The role of psychological symptoms and social group memberships in the development of post-traumatic stress after traumatic injury.
ABSTRACT Objectives. The costs associated with traumatic injury are often exacerbated by the development of post-traumatic stress symptoms. However, it is unclear what decreases the development of post-traumatic symptoms over time. The aim of the present research was to examine the role of psychological symptoms and social group memberships in reducing the development of post-traumatic stress symptoms after orthopaedic injuries (OIs) and acquired brain injuries (ABIs). Design and Methods. A longitudinal prospective study assessed self-reported general health symptoms, social group memberships, and post-traumatic stress symptoms among participants with mild or moderate ABI (n= 62) or upper limb OI (n= 31) at 2 weeks (T1) and 3 months (T2) after injury. Results. Hierarchical regressions revealed that having fewer T1 general health symptoms predicted lower levels of T2 post-traumatic stress symptoms after OI but forming more new group memberships at T1 predicted lower levels of T2 post-traumatic stress symptoms after ABI. Conclusion. A focus on acquiring group memberships may be particularly important in reducing the development of post-traumatic stress symptoms after injuries, such as ABI, which result in long-term life changes. STATEMENT OF CONTRIBUTION: WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • Post-traumatic stress symptoms are a common outcome after accidental traumatic injury. • Persistent post-traumatic stress symptoms can be a risk factor for the development of PTSD. WHAT DOES THIS STUDY ADD?: • New insight into the contributions of general health symptoms and social group memberships in the development of post-traumatic stress symptoms after accidental injury. • The development of post-traumatic stress symptoms over time is associated with higher levels of general health symptoms among individuals with orthopaedic injuries; They are associated with lower levels of social group memberships among individuals with acquired brain injuries.
- SourceAvailable from: Tegan Cruwys[Show abstract] [Hide abstract]
ABSTRACT: Maladaptive schemas are stable cognitive working models of the world, learnt early in life, that interfere with effective functioning and underlie chronic mental illness. A major challenge for cognitive therapy has been how to modify schemas when they are so enduring and stable. We propose that because maladaptive schemas are formed through social experiences (typically abusive or neglectful ones), they might best be corrected through positive social experiences that directly challenge the schema. Two longitudinal studies were conducted, one with patients undergoing group cognitive-behavioural therapy (N = 92) and one with homeless individuals residing in temporary accommodation (N = 76). In each study, social isolation schema was measured at Time 1 and again at Time 2 following a group-based social experience (group psychotherapy or temporary residence at a community organization). A positive experience of group life was operationalized as social identification with the therapy group in Study 1 or the community organization in Study 2. In both studies, social identification led to a significant reduction in social isolation schema. Study 2 indicated that these effects were fully mediated by the formation of ties to new social groups, such that social identification scaffolded the development of new group memberships, which in turn decreased the endorsement of maladaptive schema. Social identification facilitates the correction of socially situated schema such as social isolation. Maladaptive schemas are modifiable in short-term therapy or even in community settings. The experience of being accepted and belonging to a social group can challenge a person's deep-seated belief that they are socially isolated. Positive social experiences may act as scaffolding to help socially isolated individuals build new social group memberships. Less positively, social isolation schema can also act as a feedback loop, preventing people from identifying with groups, resulting in a negative social experience that may further embed the schema. Further research is needed to determine how clinicians might facilitate social identification.British Journal of Clinical Psychology 01/2014; · 1.90 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Background: Clinical depression is often preceded by social withdrawal, however, limited research has examined whether depressive symptoms are alleviated by interventions that increase social contact. In particular, no research has investigated whether social identification (the sense of being part of a group) moderates the impact of social interventions. Method: We test this in two longitudinal intervention studies. In Study 1 (N=52), participants at risk of depression joined a community recreation group; in Study 2 (N=92) adults with diagnosed depression joined a clinical psychotherapy group. Results: In both the studies, social identification predicted recovery from depression after controlling for initial depression severity, frequency of attendance, and group type. In Study 2, benefits of social identification were larger for depression symptoms than for anxiety symptoms or quality of life. Limitation: Social identification is subjective and psychological, and therefore participants could not be randomly assigned to high and low social identification conditions. Conclusions: Findings have implications for health practitioners in clinical and community settings, suggesting that facilitating social participation is effective and cost-effective in treating depression.Journal of Affective Disorders 02/2014; 159:139-146. · 3.30 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Social identity research was pioneered as a distinctive theoretical approach to the analysis of intergroup relations but over the last two decades it has increasingly been used to shed light on applied issues. One early application of insights from social identity and self-categorization theories was to the organizational domain (with a particular focus on leadership), but more recently there has been a surge of interest in applications to the realm of health and clinical topics. This article charts the development of this Applied Social Identity Approach, and abstracts five core lessons from the research that has taken this forward. (1) Groups and social identities matter because they have a critical role to play in organizational and health outcomes. (2) Self-categorizations matter because it is people's self-understandings in a given context that shape their psychology and behaviour. (3) The power of groups is unlocked by working with social identities not across or against them. (4) Social identities need to be made to matter in deed not just in word. (5) Psychological intervention is always political because it always involves some form of social identity management. Programmes that seek to incorporate these principles are reviewed and important challenges and opportunities for the future are identified.British Journal of Social Psychology 03/2014; 53(1). · 1.76 Impact Factor
British Journal of Health Psychology (2012)
C ?2012 The British Psychological Society
The role of psychological symptoms and social
group memberships in the development of
post-traumatic stress after traumatic injury
Janelle M. Jones1∗, W. Huw Williams2, Jolanda Jetten3,
S. Alexander Haslam2, Adrian Harris4and Ilka H. Gleibs5
1Department of Psychology, Simon Fraser University, Canada
2School of Psychology, University of Exeter, UK
3School of Psychology, The University of Queensland, Australia
4Department of Emergency Medicine, Royal Devon & Exeter NHS Foundation
5School of Psychology, University of Surrey, UK
Objectives. The costs associated with traumatic injury are often exacerbated by the
development of post-traumatic stress symptoms. However, it is unclear what decreases
was to examine the role of psychological symptoms and social group memberships in
reducing the development of post-traumatic stress symptoms after orthopaedic injuries
(OIs) and acquired brain injuries (ABIs).
Design and Methods. A longitudinal prospective study assessed self-reported general
health symptoms, social group memberships, and post-traumatic stress symptoms
among participants with mild or moderate ABI (n = 62) or upper limb OI (n = 31) at
2 weeks (T1) and 3 months (T2) after injury.
Results. Hierarchical regressions revealed that having fewer T1 general health symp-
toms predicted lower levels of T2 post-traumatic stress symptoms after OI but forming
more new group memberships at T1 predicted lower levels of T2 post-traumatic stress
symptoms after ABI.
Conclusion. A focus on acquiring group memberships may be particularly important
in reducing the development of post-traumatic stress symptoms after injuries, such as
ABI, which result in long-term life changes.
Traumatic injuries have considerable economic and physical costs. These injuries
account for one tenth of lost lives and one sixth of the disease burden worldwide
(World Health Organisation, 2008) and an estimated $80 billion in medical treatment
Drive, Burnaby, BC V5A 1S6, Canada (e-mail: email@example.com).
Janelle M. Jones et al.
and $326 billion in lost productivity in the United States alone (Corso, Finkelstein,
Miller, Fiebelkorn, & Zaloshnja, 2006). Over half of the injuries sustained in developed
motor vehicle accidents; Johnson, Thomas, Thomas, & Sarimento, 2009; Polinder et al.,
2004). When fatality does not occur, these accidents often result in injuries that lead to
temporary or life-long disability. Two major types of injury are orthopaedic injury (OI),
such as a strain, sprain, dislocation, or fracture of the musculoskeletal system (e.g., arm,
leg, tendon), and acquired brain injury (ABI), where normal brain function is impaired
by a blow to, or puncturing of, the head.
Given that OI and ABI are often caused by traumatic incidents, it is not surprising that
post-traumatic stress symptoms and post-traumatic stress disorder (PTSD) are common
outcomes. PTSD occurs for 10–14% of individuals who have experienced any traumatic
(e.g., Breslau, Davis, Andreski, & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, &
Nelson, 1995). There is also an increased incidence of these outcomes among people
with traumatic accidental injuries. For instance, Mellman, David, Bustamente, Fins, and
Esposito (2001) found that 16% of patients with accidental OI exhibited post-traumatic
stress symptoms roughly 2 weeks after injury. This number increased to 24% 6 weeks
after injury, with an additional 22% of patients exhibiting subclinical PTSD (i.e., two
of three symptoms). Findings reported by Starr and colleagues (2004) were even more
striking. They found that 43–57% of patients with OI (due to falls and motor vehicle
accidents) met the criteria for PTSD 1 year after injury. Reports indicate that a similar
after injury (see McMillan, Williams, & Bryant, 2003).
In light of these findings, the importance of trying to reduce the likelihood of post-
traumatic stress symptoms after accidental injury becomes obvious. A first step in this
process is to identify and address the risk factors associated with post-traumatic stress
symptom development. The present research examined the role of two factors in the
symptoms and (2) social group memberships.
General health symptoms as predictors of post-traumatic stress symptoms
Symptoms can tell us a lot about injury. Indeed, the persistence or dissipation of
symptoms is an important indicator of people’s overall health and well-being. One of the
more robust findings in the PTSD literature is that stress symptoms immediately after a
reason, many post-trauma interventions have focused on reducing initial post-traumatic
stress symptoms. However, this strategy is not always effective – suggesting that other
factors might also play a role in the experience and development of initial post-traumatic
stress symptoms and PTSD over time. We propose that general health symptoms can
provide additional insight into these outcomes.
General health symptoms refer to the presence of psychological and somatic
symptoms such as fatigue (e.g., feeling run down), anxiety, insomnia, social dysfunction
(e.g., been able to enjoy normal day-to-day activities), and severe depression (e.g.,
feeling life is hopeless) after traumatic incidents, and have been associated with several
negative outcomes. For example, Michaels and colleagues (1999) found that a decline
in general health 6 months after injury due to a motor vehicle accident was associated
with significantly higher levels of PTSD. This finding, like much of the research on
Developing post-traumatic stress
general health, is based on retrospective self-reports of general health symptoms some
time after injury. Accordingly, it is not clear whether general health symptoms are
predictive of the development of initial post-traumatic stress symptoms, or PTSD, over
Given that these somatic and psychological concerns may prove to be an unwelcome
change to an individual’s daily functioning, we contend that the extent to which general
health symptoms are perceived to be severe or debilitating might be associated with
higher levels of post-traumatic stress symptoms over time.
Social group memberships as a predictor of post-traumatic stress symptoms
The social identity approach to health and well-being suggests that social group
people’s outcomes (Haslam, Jetten, Postmes, & Haslam, 2009; Jetten, Haslam, & Haslam,
health effects of group memberships are often most apparent when people experience
important life changes as a result of illness and injury. For example, it has been found
that maintaining or gaining group memberships is associated with higher levels of life
satisfaction and self-esteem, improved cognitive functioning, enhanced physical health
and lower mortality when faced with stroke, dementia, and ABI (Boden-Albala, Litwak,
Elkind, Rundek, & Sacco, 2005; Ertel, Glymour, & Berkman, 2008; Haslam et al., 2008;
Jetten, Haslam, Pugliese, Tonks, & Haslam, 2010; Jones et al., 2011).
Why would maintaining or gaining group memberships be such an important
determinant of healthand well-being?Equallyimportant, why might groupmemberships
play a role in whether people develop post-traumatic stress symptoms? Social identity
theorizing points to the importance of three interrelated sets of processes. First,
internalized group memberships provide a basis for the receipt of social support (as
well as positive responses to that support; Haslam, O’Brien, Jetten, Penna, & Vormedal,
2005). From theories that address issues of social identity (Tajfel & Turner, 1979) and
conservation of resource (Hobfoll, 1989, 2002) we know that belonging to many groups
is one way that people can have access to multiple types of support (i.e., cognitive,
emotional, material) needed to understand and cope with illness, injury, and important
life transitions (e.g., Haslam et al., 2009; Iyer, Jetten, Tsivrikos, Haslam, & Postmes, 2009;
Jones et al., 2011; Putnam, 2000). Furthermore, past research has shown that lack of
social support is a strong predictor of traumatic stress and PTSD (see Brewin, Andrews,
& Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003). For instance, lower levels of
social support are associated with higher levels of PTSD 14 years after spinal cord injury
(Nielsen, 2003) and after motor vehicle accidents (Clapp & Beck, 2009). However, what
is not known is whether group memberships predict the initial development of post-
traumatic stress symptoms and the persistence of these symptoms over time. If group
memberships provide a basis for social support, then it follows that having access to
more group memberships (and thus more coping resources) should be associated with
reduced traumatic stress (Hobfoll, 1991).
Second, because group life is central to our sense of who we are, the maintenance
of group memberships provide individuals with an important sense of self-continuity
(Haslam et al., 2008; Sani, Bowe, & Herrera, 2008). When people are able to maintain
memberships in groups that they belonged to before injury, this provides psychological
ties to the past that can help them make sense of the present (Iyer et al., 2009; Iyer &
Janelle M. Jones et al.
Jetten, 2011). Moreover, such self-continuity also provides a platform for the acquisition
of new group memberships in the future (Bluck & Alea, 2008).
Third, because group life is also a crucible for the formation of identity (Postmes,
in self-(re)construction after illness or injury. In particular, new group memberships
provide opportunities for interaction, influence, and sense-making that allow individuals
to renegotiate, redefine, and reinvent who they are when faced with important life
changes such as traumatic injury (e.g., Jones et al., 2011). This in turn is linked to
post-traumatic growth (Muenchberger, Kendall, & Neal, 2008). For all of these reasons,
we contend that changes to social group memberships might play an important role in
determining the development of post-traumatic symptoms and the persistence of such
symptoms over time.
Research overview and hypotheses
The aim of the present research was to examine the contributions of general health
symptoms and social group memberships in reducing the development of post-traumatic
stress symptoms over time. We examined this question within two injury groups –
individuals with OIs and individuals with ABIs – at 2 weeks (T1) and 3 months (T2) after
discharge from the emergency department of a large hospital in the United Kingdom. At
both measurement points, we obtained self-reports of post-traumatic stress symptoms,
symptoms post-injury (T1) would be associated with lower levels of post-traumatic stress
symptoms at T2 over and above initial levels of post-traumatic stress symptoms (H1),
and (2) that the more social group memberships individuals maintained and acquired
immediately following injury, the lower their levels of post-traumatic stress symptoms
would be at T2 (over and above initial levels of post-traumatic stress symptoms) (H2).
We also explored whether there might be differences in the contributions of
symptoms and group memberships to post-traumatic stress symptoms over time as a
function of the type of injury sustained (H3). On the one hand, there are important
similarities between ABI and OI: both result from traumatic incidents, are treated at
hospital emergency departments, and vary in their severity. On the other hand, there
are marked differences. The effects of OI on individuals are often temporary: symptoms
heal and relationships with others tend to be unaffected. However, the effects of ABI on
individuals can be permanent: symptoms can persist or get worse and relationships with
and physical changes that do not occur with OI (Wood, Liossi, & Wood, 2005; see
also Haslam et al., 2008). Exploring the impact of these variables within injuries could
highlight important differential indicators of post-traumatic stress symptoms over time.
Two weeks after being admitted to a large hospital in England 141 patients completed
the first measurement (T1; overall age: M = 45.16, SD = 14.31; male: n = 57, female:
n = 84; all White British). Patients had sustained mild head injury (MHI) (i.e., no loss of
reported: n = 40), or upper limb OI (no loss of consciousness reported: n = 43). Data
Developing post-traumatic stress
had been screened to eliminate individuals who had sustained injury from assault, sexual
assault, and individuals who had sustained OIs that also involved blows to the head. All
T1 participants were also contacted 3 months after discharge (T2). T2 participants were
93 patients (overall age: M = 47.24, SD = 14.01; male: n = 36, female: n = 57) who
had sustained MHI (n = 35), MoHI (n = 27), or upper limb OIs (n = 31). All analyses
reported below were conducted with the 93 participants who had participated at both
T1 and T2 and who had completed all relevant measures. For these participants, injuries
had been sustained through falls (n = 57), accidents (n = 12), sports injury (n = 11),
hitting their head (n = 4; MHI only), road traffic accidents (n = 4), migraine/virus (n =
2; HI conditions only), or alcohol-related fall/blackouts (n = 3; MoHI only). Participants
responded to a single item to assess injury severity (i.e., How serious was the event?) on
a scale from 1 (Minor) to 4 (Severe). On average, injuries were seen as minor, although
participants who had sustained MoHI rated their injuries more serious (M = 1.77, SD =
HI condition differed significantly from the OI condition in perceived injury severity
(M = 1.52, SD = .51, ps > .12; F (87) = 4.48, p = .014, ?p2= .09; three participants
did not rate their injury’s severity). Analyses indicated that there were no significant
differences in the number of participants who remained versus dropped out in terms of
their membership in different injury groups: ?2(2) = 1.58, p = .46 or by gender: ?2
(1) = .33, p = .56. The only observed difference was in terms of age. Participants who
remained in the study were significantly older (M = 47.24, SD = 14.01) than those who
dropped out (M = 40.87, SD = 14.11; t(136) = 2.50, p = .014.
Measures and procedure
Participants who had given their consent to be contacted at discharge were contacted
by mail to take part in a longitudinal study on well-being after injury. During the first
and the questionnaire. The questionnaire assessed general health symptoms, group
memberships, and post-traumatic stress and asked for demographic information (e.g.,
injury severity, age, gender). Participants were told that they would be approached again
at 3 months post-injury to complete the same questionnaire and told that they could opt
out at any point. A total of 890 questionnaires were mailed out as part of our initial
data collection. In total, we had a response rate of 16% at T1, and retained 66% of these
respondents at T2. Respondents were entered into monthly draws for £50 worth of
department store vouchers.
Participants completed the short form of the General Health Questionnaire (12;
Goldberg, 1992) to assess their symptoms after injury. Here, they made subjective
anxiety, insomnia, social dysfunction, and depression over the past week on a 3-point
scale (worse = −1, same = 0, better = 1). Participants’ scores were summed across the
12 questions to compute a total GHQ score, where negative scores indicated worsening
symptoms and positive scores indicated improving symptoms (T1: ? = .88, M = −1.96,
SD = 3.86; Range: −12 to 6).
Participants also completed three measures assessing the sense of belonging, con-
nection, and support associated with their group memberships before and after injury
(EXeter Identity Transitions Scales – EXITS; Haslam et al., 2008). Four items measured
that I was in before; I still receive support from the same groups I was in before; T1:
Janelle M. Jones et al.
? = .87, M = 3.80, SD = .81), and four items measured their new group memberships
since injury (e.g., I am active in one or more new groups; I get practical help from people
in one or more new groups; T1: ? = .95, M = 2.24, SD = .96). To control for pre-existing
differences in the number of group memberships participants belonged to before the
injury, four items measured their pre-injury group memberships (e.g., I was a member
of lots of different groups, I had friends in many different groups; T1: ? = .91, M = 3.27,
SD = .99).
Post-traumatic stress symptoms were measured using the Trauma Screening Ques-
tionnaire (Brewin et al., 2002). Participants agreed or disagreed to 10 yes/no statements
concerning emotional and physical disturbances related to their injury (e.g., bodily
reactions when reminded of the event; upsetting thoughts or memories about the event
come into your mind against your will). The number of statements with which they
agreed was summed and divided by the total number of items to produce an index of
the proportion of post-traumatic stress symptoms experienced (T1: Myes= .24, SD =
.24, T2: Myes= .16, SD = .18). Using Brewin et al.’s criteria of experiencing six or more
disturbances, we found that 17% of participants with ABI and 11% of participants with
OI experienced post-traumatic stress symptoms at T1. These figures dropped to 9 and
3%, respectively, at T2. It should be noted that there were no significant differences
between participants who remained in the study and those who left in terms of their
GHQ scores, the number of maintained groups or new groups that they had formed, or
their reported PTSD at T1, all ts < −.93, all ps > .34.
Pearson’s correlations were computed to examine the bivariate relationships between
general health symptoms, groups memberships, and post-traumatic stress symptoms
after injury (see Table 1). Findings revealed that higher levels of post-traumatic stress
general health symptoms at T1, and fewer new group memberships at T1. There were
no relationships between age, injury severity, the number of old group memberships, or
the number of maintained group memberships, on T2 post-traumatic stress symptoms.
However, old and new group memberships were positively related to new group
Table 1. Correlations between symptoms, group memberships and post-traumatic stress symptoms
– both injuries (n = 93)
2. Injury severity
3. General health symptoms
4. Pre-injury groups
5. Maintained groups
6. New groups
7. Post-traumatic stress symptoms (T1)
8. Post-traumatic stress symptoms (T2)
∗∗∗ ∗ ∗ ∗
∗∗∗∗ ∗ ∗
∗ ∗ ∗
ap ? .06;
∗p ? .05;
∗∗p ? .01;
∗∗∗p ? .001.
Developing post-traumatic stress
memberships at T1. General health symptoms were also marginally correlated with
new group memberships at T1.
Next, hierarchical multiple regressions were used to examine the contributions
of symptoms and group memberships, over and above initial levels of post-traumatic
stress symptoms, on post-traumatic stress symptoms over time. On the basis of the
correlations and our hypotheses, we targeted our analyses on the two T1 predictor
variables that were significantly related to post-traumatic stress symptoms at T2. Post-
traumatic stress symptoms at T1 were entered into the first step as a control variable.
General health symptoms at T1 were entered into the second step and new group
memberships at T1 were entered into the third step. Post-traumatic stress symptoms at
T2 served as the dependent variable. The control variable and predictors were all mean
Post-traumatic stress symptoms at 3 months
Over and above the contribution of post-traumatic stress symptoms at T1, we found
that general health symptoms at T1 accounted for an additional 3% of the variance in
post-traumatic stress symptoms at T2 (see Table 2). In support of H1, fewer general
health symptoms at T1 were associated with lower levels of post-traumatic stress
symptoms at T2, ? = −.20, t = −2.02, p = .047. In support of H2, we found that
new group memberships at T1 accounted for an additional 7% of the variance in post-
traumatic stress symptoms at T2 when controlling for post-traumatic stress symptoms
and general health symptoms at T1. Participants who indicated they had joined new
groups after injury at T1 reported lower levels of PTSD symptoms at T2 (? = −.19, t
= −2.19, p = .031). Having fewer general health symptoms and joining new groups 2
weeks after injury, explained some of the variance in post-traumatic stress symptoms
over time, with new group memberships having an impact on post-traumatic stress
symptoms over and above that of general health symptoms. Yet while these patterns
are broadly consistent with H1 and H2, we argue that it is also important to examine
support for these hypotheses as a function of the nature of the injury sustained
Separate analyses of individuals with OI (see Table 3) indicated that over and above the
effects of initial levels of post-traumatic stress symptoms, general health symptoms at
Table 2. The effects of symptoms and group memberships (T1) on post-traumatic stress symptoms
at 3 months (T2) – both injuries
Post-traumatic stress symptoms (T1)
General health symptoms (T1)
New group memberships (T1)
F (1,82) = 53.16, p ? .001
F?(1,81) = 4.08, p = .047
F?(1,80) = 4.81, p = .031
Janelle M. Jones et al.
Table 3. The effects of symptoms and group memberships (T1) on PTSD at 3 months (T2) –
F (1,27) = 12.34, p = .002
F?(1,26) = 4.95, p = .035
F?(1,25) = .52, p = .48
T1 accounted for an additional 10% of the variance in post-traumatic stress symptoms at
T2. In particular, there was a significant effect such that fewer general health symptoms
at T1 were associated with lower levels of post-traumatic stress symptoms at T2, ? =
−.36, t(26) = −2.23, p = .035. Acquisition of new group memberships at T1 did not add
any additional explanatory power to understanding subsequent levels of post-traumatic
Analyses of individuals with ABIs (see Table 4) indicated that general health symptoms
at T1 did not contribute any additional explanatory power to our understanding of
post-traumatic stress symptoms at T2. However, group memberships at T1 explained an
additional 4% of the variance in post-traumatic stress symptoms at T2. Participants who
were able to form new group memberships at T1 reported experiencing lower levels
of post-traumatic stress symptoms at T2, ? = −.21, t = −2.09, p = .042. In support
of H3, then, there appear to be clear differences in the additional factors that predict
post-traumatic stress symptoms as a function of the type of injury that individuals have
Table 4. The effects of symptoms and group memberships (T1) on post-traumatic stress symptoms
at 3 months (T2) – acquired brain injuries
Post-traumatic stress symptoms (T1)
General health symptoms (T1)
New group memberships (T1)
F (1,53) = 45.99, p ? .001
F?(1,52) = .19, p = .892
F?(1,51) = 4.36, p = .042
Developing post-traumatic stress
The present study sought to identify the factors that might reduce the development of
post-traumatic stress symptoms after unintentional accidents resulting in OI and ABI. We
found that when controlling for initial levels of post-traumatic stress symptoms, having
more new group memberships predicted lower levels of post-traumatic stress symptoms
after injury over and above the contribution of general health symptoms.
Importantly, we provide novel evidence that the contribution of general health
symptoms and group memberships to post-traumatic stress symptoms after injury differs
as a function of the type of injury sustained. For individuals with OIs, fewer general
health symptoms were associated with lower levels of post-traumatic stress symptoms
3 months later. For individuals with ABIs, gaining new group memberships post-injury
predicted lower levels of post-traumatic stress symptoms at 3 months. Although post-
traumatic stress symptoms are a common experience for individuals with both types
of injuries, these findings suggest that addressing general health symptoms may further
reduce the development of post-traumatic stress symptoms after OI, whereas facilitating
of post-traumatic stress symptoms after ABI.
Evidence that general health symptoms and group memberships appear to have
different implications for the development of post-traumatic stress symptoms as a
function of the type of injury sustained might reflect fundamental differences in the
consequences of OIs and ABIs. As noted earlier, despite the fact that these injuries
are similar in some ways, they differ in the extent to which they involve long-term
life changes. OIs often result in temporary impairment of physical functioning. Broken
bones, fractures, strains, and sprains eventually heal, enabling individuals to regain most,
if not all, of their physical functioning. Individuals with OIs and fewer initial symptoms
may therefore experience lower levels of post-traumatic stress symptoms over time
because their injury is minimally disruptive of their way of life – it does not result in
major changes or challenges to which they must adjust.
In contrast, ABIs often result in more lasting impairment of physical and psycho-
logical functioning. The physical, cognitive, emotional, and behavioural changes that
accompany ABIs do not always heal, and are often absent from OIs. In fact people who
sustain brain injuries can be left with permanent changes to both their abilities and
their sense of self. These changes often strain social relationships (e.g., Wood et al.,
2005), which may jeopardize a person’s ability to deal effectively with the consequences
of the permanent changes associated with injury. Individuals with ABIs who are able
to join new groups may experience lower levels of post-traumatic stress symptoms
because these relationships provide the psychological resources (e.g., opportunities for
self-continuity and identity formation) and social resources (e.g., social support) needed
to manage the changes associated with brain injury that can help them makes sense of,
and reframe, their post-injury experiences (Hobfoll, 1991; Iyer & Jetten, 2011). In these
ways, group memberships might help to smooth the disruption to one’s life caused by
more permanent injuries.
Implications and recommendations
In light of these findings, we can make two simple recommendations for dealing
with individuals who have sustained accidental injury. First, upon discharge, patients’
group memberships should be assessed at various points in time (see Haslam, Jetten, &
Janelle M. Jones et al.
Haslam, 2011). Monitoring the quantity and quality of lost, maintained, or gained group
after injury. Indeed, research suggests that the more groups individuals belong to, the
more resources they can draw upon, and the better they cope when faced with the
changes and challenges of life transitions and physical stressors (Iyer et al., 2009; Jones
& Jetten, 2011). Furthermore, having good, supportive groups that provide useful and
needed resources plays a substantial role in the reduction of negative outcomes when
contending with the changes and challenges associated with different health conditions
(Cohen, 2004; Haslam et al., 2011; Stinson et al., 2008). In addition to more traditional
assessments of symptoms, monitoring changes in the quantity and the quality of pre- and
negative outcomes such as post-traumatic stress symptoms, or PTSD over time.
The present findings are notable because they reflect one of the first prospective and
longitudinal assessments of the contribution of both psychological symptoms and group
memberships in the development of post-traumatic stress symptoms. They suggest that
group-building activities might be a fruitful avenue for the design and implementation
of interventions to reduce post-traumatic stress symptoms. Recent work by Gleibs and
her colleagues has demonstrated that group-based interventions, such as water clubs
to promote behaviour change among older adults, and gender-based clubs to promote
social connection and community within residential care, are associated with positive
outcomes including increases in water consumption and lower levels of psychological
distress (e.g., depression, anxiety; Gleibs et al., 2011; Gleibs, Haslam, Haslam, & Jones,
2011). On the basis of such findings, a second recommendation would be to have
health care professionals and clinicians refer individuals who have sustained traumatic
injuries to relevant support groups. The mutual support gained from these groups may
be especially useful for conditions that carry a large social burden (i.e., conditions that
are embarrassing, disfiguring, or stigmatizing; Davison, Pennebaker, & Dickerson, 2000).
or a much-needed supplement for patients who have lost other social resources (e.g.,
Hobfoll, 2002). Informing patients that support groups exist can increase the uptake of
these types of services, and has the potential to increase the breadth of the care received
by patients, which may improve their outcomes.
Limitations and future directions
Despite the important contribution to our understanding of the development of post-
traumatic stress symptoms over time, there are some limitations associated with the
present research. First, the sample size was relatively small. Our initially low response
rate and subsequent dropout may reflect the fact that participants were entered into
a random prize draw rather than receiving compensation individually. Questionnaire
length and the multiple time points for data collection might have also contributed
to participant dropout (see Edwards et al., 2002, for relevant discussion). While this
does not invalidate our findings, it does make it necessary to determine whether similar
patterns are observed among larger samples of injured individuals.
Second, the incidence of post-traumatic stress in the present sample was low
over time in comparison to some of the numbers reported in the literature (e.g.,
McMillan et al., 2003; Starr et al., 2004). This may reflect national differences in the
perception of traumatic events and/or the support available to manage injuries. Indeed,
differences in the British versus American medical systems might have an impact on the
Developing post-traumatic stress
personal economic burden of treatment and/or the type of care and support obtained.
Furthermore, national differences also exist in the outcomes associated with accidental
injuries. Developing countries (e.g., Eastern Europe) report higher levels of mortality
from accidental injuries relative to developed countries (e.g., Western Europe, North
America; Peden, McGee, & Sharma, 2002). More detailed cross-national comparisons
risk factors) could provide useful information about the generalizability of the present
findings across different cultural contexts.
Third, while 3 months after injury is a considerable length of time, it could take
longer to recognize and diagnose PTSD after accidental injury. Extended follow-ups of
individuals at 6 and 12 months after injury might yield additional insight into the roles
that symptoms and groups memberships play in the development of PTSD.
Finally, although the measures used in the present research are adequate, future re-
search could use measures that conceptualize general health, social group memberships,
and post-traumatic stress symptoms in slightly different ways. For instance, with respect
to social group memberships, we do not know the specific groups that individuals
were thinking about when responding to the EXITS items. Future research should ask
individuals to list these groups and examine whether there are specific types of groups
Alternative measures of general health symptoms (e.g., the Short-form 36 Health Survey;
Ware, Kosinski, & Keller, 1996; Ware & Sherbourne, 1992) and post-traumatic stress
symptoms (e.g., the PTSD Symptom Scale Self-Report; Foa, Riggs, Dancu, & Rothbaum,
1993) might also improve the specificity of the variables of interest in the present
research and, if patterns are similar, can provide converging evidence of the roles of
symptoms and groups memberships in the development of initial post-traumatic stress
symptoms and PTSD over time.
Accidental injury has substantial costs that are often compounded by the development of
post-traumatic stress symptoms after injury. The present research suggests that whether
symptoms or group memberships contribute to the development of post-traumatic stress
symptoms after injury depends on the nature of the injury and its implications for long-
term physical and psychological functioning. Strategies for reducing the development of
post-traumatic stress symptoms may therefore need to be more sensitive to the nature
of the injury itself. In particular, while a traditional strategy of symptom alleviation
seems to be the best way of managing those recovering from OI, the maintenance and
development of group memberships seems to the best way of improving outcomes
for those who are recovering from ABI. This conclusion is consistent with growing
recognition that the road to cure is not only physical but also social (Jetten et al., 2011),
and that effective patient management requires sensitivity to both of these pathways.
We thank Kathryn Bristow and Tamar Lawrence for their help with data management. This
research was funded by the Economic and Social Research Council (RES-062–23-0135).
Janelle M. Jones et al.
Bluck, S., & Alea, N. (2008). Remembering being me: The self continuity function of autobiograph-
ical memory in younger and older adults. In F. Sani (Ed.), Self continuity: Individual and
collective perspectives (pp. 55–70). New York: Psychology Press.
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic
stress disorder in an urban population of young adults. Archives of General Psychiatry, 48,
Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic
stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68,
Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., ... Foa, E. B. (2002). Brief
screening instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181,
The role of negative network orientation. Behaviour Research and Therapy, 47, 237–244.
Cohen, S. (2004). Social relationships and health. American Psychologist, 59, 676–684.
Corso, P., Finkelstein, E., Miller, T., Fiebelkorn, I., & Zaloshnja, E. (2006). Incidence and lifetime
costs of injuries in the United States. Injury Prevention, 12, 212–218.
Davison, K. P., Pennebaker, J. W., & Dickerson, S. S. (2000). Who talks? The social psychology of
illness support groups. American Psychologist, 55, 205–217.
Edwards, P., Roberts, I., Clarke, M., DiGiuseppi, C., Pratap, S., Wentz, R., & Kwan, I. (2002).
Increasingresponseratestopostalquestionnaires:Systematicreview.British Medical Journal,
324, 1183. doi:10.1136/bmj.324.7347.1183
Ertel, K. A., Glymour, M. M., & Berkman, L. F. (2008). Effects of social integration on preserving
memory function in a nationally representative US elderly population. American Journal of
Public Health, 98, 1215–1220. doi:10.2105/AJPH.2007.113654
Foa, E. B., Riggs, D. S., Dancu, C. V., & Rothbaum, B. O. (1993). Reliability and validity of a
brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6,
Gleibs,I.H.,Haslam, C.,Haslam,S.A.,& Jones,J.M.(2011).Water clubs inresidentialcare: Isitthe
water or the club that enhances health and well-being? Psychology & Health, 26, 1361–1377.
Gleibs, I. H., Haslam, C., Jones, J. M., Haslam, S. A., McNeill, J., & Connolly, H. (2011). No
country for old men? The role of a ‘Gentlemens’ Club’ in promoting social engagement
and psychological well-being in residential care. Aging and Mental Health, 15, 456–467.
Goldberg, D. (1992). General health questionnaire (GHQ-12). Windsor, UK: NFER-Nelson.
Haslam, C., Holme, A., Haslam, S. A., Iyer, A., Jetten, J., & Williams, W. H. (2008). Maintaining
group membership: Identity continuity and well-being after stroke. Neuropsychological
Rehabilitation, 18, 671–691. doi:10.1080/09602010701643449
Haslam, C., Jetten, J., & Haslam, S. A. (2011). Advancing the social cure: Implications for theory,
practice, and policy. In J. Jetten, C. Haslam, & S. A. Haslam (Eds.), The social cure: Identity,
health, and well-being (pp. 319–342). London: Psychology Press.
Haslam, S. A., Jetten, J., Postmes, T., & Haslam, C. (2009). Social identity, health and well-being:
An emerging agenda for applied psychology. Applied Psychology: An International Review,
58, 1–23. doi:10.1111/j.1464-0597.2008.00379.x
Rundek, T.,& Sacco,
Developing post-traumatic stress
Haslam, S. A., O’Brien, A., Jetten, J., Vormedal, K., & Penna, S. (2005). Taking the strain: Social
identity, social support and the experience of stress. British Journal of Social Psychology, 44,
Psychologist, 44, 513–524. doi:10.1037/003-066X.44.3.513
4, 187–197. doi:10.1080/08917779108248773
Hobfoll, S. E. (2002). Social and psychological resources and adaptation. Review of General
Psychology, 6, 307–324.
Iyer, A., & Jetten, J. (2011). What’s left behind: Identity continuity moderates the effect of nostalgia
on well-being and life choices. Journal of Personality and Social Psychology, 101, 94–108.
Iyer, A., Jetten, J., Tsivrikos, D., Haslam, S. A., & Postmes, T. (2009). The more (and the more
compatible) the merrier: Multiple group memberships and identity compatibility as predictors
of adjustment after life transitions. British Journal of Social Psychology, 48, 707–733.
Jetten, J., Haslam, C., & Haslam, S. A. (Eds.) (2011). The social cure: Identity, health, and well-
being. New York: Psychology Press.
Jetten, J., Haslam, C., Haslam, S. A., & Branscombe, N. (2009). The social cure: How and why
groups make us healthier. Scientific American Mind, 20, 26–33.
Jetten, J., Haslam, C., Pugliese, C., Tonks, J., & Haslam, S. A. (2010). Declining autobiographical
memory and the loss of identity: Effects on well-being. Journal of Clinical and Experimental
Neuropsychology, 32, 408–416.
Johnson, R. L., Thomas, R. G., Thomas, K. E., & Sarmiento, K. (2009). State injury indicators
report: Fourth edition— 2005 data. Atlanta, GA: Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control.
Jones, J. M., Haslam, S. A., Jetten, J., Williams, W. H., Morris, R., & Saroyan, S. (2011). That which
doesn’t kill us can make us stronger (and more satisfied with life): The contribution of personal
Jones, J. M., & Jetten, J. (2011). Recovering from strain and enduring pain: Multiple group
memberships promote resilience in the face of novel physical challenges. Social Psychological
and Personality Science, 3, 239–243.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.
McMillan, T. M., Williams, W. H., & Bryant, R. (2003). Post-traumatic stress disorder and traumatic
brain injury: A review of causal mechanisms, assessment, and treatment. Neuropsychological
Rehabilitation, 13, 149–164.
Mellman, T. A., David, D., Bustamante, V., Fins, A. I., & Esposito, K. (2001). Predictors of post-
traumatic stress disorder following severe injury. Depression and Anxiety, 14, 226–231.
Michaels, A. J., Michaels, C. E., Moon, C. H., Smith, J. S., Zimmerman, M. A., Taheri, P. A.,
& Peterson, C. (1999). Posttraumatic stress disorder after injury: Impact on general health
outcome and early risk assessment. The Journal of Trauma: Injury, Infection, and Critical
Care, 47, 460–467.
Muenchberger, H., Kendall, E., & Neal, R. (2008). Identity transition following traumatic brain
injury: A dynamic process of contraction, expansion and tentative balance. Brain Injury, 22,
Nielsen, M. S. (2003). Prevalence of posttraumatic stress disorder in persons with spinal
cord injuries: The mediating effect of social support. Rehabilitation Psychology, 48, 289–
Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic
stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52–
Peden, M., McGee, K., & Sharma, G. (2002). The injury chart book: A graphical overview
of the global burden of injuries. Geneva: World Health Organization. Retrieved from http:
Janelle M. Jones et al.
Polinder, S., Meerding, W. J., Toet, H., van Baar, M. E., Mulder, S., & van Beeck, E. (2004). A
surveillance based assessment of medical costs of injury in Europe: Phase 2. Amsterdam:
Postmes, T., Haslam, S. A, & Swaab, R. (2005). Social influence in small groups: An inter-
active model of identity formation. European Review of Social Psychology, 16, 1–42.
Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community. New
York: Simon & Schuster.
Sani, F., Bowe, M., & Herrera, M. (2008). Perceived collective continuity and social well-being:
Exploring the connections. European Journal of Social Psychology, 38, 365–374.
M. (2004). Symptoms of posttraumatic stress disorder after orthopaedic trauma. Journal of
Bone & Joint Surgery, 86, 1115–1121.
Stinson, D. A., Logel, C., Zanna, M. P., Holmes, J. G., Cameron, J. J., Wood, J. V., & Spencer, S. J.
(2008). The cost of lower self-esteem: Testing a self- and social-bonds model of health. Journal
of Personality and Social Psychology, 94, 412–428. doi:10.1037/0022-35184.108.40.2062
Tajfel, H. & Tuner, J. C. (2004). The social identity theory of intergroup behavior. In J. T. Jost & J.
Sidanius (Eds). Political Psychology: Key Readings (pp. 276–293). London: Psychology Press.
Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction
of scales and preliminary tests of reliability and validity. Medical Care, 34, 220–233.
Care, 30, 473–481.
Wood, R. J., Liossi, C., & Wood, L. (2005). The impact of head injury neurobehavioural sequelae
on personal relationships: Preliminary findings. Brain Injury, 19, 845–851.
//www.who.int/entity/healthinfo/global burden disease/GBD report 2004update full.pdf
Yehuda, R. (2002). Post-traumatic stress disorder. The New England Journal of Medicine, 346,
Received 23 August 2011; revised version received 21 February 2012