Introduction

Afghans represent the third largest refugee population in the world [1]. Since the Taliban takeover in 2021, the number of Afghan asylum seekers and refugees (ASR) has increased for the 15^th consecutive year [1]. The following year, Afghanistan was the most common country of origin of asylum seekers in Austria [2]. The Afghan population comprises over 45,000 individuals in Austria, making this ASR population one of the largest in this country [3]. Numerous asylum seekers and refugees (ASR) from Afghanistan have been affected by high rates of potentially traumatic experiences (PTEs) before and during their flight [4, 5] and also have to deal with a multitude of migration-specific stressors [6].

The construct of so-called post-migration living difficulties (PMLDs) includes intrapersonal (e.g., worries about the future, homesickness), interpersonal (e.g., isolation, conflicts), societal (e.g., discrimination, asylum law, mass media), and cultural stressors (e.g., culture, foreign language) [7–9]. Research has revealed that the impact of PMLDs on mental health problems and reduced quality of life is comparable to the impact of potentially traumatic experiences [4, 10].

Since the outbreak of the COVID-19 pandemic, socio-economic challenges and mental health problems have become increasingly common among the Austrian population [11, 12] and particularly among ASR in Austria, who already faced instability and crises before [13, 14]. Accordingly, ASR show a higher prevalence of mental health problems, which is higher still in treatment-seeking ASR populations [4, 15, 16]. Compared to ASR from other countries of origin, individuals from Afghanistan in Austria were found to have lower levels of education, longer waiting periods for asylum decisions, poorer health and lower quality of life [17–19].

Stress-related disorders such as posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) are among the most commonly reported mental health problems among ASR in high-income countries [20, 21]. In the ICD-11, the diagnostic criteria for CPTSD encompass the symptom clusters of PTSD (re-experiencing, avoidance, sense of threat) and three additional symptom clusters associated with disturbances in self-organisation (affective dysregulation, negative self-concept, disturbances in relationships) as well as functional impairment [22]. Besides the general functional impairments associated with PTSD or CPTSD (C/PTSD) [23, 24], ASR with C/PTSD have been found to suffer from higher levels of distress associated with PMLDs [25, 26]. However, using the sum of PMLDs as predictor of psychopathological distress is problematic [27, 28], providing little insight into the underlying mechanisms of action and limited guidance for psychological therapy for ASR [29].

To better capture the complex interplay between PMLDs and mental health in ASR, ecological models have suggested mutual relationships between and within different forms of protective and risk factors (e.g., PMLDs) [7, 30, 31]. Moreover, according to these models, an experienced loss of resources might increase the risk of further loss and set in motion a spiral of loss [31]. For example, prior to migration, a variety of satisfying social relationships might stabilise a vulnerable self-esteem. After migration, traumatic experiences and a loss of social resources might contribute to a destabilisation of self-esteem and increase the risk of developing CPTSD. Low self-esteem might make it harder to establish new contacts in the host country and increase mental health problems, which may in turn further diminish self-esteem and exacerbate, for instance, social withdrawal, difficulties acquiring the language of the host country, and psychopathology.

In parallel to the postulated ecological models, research on various forms of psychopathology has investigated the complex interplay of individual symptoms [32], but has rarely included external factors [33, 34]. Accordingly, the interplay between different forms of PMLDs and psychopathology at the symptom level has rarely been examined so far. However, initial studies have reported associations beyond the constructs of PMLDs and psychopathology, supporting the assumption that individual symptoms might interact in distinct ways with different forms of PMLDs [29, 35–37]. Studies comparing the associations between PMLDs and anxiety disorders, depression, and PTSD have indicated the strongest associations between PTSD and almost all forms of PMLDs [26, 38]. Therefore, it seems especially important to examine this relationship in depth.

Further analyses of the associations between different forms of PMLDs and CPTSD symptom clusters have revealed an important role of re-experiencing and affective dysregulation [39]. This finding is consistent with previous evidence that people with C/PTSD use more maladaptive coping strategies such as rumination or avoidance [40, 41]. The recognition of these associations represents important information per se. However, the question of how CPTSD symptoms influence the subjective experience of and coping with PMLDs in daily life among ASR cannot be sufficiently investigated using checklist-based quantitative methods [42].

Initial qualitative investigations reported differences in the experience of PMLDs between ASR with low and high levels of PTSD symptoms [8, 43]. ASR with high PTSD showed lower levels of attachment to both the home and host country [8, 43] and had fewer future plans. Moreover, they experienced higher levels of distress, social isolation, relationship problems and conflict, used more avoidance-based strategies to deal with these problems [8] and reported poorer self-reflection [43]. In comparison, ASR with lower levels of PTSD were more likely to feel comfortable in their new community. They were pleased with their housing conditions and had sufficient money for their daily needs as well as access to health care services, education, skills training, and employment programs [8]. Furthermore, individuals with low PTSD reported a clearer sense of identity and subjective meaning in the refugee experience [43]. To the best of our knowledge, hardly any research has employed a qualitative approach to explore how ASR experience and cope with PMLDs while taking into account CPTSD symptoms beyond the classic symptoms of PTSD [8, 43].

To promote better mental health care for ASR in the future, the main aim of this study was to explore the subjective experience of and coping with PMLDs under consideration of C/PTSD symptoms. Based on previous empirical studies, we hypothesised that individuals with C/PTSD might differ from those without C/PTSD in terms of cognitive, emotional, physical and/or behavioural responses and coping strategies to PMLDs. The more frequent use of maladaptive coping strategies, such as rumination or avoidance, among ASR with C/PTSD was expected to contribute to increased distress related to PMLDs and potentially generate additional stressors. By conducting an in-depth examination of the differences in responses to PMLDs between ASR with and without C/PTSD, valuable insights might be gained into the underlying characteristics of these reactions and the influencing role of C/PTSD. Furthermore, we examined the subjectively experienced consequences of potentially traumatic experiences among Afghan ASR and their influence on daily life. These findings may offer initial guidance for the development of interventions that integrate approaches to reduce C/PTSD and address the distress due to PMLDs. By incorporating these insights into mental health care, we can strive for improved support and well-being for ASR in the future.

Materials and methods

This study was part of the research project “A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees” (PIAAS-Study) [44, 45].

Participants

Inclusion criteria for study participation were 1) treatment-seeking adult Afghan ASR, 2) Dari as native language, 3) elevated psychological distress on the Refugee Health Screener-15 (RHS-15) questionnaire (total score ≥ 12 or Distress Scale score ≥ 5), and 4) participants of the intervention arm after completed post-assessment. The exclusion criteria, which were observed and asked during the interview at the baseline assessment, were 1) severe cognitive impairment (moderate to severe intellectual disability or dementia) which hinders the necessary understanding of study-relevant contents and questions, 2) ongoing trauma-focused therapy, and 3) current physical or mental health conditions that require other treatment and/or interfere with participation (e.g., acute suicidality, psychotic symptoms). Each participant was assigned a pseudonym. An overview of the sociodemographic characteristics of the total sample (N = 24) is provided in Table 1.

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Table 1. Sample characteristics for each group.

https://doi.org/10.1371/journal.pone.0288691.t001

Results

Aim 1: Subjective experience of and coping with PMLDs

When asked to describe subjectively meaningful experiences in Austria, each participant reported between one and ten different experiences occurring individually or jointly (e.g. discrimination during a job interview). These 16 identified themes are presented in Table 2. The most frequently reported cognitive, emotional, physical and behavioural reactions to these experiences in a comparison between the C/PTSD group and the non-C/PTSD group are described in more detail below. For all themes and their corresponding frequencies, see Table 3.

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Table 2. Themes related to post-migration living difficulties & daily stressors.

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Table 3. Themes related to reactions and coping strategies.

https://doi.org/10.1371/journal.pone.0288691.t003

Aim 2: The subjective consequences of traumatic experiences for daily life

In the second part of the interview, the participants were asked about the subjective consequences of traumatic experiences for their daily life. While we did not specifically ask about traumatic experiences, they were mentioned repeatedly in the narratives and were therefore entered into the analysis. For the full list of identified themes, see Table 4.

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Table 4. Themes related to traumatic experiences and subjective consequences of trauma.

https://doi.org/10.1371/journal.pone.0288691.t004

Most frequently, participants in the C/PTSD group (53.3%) reported individual psychological and physical consequences of potentially traumatic experiences, such as persistent anxiety despite now being in a safe environment. For instance, one participant reported, “That didn’t happen here, it all happened in Afghanistan, that’s where this pain I got came from." (Mustafa, C/PTSD group, age 57).

By contrast, participants in the non-C/PTSD group more often did not report personal consequences of PTEs, but rather societal consequences of war and flight for people from Afghanistan.

"I think that because there has been war in Afghanistan for so many years, for 30–40 years and so. They (Afghans) were all struggling before with the war, yes with this situation and so . . . But now, I think they are all psychologically burdened. And yeah, if just a little thing happens, they explode." (Fatima, non-C/PTSD group, age 37)

Fewer ASR reported emotional and behavioural patterns shaped by their past. Some described aggressive reactions, mistrust, avoidance of other people, and constantly caring for others while neglecting one’s own needs. One participant reported being constantly closed to others, "I can’t trust anyone anymore because the people I trusted betrayed me . . . I don’t talk about these things with anyone anyway." (Amar, C/PTSD Group, age 25). Several participants described positive consequences associated with a feeling of inner strength and increased self-confidence.

"After some time, I had to do something every day to somehow get ahead. Then I did that… I managed that. I said to myself, "I can do it on my own." And I started to feel stronger and stronger. " (Samira, C/PTSD group, age 36).

Overall, three participants from each group reported that they had not observed any consequences of potentially traumatic experiences, repeatedly answering this question simply with "no". One of the few explanations provided for this response was, "Because of the fact that I have come this far, I have not had any bad consequences." (Zaira, non-C/PTSD group, age 40).

Discussion

The current study aimed to explore the role of C/PTSD symptoms in the subjective experience of and coping with PMLDs among Afghan ASR in Austria. The results revealed remarkable differences in the frequency of reported different types of PMLDs and associated reactions as well as coping strategies between ASR with and without C/PTSD. In particular, individuals with C/PTSD were more likely to report problems associated with unmet basic needs, occupation or asylum processes. Notably, distinct cognitive, emotional, physical, and behavioural responses were observed between the two groups. The C/PTSD group exhibited elevated levels of recurrent thoughts linked to PTEs and PMLDs. They also tended to employ cognitive and behavioural avoidance strategies more frequently. Moreover, individuals with C/PTSD reported more frequent and intense negative emotions, such as persistently depressed mood or pervasive non-specific bad feelings. Conversely, individuals without C/PTSD reported more frequent experiences of positive emotions, engaged in positive self-verbalisation, and perceived positive developments. It is noteworthy that despite recognizing numerous psychological and physical consequences of PTEs, few links have been made between these consequences of PTEs and their impact on perceptions of and responses to PMLDs.

Over half of the participants met the criteria for probable C/PTSD. In contrast to most previous research findings [17], a larger proportion of men met the criteria for probable C/PTSD in the present study. The majority of PMLDs reported by our participants reflected those that are already known from previous research [55–57]. Beyond the moderating effects of origin-related and country-specific factors [17, 55] as well as time spent in the host country [28], Afghan ASR with probable C/PTSD reported different types of PMLDs compared to those without. The lack of basic needs have previously been found to be particularly impactful among ASR and were associated with traumatic experiences and psychopathology [29]. In line with this, in the present study, Afghan ASR with probable C/PTSD were more likely to report unmet basic needs, occupational problems (e.g., unemployment), and an insecure asylum status. Along with previous research indicating a bidirectional relationship between PMLDs and psychopathology [36], we likewise suggest a reciprocal association. Many ASR experienced homelessness and financial hardship in their country of origin, and these potentially traumatic experiences might influence the subjective experience of unmet basic needs in the host country [28]. Indeed, in some cases PMLDs might act simultaneously as stressors and triggers [58]. Consistent with the assumption that not all forms of PMLDs have the same impact on mental health [28, 29], unmet basic needs might particularly exacerbate or even trigger C/PTSD symptoms. Moreover, the possibility to deal with these PMLDs might be further limited due to the insecure asylum status and associated prohibition to work, which was reported more frequently in ASR with probable C/PTSD.

Affective dysregulation is already recognised as a consequence of childhood trauma [59, 60] and is a criterion for a diagnosis of CPTSD in the ICD-11 [22]. In accordance with this, the present findings support the hypothesised differences in cognitive, emotional, physical and behavioural coping strategies between ASR with and without C/PTSD. In line with previous studies, our participants with probable C/PTSD reported a more frequent use of maladaptive coping strategies [40], which have been found to mediate the association of traumatic experiences with PTSD and with PMLDs [59, 61]. In contrast to previous research which found no associations between adaptive emotion regulation strategies and either traumatic experiences or PTSD [40, 59]), participants with probable non-C/PTSD more frequently reported adaptive coping strategies in the present study. Nevertheless, it should be critically noted that the relationship between the different coping strategies and mental health is predominantly ambiguous [41]. Therefore, to ascertain whether adaptive coping strategies actually have the desired effect, further in-depth research might be necessary.

In terms of cognitive responses and coping strategies, participants with probable C/PTSD frequently mentioned intrusive memories and rumination [62], which were accompanied by further cognitive, emotional, physical and behavioural reactions and coping strategies. Spiller et al. pointed out that fear reactivity, which is often increased in individuals with PTSD, might increase the frequency and intensity of intrusive memories and rumination [58]. In this vein, our participants reported thought avoidance and trying to forget traumatic experiences, which is a commonly used strategy to cope with triggers and distress among ASR [63, 64]. In line with previous research [65], about half of the ASR with probable C/PTSD in the present study described difficulties in staying present due to dissociative reactions or concentration problems, often related to rumination. Since dissociative symptoms, rumination and concentration problems are not included in the ICD-11 CPTSD diagnosis [22], few studies have examined these symptoms in individuals with CPTSD [65]. Overall, only three participants with probable C/PTSD in our study reported using reappraisal or positive self-verbalisation. Moreover, general positive aspects of life in Austria or positive personal developments were often mentioned only briefly by participants with probable C/PTSD, followed by more detailed reports of unmet expectations. By contrast, participants in the non-C/PTSD group reported concrete positive personal developments more frequently and in greater detail. We suggest that the high degree of stress might hinder positive adaptation while also increasing the likelihood of attentional bias, which might in turn reduce the perception of positive experiences and developments [66].

Several group differences emerged regarding emotional reactions and complaints. Overall, increased negative and reduced positive affectivity were associated with various psychopathologies, including PTSD [67]. Consistent with this finding, participants in the non-C/PTSD group more frequently reported positive emotions (e.g., gratitude, hope). The ASR with probable C/PTSD were more likely to report suffering from depression and non-specific bad feelings, which may indicate a lack of emotional clarity [68]. Many of the participants reported social withdrawal and inactivity in dealing their emotions as they did not believe they could change their own negative mood [69]. The resulting intense, persistent emotional reactions might point to an under-regulation of emotional hyperactivation already associated with C/PTSD [70].

Poor physical health has frequently been associated with C/PTSD [24]. Similar to findings from a study in Syrian refugees in Germany [71], sleep disturbances were the most commonly reported physical reaction and complaint among Afghan ASR in the present study. Indeed, over half of the ASR with probable C/PTSD reported sleep disturbances, which is unsurprising given that trauma-associated nightmares are a symptom of C/PTSD. As in other studies [72, 73], several participants reported increased stress and C/PTSD symptoms the day after suffering from nightmares. Additionally, in line with previous evidence [73], body weakness and stress-associated pain were also reported more frequently by the ASR with probable C/PTSD. These physical complaints, which often occurred spontaneously in response to PMLDs or were reported as chronic stressors, were associated with severe distress and, in rare cases, with suicidality.

In accordance with previous findings, the most commonly reported behavioural reactions and coping strategies in both groups were seeking and accepting social support, followed by social withdrawal and inactivity [8, 41, 74, 75]. Although social support has predominantly been considered as a protective factor, this strategy was repeatedly linked to increased mental health problems. In some cases, it remained unclear whether social support actually brought about emotional relief or a sense of connectedness. For instance, several participants addressed the psychosocial costs of social support, such as feeling pressure due to expectations or critique, in turn potentially leading to subsequent social withdrawal [41]. C/PTSD symptoms might lead to limited subjective experiences of interpersonal connectedness and social support [76]. Social withdrawal, inactivity and avoidance are often used to deal with negative emotions triggered, for example, by trauma-associated memories or PMLDs, and have been assumed to be interrelated with psychosocial distress (e.g., depression, rumination) [41]. Active, solution-oriented behaviour was reported less frequently by the ASR with probable C/PTSD [61]. Previous research has reported a positive relationship between lack of access to adaptive emotion regulation strategies and PTSD [68]. As emphasised by Perez et al. [77], it remains unclear whether access to adaptive emotion regulation strategies is actually lacking or whether this phenomenon may be explained by the reduced self-efficacy associated with childhood trauma. Nevertheless, the lack of active, solution-oriented coping strategies might hinder the successful handling of PMLDs and intensify emerging problems [78].

Many of our participants reported subjective consequences of traumatic experiences for their daily life, mostly comprising physical or psychological complaints [79]. While none of the participants described C/PTSD and its influence on the experience of PMLDs as a result of traumatic experiences [80], intrusive memories were repeatedly mentioned. Overall, few subjective consequences or traumatic experiences were reported.

Conclusions

This study contributes to the growing body of knowledge on the influence of C/PTSD on the experience of and coping with PMLDs. C/PTSD influences the frequency of and responses to PMLDs among ASR. The symptoms associated with C/PTSD, such as recurrent thoughts and avoidance, not only exhibit an association to PTEs, but also exert a profound influence on the experienced distress and the effective coping with PMLDs. The findings highlight the importance of considering PMLDs in treatment approaches for ASR with C/PTSD and might support mental health practitioners and other professionals to develop targeted interventions on different dimensions to promote mental health and psychosocial adaptation among ASR.

On the intrapersonal dimension, a consideration of the influence of C/PTSD on the experience of and coping with PMLDs might provide important clues for individual therapy targets (e.g., reducing rumination or avoidance, promoting active, solution-oriented coping behaviour). A better understanding of the consequences of trauma and of the relationship between psychopathology and PMLDs should be addressed through psychoeducation [71, 81].

Interventions on the interpersonal dimension should focus on reducing social isolation and enhancing connectedness. Community-based interventions, group therapy and participation in interest groups should be encouraged [71].

On the societal dimension, measures should be taken to promote cultural and trauma sensitivity among professionals (e.g., mental health practitioners, teachers). Language barriers should be reduced to facilitate social inclusion and access to health services for ASR. Low-threshold services, increased use of (online) interpreters and the offer of trauma-sensitive language courses might be helpful in this regard [82]. Support in finding accommodation and employment might help overcome barriers such as opaque bureaucracies and discrimination.

Measures on the cultural dimension predominantly include subjects that policy makers have not yet sufficiently addressed. In addition to providing funding for the aforementioned interventions, it is especially important to establish accelerated and transparent asylum procedures [71, 83].

Supporting information

Acknowledgments

The authors would like to express their sincere appreciation to all the participating ASR who provided us with insights and a deeper understanding of their personal experiences. We further acknowledge the efforts of our research project team including our interpreters as well as all other supporting colleagues and institutions.