Just this morning I was discussing with a nephrologist colleague of mine whether resilience is a trait or a state. My answer is that it is a little of both. I operate out of a social learning perspective, and look at resilience as a coping resource consisting of both a set of beliefs and behavioral tendencies. According to social learning theory, our beliefs and behavioral characteristics are shaped by our experiences. As we gain more experience, who we are and what we do are changeable. At the same time, the older we get, the more difficult it is to change, but impactful experiences can, indeed, make us more (or less) resilient.

I would think both. Personality traits like self directedness (TCI) seem to confer resilience in many situations including chronic illness. But one's situation (education, social support, family status, wealth) are surely state of being and also confer resilience.

The definition of resilience is still blurry,unfortunately. As Ada said resilience can be both a state and a process. The same holds for the association between psychological resilience and coping. They are interrelated. Practical advices:

If your study is cross-sectional define psychological resilience and coping very precisely, as well as, how to measure it. Since psychological adjustment and coping are also usually described as leading to more resilience.

So, to know your study design should be your starting point to make deeper decisions.

best,

ana

I think is a variable that could be defined as a trait or as a state. When you assess this kind of variable in chronic illness you must consider both state and trait, and other variables that may mediate in coping. There are lots of information about how character strengths, optimism, and hardiness mediate in coping with chronic illness. Take a look at this research as an example:

http://education.ucsb.edu/janeconoley/ed197/documents/petersonGreaterstrengthsofcharacterandrecovery.pdf

So, be careful when designing your assessment instruments.

If you need more help, please tell me: [email protected]

Good luck with your research, it sounds amazing!

I don't know the answers to your questions, but I do know that chronic illness has an effect on resilience that can be detrimental.

I have been working with patients affected by systemic lupus erythematosus for 13 years and therefore the issues of resilience and coping are issues that connect with living with SLE. However, I do not work from the perspective of measurement or assessment. My work is through a psychoanalytic understanding of the individual which examines the individual-in-the-context-of-their-personal-relationships. Certainly, early childhood experiences, social context, education and socio-economic circumstances are important. The work of Michael Rutter is particularly illuminating eg http://psych.colorado.edu/~willcutt/pdfs/Rutter_2012.pdf

However, instead of looking at generalised patterns of behaviour, my interest is in each individual and building up case study by case study a deeper understanding of each person. Theoretically, over time this may build up a picture of commonalities that affect individuals dealing with chronic diseases such as diabetes and lupus. This may lead to a social (interpersonal or intersubjective) contextual understanding of resilience. What do we as human beings need when faced with an incurable, painful, debilitating, unpredictable disease that can strike at any time and without warning and which can destroy one physically and emotionally?

Interesting answer Rosalind. Can you share any of your thoughts, based on your case study by case study understandings, of how chronic illness affects resilience and vice versa? And do you think people with less 'serious' but still chronic difficulties will respond to them similarly?

Good point Rosalind! It is also very important to consider not only quantitative assessment of resiliency but qualitative experiences of patients, because it helps to make the difference. It is a good approach that may help to define resiliency as a trait/state variable and how both state and trait interact to build good coping strategies. I think there is a lack of good qualitative approaches in the study of resilience.

So, Sravanti, it could be interesting if you consider both approaches to the study of resilience state/trait in your patients.

Keep going on!

Interesting discussion. Important aspects of design have been mentioned. Maybe your question is somewhat general. Whether you measure trait or state aspects depends upon your instruments. If you try to measure both you can test whether the difference is significant. You need clear definiitions of resilience and coping and "impact". You should probably also test whether it is reasonable to assume any sort of entity like "chronic illness". Resilience when suffering from diabetes might not have too much in common with resilience when cystic fibrosis is your problem. The same possibly holds true for coping with different illnesses. By the way: schizophrenia too can become chronic. Best wishes.

This evidence is anecdotal but may offer some pointers.

I have a chronic illness, myasthenia gravis and, as I run a support group for around 1000 sufferers I have had the opportunity to have study this aspect of chronic diseases for some time. The thing I have noticed is that it seems to follow the same pattern psychologically.......that of a bereavement ......as patients adapt to their new self image. As with any bereavement, some adjust, some do not. It is apparent at the outset that certain personality types will not adjust, whereas children born with the condition seem to have no trouble coping. Since our personality types are also affected by our life experiences, resulting in modified behaviour ie we can LEARN to react in different ways, I think you have posed yourself an almost impossible question! Good luck!!!!!

In reply to Isobel

Chronic diseases such as type 1 diabetes or systemic lupus erythematosus often have the features of a traumatic emotional experience that exceeds the person's resilience and capacity to cope in psychic terms.

In my work, I have come across irrational anxieties rooted in the unconscious personal significance of the meaning that lupus has for the individual. One of the difficulties concerns the way in which the person is unable to emotionally process and work through what is happening to them. The body and bodily sensations constitute an "internal object" which, from the very earliest stages of life, creates a real relationship made up of sensory signals, that derives from the mother-infant interaction.

RD Hinshelwood gives an example of a baby who has a pain in his tummy (hunger) and feels there is something "bad" inside. Gradually, through the care of the mother, the baby understands this pain to be hunger and the pain in the tummy is relieved by the mother's breast. It is the mother who takes in what the baby is trying to communicate and it is the mother who takes in her baby's projections which she then returns to the baby in a more manageable way. In the earliest of forms, the baby experiences both the "good breast" and the "bad breast". Developmentally later, there is an appreciation that there is an alternative to splitting into good and bad: the third position, which requires the capacity to have a mind that can think. If, for example, the mother is depressed, she may not be able to perform this important function. It is important to note that this is not about a mother's failure or blame. It is about the importance of what Donald Winnicott called the "good-enough" mother ie the recognition that no mother can be perfect, just like no therapist can be "perfect"; and that it is through failures that growth can occur.

The embodied mind and the importance of physical aspects of the early infantile experiences along with the "rooting of the mind in the body" (Fonagy & Target 2007) are important areas of research linking attachment theory to psychoanalytic theory. As in the example above, bodily sensations or feelings precede mental representations. These feelings are the matrix of mental experience in an implicit internal dialogue within the early relationship with the object, as Freud indicated (1923): "the ego is first and foremost a body ego" (pp. 26-27. Recent research has described the influence of the somatic component of the object in enabling the child to master physiological and emotional processes.

Here, I am referring to the role internal objects play, according to British Object Relations. This includes the primary physical nature of the real object that underlines the importance of maternal handling and holding, the importance of the moment when the mother (primary care giver with her baby in her arms helps to keep the baby's sensory experiences integrated (see Winnicott's true-self, 1960). Wilfred Bion's alpha-function (1962) refers to the baby's,bodily sensations which are filtered through the mother's capacity to protect the baby from excessive or overwhelming sensory stimulation. Gradually, the mother helps her baby to develop the same capacity on his/her own.

When a chronic disease appears, the dialogue between the subject, his/her body and their inner objects stops. There appears a "narcissistic wound" and where the patient is a child, the mother can experience the sense of guilt for transmitting the disease and punishment. Where the person is an adult, there can be an experience of guilt and a feeling that this is a punishment. In the case of an adult who has suffered a childhood trauma, the person may experience the infantile anxiety that it is going to die, along with the feelings of "dread" which the baby was attempting to deal with by projective identification. Under these circumstances, the person will experience difficulty in retaining a balanced outlook (the third position) and affecting their ability to cope. The individual can experience intense feelings of depression, impotence, guilt in their own interpersonal or intersubjective relationships. This can affect the family dynamics and relationships where there may be aggressive and confusing projections. It can also lead to a cycle of transference-countertransference encounters between the patient and the doctor. Both the unconscious and transference are essential components in psychoanalytic theory.

The body becomes the main demanding object that requires attention and care, no longer able to give the sensory experience that forms the basic level of being-in-the-world. The individual's sense of identity can also be affected. A chronic diseases can impact in such a way that the individual can feel they no longer know who they are. Instead of the physiological range of sensory dialogue between the self, the body and the external and internal objects, a new and different relationship emerges. There is an object loss that needs to be recognised, accepted and worked through. The admission of the chronic disease means accepting that the former experience has ended and the pain associated with that loss must be recognised in order to allow a new relationship to start. The loss of the relationship with the former body implies the loss of the relationship with regulating external and internal objects and the impossibility of trusting anyone, even one's own self and body.

In the case of systemic lupus erythematosus, the immune system is unable to distinguish between its own cells and foreign bodies; it cannot distinguish between "Me" and Not-Me", that is "Self" and "Non-Self". Antibodies are produced which attack any and every bodily system, including internal organs and the brain. It is therefore understandable that one's body cannot be relied upon - in effect, the body has "a mind-of-its-own" - and it is hard to accept that the aggressor comes from within. It also becomes difficult to distinguish between what belongs to the self and what belongs to the non-self. Patients may report that it feels like they have been taken over from an invisible, destructive force, over which they have no control. It can feel as if their body has been invaded by an alien - an alien-self - which is destructive. In fantasy this can lead to a belief that if the body-self is integrated, this would lead to the destruction of the Self. This is a profound loss - the loss of the body-that-was-once-alive-and-well. The loss of the body that will never be the same again. Some patients have an understandable difficulty in coming to terms with such a loss leading to the following difficulties:

(1) the regulation between mental representations of self and object (the mental representation of significant others);

(2) the unconscious use of lupus, of an aspect of her reality to avoid sources of pain;

(3) the presence of irrational anxieties rooted in unconscious personal significance of living-with-an-incurable-disease.

A diagnosis of lupus, or waiting for a diagnosis, which can often take many years, can be experienced as a traumatic experience. This can be defined as a subject's capacity for resilience is exceeded and s/he is unable to deal with experience and elaborate it in psychic terms. The opposite of resilience is when the mind is presented with overwhelming stimulus that is too great to be assimilated in the usual way. A failure of the psychic apparatus occurs, one which is unable to process or perform the basic function of mediating between the needs of the organism with the stimuli which impinges.

When affects are not mentalized, they remain as proto-affects (Bion's beta elements). The individual is left with either inhibiition, such as, alexithymia, somatic disorders, or the risk of being overwhelmed by pro-affects. Sensory memories cannot be transformed into mental images, thoughts or words and thus the psychic or bodily pain becomes a traumatic experience. If this has occurred in childhood, this is suppressed and the potential traumatic break can appear later in life. The defensive structures which prevent a breakdown, come into play.

Patients with lupus may report having panic attacks. The feeling of imminent danger and death could represent a repetition of an original trauma associated with a lupus flare. Freud (1920) regarded birth as a trauma and a prototype of primary anxiety. Lupus can represent the fear of a new annihilatory anxiety. It is the maternal function to take in the baby's projections, to soothe her baby and return to the baby its fears, in a more manageable form.

I believe that emotional reactions to chronic diseases should be given more importance. The difficulty in recognising the pain from the loss of a former state of self, or being, of body image and identity should be a focus of enquiry. Without the recognition of loss, there cannot be mourning and mourning is fundamental for creating a link between one's self and others. Symptoms of trauma underline the fear that something will happen in the future. The task is not to get rid of what is disturbing but to remember the forgotten trauma in the hope that this can be worked through in the present with the help of the psychoanalytic clinician. These symptoms can also play a protective function against the death of psychic life by the subject when overwhelmed by the massive anxiety and helplessness, "the ego, which experienced the trauma passively, now repeats it actively in a weakened version, in the hope of being able to direct its course" (Freud, 1926, p. 166). Winnicott's (1974) fear of breakdown appears when the patient relives the fear of a breakdown that has already happened in the primary relationship. For this reason, all patients with a chronic disease should have the opportunity to receive psychological support as part of their overall care.

References

Bion, W (1962) Learning from experience.

Fonagy, P & Target, M (2007) The rooting of the mind in the body: New links between attachment theory and psychoanalytic thought in Journal of the American Psychoanalytic Associations, 55, 411-456.

Freud, S (1920) beyond the pleasure principle. SE Volume 18, pp. 7-64.

Freud, S (1923) The ego and the id. SE Volume 19, pp. 3-66

Freud, S (1926) Inhibition, symptoms and anxiety. SE Volume 20, pp.77-175.

Winnicott, DW (1960) The Maturational Processes and the Facilitating Environment.

Winnicott, DW (1974) Fear of breakdown. International Journal of Psychoanalysis, 1, 103-107.

Rosalind,

Thank you for such a detailed and interesting account of your ideas. I have experience of chronic pain and I can identify with quite a lot of what you say, such as feelings of 'persecution' by a body that no longer seems to respond to my efforts to care for it.

In recovering from pain, I have also experienced some of what is described in the research paper Merche recommended to us, but of course many of the advantages that arise from chronic suffering described there ARE only really achieved upon recovery, which sufferers of diabetes and lupus cannot hope for.

I think your description of the mechanisms involved here, according to Object Relations theory, suggest how difficult it is to separate the concepts of resilience as trait and resilience as state of being. Very early trauma, that would affect a person's ability to cope with illness, may not be 'visible' to the researcher or even the researched, making it easy to ignore important factors in any particular set of data. A research project would have to define its terms very concisely but also focus quite narrowly, I think, on a specific area in which to assess resilience in practice.

I've just completed my PhD developing a grounded theory of people who cope well with chronic pain. I found that there are common processes involved with coping well, one of which is receiving a clear diagnosis that the person can accept (this fits nicely with Leventhal's Common Sense Model).

The other is having a reason to cope - in occupational science terms, having an occupation that the person wants to, or needs to do. Occupation in this sense of the word is a technical term for daily activities an individuals wants to, or needs to do to be healthy.

Without the reason to cope, individuals tend to hark back to "what was" and want to "return to normal" when that's not possible - the reason to cope (valued occupation) provides forward momentum that seems to facilitate adopting new ways of coping.

Hello Bronnie,

Did you notice, in your research, any relationship between actual onset of chronic illness (or its early symptoms) and a pre-established lack of a sense of 'a reason to cope', say with life stressors rather than pain? I am wondering about the triggers of serious illness and about how far the wearing down of resilience might actually contribute to it in the first place.

Bronnie, thanks for the paper....the reply button didn't work so I am using this channel!

Saravanti, here you can find our paper where we investigate TRAIT RESILIENCE (namely ego-resiliency as a personality trait) and COPING among women with breast cancer: http://www.termedia.pl/Czasopismo/-3/pdf-19113-10?filename=Mechanisms%20of.pdf I hope it will be of interest to you. In most cases, those two approaches towards resilience (trait-like and procesual / situational) are complementary just as many other concepts (e.g. trait and state anxiety). It depends on the focus of your interest whether you emphasize any of them in your research.

I actually find the question quite precise, if interpreted as "Is resilience a mediator or moderator of succesfull coping with long-term, chronic ilness?". We could start looking at the construct of hardiness, which refers to a set of attitudes toward life characterized by an orientation toward deriving meaning, growth, and value from stressful life events (Bartone, 1995; Bonanno, 2004; Maddi et al., 2006; Kobasa, 1979). Hardiness has been shown to predict lower levels of illness and to moderate the association between stressful life events and illness (Kobasa, Maddi, & Kahn, 1982). Specifically, hardiness consists of three dimensions: commitment to persevering through stressful events, a sense of control over the outcomes of such events, and openness to learning and growing from challenges (Maddi et al., 2006). Recent literature suggests that hardiness is a key “pathway to resilience” (Maddi & Khoshaba, 2005). The way hardiness fosters resilience appears to be a combination of cognitive and behavioral mechanisms, and biophysical processes as hardiness encourage effective mental and behavioral coping, building and utilizing social support, and engagement in effective self-care and health practices. It is, thus, more semantically accurate to refer to them as “resilience resource” (Smith et al., 2008;Bonanno & Mancini, 2012).

Contemporary resilience research has progressed beyond descriptive issues, and risk and protective factors, to focus now on relational processes that imply self regulatory systems for modulating emotion, arousal and behaviour, identification and capitalization of support structures, and reduction of the likelihood of a stress response (Gucciardi et al., 2011). Multiple patterns of resilience exist, and they can all be demonstrated at the relational level and examined trough key relational processes that facilitate strengths and can be used to empower individual, families and communities on their own resources.

About Diabetes specifically, research has mostly focused on investigating the buffering role of resilience on self-care behaviours in the face of rising diabetes-related distress. Is this the focus of your research and the outcome you are interested in?

Some references:

Yi JP, Vitaliano PP, Smith RE, Yi JC, Weinger K. (2008). The role of resilience on psychological adjustment and physical health in patients with diabetes. Br J Health Psychol. 2008 May;13(Pt 2):311-25

Davis, M. C, Affleck, G. , Zautra, A. J and Tennen H. (2006). Daily Interpersonal

Events in Pain Patients Applying Action Theory to Chronic Illness. Journal of

Clinical Psychology; 62(9): 1097–1113.

Huang, Min-Feng (2009) Resilience in chronic disease : the relationships among risk factors, protective factors, adaptive outcomes, and the level of resilience in adults with diabetes. PhD thesis, Queensland University of Technology.

I, too am interested in resilience and its impact on Chronic illness or disease, but more in relation to children. This has been a great thread to follow! It is hard to put resiliency in terms to describe it as eloquently as Giovanna Gianesini. The term hardiness is the term used that most effectively describes resiliency. Don't you see hardiness more than "commitment to persevering through stressful events, a sense of control over the outcomes of such events, and openness to learning and growing from challenges?" Should we not also talk about the ability or inner fortitude that drives hardiness? Does that not come from prior knowledge or life experience in stressful events? Sorry just thinking aloud, so to speak.

Hi Isabel, yes I think the majority of participants had generally stable and non-trauma-inducing environments prior to the onset of their pain, although may not have had clear occupational goals with good self regulation to meet those goals until late teens or later in one or two cases. Mental health problems were not associated with good coping, although well-managed depression/anxiety was present in some of the participants.

Overall I think the work by Zautra et al. provides a good framework for examining hardiness, and I particularly like the way resilience is characterised by both recovery and sustainability, with some individuals also experiencing growth.

Sturgeon, J, & Zautra, A. (2010). Resilience: A New Paradigm for Adaptation to Chronic Pain. Current Pain and Headache Reports, 14(2), 105-112.

Zautra, Alex J., Arewasikporn, Anne, & Davis, Mary C. (2010). Resilience: Promoting well-being through recovery, sustainability, and growth. Research in Human Development, 7(3), 221-238. doi: http://dx.doi.org/10.1080/15427609.2010.504431

My work is slightly different in that I've been looking at the process of moving from "Pain as a mystery" to "living well" involving the search for verification of the diagnosis (is there a diagnostic label that matches my experience/understanding of my pain?), weighing up the cost/benefit of looking for treatment to abolish pain vs "getting on with life", and the energising and motivating effect of having valued occupations.

In my study, it was a combination of accepting that hurt does not equal harm, understanding the diagnosis, and most importantly, having valued occupations that drove the search for coping. Coping efforts themselves involved "anything that works" but interestingly both mindfulness and exercise were featured as separate categories.

I'm not sure that we've valued the power of important occupations (the reason for coping, if you will), in our search for learning how people cope well.

I agree that concepts such as hardiness and fortitude are very important. Also that we need to tap into a person and a community's ability to think and behave positively. However I am wary of expressing too much warmth about these ideas.

I would suggest that for those who do not suffer from the sorts of chronic illnesses people cannot get better from, or have successfully recovered from others, or for those who have not come from communities where it is difficult to display fortitude because of multifarious problems that relate to social inequality and deprivation, unequal power relations and the like....well, I would argue that it might be too easy for such commentators to give the impression that the power lies within all of us to be hardy, resilient and show fortitude, to have sufficient 'moral strength' perhaps to survive 'well,'....when in fact these psychological assets may have been crushed early in life or during the course of a tough unequal one.

This is not intended as negative commentary, but as a bit of a reality check.

Hi Bronnie,

Only just seen this from you :

I'm not sure that we've valued the power of important occupations (the reason for coping, if you will), in our search for learning how people cope well.

But it is relevant to my posting above.

The importance of occupations is, in fact, fundamental to political thought on well-being, however, isn't it? Political thought that emphasises how a person's labour needs to be valued and not just seen as a resource for economic advancement, very much recognises a variety of reasons why occupation is fundamental to 'coping.'

I am not in the medical profession, but through my readings on individuals and their values - morality and ethical abilities - resilience comes so strong as helping the individual throughout! so, pain would be one of these areas that resilience would help - but I would love to see studies on this! Good luck

It is one aspect of your trait and as you go experiencing different difficulties/stressors in life you might developed it in yourself.

Hello Rajashree,

Thanks - I totally agree...

Regards

Isabel, the way I'm referring to the value of occupation is within the occupational science perspective: occupation refers to the everyday things people do (work, self care, leisure) - things that are purposeful, meaningful, contextual and so on, rather than the narrower definition of occupation as employment or labour.

I liked Giovanna G's comment. This is a very interesting discussion. I like to define resilience as a state rather than a trait as resilient resources are continually fluctuating depending on a multitude of factors. I work with patients with chronic illnesses. I think the difference of resilience in this context is that the disease (stressful life event) will become progressively more stressful as their illness progresses. So despite their experience in coping with the disease many people with chronic illnesses become depressed - a manifestation of depleted resilience perhaps? In terms of someone with severe diabetes I would say that their levels of resilience and coping strategies at the initial stages of their disease are not so challenged in contrast with the more serious manifestations of the disease, such as amputations, when their resilience resources are seriously challenged.

Hi Bronnie,

Yes, of course, I do understand that.

However, I also think it is worth remembering that all human activity is underpinned by 'worldview' or ideology, including research: a fact whether we are fully aware of it or not.

This has implications for the way we use vocabulary and for the vocabulary we use. It also adds to the complexity of what we research and perhaps even affects not only how but what we research.

Hello Isabel,

Good points - the worldview or ideology or even belief would be of importance, even when I did my thesis, I added a section on my own worldview - just to show that I am not outside the research but very embedded in it... displaying my bias at the beginning...

Hi Roberta. I agree with the nuances that you bring up. Social support features as a prominent resource in most coping studies. Perhaps mapping out resilience resources by stage of disease progression might help indicate the change in the ratio of intrapersonal to interpersonal resources needed to sustain successful coping.

Just this morning I was discussing with a nephrologist colleague of mine whether resilience is a trait or a state. My answer is that it is a little of both. I operate out of a social learning perspective, and look at resilience as a coping resource consisting of both a set of beliefs and behavioral tendencies. According to social learning theory, our beliefs and behavioral characteristics are shaped by our experiences. As we gain more experience, who we are and what we do are changeable. At the same time, the older we get, the more difficult it is to change, but impactful experiences can, indeed, make us more (or less) resilient.

I like A. Mukolo and K. Wallston's comments especially K.Wallston's comment on the importance of change. I think Wallston's published work in relation to Health Locus of Control (HLOC) is of valuable reference here as mediating factors in patients' level of resilience (as a state). In relation to the actual coping process the evidence-based literature points to the importance of an Internal HLOC having a positive effect on patients health with the opposite for External HLOC. However, this is within the context of early-diagnoses and less serious illnesses. From a clinical viewpoint (with some supporting evidence) I think we run into problems when control needs to relinquished by the patient. For example, when a patient's condition deteriorates so much that s/he becomes fully dependent on medical interventions, such as operations, intensive care stays, etc whereby s/he can no longer control the situation/their illness. In this case an external HLOC may be more accepting of the situation. In this instance acceptance becomes an important mediating factor in coping. Whether we define this as a state or trait is debatable.

Thanks, Roberta. Many years ago, studying patients with cancer, we published a paper saying that there are times when having an external locus of control would be helpful, so your observations are "spot on."

Wow! I seem to have open a Pandora's box here!! Than you all for your contributions.

My reflections -

I think Giovanna Gianesini’s question about the moderating or mediating influence of resilience is quite precise. My concern arises as resilience can be demonstrated through a number of relational pathways, so what variables to focus on and why consider some in face of exclusion of others??? From interviews of diabetic patients to get an understanding of their experience of the illness, what i gather is most of them try to make sense of their life with diabetes by trying to find answers to question like, “why me?” From the time of diagnosis, most of them seem to be looking for answers to existential questions, to try and make sense of their life and the illness. It is not a reflection of defeatist attitude because for some of them a reflection to this has led to formulate personal coping models, helped them obtain a kind of closure which aids in their adjustment to the disease as well. True to what Roberta Symeonides points out, patients who have been dealing with diabetes for a longer time tend to have more negative orientation towards their illness and life which is also reflected in their adherence to their regimented lifestyle. I was looking forward to a qualitative understanding and quantitiave assessment of the patients. But when am trying to study the impact of resilience on coping with diabetes, the moderating or mediating effect of resilience can be studied on the blood glucose levels ( or more specifically glycosylated haemoglobin levels) of the patient. However, I feel an entirely qualitative study is not enough!! Patients afflicted with the same disease would be more or less predisposed to think, feel and act in certain similar ways irrespective of their personal and social environments. The idea is to develop a model of resilience ( state/trait approach) that can help facilitate coping to help adjust to diabetes.

Sravanti: As one of your quantitative measures, you might think about using our Brief Resilient Coping Scale (BRCS). It's only 4 items, but it is predictive of health outcomes, particularly those having to do with mental health. It is not a measure of resilience, per se, but rather a set of behaviors and cognitions consistent with being resilient. Ken

Reference: Sinclair, V.G. and Wallston, K.A. (2004). The development and psychometric validation of the Brief Resilient Coping Scale. Assessment, 11, 94-101.

Hello Sravanti

,

This comment you make is interesting, can you enlarge on it?

"But when am trying to study the impact of resilience on coping with diabetes, the moderating or mediating effect of resilience can be studied on the blood glucose levels ( or more specifically glycosylated haemoglobin levels) of the patient. "

Also "Patients afflicted with the same disease would be more or less predisposed to think, feel and act in certain similar ways irrespective of their personal and social environments."

Is this something you have evidence of?

Finally, I personally think research is more interesting and potentially more relevant if it can consider and 'cope' with aspects of Pandora's Box. Otherwise, it is tempting to answer the question, for example, about the moderating or mediating influence of resilience with a "yes" and move on.

Thank you Kenneth Wallston .

In reply to Isabel -

To enlarge the first quote:

The goal is to determine whether resilience, (whether as a process or trait) does have any impact in coping with diabetes. In assessing the role of resilience on diabetes, the idea is to determine how well the patient has adjusted to the illness and is able to maintain an optimal level of their blood glucose levels. And one measure to do so is the measure of glycosylated haemoglobin levels of the diabetic patient.

Second quote: It is based on the observations I have made from the interviews. Irrespective of the individual differences and the duration of their illness, most of the patients tended to view diabetes as a lesser illness than many other but view it as an “end” of life they knew as and a beginning of a very restrictive and curbed personal space. It mostly stems from the dietary and lifestyle modifications that their specialists have recommended. I quite agree with, Georg Siefen when he says “Resilience when suffering from diabetes might not have too much in common with resilience when cystic fibrosis”. Further, in conversations with colleagues working with cancer patients; some very different observations from her work experience were reported in how cancer patients view their life with the illness.

Finally, yes I too agree with your viewpoints about Pandora’s Box and I am very thankful to members who have not only posted their valuable experience & work but also taken the pains to share some relevant literature.

Kenneth - Your posts are great and thank you for the source. all the best Saravanti

I want to believe that psychological resilience cannot be totally detached from personality traits, even though, it is a combination of individuals' beliefs, past experience and latent learning that makes someone tick in the face of adversity. However, the different components (extroversion, neuroticsm, openness, agreeableness and conscientiousness) of our personality play important role in organizing this combination into meaningful whole for human survival.

Adeboye: i have some data to back up your belief that psychological resilience cannot be totally detached from personality traits. In (as yet unpublished) data I have been analyzing in a sample of over 7,400 persons, our measure of resilient coping (see above) correlates robustly (between .28 and .41; p < .00001) with measures of extroversion, openness, conscientiousness, and neuroticism.Those four measures of personality explained ~30% of the variance in resilient coping scores, with openness accounting for the greatest unique variance. Unfortunately, there wasn't a measure of agreeableness in the dataset, but I'm guessing that resilient coping would also be associated with agreeableness. Ken

In my previous post, I commented that my approach is different in that it focuses on psychoanalysis and attachment theory and is the basis of my work with patients-affected-by-systemic lupus erythematosus.

Animal and human research demonstrates the close relationship among attachment, stress regulation and immune and pain regulation systems. There are research findings concerning the high interpersonal and metabolic costs associated with insecure secondary attachment strategies (ie attachment deactivating and hyperactivating strategies) leading to increased vulnerability to stress. There is further evidence for the rôle of an impairment in "embodied" mentalization leading to non-mentalizing modes (that is, modes of subjectivity that antedate the capacity for full mentalization).

There are patients who, based on their personal experiences, are predisposed to difficulties with mentalization. This can be seen in terms of conditions such as alexithymia. While there is a strong relationship between people with functional somatic disorders (FSD) and failures in mentalization, this may also affect vulnerable people with chronic diseases. It is important that researchers and clinicians suspend their beliefs and assumptions and enter into what Bion describes as "without memory or desire" with each individual, since the subjective experience of living with a chronic disease is not a discrete category but highly dependent upon a myriad of attachment and interpersonal experiences. Similarly, resilience is also not a discrete entity but dependent on a multitude of interpersonal subjective experiences, which may not be readily empirically "measurable". There may be a significant difference between how a researcher/clinician understands "resilience" and the patient. Frequently in research, there is an assumption regarding the meaning of terms, say "resilience" and that the questions posed are weighted in terms of the understanding of the researcher/clinician, thus missing important evidence for the understanding of the person involved.

It would be surprising if someone with a chronic "dis-ease" did not, at some point, display symptoms of anxiety or depression. In the case of patients with lupus, one might expect to find further evidence of brain inflammation since both anxiety and depression are ordinary human responses or reactions to a condition that is painful, debilitating, unpredictable and can suddenly strike down a young woman in the prime of her life. A young woman may find her body shape changes, her inability to do what she once could do, changes in her quality of life, her realisation of the fantasy that we are in control of our lives and being forced to think about her own mortality. SLE can affect men and children, but mainly affects women during their child bearing years (9:1).

Lupus patients are also more likely to feel misunderstood and stigmatised because lupus is difficult to diagnose and treat. Many report being told that their generalised symptoms are "all in the mind", fostering feelings of invalidation and leading to difficult transference-countertransference cycles between patient and doctor or other people. In fact, lupus patients can be highly sensitive to feeling the other people is judging or criticising them for not "coping" or being "resilient"; and at best, not understanding what it means to have lupus. They are equally sensitive to the way in which most people have not heard of lupus and the way in which lupus can be trivilaised ie their perception is that lupus is somehow secondary when compared with more "popular" diseases such as certain forms of cancer, Rheumatoid Arthritis, MS or Type 1 diabetes, the latter three are genetically connected with SLE. Unhelpful diagnostic labels, simplistic theories about causation of their disorders and negative responses from the person's environment foster feelings of invalidation and isolation. It is often said that while only one person has a diagnosis of lupus, the entire family suffers from lupus!

An important area concerns the rôle of early adversity and personality/attachment. By carefully examining interpersonal factors, it is possible to see a tendency to catastrophize, externalize, rigidly adhere to somatic attributions and to exhibit clinging or demanding behaviour. Emotional avoidance, distancing and criticism of others who try to offer help can lead to clinicians and others feeling irritated, helplessness and angry. This can lead to an entanglement of the transference-countertransference cycles between the patient, doctor and other people generally.

Secondary attachment strategies can lead to further stress dysregulation and impairments in mentalization, that is, the capacity to interpret the self and others in terms of intentional mental states (feelings, wishes, desires, goals etc). These impairments may lead to interpersonal behaviours that perpetuate symptoms and complaints, leading to patterns of stress dysregulation, high symptomatic distress and interpersonal problems which complicate living with a chronic disease. Thus, should the person experience negative vicious cycles involving person-environment interactions this will impact on the person's resilience in dealing with a chronic disease.

Predisposing factors, biological and environmental may render persons vulnerable. Precipitating factors typically involve chronic psychological (work, relationships) and/or physiological (chronic infections, flares etc) stress which lead to "allostatic load" mediated by dysfunctions of the hypothalamus-pituitary-adrenal (HPA) axis, the main human stress system. Resulting HPA axis dysfunctions are associated with abnormal inflammatory activity. Pro-inflmmatory cytokines induce lethargia, increase fatigue, concentration loss, low grade fever, generalised hyperalgesia and hypersensitivity to physical and mental stressors, as well as a tendency to withdraw from the outside world. Together with neuroplastic changes in the spinal cord and brain, this may lead to cognitive, emotional, behavioural factors (eg pain-related negative affect, catastrophizing and sleep disorders) to pain sensitizing.

In an attempt to deal with increased stress, patients may rely on secondary attachment strategies (attachment deactivating and attachment hyperactivating strategies) in order to regulate stress, which gives rise to mentalizing impairments, especially with respect to embodied mentalization ie the capacity to see the body as the seat of emotions, wishes, feelings and the capacity to reflect on one's own bodily experiences and sensations and their relationships to intentional mental states in the self and others.

Attachment problems and mentalizating impairments may exist before the onset of the chronic disease. They may also result from or be exacerbated by an inability to regulate increasing levels of stress and allostatic load and reflect attempts to cope with stress. Vulnerable individuals may in part generate their own stressful environment and/or be vulnerable for the development of Functional Somatic Disorders(FSD)when they are in an environment which impinges upon their vulnerability to stress.

Patients who primarily use attachment deactivation strategies tend to regulate stress by denying attachment needs, asserting their own autonomy, independence and strength in an attempt to down regulate stress. They often present as strong autonomous and resilient, but are actually very vulnerable. This is consistent with findings of high levels of self-critical perfectionism and related features such as persistence, overactivity and all-or-nothing behaviour. This is a defensive attempt to affirm the self and soothe negative introjects.

While deactivating strategies may reduce stress in the short term, they are associated with high interpersonal and metabolic costs, which lead to increase stress and cycles of symptom exacerbation and interpersonal problems. The failure of these strategies lead to a reactivation of feelings of insecurity, negative self representations and increased levels of stress.

Those people who rely on attachment hyperactivating strategies, express themselves through anxious efforts to find support and relief, often through demanding and clinging behaviours. These lead to interpersonal and metabolic costs. There is an underlying belief that others cannot provide support and care and the behaviours expressed can often lead to resentment in other people.

Mentalization is a huge topic and I am aware of the dangers of over simplication. However, I would like to end with three examples of problems with mentalization:

1. Psychic equivalence mode is where inner and outer reality are equated. What a patient thinks is real and there is no possiblity of an alternative point of view. In psychotherapeutic terms, the person has a lack of desire or an inability to explore inner mental states, especially people who adopt attachment deactivating strategies. This may help to explain why certain people have difficulties in accepting help and find it hard to believe that professionals can be genuinely concerned about them. In this mode, psychic equivalence leads to equating psychological pain and physical pain and emotional and physical exhaustion. This may help understand the high comorbidity between pain, fatigue and depression. This can also lead to patients' resistance towards acknowledging the role of psychological factors. Thus, psychological pain is experienced as bodily pain: worries and anxieties are literally "a weight on my shoulders". States of helplessness, hopelessness and catastrophizing are likely even though a diagnosis may be given, the person may be drawn towards the worst possible scenario or that something else deadly is happening. As would be expected, psychic equivalence affects interpersonal relationships. Criticism can be experiences as an attack on the bodily-integrity of the self, experiences as physical pain and thus threatens the integrity of the Self. Research findings have shown the the common neural circuits of psychological and physical pain: rejection hurts, but the person will only experience the physical pain associated with rejection, not the emotional pain. Peter Fonagy describes the way in which the person experiences the "alien self-part" or the alien part of the self. Patients externalize these alien parts of the self in a defensive attempt to evacuate (get rid of) their feelings of anxiety, depression, helplessness to restore the coherence of the self. In some cases, these patients(consciously or unconsciously) may want others (such as the therapist or doctor) to experience their fatigue, anger, fear, helplessness and hopelessness:"I wish you could feel the way I do!" When this occurs, the clinician is able to get a sense of the attack on their mentalizating capacity.

2. In a teleological mode, the person will be drawn to only observable causes or observable behaviours reflecting rational, goal-directed behaviour and material causes). Patients will be concerned with "objective proof" and biological causes, rejecting any possibility of the link with psychosocial factors.

3.Hypermentalization or pretend mode,is where the relationship between thoughts and feelings is severed. The clinician may experience the patient as having an accurate, realistic understanding of their illness, in their narrative accounts. However, there are certain features that can be distinguished from mentalization. First, the excessive, analytical and repetitive narratives. Second, the stress on the cognitive, with little affect. Third, the inability to switch perspectives from self to other.

Prementalizating modes further hinder effective stress regulation and increase interpersonal problems which also impact on "resilience". In psychic equivalence, the person will exhibit catastrophizing behaviours. In teleological mode, alternative biological treatments will be sought that offer no relief despite high hopes, or attempt to prove they are not worthless by overactive or manic type behaviours which frequently lead to total exhaustion and helplessness. In pretend mode, excessive worry and rumination can lead to panic attacks and sleeping difficulties. Prementalizing modes increase interpersonal problems, where the person feels that others do not take their illness seriously enough. This leads to feeings of invalidation, embitterment and a state of isolation and lonliness.

In terms of diabetes, the work of Peter Fonagy, Mary Target and others will demonstrate the way in which failures in mentalization affect type 1 diabetes and their relationship with non-compliance.

"There may be a significant difference between how a researcher/clinician understands "resilience" and the patient."

Moral of the story? Choose the physician with care, if you can, and read research with an equally critical eye.