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The role of grief symptoms and a sense of injustice in the pathways to post-traumatic stress symptoms in post-conflict Timor-Leste

Published online by Cambridge University Press:  30 August 2016

A. K. Tay ,
S. Rees ,
Z. Steel ,
B. Liddell ,
A. Nickerson ,
N. Tam  and
D. Silove
A. K. Tay*
Affiliation:
The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, NSW, Sydney, Australia
S. Rees
Affiliation:
The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, NSW, Sydney, Australia
Z. Steel
Affiliation:
St John of God, Richmond Hospital and the Black Dog Institute, School of Psychiatry, University of New South Wales, NSW, Sydney, Australia
B. Liddell
Affiliation:
School of Psychology, University of New South Wales, NSW, Sydney, Australia
A. Nickerson
Affiliation:
School of Psychology, University of New South Wales, NSW, Sydney, Australia
N. Tam
Affiliation:
The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, NSW, Sydney, Australia
D. Silove
Affiliation:
The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, NSW, Sydney, Australia
*
*Address for correspondence: Dr A. K. Tay, The Academic Mental Health Unit, Psychiatry Research and Teaching Unit, Liverpool Hospital, Cnr, Forbes and Campbell Streets, Liverpool, NSW 2170, Australia and School of Psychiatry, University of New South Wales, Sydney, NSW 2052, Australia. (Email: [email protected])
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Abstract

Aims.

Grief symptoms and a sense of injustice may be interrelated responses amongst persons exposed to mass conflict and both reactions may contribute to post-traumatic stress disorder (PTSD) symptoms. As yet, however, there is a dearth of data examining these relationships. Our study examined the contributions of grief and a sense of injustice to a model of PTSD symptoms that included the established determinants of trauma events, ongoing adversity and severe psychological distress. The study involved a large population sample (n = 2964, response rate: 82.4%) surveyed in post-conflict Timor-Leste.

Methods.

The survey sites included an urban administrative area (suco) in Dili, the capital of Timor-Leste and a rural village located an hour's drive away. Culturally adapted measures were applied to assess conflict related traumatic events (TEs), ongoing adversity, persisting preoccupations with injustice, symptoms of grief, psychological distress (including depressive symptoms) and PTSD symptoms.

Results.

We tested a series of structural equation models, the final comprehensive model, which included indices of grief symptoms and injustice, producing a good fit. Locating grief symptoms as the endpoint of the model produced a non-converging model. In the final model, strong associations were evident between grief and injustice (β = 0.34, s.e. = 0.02, p < 0.01) and grief and PTSD symptoms (β = 0.14, s.e. = 0.02, p < 0.01). The sense of injustice exerted a considerable effect on PTSD symptoms (β = 0.13, s.e. = 0.03, p < 0.01). In addition, multiple indirect paths were evident, most involving grief and a sense of injustice, attesting to the complex inter-relationship of these factors in contributing to PTSD symptoms.

Conclusions.

Our findings support an expanded model of PTSD symptoms relevant to post-conflict populations, in which grief symptoms and a sense of injustice play pivotal roles. The model supports the importance of a focus on loss, grief and a sense of injustice in conducting trauma-focused psychotherapies for PTSD amongst populations exposed to mass conflict and violence. Further research is needed to identify the precise mechanisms whereby grief symptoms and the sense of injustice impact on PTSD symptoms.

Keywords

Bereavementgrief studypost-conflict and cross-cultural psychiatrypost traumatic stress disorderviolence
Type
Original Articles
Information
Epidemiology and Psychiatric Sciences , Volume 26 , Issue 4 , August 2017 , pp. 403 - 413
Copyright
Copyright © Cambridge University Press 2016 

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References

Atwoli, L, Platt, J, Williams, DR, Stein, DJ, Koenen, KC (2015). Association between witnessing traumatic events and psychopathology in the South African Stress and Health Study. Social Psychiatry and Psychiatric Epidemiology 50, 1235–1242.Google Scholar
Barrett, P (2007). Structural equation modelling: adjudging model fit. Personality and Individual Differences 42, 815–824.CrossRefGoogle Scholar
Basoglu, M, Livanou, M, Crnobaric, C, Franciskovic, T, Suljic, E, Duric, D, Vranesic, M (2005). Psychiatric and cognitive effects of war in former Yugoslavia: association of lack of redress for trauma and posttraumatic stress reactions. JAMA 294, 580–590.CrossRefGoogle ScholarPubMed
Boehnlein, JK (1987). Clinical relevance of grief and mourning among Cambodian refugees. Social Science and Medicine 25, 765–772.CrossRefGoogle ScholarPubMed
Brooks, R, Silove, D, Steel, Z, Steel, CB, Rees, S (2011). Explosive anger in postconflict Timor Leste: interaction of socio-economic disadvantage and past human rights-related trauma. Journal of Affective Disorders 131, 268–276.Google Scholar
Eisma, MC, Schut, HA, Stroebe, MS, Boelen, PA, van den Bout, J, Stroebe, W (2015). Adaptive and maladaptive rumination after loss: a three-wave longitudinal study. British Journal of Clinical Psychology 54, 163–180.Google Scholar
Hayes, AF (2013). An Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. The Guilford Press: Washington, DC.Google Scholar
Herman, JL (1992). Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5, 377–391.CrossRefGoogle Scholar
Hofmann, SG, Grossman, P, Hinton, DE (2011). Loving-kindness and compassion meditation: potential for psychological interventions. Clinical Psychology Review 31, 1126–1132.CrossRefGoogle ScholarPubMed
Horowitz, MJ (1986). Stress response syndromes: a review of posttraumatic and adjustment disorders. Hospital and Community Psychiatry 37, 241–249.Google ScholarPubMed
Hu, LT, Bentler, PM (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling 6, 1–55.CrossRefGoogle Scholar
Janoff-Bulman, R (1989). Assumptive worlds and the stress of traumatic events: applications of the schema construct. Social Cognition 7, 113–136.Google Scholar
Kaltman, S, Bonanno, GA (2003). Trauma and bereavement: examining the impact of sudden and violent deaths. Journal of Anxiety Disorders 17, 131–147.Google Scholar
Landes, SJ, Garovoy, ND, Burkman, KM (2013). Treating complex trauma among veterans: three stage-based treatment models. Journal of Clinical Psychology 69, 523–533.CrossRefGoogle ScholarPubMed
Liddell, BJ, Silove, D, Tay, K, Tam, N, Nickerson, A, Brooks, R, Rees, S, Zwi, AB, Steel, Z (2013). Achieving convergence between a community-based measure of explosive anger and a clinical interview for intermittent explosive disorder in Timor-Leste. Journal of Affective Disorders 150, 1242–1246.Google Scholar
Maercker, A, Znoj, H (2010). The younger sibling of PTSD: similarities and differences between complicated grief and posttraumatic stress disorder. European Journal of Psychotraumatology 1, 1–10.Google Scholar
Maercker, A, Brewin, CR, Bryant, RA, Cloitre, M, Ommeren, M, Jones, LM (2013). Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry 12, 1–12.Google Scholar
Mancini, AD, Prati, G, Bonanno, GA (2011). Do shattered worldviews lead to complicated grief? Prospective and longitudinal analyses. Journal of Social and Clinical Psychology 30, 184–215.CrossRefGoogle Scholar
Markowitz, JC, Milrod, B, Bleiberg, K, Marshall, RD (2009). Interpersonal factors in understanding and treating posttraumatic stress disorder. Journal of Psychiatric Practice 15, 133–140.Google Scholar
Mendeloff, D (2009). Trauma and vengeance: assessing the psychological and emotional effects of post-conflict justice. Human Rights Quarterly 31, 592–623.Google Scholar
Modvig, J, Pagaduan-Lopez, J, Rodenburg, J, Salud, CMD, Cabigon, RV, Panelo, CIA (2000). Torture and trauma in post-conflict East Timor. Lancet 356, 1763.CrossRefGoogle ScholarPubMed
Mollica, RF, Caspi-Yavin, Y, Bollini, P, Truong, T, Tor, S, Lavelle, J (1992). The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease 180, 111–116.CrossRefGoogle ScholarPubMed
Mollica, RF, Sarajlic, N, Chernoff, M, Lavelle, J, Vukovic, IS, Massagli, MP (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA 286, 546–554.CrossRefGoogle ScholarPubMed
Momartin, S, Silove, D, Manicavasagar, V, Steel, Z (2004). Comorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. Journal of Affective Disorders 80, 231–238.CrossRefGoogle ScholarPubMed
Murray, LK, Cohen, JA, Ellis, BH, Mannarino, A (2008). Cognitive behavioral therapy for symptoms of trauma and traumatic grief in refugee youth. Child and Adolescent Psychiatric Clinics of North America 17, 585–604.Google Scholar
Muthen, L, Muthen, B (2014). Mplus User's Guide, 7th edn. Muthen & Muthen: Los Angeles.Google Scholar
Nickerson, A, Liddell, BJ, Maccallum, F, Steel, Z, Silove, D, Bryant, RA (2014). Posttraumatic stress disorder and prolonged grief in refugees exposed to trauma and loss. BMC Psychiatry 14, 106–115.CrossRefGoogle ScholarPubMed
O'Connor, M, Nickerson, A, Aderka, IM, Bryant, RA (2015). The temporal relationship between change in symptoms of prolonged grief and posttraumatic stress following old age spousal bereavement. Depression and Anxiety 32, 335–340.Google Scholar
Pham, PN, Weinstein, HM, Longman, T (2004). Trauma and PTSD symptoms in Rwanda: implications for attitudes toward justice and reconciliation. JAMA 292, 602–612.CrossRefGoogle ScholarPubMed
Preacher, KJ, Kelley, K (2011). Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychological Methods 16, 93–115.Google Scholar
Rees, S, Silove, D (2011). Sakit Hati: a state of chronic mental distress related to resentment and anger amongst West Papuan refugees exposed to persecution. Social Science and Medicine 73, 1–23.CrossRefGoogle Scholar
Rees, S, Silove, D, Verdial, T, Tam, N, Savio, E, Fonseca, Z, Thorpe, R, Liddell, B, Zwi, A, Tay, K, Brooks, R, Steel, Z (2013). Intermittent explosive disorder amongst women in conflict affected Timor-Leste: associations with human rights trauma, ongoing violence, poverty, and injustice. PLoS ONE 8, e69207.Google Scholar
Rogler, LH, Cortes, DE, Malgady, RG (1994). The mental health relevance of idioms of distress. Anger and perceptions of injustice among New York Puerto Ricans. Journal of Nervous and Mental Disease 182, 327–330.CrossRefGoogle ScholarPubMed
Shear, MK, Smith, K (2002). Traumatic loss and the syndrome of complicated grief. PTSD Research Quarterly 13, 1–8.Google Scholar
Silove, D (2013). The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings. Intervention 11, 1–12.Google Scholar
Silove, D, Zwi, AB, le Touze, D (2006). Do truth commissions heal? The East Timor experience. Lancet 367, 1222–1224.Google Scholar
Silove, D, Liddell, B, Rees, S, Chey, T, Nickerson, A, Tam, N, Zwi, AB, Brooks, R, Sila, LL, Steel, Z (2014). Effects of recurrent violence on post-traumatic stress disorder and severe distress in conflict-affected Timor-Leste: a 6-year longitudinal study. Lancet Global Health 2, e293–e300.CrossRefGoogle ScholarPubMed
Smith, AJ, Abeyta, AA, Hughes, M, Jones, RT (2015). Persistent grief in the aftermath of mass violence: the predictive roles of posttraumatic stress symptoms, self-efficacy, and disrupted worldview. Psychological Trauma: Theory, Research, Practice, and Policy 7, 179–186.Google Scholar
Sonis, J, Gibson, JL, De Jong, JTVM, Field, NP, Hean, S, Komproe, I (2009). Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice, desire for revenge, and attitudes toward the Khmer Rouge trials. JAMA – Journal of the American Medical Association 302, 527–536.CrossRefGoogle ScholarPubMed
StataCorp (2013). Stata Statistical Software: Release 13. StataCorp LP: College Station, TX.Google Scholar
Steel, Z, Chey, T, Silove, D, Marnane, C, Bryant, RA, Ommeren, M (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 302, 102–122.CrossRefGoogle ScholarPubMed
Tay, AK, Rees, S, Chen, J, Kareth, M, Silove, D (2015). Examining the broader psychosocial effects of mass conflict on PTSD symptoms and functional impairment amongst West Papuan refugees resettled in Papua New Guinea (PNG). Social Science and Medicine 132, 70–78.CrossRefGoogle ScholarPubMed
Van Ommeren, M, Sharma, B, Thapa, S, Makaju, R, Prasain, D, Bhattarai, R, De Jong, J (1999). Preparing instruments for transcultural research: use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcultural Psychiatry 36, 285–301.CrossRefGoogle Scholar