Download The role of intrusion, avoidance, and cognitive coping strategies

Anxiety, Stress, and Coping,
March 2006; 19(1): 1 /14
The role of intrusion, avoidance, and cognitive coping
strategies more than 50 years after war
VIVIAN KRAAIJ & NADIA GARNEFSKI
Department of Clinical and Health Psychology, Leiden University, Leiden, The Netherlands
(Received 21 January 2003; revised 21 August 2003; accepted 6 June 2005)
Abstract
The relationships between war events, cognitive coping strategies, posttraumatic stress reactions, and
depressive symptoms were examined in 248 people who experienced war 50 years ago. The findings
suggest that people who experienced war events that indicate a more severe involvement in war
suffered from more depressive symptoms. War events that might be experienced by many people in the
community appeared not to be related to depression scores. The occurrence of intrusion and
avoidance appeared to be related to depressive symptoms. When cognitive coping strategies were
included in the analysis, intrusion and avoidance no longer were significant. However, cognitive
coping strategies, such as positive reappraisal, positive refocusing, rumination, acceptance, and selfblame, were significantly related to depressive symptoms. Intervention programs should pay attention
to these cognitive coping strategies.
Keywords: War, intrusion, avoidance, cognitive coping, depression
Some people who have experienced traumatic events during wartime have emotional
or psychiatric problems, such as posttraumatic stress disorder or depression, more than
50 years later (Nadler & Ben-Shushan, 1989; Hovens, op den Velde, Falger, Schouten,
de Groen, & van Duijn, 1992; Op den Velde et al., 1993, 1996; Bramsen, 1995;
Bramsen, Klaarenbeek, & van der Ploeg, 1995a; Lee, Vaillant, Torrey, & Elder, 1995;
Bramsen & van der Ploeg, 1999). Events experienced during war, such as seeing many
people being killed, destruction of house or neighborhood due to bombing, serious
illness, being in danger of losing one’s life, maltreatment and torture by the occupier,
have all been found to be related to psychopathology (Beal, 1995; Bramsen,
Klaarenbeek, & van der Ploeg, 1995b). It has been suggested that people who have
been exposed to a greater amount of war experiences suffer even higher levels of distress
(Bramsen et al., 1995b).
Various theories have been developed to offer insight into the nature of pathological
reactions to traumatic events. Several theories, such as those developed by Horowitz
(1976), Creamer (Creamer, Burgess, & Pattison, 1992; Creamer, 1995), and JanoffBulman (1985, 1989, 1992), propose that people have a set of preexisting beliefs and
Correspondence: Vivian Kraaij, Leiden University, Department of Clinical and Health Psychology, P.O. Box 9555,
2300 RB Leiden, The Netherlands. Tel: /31 71 5273736. Fax: /31 71 5273619. E-mail: Kraaij@fsw.
LeidenUniv.nl
ISSN 1061-5806 print/ISSN 1477-2205 online # 2006 Taylor & Francis
DOI: 10.1080/10615800500412449
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V. Kraaij & N. Garnefski
models or schemas of the world. The traumatic event confronts persons with information
that is inconsistent with the information in existing schemas about themselves, the world,
their safety and invulnerability. This leads to distress and the need to revise the schema in
such a way as to be able to integrate the new information. Intrusion and avoidance occur as
a result of opposite actions of a control system that regulates the incoming information to
tolerable doses. Normally, these mechanisms fluctuate in a way particular to the person
without making the person overwhelmed or extremely tired. The person oscillates between
the states of intrusion and avoidance until a relative equilibrium is reached and the person
has ‘‘worked through the traumatic experience.’’ In this case the person has integrated the
traumatic material with his or her long-term schematic representation (Horowitz, 1976;
Creamer et al., 1992; Joseph, Yule, & Williams, 1995; Brewin, Dalgleish, & Joseph, 1996;
Joseph, Williams, & Yule, 1997).
From the above can be concluded that intrusion and avoidance can be considered as
adaptive processes in response to traumatic war experiences. It has indeed been suggested
that the presence of intrusion and avoidance immediately after the traumatic event is a
normal reaction to the overwhelming level of stress. However, the longer the time elapsed
since the trauma, the more likely it is that intrusion and avoidance signal a failure to
successfully emotionally process the traumatic experience (Brewin et al., 1996; Joseph,
Dalgleish, Thrasher, Yule, Williams, & Hodgkinson, 1996; Joseph et al., 1997; Joseph,
2000). Therefore, it can be argued that 50 years after war, those who still experience
intrusion and avoidance are expected to report more emotional problems than those who do
not experience intrusion and avoidance.
Recently another mechanism following traumatic experiences has been described,
namely cognitive emotion regulation or cognitive coping (Garnefski, Kraaij, &
Spinhoven, 2001; Garnefski, Kraaij, & Spinhoven, 2002). Following Lazarus (1993,
1998, 1999), cognitive coping is the individual’s cognitive attempt to manage those
demands (conditions of harm, threat, or challenge) that are appraised as taxing or
exceeding the resources of the person. Cognitive coping styles are assumed to refer to
rather stable styles of dealing with negative life events; however, not to such an extent
that they can be compared with personality traits. It is assumed that in certain situations
people may use specific strategies, which may divert from the strategies they would use
in other situations (Garnefski, Kraaij, & Spinhoven, 2002). In general, cognitive coping
styles such as self-blame, catastrophizing, and rumination have been found to have a
positive association with maladjustment, while positive reappraisal (thoughts of attaching
a positive meaning to the event in terms of personal growth) has been found to have a
negative association with maladjustment (Garnefski et al., 2001; Garnefski, Legerstee,
Kraaij, van den Kommer, & Teerds, 2002; Garnefski, van den Kommer, Kraaij, Teerds,
Legerstee, & Onstein, 2002; Kraaij, Pruymboom, & Garnefski, 2002; Kraaij , Garnefski,
de Wilde et al., 2003). In these studies, cognitive coping has been studied as a general
style of handling stressful events. Which specific cognitive coping strategies are related to
well-being for people who experienced traumatic war events more than 50 years ago has
not yet been studied.
It would be of interest to know which specific mechanisms are relevant for people who
experienced traumatic war events, as several therapies have been found to be effective in
treating depression and posttraumatic stress reactions (Woods, 1993; Scogin & McElreath,
1994; Spinhoven & van Dyck, 1999). Older generations still suffer from war events
experienced many years ago. In addition, younger generations who faced traumatic war
events, for example in the war in former Yugoslavia, Afghanistan, or Iraq, also run the
Intrusion, avoidance, and cognitive coping strategies after war
3
risk of developing emotional problems in the long run. If we gain insight into which
mechanisms are maladaptive in response to past war experiences, we could integrate these
findings into treatment programs.
The underlying theoretical model we use in the present study is that the experience of
past traumatic war events leads to intrusion, avoidance, and cognitive coping strategies,
which leads in turn to depressive symptoms. We will first examine the relationship between
several traumatic war events and depressive symptoms in a sample that experienced war 50
years ago. Next, we will study the mechanisms involved: first, we will examine the
relationship between intrusion and avoidance and depressive symptoms; second, we will
examine the additional role of cognitive coping strategies.
Methods
Sample and procedure
The sample consisted of 248 people who were all registered at Stichting 1940 /1945, a
Dutch foundation for victims of war. The foundation offers help to all groups of victims
of war, such as resistance fighters, war veterans, and civilian victims of war. Seamen
victims of war and former Dutch East Indies resistance fighters are excluded. For
Holocaust survivors there is another foundation specialized in helping Jewish people.
The foundation Stichting 1940 /1945 can help in applying for a war-related disability
pension or benefit. This does not mean that all registered people actually do receive a
war-related pension or benefit (and/or have a disability status). The foundation also has
a department of social welfare work, with treatment providers specialized in the
treatment of victims of war and their relatives. Finally, the foundation offers professional
help to volunteer groups of victims of war. This help varies from performing various
structural tasks (such as organizational and administrative tasks) to the organization of
incidental activities.
Subjects were randomly selected from the address list of Stichting 1940 /1945, which has
more than 10,000 people registered. The inclusion criterion was year of birth before 1935
in order to guarantee personal memories of war events. A total of 1,000 subjects were
selected. The foundation sent those subjects a letter in which they gave notice of the study
by the University. The University included a letter that explained the nature of the study
and a questionnaire with a return envelope. A telephone number of the University was
provided for questions. A total of 248 subjects (25%) participated in the study. Because the
University had no access to the addresses (to guarantee confidentiality), no information
could be obtained about reasons for non-response. Because the foundation did not want to
put pressure on their members, no reminders were sent.
At the time of the study, the mean age of the respondents was 80 (SD 5.5, range 68 /98)
years and 48% were male. Forty-three percent were currently married or living together,
48% were widowed, and 9% were either divorced or had never married. The majority
(82%) lived independently; the others lived in sheltered accommodations (6%), nursing
homes (6%), or in other situations (6%).
The respondents had a mean age of 18 (SD 5.5) years at the beginning of war. Almost all
experienced World War II, either in the Netherlands (97%; 1940 /1945) or in the Dutch
East Indies (2%; 1942 /1945). In addition, 11% experienced the Indonesian independence
struggle and Dutch military actions in the former Dutch East Indies (1945/1949). Twenty
per cent reported having been a soldier during war, and 76% reported to have been a
resistance fighter.
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V. Kraaij & N. Garnefski
Measures
War events. War events were measured by a checklist with a yes/no response format, based
on the Negative Life Events Questionnaire as described in Kraaij (2000) and Kraaij &
de Wilde (2001), and on Bramsen (1995). The respondents were asked whether they had
personally experienced a number of war events (for the content see Table II). The questions
were without much detail. In the present study the events were used separately. In addition,
a sum score, reflecting the total number of war events experienced, was used by adding the
events. Scores range from 0 to 13.
Intrusion and avoidance. Intrusion and avoidance were measured by the Impact of Event
Scale (IES; Horowitz, Wilner, & Alvarez, 1979; for a Dutch translation see Brom & Kleber,
1985). In the present study, respondents were asked which reactions to distressing events
experienced during wartime they had experienced during the past 7 days. The IES consists
of 15 items with four-point frequency scales (0 /not at all, 1 /rarely, 3/sometimes, and
5 /often). The IES contains two subscales, namely intrusion, which consists of seven items,
and avoidance, which consists of eight items. The subscale scores can be obtained by
adding up the items belonging to the subscale, with a range of respectively 0 to 35 and 0 to
40. Higher scores indicate a greater frequency of intrusive thoughts and attempts at
avoidance. The IES has been found to have good psychometric properties (Joseph, 2000;
Sundin & Horowitz, 2002). In the present sample Cronbach’s alphas of 0.90 for intrusion
and 0.83 for avoidance were found.
Cognitive coping strategies. Cognitive coping strategies were measured by the Cognitive
Emotion Regulation Questionnaire (CERQ; Garnefski et al., 2001; Garnefski, Kraaij, &
Spinhoven, 2002). Cognitive coping strategies are defined here as the cognitive way of
managing the intake of emotionally arousing information, involving thoughts or cognitions
that help to manage or regulate our emotions (see also Thompson, 1991). More specifically,
the CERQ assesses what people think after the experience of threatening or stressful life
events. The CERQ can be used to measure either a more general coping style or a more
specific response to a specific event, referring to a coping strategy. In the present study
specific coping strategies were measured. Respondents were asked which current cognitive
coping strategies they use in relation to events experienced during wartime.1 The CERQ
consists of 36 items and nine conceptually different subscales. Each subscale consists of four
items. Each of the items has a five-point Likert scale (‘‘never’’ to ‘‘always’’). A subscale score
can be obtained by adding up the four items (with a range from 0 to 16), indicating the extent
to which a certain cognitive coping strategy is used. The CERQ subscales are: self-blame,
which refers to thoughts of blaming yourself for the way you handled the war events (e.g.
‘‘I think that I should have dealt with the situation differently’’); acceptance, which refers to
thoughts of accepting what you have experienced in the war and resigning yourself to what
has happened (e.g. ‘‘I think that I have to accept what has happened to me in the war’’);
rumination, which refers to thinking about the feelings and thoughts associated with the
events experienced in war (e.g. ‘‘I am preoccupied with what I think and feel about what I
have experienced in the war’’); positive refocusing, which refers to thinking about joyful and
pleasant issues instead of thinking about the experienced war events (e.g. ‘‘I think of
something nice instead of what has happened to me in the war’’); refocus on planning, which
refers to thinking about what steps to take and how to handle the events experienced in war
(e.g. ‘‘I think of what I can do best to deal with my war experiences’’); positive reappraisal,
which refers to thoughts of attaching a positive meaning to the experienced war events in
Intrusion, avoidance, and cognitive coping strategies after war
5
terms of personal growth (e.g. ‘‘I think I can learn something from the things experienced
in the war’’); putting into perspective, which refers to thoughts of playing down the
seriousness of the experienced war events or emphasizing its relativity when compared to
other events (e.g. ‘‘I think that it all could have been much worse’’); catastrophizing, which
refers to thoughts of explicitly emphasizing the terror of the experienced war events (e.g.
‘‘I continually think how horrible it has been what I experienced in the war’’); and otherblame, which refers to thoughts of putting the blame of what you have experienced in war on
others (e.g. ‘‘I think about the mistakes others have made in what I have experienced in the
war’’). The psychometric properties of the CERQ (both used as a more general coping style
and as a more specific response to a specific event) have been proven to be good (Baan,
Garnefski, & Kraaij, 2002; Garnefski, Kraaij, & Spinhoven, 2002; Kraaij, Garnefski, &
van Gerwen, 2003), with Cronbach’s alpha coefficients in most cases more than 0.70 and in
many cases even more than 0.80. Furthermore, the CERQ has been shown to have good
factorial validity, good discriminative properties, and good construct validity2 (Garnefski,
Kraaij, & Spinhoven, 2002). In the present study the Cronbach’s alphas of the subscales also
appeared to be good, with alphas ranging from 0.62 to 0.85.
Depressive symptoms. Depressive symptoms were measured by the Geriatric Depression
Scale (GDS; Brink, Yesavage, Heersema, Adey, & Rose, 1982), consisting of 30
dichotomous questions. Scores range from 0 to 30, with a high score indicating more
depressive symptoms. The GDS excludes items that are confounded with normal aging and
diseases associated with old age, but assesses primarily psychological components of
depression. Therefore it is very suitable for assessing depression in the elderly. The GDS
has been demonstrated as having a high reliability (Cronbach’s alpha coefficient 0.94), good
validity (established by positive correlations of the GDS with both clinical interviews and
other valid self-report measures of depression), and high levels of sensitivity and specificity
using a cut-off score of 11 (Yesavage et al., 1983; Olin, Schneider, Eaton, Zemansky, &
Pollock, 1992; Kok, 1994). In the present sample a Cronbach’s alpha of 0.90 was found.
Statistical analyses
First, Pearson correlations were computed to study the bivariate relationships between war
events, intrusion, avoidance, and cognitive coping strategies on the one hand and depressive
symptoms on the other hand. Both kinds of war events and the total number of war events
experienced were taken into consideration. Next, hierarchical regression analysis was
performed to study the multivariate relationship between intrusion, avoidance, and
cognitive coping strategies (independent variables) and depressive symptoms (dependent
variable). In order to control for the amount of stress experienced in war, the number of war
experiences was entered in the first step. In the second step intrusion and avoidance were
entered, followed in the third step by the nine cognitive coping strategies.
Results
Preliminary analyses
First, mean scores and standard deviations of the variables were calculated (Table I). The
mean GDS score was 10.50 (SD 6.93). A score of 11 or more on the GDS is taken as an
indication for depression (Kok, 1994). In the present sample, 44.8% of the subjects had a
score of 11 or more. Respondents reported an average of six war events. Table II shows the
6
Mean
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
War events
Intrusion
Avoidance
Self-blame
Acceptance
Rumination
Positive refocusing
Refocus on
planning
Positive reappraisal
Putting into
perspective
Catastrophizing
Other-blame
(SD)
1
2
3
4
5
6.03 (3.12)
/
20.24 (9.89)
0.45***
/
16.01 (10.54)
0.42***
0.62***
/
7.52 (3.22)
0.26***
0.21**
0.15*
12.25 (4.01)
0.14
0.30***
0.23**
12.02 (4.49)
0.35***
0.70***
0.50***
11.53 (4.00) /0.05
/0.08
/0.02
9.79 (4.30)
0.27***
0.56***
0.50***
/
0.27***
0.27***
0.01
0.27***
12.41
12.75
(4.16)
0.09
(4.18) /0.20**
0.29*** 0.32***
0.36*** 0.26***
9.78
10.47
(4.70)
(5.31)
Note. *p B/0.05, **p B/0.01, ***p B/0.001.
0.44***
0.26***
0.19**
/0.03
0.59***
0.46***
0.12
0.08
0.44*** 0.10
0.29*** 0.09
6
/
0.39***
/
0.26*** /0.01
0.39***
0.66***
0.18*
0.22**
0.23**
0.05
7
/
0.21**
8
10
11
/
0.46*** 0.34***
0.29*** 0.19**
0.67*** /0.16*
0.43*** /0.00
9
/
0.45***
0.44*** /0.08
0.37*** /0.07
/
/0.26*** /
/0.12
0.60***
V. Kraaij & N. Garnefski
Table I. Descriptive statistics and Pearson correlations between all independent variables
Intrusion, avoidance, and cognitive coping strategies after war
7
Table II. Valid percentage (%) of respondents who experienced the war event and Pearson correlations (r ) between
war events and depressive symptoms
War event
%
Experienced violence at close range
Loss of friends or family
Sustained serious injuries, became permanently
disabled, or experienced illness
Physical abuse by occupier
Been in danger of losing one’s life
Starvation
Experienced bombing
Had to go into hiding
Evacuation
Destruction of house or neighborhood
Imprisonment
Transported away from home
Forced labor
Total number of war events
81
76
39
0.25***
0.04
0.30***
30
78
48
71
56
20
20
37
28
28
0.34***
0.15*
0.18**
0.09
0.08
/0.04
0.03
0.24**
0.22**
0.22**
0.32***
r
Note. *p B/0.05, **p B/0.01, ***p B/0.001.
valid percentage of respondents who experienced the various war events. Mean scores of
intrusion, avoidance, and the cognitive strategies can be found in Table I.
Before performing the main analysis, Pearson correlations among the independent
variables were computed (Table I). There was no evidence of multicollinearity (see
Tabachnick & Fidell, 1996) among the measures of war events, intrusion, avoidance, and
the cognitive coping strategies. As expected, there were however a number of significant
correlations.
Relationship between war events and depressive symptoms
Pearson correlations between the various war events and depressive symptoms were
computed (Table II). Several specific war events appeared to have a significant relationship
with depressive symptoms. All significant relationships were positive, indicating that the
experience of the specific war event was related to higher depression scores. The strongest
correlations with depressive symptoms were found for physical abuse by the occupier and
sustained serious injuries, became permanently disabled, or experienced illness. The
experiences of violence at close range, imprisonment, transported away from home, and
forced labor were also significantly related to depressive symptoms. Somewhat weaker but
still significant relationships were found for starvation and being in danger of losing one’s
life. Several war events were not significantly related to depressive symptoms, namely loss of
friends or family, experienced bombings, going into hiding, evacuation, and destruction of
house or neighborhood. Finally, the experience of more war events was significantly related
to higher depression scores.
Relationship between intrusion, avoidance, and cognitive coping strategies and depressive symptoms
The relationship between intrusion, avoidance, and cognitive coping strategies and
depressive symptoms is presented in Table III. First, the bivariate relationship was analyzed
by Pearson correlations. Almost all mechanisms correlated significantly with depressive
symptoms. Only the cognitive coping strategy putting into perspective was not significantly
8
V. Kraaij & N. Garnefski
Table III. Relationship of war events, intrusion, avoidance, and cognitive coping strategies on depressive
symptoms: Pearson correlations and hierarchical regression analysis
War events
Intrusion
Avoidance
Self-blame
Acceptance
Rumination
Positive refocusing
Refocus on planning
Positive reappraisal
Putting into perspective
Catastrophizing
Other-blame
R2
Adjusted R2
Degrees of freedom
F
Fchange
r
Step 1 Beta
Step 2 Beta
Step 3 Beta
0.32***
0.38***
0.33***
0.23**
0.16*
0.44***
/0.39***
0.26***
/0.28***
/0.08
0.41***
0.28***
0.34***
0.19*
0.25**
0.14
0.17*
0.02
0.11
0.16*
0.17*
0.27*
/0.26***
/0.06
/0.36***
0.09
0.03
0.05
0.49
0.45
(12,146)
11.72***
8.72***
0.12
0.11
(1,157)
20.90***
0.22
0.20
(3,155)
14.31***
9.83***
Note. *p B/0.05, **p B/0.01, ***p B/0.001.
related to depressive symptoms. Positive refocusing and positive reappraisal had a negative
association with depressive symptoms. All other mechanisms had a positive association with
the depression score.
To study the multivariate relationship between intrusion, avoidance, cognitive coping
strategies and depressive symptoms, hierarchical regression analysis was performed
(Table III).3 To control for the number of war events, this variable was entered in the
first step. In the second step, intrusion and avoidance were entered. Both the number of war
events and intrusion were significantly related to the depression score. Subjects who
reported the experience of more war events and more intrusive thoughts also reported more
depressive symptoms. Avoidance was no longer significantly related to depressive
symptoms. In total, 22% of the variance was explained (F [3, 155] /14.31; p B/0.001).
In the third step of the hierarchical regression analysis, the nine cognitive coping
strategies were entered (additional explained variance 27%, Fchange [9, 146] /8.72, p B/
0.001). The total number of war events still had a positive significant relationship with
depressive symptoms. Intrusion and avoidance no longer had a significant relationship
with depressive symptoms. Positive reappraisal had the strongest relationship with
the depression score. Subjects who used more positive reappraisal reported fewer
depressive symptoms. In addition, subjects who used more positive refocusing also
reported fewer depressive symptoms. Furthermore, subjects who used self-blame,
acceptance, and rumination to a greater extent reported more depressive symptoms.
Refocus on planning, putting into perspective, catastrophizing, and other-blame were not
significantly related to the depression score. In total 49% of the variance was explained
(F[12, 146] /11.72, p B/0.001).4
Discussion
More than 50 years after war, some people still suffer from emotional problems. Therefore,
it is important to gain insight into the processes involved in long-term maladjustment.
Intrusion, avoidance, and cognitive coping strategies after war
9
Intrusion and avoidance have been suggested to be maladaptive in the long run. The role of
cognitive coping strategies in relation to traumatic war events has not been studied yet.
Therefore, the aim of the present study was to study the relationship between war events,
intrusion, avoidance, cognitive coping strategies, and depressive symptoms in a sample of
248 elderly people who all had experienced war events more than 50 years ago.
In line with the present study, previous studies (Beal, 1995; Beekman, Deeg, van Tilburg,
Smit, Hooijer, & van Tilberg, 1995; Bramsen et al., 1995b) also reported that several
specific war events, such as danger of losing one’s life, starvation, and physical abuse, were
related to depressive symptoms. The findings of the present study seem to suggest that
people who experienced war events that indicate a more severe involvement in war (such as
physical abuse by the occupier, sustained serious injuries, became permanently disabled, or
experienced illness, the experience of violence at close range, imprisonment, transported
away from home, forced labor, starvation, and being in danger of losing one’s life), suffered
from more depressive symptoms later in life. On the other hand, war events that might be
experienced by many people in the community (such as loss of friends or family,
experienced bombing, going into hiding, evacuation, and destruction of house or
neighborhood) appeared not to be related to depression scores in later life. This finding
might be supported by studies among elderly community samples in which no relationship
was found between the total number of experienced war events and depressive symptoms
(Bramsen, 1995; Kraaij & de Wilde, 2001). These respondents gathered from the
community most frequently reported experiences such as bombing, evacuation, and hiding
to avoid forced labor. Possibly, having experienced negative events in the group surrounding
you afterwards also gives people a sense of solidarity or provides people with good social
support, which might be a protective factor. It has been suggested that the most effective
support givers may be similar others, that is, individuals who themselves have faced the
same stressful circumstances. These similar others are more likely to offer support that best
‘‘matches’’ the emotional and practical needs of the distressed person (Thoits, 1995).
Finally, in line with other studies (Bramsen et al., 1995b; Brewin, Andrews, & Valentine,
2000; Kraaij, 2000; Kraaij & de Wilde, 2001; Kraaij, Arensman, & Spinhoven, 2002), the
experience of a higher number of war events experienced a long time ago appeared to be
related to higher depression scores.
The findings support the idea that the occurrence of intrusion and avoidance in the long
run are related to the experience of more (symptoms of) psychopathology (Brewin et al.,
1996; Joseph et al., 1996; Joseph, 2000). Subjects who reported intrusion and avoidance to
a higher extent had significantly more depressive symptoms. The multivariate analysis
suggests that of these two mechanisms, the experience of intrusive thoughts seems to be an
important process in long-term maladjustment.
When the additional role of cognitive coping strategies in relation to traumatic war events
was studied, intrusion and avoidance appeared to have no longer a significant relationship
with depressive symptoms. However, several cognitive coping strategies were significantly
related to the depression score. In line with earlier studies that focused on cognitive coping
as general styles of handling stressful events (Garnefski et al., 2001; Garnefski, Legerstee,
et al., 2002; Garnefski, van den Kommer, et al., 2002; Kraaij, Pruymboom, & Garnefski,
2002; Kraaij, Garnefski, de Wilde et al., 2003), cognitive coping strategies used in relation
to stressful war events appeared to be related to depressive symptoms. Subjects who used
positive reappraisal or positive refocusing to a greater extent, reported fewer depressive
symptoms. Furthermore, subjects who used self-blame, acceptance, and rumination to a
greater extent reported more depressive symptoms. It could be hypothesized that attaching
10
V. Kraaij & N. Garnefski
a positive meaning to the experienced war events in terms of personal growth and thinking
about joyful and pleasant issues instead of thinking about the experienced war events are
good mechanisms to conquer stressful war experiences. On the other hand, thoughts of
blaming yourself for the way you handled the war events, thoughts of accepting what you
have experienced in the war and resigning yourself to what has happened, and thinking
about the feelings and thoughts associated with the events experienced in war seem not to
be effective ways to handle negative war events. Of course, longitudinal studies should be
conducted to confirm the direction of these relationships.
In total 49% of the variance of the depression score was explained by war events,
intrusion, avoidance, and cognitive coping strategies. Although past research showed that
intrusion and avoidance are related to the experience of emotional problems in the long run,
the findings of the present study seem to suggest that cognitive coping strategies might play
an even more important role in determining whether persons develop emotional problems
after the experience of stressful war events.
Most interventions concerning the processing of traumatic events have been developed
with the aim of reducing the frequency of intrusive ideation and avoidance, for example by
exposure therapy (Joseph et al., 1996; Foa et al., 2000). However, as the present study
shows that intrusion and avoidance have no longer a significant relationship with depression
when including cognitive coping strategies, it could be argued that intervention programs
targeting the processing of war events should pay attention to cognitive coping strategies.
This could be done by supplying the more ‘‘adaptive’’ strategies, such as positive reappraisal
and positive refocusing, and by challenging the ‘‘maladaptive’’ strategies, such as selfblame, acceptance, and rumination. In treatment one could focus on the content of ones
thoughts and the extent to which one has certain thoughts, and consequently change the
content or its degree. This approach can be linked to the well-established cognitive
therapies (e.g. Ellis, 1962; Beck, 1976), which focus on changing dysfunctional and
irrational cognitions. The present study gives important clues about which specific cognitive
coping strategies should be challenged or promoted in treatment of people who experienced
war decades ago and suffer from depressive symptoms.
Some methodological considerations have to be taken into account. A first issue of
concern is the representativeness of the group studied. The response rate was moderately
low. Unfortunately, because of confidentiality, no information could be obtained about
reasons for non-response. In addition, no information could be obtained about the
characteristics of the total group of registered people at the foundation. Another sample bias
is the fact that people who were more negatively affected by war stress may be more likely to
die at an earlier age, and were hence not available for the present study. Possibly elderly
people with more severe traumatic experiences did not participate because of the
confronting questions, which may bring back unpleasant memories. This would mean
that our results could not be generalized to those victims of war who were most negatively
affected by war experiences. On the other hand, 45% of the respondents scored above the
cut-off score of the GDS, indicating that almost one-half of the sample suffered from
depressive symptoms deemed clinically significant. This means that the findings cannot be
generalized to the general community population, where about 13% suffer from clinically
significant depressive symptoms (Beekman, Copeland, & Prince, 1999). Another limitation
of the design was that depressive symptoms, intrusion, avoidance, and cognitive coping
strategies were measured by self-report instruments, which may have caused some bias. It is
important for future studies also to use other forms of data-collection, such as interviews,
expert judgments or experiments. Another issue is that of the validity of the retrospective
Intrusion, avoidance, and cognitive coping strategies after war
11
recollections of war events by these elderly subjects. There is evidence to suggest that
depressed persons, in order to account for their current emotional state, may report more
negative life events than non-depressed persons (Brown, 1972; Teasdale, 1983). It has also
been suggested that elderly people might not remember early experiences accurately.
However, Brewin, Andrews, and Gotlib (1993) concluded in their review that there is little
reason to link psychiatric status with less reliable or less valid recall of early experiences, and
that much of our autobiographical recollection of the past is reasonably free of error,
provided that we stick to remembering the broad outline of events and not to detailed
information. The present study focused on the broad outline of war events only, since no
questions regarding the details of war events were included. At the same time this lack of
detailed information is a limitation of the present study. For example, severity of trauma
might be very different for different groups of war victims (e.g. combat versus general
civilian population), and without detailed information nothing can be said about the
duration of the traumatic experience. In addition, the total number of war events
experienced is only a very rough indicator. We do not know, for example, whether
respondents experienced multiple war events of the same kind or whether events were
overlapping. Next, the study measured intrusion, avoidance, cognitive coping strategies,
and depressive symptoms at the same time. Therefore, no conclusions can be drawn
regarding the causality or temporal order of these variables. In order to solve these cause
and effect issues, these aspects should be studied longitudinally. Furthermore, it could be
argued that some of the cognitive coping strategies could also be conceptualized as
being manifestations of depression. However, as long as they are aspects that can be
changed or influenced, it is worthwhile to study these issues and include them in
treatment programs. We also think that measuring current cognitive coping strategies
concerning events in the distant past is meaningful, as good reliabilities of the subscales
were found in the present sample. Finally, several aspects that could also be related to
depression, such as health, social support, traumatic events experienced pre and post war,
and previous depressive episodes, were not included in the present study. As the
questionnaire included emotional topics and the respondents were all of older age, only a
limited number of questions could be asked. Future studies should try to include these
other issues as well. The present study focused on how people cope with stressful war
events. It has been argued that coping effectiveness depends importantly on the type of
stressful situation that an individual experiences (Thoits, 1995; Zeidner & Saklofske, 1996).
To find out whether we can generalize the present findings, future studies should
also focus on other specific negative events (such as death of a loved one or sexual abuse)
and on properties of stressors (such as chronic versus acute or controllable versus
uncontrollable). Finally, many studies use intrusion and avoidance as pathological reactions
and therefore as outcome variables. However, the present study used intrusion and
avoidance as mechanisms that perpetuate pathology. We think this is an interesting and
promising approach.
Unfortunately, many people have been exposed to traumatic war events, either in the
further past (e.g. World War II) or more recently (e.g. Afghanistan or Iraq). These people
are at risk of developing emotional problems, even in the long-term. However, each
person’s cognitive coping strategies regarding these events seem to be related to the amount
of depressive symptoms reported. If the findings of the present study can be confirmed, they
could contribute to the focus and content of (existing) intervention programs for persons
who have been victims of war.
12
V. Kraaij & N. Garnefski
Acknowledgements
The authors would like to thank Tamara Dijksman for her help in collecting the data.
Notes
1 Instructions for completing the CERQ in relation to war events: You have experienced negative events during the
war. More people have had similar experiences and everyone deals with them in his or her own way. By means of
the following questions, you are asked what you think about having experienced negative events during the war.
Please read the sentences below and indicate how often you have the following thoughts by circling the most
suitable answer.
2 The CERQ has been administered simultaneously with the Coping Inventory for Stressful Situations (CISS;
Endler & Parker, 1990) in both an adolescent and adult sample. On the whole it can be stated that the
correlations between the CERQ and CISS subscales can be interpreted in a theoretically meaningful manner.
For example, high correlations were found between the CERQ Refocus on Planning and Positive Reappraisal
subscales on the one hand and the CISS Task-oriented Coping subscale on the other hand. These scales all
reflect the active coping with or management of the problem. In addition, high correlations were found between
CERQ subscales Self-blame, Rumination, and Catastrophizing on the one hand and the CISS Emotion-oriented
Coping subscale on the other, all referring to a certain way of being preoccupied with your emotions and in
general considered less functional strategies.
3 Having been a soldier or resistance fighter during war appeared not to be related to depressive symptoms
(respectively: Pearson r / /0.04, NS; Pearson r/0.02, NS). Therefore these variables were not controlled for.
4 When controlling for age, gender, marital status (married or living together versus living alone) and living
conditions (independently versus dependent on others) in the regression analysis, by means of entering these
variables in the first step of the regression equation, none of these variables contributed significantly to the
prediction of depressive symptoms (beta/0.06, beta/ /0.04, beta/0.11, and beta/ /0.03 respectively).
Controlling for these issues does not change the findings in any significant way.
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