The deterioration and mobilization effects of trauma on social support: Childhood maltreatment and adulthood military violence in a Palestinian community sample

Abstract

Objectives:

To show that exposure to childhood maltreatment deteriorates, whereas exposure to adulthood military violence mobilizes social support; Second, to show that associations between traumatic events and mental health problems are mediated through social support and, subsequently, adulthood military violence is associated with low level and childhood maltreatment with high level of mental health symptoms; third, to explore whether the moderating (protecting) effect of sufficient and satisfactory social support would differ among victims of childhood maltreatment and adulthood military violence.

Method:

The participants were a random-sample of Palestinian men and women (n = 585) of 16–60 years of age. Exposure to military violence in adulthood was assessed by the Harvard Trauma Questionnaire (HTQ_I), and to childhood maltreatment by a 13-item questionnaire developed for the study. A Social Network Schedule was applied to assess the function, source, and satisfaction with social support, and the Revised SCL90-R Symptoms Checklist to assess mental health symptoms.

Results:

Findings supported our hypothesis that exposure to childhood maltreatment was associated with low levels of social support, whereas exposure to adulthood military violence was associated with high levels of social support. Contrary to our second hypothesis, both childhood maltreatment and adulthood military violence were associated with high levels of mental health symptoms. Finally, high level and satisfactory social support moderated the association between exposure to military violence in adulthood and mental health symptoms, but not between childhood maltreatment and mental health symptoms.

Conclusion:

The findings emphasize that the nature of trauma, that is, whether familial or political, determines the availability of protective resources versus vulnerability, which should be considered when tailoring interventions to trauma victims.

Résumé

Objectifs:

Montrer que subir la maltraitance infantile dégrade, alors que l’exposition à la violence militaire à l’âge adulte stimule. Ensuite, montrer que les associations entre des événements traumatiques et les problèmes de santé mentale sont influencés par l’aide sociale et que, ainsi, la violence militaire à l’âge adulte provoque peu de symptômes de maladie mentale alors que la maltraitance infantile est associée à un haut niveau de symptomes; Troisièmement, voir si l’effet modérateur (protecteur) d’une aide sociale suffisante et satisfaisante est différent chez les victimes de maltraitance infantile et les victimes de violence militaire à l’âge adulte.

Méthode:

Les participants constituaient un échantillon randomisé d’hommes et de femmes palestiniens (n = 585) de 16–60 ans. Leur soumission à une violence militaire à l’âge adulte était attestée par le Questionnaire Traumatique de Harvard (QTH-1), et à une maltraitance infantile par un questionnaire de 13 items élaboré pour cette étude. Une Evaluation du Réseau Social a été appliquée pour certifier la fonction, l’origine et le degré de satisfaction de l’aide sociale, et la Liste Révisée des Symptomes (SCL90-R) pour confirmer les symptomes de l’état mental.

Résultats:

les observations ont confirmé notre hypothèse que la maltraitance infantile avait reçu un faible niveau d’aide sociale, alors que l’exposition à la violence militaire à l’âge adulte était l’objet d’un haut niveau d’aide sociale. Contrairement à notre seconde hypothèse, tant la maltraitance infantile que la violence militaire à l’âge adulte s’associaient à un fort niveau de symptômes de maladies mentales. Finalement, une aide sociale satisfaisante et de haut niveau modérait le rapport entre l’exposition à la violence militaire à l’âge adulte et les symptomes de maladie mentale, mais pas celui de la maltraitance infantile et de la maladie mentale.

Conclusion:

Les observations soulignent que la nature du traumatisme, qu’il soit familial ou politique, détermine la disponibilité des éléments de protection contre la vulnérabilité, et ceci devrait être pris en considération lorsqu’on réalise des interventions en faveur de victimes de traumatisme.

Resumen

Objetivos:

Demostrar como la exposición al maltrato infantil deteriora, mientras que la exposición a la violencia militar en la adultez moviliza el apoyo social; segundo, demostrar que las asociaciones entre los eventos traumáticos y los problemas de salud mental están mediados a través del apoyo social y, subsecuentemente, la violencia militar en la adultez está asociada con bajos niveles y el maltrato infantil con altos niveles de síntomas de salud mental; tercero, explorar si el efecto moderador (protector) de suficiente y satisfactorio apoyo social podría diferenciar entre las víctimas de maltrato infantil y las de violencia militar en la adultez.

Método:

Los participantes fueron una muestra al azar de hombres y mujeres (n = 585) de 16–60 años de edad. La exposición a la violencia militar en la adultez fue evaluada con el cuestionario de Trauma de Harvard (HTQ-1), y el maltrato infantil con un cuestionario de 13 items desarrollado por esta investigación. Se aplicó un “Social Network Schedule” para evaluar la función, fuente, y satisfacción con el apoyo social, y el Inventario de Síntomas Revisado SCL90-R para evaluar los síntomas de salud mental.

Resultados:

los hallazgos apoyaron nuestra hipótesis de que la exposición al maltrato infantil estaba asociado con bajos niveles de apoyo social, mientras que la exposición a la violencia militar estuvo asociada con altos niveles de apoyo social. Contrario a nuestra segunda hipótesis, tanto el maltrato infantil como la violencia militar en la adultez estuvieron asociadas con altos niveles de síntomas de salud mental. Finalmente, un alto nivel satisfactorio de apoyo social moderaba la asociación entre la exposición a la violencia militar en la adultez y los síntomas de salud mental, pero no así entre el maltrato infantil y los síntomas de salud mental.

Conclusión:

Los hallazgos enfatizan la naturaleza del trauma, es decir, sea éste familiar o político, se determina la disponibilidad de los recursos protectores versus la vulnerabilidad, lo cual debe ser considerado al diseñar intervenciones para las víctimas de trauma.

Introduction

There is extensive evidence for the beneficial role of social support. People who can rely on someone when they need help and consolation are found to live longer (Berkman & Syme, 1979; Olsen, Olsen, Gunner-Svensson, & Ealdstrom, 1991; Reynolds & Kaplan, 1990), to enjoy better psychological and somatic health (Berkman, 1995, Cohen and Wills, 1985; Pennix, van Tilburg, Kriegsman, Boeke, & Eijk, 1997), and to recover faster from various illnesses (Andrykowski & Cordova, 1998; Kriegsman, Pennix, & Eijk, 1995). Furthermore, findings support the idea that social support can protect mental health from negative effects of environmental stressors (for reviews: Cohen & Syme, 1985; Pierce, Sarason, & Sarason, 1996) and collective (Kaniasty & Norris, 1993; Norris & Kaniasty, 1996) and individual (Sprang & McNeil, 1998; Thuen, 1997) trauma.

However, empirical evidence concerning the beneficial role of social support is not uniform. Researchers argue that various functions and sources of social support may relate differently to health and well-being (Barrera & Ainlay, 1983; Cohen and Wills, 1985, Kaplan et al., 1977). The functional aspects of social support refer to the fact that people differ in their ability and opportunities to enjoy emotional (consolation, intimacy and respect) and instrumental (advice, practical help and financial aid) social support. People also vary in receiving support from family members, friends and institutions. Furthermore, people differ in how adequate they perceive the available support, and how satisfied they are with it. In other words, they may get help, sympathy and assurance, but would like to have a different kind of support, and from different sources (Barrera, 1986, Pierce et al., 1996, Pilisuk and Parks, 1986).

It is also evident that not all hardships ‘invite’ similar degrees of support and sympathy. Some stressful and traumatic events mobilize the support network, while others deteriorate access to it (Barrera, 1986, Dunkel-Schetter and Wortman, 1982; Hobfoll & Lerman, 1989; Kaniasty & Norris, 1993). Traumatic events that mobilize social support are visually distressing, unambiguous, collectively shared and they often attribute heroic characteristics to the victims. Research shows that events like the death of a spouse (Norris & Kaniasty, 1996) and severe illness (Grassi, Caloro, Zamorani, & Ramelli, 1997) increase social support. It is also believed that war, military violence and other collective hardships increase social cohesion and support (Janis, 1951). On the contrary, traumatic events that deteriorate social support are private, ambiguous and often connote social stigma and shame. They exhaust available social support because they elicit helplessness, aversion or fear in other people (Eckenrode & Wethington, 1990; Kaniasty & Norris, 1993). Typically, victims of sexual abuse and rape face more difficulties in finding help than victims of other kinds of abuse (Cohen & Roth, 1987).

The research on mobilization and deterioration of social support indicates that support is not a stable and universal resource, but the nature of trauma may decisively influence its availability. The main research objective of this study was to examine how two traumatic events of different nature associate with social support. The mobilization and deterioration effects are studied among victims of childhood maltreatment and military violence among Palestinians living in Gaza Strip. Victims of these traumas differ in the social status of the victim, individual and collective meaning of the event, their timing in human development, and the emotional significance of the persecutor.

Research shows that victims of childhood maltreatment often feel stigmatized, self-defeated, and responsible for their fate (Gibson & Hartstone, 1996; Gold, 1986, Higgins and McCabe, 2001). The trauma is typically kept inside the house, and the victim is deprived from sharing emotions and seeking consolation. Maltreating parents often oscillate between caring and hostile attitudes towards their children, who in turn experience these mood shifts as unpredictable and incomprehensive (Crittenden, 1988, Muller and Lemieux, 2000; Newcomb & Locke, 2001). Maltreatment negatively shapes the victims’ views about themselves, other people, and the world. Abused children tend to perceive the world as an unsafe place and feel distrust towards other humans (Alexander et al., 1998, Styron and Janoff-Bulman, 1997). The social distrust further complicates the availability of social support (Kaniasty & Norris, 1993; Simpson, 1990).

Less research is available on social support-related characteristics of military trauma. The military violence studied here took place in the context of the Palestinian Intifada I, the struggle for independence in 1986–1993. International (Amnesty International, 1989), Israeli (B’Tselem, 1994, B’Tselem, 1998), and local (Al-Haq, 1988) human right organizations have documented high levels of human and material losses and imprisonment. The victims were, however, members of a relatively united society that appreciated their sacrifices for the national course. They could, therefore, consider their intrinsic traumatic experiences ideologically and socially meaningful (Qouta, Punamäki, & El Sarraj, 1997).

We may thus conclude that childhood maltreatment is socially invisible and involves individual suffering whereas military violence is visibly distressing, often dramatic, and collectively shared. Military trauma can connote heroism, while maltreatment often connotes social shame. Finally, in the military violence, the persecutor is an enemy, a clear unknown outsider, whereas in the case of maltreatment the persecutor is often a known family member (Higgins & McCabe, 2001). Accordingly we hypothesize that childhood maltreatment decreases the availability, and military violence in adulthood mobilizes social support.

Traumatic events form a serious risk for mental health problems. There is ample evidence that childhood maltreatment predicts depressive, anxiety, dissociating and somatic symptoms, and forms a risk for PTSD (Golding, Wilsnack, & Cooper, 2002; Irwin, 1996; Zoellner, Foa, & Brigidi, 1999). Little research is available on the prevalence and mental health consequences of childhood maltreatment among Palestinians. Khamis (2000) found a high level of psychological maltreatment, especially among refugee-camp residents and economically and socially deprived families. She also showed a strong association between maltreatment and psychological symptoms. Haj-Yahia (2001) reported high levels of adjustment and developmental problems among Palestinian adolescents who witnessed interparental violence which is often associated with child abuse (Haj-Yahia & Dawyd-Noursi, 1998).

Abundant research is, however, available on the mental health consequences of military violence, both in general (Ai, Peterson, & Ubelhor, 2002; Kimerling, 2000) and among Palestinians. Military violence, losses, and harassment among Palestinian women (Khamis, 1998, Punamäki, 1986), children, and adolescents (Baker, 1990; Baker & Shalhoub-Kevorkian, 1999; Khamis, 1993, Punamäki and Suleiman, 1989; Qouta, Punamäki, & El Sarraj, 1995) have been found to associate with high levels of mental health problems including depressive, anxiety, somatic, and PTSD symptoms. Research further shows that experiences of torture and ill-treatment among Palestinian men associate with elevated levels of mental health and somatic symptoms (El-Sarraj, Punamäki, Salmi, & Summerfield, 1996; Kanninen, Punamäki, & Qouta, 2002).

There is no earlier research examining the mediating and/or moderating role of social support among victims of childhood maltreatment and adulthood military violence in the same sample. Our mediating hypotheses are, first, that exposure to adulthood military violence does not associate with elevated levels of mental health problems, if it mobilizes sufficient and satisfactory social support, which in turn, associates with relatively lower levels of symptoms. Second, we hypothesize that, on the contrary, childhood maltreatment associates with elevated mental health problems through deteriorated social support.

The moderating effect of social support can protect the victims’ mental health from the negative impact of trauma. There is general evidence that exposure to traumatic stress is less strongly associated with mental health problems when the victim has sufficient and satisfactory social support (Cutrona & Russell, 1990; Holahan, Moos, Holahan, & Brennan, 1995). Some research is also available on the protective role of social support in the Middle-Eastern military-political context among civilians (Bat-Zion & Levy-Shiff, 1993; Punamäki, 1986) and soldiers (Solomon, Mikulincer, & Avizur, 1988). In this study, we examine how the nature of trauma affects the moderating or protecting function of social support, that is, whether the moderator role of social support differs among victims of childhood maltreatment and adulthood military violence.

In summary, we hypothesize that individuals exposed to childhood maltreatment report low levels of social support (deterioration effect), whereas exposure to military violence in adulthood is associated with high levels of social support (mobilizing effect). In addition we examine the gender differences in the associations between the nature of trauma and different aspects of social support (i.e., function and source of social support, and satisfaction with them). Second, we hypothesize that associations between traumatic events and mental health problems are mediated through social support. Adulthood military violence is associated with sufficient and satisfactory social support, which in turn, is associated with low level of mental health symptoms, whereas childhood maltreatment is associated with poor social support, which in turn, associates with a high level of mental health symptoms. Third, we examine whether the moderator role of social support differs among victims of childhood maltreatment and adulthood military violence. The moderator and protecting role means that exposure to trauma is less strongly associated with mental health symptoms if victims enjoy sufficient and satisfactory social support.