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Coping with Cancer Interventions for the Family
Cancer & Family continuing education psychologist CEUs

Section 22
Clinical Implications of Family Resilience

CEU Question 22 | CE Test | Table of Contents | Cancer
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Family resilience is becoming an increasingly visible concept in the family field. This article discusses resilience as a family level construct and offers several ideas about how viewing families as resilient may affect clinical work. These include a focus on strengths, recognizing resilience as a developmental pathway, a search for commonalties among diverse paths of resilience, and an emphasis on helping families identify and develop a useful family schema. A case study utilizing these ideas is presented and discussed.

An increasingly visible issue in the family field is resilience. Although the study of resilience among individuals is well established in developmental psychopathology (e.g., Garmezy, 1993; Rutter, 1987), it has only recently appeared in family literature. Much of the work on family resilience has been at the theoretical level (Hawley & DeHaan, 1996; McCubbin & McCubbin, 1993; Walsh, 1996), although studies using family resilience as a key variable are beginning to emerge (e.g., Genero, 1995).

However, little has been written about the clinical implications of family resilience. When resilience is discussed in the context of working with families, the focus tends to be on individual resilience as a protective factor in troubled families (Barnard, 1994; Valentine & Feinauer, 1993; Wolin & Wolin, 1993). However, considering how the family as a unit may be resilient and how that may affect therapy is largely untouched. Hawley and DeHaan (1996) and Walsh (1996) both touch on clinical applications of family resilience, but the primary emphasis in these articles is in clarifying a definition of the concept. The purpose of this article is to address clinical implications of family resilience. Before delving into these, however, the author will offer some background on the development of family resilience as a distinct concept.

What is Resilience?
Resilience is described in developmental psychopathology literature in numerous ways. Rutter (1987) refers to it as "individual variation in response to risk" (p. 317), Werner (1989) as "successful adaptation following exposure to stressful life events" (p. 72), and Garmezy (1993) as "functioning following adversity" (p. 129). Hawley and DeHaan (1996) suggest that many of these definitions encompass several themes. First, resilience surfaces in the face of hardship. It involves the manner in which individuals respond to difficulties. Without struggle, resilience does not exist. Second, resilience carries a property of buoyancy. It assumes that individuals exhibiting resilience are able to "bounce back" or "rebound" from adversity, reaching or surpassing a precrisis level of functioning. Finally, resilience is generally described in terms of wellness rather than pathology. Antonovsky (1987) calls this a "salutogenic orientation" (p. 2). Strengths, rather than deficits, are emphasized and are viewed as the resources that allow individuals to overcome adversity.

Resilience is often discussed in terms of risk and protective factors. Risk factors increase the likelihood of barriers to effective functioning arising for an individual, either in childhood or throughout the lifespan. Parental divorce, poverty, and physical or mental illness are examples of risk factors. Family is sometimes viewed as a risk factor which resilient individuals have overcome. For example, Wolin and Wolin (1993) provide a number of case anecdotes describing the "survivor's pride" (p. 8) of individuals who have overcome the effects of families of origin marked by alcoholism and mental illness. Protective factors, on the other hand, are resources that help individuals buffer the effects of adversity. Garmezy (1984) has identified three common categories of protective factors for resilient children: an easy temperament, the presence of an individual who takes a strong interest in the child, and a strong social network. Wolin and Wolin (1993) have identified seven protective characteristics including insight, independence, relationships, initiative, humor, creativity, and morality.

In general, resilience is most likely to be found when risk factors are minimized and protective factors are present. However, Rutter (1989) notes that risk and protective factors are not static but ever changing. In fact, what is described as a protective factor at one point in time may function as a risk factor at another time or in another context. For example, when a family moves to a new location, a protective factor may be a sense of cohesion that allows them to focus a majority of their energies toward supporting one another in an effort in transition in their new surroundings. However, if this is a continued pattern after a transitional period this inward focus may prevent them from becoming integrated into the community and can be associated with isolation--a potential risk factor. Thus, families and the professionals who work with them need to consider the context of a situation in identifying risk and protective factors in families.

Family Resilience
Multiple descriptions of family resilience exist in the family literature. McCubbin and McCubbin (1988) define resilience as "characteristics, dimensions, and properties of families which help families be resistant to disruption in the face of change and adaptive in the face of crisis situations." (p. 247), while the National Network for Family Resiliency (1996) stresses that resiliency includes strengths a family utilizes in response to difficulties.

A common thread is that family is viewed as a protective factor for individuals potentially at risk. Barnard (1994), for example, identifies several family characteristics associated with individual resilience including the absence of parent-child role reversals, the maintenance of rituals, and minimal conflict in the home during infancy. Similarly, Wyman et al. (1992) compared groups of preadolescents exposed to major life stressors and discovered that those who were more resilient reported positive relationships with primary caregivers, stable family environments, and inductive and consistent family discipline practices. In these cases, the individual is the unit of analysis with family variables serving as correlates to resilience.

Increasingly, however, resilience is being viewed as a family level construct. The work of McCubbin and McCubbin (1988) and M.A. McCubbin & H.I. McCubbin (1993) has been especially noteworthy in this regard. Coming from a family stress perspective, they have expanded on Hill's (1958) ABCX model and McCubbin and Patterson's (1983) double ABCX model to propose the resiliency model of family stress, adjustment and adaptation. In this model they suggest that a number of factors interact to predict a family's level of adaptation to stressors, including their level of vulnerability, family type (regenerative, resilient, or rhythmic), resources, appraisal of the stressor, and problem-solving and coping skills. They also propose family schema as a concept, a notion that suggests the family's overall outlook on life impacts resilience. In particular, families with a strong sense of coherence (Antonovsky, 1987), a general belief that adverse circumstances will eventually work out in a favorable way, are able to most withstand the effects of adversity and may even thrive under difficult circumstances.

The National Network for Family Resiliency (1996) has conceptualized resilience as occurring at multiple levels including individual, family, and community, with each level being unique yet interdependent. This conceptualization draws primarily on the family strengths literature to identify several factors associated with resilience in families, including commitment, communication, cohesion, adaptability, spirituality, connectedness, time together, and efficacy.

Walsh (1996), approaching this subject systemically, has introduced the notion of relational resilience. This concept also focuses on the family as a functional unit. She proposes that relational resilience emphasizes family processes and describes the manner in which families link these processes to their unique challenges. Walsh also suggests that relational resilience incorporates a developmental perspective concerned with how a family deals with stress over time. Thus, the pathway each family takes to resilience is unique, negating the possibility of discovering a "blueprint for any singular model of 'the resilient family'" (p. 269).

Hawley and DeHaan (1996), in seeking to clarify a definition of family resilience, have raised the question of whether resilience can be considered a family level construct as opposed to a collection of resiliencies held by individual family members. They conclude that resilience can be conceptualized at the family level, but that operationalizing it for research purposes may be a difficult task, particularly for definitions that rely on socially constructed meanings among family members. Hawley and DeHaan also stress the importance of viewing family resilience as a developmental construct. They suggest that it can conceptualized as a trajectory a family follows over time as it adapts and prospers in the face of stress. Thus, family resilience should be considered a process rather than a static set of qualities. Like Walsh, they indicate that the path of resilience each family follows is unique and emphasize the need for longitudinal research to adequately measure this construct (DeHaan, Hawley, & Deal, 1996).

Focus on Strengths
In his President's column in the APA Monitor, Martin Seligman (1998) recently called on psychologists to change from a deficit-based to a strengths-based focus. Calling this new emphasis positive psychology, Seligman asserts that "psychology is not just the study of weakness and damage, it is also the study of strength and virtue" (p. 2). He indicates that an approach based on pathology does not seem to significantly address the prevention of serious disorders. With evangelistic passion, he urges psychologists "to recognize that much of the best work they do is amplifying the strengths rather than repairing their patients' weaknesses" (p. 2).

I suspect there are quite a few family therapists reading these comments who would respond by saying "Its about time!" What many psychologists might see as a cutting edge movement, many family therapists view as old news. For a number of years, family therapy as a field has taken a lead in developing strengths-based approaches to therapy. For example, stemming from his work with adult children of alcoholics who did not repeat the patterns of their parents, Wolin advocates a "challenge model" (Wolin & Wolin, 1993, p. 15) that focuses on resiliencies employed by clients to over come adverse circumstances in their families of origin. Waters and Lawrence (1993) suggest that therapy should focus on competence in clients. They offer an approach that looks for healthy intentions in problem development, seeks to create a vision for healthy functioning, supports the courage of clients to take action in pursuit of therapeutic goals, and attempts to collaborate with clients in a therapeutic partnership that will sustain their growth. While approaches like these do not ignore the scars of a dysfunctional past, they do advocate a forward-looking view that underscores clients' successes rather than failures.

Nowhere is this strengths approach more evident than in social constructionist approaches to therapy such as solution-focused and narrative therapies. Solution-focused therapy assumes that clients already possess the resources they need to overcome their problems (deShazer, 1985; Walter & Peller, 1992). Therapy focuses on helping them access these resources by developing clear, specific therapeutic goals and then searching for exceptions--ways in which they are already meeting the goals (deShazer, 1985). Initially, narrative therapy (Freedman & Combs, 1996; White & Epston, 1989) appears to uphold a deficit model by helping clients flesh out their "problem-saturated story" (White & Epston, 1989, p. 16). However, a narrative approach quickly moves beyond the problem, helping clients discover alternative stories in their lives and encouraging them to endorse a preferred story. Narrative therapists help clients gain confidence in their preferred story by seeking "unique outcomes" (White & Epston, 1989, p. 16) that support its existence. Both models are more interested in how clients use their strengths to move past a particular problem than in deficiencies that need to be shored up.

These approaches are consistent with the salutogenic orientation proposed by Antonovsky (1987). Virtually any definition of resilience assumes that individuals and families exhibit a capacity to overcome difficult circumstances through the use of inherent and/or acquired resources and strengths. While outward appearances and stories of their pasts may suggest problematic functioning to a deficit-minded therapist, some families have developed strengths that have enabled them to buffer the effects of their environments and circumstances to a remarkable degree. Searching for evidence of resilience in such families may prove more fruitful to their continued growth than focusing on problem development.

Family therapists have numerous models that assist them in looking for strengths in families. However, the pragmatic reality is that most family therapists practice in a deficit-minded setting, Seligman's initiative notwithstanding. Third-party payments are based on assessing weaknesses, not strengths. Consultations with colleagues from other disciplines often focus on clients' problems rather than their resources. Battles over licensure are often about whether family therapists can diagnose, a medical term firmly planted in a pathological model. Thus, while our theoretical models acknowledge the importance of focusing on strengths, the realities of practice may make it difficult. A resiliency approach to family therapy needs to highlight the strengths a family brings to therapy in both theoretical and practical ways.

-Hawley, Dale R.; Clinical Implications of Family Resilience; American Journal of Family Therapy; June 2000; Vol. 28, Issue 2

Personal Reflection Exercise #8
The preceding section contained information regarding the clinical implications of family resilience. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Figley, C. R., & Burnette, C. E. (2017). Building bridges: Connecting systemic trauma and family resilience in the study and treatment of diverse traumatized families. Traumatology, 23(1), 95–101.

Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356–371.

Høeg, B. L., Johansen, C., Christensen, J., Frederiksen, K., Dalton, S. O., Dyregrov, A., Bøge, P., Dencker, A., & Bidstrup, P. E. (2018). Early parental loss and intimate relationships in adulthood: A nationwide study. Developmental Psychology, 54(5), 963–974.

McCleary, J., & Figley, C. (2017). Resilience and trauma: Expanding definitions, uses, and contexts [Editorial]. Traumatology, 23(1), 1–3.

Prime, H., Wade, M., & Browne, D. T. (2020). Risk and resilience in family well-being during the COVID-19 pandemic. American Psychologist, 75(5), 631–643.

Online Continuing Education QUESTION 22
What is the definition of family resilience? Record the letter of the correct answer the CE Test.

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