A Relational Model of Resilience: Understanding the Role of Relationships in Adapting to Adverse Events

1. A RELATIONAL MODEL OF RESILIENCE Dr Neil Welch Flinders University November 2010 Email: Neil.Welch@flinders.edu.au

2. THIS IS A WORK IN PROGRESS !

3. A KEY QUESTION Why do some people quickly adapt and get on with their lives after adverse life events while others don’t ?

4. INTRODUCTION This model assumes: 1. Relationships are the building blocks of our lives. 2. Their significance lies in the practical benefits they provide and the obligations this entails. 3. That we live in ‘contractual webs’ that have evolved over time. 4. That changes to key relationships have a profound impact on our life and our relationships with others. 5. That relationships play a pivotal role in the process of adapting to negative life events.

5. IMPORTANCE OF CULTURE Within the context of the family and the community, people learn things critical for their future wellbeing and resilience. People learn how to make and keep friends, how to be a ‘good’ friend, how to select friends, how to manage conflict, how and when to end relationships, how to repair relationships, and how to cope with different types of interpersonal difficulties. 2. People learn not only how to solve problems, but what things are problems and what aren’t, what causes problems, what problems are worth solving, what problems are more important than others, and when, if, how, and who to go to for help.

6. 3. People learn self and collective efficacy Expectations of self and collective efficacy determine whether coping behaviour will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles (Bandura) 4.People who live in collectivistic cultures are more likely to use communal coping than those living in individualistic cultures.

7. WHAT IS RESILIENCE ? Bouncing back ? - Continuity Principle (Omer & Alon, 1994) Lack of symptoms of distress ? - Dysfunction and distress may be a normal reaction to an abnormal event Forgetting painful memories ? - Resilience doesn’t mean forgetting 4. Not getting upset when recalling memories ?

8. Not being traumatised ? - Initial trauma is to be expected - It is the persistence of symptoms that is of significance (Shalev, 2007) 6. Adapting to a new normality ? - i.e., resilience as a transforming process ? 7. Resilience is not just about coping with adverse life events but with the unfolding practical and social challenges that follow in its wake.

9. IMPORTANCE OF RELATIONSHIPS 1. Our relationships provide our lives with structure, meaning, and a sense of continuity. 2. Relationships serve critical functions. They have practical utility and involve obligations as well as benefits. They are not just emotional ties. 3. Relationships can be assets, liabilities or both. 4. Relationships are the ‘supporting cast’ within which our identities are formed, altered and maintained.

10. WE LIVE COMMUNAL LIVES 1. We live in families, partnerships, groups and communities where we achieve many of our needs and goals only through cooperative interactions with others. 2. Our lives and wellbeing are inextricably linked to the functioning of our significant others. 3. Unilateral decision making can seriously undermine and damage relationships, when it affects the lives of others.

11. IMPORTANCE OF FAMILY 1. Families perform critical adaptive functions at times of crisis and hardship. e.g., parents play a key role in helping children cope with problems and stress (Power, 2004) - Appraisal / Choice of Coping Strategies/ Exposure to Stressors/ Enlisting Support - Parents can shield and buffer their children from negative experiences, provide emotional and practical support, as well as help in the interpretation of events - Parenting predicts children's adjustment to stress (Power, 2004)

12. 2. Family processes play an important role in diagnosis, treatment and recovery from health and social difficulties - Families influence decisions about help seeking, getting treatment, treatment adherence, lifestyle, self-medication, etc - As children seldom seek help for themselves, recognition of problems by the adults in their social networks is critical if they are to receive the care they need (Cauce et al., 2002).

13. 3. “ ... Having family around you helps, if the family members themselves are coping (Jones, 2004, p.205) 4. “Parents who are unresponsive, inconsistent, or hostile undermine children’s resilience by teaching them to mistrust others, feel insecure in relationships, and to use ineffective strategies to secure social support” (Wadsworth, 2010) 5. “The way that others interact with you will change your experience of trauma” (Gibson, 2008)

14. IMPACT OF NEGATIVE LIFE EVENTS Loss of Resources- Relationship Loss/ Disruption - Relationships serve adaptive functions and so loss or disruption of key relationships can have a profound impact of our lives. - Relationship loss or disruption can occur as a direct result of a negative life event or indirectly as result of people’s reactions to it. - “From a resource perspective, the primary goal of post- disaster interventions is to help people replace valued resources as quickly as possible. The longer a loss cycle is allowed to generate momentum, the greater are the resources required to halt that cycle.” (Norris, Friedman, Watson, 2002, p.247)

15. 2. Difficulties in replacing relationship loss - Replacing or substituting for loss or disruption of key relationships can be a major challenge - Different types of relationships serve different functions and provide different types of support - The impact of events will be determined by which of our relationships are affected - Our ‘friendship repertoire’ will influence how easy it might be to replace relationship losses

16. 3. Ongoing interpersonal challenges underpin wellbeing and trigger mental health problems - negative social interactions - loss or disruption of a key relationship - social disconnection - lack of social support - loneliness & boredom - restricted activity

17. 4. Negative events don’t just impact on one family member. - the nature of the impact on other family members and our personal community, will influence their functioning and their ability to provide support 5. The coping and functioning of our significant others shapes our own coping. - resilience is not just about an individual’s coping, it is also about the coping of their partners, family and friends 6. Timing of events is important - people are more vulnerable at different periods in their life - people confront different life challenges at each stage in the family life cycle

18. IMPORTANCE OF GENDER: 60,000 DISASTER VICTIMS SPEAK 1. Women and girls were at least twice as likely to develop PTSD as men and boys. (Norris et al., 2002) 2. The biggest risk factors for girls are related to family issues (Bloom et al., 2002) 3. “The constellation of social roles an individual is currently performing differentially exposes him or her to specific types of stressors while shielding him or her from others” (Aneshensel, 1987)

19. SOCIAL SUPPORT 1. Presence of supportive and non-supportive relationships influences how people cope with stressful events and their aftermath (Ertel, Glymour, Berkman, 2009) 2. Different networks provide different types of support for different needs. (networks - family, friends, neighbours, workmates) - e.g., live-in partners and families provide types of support that friends don’t. - Family members are better placed than others to provide many types of support

20. 4. Overburdened support networks break down. - Too heavy a reliance on one or two people can result in supporter ‘burn out’ - Traumatised people have a negative impact on those who support them 3. A recent meta analysis of 77 studies found that lack of social support is the strongest predictor of PTSD (Guay, Billette, Marchand, 2006)

21. COPING STRATEGIES 1. The research literature on coping to date has focused on the use of individualistic approaches. Yet “coping is not an exclusively individual-level process” (Gore & Eckenrode, 1996, p.48) People do not live their lives in individual autonomy. Indeed, many of the outcomes people seek are achievable only through interdependent efforts. Hence, they need to work together to secure what they cannot accomplish on their own. (Bandura, 2000, p.75)

22. 2. Much coping is a communal process involving collective as well as individual agency. Communal Coping Help Seeking Enlisting Social Support Collaborative Problem Solving 3. Excessive individualism or self reliance is an obstacle to resilience when it undermines relationships or prevents people seeking and receiving help when they need it. “Often people can’t deal with problems on their own even if they think they can “ (Stuart Diver)

23. 4. Avoidant coping and social disengagement are important determinants of mental health problems (Leventhal, 2008) - Social disengagement cuts people off from critical sources of information and support - Social isolation deprives people of positive experiences and social support, and contributes to the disintegration of social bonds and networks. - The strategy of the ‘closed self’ - shutting oneself off from others may have benefits in the short term but not in the long term

24. MEANING MAKING Meaning making is an important part of processing negative life experiences. 2. The search for meaning usually takes place in the context of close relationships and family. 3. Our stories are the way by which we make meaning of our experiences. Stories shape our lives. 4. Meaning making involves emotional processing.

25. EMOTIONAL PROCESSING A disastrous event places demands on the individual to process information that challenges core beliefs... The traumatic experience shatters fundamental assumptions that normally go unquestioned and unchallenged about the positive value and agency of the self, trust in others, the Safety of the world, and the meaning of life... Emotional processing, that is, reconciling the traumatic experience with these beliefs , is necessary for recovery. (Klingman & Cohen, 2004)

26. SPIRITUAL AND RELIGIOUS COPING Irrespective of whatever religious beliefs we hold, we need to acknowledge the importance of religion to many people. Many find religion as a ‘reservoir of hope’. - In many families religion is interwoven into all aspects of family life - Ritual observances: prayer, meditation, worship - Involvement in a faith community - Serving others - Many have a relationship with God and a belief that God is looking after them and their future.

27. “ For most victims of trauma whom I’ve studied, religion was indispensable ... religion makes ... [forgiveness] ... easier because one is answerable to a higher power rather than exclusively to oneself.” (Moffatt, 2010) “ A personal God can provide great comfort in times of adversity... Ritual observances such as daily communal prayer, and family and social support for those in need, play extremely important roles especially at times of crisis.” (Walsh, 2009)

28. HOPE AND OPTIMISM Hope and optimism shape how people cope with adversity. The antecedents of hope and optimism are to be found in prior learning experiences and the influence of others. We tend to avoid situations we believe exceed our ability to cope. Among the five intervention principles for mass trauma (Hobfoll et al.,2007) are: - Instilling hope - Promoting a sense of self and community efficacy

29. ‘RECOVERY’ 1. Recovery is about social reconnection and engagement. It is about rebuilding relationships and lives. 2. Recovery is much more than physical healing. It is not just about the management of medical symptoms. 3. It is about making meaning of what happened. 4. It is not just about cognitive change. “Refugees see recovery as primarily something that must happen in their social worlds, not in the space between their ears.” (Summerfield, 2003, p.460)

30. PSYCHOTROPIC TABLETSDO NOT - repair or re-establish relationships - replace lost relationships - address issues of loneliness and boredom - resolve conflicts or change ‘toxic’ relationships - stop instances of bullying - reduce stigma, rejection and exclusion - make people more trusting of others - solve financial difficulties - remove people from intolerable social circumstances

31. Recovery is much more than the management or cure of medical symptoms, and a return to life as it was before. It involves achieving a sense of personal control over one’s life, making meaning of what happened, socially re-connecting and building relationships, and creating a satisfying life.

32. Evidence from my research with injured workers is that recovery was not an individual journey, nor was it just about management or relief of symptoms. It was about social reconnection, life reconstruction and establishing a new normality and meaning in their lives. Relationship and social challenges were of pivotal importance in both their recovery and return to work. (Welch, 2006)

33. MENTAL HEALTH AND WELLBEING There is a widespread belief that depression and trauma are simply and effectively addressed by medical treatment. Such views ignore the pivotal role played by relationships, culture and social circumstances in the development and maintenance of mental health. Many who ‘suffer’ symptoms of depression and trauma go on to ‘recover’ without any medical intervention, while others who receive medical treatment can go on to experience ongoing symptoms. e.g., 10% of Vietnam veterans in the USA still experience severe PTSD symptoms almost 30 years on from the end of the war.(Koenen et al., 2008)

34. FINAL WORDS Being resilient is not something individuals do by themselves but in collaboration with their partners, families and communities. The resilience of individuals is dependent on their family’s resilience and their community’s resilience, and the interplay between them. Resilience is not just a bouncing back and often involves creating a new life and adapting to a new ‘normality’.

35. ANY QUESTIONS ?

36. REFERENCES Aneshensel, C. S., & Pearlin, L. I. (1987). Structural Contexts of Sex Differences in Stress. In R. C. Barnett, L. Biener & G. K. Baruch (Eds.), Gender and Stress (pp. 75-95). New York: The Free Press. Ertel, K. A., Glymour, M., & Berkman, L. F. (2009). Social Networks and Health: A Life Course Perspective Integrating Observational and Experimental Evidence. Journal of Social and Personal Relationships, 26(1), 73-92. Guay, S., Billette, V., & Marchand, A. (2006). Exploring the Links Between Posttraumatic Stress Disorder and Social Support: Processes and Potential Research Avenues. Journal of Traumatic Stress, 19(3), 327-338. Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence. Psychiatry, 70(4), 283-315. Horwitz, A. V. (2003). Creating Mental Illness: University of Chicago Press Jones, L. (2004). Then They Started Shooting: Growing Up in Wartime Bosnia. Cambridge, Massachusetts: Harvard University Press. Koenen, K. C., Stellman, S. D., Sommer, J. F., Jr., & Stellman, J. M. (2008). Persisting Posttraumatic Stress Disorder Symptoms and their Relationship to Functioning in Vietnam Veterans: A 14-Year Follow-Up. Journal of Traumatic Stress, 21(1), 49-57. Klingman, A., & Cohen, E. (2004). School-based Multisystemic Interventions for Mass Trauma. London: Kluwer Academic/Plenum Publishers.

37. REFERENCES Leventhal, A. M. (2008). Sadness, Depression, and Avoidance Behavior. Behavior Modification, 32(6), 759-779. Lyons, R. F., Mickelson, K. D., Sullivan, M. J. L., & Coyne, J. C. (1998). Coping as a Communal Process. Journal of Social and Personal Relationships, 15(5), 579-605. Moffatt, G. K. (Ed.). (2010). Survivors: What We Can Learn from How They Cope with Horrific Tragedy. Santa Barbara, California: Praeger. Norris, F. H., Friedman, M. J., & Watson, P. J. (2002b). 60,000 Disaster Victims Speak: Part 11. Summary and Implications of the Disaster Mental Health Research. Psychiatry, 65(3), 240-260. Omer, H., & Alon, N. (1994). The Continuity Principle: A Unified Approach to Disaster and Trauma. American Journal of Community Psychology, 22(2), 273-287. Power, T. G. (2004). Stress and Coping in Childhood: The Parents' Role. Parenting: Science and Practice, 4(4), 271-317. Spencer, L., & Pahl, R. (2006). Rethinking Friendship: Hidden Solidarities Today. Princeton, New Jersey: Princeton University Press. Summerfield, D. (2000). Childhood,War, Refugeedom and ‘Trauma’: Three Core Questions for Mental Health Professionals. Transcultural Psychiatry, 37(3), 417-433.

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