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9/7/2013
Andy’s Story
I first met Andy more than ten years
ago, when he walked into my office
along with his father. He explained
that he was now running a successful
landscaping business with three
employees. Andy’s father shook his
head and said, “I don’t know if I’ll ever
forgive those doctors for being so
negative.”
Andy’s Story
His father explained, “When Andy was
first hurt, the doctors told us he
probably would not live through the
night. He was in the hospital for
almost two months. A few days before
discharge, the doctors told us he
probably would never be able to walk.
They were even more certain he would
never hold a job.”
Andy’s Story
Andy recently stopped by my
office again, this time with
his wife. I talked with them
both for a long time, listening
carefully as they filled me in
on the last ten years.
Andy’s Story
They met in church and were
married after dating for more
than a year. Soon after their
third anniversary the first of
their two children was born.
Three years later their son
was born.
Andy’s Story
Andy’s wife smiled and held his hand as she
talked. She described him as a wonderful
husband, a good provider, and a loving and
patient father. His wife said, “His memory is
not the best so he writes everything down.”
She looked at him and said, “He’s never
forgotten a birthday or anniversary.
Not even once.”
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9/7/2013
The Case of Bill
Three years ago, 28 year old Bill sustained a severe
brain injury in a high speed motor vehicle collision. On
admission to the emergency room, GCS was 7. Head CT
revealed a right temporal contusion and a large left
parietal intracranial hemorrhage with a depressed skull
fracture. He underwent a left craniectomy with skull
fracture debridement and ICH removal. Hospitalized for
more than a month, Bill was discharged home in the
care of his wife.
The Case of Tom
Three years ago, 28 year old Tom sustained a severe
brain injury in a high speed motor vehicle collision. On
admission to the emergency room, GCS was 7. Head CT
revealed a right temporal contusion and a large left
parietal intracranial hemorrhage with a depressed skull
fracture. He underwent a left craniectomy with skull
fracture debridement and ICH removal. Hospitalized for
more than a month, Tom was discharged home in the
care of his wife.
The Case of Bill
Unemployed and Living with His Parents
Three years after his injury, Bill now lives with his parents and they
now have a turbulent relationship. His wife and two young children
are living without him in the home they once shared. After
repeatedly cursing and yelling at them and punching holes in the
wall, Bill’s wife obtained a court order forcing him out of their home.
Despite numerous requests from his wife and parents, Bill had
declined to see a doctor or counselor and denied having problems he
couldn’t handle himself. Bill is now unemployed. He went back to
his old job as a landscaper and three weeks later was fired for
repeatedly arguing with customers. Bill found several other jobs, but
wasn’t able to hold any of them for more than a short time. Angry, he
told his parents, “my life has been ruined forever by this accident.”
The Case of Tom
Working and Living with His Wife and Children
Three years after his injury, Tom was living with his wife and two
young children. Soon after returning home, he began to have bouts
of depression. With encouragement from his wife, he saw his family
doctor who provided medication and referred him to a counselor for
weekly sessions. Tom also began to attend a monthly brain injury
support group. He learned that sharing his thoughts and feelings with
others helped him adjust and function. Tom tried going back to work
full‐time as a landscaper and initially had problems with fatigue and
headaches. With support from his supervisor and colleagues, Tom
backed down to a part‐time schedule. After eight months, he was
gradually able to resume a full‐time schedule. Tom recently received
a sizable raise. Smiling, his supervisor told him, “I know I can trust
you. You never complain and you’re the hardest working man here.”
What Bill said….
• To avoid disappointment, I
imagine the worst thing
that can happen.
• I’ll get stronger if I trust
no one and solve my
problems by myself.
• My future has been
permanently destroyed by
this trauma.
• When something goes
wrong, I fear that I’ll
never recover.
What Tom said…
• I’m usually optimistic
and see problems as
temporary.
• I have good friends I can
talk to who help me
out.
• I’ve been made stronger
and better by this
difficult experience.
• When bad things
happen, I’m not down
for long
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9/7/2013
What Bill said….
• I’ve learned that most
people have nothing good
or helpful to say.
• I don’t like who I am now.
My self‐confidence has
vanished.
• Mistakes only lead to
depression and more
mistakes.
• I choose to be around
people who are just like me.
• If my first solution to a
problem fails, I usually
panic.
What Tom said…
• I listen carefully and
consider other people’s
opinions.
• I know my strengths and
work to build my selfconfidence.
• I do my best to learn from
mistakes and try to do
better next time.
• I enjoy being around
different kinds of people.
• If my first solution to a
problem fails, I try to find
another solution.
What is Resilience?
Definition: “… the ability to withstand
and rebound from disruptive life
challenges… involves dynamic
processes fostering adaptation within
the context of significant adversity.”
From Walsh, F. (2003) Family Process, 42 (1).
Defining
Resilience, Resilient, and Resiliency
o Cope well in the face of ongoing disruptive change
o Maintain good health and energy in the face of
constant pressure
o Overcome adversities, bounce back from setbacks
o Change to a new way of working or living when
maintaining the old way is not possible
o Do all this without behaving in harmful or
dysfunctional ways
Goals in Learning to be Resilient
o Remain calm under pressure
o Improve creative, analytical, and practical problem
solving skills
o Maintain optimism, humor, and positive feelings in the
face of challenges
o Avoid thinking of one’s self (and others) as a victim
o Be self‐reliant and socially responsible
o Understand that learning leads to a better life
o Derive good fortune from misfortune
From Siebert, A., The Resiliency Advantage, © 2005
Al Siebert (2005)
“When resilient people have their lives
disrupted they handle their feelings in
healthy ways. They allow themselves to feel
grief, anger, loss, and confusion when hurt
and distressed, but they don’t let it become a
permanent feeling state… They are examples
of Nietzsche’s statement, ‘That which does
not kill me makes me stronger’.”
The Resiliency Advantage
Attack
Al Siebert, 2003
Disruptive
Change
Numb
Upset
Thrive
Resile
Cope
Victim
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Laying the Groundwork for Resilience
• Life change is possible
• Thoughts and emotions are essential
components of our humanity
• Thinking accurately is essential
• Focus on strengths while avoiding a
tendency to focus on the negative
Life Change is Possible
“… people can change their lives. This is a powerful
concept, a modern one. The notion that humans are not
bound and gagged by the fallout of their early childhoods,
that they can change their behavior at any time in their
lives, seems such a truism to some people
today. Historically, people have believed
that lasting change was not possible.
Even now, many people cling to the
notion that the first few years of life
determine everything about a person
and her future.”
From Reivich & Shatte, The Resilience Factor, © 2002
Thoughts and Emotions
“.. Over the years he (Aaron Beck) came to
recognize what an enormous body of research
now confirms – cognitions cause emotions, and
emotions matter in determining who remains
resilient and who succumbs… The success of
cognitive therapy highlights what many of us
already suspect –that our thoughts and
emotions are the very core of who we are; that
they represent our essential humanity.”
From Reivich & Shatte, The Resilience Factor, © 2002
Thinking Accurately
“.. Realistic optimism is the ability to maintain a positive
outlook without denying reality, actively appreciating the
positive aspects of a situation without ignoring the
negative aspects. It means aspiring and hoping for
positive outcomes, and working toward those outcomes
without assuming that these outcomes are a forgone
conclusion. Realistic optimism does not assume that good
things will happen automatically. It is the belief that good
things may happen and are worth pursuing, but that
effort, problem solving, and planning are necessary to
bring them about.”
From Reivich & Shatte, The Resilience Factor, © 2002
Positive Psychology
“.. This new social science aims to create an
empirical body of knowledge of optimal human
functioning… Two basic goals: To increase
understanding of the human strengths through
the development of classification systems and
methods to measure these strengths; To infuse
this knowledge into effective programs and
interventions design to build strengths rather
than remediate weaknesses.”
From Reivich & Shatte, The Resilience Factor, © 2002
Strength‐Based Care Models
o “Disciplines which have embraced a shift
toward strength‐based models of care
have done so for both practical and
humanistic reasons
o Researchers (e.g., Duncan, 2010) have
established that a dominant factor in
positive therapeutic outcomes is a therapy
client’s orientation toward hope and
change.
Godwin & Kreutzer, Brain Injury, 2013
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Strength‐Based Care Models
o In fact, empirical support demonstrates
that 30% or more of therapy‐based
growth can be attributed to a client’s
ability to be optimistic and flexible.
o Processes designed to facilitate the
promotion of resilient traits are
tied to successful outcomes.”
Godwin & Kreutzer, Brain Injury, 2013
Focus on Strengths
“Resilience is the basic strength underpinning
all the positive characteristics in a
person’s emotional and psychological
makeup. A lack of resilience is the major
cause of negative functioning. Without
resilience there is no courage, no
rationality, no insight. It is the bedrock on
which all else is built.”
From Reivich & Shatte, The Resilience Factor, © 2002
Rationale for Investigating Resilience
• The profile of a resilient population after TBI has
not been established
• To date, the natural process of resilience
development following TBI has not been
investigated
• Identification of correlating variables and the
path to resilience can strengthen interventions
designed to promote resilience after TBI
Traits and Skills
Researchers in the field of resilience have
determined that:
a. the skills that are associated with a resilient and
adaptive response to trauma are neither
“superhuman” nor extraordinary; and
b. resilient skills can be initiated and/or
strengthened in individuals who have
previously demonstrated non‐resilient profiles.
Common TBI Challenges and
Skills Necessary for Resilience
Research project partly funded by the U.S. Department
of Education, National Institute on Disability and
Rehabilitation Research (NIDRR) #H133A120031.
Common TBI Deficits and Challenges
Anxiety, depression
Skills Necessary for Resilience
Even temperament, emotional
stability
Survivor focus on deficits, frequent Positive outlook, optimism
comparisons to pre‐injury functioning
Irritability, aggressive behaviors Self‐regulatory skills and eventempered
behaviors
Discomfort with socialization Social perception, arousal of liking
response in others
Impaired self awareness
Insightful modification of behavior
Cognitive deficits, impaired executive Good problem solving skills
functioning
Diminished communication skills Effective communication
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9/7/2013
1. Assumptions Underlying the Resilience
and Adjustment Intervention
• Successful survivorship is based in
individual resilience.
• Survivors who embody, or who learn to
adopt traits identified as key to resilient
living will find increasing success in
their recovery and growing satisfaction
with their postinjury lives.
2. Assumptions Underlying the Resilience
and Adjustment Intervention
• Achieving postinjury emotional
wellness requires a clear
understanding of injury‐related
symptoms, commonly encountered
challenges, and recovery processes.
3. Assumptions Underlying the Resilience
and Adjustment Intervention
• A key feature of resilience is
developing insight into one’s own
behavioral response to trauma.
• Survivors who are more aware of
their strengths and limitations are
more likely to lead productive and
meaningful lives.
4. Assumptions Underlying the Resilience
and Adjustment Intervention
• Resilient individuals are skillful at
problem solving, goal setting,
communicating, and managing stress
and intense emotions.
• Helping survivors develop these skills
benefits their ability to be productive
and maintain quality relationships.
5. Assumptions Underlying the Resilience
and Adjustment Intervention
• Survivors are more likely to improve
when they develop resilient traits,
such as being actively engaged in
recovery, and are able to maintain a
positive outlook.
Goals of the RAI Program
1. To provide survivors with fundamental
information about common symptoms and
challenges after TBI
2. To help survivors develop core abilities, enabling
them to more effectively problem solve and
efficiently achieve personal goals
3. To teach coping strategies that facilitate the
process of emotional recovery, helping survivors
to feel better about themselves, their lives, and
their relationships
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9/7/2013
Goals of the RAI Program
4. To teach survivors effective communication
skills, enabling them to develop effective longterm
support systems
5. To instill hope and a positive outlook by
identifying progress and personal strengths,
and helping survivors access community
resources
RAI Implementation
Five week, seven session format with two or
three topics covered during each sixty minute
session
Total of 16 topics covered via self‐assessment,
discussion, and structured learning
experiences
Sessions implemented hierarchically; earlier
topics provide foundation for later topics
RAI Implementation
Time span between sessions allows for
homework completion, reflection, trying
out strategies and solutions to problems
Sessions conducted by single qualified
therapist with single survivor
Resilience and Adjustment Intervention
Accommodations
Written materials provided in large print
to accommodate visual impairments.
Materials written at a 5 th grade level for
people with limited reading skills.
Information is presented in writing,
orally, and visually for people with
different learning styles.
No doubt, each
patient, each family
member, and each
family is unique.
Yet, research and clinical
experience indicates that
most survivors have
similar concerns and many
face similar challenges.
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Curriculum Based Approach
• Education regarding common
challenges, issues, and concerns
• Psychological support
• Skill building abilities associated with
improvement in the targeted domain
• Components adapted from validated
Brain Injury Family Intervention
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Resilience and Adjustment Intervention
Session I
Understanding the Effects of Brain Injury
1. Understand the typical consequences of
brain injury
2. Appreciate the difference between
emotional and physical recovery
3. Cope effectively with loss and change
Resilience and Adjustment Intervention
Session II
Active Engagement in Recovery
4. Realize the important role you have in
your own recovery
5. Recognize what you can do to help
yourself and feel better
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Resilience and Adjustment Intervention
Session III
Setting Reasonable Goals
6. Appreciate that success is relative
7. Improve your ability to be patient
8. Understand and implement effective
goal setting strategies
Resilience and Adjustment Intervention
Session IV
Solve Problems Effectively
9. Learn and use more effective
problem solving strategies
Resilience and Adjustment Intervention
Session V
Managing Stress, Anger, and Other Intense
Emotions
10. Monitor and manage stress more
effectively
11. Better manage intense emotions
including frustration, anger, and fear
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Resilience and Adjustment Intervention
Session VI
Communicating Effectively and Rebuilding
Relationships
12. Rebuild relationships
and overcome loneliness
13. Learn and apply more effective
communication strategies
14. Develop strategies for comfortably
discussing injury with others
Resilience and Adjustment Intervention
Session VII
Communicating Effectively and Rebuilding
Relationships
15. Avoid a negative focus, feeling guilty, or
blaming others
16. Appreciate positive aspects of your new
life and develop a positive attitude
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Investigating Resilience:
The Connor‐Davidson Resilience Scale
Review of existing resilience inventories
suggests the CD‐RISC is the most
effective measurement tool available
Established excellent psychometric
properties, e.g. reliability, internal
consistency, and construct validity
CD‐RISC
• 25‐item and 10‐item versions, both
empirically validated
• Statements ranked on a 0–4 frequency scale:
0 ‐Not true at all; 1 ‐Rarely true; 2 ‐Sometimes
true; 3 ‐Often true; 4 ‐True nearly all of the
time
• Respondents evaluate the veracity of
statements as they pertain to the last month
www.connordavidson‐resiliencescale.com
CD‐RISC Framework
Assessment via a resilience model based
on hardiness and persistence, specifically:
o Not giving up o Tolerating pressure
o Coping with o Overcoming negative
unexpected events outcomes
o Tolerating stress o Coping with
o Overcoming illness & unpleasant feelings
hardship
www.connordavidson‐resiliencescale.com
Connor‐Davidson Resilience Scale
Mean Scores for Specific Populations
PTSD
Generalized Anxiety
Psychiatric Patients
Primary Care Patients
US General Population
Connor & Davidson, 2003
0
20
40
60
80
100
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9/7/2013
Virginia Commonwealth University
Medical Center
Our work should be guided by the
experiences of the people we serve, our
perception of their needs, and our sense
of the most important things we can do
to meaningfully improve their lives.
JSK
Jeffrey S. Kreutzer, Ph.D., ABPP
jskreutz@vcu.edu
www.tbinrc.com
Department of Physical Medicine and Rehabilitation
VCU Box 980542, Richmond, VA 23298‐0542
Ph. 804 828‐3704
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