Psychological and social aspects of resilience: a synthesis of risks and resources.

It has been conventional wisdom that early deprivation and trauma can lead unequivocally to later adult debilitation and disorder. That this is not in fact the case has become abundantly clear via a variety of recent new research. While early adversity can be a severe impediment, there is a myriad of accounts of people who have been born into lives of abject destitution, yet have grown into stable, productive, and generative adults. There are certainly personal and social factors that increase the risks of frailty and failing. By the same token, these same risk factors can contribute to the enhancement of one's life, and increase the chances of resilience and of leading fulfilling lives. There is now evidence that society has the knovi/ledge to implement prevention and early intervention programs that foster and enhance personal development; the question is, does it have the will and commitment to do so?

What is resilience? Simply put, it is the ability to bounce back from some real, experienced adversity. Perhaps more elegantly, we can say that it refers to an individual's utilization of inner strengths and outer resources in order to overcome seriously adverse, even traumatic, circumstances, and still continue to pursue and succeed in one's endeavors. It is a generic, multidctermincd attribute (ie, there is no one gene site for resilience), and varies according to personal hardiness and social supports, as well as the nature and degree of the imposed hardship or impediment.

Like so many other false dichotomies prevalent in contemporary psychiatry (eg, psychodynamic versus biological, nature versus nurture, etc), there are also conflicting perspectives on this important subject. It has long been conventional (psychiatric) wisdom, in spite of our avowed professional stance on positive outcomes of psychotherapy and personal growth, that significant early deprivation and trauma in childhood inevitably and predictably eventuate in adult suffering, scarring, and psychopathology. On the other hand, there have been those who have postulated an inherent resistance or immunity to misfortune and calamity in some individuals, going so far as to invoke the unfortunate term “invulnerable” to depict either an inherent, genetic empowerment, or a vital, enviable, strength of character.[1] Of course, as with the other false dichotomies, neither polar opinion is correct, the truth, rather, lying somewhere in between.

It is entirely understandable that clinicians working directly with adults harboring major psychopath ological and social disorders would often attribute their derivation or etiology to their patients' or clients' early experiences of abuse, brutality, deprivation, etc. Similarly, those working with populations of children who have been neglected, traumatized, brutalized, and oppressed, etc, would conclude that both the causality and the inexorability of emotional and behavioral scars are clear and indeed ovcrdctermined. So much so, that activists dedicated to prevention, intervention, and healing of these victims are most often drawn from those who work clinically and socially with these wounded children.

However, when one looks at populations from an entirely different perspective (ie, not from an a priori psychopathological perspective), but rather one that focuses through a prism of individual strengths, or even more so, one that prospectively follows over years populations of youth (for example) who have experienced painful, even destitute circumstances, the picture is remarkably transformed. Our assumptions of resultant and inevitable victim status is not only incongrucnt with the latest findings, but is also unfair to the many who do in fact overcome their early calamities, and it even can preclude our positive, optimistic work with those who have indeed suffered. In this regard, there is in fact abundant cause for optimism. What numerous research findings over the last two decades have shown is that even without dedicated or therapeutic interventions, most of those at-risk children do remarkably well over the course of their lives.[2-7] Contrary to previous professional opinions, the majority of the children who suffer early oppressive circumstances, grow up to be productive, law-abiding, fulfilled, and generative adults.

In the most seminal study, done by Werner,[8-10] a large population of children in Hawaii were followed over four decades. Fully one-third of even the most at-risk children, defined by having at least four early risk factors (eg, poverty, family conflict, perinatal stress, abuse, etc), developed well (personally, socially, educationally, etc). Moreover, there have been similar, and substantiating, studies since then.[3,6,11]

From a literary point of view, no single autobiography stands out as a validation of these dramatic trajectories as much as Manchild in the Promised Land, by Claude Brown,[12] which relates the story of a young man who lived with early privation and pain, and overcame these to become a fulfilled - and fulfilling - adult. Readers of this journal will all doubtlessly know of similar moving, inspiring true stories in their own lives (family, friends), readings, and patients.

Again, this is not to say that there is a simplistic “either/or” dichotomy, because what we have seen about resilience, like all human traits and capacities, is that it is a truly multidetermined and complex phenomenon. When it comes to life's potential calamities, nobody gets away unscathed; even the hardiest amongst us will evince some emotional bruises and battering after lengthy, severe torment.

There is in fact an inherent danger in the concept and, even more so, the phenomenon of resiliency: it is that reactionary forces will (sadly) conclude from examples of individuals' overcoming of personal disaster, that social Darwinism (“Anyone should be able to do it!” “Sink or swim! ”) should be the manifest credo of society. The opposite is indeed the case.

For purposes of this particular synthesis paper, reviewing the many studies of resilience and related concepts - hardiness, invulnerability, etc - leads to certain conclusions about risks and resources, both within an individual's makeup, as well as in relation to external and societal influences.[6,13,14]

Positive personal attributes for resilience: ego resilients

Prospective studies have indicated that there are indeed consistent enhancing personal characteristics (Table I),[15,16] which contribute to one's resiliency quotient. These are cumulative and exponential in nature, positively enhancing each other, with a resultant strengthening effect on the individual's inner resolve. They are also bidirectional, in that a particularly severe trauma or deficit can cause a decrease in the positive attributes discussed herein. These positive personal attributes are correlated with personal resilience; they are, however, not unequivocally predictive. None of the attributes listed in Table I by themselves are uniquely necessary or sufficient to determine success or failure (as with risk factors - see below).

Risk factors

The most salient, crucial finding, shown repeatedly in studies, is that we can all meet our Waterloo. Meaning, of course, even the most resilient soul can be downtrodden, degraded, and ultimately defeated if there are a sufficient confluence of risk factors (Table II) and a concomitant absence of personally enhancing factors.[7-9,13,17,18] This notwithstanding, it is clear that there are early risk factors that appear in almost all data analyses as correlating with the later appearance of psychosocial problems. The early risk factors correlate with later problems; in concert with each other, cumulative risk can eventuate, and the chances of symptomatology or dysfunction are thus exponentially increased. We must reiterate that none of these, however, is solely and definitively predictive of inevitable problems. Unfortunately, many of the external stressors and burdens in Table II coexist and interact in a cumulative and mutually catalytic (potentiating) manner. Conversely and fortunately, most of these risk factors can be significantly ameliorated or even overcome (sec below).

Positive emotional factors for resilience: enhancing social contexts

The research data that consistently finds the same risk factors (above) as potentially detrimental to one's development and self-actualization clearly indicate that there are, conversely, ideal circumstances contributing to better chances for personal growth and fulfillment.[4,6,13,19-22] It is important that we strive to approximate these factors in the lives of our children. From the viewpoint of those who wish to improve conditions for the world's children - the soil, sustenance, and succor - and to increase their resilience potential, benefiting them and the rest of society, the following have been repeatedly shown to correlate with resiliency, and ultimate self-realization:

A primary attachment. The single most important factor in an infant's life is the bond formed with a primary caretaker. This is the foundation of a primal awareness that needs can be met, comfort can be provided, pain can be alleviated, and inner peace can be achieved.

Love. Love in childhood represents affection, appreciation, nurturance, commitment, dedicated time, interest, and caring - all constant reminders of being regarded as a vital presence.

Limits. Rules, laws, and consequences define expectations and, by implication, the boundaries of safety and social interaction in every community.

Stimulation. Without stimulation of the senses, and of cognitive, visual, auditory, olfactory, and tactile explorations, a child is cheated of opportunities to learn, inquire, and discover the interactions of living.

Relationships with peers. Contacts inside and outside of the family, friends, and companions help a child to answer questions like “Where do 1 fit in?” “What am I all about?” and “Who am I?” They hold up the mirrors of development and interaction; they challenge and stimulate; they reach and test; they provoke and reward.

Models and mentors. Older peers or trustworthy adults can guide, counsel, and inspire a child or youth.

Space. Children need both physical and emotional privacy, as well as temporal space for exploration. Space to be alone, to experiment, to fantasize, and to make mistakes is necessary within limits of safety, but also for the internal, private reflections that often occupy the children's thoughts.

Respect. By modeling civility in everyday discourse and empathy for others, respect is evident in words and deeds, and is “transferred” to future generations.

Consistency. Children need a sense of predictability, stability, routine, and ritual. They need to know that those who care for them are reliable, dependable, and stable, and are there in good times and in bad.

Responsibilities. Holding a child responsible for certain obligations invites him or her to share in the adults' reality, teaches mutual dependence, and dispels the notion of a perpetual free ride.

Safely and subsistence. Freedom from fear and want is a prerequisite of freedom for growth, exploration, and opportunity.

Opportunities. All children should have access to quality medical care, education, recreational activities, and vocational choice.

Traditions. Ritual and repetitive family, cultural, or religious events not only enhance the present; they also enrich the future and endow the past with a sense of continuity and community.

Altruism. To receive a kindness or to bestow one can be a moving experience for anyone, at any age. Human beings seem to need reminding to bring altruism forth and to battle the fear that opposes it. Children do, in fact, model their parents' generosity and altruism.

Values. Young people need to be inspired, to believe in a reason for being beyond the mundanities of life. Their essential energies are longing to be stimulated and energized. Idealism can more readily be kindled in youth than at any other time of life.

The tetrad of Bs

In studies done on youth and young adults in a variety of settings,[6,22-25] and in interview research with elderly people,[26] four particular determinants repetitively and consistently manifested themselves in evaluating the self-perceived satisfaction and worth of one's life. They are:

(Personal) being - a sense of self. This refers to one's self-image and accommodation to one's sense of identity. It includes an appreciation of strengths, as well as an awareness of one's limitations, and reflects a perception of being “grounded,” comfortable in one's skin (“le confort dans sa peau”).

(Social) belonging. This refers to a sense of being an integral, accepted, appreciated part of a community. It is more than merely being with like-minded people; support and nurturance are dc rigeur. It encompasses the sharing of noteworthy personal (pain and pleasure) experiences, mutual empathy, common goals, and a sense of being affiliated and “connected” in a basic, meaningful way.

(Ideological) believing. This is the sense of personal embodiment of an overriding system of values and principles of life, beyond the everyday mundanities of living. This is especially so beyond unbridled competition, materialism, and acquisitiveness. It refers to a “higher order” raison d'être, a moral compass, and even a spiritual guide (although it need not be religious in nature).

(Altruism) benevolence. This serves to complete the tetrad of Bs, but it is clearly related to the other Bs and really depends on the existence of the others. This encompasses the degree to which an individual is authentically generous and generative. This is the ultimate criterion in the personal evaluation of one's selfimage - the extent of self-initiated mentoring and magnanimity, caring for and charity to others, nurturing and supporting, giving of one's self for the benefit of family, friends, the less fortunate, etc. This is particularly meaningful in the context of deprivation, where a battered individual is still committed to sharing, giving, and mentoring.

Fostering resilience

This leads us to the most crucial and salient question in this discourse on the concept of resiliency. First, we should consider that: (i) many individuals do in fact recover from destitution and go on to lead meaningful, productive lives; (ii) there are discerned social risk factors associated with the appearance of personal difficulties, symptoms, and maladaptive or destructive behaviors; and (iii) there are equally well-documented personal characteristics that are shared by those who have demonstrated resiliency in their personal trajectories.

If these statements are valid, then the crucial question is whether there are active preventive and interventional programs that we can introduce, which have been shown (prospective research data) to be effective in (i) significantly reducing social risk factors; (ii) ameliorating personal distress and debilitating behaviors; (iii) significantly improving the resiliency potential of individuals at risk; and (iv) dramatically improving the outcomes of children (personally, scholastically, behavi orally).

The answer to this seminal question, is a resounding “Yes!”[2,19,20,27,28] In reviewing the literature, what we clearly glean is that much can be accomplished by the following dedicated measures.

First and foremost, the introduction, initiation, and implementation of these protective interventions require a societal commitment. This, of course, has taxation implications, because the up-front investment would indeed be considerable, and perhaps more than most societies could afford. However, to the extent that even a modicum of well-designed preventive and interventional programs can be enacted with high-risk children, the later savings to that society in terms of working, productive, tax-paying, caring, healthy, law-abiding, generative adult citizens would be enormous (and also far exponential to the initial cost).

Successful programs - and examples are legion[21,29,30] - are often initiated to combat specific and difficult examples of psychosocial problems (eg, scholastic failures and dropouts, vandalism, gangs, violence, early teenage pregnancy, drug use, etc). When they work, ie, when they are effective and efficacious in their respective domains, there is a generalization to other social and personal spheres of endeavor. All these programs involve similar and simultaneous approaches, which are listed in Table III.[31-37]

Discussion

We have learned from the many studies of resilience, including our own, and especially from interviewing many of the resilients among us, the following salient and salutary lessons:

Early trauma and destitution by no means inevitably lead to permanent scarring and debilitation.

Early devastating trauma can take many forms: severe, acute or chronic illness; abject poverty; brutality; abuse; forces majeures (earthquakes, floods, fire, landslides, drought, hurricanes); persecution; omnipresent danger and fear, etc. The nature and severity of the trauma, the presence or absence of inner and other resources, and the immediate and subsequent mobilization of the same all determine the quality of the coping process and the resiliency of the individual.

Nobody is invulnerable. All children and adults have their limitations and breaking points. Given an existing stress or, more often, a confluence of different stressors with sufficient severity, any of us can succumb to these oppressive forces, and be debilitated.

There has been a report of the existence of a single gene, called 5-HTT, the long form of which may serve to confer some increased resistance to external stress, while the short form appears to be more associated with psychological difficulties in response to adversity.[38]

Few are helpless. Almost all children, adolescents, and adults have some resources (biopsychosocial fortifications), which can be strengthened and built upon to greatly enhance their resiliency potential.

Nobody does it alone. In literally every instance (case) of those we have studied, there has been at least one crucial individual who took an interest, extended an arm, and served as a nurturcr or mentor helping recalibrate a corrective trajectory, by facilitating, exhorting, and advising (constraining if necessary) along the arduous path.

We all have different levels of individual resources and levels of tolerance for stress. As with intellectual and scholastic abilities, social skills, and athletic, artistic, and musical talents, we differ in our abilities to withstand major difficulties in our lives.

The resilient individual utilizes social skills, trust, initiative, and motivation to grasp the extended arm.[6,24,25]

Even those resilients who have thrived after calamitous losses will have suffered some ill effects down the road, ie, nobody gets away unscathed in life (eg, symptoms of anxiety, posttraumatic stress disorder, etc).

The presence of a personally committed, consistent, nurturing caregiver in the first year or more of life is a vital advantage to any child. It is what we would wish for all children; but, even without this soulful ingredient, children can and do thrive if other basic needs and opportunities are provided.

As risk factors increase in a population, so too do the appearance of deleterious problems in children and adolescents.

As resources (preventive, interventional) are shored up in a community, so too do at-risk children and adults manifest increased evidence of coping skills and resilience.

Every child merits and needs the universal availability of: (i) good schools and education; (ii) good affordable, accessible health care; (iii) good recreational facilities; (iv) good private and public sector jobs training and programs; and (v) outlets for contribution to others (volunteer programs).

It does indeed take a village to raise a child (Zulu saying).

Conclusion

We are thus led to an optimistic, yet challenging, conclusion. In this era of seemingly omnipresent conflicts, turmoil, and wars, we still can and do conclude from the foregoing, that, even given our relatively limited level of knowledge regarding the human condition, humanity does have the capacity to take a quantum leap forward in assuring the growth and development of children. We can do this by enhancing their innate resources, fostering their blossoming into adults who maximize their potential and thus contribute significantly to society, to us, and to themselves. We are thus confronted with an opportunity and a challenge of great consequence. The crucial question is “Do we have the will and commitment?”

Case histories

Jacob

Jacob was 9 when he saw his parents and bother shot by German Nazi storm troopers in Poland. He fled and lived in the woods for 2 years. He was placed in a refugee camp in Vienna in 1945, and was sent to Israel in 1948, where he knew no one and had no money. He moved to the USA in 1951 . Jacob became a successful developer and philanthropist; he married and had three children; his two daughters are lawyers and his son a playwright.

Ngo

Ngo saw her family napalmed at age 5. She was raised in a brothel in Saigon, and was raped and beaten. In 1976, she escaped in a boat to Thailand, which was hijacked and she was again raped and beaten. She was sent to a refugee camp in Hong Kong, and from there to Canada in 1979, where she was adopted into a dysfunctional family. She was suspended from high school for drugs, theft, and sexual misconduct. She now has a graduate degree in social work.

Isaiah

Isaiah was born into poverty. His biological father disappeared when he was a baby. His alcoholic mother was illiterate and suffered bipolar disorder. He had multiple stepfathers, who were often abusive. He grew up in the inner city exposed to gangs, guns, drugs, violence, and armed robbery. All of his friends are either dead, in institutions, or on the “mean street” Isaiah went to law school and is now a lawyer.

Table I.

Personal attributes that are positive for resilience.

Secure early attachments	As Erickson so lucidly showed,[15,16] the availability of a close, caring consistent responsive and loving parent (caretaker) is most conducive to an individual's/child's sense of trust and self-esteem
Temperament	A temperamental style that is fluid and easy, as opposed to erratic and brittle, acts as a facilitator of social involvement, adaptability, coping, belonging, and resilience[4]
Intelligence	A basic modicum of intellectual/cognitive skills is paramount to adequate comprehension and funtioning (brilliance, however, does not guarantee exceptional resiliency skills)[4]
Health	Both physical health and emotional stability are correlated with coping skills and resilience. However, there are innumerable examples of chronically ill or psychiatrically disordered individuals who have shown extraordinarily resiliency skills and thrived
Appearance	While this may offend some readers, it is clear that an attractive facies and demeanor enables more approach than avoidance interactions (even more so, trust than distrust), with the consequent social reinforcement for one's perceived self-worth
Social skills	Individuals with a positive interpersonal manner, who can interact with facility and warmth, who can read their companion's mood and receptivity, who have empathy for others' situations, who inspire confidence and trust, and who are engaging and communicative are much more inclined to have help and opportunities proffered to them[8,14]
Self-awereness	Like empathy for others, the capacity to size up oneself, to recognize strengths as well as weaknesses, to have some insight into one's own moods, relationships, etc, is of salient importance in dealing with the challenges, obstacles, disappointments, and failures, that life inevitably throws in one's way[6]
Optimism	“The glass half full” goes a long way towards enabling one te cope with life's travails[6]
Sense of humor	To be able to laugh, be amused by one's own foibles and frailties, and by the vagaries of life, is a wonderfully enhancing attribute
Purpose and planning (organization)	The most resilient individuals are seemingly more purposeful and committed to an organized, analytical approach, as well as to a sequential plan of dealing with difficulties or challenges and resolving problems
Productivity	Resilient people tend to be dedicated workers, task-oriented, with an eye on successful fulfillment and completion of duties and responsibilities
Compartmentalization	This is an attribute that enables individuals to cope with the inevitable vicissitudes of life temporarily by walling off or circumscribing worries about other significant problems in their lives, so that they do not become debilitated
Recreation	This refers to the ability to play, relax, “kick back,” enjoy one's leisure, and appreciate the time and space afforded by lack of time- and task-inspired duties and demands
Contactful, approachable	While this relates to the social skills characteristic, it more specifically refers to the ability to respond to another's offer of help, during a particularly tough time

Table II.

Negative environmental factors for resilience: risk factors for psychosocial problems.

Poor pre-, peri-, and post-natal care of mother and child	Highly implicated in cognitive, behavioral, or emotional dysfunction
Abject poverty	Adds deprivation and stress on farmilies, making coping more difficult, and diminishing opportunities for personal growth
Abuse/neglect/molestation	Remarkably associated with difficult development, and later manifestation of symptoms
Family dysfunction/discord/upheaval	Imposes an environment of chaos and instability on children who benefit most from stability predictability, and nurturance
Parental psychopathology	If untreated or managed, has been shown to affect offspring in two ways either by genetic vulnerability, or by adding to the chaos and turmoil (above)
Inadequate/poor schools	School is one of the most vital preventative and rehabilitative allies we have in our struggle against the loss of children in society. Schools can often make up for the psychosocial deficits elsewhere in a child's life
Lark of significant nurturing adults	Perhaps the most salient, crucial loss of all the necessary ingredients in the life of a child
Absence of mentors and models	Related to the above, but is often adjunctive or can even serve as a surrogate or replacement, especially for older youth
War/culture of violence and chaos	Need not be graced by descriptions of egregious harm
Forces majeures (natural disasters)	Can destroy families, inflict brutalizing injuries and losses, and remove any semblance of stability

Table III.

Approaches used by successful protective intervention programs. SED, Severly emotionally disturbed.

Family-centered programs	Utilizing parent support, parental training and education, babysitting, respite care, recreational activities, hotlines, case management, parent groups, child support, advocacy, welfare,[31] etc
School-centered programs	Using good teaching (teachers, space, materials, etc), tutoring, special SED classes, counseling programs, health centers, involvement of parents, after-schooll programs, summer programs, peer groups, [29,32] etc
Neighborhood-centered programs	Removal of guns; use of safety committees, block parents, community-based institutions (church, school, recreation centers, etc), police patrol, mentorship programs, parental involvement, etc
Private sector	Use of apprentice programs, paid/part-time and summer jobs, educational equivalency credits, at-school presentations, tours and visits, “mentorsnips,” parental involvement, etc
Police	Use of visits to schools, “cop-on-the beat” programs, friendship emphasis (as opposed to purely punitive), tours of facilities, community officers, recreational programs, etc
Effective therapeutic interventions in high-risk families	For children with serious disorders and high-risk circumstances, a child-centered aggregation of parents, case managers, physicians, social workers (and teachers, librarians, neighbors, police, recreation supervisors, nurses, employers, etc - any or all of the above), as dictated by the individual child's needs,[28,31,33-37] eg, wraparound programs and multisystemic therapy