Dealing with man-made trauma: the relationship between coping style, posttraumatic stress, and quality of life in resettled, traumatized refugees in the Netherlands

This study investigated the relationship between coping style, posttraumatic stress disorder (PTSD) symptoms, and quality of life in traumatized refugees (N = 335). Participants had resettled in the Netherlands on average 13 years prior and were referred to a Dutch clinic for the treatment of posttraumatic psychopathology resulting from persecution, war, and violence. The majority (85%) of the research sample met diagnostic criteria for PTSD. Path analysis suggested a model in which PTSD symptoms (β = −.61, p < .001), social support seeking (β = .12, p < .05), and emotion-focused coping (β = .13, p < .01) have a direct effect on quality of life. The role of avoidant and problem-focused coping could be interpreted in 2 ways. Either these coping styles are influenced by PTSD severity and have no effect on quality of life, or these coping styles influence PTSD severity and therefore have an indirect effect on quality of life. Intervention strategies aimed at modifying coping strategies and decreasing PTSD symptoms could be important in improving the quality of life of traumatized refugees. Refugees have often experienced severe, prolonged, and deliberately inflicted traumatic events, including shootings, killings, torture, rape, and loss of family (Mooren, 2001). These premigration traumatic events and postmigration stressors contribute to mental health problems (Schweitzer, Melville, Steel, & Lacherez, 2006; Silove, & Ekblad, 2002), which are highly prevalent among refugees in the Netherlands (Gerritsen et al., 2006). In addition to posttraumatic stress disorder (PTSD), trauma exposure is often associated with poor quality of life (Carlsson, Olsen, Mortensen, & Kastrup, 2006). Refugees' long-term psychological adjustment to traumatic and stressful experiences may partly depend on their coping. This is defined as the cognitive and behavioral efforts to manage external and internal stressors (Lazarus & Folkman, 1984) and includes problem-focused coping (dealing with sources of stress), emotion-focused coping (handling feelings and thoughts associated with the stressor), avoidant coping (avoiding dealing with the stressor or associated emotions), and social support seeking (obtaining advice or expressing emotions; Carver, Scheier, & Weintraub, 1989; Endler & Parker, 1990b; Litman, 2006). Generally, problem-focused coping and social support seeking are considered as effective strategies, and emotion-focused and especially avoidant coping as less effective in the long term. Accordingly, problem-focused coping and (seeking) social support have been associated with lower PTSD levels (Ahern et al., 2004; Gorst-Unsworth & Goldenberg, 1998; Ozer, Best, Lipsey, & Weiss, 2003) and higher quality of life (Araya, Chotai, Komproe, & De Jong, 2007), whereas emotion-focused coping seems to increase the likelihood of PTSD symptoms (Hooberman, Rosenfeld, Rasmussen, & Keller, 2010) and to reduce quality of life (Araya et al., 2007). In addition, emotion-focused and avoidant coping have been associated with depressive affect and poor physical health in refugees (Matheson, Jorden, & Anisman, 2008). The relationships, however, between traumatic events, coping, and negative outcomes such as PTSD or reduced quality of life, are complex and remain poorly understood (Schweitzer et al., 2006). Specifically, little is known about the pattern and direction of the causal pathways between these variables. Trauma, for example, could directly undermine psychological health (Mollica, McInnes, Poole, & Tor, 1998) and quality of life (Araya et al., 2007). Alternatively, trauma could diminish the capacity to cope with stressors (Lindencrona, Ekblad, & Hauff, 2008), increase vulnerability to future stressors (Schweitzer et al., 2006; Steel, Silove, Bird, McGorry, & Mohan, 1999), increase the use of negative coping strategies (Emmelkamp, Komproe, Van Ommeren, & Schagen, 2002), and thereby indirectly increase vulnerability to psychopathology (Matheson et al., 2008). The robustness of the relationships between these variables also remains unclear, and is hardly studied across subgroups of refugees. To better understand some of these relationships, this study examined four models of the relationships between coping style, posttraumatic stress, and quality of life. We aimed to determine which model best reflected long-term adjustment of refugees who had endured severe trauma in their countries of origin. Also, we explored whether these models fit differently in male and female refugees, refugees from different countries of origin, and refugees with diverse lengths of stay in the Netherlands. Specifically, the study was designed to compare goodness-of-fit indices across these models: (a) coping style affects both PTSD and quality of life, (b) PTSD affects both coping style and quality of life, (c) coping style affects quality of life via PTSD, and (d) PTSD affects quality of life via coping style. Each model is consistent with the aforementioned literature, but has different theoretical and clinical implications