_______________________ Jacky Thomas, PhD, MSW, LCSW is an Associate Professor of Social Work at California State University, San Marcos, CA, 92096 . Blake Beecher, PhD, MSW, LCSW is Associate Professor and Social Work Program Director, also at California State University San Marcos. Copyright © 2018 Authors, Vol. 18 No. 4 (Fall 2018), 1113-1134, DOI: 10.18060/21589 This work is licensed under a Creative Commons Attribution 4.0 International License. What Doesn’t Kill You: Correlates of Resilience Among Master of Social Work Students Jacky T. Thomas Blake Beecher Abstract: The purpose of this exploratory study was to examine the relationship between adverse childhood experiences (ACEs) and resilience in a sample (n=139) of Masters of Social Work (MSW) students. Perceived stress, religious faith, experiential avoidance, and mindfulness were also examined as correlates of resilience. Resilience scores for the MSW students were comparable to general population and college student norms, but ACEs and perceived stress scores were higher. Despite a broad literature supporting associations of high ACE scores with varied measures of physical and psychological problems, this study paradoxically showed a positive relationship between higher ACE scores and resilience. Regression analysis indicated a model including age, ACE scores, experiential avoidance, religious faith, and perceived stress explained 39.2 % of the variance in resilience scores. Prior adverse childhood experiences and stronger religious faith are associated with increased resilience, while experiential avoidance and perceived stress are associated with lower resilience. This study provides further evidence that many students come to social work education with substantial trauma histories and experience considerable stress during their studies. Results suggest that social work educators should acknowledge risks associated with avoidant coping, and provide learning experiences aimed at developing students’ capacities for increased awareness and acceptance of challenging experiences— their own and others. Keywords: Resilience, Adverse Childhood Experiences (ACEs), experiential avoidance, MSW students The concept of resilience, defined generally as the experience of having relatively good outcomes in the face of adversity (Rutter, 2007), has received considerable attention in the research literature. In light of greater understanding of the substantial risks involved in providing services to persons who are suffering or traumatized, researchers more recently have attempted to investigate resilience among helping professionals and trainees. In the social work profession particularly, work-associated stress is high, with burnout, vicarious trauma, and compassion fatigue taking a significant toll on individual workers, on the clients they serve, and on the stability of the professional workforce (Bride & Figley, 2007; Grant & Kinman, 2012). Social work students also experience high levels of stress in both coursework and field placements (Carello & Butler, 2015; Grant & Kinman, 2012), but are often hesitant to speak about their stress to instructors and supervisors (Grant & Kinman, 2012). Additionally, the experience of prior trauma is fairly consistently considered a risk factor for the development of stress-related disorders among helping professionals (Zosky, 2013), and many, if not most, students in clinical training programs have experienced trauma (Carello & Butler, 2015, p. 263). Several studies have indicated https://creativecommons.org/licenses/by/4.0/ Thomas & Beecher/WHAT DOESN’T KILL YOU 1114 that many social workers come to the profession with a personal history of adverse childhood experiences, and that those trauma histories may, in fact, have motivated them to enter the profession (Grant, 2014; Rompf & Royse, 1994). With increasing awareness of the stressors faced by social work professionals and students, educators and researchers have begun to examine ways that resilience can be developed and enhanced during training. This study explored the associations between adverse childhood experiences and resilience, and also examined relationships between resilience and perceived stress, religious faith, experiential avoidance, and mindfulness among a sample of MSW students. Literature Review Resilience We know that trauma does not invariably result in bad outcomes (DuMont, Widom, & Czaja, 2007; Yehuda & Flory, 2007); rather, there is great variability in responses to traumatic events (Rutter, 2013). About half of those who experience childhood physical or sexual abuse, for example, show positive psychosocial functioning in adulthood (Rutter, 2007). What makes one person able to endure significant adversity and survive, even grow, while another can experience the same event and suffer chronic, debilitating effects? Is it possible for individuals and organizations to develop strategies which contribute to resilient responses to adversity? The idea that people can thrive despite challenges, and that the capacity to do so can be developed or enhanced, is congruent with the strengths-based, person-in-environment focus of social work, and with the Recovery Model of mental health practice (Atkinson, Martin, & Rankin, 2009). Resilience has been defined as “a dynamic process encompassing positive adaptation within the context of significant adversity” (Luthar, Cicchetti, & Becker, 2000, p. 543). Rutter (2007) described it as “the phenomenon that some individuals have a relatively good outcome despite suffering risk experiences that would be expected to bring about serious sequelae” (p. 205). Richardson’s (2002) model of resilience suggested that stressors or traumas challenge bio-psycho-spiritual homeostasis, resulting in disruptions in that homeostasis (depending on the interaction between stressors and existing protective factors). The individual’s worldview is then changed, requiring a reintegration of the new experiences. The result may be: resilient reintegration (posttraumatic growth), implying growth from the original homeostatic state; reintegration back to the original state, in which people just get through the crisis and back to their homeostatic state (but without growth); reintegration with loss, meaning that some motivation, hope or drive is lost as a result of the stressor; or dysfunctional reintegration, when people resort to various destructive behaviors to deal with the experience (Richardson, 2002). Viewed as successful stress coping (Connor & Davidson, 2003), resilience is not a collection of personality traits, but a biopsychosocial process which can only be developed in the presence of adversity (Rutter, 2007). Resilience occurs in a complex ecological context (Greene, 2008) and involves reciprocal interactions between a person experiencing stress and his or her environments. It involves an intricate interplay of genetics and ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1115 environment, coping styles, and mental processes, and may depend on experiences that occur subsequent to risk exposure (Rutter, 2006, 2007). In short, what people do in response to the challenges they face matters (Rutter, 2007). Various authors argue that within clinical training programs, including social work, more attention should be paid to developing intrapersonal, interpersonal, and organizational capacities that contribute to a more resilient and sustainable professional workforce (Grant & Kinman, 2012; Howard et al., 2015). Yet, information is limited regarding the types of experiences that contribute to resilient responses. According to Rutter (2013), stable and positive social relationships, social role satisfaction, and a sense of community all had positive associations with resilience. Particular emphasis was placed on “inoculation”, “steeling”, or “turning-point” experiences which involve exposure to manageable stressors and opportunities for successful coping, intentional self-reflection, and a sense of personal agency (Rutter, 2007, 2013). Kinman and Grant (2011) found trainee social workers who showed greater emotional intelligence, reflective ability, social confidence, and aspects of empathy were more resilient to stress. Wilks (2008) studied a sample of undergraduate and graduate social work students and found that social support was positively associated with resilience, and that social support from friends, specifically, moderated the negative relationship between academic stress and resilience. Kapoulitsas and Corcoran’s (2014) qualitative study indicated the complexity of various personal and organizational processes in the development of practitioner resilience, including the importance of supportive supervision and training and the development of professional wellness. Although this current study does not examine social support or organizational/structural variables related to resilience, we wish to explicitly acknowledge the importance of these considerations. We agree with Grant and Kinman (2014) who caution against attempting simply to enhance the ability of clinicians to cope with difficult circumstances without also making needed institutional and structural changes in resources and organizational culture (p. 12). Adverse Childhood Experiences The Adverse Childhood Experiences (ACEs) Study, a large prospective epidemiological study conducted in 1994 by the U.S. Centers for Disease Control and Kaiser Permanente Health Network, examined rates of childhood adverse experiences among over 17,000 Health Maintenance Organization participants coming in for routine wellness checks (Anda et al., 2006). The participants reported on 10 categories of adverse experiences occurring before age 18, including physical, emotional, and sexual abuse, emotional and physical neglect, domestic violence, parental separation or divorce, and mental illness, substance abuse, or incarceration of household members. The study found that most respondents had experienced at least one adverse event, and 12.5% had experienced four or more (Anda et al., 2006). Rates of childhood adverse experiences were strongly correlated with a remarkable variety of negative health and social outcomes in later life, including obesity, heart disease, anxiety, depression, substance abuse and interpersonal violence (Anda et al., 2006; Dube, Williamson, Thompson, Felitti, & Anda, 2004). ACEs can cause neurodevelopmental injuries and deficits (Anda et al., 2006; Thomas & Beecher/WHAT DOESN’T KILL YOU 1116 Nurius, Green, Logan-Greene, & Borjaa, 2015), which then result in an increase in risk behaviors used to cope with trauma reactions, ultimately compromising healthy future adaptation. The original ACE study has been replicated in various populations, and findings are beginning to shift our understanding of trauma and the multiple and cascading consequences of early adverse events (Center for Youth Wellness, 2013; Centers for Disease Control and Prevention, 2010). Efforts are increasing to incorporate the implications of the ACE study (and consequent trauma-informed practices) into organizations, policies, and provider networks (Larkin, Shields, & Anda, 2012). Researchers are beginning to examine adverse childhood experiences not just in clinical populations, but also among helping professionals, including social workers and social work students (Thomas, 2016). Esaki and Larkin (2013) looked at adverse childhood experiences among social workers employed at a residential child service agency serving traumatized children, and found much higher ACE scores than those reported in the original ACE study. For example, 27.6% of the child service workers had ACE scores of 4 or more, compared with only 12.5% in the general population sample. Howard and colleagues (2015), in a study of 192 social workers providing services to children in foster care, examined the relationship between professional quality of life, adverse childhood experiences, resilience, and work environment. This study again showed higher rates of ACEs among these workers than in the general population (25.1% vs. 12.5% with ACE scores of 4 or more). However, contrary to expectations, higher ACE scores predicted greater compassion, satisfaction, and reduced risk for burnout (Howard et al., 2015). Several other studies have examined trauma histories among social work students, though few have used the exact criteria from the Adverse Childhood Experiences Study. Black, Jeffreys, and Hartley (1993) found that MSW students reported a significantly higher frequency of family trauma than did the comparison group of MBA students, and Rompf and Royse (1994) found that social work students reported significantly more marital discord, familial emotional problems, and alcohol or drug addiction in their families of origin than did a comparison group of students in English classes. Dykes (2011) reported 73% of social work students in her sample had experienced adverse childhood experiences. Additional Variables Perceived Stress. Stress occurs when the resources of an individual are insufficient to manage existing demands (Lazarus & Folkman, 1984). The prevalence of stress is increasing among college students, and the perception of stress influences adjustment to academic life and academic success (Friedlander, Reid, Shupak, & Cribbie, 2007; Robotham & Julian, 2006). Relatively high levels of perceived stress are found among graduate students in general, and MSW students in particular (Addonizio, 2011; Collins, Coffey, & Morris, 2010). Graduate students participate in the full complement of adult life stressors, including financial and employment worries, relationship conflicts, and family and health concerns. Additionally, Grant and Kinman (2012) suggest that social work students may face stressors beyond those faced by other graduate students because of the complex and http://www.tandfonline.com.ezproxy.csusm.edu/doi/full/10.1080/03098770600617513?src=recsys ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1117 emotionally demanding content within the curriculum and field placements, and also may be more reluctant to disclose their stress and seek assistance. Previous studies have shown significant associations between perceived stress and resilience in college student and general adult populations (Abdollahi, Talib, Yaacob, & Ismail, 2014; Abolghasemia & Varaniyaba, 2010; Moore et al., 2015; Mroz, 2015; Seyedfatemia, Pourafzalb, Inanlooc, & Haghani, 2015; Willis & Burnette, 2016). Religious Faith. According to Canda, Nakashima and Furman (2004), the majority of social work students, faculty, and practitioners see religious faith and spirituality as important to themselves and their clients. Religion is defined as “an organized, structured set of beliefs and practices shared by a community related to spirituality” (p. 28), while spirituality is broader and reflects a search for meaning and purpose in life and a morally fulfilling connection to self and others (Canda et al., 2004). Religious faith is increasingly associated with a variety of health benefits (Plante, Vallaeys, Sherman, & Wallston, 2002), including hardiness and self-esteem (Kamya, 2000), lowered depression in older adults (Koenig, George, & Peterson, 1998), and resilience among persons in substance abuse recovery (Pardini, Plante, Sherman, & Stump, 2000). Religious faith and spirituality may buffer the impact of stress in both MSW (Lee, 2007) and psychology students (Brown, 2012) and has been positively correlated with resilience (Eriksson & Yeh, 2012; Javanmard, 2013). Experiential Avoidance. Traumatic states can be perpetuated by maladaptive coping strategies which, though aimed at protecting the self, actually keep the traumatized person stuck in negative patterns of thinking and behaving leading to problems in flexible and adaptive self-regulation (Wells & Sembi, 2004). These coping strategies include vigilant attention to threat, worry and ruminative thinking, and attempts to suppress or avoid thoughts and reminders of the trauma. The latter strategy, experiential avoidance, is especially relevant in examining vulnerable or resilient responses to trauma. Experiential avoidance is described as an unwillingness to experience thoughts, memories, emotions, and bodily sensations, even when doing so interferes with quality of life (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Experiential avoidance reduces psychological flexibility (Boulanger, Hayes, & Pistorello, 2009) and is associated with lowered functioning in both clinical and non-clinical populations and a broad range of psychological and behavioral problems, including depression, anxiety, substance abuse, and post-traumatic stress disorder (PTSD) symptoms (Boulanger et al., 2009; Thompson, Arnkoff, & Glass, 2011). Bond and colleagues (2011) similarly found that greater experiential avoidance is associated with increased symptoms of anxiety, stress, depression, thought suppression and psychological distress, and suggest that it may increase risk for mental health problems. Campbell-Sills, Cohan, and Stein (2006) found associations between experiential avoidance and lowered resilience, and Boulanger and colleagues (2009) cite several longitudinal studies examining the predictive power of experiential avoidance for later development of psychopathology and argue that strategies of avoidance may prevent healthy resolution of traumatic experience and predict disordered responses such as PTSD. Thomas & Beecher/WHAT DOESN’T KILL YOU 1118 Mindfulness. Mindfulness is most commonly defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994, p. 4) and involves an ability to pay attention to what is occurring in the present moment, in which the person is able to simply observe what is taking place, without filtering events through cognitive appraisals, evaluations, memories, beliefs, etc. (Brown & Ryan, 2003). Mindfulness is associated with greater psychological adjustment following trauma (Thompson et al., 2011), improved academic performance (Shapiro, Brown, & Astin, 2008), and increased resilience among social work students (Roulston, Montgomery, Campbell, & Davidson, 2017) and professional social workers (Crowder & Sears, 2017; Kemper, Mo, & Khayat, 2015). Mindfulness has also been linked to improved stress coping, decreased rates of burnout, and greater compassion satisfaction among healthcare workers, physicians, and social workers (Galantino, Vaime, Maguire, Szapary, & Farrar, 2005; Krasner et al., 2009; Thomas, 2013). Current Study Many MSW students come into their training with histories of adverse experiences, and then encounter additional stressors as they complete academic and field education. Resilience is not fixed and static, and may be influenced by experiences both prior to and following stressful events. Given this, it is important that social work educators understand factors associated with resilience in order to do the best job possible in preparing students for sustainable careers. Resilience can be learned, and social work education should place explicit focus on ways to better develop resilient practitioners (Beddoe, Davys, & Adamson, 2013). We know that the meaning people make of their experiences can be critical in how they cope with traumatic and stressful events (Calhoun & Tedeschi, 2013). There is evidence that the ability to acknowledge and reflect on experiences is important to meaning-making, and is an important factor in the development of resilience (Rutter, 2013; Kinman & Grant, 2011). This study examined relationships between resilience and several factors which may influence how MSW students cope with, interpret, and ultimately respond to challenges they have experienced or are currently experiencing. Based on the review of the literature cited above, we hypothesized the following: 1) ACE scores for this sample of MSW students would be higher than those reported in general population and college samples described earlier; 2) Higher ACE scores would be associated with lower resilience scores; 3) Higher perceived stress scores would be associated with lower resilience scores; 4) Higher scores on religious faith would be associated with higher resilience scores; 5) Higher experiential avoidance scores would be associated with lower resilience scores; and 6) Higher mindfulness scores would be associated with higher resilience scores. ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1119 Method Sample and Procedures This study used cross-sectional data to explore the relationship of resilience with adverse childhood experiences, perceived stress, religious faith, experiential avoidance, and mindfulness in a convenience sample of 139 Master of Social Work (MSW) students at a regional university in the western United States. After receiving approval from the University Institutional Review Board, anonymous surveys consisting of demographic questions and 6 established scales measuring resilience, adverse childhood experiences, perceived stress, religious faith, experiential avoidance, and mindfulness were distributed to MSW student volunteers in 2015. One hundred and thirty-nine students (93.2%) chose to complete the cross-sectional survey. An analysis of the ACE prevalence data with a portion of this sample was previously reported (Thomas, 2016). Participants were drawn from both 2-year and 3-year MSW cohorts, and were concurrently completing internships in community field placements for 16-20 hours per week. Students were offered a $5 gift card for participation, and were provided with informed consent documents regarding procedures to protect confidentiality and assurances that there would be no consequences if they chose not to participate. The final sample consisted of 139 MSW students (see Table 1). Eighty-one percent of students were younger than 35, and about 82% were female. Less than half were White/Caucasian/European and 32% were Hispanic/Latino, with other categories making up the other 23%. Table 1. Demographics of Participants (n=139) Characteristics n % Gender (n=138) Female 113 81.9% Male 25 18.1% Race/Ethnicity (n=138) Alaskan Native/America Indian/First nation 3 2.2% Asian/Asian American/Pacific Islander 16 11.6% Black/African American 7 5.1% Hispanic/Latino 45 32.6% White/Caucasian/European 62 44.9% Other/Mixed 5 3.6% Age (n=139) <25 35 25.2% 25-34 78 56.1% 35-44 19 13.7% 45-54 5 3.6% >54 2 1.4% Thomas & Beecher/WHAT DOESN’T KILL YOU 1120 Survey Instrument The survey instrument consisted of 13 demographic questions; 6 established scales measuring resilience, adverse childhood experiences, perceived stress, religious faith, experiential avoidance, and mindfulness; and questions related to career motivation and coping (not addressed in the present article). Resilience is considered the primary outcome variable in this study. Scores for ACEs, perceived stress, religious faith, experiential avoidance, and mindfulness are included as correlates. See Table 2 below for scale properties. Resilience. The Connor-Davidson-Resilience Scale, CD-RISC 25 (Connor & Davidson, 2003) was used to measure resilience. The CD-RISC contains 25 items rated on a 5-point Likert scale from 0 to 4, with a total summed score range of 0 to 100 with higher scores indicating greater resilience. The scale has been translated into many different languages and studied in a variety of populations, with multiple studies demonstrating validity and reliability of the measure (CD-RISC, n.d.). Cronbach’s Alpha in this study was α = .88. Correlates. Five variables are included as potentially relevant correlates to resilience. These include ACEs, perceived stress, religious faith, experiential avoidance, and mindfulness. ACEs. The Adverse Childhood Experiences (ACEs) questionnaire (Felitti et al., 1998) consists of 10 items inquiring about physical, emotional, and sexual abuse; emotional and physical neglect; domestic violence; parental separation or divorce; and mental illness, substance abuse, or incarceration of household members. The measure has been validated in subsequent studies (Dube et al., 2004; Esaki & Larkin, 2013). One point is assigned for each category of adverse experience endorsed, with a range of total scores between 0 and 10. Cronbach’s Alpha in this study was α = .77. Perceived stress. The Cohen Perceived Stress Scale 10 (PSS-10) measures “the degree to which individuals appraise situations in their lives as stressful” (Cohen, Kamarck, & Mermelstein, 1983, p. 385). The PSS demonstrated adequate reliability and correlated with life-event scores, depressive and physical symptomatology, utilization of health services, social anxiety, and smoking-reduction maintenance (Cohen et al., 1983). The measure uses a 5-point Likert scale ranging from 0-4, with several reverse-scored items. Total scores range from 0-40, with higher scores indicating greater perceived stress. Cronbach’s Alpha in this study was α = .86. Religious faith. The Brief Santa Clara Strength of Religious Faith Questionnaire (BSCSRFQ, Plante et al., 2002) is a 5-item scale measuring religious belief and involvement, strongly correlated with the longer 10-item scale found to be reliable and valid (Plante et al., 2002). The scale uses a 4-point Likert scale with total scores ranging from 5-20. Higher scores indicate greater strength of religious faith. Cronbach’s Alpha in this study was α = .95. Experiential avoidance. The Acceptance and Action Questionnaire II (AAQ II) is a 7- item scale measuring psychological inflexibility, or experiential avoidance, which is an important predictor of psychological distress and behavioral ineffectiveness (Bond et al., http://www.sciencedirect.com/science/article/pii/S1976131712000527#bib6 http://www.sciencedirect.com/science/article/pii/S1976131712000527#bib6 ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1121 2011). The AAQ II uses a 7-point Likert scale with total scores ranging from 7-49. Higher scores indicate greater psychological inflexibility or experiential avoidance. Cronbach’s Alpha in this study was α = .91. Mindfulness. The Mindful Attention Awareness Scale (MAAS) is a 15-item scale designed to assess individual differences in the frequency of mindful states over time (Brown & Ryan, 2003). The scale has been shown to have excellent psychometric properties. It uses a 6-point Likert scale with scores ranging from 1 to 6. A mean score is calculated, thus total scores range from 1-6 with higher scores indicating greater mindfulness. Cronbach’s Alpha in this study was α = .89. Table 2. Scale Properties Scale* Number of items Possible Range of scores α (in current study) Mean SD CD-RISC 25 25 0-100 0.88 77.46 9.88 ACEs 10 0-10 0.77 3.04 2.51 PSS-10 10 0-40 0.86 18.29 6.19 BSCSRFQ 5 5-20 0.95 12.01 5.96 AAQII 7 7-49 0.91 19.02 8.47 MAAS 15 1-6** 0.89 3.99 0.89 *Resilience (CD-RISC 25), ACEs, Perceived Stress (PSS-10), Religious Faith (BSCSRFQ); Experiential Avoidance (AAQ II), and Mindfulness (MAAS) **mean score Data Analysis Variables were examined for normality, homogeneity of variance, and linearity. Skew and kurtosis statistics indicated that data were normally distributed and examination of tolerance and variance inflation factors indicated no problems with collinearity for study variables included in the regression analysis. Descriptive statistics, bivariate correlations, t tests, analysis of variance tests, and multiple linear regression were used to examine the data. Results Comparisons with Previously Normed Scores Mean scores for MSW student participants in this study were similar to previously normed scores (or to comparison scores in studies examining similar populations) for all variables except ACEs and perceived stress (see Table 3). Prevalence of ACEs Almost 38% of the MSW students in this study reported 4 or more ACEs. Only one- fifth reported no adverse childhood experiences (see Table 4). The most frequently cited ACEs were emotional abuse (46%), parental divorce/separation (43.9%), and substance abuse by a household member (41%). More than a third of participants (36.7%) reported emotional neglect, and 32.4% of participants reported mental illness in their families. Thomas & Beecher/WHAT DOESN’T KILL YOU 1122 Almost one-fourth reported a history of childhood sexual abuse. Table 5 indicates the percentage of students endorsing each of the adverse experience categories included in the ACE study. Table 3. Resilience, ACE, Perceived Stress, Religious Faith, Experiential Avoidance, and Mindfulness Scores and Comparisons Scale Mean (SD) Notes on Population or scale Source of Comparison Score Current Study Comparison Scores Resilience (CD- RISC 25) 77.46 (9.88) 80.4 (12.8) 72.9 (13.5) US gen pop College students CDRISC Users’ Guide (n.d.) ACEs 3.04 (2.51) 2.18 (2.13) human services providers Howard et al., 2015 Perceived Stress (PSS-10) 18.29 (6.19) 13 considered average; 20 > considered high stress Cohen et al., 1983 Religious Faith (BSCSRFQ) 12.01 (5.96) 13.56 (4.46) Plante et al., 2002 Experiential Avoidance (AAQII) 19.02 (8.47) 18.51 (7.05) 28.3 (9.9) Non clinical pop Clinical pop Bond et al., 2011 Mindfulness (MAAS) 3.99 (0.89) 4.20 (0.69) 3.83 (0.70) Community adults (4 samples) College students (14 independent samples) Brown & Ryan, 2003 Table 4. ACE Scores (n=139) Number of ACES n % Cumulative % None 29 20.9 20.9 One 20 14.4 35.3 Two 19 13.7 49.0 Three 17 12.2 61.2 Four 9 6.5 67.7 Five 13 9.4 77.1 Six 16 11.5 88.6 Seven 7 5 93.6 Eight 4 2.9 96.5 Nine 3 2.2 98.7 Ten 0 0 98.7 Missing 2 1.3 100.0 Table 5. Number and Percentage of Students Endorsing Each Item (n=139) ACE Category n % Physical Abuse 50 36.0 Emotional Abuse 64 46.0 Sexual Abuse 33 23.7 Physical Neglect 17 12.2 Emotional Neglect 51 36.7 Household Mental Illness 45 32.4 Family Violence 26 18.7 Parental Divorce/Separation 61 43.9 Household Member Incarceration 17 12.2 Household Substance Abuse 57 41.0 ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1123 Bivariate Correlations Table 6 presents zero-order correlation coefficients for all continuous variables. Resilience was moderately correlated with perceived stress, experiential avoidance, and mindfulness (all at the p<.001 level) and weakly correlated with ACEs and religious faith (p<.05). Additionally, perceived stress was moderately correlated with experiential avoidance (p<.001) and mindfulness (p<.001). Experiential avoidance was also correlated with mindfulness (p<.001) and ACEs (p<.05). Table 6. Correlations among Predictor Variables and Resilience Variable 1. 2. 3. 4. 5. 6. 1. Resilience 1 2. ACE .180* 1 3. Stress -.471*** -021 1 4. Religious faith .213* .068 -.032 1 5. Exp. Avoidance -.471*** .173* .595*** -.471*** 1 6. Mindfulness .337*** .055 -.463*** .098 -.482*** 1 *p<.05; **p<.01; ***p<.001 Analysis of Variance and T-tests For descriptive purposes, analysis of variance and t-tests were included to examine any influence of demographic variables of age, race/ethnicity, and gender on study variables. One-way analysis of variance (ANOVA) tests were used to examine four different age categories (<25, 25-34, 35-44, and 45+) in relation to other variables. For the purposes of this test, the 45-54 and > 54 age categories were combined because there were too few cases in the >54 category. ANOVA testing showed that the effect of different age categories was not significant in predicting ACE scores, religious faith, experiential avoidance, resilience, or mindfulness. Age was a significant predictor of perceived stress, F(3, 132) = 3.233, p<.05, with younger students reporting higher levels of stress than older students. Fisher’s Least Significant Difference (LSD) post-hoc tests indicated students in the age category <25 (M=18.94, SD=5.96) and 25-34 (M=19.03, SD=5.79) had significantly higher mean total perceived stress scores (p<.05) than students in the category 35-44 (M =15.50, SD 6.71) or 45+ (M =13.71, SD=5.44). ANOVA testing was also used to look at the four different race/ethnicity categories in relation to other variables in the study. The “Alaskan Native/American Indian/ First Nations” category (n=3) was combined with the “Other/Mixed” category (n=5) for statistical analysis. None of these tests were significant. Independent samples t-tests were conducted to compare male and female responses to all continuous variables. No significant differences were found based on gender. Regression Analysis A three step hierarchical multiple regression was conducted with resilience as the dependent variable (see Table 7). Age was entered at step one of the analysis, given the Thomas & Beecher/WHAT DOESN’T KILL YOU 1124 ANOVA results suggesting age was the only demographic variable significantly related to any of the other correlates. ACE scores were then entered at step two, based on the hypothesized relationship between ACE scores and resilience. The remaining variables, perceived stress, religious faith, experiential avoidance, and mindfulness were entered at step 3. Step 1, containing age only, explained only about 3% of the variance, F(5, 124) = 3.900 p = .050). The model for Step 1 was just short of reaching the p<.05 significance level, with an R2 ∆ of .03. Step 2 added ACE scores; that model was significant, F(2, 123)=3.413, p<.05, with an R2 ∆ of .022 (p<.05). The total model (age and ACEs) explained about 5.3% of the variance in resilience scores. Step 3 added the four additional correlates of perceived stress, religious faith, experiential avoidance, and mindfulness. This final model was significant, F(6, 119) = 12.781, p<.001, and explained over 39% of the variance in resilience scores, with an R2 ∆ of .339 (p<.001). All of the variables in the final model except age and mindfulness made significant individual contribution to the model predicting resilience, including ACEs (β = .204, p<.01); perceived stress (β = -.229, p<.05); religious faith (β = .203, p<.01); and experiential avoidance (β = -.349, p<.001). Religious faith was positively associated with resilience, and both perceived stress and experiential avoidance were negatively associated with resilience. Contrary to expectations, however, ACEs were associated with greater resilience and mindfulness was not significantly associated with resilience at all. Table 7. Hierarchical Regression Predicting Resilience Variable Model 1 Model 2 Model 3 B SE B β B SE B β B SE B β Age 2.143 1.085 .175 1.805 1.095 1.47 .336 .917 .027 ACEs .594 .351 .151 .802 .293 .204** Perceived stress -.365 .149 -.229* Religious faith .337 .119 .203** Exp. Avoid. -.407 .110 -.349*** Mindfulness .816 .926 .074 R2 .030 .053 .392 R2 change .030 .022* .339*** *p<.05; **p<.01; ***p<.001 Discussion The results of this study support several of the hypotheses (1, 3, 4, and 5) regarding the prevalence of adverse childhood experiences among MSW students, and the associations of perceived stress, religious faith, and experiential avoidance with resilience. However, hypothesis 2, indicating that higher ACE scores would be associated with lower resilience scores, and hypothesis 6, suggesting that higher mindfulness scores would be associated with greater resilience, were not supported. ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1125 Prevalence of ACEs and Comparisons with Previously Normed Scores Reported rates of ACEs were much higher among this sample of MSW students than those reported in previous studies, supporting Hypothesis1. Most studies using the ACEs questionnaire have not reported a mean score, but rather have commonly listed the percentage of participants with various total scores, often using scores of “4 or more” for comparison. Almost thirty-eight percent of the MSW students in the current study had ACE scores of 4 or more, compared to 12.5 % in a general population sample (Felitti et al., 1998); 12.4% in a university student sample (McGavock & Spratt, 2014); 27.6% with child care workers (Esaki & Larkin, 2013); and 25.1% with foster care workers (Howard et al., 2015). Despite expectations that the student sample would show high ACE scores, these results are sobering. Associations with Resilience Four variables in the current study showed a significant relationship with resilience, including ACE score, perceived stress, religious faith, and experiential avoidance. Contrary to expectations that a history of trauma in childhood would be associated with lowered resilience scores, higher ACE scores were actually associated with greater resilience (p <.01). ACES. Several previous studies have reported that social workers tend to enter their professional training with high rates of adverse life experiences (Black et al., 1993; Dykes, 2011; Rompf & Royse, 1994). Results of this current study certainly support this finding. Compelling evidence links ACE histories with negative health and social outcomes in adult life (Anda et al., 2006; Dube et al., 2004), and trauma history has generally been viewed as a potential risk factor in terms of MSW students’ vulnerability to mental health issues, truncated careers, and compromised therapeutic practice with clients. However, the implications of such trauma histories for social work students and professionals remain unclear (for more detailed discussion, see Thomas, 2016). Marcus and Dubi (2006) found that prior histories of trauma did not predict depression, anxiety, burnout, or compassion fatigue among mental health professionals, and Howard et al. (2015) found that higher ACE scores among foster care workers were actually associated with reduced risk for burnout and greater compassion satisfaction. Hypothesis 2 is not supported. There are a number of possible explanations for this finding regarding ACEs and resilience. Rutter (2007, 2013) states that resilience can only be developed within the experience of adversity. The positive association between ACEs and resilience found in this study may reflect the “steeling” or “turning point” effects (see Rutter, 2006, p. 1; 2013, p. 477) that can sometimes occur as a result of past trauma. Alternately, or additionally, it is possible that at least among the subset of students who had experienced trauma and yet were successful in pursuing graduate education, such difficult experiences resulted in a strengthening of purpose to help others who face similar challenges. Howard and colleagues’ (2015) finding that higher ACEs were associated with greater compassion satisfaction supports this explanation. Experiential Avoidance. Of all the variables in the model, experiential avoidance was most strongly associated with resilience. Higher experiential avoidance scores predicted Thomas & Beecher/WHAT DOESN’T KILL YOU 1126 lower resilience, supporting hypothesis 5. Consistent with prior research on avoidant coping (Boulanger et al., 2009; Thompson et al., 2011), these findings suggest that persons who adopt cognitive strategies aimed at suppressing or avoiding reminders of difficult experiences may struggle more than those who are able to acknowledge and accept their experiences. This makes sense in light of research suggesting the importance of reflection in resilient processing of trauma (Kinman & Grant, 2011; Rutter, 2013) and the emphasis on meaning-making as a critical factor in the metabolism and transformation of traumatic experiences (Calhoun & Tedeschi, 2013; McCann & Pearlman, 1992). Perceived Stress. The general population average score for the PSS-10 is 13, with scores of 20 or more indicating high stress (Cohen et al., 1983). Student scores in this study (M=18.29, SD 6.19) did not quite reach the cut-off for “high-stress,” but were well above the population norm of 13. This is congruent with previous research indicating that graduate students in general, and social work graduate students in particular, experience relatively high levels of stress (Addonizio, 2011; Grant & Kinman, 2012). Perceived stress was also negatively associated with resilience, supporting hypothesis 3. While a certain amount of stress is needed for optimal functioning, high levels of current stress challenge coping capacities (Lazarus & Folkman, 1984). Past trauma and significant childhood distress (as measured by the ACEs questionnaire) were correlated with increased resilience, but current distress was correlated with decreased resilience, suggesting perhaps that time, psychological processing, and/or meaning-making modifies the impact of distressing events. Bivariate analysis indicated a strong positive correlation between perceived stress and experiential avoidance (and a negative correlation with mindfulness) again indicating that avoidant coping may contribute to greater perception of stress among MSW students. These results also suggest that, within social work education, strategies aimed at helping students develop more adaptive coping skills focused on awareness and acceptance may be helpful. Religious Faith. Finally, religious faith was positively, though weakly, associated with resilience, supporting hypothesis 4. Previous reports regarding the effects of religious faith and spirituality on coping in the general population (Plante et al., 2002) and particularly among social workers and students (Canda et al., 2004) suggest multiple benefits from religion/spirituality. As mentioned previously, the meaning people make of challenging life experiences is important and will likely shape consequent responses, and “plentiful evidence” suggests that, for persons who have experienced trauma, religious faith and/or spirituality can be helpful in understanding, interpreting, and coping with subsequent difficulties (Calhoun & Tedeschi, 2013, p. 128). Mindfulness. It was surprising that mindfulness was not significantly associated with resilience in the regression model. However, though some mindfulness measures are multifactorial, the measure of mindfulness used in this study (MAAS) measures the single- factor of receptive, open, and non-evaluative awareness, and may have overlapped with the constructs measured in the experiential avoidance measure (AAQ II). Hypothesis 6 was not supported. ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1127 Limitations There are a number of limitations to this study, including the relatively small, non- random sample from one regional university. Additionally, the study relies on self-report data, and despite efforts to assure anonymity, it is impossible to rule out a social desirability bias in the responses. Causality cannot be determined due to the cross-sectional research design used in this study. As previously mentioned, the present study did not include information regarding the influence of relationships, social support, or other institutional, organizational, or cultural factors on resilience. All of these factors, in addition to the intrapersonal factors measured in the present study, likely have a significant influence on the resilience of individuals. Finally, risk of type I errors is inflated given the multiple comparisons completed in the study. Future studies should include larger and more diverse sample sizes, and more robust analytical methods such as structural equation modeling which might better handle any measurement error, allow for testing multiple models and paths, and provide a more accurate examination of the relationship between variables. Implications for Social Work Education This study provides further evidence that MSW students experience significant stress during their graduate studies, and that many come into social work education with substantial trauma histories. However, it also provides surprising evidence that those trauma histories may have actually contributed to greater resilience, and suggests that social work educators rethink assumptions that such histories are necessarily problematic. Further, the results suggest that an ability to face difficult or painful experiences with awareness and acceptance, rather than engage in strategies of experiential avoidance, may be important in strengthening resilient responses. Regardless of whether students have had previous trauma histories themselves, we know that indirect exposure to trauma in classes and field experiences can contribute to vicarious traumatization in students (Carello & Butler, 2015). In the spirit of informed consent and evidence-based intervention, it is important that social work educators explicitly provide information to students regarding trauma exposure and effects, whether past, current, or future. Students should understand that what they do (or don’t do) in response to stressful and traumatic experiences matters a great deal. In addition to didactic information about trauma, secondary trauma, and professional resilience, it is important that social work educators create learning experiences that help all students increase affective awareness of emotional responses that may be challenging, whether in response to prior or current stressors, or counter-transference experiences with clients. Social work educators can provide solid research information about the problems associated with avoidant coping, discuss the ethics of addressing issues that might impair future professional functioning, and help students with strategies for managing their experiences. These strategies might include additional opportunities for discussion and reflection about challenging or triggering experiences, as well as pro-active development/rehearsal of evidence-based mindfulness and acceptance skills. Without engaging in therapy or getting overly involved in student’s personal lives, social work educators can provide classroom experiences and field supervision aimed toward Thomas & Beecher/WHAT DOESN’T KILL YOU 1128 supporting students as they acknowledge, reflect on, accept, and cope with their difficult experiences (rather than suppressing or avoiding them). Educators can also ensure that students are aware of local university or/and community counseling/therapy or other supportive resources. Based on research suggesting that social work students are often reluctant to speak to teachers and supervisors about their distress (Grant & Kinman, 2012), we may need to recalibrate our expectations and approaches regarding how to encourage students to use more strengths-based and adaptive ways to manage their stressful and traumatic experiences. Providing repeated opportunities for such cognitive and affective experiences early in the training of helping professionals is important (Calhoun & Tedeschi, 2013; Rutter, 2006) and should be an explicit focus in social work education (Carello & Butler, 2015; Grant & Kinman, 2012). References Abdollahi, A., Talib, M. A., Yaacob, S. N., & Ismail, Z. (2014). Hardiness as a mediator between perceived stress and happiness in nurses. Journal of Psychiatric and Mental Health Nursing, 21(9), 789-796. doi: https://doi.org/10.1111/jpm.12142 Abolghasemia, A. & Varaniyaba, S. T. (2010). Resilience and perceived stress: Predictors of life satisfaction in the students of success and failure. Procedia - Social and Behavioral Sciences, 5, 748-752. doi: https://doi.org/10.1016/j.sbspro.2010.07.178 Addonizio, F. P. (2011). Stress, coping, social support, and psychological distress among MSW students. (Doctoral dissertation). Retrieved from http://scholarcommons.sc.edu/etd/1905 Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., . . . Giles, W.H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry Clinical Neuroscience, 256, 174-186. doi: https://doi.org/10.1007/s00406-005-0624-4 Atkinson, P. A., Martin, C. R., & Rankin, J. (2009). Resilience revisited. Journal of Psychiatric and Mental Health Nursing, 16(2), 137-145. doi: https://doi.org/10.1111/j.1365-2850.2008.01341.x Beddoe, L., Davys, A., & Adamson, C. (2013). Educating resilient practitioners. Social Work Education, 32(1), 100-117. doi: https://doi.org/10.1080/02615479.2011.644532 Black, P. N., Jeffreys, D., & Hartley, E. K. (1993). Personal history of psychosocial trauma in the early life of social work and business students. Journal of Social Work Education, 29(2), 171-180. doi: https://doi.org/10.1080/10437797.1993.10778812 Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., ... & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and https://doi.org/10.1111/jpm.12142 https://doi.org/10.1016/j.sbspro.2010.07.178 http://scholarcommons.sc.edu/etd/1905 https://doi.org/10.1007/s00406-005-0624-4 https://doi.org/10.1111/j.1365-2850.2008.01341.x https://doi.org/10.1080/02615479.2011.644532 https://doi.org/10.1080/10437797.1993.10778812 ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1129 experiential avoidance. Behavior Therapy, 42(4), 676-688. doi: https://doi.org/10.1016/j.beth.2011.03.007 Boulanger, J. L., Hayes, S. C., & Pistorello, J. (2009). Experiential avoidance as a functional contextual concept. In A. M. Kring & D. M. Sloan, (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 107-136). NY: Guilford Press. Bride, B. E., & Figley, C. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63-70. doi: https://doi.org/10.1093/sw/52.1.63 Brown, K.W., & Ryan, R.M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822-848. doi: https://doi.org/10.1037/0022-3514.84.4.822 Brown, T. (2012). A psychological examination of the interface between religion, stress and depression. International Review of Social Sciences and Humanities, 4(1), 59-73. Calhoun, L. G., & Tedeschi, R. G. (2013). Posttraumatic growth in clinical practice. NY: Routledge. Campbell-Sills, L., Cohan, S. L., & Stein, M. B. (2006). Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behaviour Research and Therapy, 44(4), 585-599. doi: https://doi.org/10.1016/j.brat.2005.05.001 Canda, E., Nakashima, M., & Furman, L. D. (2004). Ethical considerations about spirituality in social work: Insights from a national qualitative survey. Families in Society: The Journal of Contemporary Social Services, 85(1), 27-35. doi: https://doi.org/10.1606/1044-3894.256 Carello, J., & Butler, L. D. (2015). Practicing what we teach: Trauma-informed educational practice. Journal of Teaching in Social Work, 35(3), 262-278. doi: https://doi.org/10.1080/08841233.2015.1030059 Center for Youth Wellness. (2013). A hidden crisis: Findings on adverse childhood experiences in California. Retrieved from https://app.box.com/s/nf7lw36bjjr5kdfx4ct9 Centers for Disease Control and Prevention. (2010). Adverse childhood experiences reported by adults—Five states, 2009. Morbidity and Mortality Weekly Report. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385-396. doi: https://doi.org/10.2307/2136404 Collins, S., Coffey, M., & Morris, L. (2010). Social work students: Stress, support and well-being. British Journal of Social Work, 40(3), 963-982. doi: https://doi.org/10.1093/bjsw/bcn148 https://doi.org/10.1016/j.beth.2011.03.007 https://doi.org/10.1093/sw/52.1.63 https://doi.org/10.1037/0022-3514.84.4.822 https://doi.org/10.1016/j.brat.2005.05.001 https://doi.org/10.1606/1044-3894.256 https://doi.org/10.1080/08841233.2015.1030059 https://app.box.com/s/nf7lw36bjjr5kdfx4ct9 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm https://doi.org/10.2307/2136404 https://doi.org/10.1093/bjsw/bcn148 Thomas & Beecher/WHAT DOESN’T KILL YOU 1130 Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The Connor‐Davidson Resilience Scale (CD‐RISC). Depression and Anxiety, 18(2), 76- 82. doi: https://doi.org/10.1002/da.10113 Connor-Davidson Resilience Scale. (n.d.). CDRISC User Guide. Retrieved January 14, 2017, from http://www.cd-risc.com/user-guide.php Crowder, R., & Sears, A. (2017). Building resilience in social workers: An exploratory study on the impacts of a mindfulness-based intervention. Australian Social Work, 70(1), 17-29. doi: https://doi.org/10.1080/0312407X.2016.1203965 Dube, S. R., Williamson, D. F., Thompson, T., Felitti, V. J., & Anda, R. F. (2004). Assessing the reliability of retrospective reports of adverse childhood experiences among adult HMO members attending a primary care clinic. Child Abuse & Neglect, 28(7), 729-737. doi: https://doi.org/10.1016/j.chiabu.2003.08.009 DuMont, K. A., Widom, C. S., & Czaja, S. J. (2007). Predictors of resilience in abused and neglected children grown-up: The role of individual and neighborhood characteristics. Child Abuse & Neglect, 31(3), 255-274. doi: https://doi.org/10.1016/j.chiabu.2005.11.015 Dykes, G. (2011). The implications of adverse childhood experiences for the professional requirements of social work. Social Work/Maatskaplike Werk, 47(4), 521-533. Eriksson, C. B., & Yeh, D. (2012). Grounded transcendence: Resilience to trauma through spirituality and religion. In K. Gow & M. J. Celinski (Eds.), Individual trauma: Recovering from deep wounds and exploring the potential for renewal (pp. 53-71). Hauppauge, NY, US: Nova Science Publishers. Esaki, N., & Larkin, H. (2013). Prevalence of adverse childhood experiences (ACEs) among child service providers. Families in Society: The Journal of Contemporary Social Services, 94 (1), 31-37. doi: https://doi.org/10.1606/1044-3894.4257 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., …Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245-258. doi: https://doi.org/10.1016/S0749-3797(98)00017-8 Friedlander, L. J., Reid, G. J., Shupak, N., & Cribbie, R. (2007). Social support, self- esteem, and stress as predictors of adjustment to university among first-year undergraduates. Journal of College Student Development, 48(3), 259-274. doi: https://doi.org/10.1353/csd.2007.0024 Galantino, M. L., Vaime, M., Maguire, M., Szapary, P., & Farrar, J. (2005). Short communication: Association of psychological and physiological measures of stress in health-care professionals during an 8-week mindfulness meditation program: Mindfulness in practice. Stress and Health, 21, 255-261. doi: https://doi.org/10.1002/smi.1062 https://doi.org/10.1002/da.10113 http://www.cd-risc.com/user-guide.php https://doi.org/10.1080/0312407X.2016.1203965 https://doi.org/10.1016/j.chiabu.2003.08.009 https://doi.org/10.1016/j.chiabu.2005.11.015 https://doi.org/10.1606/1044-3894.4257 https://doi.org/10.1016/S0749-3797(98)00017-8 https://doi.org/10.1353/csd.2007.0024 https://doi.org/10.1002/smi.1062 ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1131 Grant, L. (2014). Hearts and minds: Aspects of empathy and wellbeing in social work students. Social Work Education, 33(3), 338-352. doi: https://doi.org/10.1080/02615479.2013.805191 Grant, L., & Kinman, G. (2012). Enhancing wellbeing in social work students: Building resilience in the next generation. Social Work Education, 31(5), 605-621. doi: https://doi.org/10.1080/02615479.2011.590931 Grant, L., & Kinman, G. (Eds.). (2014). Developing resilience for social work practice. Palgrave: Macmillan. Greene, R. R. (2008). Risk and resilience theory: A social work perspective. In R. R. Greene (Ed.), Human behavior theory and social work practice (3rd ed., pp. 315- 342). New Brunswick, NJ: Transaction. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152-1168. doi: https://doi.org/10.1037/0022-006X.64.6.1152 Howard, A. R. H., Parris, S., Hall, J. S., Call, C. D., Razuri, E. B., Purvis, K. B., & Cross, D. R. (2015). An examination of the relationships between professional quality of life, adverse childhood experiences, resilience, and work environment in a sample of human service providers. Children and Youth Services Review, 57, 141-148. doi: https://doi.org/10.1016/j.childyouth.2015.08.003 Javanmard, G. H. (2013). Religious beliefs and resilience in academic students. Procedia - Social and Behavioral Sciences, 84, 744-748. doi: https://doi.org/10.1016/j.sbspro.2013.06.638 Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. Kamya, H. A. (2000). Hardiness and spiritual well-being among social work students: Implications for social work education. Journal of Social Work Education, 36(2), 231-240. doi: https://doi.org/10.1080/10437797.2000.10779004 Kapoulitsas, M., & Corcoran, T. (2014). Compassion fatigue and resilience: A qualitative analysis of social work practice. Qualitative Social Work, 19(4), 255-269. doi: https://doi.org/10.1177/1473325014528526 Kemper, K. J., Mo, X., & Khayat, R. (2015). Are mindfulness and self-compassion associated with sleep and resilience in health professionals? Journal of Alternative and Complementary Medicine, 21(8), 496-503. doi: https://doi.org/10.1089/acm.2014.0281 Kinman, G., & Grant, L. (2011). Exploring stress resilience in trainee social workers: The role of emotional and social competencies. British Journal of Social Work, 41(2), 261-275. doi: https://doi.org/10.1093/bjsw/bcq088 https://doi.org/10.1080/02615479.2013.805191 https://doi.org/10.1080/02615479.2011.590931 https://doi.org/10.1037/0022-006X.64.6.1152 https://doi.org/10.1016/j.childyouth.2015.08.003 https://doi.org/10.1016/j.sbspro.2013.06.638 https://doi.org/10.1080/10437797.2000.10779004 https://doi.org/10.1177/1473325014528526 https://doi.org/10.1089/acm.2014.0281 https://doi.org/10.1093/bjsw/bcq088 Thomas & Beecher/WHAT DOESN’T KILL YOU 1132 Koenig, H. G., George, L. K., & Peterson, B. L. (1998). Religiosity and remission of depression in medically ill older patients. American Journal of Psychiatry, 155, 536- 542. doi: https://doi.org/10.1176/ajp.155.4.536 Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., Chapman, B., …& Quill, T. E. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association, 302(12), 1284-1293. doi: https://doi.org/10.1001/jama.2009.1384 Larkin, H., Shields, J. J., & Anda, R. F. (2012). The health and social consequences of adverse childhood experiences (ACE) across the lifespan: An introduction to prevention and intervention in the community. Journal of Prevention & Intervention in the Community, 40(4), 263-270. doi: https://doi.org/10.1080/10852352.2012.707439 Lazarus, R., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. Lee, B. J. (2007). Moderating effects of religious/spiritual coping in the relation between perceived stress and psychological well-being. Pastoral Psychology, 55(6), 751-759. doi: https://doi.org/10.1007/s11089-007-0080-3 Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71(3), 543-562. doi: https://doi.org/10.1111/1467-8624.00164 Marcus, S., & Dubi, M. (2006). The relationship between resilience and compassion fatigue in counselors. In G.R. Walz, J.C. Breuer, & R.K. Yep, (Eds), Vistas: Compelling perspectives on counseling (pp 223- 225). Alexandria, VA: American Counseling Association. McCann, I. L., & Pearlman, L. A. (1992). Constructivist self-development theory: A theoretical framework for assessing and treating traumatized college students. Journal of American College Health, 40(4), 189-196. doi: https://doi.org/10.1080/07448481.1992.9936281 McGavock, L., & Spratt, T. (2014). Prevalence of adverse childhood experiences in a university population: Associations with use of social services. British Journal of Social Work, 44(3), 657-674. doi: https://doi.org/10.1093/bjsw/bcs127 Moore, R. C., Eyler, L. T., Mausbach, B. T., Zlatar, Z. Z., Thompson, W. K., Peavy, G., & ... Jeste, D. V. (2015). Complex interplay between health and successful aging: Role of perceived stress, resilience, and social support. American Journal of Geriatric Psychiatry, 23(6), 622-632. doi: https://doi.org/10.1016/j.jagp.2014.08.004 Mróz, J. (2015). Predictive roles of coping and resilience for the perceived stress in nurses. Progress In Health Sciences, 5(2), 77-84. Nurius, P. S., Green, S., Logan-Greene, P., & Borjaa, S. (2015). Life course pathways of adverse childhood experiences toward adult psychological well-being: A stress https://doi.org/10.1176/ajp.155.4.536 https://doi.org/10.1001/jama.2009.1384 https://doi.org/10.1080/10852352.2012.707439 https://doi.org/10.1007/s11089-007-0080-3 https://doi.org/10.1111/1467-8624.00164 https://doi.org/10.1080/07448481.1992.9936281 https://doi.org/10.1093/bjsw/bcs127 https://doi.org/10.1016/j.jagp.2014.08.004 ADVANCES IN SOCIAL WORK, Fall 2018, 18(4) 1133 process analysis. Child Abuse & Neglect, 45, 143-153. doi: https://doi.org/10.1016/j.chiabu.2015.03.008 Pardini, D. A., Plante, T. G., Sherman, A., & Stump, J. E. (2000). Religious faith and spirituality in substance abuse recovery: Determining the mental health benefits. Journal of Substance Abuse Treatment, 19(4), 347-354. doi: https://doi.org/10.1016/S0740-5472(00)00125-2 Plante, T. G., Vallaeys, C. L., Sherman, A. C., & Wallston, K. A. (2002). The development of a brief version of the Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychology, 50(5), 359-368. doi: https://doi.org/10.1023/A:1014413720710 Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58(3), 307-321. doi: https://doi.org/10.1002/jclp.10020 Robotham, D., & Julian, C. (2006). Stress and the higher education student: A critical review of the literature. Journal of Further and Higher Education, 30(02), 107-117. doi: https://doi.org/10.1080/03098770600617513 Rompf, E. L., & Royse, D. (1994). Choice of social work as a career: Possible influences. Journal of Social Work Education, 30(2), 163-171. doi: https://doi.org/10.1080/10437797.1994.10672227 Roulston, A., Montgomery, L., Campbell, A., & Davidson, G. (2017). Exploring the impact of mindfulnesss on mental wellbeing, stress and resilience of undergraduate social work students. Social Work Education, 37, 1-16. doi: https://doi.org/10.1080/02615479.2017.1388776 Rutter, M. (2006). Implications of resilience concepts for scientific understanding. Annals of the New York Academy of Sciences, 1094(1), 1-12. doi: https://doi.org/10.1196/annals.1376.002 Rutter, M. (2007). Resilience, competence, and coping. Child Abuse & Neglect, 31(3), 205-209. doi: https://doi.org/10.1016/j.chiabu.2007.02.001 Rutter, M. (2013). Annual research review: Resilience-clinical implications. Journal of Child Psychology and Psychiatry, 54(4), 474-487. doi: https://doi.org/10.1111/j.1469-7610.2012.02615.x Seyedfatemia, N., Pourafzalb, F., Inanlooc, M., & Haghani, H. (2015). Perceived-stress and resilience in nursing students. European Psychiatry, 30(S1), 28-31. doi: https://doi.org/10.1016/S0924-9338(15)30787-2 Shapiro, S. L., Brown, K. W., & Astin, J. A. (2008). Toward the integration of meditation into higher education: A review of research. Center for Contemplative Mind in Society. Retrieved from http://www.contemplativemind.org/admin/wp- content/uploads/2012/09/MedandHigherEd.pdf https://doi.org/10.1016/j.chiabu.2015.03.008 https://doi.org/10.1016/S0740-5472(00)00125-2 https://doi.org/10.1023/A:1014413720710 https://doi.org/10.1002/jclp.10020 https://doi.org/10.1080/03098770600617513 https://doi.org/10.1080/10437797.1994.10672227 https://doi.org/10.1080/02615479.2017.1388776 https://doi.org/10.1196/annals.1376.002 https://doi.org/10.1016/j.chiabu.2007.02.001 https://doi.org/10.1111/j.1469-7610.2012.02615.x https://doi.org/10.1016/S0924-9338(15)30787-2 http://www.contemplativemind.org/admin/wp-content/uploads/2012/09/MedandHigherEd.pdf http://www.contemplativemind.org/admin/wp-content/uploads/2012/09/MedandHigherEd.pdf Thomas & Beecher/WHAT DOESN’T KILL YOU 1134 Thomas, J. (2013). Association of personal distress with burnout and compassion fatigue among clinical social workers. Journal of Social Service Research, 39(3), 365-379. doi: https://doi.org/10.1080/01488376.2013.771596 Thomas, J. (2016). Adverse childhood experiences among MSW students. Journal of Teaching in Social Work, 36(3), 235-255. doi: https://doi.org/10.1080/08841233.2016.1182609 Thompson, R. W., Arnkoff, D. B., & Glass, C. R. (2011). Conceptualizing mindfulness and acceptance as components of psychological resilience to trauma. Trauma, Violence, & Abuse, 12(4), 220-235. doi: https://doi.org/10.1177/1524838011416375 Wells, A., & Sembi, S. (2004). Metacognitive therapy for PTSD: A preliminary investigation of a new brief treatment. Journal of Behavior Therapy and Experimental Psychiatry, 35(4), 307-318. doi: https://doi.org/10.1016/j.jbtep.2004.07.001 Wilks, S. E. (2008). Resilience amid academic stress: The moderating impact of social support among social work students. Advances in Social Work, 9(2), 106-125. Willis, K. D., & Burnett, H. J. (2016). The power of stress: Perceived stress and its relationship with rumination, self-concept clarity, and resilience. North American Journal of Psychology, 18(3), 483-498. Yehuda, R., & Flory, J. D. (2007). Differentiating biological correlates of risk, PTSD, and resilience following trauma exposure. Journal of Traumatic Stress, 20(4), 435- 437. doi: https://doi.org/10.1002/jts.20260 Zosky, D. L. (2013). Wounded healers: Graduate students with histories of trauma in a family violence course. Journal of Teaching in Social Work, 33(3), 239-250. doi: https://doi.org/10.1080/08841233.2013.795923 Author note: Address correspondence to, Jacky Thomas, PhD, Department of Social Work, California State University San Marcos, 333 S. Twin Oaks Valley Road, San Marcos, CA 92096-0001. jthomas@csusm.edu https://doi.org/10.1080/01488376.2013.771596 https://doi.org/10.1080/08841233.2016.1182609 https://doi.org/10.1177/1524838011416375 https://doi.org/10.1016/j.jbtep.2004.07.001 https://doi.org/10.1002/jts.20260 https://doi.org/10.1080/08841233.2013.795923 mailto:jthomas@csusm.edu