The Effect of Self Efficacy and Meaning in Life on Posttraumatic Stress Disorder and Depression Severity Among Veterans Laura Blackburn and Gina P. Owens University of Tennessee-Knoxville
Objective:
The current study examined the relationships among combat exposure, presence of and search for meaning in life, general and social self-efficacy, and both posttraumatic stress disorder (PTSD) Participants completed and depression symptom severity for a Veteran sample (N = 93). Method: an online survey comprising the Combat Exposure Scale, Meaning in Life Questionnaire, Self-Efficacy Scale, Depression subscale of the Depression, Anxiety, Stress Scales-21, and PTSD Checklist-Specific Stressor version. The majority of participants were male and Caucasian. Participants served in various service eras Results: To determine factors that predicted PTSD and depression severity, separate hierarchical linear regressions were performed. In the final PTSD model, rank, combat exposure, and general self-efficacy were significant predictors, with officer rank, lower combat exposure, and higher general self-efficacy associated with lower PTSD severity. The interaction between combat exposure and general self-efficacy was also significant, with self-efficacy moderating the relationship between combat exposure and PTSD severity. For depression, rank, presence of meaning in life, and general self-efficacy were significant predictors in the model, with officer rank, higher presence of meaning in life, and general self-efficacy associated with lower depression severity. Conclusion: A focus on strengthening self-efficacy may assist with lower levels of PTSD and depression symptomatology after C 2014 Wiley Periodicals, Inc. J. Clin. Psychol. 71:219–228, 2015. combat trauma. Keywords: self-efficacy; meaning in life; posttraumatic stress disorder; depression; military Veterans
Knowledge of common psychological disorders in service members and Veterans is becoming increasingly important as service members from recent conflicts return from deployment. Combat exposure or other traumatic events during military service often result in posttraumatic stress disorder (PTSD) and/or depression among service members (LaPierre, Schwegler, & LaBauve, 2007; Seal, Bertenthal, Miner, Sen, & Marmar, 2007), with one study indicating that almost half of their Veteran sample reported clinically significant symptoms of PTSD and depression, or both (LaPierre et al., 2007). Over the years, much research has focused on variables that seem to worsen the severity of PTSD and depression in Veterans. In more recent years, however, researchers have also begun to focus on resilience and characteristics that may help individuals who encounter traumatic events to maintain rather consistent functioning (Bonanno & Mancini, 2010). Resilience has been associated with lower levels of PTSD and depression (Bonanno, Rennick, & Dekel, 2005; Green, Calhoun, Dennis, & Beckham, 2010). Emphasizing the importance of resilience, the Army has begun a program called Comprehensive Soldier Fitness, which develops resilience skills before deployment in the hopes of preventing long-term psychological difficulties after return from deployment (Casey, 2011). Given this recent work, investigating the potential buffers against a particular disorder, such as self-efficacy and meaning in life, is also important because they may increase a Veteran’s ability to cope with his or her symptoms, thus fostering resilience. One possible safeguard against PTSD and depression symptoms that has received attention recently is self-efficacy. Self-efficacy is commonly defined as confidence in one’s ability to produce a desired outcome with one’s available resources (Bandura, 1997). Research suggests that having self-efficacy helps to overcome stressful situations that may follow exposure to a traumatic event Please address correspondence to: Gina P. Owens, Department of Psychology, University of Tennessee, 1404 Circle Dr., Knoxville, TN 37996-0900; E-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(3), 219–228 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C 2014 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22133
220
Journal of Clinical Psychology, March 2015
(Benight & Bandura, 2004). Research with non-Veteran trauma survivors has shown a direct relationship between self-efficacy and depression and PTSD symptom severity, with higher selfefficacy associated with lower levels of depression and PTSD (Benight et al., 1999; Kia-Keating & Ellis, 2007; Luszczynska, Benight, & Cieslak, 2009; Sumer, Karanci, Berument, & Gunes, 2005). However, no prior work examining relationships between self-efficacy, PTSD, and depression among Veterans could be found. Given the literature suggesting potential beneficial effects, in the current study, the relationships between self-efficacy, PTSD, and depression will be investigated with a military Veteran sample. Two types of self-efficacy will be examined: general self-efficacy, or confidence in one’s ability to produce a desired outcome that is not related to any particular behavior, and social self-efficacy, defined as confidence in one’s ability to effectively manage interactions with others (Sherer et al., 1982). Both of these types of self-efficacy have relevance to the military because of its performance demands and need to work together as a unit. Another construct that will be investigated in the current study as it relates to lower levels of PTSD and depression symptom severity is meaning in life. Meaning in life can be described as an individual’s values and feeling of purpose in his or her life (Ryff, 1989) or as “the sense made of, and significance felt regarding, the nature of one’s being and existence” (Steger, Frazier, Oishi, & Kaler, 2006, p. 81). Searching for meaning in life has been demonstrated to be distinctly different from presence of meaning in life, and research has indicated that searching for meaning is correlated with negative affect, depression, and neuroticism (Steger et al., 2006). Research has also shown that a sense of meaning can protect against PTSD and depression symptoms after traumatic events (Frazier, Conlon, & Glaser, 2001; Krause, 2007; Updegraff, Silver, & Holman, 2008) and is associated with greater well-being (Steger et al., 2006; Zika & Chamberlain, 1992). If people are unable to maintain a sense of meaning in life after a traumatic event such as combat, then they may be more vulnerable to developing mental health problems, such as PTSD or depression. Other research with Veterans of various service eras suggests that meaning in life may reduce the potentially negative effects of depression on PTSD severity (Owens, Steger, Whitesell, & Herrera, 2009). Thus, prior research supports the idea that meaning in life may be important in reducing the possible negative effect of traumatic events such as PTSD and depression and will be included in the current study. We were unable to find prior research in which both meaning in life and self-efficacy were examined with military Veterans as potential buffers against PTSD and/or depression symptomatology. These variables may be useful areas of intervention with this population after combat exposure. Thus, the current study sought to examine meaning in life and self-efficacy as possible buffers against PTSD and depression symptom severity in a Veteran sample, as they may be important in defending against the development and maintenance of these symptoms. For example, self-efficacy beliefs have been associated with lower PTSD and depression severity in past research and have also been linked to the ability to overcome stressful situations that may follow a trauma (Benight & Bandura, 2004; Luszczynska et al., 2009). Therefore, if a Veteran has high self-efficacy, then he or she may be better able to manage potentially traumatic incidents and any resulting emotional stress during and after a trauma. Likewise, having a sense of purpose after a traumatic experience may help an individual to look toward the future and its potential, rather than remaining focused on the past (such as dwelling on a traumatic event). Specifically, for the current study, we hypothesized that higher levels of general self-efficacy, social self-efficacy, and presence of meaning in life would be associated with lower PTSD symptom severity as well as depression, and that lower levels of combat exposure and search for meaning would be associated with lower PTSD symptom severity. Lower levels of search for meaning were also hypothesized to relate to lower depression severity. In addition, we hypothesized that meaning in life and self-efficacy would serve a moderating role in the relationship between combat exposure and PTSD severity.
Self-Efficacy and Meaning
221
Method Participants and Procedure Research announcements were sent via e-mail to online Veterans’ resource groups and through personal contacts of the researchers. Interested individuals used a hypertext link to connect to the survey website, where they were provided with informed consent information explaining the purpose of the study. All procedures were in compliance with University of Tennessee-Knoxville’s Institutional Review Board. No incentives were provided for participation. A total of 114 Veterans completed the online survey. Participants who reported no combat exposure were excluded from final analyses, leaving a sample size of 93 Veterans. The majority of participants were male (91%) and mean age of participants was 40.23 years (standard deviation [SD] = 15.23). Of the sample, 88% was Caucasian, 7% African American, 1% Hispanic-American/Latino, 1% Native American, 1% Asian American, and 2% other ethnicities. Regarding service era, over half of participants served in Iraq (63%), 39% Afghanistan, 42% Vietnam and Post-Vietnam eras, 31% Persian Gulf, and 11% were from other service eras. Participants could select multiple service eras. Of the sample, 67% were enlisted. The majority of participants reported completing some college (44%), 29% reported a college degree, and 25% held a graduate degree.
Measures PTSD Checklist-Specific Stressor Version (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-S is a 17-item rating scale designed to assess PTSD symptom severity. Respondents used a 5-point anchored scale, ranging from 1 (not at all) to 5 (extremely), to report the extent to which they experienced symptoms of PTSD in the past month. Scores range from 17 to 85, with higher scores indicating greater PTSD symptom severity. A cutoff of 44 indicates a probable PTSD diagnosis (National Center for PTSD, 2014). The PCL has high internal consistency reliability of .96 and .97 and has high test-retest reliability of .96 over a 2–3 day period. Correlations with similar measures of PTSD range from .77–.93, supporting convergent validity of the PCL (Weathers et al., 1993). Internal consistency reliability for the PCL-S in the current study was .96. The PCL-S asks participants to indicate the “most stressful event” they have experienced; for this sample, 86% reported a deployment-related experience, 2% a military training-related incident, and 12% an “other” stressful experience (e.g., natural disaster rescue operations, life-threatening medical illness, death of child).
Depression Subscale of the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995). The Depression subscale of the DASS-21 is a seven-item scale designed to assess depression symptom severity. Respondents rate each item from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time) to indicate their level of agreement with each statement. The Depression subscale has good internal consistency reliability (coefficient alpha = .95) and concurrent validity has been supported by positive correlations with similar measures of depression (Lovibond & Lovibond, 1995). Internal consistency reliability for the Depression subscale in this study was .94.
Combat Exposure Scale (CES; Keane et al., 1989). The CES is a seven-item measure designed to evaluate wartime stressors experienced by combatants. Items are rated on a 5-point scale, ranging from 1 to 5, with item-specific anchor points. Total scores range from 0 to 41, with higher scores indicating more severe combat exposure. The CES has good internal consistency reliability, ranging from .75–.85, and good test-retest reliability at .97 over a 1 week period (Keane et al., 1989). Internal consistency reliability for the CES in the current study was .80. Meaning in Life Questionnaire (MLQ; Steger et al., 2006). The MLQ is a 10-item scale designed to assess respondents’ sense of and search for meaning in life. The MLQ is divided into two subscales: Presence of Meaning in Life (MLQ-P) and Search for Meaning in Life (MLQ-S). Items are rated on a 7-point scale, ranging from 1 (absolutely untrue) to 7
222
Journal of Clinical Psychology, March 2015
(absolutely true). The MLQ has good internal consistency reliability, ranging from .82–86 and from .86–.87 for MLQ-P and MLQ-S, respectively. The MLQ has also demonstrated good convergent and discriminant validity (Steger et al., 2006) and has been used previously with Veterans (Owens et al., 2009). Internal consistency reliability for the current study was .93 for Presence and .91 for Search subscales.
The Self-Efficacy Scale (Sherer et al., 1982). The Self-Efficacy Scale is a 30-item scale comprising two subscales, General Self-Efficacy (GSE) with 17 items and Social Self-Efficacy (SSE) with six items. The scale also comprises seven filler items that are not scored. Items are rated on a 5-point scale, ranging from 1 (disagree strongly) to 5 (agree strongly), with higher scores indicating higher self-efficacy. Sherer et al. (1982) reported internal consistency for GSE was .86 and SSE was .71. Validity has been demonstrated by positive correlations with personality measures that relate to personal efficacy (e.g., social desirability, ego strength, and interpersonal competency) and negative correlations with other psychological measures such as self-esteem and personal control (Sherer et al., 1982). Internal consistency reliability for the current study was .90 and .80 for GSE and SSE, respectively. Data Analysis Statistics were computed using SPSS software (version 19.0, SPSS, Inc.). Prior to analysis, variables were checked for their appropriateness for multivariate analysis. Skewness, kurtosis, and multicollinearity were in acceptable ranges. To test the study hypotheses, first a bivariate correlational analysis was performed using the variables of interest to determine which independent variables were significantly correlated with PTSD and depression severity. Next, separate hierarchical linear regressions were conducted using the variables that had significant correlations with PTSD and depression symptom severity, respectively. To investigate potential interaction effects in the PTSD model, the hierarchical multiple regression included a third step to test the possible moderating roles of (a) meaning in life and (b) general self-efficacy in the relationship between combat exposure and PTSD symptom severity. First, variables included in the interactions were mean centered, and then the centered values were multiplied to obtain the interaction terms (Aiken & West, 1991). For significant interactions, low, medium, and high levels of combat exposure and either meaning in life or general self-efficacy were plotted using points one standard deviation above and below the mean to show their relationships with PTSD symptom severity (Aiken &West, 1991).
Results Means, standard deviations and correlations among the independent and dependent variables are shown in Table 1. The mean for presence of meaning in life was slightly higher than that found with a largely Vietnam Veteran sample (Owens et al., 2009), but was similar to undergraduate samples used to evaluate the psychometrics of the MLQ (Steger et al., 2006). Means and standard deviations for the Self-Efficacy Scale were similar to those found with adults (Hayhoe & Gutter, 2012) and an undergraduate sample (Sherer & Adams, 1983). In preliminary analyses to determine whether differences existed between enlisted and officer ranks on the variables of interest, rank was recoded as 0 (enlisted) and 1 (officer). An independent samples t test was performed using the recoded rank as the grouping variable. Significant differences were found for PTSD, t(87) = 4.81, p < .001), and depression severity, t(91) = 3.03, p < .01, between enlisted and officer ranks, with enlisted ranks reporting higher mean scores. No other significant differences were found on variables of interest based on rank. Rank was therefore included in the first step of the regression models as a control variable. Correlational analyses were conducted to examine the relationships between independent variables and PTSD and depression symptom severity (see Table 1). Significant negative correlations were found between PTSD and depression severity and rank, presence of meaning, general self-efficacy, and social self-efficacy (all p-values < .05 or higher). Combat exposure was significantly positively related to PTSD symptom severity (p < .001), but was not significantly
Self-Efficacy and Meaning
223
Table 1
Means, Standard Deviations, and Correlations Among Variables for Total Sample (N = 93) Variable 1. PTSD severity (PCL) 2. Depression severity (DASS) 3. Rank 4. Combat Exposure (CES) 5. Presence of Meaning (MLQ-P) 6. Search for Meaning (MLQ-S) 7. General Self-Efficacy (SES-GSE) 8. Social Self-Efficacy (SES-SSE)
Mean (SD) 34.56 (16.88) 11.84 (5.45)
1 – .73***
– –
2 – –
3 – –
4 – –
5 – –
6 – –
7
12.50 (10.28)
−.46*** .28**
−.30** .13
– .01
– –
– –
– –
– –
25.64 (6.77)
−.47***
−.61***
.07
−.23*
–
–
–
20.75 (8.32)
.15
.25*
−.08
−.07
−.44***
–
–
66.25 (11.34)
−.54***
−.64***
.08
−.06
.63***
−.23*
–
19.48 (5.25)
−.27*
−.34**
.05
−.01
.52***
−.31**
.56***
Note. SD = standard deviation; PTSD = posttraumatic stress disorder; PCL = The PTSD Checklist; DASS = Depression Subscale of the Depression Anxiety Stress Scales-21; CES = Combat Exposure Scale; MLQ = Meaning in Life Questionnaire; MLQ-P = Presence of Meaning in Life; MLQ-S = Search for Meaning in Life; SES = Self-Efficacy Scale; GSE = General Self-Efficacy; SSE = Social Self-Efficacy. * p < .05. ** p < .01. *** p < .001.
related to depression severity. Search for meaning was significantly positively associated with depression symptom severity (p < .05), but was not significantly related to PTSD severity. Separate hierarchical linear regressions were performed using variables that were significantly correlated with PTSD or depression severity as predictors. For PTSD symptom severity, the overall model was significant, F(6, 81) = 15.37, p < .001, adjusted R2 = .52. Significant predictors in the model were rank (β = −.43, p < .001), combat exposure (β = .20, p < .05), and general self-efficacy (β = −.42, p < .001). Neither presence of nor search for meaning was a significant predictor in the model. The interaction between combat exposure and general self-efficacy was also significant (β = −.17, p < .05). However, the interaction between combat exposure and presence of meaning was not significant, and it was therefore dropped from the final model (see Table 2). The interaction plot (Aiken & West, 1991) revealed that when combat exposure was low, PTSD severity was similar at all levels of general self-efficacy. However, when combat exposure was high, as self-efficacy levels increased, PTSD severity levels decreased (see Figure 1). For depression symptom severity, the overall model was also significant, F(5, 85) = 18.76, p < .001, adjusted R2 = .51. Significant predictors in the model were rank (β = −.24, p < .01), presence of meaning in life (β = −.40, p < .001), and general self-efficacy (β = −.42, p < .001). Search for meaning was not a significant predictor in the model.
Discussion The current study examined the effects of self-efficacy and meaning in life on PTSD and depression symptom severity among a Veteran sample. Our first hypothesis was that higher levels of general self-efficacy, social self-efficacy, and presence of meaning in life as well as lower levels of search for meaning would be associated with lower levels of PTSD and depression symptom severity. We also hypothesized that lower levels of combat exposure would be associated with lower PTSD symptom severity. This hypothesis was only partially supported, however, because search for meaning in life was not significantly associated with PTSD in correlational analyses. In addition, regression analyses revealed that only rank, combat exposure, and general self-efficacy–not presence of meaning in life or social self-efficacy–significantly predicted PTSD severity.
224
Journal of Clinical Psychology, March 2015
Table 2 Multiple Regression Analyses Predicting PTSD and Depression Symptom Severity (Final Models; N = 93) PTSDa Predictorsd Step 1 Rank Step 2 Rank Combat Exposurec Presence of Meaning (MLQ-P) Search for Meaning (MLQ-S) General Self-Efficacy (GSE)c Social Self-Efficacy (SSE) Step 3 Rank Combat Exposurec Presence of Meaning (MLQ-P) Search for Meaning (MLQ-S) General Self-Efficacy (GSE)c Social Self-Efficacy (SSE) Combat exposure x GSE
Depressionb
B
SE
β
B
SE
β
−18.17
3.68
−.48***
−3.50
1.19
−.31**
−15.73 .39 −.44 – −.61 .34
3.00 .16 .27 – .16 .33
−.42*** .20* −.18 – −.41*** .103
−2.75 – −.32 −.01 −.20 .14
.87
−.24** – −.40*** −.10 −.42*** .13
−16.20 .40 −.32 – −.63 .33 −.03
2.94 .16 .27 – .16 .32 .01
−.43*** .20* −.13 – −.42*** .10 −.17*
– .09 .06 .05 .10
Note. SE = standard error; PTSD = posttraumatic stress disorder; MLQ = Meaning in Life Questionnaire; MLQ-P = Presence of Meaning in Life; MLQ-S = Search for Meaning in Life; SES = Self-Efficacy Scale; GSE = General Self-Efficacy; SSE = Social Self-Efficacy. a Adj. R2 = 0.52; R2 Step 1 = .23*** , R2 Step 2 = .29*** , R2 Step 3 = .03* . b Adj. R2 = 0.51; R2 Step 1 = .09** , R2 Step 2 = .45*** . c Centered values were used for variables included in the interaction term in the PTSD model. d The interaction between presence of combat exposure and presence of meaning in life was not a significant predictor of PTSD severity and was dropped from the final model. * p < .05. ** p < .01. *** p < .001.
Figure 1. Interaction between general self-efficacy and combat exposure with PTSD severity as dependent variable. Note. For both variables, low = one standard deviation below the mean and high = one standard deviation above the mean.
Self-Efficacy and Meaning
225
We also hypothesized that general self-efficacy and presence of meaning in life would have a moderating role in the relationship between combat exposure and PTSD. Again our results partially supported this hypothesis, indicating that self-efficacy served as a moderator, but not presence of meaning in life. In terms of depression severity, only rank, presence of meaning in life, and general self-efficacy were significant predictors, with search for meaning and social self-efficacy not reaching statistical significance. It appears that when controlling for rank, general self-efficacy exerts a stronger influence on PTSD severity than having a sense of meaning in life. However, this did not hold true for depression, where both general self-efficacy and presence of meaning significantly predicted symptom severity. Beliefs about one’s abilities to achieve outcomes may contribute to a sense of control that may be helpful with PTSD and depression symptomatology, although this cannot be determined with the cross-sectional data from the current study. Having a sense of meaning in life does seem to influence depression severity as would be expected from prior research (e.g., Frazier et al., 2001; Krause, 2007; Updegraff et al., 2008). In the PTSD model, the interaction between self-efficacy and combat exposure was also significant, suggesting that when combat exposure levels are high, self-efficacy becomes increasingly important in terms of PTSD severity. Therefore, in the face of high combat exposure, Veterans who felt they had the abilities to achieve certain outcomes or goals reported lower levels of PTSD. Prior research (Solberg, Laberg, Johnsen, & Eid, 2005) indicates that an individual’s beliefs about their military abilities and skills are the strongest predictor of their self-efficacy beliefs. Our results suggest that building a sense of self-efficacy, possibly through training experiences similar to those that will be encountered during deployment, may be particularly crucial to preparedness for high combat environments and adjustment after such experiences. Although we did not form a specific a priori hypothesis related to rank, exploratory analyses showed that rank was a significant predictor of both PTSD and depression severity, with enlisted rank associated with higher symptom severity. This finding may relate to the lower degree of control enlisted personnel may have over their environment or deployment decisions, which over time may also affect their sense of self-efficacy, or confidence that they are able to produce a certain outcome during missions. Enlisted personnel may also be subjected to higher levels of combat exposure than officers; however, we do not have additional data to examine these possibilities with the current study. Although correlational relationships were significant, presence of meaning in life was not a significant predictor of PTSD severity in the final regression model, nor was the interaction between meaning in life and combat exposure, contradicting our initial hypotheses. This finding was surprising considering earlier work with Veteran samples suggesting that Veterans often search for meaning after combat experiences (Fontana & Rosenheck, 2005) and that having a sense of meaning may moderate the relationship between depression and PTSD severity (Owens et al., 2009). However, the current study sample was significantly younger than the Owens et al. study, which largely comprised Vietnam-era Veterans, and mean PTSD scores in the present study were also lower. These differences between samples could explain the nonsignificant findings related to presence of meaning in life. Further, self-efficacy beliefs were not examined in either of these prior studies, and it may be that when examined together, self-efficacy has a stronger influence on current PTSD symptom severity than does having a sense of meaning in life. Search for meaning in life was also not significantly associated with PTSD symptom severity even in initial correlational analyses, and although significantly correlated with depression, search for meaning was not a significant predictor of depression severity in the final model. Although past research with non-Veteran samples has found associations between high search for meaning and measures of distress such as negative affect and depression (Steger et al., 2006), relationships in the current study did not reach significance, even though means for search for meaning in the current study were similar to those of Steger and colleagues. Thus, it seems that for this sample of Veterans, searching for meaning in relation to PTSD and depression symptomatology was not as relevant. Contrary to our hypothesis, efficacy expectations in social situations were not significantly associated with PTSD, nor were they a significant predictor of depression symptom severity in
226
Journal of Clinical Psychology, March 2015
the final regression model. Thus, it seems that for this sample of Veterans, confidence in one’s ability to manage social interactions effectively was not as relevant in relation to PTSD and depression symptomatology.
Limitations and Future Directions for Research Although our findings are partially consistent with prior research with non-Veteran samples, the current study has several limitations. All participants were volunteers and differences may therefore exist between participants who elected to respond versus those who did not. Veterans with interest in mental health, for instance, may have been more likely to complete the survey. Most respondents reported higher levels of education, indicating completion of at least some college. Veterans who were more educated or of a higher socioeconomic status may have had easier access to computers to complete the online survey. Further, use of an online survey design may have a number of limitations (see Wyatt, 2000). In addition, the majority of participants were Caucasian males. Our sample, although adequate for statistical analyses, was rather small and not all Veterans had experienced moderate to high levels of combat exposure. All of these potential limitations may affect the generalizability of our results to the larger Veteran population. We also did not assess whether Criterion A establishing a life-threatening traumatic event was met for PTSD, although we did have some detail about the events related to PTSD symptom severity through the use of the PCL-S. Future research would benefit from formal assessment of Criterion A for PTSD. This study identifies potential relationships between self-efficacy, meaning in life, and levels of PTSD and depression symptom severity among Veterans of various combat eras. Because some of our findings related to search for meaning and social self-efficacy contradict earlier work with depression and PTSD (e.g., Steger et al., 2006; Wei, Russell, & Zakalik, 2005), further investigation of these variables with larger and more diverse Veteran samples is warranted and would help determine whether the current results are an accurate reflection of the general Veteran population. Finally, a longitudinal study comparing Veterans at pre- and postdeployment would be useful to help establish causality and ascertain whether self-efficacy and meaning in life may serve as protective factors against development of PTSD and depression symptoms.
Conclusion To our knowledge, this study is the first to examine constructs of both meaning in life and selfefficacy and their associations with PTSD and depression symptom severity in a Veteran sample. In addition, most prior research has only explored self-efficacy as a single construct, rather than investigating subtypes of self-efficacy. Results of this study indicate a possible protective factor for postcombat distress, given that Veterans reporting high combat exposure and high levels of general self-efficacy reported lower levels of PTSD symptom severity. In terms of clinical implications, our results suggest that therapists and clergy working with military Veterans who are experiencing distress may consider implementing strategies to teach skills that may assist in increasing a sense of self-efficacy.
References Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman and Company. Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behavior Research and Therapy, 42, 1129–1148. Benight, C. C., Ironson, G., Klebe, K., Carver, C. S., Wynings, C., Burnett, K., . . . Schneiderman, N. (1999). Conservation of resources and coping self-efficacy predicting distress following a natural disaster: A causal model analysis where the environment meets the mind. Anxiety, Stress and Coping: An International Journal, 12, 107–126. doi:10.1080/10615809908248325 Bonanno, G. A., & Mancini, A. D. (2012). Beyond resilience and PTSD: Mapping heterogeneity of responses to potential trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 74–83. doi:10.1037/a0017829
Self-Efficacy and Meaning
227
Bonanno, G. A., Rennicke, C., & Dekel, S. (2005). Self-enhancement among high-exposure survivors of the September 11th terrorist attack: Resilience or social maladjustment? Journal of Personality and Social Psychology, 88, 984–998. doi:10.1037/0022-3514.88.6.984 Casey, G. W. (2011). Comprehensive soldier fitness: A vision for psychological resilience in the U. S. Army. American Psychologist, 66, 1–3. doi:10.1087/a0021930 Fontana, A., & Rosenheck, R. (2005). The role of loss of meaning in the pursuit of treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 18, 133–136. doi:10.1002/jts.20014 Frazier, P., Conlon, A., & Glaser, T. (2001). Positive and negative life changes following sexual assault. Journal of Consulting and Clinical Psychology, 69, 1048–1055. doi:10.1037/0022-006X.69.6.1048 Green, K. T., Calhoun, P. S., Dennis, M. F., & Beckham, J. C. (2010). Exploration of the resilience construct in posttraumatic stress disorder sensitivity and functional correlates in military combat Veterans who have served since September 11, 2001. Journal of Clinical Psychiatry, 71, 823–830. doi:10.4088/JCP.09m05780blu Hayhoe, C. R., & Gutter, M. E. (2012). Reliability of the scales in the NC1172 complex nature of saving data set. Family and Consumer Sciences Research Journal, 40, 284–294. doi:10.1111/j/15523934.2011.02111.x Keane, T. M., Fairbank, J. A., Cadell, J. M., Zimering, R. T., Taylor, K. L., & Mora, C. A. (1989). Clinical evaluation of a measure to assess combat exposure. Psychological Assessment, 1, 53–55. doi:10.1037/1040-3590.1.1.53 Kia-Keating, M., & Ellis, B. H. (2007). Belonging and connection to school in resettlement: Young refugees, school belonging, and psychosocial adjustment. Clinical Child Psychology and Psychiatry, 12, 29–43. doi:10.1177/1359104507071052 Krause, N. (2007). Evaluating the stress-buffering function of meaning in life among older people. Journal of Aging and Health, 19, 792–812. doi:10.1177/0898264307304390 LaPierre, C. B., Schwegler, A. F., & LaBauve, B. J. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of Traumatic Stress, 20, 933–943. doi:10.1002/jts.20278 Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation. Luszczynska, A., Benight, C. C., & Cieslak, R. (2009). Self efficacy and health-related outcomes of collective trauma–A systematic review. European Psychologist, 14, 51–62. doi:10.1027/1016-9040.14.1.51 National Center for PTSD. (2014, January). Using the PTSD Checklist for DSM-IV (PCL). Retrieved from http://www.ptsd.va.gov/professional/assessments/assessment-pdf/PCL-handout.pdf Owens, G. P., Steger, M. F., Whitesell, A. A., & Herrera, C. J. (2009). Posttraumatic stress disorder, guilt, depression, and meaning in life among military Veterans. Journal of Traumatic Stress, 22, 654–657. doi:10.1002/jts.20460 Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069–1081. doi:10.1037/0022-3514.57.6.1069 Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 US Veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482. doi:10.1001/archinte.167.5.476 Sherer, M., & Adams, C. H. (1983). Construct validation of the self-efficacy scale. Psychological Reports, 53, 899–902. doi:10.2466/pr0.1983.53.3.899 Sherer, M., Maddux, J. E., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R. W. (1982). The self-efficacy scale: Construction and validation. Psychological Reports, 51, 663–671. doi:10.2466/pr0.1982.51.2.663 Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53, 80–93. doi:10.1037/00220167.53.1.80 Sumer, N., Karanci, A. N., Berument, S. K., & Gunes, H. (2005). Personal resources, coping self-efficacy, and quake exposure as predictors of psychological distress following the 1999 earthquake in Turkey. Journal of Traumatic Stress, 18, 331–342. doi:10.1002/jts.20032 Updegraff, J. A., Silver, R. C., & Holman, E. A. (2008). Searching for and finding meaning in collective trauma: Results from a national longitudinal study of the 9/11 terrorist attacks. Journal of Personality and Social Psychology, 95, 709–722. doi:10.1037/0022-3514.95.3.709
228
Journal of Clinical Psychology, March 2015
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (October, 1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Wei, M, Russell, D. W., & Zakalik, R. A. (2005). Adult attachment, social self-efficacy, self-disclosure, loneliness, and subsequent depression for freshman college students: A longitudinal study. Journal of Counseling Psychology, 52, 602–614. doi:10.1037/0022-0167.52.4.602 Wyatt, J. C. (2000). When to use web-based surveys. Journal of the American Medical Informatics Association, 7, 426–429. Zika, S., & Chamberlain, K. (1992). On the relation between meaning in life and psychological well-being. British Journal of Psychology, 83(1), 133–145. doi:10.1111/j.2044-8295.1992.tb02429.x
Objective:
The current study examined the relationships among combat exposure, presence of and search for meaning in life, general and social self-efficacy, and both posttraumatic stress disorder (PTSD) Participants completed and depression symptom severity for a Veteran sample (N = 93). Method: an online survey comprising the Combat Exposure Scale, Meaning in Life Questionnaire, Self-Efficacy Scale, Depression subscale of the Depression, Anxiety, Stress Scales-21, and PTSD Checklist-Specific Stressor version. The majority of participants were male and Caucasian. Participants served in various service eras Results: To determine factors that predicted PTSD and depression severity, separate hierarchical linear regressions were performed. In the final PTSD model, rank, combat exposure, and general self-efficacy were significant predictors, with officer rank, lower combat exposure, and higher general self-efficacy associated with lower PTSD severity. The interaction between combat exposure and general self-efficacy was also significant, with self-efficacy moderating the relationship between combat exposure and PTSD severity. For depression, rank, presence of meaning in life, and general self-efficacy were significant predictors in the model, with officer rank, higher presence of meaning in life, and general self-efficacy associated with lower depression severity. Conclusion: A focus on strengthening self-efficacy may assist with lower levels of PTSD and depression symptomatology after C 2014 Wiley Periodicals, Inc. J. Clin. Psychol. 71:219–228, 2015. combat trauma. Keywords: self-efficacy; meaning in life; posttraumatic stress disorder; depression; military Veterans
Knowledge of common psychological disorders in service members and Veterans is becoming increasingly important as service members from recent conflicts return from deployment. Combat exposure or other traumatic events during military service often result in posttraumatic stress disorder (PTSD) and/or depression among service members (LaPierre, Schwegler, & LaBauve, 2007; Seal, Bertenthal, Miner, Sen, & Marmar, 2007), with one study indicating that almost half of their Veteran sample reported clinically significant symptoms of PTSD and depression, or both (LaPierre et al., 2007). Over the years, much research has focused on variables that seem to worsen the severity of PTSD and depression in Veterans. In more recent years, however, researchers have also begun to focus on resilience and characteristics that may help individuals who encounter traumatic events to maintain rather consistent functioning (Bonanno & Mancini, 2010). Resilience has been associated with lower levels of PTSD and depression (Bonanno, Rennick, & Dekel, 2005; Green, Calhoun, Dennis, & Beckham, 2010). Emphasizing the importance of resilience, the Army has begun a program called Comprehensive Soldier Fitness, which develops resilience skills before deployment in the hopes of preventing long-term psychological difficulties after return from deployment (Casey, 2011). Given this recent work, investigating the potential buffers against a particular disorder, such as self-efficacy and meaning in life, is also important because they may increase a Veteran’s ability to cope with his or her symptoms, thus fostering resilience. One possible safeguard against PTSD and depression symptoms that has received attention recently is self-efficacy. Self-efficacy is commonly defined as confidence in one’s ability to produce a desired outcome with one’s available resources (Bandura, 1997). Research suggests that having self-efficacy helps to overcome stressful situations that may follow exposure to a traumatic event Please address correspondence to: Gina P. Owens, Department of Psychology, University of Tennessee, 1404 Circle Dr., Knoxville, TN 37996-0900; E-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(3), 219–228 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C 2014 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22133
220
Journal of Clinical Psychology, March 2015
(Benight & Bandura, 2004). Research with non-Veteran trauma survivors has shown a direct relationship between self-efficacy and depression and PTSD symptom severity, with higher selfefficacy associated with lower levels of depression and PTSD (Benight et al., 1999; Kia-Keating & Ellis, 2007; Luszczynska, Benight, & Cieslak, 2009; Sumer, Karanci, Berument, & Gunes, 2005). However, no prior work examining relationships between self-efficacy, PTSD, and depression among Veterans could be found. Given the literature suggesting potential beneficial effects, in the current study, the relationships between self-efficacy, PTSD, and depression will be investigated with a military Veteran sample. Two types of self-efficacy will be examined: general self-efficacy, or confidence in one’s ability to produce a desired outcome that is not related to any particular behavior, and social self-efficacy, defined as confidence in one’s ability to effectively manage interactions with others (Sherer et al., 1982). Both of these types of self-efficacy have relevance to the military because of its performance demands and need to work together as a unit. Another construct that will be investigated in the current study as it relates to lower levels of PTSD and depression symptom severity is meaning in life. Meaning in life can be described as an individual’s values and feeling of purpose in his or her life (Ryff, 1989) or as “the sense made of, and significance felt regarding, the nature of one’s being and existence” (Steger, Frazier, Oishi, & Kaler, 2006, p. 81). Searching for meaning in life has been demonstrated to be distinctly different from presence of meaning in life, and research has indicated that searching for meaning is correlated with negative affect, depression, and neuroticism (Steger et al., 2006). Research has also shown that a sense of meaning can protect against PTSD and depression symptoms after traumatic events (Frazier, Conlon, & Glaser, 2001; Krause, 2007; Updegraff, Silver, & Holman, 2008) and is associated with greater well-being (Steger et al., 2006; Zika & Chamberlain, 1992). If people are unable to maintain a sense of meaning in life after a traumatic event such as combat, then they may be more vulnerable to developing mental health problems, such as PTSD or depression. Other research with Veterans of various service eras suggests that meaning in life may reduce the potentially negative effects of depression on PTSD severity (Owens, Steger, Whitesell, & Herrera, 2009). Thus, prior research supports the idea that meaning in life may be important in reducing the possible negative effect of traumatic events such as PTSD and depression and will be included in the current study. We were unable to find prior research in which both meaning in life and self-efficacy were examined with military Veterans as potential buffers against PTSD and/or depression symptomatology. These variables may be useful areas of intervention with this population after combat exposure. Thus, the current study sought to examine meaning in life and self-efficacy as possible buffers against PTSD and depression symptom severity in a Veteran sample, as they may be important in defending against the development and maintenance of these symptoms. For example, self-efficacy beliefs have been associated with lower PTSD and depression severity in past research and have also been linked to the ability to overcome stressful situations that may follow a trauma (Benight & Bandura, 2004; Luszczynska et al., 2009). Therefore, if a Veteran has high self-efficacy, then he or she may be better able to manage potentially traumatic incidents and any resulting emotional stress during and after a trauma. Likewise, having a sense of purpose after a traumatic experience may help an individual to look toward the future and its potential, rather than remaining focused on the past (such as dwelling on a traumatic event). Specifically, for the current study, we hypothesized that higher levels of general self-efficacy, social self-efficacy, and presence of meaning in life would be associated with lower PTSD symptom severity as well as depression, and that lower levels of combat exposure and search for meaning would be associated with lower PTSD symptom severity. Lower levels of search for meaning were also hypothesized to relate to lower depression severity. In addition, we hypothesized that meaning in life and self-efficacy would serve a moderating role in the relationship between combat exposure and PTSD severity.
Self-Efficacy and Meaning
221
Method Participants and Procedure Research announcements were sent via e-mail to online Veterans’ resource groups and through personal contacts of the researchers. Interested individuals used a hypertext link to connect to the survey website, where they were provided with informed consent information explaining the purpose of the study. All procedures were in compliance with University of Tennessee-Knoxville’s Institutional Review Board. No incentives were provided for participation. A total of 114 Veterans completed the online survey. Participants who reported no combat exposure were excluded from final analyses, leaving a sample size of 93 Veterans. The majority of participants were male (91%) and mean age of participants was 40.23 years (standard deviation [SD] = 15.23). Of the sample, 88% was Caucasian, 7% African American, 1% Hispanic-American/Latino, 1% Native American, 1% Asian American, and 2% other ethnicities. Regarding service era, over half of participants served in Iraq (63%), 39% Afghanistan, 42% Vietnam and Post-Vietnam eras, 31% Persian Gulf, and 11% were from other service eras. Participants could select multiple service eras. Of the sample, 67% were enlisted. The majority of participants reported completing some college (44%), 29% reported a college degree, and 25% held a graduate degree.
Measures PTSD Checklist-Specific Stressor Version (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-S is a 17-item rating scale designed to assess PTSD symptom severity. Respondents used a 5-point anchored scale, ranging from 1 (not at all) to 5 (extremely), to report the extent to which they experienced symptoms of PTSD in the past month. Scores range from 17 to 85, with higher scores indicating greater PTSD symptom severity. A cutoff of 44 indicates a probable PTSD diagnosis (National Center for PTSD, 2014). The PCL has high internal consistency reliability of .96 and .97 and has high test-retest reliability of .96 over a 2–3 day period. Correlations with similar measures of PTSD range from .77–.93, supporting convergent validity of the PCL (Weathers et al., 1993). Internal consistency reliability for the PCL-S in the current study was .96. The PCL-S asks participants to indicate the “most stressful event” they have experienced; for this sample, 86% reported a deployment-related experience, 2% a military training-related incident, and 12% an “other” stressful experience (e.g., natural disaster rescue operations, life-threatening medical illness, death of child).
Depression Subscale of the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995). The Depression subscale of the DASS-21 is a seven-item scale designed to assess depression symptom severity. Respondents rate each item from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time) to indicate their level of agreement with each statement. The Depression subscale has good internal consistency reliability (coefficient alpha = .95) and concurrent validity has been supported by positive correlations with similar measures of depression (Lovibond & Lovibond, 1995). Internal consistency reliability for the Depression subscale in this study was .94.
Combat Exposure Scale (CES; Keane et al., 1989). The CES is a seven-item measure designed to evaluate wartime stressors experienced by combatants. Items are rated on a 5-point scale, ranging from 1 to 5, with item-specific anchor points. Total scores range from 0 to 41, with higher scores indicating more severe combat exposure. The CES has good internal consistency reliability, ranging from .75–.85, and good test-retest reliability at .97 over a 1 week period (Keane et al., 1989). Internal consistency reliability for the CES in the current study was .80. Meaning in Life Questionnaire (MLQ; Steger et al., 2006). The MLQ is a 10-item scale designed to assess respondents’ sense of and search for meaning in life. The MLQ is divided into two subscales: Presence of Meaning in Life (MLQ-P) and Search for Meaning in Life (MLQ-S). Items are rated on a 7-point scale, ranging from 1 (absolutely untrue) to 7
222
Journal of Clinical Psychology, March 2015
(absolutely true). The MLQ has good internal consistency reliability, ranging from .82–86 and from .86–.87 for MLQ-P and MLQ-S, respectively. The MLQ has also demonstrated good convergent and discriminant validity (Steger et al., 2006) and has been used previously with Veterans (Owens et al., 2009). Internal consistency reliability for the current study was .93 for Presence and .91 for Search subscales.
The Self-Efficacy Scale (Sherer et al., 1982). The Self-Efficacy Scale is a 30-item scale comprising two subscales, General Self-Efficacy (GSE) with 17 items and Social Self-Efficacy (SSE) with six items. The scale also comprises seven filler items that are not scored. Items are rated on a 5-point scale, ranging from 1 (disagree strongly) to 5 (agree strongly), with higher scores indicating higher self-efficacy. Sherer et al. (1982) reported internal consistency for GSE was .86 and SSE was .71. Validity has been demonstrated by positive correlations with personality measures that relate to personal efficacy (e.g., social desirability, ego strength, and interpersonal competency) and negative correlations with other psychological measures such as self-esteem and personal control (Sherer et al., 1982). Internal consistency reliability for the current study was .90 and .80 for GSE and SSE, respectively. Data Analysis Statistics were computed using SPSS software (version 19.0, SPSS, Inc.). Prior to analysis, variables were checked for their appropriateness for multivariate analysis. Skewness, kurtosis, and multicollinearity were in acceptable ranges. To test the study hypotheses, first a bivariate correlational analysis was performed using the variables of interest to determine which independent variables were significantly correlated with PTSD and depression severity. Next, separate hierarchical linear regressions were conducted using the variables that had significant correlations with PTSD and depression symptom severity, respectively. To investigate potential interaction effects in the PTSD model, the hierarchical multiple regression included a third step to test the possible moderating roles of (a) meaning in life and (b) general self-efficacy in the relationship between combat exposure and PTSD symptom severity. First, variables included in the interactions were mean centered, and then the centered values were multiplied to obtain the interaction terms (Aiken & West, 1991). For significant interactions, low, medium, and high levels of combat exposure and either meaning in life or general self-efficacy were plotted using points one standard deviation above and below the mean to show their relationships with PTSD symptom severity (Aiken &West, 1991).
Results Means, standard deviations and correlations among the independent and dependent variables are shown in Table 1. The mean for presence of meaning in life was slightly higher than that found with a largely Vietnam Veteran sample (Owens et al., 2009), but was similar to undergraduate samples used to evaluate the psychometrics of the MLQ (Steger et al., 2006). Means and standard deviations for the Self-Efficacy Scale were similar to those found with adults (Hayhoe & Gutter, 2012) and an undergraduate sample (Sherer & Adams, 1983). In preliminary analyses to determine whether differences existed between enlisted and officer ranks on the variables of interest, rank was recoded as 0 (enlisted) and 1 (officer). An independent samples t test was performed using the recoded rank as the grouping variable. Significant differences were found for PTSD, t(87) = 4.81, p < .001), and depression severity, t(91) = 3.03, p < .01, between enlisted and officer ranks, with enlisted ranks reporting higher mean scores. No other significant differences were found on variables of interest based on rank. Rank was therefore included in the first step of the regression models as a control variable. Correlational analyses were conducted to examine the relationships between independent variables and PTSD and depression symptom severity (see Table 1). Significant negative correlations were found between PTSD and depression severity and rank, presence of meaning, general self-efficacy, and social self-efficacy (all p-values < .05 or higher). Combat exposure was significantly positively related to PTSD symptom severity (p < .001), but was not significantly
Self-Efficacy and Meaning
223
Table 1
Means, Standard Deviations, and Correlations Among Variables for Total Sample (N = 93) Variable 1. PTSD severity (PCL) 2. Depression severity (DASS) 3. Rank 4. Combat Exposure (CES) 5. Presence of Meaning (MLQ-P) 6. Search for Meaning (MLQ-S) 7. General Self-Efficacy (SES-GSE) 8. Social Self-Efficacy (SES-SSE)
Mean (SD) 34.56 (16.88) 11.84 (5.45)
1 – .73***
– –
2 – –
3 – –
4 – –
5 – –
6 – –
7
12.50 (10.28)
−.46*** .28**
−.30** .13
– .01
– –
– –
– –
– –
25.64 (6.77)
−.47***
−.61***
.07
−.23*
–
–
–
20.75 (8.32)
.15
.25*
−.08
−.07
−.44***
–
–
66.25 (11.34)
−.54***
−.64***
.08
−.06
.63***
−.23*
–
19.48 (5.25)
−.27*
−.34**
.05
−.01
.52***
−.31**
.56***
Note. SD = standard deviation; PTSD = posttraumatic stress disorder; PCL = The PTSD Checklist; DASS = Depression Subscale of the Depression Anxiety Stress Scales-21; CES = Combat Exposure Scale; MLQ = Meaning in Life Questionnaire; MLQ-P = Presence of Meaning in Life; MLQ-S = Search for Meaning in Life; SES = Self-Efficacy Scale; GSE = General Self-Efficacy; SSE = Social Self-Efficacy. * p < .05. ** p < .01. *** p < .001.
related to depression severity. Search for meaning was significantly positively associated with depression symptom severity (p < .05), but was not significantly related to PTSD severity. Separate hierarchical linear regressions were performed using variables that were significantly correlated with PTSD or depression severity as predictors. For PTSD symptom severity, the overall model was significant, F(6, 81) = 15.37, p < .001, adjusted R2 = .52. Significant predictors in the model were rank (β = −.43, p < .001), combat exposure (β = .20, p < .05), and general self-efficacy (β = −.42, p < .001). Neither presence of nor search for meaning was a significant predictor in the model. The interaction between combat exposure and general self-efficacy was also significant (β = −.17, p < .05). However, the interaction between combat exposure and presence of meaning was not significant, and it was therefore dropped from the final model (see Table 2). The interaction plot (Aiken & West, 1991) revealed that when combat exposure was low, PTSD severity was similar at all levels of general self-efficacy. However, when combat exposure was high, as self-efficacy levels increased, PTSD severity levels decreased (see Figure 1). For depression symptom severity, the overall model was also significant, F(5, 85) = 18.76, p < .001, adjusted R2 = .51. Significant predictors in the model were rank (β = −.24, p < .01), presence of meaning in life (β = −.40, p < .001), and general self-efficacy (β = −.42, p < .001). Search for meaning was not a significant predictor in the model.
Discussion The current study examined the effects of self-efficacy and meaning in life on PTSD and depression symptom severity among a Veteran sample. Our first hypothesis was that higher levels of general self-efficacy, social self-efficacy, and presence of meaning in life as well as lower levels of search for meaning would be associated with lower levels of PTSD and depression symptom severity. We also hypothesized that lower levels of combat exposure would be associated with lower PTSD symptom severity. This hypothesis was only partially supported, however, because search for meaning in life was not significantly associated with PTSD in correlational analyses. In addition, regression analyses revealed that only rank, combat exposure, and general self-efficacy–not presence of meaning in life or social self-efficacy–significantly predicted PTSD severity.
224
Journal of Clinical Psychology, March 2015
Table 2 Multiple Regression Analyses Predicting PTSD and Depression Symptom Severity (Final Models; N = 93) PTSDa Predictorsd Step 1 Rank Step 2 Rank Combat Exposurec Presence of Meaning (MLQ-P) Search for Meaning (MLQ-S) General Self-Efficacy (GSE)c Social Self-Efficacy (SSE) Step 3 Rank Combat Exposurec Presence of Meaning (MLQ-P) Search for Meaning (MLQ-S) General Self-Efficacy (GSE)c Social Self-Efficacy (SSE) Combat exposure x GSE
Depressionb
B
SE
β
B
SE
β
−18.17
3.68
−.48***
−3.50
1.19
−.31**
−15.73 .39 −.44 – −.61 .34
3.00 .16 .27 – .16 .33
−.42*** .20* −.18 – −.41*** .103
−2.75 – −.32 −.01 −.20 .14
.87
−.24** – −.40*** −.10 −.42*** .13
−16.20 .40 −.32 – −.63 .33 −.03
2.94 .16 .27 – .16 .32 .01
−.43*** .20* −.13 – −.42*** .10 −.17*
– .09 .06 .05 .10
Note. SE = standard error; PTSD = posttraumatic stress disorder; MLQ = Meaning in Life Questionnaire; MLQ-P = Presence of Meaning in Life; MLQ-S = Search for Meaning in Life; SES = Self-Efficacy Scale; GSE = General Self-Efficacy; SSE = Social Self-Efficacy. a Adj. R2 = 0.52; R2 Step 1 = .23*** , R2 Step 2 = .29*** , R2 Step 3 = .03* . b Adj. R2 = 0.51; R2 Step 1 = .09** , R2 Step 2 = .45*** . c Centered values were used for variables included in the interaction term in the PTSD model. d The interaction between presence of combat exposure and presence of meaning in life was not a significant predictor of PTSD severity and was dropped from the final model. * p < .05. ** p < .01. *** p < .001.
Figure 1. Interaction between general self-efficacy and combat exposure with PTSD severity as dependent variable. Note. For both variables, low = one standard deviation below the mean and high = one standard deviation above the mean.
Self-Efficacy and Meaning
225
We also hypothesized that general self-efficacy and presence of meaning in life would have a moderating role in the relationship between combat exposure and PTSD. Again our results partially supported this hypothesis, indicating that self-efficacy served as a moderator, but not presence of meaning in life. In terms of depression severity, only rank, presence of meaning in life, and general self-efficacy were significant predictors, with search for meaning and social self-efficacy not reaching statistical significance. It appears that when controlling for rank, general self-efficacy exerts a stronger influence on PTSD severity than having a sense of meaning in life. However, this did not hold true for depression, where both general self-efficacy and presence of meaning significantly predicted symptom severity. Beliefs about one’s abilities to achieve outcomes may contribute to a sense of control that may be helpful with PTSD and depression symptomatology, although this cannot be determined with the cross-sectional data from the current study. Having a sense of meaning in life does seem to influence depression severity as would be expected from prior research (e.g., Frazier et al., 2001; Krause, 2007; Updegraff et al., 2008). In the PTSD model, the interaction between self-efficacy and combat exposure was also significant, suggesting that when combat exposure levels are high, self-efficacy becomes increasingly important in terms of PTSD severity. Therefore, in the face of high combat exposure, Veterans who felt they had the abilities to achieve certain outcomes or goals reported lower levels of PTSD. Prior research (Solberg, Laberg, Johnsen, & Eid, 2005) indicates that an individual’s beliefs about their military abilities and skills are the strongest predictor of their self-efficacy beliefs. Our results suggest that building a sense of self-efficacy, possibly through training experiences similar to those that will be encountered during deployment, may be particularly crucial to preparedness for high combat environments and adjustment after such experiences. Although we did not form a specific a priori hypothesis related to rank, exploratory analyses showed that rank was a significant predictor of both PTSD and depression severity, with enlisted rank associated with higher symptom severity. This finding may relate to the lower degree of control enlisted personnel may have over their environment or deployment decisions, which over time may also affect their sense of self-efficacy, or confidence that they are able to produce a certain outcome during missions. Enlisted personnel may also be subjected to higher levels of combat exposure than officers; however, we do not have additional data to examine these possibilities with the current study. Although correlational relationships were significant, presence of meaning in life was not a significant predictor of PTSD severity in the final regression model, nor was the interaction between meaning in life and combat exposure, contradicting our initial hypotheses. This finding was surprising considering earlier work with Veteran samples suggesting that Veterans often search for meaning after combat experiences (Fontana & Rosenheck, 2005) and that having a sense of meaning may moderate the relationship between depression and PTSD severity (Owens et al., 2009). However, the current study sample was significantly younger than the Owens et al. study, which largely comprised Vietnam-era Veterans, and mean PTSD scores in the present study were also lower. These differences between samples could explain the nonsignificant findings related to presence of meaning in life. Further, self-efficacy beliefs were not examined in either of these prior studies, and it may be that when examined together, self-efficacy has a stronger influence on current PTSD symptom severity than does having a sense of meaning in life. Search for meaning in life was also not significantly associated with PTSD symptom severity even in initial correlational analyses, and although significantly correlated with depression, search for meaning was not a significant predictor of depression severity in the final model. Although past research with non-Veteran samples has found associations between high search for meaning and measures of distress such as negative affect and depression (Steger et al., 2006), relationships in the current study did not reach significance, even though means for search for meaning in the current study were similar to those of Steger and colleagues. Thus, it seems that for this sample of Veterans, searching for meaning in relation to PTSD and depression symptomatology was not as relevant. Contrary to our hypothesis, efficacy expectations in social situations were not significantly associated with PTSD, nor were they a significant predictor of depression symptom severity in
226
Journal of Clinical Psychology, March 2015
the final regression model. Thus, it seems that for this sample of Veterans, confidence in one’s ability to manage social interactions effectively was not as relevant in relation to PTSD and depression symptomatology.
Limitations and Future Directions for Research Although our findings are partially consistent with prior research with non-Veteran samples, the current study has several limitations. All participants were volunteers and differences may therefore exist between participants who elected to respond versus those who did not. Veterans with interest in mental health, for instance, may have been more likely to complete the survey. Most respondents reported higher levels of education, indicating completion of at least some college. Veterans who were more educated or of a higher socioeconomic status may have had easier access to computers to complete the online survey. Further, use of an online survey design may have a number of limitations (see Wyatt, 2000). In addition, the majority of participants were Caucasian males. Our sample, although adequate for statistical analyses, was rather small and not all Veterans had experienced moderate to high levels of combat exposure. All of these potential limitations may affect the generalizability of our results to the larger Veteran population. We also did not assess whether Criterion A establishing a life-threatening traumatic event was met for PTSD, although we did have some detail about the events related to PTSD symptom severity through the use of the PCL-S. Future research would benefit from formal assessment of Criterion A for PTSD. This study identifies potential relationships between self-efficacy, meaning in life, and levels of PTSD and depression symptom severity among Veterans of various combat eras. Because some of our findings related to search for meaning and social self-efficacy contradict earlier work with depression and PTSD (e.g., Steger et al., 2006; Wei, Russell, & Zakalik, 2005), further investigation of these variables with larger and more diverse Veteran samples is warranted and would help determine whether the current results are an accurate reflection of the general Veteran population. Finally, a longitudinal study comparing Veterans at pre- and postdeployment would be useful to help establish causality and ascertain whether self-efficacy and meaning in life may serve as protective factors against development of PTSD and depression symptoms.
Conclusion To our knowledge, this study is the first to examine constructs of both meaning in life and selfefficacy and their associations with PTSD and depression symptom severity in a Veteran sample. In addition, most prior research has only explored self-efficacy as a single construct, rather than investigating subtypes of self-efficacy. Results of this study indicate a possible protective factor for postcombat distress, given that Veterans reporting high combat exposure and high levels of general self-efficacy reported lower levels of PTSD symptom severity. In terms of clinical implications, our results suggest that therapists and clergy working with military Veterans who are experiencing distress may consider implementing strategies to teach skills that may assist in increasing a sense of self-efficacy.
References Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman and Company. Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behavior Research and Therapy, 42, 1129–1148. Benight, C. C., Ironson, G., Klebe, K., Carver, C. S., Wynings, C., Burnett, K., . . . Schneiderman, N. (1999). Conservation of resources and coping self-efficacy predicting distress following a natural disaster: A causal model analysis where the environment meets the mind. Anxiety, Stress and Coping: An International Journal, 12, 107–126. doi:10.1080/10615809908248325 Bonanno, G. A., & Mancini, A. D. (2012). Beyond resilience and PTSD: Mapping heterogeneity of responses to potential trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 74–83. doi:10.1037/a0017829
Self-Efficacy and Meaning
227
Bonanno, G. A., Rennicke, C., & Dekel, S. (2005). Self-enhancement among high-exposure survivors of the September 11th terrorist attack: Resilience or social maladjustment? Journal of Personality and Social Psychology, 88, 984–998. doi:10.1037/0022-3514.88.6.984 Casey, G. W. (2011). Comprehensive soldier fitness: A vision for psychological resilience in the U. S. Army. American Psychologist, 66, 1–3. doi:10.1087/a0021930 Fontana, A., & Rosenheck, R. (2005). The role of loss of meaning in the pursuit of treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 18, 133–136. doi:10.1002/jts.20014 Frazier, P., Conlon, A., & Glaser, T. (2001). Positive and negative life changes following sexual assault. Journal of Consulting and Clinical Psychology, 69, 1048–1055. doi:10.1037/0022-006X.69.6.1048 Green, K. T., Calhoun, P. S., Dennis, M. F., & Beckham, J. C. (2010). Exploration of the resilience construct in posttraumatic stress disorder sensitivity and functional correlates in military combat Veterans who have served since September 11, 2001. Journal of Clinical Psychiatry, 71, 823–830. doi:10.4088/JCP.09m05780blu Hayhoe, C. R., & Gutter, M. E. (2012). Reliability of the scales in the NC1172 complex nature of saving data set. Family and Consumer Sciences Research Journal, 40, 284–294. doi:10.1111/j/15523934.2011.02111.x Keane, T. M., Fairbank, J. A., Cadell, J. M., Zimering, R. T., Taylor, K. L., & Mora, C. A. (1989). Clinical evaluation of a measure to assess combat exposure. Psychological Assessment, 1, 53–55. doi:10.1037/1040-3590.1.1.53 Kia-Keating, M., & Ellis, B. H. (2007). Belonging and connection to school in resettlement: Young refugees, school belonging, and psychosocial adjustment. Clinical Child Psychology and Psychiatry, 12, 29–43. doi:10.1177/1359104507071052 Krause, N. (2007). Evaluating the stress-buffering function of meaning in life among older people. Journal of Aging and Health, 19, 792–812. doi:10.1177/0898264307304390 LaPierre, C. B., Schwegler, A. F., & LaBauve, B. J. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of Traumatic Stress, 20, 933–943. doi:10.1002/jts.20278 Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation. Luszczynska, A., Benight, C. C., & Cieslak, R. (2009). Self efficacy and health-related outcomes of collective trauma–A systematic review. European Psychologist, 14, 51–62. doi:10.1027/1016-9040.14.1.51 National Center for PTSD. (2014, January). Using the PTSD Checklist for DSM-IV (PCL). Retrieved from http://www.ptsd.va.gov/professional/assessments/assessment-pdf/PCL-handout.pdf Owens, G. P., Steger, M. F., Whitesell, A. A., & Herrera, C. J. (2009). Posttraumatic stress disorder, guilt, depression, and meaning in life among military Veterans. Journal of Traumatic Stress, 22, 654–657. doi:10.1002/jts.20460 Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069–1081. doi:10.1037/0022-3514.57.6.1069 Seal, K. H., Bertenthal, D., Miner, C. R., Sen, S., & Marmar, C. (2007). Bringing the war back home: Mental health disorders among 103,788 US Veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine, 167, 476–482. doi:10.1001/archinte.167.5.476 Sherer, M., & Adams, C. H. (1983). Construct validation of the self-efficacy scale. Psychological Reports, 53, 899–902. doi:10.2466/pr0.1983.53.3.899 Sherer, M., Maddux, J. E., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R. W. (1982). The self-efficacy scale: Construction and validation. Psychological Reports, 51, 663–671. doi:10.2466/pr0.1982.51.2.663 Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53, 80–93. doi:10.1037/00220167.53.1.80 Sumer, N., Karanci, A. N., Berument, S. K., & Gunes, H. (2005). Personal resources, coping self-efficacy, and quake exposure as predictors of psychological distress following the 1999 earthquake in Turkey. Journal of Traumatic Stress, 18, 331–342. doi:10.1002/jts.20032 Updegraff, J. A., Silver, R. C., & Holman, E. A. (2008). Searching for and finding meaning in collective trauma: Results from a national longitudinal study of the 9/11 terrorist attacks. Journal of Personality and Social Psychology, 95, 709–722. doi:10.1037/0022-3514.95.3.709
228
Journal of Clinical Psychology, March 2015
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (October, 1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Wei, M, Russell, D. W., & Zakalik, R. A. (2005). Adult attachment, social self-efficacy, self-disclosure, loneliness, and subsequent depression for freshman college students: A longitudinal study. Journal of Counseling Psychology, 52, 602–614. doi:10.1037/0022-0167.52.4.602 Wyatt, J. C. (2000). When to use web-based surveys. Journal of the American Medical Informatics Association, 7, 426–429. Zika, S., & Chamberlain, K. (1992). On the relation between meaning in life and psychological well-being. British Journal of Psychology, 83(1), 133–145. doi:10.1111/j.2044-8295.1992.tb02429.x
