Resilience and Renewal: Enhancing Positivity and Functional Recovery After Traumatic Brain Injury

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A traumatic brain injury (TBI) occurs when brain function is altered due to an external impact to the head or body, or from inertial forces such as rapid acceleration-deceleration of the brain within the skull.¹ Approximately 3-4 million new cases of TBI occur each year in the United States.^2,3 Emotional and psychosocial consequences are common following brain injury, and individuals with TBI are at risk for low resilience.^4,5 Low resilience following TBI is associated with psychological distress and decreased psychosocial adjustment, and may negatively influence rehabilitation outcomes.^5,6

Resilience

According to the American Psychological Association, resilience is defined as, “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility, and adjustment to external and internal demands.”⁷ Sisto et al add that psychological resilience involves the ability to recover, and is a dynamic process that evolves over time.⁸ Research demonstrates specific skills can be learned and practiced to enhance resilience and improve a person’s ability to adapt following brain injury.⁹

Positive rehabilitation outcomes following brain injury are associated with higher levels of resilience. Individuals reporting higher levels of resilience are better able to manage stress, report less anxiety, show greater adaptation and adjustment following injury, demonstrate less disability, and enjoy greater levels of community participation and higher life satisfaction.^10-13 Therefore, engaging patients in interventions to develop and strengthen resilience may improve rehabilitation outcomes by promoting psychosocial adjustment, mitigating emotional distress, and enhancing participation in the community.^13-15

Assessing Resilience

Resilience can be assessed subjectively during a structured clinical interview by asking when the person faced adversity or a challenge and overcame it. Open-ended questions and probing for more information can provide cues regarding strategies that have been successful in overcoming challenges in the past. There are a number of formal assessments that have been used with persons with TBI. Stoner et al evaluated psychosocial outcome measures and found the Connor-Davidson Resilience Scale to be a psychometrically robust measure of resilience with good reliability, validity, and sensitivity.¹⁶ The Connor-Davidson Resilience Scale is a 25-item self-report measure assessing a number of constructs associated with resilience, such as: personal competence/tenacity, tolerance for negative affect/stress, positive acceptance of change, internal locus of control, and spirituality.¹⁷

Interventions to Promote Resilience

Resilience-based interventions are simple, yet powerful strategies that focus on building on existing strengths rather than resolving deficits. These interventions strengthen resilience and may positively impact rehabilitation.¹⁸ Resilience-based interventions include: managing emotions, use of approach-oriented coping strategies, strengths-focus/positive psychology practices, optimism/maintaining a positive outlook, and spirituality.^17,19

Managing Emotions/Emotional Regulation

Emotional regulation involves a set of cognitive processes, such as attention, self-awareness, and perceptions of the emotions of others, that allows an individual to monitor, evaluate, and change emotional responses to internal and external stimuli that are appropriate to the circumstance.²⁰ Following brain injury, failure to regulate emotions can lead to irritability, anger, and impulsive behavior which can interfere with a person’s ability to fully benefit from therapy. It can also damage relationships and impair the ability to engage in meaningful activities and social roles.²¹

Mindfulness-based approaches target stress reduction through nonjudgmental awareness, mindful movements, or structured breathing exercises. In addition to reducing stress, mindfulness-based approaches increase self-efficacy, knowledge, and skills to manage symptoms, as well as improve some cognitive functions (ie, attention and processing speed).²² Another emotional regulation technique is the “10-10-10 Rule” developed by Welch.²³ Patients are asked to consider the consequences of their decisions 10 minutes in the future, 10 months in the future, and 10 years in the future. Prompting patients to consider a long-term perspective encourages consideration of the future self: the person’s goals, aspirations and values. When individuals are better connected to their future selves, they have an enhanced ability to recognize the consequences of their present-day decisions on their future selves.

Those who are better able to regulate their emotions are more resilient and bounce back quicker. Successful emotional regulation not only involves down regulating negative emotions, but also regular experience of positive emotions.²⁴

Focusing on Strengths/Positive Psychology Practices

Systems of care influenced by the medical model often adopt a “diagnose and treat” approach.²⁵ This focus on illness, deficits, and impairments does not address the holistic needs of the individual during postacute rehabilitation, and may not support successful reintegration to the community.²⁶ Focusing on deficits and weaknesses may result in psychological distress, and inadvertently promote a victim mentality or adoption of a sick role. During rehabilitation, greater attention should be placed on identifying and building upon individual strengths, providing opportunities for experiencing positive emotions, and delivering interventions that foster personal growth.²⁷ This approach is consistent with positive psychology practices.

Gratitude is a powerful positive emotion associated with happiness, well-being, and physical health. Simply documenting all the things one is grateful for, both large and small (ie, a gratitude list) can result in the experience of positive emotions. Each night for 1 week, Seligman et al asked participants to write down 3 things that went well each day, as well as the cause for the things that went well. Additionally, participants were asked to provide a causal explanation for each good thing.²⁸ After 6 months follow-up, participants reported greater happiness and less depression.

Frisch obtained similar results using a Blessings, Achievements, and Talents (BAT) exercise, in which participants were asked to record these 3 items.²⁹ Blessings were things they were grateful for; achievements included any achievement over the lifetime, large or small; and talents included personal strengths or positive things others might say about you.

Coping and Adaptation

Coping refers to the thoughts and behaviors individuals use to manage situations that are stressful, or exceed available resources.³⁰ Coping strategies are generally categorized as either adaptive (also referred to problem-focused or approach-oriented), or maladaptive (also referred to as passive, or avoidant-oriented). Adaptive or problem-focused strategies seek to actively address or confront the problem. They include gathering information, asking for and accepting help, planning and problem-solving, and/or reappraising the situation as positive. Maladaptive or avoidant-focused strategies, rather than taking action to change the stressful situation, involve denial, wishful thinking, minimization, blaming, or avoiding by using drugs and/or alcohol.³¹ Following brain injury, adaptive coping is associated with better self-esteem, greater perceived self-efficacy, increased problem-solving, reductions in anxiety and depressive symptoms, and higher quality of life.^32,33 Maladaptive coping is associated with higher levels of anxiety and depression, and lower self-esteem.³⁴

Research has demonstrated that coping skills are modifiable—that is, can change in response to specific interventions.^32,33 Cognitive behavioral therapy (CBT) interventions focusing on the development of specific coping skills (ie, problem-solving), or reappraising situations accurately or more positively, resulted in improvements in coping for individuals with brain injury. Backhaus et al describe a randomized controlled trial that involved a 12-session, manualized CBT group in which participants received psychoeducation, social support, and coping skills training.³³ When compared with a wait list control group, the participants in the CBT intervention showed greater perceived self-efficacy and less emotional distress immediately after treatment and at follow-up. Anson and Ponsford enrolled individuals with TBI in a CBT-based group intervention (coping skills group) to improve adaptive coping. Improvements in coping were noted after 10 sessions. Coping that involved problem-solving, humor, and pleasurable activities to manage stress was associated with higher self-esteem.³²

Optimism/Maintaining a Positive Outlook

Individuals who are optimistic are not immune to negative emotions or negative events; however, they do not get stuck in negative emotional states and they do not blame themselves for bad circumstances or outcomes. Instead, they view negative events or circumstances as temporary, have expectations that positive events are likely to occur in the future, and believe they have some measure of control or influence over the positive outcomes in their lives.³⁵ While approximately 25% to 50% of optimism is inheritable, about 40% of our ability to see the glass half full is under our direct control; individuals can learn to be more optimistic.³⁶ Interventions that promote optimism involve helping patients look to the future with hope. More than a positive emotion, hope is action-oriented and involves agency, setting realistic goals, and motivation to reach goals or achieve preferred outcomes.³⁷ One strategy to promote optimism is writing a letter from the future. By envisioning a positive future, participants come to believe that the predicted future is possible, thus influencing their actions and choices to move towards that preferred outcome. This approach helps patients to distance themselves from problems, imagine a more positive and hopeful future, believe that change is possible, and increase agency and self-efficacy.³⁸

Spirituality

Spirituality has been defined as the experience of a deep inner connection to something larger than oneself, and practices that connect with the transcendent.³⁷ It is a sense of being part of something timeless and infinite. Individuals who are spiritual feel a sense of meaning and purpose, as well as peace and connectedness, even in the face of challenges. Spirituality can include religious expressions and formal religious activities or ceremonies. A person does not need to be religious to be deeply spiritual. Spiritual experiences and expressions can include savoring a sunrise, helping or serving others, or public and private acts of worship (ie, reading scripture, engaging in specific rituals, etc). Waldron-Perrine et al asked 88 individuals with TBI to report on their religious/spiritual beliefs and psychosocial resources. Statistical analyses showed that religious well-being (a sense of connection to a higher power) predicted satisfaction with life, less distress, and greater functional ability.³⁹ Phillips et al examined the association between religious attendance and psychosocial outcomes after TBI using TBI Model Systems data collected between 2007 and 2012.⁴⁰ Adults with TBI responded to a survey (in-person, by mail, or by telephone) about how many times they attended religious or spiritual services (ie, church, temples, and mosques). Attending religious services was associated with better life satisfaction, greater social participation, and less depressive symptomatology.

Concluding Thoughts

Resilience is the ability to recover quickly following challenges or difficulties and successfully adapt or adjust to external demands. Resilience can be strengthened by practicing simple, yet powerful strategies. Rehabilitation outcomes following brain injury may improve by engaging patients in interventions to develop and strengthen resilience.

Dr Seale is the Regional Director of Clinical Services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a psychological associate with independent practice. He is a certified brain injury specialist training and holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

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