A Model of Dance/Movement Therapy for Resilience-building in People Living with Chronic Pain: A Mixed Methods Grounded Theory Study
CHAPTER 2: REVIEW OF THE LITERATURE
2.2 Resilience .1 Definition and Background .1 Definition and Background
Resilience is considered as one of the most heuristic and integrative concepts to have emerged in the social science inquiry on human adaptation as a result of the shift from focusing on the pathology or risk factors to attending to the strengths of the people (Zautra & Reich, 2011).
This paradigm shift from a disease model to a strength-based model has taken place not only in the social sciences but also in psychology and science in general. This has significantly changed the understanding of how people adapt to and even grow in the context of significant adversity of
life stress
(
Zautra & Reich, 2011). Current definitions of psychological resilience are varied. It has been construed as a personal trait or attribute (Bonanno, 2004; Brooks, 2005), protective factors, processes or mechanisms (Hjemdal, 2006; Rutter, 2006), or an outcome of adaptation efforts (Zautra & Reich, 2011). Although there is lack of consensus on an operational definition of resilience, fundamentally resilience refers to the capacity for, process of, or outcome of successful adaptation in the context of distress or high risk status; it is the ability to maintain or regain psychological well-being and physiological homeostasis despite adversity (Friborg et al., 2006; Herrman et al., 2011; Karoly & Ruehlman, 2006; Sturgeon & Zautra, 2010).Throughout history, humans have always been fascinated by the stories about triumph in the face of adversity, and they have inspired pioneering psychologists and psychiatrists to take a scientific look at this phenomena starting about four decades ago (Masten, 2007). These
pioneering scholars initially focused on those people who were at “high risk” for developing psychiatric problems due to their family history or environmental disadvantages yet demonstrated unexpectedly positive development. They followed the lives of these individuals and tried to study what factors were responsible for helping them overcome the odds against them (Masten &
Wright, 2010). Therefore, the concept of resilience first arose in the field of child development, based on observations of those children who sustained positive functioning and development despite the presence of significant risk factors such as abuse or low socioeconomic status (Sturgeon & Zautra, 2010). Since historical development of the resilince is closely related to developmental psychopathology, the majority of research on resilience has concentrated on the earlier part of the lifespan (Fergus & Zimmerman, 2005). However experts claim that “since adversity can occur at any point in development, with consequences that potentially alter
development over the near and the far term, a lifespan developmental perspective is essential for a full understanding of resilience”(Masten & Wright, 2010, p. 216).
2.2.2 Construct of resilience
Resilience is a multidimensional construct, and there exist inconsistencies in the
conceptualization of resilience. Largely, conceptualization of resilience as personality traits, as a dynamic process or as an outcome, has been used interchangeably by researchers (Shaikh &
Kauppi, 2010). The construct of resilience as personality traits is described as “the ability of individuals to adapt successfully in the face of acute stress, trauma, or chronic adversity, maintaining or rapidly regaining psychological well-being and physiological homeostasis”
(Feder, Nestler, Westphal, & Charney, 2010, p. 35). The identified personality traits include activity level, optimism, positive responsiveness to others, equanimity, perseverance, self- reliance, meaningfulness and existential aloneness (Greeff & Ritman, 2005; Jacelon, 1997, as cited in Shaikh & Kauppi, 2010).
Resilience as a process sees resilience as processes or mechanisms that contribute to a good outcome, despite significant stress or adversity (Hjemdal et al., 2006). According to this view “various factors and systems contribute as an interactive dynamic process that increases resilience relative to adversity; and resilience may be context and time specific” (Herrman et al., 2011, p. 260). There are multiple sources and pathways to resilience which often interact, including biological factors (e.g., genetics, immune functioning, and neuroendocrine),
dispositional attributes (e.g., intellectual functioning, social disposition), family aspects (e.g., a caring parent figure, connection to extended family networks), and social support and other attributes of social systems (e.g., bonds to prosocial adults outside the family, attendance at effective schools) (Herrman et al., 2011; Luthar & Cicchetti, 2000; Shaikh & Kauppi, 2010).
Resilience as positive adaptation/outcome equates resilience with a pattern of positive adaptation in the context of significant risk or adversity. With this view, an individual is
considered as resilient when he or she has successfully overcome exposure to a risk (Stevenson &
Zimmerman, 2005).
Earlier theories emphasized the view of resilience as personal traits, yet other scholars claim that resilience should not be conceptualized as a static trait or characteristic of an individual (Luthar & Cicchetti, 2000; Masten & Wright, 2010). It is asserted that conceiving resilience as personal attributes that are unchanging may be pathologizing an individual who lacks resilience;
and moreover, it “reduces the dynamic capacity of the systems to surprise us with their facility to learn new adaptation strategies on the run” (Reich, Zautura, & Hall, 2010, p.xiv). Reich, Zautra and Hall (2010) denote that scholars who see resilience as process propose a more open process model in which adaptation to stress is conceived of as a dynamic process involving internal capacities and external resources, and putting a focus on a resilience outcome opens up to a more multifaceted approach to the “cause-outcome” sequence (p.xiv).
A significant component of resilience construct as process is the identification of protective and vulnerability factors (Luthar, 2000). Rutter (1985) refers to protective factors as processes that “modify, ameliorate or alter” the negative effects of adversity (p. 600). Risk factors are influences that directly correlate with poor or negative outcomes “while resilience is considered to reflect protective factors which may moderate the effects of the risk factors so that the adaptation is positive” (Masten et al., 1990, as cited in Kauppi, 2010, p.160). Masten and colleagues (2004) use the term core resources, which can be thought of as a foundation or an early predictor of resilience resources. Promotive factors and adaptive resources are other commonly used terms by other scholars that refer to internal factors which are utilized in the context of stress like adaptive capability (Olsson et al., 2003). Luecken and Gress (2010) suggest that “together, protective factors and adaptive resources, constitute a more complete concept of individual-level factors in resilience” (p.243).
Specific resilience protective and risk factors have been identified by several scholars and researchers, and they are varied depending on the lifespan and specific populations in terms of the type of challenges or adversity (e.g. socioeconomic, trauma, illness). Some of the recognized promotive/protective factors are positive emotions, emotional stability, positive coping skills,
social support, finding meaning, self-esteem, self-efficacy, reflective skills, hope, creativity, flexibility, humor, and spirituality. Risk/vulnerability factors include depression, social stress, poor coping skills, abuse, violence, lack of social support and others (Carver, 1998; Kumpfer, 1999; Luthar & Cicchetti, 2000). The idea that specific protective and risk factors contribute or take away from resilience suggests that an intervention that targets these factors may impact the resilience mechanism, thus being able to enhance resilience in individuals (Luthar, Cicchetti, &
Becker, 2000; Sturgeon & Zautra, 2010; A. J. Zautra, Hall, Murray, & Group, 2008).
2.2.3 Resilience as a New Paradigm for Chronic Pain
The original meaning of the English word “resilience” is to bounce or spring back (Smith et al., 2008). Since the concept of resilience refers to “successful adaptation that unfolds within a context of significant and usually debilitating adversity or life stress” (Karoly & Ruehlman, 2006, p. 90), this ability to bounce back or recover, “may be particularly important for people who are already ill or are dealing with ongoing health-related stresses” (Smith et al., 2008, p.194).
Likewise because resilience takes a different trajectory than recovery (Bonanno, 2004), the
‘‘health-despite-adversity’’ notion of resilience fits well for the treatment of patients coping with chronic pain. According to Sturgeon (2010), resilience is “an integrative perspective that can illuminate the traits and mechanisms underlying the sustainability of a good life and recovery from distress for individuals with chronic pain” (Sturgeon & Zautra, 2010, p. 105). Also,
empirical evidence has shown how resilience resources and mechanisms can become a key factor in chronic pain sufferer’s adaptation and coping responses (Friborg et al., 2006; Karoly &
Ruehlman, 2006; Ong, Reid, & Zautra, 2010; Smith et al., 2009; Sturgeon & Zautra, 2010).
Resilient individuals demonstrate significantly more positive results in coping style, pain attitudes and beliefs, catastrophizing tendencies, positive and negative social responses to pain, and health care and medication utilization patterns, when compared to non-resilient individuals (Karoly &
Ruehlman, 2006). Friborg and colleagues’ (2006) laboratory-induced pain study to investigate the effect of resilience as a moderator of pain and stress showed that individuals with high
resilience score reported less pain and stress. A study with actual chronic pain patients was conducted by Ong, Zautra, and Reid (2010) demonstrated an interesting mediating relationship between positive emotion, pain catastrophizing, and resilience. The results showed that
experience of positive emotion counteract pain catastrophzing, and thereby reinforce resilience.
Although resilience as well as general positive health concepts is relatively new concepts in mainstream health care, and further research is needed to understand the form and mechanism of resilience in chronic pain, the present findings indicate the importance of integrating the resilience factors in the psychological treatment of pain conditions, and provides important guidance to pain management programs (Sturgeon & Zautra, 2010; Friborg et al., 2006).
2.2.3.1 Meaning and resilience in chronic pain. Throughout the resilience literature on the issue of chronic pain, it is stated that one of the most important resources for resilience for the people coping with long term suffering like chronic pain, is finding meaning and purpose in one’s life (Haase, 2004; Lightsey, 2006; Sturgeon & Zautra, 2010). Haase (2004) proposes that derived meaning in one’s health and illness related experience might play a role as a protective factor in building resilience. Since meaning-making is “a bridge from the negative emotion caused by negative life events to positive emotion through cognitive restructuring” (Lightsey, 2006, p. 103), it might play a positive role in taming the negative cognitive-emotional issues such as pain catastrophizing or fear avoidance behavior, thus helping the patients to better cope with the adversity of overall pain experience. In addition, some resilience models propose to expand the construct of resilience from coping to encompass development or even growth (Bonanno, 2004;
Lightsey, 2006; Zautra & Reich, 2011). Folkman (1980), one of the pioneers in researching and exploring the concept of resilience found and reported that in the midst of people’s stressful life circumstances, also co-occurred the positive affect that can facilitate adaptive capacity which can moderate the negative effect of the stressful experiences and enhance their well-being despite the aversive conditions (as cited in Zautra & Reich, 2011). Therefore it is propositioned that through finding meaning in adversity, one may find the positive and strength, gain new insight and greater
mastery from overcoming the stressful experience and achieve a sense of well-being despite the adversity (Ryff & Singer, 1998; Zautra, Arewasikporn, & Davis, 2010).
Above information indicates that an intervention, which can foster resilience through facilitating the meaning making process, might be useful in psychological treatment of chronic pain patients. Moreover, considering Zautura et al.’s (2010) statement, “To fully understand resilience in adults, we advocate a mind-body approach that incorporates both physical and mental health, and the interactions between the two” (p.16), the use of a mind/body intervention in which one may experience the integration of body and mind and make meaning through the creative process of movement such as Dance/Movement Therapy (DMT), might be a valuable approach in chronic pain management.