Monday, 5 October 2015

Beware of "Resilience"

Why has resilience become such a big buzzword in social science and even in social epidemiology? In 2003 or thereabouts a group of us formed a research network on "Resilience and Capability" funded by the ESRC. Even at that early point there was quite a story attached. It took them ages to decide whether to fund us or not, and this turned out to be because, naively, we had not in our wildest imaginings realised what the topic was supposed to cover. The "call" had come out in 2002 just after 9/11 and was meant to attract proposals dealing with civil defense. The kind of resilience the funders were interested in was how cities, for example, might be prepared to resist the effects of terrorism.Our group's theory expert was Ingrid Schoon and our methods expert Amanda Sacker. They had been developing a model of "Risk and Resilience over the Life Course" in a previous project. Ingrid wrote a book Risk and Resilience which is highly recommended. We did have 2 project leaders, Rich Mitchell and Sarah Curtis, who, as geographers, knew about urban processes. We were accused by ESRC of not being sufficiently interested in work and employment despite the group including Stephen Stansfeld, one of the world leaders in the social psychology of work. Our expert on later life was David Blane, who, like Stephen, has a medical training and is interested in biological processes of resilience and vulnerability. And our public health leader was Margaret Whitehead. I told someone the other day that I felt like an impresario in Hollywood putting together an irresistible cast for a movie. And it was indeed a fantastic group, supported also by people like Dick Wiggins and Danny Dorliing. As we later found out, the ESRC despite their original plan, just could not resist it.

Anyway the point of this is that in 2002-3 Resilience in terms of a human characteristic was not on anyone's radar, or at least not powerful people with money. Sometime shortly after the end of the research network, Michael Marmot pointed out to me that "everyone was talking about Resilience". And at a similar time, Capability started to be a big word in social epidemiology as well. In the Network, we all read Amartya Sen's work on it and used his ideas to guide that bit of the work. My own rather basic idea was that over the life course people who passed through "resilience-promoting environments" in their family, neighbourhood, school and work, had strengthened levels of capabilities to "live a life they have cause to value" in Sen's words. For example, one way we tested this was to see whether people who had experienced more warm relationships with their parents (fathers were just as important as mothers) had a more "securely attached" way of looking at the world. They did, and this seemed to also help the securely attached people to reach the higher levels of the Civil Service in their career. But secure attachment was not important for everyone, and this is a vital point. It only made a difference to people who had also not had an elite type of education.

This result (which I am using here as I worked on this paper myself, in contrast to the vast majority of papers from the Network, as I was really the kind of administrator who helped to make sure the bills got paid and everyone had enough sandwiches at the Network meetings) highlighted a couple of important issues. The first was that resilience is only important in the presence of adversity. We had quite a lot of discussion about this, and Ingrid distinguished several different definitions of resilience, of which this was the one we adopted. I thought it was important to distinguish it from just any kind of beneficial experience over the life course. I was worried: how could we distinguish between a resilience factor and the simple fact that people who experience only 2 adversities will do better than those who experience 3? This is the well known  "accumulation" model in life course research. We didn't want to do just more of that (although it was not quite such a cliche in 2003).

So if someone has experienced poverty in childhood and a stressful job, they will tend to have worse mental and physical health than someone who only had poverty in childhood.But does this make a financially secure childhood a resilience factor?  No, it is only a resilience factor if it is more important to people who have stressful jobs than it is to those with better jobs. It is what is called an interactive rather than an additive relationship. Lets say childhood poverty and job stress each take a score of 1. In an accumulative relationship between the 2 factors, the risk of mental ill-health (lets say) would be 0% in someone with a secure childhood and a nice job,  50% in someone with either a secure childhood or a nice job and 100% with a poor childhood and a stressful job. If childhood financial security is a resilience factor someone with a stressful job but a secure childhood would have a zero risk of mental ill-health.

Accumulative relationship

Childhood
Job

Stressful
Not stressful
Poor
100%
50%
Secure
50%
0%


Childhood financial security is a resilience factor

Childhood
Job

Stressful
Not stressful
Poor
100%
50%
Secure
0%
0%


The second point of debate within the Network was the role of childhood experiences and parenting. The paper I worked on just happened to include data on childhood experiences. But I confess that I also have a bit of a bee in my bonnet about this kind of thing. Ingrid was not having any of that! I remember her phoning me on my mobile in the middle of Marylebone High Street to straighten out some of my ideas. Similarly, Margaret was very concerned that resilience was being used as a sop or a fig leaf, as some of the people from the WHO that she was working with had feared. Ingrid and our colleague Jenny Head were concerned about "parent-blaming". They were quite clear that resilience could be fostered at any time in the life course by the right kind of environment: school, workplace, neighbourhood for example.

One implication of this kind of thinking for policy is that a resilience-promoting environment is in fact most important for people with the most adversities in the rest of their lives. It is the total opposite of what tends to happen in real life. A good school is most important for children with families suffering the effects of low income, or parental ill health, or substandard housing. Facilities for maintaining a social support network such as free efficient public transport (we used the example of the Croydon Tram) are most important for people with mobility problems for whatever reason. The accessible low-loading feature of the tram wouldn't make much difference to people who had cars, or could hop on and off of classic buses, but a huge difference to those with prams, in wheelchairs etc.

What turned out against our expectations not to increase resilience in the face of such adversities as poverty and the onset of chronic disease was the provision of services in the short term. David Blane, Gopal Netuveli and Zoe Hildon  found that older people whose health began to be affected tended to maintain good mental health if they had strong, long standing social networks. The key to this seems to have been that they were enabled to maintain a firm identity that did not revolve around the illness or disability. For example someone who developed arthritis would not become "the arthritic lady" but "our community festival organizer Barbara who has developed arthritis". Joining a patient support type group did not have the same effect. Margaret Whitehead and Krysia Canvin found, alarmingly, that even Sure Start Centers were sometimes shunned by the poorest mothers for fear that social services would remove their children.

How common was resilience in our studies? Using various different sources of data we concluded that in the face of a major adverse even such as the loss of a loved one, unemployment or the onset of a serious illness around 20% of people could "bounce back" fairly quickly. It is much harder to talk in this kind of way about resilience in the face of life long adversities.Because, as already pointed out, once an individual gets started on an adverse life course, the way social institutions work is not to try and provide "springboards" to remedy the problem, but to pile one adversity on top of another.

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