Abstract
1. Why is resilience training useful to GPs?
Resilience is our ability to deal with and/or recover from adversity. It includes our capacity to cope with stress, rise to the challenge and make the best of things. As work pressures come with the job, GPs tend to be pretty resilient already. So why bother with resilience training?
The first tip is to recognise the risks we face. When an occupational group is exposed to hazards that increase their morbidity and mortality, we usually view this as a health and safety issue and take preventative measures. We need that approach with work-related stress, because GPs are exposed to higher than average levels. Linked to this, doctors are a high-risk group for depression, drug and alcohol problems, and suicide.
In 1998, a survey showed that nearly 60% of GPs thought their physical health had suffered as a result of overwork (Appleton, House, & Dowell, 1998). Things have become worse since; a poll of GPs in 2013 showed that 93% thought their stress levels had risen in recent years, with 84% believing their workloads had substantially increased (RCGP, 2013).
2. Is resilience training evidence-based?
Twenty years ago, psychologists at the University of Pennsylvania found that resilience training reduced the risk of depression in school-aged children, with results still significant at 2-year follow-up. The intervention investigated, known as the Penn Resilience Program, has since been tested in 20 or more controlled trials, with results showing that it helps reduce anxiety and depression in both adults and children (Seligman, 2013).
The United States Army was so taken by these studies that they developed a resilience training programme for service personnel. Soldiers, like doctors, have higher rates of depression, drug and alcohol problems, and suicide. Follow-up studies have shown significantly fewer diagnoses of anxiety, depression, post-traumatic stress disorder, and drug and alcohol problems in army units that received this training compared with those that did not receive the training (Harms, Herian, Krasikova, Vanhove, & Lester, 2013).
Resilience is sometimes thought of as a constitutional quality some people have and others lack, there being little we can do to change this situation. The second tip is to recognise that research tells us something different, that resilience is linked to learnable skills that bring proven benefits.
3. Should we improve conditions rather than training ourselves to put up with excessive stress?
It is a myth that we have to choose between personal coping strategies and collective action to improve conditions. If we think of resilience as responding to adversity in ways that bring better than expected outcomes, then both have roles to play.
It is helpful here to make a distinction between resilience and endurance. If you get back problems from using an uncomfortable chair, endurance training might help you put up with the discomfort. Resilience is a broader concept that includes creative-thinking and problem-solving strategies. It is more likely to lead you to change the chair, with an ergonomic response that explores how design factors can improve comfort, safety and performance. We can take a similar approach when looking at our working conditions: if the way we work is harming us, we need some creative redesign.
With the chair example, training to improve our posture might make a difference so personal strategies are relevant. The tip here is to recognise that resilience is not purely a personal affair, but rather is something that can happen at many system levels. For a team or organisation to be resilient, it needs to look at the context people face as well as the skills they possess.
4. What can I do when I am struggling?
Whatever situation you face, there will always be different ways it can work out. A perspective check taught in the Penn Resilience training is to ask yourself: ‘What is the best that can happen here? What is the worst? And what is most likely?’
The value of looking at worst possible outcomes is that alarm about these can motivate the introduction of preventative measures. If we did not worry about what might happen in a fire, we would be less likely to address risks or develop fire drills. However, it is also possible to get stuck in the ‘awfulising’ of negative rumination. The other two questions help protect against this.
Have you ever been in a situation that seemed like a disaster, yet which later worked out much better than expected? Asking ‘What is the best that can happen here?’ reminds you that things may not be as bad as they seem, and that even if they are, turning points are possible.
Asking what is most likely to happen helps keep us reality-orientated. However, the most important tip here is recognise the difference between active and passive hope. Even if we do not feel hopeful that things will work out well, we can still be clear about what we hope for and be active in making that more likely to happen. This is active hope, and it appears to be a crucial component of resilience.
5. What if I cannot see how to improve the situation?
A metaphor I use when teaching resilience is to think of life as similar to rowing in a boat. Health (or other) problems are seen as similar to crashing into a rock. A problem-centred approach focuses attention on the rocks. This is often useful, but it only addresses part of the story. Also relevant is the water level, which represents our background level of resilience and wellbeing. When at a low ebb, with our water level depleted, we may crash into problems that on a good day we would float over.
This approach is particularly useful when we cannot see how to deal with a problem. It draws our attention to the many small steps we can take to nudge our ‘water level’ upwards and strengthen our coping capacity. When you are struggling, asking yourself ‘How is my water level doing?’ reminds you to nourish your inner reserves or address factors that cause their depletion.
An exercise here is to draw a horizontal line to represent the water level of your resilience and map out any factors that push it up or down. Common downward arrows include stress, conflict, heavy drinking and poor sleep. These are risk factors that make a bad day more likely. Upward arrows represent protective factors and include simple things, such as exercise or having breakfast, and learnable strategies, such as mindfulness or problem solving. Resilience training looks at ways to reduce downward arrows and add or strengthen upward ones.
6. What does a resilience toolkit contain?
Can you think of times when you faced something difficult but got through in a way you now feel good about? What helped you do that? In particular, see if you can identify any of the following.
Strategies you used, for example, asking for help, applying a specific technique or giving attention to diet, exercise or posture? Strengths you drew upon, for example, patience, courage or creativity? Resources to which you turned, for example, self-help books, counsellors, family or friends, special places, pets or websites? Insights that guided you, for example, the idea that crisis can become a turning point or that failure may be a step on the road to later progress
While the letters SSRI are usually associated with anti-depressant medication, I use them here to refer to our ‘self-help SSRI toolkit’ of resilience
7. How do I use this toolkit?
Once you have identified resilience tools you find useful, look for opportunities to practice using them. When you next find yourself facing an adversity, ask yourself ‘What would resilience look like here?’ and ‘What tools might help me in this situation?’
8. How clinically relevant is resilience training?
How often are you alongside someone who might benefit from help in facing an adversity? This might include not only patients, but also trainees and colleagues. Although resilience training is of proven benefit in countering anxiety and depression, its potential role in both health-care and self-care is much broader. By training ourselves in evidence-based self-help practices that help us cope with difficult situations, we not only protect our own wellbeing, we also strengthen our ability to help others help themselves.