The main objective of this research was to analyze how direct (vs. indirect) exposure to a traumatic event affects victims’ health. According to previous research [
1], we expected and found that people exposed directly to trauma showed more PTSD symptoms than those exposed in an indirect manner. Directly exposed individuals also generated more negative post-traumatic cognitions about the self and about the world than those exposed indirectly. Both results are consistent with the literature indicating that dysfunctional trauma-related cognitions are strongly related with PTSD symptom severity [
43‐
45]. Finally, as expected, victims exposed directly (vs. indirectly) reported less PWB and SoWB. These results are in line with the
Psycho-Social Model of Trauma [
17,
46], which postulates that traumas caused by intentional violence have accumulating and enduring emotional, social, and political consequences. Therefore, the impact of direct (vs. indirect) traumas on victims’ health was greater, both from a psychopathological and positive function perspective.
Beyond the greater impact of direct (vs. indirect) exposure on victim’s health, as a novel contribution, we expected that well-being would play a different role in the effect of post-traumatic cognitions on victims’ mental health depending on the type of trauma exposure. Regarding indirect exposure, and in line with previous literature [
45], we found that this type of exposure generated less dysfunctional trauma-related cognitions (vs. direct exposure). Given the close conceptual relationship expected and detected in our study between negative cognitions about the self and PWB (
r = −.46,
p < 0.01), and negative cognitions about the world and social well-being (
r = −.46,
p < 0.01), we also expected that well-being would mediate the relationship between post-traumatic dysfunctional cognitions and DTS. The results of our study confirmed this hypothesis, indicating that well-being should be a central element of public policies to protect the general population against indirect exposure to massive trauma (such as terrorist attacks). Moreover, participants who were directly exposed to trauma had different reactions than those indirectly exposed to trauma. According to Emotional Processing Theory [
12,
20], a direct exposure to a high-intensity traumatic event should produce strong dysfunctional cognitions. Therefore, in agreement with our predictions, it was expected that well-being moderated the relationship between post-traumatic dysfunctional cognitions and trauma symptoms. Our results confirmed this moderation, indicating that well-being was a “protective factor” for individuals that were directly exposed to trauma. From an applied point of view, these results have interesting implications. First, the important differences found between direct and indirect trauma exposure should be taken into consideration when developing psychological interventions. For example, although the use of classic clinical interventions to prevent the development of PTSD in vulnerable individuals exposed to indirect trauma through the mass media (e.g. based on fear conditioning or extinction models [
47]) may be effective, increase the levels of population’s well-being also seems to be an excellent recovery strategy (not only a prevention strategy). According to the literature, three well-being indicators appear to be strongly related to PTSD (or CPTSD), and thus should be the focus of this positive psychological intervention. The first is positive affect. The inability to experience positive emotions (anhedonia; DSM-V PTSD D7 criteria; severe and pervasive problems in affect regulation; ICD-11 CPTSD C1) is present in about two-thirds of PTSD patients, independently of comorbid major depressive disorder [
48] (for a review on the possible mechanisms underlying anhedonia in PTSD, see [
49]). Therefore, in order to address this issue, interventions such as the expressive writing technique can be applied to focus on positive emotions generated after the trauma (e.g. the support of close social networks such as friends or family, feelings of unity generated in the community). One of the main objectives of this kind of intervention should be to increase positive emotional granularity (i.e., the tendency to represent experiences of positive emotion with precision and specificity) given its crucial role in enhancing coping resources in the face of traumatic events [
50]. However, training individuals to employ coping strategies focused on emotion in general (and not only on positive ones), could probably also increase their well-being. According to research on coping strategies [
51], individuals who have been indirectly exposed to traumatic events and focus on emotions associated with the stressor, probably cope with trauma much better than individuals who don’t focus on emotions associated with the stressor. One reason for this may be because emotion-focused strategies (vs. problem-focused) are more adaptive in uncontrollable situations like terrorist attacks [
52]. It should be noted that, although in many cases clinical psychology and psychiatry focus on disorders and mental health taking as a frame of reference and unit of analysis a subject isolated from its environment [
46], there are also different intervention strategies that can be applied not only on an individual or a micro-social level, but also on a macro-social one. The culmination of this proposal is the development of social institutions and positive communities [
53].
Finally, regarding direct exposure, our data revealed the important role of negative post-traumatic cognitions about the self and the world in the development and maintenance of PTSD. These results are consistent with previous research indicating that trauma produces negative cognitions about the self and others [
30,
54], and that these negative cognitions subsequently increase PTSD in a vicious downward cycle [
55], thus reducing well-being over time. Therefore, the development of interventions aimed at modifying these cognitions in individuals directly exposed to traumatic events is critically important. For example, therapies such as prolonged exposure therapy [
56], or other forms of cognitive behavioral therapy [
57,
58], have been shown to be effective in this area. In the case of trauma caused by terrorist attacks we expect symptoms of persistent difficulties in sustaining relationships and in feeling close to others (ICD-11 CPTSD C3), therefore it would be also interesting to work on negative cognitions that link “others” with the intent of causing harm deliberately. Although work to modify dysfunctional cognitions is essential in post-trauma situations that focus on individuals directly exposed to traumatic events, using positive interventions to increase positive well-being is an excellent prevention strategy. In direct exposure, well-being emerges as a moderator of the relationship between dysfunctional cognitions and psychopathology symptoms, becoming a strong excellent protective factor.
Although the present study made several novel contributions to the literature, some limitations should also be mentioned. The most notable of which is related to our research design. That is, because the topic of this study does not allow the use of an experimental design, this affects our ability to draw causal conclusions regarding the relationships between variables. Another potential limitation is that we have only measured dysfunctional cognitions. Using the approaches of either Epstein [
15] or Janoff-Bulmann [
13,
16], it would have been interesting to measure the possible rupture of core beliefs caused by trauma exposure (i.e. the world is benign, the world is meaningful, the self is worthy, or people are trustworthy). However, a direct measurement of the process of beliefs’ rupture would have required a longitudinal pre-post trauma design. To obtain a sample with these characteristics is very complex since, as mentioned previously, we cannot manipulate the presence/absence of trauma experimentally. Despite these issues, future research could explore the idea that only direct traumatic events may break the “cognitive homeostasis”, a system that supports the maintenance of positive core beliefs within certain levels of equilibrium.