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Book Forum: Stress: Positive and Negative Effects   |    
Posttraumatic Growth: Positive Changes in the Aftermath of Crisis
HOYLE LEIGH, M.D.
Am J Psychiatry 2000;157:1712-1712. doi:10.1176/appi.ajp.157.10.1712
View Author and Article Information
Fresno, Calif.

Edited by Richard G. Tedeschi, Crystal L. Park, and Lawrence G. Calhoun. Mahwah, N.J., Lawrence Erlbaum Associates, 1998, 258 pp., $34.50.

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Can trauma really be good? We are all familiar with posttraumatic stress disorder, but posttraumatic growth?

The Merriam Webster dictionary defines trauma as "a disordered psychic or behavioral state resulting from mental or emotional stress or physical injury," whose etymology is traced back to the Greek word for wound. Indeed, a wound may heal, and the once-injured body part may become even stronger; therefore, a certain amount of stress is perhaps not only inevitable but necessary for optimal personality development. Although there have been many anecdotal reports of major positive personality transformations after emotional trauma, Posttraumatic Growth: Positive Changes in the Aftermath of Crisis offers a systematic discussion of the phenomenon called posttraumatic growth.

The volume begins with a comprehensive discussion by the editors of the conceptual issues of posttraumatic growth, which they describe as both a process and an outcome. They see it as "developing out of a cognitive process that is initiated to cope with traumatic events that extract an extreme cognitive and emotional toll. These events that initiate posttraumatic growth have the quality of ‘seismic events’…on a psychological level." They point out that no single term has been used to denote the positive effects of trauma and propose to use the term "posttraumatic growth" for the phenomenon that different authors have called "positive psychological changes," "perceived benefits," "stress-related growth," "thriving," and "positive re-interpretation." They describe the types of growth outcomes in perception of the self (survivor versus victim, self-reliance, and heightened awareness of vulnerability), interpersonal relationships (self-disclosure, emotional expressiveness, compassion, and giving to others), and philosophy of life (priorities, appreciation of life, existential themes, sense of meaning, spiritual development, and wisdom). Important related concepts that may affect a person’s response to trauma are also discussed here, including resilience, sense of coherence, hardiness, stress inoculation, and toughening.

In chapter 2, "Assessment of Posttraumatic Growth," Cohen et al. describe the tools that have been developed to measure posttraumatic growth. These include interviews and paper-and-pencil measures, especially the Post-Traumatic Growth Inventory, developed by Tedeschi and Calhoun, and the Stress-Related Growth Scale, developed by Park, Cohen, and Murch. The Post-Traumatic Growth Inventory has 21 items that measure five subscales (relationship to others, new possibilities, personal strength, spiritual change, and appreciation of life). The Stress-Related Growth Scale has 50 items rated from 0 to 2.

Chapter 3, "A Developmental Perspective on Posttraumatic Growth," by Aldwin and Sutton, discusses the long-term effects of stress and trauma on humans and animals and includes a rather oversimplified discussion of some aspects of physiological arousal by stress. A conceptual framework the authors propose for posttraumatic growth is the deviation amplification model, which posits that the effects of a trauma are amplified in a positive feedback loop (as opposed to homeostasis) and result in change.

Chapters 4, 5, and 6 discuss personality, social contextual, and life-change issues associated with posttraumatic growth. Especially of interest to readers of the Journal is the discussion of posttraumatic growth and physical illness (HIV infection, cancer, and bone-marrow transplantation) by Schaefer and Moos (chapter 5).

Chapters 7 and 8 deal with the implications of trauma (and growth) for individuals and society. I was intrigued with Bloom’s chapter on the social transformation of trauma, by which she means the effects of trauma on individuals that may result in a social change. Examples include the establishment of such organizations as Mothers Against Drunk Driving (MADD), Physicians for Social Responsibility, Alcoholics Anonymous, and the Truth and Reconciliation Commission of South Africa.

The book concludes with a thoughtful chapter by Calhoun and Tedeschi, who state that a key element in a trauma may be its ability to "shake the foundations" of the individual’s assumptive world. They ask, "Does the amount of posttraumatic growth increase proportionally with the stressfulness of an event…or when the seismic power of the event reaches a certain threshold?" Exactly!

I believe that this is a good reference volume concerning the aggregate of phenomena that might be called positive aspects of stressful events. I am afraid that the term "posttraumatic growth" suffers from a conceptual confusion because of its attempt to denote and quantify two different things—the dramatic and unexpected positive outcome after a "seismic" event and the everyday positive outcome after minor stresses. The former is truly an unusual phenomenon, because posttraumatic stress disorder (PTSD) is not a variant of a normal stress reaction.

Incidentally, this volume is a part of the Personality and Clinical Psychology Series, whose editor is Irving B. Weiner. As the title of the series implies, most of the contributors to the book are psychologists, the source material is mostly from the psychology literature (with very few psychiatric citations), and its primary audience seems to be psychologists. As might be expected, there is very little discussion of the neurophysiological underpinnings of posttraumatic growth, which ought to be a very exciting area of investigation, especially in view of the recent discoveries in the neurobiology of PTSD.

Is there postinfection positive outcome? Surely, if one survives an infection, one acquires a certain amount of immunity, as well as the knowledge that infections can be overcome. However, if one survives a near-fatal infection and then grows 2 feet in height or is spontaneously cured of a preexisting pathology, then postinfection positive outcome requires a totally fresh look.

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