[Paleopsych] Re: why does disaster cripple our two brains?

Bill Tillier btillier at shaw.ca
Mon Apr 11 20:06:17 UTC 2005

In follow-up to Howard's post:

I saw an exchange of letters on Human Resilience in the April 2005 American
Psychologist (about the following article). I have presented the text of the
article (no diagrams). Bill Tillier.

20 January 2004  American Psychologist  Vol. 59, No. 1, 20–28.

Correspondence concerning this article should be addressed to George A.
Bonanno, Department of Counseling and Clinical Psychology, Teachers
College, Columbia University, 525 West 120th Street, Box 218, New
York, NY 10027. E-mail: gab38 at columbia.edu

Loss, Trauma, and Human Resilience: Have We Underestimated the Human
Capacity to Thrive After Extremely
Aversive Events?
George A. Bonanno
Teachers College, Columbia University
Many people are exposed to loss or potentially traumatic
events at some point in their lives, and yet they continue to
have positive emotional experiences and show only minor
and transient disruptions in their ability to function. Unfortunately,
because much of psychology’s knowledge
about how adults cope with loss or trauma has come from
individuals who sought treatment or exhibited great distress,
loss and trauma theorists have often viewed this type
of resilience as either rare or pathological. The author
challenges these assumptions by reviewing evidence that
resilience represents a distinct trajectory from the process
of recovery, that resilience in the face of loss or potential
trauma is more common than is often believed, and that
there are multiple and sometimes unexpected pathways to
Most people are exposed to at least one violent or
life-threatening situation during the course of
their lives (Ozer, Best, Lipsey, & Weiss, 2003).
As people progress through the life cycle, they are also
increasingly confronted with the deaths of close friends and
relatives. Not everyone copes with these potentially disturbing
events in the same way. Some people experience
acute distress from which they are unable to recover. Others
suffer less intensely and for a much shorter period of
time. Some people seem to recover quickly but then begin
to experience unexpected health problems or difficulties
concentrating or enjoying life the way they used to. However,
large numbers of people manage to endure the temporary
upheaval of loss or potentially traumatic events
remarkably well, with no apparent disruption in their ability
to function at work or in close relationships, and seem
to move on to new challenges with apparent ease. This
article is devoted to the latter group and to the question of
resilience in the face of loss or potentially traumatic events.
The importance of protective psychological factors in
the prevention of illness is now well established (Taylor,
Kemeny, Reed, Bower, & Gruenewald, 2000). Moreover,
developmental psychologists have shown that resilience is
common among children growing up in disadvantaged
conditions (e.g., Masten, 2001). Unfortunately, because
most of the psychological knowledge base regarding the
ways adults cope with loss or potential trauma has been
derived from individuals who have experienced significant
psychological problems or sought treatment, theorists
working in this area have often underestimated and misunderstood
resilience, viewing it either as a pathological state
or as something seen only in rare and exceptionally healthy
individuals. In this article, I challenge this view by reviewing
evidence that resilience in the face of loss or potential
trauma represents a distinct trajectory from that of recovery,
that resilience is more common than often believed,
and that there are multiple and sometimes unexpected
pathways to resilience.
Point 1: Resilience Is Different From
A key feature of the concept of adult resilience to loss and
trauma, to be discussed in the next two sections, is its
distinction from the process of recovery. The term recovery
connotes a trajectory in which normal functioning temporarily
gives way to threshold or subthreshold psychopathology
(e.g., symptoms of depression or posttraumatic stress
disorder [PTSD]), usually for a period of at least several
months, and then gradually returns to pre-event levels. Full
recovery may be relatively rapid or may take as long as one
or two years. By contrast, resilience reflects the ability to
maintain a stable equilibrium. In the developmental literature,
resilience is typically discussed in terms of protective
factors that foster the development of positive outcomes
and healthy personality characteristics among children exposed
to unfavorable or aversive life circumstances (e.g.,
Garmezy, 1991; Luthar, Cicchetti, & Becker, 2000; Masten,
2001; Rutter, 1999; Werner, 1995). Resilience to loss
and trauma, as conceived in this article, pertains to the
ability of adults in otherwise normal circumstances who are
exposed to an isolated and potentially highly disruptive
event, such as the death of a close relation or a violent or
life-threatening situation, to maintain relatively stable,
healthy levels of psychological and physical functioning. A
further distinction is that resilience is more than the simple
absence of psychopathology. Recovering individuals often
experience subthreshold symptom levels. Resilient individuals,
by contrast, may experience transient perturbations in
normal functioning (e.g., several weeks of sporadic preoccupation
or restless sleep) but generally exhibit a stable
trajectory of healthy functioning across time, as well as the
capacity for generative experiences and positive emotions
(Bonanno, Papa, & O’Neill, 2001). The prototypical resilience
and recovery trajectories, as well as chronic
and delayed disruptions in functioning, are illustrated in
Figure 1.
In the loss and trauma literatures, researchers have
tended to assume a unidimensional response with little
variability in possible outcome trajectory among adults
exposed to potentially traumatic events. Bereavement theorists
have tended to assume that coping with the death of
a close friend or relative is necessarily an active process
that can and in most cases should be facilitated by clinical
intervention. Trauma theorists have focused their attentions
primarily on interventions for PTSD. Nonetheless, trauma
theorists and practitioners have at times assumed that virtually
all individuals exposed to violent or life-threatening
events could benefit from active coping and professional
intervention. In this section, I discuss how the failure of the
loss and trauma literatures to adequately distinguish resilience
from recovery relates to current controversies about
when and for whom clinical intervention might be most
appropriate. This failure also helps explain why in some
cases clinical interventions with exposed individuals are
sometimes ineffective or even harmful.
The Grief Work Assumption
Traditionally, mental health professionals in the industrialized
West have understood grief and bereavement from a
single dominant perspective characterized by the need for
grief work (Stroebe & Stroebe, 1991). The conception of
grieving as work originated in Freud’s (1917/1957) metaphoric
use of the term to describe the idea that virtually
every bereaved individual needs to review “each single one
of the memories and hopes which bound the libido . . . to
the non-existent object” (p. 154). Theorists following Freud
emphasized even more strongly the critical importance to
all bereaved individuals of working through the negative
thoughts, memories, and emotions about a loss (see
Bonanno & Field, 2001).
As researchers began to devote more attention to the
bereavement process, however, it became apparent that,
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 (Wortman
& Silver, 1989). 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 (see Bonanno &
Kaltman, 1999). A more plausible alternative would be that
grief work processes are appropriate for only a subset of
bereaved individuals (Stroebe & Stroebe, 1991), most
likely those actively struggling with the most severe levels
of grief and distress (Bonanno et al., 2001).
The idea that grief work may characterize only the
more highly distressed bereaved individuals (i.e., those
exhibiting either the recovery or chronic symptom trajectories)
is further supported by data indicating that the
practice of engaging a wide array of bereaved individuals
in grief counseling has proved remarkably ineffective.
Grief-focused interventions typically target both acute or
prolonged grief reactions as well as the absence of a grief
reaction (e.g., Rando, 1992). Two recent meta-analyses

Figure 1
Prototypical Patterns of Disruption in Normal
Functioning Across Time Following Interpersonal Loss
or Potentially Traumatic Events

independently reached the conclusion that grief-specific
therapies tend to be relatively inefficacious (Kato & Mann,
1999; Neimeyer, 2000). A third meta-analytic study reported
that grief therapies can be effective but generally to
a lesser degree than usually observed for other forms of
psychotherapy (Allumbaugh & Hoyt, 1999). In one of these
analyses, an alarming 38% of the individuals receiving
grief treatments actually got worse relative to no-treatment
controls, whereas the most clear benefits were evidenced
primarily with bereaved individuals experiencing chronic
grief (Neimeyer, 2000). In summarizing these findings,
Neimeyer (2000) concluded that “such interventions are
typically ineffective, and perhaps even deleterious, at least
for persons experiencing a normal bereavement” (p. 541).
Trauma Interventions and Critical Incident
Although for centuries practitioners have linked violent or
life-threatening events with psychological and physiological
dysfunction, historically there also has been confusion
and controversy over the nature of traumatic events and
over whether to consider psychological reactions as malingering,
weakness, or genuine dysfunction (Lamprecht &
Sack, 2002). The inclusion of the PTSD category in the
Diagnostic and Statistical Manual of Mental Disorders
(3rd ed. [DSM–III]; American Psychiatric Association,
1980) resulted in a surge of research and theory about
clinically significant trauma reactions. There is now considerable
support for the usefulness of interventions with
individuals meeting PTSD criteria. Cognitive–behavioral
treatments that aim to help traumatized individuals understand
and manage the anxiety and fear associated with
trauma-related stimuli have proved the most effective
(Resick, 2001). Although outcome studies generally show
few differences between treatments, there is some evidence
for superior results with prolonged exposure therapy (e.g.,
Foa et al., 1999). The essential components of exposure
treatment usually involve repeated confrontations with
memories of the traumatic stressor (imaginal exposure) and
with situations that evoke unrealistic fears (in vivo exposure;
Zoellner, Fitzgibbons, & Foa, 2001).
Ironically, the effectiveness of reliving traumatic experiences
for individuals with PTSD may have helped blur
the distinction between recovery and resilience. Researchers
have made remarkably few attempts to distinguish
subgroups within the broad category of individuals not
showing PTSD. Resilient and recovering individuals are
often lumped into a single category (e.g., King, King, Foy,
Keane, & Fairbank, 1999; McFarlane & Yehuda, 1996). As
with bereavement, however, when researchers do not address
this distinction, they risk making the faulty assumption
that resilient people must engage in the same coping
processes as do exposed individuals who struggle with but
eventually recover from more intense trauma symptoms.
The possible untoward nature of this assumption is
evidenced keenly in the often contentious debate about the
appropriateness of psychological debriefing. Whereas genuinely
traumatized individuals were once doubted as malingerers,
the pendulum has recently swung so far in the
opposite direction that many practitioners believe that virtually
all individuals exposed to violent or life-threatening
events should be offered and would benefit from at least
some form of brief intervention. 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
(Mitchell, 1983). Over time, however, debriefing has been
applied individually and broadly (Mitchell & Everly, 2000)
and sometimes, as after the recent September 11th terrorist
attacks on the World Trade Center (Miller, 2002), 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
(Rose, Brewin, Andrews, & Kirk, 1999) and can impede
natural recovery processes (Bisson, Jenkins, Alexander, &
Bannister, 1997; Mayou, Ehlers, & Hobbs, 2000).
An alternative form of early trauma intervention, recently
proposed by Litz, Gray, Bryant, and Adler (2002),
resonates with the distinction proposed here between resilience
and recovery. Litz et al. argued that, while offering
debriefing to all individuals exposed to a potentially traumatic
event is misguided, some individuals would indeed
benefit from early intervention. They proposed the development
of initial screening practices for intervention with
individuals who show possible risk factors (e.g., prior
trauma, low social support, hyperarousal) for developing
chronic PTSD. Implicit in this approach is the idea, central
to the current article, that many individuals exposed to
violent or life-threatening events will show a genuine resilience
that should not be interfered with or undermined by
clinical intervention.
Point 2: Resilience Is Common
Because research on acute and chronic grief and PTSD
historically has dominated the literature on how adults cope
with aversive life events, such reactions have generally
come to be viewed as the norm. As I discuss below,
bereavement theorists have been highly skeptical about
individuals who do not show pronounced distress reactions
or who display positive emotions following loss, assuming
that such individuals are rare and suffer from pathological
or dysfunctional forms of absent grief. Trauma theorists
have been less suspicious about the absence of PTSD
but have often ignored and underestimated resilience. A
review of the available research on loss and violent or
life-threatening events clearly indicates that the vast majority
of individuals exposed to such events do not exhibit
chronic symptom profiles and that many and, in some
cases, the majority show the type of healthy functioning
suggestive of the resilience trajectory.
Resilience to Loss
Bereavement theorists have typically viewed the absence of
prolonged distress or depression following the death of an
important friend or relative, often termed absent grief, as a
rare and pathological response that results from denial or
avoidance of the emotional realities of the loss. Bowlby
(1980), for example, described the “prolonged absence of
conscious grieving” (p. 138) as a type of disordered mourning
and viewed the experience or expression of positive
emotions during the early stages of bereavement as a form
of defensive denial. Summarizing the first wave of bereavement
research, Osterweis, Solomon, and Green (1984) concluded
“that the absence of grieving phenomena following
bereavement represents some form of personality pathology”
(p. 18). More recently, in a survey of self-identified
bereavement experts, the majority (65%) endorsed beliefs
that absent grief exists, that it usually stems from denial or
inhibition, and that it is generally maladaptive in the long
run (Middleton, Moylan, Raphael, Burnett, & Martinek,
1993). These same bereavement experts (76%) also endorsed
the compatible assumption that absent grief eventually
surfaces in the form of delayed grief reactions.
The available empirical literature, however, suggests a
very different story: Resilience to the unsettling effects of
interpersonal loss is not rare but relatively common, does
not appear to indicate pathology but rather healthy adjustment,
and does not lead to delayed grief reactions. Over a
decade ago, Wortman and Silver (1989) first drew attention
to the somewhat startling fact that there was no empirical
basis for either the assumption that the absence of distress
during bereavement is pathological or that it is always
followed by delayed manifestations of grief. Unfortunately,
at the time their article was published, there were relatively
few longitudinal bereavement studies from which to fully
evaluate their claim.
More recent prospective studies have now begun to
shed greater light on individual differences in grief reactions
(for a review, see Bonanno & Kaltman, 2001). Although
the DSM has not specified a unique category for
acute or complicated grief reactions, the available research
generally shows that chronic depression and distress tend to
occur in 10% to 15% of bereaved individuals. Considerable
numbers of bereaved individuals also tend to show more
time-limited disruptions in functioning (e.g., cognitive disorganization,
dysphoria, health deficits, disrupted social
and occupational functioning) lasting at least several
months to one or two years. Most important, in studies that
report aggregate data, bereaved individuals who exhibited
relatively low levels of depression or distress have consistently
approached or exceeded 50% of the sample. For
example, in a recent study that examined various levels of
depression among conjugally bereaved adults, approximately
half of a sample did not show even mild depression
(these individuals endorsed fewer than two items from the
DSM–IV symptom list) following the loss (Zisook, Paulus,
Shuchter, & Judd, 1997). In addition, there is now solid
prospective evidence that associates resilience to loss with
the experience and expression of positive emotion (e.g.,
Bonanno & Keltner, 1997).
How many of the bereaved individuals who do not
exhibit overt grief reactions will eventually develop delayed
grief reactions? The evidence is unequivocal on this
point: No empirical study has ever clearly demonstrated the
existence of delayed grief. For example, Middleton, Burnett,
Raphael, and Martinek (1996) used cluster analyses to
examine longitudinal outcome patterns among groups of
bereaved spouses, adult children, and parents. Despite their
conviction that delayed grief would emerge, Middleton et
al. concluded that “no evidence was found for the pattern of
response which might be expected for delayed grief”
(Middleton et al., 1996, p. 169). Data from a recent fiveyear
longitudinal study indicated a similar conclusion
(Bonanno & Field, 2001). This study contrasted the common
assumption that delayed grief is a robust phenomenon
with an alternative assumption that a few participants might
show delayed elevations but only on isolated measures
because of random measurement error. The results were
consistent with the measurement-error explanation. In fact,
when a psychometrically more reliable, weighted composite
measure was used, not a single participant evidenced
delayed grief.
The idea that the absence of grief is pathological is
rooted in the assumptions that bereaved individuals showing
this pattern must have had a superficial attachment to
the deceased or that they are cold and emotionally distant
people (Bowlby, 1980). Such explanations are notoriously
difficult to rule out because, for obvious reasons, most
bereavement studies take place after the death already has
occurred. When measured during bereavement, factors
such as the quality of the lost relationship or the situational
context of the loss are confounded with current functioning
and the possible influence of memory biases (e.g., Safer,
Bonanno, & Field, 2001).
However, a recent prospective study provided a rare
opportunity to address this issue using data gathered
on average three years prior to the death of a spouse
(Bonanno, Wortman, et al., 2002). This study provided
strong evidence in support of the idea that many bereaved
individuals will exhibit little or no grief and that these
individuals are not cold and unfeeling or lacking in attachment
but, rather, are capable of genuine resilience in the
face of loss. Almost half of the participants in this study
(46% of the sample) had low levels of depression, both
prior to the loss and through 18 months of bereavement,
and had relatively few grief symptoms (e.g., intense yearning
for the spouse) during bereavement. An examination of
the prebereavement functioning of this group revealed no
signs of maladjustment; these participants were not rated as
emotionally cold or distant by the interviewers, did not
report difficulties in their marriages, and did not show
dismissive attachment. They did, however, have relatively
high scores on several prebereavement measures suggestive
of the ability to adapt well to loss (e.g., acceptance of
death, belief in a just world, instrumental support). As in
previous studies, no unequivocal evidence for delayed grief
was found. Finally, it is important to note that even among
these resilient individuals, the majority reported experiencing
at least some yearning and emotional pangs, and virtually
all participants reported intrusive cognition and rumination
at some point early after the loss (Bonanno,
Wortman, & Nesse, in press). The difference between the
resilient individuals and the other participants, however,
was that these experiences were transient rather than enduring
and did not interfere with their ability to continue to
function in other areas of their lives, including the capacity
for positive affect.
Resilience to Violent and Life-Threatening
Epidemiological studies estimate that the majority of the
U.S. population has been exposed to at least one traumatic
event, defined using the DSM–III criteria of an event outside
the range of normal human experience, during the
course of their lives. Although grief and trauma symptoms
are qualitatively different, the basic outcome trajectories
following trauma tend to form patterns similar to those
observed following bereavement (see Figure 1). Summarizing
this research, Ozer et al. (2003) recently noted that
“roughly 50%–60% of the U.S. population is exposed to
traumatic stress but only 5%–10% develop PTSD” (p. 54).
However, because there is greater variability in the types
and levels of exposure to stressor events, there also tends to
be greater variability in PTSD rates over time. Estimates of
chronic PTSD have ranged, for example, from 6.6% and
9.9% for individuals experiencing personally threatening
and violent events, respectively, during the 1992 Los Angeles
riots (Hanson, Kilpatrick, Freedy, & Saunders, 1995),
to 12.5% for Gulf War veterans (Sutker, Davis, Uddo, &
Ditta, 1995), to 16.5% for hospitalized survivors of motor
vehicle accidents (Ehlers, Mayou, & Bryant, 1998), to
17.8% for victims of physical assault (Resnick, Kilpatrick,
Dansky, Saunders, & Best, 1993).
Although chronic PTSD certainly warrants great concern,
the fact that the vast majority of individuals exposed
to violent or life-threatening events do not go on to develop
the disorder has not received adequate attention. It is well
established that many exposed individuals will evidence
short-lived PTSD or subclinical stress reactions that abate
over the course of several months or longer (i.e., the
recovery pattern). For example, a population-based survey
conducted one month after the September 11th terrorist
attacks in New York City estimated that 7.5% of Manhattan
residents would meet criteria for PTSD and that another
17.4% would meet the criteria for subsyndromal PTSD
(high symptom levels that do not meet full diagnostic
criteria; Galea, Ahern, et al., 2002). As in other studies, a
subset eventually developed chronic PTSD, and this was
more likely if exposure was high. However, most respondents
evidenced a rapid decline in symptoms over time:
PTSD prevalence related to 9/11 dropped to only 1.7% at
four months and 0.6% at six months, whereas subsyndromal
PTSD dropped to 4.0% and 4.7%, respectively, at these
times (Galea et al., 2003).
What about exposed individuals who exhibit relatively
little distress? Trauma theorists are sometimes surprised
when exposed individuals do not show more than a
few PTSD symptoms. For example, body handlers in the
aftermath of the Oklahoma City bombing have been described
as showing “unexpected resilience” (Tucker et al.,
2002). Indeed, whereas those who cope well with bereavement
are sometimes viewed as cold and unfeeling, those
who cope well with violent or life-threatening events are
often viewed in terms of extreme heroism. However justi-
fied, this practice tends to reinforce the misperception that
only rare individuals with “exceptional emotional strength”
(e.g., Casella & Motta, 1990) are capable of resilience.
The available evidence suggests that resilience to violent
and life-threatening events is far more common. The
vast majority of individuals (78.2%) exposed to the 1992
Los Angeles riots reported three or fewer PTSD symptoms
(Hanson et al., 1995). Similarly, among hospitalized survivors
of motor vehicle accidents (Bryant, Harvey, Guthrie,
& Moulds, 2000), the majority (79%) did not meet criteria
for PTSD and averaged only 3.3 PTSD symptoms, indicating
that many participants must have shown little or no
PTSD. In a study of PTSD among Gulf War veterans
(Sutker et al., 1995), the majority (62.5%) had no psychological
distress when examined within one year of their
return to the United States. In their post-9/11 survey, Galea,
Resnick, et al. (2002) reported that over 40% of Manhattan
residents did not report a single PTSD symptom. Carden˜a
et al. (1994) examined data on a wide range of cognitive,
affective, and somatic symptoms (e.g., exaggerated startle,
recurrent distressing dreams, fatigue) measured among survivors
of five different disaster events within one to four
weeks of each event. Although they did not assess the type
of specific symptom trajectories that would allow direct
inferences about resilient individuals, Carden˜a et al. did
report that “even with such a diverse series of events and
forms of data collection . . . the percentages we obtained
for immediate reactions to disaster were very similar”
(Carden˜a et al., 1994, p. 387). And their data were consistent
with the idea that resilience is common: The vast
majority of symptoms they measured were apparent in only
a minority of respondents. Finally, although relatively little
research has been done on the experience or expression of
positive emotion following potentially traumatic events,
two recent studies have provided important preliminary
data linking positive emotions in the context of trauma with
resilient functioning (Colak et al., 2003; Fredrickson,
Tugade, Waugh, & Larkin, 2003). Positive emotion is
revisited in the final section of this article.
How many exposed individuals eventually show delayed
trauma reactions? In contrast to the absence of evidence
for delayed grief during bereavement, delayed PTSD
does appear to be a genuine, empirically verifiable phenomenon.
Nonetheless, delayed PTSD is still relatively
infrequent, occurring in approximately 5% to 10% of exposed
individuals (Buckley, Blanchard, & Hickling, 1996),
and thus applies at best only to a subset of the many
individuals who do not show initial PTSD reactions. It is
noteworthy, however, that exposed individuals who eventually
manifest delayed PTSD tend to have had relatively
high levels of symptoms in the immediate aftermath of the
stressor event (e.g., Buckley et al., 1996). Thus, these
individuals appear to be immediately distinguishable from
more truly resilient individuals (see Figure 1).
Perhaps trauma reactions might manifest indirectly
through behavioral or health problems? Although PTSD is
frequently comorbid with health and behavior problems,
individuals exposed to putative traumatic events sometimes
do evidence these problems in the absence of PTSD. As
was the case with delayed PTSD, however, even when
health and behavior problems are accounted for, many
survivors do not show such problems. This was evidenced,
for example, in a longitudinal study of survivors of the
North Sea oil rig disaster—by all accounts a horrific and
disturbing event (Holen, 1990). In the first year following
the disaster, 13.7% of the survivors were assigned psychiatric
diagnoses (at the time of the study, PTSD was not a
well-established diagnosis), compared with only 1.1% of a
matched comparison sample. In contrast, medical diagnoses
were assigned to 31% of the survivors. Although
these rates were markedly higher than those found in the
comparison sample (4.5%), they nonetheless underscore
the fact that most if not the majority of survivors exhibited
neither extreme distress nor unusual health problems.
Point 3: There Are Multiple and
Sometimes Unexpected Pathways to
If resilience and recovery represent distinct trajectories that
are informed by different coping habits, then what factors
promote resilience? Meta-analytic studies have consistently
revealed several clear predictors of PTSD reactions,
including lack of social support, low intelligence and lack
of education, family background, prior psychiatric history,
and aspects of the trauma response itself, such as dissociative
reactions (Brewin, Andrews, & Valentine, 2000; Ozer
et al., 2003). It seems likely that at least some of these
factors, if inverted, would predict resilient functioning.
However, relatively little research has attempted to address
this question. What’s more, because so little attention has
been devoted to resilience, when loss and trauma theorists
have looked for resilience, they have tended to look in the
wrong places. Indeed, the assumption that all adults exposed
to loss or to potentially traumatic events experience
prolonged distress and disruptions in functioning goes hand
in hand with the belief that resilience must be rare and
found only in exceptionally healthy people (e.g., Casella &
Motta, 1990).
Recent studies suggest a far more complex picture; as
developmental psychologists have long asserted, there is no
single means of maintaining equilibrium following highly
aversive events, but rather there are multiple pathways to
resilience (e.g., Luthar, Doernberger, & Zigler, 1993; Rutter,
1987). This evidence further suggests that, contrary to
myths about unusually healthy beings, adults resilient to
loss or trauma often appear to cope effectively in ways that,
under normal circumstances, may not always be advantageous.
For example, recall the bereavement study by Bonanno,
Wortman, et al. (2002), discussed earlier, that identified
a large resilient group with a relatively healthy profile
prior to the loss. This study also revealed a second, smaller
group of resilient individuals who had improved following
the death of their spouse. At prebereavement, members of
the improved group had spouses who were ill; were highly
depressed, neurotic, and introspective; had more conflicted,
ambivalent marriages; and believed that they were treated
less fairly in life than other people. A recent follow-up
study of these individuals (Bonanno et al., in press) indicated
that they showed no adverse reactions through 18
months of bereavement, gave little indication of denial or
avoidance, perceived greater benefits to widowhood,
gained increasing comfort from positive memories of their
spouses over time, and reported that they too were somewhat
surprised by their own coping efficacy. Thus, although
dramatically different from the larger resilient
group at prebereavement, the improved respondents also
appeared to exhibit genuine resilience during bereavement.
In this section, a number of distinct dimensions suggestive
of different types or pathways of resilience to loss
and trauma are considered.
A growing body of evidence suggests that the personality
trait of hardiness (Kobasa, Maddi, & Kahn, 1982) helps to
buffer exposure to extreme stress. Hardiness consists of
three dimensions: being committed to finding meaningful
purpose in life, the belief that one can influence one’s
surroundings and the outcome of events, and the belief that
one can learn and grow from both positive and negative life
experiences. Armed with this set of beliefs, hardy individuals
have been found to appraise potentially stressful situations
as less threatening, thus minimizing the experience
of distress. Hardy individuals are also more confident and
better able to use active coping and social support, thus
helping them deal with the distress they do experience
(e.g., Florian, Mikulincer, & Taubman, 1995).
Another dimension linked to resilience is self-enhancement.
Somewhat ironically, around the time PTSD was formalized
as a diagnostic category, social psychologists had
begun to challenge the traditional assumption that mental
health requires realistic acceptance of personal limitations
and negative characteristics (Greenwald, 1980; Taylor &
Brown, 1988). These scholars argued instead that unrealistic
or overly positive biases in favor of the self, such as
self-enhancement, can be adaptive and promote well-being.
Although most people engage in self-enhancing biases at
least some of the time, measurable individual differences
are also found. Trait self-enhancement has been associated
with benefits, such as high self-esteem, but also with costs:
Self-enhancers score high on measures of narcissism and
tend to evoke negative impressions in others (Paulhus,
1998). This trade-off may be less problematic, however, in
the context of highly aversive events, when threats to the
self are most salient (Taylor & Brown, 1988).
Support for this idea comes from a recent study of
individual differences in self-enhancing biases among bereaved
individuals in the United States and among Bosnian
civilians living in Sarajevo in the immediate aftermath of
the Balkan civil war (Bonanno, Field, Kovacevic, & Kaltman,
2002). In both samples, self-enhancers were rated by
mental health professionals as better adjusted. What’s
more, self-enhancement proved to be particularly adaptive
for bereaved individuals suffering from more severe losses.
In a similar study of individuals who were in or near the
World Trade Center towers at the time of the September
11th attacks (Bonanno, Rennicke, Dekel, & Rosen, 2003),
self-enhancers reported better adjustment and more active
social networks and were rated more positively and as
better adjusted by their close friends. Further, selfenhancers’
salivary cortisol levels exhibited a profile suggestive
of minimal stress responding.
Repressive Coping
Resilience to loss and trauma has also been found among
another perhaps less likely group: repressive copers (Weinberger,
Schwartz, & Davidson, 1979). A considerable body
of literature documents that individuals identified by either
questionnaire or behavioral measures as repressors tend
to avoid unpleasant thoughts, emotions, and memories
(Weinberger, 1990). In contrast to hardiness and selfenhancement,
which appear to operate primarily on the
level of cognitive processes, repressive coping appears to
operate primarily through emotion-focused mechanisms,
such as emotional dissociation. For instance, repressors
typically report relatively little distress in stressful situations
but exhibit elevated distress on indirect measures,
such as autonomic arousal (Weinberger et al., 1979). Emotional
dissociation is generally viewed as maladaptive and
may be associated with long-term health costs (Bonanno &
Singer, 1990). However, these same tendencies also appear
to foster adaptation to extreme adversity. For example,
repressors have been found to show relatively little grief or
distress at any point across five years of bereavement
(Bonanno & Field, 2001; Bonanno, Keltner, Holen, &
Horowitz, 1995). Further, although they initially reported
increased somatic complaints, over time repressors did not
show greater somatic or health problems than other participants.
Recently, among a sample of young women with
documented histories of childhood sexual abuse, repressors
were less likely to voluntarily disclose their abuse when
provided the opportunity to do so, but they also showed
better adjustment than other survivors (Bonanno, Noll,
Putnam, O’Neill, & Trickett, 2003).
Positive Emotion and Laughter
One of the ways repressors and others showing resilience
appear to cope well with adversity is through the use of
positive emotion and laughter (Bonanno, Noll, et al., 2003;
Keltner & Bonanno, 1997). Historically, the possible usefulness
of positive emotion in the context of extremely
aversive events was either ignored or dismissed as a form
of unhealthy denial (e.g., Bowlby, 1980). Recently, however,
research has shown that positive emotions can help
reduce levels of distress following aversive events both by
quieting or undoing negative emotion (Fredrickson & Levenson,
1998; Keltner & Bonanno, 1997) and by “increasing
continued contact with and support from important people
in the . . . person’s social environment” (Bonanno & Keltner,
1997, p. 134).
Several recent studies have supported these ideas in
the specific contexts of loss or trauma. Bereaved individuals
who exhibited genuine laughs and smiles when speaking
about a recent loss had better adjustment over several
years of bereavement (Bonanno & Keltner, 1997) and also
evoked more favorable responses in observers (Keltner &
Bonanno, 1997). Recently, Fredrickson et al. (2003) demonstrated
that the links between personality measures of
resilience and adjustment following the September 11th
attacks were mediated by the experience of positive emotions
(e.g., gratitude, interest, love). Finally, the expression
of positive emotion among young adult survivors of childhood
sexual abuse predicted better adjustment and better
social relations over time (Colak et al., 2003). The latter
study also suggested, however, that although laughter in the
context of a socially stigmatized event like childhood sexual
abuse predicts better adjustment, it may also carry
social costs (e.g., decreased social competence). Clearly,
this is an important area for further research.
Toward a Broader Conceptualization of
Stress Responding
The evidence reviewed above presents an important challenge
to the view that adults who do not show distress
following a loss or violent or life-threatening event are
either pathological or rare and exceptionally healthy.
Rather, this evidence suggests that resilience is common, is
distinct from the process of recovery, and can potentially
be reached by a variety of different pathways. What lessons
might these points offer for future understanding of human
stress responding? Within a broader context, psychologists
might try to understand why resilience in the face of loss or
trauma has so often been misunderstood by considering the
myriad errors and biases in judgment that occur under
conditions of uncertainty (e.g., the availability heuristic;
Tversky & Kahneman, 1974). Others already have probed
the limitations of clinical inference from this perspective
(e.g., Dawes, 1994). However, what might be particularly
interesting to explore is the frequent failure not only to
grasp the prevalence of resilience to loss and trauma but
also to comprehend its many forms. Clearly, researchers
and theorists need to move beyond overly simplistic conceptions
of health and pathology to embrace the broader
costs and benefits of various dispositions and adaptive
mechanisms. Trade-offs of this sort can be found everywhere
in nature. Cheetahs, for example, possess breathtaking
speed but have poor stamina and must catch their
prey quickly or starve. In a similar vein, people prone to the
use of self-enhancing biases enjoy high self-esteem but
tend to annoy those who do not know them well (Paulhus,
1998). Overly simplistic conceptions of self-enhancers as
dysfunctional obfuscate the coping advantage these individuals
show when confronted with truly aversive situations
(Bonanno, Field, et al., 2002).
It is imperative that future investigations of loss and
trauma include more detailed study of the full range of
possible outcomes; simply put, dysfunction cannot be fully
understood without a deeper understanding of health and
resilience. By viewing resilient functioning through the
same empirical lens as chronic forms of dysfunction and
more time-limited recovery patterns, researchers will be
able to examine and contrast each of these patterns. Many
questions await investigation. A crucial issue pertains to
the commonalities and differences in resilient functioning
across the life span. Developmental theorists have argued
that resilience to aversive childhood contexts results from a
cumulative and interactive mix of genetic (e.g., disposition),
personal (e.g., family interaction), and environmental
(e.g., community support systems) risk and protective factors
(Rutter, 1999; Werner, 1995). Although in some ways
adult resilience to loss and trauma presents a simpler problem
(e.g., the aversive context is centered on a single event,
and the developmental issues unfold at a more gradual
pace), it is nonetheless crucial to determine how resilience
to loss or trauma may vary across the life span, how adult
resilience relates to developmental experiences, and
whether the various factors that inform adult resilience
might also function in a cumulative and interactive manner
(McFarlane & Yehuda, 1996). Researchers might also ask
whether adults can learn to be more resilient to aversive
events by, for example, extending some of the wellnesspromotion
factors developed for children (e.g., Cowen,
1991) or whether different protective factors foster resilience
for different types of events, as has been suggested by
studies of risk factors for PTSD (Brewin et al., 2000). As
we move into the next millennium, it will be imperative to
address these questions and to take a fresh look at the
various ways people adapt and even flourish in the face of
what otherwise would seem to be potentially debilitating
Allumbaugh, D. L., & Hoyt, W. T. (1999). Effectiveness of grief therapy:
A meta-analysis. Journal of Counseling Psychology, 46, 370–380.
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, DC: Author.
Bisson, J., Jenkins, P. L., Alexander, J., & Bannister, C. (1997).
controlled trial of psychological debriefing for victims of burn
trauma. British Journal of Psychiatry, 171, 78–81.
Bonanno, G. A., & Field, N. P. (2001). Examining the delayed grief
hypothesis across five years of bereavement. American Behavioral
Scientist, 44, 798–806.
Bonanno, G. A., Field, N. P., Kovacevic, A., & Kaltman, S. (2002).
Self-enhancement as a buffer against extreme adversity: Civil war in
Bosnia and traumatic loss in the United States. Personality and Social
Psychology Bulletin, 28, 184–196.
Bonanno, G. A., & Kaltman, S. (1999). Toward an integrative perspective
on bereavement. Psychological Bulletin, 125, 760–776.
Bonanno, G. A., & Kaltman, S. (2001). The varieties of grief experience.
Clinical Psychology Review, 21, 705–734.
Bonanno, G. A., & Keltner, D. (1997). Facial expressions of emotion and
the course of conjugal bereavement. Journal of Abnormal Psychology,
106, 126–137.
Bonanno, G. A., Keltner, D., Holen, A., & Horowitz, M. J. (1995). When
avoiding unpleasant emotions might not be such a bad thing: Verbal–
autonomic response dissociation and midlife conjugal bereavement.
Journal of Personality and Social Psychology, 69, 975–989.
Bonanno, G. A., Noll, J. G., Putnam, F. W., O’Neill, M., & Trickett, P.
(2003). Predicting the willingness to disclose childhood sexual abuse
from measures of repressive coping and dissociative experiences. Child
Maltreatment, 8, 1–17.
Bonanno, G. A., Papa, A., & O’Neill, K. (2001). Loss and human
resilience. Applied and Preventive Psychology, 10, 193–206.
Bonanno, G. A., Rennicke, C., Dekel, S., & Rosen, J. (2003). Selfenhancement
and resilience among survivors of the September 11th
terrorist attack on the World Trade Center. Manuscript in preparation.
Bonanno, G. A., & Singer, J. L. (1990). Repressor personality style:
Theoretical and methodological implications for health and pathology.
In J. L. Singer (Ed.), Repression and dissociation (pp. 435–470).
Chicago: University of Chicago Press.
Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring,
M., Sonnega, J., et al. (2002). Resilience to loss and chronic grief: A
prospective study from pre-loss to 18 months post-loss. Journal of
Personality and Social Psychology, 83, 1150–1164.
Bonanno, G. A., Wortman, C. B., & Nesse, R. M. (in press). Patterns of
resilience and maladjustment before and after the death of a spouse.
Psychology and Aging.
Bowlby, J. (1980). Loss: Sadness and depression: Vol. 3. Attachment and
loss. New York: Basic Books.
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of
risk factors for posttraumatic stress disorder in trauma-exposed adults.
Journal of Consulting and Clinical Psychology, 68, 748–766.
Bryant, R. A., Harvey, A. G., Guthrie, R. M., & Moulds, M. L. (2000). A
prospective study of psychophysiological arousal, acute stress disorder,
and posttraumatic stress disorder. Journal of Abnormal Psychology,
109, 341–344.
Buckley, T. C., Blanchard, E. B., & Hickling, E. J. (1996). A prospective
examination of delayed onset PTSD secondary to motor vehicle accidents.
Journal of Abnormal Psychology, 103, 617–625.
Carden˜a, E., Holen, A., McFarlane, A., Solomon, Z., Wilkinson, C., &
Spiegel, D. (1994). A multisite study of acute stress reactions to a
disaster. In T. A. Widiger, A. J. Frances, H. A. Pincus, R. Ross, M. B.
First, W. Davis, & M. Kline (Eds.), DSM–IV sourcebook (pp. 377–
391). Washington DC: American Psychiatric Association.
Casella, L., & Motta, R. W. (1990). Comparison of characteristics of
Vietnam veterans with and without posttraumatic stress disorder.
Reports, 67, 595–605.
Colak, D., Bonanno, G. A., Keltner, D., Noll, J. G., Putnam, F. W., &
Trickett, P. (2003). Positive emotion and long-term adjustment among
young adult survivors of childhood sexual abuse. Manuscript in
Cowen, E. L. (1991). The pursuit of wellness. American Psychologist, 46,
Dawes, R. M. (1994). House of cards. New York: Free Press.
Ehlers, A., Mayou, R. A., & Bryant, B. (1998). Psychological predictors
of chronic posttraumatic stress disorder after motor vehicle accidents.
Journal of Abnormal Psychology, 107, 508–519.
Florian, V., Mikulincer, M., & Taubman, O. (1995). Does hardiness
contribute to mental health during a stressful real-life situation? The
roles of appraisal and coping. Journal of Personality and Social Psychology,
68, 687–695.
Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A.,
& Street, G. P. (1999). A comparison of exposure therapy, stress
inoculation training, and their combination for reducing posttraumatic
stress disorder in female assault victims. Journal of Consulting and
Clinical Psychology, 67, 194–200.
Fredrickson, B. L., & Levenson, R. W. (1998). Positive emotions speed
recovery from the cardiovascular sequelae of negative emotions. Cognition
and Emotion, 12, 191–220.
Fredrickson, B. L., Tugade, M. M., Waugh, C. E., & Larkin, G. R. (2003).
What good are positive emotions in crisis? A prospective study of
resilience and emotion following the terrorist attacks on the United
States on September 11th, 2001. Journal of Personality and Social
Psychology, 84, 365–376.
Freud, S. (1957). Mourning and melancholia. In J. Strachey (Ed.), The
standard edition of the complete psychological works of Sigmund Freud
(Vol. 14, pp. 152–170). London: Hogarth Press. (Original work published
Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J.,
& Vlahov, D. (2002). Psychological sequelae of the September 11
terrorist attacks in New York City. New England Journal of Medicine,
346, 982–987.
Galea, S., Resnick, H., Ahern, J., Gold, J., Bucuvalas, M., Kilpatrick, D.,
et al. (2002). Posttraumatic stress disorder in Manhattan, New York
City, after the September 11th terrorist attacks. Journal of Urban
Health Studies, 79, 340–353.
Galea, S., Vlahov, D., Resnick, H., Ahern, J., Ezra, S., Gold, J., et al.
(2003). Trends of probably post-traumatic stress disorder in New York
City after the September 11th terrorist attacks. American Journal of
Epidemiology, 158, 514–524.
Garmezy, N. (1991). Resilience and vulnerability to adverse developmental
outcomes associated with poverty. American Behavioral Scientist,
34, 416–430.
Greenwald, A. G. (1980). The totalitarian ego: Fabrication and revision of
personal history. American Psychologist, 35, 603–618.
Hanson, R. F., Kilpatrick, D. G., Freedy, J. R., & Saunders, B. E. (1995).
Los Angeles County after the 1992 civil disturbance: Degree of exposure
and impact on mental health. Journal of Consulting and Clinical
Psychology, 63, 987–996.
Holen, A. (1990). A long-term outcome study of survivors from a disaster:
The Alexander L. Kielland disaster in perspective. Oslo, Norway:
University of Oslo Press.
Kato, P. M., & Mann, T. (1999). A synthesis of psychological interventions
for the bereaved. Clinical Psychology Review, 19, 275–296.
Keltner, D., & Bonanno, G. A. (1997). A study of laughter and dissociation:
Distinct correlates of laughter and smiling during bereavement.
Journal of Personality and Social Psychology, 73, 687–702.
King, D. W., King, L. A., Foy, D. W., Keane, T. M., & Fairbank, J. A.
(1999). Posttraumatic stress disorder in a national sample of female
and male Vietnam veterans: Risk factors, war-zone stressors, and
resilience–recovery variables. Journal of Abnormal Psychology, 108,
Kobasa, S. C., Maddi, S. R., & Kahn, S. (1982). Hardiness and health: A
prospective study. Journal of Personality and Social Psychology, 42,
Lamprecht, F., & Sack, M. (2002). Posttraumatic stress disorder revisited.
Psychosomatic Medicine, 64, 222–237.
Litz, B. T., Gray, M. J., Bryant, R. A., & Adler, A. B. (2002). Early
intervention for trauma: Current status and future directions. Clinical
Psychology: Science and Practice, 9, 112–134.
Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of
resilience: A critical evaluation and guidelines for future work. Child
Development, 71, 543–562.
Luthar, S. S., Doernberger, C. H., & Zigler, E. (1993). Resilience is not a
unidimensional construct: Insights from a prospective study of innercity
adolescents. Development and Psychopathology, 5, 703–717.
Masten, A. S. (2001). Ordinary magic: Resilience processes in development.
American Psychologist, 56, 227–238.
Mayou, R. A., Ehlers, A., & Hobbs, M. (2000). Psychological debriefing
for road traffic accident victims. British Journal of Psychiatry, 176,
McFarlane, A. C., & Yehuda, R. (1996). Resilience, vulnerability, and the
course of posttraumatic reactions. In B. A. van der Kolk, A. C. Mc-
Farlane, & L. Weisaeth (Eds.), Traumatic stress (pp. 155–181). New
York: Guilford Press.
Middleton, W., Burnett, P., Raphael, B., & Martinek, N. (1996). The
bereavement response: A cluster analysis. British Journal of Psychiatry,
169, 167–171.
Middleton, W., Moylan, A., Raphael, B., Burnett, P., & Martinek, N.
(1993). An international perspective on bereavement related concepts.
Australian and New Zealand Journal of Psychiatry, 27, 457–463.
Miller, J. (2002). Affirming flames: Debriefing survivors of the World
Trade Center attack. Brief Treatment and Crisis Intervention, 21, 85–
Mitchell, J. T. (1983). When disaster strikes. . . : The critical incident
stress debriefing process. Journal of Emergency Medical Services, 8,
Mitchell, J. T., & Everly, G. S., Jr. (2000). Critical incident stress
management and critical incident stress debriefing: Evolutions, effects,
and outcomes. In B. Raphael & J. P. Wilson (Eds.), Psychological
debriefing: Theory, practice, and evidence (pp. 71–90). Cambridge,
England: Cambridge University Press.
Neimeyer, R. A. (2000). Searching for the meaning of meaning: Grief
therapy and the process of reconstruction. Death Studies, 24, 541–558.
Osterweis, M., Solomon, F., & Green, F. (1984). Bereavement: Reactions,
consequences, and care. Washington, DC: National Academy Press.
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors
of posttraumatic stress disorder and symptoms in adults: A metaanalysis.
Psychological Bulletin, 129, 52–71.
Paulhus, D. L. (1998). Interpersonal and intrapsychic adaptiveness of trait
self-enhancement: A mixed blessing? Journal of Personality and Social
Psychology, 74, 1197–1208.
Rando, T. A. (1992). The increasing prevalence of complicated mourning:
The onslaught is just beginning. Omega, 26, 43–59.
Resick, P. A. (2001). Stress and trauma. Philadelphia: Taylor and Francis.
Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., & Best,
C. L. (1993). Prevalence of civilian trauma and posttraumatic stress
disorder in a representative national sample of women. Journal of
Consulting and Clinical Psychology, 61, 984–991.
Rose, S., Brewin, C. R., Andrews, B., & Kirk, M. (1999). A randomized
controlled trial of individual psychological debriefing for victims of
violent crime. Psychological Medicine, 29, 793–799.
Rutter, M. (1987). Psychosocial resilience and protective mechanisms.
American Journal of Orthopsychiatry, 57, 316–331.
Rutter, M. (1999). Resilience concepts and findings: Implications for
family therapy. Journal of Family Therapy, 21, 119–144.
Safer, M. A., Bonanno, G. A., & Field, N. P. (2001). It was never that bad:
Biased recall of grief and long-term adjustment to the death of a spouse.
Memory, 9, 195–204.
Stroebe, M. S., & Stroebe, W. (1991). Does “grief work” work? Journal
of Consulting and Clinical Psychology, 59, 479–482.
Sutker, P. B., Davis, J. M., Uddo, M., & Ditta, S. R. (1995). War zone
stress, personal resources, and PTSD in Perian Gulf War returnees.
Journal of Abnormal Psychology, 104, 444–452.
Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: A social
psychological perspective on mental health. Psychological Bulletin,
103, 193–210.
Taylor, S. E., Kemeny, M. E., Reed, G. M., Bower, J. E., & Gruenewald,
T. L. (2000). Psychological resources, positive illusions, and health.
American Psychologist, 55, 99–109.
Tucker, P., Pfefferbaum, B., Doughty, D. B., Jones, D. E., Jordan, F. B.,
& Nixon, S. J. (2002). Body handlers after terrorism in Oklahoma City:
Predictors of posttraumatic stress and other symptoms. American Journal
of Orthopsychiatry, 72, 469–475.
Tversky, A., & Kahneman, D. (1974, September 27). Judgment under
uncertainty: Heuristics and biases. Science, 185, 1124–1131.
Weinberger, D. A. (1990). The construct validity of the repressive coping
style. In J. L. Singer (Ed.), Repression and dissociation: Implications
for personality theory, psychopathology and health (pp. 337–386).
Chicago: University of Chicago Press.
Weinberger, D. A., Schwartz, G. E., & Davidson, R. J. (1979). Lowanxious
and repressive coping styles: Psychometric patterns of behavioral
and physiological responses to stress. Journal of Abnormal Psychology,
88, 369–380.
Werner, E. E. (1995). Resilience in development. Current Directions in
Psychological Science, 4, 81–85.
Wortman, C. B., & Silver, R. C. (1989). The myths of coping with loss.
Journal of Consulting and Clinical Psychology, 57, 349–357.
Zisook, S., Paulus, M., Shuchter, S. R., & Judd, L. L. (1997). The many
faces of depression following spousal bereavement. Journal of Affective
Disorders, 45, 85–94.
Zoellner, L. A., Fitzgibbons, L. A., & Foa, E. B. (2001). Cognitive–
behavioral approaches to PTSD. In J. P. Wilson, M. J. Friedman, &
J. D. Lindy (Eds.), Treating psychological trauma and PTSD (pp.
159–182). New York: Guilford Press.
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