is a professor and head of division for the Department of Psychology, Psychopathology, and Clinical Intervention at the University of Zurich.

Andreas Maercker, MD, PhD

 is a common term that describes individuals’ amazing capacity for resistance. Its sibling term, 

 (PTG), is less well known, however. PTG describes the positive psychological changes individuals will be able to notice in themselves in spite of a traumatic experience. Examples of PTG include statements such as, “Despite all the bad things that happened, I realize that I feel much more connected to other people now,” or “After what happened, I find myself focusing more on what is important to me and not what others want me to do.”

Igor Linkov, PhD, MSc; Stephanie Galaitsi, MSEE; Katarzyna Klasa, MPH, BSN; Andrew Wister, PhD

The resiliency concept has had many academic mothers and fathers, including Emmy Werner, PhD, (1929-2017; developmental psychologist at the University of California), and George Vaillant, MD, (born 1934; psychiatrist at Harvard University). The concept of PTG derives substantially from the work of psychologists Lawrence G. Calhoun, PhD, and Richard G. Tedeschi, PhD, from the University of North Carolina. Their cutting-edge research drew inspiration from ancient sources, including Greece and the Judeo-Christian Bible, as well as some of the teachings of Hinduism, Buddhism, and Islam that contain statements on the possibility of positive change through one’s own suffering.

Over the past 20 years, the main area of application for PTG and resiliency research has remained posttraumatic stress disorder (PTSD). As this disorder is globally prevalent and one that affects many US immigrants, it is important to assess the relevance of these concepts in a global context, especially for individuals from socially disadvantaged countries. Also important is that comorbidities are common in many patients with psychiatric disorders. Therefore, the area of application of PTG and resiliency research has expanded to include more mental disorders.

A significant question that has arisen from global research on the topic remains: How much resiliency and PTG can humans draw from themselves?

 has been reported in individuals who have experienced sudden loss of a loved one, chronic life-threatening medical conditions (eg, cancer, HIV infection), 

(eg, COVID-19), sexual assault/abuse, or refugee experiences.

 PTG may coexist with distress in the context of suffering and significant psychological struggles. The changes associated with PTG are experiential and powerful, encouraging survivors of adversity to spend time altering their cognition of the world and the self.

Resiliency is the trait-like capability of maintaining normal psychological functioning in the face of adversities or challenging life conditions. It is associated with the ability to interact flexibly with the environment and use personal resources effectively. Resiliency is relatively stable but not static because this capability may grow through cognitively reconstructing one’s understanding of adversities, or it may grow during the recovery process. Therefore, the growth or development of resiliency may be accompanied by PTG.

 seeks to promote well-being through assessment and interventions involving positive psychosocial characteristics in individuals who suffer from, or are at high risk of developing, mental or physical illnesses.

 It started within the last decade and is still in the process of establishing itself in the mental health field. Positive psychosocial intervention includes several components: resiliency-enhancing training, mindfulness-based coping strategies, the meaning-making process, and culture-bound holistic healing.

The assessed effectiveness of psychosocial intervention comes from results of clinical studies that have focused on the meaning-making process. The results of a 

 that used measurement-based interventions to identify and reframe the meaning of stressors for patients in the early stages of depression showed significant clinical improvement in those patients.

 The outcomes of clinical intervention programs emphasizing resiliency-based training have also provided evidence of positive psychosocial interventions. Programs that include individualized resiliency-based training have been found effective in improving clinical outcomes in key domains of social and occupational functioning for psychiatric patients in the 

Cultural Understanding of Psychiatric Resiliency

Culture is a a social constellation of components that include practices, competencies, ideas, symbols, values, norms, institutions, goals, constitutive rules, artifacts, and modifications of the physical environment. In clinical settings, culture involves contextual features, such as the economics, availability, and accessibility of services; patient variables, including differences in prevalence or manifestation of disorders, preference of alternative or informal services, health literacy, and adherence; and provider variables, such as referral bias and patient-clinician alliance. Cultural differences in clinical representations of mental disorders have been evident in studies involving cultural samples.

 and symptom presentation in outpatients in Asia, North America, and Europe indicated that patients from Vietnam, China, and other Asian regions endorsed significantly 

 than their European and North American counterparts, despite similar levels of depression symptom severity.

 In addition, cultural differences in understanding psychiatric stigma might influence whether US patients are viewed as more likely to endorse these symptoms than Chinese patients. For instance, in 

 who have psychiatric disorders, the Chinese sample scored lower than the US sample on positive symptoms such as hallucination, delusion, abstract thinking, stereotyping, anxiety, guilt, tension, and mannerisms.

Psychiatric resiliency refers to maintaining normal psychological functioning while responding to adversities that are related to psychiatric disorders. The inverse correlations are found between resiliency and the severity of psychiatric disorders, such as 

 Individuals with higher levels of symptom severity are more likely to demonstrate lower levels of resiliency. While individuals with less resiliency may possibly experience positive changes in the aftermath of their adverse experiences, 

 are nonetheless associated with higher levels of persistence and self-directedness in patients with chronic psychiatric illness.

 According to the Cloninger model, both environment (ie, character dimensions) and genetic endowment (ie, temperament dimensions) 

Cultural factors may affect resiliency through genetics and environment. In terms of genetics, culture may contribute to, or interact with, individuals’ self-identifying process through biological characteristics (eg, skin color, eye color, or facial features associated with race), behavioral phenotype (eg, eye movement deficits in schizophrenia), and the way they perceive adversities related to psychiatric disorders.

Environmentally, culture may shape resiliency by influencing human developmental processes and behavioral patterns through religion, education, and other physical circumstances. Research indicates that 

 the relation between resiliency and psychiatric disorders such as PTSD.

As one of the most important components of culture, religion may affect one’s comprehension of the world and the self (

). Religious contexts and spiritual appraisals of traumatic events have a robust relationship with posttraumatic outcomes, including PTG. The trauma recovery process involves rebuilding an assumptive world. Religion provides a meaning-making framework to process traumatic experiences and its related distress, as has been evidenced by different cultural studies. For example, results of 

 demonstrating PTG after experiencing a traumatic event indicated that religion had a positive effect on their coping.

 Many Asian cultures are not anchored in one particular religion; instead, spirituality in such cultures might be better understood from an existential perspective. Thus, spirituality may be represented in a manner related to resilient behavior and infused within a general approach to life in those cultures.

Table. Essential Lessons of Resiliency and PTG Research for the Benefit of Patients

The Meaning and Implications of Resiliency

Preventive psychiatry aims to promote health and to protect individuals from developing mental disorders through early diagnosis, effective treatment, disability limitation, and rehabilitation. 

 have been found to reduce symptoms in some mental illnesses, including depression, psychosis, anxiety, and conduct disorders.

 The use of positive psychosocial intervention to prevent mental disorders and alleviate possible negative outcomes is part of the resiliency-enhancing process.

When we as professionals acknowledge patients’ ability to recover and grow, they feel more understood despite their often ongoing state of suffering. Interventions involving resiliency-enhancing and PTG-recognizing processes may benefit not only patients, but also health care workers and caregivers.

is an assistant professor of psychology in the Division of Social & Behavioral Science at Elmira College.

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 Preventive psychiatry: concept appraisal and future directions

Articles

Acknowledging a patient's ability to grow and recover may help them feel more understood despite ongoing suffering. 

Andreas Maercker, MD, PhD

Articles

Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists