Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress

Abstract

Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.

The Ambiguous Loss Inventory Plus (ALI+): Introduction of a Measure of Psychological Reactions to the Disappearance of a Loved One

“…Several studies have found elevated prolonged grief disorder (PGD) symptom levels in conflict-affected and refugee groups with disappeared loved ones [ 9 , 10 , 11 ]. PGD is characterized by severe grief symptoms (e.g., intense yearning or emotional pain, avoidance of loss-related reminders) causing distress and impairments in daily life for an extended period after the death of a loved person [ 12 ].…”

“…In addition, research has identified violent and potentially traumatic losses as being among the strongest risk factors for the development of PGD [ 13 ]. Therefore, it is not surprising that persons with ambiguous loss have an increased risk of developing PGD symptoms, but also other stress-related symptoms such as posttraumatic stress disorder or depression [ 9 , 11 ]; for systematic reviews, see [ 14 , 15 ].…”

“…After an ambiguous loss, family members need to reevaluate the system’s rules and roles and may experience boundary ambiguity as a specific consequence, that is, not knowing who belongs to the system [ 24 ]. Boundary ambiguity has also been associated with more PGD symptoms in Syrian refugees with missing loved ones [ 11 ]. However, as knowledge of the consequences of ambiguous losses is growing and increasingly recognized in refugee samples [ 6 , 7 , 11 ], the monitoring of specific symptoms after the disappearance of a loved one needs reconsideration.…”

“…Boundary ambiguity has also been associated with more PGD symptoms in Syrian refugees with missing loved ones [ 11 ]. However, as knowledge of the consequences of ambiguous losses is growing and increasingly recognized in refugee samples [ 6 , 7 , 11 ], the monitoring of specific symptoms after the disappearance of a loved one needs reconsideration. No questionnaire has yet been specifically developed to measure grief-like and more general reactions to the disappearance of a loved one.…”

Predicting and preventing dropout in research, assessment and treatment with refugees

“…Furthermore, resettling in a new country can provoke various post‐migration stressors. These include a challenging accommodation situation, poor socio‐economic conditions, uncertainty, fear of detention, experiences of discrimination, language difficulties, social isolation, or complications in the asylum‐application process and feelings of ambiguous loss (Böttche et al, 2016; Liedl et al, 2016; Porter & Haslam, 2005; Priebe et al, 2016; Renner et al, 2021).…”