How to raise resilience levels in brain injury survivors, their families and OTs

On World Mental Health Day (10 October 2020), we examine the research into why resilience levels differ and how coping strategies can strengthen resilience reserves during testing times.

It comes as no surprise to hear that people with pre-existing mental health conditions have been hit harder by stress caused by Covid-19.

Over 30 per cent haven't been coping well, according to new findings from an ongoing Mental Health Foundation (MHF) study of how the pandemic is affecting people's lives in the UK. [1]

On the upside, however, 57% concluded they had managed well, so far, having found internal and external sources to boost their resilience.

 

So, what is resilience?

The most straightforward answer is the ability to bounce back. But, in the words of rehabilitation experts, it's an individual's capacity to positively adapt in response to stress or adversity, such as chronic illness or catastrophic life events. [2]

Studies [3] [4] have shown that our level of resilience is influenced by several factors, such as:

 

• Genetics 
• Internal character traits.
• External environments are affecting personal risk.
• Exposure to stress or trauma.
• Childhood experiences.
• Demographics 
• Culture 
• Economic and social status.

 

To further break down some of those elements, that means all of the following can also affect our resilience [5]:

 

• Morals: the 'bedrock of resilience'. [6]
• Spirituality: shown in one study to be a 'leading' predictor of resilience in people of faith. [7]
• Goals: setting goals establishes personal control, purpose to life and motivation to overcome obstacles. [8]
• Social connections: one of the top 3 coping strategies cited in MHF's survey. [9]
• Sense of humour: recognised as a typical coping response. [10]
• Altruism: turning pain into 'pro-social action' can benefit personal healing. [11]
• Optimism: optimists are 'significantly more successful' than pessimists, one study found. [12].
• Role models: historical and current heroes lead by example, imbuing others with strength. [13]
• Fearless factor: resilient people take a pro-active approach to fear. [14]
• Hope: found to bolster resilience among family carers of people with TBI or spinal cord injury. [15]

 

Resilience and the brain

Exactly how the brain develops resilience remains a matter of ongoing scientific scrutiny. But a recent review of functional imaging studies of children and adults post-trauma revealed 'some striking regions of convergence' [16]

Those converging regions of the brain are involved in cognitive control in achieving better outcomes, emotion regulation and reward responses.

And, significantly, they are mainly the same areas linked to vulnerability for stress-related disorders. These regions are:

 

• Prefrontal, medial, and anterior cingulate cortices.
• Amygdala 
• Hippocampus 

 

Other research looking at the neurobiological correlates of resilience also points to systems and processes within the brain that begin 'tuning' it to adapt to hardships from the moment we are born. [17]

 

Resilience and brain injury

Not long before the onset of the Covid-19 pandemic, a team of US researchers made a fascinating discovery while weighing up the well-being of 67 adults with complicated mild-to-severe traumatic brain injury (TBI). [18]

 

   Brain injury, they found, did not lessen the effect of resilience on long-term well-being.   

 

Accordingly, they advised, 'Routine assessment of resilience might be beneficial to the rehabilitation team' for the following reasons:

 

• Resilience appears to function similarly among adults with TBI to those without.
• Resilience has unique characteristics and value in understanding well-being.
• Low resilience affects well-being more than high resilience.
• Individual capability to rebound from adversity likely shapes future behaviour.

 

The findings echo those of an earlier study into how correlates of resilience, such as coping strategies and social support, affected the adjustment of brain injury survivors in the first five years post-TBI. [19]

Encouragingly, the majority of participants reported high levels of resilience after their injury.

It was also evident that the survivors' correlates were similar to those in adults without cognitive impairments.

Further discoveries in another US study prompted a call to shift the focus of rehabilitation to resilience to 'allow for recovery in a broader sense that exceeds expected outcomes. [20]

 

Coping as caregivers

Resilience is the reason why there can be a positive outcome in times of stress or adversity, such as caring for a brain injury survivor during a pandemic.

It was proved in a sweeping review of 23 resilience studies involving carers of patients with chronic, advanced illness and at the end of life. [21] The report concluded:

'Promoting a resilient coping style in caregivers reduces the distress that normally results from illness-related changes in the biopsychosocial and spiritual dimensions.'

In a separate analysis of family resilience [22], no less than nine processes are identified that can help families strengthen their ties, and thereby their stability, in times of crisis:

 

• Making sense of it all: viewing crises as meaningful and manageable.
• Positivity: focusing on potential, hope and optimism.
• Interconnection: sharing mutual support and commitment.
• Creating financial security: pooling and accessing resources.
• Clarity: sharing information and consistent messages.
• Emotional support: including painful and positive feelings.
• Collaborative problem-solving: joint decision-making and goals.
• Spirituality: connecting with larger values.
• Flexibility: reorganising to provide continuity and predictability.

 

Ratchet up resilience

Almost nine out of ten of us have employed at least one coping strategy to help deal with stress caused by the Covid-19 pandemic, according to the ongoing MHF survey.

Yet few have resorted to contacting a professional for help. Even among those with a pre-existing mental health condition, only 11% sought that sort of support.

The vast majority utilised one or more coping tactics to bounce back, including:

 

• Keeping in contact with friends and family.
• Steering clear of negative thinking.
• Exercising.
• Enjoying nature.
• Taking time to relax.
• Eating healthily.
• Staying aware of alcohol or drug use.
• Mindfulness.
• Lots of good sleep.
• Enjoying hobbies.

 

Another coping strategy discussed in Psychology Today [23] is 'controlled exposure' in which individuals are gradually exposed to anxiety-provoking situations in a bid to help them overcome their fears.

Evidence suggests this can enhance resilience, mainly when it involves goal-setting and skill-acquisition.

Learning to accept life changes also shores up resilience, as does learning from past sources of personal strength, according to the American Psychological Association (APA).

But there's a clear winner in APA's eyes in the resilience-building battalion: supportive relationships within and outside of the family.

'Relationships that are caring, loving, and offer encouragement and reassurance, help cultivate a person's resilience.' American Psychological Association.

 

Building resilience with OT input

Decades of evidence points to the importance of early neurorehabilitation intervention to boost the likelihood of positive outcomes – and that includes improving resilience.

A recent US study [2] looked at the impact of occupational therapy on resilience in 36 individuals with multiple sclerosis (MS) and found:

 

• The group receiving OT showed significant improvement in resilience. The control group did not.
• Resilience plays a vital role in functional recovery and maintenance.
• OT's maybe 'uniquely positioned' to affect resilience due to their focus on daily functioning and participation.

 

The findings suggested neuro OTs can boost a client's resilience-building by:

 

• Supporting positive social and family links.
• Promoting self-esteem.
• Working on communication and problem-solving skills.
• Helping to enhance social and life skills.
• Setting goals.

 

The resilient OT

Occupational therapists may feel their resilience reservoirs running dry during challenging times globally.

But a study in the Australian Occupational Therapy Journal [24] shows there are strategies to keep those reservoirs topped up:

 

• Polish up and reaffirm that strong professional OT identity.
• Take an occupational perspective of health.
• Seek 'good' supervision.
• Establish support networks.
• Regularly reflect on the theoretical knowledge underpinning your practice.
• Stay work connected via in‐service meetings.
• Stay socially connected with family and friends.
• Work in a role that matches your knowledge with opportunities to apply it in practice.

 

Resilience rulers

There are many measures of resilience employed by health care professionals, but some of the best known include:

 

• Connor-Davidson Resilience Scale (CD-RISC): developed in 2003, this is a self-report measure of resilience as a function of 5 components, including acceptance of change, trust, tolerance and spiritual influences.
• Brief Resilience Scale: a self-rating questionnaire that rates ability to bounce back from adversity based on six positively and negatively worded items.
• Resilience Scale for Adults (RSA): this consists of 5 scoring items examining protective factors that assist adaptation to stress, including personal and social competence and social support.

 

World Mental Health Day

The World Federation for Mental Health has set this year's theme for World Mental Health Day as 'mental health for all' in response to the global Covid-19 pandemic.

Further information here: https://www.who.int/campaigns/world-mental-health-day/world-mental-health-day-2020

 

Related articles

Expert stress and anxiety advice for brain injury survivors during the covid 19- pandemic

Krysalis - Family matters

Treating yourself with compassion - Part one

Treating yourself with compassion - Part two

Krysalis - Public resources

 

References

[1] Mental Health Foundation, "Coronavirus: Mental Health in the Pandemic," 2020.
[2] Falk-Kessler, J. et al. "Influence of Occupational Therapy on Resilience in Individuals with Multiple Sclerosis," International Journal of MS Care, 2012.
[3] Southwick, S. M. et al. "Resilience definitions, theory, and challenges: interdisciplinary perspectives," European Journal of Psychotraumatology, 2014.
[4] Wu, G. et al. "Understanding resilience," Frontiers in Behavioural Neuroscience, 2013.
[5] Ackerman, C. "3 resilience scales," PositivePsychology.com, September 2020.
[6] Panter-Brick C. et al, "Understanding Culture, Resilience, and Mental Health: The Production of Hope," in The Social Ecology of Resilience, 2012.
[7] Min, J-A. et al. "Characteristics associated with low resilience in patients with depression and anxiety disorders," Quality of Life Research, 2012.
[8] Polizzi, C. et al. "Stress and Coping in the Time of COVID-19:," Clinical Neuropsychiatry, 2020.
[9] Mental Health Foundation, "Resilience across the UK during the coronavirus pandemic," October 2020.
[10] Van der Hallen, R. et al. "Coping and resilience in adults: a cross-sectional network analysis," Anxiety, Stress and Coping: An International Journal, June 2020.
[11] Hernandez-Wolfe, P. "Altruism born of suffering: how colombian human rights activists transform pain into pro-social action," Journal of Humanistic Psychology, 2010.
[12] Conversano, C. et al. "Optimism and Its Impact on Mental and Physical Well-Being," Clinical Practice and Epidemiology in Mental Health, 2010.
[13] Ponte, K. "Coronavirus: Building Mental Health Resilience," National Alliance on Mental Illness, April 2020.
[14] Iacoviello, B. M. and Charney, D. "Psychosocial facets of resilience: implications for preventing post-trauma psychopathology, treating trauma survivors, and enhancing community resilience," European Journal of Psychotraumatology, 2014.
[15] Simpson, G. K. et al. "Do spirituality, hope and resilience mediate outcomes among family caregivers after traumatic brain injury or spinal cord injury? A structural equation modelling approach.," NeuroRehabilitation February 2020.
[16] Norbury, A. et al. "Neuroimaging Resilience to Trauma: Convergent Evidence and Challenges for Future Research.," PsyArXiv PrePrints, November 2019.
[17] Feldman, R. "What is resilience: an affiliative neuroscience approach," World Psychiatry, May 2020.
[18] Rapport, L. J. et al. "Resilience and well-being after traumatic brain injury.," Disability and Rehabilitation, 2020.
[19] Hanks, R. A. et al. "Correlates of resilience in the first 5 years after traumatic brain injury," Rehabilitation Psychology, 2016.
[20] Neils-Strunjas, J. et al. "Role of resilience in the rehabilitation of adults with acquired brain injury," Brain Injury Journal, 2019.
[21] Palacio, C. et al. "Resilience in Caregivers: A Systematic Review," The American Journal of Hospice and Palliative Care, 2019.
[22] Walsh, F. "Family resilience: a developmental systems framework," European Journal of Developmental Psychology, 2016.
[23] Whitley, R. "Three Simple Ways to Enhance Mental Health Resilience," Psychology Today, 2018.
[24] Ashby, S. E. "Factors that influence the professional resilience of occupational therapists in mental health practice," Australian Occupational Therapy Journal, 2012.