Trauma, personality function, and posttraumatic reactions: A retrospective and prospective study of traumatized refugee patients

Abstract

This thesis investigates the implications of adverse childhood experiences, potentially traumatic experiences of war and human rights violations (HRVs), and personality factors for the mental health and wellbeing of adult refugee patients. The study comprises 54 multi-traumatized patients with histories as refugees and trauma survivors. Our results indicate that adverse childhood experiences and difficulties with reality testing add to the suffering and reduced function experienced by refugee patients. The participants’ trauma-related personality function was of importance to their treatment trajectory in and after treatment. Over the three years of the study a pattern emerged in which patients with adequate Reality Testing improved markedly the first year after treatment start and retained their improvement, whereas participants with impaired Reality Testing deteriorated the first year after treatment start and had not fully regained their relatively better T1-level by the end of the three years.

Many refugees suffer from mental health problems for years, while others are resilient or regain their health gradually. Mental health treatment is of great help for some, but many refugee patients do not benefit significantly from treatment. The aim of the study was to investigate some understudied areas which might contribute to more understanding of refugees’ differing trajectories both after traumatic experiences and after treatment. The research design was naturalistic and longitudinal, with no restraints on therapeutic approach or treatment duration.

The study participants were recruited as they were accepted for specialist mental health treatment at DPSs (out-patient clinics) or in individual ‘private practices’ with public funding. They were interviewed and assessed at treatment start (T1), after one year (T2), and after three years (T3). In the assessment, we used: the Harvard Trauma Questionnaire (PTSD), the Hopkin’s Symptom Checklist-25 (anxiety and depression), the WHO Quality of Life-Bref (quality of physical health, psychological health, social relationships, and environmental conditions), recording of employment history and Norwegian skills as observable aspects of their daily life function, qualitative interviews, and the Rorschach personality assessment method.

We found that childhood adverse experiences were even more strongly related to their present suffering than more recent experiences of war, persecution and other human rights violations (HRVs). Moreover, we found two new Rorschach components or personality dimensions that characterized the way these individuals functioned under the relative stress of assessment: 1) ‘Trauma Response’, along a continuum from constricted (i.e., restrained or limited associative and emotional activity) to flooded (i.e., traumatic intrusions, emotional regulation problems, and logical breaches in thinking), and 2) ‘Reality Testing’, along a continuum from impaired to adequate perceptual reality testing (i.e., ability to notice ordinary aspects of the environment and perceive events and objects in ways that correspond with realities and the ways others perceive them). Perceptual Reality Testing was more strongly related to the participants’ overall mental health and well-being than the other, more trauma-specific variable.

At T2, 37% of the therapies were terminated, and at T3, 71 % of the therapies had ended. There was little attrition from the study. At the three-year follow-up, the participants’ mean results showed statistically significant improvements in depression, anxiety, PTSD, and quality of life, but the individual variation in outcome was pronounced. At T3 most participants still qualified for a mental health diagnosis. Higher scores on the Reality Testing dimension continued to predict better functioning during follow-up. The problems with reality testing identified in this study were of an apparently trauma-based nature, not to be confused with the reality testing difficulties of psychotic patients.

Findings in our study were analyzed in relation to attachment theory, trauma theory, findings from neuroscience, and existing research in the refugee and trauma fields. Our findings point to the importance of addressing adverse childhood experiences in research and in psychotherapy with adult refugees. Furthermore, the results suggest the importance of working to enhance the patients’ capacity to perceive the context of events fully, in order to support their reality testing of potentially stressful relational and other experiences in their daily life.