Current Psychiatry Reviews - Volume 11, Issue 3, 2015

The term resilience is too often poorly operationalized and loosely conceptualized. Historically, it has been defined as a trait, characteristic, or collection of resources that facilitates healthy adjustment to a potentially traumatic event (PTE) and has typically been measured at one point in time. More recently, it has been defined as an outcome, or a successful course of adaptation following exposure to a severe and overwhelming experience. Inherent in this definition is the expectation that a cross-sectional evaluation will fall short; if resilience is an adaptation to an experience, it must then unfold over time. Unfortunately, the absence of a single unifying paradigm of resilience has hindered progress in the field. In this review, we discuss the handful of characteristics that are most consistently linked to low levels of distress following exposure to a PTE and describe several prototypic trait resilience measures for adults. We also describe and critically evaluate research that has generated distinct typologies or groups with similar trajectories of adjustment following exposure to PTEs. Finally, we provide examples of several studies of interventions to promote resilience. Ultimately, for the field to advance, clinicians, researchers, and policy-makers need to isolate the factors that reliably promote a successful adjustment across a broad range of domains, including emotional, physical, and occupational functioning. Once known, prevention and intervention strategies need to be refined and tested so that suffering and dysfunction can be mitigated before chronic and debilitating distress become entrenched in those who do not recover on their own.

The current review describes evidence for the critical role of executive functioning in the development and/or maintenance of posttraumatic stress disorder (PTSD). As part of this review, we describe associations between executive functioning, intrusive thoughts, and PTSD. Moreover, we explore evidence for the utility of cognitive training programs to improve executive functioning as a potential novel treatment approach. A model is presented that depicts how poor executive functioning and associated intrusive thoughts, in the context of unsuccessful attempt to regulate cognitions and emotions, may lead to or perpetuate PTSD symptoms.

Interest in psychotherapeutic interventions for posttraumatic stress disorder (PTSD) populations that address variants of commonly co-occurring trauma sequelae is emerging. Specifically, treatment approaches that enhance an individual’s capacity to experience and successfully modulate emotion, function interpersonally, and access social support are of particular value. The present paper briefly describes emotional and social difficulties commonly experienced by trauma survivors and outlines potential targets for intervention within the context of trauma-focused treatment. Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy is a skills-focused approach designed to foster the development and strengthening of emotion regulation and interpersonal skills and promote resilience. Empirical evidence supporting the efficacy of STAIR Narrative Therapy as an effective treatment for PTSD as well as emotion regulation and social difficulties is reviewed. Implications for treatment and directions for future research are presented.

This paper presents a narrative review of psychological treatments for posttraumatic stress disorder (PTSD) that foster cognitive flexibility. A literature search identifying all peer-reviewed studies that have been published in English resulted in 28 reports on a range of interventions. After a brief introduction to cognitive flexibility (CF), a review of all relevant studies is provided. Overall, there is some evidence for CF playing an important role in recovery from PTSD. However, very few studies include specific measures of CF and fewer still make use of statistical strategies that identify the impact of change in CF on symptom improvement, limiting the conclusions that can be drawn from their results. Given the mixed findings, future research that incorporates objective and self-report measures of CF along with appropriate statistical methods is warranted. Suggestions for optimizing change in CF during treatment for PTSD, such as incorporating mindfulness skills, are discussed.

Moral injury and acceptance and commitment therapy (ACT) are both topics that have only quite recently been introduced into the mental health literature. Although inquiries into these two domains have been advanced independent from one another, both challenge various aspects of the traditional medical model for diagnosing, understanding, and treating psychiatric problems. This article explores complementary possibilities for using ACT to approach the care of persons with moral injury. Descriptions of moral injury and ACT are provided along with an overview of the developmental histories and relevant research literature in each of these domains. Specific possibilities for attending to moral injury are explored via examination of each of the six core processes in ACT: acceptance; cognitive defusion; contact with the present moment; self-as-context; values; and committed action. It is suggested that ACT has unique potential as an evidence-based psychotherapy for approaching numerous moral injury related issues. These include: understanding human suffering as normative, expectable, and potentially meaningful; balancing both verbal and experiential understandings of morality; fostering forgiveness in a manner that is not dismissive of guilt but employs it to orient towards values; holding and honoring morally injurious experiences in a way that respects and empathizes with ongoing suffering; identifying a sense of self from which to behaviorally enact valued actions; and inviting engagement from care providers and communities outside of the traditional mental health care system. Future conceptual and empirical work is needed, including studies examining the efficacy and effectiveness of ACT for moral injury.

Many of the most widely-used, empirically-supported treatments for mental health problems are comprised of some form of cognitive restructuring techniques that aim to replace clients’ pathological or distorted attributional processes with new, healthy appraisals of the situation or self. Yet, conventional cognitive restructuring techniques may be less effective when attempting to treat guilt and shame associated with distress that arises when someone commits a moral transgression. Accidental or intentional perpetration can cause “moral injury” to the guilty party, yet few therapeutic strategies have been developed to treat difficulties emanating from accurate self-blame appraisals. A working model for conceptualizing the emotional and behavioral consequences of committing a moral transgression is presented that utilizes characterological versus behavioral self-blame appraisals and guilt and shame as mediating variables that determine the ensuing psychological response after committing an act of perpetration. A critical review of the limited literature available on the psychological correlates of accidental and intentional perpetration is reviewed to provide initial support for the paper’s working model. Emotional exposure to the feelings of guilt and shame, modification of characterological self-blame appraisals, and behavioral reparations that facilitate forgiveness from self and others are argued to be the most effective strategies for treating moral injury.