Facilitating Posttraumatic Growth

A Clinician's Guide

Lawrence G. Calhoun, Richard G. Tedeschi, Lawrence G. Calhoun, Richard G. Tedeschi

• Publisher: Routledge
• Year: 1999
• Print ISBN:
  9780805824124
• eBook ISBN:
  9781135688608
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In this book, Calhoun and Tedeschi construct the first systematic framework for clinical efforts to enhance the processes they sum up as posttraumatic growth.

Posttraumatic growth is the phenomenon of positive change through struggle with even the most horrible sets of circumstances. People who experience it tend to describe three general types of change: realistically stronger feelings of vulnerability that are nonetheless accompanied by stronger feelings of personal resilience, closer and deeper relationships with others, and a stronger sense of spirituality.

Posttraumatic growth has only recently become an important focus of interest for researchers and practitioners. Drawing on a burgeoning professional literature as well as on their own extensive clinical experience, the authors present strategies for helping clients effect all three types of positive change--strategies that have been tested in a variety of groups facing a variety of crises and traumas. Their concise yet comprehensive practical guide will be welcomed by all those who counsel persons grappling with the worst life has to offer.

1

Trauma and Growth: Processes and Outcomes

Wheresoever you are, death will overtake you, even if you are in lofty towers.

—Middle Eastern Proverb

People tend to operate with certain “positive illusions” (Taylor, 1989) that make the world appear benevolent, safe, predictable, and meaningful (Epstein, 1990; Janoff-Bulman, 1992). However, highly stressful, difficult, and unpredictable events are “neither rare nor unusual” (Freedy & Donkervoet, 1995, p. 7). The lifetime prevalence of major stressful events is high. In a sample of persons from a town in the midwestern United States, 19% reported they had experienced one or more traumatic events in the past year (Breslau, Davis, & Andreski, 1995). In a sample of persons in the southeastern United States, 21% reported a major stressful event such as assault, robbery, or traumatic death of a loved one (Norris, 1992). The frequencies of self-reported traumatic events vary across studies and perhaps across generations (Calhoun, Cann, Tedeschi, & McMillan, 1998; Vrana & Lauterbach, 1994), but exposure to highly stressful events is indeed a common occurrence. If the parameters of what constitutes traumatic are broad, then clearly a great percentage of persons, perhaps even all, will experience at least one significant loss, tragedy, or catastrophe in a lifetime.

Seismic Events: Shaking or Shattering Foundations

We use the words crisis, trauma, traumatic event, and similar expressions interchangeably as roughly synonymous expressions. It should be clear that other clinicians and scholars tend to prefer a precise distinction between these words, but we do not. Our focus is on events that, to use a metaphor, have a seismic impact on the individual’s worldview and emotional functioning. Just as an earthquake can produce a dramatic shaking or shattering of physical structures, the events on which we focus in this book produce a severe shaking up, or often shattering, of the individual’s understanding of the world (Janoff-Bulman, 1992) and a significant increase in emotional distress (Joseph, Williams, & Yule, 1995).

Some events, such as the Holocaust, are likely to shatter the understanding of the world in all persons who experience them, whereas some events may not even shake the foundations of some people’s worldview. From the clinician’s perspective, however, the criterion for significant trauma is the degree to which events have been seismic for the individual. This is a transactional view that takes into account the individual’s response within the context of a set of environmental circumstances. Traumas occur when a particular type of interaction between a person and challenging events occurs. Our focus is on those life crises, traumatic events, stressors, and tragedies that have an impact strong enough to lead the individual to experience a significant challenge to the ability to order, make sense of, and find meaning in their lives, and which are accompanied by clinically significant levels of emotional distress. The individual’s coping ability is severely challenged and he or she may feel emotionally overwhelmed.

Given our somewhat broad and mildly amorphous definition of trauma, it is clear that our focus is on a wider range of events than those that are the typical antecedents of posttraumatic stress disorder (PTSD). The sets of circumstances we have in mind include those where individuals are exposed to the life threatening or the grotesque, but they go beyond that strict limitation. The focus of this book is not only on persons who have been held hostage, raped, or who have personally experienced violently destructive combat or other horrible events. We also include the large number of persons who come to the clinician for help in coping with more common, but still emotionally overwhelming, events: the death of an infant from sudden infant death syndrome (SIDS); the loss of one’s possessions in a severe storm; a diagnosis of breast cancer; the sudden, unexpected end of a marriage of 30 years because the spouse has left to marry a much younger person; losing one’s job at age 56, after 35 years with the same company, because of “downsizing;” the suicidal death of a close family member; and any of the many problems that clients bring to clinicians that represent a severe challenge to their past ways of understanding the world and their place in it, (in other words, events that have rocked and perhaps destroyed the foundations of their way of construing the world).

Qualities of Traumatic Events

What makes events traumatic? In answering this question, a useful perspective is to think of the kinds of events that put individuals at risk for significant psychological difficulties. What are the characteristics of events that lead them to threaten mental health and produce significant psychological distress? In the language that most practitioners employ, what qualities of events make them traumatic events, major life crises, or extremely stressful? Although no single definition of these terms enjoys universal acceptance, there are several characteristics about which there is significant consensus.

Events that are shocking—that occur suddenly and unexpectedly—are more likely to be traumatic than events that come on gradually and are expected (McCann & Pearlman, 1990; Weaver & Clum, 1995). Circumstances that come on gradually and are expected can also be highly challenging, but the swift, unexpected tragedy or loss tends to be more difficult to resolve. To the extent that individuals can prepare and engage in some anticipatory coping, events tend to be less likely to be psychologically devastating. When an individual experiences the sudden death of a loved one, for example, achieving a sense of resolution and a reduction in long-term psychological pain tends to be more difficult (Weiss & Parkes, 1983).

The most painful and tragic life circumstances tend to be out of the individual’s control, and they are seen as such. The perception of lack of control over situations tends to make them more likely to produce subjective distress (Tennen & Affleck, 1990). A key element in events such as armed robbery, rape, loss of house and possessions in a fire, and similar difficulties is that the individual sees circumstances as uncontrollable. Each of these events has clear, direct, painful, and aversive consequences (e.g., bodily injury). An important quality that makes them difficult, even beyond the material or social loss, is in the individual’s view that there is nothing that he or she could do about it. In these tragic situations, perceived lack of control is empirically accurate. Many events are inherently irreversible and produce an inevitable sense of powerlessness that can overwhelm even individuals with a strong sense of perceived control over their environments, themselves, and their future. Even in severely threatening circumstances such as armed robbery, the event may be more or less traumatic depending on how much control individuals believe they could and did exercise.

One possible indication that persons believe they have no control over circumstances is by placing blame on others for what has happened. The relationships between blame for the trauma and general psychological adjustment are complex. In general, when the person blames others for his or her misfortune, the psychological consequences are likely to be worse (Tennen & Affleck, 1990). If the individual blames others for the loss, there may be greater difficulty because issues of justice and forgiveness become salient. Such issues may increase the likelihood that the person will become “stuck” in ineffective coping (Falsetti & Resnick, 1995).

Another quality of traumatic events is the threat or experience of physical harm (Green, 1990). Intentional and deliberate harm from another human being (e.g., sexual assault) may be more traumatic and produce more negative psychological response (Tedeschi, 1999), but physical harm from impersonal sources (e.g., tornado, hurricane) can also be a traumatic set of circumstances.

Circumstances that are unusual and out of the ordinary are likely to be more difficult. If events are unusual, they may also be sudden and uncontrollable. Communities and social groups may have some shared knowledge about how to provide support for common events, although they may be highly stressful. People may be less knowledgeable about helping with highly unusual stressors. The death of a loved one is a common loss for which both secular and religious communities have developed rituals designed to provide support and to help with the transition to the new set of circumstances created by death. Communities have no scripts for facing rarer events, such as the disappearance of a loved one: People may not know how to be helpful when a loved one becomes a missing person.

Events that create long-lasting problems are more likely to be highly stressful. Overlapping with the general notion of how long the after-math of the event persists in daily life is the irreversibility of negative circumstances. Although some events may produce irreversible pain, they are over quickly. For example, if a person is taken hostage during the robbery of a store and she escapes physically unharmed, the event has a clear end and it may not produce any physical change in daily life. If an individual suffers a physical disability that cannot be medically changed, there will be a permanent change imposed on that person’s daily routine. The person will now need to face daily challenges of transportation, physical accessibility, social prejudice, and perhaps basic physical self-care. Life stressors that create stressful circumstances that stay with the individual, particularly if the circumstances are not reversible, are more likely to produce significant psychological distress.

The stage of development at which the stressful event occurs may also have an impact on its long-term effects. In general, highly stressful events that occur in childhood are more likely to produce serious long-term consequences for the person. Although sexual assault is a horrible event at any age, it may be more likely to produce long-lasting emotional scars and significant psychiatric impairment when it occurs during the individual’s childhood. Most persons are likely to have some general sense of their own identity, of “who I am,” by late adolescence or early adulthood. Crises that occur before identity is developed may produce longer lasting scars than those that occur after self-identify provides a means for the individual to integrate the experience into who they are.

Traumatic events are those that are unexpected, perceived as uncontrollable, involve the threat or experience of physical harm, are unusual, have irreversible negative consequences, occur at more vulnerable developmental stages, and involve an assignment of blame to others for one’s misfortune. However, we think it helpful to further clarify the kinds of circumstances that are the focus of this book.

The Negative Aftermath of Trauma

Following is a brief summary of material that is well known to both practicing clinicians and knowledgeable readers of the trauma literature. This section provides a brief summary of some of the common negative responses to trauma. In a sense, to say that life crises have negative consequences is redundant because, by definition, such events cause disruption or distress. This book focuses on the possibilities for growth in the struggle with trauma; it is important to acknowledge that for most people, although not for all (Wortman & Silver, 1989), major life disruptions produce many negative consequences.

Risk of Psychiatric Disorders

When clinicians think about traumatic events, there tends to be a focus on persons who develop posttraumatic syndromes. Lifetime prevalence rates for PTSD have been found by some to be in the 1% to 2% range (Girolamo & MacFarlane, 1996), but some research has suggested the lifetime prevalence rates are actually higher—perhaps around 7% (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris, 1992) or even as high as 12% (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). As one would expect, rates for PSTD are higher for persons exposed to highly threatening catastrophic events such as military combat. Persons who have been tortured, brutally assaulted, or exposed to extreme combat situations, for example, have much higher rates of PTSD than persons who have lost property but who experienced no physical threat from a natural disaster.

Being exposed to traumatic events also places one at somewhat increased risk for psychiatric disorders other than PTSD (Rubonis & Bickman, 1991). If one examines the personal histories of persons who develop a wide variety of psychiatric difficulties, it is typical for those persons to report higher rates of past stressful events than comparable persons who have not developed psychological troubles.

However, it is important to emphasize that the majority of persons exposed even to the most catastrophic events tend not to develop stress-related disorders (Quarantelli, 1985). Psychopathology is not a necessary consequence of encountering major life crises. Although clinicians are likely to see as clients persons with significant levels of distress and psychological impairment, the practitioner must keep in mind that, in most situations most of the time, individuals may experience significant distress, but they often come through highly challenging circumstances without developing severe psychiatric symptoms. Even in the absence of significant psychiatric impairment, it is common for individuals exposed to highly stressful events to report a common core of negative consequences.

Common Negative Consequences of Traumatic Events

Distressing Emotions

Emotional distress may be the more salient experience for the individual survivor of a highly negative event. For persons exposed to life-threatening sets of circumstances, a major emotional response is anxiety and fear. For example, a woman who finds the courage to seek shelter from an abusive husband may have physical safety for her and her children as a primary concern (Herman, 1992). In the aftermath of Hurricane Hugo in the Carolinas in 1989, a common emotional response in survivors was high levels of worry and apprehension whenever skies became cloudy and rain was accompanied by even light gusts of wind.

The predominant emotions will vary with circumstance, but along with anxiety, depression is also a common response to stressful events, particularly those involving loss. Sadness is recognized as an almost universal reaction to the death of a loved one. It is typical for persons in grief to be sad, yearn for the deceased, and wish that things could be different (Hodgkinson & Stewart, 1991).

Guilt is another common response to major life crises. It has elements of both thought and emotion, but the guilt that clinicians are most likely to be confronted with in clients is the client’s feeling of guilt. “Survivor guilt” is a common response among persons who have survived a catastrophe that has not spared others. For example, the father of a child who was severely injured but who was recovering from a school bus accident began to experience a great sense of guilt because he was glad that his child had survived a crash that had killed several other children. He knew he had not committed an unethical act, but he felt bad that he felt so relieved. The experience of guilt may also involve the emotional component connected to thoughts about what the individual might have done or should have left undone prior to a loss. The adolescent daughter of a woman who was hospitalized after a routine appendectomy had a violent argument with her mother about the use of the family car and stormed out of her mother’s room and left home for the night. During the night, her mother died suddenly and unexpectedly of a blood clot. The daughter was troubled for a long time after her mother’s death, especially about the argument and her sense that she was to blame for her death, because she was not at home to help, and this was because she lost control of her temper.

Anger and irritability are also common responses to life crises. These may not be viewed as having the power that depression and anxiety have to create subjective distress, but these are not pleasant emotions. It is possible that men may be more likely to experience these in the after-math of trauma than women perhaps because women have been taught better ways to access their emotions of sadness and fear. Regardless of gender, anger is often seen in persons coping with crises. The anger may be expressed directly at those believed to be responsible for the stressful event, like the man who is fired from his job and returns with a gun to settle the score. The anger may be observed simply as an increase in the general level of irritability and increase in loss of temper with targets not even directly connected with the crisis. For example, a woman in hospice care became furious at the apparent “abysmal and repulsive quality of this crap they are making me eat” even when the food was quite satisfactory to others.

Distressing Thoughts

To clinicians, perhaps the most familiar and recognizable component of posttraumatic distress is in the cognitive domain (Horowitz, 1986). For sudden and unexpected events, initial reactions of shock, disbelief, and numbness are typical (Calhoun & Atkeson, 1991; Raphael, 1986). “I just couldn’t believe it. I heard the detective, but it just didn’t sink in. I was in a fog for the next week” is how the brother of a young man killed in a robbery attempt put it.

The repetitive intrusion of the challenging event into consciousness is also a common posttraumatic response (Greenberg, 1995; Thompson, Chung, & Rosser, 1994). Thinking about it frequently in the early posttraumatic days and weeks, but without wanting to, is almost a signature symptom of posttraumatic stress reactions. A woman in her 20s who had been sexually assaulted by a neighbor when she was 12 said that, “It keeps running through my head like a movie I don’t want to see.” Even 15 years later she was still haunted by the images of betrayal by a trusted adult. Recurrent thoughts without visual images may be responses that are more common than visual images or troubling dreams.

Intrusive ruminative thought is probably more commonly seen in general clinical practice than intrusive images. This kind of thought process occurs in the wake of trauma when the individual does not want to think about his or her distressi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• 1. Trauma and Growth: Processes and Outcomes
• 2. Case Examples of Posttraumatic Growth
• 3. The Process of Encouraging Posttraumatic Growth: An Overview
• 4. Helping Clients Develop New Views of Vulnerability and Strength
• 5. Helping Clients Make Changes in Relationships
• 6. Helping Clients Toward Philosophical and Spiritual Growth
• 7. Posttraumatic Growth: Issues for Clinicians
• 8. Resources for Clinicians and Clients
• References
• Author Index
• Subject Index