Young Burns Survivors-Resilience

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Restorying the Self : An Exploration of Young Burn Survivors' Narratives of Resilience

Ursula Lau and Ashley van Niekerk Qual Health Res 2011 21: 1165 originally published online 13 April 2011 DOI: 10.1177/1049732311405686 The online version of this article can be found at: http://qhr.sagepub.com/content/21/9/1165
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au and van NiekerkQualitative Health Research
QHR21910.1177/1049732311405686L
Articles
Restorying the Self: An Exploration of Young Burn Survivors Narratives of Resilience

Ursula Lau1 and Ashley van Niekerk2
Qualitative Health Research 21(9) 11651181 The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732311405686 http://qhr.sagepub.com
Abstract The results of this exploratory study reflect a shift from public health studies that aim to examine the risk and prevalence of burn injury, toward eliciting survivors subjective meaning-making processes beyond the injury event. We drew on a narrative framework to explore how young survivors experiences of burn injury led to reconstructions of self and shifts in thinking about others and the world. Although participants narratives revealed elements of heightened selfawareness, need for acceptance, and desire for recognition, these stood alongside counter narratives denoting positive, transformative, and resilient aspects of healing that reflected a rebirth of the self, life having purpose, and psychospiritual growth. A multidimensional and relational framework for resilience acknowledges the deficient, but also recognizes the pathways to growth, healing, meaning, and purpose. This shift toward person-centered meanings has value in informing interventions beyond the immediate wound care, toward the survivors lifelong (re)negotiation of identity, appearance, psychological adjustment, and social reintegration. Keywords adolescents / youth; burn injury, burns; narrative inquiry; resilience; self According to the World Health Organization (WHO), burn injuries constitute a major threat to children, especially to those younger than 12 years, who sustain the highest percentage of hospitalizations (WHO, 2004). A disproportionate concentration of burn injuries occurs in low-income contexts, with the Southeast Asia and African regions reporting the highest mortality rates (WHO, 2002). On the African continent, the burden is particularly high among children younger than 5 years (Forjuoh & Gielen, 2008). Within these settings, a myriad of factors related to poverty, lack of education, migration, poor access to water and electricity, and the development of slum settlements have contributed to higher incidences of burn injuries and fatalities (Albertyn, Bickler, & Rode, 2006). In South Africa, burns constitute the third most significant external cause of death in children younger than 18 years (van Niekerk, Rode, & Laflamme, 2004), with a significant percentage of burn injuries and deaths attributed to shack fires (Godwin & Wood, 1998). To compound the problem, limited resources for burn rehabilitation have translated to very few quality, specialized burn care units across Africa (Albertyn et al., 2006). Even in South Africa, the significant financial costs associated with burn treatment itself (Bowman & Stevens, 2004) have meant that postcare support is largely inaccessible to large segments of the population, unless this is sought via the private health care system. Early studies at the Red Cross Hospital Burns Unit in Cape Town admitting largely children from low-income settings, for instance, revealed that 70% of severely burned children had either attempted or committed suicide. Although more recent efforts have been geared toward a rehabilitative focus in South Africa, such care for burn survivors is sorely lacking (Forjuoh & Gielen, 2008). Several local epidemiological and public health studies have focused on the increasing burden of burn injuries in South Africa. These studies have yielded valuable information on the burden of burns (Albertyn et al., 2006, p. 605), and have illuminated the extent, risk, and prevalence of injury, providing an important basis for the development of prevention initiatives. However, to understand the full extent of this burden of injury, as well as to enhance avenues for prevention, we propose that it is necessary to elicit the voices of survivors themselves to shed light on processes of healing beyond the injury event.
Institute for Social & Health Sciences, University of South Africa, Johannesburg, Gauteng, South Africa 2 Medical Research CouncilUniversity of South Africa Safety and Peace Promotion Research Unit, Cape Town, Western Cape, South Africa Corresponding Author: Ursula Lau, Institute for Social & Health Sciences, University of South Africa, P.O. Box 1770 Lenasia 1852, Johannesburg, Gauteng, South Africa Email: ursula.lau@gmail.com
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1166 As some researchers have pointed out, scant attention has been given to adaptation and reintegration processes following a burn injury (Blakeney, Partridge, & Rumsey, 2007; Wiechman & Patterson, 2004; Williams, Davey, & Klock-Powell, 2003). To date, little or no qualitative research has been undertaken in South Africa that offers in-depth insight into the postburn experience from the perspective of survivors. Such viewpoints are crucial in shedding light on the human aspects involved in coping with and managing injury. Moreover, given that burn injuries are overrepresented in the lower-income areas in the country, this understanding is particularly important within this local context, which is adversely shaped by factors of poverty, violence, and limited access to resources for large segments of the population (van Niekerk, 2004). We adopted an alternative conceptual, methodological, and analytical frame, shifting the lens from the injury event itself to a consideration of the aftermath of burn injury in the contexts of healing, reconstructions of self, and worldview in the meaning-making process. In so doing, we advocate for a new dialogue on burn injury in the African context by privileging the subjective viewpoint. In this exploratory qualitative study, we explored how burn survivors constructed notions of self and social reality. We were guided by two research questions: (a) How do young burn survivors define themselves in relation to their burn injuries? and (b) How does the burn incident influence or lead to a transformation of life or worldview?
Qualitative Health Research 21(9) symptoms (Bendelow, 2006; Morse, 2000). Injury, defined in these terms, not only fails to acknowledge the emotional and subjective meanings of experience, but also removes the human response to pain and suffering; more specifically, the empathic or compassionate behaviors of those attending to the injured (Bendelow). Alternatively, social science perspectives have offered valuable shifts in understanding the person experiencing the pain, as opposed to the pain itself (i.e., management of symptoms; Bendelow, 2006). A well-developed corpus of psychological literature on burns, in turn, has focused on the impact of the trauma on survivors self-esteem, body image, social adjustment, mood, and quality of life (Bowden, Feller, Tholen, Davidson, & James, 1980; Gilboa, 2001; Orr, 1989; Pope, Solomons, Done, Cohn, & Possamai, 2007; Robert et al., 1999). Several researchers have illuminated some of the adjustment challenges associated with burn trauma, such as severe stress, emotional exhaustion, and depressive symptoms. Other investigators, however, have pointed toward the contradictory and puzzling results (Robert et al., 1999, p. 581) yielded by studies of self-esteem among burn survivors, with some reporting moderate levels of self-esteem, and others suggesting poor adjustment and significantly diminished feelings of self-worth. In this regard, criticisms related to small sample sizes, lack of control groups, use of nonstandardized measures, use of secondary source data, and variability in the period between data collection and the injury have been proposed to explain the inconsistency of results (Pope et al., 2007). By framing individuals adaptations to severe injury solely in terms of a medical lens, researchers have essentially focused on the psychopathology of burn survivors (Pope et al., p. 747). Methodologically, researchers have relied on objective measures (self-report questionnaires, psychometric scales, and other reporting instruments) that highlight symptomatology and levels of psychosocial adjustment with reference to externally derived criteria. These quantitative methods are often less suited to exploring personal, social, cultural, spiritual, and other meanings and constructions in relation to the burn identity. Although the injury might be a one-time event, rehabilitation and recovery are often lifelong psychological journeys of healing and meaning making. As Stouffer (1995, p. 208) has articulated, coping with the consequences of (burn) injury is an unfolding process whereby new meanings emerge both in relation to the injury and for the self in relation to the injury. Given the scarcity of qualitative studies on burn survivors, studies on survivors of traumatic injury and chronic illnesses have been drawn on and used as a referential basis for subsequent studies on burn-injured individuals, reasoned on the basis of commonalities in experience during the recovery process (see Morse & OBrien, 1995). These have yielded important insights into how such
Literature Review
In South Africa, an increased interest in burns has led to research typically framed from public health or health science paradigms, where emphasis is placed on understanding the clinical features; etiological, epidemiological management; and selected prevention aspects associated with burn injury (Albertyn et al., 2006; Godwin & Wood, 1998; van Niekerk, Du Toit, Nowell, Moore, & van As, 2004). Within the same conceptual paradigm, a small number of qualitative studies have contributed toward an understanding of the etiological factors in childhood injury, and how injury perceptions might be used to enhance preventative interventions (Munro, van Niekerk, & Seedat, 2006; van Niekerk, Seedat, Menckel, & Laflamme, 2007). For instance, in van Niekerk et al.s (2007) study, caregivers accounts contained several intervention strategies directed at intersecting variables (such as individual and family circumstances, cultural context, and so forth) that contributed to the childs burn injury. Underpinned by medicalized discourses, in these studies injury was depicted in rational and technical terms, pain was conceptualized in terms of risk, and suffering was denoted in the language of observable and objective
Lau and van Niekerk individuals negotiate self-identity postinjury. Based on a grounded theory analysis of interviews with survivors of life-threatening accidents (including burns, gunshot wounds, motor vehicle accidents), Morse and OBrien identified four stages of preserving self (p. 887): vigilance, disruption, enduring the self, and striving to regain self, during which the individual undergoes a transforming process from patient to the disabled person as a reformulated self. According to the authors, rather than being a rehearsed process, these stages are influenced by the individuals ability to muster resources in the midst of the experience (p. 896). Focusing on burn survivors specifically, Morse and Mitcham (1995) explored the notion of embodiment/disembodiment, which they defined as the bodily aspects of subjectivity (p. 668). Participants references to their body parts were typically made using depersonalized language (it, the, this), which signaled attempts to maintain self-integrity during prolonged periods of physical pain. These studies have provided useful insights into how survivors articulate personal meanings related to their postinjury experiences. From a symbolic interactionist approach, Charmaz (1995) explored questions about self in coming to terms with assaults on the body because of illness or disability that might disrupt a sense of the body and self as being unified. Processes of adapting were illuminated through themes of struggle and survival among several participants, where bodily disintegration existed alongside the development of a more resolute self with enhanced awareness and inner strength. Similarly, Williams et al. (2003) foregrounded themes of survival and triumph over adversity in stories of burn survivors aged between 31 and 51 years. These were denoted by both losses and gains, and emotional responses ranging from forgiveness and spiritual awakenings to experiencing bitter disappointment, on-going anger, and blame (p. 72). Moi and Gjengedals (2008) phenomenological study of burn survivors (averaging 46 years old) pointed toward their expressions of positive growth alongside their feelings of suffering. Their personal stories reflected processes that denoted a striving for regained freedom (p. 1628); in other words, enduring (i.e., having hope), expressing loss and grief, experiencing death as less frightening, making comparisons with others, and having feelings of gratitude (stemming from survival and progress). Akin to these notions, Stouffer (1995) articulated the postburn recovery of survivors (aged 22 to 37 years) as a process of rebirth, not only to metaphorically depict the postburn experience, but also as a way of conceptualizing experience and self, for themselves and for others (p. 214). The participant accounts reflected in these studies, however, seem to be skewed toward the postburn experiences of more mature adults. Child-centered experiential
1167 studies, moreover, have typically been evaluative in nature; for instance, examining therapeutic efficacies of treatment programs (e.g., Cox, Call, Williams, & Reeves, 2004; Maertens & Ponjaert-Krisoffersen, 2008; Williams, Reeves, Cox, & Call, 2004). Williams et al.s (2004) study on burn-injured adolescents perceptions of burn camps, for example, highlighted the positive influence of burn camps in contributing toward feelings of normalcy and acceptance, along with providing deeper self-insights, enhancing self-esteem, and the capacity for empathy. What is lacking in the literature is an understanding of how young burn survivors construct their identities in relation to their burn injuries. Such studies would shed light on postburn recovery experiences of burn survivors in more adverse environmental contexts in South Africa, where access to specialized burn care alone remains a challenge (Albertyn, van As, & Rode, 2008). Developing from these diverse studies on injury, illness, and disability, we drew on a qualitative research paradigm that moves beyond the reductionist strategies of risk assessment and management outlined by positivistic approaches, toward an experience-near approach, which engenders a more profound understanding of injury in the embracement of subjectivity, meaning, and context (Bendelow, 2006; Kelly, 1999). In doing so, we aimed to address the research gap by exploring processes of identity negotiation among adolescent and young adult survivors. This knowledge is crucial given that intra- and interpersonal relations are central to the task of identity development during adolescence and early adulthood (Compas & Wagner, 1991). Thus, common anxieties experienced by adolescents in generalfor instance, body image, peer acceptance needs, identity, and autonomy (Williams et al., 2004) might be amplified for young burn survivors.
Toward Poststructuralist Constructions of Resilience

In line with these studies, we attempted to draw on a strengths-orientated framework for understanding resilience (Walsh, 2003). In particular, our insights were derived from relational constructions of resilience informed by poststructuralist discourses. Moving away from more traditional structuralist understandings of resilience, where the focus is on the objective measurements of inborn qualities, an internal locus of control, or hardiness (Appelt, 2006), poststructuralist notions emphasize the subjectively defined nature of resilience, as well as the relational and multidimensional facets. Rather than being a fixed or static personality trait ascribed to the individual level, resilience from a poststructuralist lens accommodates for fluidity, variability, and the tension of opposites. For instance, as Harvey (2007, p. 15) suggested, defining resilience as multidimensional lends a new
1168 understanding of trauma survivors in the recognition that resilience co-occurs with even severe distress. As echoed in earlier studies, Higgins (as cited in Walsh, 2003, p. 58) noted that rather than merely bouncing back from adversity, individuals who triumphed over difficult childhood circumstances struggled well through a painful process. As a small cluster of studies has shown, alongside emotional struggles of sadness, anger, fear, grief, and near suicidality, survivors of burns, traumatic injury, or illness were also able to reframe their adversity in the context of personal growth, meaning making, epiphinal experiences, insight, gratitude, forgiveness and spiritual awakening, striving to regain self, and a striving for regained freedom (Frank, 1993; Moi & Gjengedal, 2008; Morse & OBrien, 1995; Williams et al., 2003; Williams et al., 2004). It might be inferred then, that these response shifts (Sprangers & Schwartz, as cited in Moi & Gjengedal, 2008) or transformative learning1 (Meizrow, 1991) reflect a multidimensional view of resilience. Aligned with this multidimensional view is the understanding that resilience involves the interacting influences of the individual, family, community, and broader society that mediate how stressful challenges are negotiated. As Walsh (2003) has noted, resilience studies have pointed toward relationships as lifelines for resilience (p. 53)whether these might include relationships of kin, strong friendships, mentor relationships (e.g., teachers, counselors), ties to a religious community, or a personal relationship with God.
Qualitative Health Research 21(9) as a source of knowledge production. The value of such a tool is embedded in the assumption that peoples lives are socially constructed through the multiple stories they tell and that these stories are colored by the cultural and historical contexts within which they occur (Hilker, 2005, para. 1). More than this, stories are also sites of change; the narrator is able to reconceptualize notions of disability and thereby effect a sense of well-being (Skinner, Bailey, Correa, & Rodriguez, 1999, p. 482). In adopting this framework for reframing disability, we give cognizance to the positive, transformative, and resilient aspects of healing that might coexist alongside the deficient and negative. We employed a depth focus characteristic of qualitative interviewing. Even though participants stories as data sources were primary, we also linked individual experience to existing theory and conceptual frameworks, knowledge of the social circumstances in which participants were contextually located, and the significance of researcher reflexivity. As Crouch and McKenzie (2006) have argued, these particular elements underpin the logic of a small number of participants typical of exploratory qualitative studies.3 We explored the complexity of injury by allowing participants diverse aspects of experience, thought, and feeling to be foregrounded, and to understand how these converge into a unified purpose (Polkinghorne, 1995), in a sense allowing healing narratives to tell themselves (Parry, as cited in Appelt, 2006, p. 33). Such an approach is powerful in its potential to validate the experiences and knowledge of ordinary people. As Fraser (2004) has pointed out, the narrative approach brings to light subjugated or hidden meanings, which become significant in challenging established and taken-for-granted truth presented by dominant theories. In place of a singular truth, the plurality of truths is uncovered (p. 181). In upholding the epistemological stance of interpretivism, we justified our use of in-depth interviews as a means to elicit subjective meaning (Neuman, 1994). After obtaining individual consent, we audiotaped the interviews and transcribed them verbatim. We designed a semistructured interview schedule to tap into topical areas framed by the objectives and research questions and, as a guide, drew on first-person accounts of burn survivors from qualitative studies (e.g., Robert et al., 1997). For instance, Robert et al.s (1997) study tapped into the concerns of postburn pediatric and adolescent burn survivors, and highlighted the range of reactions denoting concerns and/or assertions of coping, such as denial; anger; grief vs. determination and acceptance; rejection vs. acceptance by others; and chaos vs. meaning.
Methodology
We employed a qualitative research design informed by social constructionism,2 an interpretive approach that assumes that a subjective sense of reality is the basis for understanding and explaining social life (Burr, 1995). Such a view is in line with the premises of symbolic interactionism, namely that human action is based on meanings ascribed to events, and that such meanings are socially negotiated with others and society through language and thought (Blumer, 1969). Although such assumptions form the basis of our methodology, we emphasize that such meanings might be derived beyond the micro-scale processes of human interaction. Meanings are often unstable, not fixed, and are also the sites of cultural, political, or ideological struggle (Sarup, 1993). From a poststructuralist lens, we implicitly offer a critique of the scientific gaze that has dominated conceptualizations of burn injury by affording burn survivors the opportunity to speak their personal truths through their narratives. The narrative research approach informed by social constructionism therefore presented as a valuable tool to engage with the unexplored meanings of the postburn injury experience. Defined as the basis of identity in psychology (Plummer, as cited in Fraser, 2004, p. 180), narrative research encompasses the use of personal storytelling
Procedure and Analysis

In-depth interviews allow researchers to have a first-hand involvement in the research process. This is particularly
Lau and van Niekerk pertinent in terms of the narrative framework, where the storytelling process between the speaker and the listener is central to framing meaning. We sought ethical approval to conduct the study from a university research ethics committee, and thereafter sought consent from relevant burn support organizations to approach their members as potential participants. We received parental/guardian consent for two participants who were younger than 18 years prior to commencing the interviews. Depending on the protocol of the organizations, the first author (Lau) approached participants either in an informal group setting or on an individual basis, and outlined the research aims, expectations for involvement, and ethical issues pertaining to participation. Prior to the start of the interview, the first author reacquainted participants with these research aspects and provided them the opportunity to ask further questions. The interview length was influenced by the talkativeness of the participant and his or her willingness to engage on a deeper level of storytelling (see Moi & Gjengedal, 2008), and ranged from 22 to 38 minutes. The interview schedule was used merely as a guide. In most instances, participants led in their story constructions. When necessary, probes were used to elicit deeper meaning and reflection. Prior to closure, participants feelings about the interview process were explored, opening up the way for debriefing. We analyzed the data using guidelines for doing narrative analysis proposed by Fraser (2004, pp. 186-197). During the interview phase, attention was directed to how stories were narrated (e.g., body language, emotions). Points of agreement and disagreement, as well as the genres of stories (e.g., stories of triumph vs. tragedy), were noted while listening to the audiotaped interviews. In Phase 2, the first author transcribed the audiotaped material. This process allowed immersion in the data and new meanings to be pieced together. In Phase 3, individual transcripts were interpreted through identification of dominant themes, story type, and contradictions. Phase 4 involved scanning the narratives for different domains of experience (i.e., intrapersonal, interpersonal, cultural, and structural aspects) as meaning-making systems. Phase 5 involved identifying dominant discourses located in the narratives to reveal the interpretive framework of stories. In Phase 6, commonalities and differences across transcripts were examined and connecting plots, events, and themes analyzed. Phase 7 necessitated pulling together the different stories and translating participants oral talk into academic knowledge. Pals (2006) Methodological Tool for Life-Story analysis was also consulted to highlight themes that reflected self-transformation (whether in growth-promoting or limiting ways), although formalized steps were not undertaken. In writing up the results, participants self-chosen pseudonyms were used.
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Participant Characteristics
Our purpose was to seek out individuals of a kind (i.e., having the shared experience of burn injury) rather than variants within a particular social setting (Crouch & McKenzie, 2006). Our purposive method of recruitment resulted in a typically homogenous group of 6 participants from two organizations that had existing support services for burn survivors. One was located in a low-income township area, drawing in participants who had limited financial and structural resources. The other was located in an urban context, but typically attracted burn survivors from low-income areas across the country. This spread of participants was sought (irrespective of cause and specific circumstances of occurrence) from low-income contexts where the burn injuries were concentrated. To meet the purposes of the study, participants having a sufficient level of cognitive ability to reflect on their experiences and to impart personal meanings was a necessary criterion for participation.4 Other criteria included recruiting individuals who were able to express themselves fluently in English, had been hospitalized for their burns (i.e., had sustained moderate to severe burns), and had sustained their burn injury at least 2 years prior to the interview.5 Originally, the intended cut-off range for participation was limited to adolescents from age 13 to 20 years. As a result of practical constraints and difficulties in obtaining participants to meet the full criteria, however, two participants falling outside the age range (aged 23 and 24 years, respectively) were included in the study. The participants comprised four young men and two young women, averaging 19 years old (range 14 to 24 years). Although they self-identified as Xhosa (n = 2), Zulu (n = 2), Sotho (n = 1), and Venda (n = 1) first-language speakers, respectively; they were nevertheless able to express themselves effectively in English. Four participants resided in Gauteng, one was from Kwa-Zulu Natal, and one lived in the Eastern Cape. Central to our exploratory aim, the burn survivors presented as a fairly homogenous group in terms of race/ethnicity, age group, and social class (young Black individuals from historically marginalized communities and of a lower socioeconomic status). Four participants sustained injuries in the home as a result of accidents, another was a victim of a fire intentionally set in the home, and one received her injuries from a fire in a motor vehicle emanating from a faulty engine. Three participants sustained their injuries at early points in their lives, whereas the remaining three individuals were injured during their (pre)adolescent years. We justified our limited sample size not so much on the basis of phenomenological assumptions (e.g., Adamshick, 2010), which did not underpin our study, but rather on the basis of an empirical perspective reliant on in-depth interviewing, labor-intensive analysis focused on depth, and
1170 last, the employment of researcher reflexivity (Crouch & McKenzie, 2006, p. 484). In this respect, we drew on two important sampling considerations in published research: appropriateness and adequacy (Kuzel, 1999). Similar to other studies employing a limited sample (e.g., Miller, Yanoshik, Crabtree, & Reymond, 1994), our objective was to explore subjective meaning by purposively deriving a sample of like individuals. On the basis of the exploratory paradigm, the depth focus utilized, and the sample homogeneity, issues pertaining to both appropriateness and adequacy were addressed (Kuzel, 1999).6
Qualitative Health Research 21(9) Another participant, who sustained her burn injury at age 5 from an overturned kerosene lamp, learned to recognize her difference from others through the experience of social rejection and name calling. Associating the pain of peer rejection with the realization of difference, she recounted, I didnt feel any pain until, until, until I grew up, you know. . . . You realize you know you different and thats when I feel pain like. . . . You know when you at school like, some other kids, they dont understand, you know, just look at you. You so different to them. Buhle,8 who sustained hot water burn injuries at the age of 3, reflected on the distress of being ridiculed on the basis of his appearance: Oh, that was difficult, that one, cause at school they didnt treat me the way I like them to treat me, calling me names, names, names: Ja, he look like a braaing9 stand. . . . At primary [school], maybe I was in Grade 2, Grade 3, when the teachers say, Eh, you are looking like the Jackson Five family. In another instance, Buhle referred to being called names: I dont know where they get them, calling me the legendary Michael Jackson. The taunting suggests a comparison to the late celebrity figure, who was often depicted by the media as being freakish in appearance (Yuan, 1996). For another burn survivor, who was injured in an arson attack, the visibility of his scars led to awkward interactions with girls. He recounted an experience which left him feeling rejected on the basis of his disfigurement: She [the girl] tell her friend . . . What are people going to say when they see me standing with a person who have got scars? As these excerpts revealed, alongside the recognition of being different was also the feeling of being deficient or subhuman, as one participant highlighted: Some they tease you [pause] some they treat you like you are the mad one, some of them treat you like you are not normal. Buhle also articulated his struggle for acceptance, highlighting his need to be counted as a person amongst all people . . . [as] a human being. Echoing these sentiments, another participant noted, Accept what I, what I look like, and accept that Im, still a human being. Thus, on one level the pain of being too visible existed simultaneously alongside the pain of being invisible. Whereas the disfigured self was visibly apparent, the self that participants referred to as me was hidden from view, taking the form of the shadow of the highly visible and disfigured self. One participant (who chose the pseudonym John) related his frustrations at not being able to disappear in
Findings
In response to the questions guiding the study, participants responses cohered along three central themes. These included (a) the struggle for recognitionthe self as both highly visible and invisible, (b) reconciling selves or rediscovering the self, and (c) turning pointsthe search for meaning.
Theme One: The Struggle for RecognitionThe Self as Both Highly Visible and Invisible
Benjamin (1988) theorized that being recognized by another is fundamental for the achievement of self-understanding and acceptance. Participants in this study struggled for this recognition.7 Their disfigured outer appearance masked an inner self that they felt was overlooked but longed for recognition. The realization that one was physically unlike others was expressed by all 6 participants. For some participants, this recognition had its experiential basis in defining moments in which being different was made conspicuous. One participant sustained his injury in a fire caused by a toppled candle at a very young age, and was thus disfigured for most of his remembered life. Nevertheless, his early experience of social rejection was a rude awakening, inscribing difference into his concept of self, and forcing separateness from his peers: When I grow up, I didnt notice that I was different. I noticed when . . . I was like, playing with other children and then they said they cant play with me because Im, Im different. And then I said, What, am I different? And then they said, You missing an arm, you dont have an ear, and then I started to cry and I run home. . . . I felt, I felt bad. . . . I was still small . . . people looked at me like they dont know me. Some of them didnt even want to talk to me, so I started to see myself differently from other children.
Lau and van Niekerk the crowd, given that his scars were taken as the markers of his identity: They know you, much of them know you . . . and then I say, Hello. Well how do you know me? [They] just tell you that, Ive saw you, Ive just saw you somewhere. Ja, you cant run away because, he or she have seen [you] somewhere because of the scars. They remember it because you have got scars. For another participant, who sustained severe burns in a motor vehicle fire at age 18, being under continuous scrutiny was a constant challenge that engendered feelings of self-consciousness: They look at me like maybe ten hours . . . . I dont like it. The feeling of heightened visibility was moreover illustrated in another young womans painful recounting of an experience in a store, where her scars were rendered conspicuous: There was this lady . . . there at the till. I really dont like people doing that like, What has, what happened, did you burn? I mean I ignore her. Im not gonna answer, Im not gonna say anything. I keep quiet and then she say, What happen, did you burn? . . . really loudly, you know in the shop. Everyone isyou know you wanna put me in a spotlight. Even though someone didnt notice now, shes gonna notice now that Im a burnI was burned. The paradox of being both visible and invisible also stood out prominently in other participants narratives. One participant, taking Emily as a pseudonym, expressed a longing to be recognized as a person with feelings, wants, and desires: You know most people they judge you. They see you and they dont even know you, they didnt give herself time to know you. Similarly, a survivor who chose to be called Simpiwe articulated, Its like those other kids, they dont understand what am I feeling. In Buhles case, the struggle for recognition extended to experiences of positive recognition, where members of his church would constantly assist him and plead his cause (e.g., Buhle deserve[s] this, Buhle deserve[s] that). Though affirming in nature, for him these experiences nevertheless reinforced a deficient identity that placed him in a special class that excused him of his wrongdoings: Some of them, they were treating me like I was eh, a disabled person. I told them, No, dont treat me like this. I got my needs too, but . . . even if I do wrong things, you almost at my side. As these excerpts illustrate, participants felt that a label of deviance was being superimposed on a real or inner self that was struggling for acceptance. Buhles narrative
1171 revealed the flipside of this struggle as he recounted a defining moment of true recognition. As the excerpt below suggests, this moment of psychological recognition simultaneously awakened within him physical feelings of excitement and a social awakening to connect with others: I used to ignore them, just look down because I know they will be calling me by names. But now when I look down, they [say], Eh Buhle, dont look down man, whats up? And then my heart just skips a beat, and then, Im feeling more excitement. I wish I could communicate with this person, and then we talk, we talk, we talk. Symbolically for Buhle, in this act of acknowledgement, the identity carved by others was subsequently overwritten by a core identity, one that he had initially struggled to affirm: They dont call me by my nickname, they call me by my straight name, the one that is written in my ID [identity document]. Similarly, Emily narrated an incident during which she began to realize the capacity of others to see beyond the outer image and to discover the hidden person within: Everything that is inside cames outside, like thats why theres people, they do really even though they not gonna be all the people, but most of people that Ive been with, they really, they really, really like me. Compared to other participants who willingly adopted a pseudonym, Buhle was insistent on keeping his authentic name. His narrative stood out as one in which he resisted others attempts to impose their own disempowering meanings on him. In the extract below, he affirmed his own worthiness to be accepted as a person in his own right: My grandmother told me, You should stay at the house, you mustnt go outside. You should stay at the house. And then I told her, No, God has made a purpose with me. I shall never stay at the house, like Im nothing! Im a human being. I deserve to be with other people. If they dont like my treatment to them, okay right, thats fine. Ill stay with somebody who loves me and appreciate me for who I am. Although interactions with nonburned individuals awakened their emotional vulnerabilities, the participants perceived that the boundaries of self (the outer and inner) had dissolved in their interactions with fellow burn survivors. Within this space, participants found temporary reprieve from their struggles. One respondent conveyed this as the comfort of familiarity, enabling his identification with another: When I came here and saw the other children, and we like talked and we had fun and they told me, Its not only you. Theres some other kids
1172 that have the same disability as you. For another participant, these interactions were conceived as spaces of shared meaning: I just want to, to, to stay with other children . . . burned just like me, to understand each other. Another interpreted these interactions as opportunities for mutual support: I wish I can stay with those who got wounds all the time, and talk with them, and have the support to each other.
Qualitative Health Research 21(9) when I see them, its like a map that I will be touring, where I will be touring in different areas. And then I see myself being here, being there, being here, being there. And then I think to myself that I will make it with these wounds, with nobodys problem, with every matter that I will be coming across. With these wounds I will be a better person. The movement from self-denial toward self-acceptance mirrored the process of being lost then found, as reinforced in Buhles statement: I come to accept myself. Another participant, choosing to refer to herself as Bullet, underwent a similar transformation process; however, having sustained her injuries in late adolescence, her disability or disfigurement was a recent adjustment. Her grieving process was both a physical and emotional one as she attempted to come to terms with the loss of bodily functionality: I was feeling useless, and it was so burned. I, I cant do the most things. . . . I was feeling like I dont want to live anymore. Following a similar process to Buhle, Bullet engaged in avoidance behaviors that further increased her social isolation: I was just negative. I was, I dont want to go to most people like mall[s] to go shopping. I was just dont want to go there. Yes, I stay for long time, and if I was at school, if its lunchtime, I dont go outside; I was just sitting in the classroom. Like Buhle, Bullets narrative contained patterns of transformation and growth. She shared her feelings around reconciling the outer self with the self she knew within. This process of self-acceptance was facilitated by the realization that, despite the radical changing of the outer self, her inner self existed as more stable and permanent: And sometimes, I just telling myself, Bullet, dont theres nothing about outside. If you inside your heart, you are that same Bullet, theres no problem. Her constant reference to herself in the third person in some respects reflected her attempt to consolidate the old and the new. In the following exchange, she nostalgically referred back to old photographs, yet acknowledged the impracticalities of returning to the image of her former self: Bullet (B): Sometimes I think about, and when I see my photos, you see . . . I just sit there and think ei, if I have some money, maybe I just doing something for my face, because there are most people who are burned but they look, they are not black like me, you see. Interviewer (I): Mm, so theres always a wish, a wish to be back to the old you.
Theme Two: Reconciling or Rediscovering the Self

As Theme One revealed, participants encountered paradoxical struggles associated with being both highly visible and invisible at the same time. Participants, moreover, were confronted with a more private struggle associated with the reconciling of two selves. Some survivors who had sustained burn injuries at later periods in their lives made references to mourning over the lost self. Confronting the new self during the mirror momentseeing ones appearance for the first time after the burn injury (Patridge & Robinson, 1995), was an internally distressing moment for one participant as he attempted to come to terms with the loss of his facial and bodily appearance. Recounting his difficulty in reconciling the former self with the new self, he remarked, I didnt believe that its me. . . . It was painful inside me, because the way I was changed. Throughout his narrative, his reference to pain seemed to be reflected interchangeably on the levels of both the physical and the emotional (e.g., Had nothing that will be [more] painful than fire). In contrast, Buhle, whose burn identity was already established a few months into his life, narrated his struggle in terms of a symbolic loss rather than a physical one. Metaphorically depicted in imagery of smallness and a self-recoiling from the world, this was characterized by self-denial and a self-reinforcement of otherness: I was trying to hide away, just staying at my house, minding everybodys business. . . . If they could come to me, ja, I will never respond to them. Im not here, but Im still in the house. It was like I was just a little bit small to theI felt, I felt like Im nobody. I dont deserve to be in this world. At subsequent points in his narrative, Buhle recounted how he gradually embraced a survivor identity. In contrast to the immobility, passivity, and concealment, the excerpt below reflects a change revealed through metaphors of travel (or mobility), active self-discovery, and a move toward positive transformation: When I look at them now in the mirrorat first it was tears, now its just laughter uh, and fun. Like
Lau and van Niekerk B: No, I know I cant be that Bullet, I cant go back to be that Bullet, because you see my hands. I just, see ei, I cant be that Bullet. Participants who had had their injuries for most of their lives also underwent similar processes of reconciling selves. One participant spoke about reconciling the outer image with a more enduring part of herself (or personhood): But as time goes I, I became fineja, its just that, you know. Its like okay, outside I am burned but then inside Im, you knowmy personality. Employing similar metaphors of hiding vs. unveiling, she described how she pulled herself up from each fall and in the process discovered a resilience that helped her to persevere: No. No, I think if it would have affect me, I maybe I could never finish my school, maybe I was gonna hide myself, you know. . . . I would have dont want to see anyonejust hide myself, my own space know. So I think nothe more they did that, I think the more it makes me strong, makes me like, keep going up and up. Another respondent, who chose to be referred to as Innocent, offered a deeply personal account of undergoing a process of quiet reflection during which he discovered his own enduring resilience. His narrative, also denoting growth and transformation, reflected the processes of translating painful childhood experiences into positive, growth-promoting meaning in the present (Pals, 2006, p. 186), as explicated below: Yes, well its just practicingdoing, doing things that no, nobody knows, but you only know inside of yourself. You just sit down and think, you think of what will happen, think of what happened and what changed it, and how you changed yourself and how you, have been able to, to, to defend yourself from other different diseases and other situations, where you dodge, where you like never will go through, but with family and friends, you made it, you made it through. Beyond the physical transformations, some participants also made reference to undergoing a radical transformation of self (or a symbolic death of the old self). One participant identified her past burn experience as being causally connected (see Pals, 2006) to her present definition of self, whom she redefined as being more tolerant and respectful of others: When I was the old [self], I was just like to speak, like to shout. I was just of that anger, you see. I was normal and I dont care. But now Im nice person, Im changed. Other participants (despite having no normal self as a referential basis, given the early age of their
1173 injuries) embarked on similar meaning-making processes, leading to reconstructions of self. Buhle eventually renounced the self in hiding, and gave birth to a new self that was allowed to take up space in the world: Now Im seeing myself as a bigger person, a person who has a need to be in this world. And a person who goes to them, and shows them what Im doing. Another survivor embraced the self who had overcome all odds, learned perseverance, and defeated fear: Ive developed, strong full of knowledge, and I have learned a lot from this, this situation that Ive been through and now I know, how to like . . . cover it and like go through, through the disability that I have. And you . . . mustnt be scared, of anything. Alongside the dominant narratives of positive transformation, however, one narrative stood out as being marked by instability, showing no distinct evaluative relationship between self and time (Pals, 2006). Compared to the other participants, who sustained accidental burn injuries, this participant was injured in a fire set intentionally. Unlike the other narratives, his articulations were void of conscious efforts at reconciling his pre- and postburn identity. His burn experience led to the narrowing of the self (Pals); however, only to the extent that it informed a limiting view of others: I have learned that when you are burned, people treat you different. However, his narrative was not a regressive one either. For him, his disfigured appearance limited the extent of his interaction with others, particularly girls, but this did not discourage him, either: Approaching girls, some of them they can allow it, and then some . . . shes making you like [youre] stupid. Demonstrating neither progression nor decline, he seemed to adopt an attitude of resigned acceptance. Referring to a girls rejection of him, he noted, I just, accept it because if I stay thinking of it, I will be affected by her tactic. Emergent from participants narratives were points of self-awareness, insight, and renewed meaning alongside elements denoting emotional struggle. Although most participants presented positively illuminating restoried versions of their lives, it is also important to acknowledge the moments of despair that, for some, defined their emotional well-being during times of conflict, stress, or uncertainty. Another survivor also adopted an attitude of resigned acceptance as she expressed the futility of ruminating over her former appearance: Im just look at me and I see my face, I just aah, I like who am I. Theres nothing I can do. Many burn survivors expressed the constant tension between acceptance and struggle, as poignantly captured in the following: When you talk about that you become emotional, and thats when you realize that, how much it cost
1174 youthats when you realizeI ignore some other things, but then . . . when theres a time like now, I have to confront those things . . . . I see myself everywaking up, waking up very happy, waking up even though Imyou know when Im angry, sometimes I dont talk. I just sit there and I cry and I think and I cry, and then after that Im okay.
Qualitative Health Research 21(9) Ah, its helped me a lot, because they told me we must notah when I was first time here in [province], I was justI was negative with my life, so when Im join the [support group], I have found power, some energy. Like several other participants, she found meaning for her burn experience in relation to religious/transcendent cosmology (see Kelly & Dickinson, 1997). According to Wallis and Bruce (as cited in Kelly and Dickinson), under religious/transcendent cosmology it is assumed that events are under the influence of supernatural entities with powers of agency, or impersonal powers or processes possessed of moral purpose (p. 267). She ungrudgingly denoted it in terms of Gods will: Sometimes I just think why this happen to me, but I just think the most things are happen to some people. Maybe its God; its God who knows, you see . . . I dont feel its unfair . . . I cant blame anyone. It was an accident. Other burn survivors also recounted processes of praying (e.g., to feel and praying, praying all the time) as part of their physical and/or emotional recovery. Extending the religious metaphor further, another survivor referred to godly power in a miraculous form (Me, I do believe in miracles). She sought meaning from her experience through discourses of life-death-rebirth, symbolically a baptism by fire in Christian theology. For her this was characterized by the symbolic death of the old self: And then [I] didnt know I will survive, cause I was, I was even small, small, small, small, small. I didnt know how to do anything. I didnt eat. For her, going through the proverbial refiners fire was necessary as a rebirthing process for the new self: I said to myself that maybe I am a new person. Ja, I was burned there and thenactually they didnt know that I will survive. I think I was, born again, ja, and now Im someone whos supposed to be here . . . to live again and to show people, whats exactly wh-whwha you know. I dont know how I can explain this. I think thats the thing that keeps me going, cause of God, cause I think I wouldnt be here without him. He is the one who, whos inside me, who controls me. Rather than framing the meaning of his experience in religious terms, another participant recounted a transformative shift in his attitude that was brought on through his interaction with a health professional: It changed me like, when I was old, when I . . . get the point of why is it happening to me, and then I went to another doctor at the [local hospital], and
Theme Three: Turning Points: The Search for Meaning

Participants narratives also contained references to existential themes. Most made reference to relational elements (i.e., interactions with others) that facilitated this (re)framing of meaning or purpose derived from their burn injury experiences. Significantly, this theme brought to the fore the interpersonal, cultural/community aspects, and to a small extent, the structural/societal aspects that are embedded in the stories people tell (see Fraser, 2004). Such contexts were interpreted as either empowering or disempowering, or facilitating or hindering the processes of recovery and reintegration to society (some of which have been highlighted previously). One participant recounted an emotionally laden moment when she returned to her village for the first time after her hospital discharge: I: Mm, and uh, how was it for you when you went back to the village? Participant (P): When Im going back? I: When they saw you for the first time? P: Eish, they crying, but I was the one who make them to stop crying because I told them, If you, you will accept me as I am and I will really appreciate it. As indicated in this exchange, she sought acceptance from her community, who in return received her with much compassion. Their shared grief turned to collective support and paved the way for self and others acceptance. Along with a supportive network of family, friends, and school staff, she foregrounded her partners unconditional acceptance as enabling a process of positive adjustment to the postburn experience: So when I go back at my home after accident, [my boyfriend] come at my home and say, I still love you. I said, No, you cant love me now, because you see Im not that [person]. You must go to the other girls who are not, burned. But he say, I love you the way you are. And he accept me. Although she found love and acceptance from her family and community, actively joining a support group for burn survivors was credited with providing the stimulus for this participants renewed will:
Lau and van Niekerk then he knows. Hes been through all the people bad like me, but Im better than the other ones. He has seen some people thatlike they dont have anything on the body, they just have . . . a mouth and nose, no ears and no hands. So now, it just came to me like, its not, its not bad because Im still alive, its notthe fact is Im not, Im not like, dead. Im still living. Also reflected within these transformative shifts was participants carving of activist identities. One survivor expressed interest in becoming a lawyer to empower people about access to health care (e.g., They dont know law, because many of them, they dont have a lot of medication). Buhle positioned himself as one who would be a positive example to the young burn survivors (e.g., Maybe to go to hospital . . . show young kids who are burned, what other older kids who are older than them). Last, another perceived her role as one who would teach and guide others to pull through adverse challenges (Teach people . . . that you can live with something. You can live, whatever accident that you come across). For these survivors, the conceptualization of new identities emerging alongside their reframing of meaning (whether in existentialist or religious/transcendent terms) represented the turning points that facilitated their processes of healing.
1175 were Black young adults residing in low-income areas and townships. Moreover, a more pertinent marker of difference, particularly for a study of this sort, was my status as a nonburn survivor. Even outside of the interview context, this marker of difference stood out for the second author, despite his extensive research experiences with burn survivors and their families. Although this was not made explicit during the interviews, few participants made reference to individuals such as me (i.e., the first author) as normal or the normal ones. Depending on individual inclinations, these particular constructions might have facilitated or hindered not only the forms of storytelling but also the extent to which participants were willing to trust me with the emotionally vulnerable experiences of their lives.
Discussion
In the narratives examined in this exploratory study, the self was expressed in relation to change over time (typically past and present). As Kelly and Dickinson (1997) pointed out, this evaluative change is not so much about sequence but about order that the self imposes to make sense of events. Gergen and Gergen (1983) originally proposed that stories of the self could be categorized as narratives of stability, progression, or regression. Similarly, Pals (2006, p. 175) made reference to the idea that present identity is causally linked to a significant piece of [the] past. Although the aim of the present study was not to examine the narratives for their structural properties, evidence of temporal sequencing of experience and their interpretive meanings by the participants as having selfdefining significance in the present was nevertheless apparent (Pals, p. 177). Our initial focus was to examine healing narratives irrespective of the circumstances of burn injury. Nevertheless, potentially useful insights emerged that distinguished one participant from the rest. Five of the 6 narratives in particular denoted positive transformation and growth. These dominant narratives reflected growth in the sense defined by Pals (2006): self-enhancement, increased clarity of identity and life purpose, insight into self, and meaningful connections with others. Alternatively, the narrative of the arson survivor was characterized by instability, showing neither decline nor progression of the self. This deviation from the typical growth narratives is an important observation yielded in this exploratory study, as it potentially articulates a rather different psychological trajectory for survivors of intentional vs. accidental burn injuries. Further research is warranted in this respect. Participants narratives defined as interpretive acts of self-making (Pals, 2006, p. 178) is consistent with the postmodern notion of multiplicity of selves. Although participants self-definitions were linked to defining moments of the past, their narratives are continually molded and
Reflexivity
Central to narrative research is the storyteller who constructs meaning in his or her story (Freedman & Combs, 1996). Significantly, meaning that is derived during storytelling (or the interview) is coconstructed in the joint enterprise between interviewer and interviewee (Hyden, 1994, p. 99). In this light, it is necessary to examine issues of reflexivity, namely to critically render transparent how the researchers emotional investment, social location, identity, and theoretical location in relation to the participants act as potential influences on the results (Wilkinson 1988). Because of space constraints, these issues are merely highlighted here as a personal account by the first author (Lau), who had direct contact with the participants. As the first author, my approach to this study was motivated by two related passions: my interest in subjectivity and how people give voice to their experiences, and my curiosity about how people are able to find positive meaning and avenues for growth out of adversity. Approaching the study with this mindset is certainly reflected in the conceptual and theoretical underpinnings adopted. Perhaps of equal significance to issues of epistemological reflexivity is the notion of personal reflexivity. As the interviewer, my social identity as an educated Asian woman and research psychologist from an urban area stood out conspicuously against the participants, who
1176 open to being restoried as new experiences come to the fore. At this point it is important to acknowledge that narratives might reflect other transformation pathways and outcomes beyond what is presented in this exploratory study. Further research might highlight these theoretical complexities related to how the self is created in narrative; for instance, whether the self is necessarily transformed by illness or injury, or whether the emergent self is one facet of plural selves (MacAdams, Josselson, & Lieblich, 2006). Compared to other qualitative studies on survivors postburn experiences (e.g., Moi & Gjengedal, 2008; Morse & OBrien, 1995), the present study did not uncover specific stages of adaptation and recovery. Neither did the study render salient specific themes related to the early postburn adjustment period. Moi and Gjengedal found, for instance, that participants initial phase of recovery was defined by a disrupted life history (p. 1625) characterized by memory loss, nightmares, hallucinations, delusions, and so forth. Similarly, Morse and OBrien typified initial recovery as vigilance and engulfment (e.g., vivid recall of trauma, time expansion, gaps in awareness). Our intent with the present study was not to explore the traumatic response in the immediate aftermath of a burn trauma, but rather to examine the psychological work of healing and identity negotiation in the postrehabilitation phase. Compared to other studies, in which interviews took place at different phases, some at discharge from the intensive care unit or during outpatient contact, and others at discharge from rehabilitation (see Moi & Gjengedal, 2008; Morse & OBrien, 1995), most participants in the present study had sustained their injuries years before being interviewed, and subsequently had time to make sense of and reflect on their experiences. Beyond the stages of immediate coping, however, overlapping themes were apparent; for example, a striving to regain the self (Morse & OBrien) and accepting the unchangeable (Moi & Gjengedal). Themes denoting self-discovery and the search for meaning mirrored notions of triumph over adversity documented in previous qualitative studies. Williams et al. (2003), for instance, found that participants tended to reframe their burn experiences in a positive light or in terms of unexpected gains (e.g., personal growth, self-insight, self-esteem, deepened relationships, or spiritual insights). The positive reframing of adversity was also found in other qualitative studies on chronic illness and traumatic injury, including burns (e.g., Frank, 1993; Moi & Gjengedal, 2008; Morse & OBrien, 1995; Williams et al., 2004). Despite their young ages, participants in the present study offered deep insights into their burn injuries and their implications for meaning and identity. It is possible that such a level of introspection might be fostered by influences such as burn survivor groups to which they all belonged. Williams et al. (2004) noted, for instance, that
Qualitative Health Research 21(9) burn camp experiences fostered a deeper sense of self among adolescent participants. Participants within these therapeutic spaces therefore might have drawn from these discourses of hope, resilience, and self-empowerment. It is therefore important to note that the themes depicted might not necessarily be evidenced among all adolescent burn survivors, particularly for those located in settings where social and more formalized sources of support are restrained or limited (Forjuoh & Gielen, 2008). Equally significant, moreover, is that although the study participants reframed their experiences in optimistic terms, these coexisted alongside hints of underlying fragility, emotional wounding, and implicit struggles in reconciling the old self with the new. Robert et al. (1997) revealed that adolescents potentially described the postburn experience in either negative or positive terms (e.g., grief, anger, denial vs. resolution, determination). Rather than defining participants experiences in binaristic terms, however, allowing seemingly contradictory experiences to emerge in their narratives reveals the complexities and contradictions that define the posttrauma healing processes. For instance, life changes associated with burn injury have also been observed in other studies as a bitter-sweet experience (Williams et al., 2004). In other studies (Stouffer, 1995; Williams et al., 2003), survivors reframing of their adversity reflected positive gains, self-insight, and meaningful purpose despite underlying fragility. Such complexities, contradictions, and inconsistencies in experiences are most aptly captured in poststructuralist notions of resilience. A multidimensional view of resilience advocated by Harvey (2007), for instance, accommodates for participants experiences as revealed as a simultaneous suffering and surviving (p. 15). Significantly, most of the narratives presented in this study resisted the master narrative of decline present in deficitbased approaches that has dominated inquiry into postburn injury and trauma studies as a whole (Wiechman & Magyar-Russell, 2009). These conversion narratives (Kelly & Dickinson, 1997) thus become a cultural genre available to be drawn upon (p. 271) that define illness or injury in more empowering ways. In this sense, participants offered new truth perspectives that reflected posttraumatic growth discourses (Appelt, 2006). In so doing, alternative avenues toward rehabilitation and tertiary prevention of burn injuries among young survivors were highlighted. Participants narratives also suggested different domains of experience (Fraser, 2004). In addition to the intrapersonal domain of experience, participants referred to interpersonal domains, and to a lesser extent to the cultural and structural elements of experience. These domains are analogous to an ecological model of understanding resilience in trauma survivors (see Harvey, 2007). Integrating these domains, in line with more recent studies on resilience (see Lynch, Keasler, Reaves, Channer, & Bukowski,
Lau and van Niekerk 2007), the findings point toward a relational or transactional understanding of resilience (Williams et al., 2004). Hinted at in the narratives was the empowering influence of others (i.e., friends, peers, family, intimate partners, health professionals, school, community, church leaders) that was situated within each of these domains. Parry and Chesler (2005) identified such a supportive network as essential to psychosocial growth. In several narratives, features of psychospiritual growth were present, some denoting a reliance on religious discourses or meaning systems, and others reflecting a negotiation of place, meaning, or life purpose in the world and others (Parry & Chesler, 2005). For instance, for some participants, transformative shifts brought to the fore an awakened social consciousness that was also found in previous studies (e.g., Moi & Gjengedal, 2008; Williams et al., 2004). These were similarly characterized by improved relationships, greater tolerance of difference, and taking on an activist identity. Walsh (2003, p. 56) defined this transcendence: from personal tragedy and suffering to concern and action on behalf of others as a central feature of resilience. In these respects, the findings certainly have relevance beyond the South African context, and speak to aspects of recovery and healing for burn survivors in diverse contexts. Although the small number of participants was appropriate given the research objectives and the exploratory nature of the study, further research that draws on more diverse participant characteristics might shed light on other patterns of meaning across other groups. Although data saturation was achieved in the present analysis, newer insights might be yielded with a larger and more heterogeneous sample. Further research needs to explore how these integrated domains are narrated through individual experience, and how these could be harnessed to facilitate postburn adjustment and healing in resource-strapped contexts. Further in-depth qualitative investigation into how each of these dimensions facilitates posttraumatic growth would lend new meanings to how these avenues could be meaningfully harnessed in postburn rehabilitation that lends itself toward a multidimensional and transactional view of resilience. From a social constructionist orientation, the familial, cultural, historical, and community elements are interwoven in the individual story (Appelt, 2006; Palombo, 1994). The study therefore also opens up further areas for exploration, in particular how the personal is linked with the political (Fraser, 2004). Aside from personal empowerment, narratives offer a powerful tool for social change. This foregrounds questions about cultural meanings and the stigma of burns (e.g., Rossi, Vila, Zago, & Ferreira, 2005), institutional structures and the limits of access to treatment, and the dominant discourses and social conventions that either facilitate or hinder burn survivors reintegration into society. Along such lines, it paves the
1177 way for future studies on postburn injury/trauma to examine how race, gender, class, ability, and other factors affect not just access to health resources but, at a more fundamental level, our definition of resilience itself (Unger, 2004, p. 360).
Conclusion
This narrative study on young survivors postburn experiences in South Africa highlighted multidimensional experiences of resilience and healing that incorporated pronounced needs for acceptance and recognition, alongside counter narratives of positive transformation, personal and social purpose, and psychospiritual growth. These young survivors offered significant insights into the transformative emotional and social pathways to an evolving identity able to bridge seemingly contradictory experiences of suffering and survival. Applying poststructuralist notions to interventions with burn survivors would open up alternative avenues for meaning and hope. Rather than imposing expert judgment on experiences, personal and local knowledge(s) are honored, and survivors are afforded the space to draw on their own strengths and contextual realities as defined by their gender, culture, history, and social location (Carlson & Erickson, 2001; Etherington, 2005). This approach, typically conceptualized in narrative therapies, holds particular significance for adolescents and young survivors whose experiences often tend to be articulated through the voice of the parent or guardian figure. As Dickerson and Zimmerman (1993) proposed, the power of narration should rest with the young individual who owns his or her experience. This is crucial, because telling ones own story is not only the pathway toward self-defining meaning, but is also the mechanism for healing traumatic memory. Authors Note
Portions of this article were presented at the 19th International Conference on Safe Communities, 25 March, 2010, in Suwon, Korea.
Declaration of Conflicting Interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research and/ or authorship of this article.
Notes
1. The concept of transformative learning originated from the adult education literature, but has also been referred to in the literature on posttrauma healing (see Janoff-Bulman, 1992; Williamset al., 2004). It denotes a meaning-making processtypically the reframing of adversity (Williams et al.,
1178
2004)whereby an old (or new) experience is reinterpreted with a different set of expectations; in other words, with a shift in the self or outlook on life (Meizrow, 1991). Social constructionism is a theoretical orientation that informs a variety of critical approaches in psychology and includes critical psychology, discursive psychology, discourse analysis, and poststructuralism. These approaches share several defining characteristics: a critical stance toward knowledge, a critique against essentialism and realism, and language as a form of social interaction (see Burr, 1995). For process qualitative studies (e.g., evaluations or uncovering the what or process of a program), an adequate sample size remains an important consideration (see Kuzel, 1999). In comparison, in exploratory qualitative studies, it is both reasonable and positively advantageous that the number of participants is small (Crouch & McKenzie, 2006, p. 491. Williams et al. (2004) designated 13 years as the minimum age for participants meeting this criterion. The literature suggests that interviewing participants in the postrehabilitation phase would yield richer narratives as opposed to a mere factual reporting of events when participants were interviewed in the immediate aftermath of traumatic injury (e.g., upon discharge from intensive care; see Moi & Gjengedal, 2008; Morse & OBrien, 1995). As indicated in the literature, postburn stress is most chronic at 6 months postinjury (Cromes, Holavanahalli, Kowalske, & Helm, 2002; Difede et al., 2002). Given that the study aimed to explore survivor identities postrehabilitation and not trauma per se, a 1- to 2-year postinjury period was used as a guideline (see Barnum, Snyder, Rapoff, Mani, & Thompson, 1998). Kuzel (1999) offered a guideline of five to eight data sources for qualitative studies of this nature. Miller et al. (1994) proposed a similar rationale in their sample size of six physicianpatient pairs. The concept of struggle for recognition is derived from Hegels writings (see Benjamin, 1988). Benjamin appropriated the term recognition, defining it as the response from the other which makes meaningful the feelings, intentions, and actions of the self (p. 12). For Benjamin, recognition was the basis for achievement of self-understanding and acceptance. The struggle comes to fore when the search for recognition becomes a power struggle, and becomes the basis for aggression. In the present study, however, the emphasis on struggle was not so much an assertion of self over another, but rather an inner struggle for acceptance. This participant requested that his real identity be preserved, and asked that his authentic name be used in the write-up of this article. Braai (adjective braaing) is a South African term that refers to barbeque.
Qualitative Health Research 21(9)

Albertyn, R., Bickler, S. W., & Rode, H. (2006). Paediatric burn injuries in Sub Saharan AfricaAn overview. Burns, 32, 605-612. doi:10.1016/j.burns.2005.12.004 Albertyn, R., van As, S., & Rode, H. (2008). Rehabilitation for paediatric burn survivors in South Africa. In M. Peden, K. Oyegbite, J. Ozanne-Smith, A. A. Hyder, C. Branche, A. K. M. Fazlur Rahman, . . . K. Bartolomeos (Eds.), World report on child injury prevention (p. 92). Geneva: World Health Organization. Appelt, I. (2006). Narratives of hope: Trauma and resilience in a low-income South African community. (Doctoral thesis, University of Stellenbosch, Cape Town, South Africa). Retrieved from http://scholar.sun.ac.za/handle/10019.1/1470 Barnum, D. D., Synder, C. R., Rapoff, M. A., Mani, M. M., & Thompson, R. (1998). Hope and social support in the psychological adjustment of children who have survived burn injuries and their matched controls. Childrens Health Care, 27(1), 15-30. Bendelow, G. A. (2006). Pain, suffering and risk. Health, Risk & Society, 8(1), 59-70. doi:10.1080/13698570500532298 Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem of domination. London: Virago Press. Blakeney, P. E., Partridge, J., & Rumsey, N. (2007). Community integration. Journal of Burn Care & Research, 28(4), 598-601. doi:10.1097/BCR.0B013E318093E493 Blumer, H. (1969). Social interactionism: Perspective and method. Englewood Cliffs, NJ: Prentice-Hall. Bowden, M. L., Feller, I., Tholen, D., Davidson, T. N., & James, M. H. (1980). Self-esteem of severely burned patients. Archives of Physical Medicine & Rehabilitation, 61(10), 449-452. Bowman, B., & Stevens, G. (2004). Injury costing in South Africa: The state of the sector. In S. Suffla, A. van Niekerk, & N. Duncan (Eds.), Crime, violence and injury prevention in South Africa: Developments and challenges (pp. 170-183). Cape Town, South Africa: Medical Research Council and University of South Africa Crime, Violence and Injury Lead Programme. Burr, V. (1995). An introduction to social constructionism. London: Routledge. Carlson, T. D., & Erickson, M. J. (2001). Honoring and privileging personal experience and knowledge: Ideas for a narrative therapy approach to training and supervision of new therapists. Contemporary Family Therapy, 23(2), 199220. Retrieved from http://www.springer.com/psychology/ journal/10591 Charmaz, K. (1995). The body, identity, and self: Adapting to impairment. Sociological Quarterly, 36(4), 657-680. Retrieved from http://www.jstor.org/action/showPublicatio n?journalCode=sociquar Compas, B. E., & Wagner, B. M. (1991). Psychosocial stress during adolescence: Intrapersonal and interpersonal processes. In M. E. Colten & S. Gore (Ed.), Adolescent stress: Causes and consequences (pp. 67-86). New York: Walter de Gruyter.
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1181 Bios
Ursula Lau, MA, is a researcher at the Institute for Social and Health Sciences, University of South Africa, in Johannesburg, South Africa. Ashley van Niekerk, PhD, MA, is a program manager and specialist scientist with the Medical Research Council, University of South Africa, Safety and Peace Promotion Research Unit in Cape Town, South Africa.

Young Burns Survivors-Resilience

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Restorying the Self : An Exploration of Young Burn Survivors' Narratives of Resilience

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Restorying the Self: An Exploration of Young Burn Survivors Narratives of Resilience

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Toward Poststructuralist Constructions of Resilience

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Procedure and Analysis

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Theme Two: Reconciling or Rediscovering the Self

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Theme Three: Turning Points: The Search for Meaning

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Declaration of Conflicting Interests

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Qualitative Health Research 21(9)

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Lau and van Niekerk

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Qualitative Health Research 21(9)

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Lau and van Niekerk

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