RESILIENCE

IN THE PHYSICALLY ILL

Donna E. Stewart FRCPC

University Professor and

Chair of Women’s Health

Senior Scientist

Tracy Yuen BSc (Hon)

University Health Network

University of Toronto

CANADA

RESILIENCE

“A dynamic process in which psychological,

social, environmental and biological factors

interact to enable an individual at any stage of

life to develop, maintain or regain their mental

health, despite exposure to adversity.”

PreVAiL: http://prevail.fims.uwo.ca/theme2.html

RESILIENCE

• Most research done with children/adolescents

suffering from child maltreatment, family

violence, poverty, poor parenting, war, natural

disasters, traumatic events

• Over 80% of research on topic in the last

decade

• MeSH heading in 2010

PHYSICAL ILLNESS

• A common adversity in life

• Especially in older adults

• Acute or chronic

• May threaten survival, function, self esteem, relationships

• May involve forced dependence/disability

• Has economic consequences

• May alter life course

QUESTIONS

• What factors have been reported as

predicting, promoting, or associated with

resilience in the physically ill?

• Can these be used to enhance the care of

the physically ill and improve outcomes?

METHODS

• Psych INFO, Medline, CINAHL databases 1950-

2009, update 2009- Mar 2014

• Key words: resilience, (hardiness, benefit finding,

positive adaptation, adaptive behaviour)

• Physical Illness: CV, cancer, neurological disease,

arthritis, diabetes, hypertension, pulmonary

disease, infectious disease

• Titles, abstracts, full article, reference lists

• Exclusions: not English language, not resilience,

psychiatric illness, family resilience only.

METHODS (Cont.)

• 2 reviewers ranked independently

• Discussion to resolve disagreements

• Ranked by STROBE criteria

(Strengthening the Reporting of

Observational Studies in Epidemiology

• items: good, fair, poor quality

• Meta-analysis not feasible due to

heterogeneity

Medline, PsychInfo, CINAHL searched 1950-2009

Keywords: resilience, hardiness, benefit finding and chronic illness, cardiovascular disease,

cancer, neurological disease, arthritis, hypertension, pulmonary disease, renal disease,

autoimmune disease, infectious diseases and diabetes

475 articles retrieved Excluded articles (n=95):

Duplicates (n=49)

Review of concepts (n=23)

Commentary/editorial (n=18)

Text not in English (n=5)

380 articles screened for inclusion

Excluded articles (n=328):

Not positive consequences of illness (n=94)

Only family resilience (n=64)

Not physical illness (n=65)

Only risk factors (n=52)

Not health-related consequences (n=29)

Only psychological disorders (n=21)

No access to full-text (n=3)

52 articles included in review:

Cancer (n=13), Multiple medical conditions (n=10), HIV/AIDS (n=7), Diabetes (n=6)

Cardiovascular Disease (n=6), Arthritis (n=5), Miscellaneous (renal, MS, etc.) (n=5)

COMPARISON OF RESULTS

1950-2009: 475 articles retrieved

52 included in review

2009- 2014: 6060 articles retrieved

154 included in review

RESULTS

• Most papers included both sexes

• Age varied by disease state

• 80% participants were White

• Few Afro-American, Asian, East Asian,

Hispanic, Aboriginal, or not specified

• More papers had n > 100 in 2014

• Quality better in 2014

1. PSYCHOLOGICAL FACTORS

ASSOCIATED WITH RESILIENCE

• Self transcendance, self esteem, internal LOC, optimism, mastery, hope

• Self efficacy correlated with family and social functioning, self care, physical and psychological well-being

• Internal LOC associated with better resilience, adjustment, positive life outcomes

• Self esteem, flexibility, and mastery predict better psychol/physical wellbeing

1. PSYCHOLOGICAL FACTORS (Cont.)

• Hardiness predictive of: better physical, mental

and spiritual well being, adherence,

satisfaction and size of social network

• Rather than having good friends and high

income, a high level of mastery might help

chronically ill patients cope and adapt to

illness (Mertens VG et al. 2012)

2. COPING STRATEGIES

• Spirituality

• Positive cognitive appraisal

• Positive life orientation

• Sense of coherence

• Coping with uncertainty

• Benefit finding

• Anger management

3. SOCIAL SUPPORT

• SS from family and friends associated with

resilience

• SS associated with better psychological health,

benefit-finding, hardiness and self esteem

• 1914 chronic pain patients: widowed patients

were resilient: ? stress inoculation (Wade JB et

al. 2013)

• Couples’ relationship increases resilience (Blazquez A et al. 2012)

• Physician- patient relationship increases resilience (Jenkins SA. 2011)

4. ENVIRONMENTAL FACTORS 2009-14

• 5858 Scottish patients with pain: resilience associated with housing, employment, sex, age, used less healthcare, lower mortality (Elliott H AM et al. 2014)

• “Deprived” areas in English Census (2001-2003) that had “health resilience” (MMR) showed more “place attachment, natural environment and social capital” (Cairns-Nagi JM et al. 2013)

ENVIRONMENT 2009-14 (Cont.)

• Increased community and social support associated with increased resilience in elderly rural Australians (Inder KJ. 2012)

• “Hispanic culture” (familism, religion, social resources) may enhance resilience (Gallo LC. 2009)

• Leisure programs for older adults with chronic illness increased resilience (Hutchinson SL. 2012)

QUALITATIVE STUDIES THEMES

• Hope

• Empowerment

• Acceptance of Illness

• Determination

• Sense of coherence

RESILIENCE AND SPECIFIC ILLNESSES

CV: Internal locus of control, social support,

personal control, self efficacy

Stroke: Self care, self efficacy

HIV/AIDS: Positive appraisal of illness,

hardiness, cognitive appraisal, internal

locus of control, social support, spirituality

Diabetes: Self efficacy, self care, hardiness

RESILIENCE AND SPECIFIC ILLNESSES

(Cont.)

Cancer: Cognitive appraisal, social support,

acceptance, hope, empowerment,

spirituality, sense of coherence,

relationship with parents, self efficacy

Autoimmune (RA, LE, OA): optimism,

spirituality, self esteem, self efficacy

RESILIENCE AND SPECIFIC

ILLNESSES (Cont.)

Mixed diseases: Early life experiences, past successful coping, spirituality, determination, independence, hardiness, sense of coherence, education, mastery, social support, cognitive appraisal, self efficacy, self esteem, optimism

Are these REALLY specific to the illness?

Can we use this knowledge in dealing with physically ill individuals to enhance their coping and resilience?

5. INTERVENTIONS 2009-14

• Promoting acceptance, mindfulness and values-based action in patients with chronic pain. (McCracken LM et al. 2010)

• Web-based approaches in chronic physical and mental health problems. (Paul CL. 2013)

• Computer interventions on psychosocial adaptation of rural women with chronic conditions. (Weinert C et al. 2011)

• Psychosocial group interventions for children with chronic illness. (Schotten L et al. 2013)

• Acceptance training in elders with chronic conditions. (McDonald PE et al. 2011)

INTERVENTIONS 2009-14 (Cont.)

• Cognitive behavioral therapy for children with chronic illness. (Thompson RD. 2011)

• Emotion-regulation interventions in clinical populations. (Smyth JM et al. 2009)

• Bedside brief psychotherapy to address demoralization, existential concerns, hope, aging, communion with others. (Griffin JL et al. 2005)

• Nursing interventions for self management, self righting and personal qualities. (Edward SL. 2013)

INTERVENTIONS 2009-14 (Cont.)

• FREC: Family Resilience Enhancement Program for patients with schizophrenia (Lim H et al. 2013)

• 3RP: Relaxation Response Resilience Program Multimodal mind-body strategies to increase resilience to chronic stress. (Park ER et al. 2013)

• Art therapy in chronic pain (Lynch M. 2013)

• Creative arts in rural women with chronic illness (Kelly CC et al. 2012)

• PRISM: Promoting Resilience, Independence and Self Management for Mental Patients (Arva DK. 2013)

DISCUSSION

• Psychological factors that increase

resilience found in other groups, also

apply in physical illness

• Other factors identified more specifically in

physical illness

• Self care, treatment adherence,

HRQOL, illness perception,

pain perception, exercise

• Environmental contributions are new

• Interventions are new

DISCUSSION

• Study on osteoarthritis found resilience

was more important in predicting pain and

physical function than disease severity

and the effect of resilience on pain was

mediated through self esteem.

• This may well be true for other conditions

but needs evidence!

• Cost implications?

DISCREPANCIES

• Differences in study methods, quality,

personal or illness characteristics

• Internal LOC and high self efficacy more

beneficial if disease controllable

• Severe illness with physical limits more likely

to need more SS

• Effect of collectivist vs. individualistic

cultures

• Need to study relationships between factors

CONCLUSIONS

• Specific psychological, coping and social support strategies emerged that may be useful in caring for the physically ill

• Coping strategies (active, positive appaisal, spirituality)

• Encourage ill people to talk of other challenging situations they have mastered and how

• Encourage realistic sense of hope, optimism, mastery

• Self care, pain management, disease management, rehab, info

• Enhance social support and environmental support

CONCLUSIONS

• Need better studies into interventions to increase resilience: individual, group, community, web-based

• Consider full range of health providers and environment

• Across the life span: children to elderly

• Increasing resilience may have individual and social benefits (including cost savings)

“A fortunate few will not only find resilience

but discover new found strength and

meanings, resulting in benefit finding and

post traumatic growth through coping with

illness.”

“Not all physically ill may recover physical

health but assisting patients to enhance

their resilience may enable them to live

and function better with their illness-a very

worthwhile endeavor.”

Stewart and Yuen 2011