Journal of Traumatic Stress, Vol. 17, No. I , February 2004, pp.

11-21 (0 2004)

Positive Change Following Trauma and Adversity: A Review

P. Alex Linley1,2and Stephen Joseph]

Empirical studies (n = 39) that documented positive change following trauma and adversity (e.g.,
posttraumatic growth, stress-related growth, perceived benefit, thriving; collectively described as ad-
versarial growth) were reviewed. The review indicated that cognitive appraisal variables (threat,harm,
and controllability), problem-focused, acceptance and positive reinterpretation coping, optimism, re-
ligion, cognitive processing, and positive affect were consistently associated with adversarial growth.
The review revealed inconsistent associations between adversarial growth, sociodemographic vari-
ables (gender, age, education, and income), and psychological distress variables (e.g., depression,
anxiety, posttraumatic stress disorder). However, the evidence showed that people who reported and
maintained adversarial growth over time were less distressed subsequently. Methodological limi-
tations and recommended future directions in adversarial growth research are discussed, and the
implications of adversarial growth for clinical practice are briefly considered.
~~

KEY WORDS: posttraumatic growth stress-related growth: review.

Positive changes following adversity have long been Throughout this paper we will use the term adversarial
recognizedin philosophy, literature, and religion (Tedeschi growth to refer to these positive changes collectively, but
& Calhoun, 1995;Tedeschi, Park, & Calhoun, 1998).They will use specific terms when referring to literature that has
have been reported empirically following chronic illness, used these terms.
heart attacks, breast cancer, bone marrow transplants, HIV Studies of adversarial growth are an important area of
and AIDS, rape and sexual assault, military combat, mar- research for several reasons. Focusing only on the negative
itime disasters, plane crashes, tornadoes, shootings, be- sequelae of trauma and adversity can lead to a biased un-
reavement, injury, recovery from substance addiction, and derstanding of posttraumatic reactions. Any understand-
in the parents of children with disabilities. ing of reactions to trauma and adversity must take account
These positive changes share the common factor of of the potential for positive as well as negative changes
struggling with adversity, hence we refer to them collec- if it is to be considered comprehensive. Earlier reviews
tively as adversarial growth. It is through this process of have addressed this literature (Affleck & Tennen, 1996;
struggling with adversity that changes may arise that pro- Calhoun & Tedeschi, 1998;McMillen, 1999; Park, 1998).
pel the individual to a higher level of functioning than that However, recent research has changed what is known
which existed prior to the event. These positive changes about this phenomenon. There is now a need to estab-
have been 'labelled posttraumatic growth, stress-related lish more clearly the variables that are associated with
growth, perceived benefits, thriving, blessings, positive adversarial growth. This review provides a comprehen-
by-products, positive adjustment, and positive adaptation. sive summary of the published empirical data, allowing
researchers to quickly and easily compare findings across
different studies.
'Department of Psychology, University of Wanvick, Coventry, United From an applied perspective, clinicians should be
Kingdom.
*Towhom correspondence should be addressed at School of Psychology,
aware of the potential for positive change in their clients
University of Leicester, Leicester LE1 7RH,United Kingdom; e-mail: following trauma and adversity. Positive changes may be
PALll@le.ac.uk. used as foundations for further therapeutic work, providing

11
0 2004 International Society for Traumatic Stress Studies
0894-9867/04/0200-M)1111
12 Linley and Joseph

hope that the trauma can be overcome (Calhoun & the reported empirical research. Previous reviews (Affleck
Tedeschi, 1999; Linley & Joseph, 2002). Interventionsfor & Tennen, 1996; Calhoun & Tedeschi, 1998; McMillen,
posttraumatic stress disorder typically do not take account 1999; Park, 1998) covered a number of studies that re-
of the potential for adversarial growth. Although the re- ported some adjunctive positive outcomes following ad-
search findings are preliminary, early indications suggest versity. However, these were excluded from the present
that the experience of growth is related to lowered levels review unless they met the search criteria described above.
of distress (e.g., Frazier, Conlon, & Glaser, 2001), hence These strategies collectively identified 40 empirical stud-
the facilitation of adversarial growth may be considered a ies as we report ahead (see also Table 1). One report could
legitimate therapeutic aim (Linley & Joseph, 2002). not be obtained (Peltzer, 2000) and so is not included in
In this paper we briefly consider the measurement the review.
of adversarial growth, before reviewing those studies that
document adversarial growth empirically, in order to re- Measurement of Adversarial Growth
view prevalence rates. We examine studies that have inves-
tigated the variables associated with adversarial growth, Seven instruments have been published that purport
with a particular focus on the nature of the relation be- to measure adversarial growth. The Posttraumatic Growth
tween growth and distress. We review studies that have Inventory (PTGI; Tedeschi & Calhoun, 1995, 1996) has
reported the temporal course of adversarial growth. Fi- 21-items and five subscales that assess growth across the
nally, we consider the potential applications of our find- dimensions of relating to others, new possibilities,
ings, and suggest how future research might best proceed personal strength, spiritual change, and appreciation of
to promote our understanding of the structure, process, life. The Stress-Related Growth Scale (SRGS; Park et al.,
and potential clinical applications of adversarial growth. 1996) is a 50-item measure, with various test results sug-
gesting that a single-factor interpretation is most appro-
priate (Cohen, Hettler, & Pane, 1998). There is also a
Literature Search Strategies 15-item short form. The Revised Stress-Related Growth
Scale (RSRGS; Armeli et al., 2001) has 43-items and eight
Three strategies were used to establish the literature subscales assessing affect regulation, religiousness, treat-
to be included in the review. First, three major databases- ment of others, self-understanding, belongingness, per-
PsycINFO, PILOTS [Published International Literature sonal strength, optimism, and life satisfaction. The
On Traumatic Stress], and Ingenta (including Medline)- Changes in Outlook Questionnaire (CiOQ; Joseph et al.,
were searched for peer-reviewed published literature (ex- 1993) is a 26-item measure of positive and negative
cluding dissertations) during March 2002 using the spe- changes. The Thriving Scale (TS; Abraido-Lanza et al.,
cific search terms posttraumatic growth, post-traumatic 1998) is a 20-item measure that uses modified items from
growth, and stress-related growth. General searches were the SRGS (15 items) and the PTGI (3-items), together
additionally carried out for the terms thriving, perceived with 2-items developed by the authors. The Illness Cog-
benejit, perceived benejits, perception of benejit, positive nition Questionnaire (ICQ; Evers et al., 2001) has three
adjustment, and positive adaptation. These latter terms 6-item subscales of which the first, Perceived Benefits,
have been used to describeprocesses and outcomesthat are was relevant to this review. The Perceived Benefit Scales
consistent with, but not exclusive to, adversarial growth. (PBS; McMillen & Fisher, 1998) consist of 30 positive
The search results for these general terms were screened change items and 8 negative change items. The positive
for their relevance to the review. Nonempirical (i.e., theo- change items yield eight subscales:enhanced self-efficacy,
retical, literary review) publications were excluded. Ref- increased community closeness, increased spirituality, in-
erences derived from this first strategy are marked with an creased compassion, increased faith in people, lifestyle
asterisk (*) in the reference list. changes, enhanced family closeness, and material gain.
Second, these identified sources were checked for The negative change items are not scored, but were in-
references to other publications containing any of the cluded to avoid response bias. Associations with the PBS
search terms. These publications were then collated, and are not included in the review because only subscale
this process repeated until no new references were de- scores, and not total scale scores, have been reported.
rived. Third, references were included that were known As noted, different measures of adversarial growth
to the authors and were directly relevant to the review, produce different numbers of growth dimensions (from
but that had not otherwise been detected using the previ- one [SRGS] to eight dimensions [RSRGS; PBS]). How-
ous search strategies. In this way we aimed to select only ever, the dimensional structure of adversarial growth
studieswhere adversarialgrowth was a substantialfocus of remains an open question. For the purposes of this review,
Positive Change Following %uma and Adversity 13

Table 1. Summary of Studies Examining Adversarial Growth

Study Event Gender n Measure Mean(SD) Prevalence
Posttraumatic Growth Inventory
Best, Streisand,Catania, and Kazak (2001) Parents of children with Mixed 113 PTGI n/a
pediatric leukemia
Calhoun, Cann, Tedeschi, and McMillan (2000) various Mixed 54 FTGI 76.5 (22.0)
Cordova, Cunningham, Carlson, and Andrykowski Breast cancer Women 70 PTGI 64.1 (24.8)
(2001)
Healthy comparison Women 70 PTGI 56.3 (26.3)
Polatinsky and E s p y (2000) Bereaved of child Male 18 PTGI 79.72 (19.50)
Female 49 PTGI 83.47 (20.21)
Snape (1997) AccidenVassault Male 40 PTGI 55.43 (18.14)
Female 13 FTGI 52.15 (25.59)
Tedeschi and Calhoun (1996) #1 various Male 199 PTGI 67.77 (22.07)
Female 405 FTGI 75.18 (21.24)
Tedeschi and Calhoun (1996) #3 various Male 55 FTGI 70.25 (21.87)
Female 62 FTGI 81.60(21.09)
Weiss (2002) Breast cancer Female 41 PTGI 60.21 (18.81) 97.6%
Husband 41 FTGI 46.00 (22.83) 87.8%
Epel, McEwen, and Ickovics (1998) Laboratory stressor Women 58 FTGI-M n/a
Milam, Ritt-Olson, and Unger (in press) various Mixed 435 PTGI-M 29.0%
Maercker and Langner (2001) Medical illness/various Mixed 141 FTGI/G 48.68 (21.78)
Stress-Related Gmwth Scale
Park, Cohen, and Murch (1996) #I various Female 344 SRGS 5 1 S O (da)
Male 162 SRGS 45.73 (da)
Park et al. (1996) #2 various Mixed 160 SRGS 52.87 (21.40)
Park et al. ( 1996) #3 various Male 83 SRGS 45.58 (da)
Female 173 SRGS 54.88 (da)
Mixed 142O SRGS 54.57 (20.95)
King, Scollon, Ramsey, and Williams (2000) Parents of Down Mixed 87 SRGS-M n/a
Syndrome child
Koenig, Pargament, and Nielsen (1998) Medical illness Mixed 564 SRGS-S 21.7 (7.5)
Pargament, Smith, Koeing, and Perez (1998) Oklahoma City bombing Mixed 2% SRGS-S 10.43 (8.31)
residents
various Mixed 540 SRGS-S 18.41 (7.47)
Medical illness Mixed 55 1 SRGS-S 21.69 (7.48)
Pargament, Koenig, and Perez (2000) various Mixed 540 SRGS-S 18.41 (7.47)
Armeli, Gunthert, and Cohen (2001) various-adults Mixed 447 SRGS-R da
Various-students Mixed 478 SRGS-R n/a
Maercker and Langner (2001) Medical illnesslvarious Mixed 141 SRGS-SIG 13.57 (7.66)
Perceived Benejt Scales
McMillen and Cook (2003) Spinal cord injury Mixed 42 PBS 79%
McMillen and Fisher (1998) various Mixed 289 PBS
Changes in Outlook Questionnaire
Joseph, Williams, and Yule (1993) Ship sinking Mixed 35 CiOQ 46.97 (9.12) 494%
Illness Cognition Questionnaire
Evers et al. (2001) Multiple sclerosis Mixed 167 ICQ 15.53 (4.46)
Rheumatoid arthritis Mixed 263 ICQ 15.20 (4.22)
Thriving Scale
Abraido-Lanza, Guier, and Colon (1998) Arthritidchronic illness Female 106 TS 83%
Nonpublished growth measures
Affleck, Tennen, Croog, and Levine (1987) Heart attack Male 287' Single item 58.2%
20Y Single item 59.5%
Davis, Nolen-Hoeksema, and W o n (1998) Bereavement Mixed 205d Single item 342%
Bereavement Mixed 205' Single item 341%
Frazier et al. (2001) Sexual assault Female 881 17-items 20430%
91R 17-items 37-8 1%
89h 17-items 37-72%
92' 17-items 39-76%
McMillen, Smith, and Fisher (1997) Tornado Mixed 421 Single item 90.5%
Shooting Mixed 1361 Single item 76.3%
Plane crash Mixed 461 Single item 54.6%
Tornado Mixed 39k Single item 94.7%
Shooting Mixed 116& Single item 69.2%
Plane crash Mixed 41k Single item 35.0%
McMillen, Zuravin, and Rideout (1995) Child sexual abuse Female 154 Single item 46.8%
14 Linley and Joseph

Table 1. (Continued)
Study Event Gender n Measure Mean (SO) prevalence
Schnurr,Rosenberg, and Friedman (1993) Military combat Male 540 MMPI n/a
Tennen, AWeck, Urrows, Higgins, and Mendola Rheumatoid arthritis Mixed 54 5-items n/a
( 1992)
Waysman, Schwarzwald, and Solomon (2001) Combat Male 348 45-items n/a
Qualirarivegrowth measures
Fontana and Rosenheck (1998) Combat Male 1198 Open question n/a
Fromm, Andrykowski, and Hunt (1996) Bone marrow transplantation Mixed 90 Interview 96%
King and Miner (2000) various Mixed 118 Written essay n/a
Massey, Cameron, Ouellette, and Fine (1998) HIV/AIDS Female n/a Life story n/a
McMillen, Howard, Nower, and Chung (2001) Chemical dependency Mixed 65 Focus groups n/a
Parappully, Rosenbaum, van den Daele, and Nzewi Parents of murdered child Female 13 11 items + 100%
(2002)
Male 3 Interview
Poorman (2002) Adult abuse Female 21 Interview 100%
Siege1 and Schrimshaw (2000) HIV/AIDS Female 54 Interview 83%
Thompson (2000) Rape Female 5 Interview 100%
Updegraff, Taylor, Kemeny, and Wyatt (2002) HIV infection Female 189 Interview n/a

Note. Only PBS subscale scores have been reported, hence these are not included. PTGI= Posttraumatic Growth Inventory (range =0-105); PTGI-M =
modified version of the PTGI;PTGI-G = PTGIGerman version (range = 0-105); SRGS = Stress-Related Growth Scale (range = 0-100); SRGS-M =
modified version of the SRGS; SRGS-S. = SRGS-short form (range = 0-30); SRGS-SIG = SRGS-short form German version (range = 0-30); SRGS-
R = revised SRGS; PBS = Perceived Benefit Scales; CiOQ = Changes in Outlook Questionnaire (range = 11-66, although only scores >44 indicate
positive change); ICQ = Illness Cognition Questionnaire (range = 1-24); TS = Thriving Scale; MMPI = Minnesota Multiphasic Personality Inventory.
Scale ranges are reported where appropriate to allow interpretation of mean scores. Studies are organized by measurement scale (and alphabetically
within each scale).
‘At 6-month follow-up.
‘At I weeks.
‘At 8 years.
dAt 6 months.
eAt 13 months.
f At 2 weeks.
RAt 2 months.
*At 6 months.
‘At 12 months.
jAt 4 4 weeks.
‘At 3 years.

we treat adversarial growth as a unidimensional from 3% for bereaved persons (Davis et al., 1998)to 98%
phenomenon. for women with breast cancer (Weiss, 2002). The preva-
lence rates of 100% (Parapully et al., 2002; Poorman,
Prevalence of Adversarial Growth 2002; Thompson, 2000) are not considered representative
because these studies selected samples on the basis of re-
Only 12 of the 39 studies employed published mea- spondents’ reports of positive change, rather than through
sures that had also been used elsewhere. The remaining a nonbiased sampling technique.
27 studies typically used quantitative measures that had
not been subsequently used, or qualitative measures such
as focus groups or interviews (see Table 1). Variables Associated With Adversarial Growth
Table 1 provides details of the 39 included studies.
Mean scores are given to aid comparison where published Differences by Event o p e
measures have been used; otherwise we have given the
prevalence rates of positive change reported, or calculated It is potentially misleading to compare across dif-
them where possible. These rates reflect the percentage ferent studies that have not used published instruments.
of respondents endorsing positive change items. None of However, tentative comparisons can be made where pub-
the studies employed random sampling techniques; hence lished instruments have been used. Mothers bereaved of
prevalence rates should be interpreted cautiously. Where a child scored highest on the PTGI (Polatinsky & Esprey,
a range of prevalence rates are given, these reflect the 2000), whereas the husbands of women with breast cancer
range of endorsementsfor different positive change items. scored lowest (Weiss, 2002). Only three studies reported
Prevalence rates for endorsement of positive items ranged growth outcomes by event type. Two of these effects were
Positive Change Following Trauma and Adversity 15

nonsignificant(Milam,Ritt-Olson, & Unger, in press; Park scores may not be a function of event type per se. It is
et al., 1996, Studies, 1, 2, and 3). McMillen et al. (1997) more likely that, as with traumatic stress (Briere & Elliott,
reported higher growth in survivors of a tornado, a mass 2000), it is the characteristics of the subjective experi-
shooting, and a plane crash, respectively. However, this ence of the event (e.g., helplessness, controllability, life
finding can be explained by samples’ proximity to the threat), rather than the event itself, that influence adver-
stressor. In the tornado sample, a preexisting community sarial growth.
was affected, and the sample was taken from this commu-
nity. In the mass shooting sample, restaurant employees Cognitive Appraisal
were sampled whether they were on site or not at the time
of the incident, as well as customers who were present, Greater levels of perceived threat and harm are asso-
and local residents who were not present but heard the ciated with higher levels of adversarial growth (see
incident. In the plane crash sample, hotel employees were Table 2). However, there does not appear to be a consis-
sampled, whether or not they were on site at the time the tently positive linear relation between the degree of trauma
plane impacted on the hotel. Thus differences in growth and growth. Fontana and Rosenheck (1998) and Schnurr

Table 2. Variables Significantly Associated With Adversarial Growth

Variables Studies

cognitive appraisal
Awareness Park et al. (1996) #2
Control Even et al. (2001); Park et al. (1996) #2; Tennen et al. (1992)
HiUIll Fontana and Rosenheck (1998); McMillen and Fisher (1998); Pargament et al. (1998); Park et al. (1996) #1;
Tedeschi and Calhoun (19%)
Threat Armeli et al. (2001); Cordova et al. (2001); Fontana and Rosenheck (1998); F r o m et al. (1996); McMillen
et al. (1997)
Sociodemographic
Age Milam et al. (in press)
Age (negative) Davis et al. (1998); Evers et al. (2001); Polatinsky and Esprey (2000)
Education Fontana and Rosenheck (1998); Updegraff et al. (2002)
Gender (female) Park et al. (19%) #I, #3; Tedeschi and Calhoun (1996) #1, #3; Weiss (2002)
Income Cordova et al. (2001); Updegraff et al. (2002)
Personality
Agreeab1eness Tedeschi and Calhoun (1996)
Conscientiousness Tedeschi and Calhoun (1996)
Extraversion Evers et al. (2001); Tedeschi and Calhoun (1996)
Hardiness Waysman et al. (2001)
Neuroticism (negative) Evers et al. (2001)
Openness to experience Tedeschi and Calhoun (1996)
Optimism Davis et al. (1998); Evers et al. (2001); Tennen et al. (1992); Updegraff et al. (2002)
Self-efficacy Abraido-Lanza et al. (1998)
Self-esteem Abraido-Lanza et al. (1998); Joseph et al. (1993); McMillen et al. (1995); Tedeschi and Calhoun (1996)
Coping
Emotion-focusedcoping Maercker and Langner (2001)
Negative religious coping Koenig et al. (1998); Pargament et al. (1998, 2000)
Positive religious coping Koenig et al. (1998); Pargament et al. (1998,2000)
Problem-focusedcoping d e l i et al. (2001); Evers et al. (2001); Koenig et al. (1998); Maercker and Langner (2001)
Religion
Existential openness Calhoun et al. (2000)
Intrinsic religiousness Park et al. (1996)
Religious participation Koenig et al. (1998); Milam et al. (in press); Tedeschi and Calhoun (1996)
Social support
Social support received
Social suppon satisfaction Park et al. (1996)
Cognitive processing
Cognitive processing Calhoun et al. (2000); Cordova et al. (2001); Maercker and Langner (2001); Snape (1997)
Affect
Positive affect Abraido-Lanza et al. (1998); Even et al. (2001); Park et al. (19%); Tennen et al. (1992)
Negative affect (negative) Abraido-Lanza et al. (1998); Evers et al. (2001)
Psychological distress
Depression (negative) Frazier et al. (2001); Updegraff et al. (2002)
Anxiety (negative) Best et al. (2001)

Note. All associations are positive, that is, the variable specified is associated with more growth, unless otherwise indicated.
16 Linley and Joseph

et al. (1993) reported a curvilinear relationship between all positively associated with growth (see Table 2). Neu-
psychological benefits and traumatic exposure: benefits roticism appears to be negatively associated. Evers et al.
were stronger at intermediate,rather than high or low, lev- (2001)replicated the associationbetween extraversion and
els of exposure. In terms of cognitive appraisal variables, perceived benefits in people suffering from rheumatoid
awareness and controllability of the event were generally arthritis and multiple sclerosis, but this association was
associated with higher levels of adversarial growth. nonsignificant in a partial correlation controlling for neu-
roticism. The personality variables self-efficacy and hardi-
ness were both associated with growth, although sense of
Sociodemographic Variables
coherence was not. People with higher self-esteem and
who were more optimistic also tended to report more
There have been suggestions that women tend to ex-
growth.
perience higher levels of adversarial growth than do men,
but the evidenceremains mixed (see Table 2). Studies with
student populations reporting on a range of events (Park
Coping, Social Support, and Religion
et al., 1996; Tedeschi tk Calhoun, 1996), or women with
breast cancer being compared to their husbands (Weiss,
Problem-focused coping, as well as acceptance,pos-
2002), have found that women reported more growth than
itive reinterpretation, and positive religious coping were
men. Between parents bereaved of a child, no differences
positively associated with growth (see Table 2). Emotion-
were reported (Poiatinsky & Esprey, 2000). However, this
focused coping, including emotional social support, was
study used a much smaller sample size than others and
also positively associatedwith growth. Social supportgen-
showed a nonsignificant trend in the direction of women
erally tended not to be associated with growth, but social
reporting more growth.
support satisfactionwas positively associated with growth.
Younger respondents were generally more likely to
A potential confounding of this relationship may be found
report adversarial growth once a given level of develop-
in McMillen et al. (1997): perceived enhanced closeness
mental maturation was achieved (i.e., older adolescents
was associated with friendship satisfaction 3 years later.
were more likely to report posttraumatic growth; Milam
When improved interpersonal relationships are being as-
et al., in press). However, there are a number of potential
sessed as a potential growth outcome, this is likely to be
confounds in age effects. Polatinsky and Esprey (2000)
confounded with assessment of social support variables,
cautioned that their findings may have been skewed by
especially satisfaction. Hence the causal nature of the re-
outlier scores of two younger participants. The temporal
lationship is unclear: appropriate social support may pro-
proximity to one’s own death (Davis et al., 1998) may
mote adversarial growth, or adversarial growth (at least
mean that older people are more likely to be concerned
within the domain of interpersonal relationships) may be
about the imminence of their own demise, and so perhaps
an artefact of perceived positive social support. Religious
are less likely to report growth. A longer perceived du-
activities and intrinsic religiousness were both positively
ration of living with chronic illness may have prompted
associated with growth.
more benefit finding in younger people as they sought to
adapt to their illness (Evers et al., 2001).
Two studies suggested that higher levels of educa-
Cognitive Processing, w e d , Quality of Lve,
tion and income were associated with more adversarial
and Psychobgical Distress
growth. However, one of these (Updegraffet al., 2002) was
conducted with participants of low socioeconomic status,
Rumination, intrusions, and avoidance were all pos-
meaning that “higher income” was closer to a national av-
itively associated with growth (see Table 2). This is in-
erage, rather than higher income per se. The causal mech-
dicative of the cognitive processing necessary for the re-
anisms of these relations are not clear, and it seems rea-
building of shattered world views following trauma (e.g.,
sonableto suggest that they may be confounded with more
Calhoun & Tedeschi, 1998; Janoff-Bulman, 1992). Posi-
pertinent psychosocial variables that have a clearer theo-
tive affect was consistently positively associated with ad-
retical relation to adversarial growth.
versarial growth,
- whereas negative
- affect was consistently
negatively associated. However, the association between
Personality negative affect and adversarial growth was rendered non-
significant in a partial correlation controlling for neuroti-
Of the Big Five constellation, extraversion,openness cism (Evers et al., 2001). This study suggests that nega-
to experience, agreeableness, and conscientiousnesswere tive affect is only associated with adversarial growth to the
Positive Change Following Trauma and Adversity 17

extent that it is a proxy for neuroticism. Quality of life was et al., 1998). By contrast, perceiving benefit at first as-
not associated with adversarial growth. sessment was associated with increases in positive mood
Depression was generally not associated with adver- within 1 year, with neuroticism controlled.
sarial growth, but the significant relations that have been Optimism predicted benefit finding among bereaved
reported were all negative: people who were depressed persons (Davis et al., 1998), but not among parents of a
were less likely to report growth (see Table 2). Anxi- disabled child (King et al., 2000). In these parents of a dis-
ety was generally not associated with adversarial growth abled child, accommodation(characterizedby a concerted
(but significant reported associations were negative), nor effort to deal with the situation) predicted stress-related
were preincident mental health diagnoses or prior trauma. growth, as did the accommodation-closure interaction
PTSD diagnoses were negatively associated with posi- (characterized by high closure-acceptance and moving
tive life changes 2 weeks following sexual assault, but on-together with high accommodation;King et al., 2000).
not 1 year later. In contrast, PTSD diagnoses were posi- In contrast, Park et al. (1996) reported that event resolu-
tively associated with stress-relatedgrowth in residents of tion did not predict stress-related growth. Respondents
Oklahoma City following the 1995 bombing (Pargament, who thought they were going to die and who had preinci-
Smith, Koenig, & Perez, 1998). Adolescents who used dent mental disorders were more likely to perceive benefit
more alcohol, tobacco, and marijuana were less likely to 3 years after a tornado, a mass shooting, and a plane crash
report posttraumatic growth (Milam et al., in press). (McMillen et al., 1997).
Given the inconsistent nature of these findings, and
the dearth of studies providing longitudinal prediction of
Longitudinal Prediction of Adversarial Growth adversarial growth, few conclusions can be drawn. Taking
the correlational and longitudinal evidence together, we
Two studies provided details of variables associated conclude that greater traumatic experience, dealt with by
longitudinally with adversarial growth (Abraido-Lanza means of positive reinterpretation and acceptance coping,
et al., 1998;King et al., 2000). Of the variables considered, in people who are optimistic, intrinsically religious, and
only positive affect, negative affect, and self-efficacy were experience more positive affect, is likely to lead to reports
significantly associated with adversarial growth longitu- of greater adversarial growth.
dinally over 3 years. Nonsignificant associations were re-
ported for pain experienced,level of disability,age, length
of time living with the illness, self-esteem, acculturation, Temporal Course of Adversarial Growth
acceptance, and emotional support (Abraido-Lanzaet al.,
1998). King et al. (2000) reported nonsignificant associ- Several studies have found that the longer the time
ations with growth for optimism, self-esteem, life satis- since the critical event, the greater the extent of adversar-
faction, sense of coherence, and ego development over ial growth that is reported (Cordova et al., 2001; Evers
2 years. These longitudinal associations do not allow a et al., 2001; Park et al., 1996, Study 3, Time 2; Polatinsky
consideration of how these predictor variables might be & Esprey, 2000). However, other studies have not found
associated with each other, nor how they may operate to- this to be the case (Fromm et al., 1996; Milam et al., in
gether to predict adversarial growth over time. Four mul- press; Park et al., 1996, Studies 1 and 2; Study 3, Time 1).
tivariate longitudinal studies (Abraido-Lanzaet al., 1998; It is unlikely that the passage of time per se influences
Davis et al., 1998; McMillen et al., 1997;Parket al., 1996) adversarial growth, but rather intervening events and pro-
were identified in the review that provided information cesses. Three longitudinal studies provided some insights
about the longitudinal prediction of adversarial growth. into the temporal course of adversarial growth. Two weeks
Park et al. (1996) examined potential predictors of posttrauma, sexual assault survivors reported increased
stress-related growth in college students. Multiple regres- empathy and improved relationships. Positive changes in
sion analyses revealed six significant individualpredictors self and spiritualitywere generally establishedby 2 months
of stress-related growth at 6-month follow-up: positive following the event. The period between 2 weeks and
reinterpretation; intervening positive life events; accep- 2 months accounted for most changes in growth, with re-
tance coping; intrinsic religiousness; initial stressfulness ported levels remaining fairly consistent through 1 year
of the event; and social support satisfaction. Positive af- (Frazier et al., 2001). Overall reported benefits were sta-
fect was nonsignificant in this model. In a path analysis, ble over extended periods of 3 years (McMillen et al.,
social support and acceptance of one’s illness did not pre- 1997) and 8 years (Affleck et al., 1987). Significant in-
dict thriving over 3 years in women sufferingfrom chronic creases over time were reported for positive changes in
illness, but positive affect did so directly (Abraido-Lanza life philosophy, priorities, and spirituality (Affleck et al.,
18 Linley and Joseph

1987; McMillen et al., 1997). Closeness in relationships general health morbidity at an %year follow up: patients
tended to decline over time, especially as these relation- who perceived benefits were less likely to have suffered
ships became more distal, that is, communityrelationships a subsequent attack and were more likely to have better
compared to family relationships (McMillen et al., 1997). general health (Affleck et al., 1987).
Adversarial growth, when measured longitudinally, Joseph et al. (1993) found no association between
is relatively stable over time. This longitudinalevidence is reports of positive and negative changes in outlook in
inconsistent with much of the cross-sectionalevidence re- survivors of a shipping disaster, whereas significant pos-
viewed above, and may reflect self-serving biases in tem- itive associations between positive and negative changes
poral comparison (McFarland & Alvaro, 2000). Longi- have been reported following combat exposure (Fontana&
tudinal evidence should be afforded greater weight than Rosenheck, 1998) and bone marrow transplants (Fromm
cross-sectional evidence when examining the temporal et al., 1996).
course of adversarial growth, and further research is re- The evidence reviewed demonstrates a range of asso-
quired before the temporal course of adversarial growth ciations between growth and distress, and hence suggests
may be understood with confidence. these constructs are not ends of a continuum. With re-
gard to clinical applications, the evidence indicates that
while the alleviation of distress does not necessarily pro-
Predicting Adjustment From Adversarial Growth mote growth, the experience of growth does act to pro-
mote postevent adjustment and to alleviate distress (Davis
Growth and distress might be considered as bipo- et al., 1998; Frazier et al., 2001). Hence the facilitation
lar, consisting of a single dimension with opposite end- of growth in survivors may be considered as a clinical
points. If so, they must be consistently negatively associ- intervention that is different from interventions designed
ated. However, growth and distress may also be viewed as to alleviate distress. However, through facilitating growth,
two separate, independent dimensions of experience that distress may be alleviated, which suggests a new mecha-
may have a range of associations. High scores on one di- nism of potential therapeutic change in trauma survivors.
mension do not necessarily imply low scores on the other However, on the basis of this early evidence, it remains
dimension. too early to make prescriptive recommendations.
Frazier et al. (2001) found that sexual assault sur-
vivors demonstratednegative changes in beliefs about the
goodness of other people and the safety and fairness of Methodological Considerations
the world in parallel with positive changes in philosophy
of life and sense of personal strength. Positive changes From a research perspective, the need for greater
in areas of self and spirituality were associated with less methodological rigor and the use of well-validated mea-
distress, whereas negative changes in these areas were as- sures is evident. A review of controlled disaster studies
sociated with more distress, as were negative changes in noted that as the methodological rigor of empirical re-
relationships.Changes in beliefs were not associated with search increased, the probability of establishing high ef-
distress. Survivors who reported growth at 2-week post- fect sizes decreased (Rubonis & Bickman, 1991). As the
trauma but not at 12-monthposttrauma were as distressed quality of adversarial growth research increases, a differ-
as survivors who did not report growth at either time point, ent picture may emerge from that presented on the basis
whereas survivorswho reported growth at both time points of the evidence reviewed here.
were the least distressed of all participants. Particular attention to several design issues is mer-
A similar pattern of associations between benefit ited. First, overreliance on self-report measures that do
finding and distress was found in bereaved persons (Davis not allow for negative responses should be avoided. The
et al., 1998).For participantswho found benefit between 6- Changes in Outlook Questionnaire (Joseph et al., 1993)
and 13-monthpostloss, the mean distress level declined to and the Revised Stress-Related Growth Scale (Armeli
a level comparable to those participants who had reported et al., 2001) both allow for the measurementof positive and
benefit at both time points. In contrast, those who lost negative changes. Second, the issues of prospective lon-
benefits between 6- and 13-monthpostloss changed from gitudinal pre-post designs and appropriate control groups
a low level of distress at 6 months (when they reported in traumatic stress research (Noms, 1996) are also found
benefit) to a relatively high level of distress at 13 months in adversarial growth research. The lack of preevent data
(when they had lost this benefit). makes it difficult for self-reported changes to be verified,
Perceived benefits at 7 weeks following a heart at- but third party reports have reliably validated adversar-
tack significantly predicted heart attack recurrence and ial growth (Park et al., 1996; Weiss, 2002). Third, the
Positive Change Following ’Ikaums and Adversity 19

lack of objective indicators of adversarial growth sug- social variables and adversarialgrowth are typically small.
gests a need for collateral assessment of related behav- It is unlikely that adversarial growth will be substantially
ioral and physiological indicators. Bloom (1998) reported explained by one or even several factors. Researchers
social and political antecedents of adversarial growth, and should endeavor to identify new variables that contribute
Epel et al. ( 1998)linked posttraumatic growth reports with to adversarial growth. Fourth, comprehensive theoreti-
more adaptive hormonal stress responses. Researchers cal models are needed that account more fully for the
should consider how behavioral and physiological indi- range of mediating and moderating variables involved
cators may be built into their research to validate self- (e.g., Calhoun & Tedeschi, 1998).The most important re-
reported changes. Fourth, the overlap between “positive search questions, in our view, center on the potential clin-
reinterpretation” coping and adversarial growth calls into ical applications of adversarial growth research. As longi-
question the distinctionbetween these constructs. Is adver- tudinal relations between adversarial growth, distress, and
sarial growth simply a way of coping or does it represent adjustment are reliably measured and understood, we can
an objective outcome? Are closer relationships indicative begin to identify points of potential therapeutic leverage
of effective social support or an objective outcome of ad- in work with survivors of trauma and other adversity.
versarial growth?These are difficult questions to untangle,
although using multitrait-multimethodassessment proce-
dures (Campbell B Fiske, 1959) may allow them to be Acknowledgments
teased apart. Fifth,,to what extent is adversarial growth
simply the adherence to some cultural script? That is to We would like to thank those authors (J. Curtis
say, do people report growth simply because they have McMillen, Joel E. Milam, Tzipi Weiss) who kindly pro-
been led to believe that good things do come from trau- vided copies of their manuscripts in press, for our inclu-
matic events? Taking as a whole the evidence reviewed, sion in this review. We thank Leanne Andrews, Roger
we consider this unlikely. As difficult as it may be from an Bretherton, Tim Kasser, as well as Fran Norris and two
empirical perspective to demonstrate adversarial growth anonymous reviewers for their helpful comments on an
experimentally, the expanding body of research evidence earlier draft of this manuscript. This research was sup-
endorses its validity. ported by a University of Warwick Research Fellowship
From an applied perspective, it is important to em- awarded to the first author.
phasize that the studies reviewed here are nomothetic. Al-
though they allow cautious generalizations to be made
across populations, the findings do not necessarily corre- References
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