Posttraumatic Growth: Is there evidence for changing our practice?

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2007-1

Posttraumatic Growth:
Is there evidence for changing our practice?

Colleen A Jackson

Sisters of Charity Outreach
Devonport
Tasmania
Australia

Abstract

Posttraumatic Growth:
Is there evidence for changing our practice?

Positive changes emerging from adverse experience have been recognised for some time. These positive effects have been described as an enhancement or reinforcement of an individual’s “ability to cope with adversity, development of self-discipline, and the realisation of an appreciation for the value of life … a sense of accomplishment, competence, and resilience” (Dunning & Silva, 1981; p1). This posttrauma transformation is variously described in the research as finding benefit, stress-related growth, thriving, positive psychological change, adversarial growth, transformational coping and posttraumatic growth. Across the research there is considerable consistency in notions of the character of growth outcomes. For example, Aldwin (1994), in her model of transformational coping, suggests that coping is either homeostatic or transformational – the latter either negative or positive. O’Leary, Alday & Ickovics (1998), in their definition of ‘thriving’, refer to three possible outcomes of trauma – recovery (to former levels), survival (a lower level of functioning), and thriving (a higher level of functioning).

One conceptualisation of positive change from adversity, posttraumatic growth, has become the focus of an increasing body of research in search of greater understanding of the full range of sequelae, both positive and negative, that can emerge from traumatic experience. Posttraumatic growth has been defined as the experience of positive psychological change, reported by an individual as a result of the struggle with trauma or any extremely stressful event (Tedeschi, Park and Calhoun, 1998; Tedeschi & Calhoun 2004). Implicit in this concept of growth is the assumption that PTG is more than mere survival, or the resistance of damage from a traumatic experience. It implies that the person’s levels of adaptation, psychological development, and life awareness, have undergone a transformational change beyond pre-trauma levels. This benefit has been identified across a wide range of challenging life experiences and crises, including the impact of rape (Smith & Kelly, 2001; Borja, Callahan & Long, 2006), childhood sexual abuse (McMillen, Zuravin & Rideout, 1995), bereavement (Davis, 2002; Davis, Nolen-Hoeksema & Larsen, 1998; Wheeler, 2001), HIV infection (Richards, 2001), heart attack (Affleck, Tennen, Croog & Levine, 1987), combat (Aldwin, Levenson & Spiro, 1994), cancer (Weiss, 2002), spinal injury (McMillan & Cook, 2003), survivors of intimate partner abuse (Cobb, Tedeschi, Calhoun & Cann, 2006), the Holocaust, parenting very ill and high-risk children, severe burns, disasters, in emergency services personnel and more.

The experience of dealing with negative events, according to Tedeschi & Calhoun (1996), produces three broad salutary groups of outcomes: changes in self-perception; changes in interpersonal relationships; and changes in philosophy of life. Changes in self-perception reflect people’s perceptions of emotional growth and becoming a better person. People reporting such change describe feeling more experienced about life, and having an increased sense of personal strength. They feel more confident, self-reliant and self-assured, especially about their capacity to accept the way things work out and deal with future difficult situations and experiences (Carver, 1998; Davis 2002, Davis et al., 1998; Tedeschi & Calhoun, 1998; Smith & Kelly, 2001; Updegraff & Taylor, 2002). Changes in interpersonal relationships reflect people’s perceptions of closer and deepening family relations. They describe an increased appreciation of others, especially close relatives and friends, greater compassion for others, establishing more positive and intimate relationships, increased willingness to express emotions and self-disclose, handling relationships better, an acceptance of needing others and knowing that people can be relied upon in times of trouble, better utilisation of social supports, and an increased confidence in being able to manage relationships (Aldwin, 1994; Aldwin & Sutton, 1998; Carver, 1998; Smith & Kelly, 2001; Tedeschi et al., 1998; Updegraff & Taylor, 2002; Wheeler, 2001). Changes in philosophy of life reflect people’s increased appreciation for their own life, positive changes in priorities, the development of greater wisdom, and an increased sense of spirituality. They describe an increased appreciation for the value of one’s own life and of each day as it presents, no longer taking life for granted, and an improved sense of priority about what is important in life. There is an emergence of new opportunities, the ability and the inclination to make positive life changes, and the development of new interests or paths in life. People reporting this change describe an increased sense of control, intimacy, finding meaning, a better understanding of spiritual matters, and strengthening of religious or spiritual faith (Aldwin & Sutton, 1998; Edmonds & Hooker, 1992; Joseph, Williams, & Yule, 1993; Richards, 2002; Tedeschi et al., 1998).

In studies designed to measure the kind of perceived benefits arising from encounters with trauma reflected in the literature, Tedeschi and Calhoun (1996; 1998) identified five factors: new possibilities; relating to others; personal strength; spiritual change; and, appreciation of life. These five factors form the underpinning of one instrument used to measure posttraumatic growth in the current research (PTGI: Posttraumatic Growth Inventory). This five-factor structure has been replicated in Australian samples (Morris, Shakespeare-Finch, Rieck, & Newbury, 2005).

Calhoun & Tedeschi (1998) suggest that a certain degree of initial disruption may be necessary for the development of posttraumatic growth, and that this development is generally regarded to be gradual. In subsequent studies and reformulation, Tedeschi & Calhoun (2004) provided a conceptualization of the process of the growth experience, describing the process of this growth as solely an outcome variable. Growth is said to be triggered by an event that threatens or destroys a person’s assumptive world, via serious challenges to the person’s higher order values, beliefs, goals, personal, relational and world views, and their capacity to manage distress. The ensuing emotional distress sets in motion a process of initial automatic rumination and successful coping, leading in turn to more deliberate rumination (eg evaluation, meaning making, reappraisal) on the trauma and its impact and meaning in one’s life. Further serious threat triggers further rumination and a subsequent potentially higher order of reported change and growth. The availability of role models who have exhibited such rumination and positive change is said to enhance the likelihood of posttraumatic growth (Calhoun & Tedeschi, 2004, 2006; Weiss, 2002), and the emergence of PTG is said to be influenced by a range of pre-trauma variables including personal and social support and the ongoing presence of trauma related distress (Tedeschi &Calhoun, 2004).

Some studies have shown positive relationships between the severity of the event and subsequent growth (McMillan, Smith & Fisher, 1997; Park, Cohen & Murch, 1996). Others suggest a curvilinear relationship exists between the two, whereby little disruption will lead to minimal growth, moderate to high disruption may lead to maximal growth, whilst extreme disruption may in fact lead to poor adaptation (Calhoun & Tedeschi, 1998; Carver, 1998). Further, the perception of benefits of traumatic experience does not suggest the absence of negative effects – both negative effects, such as posttraumatic stress disorder and depression, and positive effects are widely reported in the same person (Aldwin, 1994; Joseph et al., 1993; Tedeschi & Calhoun, 1996).

A slightly different perspective describes the perceived benefits of posttraumatic experience as a process of coping, involving positive reinterpretation, positive reframing, interpretive control, and reconstrual (Carver et al, 1993). However, Tedeschi and Calhoun (1996) argue that the concept of posttraumatic growth emphasises outcomes - the possible benefits that may be construed or discovered in the aftermath of traumatic experience.

Posttraumatic Growth as a Coping Strategy

More recently, PTG has been posited also as a coping strategy – as distinct from merely an outcome of traumatic experience. The consideration PTG as a coping strategy places it within theories of coping as an adaptive response (Affleck & Tennen, 1996). Zoellner and Maercker (2006) in their comprehensive critique of posttraumatic growth, broadly identified four coping models that are useful for consideration:

1. Several authors point out the significant role of meaning making in the face of traumatic experience. Attention has mostly focussed on one construal of meaning – causal attributions that ask ‘why did it happen?’ However, in this context, benefit attributions – the answer to ‘what for’ questions - are regarded as significant for growth;
2. Park and Folkman (1997) distinguish between situational and global meaning making. Global meaning encompasses a person’s enduring beliefs and goals. When a trauma occurs, appraisal of the trauma leads to situational meaning making – that is, an interaction between the person’s global meaning making and the particular traumatic experience. In the context of PTG, for example, an evaluation of personal strength after a specific traumatic experience might lead a person to re-evaluate their global meaning with respect to how they see themselves.
3. A third view would see PTG as an interpretive process (Fillip, ’99) whereby a person engages in information processing to re-interpret an experience as ‘cope-able’; and finally
4. The notion of PTG as a form of self-enhancing appraisal or positive illusion (Taylor ’83) suggests that this subjective adaptation helps a person cope with threat.

Coping factors that have been identified in research into PTG include positive reframing, mental disengagement and distraction (as distinct from total avoidance), actively engaging in overcoming adversity/problems, support seeking, both emotional and practical, benefit finding, appraisal of individual and professional competence, and positive cognitive appraisal of threat. Coping could be seen to be a function of personal characteristics (like personality), cognitive processes, and systemic, or organisational, factors.
Trauma recovery cannot be considered solely as a personal issue - the role of systems (such as families, communities and organisations) in trauma recovery cannot be underestimated.

Some perplexing negative outcomes of PTG show it existing alongside increases in, for example, alienation (Hobfoll, Tracy, & Galea, 2006) and disillusionment with authority (Jackson, 2003). The same experiences that evoke personal growth can, it seems, evoke negative responses at behavioural and organisational levels.

Studies by Hart and Wearing (1995) may go some way to explaining why distress and positive outcome can co-exist. They propose that organisational climate consists of positive and negative components and that these components are independent constructs. The negative components (like poor pay, poor management, high work loads) affect distress outcomes, whilst the positive components (like responsibility, collaborative learning, affirmation, support, communal thinking, communication) influence the positive outcomes including morale and PTG.

Several researchers have identified significant organisational factors implicated in trauma recovery (Jackson, 2003; Paton, Violanti, Dunning & Smith, 2004). Research has suggested that personal and systemic factors may be stronger predictors of trauma outcomes than the events themselves or even individual factors. Paton (2005) suggests that these findings point to the importance of organisations making choices to influence positive outcomes – eg, regarding personality and disposition (selection), cognitive appraisal characteristics and organisational factors (selection, procedures, practices, culture).

Posttraumatic Growth and Negative Outcome of Trauma

Studies of relationships between PTG and PTSD reveal mixed results, though overall, when standardised measures are used, significant positive correlations between the two have been identified. It would appear that any relationship between PTG and PTSD is likely a curvilinear one, whereby more than minimal disruption (ie moderate or high disruption) may be necessary for the development of PTG, whilst very extreme levels of disruption may be less likely to evoke growth (Calhoun & Tedeschi, 1998; 2002). What is now very clear is that distress and PTG can co-exist. Studies of PTG and depression have consistently shown a negative association between the two. Mixed results have been found regarding the role of PTG in predicting future reductions of distress, or providing a buffering effect on traumatic outcome. Notably, all longitudinal studies to date show positive relationships between perceived growth and adjustment, suggesting a moderating effect of PTG on adjustment (Maercker & Zoellner, 2006).

Posttraumatic Growth and Personal and Proximal Factors

Relationships between PTG and personality and other dispositional factors have been established. Positive relationships have been found with the Big 5 dimensions of Openness and Extraversion, agreeableness and conscientiousness (Evers, Kraaimaart, van Langveld, Jongen, Jacobs &Bijlsma, 2001; Jackson, 2003; Linley & Joseph, 2004), while neuroticism seems to be negatively related to growth (Evers et.al., 2001; Jackson, 2003). Positive relationships have also been shown with hardiness, optimism, self efficacy, hope, humour and internal locus of control to name a few. Sense of Coherence is another trait thought to influence posttraumatic growth because it has been found to be a contributing factor in successful coping with adversity (Aldwin, 1994; Schaeffer & Moos, 1998; O’Leary & Ickovics, 1995, Tedeschi & Calhoun, 1995).Whilst these finding are far from conclusive, they certainly warrant further research.

Some gender differences have been evidenced in the research, suggesting that women may experience more growth than men (Tedeschi & Calhoun, 1996), however, other studies suggest that this relationship is tenuous since some studies have been confined to a single gender or sample sizes are too small to be conclusive (Calhoun & Tedeschi, 2002; Tennen & Affleck, 1998). The relationship between age and growth is unresolved.

When measures of wellbeing are examined, positive relationships with PTG are also revealed. For example, strong positive relationships between PTG and measures of Psychological Wellbeing (Ryff & Keyes, 1995; Ryff, Singer & Selzer, 2002), especially the dimensions Self Acceptance, Autonomy, Environmental Mastery, and Purpose in Life, have been found (Jackson, 2003). Similar positive associations have emerged in relation to self esteem, meaningfulness in life, making meaning and to perceived health and positive mood when effortful benefit finding is employed.

Research suggests that PTG is predicted and mediated by a range of pre-trauma, trauma and recovery variables. And each of these sets of variables is likely to be influenced by personality and dispositional factors, coping factors and organisational or collective factors.

Posttraumatic Growth , Therapeutic Intervention and Trauma Recovery

Another arena that is clearly implicated in trauma recovery and growth outcomes is therapeutic intervention. If, as a significant body of the research seems to be revealing, posttraumatic growth is a coping strategy that is constructive and adaptive, and a coping outcome of traumatic experience, then PTG is potentially a potent ingredient in the therapeutic process. However, this writer’s search for research on PTG in therapeutic practice found that there is none. This represents a significant gap in the current research that warrants addressing.

Conflicts and Contradictions

Some effort is currently being made to explain some of the conflicting study results regarding PTG. In their recent Janus-Face model, Maercker and Zoellner (2006) relate PTG to coping styles and propose a two-component model. In this model the functional side is a self-transcending, constructive one, characterised by re-appraisal and active mastery which elicits positive adaptation. The second side, an illusory one, they propose, is a cognitive avoidance strategy characterised by self-deception and distraction employed to help people counterbalance emotional distress. Positive illusion, they suggest, is dysfunctional and palliative, with PTG related to perceived change rather than actual change in distress.

Ongoing research by Hobfoll (1988; 1989; 2001) and his colleagues has shed new light on mediating factors in the struggle to cope with stress. While posttraumatic growth can certainly be measured in the aftermath of trauma, one study has shown that posttraumatic growth is associated with greater xenophobia and support for extreme political violence among Jews and Arabs exposed to terrorism and war (Hobfoll, Canetti-Nisim & Johnson, 2006). Further research needs to establish whether positive illusion is in fact maladaptive or adaptive, and its relation to PTG.

Conclusions and Challenges

The research to date is frustratingly inconclusive. On the basis of the research one could argue evidence for the adaptive value of PTG. And one could argue the absence of adaptive significance. There remains a lack of a consistent theoretical conceptualisation of PTG. For the interests of research, concrete operationalisations and theoretical specifications are imprecise. And measurement reliability and validity is yet to be sufficiently established. The positiveness and adaptiveness of PTG has not yet convincingly been demonstrated, and it is not yet reliably linked to current measures of adjustment. So what needs to happen?

These results beg the questions of exactly what are we measuring and what is its relevance, if any to adjustment? What constitutes adjustment? Is it the absence of negative symptoms (e.g. PTSD symptoms, depression), or the presence of positive outcomes (e.g. psychological wellbeing)? Is adjustment perceived or objective? Does the perception of benefit translate into objective life change? What is the relationship between PTG and psychological wellbeing?

And how is posttraumatic growth measured? Currently a range of measures of PTG are used – ranging from validated instruments (such as the Posttraumatic Growth Inventory) through to qualitative interview methods – some less reliable than others (see Linley & Joseph, 2004).

What constitutes trauma? It may be that we are currently comparing apples and pears - are measures of adaptation instructive when definitions of what is traumatic vary so greatly – the experience of the death of a loved one, the experience of surviving a terminal illness, a vicious sexual assault, the experience of a devastating natural disaster, the ongoing threat of terrorism, or, more contemporarily, the threat or actual impact of global climate change?

Could it be that PTG is maladaptive given its positive relationship to traumatic distress? Or are PTG and PTSD completely different constructs? After all, it is possible to be quite ill and yet be reasonably functional and well-adjusted in other aspects of life at the same time. And the roles of predictive and mediating factors, such as systemic factors, social support, personality, cognitive processing, co-morbidity, previous experience of trauma, religion, spiritual views, and humour, to name a few, need to be more clearly established. Could it be that post-event adjustment is more indicative of the presence of pre-existing qualities than an outcome of trauma? What roles do or can organisations play in adaptation to trauma, including the possibility for posttraumatic growth? And what of other systems like families? What role, the therapeutic process?

Positive change following adversity is now well acknowledged in research. The role of posttraumatic growth, both as an outcome of trauma, and as a coping process is informative and constructive. Further research is needed.

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