TRAUMA, PTSD, and RESILIENCE a Review of the Literature

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10.1177/1524838005277438TRAUMA,Agaibi, Wilson VIOLENCE, / TRAUMA, & ABUSE PTSD, / AND July 2005RESILIENCE TRAUMA, PTSD, AND RESILIENCE A Review of the Literature

CHRISTINE E. AGAIBI University of Akron

JOHN P. WILSON Cleveland State University

Based on the available literature, this review article investigates the issue of resilience in relation to trauma and posttraumatic stress disorder. Resilient coping to extreme stress and trauma is a multifaceted phenomena characterized as a complex repertoire of behavioral tendencies. An integrative Person Situation model is developed based on the literature that specifies the nature of interactions among five classes of variables: (a) personality, (b) affect regulation, (c) coping, (d) ego defenses, and (e) the utilization and mobilization of protective factors and resources to aid coping.

Key words: PTSD, resilience, positive coping, resilient behaviors, interactional models

THIS REVIEW OF THE LITERATURE on Theoretical models of traumatic stress syn- trauma, posttraumatic stress disorder (PTSD), dromes and the literature on PTSD have estab- and resilience examines a wide range of studies lished that there is a wide range of outcomes in over several decades. It develops a framework how persons cope with traumatic experiences by which to view the historical evolution of re- (Bonnano, 2004; Wilson, 1995; Wilson & search on psychological resilience in general Drozdek, 2004; Wilson, Friedman, & Lindy, and the nature of posttraumatic resilience in 2001; Wilson & Raphael, 1993; Zeidner & particular. The chapter organization reflects the Endler, 1996). The models of traumatic stress central conceptual issues surrounding the con- (Wilson, 1989, 2004a; Wilson et al., 2001; Wilson cept of resilience; the early developmental stud- & Thomas, 2004) and adaptive coping processes ies of resilient children growing up under ad- (Folkman, 1997) are useful paradigms by which verse environmental conditions; the paradigm to examine the question of resiliency: How is it of extreme stress, trauma, and resilient coping that persons recover and “spring back” from during and after exposure to powerful, life- psychological trauma? What are the psycholog- threatening stressors; and the need for a generic ical factors that are associated with resiliency model of posttraumatic resilience, coping, and and effective coping? What are its internal adaptation. mechanisms in the psyche and as manifest in adaptation to environmental demands?

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THE DEFINITION OF RESILIENCE KEY POINTS OF THE RESEARCH REVIEW In this article, we explore the question of • Posttraumatic resilience refers to a complex rep- trauma and resiliency. We present a conceptual ertoire of behavioral tendencies. model of trauma and resilience based on a re- • Posttraumatic resilience is associated with a clus- view of the literature. To undertake such an ter of personality traits linked to extraversion, high self-esteem, assertiveness, hardiness, inter- analysis requires definitional clarity on the nal locus of control, and cognitive feedback. meaning of resilience. Understanding the nature • Posttraumatic resilience is associated with ego re- of resilience requires conceptual and defini- silience, which includes flexibility, energy, asser- tional clarity. What is resilience and what con- tiveness, humor, transcendent detachment, and a stitutes resilient behavior? This seemingly sim- good capacity for affect regulation. • Posttraumatic resilience is a form of behavioral ple question turns out to be very complex as a adaptation to situational stress and a style of per- psychological and behavioral process. There are sonality functioning. at least five distinct ways to define human resil- • Posttraumatic resilience in response to trauma in- ience. First, what is the lexical definition of resil- cludes recovery from PTSD to optimal states of ience? Second, what constitutes resilience as a functioning and psychological immunity to psychopathology. psychological phenomenon in its purest form devoid of contextual parameters? In terms of basic processes of perception, cognition, affect traumatic (during) and posttraumatic forms of regulation, and information processing, what resilient behavior. Stated differently, what set of characterizes resilience? Third, what defines re- psychological factors are associated with resil- silient behavior under adverse environmental ient coping in the “face” and “wake” of trauma? conditions? This question spurned the early re- Fifth, the issue of PTSD and resilience similarly search on resilient children who grew up in pov- raises questions regarding the dimensions of ef- erty, in malfunctional families, or in conditions fective coping. For example, what factors are of cultural deprivation. The focus on resilient protective against the onset or later develop- behavior is a way of evaluating resilience by ment of PTSD? What factors (e.g., personal, so- outcome: How is good performance main- cial, support resources, etc.) are associated with tained in the face of adversity, overwhelming resilient recovery from PTSD versus chronic disadvantage, or impediments to highly effec- forms of the disorder? Resilient posttraumatic tive adaptation and performance as defined by coping behavior poses the question as to conti- a range of dependent variables (e.g., mental nuities and discontinuities in resiliency across health, school performance, absence of illness the life span. Is posttraumatic resiliency a char- or psychopathology, etc.)? Fourth, the question acteristic of the person or highly influenced by of psychological trauma and resilience is a vari- normative life crises of aging and unique situa- ation on conceptualizations of effective coping tional contexts that challenge coping reper- and adaptation under adverse environmental toires? circumstances. Trauma, however, is generally The Oxford English Dictionary defines resil- defined by stress events that present extraordi- ience as “the activity of rebounding or springing nary challenges to coping and adaptation. In- back; to rebound; to recoil.” It further defines re- deed, the Diagnostic and Statistical Manual of silience as “elasticity; the power of resuming the Mental Disorders (DSM-IV-TR; American Psy- original shape or position after compression, chiatric Association, 2000) definition of trau- bending, etc.” It is the ability “to return to the matic stressors includes “experiencing, witness- original position.” The lexical analysis also in- ing, or confronting events that involve actual or cludes the adjectives “cheerful, buoyant, and threatened death or serious injury, or a threat to exuberant.” The linguistic use of the term resil- the physical integrity of self or others” (p. 467). ience refers to a property: an ability of an object Thus, the issue of resilience to traumatic situa- to restore its original structural form, despite be- tions raises questions as to the nature of peri- ing temporarily altered by external forces that

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 197 would “bend” or “compress” its shape. The hood development, type of trauma or stressful property of resilience, then, would apply to be- life event, personality characteristics, cognitive havioral phenomena in engineering, physiol- style, prior history of exposure to stressful ogy, the natural environment, and human be- events, gender, age, capacity for affect regula- havior in a variety of environmental contexts. tion, social support, and ego defenses (Agaibi, Moreover, resilience is generally viewed as a 2003; Fredrickson, 2002; Schore, 2003; South- quality of character, personality, and coping wick, Morgan, Vythilingham, Krystal, & ability. Resiliency connotes strength, flexibility, Charney, 2004; Wilson, 1995; Zeidner & Endler, a capacity for mastery, and resumption of nor- 1996; Zuckerman, 1999). mal functioning after excessive stress that challenges individual coping skills (Lazarus & Folk- Resilient Persons, Resilient Behavior man, 1984; Richardson, 2002). In some and Its Process Over Time definitions, resilience refers to an ability to overcome high loads of stressful events (e.g., To facilitate a review of the relevant litera- trauma, death, economic loss, disaster, political ture, we will organize this article into sections upheaval and cultural changes) and maintain and attempt to draw conclusions from an analy- psychological vitality and mental health (Bon- sis of the findings. To be clear about the impor- nano, 2004; Harel, Kahana, & Kahana, 1993; tance of resiliency, the concept must be opera- Harel, Kahana, & Wilson, 1993; Wilson, 2004a; tionally defined. Wilson and Agaibi (in press) Wilson & Drozdek, 2004; Yehuda, 1998). In ex- suggest that it is conceptually advantageous to perimental studies, resilience has been used as define resilience as a “complex repertoire of be- independent and dependent variables. In this havioral tendencies.” regard, it is meaningful to speak of resilient per- They state that resilience Current definitions of sons and resilient behavioral adaptations and characterizes a style of be- resilience vary from outcomes in different situations. Clearly, a Per- havior with identifiable absence of son × Situation interactional model of resilience patterns of thinking, per- psychopathology in a is conceptually critical to the analysis of resil- ceiving, and decision child of a severely ience as a posttraumatic phenomena (see Aron- making across different mentally ill parent, to off & Wilson, 1985; Wilson, 1989; Zeidler & types of situations. Cur- the recovery of a Endler, 1996 for a review). What are the charac- rent definitions of resil- brain-injured patient, teristics of resilient persons that distinguish ience vary from absence to the resumption of them from less resilient persons? What consti- of psychopathology in a healthy functioning in tutes resilient behavior in different types of child of a severely men- survivors of extreme traumatic situations with varying degrees of tally ill parent, to the re- trauma. stress demands, adversity, or the complexity of covery of a brain-injured problems to be solved? patient, to the resumption of healthy function- In a metatheory of resilience, Richardson ing in survivors of extreme trauma (Folkman, (2002) proposed that the history of research on 1997; Garmezy, 1996; Harel, Kahana, & Wilson, resilience can be classified in three ways: (a) 1993; Wilson & Drozdek, 2004; Wilson & Ra- identifying the unique characteristics of per- phael, 1993). In this regard, it is helpful to study sons who cope well in the face of adversity, (b) longitudinally the process of resilience, examin- identifying the processes by which resiliency is ing positive versus negative adaptation, cop- attained through developmental and life expe- ing, and the operation of personality variables riences, and (c) identifying the cognitive mecha- in different situational contexts. For example, is nisms that govern resilient adaptations. Previ- resilience a stable characteristic of personality ous research on the phenomena of resilience has or a variable dimension of behavioral adapta- examined a substantial domain of critical fac- tion under situational pressures? Is the study of tors thought to be associated with resilience and resilience in relation to trauma a universal para- include genetics, neurobiological factors, child- digm by which to understand all forms of

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 198 TRAUMA, VIOLENCE, & ABUSE / July 2005 resilient behavior? Are resilient trauma for a middle ground, studying successful adap- survivors the “gold standard” examples of suc- tation in the context to unusually adverse life cessful coping and adaptation? circumstances. In the most basic sense, resiliency has been Researchers studying resilience recognize the defined as the ability to adapt and cope success- multifaceted task of understanding the differ- fully despite threatening or challenging situa- ent forms of adaptation that characterize resil- tions. Resilience is a good outcome regardless of ient behaviors (Caffo & Belaise, 2003). Multirisk high demands, costs, stress, or risk. Resilience is situations as well as psychobiological sustained competence in response to demands (Southwick et al., 2004) and sociocultural influ- that tax coping resources. Resilience is healthy ences have been analyzed to understand the na- recovery from extreme stress and trauma (Wil- ture and dynamics of resiliency. In regards to son & Drozdek, 2004). Resilience has been con- psychological trauma, Weisaeth (1995) has ceptually linked with curiosity and intellectual identified the nature of high-risk persons, situa- mastery as well as the ability to detach and con- tions, and reactions to traumatic stressors and ceptualize problems (J. H. Block & Kremen, proposes a matrix analysis of their interactive 1996). Resilience has also been postulated to in- effects in coping and adaptation. clude strong extroverted personality character- In relation to other concepts identified in the istics (e.g., hardiness, ego resilience, self-es- traumatic stress literature, resiliency reflects a teem, assertiveness, locus of control) and the pattern of competence and self-efficacy in the capacity to mobilize resources (Wilson & presence of extraordinarily difficult events and Agaibi, in press). raises critical questions. Are resilient individuals primarily characterized by having compe- Historical Foci in the Study of Resilience: tence in areas of psychological functioning? Children, Gender, Competence, Trauma, Competent performance indicates positive be- and PTSD liefs about self, task performance, and problem solving (Weisaeth, 1995). Areas of personal Richardson (2002) stated that “from a histori- competence extend to the successful mastery cal view, the first wave of resiliency inquiry fo- and ability to cope with traumatic stressors as cused on the paradigm shift from looking at the trauma invariably taxes coping resources risk factors that led to psychosocial problems to (Yehuda, 1998). On the other hand, chronic, ex- the identification of strengths of an individual” cessive stress imposes demands for coping and (p. 309). Indeed, prior to the onset of systematic can lead to health problems (Schnurr & Green, research on PTSD in 1980 (Wilson, 1995; Wilson 2004). In analyzing these variables, research evi- et al., 2001; Wilson & Raphael, 1993), studies dence suggests that competence is related to use tended to look at how children subjected to of psychosocial resources (Caffo & Belaise, harsh developmental and formative experi- 2003). In brief, resources to develop competence ences emerged psychologically healthy rather are less prevalent among children growing up than developing psychopathology. In his suc- in adversity. Competence does develop, how- cinct review, Richardson (2002) highlighted the ever, with sufficient resources even if there are research of Werner and Smith (1992), Michael chronically severe stressors present. Research Rutter (1990), and Norman Garmezy (1991), shows that adolescents with maladaptive be- who studied children thought to be “at risk” behavior tend to be overly reactive to stress and cause of economic poverty, severely mentally ill have a history of low resource utilization and parents, or developmental deprivations of dif- lack competence in coping with stressor de- ferent types (e.g., neglect, abuse, poverty, social mands (Masten et al., 1999). Good parenting is class). Among the classic pioneering studies of associated with the development of cognitive psychological resiliency, Garmezy (1981) and skills that facilitate greater competence in cop- Cicchetti and Garmezy (1993) noted that cau- ing with different types of stressors. Among in- tion is warranted in the study of resilient per- dividual difference variables, IQ is a significant sons by not selecting extremes for study and opt predictor of social competence and intellectual

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 199 functioning (J. H. Block & Kremen, 1996) and ables (Aronoff & Wilson, 1985; Wilson, 1989; acts as a vulnerability factor for antisocial be- Zeidner & Endler, 1996; Zeidner & Endler, havior in “at-risk” groups of children and ado- 1996). Resiliency is a multidimensional con- lescents (Masten et al., 1999). struct that is defined by performance outcome, In terms of vulnerability factors, Masten et al. the adequacy of responses to normal and severe (1999) found few differences that differentiated stressors, including traumatic ones, and how competent and resilient individuals. Resilient cognitive processes and the ability to modulate children tended to resemble their competent emotions influence the ability to utilize person- peers but differed dramatically from maladap- al and social resources (J. H. Block & Kremen, tive, vulnerable, and at-risk youth. Although it 1996). is possible to identify differences that distin- Viewed from the perspective of trauma- guish resilient from nonresilient children, the tology, resilience is efficacious adaptation re- question remains as to how internal psychologi- gardless of significant traumatic threats to per- cal processes (e.g., stress appraisal, personality sonal and physical integrity (Harel, Kahana, & differences) interact with situational pressures Wilson, 1993; Wilson, 2004a; Wilson & Drozdek, (e.g., type of trauma, threat level) to set up an ar- 2004). Children that have had exposure to ray of possible forms of resilient and nonresilient chronic stress such as war trauma, refugee sta- behavior. tus, civil violence, extreme poverty, and eco- Taking a broad view of the seminal studies on nomic or social deprivation exhibited diverse resilient and “stress-immune” children, it can forms of resiliency (Wilson & Drozdek, 2004). In be seen that among the keys to understanding examining “at-risk” populations that exhibit re- resiliency is analyzing risk and vulnerability, siliency (e.g., raped adolescent girls in situa- protective factors, coping, competence, person- tions of ethnic cleansing, displaced refugees ality factors, and the capacity to effectively use and asylum seekers, torture victims, etc.), vari- resources. As summarized by Caffo and Belaise ous protective factors have been identified (Sol- (2003), psychological resilience is a consequence omon, Neria, Ohry, Waysman, & Ginzburg, of positive human development and the capac- 1994; Wilson & Drozdek, 2004). Studies of “at- ity to cope with stressors. Protective and risk” populations (Dugan & Coles, 1989), espe- growth-promoting factors are necessary to the cially those who do not develop PTSD, mood development of competence and resilience, es- pecially in disadvantaged urban youth (Par- disorders, or comorbid disorders (Folkman & sons, 1994). Children, as well as adolescents, Moskowitz, 2000; Fredrickson et al., 2003), is es- cope more effectively with adversity if they re- pecially important because they hold clues to ceive nurturing and stable care from others. optimal functioning in the face of trauma, Rutter (1990) found that organizational or insti- extreme stress, and adversity in life (Wilson, in tutional settings that promote self-esteem and press). problem-solving behavior increase the likeli- hood of competence, resilience, and the mastery Risk Stressors for Children: Early of situations that challenge coping. Paradigms for Analyzing Resilience Research evidence suggests that resilience is not gender specific and does not increase or de- A wide array of stressors exists that puts chil- crease with age (Zeidler & Endler, 1996). It is, dren at risk for maladaptive behaviors including however, related to psychological development the development of PTSD. These stressors include and changes in emotional and cognitive compe- psychological trauma and abuse, mentally ill tency (Folkman, 1997; Fredrickson, 2001; Fred- parents, physical disability, life-threatening rickson & Tudade, 2003). Resiliency and re- birth defects and personal injuries, asylum sponses to different types of life stressors can seeking and refugee status, war, disasters, and change over time (Felsman & Vaillant, 1982). life-threatening illness (Caffo & Belaise, 2003; Moreover, coping mechanisms are situationally Masten, Morison, Pellegrini, & Tellegen, 1990; dependent and interact with personality vari- Nader, 1997, 2004; Pynoos & Nader, 1993).

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Garmezy (1991) identified traumatic stressors ment problems at later stages of development that potentially put children at risk for the devel- for children with risks such as chronic poverty, opment of psychopathology, including PTSD. low maternal education, and moderate to se- He studied disadvantaged children in Amer- vere perinatal stress. One third of the Hawaiian ica’s urban cities who were subjected to extreme sample tested was considered resilient because stress. Among other outcomes, Garmezy found they did not develop problems and were psy- that these children were twice as likely to die in chologically healthy at ages 10, 18, and 30. A the first year of life, be born prematurely, suffer comparison was made between resilient chil- low birth weight, have mothers who had little dren and a high-risk sample that developed ad- or no prenatal care, and have unemployed par- justment problems. Resilient children received ent(s). These children were 3 times more likely more attention as infants and, according to their to have mothers die during their delivery, be mothers, presented as more active and socially forced to live in foster homes, or die from abuse. responsive. In summarizing her work, Emmy They were also 4 times more likely to live with- Werner (2004) stated that resilient children out a biological parent and be supervised by a “were consistently characterized by their moth- child welfare agency. They were also 4 times ers as active, affectionate, cuddly, good- more likely to be the victims of murder by age 1 natured, and easy to deal with” (p. 61). or as teenagers. Clearly,these findings suggest a How do “distal” and “proximal” risk factors wide range of negative effects to attachment interact with each other? How does culture, so- processes, ego development, vulnerability to cial status, and economic status influence fam- stressors, and the learning of competencies in ily patterns, child development, and the pres- social behavior. ence or absence of specific stressors? Agaibi At a higher meta level of analysis, social class, (2003) stated that distal risk factors are based on as an independent variable, may be a distal risk indirect stressors, such as social class. These factor but result in proximal stressors that di- risks are, however, part of the characteristics of rectly affect those subjected to such experiences proximal risk factors that are directly experi- and lead to high rates of PTSD (Kinsie, 1988, enced. Proximal risks include such things as 1994). Risk factors of socially disadvantaged chaotic environments, family trauma (Hark- mothers often occur together and include such ness, 1993; Wilson & Kurtz, 1997), familial insta- things as poor maternal nutrition, geographical bility, parental substance abuse, inadequate nu- displacement from home, domestic violence, trition, parental dissension, mental illness, or and substance abuse. Garmezy (1991) noted antisocial behavior (Nader, 1997). Agaibi sug- that the combination of maternal social, biologi- gested that if a child is exposed to distal risks cal, and environmental disadvantages and (e.g., poverty), yet experiences no proximal risk stressors increases the risk of pathology in the (e.g., neglect, childhood abuse), it is then safer to child. Similarly, Caffo and Belaise (2003) de- assume that the family is more resilient than scribed children undergoing stressors in a cycli- not. cal, stress-related pattern that increases the In the literature on risk and vulnerability, the child’s vulnerability to pathology. Children of two terms have been used interchangeably. Re- impoverished environments tend to have poor- search on classes of risk factors traditionally an- er overall health, become school dropouts, and chors itself in epidemiological studies of psy- consequently have limited job opportunities, chopathology. Studies of risk factors have which further perpetuates the cycle of poverty focused on factors that emphasize or reduce the and allied social pathologies. However, the ma- disposition to psychopathology or increase sal- jority of the children studied that lived in utary outcomes. Vulnerability has been seen as adverse conditions did not repeat the abusive an inclination toward negative outcomes, espe- patterns in their adult lives (Luthar & Zigler, cially after exposure to traumatic stressors. We 1991). refer to this process as peri-traumatic vulnerabil- In the classic study of Hawaiian children, ity (Wilson, 1989, 2004a, in press). Sources of Werner and Smith (1982, 1992) predicted adjust- vulnerability to adversity, stress, and trauma can

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 201 be present in the individual’s personality and different effects on male and female children as coping repertoire or in the environment (Wilson determined by the mothers’ style of coping and et al., 2001; Wilson & Prabucki, 1989). These role behaviors (e.g., protective nurturance, sources of vulnerability can function independ- central family decision maker, etc.). ently or in an additive manner. Compas and To partially summarize the literature’s view Phares (1991) identified five sources of vulnera- on risk and vulnerability, one can say that al- bility: (a) coping strategies and styles, (b) age or though these terms are often used interchange- developmental level, (c) personal characteristics ably, they are distinct processes. Children may that relate to gender, (d) social-cognitive factors, be deemed “at risk” by trauma, genetics, and and (e) the stress and symptoms experienced by early environmental factors (Richardson, 2002). close family members. Vulnerability is seen as a response to a stressor. Risk behaviors are seen as responses to trau- Stress Appraisal Processes matic stressors (Weisaeth, 1995). Rutter (1990) found that psychiatric illness for children in- The perception and appraisal of stressors can creases when there are two or more risk factors be conceptualized as moderating factors to present. In other situations, vulnerability and PTSD and comorbidity (Folkman, 1997; Lazarus resiliency seem to be on opposite ends of a con- & Folkman, 1984; Wilson, 2004b). As we will tinuum, in which vulnerability identifies a risk discuss, the literature on coping supports the factor eventuating in pathology and resiliency idea that problem-centered versus emotional identifies a factor leading to positive adaptive coping is more effective in dealing with trau- behavior (Garmezy, 1996). Although vulnera- matic stress (Folkman & Moskowitz, 2000; Wil- bility can be classified in categories (e.g., age, son, Harel, & Kahana, 1988; Wilson & Raphael, nature of stressor, developmental level, person- 1993; Zeidner & Endler, 1996). Lazarus and ality, etc.), each category is a representation of a Folkman (1984) suggested that an event will be factor that is associated with a vulnerability to perceived as stressful if the person believes that develop a prolonged stress the stress exceeds coping capacity. The percep- reaction (McEwen, 2002). Research findings tion of overwhelming stressor demands may In this sense, Garmezy suggest that effective lead to self-attributions of inadequate compe- (1985, 1987, 1991) saw parenting can tence to effect positive outcomes. In this regard, protective factors as the increase self-efficacy Garmezy (1987) found that children with poor ability to moderate emo- by modeling solutions self-esteem are vulnerable to interpersonal and tions, cope with stressors, to stress. Self-esteem academic stressors and tend to perceive events and manifest positive re- and self-confidence as more stressful. Compas and Phares (1991) sponsiveness to stressors, function as found that using problem solving to cope with a view shared by J. H. personality interpersonal stressors is correlated with lower Block and Kremen (1996) moderators of levels of maladjustment in children. Compas in their analysis of ego re- traumatic and Phares predicted that the level of parents’ silience, intelligence, and experiences and and children’s stress level would be correlated coping. serve as protective and found that fathers’ symptoms were signifi- Research findings sug- factors. cant predictors of behavior problems and of gest that effective par- children’s self-reports of internalizing the enting can increase self-efficacy by modeling so- stress. They found that mothers’ symptom lutions to stress. Self-esteem and self-confidence level, in comparison to the fathers’, must be function as personality moderators of traumatic more severe before children are at risk to the de- experiences and serve as protective factors. Self- velopment of problems. Similar results were re- efficacy increases with previous mastery of ported by Harkness (1993) in a study of adoles- stressful situations (White, 1959). Secure and cent children of treatment-seeking Vietnam healthy attachment increases the potential for combat veterans. The fathers’ level of PTSD, an- mastering a stressful experience and promotes ger, aggressive behavior, and depression had autonomy (Masten et al., 1990). Similarly, Nunn

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(1995) found that intellectual skills and social cus of control, altruism, the perception of social cognitive abilities function as protective factors. and economic resources, self-disclosure, and Resourceful children with problem-solving the formation of a clear sense of identity as a sur- skills tend to be more resilient and recognize vivor. Family cohesion, warmth, and lack of danger cues more quickly than intellectually discord or tension have been identified as pro- challenged children (Nader, 1997, 2004). Be- tective factors (Garmezy & Masten, 1991). cause danger is quickly discerned, help seeking External support systems, whether perceived or is initiated proactively as a response tendency used, promote good coping. that may truncate the onset of acute stress disor- In a 40-year longitudinal study of Harvard der phenomena (Nader, 1997, 2004). University students, Felsman and Vaillant (1982) attempted to identify the childhood and Longitudinal Research and the adolescent factors associated with resiliency in Identification of Resilient Factors later adulthood. This study has direct relevance to understanding psychological trauma and re- In studies of trauma, PTSD, and coping with siliency because of its longitudinal nature and extreme stress, the personality variable, internal the wide domain of personal characteristics as- locus of control, has been associated with effec- sessed throughout the course of the study (e.g., tive adaptation to stress (Harel, Kahana, & Wil- Eriksonian life stages, maturity of ego defenses, son, 1993; Wilson, 1989; Wilson, Harel, & IQ, boyhood competence, family background, Kahana, 1989). Persons with an internal locus of socioeconomic status, etc.). control tend to exhibit less PTSD and psycho- The results produced an interesting set of pathology and have better overall adjustment findings that tend to “dove-tail” with the find- than persons with an external locus of control. ings on studies of trauma, PTSD, and resilience. In a longitudinal study, Elder and Clipp (1988), First, IQ and boyhood competence (a measure using the Oakland Growth studies data bank, of active involvement in activities and a good were able to evaluate personality variables evi- childhood environment) were positively corre- dent in childhood that predicted PTSD symp- lated with current mental health, the attainment toms in Korean and WorldWar II veterans. Prior of ego maturity (i.e., generativity), good object to military service, men who were sensitive, in- relations, and the use of mature ego defenses trospective, obsessive, and introverted were (e.g., altruism, sublimation). Conversely, their more likely to manifest psychiatric morbidity measure of childhood emotional problems was than were men who were extroverted, domi- negatively correlated with these same variables nant, assertive, and self-assured. Although risk but significantly associated with sociopathy. factors include traumatic life stressors, protec- Second, there was considerable variability in tive factors are significantly related to positive psychosocial development across early adult family and peer relationships. Preexisting psy- development for the more resilient members of chopathology tends to be a risk factor for nega- the study. There was little evidence for a linear, tive psychosocial consequences, including the uninterrupted pattern of life-span development development of PTSD following trauma (Fried- that led to successful achievements later in life. man, 2000a; Garmezy & Masten, 1991; Wilson & There were periods of discontinuity and regres- Drozdek, 2004; Yehuda, 1998). In this regard, sion. However, what seemed to distinguish the Rutter (1990) defined three broad variables as resilient adults was “a clear pattern of recovery, protective factors: (a) personality coherence, (b) restoration, and gradual mastery” (Felsman & family cohesion, and (c) social support. Person- Vaillant, 1982, p. 311). In terms of resilience, ality factors include level of autonomy, self-es- this would suggest that there were identifiable teem and self-efficacy, good temperament, and periods of rest, recuperation, and recovery that positive social outlook. In the area of traumatic facilitated a restoration of competence, active stress research, Wilson and Raphael (1993) and coping, and striving, which “gradually” culmi- Wilson (1995) identified similar factors associ- nated in the mastery of challenging personal ex- ated with resilience, which include internal lo- periences. In terms of personological variables,

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 203 the data suggest that men who come from more they do suggest that there are an interrelated set or less stable childhood backgrounds, with pos- of psychobiological processes at work that in- itive early learning periods that served to facili- fluence (a) the genetic predisposition to trauma, tate boyhood competence, developed more (b) the probable protective factors from child- functional and mature ego defenses that, in hood development, (c) the operation and mod- turn, may have moderated the development of erating functions of personality processes, and self-esteem, locus of control, and prosocial be- (d) the nature and cause of prolonged stress re- havior. This being the case, we would expect sponse patterns in the central nervous system that persons suffering from psychological (i.e., the active psychobiological metabolism of trauma and PTSD would manifest patterns of the trauma experience, including traumatic adaptation, coping, and resilience that would memories; see Southwick et al., 2004, for a wax and wane over time, marked by periods of review). continuity versus discontinuity, ego coherence In a review of studies concerned with war versus fragmentation, good versus poor object trauma, natural and technological disasters, relations, gradual assimilation and mastery of torture, the Holocaust, and duty-related trauma, the impairment of trauma to their sense of well- Wilson and Raphael (1993) and Wilson (1995) being (see Wilson, 2004a, for a discussion). identified seven factors associated with resilience. Wilson (1995) found that there were similar constellations of predictors of current well- PARADIGM SHIFT: FROM “AT-RISK” being, positive mental health, and manifesta- CHILDREN TO TRAUMA SURVIVORS AND tions of resilience in these survivor populations THE STUDY OF PTSD that included: (a) locus of control (i.e., a sense of With the advent of PTSD as a diagnostic entity efficacy and determination, (b) self-disclosure in 1980, the study of resilience began to move of the trauma experience to significant others, away from traditional social-psychological and (c) a sense of group identity and sense of self as a developmental studies to more in-depth studies positive survivor, (d) the perception of personal of trauma survivors. Studies of posttraumatic and social resources to aid in coping in the resilience examined pre- and posttrauma areas posttrauma recovery environment, (e) altruistic of adaptive competence among different or prosocial behaviors, (f) the capacity to find trauma populations, including those who do meaning in the traumatic experience and life af- and do not develop PTSD. terward, and (g) connection, bonding, and social interaction within a significant community The Core Factors of Posttraumatic of friends and fellow survivors. Viewed from Vulnerability to PTSD the perspective of resilience, these seven factors appear to be identifying important classes of Zuckerman (1999) reviewed the literature on variables that interact together in generating re- vulnerability and the development of PTSD. In silience. These include factors within the person terms of PTSD, vulnerability and resilience are (i.e., locus of control, cognitive attributions of related concepts, as they characterize twin sides being a strong survivor, a firm sense of personal of trauma and the responses to it. In his sum- identity as a survivor) as well as specific forms mary analysis, Zuckerman noted that there are of coping (i.e., perception of personal and social clearly identifiable vulnerability factors to the resources to aid coping, capacity to find mean- psychiatric sequelae of PTSD that include ge- ing) and behavioral activities in the recovery netics (True et al., 1993), individual risk factors environment (e.g., appropriate self-disclosure, (e.g., family background), personality (e.g., altruism, prosocial behaviors, bonding and fel- types of ego defense, extraversion), biological lowship with other survivors) that promote re- factors (e.g., alterations in brain function), cog- silient functioning. Persons who have an inter- nitive style, and information processing. Al- nal locus of control who can find meaning in though these findings do not directly address their trauma experiences may be able to initiate the issues of resiliency in the face of trauma, a set of processes that enables them to shape a

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 204 TRAUMA, VIOLENCE, & ABUSE / July 2005 personal sense of identity by being bonded and sumed that these consequences would lift once attached to fellow survivors who, in turn, are the stressor terminated (Bryant, 2004). Al- perceived as resources for coping with emo- though chronic stress effects developed over a tional, social, and economic needs (see Zakin, period of time, acute stress effects were sudden Solomon, & Neria, 2003). Furthermore, within a and immediately impactful. In chronic stress, trusted enclave of fellow survivors, the bonding physiological and emotional processes degrade and networks formed may facilitate healthy over time (Friedman, 2000a; McEwen, 2002). In self-disclosure and the opportunity to enact acute stress, there is a rapid and sudden change prosocial behaviors and positive emotional in these physiological and mental processes states as part of the natural transformation pro- (Friedman, 2000a; Friedman & McEwen, 2004). cess of dealing with individual trauma. In this In chronic stress, the individual experiences way, too, prosocial enactments reinforce per- feelings of being overwhelmed and struggles to sonal systems of meaning and validate the cope with the long-term consequences of pro- strengths of survivorship. Similar conclusions longed stress-related symptoms. Traumatic were found by Hendin and Haas (1984), who stress results in feelings of fear that can activate found that Vietnam combat veterans with high complex allostatic psychological responses resilience were characterized by six factors: (a) (McEwen, 2002; Thomas & Wilson, 2004; calmness under pressure, (b) acceptance of fear Wilson, 2004b; Wilson et al., 2001; Wilson & in self and others, (c) low levels of excessive vio- Thomas, 2004). lence in the war zone, (d) the importance of un- In terms of trauma and PTSD, there are sev- derstanding and good judgment, (e) absence of eral studies that have examined resilience in re- guilt, and (f) humor. lation to war trauma, internment, civil violence, PTSD symptoms following traumatic stress- and terrorism. L. A. King, King, Fairbank, ors can be a result of personal vulnerability or Keane, and Adams (1998) studied resiliency as- types of pre-traumatic vulnerability (e.g., prior sociated with PTSD among Vietnam veterans in stressors, trauma, psychological disorders). In relation to hardiness, social support, and stress- some individuals, exposure to repeated trauma ful life events. L. A. King et al. predicted that may increase resilience; in other survivors, it hardy war veterans would cope better with life can degrade resiliency. This difference in out- stresses than less hardy veterans. They sug- come of traumatic stress response has been re- gested that hardy veterans would utilize social ferred to as the “steeling effect” or “prior vul- supports in their environment to overcome a nerability” disposition to develop prolonged stress. They predicted that veterans exposed to stress reactions (Figley,1985, 1986; Wilson, 1989, extreme war stressors who had strong, current 1995; Wilson & Raphael, 1993; Wilson & Droz- social support would display fewer PTSD dek, 2004). symptoms than veterans with less support. They argued that when war stressors were mea- Traumatic Stressors and Peri-Traumatic sured at low levels, there would be a weak rela- and Posttraumatic Forms of Resilience tionship between social support and the development of PTSD. It is a truism to say that not everyone devel- The results indicated that male and female ops PTSD following trauma, a fact that makes veterans who scored high on the hardiness di- the study of resilience both interesting and im- mensions of control, commitment, and chal- portant. Clearly, it is necessary to understand lenge showed fewer PTSD symptoms. Hardi- vulnerability and resiliency factors to meaning- ness was associated with fewer PTSD fully interpret the adaptation to trauma. symptoms and appears to help the individual Yehuda (1998) clarified the difference between establish relationships that aid coping with chronic, non-life-threatening stress and acute, PTSD symptoms when present. Contrary to life-threatening stress. She indicates that al- their hypothesis, hardiness did not seem to pro- though acute stress reactions have mental and tect veterans from PTSD symptoms if these indi- physical health consequences, it has been as- viduals experienced heavy combat, a finding

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 205 replicated in studies of prisoners of war (Zeiss & PTSD, dispositional resilience, coping styles, Dickman, 1989). However, the amount of social personal resources, and social support. At the support received did predict the extent of PTSD first time interval after repatriation, those with symptoms. L. A. King et al. (1998) concurred more severe PTSD symptoms were character- with Solomon and Mikulincer (1992), who ized by avoidance coping and lack of family co- stated that negative life events tend to be nega- hesion. At the second time interval, conducted tively correlated with prevalence of intact social about 2 years after the war, avoidance coping support. Stressful events can deplete social net- and a general decrease in perceived social sup- works that, in turn, increase PTSD symptoms. port resources predicted PTSD symptoms. In a Similar findings were reported by Sutker, Davis, related study, Sharkansky, King, King, Wolfe, Uddo, and Ditta (1995) in a study of war-zone Erikson, and Stokes (2000) examined 2,949 Gulf stress, personal resources, and PTSD in Persian War veterans and measured combat exposure, Gulf War veterans. From a sample of 775 mili- coping styles, PTSD, life stressors, and depres- tary veterans, 97 with diagnosed PTSD were sion. Results showed that when comparing compared to 484 who did not show pathological postwar adjustment at two different intervals signs of distress. The results indicated that vet- within 2 years of repatriation, veterans who erans with PTSD scored lower on Kobasa’s used approach (i.e., active) coping styles had (1979) measure of hardiness (i.e., commitment, fewer PTSD symptoms than men who utilized control, challenge) and had less social support avoidant forms of coping. However, those with and family cohesion as well as avoidant coping the highest levels of combat exposure had more styles with strong tendencies to self-blame. PTSD and depressive symptoms, irrespective of These results illustrate the interaction between coping styles. personality characteristics, coping styles, and In an Israeli study, Zakin et al. (2003) exam- use of social support. ined the relationship between hardiness, at- There are several studies that examined tachment style, and long-term distress among stress, coping, and the presence of PTSD among Israeli prisoners of war (POWs) and combat vet- veterans of the 1991 Gulf War. The findings erans of the Yom Kippur War in 1973. Using Is- show a similar pattern of results that, as a per- raeli POWs and matched combat controls, the sonality dimension, hardiness moderates the ef- former soldiers were administered the Symp- fects of war-zone stress and post-war coping tom Checklist 90 (SCL-90), a measure of attach- with civilian stressors. Bartone (1999) studied ment styles, the Kobasa Hardiness Scale, and a six Army National Guard and reserve medical measure of PTSD based on the DSM-III-R (1987) units about a year after the end of the Gulf War diagnostic criteria. The results showed that har- in Kuwait and Iraq. Asample of 787 participants diness was associated with low levels of symp- were given the Kobasa Hardiness Scale, the toms reported. Using a hierarchical regression Brief Symptom Inventory, Holmes-Rahe Stress analysis, the interaction between hardiness and Scale, a 20-item measure of current health sta- attachment style account for 20% to 40% of the tus, and a 15-item Gulf War zone stressor assess- measured variance in depression, anxiety, som- ment scale. The results supported a Person × Sit- atization, and present and past PTSD symptoms. uation model of resilience (Wilson, 1980). Using These results are consistent with the findings on a regression analysis, hardiness interacted with hardiness as a personality dimension associ- combat stress in predicting the global severity ated with resilience in the form of fewer mani- psychiatric index for low- and high-hardiness fest symptoms of psychiatric distress associated participants. High-hardiness persons had fewer with exposure to war-zone stressors. psychological and health-related symptoms In a study of former prisoners of war, Gold than did low-hardiness individuals. Similar et al. (2000) examined PTSD symptoms and re- findings were reported by Benotsch, Brailey, covery in World War II and Korean former Vasterling, and Sutker (2000), who examined POWs. Former POWs whose exposure to trauma 348 Gulf War veterans at two different time in- was severe were at high risk for experiencing tervals after repatriation. The authors measured psychological problems such as PTSD, depres-

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 206 TRAUMA, VIOLENCE, & ABUSE / July 2005 sion, anxiety, or cognitive deficits (Beebe, 1975; personal characteristics, such as greater self-efficacy, Eberly & Engdahl, 1991; Engdahl, Dikel, Eberly, emotional maturity, intelligence, interpersonal skill, & Blank, 1997; Page, Engdahl, & Eberly, 1991; educational level, commitment to the war effort, or locus of control may be mediating variables that re- Sutker, Winstead, Galina, & Ayain, 1991; Ten- sulted in both promotion in rank and relative ease of nant, Goulston, & Dent, 1986). Although com- adjustment to stresses of POW life and repatriation. bat veterans have a lifetime occurrence of PTSD (Zeiss & Dickman, 1989, p. 86) at 30%, POWs have a lifetime occurrence of PTSD at 67% (Khuznik, Speed, VanVelkenberg, The effects of hardiness as a personality trait & MacGraw, 1986; Kulka et al., 1990). Gold et al. have been studied in direct relation to coping, (2000) suggested that the greater the torture and daily hassles, and life stresses. These studies weight loss experienced while imprisoned, the have direct relevance to traumatic exposure and greater the PTSD symptoms. They noted that resilience in persons characterized as hardy. In premilitary trauma, personality, age, and two related studies, Maddi (1999a; Maddi & postmilitary social support played a role in de- Hightower, 1999) examined the difference be- termining the severity of the PTSD symptoms tween high- and low-hardiness students on sev- The predictors for the severity of PTSD eral measures of coping and attitudinal outlook. symptoms were thought to include severity of In the first study, Maddi and Hightower (1999) trauma during imprisonment, factors of resil- found that hardiness predicted actual transfor- ience, and postwar social support. It was found mational coping better than measured opti- that the severity of the trauma experienced dur- mism. Undergraduate students with hardiness ing imprisonment was related to distress expe- used more active coping and planning. Hardi- rienced 40 to 50 years later. The level of distress ness was negatively correlated with behavioral was inversely associated with education and disengagement, denial, mental disengagement, age at the time of the trauma. There was a signif- and proneness to use alcohol to cope with stress. icant correlation between reexperiencing the Hardiness was positively correlated with emo- trauma and the initial coping response (i.e., tional and instrumental forms of social support. peri-traumatic coping) of avoiding triggers that The authors conclude that hardiness reflects a reminded veterans of their POW experience. propensity for active problem solving and ca- Contrary to other studies, the presence of social pacity to mobilize resources as needed to support did not moderate the level of PTSD achieve desired outcomes. In the second study, symptoms. Maddi (1999a) obtained similar results in a In a 40-year follow-up study of former study of coping and strain among 20 male man- POWs, Zeiss and Dickman (1989) assessed fac- agers at a midwestern company. The results tors associated with PTSD among WWII veter- showed that high-hardiness participants were ans who were captured as war prisoners in characterized by active enjoyment and inter- Europe and the South Pacific war zones. They employed a Person × Situation interactional ests, openness of mood, social support, and a analysis of the variables significantly associated transformational work style (i.e., one character- with the persistence of PTSD symptoms across ized by active problem-solving approaches to four decades. The results revealed that 55.7% re- the challenges of the workplace). Furthermore, ported PTSD symptoms using the DSM-III the results indicated that high-hardiness partic- (1980) diagnostic criteria. They note, however, ipants had significant fewer symptoms as mea- that PTSD symptoms waxed and waned during sured by the SCL-90 symptom checklist (e.g., this postwar period of time. In terms of demo- anxiety, depression, somatization, interper- graphic variables, higher military status (rank) sonal sensitivity, etc.). The lower level of global and education predicted better outcomes in distress on the SCL-90 suggests the possibility terms of PTSD and postwar adaptation. Dura- that the hardy individuals are better at modulat- tion of internment and age at capture did not ing affect in relation to stressful demands. correlate significantly with assessments of The concept of hardiness has also been used PTSD over time. The authors suggest that to study coping among prisoners of war in Is-

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 207 rael. Waysman, Schwarzwald, and Solomon gence and ego resiliency using Block’s measure (2001) studied Israeli POWs of the 1973 Yom of ego resilience as an independent variable Kippur War. Hardiness was viewed as either a (Block, 1981; J. H. Block & Block, 1980). The peo- direct or moderating effect leading to long-term ple were participants in the Longitudinal Study positive or negative change as a result of expo- of Cognitive and Ego Development who were sure to war trauma. Consistent with the theoret- administered measures of intelligence, a 14- ical work of Antonovsky and Bernstein (1977), item scale to assess ego resilience, and the Cali- Waysman et al. looked at the role of hardiness in fornia Adult Q-Sort of personality measure- protecting POWs from long-term negative con- ment. The study generated a wide set of find- sequences. The results revealed that hardiness ings that included descriptions of persons with was beneficial for people who were exposed to high levels of ego resilience who were charac- extreme stressors when compared with those terized on dimensions that included flexibility, who were exposed to lower levels of stress. Har- challenge, confidence, curiosity, assertiveness, diness as a stress moderator exerted an effect of control, sociability, energy, and prosocial dispo- stress-related symptoms in POWs but not on sitions. When the effects of intelligence were controls who fought in the same war but experi- controlled, resilient men and women were enced less exposure. An inverse relationship found to be outgoing, warm, assertive, calm, en- was found between hardiness and negative ergetic, autonomous, active, productive, inter- changes in both the POW and non-POW nally consistent, poised, and responsive to hu- groups. It was found that the higher the hardi- mor. In summarizing their findings, J. H. Block ness score, the fewer negative changes experi- and Kremen stated, “The biosocial problem of enced. POWs generally reported more negative the individual is adaptation. Insufficiencies of ad- changes in their lives following the trauma of aptation are signaled to the individual by the intru- war than their non-POW counterparts. Hardy sion of affect. Yet, current expanded conceptions of POWs were less adversely impacted by postwar intelligence have remained ‘cognitive’ and still negative life changes than less hardy former largely ignore affective and motivational aspects of internees. behavior” (p. 359, emphasis added). It would ap- In a study of Holocaust survivors who were pear that ego resilience reflects qualities of per- children at the time of their internment, Cohen, sonality and their use in adaptation but also a Dekel, and Solomon (2002) examined the role of attachment as a variable associated with PTSD capacity to modulate stress response, an impor- symptoms and patterns of adjustment. In com- tant issue in the dynamics of PTSD. Consistent parison to non-Holocaust controls, the survivor with Fredrickson’s (2001) formulation that posi- group manifested more symptoms of PTSD. tive emotions establish a “broaden and build” However, treatment-seeking survivors showed domain of effective behaviors in regards to higher levels of anxiety, avoidant attachment, stress modulation, ego resilience appears to re- and current symptoms of PTSD than did the un- flect an interrelated set of cognitive and person- treated survivors and matched controls. The au- ality variables that work in harmony to promote thors note that as a cohort, Holocaust survivors resilient behavior. These findings match conclu- show a wide range of variability in their scores sions by Siebert (1996), who studied the traits of for PTSD, coping styles, and issues related to at- survivors of extreme environmental hardship tachment. These findings parallel those re- and threats to life. Siebert indicated that survi- ported by Eitinger (1980); Harel, Kahana, and vor personalities were characterized by opti- Kahana (1993); and Kahana, Harel, and Kahana mism, acceptance of their situational fate, cre- (1988). ative problem solving, and the integration of As an independent variable, resilience has right-brain abilities of intuition and holistic been conceptualized as a personality character- thinking with left-brain analytical thinking. istic (e.g., hardiness, locus of control) and in These characteristics of survivor personality terms of ego processes. J. H. Block and Kremen traits are quite similar to the attributes of ego re- (1996) studied the relationship between intelli- siliency as described by J. H. Block and Kremen.

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In two related studies, Connor and Davidson search supporting the idea that positive emo- (2003; Connor, Davidson, & Lee, 2003) reported tions are associated with some types of resilient findings on the development of a scale to mea- functioning. For example, Tugade and Fredrick- sure resilience as a concept. In the first study,the son (2004) found that resilient participants in an 25-item Connor-Davidson Resilience Scale anxiety-producing experimental task returned (CD-RISC) was developed to measure dimen- to homeostasis faster than did nonresilient par- sions thought to be associated with resilience ticipants. More specifically, Fredrickson sug- (e.g., 1. able to adapt to change, 6. see the human gested that positive emotions, which include side of things, 12. when things look hopeless, I joy,interest, contentment, and love, have a func- don’t give up). Five groups of participants were tional capacity to broaden a “thought-action” selected for study: (a) general population, (b) repertoire and lead to effective coping. This idea psychiatric outpatients, (c) participants in a was tested in a study of college students who generalized anxiety disorder study, (d) patients were evaluated before and after the September in private practice, and (e) participants in a 11, 2001, terrorist attacks on the World Trade study of PTSD. The 25-item CD-RISC was ad- Center in New York City. Resilience was mea- ministered to all five groups and subjected to a sured by J. H. Block and Kremen’s (1996) ego re- factor analysis and revealed five factors: (a) per- silience scales. Personality characteristics were sonal competence, (b) affect tolerance, (c) accep- assessed by the neuroticism, extraversion, tance of change, (d) sense of internal control, openness (NEO) five-factor model and by mea- and (e) spirituality. The CD-RISC scale was also sures of current mood using a scale to rate cur- cross-validated in this study with the Kobasa rent affective states (e.g., sadness/depression, hardiness measure, the Perceived Stress Scale, joy/excitement, etc.). The results showed that and the Stress Vulnerability Scale. The results positive emotions were associated with pre-911 show that measured resilience was significantly resilience and the absence of depressive symp- correlated with high levels of hardiness and low toms post-911. In short, those who manifest levels of perceived stress vulnerability. gratitude, interest, love, and other positive emo- Connor et al. (2003) used the CD-RISC in a tions were less distressed emotionally by the study of survivors of violent trauma who com- terrorist attacks. Similar results were found by pleted an online computer survey that assessed Folkman (1997; Folkman & Moskowitz, 2000) in spirituality, anger, health, PTSD, and trauma- studies of HIV/AIDS-related caregiving related distress. As predicted, resilience was as- (Moskowitz, Acree, & Folkman, 1998, as cited in sociated with more positive outcomes in terms Folkman & Moskowitz, 2000). Those who had of current physical and mental health status and positive affect, as assessed by the Bradburn Af- fewer PTSD symptoms. The results suggest that fect Balance Scale, were less clinically depressed although the relationship between trauma and during the course of the study period than those psychological distress is complex, resilience who experienced negative affect. Building on is strongly associated with positive outcomes the seminal work of Lazarus and Folkman in terms of affect balance (i.e., less anger), fewer (1984), Folkman and Moskowitz (2000) identi- PTSD symptoms, and better overall health fied three different coping styles: (a) positive re- status. appraisal, (b) problem-focused coping, and (c) There are several recent studies that have ex- the capacity to create meaning. Clearly, resil- amined the role of positive emotions in coping ient persons and resilient forms of situationally with stress, trauma, and adverse life circum- based coping responses may use these styles of stances. Fredrickson (1998, 2001) developed the positive coping with stress, trauma, and ordin- “broaden and build” theory of positive emo- ary hassles of daily living. tions, which posits, among other things, that The relation of exposure to terrorism, war positive emotional states may mediate various stressors, and resilience among children sub- types of behavioral phenomena. Fredrickson jected to ongoing violence, chaos, and disrup- argued that the role of positive emotions has tion of normal living was studied by Punamaki, been inadequately investigated but cites re- Qouta, and El-Sarraj (2001). They found that

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 209 children exposed to terrorism experience loss, In a study of children in guerrilla urban war- danger, and fear for their lives and can suffer fare, Punamaki et al. (2001) followed Palestin- from anxiety, emotional problems, and PTSD ian children 3 years after the cessation of mili- symptoms. Children not only experienced po- tary violence in the Gaza strip and occupied litical violence but manifested positive changes territory in Israel. Results indicated that an ac- when Israeli troops withdrew from the occu- tive response to military violence, creativity pied geographical area of Gaza. The environ- (e.g., high cognitive capacity) and nurturing mental changes included lifting of a nighttime parenting styles resulted in beneficial coping curfew, cessation in attacks and bombed hous- that they viewed as resiliency factors. Those ing, the frequency and amount of death and who had responded proactively to the violence killing, and a decrease in the general violence. exhibited fewer PTSD symptoms and emo- Other relevant changes included political pris- tional disorders. The stress-related anxiety oners returning home and schools reopening. symptoms of children decreased significantly Punamaki et al. (2001) stated that children’s during the 3-year follow-up period. These chil- stress decreased after the 1991 Gulf War’s SCUD dren were considered to have plasticity in their missile attacks ceased. They suggested that re- coping behavior. Nevertheless, other children siliency depends on the parents’ and family’s experienced vulnerability that resulted in in- coping responses and that younger children creases in psychiatric symptoms during the may be more susceptible to military violence war-related violence and manifest PTSD symp- than older children. toms 3 years later. Gender differences showed Research on Palestinian children found that that girls were found to be more vulnerable than parental love and proper discipline increased a boys and that girls’ symptoms decreased less child’s resilience by increasing their creativity across time. and cognitive capacity (Ayalon, 1993; Puna- maki, 1997). If a mother was unable to control A GENERIC MODEL OF RESILIENCE IN RE- her intrusive PTSD symptoms (e.g., recalling SPONSE TO PSYCHOLOGICAL TRAUMA horrible war images) and had an avoidant coping patterns, her children would be more vul- Based on the studies reviewed above, Figure nerable to war stressors, a finding also reported 1 presents a summary illustration of resilience by Laor, Wolmer, Mayes, Gersham, and Weiz- in response to psychological trauma. The model man (1997). According to Punamaki et al. identifies key variables that interact dynami- (2001), this is evidence that the trauma experi- cally in the determination of resilient behavior enced by the child is dependent on how the par- evoked by traumatic life experiences. The figure ents react, a finding commonly shown in the di- is a simplification of the various pathways by saster literature (Green, 1993; Gleser, Green, & which resilience results from exposure to differ- Winget, 1981; Raphael, 1983; Wilson & Raphael, ent types of traumatic events (see Wilson & 1993). In addition, Laor and Wolmer (1997; Laor, Lindy, 1994, for a discussion). Wolmer, & Cohen, 2001) reported greater PTSD The model is a person-environment para- and psychiatric symptom rates for Israeli chil- digm of resiliency in relation to the perception, dren whose families were displaced and ad- processing, and adaptation to traumatic stress. versely effected by SCUD missile attacks during As such, it incorporates the earlier models pre- the first Gulf War (1991) in Iraq. Punamaki et al. sented by Green, Wilson, and Lindy (1985), (2001) found that single stressor events do not Maddi (1999b), Richardson (2002), Wilson predict resiliency or vulnerability. They suggest (1989), and Wilson et al. (2001). The integrative that even if a child has positive coping skills nature of the model helps to identify the com- (e.g., high cognitive capacity, intelligence, and plex levels of interaction among many classes of creativity) parents need to encourage these variables that can work together to produce a characteristics in the service of resilience during continuum of adaptive behavior and different situations of extreme stress, such as terrorist sui- degrees of resilient behavior in the wake of psy- cide bombings or war violence. chological trauma. Furthermore, as our review

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Traumatic Life Events

• Specific stressor dimensions (e.g., duration, severity, degree of threat, etc.) • Subjective experience of traumatic stressors (e.g., degree of affect dysregulation) • Types of stressor (single, multiple, complex, etc.) • Level of stressor impact (e.g., threat, injury, exposure, etc.) • Type of allostatic load (e.g., repetitive system failure,e tc.) • Level of affect dysregulation (i.e., negative or positive affect balance)

Impact to Personality, Self-Structure & Ego-Processes Caused by Trauma

• Structure of Personality Characteristics (e.g., five factor model) • Ego-States: (1) static, (2) fluctuating, (3) regressed, (4) accelerated • Identity configuration: fragmented vs. integrated • Bases of self-worth, ego-strength and ego-resiliency • Sense of vulnerability to master anxiety situations and cope competently • Ego defenses against injury and vulnerability • Changes in ideology, beliefs and world view • Cognitive schemas in self, others and reality • Dissociative & peri-dissociative processes

Activation of Allostatic Stress Response (a x b x c x d x e = Interactions)

Personality Affect Ego Coping Mobilization & Utilization Characteristics Modulation Defenses Style of Protective Factors

(a) (b) (c) (d) (e) Continuum of Adaptation & Resilience Low Resilience High Resilience

Normal Range of Coping Minimal Optimal Coping Avoidance / Non-Focused Approach / Active Problem- Coping Emotional Coping Solving / Coping Acute & Long- “At Risk” for Acute & Long- Term Negative PTSD & Term Positive Adaptation Psychopathology Adaptation

of the literature suggests, the model of resil- recognize the multidimensional nature of trau- iency in response to trauma serves to clarify matic experiences. Traumas are not equal in which aspects of the resilience puzzle have been their impact to the psyche and vary greatly in investigated empirically their stressor dimensions (Wilson, 1989, 2004a; To understand the and which ones have not Wilson & Lindy, 1994). Second, there are indi- plasticity of behavior been studied at all or vidual subjective responses evoked by trauma in response to within the context of an that set in motion a cascade of internal psycho- traumatic life events, interactional model that logical processes (Wilson, 2004b). Third, there it is necessary to attempts to specify how are different types of stressor events (e.g., sin- recognize the traumatic events impact gle, multiple, single vs. complex) that vary in multidimensional internal psychological their severity of impact and resultant states of nature of traumatic processes at multiple allostatic load (McEwen, 1998, 2002; Wilson experiences. Traumas levels of psychological et al., 2001). As an intricate part of allostatic load are not equal in their functioning. phenomena, there are degrees of affect dysregu- impact to the psyche To understand the plas- lation that are directly related to the cognitive and vary greatly in ticity of behavior in re- processing of traumatic experiences (Schore, their stressor sponse to traumatic life 2002). There are at least five distinct patterns of dimensions. events, it is necessary to allostatic load caused by trauma that result in

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 Agaibi, Wilson / TRAUMA, PTSD, AND RESILIENCE 211 different baseline levels of organismic function- experience that may be aided by mobilizing so- ing following trauma (McEwen, 2002). In other cial support mechanisms; and (e) the words, there is a new “set point” of stress manifestation of resilient forms of behavior as response patterns (Wilson et al., 2001; Wilson & required by specific stressors that, in turn, Thomas, 2004) evoke a stress response syndrome, whether it is It is a truism to say that traumatic events im- normal, acute, or prolonged, as in the case of pact preexisting personality organization (i.e., PTSD. structure, dynamics, defenses, competencies, self-structure, and ego processes). As Figure 1 CONCLUSION shows, there are potential impacts to active ego states, identity configurations, and cognitive Our review of the literature on trauma, PTSD, schemas of self, others, and situations. Trauma and resilience has identified a core set of find- has the power to evoke peri-traumatic dissocia- ings that fit well within the model illustrated in tion (Marmar, Metzler, & Otte, 2004; Marmar, Figure 1. In summary,these results show that re- Weiss, & Metzler, 1997) and full-blown searchers have implicitly used a Person × Situa- dissociative states (Wilson et al., 2001). Consid- tion interactional model in formulating hypoth- ered from a holistic perspective, trauma’s im- eses about the factors that influence different pact to the organism not only has the power to forms of resilient behavior for different survivor attack personality and self-processes but it also populations. However, the task of predicting re- automatically activates allostatic stress resiliency is further complicated because there is sponse patterns that are part of the sensory ner- no universally defined concept of what consti- vous system’s (SNS) neurohormonal engineer- tutes resilient behavior. In some cases, resil- ing system governing acute and prolonged iency is defined by the absence of psycho- forms of human stress response (Friedman, pathology, prolonged stress response patterns 2000b; McEwen, 2002; Wilson, 2004b). (e.g., PTSD), or maladaptive coping. In other The activation of allostatic stress response cases, resilience is defined by having superior patterns include at least five interrelated areas coping, on average, over a longitudinal course of functioning: (a) coping styles, (b) affect mod- of life-span development (Felsman & Vaillant, ulation and degrees of affect balance, (c) person- 1982). In some studies, resilience is defined as a ality characteristics (e.g., hardiness, locus of personality variable (e.g., locus of control, ego control, assertiveness, etc.), (d) ego-defensive resilience, hardiness) that is presumed to mod- processes, and (e) the mobilization and utiliza- erate outcome variables. As a personality vari- tion of protective factors that may exist in the able, high levels of resilience have been exam- repertoire of coping behaviors. ined in terms of how resilience affects thinking, The outcome of the response patterns trig- perception, affect modulation, and disposition gered by a traumatic life event is the generation to behavior. Personality processes (e.g., hardi- of a continuum of adaptation and resilience. ness, locus of control, self-esteem, assertiveness, Viewed in this way, the positive end of the con- etc.) are one side of the person-environment tinuum reflects optimal coping with trauma. equation that determines the stress appraisal This includes acute and long-term patterns of process and, by implication, the level of emo- adaptation and resilience that results from the tional arousal experienced as well as the capac- mastery of excessive stress by (a) the operation ity to modulate affect (J. H. Block & Kremen, of specific personality variables (e.g., hardiness) 1996). Personality processes, including intelli- that moderates the effects of traumatic stressors; gence and cognitive styles of information pro- (b) the function of ego defenses and protective cessing, are correlated with coping styles (e.g., factors that are part of ego states, identity con- avoidance, approach, problem solving, emo- figuration, and coping styles; (c) the capacity for tional) and the types of ego defenses used under affect modulation (i.e., affect balance); (d) the anxiety-provoking situations (Fels & Vaillant, capacity to maintain a positive outlook and cre- 1987; Vaillant, 1977). There is evidence that cop- ate a positive sense of meaning from the trauma ing style and ego defense are related to the ca-

Downloaded from http://tva.sagepub.com at UNIV OF OREGON on January 10, 2010 212 TRAUMA, VIOLENCE, & ABUSE / July 2005 pacity to mobilize and utilize protective factors Optimal coping and adaptation defines highly to master overwhelmingly stressful situations. resilient behaviors in terms of acute and long- In this regard, researchers have identified pro- term positive adaptation. At the other end of the tective factors such as social and personal sup- continuum, minimal coping defines acute and port mechanisms, mobilizing aid, and initiating long-term negative adaptation and represents instrumental actions directed at finding solu- significant risk factors for the development of tions to the problems embedded within the PTSD and psychopathology. When considering stressful situation. posttraumatic resilience on a continuum of opti- It is important to attempt to define a concep- mal levels of environmental adaptation, it is tually meaningful continuum of adaptation and possible to define the property of resilience as a resilience as pertains to normal, acute, and pro- complex repertoire of behavioral tendencies longed forms of human stress response (Fried- that may be evoked or activated by environ- man, 2000b; McEwen, 2002; Wilson et al., 2001). mental demands.

IMPLICATIONS FOR PRACTICE, POLICY, & RESEARCH • Understanding posttraumatic resilience is criti- • Posttraumatic resilience can be implemented cal to successful treatment. through training programs to reduce the ef- • Posttraumatic resilience can be learned. fects of traumatic exposure. • Posttraumatic resilience characterizes psy- chobiologically healthy survivors.

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Overcoming the odds: Sharkansky,E. J., King, D. W.,King, L. A., Wolfe, J., Erikson, High-risk children from birth to adulthood. New York: Cor- D. J., & Stokes, L. R. (2000). Coping with Gulf War com- nell University Press. bat stress: Mediating and moderating effects. Journal of White, R. W. (1959). The ego and reality in psychoanalytic the- Abnormal Psychology, 109(2), 188-197. ory. New York: International University Press. Siebert, A. (1996). The survivor personality. New York: Pedi- Wilson, J. P. (1980). Conflict, stress and growth: The effects gree Books. of war on psychosocial development among Vietnam Solomon, Z., & Mikulincer, M. (1992). Aftermaths of com- veterans. In C. R. Figley & K. S. Leventman (Eds.), bat stress reactions: A three-year study. British Journal of Strangers at home: Vietnam veterans since the war (pp. 123- Clinical Psychiatry, 31(8), 21-32. 165). New York: Praeger. Solomon,Z.,Neria,Y.,Ohry,A.,Waysman,M.,& Wilson, J. P. (1989). Trauma, transformation and healing: An Ginzburg, K. (1994). PTSD among Israeli former prison- integration approval to theory, research and posttraumatic ers of war and soldiers with combat stress reactions: A theory. New York: Brunner/Mazel. longitudinal study. American Journal of Psychiatry, 151, Wilson, J. P. (1995). Traumatic events and PTSD preven- 554-559. tion. In B. Raphael & E. D. Barrows (Eds.), The handbook Southwick, S. M., Morgan, C. A., Vythilingam, M., Krystal, of preventative psychiatry (pp. 281-296). Amsterdam, the J. H., & Charney,D. S. (2004). Emerging neurobiological Netherlands: Elsevier North-Holland. factors in stress resilience. PTSD Research Quarterly, Wilson, J. P. (2004a) Broken spirits. In J. P. Wilson & B. 14(4), 1-6. Drozdek (Eds.), Broken spirits: The treatment of trauma- Sutker, P. B., Davis, J. M., Uddo, M., & Ditta, S. R. (1995). tized asylum seekers, refugees and war and torture victims War zone stress, personal resources, and PTSD in Per- (pp. 141-173). New York: Brunner/Routledge. sian Gulf War returnees. Journal of Abnormal Psychology, Wilson, J. P.(2004b). PTSD and complex PTSD: Symptoms, 104(3), 444-452. syndromes and diagnoses. In J. P.Wilson & T. M. Keane Sutker, P. B., Winstead, D. K., Galina, Z. H., & Ayain, A. N. (Eds.), Assessing psychological trauma and PTSD (pp. 1- (1991). Cognitive deficits and psychopathology among 46). New York: Guilford. former prisoners of war and combat veterans of the Korean conflict. American Journal of Psychiatry, 148, 67- Wilson, J. P.(in press). The posttraumatic self: Restoring mean- 72. ing and wholeness to personality. New York: Routledge. Tennant, C. C., Goulston, K. J., & Dent, O. F. (1986). Clinical Wilson, J. P., & Agaibi, C. (in press). The resilient trauma psychiatric illness in POWs of Japan: Forty years after survivor. In J. P. Wilson (Ed.), The posttraumatic self: release. Psychological Medicine, 16, 833-839. Restoring meaning and wholeness to personality. New York: Thomas, R. B., & Wilson, J. P. (2004). Issues and controver- Routledge. sies in the understanding and diagnosis of compassion Wilson, J. P.,& Drozdek, B. (Eds.). (2004). Broken spirits: The fatigue, vicarious traumatization, and secondary trau- treatment of traumatized asylum seekers, refugees and war matic stress disorder. International Journal of Emergency and torture victims. New York: Brunner/Routledge. Mental Health, 6(2), 1-12. Wilson, J. P.,Friedman, M. J., & Lindy,J. D. (2001). An over- True, W. R., Rice, J., Eisen, S. A., Heath, A. C., Goldberg, J., view of clinical consideration and principles in the Lyons, M. J., et al. (1993). A twin study of genetic and treatment of PTSD. In J. P.Wilson, M. J. Friedman, & J. D. environmental contributions to liability for posttrau- Lindy (Eds.), Treating psychological trauma and PTSD matic stress symptoms. Archives of General Psychiatry, (pp. 59-94). New York: Guilford. 50, 257-264. Wilson, J. P., Harel, Z., & Kahana, B. (1989). The day of Tugade, M. M., & Fredrickson, B. L. (2004). Resilient indi- infamy: The legacy of Pearl Harbor. In J. P.Wilson (Ed.), viduals use positive emotions to bounce back from neg- Trauma, transformation and healing (chapter 6, pp. 129- ative emotional experiences. Journal of Personality and 159). New York: Brunner/Mazel. Social Psychology, 86(2), 320-333. Wilson, J. P.,& Kurtz, R. (1997). Assessing PTSD in couples Vaillant,G. (1977). Adaptation to life. Boston: Little, Brown. and families. In J. P.Wilson & T. M. Keane (Eds.), Assess- Waysman, M., Schwarzwald, J., & Solomon, Z. (2001). Har- ing psychological trauma and PTSD (pp. 349-373). New diness: An examination of its relationship with positive York: Guilford. and negative long term changes following trauma. Jour- Wilson, J. P., & Lindy, J. (1994). Counter-transference in the nal of Traumatic Stress, 14(3), 531-548. treatment of PTSD. New York: Guilford.

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Wilson, J. P., & Prabucki, K. (1989). Stress sensitivity and Christine E. Agaibi, M.A., is currently a psychopathology. In J. P. Wilson (Ed.), Trauma, transfor- doctoral student in counseling psychology at mation and healing: An integrative approach to theory, the University of Akron. She received her research and posttraumatic therapy (pp. 75-111). New bachelor’s degree in 1999 from John Carroll York: Brunner/Mazel. University and her master’s in clinical coun- Wilson, J. P.,& Raphael, B. (1993). The international handbook seling psychology in 2003 from Cleveland of traumatic stress syndromes. New York: Plenum. State University. Her professional and research interests Wilson, J. P.,& Thomas, R. (2004). Empathy in the treatment of are in the areas of resiliency, coping, child development, trauma and PTSD. New York: Brunner/Routledge. Yehuda, R. (1998). Resilience and vulnerability factors in and posttraumatic growth. She has authored a literature the course of adaptation to trauma. Clinical Quarterly, review for her master’s thesis titled “Understanding 8(1), 3-6. Resilience to the Effects of Traumatic Stress.” She is a stu- Zakin, G., Solomon, Z., & Neria, Y. (2003). Hardiness, dent affiliate member of the American Psychological Asso- attachment style, and long-term psychological distress ciation, the Society of Counseling Psychology (APADivi- among Israeli POWs and combat veterans. Personality sion 17), Division of Theoretical and Philosophical and Individual Differences, 34, 819-829. Psychology (APA Division 24), Division of Clinical Zeidner, M., & Endler, N. S. (1996). Handbook of coping. New Neuropsychology (APA Division 40), the Cleveland Psy- York: John Wiley. chological Association, Psi Chi, and is student representa- Zeiss, R. A., & Dickman, H. R. (1989). PTSD 40 years later: tive-elect for her current university’s counseling psychol- Incidence and person-situation correlations in former ogy graduate student organization. POWs. Journal of Clinical Psychology, 45(1), 80-87. Zuckerman, M. (1999). Vulnerability to psychopathology. John P.Wilson, Ph.D., is a professor of psy- Washington,DC: American Psychological Association. chology and a Fulbright Scholar at Cleveland State University. He is cofounder of the Inter- SUGGESTED FUTURE READINGS national Society for TraumaticStress Studies. He is the author of more than 10 books on Anthony, E. J., & Cohler, B. J. (1987). The invulnerable child. posttraumatic stress disorder including (with New York: Guilford. Boris Drozdek) Broken Spirits: The Treatment of Trau- Wilson, J. P.(in press). The posttraumatic self: Restoring meaning and wholeness to personality. New York: Routledge. matized Asylum Seekers, Refugees, War and Torture Wilson, J. P., & Drozdek, B. (2004). Broken spirits: The treat- Victims (Brunner-Routledge 2004); Empathy in the ment of traumatized asylum seekers, refugees, war and tor- Treatment of Trauma and PTSD (Routledge, 2004, 2nd ture victims. New York: Brunner-Routledge. ed.); and Assessing Psychological Trauma and PTSD Wilson, J. P.,& Thomas, R. (2004). Empathy in the treatment of (Guilford, 2004, 2nd ed.). He has received numerous trauma and PTSD. New York: Brunner-Routledge. awards for his work, including the George Washington Zuckerman, M. (1999). Vulnerability to psychopathology. Honor Medal. Washington,DC: American Psychological Association.

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