key: cord-1036668-reedxy9f
authors: Zhou, Xiao; Yao, Benxian
title: Social support and acute stress symptoms (ASSs) during the COVID-19 outbreak: deciphering the roles of psychological needs and sense of control
date: 2020-09-08
journal: European journal of psychotraumatology
DOI: 10.1080/20008198.2020.1779494
sha: 41729e2058685b234085036a44fe8303c3d2d996
doc_id: 1036668
cord_uid: reedxy9f

Background: A cute stress symptoms (ASSs) are likely to be a common mental health problem in the acute period following the 2019 novel coronavirus pneumonia (COVID-19) outbreak. To address this risk, substantial social support has been provided to relieve ASSs during the COVID-19 outbreak. However, the effectiveness of these support methods for relieving ASSs has not yet been assessed. Objective: The current study sought to examine the underlying mechanisms by which social support relieves ASSs, among primary and secondary school teachers. Method: A sample of 751 primary and secondary school teachers was selected to answer self-reported questionnaires regarding ASSs, social support, psychological needs, and the sense of control. Results: Structural equation modelling revealed that social support had a non-significant direct relationship with ASSs, and a significant indirect relationship with reduced ASSs via the needs for autonomy and relatedness, and via the paths from three types of psychological needs to the sense of control. Conclusion: These findings suggest that social support can play a relieving role in ASSs when the support satisfies individuals’ psychological needs and improves their sense of control. To alleviate ASSs among primary and secondary school teachers, more attention should be paid to satisfying their specific psychological needs and improving their sense of control.

The 2019 novel coronavirus pneumonia outbreak, a major public health emergency, has caused many deaths globally. There is currently a lack of targeted medical treatment and vaccines for this disease, and it continues to exhibit rapid transmission with a high level of infectiousness in the general population. In the context of this large-scale public health event, some affected individuals have been reported to exhibit mental health problems, including stress, anxiety, depressive symptoms, fear, denial, and anger (Kang et al., 2020) . Because the present situation constitutes the acute stress phase of COVID-19, these symptoms can be considered as acute stress symptoms (ASSs). Acute stress reactions have been reported to impair individuals' immune systems (Tao, 2006) , leading to negative impacts on daily life and reduced wellbeing (Holbrook et al., 2005) . Importantly, ASSs in primary and secondary school teachers may be more serious than those among the general population during the COVID-19 outbreak, because these individuals are not only confronted with mental health problems caused by COVID-19, but also undertake the responsibility for teaching and caring for students exhibiting mental health problems in class. If teachers' psychological distress is not relieved in a timely way, their teaching and overall wellbeing may be affected, with direct effects on students' mental health (Chen et al., 2014) , potentially aggravating students' psychological distress during the COVID-19 outbreak. Protecting against ASSs in teachers is thus important for their own long-term health and teaching quality, as well as students' long-term health, following However, few studies have examined effective methods for relieving ASSs in teachers. A proposed theoretical framework for thriving through relationships (Feeney & Collins, 2014) suggests that providing individuals with social support may be a useful approach for relieving ASSs. In this framework, social support can provide a safe environment for the expression of negative emotion, helping individuals to reframe their understanding of their own experiences (Feeney & Collins, 2015) . Social support also provides emotional comfort, reassurance, and acceptance to affected individuals, which can enable individuals to have positive appraisals of themselves and increase their faith in their ability to cope with adverse experiences (Zhou, Wu, Wang, & Tian, 2019) . Moreover, as an important component of social support, providing instrumental aid (e.g. social resources; specific suggestions in coping with adversity) can directly alleviate negative emotions and adverse experiences (Feeney & Collins, 2014) . Most previous studies of this issue have reported that social support is associated with less psychological distress following stressful experiences (Dworkin, Ojalehto, Bedard-Gilligan, Cadigan, & Kaysen, 2018; Smith et al., 2013; Stanley et al., 2019) .

Furthermore, the framework of thriving through relationships suggests that social support exerts a buffering effect on psychological reactions via mediators, with basic psychological needs (e.g. needs of competence, relatedness, and autonomy) and the sense of control being considered as two important mediators (Feeney & Collins, 2014) . Here, basic psychological needs refer to individuals' beliefs that they are effective in their activities, that their behaviours are self-detected, and that they experience closeness to others, entailing the needs for autonomy, competence, and relatedness, respectively . Several previous studies suggest that social support can help people to build positive interpersonal relationships and satisfy individuals' need for relatedness, provide individuals with useful coping strategies and meet their need for competence, as well as giving individuals emotional support and encouragement and thus addressing their need for autonomy (Adie, Duda, & Ntoumanis, 2008; Skinner, Furrer, Marchand, & Kindermann, 2008; Tian, Tian, & Huebner, 2016) . Furthermore, selfdetermination theory suggests that individuals who are able to meet these psychological needs can employ adaptive capacities to engage in activities, build a cohesive social group and obtain available resources and mutual protection, as well as regulating their own actions in accord with their available capacities, and thus coordinating and prioritizing processes towards more effective selfmaintenance. In turn, these processes can facilitate the improvement of individuals' wellbeing and relieve their psychological distress (Alcaraz-Ibáñez, Sicilia, & Burgueño, 2017; Auclair-Pilote, Lalande, Tinawi, Feyz, & de Guise, 2019; Kormas, Karamali, & Anagnostopoulos, 2014; Ng et al., 2012) . Taken together, these previous findings suggest that social support might have an indirect relationship with ASSs by satisfying three types of psychological need.

The sense of control is reported to act as a mediator between social support and ASSs, referring to an individual's generalized belief that they can and do master, control, and shape their own life (Keeton, Perry-Jenkins, & Sayer, 2008) . The sense of control represents a type of cognitive resource (Keeton et al., 2008) , which can be influenced by social factors such as social support (Gadalla, 2009 ). For example, previous studies have suggested that providing individuals with instrumental support can ensure that they have sufficient resources to cope with events (Green & Rodgers, 2001) , whereas emotional support facilitates positive cognitions regarding the individual being in control of the events that they experience (Martire, Stephens, & Townsend, 1998) , increasing their sense of control (Gadalla, 2009) . Improving an individual's sense of control can decrease passivity and helplessness in the face of adversity, and ultimately relieve psychological distress (Assari, 2019; Bennetter, Clench-Aas, & Raanaas, 2016; Keeton et al., 2008) . Therefore, in the current study, we hypothesized that social support would be associated with reduced ASSs, via improving individuals' sense of control.

Drawing on previous theories and studies, social support might be related to reduced ASSs via satisfying psychological needs and improving the sense of control, respectively. This possibility raises the question of whether these two mediators could also exhibit some relationships involved in the mechanisms by which social support relieves ASSs. Self-determination theory suggests that satisfying psychological needs can increase individuals' subjectively felt energy, such as vitality (Ryan, Bernstein, & Brown, 2010) , as well as helping individuals select and sustain behaviours to meet their goals (Ryan, Kuhl, & Deci, 1997) , and increase individuals' ability to cope with events . These processes can improve individuals' sense of control (Froreich, Vartanian, Zawadzki, Grisham, & Touyz, 2017; Hanfstingl, Andreitz, Müller, & Thomas, 2010) . That is, psychological needs satisfaction may be associated with a greater sense of control. This notion suggests that social support may be related to a reduction in ASSs via the path from satisfying psychological needs to improving the sense of control.

While the framework of thriving through relationships emphasizes psychological needs and the sense of control as important mediators between social support and psychological outcomes following adversity (Feeney & Collins, 2014) , the specific roles of these mediators have not yet been examined in depth. Furthermore, previous studies have not integrated Feeney and Collins (2014) theory with self-determination theory into a broader theoretical framework to assess the combined role of distinct factors in psychological distress. Moreover, it is currently unclear whether the three types of psychological needs play distinct mediating roles between social support and psychological distress. To fill these gaps, the current study was conducted to examine the mediating roles of psychological needs and the sense of control between social support and ASSs. Because more serious psychological distress is likely to occur among primary and secondary school teachers compared with the general population, the current study focused on this group.

This study began on 12 March 2020, during the COVID-19 outbreak. According to a report by the National Health Commission of the People's Republic of China, the cumulative number of confirmed cases in mainland China was 80,813 as of 12 March 2020, and the cumulative number of deaths was 3176 (National Health Commission of the People's Republic of China, 2020). In the current study, we focused on primary and secondary school teachers. Because schools were closed to reduce the likelihood of teachers and students becoming infected with COVID-19, teachers were working from home during the study period. Meanwhile, people were asked to keep at least 1-metre distance from others in public places. We conducted an Internet-based survey to assess psychological responses among teachers. Using the WeChat platform (a free messaging and calling app that is widely used in China), we sent an internet-based questionnaire to primary and secondary school teachers and invited them to respond. After respondents completed the questionnaire, they were asked to send the questionnaire to friends who were also teachers, via WeChat. Using this method, we recruited 759 participants in several provinces in China. Eight questionnaires were considered invalid because incorrect information was provided, leaving a total of 751 participants in the final analysis. The mean age of the participants was 40.02 (SD = 8.40) years, ranging from 19.0 to 59.0 years. Among the participants, 257 (34.2%) were female, and 494 (65.8%) were male. This project was approved by the Research Ethics Committee of Department of Psychology and Behavioural Sciences, Zhejiang University. Informed consent was obtained from each participant. Electronic credits were provided for participants as compensation (1-2 CNY) via WeChat's 'red envelope' feature after the investigation was completed. Zhen, Quan, and Zhou (2018) revised Received Social Support Questionnaire was used to assess teachers' social support. This questionnaire included 12 items. Responses were given on a 5-point scale ranging from 1 (never) to 5 (always). This questionnaire was reported to exhibit good reliability in a previous study of flood victims (Zhen et al., 2018) . For the current study, the internal reliability of the modified inventory was found to be good (Cronbach's alpha = 0.92). Sheldon and Niemiec (2006) basic psychological needs scale was used to assess primary and secondary teachers' psychological needs. This scale has nine items, and is divided into three subscales entailing the need for autonomy (three items; e.g. 'In my life, my choices are based on my interests and values'), the need for competence (three items; e.g. 'I feel very capable in what I do'), and the need for relatedness (three items; e.g. 'I feel close and connected with other people who are important to me'). All the items were rated on a 6-point scale ranging from 1 (completely disagree) to 6 (completely agree). This scale showed good reliability in previous studies (Sheldon & Niemiec, 2006) . In this study, the reliability for this subscale was good (Cronbach's alpha = 0.80).

The sense of control subscale in the feelings of safety scale developed by An, Cong, and Wang (2004) was used to assess teachers' sense of control. This scale showed good reliability in previous studies (Zhou, Wu, Wang, & Tian, 2018) . This subscale has eight items, which are rated on a 5-point scale ranging from 1 (completely disagree) to 5 (completely agree). In the current study, this subscale showed good reliability (Cronbach's alpha = 0.90).

Fourteen items of the DSM-5 Acute Stress Disorder Diagnostic Criteria B (American Psychiatric Association, 2013) were used to assess the teachers' ASSs. These items were rated on a 2-point scale in which 0 represented 'no' and 1 represented 'yes'. DSM-5 ASD show good validity in previous study (McKinnon et al., 2016) . In the current study, the questionnaire exhibited good reliability (Cronbach's alpha = 0.86).

To examine the mediating role of psychological needs and sense of control between social support and ASSs, Mplus 7.0 software (Muthén & Muthén, 2012) was used to build a multiple mediating effects model. The model included hypothesized paths from social support to three types of psychological needs, sense of control, and ASSs, in which all of the variables were scale mean scores rather than latent variables. In addition, hypothesized paths from three types of psychological needs to the sense of control and ASSs, and a hypothesized path from the sense of control to ASSs, were added to the model. In all of the above models, we added the correlation paths between three types of psychological needs to reduce the chance of type I errors. Next, bias-corrected bootstrap confidence intervals with a 95% confidence interval (CI) were used to evaluate the significance of the direct and indirect effects. Here, we extracted 5000 bootstrap samples and ran the model shown in Figure 1 . The 95% CI was used for identifying the significance of the paths. If the 95% CI included 0 in one direct path, we considered the path to be non-significant. In contrast, if a path did not include 0 in the 95% CI, it was considered significant.

To evaluate the model fit, we used chi-square values, comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR) values. The general cut-offs for model acceptance were ≥ 0.90 for CFI and TLI, and < 0.08 for SRMR and RMSEA. Maximum likelihood estimation (ML) was used in the estimation procedure in this study.

Based on the DSM-5 diagnostic algorithm for acute stress disorder (ASD) (the presence of nine [or more] of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event[s] occurred), a total of 68 (9.1%) participants were identified as having probable ASD. Next, we assessed the descriptive statistics and correlations among social support, psychological needs, the sense of control, and ASSs (see Table 1 ), and the main variable scale mean scores were shown.

The results revealed that social support exhibited a significant positive relationship with three types of psychological needs, but not the sense of control and ASSs. In addition, three types of psychological needs showed significant positive relationships with the sense of control and a negative association with ASSs, and the sense of control was negatively associated with ASSs.

Based on the correlation analysis and the hypothesized mediation model, we found that social support exhibited a non-significant direct relationship with the sense of control and ASSs. However, because the aim of this study was to examine the indirect relationship between social support and ASSs, the direct relationship between social support and ASSs should also be assessed. Thus, we built the following model, in which only one path from social support to the sense of control was not included (see Figure 1 ). The model exhibited acceptable index values: χ 2 (1) = 7.057, CFI = 0.995, TLI = 0.927, RMSEA (90% CI) = 0.090 (0.037-0.157), SRMR = 0.017. We found that social support had a non-significant association with ASSs, and possibly had a negative indirect relationship with ASSs via psychological needs and the sense of control. Next, bias-corrected bootstrap CIs were used to estimate the direct relationship between social support and ASSs, and the indirect relationship between social support and ASSs via psychological needs and sense of control. Based on this criterion and the bootstrap results (see Table 2 ), we found that social support exhibited a non-significant association with ASSs, but a negative indirect relationship with ASSs via the needs for autonomy or relatedness, but not the need for competence, whereas social support had a negative indirect relationship with ASSs via three multiple indirect paths from all three types of psychological needs to the sense of control.

To our knowledge, this is the first study to examine the mediating role of basic psychological needs (e.g. needs of competence, relatedness, and autonomy) and the sense of control between social support and ASSs in teachers during the COVID-19 outbreak. The findings showed that the prevalence of ASS in teachers is 9.1%. This suggests that teachers had relatively serious ASS during the COVID-19 epidemic, and carrying out psychological service to teachers is of great importance. Furthermore, we find that social support has non-significant direct effects on ASSs, whereas social support has significant negative effects on ASSs via psychological needs and the sense of control. Furthermore, these findings indicate that providing social support should satisfy teachers' needs and promote their sense of control, and, in turn, buffer the severity of ASSs. Thus, if social support does not affect teachers' psychological needs and sense of control, then the buffering role of social support in ASSs may not be exhibited.

The current results revealed that social support had a non-significant direct relationship with ASSs. This finding did not support our hypothesis, but was in accord with the results of several previous studies A 95% confidence interval of an indirect path coefficient that does not include 0 suggests that the indirect path is significant. (Ellis, Nixon, & Williamson, 2009; McCanlies, Gu, Andrew, Burchfiel, & Violanti, 2017; Zhou, Wu, & Zhen, 2017) . A possible explanation is that teachers received substantial support from others over time since the COVID-19 outbreak, enabling adaptive responses to constant social support, which may have had a non-significant effect on psychological outcomes. Only when social support from others can satisfy teachers' basic psychological needs and improve their sense of control, the support then relieves teachers' ASSs. Thus, the present findings support Feeney and Collins (2014) theoretical framework for thriving through relationships. Furthermore, we found that social support had an indirect association with reduced ASSs via the need for relatedness and via the path from the need for relatedness to the sense of control. When people came together to fight the epidemic during the COVID-19 outbreak, teachers may have received increased social support from others, helping them build positive interpersonal relationships, and satisfying their need for relatedness. Satisfying these needs can help teachers to share their experiences and emotional state with others (Liu et al., 2016) , increasing interpersonal discussions regarding adversity, which can help them to reconstruct their understanding from diverse perspectives (Zhen et al., 2018) . In addition, satisfying the need for relatedness may also inform positive interpersonal relationships. This process could encourage the development of requisite skills, provide instrumental or informational assistance in attaining necessary resources, accommodate strategies for pursuing goals, and provide direct instruction or feedback (Feeney & Collins, 2014) . These processes can increase an individual's sense of control and thus decrease passivity and helplessness in the face of adversity, ultimately relieving psychological distress (Assari, 2019; Bennetter et al., 2016; Keeton et al., 2008) .

Similarly, we also found that social support exhibited a significant indirect relationship with reduced ASSs via the need for autonomy and via the path from the need for autonomy to the sense of control. Social support can provide individuals with emotional companionship, reassurance, and encouragement, improving their beliefs regarding selfdirection and personal choices, and thus may also satisfy the need for autonomy (Adie et al., 2008; Skinner et al., 2008; Tian et al., 2016) . In the framework of self-determination theory , the need for autonomy was considered as teachers' core intrinsic motivation, indicating that the organism endeavours to incorporate more complex aspects of the world into its own organization (Ryan et al., 1997) , enabling teachers to take cognitive strategies to integrate and process the external environment, and in turn reframe their understanding of adverse experiences, finally relieving the effect of adverse environments on individuals. In addition, the need for autonomy as an intrinsic motivation can facilitate the acquisition of diverse competencies and the discovery of specific talents (Deci, 1975) . This can increase teacher's sense of mastery in handling adversity, improve their engagement in addressing adversity, and relieve their psychological distress.

The current results revealed that social support exhibited non-significant relationships with reduced ASSs via a one-step effect of the need for competency, but exhibited a significant association with reduced ASSs via the path from the need for competency to the sense of control. This finding indicates that the need for competency can exhibit an indirect relationship with reduced ASSs, by providing a sense of control. Here, social support can provide individuals with more resources to help them to cope with adversity (Hobfoll, Freedy, Lane, & Geller, 1990) , potentially increasing individuals coping efficacy, strengthening beliefs regarding their ability to handle adversity (Saltzman & Holahan, 2002) , and improving their sense of control (Aspinwall & Richter, 1999) , which may be related to reduced ASSs. That is, the need for competency may primarily play a relieving role in psychological distress through improving the sense of control.

Furthermore, the current results did not reveal a direct relationship between social support and the sense of control. Thus, a one-step indirect effect of the sense of control between social support and ASSs was not found in this study. One potential explanation is that psychological needs played a complete mediating role between these factors. This finding also extends previous studies (Gadalla, 2009 ), suggesting that when social support meets teachers' psychological needs, it can improve the sense of control and relieve ASSs.

The current study involved several limitations that should be considered. First, because the study sample only included primary and secondary school teachers, care should be taken when generalizing the current findings to other populations. Second, many factors may have influenced individuals' ASSs during the COVID-19 outbreak, but this study only assessed the roles of social support, psychological needs, and the sense of control. Future studies should include more factors to examine the development of ASSs in more depth. Third, because the current study had a cross-sectional design, no firm conclusions can be drawn regarding causal relationships.

Despite these limitations, the current study is the first to examine the underlying mechanisms by which social support relieves ASSs among primary and secondary school teachers in the acute stress phase of the COVID-19 outbreak. The current findings suggested that social support can play a relieving role when support satisfies teachers' three basic psychological needs and improves their sense of control, in accord with Feeney and Collins (2014) theoretical framework for thriving through relationships and self-determination theory . The current findings have important clinical implications. During the COVID-19 outbreak, as people come together to fight the epidemic, the government, social services, and other groups can provide individuals with more social support. Thus, it is important to develop methods for maximizing the effect of social support in relieving psychological distress. The current findings suggest that social support should be targeted to individuals' psychological needs to improve their sense of control, and that this, in turn, can relieve individuals' psychological distress.

Several specific recommendations for reliving teachers' ASS were proposed according to these findings. First, providing information support, including information about the COVID-19 epidemic (e.g. causes, transmission ways, precautions, number and places of confirmed case, etc.), information about the psychological and behavioural reactions being exposed to the epidemic (e.g. prevalence rate, characteristics, etc.), and information about self-assessment and available coping skills of these physiological and behavioural reactions (e.g. progressive relaxation practice, bellying breathing, safe island technology, etc.). These can normalize teacher's reactions to the COVID-19 epidemic, develop a comprehensive cognition about what has happened, increase their feelings of control and self-efficacy in coping, and finally relieve the severity of their ASSs. Second, helping teachers to build a good interpersonal relationship with family, friends, and others, improving their beliefs in personal choices, in order to meet their needs of relatedness and autonomy. In such ways, teachers are more willing to disclose and share their experiences and emotions, which provides an approach to reconstruct their negative cognition to the COVID-19 epidemic and relieve their ASSs. Third, it is important to establish specific channels for them, and tell them how to seek professional psychological help if they need.

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The authors have no conflicts of interest.

This study was supported by Emergency and Special Project for COVID-19 of Institute of China's System Research, Zhejiang University and 'COVID-19 and Education' Special Project of Zhejiang Educational Planning (Grant No.2020YQJY102).