Real Resilience Refuses to Tolerate the Intolerable

How a dysfunctional relationship with resilience impacts healthcare

Content warning: This article opens with a discussion of suicide. If you’re not up for that today, either skip this article or the first paragraph. 

---

On April 9, 2020, Dr. Lorna Breen called her sister. She couldn’t get out of her chair because she was nearly catatonic. She hadn’t slept in a week. She had been working well past the 12 hours she was scheduled to work because critically ill patients just kept coming. There wasn’t enough PPE, oxygen, beds, or help. She, herself, had just had COVID and quarantined for 10 days. Despite returning home to Virginia and seeking psychiatric care, seventeen days later, she died by suicide. We know her story because her sister and brother-in-law have started an organization to change laws that increase doctors’ fears that they will lose their medical license and/or credentials if they seek mental health treatment. However, even before the pandemic, 400 physicians committed suicide each year. A former colleague of mine committed suicide during the pandemic as well. 

Doctors (and all healthcare staff) more than demonstrated their resilience during the pandemic. They were the picture of withstanding difficult or impossible situations through self-sufficiency and individual toughness. In fact, they are amongst the most resilient professionals in the workforce. If individual strength was all it took to overcome adversity, doctors would have done it. Our training, while sometimes damaging, was effective at creating mental toughness, grit, and the ability to endure difficult circumstances. However, the doctors are not alright. My work in healthcare has caused me deep distress. I would call it heartbreak. I know I am far from alone. Many of us were burned out before COVID started, but psychological disconnection, frustration, compromised decision making, and working under pressure were cited as additional causes of the deterioration of mental health during the COVID pandemic. That clinical language doesn’t capture the isolation, overwhelm, and despair of three years in crisis mode. Cynicism and detachment became common coping strategies, which physiologically makes a lot of sense when the stress one’s body is under tells your nervous system that this is a life or death situation, but also leads to loneliness, isolation, and feeling out of control. 

Some institutional support services existed, but most felt like just another thing to do either when you were already overwhelmed at work or something taking time away from recovery time at home. Research indicates that I was not alone in feeling that these programs usually lacked “commitment, rigor, and sustainability”. Unfortunately, isolation and loneliness are amongst the most damaging feelings when one is struggling as we need physical contact and presence to heal from stressful situations. Indeed, isolation leads to changes in the brain which can cause thoughts to be more inward focused than outward focused. I suspect that anyone who has struggled in the past knows that being stuck in your own thoughts in such situations is rarely helpful. In fact, as Soraya Chemaly put it in her book, The Resilience Myth, “If resilience has an opposite, it’s not weakness or dependence, it’s loneliness.”

I learned of The Resilience Myth by

Soraya Chemaly

from her interview with

Courtney Martin

. Chemaly argues, effectively, that our ability to withstand the many interpersonal, political, and ecological challenges we face today has much less to do with our individual toughness and perseverance than our connections to others and our ability to provide and receive mutual care when we, inevitably, face setback, failure, or loss. 

When I think back on my experience during the pandemic, it is a feeling of abandonment that stings the most. We were called “healthcare heroes”. As Soraya Chemaly put it, this “normalized demands of superhuman performance” rather than inspiring government, healthcare organizations, or even many friends or neighbors to provide meaningful support.  Resilience is considered a universal good. Certainly, bouncing back from adversity is a necessary skill. None of us live friction-free lives. However, every skill and gift has its dark side. Our current emphasis on a very narrow form of resilience, both in medical training and societally, reduces our capacity for human connection and our ability to challenge dysfunctional and harmful systems. 

Mind Over Matter

As I have written about before (here and here), much of medical training is about learning to “soldier on”, to power through your body’s physical and emotional needs. There is value in this. There are times when lives depend on your ability to focus and perform your best even though you are hungry, tired, grieving, or overwhelmed. However, ignoring your body and pushing past those needs persists even in situations where you are just regular busy, which is nearly always. Chemaly explains, “An essential element of any mental toughness program is learning to ignore physical pain and emotional distress. People who don’t, won’t, or can’t do this are somehow inferior.” I would argue that a substantial portion of medical education is a “mental toughness program”, with particular focus on learning to ignore emotional distress. 

The dismissal of people who don’t, won’t, or can’t compartmentalize their pain and/or emotions is significant in medicine. I notice this with the explicit and implicit messages to toughen up in training, professional norms after completing training, and in the harshness of my subconscious reactions to certain patients in distress. While we are taught to ignore pain and emotional distress (both in ourselves and others), we are not taught how to replenish and nourish ourselves, show ourselves compassion, or lay down heavy emotional burdens.

We all understand that though we can ignore our physical and emotional needs in the short-term, we do so long-term at our peril. Many physical and mental health problems follow. I don’t think we realize how this interferes with our ability to empathize with others. A system that rewards “self-sufficiency, limitless positivity, and individual strength” diminishes the experience of those who are struggling. Often what many call optimism is, as Chemaly says, “a serious misnomer because what is being demonstrated is denialism, entitlement, and narcissism at scale. In this thinking, positivity means minimizing truth, history, and the advantages of power. It makes it probable that you ignore wider circumstances enabling your positivity, and shame and blame others who don’t share your good fortune.” 

Now, imagine this in a patient care setting. In general, doctors are much more likely to be white than not white, rich than not rich. Many of us are people who as football coach Barry Switzer once said, were born on third base but think we hit a triple. When we don’t recognize the advantages we have and think that we have gotten where we are through “mind over matter”, it can leave us feeling rather merciless toward those who were dealt a different set of cards. In my practice, I think of patients with chronic pain, substance abuse, or people who don’t follow up with a primary care doctor or specialist (often for a good reason like the cost or risk of losing one’s job). Like I said, doctors are often unsympathetic, to put it mildly, (perhaps a more accurate word rhymes with glass bowl), in circumstances such as these. 

In a field where care for the ill and disabled is, well, basically the whole point, Chemaly explains, “Mind-over-matter resilience is replete with scorn for “unfit” bodies, quickly making ableism foundational. This framework creates a fundamental structural problem for resilience: systematized cultural disdain for bodies, their needs, and the people who care for them. This makes it easier to subject bodies to brutalization and to minimize our material needs: food, water, care, and time to heal.” Imagine this compounded day over day, year over year, as all of the patients with chronic diseases deal with “healers” who essentially think they need to “suck it up” and overcome their need for rest or their desire to live with less pain. The relationship becomes adversarial quickly. 

Resilient physicians often think they have control over more than they do. In medicine, despite what our rational minds say about relieving suffering and curing disease, the real goal is to prevent death. When the real goal is preventing something that’s inevitable, it’s not a recipe for well-being. In this case, the positivity and sense of self-efficacy can “lead people to see themselves as more compassionate, talented, and capable than they actually are. They also tend to believe they have more influence and control over outcomes than is actually the case.” This leads to physicians thinking they are treating patients better than they are, but also leads them to taking patient deaths and bad outcomes especially hard and feeling responsible for many things that were beyond their control. 

The Resilience to Tolerate the Intolerable

One sneaky way that the promotion of resilience as a virtue serves the powers that be is through the strong linkage between resilience and productivity that has developed. Oftentimes, hospital wellness programs become what

Alicia Kwon

referred to as extractive wellness. This basically looks like “we want you to feel good enough that you can continue to produce for us”. Similarly, our current iteration of resilience often assumes conformity in the response. Chemaly shares the story of two children who were at Uvalde during the school shooting. One returned to Uvalde for school and the other went to a different school. The first was portrayed as resilient, whereas the second was not. However, that one data point tells us very little about which child will successfully overcome adversity. 

Displaying resilience has come to mean a standardized, expected response to adversity. It has come to mean returning to your “baseline” quickly, conforming to societal expectations, rather than adjusting to your new reality in your own way. However, being resilient doesn’t always mean being under control. Often when we have trouble managing our behaviors and our reactions, it’s not just about self-control and maturity. “It’s often the case that they (children) are asking for something: attention, help, quiet. Cheery children who diligently apply themselves might not feel safe but have instead learned to ignore their feelings and needs to do what they think will make the adults around them happy.” This is definitely a behavior that many of us carry into adulthood, I also long for attention, help, or quiet or someone to see that that’s what I need when I don’t realize it myself. We continue ignoring our feelings and needs to make others happy, often to the point that we no longer know what we need to feel safe.  

Teens and young adults often show their resilience in ways that make even my generation, older millennials, uncomfortable. They are faced with many crises that their elders were unwilling or unable to deal with. Rather than tolerating the intolerable, they call attention to these problems and show their feelings of “loud despair, emotionality, and rejection of norms is that their way of being resilient is having a specific effect: it makes them ungovernable.” 

This is what the healthcare system needs from physicians now. It needs us to become emotional, to become ungovernable. It is not natural for us to do this. We are champions of stiff upper lips, grinning and bearing it, but there are few things less tolerable than interacting with our healthcare system now for patient or provider. For patients, the cost is exorbitant, the results are often unimpressive, and all of that with a side of casual, cruel dismissal at the hands of an overwhelmed, emotionally unavailable doctor. For doctors, the task list is impossible, the administrative burden is absurd, and the emotional cost is gutting. If we had arrived in our current state of healthcare suddenly, we would be protesting in the streets. In fact, that was the one thing that kept me going through the hardest days of COVID, was the thought that surely this, THIS, would be a big enough crisis to prompt action. That was the last and biggest abandonment of my COVID experience, that nothing was learned and nothing would change. 

In a study of abusive relationships, researchers found that many valued personality traits like empathy, hope, resilience, and acceptance actually increased the likelihood that people would stay in abusive relationships. Forgiveness increased the likelihood that abuse would persist. Similarly, hope, acceptance, and resilience cause us to think that we can make incremental, gentle policy changes rather than demanding a radical overhaul to how healthcare training, service provision, policy, and payment happen. 

Real Resilience

Physicians have learned the same lessons the rest of us have, that we always need to be self-sufficient, strong, mentally tough and positive. However, these traits don’t arise from a place of health, rather, “They are ultimately based on the belief that you cannot trust or rely on anyone else, certainly not your society to nurture and care for you.” as Chemaly points out. Surprisingly to doctors, but unsurprisingly to everyone else, the way to heal doctors is the same way you heal everyone else. Our current view of resilience, “...makes no demands on anyone, erases social context, and absolves us of the responsibility to care for one another.” This idea that we shouldn’t rely on others, that no one owes us anything and we owe them nothing as well, is the source of problems from individual loneliness to the extinction crisis, and is not how we’re meant to live.

The research bears this out. Angela Duckworth, who is the researcher who pioneered the concept of “grit”, takes issue with how it is commonly portrayed in the media and in educational programming. “Gritty people are more dependent on other people, not less. They rely more on their coaches, mentors, and teachers. They are more likely to ask for help. They are more likely to ask for feedback.” Chemaly echoes this, saying, “Being resilient in healthy and positive ways means accepting that resilience can coexist with wanting and needing care, affection, respect, and love.” 

This feels so foreign to how we relate to each other in medicine, where the implicit, if not explicit messages tell you that you need to be perfect and invulnerable. I recently listened to a webinar about clinician wellbeing during COVID. During the meeting, one idea nearly brought me to tears. It is so simple, sometimes the agenda of a meeting may need to change to address people’s emotional lives and stress rather than simply the next quarter’s work schedule or policies and procedures. This costs leaders nothing, but both helps employees feel seen and heard and gives leaders a more accurate view of the challenges staff are facing so they can be addressed. This fits with what Chemaly found as well, “When you allow yourself and others to be pessimistic, to grieve or be sad, you build pivotal resilience tools for you and those around you. When you validate a person’s pragmatic pessimism, you show that you are listening and care deeply about the person’s well-being.” 

Chemaly notes that research indicates that most people are inherently resilient, “The question isn’t how we can help children learn to be resilient but what are we doing, as a society, to undermine their well-being and innate ability to adapt.” Of course, this doesn’t apply only to children. How can we stop undermining the well-being of all who interact with the healthcare system, patients and providers alike? The entire healthcare system rests on the resilience of healthcare staff who have been continually asked to do more with less for the entirety of my twenty year career and likely much longer. The irony is that the nurturing relationships that we have been told we are too busy for or don’t need are exactly what leads to a sense of self-worth and purpose that allows us to take risks and truly confront the challenges we face rather than avoiding them or playing small. 

Sharing our stories is the first step of building beyond self-care and toward true community care. Chemaly says, “...sharing our personal stories helps to diffuse anxiety, stress, and fear because we aren’t bearing the burden of hardship alone. But the purpose of personal narratives isn’t simply to make us feel good about ourselves. It’s also to communicate with others, form strong bonds, and, ultimately, cultivate empathy, cooperation, a shared knowledge. When we listen to or watch sympathetic stories, oxytocin, the hormone of love, compassion, and empathy, surges in us.” 

I can speak to this from experience. Last fall, I went on a wilderness fast, both before and after we sat in council, sharing our stories without interruption, without advice, and with a little reflection from our group leaders. At the beginning of the event, there were a few people who I either felt I had little in common with or even felt annoyed by. By the end of the week, after having come to understand each person and their struggles as thoroughly as you can in a week and a half, I hold them all with love in my heart. 

Good relationships are vital for resilience. Children who had adverse childhood events (ACEs), but had an adult who was invested in them were far more likely to have a good life outcome than those who had no ACEs, but also had no adult invested in them. This too, I suspect plays out throughout our lives, but maybe not to the same magnitude. This is likely a big part of what made COVID challenging for all of us. Our relationships either dissolved or were mediated by technology instead of touch. It was hard for us to understand the physical and psychological importance of actual physical presence to our wellbeing, but now we do know and we can set up our communities differently.

Self-care is necessary for those who cannot get their needs met through community care, but now we must re-establish community care where it has been lost. Steph Beecher, the basic needs coordinator at the University of Iowa describes community care like this, “Community care transcends the realm of individual acts of kindness. It embodies a culture of empathy, solidarity, and mutual support within our neighborhoods, our academic institutions like the UI and our social circles.” How do we bring community care back into our daily lives?  (From From Self-Care to Community Care: Fostering Well-being Together)

• Active listening: Listen to others without judgment. It can be helpful to ask directly if people would like advice or simply a listening ear. Asking thoughtful questions helps to build connections. Unsolicited advice often lands as criticism. 

• Offer support without prompting: If you know someone is dealing with a health crisis, a death in the family, mental health struggles, or just a general rough time. Don’t leave it open ended, “Let me know if you need anything”. Show up with what you would want in that situation, use one of your unique gifts to brighten their day, or just ask if they would like you to simply be present without expectation.

• Engage in acts of kindness: In my neck of the woods a random snow shoveling is sure to brighten someone’s day. 

• Participate in community projects: What’s important to you? Animal welfare, environmental stewardship, food insecurity, supporting the unhoused? People in your area are probably already working on these issues. How can you join in? Most of us are feeling overwhelmed these days, so start small and simple. 

• Create supportive spaces to share thoughts, feelings, and struggles without judgment. 

• Cultivate empathy: As noted above, sharing personal stories helps build understanding. 

• Celebrate achievements: Recognize the contributions and successes of community members. It feels good and helps us realize when we are making an impact. 

• Prioritize well-being over productivity: Can you even imagine a healthcare industry or society that does this?  

The era in which we can expect individuals to cover for failing systems through sheer willpower is long past. Solving the crises we face requires us to weave ourselves together again, to rely on each other. We need to change the stories we tell ourselves about asking for help and about who succeeds at overcoming adversity. Am I more resilient if I grit my teeth and return to a career in medicine or if I step out into the unknown to find something different? Am I more resilient if I continue to work in a field that is breaking my heart for a secure income or if I rely on others for financial help? To be honest, typing that last question makes my skin crawl just thinking about it. I don’t know the answers yet. How do we break out of a resilience that is isolating, constricting, and fragile into a resilience that is interconnected, difficult to control, and won’t tolerate the intolerable? 

---

One way I’m trying to build interconnections is to practice giving and receiving help. In work I’ve done with a past guide of mine, we created “labs” where we intentionally created situations that were low stakes, but pushed emotional buttons. For example, I learned that I can tell people when I am angry or frustrated. The sky did not fall and I learned that the reason they were doing things was very understandable and that often they were open to doing things differently once they knew it bothered me. In retrospect, asking for help would have been a big challenge in that regard. Honestly, I’m not sure I would have been ready for it then, but I’d like to try now. I’d love to have you join me or contribute ideas for how I/we can practice receiving help. Right now, I’m committing to simply accepting any help that is offered (that I actually want to receive) rather than dismissing it. Asking for someone to pick up kids from summer camp, asking for donations or to borrow a small amount of money would also work that muscle. Even those feel pretty edgy to me. How about you?