Post-traumatic stress disorder and Post-traumatic Growth among Police officials; Role of Coping Self Efficacy and Hope

Adversities in life can be disruptive in nature and there can be considerable variation in psychological reactions to stressful and tragic events with responses ranging from mild psychological symptoms to severe psychological symptoms like distress. ¹ Important events that can be traumatic in nature and can leave long lasting effects on the exposed population are war, personal (violent) assault (e.g., sexual assault, and physical attack), being hostage or kidnapped, being in prison, torture, being victim of terrorist attack, exposure to severe car accidents and natural disasters. Post-traumatic stress disorder (PTSD) is most common in the population exposed to tragic events.² Previous research showed that individuals who had higher exposure of trauma experience showed higher levels of distress. The level of distress can be measured by the severity of the symptoms like feeling of chronic sadness, worthlessness and loss of interest in interaction with other people. ³
Traumatic exposure can be a precondition for severe psychological reactions like posttraumatic stress, but not all individuals who face trauma suffer from PTSD. Posttraumatic growth is also reported in after math of trauma. ⁴ Posttraumatic growth includes positive consequences like positive change in social interaction, like improved relationship with others, improvement in personal strength and self-assurance and an increased sense of appreciation of life and change in priorities of life. There are many studies which have reported post-traumatic growth in the survivors of trauma. Post-traumatic growth and PTSD may co-exist after trauma exposure. There are factors that can be positively associated with one out of the two outcomes but negatively with the other. ⁵
Coping self-efficacy and Hope are important in after math of trauma. Coping self-efficacy is the belief that reflects control of personal actions and a personal and future view that is more optimistic. ⁶ After traumatic or tragic incidents, some individuals are more likely to find benefit and gains if they have strong self-efficacy and can avoid negative effects like post traumatic stress disorder. ⁷ Hope also plays a role between PTSD and PTG. Hope is a personal strength factor. This can prove a shield against post- traumatic stress disorder.⁸
Post-traumatic stress disorder development can be affected by the process adopted in face of adversities. Use of avoidant coping is linked with increased PTSD symptoms following a trauma, but on the other hand, use of active coping in relation with PTSD is equivocal. ⁹ Present study was conducted to investigate the under lying relationship between PTSD, War trauma and PTG and to explain the role of coping self-efficacy and hope among active duty police officials who have participated in war against terror and were directly exposed to trauma.
Pakistan has played an important role in global war against terror and being front line state has faced effects of this war by conducting combined operations to remove insurgency from the tribal areas and from the whole country.¹⁰. Pakistani police officials have played tremendous role along army in this war. The police troops present in federally administered areas of Pakistan remained closely engaged in combat. Police officials who participated in this war exhibited resilience in this war against terror, scarifying much more than any other police agency of any other country in the world. ¹¹

This cross-sectional study was conducted on active-duty police officials from Federally Administered Tribal Area (FATA) in 3 years duration (Jan 2019 to Dec 2021). Study participants were selected by using non probability purposive sampling technique. Inclusion criteria was police officials who had actively participated in war against terror and had direct exposure of trauma and were on post deployment in peaceful areas for 1 year. Sample size was calculated by Open epi calculator, and was estimated to be 192, with anticipate frequency of 50%, confidence limit 5 % and design effect 0.5. 200 police officials fitting in this inclusion criteria were included in the study with the response rate of 97%. Data was collected after approval of ethical committee of NIP (National institute of Psychology), permission from the concerned authorities, and after taking informed consent from the participants. Personal identity information was not taken and the confidentiality of the data was ensured.
Demographic data was collected by structured questionnaire. To determine the level of war related stress, Posttraumatic Stress Diagnostic Scale PDS-5(22 items) and short form of Comprehensive trauma inventory (20 items) were used. Hope and self-efficacy were assessed by Adult Hope Scale (12 items) and Perceived coping self-efficacy scale (26 items). Posttraumatic growth was assessed by Post traumatic growth inventory (PTGI-SF). Urdu versions of all tools were used. Analysis was done by using AMOS and SPSS version 21. Internal reliability was checked by Cronbach α, which was found satisfactory (> 0.6). After descriptive analysis of socio demographic variables such as education, age, marital status, duration spent in combat area, family system etc, correlation of variables was checked by Pearson correlation and moderation analysis was done.

This table shows the demographic variables, i.e. age, Level of education, marital status, family system ( extended or nuclear) , category, and duration spent in war.

Mean age of study participants was 33.6±6.3 years (21-56 years). Descriptive analysis of demographic variables is given in table 1. The internal consistency of all translated and adapted scales like Comprehensive Trauma, PDS-5 and Adult Hope scale showed acceptable internal consistency. Moss et al., (1998) has recommended the cutoff of α ≥ .60 for acceptable reliabilities. Skewness and Kurtosis were all in the acceptable range as suggested by Bulmer (2012) data, between -1 to +1 and -2 to +2 is considered as normally distributed. The ranges of the values of reliabilities were 0.84 to 0.93. These ranges were at satisfactory level. The skewness values also lied in acceptable range.

*p < .05, **p < .01*

Note. WT= War- trauma, PTSD= Posttraumatic stress Disorder, Hope = Hope, PSE= Perceived Self Efficacy, PTG = Post traumatic growth Study showed significant strong positive correlation of Hope and Perceived self-efficacy with Post traumatic growth and negative correlation with Post traumatic Stress Disorder (PTSD).War trauma and PTSD were positively correlated and PTSD and PTG marginally positively correlated.
Study showed significant strong positive correlation of Hopeand Perceived self-efficacy with Post traumatic growth and negative correlation with Post traumatic Stress Disorder (PTSD).War trauma and PTSD were positively correlated and PTSD and PTG marginally positively correlated.

Study confirmed moderating effects of perceived coping self-efficacy on war trauma and post traumatic growth. Moderation wasfound satisfactory for perceived and self-efficacy. Findings suggested a significant increase in post-traumatic growthafter math of exposure of trauma in presence of hope and perceived coping self-efficacy.

*p <.05.**p <.01.***p <.001.
Study confirmedmoderating effects of hope on war trauma and post traumatic growth. Moderation wasfound satisfactory for Hope. Findings suggested a significant increase in post-traumatic growth in after math of exposure of trauma in presence of hope.

This study was conducted to investigate the effects of war trauma exposure among police officials who participated in war against terror. Different studies have identified that war exposure is a significant predictor of post-traumatic stress disorder among affected population. But Post-traumatic stress is not the only outcome, sometimes experiencing such an event may result in greater motivation to make positive meaning of traumatic event, which leads to experience of positive consequences like post traumatic growth.¹² Factors which play protective role against post-traumatic stress disorder among the affected population are still understudied. ^{13, 14} Different expert studies have suggested that there are a multitude of factors that contribute for growth and boost resilience building among trauma survivors. In the present study, identification of the contributing factors of growth like hope and coping self-efficacy (which play a protective role against Post traumatic stress disorder) suggests the direction of the future research as well as potential areas like educating the exposed population to overcome the traumatic events. ¹⁵ Despite the reported negative reactions to tragic events, findings of different studies have proved that some people maintain psychological stability and different factors play important role in a meaningful positive change. ¹⁶ The study indicates that trauma exposure results in stress which can end into post-traumatic stress or growth. The moderating role of hope and coping self-efficacy positively predict growth in the after math of direct exposure of war trauma. Use of positive approach in coping leads the individuals to think positive about the trauma and promotes feelings of personal strength which turns into Post traumatic growth and reduces the chances of post-traumatic stress disorder. Results are consistent with the previous findings.^17,18
It was also confirmed from the findings that stress and PTG are positively correlated. These findings of the present study are in line with the previous studies. Present findings have confirmed that the co-existence of stress and growth is possible. ¹⁹. A growing body of research has identified variables that affect the relationship between trauma exposure, post-traumatic stress disorder and growth. These variables may be conceptualized as social and personal strength factors. Studies on the personal strength factors suggest that veterans with strong coping self-efficacy and hope suffer less from PTSD. ^19,20,21
War against terror was not a traditional war. The active-duty officials of police who had participated in this war and had direct and repeated exposure of trauma showed high levels of PTG and scored high in personal strength factors like hope and coping self-efficacy, results are persistent with previous research. ^{22, 23}.
The cross-sectional nature of the study, utilization of the self-report measures and use of non-probability sampling technique for sample selection are the limitations of the study. Family history of psychopathology was not included. Use of random sampling and longitudinal study design provides better qualification to generalization of the findings but due to time limitations and complex sample it was not possible to conduct longitudinal study. Findings have implications for soldier’s fitness programs, psychological intervention planning and health care programs for the active-duty officials of police who had faced tragedies during war on terror and other trauma survivor population.

Relationship between post-traumatic stress disorder and post-traumatic growth was moderated by perceived coping self-efficacy and hope.

More consideration is required to be given to enhance the role of the factors like perceived coping self-efficacy and hope as these factors may foster post traumatic growth in individuals and target stress and reduce the chances of PTSD.

1. Bromet EJ, Atwoli L, Kawakami N, Navarro-Mateu F, Piotrowski P, Alonso J, et al. Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys. J of PSY med. 2017 Jan; 47(2):227 doi: 10.1017/S0033291716002026 .
2. Shalev A, Liberzon I, Marmar C. Post-traumatic stress disorder. New England J of med. 2017 Jun; 376(25): 2459 doi: 10.1056/NEJMra1612499.
3. Sepahvand H, Hashtjini MM, Salesi M, Sahraei H, Jahromi GP. Prevalence of post-traumatic stress disorder (PTSD) in Iranian population following disasters and wars: a systematic review and meta-analysis. Iranian J of Psych and Beh Sci. 2019; 13(1):12. doi: 10.5812/ijpbs.66124.
4. Shuwiekh H, Kira IA, Ashby JS. What are the personality and trauma dynamics that contribute to posttraumatic growth? Intl J of Stress Management. 2018 May; 25(2):181. https://doi.org/10.1080/0000054 .
5. LaRocca MA, Scogin FR, Hilgeman MM, Smith AJ, Chaplin WF. The impact of posttraumatic growth, transformational leadership, and self-efficacy on PTSD and depression symptom severity among combat Veterans. Military Psychology. 2018 Mar 4;30(2):162-73. https://doi.org/10.1037/str0899605.2018./4250734
6. Tedeschi RG, Shakespeare-Finch J, Taku K, Calhoun LG. Posttraumatic growth: Theory, research, and applications. Routledge; 2018 Jun 12.https://doi.org/ 10.4324/9781315527451
7. Taku K, Tedeschi R G, Shakespeare-Finch J, Krosch D, David G, Kehl D, et al. Posttraumatic growth (PTG) and posttraumatic depreciation (PTD) across ten countries: Global validation of the PTG-PTD theoretical model. J of Pers. Individ Differ. 2021 Feb 1;169. https://doi.org/10.1016/j.paid.2020.110222
8. Zhou X, Wu X, Zhen R. Self-esteem and hope mediate the relations between social support and post-traumatic stress disorder and growth in adolescents following the Ya’an earthquake. Anxiety, Stress, &Coping. 2018 Jan 2; 31(1):32-45. https://doi.org/10.1080/10615806.2017./1374376
9. Cushing RE, Braun KL. Mind–body therapy for military veterans with post-traumatic stress disorder: a systematic review. The Jan of Alternative and Complementary Med. 2018 Feb 1;24(2):106-14. DOI: 10.1089 /acm.2018.0176
10. Khan R. National security imperatives of Pakistan peace in FATA and Afghanistan. J Pak Army G Book. 2016; 97-103.
11. Soherwordi H. Pakistan’s baneful courtship: No more frontline ally of US. J Pak Army G Book. 2016; 12-22.
12. Tamiolaki A, Kalaitzaki AE. “That which does not kill us, makes us stronger”: COVID-19 and Posttraumatic Growth. Psych Research. 2020 Jul; 289:113044. doi ;10.1016 /j.psychers.2020.113044
13. Foa EB, McLean CP, Zang Y, Zhong J, Powers MB, Kauffman BY, et al. Psychometric properties of the Posttraumatic Diagnostic Scale for DSM–5 (PDS5).Psychological assessment.2016Oct;28(10):1166.https://doi.org/10.1037/pas0000258.
14. Gori A, Topino E, Sette A, Cramer H. Pathways to post-traumatic growth in cancer patients: moderated mediation and single mediation analyses with resilience, personality, and coping strategies. J of Affect Disord.2021 Jan 15;279:692-700. https://doi.org/10.1016/j.jad.2020.10.044.
15. Thompson NJ, Fiorillo D, Rothbaum BO, Ressler KJ, Michopoulos V. Coping strategies as mediators in relation to resilience and posttraumatic stress disorder. J of Affect. Disord. 2018 Jan 1; 225:153-9. doi: 10.1016/j.jad.2017.08.049.
16. Finstad GL, Giorgi G, Lulli LG, Pandolfi C, Foti G , León-Perez JM, et al. Resilience, Coping Strategies and Posttraumatic Growth in the Workplace Following COVID-19: A Narrative Review on the Positive Aspects of Trauma. Int J of Environmental Research and Public Health. 2021 Jan; 18(18):9453. https://doi.org/10.3390/ijerph18189453
17. Raghavan SS, Sandanapitchai P. Cultural predictors of resilience in a multinational sample of trauma survivors. Frontiers in Psychology. 2019 Feb 5;10:131.https :// doi.org / 10.3389 /fpsyg.2019.0031
18. Hokes KE, Adams LM. The longitudinal development of posttraumatic growth among US adult burn injury survivors. Rehab PSY. 2022 Apr 14. https://doi.org/10.1037/rep0000447
19. Henson C, Truchot D, Canevello A. What promotes post traumatic growth? A systematic review. European J of Trauma & Dissociation. 2021 Nov 1;5(4):100195. https://doi.org/10.1016/j.ejtd.2020.100195
20. Park CL, Wilt JA, Russell BS, Fendrich MR. Does perceived post-traumatic growth predicts better psychological adjustment during the COVID-19 pandemic? Results from a national longitudinal survey in the USA. J of psych Research. 2022 Feb 1; 146:179-85. doi: 10.1016/j.jpsychires.2021.12.040
21. Chasson M, Taubman-Ben-Ari O, Abu-Sharkia S. Posttraumatic growth in the wake of COVID-19 among Jewish and Arab pregnant women in Israel. PSY Trauma: Theory, Research, Practice, and Policy. 2022 Feb 3; https://doi.org/10.1037/tra0001189
22. Sadaghiyani S, Belgrade A, Kira M, Lee F. Finding strength in adversity: Exploring the process of posttraumatic growth among multicultural individuals. Cultural Diversity and Ethnic Minority Psychology. 2022 Jan 27; https://doi.org/10.1037/cdp0000517.
23. Montalvo-Ortiz JL, Gelernter J, Cheng Z, Girgenti MJ, Xu K, Zhang X, et al. Epigenome-wide association study of posttraumatic stress disorder identifies novel loci in US military veterans. Translational Psych. 2022 Feb 17; 12(1):1-9; https://doi.org/10.1038/s41398-022-01822-3.