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Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included 

 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely 

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in 

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s 

 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.

 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of 

 Much of this story is documented in Tom Donahue’s film, 

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.

 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. 

 represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.

 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.

 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

7. Zoroya G. Psychologist: Navy faces crisis. 

. January 17, 2007. Accessed July 14, 2021. 

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

Strangers at home: The Untold Story of American Military Mental Health

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. 

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. 

Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior.

 Office of the Surgeon General, Department of the Army; 1966:735-759.

Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan

A working model for eliminating stigma and transforming mental healthcare within the military.

Treating Psychiatric Combat Casualties

The last week of June 2021 was a momentous one.

After the cancellation of last year’s residency graduation, I was tasked with planning an event to celebrate both the 2020 graduates and those advancing in July. I had never planned an event like this before, especially during a global pandemic. I had no idea how much preparation and effort it would take—the room, food, decorations, tables, chairs, etc. To say it was a little daunting is an understatement.

And while I successfully planned for all the minutiae needed for the event, my wife pointed out a small detail that I had been avoiding as I finally neared the big day: I needed a haircut

The last time I had gone to my friendly local barber, it had been pretty awkward. The shop was full of frustrated, angry workers strained from closures and boasting that they had no intention of following any COVID-19 guidelines. I kept quiet and tried to be polite but was eventually asked what I did for a living. After sharing that I worked in leadership at a local hospital, the demeanor changed. Suddenly the man cutting my hair began to smile almost apologetically, gently touching my shoulder as I paid him and left.

This time, I did not know what to expect. Do I wear a mask? Do I try a new shop? Do I skip it altogether? The earlier experience was making me apprehensive. After talking to my wife, I decided I would go to the same barber. Entering the shop without a mask felt almost alien to me, and I must admit, it was slightly unsettling to sit with 15 or so others waiting on cuts.

I have learned that my experiences in the barbershop were in no way unique, and many of our patients and staff are dealing with similar situations on a daily basis. It is time to embrace the fact that reentry anxiety is affecting more individuals than ever before. This kind of anxiety is frequently seen in the severely isolated, the hypervigilant, and those confined to only certain places over 

 Doesn’t that describe almost all of us? Lockdowns and social isolation may have been necessary, but they are not something our brains are used to, nor can we easily flip a switch back to normal.

The data is there. According to the American Psychological Association, Americans are now experiencing the highest levels of stress since April 2020, with 

 reporting feeling at least one emotion associated with prolonged stress in the past 2 weeks (anxiety 47%, sadness 44%, and anger 39%).

 One study found that 13% of individuals screened positive for posttraumatic stress disorder, despite COVID-19 not fitting Criterion A. Thirteen percent felt they had difficulty with lockdown, 11% feared difficulty obtaining supplies, 10% had significant difficulty self-isolating, and 22% had 

And now I needed to plan a graduation for 2 cohorts of graduates, doubling the event’s normal prepandemic attendance. Graduation is supposed to be a time of celebration and togetherness, but as I am sitting here uneasy about just getting a haircut, I am wondering if it is really a good idea to do this event. This is supposed to be fun; why am I not looking forward to this?

We are supposed to be excited. We are supposed to feel good about doing more things. But reentry anxiety will not allow us to simply enjoy it.

Cognitively, it makes perfect sense: fear of contagion, feelings that the world has changed. I have even heard people joking that their social skills have atrophied, or they no longer know how to dress for various occasions.

What can we do about this? Like most solutions in the field, we need to understand the risk factors for those more likely to struggle with reentry. Look for patients with a history of mental illness, as well as those likely to have been stressed or dealing with trauma over the last year: front-line workers; people of color; parents; and children, teens, and young adults displaced from school.

The mechanism of action is a hard one, described by 

 When individuals repeatedly end a honeymoon phase only to be met with a new crisis, they then must recover from said crisis and adjust to the new situation. The hardest part is that individuals tend to suffer from these crises repeatedly, 

Although many consider reentry anxiety an anxiety disorder, it is really more of an adjustment disorder—especially when it is short term and related to a pandemic that forced us all to adjust. That being said, ruling out other causes for anxiety should be considered if symptoms persist.

But what do we do for these patients with this unique adjustment disorder? One of the first steps is diagnosis. The 

DSM’s description of adjustment disorder

 can guide providers in understanding the clinical symptoms and how to diagnose them appropriately.

Personally, my first step is the same as for all patients with anxiety—to help them give themselves permission to feel anxious. We get anxious—if we did not, we would fail to study for exams or forget to look both ways before crossing a street. Anxiety helps us make good choices in our day-to-day lives, as well as during rapidly changing times. It is important to permit feeling anxiety and to remind ourselves that everyone will deal with this differently. Comparing your feelings and coping skills to others is not productive. Just because certain individuals take longer to readjust, or their feelings are more intense, does not mean anything has gone wrong.

Of course, if patients’ symptoms persist or become disabling, it is important to offer help. Here are a few options that I recommend as appropriate:

. Cognitive behavioral therapy is the gold standard for anxiety disorders, and exposure therapy will likely help a lot. With the variety of options in obtaining it nowadays, it is easier to fit therapy into a busy schedule.

. Some research suggests that mindfulness practices can actually mimic exposure therapy by helping patients feel and desensitize troubling emotions and physical sensations.

. Gradual exposure to more challenging situations will likely begin to extinguish these symptoms. In addition, strong social support through family and friends is always beneficial.

. From a pharmacologic standpoint, I would hold off in mild cases. But for patients with disabling symptoms, a selective serotonin reuptake inhibitor might help them push through while undergoing therapy.

Looking back to my recent trip to the barbershop, I think it is important to acknowledge that many of us have experienced some trauma during this pandemic. There is no single method for getting back to normal. Equally important is that we seek to understand and embrace these feelings of trauma. Start with small outings at first, but start soon. Start with a haircut before you host a large party. Learn from my mistakes. Graduation was fun, but hosting over 100 guests indoors was indeed overwhelming.

Admittedly, a week later, I am more comfortable going outside of my bubble; however, I still feel more comfortable wearing a mask at the grocery store. We must all take steps that make us feel personally safe, but we should also push ourselves to get back to our lives.

is chair of Behavioral Health at Arrowhead Regional Medical Center. He also serves as medical director for the Behavioral Health Department at Arrowhead Regional Medical Center. In addition to San Bernardino, Dr. Seigler has practiced clinically in Riverside and across the West Coast as a Vituity

telepsychiatrist since 2017. He received his medical degree from the UCLA David Geffen School of Medicine and completed his postgraduate training at the UCLA/San Fernando Valley residency program. He has a passion for patients’ rights and returning stabilized patients back into the community from long-term placements and conservatorship.

1. Hyde J, Bolton R, Kim B, et al. "I've just never done that:" The influence of transitional anxiety on post-incarceration reentry and reintegration experiences among veterans. 

2. American Psychological Association. Post-inauguration stress survey: More than 8 in 10 Americans (84%) report feeling emotions associated with stress in the last two weeks. January 2021. Accessed July 27, 2021. https://www.apa.org/images/sia-january-emotions-infographic_tcm7-283972.jpg

3. Bridgland VME, Moeck EK, Green DM, et al. Why the COVID-19 pandemic is a traumatic stressor. 

4. Gullahorn JT, Gullahorn JE. An extension of the U-curve hypothesis. 

5. Purtill J. Anxious about going back to normal? It's called 'reverse culture shock'. Australian Broadcasting Company. May 7, 2020. Accessed July 20, 2021. 

6. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (US); 2016.

Why does the prospect of getting back to normal after the pandemic disturb some patients? And what can be done to overcome these fears?   

Reentry Anxiety

 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.”

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.

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.

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

1. Weiss T, Berger R, eds. Posttraumatic growth around the globe: research findings and practice implications. In: Weiss T, Berger R, eds. 

Posttraumatic Growth and Culturally Competent Practice: Lessons Learned From Around the Globe

2. Tedeschi RG, Calhoun L. Posttraumatic growth: a new perspective on psychotraumatology. 

https://www.psychiatrictimes.com/view/posttraumatic-growth-new-perspective-psychotraumatology

Prevalence of posttraumatic stress disorder after infectious disease pandemics in the twenty-first century, including COVID-19: a meta-analysis and systematic review

4. Jeste DV, Palmer BW, Rettew DC, Boardman S. 

The Reliable Change Index (RCI) of the WHO-5 in primary prevention of mental disorders. A measurement-based pilot study in positive psychiatry

6. Kane JM, Robinson DG, Schooler NR, et al. 

Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE early treatment program

7. Gry Secher R, Rygaard Hjorthøj C, Austin SF, et al. 

Ten-year follow-up of the OPUS specialized early intervention trial for patients with a first episode of psychosis

8. Gafoor R, Nitsch D, McCrone P, et al. 

Effect of early intervention on 5-year outcome in non-affective psychosis

Integrated treatment vs. treatment-as-usual for recent onset schizophrenia; 12 year follow-up on a randomized controlled trial

10. Roe D, Mashiach EM, Garber Epstein P, et al. 

Implementation of navigate for first episode psychosis in Israel: Clients’ characteristics, program utilization and ratings of change

The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America?

12. Dreher A, Hahn E, Diefenbacher A, et al. 

Cultural differences in symptom representation for depression and somatization measured by the PHQ between Vietnamese and German psychiatric outpatients

13. Aggarwal NK, Zhang XY, Stefanovics E, et al. 

Rater evaluations for psychiatric instruments and cultural differences: the positive and negative syndrome scale in China and the United States

Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase

15. Verdolini N, Amoretti S, Montejo L, et al. 

Resilience and mental health during the COVID-19 pandemic

An exploration of the relationship between culture and resilience capacity in trauma survivors

17. Darling Rasmussen P, Bilenberg N, Kirubakaran R, Storebø OJ. 

Mapping factors facilitating resilience in mothers – potential clinical relevance for children with ADHD

When kindness falls apart: the disrupting effect of dependency, perfectionism, and narcissism in adjusting to cancer

19. Acar Sivri G, Ezgi Ünal F, Güleç H. 

Resilience and personality in psychiatric inpatients

Psychiatry and Clinical Psychopharmacology

20. Cloninger CR, Svrakic DM, Przybeck TR. 

A psychobiological model of temperament and character

Cultural variations in resilience capacity and posttraumatic stress: a tri-cultural comparison

Trauma and children: exploring posttraumatic growth among school children impacted by armed conflict in Kashmir

23. Trivedi JK, Tripathi A, Dhanasekaran S, Moussaoui D.

 Preventive psychiatry: concept appraisal and future directions

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

Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists

In our psychiatric practices, we naturally focus on psychopathology and the negative effects that adverse and traumatic experiences have on our patients’ mental health. We assess disaster survivors’ maladjustment in order to develop policies for mental health recovery programs. However, the majority of individuals exposed to disasters or other traumatic events do not develop posttraumatic stress disorder (PTSD) or another lasting psychiatric disorder, although they may experience temporary ripples on the surface of their emotional lives and subclinical symptoms for a time.

In considering the patients seen by my residents and me, I am often in awe of the tremendous strength that many of them have developed despite experiencing horrific abuse, neglect, disasters, extreme poverty, major losses, and other traumatic events. Some who were severely abused or neglected as children become devoted parents or highly functional adults, albeit with effort. How do we understand this 

Resilience is a relatively neglected research topic. A Medline search for medical literature related to “psychological resilience” revealed only 6471 articles, whereas a search for articles related to “PTSD” and “posttraumatic stress” (which does not include other mental health problems associated with trauma) identified 36,682 and 18,823, respectively. In fact, in my own research on biological markers for symptoms and diagnoses of PTSD, depression, and anxiety after disaster, we explored heart rate and blood pressure responses, heart rate vulnerability, and levels of cortisol, interleukin-2, and interleukin-6—yet we did not explore those markers or personal characteristics associated with resilience.

Part of the problem is that resilience is difficult to define. Is it the absence of mental health diagnosis, or is it having temporary symptoms or symptom levels below a defined threshold of distress? Or is it having a fulfilled life and pursuing cherished life goals?

However we define resilience, what factors contribute to it? Are some individuals blessed with a fortunate genetic endowment or temperament? Some research has shown heritability of resilience to range between 33% and 52%. Research on resilience has implicated 

 in expression of neuropeptide Y and regulation of the HPA axis, as well as polymorphisms in noradrenergic and dopaminergic systems and serotonin transporter genes.

 Conversely, epigenetic factors involve methylation, demethylation, and histone changes after stress, especially early life stress, which can change gene expression but not DNA structure, for a variable amount of time, contributing to 

 Does this “hop on, hop off” epigenetic model for stress response inversely explain emotional hardiness? 

 results point to an association between maternal resilience and increased cellular telomere length in newborns, with longer telomeres important in gene transcription, meiosis, and cellular longevity.

 Can promoting maternal adaptation to stress during pregnancy have protective factors in offspring?

Other biological differences associated with positive or negative adjustment after emotional stressors include, but are by no means limited to, hippocampal volume, HPA axis reactivity, the mesolimbic dopamine pathway, and differences in inflammatory markers such as neuropeptide Y, cytokines, and C-reactive protein—before or after trauma exposure.

Experience is also important in resilience. Would stress inoculation in developmental years—having just enough but not too much exposure to hardship—enable individuals to overcome lifetime adversity? This concept has been noted in different cultures—for example, an African proverb intones, “Smooth seas do not make skillful sailors,” and William Shakespeare wrote, “Sweet are the uses of adversity,” in 

. Moreover, as children learn to face inevitable life challenges, having love and support from parent figures or mentors can be protective.

: using active coping mechanisms, cognitive reappraisal of negative thoughts, physical exercise, mindfulness, and meditation.

 Having sufficient social support, higher socioeconomic status, and higher educational levels also protect individuals’ psyches. Thoughtful creators of everything from ancient religious and philosophical texts to modern neurobiological and psychological research have linked resilience and life satisfaction with the wisdom that can come with aging. Thus wisdom, resilience, and better health are promoted by the sharing of life experience lessons from older to 

Drawing on the tenets of psychoanalysis, some experts have recommended the use of mature ego defenses, such as creativity, humor, and altruism, in the face of difficulty. Humor and altruism have the particular benefit of drawing others in, thus increasing social support.

Relevant to our current pandemic, the results of a recent large study of frontline health care workers caring for hospitalized COVID-19 patients linked psychological resilience with positive emotions, self-efficacy, sense of purpose in life, and social support (including leadership support), as well as with avoidance of maladaptive behaviors, such as substance abuse.

In sum, resilience is a rich but understudied field for psychiatric research. In this Special Report, we are honored to present several expert colleagues’ wisdom on psychiatric resilience in diverse areas.

is vice chair of education for psychiatry and behavioral sciences, holds the Professor and Arnold and Bess Ungerman Endowed Chair in Psychiatry and the Robert Glenn Rapp Foundation Presidential Professorship of Medicine, and serves in the Adult Mental Health Services at The University of Oklahoma College of Medicine, Oklahoma City.

. Guilford Psychiatry Series. Guilford Press; 1987.

2. Wu G, Feder A, Cohen H, et al. Understanding resilience. 

3. Dudley KJ, Li X, Kobor MS, et al. Epigenetic mechanisms mediating vulnerability and resilience to psychiatric disorders. 

4. Verner G, Epel E, Lahti-Pulkkinen M, et al. Maternal psychological resilience during pregnancy and newborn telomere length: a prospective study. 

5. Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. 

6. Jeste DV, Lee EE. The emerging empirical science of wisdom: definition, measurement, neurobiology, longevity, and interventions. 

7. Elisei S, Sciarma T, Verdolini N, Anastasi S. Resilience and depressive disorders. 

8. Pietrzak RH, Feingold JH, Feder A, et al. Psychological resilience in frontline health care workers during the acute phase of the COVID-19 pandemic in New York City. 

Resilience is a relatively neglected topic of research, but it has the power to dramatically improve patients' lives. 

What Is Resilience?

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include

 Pillar of Salt: Gender, Memory and the Perils of Looking Back

Hard Knocks: Psychology and the Dynamics of Storytelling

How should the sociopolitical nature of PTSD as a diagnosis inform our understanding of trauma?

PTSD

Treating Psychiatric Combat Casualties

Reentry Anxiety

Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists

What Is Resilience?

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

What Can Be Done About Anxious and Violent Men?

The Global Burden of Trauma

Are Migraines and PTSD Linked?

What Does the Future Hold for Psychedelic-Assisted Psychotherapy?

Poetry for PTSD and Preventing Suicide