The effects of coping strategies on PTSD in victims of a terror attack and their spouses

Abstract

Objectives: The study examined the effect of victims’ and spouses’ coping strategies on PTSD in victim-spouse dyads, using the Actor-Partner Interdependence Model (APIM).Method: A total of 72 dyads consisting of injured victims who were exposed to terror attacks, and their spouses who were not injured, participated in the study based on lists prepared by the “One Family” organization in Israel. PTSD symptoms were assessed using PSS-SR, and coping strategies (emotion-focused and problem-focused) were assessed by means of the COPE measure.Results: The APIM model showed that spouse’s emotion-focused coping impacted victim’s and spouse’s PTSD, and victim’s gender impacted spouse’s PTSD.Conclusions: Spousal emotion-focused coping is a significant factor in both victims’ and spouses’ PTSD, while problem-focused coping is not.

Keywords

coping dyad PTSD spouses victim

Knowledge about trauma caused by a terrorist attack has increased in recent decades. Much of the literature on victims of a terror attack assesses post-traumatic stress disorder, focusing on the effects of trauma on victims who were directly exposed to a traumatic event (Gil & Caspi, 2006; Nemeroff et al., 2006). Yet, although spouses are known to be affected by the victims’ reactions to the event (Figley, 1983, 1995), few studies examined the association between PTSD of injured victims of a terror attack and their spouses, who in most cases function as the primary caregiver. Spouses may develop post-traumatic symptoms themselves, and are defined as victims of secondary traumatization (Galovski & Lyons, 2004; Nelson-Goff & Smith, 2005). Several researchers and clinicians emphasize the importance of assessing the response to extreme stress in terms of PTSD, especially after one year. Victims and their spouses may continue to suffer from symptoms of PTSD even if they have not been diagnosed with PTSD (Luxenberg, Spinazzola & van der Kolk, 2001; van der Kolk & Pelcovitz, 1999).

No research, however, has focused on the effects of coping strategies on PTSD in both injured victims of a terror attack and their spouses, even though the effects of terror attacks on victims are known to be traumatic for each family member and in turn may affect the victim’s return to normal life. The study aims, therefore, to examine the impact of problem-focused and emotion-focused coping strategies on PTSD in victims of a terror attack and their spouses using the Actor-Partner Interdependence Model (APIM) (Kenny, Kashy & Cook, 2006).

Literature review

PTSD and coping with trauma among victims and spouses

Terrorism intends to induce fear, diminish a sense of safety and heighten anxiety (Neria, Gross & Marshall, 2006; Susser, Herman & Aaron, 2002). Modern terrorism is designed to wreak maximum destruction as an end in itself, going far beyond the symbolic value of the act and turning terrorism into a veritable war of annihilation (Miller, 2006). The aftermath of terrorist attacks may involve substantial psychological morbidity (Galea, Nandi & Vlahov, 2005; Galea et al., 2002) – a condition resulting from exposure to a life-threatening event that is processed in such a way as to produce a sense of current threat (Ehlers & Clark, 2000). This leads to the experience of symptoms which generally fall into three clusters and define PTSD: re-experiencing symptoms, avoidance symptoms, and hyper-arousal symptoms (DSM-IV-TR) (American Psychiatric Association, 2000). These symptoms are caused by the threat to life and personal security, and the severe consequences that are generally experienced, namely intense fear and helplessness (Zeidner, 2007).

The literature about post-trauma symptoms mainly focuses on a series of factors which may affect the level of PTSD symptoms (e.g. North, Spilznagel & Smith, 2001; Ozer, Berst, Lipsey & Weiss, 2008; Rubin, Bernstein & Bohni, 2008; Schlenger et al., 2008). One important factor is the impact of victim gender on his/her PTSD and on spousal PTSD, namely: men and women respond differently to a traumatic event (Kimerling, Ouimette & Weitlauf, 2007). In particular, gender differences consistently emerge in the development of post-traumatic stress disorder (PTSD). Women have been found to develop PTSD at higher rates than their male counterparts, and PTSD also tends to be more likely to develop into a chronic condition in women than in men (Delisi et al., 2003; Galovski & Lyons, 2004; Haden, Scarpa, Jones & Ollendick, 2007; Kessler, 2000; Stein, Walker & Forde, 2000; Tolin & Foa, 2008). Differences have also been shown in the use of coping strategies by men and women to manage trauma-related distress, which, it has been suggested, contribute to different clinical profiles of PTSD (Blain, Galovski, & Robinson, 2010). The significance of the PTSD symptomatology is that the victim does not operate in a vacuum; his/her behavior, thinking and feelings directly impact those around him/her (Galovski & Lyons, 2004; Dekel & Monson, 2010).

Research on spouses of victims who were exposed to trauma emphasize that individuals living in close proximity to victims of violent trauma are also in a stressful situation and can themselves become indirect victims of that trauma (Figley, 1983). Traumatic stress endured by one family member may indirectly affect the entire family system. If the victim has a spouse, the spouse may develop secondary traumatization symptoms – an area that has gained increasing attention (e.g., Galovski & Lyons, 2004). Frequently, victims are inclined to talk at length about the event or about their feelings, making it more difficult for the spouse to cope with the implications of the event him/herself and be supportive of the victim at the same time (Bramsen, van der Ploeg, Henk & Twisk, 2002). Moreover, the victim may be unable to carry on with the role of partner and/or parent, and a major part of the responsibility for home and family life thus shifts to the spouse. A systematic review of secondary traumatization symptoms of spouses (Galovski & Lyons, 2004) demonstrates how PTSD and psychological symptoms of the victim can impact family members (see also Mikulincer, Florian & Solomon, 1995; Solomon et al. 1992; Waysman, Mikulincer, Solomon & Weisenberg, 1993).

How individuals who are directly or indirectly exposed to traumatic events adjust to the alteration in their lives caused by these extremely stressful experiences is likely to depend on their coping strategies. Coping strategies, which represent behavioral and cognitive efforts to deal with stressful encounters, have been classified according to outcome by their functional or adaptive value, with their effectiveness assessed in terms of the elimination of stressors and distress as well as preservation of social functioning and sense of well-being (Scheier, Carver & Bridges, 1994; Carver, Scheier & Weintraub, 1989; Lazarus, 1991, 1999; Zeidner & Saklofske, 1996; Terry, 1994). Some research has shown problem-focused (PF) coping to be more effective than emotion-focused (EF) coping in terms of neutralizing negative emotional reactions and improving performance levels (see Elwood, Kathryn, Olatunji & Williams, 2009; Folkman & Moskowitz, 2000, review; Zeidner & Ben-Zur, 1994). An illustrative study by Kanninen, Puinamkai and Qouta (2002) shows that the acuteness of the trauma was found to be important in association with appraisal and coping efforts, which, in turn, were related to post-traumatic symptoms among Palestinian former political prisoners. Prisoners who were recently released from prison were more likely to appraise their experience as harmful and involving a loss. This kind of appraisal was further associated with both emotion-focused and problem-focused coping efforts: emotion-focused coping was associated with a low level of PTSD symptoms in the long run, while problem-focused coping was associated with a low level of PTSD symptoms in the short run.

During stressful encounters, people draw on a variety of resources (external and internal) to aid them in the coping and adaptive process, such as finances, social support, intelligence and personality disposition (Lazarus & Folkman, 1984). Social support – especially the family – is considered a primary resource for coping with stress (Cohen & Lazarus, 1979). The importance of spouses as the main social support is also emphasized in coping with other types of trauma, especially chronic and terminal illness such as cancer, diabetes and arthritis (Ben-Zur, Gilbar & Lev, 2001; Yorgason et al., 2010).

Dyad coping with trauma

One of the main dyadic coping models, developed by Nelson-Goff and Smith (2005), provides a systematic description of couple adaption to traumatic stress based on research of couples exposed to trauma in World War II. It suggests that the level of adaption of one spouse affected that of the other, namely the level of PTSD in one spouse predicted that of the other, a finding supporting Bramsen, van der Ploeg and Twisk (2002). The model proposes that adaption to traumatic stress by the couple is dependent on the systematic interaction of three factors: individual level of coping of each of the partners, predisposing factors; and resources. The model assumes that the victim’s level of trauma symptoms or functioning sets in motion a systematic response with the potential to result in secondary traumatic stress symptoms in the partner (Dekel & Monson, 2010). However, because the model is bi-directional, the partner’s symptoms may intensify trauma-related symptoms in the victim, since individual and couple functioning are determined by predisposing factors and resources which refer to individual characteristics or unresolved stress experienced by either partner prior to the trauma.

Several extant studies have dealt with dyad PTSD, psychological distress, coping processes and marital adjustment among couples where the husband was a soldier in wartime (Dekel, 2007; Dekel, Enoch & Solomon, 2008; Goff, Crow, Reisbig & Hamilton, 2007; Renshaw, Rodrigues & Jones, 2008), and when couples deal with chronic illness such as cancer (Banthia, et al., 2003; Ben-Zur et al., 2001). These studies found that marital strain often occurs when patients and spouses have different views of how best to cope with the illness. For example, dyadic dysfunction, marked by a spouse’s criticism or withdrawal, may promote ineffective coping strategies such as cognitive and behavior avoidance (Manne, 1999).

No research, however, has used a dyadic model of injured victims of a terror attack and their spouses in relation to PTSD and coping strategies, nor explored the possibility of a pattern of association between the victim and his/her coping strategies, and between these strategies and the victim’s PTSD, although the examination of the impact of coping strategies on PTSD should logically involve the dyad as the unit of analysis. Moreover, no study has assessed whether the victim’s gender impacts his/her PTSD and that of the spouse based on the Actor-Partner Interdependence Model (APIM) – a paired regression technique which investigates the dyadic relationship (Kenny et al., 2006). In the present research, each group – victims and spouses – consists of both women and men, a factor which might impact PTSD differently.

Research aims and hypotheses

The goals of the study were to (1) investigate whether there are differences in level of PTSD and coping strategies between victims of a terror attack and their spouses, as well as any association between victims and spouses in terms of PTSD and coping strategies (EF and PF); (2) examine whether victims’ and spouses’ coping strategies (EF and PF) predicted spousal PTSD as well as victims’ PTSD; and (3) assess whether victim’s gender has an effect on spouse’s PTSD.

Based on the couple adaptation to trauma model (Nelson-Goff & Smith, 2005); research on PTSD of victims and spouses (Tolin & Foa, 2008); and the review by Blain, Galovski & Robinson (2010), the hypotheses posited were:

An association exists between victims and spouses in the context of PTSD, namely a high level of victim PTSD correlates with a high level of spousal PTSD, and the reverse.

Spouses’ EF coping strategies impact both their high level of PTSD and the high level of the victims’ PTSD, while spouses’ PF coping strategies impact both their and the victims’ low level of PTSD.

Victims’ gender impacts both their level of PTSD and their spouses’ PTSD, namely when the victims are female, the male partner’s PTSD is lower, but when the victims are male, the female partner’s PTSD is higher.

Method

Design and sample

The sample for this study was randomly selected from lists of victims prepared by the “One Family” organization in Israel – a registered non-profit body aiding families who were exposed to a terror attack irrespective of race, religion or nationality. Of a list of 680 injured victims exposed to such an attack between the years 2001 and 2008, 300 were married to spouses who were not directly exposed to the event. Of these, 152 couples were found to be appropriate according to the research criteria (namely, Arab citizens and new immigrants were excluded because of a language barrier), and 126 couples agreed to complete the questionnaires. Ultimately, only 72 couples completed the measures (54 reneged because of lack of time or reluctance to face questions about the event). The research sample consisted, therefore, of 72 married couples, ages 21–69, in which the victim was recognized by Israel’s National Insurance Institute as having a disability of 10% or more as a result of exposure to a terror attack (the disability percentage determines the extent of the victim’s medical and instrumental rights). Forty-seven (65.35%) of the victims were female. The mean age of the victims and spouses was 45.01 (SD = 11.5) and 43.72 (SD = 10.82), respectively. Mean years of education of the victims and spouses was 12.83 (SD = 2.67) and 12.94 (SD=2.39), respectively. Sixteen (22.22%) of the victims and 15 (20.83%) of the spouses had experienced a traumatic event previously. The mean time that elapsed between the event and the completion of the questionnaire interview was 43 months (SD = 19.62). Information gathered in a t-test of victims who consented to take part in the study and those who did not, based on their demographic files, showed no statistical differences in terms of age and years of education.

Questionnaires

The first two instruments had been translated from English to Hebrew for use in previous studies carried out by two of the authors with colleagues (Ben-Zur et al., 2001; Gil, 2005; Gilbar & Ben-Zur, 2002). The translations had then been converted back into English by three translators working independently of each other, the resulting versions were compared with the original instruments, and adjustments were made in the Hebrew format accordingly. Internal consistency (Cronbach’s alpha) of the Hebrew format was derived for each scale.

1. PTSD Symptom Scale – Self Report (PSS-SR) (Foa, Riggs, Dancu & Rothbaum, 1993). The PSS-SR is a 17-item self-report questionnaire aimed at assessing the level of post-traumatic stress symptoms over the preceding two weeks. Each item corresponds to one of the 17 DSM-III-R diagnostic criteria for PTSD. The severity of each item is rated on a four-point Likert scale ranging from 0 (not at all) to 3 (very much). The total severity score is calculated as the mean of the respondents’ ratings on the 17 items. The scale consists of three clusters: re-experiencing symptoms characterized by intrusive memories, nightmares and psychological and physiological reactivity; avoidance symptoms consisting of avoiding thoughts and activities associated with traumatic experiences; and hyperarousal symptoms including sleep disturbance, irritability and anger. The PSS-SR was found by its originators (Foa et al., 1993) to be internally consistent and highly correlated with widely used instruments assessing specific reactions to trauma, such as the Impact of Event Scale (IES) (Horowitz, Wilner & Alvarez, 1979). The Cronbach alpha was found to be .93 for victims and .90 for spouses.

2. Coping strategies were measured by a short 30-item Hebrew version of the COPE scale (Carver et al., 1989). The items depict various coping options in everyday life (e.g., “I make a plan of action; I learn to live with it”). Respondents were asked to rate the extent to which each option was used on a four-point scale (0 = not at all, 3 = great extent; the scale was transformed so that the range was 1–4). The scale includes 15 strategies, each represented by a two-item subscale as translated from the original scale (range 2–8). The subscales are active coping, planning, seeking instrumental social support, seeking emotional social support, suppression of competing activities, turning to religion, positive reinterpretation and growth, restraint coping, acceptance, focus on and ventilation of emotion, denial, mental disengagement, behavioral disengagement, alcohol/drug disengagement, and humor. Factor analyses with Varimax rotation led to the creation of two scales which were similar to those used by Ben-Zur & Zeidner (1995) but dissimilar to those used by Carver et al. (1989), conceivably due to cultural differences. The scales were (a) a problem-focused (PF) scale consisting of active coping, planning, suppression of competing activity, seeking instrumental support, seeking emotional support, positive reinterpretation and growth, and mental disengagement (alpha = .73 for victims, .78 for spouses); and (b) an emotion-focused (EF) scale consisting of ventilation, acceptance, behavior disengagement, alcohol/drug disengagement, restraint, and turning to religion (alpha = .71 for victims, .74 for spouses). The denial and humor subscales had a low loading and were therefore not included.

3. Demographic characteristics and past trauma history. A demographic questionnaire covered gender, age, education, place of birth, employment and questions about past trauma.

Procedure

A letter was sent by a researcher to the victims and their spouses explaining the importance of the research and requesting their consent to be interviewed. The questionnaire and an informed consent form were then sent to respondents who agreed to participate in the research. The respondents were asked to complete the questionnaire on their own and return the completed questionnaire to the researcher.

Data analyses

The data analyses corresponded to the three aims underlying the study. Descriptive statistics such as frequency distributions, means and SD were obtained to summarize demographic and clinical characteristics, PTSD and coping strategies. Comparisons of victims’ and spouses’ demographic characteristics were made using a paired-sample t test and an χ² test. Paired-sample t tests were used to determine differences in coping strategies (PF and EF) and PTSD between victims and spouses, and Pearson product moment correlation coefficients were used to determine correlations between these continuous variables.

In order to examine the impact of the victim’s and spouse’s coping strategies (EF and PF) on their levels of PTSD, as well as the impact of each coping strategy on the spouse’s PTSD levels, an APIM (Actor-Partner Interdependence Model) was followed using an AMOS 17 software program (Arbuckle, 2000) applied to a nested model design. The APIM uses the dyadic interaction as the unit of analysis (Kenny et al., 2006). In this type of model, each partner’s independent variables are viewed as impacting the dependent variables of both partners. Furthermore, the assumption is that since the partners interact constantly, their dependent variables may impact each other.

Results

Coping strategies and PTSD in victim-spousal dyads

Significant differences were found between victims’ and spouses’ PTSD symptoms and EF strategies. The level of PTSD was higher among victims than spouses (mean = 1.52, SD = .87; .88, .65, respectively; t-test 5.80, p = .001). EF coping strategies were higher among victims than spouses (mean = 1.55, SD = .63; 1.07, 59, respectively; t-test = 6.21, p = .001). PF strategies were also higher among victims than spouses (mean = 1.85, SD = .51; 1.76, SD = .54, respectively; t-test = 1.03, p = NS). Table 1 indicates an association between victims’ and spouses’ PTSD and between victims’ PTSD and EF and spouses’ EF. Namely, the more the victim and spouse use EF, the higher the victim’s PTSD symptoms. The more the victim uses PF, the lower the spouses’ PTSD symptoms. The more the victim uses EF, the higher the usage of EF and PF among spouses. The more the spouse uses EF, the higher his/her use of PF, while the higher the spouse’s use of EF and PF, the higher his/her PTSD symptoms. Lastly, when the victim is male, the female partner’s PTSD is higher and she tends to use PF less.

Table 1.

Correlation between victims’ PTSD and coping strategies (PF and EF); spouses’ PTSD and coping strategies (PF and EF); and victims’ gender

	PTSD	PTSD	PF	EF	PF	EF	Gender
	Victims	Spouses	Victims	Victims	Spouses	Spouses	Victims
PTSD Victims	--
PTSD Spouses	.34^**	--
PF Victims	−.05	−.24^*	--
EF Victims	.52^**	.20	.12	--
PF Spouses	.18	.25^**	.03	.31^**
EF Spouses	.35^**	.38^**	−.06	.50^**	.35^*	--
Gender Victims¹	.00	−.38^**	−.24^*	.14	−.28^*	−.19	--

*p < .01

**p < .001

¹ Spearman correlation

Impact of coping strategies on PTSD

Two-stage procedures were conducted in order to examine the APIM. In the first stage, a path analysis showing the effect of all independent variables of each partner (victim PF and EF; spouse PF and EF) on both partners’ PTSD was estimated (see Figure 1). In the second stage, insignificant paths were fixed at zero, allowing an estimation of the model fit with the data. Thus, the second model is nested within the first one (see Figure 2). The second model showed a good fit measure, with an insignificant chi-square (χ² [df = 1] 1.37, p = .241), indicating its fit with the data. Notably, spouses’ EF had an impact on both their own PTSD and the victims’ PTSD (β = .27, p = .001; β = .25, p = .01, respectively). The model also revealed that victim’s gender had an impact on spouse’s PTSD (β = -.31, p = .00), indicating that when the victim is female, the male partner’s PTSD is lower in comparison to the reverse case. Lastly, both partners’ PTSD levels were positively correlated (r = .34, p< .001).

Figure 1

The Actor-Partner Interdependence Model, including victims’ gender, victims’ PF and EF, spouses’ PF and EF, and victims’ and spouses’ PTSD

Figure 2

The Actor-Partner Interdependence Model (nested), including victims’ gender, EF spouses, and victims’ and spouses’ PTSD as predicted variables

Summary and discussion

The study focused on the psychological distress of 72 injured victims of a terror attack and their spouses, testing the differences and associations between the victims’ and their spouses’ PTSD and coping strategies (EF and PF). The study also dealt with the question of which variables (EF, PF) predicted a high level of victim PTSD, and whether gender also predicted this outcome.

As expected, a comparison of levels of PTSD distress showed that victims reported more PTSD symptoms than their spouses. This concurs with the premise that symptoms of secondary traumatization resulting from an indirect exposure to a trauma are lower in intensity (Figley, 1995). Spouses, who are generally the primary caregivers, are exposed to details of the victims’ traumatic experience, alongside bearing the burden of caring for the trauma victim and for the family – a burden exacerbated by the decline in the victim’s familial functioning and concern for their spouse’s emotional and physical state. This supports previous studies of spouses of combat veterans (Arzi, Solomon & Dekel, 2000; Mikulincer et al., 1995) showing higher levels of somatization, depression, anxiety, loneliness, hostility, and impaired marital, family and social relations among the veterans’ wives, in comparison to wives of healthy husbands. Obviously, an explanation of the differences in intensity of symptoms between victims and spouses can be attributed to the direct exposure of the victims to the event, in contrast to the spouses’ indirect exposure to the terror attack. Moreover, the victims must also cope with the implications of physical injury such as pain, disability and fatigue. In addition, the victims’ expression of distress is more accepted and more legitimated than that of their spouses.

An association found between victims’ and spouses’ levels of PTSD supports Hypothesis 1 – relying on a premise put forward by Nelson-Goff and Smith (2005) – namely the distress level of one spouse is impacted by the other. Similar results were observed regarding spouses of cancer patients (Ben-Zur et al., 2001; Hoskins, 1995) and spouses of patients suffering from various psychopathological states, for instance alcohol abuse (Dawson, Grant, Chou & Stinson, 2007), showing an association between patients and their spouses’ level of PTSD. Spouses who identify strongly with their partner’s traumatic experience may consequently internalize pathological symptoms and project them as their own (Dekel et al., 2008; Goff et al., 2007; Renshaw et al., 2008).

The picture of PTSD and coping strategies (PF and EF) by victims and spouses which emerges from Lazarus’s stress model (1999) and Nelson-Goff and Smith’s couple adaptation to stress model (2005) confirms the first part of Hypothesis 2, showing that spouses’ EF coping impacted the level of victims’ PTSD but their PF coping did not have this impact (Figure 2). Spouses’ EF strategy showed a high level of both their own and the victims’ PTSD, indicating that spouses deal emotionally with a threatening situation while living under great stress. Significantly, previous findings (Gil, 2005; Kanninen et al., 2002) have indicated that an emotion-focused strategy is less effective in dealing with acute stress, but is more effective in the long run (the mean time that elapsed between the event and the completion of the questionnaire was 43 months). This finding was partially confirmed by results showing that the victims’ use of an EF coping strategy was detrimental to PTSD, a pattern revealed in studies of patients’ distress in a situation of chronic illness such as cancer (Epping-Jordan et al., 1999; Osowiecki & Compas, 1999), but differing in part with Kanninen et al. (2002), who indicated that the use of both EF and PF coping efforts was associated with a high level of PTSD.

The dyad model (APIM) (Figure 2 nested model) showed that spouses’ EF had an impact on both their own PTSD and the victims’ PTSD. Furthermore, the model also revealed that victims’ gender had an impact on spouses’ PTSD, indicating that when the victim is male, the female partner’s PTSD is higher, in comparison to the reverse case. This concurs with the greater female tendency for empathy and for identification with others’ distress. Lastly, both partners’ PTSD levels were positively correlated. Thus, Hypothesis 3, relating to the impact of victims’ gender, was confirmed. This adds a new perspective to the pattern of relationships between PTSD and coping strategies. A possible explanation, using the dyad model analysis, is that the victim’s PTSD is greater when one spouse tries to deny the situation while the other does not, or when one spouse tries to vent emotions related to the situation and the other does not, which may be related to gender differences in coping with stress (Kimerling, Ouimette & Wolf, 2002; Galovski & Lyons, 2004; Tolin & Foa, 2008), although previous studies do not deal specifically with the impact of victims’ gender on spouses’ PTSD. When the sample consists of both genders, however, the impact of gender must be taken into account.

All the results concur with cognitive theories of stress and coping (e.g., Lazarus, 1999; Lazarus & Folkman, 1984), suggesting that emotion-focused coping strategies such as ventilation, acceptance and behavioral disengagement constitute the behavioral/cognitive variant of coping that is anticipated when a situation is uncontrollable. The findings of the study demonstrate a high use of emotion-focused coping strategies by the victims. The findings also concur with the dyadic adaptation to trauma model (Nelson-Goff & Smith, 2005), namely, the association between victims’ and spouses’ PTSD. In contrast to traditional therapeutic approaches (e.g., psychodynamic therapy, supportive therapy), which address emotional processes, the findings of this study suggest the need for programs that train and counsel couples in developing skills for reducing the differing levels of distress in victims and spouses. The primary objective of such programs is prevention and ongoing improved functioning, achieved by focusing on cognitive-behavioral techniques which can decrease the level of distress in both victims and spouses.

In sum, the study shows that EF coping by injured victims or their spouses, or both, with the aftermath of a terror attack long after the event (mean = 43 months, SD = 19.62) is positively related to PTSD, namely victims and spouses who use emotion-focused strategies are in greater distress. Nevertheless, the fact that the research was conducted at a single point in time limits the conclusions that can be drawn, as changes in distress and in the coping process over time could not be assessed. The cause-and-effect relationship suggested by the Actor-Partner Interdependence Model, therefore, is only one of several possibilities. Notably, the data were treated in the context of a cognitive paradigm which views distress as an outcome of the coping process. Conceivably, however, the reverse process may occur: a high level of distress might lead to the use of emotion-focused coping strategies and prevent the efficient use of problem-focused coping strategies by both spouses. Similarly, the victim’s PTSD may be seen as dependent on spousal PTSD and coping, as highlighted in the present analysis, but, by the same token, spousal PTSD may be seen as dependent on the victim’s distress and coping.

Limitations

Given the cross-sectional nature of the study, it is difficult to determine whether distress leads to a certain type of coping strategy at some point after trauma exposure, and whether the distress or coping strategy of the injured victim who was exposed to trauma influences the distress or coping strategy of the spouse or vice versa. Furthermore, the small size of the sample could limit generalizing the findings to a broader population. Additionally, reports of pre-morbid dyad psychological distress were unavailable, and this variable may have influenced distress rates resulting from physical injuries. Lastly, personal coping resource variables such as locus of control, self-efficacy and optimism, which may affect PTSD, as posited in Lazarus’ coping-with-stress model, were not examined. Hence, caution must be shown in interpreting the findings and drawing conclusions. Future investigations with larger samples may also benefit by the use of structural equation modeling to test causal path models.

Future directions

Several points merit further research. Studies focusing on sources of informal social support for victims and spouses, such as parents, children, siblings and friends, as well as formal social support from medical staff, social workers and psychologists, and their impact on psychological distress, would be valuable. Furthermore, studies involving victims and spouses from more diverse ethnic groups may reveal that differing marital traditions, coping habits, family structures and beliefs impact psychological distress differently.

Footnotes

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

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