Resilience after Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth Traumatic Brain Injury Model System
RESILIENCE SAME INJURY, DIFFERENT OUTCOMES
The Case of Bill Three years ago, 28 year old Bill sustained a severe brain injury in a high speed motor vehicle collision. On admission to the emergency room, GCS was 7. Head CT revealed a right temporal contusion and a large left parietal intracranial hemorrhage with a depressed skull fracture. He underwent a left craniectomy with skull fracture debridement and ICH removal. Hospitalized for more than a month, Bill was discharged home in the care of his wife.
The Case of Tom Three years ago, 28 year old Tom sustained a severe brain injury in a high speed motor vehicle collision. On admission to the emergency room, GCS was 7. Head CT revealed a right temporal contusion and a large left parietal intracranial hemorrhage with a depressed skull fracture. He underwent a left craniectomy with skull fracture debridement and ICH removal. Hospitalized for more than a month, Tom was discharged home in the care of his wife.
The Case of Bill Unemployed and Living with His Three years after his injury, Bill now lives with his parents and they now have a turbulent relationship. His wife and two young children are living without him in the home they once shared. After repeatedly cursing and yelling at them and punching holes in the wall, Bill s wife obtained a court order forcing him out of their home. Despite numerous requests from his wife and parents, Bill had declined to see a doctor or counselor and denied having problems he couldn t handle himself. Bill is now unemployed. He went back to his old job as a landscaper and three weeks later was fired for repeatedly arguing with customers. Bill found several other jobs, but wasn t able to hold any of them for more than a short time. Angry, he told his parents, my life has been ruined
The Case of Tom Working and Living with His Wife and Children Three years after his injury, Tom was living with his wife and two young children. Soon after returning home, he began to have bouts of depression. With encouragement from his wife, he saw his family doctor who provided medication and referred him to a counselor for weekly sessions. Tom also began to attend a monthly brain injury support group. He learned that sharing his thoughts and feelings with others helped him adjust and function. Tom tried going back to work full-time as a landscaper and initially had problems with fatigue and headaches. With support from his supervisor and colleagues, Tom backed down to a part-time schedule. After eight months, he was gradually able to resume a full-time schedule. Tom recently received a sizable raise. Smiling, his supervisor
What Bill said. To avoid disappointment, I imagine the worst thing that can happen. I ll get stronger if I trust no one and solve my problems by myself. My future has been permanently destroyed by this trauma. What Tom said I m usually optimistic and see problems as temporary. I have good friends I can talk to who help me out. I ve been made stronger and better by this difficult experience. When bad things happen, I m not
What Bill said. I ve learned that most people have nothing good or helpful to say. I don t like who I am now. My selfconfidence has vanished. Mistakes only lead to depression and more mistakes. I d rather be around people who are just like me. If my first solution to a problem fails, I usually What Tom said I listen carefully and consider other people s opinions. I know my strengths and work to build my self- confidence. I do my best to learn from mistakes and try to do better next time. I enjoy being around different kinds of people. If my first solution to a problem fails, I try to find another
What is Resilience? Definition: the ability to withstand and rebound from disruptive life challenges involves dynamic processes fostering adaptation within the context of significant adversity. From Walsh, F. (2003) Family Process, 42 (1).
Defining Resilience, Resilient, and Resiliency o Cope well in the face of ongoing disruptive change o Maintain good health and energy in the face of constant pressure o Overcome adversities, bounce back from setbacks o Change to a new way of working or living when maintaining the old way is not possible o Do all this without behaving in harmful or
Goals in Learning to be o Remain calm under pressure o Improve creative, analytical, and practical problem solving skills o Maintain optimism, humor, and positive feelings in the face of challenges o Avoid thinking of one s self (and others) as a victim o Be self-reliant and socially responsible o Understand that learning leads to a better life o Derive good fortune from misfortune From Siebert, A., The Resiliency Advantage, 2005
Al Siebert (2005) When resilient people have their lives disrupted they handle their feelings in healthy ways. They allow themselves to feel grief, anger, loss, and confusion when hurt and distressed, but they don t let it become a permanent feeling state They are examples of Nietzsche s statement, That which does not kill me makes The Resiliency Advantage
Disruptiv Thriv e e Change Resile Attac k Cope Numb Upset Victim Al Siebert, 2003
Strength-Based Care o Disciplines which have embraced a shift toward strength-based models of care have done so for both practical and humanistic reasons o Researchers (e.g., Duncan, 2010) have established that a dominant factor in positive therapeutic outcomes is a therapy client s orientation toward hope and Godwin & Kreutzer, Brain Injury, 2013
Strength-Based Care o In fact, empirical support demonstrates that 30% or more of therapy-based growth can be attributed to a client s ability to be optimistic and flexible. o Processes designed to facilitate the promotion of resilient traits are tied to successful outcomes. Godwin & Kreutzer, Brain Injury, 2013
Rationale for Investigating Resilience The profile of a resilient population after TBI has not been established To date, the natural process of resilience development following TBI has not been investigated Identification of correlating variables and the path to resilience can strengthen interventions designed to promote resilience after TBI
Traits and Skills Researchers in the resilience field have determined that: a. the skills that are associated with a resilient and adaptive response to trauma are neither superhuman nor extraordinary; and b. resilient skills can be initiated and/or strengthened in individuals who have previously demonstrated non-resilient
The Resilience and RAI Research project partly funded by the U.S. Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR) #H133A120031.
Common TBI Challenges and Skills Necessary for Resilience Common TBI Deficits and Skills Necessary for Resilience Challenges Anxiety, depression Even temperament, emotional stability Survivor focus on deficits, Positive outlook, optimism frequent comparisons to pre- Irritability, aggressive behaviors Self-regulatory skills and eventempered behaviors Discomfort with socialization Social perception, arousal of liking response in others Impaired self awareness Insightful modification of behavior Cognitive deficits, impaired Good problem solving skills executive functioning Diminished communication Effective communication skills
1. Assumptions Underlying the Resilience and Adjustment Successful survivorship is based in individual resilience. Survivors who embody, or who learn to adopt traits identified as key to resilient living will find increasing success in their recovery and growing
2. Assumptions Underlying the Resilience and Adjustment Achieving postinjury emotional wellness requires a clear understanding of injuryrelated symptoms, commonly encountered challenges, and recovery processes.
3. Assumptions Underlying the Resilience and Adjustment A key feature of resilience is developing insight into one s own behavioral response to trauma. Survivors who are more aware of their strengths and limitations are more likely to
4. Assumptions Underlying the Resilience and Adjustment Resilient individuals are skillful at problem solving, goal setting, communicating, and managing stress and intense emotions. Helping survivors develop these skills benefits their ability to be productive and maintain quality
5. Assumptions Underlying the Resilience and Adjustment Survivors are more likely to improve when they develop resilient traits, such as being actively engaged in recovery, and are able to maintain a positive outlook.
Goals of the RAI 1. To provide survivors with fundamental information about common symptoms and challenges after TBI 2. To help survivors develop core abilities, enabling them to more effectively problem solve and efficiently achieve personal goals 3. To teach coping strategies that facilitate the process of emotional recovery, helping survivors to feel better about
Goals of the RAI 4. To teach survivors effective communication skills, enabling them to develop effective long-term support systems 5. To instill hope and a positive outlook by identifying progress and personal strengths, and helping survivors access community resources
RAI Implementation Five week, seven session format with two or three topics covered during each sixty minute session Total of 16 topics covered via selfassessment, discussion, and structured learning experiences Sessions implemented hierarchically; earlier topics provide foundation for later topics
RAI Implementation Time span between sessions allows for homework completion, reflection, trying out strategies and solutions to problems Sessions conducted by single qualified therapist with single survivor
No doubt, each patient, each family member, and each family
Yet, research and clinical experience indicates that most survivors have similar concerns and many
Curriculum Based Approach Education regarding common challenges, issues, and concerns Psychological support Skill building abilities associated with improvement in the targeted domain
Inside the RAI Manual
Resilience and Adjustment Intervention Understanding the Effects of Brain Injury 1. Understand the typical consequences of brain injury 2. Appreciate the difference between emotional and physical recovery 3. Cope effectively with loss and change
goal attainment ratings helpfulness rating
Resilience and Adjustment Intervention Active Engagement in Recovery 4. Realize the important role you have in your own recovery 5. Recognize what you can do to help yourself and feel better
Resilience and Adjustment Intervention Setting Reasonable Goals 6. Appreciate that success is relative 7. Improve your ability to be patient 8. Understand and implement effective goal setting strategies
Resilience and Adjustment Intervention Solve Problems Effectively 9. Learn and use more effective problem solving strategies
Resilience and Adjustment Intervention Managing Stress, Anger, and Other Intense Emotions 10. Monitor and manage stress more effectively 11. Better manage intense emotions including frustration, anger, and fear
Resilience and Adjustment Intervention Communicating Effectively and Rebuilding Relationships 12. Rebuild relationships and overcome loneliness 13. Learn and apply more effective communication strategies 14. Develop strategies for comfortably discussing injury with others
Resilience and Adjustment Intervention Communicating Effectively and Rebuilding Relationships 15. Avoid a negative focus, feeling guilty, or blaming others 16. Appreciate positive aspects of your new life and develop a positive attitude
Investigating Resilience: The Connor-Davidson Resilience Review of existing resilience inventories suggests the CD-RISC is the most effective measurement tool available Established excellent psychometric properties, e.g. reliability, internal consistency, and construct validity
CD-RISC 25-item and 10-item versions, both empirically validated Statements ranked on a 0 4 frequency scale: 0 -Not true at all; 1 - Rarely true; 2 -Sometimes true; 3 - Often true; 4 -True nearly all of the time Respondents evaluate the veracity of statements as they pertain to the last month
CD-RISC Framework Assessment via a resilience model o Not giving up o Coping with unexpected events o Tolerating stress o Overcoming illness & hardship o Tolerating pressure o Overcoming www.connordavidsonresiliencescale.com
Connor-Davidson Resilience Scale Mean Scores Connor for & Davidson, Specific 2003 Populations PTSD Generalized Anxiety Psychiatric Patients Primary Care Patients US General Population 0 22.5 45.0 67.5
PRACTIC AL Our work should be guided by the experiences of the people we serve, our perception of their needs, and our sense of the most important things we can do to meaningfully improve their lives. JSK
Virginia Commonwealth University Medical Center Jeffrey S. Kreutzer, Ph.D., ABPP jskreutz@vcu.edu www.tbinrc.com Department of Physical Medicine and Rehabilitation VCU Box 980542, Richmond, VA 23298-0542