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Journal of Loss and Trauma, 17:113124, 2012

Copyright # Taylor & Francis Group, LLC


ISSN: 1532-5024 print=1532-5032 online
DOI: 10.1080/15325024.2011.635580

A Study of Posttraumatic Stress and


Growth in Tsunami Relief Volunteers
BRAJ BHUSHAN
Department of Humanities & Social Sciences, Indian Institute of Technology,
Kanpur, India

J. SATHYA KUMAR
Thiagarajar School of Management, Madurai, India

Twenty female relief volunteers who had participated in the


post-tsunami relief operations in the coastal areas of Tamil Nadu,
India, under the aegis of nongovernmental organizations and
charitable trusts were assessed for posttraumatic stress, posttraumatic growth, and dissociative experiences. They also responded
to a set of questions in order to determine the direction (upwarddownward) of their counterfactual thoughts. The observed data
were subjected to a multivariate analysis of variance and multiple
discriminant analysis to identify the key underlying dimensions.
The main effects of amnesia, depersonalization, percentage of dissociation, and family type were highly significant. Discriminant
coefficients suggested the importance of relating to others and
proactive coping. They also suggested the importance of intrusion,
avoidance, and appreciation of life.

On December 26, 2004, an earthquake measuring 8.9 on the Richter scale


triggered tsunami waves in the Indian Ocean. Although the epicenter of this
earthquake was near the west coast of Sumatra, Indonesia, heavy casualties
were reported from the coastal areas across India. Given the extraordinary
number of affected people, a large number of rescue=relief volunteers were
rushed to the site, many of whom were nonprofessionals. Researchers have
suggested that rescue and relief workers are at high risk for psychological
Received 19 April 2010; accepted 27 June 2010.
Address correspondence to Braj Bhushan, Department of Humanities & Social Sciences,
Indian Institute of Technology, Kanpur 208 016, India. E-mail: brajb@iitk.ac.in
113

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distress. As anticipated, nonprofessionals are at high risk compared to


professionals. Wagner, Heinrichs, and Ehlert (1998) reported an 18.2%
prevalence of posttraumatic stress disorder (PTSD) in professional firefighters, whereas Ersland, Weisaeth, and Sund (1989) found a 24% prevalence
in oil rig disaster rescue workers. Studying deployed and nondeployed rescue workers 6 months after 9=11, Alvarez and Hunt (2005) found higher
PTSD and general distress in the deployed workers. Hagh-Shenas, Goodarzi,
Dehbozorgi, and Farashbandi (2005) compared trained rescue workers with
student volunteers who were involved in the rescue operation for the Bam
earthquake (Iran) and found that untrained volunteers had higher PTSD
scores.
Researchers have suggested that nonprofessional rescue workers report
more stress reactions than professional workers (Dyregrov, Kristoffersen, &
Gjestad, 1996). Guo et al. (2004) investigated PTSD prevalence among professional and nonprofessional rescue workers involved in the Chi-Chi earthquake
(Taiwan) 1 month after the disaster. The prevalence of PTSD, especially
numbness=avoidance, was much higher in the nonprofessional rescue workers.
They also found mental health problems among trained professionals.
It is commonly observed that people tend to interpret painful events in a
way that is easier to accept. Such thoughts are known as counterfactual
thoughts. Counterfactual thoughts have been categorized in terms of
dichotomous dimensions, such as upward and downward, self-referent
and other-referent, and additive and subtractive counterfactuals. Studies suggest that the likelihood of counterfactual thoughts in the wake of traumatic
experiences is high (Taylor & Schneider, 1989), with upward counterfactuals
especially common after such negative events (Dalgleish, 2004). According to
White and Lehman (2005), downward counterfactuals are frequently used as
compared to upward counterfactuals in conditions where self-enhancement
is prominent. El Leithy, Brown, and Robbins (2006) found a close association
between frequency of counterfactual thoughts and continuing levels of posttraumatic stress inasmuch as counterfactual thoughts play a role in
adaptation. They argued that levels of different aspects of counterfactual
thinking [are] moderated by metacognitive control strategies as a function
of time since the trauma (p. 629).
It is also important to understand the relationship between dissociation
and trauma. Usually the cognitive mechanism of identification lessens
distress (Ursano & Fullerton, 1990), but it can also predispose someone to
possible symptoms. The association between identification and PTSD (Cetin
et al., 2005) in rescue workers is also underresearched. Structured separations of thoughts, emotions, identity, and=or memory are components of dissociation. Such responses become prominent in the aftermath of disasters
(Spiegel & Cardena, 1991) and coexist with hyperarousal (Cardena & Spiegel,
1993), intrusion (Turner, Thompson, & Rosser, 1995), and avoidance
(Feinstein, 1989). Cardena and Spiegel (1993) found a high prevalence of

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dissociative symptoms 1 week and 4 months after the Loma Prieta


earthquake. Researchers have reported that dissociative experiences in the
aftermath of a traumatic event are a predictor of PTSD (Marmar et al.,
1994). However, such investigations in the aftermath of tsunami have not
been reported.
Traumatic experiences also have positive outcomes. Researchers have
reported increased appreciation of life, a sense of greater personal strength,
improved relationships with others, and a more integrated philosophy of life
(Bhushan & Hussain, 2007; Linley & Joseph, 2004; Tedeschi & Calhoun,
2004) in the aftermath of trauma and adversity. However, typically few
positive aspects emerge in the aftermath of natural disasters of the magnitude
of a tsunami. Only a handful of studies have explored posttraumatic growth
(PTG) in those exposed to the 2004 tsunami. Kraemer, Wittmann, Jenewein,
and Schnyder (2009) compared the victims and affected=unaffected tourists
and found that, besides anxiety and depression, the victims had high PTSD
scores as well as posttraumatic personal growth.
Although family has been accepted as a support system, previous
studies have largely ignored investigating the possible impact of family type
on trauma reactions, perhaps because of regional=cultural uniqueness.
Traditionally Indian families were joint in nature, but in modern times there
has been a rise in the number of nuclear families. A nuclear family consists of
a mother-father and their children, whereas family units comprising several
generations (usually two or more) living together are called joint families.
There is a compelling need for otherwise unique studies examining psychological trauma, such as those focusing on the nature of calamity, the cultural
distinctiveness of the population, and so forth. Earlier studies incorporating
family type as a variable have suggested the relative impact of nuclear and
joint family structures on PTS and emotional distress (Bhushan & Kumar,
2007, 2008, 2009). However, to the best of our knowledge, there is no prior
evidence of a relationship between family structure and counterfactual
thinking. Considering the unique nature of this study in terms of tsunami
exposure and the regional=cultural uniqueness of the sample, we included
family type (nuclear and joint) as a demographic variable.
Although due importance has been given to those exposed to human
remains following a disaster (Newhill & Sites, 2000) and there has also been
a gradual increase in the study of disaster victims in developing countries,
rescue=relief workers are still underresearched. Recent studies examining
the impact of the tsunami in affected countries (Bhushan & Kumar, 2007,
2008, 2009) have focused on the victims and not the rescue=relief workers.
Further, studies reporting positive tsunami effects are missing from developing countries. Such data would have helped construe the negative and
positive outcomes of traumatic exposures in these areas, which usually work
with limited resources. To the best of our knowledge, no study has reported
positive outcomes of the tsunami among rescue=relief workers. We

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attempted to determine whether the volunteers performed their duty with a


sense of detachment so as to defend themselves from the shocking reality
and associated emotions or whether they were proactive in terms of coping
with the harsh reality. The primary aim of our study was to explore the role
of upward and downward counterfactual thinking and family type in determining PTS and PTG. We also investigated the influence of proactive coping
and dissociative experiences on PTS and PTG, hypothesizing that: (a)
counterfactual thinking would be related to PTS and PTG, (b) family type
would influence PTS and PTG, and (c) proactive coping and dissociative
experiences would influence PTS and PTG.

METHOD
Sample
Initially permission was sought from several nongovernmental organizations
(NGOs) and charitable trusts operational in the coastal areas of Tamil Nadu,
India. Volunteers from the consenting organizations were individually asked
for their consent; 20 female volunteers participated in this study. The age of
these volunteers ranged from 2045 years (M 31.60, SD 6.38). All of them
had served as relief volunteers for 1 full year in the tsunami-affected areas.
Fourteen were from a nuclear family background, whereas the remaining
six were from joint families. Six participants had completed their senior secondary education, eight were graduates, and six were postgraduates. Their
mean amount of education was 14.70 years (SD 2.00). Although none of
them had any earlier training in disaster management=mitigation, they were
helping the people in the tsunami-affected area to relocate victims immediately, after a day or two. In fact, most of them had worked in the area when
the remains of the drowned bodies were being removed. It merits mention
that these volunteers did not receive any special remuneration for their
services. Data were collected 4 years after the catastrophe.

Measures
DEMOGRAPHIC VARIABLES
Information was collected regarding age, sex, education (senior secondary,
undergraduate, or postgraduate), and family structure (nuclear or joint).
COUNTERFACTUAL THINKING
Counterfactual thoughts were assessed using the method adopted by White
and Lehman (2005). The subjects were asked three questions, and the
responses were categorized as upward or downward counterfactual

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thought. The three items were (a) Think back and describe a very negative,
stressful, or traumatic event that happened to you; (b) Think back and
describe a mildly negative or stressful event that happened to you; and
(c) After situations like this it is not uncommon to imagine how things might
have been different. People sometimes say If . . . We want to think about
the situation in a way that makes us learn from the situation. We select the
information that we can learn from and that we can use to improve or to
avoid a similar situation in the future. What are the most frequent If . . .
thoughts you had about the trauma that you experienced?
IMPACT OF EVENT SCALE
Posttraumatic stress was assessed using the Impact of Event Scale (IES;
Horowitz, Wilner, & Alvarez, 1979). The reported split-half reliability of the
original scale (total scale) is .86, and the alpha coefficients for intrusion
and avoidance are .78 and .82, respectively.
POSTTRAUMATIC GROWTH INVENTORY (PTGI)
Posttraumatic growth was measured using the PTGI (Tedeschi & Calhoun,
1996). The inventory consists of 21 items measuring five factors: relating to
others, new possibilities, personal strength, spiritual change, and appreciation of life. The Cronbach alpha coefficient for the PTG total score is .90.
The alpha coefficients for the subscales are .85, .84, .72, .85, and .67,
respectively.
PROACTIVE COPING INVENTORY (PCI)
Although the PCI (Greenglass, Schwarzer, & Taubert, 1999) consists of 55
items measuring seven dimensions (proactive, reflective, strategic, preventive, instrumental, emotional, and avoidance coping), we administered only
the 14 items pertaining to proactive coping. The subjects indicated how true
each of these statements were for them depending on how they felt about the
situation on a 4-point scale (1 not at all true, 2 barely true, 3 somewhat
true, 4 completely true). The reported Cronbach alpha coefficient for
proactive coping is .85.
DISSOCIATIVE EXPERIENCES SCALE (DES)
The DES-II (Carlson & Putnam, 1993) was used to measure the frequency of
dissociative experiences of varying severity. The subjects completed the
28-item self-report scale by circling the percentage of time they had the
described experience. The percentage is given in increments of 10% ranging
from 0 (never experienced) to 100 (continually experienced). The three

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factors of the DES-II (amnesia, derealization=depersonalization, and capacity


for absorption) have been identified in clinical (Carlson et al., 1991) as well
as nonclinical samples (Sanders & Green, 1994).

RESULTS
The mean and standard deviations for all of the variables are summarized in
Table 1. Fifty percent of the relief workers scored above the mean total
trauma score; 40% scored above the mean intrusion and avoidance scores.
The percentage of dissociation of 40% was above the mean value. The total
posttraumatic growth and proactive coping scores of 60% were above the
respective mean scores.
The amnestic symptom of dissociation was negatively correlated with
intrusion (r .508, p < .05) but positively with appreciation of life
(r .582, p < .01). Intrusion was also negatively correlated with depersonalization (r .507, p < .05) and total percentage of dissociation (r .471,
p < .05). On the other hand, avoidance was negatively correlated with
capacity for absorption (r .690, p < .01) but positively with personal
strength (r .490, p < .05). The total trauma score negatively correlated with
all of the dimensions of dissociative experience (amnestic r .536, capacity
for absorption r .692, depersonalization r .500, dissociation percentage r .534; p < .05). Proactive coping positively correlated with relating
to others (r .692, p < .01), new possibilities (r .594, p < .01), personal
strength (r .596, p < .01), spiritual change (r .598, p < .01), and the total
posttraumatic growth score (r .681, p < .01).
Upward counterfactual thought was witnessed in 60% of the
participants. Family type (nuclear=joint) did not contribute to the direction
TABLE 1 Means, Standard Deviations, and Standard Errors of Dependent Variables and
Covariates.
Variables
IES
PTGI

PCI
DES

Factors

Mean

SD

SE of mean

Intrusion
Avoidance
Total score
Relating to others
New possibilities
Personal strength
Spiritual change
Appreciation of life
Total score
Total score
Amnestic
Capacity for absorption
Depersonalization
Percentage

20.500
17.300
37.800
27.700
20.000
17.800
8.500
11.500
85.500
50.400
375.000
369.000
270.500
43.446

6.394
7.064
10.102
4.449
4.205
2.238
1.318
3.472
12.037
4.005
143.068
64.961
70.727
9.425

1.429
1.579
2.259
.995
.940
.500
.295
.776
2.692
.896
31.991
14.526
15.815
2.107

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(upward=downward) of counterfactual thinking. Of the 14 participants from


a nuclear background, eight showed upward and six downward counterfactual thought. Four of the six participants from a joint family background
showed upward counterfactual thinking, whereas the remaining two showed
downward counterfactual thought. The Pearson chi-square value (.159) was
nonsignificant (p < .690), indicating that family type did not determine the
direction of counterfactual thinking.
The observed data were subjected to a multivariate analysis of variance
(MANOVA) with counterfactual thinking and family type as independent
variables and trauma (intrusion, avoidance, and total trauma) and posttraumatic growth (relating to others, personal strength, spiritual change, and
appreciation of life) as dependent variables. Proactive coping strategy and
dissociate experiences (amnestic, capacity for absorption, depersonalization,
and percentage of dissociation) were the covariates. The main effects of
amnesia, Pillais trace .558, F(1, 11) 13.86, p < .003; depersonalization,
Pillais trace .571, F(1, 11) 14.65, p < .003; percentage of dissociation, Pillais trace .553, F(1, 11) 13.61, p < .004; and family type, Pillais
trace .831, F(1, 11) 54.00, p < .001, were highly significant. The main
effects of counterfactual thinking, proactive coping strategy, and capacity
for absorption were not significant. The interaction effects of counterfactual
thinking and family type also were not significant.
Levenes tests of equality of variances for the dependent variables were
not significant, F(3, 16) 2.619, p < .087, suggesting that homogeneity of
variance was met. This also extended support to the reliability of the univariate tests. Univariate tests were conducted to see how within-subject effects
accounted for the variability in each of the dependent variables. Intrusion
was determined by dissociative experiences (amnesia and depersonalization)
and family type, whereas capacity for absorption determined avoidance
symptoms. The main effects of proactive coping were significant for relating
to others (F 2,177.449, p < .001), new possibility (F 32.966, p < .001),
spiritual change (F 1,183.193, p < .001), appreciation of life (F 7.825,
p < .01), and total PTG score (F 7.303, p < .05). The amnestic symptom of
dissociation had a significant influence on intrusion (F 13.862, p < .003)
and total trauma score (F 7.254, p < .021) as well as all of the dimensions
of PTG: relating to others (F 1,003.421, p < .001), new possibility
(F 42.340, p < .001), personal strength (F 6.066, p < .032), spiritual
change (F 7,191.349, p < .001), appreciation of life (F 10.473, p < .008),
and total PTG score (F 32.618, p < .001).
Capacity for absorption significantly affected avoidance (F 17.737,
p < .001) and total trauma score (F 43.680, p < .001) in addition to the relating to others (F 129.075, p < .001), personal strength (F 21.644, p < .001),
and spiritual change (F 2,227.534, p < .001) dimensions of PTG. The main
effect of depersonalization was significant for intrusion (F 14.654, p < .003),
relating to others (F 1,679.177, p < .001), new possibilities (F 37.429,

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p < .001), spiritual change (F 2,970.545, p < .001), and total PTG score
(F 23.737, p < .001). The percentage of dissociation significantly affected
intrusion (F 13.609, p < .004) and total trauma score (F 4.439, p < .05).
Its main effect was significant for all of the dimensions of PTG except personal strength: relating to others (F 1,153.824, p < .001), new possibility
(F 37.241, p < .001), spiritual change (F 6,304.839, p < .001), appreciation
of life (F 7.022, p < .023), and total PTG score (F 27.409, p < .001). The
main effect of family type was significant for intrusion (F 54.002,
p < .001) and total trauma score (F 24.024, p < .001) as well as relating to
others (F 3,292.752, p < .001), new possibility (F 82.634, p < .001),
spiritual change (F 1,731.091, p < .001), and total PTG score (F 37.008,
p < .001). Counterfactual thinking, on the other hand, significantly affected
total trauma score (F 7.022, p < .023) and all of the dimensions of PTG:
relating to others (F 1,278.882, p < .001), new possibility (F 17.981,
p < .001), personal strength (F 4.416, p < .05), spiritual change (F
150.875, p < .001), and appreciation of life (F 7.519, p < .01). However,
its main effect on PTG total score was not significant. The interaction effect
of family type and counterfactual thinking was significant for all of the
dimensions of PTG: relating to others (F 99.081, p < .001), new possibility
(F 17.054, p < .002), personal strength (F 14.087, p < .003), spiritual
change (F 9,856.880, p < .001), appreciation of life (F 20.163, p < .001),
and total PTG score (F 25.847, p < .001).
Consequently, multiple discriminant analysis was used in order to identify
the key underlying dimensions. The summary of pooled within-groups correlations between discriminant variables along with the discriminant coefficients are
given in Table 2 in order of absolute size of correlation within function. Dissociative experiences (amnestic, depersonalization, capacity for absorption, and
percentage of dissociative experience), total trauma score, and total posttraumatic growth score failed the tolerance test. The remaining variables passing
the tolerance criteria were simultaneously entered in a canonical discriminant
analysis. As indicated in the table, the discriminant functions were significant
(p < .001). These functions explained 100% of the variance. A close look at
the variables and their discriminant loading coefficients indicates that relating
to others and proactive coping are the two variables contributing most to group
separation, followed by intrusion and avoidance symptoms and appreciation of
life. Surprisingly, the coefficient for personal strength did not show its
dominance. This was also true for new possibilities and spiritual changes.

DISCUSSION
Upward counterfactual thought was witnessed in 60% of the participants,
and other researchers have also reported upward counterfactuals in the aftermath of negative events (Dalgleish, 2004). Intrusive thoughts were associated

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TABLE 2 Pooled Within-Groups Correlations Between Discriminant Variables, Standardized


Canonical Discriminant Coefficients, and Results of Multiple Discriminant Analysis
Variablesa

Coefficient
.388
.327
.299
.090
.080
.054
.040
.039
.035
.034
.029
.021
.015
.000

Amnestic
Depersonalization
Percentage of dissociative experiences
Capacity for absorption
Proactive coping
Relating to others
Total posttraumatic growth score
Personal strength
Total trauma score
New possibilities
Avoidance
Intrusion
Spiritual change
Appreciation of life
Multiple discriminant analysis outcomes
Eigenvalue

% of
variance

Canonical
correlation

Wilks
lambda

Chi-square

df

100

.996

.008

67.187

.001

120.402

Standardized canonical discriminant function coefficients


Variables
Intrusion
Avoidance
Relating to others
New possibilities
Personal strength
Spiritual change
Appreciation of life
Proactive coping

Coefficients
7.313
6.362
9.885
16.458
.902
1.353
6.195
9.274

In order of absolute size of correlation within function.

with amnesia and depersonalization, whereas avoidance was related to


absorption. Although intrusion and avoidance were correlated with different
dimensions of dissociation, total trauma score was correlated with all of the
dimensions of dissociative experiences. The results showed the significant
effects of amnesia, depersonalization, percentage of dissociation, and family
type on PTS and PTG. Further, amnesia had a significant influence on
intrusion and total trauma score as well as all of the dimensions of PTG.
The capacity for absorption significantly affected avoidance and total trauma
score in addition to the relating to others, personal strength, and spiritual
change dimensions of PTG. The main effect of depersonalization was

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significant for intrusion, relating to others, new possibilities, spiritual change,


and total PTG score. These findings corroborate with earlier results (Spiegel &
Cardena, 1991) suggesting separation of thoughts, emotions, and so forth after
a disaster. Amnesia, depersonalization, and absorption are thought to be the
constituents of dissociation. Other researchers have also reported coexistence
of dissociation with intrusion (Turner et al., 1995) and avoidance (Feinstein,
1989). Guo et al. (2004) reported a prevalence of PTSD, especially
numbness=avoidance, in nonprofessional rescue workers. Studies have shown
that dissociative experiences are a predictor of PTSD (Marmar et al., 1994).
Interestingly, family type was observed to significantly affect intrusive
thoughts. This seems obvious as the likelihood of shared time increases
manifold in those living in a joint family structure as compared to those in
a nuclear family setup. Earlier studies of Indian subjects have endorsed the
pivotal role of family type in trying to overcome trauma after a tsunami
(Bhushan & Kumar, 2007, 2009). A finding that deserves special attention
was the positive association between amnesia and appreciation of life and
between avoidance and personal strength. Amnesia, absorption, and depersonalization significantly affected relating to others and spiritual change.
Amnesia and absorption affected personal strength. Amnesia and depersonalization affected new possibilities. Amnesia also affected appreciation of life.
The findings also reflect the implication of proactive coping on PTG. It
affected ones ability to relate to others as well as searching for new possibilities and spiritual change. Researchers have reported an increased appreciation of life, a sense of greater personal strength, and improved
relationships with others, thus adding to an integration of life philosophy
(Linley & Joseph, 2004; Tedeschi & Calhoun, 2004). It merits mention that
PTG does not necessarily confer reduced trauma. The preponderance of
coexistence of distress and posttraumatic growth has been advocated in
the trauma literature inasmuch as the growth evolves out of the struggle
and the attempt to cope rather than the trauma itself. It has been shown that
in addition to well-being, benefit (growth) is related to intrusive and avoidant
thoughts. The recent study by Kraemer et al. (2009) found that the subjects
had high levels of PTSD as well as posttraumatic personal growth.
The findings of this study have several limitations. Despite our best
effort, the sample size remained very small, which limits the generalization
of the findings. Tracing the relief volunteers years after their job was a
difficult task. Further, many of them did not agree to participate in the study.
Also, the study did not have a control group. We could not find a suitable
comparison group as the work experience of this group was unique. Further
studies can address this issue. A few key variables (such as personality) could
not be incorporated in the study. The total number of items was crucial for
this study inasmuch as we had to include only proactive coping instead of
the full range of coping strategies the PCI measures. Further studies are
warranted to understand these processes with minimal limitations.

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Braj Bhushan, Ph.D., works as Associate Professor of Psychology at the Indian
Institute of Technology Kanpur, India. He has thirty-six journal papers=book chapters
and three books to his credit. His areas of interest include trauma psychology and
cognitive neuropsychology.

J. Sathya Kumar, Ph.D., is currently working as Professor of Human Resources at


Thiagarajar School of Management, Madurai, India, where he teaches behavioral
science. He was trained in Australia in CBT, which is his area of interest and practice.
His other areas of interest are counseling and psychotherapy.

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