European Psychologist © 2009 Hogrefe 2009; Vol. & Huber 14(3):249–254 Publishers Report
Report Is Acknowledgment of Trauma a Protective Factor? The Sample Case of Refugees from Chechnya Andreas Maercker1, Marija Povilonyte1, Raichat Lianova2, and Karin Pöhlmann2 1
Department of Psychopathology & Clinical Intervention, University of Zurich, Switzerland 2 University Hospital Carl Gustav Carus, Dresden, Germany
Abstract. We assessed victims’ status and its relation to self-perceived “social acknowledgment as a victim or survivor” (Maercker & Müller, 2004) in a sample of Chechen refugees living in camps in Ingushetia. A total of 61 Chechen refugees were surveyed using a war-related trauma checklist, the Impact of Event Scale-Revised, and the Disclosure of Trauma Questionnaire. Rates of potentially traumatic events and posttraumatic stress disorder (PTSD) appeared to be very high in this sample: 100% reported one or more potentially traumatic events and over 75% were estimated to have PTSD. As expected, social acknowledgment as a victim or survivor was negatively related to PTSD symptoms. We discuss the possible causal direction of this finding. Our cross-sectional study provides further evidence that social acknowledgment should be regarded as a protective or resource factor in the aftermath of trauma. Keywords: posttraumatic stress disorder, protective factor, resources, refugees, mental health
Introduction The way in which people receive acknowledgment or disapproval for having experienced terrible things or traumatic life events can enhance or impair their health and wellbeing (Shay, 2002; Ricoeur, 2005). Interpersonal recognition or disapproval as a trauma victim or survivor can be seen as originating from concentric circles: Beginning with the inner circle of close family and friends, followed by the intermediate circle with other friends, neighbors, or acquaintances, and the outer circle of people in the community. We define social acknowledgment as a victim’s experience of positive reactions from society that show appreciation for the victim’s unique state and acknowledge the victim’s current difficult situation (Maercker & Müller, 2004). The main aim of the study was to investigate the extent of appreciation or disapproval as a victim or survivor in the refugee sample and its association with posttraumatic stress disorder (PTSD) symptoms. A lack of social acknowledgment might impede recovery from the traumatizing experience and intensify the posttraumatic reactions. Social acknowledgment forms a specific part of the broader concept of social support in trauma victims. Social support has repeatedly been shown to predict less severe psychopathological outcomes and improved salutogenic outcomes of trauma (e.g., Bonanno, Galea, Bucciarelli, & Vlahov, 2007; © 2009 Hogrefe & Huber Publishers
Brewin, Andrews, & Valentine, 2000; Charuvasta & Cloitre, 2007). As part of the broader social support concept, social acknowledgment focuses specifically on subjectively perceived, positive forms of recognition or, conversely, on disapproval (e.g., belittlement, accusations, ignorance; Guay, Billette, & Marchand, 2006). In our studies, social acknowledgment in traumatized victims has been shown to be a recovery or protective factor for PTSD in former political prisoners (Maercker & Müller, 2004), crime victims (Müller & Maercker, 2006), and traumatized developmental aid workers (Jones, Müller, & Maercker, 2006). Refugees from political conflicts or civil war often complain of ignorance toward their fate on the part of politicians or the general public. We had the opportunity not only to investigate war-related traumatic events and PTSD symptoms in Chechen refugees in Ingushetia, but also to test the new scale for self-perceived acknowledgment as a victim and to examine the extent of the victims’ disclosure of their traumatic experiences among one another (Müller, Beauducel, Raschka, & Maercker, 2000). The first aim of this study was to investigate the extent of traumatic events and resulting posttraumatic reactions. As already shown in previous studies on refugees, we expected to find high rates of traumatic events and PTSD symptoms among our sample (Mollica, Cardidad, & Massagli, 2007; Rasmussen, Smith, & Keller, 2007; Tang & Fox, 2001). The second aim was to investigate the associEuropean Psychologist 2009; Vol. 14(3):249–254 DOI 10.1027/1016-9040.14.3.249
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ations of these trauma-related data with receiving social acknowledgment as a victim. In particular, we expected such acknowledgment to be negatively related to PTSD symptomatology.
Methods Participants In 2001–2002, one of the authors (R.L.) visited Chechen refugee camps in Ingushetia (Russian Federation) to draw a convenience sample. Participants were registered refugees from the first Chechen civil war that took place between 1994 and 1996. The study was conducted shortly after the second Chechen war (1999–2000), in which the study participants did not play an active part or undergo any direct damage. All participants had held a refugee status for 5–7 years. Sixty-one Chechen refugees were investigated using the set of questionnaires. Inclusion criteria were being a refugee and having a command of the Russian language. Sixty-four percent of the participants were male and their average age was 34.7 years (SD = 11.65; range = 16–68). Data relating to living situation, marital status, highest educational degree, and occupational status are given in Table 1.
Measures Traumatic events were assessed using a checklist consisting of possible war and persecution-related traumatic event types (i.e., witnessing or experiencing injury by a gun or other weapon, beatings/torture, harassment by armed personnel, robbery/extortion, imprisonment, poisoning, rape or sexual abuse, beatings, abduction, child marriage, forced prostitution/sexual slavery, forced circumcision) to measure potential traumatic events (PTE). The first version of the checklist by Neuner et al. (2004) for African war refugees was supplemented following interviews with informants from Chechen refugee organizations. Twenty-six experienced or witnessed event types were included. For each event type, respondents were asked whether they had ever experienced or witnessed war-related or other events in the past year. The checklist is not a psychometrically constructed instrument, meaning that the extent of overlap between PTE items as well as the reliability remains unclear (see Neuner et al., 2004). The Impact of Event Scale-Revised (IES-R; Weiss & Marmar, 1997) is a commonly used PTSD self-report measure with psychometrically derived subscales for intrusion, avoidance, and hyperarousal. Respondents are asked to rate each item of on the original 4-point scale of the IES (0, 1, 3, 5) based on the previous 7 days. Serving analogously to a clinical cut-off, a widely used regression formula of the European Psychologist 2009; Vol. 14(3):249–254
Table 1. Sociodemographic characteristics of a sample (N = 61) n
%
Male
39
63.9
Female
22
36.1
16–30 yrs old
22
36.1
31–68 yrs old
39
63.9
Camp
22
36.0
House
26
42.6
Hospital
3
4.9
Unknown
10
16.4
31
50.8
6
9.8
Gender
Age
Living situation
Marital status Married Widowed Single
16
26.2
Divorced
2
3.3
Unknown
6
9.8
Education Incomplete secondary
23
37.7
Secondary
10
16.4
Technical college
11
18.0
University
6
9.8
Unknown
11
18.0
Unemployed
43
70.5
Employed
13
21.3
Unknown
5
8.2
Recent occupation
three subscale scores indicates PTSD caseness with a sensitivity of .70 and a specificity of .89 (regression formula given in Maercker & Schützwohl, 1998). The Social Acknowledgment as a Victim or Survivor Questionnaire (SAQ: Maercker & Müller, 2004) assesses the degree to which the affected individual feels validated and supported by his or her social network following a traumatic event. The 16 items of the measure are clustered into three subscales: recognition, general disapproval, and family disapproval (five–six items per subscale). The answers were rated on a 6-point Likert scale from disagreement (0) to agreement (5). The SAQ total score is a composite of all items (partly recoded with a range from –40 to +40). In the German validation sample, the reliabilities of subscores and the total score were satisfactory (Cronbach’s α = .79 –.87; Maercker & Müller, 2004). In the current sample, the scale consistencies were somewhat lower (α = .73–.79). The Disclosure of Trauma Questionnaire (DTQ; Müller et al., 2000) is a 34-item self-report measure that examines aspects of a person’s intentions to disclose traumatic events. Its subscales assess the individual’s urge to talk, © 2009 Hogrefe & Huber Publishers
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reluctance to talk, and emotional reaction. The first two subscales are independent of one another. The DTQ scales have been shown in previous research to have good retestreliability (Cronbach’s α = .82–.88) and validity. Confidentiality was assured and it was explained that researchers were not working for any Russian government organization. Informed consent was obtained using a standardized form, which explained the tasks or risks involved in participating and specified that no compensation would be provided. Respondents were given referrals to counseling services provided by NGOs where available.
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Table 2. Type of trauma suffered (N = 61) Trauma type
All of the study participants (N = 61) had experienced one or more type of potentially traumatic events. On average, they had experienced eight types of PTE and witnessed 10. The PTE sum index was, therefore, composed of eight PTEs, on average. Table 2 shows the frequencies of different kinds of trauma and how individuals were confronted with the trauma (directly experienced vs. witnessed). Taking directly experienced and witnessed traumatic events together, the most common traumatic experience consisted of acts of war/bombardment, which had been directly experienced by 95.1% of the refugees, followed by evacuation (93.4%) and forced breakup from other persons (85.2%). The PTSD rate estimate based on IES-R self-reports in the sample lay at 75.9% (N = 46). The total SAQ score of the sample lay at –8.4 (SD = 10.9) below the arithmetic mean of the scale (–40 to +40). In terms of gender, F(1, 59) = 0.13,, and the young vs. older age group, F(1, 59) = 2.11, ns, no significant differences in the mean values were found. Relationships between social acknowledgment and PTSD symptoms were examined using Pearson’s correlation coefficients (see Table 3). The total SAQ score correlated substantially negatively with all scores for intrusion, avoidance, and hyperarousal. The highest correlations among the SAQ subscales and PTSD symptoms were found between family disapproval and hyperarousal (r = .78, p > .001) and general disapproval and intrusions (r = .40, p > .01). Finally, disclosure behaviors (DTQ) were analyzed. It was shown that the total disclosure score correlated positively with all PTSD symptoms. However, neither reluctance to talk nor urge to talk showed significant correlations to PTSD avoidance. All subscales of acknowledgment and trauma disclosure correlated significantly with each other (except for the relationship between general disapproval and reluctance to talk). The correlations between acknowledgment and disclosure variables tended to be higher (all r values > .50) than those between these scales and PTSD symptoms. © 2009 Hogrefe & Huber Publishers
Witnessed Experienced and/or witnessed
n
n
%
%
n
% 95.1
War-related Acts of war/bombardment
41
7.2
58
4.9
46
75.4
47
77.0
Dead bodies
23 37.7
25
41
30
49.2
Molestation by soldiers
Injury by weapon
57 93.5 3
26 42.6
34
55.7
40
65.6
Capture
8 13.1
31
50.9
33
54.1
Executions/mock executions
2
3.2
17
27.8
17
27.9
10 16.4
21
34.4
23
37.7
8.2
29
47.6
32
52.1
Massacre
Results
Experienced
Homicide/Self-committed homicide
5
Bodily injuries Beaten
7 11.4
34
55.7
36
59.0
Accidents
23 37.7
31
50.8
40
65.6
Amputation
12 19.7
18
39.5
27
44.3
Torture
4
6.5
17
27.9
18
29.5
Suicide/suicide attempt
2
3.3
10
16.4
11
18.0
Evacuation
57 93.5
38
62.3
57
93.4
Sequestration
48.5
Expulsion 18 29.5
18
29.5
29
Forced breakup from family 52 85.3
32
52.3
52
85.2
Hiding
20
32.8
37
60.7
33 54.1
Sexual violence-related Rape (woman)
1
1.6
7
11.5
8
13.1
Forced marriage
4
6.6
15
24.6
17
27.9
Forced prostitution
2
3.3
6
9.8
7
11.5
Sex for security or food
0
0
3
4.9
3
4.9
Others Illness with no access to care 34 55.7
31
50.8
48
78.7
Absence of nutrition/water
42 68.9
24
39.3
42
68.9
Robbery
28 45.9
Kidnapping Additional events
20
32.8
35
57.4
8.2
15
24.6
18
29.5
33 54.1
10
16.4
35
57.4
5
Discussion The sample of Chechen refugees studied reported very high rates of traumatic events that they had either experienced personally or witnessed. Types of potential traumatic experiences included violence, threats to one’s life, sexual assault, witnessing death and injury, and living under severe conditions. In this sample, 95% reported one or more directly experienced potentially traumatic life events; 76% had indications of a full-blown PTSD estimated by the widely used IES-R self-report questionnaire. These figures are higher than in other studies on refugees (e.g., Mollica et al., 2007; Rasmussen et al., 2007; Tang & Fox, 2001), European Psychologist 2009; Vol. 14(3):249–254
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Table 3. Descriptive statistics and correlations of psychological variables Scale (value range) 1. Trauma severity – experienced (0–26) 2. Trauma severity – witnessed (0–26) 3. Intrusion (IES-R Scale; 0–35)
Mean SD 4.59
2
2.20 .64*
3
4
5
6
7
8
9
–.03
–.12
–.10
–.21
–.05
–.09
–.00
.20
.05
.03
–.09
.19
–.10
–.16
.09
7.93
4.97
26.10
7.12
.22
.46** .62** .46** .40**–.21 .53** .48** .21
–.42** .29*
11
12
13
–.04
.06
.08
.06
.13
.12
.38** .60** .57**
4. Avoidance (IES-R Scale; 0–40)
26.23
7.84
5. Hyperarousal (IES-R Scale; 0–35)
25.74
7.63
6. Family disapproval (SAQ; 0–25)
13.77
3.96
7. General disapproval (SAQ; 0–25)
18.11
4.47
8. Recognition (SAQ; 0–30)
16.49
6.22
.80**–.34**–.40**–.42**–.52**
9. SAQ total score (–40–+40)
–8.38 10.92
–.44**–.46**–.54**–.64**
10. Disclosure (DTQ) – reluctance to talk (0–50)
40.38
8.70
11. Disclosure (DTQ) – urge to talk (0–50) 21.39 12.50 12. Emotional reactions (DTQ; 0–50)
32.70 10.42
–.24
10
.78** .34**–.17
–.34** .08
.21
–.33*
.39** .57** .54**
.21
.40**–.44**–.78** .46** .31* –.16
–.65** .19
.29*
–.03
.32*
.28*
.52** .56** .27*
.34**
.44** .55** .57** .77** .90**
13. DTQ total score (0–150) 94.48 23.71 Note. IES-R = Impact of Event Scale-Revised; SAQ = Social Acknowledgment Questionnaire; DTQ = Disclosure of Trauma Questionnaire. *p < .05, **p < .01.
possibly reflecting the Chechen participants’ particular situations, e.g., living in refugee camps not far from the Chechen border soon after new combat activities (i.e., second Chechen war). Additionally, it should be noted that IES-Rbased assessments are not clinical diagnoses and the crosscultural applicability of this questionnaire has to be evaluated further (see Wittchen & Jacobi, 2005). The main aim of the study was to investigate the extent of appreciation or disapproval as a victim or survivor in the refugee sample and its association with PTSD symptoms. The particular measurement assessed here was the SAQ (Maercker & Müller, 2004). Its subscales capture acknowledgment of the traumatized individual in “concentric circles”: from the inner circle of close family and friends (family approval/disapproval), followed by the intermediate circle with other friends or acquaintances, to the outer circle of neighbors or acquaintances, people in the community etc. (general recognition or disapproval). On average, SAQ values for the Chechen refugees were comparatively low. Compared to previously investigated groups (e.g., crime victims, former political prisoners, developmental aid workers) the refugees showed the lowest SAQ values (Jones et al., 2006; Mueller, Moergeli, & Maercker, 2008). The main explanation for this low acknowledgment as victims for the Chechen refugees may lie in their particular context of discrimination and decreased opportunities (Politkovskaya, 2004). The other previously studied group with low social acknowledgment (German crime victims; Müller & Maercker, 2006) also had comparatively high rates of PTSD symptoms. In addition, the German crime victims were relatively recently traumatized (5 months), which may explain the high symptomatology and low perceived appreciation and support. It is likely that in the case of our Chechen sample, culturally mediated styles European Psychologist 2009; Vol. 14(3):249–254
of acknowledgment and reports of acknowledgment play a role, particularly when it comes to attitudes from family (see Nauck, 2007). Associations between social acknowledgment (sub)scores and other variables showed meaningful patterns. The two negatively poled subscales (general and family disapproval) were more strongly (positively) related to posttraumatic intrusions than the positively poled subscale of recognition. As Brewin et al. (2000) indicated, a lack of social support is more crucial to the maintenance of PTSD than the positive effect of available social support. The single strongest association was found between family disapproval and hyperarousal symptoms, indicating the close relationship between family backing and reassurance. Associations between social acknowledgment and disclosure processes replicate previous findings of close interrelations between the two psychological processes, i.e., the urge to talk about the trauma is associated with a lack of acknowledgment from friends and family (Pennebaker & Harbor, 1993). We believe the SAQ to be a valuable tool for further research and for use in the context of potential preventive interventions. The finding of noncorrelations between subscales of the DTQ and PTSD avoidance requires further study to disentangle the various facets of social avoidance processes in traumatized individuals (see Mueller et al., 2008). Methodological limitations of the study need to be mentioned, particularly cultural issues related to sampling and assessment. Because of logistics, there are no data regarding the response rate in this study. Therefore, the study cannot claim to be representative. The main results rest on the two translated instruments, the IES-R and the SAQ. Although both instruments have been properly translated and back-translated, so far no validation study exists in the Russian language. Furthermore, Russian is a foreign language © 2009 Hogrefe & Huber Publishers
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for Chechen participants and may have been regarded as the tongue of the aggressors. However, assessing not only trauma-related symptoms and disorders but also resource or recovery-related psychological processes could be regarded as an advantage in the international field research on the aftermath of trauma. Our main finding of a negative correlation between social acknowledgment and PTSD symptoms calls for a causal explanation. Since the cross-sectional design of our study does not allow for the identification of causal relations, two interpretations are possible: Acknowledgment could promote recovery or, conversely, people with more severe PTSD symptoms could tend to assume that others think something is wrong with them. Based on evidence from recent longitudinal studies either on effects of social acknowledgment (Mueller et al., 2008) or on various social-support trajectories (Kaniasty & Norris, 2008), we assume the former. If further refined studies corroborate this causal direction, sensitive interventions will be needed to mobilize, maintain, and improve societal acknowledgment after traumatic experiences even in parts of the world that are difficult to reach.
Acknowledgment The authors would like to thank Prof. Dr. Peter Joraschky for his encouragement and continuous support of the study.
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About the authors Andreas Maercker, MD, PhD, is professor of Psychopathology and Clinical Intervention at the University of Zurich, Switzerland. His research interests are PTSD research and clinical geropsychology. Marija Povilonyte, cand. psych., is a research assistant at the University of Vilnius, Lithuania, and in the Department of Psychopathology and Clinical Intervention at the University of Zurich, Switzerland. Raichat Lianova has been a medical intern at the University Hospital for Psychotherapy and Psychosomatic Medicine of the Technical University Dresden and is now working at the HELIOS Klinik Schwedenstein, Germany.
European Psychologist 2009; Vol. 14(3):249–254
PD Dr. Karin Pöhlmann, Dipl. Psych., works in the University Hospital for Psychotherapy and Psychosomatic Medicine, Technical University Dresden, Germany. Her research interests are goal development and self-regulation as well as self-concept in social phobia.
Andreas Maercker University of Zurich Binzmühlestr. 14/17 CH-8050 Zürich Switzerland Tel. +41 44 635-7310 Fax +41 44 635-7319 E-mail
[email protected]
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