Happiness, resilience, and positive growth following physical disability: Issues for understanding,...

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C H A P T E R

62Happiness, Resilience, and Positive GrowthFollowing Physical Disability: Issues forUnderstanding, Research, and TherapeuticIntervention’

Dana S. Dunn, Gitendra Uswatte, and Timothy R. Elliott

Abstract

Do well-being and happiness change following acquired physical disability? The onset of physical disabilityoccurs due to trauma or disease, either of which can mean a reduction in function (e.g., activities of dailyliving) or the literal loss of a body part (e.g., limb amputation). Restricted mobility, activity, or physical losscan have psychological consequences, so that some individuals report a variety of depressive symptomsand problem behaviors following disability onset. Yet many people with disabilities do not suffer fromdepression or behavioral difficulties; rather, they adjust to their circumstances reasonably well. Followingthe onset of disability and subsequent rehabilitation, then, many individuals report relatively favorablelevels of subjective well-being (SWB) and happiness, and that they take pleasure in daily life, including work,play, and interactions with family and friends. The focus of this chapter is those individuals who exhibitpositive reactions to living with disability. We hope that products and insights from their positiveresponses can develop new or revised existing therapies to promote the health and well-being of others,the goal of rehabilitation psychology. Our discussion is grounded in the theoretical and empiricalperspectives of positive psychology; the constructive, person-situation focus of rehabilitation psychology;and the approaches emerging from the synergy of both research areas. Positive psychology emphasizesthree complementary foci: subjective states, individual processes, and the creation and maintenance ofpositive social institutions. Against the backdrop of acquired physical disability, we consider the first twofoci by examining happiness and then resiliency and positive growth. We then consider the implications ofour review for future research and therapy.

Keywords: disability, happiness, positive growth, rehabilitation resilience

Most observers have overlooked the potentially valuableexperience of acquiring a physical disability. Writers havegiven only scant attention to positive growth and optimalliving with chronic health problems, as well as the relatedsearches for meaning, purpose, and fulfillment.——Elliott, Kurylo, & Rivera (2002, p. 687)

One of the most difficult facts for observers—agroup often referred to as ‘‘outsiders’’ in the rehabi-litation literature—to accept is that many peoplewith disabilities (i.e., ‘‘insiders’’) adjust to their cir-cumstances reasonably well (for discussion of

the insider–outsider distinction, see Dunn, 2000;Wright, 1991). A second challenging fact for obser-vers is that following the onset of disability andsubsequent rehabilitation, many individuals reportrelatively favorable levels of subjective well-being

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(SWB). Insiders often report being happy and takingpleasure in daily life, including work, play, andinteractions with family and friends (e.g., de NAbrantes-Pais, Friedman, Lovallo, & Ross, in press;Siosteen, Lundqvist, Blomstrand, Sullivan, &Sullivan, 1990; Wright, 1983). Insiders themselvesare often surprised by their ability to cope with oradjust to physical disabilities and to learn that happi-ness and leading a relatively normal (if initially newand different) life is possible. Perceived quality oflife, too, can be high in spite of physical limitationsor a compromised physique (e.g., Albrecht, 1996;Delle Fave, 2006; Weinberg, 1988).

Although the appraisal processes of both insidersand outsiders are important to consider whenstudying disability, our focus in this chapter is largelyon insiders’ perspectives and assessments. Weemphasize optimistic reactions to disability for tworeasons. First, in line with positive psychology andexemplified by research summarized in thisHandbook, the Zeitgeist in rehabilitation psy-chology is gradually becoming more salutary infocus. Second, some past efforts were overly negativein their portrayals of disability, highlighting distressand depression while creating the impression thatpeople with disabilities were victims of cruel fate,objects of prejudice or pity, or simply health-preoc-cupied, passive recipients of medical care. Webelieve that a new focus on positive aspects ofliving with acquired physical disability will addneeded balance to conceptualizations of well-being,and psychological and physical health.

Of course, the term ‘‘physical disability’’ is a broadone; some disabilities are due to trauma and thereforeare sudden and unexpected. Other disabilities aredisease related, which means those affected by them,as well as their families, often have time to anticipateor adjust to bodily as well as psychosocial changes.(Congenital disabilities constitute an important butseparate category outside the scope of this review; seeDykens, 2006.) Physical loss, too, can mean a reduc-tion in function (e.g., activities of daily living) or it canmean the literal loss of a body part (e.g., limb lossdue to automobile accident), which, in turn,restricts mobility and activity. Physical loss can havepsychological consequences and, naturally, some indi-viduals report a variety of depressive symptoms andproblem behaviors following the onset of disability(Elliott & Frank, 1996; Lawrence, Fauerbach, &Thombs, 2006; Turner, Lloyd, & Taylor, 2006).Treatment and rehabilitation options for such indivi-duals are covered in great detail elsewhere (Frank &Elliott, 2000). Moreover, contemporary definitions

of disability for understanding chronic conditionsadvanced by the World Health Organization (theInternational Classification of Functioning,Disability, and Health [ICF]; WHO, 2001; see also,Peterson & Elliott, 2008) deemphasize the explana-tory utility of medical diagnosis, recognizing the roleof socio-environmental factors in limiting ability andimposing limitations. This expanded view of dis-ability complements alternative service models thatpromote independent living, improve access to insti-tutions, and enhance role functioning and mobility toreduce disability across the WHO model’sdimensions.

Our purpose is to discuss what is known aboutindividuals who exhibit positive reactions to livingwith disability in order to learn from them. We hopethat products and insights from their positiveresponses can develop new or revised existing thera-pies to promote the health and well-being of others,the goal of rehabilitation psychology. Our approachis grounded in the theoretical and empirical perspec-tives of positive psychology (e.g., Seligman, 2002;Seligman & Csikszentmihalyi, 2000), constructive,person-situation focus of rehabilitation psychology(e.g., Frank & Elliott, 2000; Frank, Caplan, &Rosenthal, in press; Wright, 1983), and approachesemerging from the synergy of both (e.g., Dunn &Dougherty, 2005; Elliott, Kurylo, & Rivera , 2002).To date, positive psychology emphasizes three com-plementary foci: subjective states, individual pro-cesses, and the creation and maintenance ofpositive social institutions. Against the backdrop ofacquired physical disability, we will consider the firsttwo foci by examining happiness and then resiliencyand positive growth. We then consider the implica-tions of our review for future research. We begin byexamining the subjective state integral to positivepsychology—happiness—and then consider how itmay change following acquired disability.

Happiness After DisabilityTo be happy is to flourish in daily life. Happiness

or SWB is frequently defined as having three inter-related qualities: regular positive affect, elevated lifesatisfaction, and sporadic negative affect (e.g., Diener,1984; Diener, Suh, Lucas, & Smith, 1999). Happypeople typically enjoy success in several life domains,including friendship, marriage, employment, work,income, mental health, and, not surprisingly, psycho-logical well-being (for reviews, see Gilbert, 2006;Haidt, 2005; Lyubomirsky, King, & Diener, 2005;Myers & Diener, 1995; see also Ryff & Keyes, 1995).The main finding from happiness research is easily


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summarized: Most people report being happy. Butwhat factors contribute to or maintain happiness?Recently, Lyubomirsky, Sheldon, and Schkade(2005) proposed that any individual’s chronic levelof happiness is governed by three factors: the person’sset point of happiness, which is genetically deter-mined, fixed, and stable; circumstantial factors,including personal qualities (e.g., age, gender, lifehistory), events (e.g., marriage, unemployment,retirement), and situations (e.g., nation, location,culture); and intentional actions, such as whatpeople do and how they think in everyday life.These three factors constitute the ‘‘architecture ofsustainable happiness’’ (Lyubomirsky et al., 2005AQ1 ).

We believe the pursuit of happiness followingdisability needs to be considered in light of thisaffective architecture. One set of reasons is thathappy people engage in less negative self-reflectionthan unhappy individuals, dwell less on adversityand rebound more quickly from it, and react todistressing life events positively (Abbe, Tkach, &Lyubomirsky, 2003). Another reason is that someaspects of happiness following a disabling event maybe relatively immune to rehabilitative or therapeuticintervention, whereas other aspects may offer clientsopportunities to enhance their well-being. We beginby examining the extent to which an individual’srange of happiness—the so-called ‘‘set point’’—isaffected by disability.

The Hedonic Treadmill, Set-Point Theory,and Disability

A milestone study in the study of happiness anddisability found that individuals who acquired spinalcord injuries (SCIs) reported being almost as happy aspeople who could walk (Brickman, Coates, & Janoff-Bulman, 1978). This study also reported the ironicresult that lottery winners generally end up being nohappier than nonwinners. Brickman and colleaguesargued that these findings implicated a ‘‘hedonictreadmill’’ where reactions to both positive and nega-tive events are temporary—across time, people adjustto extreme good or bad fortune, returning to theirindividual set-point level of happiness. One implica-tion of this model is that happiness is forever transi-tory because people adapt to whatever comes theirway, whether good or ill. Yet, people potentiallybenefit from such adaptation when faced with nega-tive events. Eventually, the impact of the distressingevent is assimilated and individuals appear to returnto their hedonically accustomed levels (e.g., Silver,1982). Quite understandably, students of disabilityresearch were quick to interpret the hedonic

adaptation of the individuals with acquired SCI asevidence that happiness returns even in cases of unex-pected, traumatic loss.

A careful reanalysis of Brickman et al.’s (1978)findings, coupled with a revision of hedonic adapta-tion theory, suggests that happiness following someacquired disabilities is less robust than anticipated.Diener, Lucas, and Scollon (2006) note that thepositive adaptation observed in Brickman et al.’sdata was not quite so pronounced as claimed orlater promulgated by sympathetic scholars. In fact,the participants with SCI actually reported beingsignificantly less happy than the control group—themean levels of happiness were approximately 0.75standard deviations apart (Diener et al., 2006). Oneexplanation could be depressive symptoms, whichare a significant secondary complication of SCI(Elliott & Kennedy, 2004). Diener and colleaguesalso cite studies indicating that persons with SCIgenerally report lower levels of happiness comparedto the general population (Dijkers, 1997, 2005;Hammell, 2004; Lucas, 2005, 2007). In otherwords, happiness set points can change in responseto important life events, such as acquired disability,so that a return to previous levels may not occur. Toquote Diener and colleagues (p. 307), ‘‘althoughpeople with paraplegia and other individuals withdisabilities usually are not subjectively miserable,happiness levels do seem to be strongly affected bythis important life circumstance.’’ In some cases ofSCI, then, one’s set point of well-being can be sub-stantially lowered even if depression or other psy-chological disorders do not occur.

Should researchers rule out the possibility of aresurgence of happiness following the onset of dis-ability? Other research suggests that individuals withSCI sometimes report positive by-products (e.g.,heightened compassion, closeness to family, spiri-tuality) as a result of acquired disability (McMillen& Cook, 2003). However, one problem is the mis-match between clients’ self-reported benefits andthose observed by family caregivers. To date, a rea-sonable approach for determining the validity ofreported by-products, one combining methodolo-gical rigor with insider perspectives, remains to bedevised. McMillen and Cook suggest that thevalidity of these particular reports remains uncertain.As will be discussed later, such skepticism is not new.

One also needs to consider individual differencesin happiness among persons with disabilities. Oneintriguing individual difference is the relative finan-cial standing of those who acquire a disability. Mostcross-sectional studies find that once a certain level


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of material wealth is reached, additional income haslittle discernible impact on happiness (e.g., Myers,2000). However, a recent study comprised of peopleat or near retirement age found that after the onset ofdisability, individuals whose finances placed theirtotal net worth above the group’s median showedsmaller reductions in happiness than did those withassets below the median (Smith, Langa, Kabeto, &Ubel, 2005). In keeping with the set-point theoryand the impact of circumstances (to be discussedshortly), the buffering effect of wealth was a short-term phenomenon. As time passed, the below-the-median group recovered some of their former happi-ness. Although suggestive, these results warrantfurther attention and replication.

The precise nature of the causal connectionsamong happiness, disability, health, and income, aswell as other between-group and individual differencevariables, remains to be studied empirically usingrigorous longitudinal designs like those employed byLucas (2005). Moreover, set-point theory and thehedonic treadmill comprise only one factor affectingpeople’s chronic happiness; circumstance and inten-tional actions also need to be considered.

Circumstances and Affective ForecastingRegarding Disability

Circumstances relevant to happiness are usuallystable facts of life over which people have little con-trol. Matters of personal history and life status vari-ables (e.g., health, education) are exemplars ofcircumstance, as are major life events. A disablingexperience, such as an industrial accident resulting intraumatic brain injury, is one such event.Lyubomirsky and colleagues (2005)AQ2 suggest thatobjective life circumstances have relatively littleimpact on happiness in the long run due to hedonicadaptation.AQ3 Even things one can control to a degree,such as moving to a desirable part of the country,have little impact on well-bring (Schkade &Kahneman, 1998). Where a severe disability is con-cerned, the affective impact would need to be con-sidered in light of Diener et al.’s (2006) revisedadaptation theory of well-being.

Lyubomirsky and colleagues (2005)AQ4 do suggestthat some life status variables can potentially influ-ence happiness but only within limits. In the shortrun, for example, happiness can be increased ordecreased, respectively, as a result of positively(e.g., winning an award) or negatively (e.g., dissolu-tion of a intimate relationship) valenced events.Changes in happiness levels due to many life statusvariables, then, are apt to be temporary.

We believe, however, that the effects of circum-stances on happiness following disability should beexamined for another reason: the potential forbiased, especially unduly lowered, expectationsregarding future well-being. Research on affectiveforecasting, the processes whereby people make pre-dictions about their emotional reactions to futureevents, demonstrates that individuals routinely over-estimate the strength and longevity of their affectivereactions (Wilson & Gilbert, 2003, 2005). Manyindividuals do adapt physically and psychologicallyto health problems, including disability, while boththey and the general public underestimate the abilityto adjust (Frederick & Loewenstein, 1999;Lowenstein & Schkade, 1999 AQ5). Wilson and Gilbertlabel this forecasting error the ‘‘impact bias’’ andsuggest one source is undue focus on the event inquestion while simultaneously neglecting how other,competing events also shape thoughts and feelings.Different participant groups in different circum-stances illustrate the bias, including people whoanticipated undue sadness following a romanticbreakup, women who overestimated their unhappi-ness following unwanted results from a pregnancytest, professors who overestimated their unhappinessseveral years after being denied tenure, and indivi-duals who learned whether they were HIV positive,among others (Loewenstein, O’Donoghue, &Rabin, 2003 AQ6; Mellers & McGraw, 2001; Sieff,Dawes, & Lowenstein, 1999; Wilson & Gilbert,2003). Even the impact of wealth, including thedesire to be richer, has an exaggerated and transientimpact on happiness (Kahneman, Krueger, Schkade,Schwartz, & Stone, 2006).

Affective forecasting errors are relevant toacquired disability because of what Wilson andGilbert (2003) refer to as people’s ‘‘psychologicalimmune system,’’ which combats threats to emo-tional well-being via various social psychologicalprocesses (e.g., positive illusions, self-serving attribu-tions). Most such processes are nonconscious, thatis, people remain unaware that they possess or relyon such psychological defenses routinely. Whenprojecting how he will feel later, say, a year followinga traumatic accident, a person with a recentlyacquired disability will neglect the role of thesesubtle coping responses when he is predictingfuture feelings. Indeed, an important part of thisprocess is the motivation to ‘‘make sense’’ of circum-stances, especially unexpected ones. There is evi-dence, for instance, that people with acquireddisabilities actively seek and find explanations fortheir experiences (e.g., Dunn, 1994).


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What about the nature or severity of an event?Some research indicates that although major eventshave a larger emotional impact on people than minorones, the motivation to make sense of the implica-tions of the former is greater than that for the latter.Ironically, the affective anguish associated withminor events is apt to persist for a longer period oftime (Gilbert, Lieberman, Morewedge, & Wilson,2004). Indeed, people underestimate their capabilityto adjust and cope with life challenges (Gilbert,Pinel, Wilson, Blumberg, & Wheatley, 1998;Kahneman, 2000), just as they fail to notice howmotivated they are to make sense of negative emo-tional events. What remains to be demonstratedempirically, of course, is whether these findingsholds true for acquired disability. As with changesto happiness set points following disability, it maywell be that different degrees of disability lead toshorter or longer periods of emotional adaptation.

Affective forecasts after disability are apt to beimportant for a variety of reasons. First, studyingforecasting biases regarding disability adds depth towhat is known about processes of subjective adapta-tion to and the potential identification of positiveby-products following physical injury (Dunn &Dougherty, 2005). If so, then perhaps the knowl-edge gleaned from such research can be used tovalidate insiders’ positive self-reports about dis-ability, thereby convincing outsiders (includingtherapists) that adjustment claims represent norma-tive, not maladaptive, responses (Dunn, in pressAQ7 ).

Wilson and Gilbert (2005) note that affectiveforecasts play a significant role in people’s livesbecause they sometimes guide decision making.Where everyday events are concerned, emotionalmispredictions disrupt people’s ability to accuratelypursue or maximize happiness. In the case of suddendisability (e.g., stroke), an overestimate of the event’simpact could lead to excessive upset and apprehen-sion about one’s future. As a result, some individuals(even families or health-care providers) might makeless-than-optimal treatment choices by underesti-mating their abilities to adapt or overestimating theemotional toil a therapy regimen could create(Wilson & Gilbert, 2005). To date, however,attempts to improve the accuracy of people’s fore-casts have not succeeded (Ubel et al., 2001).

Construing Happiness Following Disabilityas an Intentional Act

While people’s control over circumstances is lim-ited, intentional activities are thoughts, behaviors,and volitional acts people choose to perform in daily

life (Lyubomirsky, Sheldon, & Schkade, 2005;Sheldon & Lyubomirsky, 2006). These acts arenovel or routine and generally involve some delib-erate effort. In Lyubomirsky et al.’s model, happi-ness is linked with the three categories of effortfulactivities. ‘‘Cognitive activity’’ occurs in the form ofhope for the future (e.g., Snyder, Ilardi, Michael, &Cheavens, 2000), for example, or finding side-ben-efits in an otherwise stressful situation (Affleck &Tennen, 1996). Treating others kindly or exercising(‘‘behavioral activities’’) is also linked with enhancedlevels of happiness (e.g., Keltner & Bonanno, 1997;Magen & Aharoni, 1991 AQ8). Finally, performing actsof ‘‘volition,’’ including pursuing or striving afterpersonal goals (Ryan & Deci, 2000; Sheldon &Houser-Marko, 2001), being generative (e.g., deSt. Aubin, McAdams, & Kim, 2004), or dedicatingtime to worthy causes, can lead to heightened well-being (Snyder & Omoto, 2001). In practice, allthree categories work in concert with each other.However, selectively retaining distinctions amongthem are important for developing theory andcreating interventions to increase chronic levels ofhappiness (Lyubomirsky, Sheldon, & Schkade,2005; Sheldon & Lyubomirsky, 2006).

Electing to engage in positive, effortful, inten-tional acts following disability appears to be a con-structive response, a means to stave off negativeemotions, including depression. Behavioralresponses to disability are probably the mostcommon of the three types of intentional acts, andare often initiated by others during the course ofrehabilitation. Although people respond differently,whether noted by insiders or outsiders, progressduring rehabilitation can enhance well-being(Dettmers et al., 2005; Lai, et al., 2006; Svendsen& Teasdale, 2006). According to Fredrickson’sbroaden-and-build model (Fredrickson, 1998,2001), experiencing positive emotion helps torepair the deleterious effects of stress and broadenthe repertoire of thoughts and behaviors available toindividuals. Thus, the positive emotions resultingfrom progress in rehabilitation might help to repairthe effects of stress and lead to other positive, inten-tional acts (e.g., maintaining health-related beha-viors after rehabilitation).

Following disability, people’s construal pro-cesses—how they appraise, explain, and drawmeaning from their experiences—may well representthe sort of intentional act identified as a source ofhappiness by Lyubomirsky, Sheldon, and Schkade(2005). As Dunn (in press AQ9) argues, ‘‘Well-beingshould not be equated with absence of disability nor


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should chronic disability be misconstrued as ‘perma-nent illness or loss’.’’ Happiness is subjective andtherefore subject to individual processes of construal.People both try to explain and search for meaning indisability once it occurs (Dunn, 1996), just as they tryto understand and integrate threatening events intotheir lives (e.g., Taylor, 1983). Pursuing similaragendas, psychologists have been interested in howindividual reactions to disability affect well-being inthe context of rehabilitation (e.g., Elliott, Witty,Herrick, & Hoffman, 1991). Bulman andWortman (1977), for example, examined construalfollowing disability in the context of adjustment toSCI. The authors found that many individuals intheir sample reevaluated their injuries as positiveafter asking ‘‘why me’’ questions, concluding thatsuch defensive attributions were adaptive under thecircumstances.

We suspect that intentional behavioral and cogni-tive acts can lead to volitional ones, especially whenpeople with disabilities change their frame of refer-ence from the negative to the positive. To understanddisability experiences, we believe that an importantquality of volitional acts is their future orientation.Volitional acts involve the choice to act in positiveways to work toward some desired state aligned withfuture happiness. For example, being encouraged toadopt a focus on one’s strengths, real or potential,what one can do or can (re)learn to do, may lead tomeaningful increases in happiness (e.g., Keany &Glueckauf, 1993). Several authors suggest thatacquired disability encourages some individuals toadopt ‘‘reality negotiation strategies’’ or flexible self-beliefs that preserve a positive self-image whiledirecting hopeful expectations toward positive out-comes despite dramatic life changes (e.g., illness, dis-ability; e.g., Elliott et al., 1991; Snyder, 1989). Suchstrategies induce a variety of cognitive and behavioralacts linked with happiness, including planning andgoal setting for the future (Elliott, Uswatte, Lewis, &Palmatier, 2000).

Happiness is clearly an important subjectiveresponse to acquired disability, albeit one selectivelyaffected by positive interventions. We now turn toissues of resilience and positive growth, individualprocesses offering opportunities for psychosocialinterventions following disability.

Resilience and Positive GrowthFollowing Disability

‘‘Resilience’’ describes a broad array of abilities forconstructively and positively adapting to risk, adver-sity, or some monumental negative event. Resilient

individuals not only cope with the event, they oftenlearn from and are transformed by their experiences(Grotberg, 2003). Masten and Reed (2002), forexample, argue that two criteria characterize an indi-vidual’s response as resilient. First, the individualmust be responding favorably on some set ofagreed upon indicators of psychosocial well-being.Second, the stressful situation must be recognized assufficiently threatening to reduce the likelihood ofany good outcomes occurring. In spite of the ‘‘oddsagainst them,’’ resilient people bounce back fromadversity (e.g., Carver, 1998) and do well regardlessof the nature and impact of the traumas faced (e.g.,Bonnano, 2004; Linley & Joseph, 2004).

Positive growth is one possible consequence ofresilient reactions to negative events, including dis-ability. Such growth has been examined in responseto multiple sclerosis (Mohr et al., 1999), early-stagebreast cancer (Sears, Stanton, & Danoff-Burg,2003), living with HIV/AIDS (Milam, 2004;Siegel, Schrimshaw, & Pretter, 2005), cancer andlupus (Katz, Flasher, Cacciapaglia, & Nelson,2001), and rheumatoid arthritis (Danoff-Burg &Revenson, 2005). People’s perspectives on thenature and implications of such events can changein positive ways (Somerfield & McCrae, 2000).Changes include the construal processes noted ear-lier in this chapter (e.g., finding positive meaning,benefit finding), as well as favorably reinterpretingnegative events (Scheier, Weintraub, & Carver,1986), growth following trauma (e.g., Calhoun &Tedeschi, 2006), and positive illusions (Taylor &Brown, 1988), among other processes (for a review,see Tedeschi & Calhoun, 2004).

These responses are now largely accepted as bothnormative and adaptive among those facing trau-matic events. In the past, where disability was con-cerned, such reactions were not viewed as real or truereflections of how people characterized their situa-tions. Rather, under the circumstances (e.g., irrevoc-able change, physical loss), their accounts wereviewed as perhaps understandable, if defensive, andin any case could not possibly be accurate portrayalsof the experience of disability. Regrettably, this con-descending outsider attitude toward insider viewswas even held by some rehabilitation professionals.In this section, we discuss some areas of resilienceand growth that are linked with the experience ofacquired physical disability, including knownsources of resilience and growth, the benefit of nar-ratives, the promise of positive emotion, and thecultivation of virtues. We also offer a caveatregarding promoting resilience and positive growth.



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Possible Sources of Resilience and GrowthFollowing Disability

Arguably, the most overlooked source for resili-ence and growth following disability is treating theindividual with as disability as an individual.Disability is but one aspect of a person’s life; it doesnot define a person or his or her self- or social worth.Wright (1983) claimed that a chief problem forpeople with disabilities was their frequent identifica-tion with their conditions rather than as individualswith a given condition. This ‘‘person-first’’ approachmatters a great deal where eliminating the objectifica-tion of people with disabilities is concerned.

Wright (1983) also emphasized that the advent ofany disability can be viewed as a surmountable chal-lenge, something to be coped with, or as a disastrousundoing, something to succumb to. Individual differ-ences can push people toward optimism or pessi-mism, that is, toward a coping or a succumbingframe of reference. We suggest that a client’s familymembers and friends should be counseled to focus onhis or her progress in rehabilitation while emphasizinga coping rather than succumbing orientation (Elliott,Shewchuk, & Richards, 2001; Olkin, 1999).

Sustained individuation and positive coping arealso linked with the idea that no matter how severeor disruptive a disability may be, no physical condi-tion eliminates people’s other ‘‘assets’’ (e.g., Dunn &Dougherty, 2005). Assets represent a broad collec-tion of existing or potential resources. Theseresources include a person’s proficiencies, skills, orindividual qualities connected to everyday life, suchas self-concept, work, hobbies and interests, socialnetworks, and social interactions. Assets are tangible(e.g., number of friends, income, health insurance)as well as psychological (e.g., sense of humor,autonomy, willingness to learn). Resilience and posi-tive growth following disability can be promoted byreminding individuals of assets they possess or canacquire rather than unduly highlighting those theylost, lack, or may never gain back (Keany &Glueckauf, 1993). An important part of recognizingone’s assets involves shifting from an old set of valuesregarding what matters in life to a new set based onliving with disability.

A final way to promote resilience and positivegrowth is to involve clients in the rehabilitativeprocess. The idea of clients as co-managers is along-standing value of rehabilitation psychologythat is gaining new currency in rehabilitative therapy(Balcazar, Keys, Kaplan, & Suarez-Balcazar, 1998;Wright, 1972). Involving clients, who are now oftenreferred to as ‘‘consumers,’’ emphasizes their role as

stakeholders in what happens to them following theonset of disability. Clients can contribute insightsabout their conditions as well as express their desireswhere social, medical, psychological, and technolo-gical services are concerned.

What markers point to resilience and positivegrowth after a disabling injury? The relative absenceof psychological problems (anxiety, depression, socialisolation), enhanced well-being, and general satisfac-tion with daily life point to both qualities. Wright(1983) and Taylor (1983) identify people’s sense ofpersonal worth (i.e., independent of altered appear-ance or physical limitation), gratitude for and enjoy-ment of family, and the development of spiritual,understanding, or thoughtful outlooks as compellingevidence. Elliott and colleagues (2000) suggest resi-lient reactions and positive growth can also be mon-itored by decreased risk for and infrequent incidenceof secondary complications following disability onset(e.g., pressure sores; Elliott, Bush, & Chen, 2006). Inaddition, individuals displaying favorable responseswould engage in successful problem-focused andemotion-focused coping activities aimed at maxi-mizing their psychological and physical health(Lazarus & Folkman, 1984).

Narratives as Indicators of Resilience andGrowth Regarding Disability

Life narratives are first-person accounts, the storiespeople tell about themselves to themselves and toothers regarding their experiences following disability.Narratives represent a qualitative approach forstudying resilience and growth, one that is caseoriented and less focused on traditional issues of gen-eralizability. The creation of coherent storiesregarding major life events allows people to drawmeaning from the event while shaping their identitiesin constructive ways (e.g., McAdams, 2001;McAdams, Josselson, & Lieblich, 2001; Rybarczyk& Bellg, 1997). In keeping with themes discussedearlier in this review, life stories regarding disabilitytend to emphasize that living with a disability is not adefining quality but rather one among many (e.g.,Cole, 2004; Elliott & Kurylo, 2000; Johnson, 2005;King, Brown, & Smith, 2003).

Narrative accounts foster outsiders’ under-standing about insiders’ actual experience of dis-ability (Dunn, 2005). Researchers should examinenarratives not only for evidence of resilience or posi-tive growth, but also to identify possible mechanismsdriving favorable adjustment to disability. First-person accounts may be fruitful sources of hypoth-eses for more quantitatively focused studies. We



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suspect that many researchers ignore narrative databecause they assume it is biased or merely represen-tative of a typical American cultural script whereinnegative experiences are necessarily perceived retro-spectively as redemptive (McAdams, 1993, 2005).As other scholars suggest (Peterson, Park, &Seligman, 2006), such self-views on identity mightnot be inauthentic, but they should be regarded withhealthy skepticism. We do not disagree; empiricalvalidation is surely warranted. Yet, we believe narra-tives are an underutilized source of insider perspec-tives and insights on acquired disability.

Positive Emotion, Resilience, and Growth:Issues for Studying Disability

The cultivation of positive emotions is a promisingavenue for promoting resilience with a growing bodyof evidence to support it (Fredrickson, 2006). Thereis substantial evidence that positive affect is an effec-tive coping resource (Aspinwall, 2001). Resilientpeople are more likely than less resilient individualsto experience and benefit from experiencing positiveemotions. Specifically, according to evidence from thebroaden-and-build model of positive emotions, thelatter affective states help undo any lingering effects ofnegative emotions (Tugade & Fredrickson, 2002).When linked with resilience, positive emotionscause a return toward baseline levels of psychologicaland physiological function (Tugade & Fredrickson,2004). In a prospective field project involving datacollection pre- and post-September 11, 2001, terroristattacks, when compared to less resilient peers, resilientcollege students were less depressed and demonstratedpost-event psychological growth (Fredrickson,Tugade, Waugh, & Larkin, 2003).

The research of Fredrickson and colleagues sug-gests that rehabilitation researchers should attendto the beneficial effects of positive emotion. In ourjudgment, researchers interested in coping with theconsequences of disability should consider howrehabilitative progress coupled with social interac-tion can foster positive emotions. Recent work byGable, Reis, Impett, & Asher (2004) implicates theintrapersonal and interpersonal consequences ofsharing good things with others. When people‘‘capitalize’’ on good events (e.g., successes) bytelling the news to interested others (e.g., spouses)and then receive enthusiastic feedback in return,higher relationship well-being results. Such capita-lization might be expected to serve two functionsduring rehabilitation: to mark treatment progressand to engender closer relationships with care-givers. As Gable and colleagues note, of course,

cultivating positive emotions through capitaliza-tion only operates when good news is respondedto favorably. These capitalization findings implythat the quality of client–caregiver interactionsplay an important role in maintaining well-beingfollowing disability.

Cultivating Positive Strengths and VirtuesCan character strength and virtues be cultivated

by people after a disabling experience? What impactdo existing strengths or virtues have on adjustmentto disability? Peterson and Seligman (2004) devel-oped a framework for organizing and understanding26 specific strengths or positive individual traitsunder six broad virtues: wisdom, courage, humanity,justice, temperance, and transcendence. Strengthsare psychological processes or mental practicesdefining virtues, the core qualities of good character.Gratitude, hope, and humor, for example, arestrengths that either singly or in combination impli-cate transcendence, a virtue connecting self to othersand providing meaning to an individual’s existence.

Space constraints preclude an extended discus-sion of strengths and virtues, but like Peterson andSeligman (2004), we believe that they can inoculatepeople by strengthening habits that engender flour-ishing, as well as providing sense and purpose in theface of adversity. In a large-sample, retrospectiveWeb-based study, for example, individuals with ahistory of physical illness (e.g., diabetes, arthritis,cancer, cardiovascular problems) reported greaterlife satisfaction if they possessed the characterstrengths of kindness, bravery, and humor(Peterson, Park, & Seligman, 2006). Generally, lifesatisfaction is associated with love, zest, curiosity,gratitude, and hope (Park, Peterson, & Seligman,2004). Peterson and colleagues suggest that, onoccasion, physical recovery is linked with enhancedcharacter strengths. However, these authors are notadvocating adopting a ‘‘virtue in suffering’’ perspec-tive on people’s responses to physical problems.Rather, they believe that some people appreciate areturn to physical health and well-being by devel-oping certain strengths in the process.

Currently, no studies employing a longitudinalperspective tracking character pre- and post-physicalor psychological crisis are available. Except for anec-dotal accounts that many insiders and outsiders dis-count, there is no strong evidence that people withdisabilities develop character strengths due to theirconditions. Longitudinal studies would answer ques-tions about how strengths may moderate the linkbetween physical and psychological states, such as



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life satisfaction, happiness, and other measures ofwell-being. More to the point, however, we believethat researchers and practitioners who work withpeople with acquired disabilities should also look todevelop interventions designed to increase strengths.There is evidence that some positive interventions doincrease happiness and stave off depressive symptomsin nondisabled people (Seligman, Steen, Park, &Peterson, 2005).

A Caveat: Resiliency and Growth Should BeEncouraged, Not Required

We want to be clear about one important ther-apeutic issue: positive growth must not be mandatedor forced upon clients. People with disabilities, likeall individuals, have the right to self-determinationand to participate in discussions and plans con-cerning care and treatment regimens. There is clearlya fine line between making clients aware of thepossibility of improved quality of life and informingthem that they must accept an enterprise designed toimprove their well-being. To quote Wright (1983,p. 191), ‘‘Although there is good evidence that onemay rise to great heights of emotional understandingfrom the depths of despair, this may not be the onlyor the best course’’ (italics in original). Indeed, noteveryone may experience positive growth following atrauma (Wortman, 2004).

Not so long ago, well-intentioned researchers andtherapists argued that people with acquired physicaldisabilities should be required to properly mourntheir loss of function (e.g., Wright, 1980, 1983).Failing to grieve for lost capacities was portrayed aspsychological denial or some other defensive reac-tion (e.g., Grzesiak & Hicock, 1994). The presump-tion was that postponing facing grim reality wouldundermine psychosocial well-being in the long run.Some individuals who become disabled did and domourn the loss of function. Many, however, do notdisplay grief reactions, at least not in any prescribedmanner (similar variable responses are documentedin the myths of coping with loss literature; Wortman& Boerner, 2007). Their reaction to their physicalcircumstances is normative, as research demonstratesthere is no single way to respond to personal trauma.Rather, people display various reactions based onindividual differences and particular situations.Indeed, whether a disabling event or other loss,some people portray the trauma as meaningless(Bulman & Wortman, 1977; Lehman, Wortman,& Williams, 1987). In short, there is no ‘‘right’’ wayfor individuals to respond to disability (Olkin, 1999;Trieschmann, 1988).

Finally, Henry (2006) cautions that some posi-tive psychological strategies can promote or evenachieve well-being and lasting change while othersare ineffective. Individuals’ differences may prevail;indeed, some personality factors may predisposesome people to be more resilient than others afterthe onset of disability (Berry, Elliott, & Rivera,2007). Some methods work for some people butnot others. Henry reports that exhortations, such asurgent advice, admonishment (‘‘Keep trying!’’), andcompassionate encouragement, are often seen asunhelpful. No doubt these observations do notapply universally, as many clients desire active, ana-lytically focused guidance. The point is that anypositive psychological intervention aimed at creatingresilience must be carefully planned and empiricallygrounded rather than approached as a simplistic,cheerleading exercise.

Looking ForwardAdvances in the psychology of positive subjective

states and traits are a rich source of ideas for rehabi-litation psychologists to plumb to enhance the well-being of people with disabilities. Possible approachesinclude helping consumers correct errors in affectiveforecasting when making decisions about rehabilita-tion, enhancing relationships with family caregiversby teaching both parties to reinforce each other’ssuccesses, and even employing well-known strate-gies, such as individuation, emphasizing assets, andsetting treatment goals with the goal of fosteringresilience. These approaches should be rigorouslytested before adoption into clinical practice.Randomized controlled trials are necessary to findout which approaches are actually effective, followedby components’ analyses to identify the therapeuticelements of the successful interventions.

At the same time, the study of adjustment todisability can be fertile ground for positive psy-chology. Rehabilitation psychologists study happi-ness under some of the more challengingcircumstances encountered by men and women.The experience of people with disabling injuriesalso permits the study of character strengths thatare not typically called upon frequently in the livesof able-bodied people. For example, bravery mightbe called upon in someone who is newly blind on adaily basis, whereas among able-bodied people thisstrength might be employed only in uncommoncircumstances. The study of rehabilitation popula-tions with focal damage to the brain, such as strokesurvivors, might open the door to a neuropsychologyof character strengths (e.g., Koenigs, et al., 2007).



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The Elliott et al. (2002) dynamic model ofadjustment to disability reflects the Lewinian con-cept that behavior is a function of individual andenvironmental factors (Lewin, 1997). In theirmodel, (a) enduring characteristics and individualdifferences and (b) social and environmental char-acteristics affect (c) phenomenological and appraisalprocess, which, in turn, influence (d) psychologicalwell-being and (e) physical health. Psychologicalwell-being and physical health influence eachother. These five components are framed within adevelopmental continuum that permits changes inany of the five components as people age, technologyadvances, and public policy changes.

This framework offers guidance for the study ofpositive adjustment to disability. It directs theresearcher to pay attention to both individual andenvironmental factors and to be open to dynamicinteractions between all five components of themodel. Importantly, the model also directs theresearcher to examine the phenomenological andappraisal processes that connect enduring personaland environmental characteristics to psychologicaland physical outcomes. In general, rehabilitationpsychology research to date, both in the positivepsychology arena and otherwise, has examined theassociation between individual traits and psycholo-gical well-being and physical health. For the field toadvance, it is important to examine what is ‘‘insidethe black box,’’ to delineate how particular traits areconnected to desirable outcomes (Elliott, 2002). Toaccomplish this empirical goal, relevant behaviors,thoughts, and emotions, as well as relevant charac-teristics of the environment, need to be assessed atmultiple time points during rehabilitation and infollow-up afterward. Multilevel modeling techni-ques, such as structural equation modeling and hier-archical linear modeling, can then be employed tohelp draw out relationships between the variables ofinterest across time (Elliott et al., 2002). This type ofcomplex data and analysis will help ultimately todiscover the psychological mechanisms that permitmen and women to triumph over adversity andflourish.

Questions for the Future1. When people’s set-point of happiness

decreases following disability onset, is the change arelatively permanent one? Can rehabilitationinterventions reverse the change, thereby returninghappiness to baseline levels?

2. Positive psychology tends to focus on theperson, that is, psychological characteristics

(e.g., strengths) that promote happiness and well-being, whereas rehabilitation psychology tries to linkpeople’s qualities with constraints and possibilitiesimposed by the environment. What methods andtheories can positive psychology adopt and adaptfrom rehabilitation psychology (and vice versa)?

3. Rehabilitation research concerning happiness,resilience, and positive growth tends to be cross-sectional in nature. What sorts of longitudinal,multi-method research designs can be used tocapture emotional, cognitive, and social changefollowing the onset of disability?

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QUERIES TO BE ANSWERED BY AUTHOR (SEE MANUAL MARKS)

IMPORTANT NOTE: Please mark your corrections and answers to these queries directly onto the proofat the relevant place. Do NOT mark your corrections on this query sheet.

Chapter 62

Q. No. Pg No. Query

AQ1 653 Please specity whether this citation referes to "Lyubomirsky, King, and Diener (2005)" or "Lyubomirsky, Sheldon, and Schkade (2005)".

AQ2 654 Please specity whether this citation referes to "Lyubomirsky, King, and Diener (2005)" or "Lyubomirsky, Sheldon, and Schkade (2005)".

AQ3 654 In the sentence ‘‘Even things . . . have little impact onwell-bring’’: Do you mean ‘‘Little impact onwell-being’’?

AQ4 654 Please specity whether this citation referes to "Lyubomirsky, King, and Diener (2005)" or "Lyubomirsky, Sheldon, and Schkade 2005)".

AQ5 654 ‘‘Loewenstein & Schkade, 1999’’ has been changed to‘‘Lowenstein & Schkade, 1999’’ in order to match withreferences list. Please check.

AQ6 654 ‘‘Lowenstein, O’Donoghue, & Rabin, 2003’’ has beenchanged to ‘‘Loewenstein, O’Donoghue, & Rabin,2003’’ in order to match with references list. Pleasecheck.

AQ7 655 Please clarify whether you mean Dunn, in press-a or inpress-b.

AQ8 655 ‘‘Magen & Ahroni, 1991’’ has been changed to ‘‘Magen& Aharoni, 1991’’ in order to match with references list.Please check.

AQ9 655 Please clarify whether you mean Dunn, in press-a or inpress-b.

AQ10 661 Please update the reference ‘‘de N Abrantes-Pais, F.,Friedman, J. K., Lovallo, W. R., & Ross, E. D. (inpress)’’.

AQ11 661 Please update the reference ‘‘Dunn, D. S. (in press-a)’’.AQ12 661 Please update the reference ‘‘Dunn, D. S. (in press-b)’’.AQ13 661 Please update the reference ‘‘Frank, R. G., Caplan, B., &

Rosenthal, M. (Eds.). (in press)’’.AQ14 661 Please check the page range for Gilbert, Pinel et al.

(1998).AQ15 663 Reference ‘‘Wortman and Silver (<xref ref=AQ16 664 Reference ‘‘Ydreborg, Ekberg, and Nordlund (2006)’’

has been provided in list, but not cited in text. Pleasecheck.


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