WHAT DO REFUGEES leave behind?

• They leave loved ones unable or unwilling to leave, family members and friends “disappeared” or killed by armed groups, or lost to starvation and disease.
• They leave homes, possessions, land, anything not easily carried on their backs or in a suitcase.
• They leave their sense of identity, competence, and meaning linked to the social and professional roles they once played, and to the experience of having roots in a place where they felt at home, connected to a history that may have extended across generations.

Loss, grief, and bereavement might be considered the understudied stepchildren of the refugee experience, where research has focused primarily on assessing exposure to violence and associated symptoms of psychological trauma (PTSD). There’s no question that PTSD rates are higher in war-affected populations than elsewhere, and the need for scalable trauma-focused interventions is real. Yet everywhere I’ve worked, in every war zone and refugee community, I’ve been struck by the salience of heartbreak, of grief at everyone and everything lost. I think of a grief-stricken Bosnian woman I know who lost her parents, husband, and son on a single day when Serb nationalists attacked her village and burned down her home; of Afghans I’ve met who lost family members, homes, and livelihoods during the war against the Soviets and the ensuing civil war; of the villagers of Gonagala in eastern Sri Lanka, where 54 people were slaughtered in a single night—a traumatic event to be sure, but one that also left a whole community reeling with grief; of Mayan Indians in Guatemala, coping with genocide and struggling with the complexity of grief stemming from the “disappearance” of family members; and of Syrians in refugee settlements in northern Lebanon, grieving the loss of their homes, possessions, life projects, and loved ones who did not survive the relentless war across the border.

An Afghan colleague lost his sister and much her family on a single day during the war against the Soviets. Reflecting on the tragedy from which he eventually recovered, he said, ‘People here have a strong belief in God, so we forget those images, those scenes. The images and memories disappear in time. But the heartbreak, that stays with people, sometimes forever.”

I don’t mean to suggest that most survivors of armed conflict are broken by their grief, or have clinical disorders, or even that sadness and grief are the dominant emotional experiences one encounters among refugees and others affected by war. Numerous studies have shown that we are more resilient than we are fragile in the face of loss, trauma, and other major life stressors (Bonanno, 2010). Only a minority of people become disabled by symptoms of distress, though that minority may be substantial depending on their particular set of experiences. My point is simply that the dominant focus on war-related PTSD among refugees has made it difficult to appreciate the psychological power of other experiences, from continuous stressors in the post-migration environment to the myriad experiences of loss endemic within refugee communities.

In recent years, however, an important shift has occurred. A growing number of studies have found that threats to refugees’ mental health extend well beyond exposure to potentially traumatic experiences of war-related violence. They include, for example, the numerous “post-migration stressors” present in their host setting—stressors such as social isolation, poverty, unemployment, overcrowded and unsafe housing, and heightened family violence.
They also include experiences of loss.
HOW ARE REFUGEES affected by loss? What are common reactions to, and ways of coping with, the various types of loss (interpersonal, material, and psychological), and what types of support are likely to be helpful? The findings of recent research on the mental health of refugees, and on the nature grief and bereavement generally, can shed some light on these questions.

The majority of refugees, like the majority of people generally, do not develop enduring or disabling psychological distress in the aftermath of interpersonal loss (Nickerson et al., 2014). Grief is enormously painful for many people, but we generally move through the pain, shifting continuously into and out of it, as the intensity of the sadness lessens over time. For most people who are bereaved, professional intervention is neither necessary nor even beneficial, particularly during the first few months following the loss (Bonanno, 2010; Wortman & Boerner, 2012). In contrast, naturally occurring social support, as well as spiritual beliefs and practices, may play important roles in helping people move through their grief.

The Afghan colleague I mentioned earlier, who lost his sister and her family during the war against the Soviet Union, ascribed his recovery from the tragedy to a combination of social support from family, and the Islamic concept of sabr--patience and a deep faith in God. Survivors of the massacre in Gonagala, Sri Lanka likewise attributed their healing, however partial, to the emotional and material support they had received, and to the regular practice of dane--a Buddhist ritual that is believed to earn merit for the souls of the deceased so that they will never suffer again so terribly in a future life.

Not everyone recovers naturally from loss, to be sure. A minority of bereaved individuals remain stuck in their grief, finding no relief from their distress. The hallmark of this phenomenon, known variously as prolonged grief disorder (PGD) and persistent complex bereavement disorder (PCBD), is a powerful and disabling yearning for the deceased, which does not abate with the passing of time. PGD differs from depression, which lacks the powerful yearning for, and preoccupation with, a lost loved one. Depression, which needn’t be linked to a specific triggering event, may be diagnosed after two weeks of continuous distress; PGD, in contrast, is triggered specifically by experiences of interpersonal loss, and is generally considered only after a period of six months has passed without a reduction in distress or impairment. PGD has good empirical data to support its validity as a distinct loss-related syndrome (Jordan & Litz, 2014; Lundorff et al., 2017), and a recent study found that PGD (used in the ICD 11) and PCBD (used in the DSM V) reflect the same underlying construct (Maciejewski et al., 2016); that is, they are essentially different names for the same disorder. Estimates of PGD among bereaved individuals the US are generally about ten percent.

Among refugees, symptoms of depression are most powerfully linked to “post-migration stressors”, the stressful conditions of everyday life caused or worsened by war and displacement (Miller & Rasmussen, 2016). Prolonged grief disorder, in contrast, is linked to the violent loss or “disappearance” of loved ones, and may be worsened by high levels of post-migration stress. Whether insecure attachment style increases the risk of PGD among refugees, as it does among survivors of loss in western non-refugee populations, is unknown (very few studies of refugees have assessed attachment histories). In the handful of studies that have examined PGD in refugee or other war-affected communities, prevalence rates have ranged from 20% among Palestinian adolescents (Barron et al., 2015), to roughly 32% among bpth displaced Colombians (Heeke, Stammel, & Knaevensrud, 2015) and Mandean refugees in Australia (Nickerson et al., 2014 ). Although sample bias and other methodological limitations suggest viewing these high prevalence rates with caution, the syndrome does appear to exist among diverse refugee groups, affects significant numbers of people, and merits greater attention by researchers and clinicians concerned with refugee well being.

WHAT DOES ALL this mean for efforts to help refugees adapt successfully to their lives in exile?

• The majority of refugees will recover naturally from their experiences of loss. However, that recovery may be facilitated by helping them adapt successfully to the everyday challenges of life in exile, such as those related to housing, language, employment, transportation, and the need to develop new social networks. Lowering the stress associated with these daunting tasks may free people up psychologically to move through their experiences of loss more easily and help them discover new sources of meaning and identity. It's easier to move on from the past when there are new sources of hope and meaning to invest in.
• Assessments of factors influencing refugees’ mental health (i.e., for community and clinical interventions) should include not only exposure to war-related violence, but also experiences of loss, both interpersonal and material. There are also the intangible losses, such as the loss of professional or vocational identities and valued social roles. 
• Assessments should also include the numerous post-migration stressors common within refugee communities, as these contribute significantly to all forms of psychological distress and may impede healing from war-related loss and trauma.
• It’s important not to confuse depression with prolonged grief. They are distinct, though often co-occurring syndromes. Among refugees, depression seems most strongly linked to the challenges of adapting to life in exile, while PGD has its roots in war-related interpersonal loss. This suggests the need for diverse approaches: community-based interventions for depression that foster successful adaptation to the post-migration environment, and clinical treatment or culturally-specific healing rituals for prolonged grief. There is evidence that cognitive behavioral therapy with a strong exposure component (exposure to the feared experience of loss and grief), whether delivered individually or in group format, may be particularly efficacious for helping people with PGD confront and move through their loss (Bryant et al., 2017; Jordan & Litz, 2014).
• Finally, it's helpful to bear in mind that there is no single, universally "normal" path to recovering from loss. Both across and within cultures, there is enormous variation in how people grieve. The absence of intense sadness in the wake of loss is no more indicative of psychological disorder than its presence. We need only become concerned about the provision of specialized help when grief becomes entrenched and disabling, and does not abate with the passing of time.