Protection against the adversity of neurological injury: The process of learning to be resilient

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Protection against the adversity of neurological
injury The process of learning to be
resilient Dr Ashley Craig, Professor,
Rehabilitation Studies Unit, Sydney Medical
School, The University of Sydney Based on work
funded by the ARC and MAA
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Senior Clinical Psychologist READ Clinic, Hill St
Gosford
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The resilience material presented tonight can
also be found in my Chapter 26 Resilience in
People with Physical Disabilities recently
published (2012) by Oxford Press
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Resilience following injury is an important area
of study, and which many of you I am sure have
significant ideas about. I hope this talk can
challenge those ideas, and provide new insights
into helping people who need to develop resilience
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How resilient do you think you are?
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The nature of resilience

• Resilience studies attempt to discover why and
  how people cope and adjust to adversity
• Early studies of children in New York who
  thrived with single mothers who had schizophrenia
  were the catalyst for the emergence of the study
  of resilience

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Luthar et al., (2000) defined resilience as
.. a dynamic process encompassing positive
adaptation within the context of significant
adversity. (p.543)  In disability, I have
defined resilience as the process of
maintaining stable psychological, social and
physical functioning when adjusting to the
effects of a disability or injury and subsequent
impairment. Craig, A. (2012). Resilience in
people with physical disabilities. In P. Kennedy
(Ed.). The Oxford Handbook of Rehabilitation
Psychology. Oxford Oxford University Press,
p.474-491.  


What is resilience?

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A belief in themselves as effective in self
management An ability to form close
relationships An ability to achieve positive
outcomes in their daily lives A degree of
autonomy An ability to problem solve An ability
to be optimistic and humerous despite
adversity An ability to manage stress and trauma
associated with adversity Craig, A. (2012).
Resilience in people with physical disabilities.
In P. Kennedy (Ed.). The Oxford Handbook of
Rehabilitation Psychology. Oxford Oxford
University Press, p.474-491. Rees, R. (2012).
Resilience of people with traumatic brain injury
and their carers. InPsych, April, 12-13.  
Resilient behaviour is characterised by

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Resilience research involves assessing
protective factors

Protective factors Environmental Social and interpersonal Psychological and physical
community resources stable family support robust self esteem healthy environment affection a sense of self mastery secure housing employment physically healthy financial resources socially active problem solving skills education opportunities positive attachments adequate social skills community cohesion friends support stable mood states recreation facilities access to social networks adequate coping skills
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and risk factors
Risk factors Environmental Social and interpersonal Psychological and physical
limited resources no family support elevated anxiety unhealthy environment poor social networks sense of helplessness insecure housing unemployed elderly poor finances avoids activities poor insight lack of education single lack of communication skills stressful living context frequent hospitalization depressive mood significant cognitive deficits
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Factors shown to protect against psychiatric
distress
Rutter (1985) proposed a number of protective
factors that have the potential to modify, alter
or cushion a person from the negative
consequences of adversity Factors included a
constructive/ realistic understanding of
events taking adaptive action a robust
self-esteem and a strong sense of mastery or self
efficacy being adaptable when faced with change
having problem solving skills a sense of humor
when faced with stressful events/
optimism dealing successfully with problems in
the past accepting responsibility when dealing
with problems quality social support Rutter, M.
(1985). Resilience in the face of adversity.
Protective factors and resistance to psychiatric
disorder. British Journal of Psychiatry, 147,
598611.

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Some prominent factors shown to protect against
injury and distress

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Self efficacy the extent to which a
person perceives they can control their
behaviour, lives and daily outcomes Maciejewski
et al., (2000) showed self efficacy was a very
significant predictor of depressive symptom
severity Having a higher level of self efficacy
resulted in fewer depressive mood symptoms in
adults. Self- efficacy mediated around 40 of the
effects of stressful life events on depressive
mood They concluded that maintaining a healthy
self efficacy, that is, a strong sense of control
or mastery over ones life and environment,
serves to protect a person from psychopathology,
by ameliorating the negative effect of stressful
life events Maciejewski, P. K., Prigerson, H.
G., Mazure, C. M. (2000). Self-efficacy as a
mediator between stressful life events and
depressive symptoms. British Journal of
Psychiatry, 174, 373-378

Self efficacy and resilience

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Catastrophic thinking and resilience
If a persons style of thinking is
catastrophic or very negative, then resilience is
less likely
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Thinking realistically and adaptively
about adversity helps the resilience
process For example, in chronic pain, Sullivan
et al (1998) found that catastrophising about
pain was significantly associated with reduced
capacity to cope, increased pain intensity and
perceived disability, and lowered employment
status Catastrophising contributed to the
prediction of disability over and above the
variance accounted for by pain intensity
Catastrophising was associated with disability
independent of the levels of depression and
anxiety. Rumination was the strongest predictor
of pain and disability Sullivan, M.J.L., et
al., (1998). Catastrophizing, pain, and
disability in patients with soft-tissue injuries.
Pain, 77, 253260
Catastrophic thinking and resilience
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Pain Catastrophising

• Catastrophising involves focusing on pain in a
  very negative and unhelpful manner
• Example I cant stand it any longer. Its all
  hopeless and whats the point?
• If one catastrophises, one has less ability to
  deal with pain, and catastrophisation is a
  powerful predictor of poor pain management
• The reverse is true. If one stops
  catastrophising then pain decreases
• Example My pain is difficult to manage, but I
  can cope and deal with it

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Catastrophising is not uncommon and will make it
more difficult for the injured person to show
resilience
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Social support and resilience
Helpful social support protects against
adversity Social networks act as a protective
factor in a direct manner, for instance, by
providing access to information or by enhancing
motivation to engage in adaptive behaviors.
Social support can also influence a person
positively by encouragement to adhere to
treatment recommendations, maintain health
promoting behaviors such as exercise and a
regular and balanced diet, or to provide support
such as giving a ride to someone who needs to
keep a medical appointment or shop for food
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What factors are related to resilience in people
who have a neurological-based speech disorder,
that is, stuttering? First,.
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Stuttering imposes a significant mental health
burden or adversity
Tran, Y., Blumgart, E., Craig, A. (2011).
Subjective distress associated with chronic
stuttering. Journal of Fluency Disorders, 36,
17-26.
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Further, prevalence of social phobia is high in
this population Our data indicates a social
phobia prevalence of 46, in comparison to 4 in
non stuttering control group Blumgart, E., Tran,
Y., Craig, A. (2010). Social anxiety disorder
in adults who stutter. Depression and Anxiety,
27, 687-692. So stuttering involves
significant adversity!

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What factors are related to resilience in people
who stutter?
We studied 200 adult people who had a
diagnosed stutter We defined resilience in
this study as exhibiting a low level of global
psychopathology (measured by the
SCL-90-R) Craig, A., Blumgart, E., Tran. Y.
(2011). Resilience and stuttering factors that
protect people from the adversity of chronic
stuttering. Journal of Speech, Language, and
Hearing Research, 54, 1485-1496.
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Resilient and non-resilient sub-groups
Age (yrs) Mean (SD) Age (yrs) diagnosed Mean (SD) SS Mean (SD) LAQ I Mean (SD) LAQ II Mean (SD) SOS Mean (SD) GSI Mean (SD)
Resilient (n76) 47.8 (16) 5.6 (2.6) 3.5 (2.6) 13.4 (6) 16.8 (9) 25.0 (4.3) .23 (.18)
Non resilient (n124) 44.3 (16) 5.8 (2.8) 3.8 (2.9) 15.8 (7) 25.1 (14) 22.6 (5.2) 1.47 (.58)
NOTE stuttering frequency or SS (higher scores
indicate greater severity), health risks (LAQ1
higher scores indicate higher levels of risk),
self-efficacy (LAQ2 higher scores indicate poor
self-efficacy), social support (SOS lower
scores indicate poorer social support) global
psychopathology score (GSI higher scores
indicate more severe psychopathology)

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Using regression analysis, resilience factors
found in people with a neurologically related
speech disorder consisted of
Protective factors Minor protective factors Severity of the disorder .. Annual income Vitality General health . Physical role Major protective factors Self-efficacy Helpful social support . Social integration Nature of the contribution Lower severity increased resilience Higher income increased resilience Higher vitality (or low fatigue) increased resilience Better health increased resilience Greater physical function increased resilience High self-efficacy increased resilience Greater social support increased resilience Greater social activity increased resilience

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I doubt if anyone here would question the
assumption that neurological injury is associated
with significant adversity!!
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As an example, people with spinal cord injury
face very substantial adverse conditions when
dealing with their injury and impairment For
instance, our research has shown lowered quality
of life in people with SCI
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Difference between Australian age and sex
standardised norms with people with SCI who have
low and high levels of self-efficacy (SE) on the
eight SF-36 QOL domains Source Middleton, Craig
Tran (2007). Archives Phys Med Rehab, 88,
1643-1648



Low SE SCI group sign. diff to the other two
groups in all domains plt.05
High SE SCI group only sign. diff to Australian
norms in three domains plt.05
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and elevated risks of depressive mood and anger
Almost 50 have risks of depression after many
years of living in the community, and adults
with SCI have over nine times the risk of having
increased levels of anger or irritability
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Chronic fatigue is also a high risk in people
with injury
Wijesuriya, N., Craig, A., Tran, Y., Middleton,
J. (2012). Fatigue and anger in people with
spinal cord injury. Australian Journal of
Rehabilitation Counselling, 18, 60-65.
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Fatigue negatively influences neural activity
this is seen in the impact on brain activity of
non injured people. It involves a global
reduction in theta and alpha activity, and an
increase in beta activity Craig , et al.,
(2012). Psychophysiology, 49, 574-582.



Alert fatigue
Theta Alpha 1 Alpha 2 Beta
db




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We estimate that around 50 of adults with SCI
(and TBI) have a major problem with fatigue, and
that high fatigue levels place one at risk of
depressive mood (and vice versa), and thus less
likely to be resilient Source Wijesuriya, Tran,
Middleton Craig (2012). Archives Phys Med
Rehab, 93, 319-324

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We have also shown that adult people with SCI
tire significantly after participating in a 2-3
hour mental task compared to able-bodied matched
controls. Those wih elevated depressive mood (and
therefore less resilient) will be more likely to
fatigue excessively (see below)
Craig, A., Tran, Y., Wijesuriya, N., Middleton,
J. (in press). Fatigue and tiredness in people
with spinal cord injury. Journal of Psychosomatic
Research.
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• What factors contribute to resilience in a large
  group of newly injured adults with SCI? N70,
  mean age 42 years
• Preliminary results
• Major protective factors
• Self efficacy stronger self efficacy, greater
  resilience (explains 14)
• Mood more positive mood , greater resilience
  (explains 19)
• Minor protective factors
• Age higher age, better resilience (explains
  1-2)
• Severity lower severity, better resilience
  (explains about 1)
• Cognitive capacity higher capacity, better
  resilience (explains about .2)

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Interventions that enhance resilience
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Nurturing resilience (Rees, 2012) Develop a
rewarding and pleasant events schedule Plan for
appropriate work experience options Make sure
there is a anchor person who is a constant (eg.
family member, caregiver, health
professional) Regular professional consultation
available that is ongoing (eg. psychologist) Emplo
y helpful and optimistic language Develop a
social network with peer support Engage in
challenging cognitive activities (eg. writing,
reading)
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Interventions that enhance resilience

• My feeling is that treatment very likely to
  enhance resilience should
• significantly enhance self-efficacy
• enhance social support and integration
• result in helpful rational thinking
• teach adaptive coping skills
• provide vocation support (eg return to work)
• teach problem solving
• enhance family and caregiver support
• others?

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The following slides present outcome results from
clinical trials we have run with adults with
SCI These findings suggest that resilience has
been enhanced Treatments used have involved a
mix of mental and behavioural skills that address
anxiety, poor mood, fatigue, social integration,
and so on.
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Clinical trial outcome for adults with SCI.
Chronic pain (0none, 2 discomfort,
3distressing) following group CBT. Control SCI
participants received usual rehabilitation care
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Clinical trial outcome for adults with SCI.
Depressive mood (Beck Depression Inventory where
high scores indicate high depressive mood)
following group CBT. Control SCI participants
received usual rehabilitation care
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Clinical trial outcome for adults with SCI.
Perceived control (perceptions of helplessness
where high scores indicate helplessness)
following group CBT. Control SCI participants
received usual rehabilitation care
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Controlled randomised clinical trial showing
change in levels of fatigue (high scores indicate
high fatigue) in adults with SCI who received
massage versus visualisation over 5 weeks
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Controlled randomised clinical trial showing
change in levels of chronic pain (high scores
indicate high pain) in adults with SCI who
received massage versus visualisation over 5 weeks
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When French impressionist painter Auguste
Renoir (1841-1919) was confined to his home
during the last decade of his life, Henri Matisse
was a close friend and visited him daily.
Renoir, almost paralyzed by arthritis,
continued to paint in spite of his infirmities.
One day as Matisse watched the elder painter work
in his studio, fighting torturous pain with each
brush stroke, he blurted out Auguste, why do
you continue to paint when you are in such
agony? Renoir said The pain passes but the
beauty remains. So, Renoir continued to put
paint to canvas. Below is one of his paintings,
Tilla Durieux , completed 5 years before his
death, 13 years after he developed the disease.
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Thank you