Perspectives of Somali Refugees on Post-traumatic Growth after Resettlement

Perspectives of Somali Refugees on Post-traumatic Growth after Resettlement Abstract Post-traumatic growth (PTG), a theory of positive transformation after trauma, offers a framework to consider what contributes to the thriving of some individuals after traumatic experiences. Refugees living in communities across the United States have experienced the devastating trauma of surviving war and mass dislocation from their homes and countries of origin. This qualitative focus group study sought to explore whether the constructs of PTG had congruence among resettled Somali refugees. The results indicate that there is tenacity for life rooted in strong cultural values among Somali refugees; however, significant challenges are brought to the forefront, impacting growth for refugees in resettlement. The focus group discussions revealed that PTG is impacted by acculturative stressors and that there are significant cultural differences regarding what promotes healing and thriving after traumatic events among Somali refugees. The social isolation participants described raises critical concern for the wellbeing of Somali refugees. Introduction The East African country of Somalia has a long history of political unrest that escalated from mid-1980 to the early 1990s when a catastrophic civil war erupted. Somalia continues to be a country wrought with conflict and resulting hardship. By the end of 2013, approximately 1,121,900 refugees had been forced from their homeland of Somalia (United Nations High Commissioner on Refugees (UNHCR) 2013). For the purpose of this study, refugee, as defined by the 1951 Geneva Academy of National Humanitarian Law, is someone who: owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country (UNHCR 1951: Article 1A(2)). Refugee Trauma Refugees displaced due to violent civil war and persecution in their countries of origin endure severe trauma pre migration, during migration and post migration (Boyle and Ali 2010). Prior to the civil war, throughout the twentieth century, the people of Somalia faced long periods of persecution and discrimination, with many citizens experiencing clan-based slavery, oppression and violence, with only intermittent periods of peace. Civil war erupted in 1991 resulting in the mass migration of Somali people seeking refuge (Lehman and Eno 2003). The Somali refugee migration experience includes any number of intensely traumatic events such as the catastrophic destruction of homes and communities, the murder of family members and neighbours, rape, being lost, torture, kidnappings and bombings (Bhui et al. 2003). During migration, Somali refugees endured long, dangerous travel by foot to refugee camps in neighbouring countries. In refugee camps, famine and water scarcity persist as well as ongoing violence. The Dadaab refugee camps in neighbouring Kenya are among the largest refugee camps in the world. The camps established in 1992 and are the home of over 200,000 Somali refugees (Polonsky et al. 2013). Many Somali refugees in Dadaab have had long and entrenched stays as long as two decades, with families raising children through adulthood. Camp life to this day is characterized by insufficient food and water, disease, violence and rape (Beswick 2001; Cronin et al. 2008; Miller and Ramussen 2010). When Somali refugees finally enter the United States, their struggles are still not over. Most face significant post-migration acculturation stress in resettlement as a consequence of the cultural adaptation process which involves such things as learning a new language, balancing different cultural values, financial insecurity, loss of social and occupational status and family relationship disruptions (Betancourt et al.2012; Henry 2012; Ellis et al. 2014). Additionally, acculturative stress is heightened when resettled refugees encounter sociopolitical contexts that have high levels of nationalist racial ideology and do not prioritize safety for racial and ethnic minorities (Beiser and Hou 2006; Panagopoulos 2006). The cumulative impact of stress due to the violence and losses of war, trauma endured in transit and the challenges of resettlement leaves refugees vulnerable to compromised physical and mental health (Schweitzer et al. 2011). Research demonstrates that exposure to life-threatening events and chronic stress is correlated with medical issues such as hypertension, suppressed immunity, obesity, high blood sugar, insulin resistance and mental health issues such as anxiety, depression and somatization (Anda et al. 2006; Popoli et al. 2012). Resettlement Services In the United States, resettled refugees receive time-limited and resource-based assistance available for new arrivals. Services and supports include medical assistance, case management and support accessing employment and English-language classes (Mirza et al. 2014). Although resettlement support is essential in meeting basic health-care, food and shelter needs, these services tend to fall short of addressing the physical and mental health impacts of escaping civil war and navigating discrimination (Gallagher Vongkhamphra et al. 2011). Unfortunately, mental health services that might be available to assist with traumatic stress are not easily understood or accessed by refugees after resettlement. Barriers such as language acquisition combined with the primacy of basic needs contribute to underutilization and ambiguity of mental health services for Somali refugees (Ellis et al. 2011). Stigma associated with mental health problems is also frequently an obstacle for refugees experiencing symptoms related to trauma (Ellis et al. 2010). Lehman and Eno (2003) suggest that barriers to services are often further compounded by histories of severe oppression related to a lineage of slavery in Somalia that impacts self-esteem and the ability to advocate for one’s self or family. Service providers committed to helping resettled Somali refugees are challenged to develop culturally responsive interventions that promote positive wellbeing in this population. The theory of post-traumatic growth (PTG) (Tedeschi and Calhoun 1996) offers a promising framework to guide interventions that would help refugees improve their psycho-social functioning. PTG Tedeschi and Calhoun (1996) introduced a theory of PTG and presented the Post-Traumatic Growth Inventory (PTGI), an instrument developed to measure the positive psychological change that occurs as a result of coping with highly challenging life crises (Tedeschi and Calhoun 2004). The construct was developed to allow quantification of the experience of growth in response to stressful events (Tedeschi and Calhoun 2004). The theoretical construct of PTG maintains that people often experience personal improvement in five domains following adversity: (i) Relating to Others, which is the experience of feeling a greater sense of closeness with others; (ii) New Possibilities, demonstrated by developing new interests in life; (iii) Personal Strengths, which involves a greater sense of self-reliance; (iv) Spiritual Change, the experience of a deepened understanding of spiritual matters or strengthening of religious faith; and (v) Appreciation for Life, in which there is a change of priorities about what is important in life (Tedeschi and Calhoun 1996). Implicit to PTG theory (Tedeschi and Calhoun 1996) is that it involves enduring a major or “‘seismic’ “crisis. Examples of such traumatic events in the PTG literature include refugee trauma, rape, incest, bereavement, HIV infection, cancer, combat and disasters (Tedeschi and Calhoun 1996). PTG is understood as an ongoing experience of self-improvement that occurs in the context of new reality. In other words, PTG emerges when a person’s fundamental assumptions about life have changed as a consequence of trauma (Tedeschi and Calhoun 2004). An important clarification regarding PTG is that people do not necessarily experience decreased distress or increased happiness; it is rather about living life with greater depth, personal awareness and wisdom in the aftermath of trauma (Tedeschi et al. 2014). Additionally, there is empirical support suggesting that PTG is higher for people who engaged actively in cognitive processing, soon after a traumatic event occurs (Calhoun et al. 2000). Grounded in PTG theory, Tedeschi and colleagues (2014) present compelling and well-articulated strategies for therapeutic intervention based on facilitating cognitive processing and the development of a life narrative that incorporates and appreciates the wisdom gained through their experiences in conjunction with trauma-informed treatment approaches. PTG and Collectivist Cultural Values The concept of PTG is not easily translated into Somali culture, as the construct and measurement were developed based on Western experiences and perceptions. Somali culture is strongly rooted in collectivistic values characterized by interdependent family and community relationships. Splevins and Colleagues (2010) suggest that a significant source of stress in resettlement is a consequence of the disrupted ability to maintain social roles in the context of family and community. Consequently, the primary source of stress associated with this collective vantage is significantly different than the Western concept of loss integral to PTG, which is characterized by an individual personal narrative. The strong cultural value of group cohesion over personal identity has also been found in research that describes Muslim African trauma survivors as being devastated by loss associated with not being to contribute to the wellbeing of the group (Carpenter 2000; Henry 2012). In collectivistic cultures such as Somalia, unlike that of Christian or Western cultures, the goals and wellbeing of the family and community are prioritized. Therefore, Somali people tend to evaluate themselves based on their contributions to others (Carpenter 2000). The understanding and treatment of trauma symptomology are another area of contrast between Western and Somali cultures. Mental illness from a Somali perspective would translate to madness or to be in possession of a spirit (Guerin et al. 2004). In Somalia, people with mental health problems are considered a danger to themselves and others, and therefore likely to be put in seclusion or chained up or sent to live in other countries. Importantly, mental illness in Somalia would also only be used to describe the most severe cases—those equivalent to schizophrenia in Western culture (Guerin et al. 2004). With this in mind, it is understandable that Somali refugees tend to not seek mental health services for trauma, since they lack of a framework for recovery or the belief that people can recover from mental illness. In Somalia, symptoms such as insomnia, inattentiveness or forgetfulness are often referred to as a lack of wellbeing. Interventions for people suffering from these conditions include reading the Quran or community prayer, often led by an Imam (Elmi 1999). In contrast, Westernized cultures’ trauma symptoms would likely be treated with cognitive behaviour therapy or other therapies that promote trauma reprocessing. In considering the fundamentally different conceptualizations and interventions regarding mental health in Somali culture, it becomes important to explore whether growth after trauma would align with the concept and domains of PTG before applying the theory and framework for intervention with Somali refugees. Given the substantial differences between the collectivistic world view of Somali people compared to the more individualistic Western culture, it may be a disservice, potentially even harmful, to impose PTG-based conceptualizations on Somali refugees. The Current Study PTG might provide an important framework for understanding and promoting positive wellbeing in resettled Somali refugees suffering in the aftermath of trauma. If the theory were to adequately represent the range of experiences of positive growth among resettled Somali refugees, it may be beneficial to translate the PTGI inventory and apply PTG therapeutically based on the recommendations made by Tedeschi and colleagues (2014). If the domains of PTG are congruent with Somali experiences, then the PTGI instrument could be used to assess areas where growth is thwarted or optimized so intervention strategies could be developed that target Somali refugee needs more effectively. However, given the concerns that the construct of PTG might not accurately or adequately describe or assess the experiences of growth among resettled Somali refugees after trauma, it is necessary to first understand the complexity and multiplicity of the Somali refugee experience. Therefore, the current study applied an exploratory approach and qualitative methodology in order to understand the experiences of growth after trauma from the perspective of Somali refugees. We conducted focus groups with Somali resettled refugee participants to allow exploration of the dimensions of the PTG construct. We intentionally suspended priori assumptions while conducting the analysis in order to ensure it was grounded in participant voices. These methods allowed nuances in Somali experiences to emerge that might differ from what can be measured with the PTGI (Stebbens 2001). Cultural brokers were integral to all stages of implementing the data collection and analysis in order to optimize cultural responsiveness and humility. Methodology Sampling and Procedures Somali leaders from ethnic-community-based organizations that provide refugee services in a large city in north-east United States acted as advisors in this study. They were first consulted to confirm that a study on PTG would have meaning and be of value to the resettled Somali refugee community. Somali leaders as well assisted by identifying two moderators, one male and one female, to partner in this research study as cultural brokers. The cultural brokers were involved throughout the implementation of the study, including the construction of focus group questions, moderating the focus groups and in the analysis of the data. Cultural brokering is the act of bridging or mediating between individuals or groups from different cultural systems to reduce conflict and increase understanding (Jezewski and Sotnik 2001). By adopting this framework, the role of the focus group moderators was expanded to include the role of cultural expert. Utilizing cultural brokers as expert partners assisted in trust building and decreased the power differences between the researcher and subjects in this study. The cultural brokers assisted in providing psychological safety for focus group participants who have sustained complicated trauma and have the ongoing experience of discrimination due to their minority status as refugees in the United States (Ellis et al. 2011). Focus group participants were identified using purposive sampling. Focus group members were invited to participate by the Somali moderators with intent to ensure that group members would feel safe with one another in a group setting. Random sampling and snowball sampling were not recommended by Somali leaders due to the complexities of regional and tribal differences within the Somali population. Inclusion criteria required that all participants were adults (defined as being 18 years or older), refugee residents residing in the city and resettled in the United States for a minimum of one year. The one-year minimum criterion was modelled after research conducted by established scholars on resettled Somali refugees (Ellis et al. 2010). This strategy minimized the potential that participants would be experiencing acute crisis of resettlement and increased the possibility that participants could have gained enough perspective post trauma to dialogue about experiences of growth. The duration of resettlement in the focus groups ranged from 1.3 years to 15 years. Institutional Review Board (IRB) approval from the University of Tennessee in Knoxville (UTK) was obtained prior to conducting this study. The cultural brokers reviewed the informed consents prior to signatures being gathered. Cultural brokers explained that participation was voluntary and participants could choose not to participate at any point during the focus group discussion. Compensation in the form of debit cards was provided to both the moderators, who were each paid $50.00 and the focus group participants each received $25.00. The groups were held in local Somali community organizations where both men and women frequently socialize and network for resources. Focus Groups Focus group methodology was identified as the optimal approach for the cross-cultural nature of this study because focus groups allow depth of meaning that is likely to occur in discourse when exploring beliefs and experiences (Krueger and Casey 2015). In addition, the group context provides the opportunity to observe group norms, collective opinions and shared knowledge. The Somali people utilize spoken word, as opposed to written language, to communicate, making focus groups an optimal research instrument. Additionally, focus groups reduce the hierarchy between the researcher and participants—an important consideration given the potential psychological safety issues associated with research subjects who have been victims of severe abuses of power (Vogt et al. 2004). Two gender-specific focus groups were conducted, each with six participants. Gender-specific groups were selected to enhance safety and minimize harm, particularly to female participants who may have been victims of gender-based violence that refugee women are likely to have endured during any or all phases of migration (Hynes and Cardozo 2000; Farr 2009). The six-member limit recommended by Krueger and Casey (2015) minimized people talking over each other, which would have made translation more difficult. The discussions were facilitated by the Somali moderators who spoke the native language of the Somali focus group members. Focus groups were audio taped and transcripts were interpreted with the cultural brokers after the completion of each group. The focus group discussions were guided by six overarching questions (see Table 1). The questions were developed through conversations about each of the five domains in partnerships with the cultural brokers, who also moderated the focus group discussions. The resulting questions do not directly correspond with the domains, since some of vocabulary and concepts required interpretation into terms that would be recognized by the participants. The questions served as prompts to guide discussions focused on growth following trauma endured during the participants’ refugee experiences. Interpretation and discussions about the concepts reflected in the domains of PTG occurred in the course of the dialogue as the moderators engaged members in a robust exploration of the concepts. The partnership with focus group moderators as cultural experts in both the development and the interpretation of focus group questions fostered an emic approach to knowledge acquisition that could not otherwise have been accessed in quantitative research. Additionally, the ability for participants to speak in their native language allowed fluid dialogue and created a relaxed and social atmosphere. Table 1 Focus Group Questions Addressing the Domains of Post-traumatic Growth Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Table 1 Focus Group Questions Addressing the Domains of Post-traumatic Growth Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Analysis The process of data analysis consisted of four steps: (i) linguistic and cultural translation with the moderators, (ii) bracketing, (iii) thematic analysis and (iv) member checking the coded transcripts with the moderators of each focus group. The first step of the analysis involved separate individual meetings with moderators within 24 hours following each focus group to translate the audio recording. In each meeting, the recorded focus groups were played, the moderator stopped the recorder after each natural pause and orally conveyed the interpretation so the researcher could transcribe the content. During this process, the moderators provided both linguistic translation and cultural interpretation of each sentence. The second step of this project included bracketing to self-monitor researcher bias and assumptions. Bracketing was a way to purposefully recognize researcher assumptions and bias that emerged during the focus group translations and served as a safeguard against prior knowledge and personal position (Palmer et al. 2010). In the third step, transcripts were analysed in collaboration with the cultural brokers. This process involved examining common language and ideas in the raw focus group data. After the initial step of coding, a codebook was created and then preliminary themes were developed by grouping codes into categories. The final themes were identified through a process of ensuring that concepts were distinct from each other and inclusive of all of the quotes. Partnership with the cultural brokers was critical in the analysis to help the researcher understand religious and cultural meaning embedded in the transcripts. The fourth step in the analysis process involved content validation achieved by reading the translated transcripts back to the moderators and checking for accuracy. Results Analysis of the transcripts from both the men’s and women’s focus groups elicited six core themes including: perseverance, isolation stress, busyness, parenting, religion and trauma. Pseudonyms are used in reporting the findings to protect the confidentiality of the focus group members. Perseverance Perseverance was a theme identified in the analysis of the text as participants shared stories demonstrating steadfastness as they found employment, created new homes for their families and navigated the educational system for their children despite resource challenges and acculturative stressors. One of the men expressed that he felt it was important for Somali people to discover new things that motivate them in life: “It is more likely that after suffering life might improve because everything you go through makes you look for a better outcome and if you look for a change or solution you might have the possibility to find a solution” (Abdur). Some women shared that they cultivated the strengths of tolerance and patience as a result of surviving hardship. For example, one woman described perseverance in the following quote: ‘We fall and get up, we fall and get up, fall and get up, we struggle so much we just keep getting up’ (Haajar). There were other women who expressed that they wanted Americans to know that they are all strong women due to their experiences: ‘We go through war and each and every one of us had a way to survive we were able to have strength’ (Aamira). Perseverance may contribute towards the health of the community and new possibilities, as reflected in this statement from a Somali man: “Beyond yourself if you get better than you try to help other people get better and then even more people. You reach a point where we think how we all can get better” (Emran). Isolation Stress The theme isolation stress refers to the experiences of separation from neighbours, family and community that were relayed by many of the participants. The stress of disconnection was salient in both focus groups. Participants expressed a profound sense of being alone, and additionally being unable to access natural supports such as family, friends and neighbours. The loss is evident in the following quote: “Back in Somalia we used to have good relationships now that we are here we feel abandoned because the people we were close to we can’t be close to anymore, good and bad relationships they are all disconnected” (Emran). Some explained that the sense of isolation was exacerbated by language barriers and a loss of the support of neighbours. The moderators explained the significant difference between the function of ‘neighbours’ in Somalia as families who work collectively to take care of one another verses ‘neighbours’ in the United States, which denotes people who live in close proximity to one another. Feeling confined was a topic of conversation in the women’s focus group. One woman remarked that her sense of isolation and disconnection was impacting her physical health: “I won’t lie to you I faced a lot of problems in Somalia, my husband was killed, my kids and I separated, my life was very harsh, when I came here I thought my life would be better but I feel confined and physically sick” (Harrar). The men talked as a group about feelings of sadness and frustration due to isolation, and the challenges of developing relationships in the United States. One man shared: “People don’t talk to people here in the United States it takes 5 months before you are even able to talk to people like your neighbors, people don’t talk to people here” (Mahdi). Another dimension of this theme emerged in the women’s focus group as women shared feeling disconnected from family members who were still in Somalia. One woman, for example, described how difficult it was to connect with family back home because, in Somalia, they are still in a state of survival without consistent sources of food and water. She explained: ‘I call my family and I want to talk about the red house, the pharmacy and the tree and nobody wants to talk to me they just want money’ (Aamira). In response to this statement, the moderator drew a picture of Maslow’s Hierarchy of Needs for the group. The moderator explained that, years ago, she had found a psychology text book and the image of the triangle helped her understand where she was in her own life and how it might be different for their families in Somalia who were still trying to survive war. The women had an animated discussion about Maslow’s Hierarchy of Needs, as it seemed to offer some context as to why conversations with family in Somalia were challenging. Busyness The word ‘busy’ was used frequently in both the men’s group and the women’s group in relation to the pace and loss of time in the United States. Participants conveyed that busyness contributed to isolation and disrupted relationships and that they felt tired and fatigued. Both groups discussed that being ‘busy’ in the United States contributes to lack of time for relationships, which has contributed to a breakdown in the helpfulness and quality of relationships with each other. One woman described this challenge: ‘I don’t talk to anyone since I have been here, I work, I go to school, and I don’t call anyone at all’ (Aamira). The Somali men’s focus group participants shared openly with one another their feelings and observations about the busy life that Americans lead. A dimension of this theme that emerged in their discussion involved the resulting disconnection from self: ‘Not only are you not connected to people, you get so busy you forget to connect with your own self’ (Emran). Another man stated: ‘In the United States life is challenging because everyone is running from themselves’ (Mahad). The word ‘dismissive’ was used several times to describe the quality of relationships with one another in the United States. The moderator explained that this was connected to busyness and the experience that people do not have the time to care for others: ‘I am busy with my family here and work we no longer call each other and we are dismissive, we have become forgetful of each other’ (Amira). Parenting Stress Somali men and women discussed significant stress associated with parenting in America. Parenting was an area in which cultural differences posed significant stress for refugee parents. In the United States, primary care-givers are responsible for their children as opposed to the Somali culture, in which families and neighbours parent one another’s children. In the men’s focus group, the men talked about feeling sad for their children due to this loss. The sadness emanates from a strong belief that their children were losing valuable benefits of having many adults care about them. Numerous mentions occurred in the data in which participants expressed that they experienced stress as a result of differences in how children are parented in America verses how children are raised in Somalia. The focus group discussions identified fundamental cultural differences in parenting. For example, in the United States, children are cared for by primary care-givers in their household, while, in Somalia, children are parented by family, neighbours and community members. One man shared that, in the Quran, they are cautioned to not be ‘alone with one’s own’ (Malik) and some of the men shared the belief that parenting alone fails children. A Somali father said: “My biggest regret and loss is always for my children, people used to raise children with me, even the prophet Gabrielle spoke to the importance of neighbors carrying children for one another” (Emran). A Somali woman shared the loss of neighbours’ help with children: ‘neighbors carried children together and were part of the families raising children with me’ (Saara). The men’s focus group concluded on a sobering note as several men wondered whether safety in America was worth the sacrifice of what they have lost as parents. A final remark on parenting captures these sentiments: The United States is changing our children and this is what I regret. This culture, the isolation from neighbors, the independence of the children, they are more influenced by street culture and freedom is dangerous for children, caring for our children is very dear to me and the only thing that would make me go back home from where I came from; the problems I ran from as a refugee are still there but I still think maybe I should go back because of our kids, that is how strong we worry for our kids, this is my deepest regret (Mahmud). Religion The importance of religious beliefs and the significance of God’s presence in their lives were shared by all participants: ‘We haven’t had any change in our faith, faith depends on strength and weakness, it depends on you to be true to your faith’ (Emran). One woman said: ‘We never change our faith, we are Somalis, we are born and our upbringing is Muslim and no matter what happens to us we still pray’ (Amira). In both groups, the sentiment was expressed that evaluating spiritual change or growth was contradictive to their values. Participants explained that discussing a possible change in faith involved reflecting on the past, which is not supported in the Quran: ‘My faith has not changed I believe that whatever happened to me was meant to happen to me and I know that catastrophe can happen to any human being’ (Harrar). Another Somali woman explained faith as gratitude and acceptance: ‘it doesn’t matter if you have rice or luxurious pasta you must eat like you are going to die, Inshallah if God permits I will live’ (Saara). Trauma The theme of trauma refers to quotes from the focus groups that included such things as upsetting memories, nightmares, depression, anxiety and illness. The women in the focus group spoke in detail about the trauma they experienced both individually and collectively in Somalia, and the impact of trauma on their daily lives in the United States. Several women in the group shared that they did not feel personal strength due to struggles with worry, fear, depression, loss, traumatic memories and grief due to separation from loved ones: ‘The trauma for us isn’t necessarily the beatings, the rape or the killings it was unique because it happened to all of us, something that nobody imagines is possible’ (Saara). The women’s focus group members also talked about the feeling of running for their lives and, even after years of resettlement, they still feel like they may need to run: ‘I have felt fear my entire life even though it is 15 years later I feel that I might need to run at any point’ (Fadila). The following quote captures the experience of running from war for extended periods of time: ‘My five sisters we ran in different directions for twenty years we are all in different countries United States, Sweden, and Canada’ (Haajar). One woman whose husband was murdered and who lost her hearing in the war shared with the group her feelings of isolation: ‘In the past I was a woman with a family now I am a deaf woman with no family’ (Harrar). The moderator explained that the women felt as though what they have survived is not comprehensible to people who are not refugees. Discussion This study contributes to understanding perceptions regarding positive growth resulting from having to cope with traumatic experiences as refugees in a small sample of resettled adult Somali refugees (N = 12). The study also allowed observations to be made about congruence and differences between the participants’ perceptions and the PTG construct as it was defined by Tedeschi and Calhoun (2004). The combination of qualitative focus group and cultural brokering methodologies offers unique insight into the resettled Somali refugee experience. However, there are several limitations in the study methods that must also be discussed. Strengths and Stressors Thematic analysis of the data resulted in six themes: perseverance, isolation stress, busyness, parenting stress, religion and trauma. Significant strengths emerged in the findings, including numerous quotes from participants that conveyed perseverance, or hardiness, in their capacity to stay hopeful about the future and rebuild their lives in America. Another common strength that emerged among participants was the foundational belief in God, rooted in Islamic religion and the Quran. For most participants, faith seemed to help them make sense of the past and provide hope for the future. At the same time, stresses associated with isolation, parenting and busyness were themes that emerged as sources of hardship. Although each of these themes emerged as unique sources of stress, they were all discussed in the context that stress is generated by the loss of living in a collectivistic culture in which neighbours take care of children together and manage daily tasks together. Traumatic stress emerged as a theme in the women’s focus group to a greater extent than in the men’s focus groups. Although the participants did not use the language of traumatic stress per se, they described symptoms such as difficulty sleeping, flashbacks, depression, anxiety and poor health, as well as a persistent feeling that flight may be necessary at any time despite years of resettlement. Practical and Ethical Challenges in Conducting Research with Somali Refugees Conducting research with refugees presents a number of practical and ethical challenges (Ellis et al. 2007). Primarily language and cultural barriers present some significant complexities to conducting research with this population. There are unavoidable limitations to utilizing interpreters in qualitative research, since the researchers and interpreters may have considerable difficulty in understanding one another (Squires 2009). Croot, Lees and Grant (2011) explain that language translation is not a purely technical process, and consequently is never entirely neutral. Moreover, refugees are a particularly vulnerable population due to the multiple losses and traumatic experiences they have endured. Even after surviving multiple horrific traumas in fleeing their homeland and migrating, in resettlement, traumatic stress continues as refugees manage the process of gaining asylum, reconstructing their lives and managing the acquisition of resources for basic needs such as food, housing, clothing and health care (Keyes 2000). There is therefore a risk that the participants will re-experience trauma when they revisit and discuss their experiences. They may feel that they are compelled to cooperate with research as they have needed to cooperate with government and community services out of reliance on their assistance. The use of cultural brokers mitigated some of the risks by creating a safe context and some assurance that their experiences would not be misinterpreted. The decision to partner with cultural brokers as linguistic and cultural experts in conducting the study enriched the ability to capture the nuances in the focus group data as cultural brokers contextualized the data providing cultural relevance and meaning during the interpretation process. To illustrate, this was particularly helpful when metaphors from the Quran were cited as focus group members made meaning of the questions and PTG concepts. The cultural brokers understood the metaphors and language, allowing the discussion to flow in a way that would not be possible if an interpreter was trying to translate language verbatim for English-speaking researchers. Additionally, their collaboration in the analysis brought a cultural lens and expertise that American researchers are unlikely to offer alone. The Application of PTG with Somali Refugees In many ways, the findings revealed that PTG and its five domains are congruent with perceptions of growth among the resettled Somali refugee participants. However, there were substantial differences observed as well due to dissonance between the PTG construct and Somali culture, which is rooted in collectivism and Islamic beliefs and practices according to the Quran. In particular, the domain of “New Possibilities’ seemed contrary to Muslim beliefs, practices and values, and was therefore difficult for the cultural brokers to interpret. Tedeschi and Calhoun (2016) define new possibilities as the emergence of different life pathways that are available that may not have been clear before the crises occurred. In contrast, as explained by a key informant, from a Somali cultural lens, people do not choose their own emerging pathways. A primary article of faith is that of destiny, which means that Muslims accept what has happened, including the loss of loved ones, and that God will reward patience. Belief in God holds that people who are connected to God trust that his unlimited power is infinitely merciful in both this life and the eternal afterlife. Therefore, a Somali refugee will likely accept and learn from their pathway and maintain optimism for a better life even if the pathway is one of loss or disease. The notion of choosing one’s new destiny would mean to risk losing the opportunity of earning God’s mercy and his ability to provide happiness in the current life and in eternal life. To best get at a similar meaning of new possibilities, the focus groups explored the question of how suffering may have contributed to better things in resettlement. In addition, the domain “‘Personal Strengths”’ was challenging for the moderators to translate because, from Somali cultural vantage, strength lies in the family and not in the individual. These examples illustrate why it was important to not rely on interpretation of quantitative measures. Another important point of difference between the PTG and the participants’ experiences that emerged from the analysis is that PTG presumes that a major traumatic event has been endured and that positive growth occurred afterwards. As Tedeschi and colleagues (2014) explained: ‘the story of one’s life has been divided into before and after the traumatic event’ (p. 503). Although the severity of the traumas in the trauma theme certainly meets the presumed intensity to set the context for PTG, focus group participants described struggling with ongoing, unresolved grief related to separation from family and home that they experience as current trauma. In addition, as described earlier, Somali refugees tend to endure multiple traumatic experiences over prolonged periods of time. The theme of perseverance captures all quotes in the data in which participants talked about continued effort to do or achieve something despite difficulties, failure or opposition. Some of the quotes in this theme do seem in agreement with several domains of PTG in that they were finding meaning in their hardships in having new opportunities and ideas for what is possible that they never would have had if they had not endured their experiences as refugees. For example, participants expressed sentiments congruent with the PTG domain Appreciation for Life in that they were grateful to have survived war, live in a peaceful place and have access to medical care and education. When refugee parents spoke of the access to education and the ability for their children to attend school or for adults to attend college, they demonstrated the PTG domain of New Possibilities. Education is a privilege that is highly desired but systematically denied to many people in rural Somalia (Lehman and Eno 2003). As participants talked about their investment in education for their children, they conveyed some hope for the future, that life is worth living and that there was meaning that came from the hardships they survived. The theme of perseverance also aligned with the PTG domain of personal strength when some participants conveyed tenacity for life and an awareness they had gained of their capacity to persevere through incomprehensible loss and hardship. Most of the data in this theme, however, conveyed a sense of coping and surviving the best that they can. All of the participants had endured unimaginably horrific and prolonged trauma and hardship, and have had little choice but to live through it the best they can. Some participants clearly were currently struggling, though managing significant distress. They were persevering but not necessarily adapting well. On the other hand, most of the participants did seem to demonstrate a great deal of resilience—the ability to overcome adverse conditions and adapt normatively (Luther et al. 2014). As Westphal and Bonanno (2007) point out, variation in the capacity for resilience may be related to differences in flexibility and adaptation in coping and emotion regulation influenced by different personal characteristics, cultures and life circumstances, in addition to the severity and type of trauma one has endured. This fits with our observation from the findings in the current study that there are qualities that should be taken into account in understanding and assessing PTG that are established before the traumatic experience has occurred. In particular, strong faith before the participants were subjected to their tragedies could be considered a protective factor or pre-traumatic strength. This point is illustrated further when comparing the data in the theme of religion and the PTG domain of spiritual growth. A number of empirical research findings on the relationships among religion, spirituality and PTG have found that many of the qualities of religiosity were related to PTG (Shaw et al. 2005). However, there is also something fundamentally different about the way the Somali participants in the current study talked about religion than PTG because it did not emerge as an area of growth or change resulting from their traumatic experiences. Religion rather was experienced as a constant and consistent source of strength and hope throughout their entire lives. In other words, their ongoing religious beliefs were strong before, during and after migration. The question posed of how their experiences of suffering changed their religious faith seemed to strike the participants as confusing and they were emphatic that no change had occurred. Relating to Others was the domain of PTG that seems least congruent with the participants’ experiences. What emerged in this study through the theme isolation stress is that there is a profound sense of loss in resettlement due to the experience of disconnected relationships with both family and neighbours. Interdependent and helpful relationships are essential to Muslim culture and, tragically, many of the important relationships they had in their lives previously were destroyed. Loved ones had died. Families were broken apart. While, in Somalia, neighbours and friends supported each other and helped care for each other’s children and meet each other’s needs, unfortunately, once in the United States, they have not been able to reconstruct similar support systems. Not only did they have to start over completely and develop entirely new relationships, but Western culture and values of individualism and productivity are major barriers to establishing community, support systems and friendships. Somali women and men identified that being busy in the United States contributes to lack of time for quality relationships with family members and neighbours. The busyness of life makes relationships less helpful because they are isolated from one another. As conveyed in the theme parenting stress, the fathers in particular spoke of stress that they experience because they cannot parent their children in the way the way they want to and, specifically, that they felt a sense of loss because they are not able to parent collectively, in a way that neighbours help each other, care for each other and make sure their children’s needs are met. Even in the Quran, they are cautioned to ‘not be alone with one’s own’. Implications A number of implications for future research emerge from this study. Ultimately, quantitative validation testing through factor analysis is an important step to take with the PTGI with this and other refugee populations, as is assessing PTG over time through longitudinal investigations. However, sufficient N would require considerable resources and it makes sense to first conduct additional qualitative studies with other resettled refugee cultural groups to continue to flush out in what ways PTG is a universal experience, and how it differs according to culture so that additional items or domains might be considered. The methodology of cultural brokers would likely be optimal for any research conducted with refugees. Future research would also benefit from mixed methodologies that assessed congruence between the PTGI and the qualitative findings. It may be that some of the differences perceived in the findings would be accounted for by differential levels of the various domains. There are also a number of additional potential variables that would be helpful to include in future investigations regarding PTG. For example, in the current study, there was a large range in the duration of resettlement among the focus group participants, with the years post migration ranging from 1.3 to 15 years. It may be that a greater length of time in resettlement influences the findings in ways that cannot be determined. For example, duration in resettlement may reduce the sense of ongoing trauma as resettled refugees acculturate further over time. In fact, the use of financial, social and health-care supports has been shown to decrease after the first two years, suggesting that perhaps the status of resettled refugees improves and their need for assistance is decreased (Wright et al. 2016). However, other research suggests that the severity of the pre-displacement trauma is an important variable in predicting higher health needs and care utilization (Ackerman 1997; Wright et al. 2016), as well as levels of language proficiency (Ackerman 1997). Other variables to consider in order to align with and add to the current literature are the type of traumas experienced, mental and physical health symptoms, service utilization, availability of cultural supports and English-language acquisition. It seems an inherent limitation of studying PTG that it is not likely often possible to measure predictive factors for resilience or for PTG before traumatic events are experienced in order to further what is understood about how these concepts are related to each other. Retrospective assessment of known risk and protective factors for behavioural health and wellbeing outcomes may also be valuable to include in future investigations. Practice recommendations also emerge from this study. Refugee advocates seeking to provide services that promote resilience and wellbeing are encouraged to consider the unique strengths and attributes that exist in non-Western culture. Services developed for refugee families should consider sources of acculturative stress and discrimination. In particular, the social isolation participants described raises critical concern for the wellbeing of Somali refugees. A strong body of evidence demonstrates negative impacts of social isolation on numerous indicators of health and wellbeing (Lubben et al. 2015). Therefore, people interested in supporting the thriving of refugees should also look for ideas for intervention strategies aimed towards combating social isolation. Refugee-owned community-based organizations and refugee-run mental health and advocacy agencies provide a mechanism for building connection and support among resettled refugees. Further ideas about how to integrate collectivistic approaches to childcare and develop neighbourhood gathering places might preserve natural supports and decrease isolation stress associated with being a refugee. Efforts are needed make adaptations to neighbourhoods in an effort to decrease isolation stress, support collective parenting and allow reprieve from the stress related to the busyness of the American lifestyle. Given the significant barriers to care, social service providers might consider seeking consultation from refugees living in their communities. Refugees can help professionals better understand from a cultural perspective what supports positive mental health and contributes to their wellbeing. Seeking out the expertise of Somali refugees can build trust and may assist social service providers in conceptualizing and developing services that are not contradictory to Islamic values in collectivistic cultures (Kia-Keating and Ellis 2007). The cultural wisdom of refugees can help providers understand how collectivistic cultural values such as strong interdependent relationships can support positive growth after trauma. Conclusion A main intent of the study was to assess the capacity for the theory of PTG to explain the ways in which refugees experience growth in the aftermath of traumatic experiences in Somalia, and ongoing resettlement and acculturation stresses. Support for the PTG framework was mixed. Incongruent factors seem to be largely related to the differences between the collectivist Somali culture and the Western culture within which the PTG theory was developed. Applying PTG to understand Somali refugees and other populations with collectivist cultures could actually be counterproductive, since the expectations might be unreasonable and interventions based on promoting individualistic factors might create dissonance between what refugees inherently know is good for them and what is expected and encouraged for them. Acknowledgements This focus group study was conducted in February of 2016 and the initial version of this manuscript was written in April of 2016. 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( 2007 ) ‘ Posttraumatic Growth and Resilience to Trauma: Different Sides of the Same Coin or Different Coins?’ . Applied Psychology 56 ( 3 ): 417 – 427 . Google Scholar CrossRef Search ADS WRIGHT A. M. , ALDHALIMI A. , LUMLEY M. A. , JAMIL H. , POLE N. , ARNETZ J. E. , ARNETZ B. B. ( 2016 ) ‘ Determinants of Resource Needs and Utilization among Refugees over Time’ . Social Psychiatry and Psychiatric Epidemiology 51 ( 4 ): 539 – 549 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Refugee Studies Oxford University Press

Perspectives of Somali Refugees on Post-traumatic Growth after Resettlement

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0951-6328
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Abstract

Abstract Post-traumatic growth (PTG), a theory of positive transformation after trauma, offers a framework to consider what contributes to the thriving of some individuals after traumatic experiences. Refugees living in communities across the United States have experienced the devastating trauma of surviving war and mass dislocation from their homes and countries of origin. This qualitative focus group study sought to explore whether the constructs of PTG had congruence among resettled Somali refugees. The results indicate that there is tenacity for life rooted in strong cultural values among Somali refugees; however, significant challenges are brought to the forefront, impacting growth for refugees in resettlement. The focus group discussions revealed that PTG is impacted by acculturative stressors and that there are significant cultural differences regarding what promotes healing and thriving after traumatic events among Somali refugees. The social isolation participants described raises critical concern for the wellbeing of Somali refugees. Introduction The East African country of Somalia has a long history of political unrest that escalated from mid-1980 to the early 1990s when a catastrophic civil war erupted. Somalia continues to be a country wrought with conflict and resulting hardship. By the end of 2013, approximately 1,121,900 refugees had been forced from their homeland of Somalia (United Nations High Commissioner on Refugees (UNHCR) 2013). For the purpose of this study, refugee, as defined by the 1951 Geneva Academy of National Humanitarian Law, is someone who: owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country (UNHCR 1951: Article 1A(2)). Refugee Trauma Refugees displaced due to violent civil war and persecution in their countries of origin endure severe trauma pre migration, during migration and post migration (Boyle and Ali 2010). Prior to the civil war, throughout the twentieth century, the people of Somalia faced long periods of persecution and discrimination, with many citizens experiencing clan-based slavery, oppression and violence, with only intermittent periods of peace. Civil war erupted in 1991 resulting in the mass migration of Somali people seeking refuge (Lehman and Eno 2003). The Somali refugee migration experience includes any number of intensely traumatic events such as the catastrophic destruction of homes and communities, the murder of family members and neighbours, rape, being lost, torture, kidnappings and bombings (Bhui et al. 2003). During migration, Somali refugees endured long, dangerous travel by foot to refugee camps in neighbouring countries. In refugee camps, famine and water scarcity persist as well as ongoing violence. The Dadaab refugee camps in neighbouring Kenya are among the largest refugee camps in the world. The camps established in 1992 and are the home of over 200,000 Somali refugees (Polonsky et al. 2013). Many Somali refugees in Dadaab have had long and entrenched stays as long as two decades, with families raising children through adulthood. Camp life to this day is characterized by insufficient food and water, disease, violence and rape (Beswick 2001; Cronin et al. 2008; Miller and Ramussen 2010). When Somali refugees finally enter the United States, their struggles are still not over. Most face significant post-migration acculturation stress in resettlement as a consequence of the cultural adaptation process which involves such things as learning a new language, balancing different cultural values, financial insecurity, loss of social and occupational status and family relationship disruptions (Betancourt et al.2012; Henry 2012; Ellis et al. 2014). Additionally, acculturative stress is heightened when resettled refugees encounter sociopolitical contexts that have high levels of nationalist racial ideology and do not prioritize safety for racial and ethnic minorities (Beiser and Hou 2006; Panagopoulos 2006). The cumulative impact of stress due to the violence and losses of war, trauma endured in transit and the challenges of resettlement leaves refugees vulnerable to compromised physical and mental health (Schweitzer et al. 2011). Research demonstrates that exposure to life-threatening events and chronic stress is correlated with medical issues such as hypertension, suppressed immunity, obesity, high blood sugar, insulin resistance and mental health issues such as anxiety, depression and somatization (Anda et al. 2006; Popoli et al. 2012). Resettlement Services In the United States, resettled refugees receive time-limited and resource-based assistance available for new arrivals. Services and supports include medical assistance, case management and support accessing employment and English-language classes (Mirza et al. 2014). Although resettlement support is essential in meeting basic health-care, food and shelter needs, these services tend to fall short of addressing the physical and mental health impacts of escaping civil war and navigating discrimination (Gallagher Vongkhamphra et al. 2011). Unfortunately, mental health services that might be available to assist with traumatic stress are not easily understood or accessed by refugees after resettlement. Barriers such as language acquisition combined with the primacy of basic needs contribute to underutilization and ambiguity of mental health services for Somali refugees (Ellis et al. 2011). Stigma associated with mental health problems is also frequently an obstacle for refugees experiencing symptoms related to trauma (Ellis et al. 2010). Lehman and Eno (2003) suggest that barriers to services are often further compounded by histories of severe oppression related to a lineage of slavery in Somalia that impacts self-esteem and the ability to advocate for one’s self or family. Service providers committed to helping resettled Somali refugees are challenged to develop culturally responsive interventions that promote positive wellbeing in this population. The theory of post-traumatic growth (PTG) (Tedeschi and Calhoun 1996) offers a promising framework to guide interventions that would help refugees improve their psycho-social functioning. PTG Tedeschi and Calhoun (1996) introduced a theory of PTG and presented the Post-Traumatic Growth Inventory (PTGI), an instrument developed to measure the positive psychological change that occurs as a result of coping with highly challenging life crises (Tedeschi and Calhoun 2004). The construct was developed to allow quantification of the experience of growth in response to stressful events (Tedeschi and Calhoun 2004). The theoretical construct of PTG maintains that people often experience personal improvement in five domains following adversity: (i) Relating to Others, which is the experience of feeling a greater sense of closeness with others; (ii) New Possibilities, demonstrated by developing new interests in life; (iii) Personal Strengths, which involves a greater sense of self-reliance; (iv) Spiritual Change, the experience of a deepened understanding of spiritual matters or strengthening of religious faith; and (v) Appreciation for Life, in which there is a change of priorities about what is important in life (Tedeschi and Calhoun 1996). Implicit to PTG theory (Tedeschi and Calhoun 1996) is that it involves enduring a major or “‘seismic’ “crisis. Examples of such traumatic events in the PTG literature include refugee trauma, rape, incest, bereavement, HIV infection, cancer, combat and disasters (Tedeschi and Calhoun 1996). PTG is understood as an ongoing experience of self-improvement that occurs in the context of new reality. In other words, PTG emerges when a person’s fundamental assumptions about life have changed as a consequence of trauma (Tedeschi and Calhoun 2004). An important clarification regarding PTG is that people do not necessarily experience decreased distress or increased happiness; it is rather about living life with greater depth, personal awareness and wisdom in the aftermath of trauma (Tedeschi et al. 2014). Additionally, there is empirical support suggesting that PTG is higher for people who engaged actively in cognitive processing, soon after a traumatic event occurs (Calhoun et al. 2000). Grounded in PTG theory, Tedeschi and colleagues (2014) present compelling and well-articulated strategies for therapeutic intervention based on facilitating cognitive processing and the development of a life narrative that incorporates and appreciates the wisdom gained through their experiences in conjunction with trauma-informed treatment approaches. PTG and Collectivist Cultural Values The concept of PTG is not easily translated into Somali culture, as the construct and measurement were developed based on Western experiences and perceptions. Somali culture is strongly rooted in collectivistic values characterized by interdependent family and community relationships. Splevins and Colleagues (2010) suggest that a significant source of stress in resettlement is a consequence of the disrupted ability to maintain social roles in the context of family and community. Consequently, the primary source of stress associated with this collective vantage is significantly different than the Western concept of loss integral to PTG, which is characterized by an individual personal narrative. The strong cultural value of group cohesion over personal identity has also been found in research that describes Muslim African trauma survivors as being devastated by loss associated with not being to contribute to the wellbeing of the group (Carpenter 2000; Henry 2012). In collectivistic cultures such as Somalia, unlike that of Christian or Western cultures, the goals and wellbeing of the family and community are prioritized. Therefore, Somali people tend to evaluate themselves based on their contributions to others (Carpenter 2000). The understanding and treatment of trauma symptomology are another area of contrast between Western and Somali cultures. Mental illness from a Somali perspective would translate to madness or to be in possession of a spirit (Guerin et al. 2004). In Somalia, people with mental health problems are considered a danger to themselves and others, and therefore likely to be put in seclusion or chained up or sent to live in other countries. Importantly, mental illness in Somalia would also only be used to describe the most severe cases—those equivalent to schizophrenia in Western culture (Guerin et al. 2004). With this in mind, it is understandable that Somali refugees tend to not seek mental health services for trauma, since they lack of a framework for recovery or the belief that people can recover from mental illness. In Somalia, symptoms such as insomnia, inattentiveness or forgetfulness are often referred to as a lack of wellbeing. Interventions for people suffering from these conditions include reading the Quran or community prayer, often led by an Imam (Elmi 1999). In contrast, Westernized cultures’ trauma symptoms would likely be treated with cognitive behaviour therapy or other therapies that promote trauma reprocessing. In considering the fundamentally different conceptualizations and interventions regarding mental health in Somali culture, it becomes important to explore whether growth after trauma would align with the concept and domains of PTG before applying the theory and framework for intervention with Somali refugees. Given the substantial differences between the collectivistic world view of Somali people compared to the more individualistic Western culture, it may be a disservice, potentially even harmful, to impose PTG-based conceptualizations on Somali refugees. The Current Study PTG might provide an important framework for understanding and promoting positive wellbeing in resettled Somali refugees suffering in the aftermath of trauma. If the theory were to adequately represent the range of experiences of positive growth among resettled Somali refugees, it may be beneficial to translate the PTGI inventory and apply PTG therapeutically based on the recommendations made by Tedeschi and colleagues (2014). If the domains of PTG are congruent with Somali experiences, then the PTGI instrument could be used to assess areas where growth is thwarted or optimized so intervention strategies could be developed that target Somali refugee needs more effectively. However, given the concerns that the construct of PTG might not accurately or adequately describe or assess the experiences of growth among resettled Somali refugees after trauma, it is necessary to first understand the complexity and multiplicity of the Somali refugee experience. Therefore, the current study applied an exploratory approach and qualitative methodology in order to understand the experiences of growth after trauma from the perspective of Somali refugees. We conducted focus groups with Somali resettled refugee participants to allow exploration of the dimensions of the PTG construct. We intentionally suspended priori assumptions while conducting the analysis in order to ensure it was grounded in participant voices. These methods allowed nuances in Somali experiences to emerge that might differ from what can be measured with the PTGI (Stebbens 2001). Cultural brokers were integral to all stages of implementing the data collection and analysis in order to optimize cultural responsiveness and humility. Methodology Sampling and Procedures Somali leaders from ethnic-community-based organizations that provide refugee services in a large city in north-east United States acted as advisors in this study. They were first consulted to confirm that a study on PTG would have meaning and be of value to the resettled Somali refugee community. Somali leaders as well assisted by identifying two moderators, one male and one female, to partner in this research study as cultural brokers. The cultural brokers were involved throughout the implementation of the study, including the construction of focus group questions, moderating the focus groups and in the analysis of the data. Cultural brokering is the act of bridging or mediating between individuals or groups from different cultural systems to reduce conflict and increase understanding (Jezewski and Sotnik 2001). By adopting this framework, the role of the focus group moderators was expanded to include the role of cultural expert. Utilizing cultural brokers as expert partners assisted in trust building and decreased the power differences between the researcher and subjects in this study. The cultural brokers assisted in providing psychological safety for focus group participants who have sustained complicated trauma and have the ongoing experience of discrimination due to their minority status as refugees in the United States (Ellis et al. 2011). Focus group participants were identified using purposive sampling. Focus group members were invited to participate by the Somali moderators with intent to ensure that group members would feel safe with one another in a group setting. Random sampling and snowball sampling were not recommended by Somali leaders due to the complexities of regional and tribal differences within the Somali population. Inclusion criteria required that all participants were adults (defined as being 18 years or older), refugee residents residing in the city and resettled in the United States for a minimum of one year. The one-year minimum criterion was modelled after research conducted by established scholars on resettled Somali refugees (Ellis et al. 2010). This strategy minimized the potential that participants would be experiencing acute crisis of resettlement and increased the possibility that participants could have gained enough perspective post trauma to dialogue about experiences of growth. The duration of resettlement in the focus groups ranged from 1.3 years to 15 years. Institutional Review Board (IRB) approval from the University of Tennessee in Knoxville (UTK) was obtained prior to conducting this study. The cultural brokers reviewed the informed consents prior to signatures being gathered. Cultural brokers explained that participation was voluntary and participants could choose not to participate at any point during the focus group discussion. Compensation in the form of debit cards was provided to both the moderators, who were each paid $50.00 and the focus group participants each received $25.00. The groups were held in local Somali community organizations where both men and women frequently socialize and network for resources. Focus Groups Focus group methodology was identified as the optimal approach for the cross-cultural nature of this study because focus groups allow depth of meaning that is likely to occur in discourse when exploring beliefs and experiences (Krueger and Casey 2015). In addition, the group context provides the opportunity to observe group norms, collective opinions and shared knowledge. The Somali people utilize spoken word, as opposed to written language, to communicate, making focus groups an optimal research instrument. Additionally, focus groups reduce the hierarchy between the researcher and participants—an important consideration given the potential psychological safety issues associated with research subjects who have been victims of severe abuses of power (Vogt et al. 2004). Two gender-specific focus groups were conducted, each with six participants. Gender-specific groups were selected to enhance safety and minimize harm, particularly to female participants who may have been victims of gender-based violence that refugee women are likely to have endured during any or all phases of migration (Hynes and Cardozo 2000; Farr 2009). The six-member limit recommended by Krueger and Casey (2015) minimized people talking over each other, which would have made translation more difficult. The discussions were facilitated by the Somali moderators who spoke the native language of the Somali focus group members. Focus groups were audio taped and transcripts were interpreted with the cultural brokers after the completion of each group. The focus group discussions were guided by six overarching questions (see Table 1). The questions were developed through conversations about each of the five domains in partnerships with the cultural brokers, who also moderated the focus group discussions. The resulting questions do not directly correspond with the domains, since some of vocabulary and concepts required interpretation into terms that would be recognized by the participants. The questions served as prompts to guide discussions focused on growth following trauma endured during the participants’ refugee experiences. Interpretation and discussions about the concepts reflected in the domains of PTG occurred in the course of the dialogue as the moderators engaged members in a robust exploration of the concepts. The partnership with focus group moderators as cultural experts in both the development and the interpretation of focus group questions fostered an emic approach to knowledge acquisition that could not otherwise have been accessed in quantitative research. Additionally, the ability for participants to speak in their native language allowed fluid dialogue and created a relaxed and social atmosphere. Table 1 Focus Group Questions Addressing the Domains of Post-traumatic Growth Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Table 1 Focus Group Questions Addressing the Domains of Post-traumatic Growth Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Domains of PTG Focus Group Questions Relating to Others How have your relationships with family, friends and community changed since resettlement in the United States? New Possibilities How has suffering contributed to better things in your life today? Personal Strengths What are your personal strengths and do you feel more able to handle challenges or difficulties? Spiritual Change How did your experiences of suffering change your religious faith? Appreciation for Life Compared to your life before the war are there things that you appreciate more in life? Analysis The process of data analysis consisted of four steps: (i) linguistic and cultural translation with the moderators, (ii) bracketing, (iii) thematic analysis and (iv) member checking the coded transcripts with the moderators of each focus group. The first step of the analysis involved separate individual meetings with moderators within 24 hours following each focus group to translate the audio recording. In each meeting, the recorded focus groups were played, the moderator stopped the recorder after each natural pause and orally conveyed the interpretation so the researcher could transcribe the content. During this process, the moderators provided both linguistic translation and cultural interpretation of each sentence. The second step of this project included bracketing to self-monitor researcher bias and assumptions. Bracketing was a way to purposefully recognize researcher assumptions and bias that emerged during the focus group translations and served as a safeguard against prior knowledge and personal position (Palmer et al. 2010). In the third step, transcripts were analysed in collaboration with the cultural brokers. This process involved examining common language and ideas in the raw focus group data. After the initial step of coding, a codebook was created and then preliminary themes were developed by grouping codes into categories. The final themes were identified through a process of ensuring that concepts were distinct from each other and inclusive of all of the quotes. Partnership with the cultural brokers was critical in the analysis to help the researcher understand religious and cultural meaning embedded in the transcripts. The fourth step in the analysis process involved content validation achieved by reading the translated transcripts back to the moderators and checking for accuracy. Results Analysis of the transcripts from both the men’s and women’s focus groups elicited six core themes including: perseverance, isolation stress, busyness, parenting, religion and trauma. Pseudonyms are used in reporting the findings to protect the confidentiality of the focus group members. Perseverance Perseverance was a theme identified in the analysis of the text as participants shared stories demonstrating steadfastness as they found employment, created new homes for their families and navigated the educational system for their children despite resource challenges and acculturative stressors. One of the men expressed that he felt it was important for Somali people to discover new things that motivate them in life: “It is more likely that after suffering life might improve because everything you go through makes you look for a better outcome and if you look for a change or solution you might have the possibility to find a solution” (Abdur). Some women shared that they cultivated the strengths of tolerance and patience as a result of surviving hardship. For example, one woman described perseverance in the following quote: ‘We fall and get up, we fall and get up, fall and get up, we struggle so much we just keep getting up’ (Haajar). There were other women who expressed that they wanted Americans to know that they are all strong women due to their experiences: ‘We go through war and each and every one of us had a way to survive we were able to have strength’ (Aamira). Perseverance may contribute towards the health of the community and new possibilities, as reflected in this statement from a Somali man: “Beyond yourself if you get better than you try to help other people get better and then even more people. You reach a point where we think how we all can get better” (Emran). Isolation Stress The theme isolation stress refers to the experiences of separation from neighbours, family and community that were relayed by many of the participants. The stress of disconnection was salient in both focus groups. Participants expressed a profound sense of being alone, and additionally being unable to access natural supports such as family, friends and neighbours. The loss is evident in the following quote: “Back in Somalia we used to have good relationships now that we are here we feel abandoned because the people we were close to we can’t be close to anymore, good and bad relationships they are all disconnected” (Emran). Some explained that the sense of isolation was exacerbated by language barriers and a loss of the support of neighbours. The moderators explained the significant difference between the function of ‘neighbours’ in Somalia as families who work collectively to take care of one another verses ‘neighbours’ in the United States, which denotes people who live in close proximity to one another. Feeling confined was a topic of conversation in the women’s focus group. One woman remarked that her sense of isolation and disconnection was impacting her physical health: “I won’t lie to you I faced a lot of problems in Somalia, my husband was killed, my kids and I separated, my life was very harsh, when I came here I thought my life would be better but I feel confined and physically sick” (Harrar). The men talked as a group about feelings of sadness and frustration due to isolation, and the challenges of developing relationships in the United States. One man shared: “People don’t talk to people here in the United States it takes 5 months before you are even able to talk to people like your neighbors, people don’t talk to people here” (Mahdi). Another dimension of this theme emerged in the women’s focus group as women shared feeling disconnected from family members who were still in Somalia. One woman, for example, described how difficult it was to connect with family back home because, in Somalia, they are still in a state of survival without consistent sources of food and water. She explained: ‘I call my family and I want to talk about the red house, the pharmacy and the tree and nobody wants to talk to me they just want money’ (Aamira). In response to this statement, the moderator drew a picture of Maslow’s Hierarchy of Needs for the group. The moderator explained that, years ago, she had found a psychology text book and the image of the triangle helped her understand where she was in her own life and how it might be different for their families in Somalia who were still trying to survive war. The women had an animated discussion about Maslow’s Hierarchy of Needs, as it seemed to offer some context as to why conversations with family in Somalia were challenging. Busyness The word ‘busy’ was used frequently in both the men’s group and the women’s group in relation to the pace and loss of time in the United States. Participants conveyed that busyness contributed to isolation and disrupted relationships and that they felt tired and fatigued. Both groups discussed that being ‘busy’ in the United States contributes to lack of time for relationships, which has contributed to a breakdown in the helpfulness and quality of relationships with each other. One woman described this challenge: ‘I don’t talk to anyone since I have been here, I work, I go to school, and I don’t call anyone at all’ (Aamira). The Somali men’s focus group participants shared openly with one another their feelings and observations about the busy life that Americans lead. A dimension of this theme that emerged in their discussion involved the resulting disconnection from self: ‘Not only are you not connected to people, you get so busy you forget to connect with your own self’ (Emran). Another man stated: ‘In the United States life is challenging because everyone is running from themselves’ (Mahad). The word ‘dismissive’ was used several times to describe the quality of relationships with one another in the United States. The moderator explained that this was connected to busyness and the experience that people do not have the time to care for others: ‘I am busy with my family here and work we no longer call each other and we are dismissive, we have become forgetful of each other’ (Amira). Parenting Stress Somali men and women discussed significant stress associated with parenting in America. Parenting was an area in which cultural differences posed significant stress for refugee parents. In the United States, primary care-givers are responsible for their children as opposed to the Somali culture, in which families and neighbours parent one another’s children. In the men’s focus group, the men talked about feeling sad for their children due to this loss. The sadness emanates from a strong belief that their children were losing valuable benefits of having many adults care about them. Numerous mentions occurred in the data in which participants expressed that they experienced stress as a result of differences in how children are parented in America verses how children are raised in Somalia. The focus group discussions identified fundamental cultural differences in parenting. For example, in the United States, children are cared for by primary care-givers in their household, while, in Somalia, children are parented by family, neighbours and community members. One man shared that, in the Quran, they are cautioned to not be ‘alone with one’s own’ (Malik) and some of the men shared the belief that parenting alone fails children. A Somali father said: “My biggest regret and loss is always for my children, people used to raise children with me, even the prophet Gabrielle spoke to the importance of neighbors carrying children for one another” (Emran). A Somali woman shared the loss of neighbours’ help with children: ‘neighbors carried children together and were part of the families raising children with me’ (Saara). The men’s focus group concluded on a sobering note as several men wondered whether safety in America was worth the sacrifice of what they have lost as parents. A final remark on parenting captures these sentiments: The United States is changing our children and this is what I regret. This culture, the isolation from neighbors, the independence of the children, they are more influenced by street culture and freedom is dangerous for children, caring for our children is very dear to me and the only thing that would make me go back home from where I came from; the problems I ran from as a refugee are still there but I still think maybe I should go back because of our kids, that is how strong we worry for our kids, this is my deepest regret (Mahmud). Religion The importance of religious beliefs and the significance of God’s presence in their lives were shared by all participants: ‘We haven’t had any change in our faith, faith depends on strength and weakness, it depends on you to be true to your faith’ (Emran). One woman said: ‘We never change our faith, we are Somalis, we are born and our upbringing is Muslim and no matter what happens to us we still pray’ (Amira). In both groups, the sentiment was expressed that evaluating spiritual change or growth was contradictive to their values. Participants explained that discussing a possible change in faith involved reflecting on the past, which is not supported in the Quran: ‘My faith has not changed I believe that whatever happened to me was meant to happen to me and I know that catastrophe can happen to any human being’ (Harrar). Another Somali woman explained faith as gratitude and acceptance: ‘it doesn’t matter if you have rice or luxurious pasta you must eat like you are going to die, Inshallah if God permits I will live’ (Saara). Trauma The theme of trauma refers to quotes from the focus groups that included such things as upsetting memories, nightmares, depression, anxiety and illness. The women in the focus group spoke in detail about the trauma they experienced both individually and collectively in Somalia, and the impact of trauma on their daily lives in the United States. Several women in the group shared that they did not feel personal strength due to struggles with worry, fear, depression, loss, traumatic memories and grief due to separation from loved ones: ‘The trauma for us isn’t necessarily the beatings, the rape or the killings it was unique because it happened to all of us, something that nobody imagines is possible’ (Saara). The women’s focus group members also talked about the feeling of running for their lives and, even after years of resettlement, they still feel like they may need to run: ‘I have felt fear my entire life even though it is 15 years later I feel that I might need to run at any point’ (Fadila). The following quote captures the experience of running from war for extended periods of time: ‘My five sisters we ran in different directions for twenty years we are all in different countries United States, Sweden, and Canada’ (Haajar). One woman whose husband was murdered and who lost her hearing in the war shared with the group her feelings of isolation: ‘In the past I was a woman with a family now I am a deaf woman with no family’ (Harrar). The moderator explained that the women felt as though what they have survived is not comprehensible to people who are not refugees. Discussion This study contributes to understanding perceptions regarding positive growth resulting from having to cope with traumatic experiences as refugees in a small sample of resettled adult Somali refugees (N = 12). The study also allowed observations to be made about congruence and differences between the participants’ perceptions and the PTG construct as it was defined by Tedeschi and Calhoun (2004). The combination of qualitative focus group and cultural brokering methodologies offers unique insight into the resettled Somali refugee experience. However, there are several limitations in the study methods that must also be discussed. Strengths and Stressors Thematic analysis of the data resulted in six themes: perseverance, isolation stress, busyness, parenting stress, religion and trauma. Significant strengths emerged in the findings, including numerous quotes from participants that conveyed perseverance, or hardiness, in their capacity to stay hopeful about the future and rebuild their lives in America. Another common strength that emerged among participants was the foundational belief in God, rooted in Islamic religion and the Quran. For most participants, faith seemed to help them make sense of the past and provide hope for the future. At the same time, stresses associated with isolation, parenting and busyness were themes that emerged as sources of hardship. Although each of these themes emerged as unique sources of stress, they were all discussed in the context that stress is generated by the loss of living in a collectivistic culture in which neighbours take care of children together and manage daily tasks together. Traumatic stress emerged as a theme in the women’s focus group to a greater extent than in the men’s focus groups. Although the participants did not use the language of traumatic stress per se, they described symptoms such as difficulty sleeping, flashbacks, depression, anxiety and poor health, as well as a persistent feeling that flight may be necessary at any time despite years of resettlement. Practical and Ethical Challenges in Conducting Research with Somali Refugees Conducting research with refugees presents a number of practical and ethical challenges (Ellis et al. 2007). Primarily language and cultural barriers present some significant complexities to conducting research with this population. There are unavoidable limitations to utilizing interpreters in qualitative research, since the researchers and interpreters may have considerable difficulty in understanding one another (Squires 2009). Croot, Lees and Grant (2011) explain that language translation is not a purely technical process, and consequently is never entirely neutral. Moreover, refugees are a particularly vulnerable population due to the multiple losses and traumatic experiences they have endured. Even after surviving multiple horrific traumas in fleeing their homeland and migrating, in resettlement, traumatic stress continues as refugees manage the process of gaining asylum, reconstructing their lives and managing the acquisition of resources for basic needs such as food, housing, clothing and health care (Keyes 2000). There is therefore a risk that the participants will re-experience trauma when they revisit and discuss their experiences. They may feel that they are compelled to cooperate with research as they have needed to cooperate with government and community services out of reliance on their assistance. The use of cultural brokers mitigated some of the risks by creating a safe context and some assurance that their experiences would not be misinterpreted. The decision to partner with cultural brokers as linguistic and cultural experts in conducting the study enriched the ability to capture the nuances in the focus group data as cultural brokers contextualized the data providing cultural relevance and meaning during the interpretation process. To illustrate, this was particularly helpful when metaphors from the Quran were cited as focus group members made meaning of the questions and PTG concepts. The cultural brokers understood the metaphors and language, allowing the discussion to flow in a way that would not be possible if an interpreter was trying to translate language verbatim for English-speaking researchers. Additionally, their collaboration in the analysis brought a cultural lens and expertise that American researchers are unlikely to offer alone. The Application of PTG with Somali Refugees In many ways, the findings revealed that PTG and its five domains are congruent with perceptions of growth among the resettled Somali refugee participants. However, there were substantial differences observed as well due to dissonance between the PTG construct and Somali culture, which is rooted in collectivism and Islamic beliefs and practices according to the Quran. In particular, the domain of “New Possibilities’ seemed contrary to Muslim beliefs, practices and values, and was therefore difficult for the cultural brokers to interpret. Tedeschi and Calhoun (2016) define new possibilities as the emergence of different life pathways that are available that may not have been clear before the crises occurred. In contrast, as explained by a key informant, from a Somali cultural lens, people do not choose their own emerging pathways. A primary article of faith is that of destiny, which means that Muslims accept what has happened, including the loss of loved ones, and that God will reward patience. Belief in God holds that people who are connected to God trust that his unlimited power is infinitely merciful in both this life and the eternal afterlife. Therefore, a Somali refugee will likely accept and learn from their pathway and maintain optimism for a better life even if the pathway is one of loss or disease. The notion of choosing one’s new destiny would mean to risk losing the opportunity of earning God’s mercy and his ability to provide happiness in the current life and in eternal life. To best get at a similar meaning of new possibilities, the focus groups explored the question of how suffering may have contributed to better things in resettlement. In addition, the domain “‘Personal Strengths”’ was challenging for the moderators to translate because, from Somali cultural vantage, strength lies in the family and not in the individual. These examples illustrate why it was important to not rely on interpretation of quantitative measures. Another important point of difference between the PTG and the participants’ experiences that emerged from the analysis is that PTG presumes that a major traumatic event has been endured and that positive growth occurred afterwards. As Tedeschi and colleagues (2014) explained: ‘the story of one’s life has been divided into before and after the traumatic event’ (p. 503). Although the severity of the traumas in the trauma theme certainly meets the presumed intensity to set the context for PTG, focus group participants described struggling with ongoing, unresolved grief related to separation from family and home that they experience as current trauma. In addition, as described earlier, Somali refugees tend to endure multiple traumatic experiences over prolonged periods of time. The theme of perseverance captures all quotes in the data in which participants talked about continued effort to do or achieve something despite difficulties, failure or opposition. Some of the quotes in this theme do seem in agreement with several domains of PTG in that they were finding meaning in their hardships in having new opportunities and ideas for what is possible that they never would have had if they had not endured their experiences as refugees. For example, participants expressed sentiments congruent with the PTG domain Appreciation for Life in that they were grateful to have survived war, live in a peaceful place and have access to medical care and education. When refugee parents spoke of the access to education and the ability for their children to attend school or for adults to attend college, they demonstrated the PTG domain of New Possibilities. Education is a privilege that is highly desired but systematically denied to many people in rural Somalia (Lehman and Eno 2003). As participants talked about their investment in education for their children, they conveyed some hope for the future, that life is worth living and that there was meaning that came from the hardships they survived. The theme of perseverance also aligned with the PTG domain of personal strength when some participants conveyed tenacity for life and an awareness they had gained of their capacity to persevere through incomprehensible loss and hardship. Most of the data in this theme, however, conveyed a sense of coping and surviving the best that they can. All of the participants had endured unimaginably horrific and prolonged trauma and hardship, and have had little choice but to live through it the best they can. Some participants clearly were currently struggling, though managing significant distress. They were persevering but not necessarily adapting well. On the other hand, most of the participants did seem to demonstrate a great deal of resilience—the ability to overcome adverse conditions and adapt normatively (Luther et al. 2014). As Westphal and Bonanno (2007) point out, variation in the capacity for resilience may be related to differences in flexibility and adaptation in coping and emotion regulation influenced by different personal characteristics, cultures and life circumstances, in addition to the severity and type of trauma one has endured. This fits with our observation from the findings in the current study that there are qualities that should be taken into account in understanding and assessing PTG that are established before the traumatic experience has occurred. In particular, strong faith before the participants were subjected to their tragedies could be considered a protective factor or pre-traumatic strength. This point is illustrated further when comparing the data in the theme of religion and the PTG domain of spiritual growth. A number of empirical research findings on the relationships among religion, spirituality and PTG have found that many of the qualities of religiosity were related to PTG (Shaw et al. 2005). However, there is also something fundamentally different about the way the Somali participants in the current study talked about religion than PTG because it did not emerge as an area of growth or change resulting from their traumatic experiences. Religion rather was experienced as a constant and consistent source of strength and hope throughout their entire lives. In other words, their ongoing religious beliefs were strong before, during and after migration. The question posed of how their experiences of suffering changed their religious faith seemed to strike the participants as confusing and they were emphatic that no change had occurred. Relating to Others was the domain of PTG that seems least congruent with the participants’ experiences. What emerged in this study through the theme isolation stress is that there is a profound sense of loss in resettlement due to the experience of disconnected relationships with both family and neighbours. Interdependent and helpful relationships are essential to Muslim culture and, tragically, many of the important relationships they had in their lives previously were destroyed. Loved ones had died. Families were broken apart. While, in Somalia, neighbours and friends supported each other and helped care for each other’s children and meet each other’s needs, unfortunately, once in the United States, they have not been able to reconstruct similar support systems. Not only did they have to start over completely and develop entirely new relationships, but Western culture and values of individualism and productivity are major barriers to establishing community, support systems and friendships. Somali women and men identified that being busy in the United States contributes to lack of time for quality relationships with family members and neighbours. The busyness of life makes relationships less helpful because they are isolated from one another. As conveyed in the theme parenting stress, the fathers in particular spoke of stress that they experience because they cannot parent their children in the way the way they want to and, specifically, that they felt a sense of loss because they are not able to parent collectively, in a way that neighbours help each other, care for each other and make sure their children’s needs are met. Even in the Quran, they are cautioned to ‘not be alone with one’s own’. Implications A number of implications for future research emerge from this study. Ultimately, quantitative validation testing through factor analysis is an important step to take with the PTGI with this and other refugee populations, as is assessing PTG over time through longitudinal investigations. However, sufficient N would require considerable resources and it makes sense to first conduct additional qualitative studies with other resettled refugee cultural groups to continue to flush out in what ways PTG is a universal experience, and how it differs according to culture so that additional items or domains might be considered. The methodology of cultural brokers would likely be optimal for any research conducted with refugees. Future research would also benefit from mixed methodologies that assessed congruence between the PTGI and the qualitative findings. It may be that some of the differences perceived in the findings would be accounted for by differential levels of the various domains. There are also a number of additional potential variables that would be helpful to include in future investigations regarding PTG. For example, in the current study, there was a large range in the duration of resettlement among the focus group participants, with the years post migration ranging from 1.3 to 15 years. It may be that a greater length of time in resettlement influences the findings in ways that cannot be determined. For example, duration in resettlement may reduce the sense of ongoing trauma as resettled refugees acculturate further over time. In fact, the use of financial, social and health-care supports has been shown to decrease after the first two years, suggesting that perhaps the status of resettled refugees improves and their need for assistance is decreased (Wright et al. 2016). However, other research suggests that the severity of the pre-displacement trauma is an important variable in predicting higher health needs and care utilization (Ackerman 1997; Wright et al. 2016), as well as levels of language proficiency (Ackerman 1997). Other variables to consider in order to align with and add to the current literature are the type of traumas experienced, mental and physical health symptoms, service utilization, availability of cultural supports and English-language acquisition. It seems an inherent limitation of studying PTG that it is not likely often possible to measure predictive factors for resilience or for PTG before traumatic events are experienced in order to further what is understood about how these concepts are related to each other. Retrospective assessment of known risk and protective factors for behavioural health and wellbeing outcomes may also be valuable to include in future investigations. Practice recommendations also emerge from this study. Refugee advocates seeking to provide services that promote resilience and wellbeing are encouraged to consider the unique strengths and attributes that exist in non-Western culture. Services developed for refugee families should consider sources of acculturative stress and discrimination. In particular, the social isolation participants described raises critical concern for the wellbeing of Somali refugees. A strong body of evidence demonstrates negative impacts of social isolation on numerous indicators of health and wellbeing (Lubben et al. 2015). Therefore, people interested in supporting the thriving of refugees should also look for ideas for intervention strategies aimed towards combating social isolation. Refugee-owned community-based organizations and refugee-run mental health and advocacy agencies provide a mechanism for building connection and support among resettled refugees. Further ideas about how to integrate collectivistic approaches to childcare and develop neighbourhood gathering places might preserve natural supports and decrease isolation stress associated with being a refugee. Efforts are needed make adaptations to neighbourhoods in an effort to decrease isolation stress, support collective parenting and allow reprieve from the stress related to the busyness of the American lifestyle. Given the significant barriers to care, social service providers might consider seeking consultation from refugees living in their communities. Refugees can help professionals better understand from a cultural perspective what supports positive mental health and contributes to their wellbeing. Seeking out the expertise of Somali refugees can build trust and may assist social service providers in conceptualizing and developing services that are not contradictory to Islamic values in collectivistic cultures (Kia-Keating and Ellis 2007). The cultural wisdom of refugees can help providers understand how collectivistic cultural values such as strong interdependent relationships can support positive growth after trauma. Conclusion A main intent of the study was to assess the capacity for the theory of PTG to explain the ways in which refugees experience growth in the aftermath of traumatic experiences in Somalia, and ongoing resettlement and acculturation stresses. Support for the PTG framework was mixed. Incongruent factors seem to be largely related to the differences between the collectivist Somali culture and the Western culture within which the PTG theory was developed. Applying PTG to understand Somali refugees and other populations with collectivist cultures could actually be counterproductive, since the expectations might be unreasonable and interventions based on promoting individualistic factors might create dissonance between what refugees inherently know is good for them and what is expected and encouraged for them. Acknowledgements This focus group study was conducted in February of 2016 and the initial version of this manuscript was written in April of 2016. 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Published: Feb 27, 2018

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