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Open Access 10-04-2025 | Original Article

Cognitive Flexibility as a Mechanism of Change: The Relationship Between Cumulative Trauma Exposure and Stress Reactions Before and After Psychological First-Aid Training

Auteurs: Hagit Nizri, Or Catz, Yochi Siman-Tov, Moshe Farchi, Einat Levy-Gigi

Gepubliceerd in: Cognitive Therapy and Research

Abstract

Purpose

Cumulative exposure to stressful and traumatic incidents can lead to mental deterioration, often resulting in overwhelming feelings of fear, threat, and helplessness. Previous studies revealed that cognitive flexibility plays a significant moderating role in the relationship between trauma exposure and such aversive emotional outcomes. The aim of the current study was twofold: first, to examine the potential impact of participation in a psychological first-aid cognitive-focused training on cognitive flexibility, as well as on feelings of fear, threat, and helplessness. Second, to test whether cognitive flexibility serves as a mechanism of change. Specifically, to determine whether it moderates the relationship between cumulative trauma exposure and feelings of fear, threat, and helplessness following (but not before) the training.

Methods

One-hundred seventy-two educational counselors, whose professional routine includes constant exposure to trauma and stress, were assessed before and after a 10-week psychological first-aid training, which equipped them to respond effectively and support others during traumatic incidents.

Results

The results revealed increased cognitive flexibility and reduced feelings of fear and helplessness following the training. Moreover, before the training, trauma exposure was positively associated with feelings of fear, threat, and helplessness, with no specific role for cognitive flexibility. Following the training, cognitive flexibility moderated the relationship between traumatic exposure and feelings of threat, acting as a protective factor that mitigates this effect.

Conclusions

The results highlight the importance of psychological first-aid training in reducing aversive feelings, improving cognitive flexibility, and prompting it as a protective factor against the deleterious effects of cumulative trauma exposure.

Supplementary file 1.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s10608-025-10605-1.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Introduction

Exposure to stress and traumatic incidents in the workplace is related to deterioration in mental health, with the most significant outcome being post-traumatic stress disorder (PTSD) symptoms (Dautovich et al., 2023; Robinson et al., 1997; Van Eerd et al., 2021). Most of the studies in this field have focused on first responders (Díaz-Tamayo et al., 2022; Lewis-Schroeder et al., 2018). However, there is a growing awareness of the potential stress and traumatic exposure faced by front-line responders, particularly healthcare providers (Finklestein et al., 2015; Gil & Weinberg, 2015; Huang et al., 2022; May & Wisco, 2016).

Educators are a well-studied group in the context of stress exposure. However, their role as front-line responders who deal with acute stress and trauma is not as widely recognized. Studies have shown that educators experience higher stress levels than other healthcare providers (e.g., Agyapong et al., 2022; Smith et al., 2000). This could be attributed to their direct exposure to potentially traumatic incidents such as behavioral issues, violence, and the death of students due to illness, accidents, or suicide, as well as indirect exposure to trauma, such as accompanying a student's family during a crisis and aiding traumatized students. Nonetheless, no research has examined acute stress reactions or the impact of psychological first-aid training on these reactions in educators.

Following traumatic events, most individuals experience emotional, cognitive, behavioral, and physiological acute stress reactions, including feelings of fear, threat, and helplessness, potentially leading to the onset of posttraumatic stress symptoms (Adler et al., 2024; Ehring et al., 2008; Levy et al., 2020; Yehuda et al., 1998). Research indicates that early identification and intervention to mitigate these reactions are crucial for promoting resilience (Azzollini et al., 2018; Farchi et al., 2018; Hansen & Elkite, 2011).

The current research focused on the effects of psychological first-aid training (Farchi et al., 2018). The training is based on an intervention model that helps individuals transition from helplessness to effective functioning. Participants are equipped with the knowledge and skills necessary to cognitively navigate aversive situations and develop a robust coping toolkit, strengthening their sense of control and ability to cope with trauma (Adler et al., 2020; Farchi et al., 2018; Levy et al., 2020; Svetlitzky et al., 2020).

Previous studies revealed that psychological first-aid training increases feelings of security, reduces stress, and empowers individuals to cultivate a sense of belonging and hope- key elements of adaptive coping (Hobfoll et al., 2007; Wang et al., 2021). Moreover, soldiers who participated in psychological first-aid training showed reduced stress reactions and improved self-efficacy during and following trauma exposure (Adler et al., 2020; Svetlitzky et al., 2020). However, the mechanism behind this beneficial effect remains unclear. Here, we propose that psychological first-aid training exerts its positive effect by enhancing cognitive flexibility, a protective factor in the relationship between cumulative trauma exposure and stress-related reactions.

Cognitive flexibility refers to the ability to change behaviors in accordance with situational demands (Dajani & Uddin, 2015; Gabrys et al., 2018). A growing number of studies revealed that cognitive flexibility promotes adaptive behaviors in stressful and traumatic conditions (e.g., Fu & Chow, 2017; Huang et al., 2024; Nakhostin-Khayyat et al., 2024). Most importantly for the focus of the current research, a set of studies revealed that cognitive flexibility moderates the relationship between cumulative exposure to stressful and traumatic events and the tendency to develop PTSD symptoms in various populations, including veterans, firefighters, and educators (Haim-Nachum & Levy-Gigi, 2021; Harel et al., 2023; Hemi et al., 2024; Sopp et al., 2022; Zabag et al., 2020). Specifically, in individuals with low cognitive flexibility, increased cumulative trauma exposure is associated with elevated PTSD symptoms. However, in individuals with high cognitive flexibility, PTSD symptom severity remains low independent of their exposure level. Hence, it serves as a protective factor in conditions of cumulative stress and trauma. Such role is consistent with studies demonstrating that cognitive control resources, including cognitive flexibility, are needed to cope with high-intensity emotions (Cheng, 2009; Langer et al., 2023; Sheppes, 2019).

Taken together, we predicted that psychological first-aid training would reduce acute stress reactions among front-line responders. Specifically, there would be a reduction in feelings of fear, threat, and helplessness following the training. In addition, we predicted that such training would increase cognitive flexibility. Finally, if cognitive flexibility functions as a mechanism of change, it should moderate the relationship between cumulative trauma exposure and feelings of fear, threat, and helplessness specifically after, but not before, the training. Thus, following (but not before) the training, higher levels of cognitive flexibility would weaken the positive associations between trauma exposure and feelings of fear, threat, and helplessness.

Methods

Participants

One hundred seventy-two education counselors (M age = 46 years, SD = 8.05) who work at primary (47.1%) and secondary schools (52.7%) volunteered to participate in the study.

Procedure

The training was designed for educational counselors and focused on providing knowledge, tools, and skills to intervene in stressful and traumatic situations at school (Farchi et al., 2018, 2025). It includes ten 3-h sessions for a total of 30 h. The training course is based on the Six Cs model (cognitive and verbal communication, linking actions to reinforce the sense of control, creating a sense of commitment to break down feelings of loneliness, and continuously organizing events) (Levy et al., 2020). During the course, the participants analyze case studies and simulate stressful and traumatic situations. A week before the beginning of the training course and a week after its completion, the participants filled out self-report questionnaires. Five hundred and forty counselors participated in this training course in fifteen groups led by the same instructors. Two hundred eighty-three counselors filled out the questionnaires before the training (time 1), and 216 counselors filled out the questionnaires after the training (time 2). Of these, 172 consultants were matched before and after it. The matching was according to a code given in advance.

Measures

The Cumulative Traumatic Exposure Questionnaire (CUTE; Harel et al., 2023; Levy-Gigi et al., 2016) includes ten items that describe potential traumatic incidents that can be experienced in a school environment. The participants rank each incident on a scale from 1 ("no exposure") to 6 (“At least a few times in a representative week”). The reliability was α = 0.82.

Fear, Threat, and Helplessness—for each experienced event on the CUTE questionnaire, participants rated their feelings of fear, threat, and helplessness using a 6-point Likert scale. The reliability of these feelings at both time points ranged from α = 0.90 to α = 0.92.

The Cognitive Flexibility Scale (CFS; Martin & Rubin, 1995) focuses on communication proficiency, especially in unfamiliar circumstances. It contains 12 items, each rated from 1 strongly disagree to 6 strongly agree. The CFS has good test–retest reliability of α = 0.81 (Martin & Anderson, 1998; Martin & Rubin, 1995). In the current study the reliability was α = 0.84 and α = 0.86 for times 1 and 2, respectively.

Results

Zero-Order Correlations

Pearson correlations were conducted to test whether there are relations between cumulative trauma exposure, feelings of fear, threat, helplessness, and cognitive flexibility. The results are depicted in Table 1. Feelings of fear, threat, and helplessness before the training positively correlated with the same feelings following the training. Cumulative trauma exposure positively correlated with feelings of fear, threat, and helplessness at both testing points- before and following the training. Finally, cognitive flexibility was negatively correlated with feelings of fear, threat, and helplessness only following the training.

Table 1

Means and standard deviations between the variables and correlations before and after the training (N = 172)

	Before	After	After
Before	M (SD)	M (SD)	Exposure	Fear	Helplessness	Threat	CFS
Exposure	2.61 (0.81)	2.44 (0.74)	.59***	.23**	.28***	.16*	− .07
Fear	2.13 (0.95)	1.85*** (0.88)	.24**	.59***	.79***	.48***	− .23**
Helplessness	2.21 (0.96)	1.97*** (0.97)	.22**	.67***	.59***	.46***	− .32***
Threat	1.27 (0.48)	1.31 (0.58)	.16*	.50***	.48***	.27***	− .40***
Cognitive flexibility	58.30 (7.82)	60.27** (8.35)	− .06	− .10	− .15	− .12	.52***

^*p <.05 ** p <.01 *** p <.001

(Time 1 Correlations are presented below the diagonal; Time 2 correlations are presented above the diagonal)

Pre- Post-Training Differences

Paired sampled t-tests were conducted to test whether there were differences between the measures before and following the training. The results revealed significant differences in feelings of fear, t(158) = 4.20, p < 0.001, and helplessness, t(158) = 3.51, p < 0.001, indicating significantly reduced feelings following the training. However, there were no significant differences in the feelings of threat before and following the training t(158) = − 0.62, p = 0.540. Finally, there was a significant increase in cognitive flexibility following the training t(170) = -3.26, p = 0.001.

Cognitive Flexibility as a Mechanism of Change

A series of General Linear Model (GLM) analyses were conducted to assess the interactive effect of cumulative trauma exposure and cognitive flexibility on feelings of fear, threat, and helplessness before and after the training. The independent variables were standardized as Z-scores for consistent scaling and accurate interpretation of interaction effects.

The pre-training models for feelings of fear and helplessness were significant (F(3,160) = 3.67, p = 01; F(3,160) = 4.14, p < 0.01, respectively) (Tables S1–S2 in the supplementary materials). However, as predicted, no significant interactions were found. The pre-training model examining the effects of cumulative trauma exposure and cognitive flexibility on feelings of threat was not significant (Table 2).

Table 2

The interactive effect of cognitive flexibility and cumulative trauma exposure on feelings of threat following the training (estimated coefficients, standard errors, and 95% confidence intervals)

Variables	B	S.E	t-value	p-value	95% CI
Variables	B	S.E	t-value	p-value	Low	High
Cumulative trauma exposure	.05	.04	1.25	.21	− .03	.13
Cognitive flexibility	− .21	.04	− 5.46	< .001***	− .29	− .14
Cumulative trauma exposure X cognitive flexibility	− .10	.03	− 3.11	.002**	− .16	− .04

**p <.01, ***p <.001

Following the Training

The post-training models for fear, threat, and helplessness were significant (F(3,161) = 6.91, p < 0.001; F(3,161) = 11.22, p < 0.001; F(3,161) = 15.25, p < 0.001, respectively). No significant interactive effects were detected in the fear and helplessness models (see Table S3–S4 in the supplementary materials). However, a significant interactive effect was found between cumulative trauma exposure and cognitive flexibility in predicting feelings of threat (Fig. 1). This interaction added 4.68% to the explained variance. Follow-up analyses revealed that for individuals with low post-training cognitive flexibility (− 1 SD), there is a positive relationship between cumulative trauma exposure and feelings of threat (t(161) = 3.2, p = 0.002). In contrast, for those with high post-training cognitive flexibility (+ 1 SD), levels of threat remained low independent of the levels of cumulative trauma exposure (t(161) = − 0.94, p = 0.35). These results indicate that while pre-training cognitive flexibility did not affect the relationship between cumulative trauma exposure and stress reactions, post-training cognitive flexibility attenuates the deleterious effects of cumulative trauma exposure on the counselors’ threat feelings.

To investigate the moderating role of cognitive flexibility further, we calculated a new measure demonstrating the change in cognitive flexibility following the training (post–pre). Such measure allows us to assess whether the change in cognitive flexibility, rather than its absolute level, moderates the relationship between cumulative trauma exposure and feelings of threat following the training. We conducted an additional GLM analysis. The general model was significant (F(3,161) = 8.26, p < 0.001) (Table 3). Most importantly, there was a significant interactive effect of cumulative trauma exposure and improvement in cognitive flexibility on the post-training feelings of threat. This interaction accounted for an additional 7.63% of the explained variance. Follow-up analyses revealed that for individuals with smaller improvement in cognitive flexibility (−1SD), there was a positive association between cumulative trauma exposure and feelings of threat (t(161) = 3.82, p < 0.001). In contrast, those with larger improvement in cognitive flexibility (+ 1SD) maintained lower feelings of threat, with a trend towards reduction of threat as the exposure increases (t(161) = − 1.82, p = 0.07). No significant interactions were found for fear or helplessness, suggesting that while improvement in cognitive flexibility played a key role in reducing feelings of threat, it did not moderate the relationship between exposure and feelings of fear and helplessness. These findings expand the role of cognitive flexibility as a mechanism of change, suggesting that individuals who benefit most from the training can leverage their new cognitive flexibility skills to mitigate feelings of threat even in the face of increased cumulative trauma exposure (Fig. 2).

Table 3

The interactive effect of change in cognitive flexibility and cumulative trauma exposure on feelings of threat following the training (estimated coefficients, standard errors, and 95% confidence intervals)

Variables	B	S.E	t-value	p-value	95% CI
Variables	B	S.E	t-value	p-value	Low	High
Cumulative trauma exposure	.04	.04	1.05	.29	− .04	.13
Cognitive flexibility	− .17	.04	− 3.83	< .001***	− .25	− .08
Cumulative trauma exposure X cognitive flexibility	− .16	.04	− 3.77	< .001***	− .25	− .07

**p <.01, ***p <.001

Discussion

This study aimed to examine the impact of a 10-week psychological first-aid training on cognitive flexibility and feelings of fear, threat, and helplessness, and to test whether cognitive flexibility acts as a mechanism of change by moderating the relationship between cumulative trauma exposure and feelings of fear, threat, and helplessness after (but not before) the training. The study focused on a unique group of front-line responders- educational counselors- frequently encountering stressful and traumatic events as part of their work routine.

The results revealed that following the training, there was a significant reduction in feelings of fear and helplessness. These results align with prior studies demonstrating that psychological first-aid training effectively reduces negative feelings and enhances well-being (Adler et al., 2020; Farchi et al., 2018; Svetlitzky et al., 2020; Wang et al., 2024). A possible explanation for these findings is that the practical tools provided during the training foster a greater sense of control, efficiency, and competence, all key principles in building resilience (Hobfoll et al., 2007; Zhou & Yao, 2020). Contrary to our prediction, feelings of threat did not decrease following the training. These feelings represent a pre-event reaction (McEwen & Gianaros, 2010; Shakespeare-Finch & Scully, 2024) and may be more resistant to change due to their anticipatory nature. Additionally, their survival value may be relatively high. Indeed, it was found that feelings of threat are especially crucial in signaling danger and preventing individuals from taking unnecessary risks (Ehlers & Clark, 2000; Obrenovic et al., 2021).

In addition, we found that cognitive flexibility significantly increased following the training. This finding supports previous studies demonstrating the role of psychological first-aid training in promoting cognitive flexibility (Brewin, 2001; McNally et al., 2003; Wiederhold, 2023). Moreover, it aligns with previous findings showing that individuals who undergo such first-aid training before trauma exposure are less susceptible to developing PTSD symptoms when facing future trauma (Farchi et al., 2018; Wang et al., 2024). These results contribute to growing evidence suggesting that cognitive flexibility is a core mechanism of resilience (e.g., Evans et al., 2024; Hemi et al., 2024; Rademacher et al., 2023).

Finally, as predicted after (but not before) the training, both absolute and post-intervention changes in cognitive flexibility moderated the relationship between cumulative trauma exposure and feelings of threat. Specifically, while greater exposure to stressful and traumatic events was linked to heightened feelings of threat among individuals with low cognitive flexibility, those with high cognitive flexibility experienced minimal feelings of threat, regardless of their level of exposure. These results support previous studies that demonstrated the protective role of cognitive flexibility in the relationship between exposure to stressful and traumatic incidents and the development of PTSD (Haim-Nachum & Levy-Gigi, 2019; Harel et al., 2023; Zabag et al., 2020). However, they extend this concept to include feelings of threat, which are typically more resistant to change. Furthermore, the lack of a direct effect of first aid training on feelings of threat underscores the importance of recognizing possible indirect pathways, particularly through the moderating role of cognitive flexibility.

These results align with the process-based therapy approach (Ciarrochi et al., 2024; Hayes et al., 2020; Hofmann, 2025; Moskow et al., 2023), which views psychopathology as a maladaptive response to a given context. Furthermore, rather than concentrating on diagnosing and treating distinct syndromes, process-based therapy emphasizes the mechanisms of behavioral influence that drive change and ultimately promote behavioral transformation. The findings of this study suggest that cognitive flexibility may be one such mechanism. Specifically, in addition to its direct link with improved mental health, our results indicate that cognitive flexibility serves as a mechanism of change by reducing the effects of cumulative trauma exposure on the tendency to feel threatened. As such, it adaptively shapes the way individuals function and respond to various life circumstances.

Interestingly, the moderating role of cognitive flexibility was absent in the relationship between trauma exposure and feelings of fear and helplessness. One possible explanation relates to the previously mentioned differences between feelings of threat and feelings of fear and helplessness. Specifically, threat reactions are triggered by interpreting an event as hazardous (Levy et al., 2020; McEwen & Gianaros, 2010). Since such interpretations can vary, ranging from highly dangerous to completely safe (Ehlers & Clark, 2000; Ehring et al., 2008), threat reactions may depend more heavily on the ability to discern how context shapes the situation and to react accordingly, as demonstrated by cognitive flexibility. Indeed, previous findings revealed that individuals with greater cognitive flexibility make more nuanced and accurate interpretations in ambiguous conditions (Ehlers & Clark, 2000). Conversely, helplessness and fear may represent more automatic instinctual survival reactions to threats that inhibit cognitive abilities (Farchi et al., 2018, 2025), and therefore, they are less influenced by cognitive flexibility.

While significant, the current study has several limitations. First, the sample demographics, primarily women school counselors, raise questions about how broadly the findings can be generalized to more diverse populations. Although the sample reflects the majority of women among counselors and educators (86%, according to the National Center for Education Statistics, 2020), it is possible that women experience stressful and traumatic situations differently than men (e.g., Bryant & Harvey, 2003), suggesting that the reported relationships may be unique to this group. However, several points warrant consideration. Previous research on first responders, which consists mostly of men, demonstrated a similar protective effect on cognitive flexibility (Sopp et al., 2022; Zabag et al., 2020). Additionally, earlier findings using the same training indicated that it is more beneficial for men (Farchi & Gidron, 2010); therefore, if differences do exist, the relationships between the various variables may be stronger among men. Most importantly, when gender was included in our models, the results remained unchanged. Nevertheless, future studies may examine more male educators for potential gender-related differences. Moreover, the study aimed to evaluate the effectiveness of psychological first-aid training; thus, it is inherently a field study. However, it is based on a planned and structured training program.

Second, like many studies in the field (Levy-Gigi et al., 2016; Vogt et al., 2011; Weiss et al., 2010), this study assessed trauma exposure retrospectively. A follow-up study could enhance the findings by implementing ecological momentary assessment, which allows for daily evaluation of trauma exposure.

Finally, although we did not measure functioning before and after the training, we showed decreased feelings of fear and helplessness along with increased cognitive flexibility. These changes may suggest enhanced psychological functioning, as these factors are vital for adaptive coping and resilience. Lower levels of fear and helplessness represent a shift away from maladaptive stress responses, while improved cognitive flexibility promotes more effective problem-solving, emotional regulation, and behavioral adaptability when faced with ongoing challenges. Together, these changes indicate a strengthened ability to manage stress and trauma, ultimately contributing to overall well-being and functional improvement.

In summary, this study highlights the positive impact of psychological first-aid training, demonstrating its effectiveness in reducing feelings of fear and helplessness while enhancing cognitive flexibility. Importantly, the findings emphasize cognitive flexibility as a key mechanism of change that helps alleviate threat-related emotions arising from continuous exposure to stressful and traumatic situations. This emphasizes the necessity of enhancing cognitive flexibility to promote adaptive coping and improve well-being. Ultimately, these compelling results advocate for the widespread adoption of psychological first-aid training among populations regularly exposed to stress and trauma. By incorporating this training, we can strengthen the ability to manage the ongoing effects of stress, ultimately promoting greater stability and mental health in high-risk environments.

Declarations

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. The study received ethical approval from Bar Ilan University.

All participants were informed about the objectives and procedures of the study. It was explicitly communicated that they had the right to withdraw from the study at any point. Participant anonymity was ensured throughout the research process.

All participants signed a written informed consent form.

Competing Interests

The authors declare no competing interest.

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Supplementary Information

Below is the link to the electronic supplementary material.

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Titel: Cognitive Flexibility as a Mechanism of Change: The Relationship Between Cumulative Trauma Exposure and Stress Reactions Before and After Psychological First-Aid Training
Auteurs: Hagit Nizri
Or Catz
Yochi Siman-Tov
Moshe Farchi
Einat Levy-Gigi
Publicatiedatum: 10-04-2025
Uitgeverij: Springer US
Gepubliceerd in: Cognitive Therapy and Research
Print ISSN: 0147-5916
Elektronisch ISSN: 1573-2819
DOI: https://doi.org/10.1007/s10608-025-10605-1

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Cognitive Flexibility as a Mechanism of Change: The Relationship Between Cumulative Trauma Exposure and Stress Reactions Before and After Psychological First-Aid Training

Abstract

Purpose

Methods

Results

Conclusions

Supplementary Information

Publisher's Note

Introduction

Methods

Participants

Procedure

Measures

Results

Zero-Order Correlations

Pre- Post-Training Differences

Cognitive Flexibility as a Mechanism of Change

Following the Training

Discussion

Declarations

Competing Interests

Publisher's Note

Onze productaanbevelingen

BSL Psychologie Totaal

BSL Academy Accare GGZ collective

BSL GOP_opleiding GZ-psycholoog

Supplementary Information

Bohn Stafleu van Loghum

Welkom bij Scalda & Bohn Stafleu van Loghum

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Deel dit onderdeel of sectie (kopieer de link)

Abstract

Purpose

Methods

Results

Conclusions

Supplementary Information

Publisher's Note

Introduction

Methods

Participants

Procedure

Measures

Results

Zero-Order Correlations

Pre- Post-Training Differences

Cognitive Flexibility as a Mechanism of Change

Following the Training

Discussion

Declarations

Ethics Approval and Consent

Informed Consent

Consent to Participate and Publish

Competing Interests

Publisher's Note

Deel dit onderdeel of sectie (kopieer de link)

Onze productaanbevelingen

BSL Psychologie Totaal

BSL Academy Accare GGZ collective

BSL GOP_opleiding GZ-psycholoog

Supplementary Information