Posttraumatic Growth

Theory, Research, and Applications

Richard G. Tedeschi, Jane Shakespeare-Finch, Kanako Taku, Lawrence G. Calhoun

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315527437
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Posttraumatic Growth reworks and overhauls the seminal 2006 Handbook of Posttraumatic Growth. It provides a wide range of answers to questions concerning knowledge of posttraumatic growth (PTG) theory, its synthesis and contrast with other theories and models, and its applications in diverse settings. The book starts with an overview of the history, components, and outcomes of PTG. Next, chapters review quantitative, qualitative, and cross-cultural research on PTG, including in relation to cognitive function, identity formation, cross-national and gender differences, and similarities and differences between adults and children. The final section shows readers how to facilitate optimal outcomes with PTG at the level of the individual, the group, the community, and society.

Part I
Posttraumatic Growth Theory

Chapter 1
What Is Posttraumatic Growth?

Tedeschi and Calhoun have given the same definition of posttraumatic growth (PTG) since coining the term in the mid-1990s, that is, positive psychological changes experienced as a result of the struggle with traumatic or highly challenging life circumstances. These changes occur in response to the challenge to what people assumed to be true about the lives they lived. Foundational to the concept of PTG is the constructivist perspective that people create individual versions of basic cognitive categories used to understand experience, and core beliefs about the self, their future, and their world. Personal construct theory (Kelly, 1955), schema theory (Epstein, 1990), and assumptive world models (Janoff-Bulman, 1992) provide ways to understand the PTG process in this constructivist tradition. In addition, the PTG concept has benefited from the broad existentialist tradition in philosophy and psychology, which provided a perspective on the problem of suffering and general life philosophies that guide meaning ascribed to events and initiatives taken (Frankl, 1963; Nietzsche, 1889/1990). We begin here with a careful consideration of the meaning of the term PTG, because its meaning is crucial in theory development and in how we choose to measure this construct. We will consider what we mean by trauma, posttraumatic, and growth.

There is disagreement about the definition of trauma (e.g., Weathers & Keane, 2007). Some of the reasons for this stem from the Criterion A definitions provided in the DSM-III and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 1980, 1994), which include both a situational (i.e., nature of the event) and a response requirement for a diagnosis of posttraumatic stress disorder (PTSD). The former manual describes an event that is “generally outside the range of usual human experience” that would “evoke significant symptoms of distress in most people” (APA, 1980, p. 236). The later edition extended this definition to anyone who

experienced, witnessed, or was confronted with an event … that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others … [that in adults was responded to with] intense fear, helplessness or horror.

(APA, 1994, pp. 427–428)

Controversies have not diminished with the DSM-5 (APA,2013; Wakefield, 2016). Trauma, when discussed in the classification systems devoted to psychiatric disorders (DSM; ICD), is currently defined in relation to events and to the presence of symptoms of PTSD.

However, our focus on growth led to a broader definition of what constitutes a traumatic event. As Calhoun and Tedeschi said (2004, p. 100), “it is not the event itself that defines trauma, but its effect on schemas, exposing them to reconstruction.” In this book we will use the terms trauma, crisis, and major stressor, as well as related terms, as essentially synonymous expressions to describe circumstances that significantly challenge or invalidate important components of the individual’s assumptive world (Calhoun & Tedeschi, 2006). From this perspective, to be considered traumatic events do not necessarily have to be life-threatening or narrowly defined as a cause for PTSD symptoms. We focus on both subjective and objective qualities when defining trauma, unlike the DSM-5, in which assessment of subjective responses following a traumatic event are no longer required when diagnosing PTSD. In addition, DSM-5 defines trauma as an aversive event involving actual or threatened death that must be violent or accidental, whereas we define trauma as a highly stressful and challenging life-altering event. It is not possible to determine in advance what events will be traumatic and which will set in motion substantial personal changes. This is why researchers may find no differences between DSM-defined traumatic events and others in terms of PTG outcomes (e.g., Silverstein, Lee, Witte, & Weathers, 2017). When Shakespeare-Finch and Armstrong (2010) examined PTG and symptoms of PTSD in people who had experienced (1) sexual abuse, (2) serious motor vehicle accidents, and (3) people who had been bereaved, all participants viewed their experiences as traumatic, even, for example, when their experience of bereavement was not violent or accidental. Tedeschi and Calhoun (2004b) reviewed PTG in the context of a variety of events, including HIV infection, cancer, and combat. The definition of what constitutes a traumatic event may change over time and may be different across cultures, which is another reason to take an extended view when defining an event as traumatic for a particular person. In some ways, whether or not an event is traumatic is in the eye of the beholder.

It is important to distinguish what constitutes a traumatic event from daily stressors or minor hassles. We are interested in how people change “in the aftermath of events that are undesirable in the extreme” (Tedeschi, Park, & Calhoun, 1998, p. 3)—events that are likely to cause fundamental and transformative changes. Our perspective is on traumatic events that are “seismic” (Calhoun & Tedeschi, 1999). Just as earthquakes can shake or shatter the foundations of buildings, some events are so psychologically seismic that they will seriously challenge or shatter an individual’s assumptive world. The event needs to be significant enough to challenge

the basic assumptions about one’s future and how to move toward that future, and therefore produce massive anxiety and psychic pain that is difficult to manage. Inherent in these traumatic experiences are losses such as the loss of loved ones, of cherished roles or capabilities, or of fundamental, accepted ways of understanding life.

(Tedeschi et al., 1998, p. 2)

Finally, we need to carefully consider what we mean by a traumatic, stressful, or challenging event. In many cases, people experience life-changing circumstances that are not easily described in terms of a single event. Some circumstances may occur over a period of time and include many events; this is usually the case with the aftermath of a traumatic event. In combat, it may not be a single battle that is the catalyst for change, but an entire deployment into a combat zone. A natural disaster may include a variety of specific components, including the disaster itself, finding help in the immediate aftermath, and what is sometimes a long process of rebuilding physically and psychologically. The terminal illness of a loved one may extend over days or months and include many interactions with that person and with others. Later we will consider the question of PTG for people who live in families or communities where traumatic events are an everyday fact of life. In such cases it can be difficult to identify a single traumatic event, or what is posttraumatic, and the degree to which there may be challenges to ways of thinking.

What Is “Posttraumatic”?

The construct of PTG is focused on changes in people after an event rather than their responses during an event. In addition, posttraumatic growth does not focus on changes in the immediate aftermath of the event, when people may be reacting without any careful consideration, but almost instinctively. Instead, PTG is focused on longer-term changes that come about after more careful reflection. Post-trauma is usually an extended time period, from days to years, where people develop new ways of thinking, feeling, and behaving, because the events they have experienced do not permit a return to baseline functioning. This is a crucial way that PTG is also distinguished from “resilience,” a return to baseline or resistance to trauma, and “recovery,” which has similar connotations.

What Is “Growth”?

One important feature of PTG is that the change is transformative. It involves positive changes in cognitive and emotional life that are likely to have behavioral implications; the changes can be profound and may be truly transformative (Tedeschi & Calhoun, 1995). Since 1995, research has provided evidence of positive changes in all of these domains: cognitive (Calhoun, Cann, Tedeschi, & McMillan, 2000), emotional (Park, Aldwin, Fenster, & Snyder, 2008), and behavioral (Shakespeare-Finch & Enders, 2008; Shakespeare-Finch & Barrington, 2012).

Personal development, change, increasing maturity, and growth are normative and occur throughout various developmental periods. This type of change is not PTG (Tedeschi & Calhoun, 2012). The changes characteristic of PTG may be similar to those seen in normative development, or may occur in the context of normative development as well as trauma. How the changes occur defines the difference. PTG occurs as a result of a struggle with the aftermath of a major life crisis. The struggle that leads to PTG is not usually at first a struggle to grow or change, but rather to survive or cope. The growth tends to be unplanned and unexpected, although we will discuss later that it may be facilitated by certain interventions.

The term “growth” rather than “benefits” is used in referring to PTG. In their earlier work in the 1980s and early 1990s, Tedeschi and Calhoun described the reports of growth in trauma survivors as “perceived benefits.” However, they came to appreciate that this term might indicate that reports of growth might be untrustworthy, and that the changes might be beneficial without representing growth or transformation. Although there are different degrees of personal growth that can be seen in the aftermath of trauma, and there are different trajectories of PTG, we also prefer the term “growth” because the changes people report are experienced by them as indicating positive, transformative development.

The terms “perceived benefits” and “benefit-finding” are most often seen in the literature that examines physical health and illness (e.g., Antoni et al., 2001), and these perceived benefits are sometimes described as equivalent to PTG. However, they include changes such as improved health behaviors (e.g., stopping tobacco use), which for most people are beneficial but not experienced as personally transformative. In the health-related benefits literature, we might see true PTG or other less transformational change.

Some pathways may involve profound changes in perspectives on living that will promote changes in health and social behavior that yield better health outcomes. Others may involve changed life perspectives that reduce stress responses and have effects on immune system functioning. Other pathways to better health outcomes might proceed from more specific changes in health or social behavior that yield health benefits, without more general personal transformation.

(Aspinwall & Tedeschi, 2010, p. 7)

Changes analogous to PTG have also been investigated in the context of changes that occur in the aftermath of positive events, as well as those resulting from self-initiated challenging experiences. For example, Suedfeld, Kjærgaard, and Leon reported on the personal changes that occur in the aftermath of space travel (Suedfeld, Legkaia, & Brcic, 2010), solo circumnavigations by sailing (Kjærgaard, Leon, & Venables, 2015), and arctic exploration (Kjærgaard, Leon, Venables, & Fink, 2013). These scholars used the concept of PTG and found that persons who choose to endure such challenging environments can be changed in ways that are very much like those changes reported by people who are forced to endure traumatic events. These findings suggest that changes analogous to PTG can happen in people who have not been exposed to events defined as traumatic. However, by definition, PTG is a result of processes initiated by a significant challenge to a person’s assumptive world—a challenge to their core beliefs.

Chapter 2
A History of the Concept of Posttraumatic Growth in Psychology and Related Disciplines

The specific term posttraumatic growth is relatively new. It was first published in 1995 in an early version of the PTGI in the appendix of Trauma and Transformation (Tedeschi & Calhoun, 1995) and measured using the PTGI in 1996 (Tedeschi & Calhoun, 1996). However, PTG as a phenomenon is not new. The history of mankind is the history of trauma and the history of PTG. As Tedeschi and Calhoun (2004b) have discussed, for thousands of years there have been stories of positive changes in individuals and societies in general as a result of suffering and distress. The potential for transformative positive change from the experience of great challenge and despair is referred to in the texts and teachings of all major religions and is reflected in the writings of ancient philosophers and scholars of other disciplines. Drawing on this wisdom, old and new, and combined with contemporary knowledge gained through empirical evidence of various types, it is clear that a majority of people who experience trauma recover, are resilient to the impact of potential trauma, or experience growth.

Philosophical and theoretical positions from scholars in more recent decades have articulated their thoughts about processes that parallel PTG. For example, Maslow’s humanistic stance about human life has been made clear. He wrote:

human life will never be understood unless its highest aspirations are taken into account. Growth, self-actualization, the striving toward health, the quest for identity and autonomy, the yearning for excellence (and other ways of phrasing the striving “upward”) must by now be accepted beyond question as a widespread and perhaps universal human tendency … growth is often a painful process.

(Maslow, 1970, pp. xii–xiii)

Similarly, Rogers repeatedly wrote about how painful personal growth is, “even though in the long run rewarding” (Rogers, 1961, p. 14). Dabrowski (1964) described a process of personality development called “positive disintegration,” where dissolving mechanisms challenge a mediocre life cycle that may then give way to a more creative emotional and intellectual development. Existential theorists such as Frankl (1963, 1965) have clearly focused on the theme of creating meaning in the midst of trauma, and PTG theory owes much to this theoretical perspective and the reports in the existential literature of how people not only survive trauma but are transformed by it. The historical roots of PTG theory in religion, philosophy, and literature are explored in detail in Tedeschi and Calhoun (1995).

PTG—the Beginnings

Although reports on posttraumatic growth, under that rubric, were first published in the 1990s when Tedeschi and Calhoun introduced the term, their previous studies of the potential positive impact of the struggle with stressful events appeared in the 1980s. The book Trauma and Transformation: Growing in the Aftermath of Suffering (Tedeschi & Calhoun, 1995) provides an overview of the studies of PTG that had been performed to that point using different terms, such as perceived benefits (which these authors used themselves in previous work; e.g., Calhoun & Tedeschi, 1991). Tedeschi, Park, and Calhoun (1998) also examined the development of the PTG concept, and conceptually related ones that predate it, with a chapter by O’Leary, Alday, and Ickovics in that volume particularly relevant. Some terms conceptually related to PTG include stren conversion (Finkel, 1974, 1975), positive psychological changes (Yalom & Lieberman, 1991), construing benefits (McMillen, Zuravin, & Rideout, 1995; Tennen, Affleck, Urrows, Higgins, & Mendola, 1992), stress-related growth (Park, Cohen, & Murch, 1996), adversarial growth (Linley & Joseph, 2004), flourishing (Ryff & Singer, 1998), positive by-products (McMillen, Howard, Nower, & Chung, 2001), discovery of meaning (Bower, Kemeny, Taylor, & Fahey, 1998), thriving (O’Leary & Ickovics, 1995), positive illusions (Taylor & Brown (1988), positive reinterpretation (Scheier, Weintraub, & Carver, 1986), drawing strength from adversity (McCrae, 1984), and transformational coping (Aldwin, 1994; Pargament, 1996). Tedeschi and Calhoun first used the term posttraumatic growth (PTG) in print in 1995 and in an article in 1996 describing the development of the Posttraumatic Growth Inventory (PTGI).

Interdisciplinary PTG

Before systematic research examining PTG began, the theme of personal growth from life crises had been addressed in the arts, literature, philosophy, history, sociology, economics, biology, and psychology. Philosophical inquiry, as well as the work of novelists, dramatists, and poets, has focused on understanding and discovering the meaning of human suffering (Tedeschi & Calhoun, 1995, 2004b). Since the term PTG was coined in 1995, this phenomenon has become recognized as a powerful aspect of human nature, and it has been studied in various disciplines interested in the phenomenon of trauma response, including psychology, gender and sexuality studies, cultural studies, medicine, military studies, nursing, and social work.

As more studies have been conducted, it has become clear that PTG research can benefit from an interdisciplinary perspective. Interdisciplinary research is based on a conceptual model that links or integrates theoretical frameworks from two or more disciplines, uses study design and methodology that is not limited to any one field, and requires the use of perspectives and skills of the involved disciplines throughout multiple phases of the research process (Aboelela et al., 2007). As also encouraged by grant agencies, such as NIH (National Institutes of Health) or NSF (National Science Foundation), more studies are being conducted under the name of interdisciplinarity.

PTG is, and should be, an area of interdisciplinary interest, because it has clear links to a variety of disciplines. PTG researchers, theoreticians, and clinicians will better understand this human experience and ways in which to facilitate its application to clinical settings and everyday lives by considering PTG from the perspective of other disciplines. PTG is also better understood when taking holistic views of knowledge. For example, the combination of researchers and practitioners from psychology and creative industries may approach interventions for trauma survivors that are verbal or non-verbal, such as art therapy and art groups, performance art, music, and/or drama.

Interdisciplinary research on PTG can focus, for example, on how experiences are affected by the use of language with trauma survivors by working with researchers who have backgrounds in linguistics and anthropology. Considering PTG within a bio-psycho-social-spiritual framework requires familiarity with several disciplines. As demonstrated in this book, the possibility that people can change in a positive way from their struggle with a traumatic event can generate questions that may be better approached within one discipline or another. Instead of relying on one specific discipline, it is ideal to study this complex experience from interdisciplinary perspectives.

Cacciatore and Flint (2012), for example, reported a case study supporting the PTG framework in the bereaved by using an interdisciplinary paradigm for health-care professionals, including physicians, social workers, therapists, nursing staff, and other providers. As they indicated, many mental health providers face the reality of patients’ requests, which often include alleviation of symptoms; this forces them to take pharmacologically based approaches, but at the same time, they see the hope and possibility in patients who are experiencing psychological growth. Even in patients who are dying, it is possible to see a glimpse of PTG, which may not make sense if we assume PTG and recovery are synonymous. PTG is better understood when the traditional biomedical model is combined with other models such as existential models, social-personality models, spiritual-philosophical models, and so on.

One thing we have noticed is that, although PTG research may be best studied in an interdisciplinary way, it has predominantly been conducted by psychologists and clinicians such as social workers, nurses, oncologists, psychiatrists, and other mental health specialists. So far, there has been almost no study of PTG in the humanities other than references to the concept of growth as noted above.

Another emerging approach in this area is transdisciplinary research. Rather than drawing on experts with different discipline orientations, theories, methods, etcetera, transdisciplinary research reflects the creation of a new holistic way of approaching a question—an approach that transcends traditional disciplines by creating a new subdiscipline in itself. Such approaches are understandably challenging as members of a research team learn about each other’s disciplines on the road to creating new ways of thinking and approaching important research questions of the time.

PTG and Psychology

PTG research is found in a variety of psychology subdisciplines and is rooted in a variety of theoretical perspectives in psychology, including cogniti...