Introduction
Background
Negative emotions and adversities are expected to be encountered in our daily lives, though some people seem to navigate through adversities better than others. Similar to physical immunity, our mental space also has its protective mechanism, i.e., resilience. Though there is no consensus clarifying the definition of resilience, Vella, Pai, et al. (2019) suggested that resilience constitutes the occurrence of adversity and its mitigation in promoting positive outcomes. Following the process-based definition, it is debatable whether a resilient individual relies on their innate psychological trait or adaptive state when facing risks. Nonetheless, adversity becomes the hallmark of being resilient as a trait and a state. Pragmatically, both trait and state of resilience have a particular degree of contribution to promoting individual well-being. On the other hand, looking at the outcome-based definition, resilience is the bridge between risk or adversity and positive individual experience, advancing the emotive dynamics and the propensity towards positive outcomes. Thus, it is essential to initially define the boundary of adversity and positive outcomes before conceptualizing resilience.
Defining Resilience
The first part of investigating resilience is defining adversity, an interconnecting facade between external risk factors and internal subjective experience. Quantifying adversity requires an association between adverse life events and individual adjustment. A statistical magnitude exists for measuring negative circumstances and their relation to emotional saliency; however, adversity could also be denoted without referencing the statistical threshold. As such, adversity can be evaluated as the presence or absence of suffering in relation to difficulty, implying adversity is a general setback being encountered on a daily basis (Vella, Pai, et al. 2019).
The second part of evaluating resilience is setting a boundary to what a positive outcome means. As a generic reference, a positive outcome implies an adaptive momentum that allows individuals to recover from a negative setback. When challenged by risk or adversity in life, a positive outcome is plausibly explained as the capability to prevent mental illness (Vella, Pai, et al. 2019). The presence of adaptive momentum as a positive outcome enables an individual to maintain, regain, or surpass their functional state upon exposure to a negative setback. Having a broader perspective on adversity and positive outcomes poses particular merits, including leveraging the limitation of life-event quantification and avoiding too rigid of a formal definition, which potentially hinders looking at the blue-sky picture: resilience.
Delving into the definition of adversity and positive outcomes, we understand that resilience is paramount to adapting against negative setbacks in life. Bonanno (2008) reviewed several aspects of resilience and highlighted the difference between resilience and recovery. The connotation implied in recovery is the presence of pathological symptoms within one period of time, which gradually dissipates. Meanwhile, resilience describes the mental capacity to maintain the equilibrium of well-being in the face of adversity. Denoting that resilience is different from the absence of psychological issues, Bonanno (2008) further speculated that resilient subjects might have perturbation in daily functioning without succumbing to a disorder. Perturbations may vary from one person to another; to name but a few, the perturbation can manifest as sporadic preoccupations, restless sleep, nervousness due to certain stimuli, and sadness. However, Infurna and Luthar (2016) argued that resilience could also be observed in individuals recovering from psychological disorders, implying that resilience is not only a trait but also a necessary auxiliary functioning state to expedite the recovery. Bonanno (2008) also Infurna and Luthar (2016) brought into the table a continuum progression of how a resilient trait can intertwine with the recovery process, where a resilient state connects both ends of the spectrum. In their critical appraisal, Luthar, Cicchetti, and Becker (2000) emphasized the importance of drawing a boundary in defining resilience as a trait or state, where they proposed the state of being resilient as “a dynamic process encompassing positive adaptation within the context of significant adversity.” In easing the definitional burden, figure 1 illustrates the hypothetical remarks of how resilience as a trait and state contributes to recovering from negative setbacks in life. Resilience as a trait defines the scope of how a personality trait plays the role of a threshold against adversity in determining psychological outcomes. On the other hand, resilience as a state is akin to a buffer leveraging negative impacts by promoting the recovery process.
Constituents of Resilience
Rutten et al. (2013) argued that swift recovery from negative setbacks in life relies on three emerging psychological factors, namely secure attachment, positive emotions, and purpose of life. These psychological factors are the core domains enhancing general mental health, preventing disturbance of well-being upon exposure to adversity, and improving the overall recovery process. Throughout their psychological development phases, children derive their attachment to the caregiver as an internal working model. Such a working model is important to integrate external stimuli into internal perception, especially in understanding social relationships. Infant-parent attachment influences the emergence of an internal working model during the first year of life, which continues to evolve and then consolidate at the age of five (Rutten et al. 2013). Secure attachment perceived by children is internally represented as a mental image of ideal interpersonal relationships. Children with a secure attachment will perceive themselves as worthy, others as reliable, and the environment as challenging but manageable. Children with secured attachment are more inclined towards having effective self-regulation, the ability to understand their own and other’s emotions, and the capacity to manage interpersonal relationships (Atwool 2006).
Positive emotion extensively supports psychological well-being, whereas the increase in positive emotion outweighs the decrease in negative emotion in promoting mental health. Positive emotion is the required element to learn the ability to trust and display compassion (Rutten et al. 2013). Similar to its impact on general health, positive emotion is essential in recovering mental well-being. Positive emotions, even if they only occur temporarily, have a lasting impact in bridging resilient traits to improving life satisfaction (Cohn et al. 2009). On the other hand, negative emotions do not substantially alter the benefit of positive emotions (Cohn et al. 2009) nor the expected positive behavior over time (Nylocks et al. 2018). Inversely, the presence of positive emotion mediates emotion regulation against negative emotion (Waugh 2020). Furthermore, experiencing positive emotions has the merit of buffering the perceived adversity, where Waugh and Koster (2015) instigated elevated positive emotion as a strong determinant of distress recovery. The inclination towards experiencing positive emotions varies individually, but not to a great degree after controlling for social and interpersonal stressors. Rutten et al. (2013) surmised that positive emotion is rather well defined when taking into account person-specific environment and societal influence in explaining the subjective perception of positive stimuli. Culminating positive emotion is essential in aiding the coping process, which both, in turn, shall be reflected as a state of resilience (Tugade and Fredrickson 2006).
Moving beyond secure attachment and positive emotion, having a purpose in life offers a lasting positive impact compared to a fleeting pleasure (Rutten et al. 2013). A purpose in life leads to an eudaimonic pursuit of meaning and personal values. In the pursuit of meaning, eudaimonic motives reflect an individual approach focusing on the realization and flourishing of the perceived innate potential (Kaczmarek 2017). An overarching level of experience sustained by pursuing the purpose of life promotes well-being by improving optimism and reducing the risk of depression and loneliness (Kim, Salstein, and Goldberg 2021). When sensing the values and purpose in life, Rutten et al. (2013) suggested that religion and spirituality have a crucial part in their interplay in conferring resilience. Even though social interaction is the key element supporting well-being through a hedonic pursuit, religion becomes a supporting pillar of well-being for eudaimonic pursuit in a socially disconnected population (Chan, Michalak, and Ybarra 2018). Though it is arguable that both hedonic and eudaimonic motives have an overlap of pragmatic influences on realizing purposes in life (Disabato et al. 2016), it is conclusive that the meaning of life is particularly personal and bears a solitary burden. In lieu of dwelling on impractical behavioral conquest, such as promoting the pursuit of meaning, moderating the social environment is similarly beneficial to reconstructing the grand schema of self and the world, which shapes the positive emotional experience and sense of goal (Rutten et al. 2013).
Considering resilience as a fluid psychological state, several factors contribute to the dynamic of the human psyche. Precious and Lindsay (2019) proposed seven main pillars supporting resilience, which we can derive from three psychological factors introduced by Rutten et al. (2013). In figure 2, I deliberately annotated five pillars as a result of secured attachment, while the other two reflect positive emotion and purpose of life, respectively.
First, it is well demonstrated that a secure attachment between children and parental figures correlates positively with prosocial behavior (Gilliom et al. 2002; Viddal et al. 2015; Shi et al. 2020), mediated by the mental capacity to perform self-regulatory function (Heylen et al. 2016). Effortful control explains the degree of self-regulatory capacity to adequately respond to external and internal demands. Effortful control is a volitional capacity to generate an adaptive subdominant response, denoted as temperament regulation in children; this is closely related to emotion regulation, which we will get into later. The presence of effortful control determines temperament stability in children with the tendency to externalize problems (Stifter, Putnam, and Jahromi 2008), where aggression, delinquency, and hyperactivity are their dominant responses (J. Liu 2004). Children with secure attachments are more likely to exert effortful control and develop more amicable subdominant responses to override the dominant ones. Although Gilliom et al. (2002) only reported the association of secure attachment with self-regulatory strategy in boys and Viddal et al. (2015) further supported this clause by demonstrating a positive correlation between secure attachment and self-control moderated by gender, Shi et al. (2020) showed that in the adult population, the effect of gender in self-control is much less pronounced. It implies that the consolidation of self-control (Heylen et al. 2016) supported by a secure attachment produces similar results in both men and women. Using longitudinal data with two time points, Nair et al. (2020) found that effortful control in early adolescents correlates with their resilience at each time point but not across time points. This reflects the dynamics of both resilience and effortful control, both of which can change and consolidate over time. A similar finding was also reported by Eisenberg et al. (2009), indicating effortful control as a mediator bridging secure attachment and resilience.
Second, emotion regulation is an integrative part of developing a dynamic, resilient state. Previously, we have elaborated on how temperament regulation comes forth as a derivative of child-parent attachment, which in later life shall influence the emergence of a resilient state. Emotion regulation is a more specialized development enveloping both temperament and attachment as intrinsic and extrinsic factors, accordingly (Cassidy 1994). In the bonding between child and parents, children create an internal projection of the ideal world as their expected working models. These expectations reflect the child-parent interaction, starting from the first year of life and maturing over time. Children with secure attachment are more inclined to model after a responsive emotive signal, where they acknowledge that the parental figures and those around them will reciprocate with their emotional cues. However, children with insecure attachment expect that their immediate surroundings will only selectively attend to their emotions (Bowlby 1973; Hinde and Lorenz 1996; Bretherton 2013). The failure to provide adequate emotional responses will lead children into two major categories of attachment style, namely avoidant and anxious styles, expressing a polarized spectrum of emotion recall and processing. People with an avoidant attachment style lean towards avoiding emotional attachment, presenting with a dull recall of negative memories due to their inherent habit of suppressing thoughts and emotions. On the other pole of the spectrum, people with anxious attachment styles are more likely to recall a vivid negative memory. Both avoidant and anxious types exhibit poor and fragile emotion regulation strategies, exemplified by their reduced capacity to handle severely distressing and uncontrollable chronic events (Mikulincer and Shaver 2019). Meanwhile, children whose parental figures adequately respond to their emotional cues are more open to discussing their negative feelings, which in turn helps them develop a more robust emotion-regulation strategy (Waters et al. 2009). Through attentional control and cognitive reappraisal, an emotion-regulation strategy can reduce negative emotional responses and, therefore, promote resilience (Kay 2016).
Third, the coping mechanism allows mental tempering through exposure to daily stress. The formulation of a resilient state is not merely determined by positive encouragement from intrinsic and extrinsic factors but also by experiencing eustress resulting from daily stressors (DiCorcia and Tronick 2011). The presence of a healthy amount of daily stressors shall push an individual to cope and survive, thus allowing for the development of their regulatory capacity. DiCorcia and Tronick (2011) illustrated improving a resilient state in a similar fashion to preparing for a marathon; we push ourselves to our limit, and eventually, we shall break through the shackles. In a more specific context, exposure to eustress allows an individual to develop a coping mechanism to overcome the stressor. When looking at the continuum space of concluding perceptible negative emotion, there are two opposite polars of reconciliation and catharsis: one to diminish and the other to extinguish. Ong et al. (2006) argued that the presence of positive emotions reconciles negative emotions in eliciting resilience against adversity by utilizing mature coping mechanisms. Crane et al. (2018) further supported the argument by demonstrating three capacities required to foster resilience through an adaptive self-reflection, including coping resources, usage of emotional regulatory repertoires, and belief system on resilience itself. Practicing adaptive self-reflection necessitates five consecutive steps, starting from having an emotional awareness, identifying triggers, re-appraising the stressors, evaluating the response, and focusing on the future. The first three steps focus highly on the current situation, while the latter two focus on the developmental aspect. Having an emotional awareness implies being conscious of changes in response to triggering events. Identifying triggers is a discriminating process to understand the causal relationship between events and responses. Re-appraising the stressor is a learning phase utilizing emotional awareness and the ability to identify the trigger as the inputs, where an individual can generate a more suitable response by referring to the desired goal. Then, the response was evaluated as an emotionally detached re-experience of the overall situation, i.e., an exploration of how to improve the response efficacy. Lastly, focusing on the future emphasizes what can be done better in the future in case of similar triggering events (Goodvin et al. 2008; Hamarta, Deniz, and Saltali 2009). The learning phase and maturation of coping mechanisms upon exposure to daily stressors help an individual overcome adversities (Tronick and DiCorcia 2015).
Fourth, self-efficacy is a result of working-model formation during early infant life propelled by a secure attachment to the parental figures (Bender and Ingram 2018). Self-efficacy is a perception of the personal capability to obtain the desired goals, directed by self-referent expectancy and self-reflective thoughts (Bandura 1978). Self-efficacy is attributable to a particular task, where an individual may possess different self-efficacies for different tasks. Perceiving high self-efficacy helps one to bounce back after failures and maintain the operating effort, supporting an individual to sustain their performance under pressure (Heslin and Klehe 2006). People with high self-efficiency are more ready to receive negative feedback and strive to improve their capabilities. Meanwhile, people with low self-efficiency are more prone to be depressed or anxious when receiving negative feedback due to their assumption of incapacity and incompetence. In a previous mediation analysis, Bender and Ingram (2018) demonstrated that both self-efficacy and self-care are partial mediators connecting attachment style with resilience. Individuals with secure attachment styles lean towards developing a positive attitude, strengthening their beliefs on self-capacity. A firm belief in oneself is essential to generate higher efficacy in managing individual and social environments, resulting in resilient attitudes and behaviors. Slightly quoting from Bandura and Watts (1996), belief and disbelief in one’s capacity generate behavioral validation, implying a reciprocation between self-efficacy and the resulting behavior. Self-efficacy belief is a requisite to fuel affective, motivational, and behavioral mechanisms in difficult situations, which in turn promote resilience (Schwarzer and Warner 2012).
Fifth, social support is closely related to social competencies stemming from child-parent attachment; a positive working model on social environment creates a stronger belief in supporting resilience. The presence and absence of parental figures determine the development of the working model in a child, where a secure attachment fosters a belief in social support as a positive working model. Meanwhile, insecure attachment causes fear of intimacy and a tendency to avoid social connection as a negative working model. The perceived working models are crucial in the maturation of social competency, which Mallinckrodt and Wei (2005) summarized as the required skills to develop and maintain supportive social relationships. Two building blocks of social competencies are social self-efficacy and emotional awareness, i.e., the perception of being capable of forming new connections from initial acquaintances and the capability of discerning one’s own and others’ emotions. Individuals with a positive working model tend to demonstrate better social competencies, whereas individuals with a negative working model are lacking in either one of the social competencies. People with an anxious-type attachment style suffer from a higher degree of social uncertainty, denoted by the perception of powerlessness and the inability to develop and maintain close relationships. On the other hand, people with avoidance-type attachment styles actively repress their conscious perception of emotion, displaying a higher degree of affective disinterest (Mallinckrodt and Wei 2005). Maintaining social connection is paramount to the accessibility of psychological and material resources provided by the social network, benefiting an individual’s capacity to handle adversities (Cohen 2004). In their commentary, Sippel et al. (2015) argued that social support is a necessary factor to moderate genetic and environmental vulnerabilities, which aid an individual to display state resilience. The availability of social supports can nurture stress-regulating behavior, including but not limited to improving self-confidence, preventing risky behavior, fostering mature coping mechanisms, and promoting emotion-regulation strategy.
Observing Trait and State Resilience
Resilience, both as a trait and state, contributes to maintaining psychological well-being by reducing or buffering the negative effects of experiencing adversities. Hu, Zhang, and Wang (2015) argued that resilience would be best observed as a psychological trait due to its innate and stable nature. Based on resilience traits, it is possible to classify people into groups. However, observing resilience only as a trait will subsequently underestimate the actual occurrence of resilience in the population, where Gheshlagh et al. (2017) demonstrated in their meta-analysis that resilience as measured with CD-RISC1, RSA2, ERS3; their findings presented with high heterogeneity, which indirectly implied difference in instrumental measurements of resilience. On a further note, Gheshlagh et al. (2017) and Hu et al. (2015) suggested that the level of resilience positively correlates with reduced depression, anxiety, and negative affect. Research focus on either type of resilience would be a matter of practicality, i.e., researching resilient traits is better intended for grouping the population based on their level of resilience so that clinicians can prevent mental health issues in people with low resilience (Hu, Zhang, and Wang 2015). On the other hand, focusing on a resilient state would allow the establishment of a mental health policy that can provide support to improve the resilient state. In this investigation, the author is interested in evaluating resilience as a state and its relation to adversity, medication uses, mental health policy, and psychological outcomes.
1 Connor-Davidson Resilience Scale, containing 25 items addressing factors contributing to resilient state
2 Resilience Scale for Adults; containing 33 items addressing self-sufficiency, family coherence, and social support
3 Essential Resilience Scale; 15 items mostly measuring resilient trait
Key Issues
Resilience is the adaptability of an individual to adversities in routine or occasional circumstances, factoring the biopsychosocial-ecological system supporting multiple promotive and protective factors and processes (Ungar and Theron 2020). Resilient individuals have three essential psychological characteristics, including secure attachment, experiencing positive emotions, and having a purpose in life (Rutten et al. 2013). Resilience is a dynamic process regulating the homeostatic plasticity (Vella, Pai, et al. 2019; H. Liu et al. 2018), which reflects a desirable mental control, emotion regulation, coping mechanism, self-efficacy, a sense of purpose, positive affect, and social support (Precious and Lindsay 2019). Resilient individuals are more likely to bounce back from negative events, either by promptly adapting or quickly recovering, to accomplish a more favorable mental health outcome (Ungar and Theron 2020).
Individuals with resilient traits have an overall better mental health, indicated by higher life satisfaction and positive affect. Accordingly, the lack of resilient traits also contributes to heightening depression, anxiety, and negative affect (Hu, Zhang, and Wang 2015). Several studies have also replicated the extensive impact of resilience in lowering depression (Nakazawa et al. 2018), anxiety (Ran et al. 2020; Schiele and Domschke 2018), and burnout (West et al. 2020; Luceno-Moreno et al. 2020). Intriguingly, burnout has been established as a common association between depression and anxiety (Meier and Kim 2022; Koutsimani, Montgomery, and Georganta 2019), suggesting a generic yet distinctive process in relation to mental resilience (Luceno-Moreno et al. 2020; Serrao et al. 2021). In situation-specific distress, e.g., the COVID-19 pandemic, individuals with higher resilience can adapt better to the abrupt changes, reflected by lower trepidation, reduced anxiety, and attenuated depression (Barzilay et al. 2020). In Indonesia, the COVID-19 pandemic has caused a multitude of mental health issues, especially during the large-scale containment, which halted economic activities, mostly impacting those in the mid-low socioeconomic stratum, and hindered social activities, resulting in loneliness and, in some cases, social dejection (Tampubolon, Silalahi, and Siagian 2021). The pandemic aggravates the mental health situation in Indonesia, where previously, among older adults, 46.28% experienced stress, and 31.72% felt depressed (Hanum, Utoyo, and Jaya 2022). Although the government of Indonesia implemented The Mental Health Act in 2014, the resources and facilities are not widely available (Tampubolon, Silalahi, and Siagian 2021; Hanum, Utoyo, and Jaya 2022). Several online mental health services have been spurred during the pandemic, but further regulation and mitigation from the government are necessary to abate the spread of mental health problems (Ifdil et al. 2020), i.e., by establishing a government-verified digital counseling platform, multi-stakeholder mental health support program, and improving the accessibility of mental health services in the primary health care(Tampubolon, Silalahi, and Siagian 2021). Considering the intricacies between policy-driven action, resilience, situational changes, depression, anxiety, and burnout, the upcoming investigations will be mainly concerned with unraveling the question:
“What is the long-term effectiveness and cost-effectiveness of public health policies to maintain mental resilience amidst adversities, especially regarding their impact on depression, anxiety, burnout, and related medication use?”
Research Questions
Objectives
General Objectives
This research aims to delineate the influence of state resilience as a buffer of general health stressors in eliciting depression, anxiety, and burnout.
Specific Objectives
This research poses five specific objectives, each is focused as a separate investigation:
- Systematically find the required modelling parameter through a scoping review
- Evaluate the seasonality of psychopharmaca uses
- Extract the temporal health parameter by examining the annual mental health profiles
- Measure the cost effectiveness of policy interventions affecting individual resilience
- Evaluate the output parameters through a large-scale survey
Appeals
This research focuses on the data mining process, especially to generate new insight and knowledge (knowledge mining). The tools used in this research shall be free to access under an open-source license, with some restriction to the source code of a more specific use cases, which will be protected under a closed-source license. The highlight of the proposed model is to use agent-based model as a general modelling framework using a graph object as its input. The following subsections shall further elaborate how the general framework and knowledge mining process can be beneficial for the institution, researchers, and general audiences.
Appeals to the Institution
Firstly, this research aims to disentangle the general framework of agent-based modelling in a graph object. The general modelling framework will be useful in various cases representable as a graph object, especially a knowledge graph. This framework is beneficial for the institution, since a patent for specific use cases would be applicable.
Appeals to the Researchers
Secondly, for researchers, the use of general modelling framework will aid in the modelling workflow. The agent-based model can be treated as a singular building block of an analytic pipeline. This will aid the researchers in generating a more flexible model by incorporating the general modelling framework.
Appeals to the General Audiences
Thirdly, the general audiences will gain benefits from the knowledge mining process. Generally, this research will highlight effective countermeasures against psychological stressors and psychological disorders. Furthermore, this research will yield an insight regarding improving the resilient state.