Published online February 1, 2008
PEDIATRICS Vol. 121 No. 2 February 2008, pp. 369-375 (doi:10.1542/peds.2007-1648)

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SPECIAL ARTICLE

The Human Capacity to Thrive in the Face of Potential Trauma

George A. Bonanno, PhD and Anthony D. Mancini, PhD

Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, New York

	ABSTRACT

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For decades, researchers have documented remarkable levels of resilience in children who were exposed to corrosive early environments, such as those in which poverty or chronic maltreatment were present; however, relatively little research has examined resilience in children or adults who were exposed to isolated and potentially traumatic events. The historical emphasis on psychological and physiologic dysfunction after potentially traumatic events has suggested that such events almost always produce lasting emotional damage. Recent research, however, has consistently shown that across different types of potentially traumatic events, including bereavement, serious illness, and terrorist attack, upward of 50% of people have been found to display resilience. Research has further identified substantial individual variation in response to potentially traumatic events, including 4 prototypical and empirically derived outcome trajectories: chronic dysfunction, recovery, resilience, and delayed reactions. Factors that promote resilience are heterogeneous and include a variety of person-centered variables (eg, temperament of the child, personality, coping strategies), demographic variables (eg, male gender, older age, greater education), and sociocontextual factors (eg, supportive relations, community resources). It is surprising that some factors that promote resilience to potentially traumatic events may be maladaptive in other contexts, whereas other factors are more broadly adaptive. Given the growing evidence that resilience is common, psychotherapeutic treatment should be reserved for those in genuine need.

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Key Words: resilience • posttraumatic stress disorder • death and dying • psychological adaptation • child • child development

Abbreviations: PTE—potentially traumatic event • PTSD—posttraumatic stress disorder

Bad things happen. As much as we might wish otherwise, close friends and relatives die, painful things happen to our bodies, there are natural disasters and wars, and sometimes people do senselessly horrible things to other people. Epidemiologic studies indicate that most adults experience at least 1 potentially traumatic event (PTE) during the course of their life.¹ Children are also commonly exposed to such events.² Perhaps owing to the way these events are dreaded, it has become a common assumption that they almost always cause lasting emotional damage, but this is usually not true. In this article, we use the phrase "potentially traumatic" to underscore that there are measurable and important individual differences in how people respond to such events.³ Simply put, highly aversive events that typically fall outside the range of normal everyday experience are "potentially" traumatic because not everyone experiences them as traumatic. Research on PTEs has consistently revealed a wide range of reactions; apart from a relatively finite subset of people who experience extreme distress, most people cope with such events extremely well.^3,4 In this article, we briefly review the historical background on psychological trauma, then consider recent empirical studies on individual differences in response to PTEs. We consider the most common or prototypical outcomes that people exhibit, including chronic and pathologic reactions, but also relatively healthy reactions. We focus particular on the growing evidence for the human capacity to thrive even after the most difficult of events and on the emergent concept of psychological resilience. Finally, we review the available evidence on factors that predict resilience to PTEs, suggest ways in which these data might inform a more empirically sound public health conception of trauma, and discuss the implications of the study of resilience for treatment.

	TRADITIONAL CONCEPTS OF PSYCHOLOGICAL TRAUMA

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Almost since the beginnings of psychology and psychiatry as formal disciplines, researchers, theorists, and practitioners have looked to violent or life-threatening events as antecedents to psychological and physiologic dysfunction^5,6; however, it was not until late in the 20th century that consensus emerged about the nature of trauma-related dysfunction. The formalization of posttraumatic stress disorder (PTSD) as a legitimate diagnostic category in 1980⁷ filled an enormous gap in public health knowledge. The PTSD category also helped promote a surge of new research on traumatic stress.⁸

Unfortunately, the nearly exclusive emphasis on PTSD also had a down side. With little attention devoted to anything other than PTSD, reactions to PTEs were conceptualized in increasingly simplistic, binary terms of pathology versus the absence of pathology. With this simplistic view came lingering controversies about the sometimes elusive distinction between genuine psychological trauma and malingering. Nowhere does this issue cut closer to the bone than in the case of war trauma. Warfare throughout the 20th century was plagued by an enduring tension about the proper time and place for diagnosis or treatment,^6,9 and these issues have persisted into the 21st century. One survey¹⁰ found, for example, that many soldiers who returned from combat operations in Iraq and Afghanistan desired but did not seek treatment because of prevailing stigma about perceptions of weakness.

The bereavement literature has evidenced a similar historical confusion among grief, healthy functioning, and denial. As was the case with trauma, bereavement research has tended to emphasize chronic grief reactions while offering little insight about possible resilience to loss. A summary of current bereavement knowledge in the 1980s reported that it was commonly assumed, particularly by clinicians, "that the absence of grieving phenomena following bereavement represents some form of personality pathology."¹¹(p18) Bowlby¹²(p138) considered the "prolonged absence of conscious grieving" a type of disordered mourning. A 1993 survey of self-identified bereavement experts reported that a majority (65%) endorsed beliefs that "absent grief" exists, that it usually stems from denial or inhibition, and that it is generally maladaptive in the long run.¹³

	TOWARD AN INDIVIDUAL-DIFFERENCES MODEL

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A stark contrast to the binary view of traumatic stress is offered by empirical studies of individual variation in response to PTEs. These studies reveal a number of unique and variable patterns or outcome trajectories. Most of the variability can be capture by 4 prototypical trajectories: chronic dysfunction, recovery, resilience, and delayed reactions (Fig 1).⁴ We elaborate on each trajectory next.

View larger version (20K): [in this window] [in a new window]   FIGURE 1 Prototypical patterns of disruption in normal functioning across time after potentially traumatic events (PTE). Reproduced with permission from Bonanno GA. Loss, trauma, and human resilience. Am Psychol. 2004;59:20–28..

 
Chronic Dysfunction
Despite the highly aversive nature of most PTEs, only a relatively small subset of exposed individuals typically exhibit chronic psychopathology. Although there is considerable variability in the type, severity, and duration of PTEs,¹⁴ typically PTSD is observed in 5% to 10% of exposed individuals.¹ When exposure is exceptionally prolonged or severe, the proportion who exhibit PTSD or other types of psychopathology may reach higher levels, sometimes as high as one third of the sample. For example, among a representative sample of 2752 New Yorkers who were interviewed in the months after the September 11th terrorist attack, the PTSD prevalence was estimated at 6%.¹⁵ Among those physically injured in the attack, however, PTSD prevalence was 26%. In a careful reanalysis of the National Vietnam Veterans Readjustment data, a representative sample of 1200 veterans, chronic PTSD was estimated at 9% but rose to 28% among veterans with the highest levels of combat exposure.¹⁶

Studies of psychopathology during bereavement suggest similar proportions. Typically only 10% of bereaved people will exhibit chronically elevated grief reactions¹⁷; however, chronic grief reactions tend to be more prevalent after more extreme losses, such as when the death event involves violence^18,19 or when a child dies.²⁰

It is surprising that there are relatively few data on trauma and grief reactions among children; however, the child data that are available suggest similar levels of complicated grief²¹ but somewhat less PTSD compared with adults.² As we discuss next, however, it is important to keep in mind that the question of adjustment is in many ways more complex among children. For example, children who are exposed to aversive events may fail to evidence PTSD or complicated grief but show increased externalizing symptoms, substance use, academic problems, or peer conflict.

Delayed Reactions
What about delayed reactions? A long-held assumption in the bereavement literature is that the absence of overt signs of grieving will eventually manifest in delayed grief reactions.^{11–13,22–25} Despite the strength of this belief, however, empirical evidence for delayed grief has never been reported,^26,27 even in longitudinal studies explicitly designed to measure the phenomenon.^28,29 There is some evidence for delayed PTSD reactions after potentially traumatic events, occurring in 5% to 10% of exposed individuals.^30,31 It is crucial to note, however, that this pattern does not conform to the traditional idea of denial manifesting in delayed reactions. Rather, when it is observed, delayed PTSD seems to resemble more closely subthreshold psychopathology that gradually grew worse over time.^4,30,31

Resilience and Recovery
Until recently, it was widely assumed that the enduring absence of psychopathology after exposure to a PTE occurred only in people with exceptional emotional strength.^32–34 As noted previously, bereavement theorists have persistently regarded the relative absence of grief as a form of hidden psychopathology.¹⁴ There is now compelling evidence, however, that genuine resilience to PTEs is not rare but common and not a sign of exceptional strength or psychopathology but rather a fundamental feature of normal coping skills.⁴ Moreover, several studies have demonstrated that resilience and recovery can be mapped as discrete and empirically separable outcome trajectories. Distinctions between resilience and recovery have been identified after loss,³⁵ major illness,³⁶ and potential trauma.³¹

	DEVELOPMENT OF THE CONSTRUCT OF PSYCHOLOGICAL RESILIENCE

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Much of the original theorizing on resilience came from developmental psychologists and psychiatrists during the 1970s. These pioneering researchers documented the large number of children who despite growing up in caustic socioeconomic circumstances (eg, poverty) nonetheless evidenced healthy developmental trajectories.^37–40 A surprising feature of this work was that it showed resilience in children at risk to be common.⁴¹ Whereas traditional deficit-focused models of development had assumed that only children with remarkable coping ability could thrive in such adverse contexts, these studies suggested that resilience is a result of normal human adaptational mechanisms.⁴¹ As noted previously, however, almost all of this research focused on chronically aversive contexts, rather than isolated PTEs.

The construct of resilience has slowly "trickled up" to the trauma literature.^4,42 As the idea gained currency among trauma researchers, differences between resilient outcomes in adults and children and between chronic and acute stressors became apparent.^3,4 Some of the key differences seemed to hinge on the temporal and sociocontextual characteristics of stress and adaptation at different points in the lifespan. For developing children, the definition of healthy adaptation is a complex issue.^41,43 Children at risk may evidence competence in 1 domain but fail to meet long-term developmental challenges in other domains.⁴⁴ This situation is arguably more straightforward among adults.^3,4 Most but certainly not all of the PTEs with which adults might be confronted can be classified as isolated stressor events (eg, an automobile accident) that occur in a broader context of otherwise normative (ie, low stress) circumstances. There may be concomitant stressors accompanying or extending the PTE (eg, change in financial situation), but this level of variability is usually straightforward and can be reliably measured.^16,45 Because developmental considerations are less pronounced in adults, responses to PTEs can usually be assessed in terms of deviation from or return to normative (baseline) functioning.⁴⁶

On the basis of these considerations, Bonanno⁴ proposed that resilience to potential trauma be defined as "the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event such as the death of a close relation or a violent or life-threatening situation to maintain relatively stable, healthy levels of psychological and physical functioning, as well as the capacity for generative experiences and positive emotions" (p 20–21). In this article, we propose that this definition be extended to encompass children who are exposed to isolated PTEs, with the caveat, however, that evidence for resilience in children typically requires more careful and elaborate monitoring across multiple domains (eg, peer relations, school performance). Whether applied to children or adults, this definition contrasts resilience with the traditional recovery from trauma pathway characterized by readily observable elevations in psychological problems that endure for at least several months or longer before gradually returning to baseline, pretrauma levels.

A key point is that even resilient individuals may experience at least some form of transient stress reaction; however, these reactions are usually mild to moderate in degree, are relatively short-term, and do not significantly interfere with their ability to continue functioning.^35,45,47,48 This is not to say that people who show resilient outcomes are not upset, disturbed, or unhappy about the occurrence of the event. Our point is merely that as undesirable as PTEs might be, many people cope with such events extremely well and are able to continue meeting the normal daily demands of their lives.

The earliest observations of resilience in response to isolated PTEs came from retrospective and unsystematic accounts.^42,49 More recently, a number of studies have demonstrated widespread resilience among people confronted with the untimely death of a spouse or a child.^35,45 Across studies, resilience was consistently observed in approximately half of the bereaved participants. Moreover, the resilient trajectory was validated using different measures of adjustment, including low levels of psychopathologic symptoms, ratings of positive adjustment obtained from close friends, and measures of positive emotional experiences.

Recent studies have demonstrated widespread resilience among survivors of the September 11th terrorist attack in New York City. Among a sample of people in or near the World Trade Center at the time of the attack,³¹ resilient individuals had little or no symptoms of PTSD or depression. They also showed high levels of adjustment across a number of different domains of functioning (eg, mental health, physical health, goal achievement) on the basis of anonymous ratings that were obtained from close friends and relatives. Another, more encompassing study¹⁶ examined the prevalence of resilient outcomes using data from a large probability sample (N = 2752) that closely matched the more recent New York census data. Resilient individuals had 1 or 0 PTSD symptoms, no depression, and reduced substance use. Consistent with previous studies, the proportion with resilient outcomes was 50% across most exposure groups and across most aspects of demographic variation. Importantly, even among the groups with the most pernicious levels of exposure and highest probable PTSD, the proportion of individuals who were resilient never dropped below one third of the sample.

Similar findings have also begun to emerge after serious health-related stressors. Among a large sample of hospitalized survivors of the 2003 severe acute respiratory syndrome epidemic in Hong Kong, 42% evidenced chronically low levels of psychological functioning across an 18-month period, but 35% had consistently high levels of psychological functioning across the same period.⁵⁰ Deshields et al³⁶ mapped the same outcome trajectories depicted in Fig 1 using depression scores that were obtained from women immediately after radiation treatment for breast cancer and again 3 and 6 months after treatment. Although 21% of the sample evidenced clinically significant levels of depression at 6 months, the majority (61%) had extremely low levels of depression throughout the study.

	A HETEROGENEOUS ARRAY OF RISK AND PROTECTIVE FACTORS

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We next turn to the questions of why some people are more or less likely to be resilient after a specific PTE. The initial pioneering research on resilience in children suggested that there are multiple protective factors that might buffer against adversity, including person-centered variables (eg, temperament) and sociocontextual factors (eg, supportive relations, community resources).^39,51,52 Research on resilience among adults who were exposed to isolated PTEs suggests a similar conclusion.^3,53 A particularly compelling aspect of this story is that resilience does not result from any 1 dominant factor. Rather, there seem to be multiple independent risk and protective factors, each contributing to or subtracting from the overall likelihood of a resilient outcome. Consider, for example, an enduring misconception that resilience depends almost exclusively on qualities in the person. Personality undoubtedly does play a role in resilience to trauma; however, as Mischel⁵⁴ famously observed, personality rarely explains >10% of the actual variance in people's behavior across situations. It is more accurate, therefore, to conceive of personality as 1 of many potential contributors to resilient outcomes.

Flexible Adaptation and Pragmatic Coping
We recently proposed a basic grouping of person-centered factors into 2 broad categories: pragmatic coping and flexible adaptation.^3,55 Because PTEs usually occur outside the range of normal human experience, they often pose unique and highly specific coping demands. Successfully meeting these demands may require a highly pragmatic, or "whatever it takes," approach that is single-minded and goal-directed. Sometimes pragmatic coping involves behaviors that under normal circumstances may be less effective or even maladaptive. We have also referred to this type of coping as "coping ugly"³ to underscore the idea that coping does not necessary need to be a thing of beauty; it just needs to get the job done.

Pragmatic coping can also be observed as a consequence of relatively rigid personality characteristics. For example, the construct of trait self-enhancement describes people who are narcissistic and habitually use self-serving biases. Trait self-enhancers tend to evoke negative reactions in other people; however, they also have high self-esteem and cope well with isolated PTEs, such as war⁵⁶ and terrorist attack.³¹ Another group of individuals, known as repressive copers, tend to avoid unpleasant emotional experiences. Although there is evidence linking repressive coping to health deficits, they have also been found to cope extremely well with PTEs.^57,58 The confluence of costs and benefits that are associated with these personality types suggests that they may be something of a "mixed blessing."⁵⁹

A more genuinely health personality dimension is suggested by the concept of adaptive flexibility. A core aspect of flexibility is the capacity to shape and modify one's behavior to meet the demands of a given stressor event. This capacity for flexibility has been observed very early in development yet can change over time as a result of the dynamic interplay of personality and social interactions with key attachment figures.⁶⁰ Practically speaking, then, flexibility is a personality resource that helps bolster resilience to aversive events, such as childhood maltreatment,⁶¹ but may also be enhanced or reduced by developmental experiences.⁶² Recent research also suggests that flexibility eventually becomes stable and can effectively bolster resilience to PTEs.^63,64

Exposure
As described previously, the type, duration, and intensity of exposure during a PTE has been shown to influence the prevalence of healthy adjustment, with resilience varying from 33% to >50% across exposure categories.^3,16

Demographic Variables
A more prosaic set of predictors is found in simple demographic variation. Resilience to trauma has been associated with male gender, older age, and greater education.^50,65 Although there has been relatively little research on race/ethnicity as a predictor of resilience, recent evidence indicated that ethnic Chinese were more likely to be resilient after the September 11th attack.⁶⁵

Personal and Social Resources
Numerous theorists have delineated a crucial role for social and personal resources in coping with stress.^53,66,67 There is also considerable research linking resources or change in resources with adjustment after PTEs.^68–71 Recent research on resilience to trauma has highlighted the particular importance of maintaining full-time employment and social resources (eg, social support).^50,65 Cognitive ability has also been widely observed as a protective resource against PTSD in both children⁷² and adults.⁷³ Although there are not yet data linking cognitive resources to resilience in the face of trauma, we suspect that such a link is highly probable.

Additional Life Stress
There is abundant evidence linking PTSD with increased life stress before and after the marker traumatic event.^73,74 Resilience to trauma has been associated with the relative absence of current and previous life stress.⁶⁵ An important qualifier of these findings, however, is the outcome of previous life stressors. Prospective research suggests that only previous stressors that result in PTSD tend to predict PTSD at subsequent exposure.⁷⁵ It seems likely also that resilience to past stressors will predict subsequent resilience.

	IMPLICATIONS FOR INTERVENTION

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The burgeoning literature on resilience has important implications for how physicians, mental health professionals, and close others respond to people who are exposed to a PTE. Although in many ways a deeply ingrained cultural assumption that psychotherapeutic intervention for PTEs is invariably beneficial, the study of resilience suggests that this assumption is misguided and could even lead to harm. For most people, intrinsic recovery processes will restore equilibrium relatively soon after exposure. Early interventions, such as critical incident stress debriefing, targeted indiscriminately at people immediately after exposure to a PTE, are not only ineffective but also may exacerbate trauma reactions by interfering with natural recovery processes.⁷⁶ Moreover, although a recently developed intervention has shown promise for treating chronic forms of grief,⁷⁷ traditional grief counseling models, which have defined grieving as "work," have also had a notoriously poor track record, achieving small gains for some but exposing others to significant risk for deterioration.⁷⁸

Although people who experience trauma-related psychopathology clearly benefit from empirically validated psychotherapeutic treatments, the study of resilience makes clear that such people are only a small minority; the far greater majority are not appropriate candidates for intervention. For this reason, appropriate assessment and, by extension, diagnosis are perhaps the central task before referral, as would be the case in the treatment of disease. Indeed, only people who evidence genuine dysfunction in the face of PTEs, as defined by recurring symptoms and interference with social roles and obligations, should be referred for treatment. Although the general efficacy of psychotherapeutic intervention is now beyond question, this does not preclude the possibility of iatrogenic effects, as witnessed in traditional grief treatments and blanket early interventions after PTEs. This cautionary note only underscores the importance of seeing resilient responses to PTEs as a basic human capability—neither rare nor extraordinary.

	FOOTNOTES

 
Accepted Jul 16, 2007.

Address correspondence to George A. Bonanno, PhD, Department of Counseling and Clinical Psychology, Teachers College, Columbia University, 525 W 120th St, New York, NY 10027. E-mail: gab38{at}columbia.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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