Toward a More Dynamic Understanding of the Influence of Resilience on Health

At the time of this writing there are two growing global pandemics in 2020—one whose transmission is primarily viral (e.g., COVID-19) and the other whose transmission is driven by 400+ years of systemic and structural racism (e.g., the murders of countless Black people at the hands of police officers in the United States). Both of these seemingly distinct, yet intersecting and cross-fueling pandemics have deleterious impacts on the biopsychosocial health and well-being of individuals and communities, especially those who are Black.¹ While extensive work needs to be done to address the effect of the aforementioned stressors on health, there is a burgeoning body of literature suggesting resilience can act as a buffer against the impact of negative health challenges.

The American Psychological Association (APA), defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”² Other definitions include, “the capacity of individuals to cope successfully with significant change, adversity, or risk”³ and “the personal qualities that enables one to thrive in the face of adversity.”⁴ Historically, operationalizing resilience has been a challenge^5–9 and most resilience-based research occurred within the fields of community and developmental psychology while focusing on how children cope with stress and overcome adverse life events associated with, parental criminality, severe marital discord, low socioeconomic status, and admission into foster care, among other things.^10–12 More recently, researchers have attempted to understand how childhood, familial, and environmental factors contribute to the positive outcomes associated with resilience.^7,13,14

Moreover, resilience can be understood as a trait, process, outcome, or a combination.¹⁵ As Halkitis and colleagues elucidate, as a trait, resilience refers to strength of character, determination, grit, and resourcefulness—an innate ability or temperament that allows one to meet the challenges of life.¹⁶ Simply, resilience is a natural characteristic expressed via action (or inaction) in response to a stressful situation. Similarly, Wagnlid and Young define resilience as a “personality characteristic that moderates negative effects and promotes adaptation.”¹⁷

We can also understand resilience as a process. Egeland et al. suggest that resilience is a “developmental process characterized by a hierarchical integration of behavioral systems.”¹⁸ Furthermore, they indicate that individuals participate in the process by building on historical interactions or situations to develop new attitudes, expectations, and feelings around experiences.¹⁸ Other researchers argue that resilience is likely to exist on a continuum that may be present to differing degrees throughout many facets of life.^19,20 Similarly, Zautra and colleagues indicate that “resilience is best defined as an outcome of successful adaptation to adversity,” and follow up with two questions: how well do people recover and bounce back from a challenge, and what is their capacity to carry forward in the face of adversity?^21–24 For example, an individual who adapts well to an adverse situation in their personal lives or the workplace, may fail to adapt well to a diagnosis like HIV/AIDS or COVID-19. Other ideas suggest resilience is rooted in creating conditions that help one to self-govern and self-organize in order to be more prepared and equipped to handle a future adverse situation or crisis.¹⁵

To date, one common challenge in resilience research is that while there are several paradigms that examine the foundational underpinnings, many of them focus on specific populations and/or fields (e.g. families,²⁵ medical students,^9,26 and adolescents,^27,28) rather than across populations. As such, Richardson and colleagues have outlined a three-stage model of resilience inquiry that cuts across the paradigm including resilient qualities, the resiliency process, and innate resilience, all of which constitutes their meta-theory of resilience and resiliency.^29,30 This theory is of particular importance because it can be applied at different analytic levels (individual, familial, and community) and across different types of adverse life events and stressors.⁹ Moreover, it encompasses a wide-range of ideas stemming not only from psychology but also from physics, philosophy, and medicine and may be a step toward achieving a multidisciplinary approach that spans populations.^29,31

In an effort to push these boundaries and limitations, this double special issue of Behavioral Medicine closely examines the role of resilience on biopsychosocial health outcomes throughout diverse communities and settings. In particular, these 15 manuscripts consider approaches to operationalizing resilience, including challenging our underlying assumptions and understandings of resilience to-date and the manner in which resilience may be protective of health. All of the articles span an array of topics and populations that highlight affirmative health strategies, delineate psychometric properties of instruments designed to assess multiple dimensions of resilience, and emphasize the importance of communities and collective strategies to mitigate negative health outcomes. While they are diverse in topics, they share a common theme: resilience can help improve the health and well-being of individuals and communities, especially in the face of adversity, discrimination, and inequities.

The first part of the double issue is comprised of nine articles that range in topics from the Flint Water Crisis to Hurricanes Irma and Maria to Navy SEAL training. In the first article, Lelutiu-Weinberger and colleagues examine the role of gender affirmation (e.g. transition-related medical procedures, familial support, and legal documentation changes) and discrimination (e.g. harassment, unequal treatment, and attacks) on biopsychosocial health outcomes of binary-identified transgender individuals in the U.S. These authors underscore the importance of gender affirmation on the resilience of transgender health while also highlighting the need to ensure procedures and policies are equitable for all transgender folks.

Next, Mitchell et al. discuss the association between hopefulness, discrimination, and racial/ethnic disparities on allostatic load among U.S. adults age 51 and older using data from the Health and Retirement Study. This article suggests hopefulness may be an understudied indicator of resilience however, its impact on physiological functioning may be tied to the type of stressor a person is exposed to.

Seeking to understand how resilience is displayed in a community deeply impacted by poor water infrastructure, corporate disinvestment, and high levels of poverty, Sobeck and colleagues employed a mixed-methods study to examine the Flint Water Crisis since its onset in April 2014. The authors found strong levels of resilience despite the struggles that many Flint residents face on a day-to-day basis. In particular, they challenge the idea that ‘bouncing back’ from challenges may not be the ultimate goal, but rather ‘moving beyond’ is a more productive way of adapting and adhering to a cycle of strength.

The following article by Reyes and colleagues examines family norms of disclosing mental health problems, posttraumatic stress disorder, and resilience among a sample foreign- and U.S.-born Filipino American women. Those who were not born in the U.S. had lower levels of PTSD and greater resilience compared to their U.S.-born counterparts. These findings suggest a closer examination that consider the impact of collectivistic cultural values (e.g. disclosing mental health problems), especially in future research endeavors.

Next, Pérez-Ramos and coauthors present a qualitative investigation with residents of the Puerto Rican island of Culebra following two major Hurricanes (Irma and Maria) that occurred in 2017. The strong sense of island pride was found to generate a sense of community resilience while also facilitating solutions to myriad environmental and social health challenges that come with living in a hurricane prone region in which the economy thrives on tourism.

Subsequently, Cano and colleagues assess the association between resilience, mindfulness, and distress tolerance with depressive symptoms in Hispanic emerging adults in Arizona and Florida. Their findings show that higher resilience was associated with lower depressive symptoms and add to the limited understanding of who may benefit from higher resilience based on inter- and intra-personal resources.

Utilizing a newly developed multi-dimensional scale Antonio et al. examine resilience-based factors among Native Hawaiians using data from the Hawaiian Homestead Health Survey. Based on a higher-order confirmatory factor analysis, their results indicate resilience is comprised of both internal assets (e.g. environmental mastery, satisfaction with life, and hope) and external assets (e.g. Native Hawaiian cultural identity and social support). Moreover, their findings suggest resilience slightly moderated and mediated the effect of adversity related to socioeconomic status. Future research should focus on a multi-faceted construct of resilience that can be used to promote better health outcomes.

Next, Bauer and colleagues highlight usage of mental health services among a sample of young African American men with a history of trauma in the metropolitan area of Kansas City, Missouri. Through focus groups and short surveys, the research team found that trauma exposure was a significant predictor of certain risk factors (e.g. substance use, carrying a weapon, or retaliation for a violent injury) however resilience did not moderate this relationship or predict the use of mental health services. Qualitative findings indicate a desire to maintain resilience autonomously or through other positive coping strategies (e.g. working, spending time with friends, or praying). The authors argue that more intervention and exploratory research is needed to address systemic issues and cultural norms in an effort to reduce unhealthy coping behaviors.

The final article in the first of our double special issue by Ledford et al. discusses physiological and psychological predictors of resilience in Navy SEAL Training. Their findings suggest that combining measures of physiological and psychological resilience provides a more holistic view to predict the success of an individual in an intensive training program. These results can span beyond the military community and extend to individuals seeking elite performance across many fields including emergency response workers, CEO’s and professional athletes.

Part two of this double special issue on resilience and health is focused on resilience-related research from a group of researchers who are part of the Interdisciplinary Research Leaders (IRL) program that is funded by the Robert Wood Johnson Foundation. Two investigators from that team, Schnarrs and Yamanis, provide a brief overview of their work while showcasing the importance of community-based partnerships in academic research, especially in the effort to address health inequities.

Altogether, the research highlighted in this special issue provides a pivotal steppingstone for advancing the conversation around the impact of resilience on overall health and well-being. More specifically, interventions, policies, and programing that incorporate resilience should be tailored to different communities and populations based on their feedback and needs. Additionally, it has become increasingly clear that multifaceted and holistic approach to resilience is needed in order to address biopsychosocial health outcomes. Taken together, researchers, clinicians, and practitioners can utilize this information to enact a necessary shift toward a strengths-based perspective instead of a deficit-focused model of health that has been an unfortunate reality in public health practice for far too long. This shift is more important now than ever before as the world is on high alert and finally collectively acknowledging the ‘Black Lives Matter’ movement³² with calls to systematically defund police departments³³ while redistributing monetary assets to improve public health initiatives around mental health, substance use, housing, and education.³⁴ Capitalizing on resilience can help individuals and communities thrive in this transformational time in history.