Posttraumatic growth Beyond Resilience DR KATE HEFFERON PHD

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

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 &

Recovery

Resistance

Reconfiguration

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 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 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, Mc. Ewen & 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 CD 4 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 Assimilation Psychosocial factors Accommodation Positive changes Negative changes New assumptive world

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, 2004 b) 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, 2004 a) 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, 2008 b)

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 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)

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 v Signpost 1: Taking stock v Signpost 2: Harvesting hope v Signpost 3: Re-authoring v Signpost 4: Identifying change v Signpost 5: Valuing change v 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 Self disclosure *Reduction of emotional distress *Management of automatic rumination *Disengagement from goals *Rumination more deliberate *Schema change *Narrative development Distress Narrative 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 K. HEFFERON@UEL. AC. UK WWW. KATEHEFFERON. COM