It was an article that started life as a conversation. We sat around a table in March 2016, discussing mental healthcare staff wellbeing. Someone pointed out the increase in burnout they had seen in mental health staff in the services they worked with; someone else spoke about the unique demands of working in mental health care settings, and how staff burnout may impact patient care. It felt like we were tapping important issues; etching out a line of argument we had not seen articulated in any academic articles we had read. Then I heard myself pipe up, “This feels like a paper. We should write a paper. I’ll draft it”.

Famous last words. As I left the room my enthusiasm waned a little. Had I really just volunteered to write another review?

Getting into the data
I knew I was going to need to access original data from government sources to build the case, which was new for me. I scoured NHS Digital and other sites, entering the numbers into excel files in order to plot graphs. These told me that the proportion of NHS  staff feeling unwell due to work-related stress had risen by 9% in 8 years (from 28% in 2008 to 37% in 2016; Figure 1a), and double the number of NHS staff had said they were leaving because of poor work– life balance in 2015 compared with 2011 (Figure 1b). I was stunned.

Figure 1

Figure 1. Percentage of staff reporting having felt unwell due to work-related stress on the NHS staff survey. (Source: NHS staff survey data; www.nhsstaffsurveys.com) (A) and number of staff citing poor work-life balance as their reason for leaving their NHS post. (Source: NHS Digital; https://data.gov.uk/dataset/nhs-workforce-reasons-for-leaving) (B).

Are these problems just in the UK?
The NHS has suffered significant underfunding for several years (Kingsfund, 2017) which has been a cause of staff stress, so I wanted to check whether these problems may be NHS-specific or similar in other countries. I found relevant data provided by the US Bureau of Labour Statistics (2017). Given the vast differences between the organisation of UK and USA healthcare provision it was an interesting point of comparison. This data suggested workers in healthcare support occupations take the most sickness absence of all employees, with rates 50% higher than private sector employees. It was clear that these patterns were not UK specific.

Are they any differences between staff working in mental healthcare and other settings?
Curious to compare mental healthcare staff with healthcare staff in other settings, I emailed NHS Digital to get a breakdown of sickness absence rates by trust type. These told me that mental healthcare staff are off work due to sickness on more days than the overall average for healthcare staff, and on more days than those in both acute trusts and primary care (Figure 2). Mental healthcare staff also more frequently cited anxiety, stress, depression and other mental health problems as the reason for this absence.

MH FIg 2

Figure 2. Sickness absence rate by trust type. (Source: NHS Digital: http://www.content.digital.nhs.uk/catalogue/PUB22562).

It occurred to me that the proportion of different types of staff varies across trust type. Some trusts employ relatively more doctors, and others relatively more allied health staff (such as occupational therapists and physiotherapists). What if this variation in staff type explained the variation in sickness absence? To test this, I restricted the analysis to first doctors, then nurses. It didn’t make a difference. In doctors in acute trusts, 17% of absences were in this category, compared with 26% in doctors working in mental health. In nurses in acute trusts, 18% were in this category, compared with 25% in mental health nurses (NHS Digital, 2017). It was quickly becoming apparent that the concerns we had raised in our conversation and the observations of members of the authorship team were backed up by hard data.

Impact on patient care
In order to consider the impact these high rates of stress may have on patient care, my co-authors and I reached into our knowledge of the general healthcare literature. A previous systematic review we had completed (Hall et al., 2016) found that high staff burnout is linked with greater risk of medical errors happening (or poorer patient safety) across healthcare settings. Medical errors can include being prescribed the wrong amount of a medication by your family doctor, being administered a medication you are allergic to by your nurse in hospital, or even being operated on the wrong body part by your surgeon. As expected, when we searched for studies investigating this area in mental healthcare staff a similar pattern emerged. For example, Brady et al. (2012) found that running a mindfulness-based-stress-reduction intervention with mental health staff improved patient satisfaction scores and decreased rates of patient safety events during the 3 months after the intervention. However, there was a disappointingly small amount of research linking healthcare staff wellbeing and burnout with patient care in mental health, and more is needed.

What about interventions?
There were also fewer studies looking at burnout and wellbeing interventions in mental healthcare staff than other staff groups, but I was pleased to find a recent systematic review and meta-analysis by Kimberley Dreison and her colleagues (2018) focused specifically on burnout interventions in mental healthcare staff. This review identified 27 studies. Interventions included stress management workshops, clinical supervision, and staff training. Overall, interventions were effective but only led to small improvements.

What type of interventions are most effective?
Interestingly, when interventions that focused on individual staff members (e.g., psychological therapy) were compared with those that focused on organisational changes (e.g., introducing staff support groups), individual-focused interventions were more effective. However, when staff training and education interventions were separated out from other types of organisational interventions, they led to greater improvements than individually focused interventions for overall burnout scores. This suggests that training and education interventions may be the best place for future research into burnout reduction in mental healthcare staff to focus on. It also suggests that simple comparisons between individually-focused and organisationally focused interventions could be misleading.

What now?
The purpose of the review was to produce recommendations for moving research and practice in this area forward. In the end, there were 4 of these:

  1. Ground interventions in the research literature: When developing burnout interventions, first understand what the causes of burnout are. Design your intervention to address this. Overall, the research literature suggests that poor staffing ratios, the emotional demands of caring for complex patients, lack of leadership and lack of training are all burnout contributors. Furthermore, draw on what the research tells us is likely to be effective. The best evidence at present suggests that staff training interventions may be particularly effective for reducing overall burnout.
  2. Increase the value of interventions: We know that staff burnout is consistently linked with quality and safety of patient care. It is also likely that these two operate in a feedback loop; not being able to provide high quality care is probably detrimental to staff burnout. Developing interventions which simultaneously reduce staff burnout and enhance care quality may meet two needs at once and be self-reinforcing. Again, staff training interventions would tick this box.
  3. Build bridges between universities and healthcare organisations: Partnerships between universities and healthcare organisations can help identify new and relevant topics for research, ensure studies meet current service and patient needs and help results to have a greater impact in the real world.
  4. Engage healthcare staff by emphasising the positives: There is a perceived stigma linked with admitting poor mental wellbeing in healthcare staff. Staff may fear that disclosure could cause career damage or put their professional registration at risk. As such, rather than offering burnout interventions as a fix for those who are struggling, emphasise the additional benefits that participants may reap. These include increased job satisfaction, life satisfaction, relaxation, and improved physical health. Be clear that interventions are not for the suffering but those who want to thrive in their work.

 

The article is published in the International Journal of Mental Health Nursing. To read the paper, follow this link.

 

References

Brady, S., O’Connor, N., Burgermeister, D. & Hanson, P. (2012). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, 129–137.

Bureau of Labor Statistics (2017). Absences from Work of Employed Full‐Time Wage and Salary Workers by Occupation and Industry. US Department of Labour. [Cited 18 November 2017]. Available from: https://www.bls.gov/cps/cpsaat47.htm

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18-30.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11, e0159015.

NHS Digital (2017). Sickness Absence Full Time Equivalent Days Lost by Staff Group, Organisational Type and Reason for Absence. Dataset provided by the Health and Social Care Information Centre on request on 24th April 2017.

What is perfectionism?

We often use the term ‘perfectionist’ in a light-hearted way, to refer to a friend or colleague who’s being that bit too fussy about something. However, research suggests that having higher levels of perfectionism as a personality trait is one of the strongest factors which can reduce our resilience and make us vulnerable to stress (Johnson et al., 2011). At its heart, perfectionism describes the tendency to hold rigid, unrelenting, high standards. These are the kind of high standards that don’t bend in response to stress and don’t allow for excuses. It has been suggested that there are three types of perfectionism: self-oriented perfectionism, where we impose strict and high standards on ourselves, other-oriented perfectionism, where we impose strict and high standards on others, and socially prescribed perfectionism, where we believe that other people demand overly high standards from us (Hewitt and Flett, 1991). These three types of perfectionism cluster together – that is, if you are high in one, you are likely to be high in others.

What’s this got to do with resilience?

If having more of this trait makes us vulnerable to stress, what can this tell us about resilience? Well, every positive factor has a negative opposite – and every negative factor has a positive opposite. So if more perfectionism is bad, then less is good; and if perfectionism describes rigid, high standards, then the other end of this spectrum is mental flexibility (Figure 1).

perfectionism 1

It’s not high standards that are the problem

Let’s be clear, reducing perfectionism isn’t about lowering high standards. Having high standards is often a strength, driving people to make great achievements. The problem is not the standards themselves, but the fact that they are rigid and inflexible. Aiming high when you’re feeling strong can be positive, but insisting on reaching the same standard when you’re under unusually high pressure can be exhausting. There’s a need to maintain personal equilibrium, to adjust standards in response to what is manageable, given the situation. Doing this can ensure that you bend without breaking, and feel ready to return to full strength when your situation changes. On the other hand, piling on the pressure to meet overly high standards at all times is a recipe for burnout. 

Types of inflexible thinking

There are different thinking habits we can fall into that feed perfectionist thinking and reduce our ability to be flexible. These kinds of thinking habits are inflexible, rigid and demanding. Some examples are:

  • Black-and-white thinking. This is where you lose sight of the grey areas, and go into a mode which is ‘all or nothing’. The kind of thoughts you might have are “Anything less than the best is unacceptable” and “Asking for help makes me a failure”.
  • Catastrophic thinking. This is where you blow up the consequences and believe that if something goes wrong then it will be unmanageable. Some catastrophic thoughts are “If I fail the exam, my life is over” and “If I don’t get it right, I’ll never be able to face my parents”.
  • Probability overestimation. This is where you overestimate the likelihood of bad outcomes. Some thoughts you might have are “Although I revised for the exam all week, it won’t be enough”, and “There’s no point in entering the competition, because I’d never win”.
  • Should statements. This is where you put yourself under a tyranny of rules. These are rigid, and do not adapt or relax when under times of pressure. Some thoughts you might have are “I should always be polite”, and “I should always foresee potential problems”.

 

Some ways to enhance mental flexibility

  1. Develop self-awareness

Notice when you are falling into these thinking habits and pushing yourself too hard. Some useful questions to ask yourself are:

  • Am I feeling more irritable or distracted than usual?
  • Am I showing any physical signs of stress – am I more tired than usual, or struggling with sleep?
  • Is anyone else telling me that I’m pushing myself too hard to meet these standards?

It may be useful to keep a brief diary. Write down the events of the day, your thoughts/interpretations of these, and how you feel emotionally at the end of the day. This will help you understand your own patterns of behaviour, how you interpret events and how this effects you emotionally. For example:

Event Thoughts/interpretations Emotions
Passed exam, but with a lower grade than predicted

 

I should have seen this coming. That module was tough and I’m just not up to it. I’ll have to work twice as hard next time, if I want to stand any chance of having a successful future. Worried, embarrassed, downhearted.
Saw Mary, went for a drink It was great to catch up, it’s been too long. Sounds like she’s doing really well. Had forgotten some of those times we chatted about! Happy, hopeful.

 

  1. Do something to lift your mood

Negative emotions narrow the focus of our attention (Fredrickson and Joiner, 2002). This means that we are more likely to get stuck thinking about our problems, and lose sight of the bigger picture. By contrast, positive emotions can open the scope of our attention. They help us to think more broadly and to find different ways of looking at our situation. Perfectionistic thinking is closely linked with negative emotion: it is unrelenting and demanding, and rarely helps us to feel good. A good first step in tackling this can be to do something that makes you feel more positive. This might be doing something you enjoy, like seeing friends or going to a film or something active, like exercise. You might also want to engage in the Broad-Minded Affective Coping Procedure (BMAC), a therapeutic exercise designed to boost mood (for an example of this see https://www.youtube.com/watch?v=RXLhtkHck78 ). The key thing is to do something that will give you a quick lift, as this will help you to think of things that can help you and implement change in the longer run.

 

  1. Set yourself some new, realistic and flexible standards

It can be useful to write yourself a new list of standards and statements, and to read these when you know you are pushing yourself too hard. Some examples of these are:

  • It’s not possible to be perfect all the time, and that’s ok
  • My own wellbeing is more important than my achievements
  • It’s ok to say the wrong thing sometimes, I’m only human
  • It’s not possible to be in a good mood all the time
  • I can only do my best, I can’t control all possible outcomes

 

  1. Think about your fears from someone else’s perspective

Confide your worries and fears to close friends or family who care about you and whose opinions you find helpful. Later on, when you are stressed and you think you may be pushing yourself too hard, you can then draw on these conversations in your mind. Think back to them and try and see your current situation from their perspectives. Ask yourself questions like:

  • If I told [friend or family member] how I had failed to achieve my usual standard, what would they say?
  • What advice would [friend or family member] give me about my current worry?
  • What advice would I give [friend or family member] if they had this same problem?

 

  1. Test your fears

Sometimes we need to change how we behave to change our thinking. In particular, it can be useful to challenge our fears in small ways. For example:

  • If you insist on always being early, try arriving at an event 10 minutes late.
  • If you hold very standards about your appearance, wear something that is old, creased or has a stain on it.
  • If have a very strict exercise regime, try doing no exercise for a week
  • If you have very high standards for how you behave socially, try saying something you would normally not allow yourself to do so

Before you test out your fear, write down a list of what you are worried will happen. What do you think will go wrong as a result? Then rate each fear on i) how likely you think it is to happen (from 0 [not at all likely]-100 [will definitely happen]) and ii) how bad the impact will be (from 0 [I’ll barely notice it] to 100 [it will affect every area of my life for good]). After you’ve completed the test, read your list of fears. Did they happen? For those that happened, how bad was the outcome in reality? Rate it again from 0-100. Compare your ‘before’ and ‘after’ lists. For example:

 

First list (before the test)

Feared event What I’m worried will happen How likely is it to happen? How bad will the impact be?
Wearing clothes with a mark on Other people will notice 100% 70%
  Other people will judge me, and give me funny looks 100% 80%
  I’ll be so embarrassed I’ll go bright red 100% 90%
  I won’t be able to think straight and get my words out 90% 100%
  I won’t be able to face them again 80% 100%

 

Second list (after the test)

Feared event What was worried would happen To what extend did this happen? How bad will the impact be?
Wearing clothes with a mark on Other people would notice 20% 0%
  Other people would judge me, and give me funny looks 0% 0%
  I’d be so embarrassed I’d go bright red 60% 20%
  I wouldn’t be able to think straight and get my words out 20% 40%
  I wouldn’t be able to face them again 0% 0%

 

When we do this we often realise how bad our fears were before we started. Afterwards, even though we may still be afraid of reducing our high standards, we see how that fear has been reduced. In CBT, we call this a ‘behavioural experiment’. For a video example of one of these in a therapy setting, please see: https://www.youtube.com/watch?v=ExNs8o8A4fI

Evidence for reducing perfectionism and enhancing flexibility

Enhancing flexible thinking is a key feature of most cognitive-behavioural interventions, but recent years have seen the development of some interventions focused specifically on developing this. There is now a strong body of evidence to suggest that these interventions are both successful in reducing perfectionism, and also in boosting overall mental wellbeing. A recent meta-analysis and systematic review identified 8 studies that had investigated this and reported a large-effect sizes for studies reducing perfectionism, and found evidence that these interventions also reduce anxiety and depression in participants (Lloyd et al., 2015).

 

FREDRICKSON, B. L. & JOINER, T. 2002. Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13, 172-175.

HEWITT, P. L. & FLETT, G. L. 1991. Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, 456-470.

JOHNSON, J., WOOD, A. M., GOODING, P., TAYLOR, P. J. & TARRIER, N. 2011. Resilience to suicidality: The buffering hypothesis. Clinical Psychology Review, 31, 563-591.

LLOYD, S., SCHMIDT, U., KHONDOKER, M. & TCHANTURIA, K. 2015. Can psychological interventions reduce perfectionism? A systematic review and meta-analysis. Behavioural and cognitive psychotherapy, 43, 705-731.

For more information on some of these techniques and other ideas for overcoming perfectionism, see https://www.anxietybc.com/adults/how-overcome-perfectionism

 

This blog post was first published on 24th November 2016 at  https://www.psychreg.org/enhancing-self-esteem/

What is resilience?

As discussed in an earlier post, there are a number of definitions of resilience, but it’s generally used to describe an ability that some people demonstrate to withstand the negative impact of stress. These are the people who keep their cool and keep going in the face of problems. They don’t show undue distress, act out, or give up.

Is it possible to build or increase your levels of resilience?

There’s a common misperception that resilience is a rare quality, held by the special few. This is simply inaccurate. Life is full of decisions, choices and challenges, and we all need some level of resilience to get us through. However, it’s clear that some people have a higher threshold for managing stress than others. In the past it was often believed that these kinds of abilities were part of our genetic make up: either you had them or you didn’t. This view is now rapidly changing. An ever-growing body of psychological research shows that we can change the way we think and see the world, and we can build those factors that make us more resilient.

So… which factors in particular make us more resilient?

Together with my colleagues, I have undertaken a number of studies into the factors that confer resilience. This has included two large review papers. In the past, resilience research has often confused the concept of resilience with wellbeing, suggesting that people with high wellbeing must be resilient. However, it’s possible that people who are high on wellbeing are simply low on stress. To properly understand resilience, we need to go beyond this. We need to group people depending on whether they are i) under high or low stress and ii) maintaining or not maintaining their wellbeing (see Figure 1). When we do this, we can identify those people who are coping well with stress, and find out what it is about them that helps them to do this. It is this approach that my work has taken.  

building self esteem1

Our work has suggested that higher self-esteem, more flexible thinking and higher self-confidence confer resilience. These factors are often targeted by psychological therapy. In particular, techniques included as part of cognitive-behaviour therapy (CBT) aim to enhance or increase these beliefs and abilities. Interventions to enhance these abilities hasn’t just been limited to people with diagnosed mental health problems though: studies in groups of young people and workers in high-stress environments have also focused on enhancing these factors (Morton and Montgomery, 2013, Lin et al., 2004).

In this post, we’re going to look at two ways to enhance self-esteem using psychological techniques. These interventions are brief, so they can be used in workshop and training sessions, and research suggests they work. We’ll outline the background and process to these techniques before providing some evidence for their effectiveness.

  1. Self-affirmation techniques

Background

Self-affirmation theory is a social psychological theory. It views people as story tellers who have a powerful need to tell a coherent and continuous story about themselves as people who are able to control important and moral outcomes in their lives (Cohen and Sherman, 2014). In other words, self-affirmation theory suggests we have a strong need to see ourselves as being a ‘good person’. Events which threaten this story are perceived as threats which cause upset and distress. According to self-affirmation theory, these events need not be big, like a job loss or marriage breakdown. Our need to maintain a sense of ourselves as essentially ‘good’ is so strong that it means that even mundane events can be experienced as threatening.

The technique

The good news is that, according to the theory, we don’t need to see ourselves as ‘wonderful’ or ‘excellent’ to be happier: we just need to see ourselves as being adequate. However, if we are experiencing more challenging threats than usual, we can sometimes need help to restore and strengthen our story of ourselves as a being a ‘good person’. The most commonly used self-affirmation technique to achieve this is to write a list of core personal values. Once written, people choose one value that is particularly important to them (Cohen and Sherman, 2014). They then write about why the value is important to them, and describe a time when the value was important. People often write about relationships with family or friends, religion, kindness or humour. The idea behind this is that it reminds people of the fundamentals of their story and enables them to strengthen their personal narrative around this. An excerpt from Cohen and Sherman (2014) provides an example of what one college student wrote during the exercise:

“My relationship with my family is very important to me because it is my parents and brother who helped push me to be who I am today. Without them, I probably wouldn’t have the patience and motivation to have applied for this university and be successful here. Whenever I have a problem, it is my family I can go to to help me through it.”

The evidence

A large body of research suggests that self-affirmation interventions help people to deal more effectively with stressful events. People who use them demonstrate less of a physical reaction to stress (Creswell et al., 2005), are more likely to take positive action when told they have a health problem (Epton et al., 2015), and even gain higher academic grades (Cohen and Sherman, 2014). Why? Well, the theory states that performing self-affirmations helps to build a person’s self-esteem. Strengthened in their personal story, and in their sense of who they are as a good and valuable person, they are less vulnerable to events or information that could threaten this. This explanation has been supported by evidence that people high in trait self-esteem who perform self-affirmations are those who cope best with stress (Creswell et al., 2005).

  1. Tarrier’s (2001) Cognitive-behavioural technique

Background

Cognitive-behaviour therapy (CBT) suggests that poor mental wellbeing can result from negative underlying beliefs. We can have these beliefs for sometime without being fully aware of them, but when we come across a ‘trigger’ event, they can lead to vicious cycles of negative thoughts, emotions and behavours (Figure 2). For example, we may have an underlying belief that we are worthless, but for as long as we are employed, this belief is kept at bay. However, when we find ourselves made redundant from our job, this belief is activated, leading to negative thoughts such as “I knew this would happen, I could never hold onto a job” and “I’ll never another job, no other firm would employ me”. These thoughts can lead to sad emotions and a lack of motivation, which can then contribute to decisions to become less active, to disengage from friends and to stop applying for jobs.

build self-esteem

The technique

The good news is that if negative beliefs can bring us down emotionally, then CBT suggests that more positive beliefs can boost us, and this is the principle underlying Tarrier’s (2001) self-esteem building technique. In this technique, people are asked to generate a list of positive self-qualities or statements that they think describe them. The idea is that these will be generated over 5 sessions at a rate of 2 per session (10 in total) but this number can be adapted to suit the setting and format of the intervention. For each positive quality that has been suggested, people are then asked to list as many examples of themselves demonstrating this quality as they can think of. As far as is possible, these examples should be based in their own personal memories, and should be described in a good level of detail. Next, participants are asked to mentally rehearse the examples they have described in order to strengthen their access to these memories. Before and after this exercise participants are asked to rate their level of belief in the self-qualities that they have described (on a scale from 0-100). The idea of this is to demonstrate the importance of where our attention lies. In other words, this is done to show that when we think about good things about ourselves, we will believe it more strongly and feel better (Hall and Tarrier, 2003).

The evidence

This technique has now been explored in i) a case study with an older adult suffering from low mood and depression (Chatterton et al., 2007), ii)  a randomised-controlled trial with working age adults with mental health problems, (Hall and Tarrier, 2003) and iii) a group of working age adults with substance misuse problems (Oestrich et al., 2007). In each case, it has been found to be an effective intervention for boosting self-esteem.

Summary

Self-esteem is an important resilience factor, which can help us to maintain positive wellbeing when we are under pressure or stress. Two ways to boost our self-esteem are to remind ourselves of the values that we hold important, and the things about ourselves that are good. There are specific ways of doing this, and research suggests that when undertaken, doing this can help us to maintain a strong sense of self and to build our self-esteem.

Find out more about building resilience in my blog on how to reduce perfectionism.

 

CHATTERTON, L., HALL, P. L. & TARRIER, N. 2007. Cognitive Therapy for Low Self-Esteem in the Treatment of Depression in an Older Adult. Behavioural and Cognitive Psychotherapy, 35, 365-369.

COHEN, G. L. & SHERMAN, D. K. 2014. The psychology of change: Self-affirmation and social psychological intervention. Annual Review of Psychology, 65, 333-371.

CRESWELL, J. D., WELCH, W. T., TAYLOR, S. E., SHERMAN, D. K., GRUENEWALD, T. L. & MANN, T. 2005. Affirmation of personal values buffers neuroendocrine and psychological stress responses. Psychological Science, 16, 846-851.

EPTON, T., HARRIS, P. R., KANE, R., VAN KONINGSBRUGGEN, G. M. & SHEERAN, P. 2015. The impact of self-affirmation on health-behavior change: A meta-analysis. Health Psychology, 34, 187.

HALL, P. L. & TARRIER, N. 2003. The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study. Behaviour research and therapy, 41, 317-332.

LIN, Y.-R., SHIAH, I.-S., CHANG, Y.-C., LAI, T.-J., WANG, K.-Y. & CHOU, K.-R. 2004. Evaluation of an assertiveness training program on nursing and medical students’ assertiveness, self-esteem, and interpersonal communication satisfaction. Nurse education today, 24, 656-665.

MORTON, M. H. & MONTGOMERY, P. 2013. Youth empowerment programs for improving adolescents’ self-efficacy and self-esteem a systematic review. Research on Social Work Practice, 23, 22-33.

OESTRICH, I. H., AUSTIN, S. F., LYKKE, J. & TARRIER, N. 2007. The Feasibility of a Cognitive Behavioural Intervention for Low Self-Esteem within a Dual Diagnosis Inpatient Population. Behavioural and Cognitive Psychotherapy, 35, 403-408.

TARRIER, N. 2001. The use of coping strategies and self-regulation in the treatment of psychosis. In: MORRISON, A. P. (ed.) Casebook of cognitive therapy for psychosis. London: Routledge.

What do we mean when we use the word ‘resilience’?

It’s widely accepted that when we talk about ‘resilience’ or ‘psychological resilience’, we are referring to an ability that some people show to withstand or quickly ‘bounce back’ from stress.

What can research tell us about resilience?

Researchers have been investigating psychological resilience for around 50 years. However, there have been a number of limitations with this research. For example, although we usually talk about psychological resilience as an ability to withstand stress, most researchers have not actually investigated their proposed resilience factors in relation to stress. Instead, they have simply measured their factor directly in relation to an outcome they’re interested in. For example, they have measured perceptions of social support in relation to wellbeing. They have found that high social support is linked with higher wellbeing, like this:

drawing[2]

However, if you think about it, the opposite of perceived social support is loneliness. And in fact, a number of researchers have previously shown us that feelings of loneliness are linked with indicators of poorer wellbeing, like this:

what is resilience 2

As you can see, this kind of ‘resilience’ research is not really telling us anything more than we used to learn from studies of risk factors!

So can resilience research tell us anything new?

Yes. However, we have to research it in the same way that we talk about: we need to study which variables reduce the likelihood that exposure to stressors will lead to negative outcomes. If we draw this out, it would look like this:

what is psychological resilience 3

If we research psychological resilience in this way, it becomes less important whether we use the term ‘high social support’ or ‘loneliness’: what is important is that our social relationships can influence how we will deal with stress. We can say that better social relationships can buffer or attenuate the likelihood that stress will lead to poor wellbeing, or that poorer social relationships harm our capacity for psychological resilience and will make us more vulnerable to poor wellbeing in response to stress.

To provide researchers with a guide for doing this kind of research, and to clarify the criteria that a variable should meet in order to be considered as conferring resilience, I have gathered these ideas together in a framework called ‘The Bi-Dimensional Framework’ (BDF) for resilience research (Johnson, 2016, Johnson et al., 2010a, Johnson et al., 2010b).

What advantages does the BDF offer resilience researchers?

  1. It overcomes the confusion caused by the range of terms that have been used to describe ‘resilience’

There have been a lot of words used in the research literature to describe psychological resilience, these include ‘mental toughness’, and ‘hardiness’, amongst others. This can be confusing. However, the BDF defines psychological resilience according to methodological criteria (i.e., what a variables does, or how it behaves), rather than terminology. It suggests that resilience factors are psychological variables which buffer the association between stress exposure (or exposure to risk factors) and the likelihood of negative outcomes. In particular, the BDF states that for low resilience individuals, there should be a clear increase in negative outcomes in relation to the amount of stress they experience. However, for high resilience individuals, there should be minimal increase in negative outcomes, no matter how much stress they experience. If we were to draw this relationship out, it would look like this:

psychological resilience

  1. It means we can use research to develop increasingly accurate concepts of resilience

In the past it has been common practice to propose a concept of psychological resilience, create a questionnaire to measure this, and then test it in relation to negative outcomes. If it is linked with lower levels of negative outcomes, the researchers conclude that the variable confers resilience. If it doesn’t, the researchers conclude that resilience doesn’t confer resilience in this instance. As outlined above, this doesn’t tell us whether the variable does indeed buffer the impact of stress. However, even more confusingly, how can a ‘resilience’ factor not confer resilience?! If this concept doesn’t confer resilience, then by the very definition of psychological resilience we must conclude that it is not in fact resilience at all. Instead, we could surmise that there are other factors which confer psychological resilience, which are not related to this concept.

This points to a need for concepts of psychological resilience which can be developed and adapted in response to research. As a framework for resilience research, the BDF allows for this kind of growth and development. In particular, it enables the systematic review of individual studies which have investigated factors which buffer the relationship between stress exposure and negative outcomes.

What do these reviews tell us?

Together with my collaborators, I have conducted two systematic reviews of resilience factors using the BDF approach, both of which have been published in a leading psychology journal (Johnson et al., 2016, Johnson et al., 2011). The first of these investigated psychological variables which buffer the relationship between exposure to any risk factor and suicidal thoughts. This suggested that hope, flexible thinking, self-confidence and a good way of looking at events conferred psychological resilience (Johnson et al., 2011). The second investigated psychological variables which buffer the relationship between exposure to failure experiences and psychological distress. This found that mental flexibility, higher self-esteem and a positive way of explaining events confer resilience to distress in response to failure (Johnson et al., 2016).

Together, these reviews suggest that even if you look at different kinds of negative outcomes, similar variables seem to confer psychological resilience. These variables relate to mental flexibility, self confidence and self-esteem, and a positive way of positive way of explaining events.

Can we train people to be more resilient?

Yes. The factors identified by these reviews (mental flexibility, self-esteem and self confidence and explanatory style) are those which are commonly targeted in cognitive-behaviour therapy, which is an evidence-based form of psychological therapy. CBT was initially developed as an intervention for people with mental health problems, but has since been found to be effective for improving mental wellbeing in a range of populations. With a collaborator in Australia, Dr Reema Harrison, I have been developing an intervention plan for training medical students in resilience which draws on CBT. This intervention is designed to train participants in resilience through three 60-minute workshops based on the principles of cognitive-behaviour therapy. These workshops will involve psychoeducation, experiential exercises and group work. We will be piloting this in Sydney in January 2017, and plan to then test this in subsequent research studies in different populations.

For more information on how to build psychological resilience, please see my blogs on enhancing self-esteem and reducing perfectionism.

References

JOHNSON, J. 2016. Resilience: The Bi-dimensional Framework. . In: WOOD, A. M. & JOHNSON, J. (eds.) Positive Clinical Psychology. Chichester: Wiley.

JOHNSON, J., GOODING, P. A., WOOD, A. M. & TARRIER, N. 2010a. Resilience as positive coping appraisals: Testing the schematic appraisals model of suicide (SAMS). Behaviour Research and Therapy, 48, 179-186.

JOHNSON, J., GOODING, P. A., WOOD, A. M., TAYLOR, P. J., PRATT, D. & TARRIER, N. 2010b. Resilience to suicidal ideation in psychosis: Positive self-appraisals buffer the impact of hopelessness. Behaviour Research and Therapy, 48, 883-889.

JOHNSON, J., PANAGIOTI, M., RAMSEY, L., BASS, J. & HARRISON, R. 2016. Resilience to emotional dysfunction in response to failure or error: A systematic review. Clinical Psychology Review, In press.

JOHNSON, J., WOOD, A. M., GOODING, P., TAYLOR, P. J. & TARRIER, N. 2011. Resilience to suicidality: The buffering hypothesis. Clinical Psychology Review, 31, 563-591.

Originally published 23rd Nov 2016 at https://www.psychreg.org/building-psychological-resilience/