A number of my very patient colleagues have had to endure me banging on about “resilience” recently. Because I hadn’t explained myself brilliantly well, some folk had quite reasonably assumed I was going on about emergency planning or another ‘flu pandemic.
Actually I was talking about resilience as a psychological and behavioural attribute. The things which enable people to appraise and find ways of dealing with things which may cause stress or challenges to their health.
Derek Mowbray, a psychologist working in this field (about whom more later) describes personal resilience as “a process of getting a robust attitude in the face of challenging and threatening events. It’s also about becoming a stronger person as a consequence of facing up to and overcoming challenging experiences.” He explains in two sentences around 50 years of psychological research. Those of you with an interest in spirituality will also find strong similarities here in the research which shows spirituality is a strong aid to personal coping, resilience and wellbeing.
But I digress. The point is, resilience as a psychological construct has evidence around it sufficient to warrant policymakers, practitioners and commissioners taking it seriously as an aid to keeping people as well as possible, and helping them manage their challenges.
Take the field of public mental health, for example. There is growing evidence that neighbourhood stress (poor environment, fear of crime, poor housing etc) adds to the burden on people and becomes a set of vulnerability factors [things which make people more susceptible] to poor mental health. Some recent work on Social Capital in Scotland, for example,http://www.gcph.co.uk/assets/0000/3647/Social_capital_final_2013.pdf reinforces this.
But why should people in health, social care and public health bother?
Well, the research suggests resilience as a construct or attribute can do a number of things for us:
- Help people cope with long term conditions and create the behavioural and emotional foundations for good self-care and self-management
- Help people cope with life and both prevent some common mental disorders arising and help those living with mental health challenges at low levels to adjust to daily life
- Help children and young people grow up well-adjusted and ready for life,
- Help people cope with their differences from the rest of society, especially LGBT people finding it difficult to come out
- Help carers care for themselves and remain well while caring for others
That sounds like an ambitious agenda, doesn’t it? But aren’t these outcomes which have been at the core of clinical and public health ambition for ages?
It’s part of my ongoing ambition that behavioural sciences including psychology can help us find models which contribute to achieving these outcomes.
And there is a long research pedigree, which has been around since before the now much vaunted (and valuable) field of positive psychology.
One reading which has had an effect on me is Alex Zautra’s chapter on “Resilience: A new definition of health for people and communities” in pages 3-29 of Reich, et al (2010) Handbook of Adult Resilience http://www.amazon.co.uk/Handbook-Adult-Resilience-John-Reich/dp/146250647X
They identify that risk factor research (starting with the Framingham Study in 1951 so public health colleagues take note) ” has a long and successful history of identifying biological and psychosocial vulnerabilities to chronic, as well as acute, illness. ”
They ask the question of how people “sustain themselves while ill, and how do so many who are ill recover?” They offer “resilience as an integrative construct that provides an approach to understanding how people and their communities achieve and sustain health and well-being in the face of adversity. Our aim is to define resilience based on current thinking in biopsychosocial disciplines, to outline key research methods employed to study resilience, and to suggest how this approach may further the development of public health and other intervention programs designed to promote health and well-being.”
Since I read this Chapter, I have read probably over 100 other papers which I think underpin the work they do. The challenge for us is operationalize this, to translate this stuff into useable methods and tools which have some evidence behind them, or are promising enough for us to commission and evaluate.
What are the big points in resilience, then?
This field is burgeoning, but here are some key starter points:
- Patient, carer and professional need to know that building resilience is a journey. It requires work.
- Attitude and outlook on life and your challenges are hugely important, thinking patterns which are not self-limiting, self-destructive or avoidant help you get here
- Being able to (i) appraise threats, stressors (potential sources of stress or which test your ability to cope) and daily life, (ii) identify realistically the ability to cope and (iii) identify the strategies you need to deploy to stay well and in control are important
- A portfolio of coping skills and techniques (e.g. breathing techniques for people with COPD) for daily challenges is needed, along with the ability to use these to turn daily challenges into routine non-threatening stressors
- Non cognitive coping resources (support packages, social support, engagement)
- You need some clear steps to take when you’re feeling overwhelmed and steps 3 and 4 aren’t working
- You need to know when to ask for help, knowing what help to ask for, and knowing where to go to
- You need regular feedback from others (professionals and those in the same situation) on how you’re doing
Now that doesn’t sound too complicated, does it? There is a good American Psychological Association reading resource and indeed a leaflet on this here http://www.apa.org/helpcenter/road-resilience.aspx
Resilience strategies have been successfully used with people with HIV, people recovering from Stroke and people with drug and alcohol problems for some years. Many of us just probably never called them that and never really used the full range of tools we could to enhance and deliver effectiveness.
And this is just one problem with how we use, misuse, abuse and underuse behavioural sciences in the health and social care system: we don’t really get it right, it’s bitty and incomplete and then we wonder why it isn’t working. We often think we know it and it’s common sense. Behavioural science at its best should be simple, but it’s not always common sense. Behaviour science can be very counter-intuitive. We may, perversely, over-complicate behavioural science, or not pick the right intervention, or get the pathway wrong.
The “what” of what resilience should be in daily life is frequently (unintentionally) sabotaged by how professionals and systems are organized. But if a public health skill is to identify successful interventions which are evidence-based, and then implement them with fidelity to the evidence, you’d think we should be able to overcome these challenges.
I believe that we often put behavioural science contributions in the too difficult box. If you feel you know it all already then please reconsider, you’re probably missing something. If you feel it’s too complicated then usually you’ve been reading research that hasn’t translated well out of research into English.
The list of of reasons I’ve just reeled off covers most of the factors where behavioural science approaches haven’t worked well. It’s not the science, it’s how well we use it.
As a way round this, I believe the evidence demonstrates that if we combined behavioural science know-how with practical experience on designing and implementing systems, and getting the right culture to make it work, we could actually make a substantial contribution to the health of people and the workload of our health system. That’s what I want to try to do.
What about resilience for me as a worker/carer/volunteer?
There is an important issue here in what some people call “self-care”. Resilience for those of us working in the challenges posed by our population and our health and social care system is going to become increasingly important if we are to stay the course.
Occupational Psychology has a wealth of learning to offer on how workers who are personally resilient are more effective, efficient, healthier and have better outlooks on life. Having faced some big health challenges recently and taken on a new job, I decided to work my way through Derek Mowbray’s Guide to Personal Resilience. http://www.mas.org.uk/publications/personal-resilience.html
Ok, Ok, he’s a Chartered Psychologist and you already know I have a bias towards psychology, largely because I am a psychologist by background and because I think there is ample evidence we need to learn more from psychology in health and social policy and the running of public services. But this stuff works.
Mowbray takes you through a questionnaire on your own resilience, and helps you look at things like self-awareness, determination, your vision for what you want to achieve, your organization, relationships, interaction and problem solving and so on. He also gives 18 tips for resilience.
So where next?
I am aiming to get some psychologists and behavioural scientists together with clinicians to look at what we might achieve. If you think you can contribute to this agenda, I’d love to hear from you.