Getting Beyond Recovery: Building Resilience Should be the Ultimate Goal for Health Services

Based on a Paper Prepared for The Center for Applied Behavioral Health Policy conference on 
“Exploring Resiliency”, April 17th, 2014, Mercado Building C, ASU Downtown Phoenix campus, 502 E Monroe St., Phoenix, Arizona. 

Recovery has been the metaphor that guides countless approaches to psychosocial interventions designed to repair the harm done to a person’s health by forces within and outside the self. The value of recovery was first recognized in substance abuse programs where successful treatment placed the person in a community of people “in-recovery”, as a way to emphasize the ongoing vigilance needed among those with addiction histories to maintain sobriety. In the physical health arena recovery groups have been established for almost every disease known to mankind. In the mental health field the term “recovery” has grown dramatically over the past twenty years to become a household word that is often described as the ultimate goal of treatment. However, there are limitations of this metaphor. If we are going to make progress developing better interventions for people as they age, we need to look for programs that offer paths to resilience and ways to empirically validate their claims.

Defining Resilience
Resilience is a term used in two ways: first, to define processes that lead to successful adaptation to life’s challenges and, second, to identify what constitutes success in meeting those challenges . If building resilience is to be adopted as the paradigm to replace “recovery” as the ultimate goal, we need to define both a way forward to guide interventions and to alert researchers and practitioners to measurable outcomes. Programs that are founded on evidence-based outcomes are sorely needed as the cost of healthcare escalates . There simply are not enough funds to support programs that can’t show positive health outcomes . In order to “bend the health care cost curve” it requires the person to take a more active role managing their own health. Self-efficacy is one of the key tenets of resilience.
  
To consider resilience, we need to keep three goals in mind. The first is recovery. Though limited in its scope, it has been the standard bearer of successful adaptation. The second is sustainability of purpose; a reason to continue in the face of what appear at times to be insurmountable obstacles. The third is new learning or psychological growth. These are three related but separate dimensions of the construct. Even when one does not find a way to be resilient in one dimension, the others can hold promise for elevating the quality of a person’s life both now, and in the future.

Recovery Shortcomings
There are two fundamental shortcomings with recovery when used to define the ultimate goal of health interventions. First, recovery presupposes that a former state of mind and body is optimal, and that our efforts should be addressed to return us to that prior “normal” condition. This model has various names, but is fundamentally a medical model. The process of recovery is designed to return a person from a state of illness to homeostasis.  A physical wound is healed when the body mounts a sufficient response to repair the damage, and an emotional wound is addressed when the person finds ways to put the mind back at peace with itself. As appealing as this model appears on the surface, it does not capture the core principal driving most adaptation efforts. In the recovery model, once homeostasis is achieved the person typically returns to the same place that led to the behaviors that created the condition in the first place. Something more than recovery is needed to get beyond a revolving door of sickness and health. 

Fortunately the mind is built to adapt and to change, to seek a new “normal” in response to events, not to return to a prior state. To regulate our physical and mental health, our brain changes in response to events. Though stable structure is retained, neuroplasticity is in play. Each event shapes new neural connections, new neural pathways that inform present and future adaptation efforts. Old patterns of neural connection, when not used, are pruned away. Humans are built to be adaptive organisms, learning from experience. When an individual lives with a chronic illness whether physical or mental, he/she cannot simply return to the way life was. There is a “new normal” in a life that has changed forever, if we allow ourselves to see how we have changed. By building resilience, the “new normal” can be rich and rewarding if the individual has developed new skills to adapt to the changed reality, and new resources to call upon to make his/her new life work. A resilience framework asks what has been learned to cue more adaptive responses that prevent the health condition from reemerging and assist the person in dealing with the symptoms the next time problems arise. In testing interventions, this approach defines outcomes not only based on whether the program helped repair damage and speed recovery from hurt, but whether those helped now know more about what to do, should they be hurt again.

Chronic Illness
Chronic illness, more than any other single condition of the mind-body, reveals the failure of the recovery metaphor as a means of guiding our efforts to address the challenges posed. The extent of the chronic difficulties varies greatly across the population. Some are harmed earlier in their lives than others, and many suffer from intense pathological states that intrude on their state of mind every day. Chronic pain conditions, for instance, can be so severe as to threaten to take the value of living away, altogether. Sustainability of purpose is fundamental to adaptation among those with a difficult chronic disease, but also it applies to those who are not contending with a serious illness. Indeed, this principal may be invoked to help shape preventative interventions for those at risk for future illness. There are several aspects of this process, but they all rely on a central feature: that the person defines him/herself not by his/her limitations, but by the strength of his/her engagements; One’s interests, goals, and future plans. Some work within our labs has focused on the sustainability of positive emotion for those with chronic pain. We have found that those with a steady source of positive states of mind are impaired less by painful episodes. The pain is the same, but its debilitating sting is diminished because the person has a way forward with life in spite of their difficulties. 

Two core processes underlie resilience capacities in general, and relate specifically to sustainability: Agency and Social Intelligence. Agency depends on many processes, some internal, others outside the influence of the person. An internal locus of control and sense of personal mastery develop naturally for most, are strengthened by education, experiences of success at work, and enduring family ties. At the core of agency though is “choice”. Choice informs agency, and its exercise is the way forward to sustainability of purpose. Traumatic experiences, including both those that threaten life and those that harm one’s belief in the humanity of others, reduce one’s capacity for agency. Often, the way forward in building resilience among those with a history of trauma is to first acknowledge the post-traumatic stresses that interfere with building a life with a future. But awareness is not enough. Interventions are needed that effectively enhance the efficacy expectations of those needing to reclaim control over the direction of their lives.

Resilience depends on strong social relations. Early work in the field of recovery focused on social support as a key element in the return to normal. That approach misplaced the emphasis on the value of others as providers of care, and the scientific evidence revealed mixed results regarding its influence on health outcomes. The value of others resides most prominently in the connection that is made: the relationship formed between two people when they acknowledge the worth of one other. Its absence, charted by social scientists in studies of loneliness, disregard ,and abuse have yielded the strongest evidence of the consequences of failing to meet this primary human need.

Social Relationships
The benefits of social relations arise in part through their influence on emotions. We mentioned research pointing to the value of positive emotions. Positive emotions do not arise de novo however; the person cannot simply conjure these feelings up for very long just by manipulations of the mind. Lasting beneficent states arise primarily from meaningful social connections with loved ones, family, co-workers, and friends. The capacity to navigate through complex social relationships and a willingness to engage is necessary to form and sustain strong social ties, as well as gain value from a brief connection.  This social intelligence develops naturally throughout life for many, but depends on a willingness to trust, built from a foundation of kith and kin relationships earlier in life. Those with troubled childhoods often have a more difficult time forming and retaining positive social ties. The absence of a stable attachment early does not preordain difficulties with relationships, nor do such difficulties, when present, last a lifetime. People can and do change. How to design effective and accessible public health interventions that can advance these social needs with fidelity is an important goal of future research programs.

Social Health
The importance of social health is worth further comment when advocating for a resilience paradigm as a guiding framework for our efforts. Resilience has been used in the popular culture to define extraordinary feats of individuals, even heroic acts; resilient people are thought to be exceptional. People thinking themselves as exceptional fail to grasp how their resilience is sustainable only through a positive social ties.. We are social creatures and while independence is a developmental goal to which many aspire, we are actually interdependent and require others to achieve our full potential.

Though the applicability of the resilience paradigm is most evident for those with chronic illness, it is worth noting that normal developmental transitions throughout the life course are best understood from a resilience framework. As people age, most will acquire chronic illnesses that can be treated, but for which there is no cure. Resilience as applied to aging focuses on ways to minimize the extent of those limitations, as well as promote longevity, and the scientific evidence is mounting to support its utility. Core principles of resilience come into play. Sustainability in particular, takes on special meaning for people as they age, and one should not discount the value of psychological growth for people at any age. There is already substantial evidence that the slower reaction times are accompanied by wiser choices for older adults. In sum, we encourage attention to resilience-promoting processes to guide intervention research: thought and actions in response to ongoing difficulties that focus not only on how to recover, but also how to sustain purpose and meaning, and learn from those stressors.