Social work interventions with survivors of acts of political violence

Abstract

Summary

Social workers and students in a large teaching hospital explored the characteristics of psychosocial interventions during acts of political violence. The associations between hospital length of stay, Acute Stress Reaction, and the characteristics of the implemented psychosocial interventions were also examined. One hundred and forty patients (61.4% males) treated during the so-called stabbing intifada/uprising in the years 2014–2015 in Israel in one large hospital were included. Data collection was based on clinical data mining.

Findings

The most frequent patient interventions were trauma-focused, while the most frequent family interventions were needs assessment and support-system building. Most of the interventions with the family (but not with the patient) were associated with longer hospital stays. Greater severity of Acute Stress Reaction was associated with greater use of trauma-focused interventions with the patient (but not with the family).

Applications

The findings suggest that social workers hold implicit trauma-focused intervention theories that should be written up in order to develop practice-based intervention models in the context of political violence.

Keywords

Social work trauma social work practice health and social care best practice crisis intervention

Introduction

The threat and horror of acts of political violence are part of Israelis’ daily experience (Shamai & Ron, 2009). Acts of political violence include violent behavior toward civilians in order to achieve socio-political goals. They lead to extreme fear, helplessness, and anger, and are experienced as traumatic events (Coady, 2004). These acts may lead to physical or psychological injuries. The latter are known as Acute Stress Disorder (ASD) or, when symptoms do not meet all the criteria for ASD, Acute Stress Reaction (ASR), both of which may later develop into posttraumatic stress disorder (PTSD; Bryant, 2017).

During periods of political violence, social workers in hospital settings are expected to provide crisis counseling to survivors and their family immediately following the attack and during their stay in the hospital. Crisis counseling includes psychoeducation and brief (typically, one-to-three session) counseling services aimed at facilitating survivors’ return to pre-disaster levels of functioning (Rosen, Greene, Young, & Norris, 2010). In the acute phase of a crisis, social work interventions seek to restore individual and family functioning and to mediate between existing resources and the needs of the individual and family (Pockett, 2006).

Hospital length of stay and social workers’ interventions

Shortening hospital length of stay is a major goal of health systems, as longer stays are a drain on scarce resources as well as a potential cause of patient exposure to adverse events and functional decline (Henke et al., 2018; Moore et al., 2015). Social workers are expected to advance this goal through their discharge planning (Keefler, Duder, & Lechman, 2001; Redfern, Burton, Lonne, & Seiffert, 2016; Soskolne, Kaplan, Ben-Shahar, Stanger, & Auslander, 2010). However, we know less about the characteristics of psychosocial interventions when the duration of hospitalization is longer versus shorter. Patients who were injured during acts of political violence typically have a longer length of stay than other trauma victims. This presents an opportunity to compare social worker intervention between high and low lengths of stay (Aschkenasy-Steuer et al., 2005; Peleg & Savitsky, 2009).

ASR and characteristics of hospital social worker interventions

According to DSM-5, the diagnosis of ASD requires at least eight specific symptoms manifested from three days to four weeks post-trauma that were not present before the traumatic event or that have worsened since its occurrence. The symptoms include: a subjective sense of numbing, detachment from others, or reduced responsiveness to events that would normally elicit an emotional response; an altered sense of the reality of one’s surroundings or oneself; an inability to remember at least one important aspect of the traumatic event that was probably encoded (i.e. not due to head injury, alcohol, drugs); involuntary and intrusive distressing memories of the event; dissociative reactions in which the individual feels or acts as if the traumatic event was recurring; persistent and effortful avoidance of thoughts, conversations, or feelings that arouse recollections of the trauma; and sleep disturbance and hypervigilance (Bryant, Friedman, Spiegel, Ursano, & Strain, 2011).

The best practice for ASD with the most empirical support is trauma-focused cognitive-behavioral therapy (CBT). This treatment begins with psychoeducation about trauma responses and moves to anxiety management, exposure, and cognitive restructuring. In psychoeducation, one informs the patient about common posttraumatic stress symptoms and how the core symptoms are treated in therapy. The purpose of anxiety management is to reduce anxiety through a range of techniques, including breathing retraining, relaxation skills, and self-talk. Exposure therapy is considered the key component of the treatment and optimally involves both imaginal and in vivo exposure (Bryant, 2016). Nonetheless, trauma-focused CBT is rarely used in hospital settings (Post et al., 2017) perhaps because it might be less relevant because symptoms of ASD should be manifested from three days post-trauma and, by then, many patients have already been discharged from the hospital. Moreover, studies conducted in Israel show that even when the hospital staff reach out to patients in the emergency room and offer trauma-focused treatment, many decline clinical care (Shalev, Ankri, Peleg, Israeli-Shalev, & Freedman, 2011), perhaps because they put their physical recovery as their first priority.

When an event of political violence occurs, the role of hospital social workers in Israel includes four major tasks: establishing initial contact with casualties in the emergency room, operating an information hotline, organizing a family gathering area, and helping survivors with ASD (Dekel, Hantman, Ginzburg, & Solomon, 2007; Drori, Valiner, Posen, Ginsburg, & Walderman, 1999). These tasks are only broadly defined, are not governed by specific protocols, and have received scant research attention. Moreover, they are less suitable for ongoing acts of political violence with fewer casualties, such as the present study describes. Robert’s seven-stage crisis intervention model, which includes assessment, establishing rapport, identifying problems, dealing with feelings, exploring alternative options for treatment, developing and implementing an action plan, and follow-up (Knox & Roberts, 2016; Roberts, 2002, 2005), serves as a leading intervention model among hospital social workers in the context of political violence, but these stages are also broadly defined and may not be applicable in such a context.

One should also note that in times of political violence, social workers and their clients share the same reality of traumatic events, an experience that has been termed “shared trauma”, and that they may exhibit similar psychological distress (Baum, 2014; Tosone, McTighe, & Bauwens, 2015). Studies conducted in hospitals located in the vicinity of rocket strikes and where patients who were injured and/or had acute traumatic stress reactions were treated report that exposure to the suffering of the patients along with the external reality of the armed-conflict events is associated with impaired mental health of hospital personnel, including high levels of ASR (Ben-Ezra & Soffer, 2010). These effects have been shown to appear both during and six months after the end of the armed conflict (Ben-Ezra, Palgi, Wolf, & Shrira, 2011; Koren et al., 2009). Many of the practitioners continued to suffer from at least some posttraumatic symptoms more than a year after the end of that armed conflict (Cohen, Roer-Strier, Menachem, Fingher-Amitai, & Israeli, 2015). Similarly, a study conducted among social workers in Northern Ireland more than a decade following the ceasefire found that mental health social workers, as well as their clients, still suffer from trauma experiences related to the past conflict. This study highlighted the importance of specific interventions, training, and practice, as well as organizational support, to better cope with past and current traumatic experiences (Campbell & McCrystal, 2005). As hospital social workers are on the front lines of the helping professions, acts of political violence take a heavy toll on them and may limit their capacity to make use of the best evidence-informed practices.

Between 2015 and 2016, the so-called “stabbing intifada” (stabbing uprising) occurred in the Israeli–Palestinian conflict, leaving more than 80 dead and several hundred injured (Johnston, 2016). Many of the survivors, including those with ASD and ASR, were evacuated to a large hospital in the Jerusalem area. While previous studies conducted in that hospital addressed various types of injuries sustained in previous intifadas and physicians’ responses to them (Aschkenasy-Steuer et al., 2005), the focus of the present study is the characteristics of the interventions conducted by the social workers of this hospital during the stabbing intifada. Given the potential of those interventions to enrich the literature base on this topic (Du Plooy, Harms, Muir, Martin, & Ingliss, 2014), our research study addressed the following research questions:

What are the characteristics of the implemented psychosocial interventions for survivors of acts of political violence and their families who were admitted to a general hospital in Israel?

What are the associations between hospital length of stay and the characteristics of the implemented psychosocial interventions for the survivors and their families?

What are the associations between level of ASD and ASR symptoms and the characteristics of the implemented psychosocial interventions?

Methods

Study sample

All 140 survivors of the “stabbing intifada” who were treated in this hospital during the years 2014–2015 were included. More than 60% (61.4%) of the participants were males and only 17.1% were children or adolescents (aged 0–18). Of the participants, 69.3% had sustained physical injuries (with possible combination of trauma symptoms) and 30.7% had ASD or ASR (without physical injury). Other background and hospitalization characteristics are presented in Table 1.

Table 1.

Distribution of socio-demographic, type of injuries, and hospitalization variables.

Variable	%	(n)
Religion
Jewish	89.3	(125)
Muslim	8.6	(12)
Other	2.1	(3)
Civil status
Civilians	67.9	(95)
Soldiers	23.6	(33)
Policemen	5.7	(8)
Other	2.8	(4)
Type of violent event^a
Stabbing	42.6	(63)
Run over (by a vehicle)	30.4	(45)
Shooting	9.5	(14)
Throwing stones	6.7	(10)
Explosive devices	4.7	(7)
Bomb	4.1	(6)
Other	2.0	(3)
Hospitalization duration (days)
0 (was only in the ER)	50.0	(70)
1–4 days	17.9	(25)
5–15	17.9	(25)
16–29	5.0	(7)
30+ days	9.3	(13)
Number of hospitalizations due to same event
0 (first one)	50.7	(71)
1	41.4	(58)
2–4	7.9	(11)
Type of ward^b
ER	55.7	(112)
ICU	11.4	(23)
Surgery	12.9	(26)
Neurosurgery	5.0	(10)
Orthopedic	9.0	(18)
Rehabilitation	6.0	(12)
Circumstances for terminating hospitalization
Discharge	84.3	(118)
Death	5.7	(8)
Referral to a different hospital/ rehabilitation center	3.6	(5)
Other	6.4	(9)

^aN = 148 due to combined types of hostility.

^bN = 201 due to movements between wards.

Data collection and ethical considerations

Data collection was based on clinical data mining (CDM) (Epstein, 2015). Following the approval of the hospital Helsinki committee, data were gathered from the computerized medical charts where the social workers have a special section in which to write their assessments and interventions. Data were gathered by four of the authors, and the process was guided by the two other authors. There were no exclusion criteria as all survivors were included in this study. Data entry was anonymous and conducted only within the hospital boundaries. Data coding followed Corbin and Strauss guidelines (Corbin & Strauss, 2008; Tiedtke et al., 2018). First, transcribed verbatim from 20 charts were randomly selected and marked with descriptive codes. Each descriptive code indicated another intervention characteristic. Whenever the social worker wrote “he/she”, the type of intervention was coded under “the patient” descriptive code. Whenever the social worker wrote his/her mother, father, partner, etc., the type of intervention was coded under “the family” descriptive code. Second, the descriptive codes were compared by all authors. Incongruent coding was discussed until a consensus was reached for the descriptive codes. Third, the remaining charts were coded according to the descriptive codes that were previously created. Transcribed verbatim that did not meet the pre-prepared descriptive codes were coded under the category “other” and later were coded into new or expanded categories. About 20% of the charts were coded by two investigators to obtain high-quality assurance. Duration of hospitalization, type of injury, ward, and background variables were derived directly from patients’ medical charts.

ASD and ASR

According to DSM-5 (Code 308.3), an ASD diagnosis requires that symptoms last for three days to one month following the traumatic event. As many patients had already been discharged from the hospital three days after the traumatic event, most charts did not include an official diagnosis of ASD. Social workers documented the patients’ intrusive memories, feelings, physical reactions, etc. Whenever those descriptions matched an ASD symptom, such as: intrusive symptoms (e.g. flashbacks), dissociative symptoms (e.g. inability to remember important aspects of the traumatic event), avoidance (e.g. efforts to avoid external reminders), or arousal symptoms (e.g. sleep disturbance), we marked them. We then counted the number of symptoms that appeared for every patient. This was our measure for ASR. If none of the symptoms were mentioned, we coded ASR symptoms by 0 (meaning “no symptoms”).

Descriptive codes of the psychosocial interventions

Title of the codes accompanied by quotes that are selected examples of the content that is embedded in each code are presented below.

Needs assessment—Social workers reported their conversations with patients and their family members that reflected the workers’ efforts to assess the patients’ and families’ needs. For example: (social worker 1) “She told me what happened, how terrified she was and how the administration of first aid calmed her down”; Or (social worker 2): “When I met him he was conscious and talked to me. He said his family knows about his injury and is on their way to the hospital. Later on, I spoke to his wife and updated her”.

Providing information—Social workers reported the information that they provided to patients and their family. For example, (social worker 3): “I gave her some information about what happens next”.

Trauma-focused interventions

Psychoeducation on the effect of trauma: For example, (social worker 4) “I talked to him about common reactions to traumatic events. I encouraged him to share his feelings”.

Recall of the event: For example, (social worker 1) “She recalled the event. When she left work and walked to her car, she crossed the road, sensed the loud noise of a car driving at great speed, and saw the car hit people—so she ran to the other side”.

Trauma history: The social worker explores previous traumatic events. For example, (social worker 4): “Three weeks ago, his mother passed away. . . ”.

Regaining safety: Social workers tried to make sure that the patient or family now felt safe. For example, (social worker 2): “She said that now she feels held by her children”.

Developing a support system: Social workers invested intensive efforts in tracing the patients’ families, engaging with them, and providing them with direct support. For example, (social worker 5): “The mother feels great relief that he was not severely injured. There is strong social support and they don’t need help in getting organized for the weekend”.

Duties similar to their routine tasks

Mediation between patient/family members and staff: Hospital social workers routinely mediate between patients, their families, and staff members—particularly physicians (Gibelman, 2005). They continue to do so in times of political violence. For example: (Social worker 3): “The mother felt nervous with the staff in ICU. I helped her to connect”.

Treatment coordination: The hospital social worker coordinates treatment with sources and services in the community or other hospitals or rehabilitation centers. For example: (social worker 5): “The social worker and psychologist from the patient’s (child) residential area arrived at the hospital. We spoke. They provided permission for me to give their phone numbers to the patient’s parents in order to continue follow-up and treatment in the community”.

Advocacy: The hospital social worker helps to ensure the patients’ utilization of their legal rights. For example: (social worker 1) “They received information and forms to file a claim to the social security institute to be acknowledged as a ‘victim of hate crime’” (such an acknowledgement establishes an entitlement for benefits and services, AU).

Discharge plan: referral to physical treatment. For example: (social worker 2) “I referred him to the rehabilitation unit for head injuries in. . . . [another hospital]”.

Discharge plan: referral to trauma-focused therapy in the community. For example: (social worker 4): “I referred him to. . . a trauma-focused treatment service”.

Discharge plan: accessibility. For example: (social worker 1) “In preparing for discharge, we discussed rehabilitation at home and auxiliary components that may improve his quality of life”.

The final category was a conversation without providing any other details.

Results

Distribution of types of psychosocial interventions for patients and their families

The number of documented patient interventions (366) was much higher than that of family interventions (182). As the social worker typically conducted more than one type of intervention with a given patient and his or her family, the percentage for each intervention was calculated on the basis of the total number of interventions that were conducted with the patient or family rather than the total number of participants. Figure 1 presents the rates (%) of each type of intervention for a patient and his or her family. As can be seen, patients most frequently received trauma-focused interventions, particularly recall of the event (21.6%), while the most frequently used family intervention was needs assessment (13.7%) as well as exploring and developing a support system (11.5%). Needs assessment was significantly more frequent among patients than their families χ²(1) = 11.86, p = .001. Trauma-focused psychoeducation χ²(1) = 12.16, p < .001, and trauma-focused recall χ²(1) = 43.57, p < .001 were also significantly more frequent among patients than their families. The interventions of discharge plan—referral to trauma treatment services χ²(1) = 6.40, p = .011 and advocacy χ²(1) = 4.48, p = .034 were also significantly more frequently used with patients than with their families. While families, more frequently than patients, received the interventions of developing a support system and mediation, the differences between patients and families in these interventions were not statistically significant.

Associations between duration of hospitalization and social workers’ interventions with patients and their families

We examined whether hospital length of stay is associated with conducting each of the psycho-social interventions with patients and their families. The average length of stay was 7.54 days (SD = 15.19), and the median length of stay was 0.50 day. The large discrepancy between the mean and the median length of stay stems from the fact that many survivors had mild injuries or ASR and they were discharged from the hospital (emergency room) in less than a day. The length of stay distribution was highly skewed for longer length of stay in the hospital. Thirteen patients (9.6%) stayed in the hospital between 31 and 82 days. For this analysis, therefore, we used a shorter measure for length of stay in the hospital by coding duration of stay in the hospital for these 13 patients as 31, meaning longer than one month. The average length of stay for the new variable was 5.91 (SD = 9.80), and the median stayed the same (0.50). Tables 2 and 3 (for patient and family, respectively) present the average (and SD) length of stay when each intervention is conducted and when it is not. It shows that, with regard to interventions with the patients, referral to physical treatment as part of the discharge plan is associated with longer stay in the hospital, while “conversation” without details is significantly associated with shorter stay in the hospital. Other types of interventions with the patients were not significantly associated with duration of stay in the hospital although developing a support system (p = .09) and coordination (p = .06) tended to be associated with longer stay.

Table 2.

Associations between duration of hospitalization and social workers’ interventions with the patient.

	Duration of hospitalization (days)
	When intervention is conducted		When intervention is NOT conducted		t(138)	p
	M	SD	M	SD	t(138)	p
Type of psychosocial intervention^a
Needs assessment	4.79	8.84	6.67	10.38	1.11	.27
Providing information	9.86	11.80	5.48	9.51	1.60	.11
Psycho-education on the effect of trauma	5.06	8.36	6.42	10.57	.84	.40
Recall of the event	4.77	8.54	7.39	11.12	1.53	.13
Developing a support system	10.07	9.37	5.45	9.77	1.68	.09
Coordination	8.22	11.49	4.67	8.57	1.90	.06
Advocacy	5.11	8.99	6.04	9.95	.39	.70
Discharge plan: referral to physical treatment	27.0	6.02	4.29	7.99	8.79	<.001
Discharge plan: referral to trauma-focused therapy	4.61	8.69	6.24	10.07	.79	.43
Conversation- no details	3.14	6.23	6.88	6.21	2.54	<.05

^aInterventions that were used fewer than 10 times (i.e. trauma history, mediation, regaining safety, and discharge plan-accessibility) were excluded from the analysis.

Table 3.

Associations between duration of hospitalization and social workers’ interventions with the family.

	Duration of hospitalization (days)
	When intervention is conducted		When intervention is NOT conducted		t(138)	p
	M	SD	M	SD	t(138)	p
Type of psychosocial intervention^a
Needs assessment	11.56	11.84	4.69	8.69	2.74	<.05
Providing information	14.08	14.41	5.15	8.96	2.11	.06
Psycho-education on the effect of trauma	11.64	12.27	4.85	8.93	2.48	<.05
Recall of the event	12.00	13.39	5.18	9.08	1.92	.07
Developing a support system	14.05	13.61	4.48	8.24	3.12	<.01
Mediation	16.63	11.34	4.23	8.42	4.57	<.001
Coordination	11.53	13.00	5.03	8.95	2.10	<.05
Discharge plan—referral to trauma-focused therapy	8.50	12.76	5.67	9.50	.96	.34
Conversation—no details	6.05	9.56	5.89	9.88	.07	.95

^aInterventions that were used fewer than 10 times (i.e. trauma history, regaining safety, advocacy, and discharge plan—referral and discharge plan-accessibility) were excluded from the analysis.

As for interventions with the family, most of the interventions that were detected in the study were associated (either significantly or tended to be associated p < .1) with longer stay in the hospital. Needs assessment, psychoeducation on the effects of trauma, developing a support system, mediation, and coordination were all significantly associated with longer stay.

Associations between level of ASR and social workers’ interventions with patients and their families

According to the rough measure of ASR we could construct, 54.3% (n = 76) of the patients showed no ASR symptoms, 24.3% (n = 34) showed one symptom, 13.6% (n = 19) showed two symptoms, 7.1% (n = 101) showed three symptoms, and 0.7% (n = 1) showed four symptoms. Tables 4 and 5 present the average (and SD) number of ASR symptoms when each intervention is conducted and when it is not. It shows that with regard to interventions with the patients, several trauma-focused interventions were associated with higher levels of ASR: providing information (similar to re-orientation), psychoeducation on the effects of trauma, recall of the traumatic event, and discharge-plan—referral to trauma-focused therapy. Other, more generic interventions were also associated with higher levels of ASR: coordination and developing a support system. Needs assessments also tended to be associated (p < .1) with higher level of symptoms.

Table 4.

Associations between level of Acute Stress Reaction (ASR) and social workers’ interventions with the patient.

	Level of ASR
	When intervention is conducted		When the intervention is NOT conducted		t(138)	p
	M	SD	M	SD	t(138)	p
Type of psychosocial intervention^a
Needs assessment	0.93	1.02	0.64	0.95	1.69	.09
Providing information	1.86	1.17	0.63	0.89	4.71	<.001
Psycho-education on the effect of trauma	1.19	1.07	0.50	0.84	4.00	<.001
Recall the event	1.06	1.05	0.36	0.73	4.65	<.001
Developing a support system	1.29	1.14	0.70	0.96	2.14	.034
Coordination	1.12	0.99	0.56	0.93	3.32	<.01
Advocacy	1.05	1.08	0.71	0.97	1.41	.16
Discharge plan: referral to physical treatment	1.00	(1.25)	0.74	(0.97)	.81	.42
Discharge plan: referral to trauma-focused therapy	1.21	(0.96)	0.64	(0.97)	2.80	<.01
Conversation—no details	0.64	(0.80)	0.80	(1.05)	.83	.41

^aInterventions that were used fewer than 10 times (i.e. trauma history, mediation, regaining safety, and discharge plan-accessibility) were excluded from the analysis.

Table 5.

Associations between level of Acute Stress Reaction (ASR) and social workers’ interventions with the family.

	Level of ASR
	When intervention is conducted		When the intervention is NOT conducted
	M	SD	M	SD	t(138)	p
Type of psychosocial intervention^a
Needs assessment	0.64	0.91	0.78	1.01	.65	.52
Providing information	0.92	1.31	0.74	0.96	.58	.56
Psycho-education on the effect of trauma	0.95	1.17	0.72	0.95	1.02	.31
Recall of the event	0.53	0.83	0.78	1.00	.93	.36
Developing a support system	0.71	1.10	0.76	0.97	.22	.83
Mediation	0.63	0.83	0.78	1.01	.59	.55
Coordination	0.42	1.02	0.81	0.98	1.60	.11
Discharge plan: referral to trauma-focused therapy	0.67	1.23	0.77	0.97	.33	.74
Conversation—no details	0.38	0.50	0.82**	1.04	3.07	<.01

^aInterventions that were used less than 10 times (i.e. trauma history, regaining safety, advocacy, and discharge plan-referral and discharge plan- accessibility) were excluded from the analysis.

As for interventions with the family, none of the interventions were associated with level of ASR except for “conversation—no detail”. This category was less in use when the level of symptoms was higher.

Discussion

The study was based on CDM, which is a common research method in evidence-informed practice (Epstein, 2011, 2015). CDM involves the use of available clinical and administrative data, usually through the collaborative efforts of practitioner and researcher, for practice-based research purposes (Auslander & Rosenne, 2016; Epstein, 2010). Guided by evidence-informed practice principles (Lalayants et al., 2013), which integrate theory, research evidence, and practitioners’ clinical wisdom and experience, we sought to conceptualize the characteristics of the psychosocial interventions provided by hospital social workers to patients and their families, during and after acts of political violence. We further explored whether length of stay in the hospital and ASR are associated with the characteristics and frequency of those interventions.

Our study findings show that social workers in a hospital setting draw on a large repertoire of interventions both with patients and with their families, and those patients receive more interventions than their families. Specifically, similar to previous studies in a context of terrorism (Fraidlin & Rabin, 2006) and daily routine (Soskolne et al., 2010), they assess survivors’ psychosocial needs, coordinate with sources and services in the community or other hospitals or rehabilitation centers, mediate between patients, families, and staff members, and engage in discharge planning. Social workers may themselves experience shared trauma. For example, a study conducted among 150 therapists living in Israel during an armed conflict that occurred in the summer of 2014 found that the therapists are highly exposed to the events of political conflict experience PTSD symptoms, but not dysfunctions (Freedman & Tuval-Mashiach, 2018). Similarly, Schiff et al.’s study, conducted six months after the end of an armed conflict in southern Israel among social workers in foster care services, revealed that the social workers were highly exposed to the conflict events and that exposure to the armed conflict was moderately associated with their post‐traumatic stress symptoms and functional impairment (Schiff, Dekel, Gilbar, & Benbenishty, 2018). Nonetheless, our study results show that social workers in a general hospital functioned well (similar to Freedman & Tuval-Mashiach, 2018). They were also highly committed to trauma-focused interventions, i.e. interventions that help patients to discuss painful memories and reduce anxiety to tolerable levels, to establish a safe environment which includes developing a supportive network, and to increase their ability to regulate emotion and behavior (Cohen, Mannarino, Kliethermes, & Murray, 2012). In fact, the most frequently used interventions with patients, namely, recall of the traumatic event (21.6% of the total intervention used) and with the family, namely, psychoeducation on the effects of traumatic events (12.1%), were trauma-focused.

Hospital length of stay and social workers’ interventions

Similar to previous studies (Aschkenasy-Steuer et al., 2005; Peleg & Savitsky, 2009), the average length of stay in the hospital for survivors of acts of political violence was higher than among other types of trauma survivors (which is three days among the latter). The only interventions with patients who were associated with longer hospital stay were discharge plan—referral to physical treatment, which may reflect the greater severity of patients’ injuries. In addition, social workers described their interventions in more detail, as reflected by the findings in the category “conversation-no details” which was less frequent in longer hospital stay. The latter finding may indicate the intense time pressure that social workers experience during and shortly after the traumatic event (Fraidlin & Rabin, 2006), which might be reduced when the length of hospitalization is longer.

As for interventions with the family, longer hospital stay was significantly associated with many types of interventions: family needs assessment, psychoeducation on the effects of trauma, developing a support system, mediation, and coordination. These associations might be explained by the fact that more severe injuries are associated with longer stay (Godleski et al., 2018; Stevenson, Carr, Penn-Barwell, Ringrose, & Stapley, 2018) and greater need for family support and involvement (Castellano-Tejedor & Lusilla-Palacios, 2017; Kitter & Sharman, 2015). Such associations may also reflect greater family psycho-social needs that are more typical of longer hospital duration (Keefler et al., 2001; Moore et al., 2015). In addition, longer stay may provide social workers an opportunity to work with the whole family and not just the patient, following the bio-psycho-social model that guides the work of social workers in health settings (Craig, Bejan, & Muskat, 2013; Craig, Betancourt, & Muskat, 2015; Walsh, 2002). These notions may represent fruitful avenues of future inquiry.

ASR and psychosocial interventions

Social workers did not use a standard scale to assess ASR or ASD. They preferred an open-ended conversation with the patient. This somewhat impaired our ability to assess the prevalence of patients with ASR and ASD. Findings show that the higher the level of symptoms the social workers identified, the greater their use of trauma-focused interventions with the patient. Table 4 shows that a high level of ASR is associated with greater psychoeducation on the effect of trauma and providing information in general, more recall of the event and more referral to trauma-focused center in their discharge planning. All of these are elements of trauma-focused interventions (Bryant, 2016). The greater development of a support system may also be part of ensuring the patient has a safe place to discuss painful memories and reducing anxiety (Cohen et al., 2012).

The family interventions were similar across ASR levels, suggesting that social workers tend not to use family or couples trauma-focused interventions (Figley & Kiser, 2013) and mainly use individual trauma-focused principles. This finding may be explained by the staff priorities to stabilize the patient and concentrate all efforts and resources on patient’s recovery (Verharen et al., 2015). Family needs are approached at a later stage, as suggested by the positive associations that were found between duration of stay in the hospital and the number of family interventions that were used. The focus on the patient in trauma-informed interventions may also reflect a gap in knowledge on couple and family trauma-informed interventions among the social workers and their clinical supervisors. These potential explanations should be examined in future studies.

Limitations of the study

Despite its importance for conceptualizing hospital social work interventions in the context of political violence, this study is limited in several ways. First, it is based on a secondary analysis of medical and social workers’ charts. Much information was missing from those charts, which were likely written in great haste. Second, fortunately, very few children (n = 24) were injured in those terrorist events, probably because they were at schools or kindergarten at the time of the events. Thus, we could not compare social workers’ interventions with adult patients versus child patients. Third, as this was a cross-sectional study, no causality can be inferred. Fourth, although about 20% of the charts were coded by two investigators, to obtain high-quality assurance, we did not calculate inter-rater reliability. Fifth, we did not examine social workers’ shared trauma and its associations with the characteristics of psychosocial interventions with patients and their families. Finally, we had no measure for the effectiveness of the treatments. All these issues, in addition to interviews with patients, families, and social workers during the events and in two-point follow-ups, should be addressed in future studies.

Conclusions

The findings of the present study suggest that social workers are familiar with the principles of trauma-focused interventions, especially with individuals. This may be a product of the intensive training on trauma-informed interventions that they receive yearly (personal communication with the social work department of that hospital, 3 January 2019). It is therefore recommended that social workers who work in general hospitals, especially in conflict zones, should be trained for trauma-focused interventions with individuals, couples, and families. Second, social workers should consider more structured tools that may assist them with rapid assessment of patient’s needs during the stressful time of political violence. One example is a structured needs assessments tool (Craig et al., 2013). Finally, the findings suggest that the social workers do hold implicit trauma-focused intervention theories that fit the context of general hospitals. The system should allocate them the time and space to record these theories, perhaps with the assistance of researchers, toward the development of new practice-based intervention models in the context of political violence and other mass trauma.

Footnotes

Author’s note

The article is partly based on the 2nd to 5th authors’ MSW study, as part of their curriculum commitments, guided by first and last author.

Ethics

This study was approved by Hadassah Medical Center ethic committee, Jerusalem, Israel.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Acknowledgements

The authors would like to thank Prof. Gail Auslander, the Hebrew University of Jerusalem, and the social workers in the social work department of Hadassah University Medical Center, for providing helpful feedback on previous versions of the manuscript.

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