Research supporting the centrality position

Berntsen and Rubin (2006) developed the Centrality of Event Scale (CES) to assess the degree to which an individual construes a traumatic event as key to their identity. It measures the extent to which a memory becomes (i) a reference point for everyday inferences; (ii) a turning point in the life story, and (iii) a core component of

51 personal identity. Since its development, the CES has been employed in several studies investigating the relationship between trauma-centred identity and posttraumatic

adjustment. The following is an overview of the key findings from some of the main studies to date in this area.

Berntsen and Rubin have demonstrated that CES scores are positively correlated with PTSD symptoms, even when controlling for depression and dissociation (Berntsen & Rubin 2006, 2007; Berntsen, Rubin, & Siegler, 2011). Boals (2010) replicated Berntsen and Rubin’s (2006, 2007) findings in a sample of undergraduate students and demonstrated a significant relationship between trauma-centred identity and PTSD, depression and dissociation. Furthermore, this study explored various phenomenological properties of negative/traumatic memories and found that high CES scores were

significantly related to emotional intensity of the memory, a sense of reliving, and visceral reactions while remembering.

Boals and Schuettler (2011) also found a significant positive correlation between CES scores event centrality and PTSD symptoms when controlling for depression, cognitive processing of the trauma and coping styles. The authors assert that their

inclusion of a measure of cognitive processing provides evidence that the CES effectively assesses a construct (centrality of event) that is independent of cognitive biases, and thus claim to endorse the predictive contribution of event centrality to PTSD.

Schuettler and Boals (2011), using a large sample of undergraduate students, examined the roles of event centrality and coping styles in predicting PTSD symptoms. Regression analysis revealed six significant predictors of PTSD which accounted for 66 per cent of the variance. Event centrality and avoidant coping were the top two

52 predictors. Extending this study, Smeets, Giesbrecht, Raymaekers, Shaw, and

Merckelbach (2010) included coping style in their analysis of the relationship between centrality of event and PTSD symptoms, again in a student sample. Here, however, Smeets et al. (2010) focussed on repressive coping style. Results, as per previous studies, indicated a significant positive correlation between CES scores and PTSD symptoms and between dissociation and PTSD scores. Somewhat controversially, this study

demonstrated that repressive coping correlated negatively with PTSD symptoms. Of note, in Smeets et al.’s (2010) study, repressive coping is conceived of as a “habitual emotion regulation strategy” (p. 215), an adaptive response to adverse circumstances, thus indicative of resilience. Smeets et al. contrast the concept of repressive coping with that of ‘cognitive reactivity,’ considering their results in the context of previous studies of cognitive reactivity and resilience (Bonanno, Papa, Lalande, Westphal, & Coifman, 2004; Coifman, Bonanno, Ray, & Gross, 2007). Importantly, however, such studies have found that resilience in the aftermath of traumatic events is determined by the individual’s ability to shift flexibly between enhancing and suppressing emotions (Bonanno et al., 2004). Repressive coping alone is not typically deemed adaptive. Nonetheless, Smeets et al. (2010) demonstrated in their study that centrality of event, repressive coping and dissociation were each found to be independent predictors of PTSD. Webb and Jobson (2011) also replicated findings from previous studies using the CES in a university student sample, demonstrating a significant positive correlation between trauma-centred identity and PTSD symptoms.

Brown, Antonius, Kramer, Root, and Hirst (2010) replicated findings from the aforementioned studies in a clinical sample of combat veterans. Trauma centrality and

53 PTSD symptoms remained significantly correlated when controlling for depression in subgroups of veterans with and without PTSD. Robinaugh and McNally (2011) similarly reported on findings from a clinical population of adult females reporting a history of childhood sexual abuse. CES scores were significantly positively correlated with PTSD symptom severity and depression, and significantly negatively correlated with self- esteem. Roland, Currier, Rojas-Flores, and Herrera (2013) found that CES scores and PTSD symptom severity were positively correlated in a large sample (n = 257) of violence-exposed teachers in El Salvador.

Lancaster, Rodriguez, and Weston (2011) utilised the CES in a novel way, conducting a path analytic examination of various models of the possible relationships between posttraumatic cognitions and centrality of a trauma to one’s sense of self in predicting PTSD symptoms. The authors thus empirically tested a variant of Ehlers and Clark’s (2000) cognitive model of PTSD, incorporating centrality of trauma to identity. Although the centrality concept purportedly contradicts the inadequate integration stance inherent in Ehlers and Clark’s model, Lancaster et al. (2011) posit that the proposed mechanism of PTSD maintenance is similar in both, i.e., both the cognitive model and the centrality view purport that PTSD is maintained by a heightened sense of current threat resulting from altered appraisals of the world engendered by the experience of trauma. The model employed by Lancaster et al. (2011) locates the CES as mediating the relationship between cognitions/appraisals and PTSD symptoms. Results indicate the existence of positive relationships between posttraumatic cognitions, centrality of event and PTSD symptoms. Controversially, the authors suggest that this mediating role of event centrality calls into question one of the central tenets of Ehlers and Clark’s (2000)

54 cognitive model of PTSD, that of memories for trauma being maintained because they are poorly integrated within autobiographical memory.

Robinaugh and McNally (2010) investigated levels of PTSD in an online,

community sample following events inciting shame or guilt and explored the relationship between PTSD symptoms and the centrality of the traumatic memory to participants’ identity. The study controlled for depression and also examined visual perspective in traumatic memories (field or observer) as well as other phenomenological properties of these memories, such as emotional intensity, intrusiveness, reliving, contextual details, and personal coherence. As in previous studies, a significant positive correlation was found between PTSD symptoms and centrality of event. The study also found that CES mediated the moderating effect of visual perspective on the relationship between

emotional intensity of memories and PTSD symptoms. Based on this, the authors proposed that visual perspective (field or observer) is indicative of the congruence between an individual’s identity and their autobiographical memory for the shame-/guilt- provoking event. Results indicated that from an observer perspective, there was no significant relationship between emotional intensity and PTSD symptoms, yet from a field perspective there was a significant association, i.e., greater emotional intensity was associated with increased severity of PTSD. Interestingly, from a field perspective, participants also reported lower personal coherence, but better memory for the setting and spatial layout in which the event occurred.

Rubin et al. (2011) also explored the phenomenological properties of both voluntary and involuntary memories for stressful events associated with PTSD symptoms. In both voluntary and involuntary memories, they found that emotional

55 intensity, rehearsal of the memory, and centrality of the event to one’s life story were positively associated with PTSD. The authors measured other properties traditionally associated with trauma memories, such as incoherence of voluntary memories and enhanced availability of involuntary memories (e.g., Brewin et al., 1996; Ehlers & Clark, 2000). Results showed that participants with PTSD rated their memories as more

coherent, a difference which was not modified by voluntary versus involuntary retrieval. Moreover, all memories (traumatic/stressful/important/positive) in participants with PTSD demonstrated more emotional intensity, higher rates of retrieval (both voluntary and involuntary) and were more central to identity. The authors concluded that this implies a tendency for individuals with PTSD to react with intense affect to all memories, which in turn increases rehearsal and encoding and therefore also availability. Of note, participants with PTSD were shown to have memories that were more fragmented (‘in pieces’) than participants without PTSD, thus supporting the inadequate integration view rather than the centrality position, but the authors suggest that this fragmentation may be related to alcohol abuse and lack of social support rather than PTSD symptom severity.