Psychosocial Consequences: Appraisal, Adaptation, and Bereavement After Trauma



Fig. 11.1
Triadic reciprocal causation model representing the bi-directional influence of intrapersonal (cognitive, affective, physiological), behavioral, and environmental factors



Self-efficacy beliefs are integral to self-regulation and serve as a key psychological construct within SCT (Bandura, 1997; Maddux, 1995). Self-efficacy beliefs refer to the perceived ability to engage in the necessary behaviors to bring about ­desired results (Bandura, 1997). Self-efficacy beliefs have been investigated rigorously in a wide range of human behaviors (see Bandura, 1997) and garnered outstanding empirical support (Cervone, 2000) . According to Bandura (1997), self-efficacy beliefs are the most direct, proximal predictors of human behavior in a specific domain. Although more general self-efficacy beliefs have demonstrated reliable and significant associations with a wide range of outcome variables and cultural contexts (Luszczynska, Scholz, & Schwarzer, 2005) , they are not considered to be as powerful in predicting critical outcomes as situationally specific self-efficacy beliefs. In the context of traumatic stress, specific self-efficacy beliefs associated with posttraumatic adaptation are referred to as coping self-efficacy (CSE; Benight & Bandura, 2004) .


Coping Self-Efficacy


CSE beliefs refer to the perceived ability to meet the demands imposed on an individual by experiencing a traumatic event (Benight & Bandura, 2004). Traumatic events comprise situations that include physical threat to oneself or loved ones and can happen in a wide variety of contexts including military combat, physical assault, sexual assault, natural disasters, and man-made disasters among others (Breslau et al., 1998; Norris, 1992). Each different type of event may have unique recovery demands. For example, motor vehicle accident (MVA) survivors may have to deal with physical injuries, challenges with insurance companies, and loss of transportation, whereas sexual assault survivors may have to deal with physical injuries, fear of becoming pregnant if the victim is female, decision making related to reporting the crime, as well as the challenge of intimacy after the event. Neither one of these examples exhaust the potential challenges anyone may face after such experiences. They merely highlight some of the psychological and social demands trauma can impose on an individual. It is important to note that many, if not most, of the posttraumatic recovery demands for many individuals are completely foreign, compounding the coping challenges. Of course, this may not be the case for survivors of repeated trauma such as child abuse or soldiers who have been repeatedly deployed to combat zones, for example (see Chap. 7, this volume). Multiple exposures create additional posttraumatic burdens that complicate the coping process.

The duration of the traumatic exposure can vary greatly as well. Some events may be acute and time-limited stressors such as a MVA, whereas others may persist for months or even years (e.g., the aftermath of a natural disaster; see Chaps. 10, 12, and 13, this volume). Whether acute or chronic, recovering from a traumatic event challenges an individual’s capacity to cope. Thus, it is important to understand the evolving posttraumatic coping difficulties that an individual must navigate.

Self-efficacy beliefs play a critical role during this adaptation process (Bandura, 1997; Benight & Bandura, 2004). Indeed, the process of recovering from a traumatic event can push an individual’s capacity to cope to the limits and beyond (Bandura, 1997; Benight & Bandura, 2004). The novel coping demands require that the individual draw upon previous coping experiences in different domains (Bandura, 1997; Benight & Bandura, 2004). CSE beliefs are then developed through self-evaluation and self-regulative processes throughout recovery (e.g., success or failure feedback).

These feedback systems are described in the triadic reciprocal process (see Fig. 11.1). Individuals evaluate successes or failures as they engage in coping behaviors (e.g., seeking social support, managing intrusive thoughts) targeted to help recover from the tragic event. Indeed, as SCT posits, through our ability to use forethought and self-reflection, humans are able to influence the posttraumatic recovery environment through the skillful application of strategic planning and resource utilization. Successful coping experiences after the traumatic event can foster a sense of personal mastery, a powerful source of self-efficacy beliefs . Over time, perceived successful management of critical posttraumatic demands enhances personal beliefs in one’s coping capabilities, promotes effective posttraumatic adaptation, and may potentiate posttraumatic growth (Benight & Bandura, 2004; Cieslak, Benight, & Lehman, 2008). Conversely, many survivors experience a sense of complete personal failure due to a perfect storm of intrusive thoughts related to the trauma, serious on-going environmental challenges, and social isolation. Such thoughts drive a deeper sense of one’s inability to cope, increasing distress, and feelings of despair.

Research investigating the association between CSE beliefs and posttraumatic adaptation has been conducted with a variety of different populations and traumatic events including natural disaster (Benight, Antoni, Kilbourn, & Ironson, 1997; Benight & Harper, 2002; Benight et al., 1999b; Hirschel & Schulenberg, 2009) , physical assault (Johansen, Wahl, Eilertsen, & Weisaeth, 2007) ; inter-partner violence (Benight, Harding-Taylor, Midboe, & Durham, 2004; Lambert, Benight, Wong, & Johnson, 2013) , military combat (Solomon, Benbenishty, & Mulkulincer, 1991), reintegration of veterans after combat deployment (Smith, Benight, & Cieslak, 2013), terrorist attack (Benight et al., 2000), MVAs (Benight, Cieslak, Molton, & Johnson, 2008), and bereavement (Benight, Flores, & Tashiro, 2001). Studies have consistently demonstrated the predictive power of CSE beliefs with a variety of posttraumatic outcomes (Benight & Bandura, 2004; Luszczynska, Benight, & Cieslak, 2009b). The following sections briefly describe the results of various studies investigating the association between CSE beliefs and psychosocial outcomes in different traumatic stress settings.



Coping Self-Efficacy in Various Posttrauma Environments



Natural Disaster


Natural disasters can have significant mental and physical health implications (Lowe, Tracy, Cerdá, Norris, & Galea, 2013; Norris, Slone, Baker, & Murphy, 2006; Norris, Friedman Watson, Byrne, Diaz, & Kaniasty, 2002) . Although most will recover with time, the coping challenges with a major disaster are significant (see Chaps. 5, 10, 12, and 13, this volume). Benight and colleagues investigated the role of CSE beliefs following a series of natural disasters including Hurricane Andrew (Benight et al., 1997, 1999a), Hurricane Opal (Benight et al., 1999b), and a dual wildfire and flood (Benight & Harper, 2002) .

Benight et al. (1999a) demonstrated that acute CSE perceptions after the hurricane mediated the effect of resource loss on both acute and longer-term (approximately 1 year later) distress. Also, following Hurricane Andrew, Benight et al. (1997) examined the role of CSE beliefs of human immunodeficiency virus positive (HIV+) gay male disaster survivors and healthy male controls. CSE demonstrated a significant negative relationship with posttraumatic stress symptoms. In the HIV+ sample, CSE accounted for 51 % of the variance of posttraumatic stress symptoms after controlling for the estimated damage, perceived life threat, education, income, and cluster of differentiation (CD)4 cell count (Benight et al., 1997). The results were similar when predicting general psychological distress, accounting for an additional 27 % of the variance. The same pattern was replicated in the healthy control sample as well. CSE accounted for an additional 30 % of posttraumatic stress symptoms and 25 % of general distress after controlling for other variables.

Similarly, following Hurricane Opal, Benight et al. (1999b) found that CSE accounted for 34 % of general psychological distress over and above resource loss and gender in this cross-sectional study. This study also demonstrated that CSE beliefs mediated the relationship between resource loss and posttraumatic stress symptoms, optimism and general distress, as well as social support (for predictors of PTSD, see Ozer, Best, Lipsey, & Weiss, 2003) and distress (Benight et al., 1999b).

Following a devastating wildfire and subsequent deadly flash flood, Benight and Harper (2002) assessed the longitudinal predictive capacity of CSE beliefs. The community was initially threatened with a wildfire that engulfed 12,000 acres of land and took several homes and left much of the landside charred and bare. Soon after, a flash flood claimed two fatalities and disrupted essential community resources (e.g., water, transportation, communications) for months. CSE beliefs significantly predicted posttraumatic stress symptoms and general distress immediately following the disasters after controlling for age, gender, and acute stress responses. Further, CSE beliefs, assessed at time 1, mediated the relationship between acute stress responses and general distress on posttraumatic stress symptoms at 1 year.

Taken together, these studies highlight the central role of CSE beliefs during the process of disaster recovery. Individuals who perceive the ability to exert some control in the posttraumatic environment can offset the effects of lost resources and facilitate protective factors such as social support. Benight and Bandura (2004) argue that social support is more than a tangible resource. It requires the development, and maintenance, of social networks facilitated by an individual who is confident in his or her ability to develop them (Bandura, 1997). In addition, social support may come in many forms ranging from people willing to listen to material resources delivered after mass destruction. Benight et al. (1999a) point out that regardless of the available resources, their effective utilization is dependent upon the requisite knowledge and skills to use them once obtained. CSE perceptions are also ­important to consider when an individual is trying to cope with the myriad of challenges related to domestic violence, as discussed in the following section.


Intimate Partner Violence


Intimate partner violence (IPV) poses a substantial risk for developing PTSD as well as a range of negative health outcomes (Dutton et al., 2006; Golding, 1999) . In addition to symptoms of PTSD, IPV survivors may be faced with a wide range of challenges including embarrassment, housing concerns, parenting, as well as the direct physical consequences of the abuse (i.e., black eye, strained neck). Benight et al. (2004) developed the Domestic Violence Coping Self-Efficacy Scale (DV-CSE) to assess the perceived ability to manage specific cognitive and behavioral aspects of posttraumatic adaptation following IPV. As predicted, higher DV-CSE beliefs were associated with reduced posttraumatic stress symptoms and higher levels of well-being (Benight et al., 2004), whereas lower DV-CSE beliefs were associated with increased levels of posttraumatic distress. Interestingly, in a sample of undergraduate women who responded to a hypothetical domestic violence scenario, Rhatigan, Shorey, and Nathanson (2011) demonstrated that self-efficacy perceptions were an important aspect to decision making regarding domestic violence situations.

Lambert et al. (2013) investigated the role of DV-CSE beliefs in a sample of 55 women exposed to IPV. Consistent with SCT, DV-CSE beliefs demonstrated a strong negative relationship with both posttraumatic stress symptoms as well as depression. The study also investigated an additional source of self-efficacy, the interpretation of physiological and affective states (Bandura, 1997). Maladaptive appraisals of physiological sensations during the recovery process may signal ineffective coping strategies and undermine CSE (Benight & Bandura, 2004). Consistent with SCT, the authors found that CSE beliefs mediated the relationship between the negative interpretation of physiological sensations and posttraumatic distress (Lambert et al., 2013). Military combat and post-deployment adaptation, whereas clearly different from IPV, also challenges one’s perception of posttraumatic coping capabilities.


Military Combat and Reintegration


The objectively violent nature of military combat affects a wide range of psychosocial consequences (see Chap. 7, this volume). Estimates of PTSD prevalence among troops deployed to the recent wars in Iraq and Afghanistan have varied considerably, likely due to methodological and measurement differences (Ramchand et al., 2010) . Sundin et al. (2010) recently conducted a comprehensive review of prevalence studies published from 2004 to 2008, each of which utilized large (N < 300), nontreatment-seeking samples. These authors found that among these methodologically sound studies, rates of PTSD ranged from 10 to 17 % in nonrandom studies with samples of line infantry units, and, from 2.1 to 11.6 %, in random population-based studies. PTSD prevalence among treatment-seeking samples appears to be considerably higher with rates ranging from 12 (Erbes, Westermeyer, Engdahl & Johnsen, 2007) to 37.8 % (Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008) . Depression and substance abuse are also problematic among this population (Thomas et al., 2010; Seal et al., 2009) .

Solomon et al. (1988, 1991) examined the role of perceived self-efficacy for combat situations of Israeli soldiers following their combat experiences. Soldiers were assessed at 12, 24, and 36 months after participating in combat operations. One year after combat, perceived self-efficacy was associated with performance during combat (combat stress reactions) and subsequent posttraumatic stress symptoms. Soldiers who reported low perceived self-efficacy to engage in a combat capacity reported more posttraumatic stress symptoms and were more likely to have impaired performance during combat. At 24 months, low combat self-efficacy was associated with higher posttraumatic stress and global distress symptoms. Interestingly, at 36 months, the pattern changed somewhat. Low combat self-efficacy continued to be associated with higher overall distress, but it was no longer significantly associated with posttraumatic stress symptoms (Solomon et al., 1991). The focus on combat-specific self-efficacy beliefs may account for why the relationship among the variables changed over time (see also Chap. 7, this volume).

These studies also showed that soldiers who were treated and returned to the frontline as soon as possible reported higher self-efficacy and lower subsequent distress than soldiers removed from the line for treatment (Solomon et al., 1988). Consistent with SCT, soldiers who were triaged and returned to their combat units were able to gain additional mastery experiences to bolster their perceived combat self-efficacy.

However, assessing additional self-efficacy determinants related to the specific demands of psychosocial adaptation after combat are needed. Recently, investigators have focused on the self-efficacy beliefs following combat and its impact on soldiers after they return home. Smith et al. (2013) assessed post-deployment coping self-efficacy (PD-CSE) beliefs of US operations Iraqi Freedom and Enduring Freedom (OIF/OEF) veterans after they returned home. The measure included 18 items related to the social reintegration of soldiers and post-combat adaptation. As predicted, PD-CSE demonstrated a strong negative relationship with posttraumatic stress and depression symptoms. This study also demonstrated the important mediating role of PD-CSE between social support and subsequent post-deployment distress and depression symptoms (Smith et al., 2013). Soldiers are trained to manage combat and the reintegration home. In stark contrast, terrorist attacks are by their intent sudden unpredictable actions meant to induce terror and fear in the targeted population. CSE perceptions have also been investigated under these conditions.


Terrorist Attack


In 1995, the Oklahoma City federal building was the target of a terrorist attack. A bomb decimated the building, killing 168 people and injuring many more. Benight et al. (2000) examined CSE beliefs focused on meeting the specific demands of recovery after the bombing. Individuals who worked nearby the building, many of whom were directly affected, were recruited and assessed 2 and 12 months after the attack. Two months after the attack, CSE was a significant predictor of global distress and posttraumatic stress symptoms after controlling for the threat of death, income, social support, and loss of resources. Including CSE in the model accounted for an additional 23 % of the variance of global distress, 22 % intrusive thoughts and memories of the event, and 28 % of the frequency of trauma-specific symptoms. CSE assessed 1 year after the attack remained a significant preceptor of global distress, intrusive thoughts and memories, and posttraumatic stress symptom severity after controlling for social support and loss of resources (Benight et al., 2000).

Thompson et al. (2006) studied 501 adults living in southern California 2 years following the September 11 attacks. Through qualitative interviews, the researchers found that personal control/mastery was associated with less reported distress. Dealing with the aftermath of a terrorist attack undoubtedly challenges existing coping capacities. The two studies just described suggest that perceptions of coping capability may be important to consider. Support for the predictive value of CSE beliefs following an MVA has also been reported.


Motor Vehicle Accident


MVAs may be one of the most frequently occurring traumatic events (Breslau et al., 1998). As mentioned previously, MVA survivors are confronted with not only the potential of developing PTSD but also a myriad of other consequences. Benight et al. (2008) longitudinally investigated MVA coping self-efficacy (MVA-CSE). Survivors were assessed at 1 week, 1 month, and 3 months after the accident.

In this sample, MVA-CSE demonstrated a significant negative relationship with posttraumatic stress symptoms. In addition, early change in MVA-CSE, between time 1 and time 2, was a significant predictor of 90-day posttraumatic stress symptoms after controlling for accident responsibility, involvement in litigation, peritraumatic dissociation, and posttraumatic distress at time 1 (Benight et al., 2008). They also found that the influence of time 1 posttraumatic distress on time 3 posttraumatic distress was mediated by MVA-CSE assessed at time 2.

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Oct 28, 2016 | Posted by in CRITICAL CARE | Comments Off on Psychosocial Consequences: Appraisal, Adaptation, and Bereavement After Trauma
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