Fostering Post-traumatic Growth in Trauma Survivors

Editor's Note: This text-based course is a transcript of the webinar, Fostering Post-traumatic Growth in Trauma Survivors, presented by Patrice Berry, PsyD, LCP.

Learning Outcomes

• After this course, participants will be able to describe post-traumatic growth discuss three ways it differs from resilience.
• After this course, participants will be able to identify areas of a trauma survivor’s life to assess/monitor for signs of post-traumatic growth.
• After this course, participants will be able to identify three interventions that can be used to enhance post-traumatic growth in children, teens, families, adult trauma survivors.

Course Introduction

• Learning about PTG benefits psychologists in all settings (School, Justice System, Medical/Hospital Settings, Community Programs, Outpatient Clinics, Residential/Group Homes, etc.) who encounter individuals who have experienced trauma
• Intermediate Course: assumes a foundational knowledge of trauma, trauma-informed care, the Adverse Childhood Experiences Study (ACEs)

Learning about post-traumatic growth benefits all psychologists in every setting. I have operated within many of these different settings. This includes schools, the justice system, hospital or medical settings, community programs, outpatient clinics, or residential group home settings. Trauma is anything that overwhelms someone's system. Anyone working with individuals who have experienced trauma includes many of the people I have been working with during this time. We are recording in 2022 with COVID, many different changes happening, and people presenting with increased trauma symptoms. Fostering post-traumatic growth is great for psychologists to have this information to best benefit their clients. This intermediate course assumes a foundational knowledge of trauma, trauma-informed care, and adverse childhood experiences studied (ACEs).

Limitations

• Some of the treatments listed in this presentation require additional training this training is not a comprehensive review of these treatment protocols.
• Mental Health professionals are responsible for reviewing their scope of practice, not indulging in activities that are beyond the boundaries of practice, and engaging only in those activities that comply with their professional standards.

Some of the treatments I will discuss in this presentation require additional training. This training is not a comprehensive review of these treatment protocols. Mental health professionals are responsible for reviewing their scope of practice, indulging in activities beyond that scope of practice, and adhering to local ethics boards that comply with your professional standards.

Post-traumatic Growth Defined

• Resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress” https://www.apa.org/topics/resilience
• PTG is psychological transformation “positive change experienced as a result of the struggle with a major life crisis or a traumatic event.” https://ptgi.uncc.edu/what-is-ptg/ 
• Difference between PTG resilience
  • Is a process where someone is struggling after a traumatic event finds a deeper sense of meaning…PTG "takes a lot of time, energy struggle," Taku says. https://www.apa.org/monitor/2016/11/growth-trauma
  • According to Taku, person who is already resilient may not experience PTG
• Recent research found greater levels of PTG the greater the severity of the incident (Ewert., & Tessneer, 2019)

Let's start by defining post-traumatic growth and looking at the difference between post-traumatic growth and resilience. Resilience, within APA topics, is defined as the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress; and after a negative life event a person is able to adapt at the end of it.

Post-traumatic growth is about transformation. This positive change is experienced as a result of the struggle with a major life crisis or a traumatic event.  As a result, the person changes in this transformational way. It is not about coming out well at the end. It is about this transformation process. The biggest difference between post-traumatic growth and resilience, and is also within an APA article discussing growth after trauma, post-traumatic growth is described as a process where someone is struggling after a traumatic event, and they find a deeper sense of meaning.  Much research has been done on post-traumatic growth. According to Taku, a person who is already resilient may not experience post-traumatic growth.

When we look at resilience, that is about coming out strong in the midst of it. Post-traumatic growth is about a change that happens within the person where they might be even better off than where they started. Recent research has found greater levels of post-traumatic growth based on the severity of the incident. People who go through something very severe often report very high levels of post-traumatic growth following that event. This is not something that you have or do not have. Same thing with resilience. It is not something that a person has or does not have. These are things that we can cultivate within our clients.

Why Is This Important?

• "Everyone has a right to have a present future that are not completely dominated dictated by the past" ~Karen Saakvitne
  • After a traumatic event(s) 30-70% of people report positive change growth (Joseph Butler, 2010)
  • Launched development of Psychological First Aid
  • Encourages people to look for positive outcomes after negative life events
  • Helps explain why some people may experience a horrific event experience few negative symptoms (COVID)
  • Helps survivors see themselves as more than victims capable of transformation change

(Brooks, Amlôt, Rubin, Greenberg, 2020). (Finstad, G. L., Giorgi, G., Lulli, L. G., Pandolfi, C., Foti, G., León-Perez, J. M., ... & Mucci, N., 2021).

I like this quote, "Everyone has a right to have a present and future that are not completely dominated or dictated by the past." Often people will come into treatment feeling stuck, as though they cannot move forward. This can even get into traumatic grief. The DSM-5 has even added prolonged grief. Sometimes prolonged grief can have these little symptoms that are similar to trauma symptoms as well. After a traumatic event, 30 to 70% of people reported a positive change in growth.

This was an older study by Joseph Butler, where post-traumatic growth launched the development of psychological first aid.  Psychological first aid after a traumatic event shifted from giving people a list of all the trauma symptoms they could have after a negative event to giving people a list of some of the positive things to look for after the event. The research suggested that showing people those positive things increased levels of resilience and post-traumatic growth after the event versus showing them a list of all the trauma symptoms for people that might not have been experiencing those symptoms yet. Meaning, if you show people a list of the negative symptoms, they are more likely to have those negative symptoms.

We want to have people on the lookout for the positive, which encourages them to look for positive outcomes after negative life events. This is not in a toxic positivity way where we are overshadowing the negative event and telling people to get over it. This in no way invalidates their experience. It is a way to help them regain control of their life of what they have been through and move forward. It also helps explain why some people may experience a horrific event and come out with very few negative symptoms.

Two people can go through the same thing and have very different responses and reactions. There are a lot of different reasons for that. As psychologists, there are things we can do to increase the likelihood that a person may have some of these positive outcomes. It helps survivors see themselves as more than victims. It even helps with the hope that they are capable of transforming change and that after this event, they have some power to transform change for the future.

Beyond Surviving to Thriving

• Succumbing to PTSD symptoms
• Survival with some PTSD symptoms
• •Recovery (Resilience)
• Thriving (PTG)

(Finstad, G. L., Giorgi, G., Lulli, L. G., Pandolfi, C., Foti, G., León-Perez, J. M., ... & Mucci, N., 2021; Ledesma, 2014)

The article took a look at four different levels. The first level is after a negative event, a person is having a lot of PTSD symptoms, and they are succumbing to these symptoms. It is overwhelming. It is pervasive. This is often when a person presents for treatment or care.

In the second level, we survive with some PTSD symptoms. This person may be getting back into work, getting back into their everyday life but still having some trauma symptoms. Then we have a recovery phase where the person has very few symptoms. They are doing well. We might consider that phase to be resilience. Beyond that, we have "thriving," of what I went through, of this experience. Maybe I am now motivated to help others, or I will launch a nonprofit that helps benefit this area. I have become an advocate for this group and am now thriving on what I went through.

It is nice to talk about assessing. Where is my client within these different phases? Somebody that is succumbing to PTSD symptoms, somebody that is feeling overwhelmed, they are not at a place to start thriving. You have to do this in steps, or else the person will or could lose hope if the therapist is pushing them too far beyond where they can even see themselves being.

Race/Ethnicity PTG

• Research showed that African American breast cancer survivors with higher levels of support seeking/participating in aftercare groups (but generally showed lower levels of participation) (Kent, Alfano, Smith, Bernstein, McTiernan, Baumgartner, & Ballard-Barbash, 2013)
• Gently challenging thoughts about seeking help, talking with outsiders, vulnerability while acknowledging that it may be difficult for the client to seek outside support
• Brené Brown Quotes from her book Daring Greatly (2012)
  • “Vulnerability sounds like truth feels like courage.
  • “Because true belonging only happens when we present our authentic, imperfect selves to the world, our sense of belonging can never be greater than our level of self-acceptance.”  

This was an article looking at African American breast cancer survivors with higher levels of help support that sought to participate in aftercare groups. They had higher levels of post-traumatic growth. Especially having those supports within the community, but they might have shown lower levels of participation within some of those aftercare groups.

We want to be able to challenge thoughts about help-seeking within different communities gently. In some communities, you do not go to outsiders or talk with others. It is looked at as a negative thing to talk about what is going on with you emotionally or maybe to focus more on physical symptoms, not taking a look at mental health symptoms.

There is a lot of great work, both by Brene Brown and Bell Hooks. Many other phenomenal writers talk about vulnerability, acknowledging that while it may be difficult for a client to seek outside help support, what are some ways that they could benefit from doing this? If someone is already in your office sometimes using the DSM-5, there is a cultural formation survey to use. Using things like that to assess is okay within your culture and community. How is help-seeking seen? Do the family members even know that the person is seeking treatment? Awareness of that can help if we face any barriers in treatment along the way.

I like some Brene Brown quotes from her book, Daring Greatly. "Vulnerability sounds like truth feels like courage." Pointing out the fact that vulnerability is difficult. It is not easy. The next quote is, " true belonging only happens when we present our authentic, imperfect selves to the world, our sense of belonging can never be greater than our level of self-acceptance." Often I have had many clients that have connected with some of these quotes in talking and thinking about where they are and how they view help-seeking reaching out for support. Other resources talk about it. It is okay not to be okay, but sometimes that can go against what is known or thought about within somebody's culture. It can be helpful to bring that up in treatment.

Assessing PTG

• Post-Traumatic Growth Inventory (PTGI) (Tedeschi Calhoun, 1996) looks at positive change in these five areas

1. Appreciation of life
2. Relationships with others
3. New possibilities in life
4. Personal strength
5. Spiritual change

• PTG Short Form (Cann, A., Calhoun, L. G., Tedeschi, R. G., Taku, K., Vishnevsky, T., Triplett, K. N., & Danhauer, S. C., 2010)

In looking at assessing for posttraumatic growth, there is an inventory that was developed for research. It takes a look at these five different areas. If a person has high levels of appreciation of life, that can be a signal of higher levels of post-traumatic growth. How are their relationships with others? Sometimes people can go through a negative event and isolate themselves or disconnect from others. Still, higher levels of relationship connecting with other people can be associated with higher levels of post-traumatic growth.

Are they looking at new possibilities in life? Maybe as a result of this event that a person went through, now they see a different career that they are interested in, or they see new opportunities, new possibilities that somehow opened the door to something positive for them. That is associated with higher levels of push traumatic growth. Then a person's assessment of their strength is common after somebody goes through something that they can feel broken and weak. As though they are not enough. It can affect a person's sense of self. That is a difference between somebody viewing where they are right now and are they viewing themselves as a victim. I always use survivor language with people that have been through traumatic events. That is how I see them.

When looking at the self as a survivor sees the self as strong. Even though this event happened, the person still has some strength even if they are falling apart on the inside. Then for people that do, if they have a spiritual connection, if they identify with that, another thing that the push traumatic growth inventory assesses is any spiritual change. Does the person feel more connected spiritually? Are they engaging in more spiritual activities? Assessing the level of spiritual change. There is the PTGI which is a long form. There is a shortened form, PTG, of this inventory as well.

Things to Avoid...Things to Do/Say

• Oversharing about your own experiences…Listen to theirs
• Invalidating their experience/poking holes in story before you have rapport...Validate
• Avoid reinforcing that they are currently a victim…remind them that they are a survivor of their strength despite current level of functioning

Things to avoid to things to not do as a clinician, as you are working with trauma survivors. The one thing that I do not want to do is overshare my own experiences. I talk about this with parents. Maybe have a child that is going through something traumatic. Sometimes people are trying to connect. I think It is okay if my client knows, "Hey, I have been through some things, but do not go into details as therapists, we want to make sure that we have good boundaries within our sessions to not overshare about our things, that we are connecting with our clients listening to their experiences, seeing things from their perspective." I also do not want to invalidate a client in their experience or poke holes in their story before I have rapport.

When somebody comes in, they talk about what they have been through, and there are times when timelines are not quite making sense. I am trying to understand what happened or what the person is saying, but I do not want to make a judgment of whether something happened or not. That can be incredibly invalidating can. As the client, they can experience that as yet another trauma, not being believed, not being heard, and not being seen within their therapeutic environment. The only caveat is if you are doing any assessment for social services or the justice system. Sometimes you have to poke a little more before you have that rapport, and the purpose of that eval would be different.

When doing an outpatient eval where somebody is presenting the services on their own, we are trying to find, from a strength-based approach, what is going well for this client. Then I want to avoid reinforcing that they are a victim and remind the client that they are a survivor of their strength, despite their current level of functioning. Some easy ways to do this is if a client is struggling, always coming in with all the things going wrong, and intentionally having them talk about what is going right. What are some things that are positive within their life right now? The analogy that I have heard online that I repeat to my clients is that often when bad things happen, the bad stuff will stick like glue.

Our brain is in survival mode. If I am surviving, I need to be aware of all the bad, but in order to thrive, I have to calm my amygdala. I have to calm that fight or flight, freeze or fawn response, and be able to look for some of the good intentionally. I do not need to see the flowers if a bear is chasing me. I do not need to see the positive things, but the only difference is that trauma survivors can chronically feel in this state of hypervigilance of everything's wrong and be in survival mode all the time. A way to move forward to resilience post-traumatic growth is to calm those parts of the brain and start to look for the good.

Here are some ways we can foster post-traumatic growth in families of young kids. I talk about it from a family perspective because, let's say, the child or family experiences something. For young kids, the parents are going to have the biggest role in helping create safety and security, reassuring children of love and safety. Then I can, in a one-hour-a-week session, make sure the parents are on board that there are things in place at home that can foster post-traumatic growth, not only in the child but also in the family.  Play therapy within. Maybe even bringing the parent into the session encourages positive interactions with the child's parent. Maybe the parent has been disconnected, or they are constantly redirecting the child, not letting the child have a sense of autonomy and control.

Often when people have been through something negative, they feel out of control. They will try to control everything. For many families who have survived trauma, we try to find healthy ways to let the child have some control. We want to have consistency in a routine. The one thing that can help foster post-traumatic growth is when the child knows what to expect. Now, this routine does not have to be rigid. It does not have to be exactly at 12:00 PM every day, we are going to have lunch, but there is some general flow to the day that the child knows, "Okay, I am going to wake up, do my hygiene, then breakfast." There is a general flow to the day. The brain is not constantly alert for what is next. When am I going to eat? What are we going to do? Kids who have some reassurance of that consistent routine can help their brain settle.

Fostering PTG in Families of Young Kids

• Activities that build a sense of security by reassuring children of love safety
• Play Therapy
• Consistency/routine
• Education to family on healthy ways to cope after trauma/crisis
• Parents teaching modeling coping skills
• Parents managing their reactions monitoring exposing kids to things that are outside of their developmental level
• Parents receiving their own support/therapy when needed/if there is a lack of knowledge about healthy coping

(Triplett, K. N., Tedeschi, R. G., Cann, A., Calhoun, L. G., & Reeve, C. L. 2012)

I want to educate the family on healthy ways to cope after a trauma crisis, fostering time together, playing games, talking and listening to one another, and helping them. Let's say the child is having nightmares at night. In what ways can we build safety within the home versus the parent invalidating that emotion by saying, "You are a big baby, or I do not know." Instead of invalidating that moment, being able to support them at that moment. Parents teaching and modeling healthy coping skills. Sometimes I have to work with the parent individually because they might not have some of those skills when we start.

Then parents manage their reactions, ensuring they are not exposing kids to things outside their developmental level. Particularly with listening to the news, the news will have all of these things going on, and little ears are always paying attention. I want to be careful that the child has this sense of safety within their home and life. Safety has to be felt. I can physically be safe, not feeling safe. If a child is hearing things all the time, they are hypervigilant and hyper-aware of things. They might then be worrying about things happening in other countries or all of this. I want to reinforce that feeling of safety within the home. Parents receive their support in therapy if needed especially if there is a major skills deficit with healthy coping.

Fostering PTG in Teens and Adults

• Community/social connection-support groups, churches/religious groups, etc.
• Narrative Therapy
• Create a safe space for people to safely express feel their positive negative emotions
  • Poetry
  • Music
  • Journaling
• Normalize validate negative emotions prime them to look for and/or create the positive/meaning making
• Dialectical Behavior Therapy Skills (DBT)

(Aiena, B. J., Buchanan, E. M., Smith, C. V., & Schulenberg, S. E., 2016)

Research shows self-fostering and post-traumatic growth in teens and adults through community and social connections. A lot of times for teens, they do that online. That is where the parents want to monitor. We want to make sure that they have healthy connections and that they are engaging in healthy activities. Being able to connect with others can be a positive thing. Narrative therapy has been shown to be very positive, fostering post-traumatic growth, where we are talking through the trauma and working through it.

I want to create a safe place for them to express positive and negative emotions. Within therapy, make sure that they are able to express themselves fully. I do not mind teens using curse words in a session as long as they are not cussing at a family member or at me. If they have had a rough day, they use choice words. I do not redirect that at all, but if It is directed at someone in an aggressive way, then that is when we redirect it. Being able to fully express, to feel seen and heard within a session is incredibly helpful. Often connecting through poetry, music, or journaling. I will often ask clients, "What is a song they have connected to lately, or what is a song that brings to mind what they have been going through?"

Younger kids' picks can vary. When I hear the song, I can see how it directly relates to what they are experiencing, sometimes in a deeper way than they have even expressed verbally. I want to normalize and validate negative emotions that their brain is having a normal reaction to an abnormal situation. That comes from a trauma-informed care perspective. It is about what happened and not what they are doing that we are trying to get to—understanding what happened, talking, and working through those things. Then to help them create and find positive meaning-making. I believe I am going to get into that a little bit more. Dialectical behavior skills therapy teaches clients skills of how to be more mindful, how to be in the moment, and manage their emotions through teaching specific skills. This one does require additional training if you are going to incorporate that into your practice. I have seen skills development be very helpful, especially for clients that have difficulty expressing emotions. They either mute their emotions and turn them off, or their emotions are very reactive and expressive. Going over some DBT skills training can often be helpful.

• CBT to address problematic thinking
  • Hypervigilance/threat scanning
  • Catastrophizing
  • Excessive Worry
  • Fortune telling
  • Emotional Reasoning
• Planning/Trying to return to “normal”
• Gratitude
• Breathing increasing feeling of control during difficult symptoms
• Psychoeducation on PTG

(El-Gabalawy, R., Mackenzie, C. S., Starzyk, K. B., & Sommer, J. L., 2020), (Ewert, A., & Tessneer, S., 2019)

The one note I will make with CBT is that I want to ensure that if I am working with a client and their parent is at risk of being deported, that is a real fear. It brings up a lot of feelings for them. I do not want to negate the risk of parents being deported. That is not an irrational thought, yet having excessive worry about it will not be helpful for the client. Making sure that I am able to balance some of the worries might be valid. Being able to work with clients on that can be helpful. Trying to find ways to return to some sense of normal. I think last school year in our local area was the big year where kids were going back to school full-time. It was a huge adjustment year. Anytime you have major adjustments, major changes, especially after trauma, they are going to be some feelings of anxiety, some feelings of dread. They are going to be some feelings that come up where kids and teens show that they are not okay through their behaviors. That is where I work with the parents as well. For now, what they have been through does not justify negative behavior, but it helps me understand—being able to connect with the client. We know, "Okay, school started, and they are struggling to get acclimated," what support can we get for them? They are still going to have consequences if there was something happened. I do not want to miss addressing that deeper need that behavior was communicating. 

When we talk about trauma, the brain sticks to the bad like glue, and the good rolls right off. Practicing gratitude actively goes against that process. Within the session, clients will tell me about all the bad before they tell me about some of the good. Reinforce the good and practice it as a family. There are these gratitude jars that people have started, and every day you put one thing that you are grateful for. Maybe as a family, we look at it at the end of the week or the month's end. It is a way as a group to practice gratitude. Sometimes people will do that individually for themselves, if they live alone or if an adult is also looking to practice gratitude.

Breathing increases focusing on what I do have control over during difficult symptoms. Using the breath to get out of that emotional brain activates my thinking brain. Teaching some of those breathing techniques can be helpful. Some clients need an external reminder like an app. They need to do something physical, remembering to breathe when calm. It is easy to remember when you are upset. It can be more difficult to remember some of these tools, but a lot of kids, teens, and adults have their phones accessible. Having something that is accessible to them can sometimes be helpful. Educate clients' families on posttraumatic growth. The fact that It is even a thing is something that we can work towards.

Psychological First Aid

• Crisis response training that focuses on empirical strategies that reduce negative symptoms after trauma to children, teens, adults
• Provided quickly following incident
• PFA is not “psychological debriefing”
  • Eight “Core Actions” from PFA Guide on www.nctsn.org: 1. Contact Engagement 2. Safety Comfort 3. Stabilization 4. Information Gathering 5. Practical Assistance 6. Connection with Social Supports 7. Coping Information 8. Linkage with Collaborative Services.

https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/about-pfa

Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, Vernberg E, Watson P, (National Child Traumatic Stress Network National Center for PTSD, 2006).

I mentioned psychological first aid earlier. It is a crisis response training that focuses on empirical strategies that reduce negative symptoms after trauma in children, teens, and adults. It is provided right after an incident. It is not a psychological debriefing. There are eight core actions. You can look at the guide on nctsn.org. We first want to have contact engagement. We want to talk about safety and comfort. Talk about stabilization, gather information, and give some practical assistance. Maybe people need to locate their children, or children need to locate their parents.

Giving practical assistance, connecting with social supports, giving information about coping, then linking people with collaborative services. That is the process of that psychological first aid. Many organizations, schools, I have heard of some churches, and lots of different groups are getting trained in this, especially as we hear about more incidents happening.

Meaning Making

• Viktor Frankl, developed logotherapy, an existential analysis to help people find meaning after tragedy. Quotes from his book Man's search for meaning: An introduction to logotherapy (1984)
• “Those who have a ‘why’ to live, can bear with almost any ‘how’.” 
• More Viktor Frankl quotes that encourage internal locus of control
• “An abnormal reaction to an abnormal situation is normal behavior.” 
• “Between stimulus response, there is a space. In that space is our power to choose our response. In our response lies our growth our freedom. ”
• “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”
• “When we are no longer able to change a situation, we are challenged to change ourselves.” (Frankl, 1984)

Dr. Viktor Frankl is a psychiatrist that survived the Holocaust. He wrote a book, "Man's Search for Meaning: An Introduction to Logotherapy." He talks about an existential analysis to help people find meaning after the tragedy. A quote from the book I love is, "Those who have a 'why' to live can bear with almost any how." 

Suppose you have a "why," you can get through almost anything. He encourages focusing on an internal locus of control. That internal locus of control is I have some control over what happens, over what I can do over my emotions and behavior, versus having the external locus of control, where everything is happening to me, I do not have any control. One of his quotes is an abnormal reaction to an abnormal situation is normal behavior. Another one of my favorites is "Between stimulus response, there is a space. In that space is our power to choose our response. In our response lies our growth, our freedom." There will always be things that happen that we want to have intention. That is that space. I often talk with clients about increasing that space because clients with ADHD go through trauma. We want to add space to choose our response, not say, "This person made me mad. This person ruined the day but I am able to choose." This person upset me. Then I decided to leave. Choosing a response that can activate our growth and our freedom. Another quote is, "Everything can be taken from a man but one thing: the last of human freedoms- to choose one's attitude any given set of circumstances, to choose one's own way." Once again, focusing on the power of choice in the midst of a situation that might be out of my control. The last one is, "When we are no longer able to change a situation, we are challenged to change ourselves." If a situation is completely out of my control, remember that I can focus on myself. These are some quotes that I will sometimes bring up in session, then talk with a client to see what they think about it and what they are getting from that.

Survivor Mentality

• Quote from CBT Psychological Associates “Victims often identify with negative, self-defeating emotions such as shame, guilt, anger, resentment, etc… A survivor mentality focuses on overcoming the negative activating events promotes the individual’s adaptive behaviors.” (https://cbtpsychologicalassociates.com/the-survivor-mentality/)
• Accept personal responsibility
• Internal locus of control

(Orejuela-Dávila, A. I., Levens, S. M., Sagui-Henson, S. J., Tedeschi, R. G., & Sheppes, G. 2019)

I talked earlier about creating that survival mentality. A quote from CBT Psychological Associates, "Victims often identify with negative self-defeating emotions, such as shame, guilt, anger, resentment, et cetera." All of those feelings are incredibly valid. A survival mentality focuses on overcoming the negative activating events that promote the individual's adaptive behavior. If I stay in those self-defeating emotions, I will likely increase the risk of engaging in some negative coping. It is going to increase depression anxiety versus in the midst of those emotions if I am able to find some ways to express those in healthier ways and have some adaptive behaviors. Maybe I intentionally go for a walk every day. Even though it is incredibly scary, I do not have control over who's outside or what happens—being able to increase more adaptive behaviors. A survival mentality also increases accepting personal responsibility. We always talk about if somebody went through something that is not their fault, but then what I now do. I have to take personal responsibility for my actions, my thoughts, and what I have control over. That increases that internal locus of control that I do have some control over what happens. Some things are out of my control.

Accepting Uncertainty

• Instead of fighting uncertainty increasing ability to tolerate manage uncertainty
• Implementing healthy coping skills monitoring for use of negative coping
• Psychoeducation about emotion regulation the importance of negative emotions
• Challenging when threat is perceived
• Medication

(El-Gabalawy, R., Mackenzie, C. S., Starzyk, K. B., & Sommer, J. L. 2020; Lee, D., Yu, E. S., & Kim, N. H., 2020; Orejuela-Dávila, A. I., Levens, S. M., Sagui-Henson, S. J., Tedeschi, R. G., & Sheppes, G. 2019)

From the work of Reed Wilson and Dr. Lynne Lyons, they talk about how anxiety wants certainty and control. Trauma can trigger anxiety. One of the things I have to accept is uncertainty. Instead of fighting uncertainty with the example I gave about going outside. They are going to be people outside that I do not know, that I do not have control over. I am going to have to accept, okay, the situation is uncertain and increasing our ability to tolerate and manage not knowing the uncertainty can make people feel unsafe.

That is where we find ways to find safety in the midst of uncertainty. The more I approach that uncertainty, the more I can cope with and manage it. I can then get back to how things were. I can get back. I can engage in my life again. I want to implement healthy coping skills and monitor for negative coping. As a therapist, I want to give psychoeducation about emotion regulation the importance. Negative emotions are there for a reason. If somebody went through something bad, did not feel like it, and was kind of happy about it, that would be odd that it is incredible that there is a reason for sadness.

There is a reason for anxiety in these emotions. The problem comes when those emotions are overwhelming. Now we are going to talk about how to manage them better and better cope with those in healthy ways. Then challenging, when a threat is perceived, the perceived threat often trauma survivors to when they go out or even if they are at home, they might be very hypervigilant. They might be very hypervigilant. I have to increase knowing that if I feel a threat, there is no threat to be able to sit in safety that here at this moment, anything could happen. There is a lot of perceived threat here in this room. I am 100% safe here.

Being able to sit with felt safety, a lot of that comes from the work of Dr. Eric Gentry. Sometimes referring for a medication evaluation. Sometimes the level of depression and anxiety, they need to talk about their options with their medical provider or psychiatrist.

Resources

• The Post-Traumatic Growth Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience Awaken Your Potential by Arielle Schwartz  
• Struggle Well: Thriving in the Aftermath of Trauma Paperback – March 28, 2018 by Ken Falke, Josh Goldberg  
• The Will to Meaning: Foundations Applications of Logotherapy by Viktor E. Frankl 

Many resources talk about addressing coping with post-traumatic growth. Here is a guidebook, The Post-Traumatic Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience, Awaken Your Potential. Going over some of these resources with clients and talking about them can be incredibly helpful to take a step back and work through a physical book.

Sometimes if I am giving clients resources verbally, I like to follow up with videos or book resources. Not everybody will be at a place where they can accept all of that, but working through something physical gives clients something they can do outside the session. Often people are coming and do not have much hope in coping or healing. Then as a therapist, I want to be careful that I do not own my client's treatment. This was something I learned early in practice is that the client is the one that does the work. I am the guide and support, but the client owns their progress. They own their treatment.

If someone is not the right fit or a client needs a specific type of therapy or a specific intervention or resource that I am not skilled in, being able to refer them to the appropriate people is one thing. It can go against building post-traumatic growth if the person does not have the tools to address what is going on. This training is a great first step to saying, "Okay, I want to learn more as a therapist and clinician. How can I better meet the needs of my clients?" Another resource my clients have found helpful is struggling well, thriving in the aftermath of trauma, and acknowledging that there is a way to struggle well often gives people the idea that they can cope. Building some hope that the future can look different. That is something that can come from the therapist. Dr. Viktor Frankl also wrote The Will to Meaning: Foundations Applications of Logotherapy.

Summary/Review of Learning Objectives

• Describe posttraumatic growth discuss three ways it differs from resilience
• Identify areas of a trauma survivors life to assess/monitor for signs of posttraumatic growth
• Identify three interventions that can be used to enhance posttraumatic growth in children, teens, families, adult trauma survivors

In summary, we talked about what post-traumatic growth is. Post-traumatic growth is being able to struggle well after the trauma. After what I have been through now, I am able to be even better at what I went through and how it differs from resilience. Resilience is coming out better or coming out the same. Returning to where things were, post-traumatic growth is even better than where I was before.

Then we also talked about identifying areas of the trauma survivor's life to assess and monitor for signs of post-traumatic growth—a review of some of those areas. I want to look at their social, how they are doing, and connecting with others. How are they doing spiritually? If that is something the client identifies with, how are they doing in their work life? How are they functioning in areas of their life purpose and goals after this event, and how are they doing? Then I also want to identify three interventions that can enhance post-traumatic growth in children, teens, families, and adult trauma survivors. I encourage you to take a family systems approach, especially when working with children and teens.

Then even some of my adult trauma survivors have wanted to include a family member or partner in aspects of their treatment. To be able to help everybody else understand what they are currently going through can be incredibly invalidating when the person's environment is not supportive. Finding ways to include the whole system can be helpful as one person changes. Sometimes there can be other things that pop up within the system. Having access to the whole system, I think, can be helpful.

Online Resources

• How to Help Traumatized Clients Move Out of “What Was” into “What Can Be”: Practical Treatment Strategies to Foster Post-Traumatic Growth https://www.nicabm.com/program/post-traumatic-growth/
• Psychological first aid: Guide for field workers from World Health Organization https://www.who.int/mental_health/publications/guide_field_workers/en/
• https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological-recovery/about-pfa

Some additional resources, I love sharing resources with people. How to help traumatized clients move out of what was to what can be practical treatment strategies to foster post-traumatic growth. Here is a resource for psychological first aid. If you wanted to look at that intervention a little bit more, there are psychological first aid pieces of training. There is whole training that people do to be certified in psychological first aid and references for the training.

Questions Answers

What happens, or how should a therapist handle it when a client is not moving fast enough or gets stuck in this process?

Yes, as a therapist, I want to be careful about pushing a client too fast or not pushing them enough. That will vary based on the situation of a client that is had maybe one traumatic event. They might move through this process faster than a client with complex or developmental trauma. Maybe a new incident has opened up a lot of other doors. If, as a therapist, I feel like the client is stuck where they currently are, be able to sometimes check in with the client with how they feel progress is going and what they are willing to do. I encourage you to talk with the client about it and possibly seek outside consultation to talk with another professional.

In talking with the client, they own that part of the treatment. They can say, "Yes, I want to be pushed a little more. I realize that I am minimizing what I am currently going through." They are willing to push it a little bit more, but sometimes a client, I might see them having the ability to go further, but where they currently are, they are not there yet. , I might have to pull back some support from them where they currently are. Then as a therapist, I manage my frustrations. That is why I talked about not the client owning their progress in treatment. It not being on the therapist. We both contribute to it. If a client is not ready to progress further, supporting them where they are, they might cancel a treatment if I push too much. There could be some negative things that happen with that.

I know you have a lot of experience working with children. Do we see post-traumatic growth in children? Does it manifest or unfold in the same way we see it in adults?

Yes, the awesome thing about kids is that their brains are able to adapt and adjust faster when they get positive interventions. They have done the research they have measured post-traumatic growth in kids. How I have seen it in clinical practice is a child that has been through a lot. Now they want to help other kids like them. They want to go into nursing or to be a therapist, or because of what they have been through, they now want to help others who go through similar things. I will also say that for kids, their home environment is important, that the family and the therapist, if I am working with a client for 45 minutes to an hour, are in a good place. They could go out to the lobby. The parent gives them one look. It unravels everything. That is why I talk about the importance of including their family. If safe, if possible, they will have the biggest impact, often educating the parents on trauma recovery, appropriate discipline, and things like that. That can be helpful.

Can you talk a little bit about the impact of a setback as it relates to if you have a client that maybe is moving in the right direction, you are seeing this post-traumatic growth develop in that client? Then something happens they have a setback or a trigger. How does that impact their ability to move on, or do they get stuck?

Every client is going to be different. Some people I have seen a setback unravel a lot of the work, especially people that have histories of substance abuse. If they fall back into a state of, if they start using again, that that can build up, bring up a lot of shame and guilt, that might be a major setback. for clients that do have the dual diagnoses of trauma substance, making sure that I am partnering with their addiction provider as well, or if the therapist is treating both diagnoses, being able to come in take the judgment out of it. When a client comes in with a setback, in fact, as a person, I might be disappointed, but I do not let them see that.

It is like, I am glad you are here. I am glad we took a step back, but that is what the healing process looks like. I think talking about the fact that healing is not linear, It is not always going to be a straight-up that healing is messy and that they are going to be setbacks. There are going to be times when things get harder. I think the therapist is able to come from a non-judgmental place. Nonjudgment means I am focusing on the facts. I am not saying I am disappointed or like you were doing well. I am not going to say things like that. I am going to say it must have been hard for you to bring that up today, or how was it? What did you think I was going to say? How did you think I might feel? In the midst of your story, based on what you have talked about, I can understand how that trigger brought up this other thing. Then you start from there and move forward to see where the client is. It is common for people to get stuck, especially when we have these other things. I have also seen how sometimes, for people, food is their source of addiction or that addiction can be any coping that is negative falling back into it. It can be difficult for the person to get back out of it, often reviewing are you ready to do this process again?

The therapists believe they can because research has shown that the therapeutic relationship is the most important thing, the specific intervention you do, but what is that connection? Making sure that does not mean we are addressing that therapeutic relationship so we can move forward. I have seen doing it from a place of non-judgment, which is helpful because the client often judges themselves. I have seen people cancel a session after that was hard for them to get back into the office after having a major setback. You brought up two very important points that I think we have to focus on: this type of growth or healing is not linear. I think sometimes we get into this work. We want it to be a straight shot, but our clients' lives are multidimensional. Their healing is not going to be linear. Regardless of our intervention, we will not foster the type of growth that we seek or our client needs, as the importance of the therapeutic relationship is that we are not a safe place if we do not instill hope in our clients.

References

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Ali, D. A., Figley, C. R., Tedeschi, R. G., Galarneau, D., & Amara, S. (2021). Shared trauma, resilience, growth: A roadmap toward transcultural conceptualization. Psychological Trauma: Theory, Research, Practice, Policy.

Brooks S, Amlôt R, Rubin GJ, Greenberg N. (2020). Psychological resilience post-traumatic growth in disaster-exposed organizations: overview of the literature. BMJ Mil Health,166(1):52‐56. 

Brown, B. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, lead. New York: Gotham Books. 

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (National Child Traumatic Stress Network National Center for PTSD). (2006). Psychological first aid: Field operations Guide, 2nd Edition. Available on: www.nctsn.org www.ncptsd.va.gov.

Cann, A., Calhoun, L. G., Tedeschi, R. G., Taku, K., Vishnevsky, T., Triplett, K. N., & Danhauer, S. C. (2010). A short form of the Posttraumatic Growth Inventory. Anxiety, stress, coping, 23(2), 127–137. 

Collier, L. (2016, November). Growth after trauma. Monitor on Psychology, 47(10). http://www.apa.org/monitor/2016/11/growth-trauma

DeAngelis, T. (2011). Helping kids cope in an uncertain world, American Psychiatric Association, 42, 8. 

El-Gabalawy, R., Mackenzie, C. S., Starzyk, K. B., & Sommer, J. L. (2020). Understanding the relationship between traumatic suffering, posttraumatic growth, prosocial variables. Journal of American college health: J of ACH, 1–9.