Preparation of this manuscript was supported by the Department of Veterans Affairs, including grant CDA-2-019-09S (Jeremiah A. Schumm). Content of this manuscript does not necessarily reflect those of the United States Government or Department of Veterans Affairs. We thank Misty Wolfe and Lindsey Davidson for their assistance in verifying and coding data.
Associations Between Perceived Social Reactions to Trauma-Related Experiences With PTSD and Depression Among Veterans Seeking PTSD Treatment
Article first published online: 22 JAN 2014
Copyright © 2014 International Society for Traumatic Stress Studies
Journal of Traumatic Stress
Volume 27, Issue 1, pages 50–57, February 2014
How to Cite
Schumm, J. A., Koucky, E. M. and Bartel, A. (2014), Associations Between Perceived Social Reactions to Trauma-Related Experiences With PTSD and Depression Among Veterans Seeking PTSD Treatment. J. Traum. Stress, 27: 50–57. doi: 10.1002/jts.21879
- Issue published online: 10 FEB 2014
- Article first published online: 22 JAN 2014
- Department of Veterans Affairs. Grant Number: CDA-2-019-09S
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- Traditional and Simplified Chinese Abstracts by AsianSTSS
The Social Acknowledgment Questionnaire (SAQ; Maercker & Mueller, 2004) is a measure of trauma survivors’ perceptions of social acknowledgment and disapproval from others, and these factors are shown to be associated with posttraumatic stress disorder (PTSD) among civilian trauma survivors. This study seeks to validate the structure of the SAQ among U.S. military veterans and test the hypothesis that family and general disapproval are associated with PTSD and depression among veterans. Participants were 198 U.S. veterans who experienced military trauma and completed an intake evaluation through a Veterans Affairs PTSD treatment program. Structural equation modeling (SEM) results supported a well-fitting 3-factor model for the SAQ that was similar to prior studies in capturing the constructs of social acknowledgment, general disapproval, and family disapproval. SEM results also showed that all 3 of the SAQ factors were associated with veterans’ depression (−.31, .22, and .39, respectively), whereas only general disapproval was related to veterans’ PTSD. This is the first study of which we are aware to investigate the factor structure of the SAQ in a veteran sample and to investigate the relationship between SAQ factors and trauma survivors’ depression. Results build upon prior findings by showing the importance of positive and negative social reactions to veterans’ traumatic experiences.
Traditional and Simplified Chinese Abstracts by AsianSTSS
撮要：社會確認問卷(SAQ; Maercker & Müller, 2004)量度創傷倖存者對社會確認和他人不贊同的感受，而這些因素與平民創傷倖存者的創傷後壓力症(PTSD)相關。本研究在美國退役軍人中驗證SAQ結構，並測試關於退役軍中家庭不贊同及普遍不贊同和他們的PTSD及抑鬱有相關的假設。參與者是經歷戰事創傷的198名美國退役軍，他們完成退役軍人事務PTSD治療專案的接受治療評估。結構方程式模型 (SEM) 結果支持一個SAQ 3-因子模型，與前人研究中社會確認，普遍不贊同和家庭不贊同的建構類似。SEM結果亦指出所有三個SAQ因子與退役軍的抑鬱症相連(分別是 -.31, .22和 .39)，而只有普遍不贊同是與PTSD相連。本文是首個在退役軍人樣本中檢視SAQ的因子結構，和研究SAQ因子與創傷倖存者抑鬱症的關係的研究。結論與前人研究一致，顯示社會反應的正反面都對退役人員的創傷經歷有着重要影響。
撮要：社会确认问卷(SAQ; Maercker & Müller, 2004)量度创伤幸存者对社会确认和他人不赞同的感受，而这些因素与平民创伤幸存者的创伤后压力症(PTSD)相关。本研究在美国退役军人中验证SAQ结构，并测试关于退役军中家庭不赞同及普遍不赞同和他们的PTSD及抑郁有相关的假设。参与者是经历战事创伤的198名美国退役军，他们完成退役军人事务PTSD治疗项目的接受治疗评估。结构方程式模型 (SEM) 结果支持一个SAQ 3-因子模型，与前人研究中社会确认，普遍不赞同和家庭不赞同的建构类似。SEM结果亦指出所有三个SAQ因子与退役军的抑郁症有关系(分别是 -.31, .22和 .39)，而只有普遍不赞同是与PTSD有关系。本文是首个在退役军人样本中检视SAQ的因子结构，和研究SAQ因子与创伤幸存者抑郁症的关系的研究。结论与前人研究一致，显示社会反应的正反面都对退役人员的创伤经历有着重要影响。
Negative social reactions toward trauma survivors are damaging to trauma survivors’ posttraumatic psychological adjustment. Examples of negative social reactions include perceptions that others are underestimating the severity of one's traumatic experiences or that others do not understand the negative consequences of these traumas. Ullman and Filipas (2001) found that negative reactions of others toward trauma disclosure were positively related to female sexual assault survivors’ posttraumatic stress disorder (PTSD) severity. Ullman (2007) and Ullman and Filipas (2005) demonstrated that after controlling for abuse severity, survivor self-blame, and survivor coping, negative social reactions that others had toward adult sexual abuse survivors were positively associated with their PTSD symptoms. In contrast, positive social reactions were not significantly related to survivors’ PTSD symptoms.
Maercker and colleagues examined the impact of social reactions toward trauma survivors among various samples, including German interpersonal crime victims, former German political prisoners, and Chechnyan refugees (Maercker & Mueller, 2004; Mueller, Moergeli, & Maercker, 2008; Maercker, Povilonyte, Lianova, & Pöhlmann, 2009, respectively). These researchers developed a measure of social reactions toward the trauma survivor called the Social Acknowledgment Questionnaire (SAQ). The SAQ measures three distinct sociocognitive domains: Recognition (perceiving that others offered sympathy or help), General Disapproval (perceiving that the general society does not understand the survivor's responses), and Family Disapproval (perceiving that the family underestimates the survivor's traumas or believes that the survivor's reactions are exaggerated). The SAQ total score had a stronger relationship to PTSD than a conventional measure of social support (Maercker & Mueller, 2004) and was longitudinally predictive of PTSD over and above a well-established measure of dysfunctional trauma-related cognitions (Mueller et al., 2008). General Disapproval was positively predictive of later PTSD, after accounting for other risk factors (Mueller et al., 2008). These findings show that social reactions to trauma survivors are distinct, important constructs and provide further evidence that disapproving and unsupportive social reactions are predictive of survivors’ PTSD.
Two studies examined how social reactions impact PTSD among male Vietnam veterans. Using a large-scale community sample of Vietnam combat veterans, Fontana and Rosenheck (1994) showed that after accounting for risk factors such as combat severity and noncombat traumas, veterans’ perceptions of negative societal and familial homecoming reactions toward them were strongly and positively related to veterans’ PTSD. In another large-scale study of male Vietnam era veterans, Koenen, Stellman, Stellman, and Sommer (2003) found that after accounting for prior PTSD, combat exposure severity, and discomfort in disclosing their war experiences, veterans’ perceptions of negative community reactions were longitudinally and positively predictive of veterans’ PTSD; however, veterans’ perceptions of positive family support in readjusting to civilian life were unrelated to their PTSD. These findings are consistent with those from nonveteran samples (Mueller et al., 2008; Ullman, 2007; Ullman & Filipas, 2001, 2005), and may be explained by negative social reactions having a stronger relationship to PTSD than positive social reactions. It is also possible, however, that perceptions of societal versus familial responses to trauma survivors may differentially relate to survivors’ PTSD.
The first goal of the current study was to test the factor structure of the SAQ (Maercker & Mueller, 2004) in a U.S. veteran treatment-seeking sample. We chose to examine the SAQ because this instrument provides a multilayered assessment of trauma survivors’ perceptions of societal, community, and familial reactions to their traumatic experiences. Another advantage is that the SAQ is applicable to veterans experiencing both combat and noncombat trauma. The SAQ was originally developed and tested in a German sample of crime victims and political prisoners; therefore, one goal was to test the hypothesized latent factor structure and convergent validity of the English language SAQ in a U.S. veteran sample. Maercker and Mueller (2004) used principal components factor analysis to test the structure of the SAQ. We built upon Maercker and Mueller's (2004) approach by using structural equation modeling (SEM), which provides various tests of overall model fit (Kline, 2011).
This study had several other goals. First, studies by Fontana and Rosenheck (1994) and by Koenen et al. (2003) involved male Vietnam veterans who were surveyed 10–20 years ago. The current study sought to replicate the findings that social reactions are related to PTSD in a more recent sample of U.S. veterans. Second, the present study expanded upon prior research (Littleton, 2010) by examining whether social reactions are related to depression in addition to PTSD. Understanding the link between social reactions to trauma survivors and depression among veterans will be an important advance because depression is a common co-occurring problem that frequently affects trauma survivors (e.g., Breslau, Davis, Peterson, & Schultz, 2000). Third, the current study built upon prior community- and university-based samples of trauma survivors to examine the relationship between social reactions and psychological outcomes among veterans who are seeking PTSD treatment.
Based upon prior research, we had the following hypotheses. 1. First, consistent with Maercker and Mueller's (2004) factor analytic results, the SAQ would exhibit a well-fitting, intercorrelated 3-factor model solution reflecting underlying constructs of Recognition, General Disapproval, and Family Disapproval. 2. Second, negative social reactions (i.e., General Disapproval and Family Disapproval) would be positively associated with veterans’ PTSD and depression. 3. Third, negative social reactions (i.e., General Disapproval and Family Disapproval) would have a stronger relationship with veterans’ PTSD and depression than positive social reactions (i.e., Recognition).
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Participants and Procedure
Participants were 198 U.S. military veterans who completed an initial PTSD diagnostic assessment for an outpatient Veterans Affairs PTSD treatment program and whose worst-reported index trauma occurred in the military. Based upon the diagnostic assessment, three fourths of the sample met diagnostic criteria for PTSD and over half met criteria for major depressive disorder (MDD). Participants were an average of 44.01 years old (SD = 14.01) and had an average of 13.53 years of education (SD = 1.99). The sample was predominantly male of either Caucasian or African American descent. Over three fourths of the sample served in combat, and most served during either Vietnam or Operation Iraqi Freedom/Operation Enduring Freedom (see Table 1). Most veterans reported combat as their most severe index trauma.
|Had combat experience||165||83.3|
|Met diagnosis for PTSD||149||75.3|
|Met diagnosis for MDD||115||58.1|
|Witness to death||9||4.5|
Veterans completed a pretreatment diagnostic assessment that included gathering demographic data and completion of the study measures as part of a larger assessment battery. Because assessments were delivered as part of routine clinical care, assessments were not recorded and interrater reliability data were unavailable. Item-level data were collected for the SAQ, but not for other measures. The University of Cincinnati institutional review board approved the use of veterans’ archival chart data for the purpose of this study.
The SAQ (Maercker & Mueller, 2004) is a 16-item scale that measures social acknowledgement as a victim or survivor. Respondents rate each item on a 4-point scale that ranges from 0 = I agree not at all to 3 = I agree completely. There are three subscales: Recognition, General Disapproval, and Family Disapproval. Recognition is characterized by perceptions that others offered help or sympathy in response to the trauma. General Disapproval is characterized by perceptions of being a societal outsider and others not understanding one's struggles in response to the trauma. Family Disapproval involves perceptions that family members underestimate one's traumatic experiences and that the survivor's reactions are exaggerated. Higher scores on the General Disapproval and Family Disapproval subscales represent negative social responses, and higher scores on the Recognition subscale represent positive social responses to trauma. The SAQ subscales demonstrated high internal consistency, good test-retest reliability, and correlated moderately to strongly with other trauma-related constructs including PTSD severity and social support (Maercker & Mueller, 2004).
The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995, 2000) is a clinician-administered structured interview that assesses the frequency and intensity of PTSD symptoms based on diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000).
PTSD symptoms were counted toward meeting diagnostic criteria if the frequency was rated at least 1 (symptom occurs monthly) and intensity at least 2 (symptom is associated with moderate distress). The sum of the frequency and intensity ratings of PTSD symptoms produce the PTSD severity score with higher scores indicating greater symptom severity. The CAPS was also used to determine whether participants met diagnos-tic criteria for PTSD. The CAPS has established internal consistency (Blake et al., 1995) and has also demonstrated good-to-excellent interrater reliability and convergent and diagnostic criterion validity with veteran samples (Weathers, Keane, & Davidson, 2001).
The PTSD Checklist-Specific (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report measure of PTSD symptoms that corresponds with DSM-IV-TR diagnostic criteria. The items are summed to yield a total severity score ranging from 17 to 85, where higher scores indicate greater symptom distress. The PCL-S has demonstrated excellent internal and test-retest reliability in addition to strong convergent and discriminant validity within veteran samples (Weathers et al., 1993).
The Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002) is a semistructured clinical interview designed to determine whether a DSM-IV-TR Axis I diagnosis is present. For the current study, the results from the SCID were used to determine whether or not participants had a current diagnosis of major depressive disorder. The SCID has demonstrated good-to-excellent interrater and test-retest reliability (Zanarini & Frankenburg, 2001).
The Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item self-report scale that measures depression severity within the last 2 weeks. The item scores are summed to yield a total score range between 0–63. Higher scores indicate greater depression symptoms. The BDI-II has established psychometric properties including excellent internal and test-retest reliability and strong convergent validity (Beck et al., 1996).
Using Mplus (version 6.11; Muthén & Muthén, 2011), confirmatory factor analysis (CFA) was conducted to test the model fit of Maercker and Mueller's (2004) 3-factor model solution for the SAQ. The maximum likelihood estimator with robustness correction for nonnormality was used. Statistical fit was evaluated by examining the model χ2 test, comparative fit index (CFI; Bentler, 1990), Tucker-Lewis Index (TLI; Tucker & Lewis, 1973), and root mean square error of approximation (RMSEA; Browne & Cudeck, 1993). We also examined the structural coefficients of SAQ items to determine if items were adequate indicators of the hypothesized latent constructs.
We next tested the hypothesized relationships involving the SAQ factors as correlates of PTSD and depression. This was accomplished through structural equation modeling (SEM) in Mplus (version 6.11; Muthén & Muthén, 2011). Following Kline's (2011) procedures, SEM equations were computed stepwise. First, measurement models were computed to examine the fit of the observed variables to their corresponding latent factors. Second, structural regression models were computed to test the association between SAQ factors and PTSD and depression. PTSD was indicated by the following observed variables: CAPS total severity score, PCL-S total score, and whether participants met DSM-IV-TR criteria for PTSD based upon the CAPS. Depression was indicated by the following observed variables: BDI-II total score and whether participants met major depressive disorder diagnosis based upon the SCID. Because PTSD and depression diagnoses were dichotomous variables, we used the weighted least squares with mean and variance adjustment estimator.
The proportion of missing data was low (1.4% of the dataset). To account for missing data, the full information maximum likelihood method was used in CFA and SEM analyses.
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To test our first hypothesis regarding the SAQ factor structure, we conducted a CFA using Maercker and Mueller's (2004) 3-factor structure. The model fit indices showed an unacceptable fit. The model χ2 test showed that the hypothesized model significantly deviated from the observed data, χ2 (101, N = 198) = 198.46, p < .001. In addition, the CFI (.80) and TLI (.76) were below a suggested minimum value of .95 (Hu & Bentler, 1999), and the RMSEA (.07) 90% confidence interval (CI) = [.06, .08] was above a suggested maximum value of .06 (Browne & Cudeck, 1993).
Given the unacceptable fit for the initial CFA, we explored reasons for model misspecification and ways that the model could be respecified to improve the model fit. First, we found that the structural coefficient for SAQ item 9 (“My family feels that they have to protect me”) did not significantly load (p = .855) onto the hypothesized latent factor, which Maercker and Mueller (2004) labeled as Family Disapproval. In addition, the modification indices did not provide support for Item 9 being related to either of the other two latent factors in the model, which Maercker and Mueller (2004) called Recognition and General Disapproval. Hence, Item 9 was not a good factor indicator in the present sample and was, therefore, removed from the respecified CFA model. Second, although Item 5 (“The only people who really understand me are those who have been through something similar”) significantly loaded onto General Disapproval (p = .002), the structural coefficient for this item (.31) was below a suggested minimum acceptable value of .32 (Comrey & Lee, 1992) and did not load onto other factors. Therefore, we removed this item from the respecified CFA.
Model modification indices suggested several other changes would improve model fit. First, Item 1 (“Most people can understand what I went through”) was not significantly related to the latent factor General Disapproval. Modification indices suggested that the model fit would be improved by having Item 1 to load onto the Recognition factor. Therefore, the respecified model included Item 1 as a factor indicator of Recognition instead of General Disapproval. Second, modification measures showed that the model would be improved by allowing Item 11 (“My family showed a lot of understanding for me after the incident”) to load onto Recognition in addition to Family Disapproval. Rather than retain this item, we chose to remove it to avoid having this item load onto two separate factors. Third, modification indices showed that correlating the error terms between Item 14 (“Many people offered their help in the first few days after the incident”) and Item 16 (“My boss/superior showed full understanding for any absence from work after the incident”) would improve model fit. Following these changes, a respecified CFA was computed.
The respecified CFA achieved an adequate fit, χ2 (61, N = 198) = 78.06, p = .064; CFI = .96; TLI = .94; RMSEA = .04, 90% CI = [.00, .06]. In addition, item coefficients were in a consistent and expected direction with their hypothesized underlying factors, and two of the three factors were intercorrelated (see Tables 2 and 3). In summary, although we did not fully replicate Maercker and Mueller's (2004) exact factor structure for the SAQ, the respecified model provided partial support for our first hypothesis.
|Item||Factor 1||Factor 2||Factor 3|
|1. Most people cannot understand what I went through.||.39|
|2. Somehow I am no longer a normal member of society since the incident.||.70|
|3. The people where I live respect me more since the incident.||.56|
|4. There is not enough sympathy for what happened to me.||.36|
|6. My family finds my reaction to the incident to be exaggerated.||.59|
|7. Most people cannot imagine how difficult it is simply to continue with “normal” daily life.||.64|
|8. My experiences are underestimated by my family.||.85|
|10. My family feels uncomfortable talking about my experiences.||.43|
|12. My friends show sympathy for what happened to me.||.73|
|13. The reactions of my acquaintances were helpful.||.71|
|14. Many people offered their help in the first few days after the incident.||.56|
|15. Important figures of public life (e.g., mayor, priest) expressed their sympathy for me after the incident.||.52|
|16. My boss/superior showed full understanding for any absence from work after the incident.||.56|
|Factor ρ coefficient||.60||.79||.67|
|1. Factor 1 General Disapproval||–|
|2. Factor 2 Recognition||−.11||–|
|3. Factor 3 Family Disapproval||.42***||−.24*|
SEM Measurement Model
We next tested a measurement model to assess the model fit when PTSD and depression variables were included. The SAQ latent factors and observed indicators were identical to those described in the respecified CFA and shown in Table 2. Hence, there were 3 latent and 13 observed variables that were derived from the SAQ. PTSD and depression were modeled as latent variables. PTSD had three observed indicators (CAPS severity total, PCL-S total, CAPS PTSD diagnosis), and depression had two observed indicators (BDI-II total and SCID major depressive disorder diagnosis). Therefore, the model had a total of 5 latent and 18 observed variables.
The measurement model had reasonable fit. Specifically, the overall model fit indices were suggestive of a well-fitting model, χ2(124, N = 198) = 150.07, p = .0596, CFI = .96, TLI = .95, RMSEA = .03, 90% CI = [.00, .05]. All of the observed indicators loaded significantly onto their corresponding hypothesized latent factors (ps < .01). Item 4 loaded onto the General Disapproval latent factor at .28, however, which was below a suggested minimum value of .32 (Comrey & Lee, 1992). We removed Item 4 from the model and ran a respecified measurement model, which produced an adequate fit to the data, χ2(108, N = 198) = 116.53, p > .27, CFI = .99, TLI = .98, RMSEA = .02, 90% CI = [.00, .04]. Therefore, this respecified model was used as the basis for computing the structural model.
SEM Structural Model
To test our second and third hypotheses, we computed a structural model that included the three SAQ latent variables as correlates of PTSD and depression. The overall model fit was acceptable, χ2(108, N = 198) = 116.34, p = .275, CFI = .98, TLI = .97, RMSEA = .02, [90% CI = .00, .04]. Recognition was significantly and positively related to depression, but not significantly related to PTSD. The model regression pathways were mostly supportive of Hypothesis 2. Specifically, General Disapproval and Family Disapproval were significantly and positively related to depression. General Disapproval, but not Family Disapproval, was significantly and positively related to PTSD (see Figure 1).
To test Hypothesis 3, χ2 difference test for models utilizing the WLSMV estimator (Muthén & Muthén, 1998–2010) were calculated in Mplus (Muthén & Muthén, 2011). These difference tests compared the SEM equation that freely estimate the SAQ factors in accounting for PTSD and depression with models that constrain SAQ factors as being equal in absolute magnitude in accounting for PTSD or depression. Constraining the pathway from general disapproval to PTSD to be equal in absolute magnitude to the pathway from Recognition to PTSD did not significantly deteriorate the overall model fit, χ2(1, N = 198) = 2.89, p > .09. Constraining the General Disapproval and Recognition to be equal in absolute magnitude in accounting for depression also did not deteriorate the overall model fit, χ2(1, N = 198) = 0.22, p > .63. In comparing Family Disapproval to Recognition, constraining the absolute magnitude of these variables in accounting for PTSD did not deteriorate the model fit, χ2(1, N = 198) = 0.001, p > .97. Finally, constraining Family Disapproval and Recognition to be equal for depression did not result in worse model fit, χ2(1, N = 198) = 0.32, p > .57. Hence, contrary to Hypothesis 4, General Disapproval and Family Disapproval were not significantly more strongly associated with PTSD or depression.
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The first goal of this study was to replicate Maercker and Mueller's (2004) 3-factor structure for the SAQ within a sample of U.S. veterans seeking treatment for PTSD. Our findings provided support for a well-fitting, 3-factor model that was similar to the original findings for the SAQ among community samples of German trauma survivors. Hence, our results showed cross-cultural support for three distinct domains, which Maercker and Mueller (2004) labeled as Recognition, General Disapproval, and Family Disapproval. These findings add to the evidence that these sociocognitive constructs can be reliably measured among both civilian and military samples that have varying types of traumatic experiences.
Although our findings were generally supportive of the factor domains assessed by the SAQ, we found that several of the SAQ items contributed to model fit problems and needed to be respecified or removed from the model. For example, Items 5 (“My family feels that they have to protect me”) and 9 (“The only people who really understand me are those who have been through something similar”) had unacceptably weak coefficients in the initial model, and Item 4 (“There is not enough sympathy for what happened to me”) was found to be a poor SAQ factor indicator in the subsequent model that included SAQ factors along with PTSD and depression. This suggests that although many of the items performed similarly in the current U.S. military sample in comparison to prior studies of German crime victims and political prisoners (Maercker & Mueller, 2004) and Chechnyan refugees (Maercker et al., 2009), some of these items did not effectively reflect the hypothesized constructs for the current study sample. Given the greater emphasis on individualism within the United States combined with expectations that military members are trained “protector[s]” who have the ability to independently “tough out” negative emotions related to their trauma (Nash, Silva, & Litz, 2009), U.S. veterans may not view family members’ attempts to “protect” them as being a desirable way for families to show support or approval in response to veterans’ traumatic experiences. Also, among treatment-seeking U.S. military veterans, a lack of expressed sympathy may not be necessarily interpreted as behavior that reflects general disapproval toward their traumatic experiences. Rather, due to a tendency for individuals with PTSD to avoid discussing these experiences with others (Dekel & Monson, 2010), veterans who are entering but have yet to begin PTSD treatment may perceive that a lack of expressed sympathy from others in relation to the trauma is showing a degree of respect for their efforts to avoid conversing about these traumatic experiences. It is also possible that some veterans may interpret expressions of sympathy about the trauma as indicators that others perceive them as weak, which is in conflict with military values placing emphasis on strength in the presence of adversity (Bernam et al., 2008). Such findings are an important reminder that trauma survivors’ perceptions of others’ reactions may differ in specific ways that are dependent upon societal and cultural norms. Future qualitative studies may provide insight into the nuances of sociocognitive perceptions among traumatized veterans and the manner in which sociocognitive factors differ among groups of trauma survivors.
SEM equations fully supported Hypothesis 2 with regard to the relationship between the SAQ factors and depression. As hypothesized, General Disapproval and Family Disapproval were positively related to depression. In addition, Recognition was negatively related to depression. These SAQ factors accounted for slightly less than half of the variance in depression. Hence, our findings show that understanding societal- and family-level social reactions to trauma survivors’ experiences are especially relevant to explaining their depression. These findings build upon prior research on female rape survivors (Littleton, 2010), and this is the first study to investigate the relationship between social reactions and depression among veterans. The relationship between social reactions and depression may be partially explained by cognitive distortions and negative recall bias, which are characteristic of depression (Young, Rygh, Weinberger, & Beck, 2008). Our results suggest that by working to create balanced perceptions of these interactions, intervention programs designed to promote social recognition while reducing general disapproval and family disapproval may be especially useful in lessening the burden of depression among trauma survivors.
Hypothesis 2 was partially supported regarding the relationship between SAQ factors and PTSD. General Disapproval was positively and significantly related to PTSD, whereas neither Recognition nor Family Disapproval was significantly related to PTSD. These findings replicate results from previous studies in showing that trauma survivors’ perceptions of general disapproval in response to their traumas are positively related to their PTSD symptoms (Fontana & Rosenheck, 1994; Koenen et al., 2003; Mueller et al., 2008). These findings are also consistent with those of previous studies in showing that General Disapproval, but not Family Disapproval or Recognition, may be uniquely related to survivors’ PTSD (Koenen et al., 2003; Mueller et al., 2008). The reasons for the association between PTSD and General Disapproval, but not Family Disapproval or Recognition with PTSD, are not entirely clear. Prior research, however, indicates that the source of a social reaction can determine its influence (Ullman, 2010). It is possible that different sources of acknowledgement may become more or less influential based on factors such as trauma type, gender, or culture. Future studies with a broad range of samples may provide additional information regarding whether these variables influence the saliency of different social reactions toward the survivor.
Results from the current and prior studies suggest that trauma survivors’ perceptions of societal reactions toward them may play a unique role in relationship to PTSD. The current study's results add to the literature in showing that General Disapproval may be uniquely related to PTSD and depression, as this was the only SAQ factor to be significantly related to both outcomes. These findings reinforce one of the unfortunate lessons from the homecoming experiences of Vietnam combat veterans by showing that societal reactions that are perceived as being disapproving and unsupportive may be especially psychologically damaging in survivors’ attempts to recover from these experiences (Fontana & Rosenheck, 1994; Koenen et al., 2003).
We failed to find support for Hypothesis 3, as General Disapproval and Family Disapproval did not have a significantly stronger association with PTSD and depression versus Recognition. Given that General Disapproval, Family Disapproval, and Recognition were each significantly related to depression, this finding suggests that these sociocognitive domains may have a similar degree of importance in explaining depression. The findings regarding PTSD, however, are more complex. We cannot conclude from the SEM nested model comparisons that General Disapproval is significantly stronger in comparison to Recognition. However, our results do suggest that General Disapproval is unique in its ability to explain PTSD outcomes and should, therefore, be considered an important target for interventions that are aimed at promoting trauma recovery and reducing PTSD symptoms.
The current study has several strengths. This is the first study to examine social acknowledgement and disapproval among veterans from multiple military service eras who are actively seeking PTSD treatment. Additionally, this is one of the few studies to investigate the impact of social reactions on trauma survivors’ depressive symptoms. Finally, the use of SEM allowed us to test the precision of the hypothesized model to explain the underlying data and to partition out measurement error within the model.
Moreover, results from this study have important social and clinical implications. Social responses can affect PTSD and depression by shaping individuals’ perceptions regarding the causes and impact of the trauma (Ehlers & Clark, 2000). The current research provides additional information regarding the influence of social responses on PTSD and depression symptoms, which can inform treatment by indicating specific points of therapeutic intervention, such as challenging cognitions related to general social responses surrounding trauma and decreasing negative social reactions to trauma survivors.
Limitations should also be acknowledged. The cross-sectional design of the current study precludes the ability to understand temporal or causal relationships. Because the sample was composed of treatment-seeking veterans, these results may not generalize to veterans who are not actively seeking services for PTSD. Lastly, our data do not include measures of trauma disclosure or general social support, which are shown to be important in predicting PTSD (Mueller et al., 2008; Ullman, 2007). Although prior civilian sample studies have shown that social reactions are related to PTSD after accounting for such variables (Maercker & Mueller, 2004; Mueller et al., 2008), additional research is needed to understand how disclosure, social reactions to traumatic experiences, and general social support are interrelated and influential to military veterans’ psychological reactions to trauma. Finally, the number of subjects versus model parameters may have created issues with the model being overfit, and more robust factors loadings may have produced stronger relationships between positive and negative social reactions and psychological outcomes. Nonetheless, the model adds to the literature by showing that social reactions are important in explaining psychological adjustment following military traumas.
The current study aimed to test the associations between perceived social reactions to trauma-related experiences and PTSD and depression among a sample of treatment-seeking veterans. Results from the study coincide with prior research, thereby providing further support for the influential role of social reactions on posttraumatic outcomes. However, distinctions between the influence of different aspects of social acknowledgment (e.g., Recognition, General Disapproval, Family Disapproval) on PTSD and depressive symptoms indicate the multifaceted, complex role of social processes following trauma.
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