The Mental and Physical Health Effects of Torture: The Role of Identity Salience as a Pathway to Posttraumatic Growth and Healing: The Case of Syrian Refugees and IDPs — Oak Academic Publishing
Research ArticleOpen AccessGoogle Scholar indexed
The Mental and Physical Health Effects of Torture: The Role of Identity Salience as a Pathway to Posttraumatic Growth and Healing: The Case of Syrian Refugees and IDPs
Center for Cumulative Trauma Studies, Stone Mountain, USA
,
The Center for Stress, Trauma and Resiliency, Georgia State University, Atlanta, USA
,
The Kuwait Ministry of Health (MOH), Kuwait, Kuwait
,
Sabah Hospital, Kuwait, Kuwait
,
Fayoum University, Fayoum, Egypt
1 Center for Cumulative Trauma Studies, Stone Mountain, USA
2 The Center for Stress, Trauma and Resiliency, Georgia State University, Atlanta, USA
3 The Kuwait Ministry of Health (MOH), Kuwait, Kuwait
Objective: Some studies found that torture did not predict posttraumatic stress disorder (PTSD) and is associated with more complex symptoms and that torture survivors are more resilient than other refugees. The goal is to recheck the validity of these findings. Method: A secondary analysis of data of 502 Syrian refugees, of whom 123 were torture survivors, we measured cumulative stressors and traumas (CST), PTSD, identity salience, post-cumulative trauma-related disorders (P-CTD), posttraumatic growth (PTG), and physical health. We conducted independent samples t-test between tortured and non-tortured refugees and hierarchical multiple regression analyses with PTSD, P-CTD, and PTG as dependent variables. We entered intersected discrimination, torture, and identity salience in the last step. Results: Independent samples t-test indicated that torture survivors have more neurological and musculoskeletal problems, higher psychoticism-dissociation, suicidality, and executive control deficits. There were no differences between the two groups in PTG. Further, torture survivors have higher identity salience than other non-tortured refugees. Regression analysis indicated that torture and intersected discrimination were predictors of P-CTD syndromes; torture was a stronger predictor. Torture did not predict PTSD. Identity salience was a strong predictor of PTG (Beta = .51). Conclusions: Torture survivors may develop PTSD because of other traumas other than torture. The results clarified some of the mechanisms that linked high identity salience and PTG in torture survivors, even though they have worse physical health, higher trauma load, and mental health symptom severity, compared to other refugees. Torture survivors’ stronger collective identity empowered their PTG. The clinical implications of the results were discussed.
KeywordsTorture SurvivorsRefugeesIdentity SaliencePTSDDissociationExecutive Function Deficits
Abu Suhaiban, H., Grasser, L. R., & Javanbakht, A. (2019). Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care. International Journal of Environmental Research and Public Health, 16, Article No. 2309. https://doi.org/10.3390/ijerph16132309
Al-Ibraheem, B., Kira, I., Aljakoub, J., & Al-Ibraheem, A. (2017). The Health Effect of the Syrian Conflict on IDPs and Refugees. Peace and Conflict: Journal of Peace Psychology, 23, 140-152. https://doi.org/10.1037/pac0000247
Betemps, E. J., Smith, R. M., Baker, D. G., & Rounds-Kugler, B. A. (2003). Measurement Precision of the Clinician Administered PTSD Scale (CAPS): A RASCH Model Analysis. Journal of Applied Measurement, 4, 59-69.
Boschloo, L., van Borkulo, C. D., Rhemtulla, M., Keyes, K. M., Borsboom, D., & Schoevers, R. A. (2015). The Network Structure of Symptoms of the Diagnostic and Statistical Manual of Mental Disorders. PLoS One, 10, e0137621. https://doi.org/10.1371/journal.pone.0137621
Choi, H., Lee, H. J., & Lee, H. Y. (2017). The Effects of Torture-Related Stressors on Long-Term Complex Post-Traumatic Symptoms in South Korean torture survivors. International Journal of Psychology, 52, 57-66. https://doi.org/10.1002/ijop.12276
Chu, T., Keller, A. S., & Rasmussen, A. (2013). Effects of Post-Migration Factors on PTSD Outcomes among Immigrant Survivors of Political Violence. Journal of Immigrant and Minority Health, 15, 890-897. https://doi.org/10.1007/s10903-012-9696-1
Cohen, J. (1992). A Power Primer. Psychological Bulletin, 112, 155-159. https://doi.org/10.1037/0033-2909.112.1.155
Connor, P., & Krogstadl, J. M. (2016). About Six in ten Syrians Are Now Displaced from Their Homes. PEW Research Center. http://www.pewresearch.org/fact-tank/2016/06/13/about-six-in-tensyrians-are-now-displaced-from-their-homes/
Edge, S., & Newbold, B. (2013). Discrimination and the Health of Immigrants and Refugees: Exploring Canada’s Evidence Base and Directions for Future Research in Newcomer Receiving Countries. Journal of Immigrant and Minority Health, 15, 141-148. https://doi.org/10.1007/s10903-012-9640-4
Elmore, K. C., & Oyserman, D. (2012). If ‘We’ Can Succeed, ‘I’ Can Too: Identity-Based Motivation and Gender in the Classroom. Contemporary Educational Psychology, 37, 176-185. https://doi.org/10.1016/j.cedpsych.2011.05.003
Gangamma, R., & Shipman, D. (2018). Transnational Intersectionality in Family Therapy with Resettled Refugees. Journal of Marital and Family Therapy, 44, 206-219. https://doi.org/10.1111/jmft.12267
Hair, J. F., Hult, G. T. M., Ringle, C. M., & Sarstedt, M. (2017). A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM) (2nd ed.). Sage.
Han, K., Chapman, S. B., & Krawczyk, D. C. (2018). Neuroplasticity of Cognitive Control Networks Following Cognitive Training for Chronic Traumatic Brain Injury. NeuroImage: Clinical, 18, 262-278. https://doi.org/10.1016/j.nicl.2018.01.030
Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006). A Meta-Analytic Review of Benefit Finding and Growth. Journal of Consulting and Clinical Psychology, 74, 797-816. https://doi.org/10.1037/0022-006X.74.5.797
Hollifield, M., Warner, T. D., & Westermeyer, J. (2011). Is Torture Reliably Assessed and a Valid Indicator of Poor Mental Health? Journal of Nervous and Mental Disease, 199, 3-10. https://doi.org/10.1097/NMD.0b013e3182051501
Hooberman, J. B., Rosenfeld, B., Lhewa, D., Rasmussen, A., & Keller, A. (2007). Classifying the torture experiences of refugees living in the United States. Journal of Interpersonal Violence, 22, 108-123. https://doi.org/10.1177/0886260506294999
Johnson, H., & Thompson, A. (2008). The Development and Maintenance of Post-Traumatic Stress Disorder (PTSD) in Civilian Adult Survivors of War Trauma and Torture: A Review. Clinical Psychology Review, 28, 36-47. https://doi.org/10.1016/j.cpr.2007.01.017
Kalt, A., Hossain, M., Kiss, L., & Zimmerman, C. (2013). Asylum Seekers, Violence, and Health: A Systematic Review of Research in High-Income Host Countries. American Journal of Public Health, 103, e30-e42. https://doi.org/10.2105/AJPH.2012.301136
Kanaan, A., Kira, I., Shuwiekh, H., Kucharska, J., & Al-Huwailah, A. (2019). The Dynamics behind Low Posttraumatic Growth in Victims of Type III Traumas: The Case of Syrians and Palestinians. Traumatology, 26, 205-214. https://doi.org/10.1037/trm0000229
Kim, I., Keovisai, M., Kim, W., Richards-Desai, S., & Yalim, A. C. (2019). Trauma, Discrimination, and Psychological Distress across Vietnamese Refugees and Immigrants: A Life Course Perspective. Community Mental Health Journal, 55, 385-393. https://doi.org/10.1007/s10597-018-0268-2
Kira, I. (2001). Taxonomy of Trauma and Trauma Assessment. Traumatology, 7, 73-86. https://doi.org/10.1177/153476560100700202
Kira, I. (2002). Torture Assessment and Treatment: The Wraparound Approach. Traumatology, 8, 54-86. https://doi.org/10.1177/153476560200800203
Kira, I. (2004). Secondary Trauma in Treating Refugee Survivors of Torture and Their Families. Torture, 14, 38-44.
Kira, I. (2010). Etiology and Treatment of Post-Cumulative Traumatic Stress Disorders in Different Cultures. Traumatology, 16, 128-141. https://doi.org/10.1177/1534765610365914
Kira, I. (2017). A Critical Outlook at Torture Definition, Structure, Dynamics, and Interventions. Peace and Conflict: Journal of Peace Psychology, 23, 328-333. https://doi.org/10.1037/pac0000243
Kira, I. (2019). Toward an Integrative Theory of Self-Identity and Identity Stressors and Traumas and Its Mental Health Dynamics. Psychology, 10, 385-410. https://doi.org/10.4236/psych.2019.104027
Kira, I. (2020). Refugee Status and Identity Development. In S. Hupp, & J. Jewell (Eds.), The Encyclopedia of Child and Adolescent Development. Wiley. https://doi.org/10.1002/9781119171492.wecad467
Kira, I. (2021a). Taxonomy of Stressors and Traumas: An Update of The Development-Based Trauma Framework (DBTF): A life-Course perspective on Stress and Trauma. Traumatology. Advance Online Publication. https://doi.org/10.1037/trm0000305
Kira, I. (2121b). The Development-Based Taxonomy of Stressors and Traumas: An Initial Empirical Validation. Psychology, 12, 1575-1614.
Kira, I. A., & Shuwiekh, H. (2021). Discrimination and Mental Health of Christians in Egypt: Coping Trajectories and Perceived Posttraumatic Growth. Mental Health, Religion, and Culture, 24, 1-22. https://doi.org/10.1080/13674676.2020.1832454
Kira, I. A., Ibrahim, E. R., Shuwiekh, H., & Ashby, S. (2021b). Does Intersected Discrimination Underlie the Disproportionate Impact of COVID-19 Infection and Its Severity on Minorities? An Example from Jordan. Journal of Loss and Trauma: International Perspectives on Stress & Coping. https://doi.org/10.1080/15325024.2021.1992224
Kira, I., & Tummala-Narra, P. (2015). Psychotherapy with Refugees: Emerging Paradigm. Journal of Loss and Trauma, 20, 449-467. https://doi.org/10.1080/15325024.2014.949145
Kira, I., Abou_Mediene, S., Ashby, J., Lewandowski, L., Mohanesh, J., & Odenat, L. (2012c). Post-Traumatic Growth Inventory: Psychometric Properties of the Arabic Version in Palestinian Adults. The International Journal of Educational and Psychological Assessment, 11, 120-137.https://doi.org/10.1037/t60436-000
Kira, I., Abou-Mediene, S., Ashby, J., Odenat, L., Mohanesh, J., & Alamia, H. (2013a). The Dynamics of Post-Traumatic Growth across Different Trauma Types in a Palestinian Sample. Journal of Loss and Trauma, 18, 120-139. https://doi.org/10.1080/15325024.2012.679129
Kira, I., Ahmed, A., Wasim, F., Mahmoud, V., Colrain, J., & Rai, D. (2012a). Group Therapy for Refugees and Torture Survivors: Treatment Model Innovations. International Journal of Group Psychotherapy, 62, 69-88. https://doi.org/10.1521/ijgp.2012.62.1.69
Kira, I., Alawneh, A. N., Aboumediane, S., Mohanesh, J., Ozkan, B., & Alamia, H. (2011). Identity Salience and Its Dynamics in Palestinian Adolescents. Psychology, 2, 781-791. https://doi.org/10.4236/psych.2011.28120
Kira, I., Alpay, E., Shuwiekh, H., Ashby, J. S., Turkeli, A., & Alhuwailah (Paper Submitted for Publication). The Effects of COVID-19 on Torture Survivors’ Mental Health and Cognitive Functioning.
Kira, I., Amer, M. M., & Wrobel, N. H. (2014). Arab Refugees: Trauma, Resilience, and Recovery. In S. C. Nassar-McMillan, K. J. Ajrouch, & J. Hakim-Larson (Eds.), Biopsychosocial Approach to Arab Americans: Perspectives on Culture, Development, and Health (pp. 175-195). Springer. https://doi.org/10.1007/978-1-4614-8238-3_9
Kira, I., Ashby J. S., Lewandowski, L., Alawneh, A. N., Mohanesh, J., & Odenat, L. (2013b). Advances in Continuous Traumatic Stress Theory: Traumatogenic Dynamics and Consequences of Intergroup Conflict: The Palestinian Adolescents Case. Psychology, 4, 396-409. https://doi.org/10.4236/psych.2013.44057
Kira, I., Ashby, J. S., Odenat, L., & Lewandowsky, L. (2013c). The Mental Health Effects of Torture Trauma and Its Severity: A Replication and Extension. Psychology, 4, 472-482. https://doi.org/10.4236/psych.2013.45067
Kira, I., Ashby, J. S., Omidy, A. Z., & Lewandowski, L. (2015). Current, Continuous, and Cumulative Trauma-Focused Cognitive Behavior Therapy: A New Model for Trauma Counseling. Journal of Mental Health Counseling, 37, 323-340. https://doi.org/10.17744/mehc.37.4.04
Kira, I., Barger, B., Shuwiekh, H., Kucharska, J., & Al-Huwailah, A. (2020a). The Threshold Non-Linear Model for the Effects of Cumulative Stressors and Traumas: A Chained Cusp Catastrophe Analysis. Psychology, 11, 385-403. https://doi.org/10.4236/psych.2020.113025
Kira, I., Barger, B., Shuwiekh, H., Kucharska, J., & Al-Huwailah, A. H. (2019c). Cumulative Stressors and Traumas and Suicide: A Non-Linear Cusp Dynamic Systems Model. Psychology, 10, 1999-2018. https://doi.org/10.4236/psych.2019.1015128
Kira, I., Clifford, D., Wiencek, P., & Al-Haidar, A. (2001). Iraqi Refugees in Southeast Michigan: First Report. ACCESS Community Health and Research Center.
Kira, I., Fawzi, M., & Fawzi, M. (2013d). The Dynamics of Cumulative Trauma and Trauma Types in Adult Patients with Psychiatric Disorders: Two Cross-Cultural Studies. Traumatology, 19, 179-195. https://doi.org/10.1177/1534765612459892
Kira, I., Fawzi, M., Shuwiekh, H., Lewandowski, L., Ashby, J., & Al Ibraheem, B. (2021a). Do Adding Attachment, Oppression, Cumulative, and Proliferation Trauma Dynamics to PTSD Criterion “A” Improve Its Predictive Validity: Toward a Paradigm Shift? Current Psychology, 40, 2665-2679. https://doi.org/10.1007/s12144-019-00206-z
Kira, I., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2008). Measuring Cumulative Trauma Dose, Types, and Profiles Using a Development-Based Taxonomy of Traumas. Traumatology, 14, 62-87. https://doi.org/10.1177/1534765608319324
Kira, I., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B., & Mohanesh, J. (2010). The Effects of Perceived Discrimination and Backlash on Iraqi Refugees’ Physical and Mental Health. Journal of Muslim Mental Health, 5, 59-81. https://doi.org/10.1080/15564901003622110
Kira, I., Shuwiekh, H., Al Ibraheem, B., & Aljakoub, J. (2019b). Appraisals and Emotion Regulation Mediate the Effects of Identity Salience and Cumulative Stressors and Traumas, on PTG and Mental Health: The Case of Syrian’s IDPs and Refugees. Self and Identity: The Journal of the International Society for Self and Identity, 18, 284-305. https://doi.org/10.1080/15298868.2018.1451361
Kira, I., Shuwiekh, H., Al-Huwailah, A. H., Lewandowski, L., Alawneh, A.-W. N., Abou-Mediene, S., Al Ibraheem, B., & Aljakoub, J. (2019a). The Central Role of Social Identity in Oppression, Discrimination, and Social-Structural Violence: Collective Identity Stressors and Traumas, Their Dynamics and Mental Health Impact. Peace and Conflict: Journal of Peace Psychology, 25, 262-268. https://doi.org/10.1037/pac0000363
Kira, I., Shuwiekh, H., Al-Huwailah, A., Elwakeel, S., Waheep, N., Ebada, E., & Ibrahim, E. (2020b). The Direct and Indirect Impact of Trauma Types and Cumulative Stressors and Traumas on Executive Functions. Journal of Applied Neuropsychology: Adult. Advance Online First. https://doi.org/10.1080/23279095.2020.1848835
Kira, I., Shuwiekh, H., Kucharska, J., Fawzi, M., Ashby, J. S., Omidy, A. Z., Abou-Mediene, S., & Lewandowski, L. (2018). Trauma Proliferation and Stress Generation (TPSG) Dynamics and Their Implications for Clinical Science. American Journal of Orthopsychiatry, 88, 582-596. https://doi.org/10.1037/ort0000304
Kira, I., Shuwiekh, H., Rice, K., Al Ibraheem, B., & Aljakoub, J. (2017). A Threatened Identity: The Mental Health Status of Syrian Refugees in Egypt and Its Etiology. Identity: An International Journal of Theory and Research, 17, 176-190. https://doi.org/10.1080/15283488.2017.1340163
Kira, I., Templin, T., Lewandowski, L., Ashby, J. S., Oladele, A., & Odenat, L. (2012b). Cumulative Trauma Disorder Scale (CTD): Two Studies. Psychology, 3, 643-656. https://doi.org/10.4236/psych.2012.39099
Kira, I., Templin, T., Lewandowski, L., Clifford, D., Wiencek, E., Hammad, A., Mohanesh, J., & Al-Haidar, A.-M. (2006). The Effects of Torture: Two Community Studies. Peace and Conflict: Journal of Peace Psychology, 12, 205-228. https://doi.org/10.1207/s15327949pac1203_1
Kleim, B., & Ehlers, A. (2009). Evidence for a Curvilinear Relationship between Posttraumatic Growth and Posttrauma Depression and PTSD in Assault Survivors. Journal of Traumatic Stress, 22, 45-52. https://doi.org/10.1002/jts.20378
Mayr, S., Erdfelder, E., Buchner, A., & Faul, F. (2007). A Short Tutorial of G Power. Tutorials in Quantitative Methods for Psychology, 3, 51-59. https://doi.org/10.20982/tqmp.03.2.p051
McAdams, D. P., & Janis, L. (2004). Narrative Identity and Narrative Therapy. In L. E. Angus & J. McLeod (Eds.), The Handbook of Narrative and Psychotherapy: Practice, Theory, and Research (pp. 159-173). Sage Publications, Inc. https://doi.org/10.4135/9781412973496.d13
Moreno, A., & Grodin, M. A. (2002). Torture and Its Neurological Sequelae. Spinal Cord, 40, 213-223. https://doi.org/10.1038/sj.sc.3101284
Mossakowski, K. N. (2003). Coping with Perceived Discrimination: Does Ethnic Identity Protect Mental Health? Journal of Health and Social Behavior, 44, 318-331. https://doi.org/10.2307/1519782
Nicholson, B. L. (1997). The Influence of Pre-Emigration and Postemigration Stressors on Mental Health: A Study of Southeast Asian Refugees. Social Work Research, 21, 19-31. https://doi.org/10.1093/swr/21.1.19
Olsen, D. R., Montgomery, E., Bøjholm, S., & Foldspang, A. (2006). Prevalent Musculoskeletal Pain as a Correlate of Previous Exposure to Torture. Scandinavian Journal of Public Health, 34, 496-503. https://doi.org/10.1080/14034940600554677
Rathke, H., Poulsen, S., Carlsson, J., & Palic, S. (2020). PTSD with Secondary Psychotic Features among Trauma-Affected Refugees: The Role of Torture and Depression. Psychiatry Research, 287, Article ID: 112898. https://doi.org/10.1016/j.psychres.2020.112898
Rousseau, C., Gauthier, M. F., Lacroix, L., Alain, N., Benoit, M., Moran, A. et al. (2005). Playing with Identities and Transforming Shared Realities: Drama Therapy Workshops for Adolescent Immigrants and Refugees. The Arts in Psychotherapy, 32, 13-27. https://doi.org/10.1016/j.aip.2004.12.002
Shue, H. (1978). Torture. Philosophy and Public Affairs, 7, 124-143. http://www.jstor.org/stable/2264988.
Silove, D. (1999). The Psychosocial Effects of Torture, Mass Human Rights Violations, and Refugee Trauma: Toward an Integrated Conceptual Framework. Journal of Nervous and Mental Disease, 187, 200-207. https://doi.org/10.1097/00005053-199904000-00002
Smith, T. B., & Silva, L. (2011). Ethnic Identity and Personal Well-Being of People of Color: A Meta-Analysis. Journal of Counseling Psychology, 58, 42-60. https://doi.org/10.1037/a0021528
Song, S. J., Subica, A., Kaplan, C., Tol, W., & de Jong, J. (2018). Predicting the Mental Health and Functioning of Torture Survivors. The Journal of Nervous and Mental Disease, 206, 33-39. https://doi.org/10.1097/NMD.0000000000000678
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & Van Ommeren, M. (2009). Association of Torture and Other Potentially Traumatic Events with Mental Health Outcomes among Populations Exposed to Mass Conflict and Displacement: A Systematic Review and Meta-Analysis. JAMA, 302, 537-549. https://doi.org/10.1001/jama.2009.1132
Steel, Z., Silove, D., Bird, K., McGorry, P., & Mohan, P. (1999). Pathways from War Trauma to Posttraumatic Stress Symptoms among Tamil Asylum Seekers, Refugees, and Immigrants. Journal of Traumatic Stress, 12, 421-435. https://doi.org/10.1023/A:1024710902534
Stryker S. (1968). Identity Salience and Role Performance: The Relevance of Symbolic Interaction Theory for Family Research. Journal of Marriage and the Family, 30, 558-564. https://doi.org/10.2307/349494
Summerfield, D. (2003). Fighting “Terrorism” with Torture. British Medical Journal, 326, 773-774. https://doi.org/10.1136/bmj.326.7393.773
Tabachnick, B. G., & Fidell, L. S. (2013). Using Multivariate Statistics: International Edition. Pearson.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the Positive Legacy of Trauma. Journal of Traumatic Stress, 9, 455-471. https://doi.org/10.1002/jts.2490090305
Varvin, S., & Rosenbaum, B. (2003). Extreme Traumatization: Strategies for Mental Survival. International Forum of Psychoanalysis, 12, 5-16. https://doi.org/10.1080/08037060310005223
Weathers, F. W., Keane, T. M., & Davidson, J. R. (2001). Clinician-Administered PTSD Scale: A Review of the First Ten Years of Research. Depression and Anxiety, 13, 132-156. https://doi.org/10.1002/da.1029
World Health Organization (2018). International Classification of Diseases for Mortality and Morbidity Statistics (11th ed.). World Health Organization. https://icd.who.int/browse11/l-m/en
Zerach, G., Greene, T., Ginzburg, K., & Solomon, Z. (2014). The Relations between Posttraumatic Stress Disorder and Persistent Dissociation among Ex-Prisoners of War: A Longitudinal Study. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 99-108. https://doi.org/10.1037/a0031599