J Relig Health DOI 10.1007/s10943-014-9876-5 ORIGINAL PAPER

Posttraumatic Growth in Widowed and Non-widowed Older Adults: Religiosity and Sense of Coherence J. Lo´pez • C. Camilli • C. Noriega

 Springer Science+Business Media New York 2014

Abstract Older people may experience psychological growth following a life major event. The objective of this study is to analyze the degree of posttraumatic growth (PTG) developed by widowed and non-widowed older adults (n = 103) as well as the impact of possible predicting variables such as sociodemographic characteristics, experienced or witnessed life major events, religiosity and sense of coherence. The findings suggest that, in spite of widowhood, elder people develop PTG in the same way that non-widowed elder people. Therefore, the support of a religious community, age, life major events experienced and the subjective meaning given to them correlated with PTG. Keywords Elderly
Posttraumatic growth
Religiosity
Sense of coherence
Widowhood

Introduction Widowhood is usually considered a life event or a major life event rather than a traumatic event. Nevertheless, widowhood has been described by Sa´nchez et al. (2009, p. 9) as a ‘‘tragic and complex life event that affects especially older adults.’’ Past research has also revealed that the loss of a spouse is related to an increase in psychological symptoms (such

J. Lo´pez
C. Noriega Department of Psychology, School of Medicine, Universidad CEU San Pablo, Madrid, Spain J. Lo´pez (&)
C. Noriega Institute of Family Studies, Universidad CEU San Pablo, C/Julia´n Romea, 23, 28003 Madrid, Spain e-mail: [email protected] C. Camilli Department of Behavioral Sciences, Universidad Metropolitana, Caracas, Venezuela C. Camilli Department of Education, Universidad CEU San Pablo, Madrid, Spain

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as depression and anxiety), physical health problems as well as the mortality risk of the survivors (Stroebe et al. 2007). Although some people experience psychological distress after living a traumatic event, others do not (Bonanno 2004). Indeed, recent researches have shown that many people who have experienced an aversive event, such as the death of a loved one, indicate psychological benefits and increased psychological growth (Bonanno 2004; Tedeschi and Calhoun 2004a). According to Koenig (2009), many people find religiosity and spirituality as the most significant resource to develop posttraumatic growth (PTG), followed by family, friends and community´s support (Stroebe et al. 2007). Another element related to high levels of growth is cognitive processing (Calhoun and Tedeschi 2006). Actually, a research developed by Pretter (2002) showed a negative correlation between depression and sense of coherence (SOC), social support as well as religiousness on a sample of 122 persons whose couples were currently experiencing a terminal cancer. Posttraumatic Growth Research on clinical psychology has traditionally focused on negative responses to highly stressful events (anger, depression, anxiety, grief, health problems…). In the twentieth century, several researchers became interested in understanding the meaning of suffering and the possibility that these highly stressful events offer for personal growth (Frankl 1963; Fromm 1942; Maslow 1943; Rogers 1961), being the 80s and the 90s the decades in which scientists have studied PTG and its processes more deeply (Tedeschi and Calhoun 2004b). It is important to differentiate between the terms of PTG and optimism, resilience, hardiness and SOC. All these concepts have been described as personal characteristics that may help people to cope with highly stressful events. The main difference between these concepts is that PTG, also called learning through the struggle process, is a stress caused growth responsible not only for a transformation that involves an adaptation to the circumstances and a simple return to the base line, but also for the resurfacing of a new person from the reconstruction of his or her life, with new meanings based on strength (Tedeschi and Calhoun 2004b). After experiencing an aversive life event, such as the death of a beloved one, some people experience new possibilities, develop different interests and activities, head toward a new sense of life, seek a balance and become stronger. Also, the interpersonal relationships develop significant positive changes. The sense of proximity and intimacy is enhanced during the whole illness process of the dying person. A change in the philosophy of life is obvious, such as priorities, assessments, spirituality and also, the scale of values and preferences change (Calhoun and Tedeschi 2006). PTG has been studied in stressful experiences such as natural disasters, terrorism, terminal or chronic illness and bereavement. For example, Va´zquez and Castilla (2007) state that breast cancer patients experiment PTG associated with positive emotions and psychological well-being. In line with these authors, Garlick (2009) found higher levels of PTG and positive psychological, physical and spiritual changes on breast cancer patients who attended a psycho-spiritual integrative therapy (PSIT). Therefore, Bower et al. (2008) found positive influences of PTG on physiological reactivity, recovery and habituation. It is generally assumed that PTG takes place more frequently when it is accompanied by highly disruptive circumstances for the individual. Some studies found that the greatest growth is experienced by people who suffer from higher levels of crisis associated with stress or danger (Park et al. 1996). Nevertheless, other studies showed that it is not required to be exposed to extreme situations to experiment PTG (Tedeschi and Calhoun 2004a, b).

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Actually, Tedeschi and Calhoun (1996) found personal growth in people who had not experienced any traumatic situation. However, their levels of personal growth were lower than the ones observed in trauma survivors. Seemingly, positive emotions produce significant changes in life’s schemes and prospects. Wortman and Silver (1989) found in a pioneering study on widowhood that many people who had lost a beloved one did not get depressed and that the absence of depressive symptoms did not indicate the existence, present or future, of disruption. Indeed, most people resist life’s onslaught with surprising strength. Even after extreme incidents, there is a high percentage of individuals who show a great resilience and that remain psychologically unscathed or with minimum damage. For example, Carr and Utz (2002) found that at least 70–80 percent of bereaved persons did not report clinical depression. Even women being widowed more than once are able to renew their priorities, reconstruct their lives based on their religious beliefs and extract a new meaning (Miles 2008). In a qualitative study carried out to assess the experience of widowhood, eleven African-American widows were interviewed. The results showed that the participants were able to experience positive aspects and benefits after the loss of their spouse. For example, they mentioned a higher level of independence and freedom after they had lost their spouse. They also reported a need to redefine goals, change life´s perspective, keep busy and share activities with others. However, the participants reported that before experiencing benefits and PTG, it was necessary to experience painful feelings related to bereavement. To deal with these feelings of grief, the support received from close relatives, friends and community as well as the religious beliefs were described as important sources (Harrison et al. 2004). According to Caserta et al. (2009), the demographic characteristics that have received a greater attention in growth publications are gender, race and age. Widows have more possibilities of experiencing growth than widowers, mainly because suffering tends to be more defiant for men than for women. According to some investigations, age is a variable that could predispose toward PTG as long as there is a certain tendency to learn from previous experiences, to be more optimistic during stressing situations and to seek the positive aspects of events. In line with these authors, Mancini et al. (2011) found that age was a positive predictor of resilient adults who had lost their couple and concluded that responses to life major events, such as widowhood, divorce or marriage, depend on individual differences, such as resilience or greater marital stain (Ong et al. 2010). Calhoun and Tedeschi (2006) also suggested that there is a linear relationship between the event´s severity and PTG. These authors reveal that severe events require higher levels ´ s levels. Shakespeare-Finch and of cognitive processing, which results in greater PTG Armstrong (2010) support the above mentioned. However, other studies do not support this statement. For example, Butler (2007) reveals that this relationship may be curvilinear. According to this author, the curve would travel from non-aversive events and low PTG, through aversive events and moderate levels of growth, to very aversive events and low growth. Religiosity and Spirituality: Practices and Faith Religious beliefs are solid predicting variables of psychological and physical health (Hill and Pargament 2003). According to these authors, religiousness and spirituality are a life´s motivation that not only offers a sense in the final stage of human being, but also are a viable way to reach this stage. Spirituality can be either a potential aid in the management of a traumatic situation or, on the contrary, become damaging. When spirituality acts as a

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growth source, it offers an important support, transforms objectives and priorities and also helps people to find a meaning in life (Calhoun et al. 2000; Harrison et al. 2004; Pargament et al. 2006). Koenig (2009) confirms the above mentioned. According to this author, most of the studies carried out on subjects who belong to different environments (medical or psychiatric centers and general population), ethnic (Caucasian, Afro-American, Hispanic and Native-American), age groups (young, middle aged and elder) and areas (United States, Canada and Europe) show that religiousness is related to a better stress response and a lower incidence of depression, suicide, anxiety and drug abuse. Therefore, the support that people receive from the religious community has been described as one of the most important resources when a stressing situation is being faced. In a systematic review, Shaw et al. (2005) found that in most cases, religiosity and spirituality help people to recover from adverse effects of trauma. These authors also found that a positive religious disposition, a religious openness, a predisposition to face challenges by formulating existential questions in life and religious involvement were frequently associated with PTG. Spirituality constitutes in many cases the most significant experience in PTG, even when an event is extremely stressful (Calhoun and Tedeschi 2000, 2006). Kira et al. (2006) compared levels of PTG in tortured and non-tortured Michigan´s Iraqui refugees. The ´ s levels where results revealed more religious practices in tortured refugees whose PTG higher. In line with the above mentioned, Walker (2007) analyzed the possible correlations between PTG and self-esteem, spirituality, psychological symptoms and locus of control. The results revealed that the variable religious beliefs and practices predicted PTG, concluding that religiosity and spirituality help people to cope with changes, transform priorities and determine objectives (Pargament et al. 2006) and also promotes a greater inner understanding as one of the basic purposes of life (Tedeschi and Calhoun 2008).

Sense of Coherence Sense of coherence (SOC) is a personal disposition toward the evaluation of vital experiences as being comprehensive, manageable and full of meaning (Virue´s-Ortega et al. 2007). It is the sense of connection with actions. The results of our actions are an extension of one´s self and give the human being a sense of continuity and a vital connection with the world. It is a capacity that allows persons to confront negative situations by choosing and selecting the most adequate essential experiences in order to face a stressor. The creator of this concept, Antonovsky (1993), proposes three SOC cognitive domains: understandability (the individual structures, predicts and explains the stressor, internally and externally), manageability (the resources used to face an adverse situation) and meaningfulness (the requests are seen as challenges). People who show high levels of SOC are more likely to adopt beneficial behaviors, show less drug abuse and perceive stressful events as more comprehensive, manageable and meaningful. Therefore, there is a positive correlation between SOC and higher levels of physical health (Aguerre and Bouffard 2008), adjusted coping strategies (Aguerre and Bouffard 2008) and a better immunological functioning (Virue´s-Ortega et al. 2007). Tracy (1992) evaluated a sample conformed by 26 men and women whose spouses had died as a consequence of breast cancer. This author tried to find if any of the three SOC domains proposed by Antonovsky (1993) (manageability, comprehensibility and meaningfulness) were predicting variables of several symptoms experienced by the participants

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after their loss (anger, grief, depression and anxiety). The results showed that the manageability domain was negatively related to anxiety and pain after the death, whereas comprehensibility was negatively associated with depression and anger. In contrast, meaningfulness had no association with any of the variables assessed. Virue´s-Ortega et al. (2007) also found in a sample formed by people over age 70 that SOC increases with age, being a regular and positive growth. Moreover, these authors found significant differences in the total SOC score and in understandability and manageability domains. Compared with women, men showed a slightly higher SOC total score with no significant differences regarding gender in any of the domains. Minimum SOC levels were found in the group of individuals with greater impairment.

Goals and Hypotheses The human being shows a great capacity to adapt and find a positive meaning to dramatic experiences (Frazier et al. 2009; Seligman and Csikszentmihalyi 2000). Taking above considerations into account, the aim of the present study is to compare PTG in widowed and non-widowed elders. Our initial hypothesis maintains that the loss of a spouse or a mate is positively associated with PTG in widowed older people. The inclusion of a sample of older adults who have not lost a spouse would allow us to distinguish the psychological growth processes of bereaved and non-bereaved older adults. Studying PTG in widowed older people will also give interesting information in order to know the variables that may help people to face difficult life events, such as the loss of a loved one. For this reason, it will be also examined the association between PTG and sociodemographic characteristics (gender, age, civil status, academic level and employment situation), life major events experienced or witnessed over the lifetime (motor vehicle accident, psychological, physical and sexual abuse, death of a beloved one, war combat, potentially life-threatening medical illness…), religious beliefs and practices, social support received from the religious community and SOC.

Methods Participants In the present study, a total of 103 older people, widowed and non-widowed, participated. The criteria for their inclusion were being at least 65 years old, not suffering any type of mental or cognitive impairment and having experienced at least one life major event in their lives. The levels of cognitive functioning were provided by their medical staff, and they were assessed by the Red Cross Cognitive Scale (Garcı´a-Montalvo et al. 1992). Moreover, as a specific standard for the widowed older people group, the spouse should have died at least 3 months before the evaluation. A previous study (Davis et al. 1998), which reviewed transcripts of people coping with the loss of a family member, showed a higher percentage of respondents who did not articulate their meanings for reliable coding sufficiently or indicated merely that they were still ‘‘working on it’’ in the first month post-loss. In a larger study, a sample of approximately 800 widows and widowers participated in an assessment after 3 months or more since the loss of their spouse (Wortman et al. 1993).

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Material A questionnaire was designed in order to assess sociodemographic variables (gender, age, civil status, academic level and employment situation) as well as traumatic events experienced or witnessed by the participants. In this instrument, participants were asked to report whether several traumatic events have occurred to themselves or to people they knew (accidents, war, psychological abuse, physical violence, act of terrorism or torture, illness, injury or medical intervention and death of a beloved one). When participants reported more than one traumatic event, they were asked to choose which of them had caused the most distress, when it had occurred, feelings experienced during the traumatic experience (fear, defenselessness or/and horror), possible consequences (life threatening, physical threatening, serious injury, serious injury or death of others…) and severity of symptoms (re-experiencing, avoidance and/or activation). Posttraumatic stress disorder symptoms Assessed with the Severity of Posttraumatic Stress Disorder Symptom Scale (Echeburu´a et al. 1997), which is a structured interview developed to assess the incidence and the severity of current posttraumatic stress disorder symptoms in adults. It evaluates through 17 items each of the proposed diagnostic criteria in DSM-IV-TR, assessing three categories: ‘‘re-experiencing,’’ ‘‘avoidance’’ and ‘‘hyperarousal’’ (APA 2000). Respondents rated on a 4-point Likert scale ranging from 0 (not at all), 1 (one time per week), 2 (2–4 times per week) and 3 (5 or more times per week). For a categorical diagnosis, the total score has to be higher than 15, including at least one re-experiencing item, three avoidance items and two hyperarousal items. It has excellent internal consistency with a Cronbach´s a coefficient of 0.92. Daily Life Functioning Assessed with the Daily Life Functioning Scale (Arinero 2006) contains seven statements in order to assess how a traumatic situation has affected daily life: visits to the doctor, medicines consumed, alcohol and/or drug abuse, academic/employment life, interpersonal relationships and other important aspects in life. Participants were asked whether they agreed or not with the statements. The total score range was from 0 to 7, being 3.5 the cutoff point. This instrument has a high degree of internal consistency with a Cronbach´s a coefficient of 0.73. Sense of Coherence Measured with the SOC Scale (Antonovsky 1987, Spanish version validated by Virue´sOrtega et al. 2007). It consists of 13 items which measure SOC. This term can be defined as the personal disposition toward considering vital experiences as comprehensible, manageable and meaningful. Items were scored on a 7-point Likert scale ranging from 1 (never) to 7 (always). This instrument has high internal consistency (Cronbach´s a = 0.80). Religious beliefs and practices and social support Assessed with the systems of beliefs inventory (Holland et al. 1998, Spanish version in Almanza et al. 2000), which consists of 15 items that measure two different components:

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(1) religious and spiritual beliefs and practices (10 items) and (2) social support derived from a community sharing those beliefs (5 items). Respondents rated on a 4-point Likert scale from 0 (‘‘strongly disagree’’) to 3 (‘‘strongly agree’’). The total score range was from 0 to 45, where higher scores mean higher religious beliefs and practices as well as higher social support received from the religious community. This instrument has shown a high degree of internal consistency with a Cronbach´s a equivalent to 0.91 for the global scale, 0.88 for the subscale ‘‘religious and spiritual beliefs and practices’’ and 0.82 for the subscale ‘‘social support.’’ Posttraumatic Growth Assessed with the Posttraumatic Growth Inventory (Tedeschi and Calhoun 1996, Spanish version in Pe´rez-Sales 2006). It evaluates through 21 items the perception of positive changes reported by people after a stressful event. It comprises five dimensions: (1) relating to others (7 items), (2) new possibilities in life (5 items), (3) personal strength (4 items), (4) spiritual change (2 items) and (5) appreciation of life (3 items). The factor, ‘‘relating to others,’’ evaluates the fact that a person, when is facing a difficult circumstance, feels more attached to others, is more compassionate toward those who suffer and tend to ask for help or social support. The second factor, ‘‘new possibilities in life,’’ considers changes in interests or activities as well as new life projects. The third factor, ‘‘personal strength,’’ assesses self-confidence and the capacity to overcome difficulties. The fourth factor, ‘‘spiritual change,’’ evaluates the quest of spiritual sense of things, sense of life and existential approaches. The fifth and last factor is ‘‘appreciation of life’’ and assesses a more relaxed attitude in life, a change in lifestyle or a change in essential priorities. The scoring ranged from 0 to 5, where 1 corresponds to ‘‘no change’’ and 5 to ‘‘very great change.’’ This instrument has shown strong internal consistency for the total PTGI (a = 0.95), as did the individual subscales (ranging from 0.67 to 0.85, respectively). Procedure The participants were recruited via nursing homes. Also, snowball participants were obtained from non-profit organizations. First, the directors of different nursing homes within the province of Madrid were contacted and asked for permission. Two nursing homes agreed to collaborate with our study. The next step was to contact the possible participants in order to set a date to interview them in their homes or nursing homes. The participants were asked to sign an informed consent. The questionnaires were individual administered by a trained researcher. The session usually lasted 1 h. Statistical Analysis In order to establish the uniformity of both groups (widowed and non-widowed older people) through the sociodemographic characteristics and the traumatic events experienced, chi-square analysis (v2) was performed in the case of qualitative variables and an ANOVA in the case of the quantitative variables. In order to analyze PTG differences between widowed and non-widowed participants, an ANCOVA was performed introducing as covariance those quantitative variables (sociodemographic characteristics and life major events experienced throughout life) that showed significant intergroup differences and that could affect to some extent the result in

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the dependent variable (PTG). The aim was to determine whether differences in these variables affected the participants´ PTG levels. In order to evaluate factors related to a greater PTG, we began analyzing connections between total PTG in widowed and non-widowed people, sociodemographic variables and those related with the trauma, vital functioning, SOC and religious beliefs, with Pearson (r), Spearman (r), Spearman (rs) and point-biserial (rpb) correlations. Afterward, a stepwise regression analysis was performed in order to explain the influence in the total PTG of the variables that had proved significant in the correlation analyses. Moreover, being widowed or non-widowed was included in the regression analyses, independently of their positive correlation with PTG, as this variable is the main object of analysis in the present study.

Results As can be observed in Table 1, most participants were women (65 %), had elementary or primary studies (35 %) and considered their working situation as retired (56.3 %) or being a housewife (36.9 %). Besides the logical differences in the civil status, the average age of the participants was from 65 to 97 years old (mean = 74.85, standard deviation = .093), being significantly younger the non-widowed people as compared to the widowed ones

Table 1 Sociodemographic data of participants Non-widowed (n = 53)

Widowed (n = 50)

Total Sample (n = 103)

Female

64.2

66

65

Male

35.8

34

35

Age** M (SD) [Range]

71.3 (6.01) [65–90]

78.6 (8.04) [65–97]

74.8 (7.93) [65–97]

Without studies

13.2

18

15.5

Elementary

30.2

40

35

Secondary

22.6

28

25.2

University

32.1

14

23.3

Doctorate

1.9

–

1

Full-time worker

7.5

–

3.9

Part-time worker

3.8

–

1.9

Housewife

41.5

32

36.9

Retired

47.2

66

56.3

Disabled

–

2

1

Single

15.1

–

7.8

Married

77.4

–

39.8

Separated

7.5

–

3.9

Widowed

–

100

48.5

Gender (%)

Studies (%)

Present working status (%)

Civil status** (%)

** p \ .001

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(F(1,101) = 27.257, p \ .001). Only 35 % of the participants were male, and barely 28.7 % were married. ANOVAs showed that subjects in the widowed group were significant older than in the non-widowed group. There were no other significant differences between the two groups in the sociodemographic data of participants (ANOVAs and (v2) analyses), with the logic exception of the civil status. As can be observed in Table 2, most participants have experienced several life major events in their lives, directly (M = 9.25) or through close relatives (M = 9.36). The average of participants witnessing an aversive situation is similar (M = 8.57). The most stressing situation found was the death of a close relative or a beloved one (63.1 %), followed by an illness, an injury or a medical intervention that supposed a life threatening to the physical integrity of the person or of a close relative (20.4 %). Besides the differences in the nature of the traumatic event between both groups (v2 = 37.491, gl = 8, p \ .001), as expected, the most stressing situation found in the widowed group participants was the death of a close relative or a beloved one (86 %), while there were no significant differences in other characteristics related to the traumatic situation or in the feelings reported by the subjects as showed by the ANOVAs and (v2) analyses. In almost nine out of ten cases (86.4 %), the life major event described by the participants as the most aversive had taken place more than 3 months before they were interviewed, while only the 6.8 % of the situations were experimented during childhood or adolescence. Most of the subjects reported they experienced defenselessness (80.6 %) and fear (57.3 %) during the event and almost half of them suffered a feeling of horror (47.6 %). Participants presented a good functioning in daily life (M = 4.48). Actually, the scores in posttraumatic re-experimentation symptoms (M = 1.87), avoidance (M = 3.75) and greater activation (M = 2.19) were low. As can be observed in Table 3, participants showed similar average levels in the three SOC subscales: manageability (M = 19.23), comprehensibility (M = 25.19) and meaningfulness (M = 21.98). Furthermore, high scores were found in spiritual beliefs and practices (M = 24.94) as well in the perceptions of support received from the other members of the religious community (M = 8.91). There were no significant differences in the SOC or religiosity showed by the ANOVAs. Moreover, one-factor (group) ANCOVAs of each of the PTG variables analyzed were carried out, with the age value as covariate. Thus, the differences between the two groups (widowed and non-widowed) were obtained controlling the effects of the age values. Age was the only unexpected variable that showed a statistically significant difference between widowed and non-widowed groups. No significant differences between widowed and nonwidowed people were found in the PTG global score and in any of the PTG subscales. The association between PTG levels and sociodemographic variables, life major events, SOC and religiosity were significant, as we can observe in the correlation analyses of age (r = -.279, p \ .01), total amount of traumatic events witnessed (r = -.241, p \ .05), avoidance levels (r = -.200, p \ .05), daily life functioning (r = -.200, p \ .05), comprehensibility (r = .254, p \ .01), meaningfulness (r = .350, p \ .01), grade of spiritual beliefs and practices (r = .483, p \ .01), amount of support received from a religious community (r = .508, p \ .01), being single (rpb = .268, p \ .01), levels of defenselessness (rpb = -.227, p \ .05), educational level (rs = .379, p \ .001) and when the event represented a physical threat to another person (rpb = .197, p \ .05). These variables that showed significant correlations (p \ .05) were introduced in a poststepwise regression analysis in order to determine the weight and relationship between different variables (related to sociodemographic characteristics, life major events, SOC,

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J Relig Health Table 2 Traumatic events experienced by participants Non-widowed (n = 53)

Widowed (n = 50)

Total Sample (n = 103)

Traumatic events suffered by on self M (SD) [Range]

9.1 (1.44) [6–12]

9.4 (1.34) [6–12]

9.3 (1.39) [6–12]

Traumatic events witnessed M (SD) [Range]

9.4 (1.59) [6–12]

9.4 (1.19) [7–12]

9.4 (1.41) [6–12]

Traumatic events suffered by other people M (SD) [Range]

8.9 (2.02) [2–12]

8.3 (1.87) [2–12]

8.6 (1.96) [2–12]

Transportation accident

–

6

2.9

Other type of accident (occupational, domestic, leisure…)

3.8

–

1.9

War

–

4

1.9

Psychological abuse

3.8

–

1.9

Physical violence (attack, assault, abuse…)

3.8

–

1.9

Most traumatic event** (%)

Act of terrorism or torture

1.9

–

1.0

Illness, injury or medical intervention

35.8

4

20.4

Death of a beloved one

41.5

86

63.1

Others

9.4

–

4.9

Elapsed time (%) Childhood/adolescence

9.4

4

6.8

More than three months

79.2

94

86.4

1–3 months

7.5

–

3.9

\ 1 month

3.8

2

2.9

Associated feelings (%) Fear

54.7

60

57.3

Defenselessness

73.6

88

81.6

Horror

39.6

66

49.5

Threat to life

20.8

14

17.5

Threat to the life of others*

49.1

80

64.1

Threat to the physical integrity

26.4

12

19.4

Threat to the physical integrity of others*

49.1

80

64.1

Serious injury

24.5

18

21.4

Serious injury or death of others*

56.6

82

68.9

Unpleasant scene

81.1

94

87.4

Re-experimentation

1.8 (2.15) [0–10]

1.9 (2.01) [0–9]

1.9 (2.11) [0–10]

Avoidance

2.9 (4.34) [0–21]

4.6 (4.03) [0–16]

3.8 (4.26) [0–21]

Activation

2.2 (2.44) [0–9]

2.2 (1.57) [0–7]

2.2 (2.06) [0–9]

4.6 (2.22) [0–7]

4.3 (1.87) [0–7]

4.5 (2.05) [0–7]

Consequences (%)

Severity of Symptoms M (SD) [Range]

Daily life functioning M (SD) [Range] * p \ .01; ** p \ .001

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J Relig Health Table 3 SOC, Beliefs and PTG Non-widowed (n = 53)

Widowed (n = 50)

Total sample (n = 103)

Manageability

19.3 (3.79) [11–28]

19.2 (3.88) [8–27]

19.2 (3.82) [8–28]

Comprehensibility

26.1 (4.37) [14–33]

24.2 (4.19) [16–32]

25.2 (4.37) [14–33]

Meaningfulness

23.1 (3.76) [14–28]

20.8 (3.94) [12–28]

21.9 (4.01) [12–28]

24.9 (6.38) [1–30]

25.1 (6.99) [0–30]

24.9 (6.66) [0–30]

8.6 (4.74) [0–15]

9.3 (4.25) [0–15]

8.9 (4.50) [0–15]

Sense of Coherence M (SD) [Range]

Religiosity M (SD) [Range] Spiritual beliefs and practices Social support related to a religious community Posttraumatic growth M (SD) [Range] TOTAL

62.7 (21.93) [5–101]

65.9 (22.76)[5–108]

Relating to others

20.8 (7.98) [0–35]

19.5 (6.84) [0–32]

20.2 (7.44) [0–35]

New possibilities

13.7 (6.52) [0–25]

12.2 (5.46) [0–22]

13 (6.05) [0–25]

Personal strength

17.2 (5.11) [2–25]

15.5 (6.06) [0–23]

16.4 (5.63) [0–25]

7.1 (3.18) [0–10]

6.8 (3.38) [0–10]

6.9 (3.27) [0–10]

10.1 (3.89) [0–15]

8.7 (3.38) [1–14]

9.42 (3.70) [0–15]

Spiritual change Appreciation of life

69 (23.30) [10–108]

religiosity) and PTG. The regression analysis of PTG levels showed that a greater support received from a religious community (b = .487, p \ .001), lower age (b = -.291, p \ .001), events that implied a treat to others life (b = .199, p \ .01), less events witnessed (b = -.197, p \ .01) and a greater meaningfulness (one of SOC measurements) was significantly associated with a greater PTG, accounting for 45 % of the variance.

Discussion Previous psychology research has focused on psychological disorders, weaknesses and negative consequences of stressors. In contrast, positive psychology has described human being as active, strong and capable of withstanding, recovering and growing under conditions of adversity (Gillham and Seligman 1999; Seligman and Csikszentmihalyi 2000). According to these authors, strengths and virtues act as a barrier against stressful events. Positive emotions are related to lower levels of anxiety and grief (Fredrickson 1998), increased psychological well-being, growth, interpersonal relationships, quality of life, positive mood and develop effective coping strategies (Vecina 2006). For these reasons, positive psychology researchers emphasize the study of positive qualities in order to make life most worth living. In the present study, all the participants, widowed and non-widowed, have experienced PTG with no significant differences between groups (M = 69 and M = 62.7, respectively). The results of this study show that life major events of lower traumatic intensity experienced by elderly people, such as being widowed, can be related to high PTG levels. This results match up with the PTG score found by Tedeschi and Calhoun in people who have not experienced severe trauma (1996, M = 69.75). As a consequence, these authors concluded that PTG is not only experienced by people who have experienced highly stressful situations that could be turned into a posttraumatic stress disorder as suggested in

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the DSM-IV-TR (APA 2000)—first-line combat in war, personal violent attacks (physical and sexual, assault, robbery at home), being kidnaped, being taken as hostage, tortured, suffering imprisonment as prisoner of war or confined in a concentration camp or natural disasters. Although the death of a close relative is frequently considered, a normal transition that forms part of the cycle of life is a very stressful experience. In fact, the present study reveals that the 41.5 % of non-widowed older people interviewed reported that the most stressful event they had experienced was the death of a loved one. Bereavement should be considered as a stressful factor with the capacity of originating PTG during the process of struggle and overcoming. It should be also pointed out that the general levels of psychological growth experienced by the elder adults interviewed in this study, widowed and non-widowed, were similar to those indicated by people who survived bombings during World War II (M = 69, Maercker and Herrle 2003), immigrant women in the USA (M = 71.42, Weiss and Berger 2006) and were much higher than the growth experienced by refugees and expatriated people in the Balkan War (M = 35.82, Powell et al. 2003) as well as by British general population (M = 52.04, Linley et al. 2007). It also seems that older people are highly capable of experiencing PTG after a struggle process developed when enduring traumatic events in extensive life. This result would contradict the negative stereotype that older people are insensible to past or present changes and that they tend to focus on negative aspects. Against negative perceptions related to age, elder adults, widowed or not, considered themselves as people with great inner strength and felt more confident and capable to face future adversities. They also obtained high scores in spiritual beliefs and SOC. It seems that following an aversive experience, older people manifest a greater comprehension of some spiritual questions, a stronger religious faith as well as a greater appreciation of what life can offer, changing, as a consequence, their priorities in life. According to Koenig (2009), Hill and Pargament (2003) and Tedeschi and Calhoun (2004b), spirituality and religiousness are the most important elements related to PTG. Consistent with this statement, the results of the total sample of this study indicate a positive relationship between the social support that the religious or spiritual community offers and psychological growth developed in people who have experienced at least one life major event. The more the religious community support was reported by the participants, the higher the degree of PTG was revealed. These findings also confirm what other authors have already described, such as Seligman (2008), who considers faith, religious beliefs, optimism, extraversion, hope and self-confidence as personality characteristics that may facilitate psychological growth after experiencing a life major event. Age was also correlated with psychological growth. The youngest participants of the total sample showed higher levels of PTG. These results agree with the ones reported by Klauer et al. (1988), Salmon et al. (1996) and Bellizzi and Blank (2006). A possible explanation is that younger people are more likely to show positive attitudes when facing adversity because their cognitive schemes have not been consolidated yet, allowing them more disruption and change (Powell et al. 2003). Relationships between some characteristics related to the aversive event and PTG were also found. The participants, widowed or not, who reported events in which the physical integrity of another person was threatened showed higher levels of PTG. These results support the idea that both self-oriented adversity and other-oriented adversity are related to psychological growth when the life major event is highly stressful.

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Calhoun and Tedeschi (1998) consider that the differences found in relation to the event depend more on the subjective experience, that is, how the subject lives and perceives an adverse situation related to its defenselessness, controllability and threat. Other authors such as Wagner et al. (2007) and Johnson et al. (2007) consider important to emphasize the subjective experience too. It is not enough to simply live and perceive the change. This change needs to be translated into specific actions evidenced in PTG dimensions. According to these statements, the SOC domain ‘‘significance’’ was positively associated with a greater PTG in both groups. When life demands are perceived as a challenge worth of effort and implication, it is easier to experience growth. In short, the elements related to the stressor intensity do not seem to be associated with a greater PTG, but the elements associated with the personal characteristics of the older person do, specifically those related to motivational aspects. PTG is important for elders because it is positively related to health, physical and cognitive functioning, interpersonal flourishing and social support (Heckhausen 2001; Ryff and Singer 1999). Achieving personal growth after the loss of a beloved strengthens personal control, self-efficacy and self-esteem (Jimenez 2008). Also, PTG in elders has been positively related with the ability to recognize and evaluate their performance, organize and manage future situations, control over their actions, develop curious toward learning, face new challenges and goals and experience positive emotions (Fredrikson et al. 2003). Psychotherapy can help elders to develop personal growth as it implies a recognition and integration of emotions as well as develop coping skills in order to handle adversities in life, such as widowhood. According to some authors, PTG should be discovered by the subject. However, psychologists may help to perceive any sign of PTG in order to encourage the patient´s development (Calhoun and Tedeschi 1998). Another way to enhance interventions for PTG may consist of promoting the emergence of certain coping styles and attitudes that research has shown associations with personal growth, such as resilience, not ruminative thought, active coping and expression of positive emotions (Va´zquez et al. 2009). The results found in this study have certain implications for clinical practice in order to encourage personal growth after the lost of a spouse. It is important to first assess how the subject perceives the loss, its attitudes and cognitive processing when facing adversity as well as its strengths, in order to offer a treatment adapted to the client´s needs. Clinicians should pay a special attention to the older elders, since they have shown the lower levels of PTG. As meaningfulness is the SOC domain which has shown a higher relation to PTG, clinicians, through the therapeutic relationship, can help clients increase an inner understanding of their own feelings, beliefs and values and perceive bereavement as a challenge, stimulating acceptance instead of resignation. Clinicians should also help clients recognize and deal with grief, finding a meaning to it. This study also shows a positive correlation between religious social support and PTG, which suggests the need to deepening the role played by the religious community in the client´s life. Finally, clinicians can encourage clients to seek new opportunities to rebuild their lives and increase their PTG, for example, developing different interests or activities, helping other people in similar situations or increasing social support networks. Nevertheless, there are certain limitations to be taken into consideration in order to understand the results. The first one is the fact that these findings are cross-sectional, so a causal interpretation of the results cannot be interpreted. On the one hand, post-traumatic growth suggests a development over time, but this is a cross-sectional study. Secondly, the results correspond to older people that, in most cases, have experienced traumatic events

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related with their health or the health of others, or with the death of a beloved one and thus cannot be comparable to older people having experienced another type of traumatic event in their lives. Furthermore, the subjective evaluation of PTG represents a retrospective by the respondent, not necessarily a true development. Another limitation is related to the small size of the sample. For this reason, the results of this study cannot be generalized to other similar populations. Also, the subjects that belong to the group of widows and widowers are not uniform because there are differences in the age. Finally, it should be mentioned that all the information proceeds from one source: the older person. For this reason, the possibility of obtaining information from different sources, such as close relatives or friends, would give a better understanding of older adults´ growth experience following a traumatic experience. Future investigations on PTG should be oriented toward a more extended and precise evaluation of the cultural and cognitive growth related aspects. Future research should also study positive emotions as a preexisting positive mechanism for affectivity, develop transcultural and longitudinal studies in order to understand the growth background and predictors and take into account qualitative studies that could give an enriched and profound insight on the comprehension of the individual experiences. Acknowledgments This work was supported by a grant from the San Pablo CEU University of Madrid (Grant USPCEU 01_08).

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