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“Life Starts at Less than Zero”: Trauma and Coping among Iraqi and Syrian Refugees

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26 October 2023

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26 October 2023

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Abstract
The ongoing conflict in Syria and Iraq has caused many residents of these countries to flee. This study explored how these refugees cope with traumatic experiences from pre-migration to post-migration phases and how they develop resilience experiences at the individual, familial, and community levels. Data were collected through individual interviews and analyzed using Interpretative Phenomenological Analysis. A discussion of the findings revealed (1) a cumulative effect of prolonged adversity from pre-migration to resettlement phases; (2) the impacts of post-migration context as it facilitates refugees’ adjustment or leads to re-traumatization through increased marginalization; and (3) finally, an overview of refugees’ ongoing survival. Clinical implications are presented along with policy implications and future directions for research.
Keywords: 
Iraqi and Syrian refugees
;  
displacement-related stressors
;  
eco-systemic resilience
;  
cultural racism
Subject: 
Social Sciences  -   Psychology
The wars in Syria and Iraq have produced the greatest number of the Middle East's refugees (As defined by the 1951 United Nations Geneva Convention, refugees are persons forced to leave their place of residence or nationality to seek refuge in another country outside their nationality or place of residence, due to fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (United Nations Geneva Convention, 1951). When their request for sanctuary was processed, their status is defined as a refugee. However, when their request for protection was not processed, their status becomes asylum seeker, and these groups are often called ‘prima facie’ refugees (UNHCR, 2021). In the current study, the researcher utilized “refugee” as an umbrella term to address both asylum seekers (prima facie refugees) and refugees. However, she recognizes the differences and nuances of refugees’ and asylum seekers’ experiences and pointed out considerable challenges of asylum seekers in the various sections of this paper.) in recent years and the Syrian conflict alone has been the worst humanitarian crisis of the last century (UNHCR, 2016). The ongoing conflicts in these countries have led many to seek asylum in foreign countries. However, the xenophobic discourse across the world, associating migration experience with national security issues, leads migrant groups to be perceived as a threat to a receiving society (Esses et al., 2013). Thus, it leads to anti-immigrant policy and governance. Refugee discourse and policy aiming to keep refugees out exacerbates the condition of living in fear and reduces their sense of security (i.e., legal and interpersonal) in the United States (Gowayed, 2020). Therefore, the refugee experience in the US should be understood in the context of increased Islamophobia, cultural racism, and anti-immigrant/refugee sentiment. This study is critical given that the current sociopolitical climate takes a toll on the most vulnerable groups such as refugees and it is critical to describe how they cope within this climate.
Refugees’ experiences entail a complex array of persecutions they experience in their country of origin, various challenges during their journey to a safe zone, and relocation stressors in a resettlement country (Ghumman et al., 2016). Thus, refugees face multiple losses including significant others, material possessions, and familiar landscape, culture, and community. More importantly, the post-migration environment, including social factors (e.g., lack of social support in a resettlement country), is likely to exert significant impact regardless of prior traumatic exposures and might decrease the capacity for coping and resilience (Lie, 2002). Indeed, refugees’ challenges can be aggregated in the context of socioeconomic factors such as poor living conditions, perceived discrimination, poor sociocultural adaptation, and uncertainty, which set the stage for psychological distress in the country of resettlement (Alpak et al., 2015; Betancourt, Frounfelker, et al., 2015; Nickerson et al., 2015).
Extant research indicates that post-migration stressors are an equally or more important factor in psychological morbidity than pre-migration war exposure is (Betancourt et al., 2012; Ellis et al., 2008). Reaching a resettlement country provides refugees with a great amount of relief, yet they confront further relocation difficulties (Silove et al., 1993). For example, in a study conducted among Burmese refugees, pre-migration trauma events were found to adversely impact mental health outcomes; however, post-migration challenges (e.g., employment as well as accessing educational, health, and welfare resources) were stronger predictors of mental health outcomes (Schweitzer et al., 2011). Additionally, racist, xenophobic, and prejudicial treatment in host societies adversely affected refugees’ wellbeing (Chung et al., 2008).
Cultural racism was defined as sets of characteristics perceived as inherent to members of a group due to their physical or cultural features so that certain rights and privileges can be offered or taken away (Garner & Selod, 2014). According to Selod (2014), “’Muslim’ is becoming a de facto racial classification, one that is experienced in practice even though not formally recognized. This process occurs when a religious identity is essentialized” (p. 4). This concept can lead us to understand Muslims experience in the context of homogenization and degradation by Islamophobic discourse on a daily basis in the US (Garner & Selod, 2014). Research concerning the mental health impact of sociocultural variables upon the lives of Iraqi and Syrian refugees is scarce. In a few studies, perceived discrimination, as a result of cultural racism, has been postulated and examined in the context of cumulative trauma exposure as a post-migration stressor for trauma in Muslim Iraqi refugees (Kira et al., 2008; Kira et al., 2010). Particularly, as recent research demonstrates, discriminatory experiences of Muslim Iraqi and Syrian refugees in their home countries compound with experiences of marginalization in their host country, increasing the cumulative effect of trauma (Kira et al., 2014). This is critical because additive experiences of discrimination might hinder refugees’ ability to garner new support networks in a resettlement country (Lacroix & Sabbah, 2011).
Preliminary qualitative inquiries have found that after displacement, refugees experience loss of social support and community (Miller et al., 2002), isolation (Deuchar, 2011), and changes in identity (e.g., individual, social, cultural, ethnic) (Groen et al., 2017). Afghan refugees who resettled in the US described that their depression resulted from loss, including of family and friends, material belongings, language, and culture (Alemi et al., 2016).
Despite the exposure to prolonged adversity and psychological distress, refugees manage to survive, bounce back, and move forward. Until recently, the adverse effects of pre-migration persecution and trauma were a major area of research focus, which has resulted in dismissing resilience factors and the way in which these factors interact with pre-migration and post-migration stressors. However, evidence suggests an association between increased levels of resilience with less war-related distress (Beiser & Hou, 2017; Ssenyonga et al., 2013). The findings of a study exploring Sudanese refugees’ coping factors in Australia suggest social support, religious beliefs, and cognitive strategies (e.g., reframing their experiences, reliance on inner resources, having aspirations in life) as the most common strategies (Khawaja et al, 2008).
The present study had three main objectives: (a) to examine Iraqi and Syrian refugees’ own descriptions of stressful experiences and resilience including pre-migration, flight, and post-migration phases; (b) to examine how they navigate resources to survive; and (c) to explore the impacts of sociocultural factors facilitating or hindering the refugees’ well-being. The scholarship is scarce with regards to the mental health consequences of these sociocultural variables upon the lives of Iraqi and Syrian refugees in a post-migration environment. Addressing the cultural aspects of individual narrations of distress and resilience will likely lead to a more nuanced understanding of refugee experiences. It should assist in the elucidation of psychological and psychosocial treatment implications as well as of policy implications with regard to welfare services and helping refugees adapt.
The present study aimed at answering the following research questions:
What stressors have Iraqi and Syrian refugees experienced throughout the immigration process, including life in the US?
What is helpful in getting them through adverse experiences at the individual, familial, and community levels?

Method

This qualitative study was exploratory preliminary research that sought to explore Iraqi and Syrian refugees’ stressful experiences and their resilience. To communicate perspectives and realities of communities as well as uniqueness of individual experiences, a qualitative method was chosen. Data were analyzed using Interpretative Phenomenological Analysis (IPA), which is a qualitative research methodology intended to explore people’s lived experiences and to discern how people make sense of their personal and social contexts (Smith et al., 2009). It is an appropriate method for cross-cultural studies since it allows researchers to explore how participants construct meanings (Pietkiewicz & Smith, 2014). IPA is suitable for refugee populations -- it allows for a deeper understanding of participants’ experiences with trauma and resilience since participants are viewed as experts of their own experiences (Reid et al., 2005). Epistemologically, IPA draws upon three fundamental traditions: phenomenology, hermeneutics, and idiography (Smith & Osborn, 2003; Smith & Eatough, 2007). Phenomenology, developed by Edmund Husserl, focuses on how people perceive and experience a phenomenon rather than attempting to create an objective statement of the phenomenon (Pietkiewicz & Smith, 2014). IPA entails a double hermeneutic as participants strive to make sense of their world and, simultaneously, the researcher attempts to interpret participants’ meaning-making process (Smith & Eatough, 2007). The third principle of IPA is idiography, referring to an in-depth analysis of each case, understanding the unique contexts of individual participant narratives before working toward any general statements (Pietkiewicz & Smith, 2014).

Participants

Participants were recruited through purposive sampling that entailed finding a fairly homogeneous sample so that the research question would reflect a shared perspective of respondents (Smith & Osborn, 2003), which allowed for an in-depth and rich analysis of interview data (Smith et al., 2009). Due to the challenge of accessing Syrian refugees, the researcher was able to include only one Syrian refugee in the present study. While the researcher recognizes the fact that Iraqi and Syrian refugees are not a homogeneous group, the Syrian refugee is included in the sample due to these two countries’ linguistic, cultural, and historical similarities. It also appeared that the Syrian refugee’s experience overlapped with the Iraqi participants’ experience. Eligibility for being a participant included: a) being at least 18 years old; b) being an Iraqi or Syrian refugee/asylum seeker; c) identifying as a Muslim; d) (The criterion “d” was set for two reasons: first, to capture the ways in which the length of stay impacts the participant’s adjustment and well-being; second, the difficulty in accessing newly arrived refugees (e.g., logistical difficulties, confidentiality, and acuity of psychological and legal problems).) having lived in the US for 10 years or fewer. The researcher conducted individual, semi-structured interviews. Six people participated in the study (three male, three female). Five of the participants had refugee status and one had asylum-seeker status. The age of the participants ranged from 31 to 68 years old. In the study, five of the participants were Iraqi and one was Syrian. Years from migration ranged from two to five. Four participants attended college and two participants had completed less than high school.
Table 1. Demographics.
Table 1. Demographics.
Participants Gender Age Country of Origin Legal Status Years from Migration Educational
Status
1 Female 31 Iraq Asylum seeker 2 Masters
2 Female 45 Syria Refugee 3 High School
3 Male 68 Iraq Refugee 5 College
4 Male 33 Iraq Refugee 4 College
5 Male 35 Iraq Refugee 4 High School
6 Female 39 Iraq Refugee 3 Elementary School

Procedure

Per IPA, individual semi-structured interviews were the method of data collection. One advantage of this method of data collection is to allow for the interviewer, in real-time, to explore interesting and important topics that emerge during the interview (Smith & Osborn, 2003) and to facilitate the interview process rather than dictating how to proceed (Smith & Eatough, 2007). The interview explored four main areas: (1) experiences of stressful events and coping skills from pre-migration to post-migration phases; (2) experiences of cultural racism; (3) navigating resources in the post-migration context; and (4) expectations from service providers and therapists. Institutional Review Board (IRB) approval for the study was received through the University of X prior to recruitment. The researcher reviewed the study with participants and obtained informed consent before initiating individual interviews. A verbal consent process was conducted to ensure confidentiality/anonymity since participants’ identifying information was not being recorded and only the researcher had access to the data gathered. All interviews were audio-recorded and transcribed. Each interview lasted approximately 60 minutes and participants received a cash incentive ($30) for their time. Participants were recruited through a community-based, non-profit, human service agency. All interviews took place in an urban location in the New England area. Bilingual, Arabic- and English-speaking research assistants who were trained by the researcher on appropriate interviewing techniques and confidentiality facilitated the interviews. They were chosen based on their language proficiency in both English and Arabic (classical and Iraqi/Syrian dialects), flexibility, openness to work with community participants, and strong listening skills.

Data Analysis

Three of the six interviews were conducted in English and the other three in Arabic with the help of interpreters. Two English interviews were transcribed by a transcription company and one of them was transcribed by the researcher. The researcher conducted a cross-check of the transcriptions to ensure consistency. Arabic interviews first were transcribed in Arabic by interpreters and translated into English. Translations were checked for inconsistencies by an independent bilingual interpreter. The researcher engaged all interpreters in a discussion regarding the inconsistencies until a consensus was reached. To maintain the phenomenological and methodological authenticity of the study, Smith et al. (2009)’s data analysis steps were utilized. The first stage of analysis was carried out by the researcher and involved carefully reading the transcripts multiple times, writing initial comments and notes on linguistic and conceptual aspects of the transcripts, and highlighting words, sentences, or phrases that seemed to represent the essence of the experience being described. These initial codes were then used to identify emergent themes that were similar in terms of meaning and experience in implicit or explicit ways. Next, emergent themes were grouped into higher-order themes. This process was repeated for each transcript, and a table of themes was created for each interview.

Credibility Checks

At the end of each interview, the researcher asked three questions to check for procedural integrity:
1) Anything I haven’t asked that is important?; 2) Anything about me (Turkish, woman, Muslim) that might have influenced what you felt comfortable discussing in the interview?; and 3) Did you feel comfortable or uncomfortable with any of the questions, or do you have any advice for me for my future interviews? To increase the credibility of this study, a researcher/internal auditor who has expertise in IPA first reviewed initial codes and then higher-order themes for each interview to determine whether they represented the thematic essence being explored. After each review, the researcher re-examined the codes and themes again and had a discussion with the auditor. These discussions involved the examination of inconsistencies (i.e., the wording of the phrases, meaning units, and lower- and higher-order themes) and the researcher’s potential biases that might impact the results. After inconsistencies were resolved by discussions, two researchers who have expertise in IPA reviewed transcripts and higher-order themes at each level of the study to ensure rigor and to reach an agreement regarding the content. After analysis of commonalities and differences within and across interviews, a master table of lower- and higher-order themes was created that captured the essence of the phenomenon for individual participants.

Reflexive Statement

The researcher is a female Turkish Muslim international student. At the time of study, she was a third-year doctoral candidate at the University of X. She had past experience conducting qualitative interviews and data analysis (i.e., thematic and grounded analysis) as well as providing clinical and advocacy services for refugees and asylum seekers. The researcher approached this study from a culturally-responsive perspective to trauma and resilience. She developed the following assumptions: a) Refugees’ trauma experience is cumulative in nature and the post-migration phase can be an opportunity for healing; b) Refugees would have their own way of expressing and experiencing trauma and resilience and the researcher was interested in learning these culturally-embedded expressions, meanings, and resilience resources; c) The researcher, given her cultural and religious background, expected refugees to feel comfortable sharing their experiences during the interview; and d) The researcher also expected that refugees would have difficulty sharing or identifying their experiences with discrimination and racism. Given that IPA entails a balance between the researcher’s interpretative attitude and objectivity, reflexivity is key to navigate this balance. Hence, from study development to implementation to analysis and communication of results, she was engaged in the practice of bracketing her experiences, biases, and preconceived notions in order to allow themes to emerge from the data (Pietkiewicz & Smith, 2014).
The researcher’s role as a therapist might also have influenced her objectivity as a researcher. This dialectic was dealt with through a reflective journaling and supervision. The researcher sought out a diverse group of auditors who have expertise in IPA to mitigate the biases as much as possible from the beginning of the study. All these researchers have experience with community-engaged research. They share a culturally-responsive perspective to research and clinical practice and ecological lenses to trauma and resilience. The internal auditor of this project was a fifth-year doctoral student during the analysis at X university. She identifies as a White American woman having expertise with regard to IPA, the mental health of marginalized individuals, and survivors of trauma. The first external auditor was a researcher who identifies as a Latina female having over a decade of experience working with immigrants and refugees through community-engaged methods. The second external auditor was a first-generation Indian-American female who has extensive experience with refugee and immigrant communities through research and clinical practice. Over the course of the study, they all openly discussed with the researcher their thoughts and reactions to the data to help minimize the impact of their pre-existing assumptions and biases.

Findings

The data analysis resulted in the identification of three clusters and nine themes that emerged from the participants’ accounts of their displacement and survival. In the following sections, each theme is described and accompanied by specific examples using direct quotes from the interview transcripts.
Cluster 1: Complex Traumatic Events Leading to Flight
Theme 1.1: Tragic loss of loved ones and safety
Participants expressed that losing their loved ones to war, witnessing the persecution of their neighbors, and a decreased level of safety first led them to multiple internal migrations and eventually to flee their countries. As participant (3) stated, “I had been threatened, twice they try to break in my house, armed people, I had a drive-by car shooting. So, I couldn't bear to stay and continue having these incidents.” Another participant (5) shared a tragic loss of her brother: “I found him blindfolded with hands tied behind his back. He was shot in the head…I received a death threat to my house and surrounding neighborhood. So, we fled from one city to another city.” These quotes demonstrated the complex and cumulative nature of adversities that participants went through and how their sense of safety was intertwined with the safety of their loved ones.
Theme 1.2: Shattered sense of home and community
Participants described a shattered sense of home and community due to the sectarian war. Home and community in this context refer to feelings of safety and belonging. Participant (1) remarked that she used to live peacefully in her neighborhood with people identified with various cultural and religious identities: “They [militia] tried to make two neighbors fighting for nothing just for their benefits. It was not a problem before the war.” Participants’ reflections manifested their shock and alienation towards their familiar environments and exclusion from their relational contexts, which interfered with a sense of belonging and eventually led to escape.
A strong sense of humiliation resulting from discriminatory experiences echoed in all participants’ accounts. As a participant (1) voiced her experience with gender-based discrimination, “After the war, we have been treated differently, it is like not our country, not being able to for example go outside, wearing certain types of clothes after the war happened.” Another participant (2) expressed her sadness over her husband’s feeling of humiliation:
The soldier slapped him in the face. My husband was just going to work and he’s a very honorable man. My husband kept being humiliated and wanted to leave the city to an easier region, but the transportation was a challenge with an elderly woman and injured children.
Participant (2)’s account appeared to resonate with those of other participants in the sense that discrimination led to a sense of humiliation and targeted individuals’ dignity and identity.
Cluster 2: Life Starts at Less than Zero: Post-Migration Context
Theme 2.1: Loss of career/financial stability as a major stressor
The first theme that emerged from all participant transcripts refers to the loss of their career or breadwinner role and trying to rebuild their life from scratch. Most participants have used language around “zero” to describe these experiences. They noted frustration that their previous achievements (e.g., career, degrees, material belongings, social status) disappeared after displacement. As Participant (2) noted, “In this country, I went through a lot of hardship in different phases, to the point that I started from less than zero, not from zero.” Challenges to the economic functioning of refugees have led many to question their sense of self, resulting often in mourning for the loss of earlier held identities as well as a daunting task of the reconstruction of those identities. Overall, participants shared the negative effects of financial instability and the loss of their careers and discussed how they strive for survival.
Theme 2.2: Experiences of isolation, pain of separation, & lack of social support
This section described these participants’ experiences during the initial phase of relocation in the US as being marked by their sense of isolation, confusion, and uncertainty in conjunction with the pain of separation. In particular, asylum status, compared to refugee status, resulted in less access to social services as well as to social support, which seemed to increase participants’ isolation and feelings of helplessness, especially when compounded with pre-existing stressors. It was also notable that lack of English proficiency prevented some participants, like Participant (2), from expressing their needs and from reaching social support. Participant 6 who has refugee status conveyed the pain of separation from her family:
I still not able to have a deep sleep, when I try to sleep, I start remembering everything I start remembering the kids. My husband and extended family are back in Iraq and I am always thinking about them and worried about that.
The pain of separation from family members cuts across all participants. Furthermore, limited access to resources as a result of legal status (i.e., asylum seeker versus refugee) appeared to exacerbate participants’ feelings of isolation and despair.
Theme 2.3: Home is nowhere
A strong sense of ambivalence and conflict towards describing their sense of home emerged from the accounts of all participants. For them, home is where they feel safe and belong. Losing their familiar environments in a tragic way and not feeling the resettlement country as home seemed to leave participants with questioning where their home is: here, there, or nowhere. It appeared that the cumulative effect of losses impact participants’ sense of home, as Participant (1) conveyed her ambivalence about coming to the US:
I don’t feel sense of home here, because all the depression happened here. My immigration story. It is from Iraq to the US is a story. And from the date of arrival here, struggling with the immigration and seeking asylum is another story. It was stressful before coming but it was depressing when I arrived. I wasn’t happy to come here. I wasn’t sure if it is a good decision. It was a question mark.
Theme 2.4: Cultural racism: Am I WELCOME here?
This theme relates to participants’ direct or indirect experiences with cultural racism, the ways in which it plays out in their lives, and eventually how welcome they feel in host countries.
This theme shed light on how discriminatory actions add to the feelings of isolation and less social support in host countries. Most participants expressed that they either experienced or witnessed religion- or culture-based discrimination against women who wear a headscarf in the US, leading to a sense of humiliation and discomfort. Racism sometimes emerged as a direct assault leading to a decreased sense of safety and an increased isolation for some refugees, particularly the ones with cultural identifiers such as a headscarf. The following extract reflects how a participant reacted to anti-Muslim treatment:
I don’t take my wife with me, especially after a terrorist attack in the world. One time I took my wife out and someone approached her and told her she was a Muslim terrorist. These things affect my wife deeply. When these things happen, we become scared, so we sit at home and are afraid to go out or open the door. (Participant 5)
All participants consistently identified the length of the asylum application process as a major stressor fraught with uncertainty. However, the process yielded diverse experiences for participants, with some experiencing marginalization, others perceiving it as an opportunity for freedom, and some both. Participants underlined the fact that refugees come to seek safety; they are not a threat for the society, and they yearn to be perceived as good and simple people. They pointed out that limiting refugee resettlement and treating them as terrorists into the US as unfair, which negatively impacted their sense of belonging.
Cluster 3: Art of Survival in the Face of the Lasting Effects of War
Theme 3.1: Gratitude, patience & waiting for divine justice
Spirituality emerged as an important force in all participants’ lives. They all expressed gratitude to Allah for helping them flee and giving them the ability to protect their children. They continued to maintain their patience and spirituality in the face of the lasting impacts of war. Participant (6)’s answer to how she survived atrocities was, “My belief in Allah and my prayer help me but still not able to sleep very comfortably.” She noted that in the face of discriminatory treatments in a shelter she was living in the US, she relied on patience. Participant (2) pointed out “Divine Justice”, which is one of the important tenets of Islam, and then she recommended patience to all refugees in the face of challenges in the US. It is critical to emphasize that these pre-existing values allowed refugees to move forward and navigate the opportunities for healing in a new society.
Theme 3.2: Navigating adjustment process: family & social support
The third theme emerging from all participant transcripts refers to the interplay between internal and external resilience resources and the ways in which they can merge to foster refugees’ wellbeing. Participants described their strivings to preserve their family and community during the pre-migration and post-migration periods. All participants emphasized that their main motive to survive was to protect and preserve their families. They noted that they are dedicated to their children’s education and well-being and act empathically to enhance their children’s sense of safety and belonging in the family. For some participants, being part of a community provides a sense of family and tranquility. Participant (1) who works for a community center shared, “My social support is helping families. They consider me as family, and I consider them as a family. They consider me a friend, not a worker for them. My job is my life.”
This theme also reflects the complexity of the relationship among accessing resources, freedom, and dignity. All participants underlined the importance of resources including English language proficiency, stable housing, health benefits, accessing community centers, mosques, and driver’s licenses. These variables seemed to increase not only their freedom and autonomy but also inclusion and participation in society, and dignity. As they feel more independent, they are more confident when seeking further support.
Some participants pointed to the increased cultural awareness through intercultural/religious connection. They shared openness to interacting and co-existing peacefully with people of diverse cultures. From participants’ reflections, it appeared that intercultural connection served as a social support system; therefore, a community does not have to be limited to homo-ethnic culture. Participants expressed hope that they can change negative views of Islam through positive relationships with people of other faiths and respecting cultural differences. To further intercultural connection, some participants expressed hope that people recognize the fact that refugees are victims of terrorism versus a threat to society.
Theme 3.3: Pride & Upholding Dignity
Pride emerged as a major source of resilience in all participant interviews. Data suggested even though the refugees may have lost their belongings, loved ones, and communities to the war, they relied on their pride and dignity to build a new home. This subtheme described participants’ pride in both their cultural and personal values as a pathway to resilience. Participant (3) conveyed his sense of strength and pride: “One person said that below this flesh, the outside flesh, there is stone here. I think he's right. I'm built of stone covered with a little bit of flesh.” Some participants shared their frustration about people’s distorted perception about their country:
They think we are from third world country. It is not true. We didn’t come from desert, we have a nice country, we have everything at home, we wouldn’t leave the country without any reason. The war caused this. this is the message I want to give everyone in America would know. People leave behind their homes, their friends, car, it is not easy to start from zero. (Participant 1)
This quote communicates a message of how being proud of their culture maintains their sense of dignity in the face of cultural misconceptions.
All participants revealed the significance of self-agency and taking responsibility for their future as sources of survival and pride. In addition, they stated that although starting from scratch to build a new life is not easy, their efforts eventually will pay off. Participants’ reflections also voice the importance of having a purpose to survive, which facilitated taking personal ownership and served as a building block of cultivating resilience in a post-migration context.
Empathy and pride generally emerged as ways of coping with cultural racism; however, for one participant (4) conformity arose as another way of coping and belonging. As an example of this, he described the best way of dealing with the problems coming from religion (i.e., Islam) was to keep it personal and choose conformity as well as balance spiritual and social life.
Participants appeared to develop perspective-taking to make sense of discriminatory treatments and held onto their sources of pride (e.g., cultural and personal values). Participant (5) shared he has developed empathy for people who associate Islam with terrorism by attributing their attitudes to lack of education: “I give them the benefit of the doubt. They are right in that they don’t know Islam and they think all Muslims are terrorists or criminals. But they don’t know that I am the victim of terrorism. I don’t blame them.”
Overall, participants used diverse self-protective strategies including empathy, pride, and conformity against cultural racism that might appear either more explicitly or implicitly.
Table 2. List of Clusters, Themes and Subthemes.
Table 2. List of Clusters, Themes and Subthemes.
Cluster 1: Complex Traumatic Events Leading to Flight
Theme 1.1
Theme 1.2 		Tragic loss of loved ones & safety
Shattered sense of home & community & discrimination
Cluster 2: Life Starts at Less than Zero: Post-migration Context
Theme 2.1
Theme 2.2
Theme 2.3
Theme 2.4 		Loss of career/financial stability as a major stressor
Experiences of isolation, pain of separation & lack of social support
Home is nowhere
Cultural racism: Am I WELCOME here?
Cluster 3: Art of Survival in the Face of the Lasting Effects of War
Theme 3.1
Theme 3.2
Theme 3.3 		Gratitude, patience & waiting for divine justice
Navigating adjustment process: Family & social support
Pride, upholding dignity, & resilience

Discussion

The purpose of the present study was to explore the refugees’ subjective experiences of war, resilience, and survival strategies, and to identify sociocultural factors facilitating or hindering their well-being. Overall, the findings demonstrated the cumulative effect of persistent adversity from pre-migration to post-migration phases and its ongoing negative impact upon the refugees’ well-being and adaptation. The results of this study shed light on how a new cultural context might serve as an opportunity to mitigate the refugees’ stressors or lead to re-traumatization through increased disconnection from the larger community.

Pre-to-Post-Migration Challenges

The current study captured the complex traumatic experiences of refugees including violence, destruction of communities, and discrimination leading people to flee their homelands. In addition, participants in this study spoke to how the experiences of marginalization and humiliation in their own community back home pose threats to their dignity and social and spiritual identity.
The findings of this study showed that discrimination or cultural racism become barriers to reaching social support networks and adjustment to society. Similar to previous research outcomes (Ives, 2007; Stewart et al., 2008), the interviews also revealed that insufficient informal support from limited social networks, lack of financial stability, language difficulties, lack of awareness of services (particularly for asylum seekers), isolation, cultural racism, xenophobia, and unfamiliarity with welfare systems worsen obstacles to accessing social services. Additionally, as Perez Foster (2001) stated, such post-migration living conditions compound the distress resulting from assaults experienced in immigrants’ home countries and subsequently during transit. In this study, participants’ accounts reflected how these stressors are cumulative such that they become threats to adjustment and accessing resources, which leaves participants with the sense that “home is nowhere”: they feel stateless while coping with a “shattered sense of home and community.” Post-migration time is critical for recovery. Yet, when it failed to foster the refugees’ adjustment and healing, the refugees became vulnerable to re-traumatization due to post-migration related stressors alongside existing and unprocessed pre-migration trauma. Akhtar (1999) asserted, “The suddenness of his [refugee’s] departure precludes anticipatory mourning and complicates subsequent adaptation” (p. 126). Therefore, it is important to situate refugees’ well-being in a resettlement country in the context of an ongoing dilemma between the sense of loss and change as well as the tension between mourning and reparation. When the refugees’ expectations for safety and belonging are not fulfilled, they become more vulnerable to further disappointment and psychological stress, which can interfere with their help-seeking attitudes and healing process.

Coping in Post-Migration Context

This study demonstrated the intertwined relationship between resource access, freedom, and psychological wellbeing. Psychological and psychosocial challenges are connected in a feedback loop. Psychological wellbeing is not only dependent on individual factors but also on social factors and the opportunities in the resettlement. Similar to previous research findings (Goodman et al., 2017; Nickerson et al., 2011), this study also shed light on displacement stressors including loss of financial stability, isolation, and pain of separation described by participants as “Life starts at less than zero.” Yako and Biswas (2014) noted that isolation, language difficulties, inadequate housing, and not being able to use their job skills lead to further stress and hopelessness for the future. In the face of these ongoing difficulties, which follow the adverse experiences that characterized pre-migration, survival becomes an art and fraught with an emotional cost: psychological and health problems.

Future Orientation, Intercultural Connection, and Pride

Another unique contribution of this study was to present refugees’ future-orientation and motivation for survival, which has not received much attention from researchers. While navigating the space between mourning the loss of community and familiar culture, participants highlighted their future-orientation and strivings to rebuild a community and social support networks. Also, participants who were able to feel connected seemed to be able to bounce back better and become more motivated to seek out resources (e.g., social or spiritual).
Participants in this study indicated that intercultural connection not only increased their sense of inclusion, adjustment, and openness but also helped them work on their own prejudices toward others. Therefore, in the present study, cultural integration with diverse communities made a contribution to the expansion of participants’ definitions of social support and community by adding a layer that suggests participants are developing a concept of and desire for “co-existing peacefully”. Such encounters among and across communities are likely to contribute to refugees’ sense of home and safety (Ager & Strang, 2008) while preserving their identity (Zetter et al., 2006). These results are in line with previous studies and literature on refugee experiences, insofar as social support from ethnocultural communities (Lie, 2002; Schweitzer et al., 2006; Sossou et al., 2008) and family play a significant role in participants’ wellbeing and motivation for survival.
As a unique finding in this study, having pride in their religious values while striving to co-exist with diverse people motivated participants to represent Muslims in a positive way while simultaneously feeling the pressure of being associated with terrorism and oppression. They grappled with having to renegotiate their identity in light of the prejudices with which the new community treats and perceives them. This finding contributes to the understanding of the complexity and ongoing dialectic of refugees’ experiences as to their spiritual identity in differing social contexts and interpersonal encounters. Across the interviews, participants shared particular values in Islam, such as patience, waiting for Divine Justice, gratitude for survival, hope, and the importance of familial and social interrelatedness, enabling them to cope with various war-related and sociocultural challenges. In addition, these values helped them make meaning of trauma. As has been reported in other studies (Bhugra, 2004; Goździak & Shandy, 2002; Green, 2014; Schweitzer et al., 2007), spirituality and religious rituals were identified as protective factors, and religious affiliation might contribute to social networking so that refugees can benefit from social, informational, and financial support (Schweitzer et al., 2007).
Although cultural and personal pride have been explored in many refugee groups such as Bosnian (Gibson, 2002), Liberian (Clarke & Borders, 2014), and Karen (Harper, 2017) refugees, Iraqi and Syrian refugees’ cultural pride has not been given much attention from researchers. Based on the participant interviews in the present study, cultural and personal pride were strong resilience factors. Participants shared a strong desire to be respected for their cultural identities and practices and to be perceived as normal human beings rather than being perceived as a threat or burden to society. Their survival in the war zone and in the US emerged as a source of resilience and pride that leads to identity transformation because witnessing their own survival capacity becomes strongly tied to their personal identity.

Implications for Clinical Practice and Policy

The findings drew attention to the crucial importance of a multifaceted approach to service delivery for refugees. During interviews, participants were asked if they can offer recommendations for mental health providers working with refugees. They requested more outreach programs for hidden refugees and asylum seekers, defined as those who are unable to access social resources and networks due to structural barriers (e.g., lack of social networks, unfamiliarity with the system, language difficulties). Thus, one way to alleviate refugees’ contextual stressors could be to first develop outreach programs in communities. Particularly, local community centers and mosques would play a critical role in terms of outreach to social services (i.e., legal, mental health, and language courses).
Because of the prevalence of trauma, another important recommendation voiced by several refugees was the need for more mental health outreach programs to educate refugee communities and to destigmatize mental health challenges. Therefore, community centers that are built-in communities would play a key role in accessing refugees who have mental health needs. In addition, mental health providers should have the capacity to collaborate with organizations (e.g., welfare, legal, education resources, etc.), as well as community and religious centers to advocate for clients. While doing that, mental health providers should support the agency of their clients.
Another recommendation offered by participants was to improve the quality of services provided in community centers through offering job training programs, increasing the quality of language classes, and interpretation lines while providing psychological treatments.
Community centers need further government assistance to meet refugees’ multilayered needs.
The experiences of the participants in this study showed refugees adjusted better when they were provided resources, particularly job and ESL classes targeted to develop their sense of agency and independence.
Based on the present findings, incorporating advocacy-based and culturally-responsive psychosocial approaches (e.g., facilitating how to navigate community resources) into psychological approaches would be a useful way of facilitating adjustment and resilience in a resettlement country. Addressing immediate psychosocial/daily stressors (e.g., employment, housing, health, etc.) and restoring social bonds that enhance emotional and material help might improve the wellbeing of refugees (Drožđek, 2015; Lie, 2002; Miller & Rasmussen, 2010). Since resilience takes a different form within and across cultural groups, traditional psychotherapeutic approaches warrant modifications while working with ethnic minority clients. Advocacy- and empowerment-based approaches were advised by previous researchers for clinicians working with refugees and ethnic minority groups (Al-Roubaiy et al., 2013; Clarke & Borders, 2014; Holcomb-McCoy & Mitchell, 2007; Khawaja et al., 2008). Considering the results of this study highlighted the refugees’ loss of community and their desire to preserve their cultural values, helping them with community building would be a crucial step for advocacy. This can entail assisting clients with meeting their social needs and facilitating connections among community members that can pave the way for building a social support network and resource sharing. Having an intact sense of community would facilitate community resilience and healing for this community. Community integration programs might center around schools and families. For example, schools can provide more opportunities for intra- and inter-cultural connections for families. This fosters a sense of community by establishing social support networks and further increasing refugees’ integration with the larger community. Developing connections among community members not only increases the likelihood of information and resource sharing but also creates opportunities for collaboration across advocacy efforts on a larger scale (Goodman et al., 2017).
As multiple researchers suggested (Bolton & Betancourt, 2004; Miller & Rasmussen, 2010), addressing post-migration stressors among refugees’ lives ought to be a priority in developing mental health policy, distributing limited resources, and designing interventions. On a policy level, resettlement programs should incorporate culturally-responsive, trauma-informed mental health assessments including of pre-to-post-migration stressors. Mitigating social and material ecologies might lessen the need for more resource-intensive mental health services (Bolton & Betancourt, 2004). According to Vesely et al. (2017), the development of resilience must be evaluated in light of immigration policies and laws and the ways in which these regulations perpetuate ongoing poverty, limited economic opportunities, insufficient housing, repatriation, and family separation, which result in systemic violence such as racism and anti-immigrant practices leading to further othering and patronizing. Along the same lines, Kirmayer et al. (2009) stated:
Resilience depends on complex interactions within systems, including physiological and psychological processes within an individual and social, economic, and political interaction between individuals and their environment, or between a community and the surrounding ecosystem and the larger society…. The government can play a useful role in facilitating community resilience by creating cross-cutting programs and responses, decentralizing power, and ensuring that people working in communities can work together without impediments. (p. 102-103)
It is crucial to recognize systems-level discourses impact refugee and asylum policies, investment in the resettlement process, provision of services, and funds allocated for refugee agencies and health services. These social forces also impact the reception of refugees by the members of a host country. Therefore, anti-Islamic and anti-refugee/immigrant discourses underlying macro-level oppressive systems should be challenged and mental health providers and researchers should advocate for systemic level changes to practices and policies (e.g., discrimination, xenophobia, racism, and anti-Islamic sentiments).
Clinical practice should prioritize increasing awareness about both implicit and explicit discrimination and systemic racism at the systemic and interpersonal levels. Mental health providers, when it is relevant, should attempt to enhance clients’ awareness of contextual stressors (e.g., oppression, discrimination) given that refugees are at risk of exposure to marginalization by host-society citizens (Griffiths, 2001). Hence, it is vital that clinicians working with refugees must be aware of their own cultural prejudices and misconceptions about refugees’ cultural backgrounds (Kira & Tummala-Narra, 2014). They should provide culturally-responsive care, which entails re-examining their own biases and honoring refugees’ cultural expressions of their feelings and healing resources. Then, therapy can be a fertile ground for trauma processing and healing.
Based on extracts from participants in this study, in terms of therapeutic encounters, participants shared their desire to tell their stories and to be heard compassionately by a provider. For these refugees, telling their own story did not only allow for unpacking culturally-meaningful ways of sharing trauma and resilience but also conveyed an openness to establishing a bond with a therapist. Therefore, treatment approaches that allow for the exploration of subjective experiences, cultural representations, and the meanings each person draws from their experience would enrich clinical interventions and treatment planning. Furthermore, exploration of cultural representations uncovers the roots of refugees’ suffering, healing resources, notions of social connectedness, and spirituality. Refugees’ narratives revealed a context that offers a framework for building connections between the present and the past, and for reflecting on the meaning of painful experiences (Sturm et al., 2007). In addition, Tummala-Narra (2007) suggested that with regard to the contribution of an individual’s cultural context to the processing of trauma, therapists need to address both internal (i.e., intrapsychic) experience and external (i.e., family, community) consequences of individual and collective traumatizing experiences.
Consequently, the study highlighted the crucial importance of the eco-systemic perspective in the understanding and support of refugees’ wellbeing. It calls for more systemic support for refugees and social policy improvement for developing culturally-responsive interventions and community-based resources, which would allow for the cultivation of community engagement and resilience.

Recommendations for future research

The present qualitative study used an eco-systemic approach to resilience in the face of cumulative trauma to highlight the subjective experiences of refugees as they relate to how they strive for individual, familial, and community survival. Further research should explore what adds to cumulative trauma as well as what leads to refugees’ positive development when facing a tremendous amount of adversity. The current findings also emphasized the need for further research on resilience factors in the context of the ongoing impact of traumatic experiences. Given that refugee communities differ from each other in nuanced ways as to stressors and coping, the exploration of these variables among Iraqi and Syrian refugees would inform interventions and treatment approaches in the service of their well-being in the US. Further research should explore culturally-relevant expressions of mental health in describing distress and coping for this community. This would help to expand Western models of mental health conceptualizations in a way that is responsive to these communities.
Future research needs to examine the effectiveness of services provided by existing refugee community centers and agencies, which would inform system- and policy-level improvement of the services provided in these centers. More specifically, the use and quality of services, treatment outcomes, accessibility to these services, and quality of interpreter services can be focusses of future work. In addition, the exploration of barriers to refugees’ engagement with services should be done. The current study revealed that there are many refugees living with trauma who are not engaged with any mental health resources. Therefore, the exploration of the barriers to mental health among refugees would inform outreach efforts. Future research endeavors should utilize community-based participatory research models allowing for refugee communities and researchers to develop partnerships, which would increase the inclusion, participation, and agency of refugee communities..

Limitations and Strengths

This study is not a representation of all Iraqi and Syrian refugees. Even though the sample size was sufficient for an IPA study, it was not balanced as to country of origin and legal status. There was a significant limitation related to sampling since only one out of six participants was from Syria and only one asylum seeker participated in the study. Given that IPA usually is used for a homogeneous sample (Smith & Osborn, 2007), having one only Syrian participant and one asylum seeker were limitations of this study. In comparison with individuals with refugee status, asylum seekers are more limited in terms of benefiting from social resources and deal with generally different uncertainties about their future.
Another limitation was that three out of six interviews were conducted through bilingual interpreters. Even though interviews were carefully transcribed and translated into English, subtle meanings and cultural expressions might have been lost during this process. The researcher’s biases, assumptions, identities, and worldviews might have exerted some influence on the interpretation and communication of the findings. To minimize the influence, the researcher utilized bracketing, reflective journaling, and research supervision from three diverse auditors who were engaged in reflexive attitudes. Due to logistical constraints, the researcher was not able to conduct member checking, which could have increased the credibility of the data (Cohen & Crabtree, 2008). In terms of strengths, semi-structured interviews focused on specific topics in-depth and allowed for flexibility in the topics emerged (Smith & Osborn, 2003). Another strength of the present study was not to require English-language proficiency as an inclusion criterion. This was to provide participants an opportunity to express their experiences in their native tongue. This also led to the access of linguistically-disadvantaged participants.

Conclusion

The present study explored Iraqi and Syrian refugees’ subjective experiences of trauma and resilience in the context of lasting impacts of war and also of resettlement. The findings uncovered the complexity of refugee experiences including exposure to continuous traumatizing experiences from pre-migration to post-migration phases rife with a shattered sense of home and community. It is critical to understand how the post-migration context might facilitate or impede refugees’ adaptation. The findings illuminated the mutual interaction between resilience-building and a social context promoting social inclusion, mutual recognition between refugees and locals, and culturally-meaningful expressions of resilience and trauma processing, all of which can support refugees’ social integration and collective healing. Implications presented for practice, policy, and research presented could inform psychological and psychosocial treatment implications for refugees in resettlement countries.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This manuscript was supported by the Social Science Research Council Transdisciplinary Dissertation Development Program, University of Massachusetts Boston (recipient B. Ipekci).

Acknowledgments

I would like to express my special thanks to Drs. Rosalyn Negron, Usha Tummala-Narra, and Amy Cook for providing me support at various stages of this study. I also extend my sincere gratitude and appreciation to the participants of this study.

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