The Impact of Resilience on Health: Lessons Learned and Future Directions

This double special issue of Behavioral Medicine provides an overview on the impact resilience has on behavior, well-being, and biopsychosocial health outcomes. This compilation of research provides a dynamic representation of resilience measurement and inquiry. More specifically, efforts focused on individual (e.g. positive emotional resources and/or hope, optimism, and agency), interpersonal/family (e.g. secure kin relations and/or close social ties), and community/organizational (e.g. engaging in the natural environment and/or having a satisfying work life) resources, biological (e.g. regular physical exercise and/or immune responsivity and regulation), which are all documented components of resilience.¹ However, following a general dissatisfaction with a unilateral model, many researchers included here have developed, implemented, and tested different approaches to measuring resilience that span many of the aforementioned domains. The following summary provides concrete strategies and recommendations not only for future research but also for practice and interventions.

Implications and recommendations

The need for a multidimensional approach to resilience

As demonstrated by the myriad definitions of resilience presented in the Introduction of this special issue, one thing is clear—resilience cannot be viewed as unidimensional. Its meaning, utilization, and manifestation can change depending on the setting, environment, individual, and/or community. As such, understanding the multifaceted nature of resilience in applying strengths-based solutions to negative health outcomes is critical. More recently, researchers have utilized this approach in assessing resilience to the loss of a spouse² or child,³ survivors of sexual abuse,⁴ and in undergraduate academic settings.⁵ However, this position was also clearly articulated by several of the articles included in this double special issue. For example, Antonio and colleagues’ in their work on resilience among Native Hawaiians that highlight a multidimensional approach over a unidimensional construct. They found that a combination of hope, satisfaction with life, environmental mastery, coping resources, social support, and Hawaiian cultural identity to be the most salient factors comprising resilience. Using this multidimensional approach, the authors found that resilience slightly mediated the effect of adversity on health.

In addition to the psychosocial aspects of resilience is also important to examine the biological ones as well. In their examination of a Navy SEAL training program, Ledford et al. focus on both psychological and physiological resilience in its relationship to the success of a first phase military special operations training course. They combined the three different biomarkers (brain-derived neurotrophic factor (BDNF), dehydroepiandrosterone (DHEA), and cortisol) and a validated psychological tool to assess a single metric of resilience. Their findings demonstrate that both approaches to resilience provides a more holistic view on persistence and stamina in training. Similarly, Mitchell and colleagues examined the role of hopefulness as a component of resilience on stress regulation. Results indicate that hopefulness was associated with lower allostatic load scores however this was varied based on reported experiences of discrimination based on racial/ethnic groups. As such, the protective effects of hopefulness on physiological dysregulation are tied to pas experiences of discrimination. Collectively, this work builds off of previous research that has examined the neurobiology of resilience through the development of stress-resilient profiles and allostatic load capabilities.^6–8

Moore et al. examine resilience via the role of physical activity on the effect of prosocial behavior in a low-income neighborhood with limited social and environmental resources. They utilized a novel measure of prosocial behavior to observe specific neighborhood-related intentions (e.g. willingness to help in an emergency, getting mail, or providing a ride) and found a significant relationship between prosocial behavior and moderate-intensity exercise. Taken together, their findings suggest that prosocial behaviors and highlighting positive attributes of low-income neighborhoods are important contributors to individual resilience and well-being.

Yamanis and coauthors further elucidate a multipronged approach by describing the individual and community resilience factors among Latinx clients utilizing services as a Federally-Qualified Health Center (La Clínica) in Washington DC. While participants highlighted depression/isolation, language barriers, and immigration legal status as primary barriers, utilizing individual (e.g. fighting for their children’s lives and supportive networks) and community methods (e.g. La Clínica’s safe spaces, health providers, and legal service referrals) as ways to promote resilience. Similarly, Goodkind and colleagues depict the need for collective resilience strategies, especially in the face of adversity. In particular, individual behaviors that are traditionally viewed as resilient may lead to ‘success’ but can still have negative health ramifications. In this specific example, Black girls who are empowered to be critically aware of and challenge oppression through shared action promote collective resilience rather than individual.

Relatedly, Cano et al. utilized a multidimensional framework to assess whether intra- and inter-personal resources could moderate the association between resilience and depressive symptoms among Hispanic emerging adults. In addition to demonstrating that greater resilience was associated with lower levels of depressive symptoms, they found that family cohesion, emotional regulation, and social support moderated the relationship. This work furthers the understanding of who benefits from higher resilience based on external and internal resources. Taken together, this subset of articles signifies a need for examining multipronged approaches to resilience research, practice, interventions, and implementation that moves past resilience as a single-sided construct.

Public health: sifting from a deficits-based to a strengths-based approach

For decades, public health practitioners and researchers have predominantly studied health conditions and outcomes from a deficits-based perspective.⁹ In general, there is a consensus and wide-ranging understanding around the social conditions and factors—apart from medical ones—that drive health across settings and populations.¹⁰ From poverty to racism, and from educational inequities to homophobia, these structural barriers have often driven public health theory, policy and practice. However, while these foci are vitally important and necessary, deficit models tend to define individuals and communities negatively while often disregarding what works well and is positive within a particular population.

Incorporating resilience and moving toward a strengths-based approach is a critical next step for public health. Other fields have been using this paradigm throughout the past half century including psychology through the positive psychology movement¹¹ and social work.¹² Community psychologists have also adopted a strengths-based approach in what is contemporarily referred to as post-traumatic growth.¹³ The field of social work has been using this paradigm since the early 1990s, but it is imperative that public health researchers and practitioners incorporate resilience and other strengths-based concepts into their work moving forward. The social determinants and drivers of health conditions has been well documented in the literature and as such, it is time to build upon the existing research to help ascertain the mechanisms behind which someone not only survives, but also thrives.

This argument is supported by a couple articles in this special issue. For example, Lelutiu-Weinberger and coauthors note that a strengths-based shift in framework helps to recognize transgender persons’ resourcefulness and potential to thrive as they are affirmed for being who they are. Furthermore, they discuss at times it is important to recognize each person will present various types/degrees of need for intervention for affirmation and thus some individual tailoring might be required.

Comparably, Ott and colleagues describe an implementation sciences approach to preventing adolescent pregnancy in rural settings because many such programs frequently focus on deficiencies rather than capacity for growth. Thoughtful partnerships between local community agencies and schools ensured successful implementation of pregnancy prevention programs that pushed the research team beyond commonly held assumptions about rural communities. While these examples underscore shifting to a strengths-based approach, they also support a multidimensional approach too.

Redefining resilience: it may not be enough to ‘bounce back’ from adversity

With many of the definitions of resilience pointing to the notion of bouncing back from difficulties, coping with adversity, or adapting to challenges, emerging research posits resilience needs to be more than that.^14–16 This point is particularly salient in Sobeck and colleagues’ work on the aftermath of the Flint Water Crisis. The research team underscores the historical context of Flint, Michigan in that it has faced significant disinvestment, poor water infrastructure, and high rates of poverty decades prior to the onset of the April 2014 water crisis. While the long-term impact of the stressors related to the crisis may not yet be known, members of the community demonstrated resourcefulness by embracing various collective (e.g. joining a book club, town forum, and/or community coalition) and individual (e.g. medical advice, spiritual guidance, and/or mental health counseling) coping strategies to face challenges. The authors also push the narrative around resilience further and suggest that ‘bouncing back’ from challenges may not be the ultimate goal but seeing resilience as ‘moving beyond’ in a recurrent cycle of adaptation, renewal, and strength, especially in communities that have faced consistent systemic and environmental inequities.

Similar sentiments around environmental justice are found in Pérez-Ramos and colleagues’ research on the small Puerto Rican Island of Culebra after Hurricanes Irma and Maria. There is a need to develop sustainable and community engagement approaches to combat preexisting environmental health risks that are magnified in the aftermath of a Hurricane. As such, capitalizing on community identity presents unique solutions for mobilizing tourists, health programs, local government, and nonprofit organizations can help generate community engagement and the collective ability to overcome and move beyond adversities.

Resilience as an undervalued approach to buffer sociodemographic inequities

It is timely that several articles in this special issue highlight the impact that resilience has in relation to inequities and disparities, specifically around race/ethnicity and sexual orientation. In their article examining African American youth exposed to community violence, Woods-Jaeger et al. argue for the development of health promotion programs that address unique risks and build on existing protective factors (e.g. peer, familial, and cultural contexts). More specifically, youth stressed the importance of rebuilding trust in others, returning of normalcy, and progressing in the face of adversity

Likewise, Bauer and coauthors examined the association between risk behaviors, mental health service utilization, and resilience among young African American men. Quantitative findings show that resilience was not associated with use of mental health services or moderate the relationship between trauma exposure and risk behaviors (i.e. incarceration or substance use). However, while their qualitative results revealed a desire to maintain resilience autonomously and “deal with problems yourself,” other coping strategies focused on securing employment to stay busy or using prayer and religion as a guiding force. Trauma was also assessed in Reyes and colleagues’ investigation of resilience and cultural norms among Filipino American Women (FAW). The team found that foreign-born FAW had significantly lower rates of PTSD and greater resilience compared to their US-born counterparts. Additionally, they observed a conditional moderating effect of familial norms with disclosing mental health struggles on the adverse relationship between PTSD and resilience.

Schnarrs et al. assessed whether resilience had a moderating effect on the relationship between Adverse Childhood Experiences (ACEs) and the quality of mental and physical health among sexual and gender minority adults. Their results show a significant interaction between ACEs and mental health with resilience reducing the impact of ACEs on quality mental health in adulthood. Collectively, these articles also demonstrate a need to not just recover from trauma but consistently move past it in the face of possible repetitive exposure.

Furthermore, given the tumultuous state of racial affairs in the United States and abroad, a considerable amount of attention should shift supporting Black and Brown individuals and communities using resilience as an approach. In developing the mission for the Black Lives Movement, their creators state, “we affirm our humanity, our contributions to this society, and our resilience in the face of deadly oppression” as a key part of the movements vision.¹⁷ Researchers, practitioners, and policy makers need to a concerted effort to work with and not just for communities in which they do not share a common identity as to not perpetuate cycles of suppression and lack of agency, especially on issues related to resilience and coping.

Bridging the gap: the health of populations and individuals

With the relatively recent movement toward translational research that focuses on fostering more cohesive relationships between basic scientists and clinical researchers,¹⁸ a logical next step is for a multipronged approach to research on resilience is one that includes many different disciplines. More specifically, public health researchers and practitioners need to work more intentionally with social workers and mental health providers in order to better address the needs of individuals and the population at large. For example, hey need to understand that that a person living with a history of traumatic experiences is not the trauma itself. Combining a dynamic public health model that methodically thinks about how each point of intervention informs the next with a psychological approach that focuses on details and depth of underlying causes of problems can be a formidable balance.¹⁹ While tending to the needs of individuals is crucial to improving the health of populations, there can also be a synergistic relationship by improving population-based and structural impediments of health that has a direct impact on people and populations. This relationship can be fostered by implementing multi-level resilience interventions and programs that address the interplay among individuals, communities, and the environment at-large.

Conclusions

This special double issue is part of a burgeoning body of work on resilience among diverse communities and populations. Taken together, these articles showcase the vast array of approaches to incorporate resilience into research and practice while greatly emphasizing the need for further examination moving forward. Concrete strategies to expand past popular unidimensional construct and pushing for more multifaceted approaches to work on resilience are provided. Moreover, it is imperative to bring public health researchers and practitioners together with mental health providers and clinicians in an effort to bridge the gap between disciplines and approaches to care. Furthermore, this re-alignment will help shift conversations within the public health field toward a strengths-based approach instead of focusing predominantly on deficits. Finally, we must acknowledge that the needs of individuals and communities are not monolithic. As such, we must continue to push forward research initiatives that concentrate on the myriad approaches to improving overall biopsychosocial health and well-being.

Kristen D. Krause
Center for Health, Behavior, Identity and Prevention Studies, Rutgers University
[email protected]