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Letter to the Editor

Understanding Resilience: No Place to Rest on Our Laurels—Reply to Modesto-Lowe et al

Kang Sim, MBBS, MMed (Psychiatry), MS-HPEd, FAMSa,*, and Qian Hui Chew, B Soc Sci (Hon)b

Published: July 27, 2021

See letter by Modesto-Lowe et al, article by Chew et al, reply by Peccoralo et al, and brief report by Pietrzak et al

J Clin Psychiatry 2021;82(5):21lr14035a

To cite: Sim K, Chew QH. Understanding resilience: no place to rest on our laurels—reply to Modesto-Lowe et al. J Clin Psychiatry. 2021;82(5):21lr14035a.
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© Copyright 2021 Physicians Postgraduate Press, Inc.

aWest Region, Institute of Mental Health, Singapore, Republic of Singapore
bResearch Department, Institute of Mental Health, Singapore, Republic of Singapore
*Corresponding author: Kang Sim, MBBS, MMed (Psychiatry), MS-HPEd, FAMS, Institute of Mental Health, 10, Buangkok View, Singapore 539747, Republic of Singapore (



To the Editor: In their Letter to the Editor, Modesto-Lowe et al1 in commenting on our recent article,2 raised the issue of lack of evidence-based recommendations to improve resilience among frontline health care workers (HCWs). They have appropriately highlighted a cogent need to consider the broader issue of further in-depth research and understanding about several interrelated areas pertaining to resilience among HCWs, including frontline HCWs, such as the meaning of resilience, factors influencing resilience and possible constructs, better ways to assess resilience, models to enhance resilience, and review of group or individual interventions over time.

In the midst of possible definitions of resilience that encompass the central notion of a dynamic process of positive adaptation to significant adversity,3 other facets that are also relevant for further examination include whether resilience is a trait versus a state, resilience as a coping mechanism, its malleability,4 and its personal meaning to each individual.5 In this regard, qualitative studies of HCWs of varying seniority from different disciplines in different contexts including frontline health care settings can potentially shed light on this topic.5 Pertaining to factors influencing resilience, studies have looked into individual (such as self-determination and positivity), interpersonal (such as social support), and organizational (such as workload and workplace culture) factors that can be interrelated and interactional in nature.6 There is scope to consider Engel’s biopsychosocial approach7 to the formulation of these factors affecting resilience, including consideration of biological vulnerability (such as arousal states, brain regions involved, and physical illnesses), personality, and psychosocial factors (such as intercurrent life events as well as workplace dynamics) and the complex interactions of these domains. Such a formulation of the germane vulnerability and protective factors should be personalized when planning ways to help an individual subsequently.

Measurement of resilience thus entails taking a holistic perspective of the relevant interactive factors and would necessitate an appreciation beyond the use of resilience rating scales with associated scores. In terms of care models that seek to enhance resilience, the issue raised by Modesto-Lowe and colleagues1 underscores the importance of relating the care model to underlying factors influencing resilience within a specific group of HCWs in their unique setting. Recent care models to optimize resilience have sought to address broad areas either cross-sectionally or longitudinally. Learning from the Ebola outbreak in 2014–2015, Schreiber et al8 described an APD (Anticipate, Plan, Deter) model to anticipate stressors, plan coping response, and deter adverse impact by engaging self-monitoring and activating a resilience plan. Cordova et al9 adopted a longitudinal approach to building resilience among medical professionals by attending to intrapersonal, interpersonal, and systemic and sustainability areas across the career lifespan ranging from attentional practices and intrapersonal skills early on to managing teams and groups, fulfillment, and organizations in the latter part of one’s career. Of note, there is a need for more prospective studies to evaluate the effectiveness and impact of these different models of resilience training in different HCW groups. Any attempt to improve resilience among HCWs needs to start from a better understanding of what resilience means to the individual and the complex network of factors influencing it so that the approach can be multifaceted yet integrated, developmentally appropriate, and contextually and culturally relevant.10 In the context of the evolving pandemic, there is much room for further research and understanding and no place to rest on our laurels yet.

Published online: July 27, 2021.
Potential conflicts of interest: None.
Funding/support: None.

Volume: 82

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