Posttraumatic growth:
Beyond Resilience
DR. KATE HEFFERON, PHD
UNIVERSITY OF EAST LONDON
UNIVERSITY OF WESTMINSTER
LECTURE SERIES
W E D N E S D A Y , F E B R U A R Y 1 3 TH, 2 0 1 3
THAT WHICH DOES NOT
KILL US MAKES US
STRONGER
-FRIEDRICH
NIETZSCHE
Outline of talk
 Define Posttraumatic Growth (PTG)
 Review characteristics of PTG
 Benefits of PTG
 The main models of PTG
 Review facilitators of PTG
 Review the current PTG programmes and applications in
clinical work
Defining PTG
Stress vs. trauma
 Intermittent stress=beneficial
(Charney, 2004)
 Trauma=Unexpected; out of the ordinary;
creates long lasting problems; substantially
interrupt personal narrative (Tedeschi & Calhoun,
1995;2006)
 “Before and after”
Potential responses to trauma
(O’Leary & Ickovics, 1994)
Resilience
“the flexibility in response to changing situational
demands, and the ability to bounce back from
negative emotional experiences”
(Tugade, Fredrickson, & Barrett, 2004, p.1169)
• Recovery, resistance and reconfiguration
Revenson, 2006)
(Lepore &
Potential responses to trauma
(O’Leary & Ickovics, 1994)
Posttraumatic growth
“It is through this process of struggling with
adversity that changes may arise that propel the
individual to a higher level of functioning than
which existed prior to the event”
(Linley & Joseph, 2004, p. 11)
• Focus is not to advocate suffering as a situation worth striving for,
but rather to examine the phenomenon in which suffering and grief
can co-exist with enlightenment and growth (Linley and Joseph,
2004)
• 40-70% experience some positive benefits from trauma
Previous PTG research
 Benefit finding, positive changes, growth from
adversity, thriving, stress related growth and
psychological growth (Tennen & Affleck, 2004)
 “Bereavement, breast cancer, mastectomy, bone
marrow disease, heart attack, rheumatoid arthritis,
spinal chord injury, MS, shipping disaster, tornado,
plane crash, rape, childhood sexual assault, incest,
shooting, HIV, infertility, chemical dependency,
military combat and bombing” (Joseph, Linley, & Harris,
2005, pp. 263-264)
Characteristics of PTG
1) Perceived changes
in self
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Becoming stronger
More confident
New awareness of a possible self authentic self
A ‘better self’
Deeper
More open
More empathetic
More creative
More alive
More mature
More humanitarian
More special
More humble
(Tedeschi & Calhoun, 1995, p. 456).
2) Improved relationships
 Closer relationships with family and/or friends
 Neighbours
 Fellow trauma survivors
 Strangers
 Find out who “True friends” are
3) Changing life philosophy/
increased existential awareness
 Reflection of mortality
 Meaning and purpose in life
 Finding reasons/making meaning from the trauma
 ‘Vulnerability’ and ‘the shortness of time’
‘Once you worry about whether you are going to die, nothing else
seems quite as significant to worry about’
(Kennedy, Tellegen, Kennedy, & Havernick, 1976)
4) Changed priorities
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How and with whom they decided to spend their day
Appearance
Nature
Monetary goods
Health
New appreciation of life (calling it a ‘gift’)
The ‘here and now’
Simple things
Time
Change life goals
Learn new skills
Go back to school
5) Enhanced spiritual beliefs
 Increased spirituality
 Return to faith
 Spiritual practices
 Praying
 Attending church
 Gratitude to God
 Strengthening of faith
 Bereavement
 Can be used as a coping mechanisms or as an outcome
 Importance and existence differs across culture
(Tedeschi et al., 2010)
Example of growth
“And it’s…and I feel my life’s better! I know it
sounds crazy (laughs), but I feel the quality of my
life is better because (sniffles) I’ve prioritized
(sniffles) and I know what matters.”
Brenda, Cancer survivor
Caveat
 Don’t have to have all 5 domains to have
experienced growth
 May be in existence with distress
 Current 5 domains may not include all aspects of
growth (Corporeal components missing)
Benefits of PTG
PTG and mental health (Myerson et al.2011)
 Negative relationship with depression and anxiety
 Reduced alcohol and substance abuse
 Lower levels of general and emotional distress
 Positively correlated with hope, optimism and positive
affect
 Enhanced Quality of life (Qol)
PTG and mental health
(Tennen & Affleck,
2002)
 Benefit-finding after a loss of a loved one predicted
distress 13 months later
 Mothers of acutely ill newborns who found some benefit
had better mood and less distress 6 to 18 months later
 Those who found benefits in experiencing a disaster
(plane crash, shooting, tornado) were less likely to
experience PTSD 3 years later
PTG and Health
 Lower cortisol levels (Epel, McEwen & Ickovics, 1998;
Cruess et al., 2000)
 Greater immune system functioning among HIV patients
with higher levels of PTG Milam (2004)
 High PTG scorers, with hepatoma, survived 186 days longer
than their lower scoring peers (Dunigan, Carr, & Steel, 2007)
 Less AIDS related mortality (Less rapid decline in CD4
lymphocytes) with self-reported benefit finding among HIV
positive men who had recently had someone close to them die
of AIDS (Bower et al.,1998)
 Positive psychology may be running before it can walk in
applications to cancer care (Coyne et al. 2010)
Models of PTG
Models of PTG
 Shattered Assumptions Theory (Janoff-Bulman, 1992)
 Transformational Model (Tedeschi & Calhoun, 2006)
 Organismic Valuing Theory (Joseph & Linley)
Person pre-trauma
Potentially Disruptive event
Emotional Distress
Assumptive Beliefs
Challenged
Goals/ Narrative Disrupted
Rumination
Mostly automatic& intrusive
Assumptive beliefs provide
context for event
Self analysis: Write/pray
Self disclosure: talk/share
*Manage emotional distress
*Redirect rumination
*Reassess goals
Sociocultural Influences
* Deliberate/Reflective/Constructive
*Rumination
*Schema change/Narrative revision
Proximate: Social support/Role models/
support for schema change and PTG
Distal: Cultural/societal themes
Acceptance of
‘changed’ world
Posttraumatic growth
Recognition of strengths/
resources/possibilities
More complex narrative
Increased wisdom
Well-being
Life Satisfaction
(Tedeschi & Calhoun, 2011)
Organismic Valuing theory
Assumptive world prior to trigger event
Trigger Event
Shattered assumptions
Posttraumatic stress indicative
of need for working through
Psychosocial factors
Accommodation
Assimilation
Positive changes
New assumptive world
Negative changes
Facilitators of PTG
Facilitators of PTG
 Female gender (+35) (Vishnevsky et al., 2010)
 High levels of constructive rumination (Tedeschi et al.,
2010; Segerstrom et al., 20003)
 Higher socio-economic status (Bower et al., 2005; Carpenter,
1999; Cordova, Chang et al., 2001)
 Higher education (Sears, Stanton, & Danoff-Burg, 2003)
 Younger age (Carpenter, 1999; Kurtz, Wyatt, & Kurtz, 1995)
 More/less time since diagnosis (Cordova, Cunningham, Carlson, &
Andrykowski, 2001; Weiss, 2004b)
 Trauma severity – curvilinear (Lechner et al., 2003)
Role of the type of event
 In adult populations there is yet to be confirmed link
between type of event and PTG
 Bereavement tend to report more PTG that motor vehicle
accidents or sexual assault (Shakespeare-Finch, 2012)
 Natural versus human causes
 Natural may cause more growth due to perception of
Internal/External Locus of control
Facilitators of PTG
 Personality traits (optimism) (Antoni et al., 2001)
 Positive emotions (Linley & Joseph, 2004a)
 Social support (autonomous) (Cadell, Regehr, &
Hemsworth, 2003)
 Emotional focused coping process styles (positive
reappraisal, acceptance) (Urcuyo, Boyers, Carver, &
Antoni, 2005)
 Group based therapies (Cordova, 2008; Lechner, Stoelb,
& Antoni, 2008b)
Critiques and considerations
 Cognitive dissonance (Festinger, 1954)
 Positive illusions (Taylor, 1984)
 Tyranny of positive thinking (Held, 2005;
Ehrenreich, 2010)
 Bad science (Coyne & Tennen, 2010; Coyne et al.,
2010)
 Lack of clarity in definitions
 Issues with tools used to measure
PTG/BF/SRG
However…
o Subjective sense of being bettered (Thornton, 2002, p.
162)
o No measurement tools or agreed upon definitions
for identifying illusions or distortions (Calhoun
&Tedeschi 2008)
o Current quantitative measurements of growth do
not correspond with social desirability measures
o Academic research can not be blamed for ‘The
Secret’ (Aspinwall & Tedeschi, 2010)
Measuring PTG in adults
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World assumptions scale
Core beliefs Inventory
Stress Related Growth Scale (SRGS) (Park, Cohen, & Murch, 1996)
PWB-PTCQ
CIOQ
Benefit Finding Scale (BFS) (Antoni et al., 2001; Park & Lechner, 2006)
The Posttraumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 1996)
E.g. Likert- 0-5
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1. My priorities about what is important in life
2. An appreciation for the value of my own life
3. I developed new interests
4. A feeling of self-reliance
5. A better understanding of spiritual matters
 High in internal consistency (Cronbachs’s alpha=.94, .90 and .95
respectively)
PTG in children
Major PTG studies in children
 Until recently a severely neglected area of research (last 5 years)
 First meta analysis in 2011 (25 studies) (Myerson et al., 2011)
 Children and adolescents (8.3 – 17.2 years)
 Traumas include: natural disasters, physical, emotional and sexual
abuse, parental bereavement, childhood illness
 Issues regarding cognitive development at time of trauma
 Different to normative maturational growth
 Children may need more help making meaning from an event
PTG and children: Meta-analysis findings
(Myerson et al.,
2011)
 Type of event and severity: Not enough evidence although subjective sense of
severity correlated with PTG (curvilinear)
 Time since trauma: No significant correlation
 Previous stressors: Positive relationship between previous life stressors (+1 year
to event) and PTG
 Posttraumatic stress symptoms: Positively correlated with PTG (moderate
levels)
 Social support: Some evidence for seeking family, teachers and peers and higher
levels of PTG
 Religion: Positive relationship between religiosity and PTG
 Rumination: Mixed result, but intrusive and deliberate rumination predicted
PTG over time
PTG and children: Meta-analysis findings
2011)
(Myerson et al.,
 Coping: Active and avoidant; positive reinterpretation and acceptance
 Psychological
symptoms: Negative relationship with depression,
anxiety, alcohol and substance abuse, physical health problems, general
and emotional distress
 Positive mental health resources: Hope, positive affect, optimism, self
–esteem, competency beliefs, quality of life
 Age: Mixed results with equal positive and non significant results with age
at trauma (not data collection) as significant relationship with PTG
 Gender: Non significant results
 Race and SES: Mixed results
Issues in child PTG research
 Few prospective studies
 New research (5 years)
 Tools need further testing
 Shared (mass events)
 The role of previous stressors
 Similarities and differences to adult PTG (schemas and pliability)
 Negative impact of early trauma on development of self and learning
 The role of supportive care
Facilitating PTG:
Current Programmes
Rise in programmes: 2008-2011
Therapeutic advice for clinicians:
 Become the expert companion
 Learn from the client
 Do not engage in direct attempts to foster growth
 Must be aware of growth themes
 Listen for themes
 Acknowledge themes in the clients own words
 Arise as result with struggle, not as result of events only
 Do not deny distress
 If no signs of delusion, go with the clients understanding (positive
illusions or not)
 Do not solely use it as the sign of good intervention
 Remember- not universal!
(Tedeschi & Calhoun, 2008)
PTG Module in U.S. Army (Seligman, 2011)
1) Learn about the responses to trauma including shattered beliefs
about the self and others and the future
1) Learn
anxiety-reducing techniques, which aims to reduce
automatic and ruminative thoughts and images
1) Engage in ‘constructive self disclosure’
1) Create a ‘trauma narrative’, which identifies the trauma as a
‘fork’. Also asked to discuss the strengths they used to get through
the trauma; which relationships improved; how spiritual life
strengthened; how they appreciated life better and what new
opportunities arose
1) Ask them to highlight new philosophies- ‘phoenix rising’
Cancer Resilience Growth Programme
(CRGP) (Hefferon & Ivtzan)
 Breast Cancer patients (n=20)
 6 weeks (2 hours)
 Multiple measurements and 4 time points
 Expressive writing
 Mindfulness
 Learned optimism
 Embodiment and Physical activity
 Gratitude
 Meaning
THRIVE : 6 signposts
to facilitating growth
 Presence of growth does not imply the absence of
distress or difficulties
 Signpost 1: Taking stock
 Signpost 2: Harvesting hope
 Signpost 3: Re-authoring
 Signpost 4: Identifying change
 Signpost 5: Valuing change
 Signpost 6: Expressing change in action
(Joseph, 2012)
Clinical and psychotherapeutic work in PTG
 Recognize that childhood abuse does not always lead to succumbing
 PTG does not necessarily need therapeutic intervention but can be helped
via supportive therapists in extra therapeutic factors
 Therapists can help clients find their own vehicle of change (responsibility,
validation, love, liberation and freedom, mastery and belonging)
 Inform, shape and guide assessment, interventions and overall approach
(Kilmer, 2006)
 Intervention to help restructure children cognitive appraisal of the trauma
and social skills training
 Note- not always for everyone
Future of PTG research
Area of research
 Prolonged trauma
 Shared Trauma
 Psychological wellbeing vs. subjective well-being (Durkin & Joseph, 2009;
Joseph, 2012)
 Character strengths (Seligman et al., 2008)
 Forgiveness (Pennebaker; King)
 Positive Offender Rehabilitation Models (Mapham & Hefferon, 2012)
 SCI, narrative research (Quest, Chaos and restitution) and PTG (Hefferon,
Sparkes and Painter, 2011)
 Physical activity, the body and PTG (Hefferon et al., 2008, 2009, 2010; 2012)
Internal
External
Emotional
Physical
Self
inflicted
Other
inflicted
*Adapted from Tedeschi and Calhoun's
Transformational model of growth
(2006)
Person Pre-trauma
Seismic event
Challenges
Management of emotional
distress
Beliefs and goals
Rumination
Mostly automatic& intrusive
Narrative
Self disclosure
*Reduction of emotional distress
*Management of automatic rumination
*Disengagement from goals
*Rumination more deliberate
*Schema change
*Narrative development
Distress
New Body
Fear of new body
Systematic decline in
functioning
Sociocultural
New Physical identity
Reconnection with
body
Posttraumatic
growth
Narrative and wisdom
Conclusion
 Posttraumatic growth is the phenomenon of surpassing previous levels of function
than which existed before a traumatic event occurred
 Struggle and not the event itself that creates PTG
 Several known facilitators/characteristics of PTG than we are currently studying
 Three main models of PTG
 There is a growing body of work within child populations but this is very new
 Several benefits of PTG although more longitudinal research is needed
 Clinicians can heed the advice of PTG researchers and include within practice
 Always sensitive to the fact that some do not experience and that this is ok
Thank you
[email protected]
WWW.KATEHEFFERON.COM