On the origins of resilience

Just read a pretty interesting research article coming out of Israel (Keren, 2010).  The study looked at psychological/self-regulatory functioning in children ages 0-3 and tried to see if there was a connection between the way moms interacted with their kids and the kids own psychopathology.

What they found came as no surprise and, unfortunately, fits with the classic "blame mom" approach to problematic kids (which, I think is an oversimplification of what's really going on).  Basically, a mom that is distressed, intrusive or depressed herself is more likely to have a child that has problems eating, sleeping, or attaching.  The authors did a really great job looking at different aspects of the mother-child-family dynamics and came to a few really great conclusions about what causes what, and how to move forward.  Rather than go through it, I had a few ideas that I wanted to share

1) One of the findings was that there was no direct correlation between what kinds of distress mom had (depression, anxiety, family tension) and the kinds of symptoms kids had.  Just a blanket statement that a mom in trouble has a kid that reflects it.  It just goes to show that children demonstrate their own distress to problematic situations in unique ways.  This points to the possibility that there is something in-born to the way a person deals with stress: one person can over-eat, while another will isolate.  Moreover, its intriguing that these kinds of responses could have their origins in early childhood (0-3 years of age).

2) Of the kinds of diagnoses given to the kids in this study, at least half could be considered more biological than psychological. One normally doesn't consider a feeding disorder a psychiatric symptom, but when you work with kids, you see that they express distress using whatever tools they have.  As such a feeding or a sleeping disorder, though considered physiological can represent distress in the family unit (or specifically mother-child unit).   Interestingly, when looking at research relating to resilience factors in adults, studies on the biological markers of stress and resilience make up the bulk of what's examined.  For example, I recently read an article talking about levels of levels of a neuro-hormone called NPY (Neuropeptide-Y) in veterans (Morgan, 2000).  On its own, NPY is normally a marker for satiety.  Its just interesting that it can also be found in relation to psychological stressors.  All of this is to say that resilience or vulnerability can be found in physiology in addition to psychology, and that maybe the two things aren't so different after all.

3) Though the authors didn't talk about this directly, a distressed mother is actually something different than a distressed person.  Both can co-exist (i.e. a person can have depression and anxiety independent of her being a mom), but a distressed mom might be distressed for other things more related to family structure and her own upbringing than something inherent to her.  One thing they did talk about was how fathers play a buffering role with maternal distress, but they didn't go into much detail with this. 

4) This study did a very good job of answering what happens when a mother is distressed, but not such a good one of answering how or why it happens.  In thought number two I tried to address how: biological/physiological changes happen in the child in relation to the mother's distress ultimately causing a reflexive distress in the child that physicians label as dysfunction.  I think the question of why is a lot more interesting.  If we look at what the kids are doing as problems and label them as "disorders" we don't see them as adaptations to environmental problems.  In other words, the way a child manifests a set of symptoms may actually be beneficial to him or her.  If mom is anxious by nature, a baby is going to manifest behavior where mom will be even MORE anxious about taking care of the baby.  If familial emotional resources are limited, the baby will do its best to get the most it can.  This makes a lot of sense until resources run out.  Unfortunately, that's when thing fall apart for everyone.  Up until then, baby gets what it needs even at the expense of mom.

5) Given the fact that we can look at the "problems" above as limitations in resources, one way to modify the outcome is to improve the emotional resources of the parent-child relationship.  Answering that question is going to take some time and effort.

Interesting stuff.

Differences

One more thing before I go to bed for the night. A comment I received suggested that I explain the differences between the traditional approach to medical treatment and what I am proposing through resilience medicine (and psychiatry specifically).

In the traditional model, a person comes to their physician with a problem. Through questions and diagnostic tools used to identify symptoms, signs and other markers for the illness, the physician makes a diagnosis based on an understanding of the reasons why such a problem would exist. Based on this diagnosis, the physician prescribes a medication with the goal of treating or palliating the problem. At some point in the future, the physician would reassess the patient to see if his or her symptoms had abated, and if not, revise their diagnosis and treatment until cure or adequate palliation.

In resilience health, there are two possible avenues to enter the system. In the first path, a person would approach the doctor similar to the way they might above, with a problem. In this pathway, the doctor would assess, diagnose and treat the problem in a similar way as the physician above might, but would also assess unique individual capacities, strengths and vulnerabilities and with the persons' participation, act as a guide to promote what the person is already doing well and make suggestions about modifying risk factors. This is actually what should be going on in most doctors appointments, but due to time constraints, the strength/vulnerability part is often boiled down to an assessment of problematic behaviors (drinking, drugs, smoking, dietary no-no's, sedentary habits, risky sexual behavior, sun block, seat belt use and helmet use).

The second entry point would be more of a yearly check-up/tune-up. I want to save this approach for later so I can spend a whole post outlining what this might look like.

I think the best way to demonstrate differences would be to describe two different kinds of psychiatric visits I've performed.

Traditional/typical approach:

I saw a middle aged female patient at a community clinic last week who had been given a diagnosis of bipolar disorder. After exchanging smiles and hand shakes, I asked what I could do to help. She said that she was there for a prescription and that her life, though stressful at times, was going well. I asked a little more about that and she offered that she had been having some troubles with her children who were taking advantage of her generosity and hadn't been looking for jobs as they told her they would. I asked her about how this had affected her, and she said that she was sleeping less well, and had been eating less for the past two weeks. I asked her if her mood had changed, or she had any symptoms relating to her bipolar diagnosis and she told me that she had been a little more irritable. Even so, she told me that the medication was keeping her "steady" and that she didn't make any changes to the medication regimen that she had been using for the past four years. I asked her if she wanted to see anyone to talk about her stress. She said she was fine, and that she would be talking to her case manager later in the day. I asked if she had been having any side effects from the medications. She denied any. I assessed for suicidality or homicidality, and she denied both. I wrote her scripts and suggested that we meet again in two months. She smiled, I smiled and she left the office.

Resilience approach:

I saw a younger male patient the other day who had been given a diagnosis of generalized anxiety disorder. I invited him into my office, smiled and shook hands . I asked him how he was doing. Being new to me, he provided a short explanation of the course of his illness, including where he thought things began and where he was right now regarding his symptoms. In his narrative, he told me about his love of music and performance, and how his anxiety had impacted his ability to play instruments, making him sick before shows, with horrible nausea, sweaty palms, dry mouth and a feeling like his stomach was on fire. I heard that he had suffered a great deal due to his condition, but that he was making the best of his situation. He did this by making furtive half statements like "I think things are more under control now," or "I've been working hard on that and its been a little better." I asked him what he was doing to get things "under control" and he said that, before performing he told himself that his acute anxiety would pass once he got into it (reflection), and that he "pepped" himself up before going on stage saying things like "I can do this! This is going to be fun! I love stuff like this." (reappraisal) He then looked at me and said, "no one can tell I'm scared out of my mind... I guess my natural vibrato hides the shakiness of my voice ok." (humor). I asked him if he had learned anything else that could help him and he said that his father had used beer, but that he knew better than that.

I smiled at him, and told him how much I admired his strength, and determination to overcome his fears and symptoms. I explained how the body reacts to stress using the "fight-or-flight" system and how his reactions were on the high end of the normal spectrum. I also reflected with him that it seemed as though the repeated activation of his stress system was wearing away at his reserve. I named the skills he had been using to control his anxiety (reflection, reappraisal and humor), explaining how each of them work and suggesting slight modifications that might help. I affirmed that his hope for feeling better was well founded, and that through working together, he could get a handle on how he felt. I shared my thoughts that his anxiety was part of his family's psychiatric history, and that there were better, and safer tools than beer which he could use to overcome it. After answering a few of his questions, I provided him with scripts for medications he was taking and suggested a Beta Blocker for performance anxiety. He explained that the previous doctor he had seen had suggested this too, but he had refused, worried that he would get addicted to them. We spoke about the risks and the benefits, and he was exited that they might help him before an upcoming performance. We shook hands and he said "this was the best doctors appointment I have ever had." I smiled and told him how much I admired his strength.  We planned a meeting in two weeks to see how things were going.

I've been trying to do this with every patient I see, and I manage to stay within my 30 min time window just fine!

Hope this helps!

Trying to define "resilience"

I think before I go any further with this idea, it might be important to define what resilience actually is.

Unfortunately, as is the case with many words in the medical literature, resilience has too many meanings and consequently, its hard to get a handle on.

When defined by the basic sciences, resilience is used to describe how well a material can return the energy that is put into it. In other words, it is a measurement of how well an object can return to its original state after it has been deformed -- how springy is a spring. When used in biology, it takes on additional meanings. In cell biology it refers to the ability of a cell or a community of cells to recover from a disruption introduced into their environment. This can be extrapolated to other living communities. For example, we're currently very concerned about the resilience of fragile ecosystems as they are confronted by global climate change.  Will these plants and animals be able to adapt to the changing environment?

When talking about human beings the word resilience takes on a lot of not-so-clear definitions. As it relates to the individual, a topic that I'll try to explain in the next few paragraphs, we talk about psychological resilience, familial resilience, community resilience (i.e. how well did New York recover after September 11th), physical/sports resilience (how quickly does Raphael Nadal's confidence recover after a lost point) and organizational resilience (how well does a business adapt to changes in the environment). Given that I know little about most of these topics, I'll stick to psychological resilience for the time being.

The definition of psychological resilience is not so straight forward either. The term has become a topic of research in three major areas of medicine:

1. Trauma and disaster intervention
2. At risk youth and decision making
3. The effect of medical illnesses (i.e. cancer) on mental well being

Each research domain defines resilience slightly differently based on unique research methodology considerations. Even so, there are similarities that I'd like to touch on for the rest of this post.




First, in all three of the instances above, resilience is multifaceted. This definition characterizes a unique interplay between an individual's psychological, physiological and psycho-social state, their previous encounters with environmental challenges (their perception of the event) and vulnerabilities that come into play at the moment when a stressor is introduced. A schematic of this interplay is shown above. This particular image forms one of the theoretical foundations for clinical liaison psychiatry and includes within it something called "Allostasis" that I'll address in the future.

Second, resilience is considered to be a complex dynamic process that can change from minute to minute. This is very different from other definitions where the resilience of a system is more or less static. Imagine a person, Francis, responding to a traffic accident. Within moments of seeing the accident happen, Francis has a complex interplay of emotions, physiological reactions and thoughts that would emerge predicting whether she would respond to the accident or run away. Now imagine that the person who was in the accident was Fran's friend, or that she was standing next to her favorite teacher who happened to be a very calm person. This would allow for a different response to the stressor and possibly a different psychological outcome in the end. One of the best examples of this comes from literature emerging from cancer psychiatry in children. The best predictor for how well a child does in the face of illness has to do with their parents' proximity and response to their condition. More on this later.

Third, in any given situation, resilience is a recursive process where over the course of the effect of the stressor, a person has the ability to learn and adapt or become more vulnerable. If Francis were to run away from the accident, she would feel guilty, and potentially even more stressed than if she had gone to help. Alternatively, if she had gone to help and overcome the emotional, physiological and psychological barriers to her doing so, she would, in that moment, begin a process where she potentially felt stronger and more resilient then and in future events.

Finally, and most importantly for this blog, resilience is something that can be actively modified prior to, during and following a stressful event. There are things that any person can learn to do that will help him or her cope better with stress and rebound more successfully. Many of these factors are learned throughout life; self-talk, suppression, humor, mindfulness and distraction are a few skills that seem to emerge from cultural and evolutionary wisdom. Nonetheless, there are skills that can be honed and techniques that can be learned that can help people deal with the daily (or more severe) stresses in their lives.

In clinical practice today, mental health practitioners begin with the assumption that all mental illness begins with pathology and is cured through discovering and fixing what's wrong. Patients, perhaps sensing this, arrive at their doctors appointments with questions based on this assumption: why do I feel like this? Why can’t I get what I want out of life? Why am I so sick and how can you help me?

As a culture, we have a tendency to dwell on our weaknesses with the thought that through sharpening our understanding of the things that contribute to the problem, we will find the solutions. This is and has been a very useful approach for fixing most simple and many complex problems in medicine -- it gives us a way of understanding where dysfunction occurs, provides a tool for analyzing these dysfunctions, presents a way of categorizing and naming things and inspires a methodology for returning the human being to a state of non-dysfunction.

Unfortunately, using only this approach for understanding mental health and the amelioration of the causes of human suffering is incomplete at best and harmful at worst. Though we have made significant advances in our understanding of the way the brain works, the simple explanations psychiatrists have used to understand and explain mental illness (i.e. depression is caused by a chemical imbalance) are not proven fact, and new discoveries change these frequently. Consequently, the treatment we provide often leave both patient and practitioner frustrated with the results. Through this model, we try to correct what’s wrong without recognizing just how right things are already. We stand on our mountain peaks and look out over our failures, not recognizing just how far we’ve come, what we’ve overcome and how strong we actually are.

A different way of looking at mental health is through a resilience based approach or one that examines the strengths and capacities that appear both inherently in the developing human being and which we have learned explicitly through our exploration of science, spirituality and philosophy. This model is based on the assumption that human beings are fundamentally whole, and through the recognition and cultivation of certain traits, skills and capacities, we can live happier, more productive and more meaningful lives.

This is by no means a new idea. Not only has it existed in various forms throughout history, but it is being studied by scientists and doctors today. Even so, though a resilience based approach has gained some popular acceptance, its principles and wisdom has barely penetrated the edifice of modern medicine.

I hope to do several things with this blog. First, I will examine the medical and psychiatric research to see if a resilience approach to healing has merit. Second, I will identify resilience factors that exist in human physiology, psychology and culture. Third, I will point my readers to studies, books and techniques that have proven both safe and effective in the cultivation of resilience factors. Finally, based on what I find above, I will try to articulate a way we as a culture and world can move forward through education and social interactions to help us become happier and healthier.

I understand that this is a daunting task. All I can say is that I will do my best. Over the life of this blog I hope to put out some ideas I've been working on, review and present the scientific literature in a way the public can understand, present my own patient interactions where I use this approach and, finally communicate with my readership for the purpose of ameliorating suffering, improving resilience and better understanding this complex subject.


I look forward to beginning in earnest soon.