resilience to loss and potential trauma - upaya zen center · (bonanno 2004, 2005; bonanno &...

CP07CH01-Bonanno ARI 15 November 2010 15:53

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Resilience to Loss andPotential TraumaGeorge A. Bonanno,1 Maren Westphal,2

and Anthony D. Mancini31Department of Counseling and Clinical Psychology, Teachers College, ColumbiaUniversity, New York, New York 10027; email: [email protected] of Psychiatry, College of Physicians and Surgeons, Columbia University,New York, New York 10032; email: [email protected] of Psychology, Pace University, Pleasantville, New York 10570;email: [email protected]

Annu. Rev. Clin. Psychol. 2011. 7:1.1–1.25

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This article’s doi:10.1146/annurev-clinpsy-032210-104526

Copyright c© 2011 by Annual Reviews.All rights reserved

1548-5943/11/0427-0001$20.00

Keywords

PTSD, complicated grief, risk homeostasis, prevention

Abstract

Initial research on loss and potentially traumatic events (PTEs) hasbeen dominated by either a psychopathological approach emphasizingindividual dysfunction or an event approach emphasizing average dif-ferences between exposed and nonexposed groups. We consider thelimitations of these approaches and review more recent research thathas focused on the heterogeneity of outcomes following aversive events.Using both traditional analytic tools and sophisticated latent trajectorymodeling, this research has identified a set of prototypical outcome pat-terns. Typically, the most common outcome following PTEs is a sta-ble trajectory of healthy functioning or resilience. We review researchshowing that resilience is not the result of a few dominant factors, butrather that there are multiple independent predictors of resilient out-comes. Finally, we critically evaluate the question of whether resilience-building interventions can actually make people more resilient, and weclose with suggestions for future research on resilience.

1.1


Potentially traumaticevents (PTEs): eventsthat meet criteriafrom the Diagnosticand Statistical Manualof Mental Disorders,Fourth Edition forthe PTSD diagnosisfor a psychologicaltrauma (e.g., threatof serious personalharm or injury)

Contents

INTRODUCTION . . . . . . . . . . . . . . . . . . 1.2THE LIMITS OF DIAGNOSES

AND THE PROBLEM WITHAVERAGES. . . . . . . . . . . . . . . . . . . . . . . 1.3

PROTOTYPICAL OUTCOMETRAJECTORIES . . . . . . . . . . . . . . . . . 1.4Resilience . . . . . . . . . . . . . . . . . . . . . . . . . 1.5Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5Chronic Distress . . . . . . . . . . . . . . . . . . . 1.5Delayed Reactions . . . . . . . . . . . . . . . . . 1.6Continuous Distress and Distress

Followed by Improvement . . . . . . 1.6EARLY TRAJECTORY

RESEARCH . . . . . . . . . . . . . . . . . . . . . . 1.6Latent Growth Mixture Modeling . . 1.7

MULTIPLE, INDEPENDENTPREDICTORS OF RESILIENTOUTCOMES . . . . . . . . . . . . . . . . . . . . . 1.9Personality . . . . . . . . . . . . . . . . . . . . . . . . 1.9Demographic Variation . . . . . . . . . . . . 1.10Proximal and Distal Exposure . . . . . . 1.10Social and Economic Resources . . . . . 1.11Past and Current Stress . . . . . . . . . . . . 1.11Worldviews (A Priori Beliefs)

and Meaning Making . . . . . . . . . . . 1.11Positive Emotions. . . . . . . . . . . . . . . . . . 1.12

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . 1.12CAN RESILIENCE-BUILDING

INTERVENTIONS MAKEPEOPLE MORE RESILIENT? . . . 1.13Prophylactic Interventions . . . . . . . . . 1.13Risk Management . . . . . . . . . . . . . . . . . . 1.16Compatibility . . . . . . . . . . . . . . . . . . . . . . 1.17

MOVING FORWARD . . . . . . . . . . . . . . . 1.18

INTRODUCTION

Bad things happen. Although we tend to thinkof traumatic events as rare, population-basedstudies have consistently documented that overthe course of a normal lifespan most people areexposed to at least one event severe enough tomeet the criteria from the Diagnostic and Sta-tistical Manual of Mental Disorders, Fourth Edi-tion for a psychological trauma (e.g., an event

that threatens or causes serious personal harmor injury) (Norris 1992). Bereavement is evenmore common. Most people at different pointsin their lives will experience grief over the deathof a close friend or relation. These events canbe distressing and disturbing, and sometimesdebilitating. But not everyone reacts the sameway. Prospective and longitudinal research hasrepeatedly reported clear individual differencesin how people respond to loss and potentialtrauma. Some people feel overwhelmed. Oth-ers struggle for months and then gradually re-cover, while still others manage to continuefunctioning at normal levels even soon afterthe event and appear resilient (Bonanno 2004).Indeed, the marked variability in adaptationto such events suggests that the commonlyused term “traumatic” is a misnomer. Rather,such events are more appropriately referredto as “potentially traumatic events” or PTEs(Bonanno 2004, 2005; Bonanno & Mancini2008; Norris 1992). Here we use the acronymto refer to both loss and potential trauma.

This article focuses on that portion of in-dividuals exposed to PTEs who continue todemonstrate stable, healthy adjustment or re-silience. We begin by examining how psychol-ogy has traditionally viewed outcome follow-ing PTEs. We review two approaches that havedominated the literature (Bonanno & Mancini2010, Bonanno et al. 2010): the focus on ex-treme reactions and psychopathology and thefocus on average levels of adjustment as a meansof comparing exposed and nonexposed groups.We consider the advantages and limitations ofeach approach and then present a broader viewof individual differences. To that end, we reviewthe statistical assumptions underlying both tra-ditional approaches and more recent individ-ual differences approaches, and we focus on re-cent studies that have employed sophisticatedlatent growth modeling as a means of empiri-cally identifying different longitudinal trajecto-ries of outcome. Next, we review the availableevidence on predictors of resilient outcomes.We also devote a considerable portion of ourreview to the question of whether resiliencecan be enhanced through one-size-fits-all

1.2 Bonanno ·Westphal · Mancini


resilience-building interventions. In an effort toplace such interventions in a broader empiricalcontext, we consider data from related litera-tures in which global interventions have beenused prophylactically to prevent the onset ofpsychopathology, as well as theoretical modelsof risk homeostasis and risk compensation. Fi-nally, we consider future directions for researchon resilient outcomes following PTEs.

THE LIMITS OF DIAGNOSES ANDTHE PROBLEM WITH AVERAGES

Until recently the vast majority of researchon loss and potential trauma has used ei-ther a psychopathology approach or an eventapproach (Bonanno & Mancini 2010). Thepsychopathology approach, by far the mosttypical approach, focuses almost exclusivelyon individual psychopathological reactions,most commonly posttraumatic stress disorder(PTSD), major depressive disorder, and com-plicated grief (CG). That the emphasis on psy-chopathology would dominate early researchefforts is not surprising. PTEs create an impera-tive public health need. It is inevitable that somepeople will suffer losses or PTEs and as a resultwill suffer lasting psychological difficulties, andthat some will require therapeutic intervention.Identifying and treating such problems thus be-comes an obvious first priority.

Interestingly, the question of what mightconstitute a psychopathological response to aPTE has a long and controversial history. Dur-ing most of the twentieth century, the idea ofpsychological trauma was viewed with consid-erable suspicion and clouded by doubts aboutmalingering, secondary gain, or personal weak-ness (Lamprecht & Sack 2002). These concernswere especially prominent in the context of war-related psychological difficulties and continueto be controversial in that sphere even today.For example, a recent survey of soldiers re-turning from combat operations in Iraq andAfghanistan indicated that many desired but didnot seek treatment because of prevailing stigmaabout perceptions of weakness (Hoge et al.2004). Ironically, controversies about patholog-

Resilience: anoutcome patternfollowing a PTEcharacterized by astable trajectory ofhealthy psychologicaland physicalfunctioning

Risk homeostasis:theory positingdynamic interactionsbetween externalrisk-reductionmeasures andperceived risk thatmaintain a constantlevel of actual risk

Risk compensation:theory positing thatpeople willcompensate for riskreduction broughtabout by externalchanges with behaviorsthat increase risk

PTSD: posttraumaticstress disorder

CG: complicated grief

ical grief reactions following loss have tendedto gather at the opposite end of the mentalhealth spectrum. There is a long history inthe bereavement literature of dismissing gen-uinely healthy reactions to loss as denial or hid-den pathology (see Bonanno 2009, Bonanno &Kaltman 1999).

As these diagnostic controversies were clar-ified, new research and intervention strategieswere quick to follow. The formal recognitionof PTSD as a legitimate diagnostic category inthe DSM, for example, resulted in a surge ofnew research on traumatic stress that rapidlyadvanced our understanding of the etiology,prevalence, neurobiology, and treatment of ex-treme trauma reactions (McNally 2003). Morerecently, a similar set of circumstances followedthe articulation of diagnostic criteria for CG(e.g., Horowitz et al. 1997). Although a CG di-agnosis has not yet been formally entered intothe DSM, discussion of the criteria has stim-ulated new research on the identification andtreatment of extreme grief reactions (Boelenet al. 2007, Bonanno et al. 2007b, Shear et al.2005).

The ability of diagnostic categories tostimulate inquiry and guide intervention onextreme reactions to loss and trauma is clearlyadvantageous. However, these advances havecome at a cost. Diagnostic entities are largelyconceptual rather than empirical, and as a resultthere tends to be little in the way of objectivecriteria for their revision. For example, since itsinception, the PTSD diagnosis has graduallybroadened to allow greater weight to thesubjective experience of trauma. The resulting“bracket creep” (McNally 2003) may havehad unintended consequences of reducing thevalidity of the diagnosis. Moreover, taxometricanalyses of the latent structure of both PTSDsymptoms (Broman-Fulks et al. 2006, Ruscioet al. 2002) and grief symptoms (Holland et al.2009) have failed to support their categoricalstructure. Rather, these analyses suggestthat both disorders are best understood ascontinuous dimensions and, by extension, thatspecification of a diagnostic cut-point willalways be arbitrary to some extent.

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Trajectory:a developmentalpathway that mapschanges in a dependentmeasure over time

More significantly, the nearly exclusive fo-cus on pathological categorization is uninfor-mative about the shape and characteristics ofthe distribution of nonpathological responses.Of particular relevance to this article, the simplebinary distinction between pathology versus theabsence of pathology fails to speak to the ques-tion of whether the relative absence of grief andtrauma reactions are best understood as a dys-functional aberration, a normal response, or theresult of extraordinary coping ability (Bonanno2004).

The other common approach to loss andtrauma, the event approach, attempts to under-stand the impact of PTEs by focusing on av-erage levels of continuous outcome measures.Average-level data are typically used to com-pare exposed and nonexposed, as a means ofestimating the duration of posttraumatic im-pact. Average scores are useful in determiningwithin-group predictors of grief or posttrau-matic outcome and are especially informativewhen meta-analyses are used to summarize dataacross multiple studies (e.g., Currier et al. 2008,Norris et al. 2002).

Importantly, however, the assessment ofPTEs in terms of average responses also hascrucial limitations. Similar to the focus on

Figure 1Prototypical trajectories of adjustment following a PTE (adapted fromBonanno 2004).

psychopathology, the comparison of averagelevels of adjustment provides relatively little in-formation about the distribution of nonpatho-logical reactions or the prevalence of resilientoutcomes. Moreover, average responses are po-tentially misleading. Average responses are of-ten taken to represent the modal responseto an event. Yet, as we demonstrate below,when assessed over time the statistical aver-age bears little resemblance to the typical pat-terns of response that are observed followingPTEs.

PROTOTYPICAL OUTCOMETRAJECTORIES

Recognition of the limitations of the psy-chopathology and event approaches hasspurred the development of a broader researchagenda that emphasizes individual differencesin PTE outcome across time. In part, the failureof traditional trauma and loss theory to ac-commodate the full range of adjustment in theaftermath of acute adversity can be attributed atleast in part to misconceptions about the natureof the underlying variability in change acrosstime. Both the psychopathological approachand the event approach are predicated on theassumption that aversive life events producea single homogenous distribution of changeover time (Duncan et al. 2004, Muthen 2004).By contrast, recent theoretical (Bonanno2004, 2005; Bonanno & Mancini 2008, 2010;Mancini & Bonanno 2006) and statistical(Curran & Hussong 2003, Muthen 2004) ad-vances have dramatically underscored the nat-ural heterogeneity of human stress responding.

Increasingly, the available empirical liter-ature suggests that most of this heterogene-ity can be captured by a relatively small setof prototypical outcome trajectories (Bonanno2004). The four most common trajectories andthe frequency with which they tend to occurare depicted in Figure 1: Resilience is char-acterized by transient symptoms, minimal im-pairment, and a relatively stable trajectory ofhealthy functioning even soon after the PTE;



recovery is distinguished from resilience byelevated symptoms and some functional im-pairment after the PTE followed by a gradualreturn to normal levels of functioning; chronicdistress is characterized by a sharp elevation insymptoms and in functional impairment thatmay persist for years after the PTE; finally,delayed distress is characterized by moderateto elevated symptoms soon after the PTE anda gradual worsening across time. Other tra-jectories that are also sometimes observed in-clude enduring impairment that predates thePTE (continuous distress) and elevated distressprior to the PTE that decreases markedly af-ter the event (distress-improvement) (Bonannoet al. 2002b). We elaborate on these distinctionsbelow.

Resilience

The absence of significant distress and dys-function after exposure to a PTE was onceseen as puzzling and anomalous, the likely re-sult of either exceptional emotional strengthor numbness. In the case of bereavement, itwas often thought that the relative absenceof distress was actually a form of hiddenpsychopathology. These perspectives continueto exert influence among the lay public (seeBonanno 2009). However, their currency withresearchers and theorists has rapidly waned inthe face of overwhelming evidence that mostpeople respond to even the most extreme stres-sors with minimal disruptions in overall func-tioning. Bonanno (2004) has described this ca-pacity as resilience, defining it as “the ability ofadults in otherwise normal circumstances whoare exposed to an isolated and potentially highlydisruptive event, such as the death of a closerelation or a violent or life-threatening situa-tion, to maintain relatively stable, healthy lev-els of psychological and physical functioning”(p. 20). The capacity for resilience is part andparcel of ordinary human capabilities (Masten2001), as witnessed by the substantial propor-tion of people who endure PTEs with relativelyminor effects on their everyday lives (Bonanno2004, 2009).

Recovery:an outcome patterncharacterized byelevated symptomsand functionalimpairment after thePTE, followed by agradual return tobaseline functioning

Recovery

In contrast to resilience, a quite different trajec-tory describes a pathway of recovery. The term“recovery” connotes a response to a PTE char-acterized by acute distress, moderate to severelevels of initial symptoms, and some difficultiesmeeting role obligations. Over time, these dif-ficulties abate, and the person returns to his orher baseline level of functioning, usually withinone to two years after the PTE. By contrast, re-silience is characterized by relatively minor andtransient disruptions in functioning, with few ifany marked effects on everyday functioning androutines. An increasing number of studies havedemonstrated that resilience and recovery canbe mapped as discrete and empirically separa-ble outcome trajectories in response to widelyvarying acute stressors, including interpersonalloss, major illness, traumatic injury, and terror-ist attack (Bonanno et al. 2002b, 2008; deRoon-Cassini et al. 2010; Deshields et al. 2006; Lamet al. 2010; Mancini et al. 2010a).

Chronic Distress

Relatively few individuals go on to developchronic psychopathology following exposureto a PTE. Although PTEs vary considerably intype, severity, and duration, PTSD is typicallyobserved in 5% to 10% of exposed individuals.When exposure is more prolonged or severe,the proportion exhibiting PTSD or othertypes of psychopathology may reach higherlevels, but rarely exceeds 30% of the sample(Bonanno 2005, Bonanno et al. 2010). Forexample, among a representative sample of2,752 New Yorkers interviewed in the monthsfollowing the September eleventh terroristattack, the chronic PTSD prevalence wasestimated at 6% (Bonanno et al. 2006). Amongthose physically injured in the attack, however,chronic PTSD was estimated at 26%. In acareful reanalysis of the National VietnamVeterans Readjustment data, a representativesample of 1,200 veterans, chronic PTSD wasestimated at 9% but rose to 28% amongveterans with the highest levels of combatexposure (Dohrenwend et al. 2006). Studies of



psychopathology during bereavement suggestsimilar proportions. Typically only about10%–15% of bereaved people will exhibitchronically elevated grief reactions (Bonanno& Kaltman 2001). However, chronic griefreactions tend to be more prevalent followingmore extreme losses, such as when the death-event involves violence (Kaltman & Bonanno2003, Mancini et al. 2010b, Zisook et al. 1998)or when a child dies (Bonanno et al. 2005a).

Delayed ReactionsDelayed reactions have been a source of contro-versy and debate. Although the DSM-III for-mally recognized delayed-onset PTSD in 1980,research has raised important questions aboutthe distinction. Prevalence estimates for de-layed PTSD have varied widely, from 0% to68% (Andrews et al. 2007), and some com-mentators have questioned whether it exists atall (Bryant & Harvey 2002). Empirical stud-ies that have mapped PTSD symptoms overtime in fact observed what appear to be de-layed elevations in the direction of thresholdsymptoms. However, a close examination ofthese symptom patterns suggest not the sud-den onset of pathology but rather subthresholdsymptoms levels that grew substantially worseover time (e.g., Bonanno et al. 2005b, Buckleyet al. 1996, deRoon-Cassini et al. 2010). Consis-tent with these observations, a recent review ofthe literature on delayed PTSD concluded thatdelayed-onset PTSD is attributable to an exac-erbation of existing symptoms (Andrews et al.2007). Delayed grief during bereavement haslong been a source of theoretical speculation(Wortman & Silver 1989). However, in con-trast to PTSD, longitudinal bereavement re-search has yet to offer persuasive documenta-tion of delayed symptom (Bonanno & Field2001, Bonanno & Kaltman 1999, Middletonet al. 1996), indicating that delayed grief is nota veridical phenomenon.

Continuous Distress and DistressFollowed by ImprovementIn addition to the four prototypical trajecto-ries, prospective research has identified two

additional growth trajectories, each character-ized by elevated symptoms and distress priorto the event’s onset. One of these patterns, thecontinuous distress trajectory, captures individ-uals who experience persistently elevated symp-toms and distress beginning well before the tar-get event’s onset and continuing well after thetarget event had run its course. Importantly,identification of the continuous distress pat-tern makes it possible to distinguish difficultiesspecific to the target event from longer-termdifficulties that predate the target event. Thecontinuous distress trajectory has been identi-fied in research on loss (Bonanno et al. 2002b,2005; Mancini et al. 2010a), unemployment(Galatzer-Levy et al. 2010), and terrorist at-tack (Bonanno et al. 2005b). A related patterndescribes individuals with elevated pre-eventsymptoms followed by improvement after theevent’s occurrence. The distress-improvementpattern has been identified in research onloss following chronic illness (Bonanno et al.2002b), divorce (Mancini et al. 2010a), and mil-itary deployment (Dickstein et al. 2010).

EARLY TRAJECTORY RESEARCH

Early investigations of the outcome trajec-tories described above employed relativelyrudimentary methods, using a priori cut pointsand existing theory to group participants intotheoretically derived response patterns. In anearly set of bereavement studies using rela-tively small samples, Bonanno and colleaguesdescribed a group of individuals with littleor no grief symptoms across time (Bonannoet al. 1995). Using a larger, prospective sample,Bonanno and colleagues (Bonanno et al. 2002b,2004) identified distinct outcome trajectoriesfollowing spousal loss using baseline or pre-bereavement means and standard deviations asthe metric for normal variability. The majorityof the sample (71.7%) was characterized as re-silient, recovered, or chronically distressed. Ofparticular note, resilience was the most com-mon trajectory (45.9%). Subsequent studieshave confirmed that these outcome trajectoriescharacterize the vast majority of participants



following a PTE. In a study of high-exposure9/11 survivors, for example, Bonanno et al.(2005b) found that 35% of participantsdisplayed resilience but also that the other pro-totypical outcome patterns of recovery (23%),chronic distress (29%), and delayed reactions(13%) were also well represented. In a similarapproach examining breast cancer survivors,Deshields and colleagues (Deshields et al.2006) examined change in depression scores at0, 3, and 6 months following radiation treat-ment. Here again most participants displayedresilience (60.7%), but others showed chronicdistress (11.9%), recovery (9.5%), as well as adelayed trajectory (3.5%), consistent with theprototypical response patterns described above.However, 13.1% of the sample in this studycould not be placed in any of the trajectories,illustrating one key limitation of this method.

Indeed, identifying outcome trajectories byusing simple mathematical algorithms has threesignificant limitations. The first is that this ap-proach relies on a single mean and standard de-viation to derive patterns of trajectory change(e.g., Bonanno et al. 2002b). This is problematicbecause different pathways may possess differ-ent degrees of variance, and relying on a sin-gle estimate of functioning does not permit thissource of variability to influence trajectory des-ignation. In this sense, prior investigations wereessentially relying on a fixed effects model todefine trajectories. However, given individualdifferences, a random effects approach is moreappropriate because it allows for within-personvariability. A second critical limitation of priorresearch is that using a priori cut points to definetrajectories is inherently arbitrary. The trajec-tories are necessarily imposed on the data ratherthan emerging directly from them, making itimpossible to know whether naturally occur-ring distinctions are being identified. A third,related limitation is that the operational def-initions for the trajectories were based solelyon a priori theoretical assumptions about thenature of the prototypical patterns of varia-tion across time. Although, as we describe be-low, subsequent research has for the most partsupported the findings of the initial research,

LGMM: latentgrowth mixturemodeling

the use of predetermined theoretical defini-tions necessarily limits opportunities to identifynovel or event-specific patterns of outcome.

Latent Growth Mixture Modeling

A compelling and elegant methodological solu-tion to these basic conceptual problems is foundin latent growth mixture modeling (LGMM),a suite of statistical techniques derived fromstructural equation modeling (Muthen 2004).In contrast to conventional growth modelingtechniques, such as hierarchical linear modeling(HLM), LGMM is not limited to the modelingof a single mean response pattern and there-fore a single homogeneous distribution (seeFigure 2). By relaxing the assumption of a sin-gle population, LGMM is able to identify het-erogeneous subpopulations comprising distinctresponse patterns across time. The key featureof LGMM is the incorporation of both continu-ous and categorical latent variables. Latent con-tinuous variables are random effects that defineparameters of growth across time (e.g., inter-cept, slope, and quadratic). These parameters

Figure 2Homogeneous and heterogeneous outcomedistributions for posttraumatic stress (adapted fromFeldman et al. 2009).



are allowed to vary across unobserved popula-tions or trajectory classes, which are identifiedthrough latent categorical variables that groupparticipants according to differing patterns ofgrowth. The appropriate number of trajectoryclasses is determined primarily by a set of fitstatistics, as well as by existing theory and in-terpretive rationale (Muthen 2004).

To illustrate the insights LGMM can of-fer into how people cope with adversity, wenext contrast research that employed the HLMand LGMM approaches, respectively. Impor-tantly, these studies were all conducted on thesame panel dataset, allowing us to directly com-pare the results of the two methods. Lucasand colleagues (e.g., Lucas 2005, Lucas et al.2003) used HLM to model subjective well-being following divorce, marriage, widowhood,and unemployment. The random effects HLMidentified marked within-person variation inresponse to each of these events, indicatingsubstantial individual differences in adaptation.For example, people who showed more signif-icant reductions in well-being soon after be-reavement also took much longer to recover,while those persons with the strongest posi-tive reactions to marriage saw long-term in-creases in their well-being. Of particular rel-evance here, Lucas and colleagues concludedthat divorce, widowhood, and unemploymentcan produce long-term reductions in well-being (Lucas 2005, Lucas et al. 2003). Indeed,divorce and unemployment were characterizedas having fundamentally negative effects. Al-though these findings are certainly informative,we would argue that there is more to the story.

To address this possibility, we reanalyzedthese same data using LGMMs (Galatzer-Levyet al. 2010, Mancini et al. 2010a). Consistentwith previous findings, we found multiple anddivergent trajectories in response to divorce,marriage, unemployment, and widowhood, in-dicating considerable individual differences.However, substantively different conclusionsemerged regarding the overall impact of theseevents as well as the nature of these individualdifferences. Specifically, only a relatively smallsubset of persons experienced lasting reduc-

tions in well-being after divorce, widowhood,or unemployment. Moreover, in response toeach of these events, the substantial majorityshowed a stable trajectory of high well-beingsimilar to resilience, clearly indicating thatmost people coped extremely well with theseexperiences. In addition, we found evidencefor other trajectories, including the distress-improvement pattern, following widowhoodand divorce, which characterized an importantminority of the sample for both events (5.4%and 9.1%, respectively). The HLM approachhas considerably more difficulty capturing thesedivergent patterns because it only models a sin-gle estimate of functioning. Moreover, HLMcannot group participants into trajectories andthus cannot estimate the prevalence of differentresponse patterns. We would emphasize thatthe primary reason for these different resultsis that HLMs model variation around a singleaverage response pattern and thus assume a ho-mogeneous distribution.

One distinct virtue therefore of LGMM isits capacity to differentiate trajectory patternsand then to estimate their prevalence. LGMMdoes this in an empirical and nonarbitrary fash-ion, providing estimates that are uncontami-nated by a priori assumptions. In a recent pro-gram of research, together with our colleagueswe have applied LGMM to a wide range ofstressors, and found that resilience—or a stabletrajectory of healthy adjustment across time—was invariably the modal response. For ex-ample, using LGMM, we found a high pro-portion of resilience among bereaved spouses,58.7% (Mancini et al. 2010a); divorced persons,71.9% (Mancini et al. 2010a); persons admit-ted for surgery following a traumatic injury,59.2% (deRoon-Cassini et al. 2010); breast can-cer surgery survivors, 66.3% (Lam et al. 2010);hospitalized survivors of the severe acute res-piratory syndrome (SARS) epidemic in HongKong, 35% (Bonanno et al. 2008); and unem-ployed persons, 66.8% (Galatzer-Levy et al.2010). In the context of the methodologi-cal strengths of LGMMs, these findings pro-vide further and particularly compelling evi-dence that resilience is a robust phenomenon



emerging in response to widely varying stressfulexperiences.

MULTIPLE, INDEPENDENTPREDICTORS OF RESILIENTOUTCOMES

Why are some people more likely to showresilient outcomes than others? As we notedabove, traditional models of potential trauma,which assumed stable healthy adjustment fol-lowing PTEs to be rare, viewed this questionin relatively simplistic terms: Resilience waseither the result of extraordinary mental health,and thus the province only of supercopers,or a denial-like state associated with dysfunc-tion and psychopathology (Bonanno, 2004,2009). The fact that resilience is not rare butrather typically the modal outcome trajectoryfollowing a PTE suggests a dramatically dif-ferent interpretation. For starters, before evenconsidering additional research, we shouldexpect there to be considerable heterogeneityamong resilient individuals. Because such alarge proportion of the population tends to beresilient, resilient individuals will likely varyacross demographic profiles, personality, lifehistory, past and current stressors, social andeconomic resources, and a host of other factors.

Given the heterogeneity of resilient indi-viduals, we would anticipate that there shouldbe multiple, independent predictors of re-silient outcomes. Developmental researchershave long observed that children who ulti-mately evidenced resilient outcomes despitefacing corrosive life circumstances were ableto utilize an array of resilience-promoting fac-tors, including person-centered variables (e.g.,personality) and socio-contextual factors (e.g.,supportive relations) (e.g., Werner 1985). Thesame appears to be true for both children andadults confronted with PTEs. Resilience afterthese events does not appear to result from anyone dominant factor. Rather, various risk andresilience factors coalesce in a cumulative or ad-ditive manner, each contributing or subtractingfrom the overall likelihood of a resilient out-come (Bonanno et al. 2007a). Some resilience

factors may be stable over time (e.g., personal-ity), while others will likely fluctuate with lifecircumstances or changes in the availability ofresources (Hobfoll 1989, 2002). In other words,at any given instant, persons may be more or lesslikely to be resilient, depending on their recenthistory and the broader context of their lives.

Because research that explicitly defined re-silient outcomes following PTEs is still sparse,a limited body of data is available to exam-ine predictors of resilient outcomes. Below wedetail the most robust predictors of resilientoutcomes.

Personality

It is widely assumed that resilience is deter-mined to a large extent by personality; that is,that there are resilient types who cope markedlybetter with adversity than do nonresilient types(e.g., Connor & Davidson 2003, Schok et al.2010). This assumption is rooted in wider-spread beliefs about the impact of personalityon human behavior. We caution, however, thatalthough personality traits may be salient, theirexplanatory power is easily overestimated. AsMischel (1969) famously observed, personalityrarely explains more than 10% of the actualvariance in people’s behavior across situations.In keeping with the multidimensional nature ofresilient outcomes, therefore, we suggest thatpersonality is best thought of as one of manyrisk and resilience factors that might contributeto the course and ultimately the outcome of aperson’s adjustment following PTEs (Bonanno& Mancini 2008).

A number of personality variables have alsobeen associated with favorable adjustment afterPTEs (Bonanno 2005, Bonanno et al. 2010).An important methodological limitation in thevast majority of these studies, however, is thatpersonality was measured after the PTE hadalready occurred. Personality variables are as-sumed to be stable over time, and a numberof measures have shown impressive reliabilityover relatively short intervals (e.g., six weeks;Gosling et al. 2003). Nonetheless, it is plausi-ble that the experience of a PTE may inform



Proximal exposure:events andconsequences thatoccurred during theapproximate period inwhich the PTEoccurred

Distal exposure:events andconsequences thatarise in the PTE’saftermath, such as theloss of resources orincome

participants’ personality scores rather than theother way around, especially when the person-ality variable is measured many months afterthe PTE (Bonanno & Mancini 2008).

Within the context of this limitation,then, the most compelling evidence necessar-ily comes from multivariate studies that mea-sure personality prior to the advent of the PTE.Studies that have met these stringent crite-ria have associated better post-event outcomewith high pre-event scores on perceived con-trol (Ullman & Newcomb 1999) and trait re-silience (Ong et al. 2010b), and with low pre-event scores on measures of negative affectivity(Weems et al. 2010) and a ruminative responsestyle (Nolen-Hoeksema & Morrow 1991).

Somewhat counterintuitive, there is alsoprospective evidence linking resilience withtrait self-enhancement. Trait self-enhancersare individuals who habitually engage in overlypositive or unrealistic and self-serving biases(e.g., Taylor & Brown 1988). Although this di-mension can be something of a mixed bless-ing, as trait self-enhancers often evoke nega-tive reactions in other people (Paulhus 1998),there is also considerable evidence to suggestthat trait self-enhancers cope exceptionally wellwith potential trauma (Bonanno et al. 2002a).In a recent prospective, multivariate study, traitself-enhancement predicted better adjustmentafter subsequent exposure to potentially trau-matic events, over and above its possible overlapwith the other personality dimensions, such asoptimism and neuroticism (Gupta & Bonanno2010).

A number of studies have also demonstratedassociations between personality variables andexplicitly defined resilient outcome trajecto-ries. Specifically, these studies reported linksbetween trait self-enhancement and resilienceamong high-exposure survivors of the 9/11 at-tacks in New York (Bonanno et al. 2005b), highperceived coping self-efficacy and resilience fol-lowing potentially traumatic injury (deRoon-Cassini et al. 2010), and low negative affectiv-ity and high positive affectivity and resiliencefollowing either multiple physical traumas orspinal cord injury (Quale & Schanke 2010).

Demographic Variation

Another set of factors that inform resilientoutcomes are the relatively straightforwardeffects of demographic variation. Most notably,resilient outcomes in the aftermath of a PTEhave been associated with male gender, olderage, and greater education (Bonanno et al.2007a, Murrell & Norris 1983). There is alsosome evidence to suggest a predictive rolefor race/ethnicity. For example, following the9/11 attacks in New York, African Americanand Latino groups (e.g., Dominicans, PuertoRicans) have been associated with poorer phys-ical and mental health (Adams & Boscarino2005) and less resilience (Bonanno et al. 2006)compared to whites. However, these categoriesof race/ethnicity are typically confoundedwith low socioeconomic status (Norris et al.2002), and when such factors are controlledfor in multivariate analyses, they are typicallyno longer predictive in relation to resilience(Bonanno et al. 2007a).

Proximal and Distal Exposure

The impact of PTE exposure on adjustmentevidences a consistent dose-response effect.Greater exposure is generally associated withpoorer psychological adjustment, whereas re-silient outcomes are associated with reducedexposure. As suggested above, however, expo-sure is only one of many cumulative risk andresilience factors, and the available evidence in-dicates that even when exposure is extreme, psy-chological resilience is still likely to be highlyevident. Parsing the relation of exposure andresilience is complex, however, because expo-sure potentially encompasses many different as-pects of a PTE. In the service of parsimony,we have adopted a distinction between prox-imal and distal aspects of exposure (Bonannoet al. 2010). Proximal exposure refers to eventsand consequences that occur during the approx-imate period in which the PTE occurred. Bycontrast, distal exposure refers to events andconsequences that arise in the PTE’s aftermath,such as the loss of resources or income.



Two important aspects of proximal expo-sure are captured by the event criteria speci-fied in the PTSD diagnosis: being in imme-diate physical danger and/or witnessing deathor serious injury to others. These dimensionshave been consistently linked with greater levelsof posttraumatic stress (Bonanno et al. 2005b,Nolen-Hoeksema & Morrow 1991), especiallyin youths (La Greca et al. 1996). Importantly, adetailed analysis of multiple types of proximalexposure among New Yorkers during 9/11 at-tacks indicated clear variation in relationship toresilience (Bonanno et al. 2006). For example,well over half (55.6%) of those who witnessedthe attack in person still evidenced a healthyprofile during the first six months after 9/11,whereas the proportion of resilience droppedto one third (32.8%) and was the lowest levelobserved in the study, among those physicallyinjured in the attack.

Social and Economic Resources

The important role played by social andeconomic resources in stress responding is welldocumented (Hobfoll 1989, 2002). There aremany different kinds of social resources, includ-ing emotional, instrumental, and informationalsupport (Kaniasty & Norris 2009). A growingbody of research has linked emotional supportwith positive adjustment following disaster(Kaniasty & Norris 2009, La Greca et al. 1996),and multivariate disaster studies have providedcompelling evidence for an explicit link be-tween social support and resilient outcomes(Bonanno et al. 2007a, 2008). Although it iswidely assumed that social support also buffersthe stress of bereavement, prospective researchhas failed to corroborate this idea (Stroebeet al. 2005). However, prospective data haveindicated a relationship between resilientoutcomes following loss and pre-existing levelsof instrumental support (i.e., assistance withthe tasks of daily living) (Bonanno et al. 2002b).

The availability of economic resourceshas consistently been associated with betteradjustment following PTEs (Brewin et al.2000, Norris et al. 2002). However, studies

that have explicitly examined resilient outcometrajectories have failed to detect a relationshipto economic variables (Bonanno et al. 2005b,2007a). An important consideration, however,is that PTEs can also alter the availability ofresources (Hobfoll 1989, 2002), and the lossof resources (e.g., decrease in income) hasbeen associated with reduced prevalence ofresilience (Bonanno et al. 2007a).

Past and Current Stress

Considerable research has linked past and cur-rent life stress with both increased risk forPTSD (Brewin et al. 2000) and a decreased like-lihood of resilience (Bonanno et al. 2007a). Itis important to note, however, that prospectiveresearch indicates that only prior stressors thatresult in PTSD tend to predict PTSD at subse-quent exposure (Breslau et al. 2008). It is not yetclear that resilience to past stressors also pre-dicts subsequent resilience. Interestingly, forsome types of PTEs (e.g., disaster), prior ex-perience with similar events predicts better ad-justment at subsequent exposures (see Bonannoet al. 2010), presumably because prior experi-ence helps a person prepare for and understandthe pending sequence of events.

Worldviews (A Priori Beliefs)and Meaning Making

It is widely assumed that pre-existing world-views influence reactions to aversive life events.At present, however, only a few studies have ac-tually assessed worldviews prior to the advent ofa PTE. In a prospective study of bereavementBonanno et al. (2002b) found that preloss mea-sures of beliefs (justice and acceptance of death)predicted a resilient trajectory after the deathof a spouse. Subsequent analyses showed thatfavorable worldviews were related to adjust-ment over time only among bereaved personsand not among nonbereaved controls (Manciniet al. 2010c). In one of the few investigations ofPTSD to use pre-event data, Bryant & Guthrie(2007) reported that negative beliefs about theself among a sample of firefighters undergoing



training predicted elevated PTSD symptomsfour years later, accounting for 20% of the vari-ance in those symptoms. These findings suggestthat positive worldviews, when measured beforethe PTE has occurred, are associated with moreadaptive coping.

By contrast, there is minimal evidence thatworldviews, when measured after the PTEhas occurred, predict later adjustment. In onerecent study, worldviews were assessed afterspousal loss and showed no relation to subse-quent adjustment, suggesting that worldviewsplay little or no role in maintaining symptomsacross time (Mancini et al. 2010c). A simi-lar finding emerged in a study on PTSD fol-lowing heart attacks: Compromised worldviewswere only present in persons with concomitantPTSD (Ginzburg 2004). Taken together, thesefindings suggest that negative worldviews arean associated feature of trauma-related symp-toms rather than their underlying cause. More-over, they call into question the notion thatPTEs give rise to PTSD and other symptomsby “shattering” our worldviews ( Janoff-Bulman1992).

What about the role of meaning followinga PTE? Park (2010) recently emphasized theimportant distinction between searching formeaning (“meaning-making efforts”) versusarriving at a meaning (“meaning made”). Itappears that the search for meaning is notsalutary in and of itself and may actuallyreflect a continuing preoccupation with thePTE (Bonanno et al. 2005a). Indeed, someresearch has found that seeking meaningfollowing a PTE is actually associated withworse adjustment (Bonanno et al. 2005a, Park2010). However, initial evidence does suggestthat meanings may have favorable effects onadjustment following a PTE (Park et al. 2008).

Positive Emotions

Positive emotions provide a number of adap-tive benefits (Fredrickson 2001, Keltner &Bonanno 1997). Although positive emotionsare crucial in everyday life, the link betweenpositive emotions and adjustment appears

to be especially prominent in the contextof aversive situations (Bonanno 2004, 2005;Ong et al. 2010a). In an experimental studyconducted just after the 9/11 attacks, Papa& Bonanno (2008) exposed New York col-lege students to either a sadness-inductionor an amusement-induction task and thenasked them to talk about their life since theterrorist disaster. The expression of genuinesmiles during the monologue predicted betterpsychological adjustment two years later, butonly for the students who were first madeto feel sad. Genuine smiles following theamusement induction were unrelated to long-term adjustment. In field studies, bereavedindividuals who exhibited genuine laughs andsmiles while talking about their recent losshad better adjustment over the next severalyears of bereavement compared to bereavedindividuals who did not make these expressions(Bonanno & Keltner 1997). A prospectivestudy on remote reactions to the 9/11 terroristattacks among college students showed thatpositive emotions, such as love, interest, andgratitude, fully mediated the relation betweenpre-event ego resilience, a trait-like personalitycharacteristic, and post-event depression andperceived growth (Fredrickson et al. 2003).Finally, in a study of high-exposure survivorsof the 9/11 attacks, trait self-enhancers weremore likely than other participants to exhibit aresilient outcome trajectory and were also morelikely to have experienced positive affect whentalking about the attack (Bonanno et al. 2005b).

SUMMARY

Despite the deluge of studies on resilience overthe past decade, much of the available researchhas focused on risk for poor outcome ratherthan resilience per se. Only a limited num-ber of studies have examined predictors us-ing prospective, multivariate designs and haveexplicitly defined resilient outcomes. This re-search has revealed a number of independentresilience-promoting factors, including person-ality, demographic variation, level of trauma ex-posure, social and economic resources, a priori



world views, and capacity for positive emotions.It is important to note, however, that most ofthese predictors reflect relatively stable dimen-sions that either cannot be changed (e.g., gen-der) or are not easily changed (e.g., personalityor level of social resources). Given this context,it would seem that the recent surge of interestin prophylactic programs aimed at building re-silience in large groups of individuals may besomewhat premature. Programs of this naturehave been developed primarily on the basis ofcross-sectional, retrospective studies of adjust-ment on the one hand and literature on riskfactors in psychopathology on the other, andthus in their current form rest on underde-veloped and potentially misleading theoreticaland methodological foundations. Given thesecaveats, in the section that follows we adopt arelatively critical approach in examining the po-tential risks and benefits of resilience-buildinginterventions.

CAN RESILIENCE-BUILDINGINTERVENTIONS MAKE PEOPLEMORE RESILIENT?

The growing interest in resilience among psy-chological researchers and clinicians over thepast decade has imparted several benefits to thediscipline, such as a broadening of research andintervention agendas to include the possibilityof positive outcomes in the face of adversity. In-creasing recognition of variability in outcomeafter exposure to PTEs has also resulted in thedevelopment of alternative theoretical modelsand more sophisticated statistical methods toelucidate mechanisms and factors that may con-tribute to a resilient outcome trajectory overtime. However, when it comes to preventativeinterventions aiming to promote resilience toPTEs, there continues to be a substantial gapbetween the goals of these interventions andempirical research supporting their efficacy.

To address this gap, we end our reviewby examining the potential risks and bene-fits of resilience-building interventions. First,we review universal prophylactic interven-tions designed to minimize the occurrence of

Prophylactic:describes a measuretaken for theprevention of a diseaseor condition (e.g.,dental care to preventonset of caries)

self-injurious behaviors, such as suicide anddisordered eating. On the balance, these in-terventions have been surprisingly ineffective.We consider why such interventions might failor succeed and the lessons they may hold forresilience promotion. Next we consider howresilience-building programs may directly orindirectly influence perceptions of risk andwhether changes in risk perception might in-teract with pre-existing strengths and vulnera-bilities. To this end we review the risk man-agement literature, focusing on the conceptsof risk homeostasis and risk compensation. Fi-nally, we consider issues of compatibility be-tween resilience promotion goals and variouscultural, personal, and situational differencesamong its recipients.

Prophylactic Interventions

Suicide prevention. The development of pro-phylactic interventions designed to protectagainst the onset of psychopathology or self-injury is a noteworthy goal. Alarmed by reportsof rising numbers of suicides among currentlyor recently deployed troops, federal agencieshave funded several large-scale projects to in-vestigate risk and resilience factors and to im-plement and test the effectiveness of resilienceinterventions in service members routinely ex-posed to PTEs (Natl. Inst. Mental Health2009).

While the idea of preventing the devel-opment of trauma-related psychopathologyin individuals exposed to high-stress situa-tions such as combat has obvious merit, itis important to anticipate potential adverseconsequences of these interventions. Thecase of Critical Incident Stress Debriefing(CISD), a single-session intervention that waswidely expected to lower the incidence ofpsychopathology after potentially traumaticlife events, highlights the importance of exer-cising caution when contemplating large-scaleadministrations of psychological interventions.Multiple studies have shown that CISD is notonly ineffective but actually may be psycho-logically harmful to some people (Litz et al.



2002, McNally et al. 2003). Similarly, a recentreview of multiple-session interventions aimedat everyone exposed to a specific traumaticevent concluded that there is insufficientevidence for their effectiveness (Roberts et al.2009). There was in fact an overall trend forless self-reported PTSD symptoms in the no-intervention comparison groups at 3–6-monthfollow-up (Roberts et al. 2009). The authorspointed out that whether or not these preven-tative interventions might cause harm is largelyunknown because out of the randomized con-trolled trials included in their review, only onereported data on adverse effects. The data fromthat particular trial revealed that individuals ina preventative counseling intervention with apast psychiatric history tended to do worse atsix-month follow-up (Holmes et al. 2007).

There have been a number of attempts toimplement national programs aimed at the pre-vention of specific target problems, such as sui-cide (Mann et al. 2005). The most commontypes of universal suicide preventative interven-tions can be grouped into two broad categories.One category includes large-scale public educa-tion initiatives that seek to increase recognitionof suicide risk and help seeking by providinginformation on causes and risk factors, such asmental illness, that may increase suicidal be-havior. A second category may also include aneducational component but is distinguished pri-marily by the use of screening for at-risk indi-viduals and incorporation of targeted interven-tions for the latter (e.g., treatment referrals).

Large-scale public education programs havebeen relatively ineffective in reducing sui-cide risk. Although some public education andawareness campaigns have had modest effectson changing attitudes regarding causes andtreatment of mental illnesses associated withincreased risk for suicide, they rarely led toreductions in suicidal acts or produced otherbehavioral changes that may decrease the riskfor suicide (Mann et al. 2005). Similarly, a re-view of curriculum-based programs adminis-tered to youth in school and community set-tings found no changes in the rates of youthsuicide (Guo & Harstall 2002). Many studies

have reported overall improvements in knowl-edge and attitudes toward suicidal peers andhelp seeking, and increased willingness to seekhelp if distressed (Gould et al. 2003). However,in others, program-induced changes in attitudeturned out to be contrary to what was intended(Ploeg et al. 1996). For example, Shaffer andcolleagues found that participants who at thebeginning of the program gave a negative re-sponse to the question whether suicide couldbe a reasonable solution for people with a lotof problems actually answered this same ques-tion in the affirmative after attending the pro-gram (Shaffer et al. 1991). Notably, this effectwas particularly pronounced among black par-ticipants. Similarly, another study found thatafter completion of a suicide awareness cur-riculum, male students showed increased lev-els of hopelessness and maladaptive coping re-sponses. The male students in this study werealso more likely to endorse statements that dis-cussing suicide could increase a person’s riskfor attempting suicide, a negative evaluative at-titude thought to present a barrier to addressingsuicidal tendencies in an open and constructivemanner (Overholser et al. 1989). In yet anotherstudy, Shaffer and colleagues found that adoles-cents with a history of previous suicide attemptsresponded to a suicide prevention programby endorsing more negative attitudes and be-liefs about suicide than nonattempters (Shafferet al. 1990). Despite these concerning findings,there has been widespread implementation ofcurriculum-based prevention programs in theUnited States; indeed, such programs are eitherrequired or recommended (Stevens et al. 2008).

More promising results have been obtainedfrom suicide prevention programs that includeda screening mechanism to identify those most atrisk (Spirito & Esposito-Smythers 2006). Twoprograms identified as particularly promisingare the Signs of Suicide program (Aseltine& DeMartino 2004) and the Columbia TeenScreen (Shaffer & Craft 1999). The latter pro-gram involves a stepped approach in which onlystudents identified as at-risk move on to a sec-ond level of more intensive screening that mayresult in referrals for psychiatric evaluation and



treatment. Thus, it is important to note thatunlike many universal curriculum-based pro-grams, the Columbia Teen Screen does notadminister all components of the interventionto an entire cohort in a one-size-fits-all ap-proach, but rather aims to identify and referstudents with previously unrecognized psychi-atric symptoms who evidence at least some riskfor suicidal behavior.

Eating disorders prevention. Mirroringfindings in the suicide prevention literature,universal prevention programs for eating dis-orders directed at everyone regardless of symp-tom status have tended to be less effective thaninterventions targeting subgroups of partici-pants identified at high risk for eating pathology(Stice & Shaw 2004). A more recent review(Stice et al. 2007) identified multiple promisinginterventions. Again, however, only programstargeting high-risk individuals (commonly re-ferred to as selected intervention and contrastedwith universal campaigns conducted with en-tire populations or cohorts) prevented futureincreases in eating pathology compared tocontrol groups who did not receive theintervention.

Many studies on the efficacy of eating disor-ders prevention programs have serious method-ological weaknesses, such as lack of alternativeintervention control group or nonrandom as-signment to condition (Stice & Shaw 2004).In the absence of a control group, it cannotbe determined whether positive effects are dueto the intervention, regression to the mean,the passage of time, measurement artifacts,demand characteristics, expectancies, or otherconfounders. Moreover, several interventionsthat were effective in reducing eating disordersymptoms actually resulted in increased dietaryrestriction (Groesz & Stice 2007, Presnell &Stice 2003, Stice et al. 2006), which is known toincrease risk for developing an eating disorder(Patton et al. 1990). A widely cited eating dis-order prevention study in children and adoles-cents (Carter et al. 1998) reported counterpro-ductive effects of school-based eating disorderprevention programs. Although the program

resulted in increased knowledge and temporarydecrease in the level of eating disorders features,this decrease was not maintained at six-monthfollow-up. In addition, there was an increase inthe level of dietary restraint compared to base-line. However, this study did not include a con-trol group, and in a later controlled trial of thesame intervention (Stewart et al. 2001), no suchharmful effects were observed. Importantly, ob-serving that positive changes in dietary restraintand attitudes to shape and weight were modestand not sustained over time, the authors of thefollow-up study concluded that targeting high-risk subgroups of dieters might present a moreeffective prevention strategy than offering theintervention to entire school groups or cohorts(Stewart et al. 2001).

Multiple studies have demonstrated thatmerely providing information about the harm-ful effects of eating disorders does not appearto deter people from engaging in maladaptiveeating behaviors (Pratt & Woolfenden 2002).Conversely, programs that were successful atdecreasing current eating pathology and pre-venting future increases in eating pathologyincorporated interactive exercises designed tomodify specific risk factors for onset of eatingpathology among high-risk groups (Stice et al.2007).

In summary, two interrelated patterns offindings emerging from both eating disordersand suicide prevention programs are the rel-ative ineffectiveness of universal curriculum-based programs that emphasize didactics andthe relatively greater effectiveness of intensive,interactive programs targeting at-risk groups.The challenge with such multi-component pre-vention programs is that not enough is knownabout the processes that mediate positive ef-fects (i.e., how the program works). Thus, only ahandful of studies have investigated factors thatmay mediate intervention effects, leaving un-certainty about the relative contribution of non-specific factors to outcome and which specificcomponents of programs may account for pos-itive effects (Stice et al. 2007). Similarly, only afew studies have conducted analyses examiningmoderators of intervention effects (e.g., Taylor



et al. 2006) that could shed light on characteris-tics of responders and those that do not benefitor may even be adversely affected by the inter-vention (Stice et al. 2007).

Risk Management

The fact that many and often a majority of peo-ple exposed to PTEs evidence resilient out-comes raises the intriguing question of howsuch individuals might have reacted had theybeen previously exposed to the communicationsand goals of a resilience promotion program.Ideally, such a program would only have en-hanced whatever pre-existing skills or strengthsa person might have possessed already. How-ever, it is worth considering the opposite out-come, that a resilience intervention might un-dermine a person’s natural tendencies. One waysuch an untoward shift might come about isthrough changes in a person’s perception of rel-ative risk.

Risk management is an important andwidely used concept in the area of emergencyand disaster management. The risk manage-ment framework provides a flexible vehicle forunderstanding, analyzing, and predicting vari-ability in outcome when people are exposed toPTEs (Paton et al. 2000). Risk in the contextof risk management theory refers both to therate and the magnitude of consequences asso-ciated with a specific hazardous activity suchas high-speed driving (Hood & Jones 1996).Risk management models include trait vulner-ability factors as predictors but also emphasizethe interaction of individual difference variables(e.g., sensation-seeking personality) with en-vironmental contingencies (e.g., penalties forrisky driving and financial rewards for accident-free driving records) in producing negative andpositive outcomes.

The theory of risk homeostasis (Wilde 1982)that informed much of the early research in thisarea highlights the potential perils of imple-menting interventions designed to decrease riskand promote positive outcomes. Risk home-ostasis theory was originally developed to testand explain the effects of programs designed

to increase road safety but has since been ap-plied to many other behavioral domains, suchas smoking and settling in flood-prone terri-tories (Adams 1995). The central tenet of riskhomeostasis theory is that people will continu-ously compare the amount of risk they perceivein a given behavior or situation (risk perception)with whatever level of risk is acceptable to thempersonally (target level of risk) and will mod-ify their behaviors and subsequent decision tominimize discrepancies between the two. Thisdynamic interaction of risk perceptions, targetlevel of risk, and behavior modification meansthat people will maintain a constant level of riskeven when induced to make behavioral changesthat presumably should decrease risk exposure.

The closely related theory of risk compen-sation posits that people will react to changesin their environment with behaviors thatincrease their risk of injury, thus compensatingfor reductions in risk brought about by theexternal changes (Adams 1995). This theorywould predict, for example, that the installationof airbags in cars that automatically inflatewhen the car collides with another vehicle willactually lead to an increase in “risky” drivingbehavior due to the driver’s perception thatthe airbags will protect him or her from injury(Peterson et al. 1995). Several studies on driv-ing behavior have provided evidence consistentwith the predictions of risk compensationtheory as well as studies examining the impactof product safety campaigns on consumers(see Hedlund 2000 for a review). For example,introducing safety mechanisms on cigarettelighters in households of families with childrenhas been shown to result in parents takingreduced precautions regarding lighters and firesafety (Viscusi & Cavallo 1996). Similarly, astudy by Morrongiello & Major (2002) showedthat parents perceived less risk and showedincreased tolerance for children’s risk taking inplay situations involving use of bicycle helmets.

Although risk compensation and risk home-ostasis theories are not free of controversy(e.g., Evans 1986), they provide a useful frame-work from which to evaluate the possibility thatlarge-scale interventions designed to promote



optimal adjustment among people exposed toPTEs may have unintended side effects. For ex-ample, the idea that everybody could becomeresilient if taught certain coping skills mightlead some people to overestimate their owncoping ability or to underestimate the level ofdistress they might experience in response toa potential psychological hazard such as com-bat. Misperceptions of risk and coping abilitymay be especially likely among individuals whohave previously demonstrated resilience follow-ing exposure to PTEs. Risk underestimationmay also attract certain individuals to occupa-tions they may not be suited for.

Another unintended effect of resilience-building interventions may be their potential toincrease stigma attached to mental health prob-lems experienced following exposure to PTEs(e.g., if people can be trained to be resilient, theabsence of resilient outcomes may be attributedto a person’s failure to benefit from training). Inthis way, interventions involving instruction ofcoping strategies that are thought to increaseresilience to psychological stress may conveymessages that serve to counteract or even re-verse potential positive changes resulting fromthese interventions.

Compatibility

Another important issue is the compatibilityof coping strategies taught in resilience inter-ventions with recipients’ cultural values anddispositional differences in coping with stress.Although the positive psychology movementthat inspired many of the current resilience-building interventions has found a followingacross the globe (Novotney 2009, Seligman &Peterson 2003), it is important to be aware ofthe potential of resilience interventions thatwere primarily developed in Western countriesto conflict with value systems held in othersocieties. Such conflict may detract from theability of some recipients to benefit from theseinterventions as well as potentially underminetheir use of culture-specific resources toachieve positive outcomes. Because most dataon feasibility and effectiveness of interventions

designed to prevent mental disorders in adultscome from studies conducted in high-incomecountries (Patel et al. 2007), little is knownabout the appropriateness and effectiveness ofinterventions in different cultural contexts. Re-search on mental health promotion programshas shown large variation in the effectiveness ofidentical mental health promotion or preven-tion programs across different socioeconomicand cultural context (Zechmeister et al. 2008).

An important but often overlooked as-pect of intervention effectiveness that tends tobe strongly influenced by cultural and ethnicgroup membership is the extent to which re-cipients accept the intervention. A recent meta-analysis on HIV-prevention programs high-lights that individuals are highly sensitive tothe content of the preventive interventions andthe extent to which interventions match theirneeds as recipients, particularly when recipientsbelong to a minority or disenfranchised group(Noguchi et al. 2007). Specifically, recipientsof preventative interventions are likely to seekout interventions that validate what they arealready doing (Noguchi et al. 2007) or matchtheir stage of willingness to change their be-haviors (Prochaska et al. 1994).

A mismatch between the goals of a resilienceintervention and dispositional characteristics orsituational requirements may also produce re-sults opposite to those intended by the interven-tion. For example, some dispositional charac-teristics that have proven highly adaptive in thecontext of extreme adversity, such as trait self-enhancement (Bonanno et al. 2005b, Gupta &Bonanno 2010), may conflict with and even un-dermine the goals of resilience promotion. Incertain occupational groups, instilling or rein-forcing unrealistic positive expectations of find-ing purpose in life through helping others mayincrease vulnerability to feeling demoralizedand powerless in situations where destructionand loss of life are inevitable (Moran 1999,Paton et al. 2000). For example, a detached cop-ing style may be more adaptive for a surgeonwho has to carry out amputations on scores ofdisaster victims. In this situation, seeking mean-ing may interfere with the surgeon’s ability to



effectively provide assistance to disaster victimsand could precipitate burnout.

Perhaps the most crucial limitation of pre-vention programs is their almost exclusive fo-cus on the individual. As we noted above andelsewhere (Bonanno 2004, Bonanno & Mancini2008), resilience is not solely the province ofindividual strengths. Rather, there are multi-ple risk and resilience factors, only some ofwhich have to do with personality and copingability. Hobfoll (2002) has argued, for exam-ple, that early posttraumatic interventions im-plemented by psychologists may have been in-effective because they focused exclusively onpsychological variables and neglected to ad-dress environmental factors that increase riskfor chronic posttraumatic difficulties. Similarly,the authors of a recent systematic review ofpsychosocial interventions designed to preventstress-related symptoms and psychological dis-orders in law enforcement officers (Penalbaet al. 2008) noted that none of 10 randomizedor quasi-randomized controlled trials that qual-ified for inclusion targeted stressors related tothe job context. Thus, the central aim of thesepsychosocial interventions was to help policeofficers cope with stressful events encounteredat work rather than changing the conditions orcircumstances within a specific organizationalcontext. Yet, there is evidence to suggest thatjob context may represent a more potent sourceof occupational stress within the police forcethan the job content (e.g., Collins & Gibbs2003, Kirkcaldy et al. 1995).

The need to resolve threatened or actual lossof important internal and external resources,such as safety, shelter, money, and physicalwell-being, following a trauma is likely to limitthe extent to which individuals can benefit fromearly interventions that target anxiety and affec-tive symptoms (Bonanno et al. 2010, Litz et al.2002, McNally et al. 2003). Litz et al. (2002)point out the importance of distinguishing be-tween risk mechanisms that mediate the effectof trauma exposure on an individual (e.g., re-source loss) and risk indicators that correlatewith chronic PTSD (e.g., past history of trau-matic experience). Knowledge of risk indica-

tors is important in screening individuals ex-posed to PTE who are more likely to experi-ence long-term problems. However, the goal topromote resilience on a large scale may prove tobe elusive without addressing risk mechanismsand accompanying changes in the broader so-cial systems within which preventative inter-ventions are carried out.

MOVING FORWARD

Over the past decade, the term “resilience”has gained considerable currency in psychol-ogy journals. Unfortunately, however, the termis often used casually and interchangeably withother more traditional concepts or phrases. Forexample, resilience is sometimes defined sim-ply as the absence of diagnosable psychopathol-ogy (e.g., Feder et al. 2009). Although it maysound fresh, this kind of binary operational def-inition is in fact no different from the traditionalpsychopathological approach. Put another way,defining resilience as the absence of a disorderis akin to defining health as the absence of dis-ease (Almedom & Glandon 2007) and does lit-tle to advance our understanding of genuinelyresilient outcomes.

To cite another example, the word resiliencehas begun to crop up in self-report indices(e.g., Connor & Davidson 2003). The reasonfor this trend is obvious. Self-report measuresoffer researchers a simple and easy way to assessan important construct. Unfortunately, it is notyet clear what resilience questionnaires actuallymeasure. Perhaps they assess some trait-likeaspect, akin to personality. As we noted above,however, personality rarely explains more thana small portion of the outcome variance fol-lowing a PTE. Given that caveat, it could stillbe useful to research a measure, regardless ofits name, as long as it explained some of the re-silience outcome variance. Yet, there is a dangerhere. As is often the case in psychological re-search, when an instrument is named for a con-cept, it is quickly assumed to capture the charac-teristics of that concept, regardless of its actualvalidity. Not surprisingly, researchers havealready begun to study responses to resilience



measures as a proxy for resilient outcomes, of-ten without bothering to measure actual adjust-ment (e.g., Connor et al. 2003). In some cases,researchers have studied resilience measuresin the absence even of an actual stressor event(e.g., Montross et al. 2006). We caution thatin their current form, resilience questionnaireswill add little new knowledge to the existingcorpus of evidence unless these measures canbe shown to have incremental validity. In otherwords, to be useful, a resilience measure musttell us something more than what can be gainedby using established personality measures ormethods for assessing resilient outcomes.

In the context of these limitations and po-tential pitfalls, we conclude this article with aplea for continued systematic and thoughtfulresearch on resilient outcomes in the face of lossand potential trauma. We would argue, as wehave throughout this article, that resilience canbe adequately understood only when it is opera-tionally defined as a stable trajectory of healthyadjustment across time (Bonanno 2004). We

propose further that the best way to advanceresearch on resilient outcomes is to measurevarious facets of negative and positive adapta-tion as soon as possible after the occurrence ofa PTE and at multiple times afterward. Ide-ally, whenever feasible, efforts should also bemade to obtain pre-event data on function-ing and on possible pre-event predictor vari-ables. As data of this nature are systematicallyaccrued, researchers and theorists will be in aposition to take on the bigger questions. Suchdata will make it possible, for example, to con-tinue to evaluate the most recent evidence aboutresilience, as reviewed in this article, as wellas other as yet unanswered questions. Are thesame people resilient across different types ofevents? How variable are risk and resilience fac-tors across time? How do risk and resilience fac-tors compare with the factors that predict psy-chopathological outcomes? And perhaps mostimportant: Can we, in fact, make people moreresilient, or is resilience building a flawedidea?

SUMMARY POINTS

1. Traditional approaches to loss and potentially traumatic events (PTEs) have emphasizedpsychopathology or average differences between exposed and nonexposed groups.

2. Traditional approaches to PTEs assume homogeneity in outcome, whereas individualdifference approaches assume outcome heterogeneity.

3. The prototypical longitudinal outcome patterns after PTEs are chronic distress, gradualrecovery, delayed increases in distress, and resilience.

4. Resilience, when defined as an outcome, is typically the most common pattern observed.

5. Latent growth modeling makes it possible to identify prototypical outcome patternsempirically.

6. There are multiple, independent predictors of resilient outcomes.

7. Resilience-building interventions may be ineffective and perhaps even harmful.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings thatmight be perceived as affecting the objectivity of this review.



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