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advancing science and promoting understa nding of traumatic stress
Research Quarterly
VOLUME 21/NO. 3 • ISSN: 1050-1835 • SUMMER 2010
Published by:
National Center for PTSD
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All issues of the PTSD Research
Quarterly are available online at:
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Matthew J. Friedman, MD, PhD
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Fran H. Norris, PhD
Managing Editor
Fred Lerner, DLS
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U.S. Department of Veterans Affairs
Positive Changes
Following Adversity
Throughout human history the theme of positive
changes following adversity is found in literature,
religions, and philosophies. Most notable is
Nietzsche’s famous dictum, “What doesn’t kill me
makes me stronger.” It was an idea also common
to the existential and humanistic traditions of
psychology of the mid-twentieth century. Viktor
Frankl wrote about the will to meaning following his
experiences in Theresienstadt and Auschwitz, and
Abraham Maslow noted that confrontations with
tragedy were often precursors to self-actualization.
Scientic interest was sparked when a handful of
studies appeared in the late 1980s and early 1990s,
reporting positive changes in, for example, rape
survivors (Burt & Katz, 1987), male cardiac patients
(Afeck, Tennen, Croog, & Levine, 1987), bereaved
adults (Edmonds & Hooker, 1992), and combat
veterans (Elder & Clipp, 1989).
Interest took hold during the 1990s as the construct
was elaborated (e.g., O’Leary & Ickovics, 1995;
Tedeschi & Calhoun, 1995) and with the emergence
of several psychometric self-report tools, the
Changes in Outlook Questionnaire (CiOQ: Joseph,
Williams, & Yule, 1993), the Posttraumatic Growth
Inventory (PTGI: Tedeschi & Calhoun, 1996), the
Stress-Related Growth Scale (SRGS: Park, Cohen,
& Murch, 1996), the Perceived Benet Scales (PBS:
McMillen & Fisher, 1998), and the Thriving Scale
(TS: Abraido-Lanza et al., 1998). But it is only over
the past decade, bolstered by the new positive
psychology movement, that the topic has become
rmly established as a eld of scientic research
and clinical interest. Recent major texts include
Calhoun and Tedeschi’s (2006) Handbook of Post-
traumatic Growth, and Joseph and Linley’s (2008)
Trauma, Recovery and Growth.
Stephen Joseph
Centre for Trauma, Resilience, and Growth, The Institute of
Mental Health, University of Nottingham, Nottingham, UK
Lisa D. Butler
Buffalo Center for Social Research, School of Social Work,
University at Buffalo, The State University of New York,
Buffalo
Positive changes are difcult to study well, and
much of the research is open to criticism. The eld
is still young, and as such, the reader should
beware over-generalized interpretations of specic
results to new situations and clinical practice. With
apologies to all of those whose work was omitted,
we have tried to select articles that reect the
development of the eld and the diversity of
contexts and populations that have been studied and
that illustrate a method, trend, issue, or conclusion
that is important.
Terminology
The term posttraumatic growth has now become
the most widely used term to describe the eld.
Other terms which have been used include stress-
related growth. There is debate over the use of the
term growth, which others have used explicitly to
invoke the biological metaphor associated with the
humanistic psychology tradition and how growth
arises through the resolution of an adversarial
tension between pre-existing assumptive worlds
and the new trauma-related information. To avoid
such theoretical connotations, other terms such
as benet-nding, perceived benets, and positive
change have been used. Although within the
literature the various terms are often used inter
changeably, it needs to be recognized that different
epistemological positions are represented by each.
Mindful of this, we have chosen to generally use the
term positive change in this brief review.
Correlates
The bulk of research has relied on the use of the
aforementioned, or other similar, retrospective
self-report measures. Particularly important have
Continued on page 2
Authors’ Addresses: Stephen Joseph, PhD is afliated with the Centre for Trauma, Resilience, and Growth, St Ann’s House,
114 Thorneywood Mount, Nottingham, NG3 2PZ, and Lisa D. Butler, PhD is afliated with the Buffalo Center for Social
Research, School of Social Work, at the University at Buffalo, the State University of New York, 685 Baldy Hall, Buffalo, New
York 14260. Email Addresses: stephen.joseph@nottingham.ac.uk; ldbutler@buffalo.edu.
PAGE 2 PTSD RESEARCH QUARTERLY
Continued from cover
been reviews of the literature. A systematic review of 39 studies by
Linley and Joseph (2004) suggested that positive change is commonly
reported in around 30-70% of survivors of various traumatic events,
including transportation accidents (shipping disasters, plane crashes,
car accidents), natural disasters (hurricanes, earthquakes), inter-
personal experiences (combat, rape, sexual assault, child abuse),
medical problems (cancer, heart attack, brain injury, spinal cord
injury, HIV/AIDS, leukaemia, rheumatoid arthritis, multiple sclerosis),
and other life experiences (relationship breakdown, parental divorce,
bereavement, immigration), and that growth is associated with
higher socio-economic status, higher education, younger age,
personality traits such as optimism and extraversion, positive
emotions, social support, and problem focused, acceptance, and
positive reinterpretation coping. More recently, Helgeson et al. (2006)
conducted a meta-analytic review of 87 studies, concluding that
benet nding was related to lower depression and higher well-
being, but also greater severity of intrusive and avoidant posttrau-
matic experiences. This latter nding has caused some confusion,
leading some to question the adaptive utility of growth, while others
propose that posttraumatic stress symptoms should be viewed as
signs of the cognitive processes that give rise to growth. Evidence
from the Stanford Internet survey following 9/11 (Butler et al., 2005)
indicated that there might be a curvilinear relation between levels
of posttraumatic stress and positive change, suggesting that there
may be a range of traumatic experience most conducive to growth.
Theoretical Development
Janoff-Bulman’s (1992) shattered assumptions theory was developed
prior to the establishment of the eld but has provided the funda-
mental theoretical architecture for the two main theories of positive
change, notably the transformational model (Tedeschi & Calhoun,
2004) and the organismic valuing theory (Joseph & Linley, 2005).
Organismic valuing theory attempts to provide an account of
positive changes rooted in humanistic psychology wherein post-
traumatic stress is viewed as indicative of normal, natural cognitive
processes that have the potential to generate positive change.
Theoretically, the largest challenge facing the eld over the coming
years is whether it succeeds in providing a useful alternative non-
medical paradigm for the study of traumatic stress.
The empirical literature has been limited by an over-reliance on
cross-sectional studies, but increasingly longitudinal studies are
available and beginning to paint a clearer picture of which factors
lead to positive change. For example, in a study of 206 long-term
cancer survivors (Schroevers, Helgeson, Sanderman, & Ranchor,
2010), the more emotional support was received at 3 months after
diagnosis, the greater was the experience of positive consequences
of the illness at 8 years after diagnosis, even when controlling for
concurrent levels of emotional support at that follow-up.
Of interest is whether positive changes lead to better outcomes on
other more-traditional indices. Linley, Joseph, and Goodfellow (2008)
found that people who report positive change are less likely to
experience problems of posttraumatic stress at six months. Frazier
et al. (2004) asked 171 rape survivors to complete a specially
designed questionnaire to measure positive changes at 2 weeks
following the assault, and then again 2, 6, and 12 months later. This
well-designed study allowed the investigators to see how positive
changes related to well-being over time. Four groups were created:
(1) those who reported low levels of positive change at 2 weeks
and high levels at 12 months (“gained positive change” group); (2)
those who reported high levels of positive change at 2 weeks and
low levels at 12 months (“lost positive change” group); (3) those
who reported low levels at both time points (“never had positive
change” group), and (4) those who reported high levels at both time
points (“always had positive change” group). Results indicated that
those in the “always had positive change” group did the best,
showing the lowest levels of depression and posttraumatic stress.
Afeck, Tennen, Croog, and Levine (1987) reported that heart
attack patients who found benets immediately after their rst
attack had reduced re-occurrence and morbidity statistics eight
years later. Turning to biological markers, Epel, McEwen, and
Ickovics (1998) found that high levels of positive change were
related to lowered cortisol levels in women exposed to laboratory
stress, as did Cruess et al. (2000) who reported lower cortisol levels
through the enhancement of benet nding among women with
breast cancer. Dunigan, Carr, and Steel (2007) reported that among
patients with hepatoma, those scoring high on positive change
survived 186 days longer than their lower-scoring peers, due to
higher peripheral blood leukocytes. Furthermore, Bower et al.
(1998) reported that lower AIDS-related mortality was associated
with self-reported benet nding among bereaved HIV-positive
men. Milam (2004) also reported greater immune system functioning
among HIV patients with higher levels of positive change.
Issues, Controversies, and Directions
Research has progressed considerably with the introduction of
standardized self-report instruments to assess positive change,
allowing comparisons to be made between studies, but there is still
no consensus regarding the parameters that dene the universe of
positive change. The most widely used of the measures is the Post-
traumatic Growth Inventory (PTGI), which assesses ve domains:
(1) perceived changes in self (becoming stronger, more condent);
(2) developing closer relationships with family, friends, neighbours,
fellow trauma survivors, and even strangers; (3) changing life
philosophy/increased existential awareness; (4) changed priorities;
and (5) enhanced spiritual beliefs. As research has continued to
develop and mix in-depth qualitative analysis into the inquiry, many
aspects of positive change appear to be absent from the current
scales of measurement, suggesting the need to use multiple measures,
to recognize that change can be in both positive and negative
schematic directions, and to include study-specic measurement.
One of the main current criticisms is the overreliance on retrospec-
tive self-report, with some questioning the validity of the concept
itself. However, evidence for positive change arises when before-
and-after measures are used. A fortuitous study by Peterson and
Seligman (2003) had 4817 respondents complete the on-line Values
in Action Classication of Strengths prior to September 11. When
scores for individuals who completed the survey in the 2 months
immediately after September 11 were compared with the scores
for those who completed the survey before September 11, seven
character strengths showed increases: gratitude, hope, kindness,
leadership, love, spirituality, and teamwork. So, while the use of
retrospective self-report is limited, the notion of positive change
when measured through other means seems substantiated.
VOLUME 21/NO. 3 SUMMER 2010 PAGE 3
One of the issues that makes measurement so problematic is that
the various measures of positive change ask respondents to rate
their perceptions of how much they have changed as a result of
the event. Ford, Tennen, and Albert (2008) described the complex
cognitive operations required of respondents, all of which can be
subject to bias. Data on the validity of these retrospective self-
reports was questioned by Patricia Frazier and her colleagues
(2009) who asked over 1500 students in an on-line survey to
complete a battery of questionnaires, including a measure of
psychological well-being. Eight weeks later they were asked to
complete the questionnaires again and report whether they had
experienced any major life events in the interim. Ten percent of the
sample reported the experience of a traumatic event in the preceding
eight weeks, and increases in psychological well-being were noted
when the measure of psychological well-being after the event was
compared with that completed before the event. But ratings of how
people thought they had changed did not correspond well to these
actual changes. A further complication when considering the validity
of self-report is the suggestion that some reports of positive change
are illusory, such as those that are eeting or due to positive reporting
biases or wishful, defensive, or even superstitious thinking. While
illusory change should not be considered as real positive change,
most commentators agree that a certain amount of illusory positive
reappraisal coping can be psychologically helpful.
Methodologically, the bulk of the research to date is cross-sectional
and high-quality longitudinal studies remain relatively rare, and it
cannot yet be concluded what factors are predictive of positive
change. It is likely, given the example of the wider trauma literature,
that there are complex interactions among demographic, personality,
coping, and social support variables, such that the effects of one
variable are only found at certain levels of other variables. Of note,
one prospective study examining reactions to the SARS epidemic
among a sample of Chinese who had recovered from the illness,
their family members, and other healthy adults living in Hong Kong
(Cheng, Wong, & Tsang, 2006) found those who reported “mixed”
accounts (accounts that included both benets and costs to the
experience) fared better over the longer term than those reporting
exclusively positive or exclusively negative experiences, suggesting
that enduring positive change may involve the development of a
complex, balanced, and realistic understanding of the experience.
As well as more sophisticated interactional research, there is a need
for longitudinal research in order to test the relation of proposed
predictive factors with subsequent reports of positive change.
Directionality is an issue that deserves further attention, as positive
changes might be as likely to lead to increases in many of the factors
that have been posited as predictors.
Clinical Application
One common misunderstanding is the expectation that those who
report positive changes should be free of distress, but this is neither
what the evidence suggests nor how researchers in the eld under-
stand positive change. Positive changes refer to the eudaimonic
rather than the hedonic side of well-being (Joseph & Linley, 2005).
Whereas the hedonic approach focuses on emotions, the eudai-
monic approach is derived from Aristotelian philosophy and is
concerned with the optimal functioning and development of the
person. In current positive psychology terminology, the eudaimonic
approach refers to psychological well-being (PWB) as opposed to
subjective well-being (SWB). SWB refers to people’s affective states,
the balance between their positive and negative feelings, and the
extent to which they are satised with life. In contrast, PWB is
concerned with the more existential side of life – autonomy, mastery,
personal growth, positive relations with others, self-acceptance and
purpose in life. Moreover, growth cannot undo what has happened;
neither is it necessarily psychologically pervasive. Experiences of
positive change may be domain-specic, and distress and growth
may co-exist – a condition often observed clinically in those who
have suffered a signicant loss. As such, theorists argue that positive
changes are of value in themselves and that facilitation of growth is
a worthwhile clinical outcome in its own right and not simply to be
valued in relation to how well positive changes predict lower distress.
Advice for therapists is available (Calhoun & Tedeschi, 1999).
Group interventions have been shown to be effective. Antoni et al.
(2001) tested the effects of a 10-week group cognitive-behavioral
stress management intervention among 100 women newly treated
for Stage 0-II breast cancer. The intervention increased participants’
reports that breast cancer had made positive contributions to their
lives, and it increased generalized optimism at a 3-month follow-
up. While such results are encouraging, caution is still warranted in
terms of whether and how this research can be applied in the real
world (Lechner, Stoelb, & Antoni, 2008). The topic opens up debate
on the ethics of the therapeutic process. Researchers and clinicians
are urged to be wary of the potential for patients to experience a
tyranny of positive thinking wherein they feel that they must inhibit
expression of their concerns and distress and forgo psychothera-
peutic work in an effort to remain “positive.” Professionals should
also consider carefully the moral issues associated with interven-
tions deliberately aimed at helping patients nd benets, as opposed
to non-directive interventions that work only with clients’ growth
when it spontaneously occurs.
References
Frankl, V. E. (1963). Man’s search for meaning: An introduction to
logotherapy. Boston, MA: Beacon.
Nietzsche, F. (1997/1889). Twilight of the idols, or, How to philosphize
with the hammer. (R. Polt, Trans.) Indianapolis, IN: Hackett.
Maslow, A. (1955). Deciency motivation and growth motivation.
Nebraska Symposium on Motivation, 3, 1-30.
PAGE 4 PTSD RESEARCH QUARTERLY
ABSTRACTS
Afeck, G., Tennen, H., Croog, S., & Levine, S. (1987). Causal
attributions, perceived benets, and morbidity after a heart
attack: An 8-year study. Journal of Consulting and Clinical
Psychology, 55, 29-35. In a sample of 287 heart attack victims who
were interviewed 7 weeks and 8 years after their attack or who
were known to have died during follow-up, interrelations among
causal attributions for the attack, perceived benets of the attack,
survivor morbidity, and heart attack recurrence were explored.
Analyses focused on early cognitive predictors of heart attack
recurrence and 8-year morbidity and on the effects of surviving
another heart attack on cognitive appraisals. Independently of
sociodemographic characteristics and physicians’ ratings of initial
prognosis, patients who cited benets from their misfortune 7
weeks after the rst attack were less likely to have another attack
and had lower levels of morbidity 8 years later. Attributing the initial
attack to stress responses (e.g., worrying, nervousness) was also
predictive of greater morbidity in 8-year survivors and blaming the
initial attack on other people was predictive of reinfarctions. Men
who survived a subsequent heart attack were more likely than men
who did not have additional attacks to cite benets and made more
attributions 8 years after the initial attack.
Antoni, M. H., Lehman, J. M., Kilbourn, K. M., Boyers, A. E., Culver,
J. L., Alferi, S. M., et al. (2001). Cognitive-behavioral stress manage-
ment intervention decreases the prevalence of depression and
enhances benet nding among women under treatment for
early-stage breast cancer. Health Psychology, 20, 20-32. The
authors tested effects of a 10-week group cognitive–behavioral
stress management intervention among 100 women newly treated
for Stage 0–II breast cancer. The intervention reduced prevalence
of moderate depression (which remained relatively stable in the
control condition) but did not affect other measures of emotional
distress. The intervention also increased participants’ reports that
having breast cancer had made positive contributions to their lives,
and it increased generalized optimism. Both remained signicantly
elevated at a 3-month follow-up of the intervention. Further analysis
revealed that the intervention had its greatest impact on these 2
variables among women who were lowest in optimism at baseline.
Discussion centers on the importance of examining positive
responses to traumatic events—growth, appreciation of life, shift
in priorities, and positive affect—as well as negative responses.
Bower, J. E., Kemeny, M. E., Taylor, S. E., & Fahey, J. L. (1998).
Cognitive processing, discovery of meaning, CD4 decline, and
AIDS-related mortality among bereaved HIV-seropositive men.
Journal of Consulting and Clinical Psychology, 66, 979-986. This
study investigated whether nding meaning in response to an
HIV-related stressor was associated with changes in immune
status and health. Forty HIV-seropositive men who had recently
experienced an AIDS-related bereavement completed interviews
assessing cognitive processing and nding meaning after the loss
and provided blood samples for a 2- to 3-year follow-up. AIDS-
related mortality over an extended follow-up was determined from
death certicates. As predicted, men who engaged in cognitive
processing were more likely to nd meaning from the loss. Further-
more, men who found meaning showed less rapid declines in CD4
T cell levels and lower rates of AIDS-related mortality (all ps <.05),
independent of health status at baseline, health behaviors, and other
potential confounds. These results suggest that positive responses
to stressful events, specically the discovery of meaning, may be
linked to positive immunologic and health outcomes.
Butler, L. D., Blasey, C. M., Garlan, R. W., McCaslin, S. E., Azarow,
J., Chen, X., et al. (2005). Posttraumatic growth following the
terrorist attacks of September 11, 2001. Cognitive, coping and
trauma symptom predictors in an internet convenience sample.
Traumatology, 11, 247-267. Cognitive, coping, and trauma symptom
predictors of posttraumatic growth (PTG; measured with the Post-
traumatic Growth Inventory) were examined in a large convenience
sample (n =1,505) participating in a longitudinal Internet-based
study following the terrorist attacks of 9/11/01. Results indicate
that initial PTG levels (mean 9 weeks post-attacks) were generally
associated with higher trauma symptoms (measured with the PTSD
Checklist - Specic), positive changes in worldview (measured with
the Changes in Outlook Questionnaire), more denial, and less
behavioral disengagement (measured with the Brief COPE). Addition-
ally, PTG had a curvilinear association with level of trauma symptoms,
such that those reporting symptoms at intermediate levels reported
the highest levels of growth. Levels of PTG declined somewhat
over time with the exception of Spiritual Change. As expected,
PTG levels at follow-up (mean 6.5 months post-attacks) were
primarily predicted by initial PTG levels; however, decreases from
baseline in trauma symptoms and increases from baseline in
positive worldview, acceptance, and positive reframing were also
associated with higher reported posttraumatic growth at follow-up.
These ndings suggest that there may be a range of traumatic
experience most conducive to growth and they also highlight the
important contributions of cognitive and coping variables to
psychological thriving in short- and longer-term periods following
traumatic experience.
Calhoun, L. G., & Tedeschi, R. G. (Eds.) (2006). Handbook of post-
traumatic growth: Research and practice. Mahwah, NJ: Erlbaum.
Posttraumatic growth is an area in which investigations are now
being undertaken in many different parts of the world. The view
that individuals can be changed, sometimes in radically good ways,
by their struggle with trauma is ancient and widespread. The
systematic focus by scholars and clinicians on the possibilities for
growth from the struggle with crisis, however, is relatively recent.
There are now a growing number of studies and scholarly papers
on the antecedents, correlates, and consequences of posttrau-
matic growth, and there are also theoretical models that can help
guide the research further. It is clear, however, that this phenom-
enon is not yet well understood. This volume is designed with
two general goals in mind. First, to provide both clinicians and
researchers with a comprehensive and up-to-date view of what has
been done so far. Second, to use the foundation of what has been
done to provide suggestions for the next useful steps to take in
understanding posttraumatic growth. [Preface] TOPICS TREATED:
Posttraumatic growth: theory and method (The foundations of
posttraumatic growth: an expanded framework; Relationships
between posttraumatic growth and resilience: recovery, resistance,
and reconguration; Measurement issues in assessing growth
following stressful life experiences; Re-storying loss: fostering
VOLUME 21/NO. 3 SUMMER 2010 PAGE 5
ABSTRACTS continued
growth in the posttraumatic narrative; Schema-change perspectives
on posttraumatic growth; Posttraumatic growth and other outcomes
of major loss in the context of complex family lives); Posttraumatic
growth in specic contexts (Spirituality: a pathway to posttraumatic
growth or decline?; Posttraumatic growth after cancer; Bereavement
and posttraumatic growth; Posttraumatic growth after war; Positive
changes attributed to the challenge of HIV/AIDS; Posttraumatic
growth in disaster and emergency work; Growing out of ashes:
posttraumatic growth among Holocaust child survivors; Resilience
and posttraumatic growth in children); Clinical applications of post-
traumatic growth (Expert companions: posttraumatic growth in
clinical practice; The link between posttraumatic growth and forgive-
ness: an intuitive truth; Posttraumatic growth and psychotherapy;
Resilience and posttraumatic growth: a constructive narrative
perspective).
Cruess, D. G., Antoni, M. H., McGregor, B. A., Kilbourn, K. M.,
Boyers, A. E., Alferi, S. M., et al. (2000). Cognitive-behavioral
stress management reduces serum cortisol by enhancing
benet nding among women being treated for early stage
breast cancer. Psychosomatic Medicine, 62, 304-308. OBJECTIVE:
This study examined the effects of a cognitive-behavioral stress
management (CBSM) group intervention on serum cortisol levels
in women being treated for stage I or II breast cancer. METHODS:
Participants were randomly assigned to undergo a 10-week inter-
vention (N = 24) within 8 weeks after surgery or were placed on a
waiting list (N = 10). Cortisol was assessed by means of a radioim-
munoassay of blood samples collected at the same time of day
just before the start of the intervention and immediately after its
completion. The women also reported the degree to which breast
cancer had made positive contributions to their lives. RESULTS:
Intervention participants showed increased benet nding and
reduced serum cortisol levels, whereas control subjects experi-
enced neither change. Path analysis suggested that the effect of
CBSM on cortisol was mediated by increases in benet nding.
CONCLUSIONS: These ndings suggest that positive growth
enhanced during a time-limited intervention can inuence physi-
ological parameters such as cortisol among women with early stage
breast cancer.
Ford, J. D., Tennen, H., & Albert, D. (2008). A contrarian view of
growth following adversity. In S. Joseph & P. A. Linley (Eds.),
Trauma, Recovery and Growth: Positive psychological perspectives
on posttraumatic stress (pp. 297-324). Hoboken, NJ: Wiley. The
concept of posttraumatic growth is a potentially important paradigm
shift in the traumatic stress eld. Reports of individuals experiencing
personal growth in the face of adversity run contrary to the dominant
scientic, clinical, and lay views that psychological trauma primarily
causes damage to the body, mind, and relationships. Although
posttraumatic growth has become an icon in the positive psychology
movement, we review evidence that suggests that growth in the
aftermath of psychological trauma is better conceptualized as the
resumption or continuation of preexisting psychological develop-
ment, or as an artifact of cognitive attribution processes that lead
persons who experience psychological trauma to believe that they
have experienced growth.
Frazier, P., Tashiro, T., Berman, M., Steger, M., & Long, J. (2004).
Correlates of levels and patterns of positive life changes
following sexual assault. Journal of Consulting and Clinical
Psychology, 72, 19-30. This study builds on previous work suggesting
that many survivors report positive life changes soon after a sexual
assault and that those who retain those changes over time report
the least distress 1 year post-assault (P. Frazier, A. Conlon, & T.
Glaser, 2001). The purposes of this study were to assess correlates
of early reports of positive life changes and individual trajectories
of self-reported positive changes over time among female sexual
assault survivors (n = 171) using hierarchical linear modeling. The
factors most related to reporting positive life change soon after the
assault were social support, approach and religious coping, and
perceived control over the recovery process. Increases in these
factors also were associated with increases in self-reported positive
life changes over time. The relations between social support and
positive change also were mediated by coping strategies and control
appraisals, particularly perceived control over the recovery process.
Frazier, P., Tennen, H., Gavian, M., Park, C., Tomich, P., & Tashiro,
T. (2009). Does self-reported posttraumatic growth reect genuine
positive change? Psychological Science: Research, Theory, &
Application in Psychology and Related Sciences, 20, 912-919. In
this study, we evaluated the validity of self-reported posttraumatic
growth (PTG) by assessing the relation between perceived growth
and actual growth from pre- to posttrauma. Undergraduate students
completed measures tapping typical PTG domains at Time 1 and
Time 2 (2 months later). We compared change in those measures
with scores on the Posttraumatic Growth Inventory (PTGI; Tedeschi
& Calhoun, 1996) for those participants who reported a traumatic
event between Time 1 and Time 2 (n = 122). PTGI scores generally
were unrelated to actual growth in PTG-related domains. Moreover,
perceived growth was associated with increased distress from pre-
to posttrauma, whereas actual growth was related to decreased
distress, a pattern suggesting that perceived and actual growth
reect different processes. Finally, perceived (but not actual) growth
was related to positive reinterpretation coping. Thus, the PTGI, and
perhaps other retrospective measures, does not appear to measure
actual pre- to posttrauma change.
Helgeson, V. S., Reynolds., K. A., & Tomich, P. L. (2006). A meta-
analytic review of benet nding and growth. Journal of Consulting
and Clinical Psychology, 74, 797-816. The authors conducted a
meta-analysis to examine the relations of benet nding to psycho-
logical and physical health as well as to a specic set of demographic,
stressor, personality, and coping correlates. Results from 87 cross-
sectional studies reported in 77 articles showed that benet nding
was related to less depression and more positive well-being but
also to more intrusive and avoidant thoughts about the stressor.
Benet nding was unrelated to anxiety, global distress, quality of
life, and subjective reports of physical health. Moderator analyses
showed that relations of benet nding to outcomes were affected
by the amount of time that had passed since stressor onset, the
benet nding measure used, and the racial composition of the
sample.
PAGE 6 PTSD RESEARCH QUARTERLY
ABSTRACTS continued
Joseph, S., & Linley, P. A. (2005). Positive adjustment to threat-
ening events: An organismic valuing theory of growth through
adversity. Review of General Psychology, 9, 262-280. A positive
psychological theory of growth through adversity is proposed. The
organismic valuing theory of growth through adversity posits an
intrinsic motivation toward growth, showing how this leads to the
states of intrusion and avoidance that are characteristic of cognitive-
emotional processing after trauma. The theory posits 3 possible
outcomes of this cognitive-emotional processing, namely, assimila-
tion, negative accommodation, and positive accommodation. The
theory shows how the organismic valuing process will automatically
lead to the actualization of positive changes in psychological well-
being, through the positive accommodation of the new trauma-
related information, provided that the social environment is able to
support this positive accommodation process.
Joseph, S. & Linley, P. A. Psychological assessment of growth
following adversity: A review. In: Joseph, S. & Linley, P. A. (Eds.),
(2008). Trauma, recovery, and growth: Positive psychological per-
spectives on posttraumatic stress. (pp. 21-38). Hoboken, NJ: Wiley.
Growing interest in positive change following trauma and adversity
has prompted the development of new psychometric instruments.
In this chapter, we provide a brief introduction to the measurement
literature. First, we describe existing measures. Second, we review
what is known about the structure of growth following adversity as
well as the question of the relation between positive and negative
changes, and how this informs considerations for choosing appro-
priate measures. Third, research directions and clinical implications
are discussed, with recommendations for the future of psychometric
assessment in this area.
Linley, P. A., & Joseph, S. (2004). Positive change following trauma
and adversity: A review. Journal of Traumatic Stress, 17, 11-21.
Empirical studies (n = 39) that documented positive change following
trauma and adversity (e.g., posttraumatic growth, stress-related
growth, perceived benet, thriving; collectively described as
adversarial growth) were reviewed. The review indicated that cognitive
appraisal variables (threat, harm, and controllability), problem-focused
acceptance, and positive reinterpretation coping, optimism, religion,
cognitive processing, and positive affect were consistently associ-
ated with adversarial growth. The review revealed inconsistent
associations between adversarial growth, sociodemographic
variables (gender, age, education, and income), and psychological
distress variables (e.g., depression, anxiety, posttraumatic stress
disorder). However, the evidence showed that people who reported
and maintained adversarial growth over time were less distressed
subsequently. Methodological limitations and recommended future
directions in adversarial growth research are discussed, and the
implications of adversarial growth for clinical practice are briey
considered.
O’Leary, V. E., & Ickovics, J. R. (1995). Resilience and thriving in
response to challenge: An opportunity for a paradigm shift in
women’s health. Women’s Health: Research on Gender, Behavior,
and Policy, 1, 121-142. The purpose of this article is to move
beyond the vulnerability/decit model of women and to focus on
women’s strengths and their ability to thrive in the face of adversity.
Thriving is a dynamic process of adaptation, inuenced by numerous
individual and social factors; it emerges and changes over the life
course and may be identied in behavioral, cognitive, or affective
domains. The foundation of this concept comes from the literature
on resilience, but it goes beyond the common view of resilience as
homeostasis. It suggests, instead, a value-added construct whereby
challenge provides an opportunity for change and growth. Under-
standing the concept and process of thriving can provide an
important basis for theoretical development, empirical research,
and clinical intervention. Thriving can provide a framework within
which to examine the antecedents and consequences of differential
reactions to health-related challenges. Knowledge of the factors
that promote thriving can provide an important foundation for a
paradigm shift away from a focus on illness and pathology toward
one that understands, explains, and nurtures health.
Peterson, C., & Seligman, M.E.P. (2003). Character strengths before
and after September 11. Psychological Science, 14, 381-384. Did
Americans change following the September 11 terrorist attacks?
We provide a tentative answer with respect to the positive traits
included in the Values in Action Classication of Strengths and
measured with a self-report questionnaire available on-line and
completed by 4,817 respondents. When scores for individuals
completing the survey in the 2 months immediately after September
11 were compared with scores for those individuals who completed
the survey before September 11, seven character strengths showed
increases: gratitude, hope, kindness, leadership, love, spirituality,
and teamwork. Ten months after September 11, these character
strengths were still elevated, although to a somewhat lesser degree
than immediately following the attacks.
Schroevers, M. J., Helgeson, V. S., Sanderman, R., & Ranchor, A. V.
(2010). Type of social support matters for prediction of post
traumatic growth among cancer survivors. Psycho-Oncology,
19, 46-53. Objective: Previous research in people with cancer on
social support and psychological well-being has mainly focused on
the short-term negative outcomes of adjustment. Little is known
about the role of social support in the experience of positive out-
comes in the long term. This study examined the relation between
emotional support in the period following diagnosis and the
experience of positive consequences of the illness, so-called post-
traumatic growth, at 8 years after diagnosis. We focused on three
distinct types of emotional support: perceived availability, actual
received, and dissatisfaction with received emotional support.
Methods: This longitudinal study was conducted in a sample of 206
long-term cancer survivors. Social support was assessed with the
Social Support List (SSL) at 3 months and 8 years after diagnosis.
Positive consequences of the illness were assessed with the Silver
Lining Questionnaire (SLQ) at 8 years after diagnosis. Correlation-
and regression analyses were used to examine the associations of
initial levels of emotional support with the long-term report of post-
traumatic growth. Results: Regression analyses showed that more
received emotional support at 3 months after diagnosis signicantly
predicted a greater experience of positive consequences of the
illness at 8 years after diagnosis. This association remained signicant,
when controlling for concurrent levels of emotional support at 8 years
after diagnosis. Conclusions: The ndings suggest that getting
VOLUME 21/NO. 3 SUMMER 2010 PAGE 7
ABSTRACTS continued
support from family and friends, characterized by reassuring,
comforting, and problem-solving, in the period following diagnosis
is an important resource that may help cancer survivors to nd
positive meaning in the cancer experience.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth:
Conceptual foundations and empirical evidence. Psychological
Inquiry, 15, 1-18. This article describes the concept of posttraumatic
growth, its conceptual foundations, and supporting empirical
evidence. Posttraumatic growth is the experience of positive change
that occurs as a result of the struggle with highly challenging life
crises. It is manifested in a variety of ways, including an increased
appreciation for life in general, more meaningful interpersonal
relationships, an increased sense of personal strength, changed
priorities, and a richer existential and spiritual life. Although the
term is new, the idea that great good can come from great suffering
is ancient. We propose a model for understanding the process of
posttraumatic growth in which individual characteristics, support
and disclosure, and more centrally, signicant cognitive processing
involving cognitive structures threatened or nullied by the traumatic
events, play an important role. It is also suggested that posttraumatic
growth mutually interacts with life wisdom and the development
of the life narrative, and that it is an ongoing process, not a static
outcome.
CITATIONS
Abraído-Lanza, A. F., Guier, C., & Colón, R. M. (1998). Psychological
thriving among Latinas with chronic illness. Journal of Social
Issues, 54, 405-424. A measure of thriving was created on the
basis of qualitative interviews and past research and then studied
as an outcome in a three-year longitudinal study of Latinas. Path
analyses showed that measures of competence (self-esteem and
self-efcacy) and psychological well-being were related to thriving
over time.
Burt, M. R., & Katz, B. L. (1987). Dimensions of recovery from rape:
Focus on growth outcomes. Journal of Interpersonal Violence, 2,
57-81. The authors attempted to conceptualize and measure how
women grow as a consequence of having to cope with rape and its
aftermath. Factor analyses of measures completed by 113 rape
victims yielded six dimensions of self-concept, ve dimensions of
coping techniques, and three dimensions of self-ascribed change.
Calhoun, L. G., & Tedeschi, R. G. (1999). Facilitating posttraumatic
growth: A clinician’s guide. Mahwah, NJ: Erlbaum. The authors
provide a framework for clinical efforts to enhance posttraumatic
growth. Chapters provide case examples, clinical approaches, and
resources for both clinicians and clients.
Cheng, C., Wong, W., & Tsang, K. W. (2006). Perception of bene-
ts and costs during SARS outbreak: An 18-month prospective
study. Journal of Consulting & Clinical Psychology, 74, 870-879. In
this study of persons who had recovered from SARS, family members,
CITATIONS continued
and healthy adults in Hong Kong, participants were asked about
costs and benets of the illness. Participants who identied benets
only had higher levels of defensiveness than those who identied
costs only or both costs and benets. Perceived benets given in
mixed accounts were uniquely related to future gains in personal
and social resources.
Dunigan, J. T., Carr, B. I., & Steel, J. L. (2007). Posttraumatic
growth, immunity and survival in patients with hepatoma.
Digestive Diseases and Sciences, 52, 2452-2459. In a study of 41
cancer patients, participants who scored above the median on
posttraumatic growth had higher PBL counts and survived 186
days longer than participants who scored below the median.
Edmonds, S., & Hooker, K. (1992). Perceived changes in life
meaning following bereavement. Omega: Journal of Death and
Dying, 25, 307-318. In a study of 49 college students who recently
experienced the death of a close family member, most reported
experiencing a positive change in life goals. Students who reported
positive change had signicantly higher existential meaning than
those who reported negative change in goals.
Elder, G. H. & Clipp, E. C. (1989) Combat experience and emotional
health: impairment and resilience in later life. Journal of Personality,
57, 311-341. In a sample of 149 World War II and Korean conict
veterans, heavy combat veterans were at greater risk of emotional
and behavioral problems in the postwar years than were noncom-
batants and light combat veterans. In mid-life, they hold mixed
memories of painful losses and life benets associated with military
experience. Clinical ratings show that heavy combat veterans
became more resilient and less helpless over time when compared
to other men.
Epel, E. S., McEwen, B. S., & Ickovics, J. R. (1998). Embodying
psychological thriving: Physical thriving in response to stress.
Journal of Social Issues, 54, 301-322. Using data from a laboratory
study of stress, the authors examined physical thriving by investi-
gating hormonal responses to stressful situations and the roles
played by psychological factors. Cortisol adaptation to stress may
serve as one potential marker of resilient psychological and physical
functioning.
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new
psychology of trauma. New York: Free Press. The author examined
the major tasks with which trauma survivors are confronted, including
the need to integrate the traumatic event into their experience and
render it less threatening. She also discussed the most effective kinds
of actions that can help survivors re-establish the means to cope.
Joseph, S., Williams, R., & Yule, W. (1993). Changes in outlook
following disaster: The preliminary development of a measure
to assess positive and negative responses. Journal of Traumatic
Stress, 6, 271-279. The authors described initial results (internal
consistency, relations to other measures) of a scale designed to
assess both positive and negative responses to disaster. Much of
the content for the measure was drawn from answers to open-ended
questions posed to adult survivors of a ship collision.
Citations continued on back cover
CITATIONS continued
Lechner, S. C., Stoelb, B. L., & Antoni, M. H. (2008). Group-based
therapies for benet nding in cancer. In S. Joseph & A. Linley
(Eds.), Trauma, recovery, and growth: Positive psychological
perspectives on posttraumatic stress (pp. 207-231). Hoboken, NJ:
Wiley. This chapter focuses on clinical implications of the research
on posttraumatic growth. In particular, the authors discuss the
ways in which the group milieu might help to promote growth but
conclude that the development of group-based interventions to
specically promote benet-nding is not yet warranted and may
involve risks.
Linley, P. A., Joseph, S., & Goodfellow, B. (2008). Positive changes
in outlook following trauma and their relationship to subsequent
posttraumatic stress, depression, and anxiety. Journal of Social
and Clinical Psychology, 27, 877-891. In a study of 40 traumatized
people who were interviewed twice over a six-month interval, the
experience of positive changes predicted lower levels of PTSD
symptoms, depression, and anxiety. The authors discussed implica-
tions of the ndings for clinical work with traumatized people.
McMillen, J. C., & Fisher, R. H. (1998). The Perceived Benets
Scales: Measuring perceived positive life changes after negative
events. Social Work Research, 22, 173-187. The authors presented
a new measure of self-reported positive life changes after traumatic
stressors. Factor analyses suggested that the Perceived Benet
Scales capture lifestyle change, material gain, and increases in self-
efcacy, family closeness, community closeness, faith in people,
compassion, and spirituality.
Milam, J. E. (2004). Posttraumatic growth among HIV/AIDS
patients. Journal of Applied and Social Psychology, 34, 2353-2376.
Correlates (n= 835 at Time 1) and predictors (n= 434 at Time 2) of
posttraumatic growth were examined in HIV/AIDS patients. PTG
was common—59% of participants reported having experienced
at least moderate positive changes since diagnosis.
Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment and
prediction of stress-related growth. Journal of Personality, 64,
71-105. This article reports the development of the Stress-Related
Growth Scale. In a longitudinal study of college students, stress-
related growth was predicted by (a) intrinsic religiousness; (b) social
support satisfaction; (c) stressfulness of the negative event; (d)
positive reinterpretation and acceptance coping; and (e) number of
recent positive life events.
Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation:
Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.
This volume addresses a variety of topics related to trauma and
posttraumatic growth including the religious and psychological
roots of suffering, research ndings on the negative and positive
consequences of trauma, and various factors that inuence coping
success.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth
Inventory: Measuring the positive legacy of trauma. Journal of
Traumatic Stress, 9, 455-471. The authors described the develop-
ment and uses of the Posttraumatic Growth Inventory, a 21-item
scale that includes factors of New Possibilities, Relating to Others,
Personal Strength, Spiritual Change, and Appreciation of Life.
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