Leadership Behaviors in War andDisasters for Civilian and Military
Populations to Foster Action,
Sustainment, and Recovery
Joshua Morganstein, M.D.
Captain, U.S. Public Health Service
Deputy Director, Center for the Study of Traumatic Stress
Professor & Vice Chair, Department of Psychiatry
School of Medicine, Uniformed Services University
www.cstsonline.org

Disclaimer
The ideas, attitudes, and opinions expressed herein
are my own and do not necessarily reflect those of
the Uniformed Services University, the U.S. Public
Health Service, the Department of Defense, or otherbranches of the U.S. government. I am notendorsing any of the entities or resources mentioned
in this presentation and have no relevant disclosuresor conflicts of interest to report.

ASPECTS OF THE DISASTERENVIRONMENT TO GUIDELEADERSHIP DECISIONMAKING AND BEHAVIORSDisasters
Collide…

Challenges to our Values(caring, equity, justice, connectedness)

NaturalDisaster

Pandemic(Health)(Emer Mgmt.)

Social/Civil
UnrestEconomic
Crisis(LE)(?)

War(military/civilians)(As of May 13, 2022)

https://www.statista.com/chart/26
960/number-of-ukrainianrefugees-by-target-country/

COVID-19 Global Deaths (Jul 22, 2022)

https://www.washingtonpost.com/graphics/2020/world/mapping-spread-new-coronavirus/?no_nav=true&p9w22b2p=b2p22p9w00098

Dimensions of Disasters – War & Pandemics
DIMENSIONWARPANDEMIC

Altered sense of safety

++++

++++

Local & National fear

+++

+++

Prolonged stress

++++

++++

Consequences over time

++++

++++

Community disruptions

+++

+++

Overwhelm health systems

++++

++++

Death

++++

++++

National bereavement

++++

+++

Impact societal infrastructure

++++

++

Intentional++++-Opponent is visible

++++

-

Unpredictable++++Institutional trust loss-++++

Psychological & Behavioral Responses
to War & Disasters
DistressReactions• Sleep difficulties• Decreased Sense of Safety• Physical (Somatic) Symptoms• Irritability, Anger• Distraction, Isolation

Psychiatric
Disorders

Resilience
HealthRiskBehaviors• Depression• PTSD• Anxiety• Complex Grief• Alcohol, Tobacco, Rx meds
• Family Distress• Interpersonal Conflict/Violence• Disrupted Work/Life Balance• Restricted Activities/Travel

Adapted from: Ursano, R., Fullerton, C., Weisaeth, L., & Raphael, B. (2017). Individual and Community Responses to Disasters. In R.
Ursano, C. Fullerton, L. Weisaeth, & B. Raphael (Eds.), Textbook of Disaster Psychiatry (pp. 1-26). Cambridge: Cambridge University Press.

Stress Continuum

Adapted from: Nash WP. US Marine Corps and Navy combat and operational stress continuum model: a tool forleaders. In: Ritchie EC, ed. Combat and Operational Behavioral Health. Fort Detrick, MD: Borden Institute; 2011

Psychological & Behavioral Community Phases

DeWolfe, D. J., & Nordboe, D. J. (Eds.). (2000). Training manual for mental health andhuman service workers in major disasters (2nd ed.). SAMHSA: SAMHSA.

Who is at Risk?
PRE••••••

PRE-EVENT
Socioeconomic Status
Social Support
Training Status
Work Environment
Underlying HealthConditions
Help-Seeking Behaviors

POSTDISASTER

•••
••

EVENT
Duration & Severityof Exposure
Psychological
Identification
Illness
Bereavement
Guilt / Moral injury

Morganstein, J. C., West, J. C., & Ursano, R. J.
(2019). Work-Associated Trauma. In M. B. Riba, S.
V. Parikh, & J. F. Greden (Eds.), Mental Health inthe Workplace (pp. 161–180). Springer
International Publishing.

•••••••RECOVERYLoss of Home & Community
Displacement
Financial Hardship
Social Support LossLow Organizational Support
Poor Leadership
Lack of Rest & Recovery

Norris, F. H., Friedman, M. J., Watson, P. J.,
Byrne, C. M., Diaz, E., & Kaniasty, K. (2002).
60,000 disaster victims speak: Part I. An
empirical review of the empirical literature,
1981-2001. Psychiatry, 65(3), 207–239.

Somasundaram and van dePut (2006). Management ofTrauma in Special Populations
after a Disaster. J Clin
Psychiatry;67(suppl 2):64-73

LEADERSHIP BEHAVIORSTO FOSTER ACTION,SUSTAINMENT & RECOVERYPsychological First Aid (PFA)
Five Essential Elements:
SafetyCalming
Self/Community Efficacy
Connectedness
Hope/Optimism••••••

Analogous to “First Aid”
Population-based“framework”“Do no harm” approach
Resilience-focused
NOT a cure/tx for illness
MAY mitigate illness/dz

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements ofimmediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70(4), 283–315– discussion 316–69.

Leadership Through Walking Around••••••

Walk around, be present, listen to concerns
Engage in protective leadership behaviors
Make time for “face-to-face” activities
Enhance communication and connection
Facilitate team building activities
Pandemic/other factors caused leaders to“hunker down”… creates challenges

Crisis Leadership Behaviors
••
•
•
•

Communicate
Effectively
Encourage SelfCare
Promote Cohesion
Support Emotion
Regulation
Foster PurposeHarms, P. D., Credé, M., Tynan, M., Leon,M., & Jeung, W. (2017). Leadership andstress: A meta-analytic review. The
leadership quarterly, 28(1), 178-194.

•••••

Facilitate HelpSeeking
Encourage Growth
PromoteReintegration
Address Grief
Sustain Morale

Birkeland, M. S., Nielsen, M. B., Knardahl, S., & Heir, T. (2016).
Time-lagged relationships between leadership behaviors andpsychological distress after a workplace terrorist attack. International
Archives of Occupational and Environmental Health, 89(4), 689–697.

Wood, M. D., Walker, T., Adler, A. B., Science, C.
C. O. H., & Jahangiri, K. (2020). Post-Traumatic
Growth Leadership: Mitigating Stress in a HighRisk Occupation. Occupational Health Science.

Communicate Effectively••••••••

Build trust, cohesion, morale
Facilitate risk / threat perception
Influence behaviors & recovery
Say what you know and don’t know
Early, honest, often
Mission, goals, objectives
Anticipate, clarify, normalize
Rituals & symbols
Eyre, A. (1999). In remembrance: post-disaster rituals and symbols.
Austrailian Journal of Emergency Management, (Spring), 23–29.

Reynolds, B. S., & Seeger, M. (2012). Crisis and Emergency Risk
Communication. Centers for Disease Control and Prevention.

Encourage Self-Care•

Personal needs••Family needs••

Safety, clothing, shelter

Stress management••

Sleep, food, waterMedia exposure, calming

Peer support
Adler, A. B., Bliese, P. D., LoPresti, M. L.,
McDonald, J. L., & Merrill, J. C. (2021).
Sleep leadership in the army: A grouprandomized trial. Sleep Health, 7(1), 24-30.

Albott, C. S., Wozniak, J. R., McGlinch, B. P., Wall, M. H., Gold, B. S., &Vinogradov, S. (2020). Battle Buddies: Rapid Deployment of a
Psychological Resilience Intervention for Health Care Workers During
the COVID-19 Pandemic. Anesthesia and analgesia, 131(1), 43-54.

Promote Cohesion
SOCIALTASKCOLLECTIVE

Encourage proximity for teammember interactions

Communicate (mission, goals,objectives, schedules)

Explain and model pride in beinga member of the unit

Practice inclusiveness;
discourage ”out groups”

Train... And train some more… tobuild confidence in team capability

Highlight successes to enhance
sense of pride

Resolve conflict to show teamstrength

Establish incentives and rewards toencourage pursuit of goalsConduct tough training (teamdoes what others shy away from)

Know challenges of yourpeople & share your own

Provide guidance on achieving
goals and feedback on progress

Foster friendly competition
between team elements

Encourage knowing & caring
for people & their families

Cross-train on tasks to enhanceshared understanding / confidence

Build group identity with mottosand symbols

Adapted from: https://juniorofficer.army.mil/16-ways-effective-leaders-build-cohesive-teams-in-the-army/

Anderson, L., Campbell-Sills, L., Ursano, R. J., Kessler, R. C., Sun,X., Heeringa, S. G., . . . Stein, M. B. (2019). Prospective
associations of perceived unit cohesion with postdeployment
mental health outcomes. Depression and Anxiety, 89, 81-11.

Reed-Fitzke, K., & Lucier-Greer, M. (2020). The Buffering
Effect of Relationships on Combat Exposure, Military
Performance, and Mental Health of U.S. Military Soldiers: AVantage Point for CFTs. J Marital Fam Ther, 46(2), 321-336.

Support Emotion Regulation•••••

Anger is common - adaptive vs problematic
Sadness, boredom, shame, griefContagion and impact on morale / cohesion
Breathing, grounding for intense emotions
Focus & regulate to enhance performance•••

Acceptance – what can you control?
Perspective – will it matter 1 wk / mon / yr?
Compartmentalize – “Put it away”
https://www.wrair.army.mil/sites/default/files/202204/Quick_Guide_for_Leaders_Sustaining_Readiness.pdf

Adrian, A. L., Adler, A. B., Thomas, J. L., & Britt, T. W. (2018). Integrating new
soldiers: The role of leaders and unit members. Military Psychology, 1-12.

Foster Purpose•••

Fosters meaning & understandingof individual/shared sacrifices
Connect the present to the future
New York National Guard (4k)following COVID-19 missions•Leaders reminding people of thepurpose of their work a/w:•••

Better health
Better mental healthGreater unit cohesion
Trachik, B., Tucker, R. P., Ganulin, M. L., Merrill, J. C., LoPresti, M. L., Cabrera,O. A., & Dretsch, M. N. (2019). Leader provided purpose: Military leadershipbehavior and its association with suicidal ideation. Psychiatry Research, 112722.

https://www.cstsonline.org/education-andtraining/health-campaigns/leader-support-forservice-members-working-during-covid-19

Facilitate Help-Seeking••••••

Normalize emotions
Encourage getting help early
Remove barriers to care
Avoid perceived punishment
Get help/support for yourself
Leverage family/peer support
McGuffin, J. J., Riggs, S. A., Raiche, E. M., & Romero, D. H.
(2021). Military and Veteran help-seeking behaviors: Role of mental
health stigma and leadership. Military Psychology, 33(5), 332-340.

Hom, M. A., Stanley, I. H., Schneider, M. E., & Joiner, T. E. (2017). A
systematic review of help-seeking and mental health service utilization
among military service members. Clinical Psychology Review, 53, 59-78.

Address Grief
••
•••
•
•

Communicate openly & regularly
Be visible and present
Encourage working together
Anticipate and acknowledge grief
Honor losses; make meaning
Look to the future
Encourage finding a “new normal”
Wright, K. S., Sparacino, L., Bartone, P., Cervantes, R. A., Jr, & Ingraham,L. H. (1987). The human response to the Gander military air disaster: Asummary report (p. 60). Defense Technical Information Center.

IMAGE: https://history.amedd.army.mil/booksdocs/historyofusarmymsc/page374.jpg

Encourage Growth•••

Culture of Learning
What has been gained
Soldiers 4 mon postcombat deployment w/
growth-focused leadersreported:••

Lower PTSD anddepression
Higher unit cohesion,organizational support
Wood, M. D., Walker, T., Adler, A. B., & Crouch, C. L. (2020).
Post-traumatic growth leadership: mitigating stress in a highrisk occupation. Occupational Health Science, 1-20.

AFTER ACTION REVIEW
What wassupposedto happen?

What
actuallyhappened?

AgreedFacts

How canwe learn
from this?

Why wasthere adifference?

SharedOpinions

Stoto, M. A., Nelson, C., Piltch-Loeb, R., Mayigane, L. N., Copper, F., &Chungong, S. (2019). Getting the most from after action reviews to improveglobal health security. Globalization and Health, 15(1), 58.

Promote Reintegration
••
•
•
•
•
•

Transition from prolonged highstress back to “normal life”
Loss of meaning and purpose
Tight knit teams dissolve
Lack of a shared experience
Others don’t understandUsual ”problems” seem trivial
Family expectations collide
Creech, S. K., Hadley, W., & Borsari, B. (2014).
The Impact of Military Deployment andReintegration on Children and Parenting: A
Systematic Review. Professional Psychology:
Research and Practice, 45(6), 452–464.

IMAGE: https://www.newagebd.net/print/article/164281

Danish, S. J., & Antonides, B. J.
(2013). The challenges ofreintegration for service members
and their families. American Journalof Orthopsychiatry, 83(4), 550–558.

https://www.cstsonline.org/assets/media/documents/CSTS_FS_Re
covery_and_Reintegration_for_Healthcare_Workers_Following_C
OVID_19_Surges.pdf

Sustain Morale“Confident and positive state of mind and persistent motivation to engage in theshared purpose of the group, especially during challenging conditions.”

8 Factors Influencing Morale• Cohesion• Esprit de corps• Leadership• Shared purpose/goal• Resilience• Preparedness & training• Discipline• Working conditions
Jones, N., Seddon, R., Fear, N. T.,
McAllister, P., Wessely, S., & Greenberg,
N. (2012). Leadership, cohesion, morale,
and the mental health of UK Armed Forcesin Afghanistan. Psychiatry, 75(1), 49-59.

Negative Impact on Morale• Poor communication, rumors• Mission uncertainty/confusion• Inadequate supplies• Disrespect / harassment / racism• Unresolved interpersonal conflict• Substance abuse• Lack of exercise / boredom• Defeat in combat

Van’t Wout, M. C., & Van Dyk, G. A. J.
(2015). Managing morale on thebattlefield: A psychological perspective.
Scientia Militaria: South African Journalof Military Studies, 43(1), 127-148.

Garrido, M.J.; Muñoz, M.J. (2006) Morale as a Protection Factor against Mission
Related Stress. In Human Dimensions in Military Operations – Military Leaders’
Strategies for Addressing Stress and Psychological Support (pp. 10-1 – 10-20).
Meeting Proceedings RTO-MP-HFM-134, Paper 10. Neuilly-sur-Seine, France:
RTO. Available from: http://www.rto.nato.int/abstracts.asp

Stockdale Paradox“You must never confuse faith thatyou will prevail in the end – which
you can never afford to lose – withthe discipline to confront the most
brutal facts of your current reality,
whatever they might be.”

Thank You