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  • Eur J Psychotraumatol
  • v.11(1); 2020

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Psychological resilience: an update on definitions, a critical appraisal, and research recommendations

Resiliencia psicológica: una actualización en las definiciones, una valoración crítica, y recomendaciones para la investigación, 心理韧性:定义、严格评价和研究建议的更新, christy a. denckla.

a Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

Dante Cicchetti

b Institute of Child Development, University of Minnesota, Minneapolis, USA

Laura D. Kubzansky

c Department of Social and Behavioral Sciences, Lee Kum Sheung Center for Health and Happiness, Harvard T.H. Chan School of Public Health, Boston, MA, USA

Soraya Seedat

d Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa

Martin H. Teicher

e Harvard Medical School, Boston, MA, USA

David R. Williams

f Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA

g Department of Sociology, Harvard University, Cambridge, MA, USA

Karestan C. Koenen

Background: The ability to resist adverse outcomes, or demonstrate resilience after exposure to trauma is a thriving field of study. Yet ongoing debate persists regarding definitions of resilience, generalizability of the extant literature, neurobiological correlates, and a consensus research agenda.

Objectives: To address these pressing questions, Drs. Christy Denckla and Karestan Koenen (co-chairs) convened a multidisciplinary panel including Drs. Dante Cicchetti, Laura Kubzansky, Soraya Seedat, Martin Teicher, and David Williams at the 2019 annual meeting of the International Society for Traumatic Stress Studies (ISTSS). Questions included (1) how have definitions of resilience evolved, (2) what are the best approaches to capture the complexity of resilience processes, and (3) what are the most important areas for future research?

Methods: The proceedings of this panel are summarized in this report, and prominent themes are synthesized and integrated.

Results: While different definitions emerged, all shared a focus on conceptualizing resilience at multiple levels, from the biological to the social structural level, a focus on the dynamic nature of resilience, and a move away from conceptualizing resilience as only an individual trait. Critical areas for future research included 1) focused efforts to improve assessment that has international and cross-cultural validity, 2) developing within-study designs that employ more intensive phenotyping strategies, 3) examining outcomes across multiple levels and domains, and 4) integrating conceptualizations of resilience from the individual-level to the larger social context at the population health level.

Conclusion: Increasingly sophisticated and nuanced conceptual frameworks, coupled with research leveraging advances in genetics, molecular biology, increased computational capacity, and larger, more diverse datasets suggest that the next decade of research could bring significant breakthroughs.

HIGHLIGHTS:

• The field of psychological resilience is characterized by ongoing debate over definitions, generalizability, and a research agenda.•Evolving definitions share a focus on conceptualizing resilience at multiple levels, a focus on dynamic processes, and moving away from individual trait conceptualizations.• Future research recommendations include improving assessment cross-culturally, employing within-study designs, and examining outcomes at multiple levels and domains.

Antecedentes : La capacidad de los sujetos para resistirse a resultados adversos – o demostrar resiliencia – luego de la exposición al trauma es un campo de estudios creciente. Sin embargo, persiste el debate en las definiciones de resiliencia, en cuáles son sus sustratos neurobiológicos, en qué medida los hallazgos de la literatura existente pueden ser generalizados, y en la dirección que debe tomar la investigación futura.

Objetivos : Para abordar estas preguntas urgentes los doctores Christy Denckla y Karestan Koen (copresidentes) convocaron un panel multidisciplinario que incluyó a los doctores Dante Cicchetti, Laura Kubzansky, Soraya Seedat, Martin Teicher y David Williams, en el encuentro anual de la Sociedad Internacional para los Estudios del Estrés Traumático (ISTSS por sus siglas en inglés) del 2019. Las preguntas incluyeron (1) cómo han evolucionado las definiciones de resiliencia, (2) cuáles son los mejores enfoques para capturar la complejidad de los procesos de resiliencia, y (3) ¿cuáles son las áreas más importantes para la investigación futura?

Métodos : Las actas de este panel se resumen en este informe, y los temas destacados se sintetizan e integran.

Resultados : Si bien surgieron diferentes definiciones, todas compartían el enfoque de conceptualizar la resiliencia en múltiples niveles, desde el nivel biológico hasta el nivel social estructural, el enfoque de la naturaleza dinámica de la resiliencia, y el dejar de conceptualizar la resiliencia como un rasgo individual. Las áreas álgidas de investigación a futuro incluyen 1) esfuerzos enfocados en mejorar la evaluación de la resiliencia con validación internacional e intercultural, 2) desarrollar diseños de estudio que utilicen estrategias de fenotipificación más intensivas, 3) evaluar los resultados a lo largo de múltiples niveles y dominios, y 4) integrar conceptualizaciones de la resiliencia desde el nivel individual hacia el contexto social en niveles de salud poblacionales.

Conclusión : Los marcos conceptuales cada vez más sofisticados y matizados, junto con la investigación que aprovecha los avances en genética, biología molecular, mayor capacidad computacional y conjuntos de datos más grandes y diversos, sugieren que la próxima década de investigación podría traer importantes avances.

背景: 在暴露于创伤后,抵抗不良后果或表现出韧性的能力是一个蓬勃发展的研究领域。然而,关于韧性的定义、现有文献的概括性、与神经生物学的相关性以及共识研究议程仍存在持续争议。

目的: 为解决这些紧迫问题,在2019年国际创伤应激研究学会(ISTSS)年会上,Christy Denckla和Karestan Koenen博士(联合主席)召集了包括Dante Cicchetti、Laura Kubzansky、Soraya Seedat、Martin Teicher和David Williams博士在内的多学科专家组。问题包括:(1)韧性的定义如何演变; (2)捕捉韧性复杂过程的最佳方法是什么; (3)未来研究最重要的领域是什么?

方法: 本报告总结了该专家组的会议记录,并对主要主题进行了综合整理。

结果: 尽管出现了不同的韧性定义,但所有定义都关注从生物结构到社会结构对韧性进行多水平的概念化,都关注韧性的动态性质,以及都不再仅仅将韧性概念化为个体特质。未来研究的关键领域包括:1)集中精力改进具有国际和跨文化有效性的评估; 2)开发采用更深入的表型分析策略的研究设计,3)考查跨多个水平和领域的结果,以及4)整合从个体水平到更大的人群健康水平的社会背景的韧性概念。

结论: 越来越复杂和细致的概念框架,结合促进了遗传学、分子生物学、增强的计算能力以及更大、更多样化数据进步的研究,表明未来十年的研究可能会带来重大突破。

关键词: 韧性; 应激; 创伤; 创伤后应激障碍

1. Introduction

The most comprehensive assessment of exposure to traumatic events (defined as threatened death, serious injury, or sexual violence) conducted to date found that worldwide, over 70% of respondents ( n  = 68,894) reported exposure to at least one traumatic event in their lifetime, with nearly a third reporting exposure to four or more traumatic events (Benjet et al., 2016 ; Kessler et al., 2017 ). This extraordinarily high rate of exposure to traumatic events is even more profound when other adverse experiences are taken into account including chronic childhood maltreatment (Kessler et al., 2010 ), economic marginalization (Patel et al., 2018 ), racism (Williams, 1999 ), and climate change (Doherty & Clayton, 2011 ). The neurotoxic effects of exposure to such experiences are far-reaching and range from compromised neurocompetence (Teicher, Samson, Anderson, & Ohashi, 2016 ), psychopathology including PTSD (McLaughlin et al., 2013 ) and depression (Mandelli, Petrelli, & Serretti, 2015 ), to adverse physical effects acting at molecular (Esteves et al., 2020 ; Pitman et al., 2012 ) and systemic levels (Sumner et al., 2015 ).

Given the high likelihood of exposure to trauma, coupled with the known downstream toxic consequences to health and well-being, understanding the mechanisms that might mitigate these effects is a critical area of inquiry that can inform intervention, prevention, and public health policy efforts (Magruder, McLaughlin, & Elmore Borbon, 2017 ). In this respect, research on psychological resilience has become a promising area of discovery. The commonly made observation that not all individuals exposed to trauma and adversity experience negative outcomes suggests the presence of processes that may attenuate or disrupt the adverse effects of trauma exposure. Indeed, the remarkable ability of individuals to resist adverse outcomes or to demonstrate resilience after highly adverse exposures has become a major field of study (Bonanno, 2004 ; Masten, 2001 ). This proliferation of interest in resilience in recent decades is evidenced by the results from a PubMed search suggesting a fourfold increase in research using the keyword ‘resilience’ between 2008 and 2018, compared to only a 1.7-fold increase in research focused on ‘trauma and stress’ during that same time period (see also Kalisch et al., 2017 ). This growing body of research holds the promise of filling the prevention gap and suggests an emerging paradigm shift away from disease-focused to health-focused research (Kalisch et al., 2017 ; Murrough & Russo, 2019 ; Ungar & Theron, 2019 ), offering new insights into the mechanisms of stress resilience likely to yield novel therapeutics and prevention strategies (Dudek et al., 2020 ; Feder, Fred-Torres, Southwick, & Charney, 2019 ; Iacoviello & Charney, 2014 ; Mary et al., 2020 ; Moreno-Lopez et al., 2019 ).

However, the field is not without controversy. Major concerns raised include (1) a lack of consensus on the definition and significant variation on operationalization of the construct, (2) discrepancies and confusion around trait vs. dynamic conceptualization, and (3) methodological limitations in the extant literature that limit inferences of causality and generalizability. To contribute to the effort of continued growth in resilience research, a multidisciplinary panel convened to discuss the current state of resilience research at the 2019 Annual International Society for Traumatic Stress meeting (ISTSS). This proceedings paper summarizes and reports on the content of that panel, and was conceptualized as a follow-up to the first plenary panel on resilience held in 2013 at the ISTSS annual meeting (Southwick, Bonanno, Masten, Panter-Brick, & Yehuda, 2014 ). The discussion was co-chaired by Christy Denckla, PhD and Karestan Koenen, PhD Panellists included Dante Cicchetti, PhD, Laura D. Kubzansky, PhD, Soraya Seedat, MBChB, MMed (Psych), PhD, Martin Teicher, MD, PhD, and David R. Williams, M.P.H., PhD

2. Panel discourse

2.1. dr koenen: update on resilience research since the 2013 panel.

Six years ago when I was president of ISTSS in 2013, the theme of our meeting was resilience after trauma from surviving to thriving. I have been asking my colleagues, ‘Have we learned anything about resilience in the past six years?’ People seem unsure. For example, I actually had the opportunity just moments ago. I saw Murray Stein out in the hall, so I asked him and he said, ‘I am not sure actually we have. Maybe we know more about – we have more clarity about the problem.’ I started thinking about this and what I have noticed in the last six years is certainly the interest in resilience has grown exponentially in six years, to the point where it is beyond research.

It is a term, if you have a kid in school, you hear it in schools, you hear it in common lingo all the time. The growing interest has brought new challenges. I think it has further challenged our definition of what resilience is and it has also brought some specific challenges to my own work. For example, I do work in the psychiatric genomics consortium with large amounts of genetic data. There are people like Karmel Choi who work with me and other people who are really interested in the genetics of resilience. But if we do not know how to define resilience, then how are we going to look at the genetics of resilience? Today I was on a call and people were talking about how do you look at resilience using electronic medical records or digital phenotyping? Or other ways of using big data that are really current?

The other question that comes up for me, which I hope the panel will answer is, how do you look at resilience in different contexts? A lot of us do work around the globe. Do we have definitions of resilience or can we operationalize it in ways that we can look at it? For example, I can look at it in the US, but I can also look at in Africa, or Mexico, where I also work. I am really looking forward to hear what the panellists have to say and to addressing some of these questions. I hope they will set us in a better course for the next six years.

2.2. Dr Denckla: contemporary definitions of resilience

Resilience as a domain of study was first most broadly defined in the 1970s as the capacity to maintain health, or adaptive outcomes, even in the presence of adversity (Garmezy, 1974 ). Nearly 5 decades later, the American Psychological Association’s perspective is closely aligned with Garmezy’s earlier conceptualization and defines resilience as ‘the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress’ (para. 4, American Psychological Association, 2014 ). Though useful as a broad framework, leading thinkers in the field agree that there is an ongoing need to establish a definition that supports clear hypothesis testing, falsifiable theory building, and comparison of findings across studies. In the following section, five scientists from different disciplines reflect on how their definitions of resilience have evolved over the course of their career.

2.3. Dr Seedat: resilience as mutable, scalable, dynamic and fluid

It is a pleasure to be on this panel and to share my own reflections on a theme that runs deep at this meeting. I think that resilience has gained traction in large part because of the potential to intervene with therapeutically effective treatments that are mechanistically informed. I have been working in the field of post-traumatic stress disorder for more than 20 years, but I started off, as many researchers have done, thinking about resilience as being a trait, a process, and outcome and wondering whether it was a convergence of all of these. Also, thinking about resilience in a binary way and coupled to diagnosis-based binary metrics, as well as thinking about resilience as reflecting resistance to psychopathology or recovery from psychopathology, either spontaneously or in the context of treatment. I think we have made a significant shift in terms of our understanding. We think of resilience now more as an effective adaptation to, or a navigation (or management) of, significant sources of traumatic stress or adversity and the capacity to absorb disturbance to harness resources effectively.

Resilience can be thought of as a process of relatively stable trajectories of well-being, but it is also characterized by ‘dips’ or periods of instability. I think that, for me, I consider resilience to be a mutable, scalable, dynamic, and fluid characteristic. It needs to be considered in terms of the lifespan of an individual, and it is largely context-dependent. An optimal trajectory really requires homoeostatic adaptation, both on neurobiological and psychosocial levels. There is growing evidence to support the distinction between passive resilience and more active resilience (Rakesh et al., 2019 ). There are many mechanisms at play. These can be considered as allostatic load, stress inoculation, contribution of developmental factors, epigenetic factors, and transgenerational factors, that come into play and affect multiple interdependent systems (Southwick & Charney, 2012 ).

2.4. Dr Kubzansky: expanding the conceptualization of resilience to include well-being and thriving

When I think about the research on resilience that is emerging and also about my own work, I think we have done an excellent good job of understanding the questions we should be asking about resilience, but I am not sure how many answers we have as yet. In part, this may be due to a continued lack of conceptual clarity. To illustrate this, I will review some of the issues I have been mulling over as I think about how can we might want to study resilience and move the field forward. One issue I think is becoming increasingly clear is that resilience is a dynamic process. Trying to measure it as a static trait or a static experience has been challenging and may not be as useful for answering some of our key questions of interest. Thus, we often rely on people to self-assess their own resilience and tell us the extent to which they believe they can ‘bounce back’ after stressful events. This can be problematic because it is not clear how much people are able to predict how they are going to respond to unexpected circumstances, or how much self-insight people have. However, if you cannot simply ask people to self-report on their own resilience, it can be difficult to ascertain and quantify levels of resilience. Even the most simple definitions of resilience include exposure to adversity as part of the definition, that then also includes being able to bounce back or thrive even in the fact of such an exposure. If we also believe resilience is a process rather than a trait, then to assess the presence of resilience, you have to wait for some kind of stressful experience to happen and then see how people respond; only then can a researcher ascertain if the overall process indicates resilience or not.

I was particularly struck by this measurement challenge recently. I teach a social science research methods class, and as part of the class, we ask the students to develop a questionnaire-based measure of a construct of interest, that we assign. One year, I assigned students the task of developing a measure of resilience. I thought, ‘Well, this will a good exercise since many people are interested in resilience.’ It turned out to be a complete disaster, trying to have them measure resilience. They could not figure out how to do it because they kept running into questions about whether and how to measure stress. So they would say, ‘Well, I have to measure stress. I have to find out if they had stress, but then I have to have some way of figuring out how they responded to stress and I do not know how to measure that. And, what if my respondents did not experience any significant stress? In that case, I cannot measure resilience.’ Perhaps not surprisingly, the measures they developed were problematic in all sorts of ways. It was probably one of the worst constructs that I ever assigned my students to measure and I vowed I would never do it again. I was really struck by this challenge in both conceptualizing and measuring the construct of resilience.

Another issue that I have been mulling over is that resilience, of course, implies adversity, and so anytime we talk about resilience, we are also talking about what happens in the context of adversity. I sometimes wonder if that is really the best way to think about this, given that all living organisms are going to encounter challenges and threats throughout their life and the goal is to be able to adapt appropriately to both small and larger challenges in order to be able to meet them effectively. If this is the case, then should we in fact think of resilience as occurring only in the context of trauma or major adversity (which is how it is most commonly conceptualized) or more as a capacity that is perhaps most evident in the context of major adversity but is exercised just in the process of living and making one’s way through the world. In some ways, I wonder if thinking about resilience primarily in the context of trauma or major adversity ends up leading us to a more narrowly focused or narrowly defined construct than would be ideal.

Another issue related to this concern about how narrowly we think about this construct is how we think about effects of resilience. Conceptualizing effects in the context of adversity can draw attention to how one might reverse damage or restore function (i.e. after damage has been incurred via exposure to adversity), rather than thinking about how one might build reserves or capacities that allow people to withstand and meet threats effectively, thereby preventing damage from occurring. This type of focus may be seen as after the fact-rather than preventive or health promotive (i.e. considering how people are functioning prior to confronting adversity) and changes the kinds of issues that you might examine or hypotheses you would generate.

A key question that often comes up when studying resilience is who should we consider as forming an appropriate comparison group? Of course, in part that is going to depend on your research question, but at the most general level, it is not clear whether the most appropriate comparison for people who faced adversity and then went on to function well in spite of it, is the people who never experienced stress or trauma at all, or the people who experienced stress or trauma and then went on to experience psychological or other difficulties. I have been working closely with a wonderful doctoral student, Kristina Nishimi, to try to figure out how to characterize these phenotypes. If you are willing to do the most simplistic version, you would say there are four groups. First, you have people who confront adversity and then do poorly. Then, you might have another group of people who confront adversity and then have healthy psychological functioning in spite of that. You could have a third group people who do not seem to have confronted major adversity, but they are still not functioning well, for whatever reason (or maybe they really did experience adversity, but we just were not able to capture it). Then, you would have a fourth group that we could call a thriving group – these are the people who do not appear to have confronted major adversity and are still doing really well psychologically. As a sidebar, we have sometimes wondered if the people in this fourth group are somehow weird because there are not very many of them in the world. Moreover, who somehow manages not to confront major adversity in over the course of their lives? In any case, given even these four admittedly oversimplified phenotypes, it is not immediately clear who is the appropriate comparison group – those who never face adversity or those who do but seem to function well regardless? Moreover, to be able to create these phenotypes, one needs to decide what the thresholds should be for ascertaining if individuals are doing well or not psychologically, and for how to characterize whether individuals have indeed confronted major adversity (i.e. what constitutes major adversity, is one’s experience enough or would we only characterize exposure when individuals have confronted two, three, or more of these types of events?). We probably all agree that these kinds of experiences and types of functioning really are on some kind of a continuum but it can be hard to define a construct across two continuums. Thus, we still have many questions about how best to conceptualize resilience and how to operationalize and measure it.

Another issue related to how we conceptualize resilience with which I have wrestled and sometimes been troubled by is this notion of ‘bouncing back.’ A basic premise of our work in this area is often that one faces some kind of adversity and then bounces back from and manages to recover in some way. However, what does it mean to bounce back and recover? To what are individuals bouncing back? I am always stuck on this thinking, ‘What if you were not in a good place to begin with? Then what are you bouncing back to and do you want to bounce back to that place?’ Most likely the people who are not in a good place are less likely to bounce back anywhere, but if they do bounce back, are they coming back to some kind of healthy place or not? As a result, I have not always found the notion of ‘bouncing back’ to be very helpful in terms of conceptualizing how we think about resilience. It seems to me that our understanding of resilience should account in some way, for where people start the process of confronting adversity – that is where they functioning well to begin with.

Another issue in which I have been really interested (which anyone familiar with my work will know) is regarding the relationship between psychological resilience and physical health, and thinking of resilience not as an outcome necessarily, but as a predictor. The central question here asks if people who are more psychologically resilient less likely to experience adverse effects of facing trauma, adversity, or life difficulties in terms of physical health? If so, what are the mechanisms by which that would happen? If you are going to think about resilience as a predictor, then the measurement becomes even more crucial in terms of thinking about how you define your comparison groups and how you can look at this in a way that allows you to characterize resilience as a process but still measure it in some kind of meaningful and reliable way.

Finally, an issue that I have spent a lot of time thinking about is, whether we can and should distinguish between positive functioning or thriving or positive psychological well-being (or whatever term you prefer that suggests people doing well regardless of whether they have confronted adversity) and resilience. As an aside, not long ago, I attended a meeting at the National Institute of Health (NIH) to discuss research priorities on resilience, and I made quite a few comments about this issue, but found many folks just gave me a blank stare, implying this is not an issue with which other people have been much concerned. However, I think we should be concerned with this, so I am going to put the issue out here and try again. Resilience implies that one is confronting adversity, trauma, stress, distress in some form. In contrast, the concept of thriving does not rely on the notion that you have to confront some kind of difficulty. So, an important question is what is the relationship between those two concepts? I would argue they are different but related. For instance, you might expect that people who have the skills and the capacities that enable them to do well in life are probably the same people who are more likely to be resilient and to do well in the face of adversity. As noted earlier, measuring resilience is challenging because we are forced to try to assess how people are doing in the context of adversity. While this is doable when measuring post-traumatic stress, which is defined by the fact that someone experienced a specific trauma and had a negative psychological response to that trauma, in many other situations, it can be difficult to tie psychological functioning to the occurrence of adversity specifically. Trying to do this raises some difficult questions – would we think only about a discrete event, or could that include for instance, ongoing social disadvantage or discrimination, and so forth. Another approach is to consider positive functioning regardless of adversity experiences. This leads us to ask what is positive psychological functioning or thriving and what are key elements that characterize these experiences? Once we achieve an understanding of this concept, we may also be able to understand resilience better as well as bring insight into ways in which we might help people to be more resilient. If we are explicit about the conceptual distinctions and similarities between thriving (or positive psychological well-being) and resilience, it makes it a little bit easier to think about how we identify more broadly what it means to be doing well, key components of each concept, as well as antecedents and consequences of these psychological experiences of doing well.

2.5. Dr Teicher: resilience and brain network organization

I come at the question of resilience from a more narrow framework. I am not particularly interested in resilience per se, I am more interested in the effects of childhood maltreatment, and correspondingly a specific type of resilience, characterized by individuals who experienced a moderate to high level of exposure to childhood maltreatment and who are doing much better than you would expect in comparison to other people who have had comparable levels of exposure. These are individuals who may show no signs of psychopathology in either the internalizing or externalizing domains. You observe them, you observe them clinically, you observe them in terms of your research studies and the big question for me is mechanistically, how do these individuals differ from individuals who are more vulnerable or more susceptible?

We have been looking at this from a brain imaging standpoint, and initially, our thinking was that if you are exposed to maltreatment and you develop certain psychiatric symptoms, and we look at your brain, we are going to see all sorts of alterations in susceptible structures. We will see reduced hippocampal volume, we will see alterations in amygdala function. We will find effects on your prefrontal cortex and your corpus callosum and there will be changes in your brain network organization and architecture. The assumption will be, well, if you have these experiences, and you are doing pretty close to fine, indistinguishable from an unexposed control group, then your brain is likely spared and you probably have some mechanism going on that enables your brain to be more resistant to the effects of stress hormones or something. That is how we started looking at this in terms of the brain imaging data, and it turned out that I was, as often as the case absolutely wrong.

What we hypothesized was not the way it looked at all. If you measured hippocampal, prefrontal cortical, cerebellar, and corpus callosum volumes as well as amygdala response and brain network architecture, you found basically the exact same effects in individuals who were exposed to maltreatment and had serious psychopathology and comparably exposed individuals who had no diagnosable psychiatric disorders and were asymptomatic on every scale that we have given them. Nevertheless, they had the same array of brain changes. For years, I had this data in front of me and it was well – I am trying to build a model to understand how maltreatment by affecting the brain leads to psychopathology, but every brain change that we saw in individuals with psychopathology we also observed in maltreated individuals without psychopathology. It is only recently, within the last year, that we developed an explanation for what we were observing that makes neurobiological and clinical sense and this required an examination of brain network architecture.

We were looking at the interconnections of 90 different brain regions to specify how the brain is organized. Basically, the brain has a small-world organization that consists of modules or communities of closely interconnected brain regions that are connected to other modules through hubs. The maltreated and non-maltreated brain networks are very different. It turns out that the modules have the same local connectivity patterns in maltreated and non-maltreated individuals, but there are fewer interconnections between these modules in maltreated individuals. The maltreated brain network in particular is missing a number of frontal hubs that you normally see in a non-maltreated group, so there is a different organization. The maltreated group has a sparser network organization with fewer interconnections between modules and it is correspondingly more vulnerable. That is, it has less ability to compensate for an abnormality in a module because of its sparse connections. So we have figured what is going on in the vulnerable individuals is that you have an abnormality in a brain region or a series of brain regions and you then have a brain network organization that cannot compensate. Hence, you will wind up with symptoms and these symptoms may wax and wane in a quasi-random fashion as your brain network tries to organize to effectively compensate, but may not be able to do so due to the fewer interconnections between modules. Further, this process will have a developmental time course because network vulnerability likely increases in maltreated individuals from 15 to about 21 years of age as a consequence of pruning processes that largely occur post pubertally and the failure to develop these frontal hubs which occurs during adolescence. So psychiatric disorders in maltreated individuals will often emerge during the adolescent period as your brain network reaches a point of vulnerability is then no longer able to compensate for abnormalities in specific brain regions and you start to develop symptoms. That is what we believe is occurring in maltreated individuals who are susceptible to psychiatric consequences.

In the resilient individuals, we hypothesized that maybe they are doing better because problematic brain regions are exerting less influence on the network and that they can continue compensating for a brain region that is functioning abnormally during this period of increasing network vulnerability is its volume is turned down to a certain degree. I am doing this work with Kyoko Ohashi, PhD in the lab, and we found that, yes, if you looked at the right amygdala, which is often abnormal in these individuals, it is less connected to the network in maltreated individuals without psychiatric symptoms. We then identified eight other brain regions that were less connected to the network in the resilient individuals. In the controls and in the susceptible individuals, it was equally connected, but in the resilient group, it was diminished. Well, diminished by perhaps by only 5% to 10%, but that may enable the network to fully compensate. We found that this model, using just 14 brain measures, we could classify our 300 plus individuals successfully into maltreated, non-maltreated, resilient, or susceptible with 80% cross-validated accuracy. This therefore seems to be a pretty decent model for understanding what is going on in terms of brain network organizations and resilience. That is what we have learned in this particular time. It then opens up all questions. Were these resilient individuals blessed with reduced connectivity in these regions to begin with, and does that lead to say a minimal impact pattern, as described by Bonanno and Diminich ( 2013 ), where they were exposed to adversity and never develop much in the way of symptoms? Or do these alterations in connectivity of these ‘resilient nodes’ emerge over time and led to an emergent or recovery pattern in terms of the resilience? We need to answer that question.

It seems like some of these regions may be more associated with the minimal impact and some more with an emergent resilient pattern and whether properties that you can identify beforehand that would predict that somebody would have this response. I am not sure if that is the case, how much is their psychological makeup versus how much is their neurobiology. Are there indeed protective factors, and do protective factors work by facilitating this kind of compensatory change in certain regions that will enable you to compensate?

Then, finally the big question is when you are looking at individuals who are maltreated and have serious symptomatology and you treat them, does treatment work by reversing the brain changes that you see with maltreatment or does it work by moving the nodal network architecture connections of the susceptible individuals more into the line with the more atypical network architecture of resilient individuals. So does effective treatment lead to changes in the connection of some of these nine brain regions associated with resilience, or is it undoing the early damage? So those are the questions that we are currently pondering.

2.6. Dr Cicchetti: resilience as multidimensional spanning psychosocial and neurobiological factors

I am going to begin by reminiscing about my childhood. When I was a child, I resided in a poor Italian community that was characterized by a high incidence of domestic violence, child maltreatment, poverty, and the like. Residents were all aware from things their parents had told them, articles in the newspapers, and the way in which society portrayed folks in their community, that families in the community were not expected to do well because they were poor and less educated. Poverty is considered to be one of the most ubiquitous, intractable, deleterious risk factors for individual, family, and population health.

Upon my graduation from college, I left home for the University of Minnesota where I was accepted into their PhD programme in clinical psychology. One of my professors and mentors there was Norman Garmezy, a major progenitor of early resilience theory and research (Masten & Cicchetti, 2016 ). At first Garmezy and other prominent systematizers, such as E. James Anthony and Emmy Werner, conceptualized children who experienced great adversity but exhibited normal or super normal functioning as invulnerable. Subsequently, Garmezy, Michael Rutter, and other scientists conducted hi-risk longitudinal studies, the results of which suggested that the term resilience best captured the phenomenon of functioning well in the face of serious adversity. Byron Egeland and Alan Sroufe, based on the results of their Minnesota Parent-Child Longitudinal Study (Sroufe, Egeland, Carlson, & Collins, 2005 ), concluded that resilience was a dynamic developmental process. Resilience is multi-dimensional; it is not static or trait-like. Although the pathways leading to resilient outcomes are often complex, Masten ( 2001 ) has described it as a type of ‘ordinary magic.’

Research on resilience is rooted in the field of developmental psychopathology. Scientists adhering to a developmental psychopathology framework emphasize the importance of incorporating multiple levels of analysis into their research. This approach states that different systems contribute to development and that these systems bidirectionally influence each other to contribute to outcomes.

The role of biological factors in resilience is suggested by evidence on neurobiological and neuroendocrine function in relation to stress regulation and reactivity, by behavioural genetics research on non-shared environmental effects, and by molecular research in the field of epigenetics. One of the mechanisms through which individuals might be able to acquire resilient functioning happens on a neurobiological level, through the process of neural plasticity. Neural plasticity can be framed as a process by which experience results in the reorganization of neural pathways across the course of development (Cicchetti, 2016 ; Cicchetti & Curtis, 2006 ). Thus, experience can result in physiological and structural changes in the brain. The relationship between the brain and experience is bidirectional. Experience helps shape the neural pathways in the brain, and the newly shaped brain seeks out different experiences which further alter neural pathways. Consequently, neural plasticity should ultimately be conceptualized as a process that encompasses the dynamic and continuous relationship between the brain and the environment that changes over time (Cicchetti & Curtis, 2006 ; Cicchetti & Tucker, 1994 ).

Resilient functioning is more than a product of biological systems. Psychosocial systems are equally important. Biology and psychology are so interactive that it is difficult to distinguish the unique effect of each system on resilient outcomes (Cicchetti & Curtis, 2006 ). Examples of such psychosocial factors that have been found to be linked to resilient outcomes include secure attachment relationships, an autonomous self, close friendships, supportive parenting, neighbourhood characteristics, and variation in personality types (Masten & Cicchetti, 2016 ).

Some researchers have questioned why the term resilience is necessary when we already have the term positive adaptation. We contend that resilience adds something that positive adaptation does not – namely resilience is reserved for individuals who do well in the throes of significant adversity (Luthar, Cicchetti, & Becker, 2000 ). Resilience has been conceptualized as the capacity to withstand or recover from significant disturbances that threaten its adaptive function, viability, or development. Development derives from the interaction of many systems across levels. Individual resilience depends on the resilience of other systems (Masten & Cicchetti, 2016 ).

2.7. Dr Williams: resilience as a property of a larger social context and policies

I most often think of resilience within a very narrow area, one area of my research, which is focused on understanding the ways in which racism might affect health. I started out by thinking of what are the resilience factors that protect from the negative effects, for example, exposure to racial discrimination? I will illustrate a couple of studies that reflected where my thinking was. There is a study by Gene Brody and colleagues that showed among African-American adolescents who experienced discrimination consistently at three points during their teen years have higher levels of allostatic load (stress hormones, inflammation, blood pressure, and BMI) by age 20 (Brody et al., 2014 ). However, this association between discrimination and biological dysregulation was not evident among those who received high levels of emotional and instrumental support from their families and peers. A similar pattern has been documented in two cohorts of African American teens with social relationships reducing the negative effects of high levels of discrimination as a teen on epigenetic ageing at age 20 or 22 (Brody, Miller, Yu, Beach, & Chen, 2016 ). These findings suggest that the quality of social support is a resilience resource in the face of discrimination. Similarly, the work of Christopher Ellison and colleagues, in prospective analyses of the National Study of Black Americans found that religious variables (religious attendance, church-based social support, and seeking religious guidance in everyday life) reduced the negative effects of experiences of racial discrimination on mental health (Ellison, Musick, & Henderson, 2008 ). Here again, religious involvement, measured at the individual level is a resilience resource.

However, I have been increasingly thinking of resilience, not just as an attribute of individuals, but also as a property of social policies and a property of larger social context. For example, think of the social safety net as a potential resilience resource. To illustrate my point, I want to take you on a quick walk down memory lane. In 1981, the newly elected President Ronald Reagan got the US Congress to pass the Omnibus Reconciliation Act of 1981. What did this legislation do? Some 500,000 people lost eligibility for welfare (Aid to Families with Dependent Children), a million people were dropped from food stamps (a nutrition supplementation programme for low-income families) and 600,000 lost Medicaid (health insurance for the poor) (Mundinger, 1985 ). Those funding cuts closed 250 community health centres across the USA, a million children lost access to reduced-priced school meals, and the WIC (Women’s Infant and Children) supplemental nutrition programme only had enough funding to serve a quarter of those eligible. What happened in the wake of this weakening of the social safety net? Studies showed there were increases in anaemia in pregnant women, in babies born low birth weight, in infant mortality in poor areas in 20 states, in preventable childhood diseases evident in multiple cities, in children with elevated blood lead levels and lead poisoning, and in chronic disease among adults who were dropped from Medicaid (Mundinger, 1985 ). Thus, dramatic negative effects on population health were evident from the cradle to the grave.

Another example of how I think of how we need to expand the definition of resilience to include social policies is related to child poverty. The USA has a poverty rate among children that ranks around 35th in the world with 29% of American children growing up poor (UNICEF Office of Research, 2017 ). That is a strikingly high rate of child poverty. However, if you look at UNICEF data, there are many other countries that have poverty rates produced by their economic system even higher than the US. But after transfers and taxes, the child poverty rates are dramatically reduced. Social policies could be a resilience strategy.

For example, in the country of Ireland, the economy produces a child poverty rate of 44%. After transfers and taxes, that child poverty rate is reduced to 18%, indicating that policies have made an enormous difference. In contrast, for the USA the child poverty rate produced by the economy is 36%, but after taxes and transfers, it is reduced to 29% (UNICEF Office of Research, 2017 ). So the policies that we could implement that would dramatically reduce poverty and change trajectories of economic and health outcomes for children living in poverty are resilience strategies as well. A recent National Academy of Sciences report outlines the strategies that can reduce childhood poverty by 50% in a decade (National Academies of Sciences, Engineering, and Medicine, 2019 ).

2.8. Dr Denckla: are there costs and/or benefits associated with resilience?

A theme that is emerging in these discussions on the definitions of resilience is that resilience may entail a dynamic unfolding of protective strategies to resist mental and physical health consequences, but that these strategies are complex and can come with some costs, for example as illustrated in the discussion of reduced nodal connectivity in brain architecture. How would you think about approaches that might capture these complex interacting processes between costs and benefits associated with resilience?

2.9. Dr Seedat: resilience as engendering benefits and costs

I think that there has been a huge drive to think about resilience in a more objective and quantifiable way. To think about endpoints in the pursuit of predicting resilience following exposure to trauma. One could think about the interplay between biological and environmental factors, but latent factors and unmeasured factors also are important in determining outcomes to trauma exposure, or experiences of adversity.

There is also cost to being resilient. We can think of resilience as being on a favourable continuum in that it mitigates the vulnerability to adversity and reduces emotional and cognitive sensitivity, but there is also a trade-off with sensitivity. Resilience can, in fact, reduce sensitivity to beneficial opportunities (Belsky & Pluess, 2013 ; Crespi, 2015 ).

There is good evidence for that particularly at a genetic level where cognitive trade-offs are strongly supported by evidence that particular genotypes can increase liability to psychopathology, particularly in poor environments, but that these same genotypes can be beneficial individuals who are exposed to good environments. Resilience then engenders benefits in poor environments, but can be costly in good ones.

2.10. Dr Kubzansky: importance of examining multiple domains

Well, I had a related point, although it is not quite exactly on cost, and I will come back to this issue of costs. In some of our work, we have looked at how resilience might affect subsequent physical health among people who are exposed to adversity in some fashion. We have identified individuals who appear to be psychologically resilient, in that they seem like they are doing better than you would expect based on their exposure to adversity. We then look at their physical health later on in life. One of the findings that we have had fairly consistently is that the folks who seem like they are doing better than you would expect psychologically given they were exposed to adversity are also doing better in terms of physical health outcomes. This is in comparison folks who were exposed to adversity and do not seem to be doing well psychologically. However, also of interest is that we have consistently found a residual effect of exposure to adversity on physical health, so that the psychological resilient individuals do not have quite as good subsequent health outcomes as the individuals who did not confront adversity. This suggests there is a cost involved – not so much the cost of resilience as much as the cost of adversity. It suggests to us at least so far that you cannot fully undo or unroll or reverse the potentially harmful effects of adversity exposure; you may be able to mitigate them, but you may not be able to make them go away.

Now, it is also worth mentioning there are some interesting animal studies that suggest you can make harmful effects of adversity ‘go away’ in the context of some facets of functioning, but not others. You might not be able to change certain molecular changes that occur, but you can sometimes change effects on behaviour. This also suggests a cost of adversity even among those demonstrating resilience; you cannot fully undo harm, really, truly, but you can potentially mitigate effects and possibly substantially mitigate them.

To answer your question more directly vis-a-vis the cost of resilience is as follows: I feel like the jury is still out because I do sometimes wonder if we have the right comparison groups, in terms of are we really comparing apples to apples? I feel like we need to make sure that we know enough about the people who look like they are doing better initially, to say they look just like the people who are not doing better. In that way, we can make a better assessment of whether there is truly a cost of resilience or if there might be something else going on that is driving the apparent differences down the road.

I think that as we have a better hand handle on the definitions and how we characterize people who are more or less resilient or who confronted adversity in various ways, it will get easier to do those studies in a really more rigorous way. I would also pose the question of whether there might be costs in some domains, but not in others. Also, while all of us have our silos or our domains of where we do research, and often it is easier to look at a single outcome or a single domain of outcomes, it will be important not to focus on a single domain, but rather try to take account of the whole picture. For example, suppose there are some costs evident at the molecular level but you are able to mitigate behavioural harms, and that in turn means there are multiple downstream outcomes that truly look better than if you had not changed behaviour. In that case, we would argue resilience is highly beneficial even if it does not fully mitigate the effects of initial exposure. And in that case, mitigation is certainly worth thinking about and striving for.

Increasingly, especially with more and more big data available, we probably will have the opportunity to look at multiple domains and across many different facets of functioning. Again, this will guide us to thinking in a more comprehensive way about costs and tradeoffs and so forth. I will say that from the work we have done so far, and from the animal models I have seen, I am not convinced that one can fully undo, serious exposure to adversity fully. I would love to be wrong on that.

The other thing I will say is that most of the studies that look at this are often not looking at concerted efforts to undo the adversity, they are looking at the natural course of things where some people seem to do better and some people seem to do worse. We do not really know how different it would look if we were intervening and doing something actively to change the course of things versus just relying on naturally occurring events to try to get a sense of how these things play out. I think these are really important and interesting questions. As we have more granularity on the different components, I think we will be able to look at them a little more clearly.

2.11. Dr Teicher: domain-specific resilience

I guess just following up on your point, I think another way of expressing it, is to talk about it from the idea of domain-specific resilience. Individuals are very rarely universally resilient, they tend to be resilient in some specific domain. The cost of adversity may be an example of two groups with different domain-specific resilience. One group may be resilient in terms of their academic performance or occupational performance, but not resilient in terms of their physical health while another group may be resilient in terms of physical health, but not in terms of occupational performance.

I think you can look at that in terms of cost and we can look about it in terms of specific domains. I think the model that we have, where these brain regions are less connected that provide a basic resilience, those provide the context in which you will have a cost, that there is going to be a downside of not having these brain regions connected as well. It may be protective and will enable you to not experience certain things, but you also may be limited in terms of things that are positive that you may want to experience. What we find is that if we look at a rating scale, our resilient group do not differ from controls, unexposed controls in their mean level. If you do something more sophisticated, like ecological momentary assessment, and look at the regulation of affect from hour to hour across days, what you see is they do not regulate their moods as well. Their mean level manages to come out normal, but the negative moods and more persistent than their positive moods and more variable. It is not exactly the same, but it is a fair compensation. I think that is a real important concern about these domains.

2.12. Dr Seedat: resilience as a multiple outcome concept

I agree. I think in addition to assessing domain-specific aspects of resilience, where we have fallen short in the field is that research on resilience domains has not been coupled to multiple outcomes – so much of the research focuses on PTSD and depression as compared to other psychiatric disorders. We also have not looked deeply across both psychiatric outcomes and very important physical health outcomes, some of which David has spoken to.

2.13. Dr Williams: identify under what conditions, do some resilience resources have negative effects

Dr Seedat noted the cost of resilience and that is one aspect of resilience that I have also been giving increased attention. I want to illustrate that by describing the findings from three studies that show exactly the same pattern (Brody et al., 2013 ; Chen, Miller, Brody, & Lei, 2015 ; Miller, Yu, Chen, & Brody, 2015 ). These are studies all followed Black adolescents, over time. They have all focused on low-SES African-American adolescents who have high levels of self-control self-regulation at age 11. We think of these psychological characteristics as resilience resources for youth in a difficult context – they are low SES, but they have high self-control and self-regulation and we would expect these resources to pay off. The studies find that by age 20, these students do have higher academic performance and they are doing better emotionally and have low levels of substance use (drugs and alcohol). These are all great outcomes for these youth from a poor background. At the same time, at age 20, these same youth have greater obesity, higher blood pressure, higher stress hormone levels, and higher epigenetic ageing profiles than their peers who were low SES but low on self-control, or than their peers who are higher on SES. In other words, the resilience resource that they have (self-regulation), that has provided positive benefits for mental health and socioeconomic success but is also linked to having some negative effects on multiple indicators of physical health. So our challenge is how do we begin to unpack the costs of resilience and identify under what conditions, do some resilience resources have negative effects, and what are the intervention strategies that might minimize the likelihood of observing these adverse effects. Those are critical issues that we need to better understand.

2.13.1. Dr Cicchetti: fostering resilience across developmental contexts

Psychosocial factors are particularly relevant to informing intervention efforts to promote resilience across developmental contexts. Investigations of psychosocial systems can help to identify ways in which interventions might be able to alter the environment to introduce protective factors that will increase the likelihood that individuals will have resilient outcomes. Community or school-level interventions can be designed to promote factors that are linked to resilient functioning (such as community parenting classes or fostering peer relationships in classrooms). Although it is valuable to integrate biological systems when conducting psychosocial studies to help inform social interventions (Cicchetti & Gunnar, 2008 ), it is most practical for interventions to target social systems.

2.13.2. Dr Denckla: can resilience be thought of as the inverse of risk?

In response to a question from the audience, as well as a commonly asked question central to the resilience field, is whether resilience is simply the inverse of risk. Is resilience the opposite of vulnerability, or is something distinct from vulnerability?

2.13.3. Dr Teicher: resilience as a separable mechanism from risk

Yes, I think it is an interesting point. I do think about it from the standpoint of vulnerability or susceptibility and thinking about, what about these individuals who have low vulnerability? I would agree if everything lined up in a particular way so that if their neurobiology and their psychiatric symptomatology lined up, I would say, ‘These individuals are just less vulnerable, that their brains were not affected, that their mental health was not affected.’ Then I say, ‘we have a group that is relatively immune to these consequences,’ but we wind up in a very different situation. We wind up that susceptible and resilient individuals are equally vulnerable in terms of their brain, but not equally vulnerable in terms of their psychiatric outcome. This then leads me to the idea that you can not simply talk about their outcomes in terms of overall vulnerability that you need another way of understanding it. Then, it leads to a question of what enables this group to be able to have a different kind of outcome. I think that the concept of resilience does have some use.

I see this tautology more in terms of the idea between risk factors and protective factors. There you do not want to define protective factors as the opposite of a risk factor. I think that there is real value in the concept of resilience in terms of understanding the mechanisms that lead to reduced vulnerability because two different mechanisms may come into play. There may be one mechanism that generally leads to bad outcomes, and a separate mechanism that is protective that comes into play. You cannot just think about it in a unidimensional way. That is where resilience comes in and adds value to our understanding of risk and vulnerability.

2.13.4. Dr Seedat: resilience as a combination of stress vulnerability and post-traumatic growth

I do not think that resilience is the flip side of vulnerability or that resilience is the opposite of stress or that resilience is stress invulnerability. I think that to get back to your question, resilience is probably one of stress vulnerability plus post-traumatic growth. I think of resilience as encompassing both positive and negative factors and attributes, with post-traumatic growth reflecting positive adaptation in the face of adversity, as measured over time. Resilience also encompasses stress vulnerability and so I do not agree that resilience is the flip side of stress vulnerability – rather it encompasses both stress vulnerability and post-traumatic growth.

2.13.5. Dr Kubzansky: resilience and optimal functioning

I have a lot of thoughts about that. I think it is a really interesting and provocative question. It is something we wrestle with a lot when we are trying to think about what it means to be functioning. One of the arguments we have made about the importance of studying optimal functioning or healthy functioning is that if you only ever look at what happens when things go wrong, you will never really know what it looks like when things go right or how to make that happen. Put another way, we often identify risk factors or experiences and environments that harm health or make things go wrong. These findings can generally be interpreted as the presence of a risk factor is harmful, while the absence of a risk factor is not. However, if you are trying to ascertain how to make things go right, or help individual to function, not just without obvious disease, disorder, or disability, but actually to be well, then it is not clear that the absence of a risk factor leads to positive functioning. It just means things did not go wrong. We have said in other work, ‘the absence of something negative is not the same as the presence of something positive.’

More concretely, the fact that someone is not depressed does not necessarily mean that they are functioning at a high level and doing really well. It means they are not depressed but then there is a whole spectrum there of folks who are not depressed and just trundling along and they look quite different from the folks who are doing really, really well. Maybe you would say these latter individuals are in optimal health. Distinguishing factors that promote truly healthy functioning or doing really well in the face of challenges may be a very different task from identifying factors that predict doing more or less badly. If you only assume that they are just the inverse of each other, you will never know what it looks like to get to the other end of the spectrum.

A related issue we have thought a lot about concerns biological factors that may either be underlying these propensities or sequelae of them. In parallel to the issues I described above, thinking about risk versus lack of risk, true positive functioning versus absence of negative, in the context of biology we almost do not know how to talk about positive biological factors. Most of the biology that we think when we think about health is negative biology. We think about processes like inflammation or stress axis or stress hormones, and so forth. It is really hard to think of processes that are related to things like regeneration, repair, and rest, and what those look like. In fact, there is a terrific article that somebody called Farrelly ( 2012 ) wrote some years back now on positive biology. In it, he made the case that all we ever look at is negative biology. It is really hard to understand how to achieve biological health if you only ever define processes that range from bad to not bad, i.e. having versus not having inflammation or having versus not having high blood pressure. Is there some biological set of conditions that really define functioning well? The only example people can usually come up with is physical activity – it seems to change biology in really meaningful ways that result in people are functioning much better than they were. It is hard to get your head around, trying to identify what some other positive processes might be? This seems like an important question and a really fair one. I would strongly make the case that will be critical to distinguish positive processes from just those that are not bad or those that are downright negative or harmful.

2.13.6. Dr Denckla: can the term resilience be misused?

An individual in the audience stated that in her Native American community, she had observed that among some young adults experiencing psychopathology, there was a self-perception of failure if one experienced mental health effects after exposure to trauma or adversity. Can the term resilience be misused or misunderstood, resulting in an adverse impact on individuals?

2.13.7. Dr Teicher: the importance of context

My comments on this is it makes me think of something else I have seen over the course of time in hearing about resilience and resilience research. I remember when I first start hearing Dennis Charney talk about resilience that he was talking about resilience in the context of individuals who had been prisoners of war and dealt with torture on a near daily basis, who managed to preserve some reasonable degree of mental wellbeing. These individuals were superheroes and resilience was something seen in a small minority of remarkable people. Now, over the course of time, it seems like we have gone to the Lake Wobegone School of resilience where every child is above average and everybody is resilient. In that context, resilience loses any scientific meaning.

I see this in the tendency of talking about everybody who is a survivor as being resilient. I think we need a better word to describe survivors, they are remarkable and they are amazing but do not call all of them resilient because it loses any meaning. So, I think that the danger of trying to approach everything from a resilience standpoint is that some people are definitely going to be excluded and that is going to be a problem.

2.13.8. Dr Kubzansky: resilience from a population health perspective

I think this is a really interesting point and I will come back to something that I thought David was saying related to the context in which people are living. We so frequently talk about resilience as an individual-level trait or an individual-level experience and yet there are all kinds of factors that contribute to or make it more or less likely that people will be able to do well in spite of all kind of circumstances. I think one of the dangers of looking at resilience at the individual level and failing to contextualize the larger circumstances in which people are living their lives means we miss out on potentially identifying possible community-, organizational-, and policy-level levers by which we might make it more possible for more people to do better. If it becomes all about the individual and the individual not somehow rising above things and heroically achieving, that becomes a really easy discussion point and perhaps even a distraction. Because, with a focus on the individual, larger entities and social structures do not have to take responsibility. This results in the thinking that it is not the government’s job, it is not an organization’s job, it is not a community’s job, to think about why are people not doing better.

There is an important discussion we should have frequently and repeatedly, with regard to where you locate the responsibility for how to help a population to be more resilient or how you help a population to be more likely to thrive to enable them to then face all kinds of challenges that might come up. These issues are especially important as you start thinking from epidemiologic perspective and thinking at the population level – they highlight questions like: what are the ways in which you are going to shift the population distribution at this experience? Such a perspective may also make it easier to remember that when studying resilience, it occurs in a social context and many structural factors come into play with regard to who achieves resilience and how well it serves them. We want to be really mindful of these issues when discussing resilience, also to make sure that we are not telling people that somehow they are at fault if they are not able to be more resilient.

2.13.9. Dr Seedat: critical need for improved phenotyping and biotyping in future research

We have done quite well in terms of enumerating many of the biological determinants of resilience, but our knowledge is quite disparate today because I think that we have, to a large extent, failed to meaningfully integrate and organize the multi-level data that has been gathered over the years and to distinguish between different resilience trajectories. This is really important if we want to be at a point in time where we can inform targeted treatment and resilience supporting strategies. I think that the field has also been plagued by accurate quantification of the phenotype of resilience. We have measures that are largely inaccurate and suffer from issues of internal consistency and validity. Commonly used scales like the Connor-Davidson Resilience Scale, for example, have not been shown to have good internal consistency or validity in cross-cultural populations.

Many factor analytic studies of adapted versions of resilience measures have also not been shown to have good reliability and validity. We now need to focus efforts on assessment in resilience research. As Karestan alluded to, there have been concerted efforts to gather very large-scale data to do well-powered longitudinal studies, but I think that more international and interdisciplinary investment is needed to conduct studies where we can do really good phenotyping as well as biotyping.

In addition, we need to have studies that will allow us to do within-study comparisons of resilience trajectories and identify mechanisms that are operational across different age groups (i.e. across the lifespan) and aimed at identifying a predictive biomarker panels using large data and machine learning approaches to facilitate identification of high-risk individuals. These studies should also include detailed assessment of potentially modifiable protective factors that are linked to psychological resilience. Because as I alluded to at the outset, I think there have been two quite divergent streams of research and less attention paid to identifying a psychological, psychosocial, and other environmental factors that contribute to resilience.

In addition, I think that there have not been good well run randomized control trials (RCTs) of both intervention and prevention approaches. Many of the RCTs that have been conducted have been plagued by poor operationalization of the construct of resilience as well as by the problems that we have with measuring resilience. In order to disseminate and implement novel interventions, we first need to have these methodologically robust RCTs.

In addition to validated resilience measures, it is important to include in studies measurement of factors that could actually mediate the effects of intervention – to try and parse out the specific components of the intervention that may account for the positive effects of the intervention, as well as to look at the relative contributions of non-specific factors to outcomes, both in terms of psychopathology, and in terms of resilience trajectories.

3. Discussion

In this plenary panel held at the 2019 annual meeting of the International Society for Traumatic Stress plenary panel discussion, five interdisciplinary experts from psychiatry, social epidemiology, developmental psychiatry, and psychiatric epidemiology discussed complex and dynamic current topics in resilience research. Four core themes emerged including (1) considerations related to the definitions of resilience, (2) approaches to considering domain-specific resilience, (3) population-level health perspectives, and (4) suggestions for charting a research agenda. Each theme is discussed in more detail in the following discussion.

3.1. How have definitions of resilience evolved?

Since the term psychological resilience came into common usage in the 1970s, debate surrounding the definition and rigour of the construct has permeated the field. In some respects, the same concerns addressed by Luthar & Cicchetti ( 2000 ). continue to define the debate 20 years later, including a lack of consensus on the definition, significant variation on the operationalization of the construct, discrepancies and confusion around on trait vs. dynamic conceptualization, and little consensus on the defection of terms such as ‘protective’ and ‘vulnerability.’

These sentiments were echoed by each of the panellists, and each offered their perspective on evolving definitions and conceptualizations of the term resilience. Proposed definitions included (1) an effective adaptation to or a navigation (or management) of significant sources of traumatic stress or adversity and the capacity to absorb disturbance to harness resources effectively, (2) a dynamic process or capacity that is perhaps most evident in the context of major adversity but is exercised just in the process of living and making one’s way through the world and includes some aspect of positive functioning or well-being, (3) a brain-based mechanism of compensating for the adverse impact caused by exposure to maltreatment or trauma (4) an interdependent, multilevel, multi-systemic system that drives the capacity to withstand or recover from significant disturbances that threaten its adaptive function, viability, or development, and 5) an individual attribute as well as a property of social policies and the larger social context that protects from the negative effects of adversity exposure, for example to racial discrimination. All definitions shared a focus on conceptualizing resilience at multiple levels, from the biological to the social and policy level, a focus on the dynamic nature of resilience itself as a fluid, interacting process of adaptation, and a move away from conceptualizing resilience as an individual trait. Perspectives also diverged in some areas. For example, should resilience only be considered as observable in the aftermath of a specific trauma, given that stressors are nearly ubiquitous in everyday living? Alternatively, should resilience be considered only an individual factor, or more powerfully at the social and policy level?

Similar to conclusions gleaned in 2014 (Southwick et al., 2014 ), panellists agreed that resilience is best conceptualized as a multi-level, dynamic process of adaptation to stress and trauma exposure. Panellists went further to suggest that the construct of resilience might also encompass both positive and negative factors and attributes given that some adaptive response are protective in some contexts, but are liabilities in others. For example, resilient individuals who do not demonstrate symptoms but have experienced childhood maltreatment experience alternations to brain network architecture that can have negative implications for brain health, yet these alterations might also protect against psychiatric burden. Panellists also suggested that it is increasingly important to clearly define the construct given the spread of the construct wherein the risk lies that resilience might be characterized so generally such that it ceases to have specificity.

4. Next steps in resilience research: multi-level, systemic domain-specific frameworks

The idea that resilience spans multiple levels of functioning and ultimately reflects the interaction across these multiple systems from the molecular to the community level has been highlighted in the extant literature (Ungar & Theron, 2019 ). Panellists added to this conceptualization by discussing an emerging theme in their own perspectives that converged on observing the latent tradeoffs that can accompany observed resilience. For example, panellists suggested that resilience might be on a favourable continuum in that it mitigates the vulnerability to adversity, but that such a strategy may also reduce emotional and cognitive sensitivity, thereby reducing sensitivity to beneficial opportunities (Belsky & Pluess, 2013 ; Crespi, 2015 ). In other areas of research, studies have shown that psychosocial competence in highly adverse settings can be accompanied by decrements in cognitive and physical health. For example, studies have shown that developing psychosocial competence under adverse conditions associated with low socioeconomic status is associated with markers of accelerated ageing and reduced neurocompetence (Brody et al., 2013 ; Chen et al., 2015 ; Denckla et al., 2017 ).

Panellists suggested a conceptual framework that considers resilience as a domain-specific construct could be a fruitful research agenda. For example, brain-based research has shown that reduced network connectivity is associated with resilience, but that there is a downside of not having these brain regions connected as well that might affect functioning in specific domains. That is, this reduced connectivity may be protective in the prevention of negative affect, but it may also limit the experience of positive affect.

4.1. Moving towards structural and population-level perspectives

Panellists agreed that a great deal of the research on resilience is conducted either solely at the individual level (i.e. considering the trait of resilience or individual trajectories of functioning after experiencing adverse events), or at the community level in the context of disaster-related research. In contrast, there is less work that considers resilience at the population level, with limited data on either the distribution and determinants of resilience in populations or the downstream effects of resilience on population health. Such insight is critical for understanding how to build resilience in public health interventions. Relatedly, viewing resilience as only an individual-level factor neglects the important role of social determinants on resilience, introducing ethnocentric bias and risking misunderstanding the strength of the effect of social disadvantage on well-being (Schwarz, 2018 ).

These issues are especially important from the epidemiologic perspective with respect to population-level key questions. For example, how is it possible to shift the population distribution towards resilience? Such a perspective crucially requires a focus on social context and structural factors that are associated with resilience to develop equitable prevention and intervention and to prevent downstream stigma associated with adverse outcomes following exposure to trauma. Finally, a focus on individual-level resilience factors must not distract from the enormous good that can come from proactive social policy that reduces exposure to adversity in the first place.

4.2. A research agenda

Although the surge of interest in resilience has generated a significant body of literature and important conceptual foundations for the field have been established, methodological limitations including the limited number of longitudinal, prospective studies, a lack of consensus on operational definitions of resilience, and a focus on resilience as a single stable trait rather than the product of complex interacting behavioural, genetic, psychological, and social factors suggest opportunities for continued growth. To illustrate, a recent systematic review found that among 43 randomized control trials on training programmes designed to foster psychological resilience, the lack of consistent definition of resilience, limited comparison between studies given the variability in outcomes and assessment instruments used, and major technical design problems rendered limited capacity to properly assess the efficacy of resilience-building interventions (Chmitorz et al., 2018 ). These areas represent critical areas to overcome if effective intervention and prevention strategies are to be discovered.

Several panellists agreed that an important area for future research is to integrate conceptualizations of resilience from the individual-level to the larger social context at the population health level. In terms of measurement, panellists highlighted the need to focus efforts on improving assessment in resilience research. For example, factor analytic studies of adapted versions of some resilience measures have not been shown to have good reliability and validity cross-culturally (Jorgensen & Seedat, 2008 ), and other work suggests that self-rated resilience does not demonstrate concordance with functional ascertainment (Sheerin et al., 2019 ; Nishimi et al., 2020 ). This becomes particularly problematic when considering interpreting the results of prior RCTs (see for example Chmitorz et al., 2018 ). In order to disseminate and implement novel interventions, methodologically robust definitions and measurement strategies must be in place with thorough cross-cultural validation (see for example, van der Meer et al., 2018 ). This is a critical next step to informing targeted treatment and resilience supporting strategies. There have been concerted efforts to gather very large-scale data to do well-powered longitudinal studies, but more international and interdisciplinary investment is needed to conduct studies characterized by very good phenotyping and biotyping.

In terms of study design, panellists discussed the advantages of employing within-study comparisons of resilience trajectories. This approach could identify mechanisms that are operational across different age groups (i.e. across the lifespan). This could also be done by integrating and organizing the multi-level data that has been gathered to facilitate distinguishing between different resilience trajectories. These larger datasets will potentially catalyse the identification of predictive biomarker panels using large data sets and machine learning approaches. Secondly, within-study designs that employ more intensive phenotyping strategies such as ecological momentary assessment can provide a more granular look at aspects of emotional regulation that mechanistically drive resilience. The variability that would normally be lost in averaging moment-to-moment mood shifts could then be quantified. This might show, for example, that resilient vs. unexposed individuals phenotyped using a rating scale do not differ in mean levels of negative mood, but on an hour-to-hour basis, we might find that resilient individuals have more persistent negative moods compared to positive moods. Finally, more caution is urged in selecting comparison groups in within-study designs. A key question that often comes up when studying resilience is whom should we consider as an appropriate comparison group?

In terms of considering outcomes, strategies that examine outcomes across multiple levels and domains are a critical area for growth. These approaches will offer a more nuanced understanding of the benefits vs. tradeoffs of a particular adaptation, and help critically delineate domain-specific areas of resilience. That is, by clearly defining the domain of interest (e.g. intimate partnerships vs. occupational functioning), a more specific understanding of the mechanisms that are associated with resilience is possible. This approach could also expand the scope of resilience research beyond PTSD and depression to other psychiatric disorders. Finally, outcome-wide approaches could also facilitate a better understanding of the interplay of psychological factors, social determinants, and molecular and physical factors.

Researchers interested in resilience ultimately seek to reduce the adverse health effects of exposure to trauma and adversity and even to eradicate exposure to trauma itself. In this effort, these five panellists identified emerging definitions, significant opportunities for discovery, methodological and conceptual limitations that currently exist, and directions for future research. Panellists agreed that one of the main challenges in the field is how to identify the conditions under which resilience has positive and negative effects, and what intervention strategies most optimally minimize the adverse effects of exposure to trauma and adversity. The trend of exploding interest in resilience research, coupled with advances in genetics, molecular biology, increased computational capacity, and larger, robust datasets, suggest that the next decade of research could bring significant breakthroughs.

Funding Statement

This work was supported by the National Institutes of Health [1K23MH117278-01A1].

Disclosure statement

No potential conflict of interest was reported by the authors.

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  • Published: 20 August 2020

Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers

  • Ran Barzilay   ORCID: orcid.org/0000-0002-3247-2331 1 , 2 , 3 ,
  • Tyler M. Moore   ORCID: orcid.org/0000-0002-1384-0151 1 , 2 ,
  • David M. Greenberg 4 ,
  • Grace E. DiDomenico   ORCID: orcid.org/0000-0003-1036-9592 2 ,
  • Lily A. Brown 1 ,
  • Lauren K. White 2 ,
  • Ruben C. Gur 1 , 2 &
  • Raquel E. Gur 1 , 2  

Translational Psychiatry volume  10 , Article number:  291 ( 2020 ) Cite this article

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COVID-19 pandemic is a global calamity posing an unprecedented opportunity to study resilience. We developed a brief resilience survey probing self-reliance, emotion-regulation, interpersonal-relationship patterns and neighborhood-environment, and applied it online during the acute COVID-19 outbreak (April 6–15, 2020), on a crowdsourcing research website ( www.covid19resilience.org ) advertised through social media. We evaluated level of stress (worries) regarding COVID-19: (1) contracting, (2) dying from, (3) currently having, (4) family member contracting, (5) unknowingly infecting others with (6) experiencing significant financial burden following. Anxiety (GAD7) and depression (PHQ2) were measured. Totally, 3042 participants ( n  = 1964 females, age range 18–79, mean age = 39) completed the resilience and COVID-19-related stress survey and 1350 of them (mean age = 41, SD = 13; n  = 997 females) completed GAD7 and PHQ2. Participants significantly endorsed more distress about family contracting COVID-19 (48.5%) and unknowingly infecting others (36%), than getting COVID-19 themselves (19.9%), p  < 0.0005 covarying for demographics and proxy COVID-19 exposures like getting tested and knowing infected individuals. Patterns of COVID-19 related worries, rates of anxiety (GAD7 > 10, 22.2%) and depression (PHQ2 > 2, 16.1%) did not differ between healthcare providers and non-healthcare providers. Higher resilience scores were associated with lower COVID-19 related worries (main effect F 1,3054  = 134.9; p  < 0.00001, covarying for confounders). Increase in 1 SD on resilience score was associated with reduced rate of anxiety (65%) and depression (69%), across healthcare and non-healthcare professionals. Findings provide empirical evidence on mental health associated with COVID-19 outbreak in a large convenience sample, setting a stage for longitudinal studies evaluating mental health trajectories following COVID-19 pandemic.

Introduction

The COVID-19 pandemic is impacting humankind in unprecedented and monumental ways and data is needed to plan for next steps following the acute outbreak 1 . In addition to physical health, coping with the pandemic requires mental resilience. Tools have been established to estimate resilience, broadly conceptualized as healthy and adaptive functioning in the aftermath of adversity 2 . Measuring resilience can (1) allow better planning of resource allocation and (2) inform interventions for individuals and communities to overcome the acute pandemic effects 3 expected to impact mental health 4 . Healthcare providers are on the frontlines of the pandemic response and already show deleterious mental health consequences 5 . Hence, there is an urgent need to gauge the role of resilience specifically in this population 6 .

The internet has transformed our ability to collect large-scale data through crowdsourcing, with rapid outreach to large samples complying with social distancing 7 . We previously developed and applied a tool to measure resilience using self-report items 8 . Here, we applied an interactive online platform to measure resilience in a population enriched for healthcare providers. We hypothesized that (1) COVID-19 related stress (estimated by subjective worries) will be associated with generalized anxiety and depression; (2) higher resilience scores would correlate with less worries, generalized anxiety and depression; (3) healthcare providers will report higher levels of COVID-19 related concerns, anxiety and depression. We also explored differences in COVID-19 related stress and resilience between participants from US and Israel.

Subjects and methods

Participants and procedures.

On April 6th 2020, we launched a website ( https://www.covid19resilience.org/ ) that included an interactive 21-item resilience survey and assessment of COVID-19-related stress (worries) regarding: (1) getting (contracting), (2) dying from, (3) currently having, (4) family member getting, (5) unknowingly infecting others, and (6) experiencing significant financial burden following COVID-19. Participants were asked to rate how much they worried on a 5-item scale (0—not at all; 1—a little; 2—a moderate amount; 3—a lot; 4—a great deal). At the end of the survey, participants received feedback on their resilience scores with personalized recommendations regarding stress management. The feedback was also meant to incentivize participants to complete the survey carefully. Next, participants were offered to take a second survey on their anxiety (generalized anxiety disorder 7 questionnaire (GAD7)) 9 and depression (patient health questionnaire 2 (PHQ2)) 10 . The study was advertised through, (1) the researchers’ social networks, including emails to colleagues around the world; (2) social media; (3) the University of Pennsylvania and Children’s Hospital of Philadelphia internal notifications; and (4) organizational mailing lists. In addition to English, the survey was available in Hebrew after a two-way reverse translation and consensus by three bilingual English-Hebrew speakers. The results presented here are based on data collected from April 6 to 15, 2020. Participation required responders to provide online consent. The study was approved by the Institutional Review Board of the University of Pennsylvania.

Resilience survey

The survey was based on questions associated with resilience that were recently compiled into a single battery 8 . The items included were identified following administration of 212 items to >250 participants. The 212 items were reduced, using factor analysis followed by computerized adaptive test simulation, to a 47-item battery comprising seven factors 8 . For the sake of brevity and scalability of the online survey, we use five of the seven factors, resulting in a 21-item abbreviated version: self-reliance (3 items) 11 ; emotion regulation (5 items) 12 ; positive (4 items) and negative (5 items) 13 relationship characteristics; and neighborhood characteristics (4 items) 14 , 15 . Resilience items included in the survey and their corresponding scores are described in Supplementary Table 1 . To create a resilience score, we summed the score on all 21 items after coding them such that a higher score always indicates higher resilience.

Data analysis

For COVID-19 related worries, all main and interaction effects were investigated using mixed models to account for within-person variance across items. The mixed model treated the 6 items of COVID-19 worry/stress (evaluated at the same time in this cross-sectional study) as repeated measures within individual. The key dependent variable was item response (5-point scale indicating level of COVID-19-related worry), and we addressed the following questions: (1) Are certain types of worry more common than others? (2) Are there sex differences or age-related effects on the type of worry? (3) Is resilience associated with lower worry? (4) Does the effect of resilience depend on the type of worry? (5) Do the pattern of effects differ in healthcare providers? All models included the following potential confounders: age, gender, race (white/non-white), education, income, occupation (healthcare, engineering/computers and other), marital status (married, single or other), country of residence (US, Israel or other), number of people in household, date at which the survey was taken (days and (days squared) since study launch), and exposures related directly to COVID-19 including getting tested for COVID-19, knowing someone who tested positive for COVID-19 and knowing someone who died from COVID-19. All analyses were performed using the lmerTest 16 package in R.

To evaluate the association of COVID-19 related stress with anxiety and depression, we used regression models with COVID-19-related worries (standardized z -score of the sum all 6 worry questions) as the independent variable. The key dependent variable was either a dichotomized measure of meeting screening levels of GAD and depression (binary logistic regression); or continuous GAD7 and PHQ2 score (linear regression). Based on reports of overall higher scoring in anxiety 17 and depression 18 in web-based compared to paper and pencil surveys, we chose more conservative cutoffs to capture moderate and above anxiety or depression. GAD7 score > 10 was considered a case of probable generalized anxiety 19 , PHQ2 score > 2 was considered a case of probable depression 20 . Models covaried for age, gender, race, education, income, occupation, marital status, country of residence, number of people in household, and date at which the survey was taken.

To evaluate the mitigating effect of resilience on generalized anxiety and depression, resilience score was considered as the independent variable, with continuous GAD7 or PHQ2 score (using linear regression) or dichotomous GAD/depression (using binary logistic model) as the dependent variables. All models included multiple co-variates as described above. Effects of gender, age, and being a healthcare provider were tested in separate models including interaction terms of all of the above with resilience overall score.

In an exploratory analysis we compared participants from the US and Israel using regression models with US/Israel as a binary independent variable and COVID-19 worries/stress, resilience, anxiety, and depression as the dependent variables. Models included all covariates listed above.

All regression analyses were conducted in SPSS version 26 (IBM).

We obtained data from 3042 participants 10 days into the study. The majority of participants were female ( n  = 1964, 64.6%), with a wide age range from 18 to 79 years (M = 38.9, SD = 11.9). Due to the method of advertisement through the researchers’ social networks and University/Hospital announcements, the sample was enriched for academics (54% Master/Doctorate degree) and healthcare providers (20.5% of sample were physicians ( n  = 312)/nurses ( n  = 106)/other healthcare with direct patient care ( n  = 208)). Demographics are shown in Table 1 .

COVID-19-related worries

Participants were significantly more worried about a family member contracting COVID-19 or about unknowingly infecting others than about getting COVID-19 themselves (Fig. 1a , item main effect F 5,15205  = 1536.0, p  < 0.00001, model included age, gender, education, income, marital status, number of people in household and country of residence). Participants worried to a similar extent about financial burden following COVID-19 as about getting COVID-19; worried less about dying from COVID-19; and worried least about currently having COVID-19. Females had overall higher COVID-19-related worries than males, except for the financial burden, where they were comparable to males (Fig. 1b , item-by-sex interaction F 5,15200  = 25.9; p  < 0.00001). The pattern of worrying more about others compared to self was consistent throughout the lifespan. Older participants worried more about themselves than their younger counterparts, but still worried more about others (Fig. 1c , item-by-age interaction F 5,15200  = 71.6; p  < 0.00001).

figure 1

a Patterns of COVID-19-related worry in the entire sample; b gender differences; c age differences. y -axis represents the rate of responders endorsing significant worry (a lot/a great deal, items 4/5 on a 5 option Likert scale). Error bars represent 95% confidence intervals.

Anxiety and depression

We evaluated generalized anxiety and depression in a subsample of n  = 1350 who completed the GAD7 and PHQ2 questionnaire (Fig. 2 ). This subsample did not differ from the participants who did not complete GAD7/PHQ2 scales ( n  = 1692) in terms COVID-19-related worries (worry sum score, t test, p  = 0.387) or composite resilience score ( t -test p  = 0.932). Female gender was associated with higher scores on GAD7 (standardized beta = 0.143, p  < 0.001) and PHQ2 (standardized beta = 0.069, p  = 0.03), and with higher rates of meeting threshold screening for GAD (OR = 1.93, 95% CI: 1.24–2.99, p  = 0.004), but not with meeting threshold depression (OR = 1.47, 95% CI: 0.93–2.32, p  = 0.103). Older age was associated with lower likelihood of meeting threshold anxiety (OR = 0.97, 95% CI: 0.95–0.98, p  < 0.00001) but not for depression ( p  = 0.17). Models included race, education, income, occupation, country of residence and number of people in household as co-variates.

figure 2

A positive GAD screen was considered for in GAD7 score > 10. Positive depression screen was considered for PHQ2 score > 2. GAD generalized anxiety disorder.

Association among COVID-19-related worries, generalized anxiety, and depression

Higher endorsement of COVID-19-related worries was strongly associated with meeting threshold screening for generalized anxiety (GAD7 score > 10, n  = 300, 22.2%) and depression (PHQ2 score > 2, n  = 217, 16.1%), such that for every 1 SD increase in the standardized composite score of COVID-19 worries, there was more than 2-fold increased probability of generalized anxiety (binary logistic regression OR = 2.23 95% CI: 1.88–2.65, p  < 0.001; linear regression standardized beta = 0.396, t  = 15.571, p  < 0.001) and 67% increased probability of depression (binary logistic regression OR = 1.67 95% CI: 1.41–1.98, p  < 0.001; linear regression standardized beta = 0.212, t  = 7.266, p  < 0.001). There was no difference in the strength of association between different types of COVID-19 related worries (to self, others or financial burden) and anxiety or depression (Supplementary Table 2 ). Models covaried for age, gender, education, occupation, income, marital status, number of people in household, country of residence, and date taking the survey.

Association of resilience score with COVID-19-related worries, generalized anxiety, and depression

The composite resilience score derived from the 21-item survey buffered all the COVID-19-related worries, such that participants with higher resilience scores worried significantly less than low scoring individuals about COVID-19 (Fig. 3a , main effect F 1,3023  = 134.9; p  < 0.00001). Furthermore, higher resilience scores were associated with lower generalized anxiety (total GAD7 score, linear regression standardized beta −0.418, t  = −16.44, p  < 0.001) and depression (total PHQ2 score, linear regression standardized beta −0.451, t  = −16.72, p  < 0.001). The effect was such that for every 1 SD increase in the resilience score there was a 64.9% decrease in the possibility of positive-GAD screen (binary logistic regression OR = 0.351, 95% CI: 0.29–0.424, p  < 0.0001, Fig. 3b ) and a 69.3% decrease in the possibility of positive depression screen (OR = 0.31, 95% CI: 0.252–0.383, p  < 0.0001, Fig. 3b ).

figure 3

a Y -axis represents the rate of responders endorsing significant worry (a lot/a great deal, items 4/5 on a 5 option Likert scale). Error bars represent 95% confidence intervals. b A positive-GAD screen was considered for in GAD7 score > 10. Positive depression screen was considered for PHQ2 score > 2. GAD generalized anxiety disorder.

The inverse association of high resilience score with meeting screening threshold of anxiety and depression was consistent across genders (resilience by gender interaction nonsignificant). Overall, the mitigating association of higher resilience with lower probability of anxiety was stronger in older age (resilience score by age interaction Wald = 6.955, p  = 0.008 for GAD), with trend level significance for depression (resilience score by age interaction Wald = 3.378, p  = 0.066).

Comparison between US and Israel participants

The majority of our study sample were from the US ( n  = 1607) or Israel ( n  = 1197). We conducted exploratory comparisons between samples from the two countries. Participants from the two countries differed on demographics (Supplementary Table 3 ). Except for age that was similar in both countries, the US sample included more females (84 vs. 39%), more healthcare providers (29 vs. 11%) with higher education and higher income compared to Israel.

Multivariate comparison that co-varied for multiple confounders revealed that participants from the US were overall more worried/stressed about COVID-19 (Table 2 ). US participants were specifically more stressed about self (contracting COVD-19, dying from COVID-19 and currently having COVID-19) compared to Israel participants, with no differences in worries about others (family getting COVID-19/infecting others) or about financial burden due to COVID-19 (Table 2 ). Israel participants scored higher overall on the resilience scale (standardized beta = 0.163, t  = 5.694, p  < 0.001). US participants were more likely to meet screening criteria for GAD (OR = 4.9, 95% CI: 2.6–9.4, p  < 0.001) and for depression (OR = 2.2, 95% CI: 1.2–4, p  < 0.001).

Sensitivity analyses in healthcare providers

Due to the high percentage of healthcare providers (physicians, nurses, and other direct patient care, n  = 625) in this sample, we repeated the above analyses including interactions with healthcare profession status. In COVID-19-related worries, the only difference was that healthcare providers worried more than non-healthcare providers about contracting COVID-19 ( t 15340  = 3.9, p  < 0.0005) and less than non-healthcare providers about finances after COVID-19 ( t 15340  = −6.9, p  < 0.00001, Supplementary Fig. 1 ). We did not detect higher anxiety and depression in healthcare providers compared to non-healthcare providers (Supplementary Fig. 2 ).

Higher resilience scores were associated with less COVID-19-related worries similarly across healthcare providers and non-health care professionals (main effect F 1,3053  = 102.0, p  < 0.00001; resilience by healthcare providers interaction nonsignificant, Supplementary Fig. 3 ). Similarly, higher resilience scores were associated with lower likelihood of meeting GAD or depression screening threshold across professions (resilience by healthcare providers interaction nonsignificant, Supplementary Fig. 4 ).

The rapid spread of COVID-19 creates a unique opportunity to evaluate resilience in the face of a single global adversity. Here, we captured a unique snapshot for over 3000 people who were in stressful conditions during the acute pandemic outbreak (>92% of our sample are from US or Israel that were in lockdown during the study period). Participants reported significantly more subjective worries (stress) about others (~50% worried about family member getting COVID-19) than about getting COVID-19 themselves (~20%). This pattern was consistent across genders, throughout the lifespan and was overall similar in healthcare providers compared to non-healthcare providers. This finding is consistent with work reporting increased prosocial behavior under stress 21 , and may be related to “tend-and-befriend”, where in response to threat humans tend to protect their close ones (tending) and seek out their social group for mutual defense (befriending) 22 . This finding might be interpreted as a form of altruism during acute stress of the pandemic outbreak. Notably, altruistic behavior described in acute situations throughout history was previously linked to mechanisms of resilience for overcoming adversity 23 .

The COVID-19-related worries were associated with substantial levels of anxiety (22%) and depression (16%) in the subsample that completed the GAD7 and PHQ2 questionnaires ( n  = 1350). These rates are higher than previously reported point prevalence rates 24 , 25 . Several explanations may account for the higher reported levels of anxiety and depression. First, it was previously described that people report more symptoms in web-based surveys 17 , 18 . Second, our sample was enriched for women, who are known to report more anxiety and depression. In that sense the expected gender differences we observed support the validity of our data 26 . Lastly, it is possible that during the acute phase of the pandemic when the data was collected, and in light of the high level of stress and worries related to COVID-19, there are higher levels of anxiety and depression in the population as reflected in our convenience sample. The rates we report here are also higher than the rates reported in healthcare providers during the acute COVID-19 outbreak in China 5 . This effect might be explained by cultural differences or difference in sampling, as we used an online survey and the Chinese study sampled through hospitals.

Supporting our hypothesis, the brief online resilience survey inversely correlated with COVID-19 worries, generalized anxiety and depression symptoms. The survey may tap into traits and factors that allow a buffering against COVID-19 related stressors. This “buffering effect” was evident in both genders, throughout the lifespan, and in a similar manner in healthcare and non-healthcare providers. Notably, while there is need for more longitudinal data on resilience 27 , scarce longitudinal data suggests that baseline resilience mitigates developing anxiety and depression following adversity 28 . Therefore, the framework described in this study can be used in longitudinal studies that evaluate trajectories of mental health conditions and needs following the pandemic outbreak.

This study’s main strength is the large sample and the unique timing of data collection, in which vast majority of the sample (>90% are from the US or Israel) were in lockdown, with closures of school and nonessential businesses. These unusual life circumstances are likely to have major impact on mental health 29 , and thus provide an opportunity to study resilience in the face of a global stressor. Despite the global nature of the stressor, we found significant differences between participants from Israel and the US, the latter reporting more stress, anxiety and depression. The reasons for these difference require further investigation, but it should be noted that the two countries greatly differ is their size in terms of geographic area, total population, GDP, in addition to differences in other social, cultural, political, economic and health system characteristics. Our findings might imply that local factors may contribute to the levels of stress, resilience and mental health at times of global pandemic. Specifically, it is possible that residents of countries more accustomed to dealing with collective stressors (such as Israel, due to frequent war-related events), can recruit more resilience factors during an acute stressor such as a pandemic outbreak. Future studies are needed to evaluate whether these differences between countries are maintained longitudinally, beyond the acute stress of the outbreak, as the stress is likely to shift from the medical consequences of COVID-19 to the economic impact.

Several study limitations should be considered. These include the biased sampling to a more educated, professional population that is enriched for healthcare providers and academics. More data is required from other sociodemographic backgrounds that appear to be more vulnerable 30 . There are also the inherent limitations of data collection through crowdsourcing (i.e., how generalizable are people who complete online surveys) 31 . However, we did not pay participants, but rather provided feedback based on their responses, which mitigates the concern that a participant deliberately answered inaccurately, as a main incentive to take the survey was to receive personalized feedback. In addition, we used brief screening measures for anxiety and depression. As for the healthcare providers’ data, we did not collect data regarding exposure to COVID-19 patients, militating our ability to link this exposure form to the “pandemic response frontline” to the measures studied here. Lastly, the cross-sectional design does not allow causal inferences, which can be addressed in future longitudinal studies.

To conclude, we present data collected from a large convenience sample in the acute phase of the COVID-19 pandemic, when the majority of the sample was bound to a “lockdown” with severe social distancing. We report two main findings: (1) People are worried more about others than about self when reporting COVID-19 concerns; (2) Resilience helps reduce worries as well as anxiety and depression. Longitudinal studies are needed to address whether resilience scores are consistent and whether they can predict trajectories of mental and general health as humanity moves toward the post-COVID-19 pandemic era.

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Acknowledgements

We thank participants of covid19resilience.org for their contribution to data generation. This study was supported by the National Institute of Mental Health (NIMH) grants K23-MH120437 (RB), R01-MH119219 (REG, RCG), R01-MH117014 (RCG), and the Lifespan Brain Institute of Children’s Hospital of Philadelphia and Penn Medicine, University of Pennsylvania. DMG was funded in part by the Zuckerman STEM Leadership Program. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the paper; and decision to submit the paper for publication. The authors thank Sigal Barzilay for her help with the Hebrew translation of the survey.

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Barzilay, R., Moore, T.M., Greenberg, D.M. et al. Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry 10 , 291 (2020). https://doi.org/10.1038/s41398-020-00982-4

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Resilience Theory: A Summary of the Research (+PDF)

Resilience Theory

Resilience theory argues that it’s not the nature of adversity that is most important, but how we deal with it.

When we face adversity, misfortune, or frustration, resilience helps us bounce back. It helps us survive, recover, and even thrive in the face and wake of misfortune, but that’s not all there is to it.

Read on to learn about resilience theory in a little more depth, including its relationship with shame, organizations, and more.

But first, we thought you might like to download our three Resilience Exercises for free . These engaging, science-based exercises will help you to effectively deal with difficult circumstances and give you the tools to improve the resilience of your clients, students or employees.

This Article Contains:

What is resilience theory.

  • 6 Impactful Articles on Resilience and Mental Toughness

What Research in Positive Psychology Shows

Resilience theory in social work, family resilience theory, shame resilience theory, community resilience theory, organizational resilience theory, the ‘science of resilience’, norman garmezy’s main findings and contribution, seligman’s 3ps model of resilience, a take-home message.

Resilience has been defined in numerous ways.

Defining resilience

The following definitions abound:

“the ability to bounce back from adversity, frustration, and misfortune”

Ledesma, 2014, p.1

“the developable capacity to rebound or bounce back from adversity, conflict, and failure or even positive events, progress, and increased responsibility”

Luthans, 2002a, p. 702

“a stable trajectory of healthy functioning after a highly adverse event”

Bonanno, 2004; Bonanno, Westphal, & Mancini, 2011

“the capacity of a dynamic system to adapt successfully”

Masten, 2014; Southwick, Bonanno, Masten, Panter-Brick, & Yehuda, 2014

When a panel discussion asked researchers to debate the nature of resilience , all agreed that resilience is complex. As a construct, it can have a different meaning between people, companies, cultures, and society. They also agreed that people could be more resilient at one point in their lives and less during another, and that they may be more resilient in some aspects of their lives than others (Southwick et al., 2014).

In case you’re interested, the table below from Greene, Galambos, and Lee (2004) shows even more ways resilience has been described.

Resilience theory

Resilience as a concept is not necessarily straightforward, and there are many operational definitions in existence. Resilience theory, according to van Breda (2018, p. 1), is the study of the things that make this phenomenon whole:

Its definition; What ‘adversity’ and ‘outcomes’ actually mean, and; The scope and nature of resilience processes.

6 Impactful Resilience Articles on Resilience and Mental Toughness

Ready to learn a bit more about resilience theory? For those who are keen to dig into the literature, this list demonstrates precisely how widely the concept can be applied: in social work, organizations, childhood development contexts, and more. You’ll find the full citations for these papers in the Reference section at the end of this article.

1. A Critical Review of Resilience Theory and Its Relevance for Social Work

In this literature review, Adrian van Breda (2018) considers peer-reviewed articles on resilience in the field of social work, discussing the evolution of an (as-yet to be established) consensus on its definition. He considers how it works and developments in the theory, looking at the study of resilience in South African cultures and societies.

2. Resilience Theory and Research on Children and Families: Past, Present, and Promise

Masten is known for her work on resilience and its role in helping families and children deal with adversity . In this article, she defines resilience as “the capacity of a system to adapt successfully to significant challenges that threaten its function, viability, or development” (Masten, 2018, p. 1).

Masten delves into the theory’s history and its research in this field in an attempt to integrate applications, models, and knowledge that may help children and their families grow and adjust.

3. Family Resilience: A Developmental Systems Framework

Professor Froma Walsh, cofounder of the Chicago Center for Family Health, has written extensively on family resilience and the positive adaptation of family units. In Family Resilience: A Developmental Systems Framework , Walsh (2016) considers the key processes in family resilience and gives a great overview of the concept from a family systems perspective.

4. Community Resilience: Toward an Integrated Approach

Berkes and Ross (2013) examined two distinct approaches to understanding community resilience: a social-ecological approach and a mental health and developmental psychology perspective. This article, which we unpack a little more further on, is a great read for anyone with an academic interest in the growing research on resilience at the community level.

5. Organizational Resilience: Towards a Theory and Research Agenda

Vogus and Sutcliffe (2007) attempted to define organizational resilience and examine its underpinning mechanisms. Their paper considers the relational, cognitive, structural, and affective elements of the construct before proposing some research questions for those with an academic interest in the topic.

6. Are Adolescents With High Mental Toughness Levels More Resilient Against Stress?

3 resilience exercises

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These detailed, science-based exercises will equip you or your clients to recover from personal challenges and turn setbacks into opportunities for growth.

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By filling out your name and email address below.

Resilience and positive psychology are often closely related. Both are concerned with how promotive factors work, and both look at how a beneficial construct can facilitate our wellbeing (Luthar, Lyman, & Crossman, 2014).

Resilience theory and positive psychology are both applied fields of study, meaning that we can use them in daily life to benefit humanity, and both are very closely concentrated on the importance of social relationships (Luthar, 2006; Csikszentmihalyi & Nakamura, 2011).

So let’s look at what positive psychology research shows on resilience.

Character strengths and resilience

Strengths such as gratitude, kindness, hope, and bravery have been shown to act as protective factors against life’s adversities, helping us adapt positively and cope with difficulties such as physical and mental illness (Fletcher & Sarkar, 2013).

Some character strengths can also be significant predictors of resilience, with particular correlations between resilience and emotional, intellectual, and restraint-related strengths (Martínez-Martí & Ruch, 2017).

In their 2017 study, Martínez-Martí and Ruch found that hope, bravery, and zest had the most extensive relationship with positive adaptation in the face of challenge. This led the researchers to speculate that processes such as determination, social connectedness, emotional regulation , and more were at play.

From this particular cross-sectional study, however, no causal relationship was determined. In other words, we don’t know whether resilience impacts our strengths or vice versa.

The effect may work the other way around with adversity, and post-traumatic growth helps us build character strengths, but nonetheless, it’s an example of resilience and positive psychology’s interconnection (Tedeschi & Calhoun, 1995; Peterson, Park, Pole, D’Andrea, & Seligman, 2008).

Resilience and positive emotions

Most people think of happiness whenever positive psychology is mentioned, so are happiness and resilience related? Cohn, Fredrickson, Brown, Mikels, and Conway (2009) suggested that they may well be. To be specific, happiness is a positive emotion.

According to the broaden-and-build theory of positive emotions, happiness is one emotion that helps us become more explorative and adaptable in our thoughts and behaviors. We create enduring resources that help us live well (Fredrickson, 2004).

Cohn et al. (2009) found that participants who frequently experienced positive emotions such as happiness grew more satisfied with their lives by creating resources, such as ego resilience, that helped them tackle a wide variety of challenges.

These results correspond with other evidence that positive emotions can facilitate resource growth and findings that link psychological resilience with physical health, psychological wellbeing, and positive affect (Lyubomirsky, King, & Diener, 2005; Nath & Pradhan, 2012).

Its role in positive organizational behavior

Other studies have looked at resilience as one of numerous coping positive psychological resources, alongside optimism and hope.

Positive organizational behavior has been defined by Luthans (2002b, p. 59) as “the study and application of positively oriented human resource strengths and psychological capacities that can be measured, developed, and effectively managed for performance improvement in today’s workplace.”

Can training employees help encourage positive organizational behavior? The jury is still out (Robertson, Cooper, Sarkar, & Curran, 2015).

resilience theory in social work

Some of the reasons for this are the central role of community relationships to both academic fields and the key social work principle that people should accept responsibility for one another’s wellbeing (International Federation of Social Workers, 2014).

One of the main drivers for more resilience theory research in social work contexts is the idea that identifying resilience-building factors can help at-risk clients in the following ways (Greene et al., 2004):

Promoting their competence and improving their health Helping them overcome adversity and navigate life stressors Boosting their ability to grow and survive

Concerning social workers, key issues in the field include:

Identifying protective factors and using them to inform interventions Using practical applications to promote the capacity and strength of individual clients, societies, and communities Understanding how social work policy and services promote or hinder wellbeing and social and economic injustice

Social work strategies for building client resilience

Greene et al.’s (2004) research also investigated the strategies and skills social workers relied on to boost the resilience of their clients. Some of these included:

Providing clients with safety and necessities when faced with adversity or traumatic events; for example, talking calmly with distressed individuals, reassuring them of their capabilities and ability to get through their troubles.

Listening, being present and honest, and learning from individuals’ stories while acknowledging their pain.

Promoting interpersonal relationships, attachments, and connections between people in a community or society.

Encouraging them to view themselves as a valued member of society.

Modeling resilient behaviors, such as dealing with work stress in healthy ways.

Realizing Resilience Masterclass

For social workers, therapists, and educators, an immense benefit can be gained from being able to boost your client’s resilience. To do so, enrolling in our Realizing Resilience Masterclass course would equip you to strengthen others, guide them, and teach them the six pillars of resilience.

This masterclass, based on scientific techniques, will provide you with all the material you need to deliver exceptional resilience training sessions. It is the ultimate shortcut to help others become more resilient. For more information, view our Realizing Resilience Masterclass page.

Shame resilience – Noor Pinna

Family resilience has been defined in several ways. One way of viewing the construct is as the “characteristics, dimensions, and properties of families which help families to be resistant to disruption in the face of change and adaptive in the face of crisis situations’’ (McCubbin & McCubbin, 1988, p. 247).

Another more recent definition describes it as the “capacity of the family, as a functional system, to withstand and rebound from stressful life challenges – emerging strengthened and more resourceful’’ (Walsh, 1996; 2003; 2016).

Both of these definitions take the concept of individual psychological or emotional resilience and apply it at a broader level; one of the key areas that interests researchers is how families respond immediately when faced with challenges and over the longer term (Walsh, 2016).

Family resilience processes

In a meta-analysis on family resilience, Walsh (2003) proposed that the concept involves nine dynamic processes that interact with one another and help families strengthen their ties while developing more resources and competencies.

Family Resilience Theory

  • Making sense of adversity – e.g., normalizing distress and contextualizing it, viewing crises as manageable and meaningful
  • Having a positive outlook – e.g., focusing on potential, having hope and optimism
  • Spirituality and transcendence – e.g., growing positively from adversity and connecting with larger values
  • Flexibility – e.g., reorganizing and restabilizing to provide predictability and continuity
  • Connectedness – e.g., providing each other with mutual support and committing to one another
  • Mobilizing economic and social resources – e.g., creating financial security and seeking support from the community at large
  • Clarity – e.g., providing one another with information and consistent messages
  • Sharing emotions openly – including positive and painful feelings
  • Solving problems collaboratively – e.g., through joint decision-making, a goal-focus, and building on successes

Resilience theory

The theory attempts to study how we respond to and defeat shame, an emotion we all experience. Brown (2008) describes shame resilience theory as the ability to recognize this negative emotion when we feel it and overcome it constructively in such a way that we can “retain our authenticity and grow from our experiences.”

Read more about shame resilience theory in this excellent article: Shame Resilience Theory : How to Respond to Feelings of Shame .

community resilience theory

A community resilience concept

Magis (2010, p. 401) defined community resilience as the ”existence, development and engagement of community resources by community members to thrive in an environment characterized by change, uncertainty, unpredictability, and surprise.”

In other words, one approach to defining community resilience emphasizes the importance of individual mental health and personal development on a social system’s capacity to unite and collaborate toward a shared goal or objective (Berkes & Ross, 2013).

The key focus of community resilience is on identifying and developing both individual and community strengths and establishing the processes that underpin resilience-promoting factors (Buikstra et al., 2010). Its goals also include understanding how communities leverage these strengths together to facilitate self-organization and agency, which then contributes to a collective process of overcoming challenges and adversity (Berkes & Ross, 2013).

Community resilience is considered an ongoing process of personal development in dealing with adversity through adaptation and understandably plays a vital role in social work contexts (Almedom, Tesfamichael, Mohammed, Mascie-Taylor, & Alemu, 2007).

Relevant research questions related to community resilience theory include (Berkes & Ross, 2013):

  • What are the characteristics of individual and community resilience, and how can these be fostered (Buikstra et al., 2010)?
  • How is community resilience related to health, and how are health professionals able to help (Kulig, 2000; Kulig, Edge, & Joyce, 2008; Kulig, Hegney, & Edge, 2010)?
  • How can community resilience improve readiness for disaster (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008)?

Community strengths promoting resilience

While community strengths vary between groups, Berkes and Ross (2013) identified a few characteristics that have a central role in helping communities develop resilience. These strengths, processes, and attributes include:

  • Social networks and support
  • Early experience
  • People–place connections
  • Engaged governance
  • Community problem-solving
  • Ability to cope with divisions

Just as people can develop their resilience, organizations can learn to rebound from and adapt after facing challenges. Organizational resilience can be thought of as “a ‘culture of resilience,’ which manifests itself as a form of ‘psychological immunity’” to incremental and transformational changes, according to Boston Consulting Group Fellow Dr. George Stalk, Jr. (Everly, 2011).

With a host of factors contributing to a dynamic and sometimes turbulent business environment, organizational resilience has gained incredible salience in recent years. And at the heart of it, Everly argues, are optimism and perceived self-efficacy.

How to build organizational resilience

A culture of organizational resilience relies heavily on role-modeling behaviors. Even a few credible and high-profile individuals in a company demonstrating resilient behaviors may encourage others to do the same (Everly, 2011).

These behaviors include:

  • Persisting in the face of adversity
  • Putting effort into dealing with challenges
  • Practicing and demonstrating self-aiding thought patterns
  • Providing support to and mentoring others
  • Leading with integrity
  • Practicing open communication
  • Showing decisiveness

Read more about Positive Organizations here.

InBrief: the science of resilience

Are some people born more resilient than others? Southwick and Charney (2012) discussed human biological responses to trauma and looked at a sample of high-risk individuals to understand why some are more able to cope even in the face of life-changing adversity.

They examined three samples of participants to investigate whether these individuals had a genetic predisposition toward being more resilient:

  • Special Forces instructors
  • Vietnam prisoners of war
  • Individuals who had suffered considerable trauma

Southwick and Charney (2012) looked at the psychological factors of these individuals; their genetic factors; and their spiritual, social, and biological factors.

The results:

Risk and protective factors generally have additive and interactive effects… having multiple genetic, developmental, neurobiological, and/or psychosocial risk factors will increase allostatic load or stress vulnerability, whereas having and enhancing multiple protective factors will increase the likelihood of stress resilience.

Put succinctly, genetic factors do have an important influence on our responses to trauma and stress. The image below gives a good overview of their findings.

Environmental Stressors

Source: Southwick & Charney, 2012, p. 81

In the article , mentioned in our References section, you can learn more about two key concepts that are central to resilience theory:

  • Learned helplessness – where individuals believe they are incapable of changing or controlling their circumstances after repeatedly experiencing a stressful event
  • Stress inoculation – whereby they can develop an “adaptive stress response and become more resilient than normal to the negative effects of future stressors” (Southwick & Charney, 2012, p. 80)

University of Minnesota developmental psychologist Norman Garmezy is one of the best-known contributors to resilience theory as we know it. His seminal work on resilience focused on how we could prevent mental illness through protective factors such as motivation, cognitive skills, social change, and personal ‘voice’ (Garmezy, 1992).

His pioneering work included the Project Competence Longitudinal Study (PCLS), which contributed operational definitions, frameworks, measures, and more to the study of competence and resilience. Started around 1974, the PCLS was developed to enable more structured and rigorous resilience research and look into protective buffers that help children overcome adversity (Masten & Tellegen, 2012).

One of its more impactful discoveries was that resilience is a dynamic construct that changes over time; another was the concept of developmental cascades, which describe how functioning in one domain can influence other levels of adaptive function.

If you’re curious to find out more about the work of Norman Garmezy, Masten and Tellegen’s (2012) paper is a great read: Resilience in Developmental Psychopathology: Contributions of the Project Competence Longitudinal Study .

The best-known positive psychology framework for resilience is Seligman’s 3Ps model.

These three Ps – personalization, pervasiveness, and permanence – refer to three emotional reactions that we tend to have to adversity. By addressing these three, often automatic, responses, we can build resilience and grow, developing our adaptability and learning to cope better with challenges.

Seligman’s (1990) 3Ps are:

Personalization – a cognitive distortion that’s best described as the internalization of problems or failure. When we hold ourselves accountable for bad things that happen, we put a lot of unnecessary blame on ourselves and make it harder to bounce back.

Pervasiveness – assuming negative situations spread across different areas of our life; for example, losing a contest and assuming that all is doom and gloom in general. By acknowledging that bad feelings don’t impact every life domain, we can move forward toward a better life.

Permanence – believing that bad experiences or events last forever, rather than being transient or one-off events. Permanence prevents us from putting effort into improving our situation, often making us feel overwhelmed and as though we can’t recover.

These three perspectives help us understand how our thoughts, mindset, and beliefs affect our experiences. By recognizing their role in our ability to adapt positively, we can start becoming more resilient and learn to bounce back from life’s challenges.

Resilience is something we can all develop, whether we want to grow as individuals, as a family, or as a society more broadly. If you’re interested in developing your psychological resilience, our Realizing Resilience Masterclass uses science-based tools and techniques to help you understand the concept better and cultivate more “bounce-back.”

Or, if you’re hoping to read more about the topic in general, we’ve got a vast range of blog posts, worksheets, and activities in our Resilience & Coping section on this site. Before you go, though, tell us, what interests you most about resilience theory and what fields have you been applying it in professionally?

We hope you enjoyed reading this article. Don’t forget to download our three Resilience Exercises for free .

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3 Resilience Exercises Pack

ORIGINAL RESEARCH article

How does psychological resilience influence subjective career success of internet marketers in china a moderated mediation model.

\r\nTing Wang

  • Business School, China University of Political Science and Law, Beijing, China

In this study, the research objective of psychological resilience refers to the emerging professional group of Internet marketers under the background of the COVID-19 pandemic environment. This paper studies the effect of the psychological resilience of Internet marketers on their subjective career success. The result shows that Internet marketers’ psychological resilience has a positive impact on their subjective career success. The work engagement of Internet marketers plays a mediating role in the relationship between psychological resilience and subjective career success. Meanwhile, Internet marketers’ workload positively moderates the mediating effects of work engagement. This study starts from the perspective of positive psychology to investigate the psychological resilience of Internet marketers and broadens the scope of application of positive organizational behavior and psychology.

Introduction

Since the 1970s, the internal and external working environments of organizations have changed rapidly, and the boundaries of their survival and development have increasingly blurred ( Fu and Chen, 2022 ). Hence, employees cannot clearly determine the underlying values, psychological contracts, hypothetical systems, and the specific content of rights and responsibilities that guide their work. Individuals find highly competitive external work environments extremely stressful or unhealthy. Then, against the backdrop of the current flattened world economy, there is a need for research on the psychological resilience of employees. Moreover, China is in a critical period of transformation of its economic development mode at present, new employment modes and labor patterns are constantly emerging ( Yan and Yang, 2022 ). Internet marketers, as a typical representative of the new form of employment, are the main drivers of stable employment in China during the ongoing COVID-19 pandemic.

In the combination of live broadcast and e-commerce industry, online marketers have experienced the appellation from Internet celebrities to live broadcast anchors. In July 2020, the Ministry of Human Resources and Social Security of China and other relative departments listed Internet marketers as a new occupation. Meanwhile, the professional title of Internet marketer was officially included in the “National Occupational Classification Code” ( Wu, 2021 ). Based on the interactive nature of the Internet and the characteristics of the credibility of transmission, an Internet marketer refers to a person who sells and promotes products on a digital platform ( Shen, 2020 ). It has been nearly 6 years since the outbreak of live broadcasting. As an emerging profession, Internet marketers have developed tremendously along with the continuous improvement and perfection of Internet technology. Obviously, the continuity of its professional life cycle has stood the test of time, and Internet marketers are increasingly recognized by the society.

Additionally, with the vocational certification of the Ministry of Human Resources of China and Social Security and the State Administration of Market Regulation in China, Internet marketers are being increasingly recognized by the masses. However, the novelty of the work content of Internet marketers, coupled with the fierce changes in the internal and external environment, makes the Internet marketing profession frequently bear various hidden burdens, and psychological–emotional exhaustion often has a negative impact on their personal and work development. The exploration and improvement of the quality of psychological resilience help individuals reflect on the significance and value of life brought by adversity.

Literature review

Psychological resilience.

Psychological resilience is a static situation ( Masten and Obradovic, 2006 ) wherein an individual can maintain a benign development after setbacks and negative emotions or events, or it is the ability to recover through one’s own initiative under violent and destructive external changes to overcome adversity and rebound from setbacks ( Mak et al., 2011 ; Zhou et al., 2016 ). Empirical research on resilience found that whether in the field of clinical psychology or that of positive psychology, resilience plays an important role in the adaptation, recovery, and physical health of individuals after trauma ( Lee et al., 2013 ). Studies have highlighted that an individual with high psychological resilience, as a typical representative of psychological capital ability, can overcome internal and external pressure, cooperate with others, and assume the corresponding risks as appropriate ( Han et al., 2021 ).

Work engagement

Work Engagement (WE) refers to the positive emotional experience that an individual perceives in daily work, which is characterized by long durations and multidimensional divergence to the individual’s work process ( Lin et al., 2008 ). According to the work requirement–resource model, the factors that affect the degree of work engagement generally include employees’ own resources and resources needed for work, among which individual resources refer to self-efficacy, resilience and optimism, and other individual positive trait variables. Psychological capital theory also proposes that an individual’s psychological capital resources can stimulate them to generate positive achievement motivation and strengthen work identity to ultimately increase the degree of work engagement ( Cheung et al., 2011 ; Clark et al., 2021 ). A high level of work engagement means that an individual will have more positive emotions and feelings toward work completion ( Bakker et al., 2008 ; Awan et al., 2020 ). Similarly, an individual’s positive mental state can also be reflected in the elements of psychological capital. Employees with high psychological capital are more optimistic and positive in their work attitude and will create more value for the society. Specifically, the work engagement-related effect variables mainly include job satisfaction ( Guo et al., 2016 ), job performance ( Li et al., 2015 ), turnover tendency ( Yang et al., 2017 ), and organizational citizenship behavior ( Diefendorff et al., 2002 ; Geng and Wei, 2016 ).

Workload refers to the index value of an individual’s ability to evaluate workload demand ( Wang and Li, 2017 ) or the sum of the full cost of completing work requirements, which is the integration of subjective cognition and objective resources required by individuals to perform tasks ( Veltman and Gaillard, 1996 ; Geng et al., 2020 ). In the existing domestic and foreign literature, although some scholars have proposed workload as an important “challenging” stressor, it can play a role in motivating individuals to work hard ( Cavanaugh et al., 2000 ). Empirical studies have shown that workload has a negative impact on the level of an individual’s cognition and organizational growth ( Sonnentag and Fritz, 2014 ). From the perspective of an individual’s work attitude and wellbeing, the impact of workload on work performance, job satisfaction ( Nirel and Feigenberg, 2008 ; Häusser et al., 2010 ), and work engagement all have negative effects ( Weigl et al., 2016 ). From the perspective of organizational profit and growth, workloads clearly positively affect an employees’ turnover tendency ( Torres, 2016 ). As a typical occupation in the live broadcast industry represented by emerging industries, Internet marketers often have to undertake a relatively large workload. An empirical study on work requirements and engagement found that tasks that arouse individual motivation have a significant positive effect on work engagement, whereas depressive tasks have a significant negative effect ( Zhang and Wang, 2017 ). Furthermore, specifically, challenging stressors—such as high workload, time pressure, scope of work, and responsibilities—also bring material and spiritual expectations to employees when they consume numerous personal resources, such as wage increases, personal growth, and self-development ( Crawford et al., 2010 ).

Theoretical foundation

Psychological capital theory.

The formation and value recognition of psychological capital concept benefit from the deepening of research on organizational behavior. Psychological capital pays more attention to the development of “people” as a whole, and focuses on the characteristics and development of individuals ( Luthans et al., 2005 ). Like traditional human capital and social capital, psychological capital also covers group-level content such as talent, professional skills and practical experience, as well as social support and network. However, psychological capital focused on the process of the individual’s transformation from the actual self to the potential self-more. During a career development without boundaries, the overall effect of human, social and psychological capital is the key to realize the potential power of people. Compared with single capital, the synergistic effect of three different types of capital will have a more significant impact. Whether at the individual level or at the overall one, psychological capital theory helps modern organizations to understand modern human resources and their engagement more comprehensively. As an important research basis of organizational behavior, psychological science also affects the research orientation of organizational behavior to a certain extent. Positive psychology advocates people to focus on positive power or potential. It believes that individuals need to properly treat psychological problems, in order to maintain a normal mental health state.

Resource conservation theory

The resource conservation theory proposed by Hobfoll (1989) is mainly used to explain the back-and-forth process of resources between individuals and their environment. The most basic assumption of resource conservation theory is that when people face actual or potential resource loss, they will preserve, maintain and acquire precious resources as much as possible in order to eliminate the threat of resource loss. There are three important interrelated corollaries of resource conservation theory: resource conservation priority, resource acquisition secondary, and creation of additional resources. Resource protection priority means that when resources are already lost, the individual awareness of protecting the resources he owns is higher than acquiring additional resources. Resource acquisition secondary means that the motivation of individuals to acquire resources is weaker than the motivation to save resources, but it does not mean that acquiring additional resources is not desirable. On the one hand, the acquisition of resources can reduce the risk of actual or potential loss. On the other hand, it can create opportunities for acquiring additional cherished resources. Finally, creating additional resources means that individuals will use multiple ways to strive for additional cherished resources in order to gain more resources. As a source of stress to consume resources, work stress will stimulate the motivation of individuals to protect resources. However, the latest research points out that the motivation of individuals to acquire resources can also be stimulated when resources are exhausted. Therefore, work stress will stimulate resource conservation or resource acquisition motivation, depending on which motivation is more conducive to coping with resource depletion.

Hypothesis development

Psychological resilience and subjective career success.

When individuals have high psychological resilience, they can show higher engagement at work, are more likely to develop good interpersonal relationships, improve their work remuneration and promotion opportunities, and feel additional work satisfaction. It has confirmed that psychological resilience and job performance show a positive correlation, be it in normal or extreme working environments, such as military combat ( Schaubroeck et al., 2011 ). In conclusion, resilient individuals can solve problems faster and better, overcome obstacles, and eventually achieve considerable career development. Thus, in our hypothesis, we consider Internet marketers as the research object to study the influence of psychological resilience on their subjective career success. Specifically, we propose the hypothesis 1:

Hypothesis 1 : Internet marketers’ psychological resilience has a positive impact on their subjective career success.

Mediating role of work engagement

Nowadays, although the webcast industry is increasingly becoming standardized, there are few ways to pass positive information to the public; some people retain the stereotype of “vulgarization” and “stigmatization” of the group, thus leading to a low degree of social identity for a career as an Internet marketer. For a group of Internet marketers, the relative lack of government-level social security systems and the negative propaganda of public opinion in the media have caused Internet marketers to suffer serious frustrations in the course of their work. In the face of injury or dilemma, individuals with strong resistance to frustration continue to maintain a high degree of daily work engagement, whereas groups with low levels of relative psychological resilience are unable to concentrate on work because of the influence of negative emotions. Empirical research on psychological capital recognizes that psychological capital must be related to an organization’s work results. However, work attitude variables, such as work engagement and satisfaction, also have a positive correlation with job performance outcome variables. Thus, psychological capital and employees’ work engagement are related. Individuals with a high level of psychological resilience can maintain a higher degree of engagement in their own work, which is reflected in the focus, higher work willingness, and high cost in the professional field. Specifically, we propose the hypothesis 2:

Hypothesis 2: Internet marketers’ work engagement plays a mediating role in the relationship between psychological resilience and subjective career success.

Moderating role of workload

Scholars have debated about the role of workload in the transfer mechanism of empirical research. According to Hockey’s work demand–management control model, when there is psychological and emotional stress in the working environment, employees choose to enhance their subjective initiative, that is, to continue working hard to maintain high performance levels. Thus, the higher the degree of activation of sympathetic nerves in the brain when an individual chooses to strengthen subjective effort, the higher the psychological cost it produces. Hence, in the long term, when individuals face a highly intense working environment, one is more likely to experience situations where one’s own state makes it difficult to meet the needs of work, resulting in job burnout. Scholars have focused on the work demand–management model and believed that individuals appear to deal with highly demanding work requirements in two ways, namely, one is paying a higher psychological cost to adapt to the high requirements and complete the higher target performance and the other is avoiding excessive consumption to maintain normal effort input. However, workload reduces the final level of work performance. Specifically, we propose the hypothesis 3:

Hypothesis 3: Internet marketers’ workload positively moderates the mediating effects of work engagement in the relationship between psychological resilience and subjective career success.

To sum up, the theoretical model and research hypotheses of the relationship between psychological resilience, work engagement, workload and subjective career success constructed in this paper are shown in Figure 1 and Table 1 .

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Figure 1. Theoretical research model.

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Table 1. Research hypotheses summary.

Materials and methods

Research samples.

In this study, the selection of the survey object is not limited to a fixed platform. The source of the data is mainly live broadcast bases in Lianyungang, Jiangsu, and Shiyan, Hubei, as well as the Internet marketers from many provinces such as Beijing, Shanghai, and Shenzhen. Additionally, an online questionnaire was adopted as the survey method. The questionnaire was distributed and collected primarily through the WeChat platform. Overall, 240 questionnaires were distributed, of which 224 responses were collected. The questionnaire response rate was 93.3%. After inspection, 16 invalid questionnaires were excluded and 208 valid questionnaires were retained. The effective recovery rate reached 92.8%. All research subjects completed the survey independently.

Variable measurements

In this study, the concept of psychological resilience is defined as a trait or ability. The Connor–Davidson Resilience Scale (CD-RISC) ( Connor and Davidson, 2003 ) is used to measure the psychological resilience of Internet marketers in this paper. This scale is used to assess the positive psychological traits that individuals display in difficult situations to overcome adversity and eventually achieve personal growth. The CD-RISC is currently the most commonly adopted scale to assess resilience levels. However, because the design background of CD-RISC is based on European and American cultures, Chinese scholars developed psychological resilience measurement tools suitable for local research on the basis of Chinese culture ( Yu and Zhang, 2007 ). CD-RISC divides psychological resilience into three dimensions, namely, tenacity (I can achieve my goals), self-improvement (I can adapt to changes), and optimism (I can cope with whatever happens), with 25 items. Using the Richter seven-point scale, the scoring method ranges from 1, “strongly disagree,” to 7, “strongly agree.” That is, the higher the score of the scale, the stronger the resilience of the individual. Cronbach’s coefficient of the Chinese version of the resilience scale reached 0.91. The three-factor structure is properly divided, which means that the adopted scale shows good validity of the method for analysis.

The measurement scale used in this study to assess the level of work engagement is the Utrecht Work Engagement Scale (UWES-9), a simplified version of UWES ( González-Romá et al., 2006 ). The scale is compiled and revised on the basis of the work engagement model, which specifically includes three factors: vitality, dedication, and focus ( Wilmar et al., 2002 ). The items on the vitality dimension are used to assess an individual’s strength, level of flexibility, willingness to devote time, as well as the inability to easily burnout, and firmness and maintenance in the face of difficulties, such as “At work, I perceive myself bursting with energy.” The items on the dedication dimension are used to evaluate the value that an individual obtains from one’s career, passion and pride towards the work, such as “I am proud of my own career.” The items on the focus dimension are used to assess the level of the test subject’s full immersion in their work, such as “When the work is stressful, I feel happy.” In a study on specific objects, Bakker et al. (2008) showed that the amount of work engagement has good reliability and validity. Additionally, the Chinese version of the Work Engagement Evaluation Scale ( Zhang and Gan, 2005 ) scores is relatively stable. Among them, vitality, dedication, and focus have good internal consistency, and all Cronbach’s coefficients exceed 0.70.

Role Overload Scale ( Peterson et al., 1995 ) is used in this study to assess the level of workload. Peterson developed the workload sense assessment scale on the basis of the research content in their cross-country literature study on role conflict, role ambiguity, role overload. There are five items in the workload scale, such as “my work quantity hinders the quality of work I want to maintain.” In the subjective perception of workload, Internet marketers have no significant professional characteristics; hence, all scale items in this study are consistent with the Chinese-translated items of the original scale. The Cronbach’s coefficient of the role overload scale is 0.88.

Subjective career success is an individual’s subjective perception of the success of their own career development. An individual should make a subjective measurement on the basis of their own practical experience and feelings depending on specific measurements. It is difficult to obtain the result through the organization engaged in or relying on external observation of a third party. Based on the conceptual connotation of subjective career success, many scholars have used career satisfaction ( Greenhaus et al., 1990 ) or job satisfaction to measure a subject’s perceived subjective career success. The Subjective Career Success Measurement Scale used in this study has a five-item scale developed by Greenhaus (such as “I have satisfaction with the success of my career”) that fits with the definition of subjective career success, which measures the level of individual subjective career success mainly by career satisfaction indicators. The reliability and validity of the subjective career success scale of Greenhaus, which is also a widely used subjective career success scale, were robust and were supported and verified by several sample data in China. The Cronbach’s coefficient of the subjective occupational success scale reached 0.95.

Data analysis

In this study, SPSS25.0 and AMOS 24.0 software were used to analyze the data. Pearson’s correlation analysis method was used to observe the correlation between sex, educational background, and other statistical variables such as psychological resilience, work engagement, workload, and subjective career success. To test the mediation and moderation effects, we adopted a bootstrapping method, used the program in SPSS developed by Preacher and Hayes (2008) , and selected Model 4 in the PROCESS3.0 plug-in to test the mediation effect and Model 7 in the PROCESS3.0 plug-in to examine the moderating effect. Specifically, we set a random sampling at 5,000 times and used a 95% confidence interval for testing, to obtain the specific values of the mediation and moderation effects.

Descriptive statistics

The questionnaires for this study are mainly from two live broadcast bases in Lianyungang, Jiangsu, and Shiyan, Hubei. We distributed questionnaires to 208 Internet marketers from Beijing, Shanghai, Shenzhen, Anhui, and other provinces. Descriptive statistical analysis is performed on the basis of the data, and the details are shown in Table 2 .

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Table 2. Demographic information of valid survey sample composition ( N = 208).

In terms of sex, 79 were men and 129 women, accounting for 37.9% and 62.1% of the total sample respectively. The data results show that the proportion of men and women in the survey questionnaire is significantly biased—that is, there are significantly more female Internet marketers than males, which is consistent with the phenomenon observed in real society. In terms of age, none were under the age of 20; 52 aged 21–25 years, accounting for 25% of the total sample; 41 aged 26–30 and 36–45 years, accounting for 19.71% of the total sample; 47 under the age of 31–35 years, accounting for 22.6% of the total sample; and 27 over 46 years, accounting for 12.98% of the total sample. Therefore, in terms of the proportion of age, the age of Internet marketers is at a maximum of 21–25 years, indicating that more youngsters are engaged in this profession, which is consistent with the characteristics of this profession as a representative of flexible employment. In terms of academic qualifications, the number of Internet marketers with college as the highest academic qualification is the highest (154), accounting for 74.04%, followed by undergraduate and high school levels, accounting for 20.19% and 4.81% of the total sample, respectively. There are none with a degree below the high school level or with a doctor’s degree, indicating that the education background of the group currently engaged in this occupation represents a normal distribution, and the number of people with higher and lower education levels is still small. In terms of working hours, the number of people with entry time between 1 and 3 years is the highest, accounting for 28.37% of the total sample proportion, followed by those with entry time between 1 and 6 months and from 6 months to 1 year, with 45 and 38 people, accounting for 21.63% and 18.27% of the total sample, respectively. This indirectly proves that the life cycle of Internet marketers as a new profession has withstood the test of time. In terms of income, 89 people with a salary of less than 6,000 yuan account for 42.80% of the total sample; 58 people with a salary between 6,000 and 10,000 yuan account for 27.89% of the total sample; and 61 people with a salary between 10,000 and 30,000 yuan account for the total sample. The sample proportion is 29.33%. Hence, the income of most groups of Internet marketers remains low, which is consistent with the phenomenon that the top current Internet marketers are still earning maximum resources and traffic in the industry. It also reflects the grassroots Internet. Hence, marketers find it difficult to obtain traffic that attracts the masses.

Correlation analysis between variables

Pearson’s correlation analysis between variables is used in this study to observe the correlation between sex, education, and other statistical variables such as psychological resilience, work engagement, workload, and subjective career success. Table 3 lists the mean (mean), standard deviation (standard error), and correlation coefficient (correlation index) between the control and main research variables. The control variables include the sex, age, education, working years, and income. As shown in Table 3 , psychological resilience and work engagement ( r = 0.444, p < 0.01), psychological resilience and subjective career success ( r = 0.441, p < 0.01), work engagement and subjective career success ( r = 0.496, p < 0.01), work engagement and workload ( r = –0.225, p < 0.01), and workload and subjective career success ( r = –0.189, p < 0.01) are all significantly correlated. The correlation coefficient values of the main research variables in Table 3 show that the correlation between each variable is consistent with the prediction hypothesis, and it also provides a preliminary stage of support for the following hypothesis.

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Table 3. Mean, standard deviation, and correlation coefficients of the study variables.

Hypothesis test

In the process of formal research, linear regression method is used to verify assumptions. The results are shown in Table 4 . After controlling for variables such as sex, age, education, working years and income of Internet marketers, regression analysis of psychological resilience to subjective career success is performed. We found a significant positive correlation between psychological resilience of Internet marketers and subjective career success (β = 0.310, p < 0.001) after controlling for variables such as sex, age, education, working years, and income. Hypothesis 1 is supported—that is, the psychological resilience of Internet marketers has a positive impact on subjective career success. Additionally, before testing the mediation effect of work engagement, it is necessary to analyze the relationship between the psychological resilience and work engagement, as well as the relationship between work engagement and subjective career success. The results showed that after controlling for the variables of sex, age, education, working years, and income of Internet marketers, a significant positive correlation was found between the psychological resilience of Internet marketers and work engagement (β = 0.186, p < 0.001),and between work engagement and subjective career success of Internet marketers (β = 0.291, p < 0.001).

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Table 4. Results of regression analysis for hypothesis testing.

To test the mediating role of work engagement in Hypothesis 2, we apply bootstrapping methods using the method proposed by Preacher and Hayes (2008) . Specifically, we set random sampling at 5,000 times using a 95% confidence interval. As shown in Table 5 , the results of regression analysis show that when psychological resilience is an independent variable, the prediction of work engagement proves that the test results of the first half of the mediation effect are true (β = 0.198, p < 0.001). Second, from the results of psychological resilience and work engagement to predict subjective career success, psychological resilience significantly positively predicts subjective career success (β = 0.254, p < 0.001). Meanwhile, Table 5 shows that work engagement significantly positively predicts subjective career success (β = 0.307, p < 0.001), indicating that the direct effect and the second half of the mediation effect are established. Finally, the subjective career success of dependent variables is predicted using psychological resilience as an independent variable. Table 5 shows that the β = 0.315, p < 0.001, indicating that the total effect is true.

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Table 5. Mediation test of work engagement.

To further detect the mediation effect as a complete or partial mediation, and whether it is a partial mediating role, the specific value of the mediation effect is obtained. The random sampling is set to 5,000 times using bootstrap random sampling, and the confidence interval is 95%. Finally, as shown in Table 6 , the total effect is 0.315, the confidence interval is [0.193, 0.436], which means the total effect is significant. The direct effect is 0.254, the confidence interval is [0.131, 0.377]. The mediating effect is 0.061 and the confidence interval is [0.023,0.125], indicating that the mediating effect is true. Moreover, as shown in Table 6 , the proportion of mediating effect to total effect is 19.36%. That is, the work engagement of Internet marketers plays a 19.36% mediating role between psychological resilience and subjective career success.

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Table 6. Decomposition of the total, direct, and mediating effects.

The method proposed by Hayes (2013) is used to test this moderation effect. Specifically, we set random sampling to 5,000 times using a 95% confidence interval. Consequently, the specific value of the moderated mediating effect is obtained, the results of which are shown in Table 7 . The data of the model as a whole showed a moderated effect index of moderated mediation at 0.056 and 95% CI index of moderated mediation [0.114, 0.098]. As the confidence interval in which the value is located does not contain 0, the moderation index in the model is said to be significant. Hence, this study proves that the mediation effect in the model constructed can be effectively moderated. Specifically, the amount of mediation effect in the sample of –1 SD is 0.002, with 95% CI [–0.087, 0.099]. The results showed that the mediation effect was not established in the moderated low-group sample, and the mediation effect was 0.236,with 95% CI [0.114, 0.098] in the +1 SD sample, which indicates that the mediation effect holds good for the high grouping of moderated variables. And the corresponding moderation effect diagram is shown in Figure 2 . Besides, all the research hypotheses and test results are shown in Table 8 .

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Table 7. Results of conditional indirect effects.

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Figure 2. Moderation effect of workload.

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Table 8. Research hypotheses and test results.

On the basis of a literature review, this study proposes three related hypotheses and validates them through data analysis using statistical analysis software. The results show that the psychological resilience of Internet marketers has a significant positive impact on subjective career success; the work engagement of Internet marketers plays a mediating role between psychological resilience and subjective career success; and the workload of Internet marketers positively moderates the relationship between psychological resilience and subjective career success. Specifically, it is manifested in the following three aspects.

First, the psychological resilience of Internet marketers improves their subjective level of career success cognition. This study uses psychological capital theory as the theoretical basis and highlights that individuals with high psychological resilience can overcome internal and external pressures and have a higher sense of self-efficacy and innovative spirit. This enables them to better solve problems, cope with adversity, and actively adapt to the results, which ultimately bring success, satisfaction, and development to the individual. Additionally, the results of the data analysis by SPSS 25.0 statistical analysis software show that the Internet marketers’ psychological resilience has a significant positive impact on subjective career success (β = 0.310, p < 0.001). Psychological resilience is a typical positive psychological resource. Under the effect of this positive psychological trait, individuals show stronger adaptability in the work process, are more likely to develop good interpersonal relationships, and be satisfied with work. The perceived happiness also increases accordingly, which means that it is easier for Internet marketers to achieve subjective career success.

Second, the work engagement of Internet marketers plays a mediating role between psychological resilience and subjective career success. On the basis of literature review, this study confirms that a moderation effect exists between Internet marketers’ psychological resilience and subjective career success in relation to work engagement. The empirical research results show that work engagement has a partial mediating effect between the psychological resilience of Internet marketers and subjective career success (β = 0.291, p < 0.001). Work engagement is derived from the perspective of positive psychology and organizational behavior, because it reflects the positive and full emotions and cognitive patterns of an individual at work and indicates that the individual can perceive the enthusiasm and joy of work when completing the task—that is, it has a higher sense of self-fulfillment. Thus, Internet marketers have a higher sense of job identity when they have a higher level of psychological resilience and are less likely to experience job burnout. The positive forces stimulated by an individual’s internal resilience can promote work engagement, and the results of the work often make the individual more satisfied, which will ultimately help in achieving subjective career success.

Third, workload has a positive moderating effect on the relationship between psychological resilience and subjective career success. The empirical research results of data analysis show that workload positively moderates the impact of Internet marketers’ psychological resilience on their subjective career success. According to the literature, challenging stressors, such as high workload, can also bring expectations to employees when they consume a large amount of personal resources, such as material and spiritual returns like salary increases, personal growth, and self-realization. Additionally, the empirical data show that the workload perceived by Internet marketers acts as a challenging source of pressure, which is consistent with the core concept of psychological resilience. Hence, when the level of psychological resilience is low, a relatively low workload increases the level of the Internet marketer’s subjective career success perception. When psychological resilience is maintained at a high level, the increase in workload strengthens the transmission mechanism of psychological resilience to work engagement and then to subjective career success, thus enhancing the positive effect.

With the rapid development in digitalization and informatization, the profession of Internet marketers has performed well in absorbing employment, and society should not only focus on the novelty of its job characteristics but also pay attention to their career development process. The difficulties faced by Internet marketers can be used as a direction for future improvement from the perspective of professional psychological quality training and development guarantee, which will ultimately improve the subjective career success cognition level of the Internet marketer group. Thus, based on the research results, it is necessary to provide empirical support for managers to pay attention to fostering Internet marketers’ psychological resilience and, correspondingly, reducing the workload of Internet marketers, and proposing targeted countermeasures to give full play to the positive role of psychological resilience.

First, multiple measures to improve Internet marketers’ psychological resilience. Internet marketers have a high level of psychological resilience to improve subjective career success. Relevant studies have proved that correct self-efficacy and self-acceptance can enhance employees’ psychological resilience and promote their deep development in the professional field. Internet marketers can try to improve their psychological resilience in the following three aspects: first, they should improve their professional identity. Internet marketers, as a new profession, play an important role in the new employment army under the economic environment of live broadcasting. They should highly identify with the mission of engaging in the profession and establish a sense of professional belonging and mission. When Internet marketers are faced with difficulties in their daily work, they should learn to establish the correct style of problem attribution, that is, maintain an optimistic and upward emotional state and seek multichannel and high-efficiency methods to deal with stressful challenges and strengthen emotional regulation ability to improve the level of psychological resilience. Moreover, improve the level of achievement motivation. Renewal of professional skills, emotional experience, and professional knowledge of Internet marketers all promote the level of self-acceptance in the mode of self-renewal and then improve achievement motivation to a certain extent.

Second, focus on multiple dimensions to enhance the work engagement of Internet marketers. The results show that the degree of work engagement has a significant impact on the subjective career success of Internet marketers. Interviews with successful Internet marketers showed that they love their work and are willing to think about how to improve their current work. Interest is the best teacher in the process of work to find and cultivate their own interest in work, stimulate enthusiasm for work, enhance the degree of professional work engagement, and finally succeed in their respective careers. Additionally, the level of work engagement also depends on the Internet marketers’ own problem-solving ability. Groups with high levels of psychological resilience show strong problem-solving ability in the face of difficulties; specifically, they actively think about various solutions to problems, accumulate successful learning experiences from others, and are good at arranging and solving problems based on the difficulty level. Internet marketers can improve their ability to deal with problems through the dual accumulation of theory and practice, such as reading to accumulate more professional knowledge through the practice process to accumulate more experience, thus broadening their horizons and even career and gradually improving their subjective career success cognitive level.

Third, multiple measures to promote rationalization of the workload of Internet marketers. According to this study, when the level of psychological resilience is low, the relatively low workload improves the Internet marketers’ subjective career success cognitive level. By contrast, when there is a high level of psychological resilience, the increase in workload ultimately improves the cognitive level of subjective career success. According to the rule of Yerkes-Dodson, the inverted U between stress and work results means that too high or too low pressure will result in lower work results than expected. For different levels of psychological resilience, a moderate workload can maximize work efficiency. Based on the actual situation, the source of pressure faced by Internet marketers is not only personal but also related to the assessment mechanism of the employment platform and the lack of social security system. Internet marketers can rationally deal with their workload by improving their personal abilities. Because of the novelty of the professional content of Internet marketers, individuals should constantly update their professional skills to cope with the possible working conditions. Hence, Internet marketers can improve their professional abilities, skills, and experience by constantly acquiring new knowledge. Moreover, today’s platform often views the live broadcast time of Internet marketers as one of the work completion standards, although long hours of work bring lower work results. Thus, the employment platform should carefully consider implementing some mandatory evaluation systems and establish a reasonable performance evaluation system for Internet marketers. Additionally, as a new occupation that has just been included in the professional gamut, the workload level of Internet marketers is related to the imperfect security system at the social level. In the future, governments should issue policies related to the professional group to ensure that the group’s basic interests are not hampered at the institutional level.

Contribution

On the one hand, the theoretical significance of this study entails the extension of the research on psychological resilience to the emerging professional group of Internet marketers to deepen the scope of application and improve the theoretical system of psychological resilience. On the other hand, this study creates a new perspective for the career management research of Internet marketers and attempts to use psychological capital theory and resource preservation theory as the theoretical foundation combined with the work requirement–resource model. It aims to clearly define the psychological resilience of Internet marketers and the subjective career success concept’s connotation of flexible employment under the new employment situation and introduce work engagement and workload variables to explore the mechanism based on the psychological resilience of the Internet marketer group to their subjective career success. Additionally, the psychological resilience of the professional group of Internet marketers has important practical significance and value for individuals or employment platforms. It is reflected as follows: first, when the level of psychological resilience of Internet marketers is high, the degree of investment or concentration at work will be higher than that of Internet marketers with low levels of psychological resilience and individual job satisfaction and other work result variables will also increase accordingly; that is, their own subjective level of career success is also correspondingly higher; second, Internet marketers can exercise individual psychological resilience for some workload undertaken by them so that individuals can demonstrate good work behavior.

Limitations and future research directions

However, the current study has some limitations. First, the subjects may not be motivated to respond because of the large set of questionnaire items in the survey, which has implications on the number of questionnaires. In future research, the number of samples can be further expanded by adding more distribution channels. Second, the questionnaires in this study are self-assessments by Internet marketers, and individual’s subjective perceptions and the actual situation may be different, which may influence the accuracy of the survey data. Future research can collect data in various ways. For example, the psychological resilience part of Internet marketers can also be scored through social network relationships to collect data. Additionally, this study selects work engagement as the mediating variable and workload as the moderating variable in the model. Although it has enriched the relevant research conclusions, studies on the correlation between the two still need to be expanded ( Qi et al., 2016 ; Wang et al., 2020 ). Third, the selection of variables and construction of models are based on the current work status of Internet marketers. This research model may be applied to other work characteristics similar to those of Internet marketers. Future studies should explore whether the research model has applicability for occupational groups within a certain range. Fourth, this paper has not delved into the relationship between psychological resilience and subjective career success from the perspective of working years of Internet marketers. Further studies could produce more longitudinal research about investigating the link between psychological resilience and working years. Finally, considering that Internet marketers belong to the typical representatives of flexible employees recognized by China, the research scope can be expanded to foreign flexible employees, not limited to the occupation of Internet marketers. We can also expand the research on the relationship between resilience and subjective career success of foreign flexible employees in the future.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author contributions

TW contributed to the research idea, data analysis, and writing and revising. DG contributed to the data collection, theoretical construction, and writing. Both authors contributed to the article and approved the submitted version.

This research was supported by National Natural Science Foundation of China and the project numbers are 71874205; the Key Program of National Social Science Foundation of China and the project numbers are 20AZD071; Qianduansheng Eminent Scholar Support Program of CUPL and the project numbers are 01140065138; and the Fundamental Research Funds for the Central Universities in the Scientific Research Innovation Project of CUPL.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords : psychological resilience, Internet marketers, subjective career success, work engagement, workload

Citation: Wang T and Gao D (2022) How does psychological resilience influence subjective career success of Internet marketers in china? A moderated mediation model. Front. Psychol. 13:921721. doi: 10.3389/fpsyg.2022.921721

Received: 16 April 2022; Accepted: 11 July 2022; Published: 01 August 2022.

Reviewed by:

Copyright © 2022 Wang and Gao. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Di Gao, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

  • Open access
  • Published: 14 February 2024

Posttraumatic growth of medical staff during COVID-19 pandemic: A scoping review

  • Qian Li 1 ,
  • Yirong Zhu 1 ,
  • Xuefeng Qi 1 ,
  • Haifei Lu 1 ,
  • Nafei Han 1 ,
  • Yan Xiang 1 ,
  • Jingjing Guo 1 &
  • Lizhu Wang 1  

BMC Public Health volume  24 , Article number:  460 ( 2024 ) Cite this article

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Metrics details

The COVID-19 pandemic has imposed unprecedented stress and challenges upon medical staff, potentially resulting in posttraumatic growth (PTG). This scoping review aims to synthesize the existing knowledge on PTG among medical staff during the pandemic by identifying its current status and potential influencing factors. The findings may provide a foundation for future research and interventions to enhance the medical staff’s psychological resilience and well-being.

Literature was systematically searched on PTG among medical staff during the COVID-19 pandemic from 01 January 2020 to 31 December 2022. The following databases were searched: PubMed, Web of Science, Embase, CINAHL, PsycINFO, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), and Wanfang Data. Eligibility criteria included: (1) medical staff as research subjects; (2) a focus on “posttraumatic growth” or “alternative posttraumatic growth” related to the COVID-19 outbreak and pandemic; (3) discussion of the situation and influencing factors of PTG; and (4) study types, such as qualitative, quantitative, and mixed methods. Two researchers independently selected and extracted study characteristics (study design, study population, region, measurement instruments, and primary outcomes) from the included literature. The data were synthesized qualitatively and descriptively.

Thirty-six papers from 12 countries met the inclusion criteria. Moderate PTG levels were observed among healthcare workers during the COVID-19 pandemic, with emphasis on “interpersonal relationships,” “changes in life philosophy,” and “growth in personal competence.” Influencing factors included trauma exposure, sociodemographics, psychological characteristics (resilience and positive qualities), coping, and social support.

Conclusions

This review discovered moderate PTG levels among medical staff during the COVID-19 pandemic, with critical areas in interpersonal relationships, life philosophy, and personal competence. The identified influencing factors can inform future research and interventions to enhance healthcare workers’ psychological resilience and well-being.

Peer Review reports

Introduction

Posttraumatic growth (PTG) has been defined as “positive psychological change that occurs following a struggle with highly challenging life circumstances” and through establishing perspectives for a “new normal” when the old normal is no longer an option [ 1 ]. The positive transformation developed five domains: development of deeper relationships, openness to new possibilities, a greater sense of personal strength, a stronger sense of spirituality, and a greater appreciation of life; followed by the development of the Posttraumatic Growth Inventory (PTGI), which has been translated into more than 20 languages and extensively validated worldwide [ 1 , 2 ]. PTG is associated with PTGI across numerous cultures and many different traumatized populations, including those who have survived natural disasters [ 3 ], bereavement [ 4 ], cancer [ 5 ], human immunodeficiency virus (HIV) [ 6 ], suicide [ 7 ], assault [ 8 ], refugee [ 9 ], and combat veterans [ 10 ], and so on.

Furthermore, people with a strong connection to trauma victims, such as health personnel, family members, caregivers, social workers, and psychotherapists, have also demonstrated vicarious posttraumatic growth (VPTG) in the context of secondary trauma or alternative trauma [ 11 ]. It is particularly prevalent among professionals working with trauma survivors. They may experience personal and professional growth due to witnessing their clients’ resilience and ability to overcome adversity. These experiences include positive changes in self-cognition, interpersonal relationships, life values, increased compassion, sensitivity, and insight [ 12 ], and extraordinary growth in the context of one’s professional identity, which is professional’s job satisfaction and self-competence by witnessing the growth of their clients [ 13 , 14 ].

The novel coronavirus (COVID-19) pandemic has had a profound global impact since its discovery in December 2019. As of March 11, 2023, the World Health Organization (WHO) has reported that the cumulative global cases of COVID-19 have surpassed 759 million, with nearly 6.9 million deaths [ 15 ]. Despite the WHO’s announcement on May 5, 2023, that the COVID-19 pandemic will no longer be classified as a global public health emergency, it is important to note that the threat to global health has not been eradicated. With the lifting of the state of emergency, it is imperative to address the psychological ramifications stemming from the pandemic [ 16 ]. The global healthcare system has been strained by the pandemic, placing a significant burden on healthcare workers (HCWs), particularly those in direct contact with COVID-19-diagnosed patients. This has resulted in a range of mental health issues, including pain, anxiety, burnout, depression, insomnia, posttraumatic stress disorder (PTSD), denial, and fear, which have adversely affected medical personnel, regardless of their direct or indirect exposure to trauma [ 17 ]. Despite the difficulties encountered, healthcare professionals can endeavor to adapt to demanding circumstances and rebound from traumatic experiences, which may result in favorable outcomes such as posttraumatic growth (PTG) or vicarious posttraumatic growth (VPTG). This inherent resilience among medical personnel is underpinned by their specialized training and extensive experience in crisis management, enabling them to navigate the uncertainties and pressures associated with the COVID-19 pandemic [ 18 ]. Furthermore, the daily exposure to life-and-death situations, coupled with a strong sense of professional duty, equips healthcare workers with the capacity to maintain composure and professionalism even in the face of overwhelming challenges [ 19 ]. These qualities not only facilitate their ability to cope but also lay the foundation for potential positive psychological outcomes such as PTG. Therefore, the exploration of PTG becomes integral in understanding how healthcare professionals not only withstand the adversities brought about by the pandemic but also use these experiences as catalysts for personal and professional development. The study of PTG is crucial not just for mitigating the negative psychological consequences of trauma but for promoting a resilient healthcare workforce, capable of not only enduring but thriving in the aftermath of significant challenges.

To the best of our knowledge, existing research on the level of PTG and its influencing factors among medical staff has presented some variability across different regions during the COVID-19 pandemic. A preliminary search for existing scoping reviews in systematic review databases, such as JBI, Cochrane, TRIP database, and PROSPERO, on 01 October 2022, revealed no systematic reviews or scoping reviews on this topic or any currently in progress. Consequently, this study, grounded in the scoping review methodology of Arksey and O’Malley [ 20 ], aims to (a) map the prevalence and characteristics of PTG in healthcare settings during the COVID-19 pandemic (b) identify key factors that may influence its development and (c) highlight the knowledge gaps for future research and interventions aimed at enhancing the psychological resilience and well-being of healthcare workers in the face of public health crises.

This scoping review followed the scoping review framework developed by Arksey and O’Malley [ 20 ], including five stages: (1) identifying the research questions; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results. The results were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) checklist [ 21 ]. The PRISMA-ScR was intended to guide the reporting of this scoping review based on the relevance, credibility, and contribution of evidence. The completed PRISMA-ScR checklist can be found in Additional file 1 .

Search strategy

The literature was systematically reviewed between 01 January 2020 and 31 December 2022 using the following databases: PubMed, Web of Science, Embase, CINAHL, PsycINFO, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), and Wanfang Data. A search strategy was developed by combining key and MESH terms by two research team members. The third member approved it of the research team and finally confirmed it by consulting the medical librarian. Here are the specific details: “COVID-19“[Mesh], “SARS-CoV-2“[Mesh], “COVID-19”, “SARS-CoV-2”, “coronavirus disease 2019”, “2019n-cov”; “Posttraumatic Growth, Psychological“[Mesh], “posttraumatic growth”, “post-traumatic growth”, “vicarious posttraumatic growth”, “secondary posttraumatic growth”, “alternative posttraumatic growth”; “Medical Staff“[Mesh], “Health Personnel“[Mesh], “Healthcare workers”, “health care provider”, “front line workers”, “medical workers”, “medical staff”, “healthcare professionals”, “nurse*”, “doctor*”, “physician”, “paramedic”, and adjusted in each database. The medrxiv.org and the references cited by the retrieved articles were also searched for additional references. The search strategies are detailed in Additional file 2 .

Study selection and eligibility criteria

Inclusion criteria were as follows: (1) the population described in the literature consisted of HCWs, including doctors, nurses, and other medical personnel who were directly or indirectly involved in the diagnosis, treatment, or care of patients with confirmed or suspected cases of COVID-19; (2) the research topic was “posttraumatic growth” or “alternative posttraumatic growth” associated with the COVID-19 outbreak and pandemic; (3) the situation and influencing factors of PTG were discussed in the literature; and (4) the study types included qualitative, quantitative, and mixed methods studies.

Exclusion criteria were as follows: (1) participants were medical students in clinical placement; (2) the study type was an intervention study; (3) the literature types were research protocol, conference literature, case reports, reviews, official reports, book reviews, letters to the editor, editorials, and studies published in preprint servers but not in peer-reviewed journals; and (4) duplicate and unavailable full-text, non-Chinese and non-English literature.

Data extraction

The retrieved literature was imported into the NoteExpress software, and duplicates were checked. The title and abstract of citations were independently reviewed by two reviewers for the first screening level to identify articles that met the minimum inclusion criteria. A subsequent review of the full-text articles was conducted by two reviewers for the second screening level. Studies were excluded if they did not meet the eligibility criteria or were unrelated to the research question and purpose. Disagreements were discussed with a third researcher and resolved by consensus if there were any disagreements and uncertainties relating to study selection.

A form was developed to confirm the relevance and extract study characteristics from the included sources of evidence. Then, two reviewers independently charted the extracted data from each eligible article, and disagreements among reviewers were discussed. This process aimed to create a descriptive summary of the results, including aims, study design, nation, participants, tools/method, and main findings.

Evidence was combined qualitatively and descriptively after collecting the relevant data. The similarities and differences between the included studies, their relationship, situation, and risk factors of PTG were reported.

Data integration methodology

This study employed a rigorous data integration approach to systematically synthesize and compare the results obtained from quantitative and qualitative research. This integration process aimed to gain a comprehensive understanding of PTG among medical staff during the COVID-19 pandemic. The following steps were adopted: (1) Identification of Common Themes: A detailed analysis of quantitative studies was conducted to identify key themes and patterns related to the characteristics and influencing factors of PTG. Concurrently, qualitative studies were thoroughly reviewed, employing content analysis to extract detailed individual experiences and nuanced insights on PTG. (2) Comprehensive Comparison: A comprehensive comparison table was established, encompassing the key statistical outcomes from quantitative research and the main themes from qualitative research. This table visually highlighted the consistencies and differences between the quantitative and qualitative research in terms of PTG characteristics and influencing factors. (3) Synthesis of Research Findings: The common themes from both research methodologies were synthesized. This included combining trends from quantitative data with profound insights from qualitative data to reveal a more comprehensive picture of PTG. Additionally, a detailed comparison and discussion were conducted to understand the perspectives and experiences captured by each research method in terms of PTG features and influencing factors. (4) Verification of Integrated Results: To ensure the accuracy and reliability of the integration process, the synthesized results were subjected to rigorous review by multiple researchers.

Search results

The primary search discovered 325 papers, including 24 Chinese and 301 English articles. After removing duplicates, 133 papers were left. We selected 110 articles for full-text reading based on screening titles and abstracts. We excluded 74 articles due to unrelated topics (n = 13), ineligible study populations (n = 22), noncompliant study designs (n = 34), not in English or Chinese (n = 2), and unobtainable full texts (n = 3). Finally, our analysis included 36 studies. Figure  1 presents a flowchart of the search strategy and the selection process based on identified criteria.

figure 1

Flow diagram of screening of articles based on identified criteria

Characteristics of sources of evidence

Five of the 36 articles were in Chinese, with the remaining 31 in English. Three were published in 2020, 15 in 2021, and 18 in 2022 (one of the studies was online in 2022 and published in 2023). The study included18 articles from China, four from Turkey, three from the United States, three from Korea, one from other countries, such as Greece, Italy, Canada, Spain, Israel, Serbia, and Palestine, and one from a global study covering three countries (Israel, Canada, and France).

The study population included 17 papers on frontline medical staff (care for COVID-19-diagnosed patients), four papers on nurses diagnosed with COVID-19 infection, and 15 on medical workers. It involves the emergency department, intensive care unit, dentistry, psychiatric department, and outpatient department. The medical institutions involved hospitals designated to treat patients diagnosed with COVID-19, general hospitals, communities, clinics, and other hospitals. The PTG level was measured at one to three-time points in 23 cross-sectional and six longitudinal studies, primarily using online questionnaires. Six qualitative articles utilized semi-structured interviews and questionnaires via telephone, video, or face-to-face interviews. Scale and open-question surveys were used in one mixed mothed record. Table  1 represents the general characteristics of the included literature.

Synthesis of results

Quantitative results.

The level of posttraumatic growth

The Posttraumatic Growth Inventory (PTGI), a 21-item scale developed by Tedeschi and Calhoun [ 2 ] in 1996, measures PTG, including five dimensions: relationship with others, new possibilities, personal strength, spiritual change, and appreciation of life. It is scored on a 6-point Likert scale from 0 to 5, ranging from “not at all” to “very much.” Researchers in various regions have modified this scale based on cultural adaptation. Most Chinese studies used the revised version of the 20-item PTGI by Wang Ji [ 58 ], deleting item 18, “My religious beliefs are stronger,” due to its low correlation with the total score and local culture in China. It adopted the Likert 6-point scale with a score of 0–100. Six studies [ 28 , 32 , 36 , 37 , 43 , 44 ] used a 10-entry short version of the PTGI scale (PTGI-SF), adopting a Likert 6-point scale with a total score of 0 to 50 [ 59 ]. Tedeschi et al. [ 60 ] updated the list with four new items in the spiritual and existential change subscale to better capture spiritual and existential change in non-religious cultures, comprising PTGI-X with 25 items scored from 0 to 125 with a 6-point Likert scale. Two studies included in this review used it as a measurement [ 25 , 55 ]. PTG levels reached moderate and above with mean item scores of PTGI > 3 or total scores > 60 in two studies [ 24 , 38 ]. However, another study indicates that people who scored higher than the 60th percentile might have grown [ 37 ].

HCWs experienced varying PTG levels following direct or indirect trauma during the COVID-19 epidemic. A total of 28 studies in the included literature reported specific PTGI scores, with moderate PTG levels in general and high scores on the dimension of “relating to others”, “appreciation of life”, and “personal strength” more frequently mentioned. Table  2 presents the details.

The influencing factors of posttraumatic growth

COVID-19 could be categorized as a new type of mass trauma. Different types of trauma-related scenarios or characteristics may influence PTG levels. COVID-19-exposed HCWs, such as those working in intensive care units (ICUs) or frontline or sentinel hospitals where confirmed cases are treated, had higher PTG levels [ 23 , 29 , 37 , 45 , 51 ]. HCWs diagnosed with COVID-19 or have a family member, friend, or colleague who has been diagnosed had higher PTG levels [ 51 , 56 ].

The PTG levels of HCWs differed at different stages of the COVID-19 pandemic. A longitudinal study of frontline HCWs (n = 134) in China showed that Time 1 (Feb 2020) to Time 2 (Mar 2020) participants revealed an increase in PTG, while Time 3 (May 2020) participants indicated a decrease in PTG [ 42 ]. Another three-wave longitudinal study (n = 565) from China discovered that PTG gradually increased over two years of follow-up among HCWs, and four types of PTG trajectory were identified: persistent, steady increase, high with a drop, and fluid trajectory [ 22 ]. However, one study (two-point survey) from Turkey indicated that PTGI scores decreased significantly over time among 66 HCWs participated in the study [ 24 ]. Another two-wave survey from the U.S. radiology staff revealed a consistent trend toward lower PTGI [ 23 ].

The severity of the traumatic event and PTG in HCWs may have a positive or negative correlation. Researchers have also discovered that PTG was negatively correlated with trauma [ 28 ] and PTSD symptoms [ 47 ]. Another study indicated that PTG was positively correlated with PTSD [ 36 ].

Demographic characteristics

Gender, age, work years, job title, education level, marital status, child status, religion, and race may be associated with PTG. Most studies discovered higher PTG levels among HCWs with older age [ 22 , 23 ], longer working years [ 33 , 38 ], higher job titles [ 51 ], and higher education levels [ 22 , 51 ]. However, some studies revealed that PTG was negatively correlated with age [ 25 , 34 ] and professional title [ 47 ]. Not coincidentally, gender differences were also observed across studies. A survey of 455 nurses from China indicated that women had lower PTGI scores than men [ 29 ]. A survey of 673 HCWs from Greece showed that women scored higher on all VPTG subscales [ 34 ]. However, another large (n = 12,596) study from China demonstrated a greater trauma response in women than in men but no difference in PTG [ 37 ]. Similarly, a study from Serbia produced consistent results [ 56 ].

Additionally, HCWs with religious beliefs [ 32 , 33 ], married [ 29 ], with children [ 39 ], and working part-time [ 32 ] had higher PTG levels. PTG levels differed between physicians and nurse assistants [ 43 ], and whether they were white [ 36 ] or born locally also differed from PTG levels [ 33 ]. Disaster training, rescue, critical patient resuscitation, and infectious disease treatment experience contribute to a higher PTG level [ 51 ].

Psychological factors or personal traits

Positive emotions or psychology or personal traits can promote PTG, such as resilience [ 22 , 26 , 33 , 42 ], occupational resilience [ 50 ], occupational identity [ 45 ], self-efficacy [ 47 ], deliberate rumination [ 30 , 38 , 55 ], subjective well-being [ 28 ], coherence [ 28 ], harmonious passion [ 43 ], frontline job confidence [ 38 ], risk awareness [ 38 ], transformative power of pain [ 31 ], trust, reciprocity, and identification [ 41 ], being psychological comfort [ 39 ], and positive emotions and dispositional gratitude [ 36 ], as mentioned in most studies.

Negative emotions or psychological or personal traits can inhibit the PTG onset; examples include COVID-19-related stress/anxiety/concern [ 28 ] and job burnout [ 28 , 42 ]. However, similar to trauma, the stress/anxiety/concern associated with COVID-19 has also revealed a double-edged sword effect on PTG. For instance, research from China exhibited that higher COVID-19-related worries and psychological distress meant a higher PTG level [ 32 ]. Studies from other regions have demonstrated the same effect [ 43 , 44 ]. An increased stress mindset, determining the stress response, is associated with higher PTG levels [ 25 ].

Coping and social support

A positive coping style can contribute to PTG, including conducting psychological interventions/training, engaging in online counseling, and phone app of application self-relaxation [ 25 , 29 , 38 , 47 , 56 ].

A positive association has been demonstrated between PTG and social support, including support from organizations [ 26 , 50 ], societies [ 30 , 45 , 47 , 53 ], families [ 39 , 52 ], and friends [ 39 ]. Additionally, good working relationships, such as nurse-patient satisfaction [ 51 ] and job satisfaction [ 32 ], can promote PTG in HCWs.

Seven studies explored the path analysis of the PTG influencing factors and discovered the mediating and moderating factors under their respective theoretical models, such as organizational support [ 50 ], social support [ 30 , 57 ], coping strategies [ 25 , 34 ], resilience [ 53 ], psychological security [ 41 ], expressive suppression [ 53 ], deliberate rumination [ 30 ], emotional exhaustion [ 42 ], self-disclosure [ 30 ], and positive psychological capital [ 57 ].

Qualitative results

Six qualitative studies [ 27 , 35 , 40 , 46 , 48 , 54 ] described the specific experiences of HCWs when confronted with or diagnosed with COVID-19 through three periods of stress/negativity, adjustment to adaptation, and growth, presenting PTG occurrence. The qualitative part of another mixed study [ 49 ] identified three themes: quality of workplace relationships, sense of emotional-relational competence, and clinical-technical competence. Each theme has two broad macro categories: growth and block.

Change in relationships with others

Six of the Seven studies contributed to this theme. Improved interpersonal relationships include with family, friends, colleagues, and patients. Family, friends, and colleagues’ warm love and support bring their relationship closer and more intimate. A nurse diagnosed with COVID-19 remarked, “My boyfriend cared for me, encouraged me, and gave me strength after I got sick; I will cherish the relationship between us” [ 54 ]. “When I saw my son at the gate of the community after I came back from isolation, I burst into tears and held him tightly in my arms” [ 27 ]. As healthcare worker spends more time with a patient, their empathy and compassion for the patient gradually intensifies. Like comrades who fought back the “enemy” (COVID-19), both sides cheered and encouraged each other to overcome difficulties and diseases, improving the relationship between doctors and patients. One nurse said, “When the test result returned negative for the first time after being admitted, I was so happy and cried together with the patients” [ 48 ]. Additionally, the experience of being a patient after a COVID-19 diagnosis also influences how HCWs treat patients, and role reversal and empathy improve the relationship with patients to some extent [ 27 , 54 ]. During this particular time, colleagues’ help, care, and encouragement in caring for infected patients promote teamwork and interpersonal relationships [ 27 , 35 , 48 , 49 , 54 ].

Increase in individual strength

This resulted in a shift in participants’ mental and professional perceptions of themselves. At a psychological level, HCWs reported that the experience had made them more courageous, strong, and optimistic. “I think I am a little more brave and strong than I thought I would be” [ 54 ]. In the face of difficulties or trauma, resilience allows individuals to make positive choices and respond rationally to stress. This facilitates guiding individuals to reconstruct non-adaptive states and activate their potential to resist crises to resolve difficulties. Most HCWs described their experiences exploring and reconfiguring their strengths [ 27 ].

At the professional level, HCWs had a positive attitude toward gaining work experience related to a new infectious disease [ 48 , 49 ]. They viewed their current experience as a valuable opportunity to learn new skills and enhance their work, gradually moving from unfamiliarity at the beginning to completing the work previously given to the nurse aides and being able to quickly shift and focus on enhancing the quality of care and improving patient well-being. This adds significance to their experience [ 48 ].

Changes in the philosophy of life and priorities

Four of the seven studies contributed to this theme. Interviewees mentioned a new appreciation of life and the future after experiencing trauma. They will re-examine life’s meaning and re-plan their future priorities, such as“I felt the need to live more meaningfully as the disease gave me another chance to live. I became more attached to life and realized how valuable it is …” [ 40 ].

Most life priorities change are reflected in the increased priority given to physical health. “Nothing is better than a healthy life, and nothing is as important as health” [ 27 ]. “… I realized that health is more important than anything else. Thus, I decided to stop worrying about some things, stop overthinking, and stop to give importance. I realized that health is the most important thing” [ 40 ]. Moreover, it is reflected in other meaningful and fun things, such as “I will get better for myself and my family. I will spend more time with them, cherish every day, and enjoy the fun of life. I still have many important tasks to complete” [ 27 ].

Self-identification of profession

Participants in four studies described greater vocational identity. Most participants expressed satisfaction and pride that they were making a concrete contribution to the fight against the global pandemic. Their pride was further enhanced with increased social recognition of HCWs caring for COVID-19 patients. All of these enhanced their professional identity. “The work that I am doing is truly helping others. I am contributing during this national disaster situation. I am here at this historical moment…” [ 48 ], “I am proud to be a nurse and to have assisted on the front lines” [ 35 ], and “I think every HCW is a hero” [ 54 ]. As child and adolescent psychiatrists, they have experienced a successful transition from “who we are” and “what we can do now” to “who we will become” during the pandemic and then engendered a reevaluation of and a recommitment to psychiatry [ 46 ].

Spiritual change

One research reported a change in spirituality [ 40 ]. After being diagnosed with COVID-19, the nurses questioned their spiritual lives and changed. “Inevitably, death anxiety enters your mind, and you question yourself. I realized how spiritually weak I was and made a promise to myself. I would pay more attention to my prayers after the treatment … I was angry with myself as I was living in this way….” “Thus, I realized that everything was in vain; the only real thing is after death. … I started to question my mistakes and sins and plan to get rid of them … I turned to God more.” Many of them rely on religious beliefs to manage stress.

Integration of quantitative and qualitative research

To provide a clearer understanding of the consistency and divergence between quantitative and qualitative studies in the PTG of HCWs, we have established Table  3 to compare the associations of these two research methods regarding PTG characteristics and influencing factors.

Through the comparison presented in the table, we observe a notable coherence and complementarity in understanding the characteristics and influencing factors of PTG among HCWs during the COVID-19 pandemic. In terms of PTG characteristics, the themes distilled from qualitative studies correspond closely with the five dimensions measured in quantitative PTG scales. This alignment elucidates the specific contexts and manifestations of these dimensions, providing a clearer and more comprehensive understanding of what PTG looks like for HCWs in the context of the pandemic. Regarding influencing factors, there is a synergistic relationship between the themes identified in qualitative research and the factors statistically derived from quantitative studies. For instance, qualitative themes such as “Work-related stressors” and “Psychological stress and emotional reactions” offer a vivid explanation of HCWs’ early responses to the “Trauma” of the COVID-19 pandemic. Additionally, qualitative findings explicate how internal and external factors foster PTG, detailing the process of its formation. This consistency and complementarity between qualitative and quantitative approaches highlight the importance and value of employing a combined methodological perspective for a holistic understanding of PTG.

This literature review aimed to provide insight into the existing evidence base of what PTG looks like in HCWs and internal and external factors that may contribute to and hinder this phenomenon.

Summary of findings

Thirty-six papers from 12 countries met the inclusion criteria. In the context of the COVID-19 pandemic, HCWs faced tremendous stress and strain, generating associated mental health problems. They were also stimulated to adapt and adjust, generating PTG; the most notable included “interpersonal relationships,” “changes in life philosophy,” and “growth in personal power”. The factors influencing PTG were the level of trauma exposure, sociodemographics, and the psychological traits of the traumatized individual, such as psychological resilience, positive psychological qualities, and coping and social support.

Integrated discussion

Our study reveals the alignment and complementarity between qualitative and quantitative research. The integration of these methodologies not only enriches our understanding of PTG’s features but also enhances our grasp of its complexity. The themes identified in qualitative research correspond to the dimensions of the PTGI used in quantitative studies, elucidating the specific contexts and manifestations of these dimensions within the healthcare environment. For example, the growth in the personal strength dimension of PTGI, when reflected in the workplace, manifests as enhanced skills, increased confidence, professional identity, and a sense of accomplishment [ 46 , 48 , 54 ]. Moreover, the detailed backgrounds and descriptions provided by qualitative research help explain how factors identified in quantitative studies facilitate PTG. For instance, quantitative data may show a correlation between social support and increased PTG, but qualitative insights explain the mechanisms and reasons behind these relationships [ 27 , 48 , 54 ].

Qualitative research, with its intricate depiction of the phenomenon, addresses the limitations of quantitative research, enriching our understanding across various dimensions. This profound understanding aids in a more nuanced grasp of the essence and complexity of posttraumatic growth. Ultimately, this integrative approach not only broadens our comprehension of PTG but also underscores the value of combining qualitative and quantitative methods in mental health research. It provides a blueprint for future studies, demonstrating the importance of methodological diversity for a comprehensive understanding of complex psychological phenomena.

What does posttraumatic growth look like?

The variation in cultural backgrounds, measurement instruments, dimensions, and the reliability and validity of PTG assessments made it difficult to compare specific values across studies. Discrepancies in PTG levels might also be attributed to differences in survey time frames, health service contexts, pandemic control measures, and individuals’ subjective appraisals of COVID-19-related stressors. The criteria for classifying different PTG levels varied across studies. Several studies [ 24 , 37 , 38 ] used total scores > 60, single entry scores > 3, or ≥ 60% of the total scores as an intermediate or higher level of PTG, while others did not report delineation criteria. Overall, a medium level of PTG was observed. The COVID-19 pandemic has imposed enormous stress on HCWs, leading to mental health problems. Nevertheless, they adapt and adjust, ultimately yielding positive behaviors and experiences. The pandemic prompted the most profound changes in “human relationships,” “philosophy of life,” and “personal strength,” consistent with the qualitative studies review.

After experiencing an initial period of negative emotions in response to acute stress, individuals mobilize internal and external resources to manage the effects of trauma. Internal resources, such as mental toughness, intentional reflection, and resilience, with external resources like organizational, familial, and societal support, contribute to the positive outcome known as growth [ 61 ]. During this process, support from others facilitates adaptation and adjustment while manifesting in growth expressions, enhancing relationships, and creating reciprocal influence. After the trauma, individuals develop a positive and transcendent view of themselves and a new philosophy of life, appreciating various aspects, including health, existence, subtle experiences, and relationships.

What affects posttraumatic growth?

The COVID-19 pandemic, as a traumatic event, has disrupted the assumptive world of HCWs, leading to their dysregulated cognitions and emotions. However, according to the model of “Posttraumatic Growth at Work” [ 52 ], they may achieve PTG via a recursive cycle of emotion regulation and sensemaking.

First, individuals with high trauma levels of exposure may exhibit severe PTSD symptoms, but higher trauma levels of exposure do not necessarily imply higher growth levels. There is no PTG without trauma for individuals. However, mild trauma may be insufficient to stimulate growth, and severe trauma may be more detrimental than beneficial to growth [ 62 ]. Thus, only moderate trauma exposure may trigger individual PTG and provide room for growth, demonstrating a positive correlation. For instance, a study discovered a linear and curvilinear relationship between trauma and posttraumatic development, and moderate indirect trauma was associated with the highest PTG levels [ 63 ]. A network analysis of war-related PTG revealed a U-shaped relationship between posttraumatic stress symptoms (PTSS) and PTG levels [ 9 ]. Additional studies supported these findings. The work experience of inpatient psychiatric nurses was associated with higher PTSD levels and secondary trauma. However, their growth was significantly slower compared to community nurses, which were thought to be associated with higher and continuous exposure to trauma and fewer opportunities to take breaks to reflect on it [ 64 ].

Second, although traumatic events are transient, their effects are continuous and dynamic, and post-traumatic stress and growth levels can change over time. For instance, a longitudinal study of tsunami survivors discovered that PTG could moderate the relationship between posttraumatic stress, depression, and quality of life after natural disasters [ 65 ]. Another tracking survey of earthquake survivors revealed that growth could reduce long-term PTSS [ 66 ]. Survivors may undergo self-adjustment and receive external support or intervention during the post-trauma period, which can accumulate over time and lead to different levels of trauma and growth. Their relationship remains uncertain due to the complex symbiotic relationship between trauma and growth and the many factors involved [ 67 , 68 ].

Although there are differences in the relationship between age, years of work, job title, education level, marital status, parental status, whether they were born in the local area, and PTG, they all share common factors that influence their growth. HCWs with more internal and external coping resources and a greater ability to cope with trauma exhibit higher PTG levels. Higher age, higher job title, higher years of work experience, and higher education level mean more internal resources, such as work experience and life experience, allowing them to use their clinical skills, integrate external resources through reflection, and then adopt a positive coping approach when faced with an unexpected pandemic. However, some studies also proved a negative correlation between age and growth [ 25 , 34 ]. It might result from young people’s greater willingness to change their cognitive patterns and derive positive meaning from trauma, consistent with previous research on age differences in PTG [ 69 ]. Being married and having children may provide more emotional and material support resources from the family system, leading to higher PTG levels. According to other studies, the relationship between gender and PTG differs between studies [ 29 , 34 , 37 ], possibly due to the influence of other factors, such as the gender interaction with pandemic duration and individual quarantine [ 70 ].

HCWs who have received disaster training, rescue experience, critical patient resuscitation experience, and infectious disease treatment experience exhibit greater composure when faced with COVID-19. They can utilize their professional skills effectively to provide better care for critically ill patients and even lead other HCWs to do the same. This strengthens their sense of professional identity and honor and is associated with higher PTG levels [ 51 ].

Additionally, religiously engaged healthcare professionals have been shown to effectively use their faith and spirituality to cope with adversity during disasters. Religious beliefs can provide a framework to positively view threatening situations, facilitating a sense of challenge and growth through suffering [ 71 ]. Previous research has also highlighted the social support function of religious involvement [ 72 ]. Part-time nurses have higher PTG levels than full-time nurses [ 32 ]. This could be due to the extra time part-time employees must devote to their nursing duties and stressful experiences, potentially contributing to PTG.

Demographic characteristics may be associated with an individual’s emotional regulation and psychological resources in response to traumatic events. When designing interventions, the influence of these sociodemographic characteristics on PTG should be considered. Understanding these features carries significant practical implications for promoting PTG.

Regarding the temporal course of post-traumatic experiences, it has been suggested that intrusive rumination in the early stages of trauma can exacerbate psychological distress, elicit negative emotions and outcomes, and hinder PTG. However, as time progresses, an individual’s positive psychological resources, such as positive worldviews (hope, tolerance, psychological resilience, optimism, self-esteem, wisdom, and spirituality), positive emotions (happiness, gratitude, and satisfaction), and positive attitudes towards society (social cohesion, altruistic behavior, social responsibility, and benevolence), can aid in overcoming negative emotions and enhancing coping abilities [ 73 ]. Intrusive rumination may give way to active reprocessing and constructive thinking about the traumatic event under the influence of positive self-adjustment and social support. Moreover, negative reviews in the early stages of trauma can provide material for subsequent positive processing, enabling individuals to discover the positive meaning of the traumatic experience, ultimately promoting growth.

Psychological resilience, also known as resilience, refers to the ability to adapt or recover from highly adverse circumstances. It is a source of strength that enables individuals to remain well-adjusted, develop, and grow, and a key factor influencing whether they can overcome difficulties and adversity. However, the relationship between resilience and PTG remains controversial. Previous studies have suggested that their relationship may be positive [ 74 ], curvilinear [ 75 ], or insignificant [ 76 ], and further investigation is needed to explore the mediating and moderating factors involved. Considering the dynamic nature of resilience and PTG over time, Lyu [ 42 ] explored their trends and relationships throughout the traumatic event and discovered that individuals continue to grow in a virtuous cycle after trauma. PTG promotes psychological resilience, and PTG promotes psychological resilience. Over time, these two factors positively influence each other, contributing to the individual’s continued positive functioning during and after the adverse experience.

Psychological resilience and positive psychological qualities can assist HCWs in better emotion regulation and sensemaking, thereby promoting PTG. This finding is consistent with the model of “Posttraumatic Growth at Work” [ 77 ], confirming the importance of these individual characteristics for PTG. Therefore, enhancing psychological resilience and positive psychological qualities in medical staff can improve their growth potential in the face of traumatic events.

Effective coping styles and strong social support are vital in facilitating PTG. Positive and effective coping strategies help individuals face challenges and mobilize resources from others and society to solve problems. Psychological interventions or training during or before frontline work can help HCWs maintain positive emotions, reduce attentional bias towards negative emotions, and facilitate their regulation and release, enabling them to perform their high-intensity work in a good psychological state. These interventions or training may also stimulate HCWs’ sense of mission and professional responsibility, generate positive psychological experiences, and promote growth in their front-line work [ 38 ]. Excessive attention to negative external information can trigger negative emotions, but shifting attention appropriately can help traumatized individuals detach from distress and gain new insights to reexamine and confront traumatic events. Self-motivation can enhance an individual’s self-confidence and facilitate positive psychological adjustment, prompting the traumatized person to adopt positive behaviors, solve problems, and grow. Choosing a suitable relaxation method, such as online counseling or a self-relaxation mobile app, can also help to cope effectively with pandemic stress [ 29 ].

Social support refers to the material and emotional assistance individuals receive from their social networks, including family, friends, and other socially connected individuals. Individuals can process traumatic events in a supportive environment by disclosing their internal processes to others, particularly when focusing on cognitive and emotional factors. The degree to which individuals perceive their social environment as encouraging or inhibiting plays a crucial role in the PTG process. Adequate protective materials can help HCWs better protect themselves and increase their confidence in their work, while care and support from family, friends, colleagues, and social organizations can alleviate stress and anxiety during the COVID-19 pandemic [ 26 , 30 , 39 , 45 , 47 , 52 , 53 ]. Good social support provides HCWs with external resources and emotional support, creating a safe atmosphere for self-expression, understanding, and acceptance [ 30 ].

Effective coping strategies and robust social support significantly impact PTG, aligning with the emphasis on social support, occupational backing, and attentive companionship in the “Posttraumatic Growth at Work” model [ 77 ]. This support can assist HCWs in modulating their emotions and provide a safe environment for sensemaking, thereby facilitating PTG. It is crucial to strengthen the training of coping abilities for medical staff and elevate social support during intervention measures.

Limitations and directions for future research

This study has several limitations that should be acknowledged. First, it only provided a descriptive analysis of the included literature and did not rigorously evaluate the studies’ quality. Second, the review focused exclusively on “posttraumatic growth” or “alternative posttraumatic growth,” omitting relevant topics such as positive posttraumatic experiences and perceived benefits. Third, only 28 of the 36 papers provided specific PTGI scores, and the data could not be integrated due to variations in PTGI versions, classification criteria, and result presentation. Additionally, most studies were cross-sectional, precluding the establishment of causal relationships. Some studies on risk factors did not control for confounding variables (work hours, COVID-19 exposure intensity, cultural background, and government policies), potentially affecting the results.

Our study’s findings point to several critical directions for future research to enhance the understanding of PTG among HCWs. Firstly, there is an urgent need for additional longitudinal studies to delve deeper into the dynamics and formation mechanisms of PTG. Such studies are essential for providing a more comprehensive understanding of how PTG evolves. Secondly, considering the global scope of the pandemic, it is crucial to understand PTG within various cultural contexts. Cultural differences in emotional experiences and expressions can significantly influence the process and potential of PTG. Therefore, future research should incorporate a cultural perspective, exploring how cultural factors impact the development and experience of PTG among healthcare professionals. This approach will not only enrich our understanding of PTG in diverse settings but also guide culturally sensitive support and intervention strategies. Lastly, future studies should focus on assessing various interventions’ efficacy to determine best practices for supporting HCWs’ psychological well-being and growth. This includes exploring how different types of support systems, both professional and societal, can facilitate PTG. The development and validation of these interventions will provide critical guidance for healthcare settings and policymakers in creating robust mechanisms to support HCWs during and after traumatic events.

Implications for practice and policy

The psychological health and PTG of medical staff are long-term concerns. To enhance the psychological resilience and PTG levels in medical staff, practice and policy should focus on the following aspects:

In terms of practical implications, we underscore the necessity of enhancing support systems tailored to the specific needs of HCWs. This involves developing interventions that address the key factors influencing PTG, such as trauma exposure and coping strategies. Such support systems could encompass resilience training programs, mental health workshops, and peer support initiatives, all designed to fortify the psychological resilience of healthcare staff. Additionally, there is a need for personalized interventions that take into account the individual psychological traits and sociodemographic factors of HCWs, thereby fostering PTG in a manner that resonates with their unique experiences and backgrounds. Furthermore, it is important to update the existing crisis response protocols to integrate measures for psychological well-being. This would ensure that HCWs’ mental health is a primary consideration during pandemics, aligning crisis responses with the psychological needs and challenges faced by these essential personnel.

Regarding policy implications, our study highlights the critical need for strategic resource allocation to enhance mental health services and support systems in healthcare settings. This is particularly crucial during public health emergencies, such as the COVID-19 pandemic, where the mental health demands of HCWs are significantly heightened. Adequate resource allocation should include not only immediate support but also long-term mental health services to address the ongoing needs of healthcare professionals. Recognizing the lasting impact of pandemic experiences on HCWs, it is imperative to develop comprehensive long-term mental health strategies. These strategies should encompass continuous support, regular mental health assessments, and adaptive interventions, ensuring that the evolving mental health needs of HCWs are met effectively. Such policies would not only provide immediate relief during crises but also contribute to the sustainable well-being and resilience of healthcare professionals in the long run.

This scoping review revealed that medical staff experienced moderate PTG during the COVID-19 pandemic, with notable improvements in interpersonal relationships, life philosophy, and personal competence. Key influencing factors included trauma exposure, sociodemographics, psychological traits, coping, and social support. The findings highlight the importance of addressing HCWs’ psychological well-being and resilience during and after pandemics. Further research is required to explore PTG in diverse cultural contexts, investigate the dynamic nature of PTG, and evaluate the effectiveness of targeted interventions for HCWs.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

  • Posttraumatic growth

Vicarious posttraumatic growth

Posttraumatic Growth Inventory

Short version of the posttraumatic growth inventory

Expanded posttraumatic growth inventory

Coronavirus disease 2019

World Health Organization

Healthcare workers

Preferred reporting items for systematic reviews and meta‑analyses extension for scoping reviews

Posttraumatic stress disorder

Posttraumatic stress symptoms

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We thank the Home for Researchers editorial team ( www.home-for-researchers.com ) for the language editing service.

This work was supported by the General Research Project of Zhejiang Provincial Department of Education(Y202043349).

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Qian Li, Yirong Zhu, Xuefeng Qi, Haifei Lu, Nafei Han, Yan Xiang, Jingjing Guo & Lizhu Wang

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Q.L. and L.W. are involved in the study conceptualization and design. Q.L. and X.Q. were involved in the search, acquisition, and management of peer-reviewed and grey literature records. Y.X., N.H., and J.G. were involved in the literature screening process. Q.L., H.L., and Y.Z. were involved in data extraction and interpretation. Q.L. prepared the initial draft of the manuscript. All authors were involved in the review and substantial revisions of the manuscript draft. All authors read and approved the final manuscript.

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Li, Q., Zhu, Y., Qi, X. et al. Posttraumatic growth of medical staff during COVID-19 pandemic: A scoping review. BMC Public Health 24 , 460 (2024). https://doi.org/10.1186/s12889-023-17591-7

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DOI : https://doi.org/10.1186/s12889-023-17591-7

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