Setbacks to Strengths: A Scoping Review of Positive Psychology Constructs Among Veterans and Service Members With Traumatic Brain Injury

Abstract

Purpose/Objective:

Traumatic brain injury (TBI) is a major health concern for military personnel, and recovery and rehabilitation have historically focused on pathology and deficits. Recent efforts have shifted toward strength-based approaches, with a focus on positive psychology factors in TBI recovery. This study conducted a scoping review of the current research on positive psychology con-structs (PPCs) among military personnel with TBI.

Research Method/Design:

Using Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we identified English peer-reviewed studies published from 2000 to 2024 across four databases (MEDLINE, Embase, APA PsycInfo, and Web of Science) using search terms representing PPCs investigated among adults with military background and TBI. After abstract and full-text screening of 942 studies, data were extracted from 55 studies that met the inclusion criteria for this scoping review.

Results:

The majority of studies represent veterans (n = 42) who sustained a mild TBI more than 12 months before the study. Social support (n = 18), resilience (n = 14), and quality of life (n = 14) emerged as the most studied PPCs. Studies were primarily based in the United States (n = 49) with positive constructs examined through quantitative, cross-sectional methods (n = 32) using diverse self-report measures. Positive psychology intervention studies among military personnel are sparse (n = 3).

Conclusions/Implications:

An ecological framework situates PPCs across individual, social, and environmental domains, contextualizing multiple spheres of influence on recovery from TBI. Future rehabilitation research would benefit from intentional study design planning with coherent theoretical frameworks that clarify the relationships between PPCs, outcomes, and contextual factors.

Traumatic brain injury (TBI) affects approximately 69 million individuals globally each year (Dewan et al., 2019). TBI is a major health concern for veterans and service members (V/SMs) with an estimated 414,000 service members diagnosed with TBI between 2000 and 2019 (U.S. Department of Veteran Affairs, 2024). Although TBI is a heterogenous condition (Covington & Duff, 2021), with varied clinical outcomes and recovery trajectories, its effects can be pervasive. The bulk of research with V/SMs has focused on adverse consequences, and less attention has been devoted to positive psychological factors that help V/SMs thrive or foster well-being after injury (Elliott et al., 2017). Moving beyond deficit- or pathology-focused approaches to health, Positive Psychology is a field that studies positive experiences and traits to optimize well-being and individual functioning (Seligman et al., 2005; Seligman & Csikszentmihalyi, 2000). Identifying and fostering positive outcomes can facilitate the rehabilitation process among V/SMs.

Cultivating positive emotions, meaning-making, and strengths can support adaptation to significant health challenges. Positive psychology constructs (PPCs) like resilience, optimism, and social support are linked to better adjustment, improved well-being, and quality of life across a range of health conditions (Bolier et al., 2013; Dorsett et al., 2017) and specifically in those with brain injury (Cicerone & Azulay, 2007; Rabinowitz & Arnett, 2018). Studies have demonstrated that character strengths, resilience, and meaning-making may support the emotional and functional consequences of TBI and support community reintegration (Andrewes et al., 2014; Baseotto et al., 2022; Hanks et al., 2014; Sullivan et al., 2016). In the context of V/SMs with TBI, higher resilience, for example, appears to facilitate better adjustment via psychological flexibility as a modifiable process that supports coping (Elliott et al., 2019). These benefits align with positive psychology frameworks such as model emphasizing positive emotion (P), engagement (E), relationships (R), meaning (M), and accomplishment (A) (PERMA, Seligman et al., 2005); and Unger’s resilience model highlighting multilevel systems (Ungar et al., 2013). Despite these guiding perspectives, how and to what extent these constructs influence outcomes after injury remains unclear and theoretically inconsistent, especially in military personnel’s recovery from TBI. Systematic reviews and metanalysis show that positive psychology interventions, such as hope-based practices, value-based writing, and gratitude exercise, have demonstrated feasibility and small to moderate improvements in subjective and psychological well-being across diverse populations (Carr et al., 2021; Hendriks et al., 2020). However, these reviews also highlight considerable heterogeneity, limited high-quality trials, and a lack of attention to specific clinical groups. Our review addresses this gap by examining how PPCs have been applied within TBI literature among military population. To date, no systematic efforts have been made to evaluate PPCs among V/SMs with TBI. Information on the use of specific constructs, contexts of application, specific measures to assess these constructs, and interventions that have implemented assessments or embedded positive psychology approaches in the context of military personnel with TBI are dispersed, which impedes the development of concise questions and the inclusion of relevant outcomes with this population.

This scoping review aims to address this gap by mapping the use of positive constructs investigated among military personnel with TBI. This review will aid in understanding potentially modifiable positive factors that can further inform treatment approaches to focus on protective factors. Doing so will broaden practice and research in TBI with V/SMs by underscoring a “building what’s strong rather than fixing what’s wrong” approach (Lee Duckworth et al., 2005). This review will inform future directions of TBI research using PPCs and summarize findings across different types of research and assessments used for these constructs.

Method/Design

This scoping review will be guided by Joanna Briggs Institute Reviewer’s Manual (Peters et al., 2020), and the final reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (Tricco et al., 2018). The approach included (a) identifying the research question, (b) identifying relevant studies, (c) selecting studies, (d) charting the data, (e) collating, summarizing, and reporting the results, and (f) consultation (Levac et al., 2010). This scoping review was conducted by eight individuals across several academic and veterans institutions.

Identifying the Research Question

The research question that guided this scoping review is: “What PPCs are researched in TBI literature among V/SMs?” Secondary questions included the following:

1. How are positive psychology outcomes defined and characterized?

2. How are the constructs measured and what outcomes/scales have been used?

3. What PPCs can be meaningfully clustered?

The research question was formulated following preliminary reading and exploratory searches of literature on TBI and positive psychology. As positive psychology encompasses various constructs with terms often used interchangeably, this review included the following list of constructs that guided the search strategy: resilience, posttraumatic growth, flourishing, positive affect, well-being, meaning in life, strengths, character, virtue, hope, optimism, coping style, grit, disability identity development, social support, self-efficacy, and self-esteem.

Identifying Relevant Studies

The search used in this scoping review was intended to be broad to ensure a comprehensive overview of the field of positive psychology among military personnel with TBI. Supplemental Table S1 summarizes the eligibility criteria.

Participants

This review included studies with participants with a military background, aged 18 years or older, and with a history of TBI. Participants with any military role, position, or status were considered. The review excluded studies with participants with other mixed brain injury or acquired brain injury as it usually incorporates stroke, anoxia, and tumors in addition to TBI. The review also excluded studies whose participants were caregivers to military personnel who sustained a TBI and/or studies looking at caregiver outcomes.

Concept

This review included all studies that examined PPCs listed in the search block in Table 1. Because PPCs are multidimensional, and in some cases comparable or used interchangeably (e.g., post-traumatic growth and flourishing; resilience and grit), this review included a broad range of terms to encompass and examine the extent of their use in research on V/SMs with TBI. During abstract screening, studies with commonly occurring positive rehabilitation constructs such as quality of life, life satisfaction, and community integration (focused on social participation/engagement or sense of belonging) were included and added to the list of constructs. Outcomes focused on functional aspects of community integration or health-related quality of life were excluded for their emphasis on nonpsychological assessments.

Table 1.

Search Block and Search Terms

Search block	Search terms
TBI	Traumatic brain injury, mild TBI, TBI, brain injury, head injury, brain damage, post-concussion, concussion, closed head injury
Military	Veterans, service members, military personnel, active duty, special operations, army, navy, air force, marine corps, national guard, space force
PPCs
Posttraumatic growth	Posttraumatic growth, adversarial growth, stress-related growth, positive growth, personal growth, meaning making, finding meaning, sense-making, sense of coherence, positive consequences, positive adjustment, perceived benefits, benefit finding, thrive
Resilience	Resilient
Flourishing	Flourish
Positive affect	Positive affect, positive emotions
Well-being	Wellbeing, well-being, hedonic or eudemonic wellbeing
Meaning in life	Meaning, purpose, meaning-making
Strengths of character and virtue	Character, virtue, character strengths, valued living, strengths
Hope	Hope, optimism, positive outlook
Coping style	Coping style, adaptive coping
Grit	Grit, hardiness
Disability identity	Disability identity, disability identity development, positive identity
Perceived social support	Social support
Self-esteem	Self-efficacy, self-esteem

Note. TBI = traumatic brain injury; PPC = positive psychology construct.

Context

Positive psychology terms can be examined objectively or subjectively. There were no restrictions on the research type or design of the study, settings, or interventions of the included studies in this review as long as the outcomes or the aim of the study included PPCs/outcomes. A date limit was applied to screen studies from January 2000 until May 2024 because positive psychology is a fairly recent construct developed over the last 2 decades.

Types of Evidence Sources

Peer-reviewed studies were included in this scoping review. Studies were excluded if they are not in English. This review excluded sources that are reviews, editorials, conference abstracts, commentaries, book chapters, or theses.

Search Strategy

The comprehensive search strategy was developed by the lead author (Bani Malhotra) with consultation by a research librarian (John W. Cyrus) with experience in systematic reviews. A combination of controlled vocabulary terms and keywords for the concepts were established to document relevant search blocks and terms, and consensus was obtained by the research team using an iterative process. The search strategy was adapted as necessary for MEDLINE (PubMed), Embase (Ovid), APA PsycInfo (EBSCO), and Web of Science (Clarivate). Additional searches were performed through reference lists of included studies. Supplemental Table S2 provides an example of the final search strategy used to search MEDLINE.

Study Selection

Following the search, the results were imported into Covidence (Veritas Health Innovation, Melbourne, Victoria, Australia) for duplicate identification and removal. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol for study selection (see Figure 1). Four database search results yielded 1,598 records. Manual search of studies did not yield additional results. Screening in Covidence was conducted in two phases after 656 duplicates were removed: title and abstract review followed by full-text review. Two authors independently screened 942 titles and abstracts using the inclusion and exclusion criteria as a guide. A total of 244 studies met the eligibility for full-text screening, which was assessed again by two reviewers independently. Reasons for exclusion during full-text screening were recorded and reported in the scoping review. Both the screening phases were trialed with a random selection of 10 articles by both reviewers. Disagreements between the reviewers at each stage of the selection process were resolved through discussion, or with an additional reviewer(s), or through research team discussion to reach consensus. The full-text screening resulted in the final inclusion of 55 articles.

Figure 1.

PRISMA Diagram Showing the Process of Identification, Screening, and Final Inclusion of the Studies

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses. See the online article for the color version of this figure.

Charting the Data

A data coding template was developed in Covidence and used to extract data. Data were extracted by three independent reviewers using a form that included specific details regarding “participants,” “positive psychology concept,” “context,” “study methods,” and “important findings” relevant to the scoping review questions and objectives. The template was piloted on the first nine eligible studies and updated using an iterative process until data extractors reached consensus on the final version. Supplemental Table S3 provides the coding variables extracted from the data.

Summarizing and Reporting the Results

Descriptive summary tables were maintained in Microsoft Excel to chart the characteristics of the included studies. A summary of extracted data is presented in Supplemental File 2. Findings were analyzed using summary statistics; data were tabulated and mapped. Visualizations and narrative summaries were employed to describe the findings related to the review’s objective and questions, along with future implications and recommendations to integrate PPCs in TBI research with the military population.

Transparency and Openness

All data have been made publicly available in supplementary materials and can be accessed at https://doi.org/10.1037/rep0000681.supp.

Results

Study Characteristics

Findings from the analysis of 55 studies revealed several note-worthy patterns across various dimensions. Analysis using Bibliometrix (Aria & Cuccurullo, 2017) revealed that publications of the included studies ranged from 2003 to 2024, with the highest number of studies published in 2017. These studies were sourced from 29 journals, with the majority published in Brain Injury. Supplemental Figure S1 demonstrates the annual scientific pro-duction and sources of the included articles.

Articles were published from studies conducted in five countries, with the majority conducted in the United States (n = 49) and the rest in Ukraine (n = 3), the United Kingdom (n = 1), South Africa (n = 1), and Australia (n = 1). The majority were quantitative (83.6%, n = 46), followed by qualitative research (10.9%, n = 6), with a smaller proportion using mixed-methods research (5.5%, n = 3). Types of research designs varied, the majority being cross-sectional or observational (58.2%, n = 32), followed by randomized-controlled trial studies (10.9%, n = 6). Figure 2 provides a comprehensive overview of the types of research designs for all the included studies.

Figure 2.

Research Designs for Included Studies

Note. See the online article for the color version of this figure.

Study Sample and Sociodemographic Characteristics

Supplemental Table S4 indicates demographic characteristics reported in the included articles. The median number of V/SMs with TBI across the studies was 95 with 49.1% articles including more than 100 V/SMs with predominantly male samples. Age was reported in 45 articles, with mean age ranging from 26.94 (Merritt et al., 2015) to 49.62 years (Brenner et al., 2009). More articles reported race (76.4%) than ethnicity (65.5%) with 19 studies noted as having percentage of White identifying V/SMs with TBI as 70% or more and 11 studies had 20% or more Hispanic V/SMs. Twenty-seven articles reported marital status of which 17 included married V/SMs with TBI as 50% or more. Articles reported pooled or mean education data, making it challenging to determine V/SM’s educational background. The majority of studies recruited V/SMs from outpatient settings (n = 28), followed by community settings (n = 19), inpatient (n = 3), and transitional care settings (n = 3). Settings from two articles were not available.

Injury Characteristics

Studies were reviewed for the inclusion of V/SMs with mild, moderate, and/or severe TBIs, with categories as mutually inclusive. Mild TBI was most commonly reported (n = 50), followed by moderate (n = 17) and severe TBI (n = 15). Regarding TBI diagnosis, 52 studies mentioned some form of screening medical records or conducting clinical interviews using a wide range of screening tools. Three articles did not report how TBI was diagnosed or confirmed. Time since injury for V/SMs with TBI were categorized as <6, 6–12, or >12 months with categories as mutually inclusive. Of the 55 studies, 20 did not report time since injury. The majority of studies (n = 34) included V/SMs injured more than 12 months before the study, and fewer studies included those injured 6–12 months (n = 5) and less than 6 months (n = 3).

Military Characteristics

The studies most frequently included veterans (n = 42), followed by active-duty personnel (n = 6), and both active duty and veterans (n = 6). One study included both active-duty and reserves. Twenty studies reported military affiliations, noting V/SMs from diverse branches including Army, Navy, Marine Corp, Air Force, Coast Guard, Special Operations, National Guard, and international forces. Twenty-one studies indicated combat exposures or number of deployments using the number of times V/SMs were deployed, the Combat Exposure Scale, or the combat experiences scale from the Deployment Risk and Resiliency Inventory, Version 2. Several others mentioned war cohorts of Iraq (Operation Iraqi Freedom, OIF), Afghanistan (Operation Enduring Freedom, OEF) wars, Dessert Storm, the Vietnam War, post-Vietnam, or post-9/11 veterans.

Positive Psychology Constructs

The most studied PPCs were social support (32.7%, n = 18), followed by resilience and quality of life (both 25.5%, n = 14). Community integration, a common rehabilitation outcome occurring in the search results for adaptation, adjustment, and social participation, was included in the review that was represented in 21.8% studies (n = 12), with other constructs such as positive affect and well-being studied at a much lower rate. Frequency-based ordering of the constructs is provided in Figure 3. Table 2, organized alphabetically by constructs, reports the corresponding measurement tools used to assess PPCs. Of the 55 studies, 14 studies reported using a theoretical framework. The frameworks varied from generic descriptions, research generated frameworks, to theories describing constructs such as resiliency, satisfaction with life, or community reintegration.

Figure 3.

Occurrences of Positive Constructs in the Included Studies

Note. See the online article for the color version of this figure.

Table 2.

Qualitative and Quantitative Tools Used for the Included Positive Constructs

Construct	Quantitative and qualitative tools used	Authors (year; assessment tool)	Studies that used the assessment
Community integration (social participation/engagement)	CRIS subscale: Extent of Participation (12 items) + three additional questions	Resnik et al. (2009)	Moriarty et al. (2015, 2016); Winter et al. (2016, 2017, 2018); Walker et al. (2018; nine items); Wu and Graham (2016; full scale)
	CRIS	Resnik et al. (2009)
	TBI-QoL subscale: Ability to Participate in Social Roles and Activities	Tulsky et al. (2016)	Lange et al. (2023); Lange et al. (2021); Walker et al. (2018)
	Community Integration Questionnaire	Willer et al. (1993)	Wu and Graham (2016)
	Participation Assessment With Recombined Tools Objective	Whiteneck et al. (2011)	McGarity et al. (2017)
	Semi-structured interview	N/A	Daggett et al. (2013); Libin et al. (2017)
Coping style	Brief Coping Orientation to Problems Experienced	Carver (1997)	Elliott et al. (2015, 2017); Donnelly and Donnelly (2021); Merritt et al. (2020); Sakamoto et al. (2021)
	Semi-structured interview	N/A	Daggett et al. (2013); Brunger et al. (2014)
Disability identity	Semi-structured interview	N/A	Brunger et al. (2014); Sabat et al. (2006)
Flourishing	Flourishing Scale	Diener et al. (2010)	Wallace et al. (2022)
Hope/optimism	Postintervention questionnaire	Heath and Beattie (2019)	Heath and Beattie (2019)
	Self-report surveys after sessions/clinical observations and notes	N/A	Landless et al. (2019)
	Optimism in intervention (not measured)		Assonov (2021)
Meaning in life	Integration of Stressful Life Experiences Scale	Holland et al. (2010)	Holland et al. (2013)
	The Purpose in Life scale, a 14-item subscale of the Scales of Psychological Well-Being	Ryff and Keyes (1995)	Lawrence et al. (2017)
Psychological flexibility	Acceptance and Action Questionnaire–II	Bond et al. (2011)	Elliott et al. (2015, 2017, 2019)
Positive affect	NIH Toolbox Emotion Battery positive affect	Hook and Giella (2023)	MacNulty et al. (2024)
	Self-report surveys after sessions/clinical observations and notes	N/A	Landless et al. (2019)
	Positive and Negative Affect Scale	Watson et al. (1988)	Assonov (2022; translated to Ukrainian); Assonov (2021); Kraal et al. (2015)
	WAM Questionnaire	N/A	Babov et al. (2023)
	TBI-QoL subscale: Positive Affect and Well-Being	Tulsky et al. (2016)	Lange et al. (2021)
Quality of life/life satisfaction	Postintervention questionnaire	Heath and Beattie (2019)	Heath and Beattie (2019)
	The WHOQOL-BREF assessment	WHOQOL Group (1998)	Otero et al. (2022); Sofko et al. (2016)
	TBI-QoL subscale: Quality of Life	Tulsky et al. (2016)	Merritt, Brickell, et al. (2022)
	Perceived Quality of Life	Patrick et al. (1988)	Harch et al. (2012)
	SWLS	Diener et al. (1985)	Hershaw et al. (2020); MacNulty et al. (2024); Noyes et al. (2021); Walker et al. (2018)
	Chaban Quality of Life Assessment Scale	Chaban et al. (2016)	Assonov (2021, 2022)
	Quality of Life Interview	Lehman (1988)	Romesser et al. (2011)
	Quality of Life Scale	Burckhardt et al. (1989)	Elliott et al. (2017, 2019)
Quality of relationships/family functioning/emotional support	Mutual Communal Relationship Scale (Modified)	Winter and Moriarty (2017)	Moriarty et al. (2015, 2016); Winter et al. (2018); Winter and Moriarty (2017)
	Interpersonal Relationships: Subscale of the Sydney Psychosocial Reintegration Scale	Tate et al. (1999)	Perlick et al. (2013)
	The Patient Competency Rating Scale subscale—Social/Emotional	Prigatano (2005)	Winter et al. (2016)
	PROMIS Emotional Support	Reeve et al. (2007)	Shi et al. (2023)
	Deployment Risk and Resilience Inventory–2 subscale family functioning	Vogt et al. (2013)	Pugh et al. (2018)
Resilience	TBI-QoL subscale: Resilience	Tulsky et al. (2016)	Lange et al. (2021, 2023), Walker et al. (2018); Merritt, Brickell, et al. (2022)
	Connor–Davidson Resilience Scale	Connor and Davidson (2003)	Assonov (2021, 2022; Ukrainian), Graham et al. (2013); Elliott et al. (2015, 2017); Reid et al. (2018); Shi et al. (2023); Troyanskaya et al. (2021)
	Response to Stressful Experiences Scale	Johnson et al. (2011)	Merritt et al. (2015)
	The Brief Resilience Scale	Smith et al. (2008)	Elliott et al. (2019)
Self-efficacy	General Self-Efficacy Scale	Schwarzer and Jerusalem (1995)	Lawrence et al. (2017); Stromberg et al. (2023); Walker et al. (2018)
Social support	WHOQOL-BREF subscale: Social Support	WHOQOL Group (1998)	Otero et al. (2022)
	The Abbreviated Duke Social Support Index	Koenig et al. (1993)	Perlick et al. (2013)
	Deployment Risk and Resilience Inventory–2 Social Support subscale	Vogt et al. (2013)	Elliott et al. (2015, 2017, 2019), Otero et al. (2022); Pugh et al. (2018); Seidl et al. (2015); Walker et al. (2018); Wright et al. (2023)
	Self-report surveys after sessions/clinical observations and notes	N/A	Landless et al. (2019)
	Semistructured interview	N/A	Brenner et al. (2009); Daggett et al. (2013); Kinney et al. (2024)
	Two questions from Diagnostic Interview Schedule–Version III to group responses into good, average, and poor social support	Robins et al. (1981)	Luis et al. (2003)
	Interpersonal Support Evaluation List–Short Form	Cohen et al. (1985)	Lawrence et al. (2017)
	Social Support Questionnaire–Short Form	Sarason et al. (1987)	Belanger et al. (2022)
	Medical Outcomes Study Social Support Survey Instrument	Sherbourne and Stewart (1991)	Merritt, Crocker, et al. (2022)
Spirituality	Daily Spiritual Experience Scale	Underwood and Teresi (2002)	Romesser et al. (2011)
Strengths	Self-report surveys after sessions/clinical observations and notes	N/A	Landless et al. (2019)
Well-being	WAM Questionnaire	N/A	Babov et al. (2023)
	SWLS	Diener et al. (1985)	Seidl et al. (2015); Storzbach et al. (2017); Wright et al. (2023)
	Mental Health Continuum–Short Form	Keyes (2002)	Barczak-Scarboro et al. (2020)
	Well-being measure by a composite including the physical and mental health subscales of the Medical Outcomes Study–Short Form–36 Health Survey (SF-36) and the SWLS	Ware and Sherbourne (1992); Diener et al. (1985)	Donnelly and Donnelly (2021)
	TBI-QoL subscale: Well-Being	Tulsky et al. (2016)	Lange et al. (2021)

Note. CRIS = Community Reintegration of Injured Service Members; TBI-QoL = Traumatic Brain Injury Quality of Life; NIH = National Institutes of Health; WAM = Well-Being Activity Mood; WHOQOL-BREF = World Health Organization Quality of Life–Brief Version; SWLS = Satisfaction With Life Scale; PROMIS = Patient-Reported Outcomes Measurement Information System; N/A = not applicable.

Intervention Studies

A total of 25.5% of the studies (n = 14) were intervention studies, with an even smaller proportion 5.5% (n = 3) incorporating positive construct within the intervention design. These included mindfulness-based stress, pain, emotion, and attention regulation training (MacNulty et al., 2024); therapeutic writing based on meaning and importance (Landless et al., 2019); and a resilience-based intervention (Assonov, 2021). Other interventions were psychoeducational, cognitive-based training, or physiological.

Network Graph of Conceptual Proximity

A network graph created using VOS Viewer of keywords as positive constructs is visualized in Figure 4, indicating research hotspots over time. Illustrating publications of connections between different constructs published over time, keywords appearing more frequently are depicted with larger nodes. Groups of tightly connected and cross-connecting constructs were social support and resilience, suggesting overlapping constructs. The field has shifted from a focus on meaning, disability identity, and self-efficacy to well-being and emotions in recent years among this population. It is noted that flourishing did not co-occur with any other construct in the included articles. Sparse links with dis-ability identity, spirituality, and flourishing indicate unexplored areas.

Figure 4.

Network Graph of Co-Occurrence of Keywords

Note. See the online article for the color version of this figure.

Discussion

This scoping review examined the prevalence of positive psychology outcomes examined among military personnel with TBI. Data from 55 articles were extracted from four databases that indicated multiple positive constructs examined from 2003 to 2024. Research trends underscored Western research on the topic with a large gap in research from non-U.S. countries. This scoping review suggests that the PPCs among V/SMs with TBI have primarily been studied through quantitative methods that focus on cross-sectional experiences. Although quantitative studies are necessary to examine hypothesis, the results suggest a need for comprehensive study of PPCs with exploratory research to understand lived experiences, build and test theory, and contextualize results over time.

Across the studies, social support, resilience, and quality of life were the most frequently examined, with each construct linked to a wide range of psychosocial and functional outcomes. Although the heterogeneity of the study designs and measurement tools preclude synthesizing the direction or magnitude of these associations, the results demonstrated in Supplemental File 2 suggest that these constructs were explored often in the context of mental health symptoms, community reintegration, and overall well-being. For example, social support has been examined in relation to symptom burden, psychiatric outcomes, and participation (Merritt, Crocker, et al. 2022; Pugh et al., 2018), and higher resilience was associated with lower depression and posttraumatic stress disorder symptoms and better adjustment (Elliott et al., 2015). Quality of life was explored in the context of irritability, sleep, emotional functioning, and community reintegration (Otero et al., 2022; Walker et al., 2018). A small percentage of theoretical conceptualizations that were included in the studies varied from generic descriptions, researcher generated frameworks, to theories describing particular constructs such as resiliency, satisfaction with life, or community reintegration, underscoring a need to develop coherent theoretical frameworks to ensure conceptual clarity and guide the selection of contextually relevant tools. The overall demographic and injury characteristics of V/SMs in the scoping review closely align with patterns commonly reported in rehabilitation research involving similar populations.

Theoretical Implications

A challenge within positive psychology research is the lack of conceptual clarity among its core constructs (e.g., resilience, strengths and virtues, posttraumatic growth, and self-efficacy), which prevents the systematic study of these constructs through conceptually distinct approaches, as well as their meaningful association with rehabilitation outcomes following TBI (Van Zyl et al., 2024). Addressing such ambiguity requires a framework capable of situating PPCs within clearly defined domains that also account for the multiple spheres of influence through which they can impact TBI outcomes. Adapted from Bronfenbrenner’s ecological systems model, Unger’s ecological model of resilience provides a useful framework for positioning positive constructs within a multilevel system of interacting contexts of individual, relational, social, and environmental influences (Ungar et al., 2013). The use of ecological models has highlighted the critical but understudied impact of family, community, and institutional factors on the impact of deployment and reintegration (Elnitsky et al., 2017; Paley et al., 2013), demonstrating their utility in guiding clinical practice and literature aimed at predicting military service member health outcomes after TBI.

Using Unger’s model, positive constructs identified in our review are not depicted as isolated psychological assets, but fac-tors nested across spheres of influence that may interact to influence outcomes (see Figure 5). At an individual level are capacity factors such as hope/optimism, self-efficacy, strengths, spirituality, and coping style; social positive factors reflect the family, peer, and unit factors such as social support, social participation and engagement, and quality of relationships between individual and others; social–environmental factors represent the larger cultural and systems of care that impact overall community integration and life quality/satisfaction. This supports a more holistic interpretation of resilient functioning, moving beyond the idea of PPCs as discrete traits and recognizing the interaction between individual, social, and environmental resources that create resilient responses that are culturally appropriate (Schwab et al., 2022). Doing so demonstrates that V/SMs’ positive adaptation to injury is shaped not only by personal strengths but also by social and cultural structures and systems of care to influence overall recovery (Moriarty et al., 2015; Vaz et al., 2017).

Figure 5.

Ecological Model of Positive Constructs in Rehabilitation Research

Methodological Implications

Across the studies in this review, positive psychological constructs such as resilience, social support, and quality of life frequently appeared both as outcomes of rehabilitation and as processes that facilitate recovery. This dual role underscores the need to disentangle mechanisms through which these variables operate and the contexts in which they are most influential. For example, resilience may be conceptualized as a trait that predicts adaptation to injury (Elliott et al., 2015, 2017) or as a process that unfolds through ongoing social connection, self-efficacy, and meaning-making (Rabinowitz & Arnett, 2018). Understanding these “ingredients” and the mediational relationships among them can help clarify whether interventions should target resilience itself, the mechanisms that facilitate it, or the outcomes it fosters. This mechanistic clarity is essential to forge theories of change in rehabilitation and aligns with calls for rehabilitation research to adopt frameworks like the Rehabilitation Treatment Specification System (Van Stan et al., 2019) to better define treatment targets, active ingredients, and hypothesized mediators of change. Future rehabilitation research would benefit from intentional study design planning in which PPCs are identified a priori as potential mediators, moderators, or outcomes of interest. For example, specifying resilience or psychological flexibility as hypothesized mediators of intervention effects on community reintegration (Elliott et al., 2019; Moriarty et al., 2015) would allow for empirical testing of mechanisms, rather than descriptive post hoc associations. These intentional designs would help move the field beyond correlational evidence toward a mechanistic and contextually grounded science of positive adaptation after TBI, integrating process, outcome, and context into cohesive theoretical and empirical models.

Equally important is how measurement shapes the field’s understanding of these constructs. Many of the tools used in the included studies assess overlapping domains (e.g., resilience and coping, well-being, and life satisfaction), raising questions about construct redundancy and whether measures capture intrinsic states or extrinsic contextual supports. Some scales reflect state-like processes that fluctuate with environmental conditions or over time, whereas others assess trait-like qualities presumed to be stable. Clarifying these distinctions can guide more precise operationalization of positive psychological constructs and improve interpretability across studies (Covington & Duff, 2021).

Clinical Implications

Positive psychology strategies for improving post-TBI well-being have drawn from cognitive behavioral therapy, acceptance and commitment therapy, compassion focused therapy, and dialectical behavior therapies, emphasizing emotional awareness, adaptive coping, social support, acceptance, psychological flexibility, resilience, and committed action. Collaborations with vocational, recreational, creative arts, and occupational therapists in rehabilitation psychology have a potential to enhance community engagement, social connectivity, meaning, and productive activity that can be psychologically rewarding.

Viewing positive psychology interventions as universally beneficial in all contexts, assuming that positive psychology characteristics are good for all people, all the time, and in all situations, has been questioned. Some researchers advocate for a more sophisticated approach to examining PPCs and have questioned the overall appropriateness of the construct itself. For example, does the presence of a PPC always contribute to emotional well-being? Is having good social support also a risk factor for being overly dependent on others during recovery? What if a positive psychology characteristic worked well in a person’s military career, but is no longer adaptive in the civilian world or rehabilitation setting?

McNulty and Fincham (2012) suggested that clinicians may need to assess the clinical utility of positive psychology characteristics within the context of both health and dysfunction. In particular, they indicate that whether PPCs have beneficial or harmful implications depends on the context in which they occur. Although many researchers have traditionally assumed that positive psychological traits and processes should be employed to optimize outcomes, McNulty and Fincham argue that psychological traits and processes are not inherently positive or negative. Instead, they propose that positive psychology therapeutic effects depend on the circumstances in which they function, such that clinicians and researchers need to better understand the nuances and contextual factors that determine when they work, for whom they work, and to what extent they enhance well-being. These researchers purport that PPCs may act differently for happy and unhappy people, as well as in optimal versus suboptimal circumstances. For example, a V/SM with a TBI may have differential outcomes from a positive psychology intervention depending on their family and social situation, their past mental health history, and competing reinforcers in their environment. There is also a need to understand the impact of PPCs over time. For example, do they have a different effect early on in rehabilitation and recovery than they do years postinjury? Development of well-being after TBI likely requires research that focuses on both the short- and long-term aspects of positive psychology characteristics.

Limitations

Due to our language skills, the review was limited to English sources that are peer-reviewed published articles. Due to expected heterogeneity and the broad objective of the review, we did not assess the quality of the sources or published work, potentially leading to the inclusion of studies with a high risk of bias. Furthermore, we limited our search to the last 25 years to capture studies in the post-Gulf War era and because positive psychology as a field emerged in early 2000 (Seligman & Csikszentmihalyi, 2000). Due to this restriction, some studies published before this time frame may be excluded. In addition, during the selection phase, we excluded articles when the prospective PPC was applied to a specific skill or aspect of symptom management (e.g., self-efficacy with sleep hygiene), rather than to psychological adjustment more generally, potentially excluding articles that would further characterize PPCs as moderators in interventions. This scoping review mapped constructs, measures, and research characteristics; a systematic review or metanalysis would be beneficial to determine the relationships, effectiveness, or outcomes of the constructs examined.

Conclusion

With increased interest in the use of PPCs, there is a need to clarify the extent and applicability of wide-ranging multidimensional concepts and outcomes for use among military personnel with TBI. This scoping review addresses this gap by determining evidence in the use of various PPCs. The identification of positive factors and outcomes can play a crucial role in examining how individuals with military experiences and TBI thrive in the short and long term. By compiling and analyzing patterns of constructs in use, this review provided a meaningful summary of shifts in constructs examined in rehabilitation literature for V/SMs over time and insights on knowledge gaps in operationalization and interpretability of constructs. Although some studies have employed and investigated positive experiences of V/SMs, a systematic documentation and presentation of the construct’s context, mechanistic clarity, their fit in research design, use of assessment tool, and clinical utility are needed to inform future research and intervention development.

Supplementary Material

Supplemental materials: https://doi.org/10.1037/rep0000681.supp

Impact and Implications.

This review identifies key positive psychology constructs relevant to veterans and service members with traumatic brain injury, offering practical targets for strength-based rehabilitation. The review highlights trends in the use of constructs over time and gaps in how they are measured and applied, guiding future development of theory-driven and context-specific interventions. By emphasizing an ecological perspective, the review underscores the importance of integrating individual, social, and environmental positive factors to encourage consideration of multilevel influences on recovery to tailor supports that align with the lived contexts.