New Concepts In Human Resilience

It was a dark and rainy night. The police cruiser glided into the alley like a shark onto a reef, searching for its unsuspecting prey. The ‘prey’ was concealed about half way down the alley behind a large dumpster. Engine off, windows rolled up so that their breath wouldn’t be seen on this cold winter night. All of a sudden; a flash of light, blinding in its intensity, illuminated the prey freezing them for a moment in time. Heart rates sent racing by the glare; they were caught! But their vital signs quickly returned to normal as the police cruiser slowly backed out of the alley and raced off to hide. The hunter was now the hunted, and the ‘prey’ now circled the alleys in search of the police cruiser.

Many of you as old as I will recognize this anecdote as a game we often played during night shifts to stay alert and pass the time between calls. I’m not sure how ‘spot light tag’ started or even when it ended, but I do know that it was part of a culture that protected us from the toxic effects of job-related stress.

You might not believe me but there is a growing body of research to support my opinion.

“One of the ways (those) showing resilience appear to cope well with adversity is through the use of positive emotion and laughter. Historically, the usefulness of positive emotion in the context of extremely aversive events was either ignored or dismissed as a form of unhealthy denial. Recently, however, research has shown that positive emotions can help reduce levels of distress following aversive events ….” (1)

We also played a lot of practical jokes on one another. One of my personal favorites was the oxygen tubing in the toilet tank trick. I should mention though, that this can quickly go sideways if the wrong person uses the toilet. One classic example was a situation that occurred at a special event in the 1980s. A paramedic (who should probably remain nameless) was assigned to a secure location and became bored as the day dragged on without a call. An idea emerged during the late afternoon and this paramedic prepared the toilet for the night shift. This involved lifting the lid on the water tank and attaching a length of oxygen tubing to the filling tube. The oxygen hose was then run outside of the tank and directed so that it would spray cold fresh water into the face of whomever depressed the flush lever. Unfortunately, that person on this occasion, was an RCMP superintendent who came in to use the washroom.

Incredibly, we tended to get away with this type of behaviour back in those days. There was a strong sense of family amongst the emergency services and we always had each other’s backs no matter what. I think this was because we knew that what we did was important and it often seemed like us against the world. It seemed like every shift or two a life would be saved somewhere in the city. We socialized together and celebrated holidays together while at work. In fact, we often joked that we spent more time with our work family than our real families.

We were also given a great deal of freedom and we constantly pushed the envelope to provide better care. It was a time of great optimism as our relatively new profession was gaining traction.

Although we didn’t know it at the time, some of this behaviour might have actually prevented stress, burn out and even PTSD

“A growing body of evidence suggests that the personality trait of hardiness helps to buffer exposure to extreme stress. Hardiness consists of three dimensions: being committed to finding meaningful purpose in life, the belief that one can influence one’s surroundings and the outcome of events, and the belief that one can learn and grow from both positive and negative life experiences. Armed with this set of beliefs, hardy individuals have been found to appraise potentially stressful situations as less threatening, thus minimizing the experience of distress. Hardy individuals are also more confident and better able to use active coping and social support, thus helping them deal with the distress they do experience.” (1)

We also tended to have a different attitude about bad calls. Although some of us suffered, there was no such thing as PTSD back then and certainly no debriefings. If we were involved in a tragic event, we tended to gather at the back of the ambulance while we were cleaning up. As I remember it, the talk always surrounded what we did well and what we could have done better. These talks were framed in a way that celebrated success and led to mastery. We weren’t obsessed with perfectionism as we understood that chaos could only be contained and a chaotic scene could be managed but could never be made perfect. Once the ‘bumper talk’ was over, we would usually talk about the call with our partners for a little while and that was it. If sleep disturbances came or if strong emotions resurfaced, we just battened down the hatches and soldiered on. Could it be that this might have also protected us from PTSD?

This form of behavior is now called ‘Repressive Coping’.

“Resilience to loss and trauma has also been found among another perhaps less likely group: repressive copers. A considerable body of literature documents that individuals identified as repressors tend to avoid unpleasant thoughts, emotions, and memories. … repressive coping appears to operate primarily through emotion-focused mechanisms, such as emotional dissociation… Emotional dissociation is generally viewed as maladaptive and may be associated with long-term health costs. However, these same tendencies also appear to foster adaptation to extreme adversity. For example, repressors have been found to show relatively little grief or distress at any point across five years of bereavement.… among a sample of young women with documented histories of childhood sexual abuse, repressors were less likely to voluntarily disclose their abuse when provided the opportunity to do so, but they also showed better adjustment than other survivors.” (1)

We are now learning that this type of coping strategy may also be effective because it keeps us from processing negative thoughts such as rumination. Rumination isn’t all bad as it has been linked to a part of the brain which may process solutions and goal attainment. Most of us engage in rumination because we believe it will help us solve problems and process information.

However, as with most everything, there are other factors to consider.

“Recent studies have shown that rumination is a powerful predictor of persistent post-traumatic stress disorder (PTSD). … The current investigation showed that rumination is not only used as a strategy to cope with intrusive memories but it also triggers such memories. Certain characteristics of rumination, such as compulsion to continue ruminating, occurrence of unproductive thoughts, and “why” and “what if” type questions, as well as negative emotions before and after rumination, were significantly associated with PTSD.” (2)

At this point, many of you may be saying, “Ok Boomer” enough of the ‘back in my day’ stuff. Things have changed. Particularly WorkSafe rules around horseplay in the workplace. None of your suggestions really apply to us and if we behaved like you did back in the day, we would be looking for a new employer.

Well, that may be true but there are a few new things that may help even in today’s difficult circumstances.

We know that hardiness, learned resourcefulness, internal locus of control, mastery, self-esteem and self-efficacy are all associated with mental health. Clearly, we need to be more aware of these characteristics and practice them on a daily basis.

It has also been suggested that a good sense of coherence (SOC) lowers the risk for developing PTSD.

Sense of coherence or SOC is a mixture of optimism combined with a sense of control.

The SOC has three main components:

1. Comprehensibility

2. Manageability

3. Meaningfulness

Comprehensibility refers to the ability to see things as orderly, coherent, clear and structured. The ability to make something structured out of a chaotic situation makes it much easier for us to understand and manage.

Manageability, has to do with the degree to which we might feel supported and that there are resources at our disposal. These resources are used to help manage the stimuli that we are constantly bombarded with. Formal resources might include things like dispatch, supervisors, police, social services or first responders, while informal resources might include things like family or friends.

Manageability also has to do with our ability to cope and solve problems and be willing to invest our time and energy to solve those problems. It is important to see those problems as a challenge rather than a burden.

Meaningfulness has to do with the extent to which we feel that our lives have some kind of emotional meaning or that we’re doing something important. (3)

In stressful situations a sense of coherence seems to have a moderating effect on health. People with high SOC seem to be more resilient under stress than people with a low SOC. The stronger the SOC the lower the level of symptoms and distress.

A lack of SOC is strongly and associated with anxiety, anger, burnout, demoralization, hostility, hopelessness, depression, perceived stressors, and post‐traumatic stress disorder. (4)(5)

There is one more important finding that may help you stay healthy. Recent research has focused on the role of exaggerated inflammatory responses in the development of PTSD. Something called regulatory T cells (Tregs), have been found to be altered in PTSD-affected individuals. Regulatory or ‘suppressor T cells are a subpopulation of white blood cells that modulate the immune system, maintain tolerance to self-antigens, and prevent autoimmune disease.

“Reduced levels of Treg cells have been observed following exposure of human participants to a laboratory stressor, and in male and female refugees with chronic PTSD.

Furthermore, reduced frequency of Tregs is associated with autoimmune diseases such as thyroiditis, inflammatory bowel disease, and rheumatoid arthritis, conditions for which individuals with PTSD show increased risk … Elevated levels of C-reactive protein (CRP), a clinically used marker of inflammation, have also been observed in individuals with PTSD.” (6)

An important factor determining the amount of Tregs, is the human micro-biome. The human micro-biome is another way of saying “all the micro-organisms in the human body.” These micro-organisms help us to metabolize food and drugs, fight off infection, and even produce hormones and neuro-transmitters to help us keep emotionally balanced.

In fact, they have been found to play a role in programming the hypothalamic–pituitary–adrenal (HPA) axis. The up regulation of the adrenals through activation of the pituitary gland and the hypothalamus is one of the key regulators of the stress response. This response is present in all stress-related disorders, including PTSD.

Recent studies have identified a combination of three bacteria (Actinobacteria, Lentisphaerae and Verrucomicrobia) that were altered in people with PTSD. Those with PTSD had substantially lower levels of these species, which led researchers to believe that it might be inflammation that contributes to whether or not one develops PTSD. To test this theory, researchers injected a dead immune-regulatory bacterium that increases Treg and anti-inflammatory cytokines into laboratory rodents. The results have prevented stress-induced increases in a PTSD-like syndrome in mice.

This may lead to specific medications that can be taken to protect against PTSD and other mental health disorders. But while we are waiting for that to happen, we should all understand that the human micro-biome can easily be altered with the use of prebiotics (non-digestible food substances) and probiotics (live, beneficial micro-organisms). Plant-based diets and high fibre diets are beneficial for a number of reasons and if they prove to be protective against mental illness and disease, so much the better.

It seems to me that back in my day we were fortunate. The amount of daily stress was greatly diminished due to the nature of our culture. The accidental benefits of freedom, strong social and work supports, a growth mindset and a fun-loving nature all helped us survive the toxic stress that we continually bathed in.

Today’s challenges are clearly more difficult as we work in an even more toxic environment. It is my hope that some of this information will help you to cope better and live healthier as you continue to look after us boomers.

About The Author

Mike Billingham has enjoyed a challenging 36-year career as a primary care paramedic, critical care neonatal, pediatric and obstetric paramedic, station administrator and educator.

References:

1) Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events?. American psychologist, 59(1), 20.

https://www.tc.columbia.edu/faculty/gab38/faculty-profile/files/americanPsychologist.pdf

2) Rumination in posttraumatic stress disorder. Tanja Michael Ph.D. Sarah L. Halligan Ph.D. David M. Clark Ph.D. Anke Ehlers Ph.D. First published: 13 October 2006 https://doi.org/10.1002/da.20228

3) What Does it Mean to Have a Sense of Coherence? Leslie Riopel. Positive Psychology Today. 28 08 2019.

4) PTSD in Paramedics: Resilience and Sense of Coherence. Markus Streb (a1), Pascal Häller (a1) and Tanja Michael (a1) DOI: https://doi.org/10.1017/S1352465813000337Published online by Cambridge University Press: 29 May 2013

5) Antonovsky’s sense of coherence scale and the relation with health: a systematic review

Monica Eriksson and Bengt Lindström. J Epidemiol Community Health. 2006 May; 60(5): 376–381. doi: 10.1136/jech.2005.041616

6) The Microbiome in Posttraumatic Stress Disorder and Trauma-Exposed Controls: An Exploratory Study. Sian M.J. Hemmings, PhD,et all. Psychosom Med. 2017 Oct; 79(8): 936–946.

doi: 10.1097/PSY.0000000000000512

7) Influence of diet on the gut microbiome and implications for human health. Rasnik K. Singh,1 Hsin-Wen Chang,2 Di Yan,2 Kristina M. Lee,2 Derya Ucmak,2 Kirsten Wong,2 Michael Abrouk,3 Benjamin Farahnik,4 Mio Nakamura,2 Tian Hao Zhu,5 Tina Bhutani,2 and Wilson Liao. J Translational Medicine. 2017; 15: 73. Published online 2017 Apr 8. doi: 10.1186/s12967-017-1175-y