Trauma, Mental Health, Coping, Resilience, and Post Traumatic Growth (PG)-Palestinian Experience

Based on Lazarus and Folkman’s [1] model, coping refers to the behavioral and cognitive efforts one uses to manage the internal and external demands of a stressful situation. Coping can be classified as being either problem-focused or emotionfocused in nature. Lazarus & Folkman’s [1] stress-coping theory, in which the individual assesses both the relevance of the environmental stressor (i.e. what he or she has at stake in the encounter) and his or her coping options before deciding on coping strategies to deal with the stressor. This theory’s general emphasis on “coping,” however, could be expanded to encompass “development” or “growth.” There are three dimensions are most commonly used to categorize coping strategies:


Introduction
Coping Based on Lazarus and Folkman's [1] model, coping refers to the behavioral and cognitive efforts one uses to manage the internal and external demands of a stressful situation. Coping can be classified as being either problem-focused or emotionfocused in nature. Lazarus & Folkman's [1] stress-coping theory, in which the individual assesses both the relevance of the environmental stressor (i.e. what he or she has at stake in the encounter) and his or her coping options before deciding on coping strategies to deal with the stressor. This theory's general emphasis on "coping," however, could be expanded to encompass "development" or "growth." There are three dimensions are most commonly used to categorize coping strategies: A. Problem-focused and emotion-focused coping.

B.
Primary and secondary control coping.
C. Engagement and disengagement coping (also referred to as approach versus avoidance coping) [2]. D. Problem-focused coping involves activities that focus on directly changing elements of the stressful situation.

E.
Emotion-focused coping involves activities that focus more on modifying one's internal reactions resulting from the stressful situation.
Coping strategies includes a broad diversity of thoughts and behaviors used to manage the demands of a taxing situation [1]. Multiple research groups have attempted to organize coping strategies (and styles) into different categories.
The approach/avoidance construct, as the label implies, indicates whether the individual makes attempts to change the situation or distance him-or herself from the stressor as a way to reduce negative outcomes.
Coping strategies implemented immediately following trauma exposure, and in response to post traumatic stress. Avoidance as a sort of coping, such as behavioral or emotional avoidance, have been associated with increased psychological distress among interpersonal violence PTSD populations [3]. Avoidance behaviors could lead to withdrawal from support networks and reduced opportunities for positive experience, thereby compounding negative affect and reduced emotional experiencing. Approach-oriented coping strategies, such as active coping, planning, and support seeking, have been generally deemed adaptive following exposure to stress [4].
Social support is a variable that has been considered as both a means of coping and a resource contributing to the availability of other forms of coping [5]. The different ways of conceptualizing the role of social support in coping, and the relative lack of studies that examine reciprocal relationships between coping factors, has created some confusion about what roles social support may play in helping women deal with domestic violence. 002 of coherence. All these concepts describe certain personal characteristics that allow people to manage adversity well.
Resilience is usually considered to be an ability to go on with life after hardship and adversity, or to continue living a purposeful life after experiencing hardship and adversity. Smith defined resilience as a process that leads to "strength awareness", but psychological resilience may be operationally defined as strength awareness itself-that is, the belief that one can persevere or accomplish goal-relevant tasks across varied challenges and adverse situations.
Given this growing interest in scalable definitions, resilience can be defined broadly as "the capacity of a dynamic system to adapt successfully to disturbances that threaten its function, viability, or development" [8]. This definition of resilience could apply to an individual, family, computer system, economy, or ecosystem, among other systems. The capacity of any given system to adapt to challenges depends on the function of many interacting, changing systems. The resilience of children and their families are intertwined and also linked to supports and systems beyond the family in community, culture, and the physical environment.
Child resilience investigators have long recognized that resilience is inferred from judgments about risk (discussed further below) and adaptive function or development [9]; What are the criteria or standards by which we identify whether a person, a family, or any other system is adapting well? Issues in defining positive child development, adaptation, competence, or success have received considerable attention in child resilience science. What are the criteria or standards by which we identify whether a person, a family, or any other system is adapting well? One major approach to the criteria for judging adaptation is positive, focused on age-related expectations for behavior and achievement defined by communities and societies, often termed "developmental tasks" [10]. A second approach for judging adaptation, defined by low levels or absence of symptoms or disorder, stems from the initial focus on children at risk for psychopathology in the history of child resilience science. This negative approach has been criticized theoretically [11] and also from a common-sense perspective.

Family Resilience
What does it mean for a family system to be doing well or fulflling its functions effectively? Walsh [12], the concept of family resilience shifted attention from family as a resource or protective system for the individual members of a family to the function of the family unit as a whole, studied in terms of family adaptation or maladaptation in the context of adversity and the family processes that sustain family resilience. McCubbin [13] described the desired outcomes of family resilience in terms of success in fulfilling important expected functions of the family. These tasks included functions such as providing a sense of belonging and meaning, affording economic support, educating and socializing family members, and protecting vulnerable members of the family [14]. The effectiveness or success of a family would then be judged according to these expectations. Again, the criteria were multidimensional.

Post Traumatic Growth
In contrast, post traumatic growth refers to a change in people that goes beyond an ability to resist and not be damaged by highly stressful circumstances. Calhoun defined post traumatic growth as "positive change that an individual experiences as a result of the struggle with a traumatic event". In contrast to the construct of resilience, in which the individual returns to baseline functioning following highly stressful or traumatic experience, post traumatic growth is characterized by post-event adaptation that exceeds pre-event levels. Despite this interesting body of literature, there is still limited evidence on how living in areas of war and political conflict impact on university students, and which types of personal growth they may develop in response in relation to resilience. The aim of this paper to review papers conducted in Gaza Strip targeting children and adults using coping, resilience, and PTG.

Method
The author reviewed all his previous work in the area using the available data.

Results
As shown in the  clinical problems, contrasted to 13.5% as reported by teachers. These findings indicate that the likely rates of total psychiatric morbidity were relatively low. Specific self-rated scores included hyperactivity (5.3%) and emotional problems (4.1%). Teacher-rated scores indicated conduct problems (3.1%), hyperactivity (3.1%), and emotional problems (3.1%).
Coping High rates of emotional and physical maltreatment. Reliance on emotion-focused or avoidant coping strategies was associated with exposure to maltreatment. Use of maladaptive coping also predicted emotional difficulties in the respondents. The coping strategies most commonly used in stressful situations were "acceptance of faith in God" (used almost all the time by 79.4%), and "searching for information on how to get help" (used almost all the time by 60.8%). The least commonly used strategies were "eating, drinking, or smoking" (never used by 79.4%), "being angry towards people who are not the cause of the problem" (not at all used by 59.8%), and "take risks to get what I want" (not at all used by 40.2%). The emotional problems subscale in self-rated SDQ scores were strongly predicted by the use of "trying to feel better by eating, drinking, smoking, using drugs or medication" Teacherrated total SDQ scores were best predicted by two coping strategies blaming oneself and refusing to believe what happened .
Abdel Aziz Mousa Thabet [16] 250 children from the martyrs families in Gaza strip governorates by representative sample of 112 males and 138 females aged 10-16 years old.

Gaza Traumatic event checklist A COPE (Carver,
1989) The most used coping strategy was religious coping (86.4%), but the lowest coping strategy was substance use (30.3%). There were significant differences between the means of positive reinterpretation and growth, mental disengagement, focus on and venting of emotion, use of instrumental social support, active coping, religious coping, restraint, and planning according to trauma levels in favor of severe traumatic events.
Thabet Abdelaziz [17] Participants consisted of 424 children and adolescents aged between 8-16 years, who were randomly selected from 32 schools in Gaza and the West Bank.
Traumatic Event Checklist, the Impact of Event Scale, and the Adolescent Coping Orientation for Problems Experiences Children experienced an average of 13.7 traumatic events. The most common traumatic events were, witnessing demolition of a friend's home (92.4%) and hearing killing of a close relative (84.4%). The frequency of IES scores above the established cut-off score (likely PTSD) was 21.2%. There was significant association between exposure to traumatic events and PTSD symptoms. Exposure to trauma was moderated by seeking social and spiritual support in predicting PTSD symptoms Thabet AA [18] The study sample consisted of 358 adolescents aged 15 to 18 years old age. The mean age was 16.7 years. One hundred fifty eight were boys (44.1%) and 200 were girls (55.9%).
Gaza Traumatic Events Checklist, Spence Children's Anxiety Scale, Post Traumatic Stress Disorder according to DSM-IV scale, and Adolescent-Coping Orientation for Problem experiences Scale.
The study showed that, the mean traumatic events reported by adolescents was 13.34. The traumatic experiences reported by the adolescents in order were: 90.8% watched mutilated bodies on TV, 88.5% heard shelling of the area by heavy artillery, 86.6% saw the signs of shelling on the ground, and 86.0% heard the sonic sounds of the jetfighters. The results showed the mean total anxiety was 41.18, obsessive compulsive subscale was 8.90, generalized anxiety subscale was 4.46, social phobia was 6.99, separation anxiety was 6.16, physical injury fears was 5.48, and panic/Agoraphobia was 5.4. The results showed that girls had more anxiety problems than boys including all anxiety subscales. Regard PTSD, the study showed that 11.8% of adolescents reported no PTSD, 24.2% reported less than two clusters of symptoms, and 34.31% reported symptoms meeting criteria for partial PTSD, while 29.8% reported symptoms meeting criteria for full PTSD according to DSM-IV-TR. The results showed that girls reported more PTSD than boys. Palestinian adolescents mainly cope commonly by developing social support, investing in close friends, and/or engaging in demanding activities. The study showed that adolescents experienced traumatic experiences developed less social support and positively asked more professional support as coping strategies. Adolescents with PTSD had coping by ventilating feelings, developing social support, avoiding problems, and Adolescents with less PTSD had looking more for solving his family problems. Adolescents with anxiety were ventilating feelings, developing social support, and engaging in demanding activities. Adolescents with less anxiety were seeking more spiritual support.
Thabet AA [19] 449 children of 7 to 18 years Gaza Traumatic Events Checklist-20 items-War on Gaza, UCLA PTSD scale, Birleson Depression Scale, Child Revised Manifest Anxiety Scale, and Kidcope for children.
Children reported many traumatic events (mean = 4). One third (32.5%) had partial and 12.4% had full criteria of PTSD. Children living in families with low family monthly income reported more emotional problems. There was significant association between exposure to traumatic events and developing PTSD. The rates of significant anxiety and depressive symptoms were 20.5% and 22.3% respectively. Girls reported significantly more depressive symptoms than boys. Children commonly used the following coping strategies: wishful thinking, problemsolving, emotional regulation, and distraction. Trauma was negatively correlated with social support and wishful thinking , and positively correlated with self-criticism. Lack of social support and wishful thinking predicted all three types of mental health problems, while social withdrawal specifically predicted depression.
Juma A [20] The sample consisted of randomly selected 399 university students from main four universities in Gaza Strip (Al-Aqsa, Al-Azhar, Al-Quds Open and Islamic University) Stressful Situations Checklist, Hamilton Anxiety Rating Scale, Beck Depression Inventory and Carver Brief Coping Scale.
This study showed the most frequent stressors were (92%) said prices are sharply increased due to closure, (83.5) said their study was affected so much due to cut-off of electricity and shortage of gas. The study results showed that mean stressors in males was 12.38 and was 10.33 in females. There were statistically significant differences in stress toward males. The study showed 9.5% of males and 12% of females had severe depression. No gender differences. Also, 10.3% of males and 13.8% of females had anxiety. No statistically significant differences in anxiety according to gender. The study showed that there were statistically significant positive relationship between total stress due to siege and depression symptoms and anxiety. The most frequent coping strategies were (78.2%) find comfort in religious beliefs, (71.4%) think about what steps to take (67.7%) learn to live with situation. There were statistically significant negative relationship between total score of stress due to siege and total coping strategies.
Thabet AA [21] The sample consisted of 449 subjects. The age ranged from 21 to 60 years with mean age 41.5 years.

Hopkins Symptoms Checklist Scale and Family-
Oriented Coping Scale support scale The study showed than 52.6% had anxiety, and 50.6% had depression. Females scored more anxiety and depression than males. Mental health symptoms were more in family with family monthly income $300 and less, and in families with 8 and more children. The results showed that mean total family coping strategy was 107.28. Males were significantly reported more coping strategies, including acquiring social support, reframing, seeking spiritual support, and mobilizing family to acquire and accept help. Total HSCL score was negatively correlated with total family coping strategies, acquiring social support, reframing, seeking spiritual support, and positive appraisal.
Gaza Traumatic Events Checklist-20 items, War on Gaza), PTSD, and Ways of Coping Scale.
Mean traumatic events experienced 5.4 traumatic events and 42% reported full criteria of PTSD. Mean coping scores was 107.28, acquiring social support mean was 29.59, reframing mean was 31.22, seeking spiritual support mean was 15.93, mobilizing family to acquire and accept help mean was 14.14, and positive appraisal mean was 13.89. Traumatic events were significantly negatively correlated to other coping strategies such as reframing and mobilizing family to acquire and accept help. Participants with no PTSD scored more coping, acquiring social support, reframing, and seeking spiritual support, positive appraisal. While, there was no significant differences in mobilizing family to acquire and accept help with PTSD.

Authors and Year Sample Measures Findings
Shamia NA [23] The sample consisted of 274 randomly selected nurses from representative health services in Gaza,

Gaza Traumatic Events Checklist, PTSD Checklist, and Posttraumatic Growth Inventory
According to DSM-IV criteria, 19.7% of nurses reported full PTSD. There was a significant relationship between traumatic events and total PTSD and subscales; as well as between community-related traumatic events and post traumatic growth. Participants reported a range of traumatic events but PTSD and posttraumatic growth scores were more strongly associated with community rather than work-related traumas. Nursing professionals still experienced high levels of distress two years following an acute period of conflict, although they remained exposed to trauma both as civilians and in their healthcare capacity. There is need for different levels of support for healthcare staff in war-affected areas, and these should continue beyond the end of hostilities. Mental health nursing professionals have a central role in training, counselling and support to other health care colleagues.
Thabet AA [24] The sample consisted of 381 randomly selected student's representing the four major universities in Gaza Strip.

Gaza Traumatic Events Checklist, Resilience scale, and Posttraumatic
Growth Inventory Participants reported a range of traumatic events; the highest frequencies reported traumatic events were watching mutilated bodies in TV (94.5%), hearing shelling of the area by artillery (92.4%), hearing the loud voice of drone's motors (87.4%), and inhalation of bad smells due to bombardment (78.7%). While, the least common traumatic experiences were: hearing killing of a friend (11%), and being arrested during the land incursion witnessing (18.9%). Mean traumatic events reported by universities students were 10 events. While, 6% reported mild, 36% moderate and 58% severe traumatic events. Male students reported more traumatic events than females. Mean post traumatic growth was 67.34, appreciation of life was 7.17, new possibilities were 12.25, the personal strength was 10.62, and spiritual change was 6.82. Males had significantly more post traumatic growth than females and females had significantly more spiritual changes than males. For resilience, mean resilience was 55, personal competence was 22.32, positive acceptance was 13.49, trust in one's instincts was 16.30, control was 7.96, and spiritual influences were 7.31.There were gender differences on resilience subscale. Males had significantly more positive acceptance than females, trust in others, control, spiritual influences, and females had significantly more spiritual changes than males. Traumatic events had no association with post traumatic growth and total resilience. However, resilience was positively correlated with post traumatic growth. Mean resilience was 60.84, Males had more resilience than females, more committed, more able to control, and challenging than females. People living in north Gaza had less resilient and less challenging than people living in Gaza or Khan Younis. Psychological problems, obsessive compulsive, depression, anxiety, phobic anxiety, paranoid, and psychosis were correlated negatively with resilience. Also, total psychological problems, sensitivity, and phobic anxiety were correlated negatively with commitment. Sensitivity, anxiety and phobic anxiety were negatively correlated with control. With total psychological problems, obsessive compulsive, sensitivity, depression, anxiety, paranoid and psychosis were correlated negatively with challenge. There were generally no gender differences in the exposure to traumatic events, as all. Neither were there gender differences in the mean number of traumatic events related to Israeli military violence or Palestinian factional fighting. According to the DSM-IV criterion, 12.4% of the children and adolescents reported probable PTSD, and 22.37% filled the two criteria partial PTSD, and 26.7% the one criteria partial PTSD (re-experiencing or avoidance or hyper arousal). More than a third (38.4% of the children did not have PTSD. There were no significant differences between boys and girls in PTSD. For depression and anxiety, boys and girls did not differ in the levels of PTSD, depressive and anxiety symptoms. Also only one marginal gender difference was found concerning resilience characteristics: girls reported more feelings of control than boys. The results revealed that 25.0% of the participants was classified as resilient indicating presence of high exposure to traumatic events and absence of PTSD and 22.2% as traumatized, i.e., presence of both high exposure to trauma and occurrence of PTSD. Of the children 12.7% were classified as vulnerable, and 40.1% were spared of both high trauma and PTSD The most common stressful situations due siege were: feelings of being living in a big prison cannot finish some construction and repair work in their house due to shortage of cement and building materials, prices were sharply increased in the last few years. Participants commonly reported traumatic events such as hearing shelling of the area by artillery, hearing the sonic sounds of the jetfighters, hearing the loud voice of drones, and watching mutilated bodies in TV. Males had significantly experienced severe traumatic events than females. People live in cities reported more traumatic events than those live in a village or a camp. As a reaction to stress and trauma Palestinians participants reported anxiety symptoms such as nervousness or shakiness inside, feeling tense or keyed up; while depression symptoms reported were feeling sad, and weak in parts of their body. However, feelings of worthlessness and thoughts of ending life were seldom. Females reported less stress and trauma, but they showed anxiety and somatization symptoms than males. Only 12.5% said that they evaluate their life as good, and 27.1% said they enjoy their life. Better quality of life is an indicator of wellbeing; females had higher level of quality of life. While, physical health activities of daily living were more in males was. Palestinians used religious ways of coping with the stress and trauma, and 98% said God is helping all the time, they were proud of their achievements, and had strong sense of purpose in their life. There were statistically significant positive relationship between stress due to the siege and closure and traumatic events, psychological symptoms, depression, somatization, and anxiety. However, there was statistically significant negative relationship between total score of stress due to the siege and closure and the total resilience factor and subscales, and quality of life. Total traumatic events were positively correlated with psychological symptoms, depression, somatization, and anxiety. Abdel Aziz Mousa Thabet [21] The study sample consisted of 502 randomly selected children from 16  Children reported commonly traumatic events such as hearing the loud voice of Drones (98.8%), hearing shelling of the area by artillery (98.6%), hearing the sonic sounds of the jetfighters (98.4%), and watching mutilated bodies of Palestinians in TV (98.2%). Mean traumatic events reported by children was 7 events. Boys reported severe traumatic events than girls; traumatic events were reported in children living in a city than in village and camp. This study showed that 35.9% of children showed full criteria of PTSD. Posttraumatic stress disorder and re-experiencing symptoms were more in girls. Also, children coming from families with family income less than $300 and living in city.
The children anxiety symptoms, 30.9% of children had anxiety disorder. No differences in anxiety disorder between boys and girls. Anxiety was more in children living in camps and family monthly income less than $300. Palestinians children used different ways of coping with the stress and trauma, and common resilience items were 94.6% said they were proud of their citizenship, 92.4% said they feel safe when they were with their caregivers, 91.4% said that their spiritual (religious) beliefs were a source of strength for them, and 91% said they were proud of their family background Total resilience in children, personal skills, peer component, and social skills, contextual components that facilitate a sense of belonging (Spiritual beliefs, culture, and educational items) were more in of girls. Total resilience and contextual components were more in children living in a camps and a village than in a city.
However, there were statistically significant differences in individual factors (personal skills, peer component, and social skills) were more in children from family monthly income $301-750 than families with monthly income of 300$ and less. Also, traumatic events were correlated positively with anxiety and PSTD and negatively correlated with total resilience factor.
Abdel Aziz Mousa Thabet [14] The The aims of this study were to identify the type of the traumatic experiences, to find the type of resilience, anxiety trait and state occurrence, and to determine the relationship between exposure to the traumatic experiences, resilience and anxiety trait and state among university students. It is a descriptive analytical study; the sample consisted of randomly selected 399 university students enrolled from the main four universities in Gaza Strip (Al-Aqsa, Al-Azhar, Al-Quds Open and Islamic University) at the second semester of the academic year 2012 -2013. The researcher used five questionnaires; a predesigned Socio-demographic sheet, Gaza Traumatic Events Checklist, the State-Trait Anxiety Inventory, and Connor-Davidson Resilience Scale. This study showed that the most commonly reported traumatic events were watching mutilated bodies on TV (92.7%), witnessing the shelling and destruction of another's home (47.37%), witnessing firing by tanks and heavy artillery at neighbors' homes (47.12%), and being forced to move from home to a safer place during the war (42.86%). Mean total traumatic events was 4.72. Anxiety trait mean was 36.22 and anxiety state mean was 46.62. The most common resilience concepts (most of the time/all the time) were: God can help (91.7%), things happen for a reason (90.3%), and I am proud of my achievement (85.2%). Male students had significantly more total resilience, more personal competence and more trust in one's instincts than females. The results showed that there was a significant correlation between total traumatic events and anxiety state and trait no correlations between anxiety traits. The results found that there was no significant correlation between total traumatic events and total resilience, but there was a positive significant correlation between total traumatic events and trust in one's instincts, tolerance of negative affect and strengthening effects. On the other hand, there was a significant correlation between total traumatic events and spiritual domain. There was a significant correlation between anxiety state and total resilience and its subscales except in spiritual dimension.