We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph, to turn one’s predicament into a human achievement.

Viktor Frankl, Holocaust survivor (1959, p. 112)

It has long been known that individuals have experienced positive growth in the face of hardship. Finding “something positive” as the consequences of suffering and hardship has been a characteristic attribute of many cultures and religions (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 1995, 1996, 2004). The ancient Greeks, and Christians Hinduism, Buddhism, and Islam, have attempted to incorporate the idea of suffering into their beliefs and worldviews (Tedeschi & Calhoun, 1995). In the past century, the writings of Victor Frankl (1959) on the Holocaust examined suffering and attempted to make sense of life from an existential perspective. Thus, the theme of suffering and hardship and the individual’s quest to understand adversity is nothing new. Post-traumatic growth is the experience of positive change while undergoing some trauma and adversity (O'Leary & Ickovics, 1995). In this paper, an attempt is being made to understand the possibility of growth in the context of grief, loss or challenge and changes that persons regard as positive and that emerge from their struggle with loss.

One of the famous autobiographical account of posttraumatic growth is that of Victor Frankl (1963). In his well-known classic book - ‘Man’s Search for Meaning’ he shows how an existential understanding of suffering, control, and helplessness can be used to cope with trauma. There are some studies that recognise the ability of some people to cope successfully and to manage trauma relatively unscathed: the literature on resilience, the research on the personality constructs of hardiness and sense of coherence, focused most often on resistance to disease; and the approaches of stress inoculation and toughening, processes that can help develop this resistance.

A number of researchers (Saakvitne, 1998; Tennen, & Affleck, 1998; Tedeschi & Calhoun, 1995) have noted that, at least for some people, an encounter with trauma, can lead to highly positive changes in the individual is very old. As noted by Noonan and Tennstedt (1997), when more meaning is sought, more meaning can be found. This meaning provides the grounding for the discussion regarding strategies for approaching caregiving from a strength-based perspectives.

The general premise of good emerging from the middle of disaster or trauma is timeless Bowker, 1970; Krook, 1969; Little, 1989; Raphael, 1960; Tedeschi & Calhoun, 1995, 2004). Nonetheless, with few exceptions (Caplan, 1961, 1964; Dohrenwend, 1978; Ebersole, 1970; Finkel, 1974, 1975; Frankl, 1959, 1961; Hamera & Shontz, 1978; Jaffe, 1985; Kessler, 1987; Sanford, 1977; Taylor, 1977), it is only in the past twenty years or so that systematic efforts have been made to explore the positive changes that may result from negative life events.

The major pioneers who addressed the possibility of growth from the encounter with loss includes Caplan (1964), Dohrenwend (1978), Frankl (1963), Maslow (1954), and Yalom (1980). Although some initial investigations focused on this field (e.g., Finkel, 1975) and some findings showing the possibility for positive outcomes arising from the encounter with negative events (e.g.Cella & Tross 1986, Tennen & Affleck 1996).

The topic of growth has become a attraction for research since the early work in the late 1980’s and early 1990’s, due in large part to the work of Tedeschi and Calhoun (1995) who gave the term “Posttraumatic Growth” (PTG) in 1995 as well as the positive psychology movement which focussed on the positive outcomes of traumatic and negative events. The term posttraumatic growth refers to positive psychological change experienced as a result of the struggle with highly challenging life circumstances (Calhoun & Tedeschi, 1999, 2001).

Linley and Joseph (2004) believe that it is through the process of struggling with hardship that changes may arise that push the individual to a higher level of functioning than which existed prior to the event. The focus of PTG is not to advocate suffering as a situation one should value and strive for, but rather to examine the phenomenon in which suffering, misery and grief can co-exist with growth (Linley and Joseph, 2004).

Other commonly reported negative effects of trauma include lower self-esteem, reduced interpersonal trust, poorer physical health, and an increased sense of vulnerability (e.g., de Vries, Davis, Wortman, & Lehman, 1997; Gluhoski & Wortman, 1996; Kessler, Davis, & Kendler, 1997; Lehman, Wortman, & Williams, 1987; Norris & Kaniasty, 1991; Turner & Lloyd, 1995). Some traumatic experiences, particularly in childhood, are also associated with the development of an aggressive personality style (Ferguson et al., 2008), negative parenting behaviors (Cohen, Hien, & Batchelder, 2008), and the perpetration of violent crime (Ferguson et al., 2008; Smith & Thornberry, 1995; Widom, 1989; Zingraff et al., 1993).

There is now a considerable work which reported positive changes following a wide range of stressful and traumatic events (Linley & Joseph, 2004), and substantial developments in theory (Joseph & Linley, 2006). 40-70% experience some positive outcome or benefits from trauma. Literature review has been done on similar topics such as benefit finding, positive changes, growth from hardship, and stress related growth and psychological growth (Tennen & Affleck, 2004). Tedeschi and Calhoun (2004) state that “the evidence is overwhelming that individuals facing a wide variety of very difficult circumstances experience significant changes in their lives that they view as highly positive.” (p.3).

Studies in which growth outcomes have been reported include number of different groups like for example plane crashes, car accidents, natural disasters, rape, sexual assault, abuse, medical problems, relationship breakdown, parental divorce and bereavement (Linley & Joseph, 2004; Joseph, 2005). PTG is different from resilience, as it is related only to the positive changes, and not to both the positive and negative out comes as resilience (Lepore & Revenson, 2006).

Schaefer and Moos (1992), O'Leary and Ickovics (1995), Park, Cohen, and Murch (1996) and Tedeschi and Calhoun (1995) which looked specifically at the phenomenon of positive change arising from the trauma. Calhoun and Tedeschi (2004) clarify that it must be noted that by trying to understand the positive, investigators are not ignoring the negative. Negative events do produce negative consequences for most persons. But, the data also indicates that for many persons the encounter with these negative events can also produce some positive psychological change and benefit.

PTG is more likely to occur when the circumstances are highly disturbing to the individual. Numerous studies have reported that greater amounts of growth are reported for persons who report higher levels of stress or threat associated with the crisis (Linley & Joseph, 2004; Weiss, 2004; Wild & Paivio, 2003). This pattern of results suggests that for PTG to occur in response to a stressful event, (Calhoun & Tedeschi, 1998, 2004; Tedeschi & Calhoun, 1995, 2004).

Tedeschi & Calhoun, (1995) categorized growth into three general domains: changes in the perception of self, changes in the nature and experience of relationships with others, and changes in one's general philosophy of life. Later on, through factor analysis they came up with a five-factor approach to PTG. These five domains are personal strength, new possibilities, relating to others, appreciation of life, and spiritual change (Tedeschi and Calhoun, 1996).

Goldstein (1990) emphasizes that “strength” is found in the vital, dynamic search for at least some periodic states of security and structure within the turbulence of life” (p. 273). Szabo and Strang’s (1999) suggested that even within the stressful situation of caregiving, some caregivers experience the role “better than expected” (p. 71).

1. Domains of Posttraumatic Growth

Based on the factor analysis of the Posttraumatic Growth Inventory, Tedeschi and Calhoun (1996, 2004) described PTG as having 5 domains: “personal strength”, “new possibilities”, “relating to others”, “appreciation of life”, and “spiritual change”.

1. Personal strength- perceived changes in self include feelings of becoming stronger, more confident, a new awareness of an genuine self, a ‘improved self’, more open, more empathetic, more creative, more mature, more humanitarian, more special, and more humble (Tedeschi & Calhoun, 1995, p. 456). After withstanding the trauma, the person feels a greater sense of personal strength. He recognises more capability to deal with future adversities. However, according to Tedeschi and Calhoun (2004), these feelings are accompanied by the perception of vulnerability and by a clear understanding of the negative or detrimental effect of traumatic events in one’s life.

The individual undertake cognitive reconstruction due to the confrontation with trauma, the victim develops a greater appreciation of life, and experiences a changed sense of priorities and a sense of gratitude. He understands that he cannot predict or have any control over certain events, and he might feel vulnerable. As a result he starts to pay attention to small things that were previously considered insignificant or unimportant (Tedeschi and Calhoun, 2004).

2. Changed Priorities- according to Lindstrom, Cann, Calhoun, & Tedeschi (2013) due to the cognitive reconstruction, the individual’s priorities in life change and one experiences a greater appreciation of life. Some traumas that put a person’s life in danger can set in motion a sense that one has been spared, and that this gift of a second chance should be treated with care. Several reports of persons who have been taken hostage have demonstrated such changes (Sank, 1979; Simon & Blum, 1987; Strentz, 1979), and they occur in other life traumas as well. Changes in life priorities often involve a greater appreciation for life in general and for the “smaller things” in life (Klass, 1986-1987; Taylor, Lichtman, & Wood, 1984; Tedeschi & Calhoun, 1996). People who notice growth after trauma may see a difference in their priorities for e.g.: how and with whom they decided to spend their day, their appearance, nature, monetary goods, and their health. They have a new appreciation of life. They start enjoying simple things in life. Their goals in life change. They learn new skills in life.

3. Improved relationships- Improved relationships include perceived improvement in relationships with family and/or friends, neighbours, other trauma survivors and even strangers. Warmer, more intimate relationships with others as the outcome of the crisis. The individual tries to understand the traumatic situation and to deal with stress. Therefore, they might look for help and support from their family and friends (Tedeschi & Calhoun, 1996). The individual may perceive a higher emotional connection with others, as well as a feeling of closeness in interpersonal relationships (Tedeschi & Calhoun, 1996, 2004). Eventually, the person starts to accept the help given by others more readily and makes better use of already present social networks or start making new ones.

Tedeschi and Calhoun (2004) acknowledge that people facing major life crises typically experience distressing emotions and dysfunctional thinking, and that the presence of growth does not mean an end to the suffering. However, they also imply that even though growth and distress coexist, the positive psychological changes prevail over any negative changes that occur.

4. Changed Philosophies- After the traumatic experience, one’s existential awareness increases and he or she may have reflection of mortality. The individual may realise the meaning and the purpose in life and tries to make meaning from the trauma. Yhe individualmay feel vulnerable and suddenly realise how little time they have. A array of cognitive changes regarding fundamental questions about life such as why it is important, what one can expect of it, what contribution one can make, and whether an individual life is more important and meaningful, are often affected by trauma.

5. Spiritual Development- As a result of individual confrontation with the stressful and traumatic event, the individual experience some kind of religious beliefs and perception of growth regarding religious or spiritual matters (Lindstrom et al., 2013). The belief in a religion may increase after trauma and also contribute as a coping mechanism in the cognitive process of finding meaning (Calhoun & Tedeschi, 2001). When individual is not able to explain the reason of the trauma or find answer to the question 'why', they try to explain it through religion. Tedeschi & Calhoun, (2004) reported that people who don't belief in religion may experience some growth in the spiritual sphere. The experience with spiritual growth is not consistent and varies among the people who experience trauma and is dependent on the previous relationship to religiosity and spirituality, as well as on the causal attribution to the event (Pargament, Desai, & McConnell, 2006).

The survivor discovers new avenues for his life (Lindstrom et al., 2013). The individual creates a new philosophy of life that changes the past assumptions and beliefs leading to new potential and opportunities that did not exist before the trauma (Tedeschi & Calhoun, 1996, 2004). Moreover, the spiritual beliefs get enhanced. Most of the people reported a change in their spiritual practices, increase in praying, gratitude to God, strengthening of faith (Tedeschi et al., 2010). Tedeschi et al., (2010) maintained that one does not need to have to have all 5 domains to have experienced growth. Even one or two domains could indicate the posttraumatic growth and the growth may be in existence with distress.

2. Models of PTG as Outcome

A lot of work has been done where PTG is treated as the outcome of the trauma. In general, models of unintentional change depict change – including PTG–as a by-product of attempts to cope with a life-changing, traumatic event. As Janoff-Bulman put it (1992, pp. 138): “Not a chosen fate but some choice in coping.” For example, Aldwin (1994) emphasizes the potential benefits of a stressful event. The stress might not always be negative, but apparently necessary for personal development. Aldwin (1994), postulates that coping serves either as a homeostatic or a transformational function and when coping function as transformational, it results in positive or negative changes. Similarly, in their model of discontinuous change, O'Leary and Ickovics (1995) describe three possible outcomes following challenge: Return to the old level of functioning (recovery), to a lower level (survival), or to a higher level of functioning (thriving).

Ronnie Janoff-Bulman (1992) gave the Theory of Shattered Assumptions that describes how trauma can change our perception of the world. According to this theory all people hold three main assumptions about the world and themselves- the world is benevolent, the world is Meaningful and the world is Worthy. In summation, the assumptions state that the world is benevolent and as members of this world, we are meaningful and worthy. However, in the face of trauma, the theory claims that these assumptions are shattered, and one can no longer identify with these views (Janoff-Bulman, 1992). Once individual has experienced any trauma, it is necessary for them to create new assumptions or modify their old ones in order to recover from the traumatic experience. Therefore, the negative effects of the trauma are simply related to our view about the world, and if we repair these views, we will recover from the trauma.

Schaefer and Moos (1992) outlines the determinants of positive outcomes of crises. Environmental factors like personal relationships, support from family, friends and social environment as well as financial resources and other aspects of the living situation and personal factors such as self-efficacy, resilience, optimism, self-confidence, an easy-going disposition, motivation, health status, and prior crisis experience shape the life crisis experience and its aftermath. They influence cognitive appraisal processes and coping responses which, in turn, affect the outcome of the crisis. This model points to the important role of approach coping for growth to occur as opposed to avoidance coping.

Tedeschi and Calhoun (1995, 2004) in a revised version of their earlier model (1995) they describe PTG solely as an outcome variable. The growth process is conceptualized as follows: A traumatic event, shakes or destroys some key elements of a person's important goals and worldviews. It represents a challenge to higher-order goals and beliefs, and their ability to manage emotional distress. The resulting emotional distress initiates a process of rumination and attempts to engage in behaviour that is designed to reduced stress. Initially, rumination is more automatic than deliberate. It is characterized by frequent returns to thinking activity regarding the trauma and related issues. After the first coping success (e.g. reduction of emotional distress, disengagement from unreachable goals), rumination transforms into more deliberate thinking about the trauma and its impact on one's life. Rumination in its constructive version of cognitive processing (analyzing the new situation, finding meaning, and re-appraisal) is assumed to play a key role in the development of personal growth.

In this model according to Tedeschi and Calhoun's (1995, 2004), PTG is conceptualized as a multidimensional construct including changes in beliefs, goals, behaviors, and identity as well as the development of a life narrative and wisdom. In Tedeschi and Calhoun's model (p. 7): Posttraumatic growth is predicted by “person pre-trauma characteristics, self disclosure, fundamental schemas, beliefs and goals” (distal factors) as well as by factors of “rumination, more deliberate, schema change, narrative development” and “enduring distress” (proximal factors).

3. Models of PTG as a Coping Strategy

PTG as a coping strategy to handle severe stress is usually embedded in general theories of coping as an adaptive response (Affleck & Tennen, 1996). Some approaches on personal growth within coping models are-

PTG as one construal of meaning- (Davis, Nolen-Hoeksema, & Larson, 1998). The adaptive and important role of making meaning in response to loss or traumatic events has been pointed out by many theorists. Davisetal, (1998), regarded PTG as having one more construal of meaning. The authors point that researchers have usually given much attention to only one construal of meaning, i.e. causal attributions answering the question “why did it happen to me?”They consider another important construal of meaning. The individual also try to answer to the question “what for?” According to this conceptualization of coping , the subjective perception of personal growth would signify a benefit attribution.

PTG within a meaning-making coping process. In their conceptualization of meaning in the context of stress, Park and Folkman (1997) distinguish between situational and global meaning. Global meaning encompasses a person's enduring beliefs and valued goals. Situational meaning, in contrast, is the meaning that is formed in the interaction between a person's global meaning and the circumstances of a particular person–environment interaction. A traumatic event threatens global meaning, thereby initiating the meaning–making process. It is the challenge of the coping process to integrate situational meaning (appraisal of the trauma) with global meaning. Finding benefits from the traumatic event (such as personal strength) would fall into the category of assimilation, i.e. changing the situational meaning to accommodate the global meaning.

"Positive active coping” includes religious and spiritual development, problem solving coping initiatives, active cancer rumination, and acceptance coping which all show significant association with PTG (Lelorain S. et. al, 2010, Cordova, et. al. 2001, Karanci et. al., 2007, Thombre A, 2010, Scrignaro et. al., 2010, Bellizzi et. al. 2006). All these positive coping processes are significant contributors to PTG as they require effort to process rebuild the patient’s beliefs and outlook in life (Karanci, 2007). Acceptance, coping strategies, humor, and rumination appear particularly important in the early stages of cancer leading patients to develop a more positive outlook later on in the cancer experience (Schroevers, 2003, Schroevers et al., 2006, Manne et. al., 2004, Chan et. al., 2011, Carver et. al., 1993).

PTG as an interpretative process- Filipp (1999) regards PTG as an interpretative process. This model assumes that people being confronted with loss and trauma pass through three processes in their coping efforts. At first, “perceptive reality” is construed by attentive and comparative processes. Attentive processes include the defence of positive illusions, self-enhancing illusions, and hope. The stage of “perceptive reality” is followed by the stage of “interpretative reality” which evolves as the result of ruminative thinking, finding explanations for the questions “what happened?” and “why?” Within this conceptualization, PTG is one possibility to construct “interpretative reality.”

PTG as one form of self-enhancing appraisal or positive illusion - Taylor (1983) has made positive appraisals the main aspect of the theory of cognitive adaptation to threatening events. In her formulation of the cognitive adaptation to threat, Taylor (e.g. Taylor & Armor, 1996) regards PTG as a form of “positive illusion” with an adaptive function for psychological adjustment. The perception of PTG is one possible self-enhancing appraisal that helps to cope with threat.

4. Benefit Finding, Meaning Making and Stress Inoculation

Benefit finding refers to a positive changes in life of a trauma survivor resulting from the struggle to cope with a difficult life event such as trauma, illness, or other negative experiences. Finding of benefits by individuals experiencing hardship is reported in a number of studies. BF is a process in which the patient creates a new positivity to the adverse event based on the benefit the patient identifies. This process makes the individual look at the adverse event as an opportunity to self-improve and at the same time develop PTG to uphold the damaged self-esteem (Sumalla, et. al. 2009, Mols et. al, 2009). It is highly prevalent and has been studied in a range of settings. It also had an association with emotional well-being, and can predict health outcomes month and even years later. Finding benefit enhances emotional and physical adjustment in the face of difficulty and hardship.

Meaning Making on the other hand is a process which develops after the adverse events in which the individual starts reviewing their current beliefs and world assumptions. This will then allow the individual to derive positive explanations regarding the adverse event and start making sense of the cancer experience thus allowing change in their basic beliefs. Meaning Making generates new vision of the self, others and world beliefs which all directly relates to coping (Sumalla, et. al. 2009). Interestingly, BF and MM have a positive effect on increasing the use of positive coping processes in patients (Lechner, et. al., 2006). Stress inoculation is an approach to therapy development by Meichenbaum (1985) that is a psychological analog to biological immunization. The general principle of stress inoculation therapy is that people learn to deal with stress by successfully dealing with stress. Individuals are given opportunities to deal with relatively mild stressors in positive ways, so that they gradually develop a tolerance for more difficult stressors. It is organized around three phases- a conceptual phase, a skill training and rehearsal phase and an application and rehearsal phase. Stress inoculation therapy has been used effectively to treat clients dealing with a variety of problems, including psychosomatic disorders, work site stress, pain, and chronic illness (Pierce, 1995).

There are other areas of study that recognise the tendency of some people to cope successfully and to manage trauma relatively unscathed: the literature on resilience, especially in high-risk children; the research on the personality constructs of hardiness and sense of coherence, focused most often on resistance to disease; and the approaches of stress inoculation and toughening, processes that can help develop this resistance.

5. Types of Growth Outcome

There are several ways that posttraumatic growth manifests itself, and these manifestations of posttraumatic growth may not appear together in the same person. Self-reliance- One of the most common reports of PTG involves the sense that survivors have- “if I have survived this, I can handle anything” (Aldwin, Levenson, & Spiro, 1994).

A lot of work has been done where individual suffering from spousal bereavement reported a sense of increased self-resilience or self-efficacy come. Several studies have noted that women who lose their husbands later in life, and usually do not remarry, also take on their husbands’ responsibilities. As a result, widows learn to do things that they had never approached before, have a stronger self-image (Lopata, 1973; Shucter, 1986; Thomas, Digiulio, & Sheehan, 1991), report more self-efficacy than when they were married (Calhoun & Tedeschi, 1989-1990; Gilbar & Dagan, 1995; Lund, Caserta, & Dimond, 1993), Similar findings of development of more positive views of self have been reported among children (Schlestinger, 1982) and adults (Wallerstein, 1986) experience divorce, combat experiences (Aldwin, Levenson, & Spiro, 1994; Elder & Clipp, 1989; Sledge, Boydstun, & Norris, 1972; Collins, Taylor, & Skokan, 1990; Curbow, Somerfield, Baker, Wingard & Legro, 1993).

Paradoxically, some persons who report PTG, even those who recognise their strength, often describe a heightened awareness of the vulnerability, mortality, and the preciousness and fragility of life. A sense of vulnerability that exists alongside positive changes may prompt positive changes in interpersonal relationships, appreciation for life, and priorities for spending one’s time. A sense of strengthening as a result of PTG does not seem to make people see themselves as not needing social support, and combined with a recognition of one’s vulnerability, a sense of strength may produce assertiveness in seeking useful support and rejecting that which is less helpful.

Individuals also report change in interpersonal relationship. The ability to express feelings and disclose important personal information is shown to be related in positive ways to various indices of mental and physical health (Pennebaker, 199, and Park and Stiles). People frequently reported that they have become closer to their spouses and stronger marriages as a result of traumatic events such as heart attacks (Laerum, Johnsen, Smith, & Larsen, 1987; Michela, 1987), bereavement (Feeley & Gottlieb, 1988; Ponzetti, 1992), and hostage taking (Sank, 1979).

It should be noted that openness and expressiveness may not always be seen as a more positive way of relating. Some researchers, especially in the area of rape and incest, have described positive developments in interpersonal relationships as a result of trauma in terms of increased caution (Frazier & Burnett, 1994; McMillan et al., 1995; Veronen & Kilpatrick, 1983).

Compassion and giving to others-providing help to others in difficult circumstances can also allow healing and the acknowledgment of one’s strength through a downward social comparison with those who are still struggling. The recognition of the university of suffering is one of the foundations on which mutual support programs are based ( Holmes, Heckel and Gordon, 1991; Yalom, 1985).

Some of the work have also been done with the caregivers of mental illness. The positive aspects of caregiving have been conceptualized as caregiver well-being and satisfaction. Caregiver well-being, which refers to “at least some periodic state of security and structure within the turbulence of life” (Goldstein, 1990, pp. 273), is associated with various caregiver and care receiver characteristics, symptoms and the relationship between caregiver and care receiver. Berg-Weger, Rubio and Tebb (2000) points out a connection between caregiver capability and well being as the caregiver’s awareness of his/her ability to perform tasks that satisfy basic needs. Bulger, Wandersman and Goldman (1993) in a study with of parents’ caring for schizophrenia assessed the parents appraisal of the burden and satisfaction of caring for an adult child with schizophrenia found that parents frequently experienced gratification and intimacy than they did burden or conflict.

6. To Conclude

To conclude, posttraumatic growth is a widely researched area which looks at the alternative post-traumatic experiences rather than the widely researched and thought to be “obvious” posttraumatic stress disorder. Posttraumatic growth can occur following traumatic events. Difficult events are all too common in people’s lives, but the effects of these events are not necessarily negative and may even include improved sense of self.

For clinicians, it is important to be aware of the prospect for growth, but not to imply that growth is to be expected. Tedeschi and Calhoun (2004) have emphasised, growth results from the struggle to cope with the event and find meaning and not from the traumatic event itself. It is important not to prescribe growth so that the client feels that they ought to be experiencing growth, but rather to pay attention for growth as it occurs. Therapists should be aware of the possibility for positive change in their clients following difficulty and trauma. But, it is also important to be careful as not to imply that there is anything intrinsically positive in trauma. Tedeschi and Calhoun (2004) make it clear that personal growth after trauma should be viewed as emerging not from the event, but from within the person themselves through the process of their struggle with the event and its outcome. Thus, posttraumatic growth may be an important outcome for interventions with individuals exposed to trauma.