I am very humbled to have been awarded the Linda Crane Memorial Lectureship at the Combined Sections Meeting (CSM) of the American Physical Therapy Association. I met Linda in her role as an author, when we had each written a chapter in Donna Frownfelter's text, Principles and Practice of Cardiopulmonary Physical Therapy. I remember Linda as a large presence at CSM, the kind of person that attracts people to her, seeking her counsel and her thoughts about the future and direction of the Physical Therapy (PT) profession, as well as to share a laugh or a funny story. When I received this lectureship award, I thought it fitting that I had heard so much from Linda's friends and colleagues about her resilience as she battled cancer.
Linda was a dedicated member of the PT profession: She was one of the first 3 certified specialists in 1985 in Cardiopulmonary Physical Therapy, she served on the House of Delegates, and received the Linda Blair Service Award. Linda was an educator: She received Teacher of the Year Awards from the University of New England and the University of Miami. She was a writer: She published peer-reviewed articles and several book chapters. And Linda was a scholar: She developed us the entry-level competencies in Cardiopulmonary Physical Therapy, which I eagerly sought out as a novice educator. Although she was taken from us far too soon, she will be remembered for her playfulness and love of life, her numerous contributions to our profession, and for her resilience.
Before I begin my presentation, I would like to acknowledge the people who helped me get where I am today, whom I count on daily. First and foremost, I would like to thank my incredible family: my son David and his fiancé Tenille, my daughter Sarah and her boyfriend Ryan, my son Christopher and his wife Erin, and my 6-year-old grandtwins, Dashiell and Josephine. My life certainly would not be complete without my family.
I would also like to thank the Krannert School of Physical Therapy faculty and staff at the University of Indianapolis. I love my work, and it's in no small part due to the positive relationship I have with my amazing colleagues. I also appreciate the clinicians at Indiana University Health who help me keep up with the rapidly changing healthcare environment—I couldn't do it without you. And finally, thank you to my PT colleagues across the country. I have said that attending CSM feels like “coming home” because I get to reconnect with colleagues (too numerous to mention by name), while debating the content of presentations, conversing about life stories over a glass of wine, or “synapsing” about new ideas with Ellen Hillegass late into the night. Of course, this includes the support and assistance I've received from the previous awardees of this lectureship. Thank you to you all.
So on to the topic at hand—resilience. Here's what I hope you will take away from today. You will learn about the concept of psychological resilience and its components, you will select a technique, or several techniques, to increase your positive affect and improve social support. Hopefully, you will all leave here and take action to enhance your resilience and the resilience of others!
Before we can talk about resilience as a tool for stress management, we need to talk about stress. Which of the following is a definition of stress: (1) A psychological reaction to events that one is unable to deal with, (2) A subjective appraisal of a situation as overly taxing, (3) A perception that varies according to one's recent life events, or (4) A physical response to excessive demands on oneself. Actually, stress has been described as including all of these definitions.1,2 Here are Lily Tomlin's thoughts about stress: “Reality is the leading cause of stress among those in touch with it.”3
When we experience stress and are unable to cope with demands made upon us, our bodies have a physiological response. With acute stress, cortisol, a stress hormone, is released by the nervous system, causing heart rate, respiratory rate, blood pressure, and blood glucose to increase.2 This is the basic fight or flight response, to help us react physically to the stressor. An acute stress response is immediate, and then the body returns to baseline. However, it is chronic stress and the perception of stress, the day-to-day pressures that cause long-term damage to our bodies. This includes damage to the smooth inner lining of our arteries, increased cholesterol levels, irregular heart rhythm, and increased blood clotting.4 These factors may all lead to decreased blood flow to the heart and brain—and an increased risk of heart attack or stroke. In addition, there is real damage to the cells. Chronic stress makes cells deteriorate faster, shortening the length of the telomeres in DNA (the tips of chromosomes within cells that have been likened to the aglet on the end of a shoelace that keeps it from fraying). This is a measure of the aging process and increased oxidative stress.
The other thing to remember about stress is that it is very individual. We don't all experience equal amounts of stress under the same conditions. A person first thinks about the stressor, then processes the experience, finally concluding whether it is indeed a stressor, or if they have the resources to handle it, so the experience is not stressful.1 In addition, stress is cumulative—it comes from all aspects of one's life (eg, job, relationships, responsibilities, or lack of resources). Just because you don't have stress in one part of your life doesn't mean you're stress free. I believe Ralph Waldo Emerson described the individuality of stress well when he said, “We boil at different degrees.”5
Lest you think that I have lived a charmed life and wouldn’t know stress if it stared me in the face, I'm now going to tell you about myself and some of my own stresses over the years. It may also demonstrate why I gravitated to this concept of resilience. I grew up in a family of 13 children, and until we moved when I was in high school, we only had 1 bathroom! (So there was physical stress in addition to psychological stress.) As a Latina, I was an underrepresented minority throughout my education, and suffered through comments and name calling simply because of how I looked, the family I was born into, and my difficult-to-pronounce last name. Also, partly from a desire to ease the burden on my parents, but mostly due to my stubbornness, I was determined to pay for college with my own means which caused quite a bit of financial stress. I attended the physical therapy program at the University of Colorado, graduating in 1979. As we all know, PT education is stressful in itself, but mine was compounded by a pregnancy. Although my husband and I were so very excited about this, and I loved that we were starting a family, the timing of my pregnancy definitely had its challenges. Every time a professor would turn off the lights to show slides (I know, old school!), I would struggle to stay awake. Later, after being out of school for 20 years, I decided to pursue a master's degree in Public Health at the University of North Carolina, and enrolled as a full-time student while in my 40s, when my other classmates were in their 20s. I called that experience my mid-life crisis. Finally, I decided in my 50s to pursue a PhD; I called that my Alzheimer's prevention! Then, just when I thought I had all the stress I could handle, I was diagnosed with cancer—and underwent surgery, radiation, and chemotherapy. I had finished my coursework and was starting on the dissertation, so that got put off for a while.
So enough about me, what about stress and you? There are a few studies specifically looking at stress in physical therapists and physical therapy students. Like many other health care professionals, it was found that PTs experience high emotional exhaustion.6–8 In a study on orthopedic physical therapists, it was found that less experienced therapists are at risk of burnout.9 In PT students, we know that they experience increased levels of stress compared to other types of students and young working adults of the same age.10–14 In addition (and this won’t be a surprise to PT educators), higher levels of stress are also associated with more illness.11
Hans Selye,15 known as the father of stress, said “It's not stress that kills us, it is our reaction to it.” There are hot and cold reactors among us, related to an individual response to stress. Do you ever have the kind of day that leaves you exhausted…you can't wait to finish work and get back home so you can just relax…and then something unexpected comes up? You've juggled many responsibilities throughout the long, challenging day, and you're looking forward to getting back home. Then…you clinicians get an additional complex patient put on your schedule that has to be seen today, you educators get an email about a significant student issue that can't be put on hold, and you students remember an assignment you put off that is due the next day…and now you have to cancel your plans to relax, and you just don't think you have enough energy left to cope with this new issue. How do you react? Do you (1) throw something across the room; (2) talk rudely to someone you care about; (3) break down and cry; (4) eat an entire bag of chips or carton of ice cream; or (5) close yourself off and brood? Or maybe you've reacted in each of these ways, at different times? While we might see ourselves in some of these examples, it might not be who we want to see.
Think for a minute about all the people you affect when you are under stress: your significant other, your children, your parents, roommates, siblings, other relatives, colleagues, patients, students, administrative assistants, daycare providers, grocery clerk, hairdresser, food servers, and flight attendants. You have the ability to affect so many other people and your stress may rub off on them. So how could we improve our response to stress, in whatever way it presents itself?
I believe the answer is to build resilience. Researchers have defined resilience in different ways, in the immediate and in the long term. Resilience is the ability to bounce back to baseline when confronted with a difficult situation, it is the ability to maintain equilibrium under stress, and it is successful adaptation to chronic adversity.16–19 There is a model that can be used to consider the possible trajectories of function after an adverse event (Fig. 1). If we look at the level of functioning on the vertical axis, we see that over time, an adverse event can cause 4 different responses: (1) Succumbing to the stressor without an attempt to recover, so that function proceeds far below the normal level; (2) Surviving the event with impairment, so there is improvement, but function is still below the baseline; (3) Resilience, or recovery to pre-event status; and finally, (4) Thriving, where recovery actually surpasses the previous functional level as a result of what is known as posttraumatic growth. This may bring to mind a quote by Nietzsche: “What doesn't kill us, makes us stronger.”20
Tugade and Frederickson21 have said that “…resilient individuals have optimistic, zestful, and energetic approaches to life, are curious and open to new experiences, and are characterized by high positive emotionality.” Isn’t that a great description of who we want to be? Now I will describe 4 components of resilience—think of them as pieces of the resilience puzzle: Positive Affect, Effective Coping, Purpose for Living, and Social Support. I will take each of these pieces of resilience, and present the evidence for each, suggest strategies or ways to enhance each component, and provide examples.
Our brains change when we have positive feelings. Functional MRIs show a different reaction in our brains when thinking about positive experiences compared to negative experiences. Positive feelings leave less room for negative feelings. It is thought that it takes 3 positive thoughts to outweigh the effects of 1 negative one.22 Doing good for others is a way to enhances one's own positive emotions—it's a win-win. We do know that positive affect or mood does not come naturally to everyone—it must be practiced. Optimism and humor can contribute to positive affect, so let's consider those next.
Optimism in the face of challenges has been shown to diminish negative moods. It also helps one to use active coping strategies instead of denial.23 Optimism is future oriented; it is the hope and confidence that everything will work out—so it helps one move forward. This does not include blind optimism, but realistic optimism. Here's an optimistic quote from Vince Lombardi: “We didn't lose the game; we just ran out of time.”24 This may be something the Atlanta Falcons may be thinking if they were optimistic.
Here are some strategies to enhance your optimism. Catch yourself being negative and insert positive thoughts about a person or situation. For example, a driver cuts you off in traffic and speeds through a yellow light, leaving you behind to wait at the red light. You find yourself getting mad, which doesn't do much for your positive mood. So you tell yourself a story about why the driver took such actions. Maybe she/he had a pregnant spouse in the car who was going into labor, or maybe it was a parent who was late for their child's performance, and because of work they missed the previous one. And you think to yourself, “I'm fine with that—they needed to get there faster than I did.” Another strategy is to avoid dwelling on the negative aspects of life. You can limit your exposure to negative online posts, which have the effect of making you angry. Think about any annoying situation and reframe it in a positive way to find the silver lining. I'll tell you a story about how my niece demonstrated optimism when she was 8 years old. After I had completed chemotherapy, I had taken off my scarf to show my bald head upon her request. As I was refastening my scarf, she was very quiet and thoughtful, and then she said to me: “Aunt Annie, you know what's good about not having any hair?” “No,” I replied, “Tell me!” “Well, if you get in a fight with someone, they can't pull your hair!” So that's optimism from an 8-year-old perspective.
Humor is another component of positive mood or affect. Humor that causes a positive mood can increase the attention span, promote active problem solving, and increase socializing.25,26 Humor may also improve psychological and physical well-being.27 Norman Cousins, a journalist, wrote the book Anatomy of an Illness.27 In it, he described how he used humor to aid his healing process from an undiagnosed illness. He watched funny movies, had people tell him jokes, and played pranks on the hospital staff.
There are many ways to strengthen your own funny bone to improve positive affect. Try watching a comedy show before bed, to fall asleep in a more pleasant mood. Identify the people in your life who make you laugh, and spend more time with them, in person, by email, or with a text chat. Also, when choosing a movie or TV program, make sure to include more comedies along with the other genres. You can also bring a joke or funny story to relate to your colleagues to get the day started on a lighter note.
In addition to optimism and humor, other ways to improve your positive affect or mood include finding ways to “pay it forward” by doing something good for someone else. Practice gratitude—keep a written journal of 3 things you are grateful for each day. Try reciting the loving kindness meditation: “May I be happy. May I be well. May I be safe. May I be peaceful and at ease.” There are several ways I increase positive affect in my own life. I start each day with a positive quote to put me in the right frame of mind. I enjoy spending time with my bright and optimistic grandtwins. And finally, I use humor in my interactions with my family, my colleagues, and my students to keep my mood light.
For effective coping, it is helpful to think about the Serenity Prayer: “Grant me the ability to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” First, think about your ability to change the stressor. If it can't be changed, then it is what it is. Your energy is best spent working on acceptance of the circumstances.28 While it is important to have a variety of coping strategies for different situations, one also needs to recognize when the current strategy is not working, and switch to another—this is called coping flexibility.29
Physical activity is part of an effective coping strategy. Vigorous physical activity is related to lower stress levels, and exercise releases brain-derived neurotrophic factor, a substance that improves brain health.30 As physical therapists, we often think about the physical benefits of exercise, but there are many psychological benefits as well. Dr. Ratey covers the evidence of physical activity in his book, Spark: The Revolutionary New Science of Exercise and the Brain.30 There are many ways to build activity into your day, to improve coping effectiveness. During the work day, use a bathroom on a different floor, or in a nearby building, and have walking meetings if possible. Wearing a pedometer or fitness tracker encourages more movement throughout the day, such as searching out the stairs instead of taking the elevator. Stand up instead of sitting when you read an article, such as you are doing right now, and incorporate sit-to-stands.
I use many different coping strategies, including exercise, which is an inevitable part of my life. As an extrovert, I find that social activities, especially those that include music, give me energy and help me cope with stress. Mindfulness is a technique I use to increase my appreciation of the present moment and stay positive. Finally, I prioritize the stressors I can cope with at one time, by virtually placing the overload in an imaginary box and putting it away on a shelf, but only temporarily, until I have summoned the additional energy to cope with it.
PURPOSE FOR LIVING
Finding meaning in life has been shown to increase resilience.31 In addition, having a purpose increases the chance that you will make positive changes in your life.32 Identifying one's purpose in life can increase the ability to avoid illness.32 Dr. Victor Strecher talks about the evidence for this in his book Life On Purpose: How Living for What Matters Most Changes Everything.32 One strategy for recognizing your life's purpose is to identify your core values—what means the most in your life. Writing a personal “mission statement” is another way to find the meaning in your life. Another step to take is to consider whether your actions are aligned with your purpose, or if you have strayed from your purpose. Take time to remember what is important in your life. My purpose in life is to give back to others, spread positive affect and resilience, and finally, to support and nurture future generations, of the Mejia/Downs clan, and future physical therapists.
Social support, both perceived and actual, has been shown to be protective against stress.33 It also decreases the chance of developing depression and helps to recover from emotional trauma.33 Finally, lower rates of morbidity from heart disease occur among the socially connected.33 To strengthen social support, think about all the people you come into contact with every day—friends, family, and coworkers—who make you feel good. Communicate with them more often, by text, email, chat, pictures, or in person. Take the time to build and care for those relationships. Using your phone to send texts to friends is a quick way to support your health by staying in touch with your social supports. I think Audrey Hepburn had it right when she said, “The best thing to hold onto in life is each other.”34
To use social support in my life, I rely on my family greatly to keep me connected and protected against stress. At work, it is my colleagues in the Krannert School of Physical Therapy with whom I share a bond as well as the health benefits of social support. I have also discovered that I tend to seek out increased social support during especially stressful times of my life, such as during my years as a graduate student. I formed lasting friendships during these times. Social support can also give you courage. As a PhD student seeking advice from my dissertation chair about applying for Adopt-A-Doc Award, she gave me this advice, “You can't win if you're not in the game!”
EVIDENCE FOR RESILIENCE
So those are the components of resilience that you can put together to solve the puzzle of stress management. Resilience isn’t something you either have or you don't, but rather it is something you can cultivate and enhance. It turns out that we all have it, we just need to learn how to bring it out—and we need to practice it on a regular basis. There are several randomized controlled trials of resilience training programs in a variety of populations that demonstrate significant decreases in stress and anxiety, improved positive mood and effective coping, and improved resilience. These studies have been done in many populations, including internal medicine physicians,35 breast cancer survivors,36 healthy but stressed graduate students,37 and undergraduate and graduate college students.38
My own study of resilience involved physical therapy students. For my dissertation at Rocky Mountain University of Health Professions, I developed an evidence-based resilience curriculum for DPT students in their first, second, or third years of study, from 2 DPT Programs in Indianapolis. Students were randomly assigned to attend a 4-week curriculum (n = 22) or to the waitlist control group (n = 21). Outcome measures were assessed at baseline and after intervention, including assessments of stress, resilience, optimism, coping flexibility, positive and negative emotions, social support, and illness symptoms. The curriculum was delivered in a 2-hour session each week for 4 weeks (8 hours total). There were significant increases, both in resilience and positive affect, in the intervention group (Figs. 2 and 3). Other findings from the study included the fact that both the intervention and control groups had significant increases in social support. My theory about this finding is that it is related to using cohorts of DPT students. Of interest, the curriculum led to improvement even in the third year students, who could be assumed to be already somewhat resilient. Significant independent predictors of resilience included lower levels of perceived stress, higher positive emotions, and greater coping flexibility.
USING RESILIENCE TO TRANSFORM SOCIETY
Luthar and Cichetti18 describe resilience as a “dynamic process wherein individuals display positive adaptation despite experiences of significant adversity or trauma.” Resilience is dynamic—just because you had it once, doesn't mean you always have it. If you are low on resilience now, you can work to build it up. Think of it as a bank account or a fuel gauge—you have to put something in, to be able to get something out when you need it. Resilience also occurs after adaptation to adversity. You may not even be aware of your level of resilience unless it has been tested.
So there it is again, the kind of day that leaves you exhausted. Then something unexpected and frustrating happens. How do you react now that you have increased resilience? (1) Tell yourself it's not the end of the world, (2) Call your friend who always makes you laugh, (3) Take deep breaths and count your blessings, (4) Get ready for a workout, or (5) Find a positive lesson in the stressful experience. Hopefully, you can use all of these strategies!
In the title of my talk, I ask “What will you do with your resilience?” The vision of the APTA is to transform society by optimizing movement. I believe we as PTs can also transform society by enhancing resilience! I think the best way to help your family, students, patients, colleagues, and others, is to help them build resilience. Take the first step and build your resistance to stress by enhancing your resilience! Then take the next step to help others build their resilience. When you come in contact with others during the day, exude a positive mood, role model coping flexibility, share your purpose in life, and offer social support.
We can all be more resilient!
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© 2017 Cardiovascular and Pulmonary Section, APTA
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