Coping Styles and Defense Mechanisms Mediate Associations Between Exposure to Adverse Childhood Experiences and CPTSD Symptoms in Faroese Adolescents

The Faroe Islands are a small and isolated North Atlantic country within the Danish Kingdom with a current population of approximately 54,000 people.

The Faroese value autonomy and independence, thus youth grow up with little guidance from their parents. From an early age, children are allowed to play unsupervised, and are expected to solve problems on their own or to rely on their peers (12). Furthermore, small-scale societies such as the Faroe Islands, are characterized by close social networks and high levels of familiarity. Although this means people identify more deeply with one another, it also means that anonymity is almost impossible (13).

The Faroese adolescents are an under-researched population, and the context of Faroe Islands may be a factor of exposure to ACEs (11). The Faroe Islands also represent a society facing the challenges of economic restructuration and out-migration, due to the economic crisis (12). Furthermore, mental health services in the Faroe Islands lack resources to adequately provide care for its region’s youth (11).

The unique context of the Faroe Islands in which children and adolescents may be highly vulnerable to exposure to multiple types of ACEs requires a better understanding of the psychological factors underlying mental health problems associated with exposure to ACEs. These findings could offer some insight about this cultural context and information that can improve both prevention policies and psychological interventions.

It is recognized that exposure to multiple ACEs increases risk of developing Post-Traumatic Stress Disorder (PTSD) and Complex Post-Traumatic Stress Disorder (CPTSD) in European and Asian samples (14, 15, 16). PTSD includes three symptom clusters: re-experience of the traumatic event or events; avoidance of thoughts and memories of the event(s); persistent perceptions of heightened current threat. CPTSD was introduced as a distinctive disorder from PTSD and includes three additional symptom clusters: affective dysregulation; negative self-concept; disturbed relationships (17). These additional symptoms clusters are indicators of Disturbances in Self-Organization (DSO).

In adolescence, the development of CPTSD may undermine the maintenance of a coherent sense of self, which result in impairment in identity formation (18). To the best of our knowledge, only one study analyzed the prevalence of PTSD among Faroese adolescents. It was found that 20% of the total sample fulfilled the criteria for PTSD (11). As far as we can tell, no previous study has examined CPTSD in a sample of Faroese adolescents.

Recent studies have found a positive association between higher exposure to ACEs and PTSD symptoms and DSO symptoms (6, 15, 19). Meanwhile, some studies observed that ACEs had only an indirect effect on DSO symptoms (15, 16, 20). This suggests that some psychosocial variables may mediate the link between ACEs and trauma symptoms. A better comprehension of these variables can help improve knowledge of the underlying psychological processes involved in the development of both PTSD and CPTSD.

Coping strategies is a potential protective or risk factor for the individuals’ mental health (21). Coping strategies involve conscious and voluntary use of both cognitive and behavioral strategies to manage either internal (e.g., emotional) and/or external (e.g., environmental) challenging circumstances to restore internal and external balance. The process of emotional regulation in the face of challenging circumstances is referred to as coping styles (22).

Two major complementary coping styles can be distinguished: emotion-focused and problem-focused coping styles. Coping styles have also been distinguished between engagement versus disengagement coping (23). Coping styles and their characteristics are presented in Table 1.

Exposure to multiple ACEs and living in an environment appraised as uncontrollable could impact adolescents’ coping styles. In accordance, previous studies found higher use of disengagement and maladaptive coping styles (e.g., avoidance and emotion-focused coping) in individuals exposed to ACEs when compared to individuals who did not experience ACEs (24, 25). These maladaptive coping styles are short-term approaches that only temporarily decrease the psychological impact of ACEs (21),

Furthermore, the development and maintenance of PTSD symptoms seems to be connected to specific coping styles among diverse samples and age groups. It was observed that emotional and disengagement coping styles, and cognitive avoidance were associated with higher levels of PTSD symptoms (26). In adolescents, a meta-analytical study evidenced that emotional avoidance coping styles predicted PTSD (27).

Recently, it was found that coping styles partially mediated the relationship between childhood maltreatment and mental health in a sample of college students (22). Maladaptive coping mediated the association between exposure to ACEs and internalizing symptoms in adolescents (24). Specifically, both emotional and avoidance focused coping mediated the relationship between exposure to ACEs with PTSD in a sample of Danish adolescents (28).

In the meantime, implicit emotion regulation has been found to have a greater protective effect against psychopathology, in youth exposed to ACEs, compared to explicit emotion regulation mechanisms. Defense mechanisms and implicit emotion regulation are similar processes in coping with ACEs (29). Defense mechanisms are automatic and unconscious psychological processes intended to protect the individual against distressing emotions and mental representations associated with stressful events (30), which are involved in adaptive or maladaptive adjustment to stressful life events (28).

Defense mechanisms have been grouped into three levels: immature, neurotic, and mature (31). Defense mechanisms and their characteristics are presented in Table 1.

In a context of exposure to multiple ACEs, defense mechanisms may be critical to emotional regulation associated with harmful and adverse experiences (32). Therefore, it is likely that exposure to ACEs may have an impact on the use of defense mechanisms. This is corroborated by previous studies that found that exposure to ACEs was associated with higher use of less mature defense mechanisms, namely neurotic and immature defense mechanisms (33, 34, 35).

The predominant use of less mature defense mechanisms has been attributed to a process of regression to survival-serving defenses to cope with a context of multiple and repeated adversity (36). The use of less mature defense mechanisms is an attempt to protect from a violent and harmful environment by creating an illusion of control over the generalized violence and adversity (32, 37).

It has been noticed that higher levels of immature defense styles are associated with increased psychological symptoms severity among individuals exposed to traumatic events (33, 38, 39, 40). Higher use of immature defense mechanisms was associated with PTSD in refugees (41) and war veterans (31, 42). Conversely, mature defense mechanisms were associated with lower PTSD symptoms in war veterans (31).

More recently, some studies noticed that immature defense mechanisms mediated the association between exposure to ACE and higher psychological symptoms severity in adolescents (34) and adults (40, 43). It was also noticed that both neurotic and immature defense mechanisms mediated the association between exposure to ACEs and PTSD symptoms in Danish adolescents (44).

It seems that both defense mechanisms and coping styles are complementary psychological processes involved in adjustment to exposure to adversity (45). Chabrol and Callahan (46) proposed that defense mechanisms precede coping styles. From a developmental point of view, defense mechanisms emerge earlier, whereas coping styles are activated once the individual’s fundamental unconscious defensive organization has been established. Thus, coping styles may be restricted or promoted by underlying defense mechanisms.

In accordance, neurotic and immature defense mechanisms were strongly associated with avoidant coping, whereas mature defense mechanisms were strongly associated with focused on problem or emotion coping (45, 47). Two patterns of responses to ACEs have been proposed: active response involving the use of mature defense mechanisms and problem or emotion-focused coping; passive response involving the use of less matured defense mechanisms and avoidant coping (35, 45). In a sample of Danish adolescents, higher exposure to ACEs was related to higher use of immature defense mechanisms, which were associated with higher levels of both emotional and avoidance coping, which, in turn, were associated with higher severity of PTSD symptoms (28).

The joint study of defense mechanisms and coping styles has rarely been conducted. Considering the complementary role of both processes in adjustment to multiple exposure to ACEs (45), more research is needed on the topic. Moreover, the study of the relationship between two core features of different approaches may provide some evidence, to some extent, in favor of the underlying mechanisms for psychotherapy integration.

The present study analyzed the effect of exposure to ACEs on both PTSD and DSO symptoms trough the indirect effect of defense mechanisms and coping styles in a sample of Faroese adolescents. Based on the findings mentioned above, the following hypotheses were proposed: 1) higher exposure to multiple types of ACEs will be associated with higher levels of PTSD and DSO symptoms; 2) higher exposure to multiple types ACEs will be indirectly related to higher levels PTSD and DSO symptoms through higher levels of immature defense mechanisms; 3) higher levels of exposure to multiple types of ACEs will be indirectly related to higher levels of PTSD and DSO symptoms through higher levels of emotional and avoidance coping; 4) exposure to multiple ACEs will relate to higher levels of immature defense mechanisms, that will relate to higher levels of both emotional and avoidance coping, which will then relate to higher levels of both PTSD and DSO symptoms.

The sample included 687 Faroese adolescents who were enrolled in eighth grade. Sample characteristics are presented in Table 2. The mean age of the sample was around 14 years old (age range: 13–16 years old). The proportion of females (51.4%) was slightly higher than proportion of males (48.6%). Most participants lived with both their parents (81.8%) and a very small proportion had other arrangements (2.0%). More than half of the adolescents’ parents have completed college or university education.

This study aimed to collect data about previous exposure to ACEs and psychological reactions among Faroese adolescents. Participants were recruited from 19 schools, located in six different islands. According to the Faroese Ministry of Education, there were 804 students in eighth grade at the time the data were collected; that is 85% of all the Faroese students enrolled in eight-grade participated in this study.

The research protocol was sent, successively, to the Faroese Data Inspection, Faroese Ministry of Education, and the Faroese Ethical Board, who approved the study. Next, the research protocol was presented to the school principals, who approved the study. It was applied passive consent which is a usual procedure in most school studies, i.e., the parents were informed about the study and have the right to refuse the participation of their child. The students were informed that their answers were anonymous, and they were asked to answer as openly as possible, despite the somewhat uncomfortable subject. All students present accepted to participate in the study. The research protocol was introduced to the students verbally and by letter. The participation was voluntary and those accepting to participate, gave their informed consent directly. The students filled in the questionnaire in the classroom, supervised by a team researcher in co-operation with the “head teacher”.

Sociodemographic data. Participants provided information on their sex, age, highest level of parental education and current living arrangements.

Data analysis was conducted using the IBM SPSS Statistics for Windows (version 29). Multiple Pearson correlation analyses were first conducted to test bivariate relationships between the study variables. The analyses of indirect effects were divided into two steps. A multiple step mediation methodology, with a bootstrapped confidence interval for indirect effects (55), was conducted to test our hypothesis of serial mediation. Both models described above included two outcome variables (PTSD and DSO symptoms), so that examination through Structural Equation Modeling (SEM) was chosen.

First, to address our multiple mediation hypotheses, it was examined: (a) direct effect of exposure to ACEs on PTSD and DSO symptoms; (b) the indirect effect of exposure to ACEs on PTSD and DSO symptoms through defense and the coping styles. All variables were defined as observed variables. Considering the lack of research on the association between our study variables in Faroese adolescent samples, all subscales of defense and coping styles were included in the models, although they were not considered in our hypotheses.

Second, to assess our serial mediation integrated model, it was examined: (a) direct effect of exposure to ACEs on PTSD and DSO symptoms; (b) the indirect effect of exposure to ACEs on PTSD and DSO symptoms through defense styles; (c) the indirect effect of exposure to ACEs on PTSD and DSO symptoms via a two-step mediation process through defense styles and coping styles. Only variables whose indirect effect was statistically significant in the first step of the analysis were included in the model of serial mediation (55). There were no missing values in our data due to cautious procedures adopted during data collection (e.g., checking if participants did respond to all items).

SEM (56) strategy using the AMOS software (Version 29) and the Maximum Likelihood method were employed. The following criteria for models fit were adopted: (a) χ² test should be non-significant; (b) comparative fit index (CFI), normed fit index (NFI), and Tucker Lewis Index (TLI > 0.95; (c) root mean square error of approximation (RMSEA) and standardized root mean square residual (SRMR) ranging from 0.00 to 0.08. To assess significance of indirect paths, a bootstrapped confidence interval for the ab indirect effect was adopted (57). A total of 5,000 bootstrapped samples were obtained to estimate indirect effects of each variable.

As can be seen in Table 4, the most reported event was the death of someone close, followed by threats of violence. The least prevalent events were pregnancy/abortion and rape. The average number of direct events per participant was 2.9 (SD = 3.1; range 0–20).

Intercorrelations between the study variables are presented in Table 5.

The model that tested the direct paths from exposure to ACEs to PTSD symptoms, and indirect paths through defense mechanisms and coping styles showed a good fit to the observed data (χ² (2) =1.19, p = .55; NFI= 1.0; CFI =1.0; TLI = 1.0; RMSEA =.01; SMSR =.01). Unstandardized coefficients and bootstrap solutions are presented in Table 6, and unstandardized results are presented in Figure 1. The direct paths from exposure to ACEs to PTSD symptoms (b = .44, p <.001, 95% CI, .34, .54) were significant. Higher levels of exposure to ACEs were associated with higher levels of PTSD symptoms. The indirect effects from exposure to ACEs through rational coping (b = .33, p <.001, 95% CI, .19, .47), emotional coping (b = .55, p <.001, 95% CI, .42, .68) and detachment coping (b = −.17, p <.01, 95% CI, −.07, −.27) to PTSD symptoms were significant. Higher levels of exposure to ACEs were associated with higher levels of both rational coping and emotional coping, which were associated with higher levels of PTSD symptoms. Higher levels of exposure to ACEs were associated with higher levels of detachment coping, which were associated with lower levels of PTSD symptoms.

FIGURE 1.

The model that tested the direct paths from exposure to ACEs to DSO symptoms, and indirect paths through defense mechanisms and coping styles showed a good fit to the observed data (χ² (1) =.15, p = .70; NFI= 1.0; CFI =1.0; TLI = 1.0; RMSEA =.01; SMSR =.01). Unstandardized coefficients and bootstrap solutions are presented in Table 6, and unstandardized results are presented in Figure 2. The direct paths from exposure to ACEs to DSO symptoms (b = .33, p <.001, 95% CI, .25, .41) were significant. Higher levels of exposure to ACEs were associated with higher levels of DSO symptoms. The indirect effects from exposure to ACEs through immature defense mechanisms (b = .44, p <.001, 95% CI, .17, .71), emotional coping (b = .35, p <.001, 95% CI, .30, .40) and detachment coping (b = −.10, p <.05, 95% CI, −.19, −.01) to DSO symptoms were significant. Higher levels of exposure to ACEs were associated with higher levels of both immature defense mechanisms and emotional coping, which were associated with higher levels of DSO symptoms. Higher levels of exposure to ACEs were associated with higher levels of detachment coping, which were associated with lower levels of DSO symptoms.

FIGURE 2.

Since both mature and neurotic defense mechanisms did not mediate the link between exposure to ACEs and PTSD and DSO symptoms, both defense mechanisms were not included in the two step mediation model (55). This model showed a good fit to the observed data (χ² (2) = 4.56, p = .10; NFI=. 1.0; CFI =1.0; TLI = 98; RMSEA =.04; SMSR =.02). Unstandardized coefficients and bootstrap solutions are presented in Table 7, and unstandardized results are presented in Figure 3. The direct paths from exposure to ACEs to PTSD (b = .43, p <.05, 95% CI, .20, .66) and DSO symptoms (b = .32, p <.001, 95% CI, .24, .40) remained significant. Only the indirect effect from exposure to ACEs to both psychological symptoms through emotional coping was significant. The results indicated that exposure to ACEs was significantly associated with higher levels of immature defense mechanisms, which were associated with higher levels of both rational and emotional coping, which in turn were associated with higher levels of both PTSD and DSO symptoms. It was also observed that exposure to ACEs was significantly associated with higher levels of immature defense mechanisms, which were associated with higher levels of detachment coping, which in turn were associated with lower levels of both PTSD and DSO symptoms.

FIGURE 3.

Our first hypothesis was fully supported. Higher exposure to multiple types of ACEs was associated with higher levels of PTSD and DSO symptoms. There was a stronger association between ACEs and PTSD symptoms compared to the association between the former variable with DSO symptoms. The most reported events (e.g., death of someone close, threats of violence) are usually isolated events which are more associated with the development of PTSD symptoms (58, 59). DSO symptoms tend to occur after longer and repetitive periods of exposure to ACEs (15, 16).

Our second hypothesis was supported. Both the multiple and serial mediation analysis indicated that exposure to ACEs was indirectly related to PTSD and DSO symptoms through immature defense mechanisms. It could be proposed that exposure to multiple ACEs can lead to a process of regression to immature and survival-serving defenses among Faroese adolescents to cope with a context of adversity (34, 36), which increases the risk of both PTSD and DSO symptoms (60, 61). The intensified use of these defense styles may cause impairment in identity formation (60). However, regarding the association between use of immature defense mechanisms with PTSD symptoms seems to be influenced by the coping styles used by adolescents (28, 45).

Our third hypothesis was partially supported. Exposure to ACEs was indirectly related to PTSD and DSO symptoms only through emotional coping, but exposure to ACEs was not indirectly related to PTSD and DSO symptoms through avoidance coping. Probably, adolescents who strongly attempt to cope with multiple adversity through acceptance or positive restructuring are at higher risk of psychological distress (24, 25). Conversely, it seems that the context of repeated adversity may not promote the use of avoidance coping as a coping method to deal with exposure to multiple ACEs.

It was also observed that exposure to ACEs was indirectly related to PTSD symptoms through rational coping, and exposure to ACEs was indirectly related to PTSD and DSO symptoms through detachment coping in the multiple mediation, but not in the serial mediation model. It seems that immature defense mechanisms underlie the indirect effect of both coping styles in the association between exposure to ACEs and both PTSD and DSO symptoms among Faroese adolescents (45, 62).

Finally, our final hypothesis was partially supported. The current results partially replicate Zerach and Elklit’s findings (28) on the sequential association between defense mechanisms and coping styles with psychological symptoms. It was found that higher exposure to ACEs was linked to higher levels of immature defense mechanisms, which were then associated with higher levels of emotional coping, and consequently higher levels of both PTSD and DSO symptoms. It was also observed that higher exposure to ACEs was linked to higher levels of immature defense mechanisms, which were then associated with higher levels of rational coping and lower levels of detachment coping, and consequently higher levels of PTSD symptoms.

Our results provide support for the joint action of defense mechanisms and coping styles in adjusting to multiple ACEs exposure among Faroese adolescents. Specifically, higher use of immature defense mechanisms was associated with higher use of emotional, rational and detachment coping to deal with the context of multiple exposure to ACEs (28, 45). These results indicate that coping styles are restricted or promoted by higher or lower use of underlying immature defense mechanisms (62). The present results also suggest that the pattern of typical responses to ACEs, active and passive response, may be related to higher or lower use of immature defense mechanisms which underlie higher or lower use of maladaptive coping among adolescents (45).

Moreover, it was observed that the joint action of immature defense mechanisms and emotional coping is not successful among adolescents living in a context of exposure to different types of ACEs such as Faroe Islands (27, 35). In adolescents with higher exposure to ACEs, the association between higher levels of both immature defense mechanisms and emotional coping was associated with higher levels of both PTSD and DSO symptoms (28). Additionally, the link between immature defense mechanisms and rational coping was associated with higher levels of PTSD symptoms. Considering that rational coping is mainly adopted when individuals believe that the situation can be altered, in a context of exposure to multiple types of ACEs, often occurring unpredictably, it may not afford protection against psychological symptoms among Faroese adolescents (28).

However, it was found that the link between immature defense mechanisms and higher levels of detachment coping was associated with lower levels of PTSD. These findings suggest that the avoidance of emotions and/or thoughts may provide some protection against psychological distress among Faroese adolescents. It can be proposed that some adolescents may adopt adaptive detachment, but not dysfunctional detachment, to deal with exposure to multiple ACEs which may reduce the levels of psychological symptoms (63). On the other hand, the intensified use of disconnected coping may lead to the aggravation of other symptoms, such as depression and dissociation, rather than PTSD symptoms (64).

Although our study supports some previous findings from the literature and provides new insight into the association between exposure to ACEs and DSO symptoms, some limitations need to be acknowledged. Methodological Limitations. 1. The report of exposure to ACEs was performed retrospective which can be biased by memory issues. 2. Assessment of direct exposure to ACEs did not account for the reoccurrence of specific events. 3. Only direct exposure to ACEs was analyzed in this study. Future studies should also evaluate the effect of indirect exposure to ACEs. Measurement Limitations. 1. Self-report measures were used to assess the study variables, which entails the risk of a reporting bias. 2. Exposure to ACEs, PTSD, and DSO symptoms were not assessed through validated measures. Future studies should use validated measure to assess those variables. 3. Defense mechanisms were assessed using a validated measure, but future studies should use measures that assess automatic and unconscious psychological processes. Generalizability. 1. It is not feasible to infer causality from serial mediation analysis due to the cross-sectional design. Future studies should try to analyze the hypotheses of the study using a longitudinal design. 2. The data were collected in 2012. Thus, there may have been changes in the level of exposure to adverse events suffered by adolescents associated with temporal changes in the context of exposure to ACEs in Faroese Islands. Additionally, it is recommended the replication of the mediation hypothesis among other groups of adolescents in different cultures, namely in African samples.

The present study contributes to the understanding of exposure to ACEs in an understudied population and provides new insights for clinical intervention. It also provides a foundation for implementing community-based initiatives in this country. Our results indicate that adolescence is a developmental period characterized by high risk of exposure to multiple types of ACEs, as well as the development of psychological symptoms characteristic of PTSD/CPTSD.

The close social network that characterizes the community in the Faroe Islands plays an important role in preventing exposure to multiple ACEs, as does the school community in providing some protection against this risk for adolescents. In clinical practice, clinicians working with adolescents should assess adolescents’ entire trauma history which may require asking more direct questions regarding adolescents’ traumatic experiences. Moreover, the current findings highlight the key role of immature defense mechanisms as a psychological mechanism involved in passive responses to negative experiences that are linked to psychological distress.

It is recommended that mental health professionals evaluate the prevalent use of primitive defense mechanisms, such as projection and denial, involving a regression to survival-serving defenses to deal with adverse contexts. This clinical procedure may help to identity adolescents at risk, as well as strong reliance on maladaptive coping tactics in a context of exposure to multiple ACEs. Thus, during therapy, clinicians should closely examine the associations between defense and coping styles as adaptive or non-adaptive responses to negative and adverse events. Within this developmental model, adaptive coping seems to be promoted or restricted by underlying immature defense mechanisms (62). Clinicians should intervene with the aim of reducing the use of primitive defensive mechanisms with the aim of reducing the use of non-adaptive coping styles among adolescents exposed to multiple types of ACEs.