mental health AIDS

Winter 2007 Newsletter / Volume 8, Issue 2

From Surviving to Thriving: HIV-Associated Posttraumatic Growth

Calhoun and Tedeschi first described "posttraumatic growth" (PTG) in 1995. Since that time, they have further refined their thinking on this topic through clinical experience, scholarly interchange, and the examination of emerging empirical evidence (Calhoun & Tedeschi, 2004; Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 2004).

As we have conceptualized it, the process of [PTG] is set in motion by the occurrence of a major life crisis that severely challenges and perhaps shatters the individual's understanding of the world and his or her place in it. Certain kinds of personal qualities – extraversion, openness to experience, and perhaps optimism – may make growth a bit more likely. Initially, the individual typically must engage in coping responses needed to manage overwhelming emotions, but intense cognitive processing of the difficult circumstances also occurs. The degree to which the person is engaged cognitively by the crisis appears to be a central element in the process of [PTG]. The individual's social system may also play an important role in the general process of growth, particularly through the provision of new schemas related to growth, and the empathetic acceptance of disclosures about the traumatic event and about growth-related themes. [PTG] seems closely connected to the development of general wisdom about life, and the development and modification of the individual's life narrative. Although [PTG] has been found to be correlated with a reduction of distress, our thinking is [that] some degree of psychological upset or distress is necessary not only to set the process of growth in motion, but also some enduring upset may accompany the enhancement and maintenance of [PTG]. (Tedeschi & Calhoun, 2004, pp. 12-13)

In their view, PTG "is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life" (Tedeschi & Calhoun, 2004, p. 1).

PTG & HIV

"Although the psychological sequelae of HIV infection include … depression, anxiety, fear, helplessness, and guilt, there is growing evidence that positive changes attributed to diagnosis and living with HIV/AIDS occur. These positive changes ... may influence the adaptation to this disease, from infection to disease progression/stability and death" (Milam, 2006a, p. 214).

In this way, Milam initiates his summary of the evolving body of research on PTG among people living with and affected by HIV/AIDS (2006a), as well as his own research on the relationship between PTG and HIV disease progression (2006b).

According to Milam, "there is research documenting positive changes and strengths in people living with HIV/AIDS. Studies indicate that between 59% to 83% of people living with HIV/AIDS report experiencing positive changes since diagnosis ..." (2006a, p. 215). Importantly, "[a]lthough quantitative work is increasing, the majority of the published work explicitly examining PTG (and related constructs) among HIV-positive populations is qualitative" (2006a, p. 215). Other findings reported by Milam (2006a) include the following:

• "Although [antiretroviral therapy] use has been positively associated with PTG, initiating or discontinuing [antiretroviral therapy] use has not been associated with PTG over time ..." (p. 216).

• "There are positive relationships between PTG and various health behaviors ... . That is, in addition to positive changes in relationships and life priorities, positive changes in health behaviors (diet, exercise, etc.) can also stem from HIV diagnosis ..." (p. 216).

• "[A] majority (78-82%) of HIV/AIDS caregivers report PTG. In addition, PTG was most likely to occur among individuals who have strong spiritual beliefs, support from family and friends, and high levels of distress" (pp. 216-217).

• "Research among HIV/AIDS caregivers and patients find[s] spiritual/religious beliefs/ practices [to] be associated with both PTG and psychological adjustment ... . These results support the notion that …[religiousness]/spirituality can predispose one toward PTG by providing a framework ... through which a trauma can be appraised, and/or a social network that provides ongoing support" (p. 217).

• "[A]mong people living with HIV, PTG may occur immediately after diagnosis. In a study excluding recently diagnosed patients (< 3 months), PTG had a weak inverse correlation with time since diagnosis ..." (p. 217).

• "Among HIV patients, a significant inverse correlation is found between age and PTG, such that older participants experience less PTG ..." (p. 217).

• "Women generally report more PTG than men ..., and this relationship is also seen among persons with HIV/AIDS ..." (p. 217).

• "Because there is some evidence that PTG and SES [socioeconomic status] are positively associated ..., it is generally expected that higher SES would predict greater PTG, as PTG may require personal resources that are not available to lower SES individuals. However, the data among HIV populations … [are] mixed; one study found a positive association with SES ... while another found no such association ..." (p. 217).

• "Race and ethnic differences in PTG are unknown as most studies concerning PTG have not focused on this issue. Current reports do not suggest clear ethnic differences. One study among women finds White participants to report more PTG ... whereas another among both women and men finds non-White participants to report the most PTG ..." (p. 218).

• "Although cross-sectional results show optimism is positively associated with PTG among people living with HIV/AIDS, this relationship has not held up in longitudinal analyses; optimism has failed to predict PTG over time ... . Nevertheless, these results provide evidence that PTG does not simply reflect an underlying optimistic disposition" (p. 218).

• "Although HIV diagnosis is the beginning of a difficult time requiring ... ongoing adjustment to many issues, including depressive symptoms, PTG will commonly co-occur with the negative psychological sequelae of a diagnosis of HIV/AIDS. However, PTG is hypothesized to aid in the ongoing adjustment to HIV as indicated by higher levels of mental health indicators.

• In a longitudinal study, baseline levels of PTG did not significantly predict depression levels over time among HIV patients ... . However, change in PTG was a significant predictor of depressive symptoms over time; those who always experienced PTG or gained PTG from baseline to follow-up had fewer depressive symptoms over time compared to those who never experienced or lost PTG from baseline to follow-up ... .

• ... These results suggest that the process of PTG, achieving and maintaining positive changes, is associated with lower levels of depressive symptoms/distress over time. However, this relationship is likely reciprocal. That is, among HIV patients, developing and maintaining PTG has a protective effect on the development of depressive symptoms, whereas the presence of depressive symptoms is an impediment to achieving PTG" (p. 218).

• "A number of studies have exclusively examined PTG among women living with HIV/AIDS. These studies find PTG to be associated with [SES] ... and to include positive changes in health behavior ... . ... [One investigator] found HIV-positive women with children to report less PTG than those without children. This result suggests that burdens and responsibilities associated with caregiving for children may hamper PTG for HIV-positive mothers" (pp. 218-219).

• "[A] number of studies have found salutary relationships between positive psychological factors and HIV disease progression ... . Early evidence suggests that PTG may also be one of these factors.

• ... [A] study among HIV-positive men and women found those with undetectable viral load (< 500) to have significantly higher PTG scores ... . Although PTG was not associated with viral load over time, it was associated with CD4 counts over time, particularly among non-Whites ... . That is, for non[-]White participants, those who experienced PTG had higher CD4 counts over time compared to those who did not experience PTG ... . Importantly, this interaction was not explained by differences in depressive ... [symptoms], or health behaviors.

• These preliminary results provide some promising evidence suggesting that PTG may influence the course of HIV disease ... " (2006a, p. 220).1

Bring On the Healing 

In introducing a special section of the Journal of Consulting & Clinical Psychology on PTG, Park and Helgeson (2006) point out that, 

to date, interventions generally have not been explicitly aimed at increasing perceptions of growth, with the exception of several writing studies, most of which were not designed as clinical interventions. In fact, given the conceptual and empirical questions posed ... [in this literature], clinical applications need to be made cautiously. The field is not yet at a place in basic research to endorse the development of large-scale growth interventions applied to people who have undergone traumatic life events. Until researchers understand more about the origins of growth, the conditions under which growth is veridical [i.e., actually occurring], and the best way to assess growth, links to psychological and physical health will not be fully understood. Without this latter knowledge, it may be ethically irresponsible to attempt growth-based interventions with a highly distressed population. However, this does not preclude more limited experimental studies of growth to answer some of these questions. (p. 795)

Fortunately, as Calhoun and Tedeschi make clear,

we are not proposing a new form of treatment, but rather looking for ways to integrate the perspective of PTG into common approaches to therapy for survivors of trauma. ... We believe our approach can fit with any sound intervention, but it may be particularly compatible with cognitive, narrative, and existentially based treatments ... . Our description of therapy takes into account ... [the elements of our model of PTG], using them as a guide to inform the clinician about how to focus treatment as the trauma survivor's responses gradually flow through the sequence proposed in the model, from early responses characterized by distress and intrusion to outcomes of PTG, revised narrative, and wisdom. (Calhoun & Tedeschi, 2006, p. 291)

As Calhoun and Tedeschi continue, "[i]t is not possible for us to be formulaic about the clinical maneuvers to make in an approach to trauma treatment that includes the consideration of PTG. There is much in timing and subtle commentary that is involved – but the principle of expert companionship can guide clinicians working with trauma survivors to do the kinds of things that are likely to allow for and support this PTG" (Calhoun & Tedeschi, 2006, p. 303). "We consider ourselves to be facilitators of PTG that is created or discovered by persons who are able to process information about themselves in the aftermath of trauma in a relationship with an expert companion" (Calhoun & Tedeschi, 2006, p. 298). Zoellner and Maercker (2006) offer suggestions to clinicians on how such facilitation might occur (see sidebar).

With regard to persons living with HIV/AIDS, Milam (2006a) is quick to point out that, although "preliminary research finds salutary relationships between PTG and markers of disease course and important health behaviors" (p. 221), "positive thinking is not a panacea. That is, any intervention designed to enhance perceptions of positive changes should continue to emphasize traditional health care and a realistic assessment of one's health status. Further, patients should not be chastised for holding negative attitudes" (p. 221).

– Compiled by Abraham Feingold, Psy.D

References 

Calhoun, L.G., & Tedeschi, R.G. (2004). Authors' response: "The foundations of posttraumatic growth: New considerations." Psychological Inquiry, 15(1), 93-102.

Calhoun, L.G., & Tedeschi, R.G. (2006). Expert companions: Posttraumatic growth in clinical practice. In L.G. Calhoun & R.G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice (pp. 291-310). Mahwah, NJ: Erlbaum.

Milam, J. (2006a). Positive changes attributed to the challenge of HIV/AIDS. In L.G. Calhoun & R.G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice (pp. 214-224). Mahwah, NJ: Erlbaum.

Milam, J. (2006b). Posttraumatic growth and HIV disease progression. Journal of Consulting & Clinical Psychology, 74(5), 817-827.

Park, C.L., & Helgeson, V.S. (2006). Introduction to the special section: Growth following highly stressful life events – Current status and future directions. Journal of Consulting & Clinical Psychology, 74(5), 791-796.

Tedeschi, R.G., & Calhoun, L.G. (2004). Target article: "Posttraumatic growth: Conceptual foundations and empirical evidence." Psychological Inquiry, 15(1), 1-18.

Zoellner, T., & Maercker, A. (2006). Posttraumatic growth and psychotherapy. In L.G. Calhoun & R.G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice (pp. 334-354). Mahwah, NJ: Erlbaum.

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PTG Pointers for Clinicians

Zoellner and Maercker (2006) offer the following set of guidelines to assist clinicians with incorporating a PTG perspective into their work with trauma survivors:

• Therapists should have an understanding of how the process of working through the impact of trauma is ... often associated with the development of a new self-understanding, a new understanding of the "outer world," and the relationship between the two. ...
  
  
• When patients describe positive changes as the result of their struggle with trauma, clinicians should support, emphasize, and encourage those perceptions. Because positive illusions have been demonstrated to be associated with positive adaptation to trauma and other stressful events, there seems to be no harm for patients when therapists directly address the issue of positive changes, personal growth, or benefits from coping with the traumatic event.
  
  
• In doing so, therapists should have a tolerance for obvious false, naїve, unverifiable positive illusions and positive interpretations. ... In psychotherapy, what is helpful and useful for patients is more essential than what is truthful. ... [Tolerate] obvious positive illusions held by the patient ... [if] those positive illusions, including personal growth perceptions, ... [do not] hinder a constructive, adaptive recovery and healing process.
  
  
• Psychotherapy constitutes a good context [in which] to explore positive change in the aftermath of crisis. The simultaneous ... [acknowledgment] of patients' suffering and the negative impact of trauma on their lives within the therapy process, enables clients – on the basis of a trustful and intimate therapeutic relationship – to also explore positive changes as [a] result of their coping process. Outside of the therapeutic context, clients may have been given advice by friends to "see the positive" or "concentrate on the good things" when having talked about the negative impact of trauma. That kind of rushed advice is usually not helpful because it is often linked to the denial of suffering and existing negative consequences. It goes without saying that therapists, when fostering growth within psychotherapy, should avoid ... [this] doctrine ... .
  
  
• This professional avoidance should be accompanied by an open-minded attitude on the part of the therapist that allows patients to find their own specific meanings, interpretations, way[s] of coping, and recovery. Perceptions of growth should be supported and encouraged when they occur or they can be directly addressed by the therapist, but the absence of growth or benefit finding by the patient should not be regarded as a failure. If patients can not see any positives in their struggle with crisis, the issue should be dropped, at least for some time, and therapeutic efforts should continue to reduce distress and encourage a constructive coping process.
  
  
• Also, patients' individual differences should be considered when incorporating those issues. ... [C]lients' belief systems, personality characteristics, and coping styles will predispose them toward particular appraisals and coping responses[,] making the perception or experience of growth more or less likely and more or less important for individual adjustment.
  
  
• Addressing issues of growth, benefit finding, meaning construction, and the like need[s] proper timing. In the immediate aftermath of crisis and the first coping stage, it does not seem to be useful to lead clients to focus on positive changes. Before addressing those issues, the most extreme distress needs to be reduced and some coping success need[s to occur] ... . As a ... [rule] of thumb, one could plan to address or be especially alert to those issues during the last third of therapy.
  
  
• Whether or not the role of the therapist should be more passive or active in addressing issues of growth depends on the patient's individual character, psychiatric disorders, and the reasons for ... [seeking] treatment. ... In the treatment of particular patient populations, such as trauma survivors, medically ill patients, or bereaved individuals, the inclusion of an existential dimension, and issues of meaning and growth, are probably more important for psychological adaptation and well-being than for some other patient populations. In those cases, therapists should take on a more active role and possibly incorporate explicit elements intended to foster growth from adversity. ... (pp. 350-352)

Reference

Zoellner, T., & Maercker, A. (2006). Posttraumatic growth and psychotherapy. In L.G. Calhoun & R.G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice (pp. 334-354). Mahwah, NJ: Erlbaum.

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