Introduction
According to the World Health Organization (1), over one billion people worldwide are living with some form of disabilities and chronic conditions, which translates to ~15% of the world's population. The number of people with disabilities is increasing due to simultaneous increases in chronic health conditions and aging populations (1). People with disabilities can face different psychosocial challenges, such as functional limitations, secondary health conditions, social stigma, limited vocational functioning, and compromised community participation (2–8). Therefore, it is important to examine how to better support people with disabilities and chronic conditions and facilitate optimal psychosocial functioning through the lens of contemporary approaches such as positive psychiatry and psychology.
Shifting away from the traditional disease and pathology paradigm, positive psychology emphasizes building positive qualities rather than exclusively focusing on repairing weaknesses, aiming to understand what makes life worth living and enabling human thriving (9). Psychiatry has been defined as a subfield under medicine focusing on the diagnosis and treatment of mental illnesses (10). Recently, authors defined positive psychiatry as “the science and practice of psychiatry that seeks to understand and promote wellbeing through assessment and interventions aimed at enhancing behavioral and mental wellness” [(10), p. 2]. In recent decades, understanding disability and chronic conditions including mental illnesses has focused on holistic human functioning and the identification of human strengths and potentials (11).
Dr. Beatrice Wright, a pioneer in the rehabilitation field, promoted that psychosocial adjustment to disability and chronic conditions can be considered from a positive framework and postulated a coping vs. succumbing framework (12, 13). In this framework, coping focuses on an individual's positive qualities and abilities, whereas succumbing focuses on an individual's impairments and deficits (14). Consistent with the foundations of positive psychology, the rehabilitation field focuses on individuals with disabilities' capabilities and strengths (13, 15). Many studies have examined the effects of positive psychological characteristics (e.g., hope, resilience) on functioning and quality of life from a strength-based paradigm within the disability and rehabilitation field (5, 16–20). In the current study, we sought to illustrate variation in a particular classification of positive psychological characteristics—character strengths—in a large exploratory study of over 11,000 people with disabilities.
Character strengths are one of the foundations in the science of positive psychology (21, 22). Character strengths are defined as positive personality traits that reflect core identity, produce positive outcomes for oneself and others, and contribute to the collective good (21). Peterson and Seligman (23) developed VIA Classification of Character Strengths and classified 24 character strengths into six virtues: wisdom (i.e., creativity, curiosity, judgment, love of learning, perspective), courage (i.e., bravery, honesty, perseverance, zest), humanity (i.e., kindness, love, social intelligence), justice (i.e., fairness, leadership, teamwork), temperance (i.e., forgiveness, humility, prudence, self-regulation), and transcendence (i.e., appreciate of beauty and excellence, gratitude, hope, humor, spirituality). Character strengths are the psychological processes and mechanisms that depict virtues while virtues are described as the core moral characteristics that are universally valued (23). There is a large literature on the measurement, antecedents, and consequences of all 24 character strengths that suggest they play a critical role in positive psychological functioning and wellbeing [e.g., (23)]. Besides, Dahlsgaard et al. [(24), p. 2010] aimed to “create a consensual classification of human strengths while avoiding the criticism that any specific list we proposed would be culturally or historically idiosyncratic (23).” They reported that there is a convergence across place, time, and intellectual trandition about certain core virtues.
Growing research has examined the role of character strengths and character strength assessments in various disability groups, including individuals with intellectual and developmental disabilities (25, 26), multiple sclerosis [MS; (27)], traumatic brain injury [TBI; (28)], veterans with and without disabilities (29), and chronic conditions and disabilities (8). For instance, Niemiec et al. (25) discussed how building on character strengths can enhance support systems and quality of life of people with intellectual and developmental disabilities. Shogren et al. (26) examined the endorsement and psychometric properties of the VIA Inventory of Strengths of Youth (VIA-Youth) by exploring differences between youth with and without intellectual disability. Smedema (27) found that many character strengths played roles in the quality of life directly and indirectly through the negative effects of MS. Hanks et al. (28) found that character strengths and virtues were moderately associated with subjective wellbeing in people with mild to severe TBI. Umucu et al. (8) found that character strengths moderated the association between COVID-19 stress and the wellbeing among individuals with chronic conditions and disabilities.
More specifically, researchers have also been interested in examining the character strengths that were most frequently reported by people with disabilities. In a sample of adults with autism spectrum disorder, the most frequently reported character strengths were open-mindedness, creativity, and love of learning (30). Having a broader understanding of the character strengths reported by people with disabilities, including their commonalities and differences, provides us a broader insight into their psychological experiences, the sources of their wellbeing and quality of life, and provide a roadmap for moving forward in intervention work.
With the WHO's (1) emphasis on promoting rehabilitation services (e.g., psychiatric rehabilitation) and the increasing research attention on how character strengths make an impact on the lives of people with disabilities and chronic conditions, the purpose of this exploratory study was to examine the differences in character strengths for people with disabilities by using an international dataset by the VIA Institiute on Character. Specifically, we aimed to explore (a) the top and bottom five character strengths reported by different disability groups and all people with disabilities and chronic conditions more broadly, and (b) group differences in each character strength and total character strengths. To our knowledge, this is the first study using a large international sample to explore the differences in character strengths among people with different types of disabilities and chronic conditions including emotional conditions. Given positive psychiatry and psychology focuses on positive attributes and strengths, the results of the study will contribute to the existing international positive psychology, disability, and positive psychiatry literature on the role of character strengths in people with disabilities.
Discussion
This study is the first attempt, to our knowledge, to examine character strengths in individuals across a wide range of disability and chronic condition groups around the world. Growing research has suggested that positive approaches to psychological treatment (such as increasing awareness and usage of character strengths) in individuals with disabilities may be a powerful asset in meeting therapeutic goals and increasing quality of life and wellbeing (8, 11, 25, 29). An alternative to deficit-based methods, which attempt to reduce negative behaviors or symptoms associated with a given disability, character strengths provide a language with which individuals can focus on the aspects of themselves that potentially benefit themselves and society (25). The current study used a well-validated and widely-used classification system and its measurement tool, the VIA Inventory of Strengths, in a large international sample across multiple disability types, including emotional conditions and disabilities.
One of the strengths of the study was the inclusion of individuals with physical, cognitive, and emotional disabilities. In addition, disabilities occurring at different developmental stages of life are represented in the sample. For example, intellectual disabilities, like autism, constitute disabilities that emerge relatively early in life and have an enduring presence. The character strengths of individuals with these disabilities might differ compared to individuals with more acute or sudden/adult-onset disabilities, like a traumatic brain injury. Interestingly, we found that commonly reported character strengths in individuals with disabilities include love of learning, honesty, appreciation of beauty and excellence, kindness, and fairness. We found that the least commonly reported strengths in our disability sample included self-regulation, perseverance, zest, spirituality, and prudence. A previous study (27) found the top five strengths were honesty, kindness, fairness, humor, and gratitude, and the bottom five strengths were forgiveness, humility, spirituality, zest, and self-regulation in people with multiple sclerosis. In another study, authors found that the most common character strengths were curiosity, fairness, kindness, judgment, honesty, and leadership, while the least common character strengths were zest, prudence, perseverance, humility, hope, self-regulation, and spirituality in people with dysclexia (37). These results are partially consistent with our findings; however, it is also important to highlight that the most and least common character strengths may change based on disability groups.
Generally, individuals within the TBI group rated their strengths higher overall than other disability groups. For example, the TBI group's endorsements of creativity, curiosity, love of learning, bravery, honesty, perseverance, zest, love, social intelligence, fairness, leadership, prudence, self-regulation, gratitude, hope, and spirituality were significantly higher compared to other disability groups. The only character strength in which the TBI group was lower than others was teamwork, in which they were significantly lower than the MDG group, but significantly higher than IDG group. No significant differences were observed between TBI and other disability groups in judgement, perspective, kindness, forgiveness, humility, appreciation of beauty, excellence, and humor. These findings may provide some interesting avenues of future research in the TBI field. Given that individuals with TBI can often experience mood issues (38, 39), reduced quality of life (40–42), and reduced wellbeing (43), using character strengths knowledge and awareness appears to be an interesting treatment avenue to address these concerns.
One important consideration is that individuals with TBI can have significant self-awareness issues, including both under- and overestimating their skills and abilities (44–46). Therefore, endorsing strengths higher than other comparison groups may be indicative of this phenomenon. However, it would not be useful to dismiss these endorsements as “self-awareness” discrepancies in the TBI group. Rather, in the future, it may be useful to also assess the strengths of an individual with TBI through the perceptions of a trusted “other” who may give a realistic profile of an individual's strengths (e.g., friends, family). Having both the perception of the client as well as a significant other may elucidate which strengths the person expresses in daily life, which may aid in development of therapeutic goals, and which strengths might be inflated because of their limitations in accurately evaluating their strengths.
Those with emotional disturbances reported lower character strengths than other disability groups, which may reflect the poorer self-esteem and lower self-concept commonly observed in those with depression and anxiety. This lower endorsement of character strengths, however, may also provide an opportunity for clinicians to utilize strength identification in their therapy goals. Those with emotional disturbance may be less aware of strengths and therefore merely the identification of strengths may be a powerful exercise.
Another group with low endorsement of character strengths was the IDG group. There is a growing consensus in the field of intellectual disabilities, including autism, that using only a deficit-based approach when treating individuals with autism can compromise self-esteem and leave individuals unaware of their strengths. Therefore, recently a shift has emerged in the autism field to focus on not only strength-based approaches but character strengths-based approaches (25, 30, 47). Our findings indicated lower strength ratings in this group compared to other disability groups indicates that indeed, strength identification needs bolstering in this group. Interestingly, their love of learning endorsements was higher than other disability groups, which may reflect a commonly reported trait of autism: restricted interests. Specifically, those with autism may seek information about a restricted topic to a greater degree than what is typically observed in others, which is generally referred to as a “symptom” or “challenge.” However, reframing this trait as a love of learning may be beneficial as it could help autistic individuals, as well as others, understand how this trait may benefit society as well.
Some strength endorsements may reflect the commonly observed traits in individuals with disabilities. For example, low levels of zest, which was consistently one of the lowest reported strengths of the current study may be correlated with significant fatigue levels observed in individuals with disabilities. Fatigue is one of the most commonly reported symptoms in clinical care in the general population and is one of the most commonly reported symptoms in individuals with illness or disability. Thus, low levels of zest may be related to the significant feelings of fatigue felt by this population. In addition, previous literature reported that zest was one of the lowest five character strengths among university students (48) and people with disabilities (27). While increasing zest may represent a treatment target for positive psychology interventions, it may also be helpful for clinicians to keep in mind that chronic fatigue due to illness, disability, comorbidity, medications, and other reasons may make it difficult for certain disability groups to unilaterally increase their zest and energy levels. Rather, setting goals and working on the strengths of perseverance or self-regulation may be more useful, as they involve making choices to overcome obstacles or making choices (such as conserving energy). Together, these proximal goals may be more realistic for someone suffering from fatigue.
Our study findings may provide some significant clinical implications for the use of character strengths interventions in the fields of rehabilitation, psychiatry, and psychology for people with disabilities and chronic conditions. Previous research has demonstrated positive associations between character strengths and subjective health status (49). In a cross-cultural longitudinal study, researchers found that using character strengths is not only beneficial for self-perceived physical health when going through difficult situations, but using strengths is also for enhancing meaning in life, social connectedness, and mental health (50). Given the association between character strengths and health outcomes, clinicians may include interventions such as using signatures in a new way or identifying signature strengths (51) and strengths reframing and the aware-explore-apply model of strengths (25) when working with people with disabilities. By helping people with disabilities and chronic conditions identify and utilize their personal character strengths, this may potentially improve their perceived health, psychosocial functioning, and quality of life.
In addition, given this is an international study with multiple countries and disabilities [we consider each disability category as a cultural subgroup (e.g., deaf culture)], it is important to consider cross-cultural and demographic differences in character strengths. If each disability subgroup is considered a cultural subgorup, we suggest each disability group may, on average, have different top and bottom character strengths. For example, people with physical disabilities may experience or express character strengths different compared to people with psychiatric disabilities, just as individuals from different countries and cultures may express character strengths in a different ways reflecting their culture.
Positive psychiatry and psychology aims to examine positive attributes and strengths (10). Besides, positive psychiatry researchers focuses on protective psychosocial factors in chronic conditions. Given our research (a) identifies and describes character strengths in people with chronic conditions, including emotional conditions and (b) demonstrates the top and bottom character strengths among different disability subgroups, findings from this study may contribute to clinical and research practice. This research will help health professionals understand what character strengths are being used among people with different disabilities, which could be helpful in developing tailored and personalized interventions.
There are several limitations that should be considered in this study. The study comprised a convenience sample of individuals with self-reported disabilities, and some participants may not have accurately reported their disability status. As functional and cognitive abilities were not directly assessed, participants' responses may not accurately reflect their perceived character strengths and virtues when navigating an online survey. Further, the ability to complete the survey (and even have access to the survey) assumes that we may have recruited a higher functioning sample; however, there was no way to evaluate this concern. We interpreted the findings by considering that people with learning disabilities, intellectual disabilities, and TBI may have experienced difficulties understanding some concepts and questions. The majority of participants were women, had at least a bachelor's degree, and were employed, which could also limit the generalizability of this study's findings to the general disability population. Another limitation in this study was that participants were categorized into eight disability groups. A more systematic way of categorizing various disabilities could be beneficial. Also, some specific disability types may have been left out and not enough participants were present in different countries for us to formally model between-country variation in the disability group differences that we observed. Future studies are warranted to further examine character strengths in people with disabilities around the globe. We interpreted the findings considering the demographic characteristics of the respondents. For example, the majority of participants were in the age range of 25–54. Therefore, we cannot generalize our findings for all age groups. Similarly, the majority of participants were women, which decreases our ability to generalize our findings. Gender differences are especially important given previous research reported that women typically score higher on strengths than men although the top five strengths were similar among men and women (52).
In conclusion, it is important to highlight that we comment on what has been established in this unique data set and also summarize future considerations to be explored although we are aware that there are many important points to be highlighted in this study. Character strengths has been recently examined in different disability populations (3, 8, 25, 53, 54). In addition to other studies, our study provided a greater understanding of character strengths in a heterogeneous international sample of individuals with disabilities. Overall, this sample of people with disabilities reported their top five character strengths as love of learning, honesty, appreciation of beauty and excellence, kindness, and fairness, and reported their bottom five character strengths as self-regulation, perseverance, zest, spirituality, and prudence. Knowing that there is heterogeneity in character strengths across groups gives us a better understanding of the areas that people with different disabilities might thrive and provides clinicians and practitioners with a more nuanced understanding for how to possibly intervene with their clients.