Clinical Psychology Review 26 (2006) 1041 1053

Growth following adversity: Theoretical perspectives and

implications for clinical practice
Stephen Joseph a,, P. Alex Linley b
a
Department of Psychology, University of Warwick, Coventry, CV4 7AL, United Kingdom
b
School of Psychology, Henry Wellcome Building, University of Leicester, Lancaster Road, Leicester, LE1 9HN, United Kingdom
Received 28 June 2004; received in revised form 19 September 2005; accepted 31 October 2005

Abstract

A number of literatures and philosophies throughout human history have conveyed the idea that there is personal gain to be
found in suffering, and it is an idea central to the existential-humanistic tradition of psychology. However, it is only relatively
recently that the topic of growth following adversity has become the focus for empirical and theoretical work. In this paper, we
review theoretical models of growth, and discuss the implications of growth for clinical practice. Three main theoretical
perspectives are reviewed, the functional-descriptive model, the meta-theoretical person-centered perspective, and the
biopsychosocial-evolutionary view. It is proposed that these three approaches to theory offer different but complementary levels
of analysis, and that theoretical integration between them is possible. We then go on to explore the implications of this theoretical
integration for clinical practice, and conclude with a consideration of the role of therapy in facilitating growth following adversity.
2006 Elsevier Ltd. All rights reserved.

Keywords: Adversarial growth; Posttraumatic growth; Stress-related growth; Perceived benefits; Thriving

1. Introduction

A number of literatures and philosophies throughout human history have conveyed the idea that there is personal
gain to be found in suffering (see Linley, 2003; Tedeschi & Calhoun, 1995, 2004b). Growth following adversity has
also been noted and discussed variously throughout the existential (e.g., Frankl, 1963; Yalom, 1980) and psycholog-
ical literature (e.g., Park, Cohen, & Murch, 1996), but it is only within the past decade that it has become a focus for
empirical research. It is now well established that stressful and traumatic events may serve as a trigger towards
personal growth and positive change. Previously, we have reviewed the empirical evidence in this field (Linley &
Joseph, 2004a), and we will not reiterate this material here. Rather, the aim of the present article is to review theory
development, and to discuss clinical implications. First, we will briefly summarize existing research about growth
following adversity. Second, we will review theoretical perspectives. Third, we will discuss the implications of
research and theory for clinical practice.
The positive changes that have been observed following trauma and adversity have been variously labeled as
adversarial growth (Linley & Joseph, 2004a), benefit-finding (Affleck & Tennen, 1996; Tennen & Affleck, 2002),

Corresponding author. Tel.: +44 2476 528182; fax: +44 2476 524225.
E-mail address: S.Joseph@warwick.ac.uk (S. Joseph).

0272-7358/$ - see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2005.12.006
1042 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053

flourishing (Ryff & Singer, 1998), heightened existential awareness (Yalom & Lieberman, 1991), perceived benefits
(McMillen & Fisher, 1998), positive by-products (McMillen & Cook, 2003), positive changes (Joseph, Williams, &
Yule, 1993), positive meaning (Thompson, 1985), post-traumatic growth (PTG: Tedeschi & Calhoun, 1995, 1996),
quantum change (Miller & C'deBaca, 1994), self-renewal (Jaffe, 1985), stress-related growth (Park et al., 1996),
thriving (Abraido-Lanza, Guier, & Colon, 1998), and transformational coping (Aldwin, 1994). These terms have been
used interchangeably, and there is not a single agreed collective term for this field of study.

2. Existing knowledge

Within the literature, three broad dimensions of growth have been discussed. First, relationships are enhanced in
some way, for example, that people now value their friends and family more, and feel an increased compassion and
altruism toward others. Second, people change their views of themselves in some way, for example, that they have a
greater sense of personal resiliency, wisdom, and strength, perhaps coupled with a greater acceptance of their
vulnerabilities and limitations. Third, there are reports of changes in life philosophy, for example, finding a fresh
appreciation for each new day, and renegotiating what really matters in the full realization that their life is finite,
including possible changes in spiritual beliefs (see, Calhoun and Tedeschi, 1999, 2004; Cohen, Hettler, & Pane, 1998;
Linley, 2003; McMillen, 1999; O'Leary & Ickovics, 1995; Shaw, Joseph, & Linley, 2005; Tedeschi, Park, & Calhoun,
1998a,b).
But although these are considered as three separate dimensions of growth, reflected in the measurement tools
available (e.g., Tedeschi & Calhoun, 1996; McMillen & Fisher, 1998; Park et al., 1996), there is as yet little
psychometric research evidence on the structure of growth. What evidence exists suggests that these dimensions are
in fact highly related, and that growth consists of one higher order factor (see, Joseph, Linley, & Harris, 2005). Also, a
variety of different measurement tools now exist with which to assess growth, and although for the purpose of this
review it is assumed that all are assessing closely related phenomena, evidence for their interrelationships is sparse and
this too remains a focus for future research (Joseph, Linley, Andrews et al., 2005). For these reasons, until we are in a
better position to evaluate the structure of growth, we have approached the topic of growth as a unitary phenomenon.
Studies have reported growth following a range of stressful and traumatic events, for example, bereavement (e.g.,
Davis, Nolen-Hoeksema, & Larson, 1998; Edmonds & Hooker, 1992; Kessler, 1987; Lehman et al., 1993; Parappully,
Rosenbaum, van den Daele, & Nzewi, 2002; Polatinsky & Esprey, 2000), accidents and disasters (e.g., Joseph et al.,
1993; McMillen & Cook, 2003; McMillen, Smith, & Fisher, 1997; Pargament, Smith, Koenig, & Perez, 1998), cancer
(e.g., Collins, Taylor, & Skokan, 1990; Cordova, Cunningham, Carlson, & Andrykowski, 2001; O'Connor, Wicker, &
Germino, 1990; Taylor, Lichtman, & Wood, 1984; Weiss, 2002), HIV infection and AIDS (e.g., Massey, Cameron,
Ouellette, & Fine, 1998; Schwartzberg, 1993; Siegel & Schrimshaw, 2000; Taylor, Kemeny, Reed, & Aspinwall,
1991; Updegraff, Taylor, Kemeny, & Wyatt, 2002), sexual abuse (e.g., Draucker, 1992; McMillen, Zuravin, &
Rideout, 1995; Woodward & Joseph, 2003), rape (e.g., Burt & Katz, 1987; Frazier & Burnett, 1994; Frazier, Conlon,
& Glaser, 2001; Snape, 1997; Thompson, 2000), war and conflict (e.g., Elder & Clipp, 1989; Fontana & Rosenheck,
1998; Waysman, Schwarzwald, & Solomon, 2001), and illness and surgery (e.g., Affleck, Tennen, Croog, &
Levine, 1987; Curbow, Legro, Baker, Wingard, & Somerfield, 1993; Fromm, Andrykowski, & Hunt, 1996; Evers
et al., 2001; Laerum, Johnsen, Smith, & Larsen, 1987; Tennen, Affleck, Urrows, Higgins, & Mendola, 1992;
Zenmore, Rinholm, Shepel, & Richards, 1989). (For a full summary of the research, see Linley & Joseph, 2004a).
Thus, although initially there was some debate over the validity of the concept of growth following adversity, with
some commentators questioning whether it was anything more than positive illusion and self-deception, the evidence
is now overwhelmingly supportive that growth often occurs in people following trauma and adversity (e.g., Tedeschi
& Calhoun, 2004a,b). Research has also begun to document the correlates and predictors of growth, with evidence
pointing to the importance of stress-appraisal, coping and personality variables, with more extravert, optimistic, and
self-efficacious people, who use spiritual, and emotionally focused coping being more likely to experience growth.
Social support is important too (see Linley & Joseph, 2004a).

3. Theories of growth through adversity

Accompanying the empirical reports into growth following adversity there has been attention to theory. Several
models of growth have now been presented. We review the key points of these before focusing on the three most
 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053 1043

comprehensive models available to date, the functional-descriptive model of Calhoun and Tedeschi (1998, 1999;
Tedeschi & Calhoun, 1995, 2004a,b); the meta-theoretical person-centered perspective proposed by Joseph (2003,
2004, 2005; Joseph & Linley, in press) and Christopher's (2004) biopsychosocial-evolutionary view.

3.1. Early theoretical developments

In an earlier review of models of adversarial growth, O'Leary, Alday, and Ickovics (1998) reviewed eight models,
which they divided into: (i) models of intentional, incremental, evolutionary change, and (ii) models of transformative
and unintentional change, which is often sudden and unexpected.
They identified three models of intentional, incremental change during the course of psychotherapy: Nerken's
(1993) model of growth following loss; Mahoney's (1982) model of human change processes; and Hager's (1992)
model of chaos and growth. Nerken's (1993) model of growth during the grieving process emphasized active grieving.
The model shows how self-reflective activity and subsequent meaning making is essential if growth is to be achieved.
Mahoney's (1982) model of human change processes suggests that change is initiated by a psychological disequilib-
rium. Mahoney maintained that change resulted from the pursuit, construction, and alteration of meaning, a view that
is consistent with Nerken (1993). Hager's (1992) model of chaos and growth proposed that periods of confusion and
disorganization were a necessary part of the growth that preceded change, as people grappled with the reorganization
of their cognitive structures. Each of these three models emphasizes that growth arises through the reorganization and
redevelopment of cognitive structures, and that the breakdown of existing ways of viewing the world is often a trigger
for the rebuilding of more effective world views, which may be termed growth. This is a theme upon which we
elaborate much more fully below.
The five models of transformative, unintentional change identified by O'Leary et al. (1998) were those proposed by
Miller and C'deBaca (1994), O'Leary and Ickovics (1995), Aldwin (1994), Schaefer and Moos (1992), and Calhoun
and Tedeschi (1998). The quantum change model of Miller and C'deBaca (1994) proposed that sudden, unexpected
deviations in people's lives lead to permanent and over-arching change. The resilience and thriving perspective
provided by O'Leary and Ickovics (1995) proposed three possible outcomes of survival (functioning below prior
baseline), recovery (resilience through return to prior baseline), and thriving (going beyond the previous baseline to
grow and even flourish).
Drawing from the early work of Maruyama (1963) on how systems can promote change, as opposed to simply
returning the organism to homeostatis, Aldwin and Stokols (1988) proposed a deviationamplification model to
account for the long term outcomes of stress. In contrast to deviation-countering processes, that act as negative
feedback loops and return the organism to homeostasis, deviationamplification processes intensify the change. They
concluded that stressors of a rapid onset that influenced multiple domains and were more severe (i.e., traumatic
stressors) would lead to deviationamplification processes. However, this earliest formulation did not specify the
factors that would influence whether the change would be positive or negative, and in subsequent work (Aldwin,
1994; Aldwin, Sutton, & Lachman, 1996) positive change was defined as the development of coping resources, and
negative change as the depletion of these resources. Drawing from the developmental vulnerability and resilience
literature, they suggested that a range of person and situation factors would promote or impede positive change. These
factors included social support, intelligence, effective coping, determination, and flexible attitudes. In contrast, social
isolation, a difficult temperament, poor coping strategies and a lack of social resources would incline towards negative
changes (see Aldwin & Sutton, 1998).
These early formulations specified many of the psychosocial factors that would come to be included in subsequent
models of growth. For example, Schaefer and Moos (1992) posited that personal (e.g., sociodemographic variables,
personal resources including self-efficacy, resilience, motivation, health and prior experience) and environmental (e.g.,
relationships, social support, home and other environments) system factors impacted on the unfolding of life crises and
their aftermath through event-related factors, including the timing, severity, scope, and duration of the crisis. They
proposed that the combination of personal and environmental system factors would shape the cognitive appraisal and
coping responses deployed by the person following a life crisis, and the effective use of these appraisal and coping
responses would determine the positive resolution of the crisis. Moos and Schaefer (1993) distinguished between
approach coping (e.g., logical analysis of the situation, positive reappraisal, support seeking, active coping) and
avoidance coping (e.g. trying to minimize the problem, withdrawing from the problem, venting emotions). They
suggested that approach coping would lead to positive changes, whereas avoidance coping would not. They further
1044 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053

proposed three types of positive outcomes, including enhanced social resources (e.g., better relationships, new support
networks), enhanced personal resources (e.g., assertiveness, empathy, altruism, maturity) and enhanced coping
resources (e.g., logical thinking, support seeking, and affect regulation) (see Schaefer & Moos, 1998).
It is clear from the overview of these early models that modern adversarial growth theories have drawn heavily on
the work of psychosocial theorists and adopt many of the constructs employed in understanding post-traumatic stress
in the understanding of growth (e.g., Joseph, Williams, & Yule, 1995). Drawing on the empirical research, psycho-
social approaches to growth emphasize the interaction between personality, cognitive appraisal, and coping activity
(e.g., Armeli, Gunthert, & Cohen, 2001; Linley & Joseph, 2004a; O'Leary & Ickovics, 1995; Park, 1998; Schaefer &
Moos, 1992; Tedeschi & Calhoun, 1995; Waysman et al., 2001). Effortful processes directed at meaning making and
which involve intrusive ruminative activity are thought to be important (Calhoun, Cann, Tedeschi, & McMillan,
2000). The functional-descriptive model of Tedeschi and Calhoun (1995) was the most comprehensive model
reviewed by O'Leary et al. (1998) and has continued to be developed in light of these other theoretical developments.
As such, we review it separately below.

3.2. Functional-descriptive model of Calhoun and Tedeschi

Tedeschi and Calhoun (1995; Calhoun & Tedeschi, 1998, 1999; Tedeschi & Calhoun, 2004a,b) offer the most
comprehensive theoretical description of growth to date. Their model was developed in light of theoretical work in the
post-traumatic stress literature pointing to the importance of appraisal processes (e.g., Janoff-Bulman, 1992), their own
and others extensive empirical work in growth (see Tedeschi et al., 1998a), and their clinical experience (Calhoun &
Tedeschi, 1999). The functional-descriptive model they propose discusses how traumatic events serve as seismic
challenges to the pretrauma schema, by shattering prior goals, beliefs, and ways of managing emotional distress. When
these schemas are shattered in this way, this shattering leads to ruminative activity, as people try to make sense of what
has happened and to deal with their emotional reactions to the trauma. In the initial stages, this ruminative activity is
more automatic than deliberate (consistent with the reexperiencing and avoidance symptom clusters within PTSD)
(American Psychiatric Association, 1994). Although this automatic ruminative activity is often distressing, it is
indicative of cognitive activity that is directed at rebuilding the pretrauma schema. This ruminative process is
influenced by social support networks that provide sources of comfort and relief, as well as being influenced by
new coping behaviors and the options that are available for the construction of new, post-trauma schemas. Successful
coping at this stage facilitates disengagement from goals that are now unreachable, and beliefs that are no longer
tenable in the post-trauma environment, together with decreased emotional distress. As successful coping aids
adaptation, the initial ruminative activity that was characterized by its automatic nature shifts towards a more effortful
ruminative activity. This effortful ruminative activity is characterized by narrative development, part of which may be
the search for meaning. Interacting with this process is the experience and self-identification of adversarial growth.
Importantly, although this shift toward more effortful ruminative activity represents growthful adaptation, it does not
exclude the possibility of some enduring distress from the trauma, but at a lower level than was experienced in the
immediate aftermath.

3.3. Person-centered theory

A more recent theoretical perspective is the person-centered perspective proposed by Joseph (2003, 2004, 2005).
This proposes that human beings are active, growth-oriented organisms. As such, the theory proposes that individuals
are intrinsically motivated to cognitively accommodate their psychological experiences under the right social
environmental conditions. Although the study of growth is relatively recent, the characteristics of growth that we
have described above might, Joseph (2003, 2004, 2005) suggests, be viewed in terms of a movement toward becoming
what Carl Rogers (1959) referred to as fully functioning. The fully functioning person is someone who is accepting of
themselves, values all aspects of themselvestheir strengths and their weaknesses, is able to live fully in the present,
experiences life as a process, finds purpose and meaning in life, desires authenticity in themselves, others, and societal
organizations, values deep trusting relationships and is compassionate toward others, and able to receive compassion
from others, and is acceptant that change is necessary and inevitable.
Within person-centered theory post-traumatic stress can be understood as representing the normal psychological
manifestation of a process of breakdown and disorganization of the self-structure that is instigated when the self-
 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053 1045

structure comes under threat. Experiences that are incongruent with the self-structure are perceived as threatening and
not allowed to be symbolized accurately in awareness. This denial to awareness of the experience is an attempt to keep
the perception of the experience consistent with the self-structure. This is the usual state of affairs; we maintain our
self-structure with a process of defense, until we experience a threat that is overwhelmingly incongruent with our self-
structureat which time the process of breakdown and disorganization of the self-structure is instigated. Rogers'
(1959) description is consistent with the current social cognitive theories of post-traumatic stress (e.g., Janoff-Bulman,
1989, 1992) and the information processing theory of Horowitz (1982, 1986). As the person develops a new-structure
that is congruent between self and experience they should also become more fully functioning. Congruent reintegra-
tion of self with experience is not about the client returning to their pre trauma levels of functioning, but about the
client going beyond their previous levels of functioning. Such movement toward becoming fully functioning in
traumatized clients might be described as growth.

3.3.1. Organismic valuing theory

More recently, the person-centred perspective has been integrated with the positive psychology literature to provide
a more comprehensive and sophisticated theoretical analysis of growth through adversity (Joseph & Linley, in press),
the organismic valuing theory of growth. The organismic valuing process (OVP) refers to people's innate ability to
know what is important to them and what is essential for a fulfilling life. Rogers' (1959) view was that human
organisms could be relied on through their physiological processes to know what they need from their environment
and what is right for them for the self-actualization of their potentialities. In recent years, the concept of the OVP has
been reexamined by positive psychology theorists and researchers (see Ryan, 1995; Ryan & Deci, 2000, 2001;
Sheldon, Arndt, & Houser-Marko, 2003). The confrontation with an adverse event has a shattering effect on the
person's assumptive world, and following the completion principle there is a need to integrate the new trauma-related
information. Although the completion principle is the foundation of a number of cognitive-emotional processing
models, the nature of this completion principle has not been subject to theoretical attention, and none of the cognitive-
emotional processing theories make explicit how the completion tendency serves to integrate the new trauma-related
information. However, within the organismic valuing theory of growth following adversity, the completion principle is
viewed as an aspect of the organismic valuing process. Organismic valuing theory posits that when the social
environment is able to provide for the basic human needs of autonomy, competence, and relatedness, then growth
will be promoted. The theory holds that it is human nature to modify existing models of the world to positively
accommodate new trauma-related information when the social environment provides the basic nutrients for growth.
However, the social environment does not necessarily provide the nutrients for growth. Well-meaning others can be
harmful in their attempts to provide support (Harvey, Barnett, & Overstreet, 2004).
The new trauma-related information is stored in active memory, awaiting processing, and this in turn leads to the
intrusive states. However, this leads to high states of distress and arousal that need to be defended against, hence the
avoidance states. The person goes through a series of oscillating phases of intrusion and avoidance as the new trauma-
related information is processed. When a baseline is reached and intrusive and avoidant states are no longer present
this is explained as resulting from cognitive assimilation of the traumatic memory or a revision of existing schemas to
accommodate new information. The differences between assimilation and accommodation are described below.
Following adverse events, new trauma-related information can only be processed in one of two ways (Hollon &
Garber, 1988). Either, the new trauma-related information must be assimilated within existing models of the world, or
existing models of the world must accommodate the new trauma-related information. To illustrate, victims often blame
themselves for events in an attempt to maintain their sense of justice in the world. This is the attempt to assimilate new
trauma-related information within existing models of the world as just. In contrast, victims who perceived their
experience as a random occurrence would have to modify their existing models of the world to accommodate this new
information, that is, the view that the world is not a just world, but is instead a random world. Accommodation
requires people to change their worldviews (Janoff-Bulman, 1992).
Theoretically, the alleviation of PTSD symptoms can come about either through assimilation or through accom-
modation of the new-trauma-related information. However, to move beyond the pretrauma baseline requires accom-
modation as opposed to assimilation, given that as growth is, by definition, about new worldviews.
Taking into account the distinction between assimilation and accommodation, it is evident that the concept of
meaning is central to understanding adjustment to threatening events. As we have seen, a number of theories also
emphasize the importance of meaning making in the development of growth, but Janoff-Bulman advances our
1046 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053

understanding of the role of meaning through her distinctions between meaning as comprehensibility and meaning as
significance (Janoff-Bulman & Frantz, 1997). Whereas PTSD theories tend to be concerned with meaning as
comprehensibility (i.e., understanding the event and why it happened), growth theories tend to be concerned with
meaning as significance (i.e., understanding the philosophical, spiritual, world view implications of the event).
Initially, survivors may be concerned with questions of comprehension, but over time they come to ask questions
of significance (Janoff-Bulman & Frantz, 1997). Although both forms of meaning are involved in understanding
growth following adversity, it is meaning as significance that is necessary for growth.
By definition, cognitive accommodation processes require changes in meaning as significance, and this can be in
either a negative or a positive direction. At the experiential level, a person can accommodate new trauma-related
information, for example, that random events happen in the world and that bad things can happen at any time, in one of
two ways. This accommodation may be made in a negative direction (for example, a depressogenic reaction of
hopelessness and helplessness), or in a positive direction of meaning as significance (for example, that a positive life is
to be lived to the full in the here and now). Thus, the process of cognitive accommodation can lead to negative changes
in world view and resultant psychopathology, or to positive changes in world view and growth.
Thus, within the organismic valuing theory, three cognitive outcomes to the psychological resolution of trauma-
related difficulties are posited. First, that experiences are assimilated, leading to a return to pre-trauma baseline, but
also leaving the person vulnerable to future retraumatization. Second, that experiences are accommodated in a
negative direction, leading to psychopathology and distress. Third, that experiences are accommodated in a positive
direction, leading to growth because the person has evolved and developed their world view in light of the new
traumatic information. The distinctions between these three cognitive outcomes are a major novel contribution of the
organismic valuing theory (Joseph & Linley, in press).

3.4. Christopher's biopsychosocial-evolutionary view

Another recent theoretical perspective suggests that adversarial growth is one possible outcome, together with post-
traumatic pathology, of the traumatic stress response that follows exposure to an environmental stressor. Christopher
(2004) provides a biopsychosocial-evolutionary perspective that regards growth, rather than pathology, as the normal
outcome of the traumatic stress response. Christopher (2004) argues that the normal trauma response is better
understood as an evolutionary inherited mechanism for metalearning, which shatters and reconstitutes the metaschema
(i.e., concepts of self, society, and nature), in which learning normally takes place. (p. 76). He goes on to say that
the negative or maladaptive outcomes of trauma appear to be the result of a failure to adequately modulate the
normal adaptive trauma response (p. 83).
Reviewing and synthesising the trauma literature, Christopher (2004) articulates seven interconnected theoretical
conclusions: First, he argues that stress is best understood as a prerational form of biopsychological feedback. Second,
the normal outcome of traumatic stress is growth. Third, resultant psychopathology is a function of maladaptive
modulation of the stress response. Fourth, trauma transforms individuals on the biological as well as psychological
levels. Fifth, biological processes underlying the stressresponse are universal, but there are specific dynamics that are
a function of the individual. Sixth, biological changes can occur even if there are no psychological changes. Seventh,
rationality is humanity's evolutionary newest and most sophisticated stress-reduction mechanism. Together, these
seven theoretical considerations, which Christopher (2004) discussed in considerable detail in relation to evolutionary
and biological evidence, constitute the most comprehensive and holistic account of growth to date. They provide a
tentative integration of biological evidence for the adaptive nature of the traumatic stress response, together with
psychosocial findings that point to the need for the transformation of cognitive schema (i.e., changes in meaning, as
were integral to the models reviewed above) and the role of social support in modulating these biological responses.

3.5. Theoretical integration

Each of the three main theoretical perspectives reviewed above is consistent with the available empirical evidence
(Linley & Joseph, 2004a). Furthermore, the three theoretical perspectives are also consistent with each other. In
Tedeschi and Calhoun's functional-descriptive theory, there is a seismic shattering of the assumptive world that forces
a reconfiguration of the person's schemata. This has been criticized as an overly restrictive view of growth process
(see, Aldwin & Levenson, 2004). The person-centered theory of growth following adversity proposed by Joseph
 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053 1047

(2003, 2004, 2005) also suggests that although growth can take place through a seismic shattering of the assumptive
world, but growth can also take place through more gradual breakdown and rebuilding of the assumptive world. The
process of growth described in person-centered theory is a generic theory of personal growth, which is applicable to all
experiences that are incongruent with some facet of self-structure. The process of growth that we are concerned with
here is the same therapeutic process of breakdown and reorganization described in client-centered theory, but
experienced more abruptly in relation to seismic events. In addition, client-centered theory offers an integrative
view of growth processes that is compatible with social cognitive theories of post-traumatic stress (Janoff-Bulman,
1992).
Whereas, Tedeschi and Calhoun's theory provides a sophisticated understanding of the social and psychological
factors related to growth, it is a descriptive theory rather than an explanatory theory. In contrast, the person-centered
perspective provides a meta-theoretical underpinning that provides explanatory power. The biopsychosocial-evolu-
tionary perspective supports the meta-theoretical person-centered view through an appeal to evolutionary psychology,
and expands on the psychosocial approach of Tedeschi and Calhoun by broadening our understanding to include a
biological account. Thus, these are not competing theories, but complementary theories offering different levels of
explanation, at the social cognitive and the biological evolutionary levels underpinned by the meta-theoretical
perspective that people are intrinsically motivated toward growth.

4. Applications

The interest in growth can be seen as part of the wider positive psychology movement (Seligman & Csikszentmi-
halyi, 2000; Snyder & Lopez, 2002). Positive psychology is seen as a balance to mainstream psychology, which has
been for too long overly concerned with the negative aspects of human experience. Research in positive psychology is
now beginning to focus on its applications (Linley & Joseph, 2004b), and the study of growth promises to have
important applications for practicing psychologists. When working with clients who have experienced stressful and
traumatic events the positive psychologist is concerned with helping to alleviate distress and also to facilitate more
positive functioning. There are two main questions that arise out of our consideration of theory. First, does what we
know about the alleviation of distress generalize to the facilitation of growth? Second, what are the implications of
growth for well being?
First, we suggest that what we know about the alleviation of distress does not automatically generalize to the
facilitation of growth. The implication of organismic valuing theory is that the alleviation of distress can come about
through either assimilation or accommodation processes, but only accommodation can be growthful, while assimila-
tion can leave the person at increased vulnerability to future retraumatization. The accommodation process requires
cognitive work and any intervention that impedes this work may therefore be damaging. Christopher (2004) makes a
similar point in relation to drug treatment:
While pharmacological treatment may be helpful in lowering traumatic stress by modulating the HPA axis, it may
also interfere with the normal process of neural pruning and reconfiguration that is essential to PTG {post-
traumatic growth]. Therefore, if the clinical goal of trauma treatment is to facilitate PTG rather than simply
minimizing symptoms, as this perspective suggests it should be, pharmacological intervention should be used very
sparingly. Instead, the focus should be on assisting the patient to develop the metacognitive reconfiguration of
schema needed to turn anxiety into meaning (p. 92).
There is already much clinical literature on helping people deal with stressful and traumatic events, but the
literature on the facilitation of growth following adversity is now only beginning to develop, and come to the
awareness of researchers in the field of post-traumatic stress (e.g., Bonanno, 2004). Given that research remains in
its infancy, it is too early to be certain what the exact therapeutic implications of growth will be, and how best to
facilitate growth, but the fact that the facilitation of growth becomes the goal of therapeutic intervention rather than the
alleviation of distress is in itself a major paradigm shift in the field (Linley & Joseph, 2005).
Second, although the alleviation of PTSD does not necessarily indicate the presence of growth, growth following
adversity does seem to be predictive of better emotional adjustment in the longer term. Associations have been
reported between benefit finding and lowered distress (e.g., Davis et al., 1998), and better physical health (e.g.,
Epel, McEwen, & Ickovics, 1998) (see Linley & Joseph, 2004a, for a full review). However, the bulk of the
evidence to date is cross sectional, and thus the causal link between benefit finding and health-related outcomes
1048 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053

remains a focus for research. But, the research that is available is supportive of the hypothesis that benefit finding
predicts outcome.
Three notable longitudinal studies have been conducted. Affleck et al. (1987) found that perceived benefits at seven
weeks following a heart attack significantly predicted less heart attack recurrence and lower general health morbidity
at an 8-year follow up: patients who perceived benefits were less likely to have suffered a subsequent attack, and were
more likely to have better general health. Frazier et al. (2001) found that sexual assault survivors who reported growth
over 12 months were the least distressed of all participants. Danoff-Burg and Revenson (2005) found that patients with
Rheumatoid Arthritis who found interpersonal benefits from the illness had lower levels of functional disability one
year later, even controlling for initial disability level.
Thus, naturalistic evidence points toward the conclusion that helping people perceive growth can therefore be a
useful therapeutic vehicle to help people cope with adversity and illness (see also, Calhoun & Tedeschi, 1999; Kiecolt-
Glaser, McGuire, Robles, & Glaser, 2002; McFarland & Alvaro, 2000). The implication is that growth may be a useful
target of therapeutic intervention in clinical and health care settings, where the aim is long term emotional and physical
adjustment, and better coping, rather than growth per se. This is a focus for future investigation.
Experimental studies to test whether the principles of growth might somehow be introduced as part of a clinical
intervention are encouraging. Stanton et al. (2002) randomly assigned breast cancer patients to one of two groups,
either to write about the facts of the cancer experience or to write about their positive thoughts and feelings regarding
the experience. It was found that those assigned to write about positive experiences had significantly fewer medical
appointments for cancer-related morbidities 3 months later.
Thus, the emerging research and theory suggests that the field of growth will become increasingly relevant to
psychological therapy.

4.1. Clinical approaches

In this section, we review what is known about the practice of therapy for the facilitation of growth following
adversity. Although we are concerned here with growth, this is not to deny the psychological distress that can result
from experience of trauma, which has been extensively reviewed elsewhere (e.g., Brewin & Holmes, 2003). Neither
do we in any way intend to imply that there is not a need for the treatment of distressclearly there is. However, it
is important to recognize that growth is not simply the absence of post-traumatic stress, but is rather an independent
dimension of experience (Linley & Joseph, 2004a). Given that research remains in its infancy, it is too early to be
certain of the specific therapeutic implications that follow from growth. But, as discussed above, what we are clear
about is that we can not simply generalize from what we know about the treatment of post-traumatic stress disorder
to the facilitation of growth. Tennen and Affleck (1999) have cautioned that directed, imposed, or suggested
benefits will almost surely fail to achieve their desired goal (p. 298). Our view at this stage is that we will begin to
find more client-centered, experiential, and existential therapies of value in the facilitation of growth. As we have
seen, theoretical links have been made between growth and the meta-theoretical perspective of client-centered forms
of therapy and how they serve to release the intrinsic growth process toward becoming more fully functioning.
The pioneers of this field, Calhoun and Tedeschi (1999; Tedeschi & Calhoun, 2004b) outline several broad
principles distilled from their extensive clinical experience. First of all, they note that our expectations as therapists
have to shift. It is important to recognize that trauma and adversity do not necessarily lead to a damaged life and that
for some, their experiences can lead to positive change and growth. Clinicians should be aware of the potential for
positive change in their clients following trauma and adversity. This is the case across a range of stressful and
traumatic events, and unless clinicians are aware of this and acceptant of it, they run the risk of thwarting the growth
potential of their clients.
Second, although we must be aware of the potential for positive and that adversity does not necessarily lead to a
damaged life, we must also recognize that adversity does not lead to positive change for everyone and therapists need
to be careful not to inadvertently imply that the person has in some way failed in not making more of their experience.
Third, in recognizing the possibility of growth and in talking about it with our clients, we must be cautious not to
imply that there is anything inherently positive about their traumatic experiences. Calhoun and Tedeschi (1998)
suggest that in discussing growth with clients that it is important to use words that clearly locate the impetus for
growth in the arena of struggle with the event, not the event itself (p. 366). Personal growth after trauma should be
viewed as originating not from the event but from within the person themselves. This view is of course consistent with
 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053 1049

the meta-theoretical perspective of person-centered theory, which stresses the central importance of the client's inner
resources for healing and for growth.
Normally, in client-centered therapy, psychological problems are seen as a result of the internalization of conditions
of worth, and thus the client-centered therapist offers a social environment that serves to slowly dissolve the conditions
of worth, with the consequence that the self-structure is gradually broken down and the self reintegrated with
experience to rebuild a new self-structure (Rogers, 1959). In working with traumatized clients, however, aspects of
the self-structure have already been abruptly shattered, as discussed by Janoff-Bulman (1989, 1992). The task of the
client-centered therapist is therefore to help the client rebuild their self-structure by reintegrating self with experience.
As we have seen, client-centered theory suggests that as the client comes to develop a self-structure that is more
congruent between self and experience they should also become more fully functioning, and that such movement
toward becoming fully functioning in traumatized clients might be described as adversarial growth. The implication of
person-centered theory is that although a range of therapeutic approaches might work to help alleviate the symptoms
of PTSD, only those therapeutic approaches that are actively helping the person to congruently integrate self and
experience will lead to growth. Given the theoretical parsimony of the client-centered approach, its consistency with
research evidence, and its ability to synthesize existing social cognitive models of PTSD within a growth framework,
we suggest it provides much scope for further empirical research.
Current approaches to the treatment of traumatic stress reactions usually involve the use of cognitive-behavioral
techniques (see, e.g., Foa & Rothbaum, 1998; Foa, Keane, & Friedman, 2000). What must be emphasized is that our
review of growth theories cautions that treatment for PTSD may not be the same as facilitation of growth. Indeed,
client-centered and organismic valuing theory would lead us to suggest that it is possible that some treatments for
PTSD may even thwart growth insofar as they do not make the distinction between promoting assimilation as opposed
to accommodation. Thus, an understanding of growth theory points to the importance of the subtlety of the therapist's
interventive style, and the need for therapists of all persuasions to foster the self-determination of the client. Similarly,
Calhoun and Tedeschi (1999; Tedeschi & Calhoun, 2004a) caution that approaches to interventions that aim to help
the client can inadvertently serve to stifle the possibility of growth, and they note that therapists cannot create growth
for the client; all they can do is facilitate the client to achieve growth. Theory suggests that a therapist who listens
attentively and actively to the client, and helps the client to more clearly articulate the client's own new meanings as
they begin to emerge, will be helping to facilitate accommodation of the new trauma-related information, and hence
growth.
In order for these gains to be realized, it is important that the therapist is careful to respect the survivor status of
the client, and to work alongside the client in helping them to find meaning in their experience. Although these are
new ways of thinking about trauma and its treatment, they are ideas that will already be familiar to therapists of all
persuasions through their experience of clinical practice with survivors of trauma, and our conclusions therefore echo
those of many past researchers. As Roth, Lebowitz, and DeRosa (1997) write:
Researchers and clinicians evaluating traumatic meanings must access the wise and adaptive part of the victim's
mind that is holding the trauma in anticipation of finding a place for it to rest in peace (p. 515).
In this way, the client is empowered rather than disenfranchised of the part they are taking in their own
psychological recovery and growth. This approach further serves to facilitate the client's experience of participation
and control in the therapeutic process, rather than the potentially re-traumatizing experience of being out of control
and at the whim of an all-powerful other. It is also important to caution that growth must proceed at the pace of the
client, and should be identified, but not forced by the therapist (Calhoun & Tedeschi, 1999; Joseph, 2004).

4.2. Individual versus social growth

Up to this point we have discussed the concept of growth following adversity as an individual phenomenon subject
to facilitation in the one-to-one therapeutic encounter. Although we think that psychologists have a major role to play
in individual therapy settings, there are also possible applications on the social level. As societies we are subject to
various traumas, for example, the terrorist attacks on the United States of September 11th, 2001, the Asian Tsunami of
December 26th, 2004, the terrorist bombings in London of July 7th, 2005, and societies such as Northern Ireland that
have been marked by decades of political violence. Importantly, we should recognize that it is not only at the
individual level that growth takes place. For example, in his seminal study, Quarantelli (1985) reported that
1050 S. Joseph, P.A. Linley / Clinical Psychology Review 26 (2006) 10411053

community wide behavioral data, such as the number of psychiatric hospitalizations, drug use, alcohol sales, and
police reports, all decreased following a tornado that devastated a town. One of the features of growth is its
interpersonal dimension, and as psychologists we should endeavor also to find ways to facilitate growthful interactions
in the wider communities we inhabit. However, this remains a very novel topic, and one that requires much more
research attention (see also Bloom, 1998; Tedeschi, 1999).

5. Conclusions

In summary, there is much research now showing that people can experience growth and personal development
following stressful and traumatic events. A number of theories are emerging to account for this observation. The three
most comprehensive models available to date are the functional-descriptive model of Calhoun and Tedeschi (1998,
1999; Tedeschi & Calhoun, 1995, 2004a,b); the meta-theoretical person-centered perspective proposed by Joseph
(2003, 2004, 2005; Joseph & Linley, in press); and Christopher's (2004) biopsychosocial-evolutionary view. These
three theories are complementary, providing an understanding of growth processes at different levels of explanation,
and future work should begin to adopt an integrated social-cognitive meta-theoretical evolutionary approach. The main
clinical implication is the assertion that what we know about the alleviation of post-traumatic stress does not necessarily
apply to facilitating growth. Indeed, it is possible that some existing approaches to alleviating post-traumatic stress
serve to thwart growth-related processes. The struggle with adversity is one way through which we may discover new
strengths within ourselves, revitalize our relationships, and enhance our life's meaning. While positive psychology
seeks to redress the balance of psychological inquiry to a greater focus on the positive, we are reminded by trauma that
the dialectical forces of positive and negative, loss and fulfillment, suffering and growth, may often go hand in hand.

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