Trauma, stages of change and post traumatic growth in addiction: A new synthesis

ABSTRACT

Purpose

This paper proposes a foundation on which to consider post-traumatic growth (PTG) and addiction recovery. It considers addiction as a traumatic experience with a consequential impact on mental health that is a primer for PTG. It demonstrates the similarity of a prominent change model used in the field of addiction recovery with PTG theory, offering the Extended Transformational Model, a PTG life cycle model, as an output.

Research limitations

This research considers previous positive psychology (PP) work, specifically surrounding PTG and addiction recovery. As a next step, further investigation is necessary to demonstrate the efficacy of the model comparison so it can mature into one that in application can integrate PTG theory with addiction treatment services as a recognized and effective pathway to recovery.

Originality/value

While this is a first attempt at such a model comparison, demonstrating the similarity between PTG and addiction recovery through a life cycle model, offers the opportunity to develop effective interventions, in addition to building confidence in a recognized discipline of PTG in addiction recovery.

KEYWORDS:

• Addiction
• post-traumatic growth
• transtheoretical model
• positive psychology
• transformational model

Introduction

Post-traumatic growth (PTG) is a psychological transformation, where an individual attains a higher level of functioning following trauma than they have held before. This paper aims to propose a basis on which to consider PTG and addiction recovery. The scope of which is:

1. To consider addiction as a traumatic experience that can lead to PTG.

2. To demonstrate the similarity of a prominent change model, used in addiction recovery with PTG theory.

3. To review evidence of PTG among recovering addicts.

4. To examine the future application of PTG in the field of addiction recovery.

Addiction as a traumatic experience

Considerable research has been conducted on the etiology of addiction (Musto, 1996; NICE, 2011), frequently in the context of it being a by-product of preceding events, as opposed to a detached experience (Beseler et al., 2011). DiClemente (2018) discusses addiction in general terms, as opposed to measuring it as a specific result of human problems or pathology. He classifies it as a learned habit of pleasurable or reinforcing behavior, that is difficult to eradicate, even when confronted with numerous negative, and often dramatic consequences (Dyson, 2007; Hammer et al., 2012; Wise & Koob, 2014). It is a learned habit with a psychological and physiological component, that moves an individual toward dependence, that is the inability to exercise control over behavior irrespective of the escalating negative consequences (DiClemente, 2018; Dodes, 2009). In the case of drug and alcohol misuse, the pharmacological component further compels an individual to continue using the substance in an attempt to reexperience the pleasure felt (Dodes, 2009; Wise & Koob, 2014). Furthermore, in addicted individuals, this becomes cyclical as pleasure progresses to relief, necessary to manage the physical signs of withdrawal as well as the psychological turmoil raised through the burden of escalating problems (Dayton, 2000; SAMHSA, 2016; Wise & Koob, 2014). It is this repetition that places an individual in a persistent traumatic experience (Walters, 1994), with the addiction itself becoming a perpetrator of further trauma and mental illness (Pandina et al., 1992).

Addiction as a candidate for PTG

If addiction is to be likened to a traumatic experience that can lead to PTG, it should be comparable to trauma as outlined by theorists of PTG. Tedeschi and Calhoun (2006) define trauma as an event that produces an awareness of before and after, which is out of the ordinary and unexpected, and results in chronic problems that markedly disrupt one’s narrative. Except for the event being unexpected, this is relatable to the definition of addiction in the literature reviewed. Addiction is acknowledged as an atypical existence (Dodes, 2009; Walters, 1994) in which addicted individuals have a sense of what life was like before and during the addiction, illustrated in the developmental transitions and stages of an addicted lifestyle (DiClemente, 2018; Walters, 1994). This results in a persistent disrupted narrative through the establishment of anti-reward processes, where dependence outweighs the cost of other rewarding or reinforcing behavior (Wise & Koob, 2014). Is addiction unexpected, however? According to the Tedeschi and Calhoun (2006) definition, trauma should be unexpected. A point also made in Janoff-Bulman’s Shattered Assumption Theory (Janoff-Bulman, 1992). It could be disputed that addiction differs here, as the perpetrator is also the victim and as such, has had some control over the event (Pickard, 2017). However, evidence of addiction impacting brain function, the onset of which is unpredictable and unexpected, goes some way to counteract this point (Hammer et al., 2012; NICE, 2011).

Significant growth and change models

The Transtheoretical Model (TTM) is a model for describing and understanding behavior change (Prochaska & DiClemente, 1982; DiClemente, 2007). The TTM is cited in many studies investigating addiction and the assessment of recovery outcomes (Nidecker et al., 2008). It is extensively employed in the field of addiction, with research showing validity in the model stages, as well as justifying its use in aclinical capacity (DiClemente, 2018; Royal College of Nursing, 2015; SAMHSA, 1999). The model contains five stages of accomplishing behavior change (DiClemente, 2007; DiClemente & Prochaska, 1998) as shown in Table 1.

Table 1. Transtheoretical model stages

(1) Precontemplation	The individual is not thinking of change, having experienced no (or minimal) consequences.
(2) Contemplation	The individual is aware of consequences and impact on life, but remains uncertain. They are engaged in progressive thinking toward change, but may require many setbacks to build a case for change.
(3) Preparation	The individual has made a decision to change and starts planning steps to do so.
(4) Action	The individual attempts new behaviors and interventions, however they are not yet embedded. Stability and routine of new behavior is yet to be established.
(5) Maintenance	The individual’s new behavior is established and stable in continued application to the long term. The positive change achieved justifies continued adoption and development of altered behavior.

PTG theory also proposes that individuals go through change to achieve growth. Janoff-Bulman (2004) proposed three models centered on:

1. Self-understanding after suffering,

2. Adjustment of worldview around assumptions on control and beneficence of others and

3. Formulating new meaning by reprioritising and revaluing life.

An alternate theory proposed by Joseph and Linley (2005), considers PTG in terms of three outcomes. These are assimilation, negative accommodation and positive accommodation. Positive accommodation is said to enable PTG by the constructive adaptation to the trauma. While all theories have a commonality in cognitive adaptation, it is Tedeschi and Calhoun's (1995) Transformational Model (TM) that is most prominently recognized. Its endorsement is evident in the use of the Posttraumatic Growth Inventory (PTGI) by many researchers (Ivtzan et al., 2016; Lopez & Snyder, 2009; Tedeschi & Calhoun, 1996). In the TM, an individual begins with pre-trauma characteristics. This is what influences their world view, for example, their assumptions of society, personality traits and ambitions. Dissention is caused following a traumatic event, previous assumptions and attitudes are challenged, resulting in cognitive dissonance (Blix et al., 2015). This dissonance moves an individual toward rumination (Tedeschi & Calhoun, 2004). Initially, this is intrusive and unwanted, having been automatically triggered by trauma, then deliberate, as the individual’s thought processes become more focused. The intrusive cognition loses pace and is replaced with more decisive and constructive cognitive processing (Ivtzan et al., 2016). In the TM, it is through deliberate and constructive rumination that an individual accepts their changed state, in order to grow in the aftermath of a traumatic episode (Ivtzan et al., 2016; Tedeschi & Calhoun, 2004).

The TTM represents a life cycle, having a clear before, during and after (DiClemente, 2018; DiClemente & Prochaska, 1998). This echoes Tedeschi and Calhoun's (2006) concept of bridging the cognitive gap between life before and after trauma being the apex of PTG. However, by comparison, it is more complete than the TM in its depiction of a life cycle (DiClemente & Prochaska, 1998), in addition to being more mature in application (Velasquez et al., 2009). Proposed extensions to the TM have seen it develop to something more comparable to a life cycle, with the study of event centrality (EC) (Grouleau et al., 2013; Lancaster et al., 2015), rumination (Triplett et al., 2012), and control and mastery (Nelson, 2011). This is defined as the Extended Transformational Model (ETM) within this paper, see Table 2.

Table 2. Extended transformational model stages

(1) Pre-trauma characteristics	The belief system held by an individual that governs how they view their reality.
(2) Rumination	Cognitive processing needed to gain meaning following trauma. Can be intrusive or deliberate.
(3) Event centrality	The reference point from where future events will be viewed. The “turning point” in one’s life.
(4) Control	An individual’s adjustment after adversity. Reasserting control over current events.
(5) Mastery	An individual’s search for meaning, sense of control and wellbeing following the restoration of control in their life.

A comparison of TTM and ETM

Both TTM and ETM provide a framework for explaining change and growth. Each has five stages that pave the way for accomplishing change, beginning with the individual in a “pre” state and concluding with the attainment of an improved function (see Table 3).

Table 3. Combined transtheoretical model and extended transformational model stages

	Transtheoretical Model	Extended Transformational Model	Combined stage
1.	Precontemplation	Pre-trauma characteristics	The individual has a set of principles and behaviors that have yet to be challenged with any rigor.
2.	Contemplation	Rumination	The individual goes through the cognitive processes necessary to adapt to their changed sphere.
3.	Preparation	Event centrality	A culmination of previous cognitive processing. The individual has reached a turning point from which to base future events and experiences.
4.	Action	Control	The individual reasserts control by making changes to their life.
5.	Maintenance	Mastery	The individual continues to practice and refine intended change, assimilating into the everyday.

Precontemplation and pre-trauma characteristics

Research has shown that addicted individuals can exist in precontemplation for many years, with one study finding that 80% are in this stage or the contemplation stage (DiClemente & Prochaska, 1998). Whilst in precontemplation an individual does not question their beliefs or behaviors having yet to encounter an event or consequence that provides them with a sufficient test (Gutierrez & Czerny, 2018). Similarly, with pre-trauma characteristics, the individual’s beliefs remain intact over a long period. An event has yet to occur that disrupts their outlook (Lopez & Snyder, 2009).

Contemplation and rumination

Both contemplation and rumination consider cognitive processes. In contemplation, this is through accepting the consequences of addiction (Dyson, 2007). In rumination, it is in an individual’s ability to constructively reevaluate their beliefs leading to acceptance (Calhoun & Tedeschi, 2013). Studies show rumination to be a precursor to PTG (Ramos et al., 2018; Stockton et al., 2011) and contemplation to be a precursor to behavior change (DiClemente, 2018, 2007).

Preparation and EC

The locus of change in both models. Preparation and EC are the culmination of cognitive processing, from which an individual considers their future. In the preparation stage, an individual decides the cons of living with active addiction outweigh any pros that remain (DiClemente, 2018; Dyson, 2007). Research using the Pre-treatment Readiness Scale (PRS) has shown one’s ability to assess their problems as a factor in their capacity to progress with treatment (Rapp et al., 2007). Similarly, the Centrality of Event Scale (CES) (Bernsten & Rubin, 2006), developed to measure the impact of a trauma on self-identity and worldview, demonstrates a notable correlation between EC and PTG (Blix et al., 2015; Vermeulin et al., 2019).

Action and control

In the action stage, behavior is altered to accomplish change (Gutierrez & Czerny, 2018). Similarly, in the control stage, an individual reasserts control of their life (Frazier & Caston, 2014). Both action and control require active engagement from an individual, with research supporting the link between adjustment to adversity and reasserting control (Frazier et al., 2011; Patterson et al., 2010).

Maintenance and mastery

In addiction recovery, the maintenance stage is considered an extension to the change process, whereby behaviors are continually adapted to lessen the risk of relapse back to old behaviors (DiClemente, 2018; Gutierrez & Czerny, 2018; Patterson et al., 2010). This continued refinement resonates mastery, where an individual continues to acquire skills to promote a sense of control and well-being (Park, 2013).

Evidence of PTG in addiction recovery

In Krentzman’s (2013) work on addiction recovery and positive psychology (PP), alcoholics with an affiliation to Alcoholics Anonymous (AA) and at least 12 months of sobriety, were thriving in the areas of happiness, gratitude, optimism and spirituality, so much so that they outperformed comparison groups. Krentzman hypothesized that this was attributable to PTG, as the study included individuals who had worked the 12-step programme, a programme that promotes growth. A similar finding was observed by Haroosh and Freedman (2017), in their study of PTG and recovery, with participants reporting spiritual growth and an increased ability to appreciate life’s potentialities. In this study, 104 recovering addicts were assessed for PTG. The PTGI was used in conjunction with the Willingness to Seek Help Scale (Cohen, 1999) and Perceived Social Support Questionnaire (Zimet et al., 1988), to measure growth in the context of willingness to change and awareness of available support (Haroosh & Freedman, 2017). It demonstrated a link between PTG and engagement in the 12-step programme. Further evidence of this is seen in Grella and Stein's (2013) study, on substance dependence remission rates based on willingness to seek help.

Krentzman (2013), recommended using PTG theory as a framework to study and understand addiction. Further credibility to this recommendation is given in a study on rumination, control and EC as predictors of PTG (Brooks et al., 2017). In this study, EC was shown to predict growth, with an association of deliberate rumination and PTG also being noted. These predictors fit with a PTG life cycle hypothesis in demonstrating a link with the stage of adaptation in achieving PTG.

Discussion

Existing literature discussing addiction as a cyclic and distressing experience has demonstrated the difficulty individuals face in escaping active addiction, which can leave them ineffective in the face of an escalating traumatic experience, evermore detrimental to their mental health (Dayton, 2000; Dodes, 2009; Pandina et al., 1992; Walters, 1994; Wise & Koob, 2014). Addiction as an event that leads to PTG has been considered as a cause of trauma irrespective of the underlying circumstance leading to it (Collier, 2016; Dyson, 2007; Janoff-Bulman, 1992; Tedeschi & Calhoun, 2006). National statistics in England show those engaging with addiction services, present with psychological problems in 53% of the cases, 24% of which are unrecognized outside of addiction services (Public Health England, 2019). While a richer data set is required to draw reliable conclusions on addiction and comorbidity, it is plausible that psychological problems are a result of or exacerbated by addiction (NICE, 2011; SAMHSA, 2016). Why is this information so important to PTG, however? Two significant models have been discussed in relation to PTG and addiction, the TTM and ETM. The locus of change in both models is preparation and EC, where an individual reasserts control following contemplation and rumination (DiClemente & Prochaska, 1998; Grouleau et al., 2013). Having sought treatment, these individuals have recognized that addiction has impacted their mental health, so it could be reasoned they are candidates for PTG. The rationale for this is in their identified position within the TTM (and by inference, the ETM).

For growth after trauma, an individual accepts the trauma as part of their identity (DiClemente, 2018; Ivtzan et al., 2016). In the TTM, this is the transition to preparation, and in the ETM, EC. Similarly, acceptance, responsibility and accountability, are key tenets of the 12-step programme (Miller, 2015). Acceptance fits with contemplation and rumination, responsibility with preparation and EC, and accountability with control and action. Mastery and maintenance are affiliated with the continued evaluation and refinement of behavior and beliefs (Miller, 2015; Patterson et al., 2010). This further supports the model comparison and upholds previous findings linking addiction recovery and PTG, and the 12-step programme and PTG (Haroosh & Freedman, 2017; Krentzman, 2013).

Disparity in the models can be seen with the timing of the causative event and the focus on behavior (TTM) and cognition (ETM) (DiClemente & Prochaska, 1998; Tedeschi & Calhoun, 1995). Individuals with addictions could have formed a dependence, but not be conscious of it in the precontemplation stage. In pre-trauma characteristics, the causal event has yet to occur, again demonstrating the connection with precontemplation and behavior, and pre-trauma characteristics and cognition (Ivtzan et al., 2016). Dodes (2009, p. 642), associates the TM with behavior, however, noting that “PTG is not simply adopting a revised set of priorities or new philosophy of life, but also engaging in and sustaining behaviour directed towards achieving new goals.” Similarly, Gutierrez and Czerny (2018, p. 205) support the cognitive link with contemplation, by offering an analogy of one “failing to ride a horse without understanding what the saddle is for.” The models realign chronologically after the “pre” stages, although there is the question of how the ETM represents relapse. In the TTM, an individual may reach and stay at the maintenance stage; however, should they relapse, the model supports a return to precontemplation (DiClemente, 2007; Gutierrez & Czerny, 2018). The TTM supports repetition and forward and backward movement between stages (DiClemente, 2018). The equivalent in the ETM would see the transition from mastery, back to pre-trauma characteristics. Relapse back to addiction would need to be viewed as a traumatic event, comparable to the preceding period of active addiction. With the latest incantation of the trauma seeing the period of recovery as the pre-trauma characteristics leading back to rumination. Furthermore, the ETM has thus far been viewed as unidirectional. Movement between stages, and re-iteration of the model in relapse, need further study to see how robust the comparison is in application?

Future research

Further study of PTG as an applied model is required to substantiate the model comparison. Revisiting material, such as Gutierrez and Czerny's (2018) work on assessment tools and the TTM, could be extended to introduce tests for PTG to validate the association in model outcomes. In addition, a scale, such as the Brown–Peterson Recovery Progress Inventory (B-PRPI), which measures progress in recovery (Brown & Peterson, 1991), could be employed to assess whether those who report positive outcomes continue to do so, in line with maintenance and mastery.

The model comparison did highlight that the ETM requires further study as to how it represents relapse and movement back and forth between stages. The TM is unidirectional, so research such as Blix et al.’s (2015) study investigating directionality and EC, is required with samples from addiction recovery.

Having considered addiction as a cause of trauma, this could be extrapolated to facilitate change and growth, as opposed to resolving root issues in an attempt to influence future behavior, with interventions in addiction treatment being reconsidered in terms of how they can be enhanced by PTG theory. Felicissimo et al. (2014) conducted a systematic review of the TTM that if extrapolated to the ETM supports this idea by suggesting stage identification allows for the better adaptation of interventions.

A systematic review of literature on the TTM and addiction recovery would help establish where cross pollination of material could be considered to re-work studies in the context of PTG, thus providing a basis for a more established discipline of PTG in the application of the ETM. As mentioned, further study of the nature of the mental health needs of those engaging with addiction services would allow for greater assurance in the ETM and more targeted intervention. Consideration of those who do not engage with addiction services is also required. As mentioned, 80% of addicts are said to exist in either precontemplation or contemplation (DiClemente & Prochaska, 1998), having yet to reach their “turning point” (DiClemente, 2018). This begs the question of how they can be assisted in transitioning to the next stage? Collier (2016), questions whether it is possible to prepare people for PTG, noting that chronologically a therapist engages with individuals following trauma. Can interventions be considered that prepare individuals for PTG? Tedeschi suggests that therapists can assist by helping individuals see the potential for growth, normalizing PTG following adversity (Tedeschi & Calhoun, 1996). There has been some success with a pilot study of such an intervention in the application of PP to adolescents misusing alcohol (Akhtar & Boniwell, 2010). Extending this to a full study, in addition to developing similar interventions of this type, could provide those reticent in engaging with existing services an alternative path to PTG.

Conclusion

This review suggests a basis on which to consider PTG and addiction recovery. It has presented addiction as a traumatic experience that can lead to PTG, and demonstrated similarity in PTG theory and the TTM, offering the ETM as a PTG life cycle model, applicable to addiction recovery. Evidence of PTG among recovering addicts has been evaluated to support the model, in particular, showing links with the stages of change in the TTM. The future focus and direction of research into the ETM, PTG and addiction recovery has been suggested, in addition to the identification of potential candidates for inclusion in the further study. Should the proposed research yield favorable results, it could assist in the development of effective interventions, in addition to building confidence in a recognized discipline of PTG in addiction recovery.

Disclosure statement

No potential conflict of interest was reported by the authors.