CPD: the paradox of being both burnt out and resilient

In any discussion around resilience and burnout, it is important to recognise that it is implausible to obtain a state of being ‘burnt out’ without also being significantly resilient. As Alan Dovey and Michael Swift outline in this literature review and analysis, this may mean occupational health practitioners need to rethink how they develop ongoing support and intervention.

The purpose of this article is to document the literature surrounding the definition and relative impact of resilience within the general population.

The underlying theme is to establish how significantly low or high resilience can lead to both positive and negative psychological, physiological and psychosomatic impact. This article will also document a novel approach to understanding resilience and burnout; identifying the ‘paradoxical effect’ of the phenomenon.

Defining resilience

The American Psychological Association (APA) defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress” or “bouncing back” from difficult experiences (Southwick et al, 2014).

The APA suggests that people have the capacity to build and demonstrate resilience, regardless of their socioeconomic backgrounds, personal experiences, or social environments. There is currently large debate surrounding resilience as a process versus a trait, however the most common perspective of resilience highlights the phenomenon as an adaptive process that can be developed (MacLeod et al, 2016).

Are there different types of resilience?

Prior to establishing the theory of resilience within this paper, it is important to define ‘resilience’.

Historically, resilience has been a widely ambiguous term. However, this paper will establish psychological emotional resilience. Psychological emotional resilience is the ability to manage with a crisis and the ability to suitably return to a pre-crisis state in a satisfactory amount of time; such that psychological disorder is not incurred (DeTerte & Stephens, 2014).

This form of resilience is defined as when an individual uses mental processes and behaviours in order to promote protection of the self from the negative effects of stressors (Robertson et al, 2015).

In simpler expressions, psychological resilience exists in people who develop psychological and behavioural capabilities that allow them to remain grounded during crises and move on from the incident without adverse consequences.

Psychological emotional resilience can further be broken down into three factors: inherent resilience, adapted resilience and learnt resilience. Each factor is defined below:

Inherent resilience. This is the cognitive resilience we are initially born with. This natural resilience protects us from danger when we are young, and apprises how we explore the nature world such as learning to interact with others in addition to how to take risks. This natural resilience transpires within children who are typically under the age of about seven; provided that no adverse exposure to trauma has occurred within the individual’s life.

Adapted resilience. This type of resilience occurs at varying time frames throughout life, and is typically incited due to a particularly difficult or challenging experience. Some experiences that may lead to the initiation of adapted resilience include: being made redundant, and going out the next day to look for a new job, or the termination of a long-term relationship, and the ability to re-build your self-efficacy or confidence to meet a new partner. This form of resilience often needs to be learnt on the spot and quickly; if conducted properly with adequate coping mechanisms adapted resilience can provide the ability to manage stress and emotional turmoil.

Learnt resilience. This form of resilience is built through time, in which we learn to activate resilience through the difficult experiences we have encountered in our past. With learnt resilience, we develop the capacity to draw upon previous experience; permitting an individual to pull upon this resilience during stressful daily hassles or significant life events. It is through this resilience, in which individuals learn, grow and develop mechanisms for managing stress (MacLeod et al, 2016).

Literature review

The first research on resilience was conducted in 1973. The study used an epidemiological approach of studying the prevalence of disease uncover the relative risks and protective factors that have since come to define the terminology of resilience (Garmezy, 1974).

Following this, the same cohort of researchers created tools to look at systems that support development of resilience. Emmy Werner one of the pioneering researchers in resilience conducted a study looking at cohort of children from Kauai, Hawaii.

At the time, Kauai was a less economically developed area, with many children growing up to become alcohol dependent or psychologically dysfunctional. Werner established that of the children who grew up in these negative situations, two-thirds displayed destructive behaviours in later life, including aspects such as unemployment, substance abuse, and out-of-wedlock births (Werner & Smith, 1998).

The research conducted by Werner did however identify that one-third of these youngsters did not exhibit destructive behaviours. Werner henceforth coined these individuals as a ‘resilient group’ latter group (Werner & Smith). Thus, according to Werner, resilient children by definition, verified traits that permitted them to be more efficacious than non-resilient children and families.

In addition to Werners’ studies, resilience also emerged as a major theoretical and research topic from the studies of children with mothers diagnosed with schizophrenia (Masten, Best & Garmezy, 2008).

Within this research, the study presented that children with a schizophrenic parent may not obtain an appropriate level of comforting. In turn, this has a significantly detrimental impact on children’s development. In contrast, some children of ill parents thrived well and were competent in academic achievement, and henceforth led researchers to make efforts to understand such responses to adversity.

This was the fundamental underpinnings of resilience that have been further applied to occupational, clinical and social settings in following research studies. This therefore identifies how resilience as a concept could possibly be a trait developed from adversity and hardship.

How is resilience built?

An important aspect of understanding resilience and the relative effect the phenomenon can have on an individual is through comprehension of how it is established. In cognitive behavioural therapy, building resilience is considered as a matter of modifying basic behaviours, thought patterns and controlling negative automatic thoughts.

Research suggests that one of primary steps in developing resilient cognitions is to adapt the nature of self-awareness and self-efficacy through self-talk (Padesky & Mooney, 2012).

Self-talk is defined as an internal monologue that reinforce beliefs about the person’s self-efficacy and self-value. The literature suggests that in order to establish resilience, the individual requires the elimination of negative affirmations such as, “I can’t do this” and “I can’t handle this”; subsequently replacing these notions with positive affirmations such as “I can do this” and “I can handle this” (Padesky & Mooney).

Evidence suggests that such adaptations in thought patterns can significantly reduce psychological stress when a person perceives difficult challenges to overcome (Chua, Milfont & Jose, 2014).

Resilience is additionally further enhanced by developing effective coping skills for stress. Coping skills provide behavioural and cognitive mechanisms to aid an individual to reduce stress levels, so they remain in a relatively homeostatic environment; permitting consistent and functional daily functioning.

Such coping skills may include using meditation, exercise, socialisation, and self-care practices to maintain a healthy level of stress, but there are many other lists associated with psychological resilience.

Following on from coping skills and particularly in relation to cognitive behavioural paradigms, the American Psychological Association has produced literature documenting ‘10 ways to build resilience’.

This document outlines the processes of resilience and suggests evidence based patterns for improving an individual’s ability to cope with stressful situations. These 10 processes are as such:

1. To maintain good relationships with close family members, friends and others
2. To avoid seeing crises or stressful events as unbearable problems
3. To accept circumstances that cannot be changed
4. To develop realistic goals and move towards them
5. To take decisive actions in adverse situations
6. To look for opportunities of self-discovery after a struggle with loss
7. To develop self-confidence
8. To keep a long-term perspective and consider the stressful event in a broader context
9. To maintain a hopeful outlook, expecting good things and visualising what is wished
10. To take care of one’s mind and body, exercising regularly, paying attention to one’s own needs and feelings (Newman, 2005).

It is important, however, to note that resilience is a highly idiographic phenomenon and subsequently although these processes have been identified as significantly functional for the general population, each individual may require the incorporation of different behavioural traits or support.

Why is resilience important?

After establishing the foundations of resilience and the way in which it can be developed, we will now assess the relative necessity for resilience; identifying practically and psychologically as to why resilience is an important phenomenon.

As well defined within the literature, we are in a weakened position if our ability to cope with stress does not meet the satisfactory level of functioning. Therefore, resilience is significant for a number of reasons; firstly, it enables us to develop mechanisms for fortification against experiences which could be perceived as overwhelming.

Additionally, it allows us to maintain balance in our lives whilst experiencing particularly stressful hardships, whilst protecting us from the development of psychological issues.

There are several benefits to improving resilience, although resilience has an effect on individual’s dependent on age, there are common shared features of the phenomenon. It should be noted that although relationships have been established between resilience and positive outcomes; causality is often non-established within the literature.

Some of the primary benefits of establishing a foundation of resilience include but are not limited to:

• Improved learning and academic achievement.
• Lower absences from work or study due to sickness.
• Reduced use of risk-taking behaviours such as excessive drinking, smoking or use of drugs.
• Increased involvement in community or family activities.
• A lower rate of mortality and increased physical health. (Cassidy, 2015)

What is the impact of a low resilience?

Often within the literature, research studies focus upon increasing resilience to improve an individual’s overall wellbeing. However, the distinct impact of low resilience is somewhat underreported. Here we will try and fill the gap of how low resilience can affect psychological wellbeing and document the physiological impacts of such condition.

One aspect of research that has been explored is that of resilience and depression with suicidal tendencies. A study conducted in 2007 explored patients who had attempted suicide, the research noted that those who had tried to commit suicide had significantly lower resilience scores than individuals who had never attempted suicide prior. This therefore suggests the possibility that individuals with low resilience may be a risk factor associated with depression, anxiety and subsequent suicidal behaviour (Roy, Sarchiapone & Carli, 2007).

Similar findings have been documented by Toukhsati et al (2017), who identified that those individuals who displayed low psychological resilience had a direct relationship with depression.

In a more practical sense, a lack of resilience has been shown to make individuals unable to handle stress well in compromising or difficult situations. Most frequently within the literature, studies identify stress in relation to ‘burnout’.

Stress places a lot of pressure on the body and although this can be manageable in the short-term, if stress is ongoing, it can be bad for both physical and emotional wellbeing. The research posits that an increased level of stress over a prolonged period of stress can lead to the phenomenon of a burnout; a state of complete mental, physical and emotional exhaustion (Salvagioni et al, 2017).

Burnout can lead to the inability to complete daily tasks and partake in activities that prior led to fulfilment. This is possibly the most damaging aspect of low resilience as the individual is unable to cope with the crisis and can lead to a range of negative psychological symptoms, as stated above. Although there exist several definitions for psychological burnout, some of the symptoms include:

• Feeling exhausted and unable to perform basic tasks.
• Losing motivation in many aspects of your life, including your work and friendships.
• Feeling unable to focus or concentrate on tasks.
• Feeling empty or lacking in emotion.
• Losing your passion and drive.
• Experiencing conflict in your relationships with co-workers, friends and family.
• Withdrawing emotionally from friends and family (Heinemann & Heinemann, 2017).

What is the impact of high resilience?

Within the literature, high resilience by nature typically displays the opposite effect to low resilience such that emotional and psychological processing is enhanced. In recent years, a growing body of evidence has identified that higher self-reported resilience has been associated with lower levels of anxiety, psychological distress and mixed anxiety/depression (Loprinzi et al, 2011).

Researchers have also found that resilience, as measured by various self-report tools, has a mitigating effect on depression symptoms among individuals who have experienced trauma in both childhood and later life, as well as among patients experiencing severe health conditions (Bitsika, Sharpley & Bell, 2013).

Together, these studies suggest that the measurable components of individual resilience may play an important protective role in easing the negative effects of stress, trauma and adversity.

Several potential mechanisms have been posited to account for these associations, including improved health behaviour, direct physiological benefits, and enhanced resistance to and recovery from stress among individuals with high versus low positive emotional resources.

Although the evidence has largely suggested that a higher level of resilience is associated with positive affect and outcomes, some studies, particularly within occupational settings, have identified the negative effect of high resilience and its subsequent outcomes. Large-scale scientific studies have suggested that even individuals with high resilience can display maladaptive behaviours if resilient behaviours are taken to extremes (Pierce & Aguinis, 2011).

Research conducted by Kaiser and Kaplan (2013 as cited by Adler, 2015) identified that overused strengths can easily be translated into weaknesses; such that individuals can be too resilient for their own sake.

One example of where this may occur is within individuals whose extreme resilience leads to overly persistent unattainable goals in which they become unfulfilled. This has implications as although individuals who have high goals are typically revered; often this presents unrealistic goals which can in turn reduce resilience and increase stress, frequently concluding in emotional burnout.

Scientific reviews have shown that a phenomenon exists called ‘false hope syndrome’, this condition refers to individuals who waste a large amount of energy persisting unrealistic goals. Often such individuals pursue opportunities despite past behaviors clearly suggesting that the goals are unobtainable (Polivy, 2001). This henceforth shows that although high levels of resilience may be a trait that individuals seek, it can also have a detrimental impact of social, cognitive and subsequent psychological functioning.

Resilience in review

An interesting concept to consider is the ‘paradox of resilience’. Several research studies have identified the effects of strong personality types and the subsequent negative effect staying resilient has upon physiological and psychology wellbeing (Tugade & Fredrickson, 2004).

Much of the current research suggests that increased resilience can lead to individuals isolating themselves from social support networks, setting unrealistic expectations and enduring unnecessary stressors; traits associated with the development of depression (Armstrong, Galligan & Critchley, 2011).

Paradoxically however, the current literature also identifies that those with lower resilience levels are more likely to suffer from depression, and the research consistently references to a non-causal relationship with suicide attempts.

Despite several authors identifying the spectrum of resilience from low to high and the relevant impact it can have on physiological and psychological wellbeing, little research has identified the specific mechanisms.

This appears to occur due firstly to the ambiguity of resilience; although measures of resilience exist such as the CDRISC, there is no one single objective measure to establish resilience quantitatively. Because of this, it is difficult to ascertain at what level resilience is ‘most effective’ and at what ends of the spectrum become harmful to the individual. A lack of resilience objectivity raises implications for health-care and clinical populations.

If we posit the scenario ‘an individual is contemplating suicide due to high stress’, then eliminating variables such as their prior psychiatric history, social status, socio-economic status and assume that the individual is capable of sufficient activities of daily living (ADLs). This scenario purely focused on resilience raises the question as to whether the individual is contemplating suicide because they have been resilient for too long and have ‘burnt out’ or have too little resilience to cope with the stressors of everyday life and have once again ‘burnt out’ (Treglown et al, 2016).

Looking at this scenario on face value, it is difficult to determine which end of the resilience spectrum is connected to the burnout and proceeding negative psychological state of the individual.

One concept that is novel within this report and is constantly missed within the literature is that lacking resilience and being resilient for too long are directly related to each other; such that the concepts are identical.

Research has long detailed the negative impact that being resilient for too long can have on an individual, whilst simultaneously noting the impact of high resilience. To establish the role of high and low resilience the following formula has been constructed; this serves to identify how either end of the resilience spectrum is linked and subsequently how burnout is a product of both low and high resilience. (Please see formulations below).

• Under-resilient = The inability to return to a functioning state post-crisis (leading to psychological distress)
• Over-resilient = The state of being resilient for too long (leading to psychological distress)
• Burnout = Lacking the psychological resilience to maintain a functioning role post crisis
• Therefore: Burnout = [Under-resilience x over-resilience]

Subsequently this raises the issue of how can an individual burnout without being resilient. The evidence and current understanding of resilience therefore suggests that you cannot reach burnout without being fundamentally resilient.

Therefore, under-resilient versus over-resilient as primary concepts are that of the same foundations; by proxy an individual who is contemplating suicide is both under resilient and over resilient.

The current literature appears to make this determination and solely identify resilience as a categorical spectrum (low resilience; high resilience). However, the basic processes of resilience do not support this hypothesis.

Conclusions

The debate between under- versus over-resilience is relatively undocumented within the current literature. As documented, it is implausible to obtain a state of being ‘burnt out’ without being significantly resilient.

Given that high resilience and low resilience have a strong crossover of components, future research should aim to establish the holistic aspects of resilience and limit the definition of the phenomenon to two separate ends of a spectrum.

This may suggest that researchers need to think about how they are defining resilience and subsequently how the development of resilience training should be created. It may be plausible that instead of training relating to solely increasing resilience (in low resilience individuals) the focus should be shifted on how to maintain an equilibrium of resilience.

This would ensure that individuals do not have sufficiently low resilience to react to crisis events, but also do not longitudinally display high resilience; such that it will impair their physical and psychological wellbeing.

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