The challenging journey from trauma to post‐traumatic growth: Lived experiences of facilitating and hindering factors

Abstract Background Many people experience psychological trauma during their lifetime, often negatively affecting their mental and physical health. Post‐traumatic growth is a positive psychological change that may occur in an individual after having processed and coped with trauma. This journey, however, has not been studied enough. Aim The purpose of this phenomenological study was to explore people's experience of suffering psychological trauma, the personal effects of the trauma and the transition from trauma to post‐traumatic growth. Methods A purposeful sample of seven women and five men, aged 34–52, were selected whose backgrounds and history of trauma varied, but who had all experienced post‐traumatic growth. One to two interviews were conducted with each one, in all 14 interviews. Results This study introduces a unique mapping of the challenging journey from trauma to post‐traumatic growth through lived experiences of people who have experienced trauma as well as post‐traumatic growth. Participants had different trauma experience, but their suffering shaped them all as persons and influenced their wellbeing, health and view of life. Participants described post‐traumatic growth as a journey, rather than a destination. There was a prologue to their journey which some described as a hindering factor while others felt it was a good preparation for post‐traumatic growth, i.e. to overcome difficulties at an early age. Participants described six main influencing factors on their post‐traumatic growth, both facilitating and hindering ones. They also described the positive personal changes they had undergone when experiencing post‐traumatic growth even though the epilogue also included heavy days. A new theoretical definition of post‐traumatic growth was constructed from the findings. Conclusion The results suggest that the journey to post‐traumatic growth includes a recovery process and certain influencing factors that must be considered. This information has implications for professionals treating and supporting people who have suffered traumas.


INTRODUCTION
Many people suffer psychological trauma during their lifetime. Suffering trauma can play a large role in the development of various psychological problems [1][2][3][4][5]. Trauma occurs due to a threatening and unexpected event that the individual does not control and may have challenged the perception of living in a safe and predictable world [6][7][8]. The more the event affects the person directly, the greater the risk of emotional harm [5,[9][10].
Known negative emotions following trauma are shame, sadness or depression, anxiety and guilt, especially after a personal trauma [2,[11][12]. Research has shown that a variety of risk and protective factors affect an individual's response to personal trauma, such as the person's previous suffering of trauma, the severity of the trauma and other's reaction to the trauma [13]. Social support is a positive, protective factor [14][15].
Various factors other than the trauma itself may affect people's reactions to trauma, e.g. stress levels before the trauma [8,16] and current stress [17]. Furthermore, relief, adaptability, what the person considers important, life-satisfaction and positivity are also key factors when it comes to individual response to trauma [17]. Research indicates that those who suffer more than one type of trauma may be more likely to experience health problems than those who suffer a single trauma. However, other factors such as the severity of the trauma [7,18], culture, and type and combination of traumas are also important in this regard [4].
Trauma causes stress and stressful events in people's lives can have a measurable effect on their neurological and immune responses which can affect the individual's mental and physical health, well-being and quality of life [19][20][21][22][23]. Excessive stress interferes with the coordination of the body's defence systems, which can then adversely affect an individual's physical and mental well-being. If the stress is prolonged, it can contribute to long-term negative effects on the individual [24][25].
Experiencing potentially harmful life events can lead to feelings of helplessness or great fear, causing traumatic stress and even post-traumatic stress disorder (PTSD) [8,15,26] which is one of the most serious and inhibiting types of stress [5,27]. PTSD has a negative effect on the individual's physical and mental health; its main symptoms are intrusive thoughts about the trauma, avoidance of what is reminiscent of the trauma, hypersensitivity [2,[28][29] and fear [2,6,30]. Cumulative stress due to previous trauma can affect whether, how much and for how long people suffer from PTSD [7,26,31]. Studies indicate that experiencing safety and social support reduces the likelihood of developing symptoms of PTSD [6,15].
Post-traumatic growth is a positive psychological change that may occur in an individual who has suffered a trauma. Research suggests that such growth consists of five main factors: people experience increased spiritual development, see new possibilities in life, value life more than before, experience increased personal strength and better relationships with others [32][33]. When assessing post-traumatic growth, all these factors are considered [34]. Research has shown that some of those who have suffered trauma describe these extensive positive changes in their lives as a result [35][36]. Individuals living in tornado areas in Australia were studied by Pooley et al. [10] regarding stress and post-traumatic growth. The results of that study show that those who have resilience and self-efficacy are more likely to positively grow despite experiencing serious threats or adversity. Thus, trauma can sometimes increase people's ability to cope, adapt and even embrace a new stressful reality so that they become stronger than ever before [7]. Seeing post-traumatic growth as a goal, the journey from suffering a psychological trauma towards post-traumatic growth needs to be better understood so that professionals can better guide them on their journey. Therefore, the aim of the study was to increase knowledge and deepen understanding of the key influencing factors in suffering a psychological trauma, the personal effects of experiencing the trauma, and how people describe the transition from trauma to post-traumatic growth.
The research questions were: 1. What is people's experience of suffering psychological trauma? 2. What is people's experience of mental and physical symptoms following trauma? 3. What is people's experience of factors affecting their journey from trauma to post-traumatic growth? 4. What is people's experience of post-traumatic growth? 5. What is the epilogue of people experiencing trauma and post-traumatic growth? 6. Based on the participants' experience what is the theoretical definition of post-traumatic growth?

METHODOLOGY
To answer the research questions, a phenomenological method was used, i.e. the Vancouver-School of doing Phenomenology (in short Vancouver-School), which aims to understand participants' experiences of certain phenomena by examining their description and interpretation of their experiences [37]. Each participant is seen as a case study, and the method is based on analysis of individual cases (steps 1-7) and then an inter-cases analysis (steps [8][9][10][11][12]. The implementation of the study was conducted consistent with these 12 main research steps (see Table 1). The research process in the Vancouver School is characterized by seven main cognitive factors which are set up as a circular process which is repeated throughout the research process (see Figure 1).

Inclusion criteria
Inclusion criteria included having suffered a psychological trauma and having been unable to work or having dealt with reduced working capacity following the trauma due to physical and/or mental health reasons caused by the trauma, followed by a self-described post-traumatic growth. Further inclusion criterion was that a participant had not received a psychiatric diagnosis before the psychological trauma and that more than six months had passed since the participants suffered the trauma.

Sample
The participants were recruited in collaboration with different rehabilitation resources and among colleagues, who T A B L E 1 The 12 basic steps of the research process of the Vancouver School in this study

Steps in the research process
What was done in the present study Step 1. Selecting dialogue partners (the sample) Fourteen participants that self-reported post-traumatic growth (PTG) participated in the study. When interviewed it was revealed that two of them did not meet the criteria of PTG, so their data were not considered in the results. Participants were therefore twelve, seven women and five men Step 2 Silence (before entering a dialogue) The researchers reflected upon their preconceived ideas and consciously put them aside as much as possible Step 3 Participating in a dialogue (data collection) One interview was conducted with each of the twelve participants, two interviews with two participants, in total 14 interviews. The first author conducted all the interviews which were recorded, written verbatim in a computer, and encrypted Step 4. Sharpened awareness of words (data analysis) Data collection and data analysis ran concurrently. The interviews were read repeatedly by the researchers and comments were written on the margins to find the core of the interview and trying to answer the research question Step 5. Beginning consideration of essences (coding) Each interview was analysed in detail, and main themes and subthemes were constructed Step 6. Constructing the essential structure of the phenomenon from each case (individual case construction) The main themes and subthemes in each participant´s story was highlighted and the most important themes constructed into an individual analytic framework Step 7. Verifying each case construction with the relevant participant (verification 1) All participants confirmed their individual analytic framework Step 8. Constructing the essential structure of the phenomenon from all the cases (meta-synthesis of all the different case constructions) All individual analytic frameworks were compared and constructed into one main analytic framework ( Figure 2) Step 9. Comparing the essential structure of the phenomenon with the data for verification (verification 2) For verification, all the transcripts were read over again and compared to the final analytic framework Step 10. Identifying the overriding theme which describes the phenomenon (construction of the main theme) The challenging journey from trauma to post-traumatic growth: Lived experiences of facilitating and hindering factors Step 11. Verifying the essential structure with the research participants (verification 3) All participants verified the final analytic framework and the main theme, except one participant who did not reply Step 12. Writing up the findings (multivoiced reconstruction) The participants are quoted directly to increase the trustworthiness of the findings and conclusions introduced the participants to the first author. A theoretical definition of post-traumatic growth was used when recruiting participants (see Table 2). To get the widest possible scope in the study, emphasis was placed on selecting participants who had suffered different types of traumas. A purposive sample was used, and interviews were conducted

F I G U R E 2
The journey towards post-traumatic growth with seven women and five men. The participants were aged 34-52 and had all been unable to work or dealt with reduced working capacity following their trauma.

Data collection and data analysis
An interview guide designed by the researchers was used, and the length of the interviews ranged from 23 to 81 min. The data collection and analysis are described in Table 1. Examples of interview questions are, e.g. how would you describe your experience of suffering a psychological trauma? Can you describe the mental and physical symptoms following the trauma? Can you describe your experience of factors affecting your journey from trauma to post-traumatic growth? How would you describe your experience of post-traumatic growth?
Can you tell me about the epilogue of your experience of trauma and post-traumatic growth? The interviews were conducted via a tape recorder in places chosen by the participants during a three-month period. After the initial data analysis of the first author, both authors were involved in the data analysis and data presentation. The first author is experienced in interviewing people, and the second author has a 34-year experience of doing qualitative research.

Validity and reliability
To reduce the likelihood of homogeneity, participants were selected who had suffered different kinds of trauma, of both sexes and of diverse ages. Interviews were conducted until the researchers agreed that data saturation had been achieved and the research questions could be answered. The first author who conducted and did the primary analysis of all the interviews is an MSc nurse with broad experience of nursing for the past 25 years. She has considerable knowledge and experience of in-depth interviews and of building rapport with respondents. She has personal experience of suffering psychological trauma followed by post-traumatic growth. Blythe et al. [38] investigated the challenges of being an insider in storytelling research and found that this can have both advantages and disadvantages. It is important that researchers are aware of these possibilities and take measures to minimise their effects [38][39]. The first author was aware that her experience of post-traumatic growth could influence the research process. To minimise that risk, she consciously set aside her preconceived ideas of the subject, using the research process in the Vancouver School (see Figure 1) and by supporting the results by direct quotations from the participants. The research process in the Vancouver-School has inbuilt verification in steps 7, 9 and 11 which increased the validity and reliability of the study, so all participants reviewed their own individual analytic framework as well as the final analytic framework (all but one who did not respond) (see Table 1).

Research ethics
The main principles of research ethics guided researchers in the study. The Icelandic National Bioethics Committee granted permission to conduct the study (reference no: VSN-15-102). Each participant received an introductory letter and an oral presentation about the study and signed an informed consent. In the introductory letter, possible participants were informed about the purpose of the study, the research method and what was involved in participation. They were informed of their rights to participate voluntarily and to withdraw from the study whenever they wished, as well as of anonymity and absolute confidentiality. Transcripts with anonymised interview data were stored in a locked cabinet in a safe place. All names in the study are pseudonyms.
It was recognised that participation in the study could cause participants' emotional distress as they were reviewing difficult periods in their lives. Therefore, the first author contacted each participant again by phone 7-10 days after each interview to check on their well-being and again later in the research process to seek verification of each individual case construction with the relevant participant (verification 1, step 7 in the research process), as well as the verification of the final analytical framework (verification 3, step 11). Participants were offered the psychological support of a mental health professional, free of charge, if they felt the need for one. No participant took advantage of that.

RESULTS
The psychological traumas the participants suffered were negative in themselves and had a lasting effect on their lives. Everyone described how this life experience had shaped them as persons and influenced how they view life today. For the participants, post-traumatic growth was more of a journey than a destination and there were many influencing factors on the journey, both facilitating and hindering ones. The overall findings are shown in Figure  2, as well as in Tables 3-6. Figure 2 portrays the six main influencing factors that affected the participant's journey towards post-traumatic growth. It also shows the prologue to the trauma and, finally, the epilogue, i.e. how the participants felt today, their 'heavy days' and the lessons they have learned from their challenging life experience.

The prologue: The participants' history and past traumas
When participants started to tell the story of their journey from trauma towards post-traumatic growth, they talked about their previous traumas. They described how previous life experiences influenced their reaction to the latest trauma that almost caused them to lose their health. Ten participants spoke unsolicited about their childhood, describing challenging conditions and poor parenting methods at their childhood homes and the psychological traumas they suffered as children.
Hannah reminisced: [There] was a lot of drinking in the home, lack of money and such. You watched domestic violence and your parents were fighting and you did not get this warmth in childhood as you show your own children today. There was no kiss and "I love you" … You got no help with homework or anything so you were teased throughout primary school and performed very badly in school. I did not understand anything.
Participants linked their characters and defences in adulthood to their childhood experiences, but few of them had processed their childhood suffering and traumas. Gregor recounted: I was raised in such a way that you should not complain, and you should not cry. I should be big and strong, and I've always been like that … at the end I just broke. There was something [within me] that just broke.
Seven participants felt that difficult experiences in their youth had been a good preparation for the trauma they suffered later in life. Liam explained: 'I think that when I was very young, I grew some kind of "shell" [by suffering traumas as a young boy] and somehow this "shell" just kept me going in life … but still this "shell" was not comfortable to wear'. However, several participants described how the snowball effect of their previous traumas caused them to 'lose it.'

Suffering the psychological trauma
The psychological traumas that participants suffered and caused upheavals in their lives were of various kinds. The traumas were all very personal and were related to the participants' own life and health or those of their loved ones. All the traumas had serious and very personal consequences for the participants who came close to losing their mental and physical health. The traumas included accidents, serious illness of a child, suicide of a loved one, experiencing violence or severe bullying, losing a job, serious illness, divorce, mental illness of a loved one, adultery, serious financial problems and loss of housing. The period following the trauma was often accompanied by intense internal conflict and discomfort, which initially had a negative effect on the individual's self-esteem and interactions with others. Six participants described their feelings of anxiety and depression. Seven participants showed strong symptoms of PTSD, and three of them received a formal diagnosis of PTSD. The trauma and the process that followed had profound effects not only on the participants but also on their personal network, especially those closest to them. All the participants described mental and physical symptoms following the trauma (see Table 3), and

Key influencing factors on the journey towards post-traumatic growth
Despite different backgrounds and trauma histories, participants had several things in common when it came to responding to the trauma, processing it and coping with it on their journey to post-traumatic growth. According to the participants' descriptions, there were various factors that influenced how life after a trauma developed, how long the symptoms of the trauma lasted and how they recovered from the psychological trauma. Everyone agreed that support had positive effects on the journey towards post-traumatic growth, while lack of support had negative effects. The six main influencing factors were significant others, environmental factors, further traumas, internal factors, professionals and the system and, finally, rehabilitation. An overview of the key influencing factors on symptoms of psychological trauma and the process to post-traumatic growth is found in Table 4. Significant others were very important to the participants and had great impact on their journey either positively or negatively. The trauma generally put more strain on loved ones and their home life.
Environmental factors. Reactions from other people in the participants' close environment regarding their traumas were very different. Participants who experienced compassion and support said it was precious, while lack of support resulted in negative and destructive feelings.
Further traumas occurred in the lives of all participants on their journey to post-traumatic growth, which in all cases had negative effects on their well-being and delayed the process of post-traumatic growth. Four participants felt that the help they had already received from professionals in dealing with previous traumas was useful when further traumas occurred. Five participants felt that previous traumas helped them to deal with further traumas. Liam described this: I felt like I was … so used to this [to suffer trauma] … it did not surprise me anymore. It turned into anger or something. But nothing like "why me" or something like that … it all just stopped surprising me.
The most frequent type of further trauma was related to the participants' poor economy due to prior trauma.
Internal factors of all participants had either positive or negative effects on the symptoms of the trauma, the sequence of events that followed and the processing of the trauma. The most important internal factors mentioned were willpower and courage. Good upbringing, self-examination and previous suffering of traumas were among the factors that the participants felt had positive effects on their journey. On the other hand, they felt that uncertainty, self-prejudice, co-dependency and financial worries were strong negative factors that delayed their journey towards post-traumatic growth.
Professionals and 'the system'. Eleven participants had used professional help and felt that it had helped them very much. The participants sought advice and assistance of various kinds, e.g. from psychologists, trade unions, family counsellors, health professionals, social services, alternative medicine, lawyers and most participants were satisfied with these services. However, they often found information and guidance on possible next steps unsatisfactory and felt that the various systems pointed at each other. As a result, the participants sometimes experienced complete confusion, which had a negative effect on their mental and physical well-being and recovery process. So, these services had various effects on their well-being, either in a positive or negative way.
Six participants considered it necessary to make changes to many existing 'systems' in society to better care for people suffering from psychological trauma.
When people suffer trauma [it is important] that there is someone there for you within the health care system who will take you by the hand and guide you for the first week or two, to get you started. Someone who calls just to follow up on this. I think it is crucial for people who suffer traumas … There is also a need for flexibility in the labour market for people who experience such a situation (John).
Nine participants found it difficult to pursue their rights and find ways to respond to the challenging situation in which they found themselves as Ivor explained: 'The only answer I got was "you have no rights here"'.
Rehabilitation. Specialised rehabilitation measures were very important to those participants who utilised them. Participants emphasised the importance of early intervention and long-term management and support. Most participants received their rehabilitation from vocational rehabilitation services. How they got in touch with those services differed greatly as did the time that elapsed from their trauma until they got to know the rehabilitation services, which was from a few months up to seven years. The participants were satisfied in general with the services and the consultants' work and described the service as a at the time (Ivor) She said she was going to ruin me completely… just leave me in a ditch… to get even (Gregor) It was incredibly refreshing… to meet a man who found me pretty and fun and wanted to be with me because I was me.

Quotes of participants
Employer and co-workers Participants had mixed feelings towards different reactions of employers and co-workers. None of them felt significant support from their co-workers and some experienced people dividing into groups either for them or against them Five participants reported a total lack of care, rejection and negative reaction of their co-workers, which had very bad influence on their wellbeing It was a bit difficult to come to work again and experience a bit of two camps. Those who… suddenly looked at me as a seriously ill patient and didn't respected me anymore and the others who just supported me and were happy for me and just "cool!". It was only in my workplace where I experienced this dichotomy (Karen) I could hardly join meal times because of pain and no one cared, no one brought me food or anything… there was a man at the workplace who had cancer… he gave me some of his pain killers… there were no medicine or anything there… (Liam)

Further traumas
All participants experienced further trauma in their recovery process and journey towards PTG. The traumatic events were most often related to poor financial state due to the previous trauma. It was the arrangement from the hospital… that kept me going… and I remember they also said "now you're just not well", when the downslide came, and "now you just go to bed and pull the quilt up over your head if you need to and after a while it's over".

Education
Five participants went to school/continued their education following their trauma, which promoted their personal and social courage and encouraged them to think outside the box It was incredibly refreshing to walk into a completely different world, to take on new tasks, meet people on your own terms, learn something new, and meet such a wonderful attitude and demeanor (Maria)

Labour market
The Rehabilitation Services supported their people in going back to work. Only two participants went back to their previous jobs; one of those had problems with the company in going back to her job Six participants experienced a lack of cooperation and flexibility in the labor market when they wanted to go back to work All participants reported that being able to work was a very important factor in their recovery process and journey towards PTG The labour market needs to be more flexible towards people recovering from trauma… when you move from 100% working capacity to 100% working incapacity… and then suddenly at one point you are expected to go out there and work a full time job… when some paper [certificate of illness] expires (John) There was everywhere the same answer, "no, you are not suitable because you have too much medical history".. that is when you got some answers. Sometimes you did not even get an answer!… It was awful not even getting an answer! (Ellis) To go to work… to be a part of society, a part of life in general… to experience humor, just talking to people about something without it being non-stop about illness and that something is wrong… just talking to people who are working, just about everyday issues, the weather… it lifted me to another level (Florence)

T A B L E 4 (Continued)
positive turning point in their recovery process and journey to post-traumatic growth. They underlined the individual's own will and positivity as the key to success in rehabilitation.
It is meaningless to go in there just to pretend to take part in this … and you must take part with a positive mindset (Liam).
Five participants started or continued their studies and found this to have a constructive effect on their lives.
The rehabilitation services supported people in going back to work. Only two participants went back to their previous jobs; one of those had problems with the company in going back to her job. Employment, however, was very important to the participants and had a constructive effect on their lives but six participants reported hindrances when entering the labour market after their recovery.

The journey towards posttraumatic growth
All participants said that post-traumatic growth had taken place due to their own internal need for change. Each one defined their starting point and where they wanted to go. Then and not before, post-traumatic growth could begin. For many, it was the children and/or immediate family that made them realise the need for change.
I treated my daughter so badly one time … she stopped talking to me … and in losing her, my bottom was reached … Then I started trying to fix things (Liam).
The need for change in life emerged in different ways, for example after seeing a therapist or with the help of a relative or friend or even through studying. For others, it was an internal factor and ambition that became the trigger for change towards post-traumatic growth.
All participants expressed their views on the preconditions for achieving post-traumatic growth and the usefulness of external factors such as external assistance, management and follow-up. However, in general, the participants felt that their personal qualities were most important in that matter.
Look, I was completely broken down, lying completely flat on the ground and I just allowed myself to lie there. The thing is that sometimes you must lie down. After a certain time, you lift your head, you sit up and look around for a while, and then maybe you lie down again, to get a little more energy. When you are ready you sit up, sit for a while to get your bearings before you get up and move on in your life again. No one can tell you to recover and you just recover. You have to feel the desire yourself and the purpose (Maria).

Post-traumatic growth
Participants all described their post-traumatic growth: how they confront their own feelings more freely, have deeper relations to others, experience personal growth, live more wholesome lives, know themselves better and have a stronger self-image. Participants described numerous other positive outcomes of their post-traumatic growth. Some had found their vision, the process being their own resurrection. They reported increased social activity, positivity, patience, being more appreciative of themselves and felt like winners in life. They discussed their feelings of economical safety, less stress, freedom, power, and energy. They said they were in love or ready to look for love, consciously nourishing their strength and did not experience any regrets. An overview of their experience is found in Table 5, and the resulting new definition of post-traumatic growth from the participants' perspective is found in Table 6.

Epilogue: Optimism coupled with heavy days
All the participants said that they were in a good place and that they were optimistic about the future, despite various uncertainties, and intended to continue working on their post-traumatic growth. Eight participants wanted to share their experiences, which was the reason for their participation in the study, and five of them had already done so. Despite their experience of post-traumatic growth, participants talked about negative long-term effects of their trauma, such as 'heavy days', impaired work capacity, inner insecurity and other negative outcomes (see Table 7).
Despite the great difficulties they encountered, the participants agreed that the positive factors that accompanied this life experience, the post-traumatic growth, outweighed the negative factors when they arose. Beatrix explained: 'I say it and I mean it, you know I'm the luckiest woman in the whole world… because I've been through these traumas which make me the woman I am today'.

DISCUSSION
This study introduces a unique mapping of the challenging journey from trauma to post-traumatic growth through lived experiences of people who have experienced trauma as well as post-traumatic growth. One of the important findings of the study is that according to the participants, post-traumatic growth is more like a journey than a destination and there are many influencing factors on that journey, both facilitating and hindering ones. The journey included a recovery process and had a prologue, most typically the participants' negative experiences in childhood e.g., poor home conditions and bad parenting methods. The trauma revolutionised their lives. The consequences of the traumas were serious, and they felt close to losing their physical and mental health. Yet they were thankful for this challenging life experience and described their post-traumatic growth as a valuable outcome of their suffering. They all described how this life experience had shaped them as persons and influenced their view of life in a positive way even if they still had to deal with 'heavy days'. A new theoretical definition of posttraumatic growth, from the participants' perspective, was constructed from the findings, which is a further contribution to the literature. The factors that had not been previously identified following a trauma and could therefore be culturally significant for this population is that many participants felt that difficulties in childhood were a good preparation for the traumas they later suffered. This would be worth investigating further. Notably, several participants described how the snowball effect of previous traumas made them almost lose their footing in life.
The participants unanimously agreed that social support positively affected their journey while lacking support had negative effects. This is in line with other research findings [6,15,40]. Most of the participants experienced support from friends. However, male participants experienced mixed reactions from friends. Women are known to be more likely than men to respond to traumas with social and nurturing behaviour i.e., tend and befriend, and systematically seek support [30,41]. This may explain this gender difference to some extent but is worth studying further.
Being able to work and having a job had constructive effects on the participants' lives. However, some of them experienced lack of both willingness and flexibility on behalf of the labour market when it came to going back to work, as reported in other studies [42][43].
Many of the participants said that they were not in a condition to seek their rights and find out what options were available to them after the trauma, which made them even more vulnerable. A qualitative study on the experience of individuals dealing with reduced working T A B L E 7 Participants' negative long-term effects of trauma in spite of post-traumatic growth

Themes
Description of the theme Quotes of participants Heavy days Seven participants described their "heavy days" where they still experience difficult feelings, even years after their trauma. They are conscious of those days and have developed their own personal resources to deal with them. Some participants were still using some medication due to their mental distress following the trauma I have my "days" in between where I can't stand other people and I just want to turn everything off, but that's just normal you know… it's not like I'm cured in one day… (Florence) I still experience heavy days in between, I don't know if I will get rid of them someday or if they are here to stay but during those days I just let myself be… I know these days will come but I also know that they will pass (Maria) You always fall into a loop [of insecurity] every now and then… but then you just have to know that somewhere there behind, you can spot your strength not only your weakness… you gradually learn to know the symptoms and you stop trying what you have tried multiple times and hasn't worked for you (Ellis) Impaired capacity to work Six participants had impaired physical and/ or mental work capacity as a result of their trauma. This fact caused them anxiety and uncertainty about the future These days I have self-confidence in studying but before I was very confident at the labour market. Now it's time to head to the labour market again… and my physical condition is not so good… how will that end? I've started to worry about that now (Igor) Inner insecurity Six participants described their continuing insecurity following their trauma. This fact worried them and made them feel distressed over certain things in their lives Now I doubt myself much more than I did before… If I take on a job I often doubt that I can complete it and when I complete the job I doubt that my work is good enough… there is some kind of punk in the back of my head that doesn't want to leave me alone… I guess this is my shame or my self-blame… (John) capacity and their communication with professionals during that period showed that advice and support from caring, professional and humane professionals is valuable [43]. It is important that all professionals, e.g. in the social-and healthcare systems, respond to the traumas of their clients through early diagnosis and intervention, as well as support, care and follow-up. The participants experienced that they had the willpower and courage needed to reach post-traumatic growth. It must be borne in mind that only people who had reported post-traumatic growth were included in the study. It is potentially worthwhile to investigate willpower and courage further among people suffering trauma and even find ways to help them develop these important characteristics.
Participants described improved communication and emotional connection with their loved ones, positive change in self-image and positive changes in worldview as part of post-traumatic growth. These descriptions are consistent with Calhoun's and Tedeschi [32] descriptions of the three main factors of post-traumatic growth.
Many of the participants spoke of the need to make changes to the 'system' so that it becomes more flexible and individualized, thus contributing to the person's recovery and post-traumatic growth. These research findings support the ideas of other studies on how the structure of the system can affect recovery and post-traumatic growth [44][45][46].

Limitations of the study and future studies
The results of this study describe the influencing factors on the journey to post-traumatic growth. This information can be useful when treating and supporting people who have suffered traumas. The results are based on 12 participants' accounts of their suffering of trauma and the experience of post-traumatic growth. Most participants had attended vocational rehabilitation services, and therefore the sample selection may involve a bias in that regard. Moreover, the participants' willingness, and ability to express themselves about their experience of trauma and post-traumatic growth may have influenced the results since many were describing their experience for the first time. It could also be a limitation that participation in this study was based on self-reported post-traumatic growth. The psychological traumas that participants had suffered were of various kinds which can be a limitation to this research. Therefore, it would be useful to do further research on post-traumatic growth among groups of people with defined trauma suffering, such as among women who have survived intimate partner violence.