Dementia challenges a salutogenic approach because the GRD headwinds grow stronger as people age and managing day-to-day living becomes physically more trying. People's sensitivity to the environment also becomes greater, especially when there are cognitive and memory losses. Furthermore, as one SRR is eroded (typically comprehensibility with dementia and manageability with ageing generally), the other SRRs are threatened. Take hearing, for instance. When a person becomes particularly hard of hearing, they do not merely lose the ability to hear: their ability to communicate with others diminishes – especially amongst other elderly people with similar losses, and to children who may not be able to compensate with writing and other visual cues. Unchecked, this leads to the distancing of friends and family, a key meaningfulness SRR. Given such circumstances, a person can easily give up. *'Why bother?'* is a question that cuts at the heart of meaningfulness. Because salutogenic dynamics shift with age, this question does not change underlying salutogenic principles, it simply means the SRRs must be reinforced as they are required to work harder.

To get the balance right when dealing with advancing dementia, it is essential to identify and, as far as possible, remove environmental stressors – pathogens, social stressors, and anything else that directly burdens the natural salutogenic resources and counteracts salutogenic interventions. Such stressors include confusing building plans which affect comprehensibility and process-centred models of care (MOCs) that compromise a person's sense of meaningfulness. Salutogenic interventions must be more strident and bespoke to compensate for cognitive decline, through greater support for the SOC generally, and comprehensibility, manageability, and meaningfulness specifcally.

#### **Zeisel's Hope Versus Despair Model**

Zeisel's hope versus despair model (Zeisel, 2020a, b), as shown in Fig. 48.2, is formulated on empirical, praxis-based evidence, gathered over many years. Zeisel and his team charted the health benefts associated with maintaining hope when dealing with dementia, versus the decline that is all but assured when people meet a diagnosis by collapsing into despair. The hope model refects salutogenic principles providing a useful window into how other SRRs fll the gap for persons living with dementia when comprehensibility is challenged and manageability confronted.

The public narrative represented in most media around dementia is one of despair, focusing primarily on what people lose as they live with dementia. Despair is a natural response to learning that you or someone you care about has dementia; the prevalent public narratives about dementia are frightening and inevitably mean a huge change in people's lives. The narrative of despair defnes dementia as having no cure, leading easily to the conclusion that giving up seems like the only thing a person can do until a magic bullet can be found. The completely natural tendency to fall into despair becomes a self-fulflling prophecy: *'if someone I love is*

**Fig. 48.2** Hope versus despair model. (Zeisel, 2020a. Published with permission of © J. Zeisel 2020. All rights reserved)

*going to lose her sense of self, how can I treat her like the person she was?'* This kind of response causes people to simply give up – the opposite action we get from meaningfulness. This very normal attitude represents a lapse into meaninglessness. When meaningfulness is decimated, the illness accelerates triggering many disturbing experiences.

Hope, on the other hand, establishes a positive narrative even when all else appears to be stacked against us. In salutogenic terms, hope flls the void caused by memory-related losses and loss of comprehensibility generally. Hope enables us to maintain (and even foster) the *'dynamic feeling of confdence that one's internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected'* (Antonovsky, 1987: xiii). Hope refects our impulse to live and thrive (meaningfulness) and with it the power to stay present, curious, engaged, and creative. In other words, hope provides a scaffold for meaningfulness, so it is not lost with dementia. Hope functions as a scaffold for comprehensibility, thereby supporting meaningfulness – the impulse to fgure out how to make the most out of life's situations and challenges.

In the hope versus despair model (Fig. 48.2), hope is not a vague notion, wishful thinking, or ungrounded optimism. It is the positive knowledge that each of us can make a difference in our and others' lives: understanding that a dedicated community armed with appropriate design and engaging care programmes can make a positive difference. Counter to despair, hope enables greater confdence, connectedness and well-being. It is little wonder that hope leads to different outcomes than despair. How a person thinks about the future is a major determinant for how their future evolves – it is genuinely a 'self-fulflling prophecy'.

#### **Design Approaches: How They Can Help?**

The built and natural environments can help people live life meaningfully with a true sense of agency until the end. Physical and social environments are not passive elements in life as many since Descartes believe them to be.

Descartes considered the brain an organ to transmit messages from the earthly plane to a detached and ethereal mind. In this view, architecture is an unconnected and passive thing to observe (Descartes, 1641 (tr. 1986)). This idea stuck tenaciously until the Second World War, when psychiatrist Victor Frankl observed that while some people fare reasonably well by maintaining positive social connections, ambitions and outlooks, others deteriorate very quickly in identical aversive circumstances (Frankl, 1963). Frankl's 'natural' experimental conditions were the Nazi concentration camps – Theresienstadt, Auschwitz, Kaufering and Türkheim – where Frankl himself was imprisoned.

Since the 1980s, the idea that the physical environment is a signifcant 'factor' in health has grown, with a slow accumulation of measurable evidence correlating the physical environment with somatic health, mental health, and even spiritual beliefs (Sloan Devlin & Arnell, 2003; Dijkstra, 2009; Ulrich et al., 2008).

Descartes' hypothesis is today an anachronism because most health professionals see the mind housed in the brain connected to the body through a shared nervous and endocrine system. The idea that a person's social network has an impact on their quality of life is now widely accepted, even though health professionals still struggle to understand how to identify useful environmental factors, and even more so with how to 'prescribe' them. That the environment plays a role in health beyond simplistic infuences (like protection from the weather) is growing. Evidence is plentiful that views of nature positively affect a broad range of health outcomes (Bossen, 2010; Clay, 2001; Diette et al., 2003; Hartig et al., 2014; Kaplan & Kaplan, 1989; Larsen, 1992; Ulrich, 1984; Ulrich & Parsons, 1990; Ulrich & Simons, 1986). Although intuitively understood, the aetiology pathways involved are not immediately evident.

One of the brain's principal tasks is to make sense of the world and situations we fnd ourselves in; that is, *to perceive* (de Wit et al., 2017). When we look around, however, there usually is not much that is natural to be perceived; what we largely are faced with is artifcial – the 'designed' environment (Golembiewski, 2016). Perception, as it is moderated by language and visual culture, leads us to perceive according to implied meanings with powerful psychological implications (Moen et al.,1995). Perceptions are also ecological: the very act of perceiving an object is diffcult to extricate from the actions that object inspires (Gibson, 1979). When a person perceives an opportunity to act or think (the 'affordances' the circumstances offer), perceptions trigger an impulse to take associated actions and thoughts (Bargh & Dijksterhuis, 2001). Choice is a cognitive process that slows and inhibits the perception-triggered action/thought process, committing it to memory – if it is inhibited at all (Bargh & Chartrand, 1999). When perceptions lead to uninhibited (or disinhibited) actions (or thoughts), as often occurs with dementia, the ecological perception/action expressway can lead both to memory loss (Golembiewski, 2014) and to reactive behaviours and behaviours that are interpreted as symptoms of dementia (American Psychiatric Association, 2014) as well as an apparently wilful defance of the rules that are intended to keep PLWD safe.

Much of the built environment is designed and constructed for human use. Designed affordances deliberately trigger actions and thoughts. Just about *every* object in a building and its context makes demands of this kind on our perceptual apparatus. An exit door in a place where people live with dementia is *not* an opportunity to *escape*; it is an *invitation* for residents to leave. This is how *the language of design* works. The way affordances like this are created and managed directs the way design makes a difference to people with dementia.

Affordances – physical, aesthetic and sensory – trigger intangible, often emotional, responses: A beautiful woodland or a park with children playing might trigger feelings of joy. A locked door might trigger anger. These responses become more pronounced with the loss of cognitive capacity and advancing disinhibition; thus, PLWD are particularly reactive to the emotional quality, aesthetics, and 'tone' of their environment (Lhermitte, 1986). When an environment is perceived as aversive, PLWD's negative reactions are prone to be stronger. Equally, when an environment is distinctively positive, people with dementia are likely to refect this powerfully.

These dynamics have extraordinary implications for physical design and MOCs, as well as for the way we communicate with people with dementia. Seemingly innocuous choices of design features, innuendo in communication, and other subtle contextual features can elicit strong behavioural reactions. When these reactions are disturbing, they create further pressure on SRRs. Not only might this leave people prone to illness and exacerbate apparent dementia symptoms; these actions can fow through to social interactions and into treatment and management regimens which only make matters worse over the long term. It is one thing to treat individuals for an illness, and another to treat them for reactions to the very environment in which the treatment is taking place!

We can, however, change the direction of treatment by 'treating' both the physical and social environments. That is, to 'treat' the way social interactions are managed by planning them carefully within the model of care (MOC). This includes briefng carers, friends and family to respect the dignity of each PLWD, to engage those receiving care with their own care as much as possible, to rely on PLWD to lead engagement activities employing their natural and life-long skills, and by taking care that the way they and we communicate does not unnecessarily tax memory and other comprehensibility SRRs.

Zeisel's (2009) eight suggested design approaches and positive MOC strategies (Zeisel, 2020b) can be interpreted both as salutogenic interventions and as affordance management. They have been shown in practice to increase wellbeing and decrease dementia 'symptoms' and can easily be understood and enacted within the salutogenic framework. For example, the decision to hide and obscure doorways to areas that are dangerous for PLWD both reduces the need to continually restrict their access to these areas, and also decreases the demands on residents' salutogenic resources required to respond to repeatedly being told to stop using a particular door and adapt to such restrictions. A sign that frustrates residents with dementia saying, *'residents are forbidden to leave through this door'* taxes the comprehensibility SRR. In salutogenic theory, an insurmountable frustration (however minor) leads to deterioration. A door that invites passage, yet is nevertheless labelled impassable, is intrinsically negative. This confict creates an ambiguity which in turn triggers amygdala activity, leading to a cascade of deleterious downstream effects including increased anxiety, psychotic reactions, and hormonal and endocrinal imbalances that even turn into chronic illness (Sapolsky, 2017), none of which helps a person living with dementia.

Perception of negative environments depletes SRRs; conversely, positive perceptions support SRRs and therefore help with dementia. Some researchers point to emerging evidence that dementia may even be reversible – or at least symptoms can be reversed – under positive conditions (Francis & Murtha, 2021). Even if dementia might not currently be curable, like autoimmune disorders, most mental illnesses, and many viruses, the best treatment involves symptomatic relief and appropriate environmental modifcations to make environments better ft the needs of those with the condition (Zeisel, 2009) – in other words, support for the SRRs.

'Challenging behaviours', formerly regarded as symptoms of dementia, are now, in many cases, understood to be responses to physical and MOC stressors – and are more accurately referred to as 'responsive behaviours'. Responsive behaviours in dementia increase when faced with adversity and functional decline. Environmental stressors are strongly implicated – destinations that are around corners, for instance, are quite 'normal' architectural choices.  They force PLWD to try to remember what is around the corner, and therefore rely on spatial memory – a particular challenge in dementia. Similarly, long hallways with no identifying landmarks to signpost activities along the path confuse and offer no guidance for PLWD; common rooms that all look alike make it diffcult to know what is expected in each room; institutional settings make it diffcult for PLWD to feel at home; lack of access to an outdoor garden means it is diffcult for PLWD to feel free and connected to nature; inviting doors to no-go areas and dangerous places mean that PLWD are continually being restricted and chided; when there is no personal space to make their own, PLWD feel a sense of loss; auditory and visual pollution and confusion make it diffcult for PLWD to make sense of where they are; and the absence of aids such as toilets that are high enough to use easily (with weak knees) prevent PLWD from being as independent as they can be.

Removing social stressors, which might be taken for granted in traditional MOCs, leads to more salutogenic alternatives. For example, personalised schedules that respect and adapt to each person's history and habits, in lieu of standardised schedules for getting up in the morning and going to bed at night, reinforces each person's sense of self. A person's comprehensibility SRR is supported when friends, family and carers ask bifurcated questions (e.g. *'Would you like to wear your comfortable shoes or your smart ones today?'* as opposed to *'which shoes do you want to wear today?'*). It helps to provide PLWD answers to questions before asking the question (e.g. *'That's Uncle Evan in the picture, do you know who that is?'*). Embarrassment and other emotional problems can be avoided by refraining from the common habit of testing PLWD with questions like, *'Do you remember me?'* or *'What is the name of that bird over there?'*

From a salutogenic perspective, it is easy to see how poor design choices and communication practices like these break down critical SRRs, creating symptomatology and disability. When the following design approaches are respected, symptoms are passively reduced, SRRs are supported (particularly those related to comprehensibility), resulting in disabilities becoming less apparent and restrictive, with PLWD happier and more positive (Zeisel, 2013).

In the following, photographs are used to bring life to the text because, as they say, a picture is worth a thousand words.

#### **Unobtrusive Control of Exits to Dangerous Places**

To avoid frustration and related behavioural side-effects associated with reduced comprehensibility, it is important to carefully plan affordances and the actions they are likely to trigger for PLWD. Some affordance/action relationships are desirable – such as a door that leads to a person's personal space, or a safe garden. When PLWD exercise such 'choices', their independence as well as their comprehensibility is maintained. Other affordances, however, are undesirable such as when a door leads somewhere risky – to a busy street, into mechanical or electrical rooms or to an unfenced garden. Undesirable affordances such as these need to be made less inviting and, wherever possible, well camoufaged (Fig. 48.3). Memory-taxing, complex locking systems can be added for additional security, typically a numerical keypad somewhere other than by the door – ideally, in a place that directs PLWD away from the exit and towards a destination that offers an attractive and desirable alternative affordance. For complete safety (which is required to provide residents with independence and freedom of movement within a residence), unobtrusive access control of some sort is also needed for external windows and fences (Fig. 48.4). When doors to safe and desirable places look and feel to residents like a front door, are as inviting and are even designed to provide attractive views to what is beyond (a door between a residence and a garden for instance), residents will naturally use that door rather than ones that are less evident and less inviting.

**Fig. 48.3** A door blended into the wall colour, with a keypad around a corner and behind furniture does not communicate 'please enter'. And if PLWD do recognise it as a door, fnding and using the keypad requires memory and sequence – the kind of cognitive processes that challenge PLWD. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.4** An opaque garden fence, obscured by vines, provides security because of its height and the vines which do not speak of an invitation to explore the world beyond. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

J. A. Golembiewski and J. Zeisel

Doors with transparent panes invite PLWD to look out and seek whatever is beyond. When a transparent door is an exit or otherwise leads to somewhere dangerous, the PLWD who try to use it are not attempting to escape – the problem is one of design. The door communicates 'please come through', while the rule says 'NO EXIT'. This is equally the case for doors that have signs on them – any sign at all (whether the sign says 'NO ENTRY' or 'THIS WAY OUT') – indicating that there is a door, which means there is somewhere to go, regardless of what the sign reads.

MOCs that promote continuous personalised engagement and activities for PLWD are complementary to good exit control design. PLWD engaged in interesting and meaningful activities have less desire to leave. Engagement replaces anxiety and the desire to get away (Zeisel, 2020b).

#### **Walking Paths with Clear Destinations**

In his seminal work, Image of the City, Lynch (1960) identifes fve critical elements for wayfnding: paths, edges, districts, nodes and landmarks. Each of us uses these environmental elements as tools to understand our milieus and for wayfnding and orientation – all-important for comprehensibility. For PLWD, these elements are even more important.

When PLWD know where they are and where they are going, they walk with purpose.  Visible destinations – particularly those they enjoy and are interested in – at the end of corridors and paths provide PLWD with purpose and knowledge.

Corners and curves in 'wandering loops' obscure destinations and are confusing. PLWD are encouraged to know where they are going and why, by being provided with 'nodes', (that is, when recognisable and meaningful objects including photographs and furniture from people's own lives and spaces overlap with meaningful activities at destinations). This supports the comprehensibility SRR and, as demonstrated in Figs. 48.5 and 48.6, the other SRRs as well.

Lynch (1960) identifed landmarks as particularly important for orientation. If you are asked to fnd your way from where you are now to your car or back to your home, you will fnd yourself thinking in terms of landmarks – 'turn left at the [landmark] corner store'. Cues along a path and visible destinations serve such a landmark function for PLWD, for whom landmarks need to be more recognisable, regular and meaningful. The result is that in such environments PLWD 'walk' purposefully rather than 'wander' aimlessly. Our curious brains naturally search for purpose and direction. When we are confused about where and why we are someplace, landmarks and destinations provide meaning to this search for purpose.

MOCs that provide attractive engagement opportunities for individual or group activities at visible destinations further support orientation and wayfnding. This MOC intervention also supports the *common space differentiation* design criterion.

#### **Common Space Diferentiation**

Residents, even those living with dementia, are expected to behave socially and appropriately. To achieve this, designers can organise spaces around another of Lynch's basic wayfnding elements – differentiated areas – the residential equivalent of 'districts'. Common space design emphasises 'local' [district] qualities and opportunities for engagement. Interior 'districts' with thematically associated nodes and landmarks combine to create 'behaviour settings'. To an extraordinary extent, the language of behaviour settings determines the acceptable limits of behaviour in an area, especially when people are uninhibited (children) (Barker & Wright, 1954) or disinhibited (a common feature of dementia) (Golembiewski, 2013b). Some common space interior 'districts' might be more sociable, others quieter and more contemplative, others will communicate specifc activities. Kitchens, dining rooms, music rooms and other shared com-

**Fig. 48.5** Memory boxes on walls and a decorated Christmas tree at end of a corridor makes a corridor a meaningful and social space. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.6** Familiar museum portraits, furniture and open doors leading to engagement spaces support the comprehensibility SRR. (Portrait (left): Migrant Mother, Library of Congress, Prints & Photographs Division, FSA/OWI Collection, LC-USF34– 9058-C. Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

mon spaces, designed with the appropriate character, messages and landmarks, communicate and reinforce their intended uses (Figs. 48.7, 48.8, 48.9 and 48.10). Scale, furniture and built-in features and fxtures communicate to residents what is appropriate in these spaces – preparing meals in the kitchenette, serving and eating meals in the dining area, flms on a video screen in the living room, planting seedlings in the greenhouse. When there are two or three such places in a shared residence, each with a different character, residents can choose between clearly different common areas rather than unnaturally spending all day in only one or in more than one of several places that all feel the same.

#### **Private Spaces and Personalisation**

If a person's bedroom – their personal territory – is to support a salutogenic sense of coherence (SOC), it must provide visual and audio privacy. Bedrooms provide an opportunity for refuge and respite. While the need for privacy is the same for all humans, the need is redoubled when people require more time to process sensory and emotional information.

No one's memory is perfect. All of us use cues in our environment to remind us of the memories we want to recall. Papers on the desk remind us to work on something. Leaving our umbrella near the front door reminds us to take it when it rains. We use personal mementoes to remind and reinforce our 'sense of self'; who we are, where we live and work, and what we care about. Items we choose to surround ourselves within our living and work environments sharpen our memories about events and times we consider important. They also communicate to others a sense of who we are. The same is true for people with dementia – only more so, yet unfortunately, institutional residences sometimes remove possibilities for personalisation. The more PLWD are surrounded by photos of family, mementoes from trips, or artwork they have created or collected, the more they remember the people and events involved and the more they are aware of their creativity (Figs. 48.11 and 48.12).

MOCs that respect the identity and abilities of each person support personhood just as personalised private spaces do, for example, when residents are addressed as they wish to be addressed – 'Dr. Watson', 'Bill', 'Mrs. Jones', 'Reverend Judith' and so on*.* It stands to reason that these communication approaches reinforce each individual's sense of self. Care staff who make it a point to be familiar with and purposefully use in conversation a person's personal, family, and professional history, further support personhood and related SRRs.

**Fig. 48.7** Kitchen-like décor as shown here indicates what functions a room serves. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.8** Kitchen-like décor indicates that it is appropriate to wash dishes and set the table there. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.9** Music room. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.10** Hairdresser salon. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

#### **Access to Accommodating Secure Gardens**

In residences for PLWD, gardens are a necessary fourth common area – albeit without a roof. Being outdoors in sunshine sets our diurnal clocks, thereby reducing time disturbances and 'sundowning', a phenomenon where reactive behaviours intensify as the sun sets in the evenings (Gnanasekaran, 2016), when they are reminded 'it is time to go home from work' or 'it is time to plan for evening activities'. To achieve these ends, outdoor areas for

dementia feels comfortable and in control of herself there. **Fig. 48.11** Memory shadow boxes outside residents' rooms. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.12** Personal furniture, photos and mementoes all give the person as well as others who visit a sense of the person as a whole person. (Photograph © J. Zeisel 2005. Published with permission. All rights

reserved)

people with dementia must be safe to use, include imaginative and engaging elements, provide clear direct walking paths with no ambiguous choices, and be secure from potential public dangers beyond the garden such as car traffc (Fig. 48.13).

The more gardens are accessible and inviting, and the more staff understand just how important gardens are, the more people with dementia will get outside and maintain their sense of time and the seasons. In residences for PLWD, garden design and enclosure decisions are intimately linked to the garden's governance which also has to be carefully planned, including decisions such as when the door to the garden is unlocked; who controls the key; and whether residents or staff do the gardening. Decisions like these are ultimately as important for accessibility for PLWD as providing ramps for wheelchairs.

Gardens often serve as the main outside place to which PLWD have ready access (Fig. 48.14). When a garden is truly secure and safe, it can be used independently without a care partner present. Security is essential for staff to feel comfortable leaving the door open and providing access. If security is not 100%, when fences are too low, or if there are attracting views out to parking areas, busy streets, or nearby affordances, staff members who naturally want to protect those in their charge understandably restrict residents' access to a garden except under tight supervision. The more a garden is designed safely and therapeutically, the more the person with

**Fig. 48.13** Landmarks, self-evident walking path, and patio furniture all help defne therapeutic gardens. (Photographs © J. Zeisel 2005. Published with permission. All rights reserved)

**Fig. 48.13** (continued)

**Fig. 48.14** Public parks such as Riverside Park in New York City can provide enough interest to make it a therapeutic garden venue. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

An MOC that encourages freedom of access to the outdoors and nature is also more likely when passive surveillance of the entire garden is possible from inside. To achieve this, carers must be trained to be vigilant to what is happening in the garden – on the lookout for both positive interactions and possible falls or upsets. Even when there is good outdoor access, benefts of gardens can be further enhanced with affordances organised outdoors such as barbeques, family gatherings, playgrounds for children, and harvests that continually remind PLWD about their outdoor spaces.

#### **Nature and Internal Clocks**

The Biophilia Hypothesis (Wilson, 1984) holds that our brains are hard-wired to respond to nature. A baby does not have to be taught to enjoy the warmth of the sun on her skin in the summer or the pleasure of looking at and even caressing a tulip in the spring. Similarly, no one needs to teach us to be afraid and protect ourselves during a ferocious thunderstorm. Being outdoors gives people with dementia the opportunity to use their hard-wired understanding of nature.

A basic and well-accepted principle of design for care environments is to invite sunlight and 'views of nature' into a residence; the effect of nature on health outcomes being amongst the most well-known and evidence-based effects (Hartig et al., 2014). Due to safety concerns, low staff levels, or lack of interest, gardens are too often kept in sight but out of bounds (Golembiewski, 2013a). An inability to access nature while a person is often ambulatory causes frustration, eroding the meaningfulness SRR; such an affordance denial ultimately conficts with our very will to live. Access to these spaces, on the other hand, feeds the same SRR with a sense of joy. When a garden is kept locked, the message of hope that the garden conveys is dashed, leaving a clear message that the person is being restrained and that staff are there to obstruct movement rather than provide help. While views of nature are essential, if a garden is glazed in, yet inaccessible, it may be better if there were no garden at all (Golembiewski, 2010).

#### **Residential Quality**

When the environment is familiar and PLWD personalise their personal space with their objects and mementoes, it helps them feel at home and in control. Rooms of a residential scale, not institutional in scale, homelike furniture and fxtures, and residential rather than institutional decorations and colours all help achieve this end. Families of residents, as well as those care partners working at the residence, must reinforce this message: the residence where PLWD live is residents' *'home'* which staff and visitors must respect. Family and staff understand this best when the environment is designed to look like a home from the outside (the typology might be that of a large family house); and when family members are welcomed and accommodated. Feeling guilty about 'putting parents into a place that looks an institution' may even keep them from visiting or behaving appropriately. The many shifts in life associated with a condition like dementia are disconcerting enough without the physical environment and MOC reminding us of these changes. One of the ways the environment can soothe transitions and 'normalise' new living arrangements is to look like and feel like 'home' whenever possible (Fig. 48.15).

 Most important, however, is the way care partners themselves feel and act – for example, making a habit of knocking on the door of a person's personal space and asking if they might enter, and respecting that the entire residence is 'home' to PLWD and as carers behave as guests rather than entitled users in their workplace.

#### **Comprehensible Sensory Environment**

Residents feel most comfortable in settings where they comprehend what they see, hear, smell, and touch. This does not mean designing environments that match long-term memories, but rather that the messages sent by the colours, sounds, smells, and textures are coherent and multifactorial (Fig. 48.16). Like anyone else, PLWD comprehend their environments through all their senses – sight, feeling, the sense of smell, hearing, and even taste – not just one sense. People in old age (and especially with dementia) are even more reliant on multimodal perception because age and illness weaken sensory perception and cognition unevenly, and alternative modes of perception are used to compensate for these losses. Design can be used to intensify the senses that speak of wholesome normalcy. The greater the coherence amongst sensory inputs, the greater the understanding a person has of their environment.

MOCs that offer a full calendar of special affordances such as celebrations, special foods, and holidays further foster comprehensible engagement. To be most effective, these must be carefully individualised according to the cultures and life narratives of residents. Religious holidays do not have to be the only drivers of such events. Positive emotions can also be summoned with rituals like ceremonially raising a fag in the morning, and bringing it down in the evening (Perkins, 2013).

#### **Support for Independence**

Most of the aforementioned details relate to the comprehensibility and meaningfulness SRRs, but manageability is also signifcant in contributing to a strong SOC. Manageability, closely linked to the degree of a person's independence, is improved by such elements as lean rails along corridor walls, toilets high enough to rise from without help, and chairs with arms to lift oneself by (Fig. 48.17). The failure to provide such simple affordances is akin to restraint. If people with arthritis are put into deep recliner chairs, they require help to get out, and without such help, they may as well be chained in place (The Royal Commission into Aged Care Quality and Safety, 2019). When environmental conditions and MOCs **Fig. 48.15** Family photographs (top), personal furniture and pets (bottom) provide a strong and recognisable sense of 'home'. (Photographs © J. Zeisel 2005. Published with permission. All rights reserved)

support people's use of the capacities they still have, they remain as independent as possible for as long as possible, whether or not they are living with dementia.

To deliver independence-supportive care is not easy because carers tend naturally to balance risks that accompany such independence – the risk of a person catching a cold in the garden when the weather is poor, falling when walking independently, getting upset when they try to do something and then discover they cannot. Rather than restrict activity that might cause such consequences or blankly accept these consequences, care partners must be ready to respond when such setbacks happen – rather than predicting the problem and pre-emptively protecting the PLWD by reducing their independence. This strategy built into the **Fig. 48.16** The smell of recently baked muffns remain a coherent sensory experience for PLWD. (Photograph © J. Zeisel 2005. Published with permission. All rights reserved)

MOC, can even be documented in a shared risk agreement with the PLWD and their families.

#### **Support Verbal Communication with Nonverbal Communication**

When happy and settled, PLWD appear to others quite normal; in many ways, they genuinely are. Unfortunately, this often leads visitors and carers to test the PLWD to check 'how bad' or 'how improved' their condition is. Verbal communication generally can be treacherous for PLWD and is so much worse when someone attempts to plumb the depths of a person's memory loss. PLWD may drift when speaking and attempt to recall specifc memories that are not readily accessible. This can be stressful. Visitors and carers can make communication less stressful by flling unavailable memory gaps with relevant information before asking a question, having a laugh with the person, or ignoring or making light of simple mistakes. Visitors and family who dig in and challenge the PLWD by asking them to remember something specifc on cue set the PLWD up to fail. Typical examples include, *'Do you know who I am?'* or *'Where do you live?'* Such challenges are extremely stressful in salutogenic terms – like pulling the comprehensibility rug from under a person's feet.

Communication is often most effective when multifactorial and supported by contextual aids. For example, visual cues and delicious smells together are better at suggesting it is dinner time than just telling someone to come to dinner. Emotionally salient contextual cues are especially important. The daughter of a PLWD who does not want to create anxiety must not ask, *'Do you remember who I am?'*   Being kind and affectionate also reduces anxiety, which makes remembering easier. Carers, therefore, should be caring (Zeisel, 2009). Similarly, if you know what a PLWD has done in their earlier lives, this can be celebrated with them. When visiting an art gallery with a retired ambassador, for instance, the question, *'What artworks would you select for a new embassy building?'*

#### **Choices, 24 Hours a Day**

Choices of good things to do is a key meaningfulness SRR – it is more than just nice to be offered a choice of good things to do. Throughout our evolutionary history, we have been kept busy much of the time doing what our immediate needs require. But once the grain has been harvested and all other tasks have been completed, we are presented with a rare moment of choice: What would we like to do now? These moments allow us to stop, consider, and dream, engaging the anterior regions of the frontal cortex – an action, which in positive circumstances is strongly associated with health and the development of meaning (Golembiewski, 2012).

**Fig. 48.17** Lean rails along corridor walls provide suffcient support for many residents to walk independently (top); as do walks on public streets, accompanied by care partners, friends, or family members (bottom). (Photographs © J. Zeisel 2005. Published with permission. All rights reserved)

Providing options as to what a person can to do in a residence for PLWD is well within the control of such a residence – and it is an excellent way to foster meaningfulness (Zeisel, 2009).

When elders have trouble sleeping as they often do, choices need to be offered 24 hours per day and be appropriate for the time of day or night. During the day, residents might be offered choices including gardening, cooking, or looking after pets. In the evening, they might choose to dance, watch a movie, or play music. Late at night, they might be offered the choice to watch movie trailers and decide tomorrow's movie programme or a restful activity like drawing.

#### **How Improving the Comprehensibility SRR Supports Manageability and Meaningfulness**

Environmental innovations such as those described above aim specifcally to support the comprehensibility SRR, perhaps the most critical SRR for dementia. But such interventions also support manageability and meaningfulness – the other SRRs. The freedom to move around purposefully, for example, translates as meaningfulness; PLWD empowerment, seen in selfdirected action, is a feature of manageability. Similarly, access to nature and the freedom to garden or enjoy birds and other animals also supports the meaningfulness SRR, not only because of our evolutionary relationship with nature (Wilson, 1984), but also because the stories we associate with such environments are diffcult to perceive as pernicious (Golembiewski, 2017a). Caring for anything (even just for plants) generates meaning (Francis & Murtha, 2021). Being a feld of action, involvement with nature supports manageability. If the plants produce food as a result that PLWD can use themselves or give to visitors, the sense of meaning and manageability is richer still (Golembiewski, 2019).

Family and friendships are critical to meaningfulness; providing engaging affordances for visitors and family are therefore essential. If family and friends feel welcome and have something to do when they visit, the guilty feelings many already have will be reduced, visiting will be more pleasurable, and they may choose to show up more frequently (Golembiewski, 2017b).

With the prison-guard responsibility taken off care partners' shoulders, they can focus their attention on the person rather than on safety and security. This enriched relationship maximises available salutogenic resources, which in turn leads to more intimate and informed person-centred care. Care partners can truly treat PLWD less as 'patients' and more like the people they are.

The more comfortable and settled PLWD are, the less they exhibit the four 'A's of Alzheimer's – anxiety, agitation, aggression, and apathy. Not only does this reduce reactive behaviours, but it may also slow the progressive increase in such reactive behaviours.

In sum, a good place to begin employing salutogenic principles to reinforce the capacities and personhood of PLWD is to include these salutogenic principles and guidelines into environmental design and communications.

#### **Salutogenic Design for Treatment, Not Management**

A primary salutogenic goal of residential facilities is to treat the behaviours that are considered by white-coat medicine as 'symptoms'; to help residents help themselves and contribute to their quality of life. The pivot point lies in a positive approach, focused on how opportunities are offered and perceived: Are they given generously? Are they offered as choices? Are they presented with love, affection, and even drama? Are they associated with fond memories? Or are they presented as obligations obscured with risk-aversion?

Salutogenic healthcare design takes design's contribution to treatment with the same seriousness as safety and functional operational concerns. This point is clearly made in the 2020 Annual Report of Alzheimer's Disease International – Design Dignity Dementia – which emphasises the role of salutogenesis in design for dementia and makes the important distinction between design goals, principles, approaches and design responses (Fleming et al., 2020).

To treat dementias using salutogenic principles means providing an abundance of appropriate and positive choices of things to do, 24 hours a day, gardens that are accessible and productive and so, too, kitchens and bathrooms. Institutions can do better than just being generically homely. A cluster of homes, rooms, or apartments might allow for shared facilities and activities like a steam room, a massage room, a cinema, restaurants instead of dining halls, multisensory rooms, and rooms for music and art – the kinds of things most houses do not have. They can also be far more considered (and research-driven) in bringing appropriate stimulus into bedrooms, dayrooms, courtyards, and other facilities that are offered.

To assess the salutogenic success of a place people living with dementia call home, the degree that the design reinvigorates self-effcacy, self-esteem, power, community activism, righteous anger, optimism, and sense of control over the future must be measured. These salutogenic goals require a commitment to each person's sense of purpose and a signifcant growth of understanding.

Environments make a real difference to healing outcomes with designers increasingly able to achieve this as they continue to learn about salutogenesis and the forces that underlie the salutogenic model. Residents deserve health support when living in residential care. Salutogenesis does this – it supports health. It also does so much more for PLWD, especially in an institutional setting. Salutogenic guidelines keep everyone concerned in lockstep to maximise residents' free will, happiness, and sense of well-being, while at the same time limiting the expression of reactive behaviours. Salutogenesis can be used broadly; not just as a tool for the design of residential homes, but also for designing psychosocial approaches and MOCs to enable people to manage themselves (as much as they can), to invest in residents' sense of agency (in salutogenic theory–comprehensibility) and, most importantly, to help PLWD develop and maintain a sense of meaningfulness.

#### **Bibliography**

*of the design and build of healthcare infrastructure in Australia* (pp. 57–62). International Academy of Design and Health.

based healthcare design. *Health Environments Research & Design Journal*, 1(3), 61–125.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons. org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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**Salutogenesis as a Framework for Social Recovery After Disaster**

**49**

Mélissa Généreux, Mathieu Roy, Tracey O'Sullivan, and Danielle Maltais

#### **Introduction**

The Salutogenic Model of Health is well established in health promotion, and the links between community assets and positive health outcomes are well recognized. Making the link between positive health and salutogenic factors in a disaster context, however, requires more discussion, as the feld of disaster risk reduction (DRR) is often associated with risk and vulnerability and how to protect the population. In this chapter, we discuss how salutogenesis is relevant in disasters and how it can be incorporated into post-disaster recovery strategies to promote resilience. We present a case study from a small community in Quebec, Canada, where a salutogenic approach was used to help the community of Lac-Mégantic in its recovery from a profound tragedy.

#### **What Happened on July 6, 2013, and How Was Public Health Involved Initially?**

On July 6, 2013, in the middle of the night, a train carrying crude oil derailed in the heart of Lac-Mégantic (Quebec, Canada). This municipality has a population of 6000 resi-

M. Roy

CIUSSS de l'Estrie-CHUS; Faculté de médecine et des sciences de la santé, University of Sherbrooke, Sherbrooke, QC, Canada

Quebec National Institute of Public Health, Québec, QC, Canada e-mail<EMAIL_ADDRESS>
T. O'Sullivan Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada e-mail<EMAIL_ADDRESS>
Département des sciences humaines et sociales, Université du Québec à Chicoutimi, Québec, QC, Canada e-mail<EMAIL_ADDRESS>
dents and is the seat of the Granit area, one of seven areas in the Estrie region of Quebec, Canada. This charming small town is situated on the shores of Lac-Mégantic, from which the community derives its name.

The train, with no engineer at the controls, spontaneously rolled downhill from its night stop location near Nantes toward the town of Lac-Mégantic approximately 11 km away. With a relatively constant downhill slope between its initial location and Lac-Mégantic, the train's descent accelerated to almost 100 kph by the time the locomotives encountered a sharp curve in downtown Lac-Mégantic and most of the trailing cars derailed. As they derailed, 63 tank cars ruptured and escaping crude oil ignited, leading to a succession of powerful explosions and a major confagration. The fre spread rapidly to nearby structures, destroying 44 buildings. The derailment, the explosions, and the subsequent fre also resulted in 47 deaths and necessitated the mass evacuation of 2000 persons, equivalent to one-third of the town's population.

This tragic, sudden, and unprecedented event has therefore generated signifcant impacts on the social, environmental, and economic levels. Indeed, coupled with the human suffering and the environmental degradation, the Lac-Mégantic derailment caused serious psychosocial and economic consequences, including the relocation of many families forced to leave their homes, the loss of many jobs, and the closure of many local businesses for weeks before relocating elsewhere in town (Généreux et al., 2015).

Given the impact of this technological disaster on this local community, the involvement of public health personnel and resources was critical throughout the emergency response operations. The Public Health Department (PHD) for the Estrie region responded immediately, within the frst hours, to provide direct services that were needed to protect the citizens of Lac-Mégantic and the on-site responders from several health hazards. The priority at that time was to assess, communicate, and manage immediate risks to public health associated with exposure to chemical, physical, and biological agents (Généreux et al., 2015).

M. Généreux (\*)

CIUSSS de l'Estrie-CHUS; Faculté de médecine et des sciences de la santé, University of Sherbrooke, Sherbrooke, QC, Canada e-mail<EMAIL_ADDRESS>
D. Maltais

In the face of disasters, and despite the short-term health issues that can be of great concern in such settings, it is important to recognize that the operational domain of the public health in affected communities extends beyond health protection and disease prevention, to include the promotion of health and well-being. It is with this in mind that Estrie PHD, in collaboration with researchers in the feld of psychosocial recovery, conducted a population health survey entitled "*Enquête de santé populationnelle estrienne*" (ESPE) in 2014. Unknowingly, this was the frst of a long series of promising initiatives to mobilize the local community in this post-disaster landscape.

#### **Quantitative Methods in Addressing Challenging Environments: Monitoring the Psychosocial Impacts of Disasters**

Disasters (either technological or natural), as well as other types of collective trauma, often lead to adverse impacts for community health and well-being over the short and long term; as well as on the personal, conjugal, family, social, and professional lives of those involved. Tragic events like the Lac-Mégantic train derailment affect people and communities by causing extensive stress, as well as human and material losses. Fortunately, not everyone exposed to such events faces long-term psychosocial issues, a wide range of pre- and post-disaster-related factors being positively or negatively associated with the risk of developing such problems (Généreux et al., 2019a). It is now well understood that the recovery period can take many months, if not years, following such an event. Numerous studies indicate that physical and psychological health problems following disasters are substantial in affected communities and can persist over time in the absence of adequate support (Goldman & Galea, 2014; Galea, 2007; Maltais et al., 2005). On the other hand, according to a number of studies, exposure to a disaster can have a positive long-term effect on the beliefs and values of certain individuals and create a stronger sense of family and collective solidarity. Some individuals may even discover personal strengths which were left untapped until then (Généreux & Maltais, 2017; Maltais et al., 2020).

Public health organizations have to intervene and help citizens and communities to cope in the aftermath of disasters. Monitoring the physical and psychological consequences of a community struck by a disaster can help to raise awareness, tailor interventions aimed at supporting citizens, communities, and inter-sectoral partners (e.g., municipalities, schools, community organizations), and promoting resilience and recovery processes. This can serve as a powerful lever for the development and the implementation of health promotion measures that can properly respond to the evolving needs of the individual and wider community while M. Généreux et al.

considering local assets and capacities. It is in that spirit that Estrie PHD, in close collaboration with the "*Université du Québec à Chicoutimi*" (UQAC) and the "*University of Sherbrooke*," has spent the frst 6 years tracking the evolving health of those living in the Granit area using repeated crosssectional population-based surveys.

One year following the tragedy, in summer 2014, the PHD conducted a frst health survey using a populationbased sample of about 800 respondents from the Granit area and additional 8000 respondents elsewhere in the Estrie region. Recruited at random, this representative sample of the Estrie population responded to a telephone or web survey covering a variety of physical and mental health outcomes. The second phase of the ESPE was carried out in the fall of 2015 and sought to better understand the local population's health and well-being, along with its possible link to the July 2013 railway disaster. In total, 1600 adults were recruited randomly in 2015 to take part in this large-scale telephone survey. These included 800 from the Granit area and 800 from elsewhere in the Estrie region. In the fall of 2018, a third survey, similar in nature, was conducted. Each of these three studies is composed of a separate sample of adults residing in the Granit area or elsewhere in Estrie. In other words, the participants were not monitored in time. A fourth study, funded by a federal research funding agency, was conducted in 2016 by UQAC. This additional study used a different sampling strategy, with a fnal sample composed of 400 adults in Lac-Mégantic, 400 adults elsewhere in the Granit area, and no "control group" from elsewhere in the Estrie region. For this reason, results from the 2016 survey are hardly comparable with those from the three other surveys (Maltais et al., 2019a, b).

Adults who agreed to participate in any of these studies were asked to answer an anonymous questionnaire, which lasted an average of approximately 30 min. A number of questions were identical across all three surveys, allowing for the comparability of results over time (years 1 to 5 following the tragedy). Various psychosocial outcomes were examined over time, including not only adverse effects of disasters (e.g., psychological distress, depressive episodes, signs of post-traumatic stress, diagnosed anxiety or mood disorders, social worker or psychologist consultation, anxiolytic drug use, alcohol abuse) but also positive ones (e.g., resilience, positive mental health, sense of coherence, sense of community belonging, social support) (Généreux & Maltais, 2017; Généreux et al., 2019b).

In each survey, three types of losses were examined: human losses (i.e., loss of a loved one, fear for one's life or that of a loved one, suffering injuries), material losses (i.e., home damage, permanent or temporary relocation, job loss), and subjective losses (i.e., perception that the event was stressful, that something important was lost, that something important was interrupted, or that harm will potentially occur in future). Respondents were then classifed according to the following categories, and each outcome was compared to these specifc levels of exposure (Généreux & Maltais, 2017, Généreux et al., 2019b):

Findings from the frst two surveys, conducted in 2014 and 2015, were quite disturbing. In the Granit area, human losses were the most common type of loss following the tragedy with almost two-thirds of citizens experiencing such type of loss. Furthermore, about one in six adults in this area (i.e., 16.7% in 2014) reported being intensely exposed to the disaster (Fig. 49.1).

In 2014 and 2015, steep gradients were observed in the prevalence of adverse psychosocial outcomes in the Granit area as a function of the intensity of exposure to the train derailment. In 2014, adults reporting intense exposure were four times more likely to report excessive drinking as compared to those with low exposure (15.2% vs. 3.5%, *p* = 0.001). Similar gradients were observed for various psychosocial outcomes, both 1 year and 2 years after the train derailment (i.e., psychological distress, depressive episode, anxiety disorder, and anxiolytic drug use). Some adverse psychosocial outcomes were examined in 2015 only. Findings from the 2015 wave notably revealed that three quarters (76.1%) of adults in the Granit area intensely exposed showed moderate to severe signs of post-traumatic stress 2 years after the disaster. Interestingly, in 2015, environmental problems were still perceived as more frequent among intensely exposed adults in the Granit area as opposed to less exposed ones (Fig. 49.2).

Finally, some signifcant time trends from year 1 to year 2 post-disaster were also observed. While most psychosocial out-

**Fig. 49.1** Type and intensity of exposure to the 2013 Lac-Mégantic train derailment, ESPE 2014 (Granit area, 811 adults)

comes did not show any statistically signifcant improvement among these adults (Fig. 49.3), the use of psychosocial services decreased by half among intensely exposed adults between 2014 (26.9%) and 2015 (15.9%) (Généreux et al., 2019b).

In addition to adverse psychosocial outcomes, a diverse set of asset-based outcomes should be considered in postdisaster contexts. Several health asset indicators were assessed both in ESPE 2014 and 2015 (i.e., resilience, positive mental health, sense of community belonging). In 2014 and 2015, regardless of the intensity of exposure to the tragedy, about half of respondents had a high level of resilience score based on the Connor and Davidson resilience scale (score ≥30; Connor & Davidson, 2003). Regarding positive mental health, based on Keyes' scale (Keyes, 2002, 2005), it was observed that intensely exposed adults were less likely to report optimal mental health in 2015 (as opposed to low exposed ones), while no such differences were observed in 2014. These fndings suggest that the stock of health assets can weaken with time among people directly impacted by a

**Fig. 49.2** Perception of various environmental problems as a function of the intensity of exposure to the Lac-Mégantic 2013 train derailment, ESPE 2015 (Granit area, 800 adults)

**Fig. 49.3** Diagnosed anxiety disorders as a function of the intensity of exposure to the Lac-Mégantic 2013 train derailment, ESPE 2014 and 2015 (Granit area, 811 and 800 adults, respectively)

disaster, especially in the absence of adequate support and services.

The short version (3 items) of the sense of coherence was also measured (Lundberg & Nyström Peck, 1995), but only in 2015. A low sense of coherence was observed among 24.5% of adults residing in Lac-Mégantic, regardless of the level of exposure, and this proportion was signifcantly lower than that observed elsewhere in the Estrie region (13.6%). Interestingly, a low SOC-3 score was found to be one of the strongest predictors of severe signs of post-traumatic stress, even stronger than having suffered human or material losses. Overall, the use of asset-based outcomes was judged as useful, not only to take into account the strengths and capacities of the community but also to point out strategies specifcally targeting these protective factors.

#### **Qualitative Methods in Addressing Challenging Environments: Asset Mapping and Co-construction of an Action Plan After Disasters**

Over the past decades, many positive health concepts emerged in science (e.g., self-effcacy, resilience, social support or participation, civic engagement). From Antonovsky's original theory, a salutogenic orientation emerged. This orientation goes beyond the sense of coherence or any other positive health concepts with a perspective that unites measures on capacities. Extensive research has shown that having a higher stock of assets has a positive infuence on health. This assertion is true directly and indirectly as studies have identifed direct associations between assets and better health; as well as indirect associations in which assets moderated the effects between unhealthy states or behaviors and undesirable outcomes (Levasseur et al., 2017; Roy et al., 2018).

There is currently a paucity of knowledge on communitylevel strategies that enhance health, well-being, and resilience in a post-disaster landscape in an effective manner. While much is known about strategies targeting vulnerabilities following disasters and emergencies, less is known about what could activate resilience. This tendency to focus on what is going wrong after a collective trauma requires signifcant resources and could promote dependency on limited services (Kretzmann & Mcknight, 1993; Ziglio et al., 2000). This leads to interventions working on needs and problems (i.e., defcit-based approach) rather than fostering capacities and resources (i.e., asset-based approach) (Morgan & Ziglio, 2007; Lindstrom & Eriksson 2010). An asset-based approach was proposed, to shift the focus toward what could produce health and well-being instead of diseases and psychosocial problems in Lac-Mégantic. This approach draws inspiration from the salutogenic theory (Antonovsky, 1987, 1996).

The release of the ESPE 2015 data (i.e., in February 2016) stimulated the emergence of health promotion and advocacy interventions for the local population. Given the magnitude of the tragedy, it was necessary to take a step back to understand and situate ourselves in relation to the normal process of community recovery. It was in this context that in March 2016, the Estrie PHD intensifed its work with community partners, frst by organizing a day of collective refection. The purpose of holding a collective refection day was to work together to gain control of the situation and reverse the cycle. During this day, no fewer than 50 key actors (decisionmakers, stakeholders, citizens, and experts) gathered. The refection day was divided into two parts: (1) conference and workshops on resilience and lessons learned from the past, and (2) conference and workshops on levers for long-term recovery and priorities for the future. A defning moment was the asset mapping activity through which participants were invited to construct together a historical timeline that traces key milestones in the recovery of their community and to recognize the progress made (Fig. 49.4). By highlighting a series of interventions and initiatives previously implemented by social workers and other partners, the group was

**Fig. 49.4** Historical timeline tracing key milestones in the recovery of Lac-Mégantic community (March 2016)

able to identify benefts at the individual and community level, as well as features common to the actions that created positive effects.

Throughout the "*collective refection day*," a common vision of the desired future emerged and priorities for action and research were identifed, leading to the co-construction of what would become the "Plan for the Recovery and Development of a Healthy Community in Lac-Mégantic and the Granit area." This plan pursues the following objectives:

In the weeks following the elaboration of the plan (i.e., April 2016), Estrie PHD advocated for additional funding to support its implementation. In June 2016, the "*Ministère de la Santé et des Services sociaux*" (MSSS) and the Canadian Red Cross announced substantial investments that would serve as fnancial levers to implement the adopted action plan. The ESPE data were an important contribution supporting an informed decision, based on a fair understanding of the long-term psychosocial impacts of the 2013 tragedy.

In sum, holding such a day of refection, which brought together key players from the community, contributed to the development of a common vision of solutions and the transmission of a clear, coherent, and positive message to decision-makers and the community.

"*Building a project together is really motivating. Especially since everyone feels involved: from citizens to elected offcials. It was a very inspiring day!*"

This positive experience supports the fact that beyond traditional surveys, qualitative methods are valuable for listening to, learning from, giving voices to, and engaging local partners and high-risk citizens. Through inclusive and empowering approaches, public health practitioners and researchers can better integrate members of the community as assets rather than victims and take into considerations their capacities in addition to their needs (O'Sullivan et al., 2014).

#### **A Community Outreach Team, Based on a Multilevel Approach**

One of the components of the action plan was the creation of a permanent community outreach team in Lac-Mégantic in the summer of 2016. Located outside formal clinical settings (i.e., in the downtown area), this unique multidisciplinary team aims to bring psychosocial services closer to the population. It is composed of four full-time professionals (two social workers, one outreach worker, and two community organizers) and two part-time professionals (a kinesiologist and a nutritionist).

The following principles guided the entire Lac-Mégantic outreach approach: global health, prevention, scientifc rigor, a strengths-based approach, empowerment, interorganizational and intersectoral collaboration, and inclusion. Citizen participation and community development were at the heart of this approach. A wide range of services are offered, ranging from daily interactions with citizens and local organizations (in the form of psychosocial support, response to service requests, rapid detection and response to emerging needs, collaboration with the organization of activities, etc.) to involvement in various projects emerging from the action plan (Généreux & Maltais, 2019).

#### **Promising Initiatives to Mobilize the Local Community in a Post-disaster Landscape**

The *EnRiCH community resilience framework for high-risk populations* (O'Sullivan et al., 2014) inspired the strategies developed within this community to promote community resilience, health, and well-being (Généreux et al., 2018a, b). Based on qualitative research conducted in fve Canadian communities and a review of scientifc literature, this framework advocates for an integrated upstream and downstream approach to disaster risk. With the development and use of adaptive capacities as a central element, it advocates three pillars and four areas of intervention, as described in Fig. 49.5, all in a cultural context and working with the complexity specifc to disasters.

In line with this reference framework, several promising initiatives have been implemented in recent years within the Lac-Mégantic community to activate community resilience, social cohesion, and citizen participation in a post-disaster setting. Committed to keeping track of local innovations and sharing them in formats that are suitable for both experts and practitioners, a synthesis of some of these promising initiatives has been produced and updated on an annual basis by the Outreach Team since 2017 (Généreux et al., 2018). These initiatives (e.g., social animation, Photovoice, Greeters, walking club) all contributed signifcantly to empowering citizens and mobilizing the community of Lac-Mégantic and surrounding areas. These initiatives also appear to have had a positive impact on the mental health and well-being of the citizens of this community.

As is generally known, organizing community projects or collective events, increasing opportunities to become involved as citizens, as well as other elements that strengthen social capital contribute to building resilience in a post**Fig. 49.5** *EnRiCH* framework components. (Source: O'Sullivan et al., 2014)

disaster context. The data collected in this regard from 800 adults in MRC du Granit in the framework of ESPE 2018 speak for themselves (Fig. 49.6) (Généreux & Maltais, 2019).

#### **Concrete Examples of Promising Initiatives**

#### **Photovoice**

In 2017, in collaboration with the University of Ottawa EnRiCH research team and PHD of Estrie, the citizens of Lac-Mégantic took part in a Photovoice Initiative to map the assets of their community and develop a positive campaign and vision for the community looking forward to 2025. Over a 6-month period, the Lac-Megantic Photovoice Group met monthly to take photos of community assets and ideas to support their vision for the community. They met to discuss their photos with the group, and share their ideas around issues that matter to them. The Lac-Mégantic Photovoice Group planned and hosted two exhibitions to facilitate knowledge mobilization and foster dialogue with decisionmakers in Lac-Mégantic and Ottawa, including local and federal politicians. The Photovoice Initiative was highlighted as an inspirational example of community engagement in resilience initiatives in a report by the World Health Organization (The Lac-Mégantic Photovoice Group et al., 2018).

"*We could express our sadness, our emotions openly because we were welcomed, without criticism. At frst, it was quite emotional, but over the meetings, this overfow was transformed into something lighter. It did me good. It made a big difference.*"

#### **Ephemeral Place**

The population is struggling to reclaim the downtown area of Lac-Mégantic, which was largely destroyed during the railway tragedy of 2013. Being under reconstruction, this new place, full of meaning and memories, constantly recalls the loss of landmarks, but also the loss of gathering places. At the same time, there is a desire among citizens to get involved and to revitalize their living environment. In 2018, the concept of Ephemeral place in the heart of the city arose from this desire, a space promoting social activities, networking, and gatherings. This outdoor venue, under the responsibility of the Outreach Team, allows the involvement of citizens of all ages and all horizons, as well as their participation in various activities aimed at bringing people together and developing meaningful links. Since these are temporary installations, it is an opportunity to experiment with concepts or ideas, while creating positive experiences. Through its free and varied leisure activities offered to citizens (5 to 7 with musicians, barbecues, outdoor flm screening with popcorn, laughter yoga, intergenerational karaoke, etc.) and its unique approach, Ephemeral place undeniably supports the longterm recovery of the Lac-Mégantic community (Généreux et al., 2018).

#### **Lessons Learned from a Citizen's Perspective**

Inspired from a similar initiative following the bushfres which swept across Victoria, Australia, in 2009 (McAllan et al., 2011), the idea behind this project was to collect the statement of people who experienced the tragedy through one-on-one and/or group interviews and to identify overriding themes. This initiative provided a voice and brought together people who wished to contribute in this way, naming what could be changed or improved as a way of managing future disasters. Through their experience, citizens could thus make recommendations to the different bodies with which they interacted during the rail tragedy of July 2013 but also during the months and years that followed it. A semistructured interview guide was developed based on the CHAMPSS Functional Capabilities Framework (O'Sullivan et al. 2013). The acronym stands for the following categories of functional capabilities: Communication, Awareness, Mobility/Transportation, Psychosocial, Self-Care & Daily Tasks, and Safety & Security. A dozen interviews were conducted with citizens that would not have been reached otherwise, in order to make their voice heard. Data collected through these interviews were then pooled and analyzed to draw emerging themes that were sent to participants for further validation. By being inclusive and by recognizing the various experience lived, this project gave citizens a different opportunity to contribute following the tragedy.

#### **Long-Term Trends in Psychosocial Outcomes Following a Disaster**

As in many other disaster settings, huge efforts have been made in Lac-Mégantic over the past few years to foster resilience and well-being, but has there been any progress in terms of psychosocial outcomes? With regards to all the data collected from our surveys, major fndings emerge. First, the psychosocial impacts observed in the years following the Lac-Mégantic rail tragedy in 2013 seem to be receding. For **Fig. 49.7** Diagnosed anxiety disorders following the 2013 train derailment, ESPE 2014, 2015, and 2018 (Estrie region; 8737, 1600, and 8830 adults, respectively)

example, after reaching a peak in 2015, the proportions of adults reporting an anxiety disorder diagnosed by a doctor stabilized in 2018 in Lac-Mégantic. On the other hand, these proportions increased signifcantly elsewhere in Estrie from 2014 to 2018 (Fig. 49.7). In other words, the gap that had developed between Lac-Mégantic and the rest of Estrie in the frst 2 years after the tragedy is no longer, in many respects.

Second, there is still a high prevalence of signs of posttraumatic stress. Despite a gradual adaptation of citizens to the losses and stressors experienced during and after the 2013 tragedy, the local community seems to have been deeply affected by the traumatic event and its aftermath. These marks could persist for many years, without preventing the proper functioning of individuals and their community. Finally, protective factors are also increasingly observed in Lac-Mégantic, particularly high social support and a strong sense of belonging to the community (Généreux & Maltais, 2019). These factors may act as powerful moderators of the adverse effects of primary and secondary stressors typically arising from large-scale disasters.

#### **Conclusion**

Our various population studies, combined with our continuous on-the-ground presence, indicate that the psychosocial impacts resulting from the 2013 Lac-Mégantic rail tragedy decreased over time. Although this tragedy has left its mark, the local community is gradually adapting to its new reality. The asset-based approach that has been promoted seems to have contributed to this "new reality" and emphasizes the importance of social capital to activate individual and community resilience in post-disaster contexts.

This rich experience in Granit over the last 6 years enabled us to identify three key ingredients for success in supporting the recovery of citizens and social reconstruction of their community following a disaster:

To conclude, let us recall the importance of understanding, preventing, and reducing psychosocial risks in the months and years following a disaster, whether natural, technological, or intentional. In any case, concerted action to promote community resilience is required during, after, and ideally before the occurrence of such an event. As advocated by the United Nations, we must move from a disaster management logic to a risk management logic associated with these events, in partnership rather than silos for the good of the community (United Nations, 2015). The positive development of the psychosocial situation in Lac-Mégantic demonstrates the importance of developing a common understanding of risks and working together in fnding solutions.

Climate change, urbanization, and the aging of the population are here to remind us that the frequency and intensity of disasters, as well as the exposure and vulnerability of the Quebec population to this type of event, are expected to increase in the years to come. Therefore, it is best to prepare for it now.

#### **Key Messages**

#### **References**

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## **Salutogenesis and the Mental Health**

**of First Responders**

Avishai Antonovsky

#### **Introduction**

Pictures of beautiful sunsets, crystal-clear lakes surrounded by lovely forests, snowy mountains, rocky canyons, pastoral meadows, and exotic beaches often create an emotional, sometimes even sensory, experience of tranquility and peace of mind. Likewise, a quiet evening spent in one's living room with a few good friends, a glass of wine, and a burning log in the freplace is a perfect recipe for what would be termed "hygge" in Danish – the feeling of coziness, togetherness, comfort, and contentment.

However, while at times, nature can be a source of relaxation, health, and well-being (Bodman, 2017), and being in a group of people whom you know and value can produce feelings of joy and security, at other times the opposite may occur. Natural and human surroundings can be the places where disastrous and fatal events occur. During the decade between 2008 and 2018, an annual average of 1.35 million people around the globe died in automobile accidents (World Health Organization, 2018); more than 20,000 were killed in terrorist attacks (Ritchie et al., 2019); about 140,000 lost their lives in fres (Ritchie & Roser, 2019a); and 60,000 fatalities were caused by natural disasters each year (Ritchie & Roser, 2019b). As of September 2021, the death toll of the coronavirus (COVID-19) pandemic has crossed 4,500,000 victims worldwide (www.worldometers.info).

These unfortunate circumstances will be the context of the discussion in this chapter. However, the focus will not be on those who died, but rather on those who were there to help and save lives: the *frst responders*. First responders (FRs) are people who are frst to arrive and provide care at emergency sites like fres, terrorist attacks, or natural disasters. FRs may be professionals such as frefghters, paramedics, body handlers, search and rescue teams, mental health professionals, forensic examiners, or police offcers. Still, they

A. Antonovsky (\*)

Department of Health and Well-being, Medical Corps, Israel Defense Forces, Ramat-Gan, Israel e-mail<EMAIL_ADDRESS>
may also be nonprofessional volunteers in their communities. Or, in the words of Allison McCullough from the US First Responders Association, "A frst responder is any individual who runs toward an event rather than away" (USFRA, 2019).

There is a large body of literature on psychopathological consequences among FRs and the treatment of them following disastrous or potentially traumatic events. Despite this, structured programs for mental preparation of FRs before these events are relatively scarce, and most of them are pathogenically oriented (i.e., aimed at preventing psychopathology). In this chapter, I will frst review the mental effects that repeated exposure to emotionally challenging scenes may have on FRs, and some protocols used following disasters for what has been generally termed "helping the helpers." Then, I will present what I have found about programs designed to enhance FR's mental ftness. Finally, I will suggest an outline for a salutogenic model of mental preparation for FRs, based on what has been done in the Israel Defense Forces (IDF) in the last few years.

#### **Mental Hazards in the Work of First Responders**

As part of my job as civilian researcher in the IDF's Department of Health and Well-being, I worked with a military unit of body handlers that is in charge of taking care of bodies and bodily remains of people who were killed in unnatural circumstances (automobile accidents, terrorist attacks, fres, etc.). One of these FRs told me about his 2-year-old daughter and how he sings to her every evening before she goes to sleep. "But," he said, "I cannot bring myself to cover her with her blanket and tuck her in." Covering someone with a blanket is part of what he does at work, and this physical act is something that he cannot manage, emotionally, to transfer from one context to another.

Most of the literature about crisis intervention, which is where FRs are usually needed, focuses on the needy – those

<sup>©</sup> The Author(s) 2022 543 M. B. Mittelmark et al. (eds.), *The Handbook of Salutogenesis*, https://doi.org/10.1007/978-3-030-79515-3\_50

who get hurt physically or mentally. Many intervention models for these circumstances have been developed all over the world. This is not the main topic of this chapter, but I will mention just two, to set the context for the reader.

Over the past 30 years, Israel has experienced several bomb and missile attacks on its northern and southern borders. The work of mental health professionals during these events – usually social workers – has been important in the treatment of mentally injured people, usually suffering from anxiety. Two well-known models for crisis intervention by FRs that were developed in Israel are BASIC-Ph (Lahad, 2017), which is intended for professional FRs, and the Six-C model (Farchi et al., 2018; Hantman & Farchi, 2015), which is intended for nonprofessionals who fnd themselves with victims of a disaster or catastrophic event. Farchi's Six-C model addresses the need to provide immediate standardized mental frst aid to a person who is exhibiting an acute stress reaction (ASR) and to shift the person from being a helpless victim of functional breakdown to becoming a coping survivor. This can be in the face of a terrorist attack, or a food, or a fre, or any other unexpected human or natural disaster. Theoretically, the protocol is based on the concepts of sense of coherence (SOC) (Antonovsky, 1979, 1987), self-effcacy (Bandura, 1997), and hardiness (Kobasa, 1979), as well as on neuropsychological processes involving the relation between the limbic system and the prefrontal cortex during stressful events (Farchi et al., 2018). In a few meetings I had with Farchi over the years, he would always mention the salutogenic model and how important it is for health promotion. Still, his Six-C model is focused on *emergency treatment* of ASR to prevent the *reaction* from becoming a *disorder*. In other words, the Six-C model, while being quite helpful (Farchi et al., 2018; Svetlitzky et al., 2019), is about diagnosis and treatment, not about salutogenic health promotion. People with ASR are those who experience functional breakdown during an emergency – characterized by detachment, shaking, loneliness, confusion, emotional shock, and helplessness. This is a normal reaction to an abnormal situation and can occur to anyone. If 48–72 hours pass without treatment, people who have exhibited an ASR may develop an acute stress disorder (ASD). ASD is diagnosed by the existence of a variety of posttraumatic stress disorder (PTSD) symptoms (intrusion, avoidance, and alterations in cognition, mood, and arousal; see American Psychiatric Association, 2013). For some people, spontaneous recovery may occur. For others, ASD may evolve over a few months, stabilize, and crystalize into chronic PTSD.

For FRs to witness or treat people with an ASR, or to see death and serious bodily injury repeatedly, is emotionally draining. Thus, FRs are prone to mental diffculties in two ways. One is through experiencing direct trauma because of being exposed to a life-threatening situation of self or others, and the other is by the recurring witnessing of death and destruction. Either way, psychological distress and PTSD can develop within emergency FRs (e.g., paramedics, body handlers, police investigators, and frefghters; see Donnelly, 2012; Ramey et al., 2016; Smith et al., 2018; Zerach & Levin, 2015, to mention just a few). The occurrence of these outcomes is usually related to the frequency of exposure and severity of exposure to critical incidents (Weiss et al., 2010). The prevalence of PTSD among FRs can reach 10% and is relatively high in developing countries and among ambulance personnel. This is very high (up to 20 times as much) compared to the prevalence in the general adult population (American Psychiatric Association, 2013; Berger et al., 2012; Bezabh et al., 2017). For example, Bezabh et al. reported that 19.9% of FRs working in the Fire and Emergency Control and Prevention Authority in Addis Ababa, Ethiopia, were diagnosed with PTSD while still on their job. In a recent paper on the prevalence of PTSD among Canadian FRs, the numbers are even higher (Szeto et al., 2019). Considering these data, it is worth supplying the readers with the defnition of *trauma*, which is the frst and necessary criterion for the diagnosis of PTSD and is relevant to FRs (see criterion A4) (American Psychiatric Association, 2013, p. 271):

	- 1. Directly experiencing the traumatic event(s).
	- 2. Witnessing, in person, the event(s) as it occurred to others.
	- 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
	- 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., frst responders collecting human remains; police offcers repeatedly exposed to details of child abuse).

**Note:** Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related.

In addition to PTSD, FRs are at higher risk than the general population for anxiety disorders, depression, alcohol abuse, early retirement, divorce, and suicide (Brondolo et al., 2012; Haugen et al., 2017). The reported rates of these cases are probably lower than the actual numbers because shame, stigma, and unawareness prevent many FRs from accessing mental health services (Haugen et al., 2017; Heyman et al., 2018).

The COVID-19 pandemic provided a unique and unusual example of FRs' exposure to threat. Several doctors and nurses were assigned to take care of coronavirus patients under circumstances that are very different from what they are accustomed to in their routine work. A considerable number of studies have already found that these healthcare professionals experience high levels of anxiety, depression, burnout, and sense of threat, related to their possible exposure to the virus (e.g., Adams & Walls, 2020; Chen et al., 2020; Lai et al., 2020; Tan et al., 2020). Similar fndings were reported in an Israeli study among military reserve rescue teams of the Home Front Command. They were recruited and assigned to reinforce Israel's national emergency medical service at its operational call center (Avishai Antonovsky et al., 2021). These are examples of a unique situation in which healthcare professionals were acting as FRs on assignments which they had never been trained for, accompanied by a great deal of uncertainty regarding the proper treatment of patients and the personal security measures that need to be taken.

Like FRs on the site of an emergency, mental health workers in a clinic who treat individuals who have suffered trauma are at risk themselves for compassion fatigue. Compassion fatigue (or the earlier term used, secondary traumatic stress disorder) refers to the infuence on mental health professionals of the therapeutic encounter or intervention with victims of disaster suffering PTSD (Lahad, 2000). Here, too, the literature concentrates on interventions for helping the helpers in terms of treatment targeted to alleviate the effects of such mental diffculties that mental health workers go through (Bercier, 2013). Likewise, Brondolo and her colleagues offered a model used to generate worksite intervention strategies to reduce the risk for PTSD among FRs (Brondolo et al., 2008).

In the context of mental preparation and intervention programs, there is a common use of the term "resilience." For reasons I will shortly bring forward, in the current context, I prefer the term "mental ftness" over "resilience." Conceptually, the construct of mental ftness is like that of physical ftness: it is something that can be learned, trained for, and preserved by exercise (see Bolier et al., 2013, and Robinson, 2014, for similar conceptualizations). It is multifaceted in the sense of having a reservoir of various resistance resources and can be measured at a personal as well as a group level. Mental ftness is defned as follows:

a *learned* and *conservable competency* which is a product of the *social*, *emotional*, *cognitive*, and *physiological* capacities of a *person* or a *group* to cope successfully with mental challenges (Avishai Antonovsky et al., 2017).

Enhancing mental ftness is therefore the process of building mental strength to withstand and cope well with mental challenges. This is different from resilience. Resilience, although intuitively understood, seems to be an elusive concept. As Windle (2011, p. 152) argued, on a conceptual level, "the complexities of defning what appears to be the relatively simple concept of resilience are widely recognized, especially within the behavioural sciences." On an empirical level, she added, "This creates considerable challenges when developing an operational defnition of resilience; defnitional variation leads to inconsistencies relating to the nature of potential risk and protective processes, and in the estimates of prevalence." According to Windle, resilience is considered a psychological trait, and it seems that the one characteristic of resilience which is agreed upon is its meaning of being able to "bounce back" in the face of adversity. As Zamorski (2008, p. 7) stated, "Psychological resilience … is defned as the 'sum total of psychological processes that permit individuals to maintain or return to previous levels of well-being and functioning in response to adversity'." Eshel et al. (2017), who studied individual attributes as predictors of resilience, opened their article with three different defnitions of resilience, after which they offer their own. All four defnitions have in common the idea of functioning (or bouncing back) following adversity or a traumatic event. Hence, an operational defnition of resilience must include the existence of adversity from which bouncing back can be measured, just as PTSD can be diagnosed only if a traumatic event has occurred. Mental ftness, on the other hand, is not considered a trait, and it can be trained for. It is not narrowed to a unidimensional psychological construct and can be operationalized without the need for adversity to occur. While resilience is important to have once a person has experienced a (potentially) traumatic event, mental ftness is important to have *before* such an event occurs. Taken to the hypothetical extreme, it can be argued that a person with a very high degree of mental ftness does not have to worry about being resilient.

The concept of mental ftness shares two important characteristics with SOC: one is having cognitive, behavioral, and emotional aspects (which parallel SOC's components of comprehensibility, manageability, and meaningfulness). The other is that both are conceptualized and can be operationalized at both the individual and the group levels. Mental ftness is more specifc and task oriented than SOC, but the stronger the people's SOC, the easier it will be for them to develop and maintain a high level of mental ftness. For example, in the study described earlier of military rescue soldiers in Israel's national emergency medical service during the COVID-19 pandemic, SOC was the best predictor of (and inversely related to) sense of threat, state anxiety, and burnout (Avishai Antonovsky et al., 2021). In that study, it was also found that a subgroup of soldiers who had been given structured mental preparation based on salutogenic principles of providing information, strengthening resistance resources, and emphasizing meaningfulness exhibited less burnout and a higher degree of subjective well-being than those who had not received such preparation (Danon et al., 2020). Likewise, in a study among volunteer body handlers who belonged to the Israeli organization ZAKA (Hebrew acronym for "identifcation of disaster victims"), SOC was found to have a buffering effect on posttraumatic stress symptoms and burnout (Zerach & Levin, 2015). Zerach and Levin recommended that SOC "should be taken into account in the process of recruitment and training of body handlers" (p. 2).

As mentioned earlier, mental preparation for FRs is not common. The literature on "helping the helpers" is mostly devoted to postevent treatment. Large-scale, theoretically driven, and evidence-based programs intended to proactively prepare FRs for coping with mentally challenging and emotionally draining situations are hard to fnd.

Searching the literature, I found a few papers that recommended "pre-incident training" as a prevention technique for traumatic stress among FRs (e.g., Cochran & Bardi, 2010). Still, this kind of training is usually limited in its scope and centers on generic forms of psychoeducation. One example is the seemingly promising "Road to Mental Readiness" (R2MR) program, developed by Canada's Department of National Defence (Szeto et al., 2019). The R2MR program is intended to reduce stigma and negative attitudes toward those struggling with poor mental health (thus removing barriers from seeking care), to provide FRs with a broad understanding of mental health and wellness, and to use a mental health continuum scale as a self-assessment tool for defning mental health in themselves and others. The R2MR program is usually carried out in one 4-hour psychoeducational session. Szeto and his colleagues reported that the R2MR intervention has increased self-reported resiliency and decreased stigmatizing attitudes at a 3-month follow-up. However, Carleton et al. (2018) studied long-term effects of the one-session R2MR intervention on a series of outcome measures and reported that besides a small short-term decrease in stigmatic attitudes toward mental illness, there were "no statistically signifcant changes in symptoms of depression, anxiety, stress, posttraumatic stress, and alcohol use, at any follow-up time point, following the training intervention" (p. 521). Although I read a few sources besides the ones cited here, I could not uncover any sound theoretical foundation for the development of the R2MR program, besides the logical assumption that psychoeducation on mental health and stigma has the potential of increasing help-seeking behavior.

I agree with Szeto et al. (2019) who wrote "it seems evident that implementation of a program that addresses resilience and stigma reduction in frst responders is warranted and may offer positive impact (e.g., improved mental health)" (p. 19S). However, what they offer in the R2MR program is mainly treatment oriented and may not consider all aspects of what is needed to increase mental ftness, as part of a general health promotion approach toward helping the helpers.

Another example of what at frst seemed like a salutogenic approach to enhancing FRs' mental ftness is a webbased training program for medical examiners, which consists of self-paced instruction modules (Brondolo et al., 2017). The training is aimed at developing emotion regulation skills, as a means of reducing the risk of mental problems such as depression and PTSD. Brondolo and her colleagues appeared to be adopting a positive psychology approach when in the last paragraph of their paper they wrote: "a combined program of research and intervention can provide insight into strategies for strengthening psychological capital among the frst responder community" (p. 13). But in their study, they had actually relied on social-cognitive models of PTSD (see, e.g., Belsher et al., 2012).

In sum, three points can be made. The frst is that FRs are prone to several negative psychological consequences as a result of repeated exposure to harsh circumstances. The second is that there is awareness of these outcomes, and therefore, several treatment approaches have been developed to aid FRs who suffer psychopathological symptoms. The third is that there has been little effort to develop comprehensive health promotion programs for FRs, which could boost their strengths and provide them with generalized and specifc resistance resources to help them cope in the face of the mental challenges they confront. Therefore, there seems to be a need for a model of enhancing mental ftness in a salutogenic orientation. Such a model will be offered in the following section.

#### **A Mental Eforts Scale as an Aid in Preparing FRs for Coping with Mental Challenges: Proposing a Salutogenic Mental Fitness Model**

Professional FRs are a subgroup of "exposed populations" – groups of people who are repeatedly exposed to aversive details of traumatic events (see PTSD criterion A4) but are not necessarily *responders*. These include, for example, clerks in criminal courts and administrative workers in emergency rooms or police stations. Whether on the site of an emergency or not, these various populations each have a specifc list of tasks they fulfll on their job on a routine basis. Let us take frefghters as an example. When we think of a frefghter, the frst thing that probably comes to mind is an image of a person in a protective outft and a helmet, holding a hose and spraying water on fames. But when we examine carefully what frefghters' work consists of, we come up with a long list of tasks, activities, and situations. Here is a detailed, though not exhaustive, list of examples:

Which of the above is the most stressful task, activity, or situation? It is hard to say. We might intuitively think that tasks involving presence at a fre scene would be much more stressful (e.g., carrying a wounded person out of a burning building) than tasks done at the fre station (e.g., having to share a room with buddies). But we may be wrong. I have learned that sometimes having to sprint "from zero to one hundred" (leaving your dish full of food which had just been prepared at the station, putting on your protective gear, and jumping into the fre engine) is more diffcult, mentally, than fghting the fre itself. How can this counterintuitive rating of stress be explained? One possible explanation is that frefghters are trained continuously for fghting fres and rescuing people; frefghters are *not* usually trained for standing in a safe place away from the fre and talking to a victim's family members, or for maintaining good social relationships with the buddies in their shift. If frefghters are stressed by tasks and situations which are not life-threatening (especially involving developing trust in their chief or buddies), this may have a negative impact on their operational effciency when they run into a burning house.

The kind of list above can be prepared for other groups of FRs (police investigators, paramedics, etc.). To further elaborate, I will now describe a working model which was developed in the mental ftness branch (established in 2017) of the Department of Health and Well-being of the IDF. The model is still under examination, but so far seems to have promising outcomes. Perhaps, the most distinctive characteristic of the model, in practical terms, is its "tailor-made" nature. While based on the same general salutogenic principles, it is suited differently for every specifc kind of exposed population (FRs and others). As an example, I will take the crime scene investigators (CSI) unit in the military police.

*Stage 1: Create a list of tasks, activities, and situations*

Contact is made with the unit, and we have an informal meeting or a focus group with a small number of soldiers and ask them to describe, in as much detail as possible, all the duties and events they have or may encounter, on their job. We usually end up with a list of 30–60 items. Examples are a search for drugs at someone's home, interrogating suspects of sexual assault, answering a defense attorney's questions in court during cross-examination, lack of sleep, arriving at the scene of an automobile accident, direct exposure to body parts, exposure to diffcult life stories, and time management.

#### *Stage 2: Develop a "situation perception*" *questionnaire*

At this stage, we construct a questionnaire to measure soldiers' perceptions of their duties and events in terms of the amount of stress each task or situation elicits, and the amount of confdence they have in performing their duties or coping with the events. Conceptually, it resembles (to a limited extent) the idea of using the critical incident technique (Flanagan, 1954) and qualitative content analysis to develop a job-related self-effcacy scale (see Judge et al., 2007; Lorente et al., 2011). The situation perception questionnaire (SPQ) looks like the example in Table 50.1.

For the CSI unit, we have 36 items. They are ordered *randomly* to prevent order bias or a halo effect. For each respondent, we calculate the median value for each of the two measures and mark very high-stress scores and very low confdence (or job self-effcacy) scores. We do the same for the unit as a whole. Questionnaires are not anonymous, so we can identify those who have diffculty in specifc duties more than in others. We explain the importance of identifying diffculties in order for them to be addressed and treated, and we ensure that the soldiers' commanders do not see the results.

Test-retest correlations we have measured so far are high and are evident of the SPQ's reliability (as stability). There is no point in measuring internal consistency because the questionnaire items are not assumed to measure a single construct. We also measured convergent validity using correlational analyses: we examined the relationship between the perceived stress and the confdence ratings, on the one hand, and other variables such as degree of experience as investigators and SOC, on the other hand. The fndings in several units we have worked with so far are consistent: frst, there is a very high negative correlation between perceived stress and confdence (or job self-effcacy). Second, the more experienced one is on the job, the less stressed and the more

**Table 50.1** Example of three items in the situation perception questionnaire (SPQ)

confdent he or she feels (however, this relationship is weak to moderate). Third, SOC is a good predictor of both measures (medium-high negative correlation with perceived stress and medium-high positive correlation with confdence). These repeated results allow us to infer the validity of the SPQ.

#### *Stage 3: Construct and implement a mental efforts scale*

With the results of the questionnaire, we can now order the items according to the degree of perceived stress. We usually do it only at the unit level (i.e., sorted by the median unit score), but when requested by the unit's mental health offcer (MHO), we can do it for individual soldiers. Mostly, this is done for soldiers who have a history of meetings with the MHO.

After having a picture of what kinds of tasks, activities, and situations are perceived as less or more stressful, we meet with the unit commanders and offer ways to lessen the pressure when needed. For example, in the case of the CSI unit, they were surprised to fnd out that being crossexamined by a defense attorney (when investigators were called to testify for the military prosecution) was about as stressful as arriving at a suicide scene. Our recommendation was to train investigators for cross-examination using simulations. Another fnding (common in most units) was that tasks involving a great deal of uncertainty (including administrative chores) were experienced as stressful, as well as tasks for which soldiers felt they do not have enough tools or resources. In salutogenic terms, they experienced a lack of comprehensibility and manageability. We recommended that whenever possible, give soldiers as much information you can, or build up uncertainty gradually along the training timeline. Also, make sure they know they have the resources they need (e.g., technological devices or commanders' social support).

This does *not* require a change in the professional aspects of training. We believe commanders have the knowledge and experience needed for training their soldiers well. We *do* offer "mental fne-tuning" of the training protocols to overcome mental challenges of which commanders may be unaware. This can be a small change in the way various tasks are taught, or the order in which they are learned, or a change in the general climate.

#### *Stage 4: Offer salutogenically oriented psychoeducational workshops and training techniques*

In addition to mental fne-tuning, we have workshops which offer psychoeducation *relevant to the unit's activities,* especially those who were found as most stressful for that specifc unit. Although during the workshops we do give room for answering questions which usually pertain to psychopathology (such as fear from PTSD), we give more room for discussion and techniques that are aimed at enhancing mental ftness and psychological strengths. Many groups of FRs are nonacademic (although some have earned a bachelor's degree), so we do not present the salutogenic model or SOC in a strict academic manner. Instead, we talk about comprehensibility, manageability, and meaningfulness in a way that will make sense to the FRs. First, we ask what kinds of knowledge and experiences they have, or would like to have, for them to understand what they need to do in various job-related situations as well as in life in general, and what will help them predict how their life (on the job and in general) will look like in the future. Second, we discuss the kinds of resources that are available for them (and those they are missing) to cope with challenges (on the job and in life in general). The kinds of resources may differ from one group of FRs to another, but what is important is that resources are *relevant* to the challenges; social support is almost always mentioned (and usually described as most important). Third, we discuss the importance of the things they do and the challenges they face (on their job and in life in general) in terms of their meaning and try to fnd specifc factors that create motivation and make coping with the challenges worthwhile.

This discussion of comprehensibility, manageability, and meaningfulness relates to the FRs specifc job and life in general. In this way, we keep the workshop directly relevant to their daily work (and to the purpose of having the workshop), and also bring to their awareness, and possibly alter, their thought patterns and general orientation to life. It should be reminded that the soldiers we address are usually 18–20 years old, an age at which the sense of coherence is still in its shaping period.

By raising awareness of the three components of SOC, we cover cognitive, behavioral, and emotional aspects of mental ftness (see defnition described earlier), as well as conscious and unconscious processes. The social aspect is touched upon when we speak about manageability, but there is also group work as part of the workshop. Also, we have the participants exercise techniques such as Farchi's Six-C protocol for psychological frst aid (Farchi et al., 2018). This protocol was adopted by the IDF (called "Magen," which means "shield" in Hebrew; see Svetlitzky et al., 2019) and later by the US Military (called "iCOVER"; see Adler et al., 2019). An 11-minute video (in English) depicting the iCOVER protocol can be found at https://www.youtube.com/ watch?v=t84\_QvbnIT0.

Besides the workshops, and in line with the underlying principle of the iCOVER protocol, neurocognitive training techniques help shift arousal and attention from the amygdala (part of the limbic system, in charge of emotional reactions such as fght, fight, or freeze) to the prefrontal cortex (in charge of rational decision-making). Some of these are known as attention bias modifcation (ABM) techniques (see Wald et al., 2016). There are also mindfulness workshops and similar sessions to teach relaxation techniques that we employ. All these together are relevant to the physiological aspect of mental ftness.

In addition, we present the salutogenic model and SOC to senior commanders, both as a description of our approach toward mental health promotion and as a new thought paradigm for them to consider. Most of the senior commanders we have met with expressed a positive attitude toward the salutogenic orientation. They have shown interest in mental health promotion activities and the training techniques we employ.

#### *Stage 5: Accompany the intervention with research*

When offering mental fne-tuning in a unit for the frst time, we test its effciency by implementing it in only part of the platoons, while having the others carry out the training as they have done before. We administer the SPQ and the SOC-13 questionnaire at the beginning of training, at its end, and at a follow-up period (usually about 3 months) and compare the change in platoons that received the refned training to the change in those which have not. Unpublished data that have accumulated so far point to the effcacy and usefulness of our model.

#### **Summary and Recommendations**

Research has found FRs to be prone to psychological distress and psychopathology resulting from their repeated exposure to potentially traumatic events. Most of the literature is focused on postevent treatment or on pathologyoriented (preventive) preparation. The mental ftness model proposed earlier, which includes an application of a mental efforts scale accompanied by salutogenically oriented psychoeducation and other activities, is intended to enhance mental ftness among FRs and build their psychological strengths as they face adversities on their job. I believe that having a stronger sense of comprehensibility, manageability, and meaningfulness will enable FRs to cope with such adversities in a way that will reduce the chances of suffering mental injuries, thus preventing the need for postevent treatment. One can say that this does not differ from pathogenically oriented preventive medicine. But this can be said of salutogenesis in general: anything that promotes health thereby prevents disease. However, pathogenesis and salutogenesis are not two sides of the same coin. Disease prevention is indeed a favorable consequence of salutogenic health promotion, but while prevention tends to be diseasespecifc (we take a pill to lower blood pressure; we reduce the amount of fat we eat to protect ourselves from heart problems), salutogenic health promotion is holistic in its nature and is targeted for whole populations and not only for individuals at risk.

Therefore, it is recommended that besides psychopathology-oriented programs intended for providing mental frst aid to FRs and to the communities who experience potentially traumatic events, there should be more focus on salutogenically based mental preparation programs. These should emphasize the strengths and resources that could help FRs arrive at scenes of disaster equipped with salutogenic resources, at the strategic as well as tactical levels. This way, not only the FR's coping mechanisms will beneft, but they will also better succeed in helping, and even saving, those who need aid and rescue.

Finally, I should add that the idea of salutogenically helping the helpers is not new. After I had fnished writing this chapter, I was looking through a box of old papers and found the frst page of a lecture given in 1989 in Sweden by Aaron Antonovsky. The lecture was entitled "Caring for the carers," and this was the opening paragraph:

In this lecture, I will attempt to apply what I call *the salutogenic model* to a crucial problem that is often ignored: the conditions which facilitate the adaptive survival and fulfllment of responsibilities of those who work in the caring professions.

Therefore, I rest my case.

#### **References**

Chan, B. P. L., Sunny, S., Chandra, B., Ong, J. J. Y., Paliwal, P. R., Wong, L. Y. H., Sagayanathan, R., Chen, J. T., … Sharma, V. K. (2020). Psychological impact of the COVID-19 pandemic on health care workers in Singapore. *Annals of Internal Medicine*. https://doi. org/10.7326/M20-1083

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## **Salutogenesis in Prison**

James Woodall, Nick de Viggiani, and Jane South

#### **Introduction**

An increasing shift in the international discourse on Prison Health towards a salutogenic perspective has emerged with the ever-expanding interdisciplinary public health movement that recognises prison health to be a signifcant arm of public health. This shift is refected in the World Health Organization's (WHO) *healthy prisons* ethos that advocates tackling health and social inequality and harnessing the social determinants of health to create settings where effective health improvement can occur. In the spirit of the Ottawa Charter for Health Promotion, this means "enabling people to increase control over" their health through supportive environments where they can harness key social and structural resources that enable them to attain health (WHO, 1986). The prison public health movement recognises that health inequalities disproportionately impact criminal justice populations (WHO, 2020). Prisoners, in particular, experience comparatively higher prevalence of physical and mental ill-health, disability and preventable communicable and noncommunicable disease than their host populations. This is the WHO's (2016: 1) statement on prisoner health:

The health status of prisoners is almost always inferior to that of people at liberty. The risk of becoming seriously ill tends to be much higher in prison than in the general population

The high levels of health need are associated with a further set of challenges around inequality. Communities with relatively high levels of material deprivation and socioeconomic inequality are signifcantly over-represented within criminal justice systems and settings (Cavadino & Dignan, 2006; Marmot et al., 2020). "Offenders" are, moreover,

N. de Viggiani Department of Health and Social Sciences, University of the West highly likely to lack protective predispositions that prevent them from becoming involved in or affected by crime, and to avoid being exposed to criminogenic environments (Morse, 1975). Ewing (2018: 29) furthermore argues that individuals who experience social disadvantage – such as poverty, lack of educational opportunity, racial oppression or interpersonal abuse, particularly in combination – are at higher risk of entering criminal justice agencies or settings. This was recently emphasised by the UK charity Revolving Doors (2017), which argued that "the health, economic and social inequalities faced by the population in contact with the criminal justice system are stark and striking."

Persons who experience "criminogenic disadvantage" (Ewing, 2018: 29) may fnd it considerably diffcult to avoid the adverse health and social consequences of inequality. It is widely acknowledged that this refects both the relatively poor material and socioeconomic circumstances of prisoners' pre-imprisonment and the harmful and depriving effects of imprisonment and other criminal justice processes.

The over-arching goal for prison health is therefore to develop "upstream" public health strategies that enable salutogenesis – or health creation – and to negate deleterious, harmful and unjust effects of criminal justice processes and reverse criminogenic potential within communities at risk of offending. In this chapter, it is argued that a salutogenic prison health ethos should provide the conditions to develop effective and meaningful public health and health promotion strategies for people in criminal justice or correctional settings. This means developing healthy correctional policies, re-orientating custodial and non-custodial corrections environments and enabling prisoners and prison staff to attain power and agency in accessing resources to improve their health chances and health outcomes. A healthy prisons approach fundamentally draws the focus away from indicators of disease, ill-health and disability and towards a salutogenic perspective (Baybutt & Chemlal, 2016). This is not to say that healthcare management is not important but to suggest that prison-based public health and health promotion are much more than techniques to prevent ill-health.

of England, Bristol, UK

J. Woodall (\*) · J. South

School of Health and Community Studies, Leeds Beckett University, Leeds, UK e-mail<EMAIL_ADDRESS>
M. B. Mittelmark et al. (eds.), *The Handbook of Salutogenesis*, https://doi.org/10.1007/978-3-030-79515-3\_51

This chapter addresses three key objectives. First, it critically reviews the regressive historical, biomedical and individualistic position that prison health has occupied internationally, against which reactive preventive policies and practices have become anchored. It examines how this traditional position has suited the dominant neoliberal political standpoint of western societies, with its limited scope to engage and advance a healthy prisons agenda. Second, this chapter reviews the *healthy prisons* ethos and its embracement of salutogenic principles, emphasising the instrumental role of the WHO in operationalising this agenda. Third, this chapter explores how to practically create salutogenic prisons but being mindful of the inherent challenges of delivering a progressive prison health agenda across an international context, where security and control services to routinely disempower and disable prisoners and undermine attempts to rebuild lives.

#### **The Pathogenic Approach Towards Prison Health Policy and Practice**

"Prison health" is commonly understood and interpreted as a biomedical construct pertaining to the commissioning, management and prevention of disease, illness and disability within prison populations. Arguably, this perspective refects the somewhat outdated paradigm of public health medicine that considers the prevention of communicable and noncommunicable disease to be the primary role of public health within prison contexts. Such an approach fails to acknowledge the broad social, economic and environmental context of health and illness, and is individualistic in orientation, associating prison health with the individual prisoner, offender or agent rather than with the circumstances surrounding the individual – the prison, correctional setting, criminal justice system or wider society. A healthy or unhealthy prison, after all, should refer as much to the social and material fabric of the prison, and the experience of imprisonment, as much as to the health of the prisoner. The response of correctional services is logically to treat or manage individual prisoners with respect to their individual criminogenic or pathogenic/healthcare needs. This reactive and reductionist version of prison health draws upon health professionals to intervene at an individual clinical or behavioural level to "fx the problem" rather than to address the underlying causes. It serves to draw resources away from addressing fundamental root causes of poor health and offending – those wider social and criminogenic determinants, inequalities and prerequisites for health. This was aptly summed up by Roberts (2009), who has argued that "the process of criminal justice mystifes rather than clarifes what is harmful in society and might be done about it."

Hence there is a longstanding tradition within correctional services across the world to anchor prison health within the biomedical paradigm and consequently to situate prison health policies and practices within a healthcare context. This was, for instance, refected in the development of the US correctional health system in the 1930s, with the establishment of the frst Medical Center for Federal Prisoners in Springfeld in 1933; this service was "dedicated solely" to caring for the diseased and the "broken bodies and minds of offenders" (Bosworth, 2002: 79). This emphasis on medical and psychiatric treatment was highlighted by Sim (1990) in his infuential debate on medical power in prisons. It was colourfully illustrated by Morris and Morris (1963: 193) in their study of Pentonville prison in London in the 1960s:

For the prison, health is essentially a negative concept; if men are not ill, de facto they are healthy. While most modern thinking in the feld of social medicine has attempted to go further than this, for the prison medical staff it is not an unreasonable operational defnition

In some ways, this adherence to the biomedical and psychiatric paradigms is not surprising given the negative health consequences of imprisonment and correctional processes more generally. Much debate, commentary and evidence have highlighted the harms that imprisonment can facilitate. Indeed, Roberts (2009) argued that criminal justice systems orchestrate harmful effects to society through their negative impacts on the social, material and economic potential of the most disadvantaged and in terms of their health and wellbeing. As far back as the mid-nineteenth century, the social reformer Jeremy Bentham (1864: 351–352) referred to prisons as pathogenic environments that:

… include every imaginable means of infecting both body and mind. Consider merely the state of forced idleness to which prisoners are reduced … Want of exercise enervates and enfeebles their faculties, and deprives their organs of suppleness and elasticity

Gresham Sykes (1958: 79), in his ethnographic research of the mid-twentieth-century US penitentiary system, similarly observed how:

The individual's picture of himself as a person of value – as a morally acceptable, adult male who can present some claim to merit in his material achievements and his inner strength – begins to waver and grow dim

The United Nations' International Covenant on Economic, Social and Cultural Rights (UN General Assembly, 1966) asserted the right to all citizens of the world "to the enjoyment of the highest attainable standard of physical and mental health." This was refected in Rawls' (1973) egalitarian argument that a socially just society is one:

… in which basic human needs are met, unnecessary stress is reduced, the competence of each person is maximised, and threats to well-being are minimised; and where value is recognised in enabling each person to have a fair share of benefts and burdens resulting from their participation in society, or 'social cooperation'

This was a position echoed by the WHO Offce of the European Region (1985). They asserted that all EU member states should improve the level of health of the most disadvantaged groups within their societies by providing equitable health policies that extend beyond the meeting of basic healthcare needs. This was an interpretation of the notion of "equivalence" that implies not only reducing a population's observed health differences but eliminating those health needs arising from avoidable or unfair societal determinants (Charles & Draper, 2012; Ismail et al., 2019). This was also recently conveyed by the WHO Commission on the Social Determinants of Health:

These ethical principles apply as much to prisoners as to other vulnerable groups. Indeed, the UN's 1966 International Covenant underpinned its 1990 Basic Principles for the Treatment of Prisoners (United Nations, 1990), stating that prisoners should be provided with access to health services equivalent to those provided for the general population of their respective host countries.

In the United Kingdom, prison health services are commissioned to address prisoners' observed healthcare needs; these are routinely measured through healthcare needs assessments, screening and public health surveillance. This principally reactive approach tends to refect more the needs of the criminal justice system, of the health services and the State since it seeks to "contain" the problem rather than prevent it and avoids measures to address the deeper-seated needs of society more broadly. Healthcare services are therefore commissioned to respond to acute disease, illness or disability that present within prison populations (HMIP, 1996). They essentially detect, manage and treat morbidity arising from acute and longstanding non-communicable and communicable disease (de Viggiani, 2006a). This refects a preoccupation with an interpretation of prison health that is fundamentally individualistic, which results in an approach to health promotion that is reactive to and pre-occupied with lifestyle issues. Interventions believed to be effective in tackling risky behaviours are routinely commissioned and located within healthcare services (Department of Health, 2002: 2). This inevitably means that prison authorities interpret prisonbased health promotion as an exclusive educational role for healthcare professionals. Consequently, opportunities to engage prison personnel in progressive partnership work across conventional professional boundaries are not explored where there would be potential to promote and improve health at a system-wide level (Meek, 2018). Squires (1996: 1161), moreover, has argued that: