PSYCHOSOCIAL FACTORS ASSOCIATED WITH SEPARATION TRAUMA IN A Content Analysis of 9 Case Studies Presenter Talli Ungar Felding, Cand. Psych., Clinical Psychologist, Specialist and Supervisor in Psychotherapy Psykologisk Center, Copenhagen, Denmark Monday, January 9, 2012, 2:15 PM to 2:35 PM Trauma through the Life Cycle from a Strengths perspective: An International Dialogue 1
BACKGROUND OF THE STUDY The Danish Mental Health Care System is universal and free of charge The Danish population is very homogeneous. Refugees and immigrants in large numbers are a new phenomenon The Danish society is troubled by antisocial behavior in refugee and immigrant adolescents 2
POPULATION 9 adolescents were separated from parental figures in the age of 2 to 12 years simultaneously with flight or emigration to Denmark In the age of 14 to 17 years they underwent a psychological investigation 3
PURPOSE OF THE STUDY Do refugee and immigrant adolescents with a history of separation have mental health problems due to cultural circumstances or due to psychopathology? Do Danish social workers overestimate the importance of cultural circumstances and underestimate the importance of psychosocial factors? Are refugee and immigrant adolescents with a history of separation offered relevant mental health care? 4
METHOD A preliminary study of 9 refugee and immigrant adolescents referred for psychological investigation The psychological investigations were carried out by a clinical psychologist trained in Otto Kernbergs method of Structural Interviewing and experienced in psychotherapy of antisocial adolescents The psychological investigation did not focus on religion, culture or native country. Focus was on individual psychosocial factors The content of the investigation reports was analyzed following principles of emergent coding of the content 5
DATA Separation Trauma Symptoms Defense mechanisms Psychosocial risk factors Personality structure 6
Number of adolescents Age at separation & flight / emigration 1 2 1 5 3 7 3 9 1 12 7
Cumulative Separations Number of adolescents Total number of separations Age at separations 4 1 A: 2 B: 2 C: 7 D: 9 3 2 E: 5, 12 F: 6, 12 G: 9, 13 1 3 H: 7, 8-13, 14 1 4 I: 9, 11, 12, 13 8
DSM-IV-TR Diagnostic criteria for Posttraumatic Stress Disorder The person has been exposed to a traumatic event in which both of the following were present: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others & The person's response involved fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior 9
DSM-IV-TR Diagnostic criteria for Posttraumatic Stress Disorder The traumatic event is persistently reexperienced in one or more of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 2 2 5 2 10
DSM-IV-TR Diagnostic criteria for Posttraumatic Stress Disorder Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: Efforts to avoid thoughts, feelings, or conversations associated with 7 the trauma Inability to recall an important aspect of the trauma 2 Feeling of detachment or estrangement from others 1 Restricted range of affect (e.g., unable to have loving feelings) 2 11
DSM-IV-TR Diagnostic criteria for Posttraumatic Stress Disorder Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: Difficulty to falling or staying asleep 2 Irritability or outbursts of anger 7 Difficulty concentrating 5 Hypervigilance 2 12
DSM-IV-TR Diagnostic criteria for Posttraumatic Stress Disorder Duration of the disturbance is more than one month 8 The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Acute: If duration of symptoms is less than 3 months 0 Chronic: If duration of symptoms is three months or more 8 6 13
IMPLICATIONS OF LACK OF RECOGNITION OF PSYCHOSOCIAL RISK FACTORS 5 adolescents had been seen by a school psychologist 2 adolescents received brief or sporadic psychotherapy 7 adolescents never received psychotherapy 1 adolescent received brief psychiatric treatment Danish Social Authorities are not very inclined to offer psychological or psychiatric treatment to traumatized adolescents 14
Antisocial symptoms Number of adolescents Distrust 8 Lack of honesty 8 Truancy 7 Lack of empathy 7 Lack of guilt feelings 5 Low frustration tolerance 5 Sensitivity to humiliation and insult 5 15
DSM-IV-TR Diagnostic criteria for Conduct Disorder A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months: Aggression to people and animals 4 Destruction of property 3 Deceitfulness or theft 4 Serious violations of rules 2 The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning 5 5 16
DSM-IV-TR Diagnostic criteria for Conduct Disorder Age at onset: Conduct Disorder, Childhood-Onset Type: Onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years Conduct Disorder, Adolescent-Onset Type: 1 Absence of any criteria characteristic of Conduct Disorder prior to age 10 years Conduct Disorder, Unspecified Onset: Age at onset is not known 2 2 17
DSM-IV-TR Diagnostic criteria for Conduct Disorder Severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others Moderate: Number of conduct problems and effect on others intermediate between "mild" and "severe" Severe: Many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others 1 1 3 18
DSM-IV-TR Diagnostic criteria for Antisocial Personality Disorder Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure Impulsivity or failure to plan ahead 5 Irritability and aggressiveness, as indicated by repeated physical fights or assaults Reckless disregard for safety of self or others 3 Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another 3 1 6 3 19
Other symptoms Symptom Number of adolescents Identity diffusion 7 Depression 6 Anxiety 5 Feelings of emptiness 5 Disturbances in object relations 5 20
Defense mechanisms Defense mechanism Number of adolescents Denial 7 Projective mechanisms 7 Splitting 6 Devaluation and idealization 5 21
Object relation Object relation Number of adolescents Deep 1 Ambivalent 5 Superficial 3 22
Personality structure Personality structure Number of adolescents Normal 2 Borderline 6 Psychotic 1 23
REFERENCES Connection between separation trauma and antisocial symptoms August Aichhorn (1925): Wayward Youth John Bowlby (1946): Forty-four Juvenile Thieves John Bowlby (1972): Separation: Anxiety and Anger John Bowlby (1951): Maternal Care and Mental health D. W. Winnicott (1956): The Antisocial Tendency 24
Psychosocial risk factors Risk factor Number of adolescents Use of corporal punishment 8 Parental neglect 7 Separation/divorce among parents 7 More than one separation from parental figures 5 Substance abuse among parents 5 25
Level of recognition of psychosocial risk factors Psychosocial risk factor Corporal punishment (8 cases) Parental neglect (7 cases) More than one separation from parental figures (5 cases) Substance abuse in parents (5 cases) Psychiatric illness in parents (5 cases) Not recognized by Danish Social Authorities Recognized by Danish Social Authorities, but no intervention Recognized and intervened in by Danish Social Authorities 2 cases 2 cases 4 cases 2 cases 3 cases 2 cases 0 cases 4 cases 1 case 2 cases 2 cases 1 case 0 cases 2 cases 3 cases 26
CONCLUSIONS Independent of ethnicity, antisocial adolescents often face psychosocial risk factors, such as Cumulative traumas Parental neglect Use of corporal punishment Substance abuse among parents 27
CONCLUSIONS A high number of antisocial refugee and immigrant adolescents have more severe psychopathology than previously assessed by Danish Social Authorities Danish Social Authorities focus to much on cultural and ethnic factors, and to little on psychosocial factors, when they take decisions about help offered to antisocial refugee and immigrant adolescents 28
CONCLUSIONS Because Danish Social Authorities do not recognize psychosocial factors related to antisocial behavior in immigrant and refugee adolescents with separation trauma, they do not offer them psychosocial and psychological intervention. Because Danish Social Authorities do not differentiate between collective, ethnic and cultural factors and individual, psychosocial factors, they fail to notice psychopathology in immigrant and refugee adolescents with separation trauma, and unknowingly discriminate against them compared to Danish adolescents with similar psychopathology, who are more likely to receive relevant treatment. 29
IMPLICATIONS FOR PRACTICE Immigrant and refugee adolescents have less access to mental health services than Danish adolescents Danish Social Authorities must develop better methods for identifying psychosocial risk factors in immigrant and refugee adolescents in order to offer them relevant intervention 30
STRENGTHS AND LIMITATIONS OF THE STUDY Strengths: In-depth study of psychological and psychosocial factors Limitations: Small sample Religious, cultural and ethnic factors are not discussed Consequences of separation from parental figures in different ages are not discussed 31
FUTURE DIRECTIONS Expand the study to a substantial number of immigrant and refugee adolescents with separation trauma in order to make it a statistically significant study Educate Danish social workers to identify signs of antisocial psychopathology in immigrant and refugee adolescents with separation trauma in order to offer appropriate help 32
Talli Ungar Felding tuf@psykologisk-center.dk www.psykologisk-center.dk +45 33 14 21 33