Marital satisfaction and trauma-related symptoms among injured survivors of terror attacks and their spouses

Abstract

This study examined the relationships between marital satisfaction and trauma-related symptoms (i.e., post-traumatic stress disorder, depression, and anxiety) among 105 couples of injured survivors of terror attacks and their spouses (N = 210). Structural equation modeling and the actor–partner interdependence model were used to test the interdependence relationship between survivors’ and spouses’ marital satisfaction and trauma-related symptoms. The results demonstrated that the level of marital satisfaction reported by unexposed spouses was negatively associated with their own trauma-related symptoms as well as with the symptoms reported by the survivors. In contrast, the level of marital satisfaction reported by the survivors was negatively associated with their own trauma-related symptoms but had no connection with trauma-related symptoms reported by their spouses. Taken together, our findings shed new light on the potential links between marital satisfaction and trauma-related symptoms for survivors of terrorism and their spouses. Theoretical and clinical implications of these findings are also discussed.

Keywords

APIM marital satisfaction spouse survivor trauma traumatic symptoms

Terrorist attacks aimed at civilian populations may expose unarmed individuals to extreme danger. Research has shown that globally, 15% of people fear terrorism as a threat to their personal security (Williamson, 2016). Previous studies have suggested long-lasting, broad effects of exposure to terrorist attacks on multiple domains within the family, including family cohesion, parenting satisfaction, relationships with spouses, spouses coping strategies, self-identity of the spouses, as well as functioning and emotional security of the children (Galovski & Lyons, 2004; King, King, Vogt, Knight, & Samper, 2006; Weinberg, 2011). Such effects are consistent with the previous research suggesting that stressful life events are often associated with poorer marital quality and satisfaction (Williams, 1995).

Furthermore, spouses are often the primary source of support for survivors of traumatic violence, which puts them at increased risk for psychological and marital distress (Renshaw, Rodebaughc, & Rodriguesb, 2010; Weinberg, 2013). With the ongoing expansion of research concerning the consequences of exposure to violence, researchers have begun focusing attention on the role that romantic partners play in the development and prolongation of post-traumatic stress disorder (PTSD; e.g., Campbell & Renshaw, 2013). Mills and Turnbull (2004) suggest that trauma survivors experience an array of neurobiological changes that may result in an impaired capacity for psychological intimacy. Further, Dekel and Solomon (2006) found that traumatized veterans exhibited emotional numbing, withdrawal from their spouses, and outbursts of aggressive behavior. These behaviors may have initiated a vicious cycle that included feelings of estrangement and loneliness by the veterans and apprehension, rejection, and anger on the part of their spouses. Consistent with these findings, a recent meta-analysis concluded that PTSD severity was positively associated with the measures of relationship conflict across 31 studies, with observed correlations for these studies typically in the range of .32 to .36 (Taft, Watkins, Stafford, Street, & Monson, 2011).

However, to date, little attention has been given to the impact of traumatic events on unexposed spouses while taking into account survivor–spouse relationships (e.g., Besser, Weinberg, Zeigler-Hill, Ataria, & Neria, 2015; Weinberg, Besser, Ataria, & Neria, 2016). Research has shown that the survivor–spouse relationship is bidirectional. Therefore, the unexposed spouses are not only affected by the survivor’s PTSD but they may also affect the survivor’s PTSD symptoms (Nelson-Goff & Smith, 2005). Thus, the survivor’s trauma symptoms may set a systematic response into motion which may have implications for the psychological adjustment of the unexposed partner (e.g., secondary traumatic stress symptoms; Dekel & Monson, 2010; Nelson-Goff & Smith, 2005). The survivor–spouse interdependent nature of this relationship suggests that the partner’s symptoms may also affect the trauma-related symptoms experienced by the survivor. Previous research has demonstrated this relationship related to the PTSD symptoms of survivors and their spouses, including coping mechanisms and attachment styles (Ein-Dor, Doron, Solomon, Mikulincer, & Shaver, 2010; Gilbar, Weinberg, & Gil, 2011; Henry et al., 2011; Nelson-Goff & Smith, 2005; Weinberg, 2013). However, PTSD was often the only psychological consequence that was examined in most of these studies, with relatively little attention being given to other symptoms of psychological distress among terror survivors and their spouses (for exceptions, see Besser et al., 2015; Marini, Wadsworth, Christ, & Franks, 2015; Monk & Nelson-Goff, 2014).

Moreover, despite increased knowledge about interdependence relationships between trauma survivors and their spouses, few studies have examined the survivor–spouse relationship between marital satisfaction with trauma-related symptoms among trauma survivors and their spouses, while even fewer studies have examined the wide array of traumatic symptoms in addition to PTSD. Hence, the goal of this study is to extend the knowledge about the links between levels of marital satisfaction and their association with trauma-related symptoms in addition to PTSD (i.e., anxiety and depression) experienced by survivors of terror attacks and their spouses in the context of the interdependence relationship. Previous research suggesting that although PTSD is the most commonly examined outcome of trauma, it is not the only negative consequence of trauma. In fact, research has consistently demonstrated that trauma exposure has broad implications for a range of outcomes, including anxiety and depression (e.g., Besser et al., 2015; Besser, Weinberg, Zeigler-Hill, & Neria, 2014; Besser, Zeigler-Hill, Pincus, & Neria, 2013; Bond et al., 2016; Ginzburg, Ein-Dor, & Solomon, 2010; Weinberg, Besser, Zeigler-Hill, & Neria, 2015).

Yet, the association that marital satisfaction has with a range of trauma-related symptoms previously reported (Ghafoori et al., 2009; Helpman, Besser, & Neria, 2015; Neria, Besser, Kipper, & Westphal, 2010) in the aftermath of terrorism (i.e., PTSD, depression, and anxiety symptoms) has not been directly examined as associated with both the survivor and the spouse. The goal of the present study was to examine these relationships in a sample of injured survivors of terrorist attacks and their spouses.

Accordingly, we hypothesized that:

A significant positive association would be found between trauma-related symptoms reported by survivors and those reported by their spouses.

The levels of marital satisfaction reported by survivors and their spouses would be negatively associated with their own trauma-related symptoms.

Marital satisfaction reported by one member of the dyad would be negatively associated with the trauma-related symptoms reported by the other member of the dyad. For example, the marital satisfaction of the unexposed spouse would be negatively associated with the trauma-related symptoms of the survivor.

Method

Participants

The sample consisted of 105 Israelis who had been injured in terrorist attacks and their spouses (N = 210). The eligible participants were drawn from the database of the One Family organization, an Israel-based foundation providing assistance to the survivors of terrorism regardless of religion, nationality, gender, or financial situation. Eligibility for participation in the study was based on the following criteria: (a) one of the spouses had survived a terrorist attack since 2001; (b) the survivor had been recognized by the National Insurance Institute as having a 20% (or greater) disability, including both physical and psychological disabilities; (c) the survivor was married; (d) the survivor was currently between the age of 21 and 70 years; and (e) the survivor was at least 18 years of age at the time of the terrorist attack. The study sample consisted entirely of couples in which only one partner was exposed to a terror attack. As members of the “One Family” organization, they all participated in retreats and additional programs for terror survivors thus could be regarded as support groups. Following the Institutional Review Board (IRB) approval, the participants were not questioned about specific types of personal and couple treatments they underwent privately, in the interest of protecting participant privacy. Of the 182 couples who met the inclusion criteria, 22 couples could not be reached due to outdated contact information, 48 couples declined to participate, and 6 couples failed to complete all the questionnaires. The final sample consisted of 105 married couples who responded to all the survey items. The data for the study were taken from a larger project designed to study the mental health consequences of terrorist attacks for survivors and their spouses (e.g., Besser et al., 2015; Weinberg et al., 2016).

Of the 105 survivors who participated, 65 were men and 40 were women. The mean age of the survivors was 49.32 years (SD = 11.05) and the mean age of the spouses was 48.47 years (SD = 11.20). The mean number of years of education for the survivors was 12.72 years (SD = 2.83) and the mean number of years of education for the spouses was 12.70 years (SD = 2.50). The mean number of years of marriage for the 105 couples was 24.33 years (SD = 11.17). All the couples were involved in intimate relationships with one another for at least 3 years prior to the terrorist attack. No statistical differences in demographic features were found between the couples who consented to participate in the study and those who did not.

The terrorist attacks experienced by the survivors fell into three broad categories: 42 survivors had been exposed to a suicide bombing or other explosive attack; 40 survivors had been exposed to a rocket and/or mortar attack; and 23 survivors had been exposed to a shooting, stabbing, or other physical assault. The attacks were significant events in the lives of these individuals, as indicated by the fact that 59 survivors (and 61 spouses) defined the injuries that were sustained as severe, and 78 survivors (and 69 spouses) noted that the terrorist attack had a major negative impact on their lives. The mean number of years since the terrorist attack was 10.3 years (SD = 2.55).

Measures

Marital satisfaction

Marital satisfaction was measured by the Marital Quality Scale (MQS-I; Lavee, 1995; Lavee & Ben-Ari, 2007; Lavee & Katz, 2002). The MQS-I is a 10-item scale that is a modified version of the short ENRICH scale (Fowers & Olson, 1993). Responses were provided using scales ranging from 1 (not at all) to 5 (very much). The scale assesses perceived quality of the respondent’s marriages across 10 dimensions of the relationship (i.e., spouse’s personal traits, communication, conflict resolution, financial management, leisure activities, sexuality, parenting, relationship with the extended family, division of household labor, and trust). The internal consistency coefficients for the MQS-I were .96 for both the survivors and the spouses.

PTSD symptoms

Symptoms of PTSD were assessed using the PTSD Checklist—Civilian Version (PCL-C; Weathers & Ford, 1996). This 17-item self-administered questionnaire is based on the diagnostic criteria for PTSD from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994). The criteria capture three separate PTSD symptom clusters: re-experiencing (e.g., “suddenly acting or feeling as if the stressful experience is happening again—as if you were reliving it”), numbing/avoidance (e.g., “avoiding activities or situations because they remind you of your stressful experience”), and hyper-arousal (e.g., “having difficulty concentrating”). Respondents were asked to rate the PTSD symptoms they had experienced during the past month (related to exposure to the terror attack) on a scale of 1 (not at all) to 5 (extremely). The total score for the PCL-C was the index of the PTSD symptoms, which ranged from 17 to 85, with higher scores representing higher levels of PTSD symptoms. The internal consistency coefficient for the PCL-C was .94 for both the survivors and the spouses.

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001) was used to examine depressive symptoms. The PHQ-9 scale comprises 9 items relating to symptoms of depression as defined by the DSM-IV. Each of the items is scored from 0 (not at all) to 3 (almost every day), resulting in a maximum total score of 27, with higher scores representing more severe depression. The internal consistency coefficients for the PHQ-9 were .92 for the survivors and .90 for the spouses.

Anxiety symptoms

The Generalized Anxiety Disorder Scale (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006) was used to assess anxiety symptoms. The GAD is a 7-item instrument corresponding to the diagnostic criteria for GAD-7. Participants were asked to respond to each item using scales that ranged from 0 (not at all) to 3 (almost every day). Scores for the GAD-7 ranged from 0 to 21 with higher scores representing higher levels of GAD symptoms. The internal consistency coefficients for the GAD-7 were .94 for the survivors and .93 for the spouses.

Procedure

Following the approval of the Sapir Academic College Ethics Committee, a letter was sent to the survivors of terrorist attacks and their spouses providing information about the research project and requesting their consent to participate by completing a series of questionnaires. Representatives from the One Family organization who were trained in the research procedures obtained informed consent and assisted with the administration of the study questionnaires. This assistance was limited to clarifying instructions, making sure all items were completed, and ascertaining that survivors and their spouses completed the questionnaires separately and independently.

Results

Data analyses were performed in three stages. First, we examined the normality of the distributions of the variables. Second, the demographic features of the participants, as well as the descriptive statistics for marital satisfaction and trauma-related symptoms, were examined. Bivariate analyses of the associations between the levels of marital satisfaction and trauma-related symptoms were also conducted for the survivors and their spouses (see Table 2). Third, the actor–partner interdependence model (APIM; Kenny, Kashy, & Cook, 2006) was used to examine the dyadic associations that marital satisfaction had with trauma-related symptoms experienced by the survivors and their spouses. The APIM uses the dyadic interaction as the unit of analysis (Kenny et al., 2006) so that each partner’s levels of marital satisfaction were viewed as potentially associated with the trauma-related symptoms experienced by both partners. In the APIM framework, each dyad member is considered to be an actor as well as a partner in the analysis. Thus, the analysis controls for the extent to which the spouse’s symptoms are affected by the survivor’s symptoms and vice versa. The relationships between the marital satisfaction of the survivors and their spouses with their own symptoms (i.e., defined as a latent construct captured by PTSD, depression, and anxiety) are referred to as “actor effects.” The relationships between the levels of marital satisfaction of one member of the dyad with the symptoms experienced by the other member of the dyad are referred to as “partner effects.” Marital satisfaction and the trauma-related symptoms of the survivors and their spouses were defined as APIM associations (see Figure 1).

Figure 1.

An APIM of the effect of marital satisfaction on traumatic symptoms. Note. Rectangles indicate measured variables, and large circles represent latent constructs. Small circles reflect residuals (e) or disturbances (d). Bold numbers above or near endogenous variables represent the amount of variance explained (R2). Bidirectional arrows depict covariance, and unidirectional arrows depict hypothesized directional links. Standardized maximum-likelihood parameters were used. APIM: actor–partner interdependence model.

First, we used the Kolmogorov–Smirnov test, the Lilliefors test, and the Shapiro–Wilk test to examine the normality of the distributions of the variables. The results of these tests indicated that these distributions were relatively normal (non-significant p values). We also examined whether multicollinearity among variables was a concern. The eigenvalues of the scaled and uncentered cross-products’ matrix, condition indices, and variance decomposition proportions, along with the variance inflation factors and tolerances from the multicollinearity analyses, indicated the absence of any multicollinearity.

In the second stage, demographic and the study variables were examined. As shown in Table 1, paired-sample t-tests indicated that the survivors reported higher trauma-related symptoms than their spouses for PTSD, t(104) = 9.51, p < .001; depression, t(104) = 7.77, p < .001; and anxiety, t(104) = 5.90, p < .001, while the spouses reported significantly lower levels of marital satisfaction, t(104) = 2.0, p < .05.

Table 1.

Differences between marital satisfaction, PTSD, depression, and anxiety symptoms of survivors and their spouses.

	Survivors		Spouses
	M	SD	M	SD	t(104)
Marital satisfaction	47.25	14.04	45.07	14.86	2.00*
PTSD	54.32	17.14	39.92	15.22	9.51**
Depression	13.23	7.31	8.50	6.29	7.77**
Anxiety	12.02	6.65	8.47	5.97	5.90**

Note. PTSD: post-traumatic stress disorder.

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

Table 2.

Correlations between marital satisfaction, PTSD, depression, and anxiety symptoms for the survivors and their spouses.

	1	2	3	4	5	6	7	8
1. Marital satisfaction (S)	–	−.50***	−.58***	−.49***	.70***	−.25**	−.37***	−.35***
2. PTSD (S)		–	.87***	.83***	−.51***	.55***	.57***	.54***
3. Depression (S)			–	.89***	−.52***	.48***	.59***	.50***
4. Anxiety (S)				–	−.42***	.43***	.56***	.53***
5. Marital satisfaction (P)					–	−.49***	−.53***	−.50***
6. PTSD (P)						–	.81***	.80***
7. Depression (P)							–	.85***
8. Anxiety (P)								–

Note. Italicized estimates reflect paired samples’ correlations, estimates highlighted in gray reflect actor effects, and bold estimates reflect partner effects. (S) = survivor; (P) = spouse; PTSD: post-traumatic stress disorder.

*p < .05; **p < .01; ***p < .001.

In the second stage, as noted above, the research hypotheses were examined using the APIM technique. Analyses were conducted with AMOS (version 18; Arbuckle, 2009) using the maximum-likelihood method. In addition to the overall χ² test of exact fit, the following fit indices were used to evaluate the proposed models: (a) the χ²/df ratio, (b) the root mean square error of approximation (RMSEA), (c) the comparative fit index (CFI), and (d) the non-normed fit index or Tucker–Lewis index (NNFI/TLI) and the standardized root mean square residual (SRMR). A model in which the χ²/df was less than or equal to 2, the CFI and NNFI/TLI were greater than .90, the SRMR is less than .08, and the RMSEA index was between .00 and .09 (Hu & Bentler, 1999) was deemed acceptable. These moderately stringent acceptance criteria clearly reject inadequate or poorly specified models but accept models that meet real-world criteria for reasonable fit and representation of the data (Kelloway, 1998).

The APIM

The associations between marital satisfaction and trauma-related symptoms

The model that examined the APIM association between survivors’ and spouses’ marital satisfaction and trauma-related symptoms (Figure 1) fits the observed data very well, χ²(13) = 20.05, p = .10, χ² /df = 1.54, NNFI/TLI = .98, CFI = .99, SRMR = .03, RMSEA = .07. As shown in Figure 1, a significant relationship was found between the level of marital satisfaction reported by survivors and their spouses (r = .70, t = 5.86, p < .001) as well as with their trauma-related symptoms (r = .50, t = 3.99, p < .001). The marital satisfaction of survivors was negatively associated with their own trauma-related symptoms (β = −.42, t = −3.65, p < .001) but not with the trauma-related symptoms experienced by their spouses (β = .04, t = 0.36, p = .72). The level of marital satisfaction reported by spouses was negatively associated with their own trauma-related symptoms (β = −.59, t = −4.75, p < .001) as well as with the trauma-related symptoms experienced by the survivors (β = −.23, t = −2.0, p < .05). The model explained 36% of the variance in the trauma-related symptoms of survivors and 31% of the variance in the trauma-related symptoms of spouses.

Discussion

The primary goal of the study was to examine the relationships between marital satisfaction and trauma-related symptoms among trauma survivors and their spouses. Following the conception that the survivor–spouse relationship is bidirectional, namely, the unexposed spouse is not only affected by the trauma-related symptoms of the survivor but may also be affected by the symptoms experienced by the survivor (Nelson-Goff & Smith, 2005), our study examined the potential links between marital satisfaction and trauma-related symptoms of both the survivors and their spouses. The results demonstrated a positive association between levels of marital satisfaction reported by survivors and their spouses. Similarly, positive associations emerged between the symptoms of the survivors and their spouses.

The level of marital satisfaction reported by unexposed spouses was negatively associated with their own trauma-related symptoms as well as with the symptoms reported by the survivors. In contrast, while the marital satisfaction reported by the survivors was negatively associated with their own trauma-related symptoms, we observed no association between survivor’s marital satisfaction and trauma-related symptoms reported by their spouses. These results are consistent with an interdependence relationship that includes trauma-related symptoms beyond those directly tied to PTSD. The results are especially notable given that the study was conducted at an average of 10 years after the trauma took place. The results suggest that clinicians working with trauma survivors should be aware of the links between marital satisfaction and trauma-related symptoms within the marital dyad, thereby acknowledging the differences in the level where spouse’s marital satisfaction is linked both to self-traumatic symptoms and partner’s traumatic symptoms, while survivor’s marital satisfaction is linked to self-traumatic symptoms only. Nevertheless, given the cross-sectional nature of the study design and the concept of the victim-spouse effect (Nelson-Goff & Smith, 2005), this assumption should be addressed with caution. Spouse’s marital satisfaction could also be influenced by their traumatized spouse’s symptoms. Thus, not only may trauma influence the mental health of exposed individuals, it may also influence how accessible the traumatized individuals are in their romantic relationships. If they have high levels of traumatic symptoms, the survivors may not be able to provide support for their spouse. Namely, they need more attention, assistance, and support than they are able to give (Guay, Billette, & Marchand, 2006; King, Taft, King, Hammond, & Stone, 2006; Lui, Glynn, & Shetty, 2009; Wu, Chen, Weng, & Wu, 2009). Especially, if they still have high levels of symptoms after 10 years, the spouses may have endured 10 years of being the “forgotten spouse” because their traumatized partners may have been preoccupied with the traumatic experiences.

In accordance with previous research studies (e.g., Galovski & Lyons, 2004; King, King, et al., 2006; Renshaw et al., 2010), we found that the level of marital satisfaction reported by the survivors and their spouses was negatively correlated with their own trauma-related symptoms. These results are important because they suggest a possible interplay between marital satisfaction and post-trauma psychopathology within the dyad. While it is known that marital satisfaction is a consequence of trauma-related symptoms, our study suggests that it is possible that marital satisfaction may also have an effect on the development and prolongation of the post-trauma symptoms. This notion might be suggested when considering the theoretical concept that adaptation to traumatic stress in the couple dyad is dependent on the systemic interaction of three primary components: individual level of functioning, predisposing factors and resources, and couple functioning. Rather than being a source of problems, the couple relationship might serve as a crucible or resource for healing the primary trauma survivor by developing bonds of attachment, breaking dysfunctional patterns, and creating healthy functioning in interpersonal relationships (Nelson-Goff & Smith, 2005). However, it is important to note that while the present data do not refer to the causal link between marital satisfaction and trauma-related symptoms, as it was a cross-sectional study, nevertheless the results of the study provide additional support for the multiple connections between marital satisfaction and trauma-related symptoms for survivors and their spouses. Therefore, further longitudinal examination and cross-lagged panel models are required to better determine whether the trauma symptoms created the change in satisfaction in the union (i.e., hypervigilance, angry outbursts, and other intra/interpersonal symptoms change the satisfaction level of the other person).

Notably, we observed that only partial dyadic associations were found between the marital satisfaction of one partner and the trauma-related symptoms reported by his/her spouse. More specifically, the level of marital satisfaction reported by the unexposed spouses was negatively associated with the trauma-related symptoms experienced by them and by the survivors, but the marital satisfaction of the survivor was not linked to the trauma-related symptoms of the spouse. This pattern only partially supports an interdependence link (Nelson-Goff & Smith, 2005), which would require that the level of marital satisfaction reported by both members of the dyad would be associated with the trauma-related symptoms experienced by the other member. However, these results are consistent with the results that have emerged from previous studies concerning trauma survivors and their spouses (Besser et al., 2015; Marini et al., 2015; Monk & Goff, 2014; Weinberg, 2013; Weinberg et al., 2016). Such a pattern may suggest different trajectories for marital satisfaction among survivors and their spouses. One possible explanation is that the survivor may find it difficult to act and contribute to the marital relationship as he/she did prior to the attack. Thus, the survivor may need the spouse to fill the vacuum created by their difficulties in the wake of the attack. If the spouse is still satisfied with the marriage, he/she may tend to function more effectively and provide more emotional support for the victim. The marital satisfaction of the spouse may play a vital role in the daily conduct of the dyadic unit, which may provide survivors with reassurance and a sense of security. Thus, as terror survivors and their spouses cope with their traumatic symptoms, they need to be aware of the interplay between their personal relationship with each other as it is expressed and conveyed via their marital satisfaction. While doing so, acknowledgment of the potential effect of this relationship on their own and on the other’s traumatic symptoms is suggested. Following this concept, focusing on the marital unit, in addition to the individual, during the course of treatment in the aftermath of trauma may be highly important. For example, conjoint therapy designed to improve trauma-related symptoms as well as enhance intimate relationships (Fredman, Monson, & Adair, 2011) can benefit both the survivors and the spouses.

The study has a number of strengths, including sample size and a unique cohort of both the survivors of terrorism and their spouses. Yet, several limitations should be noted. First, data concerning the emotional, functional, and psychosocial states of the participants prior to the terror attack were unavailable, which prevented us from exploring whether any of these factors influenced the trauma-related symptoms reported in the present study. Second, while the study utilized a substantial number of dyads drawn from the records of the One Family organization—the largest organization in Israel to provide support for survivors of terrorist attacks—conceivably, the sample may not fully represent all the individuals who may have experienced terrorist attacks. This potential limitation may limit the generalizability of these findings. Third, the cross-sectional nature of the study does not allow us to establish the causal relationships between marital satisfaction and symptoms. Future research should attempt to gain a clearer insight into the causal links between marital satisfaction and the trauma-related symptoms experienced by the survivors of terrorist attacks and their spouses, using cross-legged study designs. In this context, additional variables, and especially different social construct variables associated with traumatic symptoms and dyadic relationships, should be examined further. Despite these limitations, we believe the study makes a valuable contribution to the understanding of the connections between marital satisfaction and trauma-related symptoms for married couples.

Footnotes

Acknowledgments

The authors would like to thank the One Family organization and all the participants in the study. The authors would also like to thank Yochai Ataria, PhD, for his help in recruiting the research sample.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by a Mission Awards grant from Psychology Beyond Borders.

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