Resilience is not all or nothing. It comes in amounts. You can be a little resilient, a lot resilient; resilient in some situations but not in others. And, no matter how resilient you are today, you can become more resilient tomorrow.
—Karen Reivich, psychologist, professor at the University of Pennsylvania, and director for the Penn Resilience Program
What comes to mind when you think of the word ‘resilience’? What qualities and strengths do resilient people you know possess? How about resilient teams?
Resilience is an essential tool for dental professionals navigating challenges and constant changes in the dental world. Furthermore, it is a critical life skill. Training our minds to become more resilient is essentially about learning how to tap into psychological tools to navigate adversities, recover, and grow through them. Far from the outdated ‘bounce back’ analogy, resilience actually is a journey, one that is dynamic, and there is no instant recoil back to recovery but a more compassionate finding of our internal resources and seeking social support.
The ‘Tree of Life’, located on the US West coast in Olympic National Park, Washington, has forged roots that supply the tree despite not having soil. This tree and countless others show nature’s ability to adapt to different weather conditions; to bend with it rather than break. Similarly, resilience requires us to think flexibly, to roll with the rough and smooth. This dynamic process involves an interplay of protective factors in an individual, family, peer network, and community that allows us to develop, maintain, and regain mental health despite adversity.
A great dental analogy of thinking about resilience is composite. It gains its strength by small increments of material that are cured. We can also gain mental strength by building ourselves up, one increment at a time. Similarly, team resilience can be thought as the capacity for a group of individuals to respond to change and adversities in an adaptive way. As dental professionals working in teams, safeguarding our team members through resilience and well‐being training has tremendous benefits:
- Greater ability to regulate emotions
- Enhanced ability to handle challenges and stress
- Reduced occupational hazards, such as burnout and compassion fatigue
- Reduced presenteeism and absenteeism
- Enhanced communication
- Improved interpersonal relationships
- Openness in upskilling and developing
- Greater ability to give and receive support
- Increased authenticity at work.
Resilience Myths Debunked
Myth 1: Resilience Is Something You Either Have or Do Not
This is the most common myth surrounding resilience. And for many years, we believed that individuals possessed a fixed amount of resilience. We now know otherwise. Our brains have a special capacity to change structurally through experiences, known as neuroplasticity. With effort, new neural pathways for positive habits can be created at any age. Just as Karen Reivich emphasises in the quote at the start of this chapter, resilience indeed can be strengthened because, just like any muscle of the body, it can be trained. Without use, this muscle atrophies, and so continual active effort in mind training is essential.
Myth 2: Resilient People Do Not Have Problems or Stress
Being resilient does not mean you are immune to challenges. As we discussed in Chapter 1, in actuality, we are all on the mental health continuum. Our position on the continuum is influenced by what is going on in our lives. This means that any of us can shift into poorer mental health and lower resilience depending on negative life events. Resilient people buffer against these stressors by enhancing their well‐being protective factors, hence actively building the muscle of resilience and minimising the risk of developing mental illness.
Myth 3: Resilient People Do Not Need Help
Resilience does not mean we are completely self‐sufficient. Resilient people appreciate the importance of strong, positive relationships and community. When they experience adversities, they are comfortable in asking for help from others. This help could be from partners, friends, organisations, or professionals. Having loving, supportive relationships helps resilient people buffer against stressors, big or small.
Training the Brain for Greater Resilience
Unlike traditional psychology, which concentrates solely on what is wrong with an individual and how to fix it, positive psychology encourages individuals to recognise what is going right and amplify the positive. Evidence‐based tools to build resilience and well‐being come from this beautiful specialty of psychology. Interestingly, positive psychology already underpins positive education within schools, organisations, sports, and coaching and has started to make its way to healthcare, most notably with medical students.
We are currently in a new era of increasing interest in psychological interventions targeted at strengthening well‐being. To date, however, there are limited research studies that have examined interventions specifically targeting dental professionals. In this section, we explore the insight from these small studies. Cognitive‐behavioural therapy (CBT) is explored later in this chapter, and mindfulness‐based interventions are explored in Chapter 6.
In the last two decades, there have been three small counselling studies for postgraduate dental professionals (Newton et al. 2006; Gorter et al. 2000; Gònzalez and Quezada 2016) and three studies assessing the efficacy of CBT to enhance well‐being (Chapman et al. 2017; Aboalshamat et al. 2015; Metz et al. 2020). Two of these studies targeted undergraduates and the third focused on GDPs. Encouragingly, all reported significant improvements in mental well‐being, but these findings were limited due to use of different outcome measures and small selective sample sizes.
The literature for healthcare professionals, specifically our medical colleagues, is growing rapidly. Since medical professionals are most similar to dental professionals with regards to medical training, high stressors working closely with patients, long hours, and litigation, we can glean insights that could help to shape future interventions for dental professionals. The UK General Dental Council (GDC) recently recommended interventions to be adapted from other healthcare professions (Plessas et al. 2021). They argued that this should be part of contemporary education, both at the undergraduate and postgraduate level. Below we highlight some of the key intervention studies from other medical professions.
The research on interventions for medical professionals incorporates either predominantly or in combination CBT, mindfulness‐based, positive psychology–based, support groups (known as Balint groups), or stress management. Sood et al. 2011 reported benefits of significant increase in resilience, decrease in perceived stress and anxiety, and increase in quality of life postintervention after a 90‐minute Stress Management and Resilience Training (SMART), followed by 30–60 follow‐up session. The SMART training included areas of positive psychology: attention, gratitude, compassion, acceptance, meaning, and forgiveness and components of mindfulness‐based stress reduction (MBSR). The results of positive psychology interventions (PPIs), like this one, may be because of helping clinicians to enhance positive emotions despite adversities, such as the humble yet important emotions of gratitude, optimism, and compassion, and to leverage their values and character strengths to live a meaningful, engaged life and bring the best of them to patient interactions.
Although support groups are helpful in making us feel less isolated, they may be less effective than some other modalities. Four Balint groups reported by Clough et al. (2017) showed no evidence in enhancing well‐being measures. Perhaps they were ineffective in stress and burnout prevention, as Balint groups do not target underlying thoughts associated with stress, enhance self‐awareness or emotional regulation, or aid in coping skills that are necessary in building resilience. The equivalent of Balint groups in dentistry is study groups and local dental committee groups. Although they do provide a sense of community, they may be expensive to run and difficult to recruit consistent dental professionals to attend.
Dental students have very similar undergraduate training to medical students, not just in terms of curriculum but also with treating patients and having the responsibility of clinical care early on in their undergraduate training. Embedding resilience and well‐being training into the dental undergraduate curriculum could be beneficial in teaching students the necessary mind tools early on in their careers and preventing subsequent burnout and poor mental health. Approaches that worked with the existing dental curriculum to enhance it with an emphasis on increasing students’ protective factors for resilience – for example, incorporating virtues training highlighting benefits to both the clinician and patient – during communication sessions could be one method of bypassing the resistance from dental deans. Future research could also explore whether customised interventions would be possible, with autonomy for choosing different resilience elements, as these interventions are not a one size fits all. Additionally, dental student informed well‐being components would be extremely beneficial in ensuring that the intervention is tailored to the needs of the cohort.
PPIs targeting medical students include mindfulness‐based interventions (Rosenzweig et al. 2003) and character strengths as well as generalised positive psychology–based programmes (Machado et al. 2019) and the Penn Resilience Program (Peng et al. 2014). The Penn Resilience Program for a Chinese medical student cohort reported encouraging results (Peng et al. 2014). Resilience, positive emotions, and the cognitive appraisal scores of a low‐resilience experimental group increased significantly after training. The positive results may be due to protective resilience factors – such as resilient thinking, positive emotions, leveraging character strengths, and nurturing positive relationships – being enhanced through this PPI. This study is limited, however, by no long‐term follow‐up and whether the positive results can be extrapolated to other cultures.
Another fascinating area in the research in resilience is the phenomenon known as post‐traumatic growth (PTG). This describes the process in which individuals experience trauma, become further strengthened by it, reconfigure, and grow with capabilities greater than those preceding it. They become a 2.0 version of themselves! These individuals experience a positive growth as a result of their trauma. PTG does not deny the deep psychological distress; rather it recognises that positive psychological change may occur after a life crisis.
Resilience Protective Factors
In Chapter 1 we spotlighted the significance of protective factors on our levels of resilience and positive health. In this section we delve into these factors further. Let us take the analogy of an umbrella, imagining each spoke of this umbrella as an element of protection from life’s invariable adversities (see Figure 3.1). The different spokes are explored below, summarising the key research findings on protective factors for greater resilience.
Genetics: Our biology plays a part in how resilient we naturally are. However, since this is the only factor we cannot directly influence, it is worth not being too hung up on your starting point.
Self‐awareness: That is the awareness of our thoughts and emotions at any given moment. We are often more aware of our physical reaction to stress but less aware of our thoughts due to a disconnection between the mind and body.
Self‐regulation: Once we are self‐aware, we are then able to self‐regulate, another key protective factor. This is the mind skill in recognising which thoughts or emotions may be helping or hindering us and finding strategies to influence those thoughts and calm our physiology when our brain is in a threat response (fight or flight mode).
Positive emotions: This includes the elevated emotions of love and happiness, not to discount the underrated yet humble emotions of gratitude, optimism, self‐compassion, and curiosity.
Self‐belief: Our ability to complete goals and master our environment, known as self‐efficacy, is another crucial component. This impacts our choices, goal setting, effort, and persistence. We know that individuals with more self‐efficacy are more likely to achieve difficult goals and try again despite rejections.
Positive relationships and organisations: Since humans are hardwired for social connection, it is unsurprising that our community also provides us protection from adversities. Nurturing positive relationships and positive organisations is essential in building both resilience and our well‐being.
Meaning: Essentially, meaning making despite pandemics or tragedies is centred in engaging in something bigger than ourselves. We may find meaning through spirituality or reflection. Research validates a strong correlation between meaning and resilience. Interestingly, higher levels of meaning are also strongly correlated with better mental health, self‐esteem, self‐acceptance, and emotional regulation and a lower risk for substance abuse and addiction.
PERLE Resilience Model for Dental Professionals
Drawing from the research on the protective factors for resilience, PERMA, and lifestyle medicine, I present a resilience framework designed specifically for dental professionals: PERLE (see Figure 3.2). The PERLE Resilience Model for Dental Professionals describes five key pillars of building resilience at work: Purpose, Emotional intelligence (divided into self‐awareness, emotional regulation, and positive emotions), Resilient mindset, Lifestyle, and Environment at work (divided into High‐Quality Connections [HQCs] and engagement). Increasing any pillar individually can increase our levels of psychological resilience and shift us towards engagement and thriving.
The analogy of the oyster and the pearl beautifully captures the process of resilience. When a grain of sand or another organism floats into the deepest parts of an oyster, the oyster begins to coat the foreign body and protect itself from the stressor, covering the painful intruder with layer upon layer of nacre. This makes up the oyster’s inner shell. Over several years, these many layers create the beautiful, iridescent pearl. In the same way that the oyster uses its own internal resources to navigate stress and thrive, we can also use our own internal and external psychological resources when we face challenges in dentistry.
The PERLE model is designed to be used at the individual level, through supporting dental professionals in taking a proactive role in identifying areas they are lacking or wanting to strengthen and taking positive step forwards towards thriving. PERLE can also be used at the organisation level, with teams playing a critical role in building positive environments and dental organisations integrating the framework as part of resilience and well‐being workshops and programmes.
Understanding Each Pillar
|Purpose||This pillar explores having meaning at work and alignment with a greater purpose than ourselves. This includes understanding our core values as dental professionals and creating goals that align with them.
To learn more, see Chapter 4.
|Emotional intelligence||Emotional intelligence (EI) is the ability to monitor our own and others’ feelings and emotions, to discriminate among them and use this information to guide our own thinking and actions. This pillar splits into three sections:
|Resilient mindset||Thinking styles that impact how we feel and act and are highly relevant to dental professionals, specifically developing optimistic, compassionate, and growth mindsets.
|Lifestyle||This pillar recognises the impact of our physical health, particularly sleep, movement, and nutrition, on our psychological well‐being.
See Chapter 9 for an in‐depth look at lifestyle factors.
|Environment at work||This pillar focuses on cultures at work that are kind, compassionate, and positive. It is split into two parts:
Resilience Seesaw for Dental Professionals
The resilience seesaw (Figure 3.3) illustrates how PERLE factors boost us towards positive mental health. Each PERLE pillar can be considered a protective factor in helping us thrive at work. The initial placement of the fulcrum is dependent on our genetic makeup but is influenced by the interplay between our risk, protective factors, and what is going on in our lives. When positive life experiences and protective factors outweigh negative experiences and risk factors, a dental professional’s ‘scale’ tips towards positive mental health outcomes. Over time, the cumulative impact of positive life experiences and protective factors shifts the fulcrum position, making one more susceptible to achieving positive mental health, away from clinician burnout to engagement and flourishing.