Journal of Traumatic Stress Disorders & Treatment ISSN: 2324-8947

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.

Research Article, J Trauma Stress Disor Treat Vol: 5 Issue: 2

Relations between Tendency to Forgive, PTSD and Well-Being in a Non-Combatant Population during Wartime

Michal Shamai*, Michael Weinberg and Sharon Gil
Faculty of Social Welfare and Health Sciences, School of Social Work, University of Haifa, Mount Carmel, Haifa, Israel
Corresponding author : Michal Shamai
Faculty of Social Welfare and Health Sciences, School of Social Work, University of Haifa, Mount Carmel, Haifa-3498838, Israel
Tel: 972-4-8249-234
E-mail: [email protected]
Received: September 01, 2015 Accepted: March 22, 2016 Published: March 29, 2016
Citation: Shamai M, Weinberg M, Gil S (2016) Relations between Tendency to Forgive, PTSD and Well-Being in a Non-Combatant Population during Wartime. J Trauma Stress Disor Treat 5:2. doi:10.4172/2324-8947.1000156

Abstract

Relations between Tendency to Forgive, PTSD and Well-Being in a Non-Combatant Population during Wartime

Objective: The study examined the association between the tendency to forgive (self, others, and situations); each of the DSM 5 clusters of post-traumatic stress symptom levels; and well-being among civilians during wartime.
Method: A sample of 501 Israeli civilians was assessed through web administration in real-time exposure to missile and rocket attacks during the Gaza war in the summer of 2014.
Results: A structural equation model design revealed that the various dimensions of the tendency to forgive were associated differently with the four clusters of traumatic symptoms and wellbeing. Of all the dimensions of tendency to forgive, only forgiving the situations was associated with lower traumatic symptom levels in all four clusters and in higher well-being. Additionally, the tendency to forgive the situation was the only mediating variable between subjective exposure and the four clusters of traumatic symptoms and well-being.
Conclusions: During war the dimensions of tendency to forgive interact differently with traumatic symptoms clusters and wellbeing. Thus, attention should be directed to this diversity, allowing for better understanding and intervention. Theoretical and clinical implications of the findings are discussed.

Keywords: PTSD; Forgive; Israeli civilians; War; Traumatic symptoms; Wellbeing

Keywords

PTSD; Forgive; Israeli civilians; War; Traumatic symptoms; Wellbeing

Introduction

Exposure to war is considered to be a risk factor for developing acute stress disorder (ASD) during the exposure, and in severe cases might develop into post-traumatic stress disorder (PTSD) [1]. However, several protective factors which are related to personal traits, such as hardiness [2], sense of coherence [3] and resilience [4], and contextual conditions such as social support [4], may significantly reduce the probability of developing psychopathology during or following the exposure to war. The tendency to forgive was found to be a possible protective variable as well. The goal of the study was to examine the association between the three dimensions of tendency to forgive (self, others, and situations); the four clusters of traumatic symptoms as defined in the description of acute and post-traumatic stress disorders in the DSM 5 [5]; and well-being in a noncombatant population during a war situation.
War as a series of sotential traumatic events
Mental health literature has described populations living in situations of war as being at high risk for developing symptoms of distress [1]. These symptoms might include generalized fear and anxiety, recurrent thoughts about attack, avoidance behavior, physiological symptoms, depression, problems in daily functioning, and difficulties relating to and trusting others. In severe cases, such a distress reaction can result in PTSD symptoms [6-9]. Yet, several studies have found that actual exposure alone is not a sufficient precondition for developing ASD and PTSD (e.g., [10]). Therefore, researchers in the area of stress and trauma attempted to identify both risk and protective factors as leading to the development or prevention of pathology related to exposure to potential traumatic events, including exposure to war.
Various studies found low level of education, low socio-economic status, female gender, stress adversities throughout life span, severity of the perception of the stressor, and severity of exposure (time to find shelter from incoming missiles and rocket fire launch, i.e., low, moderate, and high length of exposure) to be among the variables viewed as risk factors. Resilience, sense of coherence, hardiness, social support, self-esteem and problem-solving skills were found to be protective factors [6,11-19]. Among the protective factors that have gained special attention in the last decade when dealing with traumatic events is the tendency to forgive [20-24].
Tendency to forgive as a protective factor
The tendency to forgive has been found to be an internal resource in dealing with stressful or traumatic events [25-28]. Forgiveness includes cognitive, emotional, and behavioral reactions in response to a transgression [28-30]. The ability to forgive helps people transform negative feelings into neutral or positive ones without necessarily forgetting or denying the offensive act, or excusing the person or people who perpetrated it [31-33].
Research in the area of forgiveness has found that forgiving individuals, in contrast to people who are not forgiving, showed higher levels of optimism and confidence, and lower levels of anxiety, worry and moodiness. Forgiveness was also found to be associated with better mental and physical health and life satisfaction [34-39]. Notably, forgiveness was conceptualized from two perspectives: as a state referring to forgiving a specific transgression [29], and as a personal trait referring to forgiveness across numerous situations and times [32,40,41].
Perceiving forgiveness as a personal trait is based on the conservation of resources (COR) theory [42] which posits that 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. In this manner, resource loss is central to the stress experience. Resource gain, in turn, becomes more salient in the face of resource loss [42,43]. Indeed, trauma research demonstrates the significance of personal traits such as sense of mastery, self-esteem, hope, and optimism in the process of coping with traumatic symptoms [9,44,45]. The present study examines the association between tendency to forgive as a personal trait and the individual’s ability to cope with and withstand traumatic situations, including in post-conflict societies [23].
Three dimensions of the tendency to forgive were identified: (a) self-forgiveness, representing the tendency to shift from being extremely critical to an accepting attitude towards the self [46], (b) forgiving the other, who was actually or perceived to be responsible for the transgression, and (c) forgiving the situation, referring to the source of a perceived transgression that is attributed to an “unjust world,” “life,” or “fate,” rather than to another person or oneself [32,47].
Forgiveness during and following wars
The role of the tendency to forgive, as related to the mental health outcomes of exposure to war, has hardly been studied. Most research that refers to war and forgiveness focuses on forgiveness as a state rather than as a tendency to forgive – namely, as a trait. These studies cover such areas as reconciliation activities and spiritual therapies following war with the aim of reaching a state of forgiveness (e.g. [48-50]. While forgiveness as a state focuses on a specific offense [29,30], the tendency to forgive as a trait is much less focused on a specific offense or a specific situation.
The number of studies that examined the trait of tendency to forgive and its role in coping with war or a national terror attack is minimal. Of the studies conducted, most took place after the war or terror attack ended, some up to ten years following the war [51-53]. Moreover, none of the extant studies specified which of the dimensions of tendency to forgive was associated with a specific PTSD cluster. In this context, several studies showed that there is a difference in the way each one of the three dimensions of the tendency to forgive operates in stressful or traumatic situations. Several studies have documented differences in how the three dimensions of tendency to forgive operate in stress or traumatic situations. For example, Weinberg, Gil and Gilbar [27] found that among terrorist survivors the tendency to forgive the situation was significantly associated with lower PTSD symptoms. Forgiveness of self and situations was found to be more positively associated with aspects of psychological well-being and negatively associated with PTSD, as compared to forgiveness of others. In situations where the offenders could be specifically identified, such as in cases of sexual abuse, the positive and negative associations between forgiveness of others and well-being, and PTSD are absent [25,32]. Moreover, a lacuna in knowledge still exists regarding the unique contribution of each one of the forgiveness dimensions as a resource when facing different kinds of stressful situations, since war differs from intimate violence or sexual abuse, and being a combatant at war differs from being a civilian exposed to war.
The goal of the present study, therefore, is to narrow this gap by examining the role of tendency to forgive as related to the mental health outcome of civilians’ exposure to war in real time as the traumatic events unfold. The association between the tendency to forgive and traumatic symptoms is usually measured by relating to ASD and PTSD as a single general construct without focusing on the associations with each of the clusters, and certainly not with the new clusters as defined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders [5]. Conceivably, however, not all the clusters of traumatic stress will be associated with the tendency to forgive. Since various studies on resilience and coping have shown that the majority of the population is considered to be resilient, and may develop only one or two symptoms during the exposure, it is important to find out which dimension of the tendency to forgive is a protective factor, and for which symptom.

Research Hypothesis

Following the theoretical premises of the COR theory [42], the study measured the association of the different dimensions of tendency to forgive with each one of the clusters of traumatic symptoms as specified and defined in DSM 5 (intrusion, the modified hyper-arousal and avoidance clusters, and the new cluster-negative alterations in cognition and mood). Notably, since the study took place during real time, traumatic symptoms were not examined as a clinical pathological diagnostic of ASD or PTSD, but rather in terms of the severity of emotional distress with a focus on traumatic symptoms and well- being.
Accordingly, the following hypotheses were posited:
H1. High levels of tendency to forgive (self, others, and situations) will be associated with low levels of traumatic symptoms (intrusion, hyper-arousal, avoidance, and negative alterations in cognition and mood).
H2. High levels of tendency to forgive (self, others, and situations) will be associated with high levels of well-being.
H3. Tendency to forgive (self, others, and situations) will mediate between level of exposure (objective and subjective) and level of traumatic symptoms (intrusion, hyper-arousal, avoidance, and negative alterations in cognition and mood) and well- being.

Methods

Sample and sampling
The data in the study are based on real-time responses of Israeli civilians during the Israeli-Hamas war in Gaza in the summer of 2014. Over 60% of the Israeli population was exposed to missile attacks and rocket fire during this conflict. The sample consisted of 501 residents living within the rocket range, divided into three groups based on proximity to the Gaza Strip border: 13.4% (n=67) living 7-40 km from the border; 32.93% (n=165) living 40-80 km from the border; and 53.7% (n=269) living more than 80 km from the border. All three areas were under constant attack. The time available to reach a shelter between the air-raid siren warning of incoming fire and the impact of the missiles varied, depending on distance from the border, ranging from 15 seconds or less in the closest border areas to 90 seconds in areas that were over 80 km from the border. The definition of threat in the study was based on the Israeli HFC (Home Front Command) calculations of the amount of time an individual had in order to get to a shelter from the moment the siren started until the rockets fell. This time span signified the degree of threat to each individual – the less time one had, the higher the chances to be physically or mentally impaired.
Since the study aimed to investigate the respondents’ reports in real time under ongoing life-threatening conditions, the authors decided to rely on a web administration of the study, which allowed simultaneous data collection from respondents in the three regions under attack. Consequently, a snowball sampling technique was chosen utilizing Internet-based social media outlets to request residents in the specified areas to participate in the study, and asking them to contact friends and family members to agree to take part in the study as well. Of the participants, 97 (19.5%) were male and 404 (80.5%) were female; mean age 37.32 (SD=10.74); mean years of education 17.10 (SD=5.15). The relatively low rates of male respondents may be attributed to their military recruitment.
Measures
Demographic questionnaire: The questionnaire covered variables such as gender, age, education, family statues, religion, and occupation.
Objective and subjective levels of threat: The objective threat was defined by the time available to reach shelter. Three levels of threat were defined: (1) High Exposure Severity: 7-40 km from the border; (2) Moderate Exposure Severity: 40-80 km from the border; and (3) Low Exposure Severity: over 80 km from the border. The subjective threat was examined by a single question: “In your estimation, is there a real threat that missiles will harm your living space?” The answer was rated on a 4-point Likert scale ranging from 1=not at all, to 4=high risk.
Trait tendency to forgive: Tendency to forgive was examined using the Heartland Forgiveness Scale [30]. This questionnaire includes 18 items rated on a seven-point Likert scale ranging from 1=not appropriate to 7=very appropriate, including three subscales that examine trait forgiveness of self, others, and situations.
Thompson’s study [32] showed internal consistency for the subscales ranging from 0.72 to 0.87. Tendencies to forgive self, others, and situations were measured by the average overall score of the subscales. Higher scores represented a stronger tendency to forgive. The Cronbach’s alpha internal consistency for subscales measuring forgiveness of self, others, and situation were 0.68, 0.81, and 82, respectively. The Cronbach alpha internal consistency for the general scale was 0.86.
DSM 5 PSTD symptom levels scale (PSLS): Posttraumatic stress disorder symptoms were evaluated by the PSLS questionnaire [54]. The questionnaire corresponds fully with the DSM 5 [5] clusters for PTSD. The questionnaire adheres to the construct and expert validity of the DSM 5 diagnosis of PTSD. It is a 20-item self-report questionnaire aimed at assessing levels of PTSD symptoms over the preceding 2 weeks. Each item corresponds to one of the 20 DSM 5 diagnostic clusters for PTSD. The severity of each item is rated on a four-point Likert scale ranging from 0=not at all to 3=severely. The total severity score is calculated as the mean of the respondent’s ratings of the 20 items. The scale is divided into four clusters: intrusion (items 1-5), avoidance (items 6-7), negative alterations (items 8-14), and alterations in arousal (items 15-20). The scale showed high Cronbach alpha internal consistency for both the general scale and for its subscales. The Cronbach alpha internal consistency for the intrusion subscale was 0.87; for the avoidance subscale 0.84; for the negative alterations subscale 0.86; and for the alterations in arousal subscale 0.85. The Cronbach alpha internal consistency for the general scale was 0.94. Notably, the measurement was taken during the war while the traumatic events occurred, and not a month later when the traumatic event ended. Additionally, the questionnaire was used to examine PTSD symptom severity according to the average overall score of the questionnaire and not for a clinical diagnosis of PTSD.
Well-being: Well-being was assessed using the nine-item Personal Well-Being scale [55]. The scale measures satisfaction with one’s quality of life, for example personal health, life achievements, personal relationships, personal safety, community connectedness and future security. Respondents are asked to rate their level of satisfaction using an 11-point Likert scale ranging from 0=completely dissatisfied to 10=completely satisfied. The scale was translated to Hebrew and validated by Golan [56]. Higher scores represent a higher sense of well-being. The Cronbach alpha internal consistency for the scale was 0.94.
Procedure
Data collection began approximately two weeks after the start of the operation and ended four weeks later following the first 72-hour ceasefire declared by the U.N. The study was approved by the Haifa University Ethics Committee, ensuring privacy and confidentiality. All participants provided electronic informed consent before participating in the study.

Results

Data analyses were performed in two stages, corresponding to the aim of the study. In the first stage, SPSS 21 was used to examine the relationship between levels of traumatic symptoms and risk factors. As indicated in Table 1, Pearson product-correlation coefficients revealed a negative relationship between the four clusters and tendency to forgive self, others and situations, and positive correlations with well-being. However, forgiveness for others was not significantly correlated with intrusion and avoidance symptoms. In addition, no significant differences were found between traumatic symptoms reported during the first half and the second half of the data-gathering period (Table 1).
Table 1: Means, standard deviations and Pearson product correlations between PTSD clusters (intrusion, avoidance, negative alterations and hyper arousal), tendency to forgive (self, others and situations), objective threat and subjective threat (N=501).
The second stage examined the associations posited in the second research hypothesis applied to a structural equation model (SEM) design (Figure 1).
Figure 1: Results of a structural equation modeling analysis of objective threat, subjective threat, tendency to forgive, PTSD clusters and well-being.
Analyses were conducted with AMOS [57] using the maximumlikelihood method. Non-significant paths were deleted. In addition to the overall 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 (NNFI). A model in which χ2 /df was ≤ 2, CFI and NNFI were greater than 0.90, and the RMSEA index was between 0.00 and 0.09 [58] was deemed acceptable. These moderately stringent acceptance criteria clearly reject inadequate or poorly specified models but they accept models for consideration that meet real-world criteria for reasonable fit and representation of the data [59]. The present model fit the observed data very well [χ2 (df=14)=27.794, p=0 .083, χ2 /df=1.56] with a good fit measure (NNFI=0.988, CFI=0.996, RMSEA=0.033). In addition, a bootstrap with 2000 repetition with bias corrected percentile, according to Preacher & Hayes (2008) principles, was conducted using AMOS 18 software [57]. The bootstrap analysis confirmed the presented results.
As indicated in Figure 1, tendency to forgive situations was associated with lower intrusion symptoms (β=-0.24, p<0.001), avoidance symptoms (β=-0.23, p<0.001), negative alterations (β=- 0.33, p<0.001), hyper-arousal (β=-0.34, p<0.001), and higher wellbeing (β=0.36, p<0.001). The tendency to forgive self was associated with lower avoidance symptoms (β=-0.09, p=0.019) and negative alterations (β=-0.10, p=0.004), while tendency to forgive others was associated with higher avoidance symptoms (β=0.11, p=0.004) and higher well-being (β=0.16, p<0.001).
Objective threat (living further away from the war zone) was associated with lower intrusion symptoms (β=-0.13, p<0.001), negative alterations (β=-0.23, p=0.001), and hyper-arousal (β=-0.17, p<0.001). Subjective threat was associated with lower tendency to forgive situation (β=-0.11, p<0.003) and higher intrusion symptoms (β=0.27, p<0.001), avoidance symptoms (β=0.26, p<0.001), negative alterations (β=0.16, p<0.001), and hyper-arousal (β=0.20, p<0.001). The only mediating variable was tendency to forgive the situation, which partially mediates between subjective exposure and all traumatic stress symptom clusters, and fully mediates between subjective exposure and well-being. The significance for all the intercorrelations between variables presented (Figure 1) was p<0.001.
The model explained 20% of the variance in intrusion symptoms, 14% of the variance in avoidance symptoms, 22% of the variance in negative alteration symptoms, 23% of the variance in hyper-arousal symptoms, and 20% of the variance in well-being.

Discussion

The primary purpose of the study was to examine the association between tendency to forgive (self, others and situation) and traumatic stress symptoms according to the updated PTSD subscales in the DSM 5 [5], as reflecting acute stress reactions and well-being among civilians exposed to rockets and missile attacks.
In accordance with previous research which found tendency to forgive as a significant internal resource when dealing with traumatic events including war and national or terrorist attack situations [27,52,53], our findings generally demonstrated that tendency to forgive is associated with reduced traumatic stress symptoms and higher well-being. This reinforces the COR theory [42] demonstrating the importance of personal trait as a resource when dealing with traumatic and stressful events.
However, not all the dimensions of the tendency to forgive were associated with reduced traumatic stress symptoms and wellbeing. Notably, among the three dimensions of the tendency to forgive, only tendency to forgive the situation was related to all four traumatic stress symptom clusters and to well-being. Moreover, tendency to forgive the situation was the only dimension found which mediated the relationship between subjective exposure and traumatic stress symptoms as well as well-being. This finding emphasizes the importance of the varied dimensions of forgiveness and their relationship to potentially different traumatic events. Possibly, the strong impact of tendency to forgive the situation is related to the unique circumstance of civilians being targeted by distant missiles and rocket fire. Unlike cases of rape, abuse, assault, or violation of rights – situations in which the traumatic event might be refereed and addressed to a specific offender who can be pointed out addressed physically during war, civilians are targeted by distant missiles and rocket fire with no tangible connection to them. These circumstances, which preclude any personal or social connection, might influence the perception of the situation as destiny, god’s will or fate, which might weaken the association between tendency to forgive others or self, and enhance situational forgiveness.
In contrast to previous studies, which did not find significant associations between forgiving the other and PTSD [25,32], our model shows a significant path to forgiving the other, along with an avoidance of the cluster of traumatic stress symptoms. Furthermore, while the expectation was to find a negative association with forgiving the other, and avoidance, our findings revealed a positive association. A possible explanation for this variance could be due to the way PTSD was measured in previous studies. While previous studies examined PTSD as one construct referring to the entire PTSD scale, the present study examined each of the clusters separately, thereby allowing more focused and precise findings. Nevertheless, this explanation still leaves us with a question regarding the positive association. One possible answer, based on Monson and Shnaider [60], is that victims tend to forgive the other as a way of avoiding negative feelings related to blame and anger. Thus, forgiving the other can be perceived as avoiding dealing with the traumatic event. Another possible explanation refers to the specific context – living under constant missile attacks – which influences the quality of the tendency to forgive. In such a stressful situation, the decision to forgive the other might create ambivalent feelings, which can be resolved by avoiding the need to deal with the other directly or indirectly and therefore might result in higher avoidance symptoms. In this context, avoidance might be used as a kind of defense mechanism that helps confront the ambivalent feelings towards the other.
Regarding the relationship between tendency to forgive the other and well-being, based on our findings it is possible to perceive the tendency to forgive the other as a resource for well-being. Additionally, our findings demonstrate the importance of measuring mental health from pathological (PTSD symptoms) and health (wellbeing) perspectives during acute stressful situations such as war.
Notably, objective and subjective threat were not associated directly with well-being. However, subjective threat was associated with well-being through the mediation of tendency to forgive the situation. Conceivably, well-being, which is often perceived as a general personal construct, is not associated with short-term acute stress (2-4 weeks of war). However, a situation of war may be perceived as an uncontrolled situation, reflected in a subjective threat and associated with a personal trait – the tendency to forgive the situation as a personal trait, tendency to forgive associates with well-being. These findings demonstrate the differentiation between objective and subjective threat as two independent variables, and calls for further study.

Limitations and Implications

Several limitations of the study dictate treating it with caution. The first limitation is its cross-sectional design. The second limitation is based on the technique used to recruit respondents. Internet-based recruitment is inherently biased in favor of Internet responders. However, in light of the circumstance of recruiting individuals under fire, this recruitment process can be regarded as an acceptable tradeoff. In addition, although the study assembled the largest sample to date in measuring tendency to forgive, PTSD, and well-being in a noncombatant population exposed to heavy rocket and missile attacks, the sample size is relatively small and includes an Israeli population only, which may limit generalization to a broader population. Thus, further studies in other cultures are recommended. It would be especially interesting and important to assess the Palestinian non-combatant population on the other side of the border who were also exposed to, and suffered from, massive attacks by the Israeli army. Lastly, the study took place as the traumatic events unfolded. Although no significant differences were found between the participants who filled out the study questionnaires, research literature has demonstrated that cumulative traumatic events might serve as a risk factor in increasing traumatic symptoms. Therefore, caution should be used when drawing conclusions from the research findings.
Despite these limitations, the study has theoretical and practical implications. Its theoretical contribution focuses on the complexity of the tendency to forgive, with each dimension independently influencing each one of the PTSD clusters, and well-being. Notably, PTSD measures were used for their potential to show acute stress disorder. Further research is needed to determine the precise relationships between these concepts.
The contribution to clinical practice underscores the importance of acknowledging each dimension of the tendency to forgive in treating people who were exposed to potential traumatic events such as wars, and to use this knowledge as an important resource for maintaining well-being and reducing potential PTSD symptoms. Mental health practitioners in societies living in such situations might develop programs that acknowledge and enhance the tendency to forgive, especially by emphasizing the situational dimension. In addition, following the new conceptualization of PTSD, an assessment of each one of the aspects separately in order to determine the specific type of traumatic symptoms that needed to be treated is recommended. Our study shows that exposure to war does not necessarily impact all the cluster PTSD clusters. Special attention needs to be given to the difference between objective and subjective exposure to the traumatic event, since they have different associations with PTSD clusters and the tendency to forgive. Working through experiences that construct the subjective experience may reduce the sense of subjective threat and lead to lower PTSD symptoms.

References





























































Track Your Manuscript