'But we have this treasure in jars of clay to show that this all-surpassing power is from God and not from us. We are hard pressed on every side, but not crushed; perplexed, but not in despair; persecuted, but not abandoned; struck down, but not destroyed.' (1)

My favourite piece of resilience research (2) used the number of teeth retained by adults as a marker of resilience in a socially deprived, inner city community. Good dental health was an indication of parenting that had paid attention to children's general health and diet, which in turn was linked to family stability, employment, adequate housing and with belonging to a faith group. This study encapsulates many of the factors that influence resilience.

What is resilience?

Resilience was originally an engineering term denoting the ability of an object to spring back into shape. It was later appropriated by psychologists to refer to the human capacity to recover from difficulties.

It has two main elements: recovery, which is the ability to return to normal following stress and sustainability, which is the ability to keep going under stress. Rather than the more traditional medical method of trying to estimate risk, assessment of resilience looks at what enables people to cope when they have illness or encounter other potentially life-altering events and situations.

As a junior doctor on a general medical rotation, I found it fascinating to see how patients and their families reacted in different ways to apparently similar conditions and diagnoses. It was one of the reasons I moved into psychiatry.

When thinking about resilience from a Christian perspective, it is important to remember those words of Paul to the Corinthian church. When we know that trials and difficulties are normal for the Christian life and that God uses them for our good and his glory, we will not expect to be unaffected by stress or to always come through it unchanged. However, understanding what modern science shows us about human resilience can also help us to live lives worthy of God's calling.

Are children naturally resilient?

My interest in resilience came from studying children coming from very difficult and traumatic circumstances and finding that there were some who coped unexpectedly well. This 'ordinary magic', as Ann Masten (3) described it, is not automatic but depends to a large extent on good relational bonds in early life with at least one caring adult. The child can then develop the ability to regulate their own emotions and learn helpful coping strategies. The functioning of the hypothalamic pituitary axis and other brain processes involved in reactions to stress are influenced by early life experiences. Although there is always the possibility of changes in these processes because of the wonderful plasticity of the brain, they do exert significant influence on how a person reacts to life's stresses.

Sometimes the mechanisms children find to enable them to keep going when life is hard prove less helpful in later life. An extreme example is when dissociation (mentally shutting off from present reality) is a refuge from the emotional and physical pain of abuse, but in adulthood it prevents healthy processing of distress. Childhood abuse of any kind, including bullying, affects resilience and some ways of trying to relieve emotional distress such as self-harm and substance misuse (think of street children, many of whom use glue or other solvents) bring their own dangers and cause long-term damage to resilience.

Using our brains

Resilience does not require extraordinary intelligence, but simply 'a human brain in good working order and some knowledge about what is going on and what to do'. (4) In the long-term, cognitive ability may be affected by brain damage or disease, in the short-term cognitive processing can be impaired by lack of sleep, alcohol and other drugs, illness etc, so that the capacity for handling stressful situations is reduced. Resilience is a dynamic concept, not a superhuman power, and there are many circumstances that make it difficult to 'think straight'; it is important to be aware of our own vulnerabilities and not to expect to function effectively regardless of our mental state.

Normal cognitive development allows the mastery of skills, which is an important motivation in life from childhood onwards. If mastery is denied or hindered by neglect or adversity, then the sense of agency is limited and a sense of helplessness may prevail when trouble comes. This was demonstrated in studies of children raised in orphanages where they received physical care but no emotional nurture or stimulation; many remained apathetic and had great difficulty learning to function independently even when care improved. Michael Marmot's Whitehall studies showed an increased cardiovascular risk, not as predicted among those with the top jobs, but among the lower levels of civil servants. One of the theories to explain this, which is supported by other studies (though not all), was the discrepancy such workers experienced between responsibility to be productive and a perceived lack of agency, a sense of being able to affect things or to bring about change. Helen Keller, who was born blind and deaf, but with the help of an inventive and devoted governess went on to become a world-renowned speaker and writer said, 'A happy life consists not in the absence but in the mastery of hardships.' (5)

Working to maintain cognitive fitness is helpful to maintaining resilience. Continuing to learn, to develop new interests and to give time for reflection and to pray, can all help. Learning new things may get harder as we age, but the ability to see patterns, and to quickly identify solutions because of experience, may emerge as a skill to be drawn on and enjoyed. Achieving mastery ourselves may fade as a motivation but enabling others to master the necessary skills for them to progress can replace it.

The importance of purpose

To be resilient is to be motivated, to have purpose. Alim et al (6) concluded in their study of a high-risk population that 'Purpose in life is a key factor associated with resilience.' Viktor Frankl, a psychiatrist and concentration camp survivor, called the book of his experiences, Man's Search for Meaning because 'Life holds a potential meaning under any conditions even the most miserable ones.' (7) Those prisoners who lost their sense of purpose weakened and died very quickly, whereas those who retained hope tended to survive the longest. A recent BMJ editorial (8) was about hope as a therapeutic tool; patients look for hope as well as for understanding of their illness and likely outcomes whenever they see their doctor.

Our hope is in the Lord, and that should help to sustain us in difficult times. Even when we may not be able to fully share what we believe, we can impart some sense of true hope to our colleagues and patients when they express their underlying fears and concerns.

As the writer of Ecclesiastes insists, life without God is ultimately meaningless; in faithful obedience to him we find our chief end and purpose. (9)

Relationships matter too - with others and with God

Hope does not emerge from a vacuum. It is embedded in relationship. The importance of relationship for resilience has been noted in all the major reviews. Not only in the early years of development, but throughout life supportive relationships are vital. As those with religious faith tend to have more social support, some have seen this as the explanation for religion emerging as a potent positive influence on resilience. However, very often religion is associated with the active confrontation of problems rather than denial and avoidance. There is also the sense of meaningfulness given to life and even to adversity which comes from belief in God. As Glynn Harrison wrote in a recent Triple Helix article (10) 'A spirit of thankfulness acknowledges the sovereignty of God and asserts the dependency of his creatures. It positions grace at the very centre of our spiritual journey.' Furthermore, 'Psychologists are beginning to uncover how cultivating gratitude benefits mental health and well-being.' (11) Several studies have shown the benefits of being grateful, including increasing stress resistance.

So, is resilience the main goal?

The Bible tells us of many people who faced significant hardship and loss. The emphasis is not on how well they coped, (though we might well think of them as resilient) but how they coped as they trusted God and saw God's faithfulness to them.

Recognising the sovereignty of God and his purpose to make us for the praise of his glory (12) as individuals, but also as a community of his people, Christians will not see resilience itself as the ultimate goal, but spiritual growth as we 'make it our goal to please him'. (13)

'To him who is able to keep you from stumbling and to present you before his glorious presence without fault and with great joy - to the only God our Saviour be glory, majesty, power and authority, through Jesus Christ our Lord, before all ages, now and forevermore! Amen.' (14)

Evelyn Sharpe is a retired Consultant Psychiatrist