Welcome back to the Healing Pain Podcast with Dr. Melissa Zeligman, PhD
We have a new topic that we are highlighting on the show. We are discussing resilience and growth after trauma, also known as post-traumatic growth, which is a theory that explains the positive human transformation that can occur after any type of physical trauma, psychological or emotional trauma, spiritual trauma, or even after struggling with a prolonged illness.
Joining us to discuss trauma and post-traumatic growth is Dr. Melissa Zeligman. She is an Assistant Professor of Counseling Education at the University of Central Florida. Prior to her Doctorate, she served as a mental health counselor working in the agency, medical, legal, as well as high school settings.
Her research focuses on trauma work, including the experience of post-traumatic growth. Positive growth or post-traumatic growth is something that interests me, especially within the context of treating people with chronic pain or other chronic health conditions that we see in physical therapy or other physical medicine or rehabilitation settings.
You are going to learn a lot about this topic. Hopefully, you will embrace it as much as I have in both clinical practices and become very interested in the research. If you are interested in learning more about a trauma-informed approach to treating chronic pain, make sure to check out our course at the IntegrativePainScienceInstitute.com called Trauma-Informed Pain Care, where you will learn how to treat trauma from a trauma-informed perspective for people living with chronic pain. Without further ado, let’s begin and learn all about post-traumatic growth.
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We have a new topic that we are highlighting on the show. We are discussing resilience and growth after trauma, also known as post-traumatic growth, which is a theory that explains the positive human transformation that can occur after any type of physical trauma, psychological or emotional trauma, spiritual trauma, or even after struggling with a prolonged illness.
Joining us to discuss trauma and post-traumatic growth is Dr. Melissa Zeligman. She is an Assistant Professor of Counseling Education at the University of Central Florida. Prior to her Doctorate, she served as a mental health counselor working in the agency, medical, legal, as well as high school settings.
Her research focuses on trauma work, including the experience of post-traumatic growth. Positive growth or post-traumatic growth is something that interests me, especially within the context of treating people with chronic pain or other chronic health conditions that we see in physical therapy or other physical medicine or rehabilitation settings.
You are going to learn a lot about this topic. Hopefully, you will embrace it as much as I have in both clinical practices and become very interested in the research. If you are interested in learning more about a trauma-informed approach to treating chronic pain, make sure to check out our course at the IntegrativePainScienceInstitute.com called Trauma-Informed Pain Care, where you will learn how to treat trauma from a trauma-informed perspective for people living with chronic pain. Without further ado, let’s begin and learn all about post-traumatic growth.
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Growth After Trauma And Chronic Illness With Melissa Zeligman, PhD
Melissa, welcome to the show. It is great to have you here.
Thank you so much for having me. It is great to meet you.
I am excited to talk to you. This is a new topic that I have not covered on the show. Even when I think back to the almost 300 episodes that we did, people have mentioned the term post-traumatic growth, but we have not had an episode where we started to dissect what it is, how it relates to chronic health and chronic pain and the things that we should be aware of as licensed health professionals. A good place to start is to tell us what post-traumatic growth is and define it for us because I know you have done research on this.
I am glad that we are able to bring this topic. It sounds like it is time for it to be here. Most people are familiar when we talk about chronic illness or any form of trauma because, in order to talk about post-traumatic growth in this way, we have to conceptualize chronic illness in some ways as trauma. When people think about trauma, it is easy for them to think about post-traumatic stress disorder. That is a term that is used pretty commonly.
It is easy for us to think of some of those more negative symptoms that come out of living with a chronic illness or experiencing something that is highly stressful or a crisis even. Post-traumatic growth is looking at the other side of that. It is not that those stressful symptoms or negative symptoms are not present, but at the same time, there is this possibility for something more to come out of this experience.
Sometimes, people ask me, “How is that different from resilience?” I like to give the example that we all have a little bit of a status quo for our functioning. We all have where we are functioning, and if something stressful or traumatic happens later, we are able to get back to this place of functioning that we are at now. That would be resilience, but if we are able to move up, grow, and develop in some areas, that is post-traumatic growth. It is not that we are able to maintain during a crisis. It is we are able to move forward and grow in some areas following a crisis, which could be a chronic illness.
There is a lot of hope in this type of approach or construct.
Hope or optimism is something that can help people experience this sometimes.
Before we get to the growth part, people use the term trauma so often. Some people understand things like big T and little T, and people are becoming more aware of trauma-sensitive or trauma-informed. What type of traumas should help professionals be on the lookout for when they are evaluating their patients?
Maybe this is my personal bias, but I like to conceptualize trauma as more of a socio-cognitive model. From that lens, what we are saying is it is anything that shifts our worldview or our idea of what is fair. You could think about any kind of trauma. Think about somebody who has lived through a natural disaster, had an accident, or had some sort of abuse. Suddenly, their sense of what is just and right in the world has shifted.
That can certainly happen for somebody who has a new diagnosis of chronic illness or is living with long-term pain and trying to make sense of that. Suddenly, it might shift, and we think, “Good things happen to good people.” It turns a little bit of that on its head. From that model, we can start to see that if any time somebody has experienced that shift in worldview or had a violation of what their beliefs are about the world, we can start to conceptualize that as a form of trauma.
Worldview is a big part of this. You are going about life. You are a good person, going to work, raising your kids, and paying your taxes. You are doing all the things you should do, and then you experience something that causes a major shift in the way you view yourself in relation to the world.
That is an important piece. They are like, “How do I fit in here? What is my idea of what is right and just in the world, and where do I fit in there?” It can shift that and violate some of the ways that we have viewed the world.
Can you give us an example of a client or past patient in how you might have seen that occur in someone?
There is a lot of intersection here when we think about race, gender, and all of those pieces, but it is the piece that I said about the idea that good things happen to good people. We hear this all the time if we know somebody who has gone through a difficult life event. We are so quick to say, “Try to make sense of it and make meaning. There was a reason or a purpose for this.” It is our autopilot to want to make sense of things as people. It brings us comfort when something happens.
Some of this work grew out of my experience working with individuals who were living with HIV. To have a diagnosis like that and suddenly say, “This does not fit into these ideas that I had about the people who might get diagnosed with HIV.” I have to now shift to what I thought was true for not just myself but for everybody else, “What is the reason for this? How do I make sense of that quick instinct to say everything makes sense and things happen for a reason? What is the reason?”
Trying to make sense of something that sometimes takes a bit of navigating to try to make meaning can be exhausting. Certainly, many of my clients have gone through that process, specifically clients living with HIV. That process can help get to a place of growth, which is the beautiful part here and eventually can lead to post-traumatic growth.
The phrase that you said about everything happens for a reason. You hear people say that all the time. This makes us think about that and do it in a much different light. You have done research in this area and you teach at a university level. Was there something specific that brought you to this one? It is a niche topic that I do not think gets enough attention.
I was working with individuals living with HIV, and much of this work is around Post-Traumatic Growth or PTG. It started to take place with cancer survivors. As I was working with individuals who also were living with chronic illness in a different way, I started to hear stories of people saying, “I would not be substance-free. I would no longer be using or abusing substances at this point in my life if not for this HIV diagnosis.” I started to say, “There is some phenomenon going on here.”
I am very Pollyanna, but it is not the Pollyanna approach. It is not that people were grateful for chronic illness in their life, but they could also see that something came from this. I started to experience this phenomenon with clients and was curious to see what was going on. I started to see that there was something that Tedeschi and Calhoun had claimed as this post-traumatic growth that was happening, but it was primarily looking at cancer survivors. There is the piece that maybe makes HIV or diabetes different or some of these illnesses that also bring with it like stigma and shame. I started my research looking at post-traumatic growth and trying to understand how stigma or shame might fit into that picture as well.
In the research, I believe post-traumatic growth has 3 to 5 different aspects of it that you can test for with a certain tool. Maybe you can give us some of the more scientific evidence-based backgrounds about what defines post-traumatic growth if you are a clinician trying to measure this.
There is a post-traumatic growth inventory that can measure these things. We are measuring it on five domains. Some of those are relationships with others. If you think about the bulk of this work being with cancer survivors, it can be easy to conceptualize how somebody who maybe has gone through a cancer diagnosis or a series of treatments certainly faced some fears about what life would look like and how they talk about their relationships with others growing. They are like, “I am now closer to my family than I have ever been. I have a relationship with my children that I did not have before because of what I have gone through.”
Some of the other things would be new possibilities. It is not uncommon for individuals who go through a scare or treatments like cancer to say, “I am starting to second guess my career. Maybe I want to stop doing what I have done and do something that will make me happy for the rest of my life.” They think about their future in new ways.
Personal strength is another one. People who go through something like a chronic illness or cancer will start to say, “I did not know I had it in me to be this strong and to be able to get through this.” Spiritual change is a huge one, and we could have a whole episode talking about the way that spirituality plays into this. For better or for worse, people often find spiritual changes. They are turning to a higher power in a way that they did not use to or sometimes having a bit of stress or anger with the higher power.
The last one is an appreciation for life. If you have been diagnosed with cancer or living through a chronic illness, you have potentially had to think about your own mortality for the first time. Most people come away with a stronger appreciation for what they have in life. Those are the ways that the post-traumatic growth inventory measures growth. Certainly, those are the domains where we typically see people grow after that type of stress.
That makes me wonder. Do we have a way to identify who is more likely than others to enter into post-traumatic growth and who might not have the skills to cope with the trauma that has happened in their life? How can we help them facilitate that growth?
There are so many great outcomes that come from most post-traumatic growth that we would love to facilitate that in our clients. We do start to see some demographic differences. A big one is a gender. Women, in general, tend to experience PTG at greater rates, and a huge part of that is because one of the greatest predictors of PTG is support. Women tend to be better at identifying support, turning to others, and getting those needs met.
As clinicians, whether medical doctors or mental health professionals, one great way that we can help to support our clients and get to this growth is to provide that support. Whether it is support groups or having individual counseling, we should provide that space so that people can get that support for what they are going through. I mentioned spiritual growth. It is a huge piece of it, and that ties into the support as well. People who maybe have existing spiritual communities that they are able to turn to can be a huge gift in getting to that place.
How much is one’s ability to cognitively reappraise what happened? You mentioned resilience before that it is different than post-traumatic growth. The little research I have done on post-traumatic growth sounds like there is some type of reappraisal process that someone has to go through where they are not only reappraising their own thoughts but the world that they are functioning in.
It is huge. I am glad you bring that up. Sometimes, this part of it gets a little bit of a bad reputation because, at least in my world, in mental health, when we talk about things like rumination, it can be said as a negative thing. We do not want people to be ruminating on the events that happened. However, there is this reappraisal.
There is something healthy that can come from a little bit of healthy rumination. The big piece here is meaning-making. If you are able to ruminate on the event or this new diagnosis, we, as people, naturally want to make meaning. Whether we want to or not, oftentimes, we are going to find ourselves ruminating about these things just in an attempt to make meaning.
I get so nervous talking about this. I want to give the warning that it is not all rainbows and butterflies. Oftentimes, our response when somebody has gone through something painful is, “This was meant to happen.” Certainly, that is rarely a comforting thing to hear when you have gone through something painful or have been given a diagnosis that feels scary.
It is not that, “Thank goodness this happened in my life. Thank goodness I was given this diagnosis of chronic illness,” but also, we are like, “With that being here, how can I make sense of that in my own life?” The client that I gave the example of that said, “I would still be using substances if not for this HIV diagnosis,” is one example of, “Now that this is part of my life, how can I try to find some meaning that makes sense of living with this?”
That is interesting to think about. You mentioned rumination tends to be this negative thing. How do we, in essence, stop rumination?
How do we make it intentional? How can I have conversations? This is where support is so important. Not just having people in my life but having meaningful relationships where I am able to have these conversations and talk about what I am going through leads me to make sense of this new part of my life slowly.
It is a positive aspect of rumination.
It can be used in a healthy way.
You mentioned meaning, which I am sure people think about Man’s Search for Meaning. It is a pivotal book by Viktor Frankl.
In all my presentations, I am like, “If you have not read that, that is the only thing I need you to take away from here.”
The book leads all of us to think, “What is my search for meaning in life?” Whether I have had a trauma or have not had trauma, is it always healthy for people to search for the meaning, or does that come up through a process of working with therapists or support groups? Can that search for meaning become maladaptive?
The risk is that we try to ignore the pain or suffering that may also be tied to the meaning. If we think of somebody who maybe has a diagnosis, has been through a great loss, or another form of trauma, to say that this meaning takes away or excuses that pain can be potentially harmful. We want to ride that line of making sense of what you are going through and not saying, “This is the reason why you have been through this pain. Now, that pain is almost justified.” Those two things can coexist. We can try to make meaning of what we are going through and still be in a lot of pain and need a lot of protection, support, and comfort during that time.
Post-traumatic growth is a pretty linear relationship. It is called Post-Traumatic Growth. The T is in there, so we need to have some pain or trauma present to even have the growth, but if we get to an area where the pain, the trauma, or distress symptoms is so present and high, we are at a place where we are not able to get to a place of growth.
It is finding this balance of how we can eliminate some of that distress so that we are able to even grow. The first step when working with clients might not even be considering post-traumatic growth, but how do we work on eliminating some of those distress symptoms so that the person can even get to a place where growth is possible?
Over time, I can be actively working with my distress. At the same time, I am, in essence, searching for meaning in this greater event that has happened.
We often see it. When we do the research, we see both of those things coexisting at the exact same time with clients within a number of samples with chronic illness certainly included. Individuals are still reporting a lot of trauma or distress symptoms at the same time that they are reporting these growth symptoms.
You brought up a good point, which we should talk about a little bit. It is not that when someone first comes to a health professional, they are working on post-traumatic growth on the first visit. That is not necessarily the aim of what we are talking about here.
There are still plenty of opportunities. We all had a bad day or have gone through something stressful, and somebody says like, “This was meant to be.” If they are spiritual, they are like, “This was God’s plan.” All beautiful intentions behind them also can be invalidating. We are like, “The plan was for me to be in pain? That does not sound like a great plan at all.” How can we first give some of that support and validation and continue to give those so that the distress is lowered and somebody can get to growth? We do not need to go to that place immediately. We can start by acknowledging the pain somebody is in.
In the context of chronic pain, because chronic pain can be like other conditions, it can be a long-term and sometimes a lifelong condition. We have ways to reverse pain with some conditions completely, and for other people, we don’t. We are not quite there yet. How do we start to look at chronic pain? It may not be curable, but it is treatable. At the same time, it may be with you for a long time, and even within that, there is still growth happening. Even with what I said, there are so many moving different parts in that one sentence.
That is a lot of the next stages in the work that I am hoping to do. One of the things that I am exploring now is the idea of post-traumatic growth. The post is not always there. What we have seen is that growth is possible for individuals who may be active in interpersonal violence relationships and are still active in those relationships, and growth is still occurring.
We have certainly seen this with individuals who are in areas of war or conflict. The conflict is ongoing. There is no post anything. It is still an ongoing trauma, and the growth is still happening. This may be something that we are navigating or living with for life. What we can take from those examples is that even if the pain is going to be continuous, how can we continue to navigate that and have ongoing growth?
Present pain can still equate to positive growth.
Correct, even if we are actively in a place where there is pain or even trauma from trying to navigate this new situation.
It is a completely different paradigm than most of what is taught in healthcare.
What is wild is it is pretty different than what is taught in mental healthcare. It is typical for us that when we talk about trauma and counseling, we go straight to talking about post-traumatic stress disorder and maybe some of those symptoms of distress that individuals experience. My field is counseling, which is focused on wellness. The entire paradigm is how we talk about wellness. This shift is incorporating that so we can look at trauma and pain and acknowledge the wellness or the growth that comes out of that.
I know you have done some research in this area with regard to locus of control, which is a term that we use in pain a lot and help people access that. You mentioned counseling models and frameworks are based on wellness models and bringing that into the treatment or recovery process of someone.
When I will interview people or meet with individuals who are living with chronic illness for data collection, they are always pretty grateful that somebody is talking from this lens as opposed to someone saying to them, “Tell me all the things that have been difficult as a result of your chronic illness.” Some of the recommendations I do through my research are coming through treatment in a strengths-based approach. You speak about the locus of control, and some of these approaches naturally will allow individuals to take some of that power back. How empowering is that when we know that sometimes so much power is taken away without our consent with chronic illness?
Trauma itself is a power struggle.
It is to have a strengths-based approach for clinicians. One of the things I write about is a narrative therapy approach. Narrative therapy is an approach that can work with clients to empower them and take back some of that power that has been taken as a result of trauma or changes in your body that you did not ask for.
As a mental health professional, you have done some research in this area. You mentioned that they are not always trauma-sensitive approaches that are going on. How would you like to see that change so we can start to incorporate more of this post-traumatic growth or positive growth into treatment in recovery?
You hit the nail right on the head when you said this is not exactly how we typically are trained in healthcare, and that is the same within mental healthcare. Part of it is acknowledging that there is this other side to the coin. Trauma can also bring this with it, and those things exist simultaneously. We are not saying to take away any of the treatment approaches that we have been using for pain and trauma, but to also add in this piece of this other experience that clients might be going through. Bringing that to the forefront would be helpful.
Also, because we know that support and meaning are huge aspects of this, bring those into treatment and see how we can support clients. Are there support groups that we can open up? Knowing that meaning-making is so important, are there support groups that can be run with a counselor? Getting together for pizza and sharing experiences is great. I do not want to take away those, but can we also have some support groups or process groups that are sharing meaningful stories where people can share about what they are going through in ways that will help them make sense of this experience?
Trauma is oftentimes a part of life. People experience many different types of trauma. Some of them are even medical traumas, which are key to the chronic pain community as they encounter a medical system that is not prepared to treat them physically or emotionally. Do we have a sense that people can go through these phases and stages of post-traumatic growth even without the help of a licensed professional?
The keys there are going to be, are there other people in their life that are able to have these conversations with them? The tricky thing is that, in cases of trauma, those are some of the things that we see go. We may have these meaningful connections in our life. Family, significant others, and close friendships would be great, but if we are in pain and it is making us maybe isolate ourselves, we are not able to go out with our friends anymore, or we are feeling depressed. These are things that can sabotage relationships.
It is a difficult situation when the key to experiencing this without the potential intervention of a licensed professional would be to have strong support in place. This type of trauma is something that can mess with some of the support you have in place, so trying to maintain those supports in spite of the pain can be helpful.
I know you mentioned you are actively researching in this area, which is exciting because it is needed. Can you give us a sneak peek into some of the things that interest you that are on your horizon?
Something that is coming out soon will be this idea of spiritual bypass. Is this a term you are familiar with?
I am familiar with it, but please let us know more about it, so everyone understands.
I spoke about the influence that spirituality could have in healing or getting to a place of growth following trauma. I have an example from a client that I can share. It is a client living with HIV who said that they were not going to take their medication because it was a God-will-take-it-from-here type of situation.
They had a very strong faith to the point of asking God or a spiritual being to bypass and take over from here. In the literature, it says that this can be a problematic clinical approach. In counseling, we like to say, “You can’t go around it. You got to go through it.” Spiritual bypass is going right around it. It is something like, “We are not going to deal with this head-on. We are going to pretend this is not happening a little bit.”
It takes going through it out of the picture, which is not typically what we would recommend. What we are finding in the data set I have that we are hoping to send out to publication soon is looking at individuals with chronic illness. That spiritual bypass can help get to a place of growth because what it does is, for better or for worse, temporarily takes a bit of that pain away.
Would I say that this is an ideal long-term clinical solution? Probably not. There is some research coming out of spiritual bypass in general. Hopefully, with this data that we are presenting with spiritual bypass and individuals with chronic illness, it suggests that there might be something more here. Even if it is not the long-term solution, it can eliminate pain for a little bit in a way that can help people get to a place of growth.
Instead of a bypass, it is almost like a spiritual shortcut to post-traumatic growth.
It eliminates pain. What a stress release if it is like, “I do not have to deal with this. My higher power is going to take over from here. I can sit this one out for a minute.” It does eliminate distress quite quickly to get people to grow.
That is interesting. A long time ago, way back in this series, I did an episode on spirituality and pain. We talked a lot about how when you look at the research on treatments for chronic pain, most of them have minimal outcomes. The exercise was minimal. CBT and ACT were pretty minimal. Mindfulness was also minimal.
All were minimal, but when you get to spirituality, you start to see more moderate outcomes just with one intervention. I will say this lightly. If we think that God or whatever spiritual entity you connect with could come down and take our pain, we can’t prove that, but what is happening in that relationship between you and the belief is helping you cope with whatever the challenge is.
I imagine this is something you see in your field as well, but certainly, in mental health. We see that people are nervous to talk about spirituality with clients. We do not talk about these things on first dates, so we are not used to talking about them ever. We do not talk about them with clients. If it is a part of somebody’s identity and a strong piece of their identity in how they move through the world or how they cope, then we are doing a disservice to our clients or our patients by not talking about their spirituality. Something that we try to advocate for our counseling students is this is a part of somebody’s cultural identity. In order to be culturally competent, they need to be exploring their spirituality and see if that is an important part of their life.
The other side of that is punishment, which is a whole other topic or episode in and of itself. Spirituality is part of that post-traumatic growth. What is it about spirituality that can either help or potentially hinder someone’s PTG?
You talked about punishment. There is some data that we have with seeing a higher power as benevolent, kind, and forgiving. If you think about it in terms of chronic illness, it is like, “The higher power is the reason that I am suffering in this way. This is my punishment.” We see different relationships with post-traumatic growth based on the way that you view God or a higher power. If we know that somebody is turning into a higher power in a negative way or is using it as a harmful coping, how can we work with it and acknowledge that relationship so that it can go into a place that allows growth?
In the world of physical therapy, spirituality is still an untouched area that most professionals are not talking about. You mentioned that even starting to touch on it is useful to probably someone’s post-traumatic growth in some way. You can always refer people out to resources that may help them with those types of topics if you do not feel well versed.
We do not need to carry the burden of knowing the ins and outs of everybody’s spiritual relationships and all those things. If we find out that this is something important to somebody and maybe something that is also causing distress or they are having anger with God because of their illness or pain, we can refer them to a leader in their religious community who might be able to navigate that relationship with them.
Most of your research is interesting to all of us here on the show, so we want to be able to follow you and your work. I am sure people will start to go into Google Scholar and PubMed and start to look up some of your research. Tell us how we can follow the great work you have done.
That is the best way to find me. Type in Melissa Zeligman and find some publications on this. I teach at the University of Central Florida, so if you are looking at my name there, you will be able to find my vitae and see those publications that might be of interest.
I want to thank you for giving this great introduction to post-traumatic growth, chronic pain, and chronic disease. Make sure you share this episode with your friends and family on Facebook, LinkedIn, Twitter, Instagram, or where anyone is talking about post-traumatic growth. We’ll see you in the next episode. Take care.
Thanks.
Important Links
- Dr. Melissa Zeligman
- Trauma-Informed Pain Care
- Man’s Search for Meaning
- Demystifying The Role Of Spirituality In Pain Management – Previous episode
- Google Scholar – Dr. Melissa Zeligman
About Dr. Melissa Zeligman, PhD
Dr. Melissa Zeligman is an assistant professor of counselor education in the Department of Counselor Education and School Psychology at the University of Central Florida. Prior to completing her doctorate, Dr. Zeligman served as a mental health counselor, working in agency, medical, legal, and high school settings. Her research focuses on trauma work- including the experience of posttraumatic growth, the experiences of clients living with HIV/AIDS and other chronic illnesses, and clinical skill development for counselors-in-training.
