Family Roles in Refugee Youth Resettlement from a Prevention Perspective

Synopsis

The families of refugee youth in resettlement bear both strains and strengths that impact their children’s adjustment and coping. Preventive interventions aimed at helping youth through helping their families should be developed. Given that many refugee youth struggle in school and may have inadequate involvement of their parents, one area in need of preventive intervention is parental involvement in refugee youths’ education. The design, implementation, and evaluation of family-focused preventive interventions should be informed by research findings, family resilience theory, a community based participatory research approach, and a focus on engagement.

Where is the Refugee Family?

Service providers from many different fields who are working with resettled refugees are committed to making their hometowns great cities of refuge. They extend helping hands to the newcomers, no matter where they come from, what language they speak, their color or religion. They pick them up at airports, find them apartments, teach them city transit, get them jobs, teach them English, give them health and mental health care, and teach their children.

In particular, they reach out to the children. Sometimes the children are old for their years but they are still open to the new circumstances and are looking for helping hands. Many times, one or both of the youths’ parents are not there, or the parents are too occupied with work or their own adjustments to a new world and a new way of life. A practice pattern has been established in refugee services, which takes advantage of refugee children loosened from their families, and targets children rather than their less reachable parents or the family as a whole. And this is called “youth services”, “psychosocial services”, or “mental health interventions”.

While this youth-focused practice pattern has likely benefited some refugee youth and adults, it also has limitations. One particular concern is that it may overlook the role of the family in the lives of resettling refugee youth – “overlook” in the sense that it intervenes primarily with youth, and does not seek to make changes in the family system or the families’ interactions with communities, organizations, or other families. Yet, refugee families, even given the losses or separations they have suffered, are still the primary social context for resettled refugee youth. As such, families should not be overlooked by refugee service providers.

Some helping professionals in the refugee services field, such as family therapists, have kept a focus on the family. The perspective and activities of family therapists can be found in the family therapy literature on refugee families, including families from Central American, the Balkans, and Asia. This literature is largely an outcropping of therapeutic activities and applied family theory, rather than a product of systematic research. Family therapy has tended to focus on family conflicts that result from the interaction of unprocessed traumatic experiences and intergenerational stresses stemming from adjustment in the resettlement context [1]. These include “relational and emotional conflicts” in which previously functional patterns of behavior within families are found not to work well within the resettlement setting. Consider, for example, how traditional cultural values and patriarchal gender roles are challenged in the resettlement context by a more liberal cultural environment with different expectations and where there is a financial need for women to work outside of the home [2].

Although the family therapy perspective on refugees makes clinically accurate and helpful observations, it may at times be somewhat biased towards identifying family conflicts, and less attuned to family strengths. This leads one to ask: Are the family conflicts actually as prevalent, intense, or significant as this literature indicates? There is also some risk for any service provider to view family conflicts as inherent properties of a family as opposed to sequelae of social and economic conditions thrust upon these families. Even though family therapists know to look for family cultural strengths (e.g. extended families, family obligations, religious faith), when the traumas, losses, and strains upon refugee families are so great, there is nonetheless also the risk for any service providers that they do not sufficiently comprehend or acknowledge the resources and strengths that lie within families [3].

We have been conducting a program of research on refugee families that has focused on the prevention of mental disorders and behavioral problems in refugee families. Later I will define what is meant by prevention. At this juncture, I want to note that in comparison with family therapy, family-focused prevention places less emphasis on identifying what is broken in families that may need to be fixed therapeutically. Instead, the emphasis is more on identifying family strengths and resources that can be enhanced through preventive interventions so as to better address strains upon the family and the risks posed to youths’ functioning [2]. As a research based program, we have endeavored to base prevention strategies on a systematic characterization of both the strains and the strengths of refugee families through ethnographic and qualitative research.

Strains upon Refugee Families

Our family has not been together since we fled our village. My brother was killed and two of our children went with his wife into the jungle and ended up in a different camp. When the officials came to interview us at the refugee camp for coming to the U.S., they asked for our papers and had us draw a family tree. They thought we might be lying, but we cannot help it if we don’t think the same as they about who is in our family. They gave us cultural orientation, which was real nice, but one thing that we did not like was when they said that we could not discipline our children and that if we did we would be put in jail or deported. What will happen to our children if they do not know right and wrong? That was only the beginning of the changes to our family. Here, the children are going places, making friends, and having a better life. All we do is work, worry about bills, worry about sending money back home, and if we are ever going to see the rest of our family. Our life here is not how they said it was going to be and there is nothing my wife and I can do to make it better.

Refugee families may enter resettlement having suffered major family traumas, losses, or separations due to political violence and forced displacement, or even to the manner in which they were processed through the refugee resettlement system. This system may have a way of defining the family and its members that is different from how these families think of themselves as a family. One example is that families from cultures that practice polygamy have to divide into nuclear families, each of which may be resettled in different cities or countries. Another example is that families from cultures that are not accustomed to distinguishing between sons/daughters and nieces/nephews, also may encounter problems given that the system for resettling refugees is based upon the Western construct of the nuclear family.

Refugee families, like other immigrants, come with expectations of a better life in America. Their expectations of America have been nurtured by word of mouth from friends and family, Hollywood movies, and the overseas cultural orientation sessions funded by the U.S. Department of State's Bureau of Population, Refugees, and Migration and implemented by one of several non-governmental organizations. When refugees first arrive in U.S. resettlement locations, most refugee families find themselves living in urban areas, in poverty, working low-wage jobs that require that both parents be income earners, and having less time to spend with their family than they are accustomed to [4]. In addition to the traumas and losses that the families experienced in their home countries or in flight, resettlement conditions subject them to further strain.

Our prior research with Bosnian refugees has documented multiple areas of family life amongst refugees where family members report adverse consequences caused by war, forced displacement, exile, and urbanization [5]. They report multiple changes to family roles and obligations including: living through their children; having less family time, and finding challenges to patriarchalism. Families that survived political violence live with memories linked to those experiences, often traumatic, and this may complicate family communication. Families report changes in their relationship with other family members, such as now being part of transnational families, either with other family members in their home country or in other countries of exile. Family members are concerned about changes in their connections with the ethnic community and nation state, citing concerns about children becoming Americanized and losing touch with traditional ways of life.

Though refugee children are not equivalent to immigrant children, there exist substantial overlap, and it is pertinent to mention that quantitative research on immigrant children has identified several statistically significant factors that make adjustment more difficult, including: 1) less educated parents; 2) low-wage work with no benefits; 3) no English speaking adults in the home; 4) family poverty; 5) lack of supports to the family; 6) discrimination and racism against family members [6].

Other sources of difficulty for refugee families that deserve further mention pertain to particular areas of cultural difference. Families that come from cultures that practice corporal punishment are told in cultural orientation sessions both overseas and in the U.S. that such behaviors will be considered child abuse and that they may be subject to jail or deportation [7]. These families are challenged to devise other approaches to child discipline, but this often leaves parents feeling powerless with respect to controlling their children’s behaviors. Another important area of cultural difference concerns adolescents [8]. For families from many cultures, where there is traditionally no such prolonged transitional period between childhood and adulthood, the very idea of a youth becoming a “teenager” is often a new cultural construct. When refugee youth start to behave like American teenagers, refugee parents are often unsure how to respond. In particular, they are unfamiliar with the kind of parental monitoring and supervision that parents need to provide to help their teenagers stay safe in urban America.

Family Resources and Strengths

The reason that our people have survived so much hardship is because of our families. We believe very much in families and we work to keep them strong. Everybody has a place in the family and they know where they belong. They know that they can always count on others in the family to help them if they have a problem. Our families tie together male and female, and young and old, across the generations, and even over the centuries. Our families have lots of faith and keep us close to God. If you visit any of our houses, you can see that we try to make it a place where all of us feel comfortable and like to be together. Just being together gives us all great pleasure.

Although the emphasis placed upon the strains of refugee families is certainly supported by facts, the existence of strengths is just as real and important of a dimension in their lives. Our prior research with Bosnian refugee families in the U.S. has documented multiple areas of family life where family members report engaging in helpful responses to the aforementioned strains [5]. Families have found ways to manage the changes in family roles and obligations. These include letting children provide hope; fostering flexibility, tolerance, and trust in the family; and promoting family togetherness. Families manage difficulties of communication by sharing good memories, talking with children, and expressing their emotions. Regarding relationships with other family members, refugee families respond to these changes through several strategies that help maintain a sense of connectedness with the larger family and its members, such as sending money home, planning an eventual return, and maintaining a transnational family. To cope with changes in their connection with the ethnic community and nation state, family members adopt several strategies, including teaching children the history and language and strengthening ethno-cultural identity.

The quantitative impact of family strengths upon refugee youth is not well studied. There are a number of small and mostly cross-sectional quantitative studies, and these have identified possible protective resources, such as family support [9,10], parental well being and lower caregiver distress [11], family connection to the large community/ social support, family connections to the culture of origin [12], and affirmation through shared experience [13]. Also of interest, research on immigrant youth has identified the following family related characteristics impact youth adaptation: 1) healthy, intact families; 2) strong work ethic and aspirations, and; 3) community cohesion [14].

The domain of culture, which as previously stated poses difficulties for refugees, is also associated with strengths. Commonly cited strengths documented in our research include a sense of obligation to family, work ethic, and support from the same ethnic community [15]. Research with refugees has indicated that stronger cultural identity may play a protective role regarding mental health outcomes [16]. Family research on other populations has demonstrated that family stories, family rituals, and family routines is associated with changes in the family as a whole and improved health behaviors and health outcomes [17]. Although this type of research has not yet been conducted with refugee families, our ethnography has shown how refugee families are able to draw upon some of these existing family cultural scripts and have to convert others to be most useful in the new surroundings.

Family Focused Interventions with Refugees

Out of necessity, some providers of psychosocial services to refugees have developed patterns for how they work with refugee families. In the case of family therapists, they have conducted family assessments, provided brief or long-term family therapy to address issues of family conflict, or provided family therapy consultation regarding mental health or health problems of individual family members. Family therapists’ work with refugee families is most often provided through refugee resettlement agencies, refugee mental health programs, schools, or faith-based organizations.

Alternatively, multiple-family groups have been used with refugee families to provide family support and education and to facilitate access to mental health services. Our research program designed, implemented, and evaluated several multiple-family group interventions with Bosnian and Kosovar refugees in Chicago. The first such intervention was conducted with Bosnian refugees and known as CAFES (Coffee and Family Education and Support). CAFES was a community-based, time-limited multiple-family education and support group for survivors with Post Traumatic Stress Disorder (PTSD) and their families. Longitudinal assessments showed that CAFES was effective as an access intervention for mental health services [18]. We then adapted CAFES for a focus on families of early and middle adolescents called Youth CAFES, and conducted a feasibility pilot with qualitative assessments [19]. Next, we adapted CAFES for newly resettled adult refugees from Kosovo, designing a TAFES (Tea and Families Education and Support) group. The uncontrolled post-intervention assessments demonstrated increases in social support and psychiatric service utilization and improvements over time in scale scores assessing trauma mental health knowledge, trauma mental health attitudes, and family hardiness [20]. It is pertinent to mention that researchers working with Hispanic migrants have also developed multiple-family group interventions to diminish the acculturation gap between parents and children. For example, Szapocznik developed and evaluated the Bicultural Effectiveness Training for Hispanic youth and families [21].

Other types of family interventions being used with refugees come from the family strengthening movement, which has spawned the development of family education initiatives [22]. In the refugee field, these are primarily focused on parenting and marriage education [22, 23]. Family strengthening interventions with refugees are at present largely donor driven initiatives and practice based programs that takes models that have been used in the general population and apply them on a trial and error basis with refugee populations. At this point, these initiatives do not systematically approach the issue of evaluating their family-focused interventions.

Refugee families will have areas of cultural difference from the host community, organizations, and providers, and so these efforts at family intervention with refugees are complicated by cultural issues. For example, refugees and interveners may have different understandings regarding the definition of the family. Thus, providers for refugee families face the difficult challenge of adapting interventions from one cultural context to another. Unfortunately, there has been little systematic study to identify what are the constructs applicable across socio-cultural contexts and which are group-specific. The issue of translating intervention strategies is a major challenge for both prevention and treatment in refugee services. Given the increasing number of immigrants and refugees in the U.S. population, intervention, adaptation and translation has also become a growing concern in mental health services research [24].

Need for Family Centered Preventive Interventions

Overall far more is known about PTSD than about how young people manage to survive, adjust, and prosper. Far more is known about the clinical treatment of PTSD in refugee youth than how to design, implement, and evaluate preventive interventions that include a focus on their families or communities.

In the 1980s, to improve prevention efforts amongst state refugee mental health programs, the National Institute of Mental Health and the Office of Refugee Resettlement funded a project to integrate the research on refugee mental health with the primary prevention of psychopathology [25]. It produced reports calling for the development of preventive interventions to address mental health problems in refugees, especially children [26]. None were developed because at the time, institutional priorities favored either individually oriented clinical services or large-scale preventive intervention studies [Williams, personal communication]. With increasing numbers of new refugee arrivals and their known psychosocial needs, there is now greater interest in developing preventive interventions for refugees. In addition, the limitations of youth-targeted clinical approaches are becoming more apparent to policymakers, scientists, and front-line workers.

Although there has been little prevention work in the field of trauma mental health, the concept of prevention has been discussed recently in relation to disaster preparedness and early intervention [27]. WHO’s major report on prevention of mental disorders uses the following framework [28]: Primary prevention which encompasses: 1) Selective prevention which targets individuals or subgroups at elevated risk for a mental disorder because of risk factors (e.g. exposure to trauma); 2) Indicated prevention which targets persons at high-risk with minimal but detectable signs or symptoms (e.g. traumatic stress symptoms); Secondary prevention that seeks to lower the rate of established disorders (e.g. PTSD) through early detection and treatment; Tertiary prevention which seeks to reduce disability, enhance rehabilitation, and prevent relapse and recurrence. WHO recommended that preventive interventions in trauma mental health may focus on any of these different points, separately or together.

WHO and IOM have also spoken of mental disorder prevention, which aims at “reducing incidence, prevalence, and recurrence of mental disorders, the time spent with symptoms, or the risk condition for a mental illness, preventing or delaying recurrences and also decreasing the impact of illness in the affected person, their families and the society.”[(p. 17) 28, 29]. These frameworks can be used as starting points to inform the development of preventive interventions for refugee families.

Through a prevention approach, services may be able to enhance protective resources so as to stop, lessen, or delay possible mental health and behavioral sequelae in youth such as PTSD, depression, substance abuse, and school problems [30]. If there were effective preventive interventions, then they would likely be cost saving, give the high costs of treatment and untreated conditions. There are important protective resources within refugee families that may be harnessed towards prevention if they can be identified [31, 32].

Multiple indicators suggest the need to broaden the concept of prevention with refugee youth beyond PTSD and even diagnosable mental disorders. Refugee providers routinely document a range of diagnosable disorders, such as depression, anxiety, substance abuse, and behavioral problems including HIV/AIDS risk behaviors, early pregnancy, and school problems [15, 17, 33]. Researchers recognize that the refugee field has been too exclusively focused on the etiological significance of war trauma, and now seeks to place more emphasis upon stresses associated with forced migration, as well as other contextual variables, such as discrimination, or gender and power differentials. Services researchers recognize that little is known about how trauma services operate in different cultural and organizational contexts [34]. In addition, little research has systematically examined trauma from a family perspective (e.g. family as a context) both for risk (e.g. parental mental illness) and protection (e.g. parental support). All of these have important implications for developing targeted preventive interventions for refugee families.

Another important impetus for developing preventive interventions is that although many youth are suffering, the vast majority do not seek mental health services. Amongst refugees, the stigma related to mental illness and seeking mental health services is often very high [35, 36]. Experience with refugees from Africa and Asia suggests that higher degrees of cultural difference are associated with even higher stigma and barriers to mental health services [33, 37]. Preventive interventions are needed because they offer other paths for reaching persons whom are otherwise difficult to reach through clinical interventions [38].

A Family Resilience Perspective on Refugees

To build preventive interventions for refugee youth calls for further developing a family resilience perspective upon refugee youth and their families. A family resilience perspective claims that the family is a key context for refugee youth. Refugee youth live in families where there is the possibility that multiple traumas and losses interact with social and economic difficulties, cultural transitions, and parental mental illness. Still their families also contain resources that may be protective against negative outcomes for youth. To deploy them effectively in their new circumstances, families may need additional knowledge, skills, relationships, or practice.

Because families do not function in isolation, a family resilience conceptualization also encompasses ecological protective resources such are those involving the school and community. The theoretical underpinning of this view of family resilience is family eco-developmental theory, which envisions youth in the context of a family system that interacts with larger social systems [39, 40].

Prevention researchers working with non-refugee populations have studied resilience-based family and school intervention programs and found that effective preventive interventions build upon existing protective resources associated with families and communities [28, 41]. For example, Beardslee developed and evaluated a family oriented preventive intervention for youth of parents with affective illness and demonstrated improvements in understanding, coping strategies, and functioning in families [42, 43]. Strategies learned from the resilience program implementation may be applied to thinking about preventive interventions with refugees. Family focused interventions may be more effective than strictly child or parent focused, but these interventions are tailored to the cultural traditions of the families [44, 45].

In a related area of research, developmental psychopathology research has focused on the resilience of children facing poverty, alcoholism, physical illness, and mental illness [46, 47]. Werner’s empirically derived conceptual model specifies five clusters of protective factors: 1) “temperamental characteristics”; 2) “skills and values that lead to efficient use of whatever abilities they had”; 3) “parental care giving that fostered child self-esteem”; 4) “supportive adults who fostered trust and were gatekeeper to the future”; and 5) “opening of opportunities at major life transitions” [48(p. 134), 49]. Other researchers have identified within family protective factors such as supportive parent-child relationships, positive discipline methods, monitoring and supervision, and advocacy for children [50, 51]. The challenge in applying these research findings to developing preventive interventions that are focused on family resilience is to re-conceptualize protective factors not as static properties but as active family processes that directly or indirectly facilitate positive youth outcomes and that can be modified through interventions.

Focus on Family Role in Education: Problems and Approaches to Preventive

It is hard for me to talk with my parents about the problems that I am having at school. They don’t understand the system here and it is completely different from the system in our country. The only time my mother has been to school was to pick up the report cards. My father doesn’t go. They are both too busy with work and because of the language problem they can’t communicate. Ever since the school put me in the wrong grade I’ve had so many problems. The programmer just put me there and there was nothing I could say. They give me homework which I don’t understand. My parents think that if it was a better school it would finish everything there and not need to send all this work home. They don’t like my friends and the new way I cut my hair. I know they care but when they yell it makes things worse. I guess that’s why some of my friends stopped going to school.

To deepen this discussion of family roles in refugee youth resettlement from a prevention perspective, I will now consider one area of concern in greater detail: the role of parents in youth’s education. Parental involvement may be defined as the active participation of parents, both in school and at home, to support their children’s education achievement [52]. The reason I chose this topic is that although many refugee youth do exceedingly well at school, unfortunately many do not.

There is little published research on the refuge parents’ involvement in youths’ education. A study of Hmong refugee families showed that parents viewed the teachers as the experts and did not expect to be involved [53]. A study of Khmer parents found low parental involvement in youth’s education and parents explained that they did not see it as in their role to push their children to achieve [54]. Studies of Russian refugee families report conflicts between parents and children over youth not studying enough [55]. These findings are of concern given that existing research from non-refugee populations suggests that parental involvement in education is associated with improved outcomes for youth (e.g. educational achievement, behavioral improvement, and longer-term functioning), parents (e.g. improved attitudes, advocacy, and community ties), and schools (e.g. improved teacher morale and school performance) [56, 57]. Could inadequate parental involvement of refugee parents be part of the explanation for school problems amongst refugee youth?

All refugee parents say they want their children to have a better life in their new country, but understandably, they may have difficulties converting these hopes into involvement that is effective in the new context. After all, refugee parents differ in terms of their prior experiences with education. For example, those who come from rural settings often have lower levels of formal education. Refugee families also differ in terms of how much emphasis they currently place upon education as a means of improving their children’s lives [58]. It is common to hear refugee parents say that education is important because it leads to better jobs. If you ask them if they mean high school or college, they almost always say college. Yet too often, parents have very little familiarity with primary and secondary schools in the U.S., let alone colleges. Often times more emphasis is placed upon refugee youth working part of full time while attending high school.

Parents in refugee families face many obstacles to involvement in their children’s education. These include illiteracy, not speaking English, heavy work schedules, unaccustomed to active school involvement, sense of embarrassment about their children’s performance or conduct, and unfamiliarity with how to support their child’s education. Many parents’ prior educational experiences in their societies were such that their involvement in their youths’ education was viewed as interfering and disrespectful. Some schools that work with refugees and immigrants have developed helpful strategies for addressing these impediments, including: making information available to parents in their home language, inviting parents to participate in special activities, and encouraging parent to teacher liaison [59]. Nonetheless, the impediments that refugee parents face regarding involvement are most often greater than the schools’ or resettlement organizations’ strategies of response. For example, both regular and bilingual teachers may not receive adequate training, support, or resources to work with refugee students and families.

From a family resilience perspective, parental involvement in education may be considered a protective factor for refugee youth, which could have potentially high impact on the youth and the family in multiple realms of individual and family functioning. In addition to facilitating school achievement for youth, parental involvement in education may be associated with other youth level outcomes. These may include improved youth mental health outcomes, youth peer relations, youth employment, and earning capacity. Parental involvement in education may also facilitate family level changes including family advocacy for youth, family communication, family integration in communities, and family contact with other families. Lastly, it can promote school level changes as teachers and administrators gaining a greater familiarity with refugee families, better communication with their students’ parents, and better collaborative partnership with parents regarding refugee children’s educational planning [57].

Of course parental involvement in education is not the only protective factor that has been identified for refugee youth. But in comparison with others, such as mentoring or family stories and rituals, it may be the one that has the broadest reach. This suggests that parental involvement in education would serve well as a primary aim of preventive interventions with refugee youth.

At present, parental involvement in education receives some attention from resettlement organizations and from schools. For example, in initial cultural orientation sessions and ongoing parenting classes, refugee parents are informed about schools and encouraged to become involved in their children’s’ education. In schools with substantial numbers of refugees and bilingual programs, the bilingual coordinator or bilingual teachers may make special efforts to reach out to refugee parents. Schools may also have a bilingual parent council or cultural events that attempt to engage with refugee families. Despite these valuable efforts, my concern is that parental involvement in education is still not sufficiently being addressed by schools, voluntary agencies, or communities.

One particular concern I have is that to achieve parental involvement in education may require a level of change within the families that is beyond the scope of the aforementioned agency or school-based efforts. That is to say, to make significant changes in the attitudes, roles, and behaviors of parents with respect to involvement in their children’s education, may require more than new information alone. Another concern is that the types of activities that parents need to undertake for involvement in youths’ education may require fairly intensive skills training. For example, some existing parental involvement programs are focused on increasing the parents’ ability to ask appropriate questions of the teacher; increasing the parent’s ability to help their youth doing homework; and increasing parent to parent interaction [60, 61]. Helping some refugee parents to achieve these tasks can be quite challenging.

Although no known preventive interventions to improve parental involvement in education have been tested in refugees, many different interventions have been evaluated in non-refugee populations. Furthermore, while there are concerns about the quality of the research methodology, and some of the results are mixed, there are promising findings regarding certain approaches, including: school outreach to families; respecting and understanding the cultural differences of families; building trust through family, school, community collaborative relationships [57].

Applying family eco-developmental theory also suggests that interventions that aim to promote parental involvement should target not only the parents, but the school and community as well. Consistent with that view, some existing parental involvement programs are focused on: 1) improving teachers’ abilities to work with immigrant parents; 2) improving schools’ accessibility to immigrant parents by offering other services; 3) improving schools’ engagement with community by engaging with or hosting community activities [59].

Of course, several important questions concerning a preventive intervention to increase parental involvement in education have yet to be answered. These include: Who should conduct the intervention and where? What is the target age group? What are the specific aims and methods of the intervention? How would the intervention need to vary across different refugee groups? Further research on refugee families, schools, and communities, including preventive intervention trials are needed to answer these questions. Nonetheless, it is hard to escape the conclusion that there is a need for developing prevention interventions that promote parental involvement in education. This should be undertaken by those who share in the responsibility for promoting parent involvement with refugees including communities, schools and school districts, resettlement agencies, and the state.

Collaboration with Families and Communities

Parental involvement is a Western middle class idea. We didn’t have nothing like that in our country. Involvement meant that you didn’t show respect for the authority of the teachers. We would never want to show that.

If you are asking parents or families to change their behaviors, it helps to know what these behaviors mean to them and what are the underlying beliefs or experiences that they bring to it. The example of parental involvement in education is a construct which will vary according to socio-cultural context and that can be best understood through an inquiry based upon partnership. This is one reason for using a community based participatory research (CBPR) approach, defined below, to the development of preventive interventions for refugee families. Another indication for CBPR is that refugee families and communities may have justifiable problems trusting service organizations or providers given prior experiences with traumas and betrayals [34]. Interventions will not succeed unless there is first adequate trust established.

Our approach to family preventive interventions is informed by a community based participatory research approach where adult and youth family and community members, and other key community stakeholders are partners in each phase of the work from conception to dissemination of results. Key CBPR principles that we follow include [63, 64]: 1) Building on cultural and community strengths (e.g. family values); 2) Co-learning among all community and research partners; 3) Shared decision-making; 4) Commitment to application of findings with goal of improving health by taking action, including social change; 5) Mutual ownership of the research process and products.

We believe that a CBPR approach is necessary to address the specific mental health challenges in refugee families and communities. Most important is giving families, youth, schools, and community leaders a real say in the development and implementation of interventions. Also essential is fostering collaborations with community, health, mental health, and scientific institutions. Thus, a CBPR approach should: 1) make the voices of refugee youth and parents heard and relevant to services and science; 2) increase the confidence and competence of parents, community based providers, educators, and leaders; and 3) build a learning system that keeps knowledge flowing and communication open between these families, communities, schools, organizations, and researchers.

Each refugee community is likely to have its own needs, meanings, strengths, and preferences. These would be expected to inform the prioritization of concerns and their opinions about what problems are in need of what types of interventions. Thus, it is potentially complicated but nevertheless important to give refugee communities the opportunity to introduce these issues into the design, implementation, and evaluation of interventions. Unfortunately, investigating this type of complexity does not lend itself easily to a randomized controlled trial type of testing of intervention effectiveness. However, newer models, such as the comprehensive dynamic trial methodology, may be appropriate [65].

Need For Focus on Engaging Refugee Families

The group sounds good but it’s hard for us to get there. My husband works days and I go to work at four, just after the children come home from school. If it’s on the weekend, which is the only time we have to be at home as a family. We don’t know all these other families and they don’t know us. To get there, we would have to pay for the transportation. I don’t know, maybe we’d give it a try. It might help if it were on a Sunday. Should we bring our small children?

Even the best preventive intervention does no good if the invited participants do not come to the meetings. On any given day, refugee families have many obstacles that would keep them from attending any type of psychosocial intervention. Some of these barriers are more practical (e.g. transportation and babysitting) and some more existential (e.g. a belief that what is happening in our family should stay in our family). The impediments for participating in a preventive intervention are especially pressing given that parents and other family members do not necessarily see themselves as having a problem that they need immediate help with. That is why preventive interventions with refugee families require specific strategies for engagement [66].

Our prior studies of engagement with Bosnian refugee families demonstrated that we were effective in engaging (73%) and retaining (83%) family members [62]. The findings indicated that families that engaged in a multiple-family support and education group had experienced significantly more transitions, more traumas, and more difficulties in adjustment than those who did not engage. Engagement was also related to family member’s perceptions about strategies for responding to adversities. Families that engaged had concerns about traumatic memories that persisted despite their avoidant behaviors. However, they were more concerned about keeping the family together, supporting their children, and rebuilding their social life. This study underlined the importance of a focus upon engagement in conducting preventive interventions with refugee families. It suggested that the strategies for engaging refugee families in multiple-family groups should correspond to the particular ways that the targeted families manage transitions, traumas, and adjustment difficulties.

Overall, we have found that a family prevention program requires spending at least as much effort in engaging families as it does in conducting the intervention itself. The first step in engagement is understanding the primary concerns of the parents and the youth. We have developed engagement scripts that group facilitators or other recruiters can use to talk with families about the group. These scripts clarify for families that this group is focused on the areas of concern that they and most refugee families have. It also specifically describes the obstacles to their participation and achievable steps for overcoming these obstacles. Once a family come to the first group, sees other families that share the same difficulties, and hears that the group leaders want to help them to draw upon family strengths to address today’s and tomorrow’s challenges, they will commit to working together.

Biography

Stevan Weine M.D. is Professor of Psychiatry and Director of the International Center on Responses to Catastrophes at the University of Illinois at Chicago. He is author of When History is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina (Rutgers, 1999) and Testimony after Catastrophes: Narrating the Traumas of Political Violence (Northwestern, 2005), and Our City of Refuge (forthcoming).