A Community-Based Intervention to Enhance Posttraumatic Growth among Refugees in Receiving Societies

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ This is an Accepted Manuscript of a book chapter published by Routledge in The Routledge International Handbook of Posttraumatic Growth on 8 December 2023, available online: https://doi.org/10.4324/9781032208688 It is deposited under the terms of the Creative Commons Attribution-NonCommercial- NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. POSTTRAUMATIC GROWTH AMONG REFUGEES 1 A COMMUNITY-BASED INTERVENTION TO ENHANCE POSTTRAUMATIC GROWTH AMONG REFUGEES IN RECEIVING SOCIETIES Virginia Paloma, Sara M. Martínez-Damia, Irene de la Morena, Clara López-Torres, & Isabel Berbel POSTTRAUMATIC GROWTH AMONG REFUGEES 2 Abstract This chapter aims to describe a community-based intervention aimed at enhancing the Posttraumatic Growth (PTG) of refugees in receiving societies. First, we contextualize this contribution by presenting the literature on PTG in forced migration. Specifically, we present the main factors identified in the literature that fuel the emergence of PTG among refugees, as well as the interventions that have been carried out to enhance PTG in this population. We highlight the scarce existence of interventions in general, and of those with a community-based approach in particular. Later, we describe in depth the proposed community-based intervention, providing access to its implementation manual to facilitate its worldwide adaptation. Finally, based on our experience in southern Spain, lessons learned and implications for PTG promotion among forcibly displaced individuals are discussed. We stress the need to value the strengths of the refugees themselves, to create safe community-based scenarios through peer-mentoring and peersupport-group formats, and to offer refugees the possibility of playing an active and meaningful role as agents of change for their own growth and that of their community. Introduction The past years have been characterized by an ever-increasing influx of forcibly displaced people all over the world. The United Nations High Commissioner for Refugees estimates that global forced displacement has surpassed 84 million people at mid-2021, with 85% of them being hosted by developing countries such as Turkey, Colombia, Uganda, or Pakistan (UNHCR, 2021a). More than two-thirds of forcibly displaced people are coming from just five countries: the Syrian Arab Republic, Venezuela, Afghanistan, South Sudan, and Myanmar (UNHCR, 2021a). In this context of forced migration, a refugee is someone “who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, POSTTRAUMATIC GROWTH AMONG REFUGEES 3 membership of a particular social group, or political opinion” (United Nations General Assembly, 1951, p. 3). For its part, an asylum seeker is someone “who has applied for refugee status [...] and has not yet received a final decision on their claim” (UNHCR, 2021b). Although these terms are clearly different, in the interest of simplification, in this chapter, we use “refugees” to refer both to “refugees” and “asylum seekers.” We can conceptualize forced migration as a traumatic event or as an extremely painful experience that challenges the psychological stability of any individual. In fact, forced migration involves “separations, losses, changes, conflicts, and demands that severely challenge or shatter individuals’ past ways of making meaning and defining themselves” (Berger & Weiss, 2003, p. 22). Under certain circumstances, the adverse experiences suffered by refugees during the pre-migration (e.g., witnessing some atrocities), transit (e.g., living in refugee camps), and settlement stages (e.g., social isolation) may lead to pathological conditions such as depression, anxiety, posttraumatic stress disorder, or psychosomatic disorders, among others (Fazel et al., 2005; Slobodin & Jong, 2015). However, research with refugees has suggested the idea that forced migration is not only a traumatic event with negative consequences but may also represent an opportunity for posttraumatic growth (PTG; e.g., Abraham et al., 2018; Ferriss & Forrest-Bank, 2018; Gökalp et al., 2021; Matos et al., 2021; Shakespeare-Finch et al., 2014; Taylor et al., 2020). PTG refers to an individual’s perceptions of significant positive changes resulting from the struggle with trauma and involves a cognitive processing of the losses and a rebuilding of one’s assumptive world and views of self, relationship with others, and philosophy of life (Tedeschi & Calhoun, 2004). That is, PTG is a positive mental health indicator that, far from negating the suffering of forced displacement for refugees, views it as a potential learning experience and a personal strengthening source for them (Paloma POSTTRAUMATIC GROWTH AMONG REFUGEES 4 et al., 2020a). This can imply appreciating life more, becoming more aware of one’s strengths, experiencing the value of significant relationships more, recognizing new opportunities flourishing in the receiving society, and increasing one’s spirituality (Gökalp & Haktanir, 2021; Taher & Allan, 2020; Taku et al., 2008). A systematic review found that PTG predicts the overall quality of life among refugees settled in high-income countries (van der Boor et al., 2020). Although there is a clear interest in strengthening the mental health of refugees in host societies (WHO, 2018), and particularly in the crisis of the COVID-19 pandemic (WHO, 2020), there is still little practice-based evidence that informs how to appropriately enhance refugees’ PTG. In this chapter, we aim to offer some insights from an intervention designed for that purpose. Going beyond an individualistic perspective of treatment (e.g., psychotherapy, medication), we present a community-based intervention through which refugees are actively involved in peer-mentoring and peer-support-group formats. This chapter is organized as follows. First, we offer an overview of the main literature developed around the refugees’ PTG. Second, we offer a practice-driven applied view by describing a community-based intervention aimed at enhancing refugees’ PTG. Finally, and based on our experience of implementation of the proposed intervention in southern Spain, we discuss some lessons learned and implications for the promotion of PTG among forcibly displaced individuals. An Overview of PTG among Refugees Berger and Weiss (2003) were the first authors to highlight the “missing link” between migration and PTG. In this section, we offer an overview of the main topics and findings obtained in the literature about refugees’ PTG. This overview does not intend to POSTTRAUMATIC GROWTH AMONG REFUGEES 5 be exhaustive, but rather offers a general overview of what has been studied up to now when we link “forced migration” and “PTG.” The first line of research has addressed its efforts towards the identification of the main factors that fuel the emergence of PTG among refugees. At the individual level, variables such as hope, dispositional optimism, coping strategies, religiosity, and some socio-demographic characteristics have been identified as important facilitators of PTG. Hope is a positive emotional state through which refugees are confident about the future and it has been found to be related to PTG (Ai et al., 2007; Umer & Elliot, 2019). Apart from being hopeful, people with dispositional optimism also have a higher chance of gaining growth after a traumatic event (Acquaye, 2017). Concerning coping strategies, refugees who use adaptive cognitive or emotional strategies, such as processing, positive refocusing, putting their situation into perspective, emotion regulation, or problemfocused coping show higher levels of PTG (Acar et al., 2021; Ai et al., 2007; Ersahin, 2020; Gökalp & Haktanir, 2021; Hussain & Bhushan, 2011; Prasetya et al., 2020). On the contrary, maladaptive strategies such as suppression or avoidance were found to be negatively associated with PTG (Ai et al., 2007; Kira et al., 2019), albeit in some cases, avoidance was found to be a positive tool for surviving (McCormack & Tapp, 2019). Religiosity represents a spiritual resource and can be considered a specific coping strategy that refugees often use during difficult times (e.g., praying, attending church), thus promoting their PTG (Abraham et al., 2018; Kim & Lee, 2009). However, Acquaye et al. (2018) noted that when religiosity is high, the effect of trauma on PTG decreases and they stated that a moderate level of religiosity is more adequate. All these individual factors can be conceptualized within the resilience term, that is, the process through which refugees are competent to successfully adapt to and/or withstand inevitable adversity (Paloma et al., 2020b). The literature suggests that resilience promotes PTG among POSTTRAUMATIC GROWTH AMONG REFUGEES 6 displaced people (Cengiz et al., 2019). Regarding socio-demographic characteristics, being young, female, educated, and with high income has been related to a stronger PTG (Ai et al., 2007; Hussain & Bhushan, 2011; Powell et al., 2003; Rizkalla & Segal, 2018), although some studies found that these variables were not related to PTG (Berger & Weiss, 2006; Özdemir et al., 2021). At the relational level, social support has been found to be connected to the increase of PTG (Chan et al., 2016; Joseph, 2009). In particular, refugees report a higher degree of personal growth when they feel supported by professionals (Copping et al., 2010; Gökalp & Dilmac, 2021; Rizkalla & Segal, 2018), by people of their countries of origin (Abraham et al., 2018), and by people of the receiving society (Kim & Lee, 2009; Kroo & Nagy, 2011). This suggests that having opportunities to process the trauma by talking about it with others is important to increase PTG (Berger & Weiss, 2006). Finally, at the community level, Matos et al. (2021) highlight how a welcoming and safe receiving country may provide the conditions for refugees to reappraise the world and the self in a positive light. In the same line, others have stressed the relevance of enjoying retributive justice and perceiving support from official authorities in the receiving sociopolitical context as factors that facilitate the PTG among refugees (Kira et al., 2006; Taylor et al., 2020). The type of trauma has also been identified as an important variable to take into account when explaining the emergence of PTG among refugees. Indeed, trauma that is collective and shared positively predicted personal growth, while personal trauma that is directed toward the self hinders it (Kiliç et al., 2016). Also, concerning the severity of trauma, an inverted-U hypothesis has been observed (Chan et al., 2016), such that moderate levels of trauma promote the highest degree of PTG, while low and high levels POSTTRAUMATIC GROWTH AMONG REFUGEES 7 block it (Acar et al., 2021; Berger & Weiss, 2006; Powell et al., 2003; Teodorescu et al., 2012; Wen et al., 2020). The second line of research has addressed its efforts towards the design, implementation, and evaluation of interventions that aim at enhancing the refugees’ PTG. Slobodin and Jong (2015) pointed out that the majority of the studies used the improvement of posttraumatic stress disorder symptoms as an indicator of intervention efficacy and stressed the need to include other more positive dimensions. Maybe for this reason, to our knowledge, there are only four studies that addressed the issue focusing on PTG. The first intervention was developed in Liberia with refugees coming from Côte d’Ivoire (Gregory & Prana, 2013). This intervention was based on the companion recovery model, built on peer-support theory, gestalt therapy, and cognitive behavioral therapy, and was developed through group-based sessions in a six-day period. A second intervention was developed in the United States with Iraqi refugees (Hijazi et al., 2014). This intervention was based on brief narrative exposure therapy and was run through three individual sessions. The third intervention was developed with young East African refugees in the United States and consisted of eight sessions of group therapy (Acquaye et al., 2020). Finally, Paloma et al. (2020a) carried out a community-based intervention with refugees coming from different countries in conflict and settling in southern Spain. This intervention will be described in depth in the following section. All these interventions were considered to be good practices to enhance refugees’ PTG. As can be seen, practice-based research that describes interventions aimed at enhancing PTG in this population is scarce, especially from a community-based approach. However, “support groups or mentoring schemes may be particularly effective for forced migrants, particularly when involving members of the [...] community who have made a successful transition” (Copping et al., 2010, p. 58). In the same line, Murray POSTTRAUMATIC GROWTH AMONG REFUGEES 8 et al. (2010) warn that more practice-based evidence is needed on “community-based interventions that aim to facilitate personal and community growth and change during the refugee resettlement phase” (p. 583). To overcome this knowledge gap, the following section presents a community-based intervention that has been labeled as the “best practice” by the Spanish Commission for Refugee Aid. Empirical evidence shows how this intervention generates significant improvements in refugees’ PTG while simultanously showing high intervention acceptability, appropriateness, and feasibility (Paloma et al., 2020a). A Community-based Intervention to Enhance Refugees’ PTG The community-based intervention presented in this chapter was designed by the Center for Community Research and Action at the University of Seville (CESPYD; see https://cespyd.es/en/). CESPYD is one of the leading research units in Spain conducting high-quality community-based research projects designed to increase the power, health, and wellbeing of low-income migrants, refugees, and other unprivileged groups. In particular, this intervention has been successfully implemented twice, in 2017 and 2021, thanks to collaboration agreements between CESPYD and the Spanish Commission for Refugee Aid and the Cepaim Foundation, respectively. The implementation manual of this intervention has been published in an open-access format and is freely available in English and Spanish on the CESPYD web page (Paloma et al., 2021). This intervention is framed within the Comprehensive Mental Health Action Plan (2013-2030), which has among its main objectives: (a) the implementation of strategies for the promotion of mental health and the prevention of mental disorders for those at risk; and (b) the provision of comprehensive mental health services in community-based settings (WHO, 2021). The intervention was designed to be implemented during fifteen weeks and comprises of two phases: (1) a peer-mentorship training targeting settled POSTTRAUMATIC GROWTH AMONG REFUGEES 15 A fourth lesson is related to the evaluation of the intervention. Given the importance of evaluating the effectiveness of our endeavors and guaranteeing the accuracy of the data collected, mentors must be trained (during the peer mentorship training) in the formative and summative evaluation process. Depending on the decisions taken about the measurement instruments to be used in the program (see Paloma et al., 2021, for a suggestion), we will need to train mentors in filling out their own scales and field notes, reporting the progress of their cultural peer-support groups using structured observational grids, and/or administering scales or conducting focus groups with open questions to participants. To avoid participants’ fatigue, we recommend using only a few well-selected short scales together with several minimally invasive sources of evaluation (e.g., open questions at the end of each session, field notes, observational data from mentors). Moreover, for cultural peer-support groups where participants are struggling with the language or with a low educational background, it is recommended to set aside two extra sessions for evaluation, before and after the second phase. In these sessions, mentors can support newly arrived refugees to fill in the scales, explain the meaning of the most challenging items, and thus guarantee successful completion of the assessment. Finally, we have learned some lessons that allow us to envision lines of future action for this community-based intervention in its promotion of refugees’ PTG. Thus, in order to refine it, we found that art-based sessions were powerful to elicit intimate feelings, especially when participants had a very heterogeneous educational background. Although this format is quite present in the group dynamics already proposed (Paloma et al., 2021), we need to advance this line of work. In addition, the training sessions in peer mentorship should be fortified by providing more specific content about leadership, group processes, emotional management, and evaluation. Lastly, we think it would be useful to stress an intercultural and gender approach to this intervention. For example, carrying out POSTTRAUMATIC GROWTH AMONG REFUGEES 16 joint sessions between different cultural peer-support groups, adding a third phase where members of the receiving society are matched with participants, or offering child care for women who intend to participate in the sessions and being sensitive to their specific feminine view. From a conceptual viewpoint, future research should advance in evaluating the consequences of this community-based intervention in the whole field of refugees’ mental health. Some studies found a positive correlation between PTG and posttraumatic stress disorder (Acquaye, 2017; Cengiz et al., 2019; Hussain & Bhusshan, 2011; Kiliç et al., 2016) whereas others found a negative correlation (Davey et al., 2015; Teodorescu et al., 2012) or no correlation (Ai et al. 2007; Powell et al., 2003; Sleijpen et al., 2016). This literature suggests that PTG may coexist with symptoms of suffering in refugees. Therefore, together with PTG, we need to evaluate also the negative mental health outcomes to be able to establish which specific aspects of mental health this intervention can impact. As Roepke (2005) concluded, “more research is needed to uncover the relationship between growth and distress during intervention programs” (p. 139). In addition, our findings suggest the relevant role that active participation and social connectedness play in the development of PTG. It seems this is encouraged by others and fueled when one feels valued within a group of people in a similar situation. Future research could analyze the role of the evolution of the psychological sense of community throughout the program in the increase of PTG. As Gökalp and Dilmac (2021) argue, “social support systems can be made use of to speed up refugees’ posttraumatic growth processes” (p. 107). Finally, this intervention is currently limited to its implementation with refugees. However, it is expected that economic migrants and other unprivileged groups in movement may also benefit from the program. Future practice-based research should verify this. POSTTRAUMATIC GROWTH AMONG REFUGEES 17 This chapter, and the intervention presented here offer an alternative way to increase PTG beyond individual-oriented treatments, by creating supportive communitybased scenarios as well as valuing the refugees’ own capabilities as the main resources for the program’s success. Through peer-mentoring and peer-support-group formats, this intervention offers refugees the possibility of playing an active and significant role within the program for their own growth and that of their community. Thus, our intervention adheres to the guidelines proposed by the UNHCR (2017), as it: (a) strengthens refugees’ capacity to support each other through community-based activities, and (b) promotes the meaningful engagement of refugees, who are not experts, as agents of change within their communities. Moreover, as our program aligns with the Comprehensive Mental Health Action Plan (WHO, 2021), we expect it to contribute to the advance towards the consolidation of a community-based mental health approach (Bauman, 2018; Hamza & Clancy, 2020). This approach allows us to avoid the pathologization of the refugees’ condition by understanding suffering as the normal reaction among those who have experienced social injustices such as forced migration. It also allows us to broaden the pool of potential beneficiaries of the intervention beyond those with severe psychological distress, strengthening and building capacities within the refugee community as a whole. 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