Journal of Faumaric Stress, Vol. 11, No. 4, 1998

Cognitive Coping: The Psychological Significance of Knowing What Happened in the Tkaumatic Event

Dagfinn Winje'

The longitudinal relationships between aspects of cognitive coping and pvchological symptoms in a group of 36 adults were eramined I , 3, and 5 years after a fatal school bus accident in Nonvay in 1988. The need for information about what happened in the accident was unrelated to symptoms during the period when the parents' search for facts was dominant, indicating that this is part of a normal adjustment process. However; persistent need for information afier factual information had been provided was associated with poorer adjustment. People who felt they were adequately informed and who viewed the accident as a random incident showed better psychological adjustment. KEY WORDS: cognitive coping; accident; posttraumatic reactions.

Clinical experiences indicate that traumatized people are characterized by a search for information about the possible causes of the traumatic event, what happened, and what could have been done to prevent it. The process of working through such information is assumed to be an important factor in adjusting to trauma (Everstine & Everstine, 1993; Figley, 1985; Hodgkinson & Stewart, 1991). Lack of event-related information may leave victims and families in years of rumination and fantasy about the actual events (Bugen, 1977; Lehman, Wortman, & Williams, 1987; Lifton, 1983; Parkes & Weiss, 1985; Stroebe, Hansson, & Strctebe, 1993; Worden, 1992). To the author's knowledge, there are no prospective studies examining what traumatized people want to know about the traumatic event, which infor-

'Department of Clinical Psychology, University of Bergen, Christies gt. 12, N-5015 Bergen, Nonvay.

627

0894-9867/98/1Mx)-oh27115.00/1 8 1998 International Society for Traumaric Stress Studies

628 Winje

mation sources are available, and the possible causal relationships between information seeking and posttrauma adjustment.

After a fatal bus accident in Norway in 1988 involving 23 Swedish school children and 11 adults, a research project was initiated to investigate the long-term effects of trauma in the survivors and the passengers’ fami- lies. A crisis-intervention program for these families was held at a hospital in Norway the first nine days after the accident. Based on the clinical ob- servations of the family members during this period, a model of coping processes was developed for understanding factors that might aid or impede the short- and long-term recovery after the accident (Winje & Ulvik, 1995). The model, named “CESBE,” from the first letter of the themes, comprises five themes representing different, but possibly related, aspects of coping with trauma: The individual’s need to know what happened (“cognitive cop- ing”), the need to express emotions (“emotional coping”), the need to share thoughts and feelings with others (“social coping”), the need to respond according to the new situation (“behavioral coping”), and to reestablish a sense of meaning with life and death (“existential coping”). It was assumed that favorable coping, aimed at assimilation and accommodation of the new life situation, would be easier when traumatized people focused upon these themes over time.

The present study focused on the adult family members and was lim- ited to the exploration of the first theme of the CESBE-model: cognitive coping related to information about what happened in the accident. The aim of the study was twofold: (1) to show that information-seeking was an essential part of traumatized adults’ long-term coping efforts; and (2) to investigate how aspects of this cognitive coping were related to con- current and subsequent psychological symptoms posttrauma. It was as- sumed that motivation to obtain information about the traumatic event represented a wish to confront reality and therefore should be regarded as an effort to adjust to the new life situation caused by the traumatic event. Consequently, factors contributing to the traumatized person’s knowledge of what happened should foster long-term psychological ad- justment. The individual’s view concerning the preventability of the event is also central to hidher search for information. Also, it was assumed that viewing the event as random was related to better posttrauma adjustment (Bugen, 1977; Eranen & Liebkind, 1993; Janoff-Bulman, 1992; Kirschling, 1989).

The specific hypotheses of the study were: (1) people who wanted a lot of information about the traumatic event would show better psycho- logical adjustment than those who wanted little or no information; (2) peo- ple who felt that they had been adequately informed about the accident would show better psychological adjustment than those who felt they had

Cognitive Coping 629

not received sufficient information; and (3) people who viewed the accident as random would show better psychological adjustment than those who be- lieved that the accident was preventable.

Method

The research project, the families’ pretraunia situation, and the parents’ posttrauma reactions have been described elsewhere. Only details relevant to this study are presented here (Winje, 1996; Wnje & Ulvik, 1995).

The Accident

On August 15, 1988, a tour bus traveling from Sweden to the Shet- land Islands on a school outing crashed into a tunnel wall in a canyon in western Norway. The passengers were 23 sixth-grade pupils, 9 parents, a teacher and her husband. The primary cause of the incident was brake failure. Twelve children and 3 parents died in the accident, and 1 parent, the driver, died 12 days later. Eleven children and 7 adults survived, the majority with multiple injuries affecting the head, chest, abdomen, and limbs. No permanent neurological damage was reported.

All of the injured people regained physical mobility within months. The injured children resumed regular school attendance from one week to four months after the accident. Five of the injured adults were under medi- cal rehabilitation between 180 and 365 days after the accident, and 2 adults received disability pensions due to their injuries.

The major traumatic factors affecting the families were the sudden death of a child, a spouse or both, or life-threatening injuries to a child, a spouse or both. Additional trauma stemmed from the death or injury of their childrens’ school friends, neighbors or acquain- tances.

Information Seeking and Use of Official Reports

A short description of the author’s observations of the families’ search for information is given to provide a context for the study. A strong desire for information was predominant among victims and their families during the stay at the hospital in Norway. The initial tension was markedly reduced when reliable information was provided through the crisis intervention pro- gram about when, how and where the accident had occurred, the modes

630 WiNe

of death of the deceased, and the medical condition of the survivors (Winje & Ulvik, 1995).

One year after the accident, most of the families participated in a jour- ney from Sweden to the accident site in Norway to attend a commemorative ceremony. At this occasion, the hospital arranged an informal meeting be- tween parents and some rescue and medical personnel so the parents could ask for further details about the rescue operations and medical care of the passengers (Winje & Ulvik, 1995).

The police concluded that the cause of the accident was brake failure and that there had been no violation of the law by the bus company, the bus repair shop, or by the authorities who had licensed the bus. However, the passengers’ families did not accept these conclusions and engaged a lawyer to assist in their search for more information about possible causes of the accident. The motives for this action were diverse: All of the parents wanted the causes of the accident to be revealed, in hopes of reducing the risk of similar accidents; some wanted to find the responsible person(s) or authorities, while others focused on insufficient legislation and rules for licensing tour buses. The parents also considered seeking economic compensation from people or agencies they believed may have been re- sponsible for the accident. Two years after the accident (1990), all of the families signed a petition to the Prime Minister of Sweden requesting an independent investigation to be conducted by a neutral party. One year later (1991), the Swedish government ordered the Swedish Board of Ac- cident Investigation to conduct an independent investigation of the acci- dent. This report, completed four years after the accident (1992), concluded that brake failure was the main cause of the accident (Swedish Board of Accident Investigation, 1992). No person, firm or authority was found responsible for the accident, and only standard amounts of insur- ance were disbursed. The investigation resulted in a change of legislation concerning inspection of tour buses.

The bus accident was the first major incident in many years involving Swedish victims. Mass media submitted detailed reports, a documentary film and book were published, and the incident resulted in a report from the Swedish Board of Accident Investigation. Thus, the families were pro- vided with an amount of information that is quite uncommon after traffic accidents in Scandinavia.

Research Participants and Recruitment Procedures

Initial contact with the families was established through the crisis in- tervention program during the nine day stay at the hospital in Norway. At

Cognitive Coping 63 1

that time, systematic assessments of trauma reactions were considered det- rimental to the families’ adjustment process. Seven months after the acci- dent, a letter was sent to all of the families asking if they would participate in a research project on the childrens’ and the parents’ posttrauma reac- tions and coping processes.

All adults who had a family member (child or spouse or both) among the bus passengers were asked to participate in the study ( N = 44). All were living in Stockholm. Three (7%) refused to participate, and five (11%) participated in only one or two of the follow-ups. The sample for this study consisted of the 36 people (18 men, 18 women) who partici- pated at all three follow-ups. The participation rate was 82%. There were no significant differences between participants and nonparticipants with respect to types of trauma, age or gender. Thirty-two participants were biological parents, and two were step-parents of the child passengers. The teacher and her husband, both attending the journey, had no child among the passengers. For ease of presentation, the term “parents” is used in the present study because 34 of the 36 participants were parents of the child passengers.

In 1989, the mean age of the sample was 41.0 years (SD = 5.2, range: 32-53 years). Mean number of children in the families (the 12 deceased children included) was 2.4 (SD = .96). Twenty-seven of the participants (75%) were married; five (14%) were divorced, and four (1 1%) were widowed. Thirty two of the participants (89%) were perma- nently employed. In 1990, their mean household income was $36,345 US (SD = $16,253).

To examine the possible effects of loss trauma, the sample was di- vided into two groups: The loss group (n =: 20; 10 men, 10 women) comprised of those who had experienced the death of a child or spouse or both in the accident, and the no-loss group (n = 16; 8 men, 8 women), none of whom had experienced the death of a relative in the accident. To examine the possible effects of passenger trauma, the sample was divided into two groups: The passenger group (n = 7; 3 m e n , 4 women), who had experienced the accident as passengers, and the nonpassenger group (n = 29; 15 men, 14 women), who were not in the accident.

There was a significant association between loss trauma and passenger trauma. Only 1 of the 7 passengers (14%) experienced loss in the accident, whereas 19 of the 29 nonpassengers (66%) experienced loss in the accident, ~ ’ ( 1 , N = 36) = 4.00, p = .04. No significant differences were observed in gender age and income between the loss and the no-loss groups, or be- tween the passenger and the nonpassenger groups.

632 Winje

Instruments

The CESBE-questionnaire was developed for the assessment of the parents’ long-term coping with the effects of the accident and focuses on aspects of cognitive, emotional, social, behavioral and existential cop- ing (Winje & Ulvik, 1995). Similar scoring procedures were used across the five themes, and all items were assessed using a 4-point scale: 0 = Not at all, 1 = Small degree, 2 = Some degree, and 3 = High degree ( a complete version of the questionnaire is available from the author).

In the present study, only aspects related to cognitive coping are pre- sented. The following questions were used at all three follow-ups to assess the individuals’ views regarding information pertaining to the traumatic event.

Need for information (NEED): “How important is it for you to know (in detail) what happened to your loved one in the accident?” If the person was a passenger (accompanying parenthpouse), the term “your loved one and yourself” was used.

Kjrowing what had happened (INFO): “To which degree do you feel that you know what happened to your loved one?” (or “your loved one and yourself”).

Randomness of the accident (RAND): “To which degree do you think that this accident depended on accidental circumstances that are impossible to safeguard against?”

At the second and the third follow-up (1991 and 1993), the following questions concerning the parents’ use of information sources were added and assessed using the same 4-point scale as the other items:

“To which extent have you read: the newspaper reports about the accident? the police reports about the accident? the Official Driving and Motor Vehicle Examiners’ report about the mechanical conditions of the touring bus? the report from the Swedish Board of Accident Investigation about the causes of the accident?”

Psychological symptoms were assessed by SCL-90, a questionnaire as- sessing symptoms during the last week before assessment (Derogatis, 1977). Nine subscale scores can be calculated along with the Global Severity Index (GSI; average score of the 90 items), the Positive Symptom Distress Index (PSDI; average score of items scored > 0) and Positive Symptom Total (PST; number of acknowledged symptoms). For these analyses, the PSDI measure was selected because it reflects the intensity of all acknowledged symptoms; the Depression subscale was selected because of its relevance to bereavement reactions; and the Hostility subscale was selected because of its possible association with the person’s opinion concerning the pre-

Cognitive Coping 633

ventability of the accident. Internal reliability coefficients, estimated by Chronbach’s a, were as follows: the Global Seventy Index (GSI): .94, .91, and .93; the Depression subscale: .90, .89, and 3 8 ; and the Hostility subscale: .86, .88, and .89; at the 1-year, 3-year, and 5-year follow-up, re- spectively.

Procedure

The study included 1-year (1989), 3-year (1991), and 5-year (1993) posttrauma follow-ups. The main methods of data collection were ques- tionnaires (in Swedish translations). To reduce the impact of anniversary reactions, no data were collected in August. The questionnaires were ad- ministered in July at the 1-year follow-up, and in September and October at the 3-year and 5-year follow-ups.

Results

Descriptive Analyses

Need for information (NEED). As inspection of Table 1 indicates, the majority of the sample, ranging from 94% to ‘72% during the follow-up, reported moderate to strong need for information about the accident. The analysis of variance (ANOVA) showed that a statistically significant de- crease in the sample’s average level of need for information occurred be- tween the 1- and 3-year follow-up. There was no significant difference between the 3- and 5-year follow-up means. The high test-retest correla- tions for NEED in Table 2 show that there was considerable temporal sta- bility in NEED for most participants. Women had a higher mean score (M = 2.63, SD = 0.50) on NEED than men (M = 2.11, SD = 0.89), F(1, 34) = 4.63, p < .05. There were no statistically significant differences in NEED between the loss and the no-loss group, or between the passengers and the nonpassengers.

Knowing what had happened (INFO). As also depicted in Table 1, most participants, ranging from 61% to 78% during the follow-up, said that they were well informed (scores 2 2) about what had happened in the accident. The ANOVA shows that the mean INFO scores, or level of knowledge about what had happened, did not change over time. The test-retest cor- relations for this variable show moderate intra-individual stability (Table 2). There were no statistically significant differences on INFO between men

634 Winje

Table 1. Aspects of Cognitive Coping: Percentage Distribution of Scores 22, Mean (SO) and F-values (ANOVA) at l-Year (1989), 3-Year (1991). and 5-Years (1993) Posttrauma

IN = 36’1

Percentage of scores t 2 Mean (SD) Coping

(Range 0-3) 1989 1991 1993 1989 1991 1993 F-values

NEED 94.4 75.0 72.2 2.64, 2.25, 2.22, F(2, 70) = 6.01* (0.59) (1.03) (0.99)

(0.76) (0.81) (0.89)

(1.27) (1.16) (1.15)

INFO 61.1 69.4 77.8 1.67, (1.83), 1.89, F(2, 70) = 1.38

RAND 52.8 50.0 58.3 1.58, 1.42, 1.61, F(2, 70) = 0.51

Note. NEED = Need for information about what had happened in the accident. INFO = Level of knowing what had happened in the accident. RAND = Viewing the accident as a random incident. Differences between means, as indicated by different subscripts, are statistically significant according to Newman-Keuls post-hoc test.

*p < .01

and women, between the loss and the no-loss group, or between the pas- sengers and the nonpassengers.

Thirty one participants (86%) said they had read all the reports about the accident some time during the follow-up period, whereas five persons (14%) avoided reading any of the reports. The loss group reported having read the police reports ( M = 2.20, SD = 0.98) more often than the no-loss group ( M = 1.13, SD = 0.98), F(1, 34) = 10.76, p = .002, and having read more of the Official Vehicle Examiners’ report ( M = 1.98, SD = 0.94) than the no-loss group (M = 1.16, SD = 0.98), F (1, 34) = 6 . 5 2 , ~ < .05. There were no statistically significant differences in the use of information sources between men and women or between the passengers and the nonpassengers.

Randomness offhe accident (RAND). Half the sample reported a mod- erate to strong conviction during the follow-up that the accident was a random incident. The ANOVA shows that the sample’s average level on this measure did not change during the observation period (Table 1). The test-retest correlations show that the intra-individual stability concerning the randomness of the accident was low between 1989 and 1993, but very high between 1991 and 1993 (Table 2). The no-loss group was more in- clined than the loss group to regard the accident as a random incident, as indicated by a higher average score (M = 1.94, SD = 0.70), than the loss group (M = 1.22, SD = 1.02), F (1, 34) = 5 . 8 2 , ~ = .02. No statistically significant differences on randomness of the accident were observed be- tween men and women, or between the passengers and the nonpassengers.

Psychological symproms. Among the three symptom measures, only depression showed a statistically significant difference between the loss and the no loss groups: The loss group had a higher average score over the three follow-ups on the Depression subscale ( M = 1.50, SD = 0.65)

Cognitive Coping 635

Table 2. Stability and Intercorrelations Among Measures, of Cognitive Coping at 1-Year (1989), 3-Years (1991), iind 5-Years (1993) Posttrauma (N = 36) -

Stability

Measure 1989-1991 1991-1993 1989-1'993

NEED .61'** .a*** .53'** INFO .61*** .45 * .41** RAND .37* .60*** .39'

Intercorrelations

Measures 1989 1991 1993 RAND-NEED -.32 -.60* * * - S O * * ' RAND-INFO .48** .16 .48** NEED-INFO -.28 -.19 .06

Note. NEED = Need for information about what had happened in the accident. INFO = Level of knowing what had happened in the accident. RAND = Viewing the accident as a random incident.

*p c .05. **p < .01. " p < .001.

-

than the no-loss group (M = 1.03, SD = 0.72), F(1, 34) = 4.21, p = .05. No statistically significant differences were observed on the three symp- tom measures from the first to the third follow-up between men and women, or between the passengers and the nonpassengers (Winje, 1996).

Relationships Between Aspects of Cognitive Coping

There was a strong negative correlation between viewing the accident as random (RAND) and the need for information (NEED) alt the two latest follow-ups as is reflected in Table 2. In contrast, viewing the accident as random (RAND) and knowing what had happened (INFO) were positively correlated both in 1989 and in 1993. Thus, viewing the accident as random was associated with less need for information (NEED) and a strong feeling of knowing what had happened (INFO) in the long-term.

Relationships Between Aspects of Cognitive Coping and Psychological Symptoms

The concurrent correlations between aspects of cognitive coping and psychological symptoms are found in the diagonals in Table 3. The cross- lagged correlations between aspects of cognitive coping arid later assess- ments of symptoms are found in the upper triangles (dotted), whereas the cross-lagged correlations between aspects of cognitive coping and earlier

636 Winje

assessments of symptoms are found in the lower triangles (broken lines) of the table.

The concurrent correlations between need for information (NEED) and all three symptom measures became stronger over time: In 1989 they were close to zero and nonsignificant, whereas all concurrent correlations were positive and statistically significant in 1993. These findings indicate that at five years posttrauma, a stronger need for information was asso- ciated with poorer psychological adjustment. In contrast, knowing what had happened (INFO) and viewing the accident as a random incident (RAND) were associated with better psychological adjustment: 17 of the 18 concurrent correlations between these aspects of cognitive coping and the symptom measures were negative; nine of the 17 were statistically significant.

All cross-lagged correlations between need for information (NEED) and the three symptom measures were positive. Three of the nine cross- lagged correlations between NEED and later symptoms (upper triangles) were statistically significant, whereas one of the nine cross-lagged correla- tions between symptoms and later need for information (lower triangles) was significant. It should be noted that need for information (NEED) in 1989 was not associated with later symptoms, whereas need for information (NEED) in 1991 was positively and significantly correlated with all three symptom measures in 1993.

Fifteen of the 18 cross-lagged correlations between knowing what hap- pened (INFO) and the three symptom measures were negative. Five of the nine cross-lagged correlations between INFO and later symptoms (upper triangles) were statistically significant, whereas two of the nine correlations between symptoms and later level of INFO (lower triangles) were signifi- cant. This indicates that knowing what had happened (INFO) was related to fewer symptoms with a stronger influence on later symptoms than vice versa.

All of the 18 cross-lagged correlations between viewing the accident as a random incident (RAND) and the three symptom measures were negative. Four of the nine cross-lagged correlations between RAND and later symp- toms (upper triangles) were statistically significant, and three of the nine correlations between symptoms and later level of RAND (lower triangles) were significant. This indicates that viewing the accident as a random inci- dent was related to fewer symptoms but that the influence was reciprocal. However, this association was most pronounced for the Hostility subscale.

Because viewing the accident as random (RAND) was related to the experience of no loss in the accident, block-wise hierarchical multiple re- gression analyses were carried out to explore the possible influence of loss trauma on the relationship between RAND and Hostility. In the first

Tabl

e 3.

Cor

rela

tions

Bet

wee

n M

easu

res

of C

ogni

tive

Cop

ing

and

PSD

I, D

epre

ssio

n, a

nd H

ostil

ity (

SCL-

90)

at

1-Y

ear (

1989

), 3-

Yea

r (1

9Y1)

and

5-Y

ear

(199

3) P

osttr

aum

a (N

= 3

6)

PSD

I D

epre

ssio

n H

ostil

ity

Mea

sure

Y

ear

1989

19

91

1993

19

89

1991

19

93

1989

19

91

1993

........

....

NE

ED

19

89

.10

:..06

.21 ;

%

~*

. 19

91

1.26

- - ..2i*

-.

.3s*

t .

'.....*

19

93

1.35

' .1

6,

.43*

* -_

----

IN

FO

1989

-.4

1*

-.39"

-3

9'

%

~*

. 19

91

1.26

- - ..2i*

-.

.3s*

t .

'.....*

19

93

1.35

' .1

6,

.43*

* -_

----

IN

FO

1989

-.4

1*

-.39"

-3

9'

1991

-.1

9 -.2

7 -.1

2

1993

.0

4 -.3

4*

-.15

RA

ND

19

89

-.34*

-.2

8 -.1

9

lYY

l -.3

1 -.3

1 -.3

8*

1993

-.3

8*

-.14

-.30

-. 14

.14

.09

-.12

-.14 .11

-.33

-.05

-.17

.01

.12

.29

.35 *

.2

2 .4

3**

-.54*

**

-.33

-.39*

-.3

1

-.2 1

.0

4 -.3

0 -.3

1

-.23

-.30

-.25

-.34*

.14

.32

.28

-.34*

-.4

0' .o 1

-.47*

*

-.41*

-.5

9*.*

.19

.25

.20

-.40*

-.5

3***

-.28

-.48*

* -.4

9**

-.33

.22

.35*

.39*

-.32

-.31*

-.0

6 -.4

1*

-.49*

* -.5

4***

Nore

. NEE

D =

Nee

d fo

r inf

orm

atio

n ab

out w

hat

had

happ

ened

in

the

acci

dent

. IN

FO =

Lev

el o

f kn

owin

g w

hat h

ad

happ

ened

in

the

acci

dent

. RA

ND

= V

iew

ing

the

acci

dent

as

a ra

ndom

inc

iden

t. PS

DI

= P

ositi

ve S

ympt

om D

istre

ss

inde

x (S

CL-Y

O).

Dep

ress

ion

= D

epre

ssio

n su

bsca

le (

SCL-

90).

Hos

tility

= H

ostil

ity s

ubsc

ale

(SC

L-90

). D

otte

d lin

e (..

...) s

urro

unds

cros

s-hg

ged c

orre

latio

ns b

etw

een

cogn

itive

copi

ng a

nd su

bueq

rretr

f sym

ptom

leve

ls. B

roke

n lin

e (-

-)

surr

ound

s cr

oss-

lagg

ed c

orre

latio

ns b

etw

een

copi

ng a

nd p

revr

oiis

sym

ptom

leve

ls.

*p <

.05.

**p

< .

Ole *

**p c

,001

.

6 z.

W

638

Table 4. Summary of Blockwise, Stepwise Multiple Regression Analyses of the Relationships Between Loss/No-Loss, Perceived Randomness of the Accident (RAND) and Hostility (SCL-90) (Changes in Explained Variance and Final Beta Weights) (N =36)

Hostility 93 RAND 93

AR2 P AR2 P Block I Block I

Block I1 Block I1

Block 111 Block 111

L~SS/NO-IOSS 5.3 ,047 LOS~NO-IOSS 12.6 -.249

RAND 89 13.5 -.260 Hostility 89 27.6 -.536**

RAND 91 11.7 -.380* Hostility 91 a 4

R2 .3 1 .40 R2 adj. .24 .37 F 4.68 11.09

3/32 2/33 .01 .oo

df P Nore. NEED = Need for information about what had happened in the accident. INFO = Level of knowing what had happened in the accident. RAND = Viewing the accident as a random incident.

4Did not fulfill inclusion criterion (p < .05). *p < .05. **p < .001.

multiple regression analysis, using Hostility in 1993 as outcome, the losdno- loss variable was forced to enter into the first block of the model. RAND in 1989 was placed in the second block and RAND in 1991 was placed in the third block. The variables in blocks 2 and 3 were allowed to enter the equation if they fulfilled the inclusion criterion (p < .05). When controlling for loss/no-loss, RAND in 1989 had no statistically significant contribu- tion, whereas RAND in 1991 had a significant contribution to the ex- p la ined var iance in Hostility in 1993 (Table 4). In the second multiple-regression analysis, using RAND in 1993 as outcome, the loss/no-loss variable was forced to enter the first block of the model; Hos- tility in 1989 was placed in the second block, and Hostility in 1991 in the third block. These variables were allowed to enter the equation in a stepwise hierarchical procedure if they fulfilled the inclusion criterion (p < .05). When controlling for lossho-loss, Hostility in 1989 had a statis- tical significantly contribution, whereas Hostility in 1991 had no signifi- cant contribution to the explained variance of RAND in 1993 (Table 4).

Discussion

Before commenting on the main findings, some limitations of the study should be addressed. Conclusions about the influence of mediating vari- ables and the course of cognitive coping should be viewed as tentative

Cognitive Coping 639

due to the small sample size and the lack of data from the first 12 months posttrauma. The CESBE-questionnaire used to assess aspects of cognitive coping is not cross-validated against other instruments and was used for the first time in this study. The data reflect the person’s subjective evalu- ation of different aspects of cognitive coping, and the findings are based on a small number of items. However, the strength of the study is the close relationship between clinical observations made during the crisis interven- tion period and the model developed for the study which serves to bridge the gap between clinical work and research methods. Three repeated meas- ures within uniform time periods over four years from a sample which has experienced distinct types of trauma caused by the same accident minimize some major confounding factors within this field of research (Blank, 1993; Green, 1993). The participation and retention rate of 82% over three follow- ups also compares favorably to other studies (Blank, 1993).

The study supports the clinical impression that a strong need for information about the traumatic event is a salient phenomenon in long- term coping with trauma. However, the hypothesis that a need for in- formation would be a marker of favorable adjustment was not supported. The findings indicate that need for information was not re- lated to symptoms during the first three years after the trauma but be- came associated with poorer psychological adjustment after that. A possible explanation of these findings could be that the parents’ search for information was mainly directed toward searching for verifiable (ob- jective) information until 1992, which was the period when the two first assessments were conducted. This search for such information could be seen as having ended with the release of the report from the Swedish Board of Accident Investigation in 1992. One may speculate whether a high need for information that remains at the third assessment (1993) reflects diffi- culty in confronting reality and therefore indicates a risk for long-term psy- chological problems. This interpretation is supported by additional analyses showing that people who maintained a high level (scores 2 2) on need for information (NEED) at all three follow-ups (n = 23) had significantly higher scores on all three symptom measures at the 5-year follow-up than those who maintained a low level (scores c 2) on NEED (n = 13). The groups with persistently high and persistently low levels on NEED did not differ regarding their knowledge of what had actually happened in the accident. Thus, the association between NEED and long-term psychological symp- toms cannot be explained by lack of knowledge: about the specific details of the accident.

However, it may be that a strong need for information present 5-years posttrauma reflects a search for information inore related to emotional (therefore subjective) topics (“what did my child feel and think in the ac-

640 Winje

cident?”) than to verifiable topics (“what did actually happen in the acci- dent?”). A similar differentiation was proposed by Joseph, Williams, and Yule (1995) in their outline of a cognitive-behavioral model of adaptation to traumatic stressors. They suggest a differentiation between processing of “event cognitions” and processing of “emotion cognitions.” Although there is strong interaction between these two types of processing, they may contribute to outcomes at different times in the adjustment process. It may be that lack of definitive answers about facts, but particularly regarding emotional topics, contributes to the symptomatic rumination so frequently observed in traumatized persons (Lehman et al., 1987; Shanfield & Swain, 1984; Shanfield, Swain, & Benjamin, 1987). More research on this topic is needed, and future studies should differentiate between objective and sub- jective types of information in the investigation of associations between need for information about the traumatic event and long-term psychological symptoms.

A considerable proportion of the sample felt adequately informed throughout the study period. The findings support the assumption that peo- ple who felt adequately informed would show better psychological adjust- ment. One should note that this aspect of cognitive coping at the first assessment (1989) had the strongest relationship with later symptoms. These findings suggest that assisting traumatized persons in their search for verifiable information may be important in early intervention efforts.

Half the sample viewed the accident as a random incident and this did not change over time. The hypothesis that viewing the accident as a random incident would be associated with better psychological adjust- ment was supported. Both the correlation analyses and the multiple re- gression analyses indicate a reciprocal relationship between hostility and viewing the accident as preventable. There has been a great deal of at- tention to the role played by hostility in coping with daily stress, illness, and trauma. Several studies have documented that hostility strongly im- pairs the process of adaptation to such challenges (Friedman, 1992). However, hostility is a broad psychological concept, and its relationship with poor psychological adjustment may be due to different aspects: heightened emotional reactivity, reduced ability to obtain social support, o r maintenance of negative cognitive assessments of other people and the world. The Hostility subscale (SCL-90) used in this study comprises items related to anger and irritability and probably reflects the emo- tional reactivity component of hostility. Tennen and Affleck (1990) pro- posed that “outcome severity” determines the traumatized person’s hostility and blaming of others for one’s misfortune, thus contributing to impairments in adjustment to trauma. The present findings do not

Cognitive Coping 641

support their assumption. Although the loss group, more than the no-loss group, tended to view the accident as preventable, controlling for the ex- perience of loss in the accident did not change the relationship between hostility and opinion about the accident as a random incident. People with hostile feelings tended to view the traumatic event as preventable and re- ported a strong, persistent need for information despite having been in- formed. It seems that this constellation of reactions can initiate a cycle that impairs parents’ long-term adjustment.

In summary, the aspects of cognitive coping, developed in the CESBE-model and investigated in the present study, showed interesting associations with the victims’ long-term adjustment to trauma. While the search for facts was going on, there were no associations between need for information and symptoms, indicating that attempts to understand what had happened should be regarded as part of a normal adjustment process. However, when a strong need for information persisted after factual information was provided, it was related to poorer psychological adjustment.

There are few longitudinal studies investigating the specific mecha- nisms involved in the recovery process. The present findings show that a more detailed investigation of the victims knowledge about the trau- matic event may contribute to a better understanding of recovery from trauma. However, more information is needed on how to influence and modify such coping variables and more sophisticated methods are re- quired in future studies of the complex pattern of associations be- tween aspects of cognitive coping and psychological adjustment to trauma. It may be particularly important to differentiate between need for factual and need for emotional information in studies of long-term adjustment. The clinical implications of this study suggest that providing factual information about what happened may contribute to the individual’s long-term efforts to assimilate and accommodate to life after trauma.

Acknowledgments

The author is indebted to the participan ; for their willingness 0 - share their long-term experiences of trauma, and to the personnel from the Kista Congregation who have provided valuable assistance. The author acknowledges the assistance of Odd E. Havik, Dr. philos., in the preparation of this paper. This study has received financial support from The Norwegian Research Council, The Norwegian Council for Mental

642 Winje

Health, Skandiamesta Insurance Company and the Multiple Sclerosis As- sociation of Norway.

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