Posttraumatic Growth: The Preferred Outcome

As humans we know that sometimes bad things happen to people, whether it is to ourselves, or others, tragedy in a life-time is inescapable; the good news however, is that as humans, we have the ability to overcome tragic events. Trauma or adversity can come at any time or in any form, differing in severity or length of time, and yet possibility for recovery is always an option. In fact, more than just recovery, research has found that some people are said to ‘benefit’ from or feel a transcendence following trauma.

The sudden knowledge of one’s mortality is said to leave some people feeling enormous appreciation for life. Unfortunately, however, in most cases, trauma leaves people suffering posttraumatic stress which may go on to develop into a psychiatric illness known as Posttraumatic Stress Disorder. This illness has traditionally been associated with war veterans, but trauma of any kind can leave people psychologically impaired in this way. The symptoms are devastating, they include flashbacks, irritability, insomnia, disassociation, hyper-vigilance, and avoidance of situations which take them back to the event.

Sadly, trauma or major life crises are here to stay, the only difference being that some people recover quickly with great fervour and reverence while others are left devastated and unable to continue as they once did (the latter being the more common outcome). Psychologists therefore are particularly intrigued by the individuals who, not only recover quickly, but astonishingly seem to ‘benefit’ from, or gain something from trauma. A well known example is that of Trisha Meilie, a young woman who in 1989, was brutally assaulted and raped while jogging in New York’s Central Park.

When found, she had injuries that had left her close to death. During her long recovery from brain damage and re-learning to walk, she remained anonymous, but fourteen years later she re-appeared, whole and happy, with a best-seller I am the Central Park Jogger: A Story of Hope and Possibility. She is now a highly sought after speaker, giving inspiring speeches on several lecture circuits as she relates her miraculous story (www. centralparkjogger. org, 2007). The fascinating ability to turn one’s life around after devastation is not a new one, noted and documented throughout history, there are several significant examples.

Friedrich Nietzsche (1844 – 1900) a German philosopher is famous for his profound statement “that which does not kill me makes me stronger” (Nietzsche, 1889/1997). Viktor Frankl (1905 – 1997), a holocaust survivor who spent 3 years in a concentration camp wrote: “Everything can be taken from man but the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way” (p. 106). Even at times of great human suffering, these individuals overcame adversity and remained positive about their lives (Boniwell, 2006).

The phenomenon is called ‘Posttraumatic Growth’. The remarkable ability for some people to recover from trauma in this way leaves one perplexed. What makes these individuals different? How do they differ to those who do not find happiness or higher levels of functioning in the aftermath of trauma? The adaptive response to something negative should surely be, negative. This review looks at these questions, as well as the origins and the reality of the concept of posttraumatic growth.

It then considers whether growth is a necessary or a preferable outcome following a trauma, and if so, what are the pre-trauma factors to facilitate such an outcome? Finally, it offers a balance between the two extremes: ‘those who grow’ and ‘those who do not’. Given its name in 1996 by psychologists Richard Tedeschi and Lawrence Calhoun, posttraumatic growth is defined as “the experience of significant positive change arising from the struggle with a major life crisis” (Calhoun, Cann, Tedeschi, and McMillan, 2000 p. 21).

An important aspect of the concept is that it refers to positive changes that do not exist pre-trauma but come as a result of trauma, thus, the person functions even better following their recovery from a trauma (Tedeschi & Calhoun, 1998). Inspired by previous literature, Tedeschi and Calhoun (1995) approached the phenomenon empirically and systematically, considering the circumstances under which posttraumatic growth occurs; to whom; and whether it can be measured.

They found that posttraumatic growth is indeed not just a ‘research artefact’, or a ‘positive illusion’, it is something that exists and can be measured systematically and reliably (Tedeschi & Calhoun, 1998). They identified five common attributes in individuals who reported Posttraumatic Growth: new possibilities for one’s life; profound appreciation for life; deeper empathy and altruism for others; personal strength and spiritual change (Tedeschi & Calhoun, 1998); they then incorporated these factors into their five factor inventory as a measure for posttraumatic growth.

The PTGI or Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1998), as well as the CiOQ, a 26-item – ‘Changes in Outlook’ – Questionnaire (Joseph, et al 1993, 1997), have since become accepted measures of posttraumatic growth. The three components involved in posttraumatic growth: the trauma, the person, and the outcome, have also been widely researched and are thus considered in turn. A trauma, according to DSM-IV (APA, 1994), is when ‘a person has experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity to self or others’.

The person’s response involved intense fear, helplessness or horror’ (p. 467). A trauma is often sudden, random and uncontrollable. Natural disasters (floods, earthquakes); deliberate disasters (terrorism, rape); accidents (car and plane crashes); sustained repeated events (sexual abuse, spousal abuse, torture); military combat; as well as a diagnosis of chronic/life threatening illness, are all examples of trauma. The list is not exhaustible due to its subjective nature, what may count as traumatic to one may not be to another, therefore, not all examples can be listed.

What remains apparent, however, is the sheer devastation that follows the event. In the immediate aftermath of trauma, the individual experiences severe cognitive upheaval as they try to make sense of what has happened. The event shatters what has been familiar and predictable to them. Their worldviews or core beliefs (schema), which may have been invisible up until that point, are thus challenged (Janoff-Bulman, 1992; Linley & Joseph, 2004).

For example, a devout Christian may question why ‘a loving God would allow a dreadful accident’, following which, they may begin to question the existence of God and then despair at the loss of meaning to their life without God. Later, through the painful process of accommodation, they begin to modify their existing schema to include the new (traumatic) information (Joseph & Linley, 2004). Their schema may now include the understanding that God or spirituality is a separate issue to the misfortunes of earthly events and thus they are able to integrate God into a new set of beliefs.

This transformational coping by constant rumination (Tedeschi and Calhoun, 2004) or modifying old beliefs is what brings the eventual psychological outcome. According to O’Leary and Ickovics (1995), there are three possible outcomes following trauma: ‘recovery’ (returning to pre-trauma functioning or homeostasis); ‘survival’ (lower functioning or distress); and ‘thriving’ (higher level functioning or ‘growth’) (O’Leary et al. , 1998).

However, the psychological outcome after trauma will depend on the individual’s coping style, for example ‘homeostatic coping’ will lead to ‘base line’ or recovery, whereas ‘transformational coping’ will lead to a higher level of functioning or ‘growth’ (O’Leary et al. , 1998). The individual’s method of coping will depend on several pre-trauma factors, as well as post-trauma factors (such as social support), which will eventually result in one of the three mentioned outcomes; ‘growth’ being the preferred outcome.

Growth is the preferred outcome because of the positive changes it brings to peoples’ lives. Meaningfulness and greater appreciation for life, not only benefit those who experience it but offer some encouragement and inspiration to others in similar situations. Researchers are therefore interested in the cognitive, social and emotional factors concerned with posttraumatic growth as it may be of relevance to counsellors or clinicians who wish to facilitate the process for growth in practice (Tedeschi & Calhoun, 2004).

Understanding the dynamics of different coping styles, may enable clinicians to apply their knowledge in a therapeutic setting which will encourage a process towards growth. Thus, various pre-trauma factors which illicit certain methods of coping, or coping styles, have been identified: an optimistic personality style, a cognitive neural circuit ‘conducive to coping’, a good social network, and, resilience (Masten & Reed, 2002).

A study investigating the impact of personal resilience in 67 Chinese coronary heart disease patients, found that they experienced posttraumatic growth and better recovery as opposed to those with low personal resilience (Chan, Lai & Wong, 2006). Resilience is the ability to successfully ‘bounce back’ or overcome significant risks or traumas. Masten & Reed (2002) define ‘bouncing back’ as an external or internal adaptation where the person is able to once again function ‘normally’ within a social context (they are meeting educational or occupational expectations) following the trauma.

Resilience is important because it contains several implicit attributes including self-esteem, initiative, humour, insight, problem-solving abilities and an internal locus of control; all of which function towards a greater outcome (Masten & Reed, 2002). Having established that resilience is an essential factor in posttraumatic growth, researchers also concede that the ability to cope effectively in a positive way has to do with personal disposition, specifically one of optimism (Moos & Schaefer, 1993).

An optimistic style of coping will encourage a positive mental process which will indeed influence a positive outcome after trauma. Personal disposition or personality, profoundly affects the way in which people behave in the aftermath of trauma and thus it is an important factor if growth is to be the outcome. A longitudinal study of those who had lost a loved one to a terminal illness, found that people with a ‘ruminative coping style’ sought out social support more often and were more likely to benefit from social support than those ‘without a ruminative coping style’ Nolen-Hoeksema, (2002).

Social support is a significant predictor of posttraumatic growth (Joseph & Linley, 2004). Individuals who are encouraged to talk about their trauma or who are surrounded by others who have had a similar experiences, are more likely to experience posttraumatic growth (Joseph & Linley, 2004); thus, it can be said that those with a certain disposition (inclined to be sociable), are at a distinct advantage. In addition to personality, the individual’s cognitive neural circuitry may also contribute to an effective coping style.

Brain models have suggested that those who are goal-directed or who strive to achieve, even at times of severe stress, very often share a common neurology in-so-much that higher activation in the left frontal lobes has been correlated with posttraumatic growth, whereas activation in the right, showed the reverse (Rabe, et al. , 2006). A study of 82 individuals who survived a severe motor accident found that those who had high electroencephalographic activity in their left frontal lobes also reported perception of posttraumatic growth (Rabe, et al, 2006).

Left lobe activation showed a natural tendency towards achievement and meaning making after trauma. What differentiates these individuals from others is that they possess a natural tendency to ‘achieve’ and ‘make meaning of’, after trauma – an advantage that does not require extra work. The individual who attempts to cope in this way will unintentionally proceed towards the positive outcome of posttraumatic growth (Zoellner & Maercker, 2006). The individual’s unique coping style allows an automatic response, one that cannot be engineered.

Frankl (1905 – 1907) believed that the one thing humans have that cannot be taken away is their ‘choice’, yet there is very little choice in personal disposition, neural circuitry and good social support. Considering the above, it follows that the ‘outcome’ after trauma is predestined. Due to innate internal and external factors of the individual, the outcome will follow its natural course, leaving very little for clinicians to grapple with. This warrants the question of how necessary it is for clinicians to encourage posttraumatic growth.

The ultimate aim of the clinician is to provide a supportive context, one in which the individual may recover at their own pace. Also, research suggests that too much enthusiasm towards ‘growth’ may be counterproductive. Tedeschi and Calhoun (2004) caution that posttraumatic growth is still in its infancy, not all the effects of growth after trauma have been researched in adequate depth – such as the illusory side to outcome. For some, posttraumatic growth is partly illusory.

The individual experiences unrealistic optimism and an exaggerated sense of control which is only a means of ‘coping’, and not necessarily growth. The ‘Janus-face’ model (Maercker & Zoellner, 2004) explains this phenomenon. According to the Janus-face model, there are two sides to posttraumatic growth, on the one hand the individual is adjusting functionally by ruminating and understanding piece-by-piece all facets of their trauma, but on the other hand, they are in denial or engaged in wishful thinking (Tedeschi & Calhoun, 2004).

For example, by believing that they have ‘transcended’ as a temporary means of coping, the individual may hinder emotional processing of the trauma. It is however acknowledged, that not all of the illusory side of the model is detrimental, in the early stages of coping with trauma, positive illusions, are a helpful way of calming down (Antoni 2001 cited in Tedeschi and Calhoun, 2004). Whatever the coping style, whether realistic or illusory, it is recommended that clinicians remain fairly permissive and supportive by working towards recovery at the pace of the individual.

Trauma is a sad and devastating fact of life, but fortunately it is reasonable to conclude that all people can recover, with possibility of the ‘preferred outcome’: posttraumatic growth. People have various ways of coming to terms with, or coping with trauma, depending on their unique pre-trauma factors, and it is done in their own time. Cleverly summarised by Nietzche, ‘that which does not kill me makes me stronger’, is a truism (even though the word ‘eventually’ was omitted from the end of the statement). The time it takes for recovery from trauma is unpredictable, and so is the eventual outcome.

As mentioned by Tedeschi and Calhoun, (2004), clinicians should not see ‘growth’ as the only measure for evaluating successful treatment, for there is no certainty that those who do not report growth at the time of therapy will not go on to experience it later in life. Conversely, those who report growth initially, may indeed find that ‘appreciation for life’ (or other dimensions of posttraumatic growth), wears off over time. With this in mind, one need not draw an extreme distinction between those who experience growth and those who do not.

Everyone is capable of successful recovery following trauma, even those who suffer Posttraumatic Stress Disorder, eventually recovery from that too is possible. If the ‘coping’ after trauma (which is every human’s natural response), results in any of the three possible outcomes, such as ‘growth-after-trauma’, it may suffice to say that this is a human inevitability, and perhaps not so much a phenomenon. Everyone, in the wake of trauma has the human ability to cope, and with the right support, they may even go on to develop the by-product of their courage – posttraumatic growth.