Posttraumatic Growth: A New Perspective on Psychotraumatology

There is a long tradition in psychiatry, reaching at least back to World War I, of studying the response of people who are faced with traumatic circumstances and devising ways to restore them to psychological health. The main focus of this work has been on the ways in which traumatic events are precursors to psychological and physical problems. This negative focus is understandable and appropriate to the requirements of these contexts. However, only a minority of people exposed to traumatic events develop long-standing psychiatric disorders.

Although not prevalent in either clinical or research settings, there has been a very long tradition of viewing human suffering as offering the possibility for the origin of significant good. A central theme of much philosophical inquiry--and the work of novelists, dramatists and poets--has included attempts to understand and discover the meaning of human suffering (Tedeschi and Calhoun, 1995). In the 20th century, several clinicians and scientists have addressed the ways in which critical life crises offered possibilities for positive personal change (e.g., Caplan, 1964; Frankl, 1963; Maslow, 1970; Yalom and Lieberman, 1991). However, the widespread assumption that trauma will often result in disorder should not be replaced with expectations that growth is an inevitable result. Instead, continuing personal distress and growth often coexist (Cadell et al., 2003).

In the developing literature on posttraumatic growth, we have found that reports of growth experiences in the aftermath of traumatic events far outnumber reports of psychiatric disorders (Quarantelli, 1985; Tedeschi, 1999). This is despite the fact that we are concerned with truly traumatic circumstances rather than everyday stressors. Reports of posttraumatic growth have been found in people who have experienced bereavement, rheumatoid arthritis, HIV infection, cancer, bone marrow transplantation, heart attacks, coping with the medical problems of children, transportation accidents, house fires, sexual assault and sexual abuse, combat, refugee experiences, and being taken hostage (Tedeschi and Calhoun, in press).

The Domains of Posttraumatic Growth

The kinds of positive changes individuals experience in their struggles with trauma are reflected in models of posttraumatic growth that we have been building (Calhoun and Tedeschi, 1998) and in a measure of posttraumatic growth that we developed based on interviews with many trauma survivors (Tedeschi and Calhoun, 1996). These changes include improved relationships, new possibilities for one's life, a greater appreciation for life, a greater sense of personal strength and spiritual development. There appears to be a basic paradox apprehended by trauma survivors who report these aspects of posttraumatic growth: Their losses have produced valuable gains.

We also find that other paradoxes are involved. For example: "I am more vulnerable, yet stronger." Individuals who experience traumatic life events tend to report--not surprisingly--an increased sense of vulnerability, congruent with the experience of suffering in ways they may not have been able to control or prevent. However, these same people also may report an increased sense of their own capacities to survive and prevail (Calhoun and Tedeschi, 1999). Another experience often reported by trauma survivors is a need to talk about the traumatic events, which sets into motion tests of interpersonal relationships--some pass, others fail. They also may find themselves becoming more comfortable with intimacy and having a greater sense of compassion for others who experience life difficulties.

Individuals who face trauma may be more likely to become cognitively engaged with fundamental existential questions about death and the purpose of life. A commonly reported change is for the individual to value the smaller things in life more and also to consider important changes in the religious, spiritual and existential components of philosophies of life. The specific content varies, of course, contingent on the individual's initial belief system and the cultural contexts within which the struggle with a life crisis occurs. A common theme, however, is that after a spiritual or existential quest, philosophies of life can become more fully developed, satisfying and meaningful. It appears that for many trauma survivors, a period of questioning their beliefs is ushered in because existential or spiritual issues have become more salient and less abstract. Although firm answers to the questions raised by trauma--why do traumatic events happen, what is the point to my life now that this trauma has occurred, why should I continue to struggle--are not necessarily found, grappling with these issues often produces a satisfaction in trauma survivors so that they are experiencing life at a deeper level of awareness. It should be clear by now that the reflections on one's traumas and their aftermath are often unpleasant, although necessary in reconstructing the life narrative and establishing a wiser perspective on living that accommodates these difficult circumstances. Therefore, posttraumatic growth does not necessarily yield less emotional distress.

Cognitive Engagement and Growth

A central theme of the life challenges that are the focus here is their seismic nature (Calhoun and Tedeschi, 1998). Much like earthquakes can impact the physical environment, traumatic circumstances, characterized by their unusual, uncontrollable, potentially irreversible and threatening qualities, can produce an upheaval in trauma survivors' major assumptions about the world, their place in it and how they make sense of their daily lives. In reconsidering these assumptions, there are the seeds for new perspectives on all these matters and a sense that valuable--although painful--lessons have been learned.

As the individual comes to recognize some goals as no longer attainable and that some components of the assumptive world can not assimilate the reality of the aftermath of the trauma, it is possible for the individual to begin to formulate new goals and to revise major components of the assumptive world in ways that acknowledge their changed life circumstances. The individual's cognitive engagement with and cognitive processing of trauma may be assisted by the disclosure of that internal process to others in socially supportive environments. At some point, trauma survivors may be able to engage in a sort of meta-cognition or reflection on their own processing of their life events, seeing themselves as having spent time making a major alteration of their understanding of themselves and their lives. This becomes part of the life narrative and includes an appreciation for new, more sophisticated ways of grappling with life events (McAdams, 1993).

Facilitating Posttraumatic Growth

The changes that trauma produces are experiential, not merely intellectual, and that is what makes them so powerful for many trauma survivors. This is the same for posttraumatic growth--there is a compelling affective or experiential flavor to it that is important for the clinician to honor. Therefore, the clinician's role is often subtle in this facilitation. The clinician must be well-attuned to the patient when the patient may be in the process of reconstructing schemas, thinking dialectically, recognizing paradox and generating a revised life narrative. What follows are some general guidelines for this process. More extensive discussion and case examples can be found in Calhoun and Tedeschi (1999).

Attention to elements of posttraumatic growth is compatible with a wide variety of approaches that are currently utilized to help people who are dealing with trauma. Initially, clinicians should address high levels of emotional distress, providing the kind of support that can help make this distress manageable (Tedeschi and Calhoun, 1995). Allowing a distressed patient to regain the ability to cognitively engage the aftermath of the trauma in a rather deliberate fashion will promote the possibility for posttraumatic growth.

Clinicians must feel comfortable and be willing to help their patients process their cognitive engagements with existential or spiritual matters and generally respect and work within the existential framework that patients have developed or are trying to rebuild in the aftermath of a trauma. Further-more, although individual patients may need additional specific interventions designed to alleviate crisis-related psychological symptoms, listening--without necessarily trying to solve--tends to allow patients to process trauma into growth (Calhoun and Tedeschi, 1999). In fact, one way of insuring that clinicians practice this sort of approach is to relate to the trauma survivor's story in a personal manner. Being changed oneself as a result of listening to the story of the trauma and its aftermath communicates the highest degree of respect for the patient and encourages them to see the value in their own experience. This acknowledged value is a short step away from posttraumatic growth.

The immediate aftermath of tragedy is a time during which clinicians must be particularly sensitive to the psychological needs of the patient. Never engage in the insensitive introduction of didactic information or trite comments about growth coming from suffering. This is not to say that systematic treatment programs designed for trauma survivors should not include growth-related components, because these may indeed be helpful (Antoni et al., 2001). A posttraumatic growth perspective can be used even in critical incident stress management (Calhoun and Tedeschi, 2000). However, even as part of a systematic intervention program, matters related to growth are best addressed after the individual has had a sufficient amount of time to adapt to the aftermath of the trauma.

Caveats About Posttraumatic Growth

In order to clarify the clinical perspective on posttraumatic growth, we offer these reminders. First, posttraumatic growth occurs in the context of suffering and significant psychological struggle, and a focus on this growth should not come at the expense of empathy for the pain and suffering of trauma survivors. For most trauma survivors, posttraumatic growth and distress will coexist, and the growth emerges from the struggle with coping, not from the trauma itself. Second, trauma is not necessary for growth. Individuals can mature and develop in meaningful ways without experiencing tragedy or trauma. Third, in no way are we suggesting that trauma is "good." We regard life crises, loss and trauma as undesirable, and our wish would be that nobody would have to experience such life events. Fourth, posttraumatic growth is neither universal nor inevitable. Although a majority of individuals experiencing a wide array of highly challenging life circumstances experience posttraumatic growth, there are also a significant number of people who experience little or no growth in their struggle with trauma. This sort of outcome is quite acceptable--we are not raising the bar on trauma survivors, so that they are to be expected to show posttraumatic growth before being considered recovered.

References:

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