Our greatest glory is not in never failing, but in rising up every time we fail. -Ralph Waldo Emerson

What Mental Toughness Is…

As concepts regarding performance psychology have developed throughout the latter half of the twentieth century, the search for what mental traits make a truly superior performer, in any profession, has been a priority. There has been an abundance of research in distinct domains, from NASA to multinational corporations, that suggests the quality of mental toughness is linked to being remarkable and simply outstanding.

Surprisingly, I have found that some people in medicine find the idea, the very concept of mental toughness “distasteful” in some way, shape, or form. I would submit that this is not, in fact, due to the true nature of the subject as I refer to it or as it is discussed in the literature. Perhaps it is the connotation and psychological schema of the idea, as it has been portrayed in popular culture and various media outlets, which some academics find so objectionable. It is important to realize, however, that the powerful underpinnings of this concept go far beyond its sometimes superficial, macho, and pugnacious presentation in movies and television.

So, what is the essence of mental toughness? How do we define it? Mental toughness has been explained in different ways by different authors. Yet, quite broadly, this attribute seems to be related to concepts of motivation, managing arousal, dealing with stress, confidence, and the ability to focus and maintain concentration.^1,2,3,4 Following extensive research and building on previous interpretations of the concept, Coulter et al proposed the following comprehensive definition:

Mental toughness is the presence of some or the entire collection of experientially developed and inherent values, attributes, emotions, cognitions, and behaviors that influence the way in which an individual approaches, responds to, and appraises both negatively and positively construed pressures, challenges, and adversities to consistently achieve his or her goals.⁵

I find this definition, while certainly inclusive, to be somewhat unwieldy for practical application. Perhaps a more user-friendly template predates Coulter and was proposed by Clough, Earle, and Sewell in 2002. Their “4C model” outlined the primary components of mental toughness. The authors proposed that it is characterized by four primary factors:

1. control: a tendency to feel and act as if one is influential
2. commitment: a tendency to involve oneself in rather than experience alienation from an event
3. challenge: belief that life is changeable and to view an experience as an opportunity rather than a threat
4. confidence: a high sense of self-belief and faith regarding one’s ability to succeed.^6,7

After dissecting the concept and breaking it into it’s component parts, it seems somewhat less contentious. After all, who wouldn’t want to develop trainees that are confident and committed to providing the very best care? Who would argue that it would be bad idea to produce physicians, nurses, and paramedics that see difficult clinical interaction as an opportunity to become better care providers?

Mental Toughness and Performance

There is evidence that suggests that mental toughness is associated with enhanced performance. Kuan and Roy found that self-confidence and the ability to control negative thoughts were associated with better performance in competition.⁸ In addition, more elite, higher-performing athletes seem to score higher on validated tools measuring mental toughness, such as the Sports Mental Toughness Questionarre.⁹ Subjectively, elite performers such as Olympic gold medalist believed that mental toughness was a vital prerequisite to high-level performance.¹⁰ Although further investigation is warranted to establish more concrete connections between mental toughness and performance in areas beyond athletics, this evidence seems to provide important clues to the presence and nature of this association.

Mental toughness is a characteristic that can be taught, cultivated, and developed in a variety of ways.^11,12 Many of these techniques include teaching different psychological skills in conjunction with other training methodologies; for example, individuals can be exposed to gradually more demanding situations to practice applying psychological skills and develop the components of mental toughness. They build confidence by overcoming more and more difficult challenges. Even if individuals make mistakes in the face of very formidable training situations, they have control. One can build his or her skills and knowledge base, readdress the situation, and succeed. Also, constructive reflection techniques can be used to maximize the learning value while reviewing failures and setbacks. Finally, including cognitive-behavioral techniques such as identifying automatic thoughts and testing the accuracy of those thoughts, can be developed to promote higher levels of optimism and confidence, key components of mental toughness.¹³  One comprehensive way to build confidence, teach stress management techniques, and foster mental toughness is Stress Inoculation Training (full post on Stress Inoculation training).

Concepts of Mental Toughness in Medicine

 The quality of equanimity, having the proper mental balance or “evenness of mind especially under stress”¹⁴, has been valued by different cultures throughout the course of human existence. This is especially true of professions that are expected, by their very nature, to intervene and mitigate emergencies or crisis situations. Resuscitation of critically ill or injured patients is one of these situations. In his address to the faculty and students of the University of Pennsylvania in 1889, titled Aequanimitas, Sir William Osler said:

In the first place, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue…Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.¹⁵

Osler’s concept of “imperturbability” shares similarities with the conventional understanding of mental toughness. Osler’s reference to “calmness amid strong, coolness and presence of mind,” is very much like the important concept of control, specifically arousal control. Also, there are connections between Osler’s mention of “impassiveness” and the idea of commitment: an emergency medical provider needs to take action and get involved to save life and reduce suffering. Furthermore, the necessity of confidence and faith in one’s abilities is manifest in Osler’s warning about what happens to the physician who “is flustered and flurried”.

Despite Osler calling attention to this important quality more than a century ago, and even suggesting ways to attain it, few (if any) undergraduate or graduate medical training programs teach or discuss concepts of mental toughness and resilience to promote “imperturbability.” It is also seldom found in the curriculum of any nationally recognized certification course that teaches the technical skills of medical or trauma resuscitation.

Recently, however, there have been attempts to address the topic in literature and media. Psychologist Michael Asken, PhD published a book in 2009 titled Code Calm: Mental Toughness Skills for Medical Emergencies.¹⁶ In 2012, Whitelock and Asken completed a publication specifically targeting physicians, nurses, paramedics, firefighters and EMTs that work outside the hospital, Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel.¹⁷ These innovative books adapt various psychological skills and techniques that have been used to develop mental toughness in areas such as athletics or the military, and adapt them to the world of emergency medicine.

Developing mental toughness

So, how do we develop mental toughness in the various career fields involved the care of critically ill and injured patients? We know that mental health issues such as depression and suicide are a serious problem in medicine.^19,20 Could cultivating elements of mental toughness in doctors, nurses, paramedics, and other health professionals help improve mental health? Stay tuned for a future post.

In the mean time…

Let me know what you think. Do you think that resilience training for medical, paramedic, and nursing students is necessary or possible? Do you think building mental toughness for resuscitationists of all levels is needed?

Listen to the podcast where we talk about mental toughness.

Also, check out this TED Talk by Dr. Sean Richardson titled Mental Toughness: Think Differently about your World.

Check out the following books:

• The Champion’s Mind: How Great Athletes Think, Train, and Thrive by Jim Afremow
• Mental Toughness: The Mindset Behind Sporting Achievement by Michael Sheard
• Mental Toughness for Sport, Business, and Life by Robert Weinberg
• With Winning in Mind by Lanny Bassham
• Antifragile by Nassim Nicholas Taleb
• An Astronaut's Guide to Life on Earth by Col. Chris Hadfield

References

1. Crust L. Mental toughness in sport: A review. Int J Sport Psychol. 2007; 5(3): 270–290.
2. Crust L, Clough PJ. Relationship between mental toughness and physical endurance. Percept Motor Skill. 2005; 100(1): 192–194.
3. Jones G. What Is This Thing Called Mental Toughness? An Investigation of Elite Sport Performers. J Appl Sport Psychol. 2002; 14(3): 205–218.
4. Connaughton D, Hanton S, Jones G. A framework of mental toughness in the world’s best performers. Sport Psychol. 2007; 21: 243-264.
5. Coulter TJ, Mallett CG, Gucciardi DF. Understanding mental toughness in Australian soccer: Perceptions of players, parents, and coaches. J Sport Sci. 2010; 28: 699-716.
6. Clough P, Earle K, Sewell D. Mental Toughness: the concepts and its measurement. In: Cockerill IM, ed. Solutions in sport psychology. London: Thompson; 2002: 32-45.
7. Levy A R, Polman RC, Clough PJ, Marchant DC, Earle K. Mental toughness as a determinant of beliefs, pain, and adherence in sport injury rehabilitation. J Sport Rehabil. 2006; 15(3): 246-254.
8. Kuan G, Roy J. Goal Profiles, Mental Toughness and its Influence on Performance Outcomes among Wushu Athletes. J Sport Sci Med. 2007; 6(CSSI-2): 28–33.
9. Chen MA, Cheesman DJ. Mental toughness of mixed martial arts athletes at different levels of competition. Percept Motor Skill. 2013; 116(3): 905–917.
10. Gould D, Dieffenback K, Moffett A. Psycholigcal talent and its development in Olympic champions. J Appl Sport Psychol. 2002; 14, 177-210.
11. Crust L, Clough PJ. Developing Mental Toughness: From Research to Practice. J Sport Psychol Action. 2011; 2(1): 21–32.
12. Mallet C, Coulter T. Understanding and developing the will to win in sport: Perceptions of parents, coaches, and athletes. In: Gucciardi D, Gordon S, eds. D. Mental toughness in sport: Developments in theory and research. New York, NY: Routledge: 2011: 187-211.
13. Parkes JF, Mallett CJ. Developing mental toughness: Attributional style retraining in rugby. Sport Psychol. 2011; 25(3): 269-287.
14. Merriam-Webster Dictionary Online. Equanimity [Def. 1]. Available at: http://www.merriam-webster.com/dictionary/equanimity. Accessed July 13, 2015.

15. Osler W. Aequanimitas. Presented at: University of Pennsylvania Commencement Address; May 1, 1889; Philadelphia, PA.
16. Asken M J. Code Calm: Mental Toughness Skills for Medical Emergencies. 1^st Camp Hill, PA: Mindsighting; 2009.
17. Whitelock K A, Asken MJ. Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel. 1^st Sunbury Press, Inc; 2012.
18. Rubin R. REcent suicides highlight need to address depression in medical students and residents. JAMA. 2014; 312(17): 1725-1727.
19. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: A consensus statement. JAMA. 2003;289(23):3161-3166.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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