What Prevents Refugees and Asylum Seekers Exposed to Violence from Disclosing Trauma?
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WHAT PREVENTS REFUGEES AND ASYLUM SEEKERS EXPOSED TO VIOLENCE FROM DISCLOSING TRAUMA? Diana Bogner DOCTORATE IN CLINICAL PSYCHOLOGY THESIS (Volume 1) 2005 UNIVERSITY COLLEGE LONDON UMI Number: U592641 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U592641 Published by ProQuest LLC 2013. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 CONTENTS OVERVIEW VI ACKNOWLEDGEMENTS VII PART 1: LITERATURE REVIEW 1 Shame and Disclosure in Traumatised Refugees and Asylum Seekers ABSTRACT__________________________________________________________ 1 1. REFUGEES AND ASYLUM SEEKERS AND THE LEGAL SYSTEM______ 2 1.1 Definitions........................................................................ 2 1.2 Immigration Grounds and Statistics ................................... 3 1.3 The Asylum Process........................................................ 4 1.4 Home Office Decision Making ......................................... 6 1.5 Summary.......................................................................... 7 2. DISCLOSURE_____________________________________________________ 8 2.1 Patient Disclosure in Psychological Therapy.................... 8 2.1.1 History and Conceptual Issues 8 2.1.2 Empirical Studies of Non-Disclosure 9 2.1.3 Contents of Disclosure 10 2.1.4 Factors Impeding Disclosure 10 2.1.5 Factors Facilitating Disclosure 12 2.2 Inconsistencies of Recall................................................... 13 2.2.1 Autobiographical Memory Research 14 2.2.2 Hypermnesia 17 2.2.3 Memory and Disclosure 18 2.3 Disclosure during Asylum Interviews ............................... 19 2.4 Summary.......................................................................... 22 3. TRAUMA_________________________________________________________ 24 3.1 Torture and Organised Violence ...................................... 24 3.2 Physical and Psychological Sequelae of Trauma .............. 25 II 3.3 Post-Traumatic Stress Disorder ........................................ 26 3.3.1 Empirical Studies 27 3.3.2 Limitations 29 3.4 Post-Migratory Factors..................................................... 30 3.5 Trauma and Dissociation .................................................. 32 3.5.1 Post-Traumatic Dissociation 32 3.5.2 Peri-Traumatic Dissociation 34 3.6 Summary.......................................................................... 36 4. SHAME ___________________________________________________________ 37 4.1 Definitions and Conceptual Issues .................................... 37 4.2 Shame and Psychopathology ........................................... 39 4.2.1 Shame and Trauma 39 4.2.2 Shame and PTSD 40 4.3 Shame and Disclosure ...................................................... 41 4.4 Shame and Psychological Therapy .................................. 44 4.5 Summary ......................................................................... 46 5. CONCLUSION _____________________________________________________ 47 REFERENCES_______________________________________________________ 50 PART 2: EMPIRICAL PAPER 74 What Prevents Refugees and Asylum Seekers Exposed to Violence from Disclosing Trauma? ABSTRACT 74 INTRODUCTION 74 METHOD___________________________________________________________ 81 Participants........................................................................... 81 Measures ............................................................................... 82 Quantitative Measures 82 Qualitative Measures 85 III Procedure 88 RESULTS____________________________________________________________ 88 Quantitative Results .............................................................. 88 Preliminary Analyses 88 Participants 89 Quantitative Measures 90 Comparison of Participant Group Characteristics 91 The Relationship of Shame to PTSD Symptoms 94 The Relationship of Dissociation to PTSD Avoidance Symptoms and Shame 94 The Relationship of Disclosure to the Dependant Variables 95 Qualitative Results ................................................................ 97 Method of Analysis 97 Disclosure of Sensitive Personal Information 98 Reactions towards People in Authority 100 Situation- and Context-Specific Factors 103 Culture-Specific Issues 105 Other Issues and Recommendations 105 DISCUSSION_______________________________________________________ 107 Group Comparisons ............................................................. 108 The Relationship of Shame to Psychopathology ................... 108 The Relationship of Dissociation to PTSD ............................ 109 Disclosure F indings .............................................................. 110 Factors Impeding Disclosure 111 Factors Facilitating Disclosure 113 Limitations........................................................................... 114 Implication of Findings........................................................ 115 Conclusion ........................................................................... 117 REFERENCES 118 PART 3: CRITICAL APPRAISAL 130 The Challenges of Researching Refugees and Asylum Seekers ABSTRACT 130 IV 1. METHODOLOGICAL ISSUES_______________________________________ 130 Language and Cultural Barriers....................................................... 130 Measurement Issues........................................................................... 134 Ethical Considerations ...................................................................... 136 Sampling Issues................................................................................... 138 2. SYSTEMIC ISSUES________________________________________________ 138 3. RESEARCH PARTICIPATION______________________________________ 141 4. CONCLUSION ____________________________________________________ 148 REFERENCES 149 APPENDICES 153 APPENDIX 1: Ethical approval _________________________________________ 153 APPENDIX 2: Consent form___________________________________________ 156 APPENDIX 3: Patient information sheet _________________________________ 157 APPENDIX 4: Covering letter __________________________________________ 159 APPENDIX 5: Translated patient information sheet (Albanian version) ________ 160 APPENDIX 6: Translated patient information sheet (Turkish version) _________ 162 APPENDIX 7: PTSD Symptom Scale____________________________________ 164 APPENDIX 8: Hopkins Symptom Checklist - Depression___________________ 165 APPENDIX 9: Experience of Shame Scale_________________________ 166 APPENDIX 10: Peritraumatic Dissociative Experiences Questionnaire _________ 167 APPENDIX 11: Interview schedule ______________________________________ 168 APPENDIX 12: Participant quotes ______________________________________ 170 APPENDIX 13: Research Participation Questionnaire _______________________ 172 V OVERVIEW Part 1 of this thesis is a literature review, which explores the factors surrounding refugees’ and asylum seekers’ disclosure during Home Office interviews. It places particular emphasis on the role of shame in trauma and disclosure. The first section is an outline of the UK immigration system. Section 2 explores the potential factors involved in inconsistent recall and disclosure by drawing on the literature of patient disclosure in psychological therapy and memory research. Section 3 looks at the psychological impact of trauma in refugees. The last section provides an overview of the shame literature and focuses particularly on the role of shame in disclosure and psychopathology. Part 2 is an empirical study that aims to test some of the issues discussed in the literature review. Semi-structured interviews with refugees and asylum seekers showed that people with a history of sexual violence found it more difficult to disclose during their Home Office interview than those with a history of non-sexual violence. Feelings of shame were frequently cited in this group as a factor preventing disclosure. These findings were confirmed by quantitative analyses, which found that this group scored significantly higher on measures of posttraumatic stress symptoms, shame, dissociation and disclosure. The study also replicated previous findings showing that sexual violence is linked to avoidance symptoms, and it also supported the hypothesis that there is an association between shame and avoidance reactions. Part 3 is a critical appraisal, which focuses on the challenges of researching refugees and asylum seekers. It includes sections on methodological and systemic issues and on research participation. VI ACKNOWLEDGEMENTS I would like to thank my supervisors, Jane Herlihy and Chris Brewin, for their invaluable help with all aspects of the thesis. I am grateful to all the people and organisations that have helped me with the recruitment process. I particularly would like to express my gratitude to all the refugees and asylum seekers who participated in this study and hence made this research possible. The UCL Central Research Fund is gratefully acknowledged for funding this study. I also acknowledge the continuous support and encouragement offered by my friends and my family.