The Resilience Paradox

Host 00:00
From the Mount Sinai Health System in New York City. This is Road to Resilience, a podcast about facing adversity. I'm Jon Earle. My guest today is Dr. George Bonanno. He's a Professor of Clinical Psychology at Columbia University's Teachers College. Dr. Bonanno has been studying trauma, bereavement and resilience for decades, and he's reached a surprising conclusion—resilience, he says, is common. It's how most people respond to challenging experiences. In our conversation, we talk about that and mental flexibility, which, in a new book titled The End of Trauma, he argues ties all the resilience factors together. So here's Dr. George Bonanno. Enjoy. Dr. Bonanno, welcome to Road to Resilience.

Dr. George Bonanno 00:46
Thank you, Jon. Happy to be here.

Host 00:48
So I want to start out with a bit about your background. I know you've been working on resilience and grief and bereavement for many years. How did you get interested in this subject?

Dr. George Bonanno 01:00
Well, that's a wonderful question. I actually love answering this question. It was completely an accident. I had been doing a lot of experimental work as a doctoral student, and at the end of that tenure as a doctoral student, I felt like I was getting lost in the experimental design that I was doing. I'm a trained clinical psychologist, and I was getting too far away from what I really wanted to do. So I decided to do a post-doctoral fellowship with a very famous trauma researcher, Mardi Horowitz, out in San Francisco, but he wanted me to head a project not about trauma, but about bereavement. And we right away began to study large groups of people right after a loss and follow them over time, which was a novel approach in those days. Most of it was sort of clinically focused on people who couldn't recover from their losses. So we really just got kind of everybody and we followed them over time and we used experimental techniques. We studied facial expressions, we used psychophysiology. And almost immediately we began to see a great deal of resilience and we didn't use the word yet because it wasn't used then, but we began to see that many people, though they were upset when they talked about the loss, they were basically functioning well and able to move on with their lives. And I did that for a number of years, and then gradually I began to get interested in trauma more broadly. And I was in New York by this time, at Columbia, I had moved to Columbia University, and this was right around I guess it was 1999. And then 9/11 happened.

Host 02:43
Correct me if I'm wrong, but one of your main conclusions in your work in general, in the 9/11 work, and again in the new book, is that resilience is common.

Dr. George Bonanno 02:52
Yes, absolutely.

Host 02:54
It's not some special quality that superhumans have that we all should be looking to this select few that are resilient. It's not like that at all.

Dr. George Bonanno 03:01
You're exactly right, Jon. And I don't know exactly why that was hidden from view. But we began to simply follow people over time. And we always saw this, that large numbers of people, usually the majority, actually almost always the majority of people exposed to all kinds of adverse events—we looked at some pretty nasty events—and almost always the majority show pretty much stable mental health. Everybody gets a little bit upset and in fact people can be quite a bit upset for a week or two after an event, that's quite natural, but then it passes and they continue to function often the way they had before. They're able to work. They're able to concentrate. They're able to be loving with the people in their lives—all those things that we consider mental health. And we've now done, gosh, I don't know, recently we did a review of 54 different studies doing the same kind of approach we use and we found that it's around two-thirds.

Host 04:04
So in other words two-thirds of people who go through a potentially traumatic event, they may experience post-traumatic stress for a period of days or weeks, but then they return to something that's more or less their normal functioning state.

Dr. George Bonanno 04:16
Yes.

Host 04:17
I can't emphasize enough how much this flies in the face of the popular conception of trauma and PTSD. There's an assumption that people who go through things like 9/11, oh they're just gonna be messed up forever, you know? So this was really surprising.

Dr. George Bonanno 04:33
Yeah. And I've thought about this a lot. Because early in my career, people didn't refute what I said as much as just ignore it and then gradually it began, the idea is kind of now catching—it's moving with considerable progress through the field, and people are, and I think sometimes people now say these things without even knowing where it came from. It's becoming a common idea. But I think why we're so slow to accept this idea—there are a couple of good reasons. I think, first of all, a lot of the literature on potentially traumatic events and bereavement as well, also came from the clinical world—people who were studying their patients or studying clinical patients. So they were basically looking at people who were not getting over the event. And many mental health professionals, those are the people they see when there's a traumatic event or a potentially traumatic event. They don't see resilient people, people who are resilient afterwards, because they have no reason to talk with them. So they develop a very, very human bias to assume that traumatic events cause chronic problems. This then is also magnified by the media. Nothing is evil here, it's just simply because it's more attention-getting to talk about adverse consequences. But I think also in the general public, we want short memes. Memes are everywhere. We want short, simple things we can hold on to, and the idea that traumatic events or potentially traumatic events are harmful is the meme. And there are probably even more reasons, but I think that's slowly changing. But still I sometimes have people come up to me after a talk and say, "I'm sorry, but you are just wrong. I don't care what your little studies say." I don't get offended by this. I did a little bit at first, but I just say, well okay, whatever.

Host 06:40
I think it's important to say that—so you mentioned that the two-thirds who after days or weeks bounce back to something like normal. There's another trajectory that's more gradual where people take a little bit longer to bounce back. And then there's the third trajectory, which is the chronic, the post-traumatic stress disorder trajectory. And I just want to say that there is incredible resilience in each of these. So when we're referring to resilience and a resilient person, that's strictly in the confines of this conversation, that's the two-thirds that bounce back relatively quickly.

Dr. George Bonanno 07:10
Yeah. And Jon, I should've clarified that. So there's a lot of confusion, there's probably even more confusion about the word "resilience." And I think it's related to the sort of confusion about trauma and PTSD. Because, I don't know, from a philosophical viewpoint, we've essentialized these things. "These events are not normal events. They are special events and they cause PTSD, and it's there whether we are aware of it or not." That's essentialism. But the idea then that people are resilient could only be defined in the same way, as essentialist. It's in the person. And I have to force myself not to speak that way because it's so common. But resilience is not in the person, resilience is an outcome. And people are resilient to an event. So that's the way I use it. Now, people may recover and people do recover. That's a different kind of process. We can call that "resilience," I mean, I prefer to call it "recovery" because it's more accurate, and that's in fact what we call it in the research to distinguish it. That's not to say they're not—they've worked hard and they've done this, they've gotten over this thing. They certainly have worked hard to do that. But I think just in terms of being specific, resilience in my mind is that outcome. We can only be resilient to something. So when an event happens we're resilient to it, that's the outcome that we're talking about. At least that's how I'm using it.

Host 08:43
You brought up 9/11 a bit earlier. This episode will be coming out right around the 20th anniversary of 9/11. And it's a great example of the misconception, the idea—there was an assumption in the immediate aftermath that there would be a huge wave of people needing mental health services and just this overwhelming wave. And that didn't turn out to be the case, to your point.

Dr. George Bonanno 09:08
That's a perfect example that we still need to relearn because it happens almost every time we have a mass-disaster event. When we are in the throes of what I'm calling traumatic stress, the first few days or a couple of weeks, any time in that initial period after there is a potentially traumatic event, and a disaster is even more dramatic because it influences many people who are then looking and talking to each other. When we feel that way, it's hard not to believe that it won't last forever or won't last a long time. And because we've been so focused on PTSD in our minds, in our culture, trauma, when we're having nightmares, when we're thinking about the event, having intrusive images or memories pop into our minds and a ghastly image suddenly pops into mind and we try to push it away. When we're feeling on edge for more than a day or two, we're on edge for 10 days, say, that makes us think or assume that we are traumatized and this will become PTSD. But in fact those reactions are perfectly natural. That's our stress system dealing with what we've experienced, that we can look at those things a little bit more closely. Intrusive thoughts popping into our mind is actually a very adaptive way to learn from the event. And you think of that across the course of human evolution, this was hugely adaptive because we learn, we think, what happened and what can I do to prevent that from happening again, or make sure it doesn't happen again? So after 9/11, to get back to your question, many, many people were confused and upset and having images and having nightmares in New York, for sure, and in fact after 9/11 there was a market increase in anxiety and distress and some PTSD symptoms in many people, particularly in New York, but also across the country. And then to everybody's surprise within a few months, probably within a month, but nobody had measured, it pretty much disappeared. People still talked about 9/11. People still felt a little anxious about it, but most people were functioning normally. And that is very much documented after 9/11. The same thing is happening in the COVID crisis. There was a marked increase in distress and anxiety symptoms, and many newspapers carried many reports, mental health experts saying, "We are in for a mental health crisis of unprecedented proportions. There'll be mass suicide. There will be PTSD everywhere. There'll be anxiety everywhere." And that hasn't happened.

Host 11:56
I want to move to another misconception that you have tackled. And it's the idea that we know where resilience comes from, that we know how to cultivate it. I think in the popular imagination, there are—I'll say countless articles about how to cultivate resilience. And they go through the mindsets and the habits and all the different things that are associated, perhaps with resilience in research, perhaps associated simply in our imagination with resilience, that seemed like they're resilient-y. But you identify something that you call the resilience paradox, which is that these things are mostly—well, I'll have you explain it, but these things are mostly weakly correlated with resilience, and in fact they don't add up to resilience. We can't look at a person and assess their, let's say optimism or how much they meditate, any of these things, and predict whether or not they will be resilient after an event.

Dr. George Bonanno 12:49
You're exactly right. It's very common to see in the newspapers and even in some scholarly work the magic traits of resilience, the five or seven traits. And when we think about resilience that way, then we could easily assume we just have to bolster those traits and then people will be more resilient. And it's enormously popular. And I'm a little bit chagrined to say this, it's also highly marketable. And many, I think, a number of people are marketing themselves to corporations and other entities that can pay for it. And I'm sorry if this is cynical and I don't mean to sound so critical, but people are doing this, and they're basically resilience experts who will then teach people how to be resilient. And I've rallied against this for a number of years. And because as you say this phenomenon I've called the resilience paradox. And the idea of the paradox is just this, as you mentioned, Jon, that we can identify who's resilient afterwards, after an event, we can identify factors that are correlated with it, but each one of those things individually explains only a tiny bit. If we think of resilience as a pie, there are tiny little slices of pie. And I've puzzled over this for years. Well then how is this possible? And then I began to realize, I'd been doing an independent line of work on flexibility, and I'm almost embarrassed to say this that I didn't see the connection for a long time. And then it dawned on me what flexibility is about, what I've been studying, is how people deal with an immediate situation. And we broke it down into different pieces, like the way people assess what's happening to them, the kind of behaviors that they have at their disposal, and their ability to update or to modify what's happening. If it's not working, they can try something else. And that idea really is about taking the problem at hand and trying to get through it, and then taking the next problem at hand and the next. And it's based on the idea—I realize I'm mentioning a number of different ideas at once—but it's based on the simple fact that no matter what behavior we have, be it optimism or problem-solving ability or talking to other people or seeking support from your friends, none of those behaviors, none of those traits and behaviors are ever always effective. And this is true anywhere in nature, that everything has cost and benefits, everything works sometimes and not other times, and sometimes it's even harmful.

Dr. George Bonanno 15:32
A great example is what emotion researchers call reappraisal. When an event happens, you rethink, you reframe it in another way, and that helps us deal with it. And that's probably the most popular emotion-regulation strategy out there, most people consider it kind of the best strategy. But there's now research showing that in some situations reappraisal doesn't work very well, and in some situations it actually makes people worse. Because instead of reappraising the meaning, they should have just changed the situation and they would be okay depending on the situation. Another one is mindfulness. We tend to think of mindfulness as a kind of a panacea. And, full disclosure, I practice mindfulness and I like it. It's very helpful. But it's a tool like anything else. Sorry to Buddhists out there who think that mindfulness is—and I know there are many who think that mindfulness is part of a philosophy of life, which I believe it is, but there isn't much data linking mindfulness to resilience. As much as we think mindfulness makes people resilient, there's really hardly any data. And resilience, again, in the way I'm thinking of it. And there's plenty of reason, there's plenty of arguments and there's some data to suggest that mindfulness can be maladaptive in certain situations, particularly when we're highly distressed. Mindfulness can actually make people worse sometimes in those situations, because we focus internally and we may actually become more focused on what's going on inside us, and it may be disturbing. So regardless of the factor, there's always a cost to it.

Host 17:08
There were two examples that struck me from the book when you're writing about a young man named Jed who has been through a very difficult experience. One was distraction and one was social support. And this is to your point that even these tools, resilience tools, that are generally thought of as good in the case of social support, bad in the case of distraction. I think I certainly think of distractions as like, well, the person is avoiding the experience, they're avoiding dealing with it. That's bad. But in fact, you're saying that it can be one of the tools that's appropriate at a certain time, in a certain place, for someone with a certain experience. These are all—what we have as a toolkit. There's no single prescription to resilience that applies to everybody at every time.

Dr. George Bonanno 17:54
Yes, absolutely. Basically anything we might use all the time would be maladaptive. But we can use any mechanism, any behavior, any trait like social support, any quality or resource we have, or ability, like distraction—in some situations we can use it. And something that's good, like social support, is not always useful. And there are many reasons for that.

Host 18:19
There's the—well, the part in the book when he isolates, he decides to be in less contact with his outer circle or even his close friends and really reduce it to his closest inner circle. And that's what he needs at that period of time.

Dr. George Bonanno 18:34
Yes, absolutely. And in an earlier book about bereavement, The Other Side of Sadness, I had coined the term, actually in some scientific articles before that, I'd coined the term "coping ugly." And I mention that as well in the new book. What I mean by coping ugly is we might even use behaviors that we don't even imagine they're adaptive, like things that really are not so healthy, but in one situation, even for an evening, like getting drunk, or something like that. And there are many examples of people doing this, "I just had to completely just get out and be with friends and get drunk." And even though the next day they're not feeling so good, it was a way to kind of kickstart something else. And people told me about these things over the years that they—in that moment, it's useful. It's not useful to be drunk for the next two months after an event. I mean, it really is again, because we have to just deal with what's happening to us at that moment. What do I need to do right now? And that moment could stretch on for a while, but what do I need to do right now to get through this? And that's what we need to do. We don't have—there is no prescription that we just look into. And you mentioned that we choose from what we're able to do, and that's what I call the repertoire component of flexibility. And that's something we can actually do. It can actually build, we can build ourselves a broader repertoire. We can try new things and ideally we would do that before something happens. It's harder to do it then, but you know, it's really, it's very hard to try new things and develop new skills and behaviors when we're really stressed, but, you know, that's really part of the process.

Host 20:24
You break up flexibility into two parts. First, there's the mindset, and then there's the sequence. So let's start with the mindset. Can you take us through what the flexibility mindset is?

Dr. George Bonanno 20:35
So the mindset is part of my effort to come to terms with these small, little, tiny effects of the resilience paradox. And there are actually three components I define of the mindset: optimism, confidence in our ability to cope, and the sense of challenge. We think, okay, whatever's happening to me, I see it as a challenge. And those three things, and there may be others, but these seem to be the most well-researched. And these three components— optimism, confidence in our ability to cope, and the sense of focusing on things as a challenge—have all been empirically linked to resilient outcomes. They all are highly related to each other. And again, the relationships are very small, but what they do is they don't make a person resilient. What they do is get a person focused on the task at hand. And when we're focused on the task at hand, then we say, okay, what do I need to do here? We don't say, I'm resilient or I'm not resilient, or this is horrible and I'm never going to get through this. Instead we say, alright, things will be better in the future. I have some skills in coping with things. And let's look at the problem. What is it that I need to do here? And those three things together kind of have a little synergy about them. They feed off each other, and there's some research, of course, showing this as well. And they, as I like to use the term, get us into the game, they get us focused on it.

Host 22:00
Yeah. It's the thing that powers the resilience, it powers someone to go through what we'll talk about in a moment, which is the sequence, which is this sort of trial and error of trying out some of the tools that people are familiar with, many of these that are in the popular mind. So what's the sequence all about how would somebody move through that?

Dr. George Bonanno 22:19
Just to add one more point to what you just said about driving the rest of it. I mean, potentially traumatic events, highly aversive events, scary events, medical procedures that are frightening to us—all of those things put us into a state of being uneasy and we don't want to think about it. And, you know, it's much easier to say, I'm traumatized, this is horrible. But the mindset gets us to think about it in a constructive way, and we're a little resistant to that, it's not easy to do that, but once we do that, then we can engage with the flexibility secrets, which is the second part that you mentioned. So the flexibility sequence, I've been studying this in different ways for about 15 years. And the three components are, first, we call the first component context sensitivity. We have to look at what's happening to us, the context around us. What is happening? We can ask ourselves these questions. What's happening? What do I need to do here? What am I feeling? And when we answer those questions, it's often not so difficult when we actually think about it. Then we get a sense of actually what do we need to do here for this particular problem at this moment in time? Not the whole game, not the whole broad picture, but this particular moment. Something is happening to me right now. I'm having nightmares, or I can't stop thinking about this event, or I'm feeling like I want to hide from other people, or I'm really worried about myself. Whatever the problem may be, we can focus on that problem. But once we identify the problem, we get a sense of what I need to do. Do I need to find a way to distract myself? Or do I need to find a way to—maybe I shouldn't be around other people. I need to work that into my life somehow and find a way to make that so it's not confusing for other people. Or I need to look at what these intrusive thoughts are, or etc. Or the nightmares—maybe I need to accept that these nightmares are going to happen and somebody can make sure I'm safe, whatever the problem might be. And then once we understand that, then we shift into the second part. So the first is looking at what I need to do, then we shift to the second part, which I call repertoire, which is really what am I able to do? Okay. I know kind of what the problem is, but what are the tools at my disposal? This is the repertoire component we just talked about a minute ago. What are the tools I have? What can I do? What's at my disposal? Other people: my wife, my friend, my partner, my good friends, my parents, my children, whatever we have, whatever it might be, the abilities we have. I can do this. And we then try something. We come up with a plan. I'll do this. And then we slide naturally into the third part, which I call feedback responsiveness. It's a little technical sounding, but what that really means is we're really just checking what's happening. Is it working? Is this helping us? Is it really addressing this problem that's happened to us right now? And if it isn't, then we slide backwards and say, okay, let's try something else that might work. And we explore this. What is it that will work? What will help me right here? And that kind of runs its course. Sometimes we repeat it a few times. It runs its course and, you know, that isn't the whole picture, we're not done yet, but then typically we move on to something else. What else is happening to me? And typically these highly aversive events, they're not stagnant. They change over time. So new or different things that we're confronted with, and we simply again ask ourselves, well, what's happening now? Am I okay? Is there something bothering me? Is there something that is not right? And then again, what tools do I have at my disposal to address that? And then try again. Is it working? And what I find is, actually, I didn't mention this in the book and I'm regretting that, is that what's so important about this approach, whether it be flexibility or some other approach that's similar to it, is it shifts us, and the mindset as well, shifts us from the whole picture, which can be very disturbing. "Maybe I'm traumatized. Oh, this is really bad. I feel terrible. Or maybe I have a health problem now. I don't know how I am going to live my life." Any of these things that happen to us, it shifts us from that broad picture, which we sometimes need to think about, of course, but it shifts us more to what is happening to me right now. And that surprisingly—this may be really shocking to some people—but it's surprisingly uplifting. It gives us a sense of, okay, I can do this. I got it. I can do this. And then we shift to the next thing and, okay, I can do this too. It takes us away from this big scary thing that's happening to us and instead allows us to say, "Well, if I can manage this, maybe I can manage this as well. And I have some control over what's happening to me."

Host 27:25
I managed the last thing. I can figure this one out. Listening to you, it strikes me—it's like it turns it into a sort of engineering problem. It's like the mindset gives you the will to do the work. And then the sequence is sort of, oh, well this is this very concrete problem—again, we're not focusing on the 10,000 foot problem—what's our problem right now? Let's figure this out. What are the tools I have? Let's try this tool. Did it work? No. Let's try something else. Tomorrow, what's the problem now? What are the tools I have? And going through that again and again. It's a constant process.

Dr. George Bonanno 27:58
Yeah, absolutely. I haven't ever thought of it as an engineering problem, but various people have suggested metaphors that are, I guess, very engineering-oriented. But I've never quite been able to find anything that fits quite so well.

Host 28:15
How can somebody prepare themselves for a potentially traumatic event that will make it more likely that they will be resilient to it?

Dr. George Bonanno 28:23
Well, I've tried to embrace that a little bit in the book. I don't normally do intervention work or this kind of work, but I think that we can think about these things in advance and we can just kind of assess them in our life. We can also use them for everyday problems. You know, there's no shortage of financial concerns or other kinds of things that bother us. And we can begin to think about those everyday problems this way as a kind of a way to start using, if we're so inclined, to use these ideas or these skills. So if we take the flexibility mindset, I think we can begin kind of by reviewing our life and thinking, well, to cultivate, say, optimism, challenge orientation, thinking about events as challenges, and the sense of confidence in coping. There's pretty good research that all three of these things can be enhanced. There isn't an enormous amount of research, but they seem to be learnable. And there are people who have written about learned optimism. Martin Seligman, the famous positive psychologist, has written about, I think he wrote a book called, Learned Optimism. I haven't looked at it yet, but I think the idea is very appealing. And I think we go back to our life and think, I got through all these other things. Obviously, most people have. So things kind of happen to us and then it's okay afterwards. So that can help us be more optimistic that we'll be able to deal with other things. We can evaluate what we're able to do, which both gives us confidence and is also the repertoire component. What can I actually do? What have I actually done in the past? Are there things I could try that I haven't tried? And maybe enhance those skills before anything happens by simply thinking about it and maybe trying some new things. What if instead of getting angry on the phone with the person who wasn't helping me, maybe I can try being nice to that person and see what happens? Or being pleasant? Just see what happens. And then, of course, the feedback component, monitoring what we try. Most people are also pretty good at that. We have, again, shown that in our research. And we don't pay attention to it. We just sort of do it. But we can begin to pay attention to it and say, okay, did that actually work? And we mentally learn from that.

Host 30:51
This was wonderful. George, thank you so much for coming on the podcast.

Dr. George Bonanno 30:54
Sure, absolutely. My pleasure.

Host 30:57
Dr. George Bonanno is a Professor of Clinical Psychology at Columbia University's Teachers College. His new book is The End of Trauma. That's all for this episode of Road to Resilience. The podcast is a production of the Mount Sinai Health System in New York City. It's made by me, Jon Earle, Nicci Cheatham, Emma Stoneham, and our executive producer, Lucia Lee. From all of us here, as always, thanks for listening. And we'll see you next time.