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By Kimberly Leonard June 7, 2020
Introduction/Thesis

“But God remembered Noah” begins the next phase of the familiar story of Noah’s ark as Noah, his family and an ark full of animals find themselves adrift for months with nothing but water as far as they can see, the lone survivors to an earth changing flood (Holy Bible: New International Version, 2002, Genesis 8:1a).  These four words share the value of coming alongside and seeing the needs of a human after tragedy.  While as humans, it may be impossible to know exactly how to do so most effectively, there is research suggesting the real benefits of social support for those who experience Posttraumatic Stress Disorder (PTSD).

The need for social support is of particular importance in large traumatic events to include natural disasters, mass shootings, and even pandemics to name a few.  Moukaddam and Shah (2020) imply “Panic and stress have also been linked to outbreaks” (p. 11), which demonstrates the vast number of individuals who will benefit from support.  As Florez, et al. (2017) share “lifetime prevalence rates [of PTSD] in the United States are estimated at 8%” (p. 46) reinforces the need for research discovering effective social support has the potential to impact many lives.  Much of the current research has focused primarily on the military and its effects; however, the author also recognizes the value of understanding the trauma that large group disasters can inflict upon many in a compressed amount of time.

These large traumas create unique needs and challenges for physical, socioeconomic and the oft forgotten mental health challenges, and have the potential to overwhelm systems already in place.  Humans, themselves, have been wired to “consider how we may spur one another on toward love and good deeds” (NIV, 2002, Hebrews 10:24).  So, while the research is growing about PTSD itself, there is value in understanding the connection between PTSD and social support, the research behind this, the psychological theories to integrate the research, the multi-levels of social support, and recommendations going forward to come alongside those who have experienced trauma in their lives in the most effectives ways.

 Problem Question

Looking at PTSD from a large lens with many potential topics to investigate, the author has chosen to focus in and examine the question if social support will create greater resiliency and progress for those with PTSD especially from large traumatic events.  This question is particularly relevant within our current world situation as the author has been curious about the mental health effects to come from months of quarantine and isolation.

First, as with any large group trauma that may appear similar to all involved, it is crucial to remember “On an individual level, it may differentially exacerbate anxiety and psychosis-like symptoms as well as lead to non-specific mental issues” (Moukaddam & Shah, 2020, p. 12).  PTSD seems to be more commonly accepted by society to occur for those in combat, but in reality, because of the frequency, “civilian traumas have been the trigger of stress disorders at least 10 times as often as combat traumas” (Comer & Comer, 2018, p. 160). Misperceptions like these according to Correll, et al. (2020) demonstrate “a primary barrier to mental health treatment seeking is stigma” (p. 1).

Second, due to the sheer size of individuals in need of assistance during a large- scale event, social support can have a significant role in the life of someone with PTSD.  Maercker and Hecker (2016) share “that ‘(perceived) social support’ as the most important variable was negatively related to PTSD symptom severity” (p. 2), demonstrating the effectiveness of bringing others alongside in the aftermath of trauma.  Third, for both the individual with PTSD and the supporters it is important to recognize the value of resiliency. Resiliency, as defined by Macedo, et al. (2014), is “the effective adaptation after significant threats to personal and physical integrity” (p. 2).

It is time and effort well spent developing healthy adaptive emotional and stress relieving resilience as Powell, et al. (2019) point out that natural disasters can reoccur within the same population causing “emotional distress, putting disaster survivors at risk for grief, anxiety, substance use, and posttraumatic stress disorder (PTSD), depression” (p.1-2).  Finding effective social support for those working through PTSD in large scale trauma’s that can lead to greater resiliency for both the trauma survivor and those in the support role can be healthy adaptations for all.

 Literature Review/Research

Developing the question to research the overall effectiveness of social support for those individuals with PTSD requires looking at research from several perspectives: PTSD-military perspective, PTSD mass trauma, quality versus quantity support, resiliency and posttraumatic growth, spirituality.  Significant focus of PTSD research has been directed towards military and combat traumas.  There are applications to be made such as Correll, et al. (2020) finding “the need to focus on the roles society and institutions play in the construction and maintenance of stigma” (p. 7) in regards to how as a society trauma is viewed and supported.  They continue to emphasize “inaccurate information” (p. 7) by the media has played a role in reinforcing the stigma through the way those with severe trauma stress like PTSD are portrayed (Correll et al., 2020).

Whether this is the view society holds for those suffering from combat or natural large disasters, education and involvement by others who are able is the key to addressing the stigma and giving resources to those who are in the supportive roles of those trauma survivors.  Maercker and Hecker (2016) imply that there are three areas to address and provide therapeutic modeling and support for both the individual with PTSD and those within connection. They include social affects, therapy and education for emotion regulation examples like guilt and shame; close relationships, education and therapy for all; and culture and society, mental health programs designed to address large traumas.  Of special note, is the importance of preparing for trauma in children as Stevenson, et al. (2009) explain “During a severe pandemic, community mitigation strategies are likely to cause stress and confusion among children, as well as parents and other family members” (p. S258).

Understanding the groups and community that trauma survivors are a part of is important.  In addition, Shang, et al. (2020) contends in their study of survivors from the Lushan earthquake that survivors who “appraised the post disaster social support they received as higher in quality, greater amounts of received support were associated with more subsequent PTG [posttraumatic growth]” (p. 6) and by contrast greater quantity did not facilitate similar growth.

Discussing growth in a trauma survivor as mentioned above also needs to be defined because there are many opinions that growth means complete in the healing process.  Instead, a more effective understanding involves building resiliency that include understanding the phases post trauma, building mindfulness, and including the role spirituality also plays in fostering posttraumatic growth.  Hung, et al. (2019) share the stages include the injury event(s), acute treatment phase, rehabilitation phase, and the adaptation phase, and that “Individuals who described having strong social support from friends and families in different recovery stages generally expressed more hope and reduction in distress” (p. 51).

The value of strong social support even perceived social support (PSS) is backed by Simon, et al. (2019) endorsing “an opportunity to develop and enhance skills training by specifically targeting factors relating to PSS” (p. 8).  As both the trauma survivor and the social support work in connection, tools such as mindfulness can help both members to work through the trauma, survivor’s guilt and deepen relationship connections through this process.

Mindfulness, as defined by Harrington (2013), focuses on “the state of being attentive and aware of what is taking place in the present” (p. 57).  Gilbert (2014) supports the affect of mindfulness asserting it can help put “people into what is called ‘being mode’ rather than ‘doing mode’” (p. 16) and is very effective for building relationships in trauma survivors and for reducing the instincts of fight or flight that is common among individuals with PTSD.  Mindfulness is part of acceptance that builds on resiliency and studies support the impact of this acceptance and spirituality is a powerful support system when engaged by the PTSD member and their support.

Faith will oftentimes go through a transitional period amongst those with PTSD.  In fact, Kuile and Ehring (2014) note that faith oftentimes is an unpredictable measure for those learning to work through their PTSD.  It is important that social support recognize this questioning and changes as “traumatic events can lead to both increases as well as decreases in religious beliefs and activities” (p. 359) is common.  A powerful reminder is God is faithful through the questioning and searching.  Isaiah declares “He was beaten so we could be whole.  He was whipped so we could be healed” (Holy Bible: New Living Translation, 2013, Isaiah 53:5b).  This demonstrates the ultimate social support as Christ took on the traumas of individuals in order to bring healing.

Integration of Psychological Theories

When developing impactful support for those with PTSD, there is value in looking at the psychological theories that can influence those involved.  Three theories this author intends to address are developmental theories, social psychology theories, and compassion/empathy theories.

Developmental theories are relevant because they have the ability to provide an understanding framework to work from with an individual with PTSD.  The author believes this does not provide excuses for maladaptive behaviors, but instead reflects the reality that if a trauma survivor has not experienced healthy, supportive relationships in their childhood, it is more difficult for them to see the value in them as they work through their trauma.  Horney believes one of the most vital needs is safety in the childhood years and Erikson’s lifespan model emphasizes the importance of children completing each stage of development to build adaptive coping (Schultz & Schultz, 2017).  Within current research, Simon, et al. (2019) share the vital role social support offers in trauma “drawing on the importance of attachment styles and systems, with increasing evidence that attachment plays an important role in the development and maintenance of PTSD” (p. 6).

The research supports the impact early childhood development can have on a trauma survivor’s ability to welcome social support and the impact it can have on relationships.  For the trauma survivor, having grown up with maladaptive relationships, this may present as negative affects in their current relationships, since childhood experiences have them “caught in a cycle of stress with little or no opportunity to develop self-regulation, resilience or supportive attachment” (Roberts, 2019, p. 144).  Understanding the developmental needs leads to more effective social support in creating meaningful relationships that promote healing.

The social support surrounding trauma survivors is best viewed through the lens of social psychology.  Because many who would desire to engage in supportive roles are unsure of the role they can play, even with those closest to them.  Stigma and lack of understanding can leave many individuals with PTSD alone and without the very support that can offer the potential for posttraumatic growth they desire.  Sabates (2012) describes an individual’s “need for social connection is so strong and central to our being that they [Baumeister and Leary] refer to it as the fundamental need to belong” (p. 110).  Stanley, et al. (2019) address the stigma against receiving necessary support in research conducted on firefighters with PTSD and emphasize “Greater perceptions of belongingness and social support have been shown to mitigate the severity of PTSD symptoms following exposure to a traumatic event” (p. 552).  In the case of these firefighters, this looks like support and openness from their fire chief and others in leadership positions to create a more open environment to seek assistance.

There is additional pressure to meet social norms due to a lack of understanding or compassion towards those with PTSD or trauma in general, doing so to put “a more comfortable psychological distance and pushing the person away with it” (Nolasco, Jr. & MacDonald, 2016, pp. 25–26).  Teaching compassion in order to close the distance requires “a large degree of intentionality, willingness or choice that must be carried out on a regular and daily manner” according to Noalsco and MacDonald (2016, p. 67).  This intentionality is discussed by Shteynberg, et al. (2020) in their research on social learning theory in regards to trauma. Sharing not only is it of value to know how to educate others, but also to have “The ability to think together…when facing challenges that overwhelm an individual mind’s capacity to resolve” (p. 10).

A reminder that “Two people are better off than one, for they can help each other succeed” (NLT, 2013, Ecclesiastes 4:9).  It is crucial to recognize the many ways a person’s development, understanding of social biases and compassion can impact the way in which social support will be adaptive or maladaptive in coming alongside the trauma survivor.

 Cultural Diversity, Social, and Ethical Issues

Understanding human development and nature are not the only areas to investigate.  There is sufficient research to support the need to understand the culture, social and ethical issues when offering supportive assistance to an individual or community who have experienced trauma.  One of the largest detractors to effective social support is not understanding the culture that is in need.  This includes understanding the economics of a culture as education levels may determine the way information can be shared.  Schnyder, et al. (2016) point out that cultural competency, recognizing cultural differences, is vital in treating and supporting trauma survivors.  Additionally, Schnyder, et al. (2016) imply understanding the difference between individualist versus collectivistic cultures, where within “collectivistic cultures, harmony within the group is of highest priority” will alter the way social support will be the most impactful.  Recognizing multiple disaster traumas within a coastal community can “undermine feelings of safety, security, and hope for the future” (Lowe et al., 2019, p. 201) will also play a role in the way social support will be most effective as it will be important to provide more on-going support.  These are representative of the many cultural obstacles that can impede well meaning social support for those trauma survivors.

There are a multitude of social issues that can positively and negatively affect support.  The author will address just a few in this discussion.  Maercker and Hecker (2016) indicate that broadening social support post trauma can be impactful when “Interventions that aim at improving the community situation after traumatic events…give people a voice, encourage actions against deterioration of social support over time” (p. 6).  This positive affect allows those most impacted by a traumatic large-scale event to have a part in their healing both individually and socially within their care of their own community.

Great caution needs to be taken to ensure it is sensitive to those most impacted.  As previously mentioned, there is social stigma of those with mental illness which then “contributes to self-stigma, or the social and psychological effects of being stigmatized” (Correll et al., 2020, p. 1) which can lead others to hide their need for assistance.  Perhaps one of the most tragic social issues this author has discovered is when culture and social climates combine to tragically burden those already suffering greatly.  Wang, et al. (2019) illustrate this as they describe the increase in PTSD and suicidal ideation amongst grieving parents who have suffered the loss of their only child.  These shidu parents as they are referred to not only are left to deal with the unimaginable death of their only child, but are also culturally shunned for no longer having a role in society. Examples like these show that social impacts can have adaptive properties, as the community interventions, or maladaptive properties, as life altering for those who do not fit the societal expectations.

Given the cultural and social impacts, ethically there are ways that can impact social support with great care taken.  From a professional perspective, there are research ethics put into place by the American Psychological Association (2017) so that any research performed in these areas cannot cause greater harm to those suffering.  Along with those protective provisions, training can be valuable in career fields that may have more impact on supporting PTSD individuals than previously understood.  Prescod and Zeligman (2017) offer career counselors, for example, “will infuse work on coping skills into their career counseling to ensure clients have healthy coping skills for moving forward in all areas of their lives, including vocational areas” (p. 117).  It is valuable social support to help a trauma survivor be able to work again and understand their needs for assistance are realistic.  Finally, spirituality must be recognized as an important part of a trauma survivors healing as Kira, et al. (2019) share in their research demonstrating the role between religion and higher PTG.  Jesus himself speaks of the choice he offers “I am the gate; whoever enters through me will be saved.  He will come in and go out and find pasture” (NIV, 2002, John 10:9).  Ethically, it is important to pursue ways that will provide healing social support that does not further harm the traumatized individual.

Solution

When looking at the larger question of how can social support be most effective to come alongside those with PTSD, the author recognizes there are no perfect solutions. Thankfully, there are many steps that can be taken to move towards those in need.  First there is proactive intervention as Yoon, et al. (2016) share having a system in place that provides “information to quarantined individuals during monitoring concerning managing psychological difficulties that might arise during quarantine and using the consultation service” (p. 3).  As this was provided during the MERS outbreak in South Korea and found to be effective with most only requiring one session to develop coping strategies.

Second, there is the recognition that support for both the individual and those in social support roles is highly effective.  It allows for education, communication and a reduction in compassion fatigue for both.  Social support both actual and perceived lead to greater relationship skills, coping skills and even immune functioning to name a few (Harrington, 2013) which is important for a trauma survivor to be able to reconnect with those who care about them.  A holistic approach as mentioned by Correll, et al. (2020) “may hold the key to improving the quality of life for both service members and civilians with PTSD” (p. 8).  This is reinforced by the Apostle Paul sharing “Be joyful in hope, patient in affliction, faithful in prayer” (NIV, 2002, Romans 12:12) as the spiritual needs are well researched.  Florez, et al. (2017) assert “having a sense of meaning in one’s life appears to have a greater impact in protecting at-risk individuals with PTSD from becoming hopeless and suicidal” (p. 55).   All of these areas demonstrate the need to have a well-rounded approach to offer the best social support for those with PTSD.

 Conclusion

Throughout this exploration of the value of social support for those with PTSD and traumatic exposures, the research is behind the need for increased, meaningful support.  The individual and community needs will dictate the methods going forward.  One of the primary reasons the author wanted to address this topic is because there is a great concern in the months and years ahead of an overburdened mental health system in light of the current pandemic and its ramifications still be fully felt.  Community social support may be all some will need and it might also be the first interactions to getting individuals to more intensive help that they need as awareness grows.

Family and friend social support is validated by Price, et al. (2018) implying “elevated perceived social support during PTSD treatment is associated with improved treatment response” (p. 267), and Ecclesiastes 4:12 reminds “A person standing alone can be attacked and defeated, but two can stand back-to-back and conquer.  Three are even better, for a triple-braided cord is not easily broken” (NLT).  Coming alongside another individual, showing compassion is reflecting the “mind of Christ” (Nolasco, Jr. & MacDonald, 2016, p. 59) towards those most in need.  Luke chapter ten reminds us of the story of the Good Samaritan and how those most assumed capable of helping the man beaten and left for dead did not stop and help because of a lack of compassion, but it was the one least likely to offer assistance in the end who stepped up and saved a life.

As the research bears out and Sabates (2012) shares we are created to belong.  There are times that in large traumatic events there might not be the right amount or even the right background to help another, but it will be compassion that ultimately bridges those inadequacies to help a traumatic survivor find hope because they are not standing alone.  “Because of the Lord’s great love, we are not consumed, for his compassions never fail” (NIV, 2002, Lamentations 3:22).  When an individual finds themselves in a place where they need help to walk through their darkest days, the social support of others and the reminder of the ultimate hope that comes from Christ can lead the way to healing and hope for a more expectant future.

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