What are some common misconceptions about PTSD

Post-traumatic growth

Summary

The phenomenon of post-traumatic growth describes the possibility that victims of traumatic experiences not only experience psychological and social losses as a result of what they have experienced, but can also trigger personal development processes. This article of the Journal of Psychodrama and Sociometry gives an overview of the current state of knowledge about post-traumatic growth as well as its development and promotion. The relationship to other responses to traumatic events, such as resilience and post-traumatic stress disorder, is explained. Post-traumatic growth can become a central resource in the life of those affected and, conceptually, can be an important enrichment for working with traumatized clients.

Abstract

The term posttraumatic growth describes the phenomenon of personal growth after adverse life events. It highlights the possibility that potentially traumatic experiences cannot only cause suffering but can also foster personal growth. This article in the journal Journal of Psychodrama and Sociometry provides an overview of the latest research and practice in this field, as well as its origin and facilitation. It highlights the relation to other reactions to trauma, including resilience, recovery, and posttraumatic stress disorder. Posttraumatic growth can be a critical resource in the life of people who have experienced great adversity and conceptually be an important enrichment for the clinical work with traumatizes individuals.

introduction

“What doesn't kill us makes us strong.” This widespread expression, which goes back to the German philosopher Friedrich Nietzsche (1997), describes a psychological phenomenon that has recently attracted increasing scientific attention: post-traumatic growth. But contrary to what Nietzsche's quote suggests, a critical experience that does not cost your life does not necessarily lead to growth and strength. What exactly post-traumatic growth is, under what circumstances it occurs and how it can be promoted is therefore the focus of this article.

Traumatic experiences

Radical events are part of the life of every human being. These include normative experiences such as the birth of a child or the death of older relatives. At the same time, life confronts many people with serious, non-normative events such as experiences of violence, life-threatening accidents or sexual assault. In the most critical case, these events, described as potentially traumatic, can lead to post-traumatic stress disorder (PTSD).

In the context of post-traumatic growth, however, it is essential to expand the concept of trauma. Even drastic events that are not directly related to a threat to one's own life often require massive adjustment efforts and can lead to post-traumatic growth. This includes, for example, being suddenly abandoned by a long-term partner.

The following remarks apply equally to potentially traumatic events as well as to drastic experiences in a non-clinical sense, as both can be triggers for post-traumatic growth.

Post-traumatic growth - a disambiguation

“How did the traumatic experience change your life?” The answer to this question is often complex and not infrequently marked by severe losses. The loss of significant relationships, such as the one with the deceased partner, but also the loss of health or sexual integrity after being assaulted, are only examples of the multitude of impairments experienced. An observation made by various scientists in the 1990s is all the more interesting. The research teams came across more and more reports in which the respondents said that the traumatic experience had not only cost them a lot, but also enriched them. Survivors of the most varied of events shared the perception that by dealing with what they had experienced they had gained a deeper understanding of themselves and life as a whole. Tedeschi and Calhoun (1996, p. 455) called this phenomenon of trauma-associated expansion of psychological resources post-traumatic growth, while Park et al. (1996, p. 71) called it stress-related growth. Tedeschi and Calhoun (1996, p. 455) identified five specific areas of post-traumatic growth: a greater appreciation for life, deeper social relationships, more personal strength, new priorities in life, and an expanded sense of spirituality (Tedeschi and Calhoun 1996, 2004) . The integration of the growth perspective expanded the scientific examination of the consequences of critical experiences. Both resilience research and research on PTSD focused on the question of when those affected manage not to suffer any negative consequences or to cope with them after they occur (cf. Bonanno 2004). The concept of post-traumatic growth supplemented this perspective with the possibility that those affected can also experience positive effects after successfully coping with trauma.

Origin and prerequisites

Research has shown that some people report post-traumatic growth after potentially traumatic experiences, while others remain unaffected or experience predominantly negative consequences. The question therefore arises as to the specific conditions under which post-traumatic growth occurs. The best researched genesis theory assumes that basic personal convictions (core belief disruption; Cann et al. 2010, p. 19) are the most important prerequisite for post-traumatic growth. Cann and colleagues (ibid.) Assume that the confrontation with potentially traumatic experiences must result in a severe shock to one's own view of the world so that growth can then arise. Comparable to an earthquake that destroys large parts of the existing cityscape and necessitates a new building or reconstruction, it is assumed that the psychological shock is obviously a necessary prerequisite for far-reaching processes of change.

In addition to this assumption, a large number of models have been developed since the first early research work with the aim of explaining the occurrence of post-traumatic growth (Jayawickreme and Blackie 2014, 2016; Joseph and Linley 2004; Park et al. 1996; Park and Helgeson 2006; Tedeschi and Calhoun 1996, 2004). One of the most far-reaching among them is the theory of dynamic systems (Dynamic systems framework; Cicchetti and Toth 2009; Masten 2014; Overton 2015). It is based on the assumption that human development in general is shaped by the interaction of various molecular, psychological and social systems as well as by environmental influences. When confronted with a potentially traumatic event, system functions can be disrupted or destabilized. Previous roles, thought and behavior patterns can no longer be maintained due to the changed situation and world of experience. From a psychodramatic perspective, this also means that roles and role assignments that are significant for identity are questioned or completely destroyed. A classic example of this is the sudden death of a partner, the death of which not only causes severe emotional loss, but also brings about far-reaching systemic losses. According to the theory of dynamic systems, the destabilization caused by the traumatic event can lead to a reorganization, change or transformation of existing system levels and thus also to growth (Mangelsdorf et al. 2019, p. 2). For example, a consequence of the loss of a partner can be that social relationships with family members, friends or even strangers arise, intensify or change in quality. In summary, post-traumatic growth can be seen as the potential of a dynamic system to adapt to aversive events and thereby expand previous resources. At an individual level, these resources can include psychological components such as knowledge of one's own purpose in life, but also social aspects such as the depth of relationships.

Resilience and Post Traumatic Growth

Contrary to what the saying “What doesn't kill us makes us strong” suggests, post-traumatic growth is just one of the possible reaction patterns after traumatic events. A total of four types of reaction can be distinguished: Resilience, recovery, post-traumatic stress disorder and post-traumatic growth (Fig. 1; based on Mangelsdorf 2014). The four graphs show how severe and persistent the initially experienced psychological impairment is due to the event in the respective form of reaction and whether the adaptation phase leads to an increased psychological functional level of the person concerned.

Resilience

The resilient reaction is characterized by the fact that there is only a small and short-term decline in psychological functionality. Those affected reach their initial psychological level within a short time and can continue their lives as before.

recreation

In contrast to this, those affected experience in the case of recreation considerable psychological losses, which can extend over a longer period of time. This is where the psychological shock described above occurs, which is compensated for over time, so that people who show this reaction pattern return to their initial level. In contrast to post-traumatic growth, however, there is no expansion of psychological resources.

Post-traumatic stress disorder

Probably the most intensely studied response to traumatic experiences is that of post-traumatic stress disorder. In this case, there is a sharp drop in the level of psychological functioning, which either immediately follows the event or can occur after a time. In many cases, those affected can only restore the full level of psychological functionality with professional help. The losses experienced are often massive and long-lasting. It is not uncommon for them to experience lifelong psychological restrictions that can be traced back to the traumatic event.

Post-traumatic growth

The final psychological response pattern is post-traumatic growth. Here, too, the traumatic experience is initially followed by severe psychological losses. Similar to the case of post-traumatic stress disorder and the recovery pattern, those affected first struggle to adapt to the changed psycho-emotional situation. Unlike in these cases, however, dealing with the potentially traumatic experience not only leads to an adaptation back to the original functional level, but to an expansion of psychological resources. It is important to emphasize that post-traumatic stress disorder (PTSD) and post-traumatic growth as reactions are not mutually exclusive, but are often closely related. For example, post-traumatic growth may follow coping with PTSD. Whether the experience of a potentially traumatic event can be turned into growth depends on various factors, which are discussed in more detail below.

One of the most common misconceptions is equating post-traumatic growth and resilience. While both represent desirable psychological response patterns, they are completely distinct phenomena that, according to the current state of research, rarely occur at the same time in relation to the same event. At the center of the emergence of post-traumatic growth is the shaking of basic psychological assumptions. This destabilization of the existing psychological system often has the consequence that the well-being and the psychological functionality suffer considerably. Instead of a resilient reaction, which is precisely characterized by not being affected by the event, or only to a small extent and for a short time, post-traumatic growth is often preceded by a period of suffering. In the case of a resilient reaction, i.e. in the absence of a psychological shock, in contrast to post-traumatic growth, there is no or only very rarely a subsequent expansion of psychological resources.

Can you measure personal growth? A challenge to the empirical

When the research groups around Richard Tedeschi and Crystal Park set out to scientifically research the phenomenon of post-traumatic growth, there were no established reliable measuring instruments. All that could be used back then were the statements of those affected who had survived serious illness, violence or natural disasters. Both research groups each created a questionnaire with the aim of retrospectively measuring post-traumatic growth: the Post-traumatic Growth Inventory (PTGI, Tedeschi and Calhoun 1996) and the Stress Related Growth Scale (SRS, Park et al. 1996). Both measuring instruments provide statements of positive change, for example: “The event has given me deeper social relationships today.” Participants are then asked to indicate how much they agree with these statements on a scale from 1 to 5. In the two decades that have passed since then, the PTGI and the SRS have become the most widely used scales for recording post-traumatic growth. Many hundreds of studies, not just psychological but also medical research, used them.

It is only in the last few years that the voices of scientists who take a critical look at the resilience of retrospective self-statements after potentially traumatic events have increased. Jayawickeme and Blackie (2014, pp. 316–317; 2016, pp. 19–22) raised the following problem in particular: In order to be able to answer the statement to what extent I have deeper social relationships today than before a specific event, I have to make it clear to myself how my social relationships are today, what my relationships were like before the event, how big the difference between then and now is and how much of this perceived difference is actually only due to the one life event examined and not to other experiences made in the meantime. Taken together, this retrospective self-assessment is such a complex process that it cannot be assumed that respondents can make reliable self-statements. With this very precise assessment, Jayawickreme and Blackie (2014) put almost 20 years of research on post-traumatic growth to the test.

New methodical approaches should now provide a remedy. Studies that attempt to make personal growth more measurable with the help of EEG (Rabe et al. 2006) and MRT data (Mangelsdorf 2017) are faced with the challenge of the multidimensionality and complexity of the phenomenon. In the largest meta-analysis on post-traumatic growth published to date, Mangelsdorf et al. (2019) put together the data from 122 longitudinal studies that examined drastic life events in order to question the authenticity of post-traumatic growth. The meta-analysis only included studies that did not actively influence the participants through interventions. All included studies collected psychological dimensions such as meaning in life, self-worth or spirituality around the critical event at several points in time. The authors found that after an average of one and a half years, many subjects had higher self-esteem, deeper relationships and better coping with everyday life than before the event.

Supporting factors for post-traumatic growth

Longitudinal research is still thereFootnote 1 to post-traumatic growth in its infancy. Most of the findings about what helps people to emerge stronger from potentially traumatic events relate to cross-sectional studies and can therefore only be seen as the first source of ideas. In an international comparative study, Mangelsdorf and Eid (2015) examined three central factors: the presence of positive emotions, social support and the creation of meaning from the experience. All three factors were highly associated with post-traumatic growth. People who succeeded in creating moments of positive emotionality despite the critical experiences, who had supportive social relationships and who, in retrospect, were able to attach meaning to the experience, showed more frequent post-traumatic growth. While the above three factors are not the only ones presented in the literature, they can be understood as key drivers for interventions to support post-traumatic growth.

Ways to Promote Post Traumatic Growth in Trauma Therapy

The majority of trauma therapeutic methods, such as TRIMB (Spangenberg 2015) or EMDR (Shapiro 2017), aim to reduce trauma-associated symptoms and to integrate the experience.This approach is also the basis of therapeutic action in the subsequent promotion of post-traumatic growth. It is complemented by the growth-oriented focus. The most important principle in the therapeutic work on post-traumatic growth is the choice of the right time. Post-traumatic growth is not a result of the potentially traumatic experience itself, but rather the coping with this experience (Tedeschi and Calhoun 2004, p. 1). As can be seen from the progression model for post-traumatic growth in Fig. 1, growth only occurs after the acute collapse in psychological functionality has been overcome. Without therapeutic support, it can be assumed that post-traumatic growth will occur no earlier than one and a half years after the event (Mangelsdorf et al. 2019). As a consequence, therapeutic work on post-traumatic growth should not begin until the acute phase of adaptation has already been mastered.

In a meta-analysis published in 2015, Roepke found that post-traumatic growth can be actively supported (Roepke 2015). The meta-analysis focused primarily on intervention formats that were not developed directly to enable growth, such as training on emotion regulation and mindfulness, psychoeducation and behavioral therapy methods (see also Zoellner et al. 2011). Research into explicit treatment concepts to promote post-traumatic growth is still pending. Therefore, two concrete approaches to working with traumatized patients are presented below, with the indication that some of these have not yet been empirically validated or only in the first stages. The three components named above - the presence of supportive relationships and positive emotions as well as the finding of meaning in what is experienced - represent important signposts here. Since the therapeutic relationship is the basis of joint work anyway and the promotion of other supporting relationships and the development of new roles to the established therapeutic one If you have heard of the repertoire, the other two funding options will be discussed here in particular.

Support positive emotions

The processing of potentially traumatic experiences is primarily shaped by one thing: experiencing suffering. The associated negative emotions of fear, anger, sadness, despair, shame and guilt, which are an important part of the processing process, also narrow the cognitive possibilities to use new perspectives and thought patterns for integration. Conversely, moments of positive emotions enable new solutions to be found and new perspectives to be adopted (Fredrickson 2004, p. 1367). They make it easier to build new relationships and dampen the effects of negative emotions (Fredrickson et al. 2000, p. 237). In a prospective longitudinal study that examined resilience and the emergence of post-traumatic growth as a result of the terrorist attacks on the World Trade Center, it was shown that the presence of positive emotions predicted the emergence of post-traumatic growth (Fredrickson et al. 2003, p. 365).

While there are hardly any controlled intervention studies to date, these findings suggest that the targeted promotion of positive emotions can be helpful in dealing with trauma. Three low-threshold methods with which positive emotions can be supported are briefly described here.

Three good things

For this empirically proven exercise, clients are asked to write down three things at the end of each day for which they are grateful today (Emmons and McCullough 2003). This exercise causes a change of perspective and a shift in attention towards the positive aspects of one's own life.

4 evening questions

In a more in-depth form of the exercise described above, the effect of which has also been proven (Ebner 2017), four different questions are answered for the day in review: 1. What gave me pleasure today? 2. What and whom can I be grateful for today? 3. Where did I feel alive today? 4. Which strengths could I live out today? While the first two questions follow on from the “Three Good Things” exercise, questions 3 and 4 aim to bring clients closer to their own strengths. In particular, the joint reflection on the answers to questions 3 and 4 collected over a longer period of time can be decisive moments in order to develop resources for successfully coping with the traumatic experience. After central strengths have been identified, an important follow-up question can be: How can you specifically use this strength to cope with the current challenge?

Mini vacation

Another proven way to encourage positive emotions is to plan positive activities in a concrete way. To do this, the clients create a list of activities that is as extensive as possible, which they experience as beneficial and exhilarating. Then the task is to reserve a daily time window of 20 minutes for a “mini vacation” in which at least one of these activities is carried out.

Supporting positive emotions through these and other exercises can be a crucial key in laying the psycho-emotional foundations for encouraging post-traumatic growth.

Finding meaning in what is experienced

A question often formulated by those affected in the coping phase is: "Why me?" This question is often misunderstood as an attempt to undo the past or as a wish that this fate could have fallen to someone else. Much more often, however, it is the attempt to find meaning in a situation that is experienced as painful and at the same time senseless. This can be used therapeutically.

A first indication of how this could be done is provided by a research paper published in 2008 by Watkins and colleagues (Watkins et al. 2008). In a pioneering intervention study, they asked the test subjects to describe their critical experiences from three different perspectives. The first group was instructed to only write specifically about what had happened. In the second group, the subjects wrote about the experience with a focus on which emotions it had evoked in them, and the last group was asked to describe the experience from a perspective of gratitude. It turned out that writing with a focus on the experienced emotions had a stronger effect than simply reporting on the experience, but that the perspective of gratitude had the most positive effect on the subjects (Watkins et al. 2008). It is important to note that Watkins' study looked at uncomfortable, but not explicitly, traumatic memories. Nonetheless, this approach can be an important guide in supporting post-traumatic growth and a way to make sense of what you have experienced.

Since the perspective of gratitude can only be introduced very sensitively in the trauma context and should only refer to what has been learned through coping, but not the trauma itself, key questions such as: 1) From today's perspective are particularly suitable for working with traumatized people : What was it good for? 2) How can you use the experiences you have gained today for yourself or others? 3) What did the experience enable you to do? Answering these questions in writing or orally can bring about a change of perspective in those affected, which can facilitate integration and positively influence growth. Question 2 in particular should be the focus and should be translated into practical action.

Criticism and Challenges - The Janus Face of Post-Traumatic Growth

The Roman god Janus has two faces. One looks ahead, the other backwards. Derived from this mythical figure, the Janus face has always been a symbol of ambivalence, which is also part of post-traumatic growth (Maercker and Zoellner 2004, p. 41). For many people, the traumatic events of the past are associated with great losses, which not infrequently also determine the present. So the prospect of a gain in the experienced suffering represents a temptation and also a desire to attach something valuable to the otherwise senseless experience. Most people tend to readily accept positive consequences of traumatic experiences when asked directly (Jayawickreme and Blackie 2014, p. 320). Studies examining whether the retrospective self-perception of growth corresponds to the actual processes of change (Frazier et al. 2009; Ransom 2005) came to the conclusion that self-perceived change is only marginally related to real psychological growth. It can therefore be assumed that only some of the perceived change processes actually represent psychological maturation, while the other part is positive illusions (Taylor and Armor 1996, p. 873).

In addition to the ambiguity of self-statements about post-traumatic growth, which is primarily an empirical problem, one of the greatest challenges lies in the possible prompting for traumatized people to show growth have to. The danger is that by emphasizing the possibility of experiencing post-traumatic growth, social and personal pressure is increased to cope with trauma positively. This can become an additional burden for those affected. Precisely for this reason it can be helpful to be very careful with psychoeducational measures on the subject and instead to support therapeutic factors that enable growth without explicitly explaining it verbally.

Conclusion

To this day, critical and traumatic events are primarily understood as a psycho-emotional threat (see Filipp and Aymann 2018). Trauma therapeutic work is therefore primarily oriented towards resolving the negative consequences of traumatization (Huber 2012). Only in the more recent trauma research presented here is this approach supplemented by the possibility that potentially traumatic events can also be catalysts for psychological maturation and personal growth. While prospective research into the effectiveness of supporting factors for post-traumatic growth is still in its infancy, the first promising approaches are emerging as to how post-traumatic growth can be therapeutically supported and promoted. Due to this changed perspective on traumatic experiences, they can be understood not only as painful, but also groundbreaking and thus also pave the way for a new, more fulfilling future.

Notes

  1. 1.

    Longitudinal studies accompany the participants in the examinations over a longer period of time and have several measurement times. This makes it possible to examine development processes and changes, whereby causal relationships can also be determined. Cross-sectional studies only have one measurement point in time. In doing so, they show which factors are related to one another, but do not allow any causal conclusions.

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