Prolonged Grief Disorder Among Refugees and Resilience

There are currently 70.8 million displaced people worldwide as a consequence of violence, persecution, conflict, or human rights violation (1). Forcibly displaced people frequently experience interpersonal loss and bereavement along with potentially traumatic events (PTE), including interpersonal violence, torture, life-threatening injuries and witnessing the death of loved ones (2).

Participants were 88 refugees and asylum seekers receiving psychological treatment in two outpatient clinics for victims of torture and war in Bern and Zürich, Switzerland.
This study examined the relationship between PGD severity and potential associated factors (emotion regulation, perceived self-efficacy, PMLD, PTE) in a clinical sample of refugees.

To assess the likelihood of PGD diagnosis five criteria must be considered:

(A) event: the respondent has experienced the loss of a loved one;
(B) separation distress: grief-related yearning is experienced at least daily;
(C) duration: symptoms of separation distress remain at least 6 months after the loss;
(D) cognitive, emotional, and behavioral symptoms: at least five symptoms based on items 4–11 are experienced at least “once a day” or “quite often”;
(E) impairment: the respondent must have significant impairment in social, occupational, or other important areas of functioning
obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning, and social integration. The refugees have resilience based and trauma centered interventions. These are perceived self-efficacy and emotion regulation.

Perceived self-efficacy refers to positive beliefs about one’s abilities to influence events that affect one’s life. These beliefs may alter personal goals, motivation, everyday functioning, resilience to adversity, and vulnerability to distress and depression.

Whereas self-efficacy has been considered a relevant variable among refugees due to its positive association with mental health and well-being (37, 38), its relationship to PGD remains unknown.

Emotion regulation can be defined as one’s ability to monitor, assess, and modulate experienced emotions in order to facilitate adaptive functioning (39). In this study, we refer to emotion regulation as conceptualized by Gratz and Roemer and involving the following features: awareness, understanding and acceptance of emotions, as well as impulse control and ability to modulate emotional responses and behaviors according to desired goals and situational demands (39)
As grief is characterized by a wide range of strong, often negative emotions, difficulties in emotion regulation or active avoidance of grief-related emotions might lead to maladaptive bereavement responses (11, 40).

A small number of studies among refugees suggested that emotion regulation mediates the relationship between trauma and psychological symptoms (41) and that difficulties in emotion regulation are associated with more severe symptoms of PTSD, depression, and anxiety (42).

Given the finding that difficulties in emotion regulation and lower perceived self-efficacy are associated with greater PGD severityThis study is one of the very few investigating PGD among refugees residing in western countries.

Our findings highlight the relationship between both emotion regulation and perceived self-efficacy and the severity of PGD among refugees receiving psychological treatment in Switzerland.

We consider the concepts of perceived self-efficacy and emotion regulation particularly relevant for clinical practice as they relate to subsequent behaviors and may constitute key targets for treatment intervention. Enhancing perceived self-efficacy and emotion regulation may be useful to improve treatment response of PGD in treatment-seeking refugees.