Research reportWhen hope and grief intersect: Rates and risks of prolonged grief disorder among bereaved individuals and relatives of disappeared persons in Colombia
Introduction
After more than 50 years of armed conflict, millions of Colombians have experienced severe human rights violations. About one tenth of the Colombian population has been displaced by paramilitary or guerilla groups. According to recent data, about 80,000 persons are unaccounted for, 25,000 of whom are known to be victims of forced disappearance (Grupo de Memoria Histórica, 2013, Instituto de Medicina Legal y Ciencias Forenses, 2013).
Many people go missing during acts of war, conflict, or natural disasters. Forced disappearance is an exceptional form of disappearance involving forced abduction by agents of the state, followed by the refusal to acknowledge the abduction or to provide any information about the fate of the disappeared person (United Nations, 2007). In several countries, forced disappearance is used as an instrument of political repression to weaken political opponents and to create an atmosphere of silence and fear (De Alwis, 2009, Rozema, 2011).
The loss of a significant other represents one of the most painful experiences in human life. Although most persons who experience a significant loss are capable of adjusting well, a significant number of bereaved individuals develop symptoms of depression or prolonged grief as a consequence of their loss (Stroebe et al., 1988). Prolonged grief disorder (PGD) has been defined as a maladaptive grief reaction following loss. It is characterized by intense longing and yearning for the lost person as well as by feelings of hopelessness and emptiness over a period of at least 6 months (Prigerson et al., 2009). Although PGD and depression share certain symptoms and are therefore often comorbid, research has shown that the two disorders are distinguishable in terms of clinical course and response to treatment (Boelen et al., 2006, Jacobs et al., 1987). Especially after exposure to the violent death of a significant other, PTSD can occur together with PGD (Nickerson, 2014). However, avoidant symptoms in PGD rather refer to reminders of the loss and moving on without the deceased than the avoidance of fear-inducing stimuli as in PTSD (Prigerson et al., 2008).
Persons who lose a significant other to disappearance may experience grief differently from those mourning a deceased loved one, as they have to cope with constant uncertainty about his or her fate (Blaauw and Lähteenmäki, 1997). They are often preoccupied with the potential whereabouts of their significant other and, in repressive states, with the fear of that he or she has been subjected to torture as well as the fear of being subjected to torture or other human rights violations themselves as a form of kin liability (Blaauw and Lähteenmäki, 1997, Grupo de Memoria Histórica, 2013). These preoccupations may exacerbate the processing of the loss. Families of disappeared persons are often confronted with financial hardships as in most cases the person sustaining the family is the one being disappeared (Haugaard and Nicholls, 2010). Without the verification of death, families often have to cope with confusion about roles in the family system (Boss, 2004). Social marginalization and a decline of social support by the community have also been reported to result from disappearance of a significant other (Quirk and Casco, 1994, Robins, 2010). It has therefore been proposed that relatives of disappeared persons experience more severe mental health consequences than do bereaved individuals (Quirk and Casco, 1994). Powell et al. (2010) found higher levels of traumatic grief and severe depression in a group of 56 women whose husband was missing after the war in Bosnia and Herzegovina than among widows who knew their husbands had died in the conflict. Quirk and Casco (1994) interviewed Honduran families in the aftermath of the forced disappearance of a family member and found them to experience higher levels of psychological and physiological distress than families who had lost a family member to accident or illness or than families who had not lost a family member in the last 10 years. In a study on the differential effects of parental loss due to war, early adolescents whose fathers were missing expressed significantly higher levels of depression than did those whose fathers were killed during the war in Bosnia and Herzegovina (Zvizdic and Butollo, 2001).
The uncertainty regarding the whereabouts of a loved one may constitute an important risk factor for mental health problems. After a certain time, some relatives assume the death of the disappeared person, while others continue to believe or maintain hope that the disappeared person is still alive (Robins, 2014, Sluzki, 1990). This belief may prevent them from achieving closure and eventually contribute to the development of prolonged grief reactions (Blaauw and Lähteenmäki, 1997). The idea that hope in the disappeared person returning is associated with increased psychological distress has been suggested elsewhere (Robins, 2010), but has not yet been empirically tested.
A growing body of literature has addressed risk factors of PGD—that is, factors that increase the likelihood of PGD emerging. Recent studies in the context of war and definite loss have shown that PGD is more likely to develop when the death was relatively recent and due to violent causes (Schaal et al., 2010). Concurrent symptoms of depression and PTSD have also been found to constitute a higher risk for PGD (Morina et al., 2011, Stammel et al., 2013). Findings on gender effects have been mixed: Some studies have found that women are more likely to develop PGD; others did not find this association (Morina et al., 2010, Stammel et al., 2013). Whether these risk factors also apply in the context of the disappearance of a significant other has not yet been investigated.
The aim of the present study was to investigate PGD in a sample of persons who lost a significant other to disappearance and in a sample of bereaved individuals. Both groups were victims of displacement due to the armed conflict in Colombia. The first goal was to explore whether psychological distress among persons who lost a significant other to disappearance can be captured by PGD, to determine the rates of PGD, depression, and PTSD and to compare them with the respective rates among persons bereaved through the armed conflict. In accordance with previous findings, we expected persons who had lost a significant other to disappearance to experience more severe mental health distress than bereaved persons. Second, we examined the specific impact on PGD symptom severity of the extent to which relatives or friends of disappeared persons hoped their loved one to be alive. Finally, we sought to gain a more comprehensive understanding of potential risk factors that influence PGD. Based on previous findings, we expected severity of symptoms of depression and PTSD as well as time since the loss to form predictors of PGD among bereaved individuals. Whether these risk factors also applied in persons having lost a significant other to disappearance was subject of research in this paper.
Section snippets
Method
The study utilizes data from a survey on the mental health of internally displaced Colombians and their attitudes to the current reparation program. The cross-sectional study was carried out in four districts of Colombia between September and December 2012. The study was reviewed and approved by the ethics commission of the Freie Universität Berlin. Participants were identified by linear systematic sampling (Chang and Huang, 2000) from a list of N=1898 displaced persons affiliated with our
Sociodemographic characteristics and psychopathology
The sample consisted of n=181 (61.4%) female and n=114 (38.6%) male participants aged M=48.60 (SD=12.50) years on average. Of these, n=73 participants had lost a significant other due to forced disappearance, and n=222 had lost a significant other due to death in relation with the armed conflict.
The two loss groups (‘disappeared’ vs. ‘deceased’) were comparable with regard to sociodemographic variables and did not differ from each other in terms of traumatic exposure, time since loss, or
Discussion
The aim of this study was to investigate PGD in a sample of persons who had lost a significant other to disappearance and in a sample of bereaved individuals, both of which had been affected by displacement due to the armed conflict in Colombia.
High levels of psychological distress were found across the sample (depression: 71.2%, PTSD: 68.1%). These findings may be attributable to several factors, including the wide range of traumatic events to which participants had been exposed, the horrors
Conclusion
This study investigated prolonged grief disorder in a sample of persons who had lost a significant other to disappearance and in a sample of bereaved individuals; both groups had been displaced due to the armed conflict in Colombia. Results showed that persons who lost a significant other to disappearance did not differ from bereaved individuals in terms of traumatic exposure, PGD, depression, or PTSD symptom severity. We further addressed the specific impact on PGD severity of the extent to
Funding body agreements and policies
This work was supported by grants from the German Ministry of Foreign Affairs. The funding organizations had no role in the design and the conduct of the study, in the collection, analysis, and interpretation of the data, or preparation, review, or approval of the manuscript.
Conflict of interest
All authors reported having no competing interests.
Contributors
Carina Heeke had full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Nadine Stammel and Christine Knaevelsrud are responsible for the study design and concept. Data were acquired by Carina Heeke. Carina Heeke undertook the statistical analyses. Carina Heeke drafted the manuscript, which was critically revised by all authors. All authors contributed to and have approved the final manuscript.
Acknowledgments
We thank María Teresa Díaz Gómez and Marlene Ziegler for their immense collaboration in the implementation and carrying out of the study in Colombia. We are very grateful to our colleagues Iván Orlando López Arias, Cristian Julian Suárez Murillo, Federico Troll Gonzalez (all M.A.) for collecting the data. Also we thank Sebastian Burchert for his valuable support and advice in the implementation of the study. Our gratitude goes to our partner organization, the National Association of Victims for
References (35)
- et al.
Psychometric properties of the PTSD Checklist (PCL)
Behav. Res. Ther.
(1996) - et al.
Stress disorders of families of the disappeared: a controlled study in Honduras
Soc. Sci. Med.
(1994) - et al.
Prolonged grief disorder three decades post loss in survivors of the Khmer Rouge regime in Cambodia
J. Affect. Disord.
(2013) - ASFADDES, 2003. Veinte años de historia y lucha: ASFADDES Asociación de Familiares de Detenidos-Desaparecidos....
- et al.
׳Denial and silence׳ or ׳acknowledgement and disclosure׳
Psychiatry
(1997) - et al.
A cognitive-behavioral conceptualization of complicated grief
Clin. Psychol. Sci. Pract.
(2006) Ambiguous loss research, theory, and practice: reflections after 9/11
J. Marriage Fam.
(2004)- et al.
Healing loss, ambiguity, and trauma: a community-based intervention with families of union workers missing after the 9/11 attack in New York City
J. Marital Fam. Ther.
(2003) - et al.
Remainder linear systematic sampling
Sankhyā:Indian J Stat Ser B
(2000) ׳Disappearance׳ and ׳displacement׳ in Sri Lanka
J. Refug. Stud.
(2009)