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The five major domains of Posttraumatic Growth that represent the variety of outcomes of the PTG process are described: Personal Strength, Relating to Others, New Possibilities, Appreciation of Life, and Spiritual and Existential Change. In addition, an overview of the PTG process is offered that emphasizes the roles of core belief challenge, rumination, disclosure, acting on people who have a variety of personality characteristics that may play a role in how they respond to the challenges they face posttrauma.
PTG can be both a process and an outcome. Whether it is considered to be one or the other may simply depend on where a person is standing in time. For example, positive reappraisals may be a component of PTG as a process, whereas an assertion that a person’s life has changed in a lasting and positive way may be more accurately conceptualized as an outcome. PTG as a process is initiated by an encounter with highly challenging life events, prompted by an initial challenge to one’s assumptive world or core beliefs, experiencing psychological struggle, coping with emotional distress and intrusive ruminations, and moving to deliberate or effortful ruminating about what has happened, accepting the world that is different from that of pre-trauma, and eventually realizing the experience of PTG.
This realization of PTG, that is the outcome, can be understood to refer, broadly, to a cluster of positive transformative changes that result from a complex combination of cognitive, emotional, and social processes (Tedeschi & Blevins, 2015). PTG is an outcome of these processes, reflected in the permanency of changes that have occurred. A sense of personal strength, for example, may not be identified during the initial process of psychological struggle, especially immediately after the triggering life event, even though it is a part of PTG, and only later may it be recognized as a consequence of struggle, and integrated into the new self. Thus, PTG as process and PTG as outcome may be sequential, as people engage in such processes as positive reinterpretation, positive reframing, interpretive control, or reconstruction of the narrative related to the event/s (Tedeschi & Calhoun, 1996).
Another consideration in this discussion of the processes involved in PTG, and of what outcomes are to be considered PTG, is that different researchers may focus on different indicators of growth. Some have insisted on observable behavioral changes as the only criterion for PTG (e.g., action focused growth: Hobfoll et al., 2007), whereas others focus on cognitive elements such as reorganization of one’s beliefs or assumptive world (Calhoun & Tedeschi, 2010), and others focus on changes in personality (e.g., positive personality changes: Jayawickreme & Blackie, 2014). PTG can be seen in all of these ways – cognitive, emotional, behavioral, and more recently, biological.
Although the conceptual model of PTG is sometimes categorized as a focusing on outcome (e.g., Zoellner &Maercker, 2006), it is still “an ongoing process, not a static outcome” (Tedeschi & Calhoun, 2004, p. 1). The process may take various shapes, such as a spiral, going back and forth in interactions with other systems, in a non-linear way (Lyon, Fisher, & Gracey, 2021).
PTG as an outcome, in some cases, may be quite sudden and may not involve an extended process. For example, consider patients who have experienced a severe heart attack. They may engage in a prolonged period of adjustment and reconstruction of their lives following this threat to their lives or, positive changes may come about quite suddenly, akin to an epiphany about life and what the future may hold. In that way it may sometimes be difficult to separate PTG as process from PTG as outcome. Having established a new path in life or made a career change that never would have otherwise been considered without experiencing a particular trauma may sound like an outcome; however, starting to explore a new path or career, that one did not consider before, may sound like a process.
Similarly, consider survivors who experienced a severe natural disaster, such as wildfire. They may have chosen the career of firefighter but they may deny any connections between their life experiences and career choice and have nor experienced any psychological struggle or rumination. Here the outcome may look like PTG but because of the lack of process, they would not label their experiences as “PTG”. Likewise, some people have experienced PTG processes and yet, might feel unsure if it leads to some PTG “outcome”.
A 1-year prospective study that investigated different patterns of PTG among people living with HIV, for instance, identified four trajectories (Rzeszutek & Gruszczyńska, 2022). By using a person-centered approach, the first was labeled as a curvilinear pattern, that starts with a moderate level of PTG, leading to a small increase at 6 months later, and then showed a small decline at 1 year later. The second was low stable, being demonstrated by consistently low levels of PTG throughout the year. The third was the opposite, high stable, consistently high levels of PTG. And, the fourth was called a rapid change, showing a dramatic change from the baseline to a 6 month later, then being stable at 1 year later. The researchers of this particular study focusing on the various PTG trajectories concluded that there is no single pattern of PTG that fits all people living with HIV. It is important, then, to pay attention to the overall context, rather than focusing on a single statement, in order to capture both process and outcome elements of PTG (e.g., Hefferon, Grealy, & Mutrie, 2010; Shakespeare-Finch & Barrington, 2012).
Early studies of PTG focused on an examination of PTG experiences as outcomes (Calhoun & Tedeschi, 1989-1990; Tedeschi & Calhoun, 1988; Tedeschi, Calhoun, Morrell, & Johnson, 1984). Based on these early studies, a quantitative measure, the Posttraumatic Growth Inventory (PTGI) was developed (Tedeschi & Calhoun, 1996). The items for this measure were based on quotations from recorded interviews and from a thorough review of the literature available at the time, and they represent self-recognized PTG outcomes. A number of qualitative studies have since been published which demonstrate a high degree of consistency in the kinds of positive posttrauma outcomes that are captured by the PTGI; at the very least are broadly representative of the construct (Kampman, Hefferon, Wilson, & Beale, 2015).
Some studies have considered whether different types of events may lead to different patterns of PTG. For example, circumstances that involve disability or illness may lead to a new way of relating to one’s own body and engagement in health-promoting behavior (Hefferon, 2013). Similarly, circumstances that involve loss of a loved one may sometimes lead to positive changes in health values and reduced alcohol usage among college students (McDiarmid, Taku, & Phillips, 2017). We will consider the role of trauma type later, but in keeping with the more general theme of PTG as a transformative experience that has common themes, we can describe PTG outcomes in a few different ways. Prior to the development of the PTGI, growth outcomes were described in three general areas: changes in relationships with others, philosophy of life, and views of the self (Tedeschi & Calhoun, 1995). Later, with the development of the PTGI, statistical analyses, such as factor analysis, yielded five domains: appreciation of life, personal strength, new opportunities, relating with others, and spiritual change (Tedeschi & Calhoun, 1996), although the fifth domain, spiritual change, was expanded as spiritual and existential change to be more inclusive (Tedeschi et al., 2017). A more detailed discussion of the measurement of PTG will focus on these five domains, and the degree to which they have been empirically supported in subsequent work. However, there is enough support that we can illustrate the concept of PTG outcomes using these five dimensions here (e. g., Morris, Shakespeare-Finch, Rieck, & Newbery 2005; Taku, Cann, Calhoun, & Tedeschi, 2008; Tedeschi, Cann, Taku, Senol-Durak, & Calhoun, 2017).
The outcomes are domains of life where people grow.
This domain can be summarized in the phrase - "I am more vulnerable than I thought, but much stronger than I ever imagined (Calhoun & Tedeschi, 2006, p. 5)”. PTG can be experienced by an increased sense of self-reliance, a sense of strength and confidence, and a perception of self as survivor, thriver, or victor, rather than “victim.” It can also involve the idea of having survived the traumatic event that could have literally or figuratively killed them. This is a sense that there’s nothing a person feels they cannot do, which can then lead to behavioral changes, such as a newfound engagement in the challenges of learning something completely new (Shakespeare-Finch & Barrington, 2012).
This domain reflects the experience of positive changes in relationships (e.g., PTGI items “being more compassionate;" "feeling a greater connection with others”). Not only the relationship itself, but one's attitudes or behaviors in relationships may be changed in positive ways (e.g., PTGI items "more willing to express emotions;" "more willing to accept help from others"). It also includes making a conscious decision to spend more time with family and friends, telling them how much they are loved and valued (Shakespeare-Finch & Barrington, 2012; Washburn, 2011). Changes in relationships are also evident in accounts of PTG that include decisions to move on from relationships that were no longer seen as positive or meaningful. Changes in this way may also be connected to changes in personal strength. For example, following a stillbirth, a mother said that the experience acted as a catalyst to reevaluate her life and her relationships to include only those people that she perceived to give her the support she needed and deserved (Krosch & Shakespeare-Finch, 2017). Such decisions about relationships have also been found in survivors of natural disasters. For example, following devastating bushfires that killed 173 people, one woman, nodding toward her husband conversing with a neighbor at their fenceline said -- “We never really spoke (to the neighbor) before the fires, in fact he was quite rude – that’s all changed now” (Shakespeare-Finch, 2009).
This domain can be seen in the individual's identification of new possibilities for one's life or of the possibility of taking a new and different path in life (Tedeschi & Calhoun, 2004). It also can be experienced by developing new interests, new activities, new habits, or by building a new career that would not have been a part of one's life if there were no trauma in the first place. For example, those who have faced a life-threatening illness often report positive changes in health behavior (Morris, Campbell, Dwyer, Dunn, & Chambers, 2011), and people who have been bereaved may decide not to wait until retirement to embark on the travel they have always wanted to do. Others have reported changes in career path and greater involvement in community groups (Shakespeare-Finch & Barrington, 2012). The aftermath of trauma may provide people with a sense they are called to address the kinds of circumstances they have gone through by making changes in their personal and work lives so that they can be of service. The sense of being called to this service may also connect this kind of outcome with the domain of spiritual and existential change, illustrating that the domains of PTG are not sharply separated in people’s experience.
This domain includes a greater appreciation for all the things that life has to offer, be they small things previously taken for granted or a greater appreciation for things that people still have in their lives. Because of what has happened, some people may see life as the gift of a second chance that should be cherished. People may report, for example, that having to deal with a major stressor has made them realize that it is important to spend more time on their intimate relationships, to appreciate each day, and its small pleasures more, to take life easier and to simply be more aware and appreciative of their environment. Thousands of conversations with people who have experienced traumatic events indicate that a common PTG theme is about noticing things that, for most people, are simply incidental to daily existence -- a sunset, a clear blue sky, a beautiful flower, or other things that were in a person’s landscape that they simply had not taken the time to deeply appreciate before. Of five PTG domains, the appreciation of life has been most frequently reported by people who experienced various life events, such as terrorist attacks (Ikizer & Ozel, 2021), health issues (Triplett, et al., 2022) and COVID-19 pandemic (Ellena et al., 2021), as well as by older adults (Kadri et al., 2022).
This domain reflects the experience of people who are religious, but also the experience of people who are not, including agnostics and atheists. In the original PTGI (Tedeschi & Calhoun 1996), only 2 out of 21 items reflected this domain -- one that asked about spiritual changes and one about religious change. The extent to which people endorsed such changes varied across cultures (Weiss & Berger, 2010), and subsequent research around the world indicated a need to increase and broaden the items assessing this domain to reflect a broader concept of spiritual and existential changes. The PTGI was then expanded to include a broader, and more cross-culturally applicable set of items relevant to this domain. Four items were added, that include the measurement of existential aspects of these changes. This 25-item expanded version of the PTGI includes items that ask about reflections on interconnections with others, harmony, and mortality (Tedeschi, Cann, Taku, Senol-Durak, & Calhoun, 2017). This domain now reflects an engagement with matters related to religious beliefs, spiritual matters, and existential/philosophical questions.
The term “pathways” can refer to the results of statistical model found in path analysis or structured equation modeling, but the term may also refer to possible avenues to PTG suggested in the model. Here we focus on the latter. The model of PTG that has evolved since 1995 (Calhoun, Cann & Tedeschi, 2010; Calhoun & Tedeschi, 1998; 2006; Tedeschi & Calhoun, 1995, 2004) emphasizes how PTG originates from psychological struggle with a highly stressful or traumatic event.
Circumstances that are precursors to PTG are those that challenge one’s assumptive world or core beliefs. The emotional and cognitive challenges that emanate from such disruption of core beliefs give rise to a path with multiple specific aspects through which intra-individual (i.e., emotional or cognitive processing) and inter-individual (i.e., social or contextual) factors that are likely to influence PTG. As suggested in the PTG model, there are specific factors that can operate within the general pathway. For example, PTG progress is assumed to be influenced by the characteristics of events as well as pre-trauma individual differences.
The PTG model also indicates that the way one experiences a traumatic event is critical. This involves whether the event is impactful or seismic enough to challenge one’s cognitive schemas, how relevant or central the event might be to the person’s core beliefs, how emotional distress is managed in the initial time post-trauma, what kind of characteristics people or the triggering event itself contain, how ruminative thinking occurred and how the characteristics of rumination were changed over time, how self-disclosure through writing or talking was activated and the responses of others to disclosures which socio-cultural contexts affect this whole process, how life narratives have been developed, how the post-trauma world is accepted or integrated into one’s identity, and how the ongoing distress is managed, which, in turn, all affect PTG process as well as PTG outcomes.
It is important not to consider PTG as the opposite of PTSD, as the moderate levels of distress are generally associated with the highest levels of PTG, being demonstrated by a curvilinear relationship (Shakespeare-Finch & Lurie-Beck, 2014). More recent study (Dar & Iqbal, 2020) also found a critical period, between 18 and 24 months since trauma, at which the inverted U-shaped curvilinear effect is manifested.
These aspects of the general pathway to PTG will be fully described later.
Because the model of PTG is comprehensive, multiple factors exist within it. For example, the model shows parallel relationships between PTG development and narrative development/reconstruction – although this relationship is common (Jirek, 2017[RT1] ), multiple specific pathways can exist depending on whether a person is introverted or extraverted, whether the damage is caused intentionally or not, whether or not the person engages in disclosures about the events to other people, the kinds of responses others give to such disclosures, and how cognitive processing is activated. For example, persons with different personality dispositions, such as dispositional mindfulness, may respond to traumatic events in ways that lead to different effects on core beliefs (Huang et al., 2022). Another personality trait, hardiness, especially a commitment to live, has been reported to be associated with PTG, regardless of the ways people experienced trauma, such as direct exposure or indirect exposure (Altinsoy & Aypay, 2023). Persons with different attachment styles may also experience PTG in a different way (Captari, Riggs, & Stephen, 2021). Persons with different sets of core beliefs may be more or less likely to have such beliefs challenged, decimated, reconstructed, modified, or strengthened.
Evidence supporting the influence of the elements included in the PTG model can be found in many studies. For example, Cann et al. (2011) found strong support for the proposed pathway to PTG through challenges to core beliefs, intrusive rumination, and deliberate rumination. Similarly, the pathway to PTG through deliberate rumination and social support has also been supported (Morris & Shakespeare-Finch, 2011). During the COVID-19 pandemic, these pathways were once again replicated, emphasizing the importance of core beliefs disruption and social support (Dominick et al., 2022). Pathways to PTG through positive coping, such as problem-focused coping, emotion regulation strategies (including accessing instrumental and emotional social support, prayer, positive reinterpretation, and acceptance), have also been found (Park, Aldwin, Fenster, & Snyder, 2008). A pathway to PTG after events that include a significant interpersonal transgression, such as infidelity, physical harm, or betrayal, has been found to occur through forgiveness, religiosity, and spirituality (Schultz, Tallman, & Altmaier, 2010). Meta-analytical findings that time since the event does not seem to significantly affect PTG may also support the possibility of multiple versions of the process that leads to PTG (Prati & Pietranton, 2009); some people may show signs of PTG very early following a traumatic or highly challenging experience whereas the road to PTG may take years for others to traverse.
It is interesting to note that although PTG research has been undertaken across the globe for approximately 30 years now, there are still many parts of the puzzle that are unclear.
Other researchers have also looked at factors that are key to the PTG model and considered them in relation to both PTG and posttraumatic stress symptoms. For example, deliberate and intrusive rumination, the centrality of the events, and controllability were examined as predictors of PTG and posttraumatic stress (PTS) symptoms in a sample of 250 people who had experienced various kinds of traumatic experiences (Brooks, Graham-Kevan, Lowe, & Robinson, 2017). Their results showed significant pathways of all predictor variables on PTG and distress. The model accounted for 68% of variance in distress and 30% in PTG. Intrusive rumination had the strongest relationship with PTS (Standardized coefficient = .66) whereas a sense of control in the present (.41) and event centrality (.40) had the strongest relationship with PTG.
It is interesting to note that although PTG research has been undertaken across the globe for approximately 30 years now, there are still many parts of the puzzle that are unclear. Just as Brooks and colleagues were able to account for more than double the variance in posttraumatic stress systems than PTG, Gul and Karanci (2017) accounted for 64% of variance in PTS scores and only 40% in PTG scores using multiple predictors including coping, rumination, social support, extraversion, openness, conscientiousness, neuroticism, agreeableness, previous history of psychiatric problems, and various demographic variables. There was a significant correlation between PTS and PTG scores in their study of 740 community participants in Turkey but the coefficient between them of .14 indicates a negligible to weak relationship accounting for very little variance.
The differential predictors of PTG and PTS symptoms further supports the relative independence of these constructs in many studies and varying cultural contexts. It is important to remember that the pathways to PTG are not the same as the pathways to recovery from post-traumatic stress symptoms. Although these pathways may overlap with one another, experiencing PTG and alleviating posttraumatic symptoms of distress do not necessarily have parallel processes. And yet, in a long term, PTG experiences are likely to affect the ways to handle PTSS.
For example, a study with service members showed that the more PTG reported, the less suicidal ideation reported (Bush et al., 2011), replicating the study that was conducted with adolescents who experienced the Sichuan earthquake in China that also showed a negative association between PTG and suicidal ideation (Yu et al., 2010). These studies converge to the similar findings that PTG may serve as a protective factor against suicidal thoughts. Thus, even though the PTG process and recovery process are not identical, they can influence each other.
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