Posttraumatic Growth in Clinical Practice

Lawrence G. Calhoun, Richard G. Tedeschi

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136619724
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

From the authors who pioneered the concept of posttraumatic growth comes Posttraumatic Growth in Clinical Practice, a book that brings the study of growth after trauma into the twenty-first century. Clinicians will find a framework that's easy to use and flexible enough to be tailored to the needs of particular clients and specific therapeutic approaches. And, because it utilizes a model of relating described as "expert companionship, " clinicians learn how to become most empathically effective in helping a variety of trauma survivors. Clinicians will come away from this book having learned how to assess posttraumatic growth, how to address it in treatment, and they'll also have a basic grasp of the ways the changes they're promoting will be received in various cultural contexts. Case examples show how utilizing a process developed from an empirically-based model of posttraumatic growth can promote important personal changes in the aftermath of traumatic events.

one

The Process of Posttraumatic Growth in Clinical Practice

He did not marry until he was 39, several months after he met the woman he described as being “my perfect match.” She was three years older—successful, intelligent, warm, highly educated, with the same core values. They both wanted children, but knew that the chances of having their own biological children diminished with each year.

They were delighted when her pregnancy was confirmed in their third year of marriage. Their baby boy was born without incident, and he developed quickly and precociously. As the years passed, however, the parents slowly drifted apart. Her job required her to travel frequently and his required him to work long hours, often into late night. That combination proved fatal to what had been a thriving and happy relationship. When the boy was nine the marriage ended, but the divorce was civilized and amicable. They decided that the circumstances made it wiser for him to assume primary custody, with visitation whenever she would like. Things remained amicable and peaceful in the now separated family.

However, during the boy's first year of high school, things started to go wrong. His teachers reported that his performance in school was suffering. In spite of being very intelligent and capable, his grades became poor. On some days he had great difficulty getting ready for school, moving slowly and complaining that he did not want to go. On others, he was extremely irritable. The parents sought professional help.

The clinician indicated that the boy was clinically depressed and recommended psychotherapy and a medical consultation for antidepressants. Medication was prescribed and psychotherapy sessions began and continued for the next months. However, his depression did not abate. He was moody and angry, stayed in his room most of the time when he was not at school, he had no friends, and showed little interest in engaging in any activities beyond lying in his bed.

Neither his parents nor the professionals who had been seeing him expected it when it happened. One evening, when his father went to his room to call him to supper, he found him hanging from the back of the door. He had used his belt—it should not have worked, but it did. Although the emergency medical team went through the motions, it was clear that they could not revive him. At the age of 14, his first suicide attempt had been successful.

The father sought professional help and started regular sessions with an experienced, caring, and empathetic clinician. A clear element in his distress was his overwhelming sense of guilt at having “failed my son.” From his perspective, he believed he should have been able not only to foresee, but also to prevent his son's suicidal death. Although the clinician would sometimes provide gentle reassurance and occasional gentle probing of the degree to which the sense of guilt was truly merited, the clinician's main contribution was simply to listen, using his expertise occasionally and then only when it appeared useful to the grieving father.

As time progressed and the father's distress was somewhat reduced, the clinician began to notice something intriguing in the clinical sessions. In the midst of describing his continuing sense of guilt, his sadness, and his continued yearning for his son, the father would sometimes talk about how his struggle and pain had changed him—being forced by suffering “to be a better man, a different man. I am not who I used to be. I am permanently wounded, a man who will never be whole again. But I am also stronger than I thought I would be, and I find my heart going out to other parents whose children suffer or other parents who have had to face the kind of hell I have been forced to live in. Maybe I can use my pain to somehow help others live through theirs.”

How should clinicians respond to, and deal with, not only the great pain and suffering that this father had to endure, but also his reports of being a better person and wanting to help others, as a result of having to walk through his own personal valley of the shadow? Although some professionals specialize in working exclusively with survivors of traumatic events, or with persons dealing with grief and loss, even those who do not have such specialty practices will have clients like this father. Or they will see people who have been traumatized in other ways, or who have faced other major life crises and severe stressors. This book suggests a particular stance to take in working with persons facing these kinds of very difficult struggles. The perspective described here is not an alternative to be used instead of the demonstrably effective therapeutic approaches for helping people deal with the aftermath of traumatic events. What we describe in this book is a therapeutic perspective that adds to and expands best practices. This book is about posttraumatic growth in clinical practice and the therapeutic stance of the expert companion for working with persons facing major difficulties in life. However, before focusing on growth it is important to be reminded that life crises can bring significant distress.

The Negative Side of Life Crises

People who have personal experience with traumatic events¹ and clinicians who have worked with them know that, although many persons can be resilient or can bounce back quickly in the face of trauma, negative reactions are common and pervasive (Bonanno, 2004; Keane, Marshall, & Taft, 2006). More extensive description of the kinds of psychological distress persons facing major life crises can be found elsewhere, but it is important to be reminded that in spite of great resilience, human beings can also experience significant distress when they encounter trauma. The present description will provide only a brief summary of some of the most common reactions.

Distressing Emotions

A general rule of thumb is that the more prolonged the exposure and the more intensely negative the circumstances are, the more likely it is that people will experience distressing emotions. For persons exposed to life-threatening events a major emotional response is anxiety and fear, particularly about the future occurrence of similar events. A woman who seeks shelter from a physically abusive relationship, for example, may have great concern about her physical safety. In the aftermath of the devastating tornados that strike various parts of the United States every year, a common response is worry and apprehension when skies become dark, cloudy, and rainy.

The specific emotions will vary with the person and the circumstance, but most people, even highly resilient people, will experience some degree of distress in situations that are challenging. Sadness is recognized as an almost universal reaction to the death of a loved one. It is typical for bereaved persons to be sad, yearn for the deceased, and wish that things could have been different (Neimeyer, Harris, Winokuer, & Thornton, 2011).

As it was with the father described above, guilt is not uncommon among persons dealing with life crises. Guilt has elements of both thoughts and emotions, but the guilt that most clinicians will encounter in their clients is a feeling of guilt. Survivor guilt is a common response for persons who have survived a catastrophe that did not spare others. For example, the mother of a child who was recovering from a very serious school bus accident began to feel a great sense of guilt over her joy that her child had survived, when that same crash had killed several other children.

The sense of guilt may be tied to ruminations about what the person might have done, should have done, or should have left undone (Gilbar, Plivazky, & Gil, 2010). The 16-year-old daughter of a woman who was hospitalized for a brief and routine operation had a heated argument with her mother about the use of the family car and stormed out of her mother's room and left for the night—her mother died of unexpected complications only a few hours later. The daughter was troubled for a long time by the guilt she felt over that last encounter with her mother.

Anger and irritability are also common responses to major stressors. Although these are usually not regarded as having the same clinical significance as anxiety or depression, these are not pleasant emotions. The anger may be expressed directly at those believed to be responsible for the event, like the man whose job is lost to “downsizing” and who later returns well-armed thinking about killing those whom he believes cost him his job. But the irritation and anger may be focused on targets unrelated to the event. For example, a man whose mother was in hospice care became furious at the “total lack of care my mother is getting,” although hospice was providing quite good care for his dying mother.

Unwelcome Intruders: Distressing Thoughts and Images

Re-experiencing the event is one of the symptoms of posttraumatic stress disorder. Most people who are exposed to traumatic events do not develop the disorder, but they may well experience repeated intrusions into consciousness of memories of traumatic events, sometimes in the form of images but more commonly in the form of intrusive thoughts. “I keep thinking about it, but I don't want to” describes a common response of persons facing difficult situations. A man recently diagnosed with prostate cancer, for example, found that even minor reminders would lead him to think, over and over again, about what would happen to him as he faced choices about treatments and the variety of possible outcomes that the illness and its treatment held for him.

The content of the intrusive thoughts will vary greatly, but intrusive thoughts are common and they will to be experienced as negative and unpleasant.

Problematic Behaviors and Physical Symptoms

Although not a typical response to major stressors, some people may begin or intensify problematic behaviors. One possibility is the problematic use of substances (Schwabe, Dickinson, & Wolf, 2011). The misuse of commonly available drugs, such as alcohol or tobacco, may be triggered or intensified by the occurrence of a major life crisis. For some people, the maladaptive or excessive use of food, as a way to provide some sense of psychological comfort, may also be a possibility.

The experience of distressing emotions is common, and some persons may assume that others cannot, or will not want to, listen, understand, or help in any significant way (Kaynak, Lepore, & Kliewer, 2011). People may then either withdraw from others, or fail to seek support in the ways that might be most useful, making support more difficult. If the person experiences significant depression or if the event involved elements of sexual violence, then another challenge may be the emergence of sexual difficulties.

Another behavioral problem may be an increase in the likelihood of aggressive behavior. A very cautious and tentative generalization is that anger and aggression may be somewhat more likely in men who are faced with significant life challenges. A particularly lethal combination is the excessive use of alcohol together with an increase in angry and aggressive behavior. People who are themselves survivors of childhood physical or sexual abuse may be at somewhat higher risk of engaging in similar behaviors as adults, and alcohol use can act as a disinhibitor for those undesirable behaviors.

The relationship between life stress and the presence of physical symptoms, and on occasion even physical illnesses, is widely recognized. Exposure to highly stressful events can place some people at risk for psychological problems, perhaps even posttraumatic stress disorder, and exposure to stressors can also increase the possibility of developing physical illnesses (Spitzer, Barnow, Volzke, Ulrich, Freyberger, & Grabe, 2009). Even if fully developed illnesses do not occur, people exposed to major life stressors may complain of a wide variety of physical discomforts.

The body's physical activation in response to stressful circumstances, what is described in general terms as the fight or flight response, can last for some time after a particular event is over. People will then report a variety of physical symptoms, probably depending on their genetic predispositions and previous health practices. Some possibilities are fatigue, gastrointestinal difficulties, a sense of being physically “nervous,” trouble breathing, muscle tension and aches, difficulty sleeping, feeling jumpy, etc.

It is important for clinicians to recognize that some people dealing with the aftermath of a traumatic event can report such physical complaints. Under some circumstances a referral for medical evaluation may be necessary. But perhaps more often, the clinician needs simply to understand that this wide array of complaints represents the expected response of the body to the highly demanding situation the individual is facing.

Summary: The Negative Side

Highly challenging events can produce a wide range of unpleasant psychological and physical responses. The poet Ted Hughes described this possibility, in this way, when he referred to the impact of the suicidal deaths of his two wives, “I have an idea of these two episodes as giant steel doors shutting down over great parts of myself” (quoted in Allen 2002, p. 12). There are some exceptional people who will not experience even mild and temporary distress, but most people will likely go through a time where they feel psychologically or physically challenged. The type and pattern of the troubles will differ, but most people who face very difficult life circumstances are likely to experience distressing psychological states and perhaps some physical discomfort as well. In addition, individuals exposed to traumatic events may also be at risk for psychiatric disorders, such as PTSD (Posttraumatic Stress Disorder) and depression. It is important to keep in mind, however, that the emergence of psychiatric disorders appears to be the exception, rather than the rule.

The possibilities for distress emerging from the struggle with trauma have been recognized for many years by clinicians and by researchers. Practicing clinicians understandably have focused on the negative consequences of the struggle with crisis events, because their role is to help persons whose responses to trauma include distressing and painful responses for which they would like relief. But there has also been the recognition that life challenges can represent the paradoxical opportunity for the experience of growth in the very context that has produced discomfort, pain, and suffering.

Posttraumatic Growth: Background

Homer in The Odyssey, the story about Odysseus' long journey home from the Trojan War, says, “Even his griefs are a joy long after to one that remembers all that he wrought and endured.” Paul, in the Christian New Testament, says “We also rejoice in our sufferings, because we know that suffering produces perseverance; and perseverance character.” An African proverb tells us that “Smooth seas do not make skillful sailors.”

As these quotations indicate, the idea that the encounter with major adversity can change some people for the better, perhaps in radical ways, is not new. Although we did introduce the term posttraumatic growth (Tedeschi & Calhoun, 1995) to label this experience, clearly we did not discover this phenomenon. The ideas and writings of the ancient Greeks, Hebrews, early Christians, the teachings of Buddhism, Hinduism, and Islam, all have addressed the possibility of good coming from suffering. In more recent times, thoughtful scholars like Frankl (1963), Caplan (1964), Dohrenwend (1978), and Yalom (1980) addressed the possibilities for positive change offered by the encounter with critical life problems.

We defined posttraumatic growth as the experience of positive change that the individual experiences as a result of the struggle with a traumatic event (Calhoun & Tedeschi, 1999). The systematic study of this phenomenon was energized in the mid-1990s by several factors. One was the publication of articles (O'Leary & Ickovics, 1995), and at least one book (Tedeschi & Calhoun, 1995), that called attention to the possibility that positive change could be set in motion by the encounter with difficult life situations. Another factor was the publication of inventories developed to measure self-reports of growth including the Changes in Outlook Questionnaire (Joseph, Williams, & Yule 1993), the Stress-Related Growth Scale (Park, Cohen, & Murch, 1996) and the Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996). A third contributing factor may have been the renewed call to focus more on the understanding of positive elements of human behavior, what has become the influential “positive psychology” movement (Seligman & Csikszentmihalyi, 2000).

The study of posttraumatic growth is now widespread, with investigations having been conducted in many countries, including the United States, Great Britain, Brazil, Australia, Chile, China, Germany, Malaysia, the Netherlands, Portugal, Pakistan, India, Spain, Norway, Sweden, Denmark, and Japan. Entering the restricted term posttraumatic growth into the search engine Google produces more than 100,000 “hits.” Entering the same phrase into PsychInfo results in over 650 references. In the remainder of this chapter, we will provide an overview of some of the findings about posttraumatic growth. We will first provide a description of the general ways in which posttraumatic growth is typically experienced. Following that, we will address the validity of reports of growth. Next we describe a general model of the process of growth, and the chapter will conclude with a discussion of the possibility of posttraumatic growth in couples, families, and communities.

The Experience of Posttraumatic Growth

When US Airways flight 1549 struck a flight of geese, lost all power to its engines, and was landed safely by its crew on the Hudson River in New York 15 January 2009, it was called “The Miracle on the Hudson.” All on board were safely rescued. Recalling the impact of that experience, Pam Seagle, an executive with Bank of America said “I thought about my family, my family, my family.” Since then she has shifted priorities to place more emphasis on her parents, husband, and her children. “I say 'I love you' to people I never said that to before” (Washburn, June 12, 2011).

No general summary can encompass every single element that all persons will report as part of their growth experience, but there does seem to be a set of general elements that are quite common. Statistically, the experience tends to be reflected in five factors (Brunet, McDonough, Hadd, Crocker, & Sabiston, 2010; Taku, Cann, Calhoun & Tedeschi, 2008; Tedeschi & Calhoun, 1996): personal strength, relating to others, new possibilities in life, appreciation of l...