Changing for Better or Worse? Posttraumatic Growth Reported by Soldiers Deployed to Iraq

Abstract

There has been increased interest in self-perceived posttraumatic growth, but few longitudinal studies have focused on its relationship with posttraumatic stress. Self-perceived growth is generally thought to facilitate adjustment, but some researchers have proposed that it reflects a dysfunctional coping strategy that impedes adjustment and leads to posttraumatic stress. In this prospective longitudinal study, we examined the relationship between self-perceived posttraumatic growth and stress. Participants were soldiers deployed to Iraq. They were tested before their deployment (N = 479) and again 5 months (n = 382; 80%) and 15 months (n = 331; 69%) after returning home. Cross-lagged panel analysis indicated that more perceived growth 5 months postdeployment was associated with more posttraumatic stress 15 months postdeployment, even after we controlled for stressor severity, posttraumatic stress at 5 months, and potential predeployment confounders (extraversion, neuroticism, and cognitive ability). Findings suggest that it may be counterproductive to promote perceived growth to enhance adjustment after traumatic events.

Keywords

trauma stress reactions cognitions

After a traumatic event, many people initially experience symptoms of posttraumatic stress disorder (PTSD), including reexperience of the traumatic event, avoidance of its reminders or emotional numbing, and hyperarousal. According to cognitive approaches (e.g., Dalgleish, 2004), this is because salient trauma-related information is incompatible with preexisting acquired knowledge of the world as meaningful, controllable, and just and of the self as worthy. Over time, the new information may become assimilated into these schematic structures through evaluation and editing. Finding meaning that mitigates its negative implications may restore a sense of control, justness, and self-esteem. However, if the traumatic event is meaningfully interpreted as central to the person’s identity, PTSD symptoms are maintained rather than resolved (Berntsen & Rubin, 2007). Ehlers and Clark (2000) proposed that negative appraisals of the traumatic event and its sequelae (e.g., “I’ve changed for the worse,” “Nowhere is safe”) amplify distress and foster avoidance strategies, thus maintaining PTSD symptoms. This has been supported by longitudinal research (e.g., Ehring, Ehlers, & Glucksman, 2008; Engelhard, Huijding, van den Hout, & de Jong, 2007; van den Hout & Engelhard, 2004).

A growing literature has also revealed positive appraisals (e.g., “I’ve changed for the better,” “I appreciate life more”) reported by people exposed to various types of stressful events, such as breast cancer, sexual assault, military combat, and a plane crash (see Zoellner & Maercker, 2006). Initially after a traumatic event, this self-perceived posttraumatic growth is thought to be positively associated with PTSD symptoms because both follow from a shake-up of one’s worldviews and stress may fuel growth (Tedeschi & Calhoun, 2004). With respect to long-term effects, two competing predictions have been made about the linear relationship between perceived growth and PTSD symptoms. First, the dominant view seems to be that perceived growth has adaptive significance and leads to reduced levels of posttraumatic stress (see Zoellner & Maercker, 2006). Such a prediction is consistent with cognitive-stress theory (e.g., Folkman, 2001), which highlights meaning-based coping and the importance of positive affect in sustaining the coping process and furthering recovery. Empirical support for this prediction would provide a basis for developing interventions that promote posttraumatic growth. In fact, such an intervention is a component of the Comprehensive Soldier Fitness Program to enhance perceived growth among soldiers in the U.S. Army who have been exposed to traumatic stressors (see Tedeschi & McNally, 2011). Second, it has been proposed that self-perceived growth may point to a maladaptive cognitive process. It may involve illusory and self-deceptive aspects and represent avoidant or defensive coping (e.g., Frazier et al., 2009; Hall, Hobfoll, Canetti, Johnson, & Galea, 2009; Kastenmüller, Greitemeyer, Epp, Frey, & Fischer, 2012; Zoellner & Maercker, 2006), thereby impeding recovery and resulting in higher levels of PTSD symptoms.

Two meta-analyses based on cross-sectional data showed a positive relationship between perceived growth or benefit finding¹ and PTSD symptoms (Helgeson, Reynolds, & Tomich, 2006; Shakespeare-Finch & Lurie-Beck, 2014), perhaps because these symptoms reflect “cognitive processing” (Helgeson et al., 2006, p. 810). Longitudinal studies that have focused on perceived growth as well as PTSD symptoms repeatedly with standardized measures are scant. One such study among Israeli veterans who participated in the Yom Kippur War (October 1973) showed that PTSD symptoms assessed in 2003 predicted perceived growth in 2008 after growth in 2003 was controlled for but not vice versa; this result was shown for veterans not taken captive but not for ex-POWs (Dekel, Ein-Dor, & Solomon, 2012). However, there are major methodological limitations to this study: The time interval between combat and the growth/PTSD assessments was more than 30 years and the response rate at the final assessment was low (42% for veterans), which raises concerns about recall bias, confounding factors (e.g., later trauma, life events), and selection bias. In another study, Phelps, Williams, Raichle, Turner, and Ehde (2008) explored growth and PTSD symptoms in a sample of patients 6 and 12 months after amputation. The correlation between initial growth and later PTSD symptoms was positive but not significant (r = .19), and the correlation between initial PTSD symptoms and later growth was .07, but there are also concerns about selection bias in this study (only 42% of study-eligible patients were included).

Accordingly, in the current prospective longitudinal study of soldiers deployed to Iraq, we examined the relationship between perceived growth and PTSD symptoms at two points in time (5 and 15 months after returning home). Participants were recruited for this study prior to their deployment to limit potential selection bias and measure some potential pretrauma confounding factors (extraversion, neuroticism, and cognitive ability) that have been related to PTSD symptoms (Brewin, Andrews, & Valentine, 2000; Engelhard, van den Hout, & Lommen, 2009; Rademaker, van Zuiden, Vermetten, & Geuze, 2011) and perceived growth (Hall et al., 2009; Linley & Joseph, 2004).² We also measured stressor severity after participants’ deployment, which has a positive relation with both PTSD symptoms (Brewin et al., 2000) and perceived growth (Helgeson et al., 2006). The adaptive-significance theory holds that more perceived growth should predict decreased PTSD symptoms over time, whereas the maladaptive-significance theory holds that more perceived growth should predict increased symptoms over time. We examined this relationship and tested whether PTSD symptoms predict later growth. The models controlled for deployment-related stressor severity; predeployment neuroticism, extraversion, and cognitive-ability scores.

Method

Participants and procedure

This study was part of a larger project on vulnerability factors for PTSD (Engelhard et al., 2009; Engelhard, Hujjding, et al., 2007; Engelhard, van den Hout, & McNally, 2008; Engelhard, van den Hout, Weerts, et al., 2007). Participants were 479 infantry soldiers of the Royal Netherlands Army (mean age 22.5 years, SD = 4.1; 3% female, 97% male) who voluntarily enrolled in this study approximately 6 weeks before their 4-month deployment to Iraq in 2004 or 2005 and were designated Stabilization Force Iraq (SFIR) 3, 4, and 5. The majority were Caucasian. No data were collected on income or socioeconomic status. Most were single; 22% were married or cohabiting. The majority (93%) had finished high school, 4.5% had finished elementary school only, and 2.5% were college educated. Nearly two thirds had not been deployed before.

Before deployment (Time 1), the principal investigator (the first author) and her research assistant met with participants at various military bases throughout the Netherlands and provided oral and written information about the study. Participation was voluntary without financial compensation. The soldiers were told that commanders would be informed only about pooled results. After providing written informed consent, participants completed various measures in small groups, including the Eysenck Personality Questionnaire (EPQ; Sanderman, Arrindell, Ranchor, Eysenck, & Eysenck, 1991) and Raven’s (1976) Standard Progressive Matrices (Raven test). Approximately 5 months after returning home from deployment (Time 2), 382 participants (80%) completed Dutch translations of the Potentially Traumatizing Events Scale (PTES; Maguen, Litz, Wang, & Cook, 2004; Dutch version: Engelhard & van den Hout, 2007), the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), and the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993; Dutch version: Engelhard, Arntz, & van den Hout, 2007). In addition, 339 participants (71%) completed the Structured Clinical Interview for DSM–IV Axis-I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1996), which was administered by a clinical psychologist or a clinical psychology graduate student. Approximately 15 months after returning home from deployment (Time 3), 331 participants (69%) completed the PTGI and PSS again. The principal investigator and research assistant retested most participants at the military base at Time 2 (a small minority completed a mail-in questionnaire) and retested more than two thirds of participants at the base at Time 3 (31% completed a mail-in questionnaire). The Maastricht University internal review board approved this study.

Measures

The EPQ was used to assess neuroticism (EPQ-N, possible range: 0–22; obtained range in this study: 0–17, α = .80) and extraversion (EPQ-E; possible range: 0–19; obtained range: 2–19, α = .82).

The Raven test (possible range: 0–60; obtained range: 12–60) was used to measure cognitive ability to solve novel problems and adapt to new situations.

The PTES was used to measure exposure to stressors in Iraq. It consisted of 22 war zone–related events that were slightly adapted to deployment to Iraq (Engelhard & van den Hout, 2007). For each item, participants indicated whether they had experienced the stressor and, if so, how much of a negative impact it had on them at the time of the event. For the analyses, we calculated the total number of experienced events (possible range: 0–22, obtained range: 0–22).

The PTGI is a widely used standardized instrument that measures posttraumatic growth. It includes 21 items in five subscales: Spiritual Change, Personal Strength, Appreciation of Life, Relating to Others,³ and New Possibilities. Responses were made on a scale ranging from 0 (did not experience this change) to 5 (experienced this change to a very great deal) on the basis of the person’s experiences in Iraq (possible range: 0–105; obtained range at Time 2: 0–92, α = .95; obtained range at Time 3: 0–82, α = .94).

The PSS was used to measure PTSD symptom severity and consists of 17 items that reflect the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) PTSD symptoms. Responses were made on a scale from 0 (not at all) to 3 (almost always; possible range: 0–51; obtained range at Time 2: 0–32, α = .89; obtained range at Time 3: 0–39, α = .91).

Statistical analysis

We used SPSS 16 and Mplus 6.11 for analyses. First, we tested whether there were differences between participants who did or did not drop out on characteristics from earlier measurements. We computed zero-order correlations among the variables of interest, followed by a cross-lagged panel model to test the relationship between PTGI and PSS over time, while we controlled for the stability of these variables over time, PTES, and predeployment variables. A maximum likelihood estimator was used, which is robust to nonnormality of data. Full information maximum likelihood was used to deal with missing data. Model fit was evaluated using root-mean-square error of approximation (RMSEA), comparative fix index (CFI), and Tucker-Lewis index (TLI). Conventional guidelines consider less than .06 as adequate fit for RMSEA and more than .95 as adequate fit for CFI and TLI (Hu & Bentler, 1999). Significance tests were two-tailed (α = .05).

Results

Descriptive statistics and correlations

Participants who did not complete Time 2 questionnaires had slightly more prior deployments than those who did. There were no other significant differences on the predeployment variables described earlier. Responders and nonresponders at Time 3 did not differ on Time 1 variables. Dropouts were treated as occasions missing at random.

Table 1 shows means, standard deviations, and correlations of the variables of interest. On the PTES, all but 3 participants rated at least one item as having been experienced in Iraq. The commonly endorsed items were going on patrols or having to perform other dangerous duties (94%), witnessing violence (79%), witnessing an explosion (70%), disarming civilians (65%), and being shot at (58%). According to the SCID, PTSD prevalence was 3.5% at 5 months (Engelhard, van den Hout, et al., 2007). The most common PTGI items with scale responses of at least 4 (experienced a great deal) were a feeling of self-reliance (42%), knowing I can handle difficulties (38%), knowing that I can count on people in times of trouble (34%), appreciation of the value of my own life (30%), and a sense of closeness with others (27%).

Table 1.

Correlations and Descriptive Statistics

Measure	1	2	3	4	5	6	7	8
Time 1
1. EPQ-N
2. EPQ-E	−.29*
3. Raven	−.09	−.02
Time 2
4. PTES	−.02	.12*	−.05
5. PTGI	.06	.17*	−.19*	.24*
6. PSS	.27*	−.11*	−.16*	.27*	.28*
Time 3
7. PTGI	.10	.10	−.16*	.09	.68*	.13*
8. PSS	.36*	−.15*	−.08	.25*	.29*	.61*	.19*
M	3.68	14.91	48.04	10.29	40.77	4.61	38.78	3.54
SD	3.45	3.63	6.31	4.30	20.75	5.86	19.40	5.82

Note: EPQ-N = Eysenck Personality Questionnaire, Neuroticism subscale; EPQ-E = Extraversion subscale; Raven = Standard Progressive Matrices; PTES = Potentially Traumatizing Events Scale; PTGI = Posttraumatic Growth Inventory; PSS = PTSD Symptom Scale.

p < .05.

Table 1 shows that more posttraumatic growth at Time 2 was associated with higher extraversion scores, lower Raven scores, more deployment stressors, and more PTSD symptoms at Times 2 and 3. The five subscales of the PTGI at Time 2 were all positively correlated with PTSD symptoms at Time 2 (Relating to Others had the lowest correlation at .19, p < .001; New Possibilities had the highest correlation at .32, p < .001) and at Time 3 (Spiritual Change had the lowest correlation at .19, p < .001; New Possibilities had the highest correlation at .31, p < .001). At Time 3, growth and PTSD symptoms were also positively related.

Cross-lagged panel model

Figure 1 shows the cross-lagged panel model that includes the PTES, PTGI, and PSS. The fit was good, χ²(2, N = 381) = 3.71, p = .16, RMSEA = .05, CFI = .99, TLI = .97. Stability paths of the PSS and PTGI were significant. Higher PTES scores predicted higher PSS and PTGI scores at Time 2. Partial correlations between PTGI and PSS were significant at Time 2 but not at Time 3. Regarding the cross-lagged paths, higher PTGI scores at Time 2 predicted higher PSS scores at Time 3. PSS scores at Time 2 did not predict PTGI scores at Time 3. Including paths from PTES to PSS and PTGI at Time 3 (with fixed correlations between PTGI and PSS at each time point, derived from the earlier model) did not significantly improve model fit, Δχ²(2, N = 381) = 3.89, p = .14.

Fig. 1.

Cross-lagged panel model showing stressor severity (Potentially Traumatizing Events Scale, PTES), symptoms of posttraumatic stress disorder (PTSD Symptom Scale, PSS), and posttraumatic growth (Posttraumatic Growth Inventory, PTGI). Values are standardized coefficients. Solid lines indicate significant associations (*p < .05); dashed lines indicate nonsignificant associations.

To control for predeployment variables, we ran the model again, with neuroticism (EPQ-N), extraversion (EPQ-E), and Raven scores added as predictors of the PSS and PTGI at Time 2. This model yielded the same results: Higher PTGI scores at Time 2 predicted higher PSS scores at Time 3, and PSS scores at Time 2 did not predict PTGI scores at Time 3. Moreover, higher PTES and EPQ-N scores predicted higher PSS and higher PTGI scores, whereas higher Raven scores predicted lower PSS and lower PTGI scores. Higher EPQ-E scores predicted higher PTGI scores but did not predict PSS scores. Finally, we tested whether PTES, EPQ-N, EPQ-E, and Raven scores also predicted PSS and PTGI scores at Time 3 (with fixed correlations between PTGI and PSS at each time point, derived from the model described earlier). Model fit improved significantly, Δχ²(8, N = 364) = 24.29, p < .01. The effects of the exogenous variables on PSS and PTGI at Time 2 and the relationships between PTGI and PSS remained the same as in the earlier model. Furthermore, PSS at Time 3 was predicted by PTES scores, β = 0.12, p = .02, and EPQ-N scores, β = 0.19, p < .01, but not by EPQ-E or Raven scores. PTGI at Time 3 was not predicted by any of these added exogenous variables.

Discussion

In this study, we sought to clarify the relationship between perceived posttraumatic growth and PTSD symptoms in soldiers deployed to Iraq. Many soldiers reported positive changes as a result of their deployment experiences. Many said they felt more self-reliant, appreciated their life more, and felt closer with others. Soldiers with higher neuroticism scores did not report less perceived growth, which suggests that it does not reflect general negative affectivity. Soldiers with higher extraversion scores before deployment and more deployment stressors did report more growth. This finding is consistent with results from earlier research in which extraversion was assessed after trauma exposure (Tedeschi & Calhoun, 1996; Val & Linley, 2006). The negative correlation between Raven scores before deployment and posttraumatic growth was small and unexpected, given that earlier research has shown a positive relationship between education and growth (Linley & Joseph, 2004).

Cross-lagged panel analysis showed that higher levels of growth 5 months postdeployment predicted more PTSD symptoms at 15 months, beyond stressor severity, earlier PTSD symptoms, neuroticism, extraversion, and cognitive ability. This positive association was modest, but it is inconsistent with the notion that perceived growth leads to better psychological adjustment over time. These results add to a large number of cross-sectional studies that also showed positive associations between perceived growth assessed with questionnaires and PTSD symptoms (Helgeson et al., 2006; Shakespeare-Finch & Lurie-Beck, 2014). It should be noted that some studies showed no relationship or a curvilinear relationship (e.g., Kleim & Ehlers, 2009), and some longitudinal studies showed a negative association between growth and PTSD symptoms, but these typically used an interview format or unstandardized scales (e.g., single open-ended question) to assess growth (see Zoellner & Maercker, 2006; see Dekel et al., 2012). The current results are the opposite of those found by Dekel et al. (2012) in their sample of veterans, but methodological differences between the studies hamper a proper comparison (e.g., the time interval between combat and the first growth assessment was 30 years in their study and approximately 5 months in our study, and the response rate at the final assessment was 42% in their sample of veterans and 71% in our sample). The current results support a model that states that perceived growth may reflect denial of adverse effects of traumatic experiences and have negative implications for mental health (e.g., Colvin & Block, 1994; Hobfoll et al., 2007; Zoellner & Maercker, 2006).

Although the data show that perceived growth is associated with more rather than less long-term PTSD symptoms, the possibility cannot be ruled out that perceived growth does have favorable effects on other types of problems, such as interpersonal functioning. Furthermore, the data are silent about actual growth or growth perceived by others. Frazier et al. (2009) found in a study of undergraduates that scores on the PTGI were generally unrelated to “actual growth” in PTGI-related domains that was assessed by comparing changes in measures that tapped these domains over time. It is interesting that perceived growth was associated with increased distress from pre- to posttrauma, whereas actual growth was generally related to decreased distress.

Using the same sample, Gunty et al. (2011) found that perceived growth was related to actual growth for trauma-exposed undergraduates who were less distressed but not for those who were more distressed, thereby suggesting that reporting growth may be a coping strategy for dealing with distress. This is consistent with the notion that self-perceived growth may have constructive and illusory aspects (Zoellner & Maercker, 2006). Other important moderators are an empirical issue that awaits future research. We also do not know whether participants who reported more growth had increased positive and decreased negative emotion. Increased positive emotion generally contributes to positive health outcomes, but pursuing positive feelings can be self-defeating, perhaps because it sets people up for disappointment (Gruber, Mauss, & Tamir, 2011). A key point here is whether deliberately trying to “grow” psychologically after trauma is maladaptive, which the results of the current study seem to imply. Attempts to foster perceived posttraumatic growth among veterans (and other trauma survivors) may backfire and result in worsening of symptoms over time.

It should be noted that the level of PTSD symptoms reported by participants was low. This limits the degree of variance available to predictors and may reduce the generalizability of the findings. A potential additional concern is the assessment of PTSD symptoms in two different settings (typically at the military base at Time 2 and for nearly one third of participants at home at Time 3). We used a well-validated scale (PSS), but it is possible that soldiers underreported their PTSD symptoms at the base or at home. Nevertheless, it seems unlikely that they underreported symptoms at Time 2 because compared with the SCID, the PSS provided higher estimates of the PTSD rate (Engelhard, van den Hout, et al., 2007). The deployment-related PTSD rate based on the SCID (3.5%) was similar to the rate shown in studies of British (Hotopf et al., 2006) and Danish (Berntsen et al., 2012) soldiers deployed to Iraq or Afghanistan but was somewhat lower than the rate shown in prospective research among U.S. soldiers (6.7% of single deployers and 4.5% of multiple deployers; Bonanno et al., 2012; see McNally, 2012).

Other limitations of our study should also be taken into account. The sample consisted mainly of young male soldiers, which may impede generalizability of the findings. In the context of functioning of professionals who have been under extreme stress, the need for self-enhancement and perceiving growth may be increased. Hall et al. (2009) suggested that perceived growth in the context of ongoing stressors (e.g., terrorism) may have different effects than in the context of a single-incident traumatic event, and this may also be the case for job-related stressors. Future research might be able to identify the conditions under which perceived growth is maladaptive or adaptive. For both theoretical and clinical reasons, another direction for future research is to investigate the underlying mechanisms: Why would individuals who report more growth report more PTSD symptoms over time? Strengths of this study are the prospective design, low drop-out rates, homogeneous types of stressors, and repeated assessment of perceived growth and PTSD symptoms.

In sum, this study demonstrates that soldiers deployed to Iraq who reported more posttraumatic growth had more posttraumatic stress later on, even when earlier symptoms were controlled for. The findings are inconsistent with the general idea that perceived growth has positive implications for mental health after stressful events.

Footnotes

Acknowledgements

Miriam J. J. Lommen is now at the Department of Experimental Psychology, University of Oxford. The authors thank (representatives of) the Netherlands Ministry of Defense, especially Kees Ijzerman, for their support and advice; Marieke van Baars for assistance with the data collection; and the commanders and troops for their time and effort. We thank Jos Weerts, Marcel van den Hout, and three anonymous reviewers for helpful comments on an earlier version of this manuscript.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with respect to their authorship or the publication of this article.

Funding

I. M. Engelhard was supported with a Veni grant (Project NR 451-03-106) and a subsequent Vidi grant (452-08-015) by the Netherlands Organization for Scientific Research. This study was also supported with a grant from the Veterans Institute in the Netherlands awarded to I. M. Engelhard (no grant number is available).

Notes

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