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‘Instead of ignoring loss and trauma, or moving quickly pass them, we can choose to slow down, sit with each loss, examine it and grieve it. It’s better to sink in and experience it now, than to find yourself drowning years later in losses that had no voice.’ Christina Hibbert Psy.D.
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I work as a counsellor in the Hospice supporting the dying patient, their families and close friends. This can be working naturally with the process of grief, denial, anger, bargaining, depression and acceptance (Kubler-Ross 2005) clients will sometimes hold onto these phases and become upset if they are not moving through them in order. I find it is important to client to understand that we all grieve differently and may not need to go through all the stages it may depend on the death. There are many tools used in grief work, the whirlpool of grief (Wilson 1993), the Dual Process Model (Strobe and Schut 1999) and Growing Around Grief (Tonkin 2006). I have used these quite successfully in one to one and group settings and this has helped the client understand some of what they are going through to be natural. Yet in the Hospice things are rarely that simple as even the most comfortable of deaths can leave family members traumatised, the last breath, the drop of the head or the simple fact of seeing their loved one no longer breathing. In the beginning, I found this challenging I was surprised there is so much trauma in the room related to bereavement counselling everyone grieves uniquely but it is the way people grieve that is interesting. Some clients a couple of sessions in the therapy room and some need far more. This is where I became interested in the trauma and the relation of past trauma reappearing when someone suffers a loss. Throwing myself into the world of research I found Post Traumatic Growth (PTG) and this not only inspired me but excited me into how I could improve my work with my clients experiencing this phenomenon.
This led me to ask many questions ‘What evidence is prevalent for a therapist to notice the beginning of Post traumatic growth?’ What is PTG (Post traumatic growth) and does it work for everyone? And Where did it originate and how are therapists working with it today? I researched 18 articles, papers, journals and books to explore the phenomena to enable me to enhance my knowledge and practice as a bereavement counsellor. The selected papers for this review covered from 1998 to 2013 that answered aspects of my question to obtain a broad range of information covering the history to present day. The excluded papers were not linked to bereavement although they have increased my knowledge regarding PTG. In the research I would also like to identify the obstacles and complexities ‘if any’ with PTG to help me to become more aware of pit falls and where a change of practice may be required.
The papers selected are a variety of journals (peer reviewed), a meta-analysis, articles and systematic reviews. Also books exploring the subject of PTG and Bereavement. The review will not explore other studies not related to bereavement.
The general findings have been informative, the papers explored the implications of practice of PTG for clinicians, growth verses depreciation, what contributes to PTG, pathways to PTG and finishes with a systematic review of PTG following a bereavement. The availability of sources were overwhelming and this proved difficult in the beginning to select the most valid papers for my research question.
Beyond Recovery From Trauma: Implications for Clinical Practice. This Journal is of interests to the research question as it not only explores working with trauma through to PTG but discusses some of the implications that can occur for the therapist. The hypothesis explores how growth develops in four areas relating to psychological well-being, distress and growth, the implications in this field work, the process of working with PTG and suggestions for further research.
Psychological Well-being and Psychological thriving.
It is stated that individuals suffering with trauma perceived growth through three domains, changes in perception of self, changed relationship of others and a changed philosophy of life (Tedeschi and Calhoun 1996-98). The literature hypothesis that growth can emerge after trauma and that process is unique to the individual. In a study by Lehman, Lang, Wortman, and Sorenson (1989) they explored the long-term effects of family adjustment to sudden, unexpected bereavement. They found that 29% of parents whose child died in a car crash felt their marriage had become stronger, 32% stated their relationship with their other children had improved and become closer after the death of a child or spouse. This raised a question of looking at relationships of well-being and distress on the one hand and benefits and growth on the other. Park 1998 expressed the results are not consistent across studies. Joseph, Williams And Yule (1993) argued that there was not a reliable connection between growth and adjustment. At this point there was very little research, therefore only speculation that of what recovery from growth looked like was being argued.
Conceptualising Thriving in Clinical Contexts.
In this part of the journal accepting the limited resources on the research of PTG the writers changed direction to explore the traumatic events that initiate the process of growth. This was key for me as I wanted to be able to identify growth in the therapy room. It is stated that PTG has the same elements of psychological distress therefore recognising that both distress and growth coexist. This appears to be the case in bereavement, where the death of a loved one can shatter the life of the individual left behind and the rebuilding of ones’ new future begins. Persons who must face bereavement may also experience significant psychological growth (Calhoun and Tedeschi, 1989-90; Yalom and Lieberman, 1991) but the psychological pain associated with the loss may persist. It is stated the clinician needs to keep in mind that coping and growth are not the same, it is through coping that the individual will be able to experience growth.
Elements of treatment.
In the case of trauma the client needs to feel safe and secure with the therapist and that of the therapist too, the explicit dialogue of the client will need to be explored and this can be incredibly difficult to be spoken and heard therefore a solid relationship will need to be established before the process can begin. It is important to remember that growth may occur in some areas and not in others for e.g. new possibilities for the future but not in relationships with others as previously thought. There is a balance between positive and negative forming in the literature.
The Study towards Wisdom.
Tedeschi and Calhoun gives the example to manage trauma one must be active, yet let time take it’s course; one must accept help, yet recognize that no one else can manage the trauma; one must acknowledge that the trauma must be left in the past but also woven into the future. Survive then thrive. (Tedeschi and Calhoun 1998).
Growing by Explaining.
The author states, that the final stage of growth is when the individual is able to retell the event to themselves and others. It is important that the process of the narrative development can retold by the individual comfortably, understanding the trauma is in the past but still a part of their life without affecting the future.
In this literature it states that there is little available evidence at this point as to if the clinician can in fact influence PTG in the individual and it is suggested that the following are general considerations; working with the clients belief systems (spiritual, religious), preparation for and willing to support the individuals perception of thriving and withstanding the temptation to rush the process.
Research with Clinical Implications.
Being early on in the research into this topic there were a few questions for future research that evolved from this review, how can the growth be measured? So far the measurements have been recorded by assessments of self-reported growth. To further these findings Tedeschi and Calhoun would like to include increases and compassion and altruism, relationships and solving life problems. This is covered later in this review. Secondly a longitude study exploring ruminative cognitive processing in highly stressful events. Negative rumination predicts poor results verses positive rumination predicts growth? This research had been suggested but not undertaken at the time of this review. Thirdly Social Networking in aiding PTG needs systematic investigation and lastly gender review, it is stated that women experience PTG more than men but it is at this point under researched.
An examination of Posttraumatic Growth and Posttraumatic Depreciation: Two exploratory studies. This journal was of interests as it raised the question in the last paper regarding the conceptualising thriving in clinical contexts re distress and growth coexisting and introduces the Posttraumatic Growth Inventory. The hypothesis for this research is that people experience both growth and depreciation following a stressful event. The implications for these were discussed.
There are two instruments used for measuring PTG and PTD in this review, the Stress Related Growth Scale (SRGS) (Park, Cohen and Murch 1996) and the Post Traumatic Growth Inventory (PTGI) (Tedeschi and Calhoun 1996). The scales had proved successful as responses from those close to the individual agreed the outcome of the tests agreed with how they found their relative/friend to be.
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Limitations of the scales are that the individual only gets to report on the positives of their growth and not the negative aspects. From this further scales had been developed that measure both positive and negative effects, The Changes in Outlook Questionnaire (Joseph et al, 1993) although this appeared consistent and reliable it was found to be vulnerable of the same critique as individuals could not report depreciation in the domains as the growth items. The question is can individuals report both growth and depreciation when experiencing a traumatic event?
The two studies investigated in this journal were designed to answer four questions; 1) when provided with the opportunity to record both growth and depreciation in both domains will individuals report both? 2) if both are reported will there be a difference in the amount of growth to depreciation? 3) what is the relationship between growth and depreciation? And finally 4) what are the consequences if any of the order of which they are presented.
In the first study 286 undergraduate students were used all participants reported a highly stressful event that were all rated above three on a seven point scale (highly stressful at the time of the event.)
This 21 item scale measure positive changes in life after a traumatic event, items include; relating to others, new possibilities, personal strength, spiritual change and appreciation of life.
This 21 item scale measures the opposite to the PTGI alongside the same domains, for example – ‘have established a new path for my life’ ‘I have a less clear path in my life’. The assumption is that both PTG and PTD can be experienced in the same domain.
The two studies used both scales but in different orders, PTGI first and PTD second, visa versa and then both at the same time. The results in all three were that PTGI scored slightly higher and that all individuals reported on both scales. The validity of the study can be questioned as to the use of university students as a pose to the general public. The variety of losses and stressors would not all meet the criteria for the study and lastly the scales had not undergone the necessary evaluations of the scale construction therefore are not yet regarded as independent inventory.
From this literature I have found that therapists need to notice and explore the depreciation as well as the growth.
Optimism, Social Support and Coping Strategies as Factors Contributing to Posttraumatic Growth: A Meta-Analysis.
Factors contributing were discussed breifly in the previous papers, Tedeschi and Calhoun had an interest as to what supports PGT in their earlier research. This Meta-analysis examines contributors and implications for PGT. Again this is related to my question to find out if there are successful contributors to expand my knowledge and practice and if not where to search next if anywhere.
The first meta-analysis in this area was conducted by Helgeson, Reynolds and Tomich (2006) they explored PTG in relation to personality, faith maturity, well-being and positive affect. It was stated suffering stimulated a search for meaning? In this meta-analysis what was taken into account in Helgeson et al.’s study would not be repeated.
The search was through four databases MEDLINE, PsycINFO, PILOTS and ERIC and five review articles for the benefit of additional articles. Included studies were those who reported positive change after a stressful event, had experienced PTG to one of the variables, (optimism, social support, active coping, seeking social support coping, religious coping, acceptance coping and positive reappraisal) and provided the information to prove effect size. Longitude data that identified the longest period or largest sample.
Religious coping and positive reappraisal coping were strongly connected with growth. Moderately connected were social support and seeking social support coping, spirituality and optimism. The smallest effect was acceptance coping.
This Meta-Analysis support the contributors are related to PTG, although social support was medium Schaefer and Moos (1998) implied social support fostered a more favourable appraisal of the event and more effective strategies. It appears that the benefits of social support are different when the support is required during the time after the trauma, this will affect the result with the differing circumstances.
Optimists were portrayed as having the ability to manage difficult situations. Social support was considered to be key for PTG, (family, friends, the environment) but once again this has been argued that social support can be both positive and negative Schaefer, & Moos (1998) and Linley, & Joseph (2004) claiming the findings to be mixed. Religiousness and religious coping was analysed and was found to be related to positive adjustment to stress but not specific to PTG,
The data presented overall that the contributors may promote positive change in the aftermath of a traumatic event.
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