Coping styles in the treatment of traumatized refugees

Master Thesis

by

Daniël Medema

In association with:
Foundation Centre ’45, the Netherlands
Partner in ARQ Psychotrauma Expert Group
Research internship 01/03/2011 – 31/08/2011

Master Clinical and Health Psychology 2011/2012

Faculty of Social Sciences
Utrecht University

Submitted july 2012

By D.M. Medema, 0467944

Supervisors:
Dr. J.W. Knipscheer Utrecht University
Drs. F.J.J. ter Heide Foundation Centre ‘45
 Abstract
Coping styles may influence refugees’ psychological adjustment to traumatic experiences and have
been associated with PTSD severity and quality of life. This study investigated if coping styles interact
with psychological adjustment, dropout and treatment response and if treatment changes coping.
Participants were traumatized refugees and asylum seekers (N=72) referred to a specialized Dutch
clinic and met diagnostic criteria for PTSD. Clinician-rated PTSD severity, self-reported quality of life
and coping styles were assessed before and after treatment and participants were randomly assigned
to either 9 EMDR or 12 stabilisation sessions. Results indicated that avoidance coping decreased
significantly in EMDR, which is important because pre-treatment avoidance had a detrimental relation
to treatment response. Stabilisation was found to be most beneficial for highly problem-focused
refugees. Assessing coping styles could have value in planning treatment for traumatized refugees
and interventions specifically aimed at modifying coping styles might be of importance.

KEYWORDS: Refugees, Asylum Seekers, Coping, Posttraumatic Stress Disorder (PTSD), Quality of Life,
Treatment Outcome, EMDR, Stabilisation.

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 Introduction
Clinicians and psychologists have long been trying to understand the human psychological reaction to
traumatic events and since the horrors of World War II this enigma deserved considerable clinical
attention. For example Viktor Frankl, holocaust survivor and psychiatrist, already described his
experiences with and theories on human reactions to the horrors of the Nazi concentration camps in
his book Man’s search for meaning back in 1959. As violent conflict, torture and the aggression
accompanying oppression are still the order of the day in many parts of the world, for instance in the
wake of the recent ‘Arabic Spring’, the number of traumatized refugees worldwide increases (UNHCR,
2012) and the need for evidence based treatments for this population is as topical as ever. Guidelines
on posttraumatic stress disorder (PTSD) advocate trauma-focused therapies such as Eye Movement
Desensitization and Reprocessing (EMDR) and Trauma Focused Cognitive Behavioural therapy (TF-
CBT), but a discussion (e.g. Nickerson, Byrant, Silove, & Steel, 2011) exists whether guidelines should
be followed when treating refugees. Some argue that refugees lack safety and stability in different
areas of life, impeding them from benefiting from a trauma-focused treatment. Therefore, a phased
approach is often advocated (e.g. National Institute for Clinical Excellence [NICE], 2005) in which
trauma-focused therapy is preceded by a stabilisation phase that aims to stabilize social, emotional,
cognitive and behavioural functioning of the refugee. Which approach is most beneficial is yet unclear
and Basoglu (2006) critiques this lack of progress in the field and pleas for empirically driven
interventions on PTSD. To address this issue, Ter Heide is currently conducting a randomized trial to
compare the efficacy of EMDR and stabilisation in a sample of of traumatized refugees and asylum
seekers (hereafter the term refugees refers to both refugees and asylum seekers). The feasibility and
acceptability of such a trial was demonstrated in a pilot study (Ter Heide, Mooren, Kleijn, De Jongh, &
Kleber, 2011). To further counseling theory, research and practice, it should however also be
examined “when” and “for whom” PTSD treatments are effective and therefore we should engage in
research on moderators (Frazier, Tix & Barron; 2004). Hence, the present study examines the role of
coping styles as possible moderators in EMDR and stabilistation treatment of traumatized refugees.
This study attempts to add empirical value to the theoretical framework on the treatment of PTSD in
refugees and this may also have clinical implications as to which treatment is more beneficial for which
patients.

Coping with trauma

Coping has been defined as cognitive and behavioural strategies that people employ to deal with
stressful situations (Lazarus & Folkman, 1984) and may influence refugees’ psychological adjustment
to traumatic experiences. Coping processes or coping styles, introduced in more detail below, have
been associated with severity of PTSD symptoms and quality of life in different refugee populations
(e.g. Hooberman, Rosenfeld, Rasmussen, & Keller, 2010; Huijts, Kleijn, Emmerik, Noordhof, & Smith,
2012) and therefore coping styles should be incorporated in our theoretical framework on the
treatment of PTSD. Coping styles may relate to this framework in four different ways: (a) coping styles
may play a part in the etiology and maintenance of PTSD, (b) coping styles may affect treatment
participation, (c) coping styles may interact with treatment effectiveness, and in turn (d) treatment may

3
change coping styles. After providing a definition of coping and an introduction to the field of coping
literature, relevant research considering the four premises will be reviewed one by one.

Defining coping
The concept of coping is defined and operationalized differently in literature which leads to difficulties
in comparing and cumulating results from different studies (Skinner, Edge, Altman, & Sherwood,
2003). An introduction to the different theoretical approaches on coping is given here, to provide a
vocabulary that enables discussing and comparing studies on coping. (For an exhaustive review and
commentary on the categorization of coping behaviours, see Skinner et al., 2003). The greatest
difference in approaches could be viewed as a dispositional versus situational coping dichotomy.
The coping styles approach draws on the psychoanalytic approach on defense mechanisms and
assumes that individuals have a certain tendency towards particular coping strategies, as a consistent,
trait-like, pattern of behaviours (Aldwin & Yancura, 2004; Beutler, Moos, & Lane, 2003). According to
the coping process approach, emerging from the cognitive-behavioural perspective, coping is flexible
and responsive to both environmental demands and personal preferences. Instead of examining
general coping styles, coping process approaches examine how individuals cope with a particular
stressor (Aldwin & Yancura). Others refer to these specific responses by the term coping skills (e.g.
Beutler et al.). Coping strategies can differ in their stability (Aldwin & Yancura). Approaching or
avoiding situations may be more situationally determined than expressing emotions or using religious
resources. Three distinctions in coping domains are very common, although Skinner et al. (2003)
recommend they should no longer be used. One of the oldest distinctions is that of problem-focused
coping versus emotion-focused coping (Skinner et al.). The former involves dealing with the source of
stress, whereas the latter reflects attempts to handle thoughts and feelings associated with the
stressor. Seeking social support, for example may serve either function. Discussing how to solve a
problem with a friend is an example of problem-focused coping. Calling a friend to discuss the feelings
that a situation evokes and eventually crying on the phone, could be categorized as emotion-focused
coping. Another distinction is that of approach versus avoidance coping. Problem solving and support
seeking could be viewed as approach coping for example whereas social withdrawal and emotional
discharge is said to be avoidant coping (Skinner et al.). Another widely used distinction is that between
behavioural and cognitive coping. Some researchers have argued instead that a conscious choice
should be a hallmark of coping but others have critiqued this view because over time coping strategies
may become routinized (Tennen, Affleck, Armeni, & Carney, 2000). Considering avoidance for
example, denial of the problem is seen as cognitive avoidance whereas seeking distraction could be
categorized as behavioural coping strategy. These distinctions are limited in many ways; the principal
problem is the conceptual overlap between the categories. In the aforementioned example, support
seeking can include seeking either problem-oriented advice or emotional disclosure. In other words,
these categories are neither mutually exclusive nor conceptually clear (Skinner et al.) but the reviewed
literature discussed next is still largely based on these distinctions.

4
Coping styles are associated with PTSD symptoms and quality of life in refugees
Several authors have linked coping styles with the prevalence and maintenance of PTSD symptoms
and functioning outcomes in traumatized refugees. Sachs, Rosenfeld, Lhewa, Rasmussen, and Keller
(2008) reported that the level of overall use of coping behaviours was a significant predictor of trauma
symptoms in a sample of Tibetan refugees. Interestingly, trauma experience did not significantly
predict trauma symptoms after controlling for coping activity, indicating that coping styles may buffer
the development of PTSD. Kanninen, Punamäki, and Qouta (2002) investigated how trauma
experience relates to post-traumatic stress symptoms via coping and cognitive appraisals in 103
Palestinian ex-prisoners who experienced torture. They view coping as emotional action readiness
and discern only problem-focused coping (e.g. wanting to understand and wishing to receive social
support) from emotion-focused coping (e.g. feel like giving up, feeling helpless). Using path analysis
and regression analyses they found that men who were recently released were more likely to appraise
their experience as harmful and involving loss. This negative appraisal was in turn associated with
both coping efforts. Furthermore, emotion-focused coping was positively associated with vigilance and
intrusion symptoms and problem-focused coping with avoidance symptoms. Their findings suggest
that coping styles differ in adaptive function across time because problem-focused efforts short after
the traumatic experience were associated with fewer symptoms whereas emotion-focused coping was
associated with a lower level of symptoms in the long run. Emmelkamp, Komproe, van Ommeren, and
Schagen (2002) studied the relationship between coping styles, social support and psychological and
somatic symptoms in two samples of tortured refugees in Nepal. They used the Refugee Coping
Scale, which lists ten so-called positive and ten negative coping styles. Positive coping incorporates
discussing the problem with friends or family, worshipping, going for a stroll, and accepting the
situation, amongst others. Negative coping incorporated for example blaming oneself, drinking alcohol,
and giving up hope. Both positive and negative coping correspond to aspects of problem-focused,
emotion-focused, avoidant as well as religious coping and social support seeking and the results are
therefore difficult to interpret. Regression analyses revealed significant, but weak relationships
between negative coping, received social support, and symptom severity (as measured with the
Symptoms Checklist, SCL). Higher negative coping and lower received social support were related to
higher symptom levels. No relationship between positive coping and symptoms was found but this is
no surprise given the operationalizational limitations. Recently Huijts et al. (2012) demonstrated that
coping styles do not only interact with the level of PTSD symptoms, but also play a role in the quality
of life of refugees. In their study among 335 resettled refugees in the Netherlands they used the
COPE-easy (Kleijn, Van Heck, & Van Waning, 2000) to measure coping styles. This instrument
discerns problem-focused coping, emotion-focused coping, avoidant coping, and social support
seeking. Huijts et al. found that problem-focused and emotion-focused coping correlate inversely with
PTSD symptoms and positively with perceived quality of life. For avoidance coping these correlations
were significant the other way around: greater reliance on avoidance was associated with more
symptoms and a lower quality of life. No significant correlations were found between social support
seeking and either symptom level or quality of life. Path analyses yielded two well-fitting models, which
are depicted in figure 1. In the first model PTSD affects both quality of life and problem-focused and

5
avoidance coping styles. Social
support seeking and emotion-focused
coping affect quality of life directly. In
the second model, avoidant coping
and problem-focused coping affect
quality of life via PTSD and social
support seeking and emotion-focused
coping affect quality of life directly.
Thus, although the direction of the
causal pathways between these
variables should be further
investigated, it is plausible that social
support seeking and emotion-focused
coping have a direct beneficial impact
on quality of life. The role of avoidant
coping and problem-focused coping is
more ambiguous. Trauma may
diminish the capacity to be problem-
focused and increase an avoidant
coping style. Alternatively the mixture
Figure 1: Well-fitting models described by Huijts et al. (2012).
of problem-focused coping and
avoidance coping may impact symptom severity, and thereby influence quality of life.
Hooberman et al. (2010) studied the relationships between coping styles and PTSD symptoms in a
sample of 75 torture survivors. They observed that higher emotion-focused disengagement coping
was associated to greater trauma symptom severity. Emotion-focused disengagement can best be
regarded as a combination of emotion-focused and avoidant coping styles, and it encompasses social
withdrawal and self-criticism. Problem-focused engagement, emotion-focused engagement and
problem-focused disengagement were not significantly associated with trauma symptom severity. In
addition, Hooberman et al. examined the interplay between coping styles and other resilience
variables, namely social comparisons, cognitive appraisal and social support. They found that greater
reliance on downward comparisons (seeing others as worse off than oneself) corresponded to
increased PTSD symptoms. One explanation is that survivor guilt contributes to downward
comparisons, and this leads to greater distress. Furthermore, the significant interaction between
downward comparisons and emotion-focused disengagement coping suggests that this effect is
greater for those who are more self-critical and withdrawn. Hooberman et al. also found that
individuals who rely more on emotional disengagement coping and perceive the traumatic events as
more negative, experience more trauma symptoms. This suggests that those who are prone to be
inward focused may be more likely to blame themselves for the harmfulness of the trauma, and
therefore experience increased distress. Individuals who rely more on emotional disengagement
coping and perceived more control over the traumatic events reported more PTSD symptoms.

6
Perhaps, these individuals feel guilty about not taking actual control while they perceive they could
have, and therefore experience greater distress. The data of Hooberman et al. (2010) suggest that
neither problem-focused coping style nor perceived social support buffer the effects of torture on
distress symptoms which seems to be in line with the findings of Emmelkamp et al. (2002) but contrast
the findings of Huijts et al. (2012) and Kanninen et al. (2002). This lack in consistency may be
explained by the fact that different measures were used. Araya, Chotai, Komproe, and De Jong (2007)
report gender differences regarding the possible influences of coping. They investigated the role of
task-oriented, emotion-focused and avoidance-oriented coping in the relationships between trauma,
subsequent mental distress and quality of life in Ethiopian refugees. Interestingly, avoidance coping
was beneficial in women because it was negatively correlated with mental distress and positively
correlated with quality of life. Emotion-focused coping on the other hand was associated positively with
mental distress and negatively with quality of life. Task-oriented coping was associated with lower
distress only in men, and higher quality of life only in women. A moderating role for task-oriented
coping was found for the effect of mental distress on quality of life. Task oriented coping was found to
be particularly beneficial when mental distress was high.
In summary, different coping styles have been linked to PTSD symptoms and quality of life in different
refugee populations, although all of the discussed studies are limited because of their cross-sectional
character that prohibits drawing conclusions on causality. Though it is assumed that coping styles
have an impact on symptom severity, one may also argue that the relationship is reversed and that
trauma may influence the capacity to cope (Huijts et al., 2012). Trauma experience may motivate an
increase in certain coping efforts (Kanninen et al., 2002). Furthermore, the results are not consistent
and therefore further research on the relationships between coping, symptom severity and quality of
life is legitimate.

Coping and dropout

The role of coping styles in treatment participation has been underexposed in the refugee population,
whilst literature has demonstrated the connection between patient’s coping skills and their treatment
participation in other populations. For example Beutler et al. (2003) point out that patients with alcohol
use disorder who rely more on approach coping are more likely to obtain treatment. Because the
current research collected a sample of individuals who sought care, treatment seeking behaviour and
treatment entry are not examined in this study. However, treatment participation also encompasses
dropout of treatment. According to Beutler et al. there is evidence that those who rely more on
avoidance coping are at higher risk for early dropout. In this perspective, it is notable that avoidance of
trauma related material is one of the defining characteristics of posttraumatic stress disorder (APA,
1994). In exposure therapies, and in lesser extent in EMDR, patients have to engage in the
recollection of their traumatic memories against their tendency to avoid these memories. It could
therefore be expected that highly avoidant patients dropout of EMDR more often than they dropout of
therapies that do not require engaging traumatic memory, such as stabilisation. Hembree et al. (2007)
report no differences in dropout rates between EMDR, exposure therapy, cognitive therapies and
stress-inoculation training in a review of twenty-five studies on PTSD-treatments, however they did not

7
account for differences in coping styles. Lester, Resick, Young-Xu, and Artz (2011) found that African
Americans drop out of cognitive behavioural treatment for PTSD significantly more often than
Caucasians and they hypothesize that differences in coping styles may underlie this racial difference.
The findings of Leiner (2006) do not support this hypothesis because he found that pretreatment
avoidance coping did not predict dropout of prolonged exposure (PE) or EMDR treatment. In contrast,
Bryant et al. (2007) report that civilian trauma survivors who dropped out of treatment for PTSD had
higher avoidance tendencies and catastrophic cognitions than completers, when controlled for the
influence of pretreatment PTSD-severity. In summary, thus far only little evidence supports the
theoretically predictive value of avoidance coping for treatment dropout.

Coping in treatment
Research on moderators could be especially elucidating when there are unexpectedly weak or
inconsistent relations between a predictor and an outcome (Frazier, Tix, & Barron; 2004) as has been
repeatedly the case in PTSD-treatment in refugee populations (Nickerson et al., 2010). Therefore this
article explores the moderating role of coping styles on the relationship between treatment condition
and treatment outcome in the treatment of PTSD in refugees. When assuming that coping styles are
trait-like and relatively stable over time, it can be expected that untargeted coping styles do not
change much over the course of treatment. Coping styles are linked to symptom severity and quality
of life, as is discussed before, the same variables that are targeted in treatment. Therefore coping
styles may also interfere with treatment responsiveness. Few studies have investigated this notion, if
any in traumatized refugees. Brune et al. (2002) studied belief systems as coping factors for
traumatized refugees in a pilot study amongst 141 treated refugees. Their study indicates that a firm
belief system, based on either faith or politics, is beneficial for traumatized refugees. Although the
authors state that belief systems can be regarded as coping strategies they may be only conceptually
related to religious coping or even cognitive appraisals similar to those investigated in the study of
Kanninen et al. (2002). Subjects with a firm belief system showed a significantly greater reduction of
depression symptoms and an improvement in clinical global impression than subjects with a belief
system of no or low importance. Interestingly, no differences were found between therapy forms and
duration of treatment, the use of psychopharmaca and levels of education seemed to be of no
importance. Due to methodological issues such as its retrospective nature, lack of valid measures and
a small religious subgroup in the sample, the findings of Brune et al. can only be interpreted with
caution. There is a small, but growing interest in the role of coping in treatment outside the field of
refugees. Recently Leinier, Kearns, Jackson, Astin, and Rothbaum (2012) examined the role of
avoidant coping in the treatment of rape-related PTSD. Their study revealed that pretreatment
avoidance was inversely associated with post treatment PTSD severity, even when pretreatment
severity was taken into account. This finding is consistent with cognitive-behavioural theories of
recovery of PTSD that state that recovery is associated with decreases in avoidance (Leiner et al.). A
high level of pretreatment avoidant coping was associated with a more rapid decline of PTSD
symptoms during treatment suggesting that women with higher levels of avoidant coping benefit more
from both EMDR and PE than women with lower levels of avoidant coping.

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No studies were found that describe relationships between pretreatment coping styles and outcomes
of stabilisation treatment. Stabilisation aims to enhance stability and control over current symptoms
and daily stressors and confrontation with traumatic memories is avoided. Stabilisation incorporates
techniques from different kinds of interventions that may draw on cognitive behavioural practices and
supportive counseling for example. Stabilisation may also involve teaching the patient specific coping
skills and thus theoretically, it can be argued that stabilisation is most beneficial for those that have
inadequate coping skills. Thus stabilisation may improve quality of life by changing coping styles, a
subject discussed next.

Treatment and changing coping styles

Published accounts of coping interventions for PTSD appear to be missing, according to Aldwin and
Yancura (2004). However, treatments that specifically target coping styles exist in other areas of
clinical psychology. Smith, Tarakeshwar, Hansen, Kochman, and Sikkema (2009), for example,
describe satisfactory results with their coping-focused group therapy in HIV-positive bereaved adults.
They reported a decrease in avoidance coping as a result from the intervention and this decrease was
associated with decrease in depression and grief. Skills Training for PTSD, as described by Cloitre,
Koenen, Cohen, and Han (2002), yields improvement in perceived social support, which is in turn
associated with better treatment outcome. Notably, this perceived social support should be regarded
as the behavioural aspect of coping, rather than the trait-like tendency of seeking support that occurs
frequently in coping literature.
Regarding EMDR, this treatment requires the recollection of vivid trauma memories, and this is
incompatible with trauma-related avoidance. Thus, EMDR requires overruling of the tendency to avoid,
which may lead to an overall decrease in avoidant coping style. Shapiro (1994), the originator of
EMDR, even claimed that EMDR incorporates new coping skills and assists in learning more adaptive
behaviours. Leiner (2006) described in an earlier report on the aforementioned published study (Leiner
et al., 2012) that avoidant coping decreases in patients treated with EMDR and that this decrease was
associated with treatment outcome. Cognitive behavioural theories of coping state that a decrease in
avoidance is essential in the treatment of PTSD (Leiner, 2006). It should be noted however, that there
might be a potential overlap between the concepts of avoidance coping style and symptoms in the
avoidance cluster of PTSD. Concluding, however treatment may not specifically target coping styles,
these might change as a treatment side effect, and contribute to the overall outcome.

Study aims
The present study aims to explore four hypotheses concerning coping in the treatment of traumatized
refugees. First, it is hypothesized that coping relates to pretreatment PTSD symptoms and quality of
life. It is expected that these relationships will be in line with the findings of Huijts et al. (2012) since
they used the same measures for coping and quality of life in traumatized refugees. Thus it is
hypothesized that problem-focused coping and emotion-focused coping correlate inversely with PTSD
symptoms and positively with quality of life. Furthermore it is hypothesized that avoidance coping
correlates positively with PTSD symptoms and negatively with quality of life. It is hypothesized that

9
social support seeking is not related to PTSD symptoms but is associated with higher quality of life.
The second aim of this study is to examine if coping styles predict partitcipant’s dropout. Theoretically,
avoidance coping may predict dropout but the outcomes of the little research on this notion are
contradicting. Therefore, it is hypothesized that avoidance coping does not predict dropout in either
treatment condition. There are no reasons to believe that the other coping styles are associated with
dropout, so the examination of this assumuption has an explorative character. The third objective is to
explore the moderating effect of coping styles on the relationship between treatment condition and
treatment outcome in refugees. In line with the findings of Leiner et al. (2012) it is predicted that
avoidance coping moderates the changes in PTSD severity and quality of life in the EMDR condition.
In other words, it is hypothesized that participants with higher initial avoidance coping will benefit more
(c.q. experience less symptoms and higher quality of life at posttreatment level) from EMDR than
individuals with lower avoidance coping. Though stabilisation may incorporate teaching more adaptive
coping skills, the stabilisation condition in this investigation was not standardized and may thus be
dependant on participants specific needs and therapists’ preferences. Therefore it is predicted that the
treatments effects of stabilisation will be independent of the extent of used coping styles. Fourth, the
present study investigates whether the use of coping styles changes during treatment. Consistent with
the findings of Leiner (2006) it is predicted that EMDR decreases only avoidance coping. From the line
of thought mentioned above, stabilisation may stimulate problem-focused, emotion focused and social
support seeking coping but the treatment had an unstandardized character in this study. Therefore, it
is predicted that these coping styles do not change consistently over the course of stabilisation.
Confrontation with traumatic memories is explicitly avoided in the stabilisation condition, thus it is
predicted that stabilisation has no effect on avoidance coping.

Method
The present study was executed with data that were collected in Ter Heide’s ongoing investigation
and therefore the following study design was based on the pilot study that Ter Heide et al. (2011)
conducted to examine the feasibility of the current randomised trial.

Participants
Participants were refugees and asylum seekers referred to Foundation Centrum ’45, a Dutch institute
for specialist diagnosis and treatment of psychotrauma symptoms resulting from persecution, war, and
violence. Only refugees and asylum seekers (whom are awaiting final decision upon refugee status) of
at least 18 years old who sought treatment for posttraumatic stress complaints were offered
participation in this study following their intake interview. Participants were informed about the study’s
purposes and procedures before signing informed consent. The Medical Ethics Committee of the
Leiden University Medical Centre approved research procedures. Eligibility was then judged during a
clinical interview using the Dutch version of the Mini International Neuropsychiatric Interview (MINI;
Overbeek, Schruers, & Griez, 1999). Patients were excluded whose main diagnosis demanded care in
another setting or who suffered from serious comorbid depression (with psychotic features and/or high
suicidal intent), psychotic disorder, bipolar disorder, substance dependence, or eating disorder. A
sample size of minimal N=68 was thought to be sufficient after power analysis (N=34 per treatment

10
condition, two-sided test, expected effect size .70, α = .05, power of .80) and the number of
participants was set beforehand on 72. Of the 165 eligible participants, 71 declined participation and
22 were excluded on basis of the aforementioned exclusion criteria. Reasons for refusal of
participation were diverse. Some, for example estimated the research as too time consuming, but also
some refugees did not want to be treated with EMDR. Eventually 72 participants were included of
which 14 participants dropped out and thus far 49 participants who completed treatment were
administered their post-treatment measurement.

Procedures
A mixed factorial design was used with two conditions and three moments of measurement. Following
inclusion, block-randomization was used to assign participants to either the EMDR or stabilisation
condition using blocks of the latest two included participants. Participants were administered a series
of measures at pre-treatment, post-treatment and 3-months follow up by blind, trained interns or
research associates. Interventions consisted of respectively 9 and 12 weekly or bi-weekly sessions of
EMDR or stabilisation, of which the first three were preparatory sessions of 60 minutes each. The 6
subsequent EMDR-sessions lasted 90 minutes, of which 60 were designated for essential EMDR. In
these sessions, the trained EMDR therapists aimed at reduction of mental distress associated with the
most troubling traumatic memory following the Dutch version of the EMDR-protocol (De Jongh & Ten
Broeke, 2003). The 9 remaining stabilisation sessions lasted 60 minutes and therapists were
instructed to follow a guideline developed for this particular study. Therapists were instructed to aim at
the enhancement of stability and control over current complaints and to avoid discussion of and
exposure to the traumatic memory. Interpreters were used for both treatment and measurements if the
participants were not sufficiently fluent in Dutch or English.

Sample characteristics are provided in table 1. The majority of participants were male (n = 52, 72.2%)
and the mean age was 41.6 years (SD = 11.3), with a range of 19-73 years. No significant difference
in mean age between conditions existed. Participants had fled from 22 different countries, with half of
the participants (n = 41, 56.9%) from the Middle-East (Afghanistan, Iran, Iraq, Lebanon and Turkey),
and the largest groups of respectively 17 and 15 participants from Iraq and Afghanistan. Fifty-one
(67.1%) participants had been granted permanent or temporary legal residency in the Netherlands.
The participants had resided in the Netherlands on average 10.0 years (SD = 6.5) with a range of 1-35
years. There were 6 and 8 dropouts in EMDR and Stabilisation respectively. Thusfar, 41 (53.9%) non-
dropouts completed the post-treatment measure of coping. Forty-two (55.3%) and 37 (48.7%) of the
non-dropouts completed the post-treatment measures of symptom severity and quality of life
respectively.

Measures
Sociodemographic information was collected using a designated form and included only gender, age,
country of origin, residency status, number of years spent in the Netherlands, education level, religion,
marital status, domestic situation, number of children, number of family members in the Netherlands

11
and occupation status. Furthermore, therapy history and current medication use were inventoried.
Medication was maintained stable and if not possible, changes were monitored, as were important life
events.

Table  1        
Baseline  demographics  of  intent-­‐to-­‐treat  sample    

  Total   EMDR   Stabilisation  

  (N  =  72)   (n  =  36)   (n  =  36)  
Variable   n  (%)  /  M  (SD)   n  (%)  /  M  (SD)   n  (%)  /  M  (SD)  
Dropout   14  (19.4%)   6  (16.7%)   8  (22.2%)  
Age   41.6  (11.3)   43.4  (10.7)   39.7  (11.7)  
Gender        
   Male   52  (72.2%)   30  (83.3%)   22  (61.1%)  
   Female   20  (27.8%)   6  (16.7%)   14  (38.9%)  
Region  of  birth  1        
   Africa   19  (26.4%)   9  (25%)   10  (27.8%)  
   Asia   2  (2.8%)   1  (2.8%)   1  (2.8%)  
   Balkan   10  (13.9%)   3  (8.3%)   7  (19.4%)  
   Middle  East   41  (56.9%)   23  (63.9%)   18  (50%)  
Education  level        
   <  Highschool   22  (30.6%)   11  (30.6%)   11  (30.6%)  
   Highschool  or  equivalent   15  (20.8%)   5  (13.9%)   10  (27.8%)  
   Higher  education   24  (33.3%)   15  (41.7%)   9  (25%)  
   Unknown   11  (15.3%)   5  (13.9%)   6  (16.7%)  
Marital  Status        
   Married   36  (50%)   21  (58.3%)   15  (41.7%)  
   Never  married   17  (23.6%)   6  (16.7%)   11  (30.6%)  
   Seperated/divorced   10  (13.9%)   5  (13.9%)   5  (13.9%)  
   Widowed   5  (6.9%)   1  (2.8%)   4  (11.1%)  
   Unknown   4  (5.6%)   2  (5.6%)   2  (5.6%)  
Refugee  status        
   Asylum  seeker   8  (11.1%)   3  (8.3%)   5  (13.9%)  
   Limited  residence  permit   12  (16.7%)   6  (16.7%)   6  (16.7%)  
   Unlimited  residence  permit   24  (33.3%)   10  (27.8%)   14  (38.9%)  
   Dutch  nationality   15  (20.8%)   9  (25%)   6  (16.7%)  
   Rejected   2  (2.8%)   1  (2.8%)   1  (2.8%)  
   Unknown   11  (15.3%)   7  (19.4%)   4  (11.1%)  
Religion        
   Atheïst   3  (4.2%)   2  (5.6%)   1  (2.8%)  
   Muslim   32  (44.4%)   13  (36.1%)   19  (52.8%)  
   Christian   13  (18.1%)   6  (16.7%)   7  (19.4%)  
   Hindu   2  (2.8%)   1  (2.8%)   1  (2.8%)  
   Other   1  (1.4%)   0   1  (2.8%)  
   Unknown   21  (29.2%)   14  (38.9%)   7  (19.4%)  
Number  of  years  spent  in  
Netherlands   10.0  (6.50)   10.96  (7.65)   9.31  (5.41)  
1
 Categorized  geographically      

12
Coping style was assessed with an adapted version of the Coping Orientations to Problems
Experienced inventory (COPE; Carver, Scheier, & Weintraub, 1989, as cited in Kleijn et al., 2000): the
COPE-easy (Kleijn et al.). This study used the trait version of the COPE-easy in Dutch and English
translations, if necessary administered orally with the help of an interpreter. This instrument was
chosen because of its putative suitability with refugees and asylum seekers (Kleijn et al., 2000) and its
relative brevity. The creators argue that the scale is simple and clear and therefore appropriate for
measures across diverse ethnic groups. The series of measurements that was administered would
take three hours on average, so brevity was an important factor in the choice of this instrument. The
COPE, Brief COPE and COPE-easy have proven to be reliable and valid across various populations
(e.g. Kallasmaa & Pulver, 2000; Perczek, Carver, Price, & Pozo-Kaderman, 2000), but it should be
noted that the current sample is of different cultural constitution. The 32 items constitute 15 scales that
can be categorized in different ways. After comparison of different factor-solutions of the COPE
(Carver et al, 1989, as cited in Kleijn et al., 2000; Litman, 2006), a factor solution of the COPE-easy by
its creators (Kleijn et al., 2000) and a reliability analysis with the current sample, in this study was
chosen for the four following coping categories. The current sample was too small to conduct a factor
analysis. The four discerned factors measure problem-focused coping (active coping, planning,
suppression; Cronbach’s α: .83), emotion-focused coping (restraint coping, positive reinterpretation,
acceptance; Cronbach’s α: .77), avoidant coping (denial, behavioural disengagement, mental
disengagement; Cronbach’s α: .48) and social support seeking (instrumental social support, emotional
social support, venting of emotions; Cronbach’s α: .70). The subscales substance abuse, humor and
religion were not included in these categories because they yielded low factor loadings in the
aforementioned studies and decreased the reliability of the factors to an unacceptable level. An
adapted version of the subscale avoidant coping was constituted to enhance the reliability and to
enable refined statistical analyses. Behavioural disengagement was therefore removed from the
avoidant subscale which resulted in a Cronbach’s α of .63.

Severity of PSTD symptoms was assessed using the Clinician Administered PTSD Scale (CAPS) as
constructed by Blake et al. (1995, as cited in Weathers, Keane, & Davidson, 2001) or its Dutch
version. It assesses all DSM-IV (A-F; APA, 1994) diagnostic criteria for PTSD. Only the data of criteria
B (symptoms of re-experiencing), C (numbing and avoidance) and D (hyperarousal) were used to
compute a total severity score (range 0-136, higher scores reflecting more severe PTSD) that was
used for analyses in this study. The other criteria (exposure to traumatic event, chronology, functional
impairment) are included for diagnostic purposes but do not validly measure severity of symptoms.
Criteria B, C and D consist of 17 symptoms for which frequency and intensity are measured on
separate five-point scales (0-4) that construct a nine-point (0-8) severity score for each symptom when
summed. For the last 9 symptoms (emotional numbing and hyperarousal) only, a three-point scale
(definite, probable, unlikely) was used to determine if the symptom was attributable to a specific
traumatic event (Weathers et al.). If scored ‘unlikely’ the symptom’s severity score was set to 0. The
CAPS was chosen because it has excellent psychometric properties across a wide range of clinical
samples (Weathers et al.). Thanks to the use of initial and follow-up prompt questions and explicit

13
rating anchors with behavioural referents, the instrument is well standardized across interviewers.
Interrater-reliability levels have been found to be consistently above .90 and correlations of .70 and
above with various self-report measures were found, demonstrating its convenient convergent validity
(Weathers et al., 2001). If consented, videotaping was also used to examine the inter-rater reliability of
the CAPS, although its discussion reaches beyond the scope of this article. In a study with the Dutch
translation the cronbach’s alpha for the individual clusters B-D were found to range from .63 to .79 and
the internal consistency of the total 17 symptoms was found to be .89 (Hovens et al., 1994 as cited in
Weathers et al.). The CAPS is validated in different refugee populations such as Cambodian refugees
(Hinton et al., 2006), but considering that the current sample is of different cultural composition, its
validity should be regarded with caution. Relatively low cronbach’s alphas of .65, .61 and .53 for PTSD
symptom clusters B, C and D respectively and an acceptable alpha of .75 for the entire syndrome
score, were found in the present investigation.

Quality of life was assessed with translations of the 26-item WHOQOL-BREF, an abbreviated version
of the WHOQOL-100 assessment (World Health Organization Quality Of Life; The WHOQOL Group,
1998). It comprises of 24 items loading onto four domains Physical Health, Psychological Health,
Social Relationships and Environment and the remaining two items concerning Overall quality of life.
Each item can be scored on a five-point scale (1-5) and three items have reverse coding. The
WHOQOL-BREF was chosen because of its alleged fine psychometric qualities and its brevity. The
WHOQOL Group found cronbach’s alpha values ranging from .66 to .84 for the four domains. Initially
exceptionally low alphas were found in the current sample. After removal of the three reverse coded
items all domains were conveniently reliable. Extremely low item-total correlations for these items are
presumably due to a yet unidentified data entry error. Eventually the alphas were .68, .58, .43, and .74
for Physical Health, Psychological Health, Social Relationships and Environment respectively. It
should be noted that the alpha value for social relationships (.66 in The WHOQOL Group’s sample)
was based on only three items so its reliability cannot be validly assessed. The WHOQOL Group
found that all four domains contribute significantly to overall quality of life. The consistency of the total
scale was found to be .84 after removal of the three error items. Means for the four domains and the
total were computed and multiplied by four to range between 4 and 20 (The WHOQOL Group), with
higher scores reflecting a higher quality of life.

Statistical analyses
Statistical analyses were performed using SPSS (PASW version 18.0.0). First, demographic and
clinical descriptives were computed. To assess the relationship between coping and symptom
variables at baseline pearson’s correlation were computed. A loglinear regression was performed to
test if coping styles can predict dropout. Independent t-tests were performed to check for baseline
differences between the two conditions at baseline. The moderating role of coping styles was tested
with a series of multiple regression analyses. The change of coping style over the course of treatment
was assessed with a series of dependent t-tests and ANOVAs.

14
 Results
Table 2 presents the clinical descriptives of the sample at baseline and post-treatment. Difference
scores for CAPS, COPE-EASY and WHOQOL-BREF domains and total were obtained by subtracting
the pre-test score from the post-test score so that negative difference scores indicate a decrease and
positive difference scores indicate an increase in symptoms or use of coping strategies. For linear and
loglinear regression analyses, the CAPS, WHOQOL-BREF and COPE-easy scores were centered, as
recommended by Frazier et al. (2004), by subtracting the mean from the individual score on each
instrument.
The mean total PTSD-severity score did not differ between both treatment conditions at pre-treatment
measure, t(68) = -.82, p > .05, nor did the WHOQOL-BREF-total score, t(69) = 1.13, p > .05, nor did
the score for psychological health domain, t(58.99) = -.06, p > .05. Problem Focused coping (t(68) = -
1.01, p > .05), Avoidant coping (t(68) =.27, p > .05) and Social Support Seeking (t(68) = -1.46, p > .05)
did also not differ for treatment groups at baseline measure. The EMDR-group (M = 2.33, SD = .55)
seemed to differ from the Stabilisation group (M = 2.58, SD = .64) on Emotion Focused coping but the
difference did not reach a convincing significance level, t(68) = 1.75, p = .08.

Table 2
Clinical descriptives
Pre-treatment Post-treatment
a
Variable n M (SD) n M (SD)
CAPS B 71 24.56 (7.30) 48 22.00 (9.61)
CAPS C 71 28.59 (9.35) 49 25.12 (10.57)
CAPS D 71 23.46 (6.68) 49 22.14 (7.51)
CAPS Total 70 77.09 (17.76) 47 70.26 (24.04)
Problem-focused coping 70 2.76 (.71) 49 2.61 (.63)
Emotion-focused coping 70 2.46 (.60) 49 2.36 (.60)
Avoidant coping 70 2.59 (.57) 49 2.37 (.64)
Social support seeking 70 2.39 (.66) 49 2.52 (.79)
b
WHOQOL-BREF Total 71 10.13 (2.19) 49 9.96 (2.40)
b
WHOQOL-BREF Psychological 71 10.04 (2.62) 49 9.57 (2.80)
a
dropouts excluded
b
adapted version for improved reliability

One outlier regarding traumatic complaints was identified for which the CAPS-score decreased
conspicuously from 98 to 15 after treatment. After removal of the outlier a paired t-test revealed that
the CAPS Total score decreased significantly from pre- to post-treatment, t(45) = 2.23, p < .05, with a
mean difference of 5.70 points (SD = 17.35) representing a medium sized effect (r = .32). An
independent t-test revealed no difference in symptom decrease between treatment conditions,
t(44) = -.853, p > .05.
The total WHOQOL-BREF-score did not change significantly, t(48) = -.68, p > .05, neither did the
WHOQOL-BREF-score for the psychological domain, t(48) = -.72, p > .05. There was no difference
between conditions in the change of both total WHOQOL-BREF-score (t(47) = .67, p > .05) and the
Psychological domain, t(47) = .61, p > .05.

15
Relationships between variables at baseline level
Pearson’s correlations between the coping styles and pre-treatment measures were computed and are
presented in table 3. In addition, correlations between the various subscale scores were analysed and
some remarkable findings are described next. Though the avoidance subscale did not correlate
significantly with either the CAPS-score nor the adapted total WHOQOL-BREF-score, there was a
significant positive correlation with the self-report symptom severity measure (Harvard Trauma
Questionnaire, HTQ; r=.27, p<.05). The adapted avoidance subscale was found to significantly
correlate negatively with the adapted version of the psychological quality of life subscale (r=-.25,
p<.05). Though emotion-focused coping did not correlate significantly with the total CAPS and
WHOQOL-BREF-scores, negative correlations with the vigilance domain (CAPS-D; r=-.24, p=.05) and
the avoidance domain (CAPS-C; r=-.22, p=.07) tended towards significance. Notably, avoidance
coping did not correlate with the avoidance domain of the CAPS.

Table 3.
Correlations between pre-treatment measures
Measure 2 3 4 5 6
b
1 CAPS -.41** -.10 -.21 -.04 .05
a
2 WHOQOL-BREF Total - .27* .17 -.07 -.09
3 Problem focused coping - .54*** .13 .29*
4 Emotion focused coping - .34** .48***
5 Avoidant coping - .14
6 Social support seeking -
a
Adapted Total WHOQOL-BREF score with improved reliability  
b
p = .09.
* p<.05. ** p<.01. ***p<.001.  

To elucidate the associations between variables further, hierarchical regressions with three steps were
performed with modified total quality of life as dependent variable. The centered total CAPS-score was
entered in step one. Subsequently one of the centered coping styles and the interaction between that
particular coping style and total CAPS-score were entered into the model.
The association between problem-focused and quality of life remained significant and independent of
2 2
CAPS-score (F(1,50) = 4.19, p < .05, ΔR = .06, model R = .26). The relationship between problem-
focused coping and quality of life was positive thus higher problem-focused coping was associated
with higher quality of life (β = .25, t(52) = 2.05 , p < .05). Adding the interaction term did not
2
significantly improve the model (F(1,49) = .10, p > .05, ΔR = .00). Emotion-focused coping and
avoidance coping did not predict quality of life directly nor via interaction, when controlled for symptom
severity. Social support seeking did not predict quality of life directly but the interaction term with
2 2
symptom severity was found to be significant (F(1,49) = 6.19, p < .05, ΔR = .09, model R = 2.91).

16
The regression coefficient of the interaction was positive (β = .30, t(52) = 2.49, p < .05), suggesting
that higher social support seeking is more beneficial, specifically for those that have more PTSD
symptoms.

Coping styles and dropout

A series of standard loglinear regressions was performed to test if coping styles can predict dropout.
First, dichotomized treatment condition, centered CAPS scores, centered coping styles scores and
interaction variables for coping styles with the dichotomized treatment condition were computed.
Considering the small sample that dropped out (n=14), an α of .10 was regarded acceptable
for testing the loglinear regressions. First, an overall model was tested, with dichotomized condition,
centered CAPS score and the four coping styles scores as predictors. The goodness of fit test of the
2
model was not significant (Χ (6) = 5.93, p > .05), but when considering individual variables it was
noticed that problem-focused coping might be a significant predictor (Wald(1) = 3.62, p =.06, B =
1.06). Next, individual models were tested for each coping style, including its interaction term,
dichotomized condition and centered CAPS score. None of the models fitted the data significantly
2
better than a model with only a constant as was tested with Chi -tests. Again, when examining
2
problem-focused coping, although the model was not significant (Χ (4) = 4.10, p > .05) it might be a
significant predictor of dropout (Wald(1) = 2.78, p < .10, B = 1.11). Greater reliance on problem-
focused coping may enhance the chance of dropout.

Coping styles, treatment condition and treatment outcomes

A series of hierarchical regression analyses was performed after removal of the aforementioned
outlier, because outliers reduce the power to find significant results (Frazier et al., 2004). The analyses
were performed with post-treatment CAPS-score, total WHOQOL-BREF-score and psychological
WHOQOL-BREF-score as dependent variables. For coping, baseline measure was used based on the
assumption that coping is a relative stable trait end because the general (dispositional) version of the
COPE-EASY-measure was used. Four interaction variables between treatment condition and each of
the four coping styles were computed. A model with three steps was tested for each coping style with
post-treatment CAPS-score as a dependent variable. The first step included centered pre-treatment
score and dichotomous treatment condition. In the next step, the centered coping style was entered
and finally the interaction between coping style and condition was entered. Models that yielded
significant findings are displayed in table 4 and table 5.
Considering CAPS-scores, only problem-focused coping and avoidance coping seemed to be of
importance, there was never a main effect for condition. A small effect for the interaction between
condition and problem-focused coping was found, but the effect did not reach significance at the α =
.05 level. The interaction term has the greatest negative value for highly problem focused individuals
that receive stabilisation, which indicates a greater decrease in symptoms for those individuals. No
significant main effects for condition or problem-focused coping were found. The interaction between
condition and avoidance coping was not significant but a small main effect for avoidance coping was
found to be significant. A small main effect for avoidance coping on the post-treatment quality of

17
psychological health was also found, independent of treatment condition. No interaction effect with
condition was found for this coping strategy. Thus, individuals with higher avoidance coping
experience more symptoms after treatment, controlled for pre-treatment symptom score. Furthermore,
they report a lower quality of psychological health after treatment, controlled for their pre-treatment
score on this scale. All other models considering total quality of life and quality of psychological health
yielded no significant changes in explained variance.

Coping Change
Paired samples t-tests showed that avoidance coping decreases (M of difference = .19, SD = .70) from
pre- to post-treatment significantly (t(46)= 2.03, p<.05). The effect size was .29, thus the effect can be
considered a medium effect. A t-test revealed (t(45)= 1.62, p=.05, one-sided test) a small (r=.23)
difference in avoidance decrease between EMDR (M=.35) and Stabilisation (M=.02). No other
significant changes in coping where observed.

Table  4          
Moderator  Models  of  Coping  styles  on  CAPS  post-­‐treatment  score  
R2  change  
2
Model  &  Variables   R  model     (p-­‐value)   β   t  value  (p)  
Problem-­‐focused  coping          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .50   .00  (ns)      
   COPE-­‐PF       -­‐.05   -­‐.47  (ns)  
Step  3   .54   .04a      
   Condition  x  COPE-­‐PF       -­‐.28   -­‐1.73a  
         
Avoidant  coping  (modified)          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .56   .06*      
   COPE-­‐AV       .13   2.39  *  
Step  3   .57   .01  (ns)      
   Condition  x  COPE-­‐AV       -­‐.15   -­‐1.13  (ns)  
         
* p < .05, ** p < .01, *** p < .001
a
p = .09

18
 Table  5          
Moderator  Model  of  Coping  styles  on  WHOQOL-­‐BREF  PSY  subscale  post-­‐treatment  score  
R2  change  
2
Model  &  Variables   R  model     (p-­‐value)   β   t  value  (p)  
Avoidant  coping  (modified)          
Step  1   .26     .26  **      
   CAPS  T1       .49   3.58***  
   Condition       -­‐.13   -­‐1.03  (ns)  
Step  2     .34   .08*      
   COPE-­‐AV       -­‐.30   -­‐2.27*  
Step  3   .34   .00  (ns)      
   Condition  x  COPE-­‐AV       .02   .13  (ns)  
         
* p < .05, ** p < .01, *** p < .001

Discussion
This study examined the roles of coping styles in EMDR and stabilisation treatment of traumatized
refugees by testing four hypotheses. Although a handful of studies examined how coping styles relate
to PTSD and quality of life in refugees, this is the first known study that examines the role of coping in
treatment of PTSD in this highly distressed population. The results confirm that more PTSD-symptoms
correspond with a lower quality of life (e.g. Araya et al., 2007; Huijts et al., 2012). Furthermore,
problem-focused coping was found to be related to higher quality of life, but the study fails to confirm
the relationship between problem-focused coping and lower PTSD-symptoms that Huijts et al. found.
This is in line with the findings Hooberman et al. (2010), but Araya et al. demonstrated that the
aforementioned associations were gender specific, which may explain the failure to find the expected
association. Greater reliance on emotion-focused coping was related to less PTSD symptoms, but the
expected relationship with quality of life was not found. This is a surprising finding because in the
models of Huijts et al. emotion-focused coping was directly and positively associated with quality of
life, without mediation by PTSD symptoms. This may be explained by the fact that in their study,
religion and humor were also included in the emotion-focused category, whereas these subscales
were excluded here. Araya et al. found emotion-focused coping to relate to well-being in a negative
manner, so the role of emotion-focused coping remains unclear because of differences in
operationalizations. The role of emotion-focused coping, may be moderated by other resilience
variables, such as perceived control over a stressor as proposed by Hooberman et al. and Penley,
Tomaka, and Wiebe (2002). Contrary to expectations, avoidance coping was not associated with
either quality of life or clinician-rated PTSD severity. However, more avoidance was associated with
more self-reported PTSD symptoms, in line with previous findings. These findings may be explained
by the plausible mediating role of PTSD severity in the relationship between quality of life and
avoidance coping. As expected, social support seeking was not related to PTSD-symptoms, but
surprisingly it was not directly associated with quality of life as was found by Huijts et al. However, a

19
significant interaction effect was found, indicating that higher social support seeking is especially
beneficial for individuals that have more PTSD symptoms.

Coping styles and dropout

None of the coping styles had a predictive value regarding dropout, confirming the second hypothesis.
The finding that avoidant coping style does not predict dropout in this study is consistent with the
findings of Leiner et al. (2012). Neither emotion-focused coping nor social support seeking were
associated with dropout, as was expected. Interestingly, there were weak indications that problem-
focused coping may predict dropout. The major cause for dropout in this study was that patients
missed too many sessions without a clear argumentation. In line with evidence that comorbid
depression severity contributes to dropout in PTSD-treatments (Scott & Stradling, 1997) one subject
was considered a dropout because of severe depression, and another after a suicide attempt. Two
participants refused to talk about traumatic experiences in the EMDR-condition, which hypothetically
could be related to a high avoidant coping style. Furthermore, very practical reasons played a part in
dropout: one participant emigrated, and another had to travel to far to reach the treatment centre.
Thus, the causes for dropout can be diverse, which explains that no strong predictors were found. It
cannot be ruled out, however, that coping styles may be one of the many variables that play a part in
dropout.

Coping styles, treatment condition and treatment outcomes

The third objective of the present study was to explore the impact of coping on treatment response.
Against expectations higher pre-treatment avoidance was associated with higher post-treatment
symptoms and lower quality of psychological health, independent of treatment condition. These results
compete with the findings of Leiner et al. (2012) that demonstrated that participants with higher
avoidance coping at baseline measure benefit most from EMDR. Leiner et al. suggested that a
decrease in avoidance is essential to recovery and therefore individuals with the highest avoidance
may gain the most from therapies that induce such a decrease. Indeed, avoidance coping decreased
in the EMDR condition, but high pre-treatment avoidance was still associated with detrimental
outcomes, thereby supporting the opposing theory. This states that the process of treatment recovery
is similar to that of naturalistic recovery (Leiner et al.) that is hindered by avoidance coping. After all,
avoidance coping has been associated with increased PTSD severity and lower quality of life (e.g.
Huijts et al.), as described above. From this theory, it follows that higher avoidance may impede
individuals from benefiting from treatment.
When considering problem-focused coping, findings were also unexpected. Highly problem-focused
individuals seem to benefit more from stabilisation. A possible explanation for this finding is that
stabilisation may match with the preferences of the highly problem-focused individual because it aims
to control current symptoms and daily stressors. Patients that are strongly inclined to engage problems
actively may not possess the knowledge in which way symptoms and other stressors can be
adequately dealt with. When a therapist teaches them these skills, they are more likely to put these
into action than less problem-focused patients. On the other hand, there is little time in EMDR-

20
treatment to discuss skills that enhance control over symptoms, so patients that are treated with
EMDR do not benefit from being more problem-focused. Highly problem-focused patients might also
require another treatment approach from the therapist than others. They might be more active in
asking questions on how to deal with their stressors and thereby obtain more information on how to
develop adequate skills. Higher emotion-focused patients for example, might demand more time in
treatment to discuss their feelings.
No associations with treatment response were found for emotion-focused coping and social support
seeking. A possible explanation for the fact that no or unexpected linear relationships between coping
styles and treatment response were found might be that these relationships are non-linear (Frazier et
al., 2004), although the results provide no indications in this direction. For example, a certain degree
of each coping styles may be beneficial because coping styles may serve different functions
(Kanninen et al., 2002). A total lack of a coping style, or exactly the excessive use of this coping style
may both be maladaptive. From this line of thought, non-linear relationships seem plausible. Models
explaining treatment response could be far more complex than investigated here and involve
interactions between coping styles and other variables. Penley et al. (2002) found that stressor type,
controllability and duration play a part in the adaptive function of coping strategies. Araya et al. (2007)
demonstrated gender differences for the influences of coping styles and Hooberman et al. (2010)
showed that the interactions between coping styles and cognitive appraisals and social comparisons
explain PTSD severity in part. However, investigations into these complex models in treatment are a
methodological challenge.

Coping Change
The fourth aim of this study was to investigate changes in coping style over the course of treatment.
As was predicted, avoidance coping decreased in the EMDR condition but not in the stabilisation
condition. This finding suggests that EMDR is successful in convincing patients that engaging in the
recollection of traumatic memory becomes less distressing over time as is a major goal of EMDR (De
Jongh & Ten Broeke, 2003). When a stressor becomes less distressing, it becomes less necessary to
avoid, which might explain the decrease in avoidance coping. As expected, no other changes in
coping styles were observed in either treatment condition. Stabilisation may incorporate the
strengthening of certain coping skills, but the fact that this was not done in a standardized manner
may explain the stability of the coping styles. These findings contribute to the coping styles approach
that assumes that coping styles are relatively stable, trait-like characteristics.

Methodological considerations
The present investigation suffers from a number of general limitations. Obviously, the small sample
size (only 45 participants completed all pre- and post-treatment coping and symptom measure) greatly
limits the power of the conducted analyses. Small sample sizes prohibit finding significant results that
may exist in the population. According to Frazier et al. (2004) greater sample sizes are needed
especially when investigating interaction effects such as the examined moderator effect of coping
styles on treatment response. Field (2005) argues that even though there are different rules of thumb

21
to calculate an acceptable sample size, also depending on the expected effect size, an absolute
minimum for regression analyses would be a sample size of 60. Not even this minimum is met in this
study, although apparently there was enough power to detect some significant effects. Because only
12 participants dropped out, the results of the loglinear regressions that were used to assess the
relation of coping styles to dropout should be regarded with great caution.
Other limitations are inherent to the measures used. The COPE-easy and the WHOQOL-BREF are
both self-report measures that depend on the comprehension of the participants. Language barriers
could have an impact on this, although assistance of interpreters was used when necessary. Though
the trained assessors encouraged asking for assistance with the answering of the measures, shame
may have prohibited this, resulting in unrepresentative answers. Though Kleijn et al. (2000) argue that
the COPE-easy is simple and comprehensible for refugees; the experiences of this investigation teach
that it was the most difficult questionnaire in the test battery and frequently participants were inclined
to give up on the measure. Both the COPE-easy and the WHOQOL-BREF have not been extensively
validated in refugees, and cultural differences in both the psychological construct and the
comprehension of the measures may exist.
Another disadvantage of the use of self-report measures is the possibility of aggravation or
downplaying of symptoms or quality of life by participants. In this study, participants may have
aggravated their symptom severity before treatment in order to gain empathy and possibly sooner
care. Though the CAPS is not a self-report measure, assessors still have to trust that the verbal
responses of the participants are factual. On the other hand, it can be argued that the strictness of the
clinician-rated measure prohibited finding associations that may have been found when analyzing self-
reported PTSD-severity. For example, Held, Owens, Schumm, Chard, and Hansel (2011) found a
mediating role for disengagement coping (comparable with avoidance coping) in the relationship
between guilt and self-reported PTSD, but not for clinician-rated PTSD. In the present investigation, it
was found that self-reported PTSD severity, as measured with the HTQ, was associated with
avoidance coping at baseline whereas no such association was found with clinician-rated PTSD
severity. Studies have shown that the two types of measures use different standards, with self-report
measuring a subjective experience of severity, which may have additional value over objective
measures (Held et al., 2011).
The low reliability of the WHOQOL-BREF was another issue in this study, but because of removal of
conspicuous items, this will probably have had no effect on the conducted analyses. This fact should
however be noted when comparing the results with previous findings in literature.

The operationalization of coping styles is an important issue in research on coping (Skinner et al.,
2003) and this investigation proves no exception because the COPE-easy is limited in several ways.
The first problem becomes apparent in the instruction and is inherent to the dispositional versus
situational coping dichotomy. The COPE-easy was used with the dispositional instruction ‘how do you
generally cope with problematic situations?’ However, early research demonstrated that especially in
highly stressful situations, individuals alternate between coping strategies (Aldwin & Yancura, 2004).
The current finding that the use of an avoidant coping style decreased after a relatively short period of

22
9 EMDR-sessions supports this notion, although the other coping styles did not change. A second
problem with the instruction exists: problematic situations are not specified and therefore participants
may report coping with drastically different events (Penley, Tomaka, & Wiebe, 2002). For example,
some may report how they cope with intrusive traumatic memories whereas others report coping with
trivial problems like encountering a flat tire. The way that individuals cope with practical issues could
differ from the way they cope with problems that have to do with physical and psychological health.
This interpretation may differ over time and between persons and is essentially an issue of reliability
and validity. Frazier et al. (2004) demonstrated that the use of measures with lower reliability
undermines the power to find significant effects, especially interaction effects.
Another issue with the COPE-easy considers the overlap between coping styles. Although acceptable
factor solutions have been offered (Kleijn et al., 2000; Litman, 2006), the relatively high factor loadings
of one coping strategy (Kleijn et al.) on two different styles raise suspicion. Restraint coping, for
example, may contribute to either emotion-focused coping or problem-focused coping and social
support seeking can include seeking either problem-oriented advice or emotional disclosure. There is
a considerable overlap between emotion-focused coping and the other coping styles, following out of
the relatively strong correlations with all other three coping styles. It is therefore not surprising that
emotion-focused coping was neither associated with symptoms severity nor quality of life.

Several strengths distinguish this study from previous research. This study is one of few studies that
compare treatments for traumatized refugees. Furthermore, it is one of the first investigations that
examine the role of coping styles in treatment. Only Leiner et al. (2012) examined the interplay
between coping styles and treatment, yet they focused only on avoidance and examined another
population. The refugee sample was highly heterogenic which promotes generalization of the findings
over different subgroups. Both men and women from different cultural backgrounds, with different
trauma experiences, with or without a legal status, and with or without the need for an interpreter were
included. Furthermore, only limited exclusion criteria were applied, resulting in the inclusion of
participants with comorbid depression for example.

Conclusions
Despite the above limitations, the results of this study may have a number of implications for clinicians
working with refugees. It demonstrated that the assessing of coping styles is important because they
are linked to functioning outcomes. New treatments may be designed or stabilisation may be
standardized to specifically target coping styles in refugees as a means of improving quality of life.
Highly problem-focused individuals seem to benefit more from stabilisation than EMDR and
stabilisation should therefore be the first approach applied to these individuals. EMDR appeared to
successfully decrease avoidance coping, which is good news considering high avoidance is related to
poorer outcomes. Highly avoidant refugees did not have a greater chance on dropout and because of
these findings it could be advocated that EMDR should be applied as treatment of choice and one
should refrain from a phased approach for highly avoidant patients. Of course, no harsh statements
can be made on the basis of these results and the aforementioned limitations. This study highlights

23
therefore the need for future research on the role of coping in PTSD treatment response. This may
provide more knowledge on which treatments are most appropriate for different individuals, allowing a
more nuanced approach to intervention, instead of a “one size fits all” approach. Investigators should
then consider some methodological improvements, such as greater sample size to have greater power
to detect interaction effects. Furthermore, they should use more extensively validated instruments, and
especially a coping measure that is highly specific and discriminative between coping strategies. To
investigate cultural differences in the role of coping, they might investigate different homogenous
cultural samples. It should also be considered to incorporate other resilience or stressor variables in
future investigations adding to a more complex framework on the treatment of PTSD.
This study improved our understanding of the role of coping styles in the treatment of refugees,
although it is far from providing definitive conclusions. Therefore more efforts are certainly needed to
optimize treatment for this much afflicted and vulnerable population.

24
 References
Aldwin, C. M., & Yancura, L. A. (2004). Coping and health: A comparison of the stress and trauma
literatures. In P. P. Schnurr & B. L. Green (Eds.), Physical health consequences of exposure to
extreme stress (pp. 99–125). Washington, DC: American Psychological Association.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th
ed.). Washington, DC: Author.
Araya, M., Chotai, J., Komproe, I. H., & De Jong, J. T. V. M. (2007). Effect of trauma on quality of life
as mediated by mental distress and moderated by coping and social support among postconflict
displaced Ethiopians. Quality of Life Research, 16, 915–927.
Basoglu, M. (2006). Rehabilitation of traumatised refugees and survivors of torture: After almost two
decades we are still not using evidence based treatments. British Medical Journal, 333, 1230-
1231.
Beutler, L. E., Moos, R. H., & Lane, G. (2003). Coping, Treatment Planning, and Treatment Outcome:
Discussion. Journal of Clinical Psychology, 59(10), 1151–1167.
Brune, M., Haasen, C., Krausz, M., Yagdiran, O., Bustos, E., & Eisenmen, D. (2002). Belief systems
as coping factors for traumatized refugees: A pilot study. European Psychiatry, 17(8), 451-458.
Bryant, R. A., Moulds, M. L., Mastrodomenico, J., Hopwood, S., Felmingham, K., & Nixon, R. D. V.
(2007). Who drops out of treatment for post-traumatic stress disorder? [Abstract]. Clinical
Psychologist, 11, 13–15.
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal
regulation followed by exposure: A phase-based treatment for PTSD related to childhood
abuse. Journal of Consulting and Clinical Psychology, 70, 1067−1074.
De Jongh, A., & ten Broeke, E. (2003). Handboek EMDR [Handbook EMDR]. Lisse, The Netherlands:
Swets & Zeitlinger.
Emmelkamp, J., Komproe, I. H., Van Ommeren, M., & Schagen, S. (2002). The relation between
coping, social support and psychological and somatic symptoms among torture survivors in
Nepal. Psychological Medicine, 32, 1465–1470.
nd
Field, A. (2005). Discovering Statistics Using SPSS (2 ed.). London, United Kingdom: Sage
Publications Ltd.
Frankl, V. E. (1959) Man’s search for meaning. Boston, MA: Beacon Press.
Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling
psychology research. Journal of Counseling Psychology, 51, 115–134.
Held, P., Owens, G.P, Schumm, J.A., Chard, K.M. & Hansel, J.E. (2011). Disengagement Coping as a
Mediator Between Trauma-Related Guilt and PTSD Severity. Journal of Traumatic Stress, 24
(6), 708-715.
Hembree, E.A., Foa, E.B., Dorfan, N.M., Street, G.P., Kowalski, J., & Tu, X. (2003). Do Patients Drop
Out Prematurely from Exposure Therapy for PTSD? Journal of Traumatic Stress, 16 (6), 555-
562.
Hinton, D. E., Pich, V., Chhean, D., Pich, V., Pollack, M. H., Orr, S.P., & Pitman, R.K. (2006).
Assessment of Posttraumatic Stress Disorder in Cambodian Refugees Using the Clinician-

25
 Administered PTSD Scale: Psychometric Properties and Symptom Severity. Journal of
Traumatic Stress, 19 (3), 405-409.
Hooberman, J., Rosenfeld, B., Rasmussen, A., & Keller, A. (2010). Resilience in Trauma-Exposed
Refugees: The Moderating Effect of Coping Style on Resilience Variables. American Journal of
Orthopsychiatry, 80 (4), 557–563.
Huijts, I., Kleijn W. Chr., Emmerik, A. A. P., Noordhof, A., & Smith, A. J. M. (2012). Dealing With Man-
Made Trauma: The Relationship Between Coping Style, Posttraumatic Stress, and Quality of
Life in Resettled, Traumatized Refugees in the Netherlands. Journal of Traumatic Stress, 25,
71–78.
Kallasmaa, T., & Pulver, A. (2000). The structure and properties of the Estonia COPE inventory.
Personality and Individual Differences, 29, 881–894.
Kanninen, K., Punamäki, R.-L., & Qouta, S. (2002). The relation of appraisals, coping efforts, and
acuteness of trauma to PTS symptoms among former political prisoners. Journal of Traumatic
Stress, 15, 245–253.
Kleijn, W. C., Van Heck, G. L., & Van Waning, A. (2000). Ervaringen met een Nederlandse bewerking
van de COPE copingvragenlijst: De COPE-EASY. [Experiences with a Dutch adaptation of the
COPE coping questionnaire: The COPE-EASY]. Gedrag en Gezondheid, 24, 213–225.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping (1st ed.). New York, NY: Springer.
Leinier, A.S. (2006). The role of Avoidant Coping in the Treatment of Rape-related Posttraumatic
Stress Disorder. Unpublished doctoral dissertation, University of Georgia, Athens, GA, United
States of America.
Leinier, A.S., Kearns, M.C., Jackson, J.L., Astin, M.C., & Rothbaum, B.O. (2012). Avoidant Coping and
Treatment Outcome in Rape-related Posttraumatic Stress Disorder. Journal of Consulting and
Clinical Psychology, 80(2), 317-321.
Lester, K., Resick, P.A., Young-Xu, Y, & Artz, C. (2010). Impact of Race on Early Treatment
Termination and Outcomes in Posttraumatic Stress Disorder Treatment. Journal of Consulting
and Clinical Psychology, 78(4), 480-489.
Litman, J. A. (2006). The COPE inventory: Dimensionality and Relationships with Approach- and
Avoidance-Motives and Positive and Negative traits. Personality and Individual Differences, 41,
273–284.
National Institute for Clinical Excellence. (2005). Post-traumatic stress disorder: The management of
PTSD in adults and children in primary and secondary care. London: Gaskell.
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments
of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399!417.
Overbeek, I., Schruers, K., & Griez, E. (1999). Mini international neuropsychiatric interview:
Nederlandse versie 5.0.0., DSM-IV [Dutch version]. Maastricht, The Netherlands: Universiteit
Maastricht.
Penley, J.A., Tomaka, J., & Wiebe, J.S. (2002). The association of coping to physical and
psychological health outcomes: A meta-analytic review. Journal of Behavioural Medicine, 25,
551-603.

26
Perczek, R., Carver, C. S., Price, A. A., & Pozo-Kaderman, C. (2000). Coping, mood and aspects of
personality in Spanish translation and evidence of convergence with English versions. Journal
of Personality Assessment, 74, 63–87.
Sachs, E., Rosenfeld, B., Lhewa, D., Rasmussen, A., & Keller, A. (2008). Entering exile: Trauma,
mental health, and coping among Tibetan refugees arriving in Dharamsala, India. Journal of
Traumatic Stress, 21, 199–208.
Scott, M.J., & Stradling, S.G. (1997). Client Compliance with Exposure Treatmetns for Posttraumatic
Stress Disorder. Journal of Traumatic Stress, 10 (3), 523-526.
Shapiro, F., Vogelmann-Sineb, S., & Sineb, L.F. (1994). Eye Movement Desensitization and
Reprocessing: Treating Trauma and Substance Abuse [Abstract]. Journal of Psychoactive
Drugs, 26 (4), 379-391.
Skinner, E. A., Edge, K., Altman, J., & Sherwood, H. (2003). Searching for the structure of coping: a
review and critique of category systems for classifying ways of coping. Psychological Bulletin,
129, 216–269.
Smith, N.G., Tarakeshwar, N., Hansen, N. B., Kochman, A., & Sikkema, K. (2006). Coping Mediates
Outcome Following a Randomized Group Intervention for HIV-positive Bereaved Individuals.
Journal of Clinical Psychology, 65 (3), 319-335.
Tennen, H., Affleck, G., & Armeli, S. (2000). A daily process approach to coping: Linking theory,
research, and practice. American Psychologist, 55, 626–636.
Ter Heide, F.J.J., Mooren, T.M., Kleijn, W., de Jongh, A., & Kleber, R.J. (2011). EMDR versus
stabilisation in traumatized asylum seekers and refugees: results of a pilot study. European
Journal of Psychotraumatology, 2: 5881.
The WHOQOL Group. (1998). Development of the World Health Organisation WHOQOL-BREF quality
of life assessment. Psychological Medicine, 28, 551"558.
Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-Administered PTSD Scale: A
review of the first ten years of research. Depression and Anxiety, 13, 132–156.

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 Appendices

Table  6          
Moderator  Models  of  Coping  styles  on  CAPS  post-­‐treatment  score  
Model  &  Variables   R2  model   R2  change     β   t  value  
Problem-­‐focused  coping          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .50   .00  (ns)      
   COPE-­‐PF       -­‐.05   -­‐.47  (ns)  
Step  3   .54   .04a      
   Condition  x  COPE-­‐PF       -­‐.28   -­‐1.73a  
         
Emotion-­‐focused  coping          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .50   .00  (ns)      
   COPE-­‐EF       .00   .02  (ns)  
Step  3   .50   .00  (ns)      
   Condition  x  COPE-­‐EF       .01   .06  (ns)  
         
Avoidant  coping  (modified)          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .56   .06*      
   COPE-­‐AV       .13   2.39  *  
Step  3   .57   .01  (ns)      
   Condition  x  COPE-­‐AV       -­‐.15   -­‐1.13  (ns)  
         
Social  Support  Seeking          
Step  1   .50   .50***      
   CAPS  T1       .69   6.26***  
   Condition       .08   .74  (ns)  
Step  2     .50   .00  (ns)      
   COPE-­‐SS       .05   .46  (ns)  
Step  3   .50   .00  (ns)      
   Condition  x  COPE-­‐SS       -­‐.07   .39  (ns)  
         
a
p = .09

28
Table  7          
Moderator  Models  of  Coping  styles  on  WHOQOL  post-­‐treatment  score  
Model  &  Variables   R2  model   R2  change     β   t  value  
Problem-­‐focused  coping          
Step  1   .56   .56***      
   WHOQOL  T1       .74   7.27***  
   Condition       -­‐.06   -­‐.59  (ns)  
Step  2     .56   .00  (ns)      
   COPE-­‐PF       -­‐.05   -­‐.47  (ns)  
Step  3   .56   .01  (ns)      
   Condition  x  COPE-­‐PF       .11   .73  (ns)  
         
Emotion-­‐focused  coping          
Step  1   .56   .56***      
 WHOQOL  T1       .74   7.27***  
   Condition       -­‐.06   -­‐.59  (ns)  
Step  2     .56   .00  (ns)      
   COPE-­‐EF       .09   -­‐.92  (n  s)  
Step  3   .57   .01  (ns)      
   Condition  x  COPE-­‐EF       .13   .81  (ns)  
         
Avoidant  coping  (modified)          
Step  1   .56   .56***      
 WHOQOL  T1       .74   7.27***  
   Condition       -­‐.06   -­‐.59  (ns)  
Step  2     .58   .03  (ns)      
   COPE-­‐AV       -­‐.17   -­‐1.65  (.11)  
Step  3   .58   .00  (ns)      
   Condition  x  COPE-­‐AV       -­‐.01   -­‐.09  (ns)  
         
Social  Support  Seeking          
Step  1   .56   .56***      
 WHOQOL  T1       .74   7.27***  
   Condition       -­‐.06   -­‐.59  (ns)  
Step  2     .56   .00  (ns)      
   COPE-­‐SS       -­‐.03   -­‐.30  (ns)  
Step  3   .56   .00  (ns)      
   Condition  x  COPE-­‐SS       -­‐.02   -­‐.10  (ns)  
         

29
Table  8          
Moderator  Models  of  Coping  styles  on  WHOQOL  PSY  subscale  post-­‐treatment  score  
Model  &  Variables   R2  model   R2  change     β   t  value  
Problem-­‐focused  coping          
Step  1   .26   .26**      
   WHOQOL  PSY  T1       .50   3.85***  
   Condition       -­‐.13   -­‐1.03  (ns)  
Step  2     .27   .00  (ns)      
   COPE-­‐PF       .02   .14  (ns)  
Step  3   .27   .00  (ns)      
   Condition  x  COPE-­‐PF       .05   .27  (ns)  
         
Emotion-­‐focused  coping          
Step  1   .26   .26**      
 WHOQOL  PSY  T1       .50   3.85***  
   Condition       -­‐.13   -­‐1.03  (ns)  
Step  2     .27   .00  (ns)      
   COPE-­‐EF       -­‐.02   -­‐.15  (ns)  
Step  3   .27   .01  (ns)      
   Condition  x  COPE-­‐EF       .15   .72  (ns)  
         
Avoidant  coping  (modified)          
Step  1   .26   .26**      
 WHOQOL  PSY  T1       .49   3.85***  
   Condition       -­‐.13   -­‐1.03  (ns)  
Step  2     .34   .08*      
   COPE-­‐AV       -­‐.30   -­‐2.27*  
Step  3   .34   .00  (ns)      
   Condition  x  COPE-­‐AV       .02   .13  (ns)  
         
Social  Support  Seeking          
Step  1   .26   .26**      
 WHOQOL  PSY  T1       .50   3.85***  
   Condition       -­‐.13   -­‐1.03  (ns)  
Step  2     .27   .00  (ns)      
   COPE-­‐SS       -­‐.03   -­‐.23  (ns)  
Step  3   .27   .00  (ns)      
   Condition  x  COPE-­‐SS       -­‐.01   -­‐.06  (ns)  
         

30