https://orcid.org/0000-0001-5750-5585
ABSTRACT
Our study examined the association between problem-focused coping and resilience among fibromyalgia (FM) patients who live under constant security threats. Resilience is a coping resource and detrimentally affects FM female patients (FMPs) to get up and cope with life. A cohort of 96 FMPs ages 19–75 was subjected to a Fibrotherapy intervention program in the Rehabilitation Help Center in Sderot (Ezra Le’Marpeh), Israel. We examined levels of problem-oriented coping and levels of resilience among the sample. In addition, we assessed whether there is a correlation between their resilience level and their medical metrics. The research included medical metrics and physical metrics. A cohort of 16 FMPs who participated in the quantitative phase composed the qualitative sample. Data from the t-test showed improved mental resilience among all the sample, with a significantly higher level among problem-oriented FMPs. We conclude that resilience is acquired through problem-oriented coping strategies. Furthermore, the association between resilience and problem-oriented coping helped to improve health indicators since coping with the disease included entering a regime of physicals activity and maintaining a healthy lifestyle.
Introduction
Fibromyalgia (FM) is a chronic widespread pain syndrome of an unknown origin (Efrati et al., Citation2015; Hallberg & Carlsson, Citation2000) part of functional somatic syndromes. As high incidence of FM has also been found among relatives of FM patients (FMPs), it is often attributed to genetic and environmental factors (Neumann & Buskila, Citation2003). Cohen-Biton et al. (Citation2022) found that the treatment of the disease is administered in three dimensions: relief to the pain; physical therapy to strengthen the body; treating the mental component due to the psychosomatic structure of the disease. A holistic body-mind-spirit treatment can provide an adequate response and promote the FMPs’ health. The Rehabilitation Help Centre in Sderot (Ezra Le’Marpeh), headed by Rabbi Avraham Elimelech Firer designed the Fibrotherapy intervention (FTI) program to treat FMPs who live under constant security threat due to their residence in the Gaza Envelope region in Israel. The FTI holistic model combines physical therapy treatments, Pilates, a hydrotherapy pool, therapeutic support groups, gardening and cooking therapy, and a unique ceramics workshop that summarizes the process they go through at the center. The treatment is given in three rounds of 10 weeks; in each round, patients receive a different response – a total of 30 weeks.
The security threat issue is significant since previous studies have found correlations between FM symptoms and post-traumatic stress disorder (PTSD) (Buskila et al., Citation2019; Littlejohn & Guymer, Citation2018; Ming & Coakley, Citation2017). Stress in general and life-threatening situations are significant adversaries to FMPs. Studies found that traumatic experiences and life-threatening conditions were linked to developing FM (Haviland et al., Citation2010) and overwhelm its symptoms (Milstein et al., Citation2013).
The objective of the study was to examine the impact of FTI on the resilience of FMPs who live under a continuous security threat, and whether the improvement in their clinical metrics is related to problem-oriented coping strategies.
The concept of resilience is related to exposure to a considerable threat or a feeling of adversity and positive adaptation despite the difficulties (Luthar et al., Citation2000; Luthar, Citation2015). Resilience is a process of optimal adaptation to significant sources of stress such as trauma, tragedy, and threats (Grotberg, Citation2001) and refers to positive outcomes in stressful situations. It marks people’s ability to emerge out of their stressful situation and be on a path to recovery (Ploughman et al., Citation2020; Resnick et al., Citation2011; Robertson & Cooper, Citation2013). Understanding what helps some people function well in high level of stress, may be instrumental in integrating that knowledge into new practice strategies (Rafati et al., Citation2017).
Problem-oriented coping aims to resolve the situation or stressful event or change the source of the stress (Folkman & Moskowitz, Citation2004). Coping begins first with recognizing and accepting the illness, while the patient’s daily life interpretations are vital (Paterson, Citation2001). Problem-oriented coping strategies include mastering the stress, seeking information or assistance in coping with the situation, and removing and moving away from the stressful situation (Chen et al., Citation2018). It includes proactive planning (Hock & Kohlmann, Citation2017) and taking actions to change the problematic situation, such as focusing on problem management and searching for alternative solutions (Bose et al., Citation2015). A reliable correlation was found between problem-oriented coping strategies and positive health outcomes (Penley et al., Citation2002).
Material and methods
This study used quantitative analysis and in-depth interviews for the qualitative research. Since coping is subjective and perceptual, we attempted to understand both the perspectives of coping subjectively and the clinical metrics. The development and the perception of both types of research, quantitative and qualitative, as legitimate in the social sciences has led to the expansion of this approach (Creswell, Citation2003).
Participants and procedure
The quantitative part of the research consisted of 96 FMPs ages 19–75. The participants live in communities in the Gaza Envelope. For maximum diversity, the sample included women of different ages, family statuses, levels of religiosity, and diagnosis times. 16FMPs who participated in the quantitative part were interviewed. The criterion for that part was patients who completed all ten weeks of the treatment program the FTI.
Inclusion criteria
FMPs ages 19–75 who live in the Gaza Envelope area and completed at least half of the FTI program.
Exclusion criteria
FMPs over the age of 75 and under the age of 19; FMPs who do not live in the Gaza Envelope area; FMPs who did not complete at least half the FTI program.
Measures
Personal and medical data
Personal data were collected, including age, socio-economic status, and level of religiosity. Medical data were collected using a questionnaire that included data on the medical condition of the subjects to establish their medical condition and the symptoms of FM. The Physical metrics included The Six-Minute Walking Test (6 mw test) (Crapo et al., Citation2002).
Fibromyalgia
FM symptoms were tested with the Fibromyalgia Impact Questionnaire-Revised (FIQR). This questionnaire covers the areas of activity, overall impact, and symptoms of FM and includes Questions about memory, tenderness, balance, and environmental sensitivity. All Questions are rated on a scale of 0–10. Cronbach’s alpha coefficient in similar studies is 0.95, with correlations between items ranging from 0.56 to 0.93 (Bennett et al., Citation2009).
Resilience
The Connor-Davidson Resilience CD-RISK-10 scale (Connor & Davidson, Citation2003): The 10 items in the questionnaire are rated on a 1–5 Likert scale developed by Campbell‐Sills and Stein (Campbell-Sills & Stein, Citation2007). The scale measures components of resilience (the degree to which an individual can recover after stressful events, tragedy, or trauma): the ability to adapt to change; The ability to cope with what comes along; The ability to cope with stress; The ability to stay focused and think clearly; The ability to not get discouraged in the face of failure; And the ability to handle unpleasant feelings such as anger, pain, or sadness. Internal reliability in Connor-Davison’s original study was 0.89.
Coping
The Brief-COPE self-report questionnaire (Carver, Citation1997) has 28 statements about coping with stressful situations. The questionnaire was designed to examine personal coping tendencies. A reliability test of the questionnaire in similar studies revealed the following Cronbach’s alpha coefficients: problem-oriented − 0.85; emotion-oriented − 0.67; avoidance coping − 0.65 (Sagy & Braun Lewensohn, Citation2009).
Psychological distress
The abbreviated version of the scale of the Psychological Distress questionnaire developed by Sagy and Dotan (Citation2001) contains six items on a 1–4 scale that examines psychological stress and addresses the frequency and occurrence of known psychosomatic symptoms. Five items measuring psychological equilibrium are from Langer’s Index (Langer, Citation1962). A reliability test of the questionnaire in similar studies revealed that Cronbach’s alpha coefficient is 0.75.
Quality of life
The abbreviated version of the Health-Related Quality of Life (HRQOL) questionnaire (SF-36) designed to assess health status among FMPs consists of 36 items on eight aspects of health status: physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The questionnaire was tested and validated (Lewin-Epstein et al., Citation1998). Cronbach’s alpha coefficient ranged from 0.76 to 0.93.
Exposure to threat
The degree of exposure was measured by five items questionnaire (‘yes’/‘no’). The level of exposure index was constructed by connecting the items (Braun Lewensohn et al., Citation2013).
In-depth semi-structured interviews
The interviews allow the interviewer to delve deeper into social and personal matters and provided information on a wide range of this study’s topics: how patients with chronic disease perceive pain (Appendix A).
Ethical considerations
The study participants were informed of its details and signed an informed consent form after receiving a thorough explanation of the research process. The recorded and transcribed interviews were used to examine the credibility and reliability of the study’s findings. All personal details of the participants were kept confidential so that their rights would not be infringed.
Results
Correlation between psychological distress and functional ability
We hypothesized that after participating in FTI, psychological distress and physiological indicators (increase in endurance) will decrease so that problem-oriented FMPs functional ability will improve. present the mean differences, standard deviations, and t-test values for dependent samples before and after FTI for the research variables. refers to problem-oriented FMPs, while refers to FMPs who employ problem-oriented strategies.
Table 1. T-test data in the indicators of psychological distress, functional ability, and physiological indicators before and after FTI among problem-oriented FMPs (N = 56).
Table 2. T-test data on the psychological distress, functional ability, and physiological indicators before and after FTI among FMPs who did not employ problem-oriented strategies (N = 40).
shows that following FTI, among problem-oriented FMPs, there was an increase in the ‘distance before exercise’ index (t(55) = 3.48, p < .001) and also in the ‘distance after exercise’ index (t(55) = 3.44, p < .01). Also, the ‘VAS after exercise’ index showed a decrease in its (t(55) = 2.62, p < .05); however, there was no significant change in the ‘VAS before exercise’ index (p = .78). In addition, there was a decrease in the ‘MBS before exercise’ index (t(55) = 2.85, p < .01), as well as a decrease in the ‘MBS after exercise’ index (t(55) = 3.62, p < .01).
Among FMPs who did not employ problem-oriented strategies following FTI, there was a significant increase in the ‘distance before exercise’ index (t(39) = 4.06, p < .001) and also in the ‘distance after exercise’ index (t(39) = 3.99, p < .001). There was a decrease in the ‘VAS before exercise’ index (t(39) = 4.25, p < .001) and a decrease in the ‘VAS index after exercise’ (t(39) = 4.82, p < .001). Data show a significantly lower level of ‘MBS before exercise’ (t(39) = 3.83, p < .001) and also a significantly marginal decrease of ‘MBS after exercise’ (t(39) = 1.92, p = .06) compared to the VAS index measured before FTI. The findings show a significant improvement in the three indicators related to psychological distress and functional ability among problem-oriented FMPs. However, there is a significant improvement in the functional ability index in FMPs who did not employ problem-oriented strategies. There has been an increase in the endurance of problem-oriented FMPs across all physiological indices measured except for the pre-exercise VAS index. However, an increase in endurance in the physiological indices was not unique to this group of patients. There was also a significant improvement in endurance among FMPs who did not employ problem-oriented strategies in all the physiological indices measured before and after exercise. Hence, the research hypothesis has been confirmed but is not exclusive.
Correlation between resilience and problem-oriented strategies
Our second hypothesis was that problem-oriented FMPs will report higher mental resilience following FTI. Analysis of t-test data for dependent samples found that there was a significant improvement in the level of mental resilience among problem-oriented FMPs (t(55) = 9.38, p < .001), so this group of patients reported a higher level of mental resilience (M = 2.96, SD = 0.50) following FTI compared to previously reported (M = 2.04, SD = 0.58). The effect between the two measurement dates was high (Cohen’s d = 1.68).
Similarly, there was also a significant difference in the level of mental resilience among FMPs who did not employ problem-oriented strategies (t(39) = 5.05, p < .001), so this group reported a higher level of mental resilience (M = 2.82, SD = 0.74) following FTI compared to previously reported (M = 2.02, SD = 0.62) when the effect size was high (Cohen’s d = 1.16).
The findings show that although there was an improvement in mental resilience among the two groups of FMPs, according to the effect size index, the improvement was significantly higher among problem-oriented FMPs.
Main themes
The ability to adapt to change
Adaptability is at the core of resilience. It is the ability to adjust physically, emotionally, and mentally based on new circumstances and information. The more effective a person is in adapting and changing, the more resilient they will be and the more capable of recovering from extreme situations of trauma and stress. Resilience reflects a dynamic encounter of factors that promote positive adaptation in the face of exposure to adverse life experiences.
‘I went through both physical and mental pain since I had a tough time accepting it’.
‘They [family members] didn’t understand, but it was hard for me to understand. I started to think that something was wrong with me at one point. The more I learned about my condition, the more I realized that it’s not just me’.
‘The beginning was terrible. I didn’t cope with it in any way. I didn’t accept it. I felt that my independence was taken away from me and completely disabled me. Having to use crutches felt as though I was becoming an invisible human being’.
The FMPs understood that the pace at which things would be conducted in their lives would be slower, and they accepted it. Some FMPs took to sports activities to understand how to improve their condition.
‘I realized how important exercise was to me, and even though I hated exercise, now I can’t do without it. Every day I exercise in front of the TV’.
‘Each time I try to be active is a challenge, and I try to look for something else to do, something new’.
The ability to cope with what comes along
Emotionally resilient people understand the essence and the reasons for their feeling. They use realistic optimism, using internal and external resources even when they cope with a crisis. Consequently, they can manage their stress and emotions healthily and positively. Adopting effective techniques for managing personal stress can translate into better awareness of the ‘self’.
“Now I allow myself to say to my family, ‘if you don’t prepare the weekend meal, there will be no meal because I don’t feel good and can’t prepare it”.
‘I’m not scared anymore. Today, I’m much stronger. I’m mentally stronger than I used to be, and I’m not afraid of the anxiety attacks either’.
The ability to cope with stress
One factor that may play an essential role in cultivating adaptive responses to pain and its consequences is a positive emotion. Positive emotion is beyond being a happy person. It is a deeper approach to how life is experienced. Optimism stores many benefits for physical health, including improved immune function, lower levels of stress hormones, reduced inflammatory response to stress, decreased blood pressure, reduced pain, and even better sleep.
‘I walk around to release some of the stress I feel inside. I allow my body to relax, and it helps my back, and it also helps me’.
‘Living with pain is like not living. Every day, it was coping with pain again’.
The ability to stay focused and think clearly
The FMPs demonstrated the theme of being focused, aware, and connected to themselves here and now. They perceived it as an ability to find their voice.
‘Precisely in all this turmoil, for the first time in 45 years, I discovered that I know how to find my voice and stay coherent for myself, not others. I’m not coherent, so others will be comfortable when they see me, but I’m coherent for myself, which comes from deep inside’.
‘I’m going to learn how my body works from the inside out. If I understand how my body works, I can also help myself’.
The ability to not get discouraged in the face of failure
The feeling of failure led the FMPs to despair and convergence within the anger and the pain – the ability not to despair caused them to get up both metaphorically and practically. The FMPs illustrated how they learned new things about themselves. Precisely amid the pain, they learned to keep moving forward. The positive attitude released the depression, and from that, a sense of well-being grew.
‘I’m not giving up, and that’s a very new statement for me’.
“Today, I’m much more optimistic; I don’t think about the pain all the time, even when it hurts. I release it, and I feel that I can be happy even if I feel pain”.
“I keep telling myself that I will go against the pain. I will not let it break me because I don’t want to get into depression and spend all my time in bed”.
The ability to handle unpleasant feelings such as anger, pain, or sadness
At the core of the structure of resilience is the ability to return from negative emotional experiences in a flexible adaption to the changing demands of stressful experiences. In other words, the stressful experience exists, but the ability to cope with it constitutes resilience and a demonstration of ability. The pain was the most negative experience of the FMPs since it also brought along negative feelings of being betrayed by the body, of physical disability, or inability to function ‘as before’, a sense of being an incomplete person who cannot provide for herself and her environment what they provided before. The FMPs have metaphorically ‘moved’ the pain to another time and moved forward.
‘The FTI got me on my feet mentally and physically. The fact that I could come to the therapy sessions and put everything on the table, even the scariest things in the world, and they [the group] coped with it amazingly, gave me so much strength’.
Discussion
Analysis of the findings showed that FTI has led to significant changes and improvements at various levels in the lives of the FMPs who participated in the research. The findings showed that the participants’ health scores (psychological distress and QOL) improved, although a higher improvement was found among problem-oriented FMPs. The patients described the actions they took to cope with the disease. Some approached physical activity, and some approached volunteering; they all coped with the disease actively. Studies have shown that problem-oriented coping leads to acquiring resources that help cope with the problem, including instrumental and task-oriented actions (Folkman & Moskowitz, Citation2004).
According to Paterson (Citation2001), the perception of reality provides a basis for how people with chronic illnesses interpret and cope with their illnesses. FMPs who have developed, or have had before, problem-oriented coping patterns employ what Antonovsky referred to as ‘generalized resistance resources’ (GRR), that is, the traits or resources that provide support and assistance in coping with everyday stressors (Antonovsky, Citation1993, Citation2002). According to Shing et al. (Citation2016), one major factor contributing to resilience is harnessing positive emotions, even during a particularly difficult or stressful time. Positivity improves resilience in several ways. First, positive emotions help build social, psychological, and physical resources over time, developing coping skills in periods of stress in the future. According to Fredrickson’s theory of expansion and construction (Fredrickson, Citation2004), positive emotions can help people expand their thoughts, actions, and attention to the moments around them. Our research found that the participants’ mental resilience levels increased following participation in FTI. This finding is of great significance since the term ‘resilience’ incorporates the resilience and ability to return to life and components that relate to the acceptance and adaptation of change and coping with the consequences of FM. The more adaptive a person is, the higher their resilience level, enabling them to cope with stressful situations (Cabanyes Truffino, Citation2010).
The physical pain that the FMPs felt about the disease can be perceived as a kind of failure since the general feeling was that their bodies betrayed them. Hence, the ability to move on and work through the pain, not allowing it to run their life and manage their agenda, constitutes the ability not to be discouraged in the face of failure. Resilience does not eliminate stressful situations or erase the hardships of life. Resilient people do not necessarily observe life through pink lenses. They understand that in life, there are setbacks, and sometimes those setbacks are painful. They still experience emotional pain, grief, and a sense of loss, but their mental outlook allows them to work on those feelings and recover (Shi et al., Citation2019). Our findings are consistent with studies that have shown that resilience in patients with chronic illness was related to various factors, such as self-care, adherence to treatment plans, health-related QOL, patients’ perceptions of illness and pain, adherence to exercise, self-empowerment, depression, and increased optimistic perspective that contributed to the acceleration of recovery (Chan et al., Citation2006; Kilic et al., Citation2013; Robottom et al., Citation2012; Santos et al., Citation2013).
The FMPs in our research illustrated extensive degrees of pain and coping difficulties before participating in FTI. The lack of physical evidence of having a disease was one of the factors that also led to a feeling of despair. Thus, as they learned to accept the disease and adapt to the change it brought, their coping strategies induced coping resources of resilience. One of the essential components of resilience is the ability not to despair in the face of failure and pain and to cope with negative emotions, as the disease places different demands on them than before (Lazarus, Citation1993). Being active and healthy women, they felt they disappointed themselves and their immediate environment as their bodies betrayed them and did not cooperate. However, the ambiguity involved in FM added to the feeling of despair and sadness. When they participated in FTI groups, performed physical activities, and organized their lives in a focused and conscious manner, they understood that although this pain may accompany them through life, its significance may be diminished by developing resilience and resistance. The participants have come a very long way and have developed an ability to look at the pain from a broader perspective. The pain ceased to be the essence and became a component of the disease they successfully coped with. Resilience is manifested not in the times of good feelings but in the backdrops of downfalls, and from these low places, they managed to grow.
Conclusion
Resilience is a coping resource acquired through problem-oriented coping strategies. When the participants faced their problems and coped with them in a specific manner, they employed coping resources of resilience, the mental flexibility that helped them repeatedly to stand back up and cope with life. Physical activity is essential in coping with FM symptoms. FMPs suffer from widespread musculoskeletal pain. It improves their health metrics when they enter a regime of sports activity from the desire to cope with the disease and not succumb to the pain.
Implications for clinical practice
The geographical location of the State of Israel poses challenges when it comes to mental health and resilience. Therefore, research that sheds light on populations of interest in similar situations can help build knowledge-based therapeutic interventions to understand disease management strategies in different types of diseases, not only in FM. This study offers a broad perspective on a personal and professional level. The findings of this study could contribute to formulating a policy for providing an emotional response to FMPs and shed light on the importance of mental resilience in improving clinical metrics.
This study offers a deepening of a unique research field where FMPs are exposed to a continuous security threat that contributes to the progression of the disease and its intensity. FM research has not yet been examined from a theoretical-resilience prism focusing on resources and coping patterns using a combined quantitative and qualitative research method.
Limitations
Since our study focused on a population living in a very specific place, the Gaza Envelope, which is under prolonged terror threats, naturally our sample is not as large as it could have been had we examined other areas. However, the Gaza Envelope area constitutes a research foundation for future studies in the field of the relationship between fibromyalgia and security threat.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
References
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Appendices Appendix A:
Interview Guide
Background data of the interviewee
Age: __________
Marital status: 1. Single 2. Married 3. Divorced/separated 4. Widowed 5. Unmarried and in a permanent relationship.
Number of children: ____________
Questions
How many years ago have you been diagnosed with fibromyalgia?
Please describe the daily struggle with the disease.
Please describe your coping in emergencies.
Please describe a personal experience from periods of rocket escalation or a military operation.
Are your feelings different during periods of rocket escalation and calmer times?
What was the most significant event you experienced during the escalation period in the context of coping with the disease?
Do you avoid activities/people that remind you of the event?
Why is this event most meaningful to you?
Please describe how coping with the disease and exposure to a security threat affect you personally in the following aspects:
Emotional aspects
Family aspects
Social aspects
Mental aspects
In what ways did you cope?
What helped you cope?
Do you maintain a ‘routine’ and cope with the disease during an emergency?
Are you achieving the goals you set for yourself?
Are you careful about managing the disease?
Can you meet the challenges?
How would you like to summarize this interview?