Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 4, 405– 411
© 2015 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/tra0000032
Coping Strategies and Internal Resources of Dispositional Optimism and Mastery as Predictors of Traumatic Exposure and of PTSD Symptoms: A Prospective Study Sharon Gil and Michael Weinberg
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University of Haifa This prospective study aimed at examining the role of trait internal resources and coping strategies in predicting traumatic exposure and levels of posttraumatic stress disorder (PTSD) symptoms after such exposure. In total, 870 Israeli students participated in the study, of whom 182 (20%) reported a lifetime history of traumatic exposure at baseline (t1), and a total of 231 (27%) respondents reported traumatic exposure during follow-up (t2, t3). After controlling the effect of lifetime history of traumatic exposure either by using it as a covariate in a multivariate analysis of covariance (MACNOVA) or as a predictor in regression analyses, the results indicate that individuals high on trait avoidance coping style and low on mastery are at a higher risk for traumatic exposure, while those high on trait problem-focused coping style, mastery and dispositional optimism are at a lower risk for PTSD symptoms after such exposure. Keywords: well-being, trauma, war, DSM-5 PTSD symptoms questionnaire
Folkman (1984), in developing the transactional stress model, classified coping modes by function as either problem-focused, defined as efforts to recognize, modify or eliminate the impact of a stressor or a cognitive activity; or emotion-focused, defined as efforts to regulate the emotional state associated with the experience of stress. Carver, Scheier, and Weintraub (1989) added another coping strategy—avoidance, which aims to ignore or avoid the problem and its emotional consequences (Carver & ConnorSmith, 2010). Additionally, the coping process involves coping resources. Dispositional optimism is an internal resource defined as the generalized expectancy that good outcomes will occur when confronting major problems (Scheier & Carver, 1985). This personal quality is considered to be a determinant of sustained efforts to deal with problems, in contrast to turning away and giving up. Higher levels of optimism have been related to better coping with various life events (Carver, Scheier, & Segerstrom, 2010; Prati & Pietrantoni, 2009). Another internal resource that has been found to be significant in dealing with stressful situations is mastery. Mastery refers to the extent to which one regards life events as being under one’s own control, in contrast to adopting a fatalistic outlook (Pearlin & Schooler, 1978). It is also defined as inner feelings of strength, and as the capacity to cope with and overcome obstacles by relying on one’s own efforts (Hobfoll, Jackson, Hobfoll, Pierce, & Young, 2002). Research literature has demonstrated that mastery is associated with lower levels of anger and depressive moods (Ennis, Hobfoll, & Schroder, 2000), caregiver stress (Mausbach et al., 2007), and lower levels of negative affect and higher levels of positive affect (Ben-Zur, 2002). The coping strategies and internal resources may serve either as trait personality features, utilized by the individual routinely in everyday stress, or as state-reaction in times of unusual circumstances, when equilibrium is imbalanced. The state reaction is likely to be consistent with everyday coping efforts, or it may be
Posttraumatic stress disorder (PTSD), by definition, follows and is a result of exposure to a traumatic event (Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [DSM-5]; American Psychiatric Association, 2014). Nevertheless, exposure to a traumatic event by itself is not a sufficient precondition for subsequent PTSD. Research literature has demonstrated that only a relative minority of trauma-exposed individuals develop PTSD or other trauma-related disorders (for review, see Breslau, Kessler, Chilcoat, Schultz, Davis, & Andreski, 1998; Frans, Rimmo, Aberg, & Fredrikson, 2005). Thus, aside from the most salient predictor of PTSD— exposure to a traumatic event— other variables can also be considered as risk factors for the development of PTSD. These variables fall into three main categories: pretraumatic, peritraumatic, and posttraumatic (Vogt, King, & King, 2007). Pretraumatic factors are viewed as predisposing vulnerability before the traumatic exposure, such as personality traits, biological vulnerability and demographic variables (Bomyea, Risbrough, & Lang, 2012; Vogt et al., 2007). Peri-traumatic factors are those linked to the actual traumatic occurrence, and include dissociation, magnitude of the event, level of physical injury, and victim’s subjective appraisal of the event (Ozer, Best, Lipsey, & Weiss, 2003). Posttraumatic factors are those characterizing the immediate and longterm reaction and coping ability of the victim and of those surrounding him or her (Gil, 2005). Trauma victims, seeking to relieve the ongoing stress posed by the exposure, make efforts to cope with the stress. Lazarus and This article was published Online First April 13, 2015. Sharon Gil and Michael Weinberg, The Interdisciplinary Clinical Center, School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa. Correspondence concerning this article should be addressed to Sharon Gil, The Interdisciplinary Clinical Center, School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel. E-mail: [email protected] 405
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altered among some individuals because of the disordered nature of the event (Lazarus, 1999, 2006; Lazarus & Folkman, 1984). To date, no studies have examined the role of these coping components in the risk for exposure to trauma, and relatively few studies applied them as risk factors for PTSD after traumatic exposure (e.g., Carmelo, Gonzalo, & Perez-Sales, 2008; Gil, 2005; Gilbar, Weinberg & Gil, 2011; Weinberg, Gilbar & Gil, 2014). The results of this study demonstrated that problem-focused coping strategies are associated with fewer PTSD symptoms than emotion-focused and avoidance strategies. In addition, higher levels of dispositional optimism have been related to better coping with stress and trauma (Carver, Scheier, & Segerstrom, 2010; Prati & Pietrantoni, 2009). Specifically, high levels of dispositional optimism were found to be associated with higher levels of wellbeing and lower levels of PTSD and other trauma-related disorders, such as depression, dissociation, and anxiety among traumatized individuals (Ai, Evans-Campbell, Santangelo, & Cascio, 2006; Ben-Zur & Debi, 2005; Carver, Lehman, & Antoni, 2003; Weinberg, Besser, Zeigler-Hill, & Neria, 2015). This conforms with research literature demonstrating that mastery is associated with lower levels of anger and depressive moods (Ennis, Hobfoll, & Schroder, 2000), PTSD (Ben-Zur, 2008), caregiver stress (Mausbach et al., 2007), and lower levels of negative affect and higher levels of positive affect (Ben-Zur, 2002). However, the ability to examine coping strategies and internal resources as predictors of traumatic exposure and of PTSD symptoms after such exposure is limited, mainly because of methodological restraints in locating trauma victims before the traumatic exposure. To bridge this gap, the present study applied a prospective design with twofold aims: (a) to examine the role of pretraumatic trait internal resources and coping strategies in the risk for exposure to trauma, and (b) to explore the role of pretraumatic trait internal resources and coping strategies in the risk for developing PTSD symptoms after traumatic exposure. Because of the lacuna in studies examining internal recourses and coping strategies as predictors of traumatic exposure, our hypotheses were based on their role in the risk for PTSD symptoms as reviewed above: 1.
High levels of pretraumatic trait internal resources of distortional optimism and mastery will decrease the risk for traumatic exposure and for PTSD symptoms after such exposure.
2.
High levels of pretraumatic trait problem-focused coping strategies will decrease the risk for traumatic exposure and for PTSD symptoms after such exposure, whereas emotional-focused and avoidance coping strategies will increase that risk.
3.
A lifetime history of traumatic exposure will increase the risk for additional traumatic exposure and for PTSD symptoms.
Method Sample The research sample consisted of 870 undergraduate students recruited from a university in northern Israel. Initial recruitment
(t1) took place at the beginning of the winter semester of the 2010 academic year. Overall, a total of 1,430 first-year undergraduate students were approached, and 1,360 (95%) completed the study questionnaires and complied as the sample base. The respondents were reassessed at two additional follow-up points: at the end of the second academic year (t2; M ⫽ 18 months from t1, SD ⫽ 1.9) 930 of the original 1,360 students (65%) were located and agreed to participate in the follow-up, and at the end of the third academic year (t3; M ⫽ 11 months from t2, SD ⫽ 1.6) 870 of the original sample (60%) were located and agreed to participate. A comparative analysis of the 870 students who participated in the t3 follow-up and the 560 (40%) students who dropped out revealed no significant differences in demographic profile, including in lifetime history of traumatic exposure. Nevertheless, the 40% students who dropped out showed higher levels of avoidance (M ⫽ 2.31, SD ⫽ 1.22) and mastery (M ⫽ 4.95, SD ⫽ 1.11) at baseline (t1), as compared with those who completed the follow-up (M ⫽ 1.91, SD ⫽ 0.9; M ⫽ 4.53, SD ⫽ 1.2, respectively; t ⫽ 2.6, p ⬍ .001, t ⫽ 2.3, p ⬍ .001). All the analyses that followed include only the 870 students who completed the t3 follow-up. The mean age of the sample (n ⫽ 870) was 23.5 (SD ⫽ 1.3), mean years of education was 12.1 (SD ⫽ 0.6), and the majority were female (63%), single (74%), born in Israel (88%), and secular (92%). A personal history of psychiatric intervention was reported by 16 (1.8%) respondents and 5 (0.5%) reported a familial history of such intervention.
Measures Demographic characteristics. A demographic questionnaire covered variables such as age, gender, years of education, and lifetime history of traumatic exposure or psychiatric intervention. Traumatic exposure. Lifetime history of traumatic exposure was examined using the following questions at t1: (a) Have you ever been exposed to a traumatic event? (b) If yes, what was the event? (c) If you have been exposed to more than one traumatic event, please indicate only one event—the most traumatic one in your experience, and relate to it exclusively in the following Question 3. When and where did this event occur? At the t2 assessment point the respondents were asked whether they had been exposed to a traumatic event since the t1 assessment point— that is, from the beginning of their first academic year onward; if yes, indicate the single most traumatic experience, if more than one was indicated, and relate to it exclusively in the following question. Item 3 remained the same. At the t3 assessment point the respondents were asked whether they had been exposed to a traumatic event since the t2 assessment point—that is, from the end of their second academic year onward; if yes, indicate the single most traumatic experience, if more than one was indicated, and relate to it exclusively in the following question. Item 3 remained the same. A few respondents, who cited normal life distress (such as work or academic distress) as traumatic, were excluded from the sample. Posttraumatic stress disorder. PTSD symptoms were evaluated using the PTSD Symptom Scale-Self Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993). The PSS-SR is a 17-item self-report questionnaire aimed at assessing the level of posttraumatic stress symptoms over a period of the preceding 2 weeks. Each item corresponds to one of the 17 Diagnostic and Statistical
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PREDICTING TRAUMATIC EXPOSURE AND LEVELS OF PTSD
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consists of eight items rated on a 1–5 scale (1 ⫽ disagree to a large extent, 5 ⫽ agree to a large extent) with a high score indicating an optimistic tendency. The internal reliability and the test–retest of the original version were satisfactory (Cronbach’s ␣ ⫽ .76, test–retest ⫽ .79; Scheier & Carver, 1985). The questionnaire was filled in three times: at t1, t2, and t3, with a mean Cronbach’s ␣ of .86.
Manual of Mental Disorders-Fourth Edition-Text Revision (DSM– IV–TR; American Psychiatric Association, 2000) diagnostic criteria for PTSD. The severity of each item is rated on a four-point Likert scale ranging from 0 ⫽ not at all to 3 ⫽ very much. The total severity score is calculated as the mean of the respondent’s ratings on the 17 items. The questionnaire was filled in at three time intervals: t1, t2, and t3. The Cronbach’s ␣ in the present study was .94, .92, and .94, respectively. COPE scale. Coping strategies were measured by a short 30-item Hebrew version of the COPE scale (Carver et al., 1989). The shortened version contains 15 coping strategies, each represented by the sum of two items (Zeidner & Ben-Zur, 1994). Respondents indicate the extent to which each of the 15 strategies is used either in everyday life (trait coping strategy at t1) or in response to a specific event (state coping strategy at t2 and t3 for respondents who reported traumatic exposure). Responses are rated on a 4-point scale, ranging from 0 ⫽ not at all to 3 ⫽ great extent. Based on a factor analysis, three main subscales were used: problem-focused coping (including active coping, planning, and suppression); emotion/support coping (including instrumental and emotional support, and ventilation); and avoidance coping (including behavioral and mental disengagement, denial, and alcohol/drug use). The questionnaire was filled in at three time intervals: t1, t2, and t3. The mean Cronbach’s ␣ for the problem-focused subscale at the three assessment points was .88; for the emotion-focused subscale .89; and for the avoidance subscale .87. Mastery. Mastery was examined using the mastery scale developed by Pearlin and Schooler (1978). The scale contains seven items rated on a 1–7 scale (1 ⫽ not appropriate, 7 ⫽ very appropriate) with a high score indicating a high level of mastery. Hobfoll and Walfisch (1984) reported a test–retest reliability of .85 or above with reasonable internal reliability levels (Cronbach’s ␣ ⫽ .75). The questionnaire was filled in three times: at t1, t2, and t3, showing a mean Cronbach’s ␣ of .90. Optimism. Dispositional optimism was examined using the Life Orientation Test (LOT; Scheier & Carver, 1985). This scale
Procedure Following approval by the University of Haifa Ethical Committee for Research with Human Participants, Welfare and Health Sciences Division, the five largest faculties at the university (education, social sciences, social welfare and health studies, law, and humanities) were approached to participate in the study. The main first-year introductory class in each faculty was selected as the sample base. The respondents were reassessed at two additional follow-up points: the end of the second academic year and the end of the third academic year. All the respondents completed the questionnaires voluntarily. No compensation was offered for participation in the study.
Results Lifetime History of Traumatic Exposure In total, 182 respondents (20%) reported a lifetime history of exposure to a traumatic event at t1. The most prevalent incidents were car accident (32%), death of a significant other (29%), and combat (19%). The demographic profile, coping strategies, and internal resources of respondents who reported a history of a traumatic exposure were compared with those who did not report such a history. As indicated in Table 1, differences in age and gender distribution that were not statistically significant were observed between participants with and without a history of traumatic exposure.
Table 1 Demographic Profile, Coping Strategies, and Internal Resources of Respondents With (n ⫽ 182) and Without (n ⫽ 688) History of Traumatic Exposure With a history of traumatic exposure
Without a history of traumatic exposure
(n ⫽ 182)
(n ⫽ 688)
t/2
87 (48) 95 (52)
235 (34) 453 (66)
2 ⫽ 21.3
Gender (%) Male Female Age Coping strategies Problem-focused Emotion-focused Avoidance Resources Dispositional optimism Mastery PTSD symptoms at t3
M
SD
M
SD
22.9
1.0
23.8
1.5
1.9
.91 1.92 2.63
.87 1.25 1.32
1.32 1.27 1.71
.92 .88 .79
0.88 2.7ⴱ 3.1ⴱⴱⴱ
2.51 3.11 1.96
0.86 1.1 1.0
3.78 4.91 0.91
1.3 0.78 1.21
2.9ⴱⴱ 2.6ⴱ 3.1ⴱⴱⴱ
Note. PTSD ⫽ posttraumatic stress disorder. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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all three assessment points than those who had not been exposed. However, respondents who had been exposed to a traumatic event scored significantly higher in levels of PTSD symptoms at t2 and at t3 than those who had not. No significant changes were found in level of PTSD symptoms as measured at t2 compared with measurement at t3. Next, to identify predictors of traumatic exposure, a logistic regression analysis was conducted with exposure (yes/no) as the dependent variable. Only the 231 (27%) respondents who reported traumatic exposure during the follow-up were included in the analysis. Age, gender (male ⫽ 0, female ⫽ 1), history of traumatic exposure (no ⫽ 1, yes ⫽ 0), internal resources, and coping strategies were entered as the independent variables. The results revealed that high use of an avoidance coping strategy increased the risk for traumatic exposure threefold (odds ratio [OR] ⫽ 3.34, p ⬍ .001, 95% confidence interval [CI] [1.91, 7.08]), and low levels of mastery increased the odds/risk for traumatic exposure twofold (2.26, p ⬍ .001, 95% CI [1.88, 3.93]). Nagelkerke R2 for the entire model was 0.19. Thereafter, a hierarchical regression analysis was conducted to explore levels of mastery, dispositional optimism, and coping strategies measured at t1 as predictors of PTSD symptoms among the 231 participants who reported traumatic exposure during follow-up. To control the effect of lifetime history of traumatic exposure, this variable alone was entered in Block I as a dummy variable. Block II included levels of internal resources of dispositional optimism and mastery, and Block III included levels of problem-focused, emotion-focused, and avoidance coping strategies. To maintain the power of the regression analysis, demographics were excluded. The results of the analysis are presented in Table 3. The model explained 57% of the variance in predicting levels of PTSD symptoms. The block that contributed the most to the prediction of PTSD symptoms was Block II (R2 ⫽ .311), with mastery ( ⫽ .061, p ⬍ .001) and dispositional optimism ( ⫽ .052, p ⬍ .001) as predictors, respectively. Block III added a further 18% of the explained variance, with problem-focused coping strategy as a positive predictor ( ⫽ .053, p ⬍ .001), avoidance ( ⫽ ⫺.054, p ⬍ .001), and emotional-focused ( ⫽ ⫺.021, p ⬍ .001) coping strategies as negative predictors, respectively. Lastly,
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Levels of PTSD symptoms at t1 were significantly higher among respondents who reported a lifetime history of traumatic exposure than those who did not report such a history. Additionally, respondents who reported a previous history of traumatic exposure scored significantly higher in level of use of emotion-focused and avoidance coping strategies than those who did not report such a history. Lastly, respondents who reported a history of exposure to a traumatic event scored significantly lower in levels of dispositional optimism and mastery than those who did not report such a history. To control the potential effect of lifetime history of traumatic exposure, this variable was entered in the following analyses either as a covariate or as an independent predictor.
Predictors of Traumatic Exposure At t2, 141 (16%) respondents reported being exposed to a traumatic event during the time interval from t1 to t2. At t3, an additional 90 (10%) respondents reported being exposed to a traumatic event during the time interval from t2 to t3. The most prevalent events at both assessment points were car accidents (44%), death of a significant other (29%), and combat (16%). A comparison between respondents who had been exposed to a traumatic event and those who had not, as measured at the follow-up assessment points, was conducted utilizing a MANCOVA analysis, with the effect of lifetime history of traumatic exposure as a controlled covariate. Two factors were entered: group (exposed/not exposed) and assessment point (t1, t2, and t3). As shown in Table 2, a main effect for group was found in the use of emotion-focused coping strategy, avoidance coping strategy, level of mastery, and level of PTSD symptoms. Specifically, the use of an emotion-focused coping strategy at t2 increased significantly among respondents who had been exposed to a trauma but not among those who had not been exposed. Such differences, however, were not observed at t3. Respondents who had been exposed to a traumatic event scored significantly higher in the use of an avoidance coping strategy both before and after the traumatic exposure. However, no significant differences were found between the uses of an avoidance coping strategy at the different assessment points. Respondents who had been exposed to a traumatic event scored significantly lower in level of mastery at
Table 2 MANCOVA Comparing Scores of Respondents With and Without (n ⫽ 729) Traumatic Exposure, Controlling for Lifetime History of Traumatic Exposure t1 (n ⫽ 182)
Coping strategies Problem-focused Emotion-focused Avoidance Resources Dispositional optimism Mastery PTSD symptoms
t2 (n ⫽ 141)
t3 (n ⫽ 90)
Exposed (M/SD)
Not exposed (M/SD)
Exposed (M/SD)
Not exposed (M/SD)
Exposed (M/SD)
Not exposed (M/SD)
Fgroup/Ftime
1.19 (.87) 1.31 (.78) 1.91 (1.1)
1.21 (.91) 1.26 (.68) 1.46 (.92)
1.90 (.86) 1.47 (.92) 1.93 (.83)
1.21 (.78) 1.01 (1.1) 1.44 (.78)
1.89 (.91) 1.33 (.67) 1.90 (.97)
1.22 (.67) 1.27 (.99) 1.47 (1.1)
2.12/2.01 2.78ⴱ/2.84ⴱⴱ 3.71ⴱⴱ/2.2
3.50 (.56) 4.01 (.88) 1.22 (.93)
3.46 (.85) 4.36 (1.2) 1.20 (1.1)
3.44 (.36) 3.21 (.78) 2.22 (.45)
3.51 (.51) 4.88 (1.3) 1.21 (1.3)
3.46 (.68) 3.33 (.83) 2.02 (.56)
3.49 (.77) 4.71 (.89) 1.22 (1.1)
2.61/2.12 3.41ⴱⴱ/2.34 3.78ⴱⴱⴱ/3.11ⴱⴱ
Note. PTSD ⫽ posttraumatic stress disorder. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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Table 3 Hierarchical Regression Analysis With Levels of Posttraumatic Stress Symptoms (PTSS) at t3 as the Dependent Variable (n ⫽ 231) Adjusted R2
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Block I Lifetime history of traumatic exposure at t1 Block II Dispositional optimism at t1 Mastery at t1 Block III Problem-focused at t1 Emotional focused at t1 Avoidance at t1 ⴱ
p ⬍ .05.
ⴱⴱ
p ⬍ .01.
ⴱⴱⴱ
B
SE(B)

t value
0.06 (F ⫽ 2.20)ⴱ .311 (F ⫽ 6.82)ⴱⴱⴱ .181 (F ⫽ 3.925)ⴱⴱⴱ
.022
.014
.013
2.621ⴱ
.052 .061
.013 .014
.257 .347
2.621ⴱⴱⴱ 3.121ⴱⴱⴱ
.053 ⫺.021 ⫺.054
.019 ⫺.013 ⫺.023
.289 ⫺.211 ⫺.280
2.954ⴱⴱⴱ ⫺2.122ⴱⴱⴱ ⫺2.741ⴱⴱⴱ
p ⬍ .001.
the effect of lifetime history of traumatic exposure contributed another 6% of the explained variance.
Discussion This prospective study aimed at examining the role of pretraumatic trait internal resources and coping strategies in predicting traumatic exposure, and to explore the role of pretraumatic trait internal resources and coping strategies in predicting PTSD symptoms after such exposure. In total, 870 Israeli students participated in the study, of whom 182 (20%) reported a lifetime history of traumatic exposure at baseline (t1); 141 (16%) reported being exposed to a traumatic event during the time interval from t1 to t2 (M ⫽ 18 months, SD ⫽ 1.9); and 90 (10%) respondents reported being exposed to a traumatic event during the time interval from t2 to t3 (M ⫽ 11 months, SD ⫽ 1.6). That is, a total of 231 (27%) respondents reported traumatic exposure during follow-up. The most prevalent events at all assessment points were car accidents (44%), death of a significant other (29%), and combat (16%). In general, and in line with the study’s hypotheses, high levels of pretraumatic trait internal resources of mastery and distortional optimism decreased the risk for traumatic exposure and for PTSD symptoms after such exposure, during follow-up. High levels of pretraumatic trait problem-focused coping strategies decreased the risk for traumatic exposure and for PTSD symptoms after such exposure, whereas high levels of emotional-focused and avoidance coping strategies increased those risks. Lastly, a lifetime history of traumatic exposure increased the risk for additional traumatic exposure and for PTSD symptoms after such exposure. More specifically, and in accord with the research literature, emotion-focused and avoidance coping strategies were associated with elevated levels of PTSD symptoms (Gil, 2005; Gilbar et al., 2011; Weinberg et al., 2015). However, emotion-focused coping strategies were associated with PTSD symptoms only in close time proximity to the traumatic event at t2, and decreased with the passage of time from the traumatic event, indicating that the elevated levels of use of emotion-focused coping strategies by those who were exposed to a traumatic event was time- limited. This accords with previous results (e.g., Ben-Zur, 2008; Ben-Zur, Gilbar, & Lev, 2001), demonstrating that although a problemfocused coping strategy is more effective in the immediate aftermath of stress and trauma, an emotional-focused coping strategy is
useful in the long run. The avoidance coping strategy was found to be generally ineffectual. A possible explanation for these results is that the chaotic and uncontrollable nature of the immediate response to trauma demands utilizing strategies aimed at troubleshooting to regain control and equilibrium. Conceivably, as time goes by, the effect of the traumatic event may weaken and may be perceived as more controllable, which in turn will allow those who were exposed to trauma to withdraw from the use of problem-focused coping strategies and focus more on emotional processing (Lazarus, 2006; Lazarus & Folkman, 1984). This explanation also conforms with results showing that a problem-focused coping strategy is a negative predictor of PTSD symptoms, whereas an emotion-focused and an avoidance coping strategy are positive predictors for such symptoms. A longer follow-up is needed to identify effective alternation or combination between coping strategies. This assessment is viable when such personality traits, namely, problem- and emotion-focused coping strategies, and mastery and dispositional optimism, are available traits for the use of the exposed individual. Despite the strengths of the present study, the research has several limitations. A significant limitation is its use of a sample of university students. Accordingly, generalizations should be made with caution. In addition, the diversity of the traumatic events studied may have generalized the effects of coping strategies, mastery and optimism in the context of particular events. Furthermore, it is possible that the time periods between the traumatic event and the follow-up assessments, which were relatively short for some participants, may have adversely impacted the observed relationships. Nevertheless, the findings of the study are highly informative, particularly because this is a prospective study. Together, the findings suggest that preventive efforts to reduce exposure to a traumatic event should focus mainly on individuals high on avoidance coping strategy, dispositional optimism, and mastery. Evidently, this is true for events over which the individual has control, such as car accidents. Immediate preventive efforts to reduce PTSD symptoms among individuals exposed to a traumatic event should focus mainly on those high on emotional and avoidance coping strategies and low on dispositional optimism and mastery. Accordingly, when dealing with traumatic events, therapists and trauma survivors should take into account both the short- and the long-range effect of the traumatic event, and mainly be aware that
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emotion-focused strategies may differ as time passes. Moreover, in devising a therapeutic framework, it is important to address, encourage, and reinforce mastery and optimism as a valuable resource when confronting PTSD. Furthermore, effective emotionfocused coping strategies in the long run may be useful in processing the trauma. An awareness of the negative effect of avoidance coping is warranted. An unrelated yet significant issue that emerged from the findings of the study is that students who dropped out during the follow-up scored higher on avoidance and mastery at baseline (t1), compared with those who completed the follow-up. These results may expand our perspective on the issue of responsiveness to follow-up, pending further and specific examination in future studies. In summary, the results of the study indicate that individuals high on trait avoidance coping style and low on mastery are at a higher risk for traumatic exposure, whereas those high on trait problem-focused coping style, mastery, and dispositional optimism are at a lower risk for PTSD symptoms after such exposure.
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Social Psychology, 84, 813– 821. http://dx.doi.org/10.1037/0022-3514 .84.4.813 Carver, C. S., Scheier, M. F., & Segerstrom, S. C. (2010). Optimism. Clinical Psychology Review, 30, 879 – 889. http://dx.doi.org/10.1016/j .cpr.2010.01.006 Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267–283. http://dx.doi.org/10.1037/0022-3514 .56.2.267 Ennis, N., Hobfoll, S. E., & Schroder, K. E. E. (2000). Money doesn’t talk, it swears: How economic stress and resistance resources impact innercity women’s depressive mood. American Journal of Community Psychology, 28, 149 –173. Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459 – 473. http://dx.doi .org/10.1002/jts.2490060405 Frans, O., Rimmö, P. A., Aberg, L., & Fredrikson, M. (2005). Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatrica Scandinavica, 111, 291–299. http://dx.doi.org/ 10.1111/j.1600-0447.2004.00463.x Gil, S. (2005). Coping style in predicting posttraumatic stress disorder among Israeli students. Anxiety, Stress & Coping: An International Journal, 18, 351–359. http://dx.doi.org/10.1080/10615800500392732 Gilbar, O., Weinberg, M., & Gil, S. (2012). The effects of coping strategies on PTSD victims of terror attacks and their spouses: Testing dyadic dynamics using an Actor-Partner Interdependence Model. Journal of Social and Personal Relationships, 29, 246 –261. Hobfoll, S. E., Jackson, A., Hobfoll, I., Pierce, C. A., & Young, S. (2002). The impact of communal-mastery versus self-mastery on emotional outcomes during stressful conditions: A prospective study of Native American women. American Journal of Community Psychology, 30, 853– 871. http://dx.doi.org/10.1023/A:1020209220214 Hobfoll, S. E., & Walfisch, S. (1984). Coping with a threat to life: A longitudinal study of self-concept, social support, and psychological distress. American Journal of Community Psychology, 12, 87–100. http://dx.doi.org/10.1007/BF00896930 Lazarus, R. S. (2006). Emotions and interpersonal relationships: Toward a person-centered conceptualization of emotions and coping. Journal of Personality, 74, 9 – 46. http://dx.doi.org/10.1111/j.1467-6494.2005 .00368.x Lazarus, S. (1999). Stress and emotion: A new synthesis. London, UK: Free Association Books. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New York, NY: Springer-Verlag. Mausbach, B. T., Patterson, T. L., Von Känel, R., Mills, P. J., Dimsdale, J. E., Ancoli-Israel, S., & Grant, I. (2007). The attenuating effect of personal mastery on the relations between stress and Alzheimer caregiver health: A five-year longitudinal analysis. Aging & Mental Health, 11, 637– 644. http://dx.doi.org/10.1080/13607860701787043 Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52–73. http://dx.doi.org/10.1037/00332909.129.1.52 Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2–21. http://dx.doi.org/10.2307/ 2136319 Prati, G., & Pietrantoni, L. (2009). Optimism, social support, and coping strategies as factors contributing to posttraumatic growth: A metaanalysis. Journal of Loss and Trauma, 14, 364 –388. http://dx.doi.org/ 10.1080/15325020902724271 Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Assessment and implications of generalized outcome expectancies.
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Received August 15, 2014 Revision received January 11, 2015 Accepted January 16, 2015 䡲
© 2015 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/tra0000032
Coping Strategies and Internal Resources of Dispositional Optimism and Mastery as Predictors of Traumatic Exposure and of PTSD Symptoms: A Prospective Study Sharon Gil and Michael Weinberg
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University of Haifa This prospective study aimed at examining the role of trait internal resources and coping strategies in predicting traumatic exposure and levels of posttraumatic stress disorder (PTSD) symptoms after such exposure. In total, 870 Israeli students participated in the study, of whom 182 (20%) reported a lifetime history of traumatic exposure at baseline (t1), and a total of 231 (27%) respondents reported traumatic exposure during follow-up (t2, t3). After controlling the effect of lifetime history of traumatic exposure either by using it as a covariate in a multivariate analysis of covariance (MACNOVA) or as a predictor in regression analyses, the results indicate that individuals high on trait avoidance coping style and low on mastery are at a higher risk for traumatic exposure, while those high on trait problem-focused coping style, mastery and dispositional optimism are at a lower risk for PTSD symptoms after such exposure. Keywords: well-being, trauma, war, DSM-5 PTSD symptoms questionnaire
Folkman (1984), in developing the transactional stress model, classified coping modes by function as either problem-focused, defined as efforts to recognize, modify or eliminate the impact of a stressor or a cognitive activity; or emotion-focused, defined as efforts to regulate the emotional state associated with the experience of stress. Carver, Scheier, and Weintraub (1989) added another coping strategy—avoidance, which aims to ignore or avoid the problem and its emotional consequences (Carver & ConnorSmith, 2010). Additionally, the coping process involves coping resources. Dispositional optimism is an internal resource defined as the generalized expectancy that good outcomes will occur when confronting major problems (Scheier & Carver, 1985). This personal quality is considered to be a determinant of sustained efforts to deal with problems, in contrast to turning away and giving up. Higher levels of optimism have been related to better coping with various life events (Carver, Scheier, & Segerstrom, 2010; Prati & Pietrantoni, 2009). Another internal resource that has been found to be significant in dealing with stressful situations is mastery. Mastery refers to the extent to which one regards life events as being under one’s own control, in contrast to adopting a fatalistic outlook (Pearlin & Schooler, 1978). It is also defined as inner feelings of strength, and as the capacity to cope with and overcome obstacles by relying on one’s own efforts (Hobfoll, Jackson, Hobfoll, Pierce, & Young, 2002). Research literature has demonstrated that mastery is associated with lower levels of anger and depressive moods (Ennis, Hobfoll, & Schroder, 2000), caregiver stress (Mausbach et al., 2007), and lower levels of negative affect and higher levels of positive affect (Ben-Zur, 2002). The coping strategies and internal resources may serve either as trait personality features, utilized by the individual routinely in everyday stress, or as state-reaction in times of unusual circumstances, when equilibrium is imbalanced. The state reaction is likely to be consistent with everyday coping efforts, or it may be
Posttraumatic stress disorder (PTSD), by definition, follows and is a result of exposure to a traumatic event (Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [DSM-5]; American Psychiatric Association, 2014). Nevertheless, exposure to a traumatic event by itself is not a sufficient precondition for subsequent PTSD. Research literature has demonstrated that only a relative minority of trauma-exposed individuals develop PTSD or other trauma-related disorders (for review, see Breslau, Kessler, Chilcoat, Schultz, Davis, & Andreski, 1998; Frans, Rimmo, Aberg, & Fredrikson, 2005). Thus, aside from the most salient predictor of PTSD— exposure to a traumatic event— other variables can also be considered as risk factors for the development of PTSD. These variables fall into three main categories: pretraumatic, peritraumatic, and posttraumatic (Vogt, King, & King, 2007). Pretraumatic factors are viewed as predisposing vulnerability before the traumatic exposure, such as personality traits, biological vulnerability and demographic variables (Bomyea, Risbrough, & Lang, 2012; Vogt et al., 2007). Peri-traumatic factors are those linked to the actual traumatic occurrence, and include dissociation, magnitude of the event, level of physical injury, and victim’s subjective appraisal of the event (Ozer, Best, Lipsey, & Weiss, 2003). Posttraumatic factors are those characterizing the immediate and longterm reaction and coping ability of the victim and of those surrounding him or her (Gil, 2005). Trauma victims, seeking to relieve the ongoing stress posed by the exposure, make efforts to cope with the stress. Lazarus and This article was published Online First April 13, 2015. Sharon Gil and Michael Weinberg, The Interdisciplinary Clinical Center, School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa. Correspondence concerning this article should be addressed to Sharon Gil, The Interdisciplinary Clinical Center, School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel. E-mail: [email protected] 405
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altered among some individuals because of the disordered nature of the event (Lazarus, 1999, 2006; Lazarus & Folkman, 1984). To date, no studies have examined the role of these coping components in the risk for exposure to trauma, and relatively few studies applied them as risk factors for PTSD after traumatic exposure (e.g., Carmelo, Gonzalo, & Perez-Sales, 2008; Gil, 2005; Gilbar, Weinberg & Gil, 2011; Weinberg, Gilbar & Gil, 2014). The results of this study demonstrated that problem-focused coping strategies are associated with fewer PTSD symptoms than emotion-focused and avoidance strategies. In addition, higher levels of dispositional optimism have been related to better coping with stress and trauma (Carver, Scheier, & Segerstrom, 2010; Prati & Pietrantoni, 2009). Specifically, high levels of dispositional optimism were found to be associated with higher levels of wellbeing and lower levels of PTSD and other trauma-related disorders, such as depression, dissociation, and anxiety among traumatized individuals (Ai, Evans-Campbell, Santangelo, & Cascio, 2006; Ben-Zur & Debi, 2005; Carver, Lehman, & Antoni, 2003; Weinberg, Besser, Zeigler-Hill, & Neria, 2015). This conforms with research literature demonstrating that mastery is associated with lower levels of anger and depressive moods (Ennis, Hobfoll, & Schroder, 2000), PTSD (Ben-Zur, 2008), caregiver stress (Mausbach et al., 2007), and lower levels of negative affect and higher levels of positive affect (Ben-Zur, 2002). However, the ability to examine coping strategies and internal resources as predictors of traumatic exposure and of PTSD symptoms after such exposure is limited, mainly because of methodological restraints in locating trauma victims before the traumatic exposure. To bridge this gap, the present study applied a prospective design with twofold aims: (a) to examine the role of pretraumatic trait internal resources and coping strategies in the risk for exposure to trauma, and (b) to explore the role of pretraumatic trait internal resources and coping strategies in the risk for developing PTSD symptoms after traumatic exposure. Because of the lacuna in studies examining internal recourses and coping strategies as predictors of traumatic exposure, our hypotheses were based on their role in the risk for PTSD symptoms as reviewed above: 1.
High levels of pretraumatic trait internal resources of distortional optimism and mastery will decrease the risk for traumatic exposure and for PTSD symptoms after such exposure.
2.
High levels of pretraumatic trait problem-focused coping strategies will decrease the risk for traumatic exposure and for PTSD symptoms after such exposure, whereas emotional-focused and avoidance coping strategies will increase that risk.
3.
A lifetime history of traumatic exposure will increase the risk for additional traumatic exposure and for PTSD symptoms.
Method Sample The research sample consisted of 870 undergraduate students recruited from a university in northern Israel. Initial recruitment
(t1) took place at the beginning of the winter semester of the 2010 academic year. Overall, a total of 1,430 first-year undergraduate students were approached, and 1,360 (95%) completed the study questionnaires and complied as the sample base. The respondents were reassessed at two additional follow-up points: at the end of the second academic year (t2; M ⫽ 18 months from t1, SD ⫽ 1.9) 930 of the original 1,360 students (65%) were located and agreed to participate in the follow-up, and at the end of the third academic year (t3; M ⫽ 11 months from t2, SD ⫽ 1.6) 870 of the original sample (60%) were located and agreed to participate. A comparative analysis of the 870 students who participated in the t3 follow-up and the 560 (40%) students who dropped out revealed no significant differences in demographic profile, including in lifetime history of traumatic exposure. Nevertheless, the 40% students who dropped out showed higher levels of avoidance (M ⫽ 2.31, SD ⫽ 1.22) and mastery (M ⫽ 4.95, SD ⫽ 1.11) at baseline (t1), as compared with those who completed the follow-up (M ⫽ 1.91, SD ⫽ 0.9; M ⫽ 4.53, SD ⫽ 1.2, respectively; t ⫽ 2.6, p ⬍ .001, t ⫽ 2.3, p ⬍ .001). All the analyses that followed include only the 870 students who completed the t3 follow-up. The mean age of the sample (n ⫽ 870) was 23.5 (SD ⫽ 1.3), mean years of education was 12.1 (SD ⫽ 0.6), and the majority were female (63%), single (74%), born in Israel (88%), and secular (92%). A personal history of psychiatric intervention was reported by 16 (1.8%) respondents and 5 (0.5%) reported a familial history of such intervention.
Measures Demographic characteristics. A demographic questionnaire covered variables such as age, gender, years of education, and lifetime history of traumatic exposure or psychiatric intervention. Traumatic exposure. Lifetime history of traumatic exposure was examined using the following questions at t1: (a) Have you ever been exposed to a traumatic event? (b) If yes, what was the event? (c) If you have been exposed to more than one traumatic event, please indicate only one event—the most traumatic one in your experience, and relate to it exclusively in the following Question 3. When and where did this event occur? At the t2 assessment point the respondents were asked whether they had been exposed to a traumatic event since the t1 assessment point— that is, from the beginning of their first academic year onward; if yes, indicate the single most traumatic experience, if more than one was indicated, and relate to it exclusively in the following question. Item 3 remained the same. At the t3 assessment point the respondents were asked whether they had been exposed to a traumatic event since the t2 assessment point—that is, from the end of their second academic year onward; if yes, indicate the single most traumatic experience, if more than one was indicated, and relate to it exclusively in the following question. Item 3 remained the same. A few respondents, who cited normal life distress (such as work or academic distress) as traumatic, were excluded from the sample. Posttraumatic stress disorder. PTSD symptoms were evaluated using the PTSD Symptom Scale-Self Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993). The PSS-SR is a 17-item self-report questionnaire aimed at assessing the level of posttraumatic stress symptoms over a period of the preceding 2 weeks. Each item corresponds to one of the 17 Diagnostic and Statistical
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PREDICTING TRAUMATIC EXPOSURE AND LEVELS OF PTSD
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consists of eight items rated on a 1–5 scale (1 ⫽ disagree to a large extent, 5 ⫽ agree to a large extent) with a high score indicating an optimistic tendency. The internal reliability and the test–retest of the original version were satisfactory (Cronbach’s ␣ ⫽ .76, test–retest ⫽ .79; Scheier & Carver, 1985). The questionnaire was filled in three times: at t1, t2, and t3, with a mean Cronbach’s ␣ of .86.
Manual of Mental Disorders-Fourth Edition-Text Revision (DSM– IV–TR; American Psychiatric Association, 2000) diagnostic criteria for PTSD. The severity of each item is rated on a four-point Likert scale ranging from 0 ⫽ not at all to 3 ⫽ very much. The total severity score is calculated as the mean of the respondent’s ratings on the 17 items. The questionnaire was filled in at three time intervals: t1, t2, and t3. The Cronbach’s ␣ in the present study was .94, .92, and .94, respectively. COPE scale. Coping strategies were measured by a short 30-item Hebrew version of the COPE scale (Carver et al., 1989). The shortened version contains 15 coping strategies, each represented by the sum of two items (Zeidner & Ben-Zur, 1994). Respondents indicate the extent to which each of the 15 strategies is used either in everyday life (trait coping strategy at t1) or in response to a specific event (state coping strategy at t2 and t3 for respondents who reported traumatic exposure). Responses are rated on a 4-point scale, ranging from 0 ⫽ not at all to 3 ⫽ great extent. Based on a factor analysis, three main subscales were used: problem-focused coping (including active coping, planning, and suppression); emotion/support coping (including instrumental and emotional support, and ventilation); and avoidance coping (including behavioral and mental disengagement, denial, and alcohol/drug use). The questionnaire was filled in at three time intervals: t1, t2, and t3. The mean Cronbach’s ␣ for the problem-focused subscale at the three assessment points was .88; for the emotion-focused subscale .89; and for the avoidance subscale .87. Mastery. Mastery was examined using the mastery scale developed by Pearlin and Schooler (1978). The scale contains seven items rated on a 1–7 scale (1 ⫽ not appropriate, 7 ⫽ very appropriate) with a high score indicating a high level of mastery. Hobfoll and Walfisch (1984) reported a test–retest reliability of .85 or above with reasonable internal reliability levels (Cronbach’s ␣ ⫽ .75). The questionnaire was filled in three times: at t1, t2, and t3, showing a mean Cronbach’s ␣ of .90. Optimism. Dispositional optimism was examined using the Life Orientation Test (LOT; Scheier & Carver, 1985). This scale
Procedure Following approval by the University of Haifa Ethical Committee for Research with Human Participants, Welfare and Health Sciences Division, the five largest faculties at the university (education, social sciences, social welfare and health studies, law, and humanities) were approached to participate in the study. The main first-year introductory class in each faculty was selected as the sample base. The respondents were reassessed at two additional follow-up points: the end of the second academic year and the end of the third academic year. All the respondents completed the questionnaires voluntarily. No compensation was offered for participation in the study.
Results Lifetime History of Traumatic Exposure In total, 182 respondents (20%) reported a lifetime history of exposure to a traumatic event at t1. The most prevalent incidents were car accident (32%), death of a significant other (29%), and combat (19%). The demographic profile, coping strategies, and internal resources of respondents who reported a history of a traumatic exposure were compared with those who did not report such a history. As indicated in Table 1, differences in age and gender distribution that were not statistically significant were observed between participants with and without a history of traumatic exposure.
Table 1 Demographic Profile, Coping Strategies, and Internal Resources of Respondents With (n ⫽ 182) and Without (n ⫽ 688) History of Traumatic Exposure With a history of traumatic exposure
Without a history of traumatic exposure
(n ⫽ 182)
(n ⫽ 688)
t/2
87 (48) 95 (52)
235 (34) 453 (66)
2 ⫽ 21.3
Gender (%) Male Female Age Coping strategies Problem-focused Emotion-focused Avoidance Resources Dispositional optimism Mastery PTSD symptoms at t3
M
SD
M
SD
22.9
1.0
23.8
1.5
1.9
.91 1.92 2.63
.87 1.25 1.32
1.32 1.27 1.71
.92 .88 .79
0.88 2.7ⴱ 3.1ⴱⴱⴱ
2.51 3.11 1.96
0.86 1.1 1.0
3.78 4.91 0.91
1.3 0.78 1.21
2.9ⴱⴱ 2.6ⴱ 3.1ⴱⴱⴱ
Note. PTSD ⫽ posttraumatic stress disorder. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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all three assessment points than those who had not been exposed. However, respondents who had been exposed to a traumatic event scored significantly higher in levels of PTSD symptoms at t2 and at t3 than those who had not. No significant changes were found in level of PTSD symptoms as measured at t2 compared with measurement at t3. Next, to identify predictors of traumatic exposure, a logistic regression analysis was conducted with exposure (yes/no) as the dependent variable. Only the 231 (27%) respondents who reported traumatic exposure during the follow-up were included in the analysis. Age, gender (male ⫽ 0, female ⫽ 1), history of traumatic exposure (no ⫽ 1, yes ⫽ 0), internal resources, and coping strategies were entered as the independent variables. The results revealed that high use of an avoidance coping strategy increased the risk for traumatic exposure threefold (odds ratio [OR] ⫽ 3.34, p ⬍ .001, 95% confidence interval [CI] [1.91, 7.08]), and low levels of mastery increased the odds/risk for traumatic exposure twofold (2.26, p ⬍ .001, 95% CI [1.88, 3.93]). Nagelkerke R2 for the entire model was 0.19. Thereafter, a hierarchical regression analysis was conducted to explore levels of mastery, dispositional optimism, and coping strategies measured at t1 as predictors of PTSD symptoms among the 231 participants who reported traumatic exposure during follow-up. To control the effect of lifetime history of traumatic exposure, this variable alone was entered in Block I as a dummy variable. Block II included levels of internal resources of dispositional optimism and mastery, and Block III included levels of problem-focused, emotion-focused, and avoidance coping strategies. To maintain the power of the regression analysis, demographics were excluded. The results of the analysis are presented in Table 3. The model explained 57% of the variance in predicting levels of PTSD symptoms. The block that contributed the most to the prediction of PTSD symptoms was Block II (R2 ⫽ .311), with mastery ( ⫽ .061, p ⬍ .001) and dispositional optimism ( ⫽ .052, p ⬍ .001) as predictors, respectively. Block III added a further 18% of the explained variance, with problem-focused coping strategy as a positive predictor ( ⫽ .053, p ⬍ .001), avoidance ( ⫽ ⫺.054, p ⬍ .001), and emotional-focused ( ⫽ ⫺.021, p ⬍ .001) coping strategies as negative predictors, respectively. Lastly,
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Levels of PTSD symptoms at t1 were significantly higher among respondents who reported a lifetime history of traumatic exposure than those who did not report such a history. Additionally, respondents who reported a previous history of traumatic exposure scored significantly higher in level of use of emotion-focused and avoidance coping strategies than those who did not report such a history. Lastly, respondents who reported a history of exposure to a traumatic event scored significantly lower in levels of dispositional optimism and mastery than those who did not report such a history. To control the potential effect of lifetime history of traumatic exposure, this variable was entered in the following analyses either as a covariate or as an independent predictor.
Predictors of Traumatic Exposure At t2, 141 (16%) respondents reported being exposed to a traumatic event during the time interval from t1 to t2. At t3, an additional 90 (10%) respondents reported being exposed to a traumatic event during the time interval from t2 to t3. The most prevalent events at both assessment points were car accidents (44%), death of a significant other (29%), and combat (16%). A comparison between respondents who had been exposed to a traumatic event and those who had not, as measured at the follow-up assessment points, was conducted utilizing a MANCOVA analysis, with the effect of lifetime history of traumatic exposure as a controlled covariate. Two factors were entered: group (exposed/not exposed) and assessment point (t1, t2, and t3). As shown in Table 2, a main effect for group was found in the use of emotion-focused coping strategy, avoidance coping strategy, level of mastery, and level of PTSD symptoms. Specifically, the use of an emotion-focused coping strategy at t2 increased significantly among respondents who had been exposed to a trauma but not among those who had not been exposed. Such differences, however, were not observed at t3. Respondents who had been exposed to a traumatic event scored significantly higher in the use of an avoidance coping strategy both before and after the traumatic exposure. However, no significant differences were found between the uses of an avoidance coping strategy at the different assessment points. Respondents who had been exposed to a traumatic event scored significantly lower in level of mastery at
Table 2 MANCOVA Comparing Scores of Respondents With and Without (n ⫽ 729) Traumatic Exposure, Controlling for Lifetime History of Traumatic Exposure t1 (n ⫽ 182)
Coping strategies Problem-focused Emotion-focused Avoidance Resources Dispositional optimism Mastery PTSD symptoms
t2 (n ⫽ 141)
t3 (n ⫽ 90)
Exposed (M/SD)
Not exposed (M/SD)
Exposed (M/SD)
Not exposed (M/SD)
Exposed (M/SD)
Not exposed (M/SD)
Fgroup/Ftime
1.19 (.87) 1.31 (.78) 1.91 (1.1)
1.21 (.91) 1.26 (.68) 1.46 (.92)
1.90 (.86) 1.47 (.92) 1.93 (.83)
1.21 (.78) 1.01 (1.1) 1.44 (.78)
1.89 (.91) 1.33 (.67) 1.90 (.97)
1.22 (.67) 1.27 (.99) 1.47 (1.1)
2.12/2.01 2.78ⴱ/2.84ⴱⴱ 3.71ⴱⴱ/2.2
3.50 (.56) 4.01 (.88) 1.22 (.93)
3.46 (.85) 4.36 (1.2) 1.20 (1.1)
3.44 (.36) 3.21 (.78) 2.22 (.45)
3.51 (.51) 4.88 (1.3) 1.21 (1.3)
3.46 (.68) 3.33 (.83) 2.02 (.56)
3.49 (.77) 4.71 (.89) 1.22 (1.1)
2.61/2.12 3.41ⴱⴱ/2.34 3.78ⴱⴱⴱ/3.11ⴱⴱ
Note. PTSD ⫽ posttraumatic stress disorder. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
PREDICTING TRAUMATIC EXPOSURE AND LEVELS OF PTSD
409
Table 3 Hierarchical Regression Analysis With Levels of Posttraumatic Stress Symptoms (PTSS) at t3 as the Dependent Variable (n ⫽ 231) Adjusted R2
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Block I Lifetime history of traumatic exposure at t1 Block II Dispositional optimism at t1 Mastery at t1 Block III Problem-focused at t1 Emotional focused at t1 Avoidance at t1 ⴱ
p ⬍ .05.
ⴱⴱ
p ⬍ .01.
ⴱⴱⴱ
B
SE(B)

t value
0.06 (F ⫽ 2.20)ⴱ .311 (F ⫽ 6.82)ⴱⴱⴱ .181 (F ⫽ 3.925)ⴱⴱⴱ
.022
.014
.013
2.621ⴱ
.052 .061
.013 .014
.257 .347
2.621ⴱⴱⴱ 3.121ⴱⴱⴱ
.053 ⫺.021 ⫺.054
.019 ⫺.013 ⫺.023
.289 ⫺.211 ⫺.280
2.954ⴱⴱⴱ ⫺2.122ⴱⴱⴱ ⫺2.741ⴱⴱⴱ
p ⬍ .001.
the effect of lifetime history of traumatic exposure contributed another 6% of the explained variance.
Discussion This prospective study aimed at examining the role of pretraumatic trait internal resources and coping strategies in predicting traumatic exposure, and to explore the role of pretraumatic trait internal resources and coping strategies in predicting PTSD symptoms after such exposure. In total, 870 Israeli students participated in the study, of whom 182 (20%) reported a lifetime history of traumatic exposure at baseline (t1); 141 (16%) reported being exposed to a traumatic event during the time interval from t1 to t2 (M ⫽ 18 months, SD ⫽ 1.9); and 90 (10%) respondents reported being exposed to a traumatic event during the time interval from t2 to t3 (M ⫽ 11 months, SD ⫽ 1.6). That is, a total of 231 (27%) respondents reported traumatic exposure during follow-up. The most prevalent events at all assessment points were car accidents (44%), death of a significant other (29%), and combat (16%). In general, and in line with the study’s hypotheses, high levels of pretraumatic trait internal resources of mastery and distortional optimism decreased the risk for traumatic exposure and for PTSD symptoms after such exposure, during follow-up. High levels of pretraumatic trait problem-focused coping strategies decreased the risk for traumatic exposure and for PTSD symptoms after such exposure, whereas high levels of emotional-focused and avoidance coping strategies increased those risks. Lastly, a lifetime history of traumatic exposure increased the risk for additional traumatic exposure and for PTSD symptoms after such exposure. More specifically, and in accord with the research literature, emotion-focused and avoidance coping strategies were associated with elevated levels of PTSD symptoms (Gil, 2005; Gilbar et al., 2011; Weinberg et al., 2015). However, emotion-focused coping strategies were associated with PTSD symptoms only in close time proximity to the traumatic event at t2, and decreased with the passage of time from the traumatic event, indicating that the elevated levels of use of emotion-focused coping strategies by those who were exposed to a traumatic event was time- limited. This accords with previous results (e.g., Ben-Zur, 2008; Ben-Zur, Gilbar, & Lev, 2001), demonstrating that although a problemfocused coping strategy is more effective in the immediate aftermath of stress and trauma, an emotional-focused coping strategy is
useful in the long run. The avoidance coping strategy was found to be generally ineffectual. A possible explanation for these results is that the chaotic and uncontrollable nature of the immediate response to trauma demands utilizing strategies aimed at troubleshooting to regain control and equilibrium. Conceivably, as time goes by, the effect of the traumatic event may weaken and may be perceived as more controllable, which in turn will allow those who were exposed to trauma to withdraw from the use of problem-focused coping strategies and focus more on emotional processing (Lazarus, 2006; Lazarus & Folkman, 1984). This explanation also conforms with results showing that a problem-focused coping strategy is a negative predictor of PTSD symptoms, whereas an emotion-focused and an avoidance coping strategy are positive predictors for such symptoms. A longer follow-up is needed to identify effective alternation or combination between coping strategies. This assessment is viable when such personality traits, namely, problem- and emotion-focused coping strategies, and mastery and dispositional optimism, are available traits for the use of the exposed individual. Despite the strengths of the present study, the research has several limitations. A significant limitation is its use of a sample of university students. Accordingly, generalizations should be made with caution. In addition, the diversity of the traumatic events studied may have generalized the effects of coping strategies, mastery and optimism in the context of particular events. Furthermore, it is possible that the time periods between the traumatic event and the follow-up assessments, which were relatively short for some participants, may have adversely impacted the observed relationships. Nevertheless, the findings of the study are highly informative, particularly because this is a prospective study. Together, the findings suggest that preventive efforts to reduce exposure to a traumatic event should focus mainly on individuals high on avoidance coping strategy, dispositional optimism, and mastery. Evidently, this is true for events over which the individual has control, such as car accidents. Immediate preventive efforts to reduce PTSD symptoms among individuals exposed to a traumatic event should focus mainly on those high on emotional and avoidance coping strategies and low on dispositional optimism and mastery. Accordingly, when dealing with traumatic events, therapists and trauma survivors should take into account both the short- and the long-range effect of the traumatic event, and mainly be aware that
GIL AND WEINBERG
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emotion-focused strategies may differ as time passes. Moreover, in devising a therapeutic framework, it is important to address, encourage, and reinforce mastery and optimism as a valuable resource when confronting PTSD. Furthermore, effective emotionfocused coping strategies in the long run may be useful in processing the trauma. An awareness of the negative effect of avoidance coping is warranted. An unrelated yet significant issue that emerged from the findings of the study is that students who dropped out during the follow-up scored higher on avoidance and mastery at baseline (t1), compared with those who completed the follow-up. These results may expand our perspective on the issue of responsiveness to follow-up, pending further and specific examination in future studies. In summary, the results of the study indicate that individuals high on trait avoidance coping style and low on mastery are at a higher risk for traumatic exposure, whereas those high on trait problem-focused coping style, mastery, and dispositional optimism are at a lower risk for PTSD symptoms after such exposure.
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Received August 15, 2014 Revision received January 11, 2015 Accepted January 16, 2015 䡲
