Israel Journal of Psychiatry and Related Sciences

israel journal of

psychiatry

Vol. 50 - Number 2 2013

ISSN: 0333-7308

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Editorial: Psychiatry and Conflict Avi Bleich et al.

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The Utility of Criterion a Under Chronic National Terror Moshe Bensimon et al.

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Elaboration on Posttraumatic Stress Disorder Diagnostic Criteria: A Factor Analytic Study of PTSD Exposure to War or Terror Moshe Bensimon et al.

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PTSD, Resilience and Posttraumatic Growth Among Ex-Prisoners of War and Combat Veterans Gadi Zerach et al.

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A Longitudinal Study of Changes In Psychological Responses to Continuous Terrorism Marc Gelkopf et al.

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Sense of Coherence and Sense of Community as Coping Resources of Religious Adolescents Before and After the Disengagement from the Gaza Strip Orna Braun-Lewensohn et al.

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Trauma and Psychological Distress Observed in Journalists: A Comparison of Israeli Journalists and their Western Counterparts Yael Levaot et al.

Psychiatry and Conflict: Part 1

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Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist Rael D. Strous

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On the Links between Religion, Mental Health and Inter-religious Conflict: A Brief Summary of Empirical Research Hisham Abu-Raiya

israel journal of

psychiatry and related sciences EDitor

Psychiatry and Conflict: Part 1

DEPUTY EDITORS

78 > Editorial: Psychiatry

David Greenberg David Roe Rael Strous Gil Zalsman

Sense of Community as Coping Resources of Religious Adolescents Before and After the Disengagement from the Gaza Strip

and Conflict

Avi Bleich, Zahava Solomon and Mark Gelkopf

Yoram Barak

81 > The Utility of Criterion a Under Chronic National Terror

PAst Editor

Moshe Bensimon, Zahava Solomon, and Danny Horesh

Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Omer Bonne Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Zvi Zemishlany International Advisory Board

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Phyllis Palgi Robert Wallerstein Myrna Weissman Associate editor

Rena Kurs Assistant Editor

Joan Hooper

Marketing: MediaFarm Group

+972-77-3219970 23 Zamenhoff st.

Tel Aviv 64373, Israel

amir@mediafarm.co.il www.mediafarm.co.il

84 > Elaboration on Posttraumatic Stress Disorder Diagnostic Criteria: A Factor Analytic Study of PTSD Exposure to War or Terror Moshe Bensimon, Stephen Zvi Levine, Gadi Zerach, Einat Stein, Vlad Svetlicky and Zahava Solomon

91 > PTSD, Resilience and

Posttraumatic Growth Among ExPrisoners of War and Combat Veterans Gadi Zerach, Zahava Solomon, Assaf Cohen and Tsachi Ein-Dor

100 > A Longitudinal Study of

Changes In Psychological Responses to Continuous Terrorism Marc Gelkopf, Zahava Solomon and Avraham Bleich

Vol. 50 - Number 2 2013

110 > Sense of Coherence and

Book reviews editor

Eli L. Edelstein

The Official Publication of the Israel Psychiatric Association

Orna Braun-Lewensohn, Shifra Sagy, Hagit Sabato and Rinat Galili

118 > Trauma and Psychological Distress Observed in Journalists: A Comparison of Israeli Journalists and their Western Counterparts Yael Levaot, Mark Sinyor and Anthony Feinstein

122 > Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist Rael D. Strous

130 > On the Links between

Religion, Mental Health and Inter-religious Conflict: A Brief Summary of Empirical Research

Hisham Abu-Raiya, PhD

140 > Book reviews Yoram Barak Hebrew Section

144 > Abstracts

A community art exhibit Lev Hasharon Mental Health Center “The right to a window of hope and healing,” inspired by the art of Hundertwasser Friedensreich (1928-2000), an Austrian-Jewish painter, sculptor and architect, known for his community and environmental activism. The crowd-sourced art exhibit was created by patients, volunteers and staff who worked individually and in groups under the guidance of community artists Anat and Yuti Shammai, with the support of the association of friends of Lev-Hasharon, “Yedid belev vanefesh” (literally, Friends in heart and soul).

The 20 square meter mosaic exhibit greets those who enter the hospital grounds.

Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Editorial: Psychiatry and Conflict The ongoing Israeli Palestinian conflict has taken many forms and has entailed numerous traumatic experiences, including seven full fledged wars, two Palestinian uprisings (Intifada), numerous terrorists attacks and border skirmishes and disengagement or forced relocations of Israeli citizens.

These various traumatic facets of the conflict encompass diverse threats, hardships and challenges that affect both Israelis and Palestinians. The articles that comprise these two special issues of the IJP aim to cast light on some of the psychiatric effects of this ongoing intractable political conflict.

PTSD is conceptually related to traumatic stress, such as during armed conflicts, and is the most prevalent disorder in this context. Diagnostic criteria set by international classification manuals (DSM; ICD) are conceived to be universal and generic. As such, diagnostic criteria for PTSD should be applicable and useful across diverse types of trauma, populations and culture.

Clinicians and researchers have, however, repeatedly questioned the validity and generalizability of PTSD diagnostic criteria. Two of the papers in this issue examine two aspects related to the applicability of DSM-iv criteria for PTSD in Israelis. Bensimon et al. (1) assessed the utility of Criterion A under chronic national terror.

They concluded their thought provoking paper stating that the DSM and the ICD appear to be largely products of North American and European societies and, therefore, may be culturally-biased. Their review raises the question of whether the proposed DSM-5 changes to Criterion A are congruent with the reality of nations, such as Israel, where exposure to terror is persistent, constant and of national proportions. In a related paper Bensimon et al. (2) examined the validity of the PTSD symptom clusters in elements of Israeli society exposed to man-made trauma: 2,198 survivors of seven different war and terror-related traumas were assessed using a DSM-IV-TR based PTSD inventory. Four confirmatory factor analytic models were compared. The most acceptable model was a correlated model consisting of four factors of re-experiencing, avoidance, emotional numbing, and hyperarousal. DSM-IV-TR avoidance empirically split into active avoidance and emotional numbing. These results suggest that in Israel, where stressors are ongoing, the PTSD symptom clusters may be reformulated in 78

DSM-5 to consist of re-experiencing, active avoidance, emotional numbing and hyperarousal.

Zerach et al. (3) expand the spectrum of psychological responses to war trauma. Adopting a salutogenic perspective they aim to clarify the relations between posttraumatic stress symptoms (PTSS), resilience and posttraumatic growth (PTG) among Israeli exPOWs and war veterans of the 1973 Yom Kippur War. Interestingly, their findings show that resilience, defined as the absence of posttraumatic symptoms, and PTG are negatively correlated. Resilient ex-POWs and veterans reported the lowest levels of PTG when compared to participants diagnosed with clinical and sub-clinical posttraumatic stress disorder (PTSD). Furthermore, PTG dimensions were found to be the most differentiating factor between study groups, followed by war exposure measures and clinical reports of depression and anxiety symptoms. The authors concluded that their findings strengthen the understanding that combatants who report high-level PTSD symptoms also report higher levels of positive psychological changes in the face of severe adversity.

Life in Israel during the second Intifada actually meant living under continuous traumatic stress. Gelkopf et al.

(4) assess the impact of living under repeated and unrelenting ongoing terror. Specifically, prevalence and trajectories of posttraumatic symptoms were prospectively assessed in Israeli civilian adults. The study uncovers various and multifaceted responses to terror. While in some cases distress increases with time, some individuals initially appear to be resilient only to have symptoms emerge as time goes on. In other cases initial posttraumatic distress abates with time. The authors concluded that while continuous exposure to terror has a negative impact on mental health, a large proportion of individuals with elevated levels of posttraumatic symptomatology recover over time and that prolonged exposure to terror has a triggering rather than formative effect.

The traumatic experience of uprooting Jewish settlers from their homes near Gaza (2005) is still a controversial issue and bleeding wound in Israeli society. BraunLewensohn et al. (5) assessed the effects of the disengagement or forced relocation of Israeli settlers from the Gaza Strip. The disengagement or uprooting was perceived by the settlers as brutal uprooting, dismembering and disin-

Avi Bleich et al.

tegration of their communities. Moreover, they helplessly watched the destruction of their homes by their own people. The article describes the subjective experience, perceptions and meaning making of the uprooted settlers via the salutogenic approach. The authors explore the role of individual and community resources – sense of coherence and sense of community – among adolescents who were displaced in the disengagement. This longitudinal study points at the complexity of psychological responses.

While anxiety was reduced (over a five year follow-up), anger, on the other hand, did not abate with time. A sense of betrayal by the state, and sense of severe injustice account, according to the authors, for these outcomes.

An increased coverage of armed conflicts by the media is sometimes related to pathogenic exposure of the public, but what about the reporting journalists themselves?

Levaot et al. (6) compared Israeli journalists to Western war journalists on various psychological and behavioral parameters. Both groups reported similarly high exposure to traumatic incidents but they differed in their reactions, with more posttraumatic intrusion symptoms and alcohol consumption by the Western journalists, and higher levels of depression, anxiety and somatic distress by the Israelis. Discussion of the findings refers to the possible role of cultural, social, and circumstantial factors on the mode of reaction. For example, reporting from your own home land/community may be related to a greater sense of belonging and social support but at the same time to increased anxiety and worries about your dear ones.

Strous (7) describes the specific role of the psychiatrist in relation to his “social contract” with society, and to his professional competence to influence conflicts and crises management specifically by treating mental casualties and ameliorating mental distress. At the same time Strous underscores the ethical difficulties and failures during times of conflict, including disruption of boundaries between the psychiatrist’s professional identity (and commitment) and his civilian one, specifically in relation to “double loyalty” issues. In this context Strous points out that psychiatrists are often recruited, used and even exploited to serve one side against the other. Their professional knowledge and skills are at times viciously used to control, manipulate and punish, thus violating basic medical ethical principles. Strous presents his view of the psychiatrist role during armed conflicts advocating strict adherence to the professional ethical code.

In his scholarly article, Abu-Raiya (8) critically reviewed the empirical data concerning the influence of religion on people’s well-being, demonstrating a dual effect. On one

hand religious beliefs and practices were found to positively affect health and well-being, and to help the individual to deal with life stressors. On the other hand, religion may be a source of personal strain and inter-religious conflict, and this duality is discussed with reference to religious variables that promote or mitigate prejudice and perceived conflict with others. The crucial involvement of religion in conflicts all around the globe underscores the challenge to further study these issues.

The issue of POWs is a very sensitive one, including the health trajectories of their traumatic experiences.

Zerach and Solomon (9) assess complex PTSD in Israeli ex-POWs who were held captive by the Egyptians and the Syrians during the Yom Kippur war. War captivity is one the most brutal of man-made trauma and often comes at the heels of fierce combat. This assesses the complex and multifaceted psychiatric outcome of war captivity focusing on Disorder of Extreme Stress not otherwise Specified (DESNOS) also known as complex PTSD. War captivity has been an inevitable part of almost all Israeli wars yet the plight of ex-POWs in Israel was only recognized many years after their repatriation.

Importantly, even to date Complex PTSD in Israeli exPOWs is still not formally acknowledged.

Children deserve increased attention in the context of armed conflicts and traumatic stress. Shechory (10) studied 152 dyads of mothers and their children, who were exposed to continuous terror incidents near the Gaza strip and found that the mothers’ posttraumatic symptoms significantly influenced their children’s posttraumatic symptoms, as well as their current behavioral and social problems. Thus a mother- child dyad may be an important object for studying and probably modifying the adverse reactions to continuous traumatic stress.

Wolmer et al. (11) studied posttraumatic reactions of Israeli Jewish and Arab children who were exposed to rocket attacks during the 2006 Lebanon war, and the therapeutic effect of a 16-weeks intervention program delivered by teachers and focusing on resilience enhancement. The encouraging findings showed that the intervention diminished the adverse reactions significantly and similarly for all the subjects, an effect which may also be related to the intervention’s effectiveness to moderate vulnerabilities of ethnic minorities.

A unique point of view on the effects of the conflict on mental health is presented by Haber et al. (12). This article examines compassion, fatigue, burn out and psychiatric symptoms in Israeli physicians who work in a shared traumatic reality with their patients, increasing their risk 79

Editorial: Psychiatry and Conflict

for secondary traumatization. Another related study by Ben-Ezra et al. (13) focuses on hospital nurses who were exposed to rocket firing during the Gaza war (2009), and showed an increased level of traumatic stress symptomatology as well as a remarkable ability to recover in terms of distress and functioning.

Concluding remarks from a personal perspective: The personal and professional experience of the editors, who served as mental health professionals in both military and civilian positions, including during times of war, explored and were sometimes confronted with ethical and moral conflicts. Conflicts arise which may be related to issues of boundaries of the profession; ambiguity between the interests of the patient and those of the “organization”; and the interaction between the professional and the political. A few representative examples may be: denial and avoidance of the issues of combat stress reaction during the first decades of the young State of Israel, which may be related to a strong social ethos that overruled professional knowledge (14); claiming mental disability due to a psychological break in battle, for which the casualty needs to confront the army which sent him to war as its “dear son” (15); and the difficulty and complexity in dealing professionally with politically related issues, such as the psychological toll of the occupation (16), or the mental health impact of terrorism on Israeli Arabs and Jews (17). Recognizing the importance of the subject initiated in this special issue, we hope it will prompt on going discussion of the professional and moral dilemmas of those who choose the helping professions.

References 1. Bensimon M, Solomon Z, Horesh D. The utility of Criterion A under chronic national terror. Isr J Psychiatry 2013;50:81-83.

2. Bensimon M, Levine SZ, Zerach G, Stein E, Svetlicky V, Solomon Z. Elaboration on posttraumatic stress disorder diagnostic criteria: A factor analytic study of PTSD exposure. Isr J Psychiatry 2013;50:84-90.

3. Zerach G, Solomon Z, Cohen A, Ein-Dor T. PTSD, resilience and posttraumatic growth, among ex-prisoners of war and combat veterans.

Isr J Psychiatry 2013;50:91-99.

4. Gelkopf M, Solomon Z, Bleich A. A longitudinal study of changes in psychological responses to continuous terrorism. Isr J Psychiatry 2013;50:100-109.

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5. Braun-Lewensohn O, Sagy S, Sabato H, Galili R. Sense of coherence and sense of community as coping resources of religious adolescents before and after the disengagement from the Gaza Strip. Isr J Psychiatry 2013;50:110-117.

6. Levaot Y, Sinyor M, Feinstein A. Trauma and psychological distress observed in journalists: A comparison of Israeli journalists and their western counterparts. Isr J Psychiatry 2013;50:118-121.

7. Strous RD. Ethical considerations during times of conflict: Challenges and pitfalls for the psychiatrist. Isr J Psychiatry 2013;50:122-129.

8. Abu-Raiya H. On the links between religion, mental health and inter-religious conflict: A brief summary of empirical research. Isr J Psychiatry 2013;50:130-139.

9. Zerach G, Solomon Z. The relations between posttraumatic stress disorder symptoms and disorder of extreme stress (not otherwise specified) symptoms following war captivity. Isr J Psychiatry 2013;50 (in press).

10. Shechory M. The impact of repetitive and chronic exposure to terror attacks on Israeli mothers’ and children’s functioning. Isr J Psychiatry 2013;50 (in press).

11. Wolmer L, Hamiel D, Slone M, Faians M, Picker M, Adiv T, Laor N. Post-traumatic reaction of Israeli Jewish and Arab children exposed to rocket attacks before and after teacher-delivered intervention. Isr J Psychiatry 2013;50 (in press).

12. Haber Y, Palgi Y, Hamama-Raz Y, Shrira A, Ben-Ezra. Predictors of professional quality of life among physicians in a conflict setting: The role of risk and protective factors. Isr J Psychiatry 2013;50 (in press).

13. Ben-Ezra M, Palgi Y, Shrira A, Hamama-Raz Y. Somatization and psychiatric symptoms among hospital nurses exposed to war stressors.

Isr J Psychiatry 2013;50 (in press).

14. Bleich A. Military psychiatry in Israel: Historical review and guiding principles. Isr J Psychiatry 1992; 29:203-217.

15. Bleich A, Solomon Z. Psychiatric evaluation of mental disability in PTSD casualties of military origin. Isr J Psychiatry 2004; 41: 268-276.

16. Bleich A, Gelkopf M, Berger R, Solomon Z. The psychological toll of the intifada: Symptoms of distress and coping in Israeli soldiers. Isr Med Assoc J 2008; 10:873-879.

17. Gelkopf M, Solomon Z, Berger R, Bleich A. The mental health impact of terrorism in Israel: A repeat cross-sectional study of Arabs and Jews.

Acta Psychiatr Scand 2008; 117:369-380.

Prof. Avi Bleich Lev-HaSharon Mental Health Center and Sackler Faculty of Medicine, Tel Aviv University bleich@post.tau.ac.il

Prof. Zahava Solomon

Shappell School of Social Work, Tel Aviv University

Prof. Marc Gelkopf

Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, Haifa University

Guest editors

Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Moshe Bensimon et al.

The Utility of Criterion a Under Chronic National Terror Moshe Bensimon, PhD,¹ Zahava Solomon, PhD,² and Danny Horesh, PhD³ 1

The Department of Criminology, Bar-Ilan University, Ramat Gan, Israel The Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel 3 School of Behavioral Sciences, Peres Academic Center, Rehovot, Israel 2

Abstract According to DSM-IV-TR, both an objective and a subjective exposure component (A1 and A2 criteria, respectively) are required in order to qualify for a Posttraumatic Stress Disorder (PTSD) diagnosis. One proposed DSM-5 change is that Criterion A be more explicitly defined and made purely objective. The DSM and the ICD appear to be largely products of the North American and European societies and, therefore, may be culturally-biased. Compared with other societies, the latter are not exposed to chronic national traumatic stress. Therefore, the current structure of Criterion A may be especially relevant to single traumatic incidents, rather than to chronic national scale. The current review raises the question of whether the proposed DSM-5 changes to Criterion A are congruent with the reality of nations where exposure to terror is persistent, constant and of national proportions.

The diagnosis of Posttraumatic Stress Disorder (PTSD) requires the occurrence of a traumatic event. According to DSM-IV-TR (1), in order to qualify for a PTSD diagnosis one must fulfill an objective A1 criterion (experiencing, witnessing or confronting an event or events that entail actual or threatened death or serious injury, or a threat to the physical integrity of self or others) and a subjective A2 component (responding in the immediate wake of the event/s with intense fear, helplessness, or horror). While DSM-IV-TR criteria include one’s subjective response to the stressor (A2), the tenth revision of the International Classification of Diseases (2) includes only objective expoAddress for Correspondence: bensimm@biu.ac.il

sure to the stressor. One of the suggested revisions for the upcoming DSM-5 (3) is to dispose of the more subjective A2 criterion while exclusively relying on the objective A1 criterion to determine whether or not an event was traumatic. The utility of these proposed changes in diagnosing PTSD under circumstances of chronic traumatic exposure is questioned and discussed in this paper.

Research has traditionally shown a “dose-response” effect, in which the level of objective exposure to traumatic events (A1) is positively associated with the severity of PTSD symptoms. This effect is well-documented in the trauma literature, and has been demonstrated among various populations (4-8), including victims of terror attacks (9-11). Studies have also shown a positive correlation between chronic traumatic exposure and the development of posttraumatic symptoms (PTS) among various samples, such as sexually abused children (12), combat veterans (e.g., 13) and victims of domestic violence (e.g., 14). In what follows, we wish to examine the relevance of the dose-response effect in the face of a specific type of chronic stressor, i.e., persisting terror attacks. For that purpose, we shall use terror in Israel as a case study.

Due to its long-standing political and security situation, Israel has become a “stress laboratory” for the study of war- and terror-related stress. The Israeli population has been exposed to chronic terror attacks during the Palestinian Al-Aqsa Intifada (uprising) between 2000-2006. According to the 2006 Israel Defense Forces statistics (15), during that period Israelis were exposed to over 13,000 terrorist attacks, including shootings and suicide bomb attacks on buses and in markets, shops, and discotheques. During that period, approximately 0.1% of the population was injured (physically and/or mentally) or killed. Attacks were carried out in major cities such as Tel Aviv, Jerusalem and Haifa, as well as

Moshe Bensimon, PhD, Department of Criminology, Bar-Ilan University, 52900 Ramat Gan, Israel.

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The Utility of Criterion a Under Chronic National Terror

in rural areas. Civilians in the settlements and cities of the West Bank and in the Gush Katif Settlements in the Gaza Strip were also exposed to daily threats of snipers, grenades, mortar and missile attacks, and roadside bombs (16). In other words, no place was safe. Since the attacks encompassed most of Israel’s area, they may be regarded as a national phenomenon.

Despite the aforementioned research showing a correlation between the level of exposure to chronic traumatic events and PTS in various populations, examination of the Israeli population’s response to chronic terror attacks during the Al-Aqsa Intifada fails to support these findings.

This was found among a wide variety of populations. In a study of adult suburban residents, no relationship was found between levels of objective exposure to terror and rates of PTSD, despite the fact that one group’s exposure to terror attacks was three times higher compared to the other (17, 18). Another study, examining students from Tel Aviv University and students from a higher exposure sample – the College of Judea and Samaria in the West Bank, found no relationship between objective exposure and trauma symptoms for either group (19). Finally, a study of an Israeli national representative sample during the Al-Aqsa Intifada showed no association between level of objective exposure and PTS among adult Israeli residents (20).

These results may be attributed to the fact that in the Israeli reality, terror attacks were so frequent and widespread that exposure to terror failed to differentiate between those with/without posttraumatic residues. Thus, in contrast to other chronic stressors, exposure to chronic terror attacks did not contribute to the prediction of PTSD. When exposure levels are high across the board, their predictive power dramatically declines. Breznitz and Eshel (21) suggested that due to the high baseline of pressures and stressors, most of the Israeli population may in fact experience habituation in the face of repeated exposure. When the threat of terror becomes the norm rather than the exception, it is as if “figure and ground” converge. Under these circumstances, specific stressful experiences fail to stand out from the pack, thereby losing their unique predictive strength. A related explanation seems to be that among populations regularly exposed to stress, the dose-response association between exposure and symptoms may be limited by a “ceiling effect.” Thus, it is possible that while a positive correlation does in fact exist between stress exposure and posttraumatic symptoms up to a certain point, this correlation gradually weakens as additional stressors fail to significantly contribute to individuals’ reactions beyond a certain stress “ceiling.” Such ceiling effects were previously reported among populations 82

exposed to the threat of terror attacks (e.g., 22). It thus may be inferred that whereas Criterion A1 may well be associated with PTS following exposure of some chronic stressors, this is not the case when chronic terror attacks are national and persistent over time. Thus, it can be argued that in such cases Criterion A1, as the objective part of Criterion A, may not be as relevant to the diagnosis of PTSD as it is in single traumatic events. What may prove to be more crucial under chronic exposure to stress is one’s subjective emotional response to the event, as currently assessed by the A2 criterion. This notion receives support from studies showing that non-Criterion A chronic events, such as caring for a chronically ill loved one (23) or chronic bullying (24), may bring about a variety of posttraumatic reactions.

The importance of understanding stressful events in their social context has been emphasized in recent years (25). The DSM and the ICD both appear to be largely products of North American and European societies.

Therefore, the definition of PTSD may well have been influenced by western culture standards, which fail to take into account the occurrence of persistent terror attacks. This notion is in line with Young’s (26) argument that PTSD, as we now know it, does not possess an intrinsic unity.

Instead, it is a product of the scientific practices by which it is studied and diagnosed. As Young claims, this does not mean that PTSD is not a real disorder which causes real suffering, but rather that it is continually constructed and conceptualized in ways that shape our knowledge about it. DSM is a document that, while relying heavily on scientific knowledge, is still influenced by the social and cultural environments in which it is constructed.

Therefore, it is an evolving text, constantly changing its definitions and criteria.

The current review raised the question of whether the proposed changes to Criterion A are congruent with the reality experienced in nations where exposure to terror is chronic and on a national scale. Obviously, this reality exists not only in Israel, but also in other parts of the world, such as Afghanistan and Iraq. We argue that for these areas of the world, Criterion A1 may be of less importance than Criterion A2. With terror now becoming a worldwide problem, we highly recommend that this issue be further studied and discussed in light of the proposed DSM-5 revisions.

References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

Moshe Bensimon et al.

2. World Health Organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, 1993.

3. American Psychiatric Association. DSM-5 development (www.dsm5.org).

4. McCarroll, JE, Ursano RJ, Fullerton CS, Lundy A. Anticipatory stress of handling human remains from the Persian Gulf War: Predictors of intrusion and avoidance. J Nerv Ment Dis 1996;183:698−703.

5. Mollica RF, Poole C, Son L, Murray CC, Tor S. Effects of war trauma on Cambodian refugee adolescents’ functional health and mental health status. J Child Adolesc Psychiatry 1997;36:1098–1106.

6. Weiss DS, Marmar CR, Metzler TJ, Ronfeldt HM. Predicting symptomatic distress in emergency services personnel. J Consult Clin Psychology 1995;63:361–368.

7. Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall R. The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science 2006;313:979–982.

8. Henriksen CA, Bolton JM, Sareen J. The psychological impact of terrorist attacks: Examining a dose-response relationship between exposure to 9/11 and Axis I mental disorders. Depress Anxiety 2010;27:993–1000.

9. Galea S, Ahern J, Resnick H, Kilpatric, D, Bucuvalas M, Gold J, Vlahov D. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002;346:982–987.

10. North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, Smith EM. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999;282:755–762.

11. Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, Thalji L, Dennis JM, Fairbank JA, Kulka RA. Psychological reactions to terrorist attacks: findings from the national study of Americans’ reactions to September 11. JAMA 2002;288:581–588.

12. Wolfe DA, Sas L, Wekerle C. Factors associated with the development of posttraumatic stress disorder among child victims of sexual abuse.

Child Abuse Neglect 1994;18:37-50.

13. Bramsen I, Dirkzwager AJE, van der Ploeg HM. Predeployment personality traits and exposure to trauma as predictors of posttraumatic stress symptoms: A prospective study of former peacekeepers. Am J Psychiatry 2000;157:1115-1119.

14. Dutton MA, Painter S. Emotional attachments in abusive relationships: A test of traumatic bonding theory. Violence Vict 1993;8:105-120.

15. Israel Defense Force Statistics. Casualties since 9/29/2000 (in Hebrew).

16. Kaplan Z, Matar MA, Kamin R, Sadan T, Cohen H. Stress-related responses after 3 years of exposure to terror in Israel: Are ideological-religious factors associated with resilience? J Clin Psychiatry 2005;66:1146-1154.

17. Shalev AY, Tuval R, Frenkiel-Fishman S, Hadar H, Eth S. Psychological responses to continuous terror: A study of two communities in Israel.

Am J Psychiatry 2006;163:667-673.

18. Shalev AY, Tuval-Mashiach R, Hadar H. Posttraumatic stress disorder as a result of mass trauma. J Clin Psychiatry 2004;65:4-10.

19. Rosenberg A, Heimberg RG, Solomon Z, Levin L. Investigation of exposure–symptom relationships in a context of recurrent violence. J Anxiety Disord 2008;22:416-428.

20. Bleich A, Gelkopf M, Melamed Y, Solomon Z. Mental health and resiliency following 44 months of terrorism: A survey of an Israeli national representative sample. BMC Medicine 2006;4:21.

21. Breznitz S, Eshel Y. Life events: Stressful ordeal or valuable experiences?

In: Breznitz S editor Stress in Israel. New York: Van Nostrand Reihhold, 1983: pp. 228-261.

22. Mullett-Hume E, Anshel D, Guevara V, Cloitre M. Cumulative trauma and posttraumatic stress disorder among children exposed to the 9/11 World Trade Center attack. Am J Orthopsychiatry 2008;78:103-108.

23. Scott MJ, Stradling SG. Post-traumatic stress disorder without the trauma. Br J Clin Psychology 1994;33:71–74.

24. Tehrani N. Bullying: A source of chronic post traumatic stress? Brs J Guid Counc 2004;32:357–366.

25. Bronfenbrenner U. Environments in developmental perspective: Theoretical and operational models. In: Friedman S, editor. Measuring environment across the life span: Emerging methods and concepts.

Washington, DC: American Psychological Association, 1999: pp. 3-28.

26. Young A. The harmony of illusions: Inventing post-traumatic stress disorder. Princeton, N.J.: Princeton University, 1995.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Elaboration on Posttraumatic Stress Disorder Diagnostic Criteria: A Factor Analytic Study of PTSD Exposure to War or Terror Moshe Bensimon, PhD,1 Stephen Zvi Levine, PhD,1 Gadi Zerach, PhD,2 Einat Stein, PhD,3 Vlad Svetlicky, MSW,4 and Zahava Solomon, PhD5 1

Department of Criminology, Bar-Ilan University, Ramat Gan, Israel Department of Behavioral Sciences, Ariel University Center of Samaria, Ariel 3 Department of Psychology, Bar-Ilan University, Ramat Gan, Israel 4 Paul Baerwald School of Social Work, The Hebrew University of Jerusalem, Jerusalem, Israel 5 The Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel 2

Abstract Background: In societies facing prolonged exposure to war and terror, empirical research provides mixed support for the posttraumatic stress disorder (PTSD) symptom clusters groupings identified by the Diagnostic and Statistical Manual (DSM-IV-TR) as re-experiencing the event, avoidance and emotional numbing, and hyperarousal.

Method: This study examines the validity of the PTSD symptom clusters in elements of Israeli society exposed to man-made trauma. Survivors (N=2,198) of seven different war and terror-related traumas were assessed using a DSM-IV-TR based PTSD inventory. Four confirmatory factor analytic models were compared.

Results/Conclusions: The most acceptable model was a correlated model consisting of four factors of re-experiencing, avoidance, emotional numbing, and hyperarousal. DSM-IV-TR avoidance empirically split into active avoidance and emotional numbing. These results corroborate knowledge and suggest that in Israel, where stressors are ongoing, the PTSD symptom clusters may be reformulated in DSM-5 to consist of re-experiencing, active avoidance, emotional numbing and hyperarousal.

INTRODUCTION According to the Diagnostic and Statistical Manual IV-TR (1), PTSD is an anxiety disorder that consists of 17 sympAddress for Correspondence:

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toms grouped into three clusters: re-experiencing the event (e.g., distressing dreams and flashbacks); avoidance and numbing (e.g., avoidance of trauma reminders and restricted range of affect); and hyperarousal (e.g., sleep disturbances and irritability). The symptom cluster classifications are based primarily on clinical field trails and expert consensus, rather than on empirical evidence (2).

Among the proposed DSM-5 changes (www.dsm5.org/), it is suggested that criterion C (i.e., the persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness) be altered. A proposed DSM-5 change is to retain the avoidance symptoms in criterion C, and add a new criterion D, named “Negative alterations in cognitions and mood that are associated with the traumatic event(s)”. This will consist of symptoms of emotional numbing and other cognitive changes, such as shifts in world assumptions. Accordingly, the present time is particularly appropriate to empirically examine and assess the validity of the existing PTSD symptom clusters.

Avoidance and emotional numbing theoretically represent two separate factors that reflect different ways of adjusting to adversity (3, 4). Accordingly, avoidance constitutes an effortful emotional process employed to actively curtail intrusive symptoms. It serves as a strategic way to escape or minimize aversive emotional states induced by exposure to trauma-related stimuli that threaten to intrude on awareness. Emotional numbing refers to diminished responsiveness to the external world and is thought to be an automatic biological response to an extended state of uncontrollable hyperarousal.

Moshe Bensimon, PhD. Department of Criminology, Bar-Ilan University, 52900 Ramat Gan, Israel

bensimm@biu.ac.il

Moshe Bensimon et al.

The first study of the structure of a DSM-based PTSD assessment examined 524 treatment-seeking male military veterans (5). Those results show that PTSD consists of four symptom clusters: re-experiencing, avoidance, emotional numbing, and hyperarousal. These results have been subsequently replicated in groups suffering from various traumas (e.g., 6, 7). For example, one study employed confirmatory factor analysis (CFA) to examine PTSD symptom structure across three veteran samples.

CFA demonstrates that a four-factor structural model including re-experiencing, avoidance, numbing, and hyperarousal is superior to five alternate models, including the DSM-IV three-factor PTSD diagnostic model (7).

Another study employed CFA to examine PTSD symptom structure among a representative sample of U.S. active duty military personnel (N=15,593). Findings show that a four-factor model consisting of re-experiencing, avoidance, emotional numbing and hyperarousal factors was superior to four alternative models (8). These results suggest that emotional numbing is appropriate to include in the DSM as a distinct PTSD cluster. This is consistent with the proposed changes currently under consideration for the DSM-5 (www.dsm5.org/).

In contrast to the aforementioned findings (e.g., 5), other factor analytic studies identify dysphoria, rather than emotional numbing, as the fourth factor (e.g., 9, 10). For instance, analysis of PTSD in a sample of 1,896 deployed Gulf War veterans and 1,799 nondeployed controls has identified four correlated factors of reexperiencing, avoidance, hyperarousal, and dysphoria as the best fitting model (11). These findings are consistent with a meta-analysis of 40 PTSD studies (N=14,827) that used DSM-based PTSD assessments (12).

Empirical research indicates that both prominent four-factor models of PTSD are a good model fit (5, 11). Meta-analysis has shown: re-experiencing, avoidance, hyperarousal, and dysphoria factors are slightly superior (12). The dysphoria factor includes emotional numbing-related symptoms (e.g., loss of interest) as well as certain symptoms from the hyperarousal cluster (e.g., sleep disturbance). Dysphoria may reflect a nonspecific, general-distress factor that is common across anxiety and mood disorders (11). Generally, however, inconsistent results may be due to differences in analytic approach, type of trauma or the use of different PTSD measures (12). Moreover, a clear consensus regarding model superiority is yet to be reached since even Yufik and Simms’ (12) meta-analysis only provided tentative support for their model (13).

Rarely do prior studies examine the structure of PTSD in societies faced with ongoing prolonged exposure to war and terror. Most study participants in prior metaanalyses of the structure of PTSD came from Western nations (e.g., 12) and so did not face ongoing prolonged exposure to war or terror. In Israel, between September 2000 and January 2006 Israeli society was exposed to over 13,000 terror attacks, including suicide bombings, shootings, and mortar attacks (14). During this period, approximately 0.1% of the Israeli population was injured or killed. In the U.S.A. this would equate to approximately 31,000 people. Therefore, Israeli population serves as an example of a society that has been consistently exposed to acts of terror and may be used to highlight responses to continuous stressors (e.g., 15).

The current study aims to compare the confirmatory factor analytic models of PTSD that have received the most empirical support by examining a large group of Israelis who survived a war or terror-related traumatic events. These are (a) re-experiencing, avoidance, numbing and hyperarousal and its hierarchical counterpart (e.g., 5); and (b) re-experiencing, avoidance, numbing, dysphoria and hyperarousal and its hierarchical counterpart (e.g., 11, 12).

METHOD PARTICIPANTS AND PROCEDURE

The present study was based on seven samples (N=2,198) that all consisted of participants who had man-made trauma (war, captivity or terror-related) and completed the PTSD assessment in full with regard to the specific type of trauma to which they were exposed. All participants signed an informed consent form and they were informed that their anonymity would be preserved.

Ethical approval to conduct the current research was obtained from the Israeli Defense Forces and Tel Aviv University Human Subjects Ethics Committee. The mean age of the total sample was 36.99 (SD=12.76) and 34.3% (N=750) were female. Sample I included 157 male Israeli veterans aged 29.71 (SD=5.72) who were active front-line combatants during the second Lebanon War during 2006 which lasted approximately one month (16). Sample II was based on 459 college students on average aged 24.18 (SD=3.52) of whom 70.3% (N=317) were females. These participants had been exposed to prolonged intense missile attacks from the Gaza Strip (17). Sample III consisted of 248 Israeli ex-residents of Gush Katif aged on average 35.43 (SD=12.02) of whom 63.7% were females (N=158).

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PTSD Diagnostic Criteria: A Factor Analytic Study of Exposure to War or Terror

During their time in Gush Katif they were continuously exposed to terror and missile attacks, and were forcefully relocated by the Israeli authorities as their land was handed over to the Palestinian authorities (18). Sample IV included 594 Israeli civilians and army personnel aged 26.03 (SD=4.00) of whom 215 (36.2%) were females. They were residents of Northern Israel who were subjected to 34 days of intense direct missile attacks during the second Lebanon War (19). Sample V included 145 male ex-prisoners of wars (POWs) aged 57.71 (SD=4.9) who were held in captivity for an average time of 2.6 months in Egypt and Syria during the Yom Kippur War in 1973 and were assessed in 2008 (Solomon and Zerach, under review). Sample VI included 475 male war veterans aged on average 46.98 (SD=2.67) who took part in active combat in the ongoing first Lebanon War that began in 1982 and ended in 1985 were assessed 20 years after the war (20). Sample VII included 120 civilians from south Israel who were continuously exposed to intense missile attacks from the Gaza Strip during 2008 (unpublished manuscript) of whom 50% were females, aged from 17 to 29. For further demographic and procedural information please see the aforementioned studies.

PTSD SYMPTOMS ASSESSMENT

All seven samples were assessed with the DSM-IV (21) based PTSD Inventory (22). This Hebrew inventory consists of 17 statements corresponding to the 17 PTSD symptoms listed in the DSM-IV (21). Participants indicated for each statement the extent to which they have suffered from the symptom during the previous month, regarding their specific war-related or terror-related traumatic events, on a 4-point scale ranging from 1 (“not at all”) to 4 (“I usually did”). The PTSD inventory was administered twice within a 1-week interval to 20 soldiers.

The percentage of agreement was 82.3%, indicating high test–retest reliability (23). The test-retest reliability of this inventory has been reported at .93 reflecting internal consistency (α=0.93; 24). It has been reported to have high convergent validity when compared with diagnoses based on structured clinical interviews conducted by trained psychiatrists and mental health professionals (φ=0.48–0.61; 23, 25). The scale is widely used in Israel and has good psychometric properties according to a review of PTSD inventories (26).

STATISTICAL ANALYSIS

Prior to analysis the data were analyzed to assess whether missing values were missing completely at random or 86

systematically. Confirmatory factor analysis was computed using the LISREL 8 structural equation modeling software package (27). Fit indices were compared of the four models that consisted of four factors and their hierarchical counterparts. Model fit was examined with the following fit indices: χ2, Root Mean Square Error of Approximation (RMSEA), Normed Fit Index (NFI), Nonnormed Fit Index (NNFI), Comparative Fit Index (CFI), Standardized Root Mean Square Residual (SRMR), and Expected Cross-validation Index (ECVI). The χ2 goodness of fit index assesses whether or not there is a significant discrepancy between the estimated model and actual data. Statistically significant χ2 values highlight that the model and data differ and thus are indicative of a poorly fitting model. This is likely given a large sample size. Thus we examined both incremental and absolute fit indices.

Absolute fit indices, such as the RMSEA and SRMR, aim to assess how well the theoretical model reproduces the data. The SRMR expresses the average discrepancy between observed and expected correlations across all parameter estimates in a model. It ranges from 0 to 1, with lower values indicating better model fit. The RMSEA assesses the extent to which the model, with unknown but optimally chosen parameter values, would fit the population covariance matrix if it were available. Unlike most fit indices, 90% confidence intervals are available to supplement point estimates for the RMSEA and the ECVI. The ECVI is a way to assess the likelihood that the model cross-validates similar-size samples from the same population. The model with the lowest ECVI value has the greatest potential for replication. The precision of the estimated ECVI value is accounted for by reporting 95% confidence intervals. Both the RMSEA and ECVI include non-centrality parameters. Incremental fit indices measure the proportionate improvement in model fit by comparing a target model with more restricted nested baseline model. The CFI is based on the non-central Chi-square distribution and ranges from 0 and 1, with higher values indicating better model fit. The CFI penalizes small samples and so accounts for sample size. The NFI represents the proportion of total covariance among the observed variables that is explained by a target model when using the null model as a baseline model (28). The NNFI elaborates on the NFI by penalizing for additional parameters.

Due to the skewed distribution of the items, weighted least squares was used with dichotomized items following past recommendations (13; see Table 1; namely categories of absent and rare, or sometimes and frequent symptoms),

Moshe Bensimon et al.

Table 1. Descriptive statistics and structural coefficients based on a 5-factor confirmatory factor analysis consisting of re-experiencing, avoidance, numbing and hyperarousal Item

M

SD

Re-experiencing

B1. Intrusive thoughts of trauma

2.25

-1.07

0.91

Avoidance

Numbing

Hyperarousal

B2. Recurrent dreams of trauma

1.81

-1.02

0.92

B3. Flashbacks

2.08

-1.08

0.87

B4. Emotional reactivity to trauma cues

2.36

-1.15

0.90

B5. Physiological reactivity to trauma cue

1.71

-1.01

0.90

C1. Avoiding thoughts of trauma

1.98

-1.09

0.87

C2. Avoiding reminders of trauma

1.75

-1.02

0.89

C3. Inability to recall aspects of trauma

1.63

-0.93

0.69

C4. Loss of interest

1.81

-1.03

0.89

C5. Detachment

1.82

-1.00

0.87

C6. Restricted affect

1.63

-0.94

0.85

C7. Sense of foreshortened future

1.84

-1.04

0.82

D1. Sleep disturbance

1.96

-1.11

0.88

D2. Irritability

2.01

-1.06

0.85

D3. Difficulty concentrating

1.93

-1.07

0.84

D4. Hypervigilance

1.99

-1.1

0.85

D5. Exaggerated startle response

2.16

-1.15

0.86

α Reliability .87

.77 .82

.87

Structural coefficients represent loadings of each item on each factor. T-values for all loadings statistically significant at p < .001, (N=2,198).

Factor correlations: Re-experiencing-Avoidance .83, Re-experiencing-Numbing .83, Re-experiencing-Hyperarousal .90, Avoidance-Numbing: .81, Avoidance-Hyperarousal: .76, Numbing-Hyperarousal: .88

no error terms were set to correlate with factors based on post-hoc improvement fit indices, and all factors fixed. These are the models consisting of re-experiencing, avoidance, hyperarousal and either numbing or dysphoria based on Yufik and Simms (12). Specifically, the King et al. (5) four-factor model maintains a traditional emotional numbing factor, whereas in the Simms et al. (11) model the Hyperarousal factor has two items (D4 and D5), and Dysphoria consists of 7 items (D1-D3, and C3–C7). The models were compared based on the Akaike Information Criterion (AIC) where smaller values indicate a better model fit and χ2 comparisons between hierarchical and correlated models. The best-fitting model was identified and the loadings termed structural coefficients and reliability reported. These procedures followed a prior PTSD confirmatory factor analytic study recommendations (13, 29). The best-fitting model was identified and the loadings termed structural coefficients and reliability reported.

RESULTS Collectively, 2,404 people were assessed of whom 206 (8.5%) had missing values. The missing value pattern

significantly deviated from the assumption of being completely missing at random (Little’s MCAR test: χ2=976.52, DF=775, p=.00). This may reduce the generalizability of the results and so imputation would be inappropriate (30). Thus across the samples 2,198 people completed all 17 PTSD items. The mean age of the sample was 36.99 (SD=12.76) and 34.3% (N=750) were female. Descriptive statistics of the sample 17 PTSD symptom items were computed and presented in Table 1.

The confirmatory factor analytic models are presented in Table 2. These results suggest that the best fitting model is a correlated model with four factors consisting of re-experiencing, avoidance, emotional numbing, and hyperarousal (5). This model had the lowest χ2, although this fit index was significant (meaning poor model fit) due to the large sample size. Although model fit was moderate, across fit indices the hierarchical model was the best fit to the model (highest CFI and GFI, and lowest AIC, ECVI, NNFI and RMSEA). The point estimates for King et al. (5) were better than the other models since the ECVI and RMSEA confidence intervals did not overlap, except for their corresponding hierarchical models. Comparison between models showed that both 87

PTSD Diagnostic Criteria: A Factor Analytic Study of Exposure to War or Terror

Table 2. Assessment of model fit for competing hierarchical and correlated factor analytic models Model

df

χ2

χ2/df

SRMR

RMSEA

NFI

CFI

GFI

ECVI

NNFI

Model AIC

4a correlated factors

113

682.00

6.04

0.097

0.048 0.044; 0.051)

0.40

0.41

0.70

0.35 (0.31; 0.39)

.82

762.00

4b correlated factors

113

858.17

7.59

0.10

0.055 (0.051; 0.058)

0.39

0.40

0.65

0.43 (0.39; 0.47)

.28

938.17

4a hierarchical

115

721.120

6.27

0.11

0.049 (0.046; 0.052)

0.36

0.37

0.68

0.36 (0.33; 0.40)

.26

797.12

4b hierarchical

115

892.31

7.76

0.11

0.055

0.38

0.39

0.65

0.44 (0.40; 0.49)

.28

968.31

For the χ2 value significance is indicative of a poor model fit, Root Mean Square Error of Approximation (RSMEA) low values represent a better fit, Normed Fit Index (NFI) and Non-Normed Fit (NNFI) values close to 1 represent a good fit, Comparative Fit Index (CFI) close to 1 reflect a better fit, Standardized Root Mean Square Residual (SRMR) values that are lower reflect a better fit, and Expected Cross-validation Index

(ECVI) lower values are better. Akaike Information Criterion (AIC): smaller values indicate a comparatively better model fit.

Note: Items set to load following Table 2 in Yufik and Simms (12). Model 4a consists of re-experiencing, avoidance, numbing and hyperarousal (5). Model 4b consists of re-experiencing, avoidance, numbing, dysphoria and hyperarousal (11). No post-hoc adjustments for fit made.

correlated models were superior than their hierarchical counterparts (model 4a: χ2=39.12, df=2, p<.01; χ2=34.14, df=2, p<.01). Results of examination of these fit indices closely resemble earlier research (29). In addition, the AICs indicated that the best fitting model was the King et al.’s (5) correlated model and thus is consistent with the superiority of correlated models of PTSD (12).

The loadings of each symptom on each factor of this model are presented in Table 1. For example, PTSD symptoms 1 through 5 (thoughts, nightmares, flashbacks, psychological and physiological reactions) loaded on factor 1, thus factor 1 was termed Re-experiencing. All loadings were statistically significant (p<.01) and the reliability was satisfactory (31-33), since for all scales Cronbach’s α exceeded .70. Thus collectively the current results highlight that PTSD has acceptable reliability and validity, represented by a hierarchical model with four symptom clusters consisting of re-experiencing, avoidance, emotional numbing, and hyperarousal. The results therefore are most consistent with King et al.’s (5) correlated model of PTSD as consisting of re-experiencing, avoidance, numbing, and hyperarousal.

The results show that the moderately best fitting model is a correlated model with four factors consisting of re-experiencing, avoidance, emotional numbing, and hyperarousal, supporting King et al. (5). This empirical evidence suggests that the current understanding and formulation of DSM-IV PTSD, as assessed by the current self-report PTSD Inventory (22), does not best capture the structure of symptoms among people who were exposed to war or terror-related trauma in Israel.

The current results are consistent with a growing body of empirical studies reporting empirical deviation from the three factor expert-based conceptualization in DSMIV-TR (1). The study findings are inconsistent with Simms et al. (11) four factor hierarchical model consisting of re-experiencing, avoidance, hyperarousal, and dysphoria in war, captivity and terror related trauma. Dysphoria may not fit into the DSM-IV-TR PTSD conceptualization as it is a too broad and nonspecific distress factor in comparison with emotional numbing. Specifically, emotional numbing refers to chronic long-term results of an ongoing state of anxiety (e.g., restricted range of affect), while dysphoria includes both components of emotional anastasia but also components that may not reflect chronic PTSD (e.g., angry outbursts).

The current study is consistent with past research (e.g., 5, 29), pointing to a four factor correlated model consisting of re-experiencing, avoidance, numbing, and hyperarousal. This conceptualization of PTSD appears to be the most appropriate explanation of PTSD. It provides

DISCUSSION Based on a large sample of Israeli survivors of man-made trauma including war veterans, ex-POWs and civilians exposed to terror attacks, the current study compares four competing models of symptom clusters of PTSD. 88

Moshe Bensimon et al.

an acceptable fit among Israelis who have experienced war, captivity or terror-related trauma, and across prior study samples. Other studies that report the same findings are based on samples exposed to: armed combat (7), sexual assault (34), refugee torture (35), a hurricane (36), and occupational trauma (37).

The current four-factor findings are consistent with theories proposing that avoidance and emotional numbing have two separate mechanisms. For instance, avoidance serves as an escape strategy from trauma-related stimuli that may intrude on awareness, whereas emotional numbing refers to diminished responsiveness to the external world and is thought to be an automatic biological response due to hyperarousal (3). Also empirical evidence supports this distinction showing that avoidance and numbing differ in their response to treatment (38) and in relation to prognosis (39; see 40 for further review).

LIMITATIONS Several limitations are associated with the current study.

Symptom severity was assessed via self-report and not clinical interviews. Past research (22), however, has shown that the PTSD instrument used in this study has good psychometric properties of reliability and convergent validity (23, 25). Also, the items are DSM-IV based and are almost identical to the 17 statements of the military version of the PTSD Checklist (PCL-M: 41). Finally, although our study had insufficient power to examine each discrete form of trauma, the DSM does differentiate between trauma types. Future analyses are nonetheless warranted to replicate the current findings by examining large samples that focus on specific forms of trauma and different cultures.

CONCLUSIONS Based on the comparison of competing PTSD conceptual models in war, captivity and terror-related trauma victims, the current study makes three contributions.

First, it is appropriate to split PTSD criterion C into active avoidance and emotional numbing as separate symptom clusters among people exposed to war, captivity or terror. Second, treatment may focus on specific expressions (the four distinct factors) of PTSD. Third, if replication is the sine qua non for accepting a hypothesis, the current findings reinforce past research (e.g., 5) by uniquely indicating that PTSD in a society consistently exposed to war and terror consists of four correlated

factors reflecting symptom clusters. Based on the current results, past research, and the biological and emotional differences between numbing and avoidance (3, 4), the current findings support the DSM-5’s (www.dsm5.org/) suggestion to retain the avoidance symptoms in criterion C and add a new criterion D consisting of symptoms of emotional numbing.

Contribution of each author: Moshe Bensimon conducted the literature review, drafted the manuscript, data interpretation, and critical manuscript review. Stephen Z. Levine conducted data analysis and gave critical manuscript feedback. Gadi Zerach gave critical manuscript and critical manuscript review. Einat Stein assisted in data collection and critical manuscript feedback. Vlad Svetlicky assisted in data collection and critical manuscript review. Zahava Solomon – study instigation, design, statistical interpretation and critical manuscript review. All authors approved the final version of the document.

Acknowledgements We acknowledge with thanks Drs. Orit Nuttman-Shwartz, PhD, and Rachel Dekel, PhD, for providing us with the data referred to as sample II, and Drs. Rivka Tuval-Mashiach, PhD, and Prof. Rachel Dekel, PhD, for kindly providing us with the data referred to as sample III in this manuscript. Dr. Stephen Z. Levine is now at the Department of Community Mental Health, University of Haifa.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Gadi Zerach et al.

PTSD, Resilience and Posttraumatic Growth Among Ex-Prisoners of War and Combat Veterans Gadi Zerach, PhD,1 Zahava Solomon, PhD,2 Assaf Cohen, MA,2 and Tsachi Ein-Dor, PhD,3 1

Department of Behavioral Sciences, Ariel University Center of Samaria, Ariel, Israel School of Social Work, Tel Aviv University, Ramat Aviv; Tel Aviv, Israel 3 School of Psychology, Interdisciplinary Center Herzliya, Herzliya, Israel 2

Introduction

Abstract Background: Past studies have shown that adversity may yield various salutogenic outcomes. Two constructs that have been at the center of this scientific investigation are resilience and posttraumatic growth (PTG). The present study aims to clarify the relations between posttraumatic stress symptoms, resilience and PTG among Israeli war veterans.

Method: The sample includes former prisoners of war (ex-POWs) (n=103) and comparable veterans (n=106) of the 1973 Yom Kippur War. The veterans were assessed twice: 18 and 30 years after the war with self-report questionnaires.

Results: Resilience, defined as the absence of posttraumatic symptoms, and PTG are negatively correlated. Resilient ex- POWs and veterans reported the lowest levels of PTG when compared to participants diagnosed with clinical and sub-clinical posttraumatic stress disorder (PTSD).

Furthermore, PTG dimensions were found to be the most differentiating factor between study groups, followed by war exposure measures and clinical reports of depression and anxiety symptoms.

Conclusions: This study strengthens the understanding that combatants who report high-level PTSD symptoms also report higher levels of positive psychological changes in the face of severe adversity.

Authorsâ&#x20AC;&#x2122; contribution: conception and design: Gadi Zerach and Assaf Cohen; analysis and interpretation of data: Tzachi Ein-Dor; drafting or critical revision: Gadi Zerach and Zahava Solomon; final approval: Gadi Zerach, Assaf Cohen, Tzachi Ein-Dor and Zahava Solomon.

Address for Correspondence: â&#x20AC;&#x2020; gadize@ariel.ac.il

Alongside the research of the pathogenic ramifications of trauma, which mainly focuses on Posttraumatic Stress Disorder (PTSD) and its co-morbidities (1), many studies have shown traumatic experiences are also implicated in salutogenic outcomes. The most prominent findings that point to a constructive benevolent outcome of trauma have shown that the majority of victims were resilient, reported no posttraumatic symptoms (PTS) and resumed normal functioning quickly after exposure to a traumatic event (2).

Furthermore, survivors of trauma also report experiencing positive psychological changes in various dimensions such as personal strength, relations and appreciation of life; cumulatively defined as posttraumatic growth (PTG; 3).

While the relations between PTSD and PTG have been assessed by a large number of studies (4), the relationship between resilience and PTG requires further clarification. It is unclear whether resilient individuals are more likely to report PTG and whether the process of growth requires exposure to a severe crisis and an actual experience of PTS. This study aims to address this gap in trauma literature by assessing the relationship between PTSD, resilience and PTG among Israeli ex-POWs and veterans of the 1973 Yom Kippur War. Resilience and PTSD

Resilience may be defined as a dynamic process encompassing positive adaptation within the context of significant adversity (5). Alternatively, it may be defined as the ability to maintain a stable mental equilibrium in the face of adversity (6). While such a definition may be acceptable, a formulation of the operational definition or assessment of resilience still poses a significant challenge (7, 8).

Gadi Zerach, PhD, Department of Behavioral Sciences, Ariel University Center of Samaria, Ariel, 40700, Israel.

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PTSD, Resilience and Posttraumatic Growth, Among Ex-Prisoners of War and Combat Veterans

Currently, there are two approaches to the assessment of resilience. The first assesses resilience directly, as a construct comprised of various perceptions, cognitions, and emotions (e.g., the Connor-Davidson Resilience Scale, 9).

The second approach identifies resilience indirectly, by examining traumatized populations and singling out those who did not succumb to the trauma as resilient (10, 11).

In line with this perspective and since PTSD is the most common outcome of combat and captivity (12), this study will operationally define resilience as the absence of PTS. PTG and PTSD

PTG is conceived as a positive outlook following trauma (3).

This outlook is multifaceted manifested through relationships with others, perception of new possibilities, enhanced personal strength, spiritual change, and an increased appreciation for life. PTG has generated a significant body of research and an ongoing scientific debate regarding various aspects of its nominal and operational definitions (13-15).

One aspect that has been highly debated is the interrelationship between PTG and PTSD (16). Based on the current empirical data, it is suggested that there are three modes of relation between these two constructs.

The first mode of relation depicts trauma as a depleting experience which does not entail any salutogenic outcomes. According to this perspective, PTG and distress represent two opposite poles of a single dimension, and are therefore negatively correlated. This perspective is supported, for example, by a negative correlation found between PTG and distress among samples of war veterans (17), sexual assault survivors (18), and young adult cancer survivors (19).

The second mode of relation suggests that the cognitive and emotional adaptation process after a traumatic experience prompts not only psychiatric symptoms, but also a thorough self-examination of substantial personal, interpersonal and social issues. This suggests that salutogenic and pathogenic outcomes are positively correlated. Empirical support for this pattern was documented among survivors of the 1995 Oklahoma City bombing (20) and among Israeli adolescents and adults (21).

While the first two modes propose associations between PTG and PTSD, a third mode suggests that there is no such correlation (22, 23). This mode argues that in the face of extreme stress, people may respond with both psychological distress and PTG, and these responses can be regarded as two separate, independent dimensions without a clear correlation. However, there is reason to believe that lack of correlation between this two construct is the result of 92

the interactive effect of different moderating variables such as the time that had passed since stressor onset (24).

Resilience and PTG

The theoretical literature notes a conceptual confusion and a difficulty in distinguishing between resilience and PTG (25). Bonanno (6) argues that resilience should not be mistaken for recovery. Bonanno suggests that, within the process of recovery, the casualty is affected by the traumatic experience, endorses moderate levels of symptoms, and is able to retrieve a symptom-free state during a relatively short period of time. This process of recovery is not synonymous to resilience as the resilient individual does not endorse PTS at any point in time.

One option is to identify resilience as a reconfiguration process. Resilient people are assumed to rebound from trauma and adapt to change due to alterations in cognitive processing (26). Such changes in cognitive processing resemble those of posttraumatic growth. In this vein, resilience is expected to positively correlate with growth (27).

An alternative outlook suggests that resilience is a form of resistance. A resilient individual is able to experience stress without succumbing to it and, therefore, is at a reduced risk for posttraumatic symptomatology (6). According to this notion, resilience, as a form of resistance, does not entail distress and, thus, does not yield posttraumatic growth negatively correlated with PTG. To summarize, a positive relation between PTSD and PTG may indicate a negative relation between PTG and resilience, as resilience is defined as the absence of PTSD. On the other hand, a negative relation between PTG and PTSD may indicate a positive relation between PTG and resilience (see Figure 1).

This study has three main questions: First, do “resilient” veterans differ from “sub-clinical” and “clinical” veterans in socio-demographics measures, measures of battle stress and clinical measures of depression and anxiety? Second, do “resilient” veterans differ from “sub-clinical” and “clinical” veterans on dimensions of PTG. Third, in a comprehensive Figure 1. Schematic Representation of the Potential Relations between PTSD, PTG and Resilience PTSD

PTG

Resilience

+ PTG

PTSD

+ PTG

Resilience

PTG

Gadi Zerach et al.

model, we inquire which variable among socio-demographic, battle stress, clinical measures of depression and anxiety, and PTG dimensions will be found to be the most differentiating factor between the study groups.

Method Participants and Procedure

This study is part of a longitudinal study that examines the psychological and psychosocial consequences of captivity among Israeli ex-POWs. The names of ex-POWs were divulged by IDF authorities as part of the periodic examination of soldiers after their military service (see 28 for additional details).

Participants were contacted by telephone and were asked to take part in the study. A battery of questionnaires was administered to those who expressed consent in their homes or in other locations of their choice. Before filling out the questionnaires, the participants signed informed consent forms and were assured that the data would remain confidential. The participants were told that the aims of this study were to assess their current psychological and psychosocial state after their participation in war. All the questionnaires were administered in Hebrew. Approval was obtained by both IDF and Tel Aviv University human subject committees.

According to Israel’s Ministry of Defense records, 240 soldiers from the Israeli Army land forces were captured during the Yom Kippur War (October, 1973). Of the 164 POWs who participated in the previous study, 10 could not be located, four had died, and six could not participate due to a deteriorated mental status. Of the remaining 144 POWs, 103 participated in this study, constituting a 71.5% response rate. During captivity, the ex-POWs had been subjected to intense isolation and systematic torture, consisting of the infliction of severe physical pain and great mental pressure. POWs were also humiliated verbally and by interfering with their personal hygiene and natural bodily functions.

A comparison group of 280 combat veterans was assembled from combat soldiers who fought on the same fronts as the POWs. They were sampled from IDF computerized files that provide information about veterans’ rank, military role and location during the 1973 Yom Kippur War. They were matched to the ex-POWs on personal and military background (e.g., age and education, as well as rank and assignment during the war).

Out of 185 men who participated in the previous wave of the study, 41 could not be located and one had died.

Of the remaining 143 controls, 106 participated in this study, constituting a 74% response rate.

Regarding the level of PTSD, rank, age, and education in the previous study, no significant differences were found between those who participated in the second measurement and those who did not. The two groups did not differ in age (F (1,223) = 3.56, ns), education (F (1,222) = .62, ns), number of years in the relationship (marital relationship or live-in relationship) (F (1,215) = .58, ns), and number of children (F (1,220) = 2.52, ns.).

Furthermore, the groups did not differ significantly in religious orientation (χ² (1) = 1.55, p=.46, ns.), and location of residence in Israel (χ² (4) = 1.19, p=.88, ns.). There was a significant difference between the groups, however, in their fathers’ country of birth (χ² (2) = 17.10, p<0.01).

Among the ex-POWs, more participants reported that their fathers’ country of birth was Asia/Africa as compared with the comparison group veterans. Mean age of participants at the time of data collection was 54.6 (SD=4.63). Mean length of marriage was 29.08 years.

Mean years of education was 13.94 (SD=13.46), and mean number of children was 3.24 (SD=1.17).

Classification of the study groups

Participants were further divided into three groups according to their scores on the PTSD scales in 1991 and 2003. Participants who reported no PTSD symptoms, both in 1991 and 2003, were classified as “resilient” (N=36). In accordance with DSM-IV, participants who reported at least one intrusive symptom (criteria B), three avoidance symptoms (criteria C) and two hyper arousal symptoms (criteria D), and who did not have a steady job (criteria F), in one or both waves of measurement were classified as “clinical PTSD” (N=32). Lastly, participants who reported on two out of three PTSD symptoms-related criteria (B, C or D) in one or both waves of measurement were classified as “subclinical” (N=136). To validate this classification, we conducted a series of χ² analyses for independence of measures, in which we examined whether the groups differed in the prevalence of veterans who reported on emotional distress (yes, no) in three eras: from the Yom Kippur War until 1974 (T-3); from 1975 until 1984 (T-2); and from 1985 until the first assessment in 1991 (T-1). The analysis revealed that only 5.4% of the resilient group reported on emotional distress in T-3, 2.1% in T-2, and 2.9% in T-1. Conversely, 50% of the clinical PTSD group and 44.6% of the subclinical group reported on emotional distress in T-3, 59.6% and 38.3%, respectively, in T-2, and 93

PTSD, Resilience and Posttraumatic Growth, Among Ex-Prisoners of War and Combat Veterans

55.9% and 41.2%, respectively, in T-1 (all p < .05). Also, 89.2% of the resilience group, but only 36.2% from the clinical PTSD group and 47.1% of the subclinical group, reported that they continuously worked since the Yom Kippur War and 2001 (p < .001). Finally, only 16.6% of the resilience group reported that they sought therapy since Yom Kippur War compared with 62.5% of the clinical group, and 21.7% of the subclinical group (p < .001).

Measures The PTSD Inventory (29) was used to assess posttraumatic stress disorder. This is a self-report scale based on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R; (30)) criteria, which was the standard used at the time of the first measurement in 1991. To enable comparison, the same inventory was employed in the second measurement in 2003 with the required revisions (29, 31). The inventory consists of 17 statements corresponding to the 17 PTSD symptoms listed in the DSM-III-R. For each statement, subjects were asked to indicate whether or not they had experienced the symptom in the previous month, on a 4-point scale ranging from 1 (not at all) to 4 (I usually did).

Internal consistency among the 17 items was high (Cronbach α =.95 for the total score, ranging from .70 to .82 for the subscales). The scale was also found to have high convergent validity when compared with diagnoses based on structured clinical interviews (29).

The Post Traumatic Growth Inventory (PTGI, 32) was used to assess the salutary impact of trauma. The prompt and items can be linked with a specified traumatic event.

In the present case, it read: “For each of the statements below, please indicate the extent to which this change occurred in your life as a result of your captivity or your participation in the war” (according to participant’s group). This 21-item self-report scale includes five subscales: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. Each item was scored on a 4-point scale. Subscales mean scores, as well as general scores, were calculated. The PTGI has good internal consistency, and construct, convergent, and discriminant validity (30). In an earlier study, Cronbach’s α reliability values for the PTGI subscales ranged from .70 to .83, and the value for the total scale was .94.

Battle stress was assessed using a specially designed self-report questionnaire of 15 items tapping the experience of fighting. In a previous study based on the same sample (33), a factor analysis with Varimax rotation 94

revealed four factors that explained 64.7% of the variance.

Factor 1 consisted of seven items relating to encounters with injuries and death. Factor 2 consisted of two items describing active fighting. Factor 3 consisted of six items describing own army fallibilities. Factor 4 consisted of three items describing life-threatening situations. For the purpose of this study, we used mean of the questionnaire items as an index for battle severity. Internal consistency alphas ranged from .76 to .91 for the four factors.

Depression and anxiety symptoms (SCL-90; 34) were assessed with a self report measure that inquires into 90 psychiatric symptoms during the 2 weeks preceding the assessment (34). It enables examination of the overall severity of psychiatric symptomatology, as well as of the severity of specific symptom categories. The respondent is asked to indicate how frequently he experienced each symptom during the last two weeks on a 5-point scale, ranging from ‘‘not at all’’ to ‘‘often.’’ In the present study, the anxiety and depression sub-scales were used. In a previous study based on the same sample, Cronbach’s alpha coefficients were 0.88 for anxiety and 0.92 for depression. The SCL-90 is highly correlated with similar scales in the Minnesota Multiphase Personality Inventory (35), and the specific subscales display moderate to high theoretical–empirical agreement and stability across variation in the subject sample (36).

Socio-demographic measurements were assessed using demographic characteristics of country of origin, location of residence in Israel, family status, religious orientation, age, and level of education.

Data analyses

In order to answer our first research questions regarding differences between the study groups on sociodemographics, battle stress and clinical measures, we employed a set of χ², ANCOVAs and MANCOVAs analyses. In order to answer our second research questions regarding differences between the study groups on PTG, we employed set of MANCOVAs analyses. In order to answer the third research question we used Discriminant function Analysis (DA) with group classification as the grouping variable and all measures that were found to differentiate between classification groups in the previous analyses as the independent measures. DA is usually used to predict membership in naturally occurring groups. Usually, several variables are included in a study to see which ones contribute to the discrimination between groups and is preferred over Logistic regression in such cases.

Gadi Zerach et al.

Results Difference in socio-demographic measurements

In this section, we examined whether the resilient, subclinical, and clinical PTSD groups differ in the following demographic characteristics: country of origin, family status, religious orientation, age, and level of education.

A series of χ² analyses revealed that the groups were not significantly different in their country of origin, family status, or their religious orientation. Moreover, using MANOVA with group classification as the independent measure and age and level of education as the dependent measures, we found that while there were no significant age differences between the groups, there were significant differences in level of education between the groups, F(2,198)=10.46, p<.001. Planned contrasts revealed that both the resilient (M=15.43, SD=2.51) and the subclinical (M=14.13, SD=3.4) groups attained higher education levels (more years of education) than the clinical group (M=11.80, SD=3.4), t (198) =-4.49, p<.001. Moreover, the resilient group was, on average, more educated than the subclinical group, t (198) =2.09, p<.05. Therefore, we included level of education as a covariate in all subsequent analyses.

Differences in battle stress and war captivity measures

In this section, we explored whether (a) the resilient, subclinical, and clinical groups differed in the severity of their combat experiences, and (b) being a captive of war. To this end, we conducted an analysis of covariance (ANCOVA) with group classification as the independent variable, level of education as a covariate, and battle stress severity as the dependent variable. The analysis revealed significant differences in exposure to battle severity among the groups, F (2,199) =7.77, p<.001. Planned contrasts revealed that both the resilient (M=1.23, SD=.66) and the subclinical (M=1.55, SD=.59) groups reported lower severity of combat than the clinical group (M=1.77, SD=.56), t (198) =3.24, p<.001. Moreover, it was found that the resilient group reported, on average, lower levels of battle stress than the subclinical group, t(198)=-3.02, p<.01. All other effects were not significant.

In order to explore whether the groups differ in the probability of being captured, we conducted a 3 (resilient, subclinical, clinical) X 2 (ex-POWs, controls) χ² analysis of independence. The analysis revealed that while 80.6% of the participants in the resilient group were classified as the comparison group veterans, 81.3% of the participants

in the clinical group were ex-POWs, χ² (2) =25.93, p<.001.

Regarding the subclinical group, 50% of the participants were ex-POWs. Therefore, we used battle severity as a covariant and captivity as an additional independent measure in all subsequent analyses.

Differences in clinical measures

In this section, we explored the robustness of the classification to resilient, subclinical and clinical groups. To this end, we examined (a) whether the groups differ in their reported levels of anxiety and depression (as measured by SCL-90R subscales) above and beyond the contribution of level of education, battle severity, and captivity. To this end, we conducted a MANCOVA with group classification and captivity as the independent variables, level of education and battle severity as covariates, and SCL-90’s subscales at 1991 and 2003 as the dependent variables.

Means, standard deviations, univariate statistics, and follow-up planned contrasts statistics are presented in Table 1. As can be seen in Table 1, the groups differ on all clinical measures tested. The analyses revealed that both the resilient and the subclinical groups endorsed lower levels of anxiety and depression both in 1991 and 2003 than the clinical group. In contrast, the resilient group endorsed lower levels of depression both in 1991 and 2003 and lower levels of anxiety in 2003 as compared to the subclinical group. No significant differences were found between the resilient and subclinical groups in their level of anxiety in 1991. Importantly, while the mean levels of anxiety and depression of the clinical group was above the clinical threshold of the SCL-90 (i.e., .73 [33]), the mean levels of anxiety and depression for the resilient group was below the threshold. The mean levels of anxiety and depression for the subclinical group shifted from subclinical levels (<.73) at 1991 to clinical levels in 2003 (>=.73). Furthermore, the analysis revealed significant differences between ex-POWs and controls in anxiety and depression in 2003. Ex-POWs reported higher levels of anxiety and depression than the comparison group.

Lastly, the analysis revealed significant two-way interactions between group classification and captivity on the levels of anxiety and depression in 2003. Using planned contrasts, we found that while the resilient and subclinical groups reported lower levels of anxiety and depression than the clinical group in 2003, no significant differences were found between the resilient and subclinical groups among the comparison group. In contrast, among ex-POWs, the resilient and subclinical groups reported lower levels of anxiety and depression in 2003 than the 95

PTSD, Resilience and Posttraumatic Growth, Among Ex-Prisoners of War and Combat Veterans

Table 1. Means, Standard Deviations, and Test Statistics for Differences in SCL-90’s Anxiety and Depression Subscales among Resilience, Subclinical, and Clinical Groups Resilience

Subclinical

Clinical

M

SD

M

SD

M

SD

F

t1

t2

Anxiety at 1991

.22

.29

.39

.44

.89

.77

11.88***

-1.38

4.87***

Anxiety at 2003

.13

.22

.71

.72

2.09

.99

23.17***

-4.08***

6.48***

Depression at 1991

.09

.11

.32

.39

.88

.75

17.63***

-2.14*

5.93***

Depression at 2003

.21

.22

.85

.75

2.17

.91

25.66***

-4.65***

6.67***

Note: *p < .05, **p <.01, ***p <.001. t1 =Difference between resilience and subclinical groups. t2 = Difference between both resilience and subclinical groups and clinical groups.

clinical group. Moreover, the resilient group reported lower levels of anxiety and depression than the subclinical group in 2003. All effects are controlled for level of education and battle severity.

Differences in posttraumatic growth

In the current section, we explored whether the resilient, subclinical and clinical groups differed in their posttraumatic growth dimensions (PTGI sub-scales and total score), above and beyond the contribution of level of education, battle severity, and captivity. Specifically, we examined whether the groups differ in their posttraumatic growth in relations, new possibilities, personal strength, spiritual change, appreciation of life, and mean level of posttraumatic personal growth. To this end, we conducted a MANCOVA with group classification (resilient, subclinical, clinical) and captivity as the independent variables, level of education and battle severity as covariates, and posttraumatic growth scores in 2003 as the dependent variables. Means, standard deviations, and univariate statistics are presented in Table 2. As can be seen in Table 2, the analysis revealed significant differences among the resilient, subclinical, and clinical groups in the following dimensions of posttraumatic growth: relations, perceiving new possibilities, personal strength, appreciation of life, and mean level of posttraumatic personal growth. Planned contrasts revealed that both the resilient and subclinical groups reported lower levels of posttraumatic growth in relations, t(198)=2.46, p<.05, new possibilities, t(198)=1.97, p<.05, personal strength, t(198)=2.09, p<.05, appreciation of life, t(198)=2.97, p<.01, and mean level of posttraumatic personal growth, t(198)=2.57, p<.05, compared to the clinical group. In addition, the resilient group endorsed lower levels of posttraumatic growth in relations, t(198)=-2.80, p<.01, new possibilities, t(198)=-2.97, p<.01, personal strength, t(198)=-2.78, p<.01, appreciation of life, t(198)=-4.20, p<.01, and mean level of posttraumatic personal growth, 96

Table 2. Means, Standard Deviations, and Test Statistics for Differences in Posttraumatic Growth (PTG) dimensions between Resilience, Subclinical, and Clinical Groups Resilience

Subclinical

M

SD

M

SD

M

Clinical SD

F

PTG in relations

1.74

.66

2.12

.80

2.49

.72

5.23**

PTG in new possibilities

1.63

.62

2.11

.84

2.37

.71

4.92**

PTG in personal strength

2.00

.92

2.47

.99

2.79

.85

4.61*

PTG in spiritual change

1.65

.84

1.97

1.00

1.98

.96

.97

PTG in appreciation of life

2.03

.92

2.86

1.00

3.20

.89

10.17***

Mean level of PTG

1.80

.65

2.28

.76

2.57

.57

7.31***

Note: *p < .05, **p <.01, ***p <.001.

t(198)=-3.54, p<.05, compared to the subclinical group. All other main effects and interactions were also not significant.

Discriminant Function Analysis

In this section, we examined the relative contribution of previously tested measures to the difference between resilient, subclinical, and clinical groups. To this end, we used Discriminant function Analysis (DA) with group classification as the grouping variable and all measures that were found to differentiate between classification groups in the previous analyses as the independent measures. Specifically, we explored the relative contribution of level of education, war captivity, battle severity, anxiety and depression in 1991 and 2003, and PTG dimensions to the differences between the resilient, subclinical and clinical groups.

The analysis revealed one significant canonical discriminant function, Wilks’ λ=.48, χ²(24)=134.26, p<.001, which explained 90.9% of the variance between resilient, subclinical and clinical groups. The second canonical

Gadi Zerach et al.

discriminant function was not significant, Wilks’ λ=.92, χ² (11) =15.88, p=.15. In other words, as expected, resilient, subclinical and clinical groups could be placed on one continuous dimension, with resiliency on one end and PTSD on the other. Standardized canonical discriminant function coefficients are presented in Table 3. As can be seen in Table 3, surprisingly, the analysis revealed that the least differentiating measures were captivity and battle severity. The most differentiating measures were PTG dimensions, followed by the anxiety and depression measures. Hence, it seems that, for the most part, the spectrum of posttraumatic reactions from resiliency to clinical is more related to “positive” measures, such as PTG than to the “negative” dimensions, such as captivity and battle severity, or clinical measures, such as depression and anxiety.

Table 3. Standardized Canonical Discriminant Function Coefficients for Relative Differences among Resilience, Subclinical, and Clinical Groups Measure

Β

Level of Education

-0.16

Captivity

0.11

Battle Severity

0.10

Anxiety at 1991

0.16

Anxiety at 2003

0.50

Depression at 1991

0.43

Depression at 2003

0.37

PTG in relations

0.18

PTG in new possibilities

0.26

PTG in personal strength

0.23

PTG in appreciation of life

0.41

Total PTG

0.90

Note: PTG= Posttraumatic growth. Higher values refer to heighten differences between classification groups. Positive values refer to higher values for the clinical group than the resilience group. Negative values refer to lower values for the clinical group than the resilience group.

Discussion This study assessed the relationship between PTG and resilience among Israeli ex-POWS and veterans of the 1973 Yom Kippur War. Our prominent findings indicate that resilience, defined as the absence of PTSD symptoms, and PTG are negatively correlated. Resilient ex-POWs and veterans reported the lowest levels of PTG when compared to clinical and sub-clinical participants.

The negative correlation between PTG and resilience indicates that PTG is positively associated with the

endorsement of PTSD symptoms. In other words, when one does not report PTS, and is deemed as resilient, it may be argued that the trauma did not generate substantial growth. This in turn suggests that in order for growth to take place, a trauma survivor needs to feel the experience of the trauma’s pathogenic ramifications. These findings are in line with past studies which demonstrated a positive relation between growth and PTSD (37-39).

If we examine our findings regarding resilience and growth on a timeline, it is possible to state that salutogenic outcomes are likely to be observed among survivors at both the earlier and later stages of the trauma time line. At the earlier stages, as trauma ensues, the resilient individuals are spared from elevated posttraumatic symptoms, as they are able to quickly restore their balance and resume normal life. On the other hand, at later stages, the casualties who were not resilient and endorsed PTSD are capable of experiencing growth along various dimensions. In other words, our findings suggest that the capacity for employing salutogenic resources may be manifested by resisting the trauma’s ramifications, in the form of resilience, or by benefiting from it later on, in the form of growth.

The emerging literature on the psychobiology of resilience (e.g., 40) can also shed light on these study findings. For example, resilient people are characterized by dispositional optimism and high positive emotionality (41). Accordingly, mesolimbic dopamine pathways might be more responsive and/or stress resistant in individuals who remain optimistic when faced with trauma (42). It might be that in order to report posttraumatic growth a veterans need to not resist the stress or experience it as rewarding in some way as part of the reframing process. Again, the basic psychosocial factors and their neurobiological underpinnings that help build resilience might also impact the possibility for existential change in the form of PTG. It is also interesting to examine this pattern of result with regard to the specific characteristics of this sample.

According to a meta-analysis by Helgeson, Reynolds and Tomich (24) the positive relations between PTSD symptoms (intrusive-avoidant thoughts) to growth might be moderated in a primarily male sample that was assessed with well-established measure. Significant effect sizes were found also in studies where measures were administered less than two years after personal trauma. It might be that these moderating variables also play a role in the negative relation between PTSD and PTG that was found in this study.

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PTSD, Resilience and Posttraumatic Growth, Among Ex-Prisoners of War and Combat Veterans

Is growth a salutogenic resource?

While our findings highlight the manner in which resilience and growth are possibly manifested, it is still unclear whether growth, unlike resilience, could be defined as a salutogenic resource. Past studies regarding the authenticity of PTG are mixed. On one hand, there is some support for the notion of PTG as a result of real change, consisting of constructive growth (3). On the other hand, PTG is also conceptualized as an illusory entity, consisting of coping strategies and self-serving biases designed to deal with the negative effects of the trauma. Alternatively, there is evidence suggesting that PTG may be conceptualized as both illusory and real where illusory PTG occurs as an adaptive mechanism to deal with immediate, short-term distress and veridical PTG signifies the result of long-term adaptation and coping (42).

While our design is unable to address the notion of PTG as a short-term adaptive mechanism, our findings may contribute to the debate concerning PTG as reflecting real change or an illusion, many years after the trauma.

The discriminant function analysis indicated that the least differentiating measures between the three groups were captivity and battle severity whereas the most differentiating measures were PTG dimensions, followed by anxiety and depression. In other words, the salutogenic outcome of trauma was found to be more closely related to PTSD than exposure factors or psychiatric co-morbidities.

Since battle stress, anxiety and depression have been repeatedly found to be positively associated with PTSD (44) our findings suggest that growth may be even more closely related with PTSD levels.

At this point, we may argue that it is unlikely that an illusory perception of growth would be so intertwined with PTSD symptoms levels 30 years after the war. Such an outcome would suggest that, for many years, the casualties are employing self-serving illusions which do not ameliorate their posttraumatic symptoms, as self-enhancement biases usually do (45). We suggest it is more likely the strong positive relation between growth and PTSD reflects a salutogenic inclination to benefit and grow from the harsher life lessons entailed by trauma, rather than a process which aims to continuously counteract symptoms through various illusions.

Limitations of study

This study has several methodological limitations. First, it is correlative and, therefore, does not allow inferences regarding causal relations. Second, the sole employment of self-report measures, although frequently used in 98

trauma research, may yield results susceptible to bias.

Third, in this study resilience was defined as the absence of symptoms. It is worth noting that there are other ways to measure resilience such as a self-report questionnaire (e.g. Connor-Davidson resilience scale, 9). Fourth, the time lapse between the traumatic event and the first wave of measurement may have missed out on resilience-related processes such as recovery from symptoms among some of the participants. It might be unclear which individuals may have previously suffered significant symptomology which was resolved. As such, classifying individuals as â&#x20AC;&#x153;resilientâ&#x20AC;? because they do not exhibit PTS at 18 and 30 years after the event might be imprecise. Finally, it should be noted that participants were only men, although it has been suggested that women tend to experience higher levels of PTG than men (46).

Summary and Future Directions

Overall, this study contributes to a better clarification of the much debated relations between PTG and resilience, particularly since these two positive psychological processes were found to be negatively correlated. Further, our findings may indicate that PTG is unlikely to be an illusory entity and does reflect some kind of constructive change. Future research should examine both resilience and PTGâ&#x20AC;&#x2122;s relation to additional constructs, within different levels of trauma severity, in order to attain a wider picture of these substantially different outcomes of traumatic experience.

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15. Feder A, Southwick SM, Goetz RR, Wang Y, Alonso A, Smith BW, Buchholz KR, Waldeck T, Ameli R, Moore J, Hain R, Charney DS, Vythilingam M. Posttraumatic growth in former Vietnam prisoners of war. Psychiatry 2008; 71: 359-370.

16. Morrill EF, Brewer NT, O’Neill SC, Lillie SE, Dees EC, Carey LA, Rimer BK. The interaction of post-traumatic growth and posttraumatic stress symptoms in predicting depressive symptoms and quality of life. PsychoOncol 2007; 25: 4628-4634.

17. Aldwin CM, Levenson MR, Spiro A. Vulnerability and resilience to combat exposure: Can stress have lifelong effects? Psychol Aging 1994; 9: 34-44.

18. Frazier P, Conlon A, Glaser T. Positive and negative changes following sexual assault. J Consult Clin Psychol 2001; 69: 1048-1055.

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33. Dekel R, Solomon Z, Ginzburg K, Neria Y. Combat exposure, wartime performance, and long-term adjustment among combatants. Mil Psychol 2003; 15: 117-131.

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38. Taylor SE, Armor DA. Positive illusions and coping with adversity. J Pers 1996; 64: 873-898.

39. Zoellner T, Maercker A. Posttraumatic growth in clinical psychology - A critical review and introduction of a two component model. Clin Psychol Rev 2006; 26: 626-653.

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46. Linley PA, Joseph S. Positive change following trauma and adversity: A review. J Trauma Stress 2004; 17: 11-21.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

A Longitudinal Study of Changes In Psychological Responses to Continuous Terrorism Marc Gelkopf, PhD,1,2 Zahava Solomon, PhD,3 and Avraham Bleich, MD2,4,5 1

The Department of Community Mental Health, University of Haifa, Israel NATAL: The Israel Trauma Center for Victims of Terror and War, Tel Aviv, Israel 3 Adler Research Center for Child Welfare and Protection, University of Tel Aviv, Tel Aviv, Israel 4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 5 Lev Hasharon Mental Health Center, Pardessia, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 2

Introduction Abstract Objective: The impact of ongoing terror over time has received little attention. This study assesses longitudinally prevalence and predictors of posttraumatic stress symptomsâ&#x20AC;&#x2122; trajectories, namely resistance, resilience, late-onset and chronicity in the course of intensive and ongoing terror.

Method: Two surveys were performed at a two-year interval among 153 Jewish Israeli adults.

Results: Results show probable PTSD prevalence, number of traumatic stress related symptoms (TSRS), and rate of severe posttraumatic symptomatology (PTSS) to increase over time (from 18.2% to 31.2%). With this, many (66.7% of those with PTSD and 39.3% of those with PTSS at wave 1) recovered. Late-onset of severe PTSS (19.6% of the sample) was predicted by income reduction, a major lifetime traumatic event, sense of threat, dissociation, coping via disengagement and low mood. Chronicity was predicted by sense of threat, pessimism, dissociation and disengagement.

Conclusions: Continuous exposure to terror has a strong negative impact on mental health. Secondly, even within a chronic situation of terror, a large proportion of individuals with elevated levels of posttraumatic symptomatology recover over time; third, prolonged exposure to terror may also exacerbate symptomatology, but not per-se trigger new PTSD cases.

Address for Correspondence: â&#x20AC;&#x2020; emgelkopf@013.net.il

100

Terrorism strives to undermine morale, erode sense of personal security, and spread panic in the general population for the purpose of political gain. In the last decade, a variety of studies (1-6) have systematically assessed the impact of terrorism on the mental health of those exposed to it. The studies have identified a range of detrimental mental health effects, including, among others, elevated levels of distress (1-6), lowered sense of security (5, 6), posttraumatic symptomatology (2, 3, 5, 7), and depression or low mood (7-11).

Most of the research, however, has focused on the impact of a lone terror attack (1-6, 9). Little attention has been paid to the impact of repeated terrorist attacks.

Key exceptions are several cross-sectional (7, 10-15) and longitudinal (16, 17) studies carried out in Israel in the wake of the ongoing terror attacks that started in 2000.

The present study is a longitudinal assessment of the impact of continuous terror attacks. It has three main aims. First, it examines the prevalence of posttraumatic stress symptoms at different points of time. This comes to answer the epidemiological question of whether populations exposed to continuing terror become habituated to it or increasingly vulnerable.

Second, it examines the trajectories of stress responses in a situation of ongoing terror, namely the prevalence of resistance and of late-onset, recovered and chronic PTSD and of severe posttraumatic symptomatology. Study of trajectories is important to gain a better picture of the natural patterns of resistance, improvement, deterioration, and chronicity (18, 19). While PTSD trajectories

Marc Gelkopf, PhD, Department of Community Mental Health, University of Haifa, Haifa, Israel

Marc Gelkopf et al.

after trauma have been studied (18, 20, 21), only one study has assessed trajectories of distress in the course of ongoing terror (22). The present study aims to expand the knowledge in this important field.

Finally, the study examines the predictors of the abovementioned trajectories. Various studies have assessed risk factors for development of posttraumatic symptomatology.

Findings implicate female gender (23), depression (24), low education (25), prior exposure to traumatic life events (26), degree of exposure to terror (27), income loss (28), sense of threat (29), lack of social support (30), coping by means of avoidance (31), or disengagement (4), dissociation (26) and pessimism (32). Studies have also found social support (7), active coping (4), and sense of security to be protective of the development of posttraumatic symptomatology. The question is whether the same risk factors that predict the development of symptomatology following single traumatic events predict its development in the course of continuous traumatic exposure.

The study was carried out on an adult sample of the urban Jewish population of Israel in the wake of continuous terrorist attacks. Since late September 2000, the beginning of the Al-Aqsa Intifada, Israel has experienced repeated deadly terror attacks perpetrated in public places, most often in its towns and cities. By May 2004, 1,030 persons had been killed and 5,788 injured in more than 13,000 terrorist attacks (33). The attacks disrupted daily life, and created an atmosphere of fear, insecurity and shared national crisis. The first wave of data collection took place in Spring 2002 after 19 months of the Intifada, and the second wave took place in Spring 2004, after 43 months of the Intifada. Around both periods of assessment terrorist acts were carried out against the civilian population.

Materials and Methods Sample

A two-wave longitudinal telephone survey was performed by a polling institute at a two-year interval. Using a within strata random digit dialing methodology described in the paper on the first wave of the study, we reached a representative sample of 512 Jewish and Arab adults living in urban and rural communities (7). For the second wave, and for the sake of having a homogenous sample, we isolated the urban Jewish inhabitants, who numbered 406 persons, and, randomly (excel random number generator) selected 250 of them. Of these, 211 (84.4%) could be located; 153 (61.2%) of them agreed to be re-interviewed.

Mean age was 38.2 (sd=15.5); there were 83 (54.2%) women; 55 (38.5%) declared having lower than average income, 46 (32.2%) average income and 42 (29.4%) higher than average income. Seven (4.6%) had only elementary education, 65 (42.5%) high school education and 81 (52.9%) higher education. Six (4.2%) were orthodox, 21 (14.7%) religious, 44 (30.8%) traditional, and 72 (50.3%) secular. And 68 (55.6%) were born outside of Israel.

Comparison to data provided by the Israel Central Bureau of Statistics indicates that the sample is representative of the entire Israeli Jewish population of the state (34).

The participants (n=153) and non-participants (n=253) were similar on demographic variables, in their level of exposure to terror, in the objective risk they faced, and in their stress-related symptomatology.

Instruments

The respondents were asked questions drawn from several questionnaires widely used in the study of trauma and coping (7-11, 35-37). The set of questions was pilot adapted and validated (12). Participants were asked to reply to the questions with respect to â&#x20AC;&#x153;the last year.â&#x20AC;?

The 48 questions were identical in both waves, the coping measure (13 questions) was only administered in the first wave, and the major traumatic events measure (non-terror related) (14 questions) in the second wave.

Waves 1 and 2

Background variables: Gender, age, education, religiosity, residence, immigration status, and income were recorded.

Exposure was assessed by subjects being asked 1) whether they had been exposed to a terrorist attack, 2) whether they had a friend or family member who had been exposed, and 3) whether they or their friends or family members were physically injured in the attack. Based on these questions, the responses were aggregated to form two distinct exposure axes: 1) direct exposure (not exposed, exposed uninjured, exposed injured), 2) indirect exposure (friend / family exposed uninjured, injured and deceased).

Trauma and stress related mental health symptoms were measured using a modified version of the Stanford Acute Stress Reaction Questionnaire (SASRQ) (35) widely used in trauma related surveys (2). At Wave 1, it had a Cronbach alpha of .91 (7). The SASRQ was used instead of a regular PTSD questionnaire because it is more adapted to assess continued exposure, which was the case during this period of continuous and intense terrorist attacks.

The modified SASRQ consists of 23 statements, assessing persistent re-experiencing (Cluster B), avoidance 101

Psychological responses to terrorism

(Cluster C), hyperarousal (Cluster D), dissociative, and functioning impairment symptoms or behavior following the “security situation.” Subjects were asked to rate their agreement with each statement on a 5-point Likert scale and to report whether they had felt or behaved in the stated manner less or more than one month. Subjects were designated as having the symptom if they at least “agreed” (3rd choice) with the statement tapping it and reported having had it for at least one month.

Four indices were computed from the SASRQ: 1. Number of traumatic stress related symptoms (TSRS) calculated by summing up the endorsements on the 17 items of the three core PTSD clusters.

2. Probable PTSD based on DSM-IV criteria.

3. Posttraumatic stress severity (PTSS) is a dichotomous measure created for the purpose of the present study.

The measure is based upon a cut-off score of the SASRQ and distinguishes severe trauma symptomatology from non-severe. The cut-off score was created to reduce false negatives (to decrease the likelihood of failing to identify cases as having significant PTSD-like distress) as well as avoid using rudimentary measures with little statistical validity to assess significant symptomatology (see 7 and 22). Because the SASRQ does not provide an accepted cut-off, and there was no independent “gold standard” on which to rely, such as a clinical diagnosis, the sum score of symptom endorsement on the SASRQ on wave 1 subjects in the complete first wave (7) (n=512) was used in order to establish the most optimal cut-off point for sensitivity and specificity with reference to probable PTSD diagnosis. To perform this, the Receiver Operating Characteristic (ROC) curve was used and performed using probable PTSD (n=48) as the reference variable.

The perfect scale has an area under curve (AUC) of 1.0, the present AUC for the SASRQ was .98 (P≤ 0.001). The most appropriate cut-off point with a sensitivity of .98 and a specificity of 0.91 was 6.5. The resulting cut-off score was 6 or fewer symptoms indicating “non-severe” PTSS, and 7 or more “severe” PTSS. To partially validate this cut-off point those above and below it were compared on low mood and sense of personal threat.

The two measures are described in the following. The comparison showed significant group differences in both. Subjects categorized as having severe PTSS scored higher on depression than those categorized as having non-severe PTSS (t511=9.1, p<.0001), and had a greater sense of personal threat (t511=5.9, p<.0001). Thirteen of the 28 (46.4%) and 25 of the 47 (53.2%) severe PTSS cases had no PTSD at wave 1 and 2 respectively.

102

We defined four trajectories based mainly on the categorization of Bonanno (18) and Layne et al.

(19): resistant, chronic, recovered and late-onset, and categorized subjects both on PTSD and PTSS and relevant for the assessment of the impact of ongoing terror. Resistant describes subjects who did not meet the criteria for PTSD or severe PTSS at either wave.

Chronic describes subjects who met the criteria at both waves. Recovered describes subjects who met the criteria at wave 1 but not at wave 2. Late-onset describes subjects who did not meet the criteria at wave 1 but did at wave 2. The definition of “late-onset” was chosen instead of “delayed” because the setting of the study does not permit us to know in full certainty whether the appearance of late symptomatology is a delayed reaction or is due to a new trauma.

4. Dissociation was assessed categorically. Subjects who endorsed at least one of the four dissociative items were categorized as having dissociation. Cronbach alpha for the four dissociation items was .67.

Low mood was assessed by a single item, “I feel depressed or gloomy.” Respondents were asked to rate themselves on a 5-point Likert scale (from 0, not true at all, to 4, very true). A score of 2 or higher was taken to indicate low mood.

Sense of Threat was assessed by two statements that indicated respondents’ current sense of threat to themselves (personal) and to their relatives (family), on a 5-point Likert scale from “not at all” (0) to “very much” (4). A score of 3 or more was taken to indicate a low sense of safety. Cronbach alpha for these two items was found to be .83 (during the first wave), and a test-retest assessment on a sample of students was found to be satisfactory (see 7 for a description of the procedure).

Optimism was assessed by two items adapted from the Future Orientation Scale (36). These queried the respondents’ current optimism about their personal future and about the future of the State of Israel. Responses were on a 6-point Likert scale ranging from (1) very much agree to (6) do not agree at all; a score of 3 or less was taken to indicate an optimistic orientation. Cronbach alpha for these two items was found to be .57, and a test-retest assessment on a sample of students was found to be satisfying (7).

Wave 1 only

Means of coping were assessed using a modified version of the COPE questionnaire (37), consisting of 13 questions referring to distinct coping methods. Participants

Marc Gelkopf et al.

were asked to indicate how often they used each method on a 5-point scale. A principal component analysis with Varimax rotation with an Eigenvalue above 1 brought a 4 factor solution composed of “social action and support”; “denial”; “disengagement”; and “detachment.” Cigarette/ alcohol and tranquillizer use was added as a separate a priori factor in the analyses. A description of the analysis and items can be found elsewhere (29).

linear regression analyses were performed so as to assess the difference between groups of individuals with distinct trajectories. Repeated measures were not performed as we did not assess discrete events over time and therefore results would not be affected by autocorrelation issues.

The MANOVA was performed instead of a regression analysis due to the small sub-sample sizes.

Wave 2 only

Results

Major lifetime non-terror related traumatic events were assessed using a modified version of the Traumatic Event Questionnaire (38). Respondents were asked to indicate (yes/no) whether they had ever experienced each of seven non-terror related traumatic events (e.g., severe road accident, physical or other abuse, serious illness, war-related trauma, other life threatening situation) and, if so, whether they had been physically hurt (yes/ no). They were again asked to indicate whether someone close (friend or family) had ever experienced each of the events and, if so, whether they had been physically hurt.

Procedure

For the first wave, interviewers (supervised by the first author and a clinical psychologist) conducted interviews on April 30 and May 1, 2002, by which time Israelis had suffered 19 months of terror. The second wave was carried out during the last week of April, 2004, following 43 months of terror.

The Helsinki Ethics Committee of the Lev Hasharon Mental Health Center approved the studies and informed consent was obtained verbally at the beginning of the interviews.

Analyses

Univariate analyses were used for wave 1 and 2 comparisons. Chi square analyses were done to assess changes in PTSD and PTSS status over the 2 waves. An Anova was performed to assess changes in TSRS over the 2 waves comparing the four longitudinal patterns. Four x 2 MANOVA (for continuous variables) and 4 x 2 Chi square analyses (for categorical variables) were done to compare PTSS and PTSD trajectories on independent variables. Independent variables found to differ significantly between trajectories were entered in two logistic (resistant vs. late-onset and resistant vs. chronic PTSS), one stepwise linear regression (for the TSRS change score between wave 1 and 2) and one MANOVA (for the chronic vs. recovered PTSS trajectory). Logistic and

Terror Exposure

As can be seen in Table 1, 25 individuals were personally exposed at wave 1. Five previously unexposed individuals were newly exposed at wave 2. Fifty-eight individuals were indirectly exposed, six knew family or close friends who were exposed but remained uninjured between waves, nine knew people who were injured between waves and in one case a friend or relative died in between waves.

Univariate analyses found no significant relation between personal exposure or indirect exposure at wave 1 or in between waves on either PTSD, PTSS or PTSS severity. None of these exposure variables were thus entered in subsequent analyses.

Non-Terror Related Lifetime Traumatic Events

Fifty-three persons (43.6%) had had a prior to wave 1 lifetime traumatic experience and 17 (11.1%) had suffered physical consequences from this experience; 83 persons (54.2%) knew someone close who had a prior traumatic experience and 58 (37.9%) knew someone who suffered physical consequences from this experience.

Trajectories

As shown in Table 2, results show significant changes from wave 1 to 2 in probable PTSD and severe PTSS: Table 1. Exposure Categories at Wave 1 and Wave 2 Since the beginning of Intifada at Wave 1

Between Wave 1 and 2

N

%

N

%

Exposure to Terror Personal Exposure 1. No personal exposure 2. Personal exposure

128 25

83.7 16.3

148 5

96.7 3.3

Indirect exposure 1. No exposure 2. Friend/ family exposure, uninjured 3. Friend/ family exposure, injured 4. Friend/ family exposure, death

95 19 35 4

62.1 12.4 22.9 2.6

137 6 9 1

89.5 3.9 5.9 0.7

103

Psychological responses to terrorism

Table 2. Trajectories of Probable Posttraumatic Stress Disorder (PTSD), Severe Posttraumatic Stress Symptoms (PTSS) and Number of Traumatic Stress Related Symptoms (TSRS) Trajectory Probable PTSD Resistant to probable PTSD Late-onset PTSD Chronic PTSD Recovered PTSD Severe PTSS (> 6 symptoms) Resistant to severe PTSS Late-onset severe PTSS Chronic severe PTSS Recovered from severe PTSS

TSRS Wave 1

TSRS Wave 2

N

%

Mean

SD

Mean

SD

121 17 5 10

79.1 11.1 3.3 6.5

2.58 4.71 13.60 12.30

2.66 3.03 3.37 3.46

3.37 12.17 13.20 8.20

3.46 3.59 2.39 5.55

95 30 17 11

62.1 19.6 11.1 7.2

1.99 2.90 12.30 8,81

1.89 2.19 3.46 1.98

2.06 10.77 12.29 3.27

1.92 3.33 2.71 2.20

TSRS (number of symptoms), range 0-17, Mean (sd)

Wave 1

Wave 2

N

%

N

%

Statistics

15

9.8

22

14.4

28

18.2

48

31.2

Ď&#x2021;2=4.85, p=.03

Ď&#x2021;2=13.93; p=.001 3.91 (4.1)

5.00 (4.9)

F=10.02; p=0.002

Table 3. Univariate Analysis Comparing PTSS and PTSD Trajectories on Independent Variables Severe Posttraumatic symptomatology (PTS) Resistant N=95

Lateonset N=30

Chronic N=17

Recovered N=11

Posttraumatic Stress Disorder (PTSD)

Statistics

Resistant N=121

Lateonset N=17

Chronic N=5

Recovered N=10

Statistics

Traumatic stress related symptoms (Wave 1)

Av. Sd

1.99 1.9

2.90 2.2

12.29 3.5

8.91 1.97

F=130.1 ***

2.57 2.7

4.71 3.0

13.60 3.6

12.30 3.5

F=9.9 ***

Reduction in income (between Wave 1 & 2)

N %

21 22.1

19 63.3

4 23.5

2 18.2

X2=19.7 ***

31 25.6

11 64.7

1 20.0

3 33.3

X2=11.1 **

Major Traumatic Life event

N %

37 38.9

9 30.0

5 29.4

2 18.2

X2=2.59 ns

44 36.4

5 29.4

3 60.0

1 10.0

X2=4.47 ns

Felt personal threat (Wave 2)

Av. Sd

1.9 1.0

2.43 1.4

2.76 1.1

1.64 1.4

F=18.3 ***

1.31 1.1

2.47 1.5

3.20 1.1

2.60 1.5

F=11.1 ***

Optimistic regarding the country (Wave 2)

Av. Sd

4.22 1.5

3.57 1.6

2.24 1.4

4.36 1.4

F=8.9 ***

4.1 1.5

2.8 1.7

2.4 1.7

3.1 2.0

F=5.5 ***

Dissociation criteria (Wave 2)

N %

15 15.8

13 43.3

14 82.4

6 54.5

X2=35.97 ***

28 23.1

7 41.2.

4 80.0

9 90.0

X2=26.02 ***

Coping by Disengagement (Wave 1)

Av. Sd

1.14 1.0

2.15 1.2

2.94 1.4

1.73 1.4

F=16.2 ***

1.42 1.2

2.03 1.2

3.20 1.4

1.95 0.9

F=4.7 **

Coping by social action and support (Wave 1)

Av. Sd

1.71 0.8

1.47 1.0

2.45 0.8

1.96 0.7

F=5.62 ***

1.74 0.8

1.33 0.9

3.04 0.5

2.18 0.93.

F=6.67 ***

Low Mood (Wave 2)

Av. Sd

0..54 0.87

1.97 1.6

1.82 1.1

0.91 1.0

F=17.34 ***

0.67 1.0

2.39 1.3

2.80 0.8

1.50 0.9

F=19.61 ***

Note: *=p<.05; **=p<.01; ***=p<.001, ns=not significant.

17/138 (12.32 %) of those without probable PTSD at wave 1 became late-onset PTSD cases; 10/15 (66.67%) of those with probable PTSD at wave 1 recovered; 30/125 (24 %) of those without severe PTSS at wave 1 became late-onset severe PTSS cases; 11/28 (39.29%) of those with severe PTSS at wave 1 recovered.

An Anova at wave 1 shows TSRS to differ significantly in the four probable PTSD trajectories (F=59.91, p<001) and also within each of the PTSS trajectories 104

(F=130.08, p<.001). Post-hoc Scheffe tests shows the TSRS scores to be significantly different between all trajectories in both the PTSD and PTSS assessment except for the difference between resistant and the delayed onset trajectories which were not found to differ significantly.

Differences between trajectories

Table 3 presents the mean scores and standard deviations or the number of cases and percentages in each

Marc Gelkopf et al.

Table 4. Final Model of the Logistic Regression With Late-Onset PTSS Versus Recovered to PTSS, and MANOVA Comparison of Chronic PTSS vs. Recovered from PTSS 95% CI for Exp(B) B

S.E.

Wald

Sig.

Exp(B)

Lower

Upper

2.07

.89

5.39

.02

7.94

1.38

45.67

Resistant to PTSS vs. Late-onset PTSS Major traumatic life event Income reduction between Wave 1 and 2

-1.83

.73

6.29

.01

0.16

0.04

.67

Sense of personal threat at Wave 2

1.23

.35

12.41

.001

3.43

1.72

6.82

Dissociation criteria at Wave 2

-1.56

.72

4.69

.03

0.29

0.05

0.86

Disengagment coping mode

0.91

.36

6.33

.01

2.47

1.22

5.00

Low Mood at Wave 2

0.67

.28

5.83

.01

1.95

1.13

3.35

Resistant to PTSS vs. Chronic PTSS Sense of personal threat at Wave 2

1.39

.55

6.32

.01

4.02

1.36

11.88

Not Optimistic about the future of the state at Wave 2

-0.78

.36

4.65

.03

0.46

0.23

0.93

Dissociation criteria at Wave 2

-2.43

1.00

5.91

.01

0.09

0.01

0.63

Disengagment coping mode

1.27

.47

7.35

.01

3.56

1.42

8.92

Chronic PTSS vs. Recovered from PTSS

MS

F

Sig.

Not Optimistic about the future of the state at Wave 2

1.02

7.16

0.13

Dissociation criteria at Wave 2

7.10

5.07

0.33

Note: Total predicted percentage of variance in the resistant to PTSS versus late-onset PTSS logistic regression =88.8%; 94.7% for the resistant group, and 70.0% for the late-onset PTSS. Total predicted percentage in the resistant to PTSS versus chronic PTSS logistic regression =94.6%; 97.9% for the resistant group, and 76.5% for the late-onset PTSS.

trajectory of the independent variables found to differentiate significantly between trajectories using 4 x 2 MANOVA or 4 x 2 Chi square analyses. This table also presents the “major traumatic life events” and “income reduction between wave 1 and 2” variables as 2 X 2 Chi square comparisons discerned between some of the trajectories.

Predictors of changes from non-severe PTSS at Wave 1 to severe PTSS at Wave 2

To examine predictors of symptomatology severity change comparing resistant vs. late-onset PTSS cases as the dependent variable, the final results showed that late-onset PTSS could be predicted on the basis of a major traumatic life event (non-terror related), income reduction between wave 1 and 2, sense of personal threat at wave 2, dissociation at wave 2, having higher levels of disengagement as a coping means and low mood. The model explained 88.8% of the variance (Table 4).

Predictor of difference between resistant and chronic PTSS

Examining the predictors of resistant vs. chronic PTSS, the results show that chronic PTSS could be predicted on the basis of a sense of personal threat at wave 2, lack of

optimism about the future of the state at wave 2, dissociation criteria at wave 2 and a disengagement coping mode.

The model predicted 94.6% of the variance (Table 4).

Predictors of change from severe PTSS to non-severe PTSS

Examining predictors of symptomatology severity change comparing chronic to recovered PTSS cases as the dependent variable, the result showed that chronicity could be predicted on the basis of sense of a lack of optimism as to the future of the state and a sense of personal threat at wave 2 (Table 4).

Predictors of TSRS change

To examine the predictors of TSRS change between wave 1 and wave 2, a stepwise hierarchical regression was performed. At step 1, TSRS at wave 1 accounted for 14.6% of the variance; at step 2 major lifetime traumatic life events accounted for 5.5% of the variance; at step 3 income reduction between wave 1 and 2 accounted for 6.9%; at step 4 sense of threat at wave 2 accounted for 17.0%, at step 5 mental disengagement accounted for 7.6%, at step 6 dissociation accounted for 9.2% and at step 7 low mood at wave 2 accounted for 6.8% of the variance.

The model explained 67.6% of the variance (Table 5).

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Psychological responses to terrorism

Table 5. Final Stage of Linear Regression Assessing Predictors of Changes in Traumatic Stress Related Symptoms (TSRS) Between Wave 1 and Wave 2 95% CI B

SE

Lower

Upper

Sig.

R2 change

TSRS at Wave 1

-0.79

0.06

-0.90

-0.66

.001

.15

Major traumatic life event

-2.33

0.78

-3.74

-0.92

.001

.06

Income reduction between Wave 1 & 2

-0.98

0.50

-0.02

1.96

.05

.07

Personal sense of danger at Wave 2

0.97

0.19

0.60

1.36

.001

.17

Disengagment coping mode

0.66

0.20

0.28

1.05

.001

.08

Dissociation criteria at Wave 2

2.79

0.54

1.73

3.86

.001

.09

Low Mood at Wave 2

1.15

0.21

0.74

1.55

.001

.07

Discussion The study findings show the strong impact of continuous exposure to terror. The prevalence of probable PTSD, the mean number of symptoms, and the rate of severe posttraumatic symptomatology (PTSS) all increased between the study waves. These findings differ from those of longitudinal studies on the impact of a single terrorist attack, which consistently show a reduction in symptomatology over time (4, 5). They raise questions about the ability to habituate to ongoing terror and lend further support to the view that ongoing stressors are an important risk factor for the development of PTSD (39).

Roughly the same amount of time elapsed between the start of the Intifada and wave 1 as between wave 1 and wave 2. Interestingly, the late-onset cases of probable PTSD and of severe posttraumatic symptomatology as a result of the terror attacks identified at wave 2 were similar in number to the cases of probable PTSD and of severe symptomatology that were identified at wave 1. Therefore the development of late-onset cases and of severe symptomatology seem to be linearly associated with the amount of time that passed.

At the same time, the findings also point to spontaneous recovery. About two-thirds of those with probable PTSD and around two-fifths of those with severe posttraumatic symptomatology at wave 1 had spontaneously recovered two years later. These findings are consistent with those of studies showing substantial rates of recovery among PTSD victims following a single terror attack (5) 106

and similar rates of recovery from combat related PTSD (40). The findings of such rates of recovery despite the ongoing terror are anomalous, especially in view of the finding that exposure to threat is a risk factor that impedes recovery. A partial explanation might be that the sense of threat of the general public declined substantially between waves either due to a reduction of objective threat or because individuals adapt to extreme situations by reducing the amount of felt threat.

Another set of findings shows that many persons who were not identified with probable PTSD developed or retained severe posttraumatic symptomatology over time.

Late-onset severe symptomatology increased at about twice the rate as probable PTSD (24% vs. 12.3%). Over 11% of the respondents had chronic severe symptomatology, in contrast to just over 3% who had chronic probable PTSD. These findings suggest that prolonged exposure may increase the level of symptomatology more than it triggers new PTSD cases. Since posttraumatic symptoms can be disruptive even if they do not align themselves in the categories of the diagnosable disorder, the findings suggest that screening for traumatic reactions should not be restricted to screening for PTSD but include screening for severe symptomatology.

The assessment of risk factors indicates that increase in number of symptoms is predicted by similar factors as those that have been found to predict PTSD: prior traumatic life events (5, 25, 26), income reduction (11), low mood (24), sense of threat (29), dissociation (15) and coping by disengagement (4). Nonetheless, different factors were found to predict different trajectories.

The likelihood of developing late-onset severe posttraumatic symptomatology was predicted by income reduction, a prior traumatic life event, sense of threat, dissociation, coping via disengagement and low mood.

Recovery, meaning the â&#x20AC;&#x153;bouncing backâ&#x20AC;? from severe PTSS to non-severe PTSS was predicted only by optimism about the future of the state and the absence of dissociation. Chronicity of PTSS was predicted by the presence of a personal threat, the lack of optimism about the future of the state, dissociation and a disengagement coping mode. In other words, while numerous factors apparently contribute to the development of symptoms in the first place, only two factors play a significant role in maintaining severe symptomatology, namely dissociation and pessimism.

Sense of threat, it is of note, contributes to the development and worsening of symptomatology, while pessimism seems to play a role only in the maintenance of severe

Marc Gelkopf et al.

symptomatology. The power of pessimism about the future of the state to impede recovery may stem from the fact that the terror is directed at the state, not at individuals. We may assume that pessimism about the future of the state – the sense that the state will not be able to defend itself and its citizens – augments the sense of threat that persons feel in face of the terror.

Income reduction was also found to be a major risk factor. This supports the “Conservation of Resources” (COR) theory (22) that suggests loss of resources to be a major traumatogenic factor.

The present study lends support to the versatile aspects of dissociation. Indeed, this study also adds empirical evidence that a dissociative state may, on the one hand, exacerbate symptomatology over time, or second, be a risk factor for delayed onset of symptomatology as well as hamper recovery.

Finally, and in line with other studies assessing the impact of different coping means (4), “disengagement” which is a “giving up” in coping, and thus the expression of despair and the expression of the belief that nothing can be done to improve the situation or oneself, is a major risk factor for symptom exacerbation, late-onset development of symptomatology as well as chronicity.

Three of the examined predictors did not prove to be risk factors, namely exposure, gender and coping by social action and seeking social support. Indeed, as in cases of exposure to a national terror attack, neither direct nor indirect exposure was predictive of high levels of posttraumatic stress symptoms (5). This finding may be accounted for in either of two ways. One is that those who experience terrorism may understate their distress and continue with their lives without being affected by it (41, 42). The other is that it reflects the wide ranging impact of the pervasive traumatic reality in Israel, which has affected virtually the entire population (29). This interpretation is consistent with Silver et al.’s (4) conclusion that the psychological impact of a major national trauma is not limited to those who experience it directly.

The second was gender. Female gender was not found to be a risk factor for increases in posttraumatic symptomatology over time. That is, proportionately speaking, no more women than men developed symptoms between the study waves. This finding is very surprising in view of the fact that more women than men had PTSD in wave 1 (7), as well as in a subsequent cross-sectional study carried out at the same time as the wave 2 assessments (12). It is also surprising in view of the overwhelming findings in the literature showing that women are more

prone than men to developing symptomatology following traumatic events (23). Could it be that initially, after exposure, women are more at risk than men to develop symptoms of PTSD, but that as time goes by and stressors become chronic differential psychological processes come into play for men and women whereby either men become more at risk, and/or women become less at risk?

Obviously further longitudinal studies are required to determine whether ours is a reliable finding.

The last was coping with social action and support.

In a previous study on the entire wave 1 sample we have found lack of coping by social action and support to be a predictor for posttraumatic symptomatology (29) two years after the start of the Intifada. The present results suggest that coping by social action and support may be limited in its efficacy over time. A major reason for this may be found in Hobfoll’s COR theory suggesting that as traumatic situations become chronic there is a depletion of the needed resources to cope with trauma (22). Coping by social means in chronic stress situations, especially within families or within small communities, may over time become a burden instead of a resource (29).

The findings have several therapeutic implications.

First, as the number of people suffering from traumatic symptomatology grows, so does the need to improve existing therapies (43, 44). Second, with this, great care must be taken to give individuals exposed to trauma the opportunity to get well without treatment, as high percentages of persons exposed to traumatic events are resistant to their potentially damaging mental health consequences and many who initially are not recover spontaneously. Therapeutic approaches administered just after trauma, such as psychological debriefing may even be detrimental to recovery (45).

Third, since the number of new PTSD cases increases linearly under continuing terror attacks¸ at least as much effort should be put into strengthening resiliency as into treating new PTSD cases. Fourth, given the various factors found to predict changes in symptomatology, resiliency/ resistance oriented treatments should incorporate techniques for coping with resource loss, working through major life events, creating a sense of security, avoiding dissociative states, and enriching the coping repertoire.

Finally, the findings suggest that bolstering optimism and sense of security, both at a personal and a national level, may be useful in treating persons with severe symptomatology. These suggestions point towards the need to develop different levels of intervention, for different populations and at different stages of exposure (46, 47).

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Psychological responses to terrorism

This study has several methodological limitations.

The trajectory groups were relatively small in size and consisted only of Jews living in urban areas, raising questions about the generalizability of the findings to other groups in Israel. Some of the independent measures used were also one- and two-item questions whose validity can be questioned, and the PTSS severity measure has not been validated against an independent “gold standard,” therefore measurement error in the outcomes cannot be ruled out as an explanation of the findings. As we did not use any control group that had not experienced chronic traumatic stress our results may be the product of a general lack of sense of security and not per-se traumatic stress.

Finally, as these studies were telephone surveys it is possible we did not contact individuals who were physically injured, and might have higher levels of posttraumatic symptomatology, To conclude, the present study suggests that chronic stress has an incremental impact on a nation, that most factors found to affect mental health in cases of nonchronic exposure also affect individuals exposed to chronic trauma, but that different factors may be involved in the development over time of distinct trajectories of posttraumatic symptomatology.

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Anxiety Stress Coping 2005;18:165-182.

16. Freedman SA, Brandes D, Per T, Shalev A. Predictors of chronic posttraumatic stress disorder: A prospective study. Br J Psychiatry 1999; 174:353 –359 17. Shalev AY, Freedman S. PTSD following terrorist attacks: A prospective evaluation. Am J Psychiatry 2005; 162:1188-1191.

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D. Longitudinal determinants of posttraumatic stress in a populationbased cohort study. Epidemiology 2008;19: 47-54.

40. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York, N.Y.: Brunner/Mazel, 1990.

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43. Berger R, Pat-Horencyk R, Gelkopf M. School-based intervention for prevention and treatment of elementary-pupilsâ&#x20AC;&#x2122; terror-related distress in Israel: Quasi-randomized controlled trial. J Traum Stress 2007; 20: 541-551.

44. Gelkopf M, Berger R. A school-based, teacher-mediated prevention program (ERASE-Stress) for reducing terror-related traumatic reactions in Israeli youth: A quasi-randomized controlled trial. J Child Psychol Psychiat 2009; 50: 962-971.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Sense of Coherence and Sense of Community as Coping Resources of Religious Adolescents Before and After the Disengagement* from the Gaza Strip Orna Braun-Lewensohn, PhD,1 Shifra Sagy, PhD,1,2 Hagit Sabato, MA,2 and Rinat Galili, MA2 1

Conflict Management & Conflict Resolution Program, Ben-Gurion University of the Negev, Beer Sheva, Israel Department of Education, Ben-Gurion University of the Negev, Beer Sheva, Israel

2

Abstract In August 2005, all of the Jewish communities in the Gaza Strip were permanently evacuated, implementing a political decision of the Israeli government. Employing the salutogenic approach, this study explores individual and community coping resources − sense of coherence and sense of community – among adolescents who were displaced from their homes. We examined the way these coping resources operated in three stages: before the disengagement from Gaza, a few months after the event, and five years after the disengagement.

Data were gathered among religious adolescents who had grown up in small Jewish communities in the Gaza Strip. Adolescents aged 12-18 filled out self-reported questionnaires, evaluating state anxiety and state anger as stress reactions, and sense of coherence and sense of community as coping resources.

Results suggest that both sense of coherence and sense of community were weakened immediately after the disengagement. However, sense of coherence has recovered five years after the event. Furthermore, during the two stages after the disengagement, sense of coherence and sense of community had more explanatory power of stress reactions than during the acute state.

Results are discussed against the backdrop of the salutogenic model, including practical implications for different interventions which should be applied in various states of stress.

Research Background In summer 2005, 8,800 people from 21 settlements in the Gaza Strip were permanently evacuated from their homes because of a political decision to disengage from Gaza. The communities in the Gaza Strip were reported in studies as being strong and cohesive (1). The vast majority of settlements were religious in character and identity, and a majority of the settlers were nationalist orthodox in outlook with a strong ideological desire to live in “Greater Israel.” Their lives in the Gaza Strip were a core component of their ideology, and their religious faith afforded them a sense of great empowerment (2). For many of them, living in Gaza was a primary fulfillment of a religious and national mandate (3). In addition, living in the Gaza Strip had enabled them to achieve financial success (4). Settling the Gaza Strip had also been an aspect of official Israeli policy dating from the Six Day War until the decision to disengage and to remove Jewish communities from the region. The disengagement also involved the destruction of houses, synagogues and other public buildings (5). The Gaza settlers viewed the disengagement as a betrayal of the Zionist ideal (6, 7).

Prior to the actual disengagement, the settlers showed high levels of denial and they did not believe that the disengagement would actually take place. Examples of the denial are evident in interviews with two adolescent girls who participated in this study. The interviews were conducted by the fourth author immediately after the evacuation: *Disengagement: The eviction of all residents, demolition of the residential buildings and evacuation of associated security personnel from the Gaza Strip, which occurred in 2005.

Address for Correspondence: Orna Braun-Lewensohn, Conflict Management & Conflict Resolution Program, Department of Interdisciplinary Studies, Ben-Gurion University, POB 653, Beer Sheva 84105, Israel. ornabl@bgu.ac.il

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Orna Braun-Lewensohn et al.

“I was surprised; from the beginning it was like, as if it was not part of reality. And then after weeks and after months we did not hear much. We do not watch TV, we hear a little bit of news, but we are not really affected by each statement….. Again, it is not real that something like that will happen here, it is so far from us….. The more time passed the more prayers, but also in the prayers it was not that it could happen….” (Hana) “For a year and a half they were talking about it all the time, but during this time, the settlement had only grown and blossomed. New families had arrived and there was a campaign to double the [population of] the settlement….. All the time there were events and prayers and we believed that nothing would happen, until the evacuation actually started.” (Michal) Additionally, the settlers refused to leave their homes under any circumstances, and resisted Israeli soldiers who physically removed them from their homes (1).

Furthermore, the vagueness and the uncertainty (e.g., “not knowing where we will live”; “will our parents be employed,” etc.) that accompanied this move may also have enhanced stress reactions before the evacuation itself (8). Once the disengagement had taken place, the settlers had to deal with feelings of personal loss, loss of faith in the government and in the state. Since most of the settlers had been involved in the campaign against the disengagement and since many of them had not believed that the disengagement would take place, they had not planned their short or long term future (7).

Five years after the disengagement, most of the evacuees still believed they were “right” and that their expulsion from their homes was a dramatic error. Moreover, the vagueness and uncertainty remained for those who still did not have a permanent residence. The standard of living of the evacuees had decreased and some of them were still unemployed at the time of the third stage of our study (9).

The Salutogenic Model and Sense of Coherence

Salutogenesis views the human system as basically unsafe, and continuously attacked by disturbing processes and elements which cannot be prevented. In the basic chaotic condition of the world, people have the ability to find some order. From this point of view, salutogenesis suggests examining the entire population and not just a population “at risk.” The aim is to find those who maintain healthiness despite the stressful and chaotic conditions (10).

According to this model, people who conceptualize the

world as comprehensible, manageable and meaningful have the ability to cope well when facing stressful situations. This ability has been termed “sense of coherence” (SOC) (11), with those having a strong SOC tending to perceive themselves as having internal and external resources to deal with different situations (12). Therefore, they are less likely to react with symptoms such as anxiety or anger during stressful events (13). Studies have shown that during adolescence, SOC may play a protective role similar to that of the mature adult (14-16).

Antonovsky (11) considered a number of cultural dimensions which contribute to the development of a strong sense of coherence; these include a homogeneous society with historical roots, one which is socially isolated but part of the modern world. Jewish religious society can be considered as having these characteristics. This type of society enhances feelings of consistency and meaningfulness through cooperation in decision making, and balances overloads and/or underloads, thus strengthening sense of coherence. Thus, it is expected that the religious adolescents of our three samples who grew up in such a social climate have developed a strong sense of coherence.

Employing the salutogenic approach, our longitudinal study examined psychological reactions and coping resources of adolescents who faced the stressful situation of evacuation of their settlements at three points in time: before the disengagement took place, a few months after the uprooting and five years later. Since the situation was communal in nature, we found it important to examine not only personal resources but also community assets in the three stages of the study.

Sense of Community

In the past decades there has been growing research interest in the idea of communities, belonging to communities and the assets the community provides for its members (17).

In an era of globalization, there is a need to belong and to have social support (18). “Sense of community” (SOCM) describes bonding, trust and group membership (19) as well as mutual concerns and shared values among group members, leading to a sense of connection (20). Sense of community is not a result of concrete experience but rather a way of thinking in which the individual is part of a community which is or will be available when s/he needs it. Therefore, a sense of community is possible even in a new place, before personal relationships have developed (21). A different dimension of sense of community is ‘‘place attachment’’ (22) which means an emotional connection of people to their neighborhood or city (23, 24). When 111

Sense of Coherence and Sense of Community and Disengagement from the Gaza Strip

people are displaced from communities in which they have been deeply rooted, their individual and communal aspects of self-definition can be threatened (25).

Research indicates that people who have a strong sense of community will feel connected to their community.

They will perceive themselves as able to influence their community and to be influenced by it and will believe that their needs are being met in the collective and they will feel obligated to the community to which they belong (26).

A strong sense of community seems to be an attribute of resilient communities (27-30). As a result, sense of community has been found to be a protective factor against developing symptoms of depression (31), posttraumatic stress symptoms and other emotional problems among adolescents exposed to diverse kinds of stress (32, 33).

Indeed, previous research involving evacuation for political reasons has found that the evacuation threatened the evacuees’ sense of place, their sense of belonging to their own community and to the entire “Israeli community,” and that it severely damaged their convictions and values (34, 35). Thus, especially when displacement is political and/or ideological in nature, it appears that coming from a strong community could have a counter effect, that is, leaving such a community could lead to more adverse effects and greater mental health problems than leaving a weaker community (36).

Acute vs. Chronic Stress Situations

Our study examined religious adolescents before the disengagement, a few months later and five years after the disengagement. The three stages can be differentiated according to acute vs. chronic stress situations (7). We consider the first stage, before the disengagement, as an acute stress situation, while the second and third stages are characterized as more chronic stress situations (7).

The literature on psychological and behavioral effects of displacement on adolescents reveals a wide spectrum of reactions with a variety of problems such as anxiety, posttraumatic stress, depression, somatic complaints, aggressive behavior and anger (4, 8, 37). While most studies relate to displacement during wars or natural disasters, Sagy and Antonovsky (8) studied a similar disengagement in the context of a political situation.

Their study related to the evacuation of Israeli communities from Sinai more than 20 years ago following the peace treaty with Egypt. In that research, the evacuated adolescents were compared with Israeli adolescents who lived in southern Israel and had not been evacuated from their homes. Anxiety and anger were higher among 112

the evacuated youths. However, immediately after the evacuation both anxiety and anger dropped significantly.

Furthermore, in the acute state, just before the evacuation, coping resources did not explain the evacuees’ anxiety at all. However, when the situation became a more “normal” chronic stress situation, resources made a significant contribution to the explained variance.

Similar to the above mentioned research, this study too examined acute vs. chronic states of stress: the acute state, during the disengagement, and two chronic situations: a few months later, and then, a few years after the disengagement. We expected that during the acute state, the resources would have less explanatory power compared to the two chronic states.

In accordance with the literature review, the following were our research hypotheses: 1. We expected the stress reactions, state anxiety and state anger to be higher before and immediately after the disengagement compared to the third stage. At this stage, five years later, the evacuees had been settled, even if not permanently, and had returned to some routine which could help decrease the state anxiety and anger (8, 38).

2. We expected sense of coherence (SOC) to fluctuate during the different stages of the research (39) because of the major rupture and ensuing crisis. As for the environmental coping resource, we expected sense of community (SOCM) to be strongest during the first stage and to deteriorate as result of the crisis (40).

3. We anticipated that, while the personal resource of SOC would have a protective effect, with stronger SOC linked to fewer symptoms of anxiety and anger (41), the community resource of SOCM would have a counter effect with strongest SOCM linked to more anxiety and anger (36). We further expected that time would have a moderating effect. Thus, during the first stage, when the situation was acute, the personal and environmental coping resources would explain stress reactions to a lesser extent compared to the more chronic states of stress, a few months after the disengagement and five years later (8, 41).

Method Sample and procedure

One hundred and four Jewish-Israeli teenagers who lived in the Gaza Strip settlements participated in the first phase; 77 adolescents participated in the second phase and 115 adolescents participated in the third phase. Participating

Orna Braun-Lewensohn et al.

adolescents were aged 12-18. Means and SDs of the age of participants were: Stage 1: M=15.75, SD=1.86; Stage 2: M=16.46, SD= 1.32; Stage 3: M=17.07, SD=1.37. Females accounted for 81% of the first stage sample; 84% of the second sample and 48% of the third stage sample. Regarding parents’ education, in the first stage, 79% of the fathers and 86% of the mothers had post-high school education.

This was the case for 75% of the fathers and 70% of the mothers in the second stage and for 73% of the fathers and 68% of the mothers in the third stage.

Data were collected by self reported questionnaires before the disengagement (in May-August, 2005); two to four months after the disengagement (Oct.-Dec. 2005) and five years after the disengagement (May-July, 2010). Community leaders were greatly suspicious of the research since they thought it had a political agenda.

Thus, we did not get permission from school principals to enter schools. In the first two stages, adolescent research assistants administered the self reported questionnaires to their peers, and in the last stage, the last author administered the questionnaires to adolescents. All questionnaires were administered to the adolescents in their homes, and permission was received from their parents. It seems that since our research assistants in the first two stages were girls, we had a majority of girls in these stages. In the last stage, the author tried to balance the sample. When approaching the adolescents informally and personally, they were very cooperative.

Similar administrative procedures were applied for the three stages of the research. The involvement of the administrators of the questionnaire was minimal and included only explanations of words which participants did not understand. Since questionnaires are frequently used for adolescents, almost no such involvement was needed. All participants were informed that the researchers were interested in their experiences, and anonymity was emphasized. Participation was voluntary.

Measures • State Anxiety (42) was assessed using the Hebrew version of the State-Trait Anxiety Inventory (STAI). It has proved to be reliable, valid and equivalent to the English inventory (43). State anxiety includes 11 items from the 20 item inventory of the STAI (on a Likert-type scale, ranging from 1 to 4). Examples of questions are: I feel peaceful, I am afraid of disasters, I am worried, and others. Cronbach’s alpha ranged from .85 to .89.

• State Anger (42). The Hebrew translation (43) was used

in order to assess adolescents’ anger. This translation has proved to be reliable, valid and equivalent to the English State Anger Inventory (43). The scale consists of six items on a 4-point Likert scale. Examples of questions are: I am angry, I want to scream at someone, I feel frustrated. Cronbach’s alpha reliability ranged from .85 to .88.

• Sense of Coherence (SOC) was measured using a series of semantic differential items on a 7-point Likert-type scale, with anchoring phrases at each end. High scores indicate a strong SOC. An account of the development of the SOC scale and its psychometric properties, showing it to be reliable and reasonably valid, appears in Antonovsky (10, 44). In this study, the SOC was measured by the short form scale consisting of 13 items and was found to be highly correlated to the original long version (44). The SOC scale has been found to be valid in many languages including Hebrew (45).

The scale includes items such as: “Doing the things you do every day is” − answers ranging from (1) “a source of pain and boredom” to (7) “a source of deep pleasure and satisfaction.” In the present study, the Cronbach’s alpha ranged from .74 to .81.

• Sense of Community (SOCM) was measured by a scale developed by Davidson and Cotter and has been found to be reliable and valid (26). It consists of 17 questions, scored on a 4-point Likert scale. The scale was translated into Hebrew and was validated by Sagy et al. (46). It includes items such as: “I feel like I belong here” (membership); “It is hard to make friends and meet people in this place” (influence); “It would take a lot for me to move away from this community” (shared emotional connection). In the present study we used 15 of the 17 questions. The two questions which were omitted relate to politics in the community and religious observance. Since these questions could have evoked antagonism and unwillingness to answer the entire questionnaire, it was decided to omit them.

Cronbach’s alpha ranged from .75 to .84.

Data analyses

First, frequencies and percentages of the samples’ demographics were explored. Second, a one-way Anova was run to explore differences between the groups on the study’s variables. To understand the unique impact of each of the variables and interaction effects as well as the cumulative contribution to the investigated outcomes, a hierarchal regression analysis was carried out for each dependent variable.

113

Sense of Coherence and Sense of Community and Disengagement from the Gaza Strip

Statistical analyses were conducted with SPSS Version 18 and the accepted p levels were set at alpha<.05.

and five years after the disengagement. Sense of community, in turn, dropped significantly immediately after the disengagement and has not recovered since then.

Therefore, hypothesis 2 is supported.

An examination of the third hypothesis shows that while SOC was found to be significant in explaining both anxiety and anger, SOCM did not explain any reaction.

Thus, the first part of our third hypothesis is accepted for SOC which was significant for both reactions.

In order to examine our moderation hypothesis we tested interactions of the stage of the research and each of the coping resources. When entered in step 2 the interaction of stage X SOC was marginally significant (p=.053) and stage X SOCM was significant for anxiety. Both interactions were not significant for anger. Thus, we decided to run a separate regression for each stage with both SOC

Results Examination of the second hypothesis show significant differences among the three stages in state anxiety but not in state anger. Overall, results show that, five years after the disengagement, levels of anxiety were lower than the first stage prior to the disengagement. However, there was no significant change in levels of anger. Therefore, hypothesis 1 is supported for state anxiety but not for state anger.

Changes in personal and environmental coping resources were also found. The level of SOC was the lowest immediately after the disengagement and was significantly different from the pre-disengagement stage

Table 1. Mean, SD and F values of the different variables in the different stages of research May-Aug. 2005 (a)

Oct.-Dec. 2005 (b)

May-July 2010 (c)

M

SD

M

SD

M

SD

df

F

p

State Anxiety (Range 1-4)

2.93

.66

2.95

.66

2.33

.63

2

26.18

State Anger (Range 1-4)

2.21

.85

2.31

.82

2.12

.81

2

1.10

.33

Sense of Coherence (Range 1-7)

4.64

.83

3.98

.87

4.53

.74

2

16.32 ab, bc

.00

Sense of Community (Range 1-4)

3.45

.43

2.21

.57

2.90

.45

2

154.51 ab, ac, bc

.00

.00

ac, bc

Table 2. Sense of coherence and sense of community as explanatory factors of stress reactions in three different stages of the disengagement from Gaza State Anxiety R Step 1 Sense of Coherence Sense of Community

2

.22

Step 2 Sense of Coherence Sense of Community Stage X sense of coherence Stage X sense of community

.08

State Anger

B

β

SE

t

-.42 .07

-.49 .07

.05 .06

-8.45*** 1.15

-.13 .84 -.06 -.16

-.15 .81 .33 .78

.14 .20 .03 .04

-.91 4.28*** -1.95 -4.06***

R

2

.16

.01

B

β

SE

t

-.40 -.01

-.40 -.01

.06 .07

-6.66*** -.20

-.19 .19 -.05 -.04

-.19 .16 -.21 -.18

.18 .25 .04 .05

-1.08 .76 -1.17 -.84

***p<.001

Table 3. Sense of coherence and sense of community as explanatory factors of anxiety in three different stages of the disengagement from Gaza May-Aug. 2005 R2

B

β

SE

Oct.-Dec. 2005 t

R2

B

β

SE

May-July 2010 t

R2

B

β

SE

t

Sense of Coherence

.09

-.27

-.32

.08

-3.28***

.38

-.41

-.55

.07

-5.68***

.27

-.45

-.52

.08

-5.72***

Sense of Community

.02

.23

.15

.15

1.50

.06

-.28

-.24

.11

-2.53*

.00

.00

.00

.12

-.04

**p<.01 ***p<.001

114

Orna Braun-Lewensohn et al.

and SOCM as independent variables and state anxiety as dependent variable. Results are presented in Tables 1-3.

As hypothesized, the coping resources better explained anxiety a few months after and five years after the disengagement (chronic states) compared to the pre-disengagement stage (acute state). It appears that sense of community was significant in explaining anxiety only a few months after the disengagement but not in the other stages. Further, contrary to our expectations, it had a protective effect. SOC had the strongest explanation of anxiety immediately after the disengagement. We can conclude that our moderation hypothesis was supported for anxiety.

Discussion This study explored stress reactions (state anxiety and state anger) as well as individual and environmental coping resources (sense of coherence and sense of community) among religious adolescents: before and after the disengagement from the Gaza Strip. The first stage took place during the acute stress situation of the threat of the Jewish communities in Gaza to be displaced, while the two other phases were carried on in the chronic state, when the acuteness was over, a few months later and five years after the uprooting.

Our first hypothesis was comparative and related to the three stages. We found a different pattern in each of the stress reactions. While state anxiety followed our expectation and was higher before and a few months after the disengagement, state anger did not follow the same pattern.

It seems that levels of anxiety of the adolescents were connected to the vagueness of the situation as well as to the threat of the destruction of their home and community (4, 47). Anxiety was reduced only after five years, as most families have established some routine and have a place to live even if it has not been a permanent place and of lower quality than their previous homes in the Gaza Strip.

Anger, however, has not decreased significantly over time. It appears that more than anxiety, anger expresses the feelings of the evacuees. Adolescents, as well as adults of this population (48) have felt that the leaders of the state betrayed them and their mission. It seems that the incongruence between the political reality and the particular ideology of the settlers (49), as well as the loss of existential meaning in their lives, have become the main feelings among this population (50, 51). This discrepancy could lead to feelings of anger rather than to anxiety (8).

We also examined the individual and environmental coping resources over time. Our hypothesis that SOC would

fluctuate during the three stages (39) was accepted. Our study indicates that being exposed to a break in a value system and living in unstable and chaotic life conditions can weaken the individualâ&#x20AC;&#x2122;s resources, the ability to make sense of the world and to perceive it as manageable. As a result of these experiences, SOC could be meaningfully weakened. Our results indeed show a major drop in sense of coherence immediately after the disengagement. Five years after the disengagement, however, the SOC of the adolescents had been rehabilitated. These results show a different pattern from a recent study which examined stress over long periods of missile attacks in southern Israel (39).

In the present case, when there was just one acute stressful situation, we found potential for recovery of this important personal resource was clear. A long lasting stressful situation led to continuously deteriorating SOC (39). It appears that the strong beliefs of this ideological group have enabled them to maintain a high sense of coherence in the long run, in spite of some decline in the acute period.

Regarding the second coping resource, sense of community, it was strongest in the first stage of the research, significantly dropped after the uprooting and it never recovered.

The religious communities in the Gaza Strip were known to be unified and powerful. They were imbued with a strong ideology characterized by support for â&#x20AC;&#x153;Greater Israel.â&#x20AC;? Before the disengagement these communities protested against it and did not cooperate with the establishment in planning the future after the uprooting (1). Thus, it is not surprising that before the disengagement the adolescents felt a strong sense of community as they were still part of the community in which they had grown up, and they believed that their ideology would sustain them. However, the disengagement led to the disappearance of strong cohesive communities as residents of each community had been separated and settled in numerous places. Our results show that feelings of belonging to the community have not recovered among the adolescents. Five years after the disengagement it was possible to rehabilitate the personal resource of SOC but not to return to the sense of strong community. The damage had been mostly to the community level and to the feelings of belonging to the wider collective.

The second hypothesis related to the contribution for explanation of anxiety and anger by the different coping resources. Our most meaningful results relate to SOC which was found to have the strongest protective role for both stress reactions. It appears to be as important a personal asset for adolescents as it has been usually found for adults. Moreover, it appears to have a special significance even in a communal situation. Perhaps this explanatory 115

Sense of Coherence and Sense of Community and Disengagement from the Gaza Strip

power of the personal SOC can be understood on the backdrop of the distinctions of the communal life.

The last question related to the moderation effect in the three stages of the research. As was expected we found a different effect of the coping resources on anxiety in each of the three stages. Our results followed previous findings in which, in the acute situation (before the disengagement), the coping resources had less explanatory power compared to chronic states (a few months after and five years after the disengagement) (8, 52). These results support the suggested model (52) of distinguishing between acute and chronic stress in the way coping resources operate in each state.

To conclude, it seems important to prepare communities and individuals for a variety of stressful situations. The model is built on the assumption that during the acute stage the situation is overwhelming and the actual exposure to the stressful situation contributes significantly to the explanation of stress reactions. During chronic stress situations, however, personal and environmental coping resources become significant in explaining coping and stress responses (52). Thus, when the situation is acute it is most important to address situational characteristics to deal with the event/s, while, for chronic state situations which resemble more “normal” life, it is most important to enhance personal coping resources in particular.

Relating to the specific situation of uprooting, it seems most important to plan this kind of move on the community level and to include the entire community. When communities can move as a whole to a different place, it might conserve their strengths and assets. In addition, it is important to work on connectedness to the new place and new people. There should also be close relations to significant adults, so that adolescents would feel that they can be supported by them. Having said that, it is important as well to provide help to significant adults, especially teachers and educators, whose role is to reorganize and to help the youngsters develop new meaningful relations with their surroundings. Such reorganization could positively impact the meaningfulness and manageability aspects of the personal SOC of adolescents which appears to be an important asset in the long run.

consist of youngsters whom we were able to reach during the different stages. Thus, some degree of potential sample bias should be taken into account. Apparently, the distribution according to socio-demographic criteria was not sufficient.

Additionally, since all the data are retrospective selfreports, the extent to which adolescents’ experiences of stress converge with external observations, such as parental, teacher and clinical reports, remains to be investigated.

Although young people’s self-reports are generally a reliable source about internalizing and stress experiences, an assessment of outcomes may benefit from multiple informant evaluations. As a rule, the multi-informant paradigm facilitates evaluating youngsters’ psychological difficulties in different environments (54).

In spite of these limitations, the importance of this study is in its being a field research carried out in the midst of the stressful situation among adolescents who had to be evacuated from their homes and communities.

Strengths and limitations

1. Hirschberger G, Ein-Dor T. Defenders of a lost cause: Terror management and violent resistance to the disengagement plan. Pers Soc Psychol Bull 2006; 32:761-769.

2. Shamai S, Arnon S, Schnell I, Luzon N. Sense of place components of the uprooted people of Gaza strip and Northern Samaria. Soc Issues in Israel 2011;11: 8-40 (Hebrew).

3. Schnell Y, Mashaal S. Displacement from place and settlers talk about the evacuation from Gush Katif. Jerusalem: Florsheimer Institute for Policy Research, 2005 (Hebrew).

The uniqueness of this research involves the special population with their strong belief system that included a high ideological commitment to build their homes in the Gaza Strip (53). However, beyond the suggestions enumerated above, we must consider the limitations of the study. The samples are neither representative nor random but rather 116

In conclusion, individual and environmental coping resources were found to be significant protective factors when adolescents face stressful situations such as displacement from home as a result of a political agenda.

The results of this study show that most adolescents who faced this very stressful situation of being permanently evacuated from their homes and experiencing a major break in their value system can be rehabilitated and stay healthy in the long run. Our results support the grounded theory of salutogenesis upon which this research is based.

Furthermore, these results, once again, support the notion that different interventions should be applied in different states of stress (41). When the stress is acute, it seems important to target the situation itself, in attempting to help people cope better. However, when the situation becomes chronic it is important to strengthen personal and community coping resources. Additionally, it seems that coping resources can be recovered even after severe crisis. These results should alert policy makers, educators and health practitioners to the possibilities of strengthening the personal and environmental resources.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Trauma and Psychological Distress Observed in Journalists: A Comparison of Israeli Journalists and their Western Counterparts Yael Levaot, MA,1 Mark Sinyor, MSc, MD,1 and Anthony Feinstein, MPhil, PhD, FRCP1,2 1

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

2

Abstract Background: There is limited evidence on how reporting war influences journalists’ psychological wellbeing. A significant minority of journalists may develop symptoms of emotional distress; however it is unclear whether the type and amount of distress differs between those journalists who report from potentially dangerous areas within their own country compared to those who do so from war zones in other countries.

Method: We compared indices of psychological health in 38 Israeli journalists with 38 Western journalists whose careers have been defined by work in war zones.

Results: While both groups reported high levels of exposure to traumatic events, there were no significant differences in frequency or type of exposure between the groups. Western journalists reported more frequent posttraumatic stress disorder (PTSD), intrusion-type symptoms and drank more alcohol while Israeli journalists reported higher levels of depression, anxiety and somatic distress.

Conclusion: This pattern of results suggests that social circumstances and environmental factors may influence how different groups of individuals respond to traumatic events.

Introduction Journalists who cover war and disasters have significantly elevated levels of psychological difficulties relative to colleagues who limit their reportage to domestic events Address for Correspondence:

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(1). What is less clear is the psychological health of journalists who both work and live in environments that are periodically dangerous. Israel represents one such place with the country nicknamed a “lab of stress” (2).

On the one hand, working within one’s own community may confer added social support (3). On the other, frequent exposure to life-threatening events in one’s “backyard” could potentially have the opposite effect through increased levels of stress. There are no studies examining how exposure to dangerous circumstances within their own communities impacts on the mental health of journalists. Our study investigated potential social and environmental implications by comparing the psychosocial health of a group of Israeli journalists with a control group composed of war journalists working for American and British news organizations.

Methods Three Israeli Television and Print news organizations were contacted to take part in the study and all agreed. Of the 58 journalists we were able to reach, 38 (66%) agreed to participate. Control subjects were derived from a large database of Western journalists whose careers are defined by conflict and disaster reporting. Details of this group have been published elsewhere (4). Thirty eight control journalists were selected based on a demographic match (age, gender, education, years of work in journalism and type of work) with the Israeli group. Type of journalism was controlled for because of previous evidence showing that journalists who were in the visual media (stills photography, cameramen/women.) have higher rates of global psychological distress and PTSD (1). Israeli journalists’ usual genre of reporting was not controlled for since all types of journalists are recruited to report on

Anthony Feinstein, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.

ant.feinstein@utoronto.ca

Yael Levaot et al.

war intermittently. This study was powered to detect 20% absolute differences in the primary outcome measures of PTSD symptomatology and psychological distress to a confidence level of 95%.

Both groups of journalists completed the same series of questionnaires online in a study dedicated, secure website. Demographic data consisted of age, gender, education, previous military service, marital status and the number of years worked as a front line journalist.

As described in detail previously (1, 4), psychometric data included the Impact of Event Scale-Revised (IES-R) for PTSD symptomatology, the 28-item General Health Questionnaire (GHQ) for overall levels of psychological distress and the Trauma History Questionnaire (THQ) to quantify exposure to potentially traumatic situations.

The IES-R captured symptoms present during the past week; the GHQ had a one month symptom window; the THQ documented the number of times journalists had been exposed to potentially traumatic situations over the course of their lifetimes.

Data pertaining to the journalistsâ&#x20AC;&#x2122; use of illicit drugs (cannabis, amphetamines, cocaine, barbiturates, and LSD) and alcohol were also obtained. Problem drinking was defined as consumption of more than 14 units of alcohol per week for men and nine units for women (5), a unit being defined as a bottle of beer, glass of wine or shot of spirits.

All statistics were performed using SPSS version 12.0.

Categorical variables were analyzed using 2-sided chisquared tests. Continuous variables were compared using two-tailed, t tests. Given the small sample size and our inability to assure that data on the two populations are normally distributed, Mann-Whitney U tests were also

run for all continuous variables (6). Statistical significance was set at p<0.05.

Both sets of data collection received ethics approval from the Sunnybrook Health Sciences Centre Research Ethics Board prior to the investigation. Written informed consent was obtained from all subjects.

Results Demographic data for the Israeli and control journalists are shown in Table 1 and reveal tight group matching.

While none of the Western war journalists did military service, all of the Israeli journalists had served in the Israeli army. Fifteen (39.5%) of them had seen combat as soldiers but only about half of this group (7/15) rated their military experience as more emotionally difficult than their work experience as front line journalists. Most Israeli journalists (71.1%) felt that their military experience was helpful for their later professional encounters with traumatic events.

Behavioral and psychiatric differences between the two groups are shown in Table 2. War journalists reported more intrusions on the IES-R scale than the Israelis (6.4 vs. 3.1 t=-2.77, df=58, p=0.007; Mann Whitney U=288, p=0.035). The Israelis reported statistically higher amounts of distress on each of the GHQ subscales and in the total GHQ score. There were no statistical differences between the groups on the THQ. Both groups were exposed to a significant amount of traumatic events.

Israeli journalists consumed less alcohol than the control group (4 drinks/week vs. 14 drinks/week, t=-2.34, df=58, p=0.023; Mann Whitney U=220, p<0.001) and were individually less likely to exceed recommended

Table 1. Demographic Factors used to Match Israeli Journalists with Western War Journalist Controls Israeli (n=38)

Control (n=38)

Characteristic

Mean

SD

Mean

SD

T

df

p

Mean age

37.5

6.90

37.5

6.89

0.17

74

.987

Number of years in journalism

13.0

5.12

13.1

5.60

-0.09

74

.932

N

%

N

%

Χ

df

p

Gender male Female

30 8

78.9 21.1

30 8

78.9 21.1

0.00

1

1.00

Highest education level school post-secondary

8 30

21.1 78.9

4 34

10.5 89.5

1.58

1

.208

Type of Journalist print photographer/ broadcast camera/ recordist print reporter/broadcast reporter/ broadcast producer/executive both photographer and reporter

7 30 1

18.4 78.9 2.6

8 30 0

21.1 78.9 0

1.07

2

.587

2

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Trauma and Psychological Distress Observed in Journalists

Table 2. Behavioral and Psychiatric Characteristics of Israeli Journalists with Western War Journalist Controls Israeli (n=38)

Control (n=38)

Mean

SD

Mean

SD

t

df

p

95% Cl

MannWhitney U

M-W p value

4.09

4.03

13.8

19.1

-2.34

58

.023

-18.0 to -1.42

220

.000

Impact of Events Scale-Revised Intrusion Avoidance Arousal Total

3.09 3.65 1.35 8.09

3.44 3.94 2.39 8.78

6.35 5.24 3.14 14.7

5.68 5.66 3.66 13.7

-2.77 -1.28 -2.29 -2.29

58 57 58 58

.007 .205 .026 .026

-5.62 to -.909 -4.08 to .895 -3.35 to -.224 -12.5 to -.832

288 378 311 307

.035 .461 .070 .071

General Health Questionnaired Somatic Anxiety Social Dysfunction Depression Total

4.03 5.09 5.97 1.22 16.3

2.62 3.73 2.49 1.88 7.72

.730 1.30 1.35 .243 3.62

1.30 1.84 1.92 .641 4.72

6.47 5.24 8.68 2.80 8.08

44 44 67 37 50

.000 .000 .000 .008 .000

2.27 to 4.33 2.34 to 5.26 3.56 to 5.68 .269 to 1.68 9.54 to 15.8

132 232 112 318 98

.000 .000 .000 .000 .000

Trauma History Questionnairee Crime General Physical Total

1.67 24.0 .286 26.0

1.80 21.8 .463 22.4

3.47 21.2 .605 25.3

3.59 15.3 .755 17.4

-2.57 .533 -2.01 1.41

57 31 56 57

.013 .598 .049 .889

-3.21 to -.400 -.809 to 13.8 -.638 to -.002 -.976 to 11.2

281 397 317 384

.057 .975 .131 .812

N

%

N

%

χ2

df

p

12 23 3

31.6 60.5 7.9

20 16 2

52.6 42.1 5.3

3.46

2

.178

Exceeds weekly recommended alcohol dose no yes

22 0

100 0

20 18

52.6 47.4

14.9

1

.000

Drug abuse none present

18 3

85.7 14.3

29 9

76.3 23.7

.737

1

.391

Characteristic Weekly units of alcohola,b c

Marital status single married divorced/separated a

a. A unit of alcohol was defined as a regular-size bottle of beer, a glass of wine, or a shot of spirits. Fourteen units of alcohol per week for men and 9 units for women were considered the upper limits of acceptable weekly intake. b. Israeli: N=22; Control: N=38 c. Israeli: N=23; Control: N=37 d. Israeli: N=32; Control: N=37 e. Israeli: N=21; Control: N=38 f. General Health Questionnaire scores ≥ 5 are considered mental health cases. g. Centre for Epidemiologic Studies Depression Scale ≥ 16 (Israeli) and Beck Depression Inventory Scores ≥ 19 (Control) are considered “cases” of depression.

alcohol intake for the week (0% vs. 47%, χ2=14.9, df=1, p<0.001). There was no statistical difference between the groups for drug abuse.

Discussion This study compared Israeli journalists to a matched control group of Western war journalists and found significant differences in psychiatric and behavioral characteristics between the groups. Israeli journalists reported statistically higher amounts of distress on each of the GHQ subscales and in the total GHQ score. Western journalists drank much more heavily and showed higher rates of intrusion symptoms on the IES-R. Given that our study was primar120

ily descriptive in design we cannot explain these group differences with certainty. Nevertheless, some interesting hypotheses offer possible explanations.

Our data strengthen previous findings that conflict journalists are frequently exposed to dangerous and potentially traumatic situations (1, 4). Of note, however, is that while the Israeli journalists had been exposed to similar lifetime levels of traumatic events relative to the control group of war journalists, this broad statistic could in theory hide some individual differences. This reflects, in part, the limitations of the Trauma History Questionnaire, which records frequency, but not intensity of exposure to a life threatening event. It is plausible that the war group whose work environments included the

Yael Levaot et al.

current conflicts in Iraq and Afghanistan had confronted a greater level of personal threat than their Israeli colleagues and this was reflected in their higher intrusion scores on the revised Impact of Event Scale. Alternatively cultural differences, military service experience and different work circumstances (i.e., reporting from oneâ&#x20AC;&#x2122;s own country vs. a foreign country) may have influenced these results. The lower IES-R intrusions in the Israeli group may be explained by added social support of reporting from their own community blunting or reducing PTSD symptoms as has been previously reported (3). It has also been postulated that Israelis have undergone a habituation process that may mitigate PTSD symptoms (2). This is underscored by our finding that most Israelis (71.1%) found the military experience helpful in preparing them for conflict journalism.

Having made the point that working in oneâ&#x20AC;&#x2122;s own community may offer some protection from developing PTSD type symptoms, the chronicity of exposure to stress may heighten other manifestations of distress. Here the results of the General Health Questionnaire in our study are revealing. The higher depression, anxiety and overall GHQ scores in the Israeli group may reflect their personal involvement in the ongoing conflict. When interpreting the GHQ results, however, it is important to bear in mind that the scale is a broad measure of emotional health and not a specific trauma based instrument. It is therefore possible that the elevated GHQ scores in the Israeli group had little to do with exposure to trauma, but rather reflected social stressors such as difficult working conditions and economic strain. Finally, cultural factors must be considered in interpreting the data. The GHQ has been used extensively in a variety of settings worldwide (7) with results showing considerable regional variations in data. Typically, scores from Middle Eastern, African and Asian countries have been higher than those recorded in European and North American populations (8, 9) and the Israeli data can be viewed in this light. The role of culture in influencing psychometric results is underscored by our substance data where significantly lower levels of alcohol consumption were recorded in the Israeli group (10).

Our study is the first to examine differences between journalists from different cultures. It has several important limitations. The response rate in the Israeli sample was modest as was the sample size in general. Furthermore,

the absence of structured interviews means that we cannot make diagnoses in either group and cannot omit the possibility of long term effects of military training on the findings. Another potential confounder is that many of the Western journalists specialize in conflict journalism whereas Israeli journalists report on a variety of other topics and are intermittently enlisted for conflict reporting. This could potentially bias the results in favor of more trauma exposure and likewise more distress in the Western journalist group. Nevertheless, the overall THQ scores demonstrate that both groups have comparable exposure to traumatic circumstances.

Finally, the psychometric scales were not translated into Hebrew and, despite the fact all Israeli participants were fully fluent in English, results may not have captured adequately cultural nuances.

In summary, we have presented data demonstrating that Israeli journalists and demographically matched Western war journalists exhibit differences in psychopathology rates despite similar exposure to similar levels of danger.

Our findings highlight the importance of contextual differences in the study of traumatic stress.

References 1. Feinstein A, Owen J, Blair N. A hazardous profession: war, journalists, and psychopathology. Am J Psychiatry 2002; 159:1570-1575.

2. Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. Jama 2003; 290:612-620.

3. Marmar CR, McCaslin SE, Metzler TJ, Best S, Weiss DS, Fagan J, Liberman A, Pole N, Otte C, Yehuda R, Mohr D, Neylan T. Predictors of posttraumatic stress in police and other first responders. Ann NY Acad Sci 2006; 1071:1-18.

4. Feinstein A, Nicolson D. Embedded journalists in the Iraq war: Are they at greater psychological risk? J Trauma Stress 2005; 18:129-132.

5. Bondy SJ, Rehm J, Ashley MJ, Walsh G, Single E, Room R. Low-risk drinking guidelines: The scientific evidence. Can J Public Health 1999; 90:264-270.

6. Mann T. Deutschland und die Deutschen. [Vortrag, gehalten in der Library of Congress zu Washington im Juni 1945]. Stockholm: BermannFischer, 1947.

7. Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, Rutter C. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997; 27:191-197.

8. Segopolo MT, Selemogwe MM, Plattner IE, Ketlogetswe N, Feinstein A. A screening instrument for psychological distress in Botswana: Validation of the Setswana version of the 28-item general health questionnaire. Int J Soc Psychiatry 2009; 55:149-156.

9. Furukawa T, Goldberg DP. Cultural invariance of likelihood ratios for the General Health Questionnaire. Lancet 1999; 353:561-562..

10. Flasher LV, Maisto SA. A review of theory and research on drinking patterns among Jews. J Nerv Ment Dis 1984; 172:596-603.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist Rael D. Strous, MD1,2 1

Beer Yaakov Mental Health Center, Beer Yaacov, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

2

Introduction

Abstract Despite the advances of civilization, conflict remains in many areas around the world. Often psychiatry finds itself playing an essential role in dealing with the consequences of conflict or influencing the process. Along with this involvement comes great responsibility as well as many associated ethical dilemmas. Although bound by professional medical oaths, many physicians disregard fundamental medical ethical principles during times of conflict and situations of “dual loyalty.” The phenomenon should be addressed so that ethical awareness and sensitivity to these issues are nurtured. Important factors for psychiatrists during times of conflict to consider include their “social contract” with the community, dangers of boundary violations, the ethics of media contact, involvement in governmental and political activities and confidentiality. In addition, their role in conflict resolution and unique ethical considerations in the military should be considered. While as regular citizens, psychiatrists in their individual capacity may involve themselves in political activism, at an organizational level it should be discouraged. A physician’s skills should only be exploited to save lives and provide comfort as entrusted by society, and any other pursuit, even in the name of the state, should be proscribed. Rather than engage in political activism, psychiatrists can promote the rights of patients, especially if these rights are limited during conflict. Responsibility and ethically-driven commitment needs to be primary for the psychiatrist who involves himself either directly or indirectly with patients during times of conflict. Trauma and its effects during conflict should be addressed without any unbalanced attention to pathological responses.

Address for Correspondence: Israel raels@post.tau.ac.il

122

Unparalleled developments and opportunities exist in medicine today as technology and our knowledge of epidemiological factors associated with disease progress in leaps and bounds. Many barriers at the international level have been scaled down or removed and a state of globalization prevails in a manner that it never has since the beginning of recorded history (1-3). However, despite these remarkable advances, modern society remains in a perpetual state of conflict to varying degrees in many areas of the world (4). People in the medical profession in general, and often the field of psychiatry in particular, frequently find themselves playing an essential role in the conflict: either being called upon to deal with the consequences of conflict or directly playing a role and influencing the process (e.g., 5-8). Along with this involvement in times of conflict comes great responsibility. More importantly, many ethical issues arise which are associated with this involvement. Considering the often intensive involvement of psychiatrists during such times, it is critical to discuss the dilemmas that arise and become aware of the important issues. Although it is usually accepted that all doctors are bound by their professional medical oaths with comparable value systems, in practice many physicians appear to disregard fundamental ethical principles of medicine during times of conflict and situations of “dual loyalty” between the individual and state (1).

While there is often no one correct way of dealing with the issues, it remains essential to address the topic so that some level of ethical awareness and sensitivity is nurtured. In this paper, some of these issues will be addressed, including dangers of boundary violations and the ethics of media contact, involvement in governmental and political activities and confidentiality during times of conflict. In addition, the role of the psychiatrist in conflict resolution

Rael Strous, MD, Director Chronic Inpatient Unit, Beer Yaakov Mental Health Center, POB 1, Beer Yaakov 70350,

Rael D. Strous

will be explored as well as some of the unique ethical factors applying to psychiatrists working in the military.

It is hoped that the concepts discussed will be able to be extended to other dilemmas that may arise and which may become subject for ethical discussion and analysis.

Social Contract with Community The unspoken contractual relationship that society throughout history has with physicians is clearly associated with the duty to relieve pain and suffering and to manage disease and disability (9). More specifically, psychiatry is characterized by the study of human behavior and mental processes and the subsequent treatment or management of those who are struggling with pain, suffering or impairment in function.

The stipulated “social contract” that psychiatrists have with the community is to describe, understand, predict, and modify behavior, particularly in cases of mental illness and in so doing to alleviate emotional difficulties (10).

In addition, research psychiatrists investigate biological, cognitive, emotional, and social aspects of human behavior.

Along with the right and duty to explore and manage illness comes the right and privilege to enter into patients’ lives in an intimate and invasive fashion, at both the physical and emotional level, that practically no other profession is allowed. Psychiatrists arguably more than anyone else have an extended and privileged access to the human psyche and behavior. However, together with this dispensation comes tremendous responsibility and the primary duty to care and even protect the mental health of patients even under conditions of health inequality (11-13). This is the essence of the profession. Many would consider that to act otherwise would construe abandonment of professional responsibility. It is this responsibility and ethically driven commitment that needs to be first and foremost in the mind of the psychiatrist who involves himself or herself either directly or indirectly with patients during times of conflict.

Boundary Violations The primary problem with involvement in areas not mandated by the social contract that society privileges psychiatrists is violation of boundaries. The term “boundary violation” has been defined by some as a disruption of the acceptable barrier between professional and client. It refers to the distinction between professional and personal identity (14). Boundaries should not be seen as an obstacle to contact, rather they permit and foster safe interaction between the psychiatrist and the patient/

society. Thus professional boundaries define the parameters of the interactive relationship so that the patient/society can interact in a safe atmosphere with a psychiatrist who is responsive, respectful and receptive. Boundaries determine the limits of professional identity and roles and also demarcate the framework of encounters between the professional and layperson and between the professional and broader society. Boundaries come to maintain safety of both parties which is of special importance in times of conflict. Boundary violations thus reflect an affront to the safety of the interaction between the psychiatrist and patients as well as between the psychiatrist and the broader public (15). Any form of boundary violation can be a significantly damaging phenomenon. Unbridled involvement of psychiatrists during times of conflict including political activity and involvement in governmental action without any consideration of ethical principles would be considered a gross boundary violation (10).

While the attraction to involvement in many activities associated with conflict is most certainly understandable, psychiatrists in their professional capacity need to hold back from involvement in areas that supersede medical practice and thus resist any temptation to employ their training and professional skills in areas where they do not belong. If psychiatrists are compelled to participate in political activism, then it is critical that they engage in such activity as “concerned citizens” and not as professionals (10).

Involvement in Government Activities Arguably the most egregious area of involvement of psychiatrists fraught with ethical problems is involvement of psychiatrists in governmental activities to further the aims of the state during times of conflict. Psychiatrists are often called upon by the state to make use of and exploit their unique skills and understanding of human behavior in order to control, punish or manipulate situations where psychiatrists are uniquely poised to assist (e.g., 16). Such situations may range from participation in government sponsored torture and interrogation to coercion and even executions (17). The United Nations Declaration of 1975 (article 1) defines torture as “any act by which severe pain of suffering, whether physical or mental, is intentionally inflicted …… on a person for the purposes of obtaining information or confession.” In addition, such practice or complicity breaches the basic medical ethical principles of the Hippocratic Oath and the World Medical Association Declaration of Tokyo which specifically states that no physician should participate in any “practice of 123

Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist

torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty” (18). It is absolutely prohibited for any physician to participate in such activity – even to facilitate such a process by being present. Physicians including psychiatrists may not be involved in any manner or in any procedure which may cause harm to someone in detention (9). The valuable trust that psychiatrists have nurtured with the community would be jeopardized. While it may be proposed that the psychiatrist’s involvement or participation may contribute some degree of humaneness or protection during interrogation, the military medical professional participating under such conditions which may involve torture and abuse, given methods of aggressive interrogation, would violate basic tenets of human rights law and medical ethical standards (19). Moreover, psychiatrists are required to report any such coercive treatment in order to prevent any complicity in such activity (19).

Even if these activities are in the interest of the state and national security, cooperation by psychiatrists using their skills would be considered a gross boundary violation and therefore deemed unethical conduct (20). To make use of a physician’s skills to do other than save lives and provide comfort as entrusted by society even in the name of the state is a dangerous perversion (21). This is despite the psychiatrist possibly feeling torn with a sense of dual loyalty to both the patient and an obligation to the community and state (9, 19). While the rule of Law is paramount, on medical ethical grounds the duty to care for the individual patient should override any commitment the psychiatrist may have towards the state (22).

Psychiatrists during the Nazi era proclaimed that what they were doing (medical experimentation, euthanasia of mentally-ill and those unfit to work) was in the best interests of society and the country. Nevertheless, what they succeeded in accomplishing contributes to the time being considered one of the darkest periods in the history of medicine. They allowed the political atmosphere of the time to influence their professional activities. Few refused to cooperate even though those who did refuse were generally spared any retribution. They failed to recognize that civic duty in times of conflict can never override medical ethical principles (23).

Confidentiality In the midst of turmoil and conflict, both acute and chronic in nature, psychiatrists are often called upon to provide 124

information regarding situations or individuals. For example, following terror or kidnapping, psychiatrists may be consulted by private individuals or the public (media, agencies, government, etc.) to provide data, statistics or information regarding degree of acute or chronic psychological injury of those affected. In addition, psychiatrists may be approached for information regarding medical/psychological status or for an opinion of a national or international political leader. It should be stated unequivocally that without having received permission from the individual, it is unethical to provide any professional analysis of the individual’s personality, ability, competence or functionability. This is in addition to the fact that the psychiatrist has not examined the leader. Along these lines, following the problematic “Barry Goldwater affair,” in 1973 the American Psychiatric Association (24) published an unambiguous statement forbidding such analyses in a document entitled “Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.” Even if the leader is not a patient of the physician, medical ethical principles are still relevant.

It should be noted that the high standards of confidentiality which apply even in times of conflict would not necessarily apply to the same extent for political analysts or social scientists who, in contrast to the physician, may render opinions of leaders and political processes. The psychiatrist is held to a higher standard in light of his or her strict code of professional ethics. Any breach of this sacred code of confidentiality and confidence that the community places in the psychiatrist would greatly compromise the psychiatrist’s ability to provide treatment. It may as well compromise the patient’s desire to seek help and assistance.

Conflict Resolution While it is important to be aware of the unacceptable behaviors during times of conflict, it is as important to be cognizant of where psychiatrists may play a role in conflict resolution. There is a wide range of approaches to deal with conflict at both the individual, national and international level. Based on an academic and clinical understanding of human and group behavior, psychiatrists together with other social scientists may contribute to the resolution of conflict and political upheaval by means of suggestions as to how to diminish the destructiveness of conflict and how to end it. Some would argue that just as a physician has a moral obligation to exploit his or her professional skills and assist at the scene of a motor vehicle accident, so too should a physician knowledgeable of human behavior provide neutral non-judgmental

Rael D. Strous

input into the understanding of conflict. For example, academics in the field as well as experienced clinicians with a profound understanding of human behavior may assist in the general understanding of ambitions and motives of political leaders as well as the origins of such behaviors. They may assist in providing some sense of what makes a political leader charismatic and successful as well as what determines popularity at the polls in times of calm and turmoil. What are the critical determinants of a leader who may contribute to the prevention of violence between groups (25)? How may unconscious conflicts of the voter be exploited by politicians (e.g., 26)? Especially during times of conflict, what determines patriotism and nationalism or political violence and terrorism? How are attitudes and responses to conflict established? How can they be channeled in a positive manner for the good of the individual and community? What are the factors that lead individuals and nations to war hostilities?

Similar to the medical model in which there is a professional and almost moral obligation to encourage and promote disease prevention, psychiatrists may contribute in the prevention of conflict (25). This may be facilitated by contributing to the understanding of group processes and dynamics especially during negotiations to resolve conflict.

This would include awareness of the social context in which the conflict and hostilities take place (e.g., Zimbardo’s [27] notorious prison experiment). While this may be played out initially at an academic and research level, this may be expressed in consultation at the political level with true transparency and without any recourse to exploitation of manipulative mechanisms of influence using skills and knowledge of the profession. Thus psychiatrists may offer their assistance in a proactive manner to troubled communities and countries in conflict mediation and helping those involved in conflict to appreciate the mutual benefits of learning to live together (28).

There are obvious dangers and costs in this task despite the apparent benefits to society by the psychiatrist’s academic contribution (29). Most importantly, should mental health practitioners really leave the confines of the treatment room and reach out to the nation and address its psyche? Even if the contribution/analysis is neutral/ non-condemning/non-judgmental, should this be considered a boundary violation as described above? While group therapy may play a role in influencing attitudes of individuals regarding breaking down barriers between ethnic/cultural groups, should mental health practitioners extend their skills in group therapy dynamics and awareness of unconscious motivations to “clinical” intervention

even if desired by politicians and national/international decision makers? Since psychotherapy in both individual and group frameworks contributes to greater personal growth, psychological sophistication and enhancement of an inner sense of authority, some have proposed that psychotherapy should be encouraged for all combatants and politicians on moral grounds in order to improve the quality and integrity of conflict even if unavoidable (29).

Further discussion on this issue with professional bodies and their relevant ethical committees should be encouraged.

Political Involvement at Individual and/or Organizational Level Although many would argue an official response to and involvement in political conflict at the local and international level cannot and should not be made at an organizational level by psychiatry, any individual response to conflict or community activism in the context of voluntary contributions to society, however, would be desirable and honorable (10). While not all would agree with this assertion, it remains a central premise of this paper and the firm opinion of many in the field including the author of this review. Response as an individual member of society is what makes us human and which lies at the heart of democratic process. A political activist response made at the organization level would be too divisive and thus damaging to the field - redirecting much of the profession’s limited energy and time. This in turn would inevitably adversely affect patient care and would damage psychiatry’s standing and respect.

Several examples in history exist where psychiatrists have not taken heed and have engaged in critical boundary violations by involvement in political and group conflict leading to much damage to the profession. For example, psychiatrists in the former Soviet Union cooperated in the undermining of political dissent by “inventing” a diagnosis of “sluggish schizophrenia” which subsequently led to the hospitalization of some individuals whose only “misdeed” was to challenge the political establishment (30). Further examples of unethical involvement in political conflict, or provision of substandard care due to political considerations, by psychiatrists have been reported in Argentina (31), South Africa (32) and the U.S.A. (33). Some of this involvement has even led to national professional bodies declaring various levels of political involvement and commentary to be unethical.

As referred to above, a prominent example is the 1973 statement of the American Psychiatric Association indi125

Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist

cating that psychiatrists should desist from the unethical practice of analyses of political figures (24).

Rather than engage in political activism, psychiatrists can promote the rights of patients especially if these rights are limited during conflict. This includes budget and/or service cuts or human rights violations adversely compromising patient care. Much of this approach reflects the clinical therapeutic process which is to facilitate change rather than “make better.” As discussed elsewhere, this would inculcate facilitating the growth of community projects and challenging situations where the mentally ill are not treated fairly at both the clinical level and by the justice system. In this manner the psychiatrist would be upholding appropriate professional standards of conduct rather than allowing the political abuse of health care and its practitioners (10, 34, 35). The psychiatrist has a professional and ethical obligation to ensure that a comprehensive approach to trauma is based not merely on an understanding of psychobiological mechanisms, but also on the “specific psychosocial context” with which the response to trauma is associated (36). Thus care has to be taken to evade exclusive medicalization of responses after trauma (36).

Individual and Community Advice/Guidance During Times of Emergency and Crisis It is during times of acute crisis and emergent situations that the profession of psychiatry may demonstrate its commitment and service to the community. For example, it was the psychiatrist Paul Friedman, sent by the Joint Distribution Committee (JDC) to evaluate the mental health of Jewish concentration camp survivors after the Holocaust, who first described “an enormous dislocation of spirit” and “serious emotional problems” in children and adult survivors. As a responsible psychiatrist under times of stress and crisis, he proclaimed a need for urgent psychological aid and rehabilitation of these individuals (37).* Others have stated that while society has a moral obligation to hear the pain of survivors, the psychiatric profession has a professional obligation to listen rather than participate in a conspiracy of silence (38-40).

During periods of national and international conflict, psychiatrists are often called upon for assessment and *Unfortunately many of his warnings and calls for rehabilitation services for survivors went unheeded by the psychiatric profession during the early years of the State of Israel (38). Even when mental illness was addressed, any connection to earlier conflict during the Holocaust was largely ignored (38, 39).

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management of acute stress reactions and PTSD which may develop over time. It has been estimated by the World Health Report that during times of armed conflict 10% of those involved will experience traumatic events and will develop serious mental health problems. A further 10% will exhibit behavior impairment as a result of the trauma exposed to during the conflict (41). While the disorders of acute stress reaction and PTSD are the most obvious and most commonly known conditions to result during conflict, other conditions may also be commonly exhibited.

These include depression, anxiety and psychosomatic disorders (42). With specific regard to PTSD, based on differing methodological and varying risk factors (such as torture), the prevalence rates reported in conflict affected areas range from 0% in Iran to 99% in Sierra Leone (43).

Depression rates in conflict plagued regions have been described to range between 3-86% (43).

In addition, psychiatry may contribute by assisting in the establishment of mental health support structures for the community during times of escalating conflict (e.g., 42). This may include training of laymen and other mental health professionals in managing individuals affected by terror and conflict as well as the assessment of community mental health needs during conflict and war and finally the direct management of those affected by the conflict.

This may include facilitation of social support and selfhelp in the community as well as consideration of cultural factors in their delivery. While psychiatry is not able to solve all problems during conflict, many disorders have been associated with external factors such as violence, poverty and deprivation (6). Psychiatrists may have a role in anticipating problems with appropriate acute and longer term responses where initial catastrophic reactions develop into a more chronic disruption of social and economic community structure with inevitable levels of long-term psychological repercussions (6).

Although the response of clinical psychiatry during times of conflict largely includes assessment and management of stress and affective conditions, other conditions also demand psychiatric input. This includes evaluation and management of traumatic brain injury (TBI) as a result of blasts and other hostilities with subsequent neurological, behavioral and psychological consequences.

Psychiatrists should become aware of emerging technologies in the evaluation and management of such TBI conditions in order to best address the needs of those civilians and combatants affected (44). Advances in technology will contribute to the early diagnosis and management of various conflict associated conditions

Rael D. Strous

and will include a requirement for knowledge of various emerging genetic and molecular technologies. In addition, various biomarkers show promising results for the early detection of PTSD (45). The challenge will remain for those in the profession to search for appropriate biological and psychological management vehicles or combinations that will treat specific subtypes of conditions (44).

Labeling of all those exposed to trauma as potentially ill or psychologically unstable is unethical, is not without its dangers and should be avoided (46). Thus psychiatry also plays a role in contributing to the understanding of the important phenomena of resilience, recovery and effectiveness of public health responses during times of conflict (42). In addition to caring for those affected by trauma and conflict, the role of psychiatry should also extend to caring for the caregiver (local health workers, community leaders etc) by preventing, assessing and managing any mental health problems in staff and volunteers in the mental health team. All of the above requisite input by psychiatrists should be mandatory on ethical and professional grounds.

Despite the challenges, research of psychiatric practice under conditions of conflict is also demanded. Zwi et al.

(47) has reviewed some of these factors which include lack of formal ethical review infrastructure in unstable settings, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice.

The Military Psychiatrist Combat psychiatrists are faced with many unique ethical dilemmas. Based on the inevitable problem of dual allegiance as discussed above as well as multiple relationships and potential boundary crossings, military psychiatrists face intense, often competing, value systems and struggle with management decisions due to divided loyalties (19, 48, 49). This state of dual loyalty is reflected in the psychiatrist’s ethical dilemma of doing what is in the best interest of their patient (be it a fellow or opposing soldier or even terrorist) or of doing what is in the best interests of the state and other fellow soldiers. As has been discussed by Silver (22), when the soldier is in a military conflict, who is the patient – the wounded infantryman or the Army? Ethical concerns for the military psychiatrist include honest medical record keeping, accurate reporting of illnesses, prevention of falsification of death records, refraining from designing and implementing psychologically coercive interrogations and protection

of detainees’ human rights (18). It has been reported for example that in Guantanamo Bay and Abu Ghraib, military medical personnel in general and psychiatrists in particular were involved in various practices encouraged to force detainees to cooperate. These “extreme stress” situations were reported to include “sleep deprivation, prolonged isolation, painful body positions, feigned suffocation and beatings” (19, 33). It is highly conceivable that military mental health personnel would be consulted in designing the most appropriate methods for these purposes despite such practices being in stark contravention of the Geneva Convention.

Even if the military psychiatrist’s involvement brings with it some element of dignity for the detained, any cooperation in interrogation overtly compromises medical ethical principles of autonomy, beneficence and non-malfeasance. All physicians, including military psychiatrists, have obligated themselves to ensuring patient comfort and reducing pain and suffering. It would be devastating for any prisoner or detainee to discover that their mental health caregiver was at worst assisting in their interrogation or torture and/or violating their medical confidentiality or at best remaining silent in the face of such abuse or human rights violation (19).

Media Contact One of the principal minefields for psychiatrists during conflict is media contact. The media is clearly thirsty for information and “scoops” during acute conflict. They have to serve an even thirstier public clamoring for information and reassurance especially during acute conflict. Several of the hazards mentioned above frequently become the burial-ground of extremely competent psychiatrists – it is usually the best, most well known and most accomplished practitioners who are contacted by the media for information during conflict. Common pitfalls include boundary violations (commenting on individuals or situations that have nothing to do with clinical management), compromising on confidentiality (providing information on famous patients or injured patients, providing analysis of leaders – especially without their permission) (50) and commenting on political process and leadership. A further area where psychiatrists exhibit astoundingly poor judgment is in commenting offhand and in an informal manner on the psychological suitability of an individual for leadership (51). Rendering a professional opinion about a well known individual or celebrity regarding a specific diagnosis, condition or prognosis is problematic.

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Ethical Considerations During Times of Conflict: Challenges and Pitfalls for the Psychiatrist

However, general information may be provided about a condition as it may apply to a particular individual (51).

In addition, many would consider psychiatry has a role via the media in educating the public to diminish intergroup conflict by means of “learning to live together” and instruction of children and others in how not to hate (44). Finally, as was demonstrated during the Gulf War in Israel, mental health professionals may have an ethical obligation to legitimize feelings of anxiety by the general population and by means of frequent media appearances, offering advice, explanations and reassurance (38).

Conclusion Psychiatry has much to contribute to the study and analysis of political and historical processes within the context of rigorous academic investigation. This may even extend to encouragement of “conflict resolution, conflict transformation and building peace through health” (52).

Such involvement, however, is very different from political activism which may directly influence political and government activity or policy. Many would argue that the focal point of mental health professionals during times of conflict should be swayed to a focus on resilience rather than one of pathology. In this manner the expectation is created that diminishing of stress after trauma is normal and should be celebrated (36). We are living in an age where there is a rise in the culture of trauma and widening of the boundaries of psychiatric injury during times of conflict (46). The field of psychiatry has an ethical duty to ensure that trauma and its effects during conflict are placed in its rightful context without any disproportionate attention to pathological responses.

Input by psychiatry during times of conflict should be part of the total relief, rehabilitation and reconstruction process that follows the stage of conflict resolution including coherent strategies for their remedy (42). The involvement of psychiatrists in addressing and organizing a clinical response to trauma, conflict and its repercussions should be coordinated both at an individual clinician level as well as a organizational response such as statements by the World Psychiatric Association in its guidance of psychiatrists under such conditions (6). This has included international meetings convened precisely for this purpose such as the June 2003 meeting in Malta entitled “The Role of Health and Culture in Conflict Resolution” (6). In addition, a WPA taskforce on Violence and Mental Health issued a declaration following the World Conference on Psychiatry in Cairo 2005 encouraging the prevention of psychosocial 128

consequences of conflict and the recommendation to assist in the prevention of mass violence. The objective of this taskforce was to educate and increase awareness among psychiatrists of the consequences of conflict and of the devastating effects on the population of wars and violence (6). Many would argue that mental health practitioners have an ethical responsibility to use their clinical psychotherapeutic skills as well as methods and insights of psychiatry (25) in furthering the process of peace and ambiguity tolerance – thus limiting the destructiveness of war (29). Effects in this manner would trickle down to other community members not directly in contact with the mental health practitioner. Difficulties arise when psychiatrists are “blinded” by theoretical knowledge and professional dogma.

While it is important for psychiatrists to contribute during times of conflict, in order to do so competently and effectively, it is critical that practitioners acknowledge their own vulnerability and aggression (38) as well as develop a framework for their input including overcoming barriers to care. This would include training implications at graduate and post-graduate levels which should take into account conflict and post-conflict interventions as well as human rights obligations for both individual and group frameworks (19, 52). It is imperative however that this is achieved in a neutral manner. Nothing less than the dignity, pride and distinction of the profession are on the line.

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Isr J Psychiatry Relat Sci - Vol. 50 - No 2 (2013)

On the Links between Religion, Mental Health and Inter-religious Conflict: A Brief Summary of Empirical Research Hisham Abu-Raiya, PhD Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Israel

Abstract Recently, the field of psychology has begun to display a growing interest in the influence of religion on people’s psychological well-being. By and large, the empirical findings of this body of inquiry have revealed positive associations between religious beliefs and practices and different indices of health and well-being and demonstrated that religion serves as a valuable tool for individuals dealing with life stressors. Yet, there is ample data to suggest that religion can also have a negative influence on the psychological well-being of the individual. This duality of religion is the focus of this summary paper which consists of two main sections. The first considers the potential constructive and destructive sides of religion with regard to general health and wellbeing. The second section refers to religious variables that promote or mitigate prejudice and perceived conflict with others.

Religion is perhaps the most distinctive human phenomenon and was of major intellectual interest for the founding fathers of psychology (e.g., James, Freud, Jung) (1). It is surprising, therefore, that until the 1990s, the relationship between religion and psychological wellbeing was largely a neglected area of research: researchers often buried religious variables in the methods and results sections of their studies (2). More recently, the field of psychology has begun to display a growing interest in the influence of religion on people’s psychological well-being (3, 4). It could be stated with confidence now that the Address for Correspondence: aburaiya@gmail.com

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field of the psychology of religion has established itself as a legitimate body of inquiry.

By and large, the empirical findings of this body of inquiry have revealed positive associations between religious beliefs and practices and different indices of health and well-being (3, 5) and demonstrated that religion serves as a valuable tool for individuals dealing with life stressors (6, 7). Yet, there is ample data to suggest that religion can also have a negative influence on the psychological well-being of the individual (8). Thus, religion seems to be a double-edge sword: It can be a source of growth, strength and social solidarity, as well as a source of personal strain and inter-religious conflict. In this domain, researchers have extensively tested the role religion plays in the development of prejudice towards others, with consistent findings: in general, religion does promote negative attitudes toward, and perceived conflict with, others (see 1, 9, 10 for reviews).

This duality of religion is the focus of this summary paper which consists of two main sections. The first considers the potential constructive and destructive sides of religion with regard to general health and wellbeing. The second section refers to religious variables that promote or mitigate prejudice and perceived conflict with others. To set the stage for my discussion, I start with defining religion.

Definition of Religion What is religion? Social scientists and theologians have offered numerous definitions of religion, but have failed to reach a consensus. This state of affairs led sociologist Yinger (11) to conclude, “…any definition of religion is likely to be satisfactory only to its author” (p. 108).

Pargament offers a definition of religion that is relevant

Hisham Abu-Raiya, PhD, Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv 69978, Israel

Hisham Abu-Raiya

to the phenomenon of interest-health and well-being.

According to Pargament (6), religion is a “search for significance in ways related to the sacred” (p. 32). This perspective is tailored to the psychological venture, and it excludes concerns about the nature of the sacred that have little to do with significant human issues (12).

This definition includes two important elements: search for significance and the sacred. The search refers to the process of discovery of the sacred, conservation of the sacred once it has been found, and transformation of the sacred when internal or external pressures require a change (6, 13). The search can also be understood in terms of the multiple pathways people take to reach their goals and the goals themselves. Religious pathways encompass multiple dimensions, such as ideology, ethical conduct, emotional experience, social intercourse and study. These pathways can lead to diverse goals. They include personal ends, such as meaning in life and self-development, social ends, such as intimacy with others and justice in the world, and spiritual ends, such as closeness to God and living a moral and ethical life (13).

Pargament and Mahoney (13) define the sacred as divine beings, higher powers, or God and other aspects of life that take on divine character by virtue of their association with the divine. What makes religion distinctive is the involvement of the sacred in the pathways and destinations that define the individual’s search for significance.

From this perspective, religion is not a fixed set of beliefs and rituals. It is instead a dynamic process in which the sacred becomes a part of the pathways people take in search of whatever they hold significant, including the sacred itself. This process is multifaceted and individualized because people can follow diverse pathways that change over time to achieve significance. They also seek out many different destinations in living. The sacred, the heart of any religious expression, can also take many forms in the search for significance.

This conceptual framework offers the foundation for our discussion of the helpful and harmful aspects of religion.

Religion and Health and Well-being The field of psychology of religion has tested the links between various facets of religiousness and health and well-being. Among these, three areas of inquiry seem relatively more developed: religious involvement, religious motivation and religious coping. In what follows, I briefly refer to the empirical literature pertaining to each of these areas.

Religious Involvement A large body of empirical research has demonstrated links between religious involvement and physical health, drug/ alcohol abuse and mental health. By religious involvement I mean self-rated religiousness, endorsement of religious beliefs and participation in religious rituals.

Cross-sectional and longitudinal studies have consistently found significant associations between religious attendance and health status indicators, including specific conditions such as hypertension, general measures of functional disability and overall mortality (14). For example, McCullough et al. (15) conducted a metaanalysis of data from 42 independent samples examining the association of a measure of religious involvement and all causes of mortality. They found that, even after controlling for a variety of potential confounding variables, religious involvement was significantly associated with lower mortality, indicating that people with higher religious involvement were more likely to be alive at a follow-up than people lower in religious involvement.

There is also enough empirical evidence to suggest that religion impacts suicidality. Gearing and Lizardi (16) reviewed the relevant literature and reached the conclusion that one’s degree of religiousness can potentially serve as a protective factor against suicidal behavior.

There is consistent evidence that religiousness and substance use are negatively related to each other. For example, of 38 studies covered in a review by Benson (17), 29 indicated a negative relationship between religiousness and alcohol use, and 26 with marijuana use.

Working with high school students, Corwyn and Benda (18) found that a measure of personal religiousness (e.g., private prayer, evangelism) was a significant predictor of lower levels of drug use. Investigations of tobacco use and illicit drug use also show a negative relationship with religion. Using a sample of 1,092 twins, Kendler et al. (19) found that religious devotion was significantly and negatively linked to current levels of drinking and smoking as well as lifetime risk for alcoholism and nicotine dependence.

In a meta-analysis of 100 studies examining the relationship between religiousness and mental health conducted by Koenig and Larson (5), religious beliefs and practices were related to greater life satisfaction, happiness, positive affect and higher morale in 79 (nearly 80%) of the studies. Of 12 prospective cohort studies identified in their meta-analysis, 10 reported a significant relationship between greater religiousness and greater 131

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well-being. Similar levels of positive association were found between religiousness and hope, optimism, purpose and meaning; of 14 studies examining these relationships, 12 reported significant positive associations among these variables and two found no association with religion.

Salutary effects of religion have also been demonstrated with other dimensions of mental health and illness, such as self-esteem and mastery (20), depressive symptoms (21) and anxiety (22).

Overall, though a few studies have shown no links between religious involvement and indicators of mental health (e.g., 23) or even negative links (24), the literature reviewed in the above subsection indicates that there is a positive relationship between religious involvement and well-being, testifying to the constructive role religion plays in people’s lives. However, this body of research is limited in four key respects. First, much of the research is either theoretical or lacks an overarching theoretical perspective.

Second, current scientific findings are overwhelmingly based on a few items as indices of the multi-faceted complex domain of religion (25). For example, Mahoney et al. (26) found that 83% of the studies published in journals in the past 20 years on religion, marriage and parenting relied on one or two items to assess family members’ general religiousness (e.g., denominational affiliation, church attendance) or conservative Christian beliefs. Third, possible harmful aspects of religion are generally not considered. Finally, the studies that have been conducted have focused almost exclusively on Christian samples (27), and have been geared largely to members of Judeo-Christian traditions. Other traditional faiths have been neglected for the most part.

Religious Motivation According to motivational theory, it matters “both what you pursue and why you pursue it” (28). This notion can be applied to the religious realm too. Initial empirical research suggests that people who devote more of their energy to the pursuit of spiritual ends experience physical and emotional benefits. For instance, Emmons et al. (29) asked samples of college and community-based adults to generate their personal strivings and found that those who reported a higher proportion of spiritual strivings (e.g., seeking God’s will; seeking to deepen a relationship with God; attempting to live by one’s spiritual beliefs in daily life) manifested greater purpose in life, marital and overall life satisfaction. Furthermore, the correlations between these spiritual strivings and measures of 132

subjective well-being were stronger than the correlations between all other strivings and well-being.

Mahoney et al. (30) applied the construct of sanctification to college students’ perceptions of their bodies.

Students completed measures of the extent to which they viewed their bodies as being a manifestation of God (e.g., “My body is a temple of God”) and as characterized by sacred qualities (e.g., holy, blessed, sacred). Greater levels of both forms of sanctification were related to higher levels of health-protective behaviors, strenuous exercise, satisfaction with one’s body, and disapproval of alcohol consumption as well as to lower levels of illicit drug use, unhealthy eating practices, and alcohol consumption.

Conversely, people can sanctify destructive spiritual ends. As Palmer (31) wrote, “There are real dangers involved when the sacred gets attached to the wrong things” (p. 25). Palmer was pointing to idolatry. Idolatry is an issue of motivation; it speaks to the “what” part of the motivational theory. Drugs, alcohol, consumerism, and self-worship are a few of examples of idolatry, “false gods” in which people attempt to fill a spiritual vacuum in a destructive manner.

Although I am not aware of any empirical studies of idolatry, there are dramatic cases which point to the harmful ramifications of idolatry for health and well-being.

Examples include people who dedicate themselves to tyrannical authority figures, and those who make food, drugs and alcohol the center of their lives. Self-worship is another example of idolatry. Commenting on the prevalence of this phenomenon among Nazis in World War II, Jung (32) wrote: “God-almightiness does not make man divine, it merely fills him with arrogance and arouses everything evil in him. It produces a diabolical caricature of man, and this inhuman mask is so unendurable, such a torture to wear, that he tortures others. He is split in himself, a prey to inexplicable contradictions” (p. 215).

Motivational theory also highlights the importance of why people involve themselves in religion. Allport, in a classic work, distinguished between two religious orientations: the extrinsic and intrinsic. According to Allport and Ross (33), the extrinsic orientation is characteristic of those who use their religion to achieve extra-religious (social and psychological) ends. On the other hand, the intrinsic orientation characterizes those who find their master motive in religious practices, beliefs and aspirations.

Allport and Ross measured extrinsic and intrinsic religion by the Religious Orientation Scale (10). Actually, this scale consists of two subscales, one designed to measure

Hisham Abu-Raiya

extrinsic religion (items such as “the primary purpose of prayer is to gain relief and protection,” and “occasionally I find it necessary to compromise my religious beliefs in order to protect my social and economic well-being”), and one to measure intrinsic religion (items such as “it is important for me to spend periods of time in private religious thought and meditation,” and “quite often I have been keenly aware of the presence of God or the divine being”). This scale is still widely used.

Overall, research conducted mostly among Christian samples has shown a positive correlation between an intrinsic orientation to religion and well-being, and a negative correlation between extrinsic religiousness and well-being (see 34 for review). For example, in a study of religious college students, Bergin et al. (35) found a positive correlation between intrinsic religiousness and sociability, sense of well-being, and tolerance, and a negative correlation between extrinsic religiousness and the same criteria.

In recent years, researchers have been testing the intrinsic-extrinsic religiousness framework with nonChristian samples. For example, in a comprehensive review of the empirically based psychology of Islam, Abu-Raiya and Pargament (36) identified multiple studies conducted among Muslim populations which tested the applicability of Allport and Ross’s (33) religious orientation framework to the Muslim context (37-40). By and large, this group of studies has yielded support for the usefulness of Allport and Ross’s framework and identified three religious orientations relevant to Muslims: intrinsic, extrinsic-personal and extrinsic-social. The pattern of relationship between these orientations and outcomes has been quite consistent: intrinsic religiousness and extrinsic-personal were related to positive outcomes while extrinsic-social religiousness was related to negative or no outcomes.

Likewise, working with four independent Christian samples, Ryan et al. (41) concluded that two types of internalization (the process through which an individual transforms a formerly externally prescribed regulation or value into an internal one) characterize the interplay between the individual and religion. The first, introjection, is similar to extrinsic religiousness (a partial internalization of religiousness based on self and otherapproval-based pressures); the second, identification, is similar to intrinsic religiousness (beliefs based on personal values and volition). They found that higher levels of identification were associated with higher selfesteem, and less depression and anxiety, while higher

levels of introjection were related to poorer outcomes on these variables.

Clearly, research on religious motivation has overcome some of the shortcomings associated with research on religious involvement. This research has a sound theoretical foundation and measures aspects of religiousness in more sophisticated ways and refers to some possible negative types of religiousness. Further, research in this area has been extended to other religious groups. Still, this body of investigation has not addressed what is perhaps the most relevant topic for mental health professionals, namely, how religion is involved in coping with stressors and life crises. Religious coping theory and research thoroughly address this issue.

Religious Coping In 1997, Pargament wrote The Psychology of Religion and Coping: Theory, Research, Practice in which he articulated a theoretical framework of religion and coping that grew out of the seminal contributions of Lazarus and Folkman (42), the founders of coping theory.

Coping theory rests on the fundamental assumption that human phenomena are multifaceted and can be understood only as the product of on-going processes of interaction between individuals and life situations in a larger social context (42). According to this theory, people are far from passive creatures. Rather, they are proactive, goal-directed beings who search constantly for meaning and significance in their lives. When people encounter life events, major as well as minor, they appraise them with regard to their important goals and strivings in life. When the framework of significance that people hold is challenged, threatened, or lost, they apply coping strategies to conserve or, when necessary, transform significance. This process is manifested in different domains in life: physical (e.g., health), financial (e.g., money), social (e.g., friends, family), and/or psychological (e.g., self-esteem) (43).

Religious coping theory adds to general coping models with its emphasis on the sacred as an object of and part of the search for significance. Hence, religious coping methods can be defined as “sacred-related ways of understanding and dealing with negative life events” (7: p. 743). Pargament et al. (44) made the distinction between positive religious coping methods and negative religious coping methods. The former reflects a secure relationship with God, a belief that there is a greater meaning to be found, and a sense of spiritual connect133

On the Links between Religion, Mental Health and Inter-religious Conflict

edness with others, while the latter reflects an ominous view of the world, and a religious struggle to find and conserve significance in life. To establish a foundation for empirical research in this area, Pargament et al. (45) developed a comprehensive measure (RCOPE) to assess the different patterns of religious coping. The RCOPE is perhaps the most widely used measure in psychology of religion research.

Since the publication of Pargament’s book, more than 1,000 studies have appeared that deal with religion, stress and coping. Though research had initially focused on Christian samples, researchers have started recently to examine religious coping methods and their associations with health and well-being among different religious groups such as Jews (46), Muslims (47, 48) and Hindus (49). Generally speaking, the findings of these studies lend support to Pargament’s (6) religious coping theory in general and his distinction between positive and negative religious coping in particular.

A clear picture emerges from studies of the relationship between positive religious coping and mental health: positive religious coping is positively and persistently associated with desirable mental health indicators (e.g., 46-54,). Consider the following examples.

Smith et al. (53) examined the relationship between religious coping by church members and psychological and religious outcomes following the 1993 Midwest flood.

They found that positive religious attributions and coping activities predicted better psychological and religious outcomes both 6 weeks and 6 months post-flood, after controlling for exposure and demographics.

Working with 841 ministers in the Presbyterian Church, Meisenhelder and Marcum (51) examined posttraumatic stress, religious and nonreligious coping in relation to positive religious outcomes following the tragedies of 9/11. They found that looking to God for strength, support and guidance was the most frequently used strategy; the second was increased prayer. They also found that more frequent positive religious coping was related to less severe stress symptoms and numbness and avoidance, and higher positive religious outcomes.

Ano and Vasconcelles (50) conducted a meta-analysis of 49 studies testing the efficacy of religious coping for people dealing with stressful situations with a total of 105 effect sizes. The results of the study generally supported the hypothesis that positive religious coping was related to positive psychological adjustment to stress.

Ai et al. (48) collected information about religiousness, war-related trauma, religious-spiritual coping, optimism 134

and hope from a sample of 138 Muslims who escaped from Kosovo and Bosnia and settled in the United States.

Applying Pargament’s (6) concept of religious-spiritual coping and using a path model, they found that higher religiousness was positively associated with positive religious coping, which in turn was related to higher optimism and education.

However, religious coping can be also a source of strain. A significant body of empirical work is making it increasingly clear that certain forms of religious coping can be harmful. In a study of medically ill, elderly patients, Pargament et al. (55) found unexpected results. Over the two-year period of their study, 176 of the patients they studied died. Consequently, they were able to test whether religious coping measures predicted mortality.

After controlling for other variables (illness severity at baseline, mental health status, demographic variable), they found that negative religious coping was associated with a significantly greater risk of dying over two years.

Specifically, people who felt that God had abandoned them, who questioned God’s love and care, and who felt that the devil was at work in their illness had a 19 to 28% increased risk of dying. This was perhaps the first study that has established a link between certain forms of religious expression and risk of mortality.

Other studies have linked signs of religious struggle to poorer mental health and even psychopathology (44, 47, 54, 56-59). For example, Sherman et al. (59) examined general religiousness and two modes of cancer-specific religious coping, drawing closer to faith (positive) and struggling with faith (negative), among 213 multiple myeloma patients evaluated at the same point in treatment, during their initial work-up for autologous stem cell transplantation. The outcomes assessed included standardized measures and clinician ratings of depression, general distress, physical functioning, mental health functioning, pain and fatigue. After adjusting for relevant control variables, negative religious coping was associated with significantly poorer functioning in the areas of depression, distress, mental health, pain and fatigue.

Abu-Raiya et al. (47) identified religious struggle as one of two negative types of religiousness among Muslims.

Greater levels of Islamic Religious Struggle were linked consistently and strongly with greater levels of negative outcomes (angry feeling, alcohol use, depressed mood) and lower levels of positive outcomes (positive relations with others, purpose in life).

McConnell et al. (58) investigated the relationship between spiritual struggles and various types of psy-

Hisham Abu-Raiya

chopathology symptoms in individuals who had and had not suffered from a recent illness. Participants completed self-report measures of religious variables and symptoms of psychopathology. Spiritual struggles were assessed by a measure of negative religious coping. As they predicted, negative religious coping was significantly linked to various forms of psychopathology, including anxiety, phobic anxiety, depression, paranoid ideation, obsessive-compulsiveness and somatization, after controlling for demographic and religious variables. In addition, the relationship between negative religious coping and anxiety and phobic anxiety was stronger for individuals who had experienced a recent illness.

It seems that religious struggles are the symbol of the “dark night of the soul” (60). Their negative impacts are found across different religious groups and cultures.

Initially, these findings surprised researchers in the field.

After all, from Abraham to Moses to Buddha to Jesus to Muhammad to Mother Teresa, illustrious religious figures have experienced their own religious struggles only to come out the other side steeled and strengthened.

How can these findings be explained? One key may be whether the individual is able to solve his or her struggles.

Some recent analyses suggest that this may be the case; it appears that those who are unable to solve their struggles over time are at greater risk of poorer mental and physical health, while people who experience these struggles temporarily do not face the same risk (55).

Another key may be the degree to which religious struggles are socially acceptable. In this vein, Abu-Raiya et al. (61) hypothesized that expressions of religious struggles, especially doubts about the existence of God or the afterlife, are not socially acceptable in the Islamic culture. As a result, Muslims who have religious doubts may experience alienation and loneliness, which may lead to depression or angry feelings. To cope with these negative feelings, some individuals may use destructive methods of coping. Promising as these explanations might be, it is important to recognize that they are still speculative. Future studies are needed to explicate the mechanisms that mediate between religious struggles and negative outcomes.

The findings of the voluminous studies on religious coping have clear implications for psychotherapy. Helping clients identify and draw on their own resources is one of the most important services that therapists can offer.

Religion and spirituality are another critical resource that can be accessed in psychotherapy. Spiritual and religious strivings, knowledge, experience, practices,

relationships and coping methods are invaluable “tools” while working with therapy clients. Clinicians should pay close attention to these resources and help their clients to identify and draw on them in the process of dealing with life stressors.

Findings with regard to religious struggles suggest that mental health professionals need to be aware of “religious red flags” or signs of religious struggle when working with clients. Interventions to help people deal with their “dark nights of the soul” seem called for. As we will see shortly, steps in this direction have been already taken.

Referral to a pastor or religiously-trained psychologist would seem appropriate to help these individuals work their struggles through before they become chronic.

Religion and Prejudice For many years, psychologists have been puzzled by the complex connections between religion and prejudice against a wide range of social sub-groups. The eminent psychologist Gordon Allport was one of the first social scientists to explore this intriguing intersection. In his book The Nature of Prejudice, he summed up his conclusions in a classic statement, “it (religion) makes prejudice and it unmakes prejudice” (62: p. 494). His key concept in explaining this ostensibly contradictory assertion was religious orientation. According to Allport, extrinsic religiousness (i.e., a utilitarian use of religion as a means to an end) “makes” prejudice, while intrinsic religiousness (i.e., a genuine, heartfelt devotion to one’s faith) “unmakes” it. Although the significant number of empirical studies generated from Allport’s conceptual framework has yielded mixed findings (e.g., 63, 64, 68), the question whether religion encourages or discourages prejudice has continued to elicit debate and engender extensive research.

A careful scrutiny of this research reveals an unambiguous picture: there is a link between religion and prejudice toward various social, ethnic, and religious groups, especially Jews and Blacks (1). For instance, 37 out of 47 studies included in a review of the empirical literature conducted by Batson et al. (10) found that higher levels of religiousness related to higher prejudice, eight indicated no relationship, while only two studies showed an inverse relationship. In a review of 16 articles on the relationship between various types of religiousness and intolerance, over half (59%) of the results indicated a positive relationship between religiousness and intolerance for various groups (65).

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Specifically, this research has pointed to a few religiously-based variables which seem to promote prejudice.

Higher levels of self-reported prejudice have been linked to greater religious fundamentalism (e.g., 66, 67), more extrinsic religious orientation (34), more frequent church attendance (e.g., 7682), and greater religious particularism (i.e., peopleâ&#x20AC;&#x2122;s belief that their religion is the only true one; 68). On the other hand, some religiously-based variables appear to mitigate prejudice. For instance, lower levels of self-reported prejudice have been tied to religious pluralism (i.e., the degree to which individuals believe there are multiple paths to religious truth; 69) and to a higher quest religious orientation (i.e., viewing religion as an on-going search for meaning; 10).

Researchers have also hypothesized that certain personality traits might explain the links between these religiously-based variables and prejudice and found some empirical support for this hypothesis. For example, several studies have shown that the relationship between fundamentalism and prejudice is partially or fully mediated by right-wing authoritarianism or adherence to conservative traditional political and social beliefs (63, 64, 70, 71).

Clearly, the existing research has shed some light on the connection between religion and prejudice. Still, this body of research is limited in some key respects (see 3 for more detail). First, the correlations between prejudice and the various indices of religiousness are relatively small in magnitude, implying that we need to identify religiouslybased variables that are more robustly tied to prejudice.

Second, researchers have primarily assessed global religious variables, such as religious affiliation or attendance (3). Yet to avoid perpetuating prejudicial stereotypes about broad religious groups (e.g., members of certain traditions or those who frequently attend church) we need to focus on specific aspects of religiousness that may be more closely associated with prejudice. Third, most of the research on the intersection of religion and prejudice has focused on stable religious and personality characteristics (43).

With some important exceptions (e.g., 72, 73), empirical research needs to go further in exploring how situations and inter-group dynamics are involved in the development of prejudice (43). These limitations of the empirical literature indicate that more work lies ahead to illuminate the complex ways religion may either intensify or ameliorate the destructiveness of prejudice.

With the introduction of religious coping theory (6), a new line of research which may facilitate more in-depth research on religion and prejudice has emerged. Central to this line of research is the concept of desecration.

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Though still in its very early stages, the findings of this line of inquiry are consistent and promising, and have started to shed important new light on our understanding of the disturbing ties between religion and prejudice.

Desecration, Prejudice and Perceived Conflict with Others As stated earlier, Pargament (6) defined religion as â&#x20AC;&#x153;the search for significance in ways related to the sacred.â&#x20AC;? In their search for the sacred, people encounter major life stressors that have significant implications for their deepest values and strivings, including those they hold sacred (6, 74). These critical events are evaluated and appraised in terms of their import for the sacred. Life situations may be evaluated as irrelevant, benign, or harmful with respect to sanctified aspects of life. Desecration refers to one particular type of negative spiritual appraisal: perceptions that a sacred aspect of life has been violated or threatened (13).

According to Abu-Raiya et al. (9), when people perceive that other groups pose a threat to or have damaged their most sacred sources of significance, they are likely to react strongly. Prejudice from this perspective can be understood as a reaction of in-group members to perceptions that their sacred values have been threatened or violated by members of various out-groups. In one sense, these attitudes represent a natural outgrowth or protective response to the perceived sacred threat or violation. Prejudice creates distance between the individual and the group that is seen as a danger to sacred aspects of life. Part of the protective response may also include intense antagonism and hostility toward the threatening group that creates unfortunate consequences of its own.

This plausible theoretical link between perceptions of desecration and prejudice has been tested in three distinct studies 43, 75, 76) with promising results. For example, Pargament et al. (39) used a sample of 139 undergraduate Christian students to examine whether the appraisal that Jews desecrate Christian values is linked to antiSemitic attitudes. They found that greater perceptions of desecration were associated with greater anti-Semitism and perceived conflict with Jews, after controlling for demographic variables and dispositional measures (e.g., particularism, pluralism, church attendance, Christian orthodoxy, fundamentalism, and authoritarianism).

Similarly, using a sample of 192 Christian participants, Abu-Raiya et al. (75) examined the links between the appraisal that Muslims desecrate Christian values and

Hisham Abu-Raiya

teachings and anti-Muslim attitudes. They found that Christians who reported greater perceptions of Muslims as desecrators of Christianity were more likely to report antiMuslim prejudice and perceived conflict with Muslims.

The findings were robust. Significant results remained even after controlling for the same demographic variables and dispositional measures used in Pargament et al.’s (39) study.

Still, this growing body of investigation has demonstrated that the links between desecration and prejudice and perceived conflict with others are not automatic.

They depend on the coping strategies people apply to deal with perceptions of desecration. For example, Abu-Raiya et al. (75) found that positive religious coping methods that emphasized expressions of Christian love and learning from Muslim spiritual models were associated with lower anti-Muslim attitudes, while negative religious coping methods that emphasized that Muslims were being punished by God and demonic were also tied to greater anti-Muslim attitudes. Three of these religious coping methods were found also to at least partially mediate the associations between desecration and antiMuslim attitudes.

The findings of this line of inquiry into desecration have several implications (see 9 for a detailed discussion), the most notable of which is making the sacred dimension of inter-group conflict and prejudice more explicit. The knowledge that prejudice represents, in part, an effort to preserve and protect what people hold sacred may cast prejudice in a different, perhaps more manageable light.

It could lead to valuable dialogue about what people hold sacred, how people differ in what they hold sacred, and how people at times inadvertently threaten or harm what others hold sacred. This dialogue, in turn, could foster mutual understanding and may create increased inter-group empathy and promote forgiveness for hostile responses and conflict across groups. The importance of developing greater respect to the sacred objects of others cannot be underestimated.

Research on the links between desecration and prejudice is in its early stages. Consequently, the three desecration-prejudice studies I referred to in this paper are initial efforts that are limited in several respects (e.g., the samples consisted of Christian, predominantly white, college students; the studies utilized a survey format and their findings were based on self-report data; all investigations applied a cross-sectional design, and, therefore, the findings do not allow causal inferences). Despite these limitations, this line of inquiry seems promising and might shed much needed light on age-old conflicts

between other religious groups – Hindus and Muslims, Christians and Jews, Muslims and Jews. For example, could negative attitudes held by Muslims toward Jews in Israel be partially a result of the former perceiving the latter as desecrating their sacred values and places?

Concluding Remarks This brief summary of empirical research regarding the role religion plays in people’s lives clearly shows that religious beliefs, practices and teachings can either promote health and well-being or be a source of personal struggle, strain and inter-group conflict. The findings presented here should be of interest to mental health professionals who should develop methods of psychotherapy that take seriously religious concerns. In fact, steps in this direction have been taken recently (74, 77, 78) but the efficacy of religiously integrated psychotherapy is still to be determined.

Policy makers also, especially in the Middle East where religion seems to play a crucial role in the lives of people, could be informed and helped by this body of research.

The findings of studies on the links between desecration and prejudice underscore the importance of making the sacred dimension of the Israeli-Arab conflict and prejudice more explicit. The knowledge that prejudice represents, in part, an effort to preserve and protect what people hold sacred may cast prejudice in a different, perhaps more manageable light. It could lead to valuable dialogue about what Jews and Muslims hold sacred, how they differ in what they hold sacred, and how they at times inadvertently threaten or harm what others hold sacred.

This dialogue, in turn, could foster mutual understanding and may create increased inter-group empathy and promote forgiveness for hostile responses and conflict across these groups. The importance of Muslims and Jews developing greater respect for one another’s sacred objects cannot be underestimated. They should be aware of the different types of religiousness that exacerbate or mitigate prejudice and perceived conflict with others if they are interested in establishing interfaith tolerance and understanding.

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Book Reviews

Book reviews Working with the Bereaved

yet generous in attending to additional modes of therapy.

Israeli physicians and mental health professionals will find it a useful companion for navigating personal and national losses we all face in these stormy times.

Yoram Barak, Bat Yam

Simon S, Rubin, Ruth Malkinson and Eliezer Witztum Routledge, New York Paperback, 266 pages ISBN: 978-0-415-88166-1

Expert Psychiatric Evidence

Price: not specified

Keith Rix, FRCPsych

N

o three people more experienced and qualified could have written such an important and moving book. The last few decades have seen an explosion in the research and therapeutic practices of bereavement.

The authors of this book have developed an integrative theory of grief: the Two-Track Model of Bereavement.

The book is a journey towards understanding not only the biopsychosocial consequences of loss but also the ongoing relationship to the deceased.

The book is composed of four sections: choosing life after grief, the Two-Track Model of Bereavement, integrating various therapeutic approaches and lastly, expanding horizons. Throughout the book, in every chapter, essential messages and insights are framed in grey, facilitating “mini” summaries that make the reading flow. Each chapter ends with brief concluding remarks that enable a cohesive integration of the data and ideas expressed.

The authors declare in the opening chapter that their intention is to: “focus on the therapist’s encounter with loss and bereavement and how to assist clients.” The TwoTrack Model of Bereavement lives up to this promise – but not entirely. Track I is where biopsychosocial functioning is assessed and interventions offered. Track II is the relationship to the deceased and where the therapist is encouraged to explore with the bereaved the nature of longing, conflicts surrounding the deceased, features of response to loss and finally progress toward memorialization. However, only on page 222 we finally encounter the subsection titled: “Last but not least: the therapist’s selfcare.” The brevity and flimsiness of this subsection are the book’s great limitation. A sentence such as: “activity in general and physical activity in particular are relevant for therapists” is hardly what the reader expects from these leading therapists and researchers.

“Working with the Bereaved” is an excellent book. It is short yet comprehensive, focused on the two track model

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RCPsych Publications Hardback, 320 pages ISBN: 978-1-908020-32-1 Price: £40

T

his book aims to cover the roles and responsibilities of the psychiatric expert witness. Following a warm forward by a British supreme court judge and a detailed list of statutes and legal cases there are 12 chapters. All chapters are relevant to psychiatrists who encounter various aspects of forensic psychiatry. The book provides data and is based on the author’s long years of expertise. Chapter 10 may be of use only to British psychiatrists as it encompasses “Reports for the Channel Islands, the Republic of Ireland, the Isle of Man, Northern Ireland and Scotland.”

The opening sentence of the first chapter was a surprising anecdote for me: “In 1345, a court summoned surgeons for an opinion on the freshness of a wound.” I had not realized that physicians have been expert witnesses for over 600 years. Moreover, I never formulated for myself in clear and precise terms why courts need experts and what is an expert. Dr. Rix is an expert in just these fields. He is a master of language and through simple yet profound writing enlivens the nature and duties of an expert witness. We quickly learn that “a person may be qualified to give expert evidence by virtue of study, training, experience or any other appropriate means.” However, only as late as 1964 did the British court establish that: “The test of expertness … is skill, and skill alone…” Dr. Rix goes on after the opening chapter to review practical matters in the realm of fees, marketing deadlines and much more. His experience shines through with a touch of British humor: “If your instructing solicitors need credit, they should get it from a bank and not from you.”

Things become much more somber and serious from Chapter 3 onwards. The chapter on medico-legal

Book Reviews

consultation is a treasure of advice, from how to make the consulting room welcoming to self-introduction and record-keeping. Chapter 4 details the structure, organization and content of the generic report. Again the scope of Dr. Rix’s experience comes into play in the large as well as minute details.

Chapters 5, 6, 7, 8 and 9 focus on the different aspects of criminal proceedings, personal injury, family proceedings, capacity and tribunals, inquests and other bodies.

Each chapter is unique and can be enjoyed by both psychiatrists new to such an issue or the honed expert in the field.

The author’s last piece of advice should be generalized to any physician treating a patient: “If you find you have nothing more to learn (from other experts…), or have learned nothing from a book like this, it is probably time to give up being a psychiatric expert or to write your own book.”

Yoram Barak, Bat Yam

National Clinical Guidelines 120 & 123: National Collaborating Center for Mental Health “Psychosis with coexisting substance misuse” “Common mental health disorders” The British Psychological Society and The Royal College of Psychiatrists ISBN 978-1-908020-31-4, 978-1-908020-30-7 paperback + CD-ROM Price: £45

T

hese two books are part of an ongoing effort by several agencies in the U.K. to produce a series of guidelines in the field of mental health. The National

Collaborating Centre for Mental Health (NCCMH) is one of four centers established by the National Institute for Health and Clinical Excellence (NICE) to develop guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales. Established in 2001, the center is responsible for developing mental health guidelines and is a partnership between the Royal College of Psychiatrists and the British Psychological Society.

The output of this project is concise, practical and a pleasure to read. The texts are clear and the tables and figures clarify the procedures recommended. The evidence base for the guidelines is provided in the accompanying CD-ROM including the characteristics of studies.

The guideline for the identification and pathways to care of the common mental disorders is designed for primary care physicians and administrators. The disorders covered in this book are: depression, generalized anxiety, panic disorder, OCD and PTSD. The Israeli and non-British readers may find some of the sections on referral and local care pathways irrelevant. Other than that the book is a treasure. The guideline on assessment and management in adults and young people of psychosis with coexisting substance misuse is also outstanding. The evidence is presented objectively and the conclusions make assimilation of the guideline easy and almost inevitable.

The Israel Medical Association does not support the publication of guidelines. Our policy here in Israel is to rely mainly on consensus conferences. The guidelines published by the NCCMH warrant serious consideration for adaptation – after appropriate changes required to conform these to Israel’s service delivery models – as the consensus.

Yoram Barak, Bat Yam

141

‫שתיית אלכוהול מרובה יותר‪ .‬עיתונאים ישראליים דיווחו על‬ ‫רמות גבוהות יותר של דיכאון‪ ,‬חרדה ותלונות סומטיות‪.‬‬ ‫מסקנות‪ :‬מדפוס התוצאות עולה כי נסיבות חברתיות‬ ‫וגורמים סביבתיים עשויים להשפיע על תגובתן של קבוצות‬ ‫שונות לחשיפה לטראומה‪.‬‬ ‫שיקולים אתיים בזמן עימות‪:‬‬ ‫אתגרים וסיכונים לפסיכיאטר‬

‫י‪ .‬שטראוס‪ ,‬באר יעקב‬

‫למרות התקדמותה של התרבות האנושית‪ ,‬עימותים עדיין‬ ‫קיימים באזורים רבים ברחבי העולם‪ .‬לעתים קרובות‬ ‫לפסיכיאטריה תפקיד חיוני בהתמודדות עם השלכות העימות‬ ‫או שהיא אף משפיעה על התהליך עצמו‪ .‬יחד עם מעורבות זו‬ ‫באה אחריות גדולה‪ ,‬כמו גם דילמות אתיות רבות הקשורות‬ ‫למצבים אלו‪ .‬למרות מחויבות מקצועית הכרוכה בשבועות‬ ‫הרפואיות‪ ,‬רופאים רבים מתעלמים מיסודות ומעקרונות‬ ‫אתיים רפואיים במצבי עימות ובמצבים של "נאמנות כפולה"‪.‬‬ ‫יש להתייחס לתופעה זו כדי לפתח את המודעות ואת הרגישות‬ ‫האתית לנושאים אלה‪ .‬גורמים חשובים שעל פסיכיאטרים‬ ‫לשקול בזמן קונפליקט הם "האמנה החברתית" שלהם עם‬ ‫הקהילה‪ ,‬הסכנות של הסגת גבולות‪ ,‬האתיקה בקשר עם‬ ‫התקשורת‪ ,‬מעורבות בפעילויות ממשלתיות ופוליטיות‬ ‫וסודיות רפואית‪ .‬נוסף לכך יש לשקול את תפקיד הפסיכיאטר‬ ‫בפתרון עימותים ולהביא בחשבון שיקולים אתיים ייחודיים‬ ‫לצבא‪ .‬כאזרח מן השורה‪ ,‬מותר לפסיכיאטר כפרט להתעניין‬ ‫ולהיות מעורב בפעילות פוליטית‪ ,‬אך הדבר אינו מומלץ ברמה‬

‫הארגונית‪ .‬יש להשתמש במיומנויות רפואיות רק על מנת להציל‬ ‫חיים או לשפר את איכותם לפי "החוזה" עם החברה‪ ,‬וכל מהלך‬ ‫אחר‪ ,‬אפילו בשם המדינה‪ ,‬צריך להיות מוקע‪ .‬במקום לעסוק‬ ‫בפעילות פוליטית‪ ,‬פסיכיאטרים יכולים לקדם את זכויותיהם‬ ‫של חולים‪ ,‬במיוחד אם זכויות אלה מוגבלות במהלך עימות‪.‬‬ ‫אחריות ומחויבות אתית צריכות להיות העקרונות המובילים‬ ‫את הפסיכיאטר אשר כולל את עצמו‪ ,‬במישרין או בעקיפין‪ ,‬עם‬ ‫מטופלים בזמן עימות‪ .‬במהלך העימות‪ ,‬יש להתייחס לטראומה‬ ‫ולהשלכותיה ולא לתגובות פתולוגיות בלבד‪.‬‬ ‫על הקשר בין דת‪ ,‬בריאות נפשית וקונפליקט‬ ‫בין־דתי‪ :‬סיכום קצר של מחקר אמפירי‬

‫השאם אבו ריא‪ ,‬תל אביב‬

‫בשנים האחרונות החלה הפסיכולוגיה לגלות עניין הולך וגובר‬ ‫בהשפעתה של הדת על רווחתם הנפשית של אנשים‪ .‬באופן‬ ‫כללי‪ ,‬התגלו בתחום מחקר זה קשרים חיוביים בין אמונות‬ ‫ומנהגים דתיים לבין אינדיקטורים של בריאות ורווחה נפשית‪,‬‬ ‫ונמצא שדת היא כלי חשוב עבור אנשים המתמודדים עם גורמי‬ ‫לחץ שונים‪ .‬יחד עם זאת‪ ,‬יש עדויות לכך שלדת יכולה להיות‬ ‫השפעה שלילית על בריאותו הנפשית של הפרט‪ .‬השפעה‬ ‫כפולה זו שעשויה להיות לדת‪ ,‬עומדת במרכזו של מאמר‬ ‫סקירה זה‪ ,‬המורכב משני חלקים‪ .‬החלק הראשון מתייחס‬ ‫לצדדים הקונסטרוקטיביים והדסטרוקטיביים האפשריים של‬ ‫הדת בנוגע לבריאות כללית ורווחה נפשית‪ ,‬והחלק השני עוסק‬ ‫במשתנים דתיים אשר יכולים לעודד או למנוע התפתחות של‬ ‫דעות קדומות כלפי אחרים‪.‬‬

‫‪142‬‬

‫כמו כן‪ ,‬פדויי שבי דיווחו על מספר גדול יותר של מקבצי‬ ‫תסמיני הד"ק ועל שיעורים גבוהים יותר של תסמיני הד"ק‬ ‫שמילאו את הקריטריונים לאבחנת הד"ק‪ .‬נוסף לכך נמצא קשר‬ ‫חיובי בין מקבצי תסמיני ‪ PTSD‬למקבצי תסמיני הד"ק‪ .‬לסיום‪,‬‬ ‫אבדן משקל וסבל נפשי בשבי‪ ,‬כמו גם אבדן שליטה רגשית‬ ‫ואומדן סכום תסמיני הד"ק ניבאו את אומדן סכום תסמיני‬ ‫ה–‪ .PTSD‬עם זאת‪ ,‬רק אומדן סכום תסמיני ‪ PTSD‬נמצא מנבא‬ ‫את אומדן סכום תסמיני הד"ק‪.‬‬ ‫מסקנות‪ :‬מחקר זה הדגים את המחיר הכבד והנרחב של שבי‬ ‫מלחמה‪ ,‬שלושה עשורים לאחר שחרור פדויי השבי‪ .‬לקראת‬ ‫פרסום המהדורה החמישית של המדריך האבחוני והסטטיסטי‬ ‫להפרעות נפש‪ ,‬המחקר מצביע על מספר גדול של מקבצי‬ ‫תסמיני הד"ק במקביל לתסמיני ‪ PTSD‬בקרב פדויי שבי ומדגיש‬ ‫את יחסי הגומלין המורכבים בין שתי קטגוריות האבחון הללו‪.‬‬ ‫ניתן לראות את תסמיני הד"ק כמאפיינים נלווים ל–‪ ,PTSD‬אך‬ ‫האחרונים הם גורם מרכזי בתסמיני הד"ק‪.‬‬ ‫תגובות פסיכולוגיות לטרור‬ ‫מתמשך לאורך זמן‬

‫מ‪ .‬גלקופף‪ ,‬ז‪ .‬סולומון וא‪ .‬בלייך‪ ,‬חיפה‬

‫מטרה‪ :‬ההשפעה של טרור מתמשך לאורך הזמן זכתה לתשומת‬ ‫לב מועטה במחקר‪ .‬במחקר זה הוערכו לאורך זמן השכיחות‬ ‫והמנבאים של מסלולים שונים של תסמינים פוסט–טראומטיים‪,‬‬ ‫הכוללים התנגדות (‪ ,)resistance‬חוסן‪ ,‬התפרצות מאוחרת‬ ‫וכרוניות‪ ,‬בתקופה של טרור אינטנסיבי ומתמשך‪.‬‬ ‫שיטה‪ :‬שני סקרים נערכו במרווח זמן של שנתיים בקרב ‪153‬‬ ‫מבוגרים יהודים בישראל‪.‬‬ ‫תוצאות‪ :‬נמצאה עלייה לאורך זמן (מ־‪ 18.2%‬ל–‪)31.2%‬‬ ‫בשכיחות של הפרעת דחק פוסט–טראומטית (‪ )PTSD‬משוערת‪,‬‬ ‫במספר הסימפטומים הטראומטיים הקשורים לדחק (‪)TSRS‬‬ ‫ובשיעור הסימפטומים הפוסט–טראומטיים הקשים (‪.)PTSS‬‬ ‫יחד עם זאת‪ 66.7% ,‬מהסובלים מ–‪ PTSD‬ו–‪ 39.3%‬מהסובלים‬ ‫מ–‪ PTSS‬בזמן הסקר הראשון התאוששו‪.‬‬ ‫גורמים מנבאים להתפרצות מאוחרת של ‪ PTSS‬חמור‬ ‫(‪ 19.6%‬מהמדגם) היו ירידה ברמת ההכנסה‪ ,‬אירוע טראומטי‬ ‫חמור במהלך החיים‪ ,‬תחושת איום‪ ,‬דיסוציאציה‪ ,‬התמודדות‬ ‫דרך התנתקות ומצב רוח ירוד‪ .‬גורמים מנבאים לכרוניות‬ ‫היו תחושת איום‪ ,‬פסימיות‪ ,‬דיסוציאציה והתמודדות על ידי‬ ‫התנתקות‪.‬‬ ‫מסקנות‪:‬‬ ‫‪1 .1‬לחשיפה ממושכת לטרור יש השפעה שלילית חזקה על‬ ‫בריאות הנפש‪.‬‬ ‫‪2 .2‬גם במצב כרוני של טרור‪ ,‬חלק גדול מהאנשים שנראו אצלם‬ ‫רמות גבוהות של סימפטומים פוסט–טראומטיים התאוששו‬ ‫במשך הזמן‬ ‫‪3 .3‬חשיפה מתמשכת לטרור עלולה להחמיר סימפטומים‪ ,‬אך‬ ‫היא אינה בהכרח זרז למקרים חדשים של ‪. PTSD‬‬ ‫‪143‬‬

‫תחושת קוהרנטיות ותחושת קהילתיות‬ ‫כמשאבי התמודדות של בני נוער דתיים לפני‬ ‫ההתנתקות מרצועת עזה ואחריה‬

‫א‪ .‬בראון־לבינסון‪ ,‬ש‪ .‬שגיא‪ ,‬ח‪ .‬סבטו ור‪ .‬גלילי‪ ,‬באר־שבע‬

‫באוגוסט ‪ 2005‬פונו לצמיתות כל היישובים היהודיים ברצועת‬ ‫עזה בהתאם להחלטת הממשלה‪ .‬בהתבסס על התיאוריה‬ ‫הסלוטוגנית‪ ,‬נבחנו במחקר זה משאבי התמודדות אישיים‬ ‫וקהילתיים ‪ -‬תחושת קוהרנטיות אישית ותחושת קהילה ‪-‬‬ ‫בקרב בני נוער שפונו מביתם‪ .‬חקרנו את הדרך שבה משאבי‬ ‫ההתמודדות פועלים בשלושה שלבים‪ :‬לפני ההתנתקות‬ ‫מעזה‪ ,‬חודשים אחדים לאחר ההתנתקות וחמש שנים לאחר‬ ‫ההתנתקות‪.‬‬ ‫הנתונים נאספו בקרב בני נוער דתיים שגדלו וחיו ביישובים‬ ‫יהודיים קטנים ברצועת עזה‪ .‬מתבגרים בני ‪ 18–12‬מילאו‬ ‫שאלונים לדיווח עצמי ובעזרתם הוערכו מצב החרדה ומצב‬ ‫הכעס כתגובות רגשיות ללחץ ותחושת קוהרנטיות ותחושת‬ ‫קהילתיות כמשאבי התמודדות‪.‬‬ ‫התוצאות מראות כי גם תחושת הקוהרנטיות האישית‬ ‫וגם תחושת הקהילה נחלשו מיד לאחר ההתנתקות‪ .‬יחד עם‬ ‫זאת‪ ,‬תחושת הקוהרנטיות האישית שבה והתחזקה כחמש‬ ‫שנים לאחר ההתנתקות‪ .‬יתרה מזאת‪ ,‬בשני השלבים שלאחר‬ ‫ההתנתקות‪ ,‬תחושת הקוהרנטיות האישית ותחושת הקהילה‬ ‫היו משמעותיות יותר בהסבר של תגובות הלחץ ביחס לשלב‬ ‫הראשון האקוטי‪ .‬במאמר נדונות התוצאות על רקע המודל‬ ‫הסלוטוגני‪ ,‬והוא כולל השלכות פרקטיות להתערבויות‬ ‫אפשריות במצבי לחץ שונים (אקוטיים וכרוניים)‪.‬‬ ‫טראומה ומצוקה פסיכולוגית בקרב‬ ‫עיתונאים‪ :‬השוואה בין עיתונאים‬ ‫ישראליים לעמיתיהם המערביים‬

‫י‪ .‬לבאות‪ ,‬מ‪ .‬סיניור וא‪ .‬פיינשטיין‪ ,‬טורונטו‪ ,‬קנדה‬

‫רקע‪ :‬יש ידע מועט הנוגע לשאלה כיצד חשיפה לטראומה‬ ‫משפיעה על רווחתם הנפשית של עיתונאים‪ .‬מחקר קודם הראה‬ ‫כי חלק מהעיתונאים עלולים לפתח סימפטומים של מצוקה‬ ‫רגשית‪ ,‬אך עדיין לא ידוע אם מידת וסוג המצוקה שונה בין‬ ‫עיתונאים המדווחים מאזורי סכנה הנמצאים בסמיכות לביתם‬ ‫לבין עיתונאים המדווחים מאזורי סכנה בארצות הרחוקות‬ ‫מביתם‪.‬‬ ‫שיטת המחקר‪ :‬השווינו אינדקס המודד את הרווחה הנפשית‬ ‫של ‪ 38‬עיתונאים ישראלים לעומת ‪ 38‬עיתונאים מערביים אשר‬ ‫דיווחו מאזורי קונפליקט ומלחמה‪.‬‬ ‫תוצאות‪ :‬שתי הקבוצות דיווחו על חשיפה רבה לאירועים‬ ‫טראומטיים‪ .‬לא נמדדו הבדלים משמעותיים בשכיחות או בסוג‬ ‫החשיפה בין הקבוצות‪.‬‬ ‫עיתונאים מערביים דיווחו על יותר סימפטומים פוסט–‬ ‫טראומטיים מסוג חוויה חוזרת ונשנית של הטראומה‪ ,‬וכן על‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫יעילותו של קריטריון ‪A‬‬ ‫בנסיבות של טרור מתמשך‬

‫מ‪ .‬בן סימון‪ ,‬ז‪ .‬סולומון‪ ,‬ד‪ .‬חורש‪ ,‬רמת גן‬

‫לפי ספר המיון והסיווג הפסיכיאטרי האמריקאי (‪,)DSM-IV-TR‬‬ ‫יש צורך הן ברכיב אובייקטיבי והן ברכיב סובייקטיבי‬ ‫(קריטריונים ‪ A1‬ו–‪ )A2‬בכל הקשור לחשיפה לטראומה לצורך‬ ‫אבחון הפרעת דחק פוסט–טראומטית‪ .‬לקראת צאת המהדורה‬ ‫החדשה של ספר המיון והסיווג ‪ - DSM-V -‬הוצע לשנות את‬ ‫קריטריון ‪ A‬כך שהגדרת אירוע טראומתי תתבסס אך ורק על‬ ‫הרכיב האובייקטיבי‪.‬‬ ‫ספרי המיון והסיווג הפסיכיאטריים‪ ,‬ה–‪ DSM‬האמריקאי‬ ‫וה–‪ ICD‬האירופאי‪ ,‬הם תוצרים של החברה הצפון אמריקאית‬ ‫והאירופאית ולכן הם מושפעים מתרבויות אלו‪ .‬בהשוואה‬ ‫לחברות אחרות‪ ,‬חברות אלו לא נחשפו לאירועים טראומתיים‬ ‫כרוניים בקנה מידה לאומי‪ .‬לפיכך קריטריון ‪ A‬הנוכחי עשוי‬ ‫להיות רלוונטי יותר לאירועי טראומה בודדים ופחות לאירועים‬ ‫כרוניים בקנה מידה לאומי‪ .‬בסקירה זו מועלית השאלה אם‬ ‫השינוי המוצע ב–‪ DSM-V‬לקריטריון ‪ A‬מתאים למציאות‬ ‫בחברות שבהן החשיפה לטרור ממושכת‪ ,‬קבועה ובקנה מידה‬ ‫לאומי‪.‬‬ ‫בחינת הקריטריונים לאבחון הפרעת‬ ‫דחק בתר חבלתית‪ :‬ניתוח גורמים בקרב‬ ‫נפגעי טראומה במלחמה ובטרור‬

‫מ‪ .‬בן סימון‪ ,‬ס‪.‬צ‪ .‬לוין‪ ,‬ג‪ .‬זרח‪ ,‬ע‪ .‬שטיין‪ ,‬ו‪ .‬סבטליצקי‪ ,‬ז‪ .‬סולומון‪,‬‬ ‫רמת גן‬

‫רקע‪ :‬מחקרים אמפיריים בקרב חברות המתמודדות עם חשיפה‬ ‫מתמשכת לאיומי מלחמה וטרור מצביעים על ממצאים סותרים‬ ‫בכל הקשור להקבצת אשכולות תסמיני הפרעת דחק פוסט–‬ ‫טראומטית על בסיס הגדרת האגודה הפסיכולוגית האמריקאית‬ ‫(‪ .)DSM-IV-TR‬שלושת האשכולות כוללים חוויה מחדש של‬ ‫האירוע הטראומטי‪ ,‬הימנעות וקהות רגשית‪ ,‬ועוררות יתר‪.‬‬ ‫שיטה‪ :‬מחקר זה בוחן באופן ייחודי את תקפות האשכולות‬ ‫המרכיבים את הפרעת הדחק הפוסט–טראומטית בקרב פרטים‬ ‫בחברה הישראלית שנחשפו לטראומה מעשה ידי אדם‪ .‬ניצולים‬ ‫(‪ )N=2,198‬משבע מלחמות ואירועי טרור עברו הערכה תוך‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,50‬מס' ‪2013 ,2‬‬

‫שימוש בשאלון המבוסס על תסמיני ההפרעה כפי שאלו‬ ‫מופיעים ב–‪ .DSM-IV-TR‬נערכה השוואה בין ארבעה מודלים‬ ‫על בסיס ניתוחי גורמים מאששים‪.‬‬ ‫ממצאים ומסקנות‪ :‬נמצא כי המודל המוצלח ביותר היה זה‬ ‫שהכיל ארבעה אשכולות הכוללים חוויה מחדש של האירוע‬ ‫הטראומטי‪ ,‬הימנעות פעילה‪ ,‬קהות רגשית‪ ,‬ועוררות יתר‪.‬‬ ‫אשכול ההימנעות כפי שמוצג ב–‪ DSM-IV-TR‬נחלק במחקר‬ ‫הנוכחי להימנעות פעילה ולקהות רגשית‪ .‬ממצאים אלו מחזקים‬ ‫מחקרים קודמים המציעים כי לקראת צאת ספר המיון והסיווג‬ ‫החדש (‪ ,)DSM-5‬רצוי לבצע שינוי במבנה אשכולות הפרעת‬ ‫הדחק הפוסט–טראומטית‪ .‬מוצע כי ארבעת האשכולות יכללו‬ ‫חוויה מחדש של האירוע הטראומטי‪ ,‬הימנעות פעילה‪ ,‬קהות‬ ‫רגשית‪ ,‬ועוררות יתר במדינות‪ ,‬כמו מדינת ישראל‪ ,‬בהן קיימים‬ ‫גורמי לחץ מתמשכים‪.‬‬ ‫הקשר בין תסמיני הפרעת דחק פוסט־טראומטית‬ ‫לתסמיני הפרעת דחק קיצוני שלא הוגדרה‬ ‫אחרת לאחר שבי מלחמה‬

‫ג‪ .‬זרח וז‪ .‬סולומון‪ ,‬אריאל‬

‫רקע‪ :‬שבי מלחמה ידוע כגורם פתוגני לתסמיני הפרעת דחק‬ ‫פוסט–טראומטית (‪ )PTSD‬ולתסמיני הפרעת דחק קיצוני שלא‬ ‫הוגדרה אחרת (הד"ק)‪ ,‬הידועה גם בשם הפרעת דחק פוסט–‬ ‫טראומטית מורכבת‪ .‬עם זאת‪ ,‬הקשר בין שתי ההפרעות הללו‬ ‫נותר לא ברור‪ .‬בעוד חוקרים אחדים מניחים כי שתי האבחנות‬ ‫הללו חופפות וחולקות אותם מנבאים‪ ,‬חוקרים אחרים מניחים‬ ‫ששתי ההפרעות בלתי־תלויות ושונות הן מבחינת מקורותיהן‬ ‫והן מבחינת הפגיעה התפקודית שהן גורמות לה‪ .‬במחקר זה‬ ‫ביקשו החוקרים להעריך את תסמיני ‪ ,PTSD‬את תסמיני הד"ק‬ ‫ואת קשרי הגומלין ביניהן בקרב פדויי שבי וקבוצת השוואה‬ ‫מותאמת של לוחמים לשעבר‪ ,‬שלושים וחמש שנים לאחר סיום‬ ‫המלחמה‪.‬‬ ‫שיטה‪ :‬המדגם כלל שתי קבוצות של לוחמים לשעבר‬ ‫ממלחמת יום הכיפורים‪ :‬פדויי שבי (‪ 176‬לוחמים) וקבוצת‬ ‫השוואה של לוחמים לשעבר שלא נפלו בשבי (‪ 118‬לוחמים)‪.‬‬ ‫תסמיני ‪ PTSD‬והד"ק‪ ,‬גורמי דחק הקשורים בקרב ובשבי וכן‬ ‫דרכי התמודדות בשבי הוערכו באמצעות שאלונים לדיווח‬ ‫עצמי בשנת ‪.2008‬‬ ‫תוצאות‪ :‬פדויי שבי דיווחו על מספר גדול יותר של תסמיני‬ ‫‪ PTSD‬ועל שיעורים גבוהים יותר של תסמיני ‪ PTSD‬שמילאו‬ ‫את הקריטריונים לאבחנת ההפרעה‪ ,‬לעומת לוחמים לשעבר‪.‬‬ ‫‪144‬‬