Posttraumatic Growth of Southeast Asian Survivors with Physical Injuries

There is an increasing interest in studying positive changes, in addition to negative sequele, following trauma and adversity. Posttraumatic growth (PTG) or adversarial growth refers to the outcome of experiencing positive changes following highly challenging life crises (Linley & Joseph, 2004; Tedeschi & Calhoun, 2004). PTG represents a movement beyond pre-trauma levels of adaptation, and is typically manifested in an increased appreciation of life, a sense of greater personal strength, an improved relationship with others, and a more integrated philosophy of life (Tedeschi & Calhoun, 1996). A wide variety of events have been found to trigger PTG, ranging from interpersonal violence, acute and chronic medical condition, death of loved one, to natural and human-made disaster (Linley & Joseph, 2004; Tedeschi & Calhoun, 2004). Despite an accumulation of literature on PTG, very little is known about positive changes in the aftermath of natural disaster across cultural groups. To date, no research has been undertaken to investigate PTG in Asian survivors of natural disaster. This study aimed to fill these knowledge gaps by exploring the prevalence and psychosocial predictors of PTG among adult Thai survivors of the 2004 Southeast Asian mega-earthquake and its accompanying devastating tsunami.

Prevalence, Predictors , and Explanatory Models of Posttraumatic Growth

Current literature shows that prevalence rates for endorsing items that reflect PTG range from 3-41% for bereaved individuals (Davis, Nolen-Hoeksema, & Larson, 1998), 20-80% for female sexual trauma survivors (Frazier, Conlon, & Glasser, 2001), 42% for child survivors of road traffic accidents (Salter & Stallard, 2004), to 98% for women with breast cancer (Weiss, 2002). Prevalence of PTG varies according to characteristics of victims and survivors, cognitive-emotional appraisal of traumatic events, pattern of traumatic stress responses, and socio-cultural environment. Review studies (Linley & Joseph, 2004; Tedeschi & Calhoun, 2004) have shown that female gender, young age, and high educational attainment are positively related to PTG. Personality traits of extraversion, tardiness, optimism, openness to experience have been linked to PTG, as has self-efficacy; coping patterns emphasizing problem-solving, positive reappraisal, and religious openness and participation. Similarly, supportive familial and social environment have also been consistently linked to greater PTG in trauma survivors. Traumatic stress responses such as intrusive, hyper-arousal, and avoidant symptoms often show positive associations with PTG in trauma survivors.

There are three major explanatory models that integrate various perspectives on how and why individuals experience PTG following life adversity. They include the biopsychosocial-evolutionary model (Christopher, 2004), the organismic valuing model (Joseph & Linley, 2005), and the process model (Tedeschi & Calhoun, 2004). All three models view PTG as a function of biological, psychological, and socio-cultural influences, and individuals have an intrinsic motivation toward growth. Traumatic events that challenge individuals’ understanding of self, society, and nature will set the process of PTG in motion. The new trauma-related information is typically stored in active memory awaiting processing (intrusive state). This will lead to high states of distress and arousal (hyper-aroused state) that need to be defended against (avoidant state). These cognitive-emotional states will facilitate the integration of new trauma-related information in order to rebuild shattered worldviews for subsequent growth experience.

Although the above PTG models generally serve well in explaining PTG, they are also at times over-generalized and over-applied. First, these models tend to assume that middle-class White adults’ worldviews about self, others, and the world are universal, and that traumatic events such as the death of loved one will shatter these basic assumptions. Second, these models tend to undermine the role of suffering in human development and growth. In fact, cultures differ regarding their dominant ideas about the ontology of self as well as relationship between self and others, between self and the universe, and between life and death (Markus & Kitayama, 1991; Sampson, 2000). For example, many Asian cultures do not conceptualize themselves as independent entities in the world. On the contrary, they conceptualize themselves living in a network of interpersonal relationships, with family relation being the most dominant one. When traumatic events happen, they affect the whole network rather than just the individual. The Buddhist perspective, the major religious force in Asian cultures, denies the reality of a permanent self and views all things pertaining to the phenomenal world as undergoing constant transformation (Daya, 2005). It views human growth as remaining present with one’s suffering without trying to flee from it. Thus, depending on one’s culture, traumatic events may actually validate instead of violate one’s assumptive worldviews, and human suffering may be viewed as inevitable and essential to achieve self and spiritual transcendence/growth.

Purposes of the Present Study

The current literature provides little information regarding PTG following severe natural disaster that tends to occur suddenly with little forewarning, as in widespread flooding, hurricane/tornado, and earthquake. When natural disaster occurs, it not only generates massive destruction and casualties within a short period of time, it also greatly challenges individuals’ perceptions of their own abilities and their assumptions about the benevolence, predictability, and controllability of the world. According to PTG models (Christopher, 2004; Joseph & Linley, 2005; Tedeschi & Calhoun, 2004), this can provide a unique opportunity for growth as individuals rebuild their assumptive world with new meanings. Indeed, one study documented that survivors of a tornado showed the highest rates of perceived benefits as compared to survivors of plane crash and mass killing at 4-6 weeks and 3 years post-disaster (McMillen, Smith, & Fisher, 1997). However, the bulk of PTG research has been conducted with trauma survivors residing in Western countries. As specific dynamics of PTG may vary with the degree of disparity between pre-existing culturally shaped beliefs and trauma-related information, there is a need to examine PTG in more diverse ethnic and cultural groups following severe natural disaster. The aim of the present study was to explore PTG and its predictors in direct victims with physical injuries as a result of a severe natural disaster.

On December 26 in 2004, a mega-earthquake measuring 9.3 on the Richter Scale in Southeast Asia triggered a powerful tsunami along coastal regions of nearby countries. This earthquake-tsunami caused 300,000 deaths and affected at least five million people in Indonesia, Sri Lanka, Maldives, India, Thailand, Seychelles, and Myanmar. While physical and psychological impacts of this severe natural disaster will no doubt be devastating, it may at the same time facilitate PTG of survivors. An understanding of factors associated with PTG will facilitate the planning of post-disaster mental health activities in affected regions. Due to financial limitations, only adult Thai survivors with mild physical injuries were examined. Thailand was among one of the hardest hit countries in this natural disaster, resulting in 5,395 deaths and affecting over 60,000 Thai residents.

Based on current literature on PTG (Linley & Joseph, 2004; Tedeschi & Calhoun, 2004), the following hypotheses were made:

Method

Participants
Participants were 138 adult Thai (44 men and 94 women), who self-reported to experience physical injuries as a result of the 2004 Southeast Asian earthquake-tsunami. Their injuries were mostly abrasions/open wounds on faces and limbs, twisting/straining/ dislocations of joints or ankles, or fracturing of bones. All claimed their physical injuries had healed, and none indicated permanent physical disabilities from these injuries. About 85% of participants also reported personal or family properties being damaged or destroyed, and 66% needed to relocate to temporary shelters as a result of this disaster. About 67% of participants also reported family members or friends missing, injured, or killed. A majority (83%) of participants witnessed other people seriously injured or killed during the disaster.

Participants’ age ranged from 18 to 68 years old, with the average age being 35.48 years (SD=11.18). About 51% of them completed primary school education, 29% had high school education, and the remaining graduated from professional schools or universities. Among all participants, 62% were married with children. Prior to the earthquake-tsunami, 34% of participants were white-collar workers, 25% were self-employed or owners of shops and restaurants, 22% were blue-collar workers, 14% were homemakers, and 5% were unemployed.

Instruments
Posttraumatic Growth. Participants’ perceived positive changes resulting from the recent earthquake-tsunami were assessed with the Posttraumatic Growth Inventory (PGI: Tedeschi & Calhoun, 1996). This inventory assesses perceived positive changes following trauma and adversity across dimensions of relating to others, new possibilities, personal strength, spiritual changes, and appreciation of life. The full inventory and its subscales demonstrated good internal and test-retest reliabilities (Tedeschi & Calhoun, 1996). For Chinese samples, items of the inventory tended to cluster into four dimensions: (1) change in interpersonal relationship; (2) change in self, including willingness to express emotions, acceptance of how things work out in life, and developing new interests and opportunities etc.; (3) change in life orientation and priority; and (4) change in religious beliefs and spiritual life (Ho, Chan, & Ho, 2004). These four dimensions could in turn be broadly dichotomized into an interpersonal and an intrapersonal dimension, with acceptable internal reliabilities of .80 and .70. Participants responded with a 6-point scale (0 as “no change” and 5 as “a great deal of change”), and higher scores represent greater perceived PTG. For the present study, the internal reliability of the whole inventory was .89.

Adaptive Coping. A 4-item scale (Sinclair & Wallston, 2004) was used to assess participants’ coping pattern in the aftermath of the earthquake-tsunami. Items in this scale describe an active problem-solving and reappraisal coping pattern that reflects adaptive coping discussed in the literature. This scale demonstrated adequate internal and test-retest reliabilities, and correlated with measures of optimism, self-efficacy, and psychological well-being of individuals with chronic illness (Sinclair & Wallston, 2004). Participants were asked to indicate the extent to which depicted statements described themselves after the earthquake-tsunami (0 as “not describing you at all” and 3 as “describing you very well”). For the present study, the internal reliability of this scale was .78.
Social Support. Participants also evaluated with a 3-point scale (0 as “not at all” and 2 as “a lot”) the extent of perceived emotional/practical support from their family members as well as the extent of perceived financial/practical support from the local government after the earthquake-tsunami.

Cognitive-emotional States. Participants’ cognitive-emotional states in the aftermath of the earthquake-tsunami were assessed with a symptom checklist (Norris & Hamblen, 2004). It facilitated assessment of the presence of any of the DSM-IV PTSD symptoms during the past month, i.e., 6 months after the earthquake-tsunami. Depicted symptoms include re-experiencing the trauma (intrusion), avoidance and numbing of general responsiveness (avoidance), and increased arousal (hyper-arousal). This checklist has good reliabilities and convergent validities against independent structured interviews (Norris & Hamblen, 2004). Participants reporting at least one intrusion symptom, at least three avoidance responses, and at least two arousal symptoms were classified as the PTSD group.

Traumatic Earthquake-tsunami Experiences. Participants were asked to indicate whether they encountered any of the following as a result of the recent earthquake-tsunami: (1) personal injuries, (2) losses or injuries of family members, relatives, or friends, (3) losses or damage to personal or family properties, (4) being a witness to other people seriously injured or killed, and (5) loss of employment or dislocation.

Demographic Background. Participants were asked to provide information on their age, gender, marital status, educational attainment, and employment status before the disaster.

Procedure
The survey questionnaire included measures on earthquake-tsunami experiences; traumatic stress symptoms of intrusion, avoidance, and hyper-arousal; perceived social support; coping pattern; and perceived changes in self, in relationship with others, and in life philosophy following recent Southeast Asian earthquake-tsunami. The questionnaire was first translated from English to Thai, then back-translated from Thai to English, and pilot tested with five Thai graduate students to further refine the Thai version. Minor changes were then made according to their feedback. The design and objectives of the study were also written in Thai and included in the cover page of the questionnaire. The research design and protocol of the present study were endorsed by the research and survey ethics committee of the investigator’s institution.

Data collection for the present study was conducted six months after the 2004 Southeast Asian earthquake-tsunami. A convenience sampling strategy was adopted. The present investigator, assisted by a research assistant and a Thai translator, approached local residents in permanent homes and individuals working in shops and restaurants along western coastal regions of Phuket to invite them to participate in the study. A short interview was first conducted with participants to establish the initial rapport, and the purpose of the study was also explained. The local translator then explained contents of the questionnaire to participants and clarified any question that they might have. Participants were assured of the confidentiality of their responses, and that they could withdraw from the study at any time. After obtaining participants’ verbal consent, the research personnel distributed the questionnaire and returned two hours later to collect the completed questionnaire.

A total of 350 individuals were approached and 271 completed the questionnaire, with the response rate being 77%. No participant reported undue psychological discomfort in completing the questionnaire. Among those who completed the questionnaire, 138 adults met our inclusion criteria of having self-reported physical injuries as a result of the earthquake-tsunami. These 138 participants were included for subsequent data analyses.

Results

The factor structure of the PTG Inventory (Tedeschi & Calhoun, 1996) was first examined. Both the four- and two-factor models as based on Chinese samples (Ho et al., 2004) were tested to assess how well these two models represented the present data. Two confirmatory factor analyses (CFAs) with maximum likelihood estimation were conducted with the EQS computerized software program. Results showed that the four-factor model produced a marginal acceptable fit to the present data, χ²=214.91, GFI=.87, CFI=.89, and RMSEA=.09. The fit for the two-factor model was also marginally acceptable, χ²=250.34, GFI=.85, CFI=.87, and RMSEA=.09. Given both the four- and two-factor models were only marginally acceptable, results in relation to various factors of these models should be interpreted with caution. The internal reliability coefficients were .83 for self, .71 for spiritual, .74 for life orientation, and .70 for interpersonal dimensions of the four-factor model; and .70 for interpersonal and .90 for intrapersonal dimensions of the two-factor model. For subsequent analyses, results for the two-factor model were reported in detail. Results of the four-factor model were only summarized in tables to avoid redundancy.

Prevalence rates for PTG were calculated as percentages of participants endorsing varying degree of PTG at six months following earthquake-tsunami. When the least stringent criteria were being used (mean score g1 on the PTG Inventory, scale ranged from 1 as a little to 5 as a great deal of change), about 88% of participants reported at least some degree of positive changes in various dimensions of PTG. When more stringent criteria were adopted (mean score g3 on the PTG Inventory), about 32% and 37% of participants respectively reported at least moderate degree of positive changes in interpersonal and intrapersonal dimensions of PTG. Among those who reported at least moderate degree of PTG (n=59), 51% also met the full criteria for DSM-IV PTSD.

Descriptive statistics for major variables were calculated and presented in Table 1. Bivariate Pearson correlation analyses were conducted to determine associations between mean scores of various PTG dimensions and hypothesized predictors. Results were generally in the expected directions. In particular, interpersonal PTG was positively associated with intrusive, avoidant, and hyper-aroused states (r=.22, .21, .38 respectively; p<.05), perceived family emotional support (r=.39, p,>01), and adaptive coping pattern (r=.18, p<.05). Intrapersonal PTG was positively related to severity of various traumatic earthquake-tsunami experiences (r ranged from .16 to .28, p<.05), cognitive-emotional states (r=.32 for intrusion, .25 for avoidance, and .41 for hyper-arousal; p<.05), perceived family emotional support (r=.43, p<.01), and adaptive coping pattern (r=.24, p<.05). Bivariate correlation analyses were repeated for self, spiritual, and life orientation dimensions of intrapersonal PTG, and their results were also summarized in Table 1.

Table 1 Descriptive Statistics and Intercorrelation Matrix of Major Variables (N=138)

As a number of factors were significantly associated with PTG, hierarchical multiple regression analyses were conducted to determine the most salient predictors of PTG. Demographic characteristics of gender, age, education, marital status, and pre-disaster employment status were first entered in Model 1. Various traumatic earthquake-tsunami experiences were entered in Model 2 after controlling for demographic characteristics. The final Model included cognitive-emotional states, perceived support from the family and government, and adaptive coping pattern. As intrusive and hyper-arousal states were highly correlated (r=.59, p<.001), they were thus combined as one factor when being entered into the final Model to avoid multicollinearity. Results showed that all predictors together explained 36% and 38% of variances in interpersonal and intrapersonal PTG, respectively.

For interpersonal PTG, the most salient predictors were intrusive and hyper-aroused states (β=.27, p<.01), perceived family emotional support (β=.26, p<.01), being married (β=.24, p<.01), younger age (β=-.24, p<.01), witnessing death/injuries during the earthquake-tsunami (β=.19, p<.05), being employed before the disaster (β=.18, p<.05), and avoidant state (β=.18, p<.05). For intrapersonal PTG, the most salient predictors were intrusive and hyper-aroused states (β=.30, p<.01), perceived family emotional support (β=.24, p<.01), adaptive coping pattern (β=.23, p<.01), avoidant state (β=.18, p<.05), and being married (β=.17, p<.05). Similar hierarchical multiple regression analyses were conducted separately for self, spiritual, and life orientation dimensions of intrapersonal PTG, and their results were summarized in Table 2.

Discussions

For the present study, about 88% of the surveyed Thai survivors experienced varying degree of positive adaptation at six months following the 2004 earthquake-tsunami, with 32-37% reporting at least moderate degree of PTG. A study conducted in the United States also found that 90-95% of surveyed survivors indicated positive benefits at 4-6 weeks as well as 3 years following a tornado (McMillen et al., 1997). Results of the hierarchical regression analyses also revealed that common predictors of both inter- and intrapersonal PTG in Thai survivors were disaster-related cognitive-emotional states, perceived family emotional support, and being married. While adaptive coping was a specific predictor of intrapersonal PTG, younger age, pre-disaster employment, and disaster-related traumatic experiences were specific predictors of interpersonal PTG.

Past research has shown that PTG was often related to intrusive, hyper-aroused, and avoidant states of trauma survivors (see review by Joseph & Linley, 2004). The present study also found these cognitive-emotional states being positively related to PTG at six months following earthquake-tsunami. Re-experiencing and hyper-aroused states were more salient predictors than avoidant responses. It may be that repetitive ruminations and intrusive images enable the storage of disaster-related information in active memory for reappraisal and revision of schema that manifest as a growth experience (Creamer, Burgess, & Pattison, 1992; Joseph & Linley, 2004), while avoidant responses are primarily for defending against distressful emotions arising from intrusive memories. In addition, the present study supported findings that PTG and PTSD were not mutually exclusive (Salter & Stallard, 2004), as about half of the survivors who reported PTG also fulfilled the criteria for DSM-IV PTSD.

PTG can be influenced by the availability of social support networks in the aftermath of trauma and adversity (Christopher, 2004; Joseph & Linley, 2005; Tedeschi & Calhoun, 2004). This is of particular relevance to Asian collectivist cultures that emphasis mutual support among family members and kinships at all times (Markus & Kitayama, 1991; Sampson, 2000). Indeed, the present study showed that perceived family emotional support and being married were salient predictors of both inter- and intrapersonal PTG. Studies conducted in Western countries also found emotional social support being positively related to PTG following adverse life events (Park, Cohen, & Murch, 1996; Sheikh, 2004). However, instrumental support from the family and the government was found to be unrelated to PTG in this study. It may be that Asian cultural and religious thinking tends to view human suffering as inevitable, and individuals should endure hardship with dignity rather than trying to flee from it with external assistance (Daya, 2005). In fact, researchers have also suggested that PTG may be impeded by overly supportive social environment in which survivors are precluded from developing their autonomy and competence to integrate new trauma-related information and to devise their own adaptive coping strategies (Joseph & Linley, 2004).

The present results also showed that various dimensions of PTG were linked to specific factors, in addition to common predictors as mentioned in previous sections. In particular, adaptive coping was a specific predictor of intrapersonal PTG, especially with regard to participants reporting having a sense of greater personal competency and a more spiritual life. Current literature also shows coping strategies that emphasize active re-interpretation and problem solving are positively related to PTG (Manne et al., 2004; Sears, Stanton, & Danoff-Burg, 2004; Widows et al., 2005).

Specific predictors of interpersonal PTG included younger age, pre-disaster employment, and severity of disaster-related traumatic experiences. In a review of 39 studies conducted with predominantly Western trauma survivors (Joseph & Linley, 2004), a general trend towards greater PTG being reported by younger adults and by individuals with pre-disaster employment was reported.

While PTG is often related to trauma severity, there is also evidence that PTG may be impeded in severe natural disaster situations (Philfer & Norris, 1989). One plausible explanation for these mixed findings may be that for trauma and adversity to elicit PTG, it must be of sufficient magnitude to challenge survivors’ assumptions and to solicit social support. But once the disaster has reached a minimal “seismic” threshold, other factors such as cognitive-emotional states and coping strategies may become more important in sustaining or strengthening PTG.

Limitations and Implications
The present study shared many of the methodological limitations that prevail in the contemporary literature on PTG (Linley & Joseph, 2004). Consequently, the results should thus be interpreted with caution. First, this study adopted a convenience sampling strategy and most participants suffered only mild physical injuries from the earthquake-tsunami. It is possible that more severely injured survivors were still in hospitals or relocated to other places to avoid reminders of trauma.

Second, the present study relied solely on retrospective self-reports of survivors. Due to language barrier and financial limitation, clinical interviews were also not conducted with survivors for assessment of DSM-IV PTSD diagnosis. Information should have been supplemented with third-party reports for external validation.

Thirdly, given the relatively small sample size of the present study, the factor structure of the PTGI could not be reliably determined. Additional work is required to assess the PTG construct in Thai populations.

Fourthly, there was no data on pre-disaster protective or vulnerability factors such as prior psychological adjustment, history of prior trauma, and family history of psychopathology, etc. Thus, it remains unclear the extent to which PTG resulted from current earthquake-tsunami or from other underlying pre-existing factors.

Fifthly, the current literature does not provide any clear cut standard for assessing when growth should have occurred or whether PTG occurs at the same rate for all survivors. Six months post-disaster may be too early to determine the stability of PTG, and intervening events and processes may influence the temporal course of PTG (Linley & Joseph, 2004).

Finally, the investigator was aware of the important role of culture and religion on growth experience, but did not include them in the present study due to various constraints on the research. Future study should determine these aspects in detail, especially the role of Buddhist doctrines on suffering and existence.

Despite the above limitations, the present study found that a sizable proportion of Southeast Asian survivors also managed to experience positive changes in spite of the devastating disaster. Thus, the clinical goal of post-disaster management should also include the facilitation of PTG in addition to minimizing distressing symptoms. Survivors should be educated about the role of intrusive disaster-related images and thoughts in growth experience, and ways to channel aroused symptoms toward constructive activities and strengthening of support network. In large-scale severe natural disaster such as the 2004 earthquake-tsunami, it may affect the entire family and community and deplete its ability to provide support to affected individuals. Post-disaster programs should thus make use of the influx of funds to assist the strengthening of family relations and community social support network in affected regions.

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