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Making the invisible visible: A grounded theory study of female adult trauma survivors reconstructing reality with supportive others Anke Kossurok A thesis submitted in fulfilment of requirements for the degree of Doctor of Philosophy School of Health in Social Science THE UNIVERSITY OF EDINBURGH 2017 Declaration I hereby declare that this thesis is of my own composition, and that it contains no material previously submitted for the award of any other degree. The work reported in this thesis has been executed by myself, except where due acknowledgement is made in the text. Anke Kossurok Declaration | i Acknowledgements Thanks are due to my supervisors Prof Matthias Schwannauer and Dr Ethel Quayle for sharing their valuable knowledge and experience, providing important academic advice, support and insights, and particularly for guiding me through the maze of qualitative analysis. Credit is also due to my former second supervisor Dr Stella Chan for her encouragements, insights, and particularly for helping me crystallise my research question. I am also immensely grateful for the support received from research sites, and particularly from Dr Sandra Ferguson, Catriona Grant, Ruth Campbell, and Dr Claire Fyvie. In addition, I would like to thank Dr Kirsty Boyd and Dr Desmond Ryan for stimulating discussions on my findings. Further thanks are due to various friends who helped me practice interviewing. Special thanks go to Kirsty for correcting my grammar (Oh, those tenses!) and other quirks in my writing. I appreciate it enormously. Thanks are also due to Miriam for whizzing through and correcting many many entries in my reference manager. You’re a star. A lot of credit goes to Kathryn and Kirsty for keeping me sane, particularly in the final few months. Their unconditional support means a lot to me. I extend my appreciation to Edgardo for his wealth of academic guidance and stimulating across-the-desk conversations, as well as to other doctoral colleagues who added fun, inspiration and encouragements to my studies: Joanne, Zoi, Kellen, Ilayda, Javita, Erifili, Adam, Dominic, Niki, Sarah, and many more. Last but not the least, this piece of work would not have been possible without 15 wonderful participants and women trauma survivors. It has been an absolute privilege to listen to their stories. Thank you for sharing! Acknowledgements | iii Table of contents Declaration .............................................................................................................................. i Acknowledgements ............................................................................................................. iii Table of contents ................................................................................................................... v List of tables and figures ................................................................................................... xiii Abstract................................................................................................................................. xv Lay summary ..................................................................................................................... xvii Chapter 1: Introduction ........................................................................................................1 1.1. Introduction ..................................................................................................................1 1.2. Background and importance of this study ...............................................................2 1.3. About this study ..........................................................................................................6 1.4. Terms explained ...........................................................................................................7 1.5. Structure of the thesis ..................................................................................................8 Chapter 2: Literature review..............................................................................................11 2.1. Introduction ................................................................................................................11 2.2. Historical review of abuse and interpersonal trauma ..........................................12 2.2.1. Early attempts to evidence abuse of women and children...................13 2.2.2. Attempts to document neurological symptoms of hysteria .................14 2.2.3. Early psychological enquiries about women’s hysteria........................14 2.2.4. Evidence and doubts about links between child sexual abuse and hysteria .........................................................................................................15 Table of contents | v 2.2.5. Growing momentum in recognitions of child maltreatment and subsequent trauma .................................................................................... 16 2.2.6. The women’s movement prompts a wave of research into violence against women ........................................................................................... 17 2.2.7. Post-traumatic stress is recognised as a formal diagnosis ................... 18 2.3. Prevalence rates of trauma and violence against women and children ............ 20 2.3.1. Prevalence of trauma event exposure ..................................................... 20 2.3.2. Prevalence rates of interpersonal violence against children................ 21 2.3.3. Prevalence rates of interpersonal violence against women ................. 25 2.3.4. Prevalence rates of developing post-traumatic stress after interpersonal trauma events .................................................................... 27 2.4. Differentiating types of traumatic event ................................................................ 29 2.4.1. Defining child sexual abuse ..................................................................... 29 2.4.2. Defining child physical abuse .................................................................. 30 2.4.3. Defining child emotional or psychological abuse ................................. 31 2.4.4. Defining child neglect ............................................................................... 31 2.4.5. Defining intimate partner violence ......................................................... 32 2.4.6. Further critique of definitions .................................................................. 32 2.4.7. Defining interpersonal trauma ................................................................ 34 2.5. Importance of studying interpersonal trauma ...................................................... 35 2.5.1. Developing trauma symptoms (PTSD, DESNOS, complex trauma) .... 36 2.5.2. Developing additional mental health problems .................................... 38 2.5.3. Developing physical health problems .................................................... 41 2.5.4. Impact on and of education, employment and other social factors ...... 43 2.5.5. Economic costs to society ......................................................................... 44 2.6. Underlying mechanism I: Attachment ................................................................... 47 2.6.1. Attachment theory and human development ....................................... 47 2.6.2. Relationships between child maltreatment, attachment and trauma severity ........................................................................................................ 49 Table of contents | vi 2.6.3. Relationships between abuse in adulthood, attachment and trauma severity .........................................................................................................50 2.6.4. Conceptual and methodological difficulties of attachment research ....51 2.7. Underlying mechanism II: Resilience, vulnerability and coping ........................54 2.7.1. Cognitive coping ........................................................................................56 2.7.2. Emotion-focused coping and emotion regulation difficulties .............60 2.7.3. Interpersonal coping and difficulties.......................................................68 2.8. Interventions to address interpersonal trauma .....................................................75 2.8.1. Conventional trauma treatment ...............................................................75 2.8.2. Phase-based treatment ...............................................................................78 2.8.3. Other treatment approaches .....................................................................80 2.8.4. Beyond formal treatment – evidence from qualitative studies