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Cognitive Processing of Traumas: The Role of Intrusive Thoughts and Reappraisals’ MELANIE A. GREEN BERG^ The Graduate Ce

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Cognitive Processing of Traumas: The Role of Intrusive Thoughts and Reappraisals’ MELANIEA. GREEN BERG^ The Graduate Center of the City University of New York Cognitive processing theories of post-traumatic adaptation (Horowitz, 1986a; Janoff-Bulman, 1992) propose that repeated comparisons of trauma content with preexisting cognitive schemas result in trauma reappraisal or schematic revision. Thus, intrusive ruminations should facilitate cognitive integration and resolution of past traumas. However, research has shown that some survivors become stuck in endless, repetitive rumination cycles. This raises the issue of how to differentiate ruminations that promote cognitive integration from those that merely prolong or exacerbate psychological distress. Identifying substantive dimensions for categorizing cognitions about past traumas could enhance prediction of their effects on adjustment and inform clinical treatment interventions. This paper seeks to: (a) Assess the current state of theoretical knowledge concerning cognitive adaptation to trauma, (b) integrate theoretical postulates with empirical research findings, (c) define gaps or inconsistencies in our understanding of the cognitive adaptation process, and (d) identify foci for future theory and research.

During the past decade, there has been tremendous growth in theory and empirical research concerning the aftereffects of traumatic experiences. This work has enhanced understanding of the cognitive, behavioral, emotional, physiological, and neurohormonal sequelae of trauma. Despite these advances, the literature still lacks a consistent definition of what differentiates normative from maladaptive responses to severe stress. For example, intrusive thoughts and images have been described as one of two “general response tendencies to stressful events” (Horowitz, 1986a, p. 8 5 ) , as “an adaptive pathway” in the search for “personal meaning” following trauma (Williams, 1983, p. 4), and as “the cardinal symptom of the [post-traumatic stress] disorder” (Zimering, Caddell, Fairbank, & Keane, 1993, p. 339). ‘Work on this article was supported by funds from a National Institute of Mental Health Postdoctoral Research Fellowship in Health Psychology. I am grateful to Camille Wortman for providing valuable ideas and resources. I thank Suzanne Ouellette for allowing me to work on this paper as part of my postdoctoral training. 2Correspondence Concerning this article should be addressed to Melanie A. Greenberg, who is now at the Ph.D. Program in Health Psychology, California School of Professional Psychology, 6212 Ferris Square, San Diego, CA 92121. e-mail: [email protected].

1262 Journal of Applied Social Psychology, 1995, 2 5 , 14, pp. 1262-1296. Copyright 0 1995 by V. H. Winston & Son, Inc. All rights reserved.

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One possible reason for these divergent views is that the theorists are focusing on qualitatively different types of cognitive responses. The sudden feeling that a life-threatening situation is recurring may have different implications for adjustment than a mental review which provides a fresh perspective from which to evaluate past actions and decisions. A common theme underlying diverse theories of adjustment to trauma (e.g., Foa, Steketee, & Rothbaum, 1989; Horowitz, 1986a; Janoff-Bulman & Frieze, 1983; Pennebaker, 1990) is that healthy adjustment is the result of repeated confrontation with the memories of the trauma and their subjective meanings. However, mere exposure to traumatic memories does not always facilitate recovery. Some research studies have supported the conclusion that “. . . when after an extended period the search [for meaning] fails to bring understanding, the continuing process of searching and repeatedly ruminating appears to be maladaptive” (Silver, Boon, & Stones, 1983, p. 96). If the effects of contemplating past traumas are not uniformly positive, how do we differentiate between adaptive, normative, and persistently maladaptive .ways of confronting these events? The most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) defines two distinct types of psychological disorders that can result from trauma exposure: posttraumatic stress disorder (PTSD) and acute stress disorder. The stressor criterion is the same for both disorders and requires that (a) “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;” and (b) “the person’s response involved intense fear, helplessness, or horror” (APA, 1994, p. 427-428). The diagnostic criteria for both disorders also require that the following types of responses be present: Reexperiencing of the traumatic event; avoidance of stimuli associated with the trauma; increased arousal; and clinically significant distress or impairment in social, occupational, or other areas of functioning. The major difference between the two disorders involves the duration of responses. PTSD is diagnosed only if the duration of disturbance is at least one month. If disturbances are present for at least 2 days and not more than 4 weeks following the trauma, acute stress disorder is diagnosed. Because reexperiencing and arousal in the immediate aftermath of a trauma are not necessarily predictive of longer-term dysfunction (Shalev, 1992), the diagnosis of acute stress disorder also requires that three or more of the following dissociative symptoms occur either during or after the distressing event: numbing or detachment, reduced awareness of surroundings, derealization, depersonaliczation, and dissociative amnesia (APA, 1994). These criteria suggest that reexperiencing, avoidance, and arousal reactions

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are not, in themselves, signs of mental disorder. Only reactions which are both distressing or disruptive, and persistent or accompanied by dissociation, are symptomatic of psychological maladjustment. The DSM-IV criteria were designed to diagnose psychological dysfunction and, therefore, tell us little about satisfactory or optimal adjustment to trauma. Why do some individuals with acute stress disorders develop PTSD while others return to normal functioning? Perhaps the effects of confronting past traumas depend upon the types of cognitive and physiological changes that are produced by such confrontation. Mentally reviewing past traumas may be beneficial, only to the extent that such review: (a) Reduces physiological strain associated with deliberate efforts to inhibit such material and produces cognitive insight and schema change (Horowitz, 1986a; Pennebaker & Beall, 1986), (b) produces more constructive appraisals of the traumatic memory or more effective “coping strategies to address” problems posed by the trauma (Janoff-Bulman, 1989; Lazarus & Folkman, 1984), or (c) results in less physiological reactivity to and less threatening appraisals of reminiscent stimuli associated with the trauma (Foa et al., 1989; Jones & Barlow, 1980). Cognitive Processing Models of Trauma Response Cognitive processing models of trauma response are based on the assumption that information about past experiences, current world views, and expectations about future events are contained in mental schemas (Hollon & Kriss, 1984). These theories describe the ways in which traumatic events can disrupt enduring functional schemas or produce maladaptive schemas. Some theories also enumerate a variety of schematic reconstruction processes. In the past two decades, numerous stress response models with cognitive processing components have appeared in the literature (e.g., Chemtob, Roitblatt, Hamada, Carlson, & Twentyman, 1988; Epstein, 1991; Foa et al., 1989; Horowitz, 1986a; Janoff-Bulman & Frieze, 1983; Jones & Barlow, 1990; Litz & Keane, 1989; McCann & Pearlman, 1990; Pennebaker, 1990; Roth & Newman, 1991; Taylor, 1983). Whereas some models enumerate the determinants of successful adjustment to trauma, others seek to explain the development of PTSD following trauma exposure. An exhaustive review of cognitive processing theories is beyond the scope of this paper. Jones and Barlow (1990) and Litz and Keane (1 989) have written excellent reviews of this topic. The Benefits of Studying Healthy Adaptation Recently, the trauma literature has been criticized for placing too heavy an

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emphasis on psychopathology (Joseph, Williams, & Yule, 1993; Lyons, 1991b). Several authors have called for increased theoretical attention to the mechanisms that result in successful adaptation. Ursano (1987) has contended that “the study of responses to trauma must include the study of resilience and health” (p. 274). Similarly, Jones and Barlow (1990) have stated that “. . . Perhaps the most important function of any etiological model [of PTSD] is to explain the absence of symptoms in some individuals exposed to similar lraumatic conditions” (p. 300). Furthermore, Lyons (1991b) has suggested that “increased knowledge about those survivors who are able to transcend such adversity is likely to . . . suggest additional interventions for survivors who fare less well” (p. 104). Empirical evidence also suggests that some individuals exhibit resilience, even in the face of severe trauma. Methodologically sophisticated studies have shown that the bulk of individuals exposed to severe stressors, including combat in Vietnam (Kulka et al., 1988), nuclear accidents (Baum, 1987), and disasters (Hartsough & Myers, 1985), do not develop chronic PTSD. Furthermore, some individuals remain optimistic and hopeful despite exposure to severe traumas. A comparative study of Holocaust survivors and matched controls who had emigrated to Israel during the same period as survivors (Carmil & Breznitz, 1991) found that, almost 50 years after the Holocaust, both survivors and their children endorsed stronger beliefs in God and a better hture, relative to controls and their children. Another recent study of adult survivors of a disaster at sea (Joseph et al., 1993) found evidence that . . . there [were] strong positive changes in values and views about life and other people [resulting from the disaster]” (p. 276). “

An Examination of Cognitive Processes Underlying Healthy Adaptation In response to recent calls for the study of resilience, this paper will focus on the cognitive processes involved in healthy adaptation to trauma. Two wellestablished cognitive processing theories will be reviewed; Horowitz’s (1 986a) theory of stress responses, and Janoff-Bulman’s theory of assumptive worlds (Janoff-Bulman, 1992; Janoff-Bulman & Frieze, 1983). These theories were chosen because they change on the cognitive processes involved in recovery from trauma and because they are comprehensive, innovative, influential, and have generated substantial empirical research. Although other cognitive processing theories are equally well-established (e.g., Foa et al., 1989; Jones & I3arlow, 1990; Litz & Keane, 1989), their focus on PTSD did not fit as well within the framework of this paper. Pennebaker and colleagues (e.g., Pennebaker, 1990; Pennebaker & Beall,

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1986) have also proposed an influential model of the link between disclosing emotions about past traumas and improved physical health and psychosocial adjustment. Their model has two major foci: (a) The role of disclosure in undoing physiological strain associated with the inhibition of traumatic memories; and (b) the role of verbal expression in promoting insight into and cognitive assimilation of traumatic memories. Pennebaker’s model has generated considerable empirical research (e.g., Greenberg & Stone, 1992; Pennebaker & Beall, 1986; Pennebaker, Hughes, & O’Heeron, 1987; Pennebaker, Kiecolt-Glaser, & Glaser, 1988). This model will not be discussed in detail because several of its cognitive elements overlap with Horowitz (1986a). Pennebaker and colleagues have expanded upon Horowitz’s approach by emphasizing the role of physiological and social factors in adaptation to trauma (cf. Pennebaker, 1988, 1990; Pennebaker et al., 1987) and by describing how low-level thinking emerges during acute, transient stress (Pennebaker, 1989). This type of thinking is characterized by a narrowing of perspective, both in terms of the time frame considered and the use of divergent information, a reduction in self-reflective processing, and reduced emotional awareness. In the short-term, these changes facilitate optimal allocation of processing resources to the immediate crisis; however, persistent exclusive reliance on low-level thinking can impede emotional processing of the stressful experience. In the next section, two prominent cognitive processing theories of trauma will be discussed. First, each theory will be described. This will be followed by a discussion of its contribution to the trauma literature and how well it accounts for established features of post-traumatic responding. Next, conceptual questions will be raised concerning existing theoretical accounts of cognitive adaptation. Empirical research that addresses these conceptual issues will then be presented. Finally, conclusions and suggestions for future research and theorizing will be suggested. Horowitz’s Theory of Stress Responses Horowitz (1986a) has proposed two general types of response to stress. The first response mode involves intrusive repetitions of the trauma in thought, imagery, emotion, or behavior. Because states of intrusion are inherently painful, a second response mode develops, which involves attempts to suppress these intrusions, using mechanisms such as ideational denial, emotional numbing, and deliberate avoidance of reminders. The process of adjustment to trauma is described as comprising five phases: (a) outcry or initial realization that the stressor has occurred, (b) denial and numbness, (c) intrusive repetition, (d) working through, and (e) completion.

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‘This sequence of phases is not presumed to be universal; individuals may skip certain phases or demonstrate alternative sequences of phasic responding. The .working through phase involves a prolonged alternation of denial and intrusion, .with gradual decreases in the intensity of responding. Completion occurs when there is a “resolution of differences between new information and enduring mental models” (Horowitz, 1986a, p. 95). However, “later events may reignite 1.he original trauma’s emotional meaning, causing the cycle of phases to be repeated” (Horowitz, 1988, p. 22). Horowitz (1986a) explains the recurrence of traumatic memories in terms of two aspects of psychoanalytic theory; a purposeful need to master (he trauma and a more instinctive, automatic compulsion to repeat the irauma. He proposes that the contents of active (short-term) memory will be repeatedly represented in consciousness until cognitive processing of the event is complete, at which time the event is stored in long-term memory. Involuntary repetitions are not necessarily static duplications of the original irauma; they can take a variety of forms, ranging from . . . representation by action and sensory images to representation by word meanings” (Horowitz, 1986a, p. 98). Horowitz (1975) proposes that, in contrast to less stressful events, which are easily assimilated into long-term memory; “

Stress events, by definition, will impose some strain on cognitive processing. That is, the working out of how this new information is to be matched and integrated with old information about the self and the world will be hard or time-consuming. For a time, there will not be a good enough match . . . Eventually, . . . schemata of self, objects, attitudes, and expectations will have been revised so that the new memories fit adequately. (p. 1462) Recurrent representations of the trauma may be experienced as intrusive if they are intense and clear, appear despite repeated attempts to suppress them, have no apparent connection to the previous train of thought, or involve resurrection of painful emotions experienced during the trauma (Horowitz, I. 9 8 6a). Sometimes, my head starts to replay some of my experiences in Nam. Regardless of what I’d like to think about, it comes creeping in. It’s so hard to push back out again. It’s old friends, their faces, the ambush, the screams, their faces [tears]. (Goodwin, 1980, p. 2; as cited in Williams, 1983)

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Horowitz (1988) argues that these intrusive recollections are a necessary part of the psychological adaptation process. They can facilitate (a) modifications of automatic associations and substitution of new ways of thinking, (b) revision of relevant schemas to take into account the information contained in the trauma, (c) resolution of conflicting interpretations of the trauma, and (d) generation of new solutions that address problems posed by changed circumstances (Horowitz, 1986a; as cited in Williams, 1983).

Cognitive Processes Involved in Adaptation to Trauma In the normal pattern of stress response, the individual “doses” herself with tolerable levels of intrusion so that she can start “working through” the personal meanings of the event. Horowitz (1 986a) describes three sets of strategies by which the survivor could control the occurrence, content, or affective tone of intrusive ruminations: (a) controlling mental set (e.g., controlling the frequency, timing, and duration of thoughts about the trauma, or framing contemplation of the trauma within a particular time period); (b) controlling schemata as organizers of information (e.g., choosing what schemas of self, relationships, values, or world views will structure examination of the trauma); and (c) controlling ideas and sequences (e.g., choosing what information will be utilized or disregarded in reviewing the trauma, viewing the trauma from multiple perspectives, or revising schemata). For example, an individual with strong adaptive internal controls may choose to (a) focus on brief time intervals when in a problem-solving mode (e.g., thinking only about what to do next) or focus on extended time intervals to obtain a less devastating picture of the trauma (e.g., as one tragic event in a full and meaningful life), (b) maintain a view of the self as competent and of others as willing and able to provide realistic support, and (c) focus on the current implications of the trauma and avoid regretting past decisions and actions. Adaptive patterns of cognitive processing are not, however, regarded as universal. Sometimes, the normal sequence of processing is disrupted and processing is not completed. According to Horowitz and Kaltreider (1980), pathology is not usually the result of some qualitatively different response, but rather of responses that are of such magnitude that the person requires help, or they are responses that do not progress towards adaptive completion over an extended time. (P. 165) Zilberg, Weiss, and Horowitz (1982) have identified three different forms of pathological stress response syndromes, namely, “frozen in avoidant states,”

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“stuck in undercontrolled intrusion,” and “oscillating . . . between states of high intrusion and high avoidance” (p. 4 13). For survivors “ frozen in avoidant states,’’ controls are excessive and block affective responding, thereby obstructing the working through process. For survivors “stuck in undercontrolled intrusion,” control processes are unable to modulate and organize the flow of distressing information about the trauma, resulting in survivors’ “ succumbing to stress” (Horowitz, 1986a, p. 103). Commentary on Horowitz’s Theory Horowitz’s (1986a) theory of stress responses provides a conceptually rich and comprehensive account of cognitive processes involved in adaptation to trauma and the ways in which these processes can be facilitated or hindered. The theory can account for the presence of intrusive responses and avoidance phenomena following stressful events and changes in the intensity of these symptoms over time. Recovery from trauma is explained as resulting from cognitive assimilation of the traumatic memory or a revision of existing schemas to accommodate the new information. The occurrence of delayed forms of I’TSD (McFarlane, 1988) can be explained in terms of a movement from the numbing to the intrusive phase of stress response, a decay in the effectiveness of control processes over time, or a change in life circumstances that reignites the emotional meaning of the trauma. Horowitz (1986a) does not elaborate on what particular features of a given situation are likely to reignite traumatic memories. Horowitz’s (1986a) theory has been criticized for not explaining differential responding by individuals exposed to the same stressor (Jones & Barlow, 1990). Although the connection is not always made explicit, Horowitz’s (1986a) theory is, in fact, able to account for individual variability in response in terms of the degree of disparity between the trauma and preexisting expectations and beliefs, and variability across individuals in the capacity to modulate and structure their distressing thoughts and feelings about the trauma. According to Horowitz (1986b), “Excessively high inhibitory controls may interrupt the assimilation and accommodation process . . . Failures of control lead either to a continuation of outcry, as in prolonged panic-stricken states, or to an intrusive state” (p. 247). Litz (1992) has criticized four aspects of Horowitz’s (1986a) theory: (a) The exclusive focus on internal psychological processes and neglect of situational variables that might affect post-trauma responding; (b) the incompatibility of the proposed cognitive mechanisms with established information processing theory; (c) The lack of specification as to whether the intrusion and numbing phases involve differential access to specific emotions; and (d) the

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lack of clarity about whether the capacity to experience positive, gratifying mood states is impaired in PTSD patients. Because Horowitz’s (1986a) theory was designed to explain generic adaptation to trauma, rather than the features of any particular diagnostic entity, it may not be appropriate to expect the theory to account for all of the features of PTSD. Litz’s (1992) criticism concerning the lack of attention to situational variables is well taken, however. Horowitz conceptualizes adaptation to trauma purely in terms of the survivor’s internal psychological resources, however, stressor characteristics are a well-established determinant of post-traumatic responding (Fontana & Rosenheck, 1993; Foy, Sipprelle, Rueger, & Carroll, 1984; Kulka et al., 1988). Litz (1 992) has contended that Horowitz’s (1986a) theory is incompatible with empirically validated features of modern information processing theory. Although specific instances of incompatibility are not cited, Horowitz’s model of adaptive reappraisal resulting from repeated, internally generated exposures to moderated “doses” of traumatic material appears to be incompatible with the following features of information processing theory (e.g., Chemtob et al., 1988; Foa et al., 1989; Litz & Keane, 1989): (a) The storage in memory of information about traumatic stimuli, expected responses, and the meanings attached to these elements in the form of fear structures or programs for escaping danger (cf. Lang, 1985). Modification of such structures requires not only their activation, but also the provision of specific information which is incompatible with their stimulus, response, or meaning elements; (b) the existence of a feedback loop in which previously adaptive arousal and vigilance for threat-related stimuli result in a narrowing of attentional focus and increased likelihood of identifying ambiguous information as threatening. Thus, perceptions of threat associated with past traumatic memories act as self-fulfilling prophecies, strengthening views of the world as malevolent and of the self as vulnerable to imminent danger; (c) the intensity and accessibility of trauma networks, which reduces the availability of alternative, more benevolent conceptualizations that could modulate the intensity of negative emotional responses. Thus, Horowitz may have underestimated the stability and potency of entrenched cognitive and affective responses associated with past traumas. Despite these controversies, Horowitz’s (1986a) contribution is substantial. The idea that traumas necessitate revision of schemas concerning the self and world has formed the basis of subsequent theorizing about trauma (cf. Epstein, 1991;Janoff-Bulman & Frieze, 1983; McCann & Pearlman, 1990; Pennebaker, 1990; Roth & Newman, 1991). The delineation of intrusion and denial as distinct, universal stress response tendencies has generated a great deal of empirical research and has influenced the conceptualization of both normal and

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pathological post-traumatic responses. Horowitz’s stipulation of a broad range of cognitive strategies that can modulate the intensity and negative valence of intrusive reexperiencing is an important first step toward identifying substantive dimensions for classification of intrusive cognitions (cf. Lyons, :1991; Wortman, 1983). Janoff-Bulman’s Assumptive Worlds Theory Janoff-Bulman’s theory of adaptation to trauma (e.g., Janoff-Bulman, 1979, 11989, 1992; Janoff-Bulman & Frieze, 1983; [Janoffl-Bulman & Wortman, 11977) is also based on the notion of cognitive schemas. The theory assumes that people’s day-to-day functioning is guided by deeply held assumptions about the self and the world (cf. Marris, 1975; Parkes, 1975). Schematic processing is inherently conservative; individuals will first try to fit anomalous experiences into extant schemas; revision of core beliefs occurs only as a last resort. The theory posits that individuals hold three core assumptions: (a) benevolence of the world, (b) meaning in the world, and (c) worthiness of the self. The “benevolent world” schema contains the assumptions that other people are basically trustworthy, moral, and compassionate and that misfortunes occur infrequently. The “meaningful world” schema “involves people’s beliefs about the distribution of outcomes” (Janoff-Bulman, 1989, p. 118). A meaningful world is one in which events unfold systematically, according to comprehensible rules (Antonovsky, 1979). Three alternative principles of outcome allocation are suggested: justice, controllability, and chance. The “just world theory” (Lerner, 1980) contends that people get what they deserve. The principle of controllability assumes that outcomes are determined by people’s own behaviors. The principle of chance assumes that the distribution of outcomes is random and unrelated to human actions. The “worthy self’ assumptive category contains three self-evaluative dimensions: self-worth, self-controllability, and luck. If outcomes are presumed to be justly distributed, self-worth, or believing oneself to be a decent, ethical person, should decrease perceived vulnerability to adverse outcomes. Alternatively, if outcomes are the result of one’s own actions, viewing oneself as capable of exercising forethought and sound judgment should result in diminished perceptions of vulnerability. If outcomes are presumed to be random, perceptions of the self as “lucky” (Janoff-Bulman, 1989, 11. 120) should enable individuals to feel relatively invulnerable to adverse outcomes. The theory proposes that extraordinary events, which involve threats to

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survival, contradict the assumptions of self-worth, benevolence, and meaning (Janoff-Bulman, 1992; Janoff-Bulman & Frieze, 1983). Because traumatic events are extremely salient and disturbing, survivors are forcefully confronted with a catastrophic upheaval of their conceptual systems. “Victims experience the loss of old, deep, positive views of the world and themselves” (JanoffBulman, 1992, p. 71). This conceptualization is consistent with anecdotal reports, such as the following: For the common soldier . . . war has the feel-the spiritual texture-of a great ghostly fog, thick and permanent. There is no clarity. Everything swirls. The old rules are no longer binding, the old truths no longer true. Right spills over into wrong . . . You can’t tell where you are, or why you’re there, and the only certainty is overwhelming ambiguity. (0’ Brien, 1990, p. 88; as cited in Herman, 1992) Characteristics of the trauma are presumed to affect which assumptions are threatened. Disasters caused by forces of nature force survivors to confront the existence of danger and human fragility. Interpersonal victimizations force confrontation with personal vulnerability and the malevolence of other people. If the old assumptions are rapidly discarded, this could “threaten the breakdown of the entire conceptual system; for the primary postulates represent the foundation on which other beliefs are built” (Janoff-Bulman, 1989, p. 121). Thus, the coping task facing survivors is to reinterpret the trauma in ways that are less incompatible with the old assumptions or to revise their world views to accommodate the trauma. Healthy adaptation involves developing a new perspective that can account for the trauma, while preserving self-worth, connection with others, and the ability to modulate terror. Unhealthy adaptation involves a failure to reconstruct adaptive illusions. Cognitive Processes Involved in Adaptation to Trauma Two sets of cognitive strategies are presumed to facilitate the rebuilding of assumptive worlds: Automatic routines for processing novel information and deliberate efforts to reinterpret the new information in the light of what is already known. The social and interpersonal context of recovery is also hypothesized to influence the reconstruction process. Janoff-Bulman (1992) adopts Horowitz’s (1986a) definition of intrusion and denial as the primary automatic cognitive processing strategies. Intrusions

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“provide a means for rendering closer and closer approximations of the new, threatening data and the old assumptions” (Janoff-Bulman, 1992, p. 106). However, in some cases, “intrusions [that] evoke extreme levels of fear and anxiety . . . may preclude any natural process of habituation” (JanoffBulman, 1992, p. 105). Denial and numbing are regarded as adaptive control processes that enable survivors to pace their recovery” (Janoff-Bulman, 1992, p. 100). In the normal pattern of adaptation to trauma, intrusion and denial subside over time. However, in some cases, excessive intrusion or denial may interfere with social and emotional functioning. Successful recovery is defined as the cessation of intrusive reexperiencing. Instead, “relatively nonthreatening recollections, images, and thoughts should occur naturally, in response to situations that are associated with the event” (Janoff-Bulman, 1992, p. 110). Janoff-Bulman’s (1992) theory focuses “not [on] the appraisals that occur (luring the initial confrontation with the traumatic situation, but rather [on] interpretations and redefinitions of the event that occur over the course of coping and adjustment” (p. 116). These redefinitions are considered to be a natural outcome of the survivor’s reflections upon the trauma, rather than the result of deliberate attempts to restore cognitive control. Three sets of reappraisal strategies are hypothesized: (a) Social comparisons, (b) examining the survivor’s own role in allowing the victimization to happen, and (c) trying to find meaning in the trauma by reevaluating it as imparting benefits or wisdom. Taylor and colleagues (Taylor, 1983; Taylor, Wood, & Lichtman, 1983) have identified a number of social comparison strategies used by patients in coming to terms with a breast cancer diagnosis. These strategies include: “making social comparisons with less fortunate others; . . . selectively focusing on attributes that make one appear advantaged; creating hypothetical, worse worlds; . . . and manufacturing normative standards of adjustment that make one’s own coping appear exceptional” (Taylor et al., 1983, p. 19). These “downward comparisons” (Taylor et al., 1983; Wills, 1981) serve to preserve beliefs in self-worth and a benign world. Examination of the survivor’s own role in facilitating the trauma involves confronting the question “Why did this event happen to me?” (Janoff-Bulman C& Frieze, 1983, p. 6). “

It is the selective incidence of the victimization that appears to warrant explanation . . . Particularly if they regard themselves as decent people who take good care of themselves and are appropriately cautious, [victims] are apt to find themselves at a loss to

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explain why they were victimized. (Janoff-Bulman & Frieze, 1983, p. 6) One possible outcome of such an attributional search is self-blame (JanoffBulman, 1979; Janoff-Bulman & Frieze, 1983). Attributing the trauma to enduring negative personality characteristics (characterological self-blame) is regarded as maladaptive. However, attributing the trauma to controllable aspects of one’s own behavior (behavioral self-blame), is regarded as potentially adaptive because it can restore belief in personal control over outcomes. “Survival guilt” (Grinker & Spiegel, 1945) is conceptualized as a form of self-blame that follows the death of a close other as the survivor seeks to explain; “Why have I lived while others have not?” (Janoff-Bulman, 1992, p. 130), and “How did I . . . fail to do right by the lost one?” (Lindemann, 1977, p. 336). The “process of accepting and ultimately transforming the traumatic experience” (Janoff-Bulman, 1992, p. 133) involves posing the question; “For what end?” (p. 135). To maintain their beliefs in self-worth and a meaningful world, survivors are motivated to view their suffering, although not chosen, as imparting benefits to themselves or others. As one World War I1 combat veteran stated; The deepest fear of my war years, one still with me, is that these happenings had no real purpose” (Gray, 1959, p. 76; as cited in Williams, 1983, p. 10). Janoff-Bulman (1992) describes three types of cognitive construals that impart benefits to traumatic events: lessons about life, lessons about the self, and benefits to others. Learning lessons about life involves perceiving the trauma as containing a spiritual or moral message. For example, a young man who had survived attempted murder stated: After they stabbed me and left me for dead, I suddenly had a very powerful image of my father. I realized I couldn’t die yet because it would cause him too much grief. I had to reconcile my relationship with him . . . I felt that I had been given a second chance at life. (Herman, 1992, p. 60) Learning lessons about the self involves becoming more aware of one’s existing capabilities or developing new positive attributes. Some survivors develop a new appreciation for the courage, dignity, or resilience with which they responded to the trauma. As a sexual abuse survivor, who was interviewed by Silver et al. (1983), remarked, “ I learned over the years that nothing as bad as what I had been through was going to happen again. Now I know there is virtually nothing I cannot overcome” (p. 90).

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Perceiving benefits to others involves interpreting one’s suffering as promoting the welfare of other people or of future generations. For example, Herman (1992) and Sharansky (1988): And just as they [heroes from the past] had influenced the conduct of individuals in many lands and over many centuries, so I, too, with my decisions and choices had the power to inspire or disenchant those who had existed in the past as well as those who would come in the future. (Sharansky, 1988, p. 360; as cited in Herman, 1992, p. 208) The social and interpersonal context is presumed to play an important role in cognitive reconstruction. “Those close to the victim provide the most potent data available about the nature of the world and the worth of the individual victim, at a time when a victim is particularly sensitive to such information” (Janoff-Bulman, 1992, p. 146). In other words, the responsiveness of others can help to restore the survivor’s self-esteem, trust in others, and hope for a better future. On the other hand, interactions with people who are insensitive or indifferent to her suffering can impede the survivor’s attempts at cognitive reconstruction (Masters, Friedman, & Getzel, 1988; Wortman & Dunkel-Schetter, 1979).

Commentary on Janoff-Bulman’s Theory Janoff-Bulman’s (1992) theory extends Horowitz’s (1986a) account of the cognitive integration process by suggesting three specific cognitive schemas that traumatic events can disrupt. This theory can account for variability in trauma response among individuals exposed to the same event. Individuals who are able to reappraise the trauma in ways that preserve self-worth, hope, and a sense of control over future outcomes should adapt more successfully than those who maintain a fixed, negative view of the trauma. Delayed forms of PTSD (McFarlane, 1988) can be explained in terms of survivors’ newly reconstructed world views being assaulted by subsequent stressors (cf. Wortman, 1983). The presence of “negative symptoms” (Keane, 1989), such as anhedonia, depression, and alienation in some trauma survivors, can be explained in terms of the loss of meaning and disillusionment that may result from the rupture of previous world views and the failure to develop a meaningful alternative perspective. This theory does not, however, provide a satisfactory account of the role of arousal in posttraumatic responding or the role of reminiscent stimuli in provoking intrusive reexperiencing. It also does not add much to Horowitz’s

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(1986a) account of intrusion and denial. The theory also raises ethical issues concerning the potential negative effects that may result from restoring illusory assumptions about the self and world (Janoff-Bulman, 1992; Taylor, 1983). Holding comforting but inaccurate assumptions may result in inadequate contemplation of the full range of available coping options (Horowitz, 1988), impaired ability to engage in self-protective maneuvers (McCann & Pearlman, 1990), or increased vulnerability to distress if the trauma recurs (Wortman, 1983). The universal adaptiveness of behavioral self-blame has also been disputed. Miller and Porter (1983) have suggested that the distinction between behavioral and characterological self-blame is blurred in chronic victimization. They state that there would appear to be little difference between blaming an abusive spouse’s acts of violence on one’s recurrent behavior (e.g., I am always critical of him) and blaming them on one’s traits or character (e.g., I am a critical person).” (p. 148) The adaptiveness of survival guilt has also been called into question. Niederland (196 1, 1964) has characterized survival guilt as the single most pathological symptom displayed by Holocaust survivors and as a cause of chronic depression. The focus on how survivors’ perceptions of social norms influence the reappraisal process is a particularly exciting aspect of Janoff-Bulman’s (1992) theory. The process of building new assumptions necessarily involves appraisals of the social milieu and can evoke motives of altruism (perceiving one’s suffering as benefiting others), competition (perceiving oneself as coping better than others), and status (perceiving oneself as more prosperous than others). The idea that other people’s responses to the survivor are powerful data used in the construction of her new assumptive world clarifies an important role played by social supports in the recovery process. (cf. Keane, Scott, Chavoya, Lamparski, & Fairbank, 1985; Wortman & Dunkel-Schetter, 1979). The goal of adaptation to trauma has typically been conceptualized as a return to pretrauma levels of functioning (cf. Horowitz, 1986a). Therefore, Janoff-Bulman’s (1992) broader definition of adaptation as containing the potential for personal growth and transformation is significant. On the other hand, survivors’ optimistic statements may merely reflect their motivation to appear socially appropriate, while hiding the true extent of their distress (cf. Wortman, 1983; Wortman & Dunkel-Schetter, 1979; Coyne, Wortman, & Lehman, 1988). Alternatively, survivors may make optimistic Statements to

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soothe their own distress (McCann & Pearlman, 1990) or to motivate coping efforts, without literally believing in these interpretations. Janoff-Bulman’s (1992) theory integrates concepts from different literatures to provide a comprehensive and well-justified account of the ways in which thinking about past traumas can be adaptive. The strengths of the theory lie in its account of successful adaptation to trauma. It does not fare quite as well in describing the processes that can impede adaptation. Conceptual Issues Raised by the Theoretical Review The discussion of cognitive processing theories raises conceptual issues concerning the link between intrusive cognitions, reappraisals, and psychosocial adaptation to trauma. The theories depict intrusive cognitions as a normal and necessary part of the cognitive integration process and reappraisals as uniformly adaptive. Even prolonged, distressing ruminations are presumed not to result from “some qualitatively different [pattern of] response” (Horowitz & Kaltreider, 1980, p. 165). This adaptive view of intrusions stands in marked contrast to the designation of persistent intrusive reexperiencing as symptomatic of acute stress disorder or PTSD (APA, 1994). This discrepancy highlights the need for clearer definition of the substantive differences between adaptive and maladaptive ways of thinking about past traumas. Early Versus Prolonged Intrusive Ruminations It is often assumed that time-limited, intrusive cognitions are a normal, adaptive response to stress, whereas persistent intrusions are a sign of disrupted cognitive processing (cf. Horowitz, 1986a; Janoff-Bulman, 1992). For examlple, Horowitz and Kaltreider (1980) have suggested that “pathology is . . . the result o f . . . responses that do not progress towards adaptive completion over im extended time” (p. 165). Similarly, Janoff-Bulman (1992) has suggested that “ . . . intrusions [which] evoke extreme levels of fear and anxiety . . . may ]preclude any natural process of habituation” (p. 105). Although these assumptions are widely held, some evidence suggests that ithey may not be universally applicable. Wortman and Silver (1987, 1989) have summarized a body of research as suggesting that contrary to popular belief, :some survivors do not report any distress following irrevocable loss, and persistent distress and cognitive preoccupation with a traumatic loss are more common than is typically assumed. In the light of these findings, the assumptions that early intrusions are normative and adaptive, and prolonged intrusions are signs of incomplete cognitive processing deserve further empirical

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examination. Of particular interest is the issue of whether prolonged intrusions result from survivors’ “getting stuck” at a particular stage of cognitive processing, or whether they are the products of a qualitatively different process than early intrusions.

Control and Organization of Intrusive Memories What characteristics of intrusive ruminations can facilitate or accelerate cognitive processing efforts? Horowitz (1986a) has proposed that the amount of control exerted over the onset, duration, content, and affective tone of intrusions is predictive of the outcome of processing efforts. Can the survivor dose herself with tolerable amounts of distress or does he experience intrusions in an all-or-none manner? Can she shut out irrelevant information about the trauma in order to focus on the most important details, or does she experience a rapid, uncontrolled stream of thoughts and images? Can she put aside thoughts about the trauma to focus on current adaptational demands or is her preoccupation with the trauma immobilizing? Another characteristic of intrusive ruminations that could influence psychosocial adjustment is the degree to which the survivor can organize information about the trauma into a meaningful framework that provides explanations, ties together seemingly unrelated ideas, and guides what actions will be taken under particular circumstances (cf. Casella & Motta, 1990; Janoff-Bulman, 1992). Is the survivor able to understand the reasons for her reactions during the trauma or does she repeatedly ruminate about why she responded that way? Are her thoughts about the trauma logically or sequentially organized, or do they consist of fragmentary images that are difficult to decipher? Does the survivor have a way of thinking about what life will be like, given that the trauma has happened, or does she focus exclusively on past roles and competencies?

Cognitive Reappraisal as a Dynamic Process Another unresolved issue concerns the unfolding of the cognitive reappraisal process over time. Cognitive reappraisal is presumed to occur gradually, via a series of comparisons between the trauma and existing schemata (Horowitz, 1986a), or as a consequence of repeated reflections concerning the meaning of the trauma (Janoff-Bulman, 1992). However, the validity of these widely held assumptions has not been established. It is possible that the process of cognitive reappraisal does not occur through extended reflection; it may be the product of a sudden flash of insight or a deliberate act of will. Furthermore, our understanding of the factors that can impede cognitive processing efforts is

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incomplete. Finally, it is unclear what structural or dynamic aspects of intrusive reexperiencing phenomena can facilitate the cognitive integration of traumatic memories. In summary, the review of cognitive processing theories raises the following questions: (1) Are early intrusive thoughts a normative response to severe stress? (2) Do prolonged intrusive thoughts signify incomplete cognitive processing? (3) Does the ability to structure and control intrusive thoughts facilitate adjustment? (4) How does the process of cognitive reappraisal unfold over time?

In the next section, empirical data are presented that address these questions. Empirical Findings Are Early Intrusive Thoughts a Normative Stress Response? Several research studies have examined the incidence of early intrusive symptoms. Shalev, Schreiber, and Galai (1993) found that all 16 injured survivors of a terrorist act reported intrusive recollections during the first 2 post-trauma weeks. In a study of reactions to burn injury (Patterson, Carrigan, Robinson, & Questad, 1990), 63% of consecutively admitted burn patients reported intrusive recollections of the burn incident during their hospital stay. A Dutch study (Brom, Kleber, & Hofman, 1993) found that 50% of a sample of traffic accident victims reported moderate to high levels of intrusion at l-month post-trauma. In a study of 95 rape survivors, who were interviewed within 30 days of the incident, (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992), 94% of the sample reported persistent reexperiencing symptoms. Harber and Pennebaker (1 992) assessed frequency of thinking about a recent trauma in two samples: (a) San Francisco residents who were exposed to the 1989 Loma Prieta earthquake, and (b) Dallas residents who were exposed to media cover(ageof the 1991 Persian Gulf War. Results indicated that, on average, subjects )thought about the stressor multiple times each day for the first 2 weeks following its onset, and at lower rates thereafter. These findings suppport Horowitz’s (1986a) assumption that early intrusive symptoms are a normative response to stress.

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Longitudinal studies of the relationship between early intrusion and psychosocial outcomes are relatively rare. The few methodologically sophisticated studies for which data are available have generally not found a significant association between early intrusive symptoms and subsequent psychosocial adjustment. In a study of adjustment among 14 injured survivors of a terrorist attack (Shalev, 1992), intrusion, assessed within the first week following the trauma, was unrelated to psychological distress or PTSD diagnosis at 10-month assessment. In Patterson et al.’s (1990) study of burn victims, although the bulk of participants reported early intrusive recollections, none met criteria for PTSD at hospital discharge, indicating that the initial intrusions were transient. McIntosh, Silver, and Wortman (1993) interviewed 124 parents of infants who had died of sudden infant death syndrome (SIDS) concerning their adjustment to the trauma, within 30 days post-loss and 18 months later. Cognitive processing of the trauma was assessed by a measure that indexed voluntary thoughts and conversations with others, as well as intrusive thoughts and images. More cognitive involvement with the loss at initial assessment was associated with greater concurrent distress, but it predicted enhanced well-being 18 months later. These findings suggest that early cognitive processing efforts may enhance positive affect without necessarily alleviating distress. This finding highlights the need for a systematic theoretical account of the role of positive affect in post-traumatic adjustment (cf. Litz, 1992; Lyons, 1991). Because McIntosh et al.’s (1993) cognitive processing measure was quite general, it is unclear what aspects of cognitive involvement with the trauma were responsible for the effects on well-being. However, Pennebaker (1989) has suggested that inhibiting emotional reactions associated with a past trauma tends to be associated with a more general constriction of emotional responding. Thus, cognitive confrontation with past traumas could exert a paradoxical effect, increasing the accessibility of positive affect. In contrast to the previously discussed findings, Rothbaum et al. (1992) found that a significantly greater proportion of rape survivors, who subsequently developed PTSD, were rated as “reliving the trauma” on interview within 30 days post-rape, compared with victims who did not develop PTSD (90?4 vs. 56%). The reason for the discrepancy between this study and previous findings is not clear. Perhaps Rothbaum et al’s criterion of “reliving the trauma” identified survivors who were experiencing particularly intense and absorbing types of reexperiencing, or those who were least able to modulate or endure their affective reactions to the trauma. The capacity to tolerate intense negative affect has been hypothesized to be as important as symptom intensity in predicting psychological recovery from trauma (McCann & Pearlman, 1990).

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In summary, early intrusion appears to be a normal response to stress, rather than a portent of psychopathology. In addition, thinking and talking about the loss soon after it occurs may result in a greater enjoyment of life later on, perhaps because it “permits the survivor to experience” a greater breadth of affective responding (Horowitz, 1986a; Janoff-Bulman, 1992).

Do Prolonged Intrusive Thoughts Signifv Incomplete Cognitive Processing? Both Horowitz (1986a) and Janoff-Bulman (1992) have proposed that, although intrusion is inherently adaptive, prolonged intrusion is indicative of a disruption in cognitive processing. Unfortunately, these authors do not suggest quantitative or qualitative criteria for distinguishing normal from prolonged intrusion. Baum and his colleagues (e.g., Baum, 1990; Baum, Cohen, & Hall, 1993; Davidson & Baum, 1986, 1993) have presented evidence suggesting that prolonged intrusive ruminations are associated with both physical and psychological impairment. Cross-sectional studies of technological disaster survivors and Vietnam combat veterans without PTSD have demonstrated a positive association between prolonged intrusive cognitions and chronic stress (Baum 1990; Baum et al., 1993; Davidson & Baum 1986, 1993). Furthermore, higher levels of intrusive ruminations assessed 5 years after a technological disaster predicted elevated stress responding on biological, behavioral, and psychological measures 18 months later (Baum, 1990; Baum et al., 1993). These findings suggest that prolonged intrusive ruminations may act as a chronic stressor for certain individuals. In other words, intrusive ruminations, rather than merely signaling incomplete cognitive processing, may cause additional impairment in physical and mental health. Replications of the longitudinal finding would increase confidence in this interpretation. The mediational role of intrusive symptoms in the process of psychological adjustment to trauma has been examined in two prospective, multivariate studies (Creamer, Burgess, & Pattison, 1992; McFarlane, 1992). In Creamer et al.’s (1992) study, office workers who were present in the building when a mass shooting occurred, were surveyed 4, 8, and 14 months post-trauma. In McFarlane’s (1992) study, subgroups of firefighters who had been exposed to a bushfire disaster, and who were either at risk for having developed a psychiatric disorder or asymptomatic at 4 months post-trauma, participated in a diagnostic interview conducted at 42 months post-trauma. Both studies found that, consistent with theoretical predictions (Horowitz, 1986a; Janoff-Bulman, 1992), intrusive recollections mediated between trauma characteristics and longer-term psychological adjustment. The relationship

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between intrusion and subsequent psychological distress was not, however, consistent across the two studies. In Creamer et al’s (1992) study, higher levels of intrusion at 4 and 8 months post-trauma predicted decreased psychological distress at 8 and 14 months post-trauma, respectively. In direct contrast to these findings, McFarlane (1992) reported that intrusion at 4 months post-trauma predicted psychiatric disorder at the 42-month follow-up. These discrepant findings may have been due to sampling differences. McFarlane (1992) selected those individuals who were at the extremes on psychological adjustment, whereas Creamer et al. (1992) utilized unselected subjects. Furthermore, the proportion of the original sample completing all assessments was 60% and 20% for McFarlane and Creamer et al., respectively. If we assume that participants with poorer psychological status were more likely to drop out, these methodological differences suggest that McFarlane sampled a higher proportion of poorly adjusted individuals, relative to Creamer et al. Taken together, these findings indicate that “the process of intrusion . . . appears to be [an] essential element of both the normal and pathological response to traumatic stress” (McFarlane, 1992, p. 443). The finding that intense intrusive thoughts can foster both successful adaptation (Creamer et al., 1992) and psychiatric disorder (McFarlane, 1992) contradicts Horowitz and Kaltreider’s (1980) contention that “pathology is not usually the result of some qualitatively different response” (p. 165). Furthermore, in McFarlane’s study, a bidirectional relationship was found in which both intrusion and psychological distress prospectively predicted each other. These findings were interpreted as indicating that, once psychiatric disorder has set in, “. . . the cognitive preoccupation is as much a measure of the person’s disturbed arousal and affect as it is an indication o f . . . incomplete cognitive processing” (McFarlane, 1992, p. 444). McFarlane’s (1992) findings are consistent with findings from laboratory and field investigations of the effects of ruminating about depressed moods (Nolen-Hoeksema, 1991, for a description of this research). Nolen-Hoeksema and colleagues (Nolen-Hoeksema, 1991; Nolen-Hoeksoma & Morrow, 1993) have repeatedly demonstrated that ruminating while in a depressed mood can intensify depressive affect and interfere with problem-solving efforts. Thus, intrusive ruminations that are triggered by dysphoric moods may be especially difficult to dispel and may provoke dysfunctional coping responses or exacerbate psychological distress. Does The Ability to Structure and Control Intrusive Thoughts Facilitate Adjustment?

Two properties of intrusive ruminations which could determine their effects

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on psychosocial adjustment are control and structure. Horowitz (1 986a) has proposed three types of adaptive control over intrusive cognitions: (a) control over when, where, in what manner, and for how long the trauma is contemplated; (b) control over the self-concepts and world views that guide the review; and (c) control over what information about the trauma is considered and what is disregarded. Janoff-Bulman (1992) has claimed that the ability to structure and organize information about the trauma within a coherent conceptual framework is essential to successful adaptation. Empirical research has supported the adaptive value of perceiving control over memories of past traumas. In one study, repatriated prisoners of war (RPWs) without PTSD rated their war memories as more controllable, relative to RPWs with PTSD (Fairbank, Hansen, & Fitterling, 1991). The PTSD respondents’ perceptions of low control may have reflected low actual control. RPWs with PTSD rarely used active cognitive restructuring and distancing strategies to cope with their war memories. However, they were more likely than RPW’s without PTSD to use the passive coping strategies of self-isolation and wishful thinking. Another aspect of control concerns the extent to which survivors can dispel intrusive memories and engage in current life tasks (cf. Silver et al., 1983; Tait & Silver, 1989). Deliberate suppression of unwanted thoughts and feelings about the trauma and engagement in active, goal-directed activities to suppress dysphoric ruminations were the most frequent responses reported by parents of children with cancer (Chodoff, Friedman, & Hamburg, 1964) and health care personnel exposed to an emergency situation involving dead children (Dyregrov & Mitchell, 1992). Green, Lindy, and Grace (1988) found that, relative to those with PTSD, well-adjusted Vietnam veterans were more outerdirected, able to focus on current living, and able to sublimate distressing reactions to the trauma. A study of rape survivors (Burgess & Holmstrom, 1979) found that the ability to deliberately suppress intrusive thoughts was associated with faster, self-assessed recovery. On the other hand, an inability to dispel ruminations about past traumas, or to engage in other activities when ruminations occur, has been associated with lower concurrent life satisfaction (Tait & Silver, 1989). The ability to impose structure and organization on traumatic memories has been associated with successful adjustment in Vietnam combat veterans (Casella & Motta, 1990; Hendin & Haas, 1984). Relative to veterans with PTSD, well-adjusted veterans were more likely to have developed coherent ways of sequencing, organizing, and understanding their war experiences. They also reported less confusion and disintegration of self- and world-views, relative to veterans with PTSD (Casella & Motta, 1990). Cognitive structuring strategies included remaining focused on specific, manageable objectives,

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gaining an understanding of the purpose of their mission, using religious beliefs to structure perceptions of the war, remaining calm and organized under pressure, and trusting one’s own judgment in making decisions about survival. Possession of a superordinate schema that already includes ways of thinking about the trauma may accelerate cognitive assimilation (McIntosh, 1993; McIntosh et al., 1993). In an 18-month, longitudinal study of adaptation to the death of an infant from SIDS (McIntosh et al., 1993), strong religious beliefs prospectively predicted greater cognitive processing activity and enhanced well-being. The authors suggested that religious beliefs may constitute an organized schema that already incorporates ways of thinking about death and suffering. In summary, the available evidence suggests that survivors who are able to exert cognitive control over and impose structure upon their traumatic memories should adapt more successfully to traumas, compared with those who are less successful at organizing their perceptions of the trauma.

How Does the Process of Cognitive Reappraisal Unfold Over Time? Cognitive processing theories (Horowitz, 1986a; Janoff-Bulman, 1992) suggest that reappraisal occurs through repeated ruminative comparisons of the trauma with existing schemas, which produce gradual shifts in perspective. Either the trauma is reinterpreted as consistent with existing world views, or inner models are gradually revised to accomodate the trauma. These assumptions have not been empirically verified. Finkel and colleagues (Finkel, 1974,1975; Finkel & Jacobsen, 1977) sought to determine “whether there are certain experiences that strengthen the personality and contribute to the psychological growth of the individual” (Finkel, 1974, p. 265). They adopted the term “strens” (Hollister, 1967) to describe these events. In the course of these investigations, another category of event was discovered-a trauma that was subsequently converted by the survivor into a growth-producing stren. Across both college student and adult samples, approximately two-thirds of respondents reported having previously experienced a trauma-stren conversion. An example of such a conversion is the following: One subject was severely criticized by her friends and accused of needing psychiatric help. Her first reaction was “Maybe I am crazy and need help,” but . . . this interpretation was soon replaced by a second: “I’m not the sick one; it is they who are hostile and belittling.” A reexamination of her “friends” and friendship patterns followed. (Finkel, 1974, p. 269)

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The findings of (Finkel, 1974, 1975; Finkel & Jacobsen, 1977) suggest that the process of “converting” traumas into growth experiences has the following characteristics: (a) Conversion is a cognitive process; (b) it is usually done by the individual alone, but confidants can also suggest new interpretations; (c) conversion usually occurs between 2 weeks and 4 months following the stressor; (d) successful conversions can enhance coping with subsequent stressors; (e) the ability to succeed at conversion depends more on the individual’s psychological resources than on event characteristics; and ( f ) the conversion process is intuitive, rapid, and sudden, rather than the outcome of an extended logical reasoning process. Conversion experiences have been described as occurring in the form of “ a sudden insight,” flash,” or “revelation” (Finkel & Jacobsen, 1977, p. 172). These conclusions should, however, be regarded as tentative, because they were based on retrospective self-reports of unknown reliability. Furthermore, it is unclear whether findings from unselected community samples are generalizable to individuals who have experienced more severe or unusual events. The studies of (Finkel, 1974, 1975; Finkel & Jacobsen, 1977) raise some important issues concerning the nature of the cognitive reappraisal process. First, the suggestion that new meanings may be discovered in discrete leaps, rather than gradual increments, appears to contradict current theoretical positions and suggests the need for continued empirical examination of this issue. Second, the fact that conversion can occur as early as 2 weeks or as late as 4 months following the trauma raises the possibility that early and later conversions may be qualitatively different processes. Perhaps early conversions are the result of reinterpretation of the trauma to facilitate its assimilation into extant meaning structures, whereas later conversions involve the more prolonged process of schematic revision or accommodation (cf. Piaget, 1952). Finally, the concept of capacity for conversion or reappraisal as a personality characteristic deserves further attention. McCann and Pearlman (1990) have also proposed that the ability to view oneself and others from more than one perspective can facilitate adaptation to trauma. “Working through” the traumatic memory by repeatedly confronting its meaning has been proposed as the primary agent of adaptive reappraisal (Horowitz, 1986a). However, some authors (e.g., Wortman & Silver, 1987, 1989) have suggested that an extended search for meaning can exacerbate, rather than diminish, post-traumatic distress. Research indicates that a search which actually produces a meaningful way of viewing the trauma is adaptive. In Silver et al.’s (1983) study of incest survivors, respondents who were able to find some meaning in their incest reported less psychological distress, better social adjustment, higher self-esteem, and greater resolution of the experience, relative to survivors who were unable to make any sense of ‘I

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their experiences. In McIntosh et al.’s (1993) study of bereaved parents, finding meaning in the child’s death was concurrently associated with greater well-being and less distress, and indirectly related to better adjustment at 18 months post-loss, through its relationship with immediate adjustment. We can speculate that finding meaning may make salient a plausible, but relatively benign, explanation for the trauma, thereby strengthening the survivor’s resources to combat depressogenic or catastrophic thought patterns. Investigations of “ account-making,’’ defined as “people’s story-like constructions of events that include explanations, descriptions, information about relevant future events, and affective reaction” (Harvey, Orbuch, Chwalisz, & Ganvood, 1991, p. 5 16), provide further evidence supporting the beneficial effects of making sense out of past traumas. Studies of separated spouses (Weiss, 1975), Vietnam veterans (Harvey, Agostinelli, & Weber, 1989), and elderly individuals who had lost a loved one (Weber, Harvey, & Stanley, 1987), suggest that “well-developed accounts play a salutary role in providing perspective, the will to carry on, hope about the future, and closure regarding . . . stressors” (Harvey et al., 1991, p. 517). Empirical evidence suggests that ongoing searches for meaning occurring many years after the trauma are indicative of poor psychosocial adjustment (Silver et al., 1983; Tait & Silver, 1989). In Tait and Silver’s (1989) study of older adults’ reactions to their most negative events, ongoing cognitive preoccupation with past traumas was associated with more frequent, intense, intrusive, and distressing, involuntary event-related ruminations and lower self-assessed life satisfaction and recovery. A similar finding was reported in a study of 77 adult women who had experienced incest an average of 20 years earlier (Silver et al., 1983). An ongoing search for meaning was associated with greater recurrent, intrusive, and disruptive ruminations about the event; greater impairment in social functioning; lower self-esteem; and less self-assessed resolution of the event. These findings suggest that prolonged rumination is symptomatic of psychosocial distress. In apparent contrast to findings by (Silver et al., 1983; Tait & Silver, 1989), a study of 25 sexual assault victims, who had been assaulted a mean of 18.5 years ago (Harvey et al., 1991), found that retrospectively reported attempts to develop a coherent account of the assault were concurrently associated with greater perceived coping success and less negative affect. Harvey et al.’s measure included all account-making activities that were reported since the time of the assault; therefore, these findings may have reflected early, rather than prolonged, ruminations. Furthermore, these data are difficult to interpret without knowledge of the degree to which these attempts actually resulted in satisfactory accounts of the assault.

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In summary, research suggests that the majority of healthy individuals are able to engage in the process of altering the negative meaning of a stressor into a more positive interpretation (Finkel, 1974, 1975; Finkel & Jacobsen, 1977). Contrary to theoretical accounts, subjective descriptions of the conversion process depict a sudden transformation, rather than the outcome of repeated examinations. In fact, prolonged, ruminative searches for meaning in past traumas has been associated with poor psychosocial adjustment (Silver et al., 1983; Tait & Silver, 1989). Conclusions This paper examined two established cognitive processing theories of post-traumatic adjustment in the light of empirical research. The available evidence generally supported the patterns of adaptation to stressful events defined by Horowitz (1986a) and Janoff-Bulman (1992), but it also highlighted some gaps in our knowledge about the ways in which cognitive processing unfolds over time. There were a few discrepant findings concerning the definition of pathological patterns of cognitive processing. Our knowledge about the dynamics of the cognitive integration process is incomplete. The pattern of slow, progressive, step-by-step changes in conceptualization proposed by Horowitz (1986a) and Janoff-Bulman (1992) has not been empirically verified and anecdotal data suggests that conceptual change may actually occur in the form of a sudden dramatic realization (cf. Finkel & Jacobsen, 1977). Furthermore, it is unclear whether cognitive reappraisal can be willfully invoked or whether it is a fully automatic process. Are there deliberate coping strategies that survivors can use to facilitate or accelerate cognitive reappraisal? Another unresolved issue concerns the relationship between cognitive assimilation and accommodation (cf. Piaget, 1952). Horowitz (1986a) and Janoff-Bulman (1 992) depict these processes as mutually exclusive. They suggest that schematic processing is inherently conservative. In other words, if the trauma can be meaningfully reframed, more comprehensive schematic change will not occur. However, anecdotal evidence suggests that specific cognitive reappraisals can sometimes promote a more widespread change in outlook and values (Finkel & Jacobsen, 1977). For example, if an abused spouse stops blaming herself for her beatings and starts blaming her husband, this might prompt more extensive alterations in her view of the marriage and her definition of her spousal role. A further conceptual dilemma concerns the differences between intrusive thoughts and cognitive reappraisal. Janoff-Bulman (1992) defines two distinct types of cognitive processes: automatic processing routines and efforts to

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reinterpret the trauma. However, the separation of these two types of processes has not been established empirically. Perhaps intrusive thoughts contain the raw data to be used in cognitive reappraisal. Alternatively, certain types of cognitions, for example, those that contain some positive affective content (cf. Tait & Silver, 1989), may form the building blocks of healthier cognitive organizations. On the other hand, early cognitive reappraisal could protect the survivor from exposure to disquieting or guilt-ridden ruminations. For example, attributing a victimizing event to the will of God should diminish guilt and shame about not acting to prevent the tragedy. Another conceptual issue raised by this review is whether prolonged distressing intrusions are simply a more prolonged form of normal cognitive processing (Horowitz & Kaltreider, 1980), or indicative of a qualitatively different, pathological processing pattern (McFarlane, 1992). Certain characteristics of traumas, such as witnessing death and dismemberment, torture, or other gruesome scenes, appear to generate affect-laden, intrusive images whose disturbing content is quite resistant to modification and cognitive organization (cf. Rosenheck, 1985). Intrusive cognitions that are perceived as unpredictable and uncontrollable may also generate secondary pathological responses, such as hypervigilance or anticipatory anxiety, that exacerbate distress and maladjustment (cf. Jones & Barlow, 1990). Ursano, Kao, and Fullerton ( 1 992) have suggested another fundamental difference between early and later attempts to find meaning in past traumas. They argue that, relative to early intrusive cognitions, cognitive representations which are reported many years after the trauma, are more likely to reflect the individual’s recent history of adjustment and “their present view of themselves as victim or agent, alone or a member of a group, with a successful life or a life filled with personal disappointments” (p. 757). People who are able to reconstruct aspects of their lives that were damaged by a trauma may be less concerned with an ongoing search for meaning than those who have not been able to recover lost resources. Intrusive reminders that are accompanied by pervasive depressed affect could promote a narrowing of cognitive focus onto aspects of the trauma over which little control is possible. Examples of such unproductive ruminations include the following: Thinking about how the trauma could have been avoided ([JanoffJ-Bulman & Wortman, 1977), contemplating how life could have been better had the trauma not occurred (Tait & Silver, 1989), regretting past decisions that turned out to have unforeseen, painful consequences (Collins & Clark, 1989), negatively evaluating what actions one took or failed to take during the trauma (Burgess & Holmstrom, 1979), thinking about how depressed one feels because of the trauma (cf. Nolen-Hoeksema, 1991), and wishing that one could feel differently about the trauma (Fairbank et al., 1991).

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These types of cognitions may have very different effects on mental and physical health than thinking about more redeeming or controllable aspects of the trauma, including what personal and social resources have not been lost, what makes life meaningful despite the occurrence of the trauma, what can be done to rebuild lost resources, and what personal and collective goals are still achievable. Existing models of cognitive adaptation have contributed much to our understanding of longer-term adjustment to trauma. However, several conceptual questions remain to be answered. What characteristics of ruminations about a trauma and their progression over time can facilitate a more hopeful reappraisal of a trauma and its ongoing implications? What types of psychological processes and environmental influences can hinder cognitive adaptation efforts? Increased attention to these issues could enhance the explanatory power of our theories and foster the development of new methodologies for intensive, process-oriented assessment of cognitive adaptation to trauma. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Antonovsky, A. (1979). Health, stress, and coping. San Francisco, CA: Jossey-Bass. Baum, A. (1987). Toxins, technology, and natural disasters. In G . R. Vandenbos, & B. K. Bryant (Eds.), Cataclysms, crises, and catastrophes: Psychology in action (pp. 7-53). Washington, DC: American Psychological Association. Baum, A. (1990). Stress, intrusive imagery, and chronic distress. Health Psychology, 9,653-675. Baum, A., Cohen, L., & Hall, M. (1993). Control and intrusive memories as possible determinants of chronic stress. Psychosomatic Medicine, 55, 274-286. Brom, D., Kleber, R. J., & Hofman, M. C. (1993). Victims of traffic accidents: Incidence and prevention of post-traumatic stress disorder. Journal of Clinical Psychology, 49, 131-139. Burgess, A. W., & Holmstrom, L. L. (1979). Adaptive strategies and recovery from rape. American Journal of Psychiatry, 136, 1278-1282. Carmil, D., & Breznitz, S. (1991). Personal trauma and world view-are extremely stressful experiences related to political attitudes, religious beliefs, and future orientation? Journal of Traumatic Stress, 4,393-405. Casella, L., & Motta, R. W. (1990). Comparisons of characteristics of Vietnam

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