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  • 标题:Better for It: How People Benefit from Adversity.
  • 作者:McMillen, J. Curtis
  • 期刊名称:Social Work
  • 印刷版ISSN:0037-8046
  • 出版年度:1999
  • 期号:September
  • 语种:English
  • 出版社:Oxford University Press
  • 摘要:Key words: adversity; resilience; strengths perspective; theory</AA>
  • 关键词:Experiential learning;Life change events;Self evaluation;Self-evaluation

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.
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