Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists

,
Psychiatric Times, Vol 38, Issue 7,

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

SPECIAL REPORT: EXPLORING RESILIENCY

Resiliency is a common term that describes individuals’ amazing capacity for resistance. Its sibling term, posttraumatic growth (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.1

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?

PTG, Positive Psychiatry, and Resiliency

PTG has been reported in individuals who have experienced sudden loss of a loved one, chronic life-threatening medical conditions (eg, cancer, HIV infection), infectious diseases (eg, COVID-19), sexual assault/abuse, or refugee experiences.2,3 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.

Positive psychiatry 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.4 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 pilot clinical study 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.5 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 United States,6 Denmark,7 the United Kingdom,8 Norway,9 and Israel.10

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.

For example, various comparisons of cultural dynamics and symptom presentation in outpatients in Asia, North America, and Europe indicated that patients from Vietnam, China, and other Asian regions endorsed significantly higher levels of somatic symptoms than their European and North American counterparts, despite similar levels of depression symptom severity.11,12 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 comparing Chinese and US patients 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.13

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 anxiety disorders,14 depression,15 PTSD,16 attention-deficit/hyperactivity disorder,17 and personality disorders.18 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, higher levels of resiliency are nonetheless associated with higher levels of persistence and self-directedness in patients with chronic psychiatric illness.19 According to the Cloninger model, both environment (ie, character dimensions) and genetic endowment (ie, temperament dimensions) contribute to resiliency.20

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 culture may moderate the relation between resiliency and psychiatric disorders such as PTSD.21

As one of the most important components of culture, religion may affect one’s comprehension of the world and the self (Table). 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 a study of Kashmiri children demonstrating PTG after experiencing a traumatic event indicated that religion had a positive effect on their coping.22 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. Preventive assessment and intervention have been found to reduce symptoms in some mental illnesses, including depression, psychosis, anxiety, and conduct disorders.23 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.

Dr Zheng is an assistant professor of psychology in the Division of Social & Behavioral Science at Elmira College. Dr Maercker is a professor and head of division for the Department of Psychology, Psychopathology, and Clinical Intervention at the University of Zurich.

References

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. Wiley; 2010:189-196.

2. Tedeschi RG, Calhoun L. Posttraumatic growth: a new perspective on psychotraumatology. Psychiatric Times. 2004;21(4):58-60. https://www.psychiatrictimes.com/view/posttraumatic-growth-new-perspective-psychotraumatology

3. Yuan K, Gong YM, Liu L, et al. Prevalence of posttraumatic stress disorder after infectious disease pandemics in the twenty-first century, including COVID-19: a meta-analysis and systematic review. Mol Psychiatry. Published online February 4, 2021.

4. Jeste DV, Palmer BW, Rettew DC, Boardman S. Positive psychiatry: its time has come. J Clin Psychiatry. 2015;76(6):675-683.

5. Bech P, Lindberg L, Moeller SB. The Reliable Change Index (RCI) of the WHO-5 in primary prevention of mental disorders. A measurement-based pilot study in positive psychiatry. Nord J Psychiatry. 2018;72(6):404-408.

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. Am J Psychiatry. 2016;173(4):362-372.

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. Schizophr Bull. 2015;41(3):617-626.

8. Gafoor R, Nitsch D, McCrone P, et al. Effect of early intervention on 5-year outcome in non-affective psychosis. Br J Psychiatry. 2010;196 (5):372-376.

9. Sigrúnarson V, Gråwe RW, Morken G. Integrated treatment vs. treatment-as-usual for recent onset schizophrenia; 12 year follow-up on a randomized controlled trial. BMC Psychiatry. 2013;13:200.

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. Early Interv Psychiatry. 2020.

11. Ryder AG, Yang J, Zhu X, et al. The cultural shaping of depression: somatic symptoms in China, psychological symptoms in North America? J Abnorm Psychol. 2008;117(2):300-313.

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. J Psychosom Res. 2017;102:71-77.

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. J Nerv Ment Dis. 2012;200(9):814-820.

14. Uzunova G, Pallanti S, Hollander E. Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase. Int J Psychiatry Clin Pract. Published online February 26, 2021.

15. Verdolini N, Amoretti S, Montejo L, et al. Resilience and mental health during the COVID-19 pandemic. J Affect Disord. 2021;283:156-164.

16. Zheng P, Gray MJ, Duan W-J, et al. An exploration of the relationship between culture and resilience capacity in trauma survivors. J Cross-Cultural Psychology. 2020;51(6):475-489.

17. Darling Rasmussen P, Bilenberg N, Kirubakaran R, Storebø OJ. Mapping factors facilitating resilience in mothers – potential clinical relevance for children with ADHD. Nord J Psychiatry. Published online April 7, 2020.

18. Cheli S, Mancini F. When kindness falls apart: the disrupting effect of dependency, perfectionism, and narcissism in adjusting to cancer. Psychooncology. 2020;29(3):579-581.

19. Acar Sivri G, Ezgi Ünal F, Güleç H. Resilience and personality in psychiatric inpatients. Psychiatry and Clinical Psychopharmacology. 2019;29(4):650-655.

20. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50(12):975-990.

21. Zheng P, Gray MJ, Duan W-J, et al. Cultural variations in resilience capacity and posttraumatic stress: a tri-cultural comparison. Cross-Cultural Research. 2019;54(2-3):273-295.

22. Shah H, Mishra AK. Trauma and children: exploring posttraumatic growth among school children impacted by armed conflict in Kashmir. Am J Orthopsychiatry. 2021;91(1):132-148.

23. Trivedi JK, Tripathi A, Dhanasekaran S, Moussaoui D. Preventive psychiatry: concept appraisal and future directions. Int J Soc Psychiatry. 2014;60(4):321-329. ❒