Theoretical and Methodological Issues in the Assessment and Interpretation of

Posttraumatic Growth
Author(s): Susan Nolen-Hoeksema and Christopher G. Davis
Source: Psychological Inquiry , 2004, Vol. 15, No. 1 (2004), pp. 60-64
Published by: Taylor & Francis, Ltd.

Stable URL: https://www.jstor.org/stable/20447203

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 COMMENTARIES

Theoretical and Methodological Issues in the Assessment and

Interpretation of Posttraumatic Growth

Susan Nolen-Hoeksema
Departnment of Psychology
University of Michigan

Christopher G. Davis
Department of Psychology
Carleton University

Although the idea of growth following adversity is McFarland & Alvaro, 2000). Some suggest that such
not new to humanistically oriented counseling psy reports are, in part, examples of active coping efforts
chologists, few researchers gave much attention to (e.g., Affleck & Tennen, 1996; Stanton et al., 2002),
such a notion until the late 1 980s. Since then, Tedeschi whereas others suggest that self-reported growth re
and Calhoun have been at the forefront of efforts to flects an outcome or an adaptation. Tedeschi and
document the evidence for posttraumatic growth, and Calhoun (this issue) argue for the latter, although they
to suggest the processes by which distressing negative acknowledge that such reports of growth are not con
events may become catalysts for personal develop sistently correlated with traditional indicators of psy
ment, values reorganization, and the like (e.g., chological adjustment.
Tedeschi & Calhoun, 1995). In contrast, advocates of the former positions
With the recent focus on optimal human functioning, (growth as self-enhancement and growth as active cop
resilience, and well-being, research on posttraumatic ing) have presented evidence that suggests that reports
tgrowth has become popular. As increasing numbers of of growth do not necessarily represent an adaptation or
psychologists consider the potential for positive adapta an outcome. For instance, in a series of lab studies,
tional outcomes following adversity (as opposed to the McFarland and Alvaro (2000) showed that when peo
traditional focus on pathology), they have come to rec ple who have experienced trauma report "growth,"
ognize the startling frequency with which reports of they are reporting on a temporal comparison of their
growth, benefits, and other positive life changes are re present perceived status to a negatively biased percep
ported. Initially, such reports were anecdotal and de tion of their former self. The extent to which they dero
scriptive, but in recent years researchers and theorists gate their former self is directly proportional to the
have begun to consider the meaning of such reports. In (self-reported) severity of the trauma they experi
their target article, Tedeschi and Calhoun (this issue) enced. The more severe one rates the trauma, the worse
move the field ahead in this respect. They offer a con one claims to have been on a relevant characteristic. It
ceptual model to explain the disparate findings spanning is not that one is better than others on a particular di
a variety of populations and research approaches and
mension as a result of the experience with trauma, but
methods. In our commentary on their target article, we
rather that one perceives oneself to be better than a
draw attention to some unresolved theoretical issues, at
negatively biased image of one's former status on this
tempt to clarify some ambiguities, and make some
dimension. McFarland and Alvaro suggested that by
methodological suggestions for future research. Our
putting down one's former self, one is able to maintain
goal is to contribute to future research that elucidates
or protect an integrated and positive sense of self. Con
when posttraumatic growth has occurred, why it has oc
sistent with this, in one study McFarland and Alvaro
curred, or how it has occurred.
(2000, Study 4) demonstrated that threatening self-rel
evant feelings actually increased the extent of
posttraumatic growth reported. In this sense, reports of
The Meaning of Self-Reported Growth growth are not entirely veridical; they are cognitive il
lusions motivated by a need for self-protection or
Descriptive accounts of self-reported growth self-enhancement.
abound (as reviewed in the target article). We know Equally compelling are studies that suggest that
that following almost any imaginable trauma, at least the pursuit of growth or benefits is an active, inten
50%/k of those most directly affected are apt to report at tional coping strategy. Carver, Scheier, and
least one positive life change or benefit that they link Weintraub (1989) included in their coping inventory
directly to their experience. What these reports of the category of positive reinterpretation, which in
growth mean, however, is a matter of debate. Some cludes items such as "I try to grow as a person as a
suggest that such reports are, at least in part, examples result of the experience" and "I look for something
of self-enhancing and self-protecting illusions (e.g., good in what is happening." Similarly, Affleck and

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 COMMENTARIES

Tennen (1996) developed a survey questionnaire to tor researchers to assess these dimensions directly
assess the extent to which people intentionally "re and over time in an effort to gather evidence that in
mind themselves of some of the benefits that have fact people are changing.
come from [a particular adversity]" (p. 915), and In our research, we have assessed perceived benefits
find that daily scores on this measure correlate posi with an open-ended question (Davis, Nolen-Hoeksema,
tively with more pleasant daily mood. Taking this & Larson, 1998) and have avoided the use of
idea further, Stanton and colleagues (2002) experi multi-items assessment tools for measuring this con
mentally manipulated the extent to which people struct. We have then used this measure to predict tradi
with cancer seek benefits. In their study, a random tional indicators of psychological distress and
third of their sample of cancer patients was in well-being, assessed contemporaneously and subse
structed to write for 20 min. for 4 days on the bene quently. Although this approach does not shed light on
fits that had accrued from their experience with can whether perceived growth or benefits are veridical, it
cer, whereas another third wrote about their does allow us to show the change in one's well-being
emotions, and the final third wrote about the facts trajectory over time as function of whether one reports
regarding their cancer. Not only did those in the growth (in this case, taking into account preloss status
"benefits" condition more strongly perceive that on well-being). Others who have used a similar method
their involvement in the study produced long-term ology (multiple waves of data, and an open-ended, sin
positive effects and the study was personally more gle-item measure of benefits or growth) also have
meaningful relative to the "facts-only" group (as shown that those who report such benefits or growth
sessed 3 months later), they actually had fewer can tend to be better adjusted (psychologically or emotion
cer-related medical appointments in the 3 months af ally or in terms of their physical health) than those who
ter the experimental manipulation. Stanton et al. report no benefits or growth (e.g., Affleck, Tennen,
also reported effects for the benefits group on mood, Croog, & Levine, 1987; Affleck, Tennen, & Rowe,
although these effects are strongest for avoidant 1991; McMillen, Smith, & Fisher, 1997).
copers. In sum, a strong case has been made that We have resisted the use of multi-item checklists
self-reported growth may reflect cognitive illusions for the assessment of growth because we notice that
designed to protect or enhance self-worth as well as checklists tend to elicit higher rates of growth than is
active coping efforts used by some people to in the case with single, open-ended questions. Most who
crease mood. Both positions imply that self-reported have measured this construct with a single item find
growth is at best an indirect measure of adaptation. that 20% to 50% of the sample report no benefits or
In their argument for posttraumatic growth, growth (e.g., Affleck et al., 1987; Affleck et al., 1991;
Tedeschi and Calhoun (this issue) suggest that such Davis et al., 1998; Lehman et al., 1993; McMillen et
self-reports represent both a process and an outcome. al., 1997). In contrast, studies using a checklist ap
Methodologically, they treat scores on the proach routinely find that everyone reports at least one
posttraumatic growth scale as an outcome or criterion benefit or area of growth, with most participants re
variable, predicted by personality variables, coping porting 15 to 30 such changes (e.g., Frazier, Conlon, &
behavior, and characteristics of the event. They de Glaser, 2001; Park, Cohen, & Murch, 1996; Tedeschi
scribe the growth process as iterative, as a process of & Calhoun, 1996). Although it may be that single-item
discovery comparable to the development of wisdom. questions underestimate the extent of perceived bene
In their view, people do not seek out growth, they re fits or growth, it is notable that researchers who use
alize it. This view is consistent with the writings of this approach quite consistently find that the bene
Maslow and others in this tradition, but presents some fit-no benefit distinction predicts psychological ad
important methodological challenges for researchers. justment (and, when measured, physical health).
Given the alternative meanings of self-reported Moreover, we would argue that this 0 versus greater
growth discussed earlier, it is necessary for research than 0 distinction is critical. That is, it is not how many
ers to establish valid measures of the particular di changes that is important, but rather whether any bene
mensions expected to change as a result of trauma, fit has been realized. Participants in our research who
and to use prospective, longitudinal designs to test for report no benefits tend to be struck by the perception
these changes. Cross-sectional, retrospective assess that no good has emerged from their experience. They
ments of personal change have been useful in drawing often wish that something good might come of this ex
attention to the phenomenon, but will not in our view perience, but lament that nothing has. This lack of
be effective in documenting the meaning of such re meaning is yet another stressor to bear.
ports, nor the process by which change might be oc It is easy to be skeptical of life change reports
curring. Work by Tedeschi, Calhoun, and others has checked on a pencil-and-paper checklist. It is much
been instrumental in parsing the common dimensions more difficult to be skeptical of detailed personal ac
of purported change (e.g., coping resources, values, counts of how one has grown from one's experience
spirituality, relationship depth). Now it is necessary with trauma. The personal accounts provided by our

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 COMMENTARIES

research participants are often compelling, and are ar tion designed to distract participants from any ongoing
ticulated in great detail with significant passion. Nev ruminations leads to significant decreases in depres
ertheless, we entertain the notion that such reports may sive symptoms in dysphoric participants (see
to some degree represent something other than psycho Lyubomirsky & Tkach, 2003, for a review). Rumina
logical adjustment, such as a cognitive adaptation to tion inductions also lead dysphoric participants to
threatening events (Davis & McKearney, 2003; Green think more negatively about their past, present, and fu
wald, 1980; McFarland & Alvaro, 2000; Taylor, ture, and to generate relatively poor solutions to diffi
1983). This should not imply that growth does not oc cult interpersonal problems. Importantly, neither the
cur; such self-protection may pave the way for subse rumination nor distraction induction have significant
quent growth. effects on the depressive symptoms, thinking, or prob
lem solving of nondysphoric participants.
In our longitudinal survey studies, we have
The Meaning of Cognitive Processing operationalized rumination with the Response Styles
or Rumination Questionnaire (RSQ). This questionnaire asks partici
pants how they generally respond when they feel sad,
A cornerstone of Tedeschi and Calhoun's (this is blue, or depressed. The rumination items on this ques
sue) theory of posttraumatic growth is the assertion tionnaire tap thoughts about regrets ("think about a re
that cognitive processing, which they also refer to as cent situation, wishing it had gone differently"),
rumination, plays a crucial role in the process of questions about one's own reactions ("think 'Why
posttraumatic growth. They note that soon after a can't I handle things better?"'), and self-reflective
trauma, people often experience intrusive, automatic thoughts ("analyze recent events trying to understand
ruminations about the trauma, which can lead to dis why you are depressed"). Several studies using this
tress and disengagement from previous goals and as questionnaire and variations on it have found that peo
sumptions. However, for posttraumatic growth to ple who say they ruminate more when distressed are
occur, people must persist in ruminating about the more likely than nonruminators to have persistent
trauma until they rebuild the assumptions, values, symptoms of depression (see Lyubomirsky & Tkach,
schemas, and personal narratives that are challenged 2003, for a review). For example, in our study of re
by the experience of the trauma. cently bereaved people, we found that ruminators were
Tedeschi and Calhoun (this issue) note that there are more likely to have persistent depressive symptoms
several definitions and operationalizations of rumina and to meet criteria for a major depressive episode
tion in the literature (see Wyer, 1996, for examples). compared to nonruminators in the 18 months follow
They adopt Martin and Tesser's (1996) definition of ing their loss (Nolen-Hoeksema & Larson, 1999). The
rumination as thought that revolves around an instru effects of rumination on later depression tend to be
mental theme of resolving the discrepancy between found even when initial levels of depression are statis
one's past goals and one's current reality. In this sec tically controlled.
tion, we highlight our own work on rumination, which Thus, our past work shows that rumination, as we
we have defined very differently from Tedeschi and have defined it and operationalized it, is associated
Calhoun or Martin and Tesser. Although we agree with with more distress, more negative thinking, poorer
Tedeschi and Calhoun that cognitive processing of a problem solving, and other negative outcomes over
trauma may be necessary for people to rebuild their as time. This might suggest that this type of rumination
sumptions and schemas, and therefore to experience would impede posttraumatic growth following a
posttraumatic growth, we want to raise some questions trauma.
about the nature of this cognitive processing. In our bereavement study, we found that rumina
tion, as we define it, was not associated with finding
benefit in the loss experience at any of the time points
Rumination and Well-Being at which we assessed it (i.e., at 6, 13, or 18 months
postloss; Nolen-Hoeksema & Larson, 1999). Perhaps
We have defined rumination as persistent thoughts this is simply because we are looking at a form of rumi
about one's symptoms of distress, and the possible nation that is very different from the kind Tedeschi and
causes and consequences of these symptoms Calhoun (this issue) argue contributes to posttraumatic
(Nolen-Hoeksema, 1991). In our experimental work, growth.
we have operationalized rumination with an induction Recently, we have been focusing on the different
in which people are directed to focus on their current kinds of rumination that are captured on the rumination
physical and emotional well-being and on self-evalua scale of the RSQ. Using data from a randomly selected
tions. We consistently filnd that this rumination induc community sample of more than I ,3500 adults
tion leads to increased levels of depressive symptoms (Nolen-Hoeksema, Larson, & Grayson, 1999),
in already-dysphoric participants, whereas an induc Trey nor, Gonzalez, and Nolen-Hoeksema (2003)

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 COMMENTARIES

found that the rumination items on the RSQ fall into (f = -.02, ns for self-reported depression; 3 = .001, ns
two factors, which we named brooding and reflection. for interviewer-rated depression).
The brooding items tapped the kind of moody ponder These results largely replicate those of Treynor et
ing that Nolen-Hoeksema (1991) argued is toxic to al. (2003), showing that brooding is significantly re
mental health, and included "think 'What am I doing to lated to both current and future depression, whereas re
deserve this'?'," "think about a recent situation, wish flection is associated with more depression only
ing it had gone better," and "think, 'Why do I have concurrently. We did not find, however, that reflection
problems other people don't have?"' The reflection predicted less depression over time in our bereaved
items were more neutrally valenced, and several ap sample, as Treynor et al. found in their randomly se
peared to tap a resolution-oriented perspective: "ana lected community sample.
lyze recent events to try to understand why you are Reflection was not related to finding benefit in the
depressed," "write down what you are thinking and an loss experience at 6 months, but it was positively re
alyze it," and "go some place alone to think about your lated to finding benefit at 13 months. In contrast,
feelings." brooding was not related to finding benefit at either 6
Treynor et al. (2003) found that although higher or 13 months. We also found that reflection was related
scores on the reflection subscale were correlated with to the use of more reappraisal coping and prob
more depressive symptoms in concurrent analyses, lem-solving coping, whereas brooding was unrelated
higher reflection scores predicted less depression I to both of these growth-oriented coping responses.
year later, controlling for initial levels of depression. In Thus, reflection, which resembles the definition of ru
contrast, higher brooding scores were related to more mination given by Tedeschi and Calhoun (this issue),
depressive symptoms in both concurrent and longitu is associated with benefit finding and with forms of
dinal analyses. Brooding was also more strongly re coping that seem likely to contribute to long-term
lated to a sense of low mastery and experiences of posttraumatic growth.
chronic stress than was reflection. Reflection is more We also asked participants if they had been able to
akin to the kind of rumination that Tedeschi and make sense of their loss (Davis et al., 1998).
Calhoun (this issue) argue contributes to posttraumatic Sixty-eight percent answered "yes" to this question
growth, whereas brooding is more akin to the toxic and gave explanations ranging from "it was meant to
form of rumination that Nolen-Hoeksema's group has be, it was God's will" to "it helped me to grow" to "she
focused on. smoked for years; I always expected her to die of can
For this commentary, we examined whether the re cer." Interestingly, reflection was not related to being
sults Treynor et al. (2003) found with brooding and re able to make sense at 6 or 13 months postloss.
flection in a randomly selected community sample Brooding, however, was negatively related to being
generalized to our bereaved sample (see Davis et al., able to make sense at both 6 and 13 months.
1998; Nolen-Hoeksema & Larson, 1999, for details of Thus, there is some evidence here that the kind of
this sample). Our analyses focused on whether brood cognitive processing indexed by our reflection vari
ing or reflection, measured at 6 months postloss, pre able-which is akin to the definition of rumination
dicted distress or finding benefit in the loss at 6 months used by Tedeschi and Calhoun (this issue)-predicts
or 13 months postloss. finding benefit in the experience of loss. Also, reflec
Brooding was much more strongly related than re tion is associated with the use of reappraisal and prob
flection to self-reported depressive symptoms both at 6 lem-solving in coping, but brooding is not. On the
months (r= .45, p < .001 for brooding; r= .15, p < .01 other hand, when it comes to making sense of the loss,
for reflection) and at 13 months (r = .45, p < .001 for reflection neither helps nor hurts. Brooding neither
brooding, r = .08, tis for reflection). Similarly, brood helps nor hurts finding benefit, but brooding is nega
ing was much more strongly related than reflection to tively related to making sense of the loss.
interviewer-rated depressive symptoms both at 6 With the caveat that the RSQ assesses a dispositional
months (r = .42, p < .001 for brooding; r = . 15, p < .01 thinking style, these results support Tedeschi and
for reflection) and at 13 months (r = .3 1, p < .001 for Calhoun's (this issue) arguments that resolution-fo
brooding; r = .07, ns for reflection). In addition, brood cused cognitive processing assists posttraumatic
ing was a significant predictor of both self-report and growth, at least to some extent. More generally, they
interviewer-rated depressive symptoms at 13 months, suggest that there are different cognitive processing
controlling for scores on the same measure of depres styles that are differentially related to posttraumatic dis
sion at 6 months ( = .21, p < .001 for self-reported de tress and possible growth. Given the apparently deleteri
pression; e = .1 3, p < .05 for interviewer-rated ous effects of the kind of moody cognitive processing
depression). In contrast, reflection was not a signifi indexed by our brooding factor, versus the potentially
cant predictor of either self-reported or inter beneficial effects of the resolution-focused cognitive
viewer-rated depression at 13 months, controlling for processing style indexed by our reflection factor, critical
scores on the same measure of depression at 6 months questions for future research are as follows: What

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 COMMENTARIES

makes some people engage in brooding whereas others Davis, C. G., & McKearney, J. M. (2003). How do people grow from
engage in reflection? Does brooding eventually trans their experience with trauma or loss? Journal of Social and Clin
ical Psychology, 22, 477-492.
form into healthier reflection, as Tedeschi and Calhoun
Davis, C. G., Nolen-Hoeksema, S., & Larson, J. (1998). Making
suggest it might'? We have found no evidence for this in
sense of loss and benefiting from the experience: Two
our studies, but the possibility still remains and should construals of meaning. Journal of Personality and Social Psy
be investigated further. chology, 75,561-574.
On the other hand, does reflection sometimes de Frazier, P., Conlon, A., & Glaser, T. (2001 ). Positive and negative life
changes following sexual assault. Journal of Consulting and
velop into brooding and, if so, under what conditions?
Clinical Psychology, 69, 1048-1055.
Our experimental studies suggest that when dysphoric Greenwald, A. G. (1980). The totalitarian ego: Fabrication and re
people are induced into otherwise neutral self-reflec vision of personal history. American Psychologist, 35,
tion, they lapse into brooding (Lyubomirsky, Tucker, 603-618.
Caldwell, & Berg, 1999). Neutral self-reflection in the Lehman, D. R., Davis, C. G., DeLongis, A., Wortman, C. B.,
Bluck, S., Mandel, D. R., & Ellard, J. H. (1993). Positive and
absence of dysphoric mood remains neutral in tone,
negative life changes following bereavement and their rela
however. This suggests that the mood an individual is tions to adjustment. Journal of Social and Clinical Psychol
in is a critical determinant of whether reflection will ogy, 12, 90-112.
develop into brooding. This is in line with Tedeschi Lyubomirsky, S., & Tkach, C. (2003). The consequences of
and Calhoun's (thisi issue) assertion that the effective dysphoric rumination. In C. Papageorgiou & A. Wells (Eds.),
Rumination: Nature, theory, and treatment of negative thinking
ness of a trauma survivor's mood regulation strategies
in depression (pp. 21-41). Chichester, England: Wiley.
has an important influence on his or her eventual abil Lyubomirsky, S., Tucker, K., Caldwell, N. D., & Berg, K. (1999).
ity to attain posttraumatic growth. Why ruminators are poor problem solvers: Clues from the phe
nomenology of dysphoric rumination. Journal of Personality
and Social Psychology, 77, 1041-1060.
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The questions we have raised about the meaning of
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posttraumatic growth and the meaning of cognitive ceiving personal growth. Journal of Personality and Social Psy
processing or rumination are intended to motivate fu chology, 79, 327-343.
ture research to clarify these constructs. Such clarifica McMillen, J. C, Smith, E. M., & Fisher, R. H. ( 1997). Perceived ben
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Consulting and Clinical Psychology, 65, 733-739.
posttraumatic growth and the testing of the intriguing
Nolen-Hoeksema, S. ( 1991). Responses to depression and their ef
model proposed by Tedeschi and Calhoun (this issue). fects on the duration of depressive episodes. Journal of Abnor
mal Psychology, 100, 569-582.
Nolen-Hoeksema, S., & Larson, J. (1999). Coping with loss.
Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Note Nolen-Hoeksema, S., Larson, J., & Grayson, C. (1999). Explaining
the gender difference in depressive symptoms. Journal of Per
sonality and Social Psychology, 77, 1061 -1072.
Susan Nolen-Hoeksema, Department of Psychology, Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment and
University of Michigan, 525 East University Avenue, prediction of stress-related growth. Jourruil of Personality. 64,
Ann Arbor, MI 48109. E-mail: nolen@umich.edu 71-105.
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Branstetter, A. D., Rodriguez-Hanley, A., et al. (2002). Ran
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