Using the search functions of online scholarly libraries, I found over 300 reports in the past several decades over trauma or PTSD, trauma-related treatments, and resilience. My first task was to discard the unscientific reports.1 When completed, I was left with just over 50 studies.
Perhaps the most harmful failure of the modern psychologist interested in trauma is his neglect to account for (or even be aware of) a common trait in people known as “resilience”.
History, Criticisms, & Early Evidence of Resilience
The arbitrary measurement of PTSD symptoms was the first failure of the psychologist, but it turned out to be a fortuitous failure. The “severity” of the symptoms determine if someone has a mild case or a “chronic” case of PTSD. While there were no conceptual justifications for how the psychologist determines the line between PTSD and chronic PTSD, different traits exist from one side of the line to the other. That trait is “resilience”.
The majority of people will have a natural immunity to chronic levels of PTSD. They can succumb to some PTSD symptoms, but not chronic levels. These people are referred to as the resilient. This should not be surprising as all people follow different recovery trajectories after traumatic events, but as we will soon see, there exists categorically different behavior and resilience across two broad groups.
The empirical evidence in support of the theory of resilience spans across multiple domains (variables) in individuals and resilience has been found across every metric used to measure PTSD — sleep cycles, depression, anxiety, social activity, academic performance, etc.
Bonano reviewed trauma and resilience research in 2004.1 It is obvious from his comprehensive review that prior to, and throughout the 80s, the effectiveness of therapies for trauma were not supported empirically. There even appears to be a large category of individuals that either did not benefit from trauma counseling, or even regressed from it. Much of this was summarized by several researchers 2 who compiled and reviewed research on resilience in 2000; yet major psychology journals ignored the findings. In fact, individual variations in response to adversity have been catalogued and studied since the 1970s. The further back in time, the less cognizant researchers were that the resilient category existed. They viewed healthy, competent individuals that had faced adversity as exceptions to the rule.
Even some schizophrenics were shown to exhibit resiliency,3 as well as children of schizophrenic parents.4 The concept of resilience, or healthy natural trajectories, was soon observed within socioeconomic disadvantages,5 parental mental illness,6 maltreatment,7 urban poverty and community violence,8 chronic illness,9 and catastrophic life events.10
Eventually, research distinguished between protective forces that differentiated children from natural healthy adaptations in children. That is, resilience born from external factors and resilience born of personality. There appeared to be several factors attributing to resilience: (1) personality traits of the children, (2) their families, and (3) their wider social environments.11 At least two decades later, empirical research shifted away from the protective factors to protective processes; or from what things cause resilience to how those things develop.12 It became obvious that positive adaption (resilience) involves a developmental progression. The dynamic nature of resilience works in both ways, such that vulnerabilities can emerge with changing life circumstances; and new strengths can develop as well.13 While some people are naturally resilient, people may also be resilient due to external factors. It also seemed possible that even adults could become more resilient due to this dynamic nature.
Some criticisms focused on the inter-domain strangeness of resiliency, because it appears to be complex, multidimensionally. In other words, across one domain (say, social development) and another domain (say, academic development) a child may display more resilience in one domain than the other. As an example, among children with histories of maltreatment, about 66% were academically resilient while only 21% manifested social competence.14 The ultimate issue with this criticism is that the variability across adjustment domains are not observed across theoretically similar adjustment domains. After all, variable differentiation across domains is common 15 in most fields of science. In other words, if the variables are not tangibly similar, then variability is likely. This pre-1998 issue appears to be that researchers were working with too broad of categories, rather than working with more specialized variables (domains).
Researchers began to study more specific metrics of resilience. Across a period of over 30 years, most resilient children maintained high functioning in everyday life; and for those that weren’t classified as resilient but still recovered, they possessed protective “buffers” such as a caring adult,16 an example of a process of resilience, rather than ego-resilience (an inherent quality a person does or does not have).
Many independent studies have either deliberately or unwittingly confirmed further evidence of resilience, yet criticisms never waned. Bonano dispels many of those criticisms in 2004. 1
despite the near unanimity with which mental health professionals endorsed the grief work perspective, there was a surprising lack of empirical support for such a view.[17] What’s more, recent studies that have directly examined the legitimacy of the grief work approach have not only failed to support this approach but actually suggest that it may be harmful for many bereaved individuals to engage in such practices.[18] A more plausible alternative would be that grief work processes are appropriate for only a subset of bereaved individuals,[19] most likely those actively struggling with the most severe levels of grief and distress.[20]
It also became apparent that not only were the more clinical methods of treatment failing due to large-scale ignorance, but methods intended to treat large groups were also experiencing ineffectiveness:1
Critical incident stress debriefing was originally developed for relatively limited use as a brief group intervention to help mitigate psychological distress among emergency response personnel.[21] Over time, however, debriefing has been applied individually and broadly[22] and sometimes, as after the recent September 11th terrorist attacks on the World Trade Center,[23] as a blanket intervention for virtually all exposed individuals. Critics of psychological debriefing argue, however, that such a broad application may pathologize normal reactions to adversity and thus may undermine natural resilience processes. Indeed, growing evidence shows that global applications of psychological debriefing are ineffective[24] and can impede natural recovery processes.[25|26]
Data has clearly shown the ineffectiveness of trauma therapy for all but those exhibiting recovering trajectories already, or chronic symptom trajectories.
An alarming 38% of the individuals receiving trauma therapies actually regressed relative to non-treated controls; whereas, clear benefits were associated only with the chronic trajectories.27 It appears that people experiencing a normal bereavement (the resilient) are best left alone, but for that to occur, they need to be distinguished from the non-resilient.
Thus, the crucial task of the psychologist is to first distinguish between the resilient from the non-resilient. The former — which outnumbers the non-resilient — either does not benefit from treatment or even regresses from treatment.
It was a common error of psychologists in the '90s to group recovering individuals with resilient individuals, and failing to distinguish between the two.28|29 Resilient individuals could be mistakenly categorized as recovered if they had experienced trauma and subsequent therapy, which would alter the true ratio of how many individuals benefited from treatment from those of whom followed naturally healthy trajectories. For these researchers, if a patient regressed (the other ~half of the resilient), researchers assumed their treatments needed to be honed rather than not applied to begin with. It did not occur to them that the treatment itself was causing the harm in those cases. The research did indeed shift more toward theories of resilience, but some practitioners refused to believe in the evidence. Two authors from one of the most prominent psychology journals in the nation 30 baselessly denied the statistical and empirical significance of resilience and treatment ineffectiveness as recent as 2007.
Decades ago, western society considered the genuinely traumatized to be malingerers. As is often the case with societal issues, the solutions overcompensated the issue – the pendulum swung too far to the other extreme. Now, many practitioners believe that all individuals that encounter trauma would benefit from treatment.
As a specific example of more recent failures of treatment, repressors (those less willing to share their traumatic experiences) showed better adjustment than other survivors from a sample of young women with documented histories of sexual abuse.31 Once more, it seems that the majority of people are resilient to some degree and follow naturally healthy trajectories after encountering traumatic events. A critical question emerges: what proportion of people are resilient (cannot succumb to chronic PTSD)?
Only 5-10% of people develop chronic PTSD after experiencing some traumatic event in the US.32 There does tend to be great variability across types and levels of exposure to stressor events, which corresponds to variability in PTSD rates.
Only 6.6-9.9% of individuals exposed to events during the 1992 Los Angeles riots developed chronic PTSD 33
12.5% of Gulf War veterans developed chronic PTSD 34
16.5% of hospitalized survivors of vehicle accidents developed chronic PTSD 35
17.8% of physical assault victims developed chronic PTSD 36
In other words, 5—18% of people are not resilient and likely benefit from treatment. The remaining 82—95% of people are resilient and either do not benefit or will regress from treatment. Clearly, chronic PTSD is uncommon.
Of the resilient, some are more resilient than others:
The vast majority of cases (78.2%) exposed to the Los Angeles riots suffered from 3 or fewer PTSD symptoms 37
The motor vehicle accident cases that did not meet criteria for PTSD were 79% and averaged 3.3 PTSD symptoms 38
The Gulf War veterans had a 62.5% majority of no psychological distress when examined within 1 year of returning to the US 39
40% of Manhattan residents did not report a single PTSD symptom in a post-9/11 survey 40
Some groups 41|42 have even conducted (admittedly limited sample sizes) research on positive emotions such as interests and love, and how such things can act as a buffer for individuals against the depression that trauma can cause. The study focused on positive emotions that were already prevalent in the subjects; it's important to note that treatment was not implemented, and was not the cause for healthy recovery trajectories.
Over 50 studies can attest to these facts. Treatments — including informal approaches and critical stress debriefing — are still ignorantly applied today. Most people are resilient to trauma to varying degrees and naturally follow healthy recovery trajectories. A large portion of them become less healthy after being exposed to treatment, which includes informal group treatments. And lastly, there is no empirical evidence nor statistical findings that victimhood has ever resulted in patients following desired recovery trajectories.
The Psychologist Fails to Consider Interests
If a subject has low social status and little prospect, does he have an incentive to feign mental illness for the victim status it brings him?
If a subject is narcissistic (redirects conversation and attention towards his self rather than the topic at hand), is he more likely to feign mental illness for the attention it might bring him?
Once these interests are considered, the symptoms of PTSD that can indeed be faked or lied about ought to be discarded while the more scientifically objective symptoms ought to be kept.
References
*A multiple-source citation
There are a total of 57 research papers that this review considers.
[1] George A. Bonano. “Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events?” American Psychologist. January, 2004.
[2] Suniya S. Luthar, Dante Cicchetti, Bronwyn Becke The Construct of Resilience: A Critical Evaluation and Guidelines for Future Work. 2000 of May-June.
[3]* Garmezy, 1970. Zigler and Glick, 1986.
[4] Garmezy, 1974. Garmez
[5]* Garmezy, 1991 and 1995. Rutter, 1979. Werner And Smith, 1982, 1992.; 1992.
[6]* Masten & Coatsworth, 1995, 1998.
[7]* Beeghly & Cicchetti, 1994; Cicchetti & Rogosch, 1997; Cicchetti, Rogosch, Lynch, & Holt, 1993; Moran & Eckenrode, 1992.
[8]* Luthar, 1999; Richters & Martinez, 1993.
[9] Wells & Schwebel, 1987
[10] O’Dougherty-Wright, Masten, Northwood, & Hubbard, 1997.
[11]* Masten and Garmezy, 1885. Werner and Smith, 1982, 1992.
[12]* Cowen, 1997. Luthar 1999.
[13]* Masten and Garmezy, 1985. Werner and Smith 1982.
[14] Kaufman, 1994.
[15] Cicchetti and Toth, 1998a.
[16]* Werner, 1994, 1995.
[17] Wortman & Silver, 1989.
[18] Bonanno & Kaltman, 1999.
[19] Stroebe & Stroebe, 1991.
[20] Bonanno et al., 2001.
[21] Mitchell, 1983.
[22] Mitchell & Everly, 2000.
[23] Miller, 2002.
[24] Rose, Brewin, Andrews, & Kirk, 1999.
[25] Bisson, Jenkins, Alexander, & Bannister, 1997.
[26] Mayou, Ehlers, & Hobbs, 2000.
[27] Neimeyer, 2000.
[28] King, King, Foy, Keane, & Fairbank, 1999.
[29] McFarlane & Yehuda, 1996.
[30] Larson & Hoyt, 2007.
[31] Bonanno, Noll, Putnam, O’Neill, & Trickett, 2003.
[32] Ozer, 2003.
[33] Hanson, Kilpatrick, Freedy, & Saunders, 1995.
[34] Sutker, Davis, Uddo, & Ditta, 1995.
[35] Ehlers, Mayou, & Bryant, 1998.
[36] Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993.
[37] Hanson et al., 1995.
[38] Bryant, Harvey, Guthrie, & Moulds, 2000.
[39] Sutker et al., 1995.
[40] Galea, Resnick, et al. 2002.
[41] Colak et al., 2003.
[42] Fredrickson, Tugade, Waugh, & Larkin, 2003.
Footnotes
Most of the error in reports were due to a lack of or improper error analysis where statistics were being measured, improper data collection, or ambiguous or arbitrary definitions. Most notably, researchers failed to identify the cause of a healthy trajectory or the cause of an unhealthy trajectory; no control group was used or cited to account for variation.