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Growth After Trauma and at the End of Life
By J. Scott Janssen, MSW, LCSW
January 2017

Kent pointed at the tobacco shed out back. "I almost ended it all right there." He was talking about his struggles in the aftermath of his son's suicide: nightmares, guilt, shame, social withdrawal, fistfights, divorce, alcohol abuse. He recounted the walk he'd made to that shed that day, .45 caliber pistol in hand, intent on blowing his brains out.

"I'd had it. Just couldn't take the constant feeling that I'd done a bad job as a father and let him down. I really believed I didn't deserve to live. I had the barrel against my forehead."

That's when he heard the voice: "Stop! Time to heal!"

He wasn't sure if the voice came from inside his head or outside. But he was sure of one thing: it had marked the point where the arc of his life had bent away from self-destruction toward a long and painful process of healing and personal transformation.

Looking back years later, he could identify ways in which this struggle had forever altered his core identity and priorities, making him more sensitive to others, more compassionate, and less judgmental. He'd developed a greater appreciation for loved ones and deeper trust that, however difficult a situation, things would somehow work out. His temper subsided and he found himself expressing emotions instead of bottling them up. "It was a rough ride," he said. "I'd never wish it on anyone but I can honestly say if it hadn't been for the pain I'd never have opened my heart the way I have."

This notion of growth within suffering is an old one. It can be found in the earliest stories and myths of humankind. The Epic of Gilgamesh, for example, one of the earliest known pieces of literature, follows the hero on a harrowing journey of discovery after the death of a close friend. The images and metaphors of this journey speak through time as Gilgamesh is transformed through his painful ordeal into a new self who, though he fails to solve the riddle of death, no longer fears it.

In Dying Well: The Prospect for Growth at the End of Life, Ira Byock, MD, hints at how the workings of this type of journey may unfold for those facing terminal illness, noting the paradox that "people can become stronger and more whole as physical weakness becomes overwhelming and life itself wanes."   

When exploring the experiences of those who have survived psychological and emotional upheaval and been changed in positive ways, it is increasingly common to hear phrases such as "spiritually transformative experience" and "post-traumatic growth." The American Psychological Association has even developed a Post-Traumatic Growth Inventory in the attempt to measure the ways a person's response to a traumatic event may generate a new or deeper sense of self.

Respondents to the inventory are asked to rate their agreement with statements along five experiential dimensions comprising relationships, new possibilities, personal strength, spiritual change, and appreciation of life. The following sampling of these statements gives a flavor for the hard-wrought gifts that may come over time for those struggling to heal:

• I changed my priorities about what is important in life.
• I have a better understanding of spiritual matters.
• I established a new path for my life.
• I have a greater sense of closeness with others.
• I have more compassion for others.
• I put more effort into my relationships.
• I am more likely to try to change things which need changing.
• I discovered that I am stronger than I thought I was. 

As a social worker interested in both end-of life care and psychological trauma, I've had plenty of opportunities to see firsthand the ways suffering and disorienting change can open the door for fundamental life transformation. Though some see such outcomes as related to context or specific qualities of an individual, others, myself included, believe this possibility is nascent within everyone. I've often reflected on this impulse toward growth, making linguistic stabs at describing the place from which it originates—core or mindful self, life force, creative will, consciousness, heart center, inner voice, and spirit.

Finding the Words
Like any profession, social workers use a common language with acronyms, buzz words and standardized phrases when talking about clients and the situations they face. But we also, consciously or unconsciously, personalize this shared language and make it, to some degree, uniquely individualized. We make choices, adding meaningful words, images, stories and metaphors to create a lexicon with which to think about and describe the work we do. These choices then inform and texture what we see and how we understand. Choosing to name this inner capacity for growth as "originating in the spirit" is subtly different than locating its origins in something named "the core self." Being in contact with, and on the lookout for, a person's inner voice is different than trying to make contact with their consciousness.

Probing for these deeper places of resilience and wisdom within clients overwhelmed by emotional pain and grief can be tricky. Some may doubt their ability to survive this inner turmoil much less navigate through it to a vision of deeper possibility. Knowing when to move into a client's suffering and when to step back and connect with this inward place of strength and balance often feels like a nuanced and mysterious dance. Trying to move too quickly toward growth can feel contrived and may fly in the face of a person's subjective experience, running the risk of social workers appearing to lack understanding or empathy. Overly focusing on what might be perceived as a desire for a 'happy ending' can send the message to patients and clients that we are not prepared to follow them into their pain. Using phrases such as "post-traumatic growth" in some contexts can even appear naïve or imply negative judgments about those who feel very far from being on a journey of personal transformation. 

"There were days after my son died," Kent remembered, "if anyone had tried to tell me I'd come out on the other side a better person I'd have thought they were crazy. It was all I could do to just get out of bed."

With such clients, simply noticing moments of perspective, connection or courage that had gone unnoticed and unnamed can provide small footholds on the long path toward healing. It can introduce new, more empowering language with which to begin connecting to those inner resources about which a client may have been unaware or in which they may have lost trust.    

I'd asked Kent if there had been a part of him somewhere deep inside that knew he had to keep moving forward even when it was hard just getting out of bed.

"There probably was."

"What did that part know that the rest of you didn't?"

 "It knew that I had to keep trying even if I didn't want to."

"What else did that part know?"

"It knew that I could do it. I could survive the pain."

"How was that important?"

"I guess I knew on some level that if I could get through it there was something else waiting for me. Maybe part of me was curious about what it might be."

Clients in the midst of a crisis may have difficulty identifying or trusting such things. In these situations it can be helpful to try connecting with a client's deeper power not from the perspective of the self, but from that of a trusted other. For example, if Kent had not been able to locate this deeper part within himself, I might have asked questions suggesting he answer from the perspective of his mother (from whom I knew he'd felt a great deal of love). Questions such as: "If your mother could come back for a few minutes and talk with us, where would she say your strength came from?" "What would she know about you that would tell her you were going to heal?" "What is something she would want you to know for the way ahead?" "What would you ask her?" "How would she respond?"

Moving Forward

Exploration into a client's suffering is important but so is not to get stuck in the pain; connecting with strengths and a positive vision is important but so is patience and not forcing an agenda. We may start by helping a client process difficult experiences and cognitions, express emotion, identify external supports or develop strategies for enhanced coping. At some point I always float a few growth-oriented questions to see if any light bulbs go off. Examples when working with clients healing from trauma are plentiful. Indeed, any of the statements of the Post-Traumatic Growth Inventory can be rephrased as questions.

Other examples include: "What's something you learned about yourself that has been helpful to you?" "What's something important that you've come to understand better as a result of your struggles?" "How are you different?" "How do you explain the (fill in the blank—compassion, empathy, patience, etc.—you've gained?" "Is there a place inside where you most feel this compassion? What do you call that place?" "What have others noticed about the ways you've changed?"

Questions that can be used with those who are terminally ill are equally plentiful. "What's something you've come to better appreciate since being diagnosed?" "When you think about living the last days of your life, what is most meaningful to you right now?" "If the love you have for your husband had words, what would those words be?" "Where do you feel that love?" "How does it want to be expressed?" "If you told the story of your life since the beginning of your illness from the perspective of your core self (higher self, soul, etc., depending on a client's frame of reference), how would that story go?"

Such questions can be used to reflect not just on thoughts, feelings and beliefs. They can also expand into the imagistic realms of the imagination, intuition and transpersonal experiences where language stretches far beyond conventional clinical jargon and 'current procedural terminology.' At their heart, I've come to see these kinds of questions as invitations into life's spiritual dimensions—dimensions that, years ago, would have been off limits in social work practice but which today many recognize as important when working with some clients.       

Dying clients often find themselves asking spiritual questions about death, relationships, life purpose, and the nature of the self. Traumatized clients may be struggling with spiritual questions relating to difficulties trusting, loss of self-worth, why bad things happen, or a haunting sense that the world's moral order has been shattered.  For both groups (especially when they overlap) intense emotions, an increased sense of vulnerability and fears about the future can weigh heavily and throw longstanding beliefs and assumptions into disarray. In situations where old notions of self are breaking down, these are the kinds of questions that can challenge and clarify one's search for meaning and sense of identity.

It would be misleading to imply that helping clients see beyond the limits of their emotional and psychological pain is as simple as asking certain kinds of questions. The work of healing can take a lifetime. For some, simply moving in the direction of peace is significant. For other clients, questions may be considered too cognitive, conceptual, invasive, or overwhelming. Some may be better able to access deeper layers of strength through mindfulness practices or visualization. Some may prefer solitary pursuits such as journaling, reading something inspirational, or writing poetry; others may use rituals, storytelling, or walking in nature. Those who are particularly overwhelmed or afraid may need help simply regulating their nervous systems and working with physical sensations, learning to feel their bodies and relax through enhanced somatic awareness.  

Whatever approach clients take in navigating the inner and outer challenges they're facing, if we are alert to access points into their deeper reserves of creativity and potential for growth we will be better prepared to help them draw on these and use them productively. In this day where there is such an emphasis on empirical validation, best practice research and routinized clinical protocols, this probing for the deep self reminds me when I am with someone who is suffering that there is something sacred about the responsibility I bear to respond with compassion, nonjudgmental acceptance, and open-hearted humanity. It reminds me that the work itself is spiritual and that creative clinical questions and treatment protocols are worth very little if we do not have a felt connection and trust in our clients' innate wisdom and strength.

— J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell in Burlington, NC, and an editorial advisor for Social Work Today.