Rumination and Suppression as Mediators.turlIUC

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Rumination and suppression as mediators of the relationship between

dysfunctional beliefs and traumatic stress

Maria Nicoleta Turliuc1, Cornelia Mirean1,Mihaela Dana Turliuc2,

1Alexandru Ioan Cuza University of Iasi, o!ania

2"r# T# $o%a University of Medicine and $har!acy of Iasi, o!ania

Maria Nicoleta Turliuc

Alexandru Ioan Cuza University of Iasi, &aculty of $sycholo'y and (ducation )ciences,

$sycholo'y De%art!entTo!a Coz!a *, Iasi+--../, o!ania

!o0ile /-2*-23-

e+!ailturliuc4uaic#ro

Cornelia Mirean

Alexandru Ioan Cuza University of Iasi, &aculty of $sycholo'y and (ducation )ciences,

$sycholo'y De%art!entTo!a Coz!a *, Iasi+--../, o!ania!o0ile /-/-.232*1

e+!ail cornelia#!airean4%sih#uaic#ro

Mihaela Dana Turliuc

"r# T# $o%a University of Medicine and $har!acy of Iasi

Universitatii 15, Iasi+--11., o!ania

!o0ile /-335/..66

e+!ailturliuc#dana4yahoo#co!

Corresponding author:Cornelia Mirean 7a!ariei#cornelia4yahoo#co!8

cornelia#!airean4%sih#uaic#ro9

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Rumination and suppression as mediators of the relationship between

dysfunctional beliefs and traumatic stress

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Abstract

The %ur%ose of this %resent research is to investi'ate the role of dysfunctional 0eliefs in

develo%in' intrusive !e!ories, a hall!ar: sy!%to! of %osttrau!atic stress disorder 7$T)D9#

Althou'h dysfunctional 0eliefs have %redicted trau!atic stress after various ty%es of trau!atic

events, the !echanis!s throu'h ;hich co'nitive distortions influence trau!atic distress for

%ersons indirectly ex%osed to trau!atic events re!ain unclear# The hi'h levels of sy!%to!

si!ilarity su''est that esta0lished vulnera0ility factors for $T)D in %ri!ary victi!s !ay also

serve as vulnera0ility factors for trau!atic stress sy!%to!s in indirect victi!s# Therefore, ;e

hy%othesized that co'nitive %rocesses of ru!ination and su%%ression ;ould o%erate as

!ediators 0et;een dysfunctional 0eliefs and trau!atic distress# A total of 1*3 !edical staff

across three hos%itals in o!ania co!%leted !easures of dysfunctional 0eliefs, res%onses to

intrusion and secondary trau!atic stress# The results e!%hasized the i!%ortance of

dysfunctional 0eliefs as %redictors of intrusions# Also, our data indicated that ru!ination and

su%%ression !ediated the effects of dysfunctional 0eliefs a0out oneself and a0out the ;orld

;hen it co!es to trau!atic stress# These results %rovide insi'ht into a !echanis! throu'h

;hich dysfunctional 0eliefs !ay affect %osttrau!atic stress and !ay hi'hli'ht the i!%ortance

of exa!inin' !ulti%le vulnera0ility factors si!ultaneously in increasin' the understandin' of

the etiolo'y of $T)D#

Keywords: secondary trau!a,dysfunctional 0eliefs, intrusion, ru!ination, su%%ression

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&ollo;in' ex%osure to trau!atic life events, !ost %eo%le ex%erience one or !ore of the

core sy!%to!s of %osttrau!atic stress disorder 7$T)D9, such as intrusions, avoidance, ne'ative

co'nitions and hy%erarousal 7A!erican $sychiatric Association, 2-1*9# Intrusive !e!ories

7e#'#, flash0ac:s and ni'ht!ares9 are uncontrolla0le, un;anted, and distressin' i!a'es or

thou'hts of the trau!atic event that re%eatedly co!e into one

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0eliefs that could 0eco!e dysfunctional after ex%eriencin' a trau!atic event# These areas

include safety, trust, estee!, control, and inti!acy#

The current study analyzes the i!%act of dysfunctional 0eliefs on sy!%to!s of

trau!atic stress usin' McCann and $earl!an

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2--19# Therefore, !alada%tive co'nitions follo;in' trau!a are a focus in co'nitive+0ehavioural

treat!ents for $T)D 7e#'#, @utler, Cha%!an, &or!an, = @ec:, 2--59#

Rumination, suppression, and traumatic stress symptoms

Co'nitive !odels of %sycho%atholo'y su''est that co'nitive %rocesses !ediate the

relationshi% 0et;een environ!ental events, 0eliefs, and su0seuent e!otional res%onses

7is:ind = Alloy, 2--59# A!on' the co'nitive co%in' strate'ies, ru!ination and the efforts to

su%%ress the intrusions ;ere considered to 0e of %articular interest#

u!ination is co!!only defined as Ga !ode of res%ondin' to distress that involves

re%etitively and %assively focusin' on the %ossi0le causes and conseuences of ne'ative eventsH

7Nolen+>oe:se!a, Fisco, = yu0o!irs:y, 2--3, %# /--9# Defined in this ;ay, ru!ination is

considered a !alada%tive co%in' strate'y, 0ecause it has 0een sho;n that %eo%le ;ho en'a'e in

ru!ination tend to ex%erience hi'her levels of trau!atic distress follo;in' ex%osure to a trau!a

7>u, Bouc:y, @ro;n, @ruce, = )heline, 2-1/8 Meiser+)ted!an, )he%%erd, "luc:s!an,

Dal'leish, ule, = )!ith, 2-1/8 )er'estor! = Alden, 2---9# Moreover, en'a'in' in ru!ination

contri0utes not only to the develo%!ent of trau!atic stress sy!%to!s 0ut also to the

!aintenance of these sy!%to!s 7@re;in = >ol!es, 2--*9#

Another co'nitive co%in' strate'y that see!s to lead to si!ilar results is su%%ression#

Multi%le studies indicate that the tendency to su%%ress and avoid un;anted thou'hts is related

to the %resence and severity of %osttrau!atic stress sy!%to!s 7Chun' = >unt, 2-1/8 (lzin'a =

@re!ner, 2--28 Tull, "ratz, )alters, = oe!er, 2--/9# (x%eri!ental studies conducted in the

la0oratory also tested the role of su%%ression, sho;in' that deli0erate thou'ht su%%ression

deter!ines a hi'her level of intrusions follo;in' ex%osure to a trau!a 7@ec:, "ud!undsdottir,

$alyo, Miller, = "rant, 2--59# Durin' the %rofessional confrontation ;ith a trau!atic event, the

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su%%ression of e!otions and co'nitions can 0e i!%ortant for the ;or:er in order to acco!%lish

hisJher tas:s, 0ut in the lon' ter! this !i'ht %revent the recovery %rocess and lead to the

develo%!ent of trau!atic stress sy!%to!atolo'y 7Clohessy = (hlers, 16669#

Rumination and suppression as mediators in the relationship between dysfunctional

beliefs and intrusions

Fhen %re+existin' 0eliefs related to central %sycholo'ical needs are !odified 0y

trau!atic events the %erson is vulnera0le to develo%in' $T)D sy!%to!atolo'y# Althou'h

%revious research has docu!ented the i!%ortance of dysfunctional 0eliefs 7Ciesla:, @eni'ht, =

eh!an, 2--39, ru!ination, and su%%ression 7Nolen+>oe:se!a, Fisco, = yu0o!irs:y, 2--39

in the develo%!ent of intrusions, ho; these factors ;or: to'ether in accountin' for variations

in these !anifestations ;as not exa!ined# Therefore, the effect of dysfunctional 0eliefs on

intrusion is not clear, %articularly 0ecause %revious research does not %rovide evidence for the

!echanis! that facilitates this relationshi%#

Althou'h the theoretical a%%roaches descri0ed a0ove !aintain that dysfunctional 0eliefs

are the !ost i!%ortant %redictors of %osttrau!atic stress sy!%to!s, ;e 0elieve that this

relationshi% is !ore co!%lex and hy%othesize that ru!ination and su%%ression !ediate the

relationshi% 0et;een dysfunctional 0eliefs and ;or:+related $T)D sy!%to!s# $revious

research sho;in' that so!e co'nitive ;ays of co%in' 7e#'#, self+efficacy9 !ediate the

relationshi% 0et;een dysfunctional 0eliefs and %osttrau!atic distress 7Ciesla:, @eni'ht, =

eh!an, 2--39 su%%orts this assu!%tion# Different %eo%le !ay 0e !ore vulnera0le to

e!otional i!%air!ent than others ;hen confronted ;ith un;anted !e!ories and thou'hts

related to trau!a, and this !a:es the! less ca%a0le of !ana'in' these intrusions 7Ciesla: et al#,

2--39# >avin' dysfunctional 0eliefs a0out oneself and the ;orld, an individual !i'ht atte!%t to

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find !eanin' for the aversive ex%erience thou'h re%etitive thin:in' a0out the cause and

conseuences of that ex%erience 7ru!ination9# In contrast, one !i'ht atte!%t to avoid the

un;anted intrusion and :ee% those intrusions a;ay fro! consciousness, referred to as

su%%ression# Accordin' to co'nitive !odels, the use of these co'nitive co%in' strate'ies

interferes ;ith the e!otional %rocessin' of the trau!atic !e!ory and %revents its successful

inte'ration into the lon'+ter! !e!ory# Due to this interference, ne'ative co%in' res%onses

often contri0ute to the %ersistence of $T)D 7(lzin'a = @re!ner, 2--28 )halev = Ursano,

2--*9#

Contextual background

"iven the uniue settin' and socio+historical ex%eriences that have influenced the

o!anian culture, it is i!%ortant to include so!e contextual 0ac:'round for this study# The

o!anian healthcare syste! is characterized 0y a culture of learned hel%lessness as a

conseuence of the last t;o decades of refor! 7)%Knu, @0an, @ria, = Du!itraLcu, 2-129#

)uccessive refor!s of the healthcare syste! have so!e i!%ortant conseuences# ?n the one

hand, the nu!0er of fa!ily %hysicians for %ri!ary care is lo;# ?n the other hand, in recent

years the out%atient !edical services ;ere dis0anded and %atients ;ere directed either to

%rivate structures or out%atient !edical units inte'rated into health facilities ;ith 0eds# As a

conseuence, units ;ith 0eds have 0een overcro;ded and !edical %ersonnel overloaded# &or

exa!%le, everyday a %hysician tends to . to 1. 0eds in a hos%ital, and a nurse is res%onsi0le for

3 to 12 0eds#

(!er'ency !edicine in o!ania is or'anized in e!er'ency de%art!ents follo;in' the

An'lo+A!erican !odel# The %re+hos%ital e!er'ency care syste! allo;s for the intervention of

e!er'ency !edical cre;s 7%hysicians, nurses, %ara!edics9 via !o0ile intensive care

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a!0ulances or helico%ters# >ealthcare staffs receive and resolve a 'ro;in' nu!0er of %atients +

0et;een /-,--- and 6-,--- %atients %er year + in a first level e!er'ency de%art!ent of a

university or county hos%ital#

Different statistics have sho;n that o!ania has one of the lo;est densities of !edical

%rofessionals in (uro%e, ;ith fe;er than t;o %hysicians for 1,--- %eo%le, and fe;er than four

nurses for 1,--- %eo%le 7)chafer et al#, 2-1-9# Moreover, durin' the ti!e of data collection,

there had 0een a constant under+financin' of the healthcare sector, as ;ell as %oor %lannin' and

%oor !ana'e!ent of the health ;or:force, and, recently there has 0een an acceleratin'

!i'ration of !edical %rofessionals 7over 1/,--- %hysicians fro! 2--9 to other countries 7@ria,

@0an, Andreica, = Du!itra cu, 2-1*8 ldescu, )cntee, ?lsavsz:y, Allin, = Mladovs:y,

2--39#

The characteristics of the o!anian healthcare syste! are not uniue in co!%arison

;ith other (astern (uro%ean countries that face si!ilar %ro0le!s# >o;ever, there have 0een

fe; studies conducted a!on' o!anian healthcare ;or:ers and a!on' (astern (uro%ean

healthcare %rofessionals, in 'eneral# The current study is an atte!%t to 0etter understand the

;ay the challen'es of ;or:in' ;ith trau!a victi!s add to the challen'es of the syste!

descri0ed a0ove#

The current study

In this study ;e investi'ate ;hether dysfunctional 0eliefs a0out the self and the ;orld,

as ;ell as ru!ination and su%%ression contri0ute to the develo%!ent of trau!atic stress

sy!%to!s in a sa!%le of o!anian !edical %ersonnel# There ;ere several reasons underlyin'

this a%%roach# &irst, ;e found very fe; e!%irical studies on the relationshi% a!on'

dysfunctional 0eliefs, ru!ination, su%%ression and trau!atic stress sy!%to!s# Identifyin' the

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factors that %redis%ose a %erson to develo%in' trau!atic stress is an i!%ortant ste% in

develo%in' intervention strate'ies for the effective !ana'e!ent of ;or:+related stress 7itz =

"ray, 2--/8 rner, Bin', Avery, @retherton, )tolz, = ?r!erod, 2--*9# )econd, althou'h several

studies ;ere carried out to ex%lain the influence of dysfunctional 0eliefs on trau!atic stress

sy!%to!s 7@re;in = >ol!es, 2--*8 &oa = oth0au!, 16639, the !ediatin' effect of

ru!ination and su%%ression has not 0een investi'ated# )ince the %sycholo'ical intervention

desi'ned to %revent the sy!%to!s of trau!atic stress offers advice a0out enhancin' %ositive

co%in' s:ills 7@isson = Andre;s, 2--9, the understandin' of co%in' strate'ies that facilitate

the develo%!ent of intrusions !ay 0e relevant# Third, this %resent study is one of the fe;

studies conducted in the o!anian context#

Accordin' to theoretical fra!e;or: 7constructivist self+develo%!ent theory, e!otional

%rocessin' theory9 and %revious research in the field, the hy%otheses of our study are

7>19 Dysfunctional 0eliefs directly relate to intrusion, a core sy!%to! of $T)D#

7>29 u!ination and su%%ression directly relate to intrusion#

7>*9 u!ination and su%%ression !ediate the relationshi% 0et;een dysfunctional 0eliefs

and intrusions#

Method

articipants

The research too: %lace ;ithin three hos%itals in the city of Iasi, o!ania# $artici%ants

in this study ;ere !ade u% of 1/6 !edical ;or:ers# Those ;ho %rovided inco!%lete data ;ere

excluded fro! the analysis# The final sa!%le of 1*3 %artici%ants 7see Ta0le 19 consisted of

5/#.O nurses and *.#.O %hysicians fro! the Intensive Care 712 %hysicians, 16 nurses9,

(!er'ency 75 %hysicians, 2* nurses9, A!0ulance 75 %hysicians, 1* nurses9, Neurosur'ery 715

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%hysicians, 2- nurses9, and ?ncolo'y units 76 %hysicians, 1/ nurses9# ?ur research sa!%le

lar'ely co!%rised ;o!en 76O9# Their a'es ran'ed fro! 2. to 55, ;ith an avera'e a'e of

*6#11 years 7)D P 6#/39# The %artici%ants had considera0le ex%erience in the healthcare field

7MP 1-#.- years, )D P 6#539# All of the %artici%ants ans;ered a set of uestionnaires after

si'nin' a confidentiality a'ree!ent# The inclusion criteria ;ere related to the units of the

hos%ital ;here the !edical %ersonnel ;or:ed# Therefore, ;e only included ;or:ers fro! units

characterized 0y nu!erous interactions ;ith %atients ;ho had severe or unex%ected !edical

conditions# Fe excluded %artici%ants fro! hos%ital la0oratories in ;hich ;or:ers have !ini!al

or no interaction ;ith %atients# There ;ere no other exclusion criteria, includin' restrictions

0ased on de!o'ra%hic varia0les#

Insert Table 1 about here

Measures

The Traumatic Stress Institute Belief Scale7TSI-BLS8 $earl!an, 16659 assessed the

i!%act of directly and indirectly ex%erienced trau!a# The TA@) has 3- ite!s that ;ere rated on

a 5+%oint i:ert scale 71+stron'ly disa'ree, 5+stron'ly a'ree9# Ne'ative ite!s ;ere reversely

scored# In %articular, the TA@) !easures disru%tions in 0eliefs related to five areas of needs

that are sensitive to the effects of trau!a safety, trust, estee!, inti!acy and control# Fithin

each of these areas of needs, se%arate sets of ite!s ta% into the 0eliefs a0out oneself and others,

yieldin' su0scale scores and a total score# (xa!%les of ite!s of this scale include GI ;orry a lot

a0out the safety of !y loved onesH and GI 'enerally don

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The Secondary Traumatic Stress Scale7)T))8 @ride, o0inson, e'idis, = &i'ley,

2--/9, a 1+ite! scale, !easured secondary trau!a on three di!ensions intrusion, avoidance

and arousal# Usin' a Qve+%oint i:ert scale, the res%ondents indicated their a'ree!ent ;ith

ite!s that reflected s%eciQc res%onses related to their ;or: ;ith trau!a victi!s# A hi'her total

score indicated hi'her secondary trau!atic stress# The cut+off score for the )T)) ;as *6,

!eanin' that the %artici%ants ;ho scored a0ove *6 on the )T)) also !et the core criteria for

$T)D, and those %artici%ants ;ith a score of *3 or 0elo; did not 7@ride, 2--9# In our sa!%le,

Cron0ach

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%ro0le!s# The %resented issues ;ere due to lin'uistic differences8 so!e (n'lish ;ords could 0e

readily translated into o!anian or did not have the sa!e !eanin' for the study %o%ulation#

&or exa!%le, GclientH ;as translated to G%atientH to !a:e the focal %erson 7the %atient9 !ore

clearly identified for the !edical %rofessionals, GSu!%yH ;as chan'ed to Girrita0le,H ;hich is

less collouial and !ore true to the conce%t of interest, a res%onse scale descri%tion GneverH

;as chan'ed to Gnot at all,H 0ecause the %hrases are not lin'uistically differentiated in

o!anian, and the ;ord GcloseH ;as dro%%ed fro! Gclose and connected,H 0ecause these ;ords

are synony!ous in o!anian# After discussin' the discre%ancies, the o!anian version ;as

finalized#

rocedure

As a sa!%lin' strate'y, ;e used self+selection sa!%lin' ;here %artici%ants volunteered

to ta:e %art in the research of their o;n accord# The %artici%ants ;ere not re!unerated, 0ut they

;ere told that they could 0e infor!ed a0out the results of the study# $er!ission to ad!inister

the survey ;as o0tained fro! the chief %hysicians of the hos%itals, as ;ell as the hos%italsayes 72--39#

Eo0 ex%erience ;as included as a covariate to deter!ine the extent to ;hich it !ay

account for the relationshi% 0et;een dysfunctional 0eliefs and intrusions over and a0ove the

!easures of ru!ination and su%%ression# u!ination and su%%ression scores ;ere entered

si!ultaneously as !ediator varia0les of the relationshi% 0et;een dysfunctional 0eliefs and

intrusions# Testin' a sin'le !ulti%le !ediation !odel is %referred to se%arate si!%le !ediation

!odels 7$reacher = >ayes, 2--39# &irst, dysfunctional 0eliefs si'nificantly related to intrusions

70P#-3,p #--19# )econd, dysfunctional 0eliefs si'nificantly related to ru!ination 70P#-.,p #

--19, ;hich si'nificantly related to intrusions 70P#2/,p P #-19# The 6.O confidence interval

did not contain the value zero 7see Ta0le *9, indicatin' that the !ediated effect is si'nificant#

)u%%ression ;as also a !ediator of the relationshi% 0et;een dysfunctional 0eliefs and

intrusions# Dysfunctional 0eliefs si'nificantly related to su%%ression, 70P#-5p #-.9, and

su%%ression si'nificantly related to intrusions 70P#2-,p #--19# Therefore, su%%ression ;as a

!ediator of the relationshi% 0et;een dysfunctional 0eliefs and intrusions# The 6.O confidence

interval did not contain the value zero 7see Ta0le *9, indicatin' that the !ediated effect is

si'nificant# Thus, dysfunctional 0eliefs accounted for intrusions throu'h its association ;ith

ru!ination and su%%ression# The relationshi% 0et;een dysfunctional 0eliefs and intrusions

0eco!es ;ea:er 70P#-.,p #--19, yet it is still a si'nificant %ath ;ith the inclusion of the

!ediation effect# Therefore, ru!ination and su%%ression only %artially account for the effect of

dysfunctional 0eliefs on intrusions 7see &i'ure 19#

Insert Table 3 about here

Insert Fiure 1 about here

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Discussion

In the last t;o decades, the o!anian health care syste! has 0een confronted ;ith a

%oor !ana'e!ent of the health ;or:force, a shorta'e of %ersonnel and !ore recently ;ith an

acceleratin' !i'ration of !edical %rofessionals# In this context, the %resent study ai!s to

investi'ate the factors associated ;ith trau!atic stress sy!%to!s a!on' a sa!%le of o!anian

!edical %ersonnel# )%ecifically,this study set out to test and found evidence for the hy%othesis

that dysfunctional 0eliefs %lay an i!%ortant role in the develo%!ent of intrusion sy!%to!s

7$latt = &reyd, 2-118 )hiri et al#, 2-1-8 Fri'ht et al#,2-1-9# Individuals ;ith ne'ative 0eliefs

a0out the!selves and a0out the ;orld are at a 'reater ris: of develo%in' trau!atic stress

sy!%to!s 7Coc:ra! et al#, 2-1-8 >ardin' et al#, 2-129# This result can 0e ex%lained 0y findin's

that dysfunctional 0eliefs are related to anxiety and, hence, the infor!ation co!in' fro! a

trau!atic event can evo:e even hi'her anxiety and trau!atic stress sy!%to!s 7&oa =

oth0au!, 16639# &urther!ore, dysfunctional 0eliefs a0out oneself and a0out the ;orld !ay

!a:e an individual less ca%a0le of !ana'in' trau!a+related de!ands, and the feelin' of %oor

%erfor!ance could exacer0ate trau!atic stress sy!%to!s, includin' intrusions#

The study also re%licated earlier findin's that ru!ination and efforts to su%%ress

intrusive !e!ories are associated ;ith $T)D sy!%to!s 7Chun' = >unt, 2-1/8 "arland =

o0erts+e;is, 2-1*8 >u et al#, 2-1/8 Meiser+)ted!an et al#, 2-1/9# The role of ru!ination is

consistent ;ith the %revious results on the role of ;orry ;hen it co!es to !aintainin'

'eneralized anxiety# These results sho;ed that the threatenin' as%ects of a trau!atic life event

re!ain constant if ;e thin: re%etitively a0out the causes and conseuences of that event# As a

conseuence of such ru!ination, the ris: of develo%in' trau!atic stress sy!%to!s is 'reater

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7see Davey = Tallis, 166/, for a revie;9# Ironically, su%%ression has si!ilar effects 7@ec: et al#,

2--58 Tull et al#, 2--/9 and our results sho;ed that 0oth su%%ression of intrusive !e!ories and

ru!ination !i'ht foster $T)D sy!%to!s 0y !ediatin' the influence of dysfunctional 0eliefs on

intrusion# The e!otional %rocessin' theory as a%%lied to $T)D 7&oa = oth0au!, 16639 %osits

that there is a si!%le, direct lin: 0et;een dysfunctional 0eliefs and the recovery or develo%!ent

of %osttrau!atic distress# ?ur study %rovides evidence that the relationshi% 0et;een

dysfunctional 0eliefs and %osttrau!atic distress is !ore co!%lex, ;ith su%%ression and

ru!ination %artially !ediatin' this effect#

To su!!arize, the %resent research 0rin's evidence a0out the relation 0et;een

dysfunctional co'nitive assu!%tions and ;or:+related $T)D sy!%to!s a!on' o!anian

!edical %rofessionals# u!ination and the su%%ression of un;anted thou'hts also offer a 'ood

ex%lanation for this relationshi%# The results are not sur%risin', 'iven that the %artici%ants in this

study are s:illed individuals ;ho often ;or: under conditions of extre!e stress, ;itnessin'

!any distressin' scenes and ;hose %erfor!ance under such conditions !ay literally 0e vital in

life or death situations# >ealthcare ;or:ers are freuently confronted ;ith e!otionally loaded

situations and hu!an sorro;# Moreover, o!anian !edical %rofessionals 'enerally ex%erience

a hi'h ;or:load# Dealin' ;ith such an e!otionally de!andin' So0 reuires a 'reat deal of

ener'y and !ay lead to 0urnout, ;hile in order to reach their %rofessional 'oals ;or:ers !ay

need to su%%ress their o;n e!otions 7"elderen, @a::er, BoniSn, = De!erouti, 2-119# For:ers

;ho find it difficult to co%e ;ith trau!atic !e!ories !ay need to learn that avoidin' un;anted

thou'hts is counter%roductive# &irst, the su%%ression of e!otions can have %hysiolo'ical

conseuences such as increased sy!%athetic activity 7i#e#, increased s:in conductance and

fin'er %ulse a!%litude8 "ross = evenson, 1669, and a reduced control of cardiac sy!%athetic

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activity 7De!aree, )ch!eichel, o0inson, $u, = (verhart, 2--59# )econd, su%%ression see!s to

0e co'nitively costly due to the ver0al de!ands in the course of su%%ressin' the un;anted

intrusions 7"ross, 2--29#

Fe thin: that the !edical staff !ay need su%%ort in dealin' ;ith trau!atic events

;itnessed ;hile on duty# Ti!e %ressure !a:es it unli:ely that they ;ill find adeuate su%%ort at

;or: if they ex%erience difficulties# There see!s to 0e a fine line 0et;een the %rofessional

distance necessary to %revent over;hel!in' e!otions on the So0, and e!otional detach!ent

and su%%ression related to $T)D sy!%to!s# Those ;ho suffer fro! $T)D sy!%to!s !ay also

need hel% in re%lacin' ru!ination ;ith i!a'ined ex%osure to facilitate e!otional %rocessin'

and chan'e in !eanin'# Intervention %rotocols for healthcare ;or:ers, includin' trainin'

focusin' on %articular co%in' strate'ies, o%%ortunities for su%ervision, consultation and the

continuous education of staff a0out vicarious trau!a, !ay %revent %osttrau!atic distress

7Tri%%any, Fhite Bress, = Filcoxon, 2--/9# A thera%eutic self+a;areness of the ris:s of

;or:in' in the field of trau!a !ay %lay an i!%ortant role in %reventin' or reducin' the i!%act

of ex%osure to trau!atic life events 7$ross, 2--59, and in !aintainin' %ositive co'nition a0out

oneself and a0out the ;orld8 these see! to 0e %rotective factors a'ainst trau!atic stress 7uan

et al#, 2-119# )%ecific intervention strate'ies should hel% ;or:ers to have realistic ex%ectations

a0out ;hat they can fulfil in their %rofessional role 7@ell, Bul:arni, = Dalton 2--*9# Identifyin'

individuals at %articular ris: should 0e the first ste% in %lannin' and i!%le!entin' stress

!ana'e!ent services# To follo; this ste% it is i!%ortant to understand ;hat co%in' strate'ies

are used 0y healthcare ;or:ers to !ini!ize the e!otional i!%act of critical events in the

;or:%lace 7rner et al#, 2--*9# &ro! this %oint of vie;, our study Soins %revious researchers

7@o0er = e'ehr, 2--.9 ;ho have found that %osttrau!atic stress can increase if ;or:ers use

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so!e %articular dysfunctional co%in' strate'ies in order to control the un;anted distur0ances

caused 0y ;or:in' ;ith trau!a victi!s#

Certain li!itations should 0e noted# &irst, our research did not cover a 0road s%ectru!

of dysfunctional 0eliefs that !ay a%%ear in the context of indirect ex%osure to trau!atic events#

&uture research should analyse the !ediatin' role of ru!ination and su%%ression for a ;ide

ran'e of co'nitive %redictors of %osttrau!atic distress# )econd, the varia0les that could

!oderate the effects of co%in' 7e#'#, social su%%ort9 should also 0e considered to fully

understand the !echanis! throu'h ;hich dysfunctional 0eliefs, ru!ination, and su%%ression

interact in %redictin' intrusions# Third, future studies should ta:e into consideration the

distinction 0et;een ada%tive 7reflection9 and !alada%tive for!s 70roodin'9 of co'nitive

%rocessin' of trau!atic infor!ation# &ourth, our sa!%le is !ainly co!%rised of ;o!en# &or

this reason the 'eneralization of our results is li!ited# To !iti'ate this li!itation, future studies

should consider lar'er sa!%les that co!%rise 0oth !en and ;o!en# &inally, ;e should also

!ention that the cross+sectional desi'n of our study does not entitle for for!ulation of causal

relationshi%s conclusions#

Nevertheless, our results confir! the %revious literature 0y de!onstratin' an underlyin'

factor related to distress, and 0y su%%ortin' a 'eneral co'nitive !odel for ;or:+related $T)D#

?ur study adds to current literature 0y addressin' the %heno!ena of vicarious trau!a on

o!anian !edical staff, a sa!%le of %articular interest due to very hi'h ;or:loads and

e!otionally loaded situations encountered in the ;or:%lace# )econd, ;e investi'ated the

!ediatin' role of ru!ination and su%%ression in the relationshi% 0et;een dysfunctional 0eliefs

and intrusions# $revious studies have %artially ex%lored the relationshi%s 0et;een these

varia0les# @y exa!inin' the relationshi% a!on' dysfunctional 0eliefs, ru!ination, su%%ression

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and intrusions, this current study %rovided so!e insi'hts into the relationshi% 0et;een these

varia0les, ;hich can hel% us 0etter understand the ;ays in ;hich co%in', es%ecially co'nitive

co%in', could influence the develo%!ent of intrusions, a hall!ar: sy!%to! of %osttrau!atic

stress#

Acknowledgements: This !or" !as partially supported by the #$le%andru Ioan &u'a(

)ni*ersity of Iasi+ under the responsibility of the ,roect number 1./201121 4oun

researchers5 competition+ )$I&

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Ta0le 1# De!o'ra%hic and %rofessional characteristics of %artici%ants8:P1*3

n O M )D

A'e *6#11 6#/3

(x%erience 7years9 1-#.- 6#53

"ender&e!ale 1-6 6O

Male 26 21O

$rofession$hysicians /6 *.#.O

Nurses 36 5/#.O

&ield of %racticeIntensive Care *1 22#/5O

(!er'ency 26 21#-1O

A!0ulance 16 1*#5O

Neurosur'ery *5 25#-3O

?ncolo'y 2* 15#55O

Ta0le 2# $earson correlations, !eans, standard deviations 7)Ds9, and Cron0ach

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Ta0le *# Mediation of ru!ination and su%%ression on the relationshi% 0et;een dysfunctional

0eliefs and intrusions#

@ootstra%%in'

$ercentile 6.O CI @C 6.O CI @Ca 6.O CI

o;er U%%er o;er U%%er o;er U%%er

u!ination #--*- # -23. #--// #-*-* #--/* #-*-2)u%%ression #---3 #-*13 #--1/ #-*2. #--1* #-*2.

Total #-1/5 #-/* #-1.5 #-/36 #-1.5 #-/6-

:ote# @C + 0ias corrected8 @Ca + 0ias corrected and accelerated8 .,--- 0ootstra% sa!%les8

:P1*3

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ysfunctional beliefs

!uppression

"ntrusions

Ruminationb#$05%%

b#$06%

b#$24%

b#$20%%

b#$08%%&$05%%

&i'ure 1# Multi%le !ediation !odel de%ictin' relations 0et;een dysfunctional 0eliefs, !ulti%le

!ediators, and intrusions# alues re%resent unstandardized re'ression coefficients#

Note \\p #--18 \p #-.#