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Book Review

Resilience and Mental Health: Challenges Across the Lifespan

Arthur M. Freeman III, MD

Published: June 15, 2013

Resilience and Mental Health: Challenges Across the Lifespan

edited by Steven M. Southwick, Brett T. Litz, Dennis Charney, and Matthew J. Friedman. Cambridge University Press, New York, NY, 2011, 366 pages, $105.00 (hardcover).

This volume is an important resource for all mental health clinicians and others interested in trauma and resilience. While not providing a complete manual for the treatment of posttraumatic stress disorder (PTSD) and other related disorders, the book may be especially useful for pragmatic clinical psychiatrists who spend little time with current academic psychology. After exposure to the thinking and clinical research included in this text, they should be able to use the material in psychoeducational and psychotherapeutic as well as psychopharmacologic approaches to their patients.

The first section deals with pathways to resilience using neurobiology. Allostatic load is used as the construct defining resilience as the degree to which the body can maintain homeostasis under various forms of physiologic stress. The biochemistry is familiar and not overly detailed. Particularly interesting is the linking of molecular resilience to active psychological coping mechanisms of reframing, reappraisal, humor, optimism, creating meaning, and prosocial behavior. Included is the promise of future medications that affect the hypothalamic-pituitary-adrenal axis and the monoamine and neuropeptide systems. Other chapters in this section include discussions of protective emotional regulation factors such as cognitive, self-efficacy, personality, and social support components of resilience.

Several other chapters in the book are especially intriguing. A provocative chapter gives a discussion of resiliency in individuals with serious mental illness. This new plan replaces recovery programs that emphasize remission of most symptoms of severe mental illness. It broadens the focus of treatment beyond psychopathology, paying more attention to areas of social relationships, role functioning, quality of life, and finding meaning and purpose in life. Recovery themes include hope, optimism, self-respect, coping, and new experiences.

Also emphasized are resiliency factors such as faith, subjective well-being, creativity, gratitude, forgiveness, perseverance, adaptability, tolerance, and self-reliance. For clinical psychiatrists who treat severely and also moderately ill patients, the inclusion of these concepts carefully applied might improve outcomes.

The discussion of resilience in older adults presents interesting research findings. After the 9/11 attacks, participants aged 65 years or older were 3 times less likely to develop PTSD than a cohort aged 18 to 24 years. Male gender, Asian ethnicity, and lack of major life stressors also correlated with increased resilience. These findings were consistent with the sociocultural context of family and community support.

In a study of bereaved older adults, 5 of 6 adjusted well over time. One in 3 had strong resilience with little or no negative consequences. Also, in 40% of a group of aging veterans, many of whom had experienced combat, most endorsed positive aspects of their military service including enhanced self-esteem and coping skills.

The discussion of resiliency in the face of loss and grief is a succinct and hopeful survey of the topic. The authors develop the 4 areas of the phenomenology of grief: (1) cognitive disorganization, (2) dysphoric emotion, (3) health deficits, and (4) disruption in social and occupational functioning. Preoccupation with the loss, anger, sadness, and decrease in general health and in fulfilling family and work roles are addressed. Trajectories of loss and grief, including patterns of resilience, recovery, and chronic or complicated grief, are outlined in a clinically useful manner. The authors provide evidence that grief is independent of depression and PTSD symptoms in predicting functional outcomes. Given the several types of reactions, clinical interventions cannot be uniform but must be tailored to the individual. Interventions are necessary for only some who are grieving and only those in the chronic grief trajectory.

Not usually found in books of this type but included here is a thoughtful chapter on spiritual and religious aspects of resilience. More than 90% of Americans report a belief in God and 70% are affiliated (however loosely) with a faith community. The authors outline several stages of spiritual development, including awareness of transcendence, joining a spiritual group as a member or leader, reevaluation of personal spirituality, providing service to others based on an inward journey, and connection to the divine. The specifics of resilience will depend on individual levels of spiritual development, psychological structure, and the type of stress or trauma. Those who are spiritual may actually grow through adversity and disruption.

Research in positive psychology has identified several spiritual areas related to resilience, including morality, self-control, forgiveness, and love. Early attachment to primary caregivers is related to later quality of the relationship with God. In addition to providing first role models, encouragement, and reassurance, familial and other caring relationships can help individuals learn to implement realistic plans, develop self-confidence, nurture communicative and problem-solving skills, and manage emotions. The relevance of this for practicing psychiatrists is not to share religious beliefs and practices, but to be aware of healthy and unhealthy aspects of spirituality. The latter include guilt, lack of forgiveness, and loss of faith for patients who have previously professed this.

Intervention to enhance resilience is a general theme of the book and is also treated in depth in a separate chapter. This chapter integrates neurobiology, psychosocial factors, and training to enhance performance in specific stressful situations. Hardiness training may be useful as there is a growing literature supporting its effectiveness in the military, with working adults, and with college students. Also included are discussions of stress inoculation training, psychoeducational resilience enhancement, and social support interventions. The latter has been shown to be effective for individuals with depression, generalized anxiety, social phobia, or alcohol dependence and for military groups. Learned optimism training and well-being training are showing early positive results. The latter emphasizes positive outcomes rather than alleviation of psychological distress.

In summary, this book is practical as well as theoretical and offers material that is in an early stage of research. It is a compendium of ideas about stress that could be useful to many clinical psychiatrists.

Arthur M. Freeman III, MD

Author affiliation: University of Alabama School of Medicine, Birmingham.

Potential conflicts of interest: None reported.

Volume: 74

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