Basic assumptions and symptoms of posttraumatic stress among victims of bullying at work

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1 European Journal of Work and Organizational Psychology ISSN: X (Print) (Online) Journal homepage: Basic assumptions and symptoms of posttraumatic stress among victims of bullying at work Eva Gemz e Mikkelsen & Stale Einarsen To cite this article: Eva Gemz e Mikkelsen & Stale Einarsen (2002) Basic assumptions and symptoms of post-traumatic stress among victims of bullying at work, European Journal of Work and Organizational Psychology, 11:1, , DOI: / To link to this article: Published online: 10 Sep Submit your article to this journal Article views: 784 View related articles Citing articles: 119 View citing articles Full Terms & Conditions of access and use can be found at Download by: [Universitetsbiblioteket i Bergen] Date: 08 April 2016, At: 07:57

2 EUROPEAN JOURNAL OF WORK AND POST-TRAUMATIC ORGANIZATIONAL STRESS PSYCHOLOGY, AND BULLYING 2002, 11 (1), Basic assumptions and symptoms of post-traumatic stress among victims of bullying at work Eva Gemzøe Mikkelsen University of Aarhus, Denmark Ståle Einarsen University of Bergen, Norway Results from several empirical studies suggest that many victims of bullying suffer from post-traumatic stress disorder (PTSD). However, few researchers have attempted to explain why exposure to bullying may result in severe trauma. Furthermore, no studies have related these symptoms to the victims exposure to other distressing life events. The aims of this study were therefore to assess the prevalence and intensity of PTSD analogue symptomatology among a group of 118 victims of bullying at work. Second, we investigated whether victims of bullying who report being more affected by other distressing life events than by bullying were more likely to suffer PTSD analogue symptomatology. In accordance with Janoff-Bulman s cognitive theory of PTSD, a third aim was to investigate whether victims of bullying and non-bullied controls differ in their basic assumptions of themselves, others, and the world. Based on self-report measures, 76% of the victims portrayed symptoms indicating post-traumatic stress disorder. However, although 29% were found to meet all DSM-IV-TR criteria for PTSD, another 47% only failed to fulfil the A1 criterion, i.e., they did not report serious injuries or threats to their physical integrity while being bullied. Measurements of symptom severity scores indicated that 61.7% portrayed a moderate to severe or severe level of impairment, whereas 73.6% displayed a moderate or severe impairment in functioning. Compared with victims who failed to meet all or several diagnostic criteria for PTSD, a significantly higher percentage of the victims meeting all criteria reported feeling more negatively affected by an event other than bullying, indicating that exposure to other traumatic life events may increase victims vulnerability. Finally, significant group differences on six out of eight basic assumptions were demonstrated between victims of bullying and non-bullied controls, indicating that exposure to bullying at work may result in increased negative views on self, others, and the world. Requests for reprints should be addressed to E.G. Mikkelsen, Department of Psychology, University of Aarhus, Asylvej 4, DK-8240 Risskov, Denmark. egemzoe@hotmail.com 2002 Psychology Press Ltd l DOI: /

3 88 MIKKELSEN AND EINARSEN The 1990s witnessed a number of studies indicating that exposure to severe, long-term bullying at work often has devastating effects on the victims lives (Björkqvist, Österman, & Hjelt-Bäck, 1994; Kile, 1990; Leymann, 1992a, b). Some victims report that they feel that their physical and mental health is ruined and that they will never function normally again, let alone resume work or other significant activities (Leymann, 1996). Building on previous research (Björkqvist et al., 1994; Einarsen, Matthiesen, & Mikkelsen, 1999; Leymann & Gustafsson, 1996), this study aims first at exploring the prevalence and intensity of post-traumatic symptoms among victims of bullying and, second, whether the victims PTSD symptoms may be related to their exposure to other distressing life events. A third aim is to explore whether victims of bullying and non-bullied controls differ in their basic assumptions of themselves, other people, and the world. If so, this may explain the nature of the post-traumatic stress symptoms portrayed by many victims of bullying at work. The concept of workplace bullying refers to situations where, over a period of time, a person is repeatedly exposed to negative acts (e.g., verbal abuse, offensive remarks, ridicule, slander, or social exclusion) from co-workers, supervisors, or subordinates (Einarsen, 2000). Bullying differs from isolated, transitory interpersonal conflicts in the respect that it involves systematic aggression aimed at one or more individuals by another individual or a group (Hoel, Rayner, & Cooper, 1999). A prolonged exposure to repeated negative acts with which one feels unable to cope is a defining characteristic of bullying (Björkqvist et al., 1994; Einarsen, 2000; Keashly, 1998). Research has indicated that exposure to bullying at work negatively affects victims health and wellbeing. The symptoms reported by the victims include low self-esteem, anxiety, sleep disturbance, recurrent nightmares, various somatic problems, concentration difficulties, irritability, feelings of depression, and self-hatred (Björkqvist et al., 1994; Einarsen & Raknes, 1997; Einarsen, Raknes, Matthiesen, & Hellesøy, 1996; Kile, 1990; Leymann, 1990, 1996; Niedl, 1996; Vartia, 1996; Zapf, Knorz, & Kulla, 1996). Among 30 Irish victims of bullying, the most commonly reported symptoms were anxiety, irritability, and depression (O Moore, Seigne, McGuire, & Smith, 1998). A similar symptom pattern characterized German (Zapf et al., 1996) and Austrian (Niedl, 1996) victims of bullying. Based on the victims symptom constellation, researchers have proposed that some victims suffer from PTSD (Björkqvist et al., 1994; Leymann & Gustafsson, 1996). Post-traumatic stress disorder designates a configuration of stress symptoms typically seen in victims exposed to traumatic events (APA, 2000). Victims with PTSD suffer from at least one symptom of re-experiencing, such as when they relive the trauma in dreams or thoughts or when they experience psychological distress and/or physiological reactivity when exposed to cues that symbolize or resemble the event. Another characteristic is persistent avoidance of traumarelated stimuli and a numbing of responsiveness. This must be manifested

4 POST-TRAUMATIC STRESS AND BULLYING 89 through at least three symptoms, such as avoidance of stimuli associated with the trauma, inability to recall important aspects of it, lack of interest in important activities, and feelings of detachment from others or emotional numbness. Furthermore, the victims must exhibit at least two symptoms of increased arousal such as difficulty falling or staying asleep, difficulties concentrating, irritability, and hypervigilance. Lastly, the symptoms must have lasted for at least a month, causing significant impairment in functioning in various spheres of the victims lives. Results from several empirical studies suggest that some victims of bullying at work do suffer from PTSD. Björkqvist and colleagues (1994) found 19 victims of long-term bullying who exhibited a symptom pattern indicative of PTSD. Clinical and quantitative assessment of 64 victims at a Swedish rehabilitation clinic resulted in 59 victims being diagnosed with PTSD (Leymann & Gustafsson, 1996). Most of these victims were highly traumatized, with mean symptom scores on the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) exceeding those of train drivers having experienced person under train incidents (Theorell, Leymann, Jodko, Konarski, & Norbeck, 1994), and comparable to IES scores of rape victims (e.g., Dahl, 1989). A Norwegian study among 102 victims of long-term bullying at work showed that 75% portrayed stress symptoms indicating PTSD (Einarsen et al., 1999). Forty-six per cent of the victims were bullied more than 5 years earlier, which suggests that they suffered from chronic PTSD. However, in order to be diagnosed with PTSD the person must have been exposed to a traumatic event that involved actual or threatened death or serious injury to his or her physical integrity (criterion A1, DSM-IV-TR; APA, 2000). Also, the person must have experienced intense fear, helplessness, or horror while being victimized (criterion A2). With respect to the A1 criterion, this poses a problem in relation to workplace bullying since the behaviours used by adult bullies are predominately non-physical (Björkqvist et al., 1994; O Moore et al., 1998; Zapf et al., 1996). Consequently, it remains somewhat premature to conclude that victims of bullying suffer from PTSD and alternative diagnoses must also be considered. In Leymann and Gustafsson s (1996) study, many victims suffered from anxiety and depression. Symptoms of anxiety frequently displayed by victims of bullying include hypervigiliance, startle response, concentration difficulties, irritability, and sleep disturbance. Although comprising PTSD criteria D, this symptom cluster also characterizes generalized anxiety disorder (GAD). However, many victims of bullying also exhibit other types of stress symptoms. Indeed, increased arousal, symptoms of avoidance numbing, and impairments in social or occupational functioning are also found in individuals suffering from depression (APA, 2000). Of the 64 patients assessed by Leymann and Gustafsson, 33% suffered from a moderate depression, and 39% suffered more severe states of the disorder. Thus, the symptom constellation displayed by some victims of bullying may be indicative of a major depressive disorder.

5 90 MIKKELSEN AND EINARSEN On the other hand, the seemingly desperate and erratic behaviours displayed by some victims of bullying (Leymann, 1986) are not characteristic criteria of major depressive disorder (APA, 2000). Victims of bullying at work also typically report symptoms of re-experiencing such as when intrusive memories and thoughts about what have happened to them constantly come into their minds. Furthermore, they are often preoccupied with thoughts of revenge against the perpetrator and appear to be highly vigilant towards potential encroachments (Einarsen, Raknes, Matthiesen, & Hellesøy, 1994b; Leymann & Gustafsson 1996). Case studies also show that victims of bullying exhibiting such behaviour have been misdiagnosed as suffering from for example paranoid delusions (Einarsen & Hellesøy, 1998; Leymann, 1986, 1992b). For some of these victims, heavy medication replaces proper psychotherapeutic treatment (Leymann, 1986, 1992a). From a rehabilitation point of view, however, it is paramount that the victims be correctly diagnosed (Ravin & Boal, 1989). Based on the particular symptom cluster exhibited by many victims of bullying at work, we suggest that PTSD is one alternative to, for example, depression. In line with this, Ravin and Boal (1989) and Scott and Stradling (1994) argue that individuals may develop full PTSD symptomatology following exposure to work-related stressors such as bullying, work overload, and massive layoffs none of which involve serious threats or injuries to the person s physical integrity. Moreover, one of the most irrefutable critiques of the present stressor criterion highlighting the pivotal role of the stressor stems from studies (Bowman, 1999; McFarlane, 1989) showing individual variables to be more powerful predictors of PTSD than event characteristics. Ravin and Boal (1989) note that clinical experience often precedes the latest diagnostic manual and is the very basis for changes in diagnostic criteria. In addition, just as the diagnostic term used to describe stress responses following trauma exposure has changed throughout the history of the PTSD diagnosis, so have its diagnostic criteria and in particular the stressor criterion (Peterson, Prout, & Schwarz, 1991; Ravin & Boal, 1989; Yehuda & McFarlane, 1995). In light of these arguments, we believe that there are sound reasons for assessing the prevalence and severity of PTSD analogue symptomatology among victims of bullying at work. Although previous studies have shown victims of bullying to be highly traumatized, it is not known whether the stress symptoms reported in these studies may be indirectly or directly due to the victims going through or having experienced other distressing life events. Of course, exposure to such events may account for the victims symptoms. Moreover, employees who are distressed by other negative life events may also be at risk of being bullied in so far as they may be vulnerable targets or scapegoats. Also, distressed persons may violate social norms, hence eliciting aggressive responses from co-workers (Einarsen, Raknes, & Matthiesen, 1994a). Furthermore, repeated exposure to several traumas has been found to increase

6 POST-TRAUMATIC STRESS AND BULLYING 91 victims vulnerability to developing PTSD (Brewin, Andrews, & Valentine, 2000; McFarlane, 1989). Since victims of bullying are often victimized over a prolonged period of time, there appears to be an elevated risk of simultaneous exposure to other distressing life events. Thus, in line with a diathesis stress approach to PTSD, the present study investigates if victims reporting exposure to such events are more likely to suffer from PTSD analogue symptomatology. Although existing empirical evidence indicates that workplace bullying is stressful to the point of being traumatic, we still do not know exactly why. Indeed, no comprehensive theory has yet been forwarded as to why exposure to bullying may result in severe stress responses (Mikkelsen, 2001). On the basis of Janoff-Bulman s (1989, 1992) cognitive theory of trauma, this study proposes that post-traumatic stress following victimization may be due to the shattering of basic assumptions victims hold of themselves, other people, and the world (see also Mikkelsen, 2001). In accordance with Epstein s theory (1985), Janoff- Bulman (1989, 1992) describes the human conceptual system as comprised of higher and lower order postulates. Whereas the latter consists of narrow and specific generalizations, such as I m a good swimmer, the former involves abstract, global, and generalized assumptions concerning the self, other people, and the world (Janoff-Bulman & Schwartzberg, 1990). Examples of such assumptions are I m a competent person and People generally care for others (Janoff-Bulman, 1992). Developed from our earliest interactions with the world, these positive assumptions or schemas are cognitively and affectively potent (Janoff-Bulman, 1989). By providing people with expectations about themselves, others, and the world, the assumptions allow an effective daily functioning and help people maintain a sense of invulnerability. The first basic assumption is benevolence of the world and refers to the extent to which people regard the world positively or negatively, and the extent to which they think that good as opposed to bad events happen in the world (Janoff- Bulman, 1989). Comprised within this category are two assumptions: benevolence of the impersonal world and benevolence of people. The former assumption entails that the world is seen as a good place where misfortune is fairly uncommon, the latter assumption entails that people are considered as basically kind, caring, and helpful. The second core assumption, meaningfulness of the world, refers to beliefs about the distribution of positive and negative outcomes (Janoff-Bulman, 1989). This involves beliefs about why things happen in the world, particularly why they happen to some people and not to others. At least in Western cultures, this assumption can be explained in terms of three distributional principles: (1) a principle of justice, according to which people get what they deserve; (2) a principle of controllability, according to which people are able to control the outcomes of events by means of engaging in proper, precautionary behaviours, thereby increasing their invulnerability; and (3) a principle of randomness. People who believe in randomness are likely to feel highly vulnerable insofar as

7 92 MIKKELSEN AND EINARSEN justice and controllability are not regarded as primary determinants of future outcome (Janoff-Bulman, 1989). Instead, it is assumed that since the world functions according to a principle of chance, there is nothing one can do to prevent future negative events. Finally, the core assumption of self-worth, comprises three assumptions: selfworth, which involves seeing oneself as a worthy, moral, and capable person (Janoff-Bulman, 1989, 1992); self-controllability, relating to the extent to which a person sees him- or herself as someone who engages in proper, precautionary behaviours; and luck, referring to perceptions of oneself as more or less lucky or unlucky. Thus, people who perceive the world as malevolent and unjust yet feel worthy, lucky, and capable of eluding misfortune may still be capable of maintaining a sense of invulnerability. Following exposure to traumatic events, victims may realize that their assumptions of the world and themselves are no longer viable (Janoff-Bulman & Frieze, 1983). In so much as people need stability in their conceptual system (Epstein, 1985), such abrupt changes in core schemas are deeply threatening and may result in an intense psychological crisis (Janoff-Bulman, 1992). The conceptual incongruity between the trauma-related information and the prior schema leads to cognitive disintegration. This again gives rise to stress responses requiring reappraisal and revision of the victims fundamental schema (Horowitz, 1975). Subsequently, the victims must rebuild new and more viable core assumptions or schemas, which account for the experience of being victimized. However, some victims have difficulty doing so. Instead of resolving the cognitive-emotional crisis forced upon them by the traumatic event, they remain in a chronic state of cognitive confusion and anxiety that is characteristic of PTSD (Janoff-Bulman & Schwartzberg, 1990). Based on our work with victims of bullying, we contend that this extreme social stressor may challenge all of our core assumptions and that this might explain the high level of psychological impairment reported by many victims. We believe that this is because bullying involves threat aspects resembling those inherent in other traumatic stressors such as long-term abuse, violent assaults, or rape (see also Mikkelsen, 2001). When exposed to intentional and systematic psychological harm by another person, either real or perceived, victims may experience fear, anxiety, helplessness, depression and shock (Janoff-Bulman, 1992). Such victimization may even change their perceptions of the work environment to one of threat, danger, and insecurity. A characteristic feature of bullying is the victims perceived inability to cope with the aggression to which they are subjected (Björkqvist et al., 1994; Einarsen, 2000; Keashly, 1998). Inasmuch as these victims are systematically exposed to interpersonal aggression over a prolonged period of time, the quintessence of this situation is the experience of infringement of a continuing threat from which they cannot escape (Leymann & Gustafsson, 1996). In addition, many victims of bullying report lacking social support (Einarsen et al., 1996; Leymann, 1986, 1992a; Zapf

8 POST-TRAUMATIC STRESS AND BULLYING 93 et al., 1996). As such, bullying may threaten their assumptions of benevolence of the world and other people. Furthermore, since many victims believe that they are innocent victims of intentional aggression, this type of victimization may also threaten assumptions of a meaningful world. Added to this is the fact that many victims of bullying at work are subjected to secondary victimization such as when they are misdiagnosed and/or mistreated by the health-care system (Leymann, 1992b; Leymann & Gustafsson, 1996). Finally, being the subject of aggression with which one cannot cope may threaten the victims sense of selfworth and self-controllability. Indeed, low self-esteem has been found to be a consistent correlate of exposure to bullying (Einarsen et al., 1996; Kile, 1990). AIMS OF THE STUDY The study aims, first, at assessing the prevalence and severity of PTSD analogue symptomatology among self-selected victims of bullying. A second aim is to investigate the hypothesis that victims who report being more affected by other distressing events than by bullying are also more likely to suffer from PTSD analogue symptomatology. Third, using an adapted version of Janoff-Bulman s (1989) World Assumptions Scale (WAS), the study investigates if victims of bullying at work differ in their assumptions of themselves, others, and the world compared to a non-bullied control group. Participants METHOD The victims (N = 118) were recruited in two ways: One victim subgroup consisted mainly of people who, having heard about our research from union newsletters or a support group, subsequently contacted us because they wished to participate in the study. Most of the victims in this group were junior schoolteachers, pedagogues, or nurses. The other subgroup consisted of members of a trade union, who had sought the union s assistance or advice due to having experienced problems with workplace bullying or an emotionally abusive work environment. The victims in the first subgroup were informed of the study via telephone. The trade union members were informed of the study in a letter from their union representative. Along with this letter were included the questionnaire and a self-addressed stamped envelope facilitating an easy return of the questionnaire. Overall, the victim group consisted of 11 men and 107 women. The mean age was 47 years (range 20 64). With regard to occupations, 21% were nurses, 36% were trade union members, and 42% were schoolteachers or pedagogues. A total of 9% had only completed junior high school, 20% were skilled workers, 3% had graduated from university, and 60% had completed further or higher education. Sixteen per cent were in a supervisory or managerial position.

9 94 MIKKELSEN AND EINARSEN The control group (N = 118) also consisted of 107 women and 11 men, of whom 21% were hospital nurses, 36% were randomly selected members of a trade union, and 42% were schoolteachers or pedagogues doing part-time university studies. None of these 118 persons had felt subjected to bullying at a present or former workplace. A ward superior distributed questionnaires to the nurses at a local hospital, and the schoolteachers/pedagogues received the questionnaires in connection with a lecture. The group of trade union members received the questionnaires by mail along with a letter from their union representative. The victim group and the control group were matched on work role, gender, and education: However, the mean age of the victim group was 47 years (range 20 64) vs 41 years (range 20 66) in the control group. Whereas all the victims claimed that they were or had been victims of severe bullying at work, none of the controls reported having been subjected to bullying. Besides, whereas all victims reported to have been exposed to specific bullying behaviours at work on a weekly or daily basis for at least 6 months, which is the criteria for bullying proposed by Leymann (1996), participants in the control group reported only occasional exposure to such behaviours. Instruments Data were collected by means of anonymous self-report questionnaires measuring exposure to bullying, post-traumatic stress symptoms, basic assumptions, and exposure to other distressing life events. Exposure to workplace bullying was measured in two ways: first, having supplied the respondents with a definition of workplace bullying (see Einarsen, 2000), respondents were asked to what extent they felt victimized from bullying, response categories being: no, yes, to a certain extent, and yes, extremely. We also asked the participants to supply information as to when they were bullied, the duration of the bullying, who bullied them (e.g., supervisors, colleagues, or subordinates), and the number of perpetrators. In relation to this, we also asked the victims to describe in their own words how they were bullied. Second, using the Negative Acts Questionnaire (Einarsen & Raknes, 1997) we measured self-reported exposure to specific negative acts of bullying. In this study the NAQ consisted of 22 items (Cronbach s alpha =.93), all described in behavioural terms with no reference to the term bullying. The NAQ contains items referring to both direct (e.g., openly attacking the victim, abuse) and indirect (social isolation, slander) behaviours. For each item of the NAQ the respondents were asked how often they had been exposed to the behaviour during the last 6 months or during the time of exposure to bullying, response categories being: never, now or then, about weekly, about daily. Symptoms of PTSD were measured using the Post-traumatic Diagnostic Scale (PDS; Foa, 1995; Foa, Cashman, Jaycox, & Perry, 1997), which was distributed

10 POST-TRAUMATIC STRESS AND BULLYING 95 to the victim group only. Contrary to most other self-report instruments assessing PTSD symptoms, the PDS measures all DSM-IV-TR diagnostic criteria for PTSD and provides information about symptom severity as well. In its original form it consists of 49 items pertaining to trauma history, post-traumatic symptoms, and associated impairment of functioning. In the present study, we used a somewhat modified version of the scale, as 12 items pertaining to the nature of the traumatic event (e.g., accidents, assaults, life-threatening illnesses, and so on) were deemed inapplicable and thus excluded. Items included were: (1) four items (response categories yes or no ) measuring stressor criterion A1 (physical injury of self/others or perceived threat to life), and two items (response categories yes / no ) assessing the stressor criterion A2 (feeling helpless, scared, or terrified during the event); (2) 17 items assessing the core symptoms of PTSD (criteria B, C, D): re-experiencing (five items), avoidance numbing (seven items), and arousal (five items). Respondents rated each symptom on a 4-point scale according to the perceived frequency of the symptoms (0 = not at all or only one time; 1= once a week or less/once in a while; 2 = two four times a week/half the time; 3 = five or more times per week/almost always). In order to facilitate a clearer understanding, we changed the wording of these 17 items in that we replaced the phrase traumatic event with bullying ; (3) two items assessing onset and duration of the symptoms (criterion E); and (4) nine items assessing impairment in functioning in various areas of life such as work, relationships with friends and family, household chores, leisure activities, general satisfaction with life, or overall level of functioning (criterion F). In the present study the PDS scale as well as its subscales all showed excellent internal consistencies with Cronbach s alphas of.94 for the total scale,.89 for reexperiencing,.86 for avoidance, and.85 for arousal. Other studies have also demonstrated the PDS high internal consistency, and evidence of satisfactory validity and reliability has been presented (Allen, Coyne, & Huntoon, 1998; Foa et al., 1997). Basic assumptions were measured by means of the 32-item World Assumptions Scale (WAS, Janoff-Bulman, 1989). Two subscales include statements about people and the world in general and measure the core assumption of benevolence of the world. Examples of items are: The world is a good place and People really don t care what happens to the next person (reverse scored). Another three subscales assess assumptions of justice, control, and randomness, which relate to the core assumption of meaningfulness of the world. Examples of items are Generally, people deserve what they get in this world, The course of our lives is largely determined by chance, and Through our actions we can prevent bad things from happening to us. Finally, three subscales measuring perceived self-controllability, personal luck, and self-worth have been designed to assess the core assumption of self-worth. The following statements are examples of items in these scales: I almost always make an effort to prevent bad things from happening to me, I am luckier than most people,

11 96 MIKKELSEN AND EINARSEN and I often think I am no good at all (reversed scored). Respondents were asked to indicate the extent of their agreement with each statement, items scoring on a 6-point scale with endpoints strongly agree and strongly disagree. In the present study the internal consistencies of the eight WAS subscales were satisfactory, Cronbach s alpha values being.82 for benevolence of the world,.60 for benevolence of people,.73 for randomness,.86 for justice,.75 for controllability,.80 for self-worth,.75 for self-controllability, and.71 for luck. The WAS has been used in several studies (Franklin, Janoff-Bulman, & Roberts, 1990; Magwaza, 1999; Overcash, Calhoun, Cann, & Tedeschi, 1996) showing acceptable reliability and validity. Exposure to distressing life events was measured with a 17-item life event scale developed especially for this study. Examples of life events included in the scale are accidents, conflicts with friends and family, unemployment, illness, divorce, or bereavement. The respondents were asked to indicate the time of the event, response categories being 0 6 months ago, 7 12 months ago, or more than a year ago. Moreover, we asked them to assess its general effect on their lives or the quality of their lives at the present time, response categories being strong negative effect, moderate negative effect, and no effect or positive effect. The scale also included a separate item asking respondents to indicate whether any of the experienced life events affected them more negatively than the bullying. Those victims who confirmed that they were more negatively affected by life events other than bullying were asked to indicate which event(s). Translations of the PDS and the WAS from English were carried out in conformity with current requirements. Bilingual consultants with a university degree in psychology and/or English translated the scales after which other consultants with the same academic background back-translated them. Since several of the WAS items arguably reflect characteristics of Northern American culture, we took particularly care in translating and adapting this scale to reflect a Scandinavian cultural context. A preliminary translation was also tested in a pilot study, after which minor changes were implemented. RESULTS Based on victims self-reported symptoms on the PDS, 76% of the victims portrayed symptoms indicating PTSD. However, although 29% were found to fulfil all six DSM-IV-TR criteria (i.e., victims with full PTSD ), 47% did not report having experienced serious injuries or threats to their physical integrity while being bullied (i.e., victims with PTSD minus A1). Measurements of the victims symptom severity scores on the PDS revealed that 21.7% of the victims portrayed mild symptoms, 16.5% portrayed moderate symptoms, 37.4% portrayed moderate to severe symptoms, and severe symptoms were portrayed by 24.3%. Mean symptom severity score for the total sample was (SD =

12 POST-TRAUMATIC STRESS AND BULLYING ) for the total PDS scale; 7.16 (SD = 4.32) for re-experiencing; 9.74 (SD = 5.85) for avoidance numbing; and 7.17 for arousal (SD = 4.53). Mean symptom severity scores for victims with full PTSD (n = 34), victims with PTSD minus criterion A1 (n = 55), and for Foa et al. s (1997) original sample are listed in Table 1. Comparisons of symptom severity scores between victims with full PTSD (n = 34) and victims from Foa et al. s (1997) study (228 persons suffering from PTSD after exposure to or witnessing a high magnitude stressor) showed identical patterns. This clearly indicates that victims of bullying portray a symptom pattern similar to that of other trauma groups. Using the PDS we also assessed the victims level of impairment in functioning based on the number of areas of life that has been affected by the reported symptoms, be it at work, in one s family life, one s sex life, in relation to leisure activities, or in relationships with friends. According to the criteria developed by Foa (1995), only 11.9% of the victims portrayed no impairment, 13.6% portrayed mild impairment; moderate impairment was calculated for 35.6%, and 38% reported severe impairment. Moderate impairment refers to at least three areas affected, whereas severe impairment refers to seven areas of life being affected by one s symptoms. Significant positive relationships were found between the level of bullying behaviour reported as measured by the Negative Acts Questionnaire and the severity of reported post-traumatic symptoms (Pearson r =.34, p <.01). Correlation between the level of bullying behaviour experienced and symptoms of re-experiencing and arousal as measured by the PDS yielded in both cases a Pearson r of.28 (p <.01), while the correlation between the PDS subscale of avoidance numbing yielded a Pearson r of.22 (p <.05). Hence, the more bullying acts reported by the victims, the more post-traumatic stress symptoms they displayed. TABLE 1 Mean symptom severity scores (as measured by the PDS) Victims with PTSD after exposure to high magnitude stressor Victims of bullying Victims of bullying (Foa et al., 1997) with full PTSD PTSD minus criterion (n = 228) (n = 34) A1 (n = 55) PDS scale M SD M SD M SD Total symptom severity Re-experiencing Avoidance Arousal

13 98 MIKKELSEN AND EINARSEN A Pearson r of.33 (p <.01) was also found between the duration of the experienced bullying and the reported level of impairment in functioning. Victims who had been bullied for many years reported a higher level of impairment than did those who had been bullied for a shorter period of time. However, victims who were bullied at the time of the survey reported the highest symptom severity scores. A Pearson r between symptom severity and time since the bullying had ceased was calculated to.36 (p <.001). Among victims who reported that the bullying had ceased more than 5 years ago, a total of 54% still exhibited PTSD analogue symptomatology (i.e., they met criteria B F, A2, and in some cases also A1). Altogether 90% of those bullied at the time of the survey portrayed PTSD analogue symptomatology, which is also the case for those victims (n = 15) who were bullied less than 6 months prior to the study. Among victims who had been bullied between 6 months and 2 years prior to the study (n = 36), 80% still suffered from PTSD analogue symptomatology as did 62% of those who had experienced bullying between 2 and 5 years earlier. Thus, although the symptoms of intrusion, avoidance numbing, and arousal seem to decrease somewhat as time elapses, many victims still portray the full symptom pattern of PTSD many years after the bullying has terminated. The results further showed that many victims experienced being exposed to bullying as the major trauma in their lives. Although many reported having suffered other distressing life events, such as for example, accidents, divorce, serious illness, or bereavement, as many as 80.5% concluded that at the present time, no other event in their life affected them more negatively than the bullying. The remaining 19.5% who stated that they were more negatively affected by other events than the bullying typically reported events such as being fired, unemployment, having financial problems, being divorced, or having had severe conflicts and problems with family and friends. Using Chi-square tests, we tested whether victim PTSD status (full PTSD, PTSD minus A1, or non-ptsd) as measured by the PDS scale was related to reported exposure to other more distressing life events. No significant differences were found between victims with full PTSD and those portraying symptoms of PTSD minus criteria A1 (c 2 = 2.341, df = 1, p =.126). However, significant differences were found between victims with full PTSD and non-ptsd victims (c 2 = 5.889, df = 1, p =.015), perhaps indicating that, for at least some victims, it is the cumulative effects of exposure to several stressors (including bullying) or the exposure to one or more distressing life events other than bullying that may have caused their PTSD symptomatology. Significant group differences were found on all eight assumptions of the WAS, except for randomness, F(1, 232) = 3.463, p =.064, and selfcontrollability, F(1, 232) = 2.39, p =.12 (see Table 2). Hence, compared to nonbullied controls, victims of bullying considered themselves less worthy, less capable, and unluckier. They also perceived the world as less benevolent and other people as less supportive and caring. Last, in comparison with controls, the

14 POST-TRAUMATIC STRESS AND BULLYING 99 victims regarded the world as less controllable and just. Group differences were particularly notable on the assumption of justice. No significant correlations were found within the victim group between these negative assumptions and the age of the victim. Consequently, we may rule out age as an alternative explanation for these group differences. Moreover, no relationships were found between victims assumptions, the duration of the bullying, and the time since the bullying ceased. This suggests that it is the very shock of being subjected to bullying that is the primary cause of these negative schemas. This hypothesis tends to be supported by the fact that no relationships were found between the level of exposure to negative acts, as measured by the NAQ, and the victims assumptions. DISCUSSION In accordance with previous findings (Einarsen et al., 1999; Leymann & Gustafsson, 1996), the results of the present study show a high prevalence of PTSD analogue symptomatology among victims of bullying at work. Also, in agreement with these previous findings, most of the victims portray moderate to severe or severe symptoms. Furthermore, a large majority of the victims display a moderate or severe impairment in functioning in various important areas of their lives. Comparisons of mean symptom scores as reported by victims in this study and those of other trauma groups (Foa et al., 1997) show identical patterns. Together, these results are an indication that the detrimental effects of exposure to bullying at work may in many ways be compared to those of other traumatic life events. The moderate to strong correlations between symptom severity scores and level of impairment in functioning and the degree of exposure to bullying TABLE 2 Mean, standard deviation, and results of a one-way ANOVA on the World Assumption Scale Victims Controls Mean SD Mean SD F Benevolence of people ** Benevolence of the world * Randomness Justice *** Controllability *** Self-worth *** Luck *** Self controllability *p <.05; **p <.01; ***p <.001.

15 100 MIKKELSEN AND EINARSEN indicate that the more bullied, the more traumatized the victims are. Not surprisingly, victims who are bullied at the time of the survey portray the highest level of symptoms. Nevertheless, more than half of the victims bullied more than 5 years prior to the study still portray symptoms indicating PTSD. The fact that a high percentage of the victims of bullying remain traumatized years after being victimized accords with the results of a comparable Norwegian study (Einarsen et al., 1999). As predicted, many of the victims of bullying do not meet the DSM-IV-TR PTSD stressor criterion A1, which stresses that victims must have experienced serious injury or threats to their physical integrity in order to fulfil a PTSD diagnosis (APA, 2000). In recognition that a PTSD diagnosis can only be given if criterion A1 is met, Scott and Stradling (1994) have proposed a supplementary diagnosis, Prolonged Duress Stress Disorder (PDSD), which could account for the stress symptoms displayed by victims exposed to prolonged duress caused by one or more continuous life stressors of relatively less intensity. Alternatively, the symptom pattern exhibited by these victims might reflect the presence of depression. A third diagnostic alternative is adjustment disorder, which requires the development of significant emotional or behavioural symptoms within the 3 months after the onset of one or more identifiable stressors, such as, for example, marked business or marital problems (APA, 2000). Additional criteria are notable impairments in social and/or occupational functioning or that the symptoms exceed those normally expected from exposure to such a stressor. Once the stressor or its consequences have terminated, the symptoms last no longer than 6 months. If the stressor has enduring consequences, the symptoms may persist. Indeed, many victims of bullying feel that as a result of the bullying their lives have permanently changed for the worse. While considering adjustment disorder as a possible diagnostic alternative to PTSD, PDSD, or depression, we, like Leymann (1992b), question the view that, generally, the symptoms displayed by victims of bullying are in excess of what might be expected from exposure to such a stressor. The DSM-IV-TR acknowledges that the victim s response or attributions contribute to the onset of PTSD. In line with this, a large majority of the victims in the present study report feelings of fear or helplessness associated with the bullying, thus meeting the stressor criterion A2. However, diagnostically, the relevance of these subjective responses appears to be secondary to the specific nature of the stressor. Considering the high level of traumatization portrayed by many of the victims in this study in addition to the fact that in most cases victims of bullying fail to meet the A1 criterion as outlined in the DSM-IV-TR (APA, 2000), we question the relevance of this criterion. First of all, it should be considered whether events that do not involve serious injury or threats to one s physical integrity might also traumatize victims to the extent that they develop severe stress symptoms. As previously noted, researchers (Ravin & Boal, 1989; Scott & Stradling, 1994) have presented cases where employees develop full-

16 POST-TRAUMATIC STRESS AND BULLYING 101 blown PTSD following exposure to job stressors such as bullying, work overload, and lay-offs. In fact, several studies (Burstein, 1985; Solomon & Canino, 1990) demonstrate that it is difficult to establish the precise nature of a traumatic stressor. Helzer, Robins, and McEvoy (1987) found that miscarriage, a partner s affair, or poisoning were related to PTSD, although less commonly than events such as rape or combat exposure. Correspondingly, a study by Solomon and Canino (1990) showed that financial problems and moving or breaking up with best friends were more closely related to PTSD symptoms than were exposure to extraordinary events. Second, a diathesis stress approach to understanding PTSD is more in line with research findings (Bowman, 1999; Brewin et al., 2000; Lauterbach & Vrana, 2001; McFarlane, 1989; McFarlane & de Girolamo, 1996; Yehuda & McFarlane, 1995). In the present study, a significantly higher percentage of the victims meeting all PTSD criteria reported feeling more negatively affected by an event other than bullying compared with victims failing to meet any or some PTSD criteria. Since the victims rated their PTSD symptoms in relation to the experienced bullying, we suggest that the results indicate that the cumulative effects of exposure to several stressors, including bullying, have contributed to the victims developing PTSD analogue symptomatology. These results indicate that vulnerability factors may play a role in the development of severe stress symptoms among victims of bullying. Other studies have shown neuroticism and trauma intensity to interact in predicting PTSD (Lauterbach & Vrana, 2001). Likewise, Bowman (1999) and McFarlane (1989) found trait-neuroticism and perceived locus control to be significantly more powerful predictors of PTSD than event characteristics. Based on our results, we suggest that further theoretical and empirical research be performed on how individuals may differ in their vulnerability to developing post-traumatic stress symptoms following exposure to bullying at work. One of the characteristics of traumatic events is their capacity to create fear and an intense sense of threat (McFarlane & de Girolamo, 1996). When being bullied at their workplace and sometimes also after the bullying has ceased, victims are subjected to threats to their personal, social, and professional identity, and in some cases also their financial and societal status (see Mikkelsen, 2001). However, whether or not individuals are traumatized due to exposure to bullying at work probably also depends on their subjective perception of threats. The dual influence of both the objective threat qualities inherent in bullying and individual differences in the degree of perceived threat is accentuated by the fact that about a quarter of the sample of victims experienced the bullying as a life-threatening stressor. Although one-third of the victims claimed that their life was threatened or that they were physically injured, we do not know if such threats or injuries actually took place. Empirical research has demonstrated that violence or threats of such rarely occur in connection with bullying. Moreover, a qualitative analysis of the

17 102 MIKKELSEN AND EINARSEN victims accounts of the behaviours to which they were subjected suggests that the experienced threat was of a psychological nature, since no-one explicitly mentioned being the victim of actual physical violence or threats of such. Nevertheless, with respect to the aetiology of PTSD symptoms, the victims perceptions that their life was endangered may be just as important as had they actually suffered objective physical injury or threats of such. A female victim expressed this subjective aspect of trauma in the following way: I felt very I felt that my life and existence was threatened. I did! Because it was my nursing and I am supposed to live off this to earn a living working as a nurse and it was such an important part of my life, my very existence and there I felt really threatened. According to cognitive theories of trauma (Horowitz, 1975; Janoff-Bulman, 1989), events are traumatic to the extent that they threaten to shatter basic cognitive schemas. Comparisons of basic assumptions between victims of bullying and non-victims show that victims consider themselves less worthy, others as less caring, and the world as less meaningful and just, indicating that exposure to bullying at work may indeed result in increased negative assumptions on self, other people, and the world. Considering that we found significant group differences with respect to all three core assumptions, our hypothesis that the victims symptoms may be due to their formerly positive assumptions being shattered seems viable. Interestingly enough, previous studies involving victims of other kinds of trauma have yielded inconclusive support for Janoff-Bulman s theory. Magwaza (1999) compared basic assumptions of traumatized victims diagnosed with PTSD who had suffered torture and detention or had witnessed the traumatic death of close family members, and a non-traumatized control group. Even years after the trauma victims perceived the world as less meaningful and benevolent than did the controls. Conversely, other studies revealed no differences in basic assumptions among victims having experienced major stressors and non-victims (Overcash et al., 1996) or between students with or without divorced parents (Franklin et al., 1990). However, Franklin et al. (1990) found that exposure to long-term parental conflict was associated with more negative assumptions of other people and the world. Thus, the present study appears to demonstrate some of the hitherto most consistent differences in basic assumptions between traumatized victims and non-traumatized controls. Why is this so? A methodological flaw in some of the previously named studies may be one explanation. Although exposed to a traumatic event, the victims in these studies may not have been traumatized (Magwaza, 1999). In such cases one would expect few group differences. In the present study, the victims were self-selected and all of them had suffered to a certain extent or extremely from exposure to bullying. Accordingly, a substantial proportion of the victims felt traumatized. Conversely, the controls had no experience of bullying. We believe that the

18 POST-TRAUMATIC STRESS AND BULLYING 103 results of the present study indicate that bullying at work is an extreme social stressor with threat potentials comparable to those inherent in other traumatic life events. Like other victims of physical and emotional abuse, victims of bullying typically feel that the offender aims to harm them. Consequently, for most victims, this creates a strong sense of vulnerability, the effect of which is dramatically increased, as they constantly have to deal with the possibility of being subjected to additional infringements (Leymann & Gustafsson, 1996). When at work the victims are subjected to a continuing, prolonged threat. As suggested by Groeblinghoff and Becker (1996), for some victims such a situation may create a profound, exaggerated, and perhaps unrealistic anxiety. The victims may feel that their lives are threatened and that something evil might happen to them any at moment. The feeling of being the target of malevolent intentions may intensify if the victims lack support and understanding from their colleagues, friends, or family. Victims of bullying often report a scarcity of support from significant others (Einarsen et al., 1994b). Moreover, perhaps due to the stigmatization attached to victims (Lerner, 1970; Symonds, 1975), or just common ignorance, many victims of bullying at work report receiving limited, if any, assistance or even understanding from aid resources such as the personnel department, union representatives, doctors, or the legal system (Leymann & Gustafsson, 1996). Obviously, the victims may experience this as a form of secondary victimization, which may enhance their feelings of vulnerability. Combined with the bullying, such additional encroachments may indeed threaten to shatter their assumptions of the benevolence of the impersonal world and of people. Although some victims may have directly or indirectly contributed to the bullying, many appear to be truly innocent victims of emotionally abusive others (Einarsen, 1999; Kile, 1990; Zapf, 1999b). Hence, it is not surprising that victims in the present study see the world as less meaningful and just than do the controls. Most victims we have met consider themselves as decent, worthy, and capable people contributing significantly to the organization in which they work(ed). Generally, supervisors or colleagues have confirmed this positive selfimage throughout their careers. Previous studies (Thylefors, 1987; Zapf, 1999b) support the view that many victims of bullying are competent, efficient, and resourceful. Most of these victims may have had a successful professional career without any prior social problems. Consequently, they cannot comprehend why they have become targets of such undeserving aggressive acts. One victim expressed her feelings in the following way: When you feel that somebody is out to get you and you don t have anybody to talk to, well you feel so lonely... However I also felt a strong sense of injustice. I really thought that it was unfair! Without boasting I dare say that I did twice the amount of work she did. I really felt that I was being treated unjustly and that was why All the time I said to myself: You ll get to her eventually. Unfortunately I never did. Clearly, the allegations of being stupid, unworthy, or ineffective are