Personal Recovery from Posttraumatic Stress: The Contribution of Self-Disclosure, Peer Support and Self-Stigma

Posttraumatic stress is the main sequela that can develop following exposure to a traumatic event in general, and to war in particular. To date, studies on posttraumatic stress have been based mainly on the established medical model that distinguishes between presence and absence of psychopathology – that is, without reference to other aspects of life. As such, this approach to the study of posttraumatic stress does not sufficiently address the psychosocial and rehabilitative implications for the lives of military veterans coping with posttraumatic stress.

The professional literature on severe mental illness (SMI) offers a recovery-based model that rests on a wider psychosocial-rehabilitation perspective. According to the recovery model, despite the catastrophic implications of a mental illness and the need to cope with persistent symptoms, people may be able to live satisfactory lives and achieve their personal and social goals (Anthony, 1993; Leamy et al., 2011). That said, although the recovery model has been used widely in SMI research in general, it has rarely been applied in the study of people after exposure to a traumatic event. Therefore, the present study used the knowledge and dimensions from recovery-based literature in combination with trauma literature, in order to allow for a broader perspective on the recovery concept among veterans coping with posttraumatic stress.

The literature on trauma often relates to the importance of social support in general during the course of recovery; however, these studies have failed to examine the social support provided specifically by other individuals coping with PTSD, that is, peer support. Peer support has become established as a predominant practice in the area of mental health in recent decades (Repper & Carter, 2011; Shalaby & Agyapong, 2020). Yet despite the fact that peer support is likely to lead to positive outcomes, to date there is an insufficient theoretical and empirical basis in the literature on this subject.

In the current study, the social-interpersonal model was used to explain the variance in posttraumatic stress recovery (Maercker & Hecker, 2016; Maercker & Horn, 2013). This model proposes that interpersonal and social characteristics play a significant role in one’s recovery from posttraumatic stress. As recovery is a multidimensional concept, several variables were selected for the study, representing different aspects of recovery (recovery assessment, illness management and recovery, meaning-making, and quality of life).

The contributions of a personal variable (self-disclosure), an interpersonal variable (peer support), and a social variable (self-stigma) to the recovery from trauma were examined. As recovery is essentially a subjective concept, in addition to the quantitative aspect, a qualitative approach was also employed to examine the way in which the interviewees perceived their recovery journey and the role peer support played in their coping system.

Thus, the present study examined recovery processes from trauma as well as the personal, interpersonal, and social factors that contribute to this process among military veterans coping with posttraumatic stress. The aims of the current study were: (1) to explore a multivariate model that would explain the variance in recovery from posttraumatic stress by means of examining the contribution of self-disclosure, peer support, and self-stigma, and (2) to examine qualitatively how veterans coping with posttraumatic stress perceived the concept of recovery and the characteristics of peer support. The combination of quantitative and qualitative methods enabled us to observe, on both the macro and micro levels, the factors contributing to recovery.

Methods: The current study was cross-sectional in nature, and combined both qualitative and quantitative methods (mixed methods). Army veterans (n=343) who experienced a traumatic event during their army service responded to an electronic questionnaire that included the following measures: PTSD Checklist PCL-5; Recovery Assessment Scale (RAS); Illness Management and Recovery (IMR); The Manchester Short Assessment of Quality of Life (MANSA); The Integration of Stressful Life Experiences Scale (ISLES-SF); Peer Support Evaluation Inventory (PSEI); Trauma Self-Disclosure; and Internalized Stigma of Mental Illness (ISMI). Data analysis included correlations, hierarchical regression analyzes, and a path analysis model with a number of independent variables. Additionally, in-depth semi-structured interviews were conducted with eight participants. The final number of interviewees was determined applying the Malterud et al. (2016) concept of information power (Malterud et al., 2016).

Quantitative findings: Negative correlations were found between posttraumatic stress and all of the recovery measures (recovery assessment, illness and recovery management, meaning-making, and quality of life). Regarding self-disclosure, differences were found depending on the type of relationship between participant and disclosure target. Namely, whereas more self-disclosure to professionals was related to increased posttraumatic stress and decreased recovery, self-disclosure to other targets, such as partners and peers, was related to decreased posttraumatic stress and increased recovery. Additionally, an association was found between self-disclosure and peer support; that is, peer support was correlated with greater self-disclosure. However, no association was found between peer support and self-stigma.

A positive association was found between receipt of peer support and posttraumatic stress, and a negative association was found between receipt of peer support and two of the recovery measures. However, a positive association was found between the provision of peer support and one of the recovery measures. In other words, surprisingly, receipt of peer support was correlated with increased stress and diminished recovery, whereas provision of peer support was found to be correlated with increased recovery.

Additionally, a positive association was found between self-stigma and posttraumatic stress levels, whereas a negative association was found between self-stigma and recovery. Although no direct association was found between self-stigma and the overall level of self-disclosure, when the various disclosure targets were viewed separately, significant negative correlations were found between self-stigma and disclosure to partners, peers, and friends. In contrast, a positive correlation was found between self-stigma and self-disclosing to professionals. In other words, in general, an association was found between self-disclosure and self-stigma; however, the type and extent of the association varied in accordance with the disclosure target.

The indirect associations in this study were examined using path analysis. The hypothesis was that self-stigma would constitute a mediating factor in the association between peer support and posttraumatic stress and between peer support and recovery. However, this notion was not corroborated. Next, I hypothesized that self-stigma would mediate the association between self-disclosure and posttraumatic stress and between self-disclosure and recovery. This assumption was confirmed; however, its directionality was dependent on the disclosure target. Whereas greater self-disclosure to partners, peers, and friends was related to less self-stigma, which in turn was related to decreased posttraumatic stress and increased recovery, the association was the opposite in the case of self-disclosure to professionals. However, no such mediated association existed in the case of self-disclosure to family members or clergy.

An additional mediation hypothesis regarded the mediating role of self-disclosure to peers in the association between peer support and posttraumatic stress and between peer support and recovery. This assumption was validated in the case of peer support provision. In other words, the component of self-disclosure, in addition to the provision of peer support, was found to be necessary for the promotion of recovery and reduction of stress.

Qualitative findings: The qualitative findings can be divided into two main components: the perception of trauma recovery and the elements involved in peer support. It was apparent from the interviews that although the term “recovery” is deeply rooted in the literature and among mental health professionals, individuals coping with posttraumatic stress perceive this term to be confusing as they consider “recovery” to be mainly connected to healing and recuperation.

In the current study I found that peer support was based on two “languages”: army language and trauma language. Army language focused on power and ability, discussions of details of the traumatic event, and comradeship. In contrast, trauma language encompassed elements of fear, guilt, loneliness, and dissociation. In the current study, peer support included some aspects of military language and some aspects of trauma language in a way that allowed for both languages to be expressed.

In contrast to trauma, which represents a sort of stagnation, the ability to talk, be heard, and be understood may promote recovery. The shared language of peer support seems to reduce the feeling of loneliness and to signal understanding without words, giving rise to feelings of empathy and solidarity. Additionally, meeting with peers seemed to normalize the interviewees' experiences and enable them to learn new ways of coping with PTSD, potentially promoting recovery. Furthermore, it appeared that supporting another individual transformed the interviewees' status from one of being supported to one of supporting and imbued their lives with significance and meaning. However, peer support can be a double-edged sword. There seems to be a fine and elusive line between the benefits of peer support and its hazards. Therefore, when providing support, peers must maintain boundaries, in terms of both the content and the extent of sharing.

Conclusions: The findings of the present study support the notion that posttraumatic stress can be observed through the lens of the recovery paradigm. When discussing recovery from posttraumatic stress, the existence of symptoms or lack thereof should not be the only measure. Despite the fact that symptoms are indeed related to recovery, a more integrative approach, including aspects such as meaning-making, quality of life, and posttraumatic stress management, are also important. Additionally, the findings of this study support the interpersonal-social model of recovery from trauma (Maercker & Hecker, 2016; Maercker & Horn, 2013) and attest to the importance of the environment in the process of recovery from trauma.

The study findings emphasize the central role of peer support in the process of recovery from posttraumatic stress. Peer support among veterans who are coping with posttraumatic stress is typified by unique characteristics related to the two languages such peers share. The combination of these two languages enables a recognition of the hardships and painful components of trauma while simultaneously allowing for an acknowledgement of individuals’ strength and capability. Additionally, it is important to identify the challenges involved in peer support so as to optimize the experience of such support, thereby reducing the risk that it will result in flooding or triggering of traumatic memories. Individuals must aim to be aware of their personal limitations and of the potential risks involved in providing support to their peers.

Importance of the study: Practically, the findings of this study highlight the benefits of including interventions that promote recovery for individuals coping with posttraumatic stress within the framework of treatment services. Treatment of trauma cannot exist in a vacuum but must also encompass components of psychosocial rehabilitation. Furthermore, the study revealed the importance of finding ways to bridge the gap between professionals and patients regarding the terminology employed when relating to the principles of recovery. It is important to disseminate knowledge regarding recovery to veterans coping with posttraumatic stress and to explain the difference between recovery and healing. Peer support is an essential element in promoting recovery. Learning about the unique characteristics of peer support in regard to posttraumatic stress, including its risks, will enable the promotion of this valuable practice in trauma treatment. Additionally, the finding that self-disclosing to professionals is correlated with increased stress and decreased recovery emphasizes the need to continue researching and fine-tuning the therapeutic solutions offered to veterans coping with posttraumatic stress, thus enabling optimal and personalized treatment.

This study’s importance lies both in the unique model it presents and in the fact that it utilizes a mixed-methods approach, enabling a deeper understanding of an under-researched area in the literature. Observing posttraumatic stress through the prism of recovery and the integration of personal interpersonal and social factors allows for a deeper understanding of recovery from trauma.