Researching the Effectiveness of Tree of Life: an Imbeleko Approach to Counseling Refugee Youth

Abstract

With the growing worldwide refugee crisis, there is a need for evidence-based interventions that specifically deal with the consequences of cumulative trauma-exposure in refugee youth. Refugee children have unique service needs and differ from their non-refugee peers in terms of sociocultural trauma, language, culture, and educational barriers. This article explains the complexities associated with understanding refugee youth and presents a proposal for studying the possible benefits of Tree of Life therapy. At the present time, Tree of Life therapy has no evidence-base because the published studies of Tree of Life with refugee and/or immigrant youth have sample sizes of one, six, eight, and twenty-nine. As a culturally-grounded, strength-based group counseling approach, Tree of Life therapy addresses traumatic experiences, recognizes participants’ cultural differences, highlights individual skills, and aids in instilling both confidence and hope for the future. Ncazelo Ncube, the co-founder and main developer of Tree of Life, describes this therapy as a collective narrative practice that considers cultural beliefs and values (2006, 2010, 2018, 2019). The proposed research design is to study the effectiveness of the Tree of Life in Canada, the United States, the United Kingdom, and South Africa. The research plan is to use pragmatic, group-randomized controlled trials in the “real world” settings of schools and agencies in each of the four countries. In addition, the article describes the development of the Roots and Wings Questionnaire for Children and Youth, a culturally relevant, child-friendly questionnaire. The Tree of Life is a readily available therapy with great potential for helping traumatized refugee youth as well as other trauma-impacted young people worldwide.

According to a 2016 UNICEF report, Uprooted: The growing crisis for refugee and migrant children, “Around the world, nearly 50 million children have migrated across borders or have been forcibly displaced – and this is a conservative estimate. More than half of these girls and boys fled violence and insecurity – 28 million in total” (p. 3). Children and youth who are refugees are uprooted and then exposed to a series of traumatic experiences. Many refugee children experience continuous and cumulative traumatic stress. The stress originates from exposure to discrimination and persecution in the young person’s homeland. Other sources of traumatic stress in their home country are often armed conflict, war, gang violence, famine, extreme poverty, and natural disasters. The stress is added upon by dangerous forced migration and when they reach their resettlement destination, it is exacerbated by acculturative stress, discrimination, disruption in schooling, and uncertainty about the future.

Refugee Children and Traumatic Stress

The United Nations recognizes that refugee children are a very vulnerable population and set aside Article 22 of the 1989 U.N. Convention on the Rights of the Child to proclaim that children have the right to special protection and help if they are refugees. At the present time, there is an insufficient amount of information known about the consequences of trauma for refugee youth or how to best address their needs. We do know that refugee children and adolescents are different from their non-refugee peers in that they have distinct patterns of trauma exposure and mental health risks (Betancourt et al. 2017; Panter-Brick et al. 2017; Pejovic-Milovancevic et al. 2018).

In general, refugee youth have higher levels of trauma exposure, different sources of trauma, and more cultural and educational barriers to face than their non-refugee peers. Tyrer and Fazel (2014) noted in their article “School and Community-Based Interventions for Refugee and Asylum-Seeking Children: A Systematic Review”, that due to the high levels of trauma exposure for refugee youth, many interventions have focused on the reduction of trauma-related symptoms.

Some of the more recent studies of refugee youth have provided a holistic and balanced view and noted that many refugees exhibit psychological resilience, prosocial behavior, and optimism even in the face of continuous traumatic stress (Eruyar et al. 2018; Panter-Brick et al. 2018; Peltonen and Kangaslampi 2019; Pieloch et al. 2016; Sleijpen et al. 2016a, b, 2017).

Studies of refugee youth should not take a deficit approach and be limited to studying posttraumatic stress disorder, depression, anxiety, or other emotional problems. A balanced, strength-based, and holistic view of refugee youth is important in both psychotherapy and research; care must be taken not to re-traumatize youth in the process of understanding and aiding them.

High Levels of Trauma Exposure in Refugee Youth

Refugee youth face intense psychological trauma and have higher levels of trauma exposure as compared with their non-refugee peers (Pejovic-Milovancevic et al. 2018). We know from the research of Panter-Brick and her colleagues that Syrian refugee youth living in Jordan report that they have experienced many more Lifetime Trauma Events (M = 6.53, SD = 3.33), than their culturally similar Jordanian peers (M = 1.21, SD = 1.75, (p < .05) (Panter-Brick et al. 2018). They also found that Syrian refugees reported significantly more perceived stress on the Perceived Stress Scale (p < .05) and significantly more distress on the Human Distress Scale than that of their Jordanian peers (p < .05).

The findings of Panter-Brick et al. 2018 are further supported by Betancourt et al. (2017) who found that refugee youth had high “rates of exposure to forced displacement, community violence, and traumatic loss/separation/bereavement” (Betancourt et al. 2017, p. 212). Betancourt and her colleagues studied three groups living in the United States (refugee youth, U.S.-origin youth, and immigrant youth). They found that refugee youth reported significantly more total types of trauma (p < .001) and had higher exposure to forced displacement and community violence (p < .05) than either the U.S.-origin youth or the immigrant youth.

Sociocultural and Individual Trauma in Refugee Youth

Much of the trauma experienced by refugee youth is sociocultural trauma rather than individual trauma. “Sociocultural traumas are typically massive in scale and affect large proportions of a society’s population…. Traumatic stress symptomology and PTSD vary according to different kinds of sociocultural traumatic experiences. Violent, continuing, and chronic trauma are features that are associated with increases in traumatic stress symptoms and PTSD” (Toussaint et al. 2016, p. 6). The world’s current refugee crisis is massive in scale and is growing rapidly. According to a UNHCR report, in 2017 the forcibly displaced population increased by 2.9 million. Examples of violent traumatic events experienced by refugee youth include persecution, fear of death, loss of loved ones, lack of safety, and witnessing people being killed. Youth exposed to recent sociocultural trauma appear to experience increased traumatic stress symptoms (Toussaint et al. 2016).

Educational and Cultural Barriers for Refugee Youth

Refugee youth have cumulative exposure to trauma involving preflight, flight, and resettlement traumatic stressors (Betancourt et al. 2017; Pejovic-Milovancevic et al. 2018). Pre-migration and migration difficulties for refugee youth may include disruption and deprivation of education. After they reach their resettlement destination, refugees often experience communication difficulties due to not knowing the language and cultural norms of their host countries.

Refugee children and adolescents experience cultural identity issues, as well as acculturative stress from new school environments, parental pressures to succeed academically, and new roles acquired as translators and cultural brokers for parents and other family members.

Additional school-related challenges for refugee and asylum-seeking students may include limited prior schooling or an interrupted formal educational experience. Some refugee students “act out” or do not understand how to behave at school due to an unfamiliar language of instruction and/or culturally different classroom and school expectations. Acting out or perceived negative behavior can be the result of trauma as well, in addition to language and cultural differences. Some refugee children and adolescents have experienced continuous traumatic stress; “research has revealed that children with chronic stress exposure or trauma are likely to have changes in brain development that further affect their neuropsychological functioning and undermine learning performance” (Seymour, 2014, p. 272).

Do No Harm and Be Careful Not to Re-Traumatize Refugee Youth

Because refugee youth are a very vulnerable population, great care must be taken not to re-traumatize them during psychosocial interventions or research projects about them. This cautionary note is not intuitively obvious to many Western psychotherapists and researchers and so explanations of re-traumatization are provided here.

Risk of Re-Traumatization in Interventions

Providing Western psychosocial interventions for refugee youth is unwise and culturally “tailoring” Western evidence-based interventions is not sufficient. Refugee youth may not respond well to “talking” therapies due to not knowing the language of their host countries and due to the strangeness of Western, “I-oriented” individualistic, approaches to healing. In addition, refugee families often do not seek out mental health services for their children due to acculturation challenges in the host country and the cultural stigma associated with mental illness (Eruyar, et al., 2018; Garoff et al. 2019; Mustafa and Byrne 2016; Schottelkorb et al. 2012; Sleijpen et al. 2016a, 2016b).

In the majority of the world, group identity comes first; “the traditional, individualistic approach carries the risk of undermining community structures” (Jacobs 2018, p. 281). Therefore, group interventions may be more appropriate than individual counseling for refugee youth who usually come from non-Western, “we-oriented”, collectivist cultures.

Culturally Insensitive Research Projects

Researchers need to pay special attention to the racial and cultural dynamics of research procedures. If informed consent procedures are not culturally relevant and questionnaires are not culturally and linguistically appropriate, then the research environment becomes re-traumatizing, and the research participant may experience the research environment as unsupportive and choose to withdraw from the study. Additionally, research participants could feel like trauma victims and “engage in some of the reactions that occurred with the original trauma” (Helms et al. 2012, p. 72).

Merely participating in a research project about refugee youth can re-traumatize refugee and asylum-seeking youth. Researchers studying unaccompanied minors in Finland found that some of these unaccompanied children were distressed by posttraumatic stress disorder survey questions and by completing the questionnaire in a group setting (Garoff et al. (2019).

Tree of Life Therapy and the Imbeleko Approach Do not Re-Traumatize

Ncazelo Ncube, the co-founder and main developer of the Tree of Life intervention, realized “how re-traumatizing it can be for people to simply tell and re-tell a single storied account of loss or trauma as these single-storied accounts result in people dwelling only in the problem-saturated territories of their identity” (Ncube 2006, p. 6). In its earliest version, Tree of Life dwelled on trauma which resulted in children “wailing” and being miserable. Ncube decided to transform the original Tree of Life therapy and create a new Tree of Life therapy which includes opportunities for all participants to develop a second story of their lives. In describing her work with refugee youth, Ncube explains that she gives refugee children an opportunity to talk “about the boulders/roadblocks and challenges that they have come across on their journey…and she encourages them to talk about “their hopes, aspirations and skills, can be reinvigorating allowing them to reclaim that which they have lost” (Ncube cited in Tibbles, 2018, p. 184).

Ncube is not in favor of the problem-saturated approach to therapy. She appreciates the Western mental health professionals who believe that instilling hope and infusing faith are essential to the treatment process with traumatized refugee youth (Mustafa and Byrne 2016; Isakson et al. 2015). She would not agree with Western psychologists who deemphasize cultural knowledge or fear that developing culturally-specific interventions could lead to “endless adaptions or novel treatments [being] required to serve all groups effectively” (Lyon, Lau, McCauley, Vander Stoep, & Chorpita, 2014, p. 57).

Aims and Hypotheses

We describe our proposed study of Tree of Life therapy and present our research plan for evaluating the effectiveness of Tree of Life for refugee and asylum-seeking youth. Our plan is not to culturally tailor or adapt a Western, evidence-based intervention, but rather to study the effectiveness of an existing culturally-grounded intervention which is already practiced throughout the world. Tree of Life is a non-Western, alternative therapeutic approach to helping refugee youth; it includes storytelling, art, Imbeleko counseling, and narrative expressive therapy. To study the effectiveness of this non-Western therapy, we created a new questionnaire called the Roots and Wings Questionnaire for Children and Youth; culturally diverse young people helped us develop the questionnaire.

In order to study Tree of Life therapy, we plan to use pragmatic, group-randomized trials in the “real-world” settings of schools and agencies in Canada, the United States, the United Kingdom, and South Africa. Further, our article summarizes certain aspects of the distilling and matching method (DMM) and presents a study protocol with a checklist and a flow diagram for the Tree of Life intervention. Our checklist is a CONSORT checklist with extensions for pragmatic trials, and it includes proposed considerations for cultural issues and cultural validity in school psychology.

Proposed Studies about Refugee Youth

Our article is similar to articles written by Dutch psychologists studying “young refugees” and Finnish psychologists studying “refugeeism” among children. All three articles present research perspectives and proposed studies intended to help children and adolescents who have been subjected to forced migration and continuous traumatic stress. The Dutch researchers (Sleijpen et al. 2013, p. 2) addressed some “methodological issues and paths for future research” with refugee youth and we also address methodological issues. The Dutch researchers consulted with refugee youth in order to hear their perspectives and so did we (Stiles 2019). The Finnish researchers presented a proposal for studying a therapy for “treating trauma-related symptoms in immigrant children affected by war” (Kangaslampi et al. 2015, p. 217) and we also present a proposal with experimental and control groups. Similar to Kangaslampi and colleagues, we present our methods, design, and a flow diagram.

Hypotheses

There are two main hypotheses: 1) When compared with the participants in the wait-list control groups, the participants in the experimental groups will show more gains at post-test in resilience (CYRM), hope (CHS), prosocial behavior (SDQ), and the number of friends and caring adults in their lives (SSQ). 2) When compared with participants in the wait-list control groups, the participants in the experimental groups will show more reduction at post-test in emotional problems (SDQ), trauma signs on The Tree Test, and indicators of acculturative stress (ASIC).

Psychosocial Interventions for Refugee Youth

Systematic Review of Mental Health Interventions

Tyrer and Fazel reviewed mental health interventions that had been evaluated in school or community settings for refugee and asylum-seeking children (Tyrer and Fazel 2014). Tyrer and Fazel conducted searches in seven databases and obtained additional information through searching reference lists and contacting experts. After their comprehensive review, Tyrer and Fazel narrowed the list to 21 studies that addressed emotional, social, or behavioral difficulties of young refugees. To evaluate these studies, they employed the Yates Scale (2005) which assesses the quality of design and methods as well as the treatment quality.

Out of the 21 studies, several were deficient due to “small sample sizes, lack of blind assessment, and inactive or no control groups” (Tyrer and Fazel 2014, p. 8). Only 4 of the 21 studies actually fulfilled the requirements for having a satisfactory research design and methodology. Only nine of the studies reported a decrease in symptoms of PTSD. Additional significant findings from the systematic review by Tyrer and Fazel included decreases in symptoms of depression, anxiety, functional impairment, as well as emotional, relational, and behavioral problems.

Discontinuing Mental Health Interventions

In their introduction, Tryer and Fazel (2014, p. 1) state, “The choice of potential interventions can… be limitless and so developing a coherent evidence-base is crucial to ensure that those interventions that are effective can be replicated and those that are not effective, discontinued.” Their view presents a problem for promising therapeutic interventions that might have been studied with inadequate research designs or sample sizes that were too small. Tree of Life is a promising therapeutic intervention that currently has no evidence-base.

Promoting Resilience, Prosocial Behavior, and Hope in Refugee Youth

The review by Tyrer and Fazel focused on the reduction of trauma-related symptoms; this view of trauma is typical in high income countries. “Western models of illness commonly frame young refugees’ responses to stressors in terms of psychopathology” (Sleijpen et al. 2016a, p.158). Another perspective on interventions for refugee youth is to encourage resilience-promoting processes such as social support, acculturation strategies, religion, and hope. Through a “meta-ethnography” approach to synthesizing qualitative research, Sleijpen and her colleagues identified several sources of strength that often lead to positive adjustment for young refugees. Four of these sources of strength are the following: (1) social support from peers, family, professionals, and their culture (2) successful acculturation strategies, (3) religion and spirituality as a source of strength, and (4) hope, positivity, and clear goals (Sleijpen et al. 2016a). This enlarged view of refugees’ responses to stressors may be more helpful and culturally appropriate than typical Western views.

Narrative Expressive Therapy, the Imbeleko Approach, and Tree of Life

Narrative Expressive Therapy

According to Ncube (2010, p. 4), “We are constantly making up stories about our lives; our lives are multi-storied.” Narrative expressive therapy involves individuals sharing their stories, with the goals of understanding cultures, building confidence and resilience, and healing from past traumas. In narrative expressive therapy, “the metaphor of a tree and forest is used to help the participants collaboratively share their stories. The telling and retelling of the stories creates a sense of honoring and belonging, remembers and revitalizes important values, acknowledges important life lessons and connects this to the person’s social and historical heritage” (Jacobs 2018, p. 280). Tree of Life, a narrative expressive practice, seeks to assist traumatized children to build strength and become more hopeful; it often concludes with an award ceremony, which celebrates new knowledge and connections as well as reinvigorates new possibilities and dreams.

Even though the use of certificates and official documents are all very important practices in narrative therapy, at the present time there is no scientific evidence that this narrative expressive therapy works.

The Imbeleko Approach

Imbeleko refers to a blanket that African mothers use to carry their babies; Imbeleko symbolizes love and protection in African culture. “People can relate very strongly to the [Imbeleko] approach which includes aspects of their lives, community, history, and culture that they give value…. Touching on people’s stories about their origins, culture, ancestry, values, important relationships, skills and knowledge about life as well as their hopes and dreams, connects them to the things that are important to them” (Ncube 2019, p. 17). If people feel alienated during psychotherapy because the therapy has no connection to their lived experiences, they will “resign from the counseling intervention” (Ncube 2019, p. 17).

It should be noted that the attrition rates are fairly high for refugee youth who participate in therapy and research studies. Substantial missing data can be the result of migration (Masten and Osofsky 2010); dropout rates may be especially high for unaccompanied minors (Garoff et al. 2019).

Tree of Life

Tree of Life is an Imbeleko approach to counseling refugee youth. Tree of Life therapy was developed by Ncazelo Ncube, a psychologist who worked with HIV/AIDS orphaned children in a life skills camp in Southern Africa. She was drawn to Tree of Life because it does not re-traumatize bereaved, highly stressed, and vulnerable children. Ncube (2006, p.6) describes the benefits of Tree of Life the following way, [It] “engages all children and because it does not rely on the spoken word, all children (even those who were shy) were able to come up with stories and rich descriptions about their lives. It made storytelling possible and the children seemed to be proud about various aspects of their stories e.g. roots (origins, ancestry etc.) and their achievements as expressed through the fruits of their trees. The children were also able to talk about the difficulties that they had experienced in their lives.” Tree of Life is delivered to children in four parts: 1) the Tree of Life drawing, in which participants draw their personal tree 2) the Forest of Life, in which all the trees are united in a forest 3) the Storms of Life, in which participants speak about difficulties/traumas and 4) the Ceremony, in which participants receive personalized praise and certificates.

Tree of Life Is Culturally-Grounded

Tree of Life therapy may have specific benefits for refugee and asylum-seeking youth. Tree of Life is a culturally sensitive, psychosocial healing practice that helps people talk about the stories of their lives in ways that make them stronger. Through art, storytelling, and group counseling, Tree of Life therapy addresses the traumas experienced by many refugee and asylum-seeking youth in ways that recognize their language and cultural differences (Stiles et al. 2014, 2018).

Ncazelo Ncube, the main creator of Tree of Life therapy, describes the intervention as collective narrative practice, an empowering therapy in which participants become experts in their own lives. According to Ncube, Tree of Life is neither problem-saturated nor based on Western notions of catharsis. Instead, the Tree of Life “methodology ensures that children have a safe territory of identity in which to stand before speaking about difficulties in their lives” (Ncube 2006, p. 75). Tree of Life is intentionally delivered in four parts to promote connection and cultural understanding to avoid re-traumatizing the youth.

Ncube designed Tree of Life therapy to be a culturally appropriate psychosocial intervention for those affected by hardships and trauma. In a recently published interview with Ncube about collective narrative practice, she stated, “I am increasingly convinced that all services provided for refugees and migrants need to take into account their cultural beliefs, values, and expectations for improved outcomes and their well-being” (Ncube, cited in Tibbles, Ncube 2018, p. 179).

Tree of Life therapy is practiced in several countries including the U.S.A., U.K., Burma, Australia, Canada, Chile, Nepal, Nigeria, Zimbabwe, Kosovo, Sweden, Norway, South Africa, Russia and many other countries and contexts but, at the present time, Tree of Life has no evidence-base. The published studies of Tree of Life with refugee and asylum-seeking youth have sample sizes of one, six, and eight. German’s (2013) published study of Tree of Life therapy with immigrant youth had twenty-nine participants, but no control group. Because Tree of Life (a collective narrative practice) has never been studied with a scientific methodology, it is currently not an evidence-based intervention.

The Metaphor of the Tree

Tree of Life therapy uses the tree as a metaphor for aspects of young people’s lives. Leaders of Tree of Life therapy sessions have observed that participants in Tree of Life feel comfortable sharing their personal experiences, including traumatic experiences, due to the tree metaphor and the support of the group during counseling. “Across cultures, trees hold powerful positive symbolism. Everywhere, trees shelter…. The metaphoric aspects of the tree – heritage and history, daily life, personal strengths, hopes and dreams, relationships with important people, and gratitude – are universal in human experience. [Regretfully], in many cultures, self-disclosure is frowned upon, as is seeking help from a professional therapist” (Senehi 2015, p. 18). The tree metaphor overcomes these limitations.

The Tree of Life intervention often begins with the narrative therapists having a conversation with children about trees. As described by Ncube, her conversation with children often begins with a discussion about the children’s personal knowledge of trees; then she explains that they will “spend the day together talking about our lives and experiences assisted by our knowledge of trees” (2006, p. 9).

After the discussion about trees, children begin to create a drawing of a tree that eventually includes roots, ground, trunk, branches, leaves, and fruits.

Ncube (2006) explains how she invites children to Maisye, a camp for vulnerable children in Zimbabwe, to draw their Tree of Life and attend to the related themes as they process their experiences and their drawing. Her model has these elements: roots, ground, trunks, branches, leaves and fruits. The roots component considers ethnicity, family relationships, and other facts that relate to where the individual has come from. The ground represents where the children live and the people with whom they enjoy spending time. While drawing the trunk of the tree, the children examine formative life experiences and their talents and special skills, such as being helpful and encouraging others. Drawing branches allows children to reflect on personal goals and dreams for the future. The leaves are the metaphoric element that refers to key human relationships, including people who have passed away as represented in the fallen leaves. Finally, fruits represent specific successes that the participant values and wants to share and celebrate.

The metaphor of the tree is used throughout Tree of Life therapy. During the “Storms of Life” stage of the therapy, the discussion of trauma is introduced by talking about how trees are affected by storms. In response, one 16-year-old participant in Tree of Life therapy commented, “I never thought of it that way; when there is a storm in my life, it feels as if it’s never going to stop. But talking about it like this makes me realize that it is not true. It always has a beginning and an ending (Jacobs 2018, p. 279).

Benefits of Tree of Life for Refugee and Asylum-Seeking Youth

There may be many benefits for using the Tree of Life intervention with refugee youth. Ncube (2006) points out that the intervention appears to engage all children because it is enjoyable, does not rely on expressive verbal communication by participants, brings out children’s creativity, and facilitates their personal storytelling. Because the Tree of Life art and storytelling experience is positive, strength-based, and emphasizes hope for the future, it does not re-traumatize vulnerable children who have previously experienced great suffering (Ncube 2006).

More recent comments about narrative therapy from Ncube are as follows:

People’s lives are bigger than the problems that they have experienced, this includes children. They have skills and knowledge about life, values and aspirations and hopes and dreams about their future.

It takes a lot of courage for children to leave their home country, families and familiar territories…. Young people on the move want more and believe they can achieve greater things than their local contexts can offer them. They are pushed into these movements by their hopes and dreams and curiosity about what more life could offer them (Ncube 2018, p. 182).

In these comments, Ncube (2018) explains that narrative expressive practice takes a more holistic perspective on the lives of immigrant, refugee, and asylum-seeking youth than the typical problem-focused viewpoint. Through her therapeutic work, Ncube has learned that traumatized youth are bigger than their traumas; their futures cannot be predicted by the intensity or duration of the traumas they’ve experienced. Ncube’s views are supported by the research of Sleijpen and her colleagues; posttraumatic growth in refugee youth is not predicted by their traumatic life events, but rather posttraumatic growth is predicted by their dispositional optimism and social support (Sleijpen et al. 2016b).

Narrative Expressive Therapy and the Distillation and Matching Model

The Distillation and Matching Model (DMM) “provides a framework for aggregating data from the general services research evidence-base and involves two primary steps: (1) distilling effective psychosocial treatments into sets of content elements and (2) matching those elements to client problems and other characteristics” (Lyon et al., 2014, p. 60). In the DMM, distillation interventions are conceptualized as composites of the individual components of the intervention (Chorpita et al. 2005). Similarly, Abraham and Michie (2008) studied the components of behavioral change and used a comprehensive categorization technique to identify components.

Identical categorization techniques would be difficult to use with Tree of Life therapy, which is a form of narrative expressive therapy, and is not based on the principles of behavioral psychology. Tree of Life involves individuals sharing their stories, with the goals of understanding cultures, building confidence and resilience, and healing from past traumas. Narrative expressive therapy involves creativity, spontaneity, flexibility, storytelling, and the arts; it is not commonly explained in terms of strategies, techniques and components. Table 1 lists the components of narrative expressive therapy that are found on https://dulwichcentre.com.au/what-is-narrative-therapy/ or https://phola.org/therapeutic-approaches/. Table 1 matches the Tree of Life components with some of the common characteristics of refugee youth. Matching “is a method for summarizing client, setting or other factors that might be relevant considerations for selecting an intervention” (Chorpita et al. 2005 p. 6). The characteristics and relevant conditions of refugee youth are described earlier in this article about researching Tree of Life. In Table 1, the characteristics of refugees are listed with the associated component of narrative expressive therapy. Table 1 illustrates that Tree of Life appears to be a good “match” for the needs of refugee youth.

Table 1.

Narrative expressive therapy matched with characteristics of refugee youth

Components of narrative expressive therapy	Characteristics of refugee youth
Let people be the experts in their own lives.	Refugee youth have lived through unimaginable experiences.
Separate problems from people.	Refugee youth have been severely traumatized, but they are more than their trauma experiences.
Assume that people already have many skills and abilities that will assist them in reducing the influence of the problems they encounter and allowing them to heal.	Refugee youth are often seen as victims; help them to recognize their own skills and abilities and encourage resilience.
Support the collective collaborative process of narrative expressive therapy.	Collaboration and group counseling appeal to refugees who come from “we-oriented”, collectivist cultures.
Encourage the re-authoring or re-storying of people’s lives.	Refugee youth do not want to be defined by the problems that they have faced; help them to tell new life stories.
Free people from the influence of their problematic stories.	Help refugee youth to remember the gifts they’ve been given and reconnect with their hopes and dreams for a better life.
Use culturally sensitive therapeutic interventions.	Refugee youth can draw upon indigenous knowledges and skills.
Storytelling and art are culturally universal.	Let refugee youth, who often experience language barriers, express themselves through storytelling and art.

Involving Young People in Critiquing Psychosocial Interventions and Research Projects

There are many benefits to involving culturally diverse young people in critiquing psychosocial interventions designed for them and research projects about them. Many adolescents are critical thinkers and enjoy being consultants. They want their peers to be able to participate in interventions and projects without difficulty. They may remember struggling with the English language, especially the idioms; they don’t want their peers to struggle in the future. For example, the several of our young consultants were puzzled by the sentence, “I can now handle big problems better than I used to.” They wondered what a handle they might grasp with their hand in order to lift an object had to do with their personal lives (Stiles 2019).

Critiquing a CBT Psychosocial Intervention

In their book chapter titled, “Culture first: Lessons learned about the importance of the cultural adaption of cognitive behavior treatment interventions for Black Caribbean youth”, Nicolas and Schwartz (2012) describe their focus group discussions with 16 Haitian American or Haitian immigrant adolescents about cognitive behavior treatment (CBT). According to adult researchers, the most studied and effective intervention for adolescents is a CBT intervention (Tyrer and Fazel 2014). However, the Haitian adolescents living in the U.S. criticized the CBT manual because it does not reflect the language, metaphors, and cultural values of Haiti. A few of the critical comments from the adolescents about the CBT manual include:

“There were many words that I did not understand at all”

“I should not need a dictionary in order for me to be in this treatment.”

“I did not see anything at all in the book that came close to Haitian culture”

“I felt like someone was just talking down to me, like I did not know anything at all.” (Nicolas & Schwartz, 2012, p. 81).

The adolescents in the focus group and the authors of the book chapter agree that culture is first and of the greatest importance in treatment interventions.

Critiquing the Tree of Life Psychosocial Intervention

In her published study of the value of the Tree of Life intervention for promoting self-esteem, cultural understanding, and challenging racism with nine and ten-year-olds, the author Mala German (2013) asked culturally diverse participants to critique the Tree of Life project and explain what they most liked and learned from Tree of Life. Twenty-eight of the twenty-nine participants responded that they most liked learning about their own background and culture; twenty-three responded they learned about others’ background; twenty-one mentioned enjoyment and fun. In terms of what could have been better about Tree of Life, thirteen mentioned using different materials to make trees and ten answered “swap partners more” (German 2013, p. 23).

Critiquing the Tree of Life Psychosocial Intervention in our Research Study

We plan to offer opportunities for culturally diverse young campers (10–13-years-old) in a summer camp in Canada to critique the Tree of Life intervention after participation. Similar to German (2013), we will ask the campers reflective questions regarding the Tree of Life.

Critiquing the Roots and Wings Questionnaire for Children and Youth

We have already involved young people in the design of our Tree of Life research project. Thus far, thirty-one young people have tested out the Roots and Wings Questionnaire for Children and Youth. The young people served as consultants and made numerous suggestions that clarify, simplify, and shorten items as well as removing confusing idioms on the four scales. An example of changes to items on each of the four scales is provided here. On the CYRM-12 the item “My family stands by me in difficult times” was changed to “My family supports me in difficult times.” On the CHS the item “I think I am doing pretty well” was shortened and changed to “I think I am doing well.” On the ASIC the item “I often feel like people who are supposed to help are really not paying any attention to me,” was shortened and changed to “I often feel like people who are supposed to help me are ignoring me.” On the SDQ the item “I am often unhappy, depressed or tearful” was shortened and changed to “I am often unhappy, sad, or crying tears.” Most of our young consultants really enjoyed The Tree Test. Perhaps they were relieved that no English words were required. Also, they told us that they enjoyed responding to the whole questionnaire; some participants drew hearts and smiley faces on their questionnaires (Stiles 2019).

Our young consultants also found that the questionnaire takes about 20 min to complete. Due to the high involvement of our young consultants, developing out Roots and Wings Questionnaire for Children and Youth took more than a year.

Proposed Method

Participants

The proposed participants will be approximately 480 children and adolescents, ages 10 to 18 years who volunteer to take part in the research project. The participants will be recruited from schools, agencies, and summer camps in Canada, the United States, the United Kingdom, and South Africa. Participants can choose how they wish to define themselves and their “group” rather than being required to mark boxes with pre-identified criteria such as immigrant, refugee, non-resident alien (Stiles 2019). The instructions are, “The following questions ask about your ‘group’ and your thoughts and feelings now. Your ‘group’ could be your gender, culture, ethnicity, race, religion, and/or immigration status. You decide what your ‘group’ is. See the examples below.”

Measures

Alignment of Roots and Wings Questionnaire with Tree of Life Goals

The most current description of the Tree of Life intervention is on the Phola website. Phola was founded by Ncube who explains that Phola is a Nguni word meaning “heal”. The website (https://phola.org/therapeutic-approaches/) explains that Phola’s counseling approach helps “people who have experienced hardships to come together and be supported to work through these issues together.” Phola, which includes Tree of Life therapy, strives to achieve the following impact and outcomes for children and youth: “ability to cope with adversities, increased resilience, well-developed psychosocial life skills, increased confidence and hope in the future, [and] ability to make informed choices.” With those stated goals, it makes sense to study the possible positive impact of Tree of Life with posttest gains on the Child and Youth Resilience Measure, Children’s Hope Scale, Social Support Questions, and the Prosocial Scale of the Strengths and Difficulties Questionnaire (SDQ). Coping with adversities, discrimination, and trauma can be measured with the Acculturative Stress Inventory for Children, the Emotional Problems Scale of the SDQ, and The Tree Test.

Quantitative Measures

Our new questionnaire for refugee youth is named the Roots and Wings Questionnaire for Children and Youth. Many psychologists, educators, and parents agree that all children need to be provided with roots and wings as they are growing up. The Roots and Wings Questionnaire for Children and Youth was derived mainly from four inventories/scales that were developed for children and youth and have satisfactory reliability and validity: 1) the Child and Youth Resilience Measure (CYRM-12), 2) the Children’s Hope Scale (CHS), 3) Acculturative Stress Inventory for Children (ASIC), and 4) the Strengths and Difficulties Questionnaire (SDQ). The reasons for selecting these particular inventories/scales included factors such as having good psychometric qualities, being appropriate for refugee youth, being connected with Tree of Life stated goals and outcomes, and drawing on sources for positive adaptation and resilience for refugees.

Confusion about Likert Scales

Some self-reports and rating scales can be very confusing for culturally diverse youth. For instance, a study of Burmese refugee adolescents found that the participating youth were confused by the Strength and Difficulties Questionnaire (SDQ) and the Harvard Trauma Questionnaire (HTQ). The researchers discovered that the participating youth became confused in selecting “yes” or “no” rather than “sometimes” and became puzzled by words and phrases such as “popular”, “unpopular”, and “feeling blue” (Kowitt et al. 2016, p. 17). Also, some unaccompanied minors in Finland could not respond to Likert scales without interpreters providing explanations of the meanings of the numerical points on the scales (Garoff et al. 2019).

Scale Harmonization

To reduce confusion about Likert scales, participants were provided with visual assistance in interpretation of scales and “scale harmonization” with all scales on the assessment battery (Haroz et al. 2017; Panter-Brick et al. 2018). All scales became 5-points: 1 = not at all, 2 = a little, 3 = somewhat, 4 = quite a bit, 5 = a lot. Although changing the Likert scales on the CHS, SDQ, and ASIC makes it more difficult to compare the responses of our participants with those in other studies, the benefits of changing the scales outweighs the drawbacks. Scale harmonization helps our participants to complete the Roots and Wings Questionnaire for Children and Youth successfully.

Quantitative Measures and Cultural Relevance

Being culturally-grounded is essential for any work with refugee youth. In addition to evaluating psychometric properties, the cultural meanings and relevance of all four inventories have been explored.

CYRM-12

The Child and Youth Resilience Measure −12 is a twelve-item self-report brief measure of resilience that is based on the original CYRM, which had 28 items. The authors of the CYRM-12 used a thorough process for creating a culturally-grounded measure (Panter-Brick, Danjani, Eggerman, Hermosilla, Sancillio, & Ager, 2018). All of the items on the CYRM were reviewed for cultural relevance through several discussions with expert panels comprised of fieldworkers and academics as well as having group discussions with refugee and non-refugee youth. For example, “(‘People think that I am fun to be with’) was changed to ‘People like to spend time with me’ because refugee youth claimed that a sense of ‘fun’ was inapplicable to their current existence” (Panter-Brick et al. 2018, p. 1810). The CYRM-12 is a measure of resilience that is sensitive to differences in the experiences of adolescents. Culturally similar youth living in Jordan showed differences in resilience based on refugee versus non-refugee status with Syrian youth scoring as less resilient than Jordanian youth (p < .05), (Panter-Brick et al. 2018). Resilience was positively associated with prosocial behavior on the Strengths and Difficulties Questionnaire (SDQ) and inversely associated with SDQ difficulties. Cronbach’ s alphas for the CYRM-12 were acceptable for refugees. The CYRM-12 is especially useful for measuring the effects of Tree of Life because increased resilience is a goal of Tree of Life therapy.

CHS

The Children’s Hope Scale is a six-item, self-report brief measure based on a conceptualization of hope as consisting of two factors: agency and pathways (Snyder et al. 1997). Having a sense of hope is an important protective and promotive factor for children’s mental health. The CHS has satisfactory reliability and validity and has been tested with cross-cultural samples. The Children’s Hope Scale was used with war-affected children from Burundi, Indonesia, and Nepal and showed some sociocultural variation (Haroz et al. 2017). The Children’s Hope Scale was also studied with Native American youth; the authors found the CHS to be culturally relevant and valid (Shadlow et al. 2014). The authors expressed their appreciation of positive psychology and the strength-based approach for “at-risk” Native American youth.

Although imperfect, the CHS is culturally relevant and has been tested out with culturally diverse Native American children and war-affected children from three countries. Increased hope, positivity, and clear goals are believed to promote resilience in refugee youth (Sleijpen et al. 2016a). Interpreting CHS scores across groups should be done with caution. More rigorous evaluations of the measurement properties of mental health protective and promotive factors are necessary to inform both research and practice. Increased hope in the future as well as the ability to cope with adversities are goals of Tree of Life therapy.

ASIC

The Acculturative Stress Inventory for Children is a reliable, valid, and child-friendly measure of acculturative stress. It is connected with culturally relevant constructs such as ethnic identity in children and includes eight items related to perceived discrimination and four items about immigration stress (Suarez-Morales et al. 2007a, b). For immigration related stress, Cronbach’s alpha coefficient was .72; for perceived discrimination Cronbach’s alpha coefficient was .79.

Post-migration challenges for refugee youth that are often cited as concerns include discriminatory treatment, social isolation, school adjustment problems, and traumatic stress. ASIC is a culturally relevant inventory that addresses the use of successful acculturation strategies, which are believed to promote resilience according to Sleijpen et al. (2016a).

SDQ

The Strengths and Difficulties Questionnaire is a brief screening tool that is available in multiple languages (Goodman and Goodman 2009; Van Widenfelt et al. 2003). The SDQ is a widely-used, brief measure of the prosocial behavior and psychopathology of 3 to16 year-olds. SDQ has satisfactory reliability and validity. Each one-point increase on mental health difficulties corresponds with an increased likelihood of a mental disorder assigned by a clinician. In the Roots and Wings Questionnaire only two SDQ scales were used: Emotional Problems and Prosocial Behavior. An example of an item from the Prosocial Behavior scale is “I try to be nice to other people. I care about their feelings.” Maintaining a positive outlook and gaining social support promote resilience in refugee youth (Pieloch et al. 2016; Sleijpen et al. 2016a, b).

Qualitative Measures

Two of the qualitative measures we used are incorporated into the Roots and Wings Questionnaire for Children and Youth; they are The Tree Test and the Social Support Questions. The other qualitative measure – the Evaluation of the Tree of Life Drawings – is completed by the adult leaders of Tree of Life and not by the children and adolescents,

The Tree Test

The Tree Test is a non-verbal method included in the Roots and Wings Questionnaire for Children and Youth. The Tree Test is an old projective drawing technique and more recently it is described as a “parsimonious projective drawing technique”; it has simple instructions: “Draw a fruit tree” (Le Corff et al. 2014, p. 184). It does not require knowledge of reading English and it is simple to administer. While studying The Tree Test, Le Corff and colleagues (Le Corff et al. 2014) found empirical support for the validity of The Tree Test in identifying the presence of trauma, depression, and emotional instability. In their study, 172 participants completed The Tree Test and answered questions about traumatic life events. When participants who drew mutilated and scarred trees were compared with participants who drew non-mutilated trees, it was found that those drawing mutilated trees were significantly more likely to report higher levels of traumatic life events (p < .05). The Tree Test is not a traumatizing task and yet it may reveal trauma and mental health issues. It will be interesting to correlate The Tree Test results with the Emotional Problems scale on the Strengths and Difficulties Questionnaire (SDQ).

Social Support Questions (SSQ)

Also included in the Roots and Wings Questionnaire for Children and Youth is a simple new assessment called the Social Support Questions (SSQ). Social support from peers and adults is believed to promote resilience and posttraumatic growth in refugee youth (Sleijpen et al. 2016a, 2017). In this assessment, the young people define their “group” and then count the number of friends they have and the number of caring adults they know who are and are not part of their “group”. This should be a relatively easy counting exercise for refugee youth. Panter-Brick and colleagues (Panter-Brick et al. 2017) would predict that the number of listed friends and caring adults would increase as a result of the Tree of Life intervention. Professionals who were working with the adolescents in their research project reported that the adolescents remarked upon “an increase in the number of friends outside of their own community” (Panter-Brick et al. 2017, p. 537).

Also, it will be interesting to correlate the SSQ results with the Prosocial Scale on the SDQ and compare those with high and low dispositional optimism as indicated by their responses to the following item in the Roots and Wings Questionnaire for Children and Youth: My faith in myself and the future is strong.

Evaluation of the Tree of Life Drawings (EToLD)

Tree of Life leaders will review the final versions of the Tree of Life drawings. Evaluations will be based on the components of Tree of Life (roots, ground, trunk, branches, leaves, fruits), the Forest of Life comments, and the discussions related to the Tree of Life award certificates.

Qualitative Measures and their Cultural Relevance

The Tree Test has cultural relevance. For example, a cross-cultural experiment of the fruit-tree drawings of 2675 school children found commonalities and differences based on cultural background (Adler & Adler, 1977). For participants, Tree of Life can be a transformative psychosocial intervention that encourages their intercultural communication. The SSQ also has cross-cultural implications; it is hypothesized that participation in Tree of Life therapy might lead to an increase in the number of a participant’s friends or caring adults who are not part of the participant’s cultural group.

The Manual for Tree of Life Is Called the Tree of Life Practitioners Guide

Tree of Life is a counseling intervention that can significantly improve people’s lives if the Tree of Life Practitioners Guide is followed as intended. The Practitioners Guide is a step by step reference guide for those who attend the Tree of Life trainings. In the trainings, participants acquire a solid grasp of the principles of Narrative Therapy. According to Ncazelo Ncube, Narrative Therapy seeks to be a respectful, non-blaming approach to community work which centers people as the experts of their own lives. The Tree of Life Practitioners Guide is not available to those who have not completed Tree of Life training. Information about Tree of Life training can be found at Phola.org.

Research Design

Mixed Methods Approach to Research

“While quantitative methods can be used to make more general conclusions and to verify qualitative hypotheses, qualitative research can give more in-depth stories and answers to how different factors are related to each other. Combined, they can achieve a more holistic understanding of refugee youth and eventually guide therapeutic interventions” (Sleijpen et al. 2013, p. 4). As recommended by Sleijpen and colleagues (Sleijpen et al. 2013), the Roots and Wings Questionnaire for Children and Youth includes mixed methods. In addition to the four established measures designed for children and adolescents, we have three non-traditional measures: The Tree Test, the Social Support Questions, and the Evaluation of the Tree of Life Drawings.

Pragmatic, Group-Randomized Trials in the “Real-World”

The proposed design for our study includes pre- and post-tests for Tree of Life interventions in experimental groups and control groups, i.e. “wait-list control groups”. In order to later evaluate the impact of Tree of Life on refugee youth, the Roots and Wings Questionnaire for Children and Youth will be used as a pre- and post-test, with a six-month follow-up.

Evidence-Based Interventions, School Psychology, Culture, and CONSORT

Evidence-based practice in school psychology is an approach to service delivery which combines the examination of empirical evidence with other considerations, including cultural issues. The evidence-based practice “movement in school psychology gained momentum at the turn of the millennium, with the formation of the Task Force on Evidence-Based Interventions” (Shernoff, Bearman, & Kratochwill, 2017, p. 220). (See also Kratochwill and Stoiber 2002).

In 2009, the Task Force on Evidence-Based Interventions in School Psychology (2009) produced the second edition of The Procedural and Coding Manual for Review of Evidence-Based Interventions (EBI Manual). The EBI Manual (2009) identifies, reviews, and codes studies of interventions for the emotional, behavioral, and academic problems for school-aged children. Interventions are studied and coded on a 4-point scale according the degree of evidence for the following twelve key features: 1) research methodology 2) measurement 3) comparison group 4) primary/secondary outcomes 5) cultural validity 6) educational/clinical significance 7) external validity 8) durability of effects 9) intervention components 10) implementation fidelity 11) replication 12) school/field–based site.

The EBI Manual covers many of the same key features that are in the Consolidated Standards of Reporting Trials (CONSORT). Both include the following features: research methodology, randomization, measurement, outcomes, validity, statistical methods, durability/generalization. The 2009 EBI Manual includes an important feature that is notably absent from the CONSORT checklist and that is culture.

Table 2 is titled, An Adapted CONSORT Checklist of Items for Reporting Pragmatic Trials with Cultural Considerations. CONSORT checklists have approved extensions and we chose to use the extension for pragmatic trials because our study will take place in “real world” locations and situations. (See Zwarenstein et al. 2008). For instance, the majority of our participants will be children or adolescents who are attending schools; classrooms in schools are “real-world”, naturally occurring groups. Pragmatic randomized controlled trials “encounter the argument that trials are not close enough to everyday life. Within this framework, questions that are immediately relevant for everyday clinical practice can be addressed (Lange et al. 2017, p. 637).

Table 2.

Adapted CONSORT checklist of items for reporting pragmatic trials with cultural considerations

Section	Item	CONSORT with extensions for pragmatic trials	Cultural considerations from EBI Manual (2009)
Title and abstract	1	Study how participants were allocated to interventions (eg. “random allocation,” “randomized,” or “randomly assigned”).	Discuss multicultural and diversity issues in evidence-based interventions. (EBI Manual, p.7).
			Use culturally-grounded approaches and place cultural values, beliefs, and practices at the center of interventions. (EBI Manual, p.7).
			For any research projects on interventions, form partnerships with stakeholders. (EBI Manual, p.7).
Introduction
Background	2	Describe scientific background and explanation of rationale.	Provide culturally and contextually relevant interventions. (EBI Manual, p.7).
			Evaluate interventions by the extent to which they provide deeper descriptions of the cultures and values of those involved with the research project. (EBI Manual, p.7).
		Describe the health or health service problem that the intervention is intended to address and other interventions that may commonly be aimed at this problem.
			Establish the ecological validity of conceptual base established through formative research with target population OR culturally derive the conceptual base. (EBI Manual, p.7).
			Provide evidence of involvement of target group members in the formulation of the research questions EBI Manual, pp. 17, 48).
Methods
Participants	3	Determine eligibility criteria for participants; settings and locations where the data were collected.	Evaluate the clarity of descriptions of what culture means for specific groups and the measurement of individuals’ psychological experience or interpretation of cultural membership. (EBI Manual, p.51).
		Make sure that eligibility criteria is explicitly framed and shows the degree to which typical participants and/or, typical providers, institutions, communities) and settings of care are included.	Consider: To what extent does the study define how culture is conceptualized by participants? Does the study define how participants interpret their cultural membership? Are psychological experiences, such acculturation, perceptions of power, oppression operationalized and measured among participants? EBI Manual, pp. 24, 51).
Interventions	4	Provide precise details of the interventions intended for each group and how and when they were actually administered.	Consider: Is the intervention culturally specific and socially valid? Does it “incorporate the norms, values, beliefs, practices and behavior relevant to the cultural experiences and social-cultural context of the target population”? (EBI Manual, p. 16, 17, 36, 52).
		Describe extra resources added to (or resources removed from) usual settings in order to implement intervention. Indicate if efforts were made to standardize the intervention or if the
			Demonstrate sensitivity to cultural diversity and issues surrounding the context of intervention implementation in schools and community settings (EBI Manual, p. 7).
		intervention and its delivery were allowed to vary between participants, practitioners, or study sites. Describe the comparator in similar detail to the intervention.
			Provide evidence of cultural competence of implementers (EBI Manual, p. 67).
Objectives	5	Specify objectives and hypotheses
Outcomes	6	Clearly define primary and secondary outcome measures and, when applicable, any methods used to enhance the quality of measurements (eg., multiple observations, training of assessors).	Consider the following: To what extent was evidence provided to demonstrate the cultural appropriateness of the measures for the target group and the methods by which this determination was made?
		Explain why the chosen outcomes and, when relevant, the length of follow-up are considered important to those who will use the results of the trial.	In rating this item, consider the following dimensions: meaning, language, dialect, and response format used in the methods of data collection and responses. EBI Manual, p. 27, 52).
Sample size	7	Include how sample size was determined; explain any interim analyses and stopping rules when applicable.
		If calculated using the smallest difference, consider the minimally important difference and report where this difference was obtained.
Randomization—sequence generation	8	Explain method used to generate the random allocation sequence, including details of any restriction (eg, blocking, stratification).	.
Randomization—allocation concealment	9	Explain method used to implement the random allocation sequence (eg, numbered containers or central telephone), clarifying whether the sequence was concealed until interventions were assigned.
Randomization—implementation	10	Note who generated the allocation sequence, who enrolled participants, and who assigned participants to their groups.	Work very closely with all the stakeholders in implementing randomization.
Blinding (masking)	11	Mention whether participants, those administering the interventions, and those assessing the outcomes were blinded to group assignment.	Use wait-list approach for control group.
		If blinding was not done, or was not possible, explain why.
Statistical methods	12	Describe statistical methods used to compare groups for primary outcomes; methods for additional analyses, such as subgroup analyses and adjusted analyses.	Use of a combination of mixed methods and active stakeholder participation in order to facilitate the co-construction of culturally relevant interventions and data analysis. (EBI Manual, p. 17).
			Evaluate cultural relevance of statistical conclusions (EBI Manual, p. 7)
Results
Participant flow	13	Illustrate the flow of participants through each stage (a diagram is strongly recommended)—specifically, for each group, report the numbers of participants randomly assigned, receiving intended treatment, completing the study protocol, and analyzed for the primary outcome; describe deviations from planned study protocol, together with reasons.	Anticipate that a number of participants will drop out or be “lost to follow up” if the participants are refugees, undocumented immigrants, unaccompanied minors, survivors of war and human trafficking, etc.
		Provide the number of participants or units approached to take part in the trial, the number which were eligible, and reasons for non-participation should be reported.
Recruitment	14	Include dates defining the periods of recruitment and follow-up.	Determine if recruitment procedures were congruent with the target cultural group. Did the researcher use culturally appropriate ways/methods to contact, recruit, inform, and maintain participation? (EBI Manual, p. 60)
			With highly mobile populations, shorten the time for follow up to six months.
Baseline data	15	Provide baseline demographic and clinical characteristics of each group.
Numbers analyzed	16	Include the number of participants (denominator) in each group included in each analysis and whether analysis was by “intention-to-treat”; state the results in absolute numbers when feasible (eg, 10/20, not 50%).
Outcomes and estimation	17	For each primary and secondary outcome, provide a summary of results for each group and the estimated effect size and its precision (eg, 95% CI).
Ancillary analyses	18	Address multiplicity by reporting any other analyses performed, including subgroup analyses and adjusted analyses, indicating which are pre-specified and which are exploratory.
Adverse events	19	Make note of all important adverse events or side effects in each intervention group.	Do no harm. Do not put young participants “at-risk.” Be especially careful not to endanger refugees, undocumented immigrants, unaccompanied minors, survivors of war and human trafficking, etc.
Discussion
Interpretation	20	Interpret the results taking into account study hypotheses, sources of potential bias or imprecision, and the dangers associated with multiplicity of analyses and outcomes.	Note the following: Many interventions lack generalizability to culturally diverse populations.
			Participants may question whether the intervention content and process is consistent with their cultural perspectives and experiences.
			[Cultural moderating variables] are critical for interpreting the outcomes, and determining the likelihood of sustainability and transferability of interventions. (EBI Manual, p. 33).
Generalizability	21	Explain the generalizability (external validity) of the trial findings.	Investigate effects of cultural moderating variables on the outcome. Pay attention to moderator variables and include consideration of the cultural variables that may impact program implementation and outcomes. Note that moderator variables include the perceptions of the participants regarding the acceptability and cultural validity of the intervention; that is, whether the intervention content and process is consistent with their cultural perspectives and experiences, and whether they find the intervention to be feasible and enjoyable, and beneficial for their daily lives. (EBI Manual, p. 33, 55).
		Describe key aspects of the setting which determined the trial results. Discuss possible differences in other settings where clinical traditions, health service organization, staffing, or resources may vary from those of the trial.
Overall evidence	22	Interpret the general results in the context of current evidence.	Provide overall rating for cultural significance. (EBI Manual, p. 59).

The cultural perspectives on our adapted CONSORT checklist come from The Procedural and Coding Manual for Review of Evidence-Based Interventions (EBI Manual, 2nd edition). The Task Force on Evidence-Based Interventions in School Psychology developed coding criteria to review, evaluate, and identify effective interventions for school psychology practice. A Multicultural and Diversity Committee of this “EBI Task Force” on school psychology inventions was formed. The members of the Multicultural and Diversity Committee were Colette Ingraham, Evelyn Oka, Bonnie Nastasi, and Stephen Quintana. They examined evidence-based interventions from a multicultural perspective, infused cultural perspectives into the EBI Manual, developed a set of guidelines for making decisions about implementing evidence-based intervention in new settings, and stressed the importance of multicultural competence in the roles and identity of school psychologists (Ingraham and Oka 2006; Nastasi 2006).

Determining Sample Size

In “real-world” settings such as schools and agencies for children and adolescents, determining sample size for interventions is more complicated than it is in a laboratory setting where an individually randomized trial can be easily implemented. “In a group or cluster randomized trial (CRT) naturally occurring groups or clusters of individuals are the experimental units randomized to conditions and the units to which the intervention is applied” (Crespi 2016, p. 2). In a completely randomized parallel group design, groups are allocated to intervention and control conditions using simple randomization. The problem with this approach is that “estimates of intervention effects have higher variance (higher standard error) than an individually randomized trial with the same number of individuals” (Crespi 2016, p. 2). The completely randomized parallel group design requires more participants than an individually randomized trial to achieve the desired power for a comparison of means. To overcome this challenge, other approaches such as matched-pair designs, factorial designs and crossover designs should be considered. Our study has not begun yet; it will take place in uncertain, “real-world” settings in four countries. We may not be able to use matched-pair or other preferable designs. If we need to use a completely randomized parallel group design, we will use the following formula: $\frac{4{\left(z_{a/2}+z_{\beta }\right)}^2\left({\sigma }_W^2+m{\sigma }_B^2\right)}{{\left({\mu }_0-{\mu }_1\right)}^2}$. If we can use one of the preferable designs, we will calculate the sample size with one of the other formulas in the article, “Improved Designs for Cluster Randomized Trials” (Crespi 2016).

Table 3 shows the demographic characteristics of our proposed study.

Table 3.

Demographic Characteristics of the Proposed Intervention and Wait-list Control Groups

Child Groupa	Countries by Gender
	Canada		United States		United Kingdom		South Africa
	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls
Tree of Life Intervention	30	30	30	30	30	30	30	30
Wait-list Control Group	30	30	30	30	30	30	30	30

N = 480: ^an = 240 for Tree of Life group, and 240 for Wait-list group. Age of the children and adolescents ranging from 10 to 18 years of age. The exact number of subjects by sub-category may be revised after data collection

Tree of Life Flow Diagram

In addition to Tables 1, 2, and 3, we present Fig. 1. Tree of Life Flow Diagram. Figure 1 depicts the proposed flow of our study of the effectiveness of Tree of Life therapy and illustrates our overall plan for evaluating the effectiveness of Tree of Life for refugee and asylum-seeking youth.

Fig. 1.

Tree of life flow diagram

Attrition rates for studies of psychosocial interventions for refugee and asylum-seeking youth are reported infrequently (Tyrer and Fazel 2014). Based on studies reported by Peltonen and Kangaslampi (2019), Panter-Brick and colleagues (Panter-Brick et al. 2017), and Tyrer and Fazel (2014), we estimate attrition rates between 20% to 30% in our study. Therefore, we plan to invite approximately 625 participants to take part in our study. Our goal is to have 480 participants at the six-month follow-up.

Conclusion

In summary, this article describes a few of the important ideas and concerns in researching the benefits of Tree of Life therapy for refugee and asylum-seeking youth. The article explains how refugee youth differ from their non-refugee peers in that they often have been exposed to more intense trauma (eg. death of loved ones, witnessing people being killed) and often have more complex mental health needs due to exposure to complex trauma, sociocultural trauma, and continuous traumatic stress. According to the UNHCR report, Global trends: Forced displacement in 2017, the number of people being forcibly displaced is increasing; also, according to the UNHCR report, children and adolescents below 18 years of age constituted 52% of the refugee and asylum-seeking population in 2017.

The 2017 report by UNHCR is a call to action for all researchers and mental health professionals concerned about the psychological effects of trauma on refugee youth. This article has explained that some of the existing Western evidence-based therapies are not culturally sensitive and may inadvertently re-traumatize refugee and asylum-seeking youth. New culturally-grounded therapies and new culturally relevant research designs are needed for refugee youth.

Tree of Life therapy appears to be ideally suited for refugee youth. This article presents a multi-method study protocol and a plan for using pragmatic, group-randomized controlled trials to examine the effectiveness of Tree of Life. Our research plan for studying Tree of Life therapy is different from most research proposals in that 31 culturally diverse young people served as consultants. They helped us to design our research process and develop the Roots and Wings Questionnaire for Children and Youth. As a result, our proposed research project is culturally-grounded and child-friendly; our research plan is appropriate for Tree of Life which has the potential to reach millions of refugees, asylum-seeking, and other trauma-impacted young people worldwide.

Compliance with Ethical Standards

Conflict of Interest

The authors declare they have no conflict of interest.