Coping,resilience and posttraumatic growth among Eritrean female refugees living in Norwegian asylum reception centres: A qualitative study

Abstract

Background:

The links between migration and health are well documented. Being a refugee exacerbates migrants’ vulnerability through trauma and loss. The aim of this study is to identify sources of resilience, coping and posttraumatic growth in female Eritrean refugees living in Norwegian asylum reception centres.

Method:

The study had a qualitative, descriptive and explorative design with two focus group interviews and 10 individual in-depth interviews. Participants included 18 female Eritrean refugees aged 18–60, who had obtained refugee status and were still living in an asylum reception centre. A content-focused hermeneutic analytic approach was used.

Results:

Interviewees described the challenges of pre-flight and flight trauma, conditions at the refugee centre, communication difficulties and the ‘endless’ waiting for transfer to a municipality. To cope, they found it helpful to focus on the future and to think positively. Fellowship with and support from fellow Eritrean refugees were essential as they became a proxy family and provided a strong ethnic identity. Their religious belief also helped them cope and gave them hope for the future.

Discussion:

The interviewees in this study perceived their psychological problems as a normal reaction to what they had been through. Religious belief was an important resilience factor, as was social support, especially from peers.

Conclusion:

The interviewees’ coping was based on the realization of their psychological reactions being normal while doing their utmost to focus on their aims and hopes for the future.

Keywords

Refugees resilience coping posttraumatic growth religiosity positive psychiatry

Introduction

Among the many globalization processes known to affect health, migration stands out, and links between migration and increased risk of poor mental and physical health are well documented (Gerritsen et al., 2006; Macpherson, Gushulak, & Macdonald, 2007). This association may be related to contextual and psychosocial factors associated with the migration experience or the migratory lifestyle such as adapting oneself to a new sociocultural environment, changes in traditions and lifestyles, economic transitions, or barriers of access to local community services, including healthcare (Sundquist, 1993). When individuals migrate from one culture to another, the risk of developing psychiatric disorders increases, depending on their personality traits and their bio-psycho-socio-spiritual vulnerability (Bhugra, 2004).

In their research on immigration, social integration, gender differences and mental health, Dalgard and Thapa (2007) and Thapa and Hauff (2005) concluded that social integration in Norway, and probably in other Western societies as well, is associated with good mental health in men, but not in women. Several other studies also show that displacement has significantly more negative effects on women compared to men (Almedom et al., 2005), for instance regarding physical abuse and psychological traumatization (Freedman, 2016). Women and girls are especially vulnerable to sexual violence during war and civil conflicts, whether in the midst of fighting, while escaping from their homes or even when inside camps for refugees or internally displaced people (Sapir, 1993; Shanks & Schull, 2000).

Despite their increased health risks, female refugees vary in their response to the stress of migration. Thus, our study’s aim is to identify sources of resilience, coping and posttraumatic growth (PTG) among female Eritrean refugees living in Norwegian asylum reception centres through the narratives of 18 interviewed refugees.

Background

Of Norway’s 5.2 million inhabitants, 16.8% have immigrated to the country and an estimated 15,000 are refugees from Eritrea. The annual arrival of Eritrean refugees increased from about 50 in 2000 to more than 2,600 arrivals in 2014 and 2,924 in 2015. One-third of these are women (Statistics Norway, 2017).

The increasing number of Eritrean refugees is due to a number of factors. After 30 years of war between Eritrea and Ethiopia ended in 1991, a border war erupted again in 1998 (Bailliet, 2007). Unresolved border disputes and United Nations sanctions against Eritrea keep the nation in a ‘no war, no peace’ situation and lead to economic hardships for its people. The desire to escape these ongoing challenges, as well as extended mandatory military service, has led many Eritreans to flee their country and seek refuge elsewhere.

Kılıç, Magruder, and Koryurek (2016) differentiate between resilience and PTG as ‘the first refers to a return to original level of functioning after adversity, whereas the second refers to a gain or acquisition of a higher level of functioning after such events’. In addition to an enhanced level of functioning, PTG is also conceptualized as achieving a sense of meaning or spirituality, and closer relationships that were not present before the event occurred (Linley & Joseph, 2004). The fact that a person can ‘grow’ psychologically after an adverse life event has gained increased attention in the past few years.

Resilience in refugees is not only influenced by the nature of pre-migration trauma but also by post-migration psychosocial circumstances and living conditions (Araya, Chotai, Komproe, & de Jong, 2011). Women’s experiences of migration and their responses to stress are different from those of men, regardless of whether they are primary migrants or joining the primary migrant. Changes in gender roles and expectations after migration will influence the way women respond to the stress of migration and post-migration adaptation (Bhugra & Ruiz, 2011). In their country of destination, gender roles may be strikingly different and lead to conflict and self-questioning (Shishehgar, Gholizadeh, DiGiacomo, Green, & Davidson, 2017). In their study from Kampala, Muhwezi et al. (2011) found that resilience was reinforced by financial stability and social support from the local population and other refugees. Porter and Haslam (2005) found in a meta-analysis that materially secure conditions, indexed by economic opportunities and permanent private accommodation, were associated with significantly better mental health outcomes. According to Beiser, Simich, Pandalangat, Nowakowski, and Tian (2011), strong ethnic identity provides further psychological advantage. Intimate and extended family ties have little correlation with men’s distress levels, but are strongly associated with lower distress for women (Stempel et al., 2016).

Discrimination, unemployment, lack of housing and social support, limited access to health services and exposure to violence before, during and after flight are some of the challenges that routinely confront refugees (Spiegel, Checchi, Colombo, & Paik, 2010). Such adversity may subsequently decrease their capacity to cope with acculturation stressors, potentially placing them at increased risk of mental illness (Matheson, Jorden, & Anisman, 2008). Coping with resources, external social supports and systemic factors including government policies are therefore vital to their resilience (Gagnon & Stewart, 2014). Kılıç et al.’s (2016). Findings suggest that man-made traumas targeting an individual lead to less PTG than shared traumas that target a community or group of people.

In this article, we view coping, or trying to overcome that which is causing stress, as an important aspect of PTG. Coping can help individuals focus on the significance associated with their difficulties and keep them physically, psychologically and socially healthy (Folkman & Lazarus, 1985). Thus, our research questions are as follows: How do Eritrean women cope with migrating to a culturally different, wealthy western country like Norway? What factors influence their coping strategies, resilience and posttraumatic growth?

Method

This article is based on the qualitative part of a larger mixed-method study. The research was conducted in eight asylum reception centres in southern and central Norway. In the qualitative part of the study, we conducted two focus group interviews with four participants in each group and 10 individual in-depth interviews. A descriptive and explorative design was chosen for the interviews in which the interviewees were encouraged to communicate freely in their own style and tempo. With a total of 18 participants, including both the focus group and individual interviewees, we collected detailed data about female Eritrean refugees’ experiences during and after their migration to Norway.

The focus group interviews were conducted as semi-structured discussions in which the interviewees were encouraged to share their experiences and perspectives as well as to explore what makes coping, resilience and PTG possible in the face of mental and physical trauma. Rich data can be found in such discussions and a focus group interview is a particularly well-suited research method when studying attitudes and experiences in specific cultures or subcultures (Alonso et al., 1998). We encouraged interviewees to talk at their own pace and length about any trauma experiences or mental health problems that arose during their journey and since arrival in Norway, as well as their coping skills and self-identified psychosocial and existential meaning resources.

Because some focus group interviewees either found it difficult to discuss their experiences in a group or dissociated during the group interview, these participants were asked if they were willing to do an individual interview instead. Ten accepted this invitation. The purposes of the in-depth interviews were to identify (1) symptomatology related to traumatic events/episodes or difficulties/challenges during the women’s ‘escape’, (2) post-migration experiences in the host country that may have affected their psychiatric vulnerability positively or negatively and (3) their skills in coping with these experiences.

Study sample and inclusion criteria

A total of 18 female Eritrean refugees aged 18–60 who came to Norway after 2009 were recruited. Eligible participants could speak and understand Tigrinya and had obtained refugee status (granted asylum) but were still living in an asylum reception centre. The participants had been in Norway for 1–8 years at the time of the interview, thereby ensuring migration experiences as well as ample experience with life in their host country (Table 1).

Table 1.

The interviewees’ backgrounds.

N = 18	Are married	Have children	Intimate family	Have extended family in Norway	Have done military service in Eritrea
No. of yes	8	7	10 husband/boyfriend	11	10
No. of no	10	11	8 alone	7	8

As worries concerning possible or real non-asylum status would give a different interview focus, asylum seekers with unclarified or refused asylum status were excluded.

Recruitment

The Norwegian Directorate of Immigration gave permission to conduct the study as well as help recruit interviewees. The first author contacted various asylum reception centres and conducted seminars to inform refugees about the study before potential interviewees were invited to participate. Those who fulfilled the inclusion criteria and wanted to participate in the study were invited to provide their names and telephone numbers. These women were later contacted and given an appointment for the interview.

Data analysis

Translation of the interviews into English and transcription of the translated oral texts constituted important first steps in the data analysis. The analysis was conducted after all interviews were transcribed. No software was used.

Qualitative analysis requires reflexive engagement within the hermeneutic circle of understanding. Within a hermeneutic framework, a content-focused approach was chosen to formulate themes reflecting the core of the situations or meanings found in the interviews (van Manen, 2001). Since this approach requires insight into the subject matter being studied, it should be noted that the first and second authors are psychiatrists, the first author hails from the same culture as the interviewees and the third author is well-versed in anthropology.

Throughout the analytic process, we strived for depth of understanding through a circular investigation of the texts (Gadamer, 1989). Rigour was obtained by having the first and third authors read and re-read the interview texts separately while doing their best to ‘remain open to the meaning of the other person or the text’ (Gadamer, 1989, p. 268). This kind of openness is predicated on a willingness to ‘listen’ to the texts and to go where the data lead. Validity was strengthened through the three authors’ discussions of the findings. Analytic credibility is obtained by presenting quotations with the interviewees’ own descriptions of their thoughts and experiences (Polit & Beck, 2014).

Ethical considerations

Ethical approval was obtained from the Regional Committee for Medical, Health Research Ethics, south-eastern Norway, the heads of the various asylum reception centres and the Norwegian Directorate of Immigration. All interviewees signed an informed consent form prior to being interviewed. Recordings and transcriptions were stored according to the national guidelines for ethical research (Norwegian Directorate of Health, 2009) and will be deleted when the study is concluded. Confidentiality was ensured in all parts of the project, from interviews to publication.

Results

Resilience, coping and PTG emerged as significant themes during the analysis. Although the terms were not used by the interviewees, these concepts reflect the content of what was being expressed. Important sub-themes were positivity and hope for the future, the importance of religion and PTG through coping.

Pre-flight and flight trauma

All interviewees reported a multitude of difficulties and traumatic experiences before, during and after their migration to Norway. Some interviewees had left Eritrea for political or economic reasons, others to avoid being forced into marriage. Several of the younger interviewees had fled from Eritrea’s seemingly endless military service. Interviewee C explained that in the military they were trained by veteran soldiers ‘who have lost some of their humanity’. Being female in this environment was dangerous. The punishment for not following the veterans’ ‘whims’ could, for instance, include being tied up and locked in a container or having to do ‘productive service’ in the scorching sun. Some reported being raped by their superior officers. Furthermore, not following orders could get their family into trouble, a fact that was always on their minds.

The flight was also rife with trauma and a plethora of stressful occurrences were described. They felt afraid, vulnerable and worried about being harassed by male refugees, thugs or soldiers, or being shot while crossing national borders. One interviewee had crossed six national borders before reaching Norway. Some interviewees reported that they had been raped, had seen others being raped or had seen travelling companions shot or drowned. Furthermore, crossing both the Sahara Desert and the Mediterranean were terrifying experiences.

Life in Norwegian asylum centres

In the asylum centres, there are many residents with different cultural backgrounds, noise and unrest, the result being that ‘there is no peace’ (B1). The combination of pre-flight and flight trauma and conditions at the refugee centre made one of the interviewees suicidal. She was rescued and supported by her peers who ‘watched me continually and gradually my mood changed’ (S2).

The ‘endless waiting’ (B3) around for news of transfer to a municipality in addition to their prior trauma experiences were described as very difficult. Even so, of the 18 interviewees, only 3 expressed hopelessness and negativity. The rest focused on what positive aspects they could find despite the trauma they had suffered. For instance, when asked about psychiatric symptoms, most stated that psychological problems are a normal reaction to what they had been through. In fact, H1 held that it is abnormal to not have sleeping or eating difficulties, difficulty concentrating or negative feelings. Given their situation, they perceived themselves as reacting normally and not being ill, and believed their mental state would improve when they had a permanent home in a municipality and were thus able to begin their new life. The knowledge that other Eritrean refugees had successfully made the transition from the asylum reception centre to a permanent home in Norway helped them remain positive and hopeful.

Positivity

All the interviewees found life in Norwegian asylum centres very stressful. Even so, they greatly valued that they were safe and had high hopes for improvement of their quality of life in Norway. Many found it helpful to think about the future: ‘I struggle with negative thoughts but I try to think about the future, too’ (B3). Ten of the interviewees stated that they had ‘grown as a person in such difficult and challenging situations’. As to the future, many wished to further their education and have a normal life.

Along with dreams for the future, coping with language and communication difficulties were central themes. For instance, appointments with Norwegian physicians were problematic as they often had to manage without interpreters, but they solved this by calling a friend who knew better Norwegian and was able help them express themselves.

Most interviewees reported that support and positive attitudes from centre leaders and staff had given them strength to cope with the endless waiting and challenges in the asylum reception centre. Even more important was support from fellow Eritrean refugees. To be separated from their peers, whether because they were moved to a different asylum centre or to a municipality, was therefore difficult and emotional. They experienced great joy when they met someone they knew from earlier. Many pointed out that establishing relationships with others and having ‘someone with whom they could share their thoughts’ (H4) were important.

All the interviewees pointed to their religious belief as an important coping factor. They were grateful to God for having overcome difficulties and traumas and having survived. Regarding their future, they trusted in God’s help: ‘God helps us to go through difficulties and win through in the end’ (S3). Participants found that prayer, meditation, attending church services regularly and other religious activities were the main spiritual or religious resources for achieving connectedness with God.

Discussion

The themes of this article are the resilience, coping and PTG of female Eritrean refugees living in Norwegian asylum reception centres. The interviewees’ understanding of their mental health situation was in line with Antonovsky’s concept of salutogenesis, an understanding that challenges the pathogenic perception of normality/pathology (Antonovsky & Sagy, 1986). In his salutogenic theory, Antonovsky (1993) focuses on the origins of health determined by the strength of a person’s sense of coherence (SOC), that is, the degree to which a person perceives the world and inevitable stressful events encountered in life as comprehensible, manageable and meaningful. Evidence shows that SOC is strongly associated with perceived health, especially mental health (Eriksson & Lindstrom, 2007).

The interviewees viewed their psychological problems as normal under the circumstances in which they found themselves, a stance supported by Obrist and Buchi (2008). Their study shows that migrants with resilient trajectories have a dynamic and multidimensional understanding of health. Both Seligman and Csikszentmihalyi (2000) and Jeste, Palmer, Rettew, and Boardman (2015) champion ‘positive psychology’, which the latter define as ‘the science and practice of psychiatry that seeks to understand and promote well-being through assessment and interventions aimed at enhancing behavioural and mental wellness’ (p. 675). This stance is in line with our findings, and in opposition to the exclusive focus on pathology that has dominated our discipline.

In a literature review regarding internally displaced refugees in Indonesia, Turnip, Sorbom, and Hauff (2016) concluded that on a group level adaptivity is very important for survival in adverse living conditions after devastating violent conflicts. This is in line with Kılıç et al. (2016), whose research has found more PTG among persons with shared traumas that target a group or a community than with traumas aimed at a single individual. According to them, ‘trauma to self seems to “block” growth’ (p. 119) and they suggest that the type of trauma, not its severity, is the most important factor for PTG. They also suggest that individual man-made traumas like rape, torture or being held at gunpoint may be too difficult to share with others and that this lack of disclosure hinders the growth process.

According to Kılıç et al. (2016), the way in which trauma is handled by the individual may also influence their PTG. Turnip et al. (2016) found that a person’s adaptivity is paramount, a trait also found in our interviewees as they described an ability to put things into perspective, think positively and learn from their experiences, whether negative or positive. In addition, there is considerable research indicating that most people exposed to trauma and loss recover naturally and do not report significant ongoing psychopathology (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992).

Religion

Zukerman and Korn (2014) suggest that religion-related cognitive schemas directly affect world assumptions by creating protective shields that may prevent the negative effects of extremely negative experiences. Faith in God may alleviate emotional stress, and communities of worship enhance feelings of security (Tippens, 2017). According to Kılıç et al. (2016), an increased interest in spiritual matters is often seen in persons experiencing PTG, and religious affiliations seem related to this phenomenon. Nearly all the interviewees found that their religious belief helped them cope with their situation and contributed to hope for the future. Hence, religious faith was an important aspect of their coping, resilience and PTG, a finding supported by Seligman and Csikszentmihalyi (2000). Religiosity is furthermore associated with better lipid profiles, lower blood pressure, better immune function and decreased levels of cortisol (Koenig, 2001; Seeman, Dubin, & Seeman, 2003). These positive physical factors reduce a person’s susceptibility to traumatic stress, and religiosity has also been shown to moderate the relationship between self-efficacy and traumatic stress (Israel-Cohen, Kaplan, Noy, & Kashy-Rosenbaum, 2016).

In a study of Congolese refugees in Kenya, Tippens (2017) concluded that refugees promote their psychosocial well-being through three overarching strategies: (1) having faith in God’s plan and trust in religious community, (2) establishing borrowing networks and (3) compartmentalizing the past and present. The same factors were important among our interviewees: their religion helped them endure and hope for the future, they established proxy families or ‘borrowing networks’ for fellowship and social, material and emotional support, and they tried to look to the future instead of dwelling on the past.

An implication of these findings is that a person’s religiosity is a factor that needs to be seriously considered when evaluating a person’s mental health.

Posttraumatic growth and coping through social support

PTG is strongly associated with physical health, psychological health and the environment (Teodorescu et al., 2012). Long, uneventful days of waiting in uncertainty as to when the longed-for move to a municipality would happen while not knowing where in Norway they might end up, may exacerbate refugees’ mental health state. However, when centre residents are being moved to a municipality, they experience loss of their proxy ‘family’. This may produce renewed separation traumas and create an obstacle to PTG achieved by building relationships with co-residents. Turnip et al. (2016) hold that the destruction of a person’s social network may have a growth-hindering effect.

Intrusive rumination predicts posttraumatic stress disorder symptoms, and deliberate rumination predicts PTG (Lancaster, Klein, Nadia, Szabo, & Mogerman, 2015). Our interviewees seemed to be vacillating between these two points while laboriously moving towards the growth end of the scale.

The Eritrean women interviewed had left home, family and friends in the hope of escaping the endless Eritrean military service, war and other problems that made staying in their home country seem impossible. Eritrea is basically a collectivistic society. An important trait within collectivism is a sense of social cohesion and oneness with members of one’s in-group (Cukur, de Guzman, & Carlo, 2004). ‘The self is a part of a community, defined relative to others, concerned with belongingness, dependency, empathy, reciprocity and focused on small, selective in-groups’ (Basu-Zahkru, 2011, p. 2). Israel-Cohen et al. (2016) point to social support as a significant resilience factor independent of cultural background, and Demirtepe-Saygili and Bozo (2011) found that social support is an important moderator between stressors and psychological symptoms. This is supported by Lazarus (1993), who holds that social support is important for coping with stress and is based on the person’s effort to seek support within his or her social, professional and emotional spheres. The Eritrean refugees therefore built new social networks at the asylum reception centres. The fact that there were many in the same situation helped them accept their present challenges. They helped each other with practical problems, for instance, enlisting the linguistic assistance of a friend whose Norwegian was better than their own in settings where knowledge of the language was needed. Such problem solving is an important coping strategy (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986).

The interviewees’ interpersonal relations or ‘borrowing networks’ seem to be among their major coping strategies together with their acceptance of psychological symptoms such as unhappiness, sleeplessness, concentration difficulties and poor appetite as normal. Their coping seems to be built on the realization that psychological reactions to experiences such as theirs are normal, while doing their utmost to focus on their aims and hopes for the future with the help of positive thinking, peer and staff support, and the support provided by their religious faith.

Based on our findings, we agree with Baarnhielm (2005) who stresses the importance of exploring the interaction between individuals and social and cultural groups in multicultural milieus in order to obtain insights into how people make sense of their clinical encounter.

Strengths and limitations

All the interviewees spoke Tigrinya, the most common language in Eritrea. The first author is a multilingual psychiatrist familiar with the socio-cultural contexts and languages of both Eritrea and Norway. She conducted all the interviews and the translations thereof into English herself. There is always a danger of meaning being changed or lost in translation. Therefore, a second native Tigrinya speaking assistant with good English-language skills read the transcriptions and co-translated all the interviews to ensure the quality thereof.

Conclusion

One of the implications of this study is that rather than perceiving refugees as ‘passive victims’ suffering mental health problems, attention should be given to the resilience and coping of refugees and the ways in which they interpret and respond to their experiences and challenge the external forces bearing upon them (Watters, 2001). Authorities need to consider the refugees’ own experiences and expressed needs and address the broader social policy contexts in which refugees are placed.

Our interviewees were adamant that their mental problems were normal considering the trauma they had experienced. What is new in our study is the concept of normality about psychological symptoms and seeing this in the context of posttraumatic growth. This suggests the importance of reviewing the concepts of pathology and normality in mental health. This study was conducted among women who were still living in asylum reception centres and thus had not yet experienced independent life in a Norwegian municipality. The question remains whether we will see more negative emotional and mental responses to migration traumas when they try integrating into Norwegian society.

Future longitudinal studies are needed to investigate which aspects of trauma might trigger or suppress asylum seekers’ core beliefs, as they are likely to be major determinants of posttraumatic growth.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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