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September 2007 Article of the Month
 
This month’s article is highlighted by Margot Hover, D.Min., ACPE/NACC Supervisor.

 

Hernandez, P., Gangsei, D., Engstrom, D. "Vicarious resilience: a new concept in work with those who survive trauma." Family Process 46, no.2 (June 2007): 229-241.

 

SUMMARY and COMMENT: Any chaplain working in a high stress area has undoubtedly been asked numerous times how she or he copes--with death, trauma, long hours, and other draining aspects of that ministry. This article explores a possible response in a new concept: Vicarious Resilience. The authors wondered how psychotherapists who work with survivors of political violence or kidnapping are affected by their clients’ stories of resilience. In particular, the researchers looked at therapists’ interpretations of their clients’ stories and the ways they made sense of their life experiences. Previous wisdom about caregivers and caregiving dwelt primarily on the concepts of Vicarious Traumatization, secondary traumatic stress, empathic stress, and compassion fatigue. However, Hernandez, Gangsei, and Engstrom, affiliated with the departments of Social Work and Counseling/School Psychology at San Diego State University and of the San Diego organization Survivors of Torture International, also drew on information about resilience: "the way in which trauma survivors access adaptive processes and coping mechanisms to survive and even thrive in the face of adversity" [p. 229]. The specific trauma on which they focused was politically motivated violence--kidnapping, assassination, torture--and the impact on therapists involved in treatment of survivors; but I would like to suggest that their research may have implications for chaplains working with patients suffering from traumatic injury and illness.

It is worth noting that, like the November 2006 Article of the Month [Robinson, M. R., Thiel, M. M., Backus, M. M. and Meyer, E. C., "Matters of spirituality at the end of life in the pediatric intensive care unit," Pediatrics 118, no. 3 (September 2006): 719-729], this research project was conceived in the process of close listening to the unexpected voices and themes in existing data. The researchers noticed that outliers in a program focusing on therapists’ Vicarious Trauma revealed the inspiration and strength they drew from their clients' stories. They tested their notion of Vicarious Resilience by interviewing those therapists who found positive experiences in their work with torture survivors. This led to their hunch that awareness of that concept might help therapists "develop a useful resource to strengthen the work they do" [p. 230] and perhaps avoid or mitigate compassion fatigue and burnout.

Their exploratory, qualitative study used a standard approach to interview a sample group comprised of one psychiatrist and eleven psychologists from Colombia, a country fraught with extreme dangers. The subjects were asked about how they may have been positively affected by their clients’ ways of coping with persecution and violence. Standard methods of text analysis and theme identification were used to analyze transcripts of the interviews. The article serves as a good illustration of both the strengths and the limitations of small sample qualitative studies. The bibliography offers several references on methodology that CPE students interested in such research might want to explore.

One theme emerging from the transcripts was the therapists’ changing sense of proportion: "After working with people who have suffered these kinds of problems, your definition of a problem changes. One takes issues with more ease" [p. 234]. A second important, somewhat unanticipated, theme was the value of spirituality in survivors’ lives. One therapist acknowledged her previous wariness of addressing spirituality with her clients. Subsequently, as she saw how they relied on spirituality to regain their health and to move on in positive ways, she began to incorporate that into her practice as a helpful resource.

Interestingly enough, one therapist who had previously defined her work in terms of dealing with anger and pain was so touched by a young kidnapped soldier’s resilience that for the first time she began to see the possibility of clients’ recovery and her role in it. Other therapists reported restored hope and a sense of empowerment in their work to help clients they previously thought were rendered hopeless by their torture. A smaller group of therapists related a "witnessed-resilience dynamic" [p. 236] in that their clients’ healing validated their own sense of the legal and social truth of shared political values.

In discussing the data, the researchers affirm the principle that work with trauma survivors may come with a cost to the helper. They aren’t sure about whether/how Vicarious Resilience relates to Vicarious Trauma (though they observed that the two may co-occur), but their study suggests that drawing conscious attention to Vicarious Resilience increases the possibility of positive effect for the therapist.

The data from this study reveal a complex array of elements contributing to the empowerment of therapists through interaction with clients’ stories of resilience. These elements are witnessing and reflecting on human beings’ immense capacity to heal; reassessing the significance of the therapists’ own problems; incorporating spirituality as a valuable dimension in treatment; developing hope and commitment; articulating personal and professional positions regarding political violence; articulating frameworks for healing; developing tolerance to frustration; developing time, setting, and intervention boundaries that fit therapeutic interventions in context; using community interventions; and developing the use of self in therapy. Awareness of the phenomenon and component elements of VR and introducing the concept into the professional vocabulary can guide therapists in strengthening themselves and their work. [p. 238]
They continue: "The benefits of empowerment accruing to the therapists in this study included increased understanding of the therapeutic process, increased understanding of the resiliency process, and an increased sense of efficacy in their work" [p. 238]. Moreover, their sense of the usefulness of developing the concept of Vicarious Resilience for therapists may speak to CPE Supervisors in terms of the educational process:
First, it is a useful tool to counteract deeply fatiguing processes in which therapists may come to see themselves as "victims" of those who have been victimized. Learning to attend to both VT and VR supports the health and strength of those who choose to work in contexts in which brutal pain is always present. Second, awareness of VR processes may strengthen the experiences that already reinforce the motivation and persistence of therapists who work with survivors of political violence. Creating a conscious exploration of the phenomenon and a context in which to explore it may help therapists amplify and find new meaning in their work. Third, having this concept available for presentation in training and supervision settings can become part of guiding trauma workers to take care of themselves. Fourth, because the data show that vicarious learning generalizes to the broader context of therapists’ lives, trauma therapists may use what they learn from their clients in their own times of crisis. Fifth, because clients often worry about the toxic effect of their traumas on their therapists, introducing the concept of VR to clients may facilitate the clinical work. Finally, awareness of VR can enrich and motivate therapists’ conceptualizing of their clinical work and developing of their professional careers. [p. 239]

Hernandez, Gangsei, and Engstrom give a well-illustrated account of clients' effects on therapists their work, with extended quotes from participants. They also address issues of research methodology that should be insightful for follow-up study. There seems to be great potential here for application to the world of CPE training and chaplaincy research, but perhaps most of all this article points generally to a fresh way of looking at the complex experience of the work and rewards of caregiving.


 

Suggestions for the Use of the Article for Discussion in CPE: 

1) In their discussion, the authors list some of the limitations of their methodology affecting generalizability: small sample size and great variety in the subjects’ level of training and experience. They name these with a view toward follow-up studies. [See pp. 239-240.] If a study looked at Vicarious Resilience in the work of chaplains, what sorts of limitations in the sample of participants might be significant? Might one important variable be the theology of the chaplains, with regard to suffering and earthly reward, evil, and resignation?

2) The article suggests some approaches to patient care that merit consideration. For example, one resilient patient who died before seeing her husband’s release thanked her therapist for affirming her concentration on tasks of living, in contrast to the other caregivers who wanted her to talk about dying. [See pp. 236-237.] How does this particular story translate into the enterprise of spiritual care? What resources do chaplains have for strengthening the resilience of their patients?

3) Because Vicarious Resilience is a fairly new concept, the article bibliography is very heavily weighted in the direction of client trauma and its negative effects on therapists. While this was a small study focusing on therapists, it lifts up a caregiver dynamic that chaplains face as well. What value, if any, do chaplains assign to stress and burnout?


 

Related Items of Interest:

I. For more on Vicarious Resilience, look for the following article from this month's authors, currently in press:

Engstrom, D. W., Hernandez, P. and Gangsie, D. "Vicarious resilience: a qualitative investigation into a description of a new concept." Journal of Mental Health Counseling. [In press as of 9/11/07.]

II. For more about the concept of resilience per se, see:

Earvolino-Ramirez, M. "Resilience: a concept analysis." Nursing Forum 42, no. 2 (April-June 2007): 73-82. [The author, a nurse, identifies from the published literature on resilience six defining attributes of the concept: rebounding/reintegration, high expectancy/self-determination, positive relationships/social support, flexibility (easy temperament), sense of humor, and self-esteem/self-efficacy. She also notes the related concept of hardiness. She observes that the definition has been largely shaped by literature on children and adolescents. Several cases are given as illustrations, though they relate to broad social circumstances, not illness.]

Gillespie, B. M., Chaboyer, W. and Wallis, M. "Development of a theoretically derived model of resilience through concept analysis." Contemporary Nurse 25, nos. 1-2 (May-June 2007): 124-135. [(Abstract:) BACKGROUND: Resilience refers to a dynamic process that results in adaptation in the context of significant adversity (Margalit 2004). The concept of resilience has been of interest to various professional groups for many years; however, it is only recently that the nursing profession has begun to recognise its potential contribution in diverse clinical contexts. OBJECTIVE: First, to identify current theoretical and operational definitions of resilience and second, to identify and describe defining attributes of resilience. METHODS: The method of inquiry was guided by Walker and Avant's (1995) approach to concept analysis. FINDINGS: From this analysis, a conceptual model of resilience postulates that the constructs of self-efficacy, hope and coping are defining attributes of resilience. DISCUSSION: Resilience appears to be a process that can be developed at any time during lifespan, and thus is not an inherent characteristic of personality. Further, the development of resilience is based on the synergy shared between individuals and their environments and experiences. CONCLUSIONS: Further theoretical clarification of the ways in which individuals transform stressful experiences into opportunities for increased growth may contribute to nursing knowledge in the form of better understanding of the resilience concept in the context of identifying strategies that build it.]

Richardson, G. E. "The metatheory of resilience and resiliency." Journal of Clinical Psychology 58, no. 3 (March 2002): 307–321. [(Abstract:) Resiliency and resilience theory is presented as three waves of resiliency inquiry. The identification of resilient qualities was the first wave characterized through phenomenological identification of developmental assets and protective factors. The second wave described resilience as a disruptive and reintegrative process for accessing resilient qualities. The third wave exemplified the postmodern and multidisciplinary view of resilience, which is the force that drives a person to grow through adversity and disruptions. Application of resilience using an educational and practical framework provides a means for connecting with and nurturing a client's resilience. Practical paradigms of resiliency that empower client control and choice are suggested.]

III. Chaplains may be interested in the following articles on resilience that note spirituality.

Becker, G. and Newsom, E. "Resilience in the face of serious illness among chronically ill African Americans in later life." Journals of Gerontology Series B-Psychological Sciences and Social Sciences 60, no. 4 (July 2005): S214-223. [(From the abstract:) ...The purpose of this work was to examine older African Americans' philosophies about their chronic illnesses and how those philosophies affected chronic illness management. METHODS: Three to five in-depth interviews were conducted over the course of several years with 38 respondents between the ages of 65 and 91. Both open-ended and semistructured questions were asked. RESULTS: Respondents demonstrated determination, perseverance, and tenacity no matter how serious their illnesses were. Racism was instrumental in shaping the responses of these African Americans to their illnesses through cultural values that emphasized independence, spirituality, and survival. Respondents demonstrated a resilient philosophy as they faced disabling illness....]

King, G., Cathers, T., Brown, E., Specht, J. A., Willoughby, C., Polgar, J. M., MacKinnon, E., Smith, L. K. and Havens, L. "Turning points and protective processes in the lives of people with chronic disabilities." Qualitative Health Research 13, no. 2 (February 2003): 184-206. [This qualitative study of 15 people seeks to add to the knowledge and theory of resilience by "focus[ing] on the nature of protective factors for individuals with chronic disabilities such as cerebral palsy...," by looking at "protective processes arising at turning points," and by taking a "life-span perspective and look[ing] at adults’ retrospective views of the protective factors and processes that were influential at different times in their lives" (--see p. 187). The importance of spiritual beliefs is noted at a number of points.]

Kinsel, B. "Resilience as adaptation in older women." Journal of Women and Aging 17, no. 3 (2005): 23-39. [The study involved face-to-face open-ended interviews with 17 participants, identifying seven factors that contribute to resilience in older women: social connectedness, extending self to others, moving forward with life, curiosity/ever-seeking, head-on approach to challenge, bring a maverick, and spiritual grounding. Each factor is illustrated with quotes. Suggestions are made for further research.]

Lloyd, M. "Resilience promotion--its role in clinical medicine." Australian Family Physician 35, nos. 1-2 (January-February 2006): 63-64. [This commentary advocates for attention to resilience promotion in patient care. The author looks at aspects of the concept of resilience and notes connections to spirituality. The article is freely available from the journal's website at www.racgp.org.au/afp/200601/3525.]

Nelson-Becker, H. B. "Voices of resilience: older adults in hospice care." Journal of Social Work in End-of-Life and Palliative Care 2, no. 3 (2006): 87-106. [(Abstract:) Terminally ill older adults have the capacity to live well in the context of dying. Having negotiated a lifetime of challenges, they have resources to demonstrate resilience and achieve wholeness in life's final phase, but research has not adequately investigated this process. This qualitative research study considered the paths to resilience used by 30 older adult hospice clients in Kansas and Illinois. Responses were coded using the grounded theory method of Strauss and Corbin (1990) where data drives interpretation and text is coded into categories. Results centered on four themes that included: (1) a redefinition of self; (2) use of religion/spirituality or openness to uncertainty; (3) maintenance of social investments; and (4) guarding independence even as the scope of life contracted. Results imply that attention should be paid to building environments of wellness. This may be accomplished paradoxically through facilitating continuity of client interests and yet opportunities for creativity and growth as well. Listening with a healing stance and cultivating a habit of being fully present in interactions with clients assist in this process.]

Williams, N. R., Davey, M. and Klock-Powell, K. "Rising from the ashes: stories of recovery, adaptation and resiliency in burn survivors." Social Work in Health Care 36, no. 4 (2003): 53-77. [The researchers interviewed eight burn survivors about their perception of their injury and recovery and how the experience had affected them. The study was conceived with a strong attention to the concept of resilience (--see esp. pp. 54-56). Spirituality/religion is noted as a theme (--see pp. 68-69, 72, and 73).]

 


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