Motivation and emotion/Book/2020/Post-traumatic growth

Overview
What possible benefit could an individual experience following great suffering or tragedy? Through experiencing adverse events, can one become more resilient and positive? By examining the phenomenon of post-traumatic growth using psychological theory and interventions, this chapter explores the potential for post-traumatic growth and factors contributing to its development.

Focus questions:
 * What is post-traumatic growth?
 * How can psychological theories further our understanding of, and foster post-traumatic growth?

What is post-traumatic growth?


Post-traumatic growth (PTG) refers to positive psychological change an individual may experience following highly challenging or traumatic life events. Unlike resilience and optimism, PTG represents adaptation beyond pre-trauma functioning, where individuals may feel greater personal strength, new priorities, and a greater appreciation for life (Tedeschi & Calhoun, 2004). Traumatic incidents may take many forms, including natural disasters, combat, sexual abuse, child abuse, medical issues, relationship breakdown, bereavement, and immigration (see Figure 1) (Kashyap & Hussain, 2018). It is in the upheaval following trauma where one faces significant challenges to their adaptive resources and understanding of their place in the world where PTG begins.

PTG occurs through an individual’s attempts to adapt to disturbing circumstances. This process can include acute psychological distress, sadness, guilt, anger, maladaptive thinking patterns, and repetitive intrusive thoughts whilst individuals learn to live with their trauma (Tedeschi & Calhoun, 2004). For some, this may be achieved through finding value or appreciation for the traumatic experience to become more resilient than they were previously. This does not mean a preference for having experienced the trauma, but appreciating the event's significance due to how the individual adapted (Kashyap & Hussain, 2018).

Studies about PTG area growing, but research thus far indicates that growth experiences following trauma are more common than previously thought. This should not be taken that growth as a result of trauma is an automatic occurrence, but that continued distress and growth often coexist, and that crises can act as catalysts for both exacerbating significant psychological issues and personal growth (Tedeschi & Calhoun, 2004). Major crisis can shatter one’s fundamental understanding of the world, but the struggle with new realities and personal resources can also facilitate PTG. Growth occurs through forming more resilient schemas which build upon the trauma and incorporate new future possibilities.

 Karessa was shot at the Route 91 Harvest music festival shooting on October 1st, 2017. In the space of 15 minutes, a shooter fired over 1,000 rounds of ammunition from the 32nd floor of a nearby hotel, killing 60 people, and wounding 411 others (2017 Las Vegas Shooting, 2020).

As a result of her experience, Karessa underwent several surgeries, physical therapy, and mental health counselling for post-traumatic stress disorder (PTSD). Prior to these events, she was not a confident public speaker and has now given numerous speeches about her experiences. Following physical recovery, Karessa returned to college, where just two weeks prior to the shooting she was considering dropping out and now is a member of the college’s safety board which develops protocols for active shooters.

Karessa believes she has lived more life in the last eight months than she ever has and states that whilst she still experiences distress, one unexpected outcome was PTG. She now has a new appreciation for life, greater sense of personal strength, confidence, and a more hopeful outlook for the future (Royce, 2018).

To hear Karessa’s TED talk on PTG, click here



How post-traumatic growth occurs
The pathway to PTG is not a linear process whereby individuals progress through distinct stages of improvement. PTG and psychological distress are distinct dimensions, meaning that undergoing PTG does not automatically mean an end to psychological distress and vice versa. Enduring psychological distress often accompanies personal growth.

As shown in Figure 2, following a major crisis or traumatic event, individuals face challenges in management of ongoing emotional distress, and changes to their life narratives, fundamental schemas, beliefs, and goals. This dramatic upheaval can lead to automatic and intrusive rumination of the event. Automatic rumination can be a debilitating experience, as intrusive thoughts can be frequent and intense. Through social support, self-disclosure and empathetic acceptance of these disclosures, reduced emotional distress can occur through cognitively processing the event to produce new goals and schemas.

Cognitive processing of traumatic events is a central tenet of PTG. Personality facets, social support, and clinical interventions may increase the likelihood/degree of growth, and these aspects are further elucidated within this chapter. Through engaging in more deliberate rumination, individuals form new schemas and personal narratives to reduce ongoing distress. Developing new schemas and managing distress are ongoing processes which may accompany PTG, with individuals also achieving newfound wisdom though increased resilience, revised life story, and better coping capacity for the knowns and unknowns of life (Tedeschi & Calhoun, 2004).

Domains for growth: The Post-traumatic Growth Inventory
To assess PTG, Tedeschi and Calhoun (2004) developed the Post-traumatic Growth Inventory (PTGI) which measures individuals' PTG across five domains.

Individual influences
The degree to which one experiences PTG can be affected by numerous individual factors including coping strategies, cognitive processing, and personality traits.

Coping strategies
In a meta-analysis across 103 studies of PTG, religious coping and positive reappraisal of traumatic events exhibited the largest effect sizes when compared to other coping strategies including social support, optimism, and acceptance (Prati & Pietrantoni, 2009). During challenging and traumatic times, many people use religious coping methods including prayer and church attendance to improve psychological well-being (Pargament et al., 2000). Measures of religious coping include how the individual uses religion to understand and process stressors, and this deliberate cognitive processing can improve chances for positive outcomes (Pargament et al., 2000). Longitudinal studies of breast cancer survivors demonstrated that cognitive coping strategies of religion, positive reappraisal, and acceptance accounted for 46% of variance in PTG. Emotion-focused coping strategies including disengagement, denial, and venting were associated with greater perceived stress and physiological distress (Bussell & Naus, 2010).

It should be noted that religious coping methods may not be a culturally universal predictor. A large amount of research employs American participants (Prati & Pietrantoni, 2009), but in comparing two Western cultures, Australia and the USA, Shakespeare-Finch and Copping (2006) found Australian participants did not experience a significant change due to spirituality dimensions. Additionally, they stated that European participants were unlikely to answer PTGI spirituality items and did not view religiosity as a form of strength.

Positive reappraisal is the active attempt to redefine how one interprets a stressful event with the deliberate goal of seeing it from a positive perspective (Cárdenas Castro et al., 2019). In studies of women with early-stage breast cancer, positive reappraisal coping strategies were predictive of greater positive mood and perceived health months at 3 and 12 months after diagnosis, and PTG at 12 months (Sears et al., 2003). To maximise PTG, deliberate rumination must be followed by positive reappraisal of the traumatic event through constructing new narratives which reframe the traumatic experience in ways which new meaning can be derived from the event (Cárdenas Castro et al., 2019).

Dispositional optimism is defined as a generalised expectancy for positive outcomes, with a meta-analysis by Prati and Pietrantoni (2009) showing that optimism displayed a moderate relation with PTG. They found that optimism is related to employing flexible coping strategies to control stressors, predicts an individual’s perceived capacity to manage trauma, and optimists may be more likely to derive a sense of benefit from adverse events. Whilst optimism carries a smaller effect size in fostering PTG than religious coping and positive reappraisal (Bussell & Naus, 2010; Prati & Pietrantoni, 2009), optimism consistently correlates with adaptive coping strategies, social support seeking, and positive reinterpretation and as such may assist PTG through encouraging these other positive predictors (Bostock et al., 2009).

Cognitive processing
Cognitive processing of trauma through moving from automatic, intrusive rumination to deliberate rumination is imperative for adaptive schema change and PTG (Rider Mundey et al., 2019; Tedeschi & Calhoun, 2004). Rumination is a trauma response involving repetitive thoughts surrounding distressing symptoms. Emotional processing does not demonstrate a positive relation to PTG, as it may lead to endless rumination about feelings surrounding the traumatic event. Conversely, deliberate cognitive rumination has been significantly associated with higher levels of PTG (Kolokotroni et al., 2014).

Following traumatic events, individuals may experience automatic and intrusive rumination akin to PTSD. Some individuals may progress from intrusive to deliberate rumination which is characterised by reflective, purposeful, cognitive processing which assists in reducing emotional distress. In being able to deliberately ruminate on traumatic events, goal disengagement can occur, where one abandons now unrealistic pre-trauma goals to form and pursue new, restorative, situationally compatible goals and rebuild shattered fundamental assumptions (Rider Mundey et al., 2019; Tedeschi & Calhoun, 2004).

Personality
Personality traits have been shown to influence PTG through moderating individuals’ ability to perceive benefits in trauma. Using the Big Five personality factors (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness), Tedeschi and Calhoun (1996) found that all factors aside from neuroticism held a positive correlation with PTG. Across numerous studies, extraversion emerges as the strongest personality predictor on the PTGI (Panjikidze et al., 2020; Sheikh, 2004; Tedeschi & Calhoun, 2004). Panjikidze et al. (2020) examined personality factors and social support types in war-experienced children and adolescents and their effects on PTG. Results showed that the main predictors of PTG were extraversion, conscientiousness, and social support. Studies by Sheikh (2004) on PTG in individuals with heart disease found extraversion to be the only personality factor to be significantly, positively correlated to problem-focused coping behaviours. Additionally, Big Five extraversion facets of “activity”, and “positive emotions”, and the openness facet of “feelings” carry the strongest correlation to PTGI factors (Tedeschi & Calhoun, 1996). Together, these results show that during times of adversity, individuals high in extraversion may be more likely to be aware of positive emotions, be able to cognitively process experiences more effectively, and produce new, adaptive schemas in a manner consistent with PTG (Tedeschi & Calhoun, 2004).

Social influences
Social influences provide much diversity in how individuals disclose, ruminate, and cognitively process traumatic events. This includes, but is not limited to, proximal and distal cultural influences, and support networks which an individual has at their disposal.

Culture
Culture can influence PTG through immediate surroundings and broader societal sources which affect how individuals disclose, ruminate, and cognitively process traumatic events. Additionally, cultural context can shape how stressful events are perceived to be, as well as the coping mechanisms that are employed (Kashyap & Hussain, 2018). Cultural attitudes and subsequent PTG pathways stem from both proximal and distal influences. Proximal influences include groups with whom individuals directly interact, and may include friends, families, co-workers, and religious groups. Social cues provided by these close groups can be through idioms, attitudes, and emotional displays which influence what is desirable or expected coping behaviour, emotional disclosure, and subsequent cognitive processing (Kashyap & Hussain, 2018).

Distal influences are based on broad social narratives and cultural views. Individualistic and collectivist cultures may experience PTG differently as a critical distinction lies in people’s self-definition in relation to others. People from collectivist cultures are more likely to define themselves in relational terms, where the perceived thoughts, feelings, and goals of others are considered in guiding thought and behaviour. Conversely, those from individualistic cultures may see themselves as a distinct entity, where more value is placed on internal attributes, goals, and personality in guiding thought and behaviour (Splevins et al., 2010).

Following trauma, the notion of requiring high cognitive consistency, attending mostly to one’s own thoughts and feelings, and cognitive restructuring to establish new goals, self-concept, and social roles may be more descriptive of individualistic cultures. Jobson and O'Kearney (2008) showed that participants with PTSD from individualistic cultures developed more goals, self-defining memories, and cognitions than those from collectivist cultures. They propose that Western or individualistic cultural scripts enable development of the social role of trauma survivor, where focus is on unique, personal experiences and identity. This is less likely to occur in collectivist cultures where the idea of an independent self and cognitive consistency is not prioritised, with non-Western pathways of PTG remaining an area to be elucidated by future research (Jobson & O'Kearney, 2008; Splevins et al., 2010).

Support networks
Social support may facilitate PTG through sharing perspectives and beliefs, and sharing of experience can facilitate adaptive revision of schemas (Calhoun & Tedeschi, 1999). Social support by way of significant others and support groups can assist in forming positive narratives about traumatic events through offering outside perspectives that can be integrated into new schemas. In retelling a traumatic event with a supportive other, individuals craft coherent narratives which reveal the emotional aspects of events and pushes them to confront questions of meaning, shattered schemas, and steps in their subsequent reconstruction (Tedeschi & Calhoun, 1996, 2004). This process can be related to cognitive processing discussed by Kolokotroni et al. (2014), where deliberative cognitive processing has demonstrated a significant, positive correlation with development of PTG.

In a longitudinal study of cancer survivors, Schroevers et al. (2010) found that individuals who received greater emotional support at 3 months post-diagnosis were significantly more likely to exhibit PTG 8 years later. They concluded that receiving reassurance, comfort, and advice from family and friends provided valuable assistance in finding positive meaning from suffering cancer. Similarly, Romeo et al. (2017) found that the presence of a significant other can help cope with traumatic events. Women diagnosed with breast cancer and who had a partner showed greater PTG and enjoyed life and future projects more than those without a partner (Romeo et al., 2017). This demonstrates that opportunities to share personal thoughts and feelings within a caring and supportive social support network or a significant other can have beneficial outcomes for those who have suffered a traumatic experience.

Clinical influences
A meta-analysis by Roepke (2015) on psychological interventions for people who had experienced hardship or trauma found that numerous current interventions moderately increase PTG, though none of these interventions were specifically designed to promote PTG. The intervention approaches identified included written or spoken self-expression/disclosure; cognitive-behavioural therapy (CBT) for PTSD, depression, bereavement, and stress; and novel psychosocial interventions directly promoting growth.

Written or spoken self-expression/disclosure
Interventions involving writing or verbally expressing a traumatic event have been shown to reliably diminish PTSD symptoms with little difference between various methods, but mixed evidence exists whether these methods promote PTG (Roepke, 2015). Studies by Smyth et al. (2008), Park et al. (1996), and Ullrich and Lutgendorf (2002) found positive correlations between self-expression/disclosure and PTG in groups including veterans, cancer survivors, and college students. However, a smaller number of studies found these methods produced no significant growth (Rivkin et al., 2006; Roepke, 2015).

Cognitive behavioural therapies
Many cognitive-behavioural therapies have goals aligned with PTG, aiming to reduce suffering and foster personal strength, wisdom, interpersonal relationships, and hope. CBT interventions may have different goals, with some interventions primarily targeting distress, whilst others may have more comprehensive aims of alleviating suffering and promoting growth. Prolonged exposure therapy seeks to replace inaccurate beliefs with accurate positive, beliefs in a manner congruent with the PTG domain of personal strength (Roepke, 2015; Tedeschi & Calhoun, 2004). In cancer patients, cognitive-behavioural stress management (CBSM) has been shown to promote PTG through teaching awareness of stressors, replacing negative thoughts, seeking social support, and employing adaptive coping skills (Antoni et al., 2006; Roepke, 2015).

Novel interventions directly targeting growth
Interventions directly targeting PTG use approaches from various theoretical orientations and represent a new, albeit limited area of research. The Posttraumatic Growth Path employs several therapeutic approaches including CBT, psychoanalysis, solution-focused therapy, and narrative therapy to promote resiliency whilst treating and mitigating PTSD (Nelson, 2011; Roepke, 2015).

The Comprehensive Soldier Fitness program which was developed for the U.S. Army includes components for increasing probability of PTG following combat experiences. Training elements include understanding trauma response as a precursor to PTG, emotional regulation enhancement, constructive self-disclosure, creating a trauma narrative with PTG domains, and developing resilience-enhancing life principles. Additionally, the program’s components may be used outside of military settings for individual or family treatment plans and psychoeducational programs (Tedeschi, 2011; Tedeschi & McNally, 2011).

It is important to note that many novel interventions currently lack comprehensive empirical testing, and some researchers warn of potential risks in interventions specifically targeting PTG. It has been stated that PTG-focused interventions may not be necessary or desirable as this may burden participants with unhelpful expectations and set them up for disappointment if they do not thrive following trauma therapy. Whilst PTG represents a positive outcome from adverse events, it is neither guaranteed or essential for trauma recovery (Calhoun & Tedeschi, 1999; Roepke, 2015).

 Bill is a 28-year-old combat veteran with three deployments to the Middle East and escalating PTSD symptoms including nightmares, intrusive thoughts, generalised anxiety, and social avoidance. Bill is also angry that some of his friends died on deployment from what he sees as poor decisions from superiors.

Over numerous sessions, Bill’s psychologist works through the Comprehensive Soldier Fitness program with him. First, psychoeducation is given to help Bill understand that his reactions are normal reactions to the difficult events he had experienced. Work was then done on Bill’s emotional regulation using cognitive-behavioural approaches that relate back to his military experiences and build on past successes. Throughout therapy, constructive self-disclosure is employed by framing his recollections in terms of strength and potential, helping to build a coherent narrative which can be deliberately ruminated upon. Eventually, Bill learned to overcome many symptoms of his PTSD and recognised that his military service need not be the most significant point in his life, and that he had the capacity to develop his capacities and channel them into a new, constructive direction.

Adapted from Tedeschi (2011).

Conclusion
PTG involves psychological growth beyond pre-trauma functioning following adverse or traumatic life events. This may be by way of greater appreciation for life; warmer, more intimate relationships; greater sense of personal strength; recognition of new possibilities; and spiritual development (Tedeschi & Calhoun, 2004). The development of PTG is influenced by many factors including individual resources, social aspects, and clinical interventions (Kashyap & Hussain, 2018; Prati & Pietrantoni, 2009; Roepke, 2015). It is important to bear in mind that achieving PTG does not mean an end to psychological distress, but that these processes may concurrently occur.

As the study of PTG is a relatively new field, limited research and interventions directly seeking to foster its growth currently exist. However, as illustrated in Roepke’s (2015) meta-analysis of PTG interventions, growth may result from many existing interventions. Additionally, some researchers warn that PTG-focused interventions may not be necessary or desirable as this may produce unhelpful expectations and produce disappointment for individuals who do not thrive following trauma therapy. Future research elucidating situations and demographics where specifically seeking to foster PTG is most beneficial would be advantageous in further enhancing the benefits of PTG.