Since 9/11 and the United States’ subsequent wars in Afghanistan and Iraq, many Americans have grown all too familiar with the term posttraumatic stress disorder (PTSD), which was first popularly applied to veterans of the Vietnam War in the 1970s. Today the term shows up regularly in headlines and in magazine articles, in TV news accounts and on websites. Although some mental health professionals protest that posttraumatic stress is not a “disorder” but rather a normal reaction to extraordinary and disturbing events, the term is widely understood to convey that a person’s ability to cope and function has been significantly impaired.

Another trauma-related term developed in the ’90s is much less familiar to the general public and perhaps even to counselors. But given counselors’ focus on wellness and growth, both Lea Flowers and Gerard Lawson believe this term — posttraumatic growth — should be on the tips of their colleagues’ tongues in the counseling profession.

As defined by Richard Tedeschi and Lawrence Calhoun, psychology professors at the University of North Carolina Charlotte who pioneered the development of research and theory concerning posttraumatic growth (PTG) in the ’90s, PTG is a “positive psychological change experienced as the result of the struggle with highly challenging life circumstances.” To meet the criteria for PTG, the transformation the person goes through must be a by-product of the traumatic experience itself. PTG is not simply a “return to baseline functioning,” which more accurately characterizes resilience.

Lawson, president of the Association for Counselor Education and Supervision, a division of the American Counseling Association, says a general awareness of “adversive growth” spans back to World War I, “but the language was always pretty loose, and the research was not there.” He credits Tedeschi and Calhoun with giving form to the concept of PTG but acknowledges that it has taken some time for the concept to catch on, especially in the face of much greater publicity concerning PTSD.

“We need to focus on the client’s growth and not just the disorder as it relates to trauma,” says Lawson, who chairs the ACA Crisis Response Planning Task Force. “This is right in our wheelhouse as counselors. What are the strengths that this person continues to demonstrate despite [his or her] traumatic experience? We need to be deliberate about highlighting those for our clients.”

Flowers, a licensed professional counselor and ACA member who co-directs the Post-Traumatic Growth Research Team at Georgia State University, agrees. “As counselors, we are positioned to really make this concept come alive,” she says. “Posttraumatic growth really fits with our wellness and growth-oriented perspective. [With PTG] you’re not trying to figure out what’s sick and what’s not working but rather how the person coped and was transformed because of [the traumatic event]. It’s less about identifying symptoms and deficits and more about using the process as a root for growth. We will find that this is where counselors can come alive because we’re facilitators of hope and change. We’re trained to do this. That’s not what our cousins in social work and psychology necessarily do.”

Personal experience

Both Flowers and Lawson are strong advocates for counselors applying PTG principles in their trauma work with clients. This is due in large part, they acknowledge, to their personal connections to two of the most traumatic events in recent U.S. history — the devastation wrought by Hurricane Katrina in 2005 and the mass shootings by a student on the campus of Virginia Tech in 2007.

Lawson, an associate professor of counselor education at Virginia Tech, was among the key players on what came to be known as the Mental Health Advisory Group, a collaborative panel that met the day after the mass shootings to develop a strategy for providing mental health support to the entire Virginia Tech community. In the near-term aftermath of the shootings, Lawson recalls, “there was lots of exposure to PTSD, and the focus” — both in the media and within the university community — “was very much on that. But as the situation evolved some, our counseling program decided that we had to advocate for a focus on resilience and posttraumatic growth. We started asking, ‘How do we tell how our campus is doing?’ If you focus on the negative, you’re going to see the negative.”

While Lawson witnessed and helped facilitate PTG on the Virginia Tech campus, Flowers had an even more personal brush with PTG. She was in the final stages of securing her doctorate at the University of New Orleans (UNO) when Hurricane Katrina bore down on the city. Like thousands of others, she was forced to evacuate. Tuning in to coverage of the natural disaster on CNN, she was astonished to see police officers and Coast Guard personnel in a boat, cruising down the street where her home was located.

Flowers stayed with family members and lived in hotels while completing her doctorate at UNO. “I remember defending my dissertation and gutting my house in the same day,” she says. “I lost everything I owned. I lost my whole city. Everything I had was gone except for my dissertation. … What I was experiencing, what my community was experiencing, what my family was experiencing was PTSD.

“But when I started talking to people, I noticed their strength. There was a shift in our life perspective. It was a collective experience. Up until that date [when Hurricane Katrina struck], my datebook had really mattered to me. After Katrina, I was just focused on the present moment. That was a huge transformation for me.”

Flowers recalled that most of the trauma studies and training she had been exposed to previously had been focused from a crisis perspective. Recognizing that she and others she knew had been transformed in positive ways in the wake of a traumatic event, Flowers began searching for an alternative perspective and uncovered information on PTG. “I didn’t find that counselors were gravitating to trauma work, so I was excited when I discovered there was a place in trauma where I could be comfortable. Posttraumatic growth resonated with my training and who I was as a counselor. It still speaks to me today, both as a person and a professional.”

A former assistant professor at Georgia State and clinical supervisor of counselors-in-training, Flowers now owns Chrysalis Counseling and Consulting, a private practice through which she offers consulting services to organizations and professionals and provides growth-oriented counseling services for women. The mission of the practice is explained on its website: “To help facilitate a transformative process for our clients building upon her inner strengths and resilience.”

Domains of change

It is important for counselors to understand the distinction between resilience and PTG, Flowers says. While resilience implies a resistance to the negative impact of trauma, PTG implies a significant and positive change in the person. Another way to put it: “Resilience is how we get through the trauma using our coping skills,” Flowers says. “Posttraumatic growth is how we are transformed because of the trauma.”

She uses the organization Mothers Against Drunk Driving (MADD) and the TV show America’s Most Wanted as recognizable examples of PTG in action. In both instances, parents who experienced the loss of children to tragic and disturbing circumstances were transformed by the experience and took action to create positive change as a result.

Flowers also points to Steve Jobs, the visionary co-founder, chair and CEO of Apple Inc., who in a commencement address at Stanford University in 2005 described getting fired in a public and humiliating way at age 30 from the very company he had helped to build from the ground up.

“I didn’t see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me,” Jobs told the audience. “The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.

“During the next five years, I started a company named NeXT, another company named Pixar and fell in love with an amazing woman who would become my wife. Pixar went on to create the world’s first computer-animated feature film, Toy Story, and is now the most successful animation studio in the world. In a remarkable turn of events, Apple bought NeXT, I returned to Apple, and the technology we developed at NeXT is at the heart of Apple’s current renaissance. … I’m pretty sure none of this would have happened if I hadn’t been fired from Apple. It was awful tasting medicine, but I guess the patient needed it.”

“When I read this,” Flowers says, “I thought, ‘This is PTG. This is PTG in a big way.”

At the same time, Flowers cautions that all individuals who experience major life crisis will not necessarily experience PTG, and if they do, it may not show itself in a grand public manner. “Transformation is personal,” she says. “Everyone will not do something with large public impact as a result of posttraumatic growth.” What is important, she adds, is that the transformation is personally meaningful and recognizable to the client, which is where counselors can be of great assistance.

In their research, Tedeschi and Calhoun identified five domains in which positive changes take place in the PTG process:

• Greater appreciation of life and a changed sense of priorities. This suggests that clients have faced their mortality and no longer take life for granted, Lawson says. Flowers adds that this domain represents a change in philosophy concerning what really matters in life.
• Greater sense of personal strength. In this domain, clients have discovered they are able to overcome challenges they might not have thought possible before, Lawson says. At heart, Flowers says, this represents a change in perception of self — “If I could get through this, I can get through anything.”
• Warmer, more intimate relationships with others. This most often manifests itself as an ability to relate to others in a deeper, more meaningful way, Lawson says. Flowers says PTG in this area might also lead to reconciling relationships with others or bonding with another individual or group because of a shared experience.
• Recognition of new possibilities or paths for one’s life. “They begin to see life with a broader view, perhaps because they learned something about themselves through the traumatic experience,” Lawson says.
• Spiritual development. Both Lawson and Flowers point out that this domain is not necessarily about an increase in religious behavior, such as attending religious services more frequently, but rather feeling a stronger connection to God or another spiritual power. In many instances, this spiritual development helps those who have gone through a traumatic event to make meaning of the experience or to make meaning in other areas of their life where it had been absent previously.

Windows of opportunity

The possibility that client growth can potentially be cultivated out of a traumatic experience will be a revelation to some counselors. But Lawson says the fresh thinking shouldn’t stop there. “Counselors really need to expand the way they think about traumatic events in general,” he says.

This includes having an understanding that trauma isn’t limited to large-scale natural disasters, terrorist attacks and other instances of mass violence, or war-related experiences. According to the current version of the Diagnostic and Statistical Manual of Mental Disorders, an event can be considered potentially traumatic if 1) “The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” or 2) “The person’s response involved intense fear, helplessness or horror.”

More than 80 percent of people will be exposed to a traumatic event in their lifetime, Lawson says, and most of these events, such as instances of bullying or domestic violence, will never make the news. “The work we do these days as counselors puts us in direct contact more often than we may recognize with clients who have been traumatized,” Lawson says. “Given the numbers of people exposed to trauma, we need to not focus solely on the negative side of the trauma equation.”

In trying to implement the PTG concept in their work with clients, counselors should keep several important points in mind.

First, says Flowers, PTG is not an intervention but rather a way of conceptualizing the client and the treatment plan. “Posttraumatic growth is more of a perspective or a process that you integrate into whatever approach you are using with the client,” she says, adding that it weaves particularly well into existential, narrative and cognitive-based interventions.

Second, PTG is not a given with every client. “Just because there has been a traumatic experience does not mean there will be a growth experience,” Flowers says, “or that there will be a growth experience soon.”

Lawson adds that clients who were closer to healthy functioning before exposure to a traumatic event generally are also better positioned to experience PTG than clients who were already struggling to function before the trauma. This also aligns with the literature regarding which individuals are more susceptible to experiencing PTSD, he says.

Third, PTG should never be forced on or demanded of the client. “In embracing posttraumatic growth in our work, we have to be careful that we don’t come off as Pollyanna when the person just lost their house,” Lawson says. “We have to be sure that we are patient with the process of grieving and allowing clients to work through issues that are completely normal after a traumatic event. We don’t want to rush them to look better, feel better, function better. But at the same time, through the normal course of conversation, we want to highlight ways that the client may be moving [through the five domains of change]. We begin talking about it with the client in terms of, ‘And where will this take you?’”

Although there is no prescribed timetable dictating exactly when to incorporate the PTG concept into treatment with traumatized clients, Lawson says the “immediate noise from the trauma begins to calm down” three to six months after the event. “In that window especially, we begin to look at opportunities for growth,” he says. “We don’t want to be there immediately [after the traumatic event] to pounce on them, but we want to be able to be there to offer support when they need support and before their trauma membrane fills back over. It’s much harder to go back in after the fact.”

“Posttraumatic growth is not something to consider when clients are in crisis,” Flowers adds. “Growth is further down the line for these clients because we first have to help manage the initial crisis, then after things have stabilized, help facilitate them through a more reflective process. … Timing is a huge part of [the PTG process]. Counselors may have terminated their work with these clients when growth finally happens. We may just be there to plant seeds. Likewise, the client’s transformation might be very incremental instead of dramatic.” She also points out that distress from the trauma might continue even as growth is happening, meaning the two are not mutually exclusive.

The role of the counselor

No special training is needed to integrate the PTG process into counseling work, Lawson says, but a certain skill set is required to support PTG properly. “Counselors need to be comfortable doing posttraumatic work and tuned in to the factors for posttraumatic growth,” he says. “You also have to be willing to sit with clients’ grief and loss and capable of identifying their strengths. Then you need to encourage them to answer some questions: How are you going to be able to see the world in a broader way? Where are we going to focus our energy? What are we going to pay attention to?”

Flowers says counselors have been provided with all the basic tools they need in their training programs to integrate PTG into their work, but she suggests looking at growth-oriented models and frameworks to grow more comfortable with the PTG process. “Posttraumatic growth will change your clinical mindset,” she asserts.

According to Flowers, the main role of the counselor is to be a facilitator in the PTG process (rather than trying to be the “creator” of growth), to serve as a companion to the “expert” (the client) and to help the client engage in meaning-making concerning what has happened to him or her.

Using a narrative approach with clients works particularly well in identifying and cultivating PTG, Flowers says, although she adds that counselors must exude patience, empathy and a willingness to meet clients where they are at that moment. “You listen to how they story their experience and stay alert to changes in perception they have had since experiencing the trauma,” she explains. “You want to help them restory their narrative from traumatic and distressing to positive and growth-inducing, but you first have to respect the trauma survivor’s struggle. You may listen to their story and assess that they’re not yet ready to restory their experience. But keep in mind that you’re not the expert — they are. You’re coming along as the expert’s companion. You don’t want to lead the client. That can be almost as damaging as the trauma itself because it can sound like you’re diminishing what happened to them.”

Flowers breaks the narrative approach incorporating a PTG focus into simple-to-understand steps: Listen to the client’s story, reflect the story back to the client using his or her own language and then highlight for the client how he or she has emerged from the traumatic experience and been transformed in a positive way.

“You’re using very basic counseling skills in this process but helping to facilitate hope,” Flowers says. “Our job is to help clients see those areas of transformation when they’re ready and to help them make meaning of whatever is left. We’re trying to move them from a feeling of hopelessness to a feeling of hopefulness.”

Both Flowers and Lawson view PTG as an exciting and beneficial yet relatively undeveloped frontier in trauma work — a frontier that would seem particularly inviting for counselors to explore and, potentially, to break new ground in.

“Right now,” Flowers comments, “there is nothing that says, ‘These are the proper techniques you use for posttraumatic growth.’ I believe counselors are best positioned to perhaps identify or even develop those techniques.”

Lawson concurs. “This philosophy is so consistent with our approach as counselors that the natural next step is for counselors to take the lead in how clients can maximize posttraumatic growth. We need to be the ones to answer the unanswered questions about posttraumatic growth.”

 

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For more information about PTG, contact Gerard Lawson at glawson@vt.edu and Lea Flowers at drleaflowers@gmail.com.

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.