Effective Care Fosters True Resilience

Bijac/AdobeStock

CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE

This concluding article in the 5-part series presents 2 examples of how the kind of treatment provided may affect the potential development and maintenance of actual resilience. Each example contrasts a negative with a positive outcome.

A Case of True Resilience After a False Start

A 13-year-old boy living in an economically underserved neighborhood, who had been raised without a sense of secure attachment or trust, was admitted to a residential facility after manifesting aggressive behavior, poor sleep, and increasing isolation. His symptoms had developed after he watched his father, who was involved with a neighborhood gang, open the kitchen door, expecting the arrival of a neighborhood friend, only to encounter a member of an opposing gang who shot him in the head, leaving him lying dead in front of his son, who had been standing next to him. The boy idolized his father, who had repeatedly instructed him never to trust anyone.

In the days after his admission to the residential unit, the boy continued to show aggression toward peers and staff, avoiding any positive social interaction and eating and sleeping very little. Initially, he would not participate actively in therapy sessions, either group or individual.

As he acclimated to the setting and became less agitated and hostile, his individual therapist began working with him on a “resilience workbook” that outlined resilience-enhancing factors. After 2 weeks, the boy appeared to be cooperating with his therapist by reading and answering questions in his workbook. The content of the assignments included simplified explorations of reactions to traumatic loss and signs of improvement consistent with “resilience.”

By his third week in the facility, the boy apparently showed significant recovery similar to the resilient behavior described in the workbook. By the end of that week, he was refraining from further aggression, expressing positive affect, socializing, appearing to eat well, and self-reporting that he was feeling much better, sleeping without nightmares, not thinking about suicide or homicide, and feeling ready to return home to his mother, brothers, and uncle.

In view of his positive self-reports, denial of psychiatric symptoms, and behavior on the unit, in class, in therapy sessions, and in the gym, the staff and psychiatrist believed they were observing actual recovery and “resilient” features. Meanwhile, they were receiving daily phone calls and check-ins from the insurance provider stating that if the patient was no longer a danger to himself or others, was eating and sleeping well, and was interacting socially with staff and peers, he no longer met the criteria for continued care on the residential unit and should return to his family and be treated as an outpatient.

The boy was discharged after the third week of treatment to reside at home and continue with biweekly therapy sessions as well as monthly mood-stabilizing medication check-ins. Two weeks after discharge, he was readmitted to the same residential unit, having once again been behaving aggressively toward his peers and uncle, refusing medications, sleeping and eating poorly, and attempting to harm himself. At one point, he was found in his room trying to tie a cord of curtain rope around his neck.

When asked by unit staff whether he had felt any intimations of these problems when being prepared for discharge, he replied, “I could tell from the workbook and the way everybody reacted to what I was doing that, if I wanted to be discharged, I had to do what the workbook said. And so, I decided to try to get you all to think I was all better so I could get out of here, go home, and be with my friends. I felt okay for the first few days at home, then all the stuff got worse, and I couldn’t control it. So, I’m back.”

He added that he didn’t believe in “any of that stuff” from the workbook or what the therapist and staff were saying. It became very clear that the boy trusted no one on the unit and instead had remained attached to his deceased father, who had repeatedly told him, “Never trust anyone.”

This time, the boy remained in treatment on the unit for 2 years. As he processed the loss of his father, he gradually became more attached to and trusting of the staff and positive male role models on the unit. Over time, as observed by clinical staff who were meeting with him more frequently and extensively, not relying on self-report as in his previous admission, his nightmares eased, he was eating and sleeping well, and he ceased to have thoughts of self-harm, suicide, and homicide. As observed by the gym staff, he also became more adept at basketball, a skill in which he expressed great pride.

These positive signs of resilience did not develop until the staff and his therapist spent significant time and energy on building a sense of safety and secure attachments founded on consistent, clear, trust-building interactions and relationships. Near the end of his stay on the unit, the boy’s resilience manifested most markedly in his confident, controlled responses to provocative peers. His resilience was still fragile in certain areas, such as dealing with the loss of a valued roommate who was transferred to another unit. With further assistance and support, however, he was able to work through this problem with much less agitation, fewer signs of vulnerability and instability, and greater strength and flexibility than he had previously shown.

Preventing Future Tragedies

As we expand our understanding of resilience, we can apply this knowledge clinically with increasing precision and effectiveness to help patients cope with trauma, loss, aging, and other destabilizing experiences. This understanding can help us avoid mistaken perceptions of behavior or affect that may mimic the presentation of genuine resilience. We must be wary of the natural desire of clinicians, loved ones, and utilization reviewers to mistake the appearance for the reality of resilience.

An illustrative article differentiates effective from ineffective approaches to prevention in the case of surgeons, who suffer an increasing rate of suicide while being seen as personifying resilient qualities.¹ The stoicism surgeons often project is potentially deadly for them.

In a recent presentation (September 2023) to the Association of Academic Surgery, of which she was president, Carrie Cunningham, MD, MPH, an associate professor at Harvard Medical School, noted that “surgeons have some of the highest rates of suicide among physicians…many go unreported.”

Describing her history of professional success, darkened by bouts of severe depression, anxiety, and more recently substance abuse, as well as episodes of suicidal ideation, Cunningham spoke of the completed suicide of a close friend, Christina Barkley, MD, who had been a trainee in the same surgical program as Cunningham. While continuing to perform in her surgical residency, Barkley had undergone multiple attempts at treatment. Each time, she was placed on medication and returned to work quickly.

Cunningham described how Barkley “felt pressured by everyone around her to just finish her residency program…6 months later, a neighbor found Barkley at home with a self-inflicted wound…For the next 2 years, Dr Barkley cycled in and out of hospitals, oscillating between depression and mania. In April 2012, 3 days after being discharged from the hospital, she ended her life.” Barkley’s sister was quoted as saying, “My sister was fearful of ramifications to her career and ramifications to her job and her reputation.”

The article quoted Colin West, MD, PhD, a professor of medicine at Mayo Clinic, who stated, “When a patient does poorly after an operation—especially when there has been a mistake in their care—surgeons suffer emotional turmoil, anxiety, sadness, guilt, and shame. In 2017, an anonymous surgeon described the aftermath of an error: ‘We all hide our grief—suffer in silence. The pain can be close to debilitating.’”

Yet, the surgeons hide their feelings and move on to the next case. As Chris Bundy, MD, MPH, FASAM, executive medical director of the Washington Physicians Health Program, explained, “People can function at high levels within their profession very expertly with depression, with anxiety, with substance use issues.”

Michael Maddaus, MD, who developed a narcotics addiction while working as a surgeon, stated, “Part of the ethos is that you don’t complain…You just do your work and shut up and have discipline to be strong and pretend you’re okay when everything’s not.”

Essentially, surgeons are being advised to practice a form of stoicism that mimics resilience. The tragic mental health trajectory that can follow from such advice calls to mind the famous warning from the Menninger Clinic: “Never confuse resilience with stoicism.”

Fortunately, while increasing her reliance on alcohol to continue functioning and “to escape her anxiety and depression,” Cunningham told colleagues at a local bar about her depression and suicidal feelings. A coworker called Cunningham’s “boss,” who visited her at home. He suggested that, if needed, she take some time off to seek treatment with the department’s support. As a result of this unusual intervention and assistance, Cunningham began her long road to recovery.

A likely source of Cunningham’s initial response to the challenges of surgical practice can be found in her early developmental experience. A tennis prodigy driven by her stepfather’s apparent expectations, she soon was competing in international competitions. A nutritionist started her on a strict diet devised to accomplish a specific gain in size, and a psychologist “taught her to hide her feelings from her opponents. Never let them know you are struggling.” Cunningham “mastered the art of disguising her emotions.”

This developmental history contrasts sharply with the kind of childrearing most likely to nurture healthy, robust, fully formed resilience, which includes an ambience of trust, unconditional love, secure attachment, a positive alliance, and modeling (including affect regulation) by caretakers within a supportive community.

Concluding Thoughts

In summary, as reported in the other cases featured in this series of articles, the assumption that a facade of resilience, not explored in-depth, represents healthy, fully developed resilience can lead to tragic results.

In contrast to Barkley’s repeated exposure to brief, ineffective treatment, Cunningham’s recovery, as she described it, would occur over time, involving long-term treatment and support focused not only on her psychiatric symptoms, but on her substance use as well, replacing her impaired developmental experience with a strong foundation of trust, secure attachment, appropriate modeling of healthy resilient functioning, and a positive interpersonal alliance with caretakers. Such an alliance should ideally involve the cognitive incorporation of positive caretaker modeling (including affect regulation), all occurring within a reliable supportive community.

Ideally, these factors would be reinforced by an ongoing supportive community. Patients who may be severely depressed and possibly at risk for suicide are not likely to benefit from what has been termed “brief resilience training.” Thus, especially in cases of severe mental illness, one should exercise caution when considering very brief treatment approaches rather than sustained therapeutic exposure to positive developmental influences, a setting that promotes the development of enduring resilience.

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.

Reference

1. Frangou C. US surgeons are killing themselves at an alarming rate. one decided to speak out. The Guardian. September 26, 2023. Accessed June 1, 2024. https://www.theguardian.com/us-news/2023/sep/26/surgeons-suicide-doctors-physicians-mental-health