Trauma complexity and child abuse: A qualitative study of attachment narratives in adult refugees with PTSD

Abstract

The present study aimed to identify trauma types over the life course among adult refugees and to explore their accounts of childhood maltreatment. A sample of 43 Arabic-speaking refugees with posttraumatic stress disorder (PTSD) attending a treatment context in Denmark were interviewed. Using a “Trauma Coding Manual” developed for this study, trauma types were identified in interview transcripts. In both men and women with Iraqi and Palestinian-Lebanese backgrounds, high levels of trauma complexity and high rates of childhood maltreatment were found (63%, n = 27). A number of concepts and categories emerged in the domains childhood physical abuse (CPA), childhood emotional abuse (CEA), and neglect. Participants articulated wide personal impacts of child abuse in emotional, relational, and behavioral domains in their adult lives. These narratives contribute valuable clinical information for refugee trauma treatment providers.

Keywords

adult refugees with PTSD attachment trauma child abuse childhood maltreatment complex trauma qualitative analysis

Get full access to this article

View all access options for this article.

References

Al-Eissa

M. A.

AlBuhairan

F. S.

Qayad

Saleheen

Runyan

Almuneef

(2015) Determining child maltreatment incidence in Saudi Arabia using the ICAST-CH: A pilot study. Child Abuse & Neglect 42: 174–182. doi:10.1016/j.chiabu.2014.08.016.

Allen

J. G.

Lemma

Fonagy

(2012) Trauma. In: Bateman

A. W.

Fonagy

(eds) Handbook of mentalizing in mental health practice, Arlington, VA: American Psychiatric Association, pp. 419–444.

Armour

Elklit

Christoffersen

M. N.

(2014) A latent class analysis of childhood maltreatment: Identifying abuse typologies. Journal of Loss and Trauma 19(1): 23–39.

Bakermans-Kranenburg

M. J.

van Ijzendoorn

M. H.

(2009) The first 10,000 adult attachment interviews: Distributions of adult attachment representations in clinical and non-clinical groups. Attachment & Human Development 11(3): 223–263. doi:10.1080/14616730902814762.

Barenbaum

Ruchkin

Schwab-Stone

(2004) The psychosocial aspects of children exposed to war: Practice and policy initiatives. Journal of Child Psychology and Psychiatry 45(1): 41–62. doi:10.1046/j.0021-9630.2003.00304.x.

Bindekrantz

A. S.

Andersen

L. B.

(2011) Guide til NVivo 9 [Guide for NVivo 9], Copenhagen, Denmark: Hans Reitzels Forlag.

Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, (3). https://doi.org/10.1002/14651858.CD003388.pub3.

Bogic

Njoku

Priebe

(2015) Long-term mental health of war-refugees: A systematic literature review. BMC International Health and Human Rights 15(1): 1–41. doi:10.1186/s12914015-0064-9.

Bowlby

(1969) Attachment and loss: Attachment Vol. 1, New York, NY: Basic Books.

10.

Bowlby

(1973) Attachment and loss: Separation, anxiety and anger Vol. 2, New York, NY: Basic Books.

11.

Bowlby

(1980) Attachment and loss: Sadness and depression Vol. 3, New York, NY: Basic Books.

12.

Bowlby

(1988) A secure base, London, UK: Routledge.

13.

Bremner

J. D.

Southwick

S. M.

Johnson

D. R.

Yehuda

Charney

D. S.

(1993) Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. The American Journal of Psychiatry 150(2): 235–239.

14.

Buhmann, C. B. (2014). Traumatized refugees: Morbidity, treatment and predictors of outcome (PhD thesis). Danish Medical Journal, 61(8): B4871, 1–29. https://www.psykiatri-regionh.dk/centre-og-social-tilbud/kompetencecentre/transkulturel-psykiatri/CTP-Publications/Documents/traumatized_refugees_buhmann.pdf.

15.

Catani

Jacob

Schauer

Kohila

Neuner

(2008) Family violence, war, and natural disasters: A study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry 8(1): 1–10. doi:10.1186/1471-244X-8-33.

16.

Catani

Schauer

Elbert

Missmahl

Bette

J.-P.

Neuner

(2009) War trauma, child labor, and family violence: Life adversities and PTSD in a sample of school children in Kabul. Journal of Traumatic Stress 22(3): 163–171. doi:10.1002/jts.20415.

17.

Chu

J. A.

(2011) Rebuilding shattered lives: Treating complex PTSD and dissociative disorders, (2nd ed. Hoboken, NJ: Wiley.

18.

Claussen

A. H.

Crittenden

P. M.

(1991) Physical and psychological maltreatment: Relations among types of maltreatment. Child Abuse & Neglect 15(1–2): 5–18. doi:10.1016/0145-2134(91)90085-R.

19.

Cloitre

Courtois

C. A.

Charuvastra

Carapezza

Stolbach

B. C.

Green

B. L.

(2011) Treatment of complex PTSD: Results of the ISTSS Expert Clinician Survey on Best Practices. Journal of Traumatic Stress 24(6): 615–627. doi:10.1002/jts.20697.

20.

Cloitre

Garvert

D. W.

Brewin

C. R.

Bryant

R. A.

Maercker

(2013) Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology. 4, doi:10.3402/ejpt.v4i0.20706.

21.

Courtois

C. A.

(2004) Complex trauma, complex reactions: Assessment and treatment. Psychotherapy 41(4): 412–425. doi:10.1037/0033-3204.41.4.412.

22.

Dalgaard

N. T.

Todd

B. K.

Daniel

S. I. F.

Montgomery

(2016) The transmission of trauma in refugee families: Associations between intra-family trauma communication style, children’s attachment security and psychosocial adjustment. Attachment & Human Development 18(1): 69–89. doi:10.1080/14616734.2015.1113305.

23.

Daniel

S. I. F.

(2006) Adult attachment patterns and individual psychotherapy: A review. Clinical Psychology Review 26(8): 968–984. doi:10.1016/j.cpr.2006.02.001.

24.

Daniel

S. I. F.

(2015) Adult attachment patterns in a treatment context, relationship and narrative, (1st ed. Hove, UK: Routledge.

25.

De Haene

Grietens

Verschueren

(2010) Adult attachment in the context of refugee traumatisation: The impact of organized violence and forced separation on parental states of mind regarding attachment. Attachment & Human Development 12(3): 249–264. doi:10.1080/14616731003759732.

26.

Derogatis

L. R.

(1994) SCL-90-R: Symptom Checklist-90-R. Administration, scoring and procedures manual, (3 rd ed. Minneapolis, MN: National Computer Systems Pearson.

27.

Derogatis

L. R.

Lipman

R. S.

Rickels

Uhlenhuth

E. H.

Covi

(1974) The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Systems Research and Behavioral Science 19(1): 1–15.

28.

Edwards

V. J.

Holden

G. W.

Felitti

V. J.

Anda

R. F.

(2003) Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the Adverse Childhood Experiences Study. The American Journal of Psychiatry 160(8): 1453–1460. doi:10.1176/appi.ajp.160.8.1453.

29.

Egeland

Sroufe

L. A.

Erickson

(1983) The developmental consequence of different patterns of maltreatment. Child Abuse & Neglect 7(4): 459–469. doi:10.1016/0145 - 2134(83)90053-4.

30.

Elklit

(2006) Redskaber til psykologisk undersøgelse og diagnostik af traumatiserede [Instruments for psychological assessment and diagnostics of traumatized]. In: Elsass

Ivanouw

Mortensen

E. L.

Poulsen

Rosenbaum

(eds) Assessmentmetoder – håndbog for psykologer og psykiatere [Assessment methods – Handbook for psychologists and psychiatrists], Virum, Denmark: Dansk Psykologisk Forlag, pp. 245–257.

31.

Fonagy

Gergely

Jurist

Target

(2002) Affect Regulation, Mentalization and the Development of the Self. (1. ed.), USA: Other Press LCC.

32.

Fonagy

Target

Steele

(1998) Reflective functioning manual – for application to adult attachment interviews. version 5. Psychoanalysis Unit, Sub-Department of Clinical Health Psychology, University College London, London. Retrieved from https://www.mentalizacion.com.ar/images/notas/Reflective%20Functioning%20Manual.pdf.

33.

Friedman

M. J. (Ed.).

(2010) Handbook of PTSD: Science and practice, New York, NY: Guilford Press.

34.

George

Kaplan

Main

(1996) Adult Attachment Interview protocol, Berkeley, CA: Unpublished manuscript, Department of Psychology, University of California Berkeley.

35.

Gielen, U. P. (2016). The Cross-Cultural Study of Human Development: A Skeptical Yet Optimistic Historical Introduction. In U. P. Gielen & J. L. Roopnarine (Eds.), Childhood and Adolescence: Cross-Cultural Perspectives and Applications (2nd ed., pp. 3–46). Santa Barbara, California: Praeger.

36.

Green

B. L.

Kaltman

S. I.

Chung

J. Y.

Holt

M. P.

Jackson

Dozier

(2012) Attachment and health care relationships in low-income women with trauma histories: A qualitative study. Journal of Trauma & Dissociation 13(2): 190–208. doi:10.1080/15299732.2012.642761.

37.

Hamilton

(1959) The assessment of anxiety states by rating. The British Journal of Medical Psychology 32(1): 50–55.

38.

Hamilton

(1960) A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry 23(56): 56–62.

39.

Herman

J. L.

(1997) Trauma and recovery: The aftermath of violence—from domestic abuse to political terror, New York, NY: Basic Books.

40.

Hesse

(2008) The adult attachment interview: Protocol, method of analysis, and empirical studies: 1985–2015. In: Cassidy

Shaver

P. R.

(eds) Handbook of attachment: Theory, research, and clinical applications, (2nd ed. New York, NY: The Guildford Press, pp. 552–598.

41.

Heun

Bonsignore

Barkow

Jessen

(2001) Validity of the five-item WHO Well-Being Index (WHO-5) in an elderly population. European Archives of Psychiatry and Clinical Neuroscience 251(2): 27–31. doi:10.1007/BF03035123.

42.

Hill

C. E.

Knox

Thompson

B. J.

Williams

E. N.

Hess

S. A.

Ladany

(2005) Consensual qualitative research: An update. Journal of Counseling Psychology 52(2): 196–205. doi:10.1037/0022-0167.52.2.196.

43.

Iwakabe

Gazzola

(2009) From single-case studies to practice-based knowledge: Aggregating and synthesizing case studies. Psychotherapy Research 19(4–5): 601–611. doi:10.1080/10503300802688494.

44.

Kanninen

Salo

Punamaki

R. L.

(2000) Attachment patterns and working alliance in trauma therapy for victims of political violence. Psychotherapy Research 10(4): 435–449. doi:10.1093/ptr/10.4.435.

45.

Keller

(2013) Attachment and culture. Journal of Cross-Cultural Psychology 44(2): 175–194. doi:10.1177/0022022112472253.

46.

Khamis

(2000) Child psychological maltreatment in Palestinian families. Child Abuse & Neglect 24(8): 1047–1059. doi:10.1016/S0145-2134(00)00157-5.

47.

Kirmayer

L. J.

Kienzler

Afana

A. H.

Pedersen

(2010) Trauma and disasters in a social and cultural context. In: Morgan

Bhugra

(eds) Principles of social psychiatry, 2nd ed. New York, NY: Wiley-Blackwell, pp. 155–177.

48.

Kuckartz

(2014) Qualitative text analysis: A guide to methods, practice & using software, London, UK: SAGE.

49.

Maercker

Brewin

C. R.

Bryant

R. A.

Cloitre

Reed

G. M.

van Ommeren

Saxena

(2013) Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11. The Lancet, 381(9878), 1683–1685. https://doi.org/10.1016/S0140-6736(12)62191-6.

50.

Main

Goldwyn

Hesse

(2003) Adult attachment scoring and classification systems Version 7.2, Berkeley, CA: Unpublished manuscript, Department of Psychology, University of California Berkeley.

51.

Main

Kaplan

Cassidy

(1985) Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development 50(1–2): 66–104. doi:10.2307/3333827.

52.

Mallinckrodt

(2010) The psychotherapy relationship as attachment: Evidence and implications. Journal of Social and Personal Relationships 27(2): 262–270. doi:10.1177/0265407509360905.

53.

Mikulincer

(1998) Adult attachment style and affect regulation: Strategic variations in self-appraisals. Journal of Personality and Social Psychology 75(2): 420–435. doi:10.1037/0022-3514.75.2.420.

54.

Mikulincer

Ein-Dor

Solomon

Shaver

P. R.

(2011) Trajectories of attachment insecurities over a 17-year period: A latent growth curve analysis of the impact of war captivity and post traumatic stress disorder. Journal of Social and Clinical Psychology 30(9): 960–984.

55.

Mikulincer

Horesh

Eilati

Kotler

(1999) The association between adult attachment style and mental health in extreme life-endangering conditions. Personality and Individual Differences 27(5): 831–842. doi:10.1016/S0191-8869(99)00032-X.

56.

Mollica

R. F.

Caspi-Yavin

Bollini

Truong

Tor

Lavelle

(1992) The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. The Journal of Nervous and Mental Disease 180(2): 111–116.

57.

Moran, G., Bailey, H. N., Gleason, K., DeOliveira, C. A., & Pederson, D. R. (2008). Exploring the mind behind unresolved attachment: Lessons from and for attachment-based interventions with infants and their traumatized mothers. In H. Steele & M. Steele (Eds.), Clinical implications of The Adult Attachment Interview (pp. 371–398). New York: Guildford Press.

58.

National Institute for Care Excellence (NICE) (2005) Post-traumatic stress disorder (PTSD): Management (Clinical Guideline 26). Retrieved from http://www.nice.org.uk/guidance/CG26.

59.

Nickerson

Bryant

R. A.

Silove

Steel

(2011) A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review 31(3): 399–417. doi:10.1016/j.cpr.2010.10.004.

60.

NVivo (Version 10) [Computer software]. Doncaster, Australia: QSR International.

61.

Ogawa

J. R.

Sroufe

L. A.

Weinfield

N. S.

Carlson

E. A.

Egeland

(1997) Development and the fragmented self: Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and Psychopathology 9(4): 855–879.

62.

Ogle

Rubin

D. C.

Siegler

I. C.

(2015) The relation between insecure attachment and posttraumatic stress: Early life versus adulthood traumas. Psychological Trauma: Theory, Research, Practice, and Policy 7(4): 324–332. doi:10.1037/tra0000015.

63.

Opaas

Varvin

(2015) Relationships of childhood adverse experiences with mental health and quality of life at treatment start for adult refugees traumatized by pre-flight experiences of war and human rights violations. Journal of Nervous and Mental Disease 203(9): 684–695. doi:10.1097/NMD.0000000000000330.

64.

Osterman

J. E.

de Jong

J. T. V.

(2007) Cultural issues and trauma. In: Friedman

M. J.

Keane

T. M.

Resick

P. A.

(eds) Handbook of PTSD: Science and practice, New York, NY: The Guilford Press, pp. 425–446.

65.

Palic

Elklit

(2014) Personality dysfunction and complex posttraumatic stress disorder among chronically traumatized Bosnian refugees. The Journal of Nervous and Mental Disease 202(2): 111–118.

66.

Panter-Brick

Goodman

Tol

Eggerman

(2011) Mental health and childhood adversities: A longitudinal study in Kabul, Afghanistan. Journal of the American Academy of Child & Adolescent Psychiatry 50(4): 349–363. doi:10.1016/j.jaac.2010.12.001.

67.

Pappe

(2004) A history of modern Palestine: One land, two peoples, Cambridge, UK: Cambridge University Press.

68.

Riber, K. (2015). Attachment, Complex Trauma, and Psychotherapy: A Clinical study of the Significance of Attachment in adult Arabic-speaking refugees with PTSD (PhD thesis). Department of Psychology, Faculty of Social Sciences, University of Copenhagen: SL grafik, Frederiksberg C, Denmark. ISBN: 978-87-7611-856-3.

69.

Riber

(2016) Attachment organization in Arabic-speaking refugees with post traumatic stress disorder. Attachment & Human Development 18: 154–175. doi:10.1080/14616734.2015.1124442.

70.

Saile

Ertl

Neuner

Catani

(2014) Does war contribute to family violence against children? Findings from a two-generational multi-informant study in Northern Uganda. Child Abuse & Neglect 38(1): 135–146. doi:10.1016/j.chiabu.2013.10.007.

71.

Slade

(2008) The implications of attachment theory and research for adult psychotherapy: Research and clinical perspectives. In: Shaver

Cassidy

(eds) Handbook of attachment: Theory, research and clinical applications, 2nd. ed. New York, NY: Guildford Press, pp. 762–782.

72.

Solomon

Dekel

Mikulincer

(2008) Complex trauma of war captivity: A prospective study of attachment and post-traumatic stress disorder. Psychological Medicine 38(10): 1427–1434. doi:10.1017/S0033291708002808.

73.

Steel

Chey

Silove

Marnane

Bryant

R. A.

van Ommeren

(2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA 302(5): 537–549. doi:10.1001/jama.2009.1132.

74.

Stevanović

Frančišković

Vermetten

(2016) Relationship of early-life trauma, war-related trauma, personality traits, and PTSD symptom severity: A retrospective study on female civilian victims of war. European Journal of Psychotraumatology 7.. doi:10.3402/ejpt.v7.30964.

75.

Styron

Janoff-Bulman

(1997) Childhood attachment and abuse: Long-term effects on adult attachment, depression, and conflict resolution. Child Abuse & Neglect 21(10): 1015–1023. doi:10.1016/S0145-2134(97)00062-8.

76.

Sveaass

Lavik

N. J.

(2000) Psychological aspects of human rights violations: The importance of justice and reconciliation. Nordic Journal of International Law 69(1): 35–52.

77.

Tripp

(2000) A history of Iraq, Cambridge, UK: Cambridge University Press.

78.

United Nations High Commissioner for Refugees (UNHCR) (2016) Figures at a glance: Statistical yearbooks. Retrieved from http://www.unhcr.org/figures-at-a-glance.html.

79.

Usta

Farver

J. M.

Danachi

(2013) Child maltreatment: The Lebanese children’s experiences: Child maltreatment in Lebanese homes. Child: Care, Health and Development 39(2): 228–236. doi:10.1111/j.1365-2214.2011.01359.x.

80.

Van der Kolk

B. A.

Roth

Pelcovitz

Sunday

Spinazzola

(2005) Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress 18(5): 389–399. doi:10.1002/jts.20047.

81.

Van Ijzendoorn

M. H.

Sagi-Schwartz

(2008) Cross-cultural patterns of attachment: Universal and contextual dimensions, New York, NY: Guilford Press.

82.

Vindbjerg

Klimpke

Carlsson

(2014) Psychotherapy with traumatized refugees—the design of a randomised, clinical trial. Torture: Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture 24(1): 40–48.

83.

Waters

Merrick

Treboux

Crowell

Albersheim

(2000) Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Child Development 71(3): 684–689. doi:10.2307/1132386.

84.

Williams

E. N.

Morrow

S. L.

(2009) Achieving trustworthiness in qualitative research: A pan-paradigmatic perspective. Psychotherapy Research 19(4–5): 576–582. doi:10.1080/10503300802702113.

85.

Woodhouse

Ayers

Field

A. P.

(2015) The relationship between adult attachment style and post traumatic stress symptoms: A meta-analysis. Journal of Anxiety Disorders 35: 103–117. doi:10.1016/j.janxdis.2015.07.002.

86.

World Health Organization (WHO) (1992) The ICD-10 International Classifications of Mental and Behavioral Disorders: Clinical descriptions and diagnostic guidelines. Retrieved from http://www.who.int/classifications/icd/en.

87.

World Health Organization (WHO) (2017) Child maltreatment global estimates. Retrieved from http://apps.who.int/gho/data/node.main.VIOLENCECHILDMALTREATMENT?lang=en.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.21 MB