Introduction
The United Nations refugee agency reported that in 2016, 65.6 million people–or about 1 percent of the world’s population–were refugees (i.e., forced displaced people; [1]). The Syrian conflict alone has forced over 12.5 million peoples (six out of 10 of the country’s prewar population) from their homes, making this one of the largest refugee displacements in recent history [2]. Pre- and post-displacement factors associated with mental health of refugees include multiple human rights violations and abuses, primary and secondary trauma, loss and concerns about family members, limited access to basic commodities, and problems caused by cultural differences, racism and isolation [3–5]. Consequently, emotional distress in refugees persists even years and decades after resettlement [6, 7]. The most important and clinically significant problems among Syrian refugees are symptoms of emotional distress related to depression, prolonged grief disorder, posttraumatic stress disorder and various forms of anxiety disorders [8, 9]. Prominent factors determining whether psychosocial problems or emotional distress result in mental disorders are refugees’ resilience and coping mechanisms [10, 11]. However, research on these factors is scarce regarding the mental health of refugees in general and Syrian refugees more specifically, leading to calls to take them into account to better inform programs that enhance functionality and coping strategies [8, 9, 12–15].
The current work responds to these calls by exploring critical factors. Specifically, it considers (a) individual differences in self-regulation (i.e., regulatory focus; [16]) as an antecedent of coping and mental wellbeing and (b) contextual influences by investigating their relations among Syrian refugees in Turkey and Germany–countries that provide a shelter to a large number of refugees, but differ not only in terms of support structures and perspectives, but also in their proximity to the conflict zone. As such, it is one of very few social psychological investigations among this highly vulnerable population [17] and aims to make a modest contribution to this urgent problem.
Coping strategies and individual differences
Coping has been defined as cognitive and behavioral efforts that are put into place by people to manage specific external and/or internal demands that are appraised as taxing or exceeding their resources [18]. Over 400 categories or classifications of people’s ways of coping with life-problems (including behaviors, cognitions, and perceptions) exist in the literature [19]. This is due to coping being an organizational construct, encompassing the various actions individuals use to deal with stressful experiences, rather than a specific behavior or belief [20]. Consequently, different lower-order coping categories (e.g., seeking support, emotion expression, denial) have been organized into different higher-order coping categories (e.g., primary vs. secondary vs. relinquished control coping; engagement vs. disengagement coping) by different researchers [20, 21]. A widely applied and accepted conceptualization distinguishes problem-focused coping (i.e., dealing directly with the stressor to remove it or diminish its impact) from emotion-focused coping (i.e., dealing with the associated feelings of distress to minimize and manage them, e.g. using reappraisals; [18]). Building on this, the COPE inventory was developed [22] to assess problem-focused (e.g., active coping, planning), emotion-focused (e.g., positive reinterpretations, acceptance), and less useful, maladaptive coping responses. The latter includes not dealing with either the stressor or its associated distress by avoiding acknowledgement of the problem (e.g., denial; substance use), or by giving up the attempt to do anything about it (e.g., mental or behavioral disengagement). This three-fold distinction also broadly corresponds to coping dimensions in the common-sense model of self-regulation, in which individuals’ lay representations of illness stressors have been found to have direct and, via coping, indirect effects on health outcomes [23, 24]. The current work uses this prominent three-fold distinction of coping strategies affecting wellbeing [20], as has previous work on self-regulation and coping [25]. Meta-analyses found problem- and (with variations also) emotion-focused engagement coping to relate to better, and maladaptive disengagement coping to worse physical and mental health [26, 27].
However, physical and mental health under stress does not only depend on the applied coping strategies. Lazarus and Folkman’s [18] understanding of coping comprises a person-environment interaction: Different environments/stressors lead to variations in coping, and different people vary in their predispositions to cope in particular ways [24]. Indeed, differences in personality and self-regulation impact coping [21, 28]. An important individual difference is optimism, which is positively associated with problem- and emotion-focused coping, but negatively associated with maladaptive coping [29]. In a meta-analytic review the optimism-coping relationship was more substantial for engagement (positive relations with problem- and emotion-focused coping) than disengagement (negative relation with responses such as denial and venting, and thus maladaptive coping; [30]). Optimism is understood to be functional and adaptive because it sustains coping and wellbeing in times of stress. For example, optimist undergraduates were more likely than pessimists to use problem-focused coping, which in turn related to better adjustment in settling into college; they were also less likely to use maladaptive coping [31]. The relation between optimism and better mental health outcomes is thus at least partially mediated by differences in coping strategies. The concept of optimism may be somewhat misplaced when studying Syrian refugees who only recently experienced traumatic loss. However, there is a self-regulation strategy (i.e., a mindset in which goal striving is approached) that constitutes a motivational basis of optimism, namely regulatory focus, and more precisely a promotion focus [25, 32].
Regulatory focus
Regulatory focus theory [16] distinguishes two distinct self-regulatory systems operating within individuals: a promotion and a prevention focus. The promotion focus regulates nurturance needs and is concerned with growth, advancement, and accomplishments. Individuals’ goals in a promotion focus are wishes and aspirations (ideals), and they pursue them using eager strategies, focusing on the presence/absence of positive outcomes (gains). Conversely, the prevention focus regulates security needs and is concerned with safety and responsibilities. Individuals’ goals in a prevention focus are duties and obligations (oughts), and they pursue them with vigilant strategies, focusing on the presence/absence of negative outcomes (losses; [33–35]). As a consequence of these different frames (gain vs. loss) and strategic inclinations (eagerness vs. vigilance), individuals in a promotion focus are motivated by upward counterfactuals (comparing the current to a better reality). In contrast, individuals in a prevention focus are motivated by downward counterfactuals (comparing the current to a worse reality; [36, 37]). Furthermore, a promotion focus is positively associated with optimistic forecasts, and optimistic forecasting increases engagement and persistence among promotion-focused individuals. Contrary, a prevention focus is positively associated with pessimistic forecasts, and pessimistic forecasting increases engagement and persistence among prevention-focused individuals [32]. Finally, optimism itself is positively associated with a promotion focus [25].
Because regulatory focus affects both how people appraise the world and their behavioral strategies in it, it is likely to influence coping behaviors and thus adjustment, especially in high demand situations when people’s self-regulatory system is stressed [28]. For example, when facing a demanding task, a promotion focus results in experiencing more challenge and less threat than a prevention focus, due to more perceived resources [38]. However, whilst some research explored differences in regulatory focus when coping with failure, self-control conflicts and intergroup interactions [28], studies directly targeting both coping strategies and regulatory focus are scarce, and inexistent concerning highly taxing and severe situations refugees are confronted with. To our knowledge, only one study directly assessed both regulatory focus and the coping strategies (using the COPE inventory) in relation to mental health (assessed with the Hopkins Symptoms Checklist, HSCL; [39]) and measured dispositional optimism [25]. In this research, promotion was positively related to optimism. Both foci were negatively related to anxiety and depression, positively related to aspects of problem-focused coping, negatively related to aspects of maladaptive coping, and unrelated to aspects of emotion-focused coping. Finally, optimism partially mediated the promotion-psychological symptoms link. However, this research left unclear what–presumably mundane–stressors undergraduate participants were coping with, only reported results for some COPE subscales, and did not report results for the indirect effects of regulatory focus on wellbeing via coping strategies, of interest in the current work. Nonetheless, based on this research regulatory focus, and especially promotion focus, should likewise be an antecedent of coping and in turn affect mental wellbeing (i.e., directly and indirectly via coping; [24]) among refugees.
However, contextual influences are likely to modify the above reported effects. The summarized research above was conducted in WEIRD countries (i.e., Western, educated, industrialized, rich, and democratic nations; [40]) providing a very different context from the one faced by the refugee groups considered here. Furthermore, and regarding the functionality of coping strategies, a comprehensive review of the literature concluded that it is impossible to determine the adaptiveness or maladaptiveness of any particular way of coping as this is ultimately determined by the specific stressor and situational constraints [20]. For example, faced with an uncontrollable stressor–a frequent experience for refugees–it may be adaptive to disengage [41].
Contextual considerations and overview on predictions
Among different groups of Syrian refugees contexts and experiences are likely to differ substantively. An important contextual factor impacting wellbeing is closeness to the conflict zone, with refugees closer to the Syrian border reporting more distress [42]. It can thus be expected that conflict zone proximity will influence the use of the coping strategies. Likewise, the effects of regulatory focus on coping strategies and in turn on wellbeing might differ compared to earlier research due to such contextual differences.
The current work explores critical factors in coping and mental wellbeing of refugees. It builds on the notion of regulatory focus influencing coping and in turn adjustment in Western/WEIRD samples [28]. Going beyond previous research [25] it explores direct and indirect relations between regulatory focus, coping strategies, and mental wellbeing in Syrian refugees near (Sample 1, Turkey) and distal to the conflict zone (Sample 2, Germany). As such it makes several contributions. First and foremost, it responds to recent calls regarding the importance of investigating refugees’ coping and resilience [8, 9, 12–15]. Second, and relatedly, by taking into account individual differences in self-regulation it might inform more targeted interventions [21], providing an empirical basis to help design intervention programs. Third, considering samples in Turkey and Germany allows exploring the impact of conflict zone proximity on coping with the same stressor. Finally, it extends previous work considering undergraduate students and mundane stressors [25], thus allowing for a comparison with more severe stressors.
Several tentative predictions guided this research, based on the literature reviewed above. First, promotion (and to a lesser extent also prevention) should be positively related to problem-focused coping and in turn to better mental wellbeing [25] (Prediction 1, mediation; promotion and prevention should have an indirect effect via problem-focused coping on mental wellbeing). However, this relation might be stronger and perhaps only emerge in the Germany sample, as conflict zone proximity (along with other contextual factors) may lead to more distress and the situation being perceived as less controllable, thus undermining the adaptiveness of problem-focused coping in the Turkey sample [20, 24, 41, 43]. (Given the contradictory or null-findings regarding the effects of emotion-focused coping and its relation to regulatory focus and wellbeing, we did not deem it appropriate to formulate directed predictions). Second, in both samples promotion and prevention should be negatively related to maladaptive coping and in turn to better mental wellbeing [25] (Prediction 2, mediation; promotion and prevention should have an indirect effect via maladaptive coping on mental wellbeing). Third, conflict zone proximity can be expected to impact both the usage of the coping strategies as well as overall wellbeing [24, 42, 44] (Prediction 3, moderated mediation; the effects of promotion and prevention via problem-focused and maladaptive coping should be moderated by sample differences).
Discussion
The present work responds to recent calls regarding the need to investigate resilience and coping strategies amongst refugees [8, 9, 12–15]. In doing so, it drew on the notion that personality, and in particular individual’s regulatory focus influences coping and in turn adjustment [21, 25, 28]. Consequently, it explored direct and indirect relations between regulatory focus, coping strategies, and mental wellbeing in displaced Syrian refugees living in Turkey and Germany. Several findings emerged from this endeavor.
First, compared to the sample of Syrian refugees in Germany, among Syrian refugees in Turkey symptoms of anxiety and depression (measured with the HSCL) as well as levels of maladaptive coping were higher, whilst levels of problem- and emotion-focused coping were lower. Moreover, the HSCL score in the Turkey sample was well above the clinical cut-off point, stressing the urgent need for interventions among these refugees. It also suggests that Syrian refugees in Turkey experience the situation as more severe, which should impact coping responses and outcomes [24, 42]. Indeed, problem-focused coping, generally understood to be adaptive [21, 22], was detrimental to wellbeing in the Turkey but not the Germany sample. Adding to this, in the Turkey sample not only promotion focus, but also prevention focus increased symptoms of anxiety and depression indirectly via more problem-focused coping. This suggests the stressor being perceived as uncontrollable, a situation in which disengagement or emotion-focused coping are more adaptive than problem-focused coping [18, 24, 41, 54]. The fact that also prevention focus was associated with the, in this particular context, disadvantageous strategy of problem-focused coping dovetails with work showing that prevention focus can be associated with risky choices under situations of loss [55]. Taken together, the current findings indicate a much higher need for interventions targeting mental wellbeing in Turkey (compared to Germany) and suggest that reducing maladaptive may be a promising strategy. Furthermore, future research could explore if interventions to direct problem-focused coping to specific and attainable outcome (within the given the context) reverse its detrimental effect found here. Finally, enhancing emotion-focused coping beyond a critical threshold might likewise result in positive effects for mental wellbeing.
Second, in both samples maladaptive coping increased symptoms of anxiety and depression, in line with the notion that it is dysfunctional [21, 22]. Interventions should thus also target maladaptive coping and draw attention to its negative consequences: Whilst it might provide short-term alleviation, it undermines long-term mental wellbeing. Targeting first and foremost maladaptive (rather than problem-focused) coping seems warranted, as the latter was negatively associated with wellbeing in both samples.
Finally, and most importantly, in both samples promotion focus emerged as a resilience factor: It was directly associated with reduced symptoms of anxiety and depression in Syrian refugees. Also in both samples, promotion was more strongly and consistently associated with a reduction in maladaptive coping than prevention focus. This finding dovetails with research indicating that promotion entails a focus on gains [36], a preference for upward counterfactuals [37], and is associated with optimism (and, in turn, better mental health; [25, 32, 43]). In both samples a promotion focus was also associated with lower symptoms of anxiety and depression, in line with recent research showing that across different layers of personality (i.e., traits, life goals, and life stories) promotion (compared to prevention) focus is related to better psychological and physical health [56]. In the current context, further reasons for this positive influence of promotion focus might lie in its association with openness to change (vs. an association of prevention focus with a preference for stability; [57]) and that loss is experienced more severely in a prevention than in a promotion focus [58]. Future research might explore how regulatory focus shapes dimensions of the cognitive representation of the stressor as proposed by the common-sense model of self-regulation in coping with illness [23, 44]. Alternatively, regulatory focus may be a further dispositional moderator (alongside optimism and perfectionism) of the relation between stressor representations and coping strategies [24]. Regulatory focus can be found at the individual and the group level and varies chronically and situationally [45, 59]. A final intervention recommendation from the above findings is that instilling a promotion focus in refugees can be expected to have beneficial consequences.
Limitations
There are several caveats that come with our findings. First and foremost, our samples are not representative of the groups of Syrian refugees in Turkey or Germany, which limits the generalizability of the current findings. Having representative samples would obviously be desirable, but at the time of data collection, not even the exact number of refugees in both countries was known to government officials and detailed statistics were non-existent. We aimed at collecting data from heterogeneous samples by approaching refugees in various sites both in Turkey and in Germany, and within Germany in states with different policies. Nonetheless, the current data can make no claims regarding representativeness.
Additionally, and in relation to the above point, all differences between samples could either stem from differences between the refugees or the different conditions they are faced with. The demographics of our samples and media reports suggest that those who travel on from Turkey to Europe are on average younger, have a higher SES, and are male rather than female. At the same time, refugees in Turkey continue to witness the direct or indirect consequences of the conflict due to their proximity to Syria. Also, unlike Germany, Turkey does not grant Syrians refugee status along with legal rights, but only temporary asylum seeker status. To this point, a recent study found higher HSCL scores and increased worry as well as social withdrawal among refugees under restrictive (vs. supportive) immigration policies [60]. There are a host of further factors that could be driving effects related to sample differences, stemming from differences between the host countries (e.g., individualism/collectivism or income per capita) as well as different experiences of the refugees in these countries (e.g., perceived stress or experience of traumatic events). Future research is clearly needed to also explore their role in impacting coping and wellbeing. The current data does not allow identifying the causes of sample differences. They do, however, allow comparing whether effects of self-regulation via coping styles on wellbeing hold across both samples and identifying sample differences in these relations.
Further limitations are shared by other research on mental health and wellbeing in Syrian refugees [8, 9, 12, 61]. For example, cross-sectional designs do not allow for claims regarding causality and rather small, non-random convenience samples limit generalizability. Furthermore, additional factors known to impact both coping and wellbeing were not taken into account (e.g., length of displacement, previous psychological conditions). Also, the assessment of clinical symptoms is more accurate and appropriate when integrating local modes of expressing distress and understanding symptoms [62–64]. Finally, the RFQ has not been validated in refugee populations and influences of language and cultural differences cannot be ruled out [65].
Contributions
Nevertheless, the present work makes several contributions to research on mental health and wellbeing of Syrian refugees, the coping literature, and the literature on regulatory focus. It is among the first research investigating resilience factors and coping among Syrian refugees. Recent work found that social identification is one such resilience factor. Specifically, discrimination was not associated with poorer mental and physical health for Syrian refugees in Turkey who derived a sense of efficacy from their Syrian identity; and it was especially associated with lower depression and anxiety for those who derived a sense of belonging from their identity [17]. The current work suggests that differences in self-regulation constitute a further source of resilience, with a promotion focus serving a buffering function and maladaptive coping exacerbating negative effects on mental wellbeing.
The current findings also contribute to and extend the coping literature. First, research has found problem-focused coping with trauma to be associated with better [66] and worse [67] psychological outcomes. It has been suggested that the uncontrollability of a stressor might render problem-focused coping ineffective [24, 68] and that when there is no alternative to take up, continuous commitment to an unattainable goal constitutes a severe form of distress [41, 43]. In the current work problem-focused coping was either not (Sample 2) or negatively (Sample 1) associated with psychological wellbeing, highlighting the fact that indeed it is impossible to determine the general (mal)adaptiveness of any way of coping [20]. Second, research on how individual differences and personality affect coping [21] has mainly focused on the Big Five personality traits [69] and optimism [30]. The current work extends this perspective to self-regulation and the notion that how people appraise the world (“ways of seeing”) and their behavioral strategies in it (“ways of coping”) are both impacted by regulatory focus [28]. As such, it replicates and expands the scarce literature on regulatory focus and coping in undergraduates [25] to severely stressful situations.
Conclusion
Overall, the current work provides one of the very few psychological understandings of Syrian refugees’ coping and mental health. The findings suggest that effective interventions for Syrian refugees that aim to target resilience and coping would be advised to aim at reducing maladaptive coping (i.e., not dealing with the stressor or its associated distress) and to instill an orientation on nurturance, growth and gains (i.e., a promotion focus). Though generally considered effective, problem-focused coping (dealing with the stressor to remove it or to diminish its impact) had a negative (Turkey) or no impact (Germany) on mental wellbeing.