Abstract
BACKGROUND:
Trauma has high prevalence rates in populations of people with disabilities, and the effects of traumatic experiences can negatively impact employment.
OBJECTIVE:
The purpose of this article is to review the existing literature regarding post-traumatic growth (PTG), trauma informed care (TIC), and the conservation of resources (COR) theory.
METHOD:
We begin with an overview of PTG, TIC, and trauma in relation to disability and employment. Then, we review the personal, condition, object, and energy resources within the COR theory.
RESULTS:
The remainder of the article focuses on applying PTG and TIC in state-Federal VR programs with a theoretical framework defined by COR. We conceptualize the application in four major VR phases: (a) eligibility determination, (b) rehabilitation plan development, (c) service provision, and (d) job placement.
CONCLUSION:
By implementing TIC and considering the consumer’s resources, VR counselors can help emphasize PTG throughout the process and prioritize PTG as the ultimate goal. The authors provide brief and preliminary implementation recommendations for VR counselors.
Introduction
The purpose of this article is to examine the concepts of post-traumatic growth (PTG) and trauma-informed care (TIC) as they apply to vocational rehabilitation (VR) services and outcomes for Americans with disabilities. PTG and TIC have the potential to increase the quality and quantity of personal, object, condition, and energy resources that VR consumers have at their disposal and can bring to bear in pursuit of their desired career goals. Hobfull’s conservation of resources (COR) theory provides a useful framework for connecting PTG and TIC to the vocational interventions and career development tasks that are most effective in promoting long-term employment success for people with disabilities. Following a brief review of current literature regarding PTG and TIC, we introduce the COR theory as a multi-dimensional person-in-environment model that overlays well across the phases of the VR process (i.e., outreach, eligibility determination, assessment, case planning, counseling and guidance, health and mental health promotion, training, job development and placement, follow-up, and case closure) [1].
Post-traumatic growth
Understanding PTG
The collective awareness of psychological trauma flourished in the 19th century [2], centering on the development of different forms of trauma that resulted from political movements (e.g., wars and armed conflicts). This awareness evolved into action which manifested itself in a wealth of research and interventions geared toward understanding the negative consequences of trauma, along with how totreat it.
Much trauma treatment has the goal of survivors returning to their “baseline” (i.e., pre-trauma levels of functioning) [3]. However, scholarly and clinical attention to the phenomenon of individual growth in the aftermath of trauma is an alternate and relatively new perspective: this avenue was not systematically explored until the mid-1990 s [4]. The concept of PTG was the product of this systematic and collective effort, which defines this growth phenomenon as “positive psychological changes experienced as a result of the struggle with traumatic or highly challenging life circumstances” [5 p.3]. To understand PTG within an interdisciplinary context such as the one in which return to work, VR, and healthcare services are delivered to people with disabilities, we will review literature that provides ways to observe how, and under what circumstances, PTG might take place.
PTG and employment
PTG has been studied and theoretically applied in research to many different life domains, such as disability acquisition [6]; war trauma [7]; childbirth [8]; bereavement [9]; and certain types of employment/work experiences, such as military, police, emergency services, disasters/rescue work, and care providers who work with other people who have been traumatized [10]. In this latter life domain of employment, PTG is something that is borne from and can potentially buffer future, work-related trauma. Hence, PTG can be conceptualized as both a process and an outcome [11].
In this article, we endeavor to establish a new connection between PTG and employment, specifically, PTG as it facilitates employment success among people with disabilities, as explained by the COR theory. For this connection to be made, it is assumed that an individual with a disability has experienced some form of trauma, and they are working toward an employment goal. This situation is not uncommon in VR settings, although we do not mean to suggest that all people with disabilities necessarily experience trauma.
That said, disability, whether it be the acquisition of a condition or the lived experience of that condition, can certainly be traumatic. Many disability populations have been found to have experienced more trauma in the past than non-disabled people, have higher susceptibility to trauma, and be more impacted by its effects. Some of these disability populations include intellectual disability (ID) [12], psychiatric disability [13], chronic pain [14], and traumatic brain injury (TBI) [15]. Additionally, post-traumatic stress disorder (PTSD) is its own disability category that has received significant research and clinical attention in recent years. PTSD is also found to co-occur with many other disabilities [16].
Indeed, in a study cited by Barrow and colleagues [17], approximately 70% of adults in the United States have experienced at least one traumatic event in their lives. One out of five of these people will go on to develop PTSD. This is for the general population, and we remind readers that people with disabilities are disproportionately impacted by trauma. It is likely that any VR counselor or return to work (RTW) specialist will work with many individuals who have experienced some form of trauma, perhaps a form that is unresolved; and conditions will be ripe for PTG to take place.
There is no doubt that many traumatic events can significantly disrupt one’s ability to function and fulfill key life roles such as spouse/partner, parent, and worker. In the wake or aftermath of trauma, people may find themselves unable to focus; hypervigilant to certain stimuli; and experiencing many emotional, cognitive, and physical symptoms that interfere with job performance. Moreover, some people may experience negative employment events such as losing a job, being unable to continue work because of (traumatic) injury, promotion denials, and abuse at the hands of supervisors and/or coworkers as traumatic [10]. These events can certainly shake one’s core beliefs about their identity and cause distress and confusion. On the other hand, work-related trauma can facilitate new opportunities for PTG in the sense of new, broadened identities, deeper self-understanding, and a greater grasp of one’s strengths and independence [10, 11].
It is difficult to overstate the importance of sustained and meaningful work to a happy and healthy life. The loss of employment, which often accompanies the onset or exacerbation of a disability or chronic illness, is devastating for many individuals because they are robbed of the innumerable benefits that employment provides, including income, a sense of purpose, health benefits, and overall well-being. Other known benefits of successful employment include an increased appreciation for life, more meaningful social relationships, increased senses of resilience and personal control, and a richer existential and spiritual life [11]. These benefits render successful employment, an important end goal of the VR process, a powerful vehicle for PTG.
Conservation of resources theory
The COR theory is a stress and motivational framework that includes a dynamic process between individuals and settings to optimize the balance of resource costs and benefits in a way that helps them meet their personal and social goals [18]. The framework allows individuals to understand, predict, and examine this cost-benefit relationship, and then to shape the settings and environments they engage in as they pursue activities of their choice [18]. The COR theory’s essence is that individuals seek to enhance and protect resources in four categories – personal, condition, object, and energy – and that loss or the threat of loss in these resource categories increases stress and can be traumatic [19]. Individuals are naturally inclined to improve their resources and avoid (or effectively navigate) situations that reduce their resources [19]. By understanding stress or trauma as a result of the loss of resources, objective perspectives on when and why events are perceived as stressful and on the amount of stress created are provided [19–21]. COR theory further postulates that resources are critical for people to “conduct the regulation of the self, their operation of social relations, and how they organize, behave, and fit into the greater context of organizations and culture itself” [21, p. 228]. Resources are important because they allow individuals to achieve the primary motive of maintaining central values, and any disruption in the ability to create and preserve resources to achieve that motive is extremely stressful, indeed traumatic for some [19].
PTG, TIC, and COR
Promoting PTG has been described as a primary emphasis of the rehabilitation counseling process, and the state-Federal VR program provides a structured mechanism to promote PTG by helping people with disabilities build and conserve personal, condition, object, and energy resources. According to Hobfoll et al., [22] resource loss is disproportionately more salient than resource gain. Therefore, there is a need for VR counselors (VRCs) to help consumers identify, build, and conserve the types of resources delineated in the COR theory, all of which are highly valuable and necessary in obtaining and maintaining employment.
Personal resources
According to Hobfoll, personal resources are characteristics of the person (e.g., age, gender, racial/ethnic identity, educational level), psychological characteristics (e.g., self-esteem, self-efficacy), and health characteristics (e.g., severity, duration, type of illness symptoms) [19]. VRCs help consumers build personal resources such as self-efficacy, confidence, and a positive outlook by providing guidance and counseling focused on self-appraisal, skill identification, and goal achievement. VRCs can also refer consumers and financially support other types of training for key skills related to the vocational goal. VRCs also consider intersectionality among consumers’ personal resources, such as identity and cultural background, and systemic influences (e.g., racism, sexism, etc.).
Condition resources
Condition resources refer to life statuses and roles within social relationships that promote quality of life, independence, employment, and social support (e.g., spouse/partner, worker, specific occupation, parent, citizen) [19, 22]. VRCs can help consumers develop resources related to their roles as members of the labor force through direct service provision that includes career assessment, job placement, supported and customized employment, on-the-job supports, and job accommodations that result in obtaining and maintaining employment. The VRC can utilize guidance and counseling to help the consumer understand the benefits of maintaining employment (e.g., tenure, seniority) within their chosen career field to further the development and conservation of condition resources, and how successful employment may affect the other roles in consumers’ lives.
Object resources
Object resources are tangible elements in a person’s environment, such as housing and transportation, including the accessibility and adequacy of the objects [19]. VRCs can address object resources (e.g., a motor vehicle, tools for work) through services that can be specified in the Individualized Plan for Employment (IPE). Under specific circumstances, which are outlined in each state’s VR policy and procedures manual, these types of resources can be assessed and purchased using VR funds. The VRC may also know of other community sponsored referral programs that may be able to assist with object resources such as rent or mortgage subsidies, assistance with food security, and transportation vouchers.
Energy resources
Energy resources are tangible and intangible commodities, as in money, effort, and time, that can be exchanged for the acquisition and strengthening of resources in the other categories [19]. VR programs can provide information and make appropriate referrals to free or financially supported online classes, local job training opportunities, and courses at community colleges or other postsecondary institutions. Indeed, support for college training has long been documented as a cost-effective VR service that brings a high return on investment [23]. The VRC and/or RTW specialist may also conduct one-on-one counseling sessions to identify and plan for engagement with these types of resources.
Hobfoll et al., [22] suggested that the COR investment processes are deeply intertwined in complex systems of values and beliefs that provide meaning to the resources, and the consideration of resources should be viewed within the individual’s cultural context. Therefore, VRCs must consider the consumer’s cultural beliefs and values as they relate to resources and be mindful that the consumer may not assign the same meaning and value to these types of resources that the counselor does.
Trauma informed care
TIC intends to assist in coordinating the continuum of care and establishing collaborative processes that address the needs of consumers with traumatic experiences, rather than only providing trauma-specific services [24]. The main goal of TIC is to incorporate knowledge about the impacts of trauma into each phase of service delivery to provide individuals with safe and effective service environments [24].
Retraumatization has been increasingly recognized as a barrier to health and rehabilitation services and outcomes. Healthcare settings have found that inadvertent retraumatization is the leading cause of consumers leaving programs early [26]. Traumatic experiences can also transform an individual’s perception of service or helping relationships, due to the traditional hierarchical nature of these interactions being seen as anxiety-provoking or threatening [27]. Consumers are not typically aware of the connection between past trauma and current issues [28].A provider’s behaviors or word-selection could prompt a consumer’s posttraumatic reaction that may ultimately lead to exiting services. Without either party’s recognition or understanding, inadvertent retraumatization is nearly impossible to prevent or avoid. However, if VRCs utilize TIC with all consumers, there will be reduced risk of retraumatization even without requiring an in-depth understanding of an individual’s experience with trauma.
Infusing TIC into VR services is important due to the high prevalence and increased vulnerability of exposure to trauma in the disability community [25]. Further, researchers have found that employability of people with disabilities is associated with traumatic experiences, and high levels of trauma negatively affect the career development process [29]. Thus, by using TIC, VRCs can accurately conceptualize the impact of trauma [29], leading to more effective interventions throughout the VR process.
PTG is an outcome of growing interest among VR practitioners and researchers, COR principles provide a framework for conceptualizing VR services as important PTG experiences, and TIC is the delivery mechanism for VR services that provides the best opportunity for PTG and successful life outcomes after VR services have been completed. In the remainder of this article, we apply COR principles and TIC strategies to each sequential phase of the VR process, keeping the ultimate goals of PTG, competitive integrated employment, and high quality of life in mind.
Phases of the state-federal vocational rehabilitation program
To begin conceptualizing the application of PTG, COR, and TIC in state-Federal VR programs, the major phases of eligibility determination, rehabilitation plan development, service provision, and job placement are detailed in this section. Though states may differ in terminology and/or process, these four phases and terminology related to them will be understood and generally accepted acrossVR programs.
Eligibility determination
Individuals with disabilities begin the VR process by signing the state’s program application. This is usually completed at the end of the initial meeting and interview, in which the VRC discusses services and processes, then gathers specific, related information about the individual and their disability.
Once the application has been signed by the individual and the VRC, the individual is then considered an applicant for VR services and their eligibility determination must be completed within the next 60 calendar days. According to Ditchman et al., [30], the focus of VR services during the eligibility determination phase is on documenting diagnosis and functional limitations. Applicants receiving disability benefits such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) are presumed eligible for VR services. These benefits are considered to be sufficient evidence of the applicant’s need for support in order to achieve desired employment outcomes [30]. For all other applicants, the eligibility process encompasses two levels of assessment: a preliminary evaluation and a thorough diagnostic study [30].
Application to TIC, PTG, and COR
The eligibility phase explores the applicant’s current resources. Using TIC, the VRC can reduce risk of retraumatization during a lengthy interview that, at times, can feel intrusive. As the applicant and interviewer review current resources, limitations, and areas of need, PTG begins as a process. The report from the interview can be viewed as a product, and this product can be positively emphasized as the first step in VR and facilitating growth.
Rehabilitation plan development
Once the applicant has been determined eligible, based on the state’s VR criteria, the applicant is now considered a consumer (may also be referred to as client). The consumer is then moved to the IPE development phase. The IPE must be developed within 90 calendar days from the date of eligibility, unless the agency allows for and has an extension form signed by the consumer and VRC. Vocational planning can occur prior to or during the development of the IPE, which includes the VRC assisting the consumer in career exploration, development of vocational goals, and determining specific needed services. The IPE should clearly reflect the consumer’s interests, abilities, capabilities, and individualized needs.
Application to TIC, PTG, and COR
This phase will include not only exploring the consumer’s current resources, but also in which resource areas the consumer will need support. There is typically an emphasis on object (e.g., bus passes, assistive technology devices, etc.) and personal resources (e.g., self-advocacy skills, confidence, etc.) in the IPE. Similar to the previous phase, TIC should be utilized to reduce risk and increase feelings of safety, as the exploration of resources that the consumer may be lacking can be stressful and emotionally taxing. The PTG continues as a process in the planning phase. However, there may be situations when the consumer experiences considerable growth during the development of the IPE, and PTG occurs as an outcome in that event. With the exploration of resources and creation of a detailed plan, consumers may derive a sense of security and experience positive change from this process even though it occurs early in the VR sequence. Although the ultimate PTG outcome has yet to be realized, this growth is an important intermediate milestone.
Service provision
Immediately following the implementation of the IPE, the consumer moves into the service provision phase in the VR process. Services may include, but are not limited to, mental health treatment, physical or medical restoration, specific academic and vocational training, personal and vocational adjustment interventions, guidance and counseling, job accommodations and/or assistive technology assessments and services, job placement, and on-the-job supports [30]. Some services may be provided directly by the VRC (e.g., counseling and guidance), and others can be provided by other agencies or professionals [30]. There are no time limits or specific designations for service provision, and services specified in the IPE should be determined by individual needs. However, each IPE service should be provided in a timely manner consistent with the consumer’s goals and career interests.
Application to TIC, PTG, and COR
In this phase, VRCs and other service providers are focused on implementing new resources to meet the needs of the consumer. Whereas the development of an IPE centers on object and personal resources, the implementation of the plan and service provision emphasize condition resources (e.g., employment) as a goal and an outcome, resulting in energy resources (e.g., income). The trial-and-error nature of this phase can be unsettling for some consumers and has potential for retraumatization. Therefore, VRCs and other professionals must utilize TIC in all service provision. This again allows for reduced risk and increased feelings of safety for the consumer. Further, the VRC recognizes the potential for cyclical patterns in all contexts of this phase (e.g., job exploration, skill development, and trauma-reactions). As VRCs prepare for “triggering” experiences, a clear line of communication is built among the VRC, consumer, and other service providers. The TIC practice leads to PTG (as demonstrated by the Posttraumatic Growth at Work Model [10]). According to Maitlis [10], as the consumer recognizes triggering events that act as a set-back in growth, the consumer and VRC work together to find coping techniques to reduce the impact of triggering events and increase resiliency, eventually reducing risk of retraumatization during difficult situations.
Job placement
The IPE should indicate the specific provider who will provide job placement services, whether these are for a consumer who is starting their career or for one who is wishing to return to work or continue in the labor force. Once referred to that provider, the consumer enters the job placement phase in the VR process. The role of the job placement provider or RTW specialist is to help the consumer obtain and maintain employment in competitive, integrated settings that are consistent with the consumer’s abilities, capacities, interests, and informed choices [30]. During this phase, the provider should help consumers develop general and specific employability skills, as the behaviors and skills exemplified during this phase are helpful in predicting job maintenance behavior [30]. To augment individual services aimed at enhancing the consumer’s employability, the job placement provider or RTW specialist also develops employment opportunities with and on behalf of the consumer through direct contacts with employers, online employment opportunity sites, and the O*NET online system for labor market information [31].
Application to TIC, PTG, and COR
At this culminating point in the VR process, the VRC should ensure that the consumer’s resources and areas of need are being met or have plans for implementation, as detailed on the IPE goals and/or IPE updates/amendments. TIC continues to be utilized, regardless of the level of PTG that has been achieved. As previously discussed, consumers may not be fully aware of the impact of their previous traumatic experiences; VRCs can continually reduce risk and increase feelings of safety by being consistent with TIC, regardless of whether the consumer is directly manifesting the effects of trauma in any given interaction. Additionally, since there are risks of retraumatization as new situations occur, VRCs do not assume an “end-point” to the PTG process, even as the consumer draws nearer to successful case closure. Even though PTG is the ultimate desired outcome after job placement services have been discontinued and converted to job retention services for the duration of the consumer’s case, there is no endpoint or maximum level of improvement at which PTG stops becoming a long-term objective. Consumers will continue to adjust to new stressors or triggers, and VRCs provide tools and resources to prepare the consumer for the cyclical potentials in trauma, growth, and employment that may occur after the consumer exits from VR services.
Conclusion
With an increased awareness and understanding of trauma and the impact it has on many people with disabilities, VR programs can implement guidelines for counselors, other rehabilitation professionals, healthcare providers, and partners to work with consumers in a manner that is safer for consumers and more responsive to their needs to develop and conserve important resources that will guide them in their future career pursuits. By incorporating TIC and conceptualizing PTG as the ultimate outcome of rehabilitation counseling, there is potential to improve consumers’ long-term employment outcomes while helping them develop generalizable COR strategies that will aid them in managing stressful and traumatic experiences after VR services have concluded.
Because this article represents the first known combined application of TIC, PTG, and COR theory to the VR system, implementation recommendations suggested herein must be interpreted tentatively and developed more fully. After input from other VR professionals is gathered, the authors of this manuscript plan to create comprehensive and detailed guidelines for each of the VR phases to more fully inform employment acquisition and retention efforts with VR consumers.
Conflict of interest
The authors declare no conflicts of interest.
Ethical conduct of research and human subjects protection
N/A.
Informed consent
N/A.
Funding
The contents of this article were developed, in part, under a grant from the Vocational Rehabilitation Technical Assistance Center for Quality Employment, H264K200003, from the U.S. Department of Education. However, the contents do not necessarily represent the policy of the U.S. Department of Education, and readers should not assume endorsement by the Federal government. The preparation of this article was also partly funded by the U.S. Department of Labor and the Social Security Administration under a grant award of $21,600,000 to the Kentucky Office of Employment and Training that will be incrementally provided. 100% of grant funding is from U.S. Federal funds. Here again, this article does not necessarily reflect the views or policies of the U.S. Department of Labor or the Social Security Administration, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.