© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_77. Psychological Resilience in Medical Rehabilitation
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Baylor University Medical Center, Dallas, TX, USA
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University of North Texas, Denton, TX, USA
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Medical College of Wisconsin, Milwaukee, WI, USA
Keywords
ResilienceInjuryTrajectories of resilienceResilience assessmentTopic
Psychological resilience is the process of adapting well to adverse situations, including medical illness, disability, traumatic events, or extreme stressors. Research and theory in this area has been explicit that resilience is not simply the absence of psychopathology, but instead maintaining one’s ability to return to stable psychological and physical function and even have the capacity for positive emotions in the wake of a difficult life event [1]. While past conceptualizations of resilience assumed that it was an inherent and stable construct, more recent theories and research suggest that psychological resilience is malleable and thus can be bolstered to help an individual recovery following an adverse event.
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Factors of Psychological Resilience
Resilience is a multidimensional construct that is based on intra- and interpersonal resources. For example, many people who demonstrate high levels of psychological resilience display a sense of self-mastery, adequate self-esteem, and an effective social support network. Resilient people also encompass certain behaviors, thoughts, and actions that help them to maintain a particular equilibrium, even when presented with stressful situations. Below are a list of factors that have been shown in the research literature to be protective against psychopathology after an adverse event and foster positive outcomes.
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Social Support
One of the strongest attributes of resilient individuals is their available social support. The impact of social support can vary wildly by size (i.e., quantity), density, and perceived quality, which can all provide separate advantages based on individual need. However, people demonstrating high levels of resilience tend to either report a large social support network or report a high quality of social support network(s) regardless of size, or both. Social support in the wake of illness has long been considered a crucial component of adequate recovery, as it prevents feelings of isolation and helplessness. In addition, social support is associated with less disability and poorer health-related outcomes.
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Ways of Coping
The way a person copes after an injury can affect a person’s resilience and adaption to the injury. People with higher levels of resilience tend to use more problem-focused coping and task-oriented coping to manage stress (e.g., focus on improving functioning after an amputation by working hard in rehabilitation). People with lower resilience are more emotion-focused with their coping (e.g., focus on how sad they are that they lost a limb). Though everyone uses emotion-focused coping at some point of their illness, highly resilient people tend to protected more against negative emotions and rebound quicker to problem-focused coping strategies [2]. In addition, resilient individuals also tended to find benefits in spiritual coping, which may provide a sense of purpose to the illness and provide another source for support and strength.
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Optimism
Defined as a trait disposition to expect or anticipate good outcomes, is protective against distress from a variety of illnesses and medical conditions. Not surprisingly, people with high levels of resilience also tend to be optimistic, which some genetic research has argued is a heritable trait. As such, it is a characteristic of resilience believed to facilitate development of other resilient traits later in life [3].
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Hardiness
A personality trait, hardiness may help to buffer against extreme stress. People who display high levels of hardiness tend to: be committed to finding meaningful purpose in life; feel as though they have control over their environment and outcomes; and believe that they can learn and grow from both positive and negative experiences in life. People with high levels of hardiness tend to have higher levels of confidence, making them better able to solicit social support and active coping and making stressors more manageable [4].
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Positive Emotions
Positive emotions during or after adverse situations tend to reduce negative emotions and helps people maintain connection with social supports. This is not to say that a resilient person does not display or experience any negative emotions, but they are able to balance negative and positive emotions in a productive fashion.
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Trajectories of Psychological Functioning during Medical Rehabilitation
An important distinction regarding differences in how people function across time while recovering from medical illness has emerged in the empirical literature. Resilience, as described above, is about the ability of an individual to maintain a relatively stable path of functioning over time [1]. These are important when assessing the psychological health of an individual during medical rehabilitation. For example, if an individual displays moderate levels of symptoms, but reported even higher symptoms 2 months previously, it might be that the individual is not in need of intervention, as they are moving toward their baseline functioning using his/her own innate abilities. Intervention resources can be targeted toward those individuals who are displaying high levels of distress across time.
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Recovered Trajectory
Some people display psychological distress soon after an aversive event, but gradually over time, possibly even over the course of months or years, they return to baseline functioning. This is estimated in approximately 15–25 % of individuals [5].
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Delayed Trajectory
A small number of people (0–15 %) display minimal symptoms initially, but then over time symptoms increase [5]. Most research on resilience has been focused on delayed trajectories due to the consistent occurrence of symptom patterns across disease and health-related injury. People in delayed trajectories tend to show greater initial symptoms of depression and anxiety (compared to other trajectories) that then continue to increase over time.
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Chronic Trajectory
Some people tend to have a high level of distress initially that remains high across time. Around 5–30 % experience a chronic trajectory [5].
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Resilient Trajectory
The majority of people (35–65 %) display minimal symptoms of stress and disruption initially, but very quickly after the event symptoms decrease and stable function returns [5]. Resilience has consistently shown to be the most common trajectory across numerous traumatic events, including injury, bereavement, and natural or current events disasters.
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Importance
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Incidence and Prevalence of Resilience
While the majority of people will be exposed to a stressful medical event for themselves or a loved one in their lifetime, most people respond to those events in an adaptive and resilient way. In a review of PTSD literature, they noted that “roughly 50–60 % of the population is exposed to traumatic stress but only 5–10 % develop PTSD” [6]. In studies of resilience, results have mirrored this statistic showing that up to 65 % of people show a resilient trajectory after suffering a traumatic event, with the remaining experiencing a delayed or consistent trajectory characterized by persistent psychological distress.
It is important to remember that resilience is not just the absence of any major distress; just because there is an absence (or a significantly reduced) reaction to a traumatic event does not necessarily mean someone is resilient. Paying particular attention to how one copes with their distress, the prevalence of positive vs. negative affect and cognitions during the recovery process, and the persistence (or lack thereof) of negative psychological and health-related dysfunction over a period of time are the best identifiers of highly resilient people.
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Strength-Based Approach to Bolstering Resilience
Although the field is divided on whether resilience is a personality trait or modifiable, there have been several programs in recent years aimed at increasing or “bolstering” resilience to better handle stressful situations. These programs mainly target the five factors of resilience mentioned above. Similar to self-control or exercise, people with low resilience can build on their stress management and coping skills that are associated with people with high resilience. Many of these programs can be as short as a one-day workshop to several intensive sessions, but all focus primarily on enhancing the use of self-regulatory and coping skills under stressful conditions, promoting more positive affect in the wake of stress, and increasing general self-esteem and self-enhancement.Get Clinical Tree app for offline access
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Here are a few of the most recently tested resilience interventions
Penn Resilience Program (PRP) : Based on training from Seligman and colleagues, this training program focuses specifically on the improvement of cognitive behavioral skills, in order to address anxiety and depression and improve well-being and performance [7]. PRP has also been used in samples of high-risk populations, medical students, and young adults [8].
Stress Management and Resilience Training (SMART) : The SMART training program, adapted from Attention and Interpretation Therapy, consists of focus on basic foundations of perceiving and interpreting experiences, and then transitions to skill-building to strengthen positive engagement and emotional intelligence [9]. This program has been developed and tested extensively with medical professionals, staff, and patients with chronic illness within the Mayo Clinic. Collectively, the SMART program has shown to increase resilience, mindfulness, and overall quality of life, while decreasing anxiety and perceived stress weeks later [9]. A computerized, self-managed version of the program has also been tested and available.
Families Overcoming Under Stress ( FOCUS) : Designed as a trauma-informed, skill based resilience enhancing program for military families with children ages 3–18, the program uses multiple components including computerized psychological health check-ins; training in emotional regulation, problem-solving, stress-management, and goal setting; and specific psychoeducation on the impact of stress on children as well as traumatic brain injury and PTSD. Initial studies have suggested that both parents and children who have participated in this program showed significant improvements in anxiety, depression, and general decrease in emotional symptoms as well as improvements in children’s use of positive coping skills [10].
Resilience Interventions in the Military : The Department of Defense (DOD) has been actively involved in identifying strategies and programs to enhance resilience. The military clearly recognizes that for both the individuals serving and their families, the psychological toll of frequent deployments and continued conflict in Afghanistan and Iraq is significant. This is evident in not only the rates of PTSD in these conflicts but also the rates of suicide, which appear to be at a record high. Thus the DOD has taken a lead role in not only better understanding and identifying what factors contribute to resilience but also how to build and foster resilience. In a recent review by the RAND Center for Military Health Policy Research [11], current military relevant resilience building programs were assessed on a number of factors including strategies for promoting resilience, any barriers, and the effectiveness of the programs. The study defined a resilience program as “one that targets any of the factors that research has shown to improve resilience and healthy responses to stress, and provides a means for helping individuals to incorporate resilience into their daily lives.” The recommendations from this extensive review of current military intervention programs suggest that resilience should be integrated as a policy, standardized resilience measures across programs should be adopted, and more intense program evaluations should be conducted to garner support for their implementation.
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