Trauma and social support: The association between informal social support,formal social support,and psychological well-being among terror attack survivors

Abstract

This study aimed to examine the role that informal and formal social support play with psychological well-being as reflected in positive and negative emotions of injured terror survivors in Israel. A total of 150 survivors who were eligible for social support and assistance by government agencies completed questionnaires that examined positive and negative emotions, informal social support, and formal social support from public government agencies provided by professional trained social workers. A hierarchal regression demonstrated that informal social support is associated with improved psychological state. However, formal social support, although provided by professional agencies, failed to demonstrate such an association. Theoretical, clinical, and policy implications of the findings are discussed.

Keywords

Formal social support informal social support survivors trauma well-being

Introduction

Exposure to a life-threatening event might produce an ongoing sense of current threat (Ehlers and Clark, 2000) which can affect mental and functional states of individuals in a variety of life domains (Galea et al., 2005; Neria et al., 2010). Within this concept, terrorism may affect individuals as well. There is difficulty defining terrorism, and there is no single, universally accepted, definition of terrorism. However, for the purpose of this study, terrorism is defined as the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives (Counterterrorism Threat Assessment and Warning Unit, Counterterrorism Division, 1999) which might serve as a significant threat to those exposed and injured.

Since the Second Intifada started in September 2000 (the second Palestinian uprising), a new and intense wave of deadly terrorist attacks has taken place in the state of Israel. These daily attacks have claimed large numbers of civilian casualties, disrupted daily life, and created an atmosphere of fear and insecurity (Berrebi and Lakdawalla, 2007; Gelkopf et al., 2008). Terrorism has been experienced as major interruptions of daily activities such as inconsistent work hours, the need to accompany children to school, searches in supermarkets, and delays on highways, adding a significant amount of stress that resulted from the terrorist acts (Shalev et al., 2006). However, only a few studies have focused on understanding the long-range effects of a terror attack on the survivor’s psychological well-being in the context of both informal and formal social support. The main objective of the present study, therefore, was to explore the association between social support (informal and formal) and the psychological well-being of injured terror survivors, as reflected in both positive and negative emotions.

Numerous studies have documented the substantial psychological morbidity of exposure to terrorism, demonstrating the negative effect of direct exposure to terrorism (e.g. Galea et al., 2005; Gilbar et al., 2011; Neria et al., 2006). However, research has focused mainly on post-traumatic stress disorder (PTSD) (Neria et al., 2010), neglecting additional psychological aspects that might be impaired as well. While PTSD mainly addresses symptoms related directly to the traumatic event (Neria et al., 2006), survivors who were directly exposed to terror attacks are also prone to suffer from changes in their general psychological state, emotions, and distress. Thus, they might demonstrate high levels of anxiety, dissociative experiences, and depression (Weinberg et al., 2015; for review, see Weinberg et al., 2012). These changes can reflect positive psychological affect, such as enthusiasm, pursuit of activity, and pleasurable engagement, or, by contrast, negative psychological affect, such as distress, anger, nervousness, and fear (Watson et al., 1988).

Furthermore, in accordance with the conservation of resources (COR) theory, people seek to obtain, retain, and protect personal and social resources. When these resources are threatened with loss or are lost and individuals fail to regain these resources, stress occurs. This process receives heightened attention. In this manner, resource loss is central to the stress experience. Resource gain, in turn, becomes more salient in the face of resource loss. (Hobfoll, 1989, 1998, 2002). Thus, in view of trauma research which demonstrates the significance of social support (Brewin et al., 2000; Hobfoll et al., 2006; Ozer et al., 2003), the question that arises is whether a type of social support, such as informal or formal support, is associated with trauma survivors’ increased/reduced positive and negative psychological well-being.

Social support has been defined as resources provided by other persons (Cohen and Syme, 1985). It has been seen as information leading one to believe that he or she is cared for and loved, is esteemed, and belongs to a social network of communication and mutual obligation (Cobb, 1976). Social support can be provided by many types of people, both in one’s informal networks such as family, friend, and coworkers, and formal helping networks such as health care professionals and human service workers (Heaney and Israel, 2002). Thus, social support commonly refers to the availability of components of support from interpersonal relationships, including both informal and formal sources of help (Fowler and Hill, 2004). Measures of social support can be structural, such as size or frequency of contact with network members, or functional, such as types of assistance, emotional support, or tangible aid (Cohen et al., 2000). Deleterious effects of life stressors have been found to be suppressed or counteracted through an activation of social support networks (Kaniasty, 2012). Social support has consistently been found to be associated with psychological well-being in times of stress (Norris and Kaniasty, 1996). It is generally considered to be a protective factor for individuals who experienced a disaster (Norris et al., 2002), a terror attack (Hobfoll et al., 2006), or other potentially life-threatening situations (e.g. Norris and Kaniasty, 1996; Shalev et al., 2006). Research indicates that higher levels of social support serve a protective role, and have also been linked to resilience and recovery with respect to traumatic events (Besser and Priel, 2010; Gilbar et al., 2010; King et al., 1999). However, studies that include both informal and formal support in the context of traumatic events are rare (Elhai and Ford, 2009; Michel et al., 2011), while taking place within close proximity to the traumatic event and focusing mainly on the relationship between predisposing variables (such as age, gender, racial background), PTSD, and the use of formal mental health services. Moreover, the relative contribution of both informal and formal social support on psychological well-being among terror survivors remains unknown. To bridge this gap, the present study examined the association between informal and formal social support, and terror attack survivors’ positive as well as negative emotions.

Based on the theoretical conceptualization of social support resources as major components in dealing with traumatic events, and taking into account that traumatic events may affect survivors’ psychological state as reflected in positive and negative affect, the following hypotheses were posited:

H1. Informal social support (family, friends, and significant other) will be associated with terror survivors’ high levels of positive psychological affect and low levels of negative psychological affect.

H2. Formal social support (by public national agencies) will be associated with terror survivors’ high levels of positive psychological affect and low levels of negative psychological affect.

Method

Design and sample

Data were collected from 150 injured survivors of a terror attack, aged 21–70 years, between the years 2001 and 2010, according to the following criteria: recognition by Israel’s National Insurance Institute (NII) as having a disability as a result of exposure to a terror attack, and eligibility for support and assistance by the NII. The participants were drawn from a list of the One Family organization, a registered non-profit organization which provides assistance to survivors of terrorism who were injured from 2001 onward regardless of religion, nationality, gender, or financial situation. Quantitative analysis was used in order to examine the study findings. A total of 201 survivors met the research inclusion criteria. Of them, 150 provided initial consent to participate in the study, and completed the study questionnaires. Of the respondents, 67 (44.7%) were male and 83 (55.3%) female. Mean years of education was 12.6 (standard deviation (SD) = 3.14 years). Time elapsed since the terror act was mean years 5.99 (SD = 2.53 years). No statistical differences in age, years of education, or disability were found between participants who consented to participate in the study and those who did not.

Measures

Psychological well-being was examined using the Positive Affect Negative Affect Scale (PANAS) (Watson et al., 1988), a 20-item measure with a 5-point Likert-type scale (1 = very slightly or not at all, 5 = extremely) in which respondents indicate the extent to which they generally experience emotions (e.g. ‘hostility’). A factor analysis indicates that the measure assesses two global dimensions of affect: negative and positive. A large body of literature supports the psychometric properties of the PANAS (Watson, 2000). A translated questionnaire which demonstrated high internal consistency in previous research was used (Ben-Zur, 2009). In the present study, the Cronbach’s alpha for the positive affect was .83, and .86 for the negative affect.

Informal social support was evaluated using the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988). The MSPSS has been used in several studies in Israel, showing high internal consistency (Gilbar et al., 2010). The questionnaire has three social support subscales: family, friends, and significant other (4 items for each scale) on a 7-point Likert scale (1 = major disagreement with the item, 7 = major agreement with the item). The Cronbach’s alpha internal consistency for social support by family, friends, and significant other was .94, .70, and .93, respectively. The general reliability of the scale (12 items) was .90.

Formal social support (FSS) by public agencies was examined by a questionnaire compiled for this study (FSS) in the absence of extant relevant questionnaires. Survivors were given a list of items on a 7-point Likert Scale (1 = not appropriate, 7 = very appropriate) examining their assistance and satisfaction with social support from the public NII agencies provided by professional trained social workers. Factor analyses with Varimax rotation led to the creation of two subscales. The first (9 items) addressed rehabilitative support, including emotional, financial, and guidance (e.g. ‘My rehabilitation official is empathetic and tries to assist me’; ‘My rights were explained to me’; ‘I am reimbursed for medical expenses’). The second subscale (6 items) addressed support by the National Medical Committee and includes recognition and acknowledgment of physical and psychological disability (e.g. ‘The medical committee is patient and allows me to discuss my disabilities’; ‘I was examined efficiently and with dignity’). The Cronbach’s alpha internal consistency for NII rehabilitation support was .88, and .87 for National Medical Committee support. The general reliability of the scale (15 items) was .90 (Appendix 1). Demographic variables covered gender, age, education, time passed since the attack, and degree of disability.

Procedure

Following approval by the Haifa University Ethics Committee, a letter was sent to the participants explaining the importance of the research and requesting their consent. All participants voluntarily completed the questionnaires. No compensation was offered for participation in the study.

Data analyses

The data analyses and their application to the study hypotheses were undertaken in two stages, corresponding to the aim of the study. In the first stage, SPSS 19 was used to examine the descriptive statistics frequency distributions, means, and SD of the research variables. Pearson product-correlation coefficients were conducted as well to determine correlations between the variables. In the second stage, in order to examine the association between informal social support, formal social support, and psychological well-being, hierarchical regression analyses were conducted measuring positive and negative affect as dependent variables and formal and informal social support as independent variables.

Results

The findings partly reinforce the study hypotheses, pointing to significant correlations between informal social support, formal social support, and survivors’ psychological well-being as reflected with positive and negative emotions. Table 1 demonstrates a positive correlation between informal social support and positive affect (r = .45, p < .01) and a negative correlation between informal social support and negative affect (r = −.37, p < .01). In addition, a positive correlation between positive affect and both rehabilitative support (r = .19, p < .05) and medical committee support (r = .19, p < .05) was found. However, no significant correlation was found between rehabilitative support, medical committee support, and negative affect. With regard to the relationship between informal social support and formal social support, a positive correlation was found between informal social support and both rehabilitative support (r = .23, p < .01) and medical committee support (r = .17, p < .05).

Table 1.

Correlation between informal social support, formal social support, and psychological emotions (positive affect and negative affect) among 150 terror survivors.

	Formal social support		Psychological emotions
	Rehabilitation	Medical committee	Positive affect	Negative affect
Informal social support	.23*	.17*	.45**	−.37**
Rehabilitation		.50*	.19*	−.13
Medical committee			.19*	−.07
Positive affect				−.20*

p < .05; **p < .001.

The second stage examined the associations posited in the research hypotheses using hierarchical regression analyses of the contribution of demographic variables (gender and age), trauma variables (disability severity recognition percentage), formal social support (rehabilitation support and medical committee support), and informal social support in explaining the variance of survivors’ emotions as reflecting positive affect (Table 2) and negative affect (Table 3).

Table 2.

Hierarchal multiple regression of positive affect among 150 terror survivors.

	B	SE·B	β	R²	ΔR²
Step 1				1.2	1.2
Gender	−.05	.15	−.03
Age	.01	.01	.10
Step 2				1.7	.05
Gender	−.01	.16	−.01
Age	.01	.01	.10
Disability percentage	.00	.00	.07
Step 3				4.6	0.3
Gender	−.02	.16	−.01
Age	.01	.01	.08
Disability percentage	−.00	.00	.00
Rehabilitation support	.05	.06	.11
Medical committee support	.06	.06	.11
Step 4				27.2***	22.6
Gender	.06	.14	.04
Age	.01	.01	.15
Disability percentage	−.00	.00	−.05
Rehabilitation support	.01	.05	.02
Medical committee support	.03	.05	.06
Informal social support	.23	.04	.50

SE: standard error.

Regressions of positive affect on gender, age, disability percentage, rehabilitation support, medical committee support, and informal social support.

***

p < .001.

Table 3.

Hierarchal multiple regression of negative affect among 150 terror survivors.

	B	SE·B	β	R²	ΔR²
Step 1				1.3	1.3
Gender	.13	.16	.08
Age	−.01	.01	−.08
Step 2				2.0	.07
Gender	.17	.17	.05
Age	.01	.01	−.07
Disability percentage	.00	.00	−.08
Step 3				3.0	1.0
Gender	.01	.17	.05
Age	−.00	.01	−.06
Disability percentage	−.00	.00	−.05
Rehabilitation support	−.03	.06	−.06
Medical committee support	−.04	.06	−.07
Step 4				16.9***	14.0
Gender	.03	.16	.01
Age	−.01	.01	−.12
Disability percentage	.00	.00	−.01
Rehabilitation support	.00	.06	.01
Medical committee support	−.02	.06	−.03
Informal social support	−.19	.04	−.40

SE: standard error.

Regressions of negative affect on gender, age, disability percentage, rehabilitation support, medical committee support, and informal social support.

***

p < .001.

Table 2 shows that the explained variance for positive affect in Step 1 is R² = 1.2, p > .05; in Step 2, R² = 1.7, p > .05; in Step 3, R² = 4.6, p > .05; and in Step 4, R² = 27.2, p < .001. Table 3 shows that the explained variance for negative affect in Step 1 is R² = 1.3, p > .05; in Step 2, R² = 2.0, p > .05; in Step 3, R² = 3.0, p > .05; and in Step 4, R² = 16.9, p < .001. Thus, supporting the first hypothesis, only informal social support, entered in Step 4, significantly contributes to the explained variance of the terror survivors’ emotions as reflecting positive and negative affect. In contrast to the second hypothesis, however, informal social support did not demonstrate a significant association with either positive or negative affect.

Summary and discussion

The main aim of the study was to examine the association between social support (informal and formal) and the psychological well-being of injured terror survivors, as reflected in both positive and negative emotions. As anticipated, a positive association was found between informal social support (family, friends, and significant other) and positive affect, and a negative association was found between informal social support and negative affect. These findings support previous research, demonstrating the importance of social support when dealing with traumatic events (Besser and Priel, 2010; Hobfoll et al., 2006; Ozer et al., 2003) and are consistent with COR theory (Hobfoll, 1989, 1998, 2002) which posits that resource loss and resource lack are key predictors when dealing with traumatic events.

In examining formal social support, the study failed to demonstrate a significant association between formal social support and positive or negative affect. This discrepancy intensifies when taking to consideration that the rehabilitation formal social support is provided by trained social workers in the government agencies. Furthermore, while taking into account the uniqueness of the Israeli social support system which requires the survivor to interact within the formal social support agencies in order to receive emotional and financial assistance, this discrepancy intensifies. A possible explanation can be found in the interaction between formal social support and time elapsed from the traumatic event. While formal social support commonly impacts trauma survivors soon after the occurrence of the traumatic event (Michel et al., 2011), as time goes by, its impact may lessen.

In addition, formal social support is commonly provided during the period of time when the survivor’s physical and mental disability has not been established; however, after it is determined, the support offered by formal agencies often declines. Obversely, the support agencies tended to reduce their support, and these circumstances might have caused the survivors to feel that formal agencies cannot or do not want to assist them in their recovery. Moreover, it is also possible that the unique social and political climate in Israel may affect the support perceived by the survivor and capacity and the ability of the professional agencies to provide such support. Increased terror attacks over the past years due to the outbreak of the Second Intifada (Israeli Security Agency, 2014) affects the financial benefits available for survivors, increase in referrals, tension survivors and workers come with, and the demanding nature of the specialized work with terror survivors. Thus, the formal social support which may have impacted survivors in the past diminished in time and failed to demonstrate an association with the survivors’ positive or negative emotions.

Together, the findings have clinical and practical policy implications which constitute a tangible contribution to the therapy and treatment of trauma survivors. It suggests that formal public social support agencies should be proactive with trauma survivors for more varying lengths of time following the traumatic event. Additionally, it reinforces the importance that should be attributed to informal social support as an external resource when dealing with trauma survivors. Furthermore, even after survivors are entitled to medical disability, social workers in the formal social support agencies should maintain a support relationship since emotional assistance might be required even after medical disability is evaluated and determined. Moreover, in devising a therapeutic framework, it is important to address, encourage, and reinforce both informal and formal social support as valuable resources.

Notably, in the context of trauma survivors, extant research has mainly focused on the negative aspects of emotions, disregarding the positive aspects. The present study, however, reveals the significance of informal social support not only as associated with reduced negative psychological affect but also as an important resource that is associated with increased positive psychological affect.

Finally, the study findings demonstrated distinctive associations between formal social support, informal social support, and positive and negative affect. This distinction might reinforce the concept that positive and negative affect are not necessarily apposite dimensions, but rather reflect two distinctive dimensions that can be viewed as orthogonal (Watson et al., 1988) and thus function as complementary aspects.

Limitations and implications

Despite the findings, several limitations should be noted. Given its cross-sectional nature, a causal relationship cannot be unequivocally established, making it difficult to determine whether survivor distress leads to the use of a particular type of informal or formal social support at some point after trauma exposure, and whether distress and social support influence emotions, or vice versa. Furthermore, the study sample was drawn from the ‘One Family’ organization, which is the largest organization in Israel that provides support for terror survivors, regardless of religion, ethnicity, or socio-economic status. However, despite efforts to reach all survivors, and although the organization reflects a large diversity of terror survivors and their families, contact with the organization is voluntary. Finally, the relatively small size of the sample could limit generalizing the findings to a broader population.

Despite these limitations, the present study is the first and largest attempt to examine informal and formal social support as two distinguished units of support among injured trauma survivors’ psychological well-being. It illuminates the importance that should be attributed to these support systems even years after the trauma took place.

Future investigations involving assessment at two time points are recommended in order to broaden the understanding of social support and its effect. In examining terror survivors, research is also warranted to further investigate the influence of both informal and formal social support close to the time of the traumatic event, in contrast to years later. In addition, studies involving survivors of traumatic events should further examine additional aspects of their psychological well-being and the influence of internal factors and personality traits as well.

Footnotes

Appendix 1 Acknowledgements

Grateful thanks are extended to all of the participants in this study and to the One Family organization.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biography

Michael Weinberg is a social worker and lawyer, head of trauma studies at the School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel. His research focus is coping and posttraumatic stress.

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