1. RESILIENCE
IN THE PHYSICALLY ILL
Donna E. Stewart FRCPC
University Professor and
Chair of Women’s Health
Senior Scientist
Tracy Yuen BSc (Hon)
University Health Network
University of Toronto
CANADA

2. RESILIENCE
“A dynamic process in which psychological,
social, environmental and biological factors
interact to enable an individual at any stage of
life to develop, maintain or regain their mental
health, despite exposure to adversity.”
PreVAiL: http://prevail.fims.uwo.ca/theme2.html

3. RESILIENCE
• Most research done with children/adolescents
suffering from child maltreatment, family
violence, poverty, poor parenting, war, natural
disasters, traumatic events
• Over 80% of research on topic in the last
decade
• MeSH heading in 2010

4. PHYSICAL ILLNESS
• A common adversity in life
• Especially in older adults
• Acute or chronic
• May threaten survival, function, self esteem,
relationships
• May involve forced dependence/disability
• Has economic consequences
• May alter life course

5. QUESTIONS
• What factors have been reported as
predicting, promoting, or associated with
resilience in the physically ill?
• Can these be used to enhance the care of
the physically ill and improve outcomes?

6. METHODS
• Psych INFO, Medline, CINAHL databases 1950-
2009, update 2009- Mar 2014
• Key words: resilience, (hardiness, benefit finding,
positive adaptation, adaptive behaviour)
• Physical Illness: CV, cancer, neurological disease,
arthritis, diabetes, hypertension, pulmonary
disease, infectious disease
• Titles, abstracts, full article, reference lists
• Exclusions: not English language, not resilience,
psychiatric illness, family resilience only.

7. METHODS (Cont.)
• 2 reviewers ranked independently
• Discussion to resolve disagreements
• Ranked by STROBE criteria
(Strengthening the Reporting of
Observational Studies in Epidemiology
• items: good, fair, poor quality
• Meta-analysis not feasible due to
heterogeneity

8. Medline, PsychInfo, CINAHL searched 1950-2009
Keywords: resilience, hardiness, benefit finding and chronic illness, cardiovascular disease,
cancer, neurological disease, arthritis, hypertension, pulmonary disease, renal disease,
autoimmune disease, infectious diseases and diabetes
475 articles retrieved Excluded articles (n=95):
Duplicates (n=49)
Review of concepts (n=23)
Commentary/editorial (n=18)
Text not in English (n=5)
380 articles screened for inclusion
Excluded articles (n=328):
Not positive consequences of illness (n=94)
Only family resilience (n=64)
Not physical illness (n=65)
Only risk factors (n=52)
Not health-related consequences (n=29)
Only psychological disorders (n=21)
No access to full-text (n=3)
52 articles included in review:
Cancer (n=13), Multiple medical conditions (n=10), HIV/AIDS (n=7), Diabetes (n=6)
Cardiovascular Disease (n=6), Arthritis (n=5), Miscellaneous (renal, MS, etc.) (n=5)

9. COMPARISON OF RESULTS
1950-2009: 475 articles retrieved
52 included in review
2009- 2014: 6060 articles retrieved
154 included in review

10. RESULTS
• Most papers included both sexes
• Age varied by disease state
• 80% participants were White
• Few Afro-American, Asian, East Asian,
Hispanic, Aboriginal, or not specified
• More papers had n > 100 in 2014
• Quality better in 2014

11. 1. PSYCHOLOGICAL FACTORS
ASSOCIATED WITH RESILIENCE
• Self transcendance, self esteem, internal LOC,
optimism, mastery, hope
• Self efficacy correlated with family and social
functioning, self care, physical and psychological
well-being
• Internal LOC associated with better resilience,
adjustment, positive life outcomes
• Self esteem, flexibility, and mastery predict better
psychol/physical wellbeing

12. 1. PSYCHOLOGICAL FACTORS (Cont.)
• Hardiness predictive of: better physical, mental
and spiritual well being, adherence,
satisfaction and size of social network
• Rather than having good friends and high
income, a high level of mastery might help
chronically ill patients cope and adapt to
illness (Mertens VG et al. 2012)

13. 2. COPING STRATEGIES
• Spirituality
• Positive cognitive appraisal
• Positive life orientation
• Sense of coherence
• Coping with uncertainty
• Benefit finding
• Anger management

14. 3. SOCIAL SUPPORT
• SS from family and friends associated with
resilience
• SS associated with better psychological health,
benefit-finding, hardiness and self esteem
• 1914 chronic pain patients: widowed patients
were resilient: ? stress inoculation (Wade JB et
al. 2013)
• Couples’ relationship increases resilience
(Blazquez A et al. 2012)
• Physician- patient relationship increases
resilience (Jenkins SA. 2011)

15. 4. ENVIRONMENTAL FACTORS 2009-14
• 5858 Scottish patients with pain: resilience
associated with housing, employment,
sex, age, used less healthcare, lower
mortality (Elliott H AM et al. 2014)
• “Deprived” areas in English Census (2001-
2003) that had “health resilience” (MMR)
showed more “place attachment, natural
environment and social capital” (Cairns-
Nagi JM et al. 2013)

16. ENVIRONMENT 2009-14 (Cont.)
• Increased community and social support
associated with increased resilience in
elderly rural Australians (Inder KJ. 2012)
• “Hispanic culture” (familism, religion, social
resources) may enhance resilience (Gallo
LC. 2009)
• Leisure programs for older adults with
chronic illness increased resilience
(Hutchinson SL. 2012)

17. QUALITATIVE STUDIES THEMES
• Hope
• Empowerment
• Acceptance of Illness
• Determination
• Sense of coherence

18. RESILIENCE AND SPECIFIC ILLNESSES
CV: Internal locus of control, social support,
personal control, self efficacy
Stroke: Self care, self efficacy
HIV/AIDS: Positive appraisal of illness,
hardiness, cognitive appraisal, internal
locus of control, social support, spirituality
Diabetes: Self efficacy, self care, hardiness

19. RESILIENCE AND SPECIFIC ILLNESSES
(Cont.)
Cancer: Cognitive appraisal, social support,
acceptance, hope, empowerment,
spirituality, sense of coherence,
relationship with parents, self efficacy
Autoimmune (RA, LE, OA): optimism,
spirituality, self esteem, self efficacy

20. RESILIENCE AND SPECIFIC
ILLNESSES (Cont.)
Mixed diseases: Early life experiences, past
successful coping, spirituality,
determination, independence, hardiness,
sense of coherence, education, mastery,
social support, cognitive appraisal, self
efficacy, self esteem, optimism
Are these REALLY specific to the illness?
Can we use this knowledge in dealing with
physically ill individuals to enhance their
coping and resilience?

21. 5. INTERVENTIONS 2009-14
• Promoting acceptance, mindfulness and values-
based action in patients with chronic pain.
(McCracken LM et al. 2010)
• Web-based approaches in chronic physical and
mental health problems. (Paul CL. 2013)
• Computer interventions on psychosocial
adaptation of rural women with chronic
conditions. (Weinert C et al. 2011)
• Psychosocial group interventions for children
with chronic illness. (Schotten L et al. 2013)
• Acceptance training in elders with chronic
conditions. (McDonald PE et al. 2011)

22. INTERVENTIONS 2009-14 (Cont.)
• Cognitive behavioral therapy for children
with chronic illness. (Thompson RD. 2011)
• Emotion-regulation interventions in clinical
populations. (Smyth JM et al. 2009)
• Bedside brief psychotherapy to address
demoralization, existential concerns, hope,
aging, communion with others. (Griffin JL
et al. 2005)
• Nursing interventions for self
management, self righting and personal
qualities. (Edward SL. 2013)

23. INTERVENTIONS 2009-14 (Cont.)
• FREC: Family Resilience Enhancement
Program for patients with schizophrenia (Lim H
et al. 2013)
• 3RP: Relaxation Response Resilience Program
Multimodal mind-body strategies to increase
resilience to chronic stress. (Park ER et al.
2013)
• Art therapy in chronic pain (Lynch M. 2013)
• Creative arts in rural women with chronic illness
(Kelly CC et al. 2012)
• PRISM: Promoting Resilience, Independence
and Self Management for Mental Patients (Arva
DK. 2013)

24. DISCUSSION
• Psychological factors that increase
resilience found in other groups, also
apply in physical illness
• Other factors identified more specifically in
physical illness
• Self care, treatment adherence,
HRQOL, illness perception,
pain perception, exercise
• Environmental contributions are new
• Interventions are new

25. DISCUSSION
• Study on osteoarthritis found resilience
was more important in predicting pain and
physical function than disease severity
and the effect of resilience on pain was
mediated through self esteem.
• This may well be true for other conditions
but needs evidence!
• Cost implications?

26. DISCREPANCIES
• Differences in study methods, quality,
personal or illness characteristics
• Internal LOC and high self efficacy more
beneficial if disease controllable
• Severe illness with physical limits more likely
to need more SS
• Effect of collectivist vs. individualistic
cultures
• Need to study relationships between factors

27. CONCLUSIONS
• Specific psychological, coping and social support
strategies emerged that may be useful in caring for
the physically ill
• Coping strategies (active, positive appaisal,
spirituality)
• Encourage ill people to talk of other challenging
situations they have mastered and how
• Encourage realistic sense of hope, optimism,
mastery
• Self care, pain management, disease management,
rehab, info
• Enhance social support and environmental support

28. CONCLUSIONS
• Need better studies into interventions to
increase resilience: individual, group,
community, web-based
• Consider full range of health providers
and environment
• Across the life span: children to elderly
• Increasing resilience may have
individual and social benefits (including
cost savings)

29. “A fortunate few will not only find resilience
but discover new found strength and
meanings, resulting in benefit finding and
post traumatic growth through coping with
illness.”
“Not all physically ill may recover physical
health but assisting patients to enhance
their resilience may enable them to live
and function better with their illness-a very
worthwhile endeavor.”
Stewart and Yuen 2011