Can We Prescribe Resilience?

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TABLE. Common psychosocial protective factors

It is time for the psychiatric and wider medical world to embrace lessons from the growing science of resilience to treat the wide range of stress-related medical and psychiatric disorders more effectively. Quite often, physicians admonish patients to lower their stress levels, while patients quietly wonder how a lifetime of adversity can be undone, or how to extricate themselves from stressful jobs, relationships, or living environments. In these clinical situations, clinicians need to be prepared to offer concrete suggestions to build protective factors for resilience, rather than presuming that patients can magically get rid of their stressors.

The healing professions can be forgiven for coming late to the science of resilience, since vastly greater research and educational efforts have traditionally focused more on the pathogenic impact of stress and risk factors to generate disease, rather than how to harness the healing potential of biopsychosocial protective factors. It is beyond dispute that specific, well-known adverse childhood events and other developmental factors increase the risk for medical and mental illnesses. When a science of resilience began to emerge in the late 20th century, it became apparent that a subset of high-risk individuals who share a number of biopsychosocial protective factors had relatively healthy life outcomes (Table).¹

Protective factors include characteristics of the individual and environmental experiences, and may occur at various developmental stages, but all seem to derive from a small handful of fundamental requirements for resilient functioning: a sense of safety, positive social connections, feelings of competence and control, and positive outlooks. Understanding the neurophysiological systems that underlie resilient functioning is crucial to effectively prescribing to the needs of high-risk patients, and to developing innovative ways to more efficiently induce these systems to build resilience.

Evolution of a sense of safety

The human nervous system evolved to serve the fundamental function of modulating behaviors of approach and avoidance so as to optimize the organism’s chances of survival and reproduction. Polyvagal theory observes that humans engage in a continual sensory process of “neuroception,” involving constant surveillance of afferent inputs to ascertain levels of risk, threat, safety, and opportunity to produce behavioral responses that will best serve the needs of survival and reproduction.² Depending on the valence of afferent signals of neuroception, neurophysiological states are produced that bias our anticipation of novel or unexpected stimuli and result in behavioral and autonomic responses that respond to situations of risk or opportunity.³

Understanding how neuroception produces neurophysiological states in the autonomic nervous system is crucial to understanding how resilient individuals cope with stress. With the explication of polyvagal mechanisms in the parasympathetic nervous system, we have been able to move beyond simplistic models of stress response. Based on the interpretation of these sensory inputs through the brain, we not only respond to risk and threat with well-known fight, flight, or freeze mechanisms, but also respond to conditions of safety and opportunity by activating key components of the parasympathetic nervous system to promote rest, relaxation, restoration, and social engagement. The most resilient individuals seem to have an ability to adeptly use these complex neurophysiological systems, to defend or recover from threats and trauma, and to seek or generate opportunities that create a sense of safety, control, and social connection.

Social skills for resiliency

Resilient individuals often have exceptional inborn qualities of temperament, personality, and social skills, starting with “easy” infant temperament, developing through childhood into likeability, getting along with others, sense of humor, altruistic tendencies, interpersonal problem-solving, and good emotional regulation-characterized as “emotional intelligence.”⁴ These social skills typically arise under conditions of safety, from the orchestrated action of the social engagement system (SES), which, when activated, facilitates positive social affiliation, recovery and restoration, and possibly reproductive behaviors. Resilient individuals use their emotional intelligence to calm themselves quickly and effectively in the wake of risk or danger, as well as to attract and maintain loving and supportive social relationships, which in turn assist them in calming their neurophysiological state.

The SES includes the neuromotor pathways responsible for the production of the most important and intimate gestures of facial and vocal expression. Under the optimal conditions of a secure mother-infant attachment relationship, there is extensive interchange of empathic facial and vocal interaction between mother and infant to entrain the SES of the developing infant. The components of the SES, along with the insular cortex, and various other sensorimotor cortical regions interact to generate a “mirror neural system” in humans. Capacities such as empathy, emotional self-awareness, and mentalization, are thought to arise from the mirroring social-emotional interplay of mother-infant attachment. Conversely, if the attachment is insecure, disorganized, or absent, there can be profound deficits in emotional regulation, stress-coping, and social engagement, such as in borderline personality functioning.⁵

In the interest of prescribing resilience, it is crucial to understand that in-born social skills and secure mother-infant attachment are strong protective factors, but their absence does not determine destiny. The adaptive importance of effective social engagement has resulted in significant lifelong plasticity in the SES. For example, meditation favorably alters tonic EEG rhythms and thereby enhances emotional regulation. Yoga and meditation are often recommended to augment the treatment of a variety of psychiatric and medical illnesses, and involve resting or stretching in a place of comfort, quiet, and safety, breathing in a relaxed manner-using a bit of “physiological trickery” to send safe neuroception to the brain that triggers the relaxation response. Frequent or daily “dosing” of such practices seem to effect plastic neurophysiological changes.

Wolmer and colleagues⁶ report that teaching emotional intelligence skills to Israeli school children in a war zone decreased the rate of PTSD. Musical tones delivered in the frequency range of intimate social communication may activate the SES in some autistic children.⁷ Interventions aimed at producing laughter and positive affect have increasingly been shown to improve health.^8,9 This set of observations suggests that we are able to induce positive change by “imposing” protective experiences into a person’s life that result in protective plastic changes in neurophysiological systems underlying resilience. Thus, in the face of stress, our patients should be urged into practices of meditation, yoga, learning emotional intelligence, music, and laughter to enhance a sense of safety and activate the SES.

Positive social connection

The big payoff for an effective SES and exceptional emotional intelligence is the ability to form positive social connections easily. Humans are social animals, and there is safety in numbers, so social connection and affiliation serve to enhance a sense of safety and build resilience. The first example of a social connection in the human life cycle is the mother-infant attachment following birth. We know that the neuroceptive interchange between mothers and infants includes vocal and facial interactions, skin to skin contact, and breastfeeding, and results in the release of the neuropeptide oxytocin, which activates the SES, enhances pair-bonding, lowers cortisol, and has anxiolytic effects.¹⁰

Oxytocin has wide-ranging functions and affects care receiving and care giving, positive social interactions, interpersonal trust, monogamous pair-bonding, and sexuality. Moreover, it produces anti-stress effects, while enhancing immune function and wound healing. These prosocial, anti-stress actions arise from oxytocin’s function as a key regulator of parasympathetic cardiovascular control and social engagement.

While a secure mother-infant bond is a beneficial protective factor, some resilient individuals are able to thrive without it, finding other supportive relationships in the extended family, or outside the immediate family (adult mentors, peers, or loving partners), to gain the benefits of social connection. Tierney and colleagues¹¹ report that high-risk youths matched with mentors from the Big Brothers/Big Sisters program have less entry into substance abuse, better school attendance, and better relationships with parents and peers.

The stories of resilient youths also often include experiences of assuming caretaking skills at a young age, having to care for their younger siblings or disabled parents. In psychiatry, we sometimes condemn this “parentification” of children, and mourn the loss of a carefree childhood, but this early caretaking experience likely results in an oxytocin effect, building empathy, an early sense of responsibility, and problem-solving skills, all of which, promote resilience.

The neurophysiological benefits that arise in loving social support relationships may also explain how social involvement and belonging to organized social structures enhances medical and mental health. Affiliation with social, athletic, or religious organizations promotes health benefits and has been shown to moderate the progression to depression among traumatized, high-risk youths and decrease anxiety and depression in adults.^12,13 The recommendations to maximize the protective benefits of socialization include tending to, and deepening close relationships, expanding and developing new relationships, and joining structured social activities.

Feelings of competence and control

Another pathway to resilience involves finding ways to experience a sense of competence and control with the activities of daily living. Resilient individuals exhibit a wide range of competencies such athletic, musical, artistic, or writing talents as well as problem-solving skills . Remarkably, the true level of competency, or specific activity, matters less than the mere perception of competency on the part of the individual. It is the perceived competence and confidence in one’s ability, that seems to propel resilient people into higher education, entrepreneurship, or passionate hobbies and avocations.

The underlying neurophysiological mechanism by which perceived competency works its magic may partially involve testosterone, which has beneficial effects on mood in both men and women. Findings from tests of social competence indicate that winners of many types of games gain a transient increase in testosterone.¹⁴ Moreover, testosterone levels correlate with social dominance in many animal societies, and in humans, achieving a sense of competency or ascendancy in one’s chosen skill may raise testosterone, and confer a protective effect.

Resilient individuals often exhibit a perception of control (ie, internal locus of control). The underlying neurophysiological mechanism involves modulation of the hypothalamic pituitary adrenal axis (HPA) and cortisol release. Animals and humans attenuate stress response and cortisol release if they have a perception of control, even in the context of aversive experiences. Having a perception of control is the resilient antidote to the damaging neurophysiological effects of “learned helplessness” among trauma victims. The problem-solving skills of resilient individuals allows them to feel confident in the face of stressful problems. There are many examples of how we use the perception of control as a stress modulator, including straightening our desk, plucking weeds from the garden, having a drink, or being a “control freak,” all of which can be seen as attempts to gain some stress relief by asserting control in an ultimately uncontrollable life.

It is not surprising that the perception of control is a very close proxy to a sense of safety, circling back to the neuroception of safety. Overwhelmed, impoverished, or single mothers who nonetheless establish homes with routines, rules, rituals, chores, and positive discipline are in fact creating safe and predictable environments to give their children the perception of control. Immersion in such structured living environments establishes strong circadian rhythms and tunes the diurnal secretion of the HPA axis, and likely contributes to the emergence of resilient youths.

Positive perceptions and outlooks

The realization that our neurophysiological and behavioral responses to stress or safety arise from our processing of neuroceptive cues, leads to the inevitable conclusion that we live imbedded in a subjective neural system. Based on neuroceptive perceptions, we calm or activate our restive physiology, activate our social engagement system, or grow guarded and defensive under threat. We engage in necessary or frivolous activities that make us feel as though we have control and help to distract us from stress. In large part, it is these perceptions, and the behaviors we produce from them, that determine our relative resilience.

The perception of control or competence can lower cortisol or elevate testosterone. In the same way, the perception of being loved, as evidenced to the brain by positive social or tactile cues, can increase oxytocin. Our knowledge of the action of mirror neurons has revealed that we can read the emotional perceptions off the faces of others, and enact them in our own brains, providing a mechanism to understand the reciprocity of social emotions, and how our perception of love from another can impact our own physiology. Among resilient children, merely having the perception that your parent loves you, even if absent or abusive, nonetheless serves as a protective factor.

The power of the perception of love is the only secular explanation for how faith in a loving deity has tangible benefits to health and wellbeing, as it does for many resilient individuals. Likewise, resilient people may gain a perception of control as they generate realistic hopes and expectations for the future, in stark contrast to the outlook of futurelessness among drug addicts and trauma victims. Lastly, resilient individuals have the perception that they are resilient. Connor and Davidson¹⁵ found that adult medical patients who perceive themselves as resilient are more likely to have better health outcomes in a variety of medical conditions.

Cognitive behavioral therapy (CBT) has taught us that what we repeatedly think can influence how we behave. Therefore, CBT can serve as one tool to help patients change their perceptions to those of competence and control, of being loved, of future hopes, of faith, and of their own resilience. But the idea of sending all of our stressed-out patients to psychotherapy for CBT is no more realistic than telling them to eliminate the stressors from their lives.

Instead, let us suggest to our patients that they build their resilience by utilizing the intrinsic pathways that the parasympathetic social engagement system offers to give them a sense of competence and control. If we can help our patients enact the behaviors of a resilient life, their perceptions and neurophysiology are likely to follow.

Disclosures:

Dr. Vance is Associate Professor, Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA. Dr. Vance reports no conflicts of interest concerning the subject matter of this article.

References:

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