“Resilience” – is this the new black in psychiatric health care and prevention?

Thousands of children have watched the Disney cartoons in which the main character mourns the loss of a loving and caring parent. A perilous and difficult time lies ahead during which the main character almost succumbs, but then meets friends and succeeds in the formation of healthy and enduring relationships. This is the turning point. In the end, the main character grows up to become a strong adult with a bright future. It is hardly conscious, but Disney has produced several movies that confirm an emerging realization in the research regarding resilience: a strong correlation exists between the relationships we have with our parents (or, in some cases, “significant others”) and how resilient we become to deal with life’s injustices later in life. In a review and concept analysis, resilience was defined as “the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and ‘bouncing back’ in the face of adversity” (1). It has further been suggested that adversity in itself is a vital part of developing a resilient mindset (2,3). Bell-Tolliver and colleagues (4) state that the “capacity to rebound from adversity, misfortune, trauma or other transitional crises” results in children who are “strengthened and more resourceful.” Altogether, this indicates that research may have focused too much on risk factors, and putting increased focus on potential protective factors may help identify the factors responsible for the appearance and facilitation of resilience.

This may prove to be one of the more important points of the literature to consider;life does not have to be without adversity to turn out well.

However, resilience has played a less significant supporting role in psychiatric treatment strategies up until now, which may at least partly be due to difficulties in the process of defining and conceptualizing. Hence, resilience as a concept has also been subjected to criticism (5). To mention one problem, there is overlap between resilience and related psychosocial concepts, which suggests a need for improved uniformity in terminology (6,7).

It was previously believed that some children had a particular aptitude for overcoming adversity, leaving little or no room to work with the concept for clinical purposes. However, when reviewing the literature, Rutter (8) found that no combination and no severity of risk factors seems to cause negative developmental trajectories in more than half of children. Nevertheless, reviewing theories on resilience, Fletcher and Sarkar found most definitions to be based on two key concepts: adversity and positive adaptation (9). Hence, what lies ahead is exploring the potential key factors of the ability for positive adaptation.

Turning back to this question of what may be the determinant of the ability to adapt to adversity and continue a positive developmental trajectory, we may find inspiration from existing research such as from Emery and Forehand. They state that individual characteristics in a child areunlikelyto develop without a relationship with at least one adult in which they feel worthy and loveable (10). Inspired by this, Nicola Atwoll has conducted a narrative review asking the question of whether it is time to view attachment theory and theory on resilience as complementary rather than in parallel (11).

Important key features in attachment behavior include proximity seeking behavior and the use of the primary caregivers as a secure base from which the world can be explored. The securely attached child will rest assured in the parents to provide a safe haven for them to return to in need, whereas the insecurely attached child will have more negative expectations.

More clinical and epidemiological research exploring the processes underlying resilience is needed if the concept is to be included effectively in clinical settings and in the development of preventive measures. However, findings suggest that in the near future we may be able to asses some key factors in resilient development (12).

What you give to a child you can expect to come back tenfold–for better and for worse. This does not apply only to the typically developing child but also to children with innate vulnerabilities. Hence, future treatment strategies should include factors other than the somewhat narrow symptom-based approach we have had for many years. Resilience research may signify a change in perspective and a time to broaden our focus in child psychiatric treatment strategies.