By: Andrew J. Smith, Ph.D.

In the pandemic, frontline responders have been asked to maintain our critical infrastructure- public health, public safety, and educational systems. And the context for doing this has been no picnic to say the least. As singularly horrific as the pandemic has been, it has occurred in a larger context of “cascading collective traumas” (see Cohen-Silver et al., 2020), including racial violence and unrest, political miasma, weaponized social media run amok, and environmental disasters such as California and Oregon wildfires. All this with the dissolution of in-person social connection for most people - a cruel prank being played by the universe that has functionally eroded the pillar of our historic approaches to disaster recovery.

In the fog of war, a clear reality has risen to the top: Our ability to respond to future disasters is built on the resilience of our healthcare, emergency response, law enforcement, and education personnel. Resources for both job performance and self-care are essential, are woefully inadequate at the current time, and do not materialize without hard data that are capable of backing action by politicians and administrators. These are heuristics that have guided our sense of mission in an ongoing study of frontline responders in the pandemic. Whereas we set out to contribute regionally with our study, it quickly evolved into a much larger vision - an evolution that we could not anticipate, but which has been a fascinating and heavy mission to be a part of.

Study Timeline & Evolution. On March 14, 2020, I was skiing the famous champagne powder that Utah is known for, when I observed something unforgettable. What had begun as a busy powder day in the morning was a ghost town by mid-afternoon, despite the “free refills” of snow that fell between each run. Utahns usually go home in the middle of a powder day…said no one ever. This turned out to be the last official day of the ski season anywhere in the Rocky Mountain West, following a trend that was initiated after an early Summit County Colorado outbreak.

That evening, I tuned in really for the first time to the now infamous implosion of the Italian healthcare system, a near surreal scene characterized by overflowing hospitals and death toll. I made a phone call to a friend and emergency medicine physician who would eventually head up a number of COVID initiatives at the University of Utah School of Medicine. Me: “How seriously should I take this?” Dr. Ockerse: “Very. Get ready. It’s coming.”

Soon after, I received a call from a contact at a local fire department in Salt Lake County with a question: “Can you assess our firefighters? We’ve had a rash of folks not showing up for work and folks getting arrested-- DUIs and assaults. We can’t help but think it has something to do with COVID.” The question was connected to my role as director of a clinical/research operation focused on first responder wellness and resilience at the University of Utah. The answer from my end was “of course.”

Within a day, a small working group took shape with collaborators at the Lyda Hill Institute or Human Resilience (Smith, Griffin, Benight) and University of Utah (Wright and Langenecker). The members of the working group brought a well-spring of experience studying resilience during and after some of the worst disasters in recent history—Hurricanes Katrina and Sandy, Oklahoma City Bombings, the Virginia Tech Shootings, to name a few.

Three or four days of around-the-clock work resulted in our construction of an online survey tool to carry out the mission requested by our local fire department. We built the survey using existing resilience theory and evidence - designed to assess and study frontline responders across time. We also designed a paired code-base to strip the data as they came in to be able to serve our priority to provide feedback to participating organizations. Institutional review board approval was gained in a 48-hour turnaround (a minor miracle!). Full steam ahead!

We launched the tool regionally on April 1, 2020 with participating fire and law enforcement agencies, and received about 700 responses nearly instantly. We busied ourselves quickly analyzing these data to provide feedback. This pilot with emergency responders was a true learning ground by which we adapted our methods and worked out the kinks in our code-base.

While we analyzed data, communicated with departments, and refined our study, we began a conversation with a large healthcare system/academic medical center intent on achieving a similar measure. Our survey was launched via an email and endorsement from school of medicine leadership, and the response was pretty astounding: nearly 3,000 healthcare personnel participated in the study.

Invitations to expand our study began to emerge from other parts of the country and world, including healthcare systems and emergency responder agencies in Colorado, Minnesota, Washington, Arkansas, and The Netherlands. One of the invitations that has materialized was with collaborators at Virginia Tech and Wake Forest. Specifically, this group has been interested in studying teacher risk and resilience, and has since collected a sizable sample of teachers (N = 1,285) using our survey and code-base. We continue to provide consultation, quantitative methods support, and guidance to this group.

Findings to-date. Collectively, we are now studying and analyzing samples that include more than 5,000 emergency personnel, healthcare workers, and teachers in various geographic regions in the U.S. Our analyses and research questions to-date have focused on three questions.

First, a utilitarian question: what are the rates of mental health risk? This is of the most basic epidemiologic/public health value, with policy and resource allocation implications. Our study focused on two types of outcomes: traditional pathology variables (PTSD, depression, anxiety), and behavioral outcomes that set the stage for persistent/chronic pathology (alcohol and sleep disruption). Ominous signals have revealed the outline of a shape for the coping and recovery challenges that lay ahead: more than 50% of respondents are “at risk” for at least one stress-related disorder or risk factor, and more than 30% are at risk for at least two disorders.

Second: What are the novel stressors that are associated with increased risk? In particular, we have targeted individual differences that can titrate risk. At least three important findings have been revealed. (a) Having an immunocompromised condition or a household member with an immunocompromised condition in some cases doubled the risk for a stress-related mental health problem. This is the most consistent and powerful risk factor, and one that we have been able to share with organizations who are making priority decisions about vaccinations (e.g., should we prioritize healthcare workers’ family members?). (b) Alcohol abuse was particularly high among individuals in direct care provision roles and those in management roles - a short term coping value with potential long-term health consequences. We have advocated alcohol harm reduction and replacement strategies to prevent chronic disease in this area. (c) Demographic features are associated with risk, including status as female or ethnic minority. These findings likely reflect the acceleration and/or expansion of inequities revealed by the pandemic, and can be leveraged in a larger conversation that has been ongoing.

Third, a question that gets at the heart of informing interventions at individual and public health levels: What are the actionable factors that promote resilience and protect frontline workers from poor mental health outcomes? This is a question that we will be tracking across time, as this is where the true innovation and excitement for our team lies. We have continued to assess these healthcare workers across six time points (monthly through October of 2020), retaining a sizable sample (1,700) that will help to answer important questions about longitudinal risk and resilience drivers. Lines of research that will emerge grounded in this question will include identifying public-health level interventions, burnout and job loss prevention (which catalyze crises for personnel, consumers, and economies alike), and optimizing use of social resources to improve coping and resilience.

Conclusions. Whereas our data are showing a foreboding early picture, this story has yet to be written fully. We are currently living in the midst of the largest natural experiment in risk and resilience that has ever been conducted. Because of the “pandemic” nature of this disaster, more frontline personnel are simultaneously at risk than at any other point in history, defying our current models and means of determining resource allocations. Opportunities for innovative policy, interventions, healthcare system improvements, and identifying and addressing systemic inequities have never been more apparent. And the data from our studies can provide an evidence-based platform on which to build these opportunities.

We’ve learned several lessons through this project. First, our public/private partnerships allowed for close collaboration and trust with fire, law, and healthcare departments. Buy-in from regional organizations was built on the service part of our mission (i.e., we want to provide you with feedback). Often, when I hit the leaver to initiate a study, I spin my wheels to recruit adequately - this was not the case because of our applied mission and trust with local organizations. This is a foundation for effective applied resilience science, and we believe it can be sustained through demonstration of value and efficacy back to public partners. Our commitment to providing feedback allowed us to transcend cynicism associated with perceived “research opportunism” to engaged in collaborative solutions built on a shared mission. Essentially, the organizations viewed their role as part of the larger mission, together.

Our second lesson in this project has been about our spirit of collaboration now and moving forward under the theme of “open access.” Specifically, we designed our tools to be adopted and adapted to other regions of the country and world. We made these tools accessible, for instance, through offering them to national agencies such as the National Center for PTSD. The message that we paired was one of “no strings attached” - that we would provide our knowledge and materials to interested organizations and/or principal investigators to adapt and make their own.

Third, as a research team, we’ve been engaged in our own resilience and coping process through the act of this contribution. Our goal to provide feedback was truly built on our own sense of mission in a moment of high anxiety and helplessness. “What can we contribute in a disaster? Well, we study resilience and disasters, so, we’ll do that!” I would call that in hindsight an “active coping” strategy that guided the workgroup. To me, its these kinds of moments that build a foundation for resilience and coping, that is, when the going got tough, we rose to the challenge.

To date, we have conducted these studies without funding - an area that is critical for our ability to take our data to a truly applied level. Being unfunded initially had a silver lining - we were fast and flexible, and used our regional connections, knowledge, and elbow grease to get this off the ground. However, taking our work further and implementing interventions requires significant financial resources that we hope to earn.

By: Brooks Robinson, Ph.D.

"An article about grants? Skip!” Most people I know see grants as boring, tedious, and sometimes downright excruciating. But that is not always the case, and if you stick with me, I'll tell you about excitement, innovation, and yes, frustration while writing grants to support the Greater Resilience Information Toolkit (GRIT) training program.

I joined the Lyda Hill Institute for Human Resilience as Program Director - Grants Specialist in late January 2020. About a month into the new job, the country was turned upside down by the COVID-19 pandemic. Innovative scientists and clinicians within the Institute rapidly developed and deployed the GRIT community-based resilience training. This virtual training was (and still is!) offered at no cost to the public. Considering GRIT teaches skills and concepts that can be applied by anyone within any community, GRIT truly has the potential for an immense positive impact on mental health in the Colorado Springs community, across the country, and even around the world.

Individuals who took the training agreed. Soon there were calls for tailored and expanded GRIT trainings for groups severely impacted by COVID-19 - educators, healthcare workers, caretakers, first responders, small business owners, etc. This was fantastic! But at the same time, it quickly dawned on the team that help was needed, both in terms of manpower and financial resources. Cue the Grants Specialist!

Now to take a step back, I am a neuroscientist by training and have spent my entire career researching the brain, its incredible functions, and equally devastating dysfunctions. I place mental health among the highest priority issues. Period.

So, we have a great product, immense impact potential, and many groups and foundations across the country mobilizing funds in support of COVID-19 causes. Slam dunk! The grant team and the entire Institute were excited to expand and strengthen the GRIT network, and thereby build human resilience. We started writing grants almost immediately. The first funding requests were for a license to provide SilverCloud digital mental health modules for stress, resilience-building, and sleep. Going along with this, a request to fund GRIT trainings, a GRIT program targeted to military families, and GRIT trainings tailored for community leaders and business were also targeted. In rapid succession, the proposals were not funded. We were surprised, but not deterred. The work continued anyway, GRIT grew, and more grant proposals were prepared over the summer.

My favorite proposal was for a “GRIT Hub” and a mobile GRIT unit. The idea was that some communities in Colorado Springs, many of which were feeling the worst effects of the pandemic physically, mentally, and financially, may not have the technological resources to take advantage of GRIT, or were just not aware of it. We proposed to set up a GRIT Hub in a community center where individuals could access computers to take the GRIT trainings. They would also have access to Institute personnel and other GRIT leaders for support. Additionally, a van with iPads would be mobilized to different locations throughout the city to spread the word about GRIT and bring the trainings to different communities. The project design was a great collaboration between the grant team, GRIT developers, and institute researchers and clinicians. It was a large, ambitious project and everyone was hoping the grant submitted for the Colorado Springs CARES Act would be funded. Alas, it was not to be. An additional proposal for the development of GRIT for caregivers was also not selected for funding around the same time.

Fortunately, two proposals were funded over the summer. The Colorado Department of Public Health and Environment funded the development of a training tailored for healthcare workers called GRIT-4Health and El Paso County Public Health (EPCPH) funded a collaboration termed the El Paso County Method. This project brought together the local chapter of the National Alliance for Mental Illness (NAMI), AspenPointe Mental and Behavioral Healthcare, EPCPH, and the Lyda Hill Institute for Human Resilience to develop a proactive and sustainable mental health crisis response. In another innovative initiative, the El Paso County Method de-silosed these organizations to create not only a local network of mental health support for the current crisis, but also in preparation for all future crises. This initiative, which includes GRIT, aims to build community resilience and to become less reliant on reactionary and temporary crisis responses such as that provided by FEMA.

Two more unsuccessful proposals followed these up including a proposal for a GRIT mobile app, which could immensely help the propagation of GRIT and allow for easy updates and ongoing trainings.

Being frustrated after each of the many unsuccessful proposals, I went back and researched the proposals that were funded. Unsurprisingly, groups and programs offering "immediate needs” such as food, housing, and job assistance were the overwhelming recipients of funding. And who can begrudge the funders for supporting these crucial needs? But as I mentioned before, I am vehement on the importance of mental health, so I was nonetheless frustrated. So now, I want to take a moment to plug mental health and wellness as an issue that needs to be addressed with immediacy. Rates for anxiety, depression, grief, and substance abuse have all skyrocketed in the United States since the onset of the pandemic. This mental health crisis is compounded by reduced social support, disrupted and altered mental healthcare services, and financial hardship. Furthermore, mental illness is not an issue that will magically go away once COVID-19 is tamed. Millions of individuals across the globe will be struggling to recover for years to come. A further spike in suicides, drug-related deaths, and severe mental illness would be debilitating in a time when recovery is needed. Therefore, an effective and readily dispersible method for coping with current stressors and building resilience against those in the future is urgently needed. This is precisely why GRIT is so exciting and why the Lyda Hill Institute for Human Resilience will continue to innovate, distribute GRIT as widely as possible, and yes, doggedly search for funding that facilitates increased impact.