Better for It: How People Benefit from Adversity.
McMillen, J. Curtis
Recently, researchers in several different fields have discovered
that people who have experienced seriously adverse events frequently
report that they were positively changed by the experience. Respondents
in these studies typically have reported a variety of different benefits
and have reported that they also were harmed by the same experiences.
The research suggests several processes that may account for these
reports of benefit: purposeful changes in life structure, changes in
views of others and the world that result from the experience of
vulnerability, the receipt of needed support, and the search for meaning
in adversity. Thinking about benefits may help survivors of traumatic
events process painful information. This article offers guidance on how
to introduce and manage benefit content within a therapeutic
relationship and encourages social workers to cautiously reflect
clients' unstated benefits, encourage self-assessments in areas
where benefits may accrue, explore any benefits discovered, and help
clients plan for positive changes. This process converges well with the
strengths perspective and constructivist approaches to social work
practice.
Key words: adversity; resilience; strengths perspective;
theory</AA>
The social work profession has long been concerned with how
people's lives are altered by adverse experiences. For many years,
theory development emphasized how people were harmed by adversity.
Although these theories added depth to social work's understanding
of clients' troubles, they were criticized for, among other things,
accentuating the negative. During the past 20 years, many social workers
have preferred models that emphasize human potential in the face of
adversity. A number of models based on these approaches have been
developed, including the strengths perspective (Saleeby, 1997),
resilience (Fraser, 1997; Werner & Smith, 1992), hardiness (Kobasa,
1979), empowerment (Gutierrez, Parsons, & Cox, 1998), and
solution-focused approaches (DeJong & Miller, 1995). Primarily,
these models have been concerned with learning how people overcome and
resist the effects of adversity. A recent line of scholarly inquiry
challenges social workers to take an additional step and consider ways
people may benefit from adversity. During the past 15 years, several
researchers asked people who had experienced negative events to comment
on the ways that they have benefited from their troubles. As reported in
this article, perceptions of benefit were common and a wide range of
benefits were reported. This article introduces and discusses this line
of inquiry into the positive by-products of adversity, with an eye on
how social workers may be able to use this new information to help their
clients benefit from their struggles with adversity.
Literature Review: Perceived Benefit Phenomenon
People commonly perceive that they have benefited from extremely
difficult life experiences. Difficult life experiences span events as
diverse as natural, technological, and criminal disasters; sexual
assault; and health problems (Table 1).
Several studies attempted to assess the prevalence of reporting
benefit after adversity, although [TABULAR DATA FOR TABLE 1 OMITTED] not
in any systematic or uniform way. The rates of people reporting some
benefit after adversity have tended to range from 45 percent to 90
percent. Some of the lower rates were for 154 adult survivors of child
sexual abuse (47 percent; McMillen, Zuravin, & Rideout, 1995), 40
spouses of stroke survivors (45 percent; Thompson, 1991), and 41
survivors of a plane crash (55 percent five weeks after; 35 percent
three years after; McMillen, Smith, & Fisher, 1997). The highest
rates have been reported for 135 cancer survivors (91 percent; Curbow,
Somerfield, Baker, Wingard, & Legro, 1993), 39 tornado survivors (91
percent five weeks after; 95 percent three years after; McMillen et al.,
1997), and 94 caregivers of dementia patients (90 percent; Farren,
Keane-Hagerty, Salloway, Kupferer, & Wilken, 1991).
The choice of wording and the format of the questions have
influenced the rates of benefit reported in these studies. Researchers
have asked whether respondents have discovered anything positive,
experienced any rewards, found any possible benefits, learned anything,
or were able to turn things to their advantage. Undoubtedly, the phrases
used affected reported rates. For example, in a study of 1,054 college
alumni, Aldwin, Sutton, and Lachman (1996) asked respondents two
benefit-related questions about a low point in their lives. Ninety-eight
percent reported that they "learned something" from the
experience, and 79 percent reported that they were able to "turn
some aspect of the experience to their advantage."
Some studies asked a single benefit question, and others asked
several and categorized anyone who responded affirmatively to any
question as reporting benefit. Studies using the latter format naturally
yielded higher rates than those that asked single questions. For
example, in one study, sexual assault survivors were asked about
positive life changes in 20 different areas of their lives. Eighty-seven
percent reported a positive change in at least one area (Frazier, Byrne,
& Klein, 1995). When another sample of sexual assault survivors was
asked a single question, 57 percent reported positive life changes
(Frazier & Burnett, 1994).
Even when identical measures are used, different events yield very
different rates of perceived benefit. For example, 95 percent of tornado
survivors, 70 percent of mass shooting survivors, and 35 percent of
plane crash survivors reported benefit when asked an identical
single-benefit question posed three years postdisaster (McMillen et al.,
1997). The researchers speculated that the community context of the
events affected the rates of benefit reported. Several studies have
asked benefit questions at different points. Rates appear relatively
stable (Affleck, Tennen, Croog, & Levine, 1987; Frazier et al.,
1995; McMillen et al., 1997).
Perceptions of benefit appear to be more than just a Pollyannaish
denial of negative consequences. Instead, survivors of these events tend
to report that they have benefited from and been harmed by these
experiences. In two studies of cancer survivors, self-reported negative
and positive changes were common, with positive changes more frequently
reported than negative changes (Collins, Taylor, & Skokan, 1990;
Curbow et al., 1993). In a study of child sexual abuse survivors, almost
all of those who perceived benefit also felt that they were harmed by
the experience (McMillen et al., 1995). In an additional study,
perceived benefit was positively associated with perceived harm
(McMillen & Fisher, 1998). In another study, perceived benefit was
unrelated to perceived harm (Affleck, Tennen, Rowe, & Higgins,
1990).
In four longitudinal studies of varying length, perceptions of
benefit at time one predicted better adjustment at a later date. Effect
sizes tended to be small to moderate. For mothers of infants leaving
neonatal intensive care, perceived benefit at the time of hospital
discharge was related to positive mood (r = -.33), less distress (r =
-.27), and higher development scores for their children (r = .37) 18
months later (Affleck, Tennen, & Rowe, 1991). For heart attack
patients, perceived benefit at seven weeks postattack was related to a
decreased chance of heart attack recurrence (accounting for 1.4 percent
of variance) and better health status (accounting for 4 percent of
variance) eight years later, after controlling for several other
variables (Affleck et al., 1987). Perceiving benefit four to six weeks
after a disaster decreased the odds of having posttraumatic stress
disorder (PTSD) three years later by 62 percent (McMillen et al., 1997).
In two longitudinal studies, perception of benefit moderated the effect
of severity on outcome. For disaster survivors, perceived benefit
moderated the effect of severity of disaster exposure on mental health
recovery. People who had the most severe exposure and perceived benefit
shortly after the disaster had the greatest decrease in the number of
psychiatric disorders, and those who had the most exposure and did not
perceive benefit had the least decrease. For rheumatoid arthritis sufferers with high levels of pain, those who perceived benefit from
their chronic pain at the beginning of the study had fewer days of
limited impairment during the next 75 days than those who did not
perceive benefit (Tennen, Affleck, Urrows, Higgins, & Mendola,
1992).
Results have been more mixed for cross-sectional studies. Perceived
benefit has been moderately associated with better outcomes in some
studies (Fontana & Rosenheck, 1998; McMillen et al., 1995; Mendola,
Tennen, Affleck, McCann, & Fitzgerald, 1990; Thompson, 1985) and
unrelated to outcomes in other studies (Lehman et al., 1993; Park,
Cohen, & Murch, 1996). Because more severe events may be more likely
to lead to both perceived benefit and poorer outcomes, these two
variables may confound one another in cross-sectional studies,
especially if the time since the adverse event is short. In addition,
all of these studies used measures of perceived benefit with
questionable psychometric properties. Improved, multidimensional
measures have been developed recently (McMillen & Fisher, 1998;
Tedeschi & Calhoun, 1995), but they have not yet yielded a body of
literature to assess.
Many of the studies addressed the different types of positive
outcomes that people perceived after adverse events, usually by
categorizing responses to open-ended questions about benefit. Several
categories of benefit were proposed consistently and independently:
changed life priorities, increased sense of self-efficacy, enhanced
sensitivity to others, improved personal relationships, and increased
spirituality (Aldwin et al., 1996; Affleck et al., 1987, 1991; Beach,
1997; Collins et al., 1990; Curbow et al., 1993; Fontana &
Rosenheck, 1998; Frazier & Burnett, 1994; Lehman et al., 1993;
McMillen et al., 1995, 1997; Thompson, 1991). Other categories proposed
in single studies included finding a new cause, financial gain, and
increased opportunities (McMillen & Fisher, 1998; Tedeschi &
Calhoun, 1996).
In summary, it appears that people commonly perceive that they
benefit from their adverse life experiences, often in a variety of ways.
In addition, there is some preliminary evidence that these perceptions
of benefit may be protective in some way. For this information to lead
to practical social work intervention strategies, more clarity and
specificity is needed about how benefit and growth occurs as a
by-product of adverse events and the struggle to cope with them.
What the Studies Can Tell Us about How Benefit Occurs
The idea that people can benefit from adversity is not new.
Writings from several different religions, for example, discuss the role
of suffering in becoming a better practitioner of faith (see Tedeschi
& Calhoun, 1995, for a review), and stories of lives changed for the
better after trauma have been a staple of the popular press for decades.
In addition, social workers have for many years used theories and
perspectives such as crisis theory (Caplan, 1964) and system approaches
(Minuchin & Barcai, 1969; von Bertalanffy, 1968) that proposed that
positive changes could occur as a result of crisis. These theories,
however, were not specific about what these changes were like. Recently,
a number of social scientists have offered ideas about how growth occurs
or how perceptions of benefit may aid in the recovery from adverse
events (Affleck & Tennen, 1996; Aldwin, 1994; Aldwin et al., 1996;
Calhoun & Tedeschi, 1998; Holohan, Moos, & Schaefer, 1996;
McMillen et al., 1995; Taylor & Armor, 1996; Tedeschi & Calhoun,
1995; Thoits, 1995).
Calhoun and Tedeschi's (1998)
"functional-descriptive" model of growth is the fullest
explanation offered to date in the literature. The model focuses on
common elements involved in different growth processes. These include:
pre-event approaches to life that are hopeful, optimistic, and
action-oriented; a traumatic event that challenges goals, beliefs, and
the ability to manage distress; an accent on rumination about the event
and the meaning it has for one's life; successful outcomes from
coping efforts; and continued rumination focused on narrative
development. This model is a considerable improvement over other
available models, including their earlier version (Tedeschi &
Calhoun, 1995). Although Tedeschi and Calhoun recognized that growth
occurs in many forms, their model does not yet adequately describe the
different processes by which the different kinds of benefit occur and
how the recognition of benefit can affect later mental health.
By using the literature cited and the works of various authors, I
propose a number of theoretically logical pathways by which benefit can
occur and positively affect adjustment. Generally, I propose that
adverse events can lead to changes in life structure, views of self and
others, and in interpretations about meaning and purpose in life. Some
of these processes are perhaps more applicable to acute negative events
than they are to chronic adversity, because the body of research from
which they were induced involved acute stressors.
Stress Inoculation, or "What Doesn't Kill You Makes You
Stronger"
As Caplan (1964) suggested, the struggle to cope with an adverse
event can lead to increased coping skills, an enhanced sense of
self-efficacy, and hence an increased ability to prevent and cope with
future stressors. This inoculation effect may only occur if people
perceive that they have been made stronger by the first adverse event.
This pathway is the one most consistently discussed by theorists and is
linked to Bandura's (1989) ideas about self-efficacy and
Kobasa's (1979) concept of hardiness. Bandura proposed that no
other kind of thought is more central to people's behavior than
judgments of their capabilities to exercise control over events in their
lives. "It is partly on the basis of judgements of personal
efficacy that people choose what to do, how much effort to invest in
activities and how long to persevere in the face of obstacles and
failure experiences" (p. 42). Traumatic events offer opportunities
to enhance self-efficacy through the experience of successfully managing
new tasks and through a favorable social comparison with others who have
experienced similar events.
A sense of enhanced self-efficacy or self-confidence has been
reported after severe health traumas, child sexual abuse, combat, and
natural and criminal disasters (Affleck et al., 1991; Aldwin et al.,
1996; Collins et al., 1990; Fontana & Rosenheck, 1998; Frazier &
Burnett, 1994; Lehman et al., 1993; McMillen et al., 1995, 1997). In
three studies, over 80 percent of respondents reported that they used
past experiences to help cope with new difficulties (Aldwin et al.,
1996). If people do learn from past events, they may be better able to
prevent future stressors from occurring or growing into crises. In
addition, if people believe they are more capable of handling stress,
future adverse events may be perceived as less toxic. If people both
believe that they are more capable and perceive events as less toxic,
they may be more likely to approach negative events with a challenge
orientation. This sense of control and a challenge orientation are
two-thirds of the troika of personality traits that Kobasa (1979)
proposed make some people "hardy" or resistant to stress. The
third component in his model was a commitment to life roles. The role of
increased self-efficacy is an important part of all models of benefit
proposed thus far.
Health Enhancing Changes in Life Structure, or "Heeding the
Wake-up Call"
A second pathway to benefit involves changes in life structure. A
severely adverse event can serve as a "wake-up call" to some
people, signaling that it is time to make significant changes in their
lives. In other words, some adverse events trigger a self-examination of
survivors' life structures and what is important in life. If these
reviews find that previous life structures were not yielding much
satisfaction or happiness, then life priorities may be purposefully and
consciously changed to achieve greater happiness and improved physical
and mental health. A life-threatening car accident may lead a heavy
drinker to stop drinking or an overburdened parent to spend more time
with her children. Self-reports of changes in life priorities or in the
ways life is lived day to day have been reported after a variety of
traumas (Affleck et al., 1987; Collins et al., 1990; Frazier &
Burnett, 1994; Lehman et al., 1993; McMillen et al., 1997; Thompson,
1991).
The kinds of health-enhancing lifestyle changes people can make
after adverse events are numerous. Some of the most common changes may
include eliminating roles and responsibilities; seeking less stressful
employment; structuring more time with families, friends and neighbors;
and generally vowing to enjoy life more. The range of life domains that
these changes can affect are large and include satisfaction or closeness
with family, neighbors, and community; employment satisfaction; and
improvements in physical health.
This process assumes that people actively engage in their
environments and thoughtfully structure their lives to increase benefits
and decrease costs. This process is akin to many social science
theories, including theories of adult development that stress changing
life structures (Levinson, 1978, 1996), social cognitive learning theory
(Bandura, 1989), which stresses the importance of forethought, and
Homans's (1961) rationality proposition in social exchange theory.
Changed Views of Others: "People Aren't So Bad After
All" and "A Kinder and Gentler People"
Two processes may lead to changed views of others and improved
social relations. The first process involves the receipt of much needed
support. The second involves the novel experience of vulnerability.
People who have experienced seriously adverse events may find themselves
in great need of material or emotional support from others. If they
discover that others are willing to help, their views of others may
change in important ways. Loved ones, neighbors, and communities may be
viewed as more loving, caring, altruistic, and responsive. Several
theorists have suggested that viewing others favorably has profound
effects on social relations (Bowlby, 1988; Epstein, 1991). People with
favorable views of others may be more likely to seek future
relationships, treat others more favorably, and be treated favorably in
return. Theoretically, negative views of others are difficult to
disconfirm. They are developed early in life and reinforced through
thousands of self-fulfilling interactions (Bowlby, 1988). Changing these
views requires an event of considerable magnitude. The receipt of
support when it is severely needed may be one of those events. Changed,
more favorable relations with others has been the most consistent of all
of the types of benefit reported (Affleck et al., 1987, 1991; Beach,
1997; Collins et al.; Curbow et al., 1993; Fontana & Rosenheck,
1998; Frazier & Burnett, 1994; McMillen & Fisher, 1998; McMillen
et al., 1997; Tedeschi & Calhoun, 1996). There may be more than one
cause for these more favorable relationships, including changed life
structure and more favorable views of others after the receipt of
support.
The novel experience of being vulnerable and in need of assistance
from others may engender empathy to other people in need. Traumatic,
adverse events often challenge people's views of the world
(Janoff-Bulman, 1989, 1992). One belief that may be re-evaluated after
experiencing serious vulnerability is that the world is just
(Janoff-Bulman, 1992; Lerner, 1980; Lerner & Miller, 1978). Many
people believe that because they are good people, good things will
happen to them and conversely, that those who have bad things happen to
them must be deserving of those bad events in some way. Such beliefs may
be healthy, in that they allow people to live day to day relatively free
of anxiety. Such views, however, do not engender empathy toward those
who are not faring well. If people who believe in a just world find
themselves in similar need, it may become more difficult to view others
in need as deserving of their fates. Thus, the shattered assumption of
the world as a just place may lead to viewing others as more deserving
of aid. In effect, people may be transformed into kinder, gentler
versions of themselves as a result of being traumatized and experiencing
vulnerability. Being kinder, more sensitive, and more empathic have all
been reported as a result of serious adversity (Affleck et al., 1987;
Beach, 1997; Collins et al., 1990; Lehman et al., 1993; McMillen et al.,
1997; Thompson, 1991).
Transformation through Interpretation: Finding Meaning
Thinking about benefits may help people process traumatic events in
important ways. Several theorists have emphasized the importance of
finding meaning in adversity (Affleck et al., 1991; Frankl, 1962, 1986;
Moos & Tsu, 1977; Silver, Boon, & Stones, 1983; Silver &
Wortman, 1980). Their general proposition is that an adverse event, once
perceived as meaningful or understandable, seems less harsh to the
person who experienced it. Frankl (1962), a psychiatrist who survived
Nazi concentration camps, wrote, "Suffering ceases to be suffering
in some way at the moment it finds a meaning" (p. 115). Perceiving
benefit from an adverse event is one way to find meaning in it.
Social-cognitive-behavioral models of PTSD and trauma adjustment
also emphasize the interpretation of traumatic events (Foa, Steketee,
& Rothbaum, 1989; Horowitz, 1986; Janoff-Bulman, 1992). In several
of these models, information about the trauma is shunted out of
awareness, because the brain does not have a quick way to process events
that contain a large amount of material that does not fit previous
schemata of how the world is supposed to work. A cycle can develop in
which the painful information intrudes into consciousness, is shunted
away, and intrudes again until it is processed. Thinking about the ways
one has benefited from trauma may make the trauma seem more palatable,
and easier to think about and process.
Similarly, Janoff-Bulman (1992) has suggested that victims of
traumatic events cognitively restructure how they think about negative
events to maintain previously held views of themselves or their world.
When beliefs about self and the world are shattered by trauma, a person
can either change views of the world (such as believing that maybe the
world is not so just after all, as mentioned earlier), or change views
of the negative event (such as perceiving that it was not as harsh as
initially thought). Finding ways one has benefited from adversity can
help a person continue to believe that they are deserving of good things
and that only good things will happen to them.
Positive changes after adversity can be experienced through any of
the pathways mentioned thus far. The realization or perception that
benefit has occurred, or what Affleck and Tennen (1996) call
"benefit-reminding," may help facilitate completion of the
processing of traumatic information and integration of cognitive
schemata. The type of benefit perceived, or whether the perception
reflects an actual gain or not, does not matter.
The search for meaning also can result in changes in existential
outlook. For instance, views on religion, life, and death may change
after adverse events. An increase in religiosity has been reported after
traumatic events (Fontana & Rosenheck, 1998; Frazier & Burnett,
1994; Lehman et al., 1993; McMillen et al., 1997; Tedeschi &
Calhoun, 1996). As a result of these changes in life views, enhancements
in life structure or personality can occur, leading to greater physical
and mental health.
Another way people can find meaning for extraordinarily painful
events is to assist others who have experienced similar negative events
or to prevent others from experiencing similar difficulties. In rare but
compelling instances, some people transform their life structures to
work for the benefit of others, often by working to change an
environment that they believe contributed to their pain. Well-known
examples of this phenomenon include Jim and Sara Brady (gun control
legislation), Christy Lightner (founder of Mothers Against Drunk
Driving), Charlotte and Bob Hullinger (founders of Parents of Murdered
Children), and the parents of murdered Polly Klaas (who fought for the
"three strikes and you're out" criminal sentencing
legislation). Finding a new cause has been reported in survivors of
disaster (McMillen et al., 1997).
Turning Symptoms on Their Heads
Some of the sequelae to adverse events that are commonly considered
to be negative can be perceived as positive by some people who
experience them. For example, two samples of sexual assault survivors
have reported that being more cautious and alert was a positive
consequence of their assault (Frazier & Burnett, 1994; McMillen et
al., 1995). Typically, this consequence is considered negative by human
services practitioners - seen as an impediment to social relations. The
women in these studies, however, thought that this cautiousness helped
protect them from further abusive situations. Other "symptoms"
such as becoming tougher, harder, less emotional, more manipulative, and
hypervigilant, also may have positive aspects to them. Furthermore,
considering these symptoms beneficial may facilitate the processing of
traumatic information.
Financial Gain, or "Show Me the Money"
Some people benefit financially from negative events (McMillen
& Fisher, 1998; McMillen et al., 1997), either through the
restructuring of their lives (a layoff leads to retraining and a higher
paying job) or from policy and legal action. The realization of
financial benefit, like any other kind of perceived gain, could allow
further processing of traumatic material, or lead to changes in life
structure that may be health enhancing.
Who Benefits from Adversity?
Not everyone who experiences adversity is as equally likely to
benefit from it. Severity of the event; type of the event; and the age,
class, and personalities of the people involved may determine what kinds
and the amount of positive changes that ensue. Some threshold of event
severity may be necessary to trigger the processes that could lead to
positive change. Minor adverse events should not lead to re-evaluations
of life structure, views of others, beliefs about the world, and a
search for meaning. Several studies reported that people who experienced
more severe experiences were more likely to perceive benefit (McMillen
& Fisher, 1998; McMillen et al., 1997; Park et al., 1996; Tedeschi
& Calhoun, 1996). Vietnam veterans who had experienced intermediate
combat exposure reported more benefits than veterans with high or low
levels of exposure (Fontana & Rosenheck, 1998). Some kinds of events
may be more likely to lead to certain pathways toward benefit. Events
that involve loss or fear for one's survival, for example, may be
especially likely to provoke re-evaluations of life structure.
A host of person-related variables may affect benefit. Children and
people in lower socioeconomic classes might have the most difficulty
benefiting from postadversity changes in life structure. Because
children are less responsible for the creation of their life structures
than are adults, this pathway to benefit is less available to them.
People with lesser means have fewer life-changing options available to
them and fewer resources available to make desired changes. School-age
children and people of all socioeconomic classes can be strengthened by
learning new coping skills and enhancing a sense of efficacy, by
experiencing vulnerability, and by valuing others more through the
receipt of social support. Benefiting through finding meaning in
adversity is a complex cognitive function that is probably not within
the grasps of younger children. In addition, certain people may be more
motivated than others to find meaning in events. People who consider
themselves optimistic and religious have reported more benefit than
others (Tedeschi & Calhoun, 1996).
Tedeschi and Calhoun (1995) proposed that people with few coping
skills experience grim outcomes and "under such circumstances,
recognizable benefits are unlikely" (p. 56), whereas people with
exceptional coping skills have little to gain. In contrast, several of
the processes proposed here suggest that people whose lives were lacking
in some ways before the onset of an adverse event may be those most
likely to benefit from changes in life structure and views of selves and
others. The ability to make these changes is not inherently restricted
by limited coping skills. Consistent with these interpretations, in one
study, people who reported benefit from disasters met the criteria for
more preincident mental health diagnoses than those who did not report
benefit (McMillen et al., 1997).
Implications for Direct Practice
Special Insights from Earlier Approaches to Practice
Although the perspective on benefits from adversity presented in
this article is consistent with several approaches to social work
practice, few of these approaches offer specific suggestions about how
to help clients realize positive by-products of adverse events and use
them to their advantage. Logotherapy (see Frankl, 1962, 1986; Guttman,
1996) and existential psychotherapy (see Krill, 1988; Yalom, 1980) are
limited exceptions, offering views on how people can find meaning in
life in general and especially in suffering. Frankl (1962, 1986)
suggested vaguely defined techniques, which he called "attitude
modification" and "Socratic dialogue" (or naive
questioning), which have been criticized as "exhortative" and
"superficial" (Yalom, 1980, p. 470). Both Frankl (1962, 1986)
and the existentialist Yalom (1980) favored helping people find meaning
through self-transcendence, the dedication of energies to things outside
oneself, particularly to large-scale social issues or the growth of
others. Although Frankl was overtly religious in his work and Yalom was
not, they also agreed that people can find meaning in life through a
perceived understanding of the design and order of the universe. Even
when religion offers no specific answer as to the cause of an adverse
event, some may gain from having faith that a meaning for an adverse
event exists. Frankl offered the example of an ape involved in medical
research, who, of course, could not grasp the reason for his suffering.
Humans, too, Frankl concluded, cannot hope to understand a meaning that
exists in a dimension beyond their comprehension (Frankl, 1962). Yalom
(1980) added that meanings also can be personally derived, such as from
dedicating oneself to a specific cause, discovering something to live
for, desiring to make the world a better place, investing in one's
personal creativity (with adversity serving as inspiration), dedicating
oneself to living life fully, or realizing one's full in-built
potential (Yalom, 1980).
REEP-ing the Benefits: Reflecting, Encouraging, Exploring, and
Planning Benefit
The literature on the positive by-products of adversity offers
additional opportunities to clarify ways social workers can help
facilitate growth and benefit with social work clients. An acronym, REEP
- reflection, encouragement, exploration, and planning - is proposed to
help social workers remember a process they can follow to introduce and
manage clinical content related to potential benefit. The intention of
this discussion is not to offer a new approach for social work practice.
Instead, I hope that these ideas can be integrated into current
approaches.
Reflecting Benefit Perceived
The introduction of benefit into the clinical narrative is not
without risk. If clients have not yet considered the possibility that
the adversity may yield benefits, they may interpret the suggestion that
it can as a lack of sensitivity to their pain. At the extreme, clients
may think that the social worker is suggesting that the client should be
glad the event occurred, a thought that is particularly offensive to
survivors of events that involved loss of life. The introduction of
benefit-related concepts should not be attempted until clients can
recall and discuss the adverse event and the meaning it has for their
lives. A "C" for "cautiously" was considered for the
initial letter in the acronym, but the resulting acronym did not reflect
the strength-based assumptions inherent in the process. Practitioners
should be particularly cautious in their word choice, especially at the
introduction of benefit concepts. Experience has shown that phrases such
as by-products, changed views of self and others, and becoming stronger,
may be better received initially than benefit, growth, gains, or
character-building.
It is safest to allow clients to introduce benefit concepts. Social
workers who are aware of the literature reviewed in this article will be
attuned to benefit-related content and the ambivalence and conflict
often inherent in thinking about benefiting from an event that has
involved considerable pain. These social workers will be ready to
reflect the benefits to which clients allude. Thus, a statement about
ways a person has coped with a trauma can be reflected to include
benefit content: "It sounds like this has really started you
thinking about what's really important in life." These
reflections build the foundation for a more in-depth exploration of
benefit later in the process.
Encouraging Self-Assessment and Perceptions of Benefit
Social workers also can introduce benefit concepts by encouraging
client self-assessment in areas that may yield benefit. Example
assessment targets include clients' overall happiness or life
satisfaction before the adverse event, views of the goodness of others,
sense of vulnerability, sense of self-efficacy, or religious views. For
example, a social worker who wants to initiate a review of life
structure can lead clients into a discussion about what the most
important things are in life for that client. Reflections of content and
feelings are the social worker's basic tools in this effort, but
some questions that could aid in this process include the following:
"When are you happiest? . . . most content? . . . most
energized?" "Are there things you have been wanting to do, but
have put off for one reason or another?" "Are there people
that you wish you could spend more time with?" Many of these
self-assessments can be introduced as part of the natural therapeutic
course, as people discuss their adverse events. For example, as a client
talks about the aid she received after a traumatic event, the social
worker could encourage an assessment of views of others by saying,
"It sounds like people really came through for you when you needed
it. Was any part of that surprising to you?"
If the self-assessment inquiries do not yield positive by-products,
it may be appropriate for social workers to gently introduce the content
themselves. For example, a social worker dealing with a client who has
related a terrifying incident might find an appropriate opportunity to
say something such as "A moment like that really brings home the
point that life is short." If these gentle introductions do not
work, social workers might wish to ask a general benefit question.
"At some point in the future, do you think it might be possible to
imagine something positive coming out of your struggle to cope with all
of this?" If clients cannot yet imagine the possibility of positive
by-products, it may be appropriate to inform them that research suggests
many people who experience serious troubles report benefiting from their
struggles and propose that the adversity they have experienced may yet
yield opportunities for positive change.
Exploration of Benefit in the Context of Pain and Harm
For many clients, it will not be enough to briefly introduce and
discuss the possible positive by-products of their adverse experiences.
Clients may benefit from reminders that there were positive
consequences. People who have experienced traumatic events often have
feelings of shame or guilt that are strongly associated with their
memories of the event. When they think of the event, they immediately
think of what they should have done or how ashamed they are that it
occurred. Others may develop images of themselves as victims of
circumstance and tragedy. When they think of the negative event, they
are reminded once again of how harsh the world is and of all the awful
things that have contributed to the ruination of their lives. These
negative associations make it more painful to think about the event, and
may lead to avoidance of the painful thoughts and recollections.
Refutation of thoughts related to guilt, shame, and victimization is
often the recommended approach (Resick & Schnicke, 1992). It may be
useful to help clients build new associations between memories of the
event and ways their lives have been improved as a result of it. If they
recall positive images of benefit whenever the event is recalled, then
memories of the event may be more available for clients to process in
other ways. In addition, clients may be more able to reconstitute an
optimistic outlook on the basis of the belief that mostly good things
will happen to them. The building of these associations may require some
in-depth discussion of the possible ways that an event has harmed and
helped a person and some social worker-initiated reminders of benefit
whenever clients concentrate solely on the negative dimensions of an
experience.
Planning for Positive Changes
Self-assessments and discussions of meaning and benefit may lead
clients to conclude that there are things in their lives they would like
to change. As a result of a life review, for example, a woman going
through a divorce might decide she wants to change careers. A man who
explores his vulnerability for the first time might express a desire to
help others. In these cases, social workers can rely on their
problem-solving skills to help clients plan and implement these positive
changes. If these changes are made and they have a positive effect on
clients' lives, then they become further evidence that the adverse
event yielded positive as well as negative outcomes.
Integration into Current Practice Perspectives
The REEP process converges especially well with two recent emphases
in social work practice: assessing and working from client strengths
(Saleeby, 1997) and an increased understanding of how individuals
construct views of themselves and their world (Berlin, 1996; Granvold,
1996).
The strengths perspective (Saleeby, 1997) has emphasized the
importance of assessing clients' strengths and helping clients use
these strengths to solve problems. The benefit information presented in
this article can assist in the creative assessment of client strengths
and help clients build new strengths. Clients often have difficulty
enumerating their strengths, and social workers can easily fall into the
habit of thinking about client strengths in categorical, unimaginative
ways. Asking clients about potential benefits can help explicate unique
client strengths that resulted from specific events that can be used in
recovery. Adult women who were sexually abused as children provide a
powerful example. Asked in a research study about the benefits of their
childhood sexual abuse, many women reported that they had an increased
ability to protect their own children from child sexual abuse (McMillen
et al., 1995). They explained that they were better able to keep
potential predators away from their children, to explain child sexual
abuse to their children, and to develop open relationships with their
children so their children would be more likely to tell them about
potential sexual predators. Helping survivors of child sexual abuse
reframe their trauma as benefiting their children may help them process
the memories surrounding their abuse.
The questions and strategies proposed in this article also help
clients build new strengths in areas they might not otherwise explore.
Women who never considered that their child sexual abuse experiences
could make them uniquely qualified to better protect their children from
abuse may discover this possibility during discussions of potential
positive life changes with a social worker. Changes in life priorities,
enhanced views of other people, and an enhanced sense of self-efficacy
are all strengths that can be built through a dialogue about positive
life changes after negative events.
Constructivist approaches to social work practice (Berlin, 1996;
Granvold, 1996) emphasize that people build their own realities -
including views of themselves and others - which they use to navigate
through a complex world. Practitioners of this approach work to help
clients construe new realities that help them function better in the
world. The benefit question does not just highlight client strengths,
but a new awareness of these strengths may change profoundly how people
view themselves and the world and thus how they approach lift. People
who reframe tragic events as benefiting them in some important way have
stopped seeing themselves as victims and have begun to construe an image
of themselves as capable people. For example, a woman sexually abused as
a child may move from seeing herself as a victim to seeing herself as a
protector of children and educator about child sexual abuse.
Research on how people may benefit from adversity is new, and
application of these findings into direct practice strategies is even
newer. I hope that future research may offer additional ways that people
can be affected positively by adverse experiences, especially as
researchers begin posing these questions to survivors of more chronic
events, such as poverty or racism. I also hope that practitioners will
use these concepts to develop new ways to enhance clients'
exploration of benefit and new ways to use these positive changes to
facilitate recovery and growth.
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J. Curtis McMillen, PhD, is assistant professor, George Warren
Brown School of Social Work, Washington University, St. Louis, Campus
Box 1196, St. Louis, MO 63130; e-mail: cmcmille@gwbsw.wustl.edu. Work on
this article was supported through the National Institute of Mental
Health-funded Center for Mental Health Services Research at Washington
University (Grant no. 524 MH50857-02). An earlier version of this
article was presented at the annual meeting of the Council on Social
Work Education, March 1998, Orlando, FL.