The Phenomenon of Posttraumatic Growth
My academic paper submitted as part of Module 3 for my MSc. Programme in Applied Positive Psychology and Coaching Psychology. (Appendices not published). Copyright: Poornima Nair. Please do not replicate.
Abstract In the era of ‘Second Wave’ Positive Psychology (SWPP), this chapter reflects on the concept of the complex phenomenon of Posttraumatic Growth (PTG) i.e. growth emerging from the struggle with highly challenging situations. Firstly, this is explored in depth understanding the contrasts in definitions of both trauma and PTG. Pioneers in this field have studied individuals post trauma and examined the possibility of good coming out of the struggle in five main domains – personal growth, relating to others, new possibilities, appreciation of life and spiritual and existential change with many concurring that PTG is linked to eudaimonic wellbeing. Numerous quantitative and qualitative scales have been developed over the years to measure PTG with research and interventions spanning across realms including war veterans, cancer patients, victims of abuse, those affected with loss and adversity and much more. Although there are criticisms of PTG with some researchers questioning if the concept is an illusion, the strong position of this paper is that PTG is authentic – a process and an outcome, where growth and transformation becomes evident over a period of time. Chapter aims Over the last decade, the discipline of Positive Psychology (PP) has faced much criticism for adopting a positive-only focus. Although PP differentiated itself from the traditional ‘psychology as usual’, it relied heavily on a dichotomous thinking style. This message that ‘negative’ phenomena was undesirable and ‘positive’ outcomes were beneficial was seen as ‘first wave’ PP (Ivtzan et al. 2016, p.6). Responding to strong criticism from within the field of PP and outside, there came about a shift and modulated approach to the notion of ‘positive’ and ‘negative’ with the emergence of SWPP (Held, 2004). The aim of this paper is to focus on this era of SWPP which embraces both positive and negative elements as critical to many aspects of human flourishing (Lomas & Ivtzan, 2016) and this will be validated here through a concept review of the complex phenomenon of PTG.
This chapter is divided into the following sections:
Origin and definitions of PTG within SWPP
Theoretical perspectives within PTG
Measurements of PTG
Research and interventions
Critique and conclusion.
Over the years, the different definitions of trauma have caused much dissent and controversy (Weathers & Keane, 2007). This is primarily due to the shortcomings of the Diagnostic and Statistical Manual of Mental Disorders (DSM) definitions that focussed on including both a situational and response requirement for traumatic events. For instance, the DSM –III defines trauma as an event that is “generally outside the range of usual human experience… and would evoke significant distress in most people” (APA, 1980, p.236) while the DSM IV extended the definition to individuals who “experienced, witnessed, or confronted with an event…that involved actual or threatened death or serious injury…responding with intense fear” (APA, 1994, p.427-428). However, in SWPP and PTG as we are interested in how individuals change and grow “in the aftermath of events that are undesirable in the extreme” (Tedeschi et al. 1998, p.3) it is useful to focus on a broader definition of what defines trauma, one where traumatic events do not necessarily have to be life-threatening or elicit symptoms of Posttraumatic Stress Disorder (PTSD). Therefore, this paper will use the following definition of trauma “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 events 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. 1988, p.2).
Origin and definitions of PTG within SWPP
Although the specific term PTG is relatively new, the origin of this concept can be dated back to philosophical and theoretical positions from scholars like Maslow who articulated his stance on human life that closely align with PTG as “growth is often a painful process” (Maslow, 1970, p. xii-xiii). Similarly existential theorists like Frankl (1963, 1965), Rogers (1961, p.14) and Dabrowski (1964) also focused on the concept of generating meaning in the midst of trauma portraying that the historical roots of PTG theory are embedded in philosophy, religion and literature (Tedeschi & Calhoun, 1995). Tedeschi and Calhoun (1996) introduced the concept of PTG, which they define as “positive change that occurs as a result of the struggle with highly challenging life crisis” (Tedeschi & Calhoun 2004, p.1). PTG therefore engages with the agonising realisations of reality and shattered assumptions (Janoff-Bulman, 2004, p.33) and rebuilding around the traumatic experience to witness change that is transformational. This definition and phenomenon of PTG is particularly pertinent from a SWPP perspective – it reflects the ‘principle of co-valence’ indicating that flourishing includes a complex web of positive and negative elements (Lomas & Ivtzan, 2016). PTG in this ‘dark side’ of PP links positive changes and growth with trauma and adversity.
Theoretical perspectives within PTG
As expressed before, the aim of this paper is to focus on the phenomenon of PTG in SWPP and this will be demonstrated here using the two theoretical perspectives of PTG. It is useful to take a moment now and consider – how can a traumatic event lead to positive growth and transformation and where does that manifest in life? PTG can take various forms based on where the individual is at that particular point in time (Tedeschi et al. 2018, p.25) and it can manifest in the following realms:
The five domains of PTG: The first perspective of PTG was introduced by its founders and focussed on an inspection of outcomes (Calhoun & Tedeschi, 1989). Resulting from the evolution of the Posttraumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 1996) and studies with different trauma survivors, common areas of change emerged which can be classified into five empirically derived domains of PTG.
1. Personal Strength: Individuals in this domain are intrigued to discover their own internal strength. “I am more vulnerable than I thought, but much stronger than I imagined” (Calhoun & Tedeschi, 2006, p.5). There is an increased sense of self-reliance, confidence and movement from “victim” to survivor leading to behavioural changes and newfound engagement (Shakesphere-Finch & Barrington, 2012). Individuals also report feeling more authentic, with a deeper connection to self after their adverse experience.
2. Relating to others: People relate to an experience of positive changes in relationships including attitudes and behaviours. “ I put more effort into my relationships”; “I more clearly see that I can count on people in times of trouble”(Tedeschi & Moore, 2016, p. 75). Themes that flow from this domain include how relationships changed with people as a result of trauma and how they can count on others and have a greater appreciation of people. A caveat: Trauma survivors have also reported of friends who are not around and less supportive at the time of the adversity, which is painful (Hefferon & Boniwell, 2011, p. 121).
3. New possibilities: This domain focuses on shifts in priorities, identification of new possibilities and paths like changing life-goals, obtaining new skills, learning, building new careers, involvement in community groups (Shakesphere-Finch & Barrington, 2012) and so on. “I am more likely to try to change things that need changing”; “I am able to do better things with my life” (Tedeschi & Moore, 2016, p. 82).
4. Appreciation of life: There comes about a deep appreciation for life post-trauma – simple pleasures, spending time with loved ones, watching sunsets and so on. “I changed my priorities about what is important in life”; “I can better appreciate each day” (Tedeschi & Moore, 2016, p. 78).
5. Spiritual and Existential change: As one wrestles with what has happened, there tends to be an increased sense of the importance of spiritual matters with one questioning their meaning and purpose in life. Many seek guidance in scriptures, secular teachings and ideas. “I have a greater sense that I am part of the fabric of life”; “I have a deeper sense of connection with the world” (Tedeschi & Moore, 2016, p. 85).
A caveat: The current five domains of PTG explained from the original studies do not include all aspects of growth, for instance the corporeal element has been excluded. Additional research needs to be administered to determine how physical changes in the body can facilitate PTG (Hefferon, 2012). That being said, the research on PTG using the five domains is ground-breaking with researchers validating that positive transformations and behaviours can be manifested through all the five forms, and as many as 70% survivors of trauma have reported positive change in at least one of the five domains (Linely & Joseph, 2004).
The Organismic Valuing Theory of PTG: This theory posits PTG as an expansion in eudaimonic wellbeing (Joseph, 2013) i.e. emphasising that growth following distress is not about subjective wellbeing (SWB) but rather an increase in psychological wellbeing (PWB) with growth seen in the facets of self-acceptance, environmental mastery, personal growth, autonomy, positive relations with others and purpose in life (Ryff, 1989; Ryff & Singer, 1996). It proposes that trauma can be reflected in two ways – assimilation or accommodation and to support this, three cognitive outcomes are proposed post trauma for an individual. Initially, a return to pre trauma baseline, then experiences accommodated negatively and lastly, experiences accommodated positively resulting in the individual’s growth with the fundamental premise of this theory being that people are inspired to pursue positive accommodation post trauma provided the social environment can support this i.e. their psychosocial framework (Joseph & Linley, 2008, p. 12 -15). However, further theoretical and research work needs to be undertaken to address issues relating to this psychosocial framework and its impact on growth.
Measurements of PTG
Researchers over the years have used numerous qualitative and quantitative measures to test for positive growth following adversity, including The Posttraumatic Growth Inventory, The Psychological Wellbeing-Posttraumatic Changes Questionnaire, The Stress-Related Growth Scale, The Thriving Scale, The Perceived Benefits Scales, The Benefit Finding Scale for Children, The Silver Lining Questionnaire and The Changes in Outlook Questionnaire. Two popular measures will be discussed here.
· The Posttraumatic Growth Inventory (PTGI): The PTGI (Tedeschi & Calhoun, 1996) is a frequently used inventory to measure PTG as a result of the rigorous research conducted on its psychometric qualities. The PTGI is available in multiple languages and used in numerous research projects. The original PTGI items were quotes gathered using qualitative research from persons interviewed in the aftermath of trauma. The items focussed on three broad areas – perceived changes in self, relationship with others and philosophy of life and the 21-item PTGI measure was developed. Factor analysis revealed the five domains of PTG – personal strength, relating to others, new possibilities, spiritual change and appreciation of life (Tedeschi & Calhoun, 1996). The items are rated on a 6-point scale depicting a potential range from 0-105 with higher scores indicating greater levels of growth. The PTGI has recorded strong reliability validated by a number of studies (Brunet et al. 2010; Moore et al. 2011). Further, positive behavioural changes have been demonstrated in the five PTGI factors (Shakespeare-Finch & Barrington, 2012) and also through qualitative research of highly stressed individuals confirming that the construct validity of the PTGI is measuring what it’s designed to measure (Shakespeare-Finch et al. 2013).
· The Psychological Wellbeing-Posttraumatic Changes Questionnaire (PWB-PTCQ): Based on the theory of eudaimonic wellbeing, the PWB-PTCQ (Joseph et al. 2012) was developed using Ryff’s (1989; Ryff & Singer, 2008) theoretical architecture of psychological wellbeing (PWB) measuring six subscales – autonomy, environmental mastery, personal growth, positive relationships, purpose in life and self-acceptance. The measure consists of 18 items with three items per domain and asks respondents to rate how they perceive their change post trauma on a 5-point scale. The psychometric properties of the PWB-PTCQ were satisfactory with no unstable properties detected and with regards to validity, the scale correlated in the direction of its measures (La Cour et al. 2016).
Critique of PTG scales: Research conducted on PTG scales questions whether the related constructs of PTG genuinely reflect positive change and if the manner in which growth is measured is actually valid (Frazier et al. 2009). So, the question here is, do self-reported PTG scales authentically reflect positive change post trauma? Studies conducted show growth following adversity could also reflect individuals’ self-protective strategies (Mc Millen & Cook, 2003; Davis & McKearney, 2003). The validity of self-report measures of PTG have also been criticised (Shakespeare-Finch & Enders, 2008) and the main reasons for this have been identified as – a) recall of the actual trauma and b) how much authentic change can be assigned to the traumatic event. Therefore, although people change in deep ways following trauma, it is recommended that the use of self-reported questionnaires should be viewed with reservations (Nolen-Hoeksema & Davis, 2004).
Research and Interventions
The outcomes of growth following adversity have been widely researched in multiple domains including terrorism, war, cancer, childhood abuse, sexual abuse, loss and adversity with numerous studies reporting positive and lasting growth amongst trauma survivors (Joseph et al. 1993; Tedeschi & Calhoun, 1995; Mearrcker & Zoellner, 2004; Lahkav et al. 2016). However, there are still very few studies examining interventions to foster PTG (Roepke, 2015). In this section, PTG research and interventions in two areas will be explored briefly: military personnel and those affected by cancer. Growth has been documented in people affected by terrorism (Butler et al. 2005), military people (Bush et al. 2011; Elder et al. 2017; McLean et al. 2013) and within conflict (Elder & Clipp, 1989; Fontana & Rosenheck, 1998) with reported benefits including solidarity, self-discipline and comradeship, (Erbes et al. 2005). An exemplar intervention for combat veterans, trauma survivors and military personnel is the PTG Facilitation Program, which uses the five domains of PTG and companionship focus, where outdoor, physical and meditative practices are integrated into the experience. Also known as The Boulder Crest Program, this blend of the PTG model along with physical and inter-personal environments is deemed ground breaking (Tedeschi & Moore, 2016b). Extensive PTG research has also been conducted with a wide range of cancer patients with reports of positive changes in satisfaction in life, meaning in life, self-confidence, personal strength, spirituality, compassion for others and developing stronger relationships (Bower et al. 2005; Bellizzi, 2004; Thornton & Perez 2006; Weiss, 2004; Groarke et al. 2017; Hefferon et al. 2008). Activity-based interventions have been recommended to cancer patients to manage stress symptoms (Wood et al. 2011) including art therapy (Singer et al. 2013; Mohr, 2014) and exercise interventions (Hefferon et al. 2008). Strength-based interventions (Milam et al. 2015), cognitive-behavioural stress management programmes (Antoni et al. 2001) are also being used to help patients with stress reduction, effective coping strategies, emotional expression and social support. It is recommended that PTG interventions are integrated into existing cancer care programmes. A caveat: This may not be effective for patients who have high social inhibition or collectivistic cultural characteristics (Matsui & Taku, 2016).
Critique and Conclusion
Is PTG a mere illusion? This is one of the biggest criticisms of PTG and this view is based on the assumption that self-reported PTG does not necessarily reflect “real” growth in an individual. Some researchers view PTG as “illusory” (Maercker & Zoellner, 2004; Sumalla et al. 2009) and “perceived” (Frazier et al. 2009) while others argue that PTG should be considered authentic only if personality changes are involved (Jayawickreme & Blackie, 2014). Although this chapter questions the validity of self-reports, the strong position taken here is that PTG is authentic. Reason being, PTG is a process and an outcome (Calhoun & Tedeschi, 2004) – a process that begins with an effort to cope and survive the trauma with no aim to benefit; but over a period of time growth and transformation in the individual becomes apparent. The aim of this chapter was to review PTG in SWPP and despite the criticisms faced by PTG and the need for further research in clinical and non-clinical settings, my opinion here is that traumatic experiences in an individual can lead to growth and transformation over a period of time further validating that both positive and negative elements are essential for human flourishing.
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