Surviving Child Abuse in People With Mental Illness: A Grounded Theory Approach

Abstract

The aim of this qualitative study was to examine the process of surviving child abuse in people with a mental illness in order to develop an explanatory theory. The study utilized the grounded theory approach. Seventeen community-dwelling adults with a mental illness who had experienced child abuse were interviewed. For the in-depth interview, the lifeline interview method was used. Data were collected from July 14, 2019, to February 28, 2020. The constant comparative method was used for analysis, to identify similarities and differences between different statements, and similar phenomena or theories were compared and analyzed continuously. The central phenomena were “losing oneself” and “in a precarious state.” Participants used “expressing,” “standing on one’s own feet,” and “avoiding” as coping strategies. Observed outcomes were “making life work for them” and “living with others.” The core category was “losing myself, embracing myself as someone in a precarious state, and being reborn as the master of my life.” Positive religious coping, having a supportive network, and emotional or physical distance from difficult situations played a major role in surviving participants’ experiences of child abuse and being victimized because of their mental illness. Our findings provide a theoretical basis for understanding people with mental illness who have survived child abuse, and suggest that opportunities for sharing their stories, facilitating self-reliance, and avoiding the causes of their difficulties all play a role in their healing process. Based on this study, it is expected that clinical experts and policy developers will be able to formulate evidence-based interventions and policies.

Keywords

nursing child abuse grounded theory mental illness recovery victim

In the United States, the Child Abuse Prevention and Treatment Act defines child abuse as a situation where the safety of a child under the age of 18 is jeopardized due to actual or threatened physical, mental, or sexual harm by a caregiver. The prevalence of child abuse is steadily increasing worldwide (Children’s Bureau, 2018). Since the enactment of the Child Abuse Prevention and Treatment Act in 1974, the United States has the world’s most stringent child abuse prevention and response system. Despite this, the number victims of children who abused and neglected increased from 676,000 in 2016 to 678,000 in 2018, indicating a 3% increase (Children’s Bureau, 2018).

In East Asian countries, including Korea, child abuse is a very serious problem. According to a systematic literature review study examining homicide of children by family members, it was found that it occurs more frequently in East Asia and the Pacific region (61.7%) than in the United States (27.6%) and European countries (16.7%; Stöckl et al., 2017). Until recently, the issue of child abuse was considered a “family problem” or “something that happens sometimes (or may happen)” in line with the Confucian tradition (Park, 2016). It is only now that it is considered a controversial and important topic in the Korean society. Additionally, it was difficult to expect appropriate and timely responses due to “the ambiguous boundary between abuse and discipline” (Park, 2016).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), child abuse is classified as a type of trauma. As it occurs during a sensitive developmental period, the aftereffects of abuse may persist for a long time. Additionally, because child abuse mainly occurs at home, it is difficult to detect it in a timely manner (Jackson et al., 2017). In severe cases, the aftereffects may result in mental health problems, further complicating victims’ lives (Barnum & Perrone-McGovern, 2017). A previous study with 129 participants with mental illness found that 76.7% had experienced child abuse (Rossiter et al., 2015). Another study found that people with psychosis were 2.72–2.99 times more likely to be exposed to child abuse than those without any mental illness (Varese et al., 2012).

Abused children are more likely to experience cognitive impairment and developmental delays (Lean et al., 2018). Additionally, abuse has the potential to cause anatomical changes in the brain, which can lead to impaired functioning among the victims (Lim et al., 2018; Janiri et al., 2017; Teicher et al., 2016). In other words, when the victims of child abuse also have mental health problems and dysfunction, they may struggle to develop adaptive coping mechanisms (Arslan, 2017). Therefore, survivors of child abuse with a mental illness may be more likely to continue experiencing the impact of the abuse throughout their lives and may, therefore, face more difficulties than those without a mental illness. The aim of the study was to develop an explanatory theory for this process by exploring the survival process of victims of child abuse who have a mental illness.

Background

According to previous studies, victims of child abuse—be it physical, sexual, or emotional abuse or physical and emotional neglect—are known to suffer from posttraumatic stress disorder, depression, anxiety, and substance abuse during adulthood (Elliott et al., 2016; Robinson et al., 2021). Furthermore, experiencing any kind of child abuse may affect the severity of mental health problems (Rossiter et al., 2015). A clear difference in the severity of positive symptoms (e.g., hallucination, delusion) has been reported in child abuse victims with a mental illness compared to those who have never experienced child abuse (Berg et al., 2015).

In addition, the mental health of victims who are continuously exposed to abuse is particularly threatened (Steine et al., 2017). It has been confirmed that victims of abuse are more likely to be diagnosed with mental disorders, including schizophrenia and mood disorders (Curran et al., 2016; Kelly et al., 2016; Papalia et al., 2017). Severe positive symptoms are likely to be accompanied by anxiety, depression, and substance abuse, which can ultimately reduce the functioning of people with mental illness (Cotter et al., 2014). In fact, the results of a study, which used the SCL-90-R (Symptom Checklist-90-Revision), demonstrated that those who have mental illness and have experienced child abuse had more somatization symptoms, obsessive compulsions, interpersonal sensitivity, paranoid thinking, and psychosis, compared to those who have not experienced child abuse (Rossiter et al., 2015).

Previous studies that examined both mental illness and the impact of child abuse were quantitative, focusing mainly on the relationships among child abuse (physical, sexual, and domestic violence), psychosocial development, and mental health problems in people with mental illness (O’Hare et al., 2015; Woods-Jaeger et al., 2019). Their results have systematically demonstrated the close relationship between child abuse and mental health problems; however, these studies have failed to provide an in-depth analysis of people with mental illness who have directly experienced child abuse or provide an in-depth discussion of how child abuse and its effects have been dealt with by this population. Although some qualitative studies have described how poly-victimized survivors who have experienced abuse within several institution types have dealt with its effects (Sheridan & Carr, 2020), it is difficult to determine how people with mental illness perceived and survived their experience of child abuse. Therefore, the purpose of the present study was to closely examine the process through which people with a mental illness survive child abuse. To this end, we utilized the grounded theory approach (Strauss & Corbin, 1998)—which is philosophically based on symbolic reciprocity—to analyze the process of how people with mental illness who have survived child abuse and to develop a substantive, explanatory theory for this process.

Methods

Design

In this study, the grounded theory method was used to analyze and understand the survival process in detail and in-depth, considering that the behavior of individuals in society including the family is a phenomenon that is structured in interaction with others.

Sample/Participants

Participants of this study had been diagnosed with a mental illness and had suffered from child abuse; however, they were currently recovering and working as human rights activists for community-dwelling people who have mental illness. All participants were receiving psychiatric treatment, including antipsychotic medication, and therefore, did not show any active phase symptoms. All the participants were Koreans living in Seoul, whose mother tongue was Korean; therefore, all the research procedures were conducted in Korean. Theoretical sampling was used to reveal the purpose of the study (Strauss & Corbin, 1998), and the participants were recruited until theoretical saturation was achieved (Glaser & Strauss, 1967). Snowball sampling was used in combination with theoretical sampling to recruit participants. Qualitative research targeting people who have mental illness can increase the reliability of data by interviewing people who have recovered from a mental illness (Weir et al., 2019). Recovery is described as a deeply personal and unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles (Anthony, 1993). Additionally, recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness (Anthony, 1993). Therefore, we approached a human rights group to recruit people with mental illness and a rehabilitation facility for people with a mental illness. We explained the purpose of the study to the employees of the human rights group and the facility head and asked them to introduce the study to those who met the selection criteria. Potential participants were requested to contact the researcher. During the interviews with the 14^th to 17^th participants, the development process and the results of the process analysis were reconfirmed to formalize the theory. The general characteristics of the 17 participants are provided in Table 1. Nine participants were women, and the participants’ ages ranged from 20 to 64 years. Additionally, the age at which the participants were diagnosed ranged from 13 to 44 years. The types of child abuse were diverse: 1 was subjected to emotional abuse, 7 were subjected to physical and emotional abuse, 6 were subjected to physical and emotional abuse and neglect, 1 was subjected to emotional abuse and neglect, 2 were subjected to physical, emotional, and sexual abuse and neglect. Moreover, the psychiatric diagnoses were also diverse—most were diagnosed with schizophrenia (n = 10) or bipolar disorder (n = 6), and only one was diagnosed with recurrent depressive disorder.

Table 1.

General Characteristics of Participants.

No.	Age	Gender	Child abuse perpetrator	Types of child abuse	Age diagnosed	Psychiatric diagnosis
1	34	M	Parents	Physical, emotional	20	Bipolar disorder
2	64	M	Parents	Physical, emotional, neglect	34	Schizophrenia spectrum disorder
3	48	F	Parents	Physical, emotional, neglect	44	Bipolar disorder
4	33	M	Parents, teacher	Physical, emotional, neglect	23	Bipolar disorder
5	53	M	Parents	Emotional	25	Schizophrenia spectrum disorder
6	20	F	Parents, grandparents	Physical, emotional, neglect	17	Schizophrenia spectrum disorder
7	34	M	Parents	Physical, emotional	22	Recurrent depressive disorder
8	39	F	Parents, teacher	Physical, emotional, neglect	29	Bipolar disorder
9	40	M	Parents	Physical, emotional	20	Schizophrenia spectrum disorder
10	47	F	Parents	Physical, emotional	22	Bipolar disorder
11	49	F	Mother, teacher	Emotional, neglect	27	Schizophrenia spectrum disorder
12	32	M	Father	Physical, emotional	22	Schizophrenia spectrum disorder
13	40	F	Parents, neighbor	Physical, emotional, sexual, neglect	30	Bipolar disorder
14	43	M	Father, teacher	Physical, emotional	18	Schizophrenia spectrum disorder
15	23	F	Parent	Physical, emotional	13	Schizophrenia spectrum disorder
16	29	F	Parent	Physical, emotional, neglect	19	Schizophrenia spectrum disorder
17	54	F	Parent	Physical, emotional, sexual, neglect	20	Schizophrenia spectrum disorder

Data Collection

Data were collected from July 14, 2019, to February 28, 2020. Each face-to-face interview lasted approximately 1–2 hours, and an additional interview was conducted over the phone to address additional questions that arose during the analysis process. In-depth interviews were conducted using the lifeline interview method (Gramling & Carr, 2004). The lifeline spanned from birth to expected age of death. The expected age of death was directly assigned by the participant, and all the participants were assigned an age in the distant future. The first author, a mental health nurse, conducted the interview. During the interview, it was important to ensure that participants did not experience re-traumatization and were not seriously harmed. Therefore, the participants were treated carefully and respectfully. We focused on the experience of being a victim of child abuse and the participants’ responses regarding the process of surviving, rather than asking specific details about the abuse that they had experienced, per Friedman’s (2018) recommendation.

Ethical Considerations

This study was approved by the Institutional Review Board at XXX University [No. 1041078-201905-HRSB-181-01]. The researcher explained the study to potential participants, obtained a signed informed consent form for participation in the study, and then conducted the interview. We explained that the interview would be recorded, and this was also stated in the informed consent form.

Data Analysis

The interview data were analyzed using Strauss and Corbin’s (1998) grounded theory approach. Data were collected and analyzed simultaneously. The constant comparative method was used to identify similarities and differences between statements, and similar phenomena or theories were continuously compared and analyzed. Data were organized into concepts, which were then classified into categories, and ultimately incorporated into the theory. Following which, to identify the analysis’ results, we revisited and rechecked the data.

Data were collected from people with a mental illness to extract concepts related to their recovery from child abuse and the course of their lives thereafter. We repeatedly read the transcriptions of the recorded data to immerse ourselves in the content. Major concepts were underlined and summarized upon discovery; line-by-line analysis was conducted, and open coding was used to extract important statements related to the research study. Reiterative concept change, addition, deletion, and integration occurred along with repeated reading, categorization, and annotation of data. Ambiguous content or content requiring additional clarifications were clarified by consulting the participants.

Through this process, participants’ basic psychosocial problems were identified, and axial coding was performed with concepts related to the identified problem. In the axial coding process, the data were reassembled according to relationships between categories. Through the paradigm-based analysis, categories were integrated into a grounded theory paradigm consisting of causal conditions, contextual conditions, phenomena, intervention situations, actions/interactions, and outcomes (Strauss & Corbin, 1998). Subsequently, selective coding was performed based only on concepts related to the core category in the axial coding (Strauss & Corbin, 1998).

Rigor

To ensure validity, we applied Lincoln and Guba’s (1985) evaluation criteria. First, we attempted to increase reliability by describing and interpreting the phenomena vividly and faithfully. Efforts were made to maintain a comfortable context for data collection so that factual data could be obtained through the in-depth interviews. In addition, the first researcher volunteered at a rehabilitation facility for people with mental illness for 1 year to gain a deeper understanding of their real-life experiences. Prior to conducting the study, the researchers met with seven mental health experts who provide care for people with mental illness to learn more about the problems this population faces. Second, suitability was ensured by inviting participants to review the generated theory so that the theory accurately explained what happened, interpreted what is actually happening, and predicted what will happen. Third, to secure objectivity in the analysis results, we compared and reviewed the research results in consultation with five qualitative research experts who have utilized grounded theory in their research. We also made efforts to increase the likelihood of audits through several revisions and supplements so that highly valid research results could be drawn. In addition, the entire research team attempted to maintain an objective attitude by reflecting on their thoughts or prejudices arising from their personal experiences recorded in a written research journal. Relevance was achieved as the core problems and processes emerged naturally from the data, rather than from prejudice or logical reasoning. Finally, the reliability of the developed theory was further improved by creating a testable theory that could be modified with subsequent research or analysis.

Results and Findings

Core Category

Figure 1 illustrates the paradigm model resulting from the axial coding of the qualitative data from the interviews. Regarding the recovery of people with mental illness who have experienced child abuse, “losing myself, embracing myself as someone in a precarious state, and being reborn as the master of my life” was derived as the core category based on the participants’ descriptions. The explanation of each stage of the paradigm is described below. Examples of participants’ statements that are indicative of the themes are provided in parentheses.

Figure 1.

A paradigm model for surviving child abuse by people with mental illness.

Causal Conditions

Abused

The participants were survivors of abuse by their family members, which began when they were children and continued into adulthood. After they were diagnosed with a mental illness, their psychiatric symptoms were neglected due to insufficient attention and care, which worsened their symptoms. They felt that they were ignored and excluded due to the prejudice and stigma associated with having a mental illness. In addition, the abuse that began in the family led to people in their social circle abusing them as well. Within society, including school and work environments, they experienced abuse by persons outside the family. (“Smiling, my father said to my mother, ‘A stick is a medicine for a crazy bitch. Should I hit you with a stick?’ He said that.”)

Repressed

Participants reported experiencing flashbacks of repressed memories. Participants who experienced continuous abuse from others re-lived past abuse through nightmares and psychiatric symptoms. They trembled in fear of being scolded and were trapped by the memory of abuse. (“In the past, my mother hit me a lot if I did not do well on a test. I worked hard in college; however, whenever I was taking a test, I had auditory hallucinations of myself, as a child, crying. As a result, I submitted my exam paper blank and was placed under academic probation.”)

Difficulty

The participants had poor interpersonal relationships due to trust issues, insufficient interpersonal experience, repeated hospitalizations and discharges, or symptoms and adverse drug reactions. They also experienced economic difficulties. (“I slept for about 11 hours. I had a hard time because of the side effects of the drugs. The drugs did not work. One day, I fell asleep at 5 o’clock and got up at 7 o’clock the following day. I could not work.”)

Contextual Conditions

Completely Alone

The participants did not receive help from others for their difficulties. Some resorted to religion; however, when they began having symptoms related to religion, religious activities had to be stopped. (“When I was going through a difficult period, the only thing I could rely on was prayer, however, my symptoms were constantly overlapping [religious delusion], therefore, I intentionally stopped attending church.”)

Tamed

Most participants were taught by their parents not to tell others about family affairs, and therefore, they did not share their experience of child abuse in fear of damaging their relationships with others. Participants accepted the abuse, influenced by their parents’ attitude to blame the victim or to justify the abuse through pessimism about their role as the perpetrator. Some participants received care in difficult situations, either voluntarily or involuntarily, during childhood. However, those instances were in vain. Participants experienced more suffering or frustration as they faced distorted perceptions from society and people around them who sided with the perpetrator or attributed the abuse to the victim. Eventually, they were tamed by the perpetrator and felt timid. (“Because my opinions have never been accepted. To be able to express one’s opinion, there should be an experience of being accepted. That is why I thought I did not have any adults who would listen to my difficulties.”)

Central Phenomena

Losing Oneself

The participants, influenced by their parents’ attitude of blaming the victim, developed a negative perception of themselves. They attributed the cause of abuse to themselves, and the diagnosis of a mental disorder further strengthened their perception that there was a problem with them. They gradually descended into helplessness without seeking treatment, thinking that there was nothing they could do on their own to overcome their difficulties. (“It caused a significant amount of self-abuse and decline in self-esteem. I was unable to respect myself. I was a state where I treated myself like garbage.”)

In a Precarious State

As participants’ needs and lives were often relegated in favor of the needs of those who had power over them and considering the constant devaluation of their existence throughout their lives, they felt guilty even for experiencing basic human needs. Some participants adopted maladaptive behaviors, such as expressing their anger to those they regarded as weak, as they learned it from their parents and perpetrators, and thus, became perpetrators themselves. Gradually, they experienced extreme stress, sleep disturbances, and difficulty controlling their emotions, ultimately leading to them to attempt suicide at some point. (“Since I did not expect to die soon, I tried to commit suicide.”)

Intervening Conditions

Foothold

The participants agreed that the presence of supportive people and experts played a major role in surviving child abuse and mental illness. They also benefited from some governmental policies. Their process of surviving was also greatly influenced by spiritual factors (e.g., God) and human beings. (“With the help of my friends, who also have mental disorders, learned that I could register as a disabled person at the hospital, due to which I received a permanent rental apartment and benefits; therefore, I have the strength to recover because issues related to food, clothing, and shelter were resolved.”)

Momentum

As the participants grew up, they became physically stronger than their parents. In addition, by actively treating or studying the illness, they became more aware and knowledgeable about their condition. As they had new and diverse experiences, they moved away from their original way of thinking. (“I posted on the Internet saying, ‘I was bullied because I deserved to be bullied.’ There were more than 20 dislikes for that article. Therefore, I think that I realized then that it was not my fault that I had been abused or bullied.”)

Action/Interaction Strategy

Expressing

The participants voluntarily confessed their difficulties to others, hoping to resolve them and improve their lives. They attempted to express their thoughts and feelings even if their approach was not smooth or effective. (“While my father was drinking, I said to him, ‘I was diagnosed with psychosis because I was under stress because of what you did before, and it hurt me so much, and I am still having a hard time even though I continue to take my medication.’” “I slammed the door shut with an angry face.”)

Standing on One’s Own Feet

The participants attempted to become independent through various efforts, such as managing economic activities as adults, managing their illness, and studying on their own. (“I got a job at an insurance company to earn tuition. Because of this, I think I was able to recover by gaining confidence.”)

Avoiding

Many of the participants spent time reading books or playing games to escape from their suffering and the difficulties they faced. In addition, they utilized methods such as listening to music and walking to reduce the severity of symptoms when they appeared, or when they were stressed. They avoided painful or difficult situations by keeping the perpetrator as far away as possible or selectively interacting with them (“I escaped and left the house.”). Avoidance is accurately defined as being both maladaptive and adaptive depending on the situation. In this case, avoidance appears to be adaptive (e.g., setting boundaries).

Consequences

Making Life Work for Them

Most participants thought that the wounds caused by abuse and mental disorders remained as scars, and thus, they would not be able to completely escape from past trauma. However, they were comforted by the gradual fading of their scars; they were trying to lead their lives in spite of the effects of the trauma. Some participants reflected on their violence in the past and tried not to repeat their violent behaviors. Others set their goals and tried to progress and find employment. (“To minister is my dream. To do that, I plan to collect tuition and return to school.”)

Living With Others

At the time of the study, most of the participants were engaged in socially meaningful activities, such as helping people with a mental illness or adolescents in need. In addition, unlike in the past, they gradually learned to communicate their intentions and get along with others. (“I am doing volunteer work. There is a nursery school in my neighborhood, and there are friends who take general educational development [classes], so I teach them English-related subjects.”)

Discussion

The central phenomena in the process of people with a mental illness surviving child abuse that were identified in this study are “losing oneself” and “in a precarious state.” These central phenomena were triggered by the causal conditions of being “abused,” “repressed,” and experiencing “difficulty” in living their life. This finding is in line with the results of Abajobir et al.’s (2017) study, which reported that people with mental illness who have experienced child abuse by their families were more likely to continue experiencing abuse from their families into adulthood. In addition, it was reported that victims of child abuse re-lived their past trauma as a symptom of posttraumatic stress disorder, such as recalling memories of the abuse in an environment similar to the situation where the abuse occurred, or in their dreams (Hilt & Nussbaum, 2015).

“Completely alone” and “tamed” were contextual factors of the degree of the central phenomena of “losing oneself” and “in a precarious state.” People with a mental illness have difficulty interacting with others due to environmental difficulties such as limited social relationships and social prejudice whenever they return to the community after being discharged from the hospital (Burns-Lynch et al., 2016). In particular, in Korea, since people with a mental illness have traditionally been regarded as people who need to be accommodated for the maintenance of public order rather than people who require treatment, it is difficult to find a place for them to turn to (Shin, 2017). With an added history of child abuse, they are more likely to experience interpersonal problems because they have trust issues, owing to the insecure attachments formed during childhood (Gumley et al., 2014).

Many participants relied on religious practices such as praying or reading the Bible. However, when psychiatric symptoms were related to religion, they could not use these strategies. Religious coping helps people with a mental illness to improve resilience and self-efficacy, which are essential for coping with life’s difficulties (Grover et al., 2014). However, a recent study found that when abuse is related to harsh religious practices, religion may negatively affect posttraumatic growth (Sheridan & Carr, 2020). People with a mental illness report both negative and positive types of religious coping (Oxhandler et al., 2018), emphasizing that religious coping does not always have psychological benefits.

In Korea, parents often play a major role in their children’s lives because people rely on their parents even into adulthood (Lee et al., 2020). Until recently, parents physically punishing their children was a legally recognized method of discipline in Korea (Cho, 2020). This aspect of the Korean culture tends to foster an atmosphere where children who are victims of abuse feel ashamed and hide their trauma (Cho, 2020). Therefore, it can be inferred that the participants experienced difficulties due to society’s distorted perceptions, were tamed, and became victims of long-term abuse.

In our study, participants achieved the conditions for surviving child abuse through having a “foothold,” a mediating situation. This is consistent with previous studies that have consistently shown that interpersonal relationships improve when a person who has experienced a traumatic event perceives a sense of bonding, belonging, care, and love from others, and that social resources can increase an individual’s ability to cope with traumatic events (Mohr & Rosén, 2017; Sheridan & Carr, 2020). In addition, in a study that analyzed the effects of mental health literacy, stigma, and social support on psychological help-seeking, social support was reported to have a positive effect on help-seeking in people suffering from mental health problems (Jung et al., 2017), supporting the results of the current study.

The participants actively used coping through “momentum,” which was another mediating situation that made them change their existing mindset and behavior. This is in line with previous studies’ results, that cognitive changes in victims of child abuse play a key role in alleviating emotional pain in adulthood (Hartley et al., 2016; Sheridan & Carr, 2020), particularly in those with a mental illness. When a victim recognizes that the abuser is to blame for the abuse, rather than themselves or the situation, or when the perpetrator admits to their fault, it helps the victim’s posttraumatic growth (Sheridan & Carr, 2020).

In particular, cognitive changes play an important role in people with a mental illness. When they experience self-stigma and have a distorted victim perception to themselves, they experience a “Why try” phenomenon that makes them feel meaningless and empty. In other words, they find it difficult to achieve their personal goals or think it is not worth attempting (Corrigan et al., 2016). The participants were hesitant to reveal the fact that they believed that they were abused because of their problems and that mental disorders are shameful. However, it seems that they were able to survive by realizing that their beliefs are wrong.

The participants used “expressing,” “standing on one’s own feet,” and “avoiding” as strategies to resolve “losing oneself” and “in a precarious state.” In dealing with the abuse, a response that involves revealing the extent of the damage to the outside world, is considered positive as it enables them to receive help (Morrison et al., 2018). In addition, coping that involves understanding the problematic situation and actively addressing it is considered a form of problem-focused coping, an adaptive coping strategy (Lazarus & Folkman, 1984). Thus, “expressing” and “standing on one’s own feet” can be considered as problem-focused coping, whereas “avoiding” can be considered as a maladaptive coping strategy.

“Standing on one’s own feet” signifies an attempt to lead an independent life. A study on the posttraumatic growth experience of child abuse survivors concluded that when they are in an environment in which their needs related to food, safety, love, and self-esteem are met, it fosters self-actualization (Sheridan & Carr, 2020). However, the higher the self-stigma and self-reliance of a person suffering from mental health problems, the less likely they would be to seek psychological help due to the belief that they must overcome their problems on their own (Jennings et al., 2015). Thus, self-stigma may inhibit self-actualization and the ability to take steps toward gaining a sense of independence; while self-reliance may be adaptive, it can also be a barrier to receiving help to enable independent living.

The participants reported that emotionally or physically distancing oneself from difficult situations was effective in their recovery, which contradicts the view that “avoiding” is maladaptive. Indeed, some studies have shown that physical distancing or limiting interactions with parents was helpful for recovery from mental illness (Loos et al., 2017; Reupert et al., 2015). According to the results of a Korean study on the experiences of youth who were discharged from a shelter (Kim et al., 2017), those who had experienced serious child abuse wanted to sever their relationships with their parents. However, these individuals experienced some difficulties with self-reliance after discharge.

With regard to “making life work for them” and “living with others,” most participants were living a selfless life, spending their time on activities in the services of others. In a previous study, child abuse survivors were engaged in activities to help others with similar vulnerabilities, which was interpreted as behavior resulting from the alienation and exclusion that they experienced as the child abuse survivors (Sheridan & Carr, 2020). Furthermore, Greenberg et al. (2018) found that adults who experienced childhood adversity were more empathetic than those who did not.

Our findings have direct relevance for practice for individuals with a mental illness and a history of child abuse. Professionals (e.g., nurses, doctors, psychologists, social workers, and police officers) can receive education on religious and spiritual issues so they can assist people in using their religion or spirituality as a positive coping mechanism. They may also help in countering the person’s distorted beliefs about their abuse and mental illness due to self-stigmatization. Professionals should do their best to act as helpers, advocates, and mediators so that people with mental illness can talk about their condition without feeling guilt or shame (Waller et al., 2019). Individuals can be educated to help them recognize that psychological counseling is a way to become stronger and be able to better solve their problems themselves, rather than solely relying on others or social and community resources. This will enable them to feel empowered, to “stand on their own feet.” Last, in the case of separation from the parent due to abuse, avoidance of the family may actually be an adaptive coping mechanism. As such, each person’s relationship with their family and their reasons for reconnecting or continued disconnection needs to be carefully evaluated to assist them so that they can be independent in a healthy manner.

Limitations

There are limitations to qualitative research that should be considered. The main disadvantage is the findings cannot be extended to a wider population. In the present study, the participants were activists diagnosed with schizophrenia spectrum, bipolar, or depressive disorder. Only a few participants experienced sexual abuse. Thus, despite the reasonably large sample for a qualitative study, it was impossible to make generalizations about child abuse survivors with a mental illness. Future studies should consider a combination of quantitative and qualitative methods to explore the survival process of child abuse survivors with a mental illness. In addition, due to the distribution of illness, ages (20s to 60s), and various types of abuse among the participants it was difficult to proceed to the typifying process and hypothetical formalization. In a follow-up study, differences between the participants’ mental disorders, generational, and types of abuse can be subdivided to rectify this.

Implications

Despite these limitations, this study has clinical and social significance. The greatest significance of this study is that it developed a theory that can enhance the understanding of how those with a mental illness survived child abuse. In addition, it is meaningful since the developed theory can contribute to the continued development of nursing theory by verifying the theoretical model through a quantitative research methodology and refining the theory further. The results of this study will help educate victims, experts, and their families about the survival process of child abuse survivors with a mental illness, and thereby, increase their understanding of it. In clinical practice, it was found that there may be difficulties in applying the existing recovery model which emphasizes the support of the family for the recovery of child abuse survivors with a mental illness.

In addition, it was confirmed that the prejudice and stigma surrounding mental illness, disease management, and functional decline play an important role in the survival process of child abuse survivors with a mental illness. Therefore, the results of this study are meaningful because it can be used as data for the development of evidence-based, qualitative, and individual interventions to help victims of child abuse with a mental illness. Furthermore, the results of this study can be used as basic data to highlight the social responsibility toward victims of abuse who have a mental illness and to suggest the need for education and publicity to change perception about them in society. In addition, it can be used as basic data by policymakers to develop policies that address their needs and problems.

Conclusion

The present study involved the initial inquiry for developing a theory that can enhance the understanding of the process of those with a mental illness surviving child abuse. The theoretical model can be verified through quantitative research, and it can be further refined through continuous development. Furthermore, the results of this study increase the understanding and interest of experts, activists, and students in the field of interpersonal violence regarding how victims of child abuse with a mental illness survived, which will consequently be useful for the development of evidence-based treatments. Finally, the current results highlight the necessity for education and awareness regarding the social needs of those with a mental illness who have survived abuse. Our findings can serve as a basis for understanding the importance of collaboration between public health and welfare agencies and can be used by policy managers to establish a foundation for appropriate policy interventions.

Footnotes

Author contributions

JM conceived of the study, participated in its design and coordination, and drafted the manuscript, conducted the interview, performed the analysis and interpretation of the data; YJ participated in the design of the study, performed the analysis and interpretation of the data. All authors read and approved the final manuscript.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Research Fund from the Dong-A University (PI: HA). The funding sources had no role in the study design, data collection and analysis, interpretation of the data, writing the manuscript or the decision to submit the manuscript for publication.

ORCID iD

Yoonjung Kim

Author Biographies

Jeongmin Ha, PhD. Her research focuses on the recovery of mental disorders related to interpersonal violence. She is particularly interested in developing appropriate interventions based on understanding the position of the people with mental illness as victims of interpersonal violence.

Yoonjung Kim, PhD, is a Professor in the Faculty of Red Cross College of Nursing, Chung-Ang University. She earned her Ph.D. in Nursing from Chung-Ang University in Korea. She has worked at hospitals and the University. She focuses on qualitative research and analysis of national data and seeks ways to promote health. She has also conducted a number of studies on mental health and quality of life in children and adults. She is particularly interested in developing appropriate interventions based on understanding the children.

References

Abajobir

A. A.

Kisely

Williams

G. M.

Clavarino

A. M.

Najman

J. M.

(2017). Substantiated childhood maltreatment and intimate partner violence victimization in young adulthood: A birth cohort study. Journal of Youth and Adolescence, 46(1), 165–179. https://doi.org/10.1007/s10964-016-0558-3

American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596

Anthony

W. A.

(1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23. https://doi.org/10.1037/h0095655

Arslan

(2017). Psychological abuse, coping strategies, and mental health problems: A brief and effective measure of psychological maltreatment in adolescents. Child Abuse & Neglect, 68, 96–106. https://doi.org/10.1016/j.chiabu.2017.03.023

Barnum

E. L.

Perrone-McGovern

K. M.

(2017). Attachment, self-esteem and subjective well-being among survivors of childhood sexual trauma. Journal of Mental Health Counseling, 39(1), 39–55. https://doi.org/10.17744/mehc.39.1.04

Berg

A. O.

Aas

Larsson

Nerhus

Hauff

Andreassen

O. A.

Melle

(2015). Childhood trauma mediates the association between ethnic minority status and more severe hallucinations in psychotic disorder. Psychological Medicine, 45(1), 133–142. https://doi.org/10.1017/S0033291714001135

Burns-Lynch

Brusilovskiy

Salzer

M. S.

(2016). An empirical study of the relationship between community participation, recovery, and quality of life of individuals with serious mental illnesses. The Israel Journal of Psychiatry and Related Sciences, 53(1), 46–55.

Children’s Bureau . (2018). Child maltreatment 2016. administration on children, youth and families, administration for children and families. U.S. Department of Health and Human Services. https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2016.pdf

Cho

(2020). Victim silencing, sexual violence culture, social healing: Inherited collective trauma of World War II South Korean military “comfort women” (Undergraduate research poster, Virginia Commonwealth University). https://scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=1305&context=uresposters

10.

Corrigan

P. W.

Bink

A. B.

Schmidt

Jones

Rüsch

(2016). What is the impact of self-stigma? Loss of self-respect and the “why try” effect. Journal of Mental Health, 25(1), 10–15. https://doi.org/10.3109/09638237.2015.1021902

11.

Cotter

Drake

R. J.

Bucci

Firth

Edge

Yung

A. R.

(2014). What drives poor functioning in the at-risk mental state? A systematic review. Schizophrenia Research, 159(2–3), 267–277. https://doi.org/10.1016/j.schres.2014.09.012

12.

Curran

Adamson

Stringer

Rosato

Leavey

(2016). Severity of mental illness as a result of multiple childhood adversities: US National Epidemiologic Survey. Social Psychiatry and Psychiatric Epidemiology, 51(5), 647–657. https://doi.org/10.1007/s00127-016-1198-3

13.

Elliott

J. C.

Stohl

Wall

M. M.

Keyes

K. M.

Skodol

A. E.

Eaton Shmulewitz

Goodwin

R. D.

Grant

B. F.

Hasin

D. S.

(2016). Childhood maltreatment, personality disorders and 3‐year persistence of adult alcohol and nicotine dependence in a national sample. Addiction, 111(5), 913–923. https://doi.org/10.1111/add.13292

14.

Friedman

J. M.

(2018). A grounded theory investigation of adaptations to adverse childhood experiences. (Doctoral dissertation, Nova Southeastern University). NSUWorks.

15.

Glaser

Strauss

(1967). The discovery of grounded theory: Strategies for qualitative research. Aldine Transaction. http://www.sxf.uevora.pt/wp-content/uploads/2013/03/Glaser_1967.pdf

16.

Gramling

L. F.

Carr

R. L.

(2004). Lifelines: A life history methodology. Nursing Research, 53(3), 207–210. https://doi.org/10.1097/00006199-200405000-00008

17.

Greenberg

D. M.

Baron-Cohen

Rosenberg

Fonagy

Rentfrow

P. J.

(2018). Elevated empathy in adults following childhood trauma. PLoS One, 13(10), Article e0203886. https://doi.org/10.1371/journal.pone.0203886

18.

Grover

Davuluri

Chakrabarti

(2014). Religion, spirituality, and schizophrenia: A review. Indian Journal of Psychological Medicine, 36(2), 119–124. https://doi.org/10.4103/0253-7176.130962

19.

Gumley

A. I.

Taylor

H. E. F.

Schwannauer

MacBeth

(2014). A systematic review of attachment and psychosis: Measurement, construct validity and outcomes. Acta Psychiatrica Scandinavica, 129(4), 257–274. https://doi.org/10.1111/acps.12172

20.

Hartley

Johnco

Hofmeyr

Berry

(2016). The nature of posttraumatic growth in adult survivors of child sexual abuse. Journal of Child Sexual Abuse, 25(2), 201–220. https://doi.org/10.1080/10538712.2015.1119773

21.

Hilt

R. J.

Nussbaum

A. M.

(2015). DSM-5® Pocket guide for child and adolescent mental health. American Psychiatric Association.

22.

Jackson

Huffhines

Stone

K. J.

Fleming

Gabrielli

(2017). Coping styles in youth exposed to abuse: Longitudinal patterns reported by youth in foster care. Child Abuse & Neglect, 70, 65–74. https://doi.org/10.1016/j.chiabu.2017.05.00

23.

Janiri

Sani

Rossi

P. D.

Piras

Iorio

Banaj

Giuseppin

Spinazzola

Maggiora

Ambrosi

Simonetti

Spalletta

(2017). Amygdala and hippocampus volumes are differently affected by childhood trauma in patients with bipolar disorders and healthy controls. Bipolar Disorders, 19(5), 353–362. https://doi.org/10.1111/bdi.12516

24.

Jennings

K. S.

Cheung

J. H.

Britt

T. W.

Goguen

K. N.

Jeffirs

S. M.

Peasley

A. L.

Lee

A. C.

(2015). How are perceived stigma, self-stigma, and self-reliance related to treatment-seeking? A three-path model. Psychiatric Rehabilitation Journal, 38(2), 109–116. https://doi.org/10.1037/prj0000138

25.

Jung

von Sternberg

Davis

(2017). The impact of mental health literacy, stigma, and social support on attitudes toward mental health help-seeking. International Journal of Mental Health Promotion, 19(5), 252–267. https://doi.org/10.1080/14623730.2017.1345687

26.

Kelly

D. L.

Rowland

L. M.

Patchan

K. M.

Sullivan

Earl

Raley

Liu

Feldman

McMahon

R. P.

(2016). Schizophrenia clinical symptom differences in women vs. men with and without a history of childhood physical abuse. Child and Adolescent Psychiatry and Mental Health, 10(1), 5. https://doi.org/10.1186/s13034-016-0092-9

27.

Kim

S. J.

Kim

J. S.

Chung

I. J.

(2017). Relationships with the family of origin of youth transitioning from out-of-home care. Journal of the Korean Society of Child Welfare, 58, 1–45. https://doi.org/10.24300/jksc.2017.06.58.1

28.

Lazarus

R. S.

Folkman

(1984). Stress, appraisal, and coping. Springer.

29.

Lean

R. E.

Paul

R. A.

Smyser

T. A.

Smyser

C. D.

Rogers

C. E.

(2018). Social adversity and cognitive, language, and motor development of very preterm children from 2 to 5 years of age. The Journal of Pediatrics, 203, 177–184. https://doi.org/10.1016/j.jpeds.2018.07.110

30.

Lee

Park

Kim

Kwon

(2020). Typology of young Korean adults’ relationships with their parents from an intergenerational solidarity lens. Family and Environment Research, 58(1), 43–60. https://doi.org/10.6115/fer.2020.004

31.

Lim

Hart

Mehta

Worker

Simmons

Mirza

Rubia

(2018). Grey matter volume and thickness abnormalities in young people with a history of childhood abuse. Psychological Medicine, 48(6), 1034–1046. https://doi.org/10.1017/s0033291717002392

32.

Lincoln

Y. S.

Guba

E. G.

(1985). Naturalistic inquiry. Sage.

33.

Loos

Clarke

Jordan

Puschner

Fiorillo

Luciano

Ivánka

Magyar

Krogsgaard-Bording

Østermark-Sørensen

Rössler

Kawohl

Mayer

Slade

CEDAR Study Group . (2017). Recovery and decision-making involvement in people with severe mental illness from six countries: A prospective observational study. BMC Psychiatry, 17(1), 38. https://doi.org/10.1186/s12888-017-1207-4

34.

Mohr

Rosén

L. A.

(2017). The impact of protective factors on posttraumatic growth for college student survivors of childhood maltreatment. Journal of Aggression, Maltreatment & Trauma, 26(7), 756–771. https://doi.org/10.1080/10926771.2017.1304478

35.

Morrison

S. E.

Bruce

Wilson

(2018). Children’s disclosure of sexual abuse: A systematic review of qualitative research exploring barriers and facilitators. Journal of Child Sexual Abuse, 27(2), 176–194. https://doi.org/10.1080/10538712.2018.1425943

36.

O’Hare

Shen

Sherrer

M. V.

(2015). Lifetime abuse and self-harm in people with severe mental illness: A structural equation model. Psychological Trauma: Theory, Research, Practice, and Policy, 7(4), 348–355. https://doi.org/10.1037/tra0000016

37.

Oxhandler

H. K.

Narendorf

S. C.

Moffatt

K. M.

(2018). Religion and spirituality among young adults with severe mental illness. Spirituality in Clinical Practice, 5(3), 188–200. https://doi.org/10.1037/scp0000164

38.

Papalia

N. L.

Luebbers

Ogloff

J. R.

Cutajar

Mullen

P. E.

(2017). The long-term co-occurrence of psychiatric illness and behavioral problems following child sexual abuse. Australian & New Zealand Journal of Psychiatry, 51(6), 604–613. https://doi.org/10.1177/0004867416667232

39.

Park

H. J.

(2016). A suggestion for the criminal policies to prevent child abuse. Korean Criminological Review, 27(3), 253–283.

40.

Reupert

Maybery

Cox

Scott Stokes

(2015). Place of family in recovery models for those with a mental illness. International Journal of Mental Health Nursing, 24(6), 495–506. https://doi.org/10.1111/inm.12146

41.

Robinson

Ross

Fletcher

Burns

C. R.

Lagdon

Armour

(2021). The mediating role of distress tolerance in the relationship between childhood maltreatment and mental health outcomes among university students. Journal of Interpersonal Violence, 36(15–16), 7249–7273. https://doi.org/10.1177/0886260519835002

42.

Rossiter

Byrne

Wota

A. P.

Nisar

Ofuafor

Murray

Byrne

Hallahan

(2015). Childhood trauma levels in individuals attending adult mental health services: An evaluation of clinical records and structured measurement of childhood trauma. Child Abuse & Neglect, 44, 36–45. https://doi.org/10.1016/j.chiabu.2015.01.001

43.

Sheridan

Carr

(2020). Survivors’ lived experiences of posttraumatic growth after institutional childhood abuse: An interpretative phenomenological analysis. Child Abuse & Neglect, 103, 104430. https://doi.org/10.1016/j.chiabu.2020.104430

44.

Shin

K. C.

(2017). The changes and implications in Korean mental health act. Kyung Hee Law Journal, 52(3), 171–210. https://doi.org/10.15539/khlj.52.3.5

45.

Steine

I. M.

Winje

Krystal

J. H.

Bjorvatn

Milde

A. M.

Grønli

Nordhus

I. H.

Pallesen

(2017). Cumulative childhood maltreatment and its dose-response relation with adult symptomatology: Findings in a sample of adult survivors of sexual abuse. Child Abuse & Neglect, 65, 99–111. https://doi.org/10.1016/j.chiabu.2017.01.008

46.

Stöckl

Dekel

Morris-Gehring

Watts

Abrahams

(2017). Child homicide perpetrators worldwide: A systematic review. BMJ Paediatrics Open, 1(1), Article e000112. https://doi.org/10.1136/bmjpo-2017-000112

47.

Strauss

Corbin

(1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Sage.

48.

Teicher

M. H.

Samson

J. A.

Anderson

C. M.

Ohashi

(2016). The effects of childhood maltreatment on brain structure, function and connectivity. Nature Reviews Neuroscience, 17(10), 652–666. https://doi.org/10.1038/nrn.2016.111

49.

Varese

Smeets

Drukker

Lieverse

Lataster

Viechtbauer

Read

van Os

Bentall

R. P.

(2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective-and cross-sectional cohort studies. Schizophrenia Bulletin, 38(4), 661–671. https://doi.org/10.1093/schbul/sbs050

50.

Waller

Reupert

Ward

McCormick

Kidd

(2019). Family‐focused recovery: Perspectives from individuals with a mental illness. International Journal of Mental Health Nursing, 28(1), 247–255. https://doi.org/10.1111/inm.12528

51.

Weir

Cunningham

Abraham

Allanson-Oddy

(2019). Military veteran engagement with mental health and well-being services: A qualitative study of the role of the peer support worker. Journal of Mental Health, 28(6), 647–653. https://doi.org/10.1080/09638237.2017.1370640

52.

Woods-Jaeger

Briggs

E. C.

Vivrette

R. L.

Lee

R. C.

Suarez

Belcher

H. M.

(2019). The association between caregiver substance abuse and mental health problems and outcomes for trauma-exposed youth. Journal of Child & Adolescent Trauma, 12(4), 447–456. https://doi.org/10.1007/s40653-019-00251-7