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DISCUSSION

Personal growth after traumatic experiences

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The concept of post-traumatic stress disorder is widely known, but personal growth is more common than PTSD in people who have experienced trauma

Abstract

Psychiatric practice acknowledges that people who are subjected to traumatic events may develop emotional negativity requiring intervention. However, it has recently been acknowledged that emotional distress caused by a traumatic event can facilitate that person’s recovery into an emotionally stronger person. This article aims to provide a clinical understanding of the phenomenon of post-trauma growth.

Citation: Carroll M (2014) Personal growth after traumatic experiences. Nursing Times; 110: 31, 23-25.

Author: Michael Carroll is clinical nurse at Central Adelaide Local Network, Adelaide, Australia.

Introduction

There has been a long tradition of viewing human suffering as offering the possibility for the origins of significant good. This has been a central theme of much philosophical inquiry. The notion that stressful and traumatic events can provoke positive psychological changes is also part of the mainstream spiritual teachings of Christianity, Hinduism, Judaism, Islam and Buddhism.

People who are experiencing trauma or have survived a traumatic event may be more likely to become cognitively engaged with fundamental questions about life, death and the purpose of their being. A common change is to value the smaller things in life more, and also to consider important changes in religious or spiritual philosophies of life.

It is also recognised that positive changes occur as a result of suffering. However, the topic of growth following adversity has become only a focus of empirical research in the past decade.

The concept of post-trauma growth was introduced in the 1990s (Calhoun and Tedeschi, 1999), and is now part of positive psychology (Seligman, 2011). Traumatic events can shake individuals’ views of their existence, and dramatically influence their quality of life by causing enormous suffering and severely hindering their ability to feel content and fulfilled.

However, some people will discover an ability to grow in ways they had not before the distressing event; this phenomenon is known as post-trauma growth (Box 1). The widespread assumption that trauma will often result in disorder should not, however, be replaced with expectations that growth is an inevitable result. Personal distress and growth often coexist.

Box 1. The metaphor of the shattered vase

Post-trauma growth can be described through the metaphor of the shattered vase.

Imagine you accidentally knock a vase off a shelf and it smashes into tiny pieces. When adversity happens, people feel that at least some part of them – be it their interpretations of the world, their sense of self or their relationships – has been shattered. Those who try to put their lives back together exactly as they were will continue to be ruptured and vulnerable. However, those who accept the breakage and build themselves anew become more resilient and open to new ways of living.

These changes do not necessarily mean that the person will be free of the memories of what has happened to them or the grief they experienced, but that they may live their lives more meaningfully in the light of what happened.

What is post-trauma growth?

There is a long tradition in mental health of studying the response of people who have found themselves in traumatic circumstances, and devising ways to restore them to their psychological norm.

The main focus of this work has been on the ways in which traumatic events are antecedents to both psychological and physical problems. However, only a minority of people exposed to traumatic events develop long-standing psychiatric disorders (Tedeschi and Calhoun, 2004).

Joseph and Linley (2006) report that after experiencing a traumatic event people have often reported three ways in which their psychological functioning has increased:

  • Relationships are enhanced in some way - they come to value their friends and family more;
  • They change their views of themselves - developing wisdom, strength and gratitude;
  • Their life philosophy changes.

Using such measures of perceived development and open-ended consultations, a great number of studies have shown that growth is common for survivors of various traumatic events, personal experiences, medical problems and other life experiences such as relationship breakdown and parental divorce. Mental health professionals encounter patients on a daily basis whose lives have been affected by such events. However, up to now, clinicians may have relied on theories of post-traumatic stress disorder (PTSD) to plan and implement care.

Reports of post-trauma growth have varied widely. Typically, 30-70% of survivors will say that they have experienced positive changes of one form or another (Linley and Joseph, 2004). Growth occurs when a person has cognitive engagement with the traumatic event in the aftermath, or ruminates over elements of the event to repair and restructure their understanding of the world.

Rumination can be defined as persistent thoughts about an individual’s symptoms of distress and the possible causes and consequences of those symptoms. The term has acquired negative connotations within social and behavioural research due to its association with depression. However, Tedeschi and Calhoun (2004) define rumination as thinking that revolves around resolving discrepancies, and making sense of one’s previous goals and self around one’s current reality.

More deliberate, reflective rumination is associated with post-trauma growth. Rumination may be conceptualised as a form of cognitive processing in the aftermath of a crisis, leading to recognition that changes experienced are deeply profound and build a form of wisdom.

Stockton et al (2011) conducted two studies concerning intrusive thoughts about traumatic events and reported that intrusive re-experiencing and ruminative brooding were not significantly associated with post-trauma growth, while deliberate ruminations were significantly and positively associated with post-trauma growth.

Stress and post-trauma growth

Post-traumatic stress is considered to be the catalyst for post-trauma growth. Helgeson et al (2006) conducted a meta-analytic review and concluded that greater post-trauma growth was related to more intrusive and avoidant post-traumatic stress experiences. They also suggested that these constructs reflect cognitive processing. Experiencing intrusive thoughts about a stressor may be an indication that an individual is working through the implications of the stressor and these implications could lead to growth. It could therefore be argued that a period of contemplation and consideration of the stressor is required for growth to occur.

Butler et al (2005) conducted a study following the 9/11 attacks of September 2001 and found a linear correlation between post-trauma growth and post-traumatic stress. They reported that greater post-traumatic stress was associated with greater post-trauma growth. However, this is limited to a point above which post-trauma growth declines.

Low levels of post-traumatic stress indicate that the person has been minimally affected, so it could be expected that minimal post-trauma growth would be experienced. A moderate level of post-trauma growth is indicative that the individual’s assumptive world has in some way been confronted, activating the intrusive and avoidant capabilities, but the person remains able to manage, think and engage in the necessary affective/cognitive processing needed to work through. A high level of post-traumatic stress, where a diagnosis of PTSD might be considered, is likely to mean that the person’s coping ability is undermined, along with their ability to affectively cognitively process and work through their experiences unimpeded. The inverse correlation relationship between post-traumatic stress and post-trauma growth has been reported in several studies (Kunst, 2010).

Calhoun and Tedeschi (1999) pioneered the concept of post-trauma growth, defining it as a construct of positive psychological change that occurs as a result of a struggle with a highly challenging, stressful and traumatic event. They say growth can be measured by the Post-Traumatic Growth Inventory. This covers five domains that are contained within the larger construct of post-trauma growth. These are:

  • Relating to others;
  • New possibilities;
  • Personal strength;
  • Spiritual change;
  • Appreciation of life.

Measuring post-trauma growth

Although the construct of PTSD has an approved and agreed definition provided by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), there is no benchmark definition of post-trauma growth. The term does not refer to a positive emotional state but to an increase in psychological wellbeing. This can be defined as high levels of autonomy, positive relationships with others, openness to personal growth and purpose in life. People may say they have grown after trauma, but how this can be measured is limited. Therefore, retrospective accounts of change are relied on, asking people to report on positive changes they perceive themselves to have experienced since a traumatic event.

Durkin and Joseph (2009) found that studies have shown post-trauma growth to be associated with greater wellbeing. However, it is not clear whether this is related to subjective or psychological wellbeing. Subjective wellbeing is how people experience the quality of their lives, and includes both emotional reactions and cognitive judgments derived from the hedonistic tradition; psychological wellbeing is derived from the eudemonic wellbeing tradition, that is, from pursuing relationships and placing things into context that will fulfil our basic human needs. Durkin and Joseph (2009) sampled 125 college students who had experienced a distressing event, and concluded that post-trauma growth is related to psychological, rather than subjective, wellbeing.

From a physiological perspective, Tomaka et al (1993) reported that high levels of positive change were related to lowered cortisol levels in women exposed to controlled stress in a laboratory environment. This was supported by Cruess et al (2000), who reported lower cortisol levels through the enhancement of benefit-finding among women with breast cancer. A further study on patients with hepatoma found that those scoring high on positive change survived 186 days longer than their lower-scoring peers due to higher peripheral blood leukocytes (Dunigan et al, 2007). Christopher (2004) concluded that stress was best comprehended as a pre-rational formula of biopsychological feedback regarding the individual’s relationship with the environment, the normal consequence of traumatic stress is development rather than pathology, and most psychopathology is a result of the maladaptive modulation of the stress response.

Conclusion

Mental health professionals are beginning to realise that post-traumatic stress following trauma is not always a sign of disorder. Post-traumatic stress can be a sign that the person is going through a normal and natural emotional struggle to rebuild their life and make sense of what has happened.

Positive changes are difficult to research and much of the research is open to criticism. Post-trauma growth is still a young field, so health professionals must be aware of overgeneralised interpretations of results and clinical practice.

Post-trauma growth does not suggest that there is an absence of suffering, but that appreciable growth occurs within the context of pain and loss. The disruption caused by the trauma is significant enough to create psychiatric symptoms and shattering enough to the individual’s assumptive world view to generate growth. Reflections on trauma and their aftermath are often unpleasant, but are required in reconstructing the life story and establishing a wiser perspective on living. Therefore, post-trauma growth does not necessarily yield less emotional distress.

At some point, trauma survivors may be able to engage in cognitive reflection of their own life process and events. This becomes part of their life story and includes an appreciation for new ways for coping with life events. The mental health professional’s role is often subtle facilitation, and remaining well attuned to the client when they may be in the process of generating a revised life narrative.

Practitioners must feel comfortable with facilitating clients’ cognitive engagements with existential or spiritual matters and generally respect and work with the framework that clients develop or try to develop in the aftermath of a trauma.

The immediate aftermath of a tragedy is a time during which practitioners must be particularly sensitive to the client’s psychological needs. They must be cautious about the insensitive introduction of information or making initial comments about growth coming from adversity. It may be more appropriate to facilitate clients’ understanding that positive growth can be achieved from a traumatic event. Even as a part of an intervention programme, matters related to growth are best addressed after the individual has had sufficient amount of time to adapt to the traumatic event.

Key points

  • Post-trauma growth involves positive change that takes place within the context of pain and loss
  • After a traumatic event, people may report positive changes to relationships, their view of themselves and their philosophy of life
  • Up to a limited point, greater post-traumatic stress is associated with greater growth
  • A minority of people who experience traumatic events develop long-term psychiatric disorders
  • Clinicians should take account of post-trauma growth when planning and implementing care
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