The Duality of Human Experience: Perspectives From Psychosocial Adaptation to Chronic Illness and Disability—Empirical Observations and Conceptual Issues

Abstract

The authors examine the current views on the duality of the human experience as portrayed within the process of coping with traumatic life events. Emphasis is placed on those views associated with the onset or diagnosis of chronic illnesses and disabilities (CID). In a companion article, the authors reviewed experiential dualities focusing on (a) modes of psychosocial adaptation to CID, such as coping versus succumbing, disabled and nondisabled selves; (b) models of denial; and (c) models of personal growth following adversity and traumatic events, such as the onset or diagnosis of CID. Discussion then focused on the dualities espoused by the latter models, which typically dichotomize human functioning following traumatic experiences. In the present article, the authors discuss (a) the main factors, considered by the various theoretical models, that have been found to exert influence on the genuineness of personal growth, with a special emphasis on post-CID psychological growth; (b) pertinent empirical findings that, directly and indirectly, address the perceived dualities of personal growth in the context of psychosocial adaptation to CID; and (c) theoretical and research implications associated with the study of the dual nature of post-CID growth, including recommendations for investigating the veracity of this reported personal growth.

Keywords

experiential duality chronic illness and disability personal/psychological growth psychosocial adaptation denial

The historical and conceptual underpinnings of the human experiential duality, within the context of psychosocial adaptation to chronic illnesses and disabilities (CID), were reviewed in our first article on this subject. Included were such topics as dualities inherent in broad psychosocial reactions to CID onset (i.e., coping vs. succumbing, disabled vs. nondisabled identities, experiencing good vs. bad days), models of dualities regarding the concept of denial (i.e., complete vs. partial forms of denial), and finally, the experiential dualities associated with reported personal growth following CID onset, namely, real or transcendent growth versus illusory or denial-derived growth. More specifically, in this concluding section, several models that contrasted views on genuine versus illusory perceptions of growth, in the aftermath of the experience of trauma, loss, and disability, were considered. Foremost among these models, the following were outlined: (a) Taylor’s (1983) model of positive illusions; (b) Janoff-Bulman’s (1989) model of revised assumptive worlds; (c) Tedeschi and Calhoun’s (1995) model of transformative life schemas and personal growth; (d) Nolen-Hoeksema’s (1991) model of ruminative and distraction processes; (e) Stroebe and Schut’s (1999) model of alternating intrusive and denial reactions, which expands on Horowitz’s (1986) earlier work on the structure of stress reactions; and finally, (f) Maercker and Zoellner’s (2004) Janus-face model, which built on the above frameworks and contrasted two opposing processes triggered by loss and trauma experiences, namely, an adaptive, self-transformative (i.e., genuine) process and a maladaptive, self-deceptive (i.e., illusory) process. In the present article, the discussion shifts to a more fine-grained conceptual and empirical analysis of models of personal growth following CID. Included are such topics as examination of the veracity of personal growth–reported experiences and its relationships to cognitive and developmental models of the human mind, research findings from the literature on personal growth reports following CID onset, and finally the theoretical and research implications derived from findings on the nature, structure, and dynamics of personal growth following CID onset. The present analysis is important to researchers and practitioners in the field of rehabilitation counseling because psychosocial adaptation to disability has historically been viewed as a foundational content domain in rehabilitation education (Rubin, Roessler, & Rumrill, 2016) and research (Rumrill & Bellini, 2018).

The process by which individuals appraise and respond to the disability experience is a central consideration in case conceptualization, service/treatment planning, and intervention delivery across clinical settings and client populations (Smart, 2016).

The Duality of Psychosocial Adaptation to CID: Models and Perspectives

In contrast to the earlier broadly spanned, nondynamic, and trait-like dichotomies (e.g., coping vs. succumbing, adaptive vs. nonadaptive, former nondisabled self-identity vs. present disabled self-identity), most of the more recent proposed dichotomies (or pseudo-dichotomies) of psychosocial adaptation to CID, including the experience of posttraumatic growth (PTG), present mostly narrowly focused, dynamic, oscillating, and state-like frameworks. Furthermore, these conceptualizations are intimately fused with the concepts of temporality (i.e., time since CID onset or diagnosis), pace (abrupt or dramatic vs. gradual or lengthy personal growth), and order (chaotic or seismic vs. organized), as well as the recognition that any efforts to adhere to clear demarcating boundaries between any dually contrasted experiences are futile at best. In the next section of this article, several tentative conclusions, at times more appropriately termed informed speculations, are proposed.

The question of the veracity, or authenticity, of psychological growth following CID onset, as depicted by such constructs as PTG, adversarial growth, benefit finding (BF), and meaning making (MM), among others, can be summed up as the following: Does psychological growth following CID onset represent conscious, authentic growth, or is it only a manifestation of mostly unconscious, self-enhancing, denial-like positive illusions and pseudo-growth? Put differently, does the perceived experiential duality of such growth support the primacy of genuine changes (e.g., acceptance and adaptation) following adversity triggered by the onset of CID, or is it, in fact, a reflection of such selective appraisals and defensive processes as wishful thinking, self-deception, and the like (e.g., denial and maladaptation). According to the most available sources (see, for example, Greenberg, 1995; Janoff-Bulman, 1992; Joseph & Linley, 2006; Maercker & Zoellner, 2004; Taylor, 1983; Tedeschi & Calhoun, 1995), both experiences are valid occurrences and reflect natural vicissitudes of the human psyche following a major traumatic and life-changing event. More specifically, immediately following the onset of an event such as CID, which many but not all people find traumatic and life changing (Smart, 2016), the individual often faces a pressing need to regain control over his or her life and assume the pre-CID homeostasis of the affective, cognitive, and behavioral domains. To this end, he or she employs, mostly automatically and unconsciously, the assistance of reality-distorting, denial-like mechanisms to assuage present pain and distress. These mechanisms have been alternately referred to as positive illusions, self-deception, wishful thinking, MM, BF, and unrealistic optimism or hope. Yet, unlike classical, psychodynamically derived forms of (complete) denial, early CID-initiated “pseudo-growth” is temporary in nature and contains an element of adaptive functioning. That is, it includes the underpinnings of a reality-based perception, and, therefore, a recognition of the loss and its future consequences, as well as some degree of experienced distress and the need to confront the loss. Here again, the assumption is that many people with CID, but not all, experience feelings of loss following the onset of their disabling conditions. These reactions, therefore, signify the initiation of a search for personal growth. Vash and Crewe (2004) referred to the highest form of this personal growth as transcendence, which occurs when the person comes to view the CID in terms of the positive opportunities for identity formation and personal growth that were realized from his or her response to the condition. Furthermore, these two opposing processes embedded in psychological growth not only are common and natural reactions following a traumatic experience but also appear to exist contemporaneously, but often follow different time trajectories.

An often overlooked, yet potentially crucial, influence on post-CID personal growth is that of time since CID onset. The passage of time, following the onset of traumatic experiences, such as CID, appears to be a determining factor effecting the nature of the experiential duality and shaping of the course of psychological growth and adaptation. The role played by the passage of time during the adaptation process has taken a variety of viewpoints. First, the question of the pace and evenness of the adaptation process has been raised; that is, does post-CID growth proceed in an abrupt or gradual fashion? Put differently, do the observed changes reflect a dramatic and vastly inflated growth or are they a manifestation of a lengthy and temporally even trajectory of growth. It appears that, for real psychological growth to occur, the latter scenario is needed (Janoff-Bulman, 1989, 1992; Tedeschi & Calhoun, 1995). When claims of sudden growth are reported, they appear to represent mostly denial-like, reality-distorting processes (Greenberg, 1995; Janoff-Bulman, 1992). Second, the relativistic influence of denial-like, illusory self-perceptions versus deliberate, thoughtful, and realistic perceptions appear to follow reversed trends. Typically, even if not universal, the work of self-deceptive positive illusions and defensive denial (as well as its oscillating counterpart, intrusions; Horowitz, 1986) tends to subside over time, gradually being replaced by that of authentic, constructive, and functional growth (Maercker & Zoellner, 2004). To wit, immediately following the onset of the traumatic event, the illusory component of reported psychological growth appears to be the driving force behind one’s affective and cognitive operations, mostly to minimize the negative impact of the trauma. With time, however, the role played by these nonadaptive processes diminishes, as reality and acceptance gradually gain the upper hand, and the need for denial loses its initial impetus. Kalb (2016) described the long-term psychosocial adjustment to multiple sclerosis as following a similar process. Finally, it has also been speculated, although still lacking consistent empirical support, that post-CID time flow may also play a part in fashioning a progression of growth-related experiences that evolves from denial, to making sense of the loss, to BF, and finally to authentic PTG (Davis, Nolen-Hoeksema, & Larson, 1998; Tedeschi & Calhoun, 2004). Therefore, reporting PTG soon after CID onset may suggest the operation of positive illusions, whereas later on, it is more likely to reflect real positive growth. Indeed, as suggested by Horowitz (1986), Tedeschi and Calhoun (2004), and Mols, Vingerhoets, Coebergh, and van de Poll-Franse (2009), for real growth to occur, the individual must work through the experiences of defensive denial, intrusions of the traumatic event, and event-triggering ruminations before gradually internalizing and assimilating its meaning and future consequences. This, in turn, may lead to diminished emotional distress and increased emotional equilibrium.

Experiential Duality as Viewed Through the Prism of Cognitive, Developmental, and Social Psychology

To expand our understanding of the structure and dynamics of adaptation to CID, the fertile empirical and clinical research on dual models of cognitive, developmental, and social processes of the human mind has much to offer (Compas, Connor, Osowiecki, & Welch, 1997; Compas, Malcarne, & Banez, 1992; Evans, 2008, 2011; Frankish & Evans, 2009; Metcalfe & Jacobs, 1996; Metcalfe & Mischel, 1999; Shiffrin & Schneider, 1977; Smith & DeCoster, 2000). Although coping with and adapting to trauma, loss, CID onset, and the like does not necessarily invoke the same duality of the mind discussed by social, developmental, and cognitive psychologists, these disciplines do enhance our understanding of certain forms of duality of experience.

During the past 40 years, dual-process social and cognitive models have vastly increased our understanding of how human reasoning, memory, judgment, and social cognition operate. According to these dual-process models, human mental operations represent two distinct “minds” or “central cognitions” (Evans, 2008; Frankish & Evans, 2009). These two cognitive processing modalities are neither sequential to one another, nor two dichotomously structured alternatives. They are believed to “operate simultaneously” (Smith & DeCoster, 2000, p. 112). These separate, interactive processes are often referred to as System 1 and System 2. System 1 cognitive processes are described as nonconscious, automatic, reflexive, associative, relatively rapid, somewhat rigid processes—ones that require little effort from working memory. In contrast, System 2 mental operations are conscious, deliberate, controlled, slow, systematic, relatively flexible, reflective, volitional, processes that require effortful working memory. The former, mostly nonconscious, system is regarded as “implicit” system, and shares much in common with Freud’s unconscious system (Ucs) and its “primary processes” operating mode. In contrast, the latter, mostly unconscious, system is regarded as “explicit,” and it strongly resembles Freud’s conscious system’s (Cs) “secondary processes” operating mode. Further clinical and empirical evidence (Evans, 2008; Frankish & Evans, 2009; Stanovich, 1999) indicates that System 1 is best represented by fast coding and learning of novel (and often single episodic) stimuli and experiences, including unexpected and unpredicted events. Such learning requires no linguistic abilities, focused awareness, or previously acquired knowledge. It is also responsible for present-oriented cognitive biases and errors. In contrast, System 2 is more closely linked to gradual and sequential learning obtained from general regularities and accumulated life experiences. Such learning requires linguistic and cognitive capacity, as well as volition and motivation. It is also responsible for normative and future-oriented reasoning. Finally, one more distinction between the two systems appears to involve evolutionary roots. Whereas System 1 is regarded as older and, therefore, more animalistic (nonlinguistic and illogical) in nature, System 2 is seen as being newer and, therefore, uniquely human (i.e., linguistic and logical; (Evans, 2008; Frankish & Evans, 2009). Indeed, whereas System 1 relies heavily on instinct, reflexive, and concrete mental operations, as typically observed in lower order organisms, System 2 has replaced these with abstract cognitive operations that are strongly tied to learned logical problem solving and decision making from past experiences, as seen in the behavior of higher order organisms, most notably humans (Epstein, 1994; Frankish & Evans, 2009).

Other similar dualistic perspectives on the nature of human experience can be found in such domains as (a) the development of regulation of (emotional) distress (Kopp, 1989), in which elementary cognitive regulatory processes (learned basic associations) are contrasted with advanced cognitive processes (planned, organized, and monitored behaviors); and (b) the dynamics of delayed gratification (Metcalfe & Jacobs, 1996; Metcalfe & Mischel, 1999), in which a two-tier, “hot/cold” system is suggested to explain self-control or “willpower” processes. The latter framework contrasts what the authors term a hot emotional system with a cool cognitive system. The former is best recognized by its rapid emotional responding and processing of environmental triggers, whereas the latter is best exemplified by complex temporal–spatial thoughts and mental representations. More specifically, the hot system develops earlier in life, is more adept when encountering threatening situations, and is characterized by simple, automatic, reflexive, rigid, affective, rapid, explicit, and stimulus-controlled processes, whereas the cool system, which develops later in life, and operates to infuse knowledge and organization about one’s goals and actions, is characterized by complex, reflective, flexible, cognitive, slow, implicit, and self-controlled processes (Metcalfe & Mischel, 1999). When facing acute stress, the authors argue, the hot system dominates, being better equipped to act quickly and ward off excess stress. In contrast, when stress is manageable, the cool system with its ability to process complex cognitions is more advantageous to the individual.

Focusing more specifically on the domain of responses to stress, Shiffrin and Schneider (1977), as well as Compas and colleagues (Compas, 1998; Compas et al., 1997; Compas et al., 1992) have maintained that, when confronting stressful situations, individuals typically respond through either innate (temperamentally triggered), involuntary reflexes and overlearned automatic processes, or through controlled, effortful, purposeful, volitional actions. Only the latter merits the definition of coping. The authors further argue that when involuntary, automatic responses are initiated to mitigate stress, they tend to overload and drain one’s cognitive capacity. Subsequently, the normal operation of effortful coping-related responses is likely to be constrained and, therefore, effective problem-solving coping is prevented.

The theoretical and clinical insights imbued within the above dichotomies offer a fertile ground for further assessment of the veracity of trauma- and disability-triggered forms of psychosocial adaptation. A brief discussion of these insights is attempted next.

Experiential Duality as Viewed Through Supportive Cognitive, Developmental, and Social Processes

As discussed above, the theoretical and clinical literature supports the existence of a convergence of views on the duality of much of human experiencing and functioning, as viewed through the prisms of psychodynamically oriented models (Freud, 1925/1961; Rapaport, 1951), social and cognitive models (Evans, 2008; Frankish & Evans, 2009; Metcalfe & Mischel, 1999), and stress and trauma models (Compas, 1998; Compas et al., 1992; Greenberg, 1995; Janoff-Bulman, 1992; Tedeschi & Calhoun, 1995). In each of these models, a dynamically functional duality has been drawn between two distinct sets of cognitive processes, often termed Systems I and II, or “hot” and “cold” systems, respectively. These cognitive systems occupy a central place within the context of the dualities often observed within the domain of psychosocial adaptation to CID (e.g., nature of PTG, denial vs. intrusive thoughts, adaptation vs. nonadaptation processes).

It has been argued (e.g., Greenberg, 1995; Tedeschi & Calhoun, 1995) that the operation of System I processes is more prevalent during earlier phases following the onset of a stressful or traumatic event; that is, they are more proximally linked to the onset of CID. Indeed, during these earlier experiences, which often (but not always) include such reactions of shock, anxiety (e.g., as in intrusive thoughts associated with posttraumatic stress disorder [PTSD]; Horowitz, 1986), self-deception, and denial, psychological processes are exemplified by their automatic, irrational, unorganized, and rigid nature (Compas et al., 1997; Greenberg, 1995; Janoff-Bulman, 1992). Furthermore, these processes operate mostly unconsciously and to represent nonadaptive functioning (Evans, 2011; Tedeschi & Calhoun, 1995). It has also been suggested that these processes reflect mostly affective responses, or emotional-focused coping (or stress management), and operate in generalized past and present time orientations (Evans, 2011; Maercker & Zoellner, 2004; Metcalfe & Mischel, 1999). Finally, these processes are best equipped to manage and filter novel stimuli (Frankish & Evans, 2009; Greenberg, 1995; Janoff-Bulman, 1992), such as those immediately following the onset of sudden and traumatically induced CID.

In contrast to these more innate, automatic, and reflexive processes, System II processes appear to be more operative at a later stage of the adaptation process, and as such, they are more distally associated with the onset of traumatic CID (Greenberg, 1995; Maercker & Zoellner, 2004). During these later phases, psychological growth becomes gradually less dependent on defensive denial and illusory perceptions, and incorporates a sounder reality-based, constructive, and functional set of mental operations (Horowitz, 1986; Maercker & Zoellner, 2004; Tedeschi & Calhoun, 1995). Unlike System I, System II processes are best represented by deliberate, rational, well-organized, and flexible efforts. They are, therefore, consciously operated, volitional, and reflective of adaptive functioning (Compas et al., 1997; Evans, 2011; Janoff-Bulman, 1992; Tedeschi & Calhoun, 1995). These processes have been more directly linked to the cognitive domain, and to coping modalities manifested by problem-solving and decision-making strategies (Evans, 2011; Maercker & Zoellner, 2004). Their time orientation has, accordingly, been viewed as mostly future oriented, because their major thrust is planning and goal-oriented activities (Evans, 2011). Finally, these processes appear to be best suited for situations where stress is manageable (i.e., the individual, with the passage of time, has had the opportunity to process and assimilate the meaning and implications of the CID). These individuals also have the advantage of prior exposure to similar types of stress, and the ability to integrate prior life experiences, and complex cognitive activities is afforded (Evans, 2011; Metcalfe & Mischel, 1999). The linear, goal-oriented, and rational decision-making process that underlies case planning in rehabilitation counseling (Rubin et al., 2016) is highly compatible with System 2 responses.

In sum, then, the process of psychosocial adaptation to CID appears to be dominated by two dynamically alternating and distinct, yet simultaneously operating, systems or sets of processes. The first one is comprised of mostly innately driven and automatic processes (i.e., denial, avoidance, illusory perceptions) whose primary aim is to ensure psychological survival, and is geared more toward cushioning the early traumatic experiences associated with the onset or diagnosis of life-threatening CID. The second is composed largely of learned responses from accumulated life experiences including those directly associated with stressful and traumatic events. These experiences serve to reintegrate and regulate existing stress level, and bring about a more realistic view of life following CID. It is at this point when authentic and reality-based psychological growth occurs.

PTG and BF in the Context of CID: Empirical Findings

To study the ostensible duality inherent in concepts that focus on psychological growth following trauma and adversity, such as the onset or diagnosis of CID, the role of various PTG indices must be carefully examined. Partial support for such duality can be gleaned from empirical findings where PTG indices have been used as (a) predictors of quality of life (QOL; including well-being and life satisfaction), (b) moderators of or mediators between CID severity or stress level and QOL indices, and (c) outcome measures, where PTG indices are predicted by a host of CID-related variables (e.g., severity of condition, time since onset), initial affect (anxiety, depression), coping strategies (e.g., denial, acceptance), and other (e.g., personality) variables. Empirical investigations have, indeed, explored the nature of the relationships among distress (anxiety, PTSD), PTG (including BF and MM), and QOL, and have shed some light on the experiential duality inherent in these concepts and the influence of PTG (illusory vs. healthy growth) on psychosocial adaptation, in particular. In several qualitative, cross-sectional, and longitudinal studies (for reviews, see Cordova et al., 2007; Hefferon, Grealy, & Mutrie, 2009; Jayawickreme & Blackie, 2014; Park, 2004), growth-linked variables such as PTG, BF, and MM of life with CID have been shown to be associated with better adaptation. However, in many other studies, the two constructs were found to be unrelated. These conflicting empirical findings have led to a wide range of speculations as to the physiological, CID-related, and psychosocial mechanisms that may underlie the operation of, and interaction among, these constructs. In the next few paragraphs, a brief synopsis of the more pertinent findings is offered. The findings can be collapsed under five main domains, namely, the association between PTG and (a) severity of CID; (b) subjective stress level; (c) psychological distress (e.g., anxiety, depression, PTSD); (d) perceived well-being, life satisfaction, and QOL; and (e) time since diagnosis/injury (TSD/I).

Research on the influence of condition severity on reported PTG indicates a wide range of findings from no relationship between PTG and degree of severity (Park, Malone, Suresh, Bliss, & Rosen, 2008, in a longitudinal study of heart disease patients; Petrie, Buick, Weinman, & Booth, 1999, in heart disease and breast cancer survivors; Thornton & Perez, 2006, in cancer survivors), to inverse (Mols et al., 2009, among breast cancer survivors), and to positive (Pakenham, 2005, among people with MS; Tomich & Helgeson, 2004, among breast cancer survivors, such that those with more advanced stages reported higher BF). Most interesting, however, were findings of curvilinearity between PTG and condition severity (Lechner, Antoni, Carver, Weaver, & Phillips, 2006; Lechner et al., 2003, among cancer survivors; Hawley & Joseph, 2008, among traumatic brain injury [TBI] survivors). In each of these studies, those who were diagnosed with or sustained medium-level diseases/injuries reported higher levels of PTG, as compared with those with mild or severe conditions. Findings on the link between PTG and subjective stress are rather scarce, but point to a tentative trend such that increased perceived stress positively predicts higher PTG (Sears, Stanton, & Danoff-Burg, 2003, among breast cancer survivors; Tran, Wiebe, Fortenberry, Butler, & Berg, 2011, among adolescents with diabetes).

The complex structure of PTG and its possible dual nature has gained empirical support from the literature on the association between PTG and measures of psychological distress, including PTSD, anxiety, and depression. The majority of studies found no reliable link between PTG and measures of psychological distress. Indeed, research among cancer survivors (e.g., Carboon, Anderson, Pollard, Szer, & Seymour, 2005; Cordova, Cunningham, Carlson, & Andrykowski, 2001; Morrill et al., 2008; Sears et al., 2003; Silva, Moreira, & Canavarro, 2012; Thornton, 2002) concluded that perceived growth and emotional distress (including depression) often coexist independently among these survivors. Similar findings were also reported among people living with multiple sclerosis (Pakenham, 2005), and those who underwent amputation (Phelps, Williams, Raichle, Turner, & Ehde, 2008). Other research findings suggested that the two constructs are inversely related, such that higher perceived PTG was associated with lower distress among breast cancer survivors (Ruini, Vescovelli, & Albieri, 2013); stroke survivors (Gangstad, Norman, & Barton, 2009); TBI survivors at a later, but not earlier, time period (Hawley & Joseph, 2008); people with rheumatoid arthritis at a short-term, but not long-term, follow-up (Danoff-Burg & Revenson, 2005); heart disease patients (Garfenski, Kraaij, Schroevers, & Somsen, 2008); and adolescents with diabetes (Tran et al., 2011). Findings of positive association between the two have also been reported in the CID literature (Morrill et al., 2008, PTSD and PTG among cancer survivors; McGrath & Linley, 2006, anxiety and PTG among TBI survivors; Bluvstein, Moravchick, Sheps, Schreiber, & Bloch, 2013, PTSD, distress, and PTG among heart disease patients). In a recent study among SCI survivors (Kunz, Joseph, Geyh, & Peter, 2017), the intricacy of these relationships was further evidenced as PTG was positively correlated with both anxiety and global distress, yet unrelated to depression and life satisfaction. Furthermore, these relationships were moderated by perceptions of posttraumatic depreciation (PTD; a measure of negatively worded items of the PTGI), such that PTG was significantly linked to lower depression and higher life satisfaction, only among individuals who experienced higher levels of PTD, suggesting that PTG may be adaptive, mostly when negative life changes and physical losses are acknowledged and not denied. Finally, evidence of a curvilinear association between posttraumatic growth (PTG) and PTSD (and depression) has also been reported (Kleim & Ehlers, 2009, in a sample of assault survivors).

The complexity of the relationship between PTG and distress (i.e., depression) was further demonstrated by findings of two studies. In a study of individuals with multiple sclerosis undergoing psychotherapy (Hart, Vella, & Mohr, 2008), findings showed that although decreased depression was linked to increased BF over time, this relationship was mediated by two personal resources, namely, optimism and positive affect, prompting the authors to speculate that BF and optimism may not necessarily reflect real positive life change, but may simply indicate positive illusions and wishful thinking processes. In the study of stroke survivors mentioned above (Gangstad et al., 2009), findings revealed that time since stroke acted as a moderator of the inverse link between anxiety, or depression, and PTG. More specifically, these relationships were significant under longer time duration, but nonsignificant under shorter time duration. With increased time, then, these relationships assume a negative value, thus suggesting that long-term reports of growth are more likely to be reflective of positive and genuine life changes rather than continued illusory perceptions. Possibly, the most insight-generating findings on the association between PTG and psychological distress have been reported by Occhipinti, Chambers, Lepore, Aitken, and Dunn (2015), whose longitudinal study followed colorectal cancer survivors, annually, for 6 years. Among their most revealing findings were the existence of a large heterogeneity in both psychological distress and BF over time and the complexity of their interrelationships. For example, those whose BF increased earlier also tended to later experience increased distress, whereas those whose distress increased earlier tended to later experience decreased BF. Based on these unorthodox findings, the authors posited that changes in self-reported PTG may represent something other than changes in an underlying construct of psychosocial adaptation following a medically traumatic event.

A rich body of literature exists to support the contention that perceived PTG either predicts psychosocial adaptation (i.e., higher levels of reported QOL, life satisfaction, and well-being) or at least serves as one of its correlates. Indeed, findings have suggested that the two constructs are positively related among cancer survivors (Lelorain, Bonnaud-Antignac, & Florin, 2010; Mols et al., 2009; Morrill et al., 2008; Ruini et al., 2013; Sears et al., 2003; Silva et al., 2012), survivors of heart disease (Garfenski et al., 2008; Park et al., 2008), individuals with multiple sclerosis (Pakenham, 2005), and those with diabetes (Tran et al., 2011). An unexpected inverse association has also been reported between PTG and QOL, among heart disease survivors (Bluvstein et al., 2013), however, these findings were moderated by the presence of PTSD, such that under conditions of high PTG, the harmful link between PTSD and QOL was attenuated, in contrast to when PTG was low and ineffective in attenuating these relationships. Other findings, however, suggested that perceived personal growth following CID onset and measures of QOL, such as well-being, life-satisfaction, positive affect, and psychosocial adaptation may be independent of each other (Thornton, 2002).

Finally, support for the dual nature of perceived positive growth following CID onset has been garnered from research on the relationship between PTG and TSD/I. The majority of findings indicate that PTG is positively correlated with TSD/I, such that longer elapsed time is associated with higher perceived PTG among cancer survivors (Cordova et al., 2001; Sears et al., 2003) and TBI survivors (Hawley & Joseph, 2008; McGrath & Linley, 2006; Powell, Ekin-Wood, & Collin, 2007). However, other researchers reported finding no link between elapsed time and PTG (Morrill et al., 2008; Silva et al., 2012; Tran et al., 2011), and in one study, even an unexpected inverse trend (Garfenski et al., 2008, in a sample of heart disease survivors). Again, the complex interactive nature of PTG, TSD/I, and related factors was further discussed by Tomich and Helgeson (2004), who reported that in their sample of breast cancer survivors, PTG was related, over time, to greater emotional distress (lower perceived QOL), but mostly for those with more severe disease. The authors, accordingly, recognized that earlier measured perceived PTG may be but a temporary ploy to alleviate distress, thus illusory in nature, and may not reflect genuine positive changes that require longer adaptation period. Similarly, Hawley and Joseph (2008), in their sample of TBI survivors, found that in addition to the existence of a curvilinear relationship between severity of injury and reported PTG, PTG was independent of emotional distress at an early follow-up; however, it was negatively associated with it at a 10-year follow-up, prompting the authors to suggest that early on, the survivor may still be searching (haphazardly) for meaning, whereas in the longer term, the presence of PTG may indicate meaning finding and, therefore, be predictive of better psychosocial adaptation. These speculations echo the findings of Davis et al.’s (1998) widely cited research, on individuals coping with loss of family members, in which they argued that making sense of a loss is more important in the early phases of the adaptation process, whereas finding or perceiving benefits from it may require a longer time period to fully process its implications.

Five meta-analytic studies (Barskova & Oesterreich, 2009; Grace, Kinsella, Muldoon, & Fortune, 2016; Helgeson, Reynolds, & Tomich, 2006; Sawyer, Ayers, & Field, 2010; Shand, Cowlishaw, Brooker, Burney, & Ricciardelli, 2015), conducted within the recent past, lend further support to the nature, structure, and conceptual complexity often observed in the empirical literature on posttraumatic psychological growth and its correlates. In these meta-analyses, findings from zero-order correlations indicated that PTG (and BF) were associated with both lower (depression) and higher (PTSD) indicators of psychological adjustment (e.g., life-satisfaction and well-being; Helgeson et al., in a heterogeneous population of people with CID as well as other experienced traumas; Barskova & Oesterreich, in a wide range of individuals with severe medical conditions and disabilities; Sawyer et al., in cancer and HIV/AIDS survivors; Grace et al., among TBI survivors), thus suggesting that PTG is differentially, and inconsistently, linked to specific psychosocial outcomes. However, personal growth was also found to be unrelated to other indicators of adjustment, such as anxiety, depression, and global distress, or to QOL, as an outcome measure, in Helgeson et al.’s, Barskova and Oesterreich’s, and Shand et al.’s studies, further suggesting that when viewed globally and temporally nonspecific, PTG may demonstrate an inconsistent and differential link to measures of distress and QOL. Indeed, as related to the dual nature of PTG, analyses of moderator effects yielded findings implicating the interactive effects of variables such as nature of traumatic event, subjective perception of stressful event, age, ethnicity, time since occurrence of traumatic event, type of psychological growth, as well as outcome measures employed. When time since injury/disability (TSI/D) was examined as an independent factor within the context of duality of adaptation (i.e., short vs. long time since CID onset, genuine vs. illusory growth), findings revealed that it not only was directly associated with PTG but also served as a moderator between PTG and psychological adaptation (Barskova & Oesterreich, Helgeson et al., Sawyer et al.). Elapsed time significantly predicted depression, anxiety, global distress, and well-being in several of these reviews (Barskova & Oesterreich, Helgeson et al.). In the Barskova and Oesterreich review, PTG was found to be inconsistently related to anxiety, however, elapsed time since onset of medical event played a role in these relationships. More specifically, PTG was inversely related to anxiety after more than 5 years since injury or diagnosis, but independent of anxiety during the first 5 years. In the Helgeson et al. review, psychological growth was more strongly associated with lower depression and higher positive affect when elapsed time exceeded 2 years since event, but was associated with increased global distress when duration of time was shorter than 2 years. In line with theoretical assumptions, the authors speculated that these findings suggest perceived psychological growth is related to better adjustment following the operation of time-processed effective cognitive self-enhancing and successful coping strategies, but to poorer psychological outcomes when cognitive biases, early in the adaptation process, are still operational and are geared toward relieving distress. This finding underscores the potential importance of cognitively oriented early intervention counseling strategies to help clients develop System 2 coping responses during the initial stages of the rehabilitation process, preferably very soon after the onset of CID (Bishop, 2012). The sooner the client passes through System 1 responses and begins to adopt System 2 responses, the more actively he or she will be able to engage in the planful, goal-oriented process that is rehabilitation counseling.

In their review of the literature, Barskova and Oesterreich (2009) also reported that TSD/I was found to be both positively predictive of PTG, in some studies, as well as unrelated to it in others, and these findings were independent of CID type or level of severity. However, the findings were influenced by the specific measure adopted to assess personal growth (Posttraumatic Growth Inventory vs. Benefit Finding Scale). In a similar vein, Sawyer et al. (2010), concluded from their meta-analysis of PTG and psychosocial adaptation among cancer and AIDS/HIV survivors that time acted as a moderator between these two measures, such that in the short term, there was a stronger association between PTG and indicators of negative adaptation, whereas in the long term, there was a stronger association between PTG and positive adaptation. The authors concluded that reports of PTG after passage of time are more likely to reflect more successful life changes and improved QOL. In another meta-analytic study of personal growth among cancer survivors, Shand et al. (2015) reported findings that showed no association between TSD and PTG. However, their findings also indicated that moderate levels of heterogeneity existed across the studies reviewed, ranging from correlations of moderate and negative to moderate and positive values. As such, these findings suggest appreciable inconsistency in the TSD/I–PTG relationships. Finally, in their meta-analysis of the unfolding of PTG over time and its relationships to life satisfaction and perceived well-being among TBI survivors, Grace et al. (2016) concluded that with the passage of time, these survivors reported increased PTG, and these perceptions were associated with higher subjective appraisal of the traumatic event (rather than the event’s objective severity). Again, this prompted the authors to suggest that earlier in the adaptation process, PTG may reflect functional illusions and denial-derived reactions directed at stress minimization. Reports of PTG, then, at this stage, may be no more than self-enhancing cognitive biases.

In sum, the empirical literature that has examined the structure, dynamics, and correlates of ostensibly positive psychological growth indicates a highly intricate and multifaceted network of findings. These findings, however, lack a consistent or clear pattern, and, therefore, fail to elucidate the dual nature of such growth (positive illusions vs. real and adaptive psychological growth). More specifically, a sizable proportion of the available findings suggests that PTG and BF may coexist with negative affect such as anxiety or depression (i.e., revealing independence from the other); yet, other findings have shown the two to be positively related (i.e., increased PTG is associated with higher positive affect and/or lower psychological distress).

In several of the studies, a factor that was shown to interact with initial affect and influence PTG is TSD/I. Experiences of PTG and BF, typically but not consistently, increase over time following the onset of CID. In early phases, negative affect, along with attempts to make sense of life changes dominate, whereas in the long range, perceiving benefits and a gradual experience of PTG dominate. This lends some support, but does not necessarily prove the notion that reports of early phase experiences of BF and PTG may be suggestive of positive illusions, or denial-like mechanisms, rather than real and positive growth. Severity of disease stage and CID-triggered stress level also appear to play a role in promoting PTG. These relationships, however, suggest that the trend may not be necessarily linear, but may harbor an inherently quadratic association, such that moderate levels of condition severity or stress (in contrast to mild or severe) may promote higher PTG. To wit, when severity of condition is low, and when stress is low, PTG may not need to be employed, whereas under conditions of high severity and stress, psychosocial resources may be temporarily constrained, or deployed elsewhere to manage life-sustaining activities and, therefore, PTG may not be operative.

Finally, the relationships between PTG, or BF, and QOL were also found to be discordant, such that PTG was found to be both positively related to, and independent of, measures of QOL. The findings discussed in this section suggest that any attempt to delve deeply into the authenticity, fabric, and veracity of psychological growth may face an insurmountable barrier in the form of a web of interacting (i.e., moderating and mediating) effects that typically include (Barskova & Oesterreich, 2009; Helgeson et al., 2006; Linley & Joseph, 2004; Sawyer et al., 2010) type of CID (and its associated functional limitations), CID severity level, degree of psychological stress experienced, TSD/I, type and psychometric soundness of measuring instruments, and possibly some psychological traits (e.g., neuroticism, extraversion), or coping resources (e.g., optimism, hope, self-efficacy) and coping strategies (problem solving, seeking social support, venting), not explicitly discussed in the present article (Barskova & Oesterreich, 2009; Helgeson et al., 2004; Park, Cohen, & Murch, 1996; Prati & Pietrantoni, 2009).

Validation of Perceived Growth Following Adversity and CID Onset

The issue of how to validate the veracity of personal growth following adversity, including the onset of CID, has received some attention in the extant literature. Several lines of research were proposed. First, it was suggested that employing prospective (rather than the traditional retrospective) research designs may be useful in minimizing recall issues that tend to inflate perceptions of growth. For these prospective, longitudinal designs to be beneficial, predictors, temporal processing, and outcomes of personal growth must be carefully tracked and measured (Jayawickreme & Blackie, 2014; Joseph & Linley, 2006; Tennen & Affleck, 2009; Wortman, 2004). Obviously, because obtaining such data may be highly challenging, it is recommended that populations in which people considered to be of “high risk” and already being treated for life-threatening medical conditions may represent best possible study cohorts (Tennen & Affleck, 2009). Second, to examine the accuracy of perceived positive growth, researchers (Jayawickreme & Blackie, 2014; Tennen & Affleck, 2009; Wortman, 2004) also recommended obtaining validating clinical information from proxies, notably family members and others intimately anchored within the individual social network. Third, it was suggested by Helgeson et al. (2006), Frazier and Kaler (2006), and Tennen and Affleck (2009) that in addition to obtaining the typical cognitive–affective data on perceived personal growth, researchers should also seek to measure performance indicators, such as newly acquired knowledge and skills, helping behaviors, and the achievement of actual life changes. These additional data would serve to provide some type of concurrent validity to claims of personal growth (see also Weinrib, Rothrock, Johnsen, & Lutgendorf, 2006). Fourth, because much of the available data rely on recalls of past events representing ostensible personal benefits and growth, Tennen and Affleck (2009) also suggest that for genuine growth to occur, the individual should demonstrate a high level of concordance between measured and recalled growth. This should contrast with an indication of nongenuine growth, that is, positive illusions, where concordance between the two measures of growth should be low and allow for greater individual differences.

Fifth, adopting longitudinal research designs and measuring the relationships between perceived personal growth and denial over time should demonstrate decreasing magnitude of association if personal growth is indeed present. This is because the two constructs, if independent, should follow different trajectories, thus yielding decreased concordance with the passage of time. Sixth, employing longitudinal designs in which indicators of growth, as well as of PTSD and QOL, are carefully tracked over time and correlated with each other, both cross lagged and prospectively, would, also, present a useful strategy. It could be argued that although PTG and PTSD have been found to be, at times, positively correlated with each other, such a trend should diminish, and possibly even assume a low inverse relationship, over time, as the experience of PTSD gradually subsides and that of PTG gradually increases. In a similar manner, the relationships between PTG and QOL, one that has been shown to be only moderately linked or independent, would be expected to gradually increase over time as PTG gains strength and becomes more intimately infused into one’s perceived well-being, a cornerstone of perceived QOL. Researchers could employ latent variable growth curve modeling (LGCM; Duncan, Duncan, & Stryckler, 2006) to examine these complex growth-related variable relationships.

Seventh, an additional empirical method includes correlating scores on measures of PTG with those of social desirability. Reports of growth should not be merely a by-product of the need to present oneself in a socially positive light (Park et al., 1996; Tedeschi & Calhoun, 1996; Weinrib et al., 2006). As has been done on numerous occasions with similar self-report measures of suspected honest responding, appreciably high positive correlations between these two measures may signal efforts to present oneself in a socially sanctioned light, thus indicating self-deception rather than genuine growth (Heppner et al., 2015). Eighth, measures of genuine self-growth should be associated with independent personalized indicators of both depth and extent of cognitive and emotional processing of the traumatic event (Weinrib et al., 2006). Ninth, reports of positive self-growth should be related to one’s ability to cope successfully with (e.g., adopt mostly approach-oriented coping modalities rather than avoidance-oriented modalities), and be less affected by, future stressful events to be considered genuinely valid (Frazier & Kaler, 2006). Furthermore, these two sets of coping modalities should interact (i.e., be moderated) differentially with indicators of acknowledgment of the negative consequences of the incurred loss (e.g., CID) in predicting PTG. Indeed, a recent longitudinal study by Kunz, Joseph, Geyh, and Peter (2018) sought to investigate these complex relationships among SCI survivors. Unfortunately, the veracity of the reported findings was compromised by several conceptual and methodological limitations. Finally, the coexistence and unpredictable oscillations that reflect the broad coarse-grained separation of genuine versus illusory growth following CID onset could be somewhat untangled with the adoption of prospective, time-series daily measurement research designs (Porter & Stone, 1996; Stone & Shiffman, 1992; Tennen & Affleck, 1996). Indeed, these types of intensive (normally using daily measurement), idiographic designs arm the researcher with certain advantages, including the ability to track changes when dynamic, “rapidly fluctuating processes” (Tennen & Affleck, 1996, p. 153) are involved, such as those that typically follow traumatic experiences, sudden onset CID, and experienced pain. Furthermore, these designs capture experienced benefits, psychological growth, and coping efforts that are proximally linked to the triggering event. These designs also act to reduce distortions due to recall burden, and maintain temporal sequencing of measured characteristics, thus promoting causal inferences among them (Porter & Stone, 1996; Tennen & Affleck, 1996). These designs provide more granular, day-to-day analyses of the relationships among experienced stressors, growth and coping efforts, and psychosocial adaptation outcomes (Porter & Stone, 1996). When applied in the context of investigating the structure and dynamics of personal growth following CID onset (Tennen & Affleck, 1996; Wasteson, Glimelius, Sjoden, & Nordin, 2006), this design provides for both, (a) a situation-specific approach to listing and describing daily stressful situations triggered by the traumatic experience/CID, strategies used to cope with these situations, and perceptions of growth derived from them; and (b) a more formal quantitative approach where representative item parcels, from a spectrum of pertinent scales (e.g., denial, wishful thinking, PTG, anxiety, depression, well-being, QOL) can be used to gain access to the respondent’s psychological worldview on personal growth following the onset of CID.

Conclusion and Implications for Theory and Research

The various theoretical models of experiential dualities of psychosocial adaptation to CID, as well as the complexity and inconsistency of the empirical findings, indicate that no simple answer exists to resolve the nature and dynamics of such dualities. Indeed, the interrelationships among the sets of variables studied, namely, psychological growth (PTG, BF), emotional distress (PTSD, anxiety), psychosocial outcomes (QOL, well-being), and time duration since CID onset, present a rather conflicting landscape of hypotheses, findings, and speculations. More specifically, the prospects of empirically examining the assumed duality of psychological growth following trauma, and more directly CID, encounter rather daunting odds. These discouraging prospects stem from the fact that efforts to investigate the structure and dynamics of psychological growth are typically marred by the interacting and contaminating effects of such variables as (a) condition’s severity level and degree of functional limitations; (b) experienced stress and distress triggered by the condition, including its life-threatening nature (see, also, discussions by Stanton, Bower, & Low, 2006; Wortman, 2004); (c) degree of ambiguity of the imposed threat; (d) type and nature of the occurring event, including the onset and progression of CID; (e) coping resources (hope, optimism, resilience, self-efficacy; Linley & Joseph, 2004; Prati & Pietrantoni, 2009); (f) coping strategies (problem-solving, planning, acceptance, seeking social support, behavioral disengagement, avoidance; Barskova & Oesterreich, 2009; Linley & Joseph, 2004; Manne et al., 2004; Prati & Pietrantoni, 2009; Sears et al., 2003; Stanton et al., 2006); (g) preexisting personality characteristics and dispositions (e.g., neuroticism, openness to experience); (h) the measuring instruments of personal growth, adaptation, and QOL (Barskova & Oesterreich, 2009; Park, 2004; Prati & Pietrantoni, 2009; Tennen & Affleck, 2009); (i) the specific time frame in which growth and adaptation are measured, as well as the temporal relationship between the two (Park, 2004); and (j) recall issues of change and growth over time, which typically place a cognitive recall and information processing burden on the respondent (Tennen & Affleck, 2009). Future research and corresponding theoretical venues should, therefore, consider the following:

The role played by the above confounding variables should be explored to better understand their influence on the experiential duality of personal growth following onset of traumatic CID. Such a task, unfortunately, is rather daunting because teasing out, simultaneously, the influence of several confounders requires large samples and time commitment. In addition, achieving control over variables such as preexisting personality traits, coping strategies, and recollection capacity is all but impossible. Yet, meticulous accumulation of pertinent empirical data, through the employment of longitudinal research designs, and large and heterogeneous samples, could help in creating a data bank from which researchers could draw firmer conclusions on how positive growth following CID emanates and unfolds over time.

The role time passage plays in influencing the direction and trajectory of positive growth following CID onset is another pressing issue. Empirical data have indicated that the relationship between time since CID onset and personal growth is inconsistent (e.g., Barskova & Oesterreich, 2009; Stanton et al., 2006). These findings are in disagreement with theoretical models, which argue that the two should be positively linked (Janoff-Bulman, 1992; Tedeschi & Calhoun, 1995), such that with more time to ruminate about, and process-relevant information on, personal loss and adversity, the individual should experience personal growth. Future research should, therefore, pay heed to these discrepancies in findings, as well as carefully examine how post-CID onset personal growth trajectories unfold in the context of different types of CID, aging, available coping and personality resources, negative affectivity, and the relationships with simultaneously measured, longitudinal trajectories of “pseudo-growth” indicators such as wishful thinking, denial, and avoidance.

As indicated, the experiential duality believed to exist within psychosocial adaptation to CID, and the veridicality of positive growth following CID onset, could be viewed within the fabric of cognitive, developmental, and social psychological models (Evans, 2008; Metcalfe & Mischel, 1999). The latter models suggest that ontogenetically earlier phases of adaptation to life-threatening situations tend to mobilize more automatic, nonconscious, and rigid defenses that appear to underlie denial-like, self-deceptive reactions. In contrast, ontogenetically more distal reactions following CID onset, and following an elapsed recuperative period of time, are typically exemplified by their deliberate, conscious, flexible, and volitional nature. These separate, yet intimately interwoven, sequences of processes offer several predictions that could be both clinically and empirically tested.

Research indicates that the relationship between personal growth and psychosocial adaptation, or psychological distress, follow an inconsistent path, often presenting highly contradictory findings. It can be speculated that real psychological growth, positive illusions (and self-deception), and psychosocial adaptation (higher perceived well-being, lower distress), all represent unique and separate psychological domains, and may be experienced concurrently (Maercker & Zoellner, 2004; Stanton et al., 2006; Tedeschi & Calhoun, 1995). Future efforts should be directed at better understanding the mechanisms that underlie these concepts across various medical conditions and functional limitations, as well as across various cultural identity groups. For example, a question that should be addressed is how longitudinal trajectories of measures tapping these domains tend to vary (intrameasure relationships) and covary (intermeasure relationships) over time.

Finally, the very essence of the concept of experiential duality, ostensibly inherent in personal growth following CID, must be revisited. The preponderance of theoretical and empirical work on the subject suggests a covert consensus of claims that personal growth following adversity, and CID more specifically, is dichotomous in nature. But does the onset of CID, indeed, present such a dichotomy of experiences (genuine positive growth vs. positive illusions and self-deception) or does such dichotomy, itself, rest upon an illusory framework? Indeed, the complexity and multilayered experiential nature of coping with adverse and traumatic events may defy such a Draconian dichotomizing effort. Much of the spectrum of human psychosocial functioning (both negatively and positively valanced, as well as affect neutral) follows a more gradual, continuous shift in perceptions, as evidenced in scores on, and scale structure of, measures such as depression, anxiety, well-being, attitudes toward specific referent groups, coping, cognitive ability, and so forth. Is it possible, then, that previous efforts to view growth following adversity as strictly positive and genuine, or deceitful and illusory, are doomed to fail even if they follow best intentions?

Implications for Clinical Rehabilitation Counseling Practice

Systematic efforts to more thoroughly understand the theorized but not always empirically observed duality of clients’ cognitive, affective, and behavioral responses to CID are critically important to the eligibility determination, assessment, case planning, service delivery, and case evaluation and closure phases of the rehabilitation process (Rubin et al., 2016; Smart, 2016). In the parlance of personal growth, rehabilitation counselors must assist clients in the development of System 2 coping responses that are rooted in deliberate, rational cognitive appraisals of the impact that CID has on important outcomes such as employment, community living, familial role performance, and QOL. These System 2 emphases must begin early in the rehabilitation process, even if the client seems to persist in applying System 1 responses such as denial, avoidance, and positive illusions.

Personal growth also provides a framework for considering adaptation to disability within Vash and Crewe’s (2004) idealized concept of transcendence. When the client employs sufficient System 2 responses as to consider CID as a positive element of his or her self-concept based on the opportunities the CID has presented for personal growth and resilience, he or she transcends the traumatic, life-altering, and distressful qualities that are often ascribed to the disability experience. By transcending the commonly held view that disability is a necessarily traumatic event in one’s life, an individual at the highest level of personal growth following onset of CID may find it easier to focus on positive life outcomes as reasonable goals of the rehabilitation process rather than targeting his or her self-appraisals toward barriers and limitations to goal attainment. These positive self-beliefs often become self-fulfilling prophecies; the client who believes that he or she will succeed in job search, who focuses during job interviews on the contributions that he or she can make to the company rather than on disability-related limitations that require accommodation, and who begins his or her employment with a “can-do” attitude stands to realize more long-term vocational success than a client who does not possess positive self-beliefs (Wehman, 2013).

Positive psychology, with its focus on strengths, assets, and virtues rather than on deficit reduction (Chou et al., 2013), provides an additional theoretical impetus for contextualizing personal growth and QOL as the ultimate end goals of rehabilitation counseling. Job placement efforts work best when the counselor helps the client identify and express to employers his or her positive qualities such as work ethic, formal training and experience, reliability, and job-specific knowledge. This, in turn, allows the client to avail himself or herself of the well-documented impact that successful employment has on QOL, personal growth, well-being, community participation, and health (Strauser, 2013).

Another rehabilitation-linked domain to which the concept of experiential duality may be applied, albeit cautiously, is that of clinical interventions following the sudden onset of CID. Based on both theory and empirical findings, reports of abrupt and unexpected positive changes following traumatic CID onset may be reflective of denial-like, self-deceptive processes and ingenuine growth. In contrast, genuine psychological growth requires a more gradual unfolding. This conclusion suggests that practitioners encountering clients who boast of PTG benefits immediately shortly after CID onset may be engaging in illusory perceptions of personal growth, fueled by the subterfuge work of defensive denial. Such clients should be carefully counseled using denial-defusing intervention. These may include (a) a balanced and supportive–confrontive clinical environment; (b) scenarios to heighten self-awareness, suggesting inconsistencies between self-verbalizations that seem to reflect illusory and inaccurate perceptions of one’s capabilities and overt behaviors involving personal limitations; (c) social support by significant others to include encouragement of a realistic outlook; and (d) reconciling expectations regarding concrete plans that focus on medical, functional, psychosocial, vocational, and environmental issues to further enhance realism (Deaton, 1986; Livneh, 2009; Wheeler & Lord, 1989).

Other clients with CID have had sufficient time to assimilate the functional implications derived from knowledge and experience of life’s permanent restrictions. Their PTG reflects a genuine growth. With these clients, rehabilitation counselors and psychologists could consider several supportive approaches to further maintain and bolster growth. These include (a) broaden and build strategies to expand positive emotions (e.g., joy, contentment, love) and ultimately build enduring personal resources for psychological and physical well-being (Fredrickson, 2004). This approach maintains that positive emotions expand one’s “ . . . momentary thought-action repertoires” (p. 1369). In turn, additional positive emotions emerge, which further bolster search and discovery of new and creative ideas, social ties, and planful actions. (b) Well-being therapy that seeks to further promote both awareness and behaviors conducive to psychological growth (Fava & Ruini, 2003; Ryff, 1989). Based on Ryff’s six-component model, well-being consists of pursuing subjective happiness and pleasure and avoiding pain and negative emotions. Fava and Ruini, as a short-term, cognitive–behavioral, structured approach to promote personal growth, purpose in life, self-acceptance, autonomy, environmental mastery, and positive interpersonal relations (Ryff’s six components of well-being), developed well-being therapy. (c) A PTG-based approach, based on their PTG model, was advocated by Tedeschi and colleagues (Tedeschi & Calhoun, 2004; Tedeschi & McNally, 2011) to enhance growth. This method integrates ingredients from cognitive, humanistic, existential, and narrative therapies. When applied to the experience of veterans, researchers focused on enhancing emotional regulation using reflective rumination, constructive self-disclosure, a coherent PTG-linked traumatic narrative to restructure shattered beliefs, seeking new goals and pathways for reaching them, and developing cognitive and behavioral guidelines to enhance resilience.

The preceding review is as comprehensive and detailed as current literature allows. However, the rehabilitation counselor’s or psychologist’s own perspective must also be carefully weighed. Following are considerations for future researchers and practitioners in the area of adjustment to CID.

Given the documented complexity of the psychosocial adjustment process, a professional rehabilitation counselor or psychologist may choose to invest in any number of interventions known to promote psychological growth. For example, acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) is finding a niche in managing CID. ACT is an applied behavior analysis system focused on enhancing psychological flexibility (akin to a “mature” mind), and utilizes commitment to well-defined values as a path to recovery. Other ACT constructs include mindfulness, acceptance, and self as context. Admittedly, Hayes worldview is somewhat dark and his theory is rooted in relational frame theory (Hayes, Barnes-Holmes, & Roche, 2001). ACT is an “act now and understand later” solution. However, many rehabilitation professionals have very large caseloads with a diverse population that presents complex service needs. With limited resources, short-term interventions will receive ever greater priority. Clearly in the future, the PTG research must account more for the effects of rehabilitation interventions. It is rarely a solitary endeavor without significant environmental influences.

Another “act now” strategy is a reemphasis and recommitment to competitive employment as not only a rehabilitation outcome but also a primary treatment modality, an important means of enhancing effecting PTG (Chan et al., 2017). Future positive psychology researchers and practitioners would do well to identify the employment status of their research participants, and compare this variable with other important psychosocial and health outcomes. Researchers may discover that employed participants have markedly more expeditious and complete PTG, and there are many growth-enhancing benefits derived from the experience of competitive employment. Stated as a research question, “How does employment contribute to growth and maturity, benefits finding, well-being, identity, QOL, life satisfaction, and access to psychological and medical interventions?”

Next, many nonpsychological interventions are largely unaddressed in PTG theory and research: physical, behavioral, spiritual, recreational, neurological, and sensory. The studies cited herein attempt to describe a type of mostly spontaneous recovery for psychosocial adaptation. This serves to separate the psychosocial from all other life areas, but to the extent that it succeeds, it is more psycho than social. The research cited in this article has a largely intrapsychic focus, but rehabilitation counselors must pay increasing heed to the client’s treatment regimen, environment, and community participation pursuits. PTG researchers may more fully account for the environmental influences that are known to shape one’s adaptation to CID.

Finally, impairment and functionality do matter, and the disability experience is always embedded in a developmental context. A young man with a TBI may be more concerned with adjustment issues such as driving, finding a job, romantic relationships, and his desire for independence than with early retirement or provision for grandchildren. Life-threatening conditions (e.g., cancer) bring different priorities than other serious conditions that may often be controlled with a single medication (e.g., epilepsy). Future PTG researchers and practitioners may do well to account for the nature of disability, not in Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases and Related Health Problems (ICD) terms, but at least using broad categories of impairment and functionality that distinguish conditions as largely physical, behavioral, neurological, or sensory.

Although these reflections from rehabilitation researchers may dampen enthusiasm for theories of psychosocial adaptation to CID, the importance of persisting (while addressing some of these limitations in future studies) remains important. Theory provides the best foundation for helping the rehabilitation professional to decide where to go, what to expect, and what to do next. There are few things more practical than a good theory. But a good theory needs, among other features, parsimony—this appears to be the most challenging criterion to meet when it comes to psychosocial adaptation to CID. In the meantime, rehabilitation counselors and psychologists may take from this what they find useful, and continue to be highly individualized in their rehabilitation planning and case management responsibilities.

Conclusion

In sum, the study of personal growth following traumatic events and CID onset is hampered by a wide range of largely uncontrollable variables. These CID-linked, environmental and personal variables often interact unpredictably with the process of growth, thereby rendering insurmountable many efforts to study its nature and structure, including its duality. Findings from available data have painted an inconsistent picture, and have been plagued by conceptual and measurement barriers that typically stem from the complex and dynamic interactions among measures of personal growth, elapsed time since CID onset, level of emotional distress, nature or severity of impairment, and a host of personality characteristics, psychosocial resources, and coping efforts. It has been conjectured that at the bedrock of reported personal growth following CID lie two interacting sets of processes. The first steps occur earlier. These involve archaic, unconscious, automatic, rigid mental processes that may unleash denial-type, self-deceptive reactions. These serve to reduce initial distress when confronting life-threatening situations. The second steps occur later. These involve advanced, conscious, deliberate mental processes that may lead to more authentic and truthful efforts to manage the consequences of CID. This transition requires time and leads to greater control over one’s cognitions and behaviors. Validation of this model might include the use of large-sampled, longitudinal prospective research designs; obtaining independent observations from family members; and additional data on newly acquired performance indicators. Future research may also involve longitudinal designs to track, over time, the changing dynamics of the relationships among personal growth indicators: for example, illusory growth, denial, and wishful thinking; distress; perceived well-being and QOL. Finally, employing prospective, intensive, daily-assessed, time-series designs may be useful. These may involve both detailed qualitative and quantitative data to track concomitant changes in indicators of perceived personal growth, coping efforts, distress, and well-being. These research suggestions will help to disentangle the ongoing mystery that shrouds the experiential duality inherent in psychosocial adaptation to adversarial life conditions such as CID.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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