Research reportEmotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees
Introduction
There are currently over 35 million refugees and internally displaced persons internationally (UNHCR, 2012), with this number growing markedly in recent years. By definition, refugees have experienced persecution, and are thus often exposed to severe traumatic events including the death of loved ones, physical or sexual assault, and torture. Accordingly, refugees evidence elevated rates of psychological disorders including posttraumatic stress disorder (PTSD) and depression (Fazel et al., 2005, Steel et al., 2009). There is also emerging evidence that individuals exposed to conflict and persecution report high rates of other disorders, such as intermittent explosive disorder (IED; Brooks et al., 2011, Silove et al., 2009), which is characterized by spontaneous anger attacks that are out of proportion to triggering events, and may result in violence and the destruction of property (American Psychiatric Association, 2013). Research conducted over the past three decades has documented a dose–response relationship between trauma exposure and psychological distress in refugees (Mollica et al., 1998a, Mollica et al., 1998b, Steel et al., 2009). Findings from these studies suggested that the greater the number of types of trauma participants were exposed to, the greater PTSD, anxiety, and depression symptoms they exhibited, after controlling for demographics. The adverse effects of trauma on refugees are compounded by post-migration stressors, including unemployment, insecure visa status, discrimination, and distance from family (Porter and Haslam, 2005). Despite numerous studies attesting to the link between trauma exposure, post-migration stressors and psychological disorders in refugees, there has been relatively little research investigating the psychological processes that may underpin this association. Elucidation of these factors would potentially inform the development of targeted treatment interventions to reduce psychological distress in refugees.
Emotion dysregulation represents a key mechanism that may underlie the relationship between refugee-related experiences and psychological disorders. Emotion regulation can be defined as the individual׳s capacity to monitor, evaluate, and modify emotional reactions in a manner that facilitates adaptive functioning (Gratz and Roemer, 2004). Research has indicated that individuals suffering from PTSD have impaired capacity to regulate emotions (Amstadter and Vernon, 2008, Kulkarni et al., 2013, Lilly and Hong Phylice Lim, 2013, Tull et al., 2007, Weiss et al., 2012). Further, difficulties in emotion regulation have been reported to mediate the association between exposure to childhood abuse and symptoms of borderline personality disorder (Gaher et al., 2013) and PTSD (Stevens et al., 2013), as well as between betrayal trauma and symptoms of PTSD, depression, and anxiety (Goldsmith et al., 2013). Notably, the relationship between emotion dysregulation and psychopathology appears to be especially prominent in survivors of repeated interpersonal traumatization (Walsh et al., 2011). While the majority of research investigating emotion regulation in trauma survivors has focused on PTSD, there is also evidence that emotion dysregulation contributes to depression in trauma survivors (Goldsmith et al., 2013, Klemanski et al., 2012, Lilly and Hong Phylice Lim, 2013), as well as in non-trauma exposed individuals (Campbell-Sills et al., 2006, Ehring et al., 2010, Garnefski and Kraaij, 2006). Impairments in emotion regulation have also been linked to anger responses and the perpetration of aggression (Besharat et al., 2013, Mauss et al., 2007, Memedovic et al., 2010, Shorey et al., 2011). Further, there is experimental evidence that the implementation of adaptive emotion regulation strategies can significantly reduce anger and aggression (Denson et al., 2012, Szasz et al., 2011). To our knowledge, however, the relationship between emotion dysregulation and anger responses has not yet been investigated in trauma survivors. While there are multiple ways to conceptualize emotion regulation, we operationalize it in accordance with the definition used in Gratz and Roemer’s (2004) model, which focuses on domains of emotion dysregulation. Difficulties in these areas have been linked to psychopathology, including PTSD and depression (e.g., Bardeen et al., 2013, Klemanski et al., 2012, Stevens et al., 2013, Tull et al., 2007). Other conceptualizations of emotion regulation (e.g., Gross’ (1998) model) focus on specific strategies involved in regulating emotions at different stages during the emotion process. In contrast, in this study, we focus on domains of emotion dysregulation as outlined by Gratz and Roemer (2004) in order to examine the relationship between refugee experiences, broad areas of emotion regulation deficits, and psychopathology.
Refugees may be especially vulnerable to emotion dysregulation as they are typically exposed to multiple types of interpersonal trauma in the context of persecution. Research suggests that post-migration living difficulties are associated with greater symptoms of PTSD, depression, and anxiety in resettled refugees (Porter and Haslam, 2005, Silove et al., 1997), and that reductions in living difficulties mediate improvements in mental health following the transition from insecure to secure visa status (Nickerson et al., 2011). While research to date has failed to address the association between post-migration living difficulties and emotion regulation, it may be the case that these daily living stressors also interfere with refugees׳ capacity to effectively regulate emotions and adapt following trauma and displacement. Accordingly, emotion dysregulation may act as a mechanism underlying the association between refugee experiences and psychological outcomes. This is supported by research evidence suggesting that improvement in emotion regulation capacity partly mediated PTSD symptom reduction following cognitive behavior therapy in Cambodian refugees (Hinton et al., 2009).
The goal of the current study was to investigate the potential mediating role of emotion regulation difficulties in the relationship between trauma exposure, post-migration living difficulties, and psychological outcomes (PTSD symptoms, depression symptoms, and explosive anger) in a sample of treatment-seeking, severely traumatized refugees. As research has suggested that different types of emotion regulation difficulties may be associated with distinct psychological outcomes (e.g., Benoit et al., 2010, Gaher et al., 2013, Hussain and Bhushan, 2011, Tull et al., 2007, Weiss et al., 2013), we investigated the influence on psychological outcomes of the six sub-types of emotion regulation difficulties proposed by Gratz and Roemer (2004). These encompassed (a) non-acceptance of emotional responses, (b) difficulties engaging in goal-directed behavior, (c) impulse control difficulties, (d) lack of emotional awareness, (e) limited access to emotion regulation strategies, and (f) lack of emotional clarity. We hypothesized that difficulties in emotion regulation would mediate the association between trauma exposure and psychological outcomes. In this study, we also propose an exploratory hypothesis; that difficulties in emotion regulation would mediate the association between living difficulties and psychological outcomes.
Section snippets
Participants
Participants were 134 treatment-seeking refugees and asylum-seekers from a variety of backgrounds, including Turkey (N=72, 54%, with N=58, 43% being Kurdish), Iran (N=16, 12%), Sri Lanka (N=11, 8%), Bosnia (N=6, 5%), Iraq (N=6, 5%), Afghanistan (N=5, 4%), and Other (N=20, 13%). Participants were in therapy at an outpatient unit for victims of torture and war in either Zurich or Bern, Switzerland, and had received treatment for a mean of 30 months (SD=28.5). Inclusion criteria for the study
Demographic characteristics
Participants in this study had a mean age of 42.4 years (SD=9.8), and the sample comprised 78.4% (N=105) males. Marital status of the sample was 29.9% single (N=40), 58.2% (N=78) in a relationship or married, and 11.9% (N=16) were divorced or widowed. In terms of educational status, 12.7% (N=17) of the sample had not completed primary school, 32.1% (N=43) had completed primary school, 23.1% (N=31) had completed high school, 23.9% (N=32) had competed a Bachelor׳s Degree or technical college
Discussion
This study investigated the mediating role of emotion dysregulation in the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in a sample of treatment-seeking, severely traumatized refugees. We found that difficulties in specific types of emotion regulation mediated the association between trauma exposure and PTSD and depression; and the association between post-migration living difficulties and PTSD, depression, and explosive anger. These
Conclusion
Findings from this study indicated that the relationship between trauma and post-migration living difficulties, and psychological outcomes is mediated by emotion regulation difficulties in severely traumatized treatment-seeking refugees. Enhanced understanding of the mechanistic role of emotion dysregulation in contributing to psychological distress in refugees may contribute to the development of effective interventions to target the psychological effects of the refugee experience.
Role of funding source
The funding source had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication
Conflict of interest
The authors disclose no conflicts of interest.
Acknowledgments
This study was supported by the Parrotia Foundation, the Swiss Federal Office for Migration (3a-12-0495), and the Swiss Federal Office for Health (12.005187). Angela Nickerson was supported by a National Health and Medical Research Council Clinical Early Career Fellowship (1037091) and Project Grant.
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