Posttraumatic Stress and Growth:
The Contribution of Cognitive Appraisal
and Sense of Belonging to the Country
Rachel Dekel and Orit Nuttman-Shwartz
The study has three aims: (1) to compare the effect of the Qassam attacks in two types of
communities: development town and kibbutz; (2) to examine the relationship between
posttraumatic stress (PTS) and posttraumatic growth (PTG); and (3) to examine the
contribution that level of exposure, cognitive appraisal, and sense of belonging to the country
make to PTS and PTG. The sample consisted of 134 residents, 67 living on two kibbutzim
and 67 living in the development town of Sderot. Results revealed that the development town
residents reported more PTS symptoms and more PTG than did the kibbutz residents, and the
association between PTS and PTG was positive. In addition, the findings show that most of
the predictors contribute to either PTS or PTG, or predicted them differently. The discussion
examines the results in light of the current literature on PTS and PTG.
KEY WORDS: country; posttraumatic
growth; posttraumatic stress; sense of belonging; terror
O
ver the past decade, terrorism has become
a worldwide problem, with people in
many countries directly exposed. Studies
of adults exposed to political violence in Bosnia
and Croatia (Grgic, Mandic, Koic, & Knezevic,
2002), Palestine and Israel (Baker & Kevorkian,
1995; Bleich, Gelkopf, & Solomon, 2003), and
the United States (for example, Galea et al., 2002;
Silver, Holman, McIntosh, Poulin, & Gil-Rivas,
2002) revealed a range of detrimental consequences,
including heightened anxiety; depression; a reduced
sense of safety; an increased use of tobacco, alcohol,
and drugs; and, most prevalent of all, posttraumatic
stress (PTS) symptoms. These symptoms can be
grouped into three main clusters. The first is persistent re-experience of the traumatic event, such
as recurrent dreams and flashbacks. The second is
persistent avoidance of internal or external cues associated with the trauma, such as avoiding thoughts,
avoiding activities, diminished interest, detachment,
restricted affect, and sense of foreshortened future.
Finally, increased arousal is manifested in difficulty
in sleeping, irritability, difficulty in concentrating,
hypervigilance, and exaggerated startle response
(American Psychiatric Association [APA], 1994).
CCC
Code:and
0360-7283/09
$3.00 ©2009 National
Association
of Social
Workers
Dekel
Nuttman-Shwartz
/ PTS
and Growth:
Contribution
A growing body of empirical studies reveals that
many trauma survivors also experience positive
psychological changes after trauma. Posttraumatic
growth (PTG) is described as the subjective experience of positive psychological change reported by
an individual as a result of the struggle with trauma.
PTG relates to a variety of positive psychological
changes, including increased appreciation of life,
setting of new life priorities, a sense of increased
personal strength, identification of new possibilities, improved closeness in intimate relationships, or
positive spiritual change (Tedeschi, Park, & Calhoun,
1998). Such outcomes have been documented
following a variety of traumatic events, including
natural disasters (Maercker & Herrle, 2003), war (for
example, Fontana & Rosenheck, 1998), and terror
(Butler et al., 2005).
This study examines PTS and PTG among
residents of the Western Negev area of Israel. Like
other residents of Israel, they have been exposed to
the deadly violence, and threat of violence, of the
second Palestinian Intifada, the armed rebellion that
started in September 2000 and has still not abated.
Western Negev has been the target of Qassam rocket
attacks, whose number has steadily increased over
of Cognitive Appraisal and Sense of Belonging to the Country
87
the years. In 2007 the region saw more than 2,300
rocket attacks in all.
Qassam rockets are relatively unsophisticated
weapons, with low accuracy and low deadliness. At
the same time, their frequent firings, at all hours
of the day and night, have introduced considerable
uncertainty and anxiety into the lives of the residents
of the stricken area and a heightened state of physical
and emotional alert. However, since there is very
little time between the firing and the landing of the
missile, there is little opportunity for self-protection.
People abruptly stop what they are doing, run for
inadequately protected areas, and wait for the boom.
Occasional Qassams have penetrated into people’s
homes. Although most of the damage has been to
property, several people, some of them children, have
been killed in direct Qassam hits.
The first aim of the study is to compare the effect
of the Qassam attacks in two different types of communities in the Western Negev. One is the development town of Sderot. Like the other 28 development
towns in Israel, Sderot was established in the 1950s,
a few years after Israel’s declaration of independence, to settle the huge masses of immigrants who
poured into the country during those years and to
populate its peripheral areas. Despite government
efforts, most of these towns did not manage to build a
strong and varied economic base and, over the years,
have become pockets of deprivation and poverty
(Yiftachel, 2000). Like most of these towns, Sderot
is characterized by high unemployment, low education level, and a pervasive feeling among residents
that they are badly neglected by the government
and ignored by their wealthier, more fortunate
compatriots elsewhere in the country.
The other type of community is the kibbutz.This
is a uniquely Israeli community, originally established
to farm and protect the land and inspired by ideals
of economic and social equality and mutual help
and responsibility. Until the 1980s, the kibbutzim
were the centers of Israel’s elite, with their members
representing an extraordinarily high proportion of
senior military and government posts. Since then,
the economic situation of most of the kibbutzim has
deteriorated, their prestige has greatly declined, and
most of them have undergone major processes of
privatization, with resultant inequalities of income
and a loosening of the social bonds. Nonetheless,
the kibbutzim are still relatively tightly knit communities, and their members retain elements of the
old communal ideology and pride. Moreover, even
88
on the less affluent kibbutzim, the quality of life is
relatively high, with lots of greenery, good schools,
cultural activities, and very low crime rates.
Earlier studies indicated that kibbutz residents
fared better emotionally under stressful conditions
than residents of other communities (Benyamini et
al., 2004). It is suggested that the kibbutz ideology
and communal lifestyle provided a measure of protection against stress. However, given the changes in
the kibbutz, the question is whether it still affords
the psychological protection it has in the past.
The comparison is somewhat difficult to make
because of the different levels of exposure to the
rockets in the separate locations. Around two-thirds
of the Qassams landed in Sderot; the rest landed in
the various kibbutzim in the area. Given these differences, the study attempted to examine the effect
of the Qassams on the two types of communities,
beyond the difference in exposure.
The second aim of the study is to examine the
relationship between the pathological and salutary
outcomes of the attacks in the two types of communities—more specifically, to examine the association
between PTS and PTG measures. Previous findings
are inconsistent. Some studies suggest that distress
and growth are antithetical: The more distress one
experiences in the wake of a traumatic event, the less
one grows from it, and vice versa (Updegraff,Taylor,
Kemeny, & Wyatt, 2002). Other studies show positive correlations between the two outcomes, with
the most highly distressed people likely to show the
greatest psychological growth (Pargament, Smith,
Koenig, & Perez, 1998;Tedeschi & Calhoun, 1996).
Several studies have found a curvilinear relationship,
with individuals with more PTS symptoms reporting
higher growth (Butler et al., 2005). Finally, a third
set of findings shows no relation between psychological distress and growth (for example, Solomon,
Waysman, & Neria, 1999).
The third aim of the current study is to examine
predictors of PTS and PTG in the wake of the
Qassam attacks. Although many studies have been
carried out on predictors of PTS, fewer have been
carried out on predictors of PTG. Only a handful
of studies have examined predictors of both.We examine the following predictors: exposure, cognitive
appraisal of the nature of the stressor, and a sense of
belonging to the country.
Level of exposure has repeatedly been found to
be one of the strongest correlates of psychological
distress in the wake of a wide variety of traumatic
Health & Social Work Volume 34, Number 2
May 2009
events, including war (Dekel, Solomon, Ginzburg,
& Neria, 2003) and terror (for example, Tucker,
Pfefferbaum, Nixon, & Dickson, 2000). Findings
on the relationship between exposure and PTG
are less consistent. Some studies have found positive linear correlations between them (Maercker, &
Herrle, 2003); others have not (Schnurr, Rosenberg,
& Friedman, 1993).
Lazarus and Folkman (1984) argued that stressors can be perceived as either threats or challenges. The more inclined people are to perceive
the stressor as a threat, the more distress they will
experience; the more they perceive it as a challenge, the less distressed they will become. This
claim has gained considerable empirical support in
studies of people’s distress following a wide variety
of stressors, including battle (Solomon, Mikulincer,
& Benbenishty, 1989) and terror (Piotrkowski &
Brannen, 2002). Studies have also found a positive
association between cognitive appraisal and growth
(Armeli, Gunthert, & Cohen, 2001; Cordova, Cunningham, Carlson, & Andrykowski, 2001). These
studies, however, are relatively few in number, and
none of them examines the association where the
stressor is terror.
Sense of belonging refers to people’s feeling of being part of a collective (Newbrough & Chavis, 1986),
whether the neighborhood, immediate community,
nation, or any other group or place. It is characterized
by mutual concern, connection, community loyalty,
and trust that one’s personal needs will be fulfilled
by means of commitment to the group as a whole
(Chavis, Hogge, McMillan, & Wandersman, 1986).
Other manifestations include the wish to remain in
the community and to encourage others to join it
(Itzhaky, 1995). Findings show that there are lower
rates of combat stress in army units that have high
levels of solidarity and cohesion than in those in
which the soldiers’ sense of belonging is lower
(Steiner & Neumann, 1978). More recent findings
in Israel show an association between a high sense of
belonging to the country and lower levels of distress
in the wake of the ongoing terror experienced in the
country (Kovatz, Kutz, Rubin, Dekel, & Shenkamn,
2006). No studies, however, have been carried out
on the relationship between a sense of belonging
to the country and growth.
The third aim of the study is to examine the
contributions of cognitive appraisal of the stressor
and of sense of belonging to the country to both
PTS and PTG. The question is whether each of
these contributes similarly to the prediction of the
two outcomes or uniquely to one or another.
METHOD
Sample and Data Collection
The sample consisted of 134 residents of Western
Negev, 67 living on two kibbutzim and 67 in the
development town of Sderot, who were matched
in gender and age. Only those who completed the
research questionnaires in full, 122 people, were
included in the analysis and presentation.
Comparisons revealed no significant group differences in age, gender, country of birth, family status,
number of children, or self-reported economic situation. Just over half of the participants, 53 percent,
were men. The participants’ ages ranged from 18
to 76 (M = 44.89, SD = 13.34). More than half,
55 percent, were born in Israel. Sixty percent were
married, 26 percent were single, and 14 percent
were divorced or widowed. Fifty-four percent of
the participants reported below average income;
25 percent, above average income; and 21 percent,
around average income.
Significant group differences, however, were
found in education and exposure. On average, kibbutz residents reported more years of schooling (M
= 14.23, SD = 2.38) than the Sderot residents [M
= 12.63, SD = 2.40; t(120) = 3.69, p < .001]. Kibbutz residents also reported lower direct exposure
to the Qassams than did the Sderot residents [χ2(4,
N = 122) = 12.53, p < .05]. Thirty percent of the
kibbutz sample reported that they had not been
directly exposed to the rockets, compared with
only 14 percent of the Sderot residents. Conversely,
12 percent of the Sderot residents reported that a
rocket had fallen on or very close to their home; no
kibbutz resident reported such an experience. The
differences in education levels and direct exposure
were taken into account in our analyses.
Data were collected between March and July 2005
by social work students trained for the task. In Sderot,
the interviewers approached people in the streets
and public places in the town, as well as in their
homes, obtaining a random, but not representative,
sample. In the kibbutzim, contact people asked the
members to take part in the study. Almost all members of both kibbutzim participated. In both Sderot
and the kibbutzim, prospective interviewees were
told that that this was a study of people’s responses
to and coping with the current situation, and their
informed consent was obtained.
Dekel and Nuttman-Shwartz / PTS and Growth: Contribution of Cognitive Appraisal and Sense of Belonging to the Country
89
Measures
Sociodemographic Characteristics. The questionnaire
queried gender, age, family status, education, and
economic status.
Exposure to Qassam Rockets. Participants were to
indicate their direct exposure to the Qassam rockets
on a five-point scale with 1 = no direct exposure, 2
= a Qassam fell in the adjacent neighborhood, 3 =
a Qassam fell in my neighborhood, 4 = a Qassam
fell close to my home, and 5 = a Qassam fell on or
very close to my home.
Cognitive Appraisal. Cognitive appraisal of the
stressor was assessed through a questionnaire based
on Lazarus and Folkman’s (1984) Cognitive Appraisal Questionnaire.The questionnaire used in the
current study consists of 14 items tapping the participants’ perceptions of the Qassam rocket attacks.
Nine items tap the extent to which the participants
perceived the attacks as a threat (for example, the
situation can harm you). Five items tap the extent
they perceived them as a challenge (for example,
the situation is a chance to show your abilities).The
participants rated the degree to which each item described their perception on a six-point scale ranging
from 1 = not at all to 6 = strongly agree. Internal
reliability for threat perception was high (.91) and
for challenge perception was fair (.63).
Sense of Belonging to the Country. Sense of belonging to the country was measured by a 12-item
scale developed by Itzhaky (1995). The items tap
the respondents’ sense of belonging to Israel (for
example, “I feel part of the country”) and their
commitment to the country (for example, “I won’t
leave the country even if the security situation deteriorates”). For each item, respondents were asked
to indicate their agreement on a four-point scale
ranging from 1 = not at all to 4 = very much. The
Cronbach’s alpha in the current study was .87.
Posttraumatic Stress. Posttraumatic stress was
measured on the basis of the DSM-IV (APA, 1994)
diagnostic criteria.The 17 core symptoms were assessed by the Post Traumatic Stress Disorder (PTSD)
Inventory, a self-report scale consisting of 17 statements corresponding to the 17 core PTSD symptoms listed in the DSM-IV (APA, 1994). Participants
were asked to indicate for each statement whether
they suffered from the symptom on a four-point
scale ranging from from 1 = not at all to 4 = very
often. Distress was calculated as the mean number
of symptoms endorsed as having been experienced
often or very often. Cronbach’s alpha among the
90
17 items in the current study was .89, and the scale
was found to have high convergent validity when
compared with diagnoses based on structured clinical
interviews (Solomon et al., 1993).
The Postraumatic Growth Inventory (PTGI).
The PTGI was used to assess the salutogenic effect of living under continous barrages of Qassam
rockets (Tedeschi & Calhoun, 1996).The self-report
inventory taps 21 positive changes resulting from the
traumatic experiences, in five subscales: Relating to
Others (improved interpersonal relations), New Possibilities (changes in aspirations and goals), Personal
Strength (increased inner strength), Spiritual Change
(increased spirituality), and Appreciation of Life
(greater appreciation). Each item was scored on a
six-point scale ranging from 0 = “I didn’t experience
this change” to 5 = “I experienced this change to
a very large degree.” An overall total growth score
was calculated as the mean of all the responses.The
reliability of the total scale was .97.
RESULTS
Group Comparisons
PTS and PTG. Two analyses of variance (ANOVAs)
were conducted, one with PTS and one with PTG
as the dependent variables. In each of the analyses,
level of exposure and years of education served
as covariates. The ANOVA for PTS revealed a
significant effect of place of residence [F(1, 121)
= 7.69, p < .01], a significant effect of exposure
[F(1, 121) = 12.44, p < .001], and a nonsignificant
effect of education [F(1, 121) = 1.23, p > .05]. The
ANOVA for PTG revealed a significant effect of
place of residence [F(1, 121) = 5.69, p < .05], and
nonsignificant effects of exposure and education
[F(1, 121) = 0.49 and 2.42, respectively].
The residents of Sderot reported more PTS
symptoms and more PTG than the residents of
the kibbutzim, even after taking into account the
effect of exposure (see Table 1). At the same time,
both groups reported relatively low levels of PTS
symptoms.
Cognitive Appraisal and Belonging to the Country.
Three ANOVAs with threat appraisal, challenge
appraisal, and belonging to the country as the dependent variables were conducted. Again, level of
exposure and education served as covariates. The
ANOVA for threat appraisal revealed significant
effects for place of residence [F(1, 121) = 28.56, p
< .001] and level of exposure [F(1, 121) = 15.85, p
< .001]. The ANOVAs for challenge appraisal and
Health & Social Work Volume 34, Number 2
May 2009
Table 1: Means and Standard Deviations
of Study Variables, by Type of Community
Sderot
M (SD)
Kibbutzim
M (SD)
3.94 (3.84)
1.55 (1.29)
4.27 (1.05)
1.54 (0.68)
1.60 (2.31)
0.81 (1.19)
3.00 (1.11)
1.52 (0.70)
3.19 (0.69)
3.23 (0.55)
Variable
PTS symptoms
PTG
Threat appraisal
Challenge appraisal
Sense of belonging to the
country
Notes: PTS = posttraumatic stress. PTG = posttraumatic growth.
sense of belonging revealed no significant effects
(see Table 1).
The residents of Sderot were considerably more
inclined to appraise the situation as a threat than
were the residents of the kibbutzim (see Table 1).
The challenge appraisal of both groups, however,
was similarly low. Sense of belonging to the country
was similarly high (over 3 on a scale of 1 to 4) in
both groups.
Relationship between PTS and PTG
The simple correlation between PTS and PTG
was positive (r = .44, p < .001). Having more PTS
symptoms was associated with higher PTG. Curve
estimation regression analysis examining trauma
symptom levels indicated that only the linear relationships were significant for the total PTG score
[Linear: R2 = .183, b1 = 0.354, F(1, 91) = 20.35, p <
.001].The quadratic relationship was not significant
[Quadratic: R2 = .243, b1 = 1.603, b2 = –0.257, F(1,
90) = 14.41, p < .001].
Predicting PTS and PTG
Finally, two regressions with PTS and PTG as dependent variables were carried out. Both regressions
consisted of three steps. In the first step, place of
residence, level of direct exposure, and the sociodemographic variables of gender, age, and years of
schooling were entered. In the second step, threat
appraisal, challenge appraisal, and sense of belonging
to the country were entered.The regression on PTS
also included the PTG scores in this step. In the last
step, two sets of interactions were entered into both
regressions: between place of residence and the other
variables (threat appraisal, challenge appraisal, sense
of belonging) and between sense of belonging and
the two cognitive appraisal variables. In addition, the
interactions between the two appraisal variables and
PTG were entered into the regression on PTS.
To maintain a proper ratio between the size
of the sample and the number of variables in the
regression, we acted as follows. First, we entered
the variables in the first step in a stepwise manner.
This did not change the pattern of results, but it
did increase the degree of freedom. Second, in the
last step we entered only those interactions that
had been found to be significant in a preliminary
regression in which all the interactions had been
entered (see Table 2).
PTS. Together, the variables explained 54.8
percent of the variance in PTS symptoms [F(11,
121) = 12.15, p < .001]. The first step explained
23.1 percent of the variance, with level of direct
exposure, place of residence, and age making a significant contribution. Higher direct exposure was
associated with higher PTS symptoms. In addition,
as found earlier, the Sderot residents reported more
PTS symptoms than did the kibbutz residents. Also,
older people reported more PTS symptoms than
did younger people. The second step explained
another 21.6 percent of the variance, with the most
substantial contribution made by threat appraisal
and PTG and smaller contributions made by sense
of belonging to the country. Higher threat appraisal
and higher PTG were associated with more PTS
symptoms. Conversely, a higher sense of belonging
was associated with fewer PTS symptoms.
The third step added another 10.1 percent to the
explanation of the variance, with four interactions
making significant contributions. The interactions
between sense of belonging and place of residence,
threat appraisal, and challenge appraisal were significant. In addition, the interaction between threat
appraisal and PTG was significant.
To understand the interaction between place of
residence and sense belonging, we calculated the b
coefficients of sense of belonging predicting PTS
symptoms separately for the residents of Sderot
and of the kibbutzim. The calculations showed a
significant negative b coefficient between sense of
belonging and PTS symptoms among the kibbutz
residents (b = –1.60) and a low positive coefficient (b
= 0.15) among the Sderot residents. In other words,
the association between sense of belonging to the
country and PTS is different among the two places.
More specifically, among the kibbutzim, higher sense
of belonging to the country was associated with
fewer PTS symptoms.
Dekel and Nuttman-Shwartz / PTS and Growth: Contribution of Cognitive Appraisal and Sense of Belonging to the Country
91
Table 2: Multiple Variable Predictors of Posttraumatic Stress and Posttraumatic Growth
Posttraumatic Growth
Variable
Step 1
Exposure
Place of residence
Age
Step 2
Exposure
Place of residence
Age
Belonging to the country
Threat appraisal
Challenge appraisal
Growth
Step 3
Exposure
Place of residence
Age
Belonging to the country
Threat appraisal
Challenge appraisal
Growth
Residence × Belonging
Belonging × Threat
Belonging × Challenge
Threat × Growth
B
SE
b
0.96
–1.97
0.05
0.28
0.56
0.02
0.28***
–0.29***
0.18*
0.52
–0.38
0.05
–0.50
1.27
0.21
0.83
0.26
0.56
0.02
0.24
0.32
0.26
0.28
0.15*
–0.06
0.21**
–0.15*
0.37***
0.06
0.24**
0.42
–0.06
0.06
0.15
1.70
0.19
0.53
–1.74
–0.86
0.69
0.97
0.25
0.52
0.02
0.30
0.30
0.24
0.27
0.58
0.31
0.26
0.27
0.12
–0.01
0.22**
0.04
0.50***
0.06
0.15*
–0.30**
–0.23**
0.19**
0.24***
Posttraumatic Stress
% R2
Change
B
SE
b
23.1
% R2
Change
8.1
–0.74
0.23
–0.28***
21.6
21
–0.38
0.24
0.21
0.41
0.38
0.10
0.13
0.10
–0.15
0.16*
0.32**
0.29***
10.1
*p < .05. **p = .01. ***p < .001.
To understand the interaction between sense of
belonging and threat appraisal, we calculated the b
coefficient correlation predicting PTS symptoms
separately for participants with high and low sense
of belonging. The findings showed that among
people with high sense of belonging, the association between threat appraisal and PTS was low and
positive (b = 0.84), and that among participants
with a lower sense of belonging it was higher (b =
2.56).This finding indicates that sense of belonging
moderates the relationship between threat appraisal
and PTS.
To understand the interaction between sense of
belonging and challenge appraisal, we calculated
the b coefficient correlation separately for participants with high and low sense of belonging. The
calculations showed that the association between
challenge appraisal and PTS symptoms among
participants with high belonging was positive (b =
0.88) and that of the participants with lower sense
92
of belonging was negative (–0.50), pointing to the
moderating effect of belonging on the association
between challenge appraisal and PTS.
The fourth significant interaction was between
threat appraisal and PTG in predicting PTS. Calculations of the b coefficients between PTG and
PTS among participants with low and high threat
showed a significant positive correlation among
participants with high threat appraisal (b = 1.51)
and negative correlation among participants with
low threat appraisal (–0.45). This finding points to
the moderating effect of threat appraisal on the association between PTG and PTS.
PTG. Together, the variables explained 29.1 percent of the variance of the PTG [F(5, 121) = 6.96, p
< .001]. The first step explained 8.1 percent of the
variance, with only the place of residence making a
significant contribution. As found earlier, residents
of the development towns reported higher PTG
than did residents of the kibbutzim. The second
Health & Social Work Volume 34, Number 2
May 2009
step explained another 21 percent of the variance,
with sense of belonging, threat appraisal, and challenge appraisal all making significant contributions.
Higher threat appraisal, higher challenge appraisal,
and higher sense of belonging all contributed to
higher PTG. None of the interactions in the third
step made a significant contribution.
DISCUSSION
The first aim of the study was to compare the levels
of PTS and PTG among the two communities.The
findings show both more PTS symptoms and greater
PTG among the residents of Sderot, even after the
effect of their greater exposure had been discounted.
The finding on the differential PTS levels suggests
that the kibbutz still affords its members greater
protection against the psychological damage of terror than does the development town. The finding
on the differential levels of PTG is consistent with
the strong positive connection we found between
growth and PTS, with more PTS associated with
greater growth, which is discussed later.
Despite the statistical difference in the number of
the PTS symptoms in the two types of communities, the level of distress was relatively low in both,
considering the steady barrage of Qassams over
the years. The low level of distress may have any of
several explanations. One is that few of the attacks
have resulted in death. Another is that the populations have become habituated to the attacks, much
as the British had to the attacks of the German blitz
(Rachman, 1990) and most Israelis had to the first
Gulf War (Solomon, 1995) and have to the ongoing
state of terror in the country (Bleich et al., 2003). It
might reflect a situation in which the majority of
people are resilient and cope well with the threat of
terrorism, as was documented in a recent literature
review (Maguen, Papa, & Litz, 2008). A third possibility is that the distress of the populations may be
manifested in other ways that were not measured in
this study, such as interpersonal tensions or functional
impairment. The finding on the positive association between growth and distress is consistent with
earlier studies among various populations (for a
review, see Zoellner & Maercker, 2006). According
to Calhoun and Tedeschi’s (1998) theory, growth
is a result of psychologically “seismic” events and
of the individual’s struggle to make sense of them.
Since seismic events are, by nature, distressing, the
claim actually views distress as a trigger of growth.
Along similar lines, Butler et al. (2005) viewed the
key PTSD symptoms of intrusion and avoidance
not only as markers of distress, but also as evidence
of the organism’s efforts to assimilate and accommodate the traumatic event. However, the findings
also show that the level of threat appraisal affects
the relationship between PTG and PTS. Although
the relationship is positive among people with high
threat appraisal, it is negative among those with low
threat appraisal.This finding indicates that the relationship between PTS and PTG is more complex
and that the subjective perception of the event had
a moderating role on these relationships.
With respect to the predictors, the findings show
that most of those examined predicted either PTS
or PTG, but not both, or predicted them differently.
The only variable that contributed significantly to
the prediction of both, and in the same direction,
was threat appraisal. The more threatening the
Qassam attacks were viewed as being, the greater
the PTS and the greater the PTG, which supports
findings of previous studies on both PTS and PTG.
This finding could be explained by Taylor’s theory
of cognitive adaptation to threatening events (Taylor
& Armor, 1996), which regards PTG as a form of
“positive illusion” with an adaptive function for
psychological adjustment. Taylor’s perception of
PTG is one of possible self-enhancing appraisal
that helps to cope with threat. Thus, a higher level
of threat increases perception of growth. However,
because of its delusional character, it goes hand in
hand with higher distress.
Gender contributed neither to PTS nor to
growth.This contrasts with most findings on PTSD,
which show that women report more distress than
men (for example, Bleich et al., 2003), but it is
consistent with findings of some studies of PTG
(for example, Polatinsky, & Esprey, 2000).
The findings that age and exposure did not contribute to the prediction of PTG are consistent with
some studies but not with others. On each of these
variables, previous findings are mixed. Some studies
found that young people showed more PTG than did
older people; others did not (for review, see Linley
& Joseph, 2004). Similarly, although many studies
found that the level of exposure helped to predict
PTG (Maercker & Herrle, 2003), some found that
there was a curvilinear relationship (Jennings, Aldwin, Levenson, & Spiro, 2006).These findings show
that although PTS was predicted by both objective
exposure and threat appraisal, PTG was predicted
only by threat appraisal.These findings highlight the
Dekel and Nuttman-Shwartz / PTS and Growth: Contribution of Cognitive Appraisal and Sense of Belonging to the Country
93
The finding that sense of belonging is a
resource that alleviates posttraumatic distress
and increases PTG strengthens the role of
social context in coping with terror.
role of subjective perceptions of traumatic events in
predicting growth (Butler et al., 2005).
The finding that sense of belonging is a resource
that alleviates posttraumatic distress and increases
PTG strengthens the role of social context in coping with terror. Communities help people to cope
by reducing isolation, normalizing suffering, and
promoting healing disclosure. Community also
makes an important contribution in the context of
preparing for coping with the threat of future terrorism. A community can mobilize resources and
plan for future action, which may alleviate peoples’
fears (Maguen et al., 2008).
The interactive findings show that sense of belonging affected the contribution of three variables
to PTS.The salutary effects of a sense of belonging
were particularly strong among the kibbutz residents
and among those who reported high threat appraisal.
A sense of belonging mitigated PTS among kibbutz
members to a greater extent than that among the
residents of Sderot, and it tempered the contribution
of high threat appraisal to PTS.
The particular power of a sense of belonging to
mitigate PTS among kibbutz residents may reflect
the relative importance of a mutual commitment
to one another and the commitment to building
and defending the country according to kibbutz
ideology.The finding is consistent with those of an
earlier study that similarly showed that a sense of
belonging mitigated Israeli students’ distress more
than it had the distress of their Jewish American
counterparts (Kovatz et al., 2006). In contrast, a high
sense of belonging increased PTS among people
who reported a high sense of challenge. That is to
say, people with a high sense of challenge seem to
have paid a price in mental health for their high
sense of belonging. Why a high sense of belonging ceases to perform a protective function among
people with a high sense of challenge is a question
that requires further study.
Limitations
The study has several limitations. The first is the
sample size. The sample is small and, in the case of
94
Sderot, unrepresentative. It cannot be ruled out that
people from Sderot with severe PTS simply did not
participate in the study. The second limitation is
the cross-sectional design of the study: All the data
were collected at one point in time. This makes it
impossible to determine the causal sequence, if any,
between the outcome and predictor variables and
the two outcomes themselves. Furthermore, as the
threat persists and as the residents continue to be
exposed to a reality that endangers their security, the
study must be viewed as part of an ongoing cycle
of exposure to trauma. Hence, future longitudinal
investigations might examine whether students or
local residents learn to adapt to the situation over
time or whether their levels of distress become even
higher as the situation persists.
In addition, despite the fact that there were no
significant differences in several sociodemographic
background variables between the two communities,
the history and the development of each community
is very different. This might have affected personal
and social resources that were not assessed in the
study, such as competency, sense of coherence, and
family support, which in turn have affected the coping and adjustment of the different residents.
The study, however, contributes to our knowledge of the effect of ongoing terror on both PTS
and PTG. The study was carried out during a time
of ongoing attacks and is one of the relatively few
to date to examine PTS and PTG simultaneously.
In addition, the study takes into account both the
personal resources of threat and challenge appraisal
and the communal resource of a sense of belonging
and the type of community.
Implications
The study has several clinical implications. First, it
identifies risk factors for distress. Place of residence,
level of exposure, cognitive appraisal, and sense of
belonging should be taken into account when
reaching out to this population. In addition, the
findings highlight the importance of the personin-environment model (Karles & Wandrei, 1994) in
assessing individuals’ coping with traumatic stress.
Beyond its direct contribution, sense of belonging was a moderating factor for stress responses.
Hence, there is importance to intervening on the
community level, strengthening the residents’ connections and their involvement in the community.
Moreover, the treatment of people who have been
exposed to traumatic events has focused, for too
Health & Social Work Volume 34, Number 2
May 2009
long, solely on the detrimental effects of traumata
and has, thus, confined the understanding of trauma
recovery to a deficit-oriented model. Considering
PTG as a further potential outcome of coping with
trauma broadens the clinical perspective (Zoellner &
Maercker, 2006). It is important to raise clinicians’
awareness of the possibility of growth. When the
possibilities of PTG remain salient to the clinician,
he or she can help the client to identify it as it
emerges in sessions.
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Rachel Dekel, PhD, is senior lecturer, the Louis and Gabi
Weisfeld School of SocialWork, Bar Ilan University, Ramat Gan
52900, Israel; e-mail: dekell@mail.biu.ac.il. Orit NuttmanShwartz, PhD, is lecturer, Spitzer Department of Social Work,
Ben Gurion University of the Negev, Beer Sheva, Israel, and
Sapir College, D.N. Hof Ashkelon, Israel.
Original manuscript received February 13, 2007
Final revision received April 8, 2008
Accepted July 8, 2008
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