Abstract
Background:
The structure of trauma memories impacts mental health, but questions remain about how structure changes with time and may shape coping with trauma. This study considered the structure of trauma narratives collected during an emergency department (ED) visit and at one-year follow-up. We addressed change in narrative structure over time, the extent structure predicted twelve-month psychological symptoms, and possible mechanisms in coping responses.
Methods:
Sixty-eight community adults (age range 18–67; 41% women) recruited from a trauma center ED provided narratives of the traumatic event that brought them to the ED. Participants provided multiple follow-up reports on psychological symptoms and coping strategies, and another narrative of the traumatic event at twelve months.
Results:
Narrative structure improved over time. Baseline narrative structure was negatively associated with twelve-month depressive and posttraumatic symptoms. Two measures of trauma narrative structure—interpretive elaboration and coherence—predicted change in coping strategies. Interpretive elaboration (rich details of the subjective experience) promoted early gains in endorsed engagement and later declines in endorsed disengagement. Coherence (the overall thematic structure of the narrative) buffered participant endorsement of disengagement at earlier follow-ups. Engagement was tied with fewer reported symptoms, whereas disengagement was associated with higher reported symptoms. Coping served as a mediator between baseline narrative structure and later mental health.
Limitations:
The study sample was relatively small and depended on self-reports for symptoms. Conclusions: Findings suggest there is meaningful variability in trauma memory structure, and early recollections of traumatic experiences may improve targeting of individuals in need of active interventions.
Introduction
The ways people organize autobiographical memories has implications for mental health. People who construct narratives with greater structure (i.e., order and detail)—especially in response to loss or trauma—report greater well-being (e.g., Pennebaker & Chung, 2007; Tuval-Maschiach et al., 2004). Previous studies testing the roles of narrative structure in traumatic memories have focused either on concurrent relations with well-being (e.g., Rubin et al., 2016a), or, if longitudinal, have studied changes in structure well after the event has occurred (e.g., Adler, 2012). Questions remain about the nature and implications of narrative structure shortly after a traumatic experience. Here, we considered the narrative structure of trauma memories within one day of the trauma and one year later. We were interested in how narrative structure changes and the implications of structure for posttraumatic symptoms.
Structure in Autobiographical Narratives
Narrative structure reflects the ways individuals frame a clear and consistent view of themselves (Baerger & McAdams, 1999; Waters & Fivush, 2015). More specifically, three aspects of narrative structure are linked to well-being: coherence; factual elaboration; and interpretive elaboration (see Graci, Watts, & Fivush, 2018; McLean et al., 2019). Coherence provides the skeletal frame of the story: situating the experience in time and space; placing event details in a clear timeline; and connecting a well-developed story to the broader life story (Foa, Hembreee, & Rothbaum, 2007; Reese et al., 2011). Thus, coherence indexes spatiotemporal clarity and contextualizes life events. Well-structured narratives must also include the details of what occurred, providing factual elaboration about actions, people and objects (see Bruner, 1990). One can tell a coherent yet meager narrative that reveals little about the actual details of what occurred. Thus, it is critical to assess both the coherence and the level of elaborated detail to assess overall structure. Finally, well-structured narratives include interpretations of what happened, integrating interpretive elaboration about motivations, thoughts and feelings (see Stein, 1982). These narratives provide insights into what the protagonist was thinking and feeling during an event, what goals drove their actions, and how the event continues to evoke certain feelings. Both factual and interpretive elaboration lend themselves to cultural norms of a “good story” (see Dyer & Keller-Cohen, 2000; Fivush, 2011; Gonçalves, Matos, & Santos, 2009; Nelson, 2003; Reese et al., 2011).
Generally, individuals who provide well-structured life stories have higher well-being (Baerger & McAdams, 1999; Waters, & Fivush, 2015), and structure is important for recovery from disruptive life experiences (Habermas & Köber, 2015; Tuval-Maschiach, et al., 2004). Further, individuals faced with threatening experiences may be motivated to incorporate more structure to manage painful memories (Graci et al., 2018). Alternatively, individuals who struggle to structure an important experience (i.e., misplace details; interrupt the flow of an event) tend to report poorer mental health (O’Kearney & Perrot, 2006).
In the context of trauma, avoiding thinking about the traumatic event is one factor theorized to contribute to the development of PTSD and might also be associated with poorly structured narratives of traumatic events (Rothbaum et al., 2014). In contrast, efficacious forms of psychotherapy for PTSD such as Cognitive Processing Therapy, trauma-focused cognitive behavioral treatment and narrative forms of Exposure Therapy involve re-organizing and re-telling the story of the traumatic event and the life story after trauma (Cigrang, et al., 2015; Cohen & Mannarino, 1993; Lely, Smid, Jongedijk, Knipscheer, & Kleber, 2019; Resick & Schnicke, 1992). Previous research suggests that narrative structure is negatively linked to depressive and posttraumatic symptoms. However, findings remain complex and contested (see Rubin et al., 2016b and Brewin, 2016, for discussions). One critical piece in this puzzle is the role of time: the extent to which narrative structure may change over the months following trauma exposure, and possible associations between structure and the process of recovery. We have little information on how structure emerges shortly after a traumatic event—essentially in the window of encoding—or how that structure may change over time as the meaning-making process develops. Capturing narrative structure shortly following trauma and mapping change over time is critical for understanding both theoretical process and for designing appropriate interventions.
Three aspects of narrative structure—coherence, factual elaboration, and interpretive elaboration—are related and tend to share a common factor when considered alongside other affective, motivational, and meaning-making indicators within narratives (e.g., Graci et al., 2018; McLean et al., 2019). However, these three measures remain conceptually distinct and were measured separately in order to ascertain how each might change and contribute to reported symptoms over time. One mechanism by which aspects of structure may contribute to posttraumatic symptoms is through the promotion of coping (e.g., Greenhoot, Sun, Burnell, & Lindboe, 2013). Coping involves the ways individuals respond to current or potential stressors and can involve strategies for engaging with stressors, as well as avoiding or downplaying stressors (see Waldrop & Resick, 2004; Tobin et al., 1989). Coping engagement buffers from symptom reports, whereas disengagement is a risk factor for symptom reports (Waldrop & Resick, 2004). Further, narrative structure has ties with coping. Fiese and Wambolt (2003) found that coherence in families’ interviews of a child’s life functioning with asthma buffered families from coping difficulties with problem-solving, emotion responses, effective communication, and daily functioning. Hence, we were interested in how trauma narrative structure may predict coping, as well as how coping may mediate the relations between narrative structure and posttraumtic symptoms.
The Current Study
We were in a unique position to address questions about narrative structure as part of a larger study of individuals requiring emergency care following a traumatic event. Community adults provided a same-day narrative account of a traumatic experience and reports of internalizing symptoms. Across follow-ups, participants reported recent depressive and posttraumatic symptoms and coping strategies. At twelve-month follow-up, participants provided another narrative of the traumatic event from one year prior. In an initial examination of this dataset, we computer-analyzed the linguistic markers of same-day trauma narratives on well-being (Masked for Review), and found that specific word usage that could indicate structure in same-day narratives (i.e., more past-tense words; fewer cognitive process words) predicted fewer depressive and posttraumatic symptoms over time. The current study extended these initial findings in four critical ways: 1) we rated narratives to provide a more comprehensive examination of structure; 2) we included both the immediate and twelve-month narratives to assess change in structure; 3) we compared the effects of both baseline and twelve-month narratives on twelve-month outcomes of depressive and posttraumatic symptoms; and 4) we considered possible mechanisms between structure and reported symptoms via endorsements of coping.
H1: Participants would show an increase in all three aspects of narrative structure over time.
H2: Narrative structure would negatively predict depressive and posttraumatic symptoms, and narrative structure would be more strongly associated with symptom reports at twelve-month follow-up, reflecting the participants’ current conceptualizations of the traumatic event.
H3: Narrative structure would promote engagement and buffer against disengagement, and coping strategies would mediate effects between narrative organization and reported symptoms.
Method
Participants
We analyzed data from 68 participants (41.2% women, 67.6% Black, Mage = 35.67 years) drawn from a larger study of biomarkers for PTSD. This included participants who provided a narrative of the experience that brought them into the emergency department that day. Further, a subset of participants provided a twelve-month follow-up narrative of the traumatic experience.1 We note this is a small sample, but further note the unique ability to compare narratives within the window of encoding with long-term follow-up narratives in relation to depressive and posttraumatic symptoms.
Participants were patients in a Level I trauma center in the emergency department (ED) of a metropolitan, southeastern U.S. hospital. Participants had experienced a trauma within the last 1–13 hours (Mmin = 258.38, SD = 144.21). Participants were recruited if they were English-speaking, 18–65 years of age, endorsed a Criterion A trauma, endorsed feeling as if they would be seriously injured or killed during the event that brought them to the ED (DSM-IV-TR; American Psychiatric Association [APA], 2000), and provided contact info for follow-up. Exclusion criteria included current suicidal ideation, attempted suicide in the past three months, current intoxication, or altered mental state during ED visit. Of individuals who were approached, 82.45% were eligible to participate and 45.31% of eligible individuals consented.
Trauma categories included motor vehicle crashes (58.2%), non-sexual assaults (4.5%), home and industry accidents (e.g., ceiling collapse; 9.0%), pedestrian vs. auto accidents (9.0%), bicycle vs. auto accidents and bike crashes (3.0%), motorcycle crashes (6.0%), stabbings (1.5%), falls from ten or more feet (4.5%), and sexual assaults (4.4%). Exclusion criteria included individuals having a Glascow Coma Score < 15 by the time of approach and consent. Falls < 10 feet and ground level falls did not meet criteria.
Participants provided written informed consent. The Institutional Review Boards of [Masked for Review] and [Masked for Review] approved the study procedures.
Procedure
Study staff were present in the ED and/or available for referrals from 7 am to 11 pm Monday through Saturday. All patients entering the trauma center during study shifts were screened for eligibility, as well as any sexual assault patients who were often roomed in other areas of the ED. After initial medical stabilization procedures, study staff members checked with the attending physician and nurse whether the patient was at a good point in their medical care timeline to approach for study participation, often after any in-center imaging procedures (i.e., sonogram, X-ray) and prior to CT or MRI imaging.
Patients first indicated whether they would be willing to hear about a potential study. After introducing the study procedures, staff assessed inclusion and exclusion criteria, and completed the informed consent. Study procedures progressed during any quiet periods during the flow of treatment and paused during treatment from physicians and nurses.
Participants completed an hour-long assessment while in the ED and returned for follow-ups at one-, three-, six-, and twelve-months. Researchers verbally administered all measures and recorded participants’ verbal responses in Research Electronic Data Capture (RedCAP), a HIPAA-compliant web-based electronic survey tool. Interviews were recorded using a digital voice recorder and recordings were transcribed.
Measures
Trauma narratives.
At both the ED and twelve-month follow-up, participants were asked to provide narratives of the trauma experience that brought them into the ED, “Can you tell me briefly what happened to you that brought you into the ER [emergency room] today/one year ago?” The participant’s complete response was audio recorded and transcribed. ED narratives ranged from 3 to 381 words (M = 79.94 words, SD = 77.40). Twelve-month narratives ranged from 12 to 375 words (M = 107.06 words, SD = 82.04).2
Independent ratings of narrative structure.
Two-member coding teams rated narratives for factual elaboration, interpretive elaboration, and coherence, using rating scales previously used with adult samples (see Graci, et al., 2018; Reese et al., 2011). Team members separately rated a shared set of narratives (~25% of total narratives) and resolved differences in personal ratings through consensus meetings. Once reliable with each other, team members rated remaining narratives independently without consensus meetings. Table 1 describes each rating scheme and provides inter-rater reliabilities. Within ED and twelve-month time points, each measure of narrative structure was positively correlated with narrative word count (rs = .51 – 84). Hence, word count was treated as a covariate for later hypothesis tests.
Table 1.
Narrative Structure Rating Descriptions
| Structure Rating | Definition | Range | Cronbach’s α |
|---|---|---|---|
| Factual Elaboration | Rich descriptions of the actions and details of an event | 0–3 | .97 |
| Interpretive Elaboration | Rich descriptions of internal feelings, values, and interpretations of an event | 0–3 | .93 |
| Contextual Coherence | Placing an event in time and space | 0–3 | .88 |
| Chronological Coherence | Placing all interactions and experiences of the event in the clear timeline | 0–3 | .97 |
| Thematic Coherence | Building a consistent topic within the event and establishing the event within the broader life story | 0–3 | .78 |
Note. The Coherence measure used in this study was a composite of contextual, chronological, and thematic coherence. Hence, Coherence had a range of 0–9.
Computer ratings of word use.
In line with an earlier study of the baseline narratives from this sample (Masked for Review), we used the LIWC 2015 program to collect ratings of past-tense language (i.e., ago, talked, “did”) and cognitive process language (i.e., “cause”, “know”; Pennebaker, Booth, Boyd, & Francis, 2015). These variables were treated as covariates in this study.
Self-reports of depressive symptoms.
At baseline and each follow-up, participants completed the Beck Depression Inventory (BDI; Beck et al., 1996), which includes 21 items on a 4-point Likert-scale (e.g., 0 = I do not feel sad, 3 = I am so sad and unhappy that I can’t stand it). Participants rated their symptom severity for the past two weeks. Internal consistency was high (αs ≥ .89).
Self-reports of posttraumatic symptoms.
At the baseline, participants completed the Posttraumatic Diagnostic Scale - Self-Report (PDS; Foa et al., 1997). This measure included a trauma events checklist, which was the basis of participant trauma history. This measure also included a scale assessing the current severity of posttraumatic symptoms related to prior trauma experience. Symptoms were rated on a 4-point scale of symptom frequency (1 = not at all or only one time, 3 = 5 or more times a week / almost always). Internal consistency has been shown to be acceptable for this scale (Cronbach’s α = .92 for total symptom severity; see Foa et al., 1997).
At each follow-up, participants completed the PTSD Symptom Scale (PSS; Foa et al., 1993), a semi-structured interview with 17 items regarding the specific traumatic experience that brought participants into the ED. Participants were asked the number of times they experienced posttraumatic stress symptoms regarding the experience in the last two weeks (sample item, “Have you had recurrent or intrusive distressing thoughts or recollections about [the event]?”; 0 = not at all, 3 = 5 or more times). Internal consistency was high (Cronbach’s αs ≥ .88).
Coping.
At each follow-up, participants completed the Coping Strategies Inventory (Tobin, Holroyd, Reynolds, & Wigal, 1989). This scale includes 72 items that measure strategies of active engagement and passive or avoidant disengagement in responding to stresses. Items were completed on a 5-point Likert scale. We incorporated the highest-level measures of engagement and disengagement, rather than lower-level scales (i.e., problem engagement, emotion disengagement). These scales have shown high internal consistency (Cronbach’s αs .89–.90; Tobin et al., 1989).
Results
Analytical Plan
Preliminary analyses included correlation analyses and independent-samples t-tests addressing differences given a) availability of twelve-month narratives and b) whether trauma codes involved a form of automobile accident. Preliminary analyses are summarized below and presented fully in the Supplemental Materials. Descriptive statistics are presented on Table 2.
Table 2.
Descriptive Statistics
| Baseline | One Month | Three Months | Six Months | Twelve Months | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N | M | SD | N | M | SD | N | M | SD | N | M | SD | N | M | SD | |
| Trauma History | 68 | 2.09 | 1.79 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | |
| Prior Posttraumatic Symptoms | 68 | 6.22 | 9.49 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Cognitive Processing Words | 68 | 7.05 | 6.06 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Past-Tense Words | 68 | 10.78 | 5.41 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- |
| Word Count | 68 | 79.94 | 77.40 | -- | -- | -- | -- | -- | -- | -- | -- | -- | 35 | 107.06 | 82.04 |
| Factual Elaboration | 68 | 1.22 | 1.06 | -- | -- | -- | -- | -- | -- | -- | -- | -- | 35 | 1.66 | 1.08 |
| Interpretive Elaboration | 68 | .34 | .73 | -- | -- | -- | -- | -- | -- | -- | -- | -- | 35 | .60 | .98 |
| Coherence | 68 | 4.50 | 2.35 | -- | -- | -- | -- | -- | -- | -- | -- | -- | 35 | 5.69 | 1.43 |
| Engagement Coping | -- | -- | -- | 41 | 113.30 | 28.44 | 64 | 115.00 | 27.09 | 59 | 117.00 | 26.85 | 62 | 114.90 | 28.92 |
| Disengagement Coping | -- | -- | -- | 40 | 90.15 | 22.96 | 63 | 83.52 | 23.72 | 58 | 88.52 | 22.89 | 62 | 83.90 | 22.90 |
| Recent Depressive Symptoms | 62 | 9.79 | 8.89 | 66 | 9.49 | 8.73 | 62 | 10.39 | 9.82 | 67 | 9.90 | 10.16 | 67 | 9.90 | 10.16 |
| Recent Posttraumatic Symptoms | -- | -- | -- | 61 | 15.75 | 12.45 | 66 | 11.20 | 11.07 | 62 | 11.52 | 11.85 | 67 | 10.39 | 12.13 |
For H1 (change in narrative structure), paired t-tests determined whether individuals showed significant change in independently rated factual elaboration, interpretive elaboration, and coherence from baseline to twelve-month follow-up.
For H2 (predicting twelve-month depressive and posttraumatic symptoms), Bayesian regression compared multiple models for outcomes of twelve-month depressive and posttraumatic symptoms. Bayesian models differ from frequentist statistical approaches in that they are comparative in nature. These models compare the likelihood that data better fits with a null hypothesis compared to one or more alternative hypotheses (i.e., support for a regression model with no IVs vs. a model including age versus a model including age and gender). The resultant Bayes factors represent the likelihood that data supports an alternative hypothesis compared to the null hypothesis. Bayesian models were selected, because they provide information about the probabilities of models given provided data, regardless of the sample size (see Jarosz & Wiley, 2014).
For H3 (testing coping as a mediator between narrative structure and reported symptoms), we tested hierarchical linear models (HLM). Given the findings from H2 (see below), baseline narrative structure indicators predicted between-subjects and within-subjects effects for coping, depressive symptoms, and posttraumatic symptoms. HLM was selected, as it uses all available data across time points to test effects on outcomes (n observations = 207–238; see Osborne, 2000). A second set of models added the effects of coping on depressive and posttraumatic symptoms. Lastly, coping responses were tested as possible mediators between narrative structure and symptom reports (Bates, Mächler, Bolker, & Walker, 1996; R Core Team, 2019).
Preliminary Analyses
Independent-samples t-tests showed that participants did not differ on ED or follow-up measures given availability of a twelve-month trauma narrative (all ps > .10). Further, tests showed that participants differed in trauma history (p = .033) and prior posttraumatic symptoms (p = .063) given type of trauma code. Participants with non-automobile-related traumas (i.e., assaults, falls) reported more extensive trauma history and more severe prior posttraumatic symptoms. There were no differences in follow-up measures given trauma code.
H1: Change in Narrative Structure
Paired t-tests addressed mean differences in narrative structure between baseline (ED visit) and twelve-month follow-up: coherence; factual elaboration; and interpretive elaboration.3 There was a significant increase between time points for coherence, Mdiff = 1.00, SEdiff = .42, t(34) = 2.38, d = .42, p = .023 and for factual elaboration, Mdiff = .51, SEdiff = .24, t(34) = 2.11, d = .36, p = .042, and a trending increase for interpretive elaboration, Mdiff = .37, SEdiff = .20, t(34) = 1.85, d = .31, p = .074. Overall, H1 was supported. There was evidence of improvements in narrative structure in the year following the traumatic experience.
H2: Predicting Twelve-Month Symptom Reports
Bayesian modeling compared multiple, regression models predicting twelve-month symptom reports. Models compared different configurations of demographics, linguistic measures, ED and twelve-month narrative structure, ED depressive symptoms, and prior posttraumatic symptoms. A uniform prior probability was used for model comparisons—assuming that before data were accounted for, any model configuration was equally likely. The best-supported models for depressive and posttraumatic symptoms are summarized below.
For depressive symptoms, the best-supported model included baseline depressive symptoms (95% credible interval [CI]: .09, .70) and baseline coherence (95% CI: −2.39, −.11; model R2 = .37). Coherence was negatively associated with depressive symptoms. The inverse Bayes factor for this model was 34.41, which is considered strong model evidence (see Jarosz & Wiley, 2014).
For posttraumatic symptoms, the best supported model included trauma history (95% CI: 1.06, 4.33), twelve-month word count (95% CI: −.01, .07), and baseline factual elaboration (95% CI: −8.01, −2.30; model R2 = .52). Factual elaboration was negatively associated with posttraumatic symptoms. The inverse Bayes factor for this model was 70.70, which is strong model evidence.
Findings were mixed for H2. Narrative structure was negatively associated with depressive and posttraumatic symptoms, as expected. However, it was baseline, rather than twelve-month structure that had better support for informing twelve-month symptoms. This was unexpected.
H3: Coping as a Mechanism between Structure and Symptoms
HLM tested the ways ED narrative structure (and then endorsements of coping) predicted follow-up reports of coping, depressive symptoms, and posttraumatic symptoms. Structure was tested at the person-level—effects were treated as consistent within participants, across time points. With later models, coping was included and treated as time-varying—effects could vary alongside depressive and posttraumatic symptom reports. Effect sizes were computed based on an approach from Rye and colleagues (2005).4 The first series of models tested between- and within-person effects of structure on outcomes.5 Table 3 presents the fixed effects of these models.
Table 3.
Fixed Effects of Trauma Narrative Structure on Coping and Symptom Reports
| Engagement | Disengagement | Depressive | Posttraumatic | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Est. | S.E. | | d | | Est. | S.E. | | d | | Est. | S.E. | | d | | Est. | S.E. | | d | | |
| Between-Subject Effects | ||||||||||||
| Overall Intercept | 119.8 | 8.21 | 111.9 | 7.27 | 15.51 | 2.41 | 18.65 | 2.89 | ||||
| Factual | 6.13 | 4.82 | .29 | 5.49 | 4.53 | .38 | .21 | 1.46 | .04 | −.90 | 1.71 | .14 |
| Interpretive | −10.26 | 5.11 | .49 | −10.89 | 4.53 | .75 | −1.97 | 1.62 | .38 | −1.61 | 1.91 | .24 |
| Coherence | −2.84 | 2.07 | .14 | −5.68 | 1.92 | .39 | −.76 | .61 | .15 | .59 | .72 | .09 |
| Within-Subject Effects | ||||||||||||
| Linear Time Intercept | 2.87 | 1.61 | .14 | −3.81 | 2.03 | .26 | −2.19 | .71 | .42 | −1.81 | .76 | .03 |
| Factual | −1.19 | 1.06 | .06 | −2.33 | 1.38 | .16 | −.47 | .46 | .09 | −.39 | .50 | .06 |
| Interpretive | 3.82 | 1.03 | .18 | 3.20 | 1.31 | .22 | .29 | .50 | .06 | −.34 | .53 | .05 |
| Coherence | −.15 | .45 | .01 | 1.24 | .57 | .09 | .36 | .19 | .07 | .18 | .21 | .03 |
| Quadratic Time Intercept | −.24 | .11 | .01 | .21 | .14 | .01 | .14 | .05 | .03 | .09 | .05 | .01 |
| Factual | .07 | .07 | .00 | .13 | .09 | .01 | .03 | .03 | .00 | .02 | .03 | .00 |
| Interpretive | −.23 | .07 | .01 | −.22 | .09 | .02 | −.02 | .03 | .00 | .02 | .04 | .00 |
| Coherence | .02 | .03 | .00 | −.07 | .04 | .00 | −.02 | .01 | .00 | −.01 | .01 | .00 |
Note. Although accounted for, age, gender, education level, trauma history, and baseline depressive symptoms are not shown in this table. Linear time is measured in months from ED visit. Bolded effects indicate significance at the α < .05 level. N observations = 207–238.
For engagement, interpretive elaboration showed between- and within-person effects. Participants higher in interpretive elaboration started lower in engagement, showed an initial increase, then a later decline. Figure 1 (left panel) depicts estimates of engagement given minimum (0) and maximum (3) scores of interpretive elaboration. Factual elaboration and coherence did not show significant effects.
Figure 1. Estimated Scores in Engagement (Left) and Disengagement (Right) given Baseline Interpretive Elaboration of the trauma narrative.
Note. All other model effects are accounted for in presenting these estimates.
For disengagement, interpretive elaboration showed between- and within-person effects. Participants higher in interpretive elaboration started lower in disengagement, showed an initial increase in disengagement, and then a later decline. Figure 1 (right panel) depicts estimates of disengagement given minimum and maximum interpretive elaboration scores. Coherence showed between- and within-person effects. Participants with higher coherence were buffered from early endorsements of disengagement, but reported later increases. Figure 2 depicts estimates of disengagement given minimum (0), mean (4.5), and maximum (9) coherence scores. Factual elaboration did not show a significant effect.6
Figure 2. Estimated Scores in Disengagement given Baseline Coherence of the trauma narrative.
Note. All other model effects are accounted for in presenting these estimates.
Reports of depressive symptoms decreased across follow-ups. Reports of posttraumatic symptom severity decreased across follow-ups. There were no additional effects of narrative structure.
Additional models added effects of engagement and disengagement (see Table 4). Engagement had negative effects on depressive symptoms and posttraumatic symptoms. When engagement was higher within time points, reports of depressive and posttraumatic symptoms tended to be lower. Disengagement had positive effects on depressive symptoms and posttraumatic symptoms. When disengagement was higher within time points, reports of depressive and posttraumatic symptoms tended to be higher. These findings are in line with previous research on the role of coping in traumatic contexts (Rayburn et al., 2005; Thompson, Fiorillo, Rothbaum, Ressler, & Michopoulos, 2018) and fit with our expectations.
Table 4.
Fixed Effects of Trauma Narrative Structure and Coping on Symptom Reports
| Depressive | Posttraumatic | |||||
|---|---|---|---|---|---|---|
| Est. | S.E. | | d | | Est. | S.E. | | d | | |
| Between-Subject Effects (Time-Invariant) | ||||||
| Overall Intercept | 11.86 | 2.63 | 10.88 | 2.90 | ||
| Factual | −.40 | 1.64 | .08 | −3.25 | 1.75 | .54 |
| Interpretive | .50 | 1.62 | .10 | 2.08 | 1.78 | .34 |
| Coherence | −.38 | .70 | .08 | .94 | .75 | .16 |
| Between-Subject Effects (Time-Varying) | ||||||
| Engagement | −1.36 | .67 | .28 | −1.67 | .75 | .28 |
| Disengagement | 3.16 | .63 | .66 | 4.05 | .66 | .67 |
| Within-Subject Effects | ||||||
| Linear Time Intercept | −1.48 | .76 | .31 | .06 | .74 | .01 |
| Factual | −.30 | .52 | .06 | .34 | .50 | .06 |
| Interpretive | −.43 | .50 | .09 | −1.39 | .48 | .23 |
| Coherence | .34 | .22 | .07 | −.19 | .21 | .03 |
| Quadratic Time Intercept | .10 | .05 | .02 | −.02 | .05 | .00 |
| Factual | .03 | .04 | .01 | −.01 | .03 | .00 |
| Interpretive | .03 | .03 | .01 | .09 | .03 | .01 |
| Coherence | −.03 | .02 | .01 | .01 | .01 | .00 |
Note. Although accounted for, age, gender, education level, trauma history, and baseline depressive symptoms are not shown in this table. Linear time is measured in months from ED visit. Bolded effects indicate significance at the α < .05 level. N observations = 204.
Given the effects of structure on change in coping (‘a path’ effects) and the effects of coping on reported symptoms (‘b path’ effects), we tested for indirect effects. For these tests, we used the Monte Carlo mediation test provided by Selig and Preacher (2008; Preacher & Selig, 2012), considering a) the linear time effects of narrative structure onto engagement (interpretive elaboration only) and disengagement (interpretive elaboration and coherence), as well as b) coping on symptom reports. Because these effects were formed in separate models, covariance between them was set to zero. Bootstrapped indirect effects were formed using 20,000 resamples. Confidence intervals [CIs] that did not include zero provided support for an effect.
The indirect effects from interpretation elaboration and through engagement were supported for depressive (95% CI: −11.83, −.11) and posttraumatic symptoms (95% CI: −13.39, −1.14). The indirect effects from interpretive elaboration and through disengagement were supported for depressive (95% CI: 1.91, 19.88) and posttraumatic symptoms (95% CI: 2.48, 25.06). Lastly, the indirect effects from coherence and through disengagement were supported for depressive (95% CI: .36, 8.13) and posttraumatic symptoms (95% CI: .47, 10.21).
Findings were mixed for H3. Interpretive elaboration and coherence informed between- and within-person differences in coping, as expected. Higher scores in interpretive elaboration predicted greater engagement and lower disengagement over time, as expected; however, higher scores in coherence predicted increases in later disengagement—it was not beneficial over the entire course of the year. Structure did not directly inform trajectories of depressive and posttraumatic symptoms, which was surprising. Indirect effects—but not full mediation—were supported between structure and symptoms via coping responses, partially supporting hypotheses.
Discussion
The ability to frame the life story in a well-structured manner is essential for understanding oneself and presenting important details to others (McAdams & McLean, 2013). Yet, coherence, detail, and interpretation shortly after a traumatic event may be difficult to achieve, which could have implications for posttraumatic symptoms. We addressed the ways trauma narrative structure could change over time and its associations with reported posttraumatic and depression symptoms. Our findings align with theoretical and empirical work suggesting it takes time for narrative structure to progress (Fivush, Booker, & Graci, 2017; Reese et al., 2011), that structure—and particularly structure shortly following trauma—help inform later symptom reports (Baerger & McAdams, 1999; Waters & Fivush, 2015), and that early narrative structure can shape ongoing coping strategies, with implications for symptom reports (Fiese & Wambolt, 2003).
That narratives of traumatic events need time and rehearsal to gain structure fits with theoretical considerations of narratives (Fivush et al., 2017; Reese et al., 2011). Further, structure may hold different benefits given the length of time since the traumatic event. This is important because most studies considering narratives of trauma do not account for the length of time since the event (see Waters, Bohanek, Marin & Fivush, 2012), nor examine narratives in the immediate aftermath of trauma. We found that, early on, the coherence of the narrative buffered against more passive or avoidant strategies of coping—that people would be less likely to minimize or shrink from problems in their lives. However, this benefit faded over time. Further, coherence was not promotive of more active forms of engaging with life’s challenges. These findings and the null findings of factual elaboration suggest that being able to recollect richly detailed, well-developed narratives is not a guaranteed indicator of optimal coping following trauma. It is possible that even as individuals are recounting early details and even progressing through the sequence of events that brought them into the emergency department, they could be providing excessive information that becomes an encumbrance for narrator and audience alike (e.g., forms of rambling that could undermine organization and communication; see Grice, 1989). Similarly, a meta-analysis of narrative exposure therapy (NET), a trauma-focused intervention involving patients and clinicians organizing elaborative and coherent recollections of the patient’s life story, found that while NET shows general post-treatment benefits for reducing posttraumatic and depressive symptoms, it may not outperform other forms of active intervention that do not depend on similar forms of re-structuring the life story (Lely et al., 2019). Hence, questions remain on how beneficial early (and ongoing) trauma coherence and factual elaboration may be for managing stressors and psychological symptoms.
Alternatively, the tendency to frame a traumatic event with greater emphasis on one’s thoughts, feelings, and goals—with interpretive elaboration—became increasingly beneficial for promoting more active and engaged strategies of coping and buffering from more passive and disengagement coping strategies. These longitudinal patterns are in line with emotional responses seen over the course of posttraumatic stress interventions, such as prolonged exposure therapy (see Rothbaum & Davis, 2006). Ultimately, the extent individuals maintained a focus on their internal states and experiences from the traumatic event could be helpful in maintaining a clearer sense of self (Habermas & Köber, 2015), not becoming overwhelmed by the traumatic memories, and shifting focus toward active strategies for managing distress (Fiese & Wambolt, 2003), which would then promote mental health following trauma.
These findings are important for applications of trauma intervention. We found that immediate displays of narrative structure, rather than later and concurrent displays of narrative structure, better informed twelve-month outcomes of reported symptoms, and served as buffers from anxiety and mood symptoms. This is encouraging given interest in intervening and improving the structure of the life story as part of the therapeutic process—this is the explicit focus of narrative (Peri & Gofman, 2014) and expressive writing interventions (Pennebaker, 1997), and can be argued to be a major impact of many psychotherapies (Adler, 2012; Foa, Hembree, Rothbaum, & Rauch, 2019). Further, results suggest that immediate narratives may be informative about which trauma-exposed individuals may be in greatest need of intervention following the traumatic event. Importantly, however, the current study did not involve intervention, only addressing spontaneous changes in narrative structure. Hence, there remains potential for active interventions to promote narrative structure and direct that structure toward positive evaluations and meaning-making for the self.
Limitations, Strengths, and Future Directions
Our study was limited by the reliance on self-reports for depressive and posttraumatic symptoms. It is possible that responses were biased, that participants neglected valuable information in assessing these symptoms, or that memories of the traumas were impacted by participants’ existing symptoms (e.g., Dell’Osso et al., 2011). We were also limited by procedural difficulties in collecting twelve-month trauma narratives. Compared to other same-day trauma collection projects (e.g., Buck, Kindt, van den Hout, Steens, & Linders, 2006), this study sample was relatively large; still, we had a limited sample size. We used analyses that addressed the concerns of a smaller sample, including Bayesian regression analyses that shifted focus to model comparisons that are not dependent on sample size (Jarosz & Wiley, 2014) and HLM, which was sufficiently powered given the use of all available responses across time points. Though multiple trauma types were eligible for participation, participants needed a Glascow Coma Score of 15 (the maximum score) at the time of the consent conversation; hence, traumas tended to be of moderate acuity and were primarily composed of motor vehicle-related incidents and assaults. Thus, findings may not generalize to experiences with other traumas, such as those involving war and natural disasters.
This project benefited from studying a community sample that provided same-day and twelve-month recollections of the trauma, as well as longitudinal reports of psychological distress. Our focus on immediate trauma narratives and manual coding of those narratives addresses an important gap regarding initial trauma memory structure, change in that structure, and the implications of such structure. Future research will benefit from extending focus to additional narrative themes, complimenting the structure of trauma narratives with reasoning, motivation, and affect (McLean et al., 2019).
Conclusions
There is meaningful variability in how trauma-exposed adults begin to structure a traumatic experience, with unique implications for how adults cope with posttraumatic symptoms in the following year. In the context of health and clinical services, working with trauma-exposed adults to collect a recalled understanding of the traumatic experience may help target individuals in greater need of ongoing intervention to address posttraumatic symptoms. For researchers, these findings reinforce the importance and unique insights of autobiographical narratives as a rich compliment to self-reports on trauma and coping. We recommend that, where possible, researchers collect these recollections of the traumatic event for additional systematic analysis and a broader view of posttraumatic growth and coping.
Supplementary Material
Highlights.
Trauma narrative organization improves over the course of the year
Trauma memory organization has implications for psychological health
Baseline trauma organization predicted changes in posttraumatic coping
Posttraumatic coping mediated ties between organization and psychological health
Acknowledgements
We would like to acknowledge Kerry J. Ressler, M.D., Ph.D., Debra Houry, M.D., and Abigail Hankin-Wei, M.D. for their generous collaborative efforts on this study. We would like to thank Cypriana Gardner for her work in transcribing the trauma narratives. For their work in the emergency department recruiting and assessing participants, we would like to thank Vasiliki Michopoulous, Alex O. Rothbaum, Thomas Crow, Heather Grinstead, Rebecca C. Roffman, Jessica Maples, Lydia Odenat, Loren M. Post, Liza C. Zwiebach, Devika Fiorillo, Kathryn Breazeale, Jessica Morgan, Natasha Mehta, Elicia D. Skelton, Taleesha S. Booker, and Jonathan Zebrowski.
Funding details
This work was supported by the National Institute of Mental Health (R01 MH094757, F32 MH101976).
Footnotes
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Disclosure statement
The authors report no conflicts of interest regarding this work.
The collection of a twelve-month narrative was a procedural update that took longer than expected to incorporate; hence, the twelve-month narrative prompt was not collected from all participants (see Table 2).
Ratings of these narratives only included spontaneously provided content and not responses to leading questions from the interviewer (e.g., “That sounded painful. Can you tell me more about that?”).
While 48% of participants did not provide twelve-month narrative, we expected the remaining participants to be representative of the sample given a lack of differences in measures given availability of the twelve-month narrative (see the Preliminary Analyses).
d = β / (σ2)1/2, where σ2 is the level-1 error variance of the HLM model.
Secondary Bayesian regressions tested possible support of study covariates (i.e., narrative word count, trauma history, type of trauma code) on one-month engagement, disengagement, depressive symptoms, and posttraumatic symptoms. Covariates of age, gender, education level, baseline depressive symptoms and trauma history were supported for one or more outcomes and were controlled in all H3 tests. See the Supplemental Materials.
Because skewness for baseline interpretive elaboration was greater than 1.00 (skewness = 2.29), models with coping outcomes—where interpretive elaboration was originally supported—were retested with a binary score for the presence of any interpretive elaboration (see the Supplemental Materials). There was one instance of a difference in significant effects. The between-person effect supported for engagement with the original scaling (p = .048) was not supported with the binomial scaling (p = .351). This difference did not impact the primary question of H3 (support for mediation via coping responses). See Supplemental Table 4.
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