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"That which does not kill us makes us stronger;" Nietzsche's famous words strike a chord with many, highlighting the commonly held and inspiring belief that we can grow from, rather than be weakened by, challenging experiences. The concept of Posttraumatic Growth (PTG) reflects the potential of finding benefits in the aftermath of trauma or "bouncing forward". PTG broadly refers to an umbrella of positive adaptation in five core areas (increased appreciation of life, more meaningful interpersonal relationships, an increased sense of personal strength, a change in priorities and a more existential or spiritual outlook). The construct is a complex and multi-faced phenomenon that may entail paradoxical outcomes in the post-trauma adaptation process (Pat-Horenczyk and Brom, 2007).

Maercker and Zoellner (2004) have used the metaphor of the "Janus Face" in the context of PTG to delineate two proposed components: Constructive and Illusory growth. The constructive component is a functional aspect of growth and is correlated with healthy adjustment, whereas the illusory component describes the dysfunctional aspect of PTG and is assumed to involve self-deception. In other words, the latter component describes the illusions that may compensate or mask the emotional distress.

Inspired by the work of Zoellner and Maercker (2006), the present study is an intervention study by Pat- Horenczyk and colleagues, to be published in the Journal of Traumatic Stress, 2015 probes deeper into the subjective experience of PTG. This is the first study to empirically examine the two-abovementioned aspects of PTG in cancer survivors. The sample included 94 female breast cancer survivors who had completed medical treatments (mean age=51.5 years; SD=10.7). About half of the women (n=49) participated in a group intervention aimed at enhancing coping, emotion regulation and resilience. All 94 patients filled out self-report questionnaires at baseline and at 6 months follow-up; 45 women served as the control group and only completed the questionnaires. Constructive and illusory PTG were defined and operationalized based on the combination of perceived growth and adaptive coping strategies. Individuals who reported both increased levels of PTG and an improvement in coping strategies over the course of 6 months were classified as showing constructive growth. Illusory growth was defined as an increase solely in measures of PTG without simultaneous improvement in adaptive coping.

The findings showed that more than half the women demonstrated an increase in PTG at 6-month follow-up.  Pat- Horenczyk et al., also compared the proportion of constructive growth in each of the groups, and indeed, significantly more women who participated in the intervention program reported an increase in constructive PTG than women in the control group.  

Why is it important to distinguish between constructive and illusory posttraumatic growth?

The existing body of literature on the relationship between posttraumatic distress and PTG is perplexing. There is evidence of a positive relationship between distress and PTG but there is also evidence of a negative relationship, as well as evidence of no association between distress and growth. It is, therefore, important to refine the concept of PTG with the hope that it will help us to better understand what the experience of growth implies about individual post-trauma adaptation.

Before we can identify the factors that promote the development of optimal outcomes, and understand their clinical implications, we must understand how to measure the general concept of PTG with greater specificity and refinement. The present study was an attempt to test the validity of one such distinction, constructive versus illusory growth. Testing the differential quality of the PTG in the aftermath of a variety of traumatic circumstances (e.g. combat, natural disaster, interpersonal violence, etc.) may shed light on individual differences, timing of PTG, and moderating factors under which constructive or illusory PTG may be more likely.

What happens to the quality of PTG over time?

Clarifying the trajectories of PTG over time is necessary to deepening our understanding of the adaptation process, the clinical value of PTG, and potential individual differences. Indeed Pat-Horenczyk and her colleagues are currently examining the differential trajectories of PTG, and the shifts between these trajectories over time. They continue to follow the same sample of breast cancer survivors over two years. In their new study (under review), the researchers use latent class analysis to classify profiles of adaptation based on a combination of growth, distress and coping, and identified four long-term trajectories (constructive, resistant, struggling, and distressed). Struggling PTG, for example, is characterized by a high level of distress, coping and PTG, while resistant women showed low levels of distress, growth, and both kinds of coping (positive and negative). They also found that over the course of the first year, women often changed their style of coping, moving in and out of profiles, for example, moving from struggling to constructive PTG. The ability to transition out of struggling PTG may indicate that some women were able to resolve or adapt to the distress posed by cancer diagnosis and treatment.

Interestingly, the study also points to a group of women who reported constructive PTG at the very initial assessment who can be characterized as responding “too well too soon”. Women in this group were found to be at greater risk for deterioration later on; some of these women made the paradoxical transition from Constructive PTG to Struggling PTG at six months (i.e. decline in functioning).  This provides important insights for clinicians who face this phenomenon in those they work with, namely that 'premature growth" may not be optimal and may not guarantee healthy adaptation in the long run.

What are the implications for interventions with cancer patients? Can we promote constructive growth following trauma?

Interventions should focus on developing adaptive coping strategies in order to promote constructive growth. The first 12 months after the trauma can perhaps be identified as a “window of opportunity” for interventions, since it is in these first months that the transitions "in and out of growth" occurred and after which the adaptation trajectories became relatively stable. Perhaps women who report doing "too well too soon" need the opportunity to process pain and distress earlier, while those who initially report illusory growth should be encouraged to engage in interventions that are tailored to focus on coping strategies and future perspective. Although Pat- Horenczyk’s work begins to shed light on the relationship between growth and distress over time among breast cancer patients, mapping the quality of PTG over time can help in understanding the unique factors that promote PTG in the aftermath of diverse traumatic experiences.

Author Biography

Dr. Ruth Pat-Horenczyk is a clinical psychologist, an Associate Professor at the School of Social Work and Social Welfare at the Hebrew University of Jerusalem and the Director of the Child and Adolescent Clinical Services at the Israel Center for the Treatment of Psychotrauma in Jerusalem. Her research focuses on risk and protective factors for childhood PTSD, preparedness and resilience, relational trauma and posttraumatic growth. Prof Pat-Horenczyk co-edited the book “Treating Traumatized Children: Risk, Resilience and Recovery” (Routledge, 2009), and “Helping Children Cope with Trauma: Individual, Family and Community Perspective. (Routledge, 2014). 


Maercker, A., & Zoellner, T. (2004). The Janus face of self-perceived growth: Toward a two-component model of posttraumatic growth. Psychological Inquiry, 15, 41-48.‏

Pat-Horenczyk, R., & Brom, D. (2007). The multiple faces of post traumatic growth.  Applied Psychology: An International Review, 56 (3), 379-385.

Pat-Horenczyk, R., Perry, S., Hamama-Raz, Y., Ziv, Y., Schramm-Yavin, S., Stemmer, S.M. (2015, in press). Posttraumatic Growth in Breast Cancer Survivors: Constructive and Illusory Processes. Journal of Traumatic Stress.

Pat-Horenczyk, R., Saltzman, L. Y., Hamama-Raz, Y., Perry, S.., Ziv, Y., Ginat-Frolich, R., & Stemmer, S. M. (under review). Stability and Transitions in Posttraumatic Growth Trajectories among Cancer Survivors: LCA and LTA Analyses

Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.

Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology: A critical review and introduction of a two component model. Clinical Psychology Review, 26(5), 626-653.‏ doi:10.1016/j.cpr.2006.01.008.