In the Shadow of Terror: The Relationship between Continuous Exposure, Distress and Post-traumatic Growth

Background and Purpose: Civilian populations experiencing recurrent terror attacks may demonstrate different outcomes in comparisons to victims of acute exposure. A consistent finding in previous studies is that subjective perception of exposure (PTSD criteria A1, as defined by the DSM-IV-TR) has a greater impact on emotional symptoms than the actual exposure to events. Yet, little is known about the relationship between exposure to ongoing terror and positive outcomes. The purpose of the current study was to examine the emotional impact of continuous terrorism among young Israeli adults (18-40) living in areas highly exposed to continuous terror. The study aimed at identifying the contribution of objective and subjective exposure to terror, to distress and to post-traumatic growth (PTG). The hypotheses of this study were that continuous exposure to terror is related not only to higher levels of distress (post-traumatic symptoms and general health), but also to higher levels of PTG. Moreover, we hypothesized that post-traumatic symptoms contribute to higher levels of PTG.

Method: Questionnaires were completed by 195 Israeli students (age M=23.76, SD=3.31, 120 males and 75 females), during the Al-Aqsa Intifada (the second Palestinian Uprising) in July-August 2004. The battery included the Objective Exposure Questionnaire, Subjective Exposure Questionnaire, PTSD Inventory, General Health Questionnaire (G.H.Q 28) and the Post-traumatic Growth Inventory. Hierarchical multiple regression analyses and path analyses were used to examine the contribution of levels of exposure to distress and to PTG, as well as the contribution of PTSD to PTG.

Results: All participants had been exposed either directly or indirectly (through family or friends) to terror. The results indicated that subjective exposure contributed to distress and PTG. In accordance with the study's hypothesis, higher levels of subjective exposure contributed to higher levels of distress and PTG. In addition, the findings indicated that post-traumatic symptoms contribute to higher levels of PTG. Results of hierarchical multiple regression analyses and path analyses suggested that an indirect association exists between subjective exposure and PTG mediated by PTSD. Thus, higher levels of subjective exposure lead to higher levels of PTSD, which is directly related to PTG.

Conclusions and Implications: The findings support the importance of criteria A1 in assessing subjective exposure to traumatic events and its contribution to distress and to post-traumatic growth. In addition, the current study highlights the role of emotional suffering in inducing growth. These findings may encourage clinicians to provide hope for the survivors' future, by offering the growth perspective without minimizing the negative effect of the trauma.