1. Posttraumatic growth: Beyond Resilience
DR. KATE HEFFERON, PHD
UNIVERSITY OF EAST LONDON
UNIVERSITY OF WESTMINSTER
LECTURE SERIES
WEDNESDAY, FEBRUARY 13TH, 2013

3. That which does not kill us makes us stronger -Friedrich Nietzsche

4. 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

5. Defining PTG

6. 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”

7. Potential responses to trauma
(O’Leary & Ickovics, 1994)

8. 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 (Lepore & Revenson, 2006)

9. Recovery

10. Resistance

11. Reconfiguration

12. Potential responses to trauma
(O’Leary & Ickovics, 1994)

13. 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

14. 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 )

15. Characteristics of PTG

16. 1) Perceived changes in self
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).

17. 2) Improved relationships
Closer relationships with family and/or friends
Neighbours
Fellow trauma survivors
Strangers
Find out who “True friends” are

18. 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)

19. 4) Changed priorities
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

20. 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)

21. 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
lalal

22. 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)

23. Benefits of PTG

24. 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)

25. 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

26. 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)

27. Models of PTG

28. Models of PTG Shattered Assumptions Theory (Janoff-Bulman, 1992)
Transformational Model (Tedeschi & Calhoun, 2006)
Organismic Valuing Theory (Joseph & Linley)

29. (Tedeschi & Calhoun, 2011) Person pre-trauma
Potentially Disruptive event
Emotional Distress
Assumptive Beliefs
Challenged
Goals/ Narrative Disrupted
Assumptive beliefs provide
context for event
Rumination
Mostly automatic& intrusive
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)

30. 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
Negative changes
New assumptive world

31. Facilitators of PTG

32. 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, ; 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)

33. 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

34. 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)

35. 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

36. However… Subjective sense of being bettered (Thornton, 2002, p. 162)
No measurement tools or agreed upon definitions for identifying illusions or distortions (Calhoun &Tedeschi 2008)
Current quantitative measurements of growth do not correspond with social desirability measures
Academic research can not be blamed for ‘The Secret’ (Aspinwall & Tedeschi, 2010)

37. Measuring PTG in adults
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
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)

38. PTG in children

39. 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

40. 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

41. PTG and children: Meta-analysis findings (Myerson et al., 2011)
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

42. 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

43. Facilitating PTG: Current Programmes

44. 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)

45. PTG Module in U.S. Army (Seligman, 2011)
Learn about the responses to trauma including shattered beliefs about the self and others and the future
Learn anxiety-reducing techniques, which aims to reduce automatic and ruminative thoughts and images
Engage in ‘constructive self disclosure’
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
Ask them to highlight new philosophies- ‘phoenix rising’

46. 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

47. 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)

48. 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

49. Future of PTG research

50. 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
Self inflicted
Other inflicted
Emotional
Physical

51. Seismic event New Body Narrative and wisdom Person Pre-trauma
*Adapted from Tedeschi and Calhoun's Transformational model of growth (2006)
Seismic event
Challenges
Management of emotional
distress
Beliefs and goals
Narrative
New Body
Rumination
Mostly automatic& intrusive
Self disclosure
Fear of new body
*Reduction of emotional distress
*Management of automatic rumination
*Disengagement from goals
Systematic decline in functioning
Socio-
cultural
New Physical identity
*Rumination more deliberate
*Schema change
*Narrative development
Reconnection with body
Posttraumatic
growth
Distress
Narrative and wisdom

52. 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

53. K.HEFFERON@UEL.AC.UK WWW.KATEHEFFERON.COM
Thank you