The Impact of Child Abuse and Dissociation on Psychiatric Comorbidity and Self-Concealment Among Prisoners in China

Abstract

Child abuse is a common experience among prisoners in China and associated with elevated psychiatric comorbidity. However, the association between child abuse profiles and dissociation is unclear. The extent to which the relationship between these profiles and dissociation might influence psychiatric comorbidity and self-concealment is also unclear. This study examined the impact of this relationship on the preceding outcomes among prisoners in China using Latent Class Analysis. Four hundred and ninety-six male prisoners from China completed questionnaires measuring child abuse, dissociation, self-concealment, and psychiatric comorbidity. A three-class solution was achieved: Class 1 (neglected with moderate dissociation) prisoners had a minimal level of abuse, the highest level of neglect experience, and a medium level of dissociation; Class 2 (low neglect with low dissociation) prisoners also had a minimal level of abuse but lower levels of neglect experience and dissociation; Class 3 (abused and neglected with high dissociation) prisoners had high levels of child abuse, neglect, and dissociation. Controlling for age, Class 3 reported significantly higher psychiatric comorbidity and self-concealment than the other two classes. Class 1 was more depressed than Class 2; Class 2 was more likely to engage in self-concealment than Class 1. To conclude, the kinds of childhood maltreatment experienced by prisoners and their readiness to detach from distressing emotions can influence the severity of current distress symptoms and the tendency to conceal things about themselves.

Keywords

child abuse dissociation self-concealment prisoners

Introduction

Child abuse is characterized by emotional or physical neglect (act of omission) and physical, emotional, or sexual abuse (act of commission) (Briere, 1992). It has been estimated that 77% of prisoners will have experienced at least one form of child abuse (Walsh et al., 2011, 2012). A higher percentage was found among Chinese prisoners, with almost 90%, reporting more than one form of child abuse (Wang et al., 2012). Among them, there is an issue that needs to be addressed: prisoners who were abused in the past and defend their distress using dissociation tend to elevate self-concealment tendency and psychological distress. The current study aimed to investigate this issue.

To articulate the rationale for such investigation, first, the link between child abuse profile and dissociation among Chinese prisoners is unclear (Dorahy et al., 2015). One study suggested that minimal maltreatment, low abuse and high neglect, high sexual abuse with multiple maltreatment, and high physical and emotional maltreatment were the child abuse profiles associated with psychiatric comorbidity among Chinese male prisoners (Zhang & Zheng, 2018). This study, however, differed substantially from ours in that they did not examine the relation between child abuse profiles and dissociation and the impact of profiles on self-concealment and psychiatric comorbidity. Instead, they focused on personality disorder symptoms and criminal behaviors as outcomes.

According to the self-trauma model (Briere, 1992), child abuse can affect victims’ cognitive schema resulting in distorted perceptions of the self, the world, and relationship with others. This traumatized schema is incompatible with existing schema causing psychological distress (Janoff-Bulman, 1992). The abuse experiences threaten the sense of self which then triggers dissociation as a natural defense mechanism (Briere, 1992; Hentschel et al., 2004; Schimmenti & Caretti, 2016; Thomson & Jaque, 2018). Several studies have highlighted the fact that dissociation has a unique and direct relationship with psychiatric comorbidity among prisoners who have been abused as a child (Coleman & Stewart, 2010; Moskowitz et al., 2005; Roe-Sepowitz, 2007; Salgado et al., 2007; Ternes et al., 2020; Zavattini et al., 2017). This link between child abuse and dissociation has been documented among the incarcerated (Dietrich, 2003) and nonprison samples (Bailey & Brand, 2017). These studies, however, focused on Western samples (e.g., women, college students, psychiatric patients) and linked child abuse types (e.g., emotional abuse or neglect, sexual abuse), as opposed to child abuse profiles, with dissociation (Dorahy et al., 2015; Haferkamp et al., 2015; Schalinski et al., 2016; Wright et al., 2009). Little is known about whether child abuse profiles and dissociation would coexist to influence psychiatric comorbidity among Chinese prisoners, which is the second knowledge gap.

This leads to the third knowledge gap: To what extent would a child abuse profile and dissociation influence self-concealment? Why would self-concealment be relevant to the current study? Returning to the self-trauma model (Briere, 1992; Briere & Runtz, 2002), simply put, child abuse can distort cognitions and alter self-capacities resulting in affect dysregulation, that is, restricted ability to regulate and control distressing emotions. Trauma Accommodation Syndrome complements this model by arguing that distorted cognition and maladaptive emotional functioning are natural consequences of persistent child abuse (Veltkamp et al., 1994). Among prisoners (K. A. Johnson & Lynch, 2013), the limiting effect of child abuse on ability to tolerate distress using adaptive emotional regulation has been demonstrated (Ehring et al., 2013; Weidner, 2017). On the contrary, self-concealment (keeping difficult memories hidden) as a maladaptive emotional regulation strategy would likely increase to protect oneself from the stigma associated with and the trauma (the abuse), or prevent others from being aware of other distressing personal information related to thoughts, feelings, actions (Larson & Chastain, 1990; Larson et al., 2015), personal inadequacy (Wismeijer, 2011), or childhood memories of threat (Murphy et al., 2012). There has been no investigation as to the extent of influence of the relationship between child abuse profile and dissociation on the level of self-concealment among Chinese prisoners. Addressing the aforementioned knowledge gaps is important since child abuse is a highly heterogeneous clinical phenomenon manifested in different ways through dissociation. Exploring these clinical manifestations will help gain better understanding of the underlying nature of prisoners’ psychological distress and coping strategies, inform etiological models and provide guidance for treatment (e.g., Contractor et al., 2018; Litz et al., 2018; Zhang & Zheng, 2018).

The current study aimed to examine the impact of coexisting profiles of child abuse and dissociation on psychiatric comorbidity and self-concealment among prisoners in China. In other words, whether specific abuses or dissociation would affect outcomes was not the main emphasis. Rather, our emphasis was on the impact of abuse–dissociation as a coexisting psychological construct on outcomes. Latent class analysis (LCA), a person-centered approach, would therefore be an appropriate method for this purpose because, based on their pattern of response on abuse and dissociation, it would reveal discrete subgroups (classes) of prisoners who have similar patterns of responses, and whether these subgroups would vary in the levels of psychiatric comorbidity and self-concealment. While homogeneity is found between individuals within each subgroup, heterogeneity is found between individuals in different subgroups (Lubke & Muthen, 2007). Further studies can be carried out to examine the prevalence, etiological factors, and the changeability of these classes over time (Petersen et al., 2019).

It was hypothesized that the severity of psychiatric comorbidity and self-concealment would be differentially associated with each class. Given that trauma responses would vary depending on maltreatment types: acts of omission (emotional or physical neglect) or commission (physical, emotional, or sexual abuse) (Briere, 2002), we hypothesized that prisoners with higher levels of neglect, abuse, and dissociation would display a greater severity of psychiatric comorbidity and self-concealment than those with lower levels of neglect, abuse, and dissociation. We also hypothesized that prisoners with alternate levels (higher or lower abuse, neglect, and dissociation) of maltreatment experience would display different severities of psychiatric comorbid symptoms and self-concealment. In this investigation, prisoners’ demographic variables would be controlled as “victim variables” have been shown to influence distress outcomes (Friedman et al., 2007; Vogt et al., 2007).

Method

Procedure

Upon agreement from the prison services in one metropolitan city in China, and using a convenience sampling method, the research team gained access to the four units in the prison. Using these inclusion criteria: (a) 18 years or above, (b) Chinese in ethnicity, and (c) literate, prisoners were selected and approached with an information sheet explaining the purpose of the research. They were informed that the data collected would be kept confidential and anonymous, stored in a computer with password protection. No names would be mentioned nor identity revealed in subsequent publications. They were entitled to withdraw from the study at any time, and given a couple of days to look through the questionnaires described in the “Measures” section before making a decision on participation. Upon agreement, they would sign the informed consent form and complete the questionnaires. All questionnaires had gone through the back translation procedure. For the current study, ethical approval was obtained from the Institute of Psychology at the Chinese Academy of Sciences. At the time of the study, there were 522 adult prisoners in the four units, all of whom were Chinese in ethnicity; 10 were illiterate. Five hundred and twelve questionnaires were then distributed to all prisoners meeting the selection criteria. All questionnaires were returned, 16 of which were removed due to the omission of questionnaires in entirety; 496 questionnaires were included in the study.

Measures

Demographic page

It collected information on age, ethnicity (1 = non-Chinese, 2 = Chinese), marital status (1 = single, 2 = married, 3 = divorced, 4 = widowed), education level (1 = illiterate, 2 = primary school, 3 = middle secondary school, 4 = senior secondary school, and 5 = university), type of conviction, length of sentence, length of sentence served, and the number of times incarcerated.

Childhood Trauma Questionnaire–Short Form (D. P. Bernstein et al., 2003) assesses abuse and neglect, with five subscales: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, on a 5-point Likert-type scale from “never true” (1) to “very often true” (5). Good internal consistency was reported with alpha reliabilities ranging from .70 to .93 and retest reliabilities ranging from .66 to .94. Based on the current sample, the Cronbach’s α for the total score was .85.

Dissociative Experience Scale (E. M. Bernstein & Putnam, 1986) measures the frequency of dissociative experiences by asking prisoners to indicate the percentage of time (described in 10% increments ranging from 0% to 100%) during which they experience each of the 28 scenarios. It has excellent convergent validity with other dissociation measures and predictive validity for dissociative disorders and traumatic experiences (Schimmenti et al., 2012). It has achieved a high internal consistency (α = .92). Based on the current sample, the Cronbach’s α was .95 for the total score.

The Self-Concealment Scale (Larson & Chastain, 1990) measures the tendency to keep things to oneself, and to possess distressing, secretive, or negative thoughts about oneself which have been shared with very few or no other people, and apprehension about the consequences of disclosing concealed information using the rating scale of 1 = strongly disagree to 5 = strongly agree. The scale has achieved the Cronbach’s α of .83 and r = .81 for test–retest reliability. Based on the current sample, the α was .86 for the total score.

The General Health Questionnaire-28 (Goldberg & Hillier, 1979) yields four subscales: somatic problems, anxiety, social dysfunction, and depression. The questions are scored using the rating scale of 1 (not at all) to 4 (much more than usual). Reliability coefficients ranged from .78 to .95 (Goldberg & Bridges, 1987). Based on the current sample, the reliability of the four subscales was excellent (Cronbach’s α = .93).

Data Analysis

Maximum Likelihood estimation with robust standard errors and the assumption of data missing completely at random (Akaike, 1987) were adopted to examine the best-fitting class solution using LCA. Little’s missing completely at random (MCAR) test confirmed that missing data were not predicted by identifiable pattern (χ² = 1,043.52, df = 1,253, ns). The model fit indicators which were used to ascertain the best-fitting class solution were as follows: lower values of Bayesian information criterion (BIC), the sample-sized adjusted Bayesian information criterion (SS-BIC), and the Akaike information criterion (AIC), the last significant Bootstrapped Likelihood Ratio Test (BLRT) p value, higher entropy values indicating the degree of classification accuracy and a better fit in comparison with successive latent class models (Collins et al., 1993), the fit indicators, theoretical relevance, the principle of parsimony (fewer number of classes are preferred), and interpretability of findings in relation to our hypotheses (Nylund et al., 2007). Less than 5% of the sample in any class solution should be rejected since it might be considered as overfitting the data (Dziak et al., 2014).

To carry out LCA using Latent GOLD 5.1, the indicators of child abuse were categorized into “never true to rarely true” (a low level) and “sometimes true to very often true” (a high level); the total dissociation score was categorized into three groups of percentage of time ranging from 0% to 20% (low), 30% to 50% (medium), and 60% and above (high). This categorization process was adopted from the literature (Gidzgier et al., 2019). To determine latent groups in the sample, LCA was carried out using a stepwise procedure. Models between one and six classes were examined which had a specific pattern of conditional probabilities. Multivariate analysis of variance (MANOVA) was then carried out to compare between classes in the levels of psychiatric comorbidity and self-concealment. Due to non-normality, the subscales of somatic problems, social dysfunction, and depression were subject to a logarithmic transformation. No outliers were detected during the exploration of diagnostics (Mahalanobis ≥3 SD). Following exploration and transformation, the assumptions of multivariate normality, linearity, and homoscedasticity were met. Regression imputation was used to address the missing data (Schafer & Graham, 2002).

Results

Four hundred and ninety-six male prisoners participated in the study. They were all Chinese in ethnicity with a mean age of 30.47 years (SD = 9.47); 60% were single and 34% married. Just over a quarter (27%) completed primary school education and a large majority (68%) secondary school; the rest were university graduates. A large proportion (68%) had been convicted for violent crime (e.g., murder, grievous bodily harm, sexual assault) and the rest (32%), nonviolent crime (e.g., fraud, corruption). The majority (86%) had been incarcerated for the first time. On average, they were serving a 6-year sentence (M = 5.92 in years, SD = 4.34). At the time of the study, they had served just over 1 year (M = 1.18, SD = 0.50). The reason for this close proximity in the time served was because the Prison Services incarcerate prisoners in groups. The current samples were selected from several of these groups which meant they began their imprisonment at more or less the same time.

The goodness-of-fit indicators for successive latent class models are shown in Table 1. The results from BIC, SS-BIC, and AIC showed that progressive improvement was evident in model fit with high entropy values until the fourth class. The gain for adding Class 4 was marginal and BLRT was not significant, although the number of samples in Class 4 was still above 5% which was the smallest acceptable group size. Given the fact that most criteria were met, we concluded that the three-class solution was optimal. Class 1 (31%; neglected with moderate dissociation) were prisoners who had a minimal level of abuse but the highest level of neglect experience, notably emotional neglect, and a medium level of dissociation. Class 2 (33%; low neglect with low dissociation) had a minimal level of abuse but lower levels of neglect experience and dissociation and Class 3 (36%; abused and neglected with high dissociation) with high levels of child abuse (except sexual abuse), neglect and the highest level of dissociation (see Figure 1).

Table 1.

Goodness-of-Fit Statistics for Class 1 to Class 6 Models.

Model Tested	Log Likelihood	BIC	SS-BIC	AIC	Entropy	BLRT
Class 1	−1,486.94	3,011.12	2,992.07	2,985.88	—	—
Class 2	−1,409.06	2,898.81	2,857.54	2,844.12	0.57	95.12*
Class 3	−1,382.98	2,890.10	2,826.62	2,805.97	0.56	42.97*
Class 4	−1,378.45	2,924.49	2,838.79	2,810.91	0.54	33.91
Class 5	−1,374.38	2,959.79	2,851.87	2,816.77	0.54	25.77
Class 6	−1,371.19	2,996.85	2,866.72	2,824.38	0.62	19.38

Note. BIC = Bayesian information criterion; SS-BIC = sample-size adjusted BIC; AIC = Akaike information criterion; BLRT = Bootstrapped Likelihood Ratio Test.

p < .001.

Figure 1.

Latent profiles of participants based on child abuse and dissociation responses.

Prisoners were then allocated to these classes by matching their categorized responses from the Childhood Trauma Questionnaire and Dissociative Experience Scale to the patterns of classes (e.g., Class 1 = the combination of low scores on physical, emotional, sexual abuse, high scores on emotional and physical neglect and medium score on dissociation). Descriptive statistics of latent class indicators can be found in Table 2. There were significant differences (p < .001) between groups in all indicators with Class 3 reporting significantly more abuses than the other two classes; Class 2 reported significantly less emotional and physical neglect than the other two classes. All three classes differed from each other in terms of dissociation.

Table 2.

Descriptive Statistics of Latent Class Indicators and Comparison Between Classes in Child Abuse, Dissociation, Psychiatric Comorbidity, and Self-Concealment.

Variable	Class 1(31%)		Class 2(33%)		Class 3(36%)		F	$η_{p}^{2}$
Variable	M	SD	M	SD	M	SD	F	$η_{p}^{2}$
Physical abuse	5.71	1.16	5.77	1.19	9.82	4.13	98.56*	.35
Emotional abuse	6.03	1.41	5.75	1.20	12.60	4.67	211.36*	.54
Sexual abuse	5.58	1.07	5.57	1.10	8.37	3.38	62.55*	.26
Emotional neglect	19.39	4.73	10.06	4.49	18.44	3.98	180.01*	.50
Physical neglect	12.54	1.57	7.50	2.19	13.72	2.51	321.35*	.64
Dissociation	648.10	458.75	422.16	219.53	1,206.66	303.94	89.40*	.33
Somatic problem	14.18	4.24	14.56	4.55	17.64	4.77	12.71*	.06
Anxiety	14.96	5.33	14.91	5.21	18.60	4.67	10.53*	.05
Social dysfunction	14.43	3.94	14.02	3.85	17.80	4.97	17.54*	.09
Depression	11.58	4.78	10.29	4.10	15.20	5.59	20.80*	.10
Self-concealment	23.82	8.69	25.79	8.28	31.40	8.11	14.03*	.07

Note. $η_{p}^{2}$ = eta-squared (effect size); Class 1 = neglected with moderate dissociation; Class 2 = low neglect with low dissociation; Class 3 = abused and neglected with high dissociation.

p < .001.

Prior to using MANOVA to compare classes in psychiatric comorbidity and self-concealment, correlation coefficients were carried out to determine whether demographic variables were related to outcome variables. If so, they would be treated as covariates in the analysis. Ethnicity and gender were not included because the current samples were all Chinese male prisoners. Marital status, education level, type of conviction, length of sentence, length of sentence served thus far, and number of incarcerations were then entered into correlation including point biserial correlation (r_pb) with the two outcomes. Bonferroni adjustment with the new α level of .004 was applied to reduce the likelihood for Type I error. The only significant correlation was between age and psychiatric comorbidity (r = .15, p < .001). MANOVA was therefore carried out to compare classes in levels of psychiatric comorbidity and self-concealment with age being adjusted. Significant differences between classes in all psychiatric comorbid symptoms and self-concealment were found. Pairwise comparisons showed that the abused and neglected with high dissociation group (Class 3) reported significantly (p < .001) higher than the other two classes in the preceding outcomes. Comparing Classes 1 and 2, there were no significant differences in psychiatric comorbid symptoms except depression (p < .05) with Class 1 being more depressed than Class 2. Classes 1 and 2 also differed in self-concealment (p < .05) with Class 2 having a stronger tendency to keep secret than Class 1 (see Table 2).

Discussion

The present study examined the impact of child abuse profiles and dissociation on psychiatric comorbidity and self-concealment among prisoners in China. The hypothesis supported that levels of psychiatric comorbidity and self-concealment were differentially associated with different levels of abuse, neglect, and dissociation. A three-class solution was achieved. Class 1 (neglected with moderate dissociation) were prisoners who had a minimal level of abuse but highest level of neglect experience and a medium level of dissociation; Class 2 (low neglect with low dissociation) also reported a minimal level of abuse and lower levels of neglect experience and dissociation; Class 3 (abused and neglected with high dissociation) reported high levels of child abuse (except sexual abuse), neglect, and dissociation. Class 3 prisoners reported significantly more distress symptoms and a stronger tendency to keep secret than the other two neglect groups. Class 1 prisoners (who experienced the higher level of neglect and displayed a medium degree of dissociation) tended to be more depressed than Class 2 (who experienced lower levels of neglect and dissociation). On the contrary, the latter had a stronger tendency to conceal difficult memories.

Sexual abuse did not play a major role in their abusive experience, contradicting literature on sexual abuse being an important abuse associated with psychiatric comorbidity among prisoners (Huang et al., 2008; Zhang & Zheng, 2018). Looking at item-response probabilities, 80%–98% across three classes reported low scores on items measuring sexual abuse. Sexual abuse was correlated with depression (r = .12, p < .05) whereas physical abuse and emotional neglect were correlated (r values ranged from .13 to .28) with all psychiatric comorbid symptoms and self-concealment. This contradicted literature arguing that child sexual abuse was a strong preprison disposition to psychiatric “caseness” (Bowler et al., 2018) or that it was a predictor, on a par with physical and emotional abuse, and physical neglect, to psychiatric symptoms (Angelakis et al., 2020).

Male prisoners tend to report a lower prevalence of sexual abuse (10%) than emotional abuse (25%) and physical abuse (25%) (Caravaca Sanchez et al., 2019). Also, there is a regional disparity in the severity of child abuse in China (Di et al., 2018). Since the present prisoners came from different regions, this could have affected the severities of different child abuse types. Furthermore, the prevalence of sexual abuse could have been affected by how it was conceptualized and measured and the population type (e.g., the general population or prisoners) (Gopalan, 2018) and by cultural differences in attitude toward and value placed on children (Gelles & Cornell, 1983).

Focusing on Class 3 prisoners who reported high scores on items measuring physical and emotional abuse (item-response probabilities: 29%–55%), emotional neglect (44%–55%), physical neglect (30%–65%), and dissociation (60%–92%), they tended to report elevated severities in psychiatric symptoms and concealment. Abuse and neglect of the physical and emotional kind could have affected prisoners’ affective experience (Briere, 1992) leading to elevated psychiatric comorbidity and reduced capacity to regulate and process distressing emotions. These results might have reflected the well-established dose–response model suggesting that victims’ severity of distress varied with the magnitude of the trauma (high levels of physical and emotional abuse) (Dohrenwend & Dohrenwend, 1974). Seemingly, this dose–effect also affected their tendency to maintain privacy and concealed information about oneself.

To interpret the preceding results from another perspective, Chinese prisoners who have a Class 3 abuse profile can display personality disorder traits (Zhang & Zheng, 2018). Some essential features of these personality disorder traits are concerned with interpersonal relationship difficulties, emotional instability, social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation from others. Seemingly, these features corresponded to the characteristics of Class 3 prisoners who were emotionally unstable (elevated psychiatric comorbidity), concealed information about themselves to deal with the fear of personal inadequacy, personal criticism, or others’ negative evaluation. In other words, these findings might have in fact reflected possible personality disorder traits embedded within them. However, one needs to be cautious with this interpretation since no data on personality disorders have been collected in this study.

Turning to the findings on the other two Classes (1 and 2), neglect seemed to play a bigger role than abuse which corresponded to one study identifying 91% of Chinese prisoners as victims of physical neglect (Wang et al., 2012). Consistent with the literature, neglect has been linked with dissociation and depression (Kong et al., 2018; Kulacaoglu et al., 2017; Schalinski et al., 2016; Vogel et al., 2009). Adverse childhood experience of which neglect was part, was associated with depersonalization, a facet of dissociation (Thomson & Jaque, 2018); emotional neglect was associated with somatoform dissociation (Kilic et al., 2014). The link between neglect and dissociation was thought to be stronger than that with abuse (Terock et al., 2016). One study even claimed that abuse was unrelated to dissociation, while its link with physical neglect was clear (Vogel et al., 2009).

For these Class 1 and 2 prisoners, the way in which neglect interacted with dissociation affected outcomes differently. The prisoners (Class 1) who reported high scores on neglect, especially emotional neglect (item-response probabilities: 85%–96%), and medium scores on dissociation (15%–47%) displayed heightened specific symptoms, namely depression rather than other psychiatric symptoms. This provided further support to neglect (e.g., emotional neglect) being associated with internalized negative emotionality such as depressive symptoms (Dorahy et al., 2016; Ogden & Hagen, 2014). Depression is an inward problem directed toward the self with a tendency to over-control emotion (Ogden & Hagen, 2014). Prisoners with neglect experiences might have developed a feeling of helplessness in gaining control over the meeting of their basic psychological, emotional, and physical needs. This might have contributed to depression which they tried to control or inhibit through detaching the sense of self or discontinuing the normal integration of consciousness, that is, dissociation.

On the contrary, the prisoners (Class 2) who had experienced lower levels of neglect (item-response probabilities: 65%–92%) and dissociation (70%–98%) tended to report a high level of self-concealment. Low levels of neglect and dissociation could mean limited disruption on affective experience, ability to regulate or process distressing emotions, as well as limited emotional inhibition tendency, and endorsement of unconscious avoidant strategies. As a result, they might engage readily in a cognitive process whereby they endorsed conscious coping strategies, as opposed to unconscious defenses, to cope with distress by concealing distressing information about their own experience. In other words, an elevated tendency for self-concealment resulted from the combined low level of child maltreatment experienced, limited endorsement of unconscious defense for buffering against subjective distress but increased engagement in a conscious coping process of adaptation which allows the person to plan, and work intentionally toward the attainment of their goals, that is, hide information on oneself. Depending on the levels of abuse and neglect that they experienced in the past and the subsequent level of dissociation, these prisoners could have engaged in two different processes, either conscious or unconscious, to protect themselves.

Clinical implications from the current findings are noteworthy. First, a mental health screening program focusing on past trauma including childhood trauma and the level of dissociation needs to be implemented among prisoners. Second, the results of this screening should set the basis for designing a psychological intervention which has been highlighted as an important clinical service for prisoners (Khodayarifard et al., 2008). This intervention should aim to address the traumatic impact of child abuse and empower prisoners to confront and process abuse-related emotions. This should then impact psychiatric comorbid symptom severity. Third, this intervention program should also aim to empower prisoners to engage in self-disclosure which has been shown to be beneficial for physical and mental well-being among people of different ages, genders and cultures (Pennebaker, 2000). This intervention program is paramount because it can help prisoners to improve communication, relationships, build a social support network (J. E. Johnson et al., 2019), improve insight to oneself and others, develop adjustment skills (Khodayarifard et al., 2008), adaptive coping strategies, and enhance posttraumatic growth (Vanhooren et al., 2018). This in turn could improve maladjusted behavior and the rate of recidivism after release from prison (Huffman, 2013).

Limitations of the study need to be acknowledged. First, the fact that all prisoners in the current study were male, recruited using a convenience sampling method, casts doubt onto the generalizability of the findings. Abuse types, physical or sexual, could vary among prisoners depending on gender (Roxburgh & MacArthur, 2014). Male prisoners tend to report a lower rate of sexual abuse than female prisoners (Briere et al., 2016). Also, women and men prisoners differ in psychological reactions, symptom presentation, and mental health needs (Tyler et al., 2019). Second, no information was collected on whether Chinese cultural characteristics might have influenced the prevalence of trauma types, psychological symptom presentation, and coping behavior (Jayawickreme et al., 2013) in this study. Ethnic diversity has been shown to influence the relationship between self-concealment, psychiatric symptoms (Mendoza et al., 2018), and help-seeking behaviors (Heath et al., 2016). Third, this study was cross-sectional in nature which meant that comments on causality could not be made due to the lack of temporal precedence (Cole & Maxwell, 2003). A longitudinal study would have been needed for interpreting causality. Thus, the findings of the study should only be interpreted in terms of understanding the structural relationship of the latent models as opposed to causality inference (Holland, 1986).

To conclude, the traumatic effect of child abuse on Chinese male prisoners cannot be underestimated. They engage in dissociation as a form of defense against distressing feelings or emotions. This coexisting relationship between child abuse experiences and dissociation constitute a psychological response which can affect prisoners’ general psychological symptoms and tendency to conceal trauma memories or information on oneself. Intervention programs for these prisoners should address unresolved issues pertaining to past abuse, reduce dissociation as a defense strategy but empower self-disclosure.

Footnotes

Authors’ Note

Zhuo Sheng Chen is now affiliated with China university of Political Science and Law, Beijing, China.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Man Cheung Chung

Author Biographies

Man Cheung Chung earned his BA in psychology and sociology (University of Guelph, Canada), PhD in psychology (University of Sheffield, UK) and PhD in philosophy (University of Durham, UK). He is associate fellow of the British Psychological Society. He is also a chartered scientist and psychologist. He is currently professor of psychology at the Chinese University of Hong Kong.

Zhuo Sheng Chen earned his MSc in psychology (the Institute of Psychology, Chinese Academy of Sciences), and PhD in criminal psychology (China University of Political Science and Law). He is associate fellow of the Professional Committee of Legal Psychology, Chinese Psychological Association.

References

Akaike

(1987). Factor analysis and AIC. Psychometrika, 52(3), 317–332.

Angelakis

Austin

J. L.

Gooding

(2020). Childhood maltreatment and suicide attempts in prisoners: A systematic meta-analytic review. Psychological Medicine, 50(1), 1–10.

Bailey

T. D.

Brand

B. L.

(2017). Traumatic dissociation: Theory, research, and treatment. Clinical Psychology: Science and Practice, 24(2), 170–185.

Bernstein

D. P.

Stein

J. A.

Newcomb

M. D.

Walker

Pogge

Ahluvalia

… Zule

(2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect, 27, 169–190.

Bernstein

E. M.

Putnam

F. W.

(1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174(12), 727–735.

Bowler

Phillips

Rees

(2018). The association between imported factors and prisoners’ mental health: Implications for adaptation and intervention. International Journal of Law and Psychiatry, 57, 61–66.

Briere

(1992). Child abuse trauma: Theory and treatment of the lasting effects. Sage.

Briere

(2002). Treating adult survivors of severe childhood abuse and neglect: Future development of an integrative model. In Myers

L. B. J. F. B.

Briere

(Eds.), The APSAC handbook on child maltreatment (pp. 175–204). Sage.

Briere

Agee

Dietrich

(2016). Cumulative trauma and current posttraumatic stress disorder status in general population and inmate samples. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 439–446.

10.

Briere

Runtz

(2002). The Inventory of Altered Self-Capacities (IASC): A standardized measure of identity, affect regulation, and relationship disturbance. Assessment, 9, 230–239.

11.

Caravaca Sanchez

Ignatyev

Mundt

A. P

. (2019). Associations between childhood abuse, mental health problems, and suicide risk among male prison populations in Spain. Criminal Behaviour and Mental Health, 29, 18–30.

12.

Cole

D. A.

Maxwell

S. E.

(2003). Testing mediational models with longitudinal data: Questions and tips in the use of structural equation modeling. Journal of Abnormal Psychology, 112(4), 558–577. https://doi.org/10.1037/0021-843X.112.4.558

13.

Coleman

Stewart

L. M.

(2010). Prevalence and impact of childhood maltreatment in incarcerated youth. American Journal of Orthopsychiatry, 80(3), 343–349.

14.

Collins

L. M.

Fidler

P. L.

Wugalter

S. E.

Long

J. D.

(1993). Goodness-of-fit testing for latent class models. Multivariate Behavioral Research, 28(3), 375–389.

15.

Contractor

A. A.

Caldas

Fletcher

Shea

Armour

(2018). Empirically derived lifespan polytraumatization typologies: A systematic review. Journal of Clinical Psychology, 74(7), 1137–1159.

16.

Yongjie

Guowei

(2018). The severity, consequences and risk factors of child abuse in China: An empirical study of 5836 children in China’s mid-western regions. Children and Youth Services Review, 95, 290–299.

17.

Dietrich

(2003). Characteristics of child maltreatment, psychological dissociation, and somatoform dissociation of Canadian inmates. Journal of Trauma & Dissociation, 4(1), 81–100.

18.

Dohrenwend

(1974). Stressful life events: Their nature and effects. John Wiley.

19.

Dorahy

M. J.

Middleton

Seager

McGurrin

Williams

Chambers

(2015). Dissociation, shame, complex PTSD, child maltreatment and intimate relationship self-concept in dissociative disorder, chronic PTSD and mixed psychiatric groups. Journal of Affective Disorders, 172, 195–203.

20.

Dorahy

M. J.

Middleton

Seager

Williams

Chambers

(2016). Child abuse and neglect in complex dissociative disorder, abuse-related chronic PTSD, and mixed psychiatric samples. Journal of Trauma & Dissociation, 17(2), 223–236.

21.

Dziak

J. J.

Lanza

S. T.

Tan

(2014). Effect size, statistical power, and sample size requirements for the bootstrap likelihood ratio test in latent class analysis. Structural Equation Modeling, 21(4), 534–552.

22.

Ehring

Kleim

Ehlers

(2013). Cognition and emotion in posttraumatic stress disorder. In Robinson

M. D.

Watkins

E. R.

Harmon-Jones

(Eds.), Handbook of cognition and emotion (pp. 401–420). Guilford Press.

23.

Friedman

Keane

Resick

(Eds.). (2007). Handbook of PTSD: Science and practice. Guilford Press.

24.

Gelles

R. J.

Cornell

C. P.

(1983). International perspectives on child abuse. Child Abuse & Neglect, 7(4), 375–386.

25.

Gidzgier

Grundmann

Lotzin

Hiller

Schneider

Driessen

…Schafer

(2019). The dissociative subtype of PTSD in women with substance use disorders: Exploring symptom and exposure profiles. Journal of Substance Abuse Treatment, 99, 73–79.

26.

Goldberg

Bridges

K. W.

(1987). Screening for psychiatric illness in general practice: The general practitioner versus the screening questionnaire. Journal of the Royal College of General Practitioners, 37, 15–18.

27.

Goldberg

Hillier

(1979). A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139–145.

28.

Gopalan

R. T.

(2018). Influence of concept, definitions, assessments methods, and sources of data on prevalence of sexual abuse. In Gopalan

R. T.

(Ed.), Social, psychological, and forensic perspectives on sexual abuse (pp. 1–12). Information Science Reference/IGI Global.

29.

Haferkamp

Bebermeier

Mollering

Neuner

(2015). Dissociation is associated with emotional maltreatment in a sample of traumatized women with a history of child abuse. Journal of Trauma & Dissociation, 16(1), 86–99.

30.

Heath

P. J.

Vogel

D. L.

Al-Darmaki

F. R.

(2016). Help-seeking attitudes of United Arab Emirates students: Examining loss of face, stigma, and self-disclosure. The Counseling Psychologist, 44(3), 331–352.

31.

Hentschel

Smith

Draguns

J. G.

Ehlers

(2004). Defense mechanisms: Theoretical, research and clinical perspectives. Elsevier.

32.

Holland

(1986). Statistics and causal inference (with discussion). Journal of the American Statistical Association, 81, 945–970.

33.

Huang

Zhang

Momartin

Huang

Zhao

(2008). Child sexual abuse, coping strategies and lifetime posttraumatic stress disorder among female inmates. International Journal of Prisoner Health, 4(1), 54–63.

34.

Huffman

E. G.

(2013). The therapeutic relationship, prison, and responsivity. In Helfgott

J. B.

(Ed.), Theory and research: Vol. 1. Typologies, mental disorders, and profiles: Vol. 2. Implications for forensic assessment, policing, and the courts: Vol. 3. Implications for juvenile justice, corrections, and reentry: Vol. 4. Criminal psychology (pp. 175–207). Praeger.

35.

Janoff-Bulman

(1992). Shattered assumptions: Towards a new psychology of trauma. Free Press.

36.

Jayawickreme

Foa

E. B.

(2013). Using the individualism-collectivism construct to understand cultural differences in PTSD. In Gow

K. M.

Celinski

M. J.

(Eds.), Mass trauma: Impact and recovery issues (pp. 55–76). Nova Science Publishers.

37.

Johnson

J. E.

Stout

R. L.

Miller

T. R.

Zlotnick

Cerbo

L. A.

Andrade

J. T.

… Wiltsey-Stirman

(2019). Randomized cost-effectiveness trial of group interpersonal psychotherapy (IPT) for prisoners with major depression. Journal of Consulting and Clinical Psychology, 87(4), 392–406.

38.

Johnson

K. A.

Lynch

S. M.

(2013). Predictors of maladaptive coping in incarcerated women who are survivors of childhood sexual abuse. Journal of Family Violence, 28(1), 43–52.

39.

Khodayarifard

Pritz

Khodayarifard

(2008). The impact of group and individual cognitive-behavioral intervention on the mental health state of male prisoners. International Journal of Psychotherapy, 12(2), 50–66.

40.

Kilic

Sar

Taycan

Aksoy-Poyraz

Erol

T. C.

Tecer

… Ozmen

(2014). Dissociative depression among women with fibromyalgia or rheumatoid arthritis. Journal of Trauma & Dissociation, 15(3), 285–302.

41.

Kong

S. S.

Kang

D. R.

M. J.

Kim

N. H.

(2018). Attachment insecurity as a mediator of the relationship between childhood trauma and adult dissociation. Journal of Trauma & Dissociation, 19(2), 214–231.

42.

Kulacaoglu

Solmaz

Ardic

F. C.

Akin

Kose

(2017). The relationship between childhood traumas, dissociation, and impulsivity in patients with borderline personality disorder comorbid with ADHD. Psychiatry and Clinical Psychopharmacology, 27(4), 393–402.

43.

Larson

D. G.

Chastain

R. L.

(1990). Self-concealment: Conceptualization, measurement, and health implications. Journal of Social and Clinical Psychology, 9(4), 439–455.

44.

Larson

D. G.

Chastain

R. L.

Hoyt

W. T.

Ayzenberg

(2015). Self-concealment: Integrative review and working model. Journal of Social and Clinical Psychology, 34(8), 705–774.

45.

Litz

B. T.

Contractor

A. A.

Rhodes

Dondanville

K. A.

Jordan

A. H.

Resick

P. A.

… Peterson

A. L.

(2018). Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 31(2), 286–295.

46.

Lubke

Muthen

B. O.

(2007). Performance of factor mixture models as a function of model size, covariate effects, and class-specific parameters. Structural Equation Modeling, 14(1), 26–47.

47.

Mendoza

Tully

E. C.

Goodnight

Gray

Masuda

(2018). The indirect effect of self-concealment on distress through psychological inflexibility in Asian American, Black American, and White American college students. Personality and Individual Differences, 126, 93–98.

48.

Moskowitz

A. K.

Barker-Collo

Ellson

(2005). Replication of dissociation-psychosis link in New Zealand students and inmates. Journal of Nervous and Mental Disease, 193(11), 722–727.

49.

Murphy

Shevlin

Adamson

Cruddas

Houston

(2012). Memories of childhood threat, fear of disclosure and paranoid ideation: A mediation analysis using a nonclinical sample. Journal of Aggression, Maltreatment & Trauma, 21(4), 459–476.

50.

Nylund

K. L.

Asparouhov

Muthen

B. O.

(2007). Deciding on the number of classes in latent class analysis and growth mixture modeling: A Monte Carlo simulation study. Structural Equation Modeling, 14(4), 535–569.

51.

Ogden

Hagen

K. A.

(2014). Adolescent mental health: Prevention and intervention. Routledge/Taylor & Francis.

52.

Pennebaker

J. W.

(2000). The effects of traumatic disclosure on physical and mental health: The values of writing and talking about upsetting events. In Violanti

J. M.

Paton

Dunning

(Eds.), Posttraumatic stress intervention: Challenges, issues, and perspectives (pp. 97–114). Charles C. Thomas Publisher.

53.

Petersen

Qualter

Humphrey

(2019). The application of latent class analysis for investigating population child mental health: A systematic review. Frontiers in Psychology, 10, Article 1214.

54.

Roe-Sepowitz

(2007). Characteristics and predictors of self-mutilation: A study of incarcerated women. Criminal Behaviour and Mental Health, 17(5), 312–321.

55.

Roxburgh

MacArthur

K. R.

(2014). Childhood adversity and adult depression among the incarcerated: Differential exposure and vulnerability by race/ethnicity and gender. Child Abuse & Neglect, 38(8), 1409–1420.

56.

Salgado

D. M.

Quinlan

K. J.

Zlotnick

(2007). The relationship of lifetime polysubstance dependence to trauma exposure, symptomatology, and psychosocial functioning in incarcerated women with comorbid PTSD and substance use disorder. Journal of Trauma & Dissociation, 8(2), 9–26.

57.

Schafer

J. L.

Graham

J. W.

(2002). Missing data: Our view of the state of the art. Psychological Methods, 7, 147–177.

58.

Schalinski

Teicher

M. H.

Nischk

Hinderer

Muller

Rockstroh

(2016). Type and timing of adverse childhood experiences differentially affect severity of PTSD, dissociative and depressive symptoms in adult inpatients. BMC Psychiatry, 16, Article 295.

59.

Schimmenti

Caretti

(2016). Linking the overwhelming with the unbearable: Developmental trauma, dissociation, and the disconnected self. Psychoanalytic Psychology, 33(1), 106–128.

60.

Schimmenti

Guglielmucci

Barbasio

Granieri

(2012). Attachment disorganization and dissociation in virtual worlds: A study on problematic Internet use among players of online role playing games. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 9(5), 195–202.

61.

Ternes

Cooper

B. S.

Griesel

(2020). The perpetration of violence and the experience of trauma: Exploring predictors of PTSD symptoms in male violent offenders. The International Journal of Forensic Mental Health, 19, 63–83.

62.

Terock

Van der Auwera

Janowitz

Spitzer

Barnow

Miertsch

… Grabe

H.-J.

(2016). From childhood trauma to adult dissociation: The role of PTSD and alexithymia. Psychopathology, 49(5), 374–382.

63.

Thomson

Jaque

(2018). Depersonalization, adversity, emotionality, and coping with stressful situations. Journal of Trauma & Dissociation, 19(2), 143–161.

64.

Tyler

Miles

H. L.

Karadag

Rogers

(2019). An updated picture of the mental health needs of male and female prisoners in the UK: Prevalence, comorbidity, and gender differences. Social Psychiatry and Psychiatric Epidemiology: The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services, 54, 1143–1152.

65.

Vanhooren

Leijssen

Dezutter

(2018). Coping strategies and posttraumatic growth in prison. The Prison Journal, 98(2), 123–142.

66.

Veltkamp

L. J.

Miller

T. W.

Silman

(1994). Adult non-survivors: The failure to cope of victims of child abuse. Child Psychiatry and Human Development, 24(4), 231–243.

67.

Vogel

Spitzer

Kuwert

Moller

Freyberger

H. J.

Grabe

H. J.

(2009). Association of childhood neglect with adult dissociation in schizophrenic inpatients. Psychopathology, 42(2), 124–130.

68.

Vogt

King

(2007). Risk pathways in PTSD: Making sense of the literature. In Friedman

Kean

Resick

(Eds.), Handbook of PTSD: Science and practice (pp. 99–116). Guildford Press.

69.

Walsh

DiLillo

Scalora

M. J.

(2011). The cumulative impact of sexual revictimization on emotion regulation difficulties: An examination of female inmates. Violence Against Women, 17(8), 1103–1118.

70.

Walsh

Gonsalves

V. M.

Scalora

M. J.

King

Hardyman

P. L.

(2012). Child maltreatment histories among female inmates reporting inmate on inmate sexual victimization in prison: The mediating role of emotion dysregulation. Journal of Interpersonal Violence, 27(3), 492–512.

71.

Wang

Cao

Qian

Shook

A. L.

(2012). Child maltreatment in an incarcerated sample in China: Prediction for crime types in adulthood. Children and Youth Services Review, 34(8), 1553–1559.

72.

Weidner

(2017). Stress and violence. In Wadhwa

(Ed.), Stress in the modern world: Understanding science and society (Vol. 2, pp. 431–439).Greenwood Press/ABC-CLIO.

73.

Wismeijer

A. A.

(2011). Self-concealers: Do they conceal what we always assumed they do?Personality and Individual Differences, 51(8), 1039–1043.

74.

Wright

M. O. D.

Crawford

Del Castillo

(2009). Childhood emotional maltreatment and later psychological distress among college students: The mediating role of maladaptive schemas. Child Abuse & Neglect, 33(1), 59–68.

75.

Zavattini

G. C.

Garofalo

Velotti

Tommasi

Romanelli

Santo

H. E.

… Saggino

(2017). Dissociative experiences and psychopathology among inmates in Italian and Portuguese prisons. International Journal of Offender Therapy and Comparative Criminology, 61(9), 975–992.

76.

Zhang

Zheng

(2018). Childhood maltreatment profiles among incarcerated Chinese males and their associations with personality disorder symptoms and criminal behaviors. Psychiatry Research, 268, 272–278.