“We are all under the same roof”: Coping and meaning-making among older Bhutanese with a refugee life experience

Abstract

Objective:

Refugees have elevated risk of psychological distress and mental health disorders compared to the general population. The majority of research has been conducted with youth and younger adults, and little is known about the mental health of older refugees. We apply the theoretical framework of meaning making to understand how older Bhutanese with a refugee life experience cope with migratory traumas and grief.

Method:

We conduct semi-structured individual interviews with 41 ethnic-Nepali Bhutanese aged 50 and over with a refugee life experience resettled in the United States and analyze data using thematic content analysis.

Results:

Forced expulsion from Bhutan was viewed as a violation of core ethnic-Nepali beliefs and sense of purpose related to collective identity. Throughout their 30-year refugee life trajectory, participants utilized coping strategies, including interpersonal support, reappraisal of experiences of trauma and loss, and helping oneself by helping others, that were informed by, and strengthened, this collective identity. These strategies served to both reaffirm worldviews and make new, positive meaning out of a refugee life experience. Individuals who were unable to leverage these strategies struggled to find meaning.

Conclusions:

We discuss study implications for psychosocial services for older refugees and contribution to theory on meaning making among diverse, vulnerable populations who experience multiple traumas and loss.

1. Introduction

The number of civilians forcibly displaced from their homes due to war and political violence reached over 70 million in 2018 (UNHCR, 2019). Forced displacement has negative effects on mental health. Refugees are subject to traumatic and stressful events throughout the refugee experience (Fazel et al., 2005). Compared to the general population, refugees have elevated risk of mental health disorders, including depression, anxiety, and post-traumatic stress disorder (Fazel et al., 2005). Individual, family, community, and macro-level factors contribute to poor mental health outcomes of displaced populations (Fazel et al., 2012). The majority of this research has studied the impact of displacement on youth and younger adults, and little is known about the mental health trajectories of aging refugees (Virgincar et al., 2016).

1.1. Older refugees

The UNHCR estimates that older persons make up roughly 8.5% of the total population of displaced individuals (UNHCR, 2000). These individuals often receive limited attention from national and international aid providers (UNHCR, 2016) although they may be more likely to experience physical and psychological distress than younger refugees (Bazzi and Chemali, 2016; Strong et al., 2015). After resettlement, older refugees experience challenges related to language barriers, family stress, social isolation, employment, and accessing health care (Atwell et al., 2007; Oglak and Hussein, 2016). These experiences are associated with poor mental health (Cummings et al., 2011; Verhagen et al., 2014). Unfortunately, there is a dearth of evidence-based health-promotion interventions designed to meet the needs of older refugees (Lood et al., 2015). There is a need to identify the mental health and psychosocial issues faced by this vulnerable population, as well as coping strategies used by these individuals throughout a refugee life experience.

1.2. Stress, coping, and meaning-making

One theoretical framework used to understand the process of how individuals cope with and overcome experiences of trauma and loss is that of meaning-making (Park, 2010; Park and Folkman, 1997). The concept of meaning-making builds off of the cognitive theory of stress and coping (Lazarus and Folkman, 1984) and has ties to literature on trauma and post-traumatic growth (Tedeschi and Calhoun, 2004). In the 1990’s, Folkman proposed a modified model of stress and coping that integrates meaning-focused coping, a process that can generate positive emotions in response to traumatic events (Folkman, 1997, 2008). The cognitive processing that leads to meaning-making and positive emotions can ultimately result in positive change after struggling with a traumatic experience (Park and Al, 2006; Lancaster et al., 2015; Triplett et al., 2012).

In the meaning-making theoretical framework, the concept of meaning is separated into two spheres. Individuals develop, through the accumulation of life experiences, core assumptions, beliefs, and expectations about the world (Park, 2010). This worldview, called global meaning, gives individuals a sense of order and purpose in their life, and is the lens with which a person tries to understand and make sense of events that happen to them (Park and Folkman, 1997). Religion is a prime example of global meaning, as it is a belief system that provides a way for individuals to understand trauma and loss (Park, 2005; Vis and Boynton, 2008).

In contrast, situational meaning refers to the interaction between a person’s beliefs and specific person-environment interactions. Components include first appraisal of meaning, defined as a person’s initial assessment of an experience. The second component is the process in which individuals search for meaning after a stressful event, and the third component is the meaning made by a person after an event (Park and Folkman, 1997). After a traumatic experience, the meaning made from the event may violate an individual’s original worldview and cause psychological distress. There are different coping strategies individuals can use to resolve discrepancies, make meaning, and experience growth after trauma, including finding some reason for why it occurred or finding some perceived benefit of the event (Folkman, 2008; Tedeschi and Calhoun, 2004). Other strategies include minimizing the negative impact of trauma or focusing on and engaging in activities that reinforce existing global meaning (Park and Folkman, 1997).

Literature on both meaning-making and post-traumatic growth has received more attention in recent years, prompting reviews of these intersecting bodies of literature and identifying opportunities for future research. Of note is the paucity of research on how culture informs global world-views, appraisals of stressful events, and the strategies and mechanisms for making meaning and bringing about positive change (Chan et al., 2016; Park, 2010; Shakespeare-Finch and Copping, 2006). This critique is particularly salient for refugee populations that are overwhelmingly coming from non-Western countries (Matos et al., 2018; UNHCR, 2019).

There is a small body of literature on meaning-making, coping, and post-traumatic growth specific to refugees. One review identified facilitating factors including social support, religiosity, and optimism for refugee post-traumatic growth (Chan et al., 2016). Another systematic review found cognitive strategies such as positive reframing, acceptance, and hope for the future promoted psychosocial wellbeing among refugees (Posselt et al., 2019). Studies among diverse groups of refugees identified collective identity and collective resilience as tools for individuals to deal with loss and trauma and find meaning (Kevers et al., 2017; McCleary, 2017). The role of the larger community might be of particular salience to meaning-making among refugee populations, as community-level factors contribute to the psychosocial well being of resettled refugees of all age groups (Fazel et al., 2012). How meaning-making plays out among older populations is of particular interest, given their phase of life relative to reflecting on both current and past life experiences, in many instances several decades in the making.

1.3. History and ethnopsychology of Bhutanese with a refugee life experience

The experience of Bhutanese refugees started in the mid-1980s as the government of Bhutan began a campaign to create a unified Bhutanese identity and persecuted ethnic minorities (Rizal, 2004). Ethnic-Nepali citizens of Bhutan were forced to Nepal in the early 1990s (Hutt, 1996). They lived in camps for roughly 15–20 years, exposed to stressors related to basic needs, security, limited employment options, and interpersonal violence (Reiffers et al., 2013). Over 90,000 Bhutanese refugees have relocated to the United States (US) since 2008 (Embassy of the United States, 2016), with an estimated 20% of those resettled aged 45 or older (US Department of Health and Human Services, Centers for Disease Control and Prevention, & National Center for Emerging and Zoonotic Infectious Diseases, 2014).

There has been increased attention on the mental health of Bhutanese refugees given disproportionally high rates of suicide among this group, roughly double that of the general US population (Centers for Disease Control and Prevention, 2013). In a study conducted among Bhutanese adults aged 18 and over in the US, prevalence of depression, posttraumatic stress disorder (PTSD), and anxiety were 21%, 4.5%, and 19%, respectively (Aoe et al., 2016). In comparison, a meta-analysis of the prevalence of mental disorders among refugees resettled to western countries found an average of 5% of adults meeting criteria for depression, 9% PTSD, and 4% with a probable diagnosis of generalized anxiety disorder (Fazel et al., 2005).

Thoughtful attention has been given to understand the ethnopsychology of ethnic-Nepali Bhutanese and how this informs adjustment and coping for this population in refugee camps and post-resettlement (Chase, 2012; Chase et al., 2013; Kohrt and Hruschka, 2010). Nepali words such as dukha (sadness), chinta (worry/anxiety), dar (fear) and pir (sorrow/anguish) are commonly used when describing emotional responses to trauma (Kohrt and Hruschka, 2010). A common idiom of distress is that of tannab (tension/stress), and the concept of “coping” in Nepali can be best translated as “solving tension” (tannab samaadhaan garnu) (Chase et al., 2013). Traumatic events and life stressors lead to “building tension” in the heart-mind (man); mechanisms of positive and negative coping responses to relieve this tension exist on continuums of independent/interpersonal coping and problem-focused/emotion-focused coping (Chase, 2012). In work conducted among Bhutanese refugees in camps in Nepal, Chase et al. (2013) identified different dimensions of “solving tension” among the refugee population, including positive reframing and active coping, social support, acceptance, and religion (Chase et al., 2013).

To date, there is limited information on coping among older Bhutanese with a refugee life experience (Im and Neff, 2020). There are no studies, to our knowledge, that have explored the concept and process of meaning-making among ethnic-Nepali Bhutanese, nor how it may compare/contrast to the small body of literature of meaning-making among other refugee populations. Of particular interest is how the idea of collective identity may relate to meaning-making for ethnic-Nepali. Literature on social inequality in the general Nepali population highlights that not everyone may benefit from communal processes of coping (Rai and Schneiderman, 2019).

1.4. Current study

This research is part of a larger convergent mixed-methods study to understand the mental health of aging Bhutanese with a refugee life experience. In this current study, individual semi-structured interviews were used to more specifically explore traumatic and stressful life experiences of older Bhutanese, as well as coping strategies and the process of meaning-making used by these individuals over several decades. We used data to address the following research questions: 1) How, if at all, do older Bhutanese with a refugee life experience cope with migratory traumas and grief? and; 2) How, if at all, do older Bhutanese with a refugee life experience make meaning out of migratory traumas and grief?

2. Method

2.1. Participants

Study participants were Bhutanese with a refugee life experience living in a metropolitan area in New England and interviewed between 2017 and 2018. Eligibility criteria included being age 50 and older, first- generation ethnic-Nepali Bhutanese born outside the US, and prior participation and completion of a quantitative survey conducted as part of the parent study. Age 50 was chosen as the lower cut-off for eligibility based on consultation with Bhutanese community members and alignment with cultural definitions of older age. Exclusion criteria included being an immediate relative (parent) of a study team member, in acute mental distress, having cognitive deficits, or physical health problems that would impair their ability to participate. A total of 41 Bhutanese participated in interviews (see Table 1 for sociodemographic characteristics). The Institutional Review Board of Harvard T.H. Chan School of Public Health. Researchers provided ethical approval.

Table 1.

Ethnic-Nepali Bhutanese participant sociodemographic characteristics (N = 41).

Variable	N (%)
Gender
Male	22 (51.22%)
Female	19 (46.34%)
Marital Status
Married	34 (82.93%)
Divorced/Separated	3 (7.32%)
Widowed	4 (9.76%)
Religion
Hindu	26 (65.85%)
Christian	10 (24.39%)
Buddhist	4 (9.76%)
Manav Dharma	1 (2.44%)
US citizen
Yes	14 (34.15%)
No	27 (65.85%)
Schooling
Some grade school	2 (4.88%)
High school graduate	1 (2.44%)
Some college	2 (4.88%)
Informal education in refugee camp	5 (12.20%)
None	31 (75.61%)
Employed
Yes	1 (2.44%)
No	40 (97.56%)
	Mean	Range
Age	66.68	50–86
Years in US	5.63	1–10

2.2. Procedures

Study data was collected as part of a larger study conducted in partnership between Harvard T.H. Chan School of Public Health and a community-based advocacy organization created and run by Bhutanese with a refugee life experience. A Bhutanese community leader worked in conjunction with Bhutanese research assistants (RAs) to identify Bhutanese aged at least 50-years old and residing in the area known to the community organization. RAs approached eligible individuals for study participation, and used maximum variation sampling to recruit older Bhutanese based on age and sex. A total of 12 individuals declined participation or were ineligible, and 150 individuals enrolled in the parent study. As part of the consent process for the quantitative portion of the study, individuals were asked if they would be interested in being re-contacted to participate in a follow-up qualitative individual interview.

The research team used maximum variation sampling to identify a subsample of these 150 individuals to recruit for qualitative interviews. Recruitment goals, outlined in the initial grant, included having a sample of 40 individuals comprised of equal numbers 50–59, 60–69, and 70+. The team also discussed candidates in terms of including a mixture of participants with both higher and lower psychosocial functioning. This sampling strategy was chosen to have representation from people with a wide range of experiences. Recruitment continued until there were sufficient participants in each age/sex group. Verbal informed consent was obtained from individuals prior to the start of the interview. Interviews were conducted in private in the homes of study participants, and lasted between 30 min and an hour. If participants experienced distress they could discontinue the interview or reschedule for a later time. No participants discontinued participation. All study participants were compensated for their time with a $25 gift certificate.

The study team developed a semi-structured interview guide (see supplemental material) for this study. Interview questions lead participants through the major phases of their refugee experience, identified important and meaningful life events along this trajectory, and explored strategies used to overcome traumatic and stressful events. The interview guide was developed in English and forward translated by RAs into Nepali. Bhutanese RAs were trained in qualitative interviewing by the first and second author. Interviews were conducted in Nepali, audio-recorded, de-identified, and transcribed into English by Nepali-speaking RAs.

2.3. Data analysis

The data analysis team included a researcher with several years experience working with Bhutanese refugees (first author), a researcher/Bhutanese with a refugee life experience (second author), and an individual for whom this was their first experience working with the population (third author), meaning the team encompassed a range of perspectives. Researchers analyzed the data in phases, based on principles of thematic content analysis (Boyatzis, 1998; Braum and Clark, 2006). In the first phase, two team members analyzed 3 transcripts using deductive coding as a strategy to identify patterns and topics emerging from the data that were pertinent to issues of coping and meaning-making in response to traumatic and stressful life events. Based on discussions of individual transcripts, codes were refined and grouped into larger categories of linked codes. For instance, codes including “fear,” “sadness,” and “hope” were grouped into a larger category labeled “emotional coping.” The authors created a codebook that contained definitions and examples of individual codes (Boyatzis, 1998).

Next, the coders applied the same coding scheme to 6 transcripts. The coders met to resolve discrepancies, reach consensus, and ensure consistency between coders. Meetings resulted in further refinement of the codebook by adding new codes or clarifying definitions of codes. The data analysis team then split up and individually coded the remaining 32 transcripts. The team continued to meet weekly to discuss emerging issues encountered during the coding process, review each other’s work, maintain consistency in coding, and discuss emerging themes and concepts related to coping and meaning-making. Coders consulted with Bhutanese research team members to more accurately understand the historical events discussed by participants and salient Nepali-Bhutanese worldviews that informed emotional, cognitive, and behavioral responses to these events.

The data analysis team began a second analysis phase that consisted of axial coding (Saldaña, 2016). The primary aim of axial coding was to identify relationships between emotional, cognitive, and behavioral coping strategies discussed by participants and the contexts (traumatic events and stressful experience) in which these strategies were used. The meaning-making process model (Park, 2010) informed this stage of the analysis, meaning that coders reviewed transcripts to identify: 1) salient beliefs, values, and worldviews that informed ethnic-Nepali Bhutanese global meaning; 2) meaning ascribed to experiences that violated this world-view and caused distress, and 3) subsequent coping strategies used to try to resolve the discrepancy between situational and global meanings. Also, two analysts reviewed transcripts based on age (50–59, 60–69, 70+) and gender to compare and identify differences, if any, in coping and meaning-making based on these groups.

Throughout this process, team members wrote memos and met to review findings, identify and agree upon overarching themes, and develop a model of meaning-making and coping aligned with the experiences of older Bhutanese. All team members, including Bhutanese with a refugee life experience, reviewed findings and made suggestions for further revision and refinement. These discussions allowed for reflexivity among the analysts and larger team. Consideration was given to narratives that did not align with emerging themes and the meaning-making model to understand and account for variations in the meaning-making process. Data were managed and analyzed in MAXQDA 18 mixed methods software (VERBI Software, 2018).

3. Results

3.1. Global meaning and events in Bhutan

Participant interpretation of events that led to expulsion from Bhutan provides insight into ethnic-Nepali Bhutanese global meaning and worldview, including beliefs about the order of the world and sense of purpose within it. Bhutan’s “one nation, one people” campaign that began in the 1980s violated confidence in the government and political rights in Bhutan, in which people were free to express their unique identities as ethnic-Nepali and be a valued member of the larger Bhutanese society. Participants spoke about the government threatening and carrying out the imprisonment, torture, rape, and murder of Nepali civilians to make them leave the country. Government actions included stripping citizenship through the passage of a marriage act, seizing the land of subsistence farmers, destroying property, and forbidding ethnic-Nepali from wearing traditional clothing, practicing Hinduism, and speaking their own language. One man reflected on what, in hindsight, he saw as naiveté regarding ethnic-Nepali expectations and assumptions about their rights and place in Bhutan compared to what they encountered:

“We were like kids in politics. We didn’t know anything as to what politics was like, or what politics even was. It did not exist in Bhutan, and no one practiced that in Bhutan. No one knew ‘vote.’ We knew a king, and an institution that the king ran. We earned our living in agriculture. So what would we be thinking? We asked for something that’s genuine and truth[sic]. Our ask was that we were Nepali, and Hindu. We should be allowed to practice our culture; we should be allowed to wear our costumes. We should be allowed to study. Everyone on earth is getting this, so we at first used to think why would we not get it?” - (male, age 60–69)

Participants articulated feelings of injustice and betrayal for having citizenship taken away from them after living in the country for several generations. One man explained, “Bearing all the pain from the times of [our] fathers and grandfathers, we lived in that jungle nation [Bhutan], and made it bright. We the Nepalese brought a good ambition; we made things easier for the government. And how can you feel good when you have to leave the country then? I can’t explain the depth of [the sorrow]” - (male, age 70+). For this individual, grief arises out of the government viewing ethnic-Nepali as different and separate from the rest of the Bhutanese population.

Critical to the ethnic-Nepali worldview was a sense of purpose and understanding of the self that was embedded in the well being of the larger community. One participant succinctly stated, “A person without community is ruined” - (male, age 60–69). In the context of government suppression, trauma was defined in terms of violence perpetrated against individuals and their close family members, as well as more widespread cultural oppression and violence against all ethnic-Nepali. For instance, when discussing the impact of the marriage act and forced imprisonment, one man stated,

“It definitely wasn’t peaceful in mind. But on a personal level, having nothing happen at home, it did not have any major impact on me. But having experienced by others in the village, it was hard for you to tolerate either. When someone is being treated unjust, you can’t just watch it. I used to often have that feeling. All the time.” - (male, age 50–59)

Thus the actions of the Bhutanese government threatened the well being of the larger ethnic-Nepali community, viewed as a critical component of identity on the individual level.

3.2. Interpersonal support

Many study participants discussed the important role their larger community played in providing concrete and emotional support in times of stress. In Bhutan, interpersonal support took the form of families gathering together to cope with the violence perpetrated by the Bhutanese government. One woman talked about the fear and panic she felt after most of her neighbors were killed or fled to Nepal. Deciding to stay in Bhutan to see if conditions would improve, she and her family lived with others who also decided to stay. The woman stated, “At the time, I couldn’t sleep. I wasn’t calm, I didn’t want to eat … We stayed a year, we were afraid … There were like two or three houses/families there. We all stayed in one house … We’d work in the afternoon and come home and rest at night. In the same house. It was a way to remove fear” (female, age 60–69). In this instance, physically being together with others from the community helped this individual cope with the uncertainty of the future.

Emotional and financial support from others was critical in easing economic hardships and overcoming the death of loved ones once they arrived in Nepal. One participant spoke about the struggles Bhutanese faced early on in Nepal, before UNHCR established formal camps. Bhutanese refugees initially settled by the Mai River, where poor sanitation, lack of food, and infectious disease resulted in widespread death. The participant reflected on the intense sadness and despair he felt attending multiple funerals in a day, and how hopeless he felt after both his mother and wife died. He discussed the support he received for the funeral:

“I had to bring someone else’s son and perform the rituals. I could not do it myself … So I would say, ‘Brother, don’t get mad at me. You should not feel sad thinking I made you do this death ritual with all these difficulties.’ When I said that, he said ‘Uncle, don’t even say anything. We are here for you. Let us get this thing done howsoever be it … You do what you need to do, I will do what I need to do.’ We needed three calves to complete the ritual. So the two of us discussed at night. He said he would ask the Brahmin the next day. It was the 12th day. With suggestions from others, we ended up renting [participant’s emphasis] calves from a Brahmin, and paid him. We did not have to buy one … People gave me counseling … that this ‘earth’ is like this. Don’t feel bad; we are all under the same roof. Let us eat what is being given; if they stopped giving, we will die if it’s the day for us to die. Friends helped saying those sorts of things. To satisfy your soul.” - (male, age 70+)

In this instance, an individual receives both concrete and emotional support and guidance to overcome his grief over the death of loved ones.

In the US, participants discussed the importance of social support to cope with new resettlement stressors as well as old traumas. One torture survivor discussed the integral role friends played in dealing with his symptoms of post-traumatic stress disorder. He explained,

“Sometimes at night I can’t fall asleep, sometimes sleeping from the evening and when it’s morning time, I keep sleeping, sometimes, without falling asleep all night, the morning comes, like this keeps happening … And that now, if [I] stay alone then I start getting scared, even now. And because of that, I have to keep walking. Like go to a friend’s house, talk, sit, go somewhere, go to a Nepali store, go somewhere, when walking with friends, that when talking with friends, when talking with friends, I forget that and aanada huncha (it makes me feel better).” - (male, age 50–59)

This illustrates that not only were past traumas from Bhutan still relevant to the psychosocial well being of individuals in the present but that individuals drew strength from the larger community to overcome challenges, just as they did in the past in Bhutan and Nepal.

Participants frequently felt lonely and alienated when first coming to the US, struggling to adjust to a new culture and experiencing linguistic barriers. Several participants discussed getting together with Bhutanese friends as a way to cope. One woman stated, “I have peace … If something happens, when you tell a Nepali, Nepalis can understand it. They can tell what I am saying. They can say how I am feeling. There will be full understanding” (female, age 70+). Another woman recalled overcoming the tension she experienced the first year after arriving in the US from Nepal. When asked what she did to resolve this tension, she stated,

“We had to look at everyone else, others were facing things like that. It was the time and age. And we started to think that it was the time and age that was causing it. And knowing that others faced things like that, we realized that it wasn’t just us … we’d go upstairs or around the block to our neighbors … sit there, like that. We’d talk about Nepal, Bhutan … our friends would bring up stuff about Bhutan, how we stayed there, how we knew each other there … we’d pass our days talking like that.” - (female, age 60–69)

In this example, this individual finds solace in that her experience is shared by others in her community, and also finds comfort in talking about past, shared life experiences.

Notably, some participants discussed negative aspects of community relationships and how a collective identity as ethnic-Nepali led to negative experiences. A few people talked about fighting and interpersonal conflict in the camps in Nepal, and how tensions between different subgroups within the Bhutanese community created stress. One individual stated, “Religion also created debate there [in the camps]. If you talk about one, the other would start debating. Even within Hindus, there are numerous religions. Many divisions” (male, 50–59). Subgroups rested along lines such as religion, caste, and whether or not Bhutanese should accept third-country resettlement.

3.3. Cognitive reappraisal

In addition to interpersonal support, participants discussed using individual coping strategies that were rooted in a strong collective identity. For example, many individuals articulated a process of cognitively evaluating and reframing individual experiences of trauma and grief as a collective experience, which provided comfort. One man discussed the effect being forced from Bhutan had on his emotional well-being and what helped him overcome his pain in the following way:

“There was much pir having to leave behind all the land and property you had. But who would you want to tell? Everyone was like that. It’d be one thing if it were only me. Everyone has left behind and come, sparing their life. When I looked at others, I would feel relieved … once I arrived in Nepal and my papers were registered, and I got things to eat and drink … ration, water, after that, I felt very relaxed. There’s nothing to lose even if I die now. Because everyone’s here.” - (male, age 70+)

In this instance, this individual finds solace in both the commonality of the refugee experience and simply being together with others from his community. The emphasis on the collective experience of suffering and the importance of being together continued once individuals came to the US. One woman discussed how she overcame the fear she felt when she first arrived:

“For a year, we were only thinking of over there [Nepal] … not really here other than just seeing the hardships, panicking about where we were.

Interviewer: And in your heart, when you felt that stress and panic, what would you do?

Participant: What could you do? There wasn’t any choice … what could we do? And in someone else’s house we’d realize they were also facing something similar. So we’d think it was like that and make our peace.” - (female, age 50–59)

For this individual, the stress of hardships in resettlement was lessened when she understood that her experience was not unique.

3.4. Providing support to others

For some individuals, the importance of the larger community led to them cope by finding a sense of purpose in providing support to others. The connection between individual and collective well being is perhaps best illustrated by the life experience of one participant who became suicidal after fleeing to Nepal. He talked about the distress he experienced in Mai burying children who died from disease and malnutrition, despair over his own children getting ill, and his resulting feeling of hopelessness:

“In Mai … what we did was all the security guards … some of us gathered those children, some took them to rivers, some dug the pits to bury them. That’s how we had to bury children. Not adults, but mostly younger ones. We buried about 12–13 kids every day. The situation was that bad … And this second daughter of mine was also almost dead … So what I told (her) this mother [referring to his wife] … I can’t stay any more. You take care of her now … she’ll probably die. Everyone’s dying, she’ll likely die also. If she dies, just call me. I told this to her and went to sleep. Slept helpless! She somehow survived … What I thought at that time was … when you can’t save your children … you can’t take care of them … it felt like I was unable to be a good father … a good husband. At that time, I felt a lot of mental torture … I have to die also. Because I can’t be a good father. I can’t be a good husband to my wife either. I can’t be a good son to my mother either. I should also die now. I also have to die the way others are dying. At one point, I felt this, sir. But again, what I thought the next day was … I should rather have been counseling others not to die like this. That we should live like this. We left Bhutan to survive and live. Why we left Bhutan was due to fear of getting hit by a bullet, of dying. So should we really die now? This way, sharing the courage with others, I got courage and became fit, so to say … we left the country to live. We have to live.” - (male, age 50–59)

The participant went on to provide psychosocial support to others in the refugee camp and continues to reach out to individuals who are suicidal in the US. He stated, “We have to teach someone else, convince, show them. If we can save them, you can save yourself too. That is what I have understood. If you can help others, you get help.”

3.5. Making meaning in resettlement

Interpersonal and individual coping strategies, including social support, cognitive reappraisal, and providing support to others, were embedded within the context of a sense of belonging to a community. This had implications for how older Bhutanese ultimately made meaning from their life experiences in resettlement. Community identity provided a pathway for individuals to reflect and find meaning in their overall experience as a mechanism that provided an opportunity for Bhutanese to build community well being and growth in ways that would have never been possible otherwise. Even while describing their current struggles in the US, many participants talked about accomplishing things they never would have thought possible. One individual talked about overcoming challenges in the US by being optimistic about the future and thinking that “I might now [in America] be able to do something. There were new improvements in [my] mind that it will be better than the past. I felt that I can do something, and that I should start something new now. It’s a place where you can do [things] if you have [the] will. I did, and I should say I have been successful” (male, age 50–59). Other people talked about the happiness they felt in seeing their children succeed in the US. A participant explained,

“There is nothing that takes away my peace now. [I am] absolutely relaxed now. All of my children have opportunity to study. The main … from Nepal … from Bhutan, my hard work has been for my children to study. They have been able to study after coming here as well. We have to think that is happiness. For their studies, by hook-or-crook, I have been able to manage. Now, it’s up my children, for them to make progress. It’s dependent on that. And this is about America, brother. I have left worrying much.” - (male, age 70+)

This participant emphasized this importance of parental identity, and supporting and caring for subsequent generations of ethnic-Nepali Bhutanese, as critical to making meaning.

3.6. Unable to make meaning

Of course, not everyone was able to positively cope and find meaning from his or her experience. One participant articulated being isolated because of language barriers and stated,

“In Nepal and Bhutan, there were people who did not speak at all, the disabled one. How would it feel when we tried to communicate with those mute people is what it feels here with us trying to talk to others. We are the mutes here. People from this place speak. So then we are disable people. We don’t have speech. That’s how I feel as my big pir … So the children go to work, just the parents are home. We stay inside like rotten meat.” - (female, age 50–59)

This individual felt isolated both physically from others in her community, as well as within her own family because of her inability to speak English. For some, meaning-making was obstructed by a feeling of not belonging anywhere, despite having a migration trajectory shared with other Bhutanese. One man reflected on his experiences in Bhutan, Nepal, and the US in this regard:

“It felt like it was worthless being born as human being, you know. When you didn’t have anything anywhere. When you didn’t have any land anywhere to do anything … when you don’t have a place over there in Bhutan … we became “without” (or “less”). We were suddenly on the fence. Because of that, it felt very sad. Despite being a Nepali, we were outsiders [meaning alien]; we were outsiders in Bhutan as well. Now having come here [the US] as well, being a Nepali, you’re an outsider as well … when those thoughts come in the evening, sometimes (I) can’t sleep” - (male, age 50–59).

For this individual, a collective identity as an ethnic-Nepali Bhutanese did not help him overcome the feeling of not being accepted in all three countries in which he had lived.

4. Discussion

Interviews revealed a coping and meaning-making process that began with an interpretation of events in Bhutan as a violation of core ethnic-Nepali beliefs and sense of purpose related to collective identity. Throughout their refugee life trajectory, participants utilized coping strategies-including interpersonal support, reappraisal of experiences of trauma and loss, and helping oneself by helping others, -that were informed by, and strengthened, this collective identity. These strategies both reaffirmed global meaning and sense of purpose and made new, positive meaning out of a refugee life experience. Individuals unable to leverage these strategies struggled to find meaning from their trauma and loss.

Our findings align with existing literature on Bhutanese ethno-psychology. Our work confirms the importance placed on interpersonal and collective coping strategies previously identified through research among Bhutanese resettled in the US. In particular, social support from family and friends is protective against the potential negative impact of psychosocial stressors (Aoe et al., 2016; Chase and Sapkota, 2017). To our knowledge, there are no comparative studies on coping strategies used by Bhutanese of different age groups, so it is unclear if our findings are unique to older adults. Our results are note-worthy in that we did not find substantial differences in coping strategies and the meaning-making process based on subgroups such as age and gender, despite focusing on this in analysis. We did, however, find that other divisions such as religion and caste created tension and barriers to a sense of collective identity, especially during the years spent in the refugee camps.

Findings add to literature on Bhutanese ethno-psychology by integrating a life course perspective into understanding Bhutanese psychosocial wellbeing in resettlement. Stressors experienced throughout the life course impact the current mental health of refugees via direct and indirect pathways (Miller and Rasmussen, 2010). To date, research on Bhutanese in resettlement has focused primarily on understanding how contemporary stressors are associated with mental health. This is certainly critical information; however, we illustrate that past traumas also contribute to current stressors and functioning; for instance, participants who were tortured in Bhutan talked about coping with current mental and physical disabilities related to those experiences. Our work suggests that there are pathways between contemporary coping mechanisms and coping strategies used to overcome prior challenges over the lifespan.

Findings align with and build upon existing evidence on health, aging, positive coping, and post-traumatic growth among the broader refugee population. A review on the impact of forced migration on the elderly found both pre- and post-migration experiences contribute to negative mental health outcomes (Virgincar et al., 2016). In their scoping review on the health of older refugees and migrants, the World Health Organization (WHO) emphasized the need to promote environments that expand social networks and decrease isolation to enhance emotional well being (WHO, 2018). Reviews on enablers of psychosocial well being and post-traumatic growth among refugees highlight the importance of social support and individual-level cognitive strategies such as reframing negative experiences, acceptance, and positive thinking (Chan et al., 2016; Posselt et al., 2019). Our findings support this literature and add to it by qualitatively exploring the contribution of both current and past stressors on psychosocial functioning; additionally, we present an analysis of culturally informed coping strategies used throughout the refugee life experience that can be applied to the broader refugee population.

Our work contributes to theory on meaning-making by illustrating social and cultural aspects of the process. A shortcoming of existing research on meaning-making is limited investigation into how meaning is made not only intrapsychically but also interpersonally (Park, 2010). Our work is part of a growing body of literature that focuses on communal coping and meaning-making after collective traumatic experiences, such as natural disasters (see for example Richardson and Maninger, 2016; Wlodarcayk et al., 2016), as well as how culture informs coping strategies (see for example Ahmadi, Hussin, Mohammad, 2019; Almuhtaseb, Alby, Zucchermaglio & Fatigante, 2020). The global worldview of ethnic-Nepali Bhutanese, meaning they attributed to traumatic events, as well as meaning-making strategies they employed cannot be understood without taking cultural values, beliefs, and norms into consideration.

Our work contributes to theory on meaning-making by introducing a longitudinal perspective. Specifically, one critique of the meaning-making literature is that the majority of work focuses on a meaning-making process related to a one-time event, such as a death or natural disaster (Park, 2010); meaning-making is conceptualized as a cycle that begins with a significant trauma or loss and concludes once the global meaning is reestablished or reevaluated. In our work, we illustrate that the meaning-making process does not have a clear beginning and ending, with exposure to new traumas occurring at the same time individuals are trying to cope and make meaning out of prior traumas. For instance, after expulsion from Bhutan, participants tried to cope with losing citizenship and faced new stressors in Nepal. We argue that meaning-making theory needs to incorporate the layering of coping, meaning-making, and exposure to new traumas and loss over time.

4.1. Limitations

There are some limitations to our study. First, participants may not be representative of older Bhutanese with a refugee life experience living elsewhere in the US or other countries of resettlement. This is because Bhutanese were recruited within one community in the New England region of the US. However, the team did use maximum variation sampling within this community to select male and female participants from a range of ages and psychosocial functioning to have representation from a wide range of individuals. Additionally, due to the size of the Bhutanese community in the metropolitan area of our study, many participants had pre-established social relationships with RAs who conducted the interviews. This means participants may have felt pressure to provide responses that they perceived would be socially desirable. Also of note is that both interviewers were male; it is possible given gender dynamics within the Bhutanese community that women may not have felt comfortable sharing some of their experiences with men. Extensive training was done with RAs around both of these issues to try to minimize bias in participant responses.

4.2. Public health implications

Critiques of psychosocial services for older refugees include a lack of cultural specificity and failure to take into consideration the age-specific needs of the population. Typically, services are an extension of those provided to general adult refugees, and do not address age-related accessibility barriers, such as physical limitations, language skills, or intergenerational struggles (Ridout, 2016; Virgincar et al., 2016; World Health Organization (WHO), 2018). Interventions are frequently based upon and promote more Western-oriented, individualistic coping strategies that may be more suitable, familiar, and comfortable for older American-born populations (Chenoweth and Burdick, 2001). Specific to the US, the Office for Refugee Resettlement has historically had monies designated for older adults, but with restrictions based on age (60 and over) and length of time in the US (up to 5 years) (Office of Refugee Resettlement, accessed on-line 9/13/19). These parameters do not respond to cultural views on what constitutes older age, and the reality of long-term mental health needs.

Service providers should build upon culturally informed collectivist coping strategies that were historically leveraged throughout the migration journey and are still being utilized after third country resettlement (Rinker and Khadka, 2018). Social ties amongst family members, friends, and neighbors provide opportunities for psychosocial supports in the form of advice, mediating conflict, and spiritual practices (Chase and Sapkota, 2017). Continuation and adaptation of these familiar coping strategies might take the form of offering older Bhutanese group-based services. Service providers could coordinate and provide linkages with informal care providers, such as spiritual leaders (WHO, 2018). Funding is needed for community-based self-help organizations to implement initiatives that build upon, and adapt, informal care systems to the resettlement context (Chase and Sapkota, 2017). Overall, service providers should integrate a more ecological perspective when identifying risk and protective factors for older Bhutanese mental health that includes inquiring about broader social networks.

5. Conclusions

Public health organizations and service providers invest considerable resources to address the psychosocial needs of refugees. It is imperative that initiatives promote the dignity and well being of older individuals with a refugee life experience along with other at-risk groups, such as children and youth. In addition to investigating the challenges faced by older individuals, it is critical to examine and identify strengths and positive coping strategies utilized by this population to persevere through sometimes decades of trauma, loss, and grief. Specific to older Bhutanese, interventions and services need to be adapted to integrate both formal and informal systems of care and leverage culturally-informed collective coping strategies that help individuals make meaning out of their refugee life experience. More broadly, health care providers and refugee communities should partner on initiatives to make psychosocial supports for aging individuals more accessible, acceptable, and effective.