The post‐traumatic growth approach to psychological trauma

Over the years, it appears that the profession of psychiatry has become increasingly wedded to diagnostic systems such as the ICD and DSM, and to biological interventions. The major professional mental health organizations have recognized manualized "evidence-based" forms of intervention as the standard for treatment of traumatic syndromes such as post-traumatic stress disorder (PTSD). But there have been challenges to these approaches1, and here we offer an alternative. In the mid-1980s, L. Calhoun and I were interviewing people who had experienced serious physical disabilities in adulthood or traumatic grief. Listening to their stories and performing content analyses led us to examine places in the literature of psychological trauma where there were reports of surprising personally transformative outcomes. We ultimately coined the term "post-traumatic growth" as a descriptor of these experiences. In subsequent qualitative and quantitative research, we were able to identify five domains of post-traumatic growth: improved relationships with others, new possibilities for the life path, a greater appreciation for life, a greater sense of personal strength, and new perspectives on spiritual and existential issues2, 3. The burgeoning research on post-traumatic growth has yielded a model of the process by which people respond to trauma and develop these transformations over time3. It has become evident that an important aspect of this process is the challenge to the system of core beliefs or assumptive world that people maintain without questioning until events occur that appear to make that system untenable. In fact, the challenge to the core belief system or assumptive world can be a new way to define trauma, rather than making reference to certain types of events. The assumptions people have made about their identity, life path, morality, vulnerability, and the predictability and benevolence of their world are shattered by events, and this creates anxiety and cognitive disorientation. The intrusive rumination that is then set in motion may be harnessed into a more deliberate reflection on core beliefs, and a reconstruction that can lead to post-traumatic growth. This deliberate rumination is what mental health professionals need to attend to in order to facilitate the best outcomes in the aftermath of trauma. If we organize our post-trauma interventions around this post-traumatic growth model, we no longer focus on symptom reduction or even the traumatic events themselves. Though we do not ignore these sources of distress, we recognize that, in the long run, the distress will diminish or be better tolerated when people develop ways to live based on the perspective that their suffering is not in vain but a teacher of sorts about life's meaning and purpose. The traumatic events that they have experienced do not provide this meaning, but represent an opportunity to reconstruct a system of core beliefs that yields a life of purpose, where the trauma survivors see their value and are more devoted to a mission they find meaningful, as it benefits others as well as themselves4. We have developed programs based on post-traumatic growth theory and research to serve military service members and veterans as well as first responders who have been faced with trauma in personal and professional life. These programs are operated by peers and use various educational and experiential elements to promote post-traumatic growth and define a way of living a healthy life of service to others. We call this approach, which in some ways challenges the usual model of trauma treatment, and in some ways integrates elements of the usual model, "expert companionship". The philosophy that underpins this approach is rooted in an understanding that trust and connection with helpers is of crucial importance, and the peer-based program is very compatible with this. There are five elements to this approach: education about trauma response, especially the role of core belief disruption; teaching emotional regulation strategies, especially meditation and calming; disclosure of trauma memories; development of a narrative that encompasses positive aspects of the self as well as a life course perspective that integrates trauma experience; and a plan for turning traumatic life experience toward a way to be of service to others. Our research on this approach is showing remarkable indications of post-traumatic growth, while symptoms of PTSD are greatly reduced as well5. There are some important lessons that we have learnt as we have been designing, revising and evaluating our programs over the past several years6. First, we continue to listen closely to the people served by the programs as we develop them. This is an extension of the original approach to our research on post-traumatic growth, in which we started with interviewing trauma survivors and understanding their stories in depth. Furthermore, we are convinced that these programs have a greater impact when we use peers to deliver them, and that a group approach is very helpful in showing people that they are not alone in their struggles. Trust is more quickly developed as our participants find that they are intuitively understood by those trying to help, and that others have similar experiences. Second, we use concepts and language that immediately convey respect and recognition of strength. Instead of calling the program "treatment", we call it "training". Instead of "patients" or "clients", the participants are "students". About the symptoms they experience, we explain, "it is not what is wrong with you, it is what happened to you". We educate about post-traumatic growth, and we train the students in emotional regulation strategies such as meditation and breath control. We encourage disclosure of their stories in ways that emphasize that they are writing their own life narrative going forward. We help them see how they support each other in the group, and that they have valuable experience, capabilities, and emerging understanding of themselves and trauma's effects that they can use in service to others. We have also seen that providing continued support to the students in the months following those spent in the program is necessary to build on what has been started. We do this with a careful and creative use of technology to teach more and keep our students connected with their peer trainers and their cohort. These lessons and this innovative approach to trauma intervention, we believe, is a pathway to a more humane and effective way to help a variety of trauma populations. The post-traumatic growth process is very similar no matter the originating traumas7, 8. What is necessary is for expert companions to be an essential part of the response to trauma survivors and to appreciate the opportunities for much more than a recovery. Trauma changes people, but the changes do not need to be diminishment. They are more likely to be growth.