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. 2022 Dec;19(6):390–393. doi: 10.36131/cnfioritieditore20220606

Post Traumatic Growth (PTG) in the Frame of Traumatic Experiences

Liliana Dell’Osso 1, Primo Lorenzi 1, Benedetta Nardi 1, Claudia Carmassi 1, Barbara Carpita 1,
PMCID: PMC9807114  PMID: 36627947

Abstract

The psychopathological consequences of traumatic experiences have been object of study from the beginning of medical science. During the last centuries, the scientific literature in the field of mental health mainly focused on the negative consequences of traumatic events. More recently, increasing interest was paid to the features of resilience and to the possible positive consequences of trauma, leading to the concept of Post Traumatic Growth (PTG). However, the eventual co-existence of both the conditions should also be considered. The role of vulnerability and environmental factors in the balance between positive and negative outcomes after life events is discussed, particularly in light of a neurodevelopmental approach to psychopathology.

Keywords: post traumatic growth, trauma, autism, autistic traits, resilience


The concept of Post Traumatic Growth (PTG) was firstly developed in the middle of '90s (Tedeschi & Calhoun, 1995), while a more detailed model was reached only in recent years (Tedeschi et al., 2018; Kadri et al., 2022). Tedeschi et al. (2018) defined PTG as a “positive psychological changes experienced as a result of the struggle with trauma or highly challenging situations”. This phenomenon should be considered not as an alternative, but as a parallel process with respect to negative psychological consequences (Kadri et al., 2022). PTG may feature positive changes in self-perception, interpersonal relationships and philosophy of life, leading to increased self-awareness and self-confidence, a more open attitude towards others, a greater appreciation of life and the discovering of new possibilities (Tedeschi & Calhoun, 1996). In the social imaginary, both negatives and positives life experiences have always been recognized as inductors for changes. At the same time, coherently with the historical development of the psychiatric sciences, medical observations and clinical research were mainly focused on the role of traumatic experiences in the onset and exacerbation of mental conditions (Dell'Osso et al., 2019; 2022; Dell'Osso & Carpita, 2022). Trauma has become one of the cornerstones in psychopathological studies, with a specific attention on the effects that it may exert on the illness trajectories (Dell'Osso et al., 2019; Dell'Osso et al., 2021a; 2021b). Poor attention was instead paid on the possible positive outcomes of traumatic experiences. In the last few decades, after the introduction of the concept of “resilience”, research in this field have finally begun to investigate the positive consequences of trauma. In particular, the hypothesis that a potentially negative experience could not necessarily lead to negative effects, without a reversion to a status quo ante, progressively gained interest (Windle, 2010; Stratta et al., 2015). The field of investigation was further broadened with the introduction of the concept of PTG, which allowed focusing on possible positive outcomes of traumatic experiences as well as on the associated features and conditions that may facilitate or hinder this process (Brooks et al., 2020).

In order to reach a better understanding on this newly re-discovered concept, which was present since the oldest origin of medicine, but mostly forgotten, it may be useful to resume some of the bases of the psychoanalytic thought. According to the psychoanalytic perspective, the mental apparatus is the tool through which subjects can experience relational life in a frame of self-awareness. In particular, it allows the construction of subjectivity, as well as the comparison and accordance of the personal reading of reality with the collective one, thus reaching the so called “reality testing”. Both neurobiological integrity and adequate relational life stimuli are needed in order to reach this purpose, the first being grounded on the second and vice versa. In this theoretical framework, each life “event” - intended as anything that exceeds the normal flow of things – carries within itself something (potentially) traumatic, able to lead to a subjective metamorphosis, a modification of the self-representation. Despite remaining an inevitable risk factor, those events are needed for neuropsychological maturation, for the development of an efficient mental apparatus through the acquisition of self-awareness and reality-awareness. It should be noted that the event itself may not show a specific connotation, acquiring it only on the basis of its consequences.

From this viewpoint, the central role of subjective factors of vulnerability in the balance between PTSD and PTG appears clear. An event perceived as negative by one subject may be positive or indifferent for another, depending on the specific interaction between the event and the psycho(patho)logical and neurobiological asset. Noticeably, popular and medical-psychological thoughts attributed a strong negative mark to some specific events, defining them as traumatic events, thus leading to the question: when does an event become a trauma?

An event may be considered traumatic when it alters in a negative way the identity definition of the subject, leading to an impaired ability to cope with the event, to put “the right distance” among things and between himself and the things. All life events may be perceived as traumatic by more vulnerable subjects, leading, in a vicious circle, to a greater fragmentation of the identity and to an increased vulnerability towards new traumatic experiences (Limberg et al., 2011; Haruvi-Lamdan et al., 2018; Dell'Osso et al., 2019; 2022). On the other hand, it is also possible that said “event” would lead to a positive outcome. In particular, the awareness of one’s ability to handle the trauma may promote a reinforcement of the subject identity. This phenomenon, linked to the enhancement of resilience features, has been variously described in the literature, being labeled with different names: Bandura called it “Self Efficacy” (Bandura, 1997), while Erikson the “Strength of the Ego” (Erikson, 1982).

In this framework, all the psychological conditions related to the autism spectrum should be considered as potential vulnerability factors of great relevance, being characterized by the presence of a precarious achievement of a self-identity (Tomaszewski et al., 2021). In the very first description of the disorder, both the inability of the children to respond to their name and their lack of first-person self-reference were reported, as well as the difficulties in acquiring a full awareness of the “I”: all clues indicative of impaired self-representation (Hobson, 2010). Even milder forms of Autism Spectrum Disorder (ASD), as well as the broad range of subthreshold manifestations of the autism spectrum, may be linked to various grades of self-identity vulnerability, leading to a reduced resilience and an altered ability to adjust to the events (Frank et al., 1998; Dell'Osso et al., 2019). As a consequence, for subjects with autistic traits, several life events - including the most common - can be lived and perceived as traumatic. Subsequently, events commonly judged as mildly stressful may exert a disturbing and almost disrupting role for the self-image, further impairing the subject’s adjustment and worsening the ability to keep the distinction between the Self and Not-Self. However, the (subjective) traumatic experience may also play a positive role, promoting a “rebirth” of the self, together with the achievement of a new and more stable Self-representation or even a better awareness of the external world. In these cases, life events may be considered as watersheds between a “before” and an “after”, towards which subjects belonging to the autism spectrum would be more exposed. In particular, the event may lead to a pathological evolution but also to reach a new and better adjustment, eventually through the achievement of a different viewpoint on reality. In the first case, the event would be definitely marked as a true “trauma”, in the latter it may constitute a sort of “creative experience”, towards which subjects with divergent thought may be more receptive, eventually to the point of developing extraordinary abilities or new ideas capable of advancing both individual and collective knowledge (Dell'Osso et al., 2019; Chu & Yang, 2022).

Considering the clinical setting, until recently the classical and historical medical approach was mainly focused on highlighting the pathological consequence of traumatic experiences, underlining the necessity of prevention strategies and of an early detection of the possible pathological trajectories. However, this conceptualization has often led to forget the other possible outcome, the positive one, even though deeply interlaced with the traumatic ad pathological course (Dell'Osso et al., 2014; Stratta et al., 2015; Carmassi et al. 2015; 2018; Dell'Osso et al., 2019; 2021c). In the last years a growing number of studies have focused on the PTG, evaluating the possibility that life events may promote the loss of an older identity as well as the acquisition of a more functional one, endowed with greater adjustment and flexibility skills and more ultimately profitable. The so called “traumatic” events therefore carry within themselves several different evolutionary possibilities. The new direction of studies on PTG has started to match the researches on Post-Traumatic Stress Disorder (PTSD) and its clinical and developmental correlates, proposing and supporting the hypothesis that the struggle to cope with a traumatic event could lead to negative outcomes as well as to positive personal changes (Linley & Joseph, 2004). Further evidence came from studies on the consequences of various traumatic events: natural catastrophes (such as earthquakes and hurricanes) sexual abuses, terrorist attacks, psychoses and, in the very recent years, Covid-19 pandemic (Lau et al., 2021; Ng et al., 2021; Luo et al., 2022). A specific inventory has been created to measure the presence and the intensity of PTG (Tedeschi & Calhoun, 1996). The area of “growth” may feature various domains: the ability to establish more durable relationship thanks to becoming more tolerant, more sensitive and more compassionate; the “Ego Strength” and therefore the ability to handle difficulties; a different value-frame and the discovery of new possibilities; and, lastly, positive emotional changes with increased feelings of hope and appreciation of life. These studies also highlighted the key role of the environment in which the traumatic experiences occur. The specific kind of cultural context and beliefs, the access to social support and the presence of personal (and eventually social) resources oriented to promote active coping strategies are factors of the utmost importance in shaping subjects' psycho(patho)logical trajectories after traumatic experiences. To date, the literature exploring the potential of PTSD treatments to enhance PTG and vice versa is still scant. The majority of positive outcomes are associated with the use of Cognitive-Behavioral Conjoint Therapy (CBTC) in PTSD; CBCT for PTSD (Monson & Fredman, 2012) is a trauma-focused conjoint therapy that has a session specifically devoted to PTG in the protocol and, despite the relative brief focus on the latter, it has been reported to influence up to a moderate effect the PTG in PTSD patients (Zoellner et al., 2011; Wagner et al., 2016). Moreover, targeting PTG in the context of the treatment of psychiatric symptoms should not be limited to the field of traumatic disorders: as a matter of fact, promoting PTG seems also to improve anxious and depressive symptoms (Barskova & Oesterreich, 2009; Greup et al., 2018; Kivi et al., 2019) reducing demoralization and amplifying positive affects (Hart et al., 2008).

In conclusion, PTG appears to be an issue of the utmost importance, which further research should address in parallel with trauma and stress related disorders. It should be noted that the two possibilities, PTG and PTSD, are not alternative but may be often concomitant, due to the nature of life events: dangerous challenges that could mine self-identity and adjustment but also needed to enrich the experience of ourselves and of the environment. The weight of positive and negative consequences would be differently balanced depending on the interaction between the subject and the event, determining the final outcome. It is worth remembering, in a broader perspective, how sometimes the diference between the psychopathological drift and the eventual pathway towards creativity and geniality may also be very subtle, and the two conditions may coexist and proceed in pairs (Dell'Osso et al., 2019; Chu & Yang, 2022).

On a side note, it could be interesting to highlight how humanistic literature have played and still plays a crucial role in detecting and explaining the interconnections about positive and negative consequences of traumatic experiences and, above all, in knowing how to tell them. This is thanks to its ability to represent the narrative dimension of things, with all the infinite nuances given by individual and environmental differences: the same that make us very different, but that, at the same time, underline our shared core of invariance.

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