We are often told about people’s capacity to thrive after trauma – but these claims may put unnecessary pressure on survivors.

Eranda Jayawickreme was born in London but grew up in Sri Lanka during the 80s and 90s, in one of the most turbulent periods in its history. He witnessed the insurrection by the People’s Liberation Front, and the ongoing civil war with the Liberation Tigers of Tamil Eelam.

“There was a lot of violence,” he says. “But growing up with so much adversity and trauma going on around me, I was often struck by the extent to which people somehow managed to ‘keep on keeping on’ in the wake of all these bad experiences.”

When he moved to the US to study psychology at university, it was perhaps only natural that he would be drawn to the science of human resilience. Jayawickreme was particularly fascinated by the concept of “post-traumatic growth”. This is the idea that many people not only recover from life-shattering events, but also experience a positive transformation in their values, actions and relationships. The research seemed to affirm Nietzsche’s aphorism that “what doesn’t kill me makes me stronger”.

The intuitive appeal of the concept is obvious – and it has been promoted in numerous magazine articles and books, including Sheryl Sandberg and Adam Grant’s best-selling book Option B. As Jayawickreme delved into the research, however, he found that the truth was much more complicated than some of the media coverage would suggest – and that many of the scientific studies themselves may have serious flaws.

Jayawickreme’s conclusions are nuanced, but it now seems increasingly likely that the reported prevalence of post-traumatic growth has been exaggerated. This is not just nit-picking or pessimistic naysaying: it might have serious consequences.

“In some cases, this narrative around the potential to grow could be oppressive,” says Jayawickreme, who is now a professor of psychology at Wake Forest University in North Carolina, US. “It creates the expectation that not only do I have to recover from what happened to me, but apparently, I'm supposed to become better than ever before.” And this pressure, he thinks, could lead to worse mental health outcomes for some individuals.

The phoenix from the ashes

Nietzsche may have hinted at the existence of post-traumatic growth (PTG) in the 19th Century, but the scientific study of the phenomenon only emerged in the 90s, with pioneering research by the psychologists Richard Tedeschi and Lawrence Calhoun. To measure PTG, they asked participants to consider how they felt now, compared to how they felt before their trauma, in five domains: appreciation of life, relationships with others, new possibilities in life, personal strength and spiritual change. They then had to estimate how much of that change was linked to the trauma itself.

As one example, they cited the words of Rabbi Harold Kushner, describing his life after the death of his son:

I am a more sensitive person, a more effective pastor, a more sympathetic counsellor because of Aaron's life and death than I would ever have been without it. And I would give up all of those gains in a second if I could have my son back. If I could choose, I would forego all of the spiritual growth and depth which has come my way because of our experiences... But I cannot choose.

Such accounts suggest a positive transformation that goes far beyond recovery and coping. “Post-traumatic growth is not simply a return to baseline – it is an experience of improvement that for some persons is deeply profound,” Tedeschi and Calhoun wrote in one of their early papers.

Subsequent research found evidence of post-traumatic growth in the survivors of many different crises – including relationship break-ups, bereavement, cancer diagnoses, sexual abuse and immigration from war zones. And it seemed to be astonishingly common, with some estimates suggesting that as many as 70% of trauma survivors might experience PTG.

Along the way, the researchers have had to understand how post-traumatic growth emerges. Amy Canevello, a psychology professor at the University of North Carolina, US, describes it as a constructive process. “Trauma shatters your worldview and disrupts your core beliefs,” she says. “And post-traumatic growth, at least theoretically, is the result of you trying to put your worldview back together in a way that incorporates that traumatic event. You come out the other side looking different in some way.”

Supporting this hypothesis, Canevello has found that levels of post-traumatic growth tend to correlate with levels of rumination after the event: the more people think about it, the more likely they are to see a positive transformation. At first, these thoughts may be intrusive and unwanted, she says, but over time the thinking can become more controlled and reflective. “It allows you to start cognitively putting those pieces together and make sense of the event.”

Some people reporting post-traumatic growth describe enormous grit and determination to come to terms with their adversity. Ann Wild was born with a congenital spine condition and describes experiencing a series of traumas as a result of her disability and the medical procedures that she has endured – the last of which has resulted in complications that may prove fatal in the years to come. She competed in five Paralympics, has an OBE and works as an occupational therapist.

Trauma shatters your worldview and disrupts your core beliefs – Amy Canevello
“I was constantly growing as a person and always held the principles of independence optimism, gratitude and kindness,” she adds. “Although I don't follow an organised religion, I have a deep unwavering spirituality and faith in what I do in the world and what I can achieve past the limitations of my impairments… I think for some people it takes trauma to make us realise our potential.” Wild recognises that many people do not see that growth, however.

Positive illusions?

The researchers studying post-traumatic growth have been careful not to dismiss the pain of overcoming adversity. “It certainly isn’t all sunshine and rainbows,” says Canevello. “It means that you have come out the other side of this thing – that you are having these growth experiences, despite the stress.”

This message is sometimes lost in the media coverage and public understanding of post-traumatic growth, however, which can focus on the inspirational elements of the phenomenon. “The concept lends itself to a pretty ‘Pollyannaish’ understanding of recovering for adversity,” says Jayawickreme.

Jayawickreme’s main concern, however, regards the specific scientific methods behind the research and the way that post-traumatic growth is most commonly measured – problems that he recently outlined in a book for Oxford University Press. He does not doubt that some people experience a positive transformation after trauma, but believes that these flaws have led us to overestimate how likely that is to happen.

One issue is the phrasing of the survey items. Almost all studies use the “Post-traumatic Growth Inventory” (PTGI), in which participants are asked to consider a series of statements describing potentially positive changes and then report how often they have experienced them, from 0 (“I did not experience this change as a result of my crisis”) to 5 (“I experienced this change to a very great degree as a result of my crisis”).

“You can't report a change for the worse,” says Jayawickreme. This could prime people to report growth, he says. (In general, participants may be reluctant to circle 0 for every single question.)

He points to one study from 2015 that looked at people’s responses to the earthquakes in Canterbury, New Zealand, in 2010 and 2011. In these surveys, the participants were given the option of reporting negative as well as positive change – and the evidence for widespread post-traumatic growth was much less convincing than the standard studies.

Then there is the potential for memory bias to skew the results. To complete the PTGI, the participants have to look back and compare how they were before the trauma with their current state. They must then evaluate how much of that change was due to the adversity they had faced. “It’s assuming that someone can accurately calculate their change, and its cause, and my guess is that most people aren't able to do that,” he says.

Human memory is notoriously unreliable, after all, and previous research suggests that most people are naturally inclined to find improvements in their personalities over time – even when there is little reason to think it has actually occurred.

The best way of demonstrating actual growth would be to survey people before and after the traumatic event. Unfortunately, very few studies of post-traumatic growth have done this – but the results of those that have are telling.

Consider a paper by Patricia Frazier, a professor of psychology at the University of Minnesota, which examined a sample of more than 1,500 students. At the beginning and end of the study, the participants completed various in-depth questionnaires that measured the domains that are thought to be positively affected by adversity, such as appreciation of life and the state of their relationships.

One hundred twenty-two of the participants reported some kind of trauma, such as experiencing a life-threatening accident or the death of a close friend, over the two months the study took place. By comparing their responses at the start and end of that period, the researchers were able to work out if any actual psychological transformation occurred, and compared this to the participants’ perceived growth, measuring at the end of the study with the PTGI.

Despite the fact the study had only lasted a couple months, many of these people did indeed report positive change using the PTGI. Yet those responses did not generally reflect an improvement in any of the psychological measures taken at the beginning and end of the study period.

Such a discrepancy would seem to support Jayawickreme’s suspicion that many of our estimates of PTG prevalence may be flawed, and do not reflect the number of people experiencing real psychological transformation.

You might wonder whether the perception of growth after a trauma could help people to cope; perhaps it’s healthy to try to see some positive outcome from adversity. In reality, PTG may be associated with a higher risk of mental illness. One study examined soldiers deployed in Iraq for 15 months after they had returned home from service. The soldiers who reported greater post-traumatic growth five months after their return tended to show worse symptoms of PTSD at the end of the study.

This suggests that for some people, the false perception of growth may be an unhelpful way of processing trauma. If so, we should be especially wary of encouraging people to see positive transformations resulting from their trauma.

Shades of grey

Jayawickreme is not alone in these concerns, though many researchers continue to believe the standard questionnaires measuring post-traumatic growth have captured something meaningful. “There’s a split view in the literature,” says Dr Matt Brooks, a lecturer in psychology at Manchester Metropolitan University in the UK.

In his own work exploring PTG, Brooks has found that some people who report experiencing post-traumatic growth in questionnaires also describe ongoing difficulties arising from their adverse experiences. They might still struggle to leave the house, for example, or report suicidal ideation. In such cases it is natural to wonder whether the perception of positive change is illusory or may even reflect a dysfunctional coping strategy, he says. “But for some people certainly, there is a transformative change,” he adds. He describes people who have come to reassess their basic values, so that they change jobs, travel the world or commit themselves to charity work. “They've channelled [their distress] into something positive.”

Dr Hanna Kampman, a senior lecturer in psychology at the University of East London, takes a similarly nuanced view. “We have a major responsibility in how we present the theory,” she says, “so that it doesn't come with additional pressure for somebody who has already gone through a very difficult time.” It could be particularly damaging, she says, if the discourse on post-traumatic growth means that others start to expect people to recover too quickly.

Kampman is also concerned about our culture veering in the opposite direction, however – so that the potential for resilience and growth is completely neglected. Her research investigates post-traumatic growth in people with acquired disabilities, which many people may only associate with vulnerability and weakness. “It’s very important that we also show the other side – that some people are excelling and challenging themselves – rather than just focusing on the expectation of suffering.”

Future research – using better designed experimental methods – should help to resolve the uncertainty about the real prevalence of post-traumatic growth, and the factors that might help people to process their crises. With this knowledge, therapists should be better able to tailor their conversations with their clients and to guide them through their recovery.

In the meantime, we need to remember each individual’s experience is going to be very different and must be judged on its own terms. The priority should be providing whatever support they personally need to come to terms with their trauma, whether they are reporting distress or growth – or both at the same time – without imposing a narrative on their recovery.

BBC

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