Abstract
Evidence-based models are critical for understanding caregiver well-being and treatment interventions from a holistic perspective. This study introduces the Indivisible Self: An Evidence-Based Model of Wellness (IS-WEL) as a means for examining the holistic wellness of pediatric stroke caregivers. In this exploratory study, 161 participants completed a demographic survey and the Five-Factor Wellness Inventory (FF-WEL). Results indicate significant wellness score differences between the current sample of pediatric stroke caregivers and the FF-WEL norming sample on the higher order Total Wellness factor, the second-order wellness factors of Creative Self and Social Self, and the third-order wellness factors of thinking, emotions, control, positive humor, and love. These results support the veracity of the IS-WEL as an additional empirically sound holistic approach for understanding and addressing the well-being of stroke caregivers. The authors discuss practical clinical and research implications for utilizing the IS-WEL with pediatric stroke caregivers.
Introduction
Pediatric strokes can occur in utero (perinatal), between birth and 28 days (neonatal), or between 28 days and 18 years (childhood) (Lynch, Hirtz, DeVeber, & Nelson, 2002). Studies on pediatric stroke survivors reveal a litany of potential stroke-related impairments across physical (Hurvitz, Warschausky, Berg, & Tsai, 2004), neurological (de Veber, 2005), developmental (Abma, 2010), behavioral (O’Keeffe, King, & Murphy, 2012), and emotional (Hysing, Elgen, Gillberg, Lie, & Lundervold, 2007) domains. Unsurprisingly, the impact of a pediatric stroke can influence the quality of life of the surviving child, primary caregivers, and the family system at large (De Schryver, Kapelle, Jennekens-Schinkel, & Boudewyn, 2000; O’Keeffe et al., 2012).
Caregiver Wellness
The caregiving role offers considerable inherent value (Mackenzie & Greenwood, 2012); yet, pediatric strokes can trigger lifestyle changes and stressors that can challenge caregiver well-being (Kreutzer, Srio, & Bergquist, 1994) and disrupt marital and family relationships (Cameron, Naglie, Silver, & Gignac, 2013; Gaugler, 2010). For example, childcare routines may require accommodations unique to the child’s pediatric stroke-related functional or executive impairments. Given the burdens of caretaking (Graf et al., 2017), it is unsurprising to find high rates of depression (Berg, Palomaki, Lonnqvist, Lehtihalmes, & Kaste, 2005) and a diminished sense of well-being across multiple domains (Gordon, Ganesan, Towell, & Kirkham, 2002; O’Keeffe et al., 2012; Shanmugham, Cano, Elliott, & Davis, 2009) among stroke caregivers.
Conversely, pediatric stroke caregivers, their care recipient, and their family can adapt and thrive when their personal assets and resources are recognized and intentionally deployed. Rehabilitation scholars define this distinctive trait as resilience (Frain et al., 2007) and view it, along with a healthy family system, as key to optimizing the current and longitudinal well-being of stroke caregivers, stroke survivors, and their family systems (Cameron et al., 2012; Gaugler, 2010). The construct of resilience is also embedded within models used by rehabilitation professionals to assess the general health and functioning of caregivers. These include health-related quality of life (HRQoL; Frain et al., 2007), the resilience model of family stress, adjustment and adaptation (McCubbin, Thompson, & McCubbin, 1996), and the timing it right model (Cameron & Gignac, 2008). Each model considers the role of resilience in overcoming personal barriers, the nature of caregiver well-being, and the use of personal assets to effect positive client outcomes. Researchers also attend to how endogenous factors such as coping strategies (Chwalisz, 1996) and exogenous factors such as marital health (Douglas & Spellacy, 2000) influence caregiver stress and well-being. The stress process model perspective, for instance, posits that an interplay among psychosocial variables and appraisal (Bradburn, 1969) is central to how an individual frames a stressor and, by extension, is affected by the stressor (Chronister & Chan, 2006; Moos & Schaefer, 1993). Prior caregiver studies also relied on burden measures to understand caregiver stress (Vitaliano, Russo, Becker, & Maiuro, 1991), a notable diversion from the Indivisible Self: An Evidence-Based Model of Wellness’ (IS-WEL) holistic, strength-based formula. Although supportive of these models, rehabilitation scholars have encouraged adding theory-driven models that can facilitate a holistic understanding of caregiver dynamics and treatment strategies (Han & Haley, 1999; Lui, Ross, & Thompson, 2005) while remaining true to the core rehabilitation counseling tenet of focusing on client strengths and resources (Riggar & Maki, 2004). To that end, this study introduces the IS-WEL (Myers & Sweeney, 2005) and Five-Factor Wellness Inventory (FF-WEL; Myers & Sweeney, 2005) as a framework for assessing and addressing caregiver wellness from a holistic, strength-based perspective.
Wellness Paradigm
Rooted in the Adlerian notion of the indivisible self, or the view that we are more than the sum of our parts, the wellness paradigm as conceived by the IS-WEL functions as an alternative to the medical model’s reductionist perspective. Myers, Sweeney, and Witmer (2000) define wellness as “a way of life oriented toward optimal health and well-being in which the body, mind, and spirit are integrated by the individual to live more fully” (p. 252). The strength of the model is the multidimensional, strength-based approach to holistic wellness. In other words, personal wellness assets are not viewed in isolation. Thus, strength-based interventions can be designed to offset latent or underutilized areas and facilitate movement toward optimal wellness across multiple life domains (Myers & Sweeney, 2005). Today, the IS-WEL and FF-WEL are among “ . . . the most comprehensive wellness models and assessments in the field of counseling and holistic health” (Granello & Witmer, 2013). Accordingly, the IS-WEL appears particularly well-suited for helping rehabilitation professionals assess and design treatment strategies based on the unique assets of the caregiver. Therefore, the aim of this study was to utilize the IS-WEL framework to examine the wellness of parents who self-identify as the primary pediatric stroke caregivers for their child.
Method
Procedure
The target population was parents with a child who experienced a perinatal, neonatal, or childhood stroke. An online support group for guardians, family, and friends with a child who survived a pediatric stroke was identified as the accessible population. An open invitation to participate in a web-based survey on pediatric stroke outcomes was made to members of this online pediatric stroke community. Due to the voluntary nature of the survey, the sample is not expected to be representative of all caregivers who have a child or children who experienced a pediatric or childhood stroke. It is also notable that adults seeking an online support group could have different characteristics than adult populations who do not seek participation with an online support community when faced with a challenging personal or family medical event.
Participants
The majority of participants self-identified as female (N = 151, 95%), Caucasian (94.4%), and married (N = 144, 89.4%). Two did not specify a gender, whereas five identified as a minority group member. Educational-level results found 14% reported no college degree, 39.5% completing a bachelor’s degree, and 31.2% reported an advanced degree. Nearly all respondents reported having two or more adults currently in the home (93%) at the time of their child’s pediatric stroke diagnosis (97.5%).
The sample was relatively affluent, with 42.5% having annual household incomes above US$100,000% and 63% having annual household incomes above US$80,000. Comparatively, 22.6% of the general U.S. population reported household incomes above US$100,000 (American Community Survey [ACS] 2013 Household Income Report). Furthermore, the majority had private insurance (71%) or private insurance and Medicaid (18.7%). The percentage of households whose insurance paid all of their child’s medical costs (after deductible) was 41.8%, whereas an additional 46.6% indicated that insurance covered more than half of their medical expenses.
The majority of children of the caregivers in this sample (79.8%) were diagnosed with neonatal (22.3%) or perinatal (57.5%) strokes, whereas just more than 20% were first diagnosed in childhood. Furthermore, 15.7% were diagnosed within 1 year, 7.8% within 2 to 5 years, 11.3% between 1 and 5 months, and 36.5% were diagnosed between 6 and 12 months. Because a child’s level of functional and executive impairment could influence parental and family well-being (O’Keeffe et al., 2012), caregivers were also asked to rate the cognitive, physical, and emotional functioning levels of their child in comparison with their child’s peers of the same age. A majority of caregivers perceived their child’s emotional (72.1%), physical (56.3%), and cognitive (52.8%) functioning as lower than their child’s peers. Cognitive levels were the most variable, with 52.8% rated below their peers, 29.9% above, and 17.4% rated as similar to their peers.
Measures
Participants completed the online version of the FF-WEL (Myers & Sweeney, 2005), an instrument designed to examine the factors of the IS-WEL (Myers & Sweeney, 2005), and a demographic questionnaire intended to gain information related to the experiences and perspectives of those who self-identify as a primary caregiver for a child who has experienced a pediatric or childhood stroke.
FF-WEL
The FF-WEL is a holistic, strength-based, and multidimensional wellness instrument. The FF-WEL measures one higher order factor defined as Total Wellness. Total Wellness, in turn, comprises five second-order factors: Creative Self, Coping Self, Physical Self, Social Self, and Essential Self. Seventeen discrete third-order factors, grouped within the second-order factors, correspond to Adler’s (1954) five basic life tasks of work, friendship, love, self, and spirituality (Myers & Sweeney, 2005). The ultimate strength of the model is its holistic approach to wellness where personal choice and responsibility are central tenets. Importantly, the statistically significant absence of any wellness factor should not be interpreted as one not possessing or being capable of applying resources within any dimension, as this is counterintuitive to the strength-based approach of the IS-WEL.
Scale scores were coded such that higher scores represent higher levels of positive wellness. The FF-WEL has strong reliability for first- and second-order factors (α = .94–.85) and moderate reliability (.66–.87) for the third-order factors (Myers & Sweeney, 2005).
Data Analysis
The Total Wellness, second-order, and third-order factor scores of the pediatric stroke caregiver sample were compared with the validation sample for the FF-WEL for the purposes of investigating their wellness levels. One-sample z tests were used to make statistical comparisons with the norming group (Myers & Sweeney, 2005), and Δ-effect sizes were calculated using the norm group sample standard deviation values for interpreting the magnitude of the differences. SAS version 9.3 was used with an alpha of .01 to provide control for family-wise Type I error.
Results
FF-WEL Total Wellness
All 161 respondents had complete data for the first-order, five second-order, and 17 third-order scales of the FF-WEL inventory (Myers & Sweeney, 2005). The Total Wellness cumulative score was significantly higher than the norming sample of adults for which the FF-WEL was validated, z(161) = 3.285, p < .01, Δ = 0.26, indicating that this population of adults had overall wellness scores one fourth of a standard deviation above the general norming group (see Table 1). Norming population descriptive statistics were obtained from the Myers and Sweeney (2005) sample of 3,343 adults completing the FF-WEL adult version instrument. The majority of the norming sample who answered demographic questions was female (60.1%) and Caucasian (52%), although much lower than our sample of 95.0% and 94.4%, respectively. Of the norming population, 57% had a bachelor’s degree, compared with 70.7% of our sample. Emphasis and capitalization is added to distinguish FF-WEL factors. For clarification and emphasis, Total Wellness and second-order factors are capitalized and italicized, whereas third-order factors are lower case and italicized.
Wellness Scores of Caregivers of Children With Pediatric Strokes (N = 161).
Note. Δ values that are in italics represent effect sizes where the sample scored lower than the population.
p < .01.
FF-WEL Second-Order Factors
The FF-WEL second-order scales were examined next to compare the FF-WEL norming population and our respondents on specific wellness areas. Caregivers in our sample scored themselves significantly higher on the Creative Self, z(161) = 3.902, p < .01, Δ = 0.31, and Social Self scales, z(161) = 4.311, p < .01, Δ = 0.34. No significant differences were found between our caregiver sample and the norming population on the Coping Self, z(161) = 1.101, p > .01, Δ = 0.09; Essential Self, z(161) = 2.408, p > .01, Δ = 0.19; and Physical Self, z(161) = 2.168, p > .01, Δ = 0.17, scales (see Table 1). Given the multidimensional, strength- and choice-based nature of the wellness model, it merits noting that even for the second-order scales in which there were no significant differences, our sample reported higher wellness levels than the norming population.
FF-WEL Third-Order Factors
Third-order factors can add considerable detail and understanding to an individual or group’s distinctive strength(s), yet, as with all wellness factors, should not be considered in isolation. Our results found several significant third-order factors compared with the norming group (see Table 1). Additional review of these results and their potential clinical implications are outlined in the subsequent “Discussion” section.
In this study, pediatric stroke caregivers scored significantly higher on the second-order Creative Self aligned third-order factors of thinking, emotions, control, and positive humor (see Table 1) compared with the FF-WEL norming sample. Caregivers also reported a significantly higher score on love, a third-order factor aligned with the second-order Social Self. Interestingly, although no second-order Coping Self or affiliated third-order factors emerged, caretakers did rate themselves higher than the norming population on the self-worth and realistic beliefs subscales, and significantly lower on the leisure scale. This pattern also emerged across other second- and third-order dimensions. For example, caregivers rated themselves significantly higher on the Essential Self’s third-order self-care factor, yet significantly lower on the spirituality scale. Another intriguing response found caregivers rating themselves substantially higher on the nutrition scale, but lower on the exercise scale. Although not statistically significant, these patterns illustrate the FF-WEL’s ability, particularly at the second- and third-factor levels, to reveal nuanced caregiver assets, resources, and preferences. Furthermore, when considered in relation to the participant’s consistently higher second-order factor scores than the FF-WEL norming sample, these patterns bolster the notion that participants were resolute in making personal responsibility and strength-based choices central tenets of their personal and pediatric stroke caregiver approaches (Myers & Sweeney, 2005). One key example, discussed in more detail below, is their willingness to seek out and engage in an online community of pediatric stroke caregivers. It merits reminding, however, that even strength-based interventions that appear especially well-suited for a particular person or situation could have unintended or unforeseen outcomes.
Discussion
Total Wellness
The aim of this exploratory study was to assess the holistic wellness of pediatric stroke caregivers through the holistic IS-WEL (Myers & Sweeney, 2005). The significant higher order result of this study, or Total Wellness, provides rehabilitation counselors with another empirically sound holistic approach for assessing caretaker wellness and devising treatment interventions drawn from a stroke caregiver’s key assets. Because wellness is a holistic construct, the discussion on our Total Wellness result will largely center on the significant second- and third-order factors as a means of highlighting the model’s multidimensional nature. Still, key demographic data and FF-WEL factors provide structure and meaning to the significant Total Wellness result.
For example, our pediatric stroke caregiver sample was primarily White (94.4%), female (95%), married (89.4%), well educated (70.1% with bachelor’s or advanced degree), and residing in households with an annual income above the national average. The potential wellness implications of these demographic factors are extensive and applicable across all wellness dimensions. For example, it seems reasonable that pediatric stroke caregivers with college degrees, spouses in the home, and higher income households may have more disposable income or employer-sponsored insurance/retirement packages that could help ease pediatric stroke related expenses and associated stressors. The relative affluence of this sample could also provide these caregivers with opportunities to apply their disposable income in ways that could optimize their personal well-being, such as by purchasing healthier food items or intermittently contracting with private caretakers for small respites from the strains of caregiving. Viewed in isolation, each suggestion appears reasonable. However, these suggestions gain merit when viewed in relation to our results showing that caregivers reported markedly higher (although not statistically significant) scores on the third-order self-care and nutrition factors than the FF-WEL norming sample.
Demographic data also suggest that the significant Total Wellness finding is informed by the caregiver’s ability to reflect upon and apply their assets and resources in defense of both situational and longitudinal pediatric stroke-related stressors (Elliot, Shewchuck, & Richards, 2001; Shanmugham et al., 2009). For instance, early detection of pediatric stroke is linked with better executive functioning outcomes for the stroke survivor (O’Keeffe et al., 2013); yet, less than one third (28.7%) of our caregiver sample received a pediatric stroke diagnosis for their child at the time of occurrence. The study’s significant Total Wellness score also stands in contrast to research showing poorer psychosocial wellness among parents with children with higher levels of poststroke functional impairment (Gordon et al., 2002), further suggesting their unique set of assets is effective at mitigating caregiver-related stress. This is also informative given that the majority of this caregiver sample rated their child’s functional abilities lower than their peers across emotional, physical, and cognitive domains. This awareness can help caregivers create activities that match the child’s abilities or, conversely, prevent them from unintentionally creating misaligned interventions that could reduce the wellness of both the child and parental caregiver (O’Keeffe et al., 2012). Ultimately, the significant Total Wellness score suggests this caregiver sample draws on a distinct blend of strengths that appear to help mitigate known caregiver stressors and facilitate a strong sense of overall well-being. To better illustrate the holistic nature of the IS-WEL, the significant second- and third-order wellness factors are discussed with ideas as to how their interplay could have influenced each other and the Total Wellness score as a whole.
Second- and Third-Order Factors
Creative Self
The second-order Creative Self encompasses “the combination of attributes that each of us forms to make a unique place among others in our social interactions and to positively interpret our world” (Myers & Sweeney, 2008, p. 86). Five third-order wellness factors (thinking, emotions, control, work, positive humor) inform the Creative Self. In short, the interplay of significant second- and third-order scores within the Creative Self suggests that this caregiver sample, as indicated by the set of Creative Self–affiliated third-order factors (discussed below), appears to have been particularly effective in assisting them in seeking out and maintaining positive social interactions. By extension, this Creative Self finding offers rehabilitation counselors the novel opportunity to examine how a caregiver sample with Creative Self–oriented strengths may utilize their resources to positive effect. In other words, the high concentration of significant third-order factors within the broader second-order Creative Self presents a helpful pathway for exploring the distinctive strengths of this sample of pediatric stroke caregivers and their potential influence on their sense of overall wellness as indicated by the significant Total Wellness result. In the following discussion, significant third-order factors within the Creative (and Social) Self are delineated and discussed within the prism of our participant’s significant Total Wellness score to better illustrate how their unique strengths contributed to their positive sense of overall, or Total Wellness.
Thinking
As noted, the third-order thinking, emotions, control, and positive humor factors within the Creative Self constitute an array of strengths and resources among our caregiver sample. Specifically, thinking is associated with being intellectually active and flexible, open minded, creative, curious, and oriented toward learning and problem-solving (Myers & Sweeney, 2008). Cognitive acuity is also integral to healthy mind–body system functioning and, as such, is essential for personal well-being and navigating effectively across and within different social environments and activities (Day, McGuire, & Anderson, 2009; Smith & Christakis, 2008; Waldstein & Elias, 2003). Here, the significant Total Wellness result suggests that caregivers applied their thinking assets in a judicious, intentional, and integrative manner across a web-based paradigm.
As noted earlier, a significant thinking result indicates that this caregiver sample possess the intellectual flexibility and problem-solving skills conducive to positive stroke caregiver–care recipient communication and interactions that are consistent with the child’s current abilities (Granello, 2013). These thinking assets could also influence their appraisal of their child’s functional abilities across different domains and selection of personal and social interactions, a notable distinction given our caretaker sample’s acknowledged concerns related to their child’s functional abilities across domains. The IS-WEL’s holistic approach could also have an inverse effect on healthy mind–body functioning and, by extension, overall wellness. For example, family, financial, or career distress could arise unexpectedly, temporarily clouding a caregiver’s normally effective problem-solving skills and negatively influencing the caregiver and care recipient’s well-being (Elliot et al., 2001; Grant, Weaver, Elliott, Bartolucci, & Newman-Giger, 2004). Despite the insights from the thinking and other significant scores across multiple dimensions, the IS-WEL requires that the thinking factor, and all significant scores in this study, be considered holistically. For instance, the IS-WEL holds that dynamics among the caregiver’s significant second- and third-factor strengths would be central to their perception of perceived mastery and accompanying reduction in stress levels (Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995). Therefore, based on the IS-WEL’s holistic, strength-based philosophy, we posit that a blend of our caregiver sample’s intellect (thinking), capacity for emotional self-regulation (emotions), and ability to see the humor in challenging situations (positive humor) allowed them to adapt well to the realities of their caregiving situation. When further considered in relation to their interpersonal (Social Self) and intimate relationship (love) resources, the significant Total Wellness score becomes more understandable and offers rehabilitation counselors a distinctive schematic for highlighting and utilizing caregiver assets and resources within and outside therapeutic settings.
Emotions
The significant third-order emotions factor addresses the caregiver’s ability to self-identify and self-regulate both positive and negative emotions (Myers & Sweeney, 2008). Emotional regulation, predictably, contributes to healthy mind–body–spiritual functioning and is a key wellness predictor with implications across the family system (Hunnicut-Holenbaugh, 2013; Morris, Silk, Steinberg, Myers, & Robinson, 2007). Consistent with the holistic IS-WEL, however, the significant emotions finding offers unique insights, yet should must ultimately be viewed in relation to caregiver’s other significant wellness factors.
A significant emotions result is generally consistent with emotional balance and health, an idea aligned with this caregiver sample’s seeking of additional support outside their family systems through an online support group. Here, it seems reasonable to assert that caregivers applied their emotions strengths within the online support group in ways that facilitated their positive sense of Total Wellness. Still, the holistic IS-WEL posits that while caregivers were positively affected by their social support they received from the online group (Social Self), their strongest social support system remained their family (love), a finding consistent with study’s marital status demographics. Importantly, the significance of the broader Social Self finding suggests that the online support group provided a helpful additional social forum where they could feel safe and regulate their emotional commitment (Xie, 2007). Although the emotions result is important in isolation, the Total Wellness result is evidence that this sample of pediatric stroke caregivers possess a distinct blend of interpersonal (Social Self; love) and intrapersonal (Creative Self; thinking, emotions, control, positive humor) strengths that contributed to their positive appraisal of—and emotional response to—the unpredictable nature of caregiving (Bradburn, 1969). Consistent application of these strengths remain essential components in the caregiver’s ongoing efforts to reduce stress levels and increase well-being and life satisfaction.
Control
The significant third-order control factor reflects the sense among our caregiver sample that they are capable of influencing the events in their lives (Myers & Sweeney, 2005). Theoretically, control aligns with the concept of self-efficacy (Bandura, 1977), or the belief “in one’s ability to surmount challenges and to anticipate success in the face of adversity” (Pomeroy & Clark, 2015, p. 24). The notion of appraisal is also evident in the Bradburn’s (1969) two-factor theory of psychological well-being and among stress process scholars (Moos & Schaefer, 1993). Within the IS-WEL, control traits also blend well with the core IS-WEL tenets of personal responsibility and choice. Several studies explore links between self-efficacy and wellness. Of particular note is the connection between higher self-efficacy and the central wellness feature of social interest (Curlette & Kern, 2010), or the interest in and/or sense of belonging and identification with others (Adler, 1954). For example, self-efficacy studies with adults associate higher self-efficacy with the ability to frame difficult tasks as challenges instead of threats and to select more effective coping strategies (Chemers, Hu, & Garcia, 2001; Rubino, Pelam, Spitzmeuller, & Zapf, 2012). Importantly, self-efficacy research with children has also linked increased self-efficacy with the ability to handle task-oriented roles and demands across the life span (Chase, 2001). In this case, caregiver strengths aligned with self-efficacy and control are particularly useful for facilitating positive interactions and outlooks among pediatric stroke caregivers, survivors and their families. (Han & Haley, 1999).
As indicated by the significant control and Total Wellness results, control-affiliated strengths can be instrumental in helping caregivers reduce stress and optimize wellness (Bandura & Cervone, 1983; Locke & Latham, 1990; Rubino et al., 2012). Still, the holistic nature of the wellness model cautions against overemphasizing a singular wellness asset or contextual factor (Myers & Sweeney, 2005; Toker, Gavish, & Biron, 2013). In general, though, the significant Total Wellness score suggests control traits, alone or in different combinations of their distinct third-order strengths, appear to help our caregiver sample project a brighter life outlook and overall sense of wellness (Cervone, 2000; Maddux, Brawley, & Boykin, 1995).
This study’s significant Total Wellness result appears generally consistent with Bradburn’s (1969) notion of perceived mastery over their caregiver role. Thus, the essential value of the IS-WEL in this and future caregiver research is the IS-WEL’s ability to discern strengths that, individually or in unique combinations, facilitate the caregiver’s positive appraisal of their current and future caregiver role and responsibilities. In essence, the IS-WEL, alone or in combination with stress process and QoL oriented models, can be instrumental in highlighting key caregiver assets that are fundamental to their appraisal of and actions (or inactions) associated with their caregiver role. As a result, rehabilitation counselors have a richer roadmap for understanding unique caregiver strengths and resources. This nuanced awareness of caregiver resources can also prove central to developing strong therapeutic alliances and effective, individualized treatment protocols conducive to reducing caregiver stress and optimizing their overall sense of wellness and QoL.
Positive humor
The significant third-order dimension of positive humor describes the ability to use humor to deal with personal mistakes, life’s unpredictability, and as a means for addressing difficult life events (Myers & Sweeney, 2008). The IS-WEL’s view of positive humor parallels a “self-enhancing and affiliative” (Chang, Chen, Hsu, Chan, & Chang, 2015, p. 307) humor style that has been associated with improved affect, relationship quality, and wellness (Dyck & Holtzman, 2013). Researchers have also linked humor with positive wellness outcomes across cultural, emotional, behavioral, cognitive, and biochemical domains (Chang et al., 2015; Cheung & Yue, 2013; Greenberger & Padesky, 1995; Sultanoff, 2013). Conversely, humor styles infused with self-defeating and aggressive qualities show the inverse effect (Dyck & Holtzman, 2013).
The significant positive humor and Total Wellness findings support prior research indicating that humor can affect positive wellness outcomes across multiple areas (Chang et al., 2015; Sultanoff, 2013). However, foreclosing on the caregiver’s positive Total Wellness result obscures the caregiver’s potentially idiosyncratic—and dynamic—blend of positive humor and other third-order factors and their potential influence on Total Wellness. In other words, positive humor within the IS-WEL is best viewed within the context of the caregiver’s holistic wellness profile and monitored for subtle changes across time. For example, caregivers may utilize good-natured joking or light sarcasm as a means for maintaining their base notion that a bit of humor can help balance life’s unpredictability, yet such humor could be taken out of context and viewed as detrimental. On the other hand, a caregiver’s edgier use of sarcasm could indicate underlying distress. As a result, caretakers and those in their orbit should attend closely to subtle changes in how humor is percieved or utilized.
Social Self
Relationships are a core aspect of wellness (Granello, 2013). Within the IS-WEL, the second-order Creative Self considers how personality traits influence social interactions and, by extension, wellness. Alternatively, the second-order Social Self considers “social support through connections with others in friendships and intimate relationships” (Myers & Sweeney, 2008, p. 86), including family, as central to wellness. Taken together, the broader significant second-order Creative and Social Self results suggest a sample of socially conscious pediatric stroke caregivers whose Total Wellness is influenced by a unique collection of personal assets that allow them to accept and receive support from both familial and nonfamilial/intimate relationships. Importantly, the significant second-order Social Self and affiliated third-order love factor indicate our caregiver’s positive orientation to social and interpersonal relationships; yet, the significant love finding suggests that, on balance, this sample of caregivers likely uses family as their principal source of social support. This finding is particularly relevant, given the fundamental roles and challenges faced by families caring for stroke survivors (Han & Haley, 1999).
Consistent with the previous discussions on the higher order, second-order, and third-order findings, the discussion surrounding wellness implications of the significant second-order Social Self and third-order love results requires attention to demographic, FF-WEL, and empirical sources. For instance, nonfamilial social support is a core feature of the broader second-order Social Self factor and a known predictor of wellness (Chen & Feeley, 2013; Cohen, 2004). Our significant Social Self and Total Wellness results add empirical support to the not-unexpected idea that positive nonfamilial relationships can influence overall well-being. However, it is of particular importance to note that our wellness results are drawn from a sample of pediatric caregivers, primarily mothers, who actively sought out and engaged with other, nonfamilial pediatric stroke caregivers in an online community support group.
In a general sense, the significant Total Wellness and Social Self results track with prior research indicating that online relationships may provide positive wellness implications, albeit with an online twist. Xie (2007), for instance, argues that individuals benefit from online social interactions largely because of their ability to facilitate social connections rather than their capacity to generate quality social relationships. Other researchers place online interactions under the banner of leisure activities, or intentionally chosen activities that contain intrinsic value (Kleiber & Nimrod, 2009) and, by extension, can positively influence wellness. For example, quality leisure activities are shown to improve social interactions and physical well-being, and to help diminish the negative effects of distressing life events (Pressman et al., 2009). Although it is unknown whether this caregiver sample conceptualized their online activities as a leisure activity, the significant Social Self result suggests that their online interactions were a valuable resource in promoting additional positive, nonfamilial social interactions that had an overall positive effect on their overall sense of wellness. Overall, while no additional online data were gathered, the significant Social Self and Total Wellness scores provide evidence that web-based social support groups could provide caregivers with valuable and, if needed, anonymous social support from nonfamilial members at different stages of their caretaking journey.
Love
The significant third-order love finding is especially intriguing given the online support group experiences of the caregivers represented in this study. Based on their online interactions, it seems reasonable to hypothesize that the third-order friendship factor, individually or along with love, might also manifest as a Social Self and Total Wellness predictor. However, the IS-WEL has ample explanation for why this did not occur. First, as previously noted, the IS-WEL is a strength-based model that emphasizes personal responsibility and choice. Therefore, caregivers may have gained considerable social support from their online support group, yet ultimately chose to maintain their marital and extended family system(s) as their principal source of support. Moreover, the IS-WEL’s strength-based approach would not assume that the friendship dimension’s lack of statistical significance was evidence that caregivers did not receive vital social support from their online experiences. This multidimensional view of this result, or any IS-WEL result, is central for rehabilitation counselors to maintain a holistic, strength-based perspective of their client and their future treatment plans.
A more nuanced interpretation of the significant love result shows the potential bidirectional influence of wellness strengths (Myers & Sweeney, 2008). For example, the emotional intelligence, problem-solving skills, and positive humor traits inherent in the emotions, thinking, and positive humor dimensions, respectively, could certainly interact in ways that could effectively alter how love and other third-order factors interact. As an example, a caregiver could use love assets to enhance dyadic coping, or “how couples support each other or jointly deal with stress” (Vedes et al., 2016, p. 84). This stronger dyadic coping response is known to increase relationship quality (Herzberg, 2013) and, as a result, a caregiver and their spouse or partner are better able to navigate relationship stressors and experience a sense of togetherness (Falconier, Nussbeck, & Bodenmann, 2013; Vedes, Bodenmann, Nussbeck, Randall, & Lind, 2015). Given the cognitive, emotional, and social–relational strengths indicated by the caregiver’s second- and third-order wellness results, it seems reasonable to assert that positive dyadic coping was present within the family systems of the majority of our caretaker sample and, as a result, helped facilitate their sense of Total Wellness. In essence, significant assets found within the broader Creative Self and accompanying third-order dimensions illustrate the importance of personality traits and social connections. However, the significant Social Self and love results illustrate the notion that full appreciation of our significant Total Wellness result requires close examination and consideration of different social contexts and how they interact to predict the significant Total Wellness (Granello, 2013) finding for our caregiver sample.
Limitations
There are several inherent limitations to this study. First, the use of a convenience sample of parents who self-identified as pediatric stroke caregivers and who self-selected into an online caregiver support group limits the generalizability of the results to other caregivers. Second, the study’s generalizability is limited by the homogeneity of the sample. The majority of participants self-identified as married, White females with a college education residing in a household with two or more adults, with an annual income above the national average. It is certainly possible, for instance, that our sample’s higher education and income levels could have contributed to this sample’s higher level of self-reported wellness as compared with a more general population. In effect, having a higher income and higher educational level may allow for resources that may help mitigate some of the challenges experienced by caregivers in other personal situations. Third, the use of a self-report measure can result in common response bias that enhances the results among the wellness dimensions and constructs; however, this format was the same as that used for the norming group. Fourth, the roles and burdens of caregiving are dynamic and can influence the result of a wellness study based on the caregiver’s current experiences. Fourth, the IS-WEL and FF-WEL were not developed specifically for caregivers and, therefore, may not have adequately addressed areas specific to understand the unique set of caregiver strengths. Finally, because wellness and caregiving are dynamic processes, the current wellness profile of this caregiver sample should be viewed accordingly.
Implications for Research and Practice
Conceptually, the holistic, strength-based IS-WEL is aligned with rehabilitation counseling’s view of focusing on client assets and resources. As such, the IS-WEL and FF-WEL are appropriate framing, assessing, and implementing a wellness-oriented perspective when working with pediatric stroke caregivers, their care recipients, and their families. For instance, the IS-WEL allows rehabilitation counselors and their clients to frame any issue from a strength-based position where personal choice and responsibility are central to process or task-oriented therapeutic endeavors. As a result, collaborative treatment efforts can focus on utilizing a client’s (or group’s) strengths to optimize their wellness and overall functioning.
Our findings also illustrate the IS-WEL and FF-WEL’s capacity for revealing new, strength-based treatment pathways for framing, designing, and measuring wellness-based interventions with pediatric stroke caregivers. Wellness counseling (Granello, 2013), broadly considered, is a multifaceted and interdisciplinary approach that would seek to blend the caregiver’s self-identified strengths into evidence-based assessments and interventions. Consistent with the holistic IS-WEL perspective, wellness-based interventions would focus on the interconnectedness of client strengths and treatment goals (Granello, 2013).
Our results also highlight future research opportunities for using the IS-WEL and FF-WEL with caregiver populations alone or as a companion measure. For starters, the holistic, strength-based approach of the IS-WEL appears tailor-made for stroke caregivers and other rehabilitation counseling client populations, especially where pretest and posttest interventions are indicated (Tanigoshi, Kontos, & Remley, 2008). For instance, pairing the IS-WEL with a specific intervention measure or in combination with programmatic assessment measures could provide critical wellness or QoL outcome data. In addition, the IS-WEL and FF-WEL could add a crucial holistic, strength-based perspective to future stress process model studies with different caregiver populations. Awareness of stroke caregiver strengths could also advance understanding of how caregiver strengths influence their appraisal of stressful situations and their implications for caregiver stress levels and well-being. In this study, for example, the significant Total Wellness score offers evidence that the caregiver’s thinking, emotions, control, positive humor, and love–affiliated strengths facilitated a sense of perceived satisfaction regarding their caretaking experiences. In addition, given that FF-WEL data provide a snapshot of an individual or group’s subjective sense of their current strengths and resources, the measure also seems a good fit for future caregiver-oriented resilience studies across the care continuum (Cameron et al., 2013; Frain et al., 2007).
Summary
The manifold implications of caregiver well-being accentuate the importance of taking a holistic wellness approach to understanding, measuring, and addressing caregiver wellness. To that end, the present study supports the veracity of the IS-WEL (Myers & Sweeney, 2005) and FF-WEL (Myers & Sweeney, 2005) as a stand-alone or companion model for gaining a holistic understanding of caregiver well-being. As a result, rehabilitation counseling professionals gain another holistic, evidence-based holistic model for expanding their conceptualization of caregiver well-being and their unique role in designing intentional, strength-based treatment protocols based on their client’s unique wellness profile (Han & Haley, 1999; Lui et al., 2005; Riggar & Maki, 2004).
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.