Resiliency Through Psychotherapies for Guided Healing in Multiple Populations

TABLE OF CONTENTS

Abstract

CHAPTER 1: Introduction
Background of the Problem
Statement of the Problem
Purpose of the Study
Theoretical Framework
Research Questions
Hypothesis
Importance of the Study
Scope of the Study
Definition of Terms
Summary and Organization of the Remaining Chapters

CHAPTER 2: Literature Review

CHAPTER 3: Research Methods and Procedures
Methodology
Data Analysis
Methodological Assumptions and Limitations
Research Findings
Summary
Conclusions
Direction for Future Research
References

Abstract

Individuals and groups that are resilient adapt to disturbances in a successful manner to overcome adversity. This adaptive capacity for over-coming is dependent on multiples variables including social support, self-efficacy, and positive psychological coping methods. Resilience for military servicemen, families, and other individuals facing adversity emerge from a set of adaptive capacities which are often networked through personal connections, guidance of a mental health professional, or groups of social support. Useful correlations between resilient groups can aid in the formation of models to foster active coping skills which ensure success.

keywords: military and family coping, resilience, self-efficacy, resilient psychotherapies

Chapter One: Introduction

Resilience can be defined as an individual or group’s capacity to withstand and rebound from serious crises, persistent life challenge, or internal stressors (Walsh, 2002). The development of resilience focusing on guided psychotherapy may implement modalities which foster active coping skills, with emphasis on methods such as mindfulness-based approaches and the incorporations of existential/spiritually based programs (Park, 2007). Families faced with chronic or terminal illness, family members affected by traumatic injury, and families of military servicemen experience hurtles or adversities that often mirror one-another (Cacioppo, Reis & Zautra, 2011). The trials these groups face resonate between them. These trials can include facing one’s own mortality, isolation, and adjustment to unforeseeable trajectories (Cacioppo, Reis & Zautra, 2011). This resonating relationship can be seen in military families and those battling illness/injury as they utilize similar coping methods to respond to their hardships.

Ideological similarities or the ability to view others in the same light as we view ourselves is a gateway to meaning-making (Cacioppo, Reis & Zautra, 2011). Studying and treating similar populations that may share the same lens allows for the collection of information regarding styles these groups have used in response to adversity. Trauma specialist Dr. Robin Gurwitch has placed such treatments into practice as her team utilized resiliency-based methods (DeAngelis, 2013). Gurwitch selected military family resiliency as a course of study, predicting that this group could vastly benefit from such program implementation (DeAngelis, 2013). The Gurwitch team expanded their initial model of resiliency training to include families with members having cognitive impairment, individuals with brain injury, and also nonmilitary families in a project called FOCUS (Families Over Coming Under Stress). Researchers with the FOCUS group have also adapted Department of Defense (DoD) directed resilience-based treatments for couples, families with very young children and families that include service members who are wounded, ill or injured (DeAngelis, 2013). Resiliency training conducted in a collaborative study with University of California, Los Angelis (UCLA) and the Purdue University Military Family Research Institute targeted couples as they are a pillar for the successful coping of a family unit enduring stress (DeAngelis, 2013). Further study and potential cohesion of group research which emphasizes interpersonal coping styles can offer beneficial ties to promote the development of well-being, resilience to adversity, and the management of positive psychological functioning in a myriad of environmental demands (Benight & Bandura, 2004). Programs in the infancy of implementation, like those being brought forth by Dr. Gurwitch, show evidence-based research that resiliency-based models impact success in overcoming adversity (DeAngelis, 2013).

Background of the Problem

As much as individuals and communities try to prevent adversity or trauma from occurring, these scenarios inevitably exist (Sandberg & Grant, 2017). Leaning toward mental health professionals for education, support, and guidance to build a tool kit of resilience offers new meaning and “armor” when confronting these obstacles (Saltzman et al., 2011). Many survivors of cancer report their battles have allowed them a greater closeness with family or friends, and people with chronic illness often exhibit greater compassion and understanding for others (Breitbart et al., 2015). For families confronting illness or those experiencing unexpected turmoil during military deployment and reintegration, enabling protective measures acts as a shield to buffer harsh realities or environmental stressors (White, Driver & Warren, 2008).

Systematic understanding of family resilience in the protective process aids a therapist seeking to provide adaptational patterns for problematic contexts (Ungar, 2016). Adaptational patterns are strategies which are implemented to promote desirable outcomes (Unger, 2016).

Bolstering the ability to adapt to life’s changing creates a more successful journey. The capacity for veterans to actively use and sustain existing relationships appears to protect against psychopathy and reinforce resilience (Pietrzak & Southwick, 2011). A study that included predominately veterans who had served in the Reserves/National Guard conveyed a result of better resiliency rates among those veterans with a higher use of their social networks (Iacoviello & Charney, 2014). These social networks create a web of motivators that can model methods of adaptation to one-another or provide incentives for engagement in beneficial activities. Optimal use of social support structures can relieve stress through social dependence (Benight & Bandura, 2004). Those individuals that lack active social supports find less resilience when attempting to over-come hopelessness and hurtles (Benight & Bandura, 2004). This illustrates that a circle of influence that can breed positive feedback and encouragement among veterans during post-deployment, contributing toward successful resilience. Psychological, social, and biological factors impact resiliency (Paloutzian & Park, 2015). Advancements continue to be made which give insight to the brain’s ability to adapt through the method of teamwork bonding (Charney, 2004). Resilience has been noted as a key factor in those seeking to reintegrate into a community or home setting after hospitalization for traumatic injury (White, Driver & Warren, 2008). In the way that military members find ways of navigating hardships during reintegration, community or team mentalities offer insight to coping mechanism successes.

Becoming resilient requires a focused effort in response to pressing adversity. Seeking to understand what motivates clients or patients on different levels provides clinicians with fundamental principles to empower clients (Wong, 2009). Utilizing this knowledge can provide a framework for clinicians to promote healing for those encountering adversities. Factors that are included in the framework for resiliency include: spirituality, self-efficacy, social competence, family cohesion, social resources and personal structure (Benight & Bandura, 2004). “Internal motivators” that drive success can be a culmination of wisdom, knowledge of available coping skills, belief in one’s self, and perceived social support (Benight & Bandura, 2004) Religious reframing can be a model to facilitate meaning-making among those seeking to overcome trials (Paloutzian & Park, 2005). For example, events that can be visualized from the lens of a reward from God, lesson from God, opportunity from God, or God’s benevolent plan. This lens offers strategies of resilience (Emery & Pargament, 2004). Positive coping methods like spirituality and religion can be a useful tool to reduce stress in many settings including healthcare settings, palliative care, and hospice (Laversky, 2010). To improve over-all wellbeing in mind and body, seeking existential well-being as an integrated measure enhances an individual’s resilience. Studies indicate that such spiritual/religious activity buffers against the negative effects caused by uncontrollable illness and stress (Crowther et al., 2002). Comparable research has been implemented into military family re-integration programs like Strong Bonds (Matelski, 2016). Family resiliency was started within military family outreach programs (Strong Bonds) as a strategic approach to cope with operational demand, reintegration, and to assist in maintaining strong family structures (Matelski, 2016). In empirical studies, those that report a higher level of existential well-being have higher levels of psychological and subjective wellbeing (Lawler-Row & Elliott, 2009). For this reason, seeking levels of spiritual or religious based coping in psychotherapy is a viable path to developing resilience. Spiritual practices may very well alter the way a person thinks, therefore impact mental health outcomes (White, Driver & Warren, 2008).

Self-efficacy is an individual’s belief in their ability to perform tasks in order to obtain/produce a specific outcome (Benight & Bandura, 2004). Having confidence contributes to the successful adaptation to stress. Additionally, having others believe in a successful outcome furthers such success rates (Benight & Bandura, 2004). Perceived collective family efficacy is a contributing factor when family systems work together to promote each other’s development, well-being, and ability to exhibit resilience to adversity (Benight & Bandura, 2004). This active role in coping can be guided in conjunction with a therapist who offers models or frameworks to achieve these goals. This is illustrated in the current resilience therapies conducted by Dr. Gurwitch (DeAngelis, 2013). Efficacy of military families or those facing illnesses can be displayed as: control of intrusive thinking, ability to alleviate emotional stress, or managing daily life stressors (Benight & Bandura, 2004). Positive psychologies focused on helping these populations identify the qualities that help them individually, throughout the community, and in family networks have been studied marginally. Greater research that delves into the mechanisms which promote active resiliency is needed.

Statement of the Problem

Resilience is difficult to grow as the opportune place to learn to cultivate resilient response in often in the face of fear and adversity (Benight & Bandura, 2004). Evidence-based research that resiliency-based models impact success in overcoming adversity are in the beginning frameworks of creation, like those being brought forth by the FOCUS group and researchers of HomeFront Strong (DeAngelis, 2013). Resilience requires a focused effort in response to pressing adversity (Benight & Bandura, 2004). Many times, a road of grief or despair is also intertwined with the path to resilience. Self-efficacy, individual perception and actual receipt of such social support has the capability to enact active coping skills to ensure success (Benight & Bandura, 2004). Guidance for patients or clients seeking resiliency-based psychotherapies from mental health professionals holds the potential to spur healthy adaptation when adversity strikes (Patterson, 2002). The creation of resiliency models is a needed and beneficial tool for increasing positive adaptive coping.

Purpose of the Study

The purpose of this paper is to examine the effects of guided psychotherapies to promote resilience. This research examination includes adaptational patterns or strategies to foster active coping mechanisms among those facing adversities. Resilience training techniques such as mindfulness-based approaches, regulation of emotion, and spiritual/religious based interventions may allow individuals and groups to frame their lives and their challenges with more meaning (DeAngelis, 2013). Review and examination of resilience-based treatments for military families, and those who are ill or injured (DeAngelis, 2013) provide populations to research who have emphasized interpersonal coping styles, resilient adaptation to adversity, and the management of positive psychological functioning (Benight & Bandura, 2004).

Theoretical Framework

Psychoeducation is a model of guided therapy which has been utilized in the FOCUS initiative seeking, “to engage clients to learn and practice resiliency skills,” stated Dr. William Saltzman (DeAngelis, 2013). Participants evaluated by the FOCUS group intervention team reported less stress, more optimism and life satisfaction, and a greater ability to handle stress (DeAngelis, 2013). FOCUS researchers who developed this framework with military families also worked to increase family knowledge of positive psychology tools that encourage optimism (DeAngelis, 2013). Evidence has also shown that military families adapt well to deployment when they are able to find “meaning” in the situation (Riggs & Riggs, 2011).

Meaning-making frameworks consist of cognitive, motivational, and a sense of purpose perspectives (Park, 2007). These meaning systems are essentially the lens with which individuals or groups use to interpret, evaluate, or respond to life’s challenges and experiences (Park, 2007). For military families this process of finding meaning has included: belief or spiritual philosophies, optimistic outlook of the future, or a sense of pride (Riggs & Riggs, 2011). Similarly, families and individuals who have faced illness seek “meaning” as a model for resilience. Research indicated that cancer patients with spiritual beliefs may assign meaning to their illness and thus reduce the negative effects which occur during the illness onset (Crowther et al., 2002). Meaning-Centered Psychotherapy (MCP) has been researched with implementation among patients receiving palliative care (Rosenfeld et al., 2017). The goal of MCP in this environment was to create or maintain a sense of meaning and purpose in life (Rosenfeld et al., 2017), which was traced to logotherapy origins with Viktor Frankl (Frankl, 1986).

For those who seek to overcome trials, religious reframing can be a model to facilitate meaning-making (Paloutzian & Park, 2005). RCOPE (a 14-item measure of religious coping) was used with participants at a southeastern university medical center and a veteran’s affairs (VA) medical center in the study of positive religious coping (Pargament et al., 2004). After evaluating coping mechanisms such as collaborating with God, seeking social support from clergy/church members, religious direction, benevolent reappraisal (redefining the stressor through a religious lens), empirical evidence for religious coping as a resiliency tool was evident (Pargament et al., 2004). The adherence to one’s own belief/values has been used in resiliency-enhancement by prisoners of war (Southwick et al., 2016). The creation of meaning through positive attributions and/or existential strategies was a contributing factor to successful resilience (Pargament et al., 2004).

Effective coping strategies lead to resilience as well. Programs like the Family Adjustment and Adaptation Response (FAAR), assessed family interaction and ability to, “engage in family demand with family capabilities as they interact with family meanings to arrive at a family adjustment or adaptation” (Patterson, 2002). Family resilience as a coping strategy is the capacity for the family to successfully overcome difficult life circumstances. Family adaptation is the outcome which restores balance between capabilities accessed and the demands (stressors) faced (Patterson, 2002). While programs like FAAR begin to address resiliency efforts, developing models that connect military servicemen and families seeking resilience to their own beliefs, organizations, and communication networks will help them to be more resilient (Meadows et al., 2015). Specific strategies such as stress management, emotion regulation, goal setting, or problem-solving help families anticipate, plan and mitigate stressful events (Saltzman et al, 2011). In work with military families and families dealing with chronic illness, FOCUS group researchers used narrative sessions, group communication about deployment or illness stressors, and discussion of affective responsiveness to aid in coping (Saltzman et al., 2011).

Resilient behaviors are also linked to self-efficacy. In regard to stress reactions and the quality of coping in adverse situations, self-efficacy plays a key role (Benight & Bandura, 2003). Belief in coping ability influences successful activation of resilient behaviors (Benight & Bandura, 2003). Resilience to adversity relies on the enablement of a “protective shield” that buffers harsh realities (Benight & Bandura, 2003). Studies conducted of Israeli soldiers who suffered breakdowns in military combat (Solomon, Benbenishty, & Mikulincer, 1991; Solomon, Weisenberg, Schwarzwald, & Mikulincer, 1988) and exhibited lower perceived efficacy, showed these soldiers were overwhelmed by disturbing intrusions and adaptational problems following military combat (Benight & Bandura). Soldiers who received immediate frontline treatment were found to better mitigate traumatic experience and had a higher sense efficacy in coping with stress (Benight & Bandura, 2003).

Research Questions

Resilience has been defined as the ability for individuals or groups to do well in the face of adversity (Saltzman et al., 2011). Pilot studies and research has begun to delve into resilience among military service members, ill, and injured but to-date lack methods to implement, validate and assess this process (Meadows et al., 2015). To determine the effects of guided psychotherapies in the promotion of resilience, several questions must be addressed. In researching this, determining what the definitions of protective factors and coping mechanisms are of importance. Protective factors include: self-efficacy, meaning-making, social support, and spirituality/religion (Ryff & Singer, 2003). Additionally, finding the difference between resilience as an outcome versus resilience as a process offers insight to the type of guidance necessary to achieve situational or long-term results (Ryff & Singer, 2003). Previous studies conducted have hoped to spur new research aimed at fostering resilience (Clark et al., 2018). This research is to find whether resilient behaviors are changed by providing guided psychotherapies. To do so, the following questions will be addressed:

RQ1. How are resilient behaviors changed by providing guided psychotherapies?

RQ2. What skills lead to long-term acquisition of resiliency behaviors?

RQ3. What is specific methods are utilized within the military to help families increase protective factors?

RQ4. In what ways do military families increase protective factors enhance their success through resiliency?

RQ5. How do those who are ill or injured achieve resilience through coping strategies?

Hypothesis

H1: It is hypothesized that resilient behaviors are changed by providing guided psychotherapies. This hypothesis is that resilient behaviors are beneficially changed by providing guided psychotherapies because facilitated awareness of positive coping mechanisms enhance success (Kees & Rosenblum, 2015). This hypothesis has received support from recent research (Kees & Rosenblum, 2015) which finds that engaged participation and psychological interventions are feasible avenues toward resiliency among military families (Kees et al., 2015).

H2: It is also hypothesized that coping skills can enable long-term acquisition of resiliency behaviors. That is, it is expected that, among military families and those who are ill or injured their implemented coping skill can foster long-term resilience (Martz et al., 2018). Current research studying coping skills with veterans facing life-threatening illness or injury find that participants encounter resilience and post-traumatic growth (PTG), which may mitigate adverse effects (Martz et al., 2018). Post-traumatic growth is a personal change, a coping skill and development of long-term acquisition of resilient behaviors (Martz et al., 2018).

H3: It is hypothesized that the specific methods utilized within the military and among those who face illness and injury increase resilience and mediate adverse effects, therefore increase the success of resiliency. That is, individuals who were more inclined to utilize specific methods including adaptational support from mental health professionals, bolstering self-efficacy through guided therapies, social support resources guided implementation of meaning-making, and engagement in positive religious coping interventions “re-bound” better than those who do not (Blow et al., 2012; Breitbart et al., 2016; Breuninger & Teng, 2017; Koenig et al., 2012).

H4: It is hypothesized that the ways in which military families increase protective factors also enhances their success through resiliency. Protective factors have been indicated as resiliency enhancers in studies conducted by the FOCUS group, finding resilient belief systems which act to protect families (Saltzman, 2016). The ways in which these protective factors are increased may point to the success rate of resilient outcomes (Yi-Frazier et al., 2017).

H5: Finally, it is hypothesized that those who are ill or injured achieve greater resilience through coping strategies. Research indicates that coping strategies aid in the process of healing and rebound from adversity (Breuninger & Teng, 2017). This hypothesis emerged from findings that Mindful Awareness Resilience Skills Training (MARST) show significant improved measures in resilience upon implementation (Pidgeon et al., 2015).

Importance of the Study

Resiliency factors have not been studied extensively within military networks and the future correlations between resilient groups can aid in the formation of models to foster active coping skills (Palmer, 2008). This study is to assess and validate what factors mediate resilience processes within military families and those who are ill or injured. The benefits of this research can be a validated means of guided acquisition for resilience through fostered coping skills and knowledge. This goal is designed to help mental health professionals and clients in the promotion of resilience by application of proposed pathways. This benefit is achieved by recognizing models to implement through researched validation and assessment of guided psychotherapies among military members, ill and injured populations. Implications for research include connections between resilient groups which can provide evidence-based support to resilient adjustment across transitions (Kees & Rosenblum, 2015).

This study will contribute to the adaptive coping of military servicemen, and those who are ill or injured as they seek to increase quality of life through resilience. Identification of guided methods to implement, validate and assess this process will likely increase the effectiveness of interventions (Rice et al, 2015). Additionally, the creation of validated models in these populations allow provisions of positive coping through adversity rather than as a product of adversity (Southwick et al., 2016). Research prior has indicated, “… it is possible that repeated exposure to stressful situations may provide (military families) valuable learning experiences for all family members and result in better coping and maturation (Palmer, 2008). This thesis paper will improve the well-being of military families and those who are ill/injured by offering evidence-based guided therapy models at the on-set of adversity, shielding them from the plausible negative affects strife can also bring (Southwick et al., 2016).

Scope of the Study

In this thesis the main scope of study was effects of guided psychotherapies in the promotion of resilience among military servicemen and those who are ill/injured. Potential challenges and factors included the accessibility to the military, ill or injured assessments apart from those DoD public sector studies. Also, the measure of resilience from study-to-study may vary as different scales of assessment or definitions of resilience can be used by researchers. This thesis has, however, sought a central focused definition of resilience which is to follow. The sampling of these populations represented in the studies therein are just that, a sample. Nevertheless, the identification of models useful in the promotion of resilience through guided therapies is beneficial for a broad spectrum of individuals looking for success through such resources (Rice et al., 2015). Incorporation of information that identifies positive coping strategies is likely to increase effectiveness (Rice et al., 2015).

Definition of Terms

Resilience. This can be defined as an individual or group’s capacity to withstand and rebound from serious crises (Walsh, 2002). Simply put, being resilient is the ability to “bounce-back” when adversity strikes (Meadows, et al., 2015). Coping skills and protective factors to define include: self-efficacy, meaning-making, social support, spirituality/religion, and positive religious coping mechanisms.

Self-efficacy. This is described as the perceived self-belief in one’s own capability to successfully manage amid life’s demands or challenges (Benight & Bandura, 2004). The adaptational method of meaning-making is defined interventions which seek meaning and purpose in life as a key element (Rosenfeld et al., 2017).

Meaning-making. Descriptors of this consist of attributions of life events, circumstance and adversity to a greater purpose. This mindfulness-based technique is used to frame life and situations in a more meaningful way (DeAngelis, 2013). Meaning-making is created when one searches for meaning by perceptions of positive life change or PTG, deepened sense of meaning and/or restoration of core beliefs (Park et al; 2008).

Positive Religious coping. These mechanisms include behaviors or rituals which connect individuals or groups to their beliefs (Koenig, 2012). This is defined as the way spirituality/religion is activated to improve adaptive functioning (Rosmarin, Alper, & Pargament, 2016). The ways this may be activated include: trust in God, talking with religious leaders, or prayer.

Spirituality/Religion. Spirituality as a facet of religious coping includes both a search for the divine and the discovery of the transcendent, and thus coping through spiritual facets overlaps the definition of religious coping (Koenig, 2012). Engagement in positive religious coping interventions such as utilizing a spiritually-oriented relationship with God among veterans to determine enhanced coping are one such example (Breuninger & Teng, 2017).

Social support. This can be defined as the various types of support that is received from others (Schuh et al., 2016). The social support resource can be found in both formal and informal social networks (Schuh et al., 2016). Both perceived and tangible social support can be relevant factor for successful resiliency (Sippel et al., 2015). This definition of support is inclusive of psychological and material resources to deal with stress (Sippel et al., 2015). Family systems, clergy, support groups, mental health professionals and community or agency networking with together are all forms of social support.

Summary and Organization of the Remaining Chapters

Firstly, chapter 2 begins with the literature review of related material which provides insights into the study of resiliency. Current studies and the framework utilized by researchers follows including, Dr. William Saltzman (DeAngelis, 2013) with the FOCUS group intervention team. Exploration of additional literature will provide a broad perspective of guided psychotherapies in the promotion of resilience among military servicemen and those who are ill/injured. Other relevant studies are reviewed that indicate protective factors, coping strategies, and measures like MARST which report impact resilience upon implementation (Breuninger & Teng, 2017; Kees et al, 2015; Pidgeon et al., 2015; Saltzman, 2016; Yi-Frazier et al., 2017).

Secondly, chapter 3 will explore research methods and procedures in a systematic review to show the investigations of guided psychotherapy’s role in resiliency. This chapter will address the methods selected for analysis. Main factors will be assessed through methodology, data analysis, assumptions and limitations, and research findings. The research questions regarding resilient behavioral change by providing guided psychotherapies, skills that lead to long-term acquisition of resiliency behaviors, and methods utilized within the military and those who are ill or injured shall be discussed.

Finally, a review of all chapters presented, and conclusions obtained by the researcher will be addressed. Recommendations for improvement, future studies or implicated directions for continued investigation are given here. The proposed hypotheses regarding the effects of psychotherapies in relation to resilience will be re-addressed in review of research outcomes. A cumulative review of all findings and results will be summarized based on the results gathered.

Chapter Two: Review of Related Literature

Interest in guided interventions to promote resilience for multiple populations is not a new avenue of research. Previous investigations have focused efforts to study post traumatic growth (PTG) or elicited responses to pressing adversities (Benight & Bandura, 2004). PTG is defined as the positive and meaningful psychosocial change experienced as a result of struggle and stress encountered in life events (Tsai et al., 2015). Past reports have provided insight and support to mental health professionals seeking to understand and assist individuals in the aftermath of trauma or loss. New and emerging studies; however, have begun to offer effective interventions and strategies to enhance resiliency as preventative measures prior to and at the initial on-set of stressors (Sippel et al., 2015). A growing interest in models of resiliency which are inclusive of effective ways to implement and disseminate are now in preliminary trials (Saltzman, 2016).

Current research of behavioral change by providing guided psychotherapies, has included the assessment of social support and organized support networks. As a coping skill, social support provides greater potential for adaptation to adverse situations or events through interacting systems like: social networks, supportive care givers, family units, and community (Sippel et al., 2015). Community-level interventions utilized known networks and approaches that recognize people as connected and dependent upon one another (Sippel et al., 2015). Likewise, family-level interventions are designed to tap the resiliency resources found in family-centered preventative-intervention (Saltzman, 2016). Family therapists and mental health professionals need to understand the impact of facilitating social support systems, and the influence they have over resiliency efforts (Ungar, 2016). Utilization of pre-existing social networks or organizations can also be a key to confronting adversity rapidly when it strikes (Sippel et al., 2015).

Pilot studies of resiliency through HomeFront Strong (HFS) suggest that resiliency interventions are feasible for military families to improve their effective coping skills in social networks (Kees & Rosenblum, 2015). Inclusion criteria for the HFS study was intentionally broad, targeting a spouse of intimate partner of a Post 9/11 veteran or active service member. HFS program goals include enhanced life engagement and participation (Kees & Rosenblum, 2015). Participants in HFS joined 8 weeks of sessions to promote engagement and effective coping. According to Kees & Rosenblum, HFS research is the first of its kind to target interventions addressing individual resilience and psychological health among military spouses (Kees & Rosenblum, 2015). HFS also worked with the Center for Health Communications Research at the University of Michigan to develop a mobile website platform which allowed participants to engage in more accessible HFS program options (Kees, 2015).

In addressing cognitive patterns with home-front spouses, researchers aimed to provide strategies that would aid in successful transitions throughout military deployments (Kees & Rosenblum, 2015). These interventions evaluated the HFS program’s capability to enhance individual resilience by identifying and changing negative thoughts (Kees & Rosenblum, 2015). Investigations showed that spouses may experience greater levels of emotional stress than soldiers, with soldiers’ combat exposure reflected in higher levels of stress (Kahn, Collinge & Soltysik, 2016). Evidence from the Kees & Rosenblum study showed that family stress can be mitigated through HFS applications which support family system adjustments over difficult transitions (Kees & Rosenblum, 2015).

Strong social and family support are systems which act as protective factors (Shuh et al., 2016). Conversely, social isolation was indicated as a contributor for mental health challenges in families with deployed service members (Strong & Lee, 2017). To foster active coping mechanisms of social support, HFS participants met for group therapy sessions guided by Kees research facilitators (Kees & Rosenblum, 2015). During these group sessions participants shared a meal, met for discussion, joined interactive activities, viewed demonstrations of effective coping strategies and received psychoeducational materials (Kees & Rosenblum, 2015). Greater knowledge and efficacy in the ability to effectively manage stressors was reported by group participants (Kees & Rosenblum, 2015).

These family-centered preventative efforts are also being reviewed in resilience assessments by the Families OverComing Under Stress (FOCUS) group, led by UCLA Psychologist Dr. Saltzman’s and co-founder, UCLA Psychiatrist Dr. Patricia Lester (DeAngelis, 2013). Reports from previous studies have urged clinicians to consider the inclusion of family, as well as added social support which have been documented to help combat challenges with re-integration or stressors post-deployment (Sherman et al., 2015). Shifting the traditional therapeutic approach from one of symptom reduction to promotion of positive community involvement has been noted in studies to greater assist re-integration for veterans and families (Sherman et al., 2015). This is due in part to participation from many influencers of social networks (family, clergy, work, community) which offer assistance across a range of domains (Sherman et al., 2015). Greater access to support, like guided psychotherapies and family networks, was also cited as a source for resilience in a study of men diagnosed with prostate cancer (Wilson, Moore & Chambers, 2014). The men with prostate cancer studied showed signs of resilience and PTG that were positively linked to peer support (Wilson, Moore & Chambers, 2014). To strive for mastery over adversities and fear, focusing on the ultimate goal and doing so alongside friends and colleagues appear to be contributing factors (Saltzman, 2016; Southwick et al., 2015).

Researchers with FOCUS have implemented their program with multiple populations including military families who have members that are wounded, ill, or injured (DeAngelis, 2013). Interventions and coping strategies introduced during FOCUS include: emotional regulation, goal setting, problem solving, managing trauma and loss, tools to enhance emotional awareness and communication skills (DeAngelis, 2013). FOCUS was designed to reduce adverse outcomes in populations deemed “at-risk” due to stress, trauma, or loss (Saltzman, 2016). Additionally, researchers with FOCUS seek to enhance the process of resiliency within the family through facilitated instruction of coping techniques (Saltzman, 2016). While previous research has offered information pertaining to indicators and predictors of resilience, these new measures with FOCUS seek to clarify the specific coping strategies to support resilience (Saltzman et al., 2011; Saltzman, 2016). FOCUS findings showed positive results which are sustained and increase after program cessation (Saltzman, 2016). These results provide potential support for the hypothesis that implementing coping skill can foster long-term resilience. Collection of longitudinal or collaborating data to support FOCUS initiatives as a strategy for long-term acquisition of resilient coping mechanisms may further support program goals (DeAngelis, 2013).

The FOCUS group developed their program to meet the needs of multiple vulnerable populations by addressing these 5 areas: eliciting Family Systemic Goals, providing psych-education and developmental guidance, developing shared family narratives, supporting open and effective communication, and enhancing individual family member resilience skills (Saltzman, 2016). Saltzman’s team interventions offered brief, flexible modules using narratives from family members to gain enlightenment about their thoughts, feelings or beliefs. Narrative sessions allowed for the discovery of distortions or misattributions family members may be experiencing (Saltzman, 2016). Open and effective communication to achieve transparency in the family system was a chief goal for FOCUS team initiatives (Saltzman, 2016). To further help the accessibility needs to program materials for military families and other populations FOCUS groups served, a “telehealth” version of the program which was created for web/smart phone usage (Saltzman, 2016).

Social support is known to facilitate active coping which may include the search for meaning and purpose, a particularly applicable intervention for individuals with medical illness (Tsai et al., 2015). This thesis hypothesized that the specific methods used by military families and among those who face illness and injury like methods of adaptational support from mental health professionals, bolstering self-efficacy through guided therapies, social support resources guided implementation of meaning-making, and engagement in positive religious coping interventions cause individuals to “re-bound” better than those who do not use specified methods (Blow et al., 2012; Breitbart et al., 2016; Breuninger & Teng, 2017; Koenig et al., 2012). Evidence of greater resilience through the use of specific methods has been compiled in the following research.

Results from pilot studies conducted of MARST programs as group-based training show significant improvements in levels of resilience through mindfulness-based approaches (Pidgeon et al., 2015). MARST programs consisted of resilience and mindfulness-based strategies that stem from cognitive behavioral therapies (CBT) (Pidgeon et al., 2015). Psychoeducation, interactive discussion, skills training in everyday mindfulness tools, and mindfulness meditation were implemented among study participants (Pidgeon et al., 2015). This study found that the mindfulness-based approach can be utilized to replenish resilience as indicated by participants (Pidgeon et al., 2015). Studies among United States active duty servicemen and veterans using Mindfulness-Based Stress Reduction (MBSR) identified such coping strategies as likely to increase the success of resilience (Rice & Liu, 2016). Successful coping in the face of adversity can be described as one’s ability to regulate stressors (Rice & Liu, 2016). Pilot studies assessing the feasibility and impact of mindfulness-based interventions with Parkinson’s patients and their caregivers also indicated probable success (Cash et al., 2016). Participants in the Cash study attended sessions to further MBSR directed treatments which reported significant levels of increased positive emotional and cognitive outcomes (Cash et al., 2016). MBSR coping strategies for servicemen included positive reframing of their adversities and investigation of the relationships within these struggles (Rice & Liu, 2016). Positive reframing in MARST sessions involved cognitive strategies to appraise difficult situations into a more favorable lens (Pidgeon et al., 2015). MARST and MBSR interventions provide evidence that coping strategies can be learned, as well as guided through training (Pidgeon et al., 2015; Rice & Liu, 2016). Information from MARST and MSBR research support the hypothesis that specific methods utilized within the military and among those who face illness and injury increase resilience and mediate adverse effects. These methods increase successful resilience through implementation of positive reframing or mindfulness-based objectives.

Pilot studies among military women diagnosed with Chronic Pelvic Pain (CPP) sought the feasibility of MSBR for combating psychological distress and physical pain (Crisp et al., 2017). Formal MSBR training courses were offered to military participants with CPP to promote well-being and the reduction of psychological distress (Crisp et al., 2017). Women completing this intervention reported improvements with pain intensity, lessened interference in daily functions from pain, and improvements in usage of mindfulness-based techniques (Crisp et al., 2017). Although reports from the Crisp study showed support for MSBR interventions, hurtles to administering these among military woman included military and family obligations that caused difficulties for participants to attend formal training seminars (Crisp et al., 2017). Such studies suggest support for improved resiliency through guided therapies, but also point to issues in administering and disseminating interventions among vulnerable populations. Potential avenues for dissemination suggested by the Crisp research team were web-based models for ease of accessibility (Crisp et al., 2017).

Healing through resiliency-enhancing means of adherence to one’s beliefs holds potential for better coping with life’s challenges (Rosenfeld et al., 2017; Southwick et al., 2016). Wilson, Moore & Chambers examined how core beliefs influence adverse reactions to stressors of cancer diagnosis, concluding that core beliefs and intrusive thought were related variables (positive or negative) to PTG (Wilson, Moore & Chambers, 2014). The reports from Wilson and researchers support the idea that disrupting fundamental beliefs and then fostering re-alignment of core beliefs can accommodate PTG (Wilson, Moore & Chambers, 2014). Pilot studies aimed at assessing the feasibility of meaning centered psychotherapy (MCP) showed strong results with significant improvement in spiritual well-being and quality of life among those with life-threatening illness (Rosenfeld et al., 2017). In research using MCP with palliative (end-of-life care) patients, researchers extracted the most salient elements needed for implementation of this model: addressing one’s own understanding of meaning, discussion of meaningful moments, reflection upon sources of meaning, and finding meaning through courage and commitment (Rosenfeld et al., 2017). Participants reported that they felt positive about this intervention, and several of these coping elements aided their successful resilience in the face of life-threatening illness (Rosenfeld, et al., 2017). Given the apparent effectiveness of MCP with advanced cancer patients, it is reasonable to suggest adaptational models for military families and those who are otherwise ill or injured (Martz et al., 2018; Rosenfeld et al., 2017). The effectiveness of such programs amid the adversities faced by those diagnosed with chronic and life-threatening illness promote the viability of modalities which can serve as a template for multiple vulnerable populations (Gómez-Batiste et al., 2017; Rosenfeld, 2017; Martz, 2018).

Significant results in terms of psychosocial and spiritual well-being have been measured in other studies addressing palliative care patients (Gómez-Batiste et al., 2017). In a study conducted by Gómez-Batiste and colleagues, psychosocial support teams (PST) were trained and tasked to provide emotional support, spiritual care, and bereavement assistance for chronically ill patients receiving palliative care (Gómez-Batiste et al., 2017). Primary objectives included improving patient care, as well as the development of evidence-based interventions targeting emotional care. Researchers embarked on this study due to the lack of existing models which address the delivery and organization of interventions for those with life-threatening and chronic illness (Gómez-Batiste et al., 2017; Rosenfeld, 2017). The Gómez-Batiste and Rosenfeld team studies reported strong results for stress management and well-being through interventional models centered in MCP and PST guided psychotherapy (Gómez-Batiste et al., 2017; Rosenfeld, 2017). Results from MARST, MBSR, MCP, & PST studies indicated support for the hypothesis that specific methods for adaptational support increase resilience (Pidgeon et al., 2015; Gómez-Batiste et al., 2017; Rice & Liu, 2016; Rosenfeld, 2017).

Emotional care, stress management and self-care are protective variables which may contribute to resiliency in multiple populations (Gómez-Batiste et al., 2017; Yi-Frazier et al., 2017). Significant hurtles to obtaining these protective coping mechanisms were seen among parents of ill children (Yi-Frazier et al., 2017). Parents found “leaving” their ill child with others to care for difficult and often experienced guilt (Yi-Frazier et al. 2017). Military family members also described barriers like guilt or worry of social-stigmas as a deterrent to seeking self/emotional care or utilizing mental health services (Strong & Lee, 2017). A former firefighter and first responder herself, Dr. Sara Gilman became a psychotherapist to further the effects of trauma research in efforts to provide appropriate interventions to a culture that is commonly seen as “strong enough” to handle their own stress (Gilman, 2015).

Common practices for First Responders (a group that includes military members) include avoidance and hidden resilience to cope with death, loss, and traumatic events (Gilman, 2015). This “toughness” of mindset for First Responders and military members creates an environment that breeds stoicism, depersonalization, and derealization of traumas (Gilman, 2015). Stoicism and derealization was seen in reports from recent studies (Strong & Lee, 2017). Repercussions for reaching out to available services when military members were high-ranking and expected to “manage independently” was reported as a reason among Marine family members who chose not to engage in programs offered (Strong & Lee, 2017). Furthermore, military veterans considering mental health assistance expressed concerns in regard to career repercussions, long wait-times for care, and limited healthcare providers (Kahn, Collinge & Soltysik, 2016). At-home Marine spouses studied note added difficulty in accessing military services while their servicemen are deployed, as well as inability to attend outreach services for lack of childcare (Strong & Lee, 2017).

Removing the perception of these stigmas or hurtles through guided therapies or offering alternative platforms may increase protective factors to enhance resiliency success (Yi-Frazier et al., 2017). Dr. Gilman notes 3 forms of specific methods which may be used to increase resilience and mediate adverse effects among First Responders: education and training, peer support, and counseling (Gilman, 2015). Empowerment of self-care initiatives through guided psychotherapy initiatives may allow for opportunities to reframe and take ownership of one’s personal health and well-being (Strong & Lee, 2017). The health and well-being of caregivers for the ill and injured, as well as at-home family of servicemen should be a central concern in the discussion of family resiliency (Strong & Lee, 2017; Yi-Frazier et al., 2017).

Web-based or social media platforms might assist in the accessibility of guided therapeutic services for military families and those who are ill or injured (Kahn, Collinge & Soltysik, 2016; Yi-Frazier et al., 2017). Studies conducted by Kahn, Collinge, & Soltysik with post 9/11 veterans and their spouses investigated programs designed by researchers to be accessed in a self-directed manner (Kahn, Collinge & Soltysik, 2016). This study notes that 81.5% of Global War on Terror veterans have acute to chronic pain (Kahn, Collinge & Soltysik, 2016). As with others who are ill or injured, these veterans experiencing pain find it difficult due to health variables to readily access social and therapeutic supports (Kahn, Collinge & Soltysik, 2016; Yi-Frazier et al., 2017).

Kahn and researchers tested a web and mobile app-based, self-directed mind and body wellness skills training with 160 veterans from 4 regions of the United States (Kahn, Collinge & Soltysik, 2016). These programs addressed re-integration resiliency in a DoD collaborative effort with chaplaincy and VA services. The primary goal of designing these interventions was to offer a flexible form of instruction which military family members could use to improve overall well-being (Kahn, Collinge & Soltysik, 2016). Veterans took part in several programs for assessment including: Mission Reconnect (MR), and Prevention and Relationship Enhancement Programs (PREP) for Strong Bonds military weekend sessions with couples (Kahn, Collinge & Soltysik, 2016). MR and PREP study participants provided feedback at the first 8 weeks, then again at the 16-week study marker. MR participants were given instructions in a web-based and/or mobile app, as well as guidance for stress-reducing partner massage. The MR based group’s focus was the following mindfulness-based goals: connect with yourself, connect with quiet, and connect with your partner (Kahn, Collinge & Soltysik, 2016). Kahn’s team reports that the MR group had significantly greater improvements in stress, depression, PTSD symptoms, self-compassion, resilience, social support, and relationship satisfaction (Kahn, Collinge & Soltysik, 2016).

Knowledge of and skills to administer mindfulness interventions may assist in helping mental health professionals administer services to military families, and those who are ill/injured by reinforcing strategies to reduce stress and increase emotion regulation (Borden et al., 2017). How military families and those who are ill/injured obtain guidance pertaining to increasing coping strategies and protective factors point to the success rate of resilient outcomes (Kahn, Collinge & Soltysik, 2016; Yi-Frazier et al., 2017). This information supports the hypothesis for this study, that the way in which these factors are increased point to successful results. New ways of obtaining increased efficacy in coping include web-based and online guided therapies (Kees, 2015; Kahn, Collinge & Soltysik, 2016).

MR and PREP findings were due to multiple factors including the use of massage as a communication/connection tool for military members and their partners. Sustained use of web and mobile-based apps may also be encouraged through partner connectivity and accountability within this program model (Kahn, Collinge & Soltysik, 2016). Additionally, the accessibility for web-based and mobile app guided instructions allow for the access of these resources to be in the control of participants (Kahn, Collinge & Soltysik, 2016). The flexibility and new technological avenues for guided psychotherapies should be further explored to increase accessibility of coping strategies among families of military members and those who are ill or injured. Research hypothesis 1 states that resilient behaviors are changed by providing guided psychotherapies. Research of positive coping mechanisms implemented support this study’s hypothesis of the benefits for guided psychotherapy in multiple populations to produce resilient behaviors. Resilient behavioral changes were found using MCP with significant improvement in spiritual well-being and quality of life (Rosenfeld et al., 2017). MR, PREP, HFS, and FOCUS findings present change in resilient behavior through the use of guided therapies to increase communication/connection in military family member and those who are ill/injured, increased problem solving, effective management of trauma and loss, and enhancement of emotional awareness (Kahn, Collinge & Soltysik, 2016 Kees & Rosenblum, 2015; Saltzman et al, 2016).

Military families increased efficacy and use of protective factors enhance their success of resilient response (Clark et al., 2018). Protective variables can also become a cohesive unit that are constructed collectively to form a resilient response (Clark et al., 2018). Findings reported by Clark and researchers support the theoretical perspective that factors of family cohesion (social support) work in tandem with communication to become “shock absorbers” when crisis strikes (Clark et al., 2018). These findings also implied that there is potential for bolstering contributing factors considered to be “shock absorbers” before crisis occurs. Social support is a resource which allows individuals to avoid becoming overwhelmed due to the individually limited capacity of his/her own resources (Ungar, 2016). Strengthening of collective resilient factors at the on-set or when known stressful events will occur (such as a known upcoming deployment or planned surgery) could guard against mal-adaptive response (Clark et al., 2018). As suggested with hypothesis 4, the ways in which military families increase protective factors enhance their success with resiliency (Clark et al., 2018). Accessing support to absorb the shock of crisis in a manner that increases protective factors through enhanced family cohesion (Clark et al., 2018), tapping new resources developed by mental health professional in online or mobile app forums (Kahn, Collinge & Soltysik, 2016), strengthening social support networks (Kees & Rosenblum, 2015), or meaning centered psychotherapy (MCP) with spiritual guidance (Rosenfeld et al., 2017) show strong results with significant support for the hypothesis that increasing protective factors increases resilience.

Logotherapy, initially developed by Viktor Frankl a Nazi concentration camp survivor, has been studied for the feasibility of integration into traditional psychotherapy services (Frankl 1986; Southwick et al., 2016). Like MBSR, logotherapy aims to build insights through reflection when applying this lens to clarify life situations and events (Southwick et al., 2016). Learning to face fear (adversities) in a fashion that reconceptualizes them can be seen in coping strategies within military-related circumstance (Southwick et al., 2016). Examples of this include: ex-prisoners of war who exhibit signs of growth amid traumatic circumstance and post-recovery; and American military spouses who found increased appreciation for one-another during deployment communications despite exposures to stressors which accompany long deployments (Southwick et al., 2016; Ungar, 2016).

Findings among veterans evaluated for significance of PTG (Tsai et al., 2015) show similar associations between protective psychosocial factors such as perceived social support, optimism, extraversion, spirituality and perseverance. In search of validated measures to capture PTG, Tsai and colleagues (Tsai et al., 2014) aimed to examine the following: the relationship between PTSD and PTG, PTG in a large context and sample, the significance or PTG, the types of trauma independently related to PTG, and how demographics (military affiliations, medical or psychosocial) relate to the occurrence of PTG (Tsai et al., 2014). Support for PTG comes from many studies assessing individuals as they interact with systems (social networks, family, community) that surround them (Ungar, 2016). PTG may develop as a result of an increased appreciation for life, greater sense of personal strength, self-understanding, a renewed appreciation for intimate relationships, and positive spiritual changes (Tsai et al., 2015). Long-term resiliency may be acquired as individuals learn to transform (develop PTG) their coping strategies to better meet their needs in crisis (Ungar, 2016).

Previous research has shown that beliefs associated spirituality assist servicemen to cope with the stressors they encounter (Wade et al., 2016). Wade and associates assessed spirituality (a connection to God/a higher power/the universe) to explore potential benefits to servicemen (Wade et al., 2016). Spiritually Informed Cognitive Processing Therapy (SICPT) has been implemented to encourage and increase spiritual growth and well-being (Wade et al., 2016). Positive cognitive reappraisal is a specific method utilized to help increase protective factors by viewing stress and tension as part of growth and fulfillment (Southwick et al., 2015). Positive religious coping and spiritual interventions when integrated into a CBT framework have proved to be effective for a number of clinical disorders (Brueninger & Teng, 2017).

Cognitive Processing Therapy (CPT) may provide another avenue in which veterans (and those who are ill/injured) can address difficult traumas or circumstance as they explore their relationship with God (Brueninger & Teng, 2017). For families and individuals that express a desire to seek therapeutic services through a spiritual lens, coping mechanisms can be integrated with traditional psychotherapies. These mechanisms may be: prayer, scripture readings, spiritual imagery (Brueninger & Teng, 2017). Spiritual crisis or discontented has been related to combat-related PTSD, higher levels of depression and suicidality in service members (Wade et al., 2016). Spiritually-integrated therapies which include prayer or meditation are known to increase positive outcomes which may ward off these maladaptive responses (Wade et al., 2016). Traditional clinical interventions focus on decreasing symptoms of psychopathy, whereas positive psychology mechanisms like SICPT and MBSR focus on enhancing strengths and virtues (Southwick et al., 2016; Rosmarin, Alper & Pargament, 2016).

Promoting Resilience in Stress Management (PRISM) was developed by Yi-Frazier and colleagues to originally address the needs of adolescents and young adults facing chronic or serious illness (Yi-Frazier et al., 2017). Throughout PRISM studies researchers discovered a need to address resilience for parents and caregivers of ill young adults as a means to foster overall family coping methods (Yi-Frazier et al., 2017). Other studies have also indicated that including family members in outreach and treatment services increases the success rate of interventions (Sherman, Larsen & Borden, 2015). In a study of 61 family members who were supporting relatives with TBI or spinal cord injury, caregivers reported low burden when they had access to resources they required to look after themselves while providing care to their family member (Ungar, 2016). The PRISM adapted interventions focused on maintenance and well-being to foster adaptive resources among caregivers. Researchers presented PRISM’s model of coping by focusing on 4 main points: stress management, positive reappraisals of stressors, goal setting and problem solving, and meaning making (Yi-Frazier et al., 2017). Caregivers in the Yi-Frazier (2017) study attended to the needs of children/young adults who had cancer or diabetes. Results were gathered in evaluations of parent/care-giver reports of their feelings of resilience and distress in both pre and post-surveys (Yi-Frazier et al., 2017).

Complications of administering the PRISM intervention were noted due to the limited time and healthcare needs of these families. This hurtle is also present when offering resiliency interventions to military families, and those who are ill or injured (Saltzman, 2016). Studies reported that the more caregivers were validated by their extended family networks for the contributions to the well-being of their family member with a disability, the less the caregiver experienced stress (Ungar, 2016). Support focusing on at home parents and at home military spouses’ self-care/well-being provides attention that affects the overall wellness of family systems (Strong & Lee, 2017). Numerous studies show indicators of resiliency methods (self-efficacy, meaning-making, social support, spirituality/religion, and positive religious coping mechanisms) bolstering successes; however, further research is still needed to find evidence of the efficacy of these resilience interventions (Yi-Frazier et al., 2017).

Patterns of resilient response can take many forms like: avoidant resilience, hidden resilience, maladaptive coping or positive resilient coping (Ungar, 2016). An individual or family system when burdened by crisis can cause a significant decrease in positive functioning following the adversity (Ungar, 2016). Families instigate protective processes like avoidant or hidden resilience to compensate (Ungar, 2016). Although risks of dysfunctional coping are apparent with avoidant adaptions, using this strategy to evade potential re-exposure to trauma can buffer against adverse response (Ungar, 2016).

Resilient family processes were utilized in various ways among 273 military families studied from an active duty Army installation in the United States (Clark et al., 2018). As with HFS researchers, Clark recognized that military families face a “pile-up” of demands (illness, financial strain, etc.) which occurs when a spouse is mobilized for active duty (Kees & Rosenblum, 2015; Clark et al., 2018). As demands and stressors “pile-up”, military families may engage in protective factors like not speaking of military trauma or battles (Kees & Rosenblum, 2015: Ungar, 2016). Clark and colleagues noted that future research assessing the process of informing and implementing interventions/services that foster resilience may show reduction of adverse responses among military family transitions (Clark et al., 2018).

A recent study by Martz and colleagues examined the predictive ability of PTG in U.S. military veterans with life-threatening illness or disease (Martz et al., 2018). As both a variable and therapeutic goal for veterans experiencing chronic illness and disability (Martz et al., 2018). This study was representative of a large sample of broad traumatic life events among veterans. The top 3 life threatening illnesses reported in the Martz study were: sudden onset condition (heart attack or stroke), cancer, and infectious disease. Quality of life was a central focus of this study. Results indicated that experiencing life-threatening illness or injury was significantly positively related to PTG (Martz et al., 2018). Results from the Martz study suggest benefits to the assessment of resilient groups collectively in the formation of guided psychotherapy models to foster active coping skills (Martz et al., 2018). PTG in relation to personal strength has been connected to greater resilience in subsequent adversities or crisis (Martz et al., 2018). Multiple regression analysis noted the PTG was a significant positive predictor of quality of life (Martz et al., 2018). These findings support that PTG can foster resilience over time. In relation to research this study’s hypothesis 2, PTG is a personal change, an active coping skill witnessed in U.S. military veterans with life threatening illness or disease (Martz et al., 2018). H2 states that coping skills can enable long-term acquisition of resilient behaviors (Martz et al., 2018), and PTG in this study indicates that it not only acts as a buffer but develops an individual’s necessary understanding to implement active coping skills for facilitation leading to better quality of life (Martz et al., 2018).

Despite a growing body of research assessing PTG, relationships between stressors and PTG still remain unclear (Tsai et al., 2015). Drawbacks to current PTG studies include inconsistent reports in relations to PTG. As noted by Martz researchers, their study is supportive evidence of PTG links to resilience, while other researchers assessing traumatic brain injury (TBI) patients discovered lowered PTG in longitudinal studies (Martz et al., 2018). Factors associated negatively with PTG are older age at the on-set of traumas, depression, repression of feelings or impulses, and disruptions in social activities (Tsai et al., 2015). Wilson, Morris & Chambers (2014), noted in a study of individuals diagnosed with prostate cancer that intrusive thoughts can occur following diagnosis (Wilson, Morris & Chambers, 2014). Further research is needed to assess how these positive and negative factors affect PTG, and their prospective interrelationships (Martz et al., 2018).

PTG is also a common occurrence following a cancer diagnosis, with 53-95% of cancer survivors reporting some level of growth (Wilson, Morris & Chambers, 2014). Because the presence of growth does not necessarily eliminate the presence of distress, mental health professionals should be aware that additional assessments are needed alongside PTG reports (Martz et al., 2018). PTG is important as a specific target for clinicians heling multiple populations, especially for those who are ill or injured (Saltzman, 2016; Martz et al., 2018).

Traumatic events can create a myriad of changes in cognitions, affect and behavior (Brueninger & Teng, 2017). Psychological resilience and positive emotional states have been found to change the way patients cope with pain in studies conducted by Rolbiecki and associates (Rolbiecki et al., 2017). This study assessed self-efficacy in regard to disability and pain management (Rolbeicki et al., 2017). Managing pain, resourcefulness, and the ability to thrive in the face of such stressful life events was connected to development of adaptive strategies among patients (Rolbeicki et al., 2017). These adaptive developments contributed to a greater quality of life for patients and are comparable to findings in the Martz studies, which witnessed PTG as a moderator of threatening illness, injury or PTSD (Martz et al., 2018; Rolbiecki et al., 2017).

The main goal of the Rolbiecki study was to explore how patient’s living with chronic pain process resilience. This research aimed at utilizing the data gathered to foster self-efficacy and resilience among patients experiencing pain (Rolbiecki et al., 2017). Coping behaviors are connected to the belief, or self-efficacy, the one is capable of managing his/her own pain (Rolbiecki et al., 2017). The Rolbiecki research team felt that self-efficacy was a pivotal resiliency resource. To review this concept further, they interviewed 12 patients with chronic pain diagnosis gathering information about their journeys. Chronic pain patients revealed 4 components to their resilience in the face of their diagnosis: active engagement in their treatments, establishment of social connections, exhibiting pain acceptance, and developing a sense of control (Rolbiecki et al., 2017). Those studied shared that these components included multiple layers of resiliency resources, of which social support was key. These patients also expressed a “sense of control” through finding meaning in their pain or faith/prayer support which provided relief (Rolbeicki et al., 2017).

Greater social support, purpose in life and intrinsic religiosity were all associated with PTG, suggesting that guided psychotherapeutic interventions designed to promote these coping strategies may help foster psychological growth from trauma within multiple populations (Tsai et al., 2015). Positive psychology interventions appear to be best suited to foster PTG and resilience among military families and those who are ill/injured due to their reported significance to subjective well-being (Martz et al., 2018). This review and examination of resilience-based treatments for military families, and those who are ill or injured present guided psychotherapies which emphasize interpersonal coping styles, resilient adaptation to adversity, and the management of positive psychological functioning. This adaptive capacity for over-coming adversity can be seen in the studies which have been reviewed, and successful resilient response is related to multiple variables. This study provides an overview supporting the hypothesis that behaviors are changed by guided psychotherapies and further participation in and implementation of psychological interventions are feasible avenues toward resiliency among military families and those who are otherwise ill/injured.

Chapter Three

Research Method and Procedures

This study reviewed and assessed current journals, research and applications of guided psychotherapies as they relate to resiliency among military families and those who are ill/injured. Articles and research were located through online database services: EbscoHost, GoogleScholar, and PsycARTICLES. GoogleScholar returned a total of 16,100 journals in the date range 2014-2018 when the following terms were input, “resilience military families and those ill or injured”. From these, this thesis included review of 80 references and resources that were selected which had reported on resilience and positive psychology findings. Further focus on the studies implemented among 15 journals and studies of positive psychology interventions were narrowed by utilizing these keywords to search: resiliency, resilience among ill/injured and military families, strategies for coping in military families, self-efficacy of resilience, spiritual resilience, and social support linked to resilience.

Methodology

For this research, the following current journals were narrowed as most relevant and reviewed to analyze the potential useful correlations between resilient groups: the Martz and colleagues examination of predictive ability of PTG in U.S. military veterans with life-threatening illness or disease (Martz et al., 2018); FOCUS group interventions among multiple populations with a specific military family target (DeAngelis, 2013; Saltzman, 2016); studies of resiliency through HomeFront Strong (HFS) for military families (Kees & Rosenblum, 2015); MARST programs as group-based training in resilience through mindfulness-based approaches (Pidgeon et al., 2015); research with post 9/11 veterans and their spouses of programs designed to be accessed in a self-directed manner (Kahn, Collinge & Soltysik, 2016); research in support, spiritual care, and bereavement assistance for chronically ill patients receiving palliative care (Gómez-Batiste et al., 2017); and research of social support’s impact as “shock absorbers” when crisis strikes (Clark et al., 2018). The included studies emphasized hands-on research among participants located in military families and/or those ill/injured to evaluate how resilient behaviors are changed by providing psychotherapies, what skills lead to long-term acquisition of resiliency behaviors, what specific methods are used, and in what ways these populations increase protective factors to enhance their resiliency success. This thesis study compared and contrasted specific methods used and models implemented by the listed researcher in efforts to find empirical evidence for fostering resilience in multiple vulnerable populations like military families and those who are ill/injured.

Data Analysis

Data for this study was collected through scholarly search engines to obtain relevant research journals. This data was compared in efforts to decipher the best applicability to the current study of resilience among military families and those who are ill/injured. 5 categories of specific emphasis in the area of resiliency emerged while assessing this information. These included: self-efficacy, meaning-making, social support, spirituality/religion, and positive religious coping mechanisms. Additionally, useful correlations between these resilient groups formed, showcasing the effectiveness of studying them collectively to obtain models which provide adaptive capacities often networked through personal connections, guidance of a mental health professional, or groups of social support (Palmer, 2008; Pidgeon et al., 2015).

Methodological Assumptions and Limitations

Limitations in this present study include access to DoD or military family research. This study was able to obtain relevant studies from online library public forums, however. Gathering data from groups who are ill or injured, and in the military also pose some complications due to inherent commitments and life demands. This may be accessibility issues to participate in face-to-face studies, or difficulties to join in therapeutic sessions as a result of illness (Gómez-Batiste et al., 2017; Pidgeon et al., 2015; Tsai et al., 2015).

Present research included a large sample of racially diverse families and genders due to the combination of military families and those who are ill/injured (Saltzman, 2016). Research was also collected in geographically diverse locations, adding to the strength and validation of accumulated results (Kahn, Collinge & Soltysik, 2016). A common limitation to studies of resilience in military families is garnering a large sample size in deployed environments and diversity of participants (Kees et al., 2015). This thesis was able to review a larger segment of the population by considering useful correlations between resilient groups. By gathering this cohesive data, a more complete picture of military servicemen and families of illness/injury facing adversities and cultivating resilience emerged.

Research Findings

RQ1. How are resilient behaviors changed by providing guided psychotherapies?

Empirical evidence to support that resilient behaviors are changed by providing guided psychotherapies was discovered in this assessment. Throughout this thesis, positive change in regard to resilient behaviors was revealed. Positive family adjustment was indicated by the McMaster Family Assessment Device (FAD) used to assess familial problem solving, communication, affective responsiveness, affective involvement, behavioral control, and within the FOCUS group initiatives (Saltzman, 2016). From FOCUS findings in guiding familial adjustment to PTG’s result of an increased appreciation for life and positive spiritual changes, current studies indicated that implementing guided therapies had positive impact in groups and individuals (Saltzman, 206; Tsai et al., 2015). Targeted interventions within the FOCUS group program produced improvements in adaptive functioning, therefore reinforcing the idea that behaviors are changed through therapeutic contexts offering avenues toward positive gains (Saltzman, 2016). Positive behavioral change was created in participants through cultivation of individual and group techniques for combatting likely symptoms (distress, depression, anxiety, negative emotion) often associated with hardship (Kees & Rosenblum, 2015; Pidgeon et al., 2015; Saltzman, 2016).

Research participants receiving guided interventions at or before the on-set of trauma/hardship benefit from positive behavioral change that acts as “preventative medicine”, allowing them to weather stressful situation with improved adaptive capacity (Pidgeon et al., 2015; Martz et al., 2018; Saltzman, 2016). This suggests that models of guidance to resiliency are beneficial for military families and those who are ill/injured as they experience somewhat predictable hardships (i.e. deployment, life transitions, surgery or disability). For example, research indicated that cancer patients with spiritual beliefs who received experientially guided therapies assign meaning to their illness and thus reduce the negative effects which occur during the illness onset (Crowther et al., 2002). Unlike past researchers who treated maladaptive symptoms as they arose in patients, newly developed measures curb maladaptive symptoms before they manifest by bolstering individual/group resiliency (Kees & Rosenblum, 2015; Saltzman, 2016). This functional resilience model of guided therapy seeks also to directly engage in clients in the practice of resiliency skills (DeAngelis, 2013).

RQ2. What skills lead to long-term acquisition of resiliency behaviors?

Recent studies have provided examples of skills leading to long-term acquisition of resiliency behaviors. Evidence for such long-term change in behavior was most noticeable in studies involving PTG. A coping skill and a developed long-term acquisition of resilience, PTG, among veterans facing life-threatening illness or injury was a significant positive predictor of quality of life (Martz et al., 2018). PTG is a form of personal change, and this study shows that it not only acts as a buffer but develops an individual’s necessary understanding to implement active coping skills for facilitation leading to better quality of life (Martz et al., 2018). Results of the Gómez-Batiste PST visit effect showed significant decrease in anxiety of patients between the first and second visits and even greater between the first and third (Gómez-Batiste et al., 2017). This may signify a growing acquisition for resiliency. The personal change experienced and the expanded comprehension of when/why active coping is activated leads to long-term acquisition of resilience (Martz et al., 2018). Skills that lead to long-term acquisition of resiliency behavior include mental fortitude fostered through mindfulness-based guidance, Re-exposure to similar daily stresses were met with better adaptive skills and less anxiety in the wake of trauma after MARST program participants used mindfulness enhancement strategies based on cognitive behavior therapy models (Pidgeon et al., 2015). These continual and sustained improvements demonstrate efficacy in resilience and fostering psychological well-being in a group of studies conducted among healthcare workers and have been successful in a Mindfulness-Based Mind Fitness Training for improving resilience and performance among soldiers (Pidgeon et al., 2015). These long-term changes can and should be built-up through guided therapies in both individual and group contexts (marital partners, family systems, military units) (Kees & Rosenblum, 2015; Kahn, Collinge & Soltysik, 2016; Saltzman, 2016).

RQ3. What specific methods are utilized within the military to help families increase

protective factors?

Specific methods are utilized within the military to help families increase

protective factors. Adaptational support from mental health professionals, social systems, and increased efficacy through psychoeducation caused individuals to “re-bound” better than those who do not use specified methods (Crisp et al., 2017; Pidgeon et al., 2015; Rice & Liu, 2016). This information can help direct the development for therapies in populations which are faced with illness and uncertainties in military life. The MARST programs provided specific methods of interventions through targeted core aspects of mindfulness, resilience and positive reappraisal. The MARST program consisted of resilience and mindfulness enhancement strategies like: change and acceptance techniques based on cognitive behavior therapy and mindfulness meditation practice (Pidgeon et al., 2015). MARST and MSBR research are examples of this support, mediating the potential adverse effects that can arise without interventions (Pidgeon et al., 2015; Rice & Liu, 2016).

Engaging with social supports of community and family are noted in research to be strong resources for increasing protective factors (Kees & Rosenblum, 2015; Kahn, Collinge & Soltysik, 2016; Saltzman, 2016). Kees & Rosenblum reported on the benefits of community in military spouses, with participants stating, ““I know I am not alone” and “it lessens the sense of isolation” (Kees & Rosenblum, 2015). Having protective factors of community and family supports in place for military families is key to their success (Kees & Rosenblum, 2015). Psychological programs that are embedded into communities allow protective factors to be present at the time crisis strikes for these servicemen and family members (Kees & Rosenblum, 2015; Saltzman, 2016). Mental health professionals and programs servicing military families should take into account these specific methods and then implement programs that fulfill the needs established among this population (Pidgeon et al., 2015; Saltzman, 2016).

RQ4. In what ways do military families increase protective factors enhance their success through resiliency?

Ways in which military families increase protective factors enhance their success through resiliency. Building efficacy and protective factors included self-care for family members, specifically care-givers. Self-care initiatives through guided psychotherapy initiatives showed opportunities to reframe and take ownership of one’s personal health and well-being (Strong & Lee, 2017) among caregivers for ill family members, while self-care in military spouses offered avenues of wellbeing, affecting the overall wellness of family systems (Kees & Rosenblum, 2015). Communication and efficacy in household management were used as tools to create protective factors in the Clark study (Clark et al., 2018). These daily activities and influence of family communication during deployment led to the creation of a protective barrier in participants, helping them to overcome the routine stressors they encounter (Clark et al., 2018). These examples suggest that further implementation in enhancing protective variables will aid multiple populations.

Engagement is a factor in the ability for military families to increase their protective/shielding of adverse reactions when faced with difficulties. Increased engagement in resilience-directed programs may be achieved through avenues that promote accessibility to initiatives. It was noted that in both veterans and partners in the MR portion of the Kahn and colleagues guided home program, participants used online instructions far more than predicted (Kahn, Collinge & Soltysik, 2016). This usage contributed to feedback of increased psychological well-being and is indicative of sustained engagement as a factor to enhance protective factors (Kahn, Collinge & Soltysik, 2016). Enhanced success may be connected to the client/user preference in long-term engagement and accountability in partner/family approaches for this population (Kahn, Collinge & Soltysik, 2016).

RQ5. How do those who are ill or injured achieve resilience through coping strategies?

How those who are ill or injured achieve resilience through coping strategies was witnessed in studies conducted in enhancing psychosocial and spiritual care (Gómez-Batiste et al., 2017). Social support through family and medical teams coupled with meaning-making provides a beneficial source of support for these families (Gómez-Batiste et al., 2017; Tsai et al., 2015). Resilience was often achieved in meaning-making and find some greater purpose for the pain or struggle they endure (Pidgeon et al., 2015). Decreasing emotional distress and increasing good or average mood state was achieved through provisions of supportive teams (Gómez-Batiste et al., 2017). Resilience and mindfulness enhancement strategies that included change and acceptance techniques (psycho-education, interactive discussion, skills training in everyday mindfulness tools and mindfulness meditation, identifying non-resilient and resilient thinking styles, experiential exercises) proved to help those injured achieve greater resilience (Pidgeon et al., 2015).

Coping strategies in those who are ill/injured foster successful resilience by the development of PTG in veterans facing life-threatening illness (Martz et al., 2018). Components of this study which contributed to developing successful strategies included mindfulness-based approaches in relation to: one's life, a greater sense of personal strength, greater spiritual development, and a greater appreciation of life (Martz et al., 2018). How a life-threatening illness or injury can be first received as the ‘worst’ traumatic life event reported in clients, (Martz et al., 2018) and become a tool for growth exhibits a client’s success in harnessing resilience in the face of adversity.

Summary

To overcome adversity, military families and those with illness and injury employ adaptive capacities, which are enhanced through guided therapies (Kees, 2015; Pidgeon et al., 2015). Review and examination of these current resilience-based treatments for military families, and those who are ill or injured emphasized 5 specific coping styles: self-efficacy, meaning-making, social support, spirituality/religion, and positive religious coping mechanisms. HomeFront Strong (HFS) interventions showed increased efficacy in participants after use of such programs indicating guided therapy’s ability to boost psychological health and resilience in military spouses (Kees & Rosenblum, 2015). Likewise, MARST programs that targeted aspects of mindfulness, resilience report increased resilience as participants change and accept the traumas or hurtles they’ve faced (Pidgeon et al., 2015).

The use of coping styles coupled with fostering enhanced efficacy was found to work together to form a “shock absorber response to adversity in the Clark study (Clark et al., 2018). In an analysis of effectiveness, a total of 2,823 patients were assessed in the Gómez-Batiste study, which provided support for meaning-making as a specific component to gaining resilience (Gómez-Batiste et al., 2017). Meaning-making and attributions to a divine being or greater purpose in centered psychotherapy (MCP) showed strong results with significant improvement in spiritual well-being and quality of life among those receiving palliative care, making this an important component in the implementation of resilience-targeted therapy (Rosenfeld et al., 2017).

Conclusions

To achieve the goal of aiding mental health professionals and clients in the promotion of resilience is obtainable through new and innovative means. Recognition of models which validate the hurried and often overwhelming lives led by military families and those who are ill/injured can provide extensive support (Clark et al., 2018; Kees & Rosenblum, 2015; Saltzman, 2016). Assessments here provide targeted strategies and models to foster active coping. While these pilot studies and new methods are improving guided resiliency therapies, more work to determine the most beneficial factors is necessary.

This thesis paper will improve the welfare of military families and those who are ill/injured through the information of evidence-based guided therapy models at the on-set of adversity, known to shield from discord and maladaptive response (Southwick et al., 2016; Saltzman, 2016). Studies aimed at compiling various methods of interventions in a cumulative fashion from the 5 (self-efficacy, meaning-making, social support, spirituality/religion, and positive religious coping mechanisms) highlighted strategies may further research in positive adaptations to adversity.

Direction for Future Research

Further study in a cohesive fashion among vulnerable populations (military families and those ill/injured) emphasizing interpersonal coping styles to buffer hardship and increase resilience to adversity are needed (Benight & Bandura, 2004; Saltzman, 2016). The resilience shown in these groups does mirror one-another, allowing greater validity and data for those in the mental health profession to draw from (Martz et al., 2018; Tsai et al., 2015). The dissemination and accessibility of program materials, psychoeducation, and applicable models is an area in which further research is necessary for these client populations. Current studies also point to a much-needed expansion of program offerings in alternate formats such as web or mobile-based applications. FOCUS group’s “telehealth” version of the program, as well as Kahn’s study use of new technologies as a means to make program more accessible to military members and families are an innovative means to reach families in these populations (Kahn, Collinge & Soltysik, 2016). By noting potential for accountability with at-home family members, as well as the removal of illness barriers home-based, guided online interventions are an arena of therapeutic services which should continue to expand (Gómez-Batiste et al., 2017; Kahn, Collinge & Soltysik, 2016).

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