‘My child could have died’: counterfactual thoughts and psychological distress in parents of trauma survivors

ABSTRACT

Background: After exposure to a potentially traumatic event, survivors may experience thoughts about ‘what could have happened’, referred to as counterfactual thoughts (CFTs). CFTs have been found to have a negative impact on survivors’ mental health. This is the first study to investigate whether parents of trauma survivors experience CFTs and the association with psychological distress in this group.

Objective: The main aim of the present study is to investigate CFTs in parents of trauma survivors and the relationship between the frequency and vividness of CFTs and psychological distress.

Method: The participants (N = 310, 191 females) were parents of the youths targeted in the terror attack on Utøya island, Norway, in 2011. Frequency and vividness of CFTs, posttraumatic stress reactions (PTSR), and symptoms of anxiety and depression were measured 8.5–9 years post-terror.

Results: The majority of the parents (74%) reported having experienced CFTs at some time point since the attack. For almost one-third of the parents, CFTs were still present more than eight years after the attack. Higher frequency and vividness of CFTs were uniquely associated with higher levels of PTSR, anxiety, and depression.

Conclusion: The present findings suggest that frequent and vivid CFTs may contribute to mental health problems in parents of trauma survivors and should be addressed in therapy.

HIGHLIGHTS

• A quantitative study investigating the relationship between counterfactual thoughts and psychological distress, in parents of trauma survivors.

• The majority of the parents reported having experienced counterfactual thoughts at some time point since the attack. For almost one-third of the parents, counterfactual thouhgts were still present more than eight years after the attack. Higher frequency and vividness of counterfactual thoughts were uniquely associated with higher levels of psychological distress.

• The present findings suggest that frequent and vivid counterfactual thouhgts may contribute to mental health problems in parents of trauma survivors and should be addressed in therapy.

Antecedentes: Tras la exposición a un acontecimiento potencialmente traumático, los sobrevivientes pueden experimentar pensamientos sobre ‘lo que podría haber ocurrido’, denominados pensamientos contrafactuales (CFT, por sus siglas en inglés). Se ha descubierto que los CFT tienen un impacto negativo en la salud mental de los sobrevivientes. Este es el primer estudio que investiga si los padres de sobrevivientes de traumas experimentan CFT y su asociación con el malestar psicológico en este grupo.

Objetivo: El objetivo principal del presente estudio es investigar las CFT en padres de sobrevivientes de traumas y la relación entre la frecuencia, la intensidad de los CFT y el malestar psicológico.

Método: Los participantes (N = 310, 191 mujeres) eran padres de las jóvenes víctimas del ataque terrorista en la isla de Utøya, Noruega, en 2011. Se midieron la frecuencia y la intensidad de las CFT, las reacciones de estrés postraumático (PTSR por sus siglas en ingles), los síntomas de ansiedad y depresión entre 8,5 y 9 años después del atentado.

Resultados: La mayoría de los padres (74%) declararon haber experimentado CFT en algún momento desde el ataque. Para casi un tercio de los padres, los CFT seguían presentes más de ocho años después del ataque. La mayor frecuencia e intensidad de los CFT se asoció de forma única con niveles más altos de PTSR, ansiedad y depresión.

Conclusión: Los presentes hallazgos sugieren que los CFT frecuentes e intensos pueden contribuir a los problemas de salud mental en los padres de sobrevivientes de traumas y deben abordarse en la terapia.

KEYWORDS:

• Trauma
• parents
• counterfactual thinking
• posttraumatic stress
• secondary trauma

PALABRAS CLAVES:

• Trauma
• padres
• estrés postraumático
• trauma secundario
• pensamiento contrafactual

1. Introduction

As a parent, learning that one’s child has experienced a traumatic event can be extremely distressing. Indeed, parents are at risk of developing secondary posttraumatic stress reactions (PTSR) as a result of the trauma their child has experienced (Hiller et al., 2016; Landolt et al., 2003). High levels of parental PTSR have been reported after various types of trauma exposure, including severe illness (Cabizuca et al., 2009; Nelson & Gold, 2012), accidents (Landolt et al., 2003) and terrorist attacks (Haga et al., 2015; Scrimin et al., 2006; Thoresen et al., 2016). The impact of children’s trauma on parents’ mental health was also demonstrated in a recent meta-analysis, where an estimated posttraumatic stress disorder (PTSD) prevalence rate of 17% was reported for parents following their child's single-event trauma (Wilcoxon et al., 2021).

In a previous study with the parents of the 2011 Utøya terrorist attack survivors in Norway, Thoresen et al. (2016) reported five times higher PTSR, and three times higher levels of anxiety/depression symptoms, compared to the general population, 4–5 months after the terror attack. Although the PTSR scores were reduced 14–15 months after the attack, they were still considerably elevated compared to the general population. In the current study with the same population, we seek to better understand the psychological mechanisms associated with these distressful reactions in parents, by studying the cognitive processing of their child's traumatic experience.

Cognitive models of PTSD suggest that how individuals interpret and understand their experiences and reactions is highly important for the development and maintenance of psychopathology post-trauma (Brewin et al., 1996; Dalgleish, 2004; Ehlers & Clark, 2000). In line with this, numerous studies with trauma-exposed individuals have demonstrated that mental health after trauma is closely related to their cognitive processing of the traumatic experience (Gómez de La Cuesta et al., 2019; Meiser-Stedman et al., 2019). In a similar vein, for parents, cognitive processing of their child’s trauma seems to play a pivotal role in their mental health. For example, in a study of parents whose child had survived a motor vehicle accident, Hiller et al. (2016) found that maladaptive thoughts concerning the consequences of the harm their child suffered (e.g. thinking that the child would never get over what happened), were among the most important predictors of their levels of PTSR. Furthermore, in their meta-analysis, Wilcoxon et al. (2021) concluded that parents’ appraisal of the severity and the consequences of their child’s trauma is an important predictor for PTSR.

One specific thought pattern that may arise after exposure to a traumatic experience, is thoughts about what could have happened (Teigen & Jensen, 2010). This is often referred to as counterfactuals or counterfactual thoughts (CFTs) and can be illustrated by expressions such as ‘What if … ’ or ‘If only … ’. CFTs involve comparing what happened to a better outcome (i.e. upward CFT), or an even worse scenario or outcome (i.e. downward CFT) (Roese, 1994). Counterfactuals tend to be triggered by negative affect and so-called ‘close-call situations’ (Markman & Tetlock, 2000). One line of research has shown that, in the context of trauma, thinking about what could have happened is associated with psychological distress. Both upward and downward CFTs are associated with PTSR (Blix et al., 2016; Blix et al., 2018; Gilbar et al., 2010; Hoppen et al., 2020; Hoppen & Morina, 2021; Mitchell et al., 2016), while upward CFTs are associated with anxiety (Callander et al., 2007) and depression symptoms (Branscombe et al., 2003). In addition, the frequency of CFTs (Davis et al., 1995; El Leithy et al., 2006; Gilbar et al., 2010; Hoppen & Morina, 2021) and vividness of CFTs (Blix et al., 2018) have been associated with psychological distress after trauma. Counterfactual vividness refers to the degree to which the thought is accompanied by emotional responses, sensory impressions, and a sense of mental time travel.

The abovementioned studies have focused on individuals who have experienced trauma. However, a study 26 years after the fire on the passenger ferry Scandinavian, reported that higher frequency of upward and downward CFTs, and more vivid CFTs, were uniquely associated with higher levels of PTSR in both the survivors and the bereaved (Blix et al., 2018). This suggests that thoughts about what could have happened can be harmful also for individuals who have not themselves been close to danger, but who have experienced a traumatic loss. This line of research may be highly relevant to understanding parents’ reactions following their child’s trauma. Parents of trauma survivors have an indirect experience of the trauma their child has suffered and may have troublesome thoughts concerning the actual incident, as well as about alternative scenarios and outcomes. Parents have a sense of responsibility for keeping their children safe, and when doing so fails, feelings of guilt can arise (De Young et al., 2014). Particularly, parents may become preoccupied with thoughts about what they could have done differently to protect their child from the traumatic experience. Yet, to the best of our knowledge, no study has investigated CFTs and their association with psychological distress in parents of trauma survivors.

This leads up to the present study, where the main aim is to investigate the relationship between CFTs and psychological distress, among parents of the youth who were targeted in the terror attack on Utøya island, Norway, on 22 July 2011. In this attack, one man, disguised as a police officer and heavily armed, attacked the Labour Party’s youth organisation’s summer camp. There were 564 people gathered on the small island, and the perpetrator shot, killed, and wounded those he came across. The attack lasted for about one and a half hours and left 69 persons killed, and 66 physically injured. During the attack, many youths were in contact with their parents by phone, conveying short messages. For others, who were unable to establish contact, their parents followed the attack as it unfolded on the news and via digital media. As such, most parents did not know whether or not their child was alive or injured for hours.

In the present study, we will examine the association between frequency and vividness of CFTs and PTSR, and symptoms of anxiety and depression, among parents of trauma survivors. We expect to replicate previous findings with trauma-exposed groups; that higher frequency and higher degree of vividness of CFTs will be associated with higher levels of psychological distress.

2. Methods

The Utøya Study (2011–2020) is a comprehensive longitudinal interview study. It consists of four data collection waves conducted at 4–5 months (T1), 14–15 months (T2), 30–32 months (T3), and 8.5–9 years (T4) post-terror. The current paper uses data from T4.

2.1. Participants and procedure

In total, 310 parents (191 mothers, 115 fathers, and 4 stepfathers) of the youth who survived the terror attack in 2011 participated in the study 8.5–9 years post-terror. The 310 parents came from 221 families participating in T4. All these families had one or two parents participating, 132 families had one parent and 89 had two parents.

Most participants (n = 238) were interviewed face-to-face. Participants who were not available for an interview (n = 72), responded to the same questions in a questionnaire, by paper or online. The interviews lasted approximately an hour and a half, with topics ranging from their mental and physical health pre-and post-trauma to family functioning, and their children’s post-trauma school performance. If interviewers identified unmet needs (e.g. for intervention or support) among the parents, they were instructed to arrange for assistance. The study was approved by Regional Committee for Medical and Health Research Ethics in Norway, and participants provided written informed consent.

There were 310 participants and 229 non-participants at T4. A chi square test showed a significant (p = .004) sex differences in participation at T4, females 191 of 304 (63%), males 119 of 235 (51%). A t-test showed a significant (p = .008) age differences in participation at T4, participants had mean age 47.5 years, non-participants 49.0 years.

2.2. Measures

Vividness and frequency of trauma-related CFTs. Participants were asked to indicate if they had experienced counterfactual thoughts about the terrorist attack on Utøya:

After dramatic events, it is not uncommon to imagine how things might have been different. People sometimes think “what if … ..”. Have you experienced such “what if – thoughts” regarding what happened during the terrorist attack on Utøya 22nd of July?

Participants who confirmed having such thoughts were asked to describe the most common thought they had experienced about what could have happened. With this thought in mind, they were subsequently asked to answer eight questions about experienced vividness of this thought on a scale from 1 (not at all) to 7 (to a very large extent) (the individual items are presented in Table 2). The eight questions were developed based on the Autobiographical memory questionnaire (Rubin et al., 2003; Rubin et al., 2011). Items 1–6 have been used in a previous study with trauma survivors and bereaved (Blix et al., 2018). A mean CFT vividness score was calculated based on the eight items, the Cronbach’s alpha for the vividness scale in the present study was .87.

Finally, the participants were asked to report how frequently they had experienced CFT within the last month, on a 5-point scale (never, rarely, sometimes, often, very often).

Posttraumatic stress reactions over the past month were measured using the University of California at Los Angeles PTSD Reaction Index (UCLA PTSD-RI) (Pynoos et al., 1998; Steinberg et al., 2004). This is a 20-item scale constructed to cover the PTSD diagnostic criteria in DSM-5 (DSM-5; APA, 2013). Each question is explicitly related to the attack, and responses were endorsed on a 5-point scale, ranging from 0 (never) to 4 (almost all the time). In the present study, a mean score ranging from 0–4 was calculated and used in the analyses. Cronbach’s alpha for the scale in the present study was. 92. To calculate the proportion of participants scoring above a cut-off score, we used the cut-off> = 35 for the sum score reported by (Kaplow et al., 2020), this corresponds to a cut-off  = ≥35/20 which is > = 1.75 for the mean score.

Anxiety and depression symptoms within the last two weeks were measured using an eight-item version (SCL-8) of the Hopkins Symptom Checklist-25 (Solberg et al., 2011; Wilhelmsen, 2009). Each of the eight items was rated on a scale from 1 (not at all bothered) to 4 (very much bothered). Short versions of the SCL have previously been used in Norwegian population surveys and shown high correlations with the 25-item scale, and to have good psychometric properties (Strand et al., 2003; Tambs & Moum, 1993). The mean SCL-8 score is used in the analyses in the present study. The Cronbach's alpha for the SCL-8 in the present study was .86. In this study, we employed a cut-off score of ≥2.0 on the SCL-8 questionnaire, following the recommendation of Fink et al. (2004).

3. Statistical analysis

Separate mixed-effects models were conducted to investigate the relationships between the explanatory variables (i.e. frequency of CFTs and vividness of CFTs), and the outcome variables (i.e. PTSR and symptoms of anxiety/depression). First, the frequency of CFTs and vividness of CFTs were entered separately (Model 1). Second, the frequency and vividness of CFT were included simultaneously (Model 2). All models were adjusted for age and sex and estimated for the 224 persons with no missing values on age and the CFTs variables. Mixed-effects models were used to account for the clustering of parents within families. Under the assumption that data are missing at random, mixed-effects models provide valid analyses when data are missing in the dependent variable. We applied the half rule to handle missing data in the outcome variables and for the mean CFTs vividness score (i.e. only participants with valid observations on at least half of the items were included in the scale scores). The random structure was simplified when necessary for model stability, as recommended by Pinheiro and Bates (2000) and linear regression was used in case of unstable models. Mixed effects models were estimated with the R package nlme (Pinheiro et al., 2023).

4. Results

Distribution of sex, mean age at the time of the terrorist attack, mean scores for PTSR, and anxiety/depression symptoms are presented in Table 1.

Table 1. Sample characteristics, with mean scores for posttraumatic stress reactions, and anxiety and depression symptoms. Number and percent of participants scoring above the cut-off for clinical significant symptom level for posttraumatic reactions (> = 1.75) and anxiety and depression symptoms (>2.0) (N = 310).

	Mean (SD), N (percent)	N (percent) above cut-off
Female	191(62%)
Age per 22nd of July 2011 (n = 241)	56 (5)
Posttraumatic stress reactions (PTSD-RI)	.86 (.67)	38 (7)
Anxiety and depression symptoms (SCL-8)	1.50(.61)	42 (14)

A majority of the participants (n = 229, 74%) reported at some point in time to have had CFTs about the Utøya attack. The frequency distribution for each item of the CFT vividness scale is presented in Table 2. The mean CFT vividness score was 3.11 (SD = 1.55).

Table 2. Frequency distribution for the vividness of the most common counterfactual thought reported by the parents (N = 226) (percentages in parentheses).

‘When I think about what could have happened … ’.	Never-1	2	3	4	5	6	7-always
It is like I can hear what is happening	102(46)	32(14)	22(10)	19(9)	19(9)	13(6)	16(7)
It is like I can see what is happening	60 (27)	26(12)	25(11)	20(9)	25(11)	30(14)	37(17)
It is like I can smell what is happening	175(78)	11(5)	9(4)	8(4)	10(4)	6(3)	6(3)
I can feel intense emotions	31(14)	32(14)	23(10)	32(14)	37(17)	25(11)	42(19)
It is like travelling in time	94(42)	30(13)	21(9)	21(9)	19(9)	12(5)	27(12)
It is like a real episode	93(42)	29(13)	26(12)	27(12)	14(6.3)	7(3)	26(12)
My mood changes	50(22)	31(14)	31(14)	31(14)	32(14)	19(9)	29(13)
I experience a physical reaction	75(33)	34(15)	25(11)	19(8)	27(12)	16(7)	29(13)

When asked about the frequency of CFTs within the last month, 30% of the parents reported having experienced such thoughts ‘sometimes’, ‘often’, or ‘very often’ (Table 3).

Table 3. Frequency of counterfactual thoughts experienced by the parents during the last month (N = 227).

Frequency	N (%)
Never	68 (30)
Rarely	91 (40)
Sometimes	48 (21)
Often	15(7)
Very often	5 (2)

The Spearman correlation between vividness and frequency was 0.43. The Pearson correlation between the PTSR and HSCL was 0.80.

Two separate mixed-effects models showed that both frequency and CFT vividness of CFTs were significantly associated with the level of PTSR (model 1, Table 4). A mixed-effects model, where the frequency and vividness of CFTs were included simultaneously, showed that higher levels of both were uniquely associated with higher levels of PTSR (model 2, Table 4).

Table 4. Linear mixed effects models for the relationships of posttraumatic stress reactions and vividness and frequency of counterfactual thoughts (N = 224).

	Model 1			Model 2
	Coeff	95%CI	p	Coeff	95%CI	p
Vividness of CFT	.208	.157–.259	<.001	.124	.072–.176	<.001
Frequency of CFT			<.001			<.001
Rarely vs. Never	.267	.096–.437	.003	.195	.026–.363	.024
Sometimes vs. Never	.500	.287–.714	<.001	.367	.154–.580	.001
Often vs. Never	1.085	.772–.1.398	<.001	.764	.433–1.095	<.001
Very often vs. never	1.885	1.385–2.386	<.001	1.597	1.098–.2.095	<.001

*Model 1: vividness and frequency were entered separately while adjusting for age and sex. Model 2: vividness and frequency were included simultaneously while adjusting for age and sex.

The mixed-effects models with symptoms of anxiety and depression as dependent variables, accounting for clustering within families, were not stable and we proceeded with linear regression analyses. The results showed that both frequency and vividness of CFTs were significantly associated with symptoms of anxiety and depression (model 1, Table 5). In model 2 (Table 5), where the frequency and vividness of CFTs were included simultaneously, we found that both frequency and vividness of CFTs were uniquely associated with the symptom level of anxiety and depression.

Table 5. Linear regression analysis for the relationships of anxiety and depression symptoms and vividness and frequency of counterfactual thoughts (N = 224).

	Model 1			Model 2
	Coeff	95%CI	p	Coeff	95%CI	p
Vividness of CFT	.131	.083–.180	<.001	.068	.015–.120	.011
Frequency of CFT			<.001			<.001
Rarely vs. Never	.199	.027–.370	.023	.164	-.008–.336	.061
Sometimes vs. Never	.387	.183–.591	<.001	.310	.100–.519	.004
Often vs. Never	.778	.475–.1.081	<.001	.602	.273–.930	<.001
Very often vs. never	1.395	.902–1.889	<.001	1.219	.713–1.725	<.001

*Model 1: vividness and frequency were entered separately while adjusting for age and sex. Model 2: vividness and frequency were included simultaneously while adjusting for age and sex.

5. Discussion

The present study was the first to investigate CFTs and their association with psychological distress in parents of trauma survivors. The parents reported an elevated level of psychological distress eight years after the attack, their reported anixiety/depression scores were twice as high and their PSTR scores were more than three times as high compared to the general population as measured at 4–5 months post-terror (Thoresen et al., 2016). The majority of the parents reported having experienced thoughts about what could have happened at some time point since the attack. For almost one-third of the parents, CFTs were still present more than eight years after the attack. In line with our predictions, the results showed that both higher frequency of CFTs during the last month, and higher level of vividness of CFTs, were significantly associated with a higher level of PTSR, and anxiety and depression symptoms.

Thinking about what could have happened is a normal reaction after negative experiences. This type of thinking can initially have an adaptive function, by helping us identify causes for unwanted experiences and give directives for future behaviour (Epstude & Roese, 2008). However, research has also shown that this type of thinking can be harmful in the context of trauma (Blix et al., 2016, 2018; Gilbar et al., 2010; Hoppen et al., 2020; Hoppen & Morina, 2021; Mitchell et al., 2016). The present findings extend research on CFTs in trauma survivors, by demonstrating that the frequency and vividness of CFTs are associated with psychological distress in individuals who have experienced secondary trauma as caregivers of trauma survivors.

The present results showed that both frequency and vividness of CFTs were uniquely associated with PTSR and symptoms of anxiety and depression. This is in line with the results by Blix et al. (2018), where both CFTs frequency and vividness were uniquely associated with levels of PTSR among survivors and bereaved of the fire on the Scandinavian Star ferry. Taken together, the results from these two studies suggest that frequency and vividness are independent factors that may represent different ways in which CFTs after trauma can become harmful.

Persistent thoughts about what could have happened to one's child during the attack, or thinking about how much better off (s)he could have been if (s)he never had experienced the attack, may be very distressing and can trigger difficult feelings, like guilt or remorse. In this study we found a unique association between the frequency of CFTs and psychological distress, suggesting that CFTs can become ruminative or intrusive. According to theories of PTSD, rumination and intrusive trauma memories are driving factors underlying persistent psychopathology post-trauma (Brewin et al., 1996; Ehlers & Clark, 2000; Rubin et al., 2008). In line with this, previous research has shown that rumination is associated with negative affect, can impair problem-solving, erode social support (Nolen-Hoeksema et al., 2008), and hinder recovery of PTSR (Michael et al., 2007).

Furthermore, it makes sense that a parent’s vivid simulations about what could have happened to the child, particularly if these thoughts entail how their child could have been injured or died, will be experienced as very distressing. When CFTs take the form of vivid mental images, this involves a form of mental time travel and resembles episodic memories (Addis, 2018; De Brigard & Parikh, 2019; Wardell et al., 2022). From research on trauma and memory, we know that higher degrees of vividness of trauma memories are associated with higher levels of PTSR (Berntsen et al., 2003). Along this line, the results of the present study support the idea that the vividness of trauma-related CFTs might have a similar impact on PTSR as the vividness of trauma memories.

In the present study, we did not assess the distinction between upward and downward CFT. However, drawing from existing literature (Blix et al., 2018; Markman & McMullen, 2003; McMullen, 1997; Roese & Epstude, 2017), we acknowledge that upward and downward CFT could impact psychological distress through potentially different mechanisms. In line with this, we might speculate that upward CFTs among parents could influence psychological distress through contrast effects. For example, envisioning scenarios where one's child was spared from experiencing the terrorist attack and how they thus could have led a less burdened life might lead to elevated distress. Conversely, for downward CFTs among parents, assimilation effects may be at play. For instance, vividly imagining a counterfactual scenario in which their child was more injured or even died during the terror attack might contribute to heightened distress. Although our study did not directly explore these nuances among parents, we acknowledge the significance of investigating these mechanisms in future research to gain a deeper understanding of how the frequency and vividness of upward and downward CFTs respectively influence PTSR.

Some strengths and limitations of the present study should be mentioned. This was the first study to investigate CFTs among parents of trauma survivors. Furthermore, this study was the first to examine the relationship between the vividness of CFTs and anxiety and depression symptoms. The interviews were conducted by trained professionals and most of the interviews were performed in a face-to-face setting. Since CFTs were measured only at one-time point, we cannot draw conclusions about the temporal association between CFTs and psychological distress. We cannot rule out the possibility that the parents who chose to participate in the study 8.5–9 years after the attack might have a higher symptom level and a higher frequency of CFTs. The participants were all affected by the same traumatic event, by being parents to survivors of the terror attack. We did not interview parents of the youths who died as a result of the terror attack, so we do not know whether the present findings are generalisable to bereaved parents. Furthermore, in the present study we did not take into consideration the degree of exposure severity or level of psychological distress experienced by the youth themselves. Hence, future research needs to shed light on the role of the youth's exposure severity as well as the severity of posttraumatic reactions on the associations observed in the present study. Future studies are also needed to establish whether the present findings generalise to parents of survivors of various types of trauma. Furthermore, we cannot be sure to what extent answering questions regarding the frequency and vividness of CFTs in an interview setting is representative of the occurrence of such thoughts in everyday life. Future studies should examine the dynamic relationship between CFTs and psychological distress in daily life, for example in diary studies.

6. Conclusion

Thinking about what could have happened to one’s child seems to be common for parents whose child has experienced trauma. Although these thoughts will subside with time for most individuals, for some they can become persistent and be experienced as vivid mental images, even for several years after the event. The association between CFTs and psychological distress was found more than eight years after the terror attack, suggesting that the relationship is a persistent one. The present results show that both frequency and vividness of CFTs are closely linked with psychological distress. Such knowledge about the relationship between CFTs and psychological distress is important for understanding the development and maintenance of post-trauma psychopathology and might have important clinical implications. First, clinicians should be aware that in the context of trauma, excessive or vivid thoughts about what could have happened, can potentially be harmful. If these thoughts are identified and addressed in therapy, clinicians may help both survivors and caregivers better cope with these thoughts. Second, distributing information about this type of thinking to parents of trauma-exposed individuals might be an important part of psychoeducation and contribute to normalisation. Future studies should examine whether interventions specifically targeting persistent and vivid CFT can alleviate psychological distress.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data cannot be made available because of the personal and sensitive content of participants’ experiences.