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Article 19

Who Am I Now? Helping Trauma Clients Find Meaning, Wisdom, and a Renewed Sense of Self

Barbara E. Abernathy

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The role of identity in coping with traumatic events is becoming better understood and its relevance in individual coping has begun to be considered. Identity can be viewed as a lens through which individuals construct meaning and cognitive appraisal. Extensive research has explored the adaptive reconstruction of self among populations such as adult cancer patients. What can we learn about how these individuals make meaning, find wisdom, transformation, and a positive sense of self that can help other survivors?

Research on cancer patients has also recently begun documenting posttraumatic growth (PTG) or profound positive change in some adults with cancer (Calhoun & Tedeschi, 2006; Stanton, Bower, & Low, 2006). Some patients are embracing the “survivorship” identity arguably personified by Lance Armstrong, who claimed that surviving metastatic testicular cancer inspired him to win the Tour de France an unprecedented seven consecutive times and to establish a charity which seeks to empower other patients in their battle against cancer. This identity is characterized by a renewed appreciation for life and sense of purpose, and those embracing this identity often consider cancer a gift. Survivorship has become the dominant social model. Recently, the National Cancer Institute (2006) also formally adopted the newer meaning of the term: “Anv individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life.”

“Identity is not a sudden and mysterious event, but a sensible result of one’s life story” (Gergen & Gergen, 1988, p. 19). Identity is defined as the subjective concept of oneself as a person and is subject to personal agency (Thoits, 1999). Individuals make sense of experiences and re-narrate events for coherence with narratives, or life stories, providing a vehicle for identity construction (Mathieson & Stam, 1995; McAdams, 1993; Neimeyer, 2006). As individuals engage in meaning-making to regain coherence and comprehensibility (schema change), they re-narrate their stories, finding not only new meaning but a new sense of themselves (Brennan, 2001).

The research on surviving trauma suggests that part of successfully navigating the experience of trauma is a new sense of self (Neimeyer, 2006). It was once believed that self-concept was static, but now it is understood that sense of self is not only dynamic, but a guiding force for our lives (McAdams, 1993). At the core of the survivor experience is an identity shift that is not only an outcome, but a global coping strategy that may affect the illness trajectory or adjustment (Allen, 1999; Bradley, Calvert, Pitts, & Redman, 2001).

Role-identities not only provide a sense of purpose and belonging, but define who we are and provide normative cues for behavior (Thoits, 2003). Competent role-identity enhances self- efficacy, and in fact, contributes to overall mental health (Thoits, 2003). When individuals successfully solve role-specific problems identity is enhanced while events which are not successfully navigated can be identity-threatening (Thoits, 1991 & 1994). The impact of illness on valued roles determines the extent to which an individual’s physical, social, emotional, psychological, spiritual, and financial well-being is affected (Thoits, 2003). Distress occurs when an individual is unable to maintain valued roles which are salient to identity, and therefore the identity associated with those roles is undermined (Thoits, 2003). When there is a conflict between identity standards (how one believes one should act) and how one actually behaves, the individual will either seek to alter the situation or will “bring self-relevant meanings back in line with identity standards” (Thoits, 2003, p. 191).

Trauma as Loss of Self

Knowing ourselves and having a predictable performance of self gives a comfortable continuity to life and self. For many people, trauma shatters understanding of self and the world (Janoff-Bulman, 1992). Indeed, it is not the extreme nature of the event that defines a stressful experience as traumatic, but rather the internal experience of it (Janoff-Bulman, 2006). Terror is the definitive response to trauma, characterized by internal disorganization and disintegration, shattered assumptions, and feelings of self-annihilation – in other words, everything that makes our lives intelligible, meaningful, and coherent. Concomitantly, people who experience trauma suffer ‘ego shock’ (Campbell, Brunell, & Foster, 2004) or a ‘loss of self’ (Charmaz, 1983). Ultimately, traumatized individuals adjust by seeking to reclaim a coherent, culturally-situated identity or ‘self- narrative’ (Neimeyer, 2006) and a subsequent ‘renegotiation of self’ (Mathieson & Stam, 1995).

Trauma or any event that yields a sudden, shocking awareness of one’s own mortality, or ‘amputation of the future’, results in a rupture of biographical continuity between past and future self (Corbin & Strauss, 1988). These challenges to a person’s integrity of self, cohesive life narrative, and biographical continuity are ‘threats to identity’ (Corbin & Strauss). Identity is threatened when basic assumptions about self and the world are shattered (Janoff-Bulman, 1992), when awareness of one’s own mortality becomes suddenly relevant (Brennan, 2001; Taylor, 1983), and when one’s valued roles and psychologically meaningful pursuits are threatened (Charmaz, 1987, 1993; Corbin & Strauss).

Trauma threatens autonomous self through challenges to agency such as dealing with sudden, unpredictable, uncontrollable events, and loss of belief in oneself as powerful or capable of handling threats, and loss of mastery. Mathieson and Stam (1995) suggest that cancer results in ‘threats to former self-images’, such as “loss of productive functioning, financial strain, family stress, personal distress, and stigma” (p. 287), and that these threats force a transformation in identity. For example, among adults with cancer, threats to identity include: the sudden, unexpected awareness of mortality, loss of status as a healthy person, illness intrusiveness (or the interference with pursuit of psychologically meaningful life activities and functioning), body changes (e.g., alopecia, surgical scars, or amputation), and interacting with a disempowering biomedical culture (Charmaz, 1993; Moorey & Greer, 1989). Individuals lose the status of a healthy person and become a person with cancer – with all the associated societal preconceptions and expectations. How they perform or internalize those roles shapes their identity.

The individual must successfully resolve these threats to identity to reduce psychological distress and to maintain a sense of coherence about her/his life (Mathieson & Stam, 1995). The impact of each threat depends on its salience to one’s identity (Thoits, 1999). Persons must also resolve threats to identity to regain a sense of personal agency and self-efficacy. People will work to avoid negative emotions or marginalization and to achieve future selves that maximize satisfaction and self-esteem (Vignoles, Regalia, Manzi, Golledge, & Scabini, 2006).

Paths to the “Light at the End of the Tunnel”

Almedom (2005) suggests that sense of coherence (SOC), resilience, hardiness, and the newer concept of posttraumatic growth (PTG) all lead to the “light at the end of the tunnel” (p. 253). Gustavsson-Lilius, Julkunen, Keskivaara, and Hietanen (2007) agree that central elements of SOC are also found in other theories, such as Kobasa’s (1979) notion of ‘hardiness’ and Bandura’s (1977) concept of ‘self-efficacy’ which have proven important in coping with stress. The term “sense of coherence” describes internal congruence with regard to an individual’s global view of the world and the environment as comprehensible, manageable, and meaningful (Antonovsky, 1987).

Posttraumatic growth (PTG) is defined as “positive psychological change experienced as the result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004, p. 1). PTG is more than mere survival or a traumatic experience; it is transformational change beyond pre-trauma levels. One of the three domains identified as relevant to PTG is change in perception of self (the other two are: change in the experience of relationships with others and change in the general philosophy of life; Tedeschi and Calhoun, 1996). Neimeyer (2006) suggests that PTG is a function of narrative reconstruction. Ultimately there is a new sense of self that integrates the experiences and develops a more vulnerable, less naïve sense of self (Calhoun & Tedeschi, 2006).

Identity Transformation

Erikson (1980) described identity as subjective and including both a sense of self-sameness and stability over time. In this way an individual gains a sense of coherent identity despite different situations. Trauma disrupts the continuity which is so vital to the maintenance of coherent identity (Erikson). McAdams (1993) proposes that we learn about ourselves by the stories that we tell, and that, in fact, we create ourselves through conforming to our own mythic story. He also suggests that individuals make meaning of events in such a way to conform to existing life narratives which in turn inform understanding of self. Identity renegotiation occurs when clients begin to see themselves in new roles that have meaning (Charmaz, 1993); when they find new strength “because of” or “in spite of” the traumatic event or illness.

Centrality of event is the extent to which “a stressful event forms a reference point for personal identity and for the attribution of meaning to other experiences in a person’s life” (Berntsen & Rubin, 2006, p. 220). Individuals differ in regard to the degree to which an emotionally intense negative event becomes central to identity, life story and understanding of the world (Berntsen & Rubin). Berntsen and Rubin concluded that these individual differences are critically related to PTSD symptom profiles and “the extent to which a traumatic or stressful event forms a personal reference point for the attribution of meaning to other events, a salient turning point in the life story and a central component of a person’s identity and self- understanding” (p. 220).

Whittemore (2005) identified a process in ill adults she calls integration which is defined as “synthesizing changing life circumstances into one’s life identity” (p. 262) or “as a human- environment interaction whereby new life experiences such as illness are reconciled with past and present identities and roles” (p. 261). Integration of an illness experience in self-identity results in improved psychological adjustment (Whittemore). She notes that individuals have a need for coherence which is a driving force in integration as individuals seek to create meaning that renews continuity and homeostasis or a ‘new normal’ (Whittemore). She identified three specific subtypes of integration: role integration, social and community integration, and temporal integration. Role integration is defined as the disparity between stress and satisfaction in one’s primary roles. Social and community integration involves a sense of belonging with regard to relationships and activities of daily life. The temporal integration subtype addresses the disconnect individuals experience between the past and future and seeks to enhance the present, which Whittemore suggests can contribute to self-transcendence.

Whittemore’s (2005) integration model shows transitional experiences as: (a) establishing a pattern, (b) embedding a pattern, and then (c) living a pattern. The first transitional experience includes both focused attention to living with illness in conjunction with awareness of vulnerability. A phase of integration involves increased attention to managing illness and self-exploration to find personal meaning in illness. In fact, a critical element of making durable lifestyle changes is exploring self and restructuring to support change. Personal strategies lead to changes in life patterns in which illness is no longer primary, illness intrusiveness is minimized, and attention to meaningful life events is recommenced. Trial and error allows idealized expectations to transform into reality; creating workable routines and experiencing positive outcomes reinforces changes and increases the likelihood of lasting change.

Recommendations for Counselors

Individuals surviving a traumatic event often demonstrate a need to create meaning around events to make sense and regain coherence to their lives, thereby reestablishing the biographical continuity which had been lost. Narrative therapists suggest that we re-shape our stories to re-shape our understanding of them; and identity theories suggest that re-shaping our stories reconstructs our sense of self. Helping clients re-narrate their stories with a greater sense of mastery and coherence can help them find meaning and a renewed sense of self.

Taylor (1983) suggests that a need for three vital themes consistent with sense of coherence: meaning, mastery, and self- enhancement. Counselors need to help clients find personal meaning and successfully manage illness to minimize negative impact on meaningful roles and activities. This may mean exchanging previously valued activities for new equally valued activities or accepting a different definition of participation or success. Assisting clients with finding their ‘new normal’ and embracing its possibilities is critical to their long-term success. Benefit-finding may or may not be important for clients as its role is not yet established. Establishing new routines is necessary in adapting to loss and to support one’s commitment to change.

Counselors can help clients understand that even positive changes come with a cost when trauma is the catalyst. While PTG is associated with strength, it is paradoxically also associated with vulnerability. Research finds only a weak or inconsistent relationship between PTG and adjustment (Stanton, Bower, & Low, 2006). In fact, PTG may be accompanied by decreased well-being and greater stress (Calhoun & Tedeschi, 2006). Despite the almost exclusive emphasis on the positive aspects of PTG, it is necessary to remember that it is born from suffering; therefore, contradiction is inherent and inevitable (Neimeyer, 2006). Accepting one’s vulnerability is key to understanding one’s newfound strength.