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 BOOK REVIEWS

Resilience and Mental Health: Challenges Across the Lifespan

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Steven M. Southwick, Brett T. Litz, Dennis Charney, and Matthew J. Friedman. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-898393; pp 382; $99 (hardcover).

Resilience, in broad terms, is defined as the ability to bounce back, to recover one’s strengths, spirit, and functioning. Interest in resilience in the area of mental health has been increasing lately, especially in the area of trauma and posttraumatic stress disorder (PTSD) research. It may be related to the fact that we have not been successful in our quest for finding PTSD treatment, in spite of spending enormous resources and energy. Thus, the field seems to be turning to another possible approach: a better understanding of resilience to trauma and finding why some people are resilient, why some are not, and whether there is a way to enhance or strengthen resilience to trauma. As stated in the Preface to this book, “…to date, most research in the field of traumatic stress has focused on neurobiological, psychological, and social factors associated with trauma-related psychopathology and deficits in psychological functioning. While much has been learned in these areas of research, particularly about post-traumatic stress disorder (PTSD), far less is known about resilience to stress and health adaptation to stress and trauma” (p xi).

Although the area of resilience research seems interesting and promising, resilience may be far more challenging to study than studying the factors associated with trauma-related psychopathology. The first problem is, as mentioned in the Preface, the definition, because there is no single agreed-upon definition (p xi). Some examples of the definition include “symptom-free functioning following trauma exposure;” “positive adaptation despite adversity;” “enhanced psychobiological regulation of stress/fear-related brain circuitry, neurotransmitters, and hormones;” and “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat” (p xi). Another complication is that “resilience can be conceptualized as an outcome in the face of stress and trauma or as a process that mediates the response to stress and trauma” (p xi). “Process-oriented definitions of resilience include cognitions, emotional reactions, and behaviors that are adaptive in response to stress and trauma…. Other processes shown to be adaptive in relation to stress and trauma include the capacity to generate positive emotions, to accept that which cannot be changed, and to reframe the negative into positive” (p xi). Resilience also is multidimensional and traumatized persons may demonstrate resilience in some areas, such as work, and falter in others. As pointed out, “resilient processes are not strictly intrapsychic and biological; rather they reflect the transaction or interaction between the person and his or her environment” (p xii). The final issue: resilience is not static or isolated: “…the type and degree of stress and trauma typically have a marked impact on resilience processes and outcomes” (p xii). Resilience clearly is a complicated, difficult to examine, yet extremely important factor or process to examine.

This volume summarizes the available literature on resilience and its research from various relevant fields and domains. The book is divided into 5 sections. The first section, “Pathways to resilience,” consists of 6 chapters addressing neurobiology of resilience; resilience in the face of stress: emotion regulation as a protective factor; cognitive factors and resilience: how self-efficacy contributes to coping with adversities; personality factors in resilience to traumatic stress; social ties and resilience in chronic disease; and religious and spiritual factors in resilience. The chapters are solid, state-of-the-art presentations—but, state-of-the-art may look like much, yet may not really be “much.” The chapter on personality factors discusses the concept of “hardiness,” which is conceptualized as “a constellation of personality characteristics that function as a resilience resource during encounters with stressful life events…” and “…is thought to moderate the impact of stress on physical health, mental health and other indices of stress adaptation” (p 63). The chapter on religious and spiritual factors emphasizes that positive religious coping shows a strong relationship to positive adjustment after crises. It also points out some spiritual “red flags” such as loss of faith, negative religious coping, guilt, and lack of forgiveness, and mentions forgiveness and mindfulness or compassion interventions as possible resilience-specific interventions.

The second section, “Resilience across the lifespan,” includes 3 chapters addressing resilience in children and adolescents; resilience in older adults; and a treatise on a lifespan approach to resilience and potential trauma. It seems that children cope with trauma as well, if not better, than adults, though some studies point out that resilience to trauma has been associated with male sex, older age, and greater education.

The 3 chapters of the following section, “Resilience in families, communities, and societies,” focus on family resilience as a collaborative approach in response to stressful life challenges; community resilience: concepts, assessment, and implications for intervention; and trauma, culture, and resiliency. The chapter on family resilience is particularly well written with tables summarizing belief systems, structural or organizational patterns, principles for practice, and practice guidelines to strengthen family resilience. The discussion of trauma, culture, and resiliency nicely summarizes some specific cultural, racial, and ethnic considerations for cultivating resiliency (eg, in African-American culture: historical experiences, family characteristics, cultural values, ethnic orientation, strong kinship bonds, communal orientation, strong religious orientation, and importance of tradition).

The fourth section, “Specific challenges,” deals with issues such as loss and grief: the role of individual differences; reorienting resilience: adapting resilience for post-disaster research; rape and other sexual assaults; the stress continuum model: a military organizational approach to resilience and recovery; resilience in the face of terrorism: linking resource investment with engagement; resilience in the context of poverty; and resiliency in individuals with serious mental illness. The chapter on resiliency in people with mental illness includes an interesting part on resiliency strategies targeting deficits (eg, setting and pursuing goals, or novel strategies such as savoring and mindfulness, gratitude, practicing acts of kindness, and humor).

The last section, “Training for resilience,” summarizes what currently is known about enhancing resilience in 4 chapters: intervention to enhance resilience and resilience-related constructs in adults; childhood resilience: adaptation, mastery, and attachment; military mental health training: building resilience; and public health practice and disaster resilience: a framework integrating resilience as a worker protection strategy. The chapter on intervention to enhance resilience in adults probably is the most clinically relevant and useful. It reviews methods of measurement of resilience (Dispositional Resilience Scale, Connor-Davidson Resilience Scale; Responses to Stressful Experience Scale, and the Resiliency Scales for Children and Adolescents). It also summarizes interventions to enhance resilience such as hardiness training, stress inoculation training, and psychoeducational resilience enhancement, and interventions designed to enhance constructs related to resilience, such as social support interventions, learned optimism training, and well-being training. Some interventions discussed in the chapter on children and adolescents include interventions with parents and interventions in schools and community—emotional literacy, team sports, outdoor educational program, and training in moral courage. The last chapter on framework integrating resilience as a working protection strategy uses the 9/11 World Trade Center terrorist attack and the 2006 Sago (West Virginia) Mine disaster as case examples to demonstrate this framework.

This volume is really only the first serious and complex review of resilience and mental health and related issues. It conveys a lot of interesting information, but the question is how practical is the substance. The Preface and the last section are the 2 most useful parts for someone not familiar with this area and for busy clinicians. One may ask who, besides experts and researchers in the area of resilience, would be the audience for the rest.