Authors: Ines Blix, Alf Børre Kanten, Tore Wentzel-Larsen, Andrea Undset, Andrea Rustand, Siri Thoresen
Categories: Basic Research Article, Trauma, sexual-assault, counterfactual thinking, posttraumatic stress, rape, pensamiento contrafáctico, estrés postraumático, agresión sexual
Source: European Journal of Psychotraumatology
Authors: Ines Blix, Alf Børre Kanten, Tore Wentzel-Larsen, Andrea Undset, Andrea Rustand, Siri Thoresen
Background: Counterfactual thinking (CFT), involves mental simulations of alternative outcomes to past events (e.g. ‘What if … ’ or ‘If only … ’), and is commonly observed after trauma. While CFT can be adaptive, it is also linked to psychological distress, including posttraumatic stress reactions (PTSR).
Objective: The present study aims to examine the relationship between the frequency and vividness of upward and downward counterfactual thoughts and PTSR, in the recent aftermath of sexual assault (SA).
Method: The sample consisted of 327 women who had experienced SA within the last year. PTSR was measured using the International Trauma Questionnaire (ITQ), while CFT was assessed through self-reported frequency and vividness of upward (event could have been less severe or avoided) and downward (event could have been worse) counterfactual thoughts.
Results: The results revealed a significant difference in the distribution of upward versus downward CFT. Specifically, more participants reported engaging in upward CFT ‘Very Often’ and ‘Often,’ while downward CFT was reported less frequently. Vividness was higher for downward CFT. Both frequency and vividness of upward and downward counterfactuals were significantly associated with higher levels of PTSR.
Conclusion: The present findings highlight the role of counterfactual thinking in post-assault distress and emphasize the need for targeted interventions addressing CFT in the aftermath of trauma.
In the aftermath of trauma, thoughts about what could have happened tend to arise (for a review, see Hoppen & Morina, 2021). Such mental simulations of alternatives to past events are referred to as counterfactual thinking (CFT) and are often expressed as ‘What if … ’ or ‘If only … ’ (Epstude & Roese, 2008; Roese & Epstude, 2017). Counterfactual thoughts are typically categorized into upward and downward counterfactuals. After a traumatic experience, upward counterfactuals involve thoughts about how the situation could have been avoided or turned out less severe, such as when a sexual assault victim thinks ‘If only there had been more people around, someone would have intervened.’ In the case of downward counterfactuals after trauma, the victim will think of outcomes even more severe than the factual event (e.g. ‘If I hadn’t managed to get away, I would have been killed’). Although CFT in general can be adaptive in the sense that it can contribute to insight and help us to avoid future dangers (Roese & Epstude, 2017), it is also linked to psychological distress following trauma (Blix et al., 2016; El Leithy et al., 2006; Hoppen & Morina, 2021).
According to Markman and McMullen’s (2003) Reflection and Evaluation Model (REM), CFT can lead to negative (or positive) affect through two key processes. First, individuals may evaluate what happened against the backdrop of an imagined outcome (better or worse), leading to an affective contrast effect (e.g. feeling bad when thinking about how great things could have been, or feeling better when contemplating how much worse things could have been). Conversely, a reflection process where people vividly imagine a worse or better counterfactual, may give rise to affective reactions congruent with the simulated outcome (affective assimilation; e.g. feeling sad when simulating how life would have been if a loved one had not survived an accident). Thus, whereas an evaluative mode of thinking involves treating the counterfactual as a reference point, reflection entails simulating the counterfactual event in an experiential (and vivid) fashion. The process of reflection then, is akin to processing the counterfactual as if it were a real event, rather than as a comparison standard to evaluate reality. Whether counterfactual simulations become characterized by evaluation or reflection can according to REM depend on a variety of contextual features (e.g. attentional focus). Interestingly, Markman and McMullen (2003) note that these mechanisms of affective contrast vs. assimilation might not always be mutually exclusive in any given situation. Thus, this would mean that a contrast-based feeling such as relief (Roese, 1994) might coincide with more assimilation-like experiences (e.g. feeling disturbed after avoiding death by a small margin).
The cognitive model of posttraumatic stress disorder (PTSD) emphasizes that cognitive processing, in terms of how individuals react to and interpret traumatic experiences, plays a crucial role for post-trauma psychopathology (Ehlers & Clark, 2000). Research within this framework has primarily focused on the role of maladaptive appraisals in maintaining PTSD symptoms. More recently, however, research has increasingly explored how CFT might be involved in posttraumatic stress reactions (PTSR). A link between CFT and PTSR has been demonstrated in relation to various events including disasters (Blix et al., 2018), terrorist attacks (Blix et al., 2024; Gilbar et al., 2010; Undset et al., 2024), and physical assault (El Leithy et al., 2006). Several studies have demonstrated positive associations between upward CFT and symptom severity (For a review, see Hoppen & Morina, 2021), but data suggesting a similar connection with downward CFT has also been documented, specifically in the context of terrorist attacks (Blix et al., 2016; Poulin & Silver, 2020) and a ferry disaster (Blix et al., 2018).
Most of the studies cited above have focused on CFT frequency. Interestingly, a few recent studies indicate that the vividness of counterfactual thoughts might also play a role in PTSR. Specifically, more vivid counterfactuals, characterized by intense emotional responses, rich sensory details, and a heightened sense of mental time travel, have been linked to higher levels of PTSR (Blix et al., 2018, 2024; Undset et al., 2024). However, as these studies did not differentiate between vividness of upward vs. downward counterfactuals, potentially important distinctions are overlooked. Specifically, the REM (Markman & McMullen, 2003) suggests that CFT can produce affective consequences via four routes – upward/downward reflection and upward/downward evaluation. The observed positive associations between CFT and PTSR in the literature can be seen as compatible with downward reflection (associated with assimilation) and upward evaluation (associated with contrast). This configuration implies a certain level of vividness for the downward counterfactuals but not for the upward counterfactuals, as vivid ‘as if’ simulation of ‘what could have happened’ is a necessary precursor only for affective assimilation, according to the REM. This logic also implies that the documented positive relationship between the vividness of CFT and PTSR might be stronger for downward than for upward counterfactuals (as vivid simulations of counterfactual alternatives is the hallmark of the reflection process in the REM).
The studies demonstrating a positive association between downward CFT and PTSR have involved large scale events with multiple victims. As suggested by Teigen and Jensen (2011; see also Poulin & Silver, 2020), such event features may make downward counterfactuals more easily activated (‘It could have been me who died’). This notion is also consistent with the more general idea of outcome closeness as an important activator of CFT (e.g. Markman & Tetlock, 2000). However, it remains unclear whether the link between downward counterfactuals and PTSR is specific to mass trauma contexts where social comparisons are readily available, or whether a similar pattern can also be observed following interpersonal or individual trauma. The present research addresses this question by investigating both upward and downward counterfactuals, and their potential relationships to PTSR in recent victims of sexual assault.
Sexual assault is a type of trauma associated with particularly high levels of PTSR (Kessler et al., 2017). A meta-analysis found that 75% of sexual assault victims experienced PTSD symptoms above the diagnostic threshold one month after the assault, and 42% still suffered from reactions severe enough that it qualified for a PTSD diagnosis after one year (Dworkin et al., 2023). The severe consequences of sexual assault for mental health underscores the importance of understanding how cognitive processes such as CFT may contribute to these reactions. So far, only a few studies have examined CFT in the context of sexual assault (Barnett & Maciel, 2021; Miller et al., 2010).
In one study with women who had experienced rape, Branscombe et al. (2003) found that more upward counterfactuals, particularly scenarios involving self-blame, was associated with poorer well-being. Another study by Miller et al. (2010) reported that counterfactual preventability cognitions, a form of upward CFT, were associated with self-blame, but not PTSR in sexual assault victims. In both studies, the focus was exclusively on upward counterfactuals, and the potential role of downward counterfactual thinking was not addressed. In the study by Miller et al. (2010), it is unclear whether downward counterfactuals were absent from participants’ responses or whether such thoughts simply did not fit the authors’ coding scheme.
To our knowledge only one study has investigated both upward and downward CFT after sexual assault. Barnett and Maciel (2021) found that among undergraduate women who reported sexual assault, higher frequency of upward CFT was linked to greater PTSR, while frequency of downward CFT was associated with lower posttraumatic stress. However, this study measured CFT using a modified version of the Counterfactual Thinking for Negative Events Scale (CTNES; Rye et al., 2008), in which some of the items refer to concrete details or specific affective reactions. For instance, the item ‘I feel relieved when I think about how much worse things could have been’ has a built-in notion of affective contrast, not taking into account that assimilation as well as contrast effects can follow from CFT (Markman & Tetlock, 2000; McMullen, 1997). Thus, mean scores from this scale may not be particularly well suited to measure overall relationships between CFT and PTSR.
Taken together, research on CFT after sexual assault is scarce, and to our knowledge only one study has examined downward counterfactuals in this context. As studies on mass trauma suggest a link between downward counterfactuals and PTSR, it is plausible that such thoughts are relevant for interpersonal traumas as well, including sexual assault. For example, thoughts on how the assault could have resulted in more severe consequences (e.g. being killed or seriously injured) might reflect a sense of threat or perceived close-call.^1^ We suspect that these aspects of post-trauma cognition might induce affective assimilation effects and contribute to post-traumatic stress reactions in a manner similar to trauma memories (Blix et al., 2018). Furthermore, it has been suggested that upward and downward CFT may play similar roles as trauma-related intrusions and rumination, in that they can be vivid, involuntary, and emotionally distressing, thereby contributing to the maintenance of post-traumatic stress reactions (Blix et al., 2016; 2018; Michael et al., 2007). In the present study we will examine both upward and downward CFT in recent victims of sexual assault, using a more direct and less constrained measure of CFT than in previous studies.
The overarching aim of the present study is to clarify and extend previous research on CFT and trauma in the context of sexual assault. Previous research has often focused on CFT long after the trauma occurred (e.g. Blix et al., 2018). Our sample, on the other hand, consists of women who participated in the study shortly after being sexually assaulted. This provides a unique perspective on CFT in the recent aftermath of trauma.
In the present study, we will do the Examine the Frequency and Vividness of CFT after sexual We will compare the frequency and the degree of vividness for upward and downward CFT. Based on the notion that positive associations between downward counterfactuals and PTSR reported in the trauma literature might indicate instances of affective assimilation, we hypothesize that downward counterfactuals would be represented as more vivid than upward counterfactuals.Investigate the Relationship between frequency of CFT and PTSR: We hypothesize that a higher reported frequency of both upward and downward CFT will be uniquely associated with increased levels of PTSR.Investigate associations between counterfactual vividness and PTSR: We expect higher levels of counterfactual vividness to be associated with higher levels of PTSR, especially with regards to downward counterfactuals.
This study utilizes data from the first wave of the (TRUST-study) study, an ongoing longitudinal observational study examining mental health and recovery in recent victims of sexual assault in (Norway). Participants are recruited through (Norwegian) Sexual Assault Care Centers (SACCs) as well as through social media, with the aim of including both individuals who have sought help at a SACC and those who have not following their recent assault (for a more detailed description see Thoresen et al., submitted). Eligibility criteria include being at least 16 years old and fluency in (Norwegian) or English. As part of the recruitment strategy, we aimed to recruit individuals who had experienced sexual assault within the past 12 months. However, individuals who had experienced sexual assault more than a year ago were not excluded from participation. Strict protocols were implemented to maintain confidentiality, and the study received approval from the Regional Committee for Medical and Health Research Ethics.
Data are based on self-report, and participants could choose between web questionnaires or telephone interviews. Interviews were conducted by members of the (TRUST-study) research team (health personnel with experience in research interviews and one master of science in psychology). Upon completion of the questionnaire/interview, data was transferred encrypted (without local storage) to the University of (Oslo) Server for sensitive data (TSD).
Although recruitment to the first wave will not be completed until December 2024, we created a temporary data file in May 2024, at which time we had achieved a sufficient sample size to answer our research questions (n = 519). For the purpose of the present study, we selected participants who had experienced SA during the last year, and due to a low number of male participants (n = 9) we choose to include only the female participants n = 327. Among these participants, only the n = 300 (91.7%) individuals who confirmed having experienced counterfactual thoughts were included in the analyses.
Sociodemographic Characteristics. In addition to age and gender, participants provided information about other demographic characteristics. The majority identified as cisgender women; however, two participants reported that the male/female categorization did not suit them, and one participant did not respond to the gender identity question. The participants were also asked how they perceived their financial situation compared to others, 9.7% (n = 29) reported being better off than most people, 52.2% (n = 156) reported being about the same, 32.8% (n = 98) considered themselves worse off, and 5.4% (n = 16) either did not know or preferred not to answer. Furthermore, 10.7% (n = 32) of the participants identified as belonging to an ethnic minority group.
Posttraumatic stress reactions. Posttraumatic stress reactions since the assault were measured by the International Trauma Questionnaire (ITQ: Cloitre et al., 2018, Translated version by Sele et al., 2020). The ITQ corresponds to ICD-11 diagnosis of PTSD, and comprises two items for each subscale (re-experiencing, avoidance, and hypervigilance), measured on a scale from ‘Not at all’ (0) to ‘Extremely’ (4). Cronbach’s alpha in the present study was .80. In all, 292 of 300 participants had no missing, 6 participants had one missing item, 1 participant had two missing items, 1 had three missing items. A mean score (range 0–4) was calculated for all participants.
Counterfactual thoughts (Yes/No). Before answering, participants were introduced to the concept of counterfactual thinking with the following ‘After a dramatic event, one may think about how the event could have been different or had a different outcome. One might think “if” or “if only” and imagine alternative possibilities and sequences of events.’ They were then ‘Have you thought about how the incident could have been avoided, turned out differently, or had a different outcome?’ Only the participants who confirmed to have had such thoughts were given the subsequent questions about frequency and vividness of CFT (n = 300).
Frequency of upward and downward counterfactual thoughts. To assess the frequency of upward and downward CFT since the assault, two questions were included in the present study. The items assessing frequency of upward and downward CFT were developed for the present study, but are conceptually based on items used by Blix et al. (2016, 2018), originally adapted from Rye et al. (2008). In Blix et al. (2018), confirmatory factor analyses supported a two-factor structure for upward and downward CFT, indicating that the constructs are distinct but moderately correlated. The participants were asked to answer these questions on a scale ranging from 0 = never to 4 = very often. First the participants were asked about the frequency of upward CFTs: ‘Since the incident, how often have you had thoughts about how the incident could have been less severe or could have been avoided?’ Next the participants were asked about the frequency of downward CFTs: ‘Since the incident, how often have you had thoughts about how the incident could have gone worse or had a worse outcome?’
Vividness of CFT. The items used to assess CFT vividness were adapted from the Autobiographical Memory Questionnaire (AMQ; Rubin et al., 2003; 2011), and have previously been employed in studies by Blix et al. (2018, 2024) and Undset et al. (2024) to measure the vividness of counterfactual thoughts. The participants were asked to ‘Think back to the most common thought you've had about how the incident could have been different or had a different outcome.’ Next, they were asked to indicate if this thought was 1."How the incident could have had a worse outcome’ (downward), or 2. ‘How the incident could have been avoided or been less severe’ (upward). With this CFT in mind, the participants were asked to respond to six questions regarding experienced vividness of this thought, using a scale from 1 (not at all) to 7 (to a very large extent) (see Table 3 for details on the vividness questions). Thus, for some participants the vividness questions were answered referring to an upward CFT whereas other participants answered these questions referring to a downward CFT. A mean CFT vividness score was calculated based on the six items (Cronbach’s alpha = .86). Four out of 300 participants had more than half of the vividness items missing, and a mean score (range 0–4) was calculated for 296 participants.
A marginal homogeneity test was used to compare the distribution of the reported frequency of upward vs. downward CFT. This test can assess differences in the distribution of paired categorical data and allowed us to determine whether the reported frequency of upward and downward CFT differs significantly. To compare the vividness of upward and downward CFT, we conducted a t-test. This approach enabled us to evaluate potential differences in the experienced vividness across the two types of counterfactual thinking.
Separate linear regression models were conducted to investigate the relationships between the explanatory variables (i.e. frequency of CFT and vividness of CFT), and the outcome variable (i.e. PTSR). In the first analysis the frequency of upward and downward CFT were included, and the outcome variable was PTSR. In the second analysis, the vividness of CFT was included as a main predictor, and we examined the interaction between counterfactual direction (upward or downward) and PTSR. The vividness score was the same continuous variable regardless of whether the direction was upward or downward, while the direction variable was a dichotomous variable with values upward and downward. All analyses were adjusted for age.
We applied the half rule to handle missing data in the outcome variables (PTSR) and for the mean counterfactual vividness score (i.e. only participants with valid observations on at least half of the items will be included in the scale scores). The statistical analyses were conducted using SPSS software (version 29.0).
Mean age, assault characteristics and mean ITQ scores are presented in Table 1. Table 1.Descriptives and assault characteristics. Mean (SD)/% (n)Age25.24 (8.02)Posttraumatic stress reactions (ITQ)2.48 (.88)Fear of serious injury or of dying (% to some extent, a large extent, very large extent)54 (150)Experienced physical force or threats during assault (% Yes)39 (117)Penetration during assault (% Yes)82 (246)
A large majority of the participants, n = 300 (91.7%) confirmed that they have had thoughts about how the incident could have been avoided, turned out differently, or had a different outcome. 12 participants (3.7%) reported to not have had counterfactual thoughts about the assault, and 15 (4.6%) had missing response on this question.
The results revealed a significant difference in response distributions between frequency of upward and downward CFT, as indicated by a marginal homogeneity test, p < .001. There were more responses categorized as ‘Rarely’ and ‘Never’ for downward counterfactuals compared to upward counterfactuals. A higher percentage of participants reported ‘Very Often’ and ‘Often’ for upward than for downward counterfactuals (Table 2). Table 2.Distribution for the reported frequency of upward vs. downward CFT, (%) (n = 299).Frequency CategoryUpward CFT (n = 299)Downward CFT (n = 299)Very often126 (42.0)55 (18.4)Often92 (30.8)65 (21.7)Sometimes75 (25.2)100 (33.2)Rarely5 (1.7)45 (15.1)Never1 (0.3)34 (11.4)
For the vividness assessment, 243 (81%) participants identified their most common counterfactual to be in the upward direction (‘How the incident could have been avoided or been less severe’), whereas 57 (19%) participants reported a downward counterfactual as their most common counterfactual (‘How the incident could have had a worse outcome’). Thus, the majority responded to the vividness measure with an upward rather than downward counterfactual in mind.
The mean vividness score for downward CFT was significantly higher than for upward CFT (Table 3). Table 3.Mean scores on the counterfactual vividness items for upward and downward counterfactuals (standard deviations in parentheses).‘When I think about what could have happened … .’Upward (n = 243)Downward (n = 57) I can hear what is happening3.46 (2.08)4.18 (2.05) I can see what is happening4.79 (1.91)5.25 (1.81) I can smell what is happening2.83 (2.07)3.84 (2.21) It is like a real episode3.75 (1.97)4.07 (1.73) I can feel intense emotions4.82 (1.86)4.96 (1.72) I experience a physical reaction4.77 (1.98)5.18 (1.84) ***Mean total vividness CFT score (SD)***4.08 (1.50)4.57 (1.49)p = .025
Linear regression analysis showed that higher frequencies of both upward and downward CFT scores were uniquely associated with more PTSR reactions (Table 4). Table 4.Linear regression with PTSR as outcome, and frequency of CFT of upward and downward as predictors, adjusted for age (n = 298). Coefficient95% CIp-valueFrequency of Upward CFT <.001 Often vs. Very often−.227−.457−.003.053 Sometimes vs. Very often−.642−.886 – −.399<.001 Rarely vs. Very often−.427−1.151−.297.247 Never vs. Very often−1.332−2.298−.264.101Frequency of Downward CFT .011 Often vs. Very often−.187−.492−.118.012 Sometimes vs. Very often−.363−.646 – −.081.012 Rarely vs. Very often−.461−.788 – −.135.006 Never vs. Very often−.537−890 – −.184.228Notes: Some of the comparisons are based on a small number of responses (e.g. never and rarely). Negative coefficients indicate higher PTSR scores associated with more frequent counterfactual thinking (CFT), as ‘Very often’ is the reference category for all pairwise comparisons. Some comparisons are based on a small number of responses (e.g. ‘Never’ and ‘Rarely’).
Linear regression analysis revealed that the vividness of both upward and downward counterfactual thoughts was significantly linked to elevated levels of PTSR. There was no significant interaction between vividness of CFT and type of counterfactual the reported vividness referred to (Table 5). Table 5.Linear regression analysis predicting PTSR from vividness of CFT and counterfactual direction (upward/downward), adjusted for age (n = 296). Coefficient95% CIp-valueVividness if upward CFT.220.152−.288<.001Vividness if downward CFT.349.209−.490<.001Upward vs downward CFT^b^.133−.112−.378.286Interaction Vividness x CFT Direction^a^.130−.026−.285.103R^2^ .197Note. ^a^Coefficient for vividness if downward CFT – Coefficient for vividness if upward CFT.^b^If vividness is 4.
The present study demonstrates that counterfactual thinking can occur frequently in the first year following a sexual assault. The results showed that upward CFT was more frequent than downward CFT in individuals who had recently experienced sexual assault. Specifically, over 70% of the sexual assault victims reported having upward counterfactual thoughts often or very often. Whereas, approximately 40% reported experiencing downward counterfactual thoughts often or very often. Although upward CFT was relatively frequent, the frequency of downward CFT was also high, and higher than in previous studies (Blix et al., 2016; Blix et al., 2018).
Furthermore, the present findings show that following sexual assault, thoughts about what could have happened can be represented as vivid mental constructions, accompanied by intense emotional responses, sensory impressions, and a sense of mental time travel. The high level of vividness for CFT reported in the present study extends previous findings in two important ways. First, this study shows that trauma-related CFT, represented as vivid and episodic thoughts, may not only arise after large scale events with numerous victims (Blix et al., 2018; Blix et al., 2024; Undset et al., 2024), but also after interpersonal trauma such as sexual assault. Second, this was the first study to differentiate between the vividness of upward vs. downward counterfactuals in trauma-exposed individuals. In line with our hypothesis, the present results showed that downward counterfactuals were represented as more vivid than upward counterfactuals.
This study aimed to investigate the relationship between the frequency and vividness of CFT and PTSR. In line with our hypothesis and previous research (Blix et al., 2018; Blix et al., 2024; Undset et al., 2024), the present findings demonstrated a relationship between frequency of CFT and PTSR. In this study, a dose–response relationship between frequency of both upward and downward CFT and PTSR was found. This can be interpreted in line with theories of post-traumatic stress which emphasize the roles of rumination and intrusive trauma memories in the development and maintenance of post-traumatic stress reactions (Brewin et al., 1996; Ehlers & Clark, 2000; Rubin et al., 2008). Moreover, the findings are consistent with the substantial body of empirical research demonstrating the role of rumination and intrusive recollections in the development and persistence of PTSD (e.g. Iyadurai et al., 2019; Moulds et al., 2020). Furthermore, it has been suggested that CFT can be understood as a form of rumination (Michael et al., 2007) that may hinder recovery from PTSD. Supporting this, Blix et al. (2016) found that the frequency and intrusiveness of CFT – defined as repeated, disturbing, and unwanted thoughts about how the traumatic event could have been avoided – were strongly associated with PTSR in both individuals directly and indirectly exposed to a terrorist bombing at their workplace four years earlier. Together with the present findings, this suggests that trauma-related CFT may be both ruminative and intrusive in nature.
The present finding that vividness of counterfactual thoughts is associated with PTSR, is in line with our hypothesis and aligns with prior research (Blix et al., 2018; 2024; Undset et al., 2024). Recent studies, involving survivors of the Utøya terror attack and their parents, have shown that vividness of counterfactual thoughts can serve as a unique predictor for PTSR, even when adjusting for the frequency of such thoughts (Blix et al., 2024; Undset et al., 2024). Our study extends this finding by demonstrating that vividness of both upward and downward counterfactual thoughts is associated with PTSR.
In the context of sexual assault, upward counterfactuals, such as thoughts about how the assault could have been avoided may give rise to painful emotions such as guilt and shame, emotions that are often reported by victims of sexual assault (Aakvaag et al., 2016). Conversely, downward counterfactuals about being more seriously injured or killed, might sometimes trigger emotional reactions more in line with what could have happened than with what actually happened. Furthermore, vivid simulations of how a sexual assault could have turned out even more severe may contribute to a sense of current threat, and in that way contribute to maintain post-traumatic stress reactions. The association between vividness of CFT and PTSR mirrors findings from research on trauma memory, which has shown that more vivid trauma memories are linked with higher levels of PTSR (e.g. Berntsen et al., 2003). We argue that downward CFT, characterized by vivid imagery, might contribute to a heightened sense of current threat in a similar way as trauma memories, as described by Ehlers and Clark’s (2000) cognitive model of PTSD.
Viewed through the lens of the REM noted earlier (Markman & McMullen, 2003), the positive association between downward counterfactuals and PTSR, and the positive relationship between upward counterfactuals and PTSR, are consistent with processes of assimilation – and contrast, respectively. As elaborated on in the introduction, we suspected that vividness would be higher for downward counterfactuals and that it was primarily these vividness scores that would be positively related to PTSR. Interestingly, we did not find any support for the latter Vividness scores for upward vs. downward counterfactuals predicted PTSR to an equal degree, suggesting that vivid counterfactuals after trauma should be considered as generally harmful. More work to advance our theoretical understanding of the CFT/PTSR link is clearly needed.
Importantly, neither the REM (Markman & McMullen, 2003) nor we suggest that downward counterfactuals should generally be more vivid than upward counterfactuals. In fact, De Brigard et al. (2013) found that participants gave higher vividness scores to upward (vs. downward) counterfactuals, when they were asked to simulate alternative endings to personal memories. The authors pointed to the possibility that this finding could represent an extension of tendencies towards positivity in how people recall their personal pasts and envision their futures (e.g. Ritchie et al., 2015; Salgado & Berntsen, 2020). In the context of trauma however, we find it reasonable to assume that downward (vs. upward) counterfactuals, might often by virtue of their catastrophic nature be particularly attention grabbing and intrusive, making vivid simulations difficult to avoid.
Strengths and limitations. The study’s cross-sectional design prevents insights into how the relationship between CFT and PTSR may evolve over time, underscoring the need for longitudinal research. This study relied on a self-selected sample, which limits the ability to assume that the findings are representative of any broader group. The participants in the present study had all experienced sexual assault during the last year, providing a unique possibility to investigate the relationship between CFT and PTSR after recent trauma. There was relatively little missing data in the present study. Only the participants who reported to have engaged in CFT were asked about the frequency and vividness of these thoughts. We had to exclude 27 participants (8%) who did not report to engage in CFT or had missing response on this question, thus our results can only potentially be generalized to individuals who engage in CFT, which was 92% in the current sample. Additionally, vividness was assessed in relation to each participant’s most common type of counterfactual thought (either upward or downward), thus we could not compare vividness within participants for both types of CFT.
Implications and future directions. It is important to inform trauma-exposed individuals that counterfactual thinking is a common response after traumatic events and that such thoughts may be experienced as vivid and potentially distressing. Equally, it could be helpful for clinicians to be aware of the potential impact of these thoughts and assess whether trauma patients are troubled by trauma related CFT. By identifying such distressing counterfactual thoughts, clinicians can address them effectively in treatment. Professionals should also take care not to unintentionally facilitate counterfactual thinking but instead focus on managing and mitigating intrusive or distressing thoughts.
Future research should move beyond cross-sectional designs and incorporate longitudinal methods that can capture the temporal relationship between trauma-related counterfactual thinking and psychological distress. Additionally, studies are needed to explore how counterfactual thoughts arise spontaneously in everyday life and impact trauma-exposed individuals. Diary studies could offer valuable insights into their role in psychological adjustment and recovery after trauma.
Conclusion. Both upward and downward CFT occur relatively frequently among recent victims of SA. These thoughts can be experienced as vivid. The frequency and vividness of both upward and downward counterfactual thoughts were associated with PTSR, suggesting that such thoughts may interfere with recovery from trauma.