Attachment-related trauma markers and symptom severity in Afghan refugees

Afghan refugees experience high levels of cumulative trauma and psychosocial adversity, yet attachment-related trauma has rarely been examined at the narrative level. Narrative attachment assessments may capture culturally embedded expressions of distress beyond post-traumatic stress disorder (PTSD)-focused symptom models.

This study examined narrative attachment-related trauma markers in Afghan refugees receiving out-patient psychological treatment. It investigated whether trauma marker frequency differed between resolved and unresolved attachment representations and whether it was associated with psychological symptom severity.

In an exploratory cross-sectional study, 40 Afghan refugees (mean age = 25.4 years; 75% male) receiving out-patient psychological treatment completed the Adult Attachment Projective Picture System, a narrative-based attachment interview. Trauma markers were identified and quantified within the narratives. Associations with attachment representations (resolved versus unresolved) and psychological symptom severity were examined in a subsample with available self-report data (n = 27).

Participants with unresolved attachment representations showed higher trauma marker frequencies than those with resolved representations. Trauma marker frequency was positively associated with depressive symptoms and overall psychological distress (Spearman's effect size estimate (r) = 0.40-0.51; 95% bias-corrected and accelerated (BCa) confidence intervals excluding zero) but not with PTSD symptom severity.

Trauma markers captured clinically relevant distress in Afghan refugees beyond PTSD-specific symptomatology, particularly depressive symptoms and general psychological burden. Narrative, attachment-based approaches may be especially valuable in clinical encounters in which distress is conveyed implicitly, relationally, or in culturally contextualised ways rather than through explicit symptom reporting. Culturally sensitive applications of such methods, supported by well-trained interpreters, are essential for clinical understanding and meaningful clinical engagement.