In this post, I discuss an aspect of psychiatric assessment and management that can guide us towards more effective treatment for our patients. In a word, it is patient “resources,” a relative of patient “strengths” and “protective factors.” The three terms – resources, strengths, and protective factors – are sometimes used as synonyms but, although related, they are not identical. I prefer “resources” because “protective factors” and “strengths” both at least partially convey they are 1) not modifiable rather than frequently modifiable, 2) internal rather than both internal and external, and 3) currently deployed rather than either currently or potentially deployed. Resources can be understood as the most comprehensive, and thus useful, term. Consider these simple examples to see how the concept of “resources” best expands consideration of treatment interventions.
- I work with my later-middle-aged patient with depression and care-taker burnout to help her engage her siblings to share in the care-taking of their father with dementia. We do some role-playing on how she can assertively request that she and her siblings divide up the days of the week on which they manage their father. In this case, her siblings are a resource. Are they a strength or protective factor? Those words don’t seem to be reflective of their role.
- A patient with a history of childhood abuse deals with chronic PTSD and depression. However, she does not display borderline personality features and shows resilience in fighting her way through life despite her myriad symptoms. In this case, her personality trait of resilience is all three: a strength, protective factor, and resource. But even so, when characterized as a resource I am more likely to consider ways of deploying it more effectively to tackle current challenges. Viewed as a protective factor or strength, resilience seems more like an unmodifiable personality feature. We’re happy it’s there, but what else are we to do with it?
- A patient with traumatic brain injury has parents who have both financial resources and the time to drive him to his clinic appointments. However, because of the patient’s impulsive, rude, embarrassing, and at time intimidating behavior, his parents are experiencing caregiver fatigue and starting to distance themselves. I’m alarmed though not surprised by their behavior and work with them to find sustainable ways of being there for the patient. The term resource allows me to see more clearly that the parents’ relationship with their son needs to be nurtured.
To summarize, the assessment focus should be resources that are modifiable, internal and external to the patient, and those that are currently deployed and those that can be – with a little help and arm-twisting – potentially deployable. This aspect of the assessment is done in conjunction with assessment of risk factors, many of which are also modifiable. So, I imagine myself seeking to quash down risk factors and raise up resources.
List of Resources
- Internal Resources
- Emotional regulation skills
- Distress tolerance skills
- Interpersonal effectiveness skills
- Core mindfulness skills
- Problem-solving skills
- Life skills
- Coping strategies
- Personality feature of resilience
- Physical health
- Spiritual connection
- Sense of connectedness to others
- Sense of meaning and purpose
- Cognitive flexibility and resourcefulness
- External Resources
- Adequate access to healthcare
- Medical and psychiatric team resources
- Financial resources
- Emotional support from family and friends
- Childcare and caretaking supports
- Community resources
- School resources: 504 plan, IEP, inspiring teacher, after-school programs
- Work resources: Employee assistance program, informal work adjustments
- Religious community supports
- Structured days
Dynamic Aspect of Resources
The aspect of resources that I find most useful is their dynamic nature. Some are currently optimally deployed, others partially deployed, and others still potentially available but not deployed. I can work to make them even more helpful. And, as I noted in my vignette of the patient with TBI, resources convey to me that they should be managed: they need to husbanded, protected, and nurtured.
Just thinking about resources gives me a sense of comfort as a clinician. It changes my role in positive ways. First, I see I am only one resource for the patient among many. Second, I am reminded that an important role for me is to orchestrate deployment of these resources. Most of the time a treatment that is multi-systemic is more effective than one that hinges on one system, the mental health one and, more specifically, on me.
If you haven’t tried this, please consider asking patients to invite trusted supports and confidants to a session with you and the patient: a sibling, aunt, best friend, clergy, volunteer from community organization, sponsor from 12 step program. Some of my most effective interventions – and pleasant interactions – was with these “friends of the patient.”
Some caveats: since I’m looking to optimize support for the patient, I am cautious in inviting people who have a troubled or complex relationship with the patient, even if that person is a close family member. I want to avoid inviting someone who will criticize the patient or tell tales of woe going back decades. Sometimes I do need collaborative information about the patient from such a source, or perhaps I imagine a reconciliation taking place. But my priority is to develop a stronger “holding environment” for the patient and I want to meet people most motivated to help. I also am hesitant about inviting a shorter-term significant other. I don’t want to discuss highly personal issues with someone who may not be part of the patient’s life for long, or even use the personal information against them at some point.
Still, when this approach works, it is a joy to behold.
Until next time,
“We don’t heal in isolation, but in community.”
S. Kelley Harrell
“There are going to be times when you learn more about the world you’re entering and feel defeated when you see the gap between the ideal and the reality… But that’s something we’ll all face. The people that face those obstacles and overcome them are people whose dreams come true.”
“No person, trying to take responsibility for her or his identity, should have to be so alone. There must be those among whom we can sit down and weep, and still be counted as warriors.”