Clinical Pressures

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CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE

This is the first in a 5-part series of articles exploring, through clinical case examples, the pressures on clinicians to mistake the appearance for the reality of patient resilience and the consequences of such misperception. This first installment provides background about the development and application of the concept of resilience in mental health treatment.

Introductory Thoughts

During the past few decades, the concept of resilience has been invoked with increasing frequency in the mental health field. The idea of resilience, when properly understood and applied, places a beneficial emphasis on working to amplify a patient’s strengths as opposed to pathologizing. In current practice, however, the perception of resilience, especially over a short time period, can be a dangerously misleading form of wishful thinking.

What appears as resilience is sometimes feigned and is often fragile and ephemeral for a variety of intrapsychic and psychosocial reasons. In some cases, it manifests as an epiphenomenon of rote teaching by clinicians that ultimately fails to compensate for inadequate treatment.

Unfortunately, the emergence of “resilience” as a clinical mantra or rallying cry has coincided with growing pressure from insurers to reduce costs by streamlining the process of treatment. In today’s tightly constrained environment of mental health care, the false perception of resilience becomes an inadvertent rationalization for overburdened clinicians to move patients through treatment with too little time for alliance formation, in-depth understanding, and ongoing support. The resulting failure to address patients’ underlying issues can have foreseeably tragic consequences for patients and demoralizing effects on clinicians.

After exploring how the concept of resilience has developed in the context of mental health, this article will present case examples of what can happen when clinicians mistake the appearance of resilience for the reality, contrasted with 2 examples in which individuals underwent therapy of sufficient duration and depth to nurture the development of a truly resilient status.

Resilience as a Factor in Treatment and Recovery

The American Psychological Association (APA) defines resilience as “the ability to adapt in the face of adversity, trauma, tragedy, threats, or significant stress.”¹ Tang et al,² cite various interpretations of the APA definition, including the absence of psychopathology; the ability to return to normal, stable functioning, unimpaired by a traumatic event; and positive, adaptive responses to adversity.

Three types of factors contributing to resilience have been identified.³ Core factors are those predominantly defined by one’s genome. Internal factors are learned and shared traits influenced by family, friends, and life experience, involving the development of autonomy, self-control, coping styles, social competence, and the kinds of behaviors described by such terms as hardiness, grit, and toughness. External factors are primarily socioeconomic, such as community support and access to social and health care services. The most effective way to overcome traumatic adversity is to understand how these resilience factors can appear alone or in combination and to recognize their manifestations.³

Variations on the idea of resilience include Tedeschi and Calhoun’s concept of “posttraumatic growth” (PTG),^4,5 derived in part from ancient sources, which involves experiencing positive changes through one’s suffering, and Zhang and Maercker’s⁶ analysis of resilience as a capability which, although relatively stable, is not static, but rather can grow during recovery and through the cognitive reconstruction of one’s understanding of adversities.

Zhang and Maercker trace the application of resilience and PTG to posttraumatic stress disorder and other mental disorders, as well as the evolution of psychosocial interventions that include resilience-enhancing training, mindfulness-based coping strategies, the memory-making process, and culture-specific holistic healing. They cite research in which such programs have been found to improve social and occupational functioning of psychotic patients in the United States and other countries.⁶

Nzodom⁷ sees resilience as a “functional trajectory” that varies with the quality of the stressor, the surrounding culture and circumstances, and varying responses to risk. For example, an individual may do well in confronting physical violence but have difficulty dealing with verbal abuse.

For Linkov et al,⁸ resilience is a dynamic capacity for coping with stressful life events. Internal factors, such as cognitive capacity, interact with external resources, such as social status, to enable a shift from adversity and disruption to recovery, adaptation, and growth.

Factors that can strengthen resilience include positive role modeling by supportive parents who can regulate their own emotions and behavior to provide nurturing, confidence-building interactions. Factors that can undermine the development of full resilience include repeated overwhelming trauma, neglect, isolation, continual criticism and resulting humiliation, chronic stress, sexual or physical abuse, and social discrimination. Such factors can lead to emotional instability and the chronic self-doubt referred to as “learned helplessness.”⁹

Moreover, recent data from the large-scale Great Smoky Mountains Study indicate that individuals exposed to adverse childhood experiences, even when they are perceived to be resilient in childhood, have an elevated incidence of symptoms of mental illness, including anxiety and depression, in young adulthood.¹⁰ Thus, resilience following a history of dysfunction and trauma is not necessarily stable and enduring.

Lake¹¹ refers to the related factor of locus of control, a concept introduced 5 decades ago that describes the degree to which individuals believe that events affecting them are a consequence of their own choices and actions. Individuals characterized by strong internal locus of control are more confident in their ability to influence their own future and, as a result, tend to be more resilient in the face of adverse circumstances.

Those with a strong external locus of control interpret events as caused by circumstances beyond their control, so that they experience themselves repeatedly as helpless, ineffective victims. This interpretation undermines the exercise of resilience.¹² Therefore, therapeutic intervention aims to strengthen a patient’s internal locus of control, often referred to as personal agency.

In this century, a new path to understanding resilience has been opened by the study of epigenetic effects—that is, alterations in the expression of genes that do not involve changes in DNA sequence, but still can be inherited. Tang et al,² review research that shows that both external (psychosocial and environmental) and internal (biochemical and neurophysiological) factors relevant to resilience can affect the expression (whether positive or negative) of genes. These changes can then be passed from one generation to the next.

Building on the early explorations of Erikson¹³ and Gottesman and Shields,¹⁴ negative epigenetic mechanisms have now been identified in psychiatric illnesses such as addictions, major depressive disorder, and eating disorders. Moreover, positive or negative epigenetic modifications produced by exposure to traumatic events (whether prenatally, in childhood, or later) have been found to have long-term effects on an individual’s phenotype and, in turn, on how that individual and their offspring will respond to future stress.

Research reviewed by Tang et al,² with study populations as disparate as survivors of childhood trauma and Israeli combat veterans (some of whom were children of Holocaust survivors), shows the contribution of epigenetic effects to posttraumatic symptomatology and PTG, both of which can carry over either in part or in their entirety to the next generation.

Tang et al,² observe that nonpharmacological treatment of trauma and stressor-related disorders can induce beneficial epigenetic changes and enhanced resilience. Cognitive behavioral therapy (CBT), storytelling, mindfulness, and other techniques that encourage reflection and understanding can not only enhance an individual’s resilience to trauma, but also have a protective effect on that individual’s offspring.

These authors identify 6 factors as among those predictive of enhanced resilience from trauma and social isolation:

1. Early intervention
2. CBT
3. Finding meaning in suffering
4. Social support
5. Exposure to and involvement with art
6. Regular exercise

In these and other ways, family and community can contribute to creating a foundation of security, self-esteem, and self-efficacy. Children gain protection from the adverse effects of trauma through strong bonds with caregivers who share values and beliefs consistent with a potentially constructive rather than destructive perspective on their suffering. Support from family, friends, colleagues, and community leaders can promote more rapid recovery.

Acknowledgment: Dr Baker wishes to thank Tom G. Gutheil, MD, and especially Archie Brodsky for their support in providing technical suggestions and continued encouragement in moving this article successfully toward publication. Finally, she would like to thank her husband, David, for his unwavering support during the 2 and a half years, during which a fair amount of her daily focus was spent researching and writing this series.

Dr Baker, who is board-certified in both child/adolescent and adult psychiatry, has practiced and taught child, adolescent, and adult psychiatry on inpatient and outpatient units; also providing ER and unit overnight coverage as well as consult-liaison and crisis stabilization coverage at various Massachusetts hospitals including Harvard Medical Center teaching hospitals. She served as chief psychiatrist for the Residential Treatment Program at the Italian Home for Children in Boston from 2004 to 2021. She has published an earlier article with Thomas Gutheil, MD, in the Journal of Psychiatry and the Law (Volume 39 Fall 2011) dealing with treatment issues resulting from funding changes on a Massachusetts forensic unit and is a contributing member of the Program in Psychiatry and the Law at Harvard Medical School.

References

1. Building your resilience. American Psychological Association. Accessed June 1, 2024. https://www.apa.org/topics/resilience

2. Tang H, Tanaka GI, Bursztajn HJ. Transgenerational transmission of resilience after catastrophic trauma. Psychiatric Times. 2021;38(6).

3. Liu JJ, Reed M, Girard TA. Advancing resilience: an integrative, multi-system model of resilience. Pers Individ Dif. 2017;111:111-118.

4. Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress. 1996;9(3):455-471.

5. Tedeschi RG, Calhoun LG. Posttraumatic growth: conceptual foundations and empirical evidence. Psychol Inquiry. 2014;15(1):1-18.

6. Zhang P, Maercker A. Resiliency and posttraumatic growth: cultural implications for psychiatrists. Psychiatric Times. 2021;38(7).

7. Nzodom CM. Resilience can’t be taught—but it can be learned. Psychiatric Times. June 5, 2017. Accessed June 1, 2024. https://www.psychiatrictimes.com/view/resilience-cant-be-taught-it-can-be-learned

8. Linkov I, Galaitsi S, Klasa K, Wister A. Resilience and healthy aging. Psychiatric Times. July 26, 2021. Accessed June 1, 2024. https://www.psychiatrictimes.com/view/resilience-and-healthy-aging

9. Peterson C, Maier SF, Seligman MEP. Learned Helplessness: A Theory for the Age of Personal Control. Oxford University Press; 1993.

10. Copeland WE, Halvorson-Phelan J, McGinnis E, Shanahan L. Adult mental health, substance use disorders, and functional outcomes of children resilient to early adversity. Am J Psychiatry. 2023;180(12):906-913.

11. Lake J. Resilience and locus of control in the time of pandemic. Psychiatric Times. May 6, 2020. Accessed June 1, 2024. https://www.psychiatrictimes.com/view/resilience-and-locus-control-time-pandemic

12. Hiroto DS. Locus of control and learned helplessness. J Exper Psychol. 1974;102(2):187-193.

13. Erikson EH. Childhood and Society. W.W. Norton; 1950.

14. Gottesman, II, Shields J. Schizophrenia: The Epigenetic Puzzle. Cambridge University Press; 1982.