key: cord-0852908-qli0hjz5
authors: Shelef, Leah; Schiff, Miriam; Pat-Horenczyk, Ruth; Dekel, Rachel
title: COVID-19 vs. terrorism: Contribution of the COR theory to the process of coping with invisible threats
date: 2022-01-12
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2022.01.023
sha: fcb9dfa0907fc336a348da3679a535b4a4e732d0
doc_id: 852908
cord_uid: qli0hjz5

Two years have passed since the outbreak of the COVID-19 pandemic. The entire world is still struggling with the virus and its mutations, and governments have been imposing various restrictions, including social distancing and quarantine. This paper leans on the Conservation of Resources (COR) theoretical model in comparing the impact of COVID-19 with that of an ongoing threat of terror attacks, allowing us to understand the similarities and differences between them. Such exploration could result in an understanding that may guide devising psycho-social interventions to minimize the negative psychological consequences of a continuous life-threatening situation. By applying the extensive available literature on the aftermath of terrorist attacks to the little-known long-run consequences of the COVID-19 pandemic, this paper comes up with several guidelines such as increasing online social support and enhancing adaptive coping with stress, that are applicable on the individual, community, and societal levels.

No exact guidelines have been formulated to date as to how to withstand and cope with COVID-19an amorphous enemy that has put us under continuous threat for two years.

In our paper, we propose that understanding the vulnerabilities and resilience that emerge while coping with terrorism may prove relevant to coping with the COVID-19 pandemic outcomes. The goals of this paper are: 1. Exploring the similarity between the COVID-19 pandemic and terror attacks based on the Conservation of Resources (COR) theory and existing research studies; 2. Identifying differences between the pandemic and terror attacks based on the COR theory; 3. Suggesting preventive and treatment interventions on the individual and community levels, to minimize the long-run psycho-social damages of the pandemic.

Several similarities may link the COVID-19 outbreak with terrorism. Among them are life-threatening characteristics, loss of loved ones and grief, the unpredictability of the threat, diverse levels of exposure or proximity to the events, the intensity of the experience, ambiguity about protective measures, and the considerable disruption they both cause to routine daily life. Brown et al. (2019) noted that thoughts such as, "I am totally incompetent," "Others cannot be trusted," and "Nowhere is safe," often reflect common emotional reactions to trauma. Negative thoughts about oneself, others, and the world are central to the development and persistence of posttraumatic stress disorder (PTSD). Fear has been identified as a strong predictor of PTSD in people exposed to terror attacks (Laufer, & Solomon, 2009) . Although much has been learned about the epidemic, people around the world continue to fear COVID-19 and its mutations and live with high levels of uncertainty.

It is too early to determine with certainty whether fears related to COVID-19 are strong predictors of PTSD. Yet, recent evidence suggests that ordinary people (Gao et al., 2020) , medical staff (Johnson, Ebrahimi, & Hoffart, 2020) , and recovering COVID-19 patients (Xiao, Luo, & Xiao, 2020; Matalon et al., 2021) have been diagnosed with PTSD.

These phenomena are all potentially associated with psychological distress and functional impairment, as studies conducted in different countries have shown (Gallagher et al., 2020; Gao et al., 2020; Fernández et al., 2020; Huang & Zhao, 2020; Marazziti et al., 2020; Schiff et al., 2020) . At the same time, terror attacks and COVID-19 differ in various ways, such as the recommended isolation and quarantine in the latter, which are associated with unique challenges (Singh, & Singh, 2020) . We will further explore these similarities and differences based on the Conservation of Resources theory and empirical evidence.

The COR theory proposes a model that explains coping with stress and trauma. The basic premise underlying the COR theory is that humans are motivated to protect their existing resources and acquire new resources (Hobfoll, 1989) . According to the COR theory, stress response can be a normal reaction that tends to occur in one or more of the following situations: threat or actual loss of personal resourcesself-esteem, hope, or a sense of control over future events; loss of physical resources such as one's home, clothes, or accessibility to transportation; and lacking resource gain. Notably, a central principle underlying the COR theory is that resource loss is more prominent than resource gain. Nonetheless, while resource gains may have little impact on people who are not experiencing specific loss or loss cycles, these gains become potent in the case of major or sustained resource loss (Chen, Westman, & Hobfoll, 2015) . In the COVID-19 case, the gain of greater family attention under quarantine and increased virtual support has quite possibly been higher than we have been used to receiving. At the same time, uncertainty, loss of socializing, impaired economic security, and loss of other routine-life features make for more resource loss than gain. During the COVID-be less vulnerable to the consequences of the resource loss brought about by the pandemic (Chen, Westman, & Hobfoll, 2015; Thomas et al., 2020) .

Fear and loss of a sense of security are among the central emotional responses to both terror attacks and the COVID-19 pandemic (Van Bavel et al., 2020) .

In terms of the COR theory, fear underscores resource loss (i.e., a sense of insecurity at home, in the community, and the environment). Since the COVID-19 pandemic breakout, some individuals have been in fear of imminent death (i.e., loss of self-confidence). Others report guilt-feelings and worry about spreading and transmitting the virus to family, friends, and colleagues (i.e., loss of control) (Park & Park, 2020; Xiang et al., 2020) . The high rate of morbidity and mortality during the pandemic and the lack of data-based knowledge about the infection spread, risk populations, and treatment options have generated a worldwide sense of insecurity, indicating a loss of personal and social security (Pakpour, & Griffiths, 2020) .

Uncertainty associated with the COVID-19 disease has implications for the mental health of the population (Ornell et al., 2020; Park & Park, 2020; Xiang et al., 2020) . The loss of certainty, which stands for resource loss, is common among people exposed to COVID-19 and terror attacks. Uncertainty is a COVID-19 consequence that any resource gain does relatively little to offset or limit (Hobfoll, Tracy, & Galea, 2006) . In terrorism, direct or indirect exposure and proximity to the source of stress have significant implications for mental well-being (Bleich, Gelkopf, & Solomon, 2003; Chemtob et al., 2011; Neria, Nandi, indirect exposure (e.g., suspected exposure to the virus; Zhang et al., 2020) are widespread.

Moreover, suspected exposure to the virus contributes to losing the sense of well-being , a central psychological resource (Galea et al., 2002; Hobfoll, Canetti-Nisim, & Johnson, 2006 ). Yet, certain threats or actual loss of personal resources are unique to COVID-19 and do not appear in the context of terror attacks. One of them is disease-related stigma, a central attribute of infectious diseases, where a personal resource loss is identified with the COVID-19 pandemic. Stigmatization is an undesirable stereotype that can cause mental distress and disorders (Zolnikov, & Furio, 2020) . A recent review revealed that infection or suspected infection with COVID-19 was stigmatized (Brooks et al., 2020; Logie & Turan, 2020) .

Studies from previous pandemics reveals that healthcare workers may face additional public stigma and isolation because they are thought to be more likely to transmit the disease (e.g., Bai et al., 2004; Reynolds et al., 2008) . Unlike first responders in a terror attack, who the population perceives as heroes, a study conducted at the height of the COVID-19 pandemic revealed that first responders directly exposed to the virus were at a higher risk of social stigmatization by the general public (Zolnikov & Furio, 2020) . In the mental health study, conducted a year after patients had recovered from SARS (Bai et al., 2004) , medical staff reported that the stigma associated with being potentially infected by the virus led to a sense of isolation, lack of support and understanding from family and friends, decreased social interaction, or complete forced removal from one's immediate social circle. Individuals stigmatized by the community (unlike ones with an internalized stigma) often suffer from various mental health outcomes, such as depression and anxiety (Zolnikov & Furio, 2020) . Internalized stigma, namely, self-agreement with negative stereotypes that often co-occurs with rejection and distress, has been associated with loss of self-esteem, self-identity, and self-efficacy resources (Tansey et al., 2007) .

Loss and grief are two other issues that are common to terror and the COVID-19 pandemic, causing both loss of physical resources and a lost sense of certainty and familiarity. The death of a family member may result in the loss of physical resources (e.g., livelihood) or an emotional condition (e.g., lost sense of security). Those losses can contribute to psychological symptoms of grief following suffering and death. Grief is a normal and natural response to loss. The social context plays a huge part in one's loss and grief experiences. Social support is one of the strongest determinants of positive outcomes after bereavement (Breen, 2020) . Deaths usually entail gatherings. For example, funerals offer grievers an opportunity to receive support from others. But the physical distancing has damaged the traditional gatherings, with possible exacerbation of grief feelings due to physical distancing (Breen, 2020) .

Numerous families have suffered significant losses during the pandemic (Zhai, & Du, 2020) . Several studies note that quarantine and isolation have undermined various traditional bereavement rituals, impairing support and recognition of the loss. Among them are attending a loved one's burial ceremony, saying goodbye, corpse handling, and avoiding social gatherings that impairs support resources, and recognition. The need to revert to improvised grief rituals puts individuals at a greater risk of prolonged grief disorder (PGD) (Goveas, & Shear, 2020;

Zhai & Du, 2020). Moreover, government policy measures to target the pandemic, expose people whose family members died of causes other than COVID-19 to the same potential risk factors, also increasing their grief of (Eisma et al., 2020).

Quarantine and lockdown restrictions are two specific COVID-19 stressors that may also exist in connection with terrorist threat. In both contexts, these restrictions clearly define who must not leave home and when going out is permitted. For example, immediately after the terrorist attack at the Boston marathon, the authorities declared lockdowns to protect vulnerable populations (Naturale et al., 2017) . In the current COVID-19 pandemic, the lockdowns aim to reduce chain infection. Despite the different restrictions and guidelines, the purpose of the lockdown in both cases is to protect human life whether by limiting infection or reducing the danger of injury.

They are both associated with a sense of loss of freedom (e.g., having to stay at home and prohibition to go to work) and a sense of loneliness (e.g., loss of relationships, recreation, and social support (Bareket-Bojmel et al., 2021) . These losses worsen once quarantine and lockdowns are perceived as instances of coercion (Mattioli et al., 2020) . Social distancing prevents emotional and physical intimacy, and is associated with the dissolution of intimate relationships with partners, family, and friends (Zhai, & Du, 2020) .

Loss of economic resources, associated with a deteriorated mental state, is among the most significant physical resource losses experienced by numerous people in both terrorism and COVID-19 circumstances. There is ample evidence of local and national efforts to assist populations that have lost their jobs due to terrorist attacks (e.g., 9/11) or natural disasters (e.g., Hurricane Katrina). The 9/11 terror attack, for example, had a severe impact on the mental health of individuals who lost money or jobs in New York City and worldwide (e.g., Yu, et al., 2016) .

During the economic slump caused by the COVID-19 pandemic, millions of people lost their jobs. The loss of this crucial material resource has caused pain accompanied by stress (Plomecka et al., 2020) . Loss of job security and difficult economic recovery have been previously associated with mental health symptoms (Mucci et al., 2016; Plomecka et al., 2020) . Crayne (2020) pointed out that the economic aspect of losing one's job was accompanied by a psychological effect of losing meaning and value.

Resource gains contribute to improved psychological well-being, health, and functioning (Hobfoll et al., 2012) . Chen et al. (2015) maintain that resource gain is a paradoxical principle. Although the COR theory places greater weight on resource loss, resource gain plays a key role in developing resilience (Luchetti et al., 2020) . Thus, whereas resource gains may have little impact on people who have not experienced a loss or a series of losses, they become potent in cases of significant or sustained resource loss (Chen, Westman, & Hobfoll, 2015) . Hence, to gain resources and be protected or recover from resource loss, people must invest resources (Hobfoll et al., 2003) . The following example illustrates this point. A qualitative study among twenty nurses who treated patients found that at the beginning of their work with COVID-19 patients, they experienced negative emotions (fatigue, discomfort, and helplessness) due to loss of resources resulting from their high-intensity work, fear and anxiety, and concern for patients and family members. To gain resources, they had to invest in potential resources by adopting self-coping means (altruistic acts, team support, and rational cognition) that were associated with psychological growth . Several studies published during the COVID-19 pandemic have shown that gaining more tangible resources, such as a social support network, tends to reduce psychological symptoms such as anxiety (Cao et al., 2020; Spoorthy, Pratapa, & Mahant, 2020) and depression (Spoorthy, Pratapa, & Mahant, 2020) , and improve self-efficacy (Spoorthy, Pratapa, & Mahant, 2020; . Social support was also identified as alleviating psychological distress among medical staff and medical students (Li et al., 2021) .

Another crucial aspect related to the lockdown policies was that people were forced to work from home and adopt long-distance work modes that might be associated with a sense of resource loss such as by compromised working conditions at home, or resource gain such J o u r n a l P r e -p r o o f as by saving commuting time. For example, one study conducted during a COVID-19 lockdown among couples with children in Israel, all of whom were working from home, found an association between difficulty to tolerate uncertainty and psychological distress (Reizer et al., 2021) . However, while optimism (a vital personal resource) buffered the negative ramifications of intolerance to uncertainty (i.e., resource gain), the inability to schedule proper work arrangements at home during the lockdown was a risk factor for intolerance of uncertainty and psychological distress (i.e., resource loss). Another example for loss of resources emerged from a study where people who had to go on an unpaid leave of absence demonstrated significantly higher distress than those who were unemployed prior to the pandemic (Mimoun, et al., 2020) .

The COVID-19 lockdowns and the resultant ongoing economic slump have considerably reduced a highly significant material resource -social support. A loss of this kind is a risk factor for long-term mental health problems, including the risk of suicide attempts during and after the pandemic (Zalsman et al., 2020) . Moreover, in addition to loss of social support resources, a material loss may prompt a sense of reduced mastery. In their extensive discussion, Hobfoll et al. (2003) suggested that acquiring a sense of mastery and social support resources may mediate the impact of material loss on depressive mood and anger so that a more definite sense of mastery and social support would reduce anger and depressive moods (Hobfoll et al., 2003) .

Social distancing policies potentially lead to social isolation and reduce the sense of belongingness, increasing the risk of devastating outcomes such as suicidal behaviors (Sheffler, Joiner, & Sachs-Ericsson, 2020) . Gaining resources such as social support and belongingness may even prevent future losses (Hobfoll, 1989 ) and further impairment (Chipman et al., 2011) . The pandemic threat is different from terror attacks (a natural threat vs. a human one). One typical challenge of the COVID-19 that considerably differs from the challenges of terror attacks is, as noted, the collapse of social support structures (Jung & Jun, 2020; Logie, & Turan, 2020). In contrast, after a terror attack people tend to gather, hold ceremonies, and find comfort in each other.

Two COR theory principles relevant to the current discussion are that individuals who have more resources in the first place are better positioned for resource gains, and individuals with fewer resources are more likely to keep losing resources (Hobfoll, & Lilly, 1993) . In practice, this means that a person with extra personal resources can resist resource depletion to some extent and is, therefore, less prone to emotional exhaustion due to cumulative stress or strain. Excessive resource depletion, however, can lead to emotional exhaustion and burnout (Westman et al., 2004) . Thomas et al. (2020) identify several groups as vulnerable and having fewer resources from the start. They include minority groups, younger ages, females, individuals with a mental health history, and ones with high levels of COVID-related anxiety or economic insecurity (Thomas et al., 2020) . Many of these groups were also found vulnerable in connection with terrorism (e.g., Bleich et al., 2006; Brewin, Andrews, & Valentine, 2000) , and therefore require special attention.

A discussion of the COR theory in light of the COVID-19 situation is more relevant now than ever towards finding better ways to help people gain the resources they have lost.

Challenges, dilemmas, and conflicts revealed during the pandemic pointed to the loss of resources in many unexpected areas of life and have been related to distress (e.g., frustration, anger, annoyance, irritation, fear, and helplessness) going above and beyond demographic variables such as age, gender and other. Nonetheless, groups that had fewer resources on the pandemic outbreak, such as minority groups, experienced a higher level of stress than the general population (Thomas et al., 2020) . The unique characteristics of the pandemic compelled certain groups to become involved in activities with which they were not familiar.

This was the case with parents who had to acquire teaching skills over the home-schooling period (Parczewska, 2021) . Other groups were new to online resources, lost valuable resources such as information or personal support, and tried to gain those resources from the internet (Laslo-Roth et al., 2021) .

The community plays an essential role in restoring individual resources and providing social support, and can positively affect the way individuals deal with a common stressful event. This may involve boosting material resources such as food, clothing, and medicine, as well as increasing the community's non-material resources by supporting the psychosocial needs of its members. One such example is found in Israeli villages that have come under continuous terror attacks. In those places, a higher sense of belonging among those exposed to terror attacks has been associated with lower levels of distress (Dekel, & Nuttman-Shwartz, 2009; Kaplan et al., 2005; Nuttman-Shwartz, & Dekel, 2009a; Nuttman-Shwartz, Dekel, & Regev, 2015) . Moreover, a sense of belonging in different groups and communities has helped reduce PTSD symptoms (Dekel & Nuttman-Shwartz, 2009 ). The amount of social and objective resources (e.g., a sense of belonging to the community) was a better predictor of PTSD than the level of actual exposure to terrorism (Nuttman-Shwartz, Dekel, & Regev, 2015) . Mao and colleagues (2020) showed that adequate management could affect employee psychological capital through the employees' perceived organizational behavior. They based their study on the COR principle that people tend to work hard to obtain and maintain valuable psychological resources and reduce or avoid the loss of such resources (Halbesleben et al., 2014) . Based on the COR theory, this implies that organizations (and states) may prove capable of preventing psychological symptoms and resource loss and enhance the sense of security.

Similar to the findings concerning exposure to terror, several studies have indicated that in COVID-19 circumstances various resources provided by the community have played a part in preventing the aggravation of post-traumatic effects while also promoting means of increasing the sense of belonging, and projecting concern for at-risk populations. In communities having the means to invest in resilience, a reduction in negative consequences is predicted in many areas (Kim, & Su, 2020; Qiu et al., 2020) .

Despite the similar behaviors of people exposed to terror attacks and to an epidemic outbreak, the COVID 19 circumstances are fundamentally different. The COVID-19 pandemic's consequences have resembled those of a worldwide mega terror attack rather than a local one, grave as it may be. Thy have crossed state borders, impacting populations in a way that had nothing to do with politics, opinions, ideology, or any other man-made values.

By this, the pandemic has increased the vulnerability of individuals and whole societies, intensifying uncertainty and undermining the sense of security. A significant difference has emerged in the way people perceive terrorist events and the epidemic. Although since the early 20 th century, many more people have lost their lives to epidemics than to terrorist attacks, more research studies have examined the psychological impact of terrorist attacks than of epidemic outbreaks (e.g., SARS, MERS, Ebola).

An urgent need exists for further research that would explore ways to mitigate the mental health implications pandemics have for vulnerable groups (Holmes et al., 2020) .

Nevertheless, we venture in this article to offer several recommendations based on the knowledge accumulated since the outbreak of the COVID-19 pandemic, past mass terrorist attacks, and leaning on the COR theory.

We suggest guidelines at the individual, community, and social levels that are likely to lead to resource gain and mitigate resource loss.

1. Identify the stressors. List optional distracting activities (self-care activities) on a hierarchic scale (e.g., make a telephone call, engage in sports, watch TV) to help reduce distress (Polizzi, Lynn, & Perry, 2020) . For example, The US National Center for PTSD developed an app that explains how people can help themselves, proposing a suitable and accessible way to manage stress caused by the epidemic (U.S. National

Center for PTSD, November 2021). The app offers psycho-educational information, practice of accessible strategies of stress reduction and self-concern, and a delfmonitoring method that has proven to be effective for physical and emotional regulation (https://www.ptsd.va.gov/appvid/mobile/COVID_coach_app.asp.).

Although the epidemic seems to continue forever, it will reasonably die down eventually. Critical thinking may help evaluate correctly frequently biased information. Avoid cognitive distortions or dichotomous thinking, and apply critical thinking to reduce psychological distress. List the deterministic or negative sentences that come to mind, and exchange them with a list of optimistic, positive statements.

3. Limit excessive exposure to the media and social networks. Overwhelming exposure to the media and social networks tends to increase catastrophic thinking and a sense of threat and may lead to losing control. Limiting unnecessary exposure reduces the likelihood of mental disorders (Gao et al., 2020) . People who cannot do without the news and social networks might minimalize thinking distortions by applying critical thinking. Select one news program per day, and in the remaining time, replace news programs with other TV programs that entertain or interest you. 4. Find meaning and be active. Finding meaning and active coping (e.g., planning, seeking support, active search for information) has been associated with a decrease in the levels of distress (Bleich, Gelkopf, & Solomon, 2003; Silver et al., 2002) . Social connectedness decreases loneliness, ambiguity, and uncertainty and increases cohesiveness. We, therefore, recommend joining groups or participating in activities that enhance one's sense of meaning, mission, altruism, and belongingness.

5. The centrality of maintaining a daily routine. It has been shown that keeping a daily routine despite the ongoing threat contributes to better mental health and coping (Pat-Horenczyk, Schiff, & Doppelt, 2006) . In Pandemic-related isolation, maintaining a regular daily routine can help overcome the unfavorable consequences of the situation. Decide what daily activities you would not give up (including simple activities, such as getting dressed and not remaining in your pajamas).

6. Increase social support. Developing as many social activities as possible will enhance adaptive functioning (Bonanno, Galea, Bucciarelli, & Vlahov, 2007) . For example, organizing several small groups to meet regularly (on zoom, in the open air, or in a spacious room) for various social purposes, such as chats, cooking, or movie watching. Try to find a group you can be the one to manage and set the frequency and characteristics of the meetings.

Seek any available kind of help. Seeking psychological help is an effective way to cope with psychological distress. A brief video intervention has increased treatmentseeking intentions among people prone to mental distress, such as military veterans with PTSD, through identification and emotional engagement with the video protagonist (Amsalem et al., 2021) . All the populations should be encouraged to seek help, any help. Prepare an emergency list of telephone numbers of all the people you can call if you feel distressed, including a helpline.

The community level 8. Resource gain through volunteering activities. Engaging in volunteering activities is one way of regaining resources such as a sense of physical and social safety, selfcontrol, hope, connectedness, and community cohesion (Girdhar, Srivastava, & Sethi, 2020; . As already mentioned, participating in activities is a way to enhance one's sense of meaning (e.g., altruism). Offering the most deprived communities (Borkowska & Laurence, 2020) material resources by supplying food, clothes, and medical care, and social resources, such as a sense of caring, and belongingness would help them regain their lost resources.

9. Enhance the sense of social solidarity and mutual responsibility. In times of crisis, strengthen community social connections, develop a network of volunteers, and identify trustworthy community leaders that can lead processes and contribute to the community's health are central first-rate necessities (Miao, Schwarz, & Schwarz, 2021; Roberts, 2020) . Mutual responsibility will boost meaningfulness, a sense of control, competence, coherence, and positive functional behaviors, all crucial to crisis management.

In a global health crisis of the COVID-19 magnitude, trauma-related mental health care is no less important than physical care (Horesh, & Brown, 2020) . Since most of the population will recover and return to pre-event functioning (Bonanno, Rennicke, & Dekel, 2005; Bonanno et al., 2006; Solomon, 2013) , any symptomatic response should include emotional support.

10. Early interventions. Developing continuity of mental health services from preparedness to early interventions followed by short-and long-term treatment modalities (e.g., the five-steps of first-aid intervention; Everly, Barnett, & Links, 2012) . It is necessary to identify, evaluate, and devise interventions for those mental health effects to address the psychological and social aspects of the pandemic preserving the therapists' resources should be a central factor in planning interventions that follow an emergency (Benedek et al., 2007) . Thus, professional training for emergency will affect the functioning of both caregivers and individuals in need of assistance (Van Der Veer & Francis, 2011).

There is evidence that individuals who experience a respite in negative post-trauma cognitions also display reduced PTSD, and vice versa, i.e., treatments that have effectively reduced PTSD symptoms have also decreased negative post-trauma cognitions. (Brown et al., 2019) . J o u r n a l P r e -p r o o f

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