The Nature of Posttraumatic Growth in Adult

Journal of Child Sexual Abuse
ISSN: 1053-8712 (Print) 1547-0679 (Online) Journal homepage: http://www.tandfonline.com/loi/wcsa20
The Nature of Posttraumatic Growth in Adult

Survivors of Child Sexual Abuse
Sarah Hartley, Carly Johnco, Marthinus Hofmeyr & Alexis Berry
To cite this article: Sarah Hartley, Carly Johnco, Marthinus Hofmeyr & Alexis Berry (2016) The
Nature of Posttraumatic Growth in Adult Survivors of Child Sexual Abuse, Journal of Child
Sexual Abuse, 25:2, 201-220, DOI: 10.1080/10538712.2015.1119773
To link to this article: http://dx.doi.org/10.1080/10538712.2015.1119773
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Download by: [University of California, San Diego] Date: 08 March 2016, At: 05:58
JOURNAL OF CHILD SEXUAL ABUSE
2016, VOL. 25, NO. 2, 201–220
http://dx.doi.org/10.1080/10538712.2015.1119773
The Nature of Posttraumatic Growth in Adult Survivors of

Child Sexual Abuse
Sarah Hartleya, Carly Johncob, Marthinus Hofmeyrc, and Alexis Berryd
a
University of Oxford, Institute of Clinical Psychology Training, Isis Education Centre, Warneford
Hospital, Headington, Oxford, UK; bUniversity of South Florida, St. Petersburg, Florida, USA; cSt.
Andrews Healthcare, Northampton, UK; dOlder People’s Clinical Psychology Service, Northampton, UK
Downloaded by [University of California, San Diego] at 05:58 08 March 2016
ABSTRACT ARTICLE HISTORY

Potential negative sequelae for survivors of child sexual abuse Received 13 March 2015
is well documented. However, growing evidence suggests that Revised 8 August 2015
some individuals who actively cope with traumatic events can Accepted 24 September
2015
progress from a negative trajectory toward positive psycholo-
gical change, often termed posttraumatic growth. Current KEYWORDS
posttraumatic growth theories may be of limited applicability Abuse; childhood sexual
to developmental considerations involved in child sexual abuse; incest; posttraumatic
abuse. This explorative study examines posttraumatic growth growth; trauma; women
among adult female survivors of child sexual abuse. In-depth
interviews were conducted with six participants who believed
they had grown through coping with their abuse. Data was
analyzed using interpretative phenomenological analysis.
Three superordinate and nine subordinate themes were iden-
tified and explored. Some participants reported experiencing
growth and distress simultaneously. Theoretical and clinical
implications are examined in relation to the study’s findings.
Estimates suggest that 15–33% of women have experienced sexual abuse in

childhood (Finkelhor, Hotaling, Lewis, & Smith, 1990), with rates increas-
ing to 35–75% in clinical populations (Chu & Dill, 1990). The negative
sequelae experienced by many survivors of child sexual abuse (CSA) are
well documented and include anxiety disorders, oppositional defiant dis-
order, posttraumatic stress disorder (PTSD), and attention deficit/hyperac-
tivity disorder (Ackerman, Newton, McPherson, Jones, & Dykman, 1998).
Long-term outcomes in adulthood can include anxiety, depression, self-
harm, substance abuse, binge eating, borderline and antisocial personality
disorders, low self-esteem, and difficulties with interpersonal and sexual
relationships as well as increased rates of revictimization (Kilpatrick et al.,
2003; Polusny & Follette, 1995). There is increasing recognition that some
individuals are resilient, or they “bounce back” quickly despite exposure to
highly adverse events (Kendall-Tackett, Williams, & Finkelhor, 1993;
Mancini & Bonanno, 2009), and there is a growing awareness that others
CONTACT Dr. Sarah Hartley sarahhartley222@gmail.com The Forensic Hospital, PO Box 150, Matraville
NSW Australia 2036.
© 2016 Taylor & Francis
202 S. HARTLEY ET AL.
may even experience some level of positive personal change as a result of

coping with their trauma experience (Calhoun & Tedeschi, 1999; Joseph &
Linley, 2005; Tedeschi & Calhoun, 2004). These changes have been given a
variety of different labels including “posttraumatic growth” (PTG), “thriv-
ing,” “stress-related growth,” and “positive adjustment” (Joseph & Linley,
2005). While the presence of PTG has been documented in CSA survivors
(e.g., Shakespeare-Finch & de Dassel, 2009; Wright, Crawford, & Sebastian,
2007), studies elucidating the process through which this occurs are sparse.
The term “posttraumatic growth” refers to the experience of positive
psychological change as a consequence of coping with extremely challenging
life circumstances (Calhoun & Tedeschi, 1999). Growth has been reported
after a range of traumatic events, including multiple sclerosis (Evers et al.,

2001), sexual assault (Frazier, Conlon, & Glaser, 2001), HIV/AIDS (Massey,
Cameron, Ouellette, & Fine, 1998), adult abuse (Poorman, 2002), and child-
hood abuse (Woodward & Joseph, 2003). Meta-analytic results have sug-
gested that women report higher levels of PTG than men, with older women
reporting the greatest levels of growth (Vishnevsky, Cann, Calhoun,
Tedeschi, & Demakis, 2010). Studies found that 40–70% of people report
some level of benefit following coping with a traumatic event, with reports of
growth outnumbering reports of psychiatric distress (Tedeschi & Calhoun,
2004). In one study 87% of female survivors of CSA reported some level of
benefit as a result of coping with their abuse (Wright et al., 2007).
While PTG typically relates to the individual’s cognitive appraisals of the
event (Woodward & Joseph, 2003), there is some evidence that the char-
acteristics of the trauma may also be important. Higher levels of PTG have
been reported in response to bereavement stressors than in survivors of
motor vehicle accidents and CSA (Shakespeare-Finch & Armstrong, 2010),
and higher PTG has been reported where CSA has been perpetrated by a
family member as opposed to a stranger (Lev-Wiesel, Amir, & Besser,
2004). Although theoretical models of PTG are emerging, our understand-
ing of the mechanisms of how growth occurs in different populations is in
its infancy.
The dominant theory of PTG (Tedeschi & Calhoun, 2004) is based on the
idea that individuals develop a set of assumptions and beliefs about the world
that provide a framework to guide their actions and develop a sense of
meaning in their lives. When an individual is faced with trauma, their belief
system becomes unstable, including their views of themselves, their future,
and the way they perceive the world. Some form of cognitive restructuring
occurs after the event to take into account the fact that traumatic events do
occur. One possible effect of this is that the individual’s beliefs become more
resistant to future trauma, and this is experienced as “growth.” Beliefs may
become more resistant when the individual integrates “trauma information,”
which helps them to process future traumatic situations and makes it less
JOURNAL OF CHILD SEXUAL ABUSE 203
likely for their world beliefs to be shattered. However, in the context of

childhood trauma, it is unclear whether this assumptive world has been
fully developed in order for a “shattering” to occur.
Although seemingly discrepant, it has been suggested that PTG and post-
traumatic stress are not opposite ends of a spectrum but are distinct con-
structs that can be experienced at the same time (Zoellner & Maercker, 2006).
Empirical studies have documented concurrently high levels of distress
and PTG among survivors of sexual assault (Grubaugh & Resick, 2007) and
CSA (Lev-Wiesel et al., 2004; Shakespeare-Finch & de Dassel, 2009). The
organismic valuing theory of growth (Joseph & Linley, 2005) explains this co-
occurrence as a result of assimilation and accommodation processes post-
trauma that can lead to either positive or negative outcomes. There is conflict
between preexisting ideas about how the world functions and new informa-
tion acquired after trauma exposure. The individual oscillates between an
intrusion of thoughts/feelings and avoidance of them, leading to symptoms
characteristic of PTSD. An individual then either “assimilates” the new
information (they negate the “trauma” information and revert back to their
pre-trauma beliefs) or they “accommodate” the trauma information and
create a new belief structure. Accommodation can be positive (e.g., expecting
that bad things can happen, therefore seizing the day), or negative (e.g., when
the new belief causes them to feel worse about themselves, their life, or their
future).
PTG following CSA remains controversial in the context of existing
models given that the trauma (by definition) occurs at a young age,
potentially before these assumptive worldviews are fully formed. As
such, it is unclear whether accommodation and assimilation processes
may truly be able to account for PTG in this population. One qualitative
study with female survivors of CSA examined their experience of coping
with their abuse and highlighted four coping processes utilized more by
women who were “well-adjusted” in comparison to those who were
“poorly adjusted”: disclosing and discussing CSA, minimizing the impact
of CSA, positive reframing, and refusing to dwell on the experience
(Himelein & McElrath, 1996). While dominant models of accommodation
and assimilation processes appear to focus on dispositional aspects of the
person, these findings suggest a social aspect of coping that may be
important for growth following CSA. The social aspect of coping in
PTG has also been noted in a sample of survivors of childhood emotional,
physical, or sexual abuse for whom change occurred in the context of
feeling nurtured and validated within interpersonal relationships
(Woodward & Joseph, 2003).
This study aims to explore the perceptions and phenomenon of PTG in
adult female survivors of incestuous CSA based on previous findings that
suggest higher rates of PTG in survivors of CSA perpetrated by a family
member as opposed to a stranger (Lev-Wiesel et al., 2004) and in women as

opposed to men (Vishnevsky et al., 2010). Given that the theoretical and
conceptual explanations of PTG have not yet fully accounted for develop-
mental considerations relevant to PTG following CSA, a qualitative metho-
dology was utilized to provide a more subtle and nuanced understanding of
processes involved and to contribute to the growing body of knowledge
about unique aspects of PTG in this population. The main aim of this
study was to identify factors involved in the women’s experiences of growth
and how growth affects the women’s lives as well as identifying what helped
or hindered their growth. Semi-structured interviews gave flexibility to
explore individual processes that are not necessarily driven, or limited, by
current theoretical models of PTG. These findings may have implications for
the advancement of models of PTG as well as for informing clinical treat-
ment of individuals following CSA.
Method
Participants
Semistructured interviews were conducted with six women who reported
experiencing CSA perpetrated by a family member before the age of 16 and
who reported having experienced growth in some area of their life as a result
of coping with their experience. Due to the explorative nature of the study,
growth was subjectively determined by the participants.
Participants were recruited via advertisements on the website of two UK-
based national organizations for survivors of CSA. Individuals expressed
their interest via e-mail or telephone. The first author then telephoned
them to discuss the study in more detail and provided the information
sheet. Eight women expressed interest; one woman did not meet the criteria
(her abuse had occurred in adulthood), and another woman chose not to take
part in the study after reading the information sheet.
Sexual abuse was defined as an adult (over 18 years) intentionally
pressuring, forcing, or tricking a child (under 16 and at least 5 years
younger than the adult) into a sexual act. Participants reported distress
from their experience at one point in their history and perceived their
experience as traumatic. Exclusion criteria were active suicidality, psychosis,
significant cognitive impairment, and poor fluency in spoken and written
English. Participant demographic and descriptive information is summar-
ized in Table 1. All women reported receiving previous psychological
counseling, ranging from a few sessions to four years. One participant
had previously had psychiatric treatment and two had received psychody-
namic psychotherapy. At the time of interview one participant was engaged
in couples counseling.
Table 1. Participant Demographic and Abuse Information.

Namea Emily Seema Parul Brigit Kate Carla
Age 30 41 35 36 52 41
Ethnicity British Indian Indian Indian British British
Relationship status Single Married Single Divorced Married Separated
Children None 2 None 2 8, and 7 2
stepchildren
Age at time of 14 7–10 Under 5 Earliest memory 4 3 14
abuse
Length of abuse 2 Stopped Stopped Stopped age 15 Stopped age Stopped age
occasions age 19 age 9–10 13 19/20
Age and Brother Brother Uncle (in Mother, father, male Father Brother-in-
relationship of 7 years 5 years 30s at time cousin (27 years law (plus
perpetrator older older of abuse) (granddaughter of older, gang rape
neighbor) grandfather) age 21)
Age at first 22 26 15 14 27 38
disclosure
Note: aAll names are pseudonyms.
Measures
Abuse questionnaire
Participants provided brief contextual information about the circumstances
of their abuse in a questionnaire adapted from a previous study (van Dyk,
2004). Questions included: their age at time of abuse, length of abuse, age of
perpetrator and relationship to individual, brief description of the abuse, age
of first disclosure, and past/present psychological support received.
Psychiatric diagnostic screening questionnaire (PDSQ)

The PDSQ (Zimmerman, 2002) is a 125-item forced choice (yes/no) self-
report questionnaire designed to screen for Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV) Axis 1 disorders (American
Psychiatric Association, 1994). This measure provides an overall indicator of
psychopathology on 13 disorders as well as a measure of suicidal ideation.
This measure demonstrates adequate internal consistency and test-retest
reliability in psychiatric outpatient samples.
Procedure
This study was approved by the university research ethics committee.
Interview location was selected by participants, with three interviews being
conducted at the university, two at the participant’s house, and one at the
participant’s local health care center. Written consent was obtained prior to
conducting the interview. The first author conducted the interviews, which
were two to four hours in length and were digitally recorded for transcrip-
tion. Questions in the interview schedule were designed to be open-ended to
facilitate participants in reporting their experiences of growth. Questions

focused on the participants’ ideas about growth and their personal definition
of growth, their experience of growth, factors that enabled growth, barriers
that prohibited growth, the perception they had of their abuse and how this
may have changed over time, coping strategies they had used, and their
therapeutic experiences. Participants received £15 for taking part in the
study and were reimbursed for their travel costs.
Data analysis
Transcripts were analyzed using interpretative phenomenological analysis
(IPA; Smith & Osborn, 2003). This approach takes an idiographic perspective
to understand the individual through cognitive, linguistic, emotional, and
physical attributes. It assumes a relationship between what people say, their
emotional state, and their thoughts; however, it recognizes that individuals
are complex beings and that the chain of events between these is not always
straightforward. Some individuals may find it difficult to talk about how they
feel or to express what they think, while others may not disclose their
thoughts or feelings for a variety of reasons. For these reasons IPA has a
theoretical association with the cognitive paradigm in mainstream clinical
psychology. It also draws on social psychology and humanistic psychology as
it views the person in a holistic sense (Lyons & Coyle, 2007).
Transcripts were coded by the first author and initially read numerous times
for familiarity. Next, each interview was coded for emerging themes and relevant
quotes. Related themes were identified, and potential connections between the
themes were considered. Third, emerging themes across all interviews were
grouped into superordinate themes and subordinate themes (see Table 2), con-
sistent with IPA methodology. The analysis attempted to focus on themes
emerging from the data rather than trying to fit the data into a preexisting
theoretical viewpoint (Smith, 2004; Smith, Jarman, & Osborne, 1999).
Given that qualitative data involves subjective interpretations, a number of
credibility and integrity checks were incorporated throughout the analysis
Table 2. Superordinate and Related Subordinate Themes.

Superordinate Theme Subordinate Theme
Making sense of and understanding Making sense of abuse and past behavior
abuse in relation to growth Subcategory: Acceptance
Talking about the abuse in the context of society
Growth in relation to religion
Growth in relation to culture
Relating to self in a new way and Growth as a new emotional experience
acknowledging the positive Growth: Having a dream, recognizing the positive and learning
to think about self in a new way
Experiencing growth through Growth experienced through relationship with children
relationships with others Relationship with family of origin: growth and barriers
process to confirm that the interpretations were grounded in the text (Mays
& Pope, 1995). The first author had primary responsibility for data coding
and engaged in two forms of monitoring. The first was keeping a reflective
diary. This practice assists with monitoring any presuppositions, prejudices,
personal beliefs, and reflections on the experience of analysis (Etherington,
2004). Second, the first author was interviewed about her hopes and expecta-
tions for the research prior to interviewing the women and again after
finishing the analysis. Credibility checks were also made independently by
the third and fourth authors where sections of transcripts were coded for
initial themes and then compared and contrasted. Inconsistencies were dis-
cussed and resolved. Finally, the first author conducted further credibility
checks by meeting on a monthly basis over nine months with two other
trainee clinical psychologists who were also conducting IPA research.
Examples of the data and emerging themes were presented to the group
and inconsistencies were discussed.
Results
Psychiatric profile of participants
Two participants (Emily and Parul; note that all names used are pseudonyms)
scored below the cutoffs for all diagnoses on the PDSQ, suggesting nonclinical
levels of psychopathology. Two participants scored above the cutoff for 2 out of
13 disorders (Seema scored above the cutoff for somatization disorder and
hypochondriasis, and Kate scored above the cutoff point for PTSD and soma-
tization disorder). One participant (Carla) scored above the cutoff for three
disorders (major depressive disorder, obsessive compulsive disorder [OCD],
and social phobia). The final participant (Brigit) reported high levels of
symptomology, scoring above the cutoff for seven out for the 13 subscales
(major depressive disorder, PTSD, OCD, social phobia, generalized anxiety
disorder, somatization disorder, and hypochondriasis).
Main emerging themes

Using IPA methodology, three superordinate themes were identified: (a)
making sense of and understanding abuse in relation to growth, (b) relating
to self in a new way and acknowledging the positive, and (c) experiencing
growth through relationships with others. Within these, nine subordinate
themes emerged from the data (see Table 2).
Superordinate theme 1: Making sense of and understanding abuse

The first superordinate theme, making sense of and understanding abuse in
relation to growth, captured the multiple ways in which participants had
attempted to understand their abuse experiences and how these unique

understandings had enabled them to move toward personal growth.
A search for meaning was described by all participants, and as Parul
expressed it: “People who have been abused always ask that question, why
has this happened to me?” Within this superordinate theme were four
subordinate themes that encapsulated the multifaceted aspects of under-
standing: (a) making sense of abuse and past behavior, (b) talking about
the abuse with others and in the context of society, (c) growth in relation to
religion, and (d) growth in relation to culture.
Making sense of abuse and past behavior reflected the variety of ways in
which the participants had attempted to understand the factors that may have
contributed to their abuse. Seema said, “There was the familial setting, the
family culture . . . it was something that was waiting to happen because it was
such chaos, it was such mess . . . not making excuses [but] given Dad’s back-
ground, given Mum’s background, [it was a] recipe for disaster.” She described
reconceptualizing the perpetrator, saying, “Sexual abuse is not about someone
being a monster; it’s more about having opportunities and some people taking
those opportunities.” Kate also described awareness of systemic family issues:
“I think that it’s probable that my father was involved in some kind of abusive
relationship as a child given my grandfather’s history,” although she high-
lighted: “But that doesn’t make it okay, you get to be grown up and you know
there are ways that you don’t relate to children, so you can’t make excuses for
it.” Kate described the positives of understanding what happened to her: “It’s a
horrible thing that shouldn’t have happened, but isn’t it wonderful that I know
that, and that I can admit that, and I can call it what it is. That’s a much better
thing that shutting it up and pretending.”
Within making sense of abuse and past behavior a subcategory of acceptance
also emerged. In order for participants to move forward and experience growth,
they talked about having found ways to accept what had happened, as described
by Parul: “I don’t want to accept it because it should never be acceptable, but I
have accepted the fact that it happened,” and similarly by Carla: “I have come to
understand, when I think about it, I’m okay, you know, in my head, it’s been, it’s
done, it’s gone. There is no point in worrying about it.”
The second subordinate theme within making sense of and understanding
abuse in relation to growth was talking about the abuse in the context of
society, a theme that emerged among all participants and described the
experience of talking about abuse at a societal level as well as some of the
barriers to this. For some, there was a belief that it was important for sexual
abuse to be discussed at a societal level to increase awareness, understanding,
and acceptance, as described by Kate:
I don’t think we are open enough. I think it has to come out from behind closed
doors . . . people have to be accepted . . . that you are telling the truth, that you
don’t have any agenda . . . just be open about it, not necessarily tell everyone our
own stories but say this is happening and it’s prevalent.
Emily described growth in learning how much of her own personal

experience of abuse to share with others: “I have done quite a lot of talking
about it with people since, because it’s quite a relief for me not to have to
keep concealing things. Then at one point I had to say Jesus, you don’t have
to tell everyone.” For Parul, discussing abuse with others in society helped
her to create a sense of hope that she would be able to move beyond her
distress:
I didn’t believe that anyone could go through really awful stuff and be okay . . . I
met this woman . . . she had been through much worse than I had . . . she was just
amazing, she was just inspirational . . . if she’s happy and she’s lived an amazing
kind of life . . . then I can do it.
However, the women also acknowledged that sharing their abuse experi-
ences was difficult. Kate described societal views toward sexual abuse that she
had experienced as a barrier to growth: “I did set up a group for other
women, a self-help group and we have an awful lot of opposition . . . people
said these things should be kept quiet and you shouldn’t make a fuss . . . just
get on with your life.” Emily had a similar experience: “It threatens the very
fabric of our society. We can’t actually admit that this goes on and people are
capable of doing this.”
A subordinate theme relating to growth in relation to religion was apparent
in the women’s stories, and captured how, for some, their religious beliefs
had enabled an understanding of their abuse and helped them find personal
strength. Having a relationship with God offered some participants comfort,
a place to express their distress, and gave them courage to face their fears, as
described by Kate: “My relationship with God . . . was always there and I
could always call on that and it didn’t matter where I was, how busy I was,
how alone I was that was always available to me.” Brigit described a complex
relationship with religion in coping with her abuse:
It didn’t mean anything to me, Sikhism . . . the people who abused me were Sikhs
and it was just a way of distancing myself from the abuse . . . Christianity . . . had
clear boundaries . . . a sense of good and evil and responsibility and consequences
for our actions . . . I know the philosophical, spiritual framework is bigger than me,
and it’s having something bigger than me to put it in and to work through it . . . I
think my faith has protected my mind from further damage and further harm . . . if
I didn’t have my faith I would be in a lot worse state mentally, and I wouldn’t have
achieved any of the things that I have achieved.
The fourth subordinate theme that emerged referred to growth in relation

to culture. Where religion was not important to some women, their relation-
ship to their culture was integral. Some associated their abuse with aspects of
their culture, and through rebelling or rejecting their culture for a time, they
experienced growth. For Brigit, this was through becoming a model:
I feel like all the harm that was done against my body when I was a child, I feel like
the artists when they are painting me and drawing me and doing sculptures of me I
feel that they are putting that right and I’m rebelling . . . against the extreme . . .
Asian culture and its attitude toward women.
Seema’s journey of growth in relation to her culture was complex. Initially

she rejected her Indian culture: “I didn’t want to have anything to do with
our culture, it was horrible, it just meant abuse, I disowned everything . . .
then I met [husband] who was white, it was easy, so I became white with
him.” She later shifted to a place where she became more accepting of her
Indian heritage and values:

Looking back on it again . . . not everything is bad . . . I feel ashamed when a few
years ago I didn’t want to know, I hated it, but . . . for the first time when I went
home . . . I went there and felt so lovely . . . I went back, the family home, and I
didn’t feel [like] I don’t want to go in that room . . . I felt at home . . . I never felt
like that. I had been running away from it, for years, I used to go there and pretend
I was something else, or not speak in Hindi.
Superordinate theme 2: Relating to the self in a new way

The second superordinate theme, relating to the self in a new way, emerged
during participants’ accounts of learning to recognize personal attributes or
actions at the time of the abuse that later impacted their growth. Participants
experienced growth through forming alternative perceptions of themselves
emotionally and cognitively, allowing them to see and experience the world
in new ways, no longer feeling guilt, shame, suicidal thoughts or depression,
being able to feel happiness and love, and shift in self-perception from
someone who is “damaged” to someone who is capable of achieving and
being successful.
Within this superordinate theme, two subordinate themes were identified.
Growth as a new emotional experience captured the accounts of new emo-
tional experiences compared with “old” ways of feeling about themselves.
Seema said, “It’s like all my life I’ve felt I was given a script . . . but all of a
sudden you wake up and start feeling oh my God, this is life, is this what they
call life, it’s such a weird experience.” Participants described moving from
positions of “not knowing” how they were feeling, unconsciously or con-
sciously trying to block out emotions, or feeling so distressed that they
wanted to die, to a position where they were reconnecting with their emo-
tions, experiencing their emotions in a more stable way. Participants reflected
on how they had cut themselves off from their emotions in numerous ways.
For example, Emily said, “When I wasn’t partying at the weekend I was
working very hard and that was a great other way to ignore my own feelings
and needs and experiences . . . it just stopped awareness from coming in.” She
described an increased awareness of her emotions as a part of her growth:
“I have . . . become aware of . . . that’s what happened and I have reconnected
with my emotional experience.” Kate explained how letting emotions “in”
was experienced as quite frightening, while also being a relief: “It’s enhanced
my life enormously not to have to keep things at bay and be afraid of them
and also to let the bad things come in too and not be afraid of them
anymore.” Growth was experienced by many as no longer feeling shame or
guilt, and this was often linked to therapy experiences. Parul noted, “She did
this visualization exercise with me that removed the shame that I felt . . .
instantly, that night it felt different . . . it just wasn’t there anymore.”
Participants used simile and metaphor as ways of describing their emotional

experiences of growth, describing moving from a “black” place to one of
“dark white” or feeling that they had traveled to a different country and were
first seeing things that previously they had only imagined.
The second subordinate theme referred to growth: having a dream, recog-
nizing the positive, and learning to think about self in a new way. For some of
the participants, holding a belief or a goal in mind, even during the abuse,
that one day things would get better, was important. This required enormous
determination and strength in the face of setbacks. Goals included wanting to
marry or travel to a new country, to be able to go to university, and for the
good times in life to outweigh the bad. Brigit said, “I’ve always been deter-
mined that despite my childhood I want the good in my life to be that much
bigger than the bad.” For Brigit, achieving her dreams meant fighting against
adversity: “Being poor and not having a duvet for a month and sleeping in
the cold, nothing was going to stop me from going to university. That was
my dream that kept me alive through all those years of being abused.” Parul
preferred to label her experience as “change” as opposed to growth because,
she concluded, “I was a strong person when I was three or four and when I
was 15 when I was telling my mum . . . I haven’t become a strong person . . .
this is always how I have been.”
Growth for most involved a shift in their perspective in how they viewed
themselves. For two women this meant taking risks trying out new career
opportunities and adopting a position of “giving it a go.” Emily said: “The
growth of your own identity as a worthwhile person is, is basically . . . the
biggest thing . . . thinking that you are a person who has got the right to do
stuff and you have got stuff to contribute.” Experiencing new opportunities
helped participants see themselves as more confident and capable, as sum-
marized by Carla: “‘I’m not going to do that because it’s not going to
happen,’ that would be my frame of mind whereas ‘give it a go, see what
happens, phone these people, if they say no, they say no, if they say yes, do it’
and that was the change.” However, participants often had to battle against
negative or self-critical thoughts to reach this perspective. Carla noted, “If
I had a negative thought enter my mind, instead of that negative thought

growing and snowballing without me consciously being aware of that hap-
pening in my head . . . I’d stop it and say don’t think that.”
Superordinate theme 3: Experiencing growth through relationships with

others
The final superordinate theme, experiencing growth through relationships with
others, encompassed three subordinate themes: growth experienced through
relationships with children, relationships with family of origin: growth and
barriers, and negotiating adult relationships: growth and barriers.
Relationships with others were described as important in either promoting
growth or at times preventing it. Participants described their abuse as having

affected their ability to form relationships with others; however, they were able
to experience growth through learning to form trusting and secure relation-
ships. Seema described learning “to be able to trust people, for attachments . . .
friendships or relationships . . . when you are sexually abused . . . you can’t
attach to others.” Being able to distance or separate themselves from their
abusers or families of origin was seen as an important step toward growth and
negotiating a new sense of self.
The subordinate theme, growth experienced through relationships with
children, encompassed the process of having children and forming a relation-
ship with them as an important aspect of growth. These relationships enabled
the women to experience “falling in love” and to learn to express love safely
through physical contact and closeness. Seema said, “Love for my kids, it was
the most amazing thing . . . it’s a feeling to the core . . . you haven’t felt it
before . . . and all of a sudden . . . you start to think, this is what they call
love.” Part of growth was also learning to set boundaries and tolerate feeling
“bad” for a short period. Kate noted, “If it was necessary to discipline . . . if
that meant they thought I’m a monster mummy for a while that was okay,
that would resolve itself.” Being emotionally available and nurturing was not
always easy for the women, particularly at times when they were feeling
emotionally detached, but seeing their children thrive enabled the women to
develop an identity as a good mother. Carla said, “I’ve found that I’ve
become such a good mother,” while Seema shared, “I’ve been good, I’ve
done this, if it wasn’t some credit to me my children wouldn’t be the way
they are.” Experiencing their children grow in the absence of abuse meant
that the participants gained a greater understanding of aspects of normal
child development and adult–child relationships. Most of the women who
had children had experienced growth, but for Brigit, becoming a mother was
more difficult, as it served to highlight her own abuse and sense of loss. She
was relieved that she was able to protect her own children from abuse but
found the process of becoming a mother “one of the most painful times of
my life . . . I wanted my mum, or a mum, to be with me to share . . . I haven’t

got a mother . . . she was never a mother to me.”
The second subordinate theme, relationship with family of origin: barriers
and growth, explored how all participants negotiated relationship boundaries
with their family of origin and perpetrators as adults. Common to all
participants was the experience that distance enabled them to begin to
move forward in their lives, helping them form alternative beliefs about
themselves and the abuse, which were different from the family “myth.”
For some this involved deciding which family members they would keep in
contact with, although the extent and the time frame of the distance varied.
Brigit’s experience was that she needed to stop contact permanently and
change her name in order to feel safe and move forward: “Unless you have a
supportive family who are on your side . . . I think you have to cut yourself off
from your family and never see them again.” For Emily, geographical dis-
tance and going to therapy was helpful in gaining a new belief that the abuse
wasn’t her fault; however, she was later able to develop a new relationship
with family members, including the perpetrator. Her experience was that
although this was difficult, her family was able to capitalize on her therapeu-
tic work and experience vicarious growth: “I think the lovely thing is how the
family has started to grow a bit . . . having orientated the family to the fact
that things needed to be thought about, talked about, and faced has moved
things on a lot for all of us and we are all getting the best out of each other.”
Kate described that learning to be an independent adult and no longer
needing to please others had helped her to grow:
I always saw myself as an adjunct to someone else before, especially my father and
it was very necessary to please him . . . I kind of carried that into adult life . . .
dealing with the trauma, has made other people irrelevant in the sense that I don’t
need to be a part of them, they can either accept me or reject me for who I am.
Most of the participants talked about growing up in family environments

that were chaotic, unpredictable, and unsafe. However, some participants
experienced conflicted feelings about their early relationships, recognizing
that although harm had been done, they had also learned the importance of
family values and education. Some of the participants experienced love and
care from other individuals such as grandparents or teachers, which was
protective and helpful in their coping. Kate said, “Loving relationship[s] . . .
are so important . . . for children who have been abused . . . if you don’t have
those things you are almost inevitably going to get stuck because there is no . . .
confidence, there’s no sense of yourself to work with.”
The final subordinate theme, negotiating adult relationships: growth and
barriers, related to the participants’ accounts of experiencing growth through
intimate relationships and friendships. For some, intimate relationships
provided the experience of unconditional regard and connection, a space to
feel respected, to talk about the abuse without judgment, to learn the abuse
wasn’t their fault, and to move forward. Seema said, “I could be a child, I
could throw a tantrum, I could hate him, I could love him, I could do all of
that.” The experience of disclosing the abuse to the partner and not feeling
judged or blamed was important, and Carla noted, “When I disclosed to him,
I thought he’d blame me, but one major relief to me was that he didn’t . . . I
thought oh my God he’s not blaming me, maybe it’s not my fault, very
confusing, one of the things was that he was totally understanding towards
me.” Seema agreed: “I told him everything and he hugged me and cuddled
me and didn’t say a word, he didn’t say a word either way, he was just
stroking my hair all night and that was just swshhhhh, feeling that someone
had a hosepipe in your head and getting all the rubbish out, he’s been like
this for many years, that nonjudgmental, he never made me feel dirty.” For
other participants, growth encompassed feeling more confident and assertive
in intimate relationships. Parul reported, “I have always been really scared of
male attention or male kind of anything . . . it was kind of ‘oh my God it’s a
boy’ . . . I guess I felt very vulnerable, whereas I don’t feel vulnerable now, I
feel more . . . confident within myself, I’m more assertive.”
However, growth within relationships was also challenging for some, and
had the potential to change the relationship, as noted by Carla: “It’s like we
have swapped roles . . . whereas before I would be the one leaning on him . . .
since I disclosed to him, we’ve swapped . . . It’s like I am enjoying my life, he’s
not, so that’s holding me back because I get frustrated.” For some, under-
standing their needs within a relationship was part of their growth experi-
ence. Emily discussed forming intimate relationships with other women:
That was in part a nice way to move away from threateningness and the negative
experience with my brother . . . looking for that care that I couldn’t probably get at
home, the dislocation from the family . . . and then, girls just being quite a bit more
nurturing.
She described growth in relation to understanding her own sexuality and

how closeness with others allowed her to understand her own current needs:
“It was about wanting . . . closeness . . . the point of growth at the moment, is
to see how can I look after myself in the way that I look to these very close
relationships to look after me.”
A subcategory relating to friendships was apparent within the subordinate
theme negotiating adult relationships: growth and barriers. All participants
talked about how growth was experienced through friendships in a variety of
ways. Growth was experienced through recognizing and rejecting the friend-
ships that were harmful to them through developing a deeper understanding
of the self and through learning that friendships are as much about laughing
and talking about positive things as they are about discussing difficulties.
Friendships were seen as important relationships through which feelings are
validated and alternative perspectives are offered. Emily said, “Friendships . . .

the beautiful thing is that the more of the sense of myself and understanding
of what I am feeling, the more that had deepened, the closer my friendships
have become.” Although Brigit talked about the positives of having close
friendships with men, she was saddened that she had no close female friend-
ships. Having been abused by her mother, she believed that the abuse had
fundamentally affected her ability to trust women, and she stated that this
was an area in which she was currently unable to make changes: “I do get sad
that I can’t feel intimately, emotionally intimate with any females . . . I think
it would be nice to have a girlfriend . . . but all my barriers come up.”
Discussion
The aim of this study was to explore the nature of PTG with adult female
survivors of CSA. Three superordinate themes and nine subordinate themes
emerged in relation to the participants’ experiences of growth following CSA.
Growth was complex and multifaceted in this population and involved
elements of making sense of the abuse and learning to relate to oneself in
new and more adaptive ways as well as experiencing growth through devel-
oping healthy relationships with others. Given the relative dearth of research
exploring the experience of PTG following CSA, this study provided valuable
insight into similarities and differences in the experience of PTG compared
with other trauma populations. Most women described being unable to
experience PTG until adulthood, when they were capable of making deci-
sions and responding to the world in ways that influenced their coping.
The experience of growth reported in this study showed considerable
similarity to that reported in theoretical models (Tedeschi & Calhoun,
2004). For example, participants had attempted to make sense of and under-
stand their abuse, including the context of religious and cultural issues. The
women described changes in the way they related to themselves, acknowl-
edging positive aspects of themselves as they moved from positions of denial,
guilt, shame, self-blame, and disgust to a position where they could recognize
their personal achievements, see their own positive qualities, soothe them-
selves, and rationalize or reject self-criticism. High self-blame following
sexual assault has been associated with increased psychopathology and
poorer PTG in comparison with those who assign blame to the perpetrator
or indeed those who blame no one (Feinauer & Stuart, 1996; Ullman, 2014).
Results from the current study parallel these findings, with many of the
women reporting that labeling their experiences as abusive and understand-
ing that they were not to blame for the abuse was important for growth.
Learning to relate to themselves with acceptance and self-forgiveness was also
dominant among participants’ reports of growth and included being able to
accept what had happened as well as forgive themselves for their past
behavior. Forgiveness (particularly self-forgiveness rather than the forgive-

ness of others) has been found to mediate the relationship between CSA and
PTSD (Snyder & Heinze, 2005), although this has not been examined in
relation to positive coping outcomes. Consistent with previous findings, the
results of the current study suggest that forgiveness of the perpetrator is not
necessary for coping following CSA (Snyder & Heinze, 2005), as many
participants understandably report being unable to forgive or excuse the
behavior of the perpetrator.
Despite considerable similarities to other trauma populations, the role of
relationships with others as a facilitator of growth was common in partici-
pants’ stories and differs somewhat from existing conceptualizations of PTG
(e.g., Joseph & Linley, 2005; Tedeschi & Calhoun, 2004). The women referred
to their experiences of growth through relationships with others, including
their relationship with their own children, friends, partners, therapists, and
other CSA survivors. Within these relationships, key processes included
learning to assert their own needs and take control in relationships as well
as to separate themselves from relationships that were harmful. New relation-
ships offered a space to learn about love, explore their sexuality, and learn
how to feel differently about themselves in relation to others. Although
relationships have been acknowledged as important in the experience of
growth following CSA through the context of feeling nurtured and validated
in healthy relationships (Woodward & Joseph, 2003), these findings extend
these results to include a focus on the value of providing nurturing and
validating relationship for others. The idea that growth can also occur
through the individual offering a functional, healthy, and secure relationship
to others, specifically children, is important and suggests that this may be an
empowering process that challenges existing narratives and beliefs about
adult–child relationships, helping women to “move beyond” their childhood
experiences.
Dominant theories of PTG are based on adult trauma and suggest a
shattering of assumptions about the self, world, and future, resulting in a
need to revise the assumptive world in order to acknowledge and accom-
modate the trauma information (e.g., Tedeschi & Calhoun, 2004). Among
adult survivors of CSA, participants did not describe a shattering of preexist-
ing beliefs as a result of their abuse but noted that the abuse impeded their
normal development and influenced the formation of their belief systems
(e.g., that they had to always please others, that they were somehow “bad” or
damaged). Participants noted that their belief systems were also influenced by
positive and competing factors (e.g., the presence of other loving relatives,
being successful at school, and having a “strong character”). In this popula-
tion, growth appeared to be more related to their ability to accommodate
alternative information (as opposed to trauma information) into their
assumptive world as adults (e.g., it was safe to experience emotions, it was
possible to create safe and loving relationship with others, there was potential
to be a successful person in their own right). Learning to accommodate
information that challenges their assumptive world (influenced by the
abuse) with a healthy narrative of themselves and their lives appears to be
central to growth in adult survivors of incestuous CSA.
It could be asked whether participants are reporting “recovery” from CSA
or growth. Recovery does not appear to capture what the women are
describing for two reasons. Recovery suggests a “return” to a normal or
healthy state of mind, suggesting that there was a normal level of functioning
in the past. The women in the study talk about growth as an experience of
themselves and others as something totally new; Seema described it as
“waking up” to life for the first time. Second, recovery suggests that negative
symptoms have been alleviated; however, as previously mentioned, the

women report growth in some areas of their life at the same time as
experiencing distress in other areas.
It is important to view the results of this study in the context of its
limitations. First, as all participants were female, observations cannot be
conferred to men. It is possible that men experience growth after coping
with CSA in a significantly different way, especially in the context of gender
stereotype issues (e.g., Easton, Coohey, Rhodes, & Moorthy, 2013). It is also
unclear how these results relate to the experience of growth following extra-
familial sexual abuse, physical abuse, emotional abuse, or neglect, and there is
considerable scope for future studies to understand differences and simila-
rities in PTG experiences in these populations. Second, although participants
identified themselves as having experienced growth, there were no validated
measures of PTG for survivors of CSA at the time this study was conducted,
and as a result no objective measure of PTG could be made. Third, this
sample included a number of women from an Indian heritage, and culture
and religion were particularly prominent themes for these women. It is
unclear whether these results would be as prominent for non-immigrant
individuals, but the study does show that cross-cultural considerations are
important for our conceptualization and treatment of CSA survivors. A final
limitation of the study is that its small sample size means it is not possible to
generalize the results to a larger population. However, this study certainly
provides valuable information for future empirical studies.
The results of this study appear to fit with some recognized aspects of
current conceptual models of PTG, including, for example, learning to
develop a new emotional and cognitive experience of oneself, finding mean-
ing, and developing acceptance related to past experiences. However, there
also appear to be some differences in the mechanisms underlying PTG within
the current study’s population. There was little evidence to suggest that the
women in this study experienced a “shattering of assumptions” after their
abuse. It seems more to be the case that their trauma played a role in shaping
the initial development of their beliefs about themselves, others, and the
world. Indeed, the majority reported not being able to experience growth
until later, when they had entered adulthood. This might suggest that, rather
than incorporating trauma information into their assumptive world, growth
appears to occur when the trauma-laden belief systems are challenged
through new nontraumatic experiences, such as developing stable, nonabu-
sive relationships; engaging in therapy, music, and writing; taking career-
based risks; and starting a family of their own.
One fear therapists may have, especially early in their career, is that abuse
survivors may have only limited capacity for change. The observations from
this study offer hope to therapists that positive change is indeed possible,
and, important, that positive change can occur concurrently with the ongoing
distress of a client. Second, as making sense of the abuse was deemed such a
pivotal factor for the women in this study, it could be argued that one of the
key factors in therapy is a thorough, individually developed formulation that
takes into account belief systems and religious and cultural influences as well
as other potentially protective factors. Finally, it is important to discuss
concepts of acceptance and forgiveness, as clients can often fear that accep-
tance somehow means “being okay with it.” As Parul stated, “I don’t want to
accept it, because it should never be acceptable, but I have accepted the fact
that it happened.” Therefore, an acceptance of the reality that the abuse
occurred can definitely assist the client in moving forward with their lives
(but significantly, “forgiveness” of the perpetrator is not a prerequisite for
growth to occur).
Notes on contributors
Sarah Hartley, DClinPsych, Justice Health and Forensic Mental Health Network, Forensic
Hospital, Sydney, Australia.
Carly Johnco, PhD, Department of Pediatrics, University of South Florida, Tampa, FL.
Marthinus Hofmeyr, MA, Adolescent Service, St. Andrews Healthcare, Northampton, UK.
Alexis Berry, DClinPsych, Department of Clinical Psychology, Older People’s Clinical
Psychology Service, Northamptonshire, UK.
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The Nature of Posttraumatic Growth in Adult

Sarah Hartley, Carly Johnco, Marthinus Hofmeyr & Alexis Berry

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The Nature of Posttraumatic Growth in Adult Survivors of

ABSTRACT ARTICLE HISTORY

Estimates suggest that 15–33% of women have experienced sexual abuse in

may even experience some level of positive personal change as a result of

after a range of traumatic events, including multiple sclerosis (Evers et al.,

likely for their world beliefs to be shattered. However, in the context of

member as opposed to a stranger (Lev-Wiesel et al., 2004) and in women as

Table 1. Participant Demographic and Abuse Information.

Psychiatric diagnostic screening questionnaire (PDSQ)

facilitate participants in reporting their experiences of growth. Questions

Table 2. Superordinate and Related Subordinate Themes.

Main emerging themes

Superordinate theme 1: Making sense of and understanding abuse

attempted to understand their abuse experiences and how these unique

Emily described growth in learning how much of her own personal

The fourth subordinate theme that emerged referred to growth in relation

Seema’s journey of growth in relation to her culture was complex. Initially

Indian heritage and values:

Superordinate theme 2: Relating to the self in a new way

Participants used simile and metaphor as ways of describing their emotional

I had a negative thought enter my mind, instead of that negative thought

Superordinate theme 3: Experiencing growth through relationships with

growth or at times preventing it. Participants described their abuse as having

my life . . . I wanted my mum, or a mum, to be with me to share . . . I haven’t

Most of the participants talked about growing up in family environments

She described growth in relation to understanding her own sexuality and

validated and alternative perspectives are offered. Emily said, “Friendships . . .

behavior. Forgiveness (particularly self-forgiveness rather than the forgive-

symptoms have been alleviated; however, as previously mentioned, the

Calhoun, L. G., & Tedeschi, R. G. (1999). Facilitating posttraumatic growth: A clinician’s

and its contribution to qualitative research in psychology. Qualitative Research in

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