Protection against the adversity of neurological injury: The
process of learning to be resilient
Dr Ashley Craig, Professor, Rehabilitation Studies Unit, Sydney Medical School, The
University of Sydney
Based on work funded by the ARC and MAA
1
Senior Clinical Psychologist
READ Clinic, Hill St Gosford
The resilience material presented tonight can also be found in my
Chapter 26 “Resilience in People with Physical Disabilities” recently
published (2012) by Oxford Press
Resilience following injury is an important area of study, and which many
of you I am sure have significant ideas about. I hope this talk can
challenge those ideas, and provide new insights into helping people who
need to develop resilience
How resilient do you think you are?
The nature of resilience

Resilience studies attempt to discover why and how people cope
and adjust to adversity
Early studies of children in New York who thrived with single
mothers who had schizophrenia were the catalyst for the
emergence of the study of resilience
What is resilience?
Luthar et al., (2000) defined resilience as: “.. a dynamic process
encompassing positive adaptation within the context of significant
adversity.” (p.543)
In disability, I have defined resilience as:
“the process of maintaining stable psychological, social and physical
functioning when adjusting to the effects of a disability or injury and
subsequent impairment”.
Craig, A. (2012). Resilience in people with physical disabilities. In P. Kennedy (Ed.). The Oxford
Handbook of Rehabilitation Psychology. Oxford: Oxford University Press, p.474-491.
Resilient behaviour is characterised by:
A belief in themselves as effective in self management
An ability to form close relationships
An ability to achieve positive outcomes in their daily lives
A degree of autonomy
An ability to problem solve
An ability to be optimistic and humerous despite adversity
An ability to manage stress and trauma associated with adversity
Craig, A. (2012). Resilience in people with physical disabilities. In P. Kennedy (Ed.). The Oxford
Handbook of Rehabilitation Psychology. Oxford: Oxford University Press, p.474-491.
Rees, R. (2012). Resilience of people with traumatic brain injury and their carers. InPsych, April,
12-13.
Resilience research involves assessing
protective factors
Protective factors
Environmental
Social and interpersonal
Psychological and physical
community resources
healthy environment
secure housing
financial resources
education opportunities
community cohesion
recreation facilities
stable family support
affection
employment
socially active
positive attachments
friends support
access to social networks
robust self esteem
a sense of self mastery
physically healthy
problem solving skills
adequate social skills
stable mood states
adequate coping skills
…and risk factors
Risk factors
Environmental
limited resources
unhealthy environment
insecure housing
poor finances
lack of education
stressful living context
Social and interpersonal
no family support
poor social networks
unemployed
avoids activities
single
frequent hospitalization
Psychological and physical
elevated anxiety
sense of helplessness
elderly
poor insight
lack of communication skills
depressive mood
significant cognitive deficits
Factors shown to protect against
psychiatric distress
Rutter (1985) proposed a number of protective factors that have the
potential to modify, alter or cushion a person from the negative
consequences of adversity
Factors included:
a constructive/ realistic understanding of events
taking adaptive action
a robust self-esteem and a strong sense of mastery or self efficacy
being adaptable when faced with change
having problem solving skills
a sense of humor when faced with stressful events/ optimism
dealing successfully with problems in the past
accepting responsibility when dealing with problems
quality social support
Rutter, M. (1985). Resilience in the face of adversity. Protective factors and resistance to
psychiatric disorder. British Journal of Psychiatry, 147, 598–611.
Some prominent factors shown to
protect against injury and distress
Self efficacy and resilience
Self efficacy: the extent to which a person perceives they can control their
behaviour, lives and daily outcomes
Maciejewski et al., (2000) showed self efficacy was a very significant predictor of
depressive symptom severity
Having a higher level of self efficacy resulted in fewer depressive mood symptoms
in adults. Self- efficacy mediated around 40% of the effects of stressful life events
on depressive mood
They concluded that maintaining a healthy self efficacy, that is, a strong sense of
control or mastery over one’s life and environment, serves to protect a person from
psychopathology, by ameliorating the negative effect of stressful life events
Maciejewski, P. K., Prigerson, H. G., & Mazure, C. M. (2000). Self-efficacy as a mediator between stressful
life events and depressive symptoms. British Journal of Psychiatry, 174, 373-378
Catastrophic thinking and resilience
If a person’s style of thinking is catastrophic or very negative, then
resilience is less likely
Catastrophic thinking and resilience
Thinking realistically and adaptively about adversity helps the resilience
process
For example, in chronic pain, Sullivan et al (1998) found that
catastrophising about pain was significantly associated with reduced
capacity to cope, increased pain intensity and perceived disability, and
lowered employment status
Catastrophising contributed to the prediction of disability over and above
the variance accounted for by pain intensity
Catastrophising was associated with disability independent of the levels of
depression and anxiety. Rumination was the strongest predictor of pain
and disability
Sullivan, M.J.L., et al., (1998). Catastrophizing, pain, and disability in patients with soft-tissue
injuries. Pain, 77, 253–260
Pain Catastrophising
Catastrophising involves focusing on pain in a very negative and unhelpful
manner
Example: “I cant stand it any longer. It’s all hopeless and what’s the
point?”
If one catastrophises, one has less ability to deal with pain, and
catastrophisation is a powerful predictor of poor pain management
The reverse is true. If one stops catastrophising then pain decreases
Example: “My pain is difficult to manage, but I can cope and deal with it”
Catastrophising is not uncommon and will make it
more difficult for the injured person to show resilience
Social support and resilience
Helpful social support protects against adversity
Social networks act as a protective factor in a direct manner, for
instance, by providing access to information or by enhancing
motivation to engage in adaptive behaviors.
Social support can also influence a person positively by
encouragement to adhere to treatment recommendations,
maintain health promoting behaviors such as exercise and a
regular and balanced diet, or to provide support such as giving a
ride to someone who needs to keep a medical appointment or
shop for food
What factors are related to resilience in people
who have a neurological-based speech disorder,
that is, stuttering?
First,….
Stuttering imposes a significant
mental health burden or adversity
1.4
SCL-90 scores
1.2
1
0.8
Stuttering
Controls
0.6
0.4
0.2
0
SOM
OC
IS
DEP
ANX
HOS
PA
PI
PSY
GS
Mood states
Tran, Y., Blumgart, E., & Craig, A. (2011). Subjective distress associated with chronic stuttering. Journal of Fluency Disorders, 36, 17-26.
Further, prevalence of social phobia is high in this
population:
Our data indicates a social phobia prevalence of 46%, in
comparison to 4% in non stuttering control group
Blumgart, E., Tran, Y., & Craig, A. (2010). Social anxiety disorder in adults who stutter. Depression
and Anxiety, 27, 687-692.
So stuttering involves significant adversity!
What factors are related to resilience in people
who stutter?
We studied 200 adult people who had a diagnosed stutter
We defined resilience in this study as exhibiting a low level of
global psychopathology (measured by the SCL-90-R)
Craig, A., Blumgart, E., & Tran. Y. (2011). Resilience and stuttering: factors that protect
people from the adversity of chronic stuttering. Journal of Speech, Language, and Hearing
Research, 54, 1485-1496.
Resilient and non-resilient sub-groups
Age
(yrs)
Mean
(SD)
Age
(yrs)
diagnose
d
Mean
(SD)
%SS
Mean
(SD)
LAQ I
LAQ II
Mean
(SD)
Mean
(SD)
Resilient
(n=76)
47.8
(16)
5.6
(2.6)
3.5
(2.6)
13.4
(6)
Non
resilient
(n=124)
44.3
(16)
5.8
(2.8)
3.8
(2.9)
15.8
(7)
NOTE
stuttering frequency or %SS (higher scores indicate greater severity),
health risks (LAQ1: higher scores indicate higher levels of risk),
self-efficacy (LAQ2: higher scores indicate poor self-efficacy),
social support (SOS: lower scores indicate poorer social support)
global psychopathology score (GSI: higher scores indicate
more severe psychopathology)
SOS
Mean
(SD)
GSI
Mean
(SD)
16.8
(9)
25.0
(4.3)
.23
(.18)
25.1
(14)
22.6
(5.2)
1.47
(.58)
Using regression analysis, resilience factors found in people with a
neurologically related speech disorder consisted of:
Protective factors
Nature of the contribution
Minor protective factors
Severity of the disorder ………..
Annual income …………………
Vitality …………………………
General health ………………….
Physical role ……………………
Lower severity: increased resilience
Higher income: increased resilience
Higher vitality (or low fatigue): increased resilience
Better health: increased resilience
Greater physical function: increased resilience
Major protective factors
Self-efficacy ……………………
Helpful social support ………….
Social integration ………………
High self-efficacy: increased resilience
Greater social support: increased resilience
Greater social activity: increased resilience
I doubt if anyone here would question the
assumption that neurological injury is associated
with significant adversity!!
As an example, people with spinal cord injury face very
substantial adverse conditions when dealing with their
injury and impairment
For instance, our research has shown lowered
quality of life in people with SCI…
Difference between Australian age and sex standardised
norms with people with SCI who have low and high levels of
self-efficacy (SE) on the eight SF-36 QOL domains
Source: Middleton, Craig & Tran (2007). Archives Phys Med Rehab, 88, 1643-1648
90
80
QOL SF-36
70
60
Low SE SCI
group sign.
diff to the
other two
groups in all
domains
p<.05
50
40
30
20
High SE SCI
group only
sign. diff to
Australian
norms in three
domains p<.05
phys fn
phys role
pain
Aust norms
health
vitality
low SE SCI
social fn
emot fn
High SE SCI
mental
health
…and elevated risks of depressive mood and anger
Almost 50% have risks of depression after many years of
living in the community, …
…and adults with SCI have over nine times the risk of
having increased levels of anger or irritability
Chronic fatigue is also a high risk in people with injury
Wijesuriya, N., Craig, A., Tran, Y., & Middleton, J. (2012). Fatigue and anger in people
with spinal cord injury. Australian Journal of Rehabilitation Counselling, 18, 60-65.
Fatigue negatively influences neural activity: this is seen in the impact
on brain activity of non injured people. It involves a global reduction
in theta and alpha activity, and an increase in beta activity
Craig , et al., (2012). Psychophysiology, 49, 574-582.
Alert
Theta
Alpha 1
Alpha 2
Beta
fatigue
db
We estimate that around 50% of adults with SCI (and TBI)
have a major problem with fatigue, and that high fatigue levels
place one at risk of depressive mood (and vice versa), and thus
less likely to be resilient
Source: Wijesuriya, Tran, Middleton & Craig (2012). Archives Phys Med Rehab, 93, 319-324
We have also shown that adult people with SCI tire significantly after
participating in a 2-3 hour mental task compared to able-bodied matched
controls. Those wih elevated depressive mood (and therefore less resilient)
will be more likely to fatigue excessively (see below)
Craig, A., Tran, Y., Wijesuriya, N., & Middleton, J. (in press). Fatigue and tiredness in people
with spinal cord injury. Journal of Psychosomatic Research.
What factors contribute to resilience in a large group of newly injured
adults with SCI? N=70, mean age 42 years
Preliminary results:
Major protective factors
1.
Self efficacy: stronger self efficacy, greater resilience (explains 14%)
2.
Mood: more positive mood , greater resilience (explains 19%)
Minor protective factors
1.
Age: higher age, better resilience (explains 1-2%)
2.
Severity: lower severity, better resilience (explains about 1%)
3.
Cognitive capacity: higher capacity, better resilience (explains about
.2%)
Interventions that enhance resilience
Nurturing resilience (Rees, 2012)
Develop a rewarding and pleasant events schedule
Plan for appropriate work experience options
Make sure there is a anchor person who is a constant (eg. family
member, caregiver, health professional)
Regular professional consultation available that is ongoing (eg.
psychologist)
Employ helpful and optimistic language
Develop a social network with peer support
Engage in challenging cognitive activities (eg. writing, reading)
Interventions that enhance resilience
My feeling is that treatment very likely to enhance resilience should:
•
•
•
•
•
•
•
•
significantly enhance self-efficacy
enhance social support and integration
result in helpful rational thinking
teach adaptive coping skills
provide vocation support (eg return to work)
teach problem solving
enhance family and caregiver support
others?
The following slides present outcome results from
clinical trials we have run with adults with SCI
These findings suggest that resilience has been
enhanced
Treatments used have involved a mix of mental and
behavioural skills that address anxiety, poor mood,
fatigue, social integration, and so on.
1.9
1.7
1.5
1.3
Treatment
1.1
Control
0.9
0.7
0.5
3-4 weeks
6 months
12 months
2 years
Clinical trial outcome for adults with SCI. Chronic pain (0=none, 2=
discomfort, 3=distressing) following group CBT. Control SCI participants
received usual rehabilitation care
18
16
14
depressive
12
mood
Treatment
Control
10
8
6
3-4 weeks
6 months
12 months
2 years
6-8 years
Clinical trial outcome for adults with SCI. Depressive mood (Beck
Depression Inventory where high scores indicate high depressive
mood) following group CBT. Control SCI participants received
usual rehabilitation care
38
36
34
32
perceived 30
helplessness 28
Treatment
Control
26
24
22
20
3-4
6
12
2 years 6-8
weeks months months
years
Clinical trial outcome for adults with SCI. Perceived control (perceptions of
helplessness where high scores indicate helplessness) following group CBT.
Control SCI participants received usual rehabilitation care
20
CHALDER FATIGUE TOTAL
19
18
17
16
15
14
13
Pre
Post
MT
GI
Controlled randomised clinical trial showing change in levels of fatigue (high
scores indicate high fatigue) in adults with SCI who received massage versus
visualisation over 5 weeks
14
McGILL PAIN
12
10
8
PRE
POST
MT
GI
Controlled randomised clinical trial showing change in levels of chronic pain
(high scores indicate high pain) in adults with SCI who received massage
versus visualisation over 5 weeks
When French impressionist painter Auguste Renoir (1841-1919) was
confined to his home during the last decade of his life, Henri Matisse
was a close friend and visited him daily.
Renoir, almost paralyzed by arthritis, continued to paint in spite of his
infirmities. One day as Matisse watched the elder painter work in his
studio, fighting torturous pain with each brush stroke, he blurted out:
“Auguste, why do you continue to paint when you are in such agony?”
Renoir said: “The pain passes but the beauty remains.” So, Renoir
continued to put paint to canvas. Below is one of his paintings, Tilla
Durieux , completed 5 years before his death, 13 years after he
developed the disease.
Thank you