Table of Contents
Table of Contents
List of Figures
List of Tables
1.1 Hostile-Helpless (HH) States-of-Mind
1.2 Severity of Early Childhood Abuse
1.3 GPACS Punitive-Behaviour
1.4 Gender Differences
1.5 Aims and Hypotheses
2.3.1 GPACS Punitive Behaviour
2.3.2 Hostile-Helpless States-of-Mind on the AAI.
2.3.3 Overall Severity of Childhood Abuse
22.214.171.124 Traumatic Stress Schedule (TSS).
126.96.36.199 Childhood Traumatic Experiences Scale-Revised (CTES-R).
188.8.131.52 Conflict Tactics Scale – Second Version (CTS-2).
2.4 Analytical Strategy
3.1 Descriptive Statistics
3.2 Correlations Between Study Variables
3.3 Differences Between Genders on Study Variables
3.4 Exploring the Potential Moderating Effect of Gender
3.5 Exploratory Analysis: Logistic Regression
4.1 Limitations and Future Directions
Firstly, I would like to thank my supervisors Dr Monja Knoll, and Dr Ingrid Obsuth for their continuous support, patience and guidance. You helped grow beyond my limits, and inspired me to continue to do so. Secondly, I would like to express my gratitude towards my dissertation team – Annemiek van Essen, Rebecca Gracher, Jasmine Wells, and Lewis Marshall for their amazing collaboration and friendship. You made great times greater, and difficult times easier.
List of Figures
Figure 1 Conceptual Model of the Hypothesised Moderated Mediation
Figure 2 Statistical Model of the Moderated Mediation
List of Tables
Table 1 Descriptive Statistics for the Overall Sample, for Females, and for Males
Table 2 Spearman's Rho Correlations Between Study Variables for the Overall Sample, for Females, and for Males
Table 3 Mann-Whitney U Test with Gender as a Grouping Variable, and Mean Ranks for Females and Males
Table 4 Frequency of HH-classifications for the Overall Sample, for Females, and for Males
Introduction: Studies show that higher severity of childhood abuse is positively correlated with higher punitive behaviour levels, and higher Hostile-Helpless (HH) states-of-mind levels. However, studies have not examined if the effect of childhood abuse on HH states-of-mind via punitive behaviour is dependent on gender.
Aims and Research Questions: The purpose of this study was to replicate the associations between severity of childhood abuse and punitive behaviour, and HH states-of-mind; and to assess the gender-dependent effect of childhood abuse severity on HH states-of-mind via punitive behaviour. We expected that higher severity of childhood abuse would predict higher levels of punitive behaviour (1), and higher levels of HH states-of-mind (2), and that the effect of childhood abuse on HH states-of-mind via punitive behaviour is dependent on gender, such that the effect of gender on the pathway from punitive behaviour to HH states-of-mind is significant for females, but not males (3).
Method: A secondary data set of longitudinally studied adolescents and their mothers was used. The study used interview and interaction measures as well as information from the state’s protective services.
Results: A moderated mediation analysis confirmed hypotheses 1, 2, and 3.
Conclusion: Results replicated findings from previous studies, and provided novel evidence that punitive behaviour subsequent to childhood abuse is likely to lead to HH states-of-mind in females, but not males. Therefore, there should be different treatments for males and females diagnosed with pathologies strongly related to HH states-of-mind.
Key-words: attachment, severity of childhood maltreatment, punitive behaviour, HH states-of- mind, gender
Higher Hostile/Helpless (HH) states-of-mind levels in late adolescence have been repeatedly linked to higher severity of abuse in childhood (Byun, Brumariu, & Lyons-Ruth, 2016; Finger et al., 2015; Milot et al. 2014), and to higher levels of adolescent punitive behaviour (Obsuth et al., 2014; Vulliez-Coady et al., 2016). The present study aimed to replicate these findings. To our knowledge, whether the link between severity of childhood abuse and adolescent HH states-of-mind is mediated by punitive behaviour has not yet been explored. Due to gender likely having an effect on the link between punitive behaviour and HH states-of-mind, the present study aims to investigate whether the link between severity of childhood abuse and HH states-of-mind via punitive behaviour differs depending on gender, so that the effect is significant for females, but not males.
1.1 Hostile-Helpless (HH) States-of-Mind
HH states-of-mind are a form of an adolescent’s or adult’s current representations of childhood attachment experiences. ‘Attachment’ describes the bond between an infant and their primary caregiver, and plays an important role in an individual’s functioning from “cradle to grave” (Scharfe, 2017, p. 1). Infants are predisposed to seek closeness to their attachment figures – usually their predominant caregiver – to increase their chances of survival (Bowlby, 1973). In this infant-caregiver relationship, the infant forms a sense of self, and whether they can trust, and rely on their caregiver (Scharfe, 2017). A caregiver’s display of frightening or frightened behaviour, or other forms of disrupted affective communication towards the infant, prevents the functional purposes of the attachment system: establishing proximity to the caregiver and reducing fear in stressful situations (Bowlby, 1982). Such behaviour can form a disorganised attachment relationship between the caregiver and their child, where the child externalises their disorganised attachment by showing contradictory approach-avoidance behaviours towards their caregiver (Lyons-Ruth et al., 2003). Furthermore, disorganised attachment experiences can have a negative impact on the development of autonomy, and individual identity in adolescence (Obsuth et al., 2014). Thus, they can have adverse influences on the adolescent’s transition into adulthood (Mills-Koonce, Rehder, & McCurdy, 2018) as well as leading the development of HH states-of-mind (Lyons-Ruth et al., 2005).
HH states-of-mind are characterised by globalised, opposing evaluations of important attachment relationships and self, which the individual neither discusses nor reconciles (Obsuth et al., 2014). This can be assessed using the Adult Attachment Interview (AAI; George, Kaplan,
& Main, 1984, 1985, 1996) - a semi-structured one-hour interview with the purpose of eliciting present representations of childhood attachment experiences. The AAI can be coded using the HH Coding System (Lyons-Ruth et al., 2005), which was specifically developed for at-risk populations, and applies when disorganised mental contents are prevalent throughout the interview (Barone et al., 2014). During the HH discourse, a caregiver is often described in devaluing manners, either as being malicious (hostile subtype), or as abdicating the role of being a parent (helpless subtype) (Barone et al., 2014), while at the same time, the individual identifies with the negatively presented caregiver (Finger et al., 2015). The contradiction between continuous self-identification with the caregiver and their global negative representation indicates that the individual has not adequately engaged in reflection about their childhood attachment experiences. Therefore, they fail to notice the contradictions on a conscious level (Byun, Brumariu & Lyons-Ruth, 2016), and have not integrated their differentiating feelings and thoughts in regards to the caregiver and themselves into a uniform organised attachment stance (Finger et al., 2015).
HH states-of-mind show relations to a number of risk factors. Investigating whether it constitutes underlying personality pathology among an older, socioeconomically disadvantaged adolescent sample, Finger et al. (2015) found that HH states-of-mind were significantly related to Antisocial Personality Disorder (ASPD) and Borderline Personality Disorder (BPD) features. The link between BPD and HH states-of-mind was consistent with Lyons-Ruth et al.’s (2007b) study: findings revealed that HH states-of-mind were significantly more prevalent in women with BPD than those with dysthymia. In the BPD group, 100% of participants were classified with HH states-of-mind, whereas in the dysthymic group, only 55% were. Women with BPD also scored significantly higher for HH-levels than women with dysthymia. In another study, Byun, Brumariu and Lyons-Ruth (2016) investigated the link between disorganised attachment representations in older adolescents and dissociation – a common symptom of BPD (Pec et al., 2018) – finding that higher HH-levels were related to significantly higher levels of dissociative symptoms.
The way an individual processed their attachment history can also determine how they will interact with their own child. In a longitudinal study, Lyons-Ruth et al. (2005) discovered that mothers’ HH representations were linked to disruptive affective communication with their infants and to their infants’ attachment disorganisation. Additionally, investigating the link between mothers’ HH states-of-mind and maternal infant maltreatment, Frigerio et al. (2013) found that HH states-of-mind were highly prevalent in maltreating mothers (75%) and in 43% of mothers at risk of child maltreatment. Barone et al. (2014) examined the contribution of
mothers’ attachment representations to the risk of committing filicide - the deliberate murder of one’s own child. The sample included mothers from the normative population, mothers with psychiatric diagnosis, and filicidal mothers. Findings showed that psychiatric diagnosis only predicted filicidal behaviour when together with HH states-of-mind.
This multitude of risk factors showcases the necessity for examining the underlying mechanisms that lead to HH states-of-mind, as knowledge thereof can facilitate evidence-based treatment interventions for personality pathology and initiate preventative measures to increase child safety. Addressing HH states-of-mind in therapy may help adolescents regain access to cognitive and affective resources that are important for developing an integrated attachment stance, more self-reflection, and a closer attachment bond with their own children in the future.
1.2 Severity of Early Childhood Abuse
HH states-of-mind have been strongly associated with prior experiences of abuse by an attachment figure in early childhood (Lyons-Ruth et al., 2003). The World Health Organization (2020) defines child abuse as any emotional or physical maltreatment, sexual abuse, neglect or other mistreatment followed by definite or possible harm to the child’s self-esteem, health, growth, or continued existence caused by a figure of trust, accountability or authority. The risk of carrying childhood abuse is especially high in families with a lower socioeconomic status due to economic hardship stressors negatively impacting parenting through changes in parental behaviours and mental health (Delker, Bernstein, & Laurent, 2017). When the child is subject to abuse by a caregiver, they are confronted with the paradox of the caregiver not only being a source of protection, but also a source of threat (Main & Hesse, 1990). As mentioned, this can lead to the child’s attachment disorganisation and subsequent unintegrated attachment representations. This is especially apparent when the abuse happened in early childhood, as infant’s lives are dependent on their caregiver’s care (Sullivan & George, 2011). However, there is significant variation in the degree of long-term effects of childhood abuse, which can be explained by the severity of the abuse itself (Evans, Steel, & DiLillo, 2013). A number of studies have found that characteristics of increased abuse severity – i.e. more frequent, invasive or enduring acts – lead to an increase in long-term difficulties (Steel et al., 2004; Trickett et al., 2001).
Accordingly, higher childhood abuse severity has found to be linked to subsequent higher HH states-of-mind levels. This was confirmed by Byun, Brumariu and Lyons-Ruth’s (2016) study involving older adolescents at high to moderate socioeconomic risk, and Finger
et al. (2015) using a sample with similar characteristics. Moreover, there is evidence of the risk of intergenerational continuity of child abuse in the presence of HH states-of-mind. Milot et al. (2014) studied 70 neglecting and at risk of neglecting mothers to assess the relation between their own childhood abuse experiences, and their current HH attachment representations. Results revealed that HH-classified mothers (64% of the sample) reported having been sexually abused, emotionally abused and physically neglected more frequently than non-HH mothers as well as having experienced nearly twice as many forms of childhood abuse. This indicates that severity of prior abuse was related to mothers’ current attachment representations and to the maltreating of their children, suggesting intergenerational transmission of childhood abuse and HH states-of-mind.
Thus, rather than creating a dichotomisation between victims and nonvictims, it is important to consider abuse severity when studying adverse outcomes associated with it. The body of evidence showcasing strong links between severity of childhood abuse and HH states- of-mind underlines the need to provide an account through which severity of childhood abuse might affect an individual’s development of HH states-of-mind.
1.3 GPACS Punitive-Behaviour
A possible underlying mechanism linking severity of childhood abuse to subsequent HH states- of-mind is punitive behaviour. Punitive behaviour - first described in early childhood - is a form of externalising, controlling behaviour characterised by a child’s harsh commands, devaluing comments, verbal threats, or subtly humiliating behaviours towards their caregiver. Controlling behaviour can also manifest itself in an opposing manner described as caretaking behaviour, where the child plays a supportive, entertaining, or encouraging role in the interaction with their caregiver. Children who exhibit controlling-punitive or controlling- caretaking behaviours do so to achieve their frightening or frightened caregiver’s submission and compliance, or to maintain an emotionally distanced caregiver’s attention and involvement (Lyons-Ruth et al., 2019). Furthermore, both controlling behaviours are characteristic of parent-child role-confusion, which “refers to a dyadic process in which the parent fails to exercise appropriate parental functions and the child takes on functions usually assumed by the parent” (Vulliez-Coady et al., 2013, p.1). Expectedly, evidence suggests that controlling- behaviours are prevalent in many previously disorganised children (NICHD Early Child Care Research Network, 2001; Moss, Cyr, & Dubois-Comtois, 2004; O’Connor et al., 2011).
The controlling-behaviours prevalent in childhood can also be examined in adolescence (Obsuth et al., 2014). As adolescents have less need for an attachment figure’s physical presence than children, the observation of ongoing and subtle responses occurring during a conflict interaction with a parent is most suitable for the assessment of their attachment (Obsuth et al., 2014). The adolescent-parent interaction is observed during a 10-minute conflict situation where the topic of the conflict is chosen based on the separately completed Issues Checklist (Kobak et al., 1993), rating sources of disagreement in the relationship. This interaction can be coded using the Goal-Corrected Partnership in Adolescence Coding System (GPACS; Lyons-Ruth, Hennighausen, & Holmes, 2005). The GPACS captures dyadic collaborative behaviour, and parental validating behaviour, which are indicative of a secure attachment relationship as well as four forms of adolescent, and four forms of parental disorganised behaviour, such as punitive behaviour (Obsuth et al., 2014). These behaviours are discussed further in section 2.3.1. Given the aforementioned relation between attachment disorganisation and severity of child abuse, it is unsurprising that there is evidence of punitive adolescent-parent interactions also being linked to prior severity of childhood abuse.
In Byun, Brumariu and Lyons-Ruth’s (2016) longitudinal study, they found that higher severity of childhood abuse displayed higher levels of punitive adolescent-mother interactions, whereas higher levels of dyadic punitive behaviour were associated with younger adolescent age. Even after controlling for adolescent age, punitive behaviour remained significantly related to prior severity of childhood abuse. To explore how parent-child interactions from infancy to late adolescence are linked to severity of childhood abuse, Khoury et al. (2020) assessed 56 mothers and their children in infancy, at the age of seven, and at age 19. In this smaller longitudinal sample, punitive interaction was not significantly associated with severity of child abuse. However, adding 54 participants – and thus, increasing the sample power – the dyadic adolescent-parent punitive interaction was significantly linked to severity of abuse in childhood.
Similarly, punitive behaviour is associated with HH states-of-mind. Evidence of this has been found studying role-confusion from the point of view of longitudinally studied mothers. Interviews with them were coded with the Parental Assessment of Role Confusion (PARC; Vulliez-Coady & Lyons-Ruth, 2009), revealing the link between mothers’ HH states- of-mind and PARC role-confusion of their children was strong and significant, and the mean adjusted PARC score was higher for HH-mothers than for non-HH-mothers (Vulliez-Coady et al., 2013). However, these results did not consider caretaking and punitive behaviour separately, but cumulatively as role-confusion. Obsuth et al. (2014) studied 120 older
adolescents at socioeconomic risk and their mothers to examine the correlates of adolescent disorganised and controlling behaviours, considering caretaking and punitive behaviour separately. They discovered that the adolescent-mother punitive interaction was significantly related to adolescents’ HH states-of-mind, and with every one-point increase in dyadic punitive behaviour, the likelihood of the adolescent being classified as HH increased by 38%.
The proven links between punitive behaviour and severity of abuse in childhood, as well as between punitive behaviour and HH states-of-mind, present punitive behaviour as a possible underlying mechanism of the link between abuse and HH states-of-mind. However, this effect is likely to be conditional upon gender, such that the relation between punitive behaviour and HH states-of-mind can be expected to be significant for females, but not males.
1.4 Gender Differences
The aforementioned characteristics of punitive behaviour – namely, giving harsh commands, devaluing comments, verbal threats, or showing humiliating behaviours towards a caregiver - are consistent with the characteristics of psychological aggression: “psychological aggression refers to verbal and behaviour acts that are intended to humiliate, criticise, blame, dominate, isolate, intimidate, and threaten” (Shorey et al., 2012, p. 2). Thus, punitive behaviour can be described as a form of psychological aggression. Research shows females are more likely to exhibit psychological aggression towards a caregiver, while males rather exhibit physical aggression – throwing things at, and hitting the caregiver (Estévez & Góngora, 2009; World Health Organization, 2000). Baeza and Fiscella (2018) studied 1,861 adolescents between the ages of 12 and 20 to assess child-to-parent violence, and their findings were consistent with this.
Evidence has revealed that the display of aggression by previously abused adolescents is linked to anomalous mentalisation (Abate et al., 2017). Mentalisation – also called reflective function - is the capacity to reflect upon, and understand mental states and emotions underlying other’s and their own behaviours (Fonagy, 1989). Abused children show anomalous mentalisation either in in the form of hypermentalisation – an obsessive attempt to understand the intentions and minds of others, thus misinterpreting ambiguous interactions as malevolent
-, or hypomentalisation – the unwillingness or inability to understand other’s minds and intentions (Abate et al., 2017). The former presents children’s way of protecting themselves by predicting inconsistent parental behaviour, whereas the latter is a form of self-protection by avoiding thinking about the caregiver’s wish to harm them (Weijers et al., 2020).
When this impaired mentalisation is maintained into adolescence, it can lead to disintegration of identity due to adolescence being the time of identity resignification (Both, Benetti, & Goodman, 2019). Both, Benetti, and Goodman (2019) studied 188 students with and without clinical symptoms between the ages of 14 and 17, to assess the links between mentalisation impairment and identity formation. Their findings revealed that adolescents with clinical symptoms showcased lower levels of mentalisation, and lower levels of mentalisation were linked to greater disintegration of identity. This confirmed findings of earlier studies suggesting that impaired mentalisation, and diffusion of identity are common in individuals diagnosed with psychiatric disorders such as BPD (Bateman & Fonagy, 2010; Kernberg, Weiner, & Bardenstein, 2000), and ASPD (Taubner et al., 2013) – personality disorders also significantly related to HH states-of-mind.
Identity diffusion might be especially prevalent in maternally abused females rather than males due to daughters identifying more strongly with their mothers, and sons with their fathers (Fäldt & Kullberg, 2012). This might be due to children’s increased time spent with the same-gender parent (Priess, Lindberg, & Hyde, 2009), or due to their perception of the same- gender parent being more strongly linked to their own developing gender identity, resulting in closer connectedness (Shrier, Shrier & Tompsett, 2004). Evidence of this has been found in Fagan et al.’s (2011) study investigating the link between gender differences and a number of family influences, including a sample of 18,512 students between the ages of 12 and 18 years, and their parents. They found that daughters reported a greater sense of connection to their mothers, while sons described a greater sense of connection to their fathers. Exploring the link between parents’ harsh physical discipline and developmental outcomes in their adolescent children, Bender et al. (2007) found that in interaction with their mothers, females but not males portrayed an impaired ability of establishing autonomy. This might be an indicator of females’ connectedness with their mothers even after experiencing maladaptive maternal parenting. Thus, females might be more likely to be presented with the paradox of identifying with an abusive mother than boys.
Given that mentalisation impairment is characteristic for HH-related personality pathology, it is likely that impaired mentalisation also plays a role in the development of HH states-of-mind. This assumption is strengthened by the fact that both the incapability of proper reflection on one’s experiences, and identify diffusion are integral parts of HH states-of-mind (Finger et al., 2015), and impaired mentalisation in adolescence (Fonagy, 1989). This identity diffusion might especially affect maternally abused daughters, due to daughters’ identification with their mothers (Bender et al., 2007). Furthermore, impaired mentalisation plays an
important role in previously abused adolescents’ display of aggressive behaviour, whereas females are more likely to use psychological aggression, such as punitive behaviour, towards their caregivers, than males (Baeza and Fiscella, 2018). Due to these linkages, it can be expected that in the present study, the effect of childhood abuse severity on HH states-of-mind via punitive behaviour is dependent on gender, such that the effect of gender on the pathway from punitive behaviour to HH states-of-mind will be significant for females, but not males.
1.5 Aims and Hypotheses
The present study firstly aimed to replicate the association between severity of childhood abuse and HH states-of-mind. Secondly, it aimed to replicate the link between severity of childhood abuse and punitive behaviour. Thirdly, to explore these associations further, the study aimed to test whether the effect of severity of childhood abuse on HH states-of-mind via punitive behaviour differs depending on gender.
It was hypothesised that (1) higher levels of severity of childhood abuse will predict higher levels of punitive behaviour; (2) higher levels of severity of childhood abuse will predict higher levels of HH states-of-mind; (3) the effect of childhood abuse severity on HH states-of- mind via punitive behaviour will be dependent on gender, such that the effect of gender on the pathway from punitive behaviour to HH states-of-mind will be significant for females, but not males. Figure 1 illustrates the conceptual model of the hypothesised moderated mediation.
Conceptual Model of the Hypothesised Moderated Mediation
Abbildung in dieser Leseprobe nicht enthalten
Note. a= X predicting M, b1= M predicting Y, c= X predicting Y, b2=effect of W on M predicting Y,
The 109 participants were selected from a secondary data set of 120 longitudinally studied adolescents (M =19.7 years; SD =1.62, 56.6% females) and their mothers. The original data set included cases with missing values. Thus, listwise deletion of those cases led to a final sample of N =109. To ensure that the listwise deletion did not affect the statistical power, a post hoc power calculation was conducted using G*Power 3.1 (Faul et al., 2009). The R 2-value was obtained conducting a linear regression analysis, (R2 =.25). Following Cohen’s (1988) guidelines, the effect size of the present study was of medium strength (f 2=.15). The power was set at .80, the alpha level at .05, and the number of predictors at 5. The required sample size for this study was N =92. As our sample size (N =109) exceeded this number, it had enough power to detect a moderate effect, reducing the possibility of making a type II error (Cohen, 1988).
Participants in the subsample were aged between 18 and 23 (M =19.89, SD =1.45), with 59.6% of them being female and 40.4% being male. While 47 of them entered the study as infants (M =10.00 months, SD =5.77), 62 had first been recruited in adolescence. Further demographic data on the subsample had not been provided. As a Mann-Whitney U test revealed that there were no significant differences between the data included in the analysis and the data not included in the analysis regarding the continuous variables of the study, further demographics were taken from published papers using the same data set (see Finger et al., 2015; Obsuth et al. 2014). An exemption of this was the adolescent age variable as there was a significant difference (U =629, p=. 001) between the adolescent age for the data included in the analysis (M =70.23) compared to the data not included in the analysis (M =40.95).
The household income of 59% of the original data set was less than $40,000 a year, putting them in higher socioeconomic risk. Regarding ethnic backgrounds, 66% of adolescents were Caucasian; 38% of mothers were single parents, and 12% of them had not graduated high school. Whereas 56 families had been followed since infancy, 64 families had first been seen in adolescence. The latter were matched to longitudinal families on mother’s single parenthood, ethnicity, and adolescent age. The 56 longitudinally-studied families came from a cohort of 75 families, recruited between the child’s first 18 months of life. There was a 26% participant attrition, leading to a retention rate of 74%. Half of the longitudinally studied families were referred to the study by social service providers as their standard of care towards the infant lead to concerns. Families that had first been seen in adolescence did not report referrals for parenting support during infancy.
Participants’ data was taken from Prof. Dr. Karlen Lyons-Ruth’s Family Pathways Project at the Harvard University Family Studies Laboratory. This study followed infants and their caregivers from adverse environments and at socioeconomic risk over 20 years, to assess the development and family processes linked to disorganised attachment behaviours from infancy to adulthood (Lyons-Ruth, 2003). Informed consent for infants’ or children’s data to be used in the original study was provided by their caregivers. In case of later participation in the study, adolescents provided their own consent. Access to the data was granted by Dr. Ingrid Obsuth, who was involved in the Family Pathways Project. Upon completion of informed consent, adolescents and mothers took part in the GPACS conflict interaction. The AAI and self-report questionnaires were administered to the adolescents prior to the interaction task. At a later point of the visit, measures of experiences of abuse and diagnostic interviews were administered (Obsuth et al., 2014). Due to utilising a secondary data set which only entailed summary scores, reliabilities have been adopted from published papers using the same data set (see Finger et al., 2015; Obsuth et al. 2014). Ethical approval for the original Family Pathways Project was granted by Harvard University, including consent to use the data in further analyses. Ethical approval for the present study was obtained by the research ethics committee of the School of Health in Social Science at the University of Edinburgh. All ethical considerations are in line with British Psychological Society guidelines.
2.3.1 GPACS Punitive Behaviour.
As described by Obsuth et al. (2014), after the introduction of the protocol, adolescents and their mothers completed interviews and questionnaires in separate rooms. They each completed an Issues Checklist – according to Kobak et al. (1993) – describing areas of conflict in their relationship. A topic for discussion was chosen based on both mother and adolescent checklists; the adolescent recorded a one- minute explanation of their position. After a five-minute unstructured reunion between mother and adolescent, the videotaped adolescent explanation was played and the area of conflict was discussed for 10 minutes.
- Quote paper
- Marie-Louise Meiser (Author), 2020, Psychology of Mental Health. Gender, Childhood Abuse and Hostile-Helpless States of Mind, Munich, GRIN Verlag, https://www.grin.com/document/1021147