Motivation and emotion/Book/2019/Vicarious post-traumatic growth

Overview
Why is it that we must suffer to grow? How do those in the helping professions maintain a positive outlook on life even though they are often exposed to the very worst in life? These questions are explored below. This chapter looks at vicarious post-traumatic growth; what it is, the major contributing factors and the theories that attempt to explain the phenomenon. Focus questions:
 * What is vicarious post-traumatic growth (VPTG)?
 * What facilitates VPTG?
 * What are the main theoretical perspectives of VPTG?

Janine works as an interpreter for refugees. She is subject to accounts of rape, displacement, suffering and death. She feels very deeply for the people with which she works and is required to attend regular debriefing sessions with a counsellor as part of her workplace health and safety plan. Despite the distress to which she is exposed Janine often speaks of her awe and admiration of the refugees who have escaped such traumatic experiences. She finds hope in their resilience and commitment to finding a better life. Janine feels very grateful for her life and for the opportunity to raise her own family in a safe place as a result of her work with the refugee community.

What is vicarious post-traumatic growth?
"That which doesn't kill me, makes me stronger" - Friedrich Nietzsche



When considering trauma, our thoughts often head straight into negative territory. There is however, another side to traumatic experience; a positive outcome termed post-traumatic growth (PTG) (Tedeschi & Calhoun, 1996). Post-traumatic growth (PTG) is described as the positive effect that direct exposure to traumatic experience has on a person’s philosophy on life, self-concept and interpersonal relationships.

Vicarious post-traumatic growth (VPTG) differs to PTG, as the positive effect manifests because of indirect exposure to traumatic experience, often by way of a professional or personal association with individuals who have experienced direct trauma (Manning-Jones, de Terte, & Stephens, 2015). It is particularly evident in fields including social work, interpreters, funeral directors, health and mental healthcare workers (Hyatt-Burkhart, 2014).

Research suggests that VPTG occurs as a result of changes to schema (see Figure 1), the cognitive structures through which we construct and interpret our reality, incorporating our beliefs, expectations and assumptions about the world and ourselves (Cohen & Collins, 2013). When exposed to trauma, established schema can be challenged and are subsequently modified to allow for new information by way of accommodation. Vicarious exposure to traumatic experience, as well as observations of change and growth in victims over time, can trigger a process of reflection by way of empathetic engagement. This instigates an existential search for meaning in the individual and results in growth (Steed & Downing,1998, as cited in Cohen & Collins, 2013).

Although few, studies into the possibility of positive change resulting from vicarious exposure to trauma have identified three broad areas of expected change (Linley, Joseph, & Loumidis, 2005):
 * 1) Increased appreciation of personal relationships
 * 2) A more positive self-perception
 * 3) Changes to one's philosophy on life

This change manifests in everyday life by way of a heightened awareness of the value of interpersonal relationships, becoming more patient, open-minded and tolerant, being less likely to become upset over small things and looking at life with a new awareness (Hyatt-Burkhart, 2014). The growth process has been described as a gradual awakening of consciousness leading to self-reflection and ultimately change. Psychological distress is identified as a powerful catalyst for the discovery of meaning and purpose in life (Mccormack, Hagger, & Joseph, 2011). Correlations exist between the influence of workplace and psychological factors in relation to increased well-being, positive psychological change and personal growth in areas including clinical supervision, empathetic engagement, gender and practice orientation. The most significant predictor of positive change is the therapeutic bond (Linley & Joseph, 2007).

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{Of the following, which professions are most likely to experience VPTG? - Teacher + Nurse - Gardener + Interpreter + Psychologist
 * type="[]"}

Key determinants
"No pain, no gain!"- Jane Fonda

A number of key factors determine the likelihood of VPTG occurring. Unsurprisingly they are emotionally charged and involve both deep connection and some suffering.

Empathetic engagement
In studying the development of vicarious resilience in sexual abuse therapists, it was determined that a vital precursor to vicarious resilience is vicarious traumatisation. This develops as a direct result of empathetic engagement with clients and exposure to accounts of their traumatic experiences (see Figure 2). Exposure to trauma prompts the development of coping mechanisms, self-reflection and a search for self and place within the context of therapeutic relationships, and society more generally. The resulting knowing becomes a resource that informs practice as a clinician and a source for self-care (Pack, 2014).



Improvement to social relationships following trauma has roots in increased sensitivity to others. Vulnerability and greater self-disclosure allow for a deepening of personal connection and strengthened relationships result (Collins, Taylor, & Skokan, 1990, as cited in Tedeschi & Calhoun, 1996). Empathy is experienced by way of the therapeutic bond between client and therapist and is noted as the likely conduit for positive change when exposed to the suffering of a client (Linley & Joseph, 2007). Studies record the highest levels of growth, on all but one measure, in therapists with high empathy scores. This may be because highly empathetic individuals require less exposure to trauma to facilitate change to more flexible personal schema (Brockhouse, Msetfi, Cohen, & Joseph, 2011).

Distress and reflection
Vicarious exposure to trauma can lead to care workers and therapists developing negative thoughts and behaviours which mirror those demonstrated by a client. These may include insomnia, intrusive thoughts, hypervigilance and irritability. Rumination is also a commonly reported behaviour (Darroch & Dempsey, 2016). Interestingly, intrusion and avoidance are both positively associated with growth following traumatic exposure. This may be explained by their demand for attention and the reflective, interactive processes that follow allowing new schema to develop, leading the way for growth. Distress must be experienced and explored to achieve growth. Personal growth is also a predictor of anxiety and depression, the two being significantly related. Intrusion is the expression of the cognitive processing of information in an attempt to understand it. Intrusive thoughts, nightmares and negative feelings compel contemplation and in this way we make meaning from events and rebuild or reinterpret our view of the world (Abel, Walker, Samios, & Morozow, 2014).

“I spend a lot more time by myself, thinking, like going for walks and trying to make sense of life—spending more time thinking about what the whole point of everything is.”

Restructuring schema
A major contributor to VPTG is the process of restructuring existing, or creating new, schema. When existing beliefs are shattered or challenged due to the shock of traumatic experience or exposure to distress we are forced to reassess our beliefs about the world. In assessing how new information fits with what we believe and know, we choose to either integrate information with previously held cognitive schema or abandon them. If abandoned, new schema may be created to accommodate new concepts (Tedeschi & Calhoun, 2004). Professionals assisting survivors of domestic violence report disruption to personal schema relating to safety, trust and power as a result of changes to their own beliefs. They can become less trustful, may feel powerless or experience negative changes to attitudes relating to control and intimacy (Dunkley & Whelan, 2006). Growth occurs as a result of accommodation, but not integration (Joseph & Linley, 2008, as cited in O’Sullivan & Whelan, 2011).

Other factors
There are a number of other recognised factors that predict VPTG. They include, but are not limited to:

Self care and social support

 * Therapists who have previously participated in personal therapy demonstrate significantly higher levels of growth than those who have not (Brockhouse, Msetfi, Cohen, & Joseph, 2011).
 * Research supports the contribution that individual supervision and social support makes to VPTG (Huddleston, Paton, & Stephens, 2006 as cited in Brockhouse et al., 2011).
 * Working in a clinic amongst other professionals with the opportunity for higher levels of supervision than in private practice, results in reports of greater spiritual change (Brockhouse, Msetfi, Cohen, & Joseph, 2011).

Sense of coherence

 * Research supports a link between higher rates of positive change and a high sense of coherence (SOC) (Linley, Joseph, & Loumidis, 2005) (see Table 1).
 * SOC is a predictor of growth although high coherence may limit opportunities for growth if individuals are less able to accommodate new information (Brockhouse et al., 2011).

Table 1.

Descriptions of the three components of sense of coherence.

Age

 * Older therapists report high levels of VPTG (Brockhouse et al., 2011).
 * Cumulative exposure to trauma results in more growth than exposure to high levels of trauma, favouring older therapists with longer careers and therefore greater exposure over time.  This is explained by positive accommodation; small accepted, changes to schema and belief systems over time (McCann & Perlman, 1990, as cited by Brockhouse et al., 2011).

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{Which key determinant is accepted as most likely to facilitate VPTG? - Age - Self care - Social support + Empathetic engagement - Sense of coherence
 * type="[]"}

Theoretical perspectives
“Man cannot remake himself without suffering, for he is both the marble and the sculptor” - Alexis Carrel

To date no specific models or theories have been developed to explain the phenomena of VPTG (Cohen & Collens, 2013), however it is widely accepted that it has a strong basis in the following theoretical perspectives.

Positive psychology


Emerging after the Second World War, Positive psychology rejects the notion that psychology is merely the study and practice of fixing what is broken or damaged, rather the opposite, in that it seeks to enhance and develop what is right and well within a person. It is proposed that in teaching people to utilise strengths including courage (see Figure 3), hope, resilience and optimism become effective preventative measures in relation to mental illness (Seligman, 2002).

Constructivist self development theory
A framework aimed at understanding vicarious traumatisation, constructivist self-development theory (CSDT) highlights detrimental impacts on the cognitive schemas by which people interpret the world, events and themselves as a result of vicarious exposure to trauma. Disruption to key areas of need (see Table 2), self-concept and memory imagery systems resulting from empathetic engagement can produce Post Traumatic Stress Disorder (PTSD) like symptoms in trauma counsellors. Gender, workload, personal history and experience all influence levels of distress and vulnerability to vicarious traumatisation (McCann & Pearlman, 1990 as cited in; Dunkley & Whelan, 2006).

Table 2.

Key areas of need which can be disrupted.

Post-traumatic growth model
This functional-descriptive model has identified three general areas in which positive change or growth are most likely, following a traumatic experience (Tedeschi & Calhoun, 1996).


 * changes in self-perception,
 * changes in interpersonal relationships, and
 * a changed philosophy of life.

Families who have children with severe medical issues, survivors of cancer and rape report an increased appreciation of the value of their personal relationships, a deeper faith or spiritual connection and a heightened sense of self-worth (Tedeschi & Calhoun, 1996). Of note is the hypothesis that alterations to established schemas may provide an explanation for the observed changes; as such, PTG is less likely to occur in young children as these are not yet well established, and more likely to be observed in teens and adults (Tedeschi & Calhoun, 2004). The Post-Traumatic Growth Inventory (PTGI) is used to measure benefit and change following traumatic events. The PTGI uses a set of 21 items, in a 6-point Likert response format, relating to five factors; new possibilities, relating to others; personal strength; spiritual change and appreciation of life (Tedeschi & Calhoun, 1996).

PTG does not develop because of the trauma, rather it is the struggle to reconstruct and understand ones altered reality in the aftermath, having severely challenged fundamentally held assumptions, that offers the opportunity for growth (Tedeschi & Calhoun, 2004).

 Melissa watched her 34-year-old husband suffer an agonizing death as a result of an aggressive cancer. Although grief stricken, she saw new possibilities for her life and decided to study nursing. Having graduated, she now works as an oncology nurse and hopes that she can provide comfort and support to patients suffering through cancer treatment.

Organismic valuing theory
This meta-theoretical framework takes the view that people are propelled towards growth through crisis. Its focus is adversity rather than trauma, recognising that sufficient distress will eventually result in growth, hence coining of the term 'adversarial growth'. Social support and coping strategies affect cognitive-emotional processes. Events are considered and assimilated into established schema or new world views are created via the process of accommodation. Accommodation produces growth, assimilation does not (Joseph & Linley, 2008, as cited in O’Sullivan & Whelan, 2011).

Self determination theory
When examining why VPTG occurs it may be useful to consider what motivates the behaviours associated with the phenomenon. These include reflective, introspective practices that lead to a more positive view of one’s self, the world around us and our place within it (Manning-Jones & de Terte & Stephens, 2015). One theory that seeks to explain what prompts humans to do this is Self-determination theory (SDT). SDT is built on the belief that humans are wired to actively engage in an innate, intrinsic and continuous process of self-development to become the best version of our self (Deci & Ryan, 2008).

SDT outlines three basic, universal psychological needs crucial to a healthy psyche and general well-being; they are autonomy, relatedness and competence (Deci & Ryan, 2008).


 * Autonomy, having control over our own decisions and choices is satisfied by the observed restructuring of schema to reflect our world view.


 * Relatedness is satisfied by the intimate connection between therapist and client known as empathetic engagement. Empathetic engagement is perhaps the key contributor when predicting whether VPTG is likely to manifest (Linley, Joseph, & Linley, 2007).


 * Competence is satisfied in those who experience VPTG by way of a reported feeling of professional competence unique to this phenomenon (Barrington & Shakespeare-Finch, 2013).

If our view of the world is significantly disrupted and well-being is negatively impacted, it stands to reason that we would attempt to re-establish a feeling of well-being by satisfying core psychological needs such as those outlined by SDT.

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{Which of the theoretical perspectives discussed above are based on disrupted schemas? + Organismic valuing theory - Self Determination theory - Positive psychology + Post traumatic growth model + Constructivist Self Development Theory
 * type="[]"}

Conclusion
What have we learned about vicarious post-traumatic growth? It is a phenomenon associated with the helping professions. A new area of study, to date there are no structured theories to explain it however, VPTG is most likely to develop as a result of changes to pre-existing schemas due to a challenge to held beliefs, world and self views (Cohen & Collins, 2013). Of note, and unique to the phenomenon, is the acquisition of a feeling of professional competence (Barrington & Shakespeare-Finch, 2013). Growth is achieved by way of the positive accommodation of new information (Tedeschi & Calhoun, 2004). Rumination and a search for meaning pave the way for growth, however that growth requires suffering (Darroch & Dempsey, 2016).

The bad news is that without trauma there is no growth; the good news is that growth is the silver lining.