Helping Victims of Terrorism:What Makes Social Work Effective?

Haya Itzhaky and Rachel Dekel

This study examined factors that contribute to effectiveness of social work for victinis ofterrorism, as reflected by a reduction of mental distress and promotion of personal growth inclients. Participants were 148 pairs of social workers and clients. Social workers completed

questionnaires tbat assessed the intervention characteristics (micro- and macro-interventioneffectiveness, supervision effectiveness, and level of directiveness in treatment), as well as

personal resources (empowerment and exposure to terrorism). Clients completed mentaldistress and growth questionnaires. Micro-intervention effectiveness contributed towardexplaining the variance in clients' mental distress, whereas effectiveness of the macro-

intervention and the directive nature of the approach contributed toward explaining tbevariance in clients'growth. Empowerment contributed toward distress and growth only when

it interacted with one of the intervention characteristics. The social workers' personalexposure to terrorism directly influenced the reduction of clients' distress and promotion of

personal growth.

KEY WORDS; distress; effectiveness; empowerineitt;growth; tcrroristn

Terrorism is a worldwide problem. Studiesconducted among adults who were exposedto political violence in 13osnia and Croatia

(Grgic, Mandic, Koic, & Knezevic,2002), Palestineand Israel (Baker & Kevorkian, 199.5;Shamai, 2001),and the United States (for example, Galea et al.,2002; Silver, Holman, Mclntosh, Poulin, & Gil-Rivas,2OO2) reveal that these experiences produceserious personal consequences, such as heightenedanxiety, depression, phobias, a reduced sense of safety,and heightened posttraumatic stress symptoms. Inaddition, experiencing terrorism can lead to in-creased use of tobacco, alcohol and drugs, and tosetf-medication. Notwithstanding these negativeconsequences, consistent efforts have been made inrecent years to document ways in which peoplemay benefit from adverse events and undergo somepositive life changes. For example, findings fromseveral studies have revealed that victims of trau-matic events experienced enhanced intimacy withothers, changed life priorities, greater sensitivity toothers, and increased spirituality (McMillen &Fisher, ]99«;Tedeschi & Calhoun. 1996).

Following terrorist attacks, social workers en-gage in short- and long-term intervention withvictims (Ribner, 1993).The rest'arch on the effec-tiveness of social work interventions in the wake ofsuch events, however, is limited. Moreover, most ofthe available studies assessed macro-level interven-tions, such as group work (Miller, 2003) or com-munity interventions (Boss, Beaulieu, Wieling,Turner, & LaCruz, 2003). Only a few studies as-sessed the effectiveness of an individual,micro-leveltreatment (Fontana, Ford, &; Ri>senheck, 2003).

Examination of the factors that contribute tosocial work effectiveness in response to terrorism isa complex task that involves consideration of inter-vention characteristics as well as the personal re-sources of the staff (Cameron, 1986; Itzhaky, 2003;Jenkins, 1987). In the present study, interventioncharacteristics are represented by effectiveness ofthe process (including effectiveness at the macroand micro levels, supervision, and the interventionstrategy). Hustin (2002) suggested that to assess in-tervention effectiveness as perceived by clients, it isnecessary to examine the efTectiveness and abilities

f CC Code: 0037-8046/05 J3.00 O2005 National Association of Social Workers 335

of the agents of change, as well as the main effectsof the therapeutic environment. In this study, wemeasured the social workers personal resources asa sense of empowerment and the extent of per-sonal exposure to terrorism. Clients' perceptionsregarding the effectiveness of the treatment (Miller,2003) was measured by the reduction of mentaldistress and promotion of growth.

SOCIAL WORK EFFECTIVENESSThe definition of effectiveness in social work is basedon three main approaches: (1) the goal-attainmentapproach, according to which success is related toachievement ot the organization's goals; (2) theconstituencies approach, which maintains that tobe effective, a program must be perceived as suchby its constituencies (Newstorm &. Davis, 1993),and (3) the process approach, which examines theeffectiveness of the activities and skills that are usedin the intervention (Bustin,2002; Fitzpatrick, 1988).In tlie present study, we used a combination ofthesethree approaches, as proposed by Itzhaky and York(1994).

A review of the literature indicates that one wayto examine effectiveness of goal attainment isthrough clients' perceptions of their own personalgrowth within the intervention process.The effec-tiveness of the process can be examined on the basisof tbe workers' perceptions (Bustin, 2002; Itzbaky&• York, 1991). In addition, Bustin noted that thecontribution of process effectiveness toward goalattainment should be examined to gain a broad viewot the efTectiveness of social work.

Intervention CharacteristicsEffectiveness as a Process. To comprehensively as-sess the efficacy of an intervention, Gorey and col-leagues (1998) posited that researchers must useboth a microanalytic and macroanalytic approachto their inquiries. Examining effectiveness as a pro-cess directs focus on the micro level, as reflected incasework (Meyurs &'Thyer, 1997) as well as on theniiicro level, as reflected in community work{Itzhaky &York, 1991). Because the two types ofintervention aim to achieve different goals, opera-tional definitions of their effectiveness differ ac-cordingly. Effectiveness of micro-intervention in-cludes performance of clinical tasks, such as diagnosisof the problem, treatment, and assistance in identi-fying strengths. Effectiveness of macro-interventionmcludes policy making, planning, and orgamzmg

groups (itzhaky 2003). In addition, Bustin (20(»2)argued that the effectiveness of supervision receivedby social workers should be taken into account.

Most research on effectiveness assumes that aneffective process promotes the achievement of goals(Bustin, 2002). However, few empirical studies haveexamined how the effectiveness of social work con-tributes to goal achievement. For example, in astudy of social work effectiveness on kibbutzim inIsrael, Itzhaky (2003) found that the social workersrole 111 community-based interventions contrib-uted to the clients' satisfaction and to their senseof empowerment,

Directipeness of Intervention. Intervention strat-egy is a requisite variable when attempting to studythe effectiveness of sociai work. In directive inter-vention, for example, the social worker determinesthe clients' needs and what steps need to be taken(York, 1988). In nondirccrive intervention,by con-trast, clients make their own decisions based on theirneeds and problems in constiltation with the socialworker (Batten, 1976). With regard to measures ofdirectiveness,York (1988) and Bustin (2002) em-phasized enterprise, goal definition, planning, andperformance. Thus, as long as social workers ini-tiate, plan, and perform, their work is considereddirective.

By contrast, Boehm (2002) suggested that non-directive strategies, in which clients are involved inall phases of intervention, are preferable in times ofcrisis.York (1988) and Bustin (2002) found that themore they involved tbeir clients, the greater socialworkers'success in achieving intervention goals. Asfor clients, Brafman (2002) found that the morethey were involved in the intervention process, thehigher their levels of satisfaction. In a study of cli-ents with posttraumatic stress disorder (PTSD),Fontana et al. (2003) revealed that participation inand commitment to treatment contributed signifi-cantly to clients' satisfaction.

Personal ResourcesEmpowerment. Fraiis (1993) proposed five compo-nents of social workers' empowerment: (1) a self-concept, which includes self-validation and self-esteem; (2) a critical awareness of one's place inlarger systems such as family, agency, or society; (3)possession of knowledge and strength to influenceoneself or others; (4) a propensity to act, whichinvolves power to initiate effective action for one-seif or others, and (5) a sense of collective identity.

336 SocialWork VOLUML 50, NUMBER 4 OCTOBER 2005

which entails sharing the goals, resources, and aspi-rations of an identified social system. The moreworkers feel empowered, the higher their level ofcooperation with clients, and the greater their con-tribution to clients' empowerment {Dodd &Gutierrez, 1990), Notably, empowerment enablessocial workers to feel professionally secure, andtherefore enhances their willingness and ability tocooperate with clients, to focus on clients' strongpoints, and to create an effective therapeutic envi-ronment (Breton, 1999;Goldstein, ]990;Guterman& Bargal, 1996; Saleebey, 1996;Shera ik Page, 1995).Thus, empowerment contributes directly to effec-tiveness of goal achievement (Bustin, 2002).

Itzhaky (2003) and Makaros (2003) found thatthe contribution of empowerment to effectivenessbecomes significant only in interaction with rolebehavior at the macro level. Notably, these studiesfocused on the relationship between workers' senseof empowerment and the extent of goal achieve-ment as evaluated by the social worker. To the bestof our knowledge, no studies have examined thelink between social workers' empowerment and goalachievement from the client's perspective.

Exposure to Terrorism. In light ofthe escalationof terrorism in Israel over the past three years, theimpact of therapists' persona] experience with ter-rorism on their work with victims of terrorist at-tacks cannot be ignored. There is ample evidencethat therapists who have been exposed to traumaticevents in the past experience greater distress thantheir unexposed counterparts in the process of treat-ing trauma victims (Follette, Polusny, & Milbeck,1994;Pearlman & Maclan, 1995).There is a dearthof research evidence, however, regarding the im-pact of social workers' exposure to terrorism ontheir achievement of therapeutic goals. Therefore,the present study examined the unique contribu-tion of intervention characteristics and therapists'personal resources (as reported by the worker) to-ward reducing mental distress and promotinggrowth {as reported by the client).

METHOD

ParticipantsThe sample of participants included 148 socialworkers who treated victims of terrorism in dif-ferent locations throughout Israel. Of the socialworkers, 89.2 percent were women. Nearly half(44.4 percent) of them were younger than 40, andthe majority of them (56.7 percent) were age 40

or older. Most were married (79 percent) and hadchildren (68 percent). The majority ofthe sociaiworkers had social work degrees: 58 percent had aBSW; 42 percent had an MSW, About 30 percentofthe social workers had more than 16 years ofprofessional experience in the field; 26 percent, lessthan five years experience; and the rest (44 per-cent), between five and 15 years of professionalexperience.

For each social worker participating in the study,we chose to examine one cHent who had been in-volved in a terrorist attack (a total of 148 cHentparticipants). Of those clients, 10.14 percent hadlost a family member in an attack, 12.16 percenthad been injured, and the rest had been exposed toa terrorist attack but had not been physically in-jured. Sixty percent ofthe client population waswomen, 40 percent of whom were age 40 or older.Most of them (approximately 84 percent) weremarried, with about three children on the average.Ten percent had graduated high school only, about54 percent had a bachelor's degree, and 36 percenthad a master's degree.

MeasuresDependent Variables. Client's emotional distress wascaptured by the Brief Symptom Inventory-53(BSI-53), a psychological screening questionnaire(Derogatis, 1977). This instrument examines theappearance of 53 different symptoms during thetwo weeks preceding the assessment. We used theGlobal Severity Index, whicb identifies the overallacute ness of psychiatric symptomatology(Deragatis). Clients were asked to indicate how fre-quently they had experienced each symptom overthe preceding two weeks, on a five-point scale,ranging from 0 = not at all to 4 = often.The BSI-53 scales correlated highly with similar scales inthe Minnesota Multiphasic Personality Inventory(Derogatis, Rickels,& Rock, 1976).

To tap into personal growth, we administeredthe Posttraumatic Growth Inventory, a self-reportmeasure that assesses positive outcomes reportedby people who have experienced traumatic events{Tedeschi & Calhoun, 1996). The inventory con-tains 21 items, loaded on five factors: (1) new pos-sibilities, (2) relating to others, (3) personal strength,(4) mental change, and (5) appreciation of life. Foreach item, clients were asked to indicate the ex-tent to which change had occurred as a result oftheir traumatic experience on a four-point scale.

ITZHAKY AND DEKEL / Hflping Victims of Terrorism: What Makes SocialWork Effictive? 337

ranging from 1 - no change to 4 - major change.The scale has good internal consistency and ac-ceptable test-retest reliability (Tedcschi &:Calhoun). Cronbach's alpha in the current studywas .86.

Independent Variahles. Itzhaky (2003) devL-lopeda multipronged questionnaire, defined hy eight skills,to assess effectiveness at the micro and macro level,which we used in the present study. The macro-level skills include policymaking, program planning,implementation of community programs, and or-ganizing groups, and the micro-level skills involvediagnosing the problem, treatment, mediating be-tween the client and formal systems, and helpingidentify strengths. Social worker participants wereasked to indicate the extent to which they felt ef-fective in each of the skills on a five-point scale,ranging from 1 = a very low extent to 5 = a verygreat extent.The Cronbach's alpha reliability valuefor effectiveness at the micro level was .82, and thevalue for effectiveness at the macro level was .86.

The Supervision Effectiveness Questionnaire,developed by Itzhaky and Lazar (1997), is a self-report questionnaire comprising six items that re-late to attainment of supervision goals.Three of theitems refer to the attainment of client's treatmentgoals—that is, the effectiveness of supervision intherapy. The other three items refer to thesupervisee's development in the course of the su-pervision process.The Cronbach's alpha reliabilityvalue for this questionnaire was .79.

Social worker participants also took the Direc-tive Approach Questionnaire (York, 1988), whichis designed to examine the extent to which thesocial worker is directive toward the client. Thequestionnaire asks about encouraging the client'senterprise,defining intervention goals.planning,andimplementing intervention programs. Items areranked on a five-point scale, ranging from 1 = verylow to 5 = very high.The Cronbach's alpha valuefor the questionnaire was .80.

The scale for measuring social worker empow-erment, developed by Frans (1993), contains 34items that measure five components: (1) perceptionof personal and professional power (that is,belief inone's capacity to change events in a client's life); (2)collective identity (that is, sense of sharing goals,resources, and aspirations of creating a meaningfulsocial system); (3) critical awareness (that is, theability to recognize one's place in the world in re-lation to larger systems); (4) self-concept (that is.

self-appraisal and self-esteem); and (5) propensityto act (that is, perceived strength to initiate effec-tive action on behalf of ones self or others). Re-sponses were based on a five-point Likert scale,rang-ing from 1 = strongly agree to 5 = strongly disagree.In the present research, the Cronbach's alpha reli-ability values for all of the factors were .83.

The questionnaire on exposure to terrorism wasdeveloped for the purpose of the present study, andon the basis of an instrument used in an earlierstudy (Solomon & Laufer, 2004).The social work-ers participating in the study were presented with alist of 11 types of terrorist attacks and asked whetherthey had been exposed to such an incident. Amongthe events included were shooting in a settlement,shooting at a car, a car bomb, stone throwing, aMolotov cocktail, or a mortar bomb. The meannumber of events was 4.23 {SD = 0.61).

ProcedureAfter receiving clearance from the Ministry ofWelfare, questionnaires were distributed in sum-mer 2002 to social workers during staff meetingsand in-service training sessions at five social ser-vices departments throughout the country. All ofthe social workers participating in the study hadbeen exposed to terrorist attacks. During the meet-ing or the training session, a general explanationwas given about the study, and the social workerscompleted the questionnaires on-site. All of thequestionnaires were collected at the end of themeeting. In addition, each social worker provideda list of four clients who had been exposed to ter-rorist attacks and would be willing to completethe questionnaire. Questionnaires were sent to thethird client on every list. Although all of the cli-ents had agreed to complete questionnaires, 38percent failed to do so. Therefore, in the secondstage, if the third client on a social worker's listfailed to respond, we sent questionnaires to the sec-ond client on the list. In the third stage, question-naires were sent to the fourth client on the listsfrom which no response was received. At the endof the process, client questionnaires were attachedto each of the questionnaires completed by socialworkers.

RESULTSTo examine the unique contribution of the researchvariables toward the effectiveness in achieving thetwo main goals (reducing distress and promoting

338 Social Work VOLUME 50. NUMBER 4 OCTOBER 2005

growth), we performed a hierarchical stepwise re-gression tor each dependent variable.The resultingcoefficient of determination (R ) indicates how wellthe set of variables in each step explains the depen-dent variable. The regression results indicate thedirection and size ofthe contribution of each vari-able to the dependent variable in each step. Thecontribution to the dependent variable is measuredby a standardized regression coefficient or beta (P).

In the first step, all ofthe independent variableswere entered. In the second step, the interactionsbetween empowerment and effectiveness variables(micro and macro effectiveness, supervision effec-tiveness) and the directiveness ofthe interventionwere entered.

As illustrated, 22 percent ofthe variance in theclients' mental distress and 29 percent of theirgrowth were explained by the independent vari-ables (Table 1).

In the first step, the clients' mental distress wasexplained by the social workers' exposure to ter-rorist attacks and by the effectiveness of micro-in-tervention. The greater the social worker's expo-

sure to terrorist attacks and the greater the effec-tiveness ofthe micro-intervention, the lower thelevel of mental distress reported by the client. So-cial workers'exposure to terrorist attacks, the socialwork approach, and supervisitm effectiveness ex-plained the variance in chents' growth.That is, thegreater the social worker's exposure to terrorist at-tacks, the more collaborative the social work ap-proach, and the more effective the supervision, thehigher the client's reported personal growth.

The social workers' sense of empowerment didnot contribute directly (first step) to changes ineither client mental distress or client growth. Rather,social workers' sense of empowerment contributedto clients' adjustment only in interaction with oneof the effectiveness variables. Empowerment Xmacro-intervention effectiveness and empower-ment X supervision effectiveness reduced the client'smental distress. Empowerment X micro-interven-tion effectiveness positively promoted the client'sgrowth.

To understand these interactions, we dividedsocial worker's empowerment into three levels: low,

Table 1: Summary of Hierarchical Regression Analysis for Variables PredictingMental Distress and Growth in People Exposed to Terrorism

SEB

Step 1

Exposure

Micro effectiveness

Step 2

Exposure

Micro effectiveness

Empowerment x macro effectiveness

Empowerment X supetvision effectiveness

Growth

Step 1

Macro effectiveness

Exposure

Social work approach

Supervision effectiveness

Step 2

Macro effectiveness

Exposure

Social work approach

.Supervision effectiveness

Empowerment X micro effectiveness

•p < .05. • • p < .01. - " ' p < .001.

—.34

- .19

-.29

-.14

-.21

.24

.26

.27

.22

.18

.28

.29

.22

.19

.11

.10

.09

.10

.09

.08

.07

.09

.10

.10

.07

.09

.10

.10

.07

.05

-.36***

-.24

- . 3 1 * *

- .17

- .27*

.35***

.32**

.30**

.24*

.24*

.35***

.32**

.24*

.26*

.20=*

.11

.22

.24

.29

ITZHAKV AND D E K E L / Helping Victims of Terrorism: What Makes SocialWork Effective? 339

medium, and high. Next, for each levelerment, we examined correlations with macro-in-tervention effectiveness and clients'mental distress.When the social workers'levels of empowermentwere low (r= -.01./) > .05) and medium (r— -.09,/) > .05}, no significant correlation was found be-tween macro-intervention effectiveness and theclients' mental distress. When the social worker hada high level of empowerment, high macro-inter-vention effectiveness correlated with low levels ofclient's distress (r = -.22, p < .05).

The interaction effect was also noticeable whenit came to examining supervision (empowermentX supervision effectiveness). In cases of high socialworker empowerment, higher supervision effec-tiveness correlated with low levels of client mentaldistress (r = -.41, p < .01). No significant correla-tion was found hetween supervision effectivenessand clients' distress when the social worker's em-powerment was low (r = -. 12 ;j > .05) or medium(r= .09, p > .05).

Regarding the interaction of empowerment *micro-intervention effectiveness and growth, thefindings revealed that at low levels of empower-ment, the correlation between micro-interventioneffectiveness and the client's level of growth wasnot significant {r= 0.12,;» > .05).When the socialworkers" empowerment was medium (r = .39 ;; <.001) or high (r = .35 /) < .001), a higher level ofmicro-intervention effectiveness correlated withhigh client growth.

DISCUSSIONThe study examined the distinctive and relativecontribution of intervention characteristics andsocial workers' persona! resources in reducing mentaldistress and promoting growth among clients.Thefindings indicate that ofthe intervention charac-teristics, the effectiveness of micro-interventioncontributed to the explained variance in clients'mental distress. Similarly, the effectiveness of macrointervention and the directive nature ofthe socialworker's approach contributed to the explainedvariance in clients'growth. As a personal resource,empowerment, contributed toward both reducingmental distress and promoting positive growth, butonly in interaction with one ofthe interventioncharacteristics. The social worker's personal expo-sure to terrorism contributed directly to the cli-ents' levels of distress and growth. Consistent withearlier research {McMillen & Fisher, 1998; Tedeschi

&: Calhoun, 1996), the results ofthe present studyconfirm that exposure to traumatic events leads toboth distress and growth.Thus, people who reportgrowth are also aware of their distress {Tedeschi &Calhoun).

Some studies claim that reports of growth repre-sent a general positive bias (Tedeschi & Calhoun,1996). whereas others suggest that such reports re-flect a human aspiration for s rowth and positivechange after difficult events {McMillen & Fisher,1998), but are not indicative of genuine changes.Nevertheless, the consistent reports of growth aftertraumatic events, based on evidence from a broadrange of cases and using a variety" of tools {McMillen& Fisher) demonstrate that beyond a desire forpositive cbangf, reported growth attests to the posi-tive change that has occurred. The findings ofthepresent study show that the variance in each ofthemeasures of clients' goal attainment—mental dis-tress and growth—are explained by different vari-ables related to the social worker, which lends sup-port to the argument that growth takes place aftertraumatic events.

We found no studies that examined the associa-tion between social workers' exposure to traumaand their clients' distress or growth. Earlier findingspointed to the positive relationship between socialworkers' exposure to personal trauma and their owndistress when treating trauma clients (Follette etal.,1994; Kassam-Adams, 1994; Pearlman & Maclan,1995), On the basis of these reports, we expectedthat the workers' personal exposure to terrorismwould correlate positively with their clients' dis-tress.We thought that workers who are concernedwith their own distress would probably be lessemotionally available to treat the distress of clients.Our findings, however, contradict these expecta-tions.We found a negative association:The greaterthe extent ofthe worker's exposure to terrorism,the less distress and the more growth reported bythe client. Several possible explanations for tbesefindings are proposed from both the social workand the client perspectives. First, social workers'exposure to terrorism may enhance their under-standing ofthe clients'difficulties and improve theirability to provide effective treatment to victims oftrauma.Trauma victims often assert,"if you didn'texperience it, you can't understand it." It is alsopossible that the coping methods used by the socialworkers to deal with their own experience of traumacan serve as a model to promote chents' growth

340 SocialWork VOLUME 50, NUMBER 4 OCTOBER 1005

and reduce their distress. It should be noted, how-ever, that even though the present study consideredthe social workers' exposure to terrorism in thecontext of their intervention with trauma victims,it did not examine their responses to their ownexperience with trauma. Exposure in itself maystrengthen the social workers and help them reahzethe unique contribution of their efforts, but thefindings may have been different if the social work-ers' responses to their own experience with terror-ism had been taken into account, as in other stud-ies. Qualitative research might help identify thecoping mechanisms that social workers use in theirown experience with terrorisni and determine howthose mechanisms enhanced the effectiveness oftheir work with clients.

An analysis ofintervention characteristics revealedthat only micro-intervention contributed towardreducing mental distress. One goal of micro inter-vention, reduction of the client's mental distress(Tantam, 2002), was validated by the present find-ings.The sense that the sociai worker's micro inter-vention is effective is "transferred" to clients andreduces their mental distress. This highlights theuniqueness and importance of the therapeutic rela-tionship at the micro level for reducing mental dis-tress after a terrorist attack. In light of the expansionof terrorism throughout the world and particularlyin Israel over the past few years, diverse therapeuticmethods have been applied in clinical work withvictims of terrorist attacks (Miller, 2002; Nuttman-Shwartz, Lauer-Karneil, & OfTir, 2002; Shalif &Leibler, 2002). The present findings reinforce theimportance of the personal therapeutic relationshipin the various interventions with such clients.

By comparison, the effectiveness of macro-in-tervention, supervision, and social work approachcontributed to prediction of growth. These find-ings suggest that growth is a complex process, inwhich significant others play a role beyond thesethree factors. Social work approach refers to thedegree of client participation:The more the clientsparticipate in the process, the more they grow. Su-pervision effectiveness reflects the contribution ofthe supervisor to the growth process: The moreeffective the supervision as perceived by the socialworker, the greater the client's growth. Finally,growth demands not only clinical skills, but alsocommunity activities such as policy making, plan-ning programs, and organizing groups that requirethe involvement and cooperation of community

leaders and others.Thus, whereas the personal thera-peutic relationship plays a crucial role in the reduc-tion of clients' distress, promotion of growth in-volves other, broader dimensions as well.

Another noteworthy finding is the distinctionbetween the components needed to reduce distressand those required for growth. In contrast to otherstudies {Bustin,2002;Dobri,2002;Goldstein, 1990;Guterman & Bargal, 1996; Itzhaky,2<K)3), the presentresearch found that social worker empowermentdoes not contribute directly to the measures of goalachievement. The impact of social workers' em-powerment on client adjustment is expressed onlywhen it interacts with one of the components ofeffectiveness. Empowerment X macro-interventioneffectiveness and empowerment X supervision con-tributed toward reducing client distress, and em-powerment X micro-intervention effectiveness wasfound to contribute toward promoting clientgrowth.

Although effectiveness is specifically related tothe therapeutic process, empowerment relates tothe social worker's personal sense of competence.Thus, the interaction between the social worker'ssense of personal empowerment and specific skillsin micro or macro-intervention led to improvedmeasures of effectiveness.This finding supports theargument that the characteristics of social workintervention should be combined with personalresources {ltzhaky,2003) to achieve maximal effec-tiveness in micro intervention. At this level of clini-cal social work, effectiveness helps promote clients'growth when combined with empowerment, andeffective macro-intervendon helps reduce distresswhen combined with enipow..'rment. Thus, at alllevels of the therapeutic process, social workers needto feel empowerment to attain an optimal level ofeffectiveness in achieving the goals of reducing dis-tress and promoting client growth.

These results notwithstanding, some limitationsof the study are noteworthy. Research on terror-ism, by nature, cannot be based on a random sample.For that reason, the sample in the present studyincluded all of the social workers at communitysocial service departments who had been exposedto terrorism. Second, a clearer definition of theexposure variable is needed. Although we exam-ined the number of times the social worker hadbeen exposed to terrorist attacks, their proximityto the event was not ascertained. Evidently, socialworkers' personal responses to the experience of

ITZHAKY AND DEKEL / Helping Victim! of Terrorism: What Makes Social Work Effectived 341

terrorism may affect their effectiveness, but thisvariable should be measured more precisely. Forexample, the study did not examine the socialworkers' subjective perceptions of the event, suchas feehngs of helplessness, shock, and fear {Pearlman& Maclan, 1995), and did not look at the level ofdistress they experienced as a result of their expo-sure to terrorism. Consideration of these variablesmay sbed hght on the process of intervention thatinvolves social workers and clients who have beenexposed to terrorist attacks. In addition, clients'understanding of therapeutic process, experience,and meaning should be added to the effectivenessevaluation (Miller, 2003). Additional studies coutdinterview clients about which of the treatment'scomponents helped to make the process effectiveand resulted in decreasing distress and increasinggrowth.

Furthermore, the present study was conductedat one point in time. We did not control the client'sprimary level of distress at the beginning oftheintervention or the length of intervention (Fontanaet al., 2003). Clients with intense PTSD symptomsat the beginning of therapy may demonstrate lessimprovement in distress than do clients with lowerinitial distress.This suggests that such variables alsomay affect the effectiveness ofthe social worker. Inaddition, because the various effectiveness variablesin this current study were based on the socialworker's self-perception, future studies could addexternal assessments of effectiveness.

On the whole, the unique contribution ofthepresent study is its emphasis on the client's per-spective in examining the correlation between so-cial work variables and outcome measures and itsassessment of process effectiveness in terms of goalachievement. This research design sheds light onwhich ofthe abilities and resources available to socialworkers are most likely to help clients who haveexperienced terrorist attacks. The findings revealdifferential and combined effects of social workers'resources and abilities on the achievement of inter-vention goals. Hni

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Haya Itzhaky, PhD, is professor and director, School of

SocialWork, Bar-llan University, Ramat Gan 52900,

Israel; e-mail: itzhah@maH.hiu.ac.il. Rachel Dekel, PhD,is a lecturer. School of Social Work, Bir-Ilan University,

Ramat GatJ, Israel.

Original manuscript received June 9, 2003Final revision received January 10. J005Accepted April 18. 2005

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O2003. Pafd tor by the United States Army, All rights i«served. AN ARHT OF ONT

ITZHAKY AND DEKEL / Helping Victims of Terrorism: What Makes SocialWork Effective? 343