on me if I reported them.”

Cyber bullying Cyber bullying is becoming a ●● Message boards. Kids with like interests discuss them online. serious problem among children ●● Short message service (SMS). Text messages can be sent and youth, and yet fewer than 30 with cell phones. percent of the victims know ●● E-mail (electronic mail). A service provider can send their bullies. Cyber bullying is messages from one person to another. any harassment that occurs via ●● Discussion groups (newsgroups). Group forums are the Internet. Name calling in devoted to one topic, and messages are posted in bulletin chat rooms, posting fake profiles on websites, vicious forum form and remain on a server instead of being e-mailed. posts and cruel e-mail messages are different forms of cyber bullying. In addition, school bulletin boards can be spammed In a survey of randomly selected middle schoolers in one of the with hateful rumors directed toward a specific student, and U.S.’s largest school districts, researchers Patchin and Hinduja fictitious profiles on a social networking site can prompt a found that cyber bullying victims were 1.9 times more likely victim to falsely engage with someone who appears to be and cyber bullying offenders were 1.5 times more likely to someone else. have attempted suicide than those who were not cyber bullying victims or offenders. The authors concluded that suicide A cyber bully can use the following forums to bully victims. prevention and intervention should be included in schools’ They include: bullying and cyber bullying response program. ●● Blogs (web logs). Blogs provide users with the tools to publish personal content online about a range of subjects. The most common forms of offending were posting online These topic areas connect children and youth with similar information about another person to make others laugh, and interests. getting an upsetting e-mail from someone victims know ●● Chat rooms. Chat rooms are virtual meeting places where (NetFamilyNews.org. 2010). users find people to communicate with online. Chat rooms can accommodate many users simultaneously. ●● Instant messaging (IM). Two or more kids can communicate online, and IM users create contact lists.

Page 22 Psychologogy.EliteCME.com Megan’s story A middle-aged Missouri woman was charged with cyber ●● A child has personal photos posted without his/her permission. bullying 13-year-old Megan Meier, a youth suffering from ●● A child spends excessive time using chat rooms. depression and attention deficit hyperactivity disorder. Megan took her own life after receiving harassing e-mails from the Author Allan L. Beane, Ph.D., outlines several “Cyber Rules.” woman, who was posing as a young boy interested in Megan. They include: ●● Never provide personal information of an intimate nature The woman was convicted of three minor offenses after federal that should be discussed only with parents, family, close prosecutors were able to charge her with conspiring to violate friends or professionals. the fine print in MySpace’s agreement that addresses creating ●● Never give out any passwords to anyone other than parents. fictitious identity and harassment. ●● Never give out personal contact information. ●● Never use inappropriate language and never write anything Cyber bullying creates the same effects as other types of that you wouldn’t mind the world reading. bullying. Victims feel overwhelmed and helpless. Bullies can ●● Do not participate in gossip or spreading rumors. Simply remain somewhat anonymous and may be more apt to bully stop communicating. because of their anonymity. It can prompt behavior that normally ●● Never upload or download photos, music or videos without would not occur because it is convenient and detached. parent’s permission. ●● Treat others online the way you want to be treated. Warning signs when a child is being cyberbullied include: ●● Immediately report any hurtful comments and threats against ●● There are large cell phone charges from the same number. yourself or anyone else and immediately stop communication. ●● The child appears secretive about using the computer. ●● Internet time should be limited and agreed upon with ●● The child sends and receives coded messages. parents (Beane, 2008). ●● A child visits websites that promote negative messages. ●● A child becomes upset, irritable and emotional after spending time texting or on the computer.

Reporting cyber bullying When children and youth are threatened, make racist remarks, or A sample list of cyber bullying and Internet websites created to spread malicious gossip to attempt slander online or otherwise, prevent, support victims and halt bullying is included here: they should be reported to the police. It is important to maintain ●● www.cybertiplin.com a record of threats. However, printouts, according to Beane, are ●● www.safekids.com generally not considered admissible evidence. The author suggests ●● www.isafe.org using a monitoring software program that collects and preserves ●● www.stopbullying.org electronic evidence. The author also cautions victims or their ●● www.cyberbullyinghelp.com caregivers not to install or remove any programs or take other ●● www.stoptextbullyhelp.com remedial action on the computer or communication device during ●● www.wiredsafety.org this process, because it will adversely affect the investigation. ●● www.netfamilynews.org

Bullying behavior has many layers There are several layers to bullying. Complex bullying combines 7. Is innocent in motive. different levels and types of aggression as bullies grow to 8. Is discontinued when the person teased becomes upset or intimate and harm their victims over time. Psychological, objects to the teasing. verbal and physical bullying often occur at the same time, and many times begin with just one act and escalate to the point of Taunting: multiple acts by multiple bullies. For example, teasing can lead 1. Is based on an imbalance of power and is one-sided: the to taunting, but teasing is not the same as taunting. Teasing is bully taunts while the bullied child is taunted. supposedly a “fun” thing to do with friends, but taunting is a 2. Is intended to harm. choice to bully someone for whom you have contempt. Author 3. Involves humiliating, cruel, demeaning, or bigoted Barbara Coloroso defines teasing and taunting differently: comments thinly disguised as jokes. Teasing: 4. Includes laughter directed at the target, not with the target. 1. Allows the teaser and person teased to swap roles with ease. 5. Is meant to diminish the sense of self-worth of the target. 2. Isn’t intended to hurt the other person. 6. Induces fear of further taunting or can be a prelude to 3. Maintains the basic dignity of everyone involved. physical bullying. 4. Pokes fun in a lighthearted, clever and benign way. 7. Is sinister in motive. 5. Is meant to get both parties to laugh. 8. Continues especially when the targeted child becomes 6. Is only a small part of the activities shared by kids who have distressed or objects to the taunt. something in common. 9. There is no playfulness associated with taunting. 10. It is intended to isolate the victim.

Psychology.EliteCME.com Page 23 Sibling taunting For example, an older sibling begins Her brother, sensing his sister’s concern begins to enjoy her to tease his younger sister about reaction. He’s feeling as though he has some control over her wearing glasses, “Hey four eyes, can emotions when he sees her face redden. His remarks continue you finally read?” At first, his sister to escalate until his sister begins to cry. Noticing her distress, laughs at his remark. She looks up to his mother asks what happened, and he behaves as though him and appreciates his attention. he hasn’t a clue. He knew his sister could or would not strike back. There was no well-intentioned give and take during the Her brother continues, “Mom told me you were the only siblings’ interaction. Instead, the young bully became excited one in the family who ever needed glasses. That’s what they and felt powerful over the success of the attack. call a defect. You’re defective.” The little girl begins to look confused, “Did her mother think she was defective? What did defective mean?” It didn’t sound good.

Psychological, social and relational bullying Bullying isn’t limited to pushes and verbal attacks. Tied closely to psychological bullying is social and relational Psychological bullying is behavior that intentionally harms bullying. This type of bullying causes negative feelings in another person by using social manipulation that includes: victims and encourages social isolation and exclusion. Social ●● Ostracizing or ignoring peers. and relational bullying often interfaces with psychological ●● Not inviting peers to join groups or activities. bullying and can include: ●● Spreading lies or rumors. 1. Passing hurtful notes on to other children and youth, or using ●● Name-calling. graffiti to send pejorative messages about a particular person. ●● Teasing hurtfully. 2. Embarrassment and humiliation, such as making lewd noises when someone begins to speak in class. Psychological bullying has effects for victims that include 3. Threatening gestures and behaviors toward victims. feeling helpless, out of control, low self-esteem, and at the 4. Social rejection and isolation through group exclusion. end of the spectrum, experiencing acute stress and long-term 5. Spreading nasty and malicious rumors and lies. symptoms of post-traumatic stress disorder (Brohl, 2008). 6. Destroying and manipulating relationships. Victims may experience insomnia, anxiety and depression.

Sexual bullying Physical, verbal and psychological bullying frequently targets a serious educational consequence as well as significant threats to child or youth’s sexuality. Questionnaire responses from a study the physical and emotional well-being of targeted kids. conducted by the American Association of University Women Educational Foundation (“Hostile Hallways” study, 1993) from While author Coloroso defines teasing and taunting differently, over 1,600 students from eighth through 11th grade provided she also defines flirting and verbal sexual bullying differently as some unsettling information: well. When she defines “flirting,” she states: ●● 86 percent of girls reported being sexually harassed by their ●● Flirting … peers. ○○ Allows and invites both persons to swap roles with ease. ●● 25 percent of girls reported being sexually harassed by ○○ Isn’t intended to hurt the other person; is an expression school staff. of desire. ●● 85 percent of girls and 76 percent of boys reported having ○○ Maintains the basic dignity of both persons. experienced sexual harassment. ○○ Is meant to be flattering and complimentary. ●● 65 percent of girls reported being touched, grabbed or ○○ Is an invitation to have fun together and enjoy each pinched in a sexual way. other’s company. ●● 13 percent of girls and 9 percent of boys reported being ○○ Invites sexual attention. forced to do something sexual other than kissing. ○○ Is intended to make the other person feel wanted, ●● 24 percent of girls stayed home from school or cut classes attractive and in control. to avoid sexual harassment. ○○ Is discontinued when the person who is being flirted ●● One third reported experiencing sexual bullying in sixth with becomes upset, objects to the flirting or is not grade or earlier. interested. ●● The youth reported that they’d experienced sexual harassment ○○ Is playful. in the school hallways (73 percent), classroom (63 percent), ●● Whereas, verbal sexual bullying … school grounds (48 percent) and in the cafeteria (34 percent). ○○ Is based on an imbalance of power and is one-sided: the bully sexually taunts, and the victim is demeaned and Girls who mature early and boys who mature late are at high degraded. risk for being sexually bullied. The study also pointed to a ○○ Is intended to harm and exploit.

Page 24 Psychologogy.EliteCME.com ○○ Is invasive and intended to assert the status of the bully. harassing behaviors are dissatisfying and therefore ○○ Is intended to be degrading or demeaning. undesirable actions that hurt people and are unworthy of ○○ Is intended to express control and domination. people of intelligence and integrity.” ○○ Is intended to violate the boundaries of the target. -Peter Minor, Sexual Respect Curriculum ○○ Is intended to make the other person feel rejected, ugly, degraded, powerless, or uncomfortable. Sexual bullying can include staring at genital areas, leering or ○○ Continues, especially when victim becomes distressed making obscene gestures, and shunning someone because of or objects to the sexually charged comment. their sexual orientation. In addition, it includes displaying sexually explicit material intended to humiliate or degrade In sexual bullying, there is no invitation – just an attack. The another person, sexually explicit graffiti and displaying sexually victim is embarrassed, humiliated and shamed and tends to explicit material that targets victims, such as graffiti in bathrooms. feel powerless. If the victim protests, she or he is assigned a pejorative name such as “bitch,” “queer” or “loser.” Physical sexual bullying can include pinching, bra snapping, “Can you espouse the values of fairness and respect, and at pulling down pants or pulling up a skirt, brushing against the the same time discriminate and injure? Sexist and sexually body in a sexual manner, sexual touching or grabbing or sexual assault (Criminal activity can include sexual bullying).

Miranda’s story Miranda killed herself when she was just 14 years old. When The school backlash included calling her terrible names and she was 12, she had reported being raped by a prominent blaming her for the rape. In one lawsuit, her parents stated that 16-year-old athlete in her rural community. The young man a teacher forced her to stand next to the rapist, even though pleaded guilty and was placed on probation. there had been a restraining order against him (Coloroso, 2008).

Physical bullying Common bullying behaviors involve physical contact, including: and shoved in front of friends, especially when bullied victims ●● Pinching. fall down or are some way physically put in the position of ●● Pushing, shoving and tripping. appearing even more vulnerable. ●● Kicking. ●● Hitting, slapping, elbowing and shouldering (slamming). Restraining someone against their will can also be extremely ●● Restraining. harmful to victims. As author Allen Beane reports in his book, ●● Flushing someone’s head in the toilet (swirling). “Protect Your Child From Bullying,” it creates multilevels of ●● Forcing someone into small spaces such as lockers or closets. bullying. He states, “One 16-year-old girl was held down on ●● Spitting, throwing objects – even food. the floor by a group of girls who then marked all over her face ●● Threatening body language. with a permanent marker. You can imagine how hurt she was emotionally.” Many physical forms of bullying are completed without adult notice. It can be humiliating and embarrassing to be pushed

Populations of children and youth most often targeted Both males and females are victims of bullying and range in age intolerable bullying she experienced at school (Coloroso, 2008). as young as toddlers and as old as young adults in college. An Females represent a larger percentage of victims who suffer from 8-year-old, thought to be the youngest child to die from bullying sexual bullying, in particular. Yet, there are sub-group child and in England, hung herself with her jump rope because of the youth populations that been historically targeted for bullying.

Teenage bullying Teenage bullying is a serious period of time. At one point, they were surrounded and squirted issue that can lead to mental with ketchup packets while teachers observed. Eric’s suicide health problems and note mentioned that in their minds, it was “payback time.” devastating consequences in victims. The Columbine High According to Teens Health, “Bullying occurs when a person School shooters, for example, is picked on over and over again by an individual or a group had been long-time victims of with more power, either in terms of physical strength or bullying. Eric Harris and social standing.” Some victims experience a decline in school Dylan Klebold killed 12 classmates and one teacher, and performance and become isolated. Phoebe Prince’s suicide is an injured 18 other students before they took their own lives. example of what can occur at the end of the spectrum as a result These two youth had been relentlessly taunted at school over a of teen bullying.

Psychology.EliteCME.com Page 25 Teen bystanders or other witnesses to teen bullying are often at ●● 88 percent of junior high and senior high school students a loss when they report their feelings watching bullying occur. said that they battled feelings of guilt and helplessness after The National Youth Violence Prevention Resource Center witnessing bullying. (NYVPRC) shares these statistics: ●● The reactions ranged from blaming the victim to avoiding the bully. ●● Fear of being targeted themselves.

Gay, lesbian bisexual and transgender teens (GLBT) Bullying can begin at an early age for children who are, Twenty-two percent of gay respondents had skipped school erroneously or not, identified or self-identified as gay, lesbian, in the past month because they felt unsafe there (Ibid). bisexual or transgender. One victim reported that taunts were ●● 28 percent of gay students will drop out of school, more than targeted at him when he entered kindergarten. The boys in his three times the national average for heterosexual students class called him a “stupid girl” because he preferred dolls and (Chase, 2001). tried on dress-up clothes during free play. ●● GLBT youth feel they have nowhere to turn. Four out of five gay and lesbian students say they don’t know one According to one study, 31 percent of gay youth had been supportive adult at school (Washington Post, 2001). threatened or injured at school in the past year (Bart, 1998). Other statistics include: Schools and other community environments where children ●● Gay, lesbian and bisexual youth are two to three times more and youth gather should be safe for all kids. For every GLBT likely to attempt suicide than their heterosexual counterparts youth who reported being targeted for anti-gay harassment, four (HHS 1989). heterosexual youths reported harassment or violence for being ●● Gay teens in the U.S. schools are often subjected to such perceived as gay or lesbian. Kids who reported there was a intense bullying that they’re unable to receive an adequate supportive faculty with an openly gay staff were more likely to education (Chase, 2001). feel as if they belonged in their school. ●● GLBT students are more apt to skip school because of the fear, threats and property vandalism directed at them.

Obese children and youth Being obese by itself appears to increase the likelihood of be bullied than children who weren’t overweight, regardless of being a victim of bullying. Researchers report that 17 percent sex, race or other factors. It found that children were bullied of children ages 6-11 were estimated to be obese between 2003 whether they were rich or poor, made better or worse grades and 2006, and parents of these children report that they rate and that race didn’t seem to be a factor (Pediatrics, 2010). bullying as their top health concern for their kids. In addition, in a study of children ages 11 to 16, researchers In a study conducted by the Eunice Kennedy Shriver National found that overweight and obese girls were more likely than Institute of Child Health and Development, obese children in normal weight peers to be teased or to be made fun of and to the early grades of school are more likely to be bullied than experience relational bullying (socially excluded). Overweight thinner kids, contributing to depression, anxiety and loneliness. and obese girls were also more likely to be physically bullied The study found that children ages 8-11 were more likely to (Janssen, Craig, Boyce and Pickett, 2004).

Children and youth with disabilities and special needs There is a small but growing amount of research literature on ●● Children with hemiplegia or paralysis of one side of their bullying among children with disabilities and special needs. This body are more likely than other children their age to be research indicates that these children may be at particular risk of victimized by peers and to have fewer friends than other being bullied by their peers. For example, research tells us that: children (Yude, Goodman & McConachie, 1998). ●● Children with learning disabilities (LD) are at greater risk ●● Children with diabetes and who are dependent on insulin may of being teased and physically bullied (Thompson, Whitney be especially vulnerable to peer bullying (Storch, et al, 2004). and Smith, 1994). ●● Children who stutter may be more likely than their peers to be ●● Children with attention deficit hyperactivity disorder (ADHD) bullied. In one study, 83 percent of adults who had problems are more likely than other children to be bullied. They are also with stammering as children said that they had been teased somewhat more likely than others to bully their peers (Unnever or bullied; 71 percent of those who had been bullied said it & Cornell, 2003). happened at least once a week (Hugh-Jones & Smith, 1999). ●● Children with medical conditions that affect their appearance, such as cerebral palsy, muscular dystrophy and spina bifida, Usually children are able to identify when their peers are are more likely to be victimized by peers. Frequently, these bullying them. Sometimes, however, children with disabilities children report being called names related to their disability do not realize they are being targeted. They may believe, for (Dawkins, 1996). example, that they have a new friend, when in fact this “friend” is making fun of them.

Page 26 Psychologogy.EliteCME.com Can bullying a child or youth with disabilities be illegal? Yes! Bullying behavior may cross the line to become “disability participation in or receipt of benefits services, or opportunities in harassment,” which is illegal under Section 504 of the the institution’s program” (U.S. Department of Education). When Rehabilitation Act of 1973 and Title II of the Americans with a school discovers that harassment may have occurred, staff must Disabilities Act of 1990. According to the U.S. Department of investigate the incident(s) promptly and respond appropriately. Education, disability harassment is “intimidation or abusive This behavior can take different forms, including verbal behavior toward a student based on disability that creates a harassment, physical threats and threatening written statements. hostile environment by interfering with or denying a student’s

The bully Bullying is related to feeling contempt for someone considered child’s perceived success with grades, wealth, popularity, to be worthless, inferior or undeserving of respect. Bullying attractiveness and so on. does not appear to be about anger or conflict. Contempt relates ●● Fear – When children bully out of fear, they have projected most closely to how the bully views his target. their insecurities and fears onto another person. Some children fear rejection from other kids or losing status in the Further, contempt is a strong feeling of dislike toward someone eyes of someone they want to impress, such as a boyfriend considered to be worthless, inferior or undeserving of respect. or girlfriend. They may fear loss of social status or being Contempt can range from disregard to scorn to hate. Bias or laughed at. Many times bullies fear losing what they have prejudice related to race, gender, sexual orientation, physical already, such as intermittent praise from a popular peer or attributes, mental capacities and religion can be fertile ground mentor. They want to protect their self-image and restrict bullies use to prey on their victims. Psychological advantages their range of contacts with the kids who appear most occur for children or youth that express contempt through vulnerable. Kids will bully someone else when they fear bullying. They include: being exposed for real or perceived weaknesses as well. ●● Power to exclude, isolate, segregate or bar the victim who is ●● Self-perception that incorporates a sense of viewed as unworthy. “superiority” toward others – This perception folds ●● The feeling of entitlement and privilege to control, dominate into the earlier discussion regarding contempt that bullies and subjugate, and otherwise abuse another human being. feel for their victims, when someone is thought to be ●● Intolerance toward differences – believes “different” means undeserving of one’s respect. Most cultures, including inferior and thus not worthy of respect. faith-based and ethnic, over centuries promoted their own specialness and even superiority of other cultures. If one In his book, author Allan Beane states that some experts believe was not of a particular caste, religion or color, he or she that aggression is a basic, inherent human trait, and that certain could easily become a victim of bullying. Parents are very factors could increase levels of aggression beyond acceptable powerful role models. One former bully remarked that his norms. High levels of testosterone in men, for example, can father often told his children how special and superior they encourage aggressive behavior that inflicts harm and leads to were because of their birth-given societal roles. antisocial behaviors. Higher levels of testosterone have been ●● Desire for attention – Some children through parental abuse found even in some preschool bullies. and neglect or parent overindulgence desire attention and In addition, a University of Michigan study by Michelle Wirth have difficulty understanding that their actions will impact and Olvier Schultheiss appears to have found that the human others. Some children and youth simply lack sensitivity brain may have a built-in mechanism that detects and responds and have been raised to believe that they are extraordinarily to emotions perceived in the faces of others. Participants in the special. Parents go a long way in demonstrating tolerance or study with high levels of testosterone seemed to enjoy or be intolerance as well as compassion. If caregivers are lacking rewarded by an annoyed look or angry face that was prompted in sensitivity, they provide strong role modeling for repeated by mistreatment. It was surmised that bullies feel rewarded for behavior in their children. mistreating others (Wirth and Schultheiss, 2007). ●● Response to tension environments – Multiple tension environments that include peer pressure, cultural oppression, According to the U.S. Department of Health and Human Services, academic stress, volatile teachers or parents, and economic there is no one single cause of bullying among children and youth. worry contribute to unregulated bullying behavior as well. Rather, individual, family, peer, school and community factors can ●● Prejudice – One well-known family therapist said, “There place a child or youth at risk for bullying his or her peers. Beane is tyranny in prescribing only one right way.” Bullies describes some of these factors, and they include: develop within environments where children are brought ●● Temperament – Child and youth temperament is significant up to believe that it is “bad” to be different. Prejudice can factor in bullying (Begsag, 1989). Temperament is a begin early and become the reason why children or youth combination of qualities that make up personality. An who behave, look or speak differently are persecuted. impulsive child with a more volatile temper may be more ●● Mimicking a culture of media violence – TV, online likely to become a bully. games and other media violence can contribute to an ●● Jealousy – When children are motivated to bully out of increase in a child’s aggression. A study conducted in jealousy, they have been threatened in some way by another 2003 by the Kaiser Family Foundation found that nearly

Psychology.EliteCME.com Page 27 half of parents with children between the ages of 4 and 6 ●● Lacking in empathy. reported that their children imitated aggressive behaviors ●● Viewing violence more favorable than most kids. on television. (The foundation also found that 87 percent of ●● Being aggressive toward adults, parents and teachers. kids mimic positive behaviors observed on TV.) ●● Demonstrating a hot temper, being impulsive and intolerant ●● Revenge – Bullies who were mistreated at some time in their of obstacles or delays. lives may grow into victim bullies (discussed earlier in this ●● Finding it difficult to fit in with rules. course). Because of those earlier experiences, they may feel ●● Needing to dominate and suppress others, asserting him- or inadequate and helpless. To compensate, they attempt to gain herself by means of force and threats, and getting his or her some “control” through overwhelming and over-powering own way (Commonwealth of Massachusetts, 2010). their victims. They may seek revenge on those who bullied them or, in the case of the Columbine High School shooters, A common myth about children and youth who bully is that they may attempt to make a larger statement to “the world” they are “loners.” In fact, research indicates that most bullies by retaliating with innocent bystanders. are not socially isolated. Bullies report having an easier time ●● Social influences – They are very powerful, especially in making friends than children and youth who do not bully. the adolescent population. Wanting to accommodate or “fit Children and youth who bully usually have at least a small in” is a natural part of this life cycle, and occurs even in group of friends who support or encourage their bullying. younger children. Peer pressure prompted by cultural and An additional myth is that children and youth who bully have societal norms plays a huge role in how others are perceived low self-esteem. In fact, they have average or above-average as socially acceptable in faith communities, schools or other self-esteem. Interventions that focus on building the self-esteem social and cultural settings. of children and youth who bully probably will be ineffective in Bullies can be impulsive and mistreat others without thinking stopping bullying behavior (www.stopbullyingnow.hrsa.gov, 2010). of the consequences to their actions. Some bullies have According to Olweus, there are three different types of bullies: experienced or observed abuse at home or have been overly 1. Aggressive bully – One who tends to be physically strong, disciplined. In addition, their caregivers may have been impulsive, hot tempered, belligerent, fearless, coercive, lax in their attention to providing guidelines and character confident and lacking in empathy. development in their children. Yet two major peer risk factors 2. Passive bully – One who tends to be insecure and is much for bullying have been identified and are: less popular than aggressive bullies, with low-self esteem 1. Bullies are more likely to have friends that bully. and few likable qualities, and is often unhappy at home. 2. Bullies share positive attitudes toward violence. 3. Bully-victim – This type includes a small percentage of Bullies are typically aggressive toward adults as well as peers. bullies who have experienced bullying themselves. They Bullies are often impulsive and they demonstrate a need to are typically physically weaker than their bullies, but are dominate, are typically lacking in empathy and are often stronger than those they bully. more willing to resolve conflict through violence. They are Dieter Wolke from the University of Hertfordshire in England more likely than other children to be convicted of a crime in identified a fourth group of bullies called “pure bullies” adulthood (Olweus, 1993). According to Wolke, this group appear to be healthy individuals Warning signs that children or youth are engaging in bullying who enjoy school and use bullying to obtain dominance. Pure behavior include: bullies just seem to enjoy bullying others.

Girls and bullying “Them – the junior caps who run the social underground deliberate and calculated random exclusions, and spreading of in these rustic gulags. They are the bully-princesses who rumors to harass their peers. Specific behaviors can include: have always abounded in Grade 6 female society. Their ●● Encouraging other kids to ignore or pick on a specific child. hair is perfect, their clothes ditto, and They decide who is ●● Playing jokes or tricks designed to embarrass and humiliate. in and who is condemned to the outer darkness, the subject ●● Anonymous prank phone calls or harassing e-mails from of ridicule, whispers, and ostracism. I knew instinctively on dummy accounts. which side of the great divide I would fall. … I had a gut ●● Inciting others to act out violently or aggressively. instinct that books were not highly regarded as a suitable ●● Deliberate exclusion of other kids with the intent to make pastime and that bookish kids came just after rabies-riddled them feel left out. raccoons in the pecking order. Oh yes … I was an odd child ●● Name calling, rumor spreading and other malicious verbal indeed.” (Taken from “What I Didn’t Do at Summer Camp” interactions. by Alexandra Shea; Glove and Mail, May 28, 2001.) ●● Being friends one week and then turning against a peer the next week with no incident or reason for the alienation. The tactics used by girls who bully are distorted versions of ●● Whispering in front of other kids with the intent to make some normal mechanisms of social development. According to them feel left out. research by Lagerspetz, Bjorqvist and Peltonen at the University of Miami, when girls bully, they use things like alienation, ostracism, The typical girl bully is popular, well liked by adults, does well in school, and can even be friends with the girls she bullies.

Page 28 Psychologogy.EliteCME.com Girl bullies do not normally get into fistfights, but use more “packs,” and good kids often get drawn into the behaviors rumors or gossip to exclude others, or shares secrets and tease because they, too, don’t want to be targeted. other girls about their appearance or athletic ability. More often than not, she will use her peers to join her in bullying and or Girls will bully boys as well as girls. Victims can experience will pressure her peer group to instigate bullying (National low self-esteem, a drop in grades, anxiety, depression, drug use Crime Prevention Council, 2010). Girl bullies may travel in and even eating problems. Many times adults are less likely to recognize bullying in girls than in boys. Often, the bullying tactics by girls are viewed as normal social interaction or “girl drama.”

Family risk factors for bullying Children and youth who bully are more likely than their non- ●● A lack of supervision by parents. bullying peers to live in homes where there is: ●● Harsh, physical discipline. ●● A lack of warmth and involvement on the part of parents. ●● A model for bullying behavior. ●● Overly permissive parenting (including a lack of limits for children’s behavior).

Bullying and other violent or antisocial behaviors Research shows that bullying can be a sign of other serious or times as likely as their non-bullying peers to have more than violent behavior. Children and youth who frequently bully their one criminal conviction by age 24 (www.stopbullyingnow.hrsa. peers are more likely than others to: gov, 2010). ●● Get into frequent fights. ●● Be injured in a fight. Both boys and girls can develop into bullies. Victims are both ●● Vandalize property. male and female as well, and methods of bullying may vary by ●● Steal property. gender. Experts are not sure now whether boys bully more than ●● Drink alcohol. girls. While boys are more overt in their bullying, girls are more ●● Smoke. subtle and used bullying more frequently to gain social control. ●● Be truant from school. There are gender differences in the types of bullying that children ●● Drop out of school. experience, such that boys are more likely than girls to report being ●● Carry a weapon. physically bullied by their peers, and girls are more likely than boys Young bullies are more likely to report that they own guns for to report being targets of rumor-spreading and sexual comments risky reasons, such as to gain respect or frighten others. And (Harris, Petrie and Willoughby, 2002, Nasel, 2001). Girls report boys who were identified as bullies in middle school were four being bullied by boys and girls, while boys report being bullied primarily by other boys (Melton, 1998, Olweus, 1993).

Bystanders Researchers Pepler and Craig (1995) examined the roles Reasons why children and youth do not intervene when of peers in bullying episodes observed in urban school bullying occurs include: playgrounds in Toronto, Ontario. Their work revealed that: ●● The bystander does not know what to do and hasn’t been ●● Peers intervened in only 13 percent of the episodes at which taught ways to intervene, to report the bullying or to help they were present. the target. Just as bullying is a learned behavior, so children ●● Peers were active participants in 48 percent of the episodes. must be taught ways to stop it. ●● Peers were involved in some capacity in 85 percent of the ●● The bystander is afraid of becoming a new target of the bully. bullying episodes. ●● The bystander is afraid of getting hurt himself. The bully ●● Peers reinforced the bullying in 81 percent of the episodes. is bigger and stronger and has a reputation that justifies the ●● Peers were more respectful and friendly toward the bullies fear; so jumping into the melee doesn’t appear to be a smart than the victims. thing to do. ●● The bystander is afraid of doing something that will only Only 15 percent of girls who see bullying or who are stuck in make the situation worse. the middle of bullying episodes speak up and say that it is not okay (National Crime Council, 2010).

A bystander’s story Looking back at her years in high school, one young woman their hair in the bathroom and she witnessed her friend being retells how she witnessed several instances where bullying bullied by older students. occurred in the girls’ bathroom at her school. She vividly remembers one incident when she and a friend were combing

Psychology.EliteCME.com Page 29 “Louise and I were standing in front of the sink talking and senior girl calmly walked out of the bathroom with her friend, laughing as we brushed our hair. Louise was very attractive, and knowing she’d put the fear of God in both of us. the boys at school really liked her. As we were standing there, two senior girls came into the bathroom, and seeing Louise, “I felt ashamed, useless, and a terrible friend. I helped Louise roughly elbowed her into a corner. When she protested, one girl gather herself together and when I asked if we should report the in particular slapped Louise and told her not to even look at the incident to the principal, she said she didn’t want to get into more senior girl’s boyfriend. Louise cried out while I just stood there trouble. Can you believe that? She thought she would be in trouble frozen, wanting to help Louise but literally unable to move. The with the school. But things like that happened all the time, and no one reported it. People were afraid they’d get into trouble with the school or get picked on even more by the bullies.”

Witness rationale Some of the excuses shared by child and youth bystanders who onlookers,” who watch what happens and don’t take a stand. And have witnessed bullying include: like the young woman who shared her story, there are “possible ●● “I don’t want to think about it. It’s too much to have to deal defenders” who don’t like the bullying but do nothing to stop it. with.” ●● “He deserved it and knew it was coming.” The one sub-group Olweus describes as non-bystanders include ●● “He’s not my friend.” “defenders of the target” who don’t like the bullying and try to ●● “I’m friends with the person who spit on her.” help the victim. ●● “It’s just part of school drama.” The aftereffects of witnessing bullying lead to school, home ●● “Why would I say something? I don’t tell on other people.” or institutional environments clouded by fear and uncertainty ●● “Why would I want to invite trouble?” during an already difficult time when children and adolescents ●● “She’s a total loser.” are struggling to understand and define themselves. ●● “He doesn’t know what he’s talking about. Maybe this will shut him up.” But bystanders can act, and should be encouraged to be part ●● “It’s not my problem!” of prevention and the solution to bullying. Bystanders are a powerful majority of children and youth, and they can use their Standing by and observing bullying is a form of betrayal and influence to: abandonment to those bullied. In addition, there are times when ●● Speak up and offer support to bullying victims, even it bystanders become active participants, described by researcher means standing up to the bully in front of other bystanders. Olweus as “henchmen/followers who take an active part but do ●● Walk away from bullies who enjoy attention when they brag not start the bullying.” Olweus also describes some bystanders about past experiences with victims. as “passive bullies” who support the bullying but do not take ●● Refuse to join in if someone is being bullied. an active part; and “passive supporters,” who like the bullying ●● Report all bullying immediately to adults. but do not display open support. In the middle are “disengaged

Bully prevention and intervention There are many signs, listed earlier in this course, that a child ●● Has stomachaches, headaches, panic attacks. or youth is being bullied. Many of these signs relate to school ●● Is unable to sleep, sleeps too much, or is exhausted. attendance or academic performance, in addition to other mood ●● Makes unusual comments about feeling hopeless or or behavior changes that a child or youth experiences in the disengaged from life. home or elsewhere. In review, they include: ●● Alludes to death as a form of feeling better. ●● Abrupt lack of interest in school or refusal to go to school. ●● Exhibits changes in mood and/or often cries or becomes ●● Takes an unusual route to school. angry or withdrawn. ●● Suffers a drop in grades. ●● Has few or no friends. If bullying includes violence or physical acting out of any kind, ●● Withdraws from family and school activities. adults are more likely to respond and intervene, and when ●● Is sad, sullen, or angry after receiving a phone call or e-mail. necessary, disrupt and discipline the child or youth bullies. ●● Uses derogatory or demeaning language when talking about However, when bullying takes on a less obvious form, even adults peers. don’t seem to know what to do. Therefore, when preventing ●● Stops talking about peers and everyday activities. and addressing all forms of bullying, it is imperative to address ●● Has disheveled, torn or missing clothing. an antiquated mindset that bullying among children and youth ●● Has physical injuries. is part of the healthy formation of a young person’s character.

Bullying and role of mental health practitioners Mental health professionals can begin to address bullying by in the therapy setting. By demonstrating appropriate boundary being role models themselves by how they comport themselves and limit setting, remaining respectful and reliable, and

Page 30 Psychologogy.EliteCME.com facilitating psychological growth and resilience in clients, ●● I will set reasonable and developmentally appropriate limits mental health practitioners demonstrate healthy interaction and and guidelines for you. provide a safe emotional environment for their clients. ●● I will help you learn how to handle life situations. ●● I will listen to you. Mental health professionals are in a unique position to help ●● I will care for you. individuals, families and communities understand what causes ●● You are important to me. bullying in order to address the problem. Because families are ●● I will not allow you to bully others. the first line of defense when it pertains to children developing into bullies, mental health professionals can help parents Mental health practitioners can help caregivers identify and reexamine conventional erroneous thinking or behavior that intercede when they see bullying occur. For example, parents promotes bullying. Through a parallel process between mental more easily see bullying in their children through sibling health practitioners and parents, parents can then guide their interaction. Allowing their own children to intimidate, terrify, own children toward identifying, negotiating and practicing shun, ridicule or physically harm one another in the home sets new thinking and behaviors. the stage for them to practice the same behavior out in the world.

When addressing family dynamics in families where bullying And yet, shaming or physically punishing young bullies for exists or has occurred, the therapist can also work on individual their behavior isn’t the answer. Studies of bullies’ backgrounds self-exploration, expression, problem solving and positive report that physical punishment played a big role in their family engagement. However, adults and children also need to lives. Isolation (including neglect), humiliation, shaming be instructed that self-expression does not exist through hurting and emotional abandonment are also not useful coping tools another person. Clear, loving and consistent limits are highly in responding to sibling bullying. Instead, the mental health recommended by practitioners with families where children professional should discuss with adult parents “common sense” bully other children. behaviors that must be consistently repeated. These include: ●● Immediate intervention and zero tolerance for bullying At times, therapist-client psychotherapy timelines are short behavior. term, and facilitating “good enough parenting” is a very ●● Examining with children the root of their behavior. What realistic goal. Promoting “good enough” parenting is solution- happened? focused with a timeline, but it does teach and promote enough ●● Teaching and demonstrating that arms are “for hugging.” skills in parents to help their children begin to feel emotionally ●● Demonstrating and practicing with children self-regulation. and physically safe within their home. In working toward that ●● Nurturing empathy. goal, mental health professionals encourage family caregivers ●● Creating opportunities to “do well.” to convey these basic messages: ●● Asking children to identify and use language to express ●● I believe in you. themselves. ●● I love you. ●● Teaching children how to dislodge and cope with physical ●● I will create a safe place for you to live. and emotional stress. ●● I will role-model respect, resiliency and optimism. ●● Role-modeling friendship skills. ●● Redirecting activities.

Reporting bullying Mental health professionals can support parents in reporting Physical assaults and serious harassment should be reported bullying to the police and other public oversight authorities to the school when applicable, and to the police when it poses such as school administrators. Encourage parents to take serious harm. Police response will vary according to the state photos of all injuries to their children. (Let them know to hold law. In some instances, parents will need to file a complaint a ruler next to the injuries to identify their sizes.) In addition, with a court-designated professional or speak to a juvenile mental health practitioners can ask parents to keep a record of court representative. An officer will more likely interview the all medical treatment, medical expenses and all related travel victim and alleged perpetrator in the presence of other adults expenses and let them know to include counseling expenses as that could possibly include parents. One principal dealt with the well to their expense list. Encourage parents to date the photos bullying at his school by negotiating an agreement with local and code them in a way that will link them back to their written law enforcement to have officers respond as soon as possible record. Children and youth bullies also need to know that any to his bullying reports. He said it had a large effect on students threats or physical assaults on their part will be reported to when a police officer explained the possible legal consequences people in authority. to alleged bullies and their caregivers.

Engaging families in bullying prevention activities Mental health professionals can also promote respectful family and arranging chores and schedules, they practice problem engagement by assigning their families “homework” that includes: solving while, at the same time, feeling respected. As ●● Practicing democratic engagement. For example, when children grow into responsibility and as their decision- children are given choices about planning their activities making capacities grow, their ability to forecast problems

Psychology.EliteCME.com Page 31 and outcomes and make good choices increases. As people they know who they believe have good character. For homework, mental health professionals can ask families example, would the list include people that demonstrate to create a chore board together and come up with chore empathy, honesty, trust and self-control? Do people with assignments and timelines. character stand up to bullies or do they tell an adult in a ●● Identifying and creating safe physical spaces within position to help? Does someone with good character know the home environment. Mental health professionals can when to act and or retreat? And do people with good prompt families to discuss what helps children within the character know when to retreat from dysfunctional behavior? family to feel safe and what parents can do to help their Even small children can engage in this type of discussion. children feel safe. This practice can extend to providing safe ●● Second opportunities. Giving parents permission to give handling of pets as well. Mental health professionals can their children second chances when they make mistakes is an ask parents to create a checklist of safety questions for their important message for mental health professionals to send to children and ask these questions during routine moments their clients. Mental health practitioners have opportunities to during the day or evening. For example, as parents drive role model this behavior when parents forget appointments or their kids to and from school, they can have a conversation make an error in parental judgment. A homework assignment about what or who helps their children feel safe or what do could include asking parents to strategize with their children their children keep with them that help them feel safe. about how to handle mistakes, missteps and ill-timed ●● Safe play. When it pertains to bullying, safe play ensures that behavior within the family. In addition, further discussion can children do not harm others while they’re engaged in play occur around mistakes that occur outside of the home through activities. For instance, while it is normal to enact certain sports, theater or shopping activities. aspects of villain versus hero themes, it is not normal to hurt ●● Cooperation and negotiation. Children and youth take their others during the process of the game. In addition, safe play cooperation and negotiating skills into the larger community ensures that children are not exposed to potential bullying if as they enter school and begin to participate in the larger their play is left unsupervised or they are otherwise exposed to community. Learning self-regulation is a major social/ older or more dominant potential bullies. Even playing board emotional milestone for children and youth, particularly during games can be an exercise where families engage with one times of stress or frustration. Mental health practitioners can another without name-calling and taunting. Practicing safe play suggest homework that includes simple and flexible tasks or while tickling children and wrestling is an important part of time to complete those tasks. Family participation in board teaching safe play. In addition, mental health professionals can games and outdoor physical activities such as volleyball ask their clients to chose and organize a special time during the or badminton also provide cooperation and negotiation day to engage in play with their children. opportunities for parents to teach their children about these ●● Philanthropy, good works and helpfulness. Teaching very important social and emotional skills. How do parents empathy and compassion is an important parenting role. As role-model planning for extended family or faith and social a homework assignment, mental health professionals can ask engagement with friends or business associates? Finally, how families to chose a volunteer activity or decide where they do parents negotiate time with their own children? would like to donate and share their resources, such as canned ●● Resiliency building. Resilience is the act of rebounding goods or clothing. In addition, professionals can consistently or springing back after being stretched or pressed, or pose the question: “Who helps whom in this family?” recovering strength, spirit and good humor. It is associated ●● Clear and consistent discipline and guidance. Clear, with being able to adapt to negative life experiences not consistent, loving guidance takes time and poses a challenge to merely by surviving but by thriving and benefiting from parents when both work and timelines are tight. Consistent and handling or experiencing difficult times. When children and loving discipline guidance also takes thoughtful self-regulation youth have been bullied, their resiliency skills or lack of at times for parents when they’re also coping with multi- skills are tested. leveled stress and their own particular upbringing. Mental ○○ Researchers have identified two major resiliency factors health professionals can ask parents to practice a specific type present in resilient children. They include individual as of behavior in response to their children’s misbehavior and well as environmental factors and emphasize the power consistently check in with parents for a) consistency and b) of a consistently supportive person in the life of a child. outcome. At all times, professionals should express a zero Research has focused on people who seem naturally tolerance for bullying among siblings or with other children. resilient, but plenty of other young people grow to be ●● Character discussion. According to James Hillman, author resilient because they are supported by their caregivers of the “The Force of Character,” an individual who to rebound from challenges and enjoy their lives and demonstrates little character is someone “with little insight continue to thrive. … is simply one who does not imagine who he is – in short, ■■ Mental health professionals can help parents an innocent. Innocence has no guiding governance but effectively communicate with their children about ignorance and denial.” (Hillman, 1999). Hillman’s ways they can learn from negative life experiences. description could very easily be describing a bully. When In the last century, during the Civil Rights addressing the topic of resiliency, mental health Movement, families communicated to their children professionals can begin by asking parents and children what that racism was more about the people who were they believe good character to be, and what qualities bullying and being oppressive with others than about constitute good character? Practitioners can assign the child victims themselves. “It’s not about you, homework to families that includes developing a list of honey,” one woman reports her mother said at the

Page 32 Psychologogy.EliteCME.com time. “It’s about them. They’re just foolish, and their dislikes, they’re building their aptitude for self-awareness. parents haven’t taught them how to behave yet.” Practitioners can ask their families as part of a homework ●● Self-awareness. Supporting the development of language assignment to take two to five minutes alone each day for skills in parents and children that prompt them to identify one week to think about and write down what helps them and express personal feelings is another important task for feel safe. Other questions professionals may want to pose mental health professionals. When people have the ability are what qualities do family members most value within to assess their personal feelings and consider their likes and themselves and with each other?

Working with parents when their children bully others It is not uncommon for parents to be in denial or somewhat because their children were capable of being bullies, they are defensive when their own children have been caught bullying probably also capable of being sensitive to the needs of others. other kids. Mental health professionals must walk a fine line between being clear about the inappropriateness of the behavior Strongly reinforce with parents that they must intervene itself and implying the character of their kids is less than sterling. immediately with discipline, not punishment, when their In fact, parents may tend to take a clinician’s message further and children bully others. Let them know that discipline, rather than misinterpret it to mean that they are less than sterling as parents punishment, takes time but is more constructive and responsive themselves. As noted earlier, studies of the background of bullies to the needs of their children. Time taken, though, is well worth conclude that physical punishment played a big role in their it as children begin to recognize that actions have intended and lives. So mental health practitioners must also be mindful not to unintended outcomes. Using discipline instead of punishment encourage excessive parental response in the form of verbal or includes four steps. physical behavior with their children either. Discipline steps Professionals should remind parents that while they are 1. Be clear with the bully about what he or she has done. responsible for their children’s actions, they are not necessarily 2. Place the responsibility of the bullying on the shoulders of to blame for them either. Remind parents that bullying that is the young bully. stopped early is positive and that to stop bullying in children 3. Require that the child or youth fix the problem. The child as early as possible prevents them from being labeled or must solve the problem he or she created through some type stereotyped as bullies. It is also helpful to remind parents that of apology, restitution, reconciliation or resolution. 4. Leave the child’s or youth’s dignity intact.

Helping to heal victims Ensuring ongoing victim safety, helping child and youth Depending on their circumstances, some victims may feel victims work through their grief, addressing trauma when it has guilty or blame themselves for being bullied, excusing their occurred, reframing or reprocessing the bullying experience with perpetrator’s behavior for any number of reasons. They may be victims to facilitate their resolution and their empowerment, and fearful of retaliation, and their fears often are well founded. In supporting family members through the recovery process are addition, young victims may experience grief because of their essential tasks for mental health professionals. loss of innocence, social standing or hope. Their worldview or perspective may have been changed, and they may repeat to The immediate and ongoing safety of the child is the primary themselves negative messages that pertain to trusting others. focus when working with bullying victims. Mental health practitioners must continue to inquire about the child or youth’s It is important that practitioners repeatedly let their young further protection as well. Asking questions to parents and even clients know that they are not bad because of bad things that children such as “What steps have been taken to further ensure happen to them. your child’s safety?” or “Has there been a plan put in place to ensure that this child will not be further abused?” is very Parents and the mental health practitioner must ensure that if important. Mental health professionals should inquire about the victim internalizes his/her experience in a self-diminished what family, school or social support systems are in place to way, they need to help the child to reprocess or reframe the protect this child. A protection/safety plan should be discussed experience to ensure that the child or youth understands that he with family, and when appropriate, with school officials and or she is not responsible for being bullied and to speak out and even law enforcement. Steps should be taken to ensure that recognize when there may be danger present for further bullying. further exposure to the bully, without a restitution plan generated In addition, it is another role of the mental health professional from the bully and his/her family, should be prevented. to support young victims in giving meaning to their experiences and recovering their resiliency and enjoyment of life.

Use of metaphor to heal victims Mental health professionals can help heal the wounds caused by helpful because they speak to an individual’s unconscious bullying in children and youth through the use of metaphorical world while bypassing normal conscious resistance, as well as storytelling. Metaphorical or symbolic stories are extremely draw upon associations presented in a story related to problem

Psychology.EliteCME.com Page 33 solving and recovery. Stories address the victim’s experience professionals must know their victims’ likes, dislikes, story of without direct discussion of it. victimization and understand the victims’ symptoms in order to formulate and share a story. Embedded within a story should be Mental health practitioners can contrive or borrow stories some key words or prompts that help victims to come up with a that indirectly address the victim’s worries, problems, solution or resolution to what has happened to them. In general, self-perceptions or anxieties that grew from their bullying practitioners share a parallel story to the victim’s personal experiences. Professionals can also use personal references experience and mask the protagonist (the victim) as the central when they approach a story or chose to use symbols more character, through using a positive symbol. relevant and topical to the victim. In either case, mental health

Working with schools Mental health professionals are called in at times to help school to call upon other teachers for help when needed. Consultants administrators sort through the issue of school bullying and can also help them understand that ignoring or overlooking help them build a bullying prevention program. Mental health the problem does not make it go away; instead it increases the professionals can begin by asking school officials, teachers chances that bullying will escalate. and students what bullying means and to talk about signs that it could have occurred at their own school. Role-play can be Many schools have used existing anti-bullying school used, and is often a fun way to demonstrate and teach assertive curriculums or adapted them to meet their particular school behavior. This can be accomplished with young children need. And many of them incorporate student peer support through puppetry or dolls within the classroom setting as well. groups and zero-tolerance policies. Parent-teacher associations It can also help to suggest ways for children to compromise have become a part of the policy-setting groups as well. or to express their feelings in a positive way. Consultants can Canada is the largest national community to incorporate an demonstrate how children can resolve problems firmly and anti-bullying campaign, called Pink Shirt Day. Normally held in fairly. And it can be helpful to teach children about how to February, Pink Shirt Day is an innovative, widespread campaign ignore routine teasing and that not all provocative behavior to increase awareness of and attention to the issue of bullying must be acknowledged. in schools and in society at large. In 2007, David Shepherd and Teaching children the value, too, of making and keeping Travis Price in Nova Scotia took a stand against bullies in their new friends is another instructional tool and helps them to school. After hearing a student was called a homosexual and understand courtesy skills. Students also look for ways to threatened for wearing pink, the two youths went to a nearby respond to bullies; mental health professionals can help them discount store and bought 50 pink shirts, including tank tops, to identify acts of aggression, bossiness or discrimination while wear to school the next day. “I just figured enough was enough,” encouraging them to trust and value their own feelings. Mental Shepherd was quoted as saying. The next day, through word health consultants can also help teachers recognize bullying spread online, hundreds of students showed up in pink clothing and its many forms and learn how to intercede immediately and and little was heard from the bullies again.

Mental health professionals and the larger community Most professional mental health association code of ethics schools, such as classroom visits with students or donating discuss good citizenship as part of their mental health time at a church to talk about the effects of bullying. professional values. As a professional community, mental ●● Urging and reinforcing non-bullying behaviors and a zero health practitioners need to stand together with other tolerance in youth organizations or child and youth sports organizations to reinforce the message that bullying will not be leagues. tolerated in any society. Part of this mission should include: ●● Demonstrating and teaching tolerance and empathy for ●● Discussion about what bullying means at its most subtle levels. difference. ●● A zero tolerance for bullying by a professional organization, ●● Exploring diversity by attending different ethnic professional network, club or office. affiliations. ●● Support of local bullying prevention programs. ●● Being a mentor to children and youth through a volunteer ●● Using one’s time and talents to volunteer where there is need organization such as the Big Brother or Big Sister programs. to increase awareness of bullying in the community and in

Summary This course has defined bullying and its effects on children and typically are vulnerable, and when there is a lack of support for youth as well as populations most vulnerable to being bullied, them, feel isolated and exposed, which can lead to damage to and settings where it most often occurs. Bullying is commonly their self-concept and behavior marked by either withdrawal or characterized by aggressive behavior that is intended to aggression. Bullying commonly occurs where there is little or cause distress or harm, and involves an imbalance of power no adult supervision, inadequate adult supervision or a lack of or strength between the aggressor and the victim. Victims structure – areas where children have nothing to do or are free

Page 34 Psychologogy.EliteCME.com to do as they wish. Bullying can be physical, verbal, emotional Olweus categorizes bullying bystanders as “henchmen or and relational or sexual, and can occur over the Internet. The followers” who take an active part but do not start the bullying, bullying relationship affirms the power needs of the abuser and or “passive bullies,” who support the bullying but do not take takes advantage of the vulnerability of the victim. an active part and passive supporters who like the bullying but do not display open support. He also discusses “disengaged Victims can acquire acute stress or post-traumatic stress disorder onlookers” who watch what happens and don’t take a stand. as a result of being bullied. Children and youth who may be He includes another group of bystanders that are “possible more vulnerable to acquiring these conditions are likely to have defenders” who don’t like the bullying but do nothing to stop it, had prior vulnerability factors, report greater perceived threat and a sub-group called “defenders of the target” that don’t like or danger, have exposure to social environments that promote the bullying and try to help the victim. self-hatred, shame, guilt and stigmatization, and have experienced greater stressors with regard to unpredictability, uncontrollability, Mental health professionals become guardians for the safety of sexual victimization, betrayal, and real or perceived responsibility. bullied children and youth by facilitating bullying prevention Researchers have discovered that there are three different victim and intervention strategies with families and victims, schools types: provocative victims, bully-victims and passive victims. and communities. Working with parents in a parallel process to Dieter Wolke says another type of bully is the pure bully. guide their children to identify bullying behaviors or to defend themselves against bullying, advocating for bullied victims Bullying does not appear to be about anger or conflict. Instead, and reporting bullying are other functions of mental health it appears to relate to feeling contempt for someone considered professionals. Working with child or youth victims to help them to be worthless, inferior or undeserving of respect. grieve, reframe and reprocess their abuse and work toward full recovery to becoming resilient against further abuse are other essential tasks for the mental health professional.

Victim support – References Books for children and adolescents and Counselors.” Bloomington, Ind., National Educational ●● Berenstain, Stan, and Jan Berenstain. (1993). “The Service. 800-733-6786. Berenstain Bears and the Bully.” New York: Random House. ●● Kaufman, G. & Raphael, L. (1990). “Stick Up for Yourself: ●● Bosch, Carl. (1988) “Bully on the Bus.” Parenting Press. Teacher’s Guide,” Minneapolis, MN, Free Spirit. ●● Brown, Marc (1983). “Arthur’s April Fool.” Boston: Little, ●● McCoy, Elin. (1997). “What To Do When Kids Are Mean Brown & Company. To Your Child.” Readers Digest Parenting Guide Services. ●● Cohen-Posey, Kate. (1995). “How to Handle Bullies, ●● Olweus, Dan (1993) :”Bullying at School: What We Know Teasers and Other Meanies.” Rainbow Books. And What We Can Do.” Oxford, England. Backwell ●● Romain, Trevor. (1997) “Bullies are a Pain in the Brain.” Publishers. 800-216-2522. Free Spirit. ●● Ross, Dorothea M. (1996) “Childhood Bullying and Teasing, ●● Romain, Trevor (1998) “Cliques, Phonies and other What School Personnel, Other Professionals and Parents Can Baloney,” Free Spirit. Do.” Alexandria, VA, American Counseling Association. ●● Shriver, Maria (2001). “What’s Wrong with Timmy?” New ●● Sheras, Peter (2002). “Your Child, Bully or Victim? York, Warner Books. Understanding and Ending School Yard Tyranny.” New ●● Walker, Alice (1991). “Finding the Green Stone.” San York, Skylight Press. Diego, Harcourt Brace Jovanovich. ●● Webster-Doyle, Terrence (1991). “Why is Everybody Always Support organizations and hotlines Picking on Me? A Guide to Understanding Bullies for Young ●● American Foundation for Suicide Prevention. www.afsp.org. People.” Middlebury, Vt. Atrium Society Publications. 888-333-2377. ●● Covenant House Youth Crisis Hotline. 800-999-9999. Books for parents and school personnel ●● Focus Adolescent Services. www.focusas.com ●● Beane, Allan L. (1999). “The Bully-Free Classroom.” Free 877-362-8727. Spirit. ●● National Center for Victims of Crime. www.ncvc.org. ●● Bonds, M. & Stoker, S. (2000). “Bully-Proofing Your 703-276-2880. School. A Comprehensive Approach for Middle Schools.” ●● National Clearinghouse on Child Abuse and Neglect Free Spirit. Information. Http://nccanch.acf.hhs.gov/pubs/reslist/ ●● Garritty, Carla, Porter, William, Sager, Nancy and Short- tollfree.cfm. Camillie, Cam. (2000). “Bully-Proofing Your School, A ●● National Domestic Violence Hotline. 800-799-7233, Comprehensive Approach for Elementary Schools (Second 800-787-3224 (TTY). Edition).” Sopris West. ●● National Mental Health Association. www.nmha.org. ●● Greenbaum, S., Turner, B. & Stephens, R. (1989). “Set 800-969-6642. Straight on Bullies,” Malibu, CA, Pepperdine University, ●● National Referral Network for Kids in Crisis. www. National School Safety Foundation. kidspeace.org. 800-543-7283. ●● Hoover, John H., and Ronald Oliver. (1996). “The Bullying ●● National Runaway Switchboard. 800-621-4000. Prevention Handbook: A Guide for Prinicpals, teachers ●● National Victim Center. 800-621-4000.

Psychology.EliteCME.com Page 35 ●● Trevor Helpline for Gay, Lesbian and Bisexual Youth. ●● www.cfchildren.org Thetrevorproject.org 800-850-8078. ●● www.familyfun.comwww. GLSEN.org National organization to fight anti-gay bias in K-12 schools. Online Support ●● www.healthyplace.com ●● www.bullybeware.com ●● www.home-school.com ●● www.bullying.org ●● www.kidshelp.org

Bibliography

1. 2001 National School Climate Survey, GLSEN 26. Limber, S..P., Cunningham, P., Florz, V., Nation, M., Chair, S., Melton, G., Bullying Among 2. APA Resolution on Bullying Among Children and Youth, July 2004 School Children: Preliminary findings from a school-based intervention program,”, 1997, 3. Bart, M,, 1998, Creating A Safer School for Gay Students, Counseling Today - September paper presented at the Fifth International Family Violence Research Conference, Durham, 4. Beane, Allan L. Ph.D., Protect your Child from Bullying, 2008, Jossey-Bass, San Francisco, NH CA 27. Nansel, T.R., Overpeck, M.D., Haynie, D.L., Ruan, W.J., Schedt, P.C., 2003, Relationships 5. Besag, V.E., 1989, Bullies and Victims in Schools, Milton Keynes, Open University Press, Between Bullying and Violence Among US youth, Archives of Pediatric Adolescent UK Medicine 6. Britton, Vickie, 2010, What parents Can Do to protect Children From School Bullies, http:// 28. National Crime Prevention Council, Arlington, VA. 2010 educationalissues.suite101.com 29. National Youth Violence Prevention Center, 2010 7. Brohl, Kathryn, 2008, Working With Traumatized Children; A Handbook for Healing, 30. Norton, Terry L., Vare, Jonathan W., 1989, Understanding Gay and Lesbian Youth: Sticks, CWLA Press, Washington DC Stones and SilencesLexis Nexis 8. Brown, Canday, 2007, Gossip, Rumors, and Name-Calling Affects Girls’ Self-Esteem, http:// 31. Olweus, Dan, Bullying at School, 1993, Oxford, UK cc.bingj.com 32. Olweus, D., 1993, Bullying at School: What We Know and What We Can Do, Blackwell 9. Center for the Study and Prevention of Violence, Boulder, CO Publishers, Inc, Cambridge, MA 10. Coloroso, Barbara, 2008, The Bully, The Bullied, and The Bystander. Harper Collins, NY. 33. Preventing Bullying: A Manual for Schools and Communities, US Department of Health NY. 34. Pytel, Barbara, 2010, Bullying Continues to Result in Teen Suicides, Slate.com 11. Fried, Suellen, Paula, Bullies & Victims: Helping Your Child through the Schoolyard 35. Pytel, Barbara, 2008, The Internet Was Uncharted legal Territory Until Now, http:// Battlefield, 1996, Evans and Company, Inc. NY, NY educationalissues.suite101.com 12. Dawkins, J.L., 1996, Bullying, Physical Disability and the Pediatric Patient, Developmental 36. Rigby, K., 2001, Health Consequences of Bullying and Its prevention in Schools, In J. Medicine and Child Neurology Juvonen and S. Graham, Eds., Peer Harassment in School: The Plight of the Vulnerable and 13. Delaney, Lorah, 2010, Pink Shirt Day increases Awareness and Media Attention in Bullying Victimized, Guilford press, NY NY Factsheet: Bullying and Gay youth, 2010, Mental health America, http://www.nmha.org 37. Smolowe, Jill, Herbst, Diane, Weisensee, Egan, Rakowsky, Judy, Mascia, Kristen, Inside Her 14. Gay Lesbian and Straight Education Network, From Teasing to Torment: School Climate in Torment, April 26, 2010, People America: A Survey of Students and Teachers 2005 38. Stephenson, P., smith, D., 1994, Why Some Schools don’t Have bullies. In M. Elliott (Ed.), 15. Gay, Lesbian and Straight Education Network and the Nationals Association of Secondary Bullying; A Practical guide to Coping for Schools, Longman, London, UK School Principals, The Principal’s Perspective: School Safety, Bullying and Harassment: A 39. Storch, E.A., Lewin, A.B., Silverstein, J.H. Heidgerken, Survey of Public School Principals 2008 40. A.D., Stawser, M.S., Baumesister, A., Gefken, G.R., 2004, Peer Victimization and 16. Girls and Bullying, 2010, http://www.ncpc.org/topics/bullying/girls-and-bullying Psychosocial Correlates of Peer Victimization in Children with Endocrine Disorders, Journal 17. Growing Number of Student Cybersecurity Experts, 2010, NetFamilyNews.org of Pediatrics 18. Hardcastle, Mike, 2010, How Girls Bully: The Covert Tactics Used When Girls Bully, 41. The Caring for Every Child’s Mental Health Campaign, 2010, Substance Abuse and Mental About.com – Teen Advice Health Administration, U.S. Department of Health and Human Services. 19. Hoover, J.H., Ovliver, R., Hazler, R.J. Bullying: Perceptions of Adolescent Victims in 42. Thompson, D., Whitney, L., Smith, P.,1994, Bullying of Children With Special Needs In Midwestern USA, 1992, Psychology International Mainstream Schools, Support for Learning 20. http://www.focusas.com/Bullying.html 43. Unnever, J.D., Cornell, D.G., 2003, Bullying, Self Control and ADHD. Journal of 21. http://youthviolence.edschool.Virginia.edu/bullying Interpersonal Violence Yude, C., Goodman, R., McConachie, H., 1998, Peer Problems of 22. http://www.webmd.com Children with Hemiplagia in Mainstream Primary Schools, Journal of Child Psychology and 23. Hugh-Jones, S., Smith, P.K., 1999, Self- Reports of Short and Long Term Effects of Bullying Psychiatry on Children Who Stammer, British Journal of Educational Psychology 44. Wirth, M.M., Schultheis, O.C., 2007, Basal Testosterone Moderates Responses to Anger 24. Janssen, I., Craig, W.M., Boyce, W.F., Pickett, W., 2004, Associations Between Overweight Faces in Humans, Physiology and Behavior and Obesity Within Bullying Behaivors in School-Aged Children, Pediatrics 45. www.stopbullyingnows.hrsa.gov 25. Kells, Tina, 2008, A closer Look at the Growing Phenomenon of Cyberbullying, http:// parentingresources.suite101.com

BULLYING IN CHILDREN AND YOUTH Final Examination Questions Select the best answer for each question and proceed to Psychology.EliteCME.com to complete your final examination.

6. Bullying is an imbalance: 9. Psychological bullying is behavior that intentionally harms a. Depending on one’s perspective. another person by using: b. That does not exist. a. Mind control. c. In real or perceived power. b. Social manipulation. d. Caused by a mental disorder. c. Several bullies. d. Verbal threats with no intent to act upon the threats. 7. Victims of bullying are frequently: a. Secure. 10. Mental health professionals should: b. Insecure. a. Encourage parents to take photos of any physical c. Happy. injuries of their bullied children. d. The smallest child in the class. b. Refrain from working with parents when there are physical injuries to their bullied children. 8. According to researcher Olweus, there: c. Never encourage parents to take photos of any physical a. Is just one type of victim. injuries of their bullied children. b. Are three types of victims. d. Recommend self defense classes for the child and c. Are no victims, just bystanders. encourage fighting back. d. Would be no victims if adults got involved. PYMA04BY14

Page 36 Psychologogy.EliteCME.com Chapter 3: Industrial/Organizational Psychology

10 CE Hours

By:Wade T. Lijewski, Ph.D.

Learning objectives This course is designed to help you: ŠŠ Critique theories of motivation as appropriate in the workplace. ŠŠ Describe the history and foundations of I/O psychology. ŠŠ Create employee selection tools and procedures. ŠŠ Discuss various types of research methods and data ŠŠ Compare organizations’ use of power and influence. collection techniques. ŠŠ Describe the elements of training in the workplace. ŠŠ Apply the concepts of leadership theories. ŠŠ Assess and apply efforts to retain employees.

Overview Psychology is typically described as the science of behavior and matching employees to jobs and maximizing cooperation in mental processes. The subfield of industrial and organizational workplace teams. The link between scientific research and (I/O) psychology is defined as the application of the methods professional practice can be especially strong in I/O psychology and principles of psychology to the workplace (Spector, 1999). because the workplace provides both a natural laboratory for studying psychological questions and a setting in which In recent years, companies have increasingly begun to hire research-based answers can be applied and evaluated. industrial or organizational psychologists to improve elements of their business. Industrial and organizational psychologists Industrial and organizational psychologists address two main goals conduct scientific research on various people-oriented in their research and practice. The first is promoting effective job workplace topics, such as what personality traits predict good performance by employees, which ultimately leads to enhanced performance under stress and what social factors cause conflict performance by the organization as a whole. The second goal is to in work groups. contribute to human welfare by improving the health, safety, and well-being of employees. In effective organizations, employees are I/O psychologists are also hands-on practitioners who help not only capable of performing their jobs well but are also healthy organizations apply research findings to problems, such as and well adjusted in the workplace.

What are the differences between industrial and organizational psychology? Now let’s break the subfield down further: of others. Organizational psychology is more likely to use Industrial psychology is the branch of applied psychology that qualitative methods to obtain information. is concerned with efficient management of an industrial labor force and especially with problems encountered by workers Industrial psychology typically encompasses topics such as: in a mechanized environment. Industrial psychology is more ●● Recruitment. likely to use quantitative methods in studies more often than ●● Selection. qualitative studies. ●● Classification. ●● Compensation. Organizational psychology is the scientific study of individual ●● Performance appraisals. and group behavior in formal organizational settings. Katz and ●● Training. Kahn, in their well-known work, The Social Psychology of Organizations (1978), stated that the essence of an organization Organizational psychology typically involves: is “patterned” human behavior. ●● Socialization. ●● Motivation. When behavior is patterned, some structure is imposed on ●● Occupational stress. individuals. This structure typically comes in the form of roles ●● Leadership. (normative standards governing behavior) as well as a guiding ●● Group performance. set of values. An organization cannot exist when people just ●● Organizational development. “do their own thing” without any awareness of the behavior

Psychology.EliteCME.com Page 37 Knowledge in these categories can be applied in a variety of ways comes with it. Organizations success provides employment to help organizations function more effectively. This is important opportunities, which facilitate the economic well-being of because effective organizations are typically more productive, members of society. Also, in many instances, employees in often provide higher-quality services, and are typically more successful organizations are more satisfied and fulfilled in their financially successful than less effective organizations. work than employees in less successful organizations. These positive attitudes may carry over to non-work roles, such as For private organizations, success often results in increased parent and community member. shareholder wealth and greater job security for employees. For public organizations, such as police departments, municipal Consumers also benefit from enhanced organizational governments, and public universities, success means higher- effectiveness because well-managed, efficient organizations quality services and cost savings to taxpayers. often produce products and provide services at a much lower cost than their less successful competitors. Such cost savings There are also indirect results associated with enhanced are often passed on to consumers in the form of lower prices. organizational effectiveness and the success that often

Where is I/O psychology used? According to a 2011 membership survey of the Society for percentage of I/O psychologists employed by academia and Industrial-Organizational Psychology, approximately two- private organizations has declined somewhat. About 15 percent thirds of U.S. I/O psychologists are employed by academic work for private companies, and the rest work at government institutions and consulting firms. Employment at consulting agencies or other organizations. (SIOP, 2011) firms has been the growth category in the profession, while the

History of industrial/organizational psychology I/O psychology began to develop in the 19th century from an In 1924, a change in direction was brought forth by the Hawthorne idea to study and measure human capabilities and motives. experiments, named after Western Electric Company’s Hawthorne Some early psychologists, noting the practical nature of plant in Chicago where the studies were conducted. Originally psychological research, sought to apply the findings to business developed as a test of some aspects of Taylor’s principles, the problems. In response to the urging of some advertising researchers sought the optimal level of illumination necessary executives, one such early psychologist, Walter Dill Scot, wrote for workers to produce telephone equipment. Instead of finding The Theory of Advertising (1903), generally considered to be Taylor’s assumed “one-best-way,” the researchers found that the first book linking psychology and the business world. It was productivity increased after each change in lighting no matter how followed by The Psychology of Advertising (1908). bright or dim they made it. Eventually, they concluded that the workers were responding to the attention they were getting as part Another founder of the field was Hugo Munsterberg (1863- of the special research study, and this phenomenon came to be 1916), a German-born psychologist who taught at Harvard known as the Hawthorne effect. University and in 1913 published The Psychology of Industrial Efficiency. Munsterberg’s book was greatly influenced by the During that time, thinking about work organizations had been focus of human efficiency so well expressed in the work of Frank dominated by classical (i.e., bureaucratic or machine) theory. and Lillian Gilbreth and Frederick W. Taylor (1856-1915). Workers were viewed as extensions of the job, and the goal was to arrange human activity to achieve maximum efficiency. These When the United States entered World War I in 1917, classical views of organization assumed a top-down management applied psychology really came into its own. Committees of point of view, emphasizing the authority structure of the psychologists investigated soldier morale, motivation, and organization. The object was to get top management’s wishes the prevalence of psychological impairment. Psychologists translated into practice on the shop floor. So essentially, the task developed a group-administered intelligence test called the was to design the job according to scientific precepts and then Army Alpha. While 1,726,000 enlisted men and officers were provide some type of incentive to get workers to comply with the tested, little use was made of the results at the time because the will of management and the industrial engineers. war ended a mere three months after the testing program was authorized. However, research studies did show that the test The Hawthorne researchers believed in a different view of scores were related to soldier performance. the business enterprise. They reported findings that indicated friendship patterns among the workers were the foundation of The first university-based center for studying the applications the organization, and also that people would work harder for of psychology to business was established at the Carnegie an organization that they believed was interested in their lives. Institute of Technology after the war in 1919. It was named the The Hawthorne researchers eschewed economic incentives U.S. Bureau of Salesmanship Research, and was funded largely as the driving force behind work and painted a rich picture by the life insurance industry for the purpose of conducting of the informal relationships (i.e., those not specified in the research for the selection and development of clerical and organizational chart or job specifications) among workers executive personnel and sales people. themselves, in addition to those among workers and managers, which was the focus of the classical view. People, in other

Page 38 Psychology.EliteCME.com words, came to work not for money, but for the social rewards that workers might not perform effectively, not because they are and satisfactions inherent in human organization. immoral but because they perceive that they are being treated indifferently or poorly by management. To motivate workers, Hawthorne researchers argued that management can govern therefore, one must attempt to change those perceptions. only with consent of the workers and that workers actually influence management decisions by controlling the impression Shortly after World War II, I/O psychology emerged as a that management had of a proper day’s work. specifically recognized specialty area within the broader discipline of psychology. Subspecialties materialized, such Additionally, the Hawthorne researchers became convinced as personnel psychology, engineering psychology, and that job performance could be influenced in ways that could not organizational psychology. In the late 1950s and into the 1960s, a be achieved with either money or job design. They proposed renewed thrust toward studying organizations with psychological motivating workers with a set of techniques called human precepts arose as social psychologists and I/O psychologists relations, which involved providing considerate supervision and gained the conceptual tools needed to model and understand management as a means of persuading the workers to conform large, task-oriented groups, including work organizations. to management’s expectations by convincing them that the company was indeed concerned about them. From this line of inquiry came the work of I/O psychologists in assessing the effects of organizational structure and functioning With this belief, the goal was to change employee attitudes rather on employees. Related applications appeared under the rubric than job design or pay. In return, productivity and reliable job of organization development (i.e., participative management, performance would presumably increase. Therefore, motivation socio-technical systems, self-managing work groups, team was seen as a function of the satisfaction of social needs for building, survey feedback, and related approaches). acceptance and status within a person’s group. They recognized

Modern approaches Contemporary I/O psychologists no longer feel they have In the early 1970s into the 1980s, organizational psychology to choose between classical bureaucratic theory or scientific began to mature as a field of study. During this period, management and neoclassical human relations. The common organizational psychologists began to break new ground in view today is that taken together, they provide a comprehensive both theory and research. As just a few examples, Salancik picture of organizational functioning. Environmental forces and Pfeffer (1978) proposed the social information processing such as management directives, human capabilities, the state of theory (SIP) as an alternative to more traditional, need-based technology, and economic considerations are potent forces on theories of job satisfaction and job design. Also during this worker performance and cannot be denied. Likewise, human period, organizational psychology began to rediscover the motivation, perceptions, and job attitudes are influential and are impact of personality and dispositions on things such as job ignored at management’s peril. attitudes (Staw & Ross, 1985) and perceptions of job-related stress (Watson & Clark, 1984). I/O psychologists recognize that there is an inherent conflict between the needs of organizations and the needs of Another development from this time that continues today was individuals. Organizations typically seek regularity and so the recognition that behavior in organizations is impacted by attempt to reduce human behavior to predictable patterns. forces at the group and organizational levels (James & Jones, Humans, on the other hand, do not typically respond well to 1974; Rousseau, 1985). This multi-level perspective has had having their behavior reduced to the acts required by a job. This major implications for the field in guiding theory development conflict will never be eliminated, only alleviated. However, it as well as statistical methodology (Dansereau, Alutto, & requires constant, ongoing effort and vigilance to contain the Yammarino, 1984; James, Demaree, & Wolf, 1985). unnatural arrangement we call social organization. During this same period, organizational psychologists The most recent major thrust in I/O psychology began in the began to devote increasing attention to what could be called 1970s following court decisions interpreting the 1964 Civil nontraditional topics, such as work/family issues (Greenhaus & Rights Act. The courts placed a heavy burden on employers Buetell, 1985), job-related stress and health (Beehr & Newman, to defend the validity (i.e., job relevance) of their recruiting, 1978), and retirement (Beehr, 1986). Such willingness to selection, and promotional procedures. Many employers explore nontraditional topics was significant because it served concluded that complying with this and subsequent anti- as evidence that the interests of organizational psychologists discrimination legislation required the skills of psychologists had broadened beyond purely management concerns. as their best defense against lawsuits brought by employees who claimed they were victims of illegal employment discrimination. Evidence of the validity of selection criteria provided by psychologists is often essential in defending against charges of civil rights violations brought by government or employees against employers.

Psychology.EliteCME.com Page 39 Research methods and statistics Research methodology and statistical analysis are extremely Several aspects of an environment can determine how important. Organizational psychologists routinely design leadership occurs. Some examples of this are the stability of scientific investigations to answer theoretically based research the environment; whether the environment centers on politics, questions about behavior in organizational settings. Methods society, or legal issues; or the types of relationships and social may range from simple observation of behavior to elaborate, networks that exist in the environment. For example, when field-based quasi-experimentation. The data from such studies an environment is unstable, perhaps during an organizational are then analyzed using a variety of statistical methods to test change or merger, leaders must behave differently than when the validity of predictions. the organization is stable. To lead successfully, they must take into account the instability of the environment. Research methodology and statistical analysis are also crucial to the practice of organizational psychology. For example, The nature of leadership may change, depending on the organizational psychologists often use systematic research character of an organization. For instance, organizations may methods to provide organizational decision makers with have different philosophies, outlooks, types, or structures. information on employees’ attitudes. In other cases, research methodology and statistical analysis are used to evaluate some Organizational culture can also affect leadership through its interventions designed to enhance organizational effectiveness. values, the views of those who founded the culture, and any emergent countercultures. An organization may want to know, for example, whether a team development intervention will enhance the functioning of Crisis is another important example of a situation affecting work groups. This question, and others like it, can be answered leadership. Crisis situations are delicate because they require with the aid of typical research methods and statistical analyses a different kind of leader than noncrisis situations. Crisis used in organizational psychology. situations are situations that involve high levels of stress and usually an unclear problem or unclear outcomes that require a In modern research studies, situational aspects are nearly leader to create a new solution. always considered as either determining leadership behavior or strongly influencing it (Vroom & Jago, 2007). Hunt, Boal, & Dodge (1999) conducted a study that focused on varying types of leadership exhibited in crisis situations; they There are several different kinds of situations that can affect found that visionary leaders, or leaders who develop visions leadership; the most frequently discussed are: similar to their followers’ values and goals, are most accepted ●● Environment. by their followers in a crisis. ●● Organization. ●● Culture. The last type of situation is change. Change is a broad concept ●● Crisis. that refers to any new efforts to alter an organization. Change ●● Change. can be carried out through mergers, divisions, or a revision of the way things are done within the organization. An organization Though we will discuss leadership in more detail later in a can change for a number of reasons, including survival and later section, let’s take a look at how these elements impact competition. A continuing question within the study of change is leadership: what type of leader is best at accomplishing change.

Methods of data collection I/O psychologists use three different types of research methods: trying to obtain and what or how they want their findings to be quantitative, qualitative, and mixed methods. The method they expressed. It may also depend on the specific interests of managers select depends greatly upon what information and data they are and leadership who are working with the I/O psychologist.

Quantitative methods Quantitative methods refer to the systematic empirical collects a sample of numerical data from participants to answer investigation of social phenomena via statistical, mathematical the question. or computational techniques. The objective of quantitative research is to develop and employ mathematical models, The researcher analyzes the data with the help of statistics. The theories and hypotheses on phenomena. The process of researcher is hoping the numbers will yield an unbiased result measurement is central to quantitative research because it that can be generalized to some larger population. Qualitative provides the fundamental connection between empirical research, on the other hand, asks broad questions and collects observation and mathematical expression of quantitative word data from participants. The researcher looks for themes relationships. Quantitative data is any data that is in numerical and describes the information in themes and patterns exclusive form, such as statistics, percentages, etc. This means that the to that set of participants. quantitative researcher asks a specific, narrow question and

Page 40 Psychology.EliteCME.com Qualitative methods Qualitative research is a method of inquiry employed in many methods are also loosely present in other methodological different academic disciplines, traditionally in the social approaches, such as action research or actor-network theory. sciences, but also in market research and further contexts. Forms of the data collected can include interviews and group Qualitative researchers aim to gather an in-depth understanding discussions, observation and reflection field notes, various texts, of human behavior and the reasons that govern such behavior. pictures, and other materials. The qualitative method investigates the why and how of decision-making, not just what, where, when. Hence, smaller Qualitative research often categorizes data into patterns as the but focused samples are more often needed than large samples. primary basis for organizing and reporting results. Qualitative researchers typically rely on the following methods for In the conventional view, qualitative methods produce gathering information: participant observation, focus groups, information only on the particular cases studied, and any more non-participant observation, field notes, reflexive journals, general conclusions are only propositions (informed assertions). structured interview, semi-structured interview, unstructured Quantitative methods can then be used to seek empirical interview, and analysis of documents and materials. support for such research hypotheses. Special note: One way to remember the difference between Qualitative researchers face many choices for data collection, quantitative and qualitative is: ranging from grounded theory practice, narratology, Quantitative = quantity (in numbers). storytelling, classical ethnography, or shadowing. Qualitative Qualitative = quality (narrative).

Mixed methods Mixed methods is an approach to professional research that The literature may be categorized according to three criteria: combines the collection and analysis of quantitative and the purported motivations to combine different types of data, qualitative data. Many researchers believe a mixed methods the extent of sequencing of the data collection, and the level approach is desirable and feasible because it gives a more of nesting of the multiple data sources (Morse 1991, Fine & complete view, and because the requirement during the Elsbach 2000, Creswell et al. 2003, Johnson & Turner 2003, different phases of the intervention (or research project) make Leech & Onwuegbuzie 2009, Creswell & Clark 2007). very specific demands on a general methodology. While it is demanding, it is more effective to choose the right tool for the There are literally thousands of research questions that job at hand. have been and continue to be explored by organizational psychologists. It can be used when you want to build from one phase of research to another. You may first want to explore the data qualitatively Some examples include: to develop an instrument or to identify variables to test in a later ●● Are employees who perceive a high level of autonomy in quantitative study. You engage in a mixed methods study when their work likely to be highly satisfied with their jobs? you want to follow up a quantitative study with a qualitative one ●● Does a high level of conflict between work and family to obtain more detailed specific information. responsibilities lead to poor health? ●● Does job performance remain consistent over time? Most empirical mixed methods studies in recent years have employed two or more different types of data or data collection Regardless of the research question being asked, there is a need techniques. The most notable characteristic of the literature is for relevant data to be collected if the questions are ever to be its diversity: Whereas mixed methods may have once referred answered. primarily to a survey with a few follow-up interviews for Let’s discuss four commonly used types of data collection “added context,” today researchers have developed more methods. These include observational methods, survey complex designs, combined more diverse kinds of data, and research, experimentation, and quasi-experimentation. integrated different kinds of data into their analyses more carefully than in the past.

Observational methods Observational methods actually encompass a variety of members, or that younger board members have less input into strategies that may be used to study behavior in organizations decisions than their more experienced counterparts. (Bouchard, 1978). Simple observation, the most basic of these strategies, involves observing and recording behavior. If a Observational methods allow researchers to study things that researcher wants to investigate the decision-making processes cannot be manipulated in a lab because of ethical concerns. used by corporate boards of directors, he or she might observe For example, while it would be unethical to study the effects these individuals during quarterly meetings and record of imprisonment by actually confining subjects, researchers relevant observations. These observations may reveal that the can gather information by using naturalistic observation in real chairperson has more input into decisions than other board prison settings.

Psychology.EliteCME.com Page 41 It can help support the external validity of research. It is one Some other disadvantages of naturalistic observation include: thing to say that the findings of a lab study will generalize to a ●● People may behave differently when they know they are larger population, but quite another to actually observe those being watched. findings actually occurring in a natural setting. ●● People may try to behave in a certain way to conform with what they think researchers expect to see. One of the disadvantages of naturalistic observation is that it can be difficult to determine the exact cause of a behavior, and the experimenter cannot control for outside variables.

Survey research Survey and questionnaires are one of the most common methods Disadvantages of the survey method: used in psychological research. In this method, a random sample ●● It can be affected by an unrepresentative sample or poor of participants complete a survey, test, or questionnaire that survey questions. relates to the variables of interest. Random sampling is a vital ●● Participants can affect the outcome. Some participants try to part of ensuring the generalizability of the survey results. please the researcher, lie to make themselves look better, or have mistaken memories. Advantages of the survey method: ●● It’s fast, cheap, and easy. Researchers can collect a large amount of data in a relatively short amount of time. ●● It’s more flexible than some other methods.

Experimental The simple experiment is one of the most basic methods of results of the two groups to determine whether the treatment determining whether there is a cause-and-effect relationship had an effect. between two variables. The experimental method involves manipulating one variable to determine whether changes in Psychologists, like other scientists, use the scientific method one variable cause changes in another variable. This method when conducting an experiment. The scientific method is a set relies on controlled methods, random assignment and the of procedures and principles that guide how scientists develop manipulation of variables to test a hypothesis. research questions, collect data, and come to conclusions.

A simple experiment uses a control group of participants who The four basic steps of the process are: receive no treatment and an experimental group of participants 1. Forming a hypothesis. who receive the treatment. Experimenters then compare the 2. Designing a study and collecting data. 3. Analyzing the data and reaching conclusions. 4. Sharing the findings.

Quasi-experimentation A quasi-experiment is an empirical study used to estimate the With quasi-experimental studies, it may not be possible to causal impact of an intervention on its target population. These convincingly demonstrate a causal link between the treatment types of designs share many similarities with the traditional condition and observed outcomes. This is particularly true if experimental design or randomized controlled trial, but they there are confounding variables that cannot be controlled or lack the element of random assignment to treatment or control. accounted for. Instead, quasi-experimental designs typically allow the researcher to control the assignment to the treatment condition, but using some criterion other than random assignment. In some cases, the researcher may have no control over assignment to treatment condition.

Quasi-experiments are subject to concerns about internal validity because the treatment and control groups may not be comparable at baseline. With random assignment, study participants have the same chance of being assigned to the intervention group or the comparison group. As a result, the treatment group will be statistically identical to the control group, on both observed and unobserved characteristics, at baseline (provided that the study has adequate sample size). Any change in characteristics post-intervention is due, therefore, to the intervention alone.

Page 42 Psychology.EliteCME.com Leadership The study of leadership is not just a popular subject, but Understanding the characteristics and behaviors of leaders and is a very important one because it also has quite serious the elements and theories linked to leadership can provide the implications. In recent years, it has become clear that errors foundation for identifying and promoting good leadership. in leadership have dramatic repercussions. Examples of this At a more basic level, we can take the findings of leadership include the unethical behaviors of the leaders of Enron and the researchers and apply them in our own lives, regardless of response efforts following Hurricane Katrina. whether we are leaders or followers.

Leaders’ actions often carry more weight than the actions of Leadership as an area of research did not really take off until others within an organization, not only because they have the 20th century, but it made particularly great strides in the greater responsibility but also because they are in more visible second half of the century. Although this might seem like a positions. Leaders are the ones who can set the tone, create relatively short period, significant progress was made in this the plan, and demonstrate to their followers the appropriate short time. The questions of leadership are quite compelling, (or inappropriate) way to behave. They are the ones held and interest in the field continues to grow at a rapid pace. The accountable, and the critical decisions fall onto their laps. first and most frequently asked – yet rarely agreed upon – question remains: What is leadership?

What is leadership? Leadership has been defined in many ways. It is very likely define leadership, do you first think of a person who epitomizes that you believe you have a clear idea of what leadership is, certain characteristics? given that you have likely been exposed to many leaders in your lifetime. The main question that seems to emerge when I/O psychology has taken a variety of approaches to studying formulating a definition of leadership is whether we are leadership. Two major types of leadership are transactional defining a person, a role, or a process. If you were asked to leadership and transformational leadership.

Transactional leadership Sometimes a leader is simply “the person in charge.” That is, that people are motivated by the rewards (or punishment) they as a leader she sees herself as responsible for running things receive for their work. but not changing things. A transactional leader is an individual who emphasizes the exchange relationship between the worker A transactional leader provides clarity and structure to and the leader (Bass, 1985), applying the principle “You do a followers. Such a leader works within the goals of the existing good job and I will reward you.” A transactional leader believes organizational system (“that’s how we do it around here”) and may exhibit management by exception, stepping in only when a problem arises.

Transformational leadership While a transactional leader concentrates most on keeping the Second, transformational leaders motivate by inspiring others ship sailing, a different type of leader focuses on defining the to do their very best. Niro Sivanathan and his colleagues stress direction of the ship. An individual with this leadership style that transformational leaders need not have natural charm or dedicates thought to the meaning of leadership itself and to charisma but rather a talent for bolstering employees’ self- the impact she might have in improving an organization. Such efficacy (their confidence in their abilities) and for persuading a transformational leader is concerned not with enforcing the them to do their best. rules but with changing them. A transformational leader is a dynamic individual who brings charisma, passion, and, perhaps Third, transformational leaders are devoted to intellectually most important, vision to the position (Mumford, Scott, & stimulating their employees. They make it clear that they need Hunter, 2006). input from employees because they themselves do not have all the answers. There are four elements of transformational leadership that have been described (Sivanathan & et al., 2004). First, transformational Fourth, transformational leaders provide individualized leaders exert what has been referred to as idealized influence. This consideration to their employees, showing a concern for each quality means that transformational leaders act as they do because person’s well-being. they believe it is the right thing to do. A good example of this is the A great deal of research supports the idea that transformational leaders of Google, who have a motto – “Don’t be evil!” – that has leadership is associated with positive organizational outcomes guided them in creatively implementing their idea of what a great in a wide variety of settings, from sports teams (Charbonneau, place to work ought to be. This commitment to integrity is likely to Barling, & Kelloway, 2001) to profit-oriented businesses instill trust in followers. (Barling, Weber, & Kelloway, 1996) to the military (Bass,

Psychology.EliteCME.com Page 43 1998). The positive impact of transformational leaders (relative For Kotter, the leadership process involves: to transactional leaders) is based on the capacity of the leader ●● Developing a vision for the organization. to foster trust in the organization, to persuade employees that ●● Aligning people with that vision through communication. their work is meaningful, and finally, to strengthen employees’ ●● Motivating people to action through empowerment and organizational identity, which is their feeling of “oneness” with through basic need fulfillment. the organization and its goals (Sivanathan & et al., 2004). In contrast, the management process involves: A person-focused definition of leadership would specify a given ●● Planning and budgeting. set of traits or skills that would identify a person as a leader. A ●● Organizing and staffing. role-focused definition of leadership would focus on a set of ●● Controlling and problem-solving. behaviors or actions that leaders must engage in to do their job. The person focus and the role focus may seem similar, but by Another important aspect to consider is that of followers. defining leadership as a role, it is possible that a person may After all, without followers, there are no leaders. Follower- occupy more than one role. Finally, a process-focused definition focused approaches look at the processes by which leaders of leadership focuses on how leaders interact with followers, motivate followers and lead teams to achieve shared goals. regardless of role. Understandably, the area of leadership motivation draws heavily from the abundant research literature in the domain The questions that researchers seek to answer about leadership of motivation in industrial and organizational psychology. are often about the person-focused concept of leadership. Because leaders are held responsible for their followers’ ability For the purpose of this discussion, we will define leadership to achieve the organization’s goals, their ability to motivate generally as encompassing all three concepts: leadership is the their followers is a critical factor of leadership effectiveness. influence of others toward a collective goal. Similarly, the area of team leadership draws heavily from the research in teams and team effectiveness in I/O psychology. In addition to defining leadership, it is critical to also identify some of the terms that we use as we discuss leadership, and Because organizational employees are frequently structured leadership research in particular. The persons subject to a in the form of teams, leaders need to be aware of the potential leader’s influence are often referred to in different terms, such benefits and pitfalls of working in teams, how teams develop, as followers, subordinates, and constituencies, among others. how to satisfy team members’ needs, and ultimately how to For the purpose of our efforts, we will use the most general of bring about team effectiveness and performance. these terms: followers. Thus, followers are the individuals a leader influences for the purpose of achieving a collective goal. An emerging area of research in the area of team leadership is in leading virtual teams, where people in the team are As Yukl (2006) pointed out, it is possible for a leader to not geographically distributed across various distances and be a manager, and for a manager to not be a leader, but there sometimes even countries. While technological advances have is a great deal more overlap possible between the two than enabled the leadership process to take place in such virtual some may think. According to Kotter (1990), the distinctions contexts, they present new challenges for leaders as well, between the two can be drawn from their outcomes. He asserts such as the need to use technology to build relationships with that management is intended to produce organization, structure, followers, and influencing followers when faced with limited clear problem-solving, and action, whereas leadership is about (or no) face-to-face interaction. coping with change.

Approaches to research on leadership The study of leadership has been ongoing for hundreds of led to a shift in which researchers began to focus more on the years. The initial work, however, focused more on general behaviors that managers and leaders exhibited and under what observations and discussing one’s own experiences. Authors conditions they engaged in certain actions. have documented the lives of leaders for centuries not only for the benefit of posterity, but also so that future leaders can learn It eventually became apparent that there was more to leadership from leaders in the past. Even religious documents are sources than just leader behavior, and scholars sought to understand the of observation and guidance on effective leadership. relational and situational dynamics involved, particularly the relationship between leaders and their followers. More recently, Over the last 50 years, there have been several broad changes in the field of leadership has focused more on the decision- the way in which researchers have approached the topic. In the making patterns of leaders, and what differentiates outstanding beginning of the century, leadership scholars were interested leadership from general leadership. Let’s take a closer look at a in finding specific traits or characteristics that differentiated few approaches to leadership research: leaders from others. A lack of conclusive findings, however,

The trait approach Before the 1950s, leaders were viewed as extraordinary from others. More specifically, it was believed that there was individuals exhibiting exceptional qualities that set them apart a set of characteristics, or traits, that made someone a leader.

Page 44 Psychology.EliteCME.com Imbedded in this approach was an overall positive spin on the the trait approach, Stogdill (1948) found that group leaders characteristics of leaders. Thus, early leadership researchers were different from group members in characteristics such as sought to identify these exceptional characteristics. The theories intelligence, alertness, sociability, and self-confidence. applied have often been referred to as “great man” theories as a result of the positive approach taken to leadership. Other studies over the years have identified different traits and situational factors that may influence whether these traits truly Studies that took this approach to research used what is impact leadership. However, the traditional trait approach focuses called the trait approach, which means researchers focused on solely on the leader, which is a characteristic of this approach identifying the personal attributes leaders possessed that set that some view as a weakness. This perceived weakness and them apart. It was believed that the presence of these particular the generally inconclusive findings of early trait studies resulted traits could cause individuals to emerge as leaders or make in a gradual shift by leadership researchers away from the trait them more effective as leaders than others who did not possess approach. these traits. For instance, in an early review of research using

The behavioral approach Following the frustration of the inconclusive findings that 1. Task-oriented behaviors. emerged from these early trait studies, leadership researchers 2. Relations-oriented behaviors. turned to evaluating what leaders do rather than their personal 3. Participative leadership behaviors (Katz, Maccoby, Gurin, characteristics. For instance, rather than study whether a & Floor, 1951; Likert, 1967). leader’s personality characteristics could predict whether they would succeed as a leader, a researcher taking the behavioral Although their findings have been subject to criticism over the approach may be interested in what goal-setting behaviors the years, the general categories of “task focused” or “initiating leader engaged in with his or her followers and whether those structure” and “relationship focused” or “consideration” are behaviors led to the desired outcomes. Two universities, Ohio still used in leadership studies to this day. State University and the University of Michigan, engaged in Following these two initial efforts, the behavioral approach significant behavioral research efforts during this time that are increased in popularity, which led to one of the major criticisms considered the foundation of the behavioral approach. of this approach: There were far too many categorizations of The researchers involved in the Ohio State studies administered leader behaviors. In addition, many of the studies relied on the questionnaires to individuals about the behaviors of their observations of followers who responded to surveys about their supervisors. They found that the behavior of the leaders fell leaders’ behaviors. This approach is limiting because it assumes into two broad categories: that those reporting on the leaders’ behaviors are witnessing 1. Behaviors related to initiating structure (e.g., “My everything the leader does, which is unlikely. supervisor assigns people under him to particular tasks”). Further, much of the behavioral approach work made generalized 2. Behaviors related to consideration (e.g., “My supervisor predictions about the effects of leader behaviors on desired treats all of his subordinates equally.”) (Fleishman, 1953). outcomes. Similarly to researchers using the trait approach, those The researchers involved in the University of Michigan using the behavioral approach did not often consider the impact studies used interviews and questionnaires given to real-world of other variables, such as follower motivation. leaders to evaluate leader behaviors, and they examined the Thus, leadership scholars began to question whether the success relationship of these behaviors to group-level indicators of of leaders with certain traits or who engaged in certain types effective leadership (e.g., group productivity). They found that of behaviors was contingent on these other variables. This leaders could be classified as effective or ineffective based on led to a shift toward research that considered more situational three types of behaviors: variables in the leadership equation, the first of which was the contingency approach.

The contingency approach The first concerted effort to consider situational variables in motivated or relationship-motivated. Fiedler and his colleagues leadership studies was initiated by a model of leadership called then classified the leader’s situation based on leader-member the LPC contingency model (Fiedler, 1967). Fielder, using relations, the leader’s position of power, and the level of the LPC contingency model, sought to explore the interaction structure of the group’s task. between a leader’s motivational tendencies and the characteristics of a situation in predicting a group’s ultimate performance. They found that either a high LPC leader or a low LPC would be better suited under different types of situations (e.g., good Leaders’ motivational tendency was determined by asking leader-member relations, structured task, and strong position them questions about the co-worker they had the most difficult of power). They reported findings that support that a situation time working with or their least preferred co-worker (LPC). could, in fact, have an impact on whether different leader traits Based on their LPC score, they were categorized as either task- or behaviors were more appropriate.

Psychology.EliteCME.com Page 45 The path-goal approach The path-goal theory of leadership expands on the contingency needs, to maximize performance and satisfaction. An important theory by explaining how a leader responds to certain situations contribution of this approach was that if it was found that and influences his or her subordinates’ paths toward the certain leader behaviors operated effectively to maintain or collective goal, specifically, influencing their job satisfaction improve subordinate satisfaction and performance in various and performance. (House, 1971). types of situations, leaders could be trained to respond appropriately in similar situations. A few years later, House and Mitchell (1974), outlined four leader behaviors: Follow-up studies, however, have often resulted in inconclusive 1. Supportive leadership. findings, which some researchers attribute to the fact that leader 2. Directive leadership. behaviors are considered separately, such that each leader 3. Participative leadership. would be classified into a behavioral type. It is more likely, 4. Achievement-oriented leadership. however, that leaders engage in different mixtures of behaviors, and this interaction between different kinds of behaviors at any They stated that a leader could use these four leader behaviors, given time may cause effects that are harder to interpret. depending on the situation and the subordinates’ motivational

The situational approach Hersey and Blanchard (1993) proposed the situational leadership Delegating and directing, along with coaching and supporting, theory, which evaluated the interaction of two types of leadership were four leadership styles proposed to be differentially behaviors in different situations. The premise of Hersey and appropriate, depending on the level of development of the Blanchard’s (1993) situational leadership theory is that different followers. situations call for different combinations of leader behaviors. This theory supports the idea that the levels of development Specifically, they proposed that different combinations of are not static, and as a result, a leader must know which supportive and directive leadership behaviors would be combination of behaviors to engage in for different situations. appropriate, depending on the development level of the followers As with the contingency and path-goal theories, the situational involved. Where the path-goal theory looked at supportive and theory can be used for leader training programs because leaders directive behaviors separately, the situational theory evaluated could be instructed on how and when to engage in these combinations of different levels of each type of behavior. different leadership styles.

For example, leaders who were engaging in low levels of Although practical, the contingency, path-goal, and situational supportive behavior and low levels of directive behavior theories all suffer from a similar criticism in that they seem were considered to be delegating, whereas leaders who were to address how the leader should respond to group situations, engaging in low levels of supportive behavior but high levels of however, individual members of the group may have very directive behavior were considered to be directing. different needs or present different situational variables.

The relational approach The relational approach to leadership research focuses on develops between a leader and each follower based on the the one-on-one, or dyadic, relationships between leaders and history of each individual’s contributions and gains from the followers. While the prior approaches to the study of leadership exchange. Graen and Uhl-Bien (1995) outlined several stages typically assumed that leaders treat all followers the same, the an exchange relationship may go through. In the beginning of dyadic approach examines the differences in the relationships a the relationship, both the leader and follower make assessments leader has with each of his or her followers. of one another’s potential contributions to the exchange, perhaps including skills or resources. Consider a situation in which you were in a work group. ●● Did the leader provide an equal amount of attention to all As expectations are met or exceeded, the exchange relationship members? may develop further. Relationships that are based solely on ●● Did the leader seem to trust some members more than the exchange of formal job requirements are considered low- others, giving them more responsibility or more challenging exchange or out-group relationships. Relationships that develop tasks? beyond these formal requirements, in which there is a sense of ●● Did some members interact with the leader beyond what trust or loyalty between the two parties, are considered high- was required of the task? exchange or in-group relationships.

The predominant theory on these exchange relationships, Some relationships may develop to a third stage, referred to as originally referred to as the vertical dyad theory, is the leader- a mature relationship, in which there is an equal commitment member exchange (LMX) theory. The basic premise of the to each other and to the ultimate goal of the effort. Hundreds LMX theory of leadership is that over time, a relationship of studies have been conducted examining how different

Page 46 Psychology.EliteCME.com variables may be related to the different exchange relationships It is difficult to discern what constitutes whether a relationship established between leaders and followers. For instance, between a leader and follower is high or low, and whether two leadership scholars have evaluated how a follower’s type of followers who are in the in-group are there for the same reasons. relationship with a leader may affect the follower’s motivation, For example, one follower may have a high-exchange relationship job satisfaction, or job performance. because he puts extra time into the group task, while another individual has a high-exchange relationship because she has a The findings of LMX research, however, are often plagued by strong interpersonal relationship with the leader. criticisms about the measurement of the exchange relationship.

The cognitive approach From the 1990s to today, a commonly used approach to their cognitive resources (intelligence and experience) when understanding leadership is the cognitive approach. This making decisions. approach refers to research that seeks to understand leadership by examining how leaders think, how others think about A second body of research on cognition and leadership is that leaders, or how their thought processes change in specific of implicit leadership theories. Implicit leadership theories situations (e.g., crisis, creative problems). make propositions about how a person’s implicit beliefs or assumptions of what a leader is and how an effective leader This may include research on the cognitive resources of leaders performs relate to the leadership process (Lord & Maher, 1991). or followers, such as intelligence or problem-solving skills (which overlap somewhat with the trait approach); research For example, followers’ reactions to a leader’s behavior may be on the cognitive steps involved in actions associated with more a factor of their perception of what a successful leader is leadership, such as planning, evaluating problem situations, than whether that leader is actually performing effectively. monitoring social interactions, or developing a mission or More recently, leadership scholars have made attempts to vision; or research on perceptions about leaders and leadership. understand the cognitive steps that occur as leaders work through Cognitive traits, particularly general cognitive ability, or typical leadership activities. For instance, both theoretical intelligence, have been studied in the area of leadership for and experimental efforts have been made to gain insight into decades. However, a specific focus on developing a theory the cognitive processes that leaders undergo to solve creative on the cognitive abilities of leaders was not undertaken until problems (Mumford, Connelly, & Gaddis, 2003), develop visions the late 1980s and early 1990s with the development of (Strange & Mumford, 2002), react to crises (Mumford, Friedrich, the cognitive resources theory (Fiedler, 1986). This theory Caughron, & Byrne, 2007), and engage in planning (Marta, proposed that the stress leaders experience affects how they use Lertiz, & Mumford, 2005), among other actions.

Outstanding leadership approach Another approach to studying leadership that has been Vision-defining behaviors refers to behaviors that a leader quite prominent in recent years is the focus on instances engages in to define a vision or desired outcome for his or her of outstanding or exceptional leadership. Please note that followers. The imagery of an impassioned leader conveying this approach is different from the “great man” theories of a vision can be quite powerful, and theories that sought to leadership developed in the first half of the century. evaluate the effects of transformational and charismatic leadership easily found popularity among both leadership Prior research may have shied away from evaluating outstanding scholars and the general public. leadership because it is more rare than standard instances of leadership, and it is quite difficult to contact and study outstanding Studies evaluating the differences in development, emergence, leaders. It is important, however, to evaluate these most exemplary and performance of transformational leaders (leaders that instances of leadership if we are to gain a complete understanding engage in more vision definition, inspirational motivation, of the leadership phenomenon. Additionally, it is important to intellectual stimulation, and individual consideration of their understand these particular leaders given the outstanding impact followers) compared to transactional leaders (leaders that these individuals have on people, groups, and organizations. exchange rewards for performance and that respond to specific critical instances or mistakes) have dominated leadership Most research on outstanding leadership has revolved around literature in the last 10-15 years. theories of charismatic or transformational leadership (Burns, 1978), picking up particular steam following Bass and This trend, however, may be shifting as it becomes clear that Avolio’s (1990) development of a measure of transformational these two categorizations of leadership may be somewhat leadership. Both charismatic and transformational leadership limiting. As Mumford (2006) notes, there are other leaders are held to be based on the vision-defining behaviors of a who have had a significant impact on the world but are not leader, a rather powerful behavior that leaders use to motivate necessarily transformational or charismatic. followers toward a change.

Psychology.EliteCME.com Page 47 Mumford (2006) proposes three types of outstanding leadership: For instance, both charismatic and ideological leadership are charismatic, ideological, and pragmatic. The differences in these considered vision-based; however, charismatic leaders have three types of outstanding leaders lie in their developmental visions oriented toward an idealized future, whereas ideological patterns, the way in which they view the world, and how they leaders have visions oriented toward an idealized past. The interact with their followers and seek to accomplish their goals. leadership behavior of pragmatic leaders, on the other hand, is based more on problem solving than vision.

Cognitive traits: Are they important to leadership? Researchers have looked at many different traits to see how There are four components to wisdom: they relate to successful leadership. Several traits seem to be 1. Seeking to reach a common good. important for leadership across a number of studies. 2. Balancing the goals of oneself, others, and an organization. 3. Considering both the short- and long-term elements of a Intelligence is very important for leaders. Leaders must perform situation. extremely complicated tasks and understand the complexities 4. Adapting to and shaping one’s environment. of organizations and the processes and products of those organizations. They must be able to retain large amounts of Additionally, expertise is a deep understanding and knowledge of information, and they must be able to use and retrieve that a specific area or situation. Expertise comes from experience; the information quickly and efficiently. You will see that a high more experience a person has with a certain area or situation, the level of intelligence is also necessary for many of the other more likely that person is to become an expert in that area. important traits, skills, and behaviors that leaders must have to be successful (Mumford, Marks, Connelly, Zaccaro, & Reiter- Leaders must have expertise in the specific organizational Palmon, 2000). area where they serve as leaders. Researchers have found that expertise (technical expertise, specific to the task at hand) is Wisdom is another important trait. Sternberg (2007) has studied highly associated with the performance of a leader’s team wisdom and leadership extensively. He proposed that wisdom (Mumford, Hunter, Eubanks, Bedell, & Murphy, 2007). involves the successful use of intelligence, creativity, and experience.

Theory X and Theory Y In his book The Human Side of Enterprise, Douglas McGregor In contrast, Theory Y managers, those with the outlook that (1960) suggested that there are two general approaches to McGregor advocates, assume that engaging in effortful management, which he termed Theory X and Theory Y. Theory behavior is natural to human beings. According to the Theory Y X managers assume that work is innately unpleasant and that view, control and punishment are not the only way to motivate people have a strong desire to avoid it. Such managers believe workers. Rather, Theory Y managers recognize that people seek that employees need direction, dislike responsibility, and must out responsibility and that motivation can come from allowing be “kept in line.” Theory X managers motivate performance by them to suggest creative and meaningful solutions to problems. exerting control and threatening punishment. These managers assume that people have untapped creative and intellectual potential that can benefit the organization.

Strength-based management In keeping with the focus of Theory Y managers on the 2002). Organizations in which employees answered “yes” to potential abilities of employees, in 2002, survey scientist this item had a 38 percent increased probability of success in Donald Clifton was the CEO of the Gallup polling organization productivity and a 44 percent higher probability of success in and was recognized as the founder of strengths-based customer loyalty and employee retention. psychology in a citation by the American Psychological Association. He emphasized the importance for managers to In another analysis, researchers evaluated the effectiveness of uncover and exploit the strengths of their employees. interventions intended to improve organizations (Clifton & Harter, 2003). Of the 65 organizations studied, four had taken a Strength-based management supports the idea that to develop strengths-based approach. Compared to the other 61, those four worker strengths, a manager must recognize that each person showed an increase in productivity equal to $1,000 per employee. has unique talents, and that the individual discovering these and putting them to use is crucial not only to an effective What does that translate into in real terms? For the average organization but also to a fulfilling life (Bateman & Snell, 2007). company in the study, that would be $5.4 million.

Using one’s strengths can be an important part of work fulfillment. In an analysis of a variety of past studies, researchers examined how responses to the item “I have the opportunity to do what I do best,” related to work outcomes (Harter & Schmidt,

Page 48 Psychology.EliteCME.com Personality traits The Big Five model is a popular way of categorizing personality Extroversion is how outgoing a person is and how much he or traits into five broad traits that encompass most of what she enjoys being around other people. distinguishes one person’s personality from another’s. The five categories that the Big Five uses to describe personality are: Agreeableness is being cheerful and optimistic. 1. Openness. Neuroticism is how controlled and emotionally stable a person is. 2. Conscientiousness. 3. Extroversion. Most leadership research on the Big Five suggests that each 4. Agreeableness. of the personality traits is important for successful leadership. 5. Neuroticism. However, results have not been entirely consistent. This could be because different researchers use different tests to (A good way to remember them is that they spell out OCEAN). measure these personality traits. Another possible reason Openness describes how willing a person is to experience new for inconsistency is that different researchers use different things. measures of leader success. While these personality traits do appear to be important in leadership, more research is needed to Conscientiousness is how dependable and hard-working a see how they specifically relate to successful leadership. person is.

Self-confidence For the most part, leader self-confidence seems related to much self-confidence could actually be bad for a leader’s leadership success. Self-confidence influences a leader’s performance. Too much confidence can cause leaders to take behavior primarily by giving him or her the assurance to excessive risks and be arrogant and annoying to people around attempt and accomplish difficult tasks and influence people. them, minimizing their success (Yukl, 2006). Clearly, self-confidence can be good for a leader, but too

Locus of control The term locus of control describes how a person views the little control over their lives and thus, cannot do anything to causes of his or her behavior. People with an internal locus of change (Rotter, 1966). control believe that the events in their lives are determined and controlled by them personally. People with an external locus of Because people with an internal locus of control believe they control believe that the events in their lives are controlled by can control and influence their lives, they are more future chance or some other external factor; they believe they have oriented and more likely to actively attempt to solve problems.

Emotional maturity People who exhibit emotional maturity have a realistic view of more self-control, and they are less prone to mood swings. Leaders their own strengths and weaknesses, and they work toward self- who are emotionally mature have more cooperative relationships improvement instead of denying their weaknesses and focusing with other people in their work environment (Cantoni, 1955). only on their strengths. They are typically less self-centered, have

Interpersonal traits Machiavellianism Authoritarianism Machiavellianism refers to a person’s tendency to deceive and Authoritarianism is a person’s tendency to stress authority and manipulate others for personal gain. People who are high in power in relationships. People who are high in authoritarianism Machiavellianism resist the influence of other people, and they are said to be conservative, emotionally withdrawn, power- are more concerned with completing their own personal tasks seeking, and resistant to change. Authoritarianism is related to instead of emotional and moral concerns. They are game players. several aspects of a leader’s behavior.

Researchers have studied specific Machiavellian manipulation For the most part, authoritarianism is associated with negative tactics in organizational leaders. Some tactics they found leadership behaviors. People high in authoritarianism are more include lying, acting like other people have a say when likely to give punishments for bad behavior than rewards they really do not, changing information, exaggerating the for good behavior. Also, authoritarianism is related to fewer importance of a task, and ignoring others. successful leadership behaviors, such as displaying sensitivity toward other people and contributing to the accomplishment of group goals (Bass, 1990).

Psychology.EliteCME.com Page 49 Integrity or stretched the truth. Second, people with integrity keep their Integrity means that a person’s behavior is consistent with promises. People do not want to make agreements with leaders their personal values, and that the person is honest, ethical, and who cannot be trusted to keep promises. Third, people with trustworthy. In fact, integrity is an important part of trust. integrity are loyal to their followers. The trust of followers will be lost if a leader does not demonstrate loyalty. Fourth, these people Several types of behavior are related to personal integrity. First, will not tell secrets. Finally, people with integrity are responsible people with integrity are honest and truthful rather than deceptive. for their own actions. Taking responsibility for their actions makes Leaders lose credibility when people discover they have lied leaders look strong and dependable to others (Yukl, 2006).

What skills are important to successful leadership?

Decision-making Leaders must make high-stakes decisions rapidly, so they must Because of the complexity and high stakes involved in be skilled at decision-making. They often do not have time to strategic decisions, leaders cannot simply use intuition for thoroughly think about each and every decision they make, and these decisions; they must actively analyze the elements of each decision often has multiple, complicated consequences. the situation. When leaders are faced with major strategic Because of this need to make quick decisions with little in-depth decisions, they analyze the following: thought, leaders have been said to be intuitive thinkers, meaning ●● The goals to be accomplished. that they do not spend valuable time analyzing complex situations. ●● The actions or tactics that will be most effective in accomplishing these goals. While intuition is likely to play a large role in the decisions ●● The causes involved in the situation. leaders make, there is also a strategic element to leaders’ decisions. These decisions involve long time frames and broad organizational elements.

Problem solving In their day-to-day work, leaders encounter several different Therefore, leaders must be able to solve problems quickly and types of social problems. These problems are extremely complex efficiently, and it is best if their solutions can address multiple and poorly defined. Not only do leaders have to address complex problems at one time. To come up with these solutions quickly, problems, they also have to address these problems in very leaders must focus on the restrictions that come with potential short time frames. Leaders typically do not have time to think solutions to determine the best action to take to solve a problem. extensively about every aspect of every problem they encounter.

Planning Planning is an ongoing process that leaders must do everyday delegate effectively), and leaders must help their organizations in organizations. Leaders must think about their future actions plan responses to competitors and environmental change. and the consequences of these potential actions, and how their actions will help them and their followers achieve their goals. Planning is always based on the goal a leader is trying to Planning is very important to organizations. It takes a lot of accomplish. Planning begins with a leader recognizing an time and cognitive resources to develop a good, thorough plan opportunity to take an action that will lead to goal achievement. (Mumford, Schultz, & Van Doorn, 2001). Then, the leader thinks about the situation and the best way to accomplish the goal. Next, the leader comes up with an initial Leaders must plan their own day-to-day activities (when and plan, and he or she revises the plan when changes need to be how they are going to work on their own tasks), plan how made to avoid potential problems. Finally, a good plan involves to divide other work tasks among their subordinates (how to ways to mark progress toward goal accomplishment and backup plans in case something goes wrong (Mumford et al., 2001).

Emotional intelligence Emotional intelligence is also important for leadership success. stops immediately experiencing a particular emotion, the Emotional intelligence is the ability to recognize one’s own feeling often remains as a good or bad mood; and moods can feelings and the feelings of others. It also involves the ability to also impact leaders’ performance. manage emotions such that they do not interfere with a person’s thinking and behavior (Goleman, 1995). Emotional intelligence is important for leadership success. A leader who has emotional intelligence is better able to solve Because emotions are strong feelings, they can distract people problems, make decisions, and manage time and crises. from their normal thinking and behavior. Even when a person

Page 50 Psychology.EliteCME.com Social intelligence Social intelligence is the ability to recognize and choose the understands how different actions will help or hurt the group. best way to address a situation. Social intelligence goes beyond Basically, a leader with high social perceptiveness understands what we commonly think of as social skills. The two elements what needs to be done to make a group or organization more of social intelligence are social perceptiveness and behavioral effective and how to do it. flexibility. Behavioral flexibility is the ability and the willingness to Social perceptiveness is the ability to recognize the needs, change one’s behavior in response to a situation. It involves the potential problems, and the potential opportunities for an taking a variety of different actions and judging their organization. It also involves understanding the characteristics effectiveness, changing one’s behavior as needed (Zaccaro, of an organization and the relationships involved in that Gilbert, Thor, & Mumford, 1991). organization. Finally, a person who is socially perceptive

Behaviors linked to leadership When researchers were unable to find a specific set of traits The leader’s role in group meetings is to guide the discussion that would lead to successful leadership, they decided to look and make sure it is constructive and that the group is solving at specific leader behaviors that are important for success. problems. It is important to remember, however, that the leader Leadership researchers have looked at four broad categories is still responsible for what the group decides, even though the of behaviors: (a) consideration, (b) initiating structure, (c) group is more involved in decisions (Yukl, 2006). participation, and (d) change-oriented behaviors. Some researchers have also studied several more specific behaviors, Change-oriented behavior like role modeling and feedback behaviors. Yukl (2006) argued that these types of behavior did not adequately cover the range of behaviors that successful leaders Consideration engage in. He and other researchers proposed an additional Consideration involves a leader showing concern for the behavior they described as change-oriented behavior. Change- well-being of his or her employees. Considerate leaders show oriented behaviors involve behaviors that are directed at appreciation of their employees’ work, help increase the self- encouraging and facilitating change in organizations. esteem of their employees by treating them well, and work to make their employees feel comfortable in the organization. Organizations can no longer be competitive by maintaining Considerate leaders are oriented toward relationships and their current processes, products, or services. They must trust. On the other hand, inconsiderate leaders criticize their continually create new products and processes to achieve long- employees publicly, do not consider their feelings, and make term success. One of the most important factors in successful them feel uncomfortable. adaptation for organizations is effective leadership (Mumford, Scott, Gaddis, & Strange, 2002). Initiating structure Initiating structure involves a leader planning and organizing a By now, you may be wondering why so much research has work group’s activity. A leader who initiates structure sets and considered the personality qualities of leaders without examining maintains standards for work, meeting deadlines, and deciding the types of groups the persons are going to lead. The results of how the work will be done. A leader who initiates structure these studies seem to indicate that leadership is not the same as establishes clear standards and rules for communication and work expertise or intelligence or even being the best at whatever the organization. These leaders are oriented toward the work tasks, as group does. If you think about the captain of your favorite sports opposed to establishing relationships with other employees. team, it is rarely the case that the person is the best player on the team. Rather, leadership is a social process, and it likely emerges Participation out of an individual’s disposition to get noticed, to assert himself With participative leadership, a leader involves his or her or herself, and to demonstrate responsibility. subordinates in making important decisions and doing supervisor- type tasks. Leadership studies conducted at The University of A good leader may not be the person who knows the most but Michigan found that successful leaders engaged in participative rather the person whose temperamental endowments predispose leadership by having group meetings to encourage individuals to him or her to flourish in a leadership role. contribute to important decisions and to improve communication.

Specific behaviors There are a number of different, specific behaviors that have projects into operation in organizations. This section will been researched to see how they relate to successful leadership. describe some of the specific behaviors found to be important Most of these behaviors are important when working with for successful leadership. teams of employees and developing and putting different

Psychology.EliteCME.com Page 51 Role modeling Role modeling can be a useful tool for leaders. Some people work in a climate in which they feel safe and supported, they may think the purpose of role modeling is for a leader to show will be better workers (Mumford, Eubanks, & Murphy, 2007). the other employees what types of behaviors are appropriate for a work environment. Actually, role modeling helps leaders Leaders may influence these aspects primarily by role modeling because it helps them set the climate of a work group. Work behaviors that indicate acceptance of these values (Jaussi & performance is enhanced when employees perceive that Dionne, 2003). Think about what a leader would do if that the work environment, or climate, is supportive (Amabile, leader wanted to make sure his or her employees made the Schatzer, Moneta, & Kramer, 2004). In general, when people organization of their work materials a priority. Would the leader be organized or disorganized?

Support Organizational tasks and projects can be costly; therefore, To make sure that their employees have enough time and these projects will not succeed if support and resources are not resources to complete their tasks, leaders must often persuade available (Amabile et al., 2004; Ekvall & Ryhammer, 1999). upper-level management of the importance of their projects It is important that leaders make sure the necessary time and (Jelinek & Schoonhoven, 1990). This can be done by resources are available to complete projects. When employees involving these senior executives in the project early on, and feel pressure to complete their tasks in a short amount of time, then working to keep them interested in the project until it is their performance will deteriorate. complete (Mumford, Eubanks, & Murphy, 2007).

Championing Another part of getting different projects accomplished involves an organization (Howell & Boies, 2004), in effect serving as making sure that an organization as a whole is prepared to accept representatives for their team within the organization (Ancona and adopt these new projects. For new projects to be adopted, & Caldwell, 1992). To gain support, leaders must show the other it is important that leaders take part showing enthusiasm for organization members how these new projects will help and or “championing” a project to gain support from the rest of support their goals.

Feedback Another very important behavior of leaders when working with In addition, leaders must make sure they are evaluating the project teams is directing the work. Leaders help guide the work based on appropriate standards; depending on the stage work of their employees in the right direction. One important and goals of the project, different evaluation standards will be way leaders direct project work is by evaluating the work of more or less relevant (Mumford, Eubanks, et al., 2007). employees and providing feedback. Leaders should try to provide constructive feedback when evaluating their employees’ work.

Ethical leadership Leaders have an important role in influencing the process of necessary and are clear about what each member can expect from decision-making to ensure outcomes that will be beneficial to the group and what is expected of each group member. the organization as a whole; to customers, including vendors and suppliers; and to individual employees within the organization. Ethical leaders must communicate accurate and concise There are times when it is important to allow individuals to voice information on the values of the organization (Standsbury, an opinion that may be in conflict with others’. However, the 2009). A focus on organizational success will foster a climate of effective leader is able to encourage authentic dissent rather than open discussion of ethical standards and expectations. Ethical dissent simply meant to disrupt (Greitemeyer et al., 2009). leaders set the standard of truth for every employee they lead (Walumbwa & Schaubroeck, 2009). The moment people take It is also useful to apply the group needs model as proposed leadership positions, they have an opportunity to place the by Bellman and Ryan (2009) because individuals relate self- highest emphasis on truthfulness (Kaptein et al., 2005). knowledge to the group’s purpose and the bigger picture of the overall goals and impact of the organization. Open discussion Ethical leaders can also make effective use of a group of in group meetings allows individuals to not only hear others’ advisors (Standsbury, 2009). They might select the sharpest opinions and ideas but to revise their own opinions as well employees within their organizations or hire some from other (Bellman & Ryan; Soll & Larrick, 2009). companies, but they must be surrounded by people with answers and information (Sama & Shoaf, 2008). The decision-making process can be aided by ensuring that all members of the group or team understand the process to the degree When change is necessary because of circumstances beyond the leader’s control, the reputation the leader has for ethical behavior

Page 52 Psychology.EliteCME.com will partially determine how this change will be received (Griggs, Leaders also can influence followers’ attitudes and beliefs, 2009). In other words, change will be received in a more positive which many believe is unethical in any circumstances (Toor & light when the leader has previously exhibited ethical leadership Ofori, 2009; Yukl, 2006). than when the leader’s ethics have been questionable (Marcy et al., 2008). When leaders attempt to make changes in the organizational culture, changes in employee beliefs may be required. The Personal integrity plays a significant role in leadership effective leader discusses the need for these changes with effectiveness and has been found to be an important attribute of individual employees, which is most likely to help bring about leadership across cultures (Yukl, 2006). Leaders may be involved organizational change. However, there are still many ethical in various activities requiring personal integrity, including questions about the extent to which leaders should influence influencing others, framing problems, facilitating issues, and follower beliefs even when the focus is on positive or necessary motivating others to accomplish important tasks (Yuki, 2006). change within the organization (Yukl, 2006).

Common definitions of personal integrity include honesty and Leaders do not operate in a vacuum and thus influence and consistency (people do the right thing when no one is looking). are influenced by many other entities or stakeholders. The There is controversy surrounding this definition, though, because it stakeholders for most organizations include owners, shareholders, does not address moral values and ethical behavior (Yukl, 2006). managers, employees, customers, vendors, and the local community (Yukl, 2006). The challenge for ethical leadership is to When understanding the topic of personal integrity, it is important balance the interests of any applicable stakeholders to produce the to understand the difference between behavior and impact. Often, best outcome for those involved. Often a decision made to benefit because every individual has different experiences and values, the one stakeholder, for example, the owners, may result in a less than behavior of a leader may be misinterpreted as having a negative favorable impact on others. It is in these situations that the ethical impact on another person. A false assumption in this case could be decision may not be apparent (Yukl, 2006). made that the leader lacks personal integrity, which may in fact not be the case. In an economic climate such as exists today, leaders in organizations are required to make difficult decisions, and When there is a conflict between what the leader personally the consequences may significantly affect a broad scope of believes and what his or her personal responsibilities require, participants. Ethical leadership involves assessing the situation, a leader may tend to serve his or her own best interest, thus evaluating the impact of any decisions, both long-term and compromising personal integrity (Martin, 2009). It is possible short-term, and maintaining ethical values throughout the for leaders to rationalize their behavior when it is not aligned process (Puffer, & McCarthy, 2008). Making the best decision with the organization’s ethical codes and values. Leaders may for the short term even though it is considered to be ethical may justify their behavior even though it breaks ethical codes. It is lead to negative effects in the future (Yukl, 2006). clear that ethics is a significant factor leading to effectiveness for those in leadership positions (McCann & Holt, 2009). In an ever-changing environment, leaders are called upon to evaluate the situation, make critical decisions, support and According to Drucker (1999), organizations must have values encourage followers, and otherwise perform at a level acceptable that align with employees, and that these individuals’ values to higher-level management, owners, shareholders, and other must be compatible with the organization to be most effective. involved parties. There are often conflicts of interest between these Organizational leadership and employee values may not groups, and it is the responsibility of the leader to make decisions necessarily need to be the same, but they need to coexist. that balance these self-interests as much as possible (Yukl, 2006).

There are significant things that leaders can do to help uphold The effective, ethical leader who has a clear moral compass high levels of personal integrity. First, it is critical that leaders may still be faced with conflict in the face of situations partner with their human resources departments to recruit requiring decisions that will have broad or long-term impact and bring onboard people who share similar values as the (Puffer & McCarthy, 2008). Leaders must be prepared to make organization. This will help to ensure a successful fit. not only decisions that may be unpopular with followers, but also decisions that may be unpopular with management or other Secondly, leaders can recognize employees who exemplify those stakeholders (Yukl, 2006). values that represent high levels of personal integrity, for example, in a group meeting setting. Aligning reward systems with personal Ethical leadership can take on two forms: endorsing ethical behavior is one way that leaders can ensure that people in the climate and resisting unethical activities (Yukl, 2006). The most organization are motivated to do the right thing (Yukl, 2006). successful leader knows how to use both forms simultaneously to maintain a culture of integrity in the workplace (Sama & Leaders are responsible for explaining and describing the Shoaf, 2008). It is imperative that leaders make their employees potential risks of failure as well as potential benefits of success aware of the ethical paradigm while also being clear about (Yukl, 2006). Effective leaders have the ability to focus on the those behaviors and practices that do not fit into the desired positive aspects and benefits of a situation while not concealing norm (Dickson, Smith, Grojean, & Ehrhart, 2001). the risks and obstacles the group will face.

Psychology.EliteCME.com Page 53 There are many factors that determine ethical leadership behavior Kohlberg followed the development of moral judgment far and will contribute to which form or combination of the two beyond the ages studied earlier by Piaget, who also claimed forms of leadership a leader chooses to enforce (Yukl, 2006). that logic and morality develop through constructive stages. Expanding on Piaget’s work, Kohlberg determined that the First, Kohlberg (as cited in Yukl, 2006) argues that leaders process of moral development was principally concerned advance through six stages to develop moral behavior. Kohlberg’s with justice, and that it continued throughout the individual’s theory holds that moral reasoning, the basis for ethical behavior, lifetime, a notion that spawned dialogue on the philosophical has six identifiable developmental stages, each more adequate at implications of such research. responding to moral dilemmas than its predecessor.

Kohlberg’s six stages of moral development Pre-conventional (Stages 1 and 2) there are no consequences for obedience or disobedience. The pre-conventional level of moral reasoning is especially Adherence to rules and conventions is somewhat rigid, however, common in children, although adults can also exhibit this level and a rule’s appropriateness or fairness is seldom questioned. of reasoning. Reasoners at this level judge the morality of an ●● In stage three (interpersonal accord and conformity- action by its direct consequences. The pre-conventional level driven), the person enters society by filling social roles. consists of the first and second stages of moral development, Individuals are receptive to approval or disapproval from and is solely concerned with the self in an egocentric manner. others as it reflects society’s accordance with the perceived role. They try to be a “good boy” or “good girl” to live up A child with pre-conventional morality has not yet adopted or to these expectations, having learned that there is inherent internalized society’s conventions on what is right or wrong, value in doing so. but instead focuses largely on external consequences that ●● Stage three reasoning may judge the morality of an action certain actions may bring. by evaluating its consequences in terms of a person’s ●● In stage one (obedience and punishment-driven), individuals relationships, which now begin to include things like focus on the direct consequences of their actions on respect, gratitude and the Golden Rule. “I want to be liked themselves. For example, an action is perceived as morally and thought well of; apparently, not being naughty makes wrong because the perpetrator is punished. “The last time I people like me.” Desire to maintain rules and authority did that I got spanked, so I will not do it again.” The worse exists only to further support these social roles. The the punishment for the act is, the more “bad” the act is intentions of actors play a more significant role in reasoning perceived to be. This can give rise to an inference that even at this stage: “They mean well. ...” innocent victims are guilty in proportion to their suffering. ●● In stage four (authority and social order obedience-driven), It is “egocentric,” lacking recognition that others’ points of it is important to obey laws, dictums and social conventions view are different from one’s own. There is “deference to because of their importance in maintaining a functioning superior power or prestige.” society. Moral reasoning in stage four is thus beyond the ●● Stage two (self-interest-driven) espouses the “what’s in need for individual approval exhibited in stage three. A it for me” position, in which right behavior is defined by central ideal or ideals often prescribe what is right and whatever individuals believe to be in their best interest but wrong, such as in the case of fundamentalism. If one person understood in a narrow way that does not consider their violates a law, perhaps everyone would. Therefore, there reputation or relationships to groups of people. Stage two is an obligation and a duty to uphold laws and rules. When reasoning shows a limited interest in the needs of others, someone does violate a law, it is morally wrong; culpability but only to a point where it might further the individual’s is thus a significant factor in this stage as it separates the own interests. As a result, concern for others is not based bad domains from the good ones. Most active members on loyalty or intrinsic respect, but rather a “You scratch of society remain at stage four, where morality is still my back, and I’ll scratch yours” mentality. The lack of a predominantly dictated by an outside force. societal perspective in the pre-conventional level is quite different from the social contract (stage five), as all actions Post-conventional (Stages 5 and 6) have the purpose of serving the individual’s own needs or The post-conventional level, also known as the principled level, interests. For the stage two theorist, the world’s perspective is marked by a growing realization that individuals are separate is often seen as morally relative. entities from society, and that the individual’s own perspective may take precedence over society’s view; individuals may Conventional (Stages 3 and 4) disobey rules inconsistent with their own principles. Post- The conventional level of moral reasoning is typical of conventional moralists live by their own ethical principles. adolescents and adults. Those who reason in a conventional way judge the morality of actions by comparing them to These principles typically include such basic human rights as society’s views and expectations. The conventional level life, liberty, and justice. People who exhibit post-conventional consists of the third and fourth stages of moral development. morality view rules as useful but changeable mechanisms; ideally rules can maintain the general social order and Conventional morality is characterized by an acceptance protect human rights. Rules are not absolute dictates that of society’s conventions on right and wrong. At this level, must be obeyed without question. Because post-conventional individuals obey rules and follow society’s norms even when individuals elevate their own moral evaluation of a situation

Page 54 Psychology.EliteCME.com over social conventions, their behavior, especially at stage six, in making ethical decisions (Kaptein, Huberts, Avelino, & can be confused with that of those at the pre-conventional level. Lasthuizen, 2005). Some theorists have speculated that many people may never reach this level of abstract moral reasoning. Although it is a relatively new area, research is ongoing to ●● In stage five (social contract-driven), the world is viewed as discover the best way for a leader to influence the ethical holding different opinions, rights and values. Such perspectives climate of an organization (Yukl, 2006). Researchers are should be mutually respected as unique to each person or attempting to resolve the disparity between endorsing ethical community. Laws are regarded as social contracts rather than climate and resisting unethical activities (Yukl, 2006; Sama & rigid edicts. Those that do not promote the general welfare Shoaf, 2008). It is important to continue the study of ethical should be changed when necessary to meet “the greatest good conduct in order to better equip leaders to shape organizational for the greatest number of people.” This is achieved through ethical culture (Dickson et al., 2001). majority decision and inevitable compromise. Democratic Ethical behavior is one of the most important aspects of government is ostensibly based on stage five reasoning. effective leadership and change management (Kaptein et al., ●● In stage six (universal ethical principles-driven), moral 2005). While most leaders choose to either promote ethical reasoning is based on abstract reasoning using universal behavior or oppose unethical behavior, the best leaders must ethical principles. Laws are valid only insofar as they are understand that it is a combination of both that will be most grounded in justice, and a commitment to justice carries successful (Sama & Shoaf, 2008). with it an obligation to disobey unjust laws. Legal rights are unnecessary, as social contracts are not essential for deontic Organizational leaders must make decisions that will not only moral action. Decisions are not reached hypothetically in a benefit them, but they also must think about how the people conditional way but rather categorically in an absolute way, in the organization will be affected (Dickson, et al., 2001). as in the philosophy of Immanuel Kant. The best leaders must make their ethical values known by ●● This involves individuals imagining what they would do communicating them verbally and in action (Walumbwa & in another’s shoes if they believed what that other person Schaubroeck, 2009). Ethical leaders exemplify the vision and imagines to be true. The resulting consensus is the action goals of the organization. taken. In this way, action is never a means but always an end in itself; the individual acts because it is right, and Ethical leaders collaborate to incorporate best practices, solve not because it avoids punishment, is in their best interest, problems, address the issues, and enlighten employees about expected, legal, or previously agreed upon. Although all of the associated information affecting the individual and Kohlberg insisted that stage six exists, he found it difficult to the organization (Kaptein et al., 2005). From this group of identify individuals who consistently operated at that level. advisors, other leaders may emerge. Ethical leaders offer training to potential successors, allowing them the opportunity Ultimately, a leader may deviate from social norms to formulate to be mentored and to build leadership skills (Standsbury, what he or she sees as morally sound (Yukl, 2006). Second, 2009). Ethical leaders know how to put personal egos aside and choices in ethical leadership can also emerge from the personal work for the greater good of the organization (Walumbwa & attributes of the leader (Yukl, 2006; Walumbwa & Schaubroeck, Schaubroeck, 2009). 2009). Change in organizations is an unavoidable phenomenon. When Constructive, group-oriented behavior is more likely for leaders leaders are forced to implement change, they must see their with personal attributes such as high emotional maturity, employees as stakeholders striving to achieve the same purpose, trustworthiness, and the ability to inspire motivation (Yukl, vision, and goals (Sama & Shoaf, 2008). Employees must be 2006; Brown & Trevino, 2006). able to trust that a leader is ethically sound and that the decision made will benefit the employee as well as the organization Last, choices in ethical behavior can be determined by varied (Walumbwa & Schaubroeck, 2009). When a leader is ethical, he situational factors (Yukl, 2006). It is important that a manager or she gains the respect and admiration of employees and upper always understand the context of the professional climate and management as well as the satisfaction gained from doing the all its organizational, communal, and individual contributors right thing (Kaptein et al., 2005).

Ethical leadership and diversity While we will discuss organizational culture with more leveraging the capability of their organizations, including its detail later in this course, let’s discuss how ethical behavior, climate and diverse human resources. leadership, and diversity are connected. Two challenging areas in today’s business climate are Leadership in organizations is multifaceted and offers many leadership ethics and organization diversity. Recent well challenges. These challenges in the climate of constant business publicized failures in business ethics and the ever changing change are even more diverse and consuming. This requires diversity of the human resource pool make these areas critical leaders to be at their best and well equipped to provide the to understand for any leader who plans to lead his or her appropriate leadership for every situation that occurs. To do organization to business success. this, today’s leader must have knowledge and options for fully

Psychology.EliteCME.com Page 55 Exploring the area of ethical leadership leads us to the values Greenleaf (as cited in Yukl, 2006) introduced the concept of and integrity of individual leaders and the role their behavior servant leadership in which the primary focus of the leader is has in shaping an organizational culture where doing what to provide the follower with support and understanding through is right is the norm. It emphasizes the need for clear, ethical listening, assessing their needs, and helping with any negative expectations that eliminate misalignment between the leader, aspects of the environment. These leaders hold themselves followers, and the entire organization so the overall business is and others to a high standard of social justice and equality in not at risk. the workplace and have a high sense of social responsibility. By being straightforward, honest, and open with employees, The same exploration in the area of diversity identifies three the result is inspired individuals who take steps to bring about subjects that are at the forefront of concern as leaders seek social change. to leverage their work force to its fullest potential. These three areas are the differences in leadership due to gender, In a world that is constantly changing, the issue of ethical the differences in leadership in different cultures, and the leadership becomes even more important (Cohen, 2009). It is importance of managing organization diversity. difficult to address the issue of ethics without discussing values (Fu, & Liu, 2009) and behaviors of employees when there There is a growing interest in ethical leadership, however there is a high level of respect and trust between management and is conflict on exactly how to define and measure the concept employees (Zigarmi, 2008). objectively for scientific research. An important aspect of ethical leadership is to lead by example, and set and encourage When there is not a match between behaviors and the vision others to follow high standards (Jackson, Clements, Averill, & statement, then the ethics of the leadership team come into Zimbro, 2009). The terms integrity, moral values, and character question (Fu, & Liu, 2009; Griggs, 2009; Zigarmi, 2008). In are used to describe the concept of ethics (Griggs, 2009). these situations, it is imperative that the leaders refer back to a code of ethics that will influence the choices made rather than In evaluating ethics in leadership, a distinction can be made simply react to a stressful situation (Fu, & Liu, 2009). between the ethics of a specific leader as compared to the ethics associated with a specific leadership style. Because of the Ethical behavior on the part of the leader combined with the use subjectivity in evaluating ethics, the results may reflect not only of a transformational leadership style tend to lead to high levels the ethics of the leader but also those of the evaluator. of trust in and respect for the leader (van Eeden, Cilliers, & van Deventer, 2008). There are many examples of what constitutes unethical behavior and how it affects employees and followers, including Developing women as leaders creates a diverse team that more falsifying information, taking credit for other’s contributions, accurately reflects society and also broadens the perspective and accepting bribes for preferential treatment. of the team (Kearney & Gebert, 2009). How women prepare for and fill their leadership roles is linked to their gender. The views of three scholars describe ethical behavior for Organizations need to recognize this and create an environment leaders in fields such as government, religion, social movement, that is accepting of and committed to working with women community services, and nonprofit organizations. Burns (as leaders (Yoder, 2001). cited in Yukl, 2006) proposes that transformational leadership is a process in which the leader as well as others within the Strategic development of leadership development programs organization move to bring each other to a higher level of that integrate unique opportunities for women and a mentoring motivation and performance, leading to social change both program that provides guidance are also needed changes in the inside and outside of the organization. arena of gender and leadership (Hopkins, O’Neil, Passarelli, & Bilimoria, 2008). In general, many organizations should be Heifetz (as cited in Yukl, 2006) proposes that leaders play a assessing the changing face of leadership, which may require significant role in addressing and solving conflict by using both leaders to alter their selection and promotion practices to be formal and informal authority by first acknowledging there is more inclusive; recognize the opportunities and perspectives a problem and then taking action to resolve it. This can best brought to the executive table by women; and engage them in be accomplished through cooperation among participants who preparatory programs that can only benefit the organization set realistic goals balanced with optimism about their ability to (Gilgoff, 2009). achieve those goals.

Leading individuals vs. leading groups It has already been stated that leadership can be geared toward consider not only the group as a whole but also each member a single person or many people. And the leader may be leading individually. multiple, independent individuals, but more often than not, the leader is leading a group of individuals. When leading groups, it is important that the group members get along with each other and that they work together Dealing with an individual is much different than dealing with effectively. In doing so, each member creates an identity within a group. When a single follower is involved, a leader has only the group, causing him or her to feel associated with the other one person’s concerns, preferences, and activities to consider. members of the group as a whole. If a leader must oversee an entire group, then he or she must

Page 56 Psychology.EliteCME.com When group members stick together, they become cohesive. of their actions as individuals, and that the group will likely However, sometimes members become too close and fall take the blame for negative consequences. into a process called “deindividuation,” which happens when members become too entrenched in the group and lose their This tends to happen when leaders motivate their followers own identities. This is a bad thing because individual members with punishment for bad behavior. When leaders offer rewards might act differently than they normally would and might for good behavior, group members tend to maintain their own participate in uncharacteristic behaviors. Group members do identities yet are still cohesive. Because of this, it is essential this because they feel they are exempt from the consequences that leaders avoid punishments and instead offer rewards to groups for their accomplishments.

Looking at leadership You may have noticed that some of these traits and skills Some traits, skills, or behaviors may be more important in some overlap. For instance, intelligence is highly related to planning situations than others. The traits, skills, and behaviors we’ve and problem-solving skills. Intelligence is also necessary discussed appear to have a wide range of usefulness across many for wisdom. This highlights the complexity of the nature of different job situations. Organizations can also use this type of leadership and what is necessary for successful leadership. traits and skills research to develop and hire their employees, and you can use this research to develop your own skills as a leader.

Power and influence Power is another important element to consider when Research has found support for Bass’s view and has revealed discussing topics in the field of industrial and organizational types of power subsumed within each factor. The types of psychology. Power is commonly referred to as the capacity of power within position power include legitimate, reward, one person to influence the behavior or attitudes of others and coercive, information (control over access to information), and focuses more on initiating change by communicating a vision ecological (control over the situation) power. or goals and seeking to inspire others into action. The different types of personal power include referent and Power can be exercised over groups as well as individuals. expert power (Yukl & Falbe, 1991). Because of the complexity Power is derived from authority, which includes a right or claim of position and personal power, it can be difficult at times to of legitimacy that serves as a justification to exercise power. distinguish between the two; however, Bass’s approach is still widely accepted among researchers. Attempts to understand power have identified many different types, and further efforts distinguished among those types. Because a leader’s amount of power can change over time Some of the most influential work in this field was done by and in different situations, two theories have been proposed to French and Raven (1959), who developed a classification explain how power is acquired and lost. First, social exchange system describing five kinds of power. Although their work had theory defines changes in power in terms of the relationship a great effect on power research, it did not include all sources between leaders and followers over time. In this way, social of power involved in leadership. interactions between members of a small group determine how power is gained or lost. The five types of power in this taxonomy include: 1. Legitimate power, which comes from a follower’s These social interactions tend to involve the exchange of internalization of values or norms and the belief that the material or psychological benefits (i.e., approval, respect, person in power has a right to his or her power, often as a affection). As leaders show involvement in a group and propose result of his or her position. successful goals and actions, they will accumulate what are 2. Expert power, which comes from a follower’s beliefs that called idiosyncrasy credits and gain power. the person in power is knowledgeable and competent. 3. Referent power, which comes from a follower liking or Idiosyncrasy credits are credits that a leader builds up with admiring the person in power. successful ideas over time. If a leader appears selfish or 4. Reward power, which comes from a follower seeking uninvolved and his or her actions fail, then he or she loses rewards provided by the person in power. power. In evaluating this theory, problems arise with the 5. Coercive power, which comes from a follower avoiding theory’s application of the different types of power. Social punishment from the person in power. exchange theory focuses only on expert power and authority and fails to consider how reward and referent power are Another approach to power sources is Bass’s (1960) theory involved in interpersonal exchanges. of position versus personal power. This model describes the two major sources of power. Position power occurs when one The second theory proposed to explain how power is gained is given a certain position that has influence over a person’s or lost is called strategic contingencies theory. This theory subordinates, such as a manager of a restaurant. Personal power attempts to describe how power is distributed among various is attributed to an individual in power, and can include expertise subunits, or departments, in an organization. or a another’s friendship with the person in power.

Psychology.EliteCME.com Page 57 Strategic contingencies theory contends that in each group, As a subunit exhibits unique expertise at solving problems power depends on: critical to the organization, it gains power. Gained power ●● Expertise in handling major problems. will first come in the form of expert power, and over time ●● The importance of the subunit to the overall work of the can evolve into legitimate power. This theory has generally organization. been supported by research; however, it fails to consider the ●● How easily the subunit’s expertise can be replaced. organizational politics that might be involved.

Influence Yukl (2006) uses the word essence to describe influence and This view of influence processes maintains that one person’s leadership. In other words, without influence, there is no influence on another depends upon the follower’s perceptions of leadership. The more power the leader possesses, the greater the the leader about the actions within the context of the situation. degree of influence that leader can have on others, both positive and negative. There are leaders who have used this power and Another way of understanding influence is the behavioral influence to promote themselves, at times to the detriment of approach. This approach views influence in terms of behavioral others. Often in the news today there are reports of misuse of tactics. Influence tactics are behaviors intended to sway the this power to the degree that many individuals no longer trust attitudes and behaviors of others. Impression management leaders and businesses to make wise and ethical decisions (Fu, tactics are behaviors used by a leader to make followers like him & Liu, 2009). or her. Political tactics are behaviors intended to affect broad organizational decisions, or how such decisions are made, to According to Yukl (2006), influencing others involves altering benefit an individual or his or her group. Proactive influence tactics the motives or perceptions of another to accomplish a given include behaviors geared toward achieving a particular outcome. goal. Related to power, influence also plays an important role These differ from proactive influence attempts in that they do not in successful leadership. In fact, influence lies at the core of necessarily have to be a single request from one person to another. leadership, and without influence, it would be impossible to gain follower support, implement decisions, or get anything done. These influence tactics can generalize across situations, but also must be considered in the context of specific situations, where Influence attempts are actions geared toward bringing about a one tactic may be more appropriate than another. For example, desired outcome. A proactive influence attempt refers to a single impression management tactics may be useful at work meetings or request from one person to another. While influence attempts are social events; however, when working on a specific project with actions, the psychological view considers influence to be a process. followers, proactive influence tactics would be more beneficial.

Behavior of power and influence Although distinct concepts, power and influence in the Support for this model has been somewhat inconsistent because leadership context maintain a complex relationship that causes of the complex relationships between the factors in the model, leaders to behave in different ways to try to enhance their the behaviors of those involved, and potential influence tactics effectiveness. used in different contexts. In general, however, the model has been supported (Yukl, 2006). One important factor in understanding how power and influence are exhibited is the direction of the interaction. To understand Q: How can a person know which influence tactics will be the directions of influence tactics, Yukl and Tracey (1992) successful? developed a model to help identify which influence tactics To answer this question, researchers proposed a second model would be most useful. This model consists of the following that contained the following five factors to predict influence interrelated factors: tactic effectiveness: ●● Adherence to existing social norms and role expectations ●● The extent to which followers resist because they disagree about using the tactic in a given situation. with a request. ●● The appropriateness of a leader’s power being used as a ●● The likelihood that the tactic will affect follower attitudes base for the tactic in a given situation. on the attractiveness of a request. ●● The extent to which the tactic will lead to a goal of an ●● The appropriateness of a leader’s power being used as a influence attempt. base for the tactic in a given situation. ●● The amount of follower resistance expected. ●● A leader’s proficiency in using the tactic. ●● The expected cost compared to the benefits of using the tactic. ●● Existing social norms and role expectations about using the tactic in a given situation. For any given situation, a leader will typically assess the relevance of these five concerns and decide which influence Application of this model suggests that an effective influence tactics will be most useful. The main idea from this model tactic will be one that is socially acceptable, appealing and is that leaders should use influence tactics that are accepted supported by followers, and appropriate for use by the leader in socially and by their followers, appropriate for the goal and that context. situation, and not overly costly to accomplish their goals.

Page 58 Psychology.EliteCME.com Employee motivation Motivation can be defined as an employee’s internal enthusiasm On the other hand, employees who feel motivated to work are about and drive to accomplish activities at work. Motivation causes likely to be persistent, creative and productive, turning out high an individual to decide to take action. An individual’s motivation is quality work that they willingly undertake influenced by biological, intellectual, social and emotional factors, but can also be easily influenced by external factors. There has been a lot of research done on motivation by many scholars, but the behavior of groups of people to try to find In the workplace, employee motivation can be the foundational out why it is that all employees of a company do not perform factor in an organization’s level of success in obtaining at their best has received limited attention from the research goals. Increased motivation in the workplace typically means world. Many things can be said to answer this question; the improved performance, increased productivity and revenue reality is that employees are motivated by different things. and profits, improved morale and organizational stability. An organization’s employees are its greatest assets. No matter how Every employee has activities, events, people, and goals in his efficient technology and equipment may be, it is no match for or her life that he or she finds motivating. Therefore, motivation the effectiveness and efficiency of an organization’s staff. about some aspect of life exists in everyone’s consciousness and actions. The challenge for employers is to figure out how to inspire Organizations with highly motivated employees are more likely employee motivation at work. To create a work environment to enjoy the following advantages: in which an employee is motivated about work involves both ●● Higher productivity levels in the workplace. intrinsically satisfying and extrinsically encouraging factors. ●● Better quality of work with less wastage. ●● Development of a greater sense of urgency. Employee motivation is the combination of fulfilling the ●● A work environment that encourages more employee employee’s needs and expectations from work and the feedback and suggestions (motivated workers take more workplace factors that enable employee motivation. These ownership of their work). variables make motivating employees challenging. ●● A work environment that facilitates greater and more Employers often understand that they need to provide a work frequent feedback from supervisors and management. environment that creates motivation in people. However, many Employee motivation has always been a central problem for employers fail to understand the significance of motivation leaders and managers. Unmotivated employees are likely to in accomplishing their mission and vision. Even when they spend little or no effort on their jobs, avoid the workplace as understand the importance of motivation, they lack the skill much as possible, exit the organization if given the opportunity, and knowledge to provide a work environment that fosters and produce low quality work. employee motivation.

Types of human motivation Intrinsic motivation refers to motivation that is driven by activity. A crowd cheering on the individual and trophies are an interest or enjoyment in the task itself, and exists within also extrinsic incentives. the individual rather than any external pressure. Intrinsic motivation is based on taking pleasure in an activity instead of Goal internalization motivation is described as an individual’s working towards an external reward. Intrinsic motivation has motive to perform because the content of the behavior is been studied by social and educational psychologists since the congruent with his or her personal value system. For example, an early 1970s. Students who are intrinsically motivated are more individual may believe in a particular cause or hold certain beliefs likely to engage in the task willingly as well as work to improve and values that motivate them to work toward a collective goal. their skills, which will increase their capabilities. Instrumental motivation is described as an individual’s Individuals are likely to be intrinsically motivated if they: motivation to perform a task or engage in behaviors because ●● Attribute their educational results to factors under their own the person perceives that his or her efforts will result in tangible control, also known as autonomy. outcomes and rewards. Such outcomes may be pay, promotion, ●● Believe they have the skill that will allow them to be stock options, bonuses, and so forth. effective agents in reaching desired goals (i.e., the results Leonard et al. (1999) explored a range of research on self-based are not determined by luck). theories, including social identity theory (Stryker, 1987; Tajfel ●● Have a genuine interest in mastering a topic or task. & Turner, 1985), self-efficacy theory (Bandura, 1986), and self- Extrinsic motivation refers to the performance of an activity to presentation theory (Beach & Mitchell, 1990). Through their attain an outcome, which then contradicts intrinsic motivation. review of the literature and a process of inductive reasoning, Extrinsic motivation comes from outside of the individual. Leonard et al. proposed a meta-theory of motivation, containing Common extrinsic motivations are rewards like money and five motivational sources. They include (a) intrinsic process grades, coercion and threat of punishment. Competition is motivation; (b) instrumental motivation; (c) external self- in general extrinsic because it encourages the performer to concept motivation; (d) internal self-concept motivation; and win and beat others, not to enjoy the intrinsic rewards of the (e) goal internalization motivation.

Psychology.EliteCME.com Page 59 External self-concept motivation is described as an individual’s Internal self-concept motivation is described as an individual’s motivation to engage in certain behaviors for the approval of motivation to perform to reinforce his or her internal standards others. The self-concept is inferred from the role expectations of traits, competencies, and values. This concept of the ideal of reference groups, with the individual seeking affirmation of self serves to motivate the individual to perform in ways that competencies and traits from others. reinforce this concept.

Motivational theories The field of psychology has provided us with a variety of psychological forces that determine the direction of a person’s theories on motivation. While some incorporate the learning behavior in an organization, a person’s level of effort, and a process, needs, and personal values, all of them refer to the person’s level of persistence.

Herzberg motivation theory Frederick Herzberg (1923-2000), an American psychologist, ●● Both the prevention of dissatisfaction and the encouragement put forward an employee motivation theory on motivation of satisfaction are necessary (through inspiring leadership). in the workplace. His motivation-hygiene theory emerged ●● The motivators and hygiene factors are independent. originally from interviews in Pittsburgh with 203 American ○○ For example, an individual can be highly motivated in accountants and engineers. his or her work and be dissatisfied with his or her work environment. Herzberg described hygiene factors as elements that do not ●● Improvements in hygiene factors have only short-term motivate employees but are essential to maintain satisfaction. effects in the removal or prevention of dissatisfaction. These include a satisfactory salary and related employee benefits, considerate human relations skills, and satisfactory Hygiene needs are cyclical in nature and come back to a starting working conditions. The absence of any of these hygiene point that leads to the “What have you done for me lately?” factors will cause employee dissatisfaction. These are also syndrome (much to the frustration of many leaders). For example, sometimes referred to as maintenance factors. employees may experience this about their pay. At times, they may become dissatisfied with their income as they see others earning The accountants and engineers were asked to think of a time more or getting bigger pay raises. When they receive a raise, this when they felt very satisfied at work and to describe the removes their dissatisfaction for awhile, but then they begin to feel circumstances that caused them to feel that way. They were dissatisfied again, and the cycle is repeated. then asked to think of a time when they felt very dissatisfied at work and to describe what caused these feelings. Hygiene factors are also often referred to as “dissatisfiers.” They are concerned with factors associated with the job itself When their answers were analyzed and interpreted, the following but are not directly a part of it. Typically, this is salary, although five key elements that people reported as causing satisfaction were: other factors that will often act as dissatisfiers include: 1. A sense of achievement. ●● Perceived differences with others. 2. Recognition for their achievements. ●● Job security. 3. Intrinsically interesting work. ●● Working conditions and work environment. 4. Responsibility (e.g., making decisions). ●● The quality of management. 5. Advancement (e.g., promotion or psychological growth, ●● Organizational policy. such as learning new skills). ●● Administration. ●● Interpersonal relations. The five key things people reported as causes of their dissatisfaction were: Motivators (sometimes called “satisfiers”) are factors directly 1. Perceived poor company policy and administration. concerned with the satisfaction gained from a job, such as: 2. Salary. ●● The sense of achievement and the intrinsic value obtained 3. Supervision (e.g., treated badly by the boss). from the job itself. 4. Interpersonal relationships with colleagues (poor teamwork). ●● The level of recognition by both colleagues and management. 5. Poor working conditions. ●● The level of responsibility. ●● Opportunities for advancement. As a result, Herzberg proposed the following key findings: ●● The status provided. ●● A bad environment (poor hygiene factors) will lead to dissatisfied people, but a good environment (good hygiene factors) will rarely lead to satisfied people.

Applying Herzberg’s two-factor theory This motivation theory is referred to as a two-factor theory The most important part of this theory of motivation is that because of the belief that motivators can be categorized as the main motivating factors are not in the environment but in either hygiene factors or motivating factors. the intrinsic value and satisfaction gained from the job itself. It follows, therefore, that to motivate an individual, a job itself must be challenging, have scope for enrichment and be of interest

Page 60 Psychology.EliteCME.com to the jobholder. From this concept, Herzberg shaped his ideas Herzberg’s other major contribution to the development of ideas about job enrichment, job enlargement, and job rotation. in the area of job design was his checklist for implementation. He provided the following tips for those seeking success in the Often, workers expect higher payment to compensate for learning enrichment of jobs: these other jobs and for agreeing to changes in working practices. ●● Select jobs where technical changes are possible without The new jobs are often only a marginal improvement in the degree major expense. of repetition, the skill demands and the level of responsibility; as ●● Job satisfaction is low. a result, workers have not always responded positively to such ●● Performance improvement is likely with increases in change. Job enlargement schemes may not be entirely feasible in motivation. some circumstances. ●● Hygiene is expensive. ●● Examine the jobs selected with the conviction that changes The concepts of both job rotation and enlargement do not have can be introduced. their basis in any psychological theory. However, the next ●● “Green light” or brainstorm a list of possible changes. generation of attempts to redesign jobs developed from the ●● Screen the list (“red lighting”) for hygiene suggestions and research of Herzberg. retain only ideas classed as motivators. ●● Remove the generalities from the list, retaining only specific From his theory, Herzberg itemized a set of principles for the motivators. enrichment of jobs: ●● Avoid employee involvement in the design process. ●● Eliminating some controls while retaining accountability. ●● Set up a controlled experiment to measure the effects of the ●● Increasing personal accountability for work. changes. ●● Assigning each worker a complete unit of work with a clear ●● Anticipate an early decline in performance as workers get start and end point. used to their new jobs. ●● Granting additional authority and freedom to workers. ●● Providing periodic reports directly available to workers Job enrichment aims to create greater opportunities for individual rather than to supervisors only. achievement and recognition by expanding the task to increase not ●● Introducing new and more difficult tasks into the job. only variety but also responsibility and accountability. This can ●● Encouraging the development of expertise by assigning also include greater worker autonomy, increased task identity and individuals to specialized tasks. greater direct contact with workers performing servicing tasks.

Maslow Abraham Maslow is often referred to as the father of humanist these needs are not satisfied, then an individual will surely psychology. He based his needs hierarchy theory of motivation be motivated to satisfy them. Higher-order needs will not on the idea that individuals work to satisfy human needs, such be recognized unless one satisfies the needs that are basic to as food, and complex psychological needs, such as self-esteem. existence. He coined the term “hierarchy of needs” to account for the ●● Safety and security – Once physiological needs are met, roots of human motivation. one’s attention turns to safety and security and to be free from the threat of physical and emotional harm. Such needs According to Maslow, a fulfilled need did little to motivate an maybe fulfilled by living in a safe area, medical insurance, employee. For example, a person who has sufficient food to job security, and financial reserves. eat cannot be enticed to do something for a reward of food. In ●● Social needs – Once lower-level needs are met, higher-level contrast, a person with an unfulfilled need can be persuaded to motivators awaken, the first of which are social needs. Social work to satisfy that need. Thus, a hungry person might work needs are about interaction with others and may include hard for food. Maslow called this the deficit principle. friendship, belonging to a group, and giving and receiving love. ●● Esteem needs – After a person feels that he or she belongs, Deficit principle the urge to attain a degree of importance emerges. Esteem ●● It is a person’s unsatisfied needs that influence his behavior. needs can be categorized as external motivators and internal ●● The unsatisfied need becomes a focal motivator. motivators. Internally motivating esteem needs are those ●● The satisfied need no longer influences an individual’s such as self-esteem, accomplishment, and self-respect. behavior. External esteem needs are those such as reputation, social ●● Managers should be alert for unmet needs and then create status, and recognition. rewards to satisfy them. ●● Self-actualization – This is the summit of Maslow’s Progression principle motivation theory. It is about the quest for reaching one’s ●● Higher order needs are not active motivators until lower full potential as a person. Self-actualized people tend to have order needs are fulfilled. motivators such as truth, justice, wisdom, and meaning. They ●● Unfulfilled lower order needs take precedence over higher are said to have frequent occurrences of peak experiences, level needs. For example, for a person who is hungry, his which are energized moments of profound happiness and need for food will far outweigh his need for self respect. harmony. According to Maslow, only a small percentage of the population reaches the level of self-actualization. The needs described within Maslow’s theory include: ●● Physiological needs – Needs required to sustain life, such as, air, water, food, and sleep. According to this theory, if

Psychology.EliteCME.com Page 61 Applying Maslow’s needs hierarchy in the workplace If Maslow’s theory holds true, there are some important ●● Social needs: Generate a feeling of acceptance, belonging, implications for management. Managers have varied and community by reinforcing team dynamics, planning opportunities to motivate employees through management style, team-based projects and social events. job designs, company events, and compensation packages. ●● Esteem motivators: Recognize achievements, assign important projects, and provide status to make employees To follow Maslow’s theory, managers are encouraged to do the feel valued and appreciated. following: ●● Self-actualization: Offer challenging and meaningful work ●● Physiological motivation: Provide ample breaks for lunch assignments that enable innovation, creativity, and progress and recuperation. Devise a salary scheme that would allow to long-term goals. Provide opportunities that would allow your workers to buy life’s essentials. your employees to reach their full career potential. ●● Safety needs: Employees cannot reach maximum effectiveness or efficiency when they feel the need to It is important for us to remember that everyone is not motivated constantly check their backs and scan their surroundings by the same needs. At various points in their lives and careers, for fear of potential threats. Physical threats in the work employees will be motivated by completely different needs. It environment can be alleviated by security guards, cameras, is imperative to recognize the needs employees are currently and responsive management personnel. Managers should also pursuing. provide relative job security, retirement benefits, and the like.

Alderfer In 1969, Clayton Alderfer developed a revision of Abraham The ERG theory does not believe in levels of needs. A lower- Maslow’s Hierarchy of Needs, called the ERG (existence, level need does not have to be gratified. This theory accounts relatedness and growth) theory of motivation. Alderfer’s for a variety of individual differences, which would cause contribution to organizational behavior was dubbed the ERG workers to satisfy their needs at hand, regardless of whether a theory, and was created to align Maslow’s motivation theory previous need has been satisfied. Hence, needs in the different more closely with empirical research. ERG areas can be felt simultaneously.

Alderfer distinguishes three categories of human needs that According to Alderfer, the frustration-regression principle has influence worker’s behavior. These are existence, relatedness an impact on workplace motivation. For example, if growth and growth. opportunities are not offered to the employees, they may 1. Existence needs: physiological and safety needs, such as regress towards relatedness needs, and socialize more with hunger, thirst and sex. co-workers. If management can recognize these conditions 2. Relatedness needs: social and external esteem involvement early, steps can be taken to satisfy the frustrated needs until the with family, friends, co-workers and employers. employees are able to pursue growth again. 3. Growth needs: internal esteem and self-actualization, the desire to be creative, productive and to complete meaningful tasks.

Kolb’s theory of adult learning Considering that all learners are not the same, David Kolb 1. Converger: Someone who wants to solve a problem and introduced an experiential learning theory in 1984. Of the who relies heavily upon hypothetical-deductive reasoning ... various existing approaches to learning, David Kolb’s theory to focus on specific problems (Kolb et al., 1979). of adult learning seems to actually take cultural differences 2. Diverger: Someone who solves problems by viewing into consideration. His theory centered around two ideas: 1) situations from many perspectives and who relies heavily upon people learn in a two-step process (information is obtained brainstorming and generation of ideas (Kolb et al., 1979). and information is processed); and 2) individuals differ in the 3. Assimilator: Someone who solves problems by inductive methods they prefer to do the two-step process (Little, 2004). reasoning and ability to create theoretical models (Kolb et al., 1979). Kolb developed four styles of learning for his theory and considers 4. Accommodator: Someone who solves problems by each group to represent four different methods of inputting and carrying out plans and experiments ... and adapting to processing information. Therefore, if cultural differences account specific immediate circumstances (Kolb et al., 1979). for variations in the manner in which people learn and are motivated, Kolb’s approach offers an understanding and various To determine a person’s learning style, the person completes approaches to motivating a diverse group of employees. an instrument called Learning-Style Inventory by answering questions contained in the Self-Scoring Inventory and Additionally, organizations have successfully relied upon Interpretation Booklet (Kolb, 1985). Kolb’s Learning Style Inventory, as defined by (Kolb et al. 1979), which includes four learning styles:

Page 62 Psychology.EliteCME.com Additionally, Kolb defined four learning cycles: These four cycles are tied into learning styles. For instance, a 1. Concrete experience: Where learning from feelings (Kolb, converger favors a learning cycle of abstract conceptualization 1995) or reactions to experience influence your learning. and active experimentation, which fits because these two learning 2. Reflective observation: Where learning from watching and cycles are characterized by learning by doing and thinking. And listening (Kolb, 1985) influence your learning. because convergers focus on reasoning and solving problems, the 3. Active conceptualization: Where learning from thinking cycles and learning styles are closely tied together. (Kolb, 1985) or analyzing problems in a systematic method influence your learning. But, it should be noted, that while students prefer one learning 4. Active experimentation: Where learning by doing (Kolb, style to another, students will move between learning cycles; 1985) or results influence your learning. Kolb says actual process of growth in any single individual ... probably proceeds through successive oscillations form one stage to another (Kolb, et al., 1979).

Applying Kolb’s theory and inventory in the workplace These four styles are based upon established learning theories, team. This then helps the organization to implement efforts to such as Kolb’s own adult learning theory. Organizations often increase motivation, based on the known learning styles of team use the inventory as a way to understand the dynamics within a members.

Management theory W. Edwards Deming was a statistician and mathematical decisions about what variation should be reduced and what physicist by trade. He believed that performance did not come variation should be left alone or even increased. from the individual, but rather that performance came from the system or the lack of a system. He also stated that one effective The third part of Deming’s system of profound knowledge solution is to engage employees in the process of improving the was theory of knowledge, which is about understanding system. People are born with intrinsic motivation, self-esteem, how knowledge is created, and how there is no substitute for and dignity. One inherits joy in work and joy in learning. knowledge in managing a system. Deming defined knowledge as rational predictions (or theories) about relationships between Deming’s management theory is centered on thinking of an phenomena that are separate in time. A rational prediction is organization and the vendors and customers of the organization a prediction that conforms faithfully to observations that have as a system. With what he called “profound knowledge,” been made through the present. A theory must change when this system may be managed to yield maximum value to all new observations refute previous theory. involved. Profound knowledge itself is a system. Knowledge is built through cycles of theory, experience, Deming identified four interacting parts to this system of and then corroboration or revisions of theory. Good theory knowledge: or knowledge is essential for creating value in a system. 1. Appreciation for a system. Knowledge must be extracted from experience, and sought 2. Knowledge about variation. from outside the system, to manage well. The alternatives 3. Theory of knowledge. to management by knowledge – such as superstition, luck, 4. Psychology. hoping and wishing, copying examples without understanding, following tradition for its own sake – tend to take away value. The first part, which is appreciation for a system, has already been mentioned: Recognition of relationships within and The last part of Deming’s system of profound knowledge, between organizations and the potential for these relationships psychology, comprises knowledge about what humans do and to maximize value is crucial to realizing value. Smart systems why they do it. Psychology is extremely relevant to organizations allow for synergy – wholes greater than the sum of their parts. in that “human beings doing things” is what organizations are. Appreciation for a system means that parts of an organization Even the non-human pieces of an organization (e.g., machines, are always considered in relationship to other parts, and the aim buildings, physical raw materials, procedures) were ultimately of the system. the result of human beings doing things.

The second part of Deming’s system of profound knowledge, He was especially concerned with effective uses of motivation knowledge about variation, is crucial for understanding various and emphasized the motivating power of the joy, satisfaction, and phenomena that occur in a system and making smart decisions pride that occurs when one contributes to an effective system. He in designing and managing a system. Deming emphasized noted how many typical employee reward programs are contrary the importance of discerning (through proper statistical to appreciation for a system, and hurt, rather than help, morale. methods) what variation is built into a repeating process and He also was concerned about organizational cultures based on will predictably occur within certain limits, and what variation fear, which is destructive to both the system and to individuals. represents extraneous phenomena, or the existence of chaos. Knowledge about variation also allows managers to make better

Psychology.EliteCME.com Page 63 Goal-setting theory In 1960s, Edwin Locke put forward the goal-setting theory of Goal-setting theory is based on the notion that individuals motivation. This theory states that goal setting is essentially sometimes have a drive to reach a clearly defined end state. linked to task performance. It states that specific and Often, this end state is a reward in itself. A goal’s efficiency is challenging goals along with appropriate feedback contribute affected by three features: proximity, difficulty and specificity. to higher and better task performance. In simple words, goals indicate and give direction to an employee about what needs to An ideal goal should present a situation where the time between be done and how much effort is required to be put in. the initiation of behavior and the end state is close. This explains why some children are more motivated to learn how to Goal-setting theory places a large focus on the following elements: ride a bike than to master algebra. ●● Self-efficiency: The individual’s self-confidence and faith that he or she has the potential to perform the task. The A goal should be moderate, not too hard or too easy to complete. higher the level of self-efficiency, the greater the efforts put In both cases, most people are not optimally motivated, because forth by the individual when he or she is faced with various many want a challenge (which assumes some kind of insecurity challenges. Meanwhile, the lower the level of self-efficiency, of success). At the same time people want to feel that there is a the fewer efforts the individual makes and the higher the substantial probability that they will succeed. likelihood the person may quit when met with challenges. Specificity is important in the description of the goal. The goal ●● Goal commitment: Goal-setting theory assumes that the should be objectively defined and intelligible for individuasl. A individual is committed to the goal and will not leave the goal. classic example of a poorly specified goal is to get the highest Goal commitment is highly dependent on the following factors: possible grade. Most children have no idea how much effort ○○ Goals are made open, known, and broadcasted. they need to reach that goal. ○○ Goals should be self-developed by the individual rather than designated. ○○ Individuals’ goals should be consistent with the organizational goals and vision.

Self-determination theory Self-determination theory (SDT) was developed by Edward Unlike these other theories, however, SDT does not include any Deci and Richard Ryan. It focuses on the importance of sort of “autopilot” for achievement, but instead requires active intrinsic motivation in driving human behavior. Like Maslow’s encouragement from the environment. The primary factors hierarchical theory and others that built on it, SDT posits a that encourage motivation and development are autonomy, natural tendency toward growth and development. competence feedback, and relatedness.

How it impacts the workplace Employers need to get to know their employees very well and Motivation varies in different people. We can also say that use different tactics to motivate each of them based on their motivation is the willingness to work at a certain level of personal wants and needs. Happy, motivated employees are effort. Motivation emerges, in current theories, out of needs, indeed better workers and will help to generate a positive work values, goals, intentions, and expectation. Because motivation environment that both customers and employees will better comes from within, managers need to cultivate and direct the appreciate. Seeking ways to motivate and build worker morale motivation that their employees already have. pays dividends to any business or organization. The motivated worker is more committed to the job and to the customer. Motivation comes from within us, such as thoughts, beliefs, ambitions, and goals. The people who are most interested in Organizations motivate employees by investing in them. motivation studies are managers of people because they may Motivating people is not just about a financial investment, provide insights into why people perform at work as they do, though, but also an emotional one. A motivated workforce has and as a result, provide managers with techniques to improve more productive employees and this translates into bottom worker productivity. line cost savings. On the other hand, motivated employees positively impact corporate culture, resulting in many One of the traditional components of management along with intangible but equally important returns. planning, organizing, and controlling is motivating. Many managers do different things, for example, contests; ranking The end result when an organization invests in employees both of people, plants, shifts, teams and departments; performance emotionally and financially is plain to see: happy customers appraisals; performance; production; sales quotas; and and increased revenues. A motivated workforce can truly commission pay. All these systems are implemented in the have bottom line impact and make the workplace somewhere belief that they drive performance. employees look forward to interacting with others instead of just a place to pick up a paycheck. But some researchers think it does the opposite. Instead of trying to use extrinsic motivators (something outside of the work itself

Page 64 Psychology.EliteCME.com such as promised rewards or incentives) to get higher levels of a greater significance, such as, marketing, a delivery system, performance from people, management will be better served by post-sale services, etc. (Krzemien & Wolniak, 2007). studying the organization as a system. Employers demand results. Without results, the organization will not survive. Managing There are numerous definitions of motivation, describing it motivation is a requirement for productivity. as activities that are focused on a particular objective whose aim is to make others behave in the expected way. However, Theorists studying intrinsic motivation have provided the clearest motivation can be defined in a subjective way, too. In this demonstration of the link between the provision of choice and aspect, strongly motivated people undertake bigger efforts in human motivation. By far the most prominent analysis of this comparison with the ones with no motivation. On this basis, concept (e.g., Deci, 1981; Deci & Ryan, 1985), which draws it may be inferred that motivation can be characterized as a in part on earlier work by deCharms (1968), virtually equates willingness to do something. The willingness depends on a intrinsic motivation with individual choice and personal self- possibility to fulfill individual needs. determination. In this analysis, people are viewed as actors seeking to exercise and validate a sense of control over their Motivation deals with factors influencing people to behave in a external environments. As a result, they are theorized to enjoy, specified way. In motivation, three elements may be distinguished: to prefer, and to persist at activities that provide them with the the direction (what a person tries to do), the effort (how hard a opportunity to make choices, to control their own outcomes, and person tries), and the persistence (how long a person will try). to determine their own fate (Condry, 1977; Deci, 1975, 1981; Motivation includes power (objectives and results). These Lepper & Malone, 1987; Malone & Lepper, 1987; Nuttin, 1973; factors initiate and control behavior. Motivation can also be Zuckerman, Porac, Lathin, Smith, & Deci, 1978). understood in two aspects. In an attributive perspective, it The absence of choice and control has been hypothesized and denotes an internal process that regulates people’s behavior at shown to produce a variety of detrimental effects on intrinsic work. The internal process affects their decisions about taking a motivation, life satisfaction, and health status (e.g., Deci, job and also about their involvement in this job. Speigel, Ryan, Koestner, & Kaufman, 1982; Schulz & Hanusa, By contrast, motivation in a functional way is often defined 1978; Seligman, 1975). as a conscious and intentional influence on people’s behavior The achievement of performance measures depends on both the with the use of knowledge about factors determining it in the collective efforts of agency employees as well as the individual work process. Problems with insufficient workers’ motivation efforts of employees in specific roles. Therefore, the motivation are much more difficult to overcome than difficulties with other for collective achievement within an organization is a key element. resources. For example, when an organization has unsuitable According to Ruvolo et al (2004), leader development initiatives machines, it is simple to replace them. When a company will fail miserably without a clear understanding of the existing has raw materials of a poor quality, it is possible to find organizational culture and the powerful impact it has on shaping new suppliers. When workers’ knowledge or performance is and maintaining behavior in ways that are almost invisible. unsatisfactory, they can attend professional courses.

Motivational elements are connected with humanistic aspects The continued need for individual and organizational development of management as well as immaterial organizational resources. can be traced to numerous demands, including maintaining (Krzemien & Wolniak, 2007). In the reality of the knowledge- superiority in the marketplace, enhancing employee skills and based economy, only intellectual resources are considered to be knowledge, and increasing productivity. Training is one of the most unforgiveable, inimitable and can meet an organization success. pervasive methods for enhancing the productivity of individuals Other assets, such as capital, machines, and devices, have and communicating organizational goals to new personnel. In recently become easy to acquire. 2000, U.S. organizations with 100 or more employees budgeted to spend $54 billion on formal training (Industry Report, 2000). Motivation links managers with their workers in the most direct way. The efficiency managers who deal with the Given the importance and potential impact of training on organization’s quality management largely depend on their organizations and the costs associated with the development leadership skills as well as their ability to motivate employees. and implementation of training, it is important that both No proper leadership can be established without an appropriate researchers and practitioners have a better understanding of the motivational system in any organization, and without it, relationship between design and evaluation features and the employees cannot perform their tasks precisely. effectiveness of training and development efforts.

The problem with workers’ motivation is particularly important Relationships within the workplace are significant to motivation in the management of the service sector, where there is a direct as well. Employees who have a positive working relationship with contact with a customer. Therefore, communication, politeness, their supervisor are more likely to be motivated to perform well. kindness, and so on are extremely crucial. In the meantime, the Those who lack this positive working relationship are less likely to importance of the service sector is growing. It is possible that be motivated. Others are motivated by their working relationships the vast majority of newly created workplaces will occur in with co-workers or with their clients. Until recently, American the service sector. The importance of services is rising even in social psychologists studying interpersonal processes have production enterprises, where internal services are coming into excluded from their studies participants in continuing relationships.

Psychology.EliteCME.com Page 65 Predictably, the main recent exception involves research on When group dynamics of continuing relationships are not the romantic relationships, although even there the focus is often focus of attention, researchers typically study the responses to on initial attraction instead of the evolving or ongoing features actions by, communications from, or even written information of the relationship itself. Even when intergroup or intragroup about strangers rather than friends, family, coworkers, or others dynamics are the focus of investigation, it is generally in long-term relationships. In a sense, relational and social previously unacquainted individuals or arbitrarily defined contexts are treated as sources of noise, or even bias, to be groups that are studied. eliminated in the search for “basic” underlying processes and functional relationships between variables.

Independent versus interdependent Some employees are intrinsically motivated to perform quality independent or interdependent approaches, which affect work, and those individuals inject a strong work ethic into cognition, emotion, and motivation. their roles and achievements. These people are often driven by the opportunity for choice and self-determination (Ivengar & Asian culture has focused on the need to be part of the group and Lepper, 1999). conform to values and beliefs of coworkers or group members. Western European culture has displayed the individual as self- Others require assistance in understanding their roles and what contained, autonomous, and independent, which may place they are working toward besides a paycheck and benefits. higher focus on individual achievements and the effect of those According to Meglino et al (1989), individuals may at times individual traits on motivation. work with a high level of efficiency and be committed to their organizations while at the same time perform behaviors that are American and Western European cultural norms place higher inconsistent with the success of their organization. emphasis on individual competition among team members, while British athletes have typically displayed levels of Research has noted considerable differences between many competitiveness on behalf of the team and its goals and Western European cultures and Asian cultures. Markus behaviors (Sullivan & Callow, 2005). & Shinobu (1991) describe these differences as rooted in

Factors that affect employee motivation

Stress Just as stress can affect the physical well-being of an employee, Stress can come in many forms. Interpersonal communications it can just as easily have a negative effect on the individual’s and relationships alone can exist in several variations, depending psychological well-being. We know that physically, stress on the roles of the individuals and the requirements that each one can lead to headaches, grinding teeth, clenched jaws, chest is focused on meeting. pain, shortness of breath, pounding heart, high blood pressure, muscle aches, indigestion, constipation or diarrhea, increased Goals and barriers will vary across levels of employment. What perspiration, fatigue, insomnia, and frequent illness. exists as a primary goal for a manager may not be the primary goal of the administrative support staff, of the quality assurance Stress can also result in psychological reactions, such as anxiety, staff, and the levels of operational staff. Even if the overall goal irritability, sadness, defensiveness, anger, mood swings, or agency mission is the same for everyone, there are different hypersensitivity, apathy, depression, slowed thinking or racing pieces of the bigger-picture goal that are more important to thoughts; feelings of helplessness, hopelessness, or of being certain people than others within the work population. This trapped. alone can create significant stress levels for all individuals involved (Moseley, Jeffers, & Paterson, 2008). Behavioral changes can occur as well, such as, overeating or loss of appetite, impatience, quickness to argue, procrastination, Stress in the workplace can also be caused by a series of other increased use of alcohol or drugs, increased smoking, elements. It can result from the access to, lack thereof, or the withdrawal or isolation from others, neglect of responsibility, efficiency of existing technological devices or available resources. poor job performance, poor personal hygiene, change in Stress can also arise from change in policies and procedures religious practices, and change in close family relationships. and a lack of clarification; changes in organizational structure or responsibilities; interactions with clients or the public; and increased Each of these types of responses has a significant impact on workload because of exiting coworkers (Westbrook et al., 2006). people’s ability to maintain their level of motivation. Overall, stress can lead to burnout, which in some fields can Stress factors in the workplace can also lead employees to feel be linked to what is called compassion fatigue. According to they might be happier elsewhere, either in a different organization Pfifferling & Gilley (2000), “compassion fatigue is a deep that may have elements that appeal to them, or in a different field physical, emotional and spiritual exhaustion accompanied by acute altogether, because they feel the current stress they experience does emotional pain ... flourishing today, due in part to the demands of not exist in other fields or organizations (Shim, 2010). managed care” (p. 39). This form of stress, often caused by having a direct impact on a person’s life as a result of career role, is often found in medical, health, and social services fields.

Page 66 Psychology.EliteCME.com Lack of advancement opportunities For employees who are motivated by external factors, a of the top five reasons people leave a place of employment. lack of advancement opportunities or increase in financial Therefore, we can assume that even if someone remains in compensation may result in decreased levels of motivation. his or her current role, the person’s level of motivation to do Lack of advancement opportunities is typically cited as one quality work will decrease over time.

Workplace violence Workplace violence is often described as threats, threatening and psychological actions, but violence can occur in other statements, or threatening behaviors that give a reasonable forms, such as excessive workloads, unsafe working conditions, cause to believe that the employee is at risk of physical injury, and inadequate support. Most individuals may not associate as well as attempted conduct of a person that endangers workload with the term “violence,” though it is easy to the physical health or physical safety of the employee. understand how it falls into this category; unrealistic workload (Occupational Health and Safety Act, 1996). assignments (especially in extreme conditions) may quickly turn into an element of a hostile work environment. Past Violence can occur in many forms. These include supervisor to research findings also suggest a direct link between aggression worker, among co-workers, and client to worker. This violence and increases in sick leave, burnout, and staff turnover. can be manifested through physical, sexual, verbal, emotional

Creativity While you may not expect to see “creativity” appear next Further, allowing employees to choose creative and challenging to stress, lack of advancement opportunities, and workplace jobs or tasks has been shown to improve motivation. To violence, interestingly, Ambrose and Kulik (1999) found increase creativity, setting “creativity goals” can positively that the same variables that predict intrinsic motivation are influence the process, along with allowing more autonomy associated with creativity. This is a helpful conclusion in that (e.g., giving employees the freedom to feel and to be creative). organizations can measure and influence both creativity and motivation simultaneously.

Organizational culture Creating a positive organizational culture is clearly an These are the kinds of questions a new employee might ask, and important aspect of great leadership and as such, a large focus the answers can reveal how formal, warm, and status-conscious within the field of I/O psychology. Organizational culture refers the workplace culture is. Organizational culture describes the to an organization’s shared values, beliefs, norms, and customs. “flavor” of an organization, often referred to as the “way we get ●● How do people dress? things done around here” (Deal & Kennedy, 1982). ●● Do they socialize? ●● Are decorated cubicles acceptable? ●● Can the employees talk to the CEO?

Types of organizational culture Researchers have proposed a variety of theoretical approaches Person culture: Everyone believes that he or she is above the to organizational culture (Schein, 2005). One approach organization itself. An organization with this type of culture describes four types of organizational culture (Handy, 1985): has difficulty surviving because the members have not “bought into” a shared mission. Power culture: Power is centralized to only a few people. Control is enforced from the center of the organization outward. Leadership among different cultures is essential in cross-cultural A power culture typically has few rules and little bureaucracy organizations (Manning, 2003). In a multi-cultural context, leaders and is characterized by quick decision-making. are increasingly addressing the need to inspire and lead people from different cultures. Effective leadership calls for both an Role culture: Structure is clearly defined and authority is awareness and understanding of these cultures. Typically, global delegated. Typically such a culture is hierarchical in structure, leaders were selected based on technical skills and organizational with authority flowing from the top down. commitment; however, today, leading across cultural boundaries requires specific interpersonal behaviors and skills. Task culture: Teams are used to solve particular problems, with expertise driving the status of members. The person who Leaders must also be able to appreciate how people from knows the most about the problem at hand takes charge until different cultures perceive them and understand actions (Yukl, some other problem comes along. 2006). Dickson, Den Hartog, and Mitchelson (2003) explained

Psychology.EliteCME.com Page 67 that different cultural contexts call for different leadership imperative to achieving both contingent and strategic changes that behaviors. One way to address the research of the relationship may be needed in the pursuit of its mission (Dickson et al, 2003). between leadership and cultural differences is through the recognition and measurement of cultural dimensions Leadership practices must be in tune with the complex milieu (Dickson et al.), which have been honed and developed by in which leaders perform. Leadership behavior is further many researchers (Hofstede, 2001; House, Hanges, Javidan, influenced by other situational behavior, such as the climate, Dorfman, & Gupta, 2004). level and function of the manager, position, power and authority (Yukl, 2006). Research has shown a strong correlation between leaders’ awareness of cultural dimensions and successful performance in As the culture of an organization changes, the relationship organizations in different societies (House et al., 2004; Javidan between members and their stakeholders change (Awal, Klingler, et al., 2006). This makes it extremely important for leaders to Rongione, & Stumpf, 2006). As the organization changes consider and perhaps modify their leadership style to fit the slowly over time, it is characterized by affiliated, communal, context and culture of the organization to successfully establish and approval values and beliefs, resulting in individuals getting relationships with employees and management. Awareness and along, avoiding conflict and following rules while demonstrating sensitivity to different operating cultures in the organization is a supportive pleasant behavior (Awal et al., 2006).

Diversity and management techniques Diversity in the workplace has increased in the United States access to promotions within the organization. Leaders who are and has contributed to individuals gaining a global perspective willing to address concerns made by individuals are more likely with an increase in opportunities for companies to grow. Yukl to gain the respect that they need so that they can offer insight (2006) pointed out that although diversity has many benefits, into the development of their organization. it may also create an environment with less trust and conflict because of the various points of view on how to address various Doyle & George (2008) concluded that organizations must issues. Managing diversity is necessary to foster a climate that measure how well they are integrating diversity. That there is conducive to overall success. is a plan in place to address the progress that individuals within a workplace are making when it comes to effective Individuals have an opportunity to learn from one another and communication, work performance, effective decision- gain knowledge that may lead to a better understanding or a making and access to growth within an organization is an better approach at resolving problems. Hosley, Gensheimer, accomplishment and a move toward equity, social justice, and & Yang (2003) indicated that successful collaborative efforts empowerment. Leaders are responsible for establishing an between individuals in a diverse work group must begin with effective framework for their employees. trust and respect. Furthermore, the various cultural, gender and or other diverse styles should be incorporated into all Broome (2003) explained that a leader should be aware of the areas of the work, including “meetings, decision-making, and unique needs within the group. He stated that embracing the communication patterns” (Hosley et al., 2003, p. 5). unique qualities that each individual contributes to the work group as well as avoiding pointing out individuals by race, gender, ethnic According to Hartel, Panipucci, & Fujimoto (2003), individuals group, or culture will increase the level of performance. are more likely to be receptive to the decisions made within a diverse work group when they are open-minded and have social Individuals are likely to form subgroups within an organization environments that value and encourage positive stereotypes if they feel that they do not belong to the group or the work rather than negative stereotypes. Hartel et al. (2003) also team as a whole. It is important for managers to recognize indicated that it is beneficial for organizations to incorporate that the inclusion of all team members, especially members HR policies and practices that are focused on the diversity who are of a minority group, is necessary to avoid motivating levels that exist. them to form their own subgroups and developing a distinct vision for themselves while dividing the team approach. It is Whereas workers may wonder if they have certain rights as also important to recognize the accomplishments of the team employees to challenge or address concerns, an HR policy that members as a team rather than as individuals (Panipucci & supports diversity would allow for employees to participate in a Hartel, 2003). grievance process that would address the concerns and provide support for the necessary changes to occur. While leaders may find it difficult to build a strong organizational culture because of the various perspectives that each team Yukl (2006) described various ways for leaders to encourage member brings, it is necessary to use their skills as a listener and diversity and teach individuals the value of working through facilitator to gain the various perspectives and incorporate them conflicting issues. A few of the methods that were outlined into the organizational culture. Miller and Fields (2000) indicated included offering diversity training, promoting structural that although individuals like to be surrounded by others who mechanisms to reduce discrimination that would allow for share the same interest, speak the same language, and have the individuals to address intolerance, effective recruitment same values, a leader in an organization is more likely to benefit strategies, and programs that provide equal opportunities to from the various perspectives that diversity offers. Miller and all employees when it comes to professional development and

Page 68 Psychology.EliteCME.com Fields stated, “Managing diversity also enhances organizational Researchers additionally argue that building teams with the right flexibility” (p. 20). individuals and using techniques that improve or create creativity are important. Coaching, training, and building communication Diversity training is an effective method for developing a safe skills are also important to improve behavior and thinking skills. environment to learn about others’ thoughts and beliefs. Karp Other techniques may involve planning events and supporting the and Sammour (2000) pointed out that although individuals may meetings by using effective facilitation techniques, interventions resist diversity training, it provides them with the opportunity to and appropriate technology to improve communication, generate learn the legal ramifications involved in making fair decisions ideas and develop group memory (McFadzean & O’Loughlin). within the workplace. The approach that is taken with diversity training will affect how it is received. Different individuals will have different preferences, and certainly the more choices available, the more these individuals Knowing the audience and choosing the appropriate individuals will be able to find and select alternatives that best match their to conduct the training as well as the topics that pertain to personal preferences. In addition, the mere exercise of choice the group that is being addressed will not only enhance the itself may have psychological benefits. People offered a choice learning opportunities for the organization, but also provide a may feel a sense of autonomy, control, or empowerment. more satisfying approach to learning about managing diversity. Pendry, Driscoll, and Field (2007) stressed that it is important But are these principles truly as self-evident and as universal as to be aware of how individuals may react to diversity training they might first appear to investigators raised and living in North scenarios and not assume that what works in the laboratory America? The American assumption is that people will find choice will work with individuals confronted with issues that they are intrinsically motivating, and psychologists have rarely paused unfamiliar with or that they are not willing to accept. to examine the more general applicability of these findings.

A trainer may provide individuals with an assessment before An influential cultural analysis presented by Markus and beginning the training to find out where they stand on tolerance Kitayama (1991a, 1991b) attempts to explain and shed and their understanding of diversity issues before actually some light on the mechanisms that might underlie these beginning the training (Hostager & Meuse, 2008). Once leaders differences. Their self-systems theory argues that whereas are able to unite their teams, they can begin working toward personal agency is an essential element of the self-constructs positive change. of American individualists, it may be much less relevant to the self-constructs of members of more collectivistic cultures In cross-cultural leadership, there are many different styles, characteristic of Asia and elsewhere. Markus and Kitayama’s models, and theories used to develop leaders for an international analysis suggests that the link between the provision of choice environment. If leaders are going to be effective in meetings, and intrinsic motivation may not be universally applicable. planning, and leading their followers, they must develop strategic skills. Many of these skills can influence attitudes and behaviors For Americans, making a choice provides an opportunity to of leaders in a number of ways (Yukl, 2006). display their preferences and consequently, to express internal attributes, assert their autonomy, and fulfill the goal of being Different cultures affect leaders because their values influence unique. For Americans, individual choice and personal autonomy their attitudes and behaviors. Through practice, intentionality, may be deeply intertwined with a their sense of self-identity. and openness to experiential learning, leaders can increase their awareness and even acceptance of the differences in In contrast to American individualists, Markus and Kitayama cultural dimensions (Brislin, Worthley, & Macnab, 2006). This (1991a, 1991b) theorize that members of more interdependent means that leaders will have to immerse themselves in the cultures (i.e., most non-Western, and particularly East Asian target culture so they can learn from the social experiences to cultures) strive for interconnectedness and belongingness with assimilate cultural intelligence. their social in-groups, seek to maintain harmony and endeavor to fulfill the wishes of those groups (DeVos, 1985; Hsu, 1985; Thomas (2006) suggested paying attention to and appreciating Miller, 1988; Shweder & Bourne, 1984). critical differences in culture and background between oneself and others, recognizing how culture affects behavior and the For such individuals, the exercise of personal choice may have importance of different behaviors. Intentions and inquisitiveness considerably less intrinsic value. Indeed, in some situations, will go a long way in equipping leaders with the capacity to the exercise of personal choice might even pose a threat to observe and adjust their behavior and leadership style to enhance individuals whose personal preferences could prove to be at their experience in new cultural situations, thus enabling effective variance with those of their reference group. Interdependent cross-cultural leadership (Templer, Tay, & Chandrasekar, 2006). people, therefore, might sometimes actually prefer to submit to choices expressed by others if the situation enables them to Cultural leaders are often faced with the challenges of fulfill the cultural goal of belongingness. making group decisions. With many changes occurring in an organization, making decisions is important. Although cultures For individuals possessing interdependent selves, we might are different, strong leaders have adopted techniques that are hypothesize that the effects of having choices made by others used in building strong group units. According to McFadzean might depend critically on the specific identity of the choosers. and O’Loughlin, (2000) some strategies for improving Depending on the degree of closeness between the chooser group effectiveness in organizations include developing and and the individual, a person making choices for another can be implementing innovative ways of decision-making. perceived either as a compassionate or as arrogant.

Psychology.EliteCME.com Page 69 If availability of individual choice is indeed less relevant In our society, for instance, it is typically presumed that when for people from more socially interdependent cultures, then a person engages in some behavior merely to please or to social psychologists may be faced with the challenge of re- conform to the ideals of others, that action is extrinsically conceptualizing a number of traditional theories and paradigms. motivated (deCharms, 1968; Deci, 1975; Harter, 1981). In deCharms’s (1968) terms, “The crux of the distinction between Such cultural differences may prove important, for example, extrinsic and intrinsic motivation lies in the knowledge or in many other classic social psychological theories in which feeling of personal causation” (p. 328). choice or perceptions of choice have been shown to play a central role. Such well-known theories as cognitive dissonance Although this assumption is clearly consistent with the (Festinger, 1957; Heine & Lehman, 1997), attribution theory American self-system, the boundaries between intrinsic and (Morris & Peng, 1994), and psychological reactance (Brehm, extrinsic motivation may need to be reconsidered when taking 1966), to name just a few, may not apply to non-individualistic into account the interdependent self for whom conformity to cultures without some modification. one’s in-group is an integral aspect of the self-system.

Gender Gender and its tie with leadership has been and continues to Miller and Fields (2000) pointed out that diversity enhances be an area of interest. Selection and promoting leaders in large the creative decision making process; therefore, incorporating organizations tends to favor males, though some increases in individuals who are willing to offer suggestions and brainstorm female leader numbers are being seen (Laff, 2007; Yukl, 2006). solutions will positively contribute to the outcome of the meeting. However, the majority of high-profile, high-level positions in organizations are held by men (Gilgoff, 2009). Various theories When individuals are open to learning, they allow for the attempt to explain why this gap exists, but the research tends to possibilities that change may bring (Mannix & Neale, 2005). be weak, inconsistent and lacks suggested remedies (de Vries, Leaders should provide a safe environment where individuals 2008; Staley, 1984; Yukl, 2006). have the opportunity to brainstorm and offer constructive criticism. A leader may be receptive to ideas and be willing The studies to date tend to focus on gender-based differences to provide feedback to those involved in the decision-making in displayed leadership behavior and effectiveness without process when it comes to the end results. Acknowledgement of thoroughly considering the variables that influence leadership. the team for its contributions and commitment to the decision- Additionally, the studies do not investigate the magnitude of making will encourage continued support and a feeling of differences or provide suggestions into why the differences accomplishment. exist (Yukl, 2006). Binns (2008) stresses that gender matters, both in the bodies Laff (2007) provides four findings from the Women’s Leader described as male and female, but also in the behaviors and scripts Study. Recognizing these findings, but also leveraging leaders live by. Recognizing those scripts and incorporating the what women bring to the meeting in terms of leadership best each leader has to offer into the decision-making process and organizational change can improve decision-making in will result in better decisions, and thus better outcomes. group meetings. Those findings include: Women leaders are more persuasive than men; they are negatively impacted by Even with the inconsistencies that exist in the research, rejection but they learn from the experience; women leaders reflecting on the assertions and theories on why this gender display an inclusive, team-oriented style to solve problems leadership inequality exists is important. Implicit theories and reach decisions; and women leaders are more likely to suggest the biases that exist about the abilities and behaviors of take risks. Fennell (1999) also suggests women leaders are women are part of the discrimination that exists in the selection less conservative than their male counterparts and tend to use and promotion of women leaders (Yoder, 2001; Yukl, 2006). relational power behaviors. Such biases arose from the notion that the personality traits It is also important that men and women be sensitive to and necessary to be an effective leader were considered to be aware of the possibility that the gendered nature of meetings masculine in nature and supported by cultural beliefs (Gilgoff, could be a barrier for female-oriented leadership (Grisoni & 2009). Conversely, the strategies used in most organizations Beeby, 2007). The key to breaking down this barrier – and today require collaboration and relationship building, which improving group decisions – is the importance of an open and are considered to be female-oriented traits and have created a inclusive dialogue that allows all team members to exchange female advantage contingent (Binns, 2008; Yukl, 2006). The information, actively listen and understand the topic as well as caution here, however, is that this theory also feeds the biased- participative discussions (Grisoni & Beeby). belief that a trait has a gender or is only displayed by a male or female (Yoder). Team meetings should have a purpose and an outline of what is to be discussed. Individuals who meet on a regular basis Sosik, Avolio, and Kahai (1997) assert that having leaders treat are more likely to have a system in place for accomplishing people as individuals with their own histories, experiences, and agenda items and the ability to move forward on action items. emotions ultimately creates better organizational commitment According to Lee (2008), assigning roles to help the meeting and productivity. This approach employs the use of traditionally run smoother is beneficial. assigned female-oriented behaviors and traits (Binns, 2008).

Page 70 Psychology.EliteCME.com Assigning gender to behaviors and traits, however, lends support leveraging social capital as a cause for the glass ceiling. By not to another approach used in gender and leadership studies, which actively networking or developing a mentoring relationship, is the application of stereotypes and role expectations (Yukl, females put themselves at a disadvantage (Eagly, 2007). 2006). Males are expected to be competitive and aggressive. Additionally, attributions of leadership and performance-based Women displaying the same type of behavior are negatively pay processes differ based on gender, with women needing to viewed and tend to be evaluated and compensated less (Eagly, be charismatic to be seen as effective leaders, while men are 2007; Kulich, Ryan, & Haslam, 2007). assessed in terms of performance measures (Kulich et al., 2007).

Geddes (2009) found in her research that in times of war, Gender and leadership are tied together in research, stereotypes, people choose older, masculine faces as their leaders, while in role expectations, and personality traits. While research is being times of stability and peace, feminine faces were chosen. This performed in this area, it tends to be inconsistent in terms of research suggests that in general, appearance and gender play a controls, methodologies, variables, and conclusions. Some strong role in determining who leads in times of war and peace research cites significant differences in gender-based leadership based on culturally influenced, assigned gender traits (Geddes). traits and effectiveness, while other studies find mixed or no gender-related differences (de Vries, 2008; Eagly, 2007; Staley, Another explanation for the lack of women in leadership 1984). More research is indicated to determine what basis may positions looks at whether and how women prepare themselves exist for the gender/leadership gaps and what actions could be to take on these leadership roles. Wang (2009) cites the lack of implemented to close the gap (Eagly, 2007; Wang, 2009).

Job satisfaction I/O psychologists are keenly interested in work attitudes, that is, and their lives in general (Bartel, Blader, & Wrzesniewski, 2007; how people feel about their jobs. Job satisfaction is the extent Jones & George, 2007). I/O psychologist Amy Wrzesniewski to which a person is content in his or her job. Job satisfaction and her colleagues (1997) studied 300 workers and found that is a relatively recent term, because in the past, the choice of their perceptions of their occupation had a substantial impact on occupation was not so much up to the individual. Instead, many important aspects of their work and well-being. people simply did whatever their parents did to earn a living. Some described the occupation as a “job,” one that involved As economic conditions and social changes have allowed more no training and allowed no personal control and little freedom. people access to education and employment, the question has These individuals tended to focus on the material benefits of become not only whether a job puts money in the bank and work. Another group of participants identified their occupation food on the table but also whether an individual feels fulfilled as a “career.” They saw their occupation as a stepping-stone to by his or her occupation. The happier that individuals are in greater advancement and accordingly focused on the attainment their jobs, the more satisfied they are said to be. of better pay, promotions, and moving up the organizational ladder. The most common way to measure job satisfaction is to ask employees to report their reactions to their jobs using rating A final group of participants viewed their occupation in terms scales. Job satisfaction can be assessed globally, as with an of a “calling.” They perceived the occupation as requiring a item such as “How happy are you with your job, overall?” great deal of training and as involving personal control and or in terms of more specific factors such as pay, work freedom. For these individuals, work was not a means to responsibilities, variety of tasks, promotional opportunities, the financial ends but rather a valuable endeavor in and of itself. work itself, and co-workers. Indeed, some saw their occupation as their “mission in life.”

Occupations define people in fundamental ways (Osipow, Importantly, all of these individuals were describing the same 2000). People identify with their work, and the work shapes job: that of a hospital maintenance worker. Other research many aspects of their lives. Work is an important influence has uncovered similar results for administrative assistants, on their financial standing, leisure activities, home location, with about equal numbers having each work orientation friendships, and health. (Wrzesniewski, 2003).

One of the strongest predictors of job satisfaction is feeling Individuals who view their occupation as a calling are that one is engaging in something meaningful or important. more likely to experience work as wholly meaningful and When asked about the meaning associated with their work, fulfilling. They show higher levels of life satisfaction and job respondents nominated contributing to the economic satisfaction. These individuals are more likely to engage in maintenance of their family, having a job that allowed them citizenship behaviors, to devote more time to work, and to miss to have a positive impact on the organization, and work as work less often (Bartel, Wrzesniewski, & Wiesenfeld, 2007; self-expression (Wrzesniewski, Dutton, & Debebe, 2003). Wrzesniewski, 2003). Genentech declares the meaningfulness of its mission in straightforward terms on its website: “To cure cancer.” Those with a calling orientation also derive more satisfaction from the work domain than from hobbies or leisure activities. The way people think about their work and its place in their lives Perhaps not surprisingly, a predictor of taking a calling can have an impact on their work performance, their workplace, orientation to work is preexisting psychological well-being.

Psychology.EliteCME.com Page 71 You might think that those who view their work as a calling person’s perception that his or her pay was fair (Cohen-Charash must have just gotten lucky and found the right job for & Spector, 2001). themselves. But Wrzesniewski (2003) argues that the ability to view one’s occupation as a calling is a “portable” resource It is possible then that it is the person, not the job, that matters that a person can take from one context to another. She uses most for job satisfaction. Certainly there is evidence that job the term “job crafting” to refer to the physical and cognitive satisfaction is relatively stable over time. A 50-year longitudinal changes individuals can make within the constraints of a task to study revealed that a worker’s emotional disposition was linked make the work “their own.” to job satisfaction 50 years later (Staw, Bell, & Clausen, 1986). Some individuals may simply be predisposed to be satisfied. Of Here is an example: course, any group has its malcontents and complainers. A hospital maintenance worker takes it upon himself to start rotating the artwork on the walls of the hospital rooms Even in the Hawthorne studies, researchers identified individuals as he cleans them. Doing so is not part of his written job called “chronic kickers” who complained no matter what the description. It is his own idea for improving the quality of researchers did (Roethlisberger, 1941). There may not be one life for patients who face long hospital stays. perfect job, but rather a very good but different job for each of us. Research that summarized the results of 21 studies indicated Job crafting means taking advantage of the freedom one has that the fit between the person and the job is the most important to bring fulfillment to an occupation, whatever it may be. aspect of job satisfaction (Verquer, Beehr, & Wagner, 2003). Job crafting opens up new avenues for meaning on the job by allowing the individual to reshape the task and relational In a study that explored the worst things about their jobs, boundaries of a job. clerical employees in India and the United States described the most stressful aspects of their work (Narayanan, Menon, One cross-country comparative study examined job satisfaction & Spector, 1999). Among the U.S. workers, lack of control in 24 different nations (Spector & et al., 2001). Workers in was the second-greatest stressor, nominated by 25 percent of Canada were the most satisfied with their jobs; workers in the participants. The Indian workers expressed the most stress England, the least satisfied. U.S. respondents fell in the upper about a lack of structure (again, about 25 percent described third for job satisfaction. this issue). Interestingly, not a single American participant mentioned structure, and not a single Indian participant Predictors of job satisfaction may vary for different jobs and mentioned control. different cultures. For example, in a study of 1,814 healthcare workers in Norway, the job satisfaction of all of the respondents When individuals are asked “What makes a job satisfying?” the was related to their feelings about the local leadership of their answer may very well be “It depends,” and the factors might organizations (Krogstad et al., 2006). But differences emerged include the person, the job, and the cultural context. for the various occupational groups in the study. I/O psychologists also have been interested in the question of Researchers have determined that one factor that is not as whether job satisfaction relates to other aspects of people’s strongly related to job satisfaction as might be expected is pay jobs, such as absenteeism, organizational citizenship, and (Brasher & Chen, 1999). Among those who are making the performance. Job satisfaction is related to lower job turnover minimum wage, some individuals are quite satisfied with their and absenteeism (Crampton & Wagner, 1994), an increase jobs. And among those who are earning a six-figure salary, in organizational citizenship (Organ & Ryan, 1995), and some are dissatisfied. One study found that job satisfaction did performance (Judge et al., 2001). However, whether happy not depend on the amount of money per se but rather on the workers are more productive workers has been the source of some debate, as the critical controversy explores.

Employee selection Industrial and organizational psychologists typically work with graduates if your organization only needs two new accountants. So HR specialists to design recruitment processes and personnel the first step in effective recruiting is to determine what employees selection systems. Personnel recruitment is the process of are needed and then to go after applicants to meet those needs. identifying qualified candidates in the workforce and getting them to apply for jobs within an organization. Personnel Determining employment needs means more than just counting recruitment processes include developing job announcements, empty chairs. Analyses by I/O psychologists help organizations placing ads, defining key qualifications for applicants, and determine how many people in each position are needed at the screening out unqualified applicants. moment and how many will be needed in the future.

It is generally agreed that people are an organization’s most Suppose that a computer company anticipates a 20 percent valuable assets because it is people who are ultimately responsible growth in business over the next five years. That growth will for success in achieving an organization’s goals. Accordingly, require a 20 percent increase in the number of customer service there is often intense competition among organizations to recruit representatives, but how many new representatives should be the “best and brightest” employees. It is a disciplined competition, hired each month? however. There is no point in hiring this year’s top 10 accounting

Page 72 Psychology.EliteCME.com An I/O psychologist’s analysis would help answer this question. employees than to unhappy employees, based on work quality, The analysis would take into account the growth projections as productivity, dependability, and creativity (Staw, Sutton, & well as estimates of how many representatives quit each year Pelled, 1994). and whether the existing ratio of customer service employees to customers is too high, too low, or about right for efficient Work performance is more strongly predicted by well-being operation. than by job satisfaction. For example, in two studies, job performance (as judged by supervisors) was significantly In making recommendations about recruitment plans, I/O related to well-being but not job satisfaction (Wright & psychologists must also consider the intensity of demand for Cropanzano, 2000). employees in various occupations. More active recruitment plans will be necessary to attract the best people in high-demand areas. A number of studies have found that happiness and positive affect are important aspects of the workplace. In one study, Another factor to consider is the initial presentation of the job happy individuals performed objectively better on a task for to the applicant. Not only is the interviewer attempting to assess their assessing managerial potential (including “leadership” whether the candidate is the right fit for the position, but the and “mastery of information,” as rated by objective observers) candidate is considering whether the position is the right fit for (Staw & Barsade, 1993). In other research, dormitory resident him or her. If the position is presented in a manner that does not advisors were described by residents as being more effective reflect the actual work experience, employees are more likely if they were also rated as high on positive affect (DeLuga & to leave sooner because of the undisclosed demands of the job Mason, 2000). or the perception that the organization did not share accurate information. Equally important is the accuracy of the physical In another study, service departments with happy leaders were job description, which is often reviewed and signed at the point more likely to receive high ratings from customers, and the of initial hire. (Faller et al., 2010) positive affective tone of the sales force was an independent predictor of customer satisfaction (George, 1995). Optimistic Even before entering the workforce, individuals with high life insurance agents appear to sell more insurance (Seligman levels of well-being are more successful. They are more likely & Schulman, 1986). And optimistic CEOs receive higher to graduate from college and to receive an interview for a job performance ratings from the chairpersons of their boards and lead or a callback for a second interview than their counterparts with companies with greater returns on investment (Pritzker, 2002). low levels of well-being (Burger & Caldwell, 2000; Frisch et al., 2004). Further, happy individuals appear to secure “better” One reason that happy workers are more likely to be high jobs. In one study, employees with happier personalities had performers is that they are less likely to show “job withdrawal.” jobs that were rated by trained observers as having more Job withdrawal often includes absenteeism, turnover, job autonomy, meaning, and variety (Staw, Sutton, & Pelled, 1994). burnout, and retaliatory behaviors (Donovan, 2000; Thoresen Another study found that happiness at age 18 was related to et al., 2003). Indeed, positive moods at work are linked to financial independence, occupational attainment, and work lower withdrawal and organizational retaliation and higher autonomy at age 26 (Roberts, Caspi, & Moffitt, 2003). organizational citizenship behavior (Thoresen et al., 2003), as well as lower job burnout (Wright & Cropanzano, 1998). Once happy individuals obtain a job, they are more likely to succeed than unhappy individuals. Happy employees receive In addition, individuals who experience calmer types of relatively more favorable evaluations from supervisors and positive emotions on the job, such as serenity and contentment, others (Wright & Staw, 1999). In one study, managers in three are less likely to want to quit and to be in conflict with other Midwestern organizations gave higher evaluations to happy workers (Van Katwyk et al., 2000).

Training Every year, organizations in the industrialized world spend training methods and content, and in evaluating the outcome billions to train their employees (Thompson et al., 2002); the of training efforts. Some I/O psychologists actually conduct figure is more than $126 billion each year in the United States training programs, but in most cases, professional trainers alone (Paradise, 2007). I/O psychologists are often directly deliver these programs. involved in identifying the need for training, in designing

Assessing training needs To help organizations identify which employees need what A second aspect of a training needs assessment is to give kind of training, I/O psychologists typically carry out a training employees a chance to describe the training they would needs assessment that takes into account the organization’s like to have. This information often emerges from personal job categories, workforce, and goals (Goldstein, 1993). One development plans that employees and their supervisors aspect of this assessment is to look at job analysis reports. As create. These plans usually include an evaluation of the mentioned earlier, the need for training is indicated when job person’s strengths and weaknesses. The weaknesses suggest analyses reveal that certain jobs require KSAOs that employees where training might be useful, especially for employees who do not have or that could be strengthened. are motivated to improve their skills (Klein, Noe, & Wang,

Psychology.EliteCME.com Page 73 2006). For example, if the supervisor notes that an individual Finally, the I/O psychologist will look at the goals of the is awkward when making presentations, a course in public organization. If those goals include reducing workplace speaking might be worthwhile. accidents or improving communication with international customers, training in safety procedures or foreign language skills would be in order.

Designing training programs In designing training programs for use by organizations, I/O a higher degree of intention to leave within the rural and urban psychologists are always mindful of the basic principles that groups than those employed in suburban areas. govern the learning and remembering of new information and skills. These principles guide efforts to promote transfer of Other significant factors in retention relate to whether or not training, feedback, training in general principles, overlearning, employees feel they are appropriately compensated for the and sequencing. amount of work they perform. Inadequate salaries and high workloads are common issues that often result in high turnover Transfer of training – The most valuable training programs in the human service field (Westbrook et al., 2006). are those that teach knowledge and skills that will generalize, or transfer, to the workplace. If employees don’t see how to Training for not only employees but also those in leadership apply what they have learned to improve their job performance, roles is another method of ensuring that workers on all levels the training effort will have been wasted. Because promoting feel confident in their job duties. Leadership is the consistent transfer of training is not always easy, I/O psychologists factor as a prerequisite to change in the workplace (Wolfson, develop written materials and active-learning exercises that not Bernabeo, Leas, Sofaer, Pawlson, & Pillittere, 2009). only clarify the link between training and application but also Further, the process of inductive reasoning may not only be give employees a chance to apply new knowledge and skills in beneficial for managers attempting to address issues in the simulated work situations. workplace, but also important within the training process itself, So trainees might first complete reading assignments, attend potentially leading to increased fluid intelligence performance lectures, and watch videos illustrating effective approaches and better academic learning of the training material or to dealing with customer complaints or defusing an office curriculum (Klauer & Phye, 2008). conflict. Then they might form groups to role-play using these Another element of training that may lead to increased retention approaches in a variety of typical workplace scenarios. These rates is the process of mentoring. In addition to quality experiences enhance transfer of training, especially when the supervision, peer mentoring by coworkers not only assists in new trainees’ newly learned skills are supported and rewarded by staff development and promotion of social networking within their coworkers and supervisors (Kontoghiorghes, 2004). the agency, but also offers an opportunity for the mentor to feel Training in general principles – People tend to learn better an increased sense of self-worth and accomplishment, taking and remember more of what they learn when they can put responsibility for another’s learning process and sharing in their new information into a broader context. In other words, accomplishments (Hartje, Evans, Killian, & Brown, 2008). This they learn better when they get some insight into how the process fosters a sense of community within inner circle team or information or skill they are learning fits into a bigger picture unit and can then impact the outer circle, encompassing the entire (Linou & Kontogiannis, 2004). In organizational settings, the agency with a team-based approach (Moseley et al., 2008). “big picture” approach takes the form of training in general Feedback – People learn new skills quicker when they receive principles, which teaches not only how to do things in particular feedback on their performance (Smither, London, & Reilly, ways but also why it is important to do so. 2005). In organizational training, this feedback usually comes In a study conducted by Strolin-Goltzman, Auerbach, from the trainer or other trainees. It takes the form of positive McGowan, & McCarthy (2008), significant findings were reinforcement following progress, constructive suggestions noted on a correlation between the type of educational degree following errors or failure, and constant encouragement to and location as well as the existence of local incentives for continue the effort to learn. For example, after one trainee has employees. Findings indicate that there were higher numbers participated in a videotaped role-play of a new way to deal with of caseworkers with social work degrees in urban and suburban an angry customer or a disgruntled employee, the trainer might settings than in rural settings. Additionally, the study indicates play the video for the entire trainee group so that everyone can offer comments, compliments, and suggestions for improvement.

Employee retention The workload of any given position is dependent upon the In addition, whether adequate training has been provided for type of organization, field of business, and the roles and employees to successfully do their jobs affects their ability to responsibilities assumed by the position. However, the constant maintain various workload levels. is that increased workload and time management issues can affect the level of retention for the individual and the agency.

Page 74 Psychology.EliteCME.com A national survey conducted in 2010 by Express Employment felt higher stress than they did the year before, and 68 percent Professionals found “staggering” results. Express surveyed said their workload had increased. Companies are trending more than 100 business owners, managers and other personnel, toward moving to a more flexible workforce populated by and of those surveyed, 79.4 percent said their workload had temporary workers, contractors and freelancers (Lee, 2011). increased in the past year, 13.7 percent said their workload had Temporary workers can help ease stress as employers attempt stayed the same and 6 percent said it had decreased. Comparing to cut labor without sacrificing productivity. According to stress levels to that of past years, 48 percent reported their the Bureau of Labor Statistics (2010), the number of workers stress level had increased, while 27.5 percent reported it to be placed by temporary-staffing agencies has risen since the same and 24.5 said it had decreased (Lee, 2011). September of 2010 by 404,000, making up 68 percent of the 593,000 jobs added by employers. Additionally, in 2010, a national survey of 9,400 business leaders showed overwhelming statistics. It showed 49 percent

Stress Stress factors in the workplace may lead employees to feel they A 15-year longitudinal study of more than 24,000 adults might be happier elsewhere, either in a different organization revealed a significant drop in life satisfaction following that may have certain elements that are appealing to them or unemployment and a substantial increase in life satisfaction in a different field altogether, because workers may feel that following re-employment. However, in this study, re-employed the current stress they experience does not exist in other fields persons did not experience life satisfaction at the level previous (Shim, 2010). to being unemployed (Lucas et al., 2004).

A key source of job-related stress is role conflict, which may For some individuals in the work world, it is not unemployment occur when a person tries to meet the demands of more than that creates stress but rather burnout, an extremely distressed one important life role, such as worker and mother. Workload psychological state in which a person experiences emotional can also be a source of stress. exhaustion and little motivation for work. Burnout may include feelings of being overworked and underappreciated and can According to Moos (1986), there are four characteristics of feature depersonalization, confusion, worry, and resentment work settings linked to employee stress and health problems: (Ahola et al., 2006; Becker, Milad, & Klock, 2006). ●● High job demands, such as having a heavy workload and time pressure. Symptoms of burnout can be physical (exhaustion, headaches, ●● Inadequate opportunities to participate in decision-making. gastrointestinal problems, suppressed immune function, sleep ●● A high level of supervisor control. disturbance), behavioral (increased use of alcohol, drugs, ●● A lack of clarity about the criteria for competent performance. caffeine; absenteeism, and social withdrawal), and emotional (increased cynicism and negativity, hopelessness, irritability, Nowhere is the importance of work in our lives more apparent emotional distancing, depression, and anxiety). Burnout may than when individuals lose their jobs. Unemployment is related result from chronic stress at work. to physical problems (such as heart attack, stroke, obesity, and diabetes), mental problems (such as anxiety and depression), marital and family problems, homicide, and other crimes.

Managing job stress Stress at work does not always lead to burnout, especially if vacations (Gump & Matthews, 2000). Then the researchers individuals develop enjoyable leisure activities. Leisure refers examined the medical and death records over nine years for to the pleasant times before or after work when individuals are men who lived for at least a year after the last vacation survey. free to pursue activities and interests of their own choosing, such as hobbies, sports, and reading. Compared with those who never took vacations, men who went on annual vacations were 21 percent less likely to die over the Some existing research on what U.S. adults regret the most nine years and 32 percent less likely to die of coronary heart revealed that not engaging in more leisure activities was one disease. The same concerns that lead men to skip a vacation, of the top six regrets (Roese & Summerville, 2005). Could such as not trusting anyone to fill in for them and fearing that taking regular vacations also help individuals to combat work they will get behind in their work and someone will replace stress? A recent study found that in the days and weeks at them, tend to promote heart disease. work just after a vacation, individuals reported that they were less exhausted, had fewer health complaints, and were putting In addition to developing enjoyable leisure activities and taking forth more efficient effort than in the week at work before the regular vacations, what else can you do to cope with work vacation (Fritz & Sonnentag, 2006). stress? Dealing with job stress in a healthy way involves taking care of your body as well as your mind (Marine et al., 2006). In a longitudinal study, 12,338 men 35 to 57 years of age Physical needs must be met by eating right, exercising, and were assessed each year for five years on whether they took getting enough sleep (Fahey, Insel, & Roth, 2007; Robbins,

Psychology.EliteCME.com Page 75 Powers, & Burgess, 2008). Because work stress, like all stress, Transforming a job into a calling is a decision that we make is about our perception of experience, it makes sense to hone about our work situation. your coping skills and monitor your patterns of behavior and well-being periodically (Blonna, 2007; Greenberg, 2008). Stress can come in many forms. Interpersonal communications and relationships alone can exist in several variations, Some things to consider when experiencing work stress: depending on the roles of the individuals and the requirements ●● Have you set realistic goals at work? that each person is focused on meeting. Goals and barriers ●● Are you taking work-related issues too personally? will vary across levels of employment. What exists as a ●● What are your strengths, and how can you use them to do primary goal for a manager may not be the primary goal of the what you do best? administrative support staff, of the quality assurance staff, and the levels of operational staff. It is important to keep in mind that work is an essential part of living a fulfilling life. Indeed, Mihalyi Csikszentmihalyi Even if the overall goal or agency mission is the same for (1990) found that while working, we are 10 times more likely everyone, there are different pieces of the bigger-picture goal that to experience “flow.” Flow is considered to be the optimal are more important to certain people than others within the work experience of a match between our skills and the challenge of population. This alone can create significant stress levels for all a task. Ironically, we are also six times more likely to wish we individuals involved. (Moseley, Jeffers, & Paterson, 2008) were somewhere else when on the job. Work provides us an unequaled opportunity to use our skills and abilities. Stress in the workplace can also be caused by a series of other elements. It can result from the access to, the lack of, or When we think of work as a calling, we might find ourselves the efficiency of existing technological devices or available listening for that call with an open mind and heart. However, a resources. Stress can also arise from changes in policy and calling orientation to work is not just about hearing a call. It is procedure and lack of clarification; changes in organizational about the active way we craft any job to our skills and abilities, structure or responsibilities; interactions with clients or the finding a way to place a personal stamp on the workplace. public; and increased workloads due to exiting coworkers (Westbrook et al., 2006).

Support and supervision Quality supervision includes understanding the responsibilities Managers may convey agency mission and values, but it is the and demands of the worker’s job, fair distribution of workload supervisors who are in daily contact with their team. Therefore, among team members, flexibility, availability, active listening, employee retention may increase as a result of supervisors respect for workers, providing a strong knowledge base of the supporting a motive to change, and sharing the vision or bigger job, setting high but attainable expectations, and providing picture of the organization (Schoo, 2008). instrumental and emotional support and praise (Westbrook et al., 2006). Quality supervision does not have to occur solely in a one-on-one supervision format. Group supervision or all staff meetings also Positive leadership has been linked to outcomes such as allow an opportunity for support, communication, leadership, employees reporting high levels of positive interpersonal and teamwork. Some organizations have developed meetings that working relationships, teamwork and retention, as well as allow workers to share the good things that happen each month, health and well-being (Schoo, 2008). Such information should with additional discussion of what resources may be lacking to be an eye opener for managers when considering the level of adequately meet the needs of their job requirements (Fessele, 2008). training they are providing to their supervisors. Innovative meetings such as these offer an opportunity for workers to increase their sense of team and maintain a vested interest in their personal successes as well as the success of the organization.

Advancement opportunities Workers also report that their own likelihood to remain with their opportunities for advanced training to further develop their current employer is a result of opportunities for advancement and skills (Gillham & Ristevski, 2007). ability to transfer into alternate areas or programs to learn and participate in other elements of their field (Westbrook et al., 2006). However, it is then important for organizations to offer opportunities for official advancement into specific promotional Successful managers often employ a strategy that includes positions. While this is a goal for many managers, budget and inquiring with their staff regularly about their career aspirations structure-related issues can create a barrier, which in turn works and plans to achieve them with the addition of challenging against them in efforts of retention. their staff by assigning specialized roles, special projects, and

Page 76 Psychology.EliteCME.com Burnout Many employees experience what is considered burnout, a term involved; negative feelings toward the recipients of their often used to refer to the experience of long-term exhaustion services; or reduced personal accomplishment with a tendency and diminished interest. A personal definition of burnout is the to minimize the self-evaluation of their own work (Westbrook process of becoming less effective in your level of performance et al., 2006). In the human service field of child welfare, where because of the level of workload responsibilities, work the intrinsic value of wanting to make a difference plays environment, or length of time conducting the same tasks. an important role in employee retention (Goodwin, 2009), compassion fatigue is often linked to these professionals being Feelings of burnout may increase if sense of accomplishment required to participate in complex tasks combined with existing is no longer part of people’s work experience. Dr. Mary policy and procedures (Warman & Jackson, 2007). Byrne (2006) conducted a study that assessed the resilience of 467 publicly employed child protective social workers, Work-life balance is an important element to combat burnout. comparing a group using a strengths-based service planning Employees often have to juggle numerous elements of approach with those who used a traditional protective services their personal and professional lives to meet the needs and approach. Within the study, levels of self-efficacy, compassion requirements of both, while retaining their own efforts toward satisfaction, compassion fatigue, burnout, personal competence, personal goals (Fessele, 2008). and personal adaptability measured resilience. Family issues, such as day care schedules not meeting their What particularly stands out from this research is the data and needs; day cares that are closed while the employee’s office analysis on burnout, which finds: remains open; and the unpredictable element of children ●● Burnout was significantly related to being in a direct service becoming ill and needing to return home from school or day role, having a higher caseload and recent trauma. care or go to additional medical appointments from illness, are ●● Lower caseloads appeared to moderate the effects of burnout. examples of situations that lead to worker stress and difficulty ●● Burnout was significantly and inversely related to age maintaining the responsibilities of family versus employment. (younger), to years employed in DSS (fewer years employment), and to lacking a graduate level degree. Recognizing the importance of work-life balance, an innovative ●● Trauma was a highly significant moderator directly on approach was developed by Swedish American Health System burnout; those reporting recent personal trauma revealed in Rockford, Ill., which implemented a concierge service for higher indicators of burnout. (Byrne, 2006). its nursing staff. This program offered assistance to workers in running errands, servicing their cars, or waiting for a repair A variation of burnout is commonly referred to as compassion person to arrive at their home. It also included travel planning, fatigue. Individuals working in the human services field, such dry cleaning, and other services that provided freedom for as a nurse, social worker, or case manager, can feel emotionally workers from having to take time off of work or spend their day exhausted by contact with others and the level of empathy off to accomplish personal tasks (Fessele, 2008).

Employee commitment By the time an employee has completed initial training, the Continuance commitment derives from employees’ perception organization has already dedicated a great deal of resources that leaving the organization would be too costly, both to the person. Clearly, it becomes important to keep the economically and socially. The person may dread the notion of employee around. Especially during times of organizational relocation or the thought of the effort that a new job search would change, understanding the factors that might maintain require. Such an individual might remain with an organization employee commitment has become important to industry and because of the feeling that he or she “has to.” Continuance psychologists (Amiot et al., 2006). commitment has been shown to be either unrelated or negatively related to job performance or citizenship behaviors (Meyer et I/O psychologists have examined work commitment as an al., 2002). In contrast to affective commitment, continuance important determinant of work-related outcomes (Cooper- commitment is related to a more individualistic sense, rather than Hakim & Viswesvaran, 2005). A highly influential framework a group sense, of identity (Johnson & Chang, 2006). emphasizes three types of commitment: affective, continuance, and normative. These are believed to be essential to Normative commitment is the sense of obligation an employee understanding an employee’s level of dedication. feels toward the organization because of the investment the organization has made in the person’s personal and professional Affective commitment refers to the person’s emotional development. If an organization has subsidized a person’s attachment to the workplace. A person with a strong affective education, for example, the employee might feel that she owes it commitment identifies closely with the goals of the organization to her boss to stick around. Normative commitment means being and wants to be a part of it. Affective commitment is associated committed because people feel they “ought to.” Theoretically, with feelings of “we-ness,” of identifying with the group that is a individuals are thought to have a commitment profile that captures person’s workplace (Johnson & Chang, 2006). Individuals with their level of commitment on all three of these dimensions at any strong affective commitment commit to the organization because given point in time (Meyer & Herscovitch, 2001). they want to. Affective commitment is thought to result in more favorable job performance because those high in affective commitment are likely to work harder (Riketta, 2002).

Psychology.EliteCME.com Page 77 Employee performance and performance appraisals People who apply for a job with a large corporation or Job performance is about behaviors that are within the control government agency are often asked to take one or more of the employee and not about results (effectiveness), the standardized tests of personality or mental ability and to costs involved in achieving results (productivity), the results participate in other assessments whose results will help that can be achieved in a period of time (efficiency), or the determine whether the person will fit well into an organization value an organization places on a given level of performance, and has the “right stuff” for the job he or she seeks. effectiveness, productivity or efficiency (utility).

Organizations commonly turn to industrial and organizational To model job performance, researchers have attempted to psychologists to design or conduct these assessment programs, define a set of dimensions that are common to all jobs. Using so one of the main areas of scientific research in I/O psychology a common set of dimensions provides a consistent basis is the development and evaluation of new and better assessment for assessing performance and enables the comparison of devices. performance across jobs.

Job performance represents behaviors employees engage in Performance is commonly broken into two major categories: while at work that contribute to organizational goals. These 1. In-role (technical aspects of a job). behaviors are formally evaluated by an organization as part of 2. Extra-role (non-technical abilities, such as communication an employee’s responsibilities. To understand and ultimately skills and being a good team member). predict job performance, it is important to be precise when defining the term.

Knowledge, skills, abilities, and other characteristics Industrial and organizational assessments are often used defined as the person’s relatively enduring capacities in areas to identify the human attributes necessary for doing jobs such as thinking and physical coordination. successfully. Those attributes are referred to collectively as KSAOs, which stands for knowledge, skill, ability, and other Skills and abilities are closely related. Some researchers consider personal characteristics. skills to be the products of inherent abilities (Muchinsky, 2003). Other personal characteristics can be almost anything else Knowledge refers to what the person already knows. Skill about a person, including attitudes, personality traits, physical refers to how well a person does a particular task. Ability is characteristics, preferences, and values.

Job analysis How do organizations know which KSAOs are important service is of great importance (Aguinis, Mazurkiewicz, & for which jobs? The answer lies in job analysis, in which I/O Heggestad, 2009). psychologists collect information about particular jobs and job requirements. This job analysis information is then used to A job analysis report can be a relatively superficial description, guide decisions about whom to hire and what kind of training is a microscopically detailed examination, or anything in between. needed to succeed at a particular job (Brannick & Levine, 2002; The approach taken and the level of detail included in a job Krause & Thornton, 2009). analysis depend mainly on how the report will be used.

There are three major approaches to job analysis: When the analysis will guide the hiring of employees, it should 1. Job-oriented approach. contain enough detail to make it clear what a particular job 2. Person-oriented approach. requires and to show in a court of law, if necessary, how the 3. Personality-oriented approach. selection process is related to the requirements established by the job analysis. The person-oriented approach is the most The job-oriented approach focuses on the tasks involved in useful one for this purpose because it describes the KSAOs that doing a job, such as wiring circuit boards, creating a computer the employer should be looking for in the new employee. database, or driving a truck. Job analysis can also help organizations recognize the need to The person-oriented approach focuses on the KSAOs needed train employees, and it can even outline the kind of training to do those job tasks. required. Suppose that you have five job openings, but when you test candidates for hiring or promotion, too few of them The personality-oriented approach focuses on the specific possess the KSAOs that a job analysis says are necessary for personality characteristics associated with success in a job. success in these positions. Obviously, some training will be needed, and because the job analysis lists specific KSAOs, you Most job analyses take either the job-oriented or person- can use that analysis to determine exactly what the training oriented approach, but the personality-oriented approach is should include. often used by organizations in which high-quality customer

Page 78 Psychology.EliteCME.com Imagine that a job analysis reveals that people in a computer as they do their jobs or even perform those jobs themselves sales position must be familiar with the Linux operating (Dierdorff & Wilson, 2003). system. As a result, you would provide Linux training for all individuals hired for that position unless they already knew that If the goals of job analysis include comparing one job to operating system. another, I/O psychologists might use an instrument such as the Position Analysis Questionnaire, or PAQ (McCormick, The most common method of job analysis is to ask current Jeanneret, & Mecham, 1972). The 189 items on the PAQ employees to fill out questionnaires about what they do in the can describe almost any job in terms of a particular set of workplace. However, a somewhat more reliable picture may characteristics, or dimensions, such as the degree to which a job emerge when specially trained job analysts observe people involves communicating with people, lifting heavy objects, or doing mental arithmetic.

Measuring employee characteristics I/O psychologists use a wide variety of instruments to measure (Lievens, Peeters, & Schollaert, 2008; Salter & Highhouse, a person’s knowledge, skill, ability, and other characteristics. 2009). Tests of job-relevant knowledge, such as basic These instruments range from simple paper-and-pencil tests accounting principles or stock trading rules and regulations, to several days of hands-on activities that simulate the tasks may also be used to confirm that an individual has the required of a midlevel manager. Some assessments are used to information necessary to succeed at a particular job. select new employees, others are designed to choose employees for promotion, and still others are meant to determine how well Finally, personality tests are used to assess a wide variety of employees are doing their jobs at the moment. other employee characteristics. Some of these tests provide information about personality dimensions that may be The three main methods to measure employee characteristics are: relevant to hiring decisions. For example, a person’s score on 1. Psychological tests. conscientiousness (i.e., reliability and industriousness) has been 2. Job applicant interviews. linked to job performance in many occupations (Dudley et al., 3. Assessment center exercises. 2006; Meyer, Dalal, & Bonaccio, 2009; Thoresen et al., 2003).

A psychological test is a systematic procedure for observing Personality-related integrity tests are sometimes used to behavior in a standard situation and describing it on a number identify people who have tendencies that might lead them scale or a system of categories (Anastasi & Urbina, 1997). to steal or engage in dangerous or disruptive acts (Berry, Some tests present a standardized series of problems or Sackett, & Wiemann, 2007; Casillas et al., 2009; Ones & questions, each of which has one correct answer, much like the Viswesvaran, 2001). These are usually paper-and-pencil tests multiple-choice exams used in some college classrooms. that ask respondents about their thoughts or temptations on theft, their perceptions of norms on dishonesty, their own social Others are more like essay exams in which the respondent is conformity, and their history of associating with delinquents asked to, say, describe an ideal sales organization. These essay- (Wanek, Sackett, & Ones, 2003). type exams are not scored by a computer but by experts who use job analysis information and their own job experience to Job applicant interviews are designed to determine an judge the correctness or quality of the responses. applicant’s suitability for a job. Interviews usually take place in person, though some are conducted by telephone, Still other tests require the respondent to demonstrate skill by videoconferencing, or even e-mail. Interviews can be structured performing a task, such as typing a letter, debugging a computer or unstructured (open-ended). program, repairing a car, or giving a sales talk. In a structured interview, the interviewer has prepared a list These tests are relatively inexpensive and easy to administer, of specific topics or even specifically worded questions to be and they do a reasonably good job of predicting how well covered in a particular order (Chapman & Zweig, 2005). In people will do on a wide variety of occupational tasks (Bertau, unstructured interviews, the course of the conversation is more Anderson, & Salgado, 2005; Jansen & Vinkenburg, 2006; Rooy spontaneous and variable. et al., 2006). Following some interviews, especially structured interviews, In addition, job applicants might be asked to participate in the candidate’s responses will be rated on a set of dimensions situational judgment tests (SJTs) in which they read about or such as product knowledge, clarity of expression, and poise. view videos of various workplace situations, such as a conflict After other interviews, the interviewer’s subjective impression between coworkers. The applicants are then asked to rate of the candidate is used to make a yes-or-no judgment about the which of several responses to that situation would be best or candidate’s suitability for the job. to describe what they would do if confronted with that same situation (Sackett & Lievens, 2008). Research consistently shows that structured interviews are far more effective than unstructured interviews in leading to good The information provided by SJTs supplements cognitive and hiring decisions (e.g., Huffcutt & Arthur, 1994). The difference personality tests and provides an additional perspective from is due largely to the fact that structured interviews focus which to predict an applicant’s eventual job performance specifically on job-related knowledge and skills, especially

Psychology.EliteCME.com Page 79 interpersonal skills, whereas unstructured interviews do not Assessment centers are often used to hire or promote managers, (Huffcutt et al., 2001). Further, lack of structure makes it easier but they can be employed for other positions as well. for personal bias to enter the hiring picture. A typical assessment center consists of two to three days of Ratings from an unstructured interview might have more to exercises that simulate various aspects of a job and that are rated do with the interviewer’s personal bias about the candidates’ by a team of judges, usually psychologists or specially trained appearance and presentation style than with the candidates’ managers (Gibbons & Rupp, 2009; Spychalski et al., 1997). objective qualifications (Barrick, Shaffer, & DeGrassi, 2009). Because assessment centers allow live observation of applicants’ reactions in a variety of realistic work situations, they provide There is some evidence that job candidates tend to prefer information about specific aspects of behavior that might not interview-based assessments over test-based assessments. emerge from a test or an interview (Gibbons & Rupp, 2009). This preference is of interest, especially when competing for top candidates, because those who have positive views of the The “in-basket” is a typical assessment center exercise for selection process are more likely to like the organization and to managers. Candidates are seated at a desk and asked to imagine accept a job offer (Hausknecht, Day, & Thomas, 2004). that they have just taken over a new management job. On the desk is the previous manager’s overflowing in-basket, containing Assessment centers are an extensive set of exercises designed correspondence, memos, phone messages, and other items. to determine an individual’s suitability for a particular job.

Measuring job performance Almost all employees of medium to large organizations receive The appraisals are also used to give employees feedback on the an annual job performance appraisal, which, much like a quality and quantity of their work (Rynes, Gerhart, & Parks, student’s report card, provides an evaluation of how well they 2005). The feedback function of job performance appraisals is are doing in various aspects of their work. Organizations use job important because it helps employees recognize what they are performance appraisals to guide decisions about employee salary doing right and what they need to do differently to reach their raises and bonuses and about retention, promotion, and firing. own goals and to promote the goals of the organization.

Establishing performance criteria One of the most important roles for I/O psychologists in a particular teacher is actually promoting student learning. designing job performance appraisal systems is to establish Therefore, there is a need for an actual criterion, which criteria, or benchmarks, that define what the organization specifies what we should measure to determine whether the means by “good” or “poor” performance. These criteria can theoretical criterion has been met. An actual criterion for good be theoretical or actual. A theoretical criterion is a statement teaching might be defined in terms of students’ performance of what we mean by good or poor performance in theory. A on a standardized test of what their teacher has taught them. If, theoretical criterion for good teaching, for example, might be on average, the students reach or exceed a particular score, the “promotes student learning.” teacher will have satisfied one of the school district’s criteria for good teaching. This criterion certainly sounds reasonable, but notice that it does not specify how we would measure it to decide whether

When do employment tests make the most sense? Employees affect an organization’s performance and profitability. needed. However, some tests do require more time up-front Hiring or promoting people who are unsuitable costs time, with individuals to determine who is and who isn’t qualified. money, and potential new business. Carefully developed and In these cases, tests can still result in savings from not administered employment tests can provide organizations with a training and compensating individuals whose productivity way to decide systematically and accurately which people have would be low or who would not remain on the job. the ability to perform well on the job, will not turn over, won’t ●● The costs of making a wrong decision are high. For certain engage in counterproductive behaviors, or will be able to learn employment decisions, a wrong decision can be very costly from training programs. Tests can also benefit individuals who in terms of training costs, errors made by a poor performer, are better matched to positions for which they are suited and in costs of replacement and so on. For these types of decisions, which they will wish to remain. investing in testing may be seen as a particularly worthwhile endeavor if testing reduces the number of wrong decisions. Some of the more commonly cited reasons for testing are: ●● The job requires attributes that are hard to develop or ●● Testing leads to savings in the decision-making process. change. Tests are often used for assessing characteristics Employment tests can be a cost-effective way to pare down that cannot be developed through training but are acquired the applicant pool. Tests can make the decision process more over long periods of time or even a lifetime (personality efficient because less time is spent with individuals whose traits, in-depth knowledge of a profession). characteristics, skills, and abilities do not match what is

Page 80 Psychology.EliteCME.com ●● Hard-to-get information can be obtained more easily and because of the unfairness of less standardized processes efficiently. One important advantage of using employment in which individuals are not all treated in a similar way, tests is that they can often provide information about an and similar information is not gathered on all individuals. individual that is not easily obtained using other methods, or Subjective biases can easily creep into decisions if the that would be much more costly to obtain by other means. process for making decisions is unstandardized. ●● Individuals are treated consistently. Using standardized ●● There are a lot of applicants. Sometimes the sheer number tools in employment decision-making ensures that the same of individuals to consider for an employment decision leads information is gathered on each individual and used in a an employer to choose testing as the most efficient and fair similar way in decisions. Employers often turn to testing means of making a decision in a timely manner.

Reasons for not testing Some of the most commonly cited reasons for not testing are: the ability to make valid inferences based on test scores. If ●● Costs. While tests vary in their costs (i.e., developing adverse impact does occur, it is important to demonstrate that customized tools costs more than purchasing off-the-shelf the inferences made based on test scores are appropriate. By products, extensive assessments typically cost more), the doing this, a company has the data to support the use of the cost of testing may be easily offset when considering costs test. U.S. case law and guidelines have clearly established of low productivity, errors, retraining times, and turnover. that well-developed and validated tests can withstand legal For example, conservative estimates of the cost of turnover scrutiny. Employers should have clear documentation on any range from one-third to one-half of the annual salary of tools they use in employment decision-making. the employee that is being replaced. The costs of replacing ●● Practical constraints. Tests may not be the best choice if management, executive and highly skilled talent can easily not many individuals are being considered in a particular be 1-2 times the annual incumbent’s salary. Further, the costs employment decision, if the resources to properly associated with hiring a wrong employee who makes mistakes administer the test are not available, or if the timing and can be quite high. Testing can be a valuable investment for logistics of the decision-making process preclude the use of organizations to make in hiring and retaining talent. an appropriate test. ●● Fear of legal action. Sometimes concerns are raised about ●● The current decision-making process would not be the legality of using tests in hiring. As with any other method improved upon by the addition of a test. Employers may of making employment decisions, tests can be scrutinized if believe they already have a quality decision-making process there is a belief that discrimination in employment decisions in place and a test would simply add costs and time with has occurred. Adverse impact exists when the selection rate no gain in decision accuracy. Often, however, this belief of a given demographic group (e.g., females vs. males, whites has not been well-assessed, because organizations do not vs. blacks) is substantially lower than the selection rate of always track the information necessary to actually evaluate the majority group. While any selection procedure may show how well their employment decision-making processes are score differences that result in exclusionary effects upon a working. A proper evaluation of a decision-making process group, some types of tests (e.g., physical ability, cognitive may reveal room for improvement, and often a test is a cost- ability) are more likely to show such score differences. effective and efficient way to improve the process.

Despite these differences, these tests are often accurate Tests are useful decision-making tools in employment contexts. predictors of job performance and other outcomes of Deciding whether a test is the right solution in a given situation interest. Before using a test, it is important to anticipate may require professional advice from someone with knowledge whether adverse impact might occur and to consider ways of both testing and employment situations. Industrial- that minimize any exclusionary effects while preserving organizational psychologists may be helpful in such a situation.

Conclusion Industrial and organizational psychology studies behavior in This is beneficial because it increases employee morale and business to find solutions to problems and discover important security, which, in turn, increases efficiency of employees and information about an organization. It has been developing over the organization. And that increased efficiency will allow an many years, and the use of it is invaluable to an organization. organization to also provide better customer service and increase the organization’s success financially (Britt & Jex, 2008). Determining solutions to common workplace problems can be made easier using organizational psychology. Changes and Understanding how individuals and groups behave in an transitions benefit from this type of research because information organizational setting can help predict outcomes of situations and knowledge gained through organizational psychology can as well as provide valuable information about influencing the ease transition and make changes occur smoothly. It also helps workforce. companies save money and increase stakeholder value because the information provided through these studies can help an Industrial psychology is more likely to use quantitative organization run effectively and efficiently. methods in studies more often than qualitative studies, while organizational psychology is more likely to use qualitative methods, such as interviews and focus groups.

Psychology.EliteCME.com Page 81 Two topics often addressed by I/O psychologists are leadership I/O psychologists use a wide variety of instruments to measure and motivation. Leaders’ actions often carry more weight than a person’s knowledge, skill, ability, and other characteristics. the actions of others within an organization because they have These instruments range from simple paper-and-pencil tests greater responsibility and also are in more visible positions. to several days of hands-on activities that simulate the tasks Leaders are the ones who can set the tone, create the plan, and required of a midlevel manager. Some assessments are used to demonstrate to their followers the appropriate (or inappropriate) select new employees, others are designed to choose employees way to behave. They are the ones held accountable, and for promotion, and still others are meant to determine how well the critical decisions fall into their laps. Therefore, leaders’ employees are doing their jobs at the moment. approach to motivating workers or their team is a critical element in the effectiveness of an organization. The three main methods to measure employee characteristics are: 1. Psychological tests. In the workplace, employee motivation can be the foundational 2. Job applicant interviews. factor in an organization’s level of success in obtaining goals. 3. Assessment center exercises. Increased motivation in the workplace typically means improved performance, increased productivity and revenue and profits, The scientific study of organizational psychology helps an improved morale, and organizational stability. No matter how organization understand the behavior of individuals and groups efficient technology and equipment may be, it is no match for in an organization. An organization can use organizational the effectiveness and efficiency of an organization’s staff. psychology to increase efficiency and effectiveness, and this will increase its success. Processes such as employee recruitment, selection, retention, training, and performance appraisals are also key elements in From research, motivation, and leadership to employee selection, the success of an organization. Industrial and organizational retention, and training, I/O psychology covers a vast realm of psychologists are often brought in to organizations to assess workforce issues. As this field of psychology continues to grow such processes, identify strengths and needs, and facilitate the and develop, its approaches and beliefs may have to change to process of change to try to improve such elements with leaders meet the needs of the ever-changing economy and job market, and managers. though additional research and findings can only lead to potential for improved outcomes for organizations and individuals.

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Psychology.EliteCME.com Page 83 Industrial/Organizational Psychology Final Examination Questions Select the best answer for each question and proceed to Psychology.EliteCME.com to complete your final examination.

11. I/O psychology began to develop in the 19th century from 19. One reason that happy workers are more likely to be high an idea to study and measure: performers is that they are less likely to show ______. a. Human capabilities and motives. a. Emotion. b. Business performance measures. b. Job withdrawal. c. Conscious and subconscious memory. c. Their discontent. d. Human development and health outcomes. d. Retaliation.

12. A ______is an empirical study used to estimate the 20. ______give employees a chance to describe the causal impact of an intervention on its target population. training they would like to have. a. Observational study. a. Performance improvement plans. b. Survey study. b. Quality improvement plans. c. Quasi-experiment. c. Personal development plans. d. Literary research study. d. Training plans.

13. A ______believes that people are motivated by 21. ______is an extremely distressed psychological the rewards (or punishment) they receive for their work. state in which a person experiences emotional exhaustion a. Transactional leader. and little motivation for work. b. Transformational leader. a. Stress. c. Strength-based leader. b. Burnout. d. Authoritarian leader. c. Depression. d. Work fatigue. 14. ______managers motivate performance by exerting control and threatening punishment. 22. The optimal experience of a match between our skills and a. Theory X. the challenge of a task is known as: b. Theory Y. a. Flow. c. Situational. b. Synergy. d. Charismatic. c. Knowledge. d. Wisdom. 15. ______is how controlled and emotionally stable a person is. 23. ______refers to a person’s emotional attachment a. Extroversion. to the workplace. b. Openness. a. Employee commitment. c. Agreeableness. b. Emotional commitment. d. Neuroticism. c. Affective commitment. d. Emotional leadership. 16. ______defines changes in power in terms of the relationship between leaders and followers over time. 24. Knowledge, skills, and abilities are the ______believed a. Social exchange theory. to be necessary for doing jobs successfully. b. Follow the leader theory. a. Traits. c. Corporation change theory. b. Characteristics. d. Social change theory. c. Qualities. d. Attributes. 17. Which theory attempts to describe how power is distributed among various subunits, or departments, in an organization? 25. ______are an extensive set of exercises designed a. Social exchange theory to determine an individual’s suitability for a particular job. b. Strategic contingencies theory. a. Personality tests. c. Maslow’s Hierarchy of Needs Theory. b. Assessment centers. d. Adult learning theory. c. Learning paths. d. Training courses. 18. Job satisfaction is related to______. a. Lower job turnover. b. Lower absenteeism. c. Lower health premiums. d. A and B. PYMA10IO14

Page 84 Psychology.EliteCME.com Chapter 4: The Returning U.S. Veteran of Modern War: Background Issues, Assessment and Treatment 3 CE Hours

By: Brett Litz, PhD. and Susan M. Orsillo, PhD. Edited For Continuing Education by: Kathryn Brohl, MA, LMFT, Lynn Thomas, MSW and Rene’ Ledford, MSW,LLSW,BCBA

Learning objectives ŠŠ Identify the form and course of adaptation to war zone ŠŠ List the important areas of functioning to evaluate returning stressors. veterans. ŠŠ Describe the kinds of war zone stressors soldiers are ŠŠ Describe the characteristics of combat fatigue casualties and confronted with in modern war. combat stress reactions. ŠŠ Identify how veterans of modern war initially present post- ŠŠ List the combat stress reactions of acute stress disorder and involvement symptoms. post-traumatic stress disorder. ŠŠ Describe how to assess the presenting symptoms of the ŠŠ Describe the basic considerations for care for returning modern war veterans. veterans. ŠŠ Compare and contrast conventional mental health treatment ŠŠ List the practitioner issues that may surface as a result of vs. treatment for modern war soldiers. working with modern war veterans. ŠŠ State the course of treatment for active duty soldiers vs. veterans seeking health care.

Introduction It is safe to assume that all soldiers are impacted by their 3. What might be beneficial for veterans of modern war who experiences in war. For many, surviving the challenges of request clinical services? war can be rewarding, maturing, and growth-promoting (e.g., greater self-efficacy, enhanced identity and sense of The material below provides an initial schematic so that mental purposefulness, pride, camaraderie, etc.). Conversely, the health professionals including clinicians in the Department of demands, stressors, and conflicts of participation in war can Veterans Affairs (VA) can begin to appreciate the experience of also be traumatizing, spiritually and morally devastating, and soldiers returning from war. Rather than a definitive road map, transformative in potentially damaging ways, the impact of it is a starting place. which can be manifest across the veteran’s lifespan. Needless to say, each veteran will have a highly individualized This course will share useful information for addressing the and personal account of what happened to him/her and what he following questions: or she experienced or witnessed in war. Each veteran will also 1. What are the features of modern war that may significantly reveal a unique set of social, psychological, and psychiatric impact the quality of life, well-being, and mental health of issues and problems. At the end of the day, the most important returning veterans? initial needs of returning veterans are to be heard, understood, 2. What are important areas of functioning to evaluate in validated, and comforted in a way that matches their personal returning veterans? style. Every war is unique in ways that cannot be anticipated. There is much to be learned by listening carefully and intently.

The form and course of adaptation to war zone stressors The psychological, social, and psychiatric toll of war can The immediate interval refers to psychological reactions and be immediate, acute or chronic. These time intervals reflect functional impairment that occur in the war zone during battle periods of adaptation to severe war zone stressors that are or while exposed to other severe stressors during the war. The framed by different individual, contextual, and cultural features, immediate response to severe stressors in the war zone has had and unique additional demands, which are important to many different labels over many centuries (e.g., combat fatigue); appreciate whenever a veteran of war presents clinically. the label combat stress reaction is currently used most often. However, this is somewhat a misnomer. As discussed in this course, direct combat exposure is not the only source of severe

Psychology.EliteCME.com Page 85 stress in a war zone. The term war zone stress reaction carries When they are able, officers routinely use post-battle “debriefing” more meaning and is less stigmatizing to soldiers who have to allow soldiers to vent and share their emotional reactions. difficulties as a result of their experiences other than direct The theory is that this will enhance morale and cohesion and life-threat from combat. It should be underscored that being fired reduce “battle fatigue.” Even if soldiers manifest clear and upon is only one of the many different severe war zone stressors. unequivocal signs of severe war zone stress reactions that affect their capacity to carry out their responsibilities, attempts are In the war zone, soldiers are taxed physically and emotionally made to restore the soldier to duty as quickly as possible by in ways that are unprecedented for them. Although soldiers are providing rest, nourishment, and opportunities to share their trained and prepared through physical conditioning, practice, experiences as close to their units as possible. The guiding and various methods of building crucial unit cohesion and principal is known as Proximity - Immediacy - Expectancy buddy-based support, inevitably, war zone experiences create - Simplicity (PIES). Early intervention is provided close to a demands and tax soldiers and unit morale in shocking ways. soldier’s unit, as soon as possible. Soldiers are told that their In addition, the pure physical demands of war zone activities experience is normal and they can expect to return to their should not be underestimated, especially the behavioral and unit shortly. They are also provided simple interventions to emotional effects of circulating norepinephrine, epinephrine counteract “fatigue” (e.g., “three hots and a cot”). All that said, and cortisol (stress hormones), which sustain the body’s alarm some combat environments do not allow for “debriefing” and reaction (jitteriness, hypervigilance, sleep disruption, appetite “three hots and a cot,” due to conditions such as sniper fire suppression, etc.). In battle, soldiers are purposely taxed so and harsh combat terrain. The point here is that soldiers who that they can retain their fighting edge. In addition, alertness, experience severe war zone stress reactions will hopefully have hypervigilance, narrowed attention span and so forth are received some sort of special care. features that have obvious survival value. On the other hand, it is without question stigmatizing for Enlisted soldiers, non-commissioned officers and officers soldiers to share fear and doubt and to reveal signs of reduced are trained to identify the signs of normal “battle fatigue” as capacity. This is especially true in the United States modern, well as the signs of severe war zone stress reactions that may all- volunteer military with many soldiers looking to advance incapacitate military personnel. However, the boundary line their careers. Thus, it is entirely possible that some veterans between “normal” and “pathological” response to the extreme who present at VA medical centers will have suffered silently demands of battle is fuzzy at best. and may still feel a great need not to show vulnerability because of shame.

Combat fatigue casualties It should be noted that a very small percentage of soldiers combatants are young and that during the late teens and early actually become what are known as combat fatigue casualties. 20s is a time when vulnerable individuals with family histories (However, this may be due to under-reporting.) Research of psychopathology (or other diatheses) are at greatest risk for on Israeli soldiers has revealed that severe war zone stress psychological decompensation prompted by the stress of war. reactions are characterized by variability between soldiers and As a result, a very small number of veterans of the modern war liability of presentation within soldiers. The formal features of may present with stress-induced severe mental illness. severe incapacitating war zone stress reactions are: ●● Restlessness. For soldiers who may be in a war zone for protracted periods ●● Psychomotor deficiencies. of time, with ongoing risks and hazards, the acute adaptation ●● Withdrawal. interval spans the period from the point at which the soldier ●● Increased sympathetic nervous system activity. is objectively safe and free from exposure to severe stressors ●● Stuttering. to approximately one month after return to the U.S., which ●● Confusion. corresponds to the one-month interval during which acute ●● Nausea. stress disorder (ASD) may be diagnosed, according to DSM- ●● Vomiting. IV. This distinction is made so that a period of adaptation can ●● Severe suspiciousness and distrust. be identified that allows clinicians to discern how a soldier is doing psychologically following the opportunity to recover However, because soldiers will vary considerably in the form naturally and receive rest and respite from severe stressors. and course of their decompensation as a result of exposure to Otherwise, diagnostic labels used to identify transient extreme stress, military personnel are prone to use a functional distress or impairment may be unnecessarily pathologizing, definition of combat fatigue casualty. For commanders, the stigmatizing and inappropriate because they are confounded by defining feature is that the soldier ceases to function militarily ongoing exposure to war zone demands and ongoing immediate as a combatant, and acts in a manner that endangers himself stress reactions. Typically, in the acute phase, soldiers are in or herself and his or her fellow soldiers. If this kind of their garrison (in the U.S. or overseas) or serving a security or severe response occurs, soldiers may be evacuated from the infrastructure-building role after hostilities have ceased. battle area. Finally, clinicians should keep in mind that most

Page 86 Psychology.EliteCME.com Acute stress disorder (ASD) symptoms The symptoms of ASD include three dissociative symptoms abuse, aggressive behavior problems, and the spectrum of (Cluster B), one re-experiencing symptom (Cluster C), marked severe mental illnesses precipitated by the stress of war. avoidance (Cluster D), marked anxiety or increased arousal Generally, the psychological risks from exposure to trauma (Cluster E), and evidence of significant distress or impairment are proportional to the magnitude or severity of exposure and (Cluster F). The diagnosis of ASD requires that the individual the degree of life-threat and perceived life-threat. The latter is has experienced at least three of the following: particularly pertinent to the war in Iraq, where the possibility ●● A subjective sense of numbing or detachment. of exposure to chemical or biological threats was a genuine ●● Reduced awareness of one’s surroundings. concern. Exposure to chemical or biological toxins can be ●● De-realization. obscure, yet severely alarming before, during and after battle. ●● Depersonalization. ●● Dissociative amnesia. A number of individual vulnerabilities have been shown to moderate risk for PTSD. For example: The disturbance must last for a minimum of two days and a ●● History of psychiatric problems (in particular, depression). maximum of four weeks (Cluster G), after which time a diagnosis ●● Poor coping resources or capacities. of post-traumatic stress disorder (PTSD) should be considered. ●● Past history of trauma and mistreatment increases risk for post-traumatic pathology. Research has shown that there is little empirical justification for the requirement of three dissociation symptoms. Individuals who show particularly intense and frequent Accordingly, experts in the field advocate for consistency symptoms of ASD (particularly, severe hyperarousal) in the between the diagnostic criteria for ASD and PTSD because weeks following trauma are particularly at risk for chronic many individuals fail to meet diagnostic criteria for ASD but PTSD. In addition, the quality and breadth of supports in both ultimately meet criteria for PTSD despite the fact that their the military and civilian recovery contexts (in the military and symptoms remain unchanged. outside the military) and beyond (e.g., in the home) can impact risk for PTSD. People who need intervention most are the ones Unfortunately, there have been insufficient longitudinal studies of that are isolated and cannot get the respite from work, family, adaptation to severe war zone stressors. On the other hand, there and social demands that they may need (or who have additional is a wealth of research on the temporal course of post-traumatic family or financial stressors and burdens), have few secure and reactions in a variety of other traumatic contexts (e.g., sexual reliable outlets for unburdening their experiences, and receive assault, motor vehicle accidents). These studies have revealed little or no validation in the weeks, months, and years following that the normative response to trauma is to experience a range exposure to war trauma. of ASD symptoms initially, with the majority of these reactions remitting in the following months. Generalizing from this Most VA clinicians will interact with veterans of the modern literature, it is safe to assume that although acute stress reactions wars during the chronic phase of adjustment. Nevertheless, are very common after exposure to severe trauma in war, the early assessment of PTSD and other co-morbid conditions majority of soldiers who initially display distress will naturally implicated from exposure to the war is crucial in providing adapt and recover normal functioning in the following months. effective treatment as soon as possible. Although technically Thus, it is particularly important not be unduly pathologizing chronic with respect to time since hostilities ceased, soldiers’ about initial distress or even the presence of ASD. mental health status will be relatively new with respect to their extra-war roles and social context. For example, a soldier might The chronic phase of adjustment to war is well known to VA be newly reunited with family and friends, which may tax mental health practitioners; it is the burden of war manifested coping resources and produce shame and lead to withdrawal. across the lifespan. It is important to note that psychosocial In this context, interventions provided as early as possible will adaptation to war, over time, is not linear and continuous. For still provide secondary prevention of very chronic maladaptive example, most soldiers are not debilitated in the immediate behavior and adaptation. impact phase, but they are nevertheless at risk for chronic mental health problems implicated by experiences during battle. Also, On the other hand, it is important to appreciate that many things although ASD is an excellent predictor of chronic PTSD, it is may have happened to a veteran with steady difficulties through not a necessary precondition for chronic impairment because the immediate and acute phases that color the person’s clinical there is sufficient evidence to support the notion of delayed presentation. For example, a soldier may have been provided PTSD. Furthermore, the majority of people who develop PTSD multiple interventions in the war zone and in the acute phase, did not meet the full diagnostic criteria for ASD beforehand. It such as critical incident stress debriefing (CISD), or pastoral is also important to appreciate that psychosocial and psychiatric counseling or formal psychiatric care. It is important to assess disturbance implicated by war zone exposure waxes and wanes and appreciate the course of care provided and not to assume across the lifespan (e.g., relative to life demands, exposure to that the veteran is first now presenting with problems. It could critical reminders of war experiences, etc.). be that some veterans experienced their attempts to get help and guidance or respite as personal failure and they may have been Post-traumatic stress disorder (PTSD) is one of many different stigmatized, ostracized, or subtly punished for doing so. ways a veteran can manifest chronic postwar adjustment difficulties. Veterans are also at risk for depression, substance

Psychology.EliteCME.com Page 87 What kinds of war zone stressors do modern day soldiers confront? It is important to appreciate the various types of demands, to suffering civilians, and exposure to death and destruction, stressors, and potentially traumatizing events that veterans of the have each been found to contribute to risk for chronic PTSD. It war may have experienced. This will help facilitate communication should also be emphasized that the trauma of war is colored by between clinician and patient and enhance understanding and a variety of emotional experiences, not just horror, terror, and empathy. Although there may be one or two specific traumatic fear. Candidate emotions are sadness about losses, or frustration events burned into the consciousness of returning soldiers that about bearing witness to suffering, guilt about personal actions plague them psychologically, traumatic events need to be seen in or inactions, and anger or rage about any facets of the war (e.g., the context of the totality of roles and experiences in the war zone. command decisions, the behavior of the enemy).

In addition, research has shown convincingly that while exposure Described below are the types of stressful war zone experiences to trauma is a prerequisite for the development of significantly that veterans of the first Persian Gulf War reported as well impairing PTSD, it is necessary but not sufficient. For veterans, as the psychological issues and problems that may arise as a there are a host of causes of chronic PTSD. In terms of war zone result. We assume that many of these categories or themes will experiences, perceived threat, low-magnitude stressors, exposure apply to returnees from the wars in Iraq and Afghanistan.

Preparedness Some veterans may report anger about perceiving that they were what it would be like in the region (e.g., the desert). Some not sufficiently prepared or trained for what they experienced veterans may have felt that they did not sufficiently know what in the war. They may believe that they did not have equipment to do in case of a nuclear, biological, or chemical attack. From and supplies they needed or that they were insufficiently trained a mental health professional’s perspective, veterans who report to perform necessary procedures and tasks using equipment and feeling angry about these issues may have felt relatively more supplies. Some soldiers may feel that they were ill prepared helplessness and unpredictability in the war zone, factors that for what to expect in terms of their role in the deployment and have been shown to increase risk for PTSD.

Combat exposure It appears that the new wars entail more stereotypical exposure bias this may bring to bear when evaluating the significance or to warfare experiences such as firing a weapon, being fired impact of experiences in modern warfare. Namely, clinicians on (by enemy or potential friendly fire), witnessing injury need to be careful not to minimize reports of light or minimal and death, and going on special missions and patrols that exposure to combat. They should bear in mind that in civilian involve such experiences, than the ground war offensive of life, for example, a person could suffer from chronic PTSD as the Persian Gulf War, which lasted three days. Clinicians who a result of a single, isolated life-threat experience (such as a have extensive experience treating veterans of other wars, physical assault or motor vehicle accident). particularly Vietnam, Korea, and WW II should be aware of the Aftermath of battle Veterans of the new wars will no doubt report exposure to the in removing dead bodies after battle. They may have seen consequences of combat, including observing or handling the homes or villages destroyed or they may have been exposed remains of civilians, enemy soldiers, U.S. and allied personnel, to the sight, sound, or smell of dying men and women. These or animals; dealing with prisoners of war; and observing other experiences may be intensely demoralizing for some. It also consequences of combat such as devastated communities is likely that memories of the aftermath of war (e.g., civilians and homeless refugees. Veterans may have been involved dead or suffering) are particularly disturbing and salient.

Perceived threat Veterans may report acute terror and panic and sustained missiles (e.g., SCUD attacks); and friendly fire incidents. anticipatory anxiety about potential exposure to circumstances Research has shown that perceptions of life-threat are powerful of combat, including nuclear (e.g., via the use of depleted predictors of post-war mental health outcomes. uranium in certain bombs); biological; or chemical agents;

Difficult living and working environment These low-magnitude stressors are events or circumstances cultural difficulties, boredom, inadequate equipment, and long representing repeated or day-to-day irritations and pressures workdays. These conditions are obviously non-traumatizing but related to life in the war zone. These personal discomforts or they tax available coping resources, which may contribute to deprivations may include the lack of desirable food, lack of post-traumatic outcomes. privacy, poor living arrangements, uncomfortable climate,

Page 88 Psychology.EliteCME.com Concerns about life and family disruptions Soldiers may worry or ruminate about how their deployment wide variety of positions (increasing their potential exposure to might negatively affect other important life-domains. For combat) significantly change the face of this new generation of National Guard and Reserve troops, this might include veterans. Single parent and dual-career couples are increasingly career-related concerns (e.g., losing a job or missing out on common in the military, which highlights the importance of a promotion). For all soldiers, there may be family-related developing a strong working relationship between the clinician, concerns (e.g., damaging relationships with spouse or children the veteran and his or her family. As is the case with difficult or missing significant events such as birthdays, weddings, and living and working conditions, concerns about life and family deaths). The replacement of the draft with an all-volunteer disruptions can tax coping resources and affect performance in military force and the broadening inclusion of women in a the war zone.

Sexual or gender harassment Some soldiers may experience unwanted sexual touching or these roles. Categories of harassment include indirect resistance verbal conduct of a sexual nature from other unit members, to authority, deliberate sabotage, indirect threats, constant commanding officers, or civilians in the war zone that creates scrutiny, and gossip and rumors directed toward individuals. In a hostile working environment. Alternatively, exposure to peacetime, these types of experiences are devastating for victims harassment that is non-sexual may occur on the basis of gender, and create helplessness, powerlessness, rage, and great stress. In minority, or other social status. This kind of harassment may be the war zone, they are of no less impact. used to enforce traditional roles, or in response to the violation of

Ethno-cultural stressors Minority soldiers may in some cases be subject to various similarity in appearance to the enemy. Also, Arab-Americans stressors related to their ethnicity (e.g., racist remarks). Some may experience conflict between American identity and identity service members who may appear to be of Arab background related to their heritage. Such individuals may have encountered may experience added racial prejudice/stigmatization, such pejorative statements about Arabs and Islam as well as as threatening comments or accusations directed to their devaluation of the significance of loss of life among the enemy.

Perceived radiological biological and chemical weapons exposure Some veterans of the war will report personal exposures to an concerns about potential unknown low-level exposure that may array of radiological, nuclear, biological, and chemical agents chronically affect their health. For some, these perceptions may that the veteran believes he/she encountered while serving produce a hypervigilant internal focus of attention on subtle in the war zone. Given the extensive general knowledge of bodily reactions and sensations, which may lead to a variety of Persian Gulf War illnesses among soldiers (and the public), somatic complaints. there is no doubt that veterans of the new wars will experience

Assessment New veterans of the wars will present initially in a myriad of a plan for how the interactions may proceed over time and how ways. Some may be very frail, labile, emotional, and needing to they might be useful. The goal in each interaction is to make sure share their story. The modal presentation is likely to be defended, the veteran feels heard, understood, respected, and cared for. formal, respectful, laconic, and cautious (as if they were talking Comprehensive assessment will inform case formulation and to an officer). Generally, it is safe to assume that it will be treatment planning. There are many potentially important difficult for new veterans of the wars to share their thoughts and variables to assess when working with a veteran of war: feelings about what happened during the war and the toll those ●● Work functioning. experiences have taken on their mental health. It is important not ●● Psychological symptoms. to press any trauma survivor too soon or too intensely and respect ●● Interpersonal functioning. the person’s need not to feel vulnerable and exposed. ●● Past distress and coping. ●● Recreation and self-care. Clinical contacts should proceed from triage (e.g., suicidality/ ●● Previous traumatic events. homicidality, acute medical problems, and severe family ●● Physical functioning. problems may require immediate attention), screening, formal ●● Deployment-related experiences. assessment, to case formulation/treatment planning, with an emphasis on prioritizing targets for intervention. In all Often, when working with individuals who have been exposed contacts, the clinician should meet the veteran where he or she to potentially traumatic experiences, there is pressure to begin is with respect to immediate needs, communication style, and with an assessment of traumatic exposure and to encourage emotional state. Also, the clinician should provide the veteran the veteran to immediately talk about his or her experiences.

Psychology.EliteCME.com Page 89 However, it is recommended that it is most useful to begin the trauma survivor’s lead in approaching a discussion of trauma the assessment process by focusing on current psychosocial exposure. Clinicians should verbally and non-verbally convey to functioning and the immediate needs of the veteran and to assess their patients a sense of safety, security and openness to hearing trauma exposure, as necessary, later in the assessment process. about painful experiences. However, it is also equally important While we discuss assessment of trauma history more fully below, that clinicians do not urge their patients to talk about traumatic it is important to note here that the best rule of thumb is to follow experiences before they are ready to do so.

Work functioning Work-related difficulties can have a significant impact on from a re-assessment of vocational interest and aptitude. This is self-efficacy, self-worth and financial stability and thus deserve particularly important for veterans that were placed in military immediate attention, assessment, and referral. They are likely occupational specialties (MOS) where very little of their to be a major focus among veterans of war. Part-time military training translates to the civilian job market. And returning employees and Afghan reservists (who make up a significant from the war or discharging from the military in a sluggish proportion of the military presence in the Mideast) face unique economy reduces the potential for the veteran’s ability to be employment challenges post-deployment. Employers vary considered for many jobs, since they have been unable to keep significantly in the amount of emotional and financial support up with technical and other career training. they offer their reservist employees. Some veterans will inevitably have to confront the advancement of their co-workers Clinicians will also encounter veterans who have voluntarily while their own civilian career has stalled during their military or involuntarily ended their military service following their service. While some supportive employers supplement reservist’s deployment. Issues related to this separation may include the reduced military salaries for longer than required, the majority do full-range of emotional responses including relief, anger, sadness, not, leaving many returning soldiers in dire financial situations. confusion and despair. Veterans in this position might benefit from employment-related assessment and rehabilitation services, Employment issues can be a factor even among reservists who including an exploration of career interests and aptitudes, work for supportive employers. Often, the challenges inherent counseling in resume building and job interviewing, vocational in military duty can impact a soldier’s satisfaction with his or retraining, and emotional processing of psychological difficulties her civilian position. Thus, some returning veterans may benefit impeding work success and satisfaction.

Interpersonal functioning Another important area of assessment involves interpersonal of interpersonal functioning over time can ensure that any functioning. Veterans of war hold a number of interpersonal relational difficulties that threaten the well-being of the veteran roles including son/daughter, husband/wife/partner, parent, and are detected and addressed. friend and all of these roles may be affected by the psychological consequences of their military service. A number of factors can Depending on specific personal characteristics of the veteran, affect interpersonal functioning including the quality of the certain interpersonal challenges may be more or less relevant relationship pre-deployment, the level of contact between the to assessment and treatment. For instance, younger veterans, veteran and his or her social network during deployment, and the particularly those who live with their family of origin, may expectations and reality of the homecoming experience. have a particularly difficult time returning to their role as adult children. The process of serving active duty in a war zone is a The military offers some support mechanisms for the families maturing one, and younger veterans may feel as if they have of soldiers, which are aimed at shoring up these supportive made a significant transition to adulthood that may conflict with relationships and smoothing the soldier’s readjustment upon parental expectations and demands over time. return from the war. It can be useful to assess the extent to which a veteran and his or her family have used these services Veterans who are parents may feel somewhat displaced by the and how much they did or did not benefit from such services. caretaker who played a primary role in their child’s life during It is important to note that these services do not always deployment. Depending on their age, the children of veterans extend to non-married partners (of the same or different may exhibit a wide range of regressive or challenging behaviors gender), sometimes leading to a more difficult and challenging that may surprise and tax their returning parent. This normal, homecoming experience. And they are also much more difficult expected adjustment can become problematic and prolonged to access for families that do not live in close proximity to if the veteran is struggling with his or her own psychological military installations where these supports are plentiful. distress post-deployment. Thus, early (and repeated) assessment and early family oriented intervention may be indicated. As with all areas of post-deployment adjustment, veterans may experience changes in their interpersonal functioning Finally, homecoming and subsequent interpersonal functioning over time. It is not uncommon for families to first experience can be compounded if the veteran was physically wounded a “honeymoon” phase of reconnection marked by euphoria, during deployment. Younger families may be particularly less excitement, and relief. However, a period of discomfort, prepared to deal with the added stress of recovery, rehabilitation role confusion, and renegotiating of relationship and roles or adjustment to a chronic physical disability. can follow this initial phase. Thus, repeated assessment

Page 90 Psychology.EliteCME.com Recreation and self-care Participation in recreational activities and engaging in good appear “stoic” and to keep busy in order to control any painful self-care are foundational aspects of positive psychological thoughts, feelings or images they may be struggling with. functioning. However, they are often overlooked in the Thus, a brief assessment of engagement in and enjoyment assessment process. Some veterans who appear to be of recreational and self-care activities may provide some functioning well in other domains may be attending less to important information about how well the veteran is coping these areas of their lives, particularly if they are attempting to post-deployment.

Physical functioning Early assessment of the physical well-being of veterans is critical. careful assessment of symptoms that could indicate more Sleep, appetite, energy level, and concentration can be impaired in significant psychological or physical impairment. Consistent with the post-deployment phase as a result of exposure to potentially good clinical practices, it is important to ensure that a veteran traumatizing experiences, the development of any of a number of complaining of these and other somatic/psychological symptoms physical disease processes or the sheer fatigue associated with be referred for a complete physical examination to investigate any military duty. Clinicians are again charged with the complex task potential underlying physical pathology and to provide adequate of balancing the normalization of transient symptoms with the interdisciplinary treatment planning.

Psychological symptoms Once the clinician gains an overall sense of the veteran’s diminish or avoid their internal experiences of pain by using level of psychosocial functioning, a broader assessment of alcohol or drugs, disordered eating, self-injurious behaviors psychological symptoms, and responses to those symptoms (such as cutting), dissociation and behavioral avoidance of that may be impairing can be useful. However, this process can external reminders or triggers of trauma-related stimuli. Given also be difficult and confusing since a wide range of emotional that a full range of psychological responses may be seen, and and cognitive responses to deployment and post-deployment given that multiple symptoms (and co-morbid disorders) may stressors including increased fear and anxiety, sadness and be present, one challenge to the clinician during the assessment grief, anger or rage, guilt, shame and disgust, ruminations and process is to prioritize targets of potential treatment. A few intrusive thoughts about past experiences, and worries and fears general rules of thumb can be helpful: about future functioning may be expected. Often a good clinical ●● First, one must immediately attend to symptoms that may interview can elicit some information about the most salient require emergency intervention such as significant suicidal symptoms for a particular veteran, which can be supplemented or homicidal ideation, hopelessness, self-injurious behavior with more structured assessment using diagnostic interviews or acute psychotic symptoms. and questionnaires. ●● Second, it is useful to address symptoms that are most disruptive to the veteran (which should be evidenced by a Again, clinicians must use their judgment in responding careful assessment of psychosocial functioning). to transient normal responses to potentially traumatizing ●● Finally, the best way to develop a treatment plan for a veteran events versus symptoms that may reflect the development or with diverse complaints is to develop a case formulation to exacerbation of a psychological disorder. Sometimes assessing functionally explain the potential relationship between the both psychological responses and even responses to those symptoms in order to develop a comprehensive treatment responses can help determine whether some form of treatment plan. Substance abuse, disordered eating, and avoidance is indicated. For instance, veterans may appropriately respond of trauma-related cues may all represent attempts to avoid to the presence of painful thoughts and feelings by crying, thoughts, feelings and images of trauma-related experiences. talking with others about their experiences, and engaging in Thus, developing an intervention that focuses on avoidance other potentially valued activities such as spending time with behavior per se, rather than on specific and diverse symptoms friends and family. However, others may attempt to suppress, of avoidance, may be a more effective treatment strategy.

Past distress and coping In determining the extent of treatment needed for a particular such as deployment to a war zone, although this relationship presenting problem, an assessment of the history of the is not absolute. problem and the veteran’s previous responses to similar stressful experiences is useful. A general sense of pre- Another area worth assessing that can provide a wealth of deployment work and interpersonal functioning along with pertinent information is the veteran’s general orientation toward any significant psychological history can place current distress coping with difficult life events and its potential relationship to in context. A diathesis-stress model suggests that veterans current painful thoughts, emotions and bodily sensations. Many with a history of mental health difficulties can be at increased veterans will enter into their military experience with a flexible risk for psychological problems following a stressful event and adaptive array of coping skills that they can easily bring to bear on their current symptoms. In other cases, veterans may have

Psychology.EliteCME.com Page 91 successfully used coping strategies in the past that are no longer can also get a general sense of how often the veteran generally useful in the face of the current magnitude of their symptoms. uses common coping styles such as stoicism, social support, Coping styles can be assessed with one of a number of self-report suppression and avoidance, and active problem solving. measures. However, through a sensitive clinical interview, one

Previous traumatic events While there is evidence in the literature for a relationship veteran’s lifetime experience with such traumatic events such between repeated lifetime exposure to traumatic events and as childhood and adult sexual and physical abuse, domestic compromised post-event functioning, this relationship may violence, involvement in motor vehicle or industrial accidents, be less evident among veterans who are seen in the months and experience with natural disasters, as well as their immediate following their return from war. However, there may still be and long-term adjustment following those experiences. important clinical information to be gained from assessing a

Deployment-related experiences Obviously, the assessment of potentially traumatizing events exposure assessment methods with openness to hearing and that occurred during deployment will be an important precursor learning from each new veteran’s personal experience. to treatment for many veterans of modern war, particularly for those who struggle with symptoms of re-experiencing, Section 1 of the Deployment Risk and Resiliency Inventory, avoidance/numbing, dissociation, or increased arousal. VA and developed by Daniel and Lynda King and colleagues at the other mental health clinicians can be highly skilled in many of National Center for PTSD, can provide an excellent starting the clinical subtleties involved in this assessment such as: point for the assessment of deployment-related stressors 1. The importance of providing a safe and nonjudgmental and buffers. Items on this measure were derived from focus environment. groups with Persian Gulf veterans, and they provide useful 2. Allowing the veteran to set the pace and tone of the information about some of the newer stressors associated with assessment. contemporary deployments. 3. Understanding the myriad of issues that involve the The inventory describes nine domains of war zone stressors disclosure of traumatic experiences such as shame, guilt, that modern war veterans may have experienced. A careful confusion, and the need by some soldiers to appear resilient assessment of each of these domains can be useful both as a and unaffected by their experiences. starting point for assessing any potential ASD and/or PTSD However, unique deployment stressors accompany involvement and more generally to establish a sense of the potential risk and in each contemporary military action that may be important resiliency factors that may bear on the veteran’s current and to assess. Thus, clinicians need to balance their use of current future functioning.

The treatment of the returning modern war veterans (This section was written by: Josef I. Ruzek, Ph.D., Erika experience in talking about trauma, educating clients and Curran, M.S.W., Matthew J. Friedman, M.D., Ph.D., Fred D. families about traumatic stress reactions, teaching skills of Gusman, M.S.W., Steven M. Southwick, M.D., Pamela Swales, anxiety and anger management, facilitating mutual support Ph.D., Robyn D. Walser, Ph.D., Patrician J. Watson, Ph.D., and among groups of veterans, and working with trauma-related Julia Whealin, Ph.D. Edited by: Kathryn Brohl, M.A., L.M.F.T.) guilt, will all be useful and applicable. The challenges, described below, discuss ways in which treatment of these veterans may It is important that VA, vet center and other mental health differ from the usual contexts of care, and pay specific attention practitioners recognize that the skills and experience they’ve to particular methods and materials that may be relevant to the developed in working with veterans with chronic PTSD will care of the veteran recently traumatized in war. serve them well with those returning from the war. Their

The helping context: Active duty vs. veterans seeking health care There are a variety of differences between the contexts of diagnosis as an organizing principle of mental health care is care for active duty military personnel and veterans normally common in VA. Patients are given DSM-IV diagnoses, and being served in the VA. These differences may affect the way diagnoses drive treatment. This approach may be contrasted practitioners go about their business. First, many veterans will with that of frontline psychiatry, in which pathologization of not be seeking mental health treatment. Some will have been combat stress reactions is strenuously avoided. The strong evacuated for mental health or medical reasons and brought to assumption is that most soldiers will recover, and that their VA, perhaps reluctant to acknowledge their emotional distress responses represent a severe reaction to the traumatic stress of and almost certainly reluctant to consider themselves as having war rather than a mental illness or disorder. According to this a mental health disorder (e.g., PTSD). Second, emphasis on thinking, the “labeling” process may be counterproductive in

Page 92 Psychology.EliteCME.com the context of early care for war veterans. As Koshes (1996) to war. For recently activated National Guard and Reservists, noted, “labeling a person with an illness can reinforce the issues may be somewhat different (Dunning, 1996). Many “sick” role and delay or prevent the soldier’s return to the unit in this population never planned to go to war and so may be or to a useful role in military or civilian life” (p. 401). faced with obstacles to picking up the life they “left.” Whether active duty, National Guard, or Reservist, listening to and Veterans may have a number of incentives to minimize their acknowledging their concerns will help empower them and distress: inform treatment planning. ●● To hasten discharge. ●● To accelerate a return to the family. War veterans entering residential mental health care will have ●● To avoid compromising their military career or retirement. come to the VA through a process different from that experienced by “traditional” patients/clients. If they have been evacuated Fears about possible impact on career prospects are based in from the war zone, they will have been rapidly moved through reality; indeed, some will be judged medically unfit to return several levels of medical triage and treatment, and treated by a to duty. Veterans may be concerned that a diagnosis of PTSD, variety of health care providers (Scurfield & Tice, 1991). Many or even acute stress disorder, in their medical record may harm will have received some mental health care in the war zone (e.g., their chances of future promotion, lead to a decision to not be stress debriefing) that will have been judged unsuccessful. Some retained, or affect type of discharge received. Some may think veterans will perceive their need for continuing care as a sign of that the information obtained if they receive mental health personal failure. Understanding their path to the VA will help the treatment will be shared with their unit commanders, as is building of a relationship and the design of care. sometimes the case in the military. More generally, the returning soldier is in a state of transition To avoid legitimate concerns about possible pathologization from war zone to home, and clinicians must seek to understand of common traumatic stress reactions, clinicians may wish to the expectations and consequences of returning home for the consider avoiding, where possible, the assignment of diagnostic veteran. For example, is the veteran returning: labels such as ASD or PTSD, and instead focus on assessing ●● To an established place in society? and documenting symptoms and behaviors. Diagnoses of ●● To an economically deprived community? acute or adjustment disorders may apply if symptoms warrant ●● To a supportive spouse or cohesive military unit? labeling. Concerns about confidentiality must be acknowledged ●● To a large impersonal city? and steps taken to create the conditions in which veterans will ●● To unemployment? feel able to talk openly about their experiences, which may ●● To financial stress? include difficulties with commanders, misgivings about military ●● To an American public thankful for his or her sacrifice? operations or policies, or possible moral concerns about having participated in the war. It will be helpful for clinicians to know Whatever the circumstances, things are unlikely to be as they were. who will be privy to information obtained in an assessment. The role of the assessment and who will have access to what The deployment of a family member creates a painful void information should be discussed with concerned patients. within the family system that is eventually filled (or denied) so that life can go on. The family assumes that their experiences Active duty service members may have the option to remain at home and the soldier’s activities on the battlefield will be on active duty or to return to the war zone. Some evidence easily assimilated by each other at the time of reunion and that suggests that returning to work with one’s cohort group during the pre-war roles will be resumed. The fact that new roles and wartime can facilitate improvement of symptoms. Although responsibilities may not be given up quickly upon homecoming their wishes may or may not be granted, service members often is not anticipated (Yerkes & Holloway, 1996, p. 31). have strong feelings about wanting or not wanting to return

Learning from Vietnam veterans with chronic PTSD From the perspective of work with Vietnam veterans whose lives in order to minimize family problems, reducing social alienation have been greatly disrupted by their disorder, the chance to work and isolation, supporting workplace functioning, and preventing with combat veterans soon after their war experiences represents use of alcohol and drugs as self-medication (a different focus a real opportunity to prevent the development of a disastrous than addressing chronic alcohol or drug problems). life course. Today, there is more of an opportunity to directly focus on traumatic stress reactions and PTSD symptom reduction (e.g., by helping veterans process their traumatic experiences, by prescribing medications) and thereby reduce the degree to which PTSD, depression, alcohol/substance misuse, or other psychological problems interfere with quality of life. We also have the opportunity to intervene directly in key areas of life functioning, to reduce the harm associated with continuing post- traumatic stress symptoms and depression if those prove resistant to treatment. The latter may possibly be accomplished via interventions focused on actively supporting family functioning

Psychology.EliteCME.com Page 93 Prevent family breakdown At time of return to civilian life, soldiers can face a variety of 1995). The possibility exists that mental health providers can challenges in re-entering their families, and the contrast between reduce long-term family problems by helping veterans and their the fantasies and realities of homecoming (Yerkes & Holloway, families anticipate and prepare for family challenges, involving 1996) can be distressing. Families themselves have been families in treatment, providing skills training for patients stressed and experienced problems as a result of the deployment (and where possible, their families) in family-relevant skills (Norwood, Fullerton, & Hagen, 1996; Jensen & Shaw, 1996). (e.g., communication, anger management, conflict resolution, Partners have made role adjustments while the soldier was parenting), providing short-term support for family members, away, and these need to be renegotiated, especially given and linking families together for mutual support. the possible irritability and tension of the veteran (Kirkland,

Prevent social withdrawal and isolation PTSD also interferes with social functioning. The challenge here into civilian life. Social functioning should be routinely discussed is to help the veteran avoid withdrawal from others by supporting with patients and made a target for intervention. Skills training re-entry into existing relationships with friends, work colleagues, focusing on the concrete management of specific difficult and relatives, or where appropriate, assisting in the development social situations may be very helpful. Also, as indicated below, of new social relationships. The latter may be especially relevant clinicians should try to connect veterans with other veterans in with individuals who leave military service and transition back order to facilitate the development of social networks.

Prevent problems with employment Associated with chronic combat-related PTSD have been high self-esteem, and give opportunities for companionship and rates of job turnover and general difficulty in maintaining friendship. In some cases, clinicians can provide valuable employment, often attributed by veterans themselves to anger help by supporting the military or civilian work functioning and irritability, difficulties with authority, PTSD symptoms, and of veterans, by teaching skills of maintaining or, in the case substance abuse. Steady employment, however, is likely to be of those leaving the military, finding of employment, or one predictor of better long-term functioning, as it can reduce facilitating job-related support groups. financial stresses, provide a source of meaningful activity and

Prevent alcohol and drug abuse The co-morbidity of PTSD with alcohol and drug problems in 2002), is seeing increased use in VA and should be considered veterans is well established (Ruzek, 2003). Substance abuse as a treatment option for war veterans who have substance use adds to the problems caused by PTSD and interferes with key disorders along with problematic traumatic stress responses. roles and relationships, impairs coping, and impairs entry into In addition, for many newly returning war veterans, it will and ongoing participation in treatment. PTSD providers are be important to supplement traditional abstinence-oriented aware of the need to routinely screen and assess for alcohol treatments with attention to milder alcohol problems, and in and drug use, and are knowledgeable about alcohol and drug particular to initiate preventive interventions to reduce drinking {especially 12-Step) treatment. Many are learning as well or prevent acceleration of alcohol consumption as a response about the potential usefulness of integrated PTSD-substance to PTSD symptoms (Bien, Miller, & Tonigan, 1993). For all abuse treatment, and the availability of manualized treatments returning veterans, it will be useful to provide education about for this dual disorder. “Seeking Safety,” a structured group safe drinking practices and the relationship between traumatic protocol for trauma-relevant coping skills training (Najavits, stress reactions and substance abuse.

General considerations of care

Connect with the returning veteran As with all mental health counseling, the relationship between because some traumatic stressors (e.g., body handling, sexual veteran and helper will be the starting point for care. Forming assault) may not involve war fighting as such. Thought needs to a working alliance with some returnees may be challenging, be given to making the male-centric hospital system hospitable however, because most newly-returned veterans may be, as Litz for women, especially for women who have experienced sexual notes, “defended, formal, respectful, laconic, and cautious” and assault in the war zone, for whom simply walking onto the reluctant to work with the mental health professional. Especially grounds of a VA hospital with the ubiquitous presence of men in the context of recent exposure to war, validation (Kirkland, may create feelings of vulnerability and anxiety. 1995) of the veteran’s experiences and concerns will be crucial. Discussion of “war zone,” not “combat,” stress may be warranted Practitioners should work from a patient/client-centered perspective, and take care to find out their current concerns

Page 94 Psychology.EliteCME.com (e.g., fear of returning to the war zone, concerns about having family, concerns about returning to active duty). One advantage been evacuated and what this means, worries about reactions of such an orientation is that it will assist with the development of unit, fear of career ramifications, concern about reactions of of a helping relationship.

Connect veterans with each other In treatment of chronic PTSD, veterans often report that benefit greatly from connection both with each other and with perhaps their most valued experience was the opportunity veterans of other conflicts. Fortunately, this is the strength of to connect in friendship and support with other vets. This is VA and vet center clinicians, who routinely and skillfully bring unlikely to be different for returning war veterans, who may veterans together.

Offer practical help with specific problems Returning veterans are likely to feel overwhelmed with consequences of war deployment may help maintain post- problems related to workplace, family and friends, finances, traumatic stress reactions. Rather than treating these issues as physical health, and so on. These problems will be drawing distractions from the task at hand, mental health practitioners can much of their attention away from the tasks of therapy, and provide a valuable service by helping veterans identify, prioritize, may create a climate of continuing stress that interferes with and execute action steps to address their specific problems. resolution of symptoms. The presence of continuing negative

Attend to broad needs of the person Wolfe, Keane, and Young (1996) put forward several of PTSD, and in some cases, war experiences will activate suggestions for clinicians serving Persian Gulf War veterans emotions experienced during earlier events. Finally, recognition that are also important in the context of present-day war. and referral for assessment of the broad range of physical health They recommended attention to the broad range of traumatic concerns and complaints that may be reported by returning experience. They similarly recommended broad clinical veterans is important. Mental health providers must remember attention to the impact of both pre-military and post-military that increased health symptom reporting is unlikely to be stressors on adjustment. For example, history of trauma places exclusively psychogenic in origin (Proctor et al., 1998). those exposed to trauma in the war zone at risk for development

Methods of care: Overview Management of acute stress reactions and problems faced by care for the war veteran with PTSD will be similar to those recently returned veterans are highlighted below. Methods of provided to veterans with chronic PTSD.

Education about post-traumatic stress reactions Education is a key component of care for the veteran returning symptoms are the result of psychobiological reactions to from war experience and is intended to improve understanding extreme stress and that, with time, these reactions, in most and recognition of symptoms, reduce fear and shame about cases, will diminish. Reactions should be interpreted as symptoms, and, generally, “normalize” his or her experience. responses to overwhelming stress rather than as personal It should also provide the veteran with a clear understanding weakness or inadequacy. In fact, some recent research (e.g., of how recovery is thought to take place, what will happen in Steil & Ehlers, 2000) suggests that survivors’ own responses treatment, and, as appropriate, the role of medication. With to their stress symptoms will in part determine the degree of such understanding, stress reactions may seem more predictable distress associated with those symptoms and whether they and fears about long-term effects can be reduced. will remit. Whether, for example, post-trauma intrusions cause distress may depend in part on their meaning for the person Education in the context of relatively recent traumatization (e.g., “I’m going crazy”). (weeks or months) should include the conception that many

Training in coping skills Returning veterans experiencing recurrent intrusive thoughts Coping skills training is a core element in the repertoire of and images, anxiety and panic in response to trauma cues, and many VA and vet center mental health providers. Some skills feelings of guilt or intense anger are likely to feel relatively that may be effective include: powerless to control their emotions and thoughts. This helpless ●● Anxiety management (breathing retraining and relaxation). feeling is in itself a trauma reminder. Because loss of control is ●● Emotional “grounding.” so central to trauma and its attendant emotions, interventions ●● Anger management, and communication. that restore self-efficacy are especially useful.

Psychology.EliteCME.com Page 95 However, the days, weeks, and months following a return home coping skills training should focus on helping them know how may pose specific situational challenges; therefore, a careful to do the things that will support recovery. It relies on a cycle assessment of the veteran’s current experience must guide of instruction that includes education, demonstration, rehearsal selection of skills. For example, training in communication with feedback and coaching, and repeated practice. It includes skills might focus on the problem experienced by a veteran in regular between-session task assignments with diary self- expressing positive feelings towards a partner (often associated monitoring and real-world practice of skills. It is this repeated with emotional numbing); anger management could help the practice and real world experience that begins to empower the veteran better respond to others in the immediate environment veteran to better manage his or her challenges (see Najavits, who do not support the war. Whereas education helps survivors 2002, for a useful manual of trauma-related coping skills). understand their experience and know what to do about it,

Exposure therapy Exposure therapy is among the best-supported treatments for supplemented by therapist-assigned and monitored self-exposure PTSD (Foa et al., 2000). It is designed to help veterans effectively to the memories or situations associated with traumatization. In confront their trauma-related emotions and painful memories, most treatment settings, exposure is delivered as part of a more and can be distinguished from simple discussion of traumatic comprehensive “package” treatment; it is usually combined with experience in that it emphasizes repeated verbalization of traumatic stress education, coping skills training, and, especially, traumatic memories (see Foa & Rothbaum, 1998, for a detailed cognitive restructuring (see below). Exposure therapy can help exposition of the treatment). Patients are exposed to their own correct faulty perceptions of danger, improve perceived self- individualized fear stimuli repetitively, until fear responses control of memories and accompanying negative emotions, and are consistently diminished. Often, in-session exposure is strengthen adaptive coping responses under conditions of distress.

Cognitive restructuring Cognitive therapy or restructuring, one of the best-validated beliefs (e.g., about perceived lack of preparation or training PTSD treatments (Foa et al., 2000), is designed to help the for war experiences, about harm done to their civilian career, patient review and challenge distressing trauma-related beliefs. about perceived lack of support from civilians). Cognitive It focuses on educating participants about the relationships therapy may also be helpful in assisting veterans to cope with between thoughts and emotions, exploring common negative distressing changed perceptions of personal identity that may be thoughts held by trauma survivors, identifying personal associated with participation in war or loss of wartime identity negative beliefs, developing alternative interpretations or upon return (Yerkes & Holloway, 1996). judgments, and practicing new thinking. This is a systematic approach that goes well beyond simple discussion of beliefs A useful resource is the Cognitive Processing Therapy manual to include individual assessment, self-monitoring of thoughts, developed by Resick and Schnicke (1993), which incorporates homework assignments, and real-world practice. In particular, extensive cognitive restructuring and limited exposure. Although it may be a most helpful approach to a range of emotions designed for application to rape-related PTSD, the methods can other than fear, guilt, shame, anger, and depression that may be easily adapted for use with veterans. Kubany’s (1998) work trouble veterans. For example, anger may be fueled by negative on trauma-related guilt may be helpful in addressing veterans’ concerns about harming or causing death to civilians.

Family counseling Mental health professionals within VA and vet centers have a parenting classes, or training in conflict resolution, will be very long tradition of working with family members of veterans with important with returning veterans. Some issues in family work PTSD. This same work, including family education, weekend are discussed in more detail below. family workshops, couples counseling, family therapy,

Early interventions for ASD or PTSD If modern war veterans arrive at VA medical centers very soon have demonstrated that brief (i.e., 4-5 sessions) individually (i.e., within several days or several weeks) following their administered cognitive behavioral treatment, delivered about trauma exposure, it is possible to use an early intervention two weeks after a trauma, can prevent PTSD in some survivors to try to prevent development of PTSD. Although cognitive- of motor vehicle accidents, industrial accidents, and assault behavioral early interventions have only been developed (Bryant et al., 1998, 1999) who meet criteria for ASD. recently and have not yet been tried with war-related ASD, they should be considered as a treatment option for some returning This treatment is comprised of education, breathing training/ veterans, given their impact with other traumas and consistency relaxation, imaginal and in vivo exposure, and cognitive with what is known about treatment of more chronic PTSD. restructuring. The exposure and cognitive restructuring In civilian populations, several randomized controlled trials elements of the treatment are thought to be most helpful. A

Page 96 Psychology.EliteCME.com recent unpublished trial conducted by the same team compared not appropriate for everyone (e.g., those experiencing acute cognitive therapy and exposure in early treatment of those bereavement, extreme anxiety, severe depression, those with ASD, with results indicating that both treatments were experiencing marked ongoing stressors or at-risk for suicide). effective, with fewer clients dropping out of cognitive therapy. Cognitive restructuring may have wider applicability in that it Bryant and Harvey (2000) noted that prolonged exposure is may be expected to produce less distress than exposure.

Toxic exposure, physical health concerns, and mental health War syndromes have involved fundamental, unanswered questions identifying the full range of contributing problems, patient about chronic somatic symptoms in armed conflicts since the U.S. goals and motivation, social support, and self-management Civil War (Hyams et al., 1996). In recent history, unexplained strategies. A sustained follow-up is recommended. symptoms have been reported by Dutch peacekeepers in Lebanon, Bosnia, and Cambodia; Russian soldiers in Afghanistan and For those with inexplicable health problems, Fischoff and Chechnya; Canadian peacekeepers in Croatia; soldiers in the Wessely (2003) outlined some simple principles of patient/client Balkan war; individuals exposed to the El Al airliner crash; management that may be useful in the context of veteran care: individuals given the anthrax vaccine; individuals exposed to the ●● Focus communication around patients’ concerns. World Trade Center following 9/11; and soldiers in the Gulf War. ●● Organize information coherently. Seventeen percent of Gulf War veterans believe they have “Gulf ●● Give risks as numbers. War syndrome” (Chalder et al., 2001). ●● Acknowledge scientific uncertainty. ●● Use universally understood language. Besides PTSD, modern veterans may experience a range of ●● Focus on relieving symptoms. “amorphous stress outcomes” (Engel, 2001). Factors contributing to these more amorphous syndromes include suspected toxic There is evidence that both cognitive behavioral group therapy exposures, and ongoing chronic exhaustion and uncertainty. (CBGT) and exercise are effective for treating Gulf War illness. Belief in exposure to toxic contaminants has a strong effect on In a recent clinical trial, Donata et al. (2003) reported that symptoms. Added to this, mistrust of military and industry, CBGT improved physical function, whereas exercise led to intense and contradictory media focus, confusing scientific improvement in many of the symptoms of Gulf War veterans’ debates, and stigma and medicalization can contribute to illnesses. Both treatments improved cognitive symptoms and increased anxiety and symptoms. mental health functioning, but neither improved pain. In this study, CBGT was specifically targeted at physical functioning, When working with a recent veteran, the clinician needs to and included time-contingent activity pacing, pleasant activity address a full range of potentially disabling factors: harmful scheduling, sleep hygiene, assertiveness skills, confrontation of illness beliefs, weight and conditioning, diagnostic labeling, negative thinking and affect, and structured problem solving skills. unnecessary testing, misinformation, over-medication, all or The low-intensity aerobic exercise intervention was designed nothing rehabilitation approaches, medical system rejection, to increase activity level by having veterans exercise once per social support, and workplace competition. The provider needs week for one hour in the presence of an exercise therapist, and to be familiar with side effects of suspected toxins so that he independently 2-3 times per week. These findings are important or she can educate the veteran, as well as the potential somatic because they demonstrate that such treatments can be feasibly and symptoms that are related to prolonged exposure to combat successfully implemented in the VA health care system, and thus stressors, and the side effects of common medications. The should be considered for the treatment of modern war veterans provider should take a collaborative approach with the patient, who present with unexplained physical symptoms.

Family involvement in care The primary source of support for the returning soldier is likely a partner and parent. While the returning soldier clearly needs to be his or her family. We know from veterans of the Vietnam the clinician’s attention and concern, help can be extended War that there can be a risk of disengagement from family at to include his or her family as well. Support for the veteran the time of return from a war zone. We also know that emerging and family can increase the potential for the veteran’s smooth problems with ASD and PTSD can wreak havoc with the immediate or eventual reintegration back into family life, and competency and comfort the returning soldier experiences as reduce the likelihood of future more damaging problems.

Outpatient treatment If the veteran is living at home, the clinician can meet with If one or both partners are identifying high tension or levels the family and assess with them their strengths and challenges of disagreement, or the clinician is observing that their goals and identify any potential risks. Family and mental health are markedly incompatible, then issues related to safety need practitioners can work together to identify goals and develop a to be assessed and plans might need to be made that support treatment plan to support the family’s reorganization and return safety for all family members. Couples who have experienced to stability in coordination with the veteran’s work on his or her domestic violence or infidelity are at particularly high risk and in own personal treatment goals. need of more immediate support. When couples can be offered

Psychology.EliteCME.com Page 97 a safe forum for discussing, negotiating, and possibly resolving a family. Even support for issues to be addressed by separating conflicts, that kind of clinical support can potentially help to couples can be critically valuable, especially if children are reduce the intensity of the feelings that can become dangerous for involved and the parents anticipate future co-parenting.

Residential rehabilitation treatment Inpatient hospitalization could lengthen the time returning phone if geographical distance is too great, can offer the family a personnel are away from their families, or it could be an forum for working toward meeting their goals. The potential for additional absence from the family for the veteran who has involving the patient’s family in treatment will depend on their recently returned home. It is important to the ongoing support of geographic proximity to the treatment facility. Distance can be the reuniting family that clinicians remain aware that their patient a barrier, but the family can still be engaged through conference is a partner and parent. Family therapy sessions, in person or by phone calls, or visits as can be arranged.

Pharmacotherapy

Pharmacologic treatment of acute stress reactions Pharmacological treatment for acute stress reactions (within When a decision has been made to use medication for acute stress one month of the trauma) is generally reserved for individuals reactions, rational choices may include benzodiazepines, anti- who remain symptomatic after having already received brief adrenergics, or antidepressants. Shortly after traumatic exposure, crisis-oriented psychotherapy. This approach is in line with the brief prescription of benzodiazepines (4 days or less) has been the deliberate attempt by military professionals to avoid shown to reduce extreme arousal and anxiety and to improve medicalizing stress-related symptoms and to adhere to a sleep. However, early and prolonged use of benzodiazepines is strategy of immediacy, proximity, and positive expectancy. contraindicated, since benzodiazepine use for two weeks or longer has actually been associated with a higher rate of subsequent PTSD. Prior to receiving medication for stress-related symptoms, the war zone survivor should have a thorough psychiatric and medical Although anti-adrenergic agents including clonidine, guanfacine, examination, with special emphasis on medical disorders that can prazosin, and propranolol have been recommended (primarily manifest with psychiatric symptoms (e.g., subdural hematoma, through open non-placebo controlled treatment trials) for hyperthyroidism), potential psychiatric disorders (e.g., acute stress the treatment of hyperarousal, irritable aggression, intrusive disorder, depression, psychotic disorders, panic disorder), use of memories, nightmares, and insomnia in survivors with chronic alcohol and substances of abuse, use of prescribed and over-the- PTSD, there is only suggestive preliminary evidence of their counter medication, and possible drug allergies. It is important to efficacy as an acute treatment. Of importance, anti-adrenergic assess the full range of potential psychiatric disorders, and not just agents should be prescribed judiciously for trauma survivors PTSD, since many symptomatic soldiers will be at an age when with cardiovascular disease due to potential hypotensive effects, first episodes of schizophrenia, mania, depression, and panic and these agents should also be tapered, rather than discontinued disorder are often seen. abruptly, in order to avoid rebound hypertension. Further, because anti-adrenergic agents might interfere with counter In some cases, a physician may need to prescribe psychotropic regulatory hormone responses to hypoglycemia, they should not medications even before completing the medical or psychiatric be prescribed to survivors with diabetes. examination. The acute use of medications may be necessary when the patient is dangerous, extremely agitated, or Finally, the use of antidepressants may make sense within four psychotic. In such circumstances, the patient should be taken weeks of war, particularly when trauma-related depressive to an emergency room; short-acting benzodiazepines (e.g., symptoms are prominent and debilitating. To date, there has been lorazepam) or high-potency neuroleptics (e.g., Haldol) with one published report on the use of antidepressants for the treatment minimal sedative, anticholinergic, and orthostatic side effects of acute stress disorder. Recently traumatized children meeting may prove effective. Atypical neuroleptics (e.g., risperidone) criteria for acute stress disorder who were treated with imipramine may also be useful for treating aggression. for two weeks experienced significantly greater symptom reduction than children who were prescribed chloral hydrate.

Pharmacologic treatment of post-traumatic stress disorder Pharmacotherapy is rarely used as a stand-alone treatment for PTSD. SSRIs appear to be effective for all three PTSD symptom PTSD and is usually combined with psychological treatment. clusters in both men and women who have experienced a variety Findings from subsequent large-scale trials with paroxetine have of severe traumas. They are also effective in treating a variety of demonstrated that SSRI treatment is clearly effective both for co-morbid psychiatric disorders, such as major depression and men in general and for combat veterans suffering with PTSD. panic disorder, which are commonly seen in individuals suffering with PTSD. Additionally, the side effect profile with SSRIs is We recommend SSRIs as first-line medications for PTSD relatively benign (compared to most psychotropic medications) pharmacotherapy in men and women with military-related

Page 98 Psychology.EliteCME.com although arousal and insomnia may be experienced early on for sedation need to be monitored. Patients should not be abruptly some patients with PTSD. discontinued from anti-adrenergics.

Second-line medications include nefazadone, TCAs, and MAOIs. Despite suggestive theoretical considerations and clinical Evidence favoring the use of these agents is not as compelling findings, there is only a small amount of evidence to support the as for SSRIs because many fewer subjects have been tested at use of carbamazepine or valproate with PTSD patients. Further, this point. The best evidence from open trials supports the use of the complexities of clinical management with these effective nefazadone, which like SSRIs, promotes serotonergic actions and anti-convulsants have shifted current attention to newer agents is less likely than SSRIs to cause insomnia or sexual dysfunction. (e.g., gabapentin, lamotrigine, and topirimate), which have yet Trazadone, which has limited efficacy as a stand-alone treatment, to be tested systematically with PTSD patients. has proven very useful as augmentation therapy with SSRIs; its sedating properties make it a useful bedtime medication that Benzodiazepines cannot be recommended for patients with can antagonize SSRI-induced insomnia. Despite some favorable PTSD. They do not appear to have efficacy against core PTSD evidence of the efficacy of MAOIs, these compounds have patients. No studies have demonstrated efficacy for PTSD- received little experimental attention since 1990. Venlafaxine and specific symptoms. buproprion cannot be recommended because they have not been Conventional anti-psychotics cannot be recommended for PTSD tested systematically in clinical trials. patients. Preliminary results suggest, however, that atypical There is a strong rationale from laboratory research to consider anti-psychotics may be useful, especially to augment treatment anti-adrenergic agents. It is hoped that more extensive testing will with first- or second-line medications, especially for patients with establish their usefulness for PTSD patients. The best research on intense hypervigilance or paranoia, agitation, dissociation, or brief this class of agents has focused on prazosin, which has produced psychotic reactions associated with their PTSD. As for side effects, marked reduction in traumatic nightmares, improved sleep, and all atypicals may produce weight gain, and olanzapine treatment global improvement in veterans with PTSD. Hypotension and has been linked to the onset of Type II diabetes mellitus.

General guidelines Pharmacotherapy should be initiated with SSRI agents. Patients ineffective medication for 36 weeks, as in this experiment. who cannot tolerate SSRIs or who show no improvement might Therefore, augmentation strategies seem to make sense. benefit from nefazadone, MAOIs, or TCAs. Here are a few suggestions based on clinical experience and pharmacological “guesstimates,” rather than on hard evidence: For patients who exhibit a partial response to SSRIs, one should ●● Excessively aroused, hyperreactive, or dissociating patients consider continuation or augmentation. A recent trial with might be helped by augmentation with an anti-adrenergic agent. sertraline showed that approximately half of all patients who ●● Labile, impulsive, or aggressive patients might benefit from failed to exhibit a successful clinical response after 12 weeks augmentation with an anticonvulsant. of sertraline treatment, did respond when SSRI treatment was ●● Fearful, hypervigilant, paranoid, and psychotic patients extended for another 24 weeks. Practically speaking, clinicians might benefit from an atypical antipsychotic. and patients/clients will usually be reluctant to stick with an

Integrating modern war soldiers into existing specialized PTSD services Service members with stress-related problems may need to classes, conflict resolution, communication skills training), with be integrated into existing VA PTSD residential rehabilitation the exception of identified treatment components. The latter programs or other VA mental health programs. Approaches elements of treatment, in which war veterans will work together, to this integration of psychiatric evacuees will vary, and each will include process, case management, and acute stress/PTSD receiving site will need to determine its own “best fit” model for education groups (and, if delivered in groups, exposure therapy, provision of services and integration of veterans. At the National cognitive restructuring, and family/couples counseling). The Center’s PTSD Residential Rehabilitation Program in the VA thoughtful mixing of returning veterans with veterans from other Palo Alto Health Care System, it is anticipated that modern wars/conflicts is likely, in general, to enhance the treatment war patients/clients will generally be integrated with the rest of experience of both groups. the milieu (e.g., for community meetings, affect management

Practitioner issues Working with modern war veterans affected by war zone ●● Feelings of personal vulnerability. trauma is likely to be emotionally difficult for therapists. It is ●● Feelings of therapeutic inadequacy. likely to bring up many feelings and concerns such as: ●● Perceptions of a lack of preparation for acute care that ●● Reactions to stories of death and great suffering. may affect ability to listen empathically to the patient and ●● Judgments about the morality of the war. maintain the therapeutic relationship (Sonnenberg, 1996). ●● Reactions to patients who have killed.

Psychology.EliteCME.com Page 99 Koshes (1996) suggested that those at greatest risk for strong treating these patients but who actually spend the most time personal reactions might be young, inexperienced staff who are with patients. Regardless of degree of experience, all mental close in age to patients/clients and more likely to identify with health workers must monitor themselves and practice active them, and technicians or paraprofessional workers who may self-care. Managers must ensure that training, support, and have less formal education about the challenges associated with supervision are part of the environment in which care is offered.

Summary and final remarks Individuals join the military for a variety of reasons, from noble The absence of immediate symptoms following exposure to to mundane. Regardless, over time, soldiers develop a belief a traumatic event is not necessarily predictive of a long-term system (schema) about themselves, their role in the military, the positive adjustment. Depending on a variety of factors, veterans military culture, etc. War can be traumatizing not only because may appear to be functioning at a reasonable level immediately of specific terrorizing or grotesque war zone experiences but upon their return home, particularly given their relief at having also due to dashed or painfully shattered expectations and survived the war zone and returned to family and friends. beliefs about perceived coping capacities, military identity, However, as life circumstances change, symptoms of distress and so forth. As a result, soldiers who present for care in VA may increase to a level worthy of clinical intervention. medical centers or through private practice environments may be disillusioned in one way or another. The mental health Even among those veterans who will need psychological practitioner’s job is to gain an appreciation of the veteran’s services post-deployment, ASD and PTSD represent only prior schema about their role in the military (and society) and two of a myriad of psychological presentations that are likely. the trouble the person is having assimilating (incorporating) Veterans of the newer wars are likely to have been exposed war zone experiences into that existing belief system. to a wide variety of war zone stressors that can impact psychological functioning in a number of ways. Typically, in traumatized veterans, assimilation is impossible because of the contradictory nature of painful war zone events. The psychological assessment and treatment of veterans returning The resulting conflict is unsettling and disturbing. Any form of from war is likely to be complicated and clinically challenging. We early intervention or treatment for chronic PTSD entails providing must enter into the assessment process informed about the possible experiences and new knowledge so that accommodation of a new stressors and difficulties that may be associated with service in set of ideas about the self and the future can occur. war zones and open to suspending any preconceived notions about how any given individual might react to their personal experience A variety of factors including personal and cultural during war. It will be important for us to broadly assess functioning characteristics, orientation toward coping with stressors and over a variety of domains, to provide referrals for acute needs, and painful emotions, pre-deployment training, military-related to provide some normalizing, psycho-educational information experiences, and post-deployment environment will shape to veterans and their families in an attempt to facilitate existing responses to modern wars. Further, psychological responses to support networks and naturally occurring healing processes. deployment experiences can be expected to change over time. Repeated assessment over time will best serve our veterans, While mental health professionals within the VA are among the who may experience changing needs over the months and years most experienced and accomplished in assessing and treating following their wartime exposure. chronic combat-related PTSD, veterans of the newer wars can be expected to present unique clinical challenges.

References and Additional Resources

1. Bien, T.H., Miller, W.R., & Tonigan, J.S. (1993). Brief interventions for alcohol 8. Curran, E. (1997). Fathers with war-related PTSD. National Center for PTSD Clinical problems: A review. Addiction, 88, 315-335. Quarterly, 7(2), 30-33. Donta, S.T., Clauw, D.J., Engel, C.C., Guarino, P., Peduzzi, P., 2. Bryant, R.A., & Harvey, A.G. (2000). Acute stress disorder: A handbook of theory, Williams, D.A., et al. (2003). Cognitive behavioral therapy and aerobic exercise for assessment, and treatment. Washington, DC: American Psychological Association. Gulf War veterans’ illnesses: A randomized controlled trial. Journal of the American 3. Bryant, R.A., Harvey, A.G., Basten, C., Dang, S.T., & Sackville, T. (1998). Treatment Medical Association, 289, 1396-1404. of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive 9. Dunning, CM. (1996). From citizen to soldier: Mobilization of reservists. In R.J. counseling. Journal of Consulting and Clinical Psychology, 66, 862-866. Ursano & A.E. Norwood (Eds.), Emotional aftermath of the Persian Gulf War: 4. Bryant, R.A., Sackville, T., Dang, S.T., Moulds, M., & Guthrie, R. (1999). Treating Veterans, families, communities, and nations (pp. 197-225). Washington, DC: acute stress disorder: An evaluation of cognitive behavior therapy and supportive American Psychiatric Press. counseling techniques. American journal of Psychiatry, 156, 1780-1786. 10. Engel, C. (2001). Outbreaks of medically unexplained physical symptoms after 5. Catherall, D. R. (1992). Back from the brink: A family guide to overcoming traumatic military action, terrorist threat, or technological disaster. Military Medicine, 166(12) stress. New York: Bantam Books. Supplement 2, 47-48. 6. Chalder, T., Hotopf, M., Unwin, C, Hull, L, Ismail, K., David, A., etal. (2001). 11. Figley, C. (1989). Helping traumatized families. San Francisco: Jossey-Bass. Prevalence of Gulf war veterans who believe they have Gulf war syndrome: 12. Fischoff, B., & Wessely, S. (2003). Managing patients with inexplicable health questionnaire study. British Medical Journal, 323, 473-476. problems. British Medical journal, 326, 595-597. 7. Curran, E. (1996). Parenting group manual. Menlo Park, CA: National Center for 13. Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: PTSD. Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford.

Page 100 Psychology.EliteCME.com THE RETURNING U.S. VETERAN OF MODERN WAR: BACKGROUND ISSUES, ASSESSMENT AND TREATMENT Final Examination Select the best answer for each question and proceed to Psychology.EliteCME.com to complete your final examination.

26. The immediate response to severe stressors in the war zone 29. A number of factors can affect interpersonal functioning, is most often currently labeled: including: a. Combat fatigue. a. The quality of the relationship pre-deployment. b. Post war syndrome. b. The level of contact between the veteran and his or her c. Combat stress reaction. social network during deployment. d. War zone stress. c. The expectations and reality of the homecoming experience. 27. The guiding principal to restore a soldier to duty as quickly d. All of the above. as possible is known as “PIES,” an acronym that stands for all of the following except: 30. One of the best-supported treatments for post-traumatic a. Proximity. stress disorder (PTSD), designed to help veterans b. Insight. effectively confront their trauma-related emotions and c. Expectancy. painful memories, is: d. Simplicity. a. Cognitive therapy. b. Intervention therapy. 28. Acute stress disorder (ASD): c. Collaborative therapy. a. Is a precondition for chronic impairment. d. Exposure therapy. b. Is linear and continuous. c. Is an excellent predictor of chronic PTSD. d. Is not common after exposure to severe trauma in war.

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Psychology.EliteCME.com Page 101 2014 CE Course for Massachusetts Psychology Professionals Customer Information All 20 Hrs ONLY $ Three Easy Steps to Completing Your License Renewal 55 Step 1: Complete your Elite continuing education courses: 99 Read the course materials and answer the test questions. 99 Submit your final exams along with your payment to Elite online. 99 Complete the course evaluation. To receive credit for your courses completion of the evaluation is mandatory. What if I Still Have Questions? Step 2: Receive your certificate of completion. No problem, we are here to help 99 You will be able to print your certificate immediately. you. Call us toll-free at 1-866- 653-2119, Monday - Friday 9:00 Step 3: Once you have received your certificate of completion you am - 6:00 pm EST or e-mail us can renew your license with the Board of Registration of at [email protected]. Please Psychologists at http://www.mass.gov/ocabr/licensee/ contact us if you have not dpl-boards/py/, or mail in your renewal. You should receive received your certificate within your renewal notice within 90 days of the expiration date. In 7-10 business days. order to avoid late fees, your CE and license renewal must be completed by June 30th.

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Phone: (617) 727-9925 | Fax: (617) 727-1627 Website: www.mass.gov/ocabr/licensee/dpl-boards/py

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