What Doesn't Kill You Changes You: Clinical Considerations for Exploring Posttraumatic Growth

U.S. Air Force courtesy photo
By Alexandra Kelly, Ph.D.
November 15, 2017

In my experience, service members and veterans with posttraumatic stress disorder (PTSD) don’t resonate with the popular notion that “what doesn’t kill you makes you stronger.” In fact, individuals who present for PTSD treatment generally report feeling quite the opposite: fearful, unsafe, on edge, exhausted, isolated, and out of control. In addition to causing tremendous internal discomfort, their symptoms also meaningfully impact their occupational functioning and/or interpersonal relationships.

Meanwhile, given the salience of these symptoms and their negative consequences, service members with PTSD will very readily agree that “what doesn’t kill you changes you.” And this is – eventually, after a fair amount of time and treatment – the way that I begin a conversation about post-traumatic growth (PTG) with therapy clients. We (rightly) spend most of our time in treatment addressing the adverse effects of trauma, but it’s also worthwhile to explore whether, in the course of their recovery process, service members have also been changed in ways that they value and appreciate.

Our last blog introduced the concept of PTG. This blog discusses considerations for mental health providers in exploring the topic of post-traumatic growth with their patients.

One note before we proceed: it’s important to recognize that not everyone experiences PTG. PTG shouldn’t be considered a uniform treatment goal, nor does the absence of PTG mean that treatment hasn’t been effective.

Cognitive Engagement as a Necessary Condition

Traumatic events are so affecting because they often powerfully contradict previously held beliefs about oneself, other people, and the world. Recovery from trauma requires that service members undertake an active process of reconciling the event and its implications with their prior assumptions and worldview. PTG researchers label this process “deliberate rumination” to distinguish it from the intrusive and automatic cognitions that often arise in the aftermath of a traumatic experience.

This cognitive engagement is thought to be a necessary condition for posttraumatic growth. Some service members will undertake this meaning-making process spontaneously in the weeks and months following the traumatic experience, whereas others might benefit from the structure of an evidence-based treatment (EBT) and the support of a mental health provider. Cognitive processing therapy (CPT) centers on guiding service members through this process, but other EBTs such as prolonged exposure (PE) and eye-movement desensitization and reprocessing (EMDR) include elements of cognitive processing as well. The upshot is that service members may well experience PTG over the course of therapy, regardless of which EBT they elect to complete.

Of course, it is important to remember that PTG is not an explicit goal of treatment for PTSD. Rather, the objective of PTSD treatment is reduction in PTSD symptoms (as well as those of co-occurring mental health conditions). That said, PTG may well emerge as a by-product of a client’s engagement in treatment. It is also possible for providers to facilitate post-traumatic growth in their patients, though the timing of such interventions must be carefully considered.

Timing of PTG Discussions

It is natural for providers to be eager to explore areas of post-traumatic growth with their clients, but broaching this topic too early in treatment can damage the therapeutic relationship. Service members who are experiencing acute PTSD symptoms may feel unheard or invalidated by a provider who asks about the upsides of their traumatic experiences without first honoring the weight of the event itself and addressing their immediate presenting concerns.

Judith Herman’s model of trauma recovery offers useful guidance in considering the timing of PTG-related interventions. Briefly, Herman describes the recovery process in three phases:

  • Safety and Stabilization: normalizing PTSD symptoms, developing skills for handling distressing emotions, addressing self-harm, establishing safety in one’s physical environment, building trust in the therapeutic relationship

  • Remembrance and Mourning: discussing the details of trauma itself, processing trauma-related emotions and cognitions, mourning losses associated with the trauma

  • Reconnection and Integration: reconnecting with loved ones and community, incorporating the trauma into one’s larger life story, moving forward with a valued life post-trauma

Thematically, discussions of post-traumatic growth are most appropriate during the third phase of recovery; this would likely correspond with the final sessions of manualized treatments like CPT or PE.

Exploring and Facilitating PTG

Once we’ve acknowledged and worked to address the ways that clients feel changed for the worse by their traumatic experiences, it’s possible to support them in exploring ways they have grown in the course of their recovery. The following strategies may be helpful for discussing PTG during your treatment sessions with service members:

  • Listening and labeling: In the course of treatment, attend to statements that reflect positive change resulting from the recovery process, and label these as examples of PTG when spontaneously offered by clients. Keying into examples or metaphors that clients volunteer can provide an opening for a discussion of PTG and themes that you’ve detected in the service member’s narrative.

  • Focus on the struggle, not the event: When querying service members directly about PTG, it’s important to emphasize that valued growth results from the process of recovery from trauma, not from the traumatic event itself. One must be careful not to suggest, even inadvertently, that the trauma was ultimately a good thing. Instead, you might say to a client: “You’re never going to be glad that this happened to you, but now that you’re on the other side of it, I wonder if you see any changes in yourself that you appreciate, that you might not have experienced otherwise.”

  • Post-traumatic Growth Inventory (PTGI): The PTGI is a 25-item self-report instrument that assesses PTG in five domains: Relating to Others, New Possibilities, Personal Strength, Spiritual and Existential Change, and Appreciation for Life. The original edition is available online, and its authors recently revised the instrument to include a wider range of spiritual beliefs. Providers can administer the PTGI to clients as a starting point for discussion, or simply use the items to get a sense of what they might query service members about as they explore potential areas for growth.

Providers can also play a role in facilitating PTG. The following between-session or post-treatment activities may be helpful in promoting PTG:

  • Constructive disclosure: Service members who discuss their trauma with others and who share their associated thoughts and feelings have been found to have higher levels of PTG. Encouraging service members to open up to trusted, supportive others in their lives may help to facilitate PTG.

  • Models of PTG: Service members may be better able to recognize positive changes in themselves – or aspire to positive changes down the road – if they have access to stories of other survivors. Group treatment or online resources like the Real Warriors Campaign provide clients with examples of fellow service members who have grown in the course of their trauma recovery processes.

  • Writing exercises: Writing assignments can help service members integrate traumatic experiences into their larger life narratives, and can serve as another starting point for identifying themes of growth and positive change. Writing prompts might encourage service members to develop a narrative that frames the trauma as a catalyst or turning point, or to articulate an identity as a trauma survivor with strength and wisdom to share with others. It may also be instructive to suggest an ongoing writing assignment in which service members monitor changes in their thinking and values over the course of recovery.

Dr. Alexandra Kelly is a contracted psychological health subject matter expert at the Psychological Health Center of Excellence. She has a master’s degree in counseling & psychological services and a Ph.D. in counseling psychology. She specializes in trauma, vocational psychology, and multicultural counseling.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • I often end up asking service members this question: if I could give you a drug or offer you a surgery that would do away with all the memories you're here to talk about, would you take it? I have yet to have anyone say they would.

  • As a survivor of the cancer battlefield, I feel some comraderie with my veteran patients, I understand hating Pollyannaish sayings. We have often discussed how what doesn't kill you, leaves an icky scar. I had picked up some additional insights from my cancer mentors. First, sometimes the scar is stronger than the original tissue. Second, never be ashamed of your scars. It shows that you were stronger than whatever tried to hurt you.

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