Riber 2017

Transcultural Psychiatry 0(0) 1–30 !
The Author(s) 2017

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DOI: 10.1177/1363461517737198 journals.sagepub.com/home/tps
Article
Trauma complexity and child abuse:

A qualitative study of attachment
narratives in adult refugees with PTSD
Karin Riber*
University of Copenhagen, Competence Centre for Transcultural Psychiatry
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 treat-
ment context in Denmark were interviewed. Using a ‘‘Trauma Coding Manual’’ devel-
oped 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 ¼ 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
Introduction
In the wake of ongoing conflicts and wars over the past century, an estimated
5.1 million refugees are located in UN camps set up for displaced Palestinians
and 3.0 million refugees, most recently from Syria, are displaced throughout the
Middle East and North African regions. Amounting to 15.1 million by mid-2015,
*Karin Riber is now at Mental Health Centre Copenhagen

Corresponding author:
Karin Riber, Strandboulevarden 96, 2100 København Ø, Denmark.
Emails: karin.riber@regionh.dk; karin.riber@psy.ku.dk; riberkarin@gmail.com
2 Transcultural Psychiatry 0(0)
the number of refugees has reached the highest global level in 20 years (United
Nations High Commissioner for Refugees [UNHCR], 2016). Preflight, refugees
face repeated and extreme traumatic events and losses, and postflight, they are
challenged with continuing stressful psychosocial resettlement issues (Bogic,
Njoku, & Priebe, 2015; Steel et al., 2009). Refugees are exposed to severe violations
of human rights (political persecution, ethnic cleansing, torture), and can be trau-
matized as a result of living in regions affected by such atrocities (Barenbaum,
Ruchkin, & Schwab-Stone, 2004; Sveaass & Lavik, 2000). Refugees with PTSD
and trauma-related diseases are a vulnerable clinical population with persistent
symptoms and relatively poor treatment response, posing complex challenges due
to limited understandings of what may produce good outcomes (Buhman, 2014;
Nickerson, Bryant, Silove, & Steel, 2011).
Traumatized refugees obviously differ on many clinical dimensions other than
exposure to war trauma and flight. In most treatment contexts, it will make sense to
attend to details of history, gender, age, trauma onset, trauma types, level of
posttraumatic stress response, comorbid psychiatric diagnoses, personality traits,
social functioning, and cultural features (Elklit, 2006). Furthermore, attachment
patterns and stressful events interact and influence mental health (Solomon, Dekel,
& Mikulincer, 2008; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000) and
attachment also influences psychotherapy process and outcome (Daniel, 2006;
Slade, 2008). For the sake of treatment planning, anticipating influences on the
therapeutic relationship, or as a focus of family therapies, treatment providers in
refugee trauma rehabilitation centers may therefore have an interest in formally
assessing life course trajectories, childhood adversities, and attachment patterns
(Dalgaard, Todd, Daniel, & Montgomery, 2016; Daniel, 2015; Kanninen, Salo,
& Punamaki, 2000; Moran, Bailey, Gleason, DeOliveira, & Pederson, 2008).
Among adult refugees, adverse childhood experiences have been less examined
than war-related trauma types (Opaas & Varvin, 2015).
Accordingly, this study aimed to (a) identify trauma types over the life course
and (b) explore accounts of the perceived impact of childhood maltreatment in
Arabic-speaking refugees with posttraumatic stress disorder (PTSD) in a Danish
refugee trauma treatment context, and analyze how the personal repercussions
following child abuse are reflected in their attachment narratives.
Background
Complex trauma results from prolonged and repeated traumatic experiences or
maltreatment that occur in ongoing chaotic relationships or extremely stressful
environments such as child abuse, domestic violence, war imprisonment, torture,
refugee flight, and human trafficking (Courtois, 2004; Herman, 1997). Complex
trauma is typically associated with early traumatic experiences in attachment rela-
tionships. In this context, the psychologically immature child is trapped in the
caregiving system and maltreatment profoundly disrupts the normal development
of attachment security, affect regulation, mentalization, personality, and
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interpersonal capacities (Allen, Lemma, & Fonagy, 2012; Fonagy, Gergely, Jurist,
& Target, 2002). Consequently, adult survivors of childhood trauma may have
profound relational disturbances because they not only suffer from the traumatic
event, but also from the dysfunctional relational environment in which it occurred
(Chu, 2011). Human-perpetrated trauma in adulthood (terror, kidnapping, captiv-
ity, sexual assaults, domestic violence) can likewise alter basic trust, attachment
systems, personality, and interpersonal functioning. For decades, it has been
argued that children and adults exposed to ongoing interpersonal trauma,
appear with reactions exceeding the PTSD diagnosis (Herman, 1997; van der
Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Complex PTSD (CPTSD)
has been investigated and proposed for inclusion in the 11th revision of the
International Classification of Diseases (ICD-11). CPTSD is composed of the
three PTSD core symptoms (reexperiencing, avoidance, arousal) along with three
elements that characterize impact on self-organization (disturbances in affect regu-
lation, self-concept, and interpersonal domains; Cloitre, Garvert, Brewin, Bryant,
& Maercker, 2013; Maercker et al., 2013).
Childhood maltreatment
Childhood maltreatment refers to sexual abuse, physical abuse, emotional abuse,
and neglect, which are often found in combinations, often involve domestic vio-
lence and result in complex trauma reactions (Chu, 2011; Friedman, 2010). Adverse
childhood experiences are linked to emotional and behavioral disturbances,
changes in attachment security, and psychiatric symptoms, and can impair chil-
dren’s development, mental and physical health into adulthood (Edwards, Holden,
Felitti, & Anda, 2003; Egeland, Sroufe, & Erickson, 1983; Styron & Janoff-
Bulman, 1997; Waters et al., 2000). Studies of Arab families and societies have
also identified impacts of child maltreatment on school performance, psychiatric
symptoms, and psychological distress (Al-Eissa et al., 2015; Khamis, 2000; Usta,
Farver, & Danachi, 2013).
Abuse in the caregiving relationship might be perceived partly as a conse-
quence of ongoing organized violence influencing family dynamics. For instance,
experiences of traumatic stress among asylum seekers have been found to inter-
fere with parental availability and responsiveness and to disrupt familial
attachment security that could otherwise have provided safety and recovery
(De Haene, Grietens, & Verschueren, 2010). A longitudinal study in Kabul
found that domestic beatings, stressful family violence, and family conflicts had
striking impacts on school children’s mental health, in contrast to the protective
effects of more positive family life—although lifetime trauma exposures were
found to trump all other risk factors with respect to PTSD scores (Panter-
Brick, Goodman, Tol, & Eggerman, 2011). Similarly, in the context of organized
violence in Northern Uganda, caregivers own childhood maltreatment experi-
ences and household violence predicted aggressive parenting behaviors (Saile,
Ertl, Neuner, & Catani, 2014).
The combination of early life trauma and war trauma has been found to influ-
ence PTSD severity in combat veterans and civilian victims of war (Bremner,
Southwick, Johnson, Yehuda, & Charney, 1993; Stevanović, Frančišković, &
Vermetten, 2016). In Denmark, 29% of traumatized adult refugees had at least
one adverse childhood experience and scored higher on complex trauma symptom-
atology than those without childhood adversities (Palic & Elklit, 2014).
Longitudinal studies of refugee populations with a focus on trauma, caregiving,
and development of psychopathology are needed.
Attachment, trauma, and treatment

The investigation of childhood trauma has led to a reexamination of attachment
theory to understand the effects of early disruptions of parent–child bonding (Chu,
2011). Attachment theory (Bowlby, 1969, 1973, 1980) provides an evolutionary-
theory-based understanding of the child’s development and need to establish a
secure base from which to explore and a protective safe haven to resolve distress.
Through interactions with primary caregiver, enduring attachment patterns are
established early in life. In adults, attachment patterns constitute an organization
of cognitive, affective, and behavioral strategies, which involve affect-regulating
strategies and unfold in close relationships (George, Kaplan, & Main, 1996).
Attachment is increasingly found to play an important role in the development,
maintenance, and response to PTSD (Mikulincer, Ein-Dor, Solomon, & Shaver,
2011; Mikulincer, Horesh, Eilati, & Kotler, 1999; Solomon et al., 2008). Meta-
analytic findings point out associations between secure attachment and lower
PTSD symptoms and between insecure attachment and higher PTSD symptoms
(Woodhouse, Ayers, & Field, 2015). Further, compared to adulthood trauma, early
trauma has been reported to have stronger relations between attachment anxiety
and PTSD symptoms (Ogle, Rubin, & Siegler, 2015).
Treatment relationships have been discussed as having features analogous to an
attachment relationship where the therapist acts as a secure base and safe haven for
the client (Bowlby, 1988; Mallinckrodt, 2010). Psychotherapeutic processes and
interactions may be influenced by attachment patterns as well as trauma (Daniel,
2015; Herman, 1997). Adults with insecure attachment patterns are unable to
affect-regulate adaptively and explore mixed emotions freely, and either use
de-activating strategies (suppressing distress, distancing from contact), or hyper-
activating strategies (increasing distress, contact-seeking; Hesse, 2008; Mikulincer,
1998). Accordingly, more negative interactions with health care providers have
been found among traumatized women with unresolved-disorganized attachment
(Green et al., 2012).
Cultural aspects of trauma and attachment

According to cross-cultural studies of trauma, both individual and collective
trauma experiences are influenced by culture. The biological mechanisms in
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PTSD reactions have been found to be universal, whereas the local expressions of
symptoms, coping strategies in traumatic stress, and explanatory models of illness,
are connected to the social and cultural context in which the individual lives
(Kirmayer, Kienzler, Afana, & Pedersen, 2010; Osterman & de Jong, 2007).
According to attachment theory, attachment patterns are universal across cul-
tures (Bowlby, 1969, 1973, 1980), and cross-cultural attachment studies have found
the three primary attachment patterns with culture-specific variations in African,
Chinese, Israeli, Japanese, and Indonesian settings (van Ijzendoorn & Sagi-
Schwartz, 2008). However, the cultural applicability of attachment theory is
debated by cultural psychologists (Gielen, 2016; Keller, 2013). Adult attachment
patterns can be assessed using the Adult Attachment Interview (AAI) which
explores childhood experiences with primary caregivers (Hesse, 2008). The inter-
view originates from a developmental psychology perspective (Main, Kaplan, &
Cassidy, 1985), but norms for what kinds of parental behavior are considered to be
loving, rejecting, neglecting, role-reversing, and pressuring to achieve are likely to
vary in Arabic and Western contexts. Likewise, the local understandings of the
severity of such experiences and ways of expressing meaning in child–parent rela-
tionships may vary with culture.
Qualitative studies have been suggested as a way to bridge the gap between
clinical research and practice by seeking detailed individual and local understand-
ings (Iwakabe & Gazzola, 2009). This qualitative study explored attachment nar-
ratives in order to identify themes of potential relevance for mental health care of
refugee trauma.
Method
Data for the present study were collected during a randomized clinical treatment
trial (NCT01362543) for multicultural refugees with PTSD (Vindbjerg, Klimpke, &
Carlsson, 2014). Participants were referred from general practitioners, psychiatric
hospitals, and private psychiatrists. Trial participation was voluntary, not a
requirement to receive treatment, and informed consent was obtained prior to
inclusion. Inclusion criteria: (a) adult refugees or family reunited with refugees;
(b) PTSD according to ICD-10 (World Health Organization [WHO], 1992); and
(c) exposure to traumatic events. Exclusion criteria: (a) non-Arabic native lan-
guages; (b) two absences from the AAI; (c) severe, non-trauma-related psychotic
symptoms; (d) hospitalization; (e) substance misuse; (f) nonconsent.
The current study only included Arabic-speaking refugees in order to minimize
potential variation from multiple languages and interpreters in the context of the
AAI. The interviews were conducted at an outpatient refugee trauma treatment
clinic, the Competence Centre for Transcultural Psychiatry, between August 2011
and June 2012. In total, 50 Arabic-speaking refugees with PTSD entered the pre-
sent study from the larger trial and 43 participants completed the AAI. Seven
subjects did not wish to participate in the AAI. The reason for the large sample
size was that this qualitative study formed part of a quantitative psychotherapy
study, and explored understandings across individuals in order to bridge the gap
between outcome research and psychological intervention. The study was approved
by the Danish Scientific Ethics Committee and the Danish Data Protection
Agency.
Interview instrument
The Adult Attachment Interview (AAI; George et al., 1996) is a semistructured
clinical interview that examines childhood experiences with primary caregivers,
abuse, loss, and trauma, as well as the impact of the interviewee’s developmental
history on adult personality (Fonagy, Target, Steele, & Steele, 1998; Hesse, 2008).
The interview is audio-taped, transcribed verbatim, and scored on the basis of the
speaker’s narrative style, and assigned to one of five major attachment categories
(secure-autonomous, dismissing, preoccupied, unresolved-disorganized, cannot
classify) by certified AAI-classification coders (Main, Goldwyn, & Hesse, 2003).
The AAI is increasingly used in clinical samples and appears robust across cultures,
with no significant differences between Japanese, Israeli, and European
samples (Bakermans-Kranenburg & van Ijzendoorn, 2009). It has not yet been
validated for Arabic-speaking populations, so the cultural validity of attachment-
coding Arabic AAI transcripts is unknown. The AAI protocol was forward- and
back-translated by two blinded, certified Arabic–English interpreters. All inter-
views were carried out by the author, using the same two certified
Arabic-speaking interpreters (male and female) who also provided explanations
of metaphors and cultural expressions. Selected illustrative quotes were translated
from Danish into English by the author.
Participants
Interviews were conducted with 21 women and 22 men from the Middle East, with
an age range of 23–57 years. Countries of origin included: Iraq (60%); Lebanon
and Palestinian territories (30%); and two participants from other countries in the
Arabic region. Participants had been exposed to continuous war-related events for
more than 10 years (70%) including imprisonment (56%), torture (56%), persecu-
tion for religious (91%) and/or political (62%) reasons, and one third had served as
combatant soldiers in the past 1–10 years.
For the Iraqi group, the transgenerational contexts of collective violence con-
sisted of Saddam Hussein’s control over Iraq from 1979 to 2003, which included
the Iran–Iraq War (1980–1985), the Gulf War (1990–1991), followed by decades of
civil war and internal political disturbances. Among these participants, one sub-
group had never experienced peacetime while growing up, whereas another sub-
group was born approximately a decade before the Hussein era. For the Palestinian
group, the transgenerational context of collective violence is even longer. After the
Holocaust, the United Nations voted to divide Palestine into independent Arab
and Jewish territories, which remains a source of political dispute resulting in
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destruction of Palestinian homes. Following the Arab–Israeli wars (1948, 1967),

Lebanon became home to over 110,000 Palestinian refugees, who endured the
Lebanese civil war (1975–1990; Pappe, 2004; Tripp, 2000). Generally, these par-
ticipants grew up in refugee camps under deprived conditions of poverty, suppres-
sion, danger, and loss.
The sample was characterized by high levels of PTSD symptoms and complex
mental health profiles on intake as indicated by quantitative measures obtained for
the larger study: Harvard Trauma Questionnaire (HTQ-total): M ¼ 3.2, SD ¼ 0.44
(Mollica et al., 1992); depression and anxiety on Hopkins Symptom Checklist
(HSCL): M ¼ 2.9, SD ¼ 0.48; Hamilton Depression Scale: M ¼ 24.0, SD ¼ 5.5,
and Hamilton Anxiety Scale: M ¼ 27.4, SD ¼ 6.8 (Derogatis, Lipman, Rickels,
Uhlenhuth, & Covi, 1974; Hamilton, 1959, 1960); high scores on the SCL-90-R
Somatization Scale: M ¼ 2.7, SD ¼ 0.72 (Derogatis, 1994); poor quality of life (The
World Health Organization Quality of Life [WHOQOL-5]): M ¼ 12.0, SD ¼ 13.5
(Heun, Bonsignore, Barkow, & Jessen, 2001); low levels of attachment security
(6%) and high levels of unresolved-disorganized states of mind with respect to
loss, abuse, and other trauma (67%) as measured on the AAI (Hesse, 2008;
Main et al., 2003; see also Riber, 2016).
Data analysis
The present study used a qualitative approach guided by recommendations for how
to maintain trustworthiness and integrity of data in qualitative research (Williams
& Morrow, 2009). The study methodology drew components from consensual
qualitative research (CQR; Hill et al., 2005) which emphasizes consistency of
data collection across participants, and consensus in identification and analysis
of narrated meaning. The procedures for selecting and coding text prior to the
analysis will therefore be described systematically. The qualitative approach to the
analysis of child abuse accounts was based on an attempt to understand and inter-
pret participants’ perceptions by developing descriptive codes for core ideas, com-
paring differences, similarities, and letting categories emerge from quotations
(Kuckartz, 2014).
Procedure
For the purpose of this study, the author developed a ‘‘Trauma Coding Manual’’
(TCM), which was applied to code the transcripts by a team of 14 students. The
TCM was designed during the data collection. The TCM domains were based on
observations and hypotheses that arose during the interview process (bottom-up),
and based on trauma theory and research (top-down; e.g., Friedman, 2010;
Herman, 1997). Before the development of the TCM, four randomly selected tran-
scripts were used as pilots for within-case analysis of possible topics to investigate.
After the consensual TCM coding, a cross-case analysis of participants’ accounts
was carried out.
The TCM consisted of definitions with examples of various types of trauma,

loss, and adversities, including: childhood sexual abuse (CSA); childhood physical
abuse (CPA); childhood emotional abuse (CEA); neglect; interpersonal traumatic
events; nonpersonal traumatic events; traumatic losses; other losses; involuntary
separations; displacements; growing up in extreme poverty; and continuous war
exposures. For every trauma type, lifetime period was coded (childhood: 0–12
years, adolescence: 13–20 years, and adult life: 21 years onwards). In cases where
age was not available, coders estimated lifetime period from the transcript context.
Ethical principles of professional confidentiality were followed, personal data
anonymized, and encrypted USB storage devices used.
Coding team and coding method

Seven psychology students (graduates or undergraduate students in their final
semester) coded trauma types. The team was trained on three precoded transcripts
to obtain consensus on the TCM’s definitions prior to the coding. The first TCM
coding step was to read through the transcript to get a survey of the trauma types
and to become familiar with the interviewees’ direct or subtle expressions of
trauma. During the second coding step, coders marked content about trauma
types and their repercussions, along with lifetime periods, using NVivo Version
10 to organize the selected text (Bindekrantz & Andersen, 2011). During the third
coding step, coders reported trauma types, quantity, lifetime period, and linguistic
examples on trauma coding sheets. Finally, all coded transcripts were merged into
a single NVivo file for further analyses. Each student individually coded 4–7 inter-
views and discussed consensus in small groups. Fifteen percent of the 43 transcripts
(n ¼ 7) were double-coded by a blinded coder from the team. Coder agreement of
child abuse types (present or not) was assessed. For CSA and CPA, 100% agree-
ment was found between all seven interviews. For CEA, 100% agreement was
found for six interviews, and zero for one interview (mean agreement 86%). For
neglect, 100% agreement was found for three interviews, whereas four coder pairs
disagreed on the presence of neglect (0% agreement; mean: 43%). The TCM high-
lighted inadequate physical care in the neglect definition and had failed to under-
score emotional aspects of neglect. This may explain the disagreement among
coders in the neglect domain.
External auditor. To minimize researcher bias and maximize trustworthiness in the

analysis of the coded accounts, an external auditor (Hill et al., 2005; Iwakabe &
Gazzola, 2009) who conducted research with traumatized refugee families was
used. The auditor checked, questioned, and critiqued the analysis and the implica-
tions of findings. Auditor and author reached a consensus regarding changes in the
analysis and interpretation of findings.
Identification of trauma types over the life course. Prior to analysis, the content of all
coding was screened. First, all coded trauma types were surveyed, recounted,
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subdivided into age periods, and tabulated fully for all 43 participants (see Table S1
in the supplemental material, which can be found online with this article, http://
journals.sagepub.com/doi/full/10.1177/1363461517737198; also fully reported in
Riber, 2015). Next, childhood maltreatment was analyzed. CSA was reported in
only one case. The more common abuse types (CPA, CEA, and neglect) were
selected for further analyses. Several coded trauma types other than child abuse
were excluded and put aside for future studies. Lastly, childhood maltreatment
data were entered into SPSS for Windows Version 20 for the purpose of descriptive
analyses.
Exploratory analysis of child abuse domains. First, NVivo (Version 10) was used to run
systematic text analyses to explore meaning-making in the accounts of child abuse.
In CPA, CEA, and neglect, initial descriptive codes were developed quotation by
quotation for all abuse accounts. Next, the descriptive codes were compared and
combined, based on personal attitudes, affective expressions, core ideas, and the-
matic content in the responses. Within each abuse domain, the emergence of
common core ideas was organized into categories of meaning. Finally, the fre-
quency of core ideas within each domain was presented. Since the sample size
was large for a qualitative study, a four-category system was used: general results
applied to all but one case in the domain; typical results applied to more than half
the cases; variant results applied to at least four cases and up to the cut-off for
typical; and rare results applied to two to three cases. Reflections on the interview
context and potential author biases were taken into consideration throughout the
research process.
Results
Cumulative complex trauma types over the life course
The first aim of the study was to identify trauma types over the life course.
Participants’ attachment narratives revealed trauma complexity and severity of
trauma for every individual throughout their developmental history.
Attachment-related and war-related trauma types were found to run parallel
throughout the developmental history from early childhood and to exert cumula-
tive effects over the refugees’ life course. Trauma types consisted of repeated
assaults and violations in the caregiving relation and domestic sphere, many
kinds of human-perpetrated political violence, and many kinds of combat traumas
or civilian war trauma. In this sample, it was not possible to identify a pretrauma
condition in the participants, due to their lifelong trauma exposure.
The character of attachment-related trauma was extremely severe. Participants
gave examples of being subjected to, or witnessing their siblings being subjected to,
torture-like punishments, such as being hung with the head down and beaten hard,
tied up and beaten under the foot soles, beaten with various objects (wire, belt,
walking stick), pushed into hot coals, burned with a red-hot knife, locked up in
dark chambers without food for entire days, or left freezing outside in a courtyard
for hours. One participant testified a brother had been lowered in ice-cold water for
hours, beaten so hard he could not walk for days, had his back ironed, was thrown
out from a rooftop balcony and had become intellectually disabled as a result of it.
Difficulties with concentration and memory problems were mentioned as conse-
quences of early childhood trauma.
For about half a century, these refugees’ sociopolitical contexts were character-
ized by ongoing war, danger, suppression, poverty, and loss (Pappe, 2004; Tripp,
2000), and collective violence influenced the daily lives of the participants, parents,
and extended families across generations. This context left caregivers with the
predicament of raising large households of children under deprived living condi-
tions, which likely encroached upon the security of family relationships in complex
ways. In this context, intrafamilial violence and attachment-related childhood
trauma were intricately interwoven and embedded within the larger societal
dynamics of conflict and violence (Catani, Jacob, Schauer, Kohila, & Neuner,
2008; Catani et al., 2009).
Table S1 illustrates the trauma complexity by placing all exposures into the
participants’ life trajectories. Table 1 exemplifies this by one participant from
each attachment category, based on the author’s selection. Needless to say, the
refugees were also very affected by their war-related trauma history, which was
beyond the scope of this study to further explore.
With respect to the distribution of childhood maltreatment, 27 of the 43 trau-
matized refugees reported one or more types of child abuse. Only one reported
CSA. Another subject reported an attempted (nonattachment-related) rape assault
in childhood, and two persons gave hints of war-related rapes as young adults.
CPA was the most common form of abuse (60%, n ¼ 26), and in many cases the
severity bordered on torture. CEA was found in 44% (n ¼ 19) and neglect in 40%
(n ¼ 17) of the participants. There was an overlap between CPA and CEA in 62%
of the sample. A total of 33% (n ¼ 14) reported three types of child abuse, 12%
(n ¼ 5) reported two types of child abuse, and 16% (n ¼ 7) reported one type of
child abuse.
Impact of childhood maltreatment

The study’s second aim was to explore accounts of the perceived impact of child-
hood maltreatment in the abused group of adult Arabic-speaking refugees with
PTSD, and to analyze how the personal repercussions following child abuse were
reflected in their narratives.
Childhood physical abuse. In the CPA domain (n ¼ 26), four categories emerged. In
the category violence as meaningless, suppressive, harsh and condemned, 18 of 26
participants expressed the feeling that their family environment was unsafe, and
that they were constantly afraid of either one or both parents. The parents were
perceived as unpredictable or malicious, and quotes described parental child-
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Table 1. Trauma types over the life course in refugees with PTSD (represented by 5
participants)
Participant Lifetime period
Secure-autonomous Childhood: physical abuse by mother and father (daily violence); loss of
maternal grandfather; much moving around; lack of care; left in home
by mother for long-term periods; domestic
violence (father hit mother).
Adolescence: physical abuse by mother and father (daily violence
until 15); lack of care; loss of paternal grandfather by whom speaker
found shelter as child; loss of mother (cancer).
Adulthood: loss of brother (cancer); loss of father; traumatic loss
of husband (murdered by house set on fire during his shower).
Dismissing Childhood: born and grew up in refugee camp; father long-term absent
due to work in other country from 8 years old; subject starts working
to support family as 8-year-old; physical abuse by mother; lack of care
(e.g., when sick); found comfort and protection against mother at
neighbor lady’s house; loss of paternal grandmother (old age); war
began when 11 years old.
Adolescence: loss of cousin (bomb); loss of vast number of
relations due to war.
Adulthood: traumatic loss of a neighbor-friend hit by bomb, and picked
up his broken body; loss of father; loss of aunt; traumatic loss of
neighbor (killed by husband); loss of elderly lady, the surrogate mother
he visited as child (diabetes); loss of vast number of relations due
to war.
Preoccupied Childhood: Grew up in refugee camp; exposed to 3 wars during
upbringing; father long-term absent (underground) from 8–12 years;
high anxiety in school, feared military would pressure subject to reveal
and find father; physical abuse by mother; missed affectionate care and
validation; witnessed father beat brother; traumatic loss of neighbor
due to war; exposed to many funerals as churchyard nearby, worried
about death; repeatedly exposed to war bombardments, corpses on
streets, death.
Adolescence: loss of paternal grandfather; loss of two remote relatives;
repeatedly exposed to war bombardments, corpses on streets, death.
Adulthood: exposed to arrest with gun to head many times; traumatic
loss of uncle (stroke during car accident); repeatedly exposed to war
bombardments, corpses on streets, death.
Unresolved Childhood: poor family conditions, could not always afford food; physical
abuse by father; domestic violence (father beat mother and all chil-
dren); father absent long-term periods; loss of maternal grandfather
(old age), traumatic loss of older brother (drowning accident); was
pawed over on public bus.
(continued)
Table 1. Continued
Participant Lifetime period
Adolescence: physical abuse by father; exposed to weapons on play-

ground; exposed to bombings and helicopter attacks around home;
war trauma as soldier (e.g., threatened with gun and ordered to
collect dead bodies after military actions).
Adulthood: loss of mother and father; loss of older brother.
Cannot classify Childhood: grew up in refugee camp; daily exposed to war-like events,
collection of dead people and burials; poor living conditions, lack of
food; father absent working up to 18 hours daily; nursed/breastfed by
maternal grandmother; mother ill, presumably with alcohol abuse;
physical abuse by mother; very severe physical abuse by father; lack of
care; trained as soldier from 6–7 years old; injured in car bombing;
traumatic loss of sister (bombing); escaped home when distressed,
once ran away 45 km alone; loss of a vast number of relatives/relations
due to war.
Adolescence: early alcohol drinker; hit by car and afraid to get punished;
injured during fights, captured by militia troops and imprisoned in
long-term POW camp (18 months); later captured in other POW
camp with degrading, inhuman treatment and daily exposed to other
prisoners’ suicides; traumatic loss of sister, father, and maternal
grandfather during invasion; same invasion blinded a sister and trau-
matic loss of vast numbers of other relations.
Adulthood: injured again, work in profession that included liquidations;
loss of vast number of relatives and other relations.
Note. Childhood ¼ 0–12 years of age; adolescence ¼ 13–20 years of age; adulthood ¼ 21 years of age
onwards. POW ¼ prisoner of war.
rearing practices as abusive, violent, fear-inducing, and devoid of empathy—in-

stances where the participant’s only source of comfort also became a source of fear.
In two cases an older brother was abusive. When narrating CPA, participants’
meaning-making was dominated by difficulties, expressed with a mixture of sur-
prise, confusion, and perplexity. They predominantly expressed meaninglessness in
relation to caregiver’s behavior. Some morally condemned the abuse, although,
they were able to produce an understanding of ‘‘why’’ parents acted as they did,
based on the context of their upbringing. Others lacked cognitive and emotional
understanding.
In one clinical case, a 36-year-old Iraqi participant had a ‘‘funny, fine’’ relation-
ship with his mother, who worked as a housewife, took care of 11 children, and
functioned in the roles of mother, father, elder brother, school teacher, and doctor,
that is, with massive responsibility. He had no positive experiences with his father
who he described as ‘‘a disgusting general.’’ The father had worked in the Iraqi
military for 33 years, and brought up his children to behave as soldiers, for example,
Riber 13
to stand in a line, polish his shoes, avoid eye contact with him, keep extremely quiet,
only talk when asked, and being beaten even so. In other words, the father treated
his children with a military discipline that took on forms of compulsive repetition.
This participant, who felt devastated by his childhood, said:
There were many punishments . . . even for small mistakes like falling when running, or
knocking a glass over. He hit me as you would hit an adult. He didn’t think I was too
little or unable to take it. Sometimes he hit so hard you would faint . . . for nothing.
This clinical vignette seems to exemplify traumatic reenactment in an abusive family

system, reflecting how the father’s likely experiences of atrocities in the Iraqi mili-
tary were transmitted onto the next generation. Besides rejections and violence (his
father once broke his arm and fingers, once gave him a burn, and regularly beat the
family with different objects), he lost two brothers, both parents, and had combat
trauma in the course of his life. He had an insecure preoccupied attachment pattern
and displayed unresolved-disorganization with respect to trauma.
The majority of the PCA examples were torture-like, consisting of threats to be
killed, being locked up, tied, beaten, burned, etcetera. Participants rarely perceived
the punishments as ‘‘natural’’ common practices that allowed parents to draw
limits, probably because the abusive behavior was extraordinarily harsh. Only
five respondent’s quotes fitted the category physical punishment as an accepted
norm, that is, as socially accepted child-rearing practices. Three respondents
spoke too terse to judge whether they belonged in one of the two first categories.
Despite the potentially intertwined nature of abuse and societal conflicts, quotes
in the emotional, relational, and behavioral costs category reflected how the nonexist-
ing or violent attachment relationship profoundly affected participants. Fathers
were especially perceived as physically and emotionally inaccessible. As a conse-
quence, participants typically (16 of 26) felt ongoing anxiety, dissociation, lack of
safety, insecurity, helplessness, indecisiveness, and excessive worry. The abuse also
affected them on personal levels in their adult lives, reflected in lacking autonomy,
low self-esteem, self-suppression, worthlessness, and a feeling of inability to protect
self/others. In the case of the Iraqi participant, the violence in his childhood had
resulted in a pervasive intrapersonal insecurity in his adult life, making him incap-
able of taking even minor decisions. Relational problems such as lack of trust,
problems of intimacy, emotional withdrawal, and introversion were also expressed.
Some participants expressed feeling damaged and developmentally broken. As
described by a 46-year-old male participant with an Iraqi background:
Honestly. There are so many things. I feel as though . . . I was born, but I wasn’t there.
I don’t know how to describe it. I am there, I had come to the world, but I wasn’t
there.
Or by a 29-year-old female Palestinian participant from Lebanon: ‘‘My childhood

was very sad and hard . . . and when I became a teenager where I was supposed to
be able to feel and think more about myself, I was broken inside.’’ In sum, the utter
meaninglessness and profound personal, relational damages stand out as aspects
that call for compassionate understanding of self and other within the therapeutic
space.
Lastly, the category reactions of physical and emotional withdrawal reflected the
situational behavior after CPA (emotional avoidance, withdrawal, running away
from home for days). See Table 2 for numbers and quotes illustrating the core ideas
in CPA findings.
Childhood emotional abuse. In the CEA domain (n ¼ 19), two broad categories
emerged. The first category, emotionally harmful and abusive parental behavior,
reflected experiences of being subjected to aggressive verbal/nonverbal attacks as
children, leaving little doubt of malicious intent. Sixteen of 19 subjects typically
depicted concrete details of (a) intrusive negative parental behavior, where care-
givers intentionally humiliated, exposed, bullied, intimidated, or threatened the
child, or (b) dismissive negative parental behavior where caregivers displayed cold-
ness, negativity, blaming, fault finding, isolation, exclusion, distrust, or denied
violations toward the participant. These adverse communication patterns—which
were probably affected by the pressure from the larger societal contexts of poverty,
social misery, and suppression—were found to pervade child–caregiver relations.
In one case example, a 39-year-old Palestinian participant who grew up as the
fifth of six siblings in a refugee camp in Lebanon, felt she was her mother’s
‘‘enemy.’’ Her mother worked endless hours for a political organization, her
father worked at a petrol station and was often absent from home, so in effect,
her 13-year-old brother was her primary caregiver. This participant’s responses
were characterized by insecure, ambivalent, and angry attachment-related feelings,
and she listed many situations of emotional abuse. She was especially saddened
when, at the age of 11, she confided to her mother her father’s sexual harassment
and was verbally and physically attacked by her mother, who denied the abuse.
This participant also described her parents’ behavior as though they saw her and
her siblings as part of their military life; thus, the abusive familial interactions were
inscribed in the larger context of political conflict. Another 49-year-old female
participant from Iraq described the feelings of public shame accompanying emo-
tional abuse: ‘‘I don’t mean to exaggerate, but it was everyday behav-
ior . . . discouraging oppressing words. In reality violence and problems, it
happened every day. And everybody knew and heard.’’ Another similar example
of shame was given by a 58-year-old Iraqi male participant who was put on public
display at the local café by his father:
[A]nd he put me there in my wet clothes in front of everybody and said ‘‘look at my
son, look what he is doing instead of going to school.’’ So they were all standing there
laughing at me and I just cannot forget. It was simply such an offence that I still think
about it. And as a child you think ‘‘why do this to me?’’ . . . such a feeling.
Riber 15
Table 2. Affective responses in subjects who experienced childhood physical abuse (n ¼ 26)
CPA Category Frequency Quotes illustrating core ideas
Perceiving violence Typical (18) Finally, you think, why is she doing this, what’s
as meaningless, the reason. And I would ask, ‘‘Am I not
suppressive, harsh, your son?’’ (Participant 37)
and condemned. She’s hard, beats and scolds every day.
It was a stick, a kind of rubber band, it looks
like a belt they beat us with. And for no
reason, for simple things. And I don’t
understand why. Is it because she is sad
herself, is there something she does not
want, or does she lack knowledge? I don’t
know why. (Participant 24)
Everything at home was scary and banned. We
were never able to explain, we couldn’t and
we didn’t dare because it was all forbidden
and frightening. I couldn’t say anything to
him, then he’d already have beaten me. He
was very angry and we were very afraid.
We didn’t have the nerve to get close to
him, the whole house just had to be quiet.
(Participant 13)
Punishment as Variant (5) You would get hit in the face or with a belt.
an accepted norm. They hit us with a belt. It was generally like
this, according to our traditions.
(Participant 16)
Articulation of emo- Typical (16) My childhood was very bleak and harsh. And
tional relational, when I became a teenager where I was
behavioral costs. supposed to feel, think, and become more
myself, I felt broken inside. I couldn’t handle
it, I felt so depressed . . . It also affected me
as an adult. It cultivated an anxiety in me so
that I was afraid of knowing anyone or
making relations. (Participant 29)
It affected me so that I don’t have so much
contact with people. I shut myself in.
And I feel very, very insecure. If I go buy
something, I can’t make a choice. I’ve lost
something. I feel very insecure.
(Participant 14)
The problem was, there was no relation.
Or the relation was distant, detached.
He never treated me like his daughter. He
treated me like his enemy. (Participant 24)
(continued)
Table 2. Continued
CPA Category Frequency Quotes illustrating core ideas
My whole life I have been frightened and

worried. I don’t remember a day where I
was capable of protecting myself. Or where
I could feel safe. To me, security, there is
nothing. (Participant 9)
Reactions of physical Variant (7) This situation became a fight between my
and emotional father and me. I knew he wanted to kill me,
withdrawal. so I escaped from home. (Participant 42)
When my mother scarred me with a burning
knife, I left the home for three days. I didn’t
come home for three days. (Participant 7)
Note. Frequency labels: general results ¼ all but one of the cases; typical results ¼ more than half the cases;
variant results ¼ in this study at least four cases up to cut-off for typical; rare results ¼ two to three cases.
CPA ¼ childhood physical abuse.
Participants typically expressed a deficit condition in the personal and emotional

repercussions category: responses conveyed an overall feeling that something fun-
damentally important was lacking in these children’s lives while growing up. Of
course, home invasions by soldiers, political persecution, and extreme traumatic
losses of spouses and children may have caused parental anxiety and depression
that could lead to harsh communication in attachment relationships. However,
with undertones of anger, regret, and recognizing that these emotional abuse
experiences were not right, participants said this abuse had made them feel
unwanted, excluded, nonworthy, or nondignified. They talked about feeling power-
less, described lack and deep losses of parental affect-regulating support, emotional
confirmation, and appreciation as human beings. Many participants spoke of
‘‘differential treatments’’ and gave examples of working as a servant for the
entire household, having heavier duties than any other sibling, or being singled
out and scapegoated. Only one 51-year-old Iraqi participant framed the memories
as encouraging her to be a good mother herself: ‘‘My siblings and I all lived our
lives in anxiety, but we have learned to be more loving and caring toward our own
children, that is what we learned from them.’’ The personal repercussions following
CEA varied for every individual, but generally involved problems with autonomy,
self-confidence and personal boundaries, insecurity, low self-esteem, identity prob-
lems, a lack of a sense of belonging, and a lack of direction in life—important
existential issues to be supported in psychotherapy. See Table 3 for numbers and
quotes illustrating the core ideas in CEA findings.
Neglect. In the neglect domain (n ¼ 17), three meaningful categories emerged. From
the first category, a quite important focus on the emotional aspects of neglect
(Category 2) consistently emerged from the teams’ coding. In the category pervasive
Riber 17
Table 3. Affective responses in subjects who experienced childhood emotional abuse

(n ¼ 19)
CEA Categories Frequency Quotes illustrating core ideas
Emotionally harmful Typical (16) When my mum showed him the marks after the
and abusive teacher’s beatings, my father said: ‘‘yeah, he
parental behavior. deserves it.’’ (Participant 1)
When I first got my period I was afraid and did
not know what it was . . . My mom called me,
and it felt like fire from her eyes, she was very
mad. She and my sister yelled, ‘‘come here!’’
and I felt I was being interrogated by the police.
They angrily scolded me ‘‘what happened to
you,’’ one asked questions and the next took
over. I became utterly confused. Finally, I said:
‘‘Nothing happened at all. Maybe I just fell,
cause’ there was blood here?’’ . . . It felt as
though I had done something criminal. They
spoke to me in a very bad way. (Participant 9)
[Grandmother] told us she absolutely didn’t care
about us, [repeating]: ‘‘Why do I have to raise
you? Why do I have to look after you?’’ When
we were all set, she denied us to visit my
mother, it was as though she was punishing us,
or wanted us not to exist. (Participant 20)
I always got the same cold reaction from him . . .
for example, if I didn’t catch the bus he said
‘‘you were late, it’s your fault,’’ even if the bus
left early. It was always and daily my fault and
me doing mistakes. He never wanted to listen
to any explanation of what happened.
(Participant 13)
Personal and Typical (16) My mother always said: ‘‘You are ugly, nobody will
emotional marry you, you are far too bad’’ . . . So I lost
repercussions. self-confidence. It sometimes affects my rela-
tion to my daughter . . . for example I wanted
her to come with me to a party because I don’t
like to go alone. I want the focus to be on her
instead of me, because I constantly feel
everyone is looking at me and saying ironic
remarks behind my back or something like
that. (Participant 6)
In first grade my father constantly said: ‘‘You are
incompetent, you can’t make it, you are
unskilled.’’ It affected me and made me leave
(continued)
Table 3. Continued
CEA Categories Frequency Quotes illustrating core ideas
school. And I always thought I was not good at

anything, that I couldn’t handle anything. It
cultivated an anxiety in me so that I can’t do
anything by myself even now. I am not com-
petent. I am not qualified for anything. I am
illiterate. (Participant 16)
She didn’t teach me to be strong . . . never made
me feel human . . . I never felt I was her
daughter, I felt as her servant. (Participant 9)
CEA ¼ childhood emotional abuse.
patterns of physical and emotional neglect (socially unaccepted), five participants

described being subjected to a pervasive lack of care, emotional emptiness, and
serious ill-treatment where sleep, hunger, bed-wetting, and keeping warm and well
clothed were low priorities for their parents. Importantly, the parental neglect was
found to be far beyond what participants considered socially acceptable, even given
their deprived social circumstances. As children, they and their siblings were
ignored or left to themselves in situations that involved attempted rape, sexual
abuse, and serious illness. In most cases, the child was treated as a slave-like
worker and caregivers were absent, working abroad, away from the home for
months, or absorbed by domestic or political work, illnesses, or alcohol misuse.
Participants’ accounts conveyed a sense of having feelings ignored and of being left
without affect-regulation. The aforementioned 39-year-old female Palestinian par-
ticipant from the refugee camp in Lebanon was subjected to all four types of
maltreatment, and she explained how this led to a lack of personal autonomy
and sense of self:
My mother was harsh, unjust, and there was no care . . . when I tried to explain that
my father harassed me, she beat me hard . . . I didn’t have anyone to talk to about my
problems, to tell how I felt or to ask a question. I grew up unable to explain anything
or give my opinion to anyone. This has affected me until now, because I am afraid and
cannot stand up for myself or explain things in many situations in my life . . . The way
she was made me lose self-confidence.
In the category emotional and some physical neglect primarily due to socioeconomic
conditions (socially accepted), 10 of 17 participants typically described that the
rough living conditions were characterized by ‘‘survival’’ which obviously affected
both family life and the caregiving relation. Childhoods were described as char-
acterized by ‘‘self-education,’’ and the accounts reflected that parents—bearing the
Riber 19
larger context of organized violence in mind—had worked hard and done their
utmost to feed and nurse the family. In these cases, it was also apparent that being
left to oneself as a child was a widespread and accepted norm which they under-
stood as an inevitable part of the socioeconomic conditions. Nevertheless, parents
were described as being emotionally inaccessible or psychologically withdrawn,
largely because the pressure of wartime, poverty, excessive work, large households
with many children, and lacking modern conveniences left parents no time for
individual emotional contact with the child, or to cultivate cohesion in the
family. Thus, participants clearly stated feeling neglected and typically expressed
a lack of emotional contact and personal interest from their parents. This involved
feelings of loss, of being emotionally deprived, and having instrumental relations.
In one case, a 42-year-old female participant from Iraq had parents who were
politically active teachers. She was the fourth out of six children, and lived alone
with her mother and siblings since she was 8 until 12 years old because her father’s
political affiliations forced him to go underground. This woman grieved and
struggled to reflect on her childhood experiences, attempting to create a model
of herself and her parents while also trying to understand their family situation
in relation to the larger context. As formulated by this participant:
We didn’t see my father much when we were little. Of course it was a hard life and my
mother was really slaving away . . . She was busy and didn’t have much time to be with
us, read, play or spoil us. It was not in the plan. It was also normal with six children.
I don’t think she tried to sense or listen to how we felt . . . She was not the type to kiss
or let us sit on her lap . . . [My parents] didn’t understand that support was so import-
ant . . . –It is as though we always lacked to hear something from mum, we were
missing it . . . it is quite [full of] embarrassment and shame, and we can’t step into
something new, I also think that it is [and was] always difficult for me and my siblings,
for example if we should meet new people . . . it affected us.
Lastly, the mild instances of emotional neglect category included two cases in which
the level of neglect was uncertain, but participants felt they had unmet needs. Two
participants’ responses were discarded because they did not represent neglect, and
four quotes were filtered out because they were too fragmented to be meaningful.
See Table 4 for frequency and quotes illustrating the core ideas in neglect findings.
Discussion
The present study has important methodological limitations. Data were collected
with the AAI, which is less interactive and exploratory than typical qualitative
interviews, and not designed to explore Arabic-speaking refugees’ child-rearing
practices. Cross-cultural attachment research has generally emphasized an etic
approach based on theories developed in Western societies, rather than emic
approaches trying to understand culturally specific developmental trajectories
from within its own frame of reference (van Ijzendoorn & Sagi-Schwartz, 2008),
Table 4. Affective responses in subjects who experienced neglect (n ¼ 17)
Neglect Categories Frequency Quotes illustrating core ideas
Pervasive patterns Variant (5) I never saw my father. I don’t even remember
of physical and him being there. He left for a foreign place
emotional neglect to work, and visited when I was 10. I didn’t
know him and don’t think he considered us
(socially his children. At least he didn’t show. My
unaccepted). mother was never at home, but attached to
a political organization, which they gave
their lives. It was always my 6-year-older
brother who took care of us, also if we
were sick. I knew that even though I was a
child, I was an adult. We had to do every-
thing at home ourselves. My mother took
no interest, not at all. (Participant 6)
My father left at 4:30 am, when we slept, and
came home late. There was not much
contact. To me it felt as separated lives.
There was no relation, nothing between us.
My mother was always busy, there was no
time. She never tucked me in, slept with or
cuddled me. My parents also felt sad. I don’t
remember us being with our parents, feel-
ing togetherness as a group, like other
families. We never sensed her maternal
feelings, and my siblings describe the same
emptiness. When my parents were
divorced, she left . . . and I don’t know what
became of my father. Perhaps I was the only
one right and capable of controlling my
thoughts, so I kept my siblings and said
‘‘I want to take very good care of them,
I am taking on responsibility now.’’ I was
about 13–14 years old. It was during the
war. (Participant 13)
Emotional and some Typical (10) They both took care of us, but were very busy.
physical neglect due They did not raise us in the sense that they
to socioeconomic created a bond. We raised ourselves.
conditions (Participant 35)
My father left for three months at a time.
(socially accepted). Compared to how fathers in this country
are involved in their children’s lives, my
father wasn’t. In that sense, he was like
every other father in the village. My mother
(continued)
Riber 21
Table 4. Continued
Neglect Categories Frequency Quotes illustrating core ideas
was very hardworking, cooking, dressing

one child, trying to wash another, taking
care of the house. She had a child every
second year, nine in total. It was very, very
hard work, and society did not take care of
anything, like here where . . . the care-
system point out your child’s problematic
motor abilities. No, children had to look
after themselves. It doesn’t mean we didn’t
like them . . . That was the conditions, and
it was no exception in my family—everyone
in our street were treated like that.
Sometimes I think it was a miracle that we
survived. (Participant 43)
We grew up in a refugee camp and no one
took care of us 12 children. My father
worked 15, 16, 18 hours to survive, which
was normal in our country. My mom got
help from an organization, flour, rice, olives
and a daily meal. There were no weekends,
so we only saw my father in family trouble
or if someone died. It took something big
to gather the family. (Participant 34)
Mild instances of Rare (2) My mother was very quiet and never showed
emotional neglect. her emotions . . . it feels like a letdown to
me, that we were not ‘‘boosted’’ for life
with her personal experience. I went
through something very tough, and think
we could have been stronger and prepared
if she had given us that . . . I was [also] afraid
she would be annoyed . . . so I covered it
and carried things inside. I didn’t feel [there
was] anyone to support me. I still carry all
consequences on my own if there is a
problem. (Participant 15)
and attachment data from Middle Eastern regions are still lacking. As mentioned
earlier, specific cultural understandings of child-rearing practices or cultural rea-
sons for punishment or abuse seldom entered the discourse, probably because the
AAI does not contain probes that target cultural features in the caregiving situ-
ation. Participants seemed to generally understand and respond to the AAI
questions in meaningful ways, although some participants seemed unaccustomed

to narrating life stories about attachment relationships. Perhaps this kind of
storytelling is culturally unfamiliar, or the constant challenge of survival
throughout their developmental trajectories limited family sharing and narration
of attachment-related experiences. Moreover, the AAI is not constructed to be a
reliable measure of trauma or child abuse, and because of the activation of attach-
ment-related defenses, participants with dismissing attachment patterns may avoid
discussion of childhood trauma in the service of down-regulating affect (Hesse,
2008). CSA, in particular, may be underreported, influenced by the presence of
native interpreters. Finally, coders with no clinical experience may have missed
subtle references to CEA and neglect in the transcripts, compared to the more
explicit descriptions of CSA and CPA.
Despite these limitations, the sample presented very high rates of one or more
types of severe childhood maltreatment (60% CPA, 44% CEA, 40% neglect, 2%
CSA), compared to the global estimates of the lifetime prevalence of child mal-
treatment (22.6% CPA, 36.3% CEA, 16.3% neglect, and 18%/7.6% CSA girls/
boys; WHO, 2017). Overlaps between several abuse types have been found to be
more common than any type of abuse occurring singly (Claussen & Crittenden,
1991), with the highest overlap between physical and emotional abuse (Armour,
Elklit, & Christoffersen, 2014), which was also the case in the present research.
While corporal punishment might have been more widespread in these refugees’
childhoods in Iraq and Lebanon, abuse was expressed as nonmeaningful experi-
ences and nonaccepted child-rearing practices. It is likely that socioeconomic cir-
cumstances and the issue of survival in the wake of extreme war trauma,
persecution, and traumatic losses of intimate relations, caused high levels of par-
ental distress, leading to inappropriate or violent parental behavior. Participants
did not accept the maltreatment as justified and clearly expressed suffering from the
lack of parental emotional closeness. Within all abuse domains, refugees expressed
common psychological impacts that continued to influence their behavior, emo-
tional conditions, and the quality of their relationships. Together, these reports
clarify some of the consequences of war violence on abusive family dynamics and
children’s mental health. Simultaneously, the data suggest the importance of past
child abuse to the trauma experience among refugees and the likelihood that this
clinical sample exemplifies those from Arabic-speaking families who were subjected
to severe child abuse.
Child abuse and war trauma: A vulnerability factor in refugees

with PTSD?
These data revealed high levels of trauma complexity consisting of various trauma
types across the developmental history, the lack of a pretrauma condition, and the
presence of lifelong trauma exposure in Arabic-speaking refugees with PTSD, with
child abuse and war trauma running parallel from early childhood. Participants
described profound psychological repercussions from abuse and neglect in many
Riber 23
domains of their adult lives. This qualitative study did not include a control group
without PTSD. However, it is unlikely that refugees without PTSD would display
such high levels of child abuse. Indeed, because the studied population was a
treatment-resistant clinical group (Nickerson et al., 2011), it is not surprising
that so many participants were marked by child abuse, as well as cumulative
extreme trauma exposures and political violence. Childhood maltreatment and
accumulating trauma complexity since early childhood may help explain symptom
chronicity and treatment challenges in refugee populations. Accordingly, child
abuse may be perceived as a vulnerability factor in traumatized refugees.
From a developmental psychological perspective, the quality of caregiving has
profound impacts on the normal development of affect-regulation and personality
(Fonagy et al., 2002), and severe child abuse and neglect can impact children’s devel-
opment in many domains of functioning (Egeland et al., 1983). A prospective, lon-
gitudinal study of a high-risk poverty sample of nonclinical young adults thus found
strong correlations between early age onset, chronicity, and severity of trauma, which
also predicted dissociative symptomatology (Ogawa, Sroufe, Weinfield, Carlson, &
Egeland, 1997). The presence of child abuse, along with other trauma types, would
therefore be likely to involve developmental deficits and disturbances in attachment
patterns, mentalizing capacities (Fonagy et al., 2002), domains of self-organization
(affect-regulation, self-concept, interpersonal domains; Cloitre et al., 2013), dissoci-
ation and traumatic stress reactions (van der Kolk et al., 2005), with important
impacts on psychotherapy processes and the therapeutic relationship.
Conclusion
The refugees interviewed in this study had complex mental health profiles, very
high levels of PTSD, attachment insecurity, and unresolved-disorganized trauma.
Participants described the care they received as children as impersonal and instru-
mental, with unloving, violent, and emotionally abusive parental behavior.
Participants also expressed developmental losses from the neglecting parental
behavior, regardless of the surrounding social predicaments in which they were
raised. Furthermore, the emotional problems that pervade their adult lives (feelings
of loss, emptiness, damaged development, intimacy and relational difficulties, lack
of personal autonomy, insecurity, low self-esteem, self-suppression) go well beyond
the core symptoms of PTSD. Attachment-related child abuse, adverse childhood
experiences, war trauma, and severity and chronicity of trauma were all frequent in
the responses from the present sample. The trauma complexity described by par-
ticipants has clinical implications for their treatment. The fact that a safe pre-
trauma condition rarely existed in this sample, along with the presence of
profound developmental vulnerabilities suggest they may have difficulties with
engagement in psychotherapy. This will have a bearing on psychotherapy
processes, useful techniques, the therapeutic relationship, transference dynamics,
as well as the goals, duration, and outcome of treatment (Daniel, 2015;
Herman, 1997). Complementary forms of intervention other than the currently
recommended choice for ‘‘classic’’ PTSD (Bisson & Andrew, 2007; National
Institute for Care Excellence [NICE], 2005) should be considered when dealing
with the complexity of refugee lifetime trauma (Cloitre et al., 2011; Riber, 2015).
The processes underlying extreme traumatization in childhood (both abuse and
war trauma) are probably different from those in adult life. In refugee trauma treat-
ment contexts as well as in future research, it may be necessary to conceptualize
models of attachment and child abuse that capture trauma disturbances from the
developmental contexts in which they appear, and integrate these with models of war-
related refugee trauma, as well as to consider the interaction between them. This study
documents that refugee trauma treatment providers should be careful not to overlook
the importance of childhood abuse, attachment trauma, and relational disturbances
in the context of manifest social and political trauma.
Acknowledgements
The author wishes to thank the refugees who agreed to share their life stories in the context
of the Adult Attachment Interview. We hope this research will promote a better understand-
ing of the way developmental vulnerabilities and experiences of growing up in a context of
war may influence refugees’ mental health. I warmly thank PhD, MSc in Psychology, Nina
Dalgård for being external auditor of the voluminous qualitative analysis in this study.
I likewise thank the team of psychology students who contributed with thorough AAI
transcriptions and Trauma Coding with scholarly enthusiasm: Anna Louise Langager,
Anna Thorlacius-Ussing, Cecilie Hedegaard, Esben Nedergård Olsen, Freja Rose
Enevoldsen, Henrik Bayer Elming, Ida Lohse, Jospehine Emilie Ohrt Würtz, Julie-Astrid
Galsgaard, Kamilla Julie Lauenborg, Katrine Schneekloth Friis Nielsen, Laura Gaun,
Mette Fonsø, Nana Marie Jespersen, Nina Eidnes Andersen, Nina Friser Holst, and
Signe Pertou Ringkøbing. I also thank the Competence Centre for Transcultural
Psychiatry and my two irreplaceable interpreters, Zeinab Hashemi and Nasir Hasan.
Finally, I warmly thank Professor Simo Køppe for academic advice and support.
The author was responsible for the administration of Adult Attachment Interviews.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This research was supported by The Health
Foundation (Helsefonden), The Department of Psychology, University of Copenhagen,
and The Competence Centre for Transcultural Psychiatry under a grant from Trygfonden
(7-10-1002).
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?lang¼en.
Karin Riber, Ph.D. in Psychology, Certified MSc in Psychology, Psychologist spe-

cialist in psychotherapy, and BA in Studies in Religion, was a PhD scholar in the
Department of Psychology at University of Copenhagen and at the Competence
Centre for Transcultural Psychiatry, currently a psychologist in the Mental Health
Services of the Capital Region of Denmark at Mental Health Centre Copenhagen.
Dr. Riber is trained in the Adult Attachment Interview (AAI), a certified Reflective
Functioning Coder on the AAI, specialized in mentalization-based therapy (MBT-
G) and compassion-focused therapy (CFT). Her published works focus on mental
health services research within the fields of attachment, mentalization, psychother-
apy, treatment outcome, PTSD/complex trauma, and refugee trauma.

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Transcultural Psychiatry 0(0) 1–30 !

The Author(s) 2017

Trauma complexity and child abuse:

*Karin Riber is now at Mental Health Centre Copenhagen

Attachment, trauma, and treatment

Cultural aspects of trauma and attachment

destruction of Palestinian homes. Following the Arab–Israeli wars (1948, 1967),

The TCM consisted of deﬁnitions with examples of various types of trauma,

Coding team and coding method

External auditor. To minimize researcher bias and maximize trustworthiness in the

Impact of childhood maltreatment

Participant Lifetime period

Participant Lifetime period

Adolescence: physical abuse by father; exposed to weapons on play-

rearing practices as abusive, violent, fear-inducing, and devoid of empathy—in-

This clinical vignette seems to exemplify traumatic reenactment in an abusive family

Or by a 29-year-old female Palestinian participant from Lebanon: ‘‘My childhood

CPA Category Frequency Quotes illustrating core ideas

CPA Category Frequency Quotes illustrating core ideas

My whole life I have been frightened and

Participants typically expressed a deﬁcit condition in the personal and emotional

Table 3. Affective responses in subjects who experienced childhood emotional abuse

CEA Categories Frequency Quotes illustrating core ideas

CEA Categories Frequency Quotes illustrating core ideas

school. And I always thought I was not good at

patterns of physical and emotional neglect (socially unaccepted), ﬁve participants

Table 4. Affective responses in subjects who experienced neglect (n ¼ 17)

Neglect Categories Frequency Quotes illustrating core ideas

Neglect Categories Frequency Quotes illustrating core ideas

was very hardworking, cooking, dressing

questions in meaningful ways, although some participants seemed unaccustomed

Child abuse and war trauma: A vulnerability factor in refugees

Declaration of Conflicting Interests

Karin Riber, Ph.D. in Psychology, Certified MSc in Psychology, Psychologist spe-

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