PTSD, Optimism, Religious Commitment, and Growth as Post-Trauma Trajectories: A Structural Equation Modeling of Former Refugees

Hannah E. Acquaye

Refugees report several mental health challenges associated with pre-, peri-, and post-flight conditions. Some of these challenges include fear, anxiety, hypervigilance, hyperarousal, and nightmares—symptoms that could meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Despite these challenges, some refugees also report psychological growth with nomenclature like post-traumatic growth, resilience, and benefit-finding. This study examined the directional relationship among war-related events, optimism, PTSD, religious commitment, and growth. Prior studies in traumatized samples have demonstrated that PTSD and growth can occur concurrently, while optimism and religiousness may enhance growth. The hypotheses undergirding this study posited that participants in this non-Western population could demonstrate concurrent PTSD and growth, while those with higher levels of optimism and religiousness would exhibit increased levels of growth compared to those with lower levels. For a sample of 444 former refugees, hypotheses were theoretically modeled to identify whether the data fit the model. Inspection of fit indices provided support for the hypothesized model. Implications for professional counselors are included and recommendations for future research are provided.

Keywords: refugees, post-traumatic growth, PTSD, optimism, religious commitment

Professional counselors who work with refugees, specifically refugees resettled as a result of war or conflict, hear their clients share the harrowing experiences encountered on their journeys toward safety (Clay, 2017; International Counseling and Community Services [ICCS], 2015). War-related internally displaced persons (IDPs) and refugees, more than immigrants or other displaced people, report suffering inhumane acts like ethnic cleansing (United Nations, 2017). Others describe running through forests to avoid warring tribal factions, defending themselves against wild animals and forces of nature, and going without food for days (Betancourt et al., 2015). These experiences can be traced through the precipitating events leading to their flight, the flight progression, and finally the pathways to resettlement. Each of these processes incurs a traumatic adjustment. Clients among this population have reported diverse somatic symptoms and physical challenges (Cline, 2013; Edge, Newbold, & McKeary, 2014), as well as difficulties associated with basic physiological needs (e.g., food, water, shelter; ICCS, 2015; Maslow, 1970). They have described symptoms that meet the criteria for diagnosing post-traumatic stress disorder (PTSD; American Psychiatric Association [APA], 2013; Zerach, Solomon, Cohen, & Ein-Dor, 2013), depression (APA, 2013; Praetorius, Mitschke, Avila, Kelly, & Henderson, 2016), anxiety (APA, 2013; ICCS, 2015; Praetorius et al., 2016), and bereavement (APA, 2013; ICCS, 2015).

Dated research has examined these conditions in refugees through the lens of psychopathology; however, studies spanning the past three decades have emphasized the salutogenic components of post-trauma experience (Antonovsky, 1987). Salutogenesis originates from the Latin salus, meaning “health,” and was developed by Antonovsky (1987), who suggested that when people encounter stress, not all will have negative health outcomes. He therefore entreated researchers to use a strength-based lens instead of a deficit-based one in understanding human reactions to stress (Antonovsky, 1993). Although a strength-based perspective of post-trauma paths was not a new concept (Splevins, Cohen, Bowley, & Joseph, 2010), it had not yet been systematically and scientifically catalogued in the academic literature until the early 1990s. Since then, there has been a plethora of studies addressing people’s strengths and resources despite hardships (Affleck & Tennen, 1996; Bonanno, 2004; Joseph & Linley, 2005; Tedeschi & Calhoun, 1996). Proponents of strength-based post-trauma paths have applied their unique nomenclature to signify the strength and benefit that clients report obtaining despite their encounters with diverse traumatic events. Terminologies such as post-traumatic growth (PTG; Tedeschi & Calhoun, 1996), benefit-finding (Affleck & Tennen, 1996), stress-related growth (Park, Cohen, & Murch, 1996), thriving (O’Leary & Ickoviks, 1995), resilience (Bonanno, 2004; Connor & Davidson, 2003), and adversarial growth (Joseph & Linley, 2005) have been associated with this concept of meaningful positive change from a traumatic experience. The common theme among these writers is that there can be positivity and strength in places in which we expect weakness, illness, and pathology. Subsequent sections of this paper will address various outcomes known to follow a traumatic experience, connect them to theories associated with these experiences, and extract hypotheses to be tested.

Aftermath of Traumatic Experiences

When humans encounter traumatic experiences, they try to make meaning of them by using available resources. While some of these resources can be physical, others are psychological and emotional. Psychological and emotional resources could include inner narratives, religious communities, spirituality, connections with significant others, and nature. Optimism and religious commitment could also be included in the psychological and emotional resources that clients use to make meaning of their war-related traumatic experiences.

Trauma and psychopathology. Trauma is described as challenging experiences that push individuals beyond their normal ability to cope (APA, 2013; Ball & Stein, 2012). Trauma is ubiquitous, with research reporting that 60–80% of adults do experience at least one traumatic event (Simiola, Neilson, Thompson, & Cook, 2015). Traumatic experiences include robbery; terminal illness, for both the sufferer and loved ones; flooding; earthquakes; terrorist attacks; rape; and war-related events, for both civilians and the military. While many people who go through traumatic experiences may not have long-term negative repercussions, between 10–50% report various mental health challenges (Friedman, Resick, & Keane, 2014).

Studies on traumatic experiences in adults have collectively established that after a traumatic encounter, people report and exhibit various symptomatology of PTSD, including avoidance, intrusive thoughts, negative alterations in cognition and mood, and the tendency to live recklessly (APA, 2013). Individuals who experience the direct effects of these traumatic events are not the only ones affected. Research has identified long-lasting effects on significant others (Lahav, Kanat-Maymon, & Solomon, 2016; Zerach, 2015) and helpers (Baum, 2014) because of the regular contact with traumatized individuals. Terms like secondary traumatization, vicarious traumatization, and compassion fatigue (Jenkins & Baird, 2002) have been used to describe the reaction to emotional demands from trauma survivors’ frightening and shocking images. Accordingly, significant others and helpers may sometimes react as if they themselves have gone through the traumatic events.

Based on the literature on war-related military and civilian populations, it is hypothesized that at least 10% of participants in the present study would meet the criteria for PTSD, with a cut-off point of 33 on the PTSD assessment instrument (Weathers et al., 2013).

Trauma and psychological growth. Another aftermath of a traumatic event is PTG (Tedeschi & Calhoun, 1996). The processes of rumination, meaning-making, and growth take place after the perceived shaking of a traumatized person’s worldview (Calhoun & Tedeschi, 2014), and eventually the person is able to put the event into perspective and gain a level of growth from the experience. In the words of the proponents, “PTG involves internal changes that can set the stage for changed behavior. There is variation in the degree to which personal changes can be noticed by others in terms of actions taken” (Tedeschi, Calhoun, & Cann, 2007, p. 399).

As a construct, PTG is seen as a legacy of trauma, containing “at least three broad categories of perceived benefits” identified by individuals and sometimes by the people in their lives (Tedeschi & Calhoun, 1996, p. 456). The three categories include changes in (a) self-perception, (b) interpersonal relationships, and (c) philosophy of life. PTG occurs when a person endures a traumatic event of seismic proportions that destroys some pivotal part of the person’s worldview (Tedeschi & Calhoun, 2004). Theoretically, PTG has been conceptualized as both an outcome and a process (Zoellner & Maercker, 2006). PTG as an outcome represents substantial positive changes in cognitive and emotional life that could be the opposite of PTSD. The constructs are not two ends of the same continuum; PTG does not imply either an increase in well-being or decrease in distress. Although PTG and PTSD are distinct and independent constructs, prior studies suggest that both phenomena can coexist in traumatized individuals (Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003). These constructs have both been observed to be higher in females than males, even when trauma experiences are greater in males (Ball & Stein, 2012; Friedman et al., 2014).

Based on these findings, it is hypothesized that both male and female participants can exhibit cohabiting symptoms of distress and growth, with females exhibiting higher PTSD and PTG scores. For the sake of this study, PTG is defined as the collective expression of growth and benefit that clients claim to gain after the type of cataclysmic event that challenges their existing worldviews (Calhoun & Tedeschi, 2014; Tedeschi & Calhoun, 1996, 2004).

Optimism. The concept of optimism is grounded in theory and research (Carver, Scheier, & Segerstrom, 2010) that explores what motivates people and how motivation is expressed behaviorally. Optimism is the belief, hope, and confidence that good things will happen in a person’s life instead of bad things (Carver & Scheier, 2002; Rand & Cheavens, 2012). Carver, Scheier, Miller, and Fulford (2009) stated that optimists are not disillusioned, but rather they acknowledge the existence and importance of adversity and choose to identify both internal and external resources that can help them cope.

Relationships between optimism and trauma have been examined in diverse groups of individuals who have encountered adversity. Research has demonstrated that individuals who perceive they are able to cope have a positive outlook on life and expect good things to happen because they can control their environments (Benight & Bandura, 2004). There also is evidence that a person’s disposition to optimism may be attributable to certain environmental factors (Broekhof et al., 2015). In the Broekhof et al. (2015) study, optimism was found to be inversely related with all subtypes of childhood trauma; however, important sociodemographic, clinical, and lifestyle characteristics moderated this inverse relation. Moreover, literature relates optimism to positive mood and good morale (Peterson & Steen, 2012). Positive mood and good morale lead to perseverance and effective problem solving (Fredrickson, 2001), which in turn lead to overcoming negative traumatic symptoms. People who are generally optimistic often explain causes of events that happen to them and use these explanations as a stepping stone toward growth from adversity (Peterson & Steen, 2012).

Additionally, optimistic or hopeful people are able to make informed decisions on their health based on provided information (Rand & Cheavens, 2012; Scheier & Carver, 1985). In a study on health and hope, high-hope women could perform better on a cancer facts test than their low-hope counterparts, even when controlling for previous academic performance. Not surprisingly, hope was inversely related to intentional attempts at self-harm because self-harm efforts are incompatible with the physical health goals that hopeful and optimistic people strive to achieve. Although there are a few scattered studies on Asian populations, there are limited studies within non-Western populations on how optimism and pessimism relate to quality of life (Chang, Sanna, & Yang, 2003); thus, the present study will contribute to the literature by testing the construct of optimism across cultures.

Consequently, it is hypothesized that participants who report higher optimism, despite their shared traumatic experiences with those who report lower optimism, will report higher PTG scores.

Religious commitment. Religiousness, religiosity, and religious commitment are constructs that are often confused and sometimes used interchangeably with spirituality (Brownell, 2015; Pargament & Mahoney, 2012; Pargament & Maton, 2000). Spirituality is a continuous search for the sacred (Batson, Schoenrade, & Ventis, 1993). Religion can also be expressed as human practices and behaviors concerned with a search for the sacred—a search founded on dogma, traditional practices, and institutional regulations (McIntosh, Poulin, Silver, & Holman, 2011; Pargament & Maton, 2000). Spirituality is an individual experience and does not necessarily work in an institutional setup like religion does.

Even though past research has not distinguished between religiosity and spirituality (Pargament & Mahoney, 2012), current researchers are consistently contrasting the two, with some asserting that religion is dogmatic, restrictive, and institutional, whereas spirituality is subjective, personal, and life-enhancing (Brownell, 2015; King & Crowther, 2004; Pargament & Mahoney, 2012; Prati & Pietrantoni, 2009). In many studies, participants often identify themselves as both religious and spiritual, which is not surprising because both religiosity and spirituality can be expressed individually as well as socially, and both can either hinder or foster well-being (Pargament & Mahoney, 2012).

In the discourse on PTG, religious coping is identified as a strong predictor of growth and partially shares the same descriptions as spirituality (McIntosh et al., 2011; Prati & Pietrantoni, 2009). However, Joseph (2011) cautioned against the assumption that higher PTG indicates higher religiosity. His caution has received corroboration from a qualitative study in Australia (Barrington & Shakespeare-Finch, 2013), in which participants in a grounded theory study described a decrease in religious commitment as indicative of psychological growth. The researchers surmised that participants whose trauma was related to their religious faith probably needed a shift in worldview about religion. Such a shift sometimes required lowered religious commitment to ensure psychological growth. This Australian study is in line with Joseph’s (2011) observation that growth could mean a decrease in religious commitment for one person and an increase for another.

In another research study, a sample of 54 students who had experienced major traumatic events took part in a study that examined the association between event-related rumination, pursuit of religion and religious involvement, and PTG (Calhoun, Cann, Tedeschi, & McMillan, 2000). Despite the study’s inability to determine longitudinal direction of effect, results provided evidence that openness to religious change independently predicted the amount of reported growth in the participants. In yet another study on the role of spirituality and religiosity in the physical and mental health after collective trauma, religiosity and spirituality were found to be highly correlated (McIntosh, et al., 2011). Religiosity, like spirituality, predicted higher levels of positive affect. Interestingly, religiosity, but not spirituality, predicted lower incidence of mental ailments.

Overall, with respect to physical health, religiosity was associated with decreased incidence of musculoskeletal ailments three years after the traumatic experience. Psychologically, religiosity was correlated with lower incidence of mental ailments, positive affect, and fewer cognitive intrusions three years after the 9/11 attacks. In sum, religious commitment has been found to enhance psychological growth after a traumatic experience. It is therefore hypothesized that participants in this study who endorse greater levels of religious commitment will have higher PTG scores.

There are contradictory results concerning the relationship between PTSD symptoms and PTG in traumatized populations. While some studies reported a positive relationship between PTG and PTSD (Hussain & Bhushan, 2011), others reported a negative relationship (Kimhi, Eshel, Zysberg, & Hantman, 2010). Proponents of the positive relationship suggested that higher distress symptoms lead to high growth. Contrarily, those who reported the negative relationship reported that distress predicts growth. Other studies have found no relationship between distress and PTG (Widows, Jacobsen, Booth-Jones, & Fields, 2005). Yet, others have identified a curvilinear relationship (Kleim & Ehlers, 2009; Kunst, 2010), in which results have indicated that higher scores of PTG are related to mild PTSD symptoms and vice versa.

Post-traumatic distress and growth need not be mutually exclusive. Results of several studies have indicated that it is possible for both PTSD symptoms and positively perceived effects of the trauma experience to coexist, even in war-related traumatized populations (Powell et al., 2003). In these studies, participants may have experienced the trauma to a greater degree; however, they reported that using their internal resources, like optimism and spirituality, contributed to their positive perception of the experience. Based on the literature reviewed, this study is situated on the following hypotheses:

Between 10–50% of participants will meet the diagnostic criteria for PTSD. Furthermore, both males and females will exhibit co-occurring PTSD and PTG, with females showing higher scores in both PTSD and PTG than males.

Those who report high optimism, despite the war-related experiences, will have higher PTG scores than those with low optimism.

Those with high optimism will also score high on religious commitment.

Those with high religious commitment will score higher on PTG.

In sum, the objective of this paper was to identify post-traumatic trajectories within a sample of former war-related IDPs in a developing country. In the process of assessing the trajectories, the study will also establish reliability of Western-based instruments in a non-Western population.



Participants for the study were adults from the West African country of Liberia who, because of the decade-long civil conflict, became IDPs or refugees. The only West African country not colonized by any of the European colonial masters (i.e., Britain, France, and Portugal), Liberia became a known republic in the 1820s. This occurred when freed slaves were brought from the Americas to the coast of Liberia. The indigenous people inhabiting the land prior to the arrival of the freed slaves were dissatisfied with how the latter, referred to as Americo-Liberians, governed the land (Gerdes, 2013; Verdier et al., 2008). This dissatisfaction festered until its culmination in an over decade-long civil conflict (1989–2003). It is estimated that more than 10% of the population died in the civil conflict (Verdier et al., 2008).

This study used a multi-stage sampling method (Fraenkel, Wallen, & Hyun, 2015). In the initial stage, criterion sampling was used for adult Liberians who were known to be former refugees and IDPs. The number of participants gained after the first sampling stage was less than the expected 500 participants. Snowball sampling was therefore employed to reach the target sample size. Because Liberia has no database of residents, participants had to be contacted face-to-face at community meetings, colleges, churches, and mosques.


All procedures of the university’s institutional review board were followed; informed consent

was provided in both verbal and written form and undertaken via individual and group formats. Additionally, local healers and pastors were introduced to participants in anticipation of traumatic memories culled up from the questions on some of the instruments. The incorporation of local healers and pastors was consistent with research in similar areas and cultural practices (Van Dyk & Nefale, 2005).

Procedural criteria for inclusion were determined prior to data collection. Participants had to be 18 years of age or older, able to read and understand English at the eighth-grade level, and old enough during the war to have remembered the flight. Participants were thereafter given the informed consent and research package, which had been printed and numbered. Participants who preferred to complete the instruments in group format stayed after class or a church service for this activity. Others chose to take it home and bring it back to the researcher at an agreed-upon place. Announcements were made to participants to provide contacts they could recommend who fit the procedural criteria.

When all of the 500 packages had been distributed, data collection stopped. Of packets given, 444 were completed and returned, demonstrating an 88.8% response rate. Statistical power was estimated at .80 for this model using the SAS syntax provided by MacCallum, Browne, and Sugawara (1996). Based on this syntax, a sample size of 200 (df = 179) was considered adequate. Our sample size of 444 was therefore acceptable for an effect size of .80.


Six instruments were given to participants. They were the Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), the War Trauma Screening Index (WTSI; Layne, Stuvland, Saltzman, Djapo, & Pynoos, 1999), the Revised Life Orientation Test (LOT-R; Scheier, Carver, & Bridges, 1994), the Religious Commitment Inventory (RCI-10; Worthington et al., 2003), the Post-Traumatic Stress Checklist for DSM-5 (PCL-5; Weathers et al., 2013), and a demographic questionnaire.

PTGI. The PTGI is a 21-item scale that measures positive changes that occur in people’s lives because of crises. The scale comprises five subscales (factors). The subscales and sample questions are: (a) relating to others (e.g., I more clearly see that I can count on people in times of trouble); (b) new possibilities (e.g., I developed new interests); (c) personal strength (e.g., I know better that I can handle difficulties); (d) spiritual change (e.g., I have a stronger religious faith); and (e) appreciation of life (e.g., I can better appreciate each day). Each item is rated on a 6-point Likert-type scale ranging from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). The range of possible scores a participant can obtain is from 0 to 105. The PTGI has demonstrated high internal consistency (α = .90; test-retest reliability = .71) and acceptable construct validity (Calhoun et al., 2000). The instrument is not correlated with measures of social desirability (Baker, Kelly, Calhoun, Cann, & Tedeschi, 2008). PTGI scores for the Liberian sample demonstrated high internal consistency (α = .93), providing support for the cross-cultural nature of the instrument in consistently measuring the construct of PTG.

WTSI. The WTSI is a 35-item dichotomously scored self-report instrument. The instrument was used to measure participants’ experiences during the Liberian war, and it was chosen because of its simplicity in assessing what participants saw, touched, or had done to them. Sample questions include, “During the war, did a bullet ever come so close to you that you could have been seriously hurt or killed?” and, “During the war, did you eyewitness someone being killed?” The highest score a person can obtain is 35. There is currently no reported psychometric evaluation of this instrument. On a cursory look, the instrument seems to be divided into broad categories consisting of (a) attack to self; (b) attack to loved one; (c) forced displacement; and (d) witnessing trauma. These four factors were therefore used as part of the structural equation modeling (SEM) procedure. Reliability analysis of the 35 items for the Liberian sample demonstrated high internal consistency (α = .90).

LOT-R. The LOT-R is a 10-item scale that evaluates dispositional optimism. The instrument has four fillers (items 2, 5, 6, and 8), thereby leaving only six items to be used for analysis. Three items are reverse coded (items 3, 7, and 9) before undertaking any analysis. Each item is rated on a 5-point Likert-type scale, ranging from 0 (strongly disagree) to 4 (strongly agree). Sample items include “In uncertain times, I usually expect the best” and “If something can go wrong for me, it will.” The LOT-R has acceptable internal consistency (α = .78), test-retest reliability (α = .60–.79), and discriminant (r =.48–.50) and convergent (r = .95) validity (Scheier et al., 1994). Reliability of the 6-item scale in the Liberian sample was modest (α = .49).

RCI-10. The RCI-10 measures the degree to which a person stands up for his or her religious values. The 10-item scale is measured on a 5-point Likert-type scale, ranging from 1 (not at all true of me) to 5 (totally true of me). The RCI-10 has two factors—intrapersonal and interpersonal religious commitment. The intrapersonal religious commitment assesses an equivalent of personal commitment not related to the social component of religious faith. Interpersonal, on the other hand, measures the social component associated with organized religious faith. Sample items include “Religious beliefs influence all my dealings in life” and “I spend time trying to grow in understanding of my faith.” A cut-off score of 38 and above is needed to identify a highly religious person. Evidence indicates that people who score more than one standard deviation above the mean view the world in terms of their religious worldview (Worthington et al., 2003). Evidence of reliability for the norm groups was high, and both construct and criterion-related validity were similarly high (Worthington et al., 2003). Internal consistency for the Liberian sample in this study was acceptable (α = .84).

PCL-5. The PCL-5 measures distress symptoms after a traumatic experience. The 20-item instrument is ranked on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). The scale comprises four subscales, consistent with the DSM-5 PTSD Clusters B, C, D, and E. The subscales and sample questions are: Cluster B, or Intrusion (e.g., repeated, disturbing, and unwanted memories of the experience); Cluster C, or Avoidance (e.g., avoid memories, thoughts, or feelings related to the experience); Cluster D, or Negative Alterations in Cognition and Mood (e.g., having strong negative feelings such as fear, horror, anger, guilt, or shame); and Cluster E, or Alterations in Arousal and Reactivity (e.g., taking too many risks or doing things that could cause you harm). Psychometric properties for the instrument demonstrated high internal consistency (α = .91), two-week test-retest reliability (α = .95), and convergent validity (r = .87; Wortmann et al., 2016). Results of reliability analysis for the Liberian sample demonstrated a high internal consistency (α = .92).

Data Analysis

Data were analyzed with three programs. SPSS (version 24; IBM, 2016) was used for descriptive statistics to understand participants’ demographics. SPSS was used to assess reliability of instruments and to answer the first research question. Finally, SPSS was used to extract the correlation matrix that was the foundation of both the confirmatory factor analysis (CFA) and SEM. SAS (SAS Institute, 2015) and AMOS (version 23; Arbuckle, 2014) were used for both the CFA and SEM.

The Hypothesized Model

Figure 1 represents the hypothesized model based on hypotheses extracted from the literature.  It is hypothesized that all participants experienced the 10-year civil war. It is hypothesized that between 10–50% of participants will meet the diagnostic criteria for PTSD. It is also hypothesized that PTSD and PTG can co-occur in participants. It is further hypothesized that those who report higher optimism scores will have higher PTG scores. Finally, it is hypothesized that those who report higher religious commitment scores will have higher PTG scores.



Figure 1. The Hypothesized Model


With SEM, there are two basic variables—unobserved and observed (Schreiber, 2008). Unobserved variables are called latent factors and are graphically depicted with circles or ovals. Observed variables are called manifest variables and are represented graphically with squares or rectangles. Large circles in the graphic represent latent constructs, and small circles represent measurement errors (in observed variables) or disturbances (in equation measurement). Straight, single-headed arrows are indicative of unidirectional paths. The arrow starts from the independent variable and points to the dependent variable. A curved arrow connecting two variables indicates two variables expected to co-vary; however, no hypothesis is made about their causality (O’Rourke & Hatcher, 2013).

Finally, SEM comprises two components: a measurement model, also called CFA, and a theoretical or structural model (Schreiber, 2008). While the measurement model specifies the relationship of the latent to the observed variables, the structural model identifies specific relationships among the latent variables. The objectives of the SEM are to determine whether a theoretical model is supported by the data collected, and to test the hypothesized direct relationships between independent, or exogenous, variables and dependent, or endogenous, variables. The hypotheses testing in SEM consists of several analyses of variances and regressions occurring simultaneously. Through this, researchers also can test mediated relationships between variables and examine the reliability of items to latent variables in a single test.

Several fit indices are reported in SEM as a global examination of how well the collected data fit the hypothesized model (Hu & Bentler, 1998; Schreiber, 2008; Sivo, Fan, Witta, & Willse, 2006). Because of well-known problems of fit estimation using chi square (χ2) in large data sets, the Bentler’s Comparative Fit Index (CFI) was used with values at .95 or higher, indicating a good-fitting model (Hu & Bentler, 1998; O’Rourke & Hatcher, 2013; Sivo et al., 2006). An absolute index, the Standardized Root Mean Square Residual (SRMR), and a parsimony index, the Root Mean Square Error of Approximation (RMSEA), were used as indices assessing the difference between the proposed model and actual variances and covariances in the data. RMSEA values less than or equal to .06 and SRMR values less than or equal to .08 are preferred (Fabrigar, Porter, & Norris, 2010; O’Rourke & Hatcher, 2013; Sivo et al., 2006).


Demography of Participants

Participants’ ages ranged between 28 and 65 years. Many fell within the 31–40 year range (45.7%). More participants were male (70.9%) than female, and many were unemployed (63.7%). Of those who were employed, 34.0% earned less than US$720 a year. Family demographics were varied: 42.3% of participants were single, 30.0% were married, and 23.6% lived with their partners. Many participants (49.3%) had one or two children.

The majority of participants (89.2%) indicated they were displaced during the Liberian civil war. There was no follow-up question to identify how some participants could have stayed in their homes despite the reported rampage that affected the whole country (Verdier et al., 2008), so I can only speculate that they either did not read that question well or had a way to stay safe during the war. Of those who were displaced, 60.4% became internally displaced, while the rest became refugees in and out of Africa. Almost half (48.4%) of the former refugees and IDPs had returned to Liberia since the cessation of the war. Additionally, to assess participants’ reaction to the Ebola epidemic and its possible ability to trigger traumatic experiences (Doucleff, 2015), participants were asked to compare the effect of the epidemic to the effect of the civil war on their mental health. The majority (65.8%) indicated that they linked the epidemic to the war several times a day, a process that could re-traumatize those who may have undisclosed PTSD symptoms.

Results From Hypotheses

The first hypothesis proposed that between 10–50% of participants in the study will meet the diagnostic criteria for PTSD (as measured by PCL-5), as well as co-occurring symptoms of distress and growth based on gender. Results of the descriptive statistics indicated that the majority (351; 79.1%) met the criteria for PTSD. Additionally, results from the one-way multivariate analysis of variance indicated that there was a statistically significant difference in post-trauma pathways based on gender (F[2, 376] = 6.016, p = .005; Wilk’s λ = .972, partial η2 = .028). Gender had a statistically significant effect on PTG (F[1, 377] = 6.354, p = .012, partial η2 = .017), but not on PTSD (F[1, 377] = 3.039, p = .082, partial η2 = .008). The PTG mean score for females (X̅= 84.49, sd = 16.030, n = 109) was higher than for males (X̅= 79.56, sd = 17.663, n = 270). Both males and females demonstrated co-occurring PTG and PTSD. Even though there was a statistically significant difference in PTG scores based on gender, there was no such difference in PTSD scores.

Hypotheses two through four were analyzed with SAS and AMOS to test the confirmatory model and the theoretical model, and to provide graphical representation. Missing data analysis was computed through the relationship between missing values on each variable of the 444 responses. Data were missing completely at random, and no statistically significant relationships were observed among variables. Listwise deletion within the correlation matrix reduced the sample size to 350.

The present analyses followed Anderson and Gerbing’s (1988) two-step procedure. The first step used CFA to develop a measurement model meant to establish an acceptable fit to the data collected. The second step was a theoretical model that was a modification of the measurement model. This modified model is a structural equation model representing the theoretical model of interest. The theoretical model was then tested and revised until a theoretically meaningful and statistically acceptable model was achieved.

The measurement model. A measurement model describes the nature of the relationship between several latent variables and the manifest indicator variables that measure those latent variables. The measurement model investigated in this study consisted of five latent variables corresponding to the five constructs of the post-trauma pathways model: War, PTSD, Optimism, Religious Commitment, and PTG (N = 350). Each of the five latent variables was measured by at least two manifest variables (Figure 2).




Figure 2.  The Confirmatory Factor Analysis (CFA) Model



The maximum likelihood estimation successfully converged in 40 iterations. The correlations table was consulted for multicollinearity; only one relationship was above .90. The relationship between war-related threat to self and intrapersonal religious commitment was .93. The fit indices indicated an acceptable fit of the data to the hypothesized structure. The CFI was .94, SRMR was 0.056, and RMSEA was .050, with a 90% confidence interval of .042–.058. All items loaded statistically significantly (p < .05) on the theorized latent variables and no modifications were warranted based on the values calculated (see Table 1). The squared multiple correlations, an indicator of reliability of items, seemed acceptable, except for some items loading onto the optimism factor. These results were unsurprising considering the low Cronbach’s alpha of the instrument in this sample.

The theoretical model. The 5-factor solution hypothesizing the directional relationship successfully converged in 29 iterations. Using the maximum likelihood estimation, evidence from the model suggested that the data did not fit the model as expected (CFI = .932, SRMR = 0.062, RMSEA = 0.052). Although all parameters within the model indicated statistically significant t-values, one of the paths linking two latent constructs was non-significant. The standardized path coefficient from religious commitment (F3) to growth (F5) was not significant (t = 1.87, se = 0.25, p = 0.06). Further, inspection of the squared multiple correlations table indicated that R-square values relating to the negatively worded optimism items (3, 7, and 9) were weak (< .25).

Revised model. To look for the best fitting model, the Wald test and the Lagrange multiplier tables were consulted. The Wald test provides information on parameters that can be dropped to improve the model. The Lagrange multipliers provide information on parameters to be added. Experts caution researchers to ensure that data-driven model modifications do not capitalize on chance characteristics of the sample data, as they have the tendency to produce a final model that is not generalizable to the population or to other samples (O’Rourke & Hatcher, 2013; Schreiber, 2008). Researchers are therefore encouraged to identify parameters that could be dropped from the model without significantly affecting the model’s fit, as it is generally safer to drop parameters than to add new parameters when modifying models (O’Rourke & Hatcher, 2013). The Wald test suggested the intrapersonal variable within the religious commitment factor be dropped. Even though that suggestion was deemed statistically feasible, it was not theoretically feasible. Furthermore, because of the problems associated with the negatively worded items in the optimism scale, the errors associated with those items were allowed to covary.

When the three errors were covaried, the model was reanalyzed. The maximum likelihood successfully converged in 19 iterations. The revised model fit the data well (CFI = .953; SRMR = 0.049; RMSEA = 0.044). All path coefficients were nontrivial and statistically significant (i.e., t > |1.96|). Figure 3 depicts standardized path coefficients for the revised model.


Table 1

Regression Weights and Squared Multiple Correlations (SMC) of the Measurement Model

Standardized t-value (standard error)
Self 0.37 7.51 (0.05) 0.14
Witness 0.64 17.22 (0.37) 0.41
Displac 0.68 19.48 (0.04) 0.47
Loved1 0.94 34.37 (0.03) 0.88
Avoid 0.49 11.00 (0.04) 0.24
Intrude 0.53 12.50 (0.04) 0.29
NACM 0.91 35.25 (0.03) 0.80
AAR 0.79 26.47 (0.03) 0.61
LOT1 0.49 7.41 (0.07) 0.24
LOT4 0.41 5.95 (0.07) 0.16
LOT10 0.24 3.41 (0.07) 0.06
RLOT3 0.29 4.29 (0.07) 0.09
RLOT7 0.40 6.07 (0.07) 0.16
RLOT9 0.44 6.59 (0.07) 0.20
inTRA 0.94 15.11 (0.06) 0.89
inTER 0.67 12.55 (0.05) 0.44
PTGf1 0.82 40.58 (0.02) 0.68
PTGf2 0.86 48.87 (0.02) 0.74
PTGf3 0.88 56.47 (0.02) 0.78
PTGf4 0.76 30.31 (0.03) 0.58
PTGf5 0.76 29.69 (0.03) 0.57

Note: Statistically significant p < .05 in bold; War = War events; PTSD = Post-Traumatic Stress Disorder; LOT = Optimism; RC = Religious Commitment; Growth = Post-Traumatic Growth




Figure 3. Standardized Estimates of the Final Model



R-square values showed that war accounted for 44% of the variance in PTSD; optimism accounted for 51% of the variance in religious commitment; and PTSD, optimism, and religious commitment accounted for 83% of the variance in PTG. As shown in Table 2, all goodness-of-fit indices for the revised model were in ideal parameters.


Table 2

Fit Indices and Modification of Theoretical Model (N = 350)




Pr > χ2

Δ χ2









< .0001

Measurement  Model (Mm)



< .0001







Theoretical Model (MT)



< .0001





Modified Theoretical Model (MTm)



< .0001







Note: χ2 = chi square; df = degrees of freedom; CFI = Comparative Fit Index; SRMR = Standardized Root Mean Square Residual; RMSEA = Root Mean Square Error of Approximation; RMSEA CL90 = RMSEA 90% Confidence Limits


Discussion and Implications

Because participants were survivors of a 10-year war-related traumatic experience, it was unsurprising that the majority of them met the PTSD diagnosis (APA, 2013). Despite the time lapse, these participants exhibited signs of intrusion, avoidance, reckless behaviors, and hypervigilance. Because the majority of the participants had joint households (married, 30%; lived with partners, 23.6%), it is likely that their loved ones could struggle with secondary traumatization (Jenkins & Baird, 2002; Lahav et al., 2016). Any therapeutic intervention for a group like this must be systemic in nature (Gehart, 2017) to address the mental health issues of not just survivors, but also the significant people in their lives.

Moreover, results of the first hypothesis indicated that there was a statistically significant difference in PTG scores based on gender, with females reporting more growth than males. These results confirm research in both Western and non-Western samples using the PTGI as an instrument to assess psychological growth after a traumatic experience (Baker et al., 2008; Powell et al., 2003). The high Cronbach’s alpha of the PTGI within the sample suggests that the construct of growth is being measured consistently across samples. Thus, interventions used in Western samples to enhance growth, barring any cultural complications, could work in non-Western samples.

In addition, results of the SEM confirm that people with dispositional optimism have a higher chance of gaining growth after a traumatic event than people who are pessimistic (Broekhof et al., 2015; Peterson & Steen, 2012). Readers are cautioned in making this leap because this Western-based instrument used in the non-Western environment was not consistent in measuring the optimism construct (α < .70). It is however possible that had the statements not been negatively worded, participants’ responses would have been different. This assertion is confirmed by the improved theoretical model from covarying the errors of the negatively worded items in the optimism factor.

There is also evidence from the data that participants used their search for the sacred to grow from the war-related traumatic experiences. These results have implications for professional counselors and counselor educators. Counselor educators can train professional counselors to appropriately assess spirituality as part of their multicultural assessment. Because of spirituality’s ability to enhance growth, incorporating spiritual competencies with a therapeutic relationship could enhance post-trauma healing. However, there were no questions assessing participants’ use of religious commitment as a community or whether their use of religious commitment arose from the war-related experiences.

In a related study assessing religious commitment’s moderating effect on the relationship between trauma and growth, the researchers discovered a curvilinear moderating effect (Acquaye, Sivo, & Jones, in press). Thus, the higher participants’ religious commitment, the lower their PTG; at mid-religious commitment, there was increased PTG. These findings were not too far from Joseph’s (2011) supposition that increased religiousness did not automatically lead to increased growth. Therefore, when clients report growth, professional counselors should not assume this growth corresponds to increased religiousness. It may well be that for some clients, decreased religiousness will lead to increased growth (Barrington & Shakespeare-Finch, 2013).

Limitations and Suggestions for Future Research

Because of the group-like nature of data collection, participants communicated among themselves. This kind of communication could skew the results, especially if some participants are providing responses that are consistent with the majority narrative. If possible, future research could be done with more privacy and not in a group format.

On the other hand, this mode of data supports the recommendation that future work take a qualitative approach and identify participants’ perceptions about growth, religious commitment, and optimism. It is possible that even though reliability analyses supported the reliability of these instruments, participants’ opinions without the prompts in such surveys could have shed a new light onto what they perceived to be growth and optimism.

It would be enlightening to conduct a comparative study to examine those who are still living outside Liberia (e.g., in the United States) and those living within Liberia to explore whether optimism and religious commitment before or after the war played a part in PTG, depending on where a person currently resides. This comparative study could identify differences in both religious commitment and optimism scores between gender and family status, depending on current residence. Finally, the comparative study may identify current post-trauma (disorder and growth) scores and how these scores reflect outlook on life.

In sum, the hypothesis that between 10–50% of participants will meet the diagnostic criteria for PTSD was supported; 79.1% of participants met the diagnostic criteria for PTSD. Furthermore, the hypothesis that both males and females will exhibit co-occurring PTSD and PTG was partially supported. Even though there were no differences in PTSD scores between gender, females reported higher PTG scores than their male counterparts. The third hypothesis that those who report high optimism will have higher PTG scores was supported. Finally, the model also supported the hypothesis that people who reported higher religious commitment scores will have higher PTG scores, as well as the hypothesis that optimism, PTSD, and religious commitment could all predict PTG. Most of the instruments used were reliable enough to aver that the measurement of the constructs is cross-cultural.


Conflict of Interest and Funding Disclosure

Data collected in this study was part of a dissertation study. The dissertation was awarded the 2016 Dissertation Excellence Award by the National Board for Certified Counselors.



Acquaye, H. E., Sivo, S. A., & Jones, K. D. (in press). Religious commitment’s moderating effect on refugee trauma and growth. Counseling and Values.

Affleck, G., & Tennen, H. (1996). Construing benefits from adversity: Adaptational significance and dispositional underpinnings. Journal of Personality, 64, 899–922. doi:10.1111/j.1467-6494.1996.tb00948.xx American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling in practice: A review and recommended two-step approach. Psychological Bulletin, 103, 411–423. doi:10.1016/j.paid.2016.09.042

Antonovsky, A. (1987). Unravelling the mystery of health: How people manage stress and stay well. San Francisco, CA: Jossey-Bass.

Antonovsky, A. (1993). The structure and properties of the Sense of Coherence scale. Social Science & Medicine, 36, 725–733. doi:10.1016/0277-9536(93)90033-Z

Arbuckle, J. L. (2014). AMOS (Version 23.0) [Computer Program]. Chicago, IL: IBM SPSS.

Baker, J. M., Kelly, C., Calhoun, L. G., Cann, A., & Tedeschi, R. G. (2008). An examination of posttraumatic growth and posttraumatic depreciation: Two exploratory studies. Journal of Loss and Trauma, 13, 450– 465. doi:10.1080/15325020802171367

Ball, T. M., & Stein, M. B. (2012). Classification of posttraumatic stress disorder. In J. G. Beck & D. M. Sloan (Eds.), The Oxford handbook of traumatic stress disorders (pp. 39–53). New York, NY: Oxford University Press.

Barrington, A. J., & Shakespeare-Finch, J. (2013). Working with refugee survivors of torture and trauma: An opportunity for vicarious post-traumatic growth. Counselling Psychology Quarterly, 26, 89–105. doi:10.1080/09515070.2012.727553

Batson, C. D., Schoenrade, P., & Ventis, W. L. (1993). Religion and the individual: A social-psychological perspective.  New York, NY: Oxford University Press.

Baum, N. (2014). Professionals’ double exposure in the shared traumatic reality of wartime: Contributions to professional growth and stress. The British Journal of Social Work, 44, 2113–2134. doi:10.1093/bjsw/bct085

Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behavior Research and Therapy, 42, 1129–1148.

Betancourt, T. S., Abdi, S., Ito, B. S., Lilienthal, G. M., Agalab, N., & Ellis, H. (2015). We left one war and came to another: Resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families. Cultural Diversity and Ethnic Minority Psychology, 21, 114–125. doi:10.1037/a0037538

Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28. doi:10.1037/0003-066X.59.1.20

Broekhof, R., Rius-Ottenheim, N., Spinhoven, P., van der Mast, R. C., Penninx, B. W., Zitman, F. G., & Giltay, E. J. (2015). Long-lasting effects of affective disorders and childhood trauma on dispositional optimism. Journal of Affective Disorders, 175, 351–358. doi:10.1016/j.jad.2015.01.022

Brownell, P. (2015). Spiritual competency in psychotherapy. New York, NY: Springer.

Calhoun, L. G., Cann, A., Tedeschi, R. G., & McMillan, J. (2000). A correlational test of the relationship between posttraumatic growth, religion, and cognitive processing. Journal of Traumatic Stress, 13, 521–527. doi:0894-9867/00/0700-0521$18.00/1

Calhoun, L. G., & Tedeschi, R. G. (2014). The foundations of posttraumatic growth: An expanded framework. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research and practice (pp. 1–23). New York, NY: Psychology Press.

Carver, C. S., & Scheier, M. F. (2002). Optimism. In C. R. Snyder & S. J. Lopez (Eds.), Oxford handbook of positive psychology (pp. 231–243). New York, NY: Oxford University Press.

Carver, C. S., Scheier, M. F., Miller, C. J., & Fulford, D. (2009). Optimism. In S. J. Lopez & C. R. Snyder (Eds.), The Oxford handbook of positive psychology (2nd ed., pp. 303–312). New York, NY: Oxford University Press.

Carver, C. S., Scheier, M. F., & Segerstrom, S. C. (2010). Optimism. Clinical Psychology Review, 30, 879–889. doi:10.1016/j.cpr.2010.01.006

Chang, E. C., Sanna, L. J., & Yang, K.-M. (2003). Optimism, pessimism, affectivity, and psychological adjustment in US and Korea: A test of a mediation model. Personality and Individual Differences, 34, 1195–1208. doi:10.1016/S0191-8869(02)00109-5

Clay, R. A. (2017). In search of hope and home. Monitor on Psychology, 48, 34–40.

Cline, L. I. (2013). The resettlement experiences of African refugee single mothers and hypertension management in United States. (Doctoral Dissertation). Retrieved from UCF Library Database. (Accession No. 2014-99060-036)

Connor, K. M., & Davidson, J. R. T. (2003). Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18, 76–82. doi:10.1002/da.10113

Doucleff, M. (2015). Ebola returns to Liberia with a mysterious case near Monrovia. Goats and soda: Stories of life in a changing world. Retrieved from

Edge, S., Newbold, K. B., & McKeary, M. (2014). Exploring socio-cultural factors that mediate, facilitate, and constrain the health and empowerment of refugee youth. Social Science & Medicine, 117, 34–41. doi:10.1016/j.socscimed.2014.07.025

Fabrigar, L. R., Porter, R. D., & Norris, M. E. (2010). Some things you should know about structural equation modeling but never thought to ask. Journal of Consumer Psychology, 20, 221–225. doi:10.1016/j.jcps.2010.03.003

Fraenkel, J. R., Wallen, N. E., & Hyun, H. H. (2015). How to design and evaluate research in education (9th ed.). New York, NY: McGraw-Hill.

Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56, 218–226. doi:10.1080/10615806.2013.784278

Friedman, M. J., Resick, P. A., & Keane, T. M. (2014). PTSD from DSM-III to DSM-5: Progress and challenges. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (2nd ed., pp. 3–20). New York, NY: The Guilford Press.

Gehart, D. R. (2017). Mastering competencies in family therapy: A practical approach to theory and clinical case documentation (3rd ed.). Boston, MA: Brooks Cole.

Gerdes, F. (2013). Civil war and state formation: The political economy of war and peace in Liberia. Frankfurt, Germany: Campus Verlag.

Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized               model misspecification. Psychological Methods, 3, 424–453. doi:1082-989X/98/J3.00

Hussain, D., & Bhushan, B. (2011). Posttraumatic stress and growth among Tibetan refugees: The mediating role of cognitive-emotional regulation strategies. Journal of Clinical Psychology, 67, 720–735. doi:10.1002/jclp.20801

IBM. (2016). SPSS Statistics for Windows, Version 24.0. [Computer Program]. Armonk, NY: IBM Corporation.

International Counseling and Community Services. (Ed.). (2015). Walking together: A mental health therapists’ guide to working with refugees. SeaTac, WA: Lutheran Community Services Northwest.

Jenkins, S. R., & Baird, S. (2002). Secondary traumatic stress and vicarious trauma: A validation study. Journal of Traumatic Stress, 15, 423–432. doi:10.1023/A:1020193526843

Joseph, S. (2011). Religiosity and posttraumatic growth: A note concerning the problems of confounding in their measurement and the inclusion of religiosity within the definition of posttraumatic growth. Mental Health, Religion & Culture, 14, 843–845. doi:10.1080/13674676.2011.609162

Joseph, S., & Linley, P. A. (2005). Positive adjustment to threatening events: An organismic valuing theory of growth through adversity. Review of General Psychology, 9, 262–280. doi:10.1037/1089-2680.9.3.262

Kimhi, S., Eshel, Y., Zysberg, L., & Hantman, S. (2010). Postwar winners and losers in the long run: Determinants of war related stress symptoms and posttraumatic growth. Community Mental Health Journal, 46, 10–19. doi:10.1007/s10597-009-9183-x

King, J. E., & Crowther, M. R. (2004). The measurement of religiosity and spirituality: Examples and issues from psychology. Journal of Organizational Change Management, 17, 83–101. doi:10.1108/09534810410511314

Kleim B., & Ehlers, A. (2009). Evidence for a curvilinear relationship between posttraumatic growth and posttrauma depression and PTSD in assault survivors. Journal of Traumatic Stress, 22, 45–52. doi:10.1002/jts.20378

Kunst, M. J. (2010). Peritraumatic distress, posttraumatic stress disorder symptoms, and posttraumatic growth in victims of violence. Journal of Traumatic Stress, 23, 514–518. doi:10.1002/jts.20556

Lahav, Y., Kanat-Maymon, Y., & Solomon, Z. (2016). Secondary traumatization and attachment among wives of former POWs: A longitudinal study. Attachment & Human Development, 18, 141–153. doi:10.1080/14616734.2015.1121502

Layne, C. M., Stuvland, R., Saltzman, W. R., Djapo, N., & Pynoos, R. S. (1999). War trauma screening index. Unpublished psychological test. University of California, Los Angeles.

MacCallum, R. C., Browne, M. W., & Sugawara, H. M. (1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods, 1, 130–149. doi:1082-989X/96/S3.00

Maslow, A. (1970). Motivation and personality (2nd ed.). New York, NY: Harper & Row.

McIntosh, D. N., Poulin, M. J., Silver, R. C., & Holman, E. A. (2011). The distinct roles of spirituality and religiosity in physical and mental health after collective trauma: A national longitudinal study of responses to the 9/11 attacks. Journal of Behavioral Medicine, 34, 497–507. doi:10.1007/s10865-011-9331-y

O’Leary, V. E., & Ickoviks, J. R. (1995). Resilience and thriving in response to challenge: An opportunity for a paradigm shift in women’s health. Women’s Health, 1, 121–142.

O’Rourke, N., & Hatcher, L. (2013). A step-by-step approach to using SAS for factor analysis and structural equation modeling (2nd ed.). Cary, NC: SAS Institute.

Pargament, K. I., & Mahoney, A. (2012). Spirituality: The search for the sacred. In S. J. Lopez & C. R. Snyder (Eds.), Oxford handbook of positive psychology (2nd ed., pp. 611–619). New York, NY: Oxford University Press.

Pargament, K. I., & Maton, K. I.  (2000). Religion in American life: A community psychology perspective. In J. Rappaport & E. Seidman (Eds.), Handbook of community psychology (pp. 495–522). New York, NY: Kluwer Academic/Plenum Publishers.

Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment and prediction of stress-related growth. Journal of Personality, 64, 71–105.

Peterson, C., & Steen, T. A. (2012). Optimistic explanatory style. In S. J. Lopez & C. R. Snyder (Eds.), Oxford handbook of positive psychology (2nd ed., pp. 313–321). New York, NY: Oxford University Press.

Powell, S., Rosner, R., Butollo, W., Tedeschi, R. G., & Calhoun, L. G. (2003). Posttraumatic growth after war: A study with former refugees and displaced people in Sarajevo. Journal of Clinical Psychology, 59, 71–82. doi:10.1002/jclp.101117–83

Praetorius, R. T., Mitschke, D. B., Avila, C. D., Kelly, D. R., & Henderson, J. (2016). Cultural integration through shared learning among resettled Bhutanese women. Journal of Human Behavior in the Social Environment, 26, 549–560. doi:10.1080/10911359.2016.1172997

Prati, G., & Pietrantoni, L. (2009). Optimism, social support, and coping strategies as factors contributing to posttraumatic growth: A meta-analysis. Journal of Loss and Trauma, 14, 364–388. doi:10.1080/15325020902724271

Rand, K. L., & Cheavens, J. S. (2012). Hope theory. In S. J. Lopez & C. R. Snyder (Eds.), Oxford handbook of positive psychology (2nd ed., pp. 323–333). New York, NY: Oxford University Press.

SAS Institute Inc. (2015). SAS/IML 14.1 User’s guide [Computer software]. Cary, NC: Author.

Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psychology, 4, 219–247. doi:10.1037/0278-6133.4.3.219

Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063–1078. doi:10.1037/0022-3514.67.6.1063

Schreiber, J. B. (2008). Core reporting practices in structural equation modeling. Research in Social & Administrative Pharmacy, 4, 83–97. doi:10.1016/j.sapharm.2016.06.006

Simiola, V., Neilson, E., Thompson, R., & Cook, J. M. (2015). Preferences for trauma treatment: A systematic review of the empirical literature. Psychological Trauma: Theory, Research, Practice, and Policy, 7, 516–524. doi:10.1037/tra0000038

Sivo, S. A., Fan, X., Witta, E. L., & Willse, J. T. (2006). The search for “optimal” cutoff properties: Fit index criteria in structural equation modeling. Journal of Experimental Education, 74, 267–288. doi:10.3200/JEXE.74.3.267-288

Splevins, K., Cohen, K., Bowley, J., & Joseph, S. (2010). Theories of posttraumatic growth: Cross-cultural perspectives. Journal of Loss and Trauma, 15, 259–277. doi:10.1080/15325020903382111

Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455–471. doi:10.1002/jts.2490090305

Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15–18. doi:10.1207/s15327965pli1501_01

Tedeschi, R. G., Calhoun, L. G., & Cann, A. (2007). Evaluating resource gain: Understanding and misunderstanding posttraumatic growth. Applied Psychology, 56, 396–406. doi:10.1111/j.1464-0597.2007.00299.x

United Nations. (2017). Ethnic cleansing. United Nations Office on Genocide Prevention and the Responsibility to Protect. Retrieved from

Van Dyk, G. A. J., & Nefale, M. C. (2005). The split-ego experience of Africans: Ubuntu therapy as a healing alternative. Journal of Psychotherapy Integration, 15, 48–66. doi:10.1037/1053-0479.15.1.48

Verdier, J. J., Dolopei, D., Syllah, O. K., Fulah, A. F., Konneh, K. F., Bull, P. B., . . . Washington, M. (2008). Final report of the Truth and Reconciliation Commission (TRRC) of Liberia. Republic of Liberia.

Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at

Widows, M. R., Jacobsen, P. B., Booth-Jones, M., & Fields, K. K. (2005). Predictors of posttraumatic growth following bone marrow transplantation for cancer. Health Psychology, 24, 266–273. doi:10.1037/0278-6133.24.3.266

Worthington, E. L., Jr., Wade, N. G., Hight, T. L., Ripley, J. S., McCullough, M. E., Berry, J. W., . . .

O’Connor, L. (2003). The Religious Commitment Inventory-10: Development, refinement, and validation of a brief scale for research and counseling. Journal of Counseling Psychology, 50, 84–96. doi:10.1037/0022-0167.50.1.84, 84–96

Wortmann, J. H., Jordan, A. H., Weathers, F. W., Resick, P. A., Dondanville, K. A., Hall-Clark, B., . . . Mintz, J. (2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment, 28, 1392–1403. doi:10.1037/pas0000260

Zerach, G. (2015). Secondary growth among former prisoners of war’s adult children: The result of exposure to stress, secondary traumatization, or personality traits? Psychological Trauma: Theory, Research, Practice, and Policy, 7, 313–323. doi:10.1037/tra0000009

Zerach, G., Solomon, Z., Cohen, A., & Ein-Dor, T. (2013). PTSD, resilience and posttraumatic growth among ex-prisoners of war and combat veterans. Israeli Journal of Psychiatry & Related Sciences, 50, 91–98. doi:10.1037/t06346-000–99

Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology: A critical review and introduction of a two component model. Clinical Psychology Review, 26, 626–653. doi:10.1016/j.cpr.2006.01.008


Hannah E. Acquaye, NCC, is an assistant professor at Western Seminary. Correspondence can be addressed to Hannah Acquaye, 5511 SE Hawthorne Blvd., Portland, OR 97215,

Unaccompanied Refugee Minors From Central America: Understanding Their Journey and Implications for Counselors

Angelica M. Tello, Nancy E. Castellon, Alejandra Aguilar, Cheryl B. Sawyer

The United States has recently seen a significant increase in the number of unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala). These children and youth are refugees fleeing extreme poverty and gang violence. This study examined the narratives of 16 refugees from the Northern Triangle who arrived in the United States as unaccompanied minors. In particular, the purpose of this study was to gain awareness of the journey experienced by unaccompanied refugee minors from their countries of origin to the United States. Thematic analysis was used to analyze the participants’ narratives, and three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Implications for counselors and areas for future research are discussed.


Keywords: unaccompanied minors, refugees, Central America, Northern Triangle, mental health


Displaced refugees are a worldwide crisis. The United Nations High Commissioner for Refugees (2015) reported there are 21.3 million refugees worldwide, and half are under the age of 18. Although much attention is given to the refugee crisis in Europe and the Middle East, the United States has recently seen a significant increase in unaccompanied refugee minors from the Northern Triangle of Central America (Sawyer & Márquez, 2017). These are children and youth from Honduras, Guatemala, and El Salvador who are traveling alone and crossing the Mexican border into the United States without legal authorization (Chen & Gill, 2015; Sawyer & Márquez, 2017; Stinchcomb & Hershberg, 2014).

Unaccompanied minors who are apprehended by immigration officials from the Department of Homeland Security (DHS) are transferred to the Office of Refugee Resettlement (ORR) for care (ORR, 2016). ORR (2016) reported that in their first nine years, they annually served an average of 7,000 to 8,000 unaccompanied minors. In 2012, ORR observed their first increase in numbers; services were provided to 13,625 unaccompanied children and youth (ORR, 2016). By 2014, there was a drastic increase in the number of unaccompanied minors arriving to the United States (Androff, 2016; DHS, 2016; ORR, 2016). DHS reported that 68,541 unaccompanied children and youth from Central America were apprehended at the southern border (DHS, 2016). There also was a 117% increase in the number of unaccompanied children under the age of 12 (Krogstad, Gonzalez-Barrera, & Lopez, 2014).

Although there has been a decrease in the number of unaccompanied minors entering the United States in the last few years, the numbers are still quite large. In 2016, 59,692 unaccompanied children and youth were apprehended, and 33% were female (ORR, 2016). Furthermore, the highest percentage of children were from Guatemala at 40%, followed by El Salvador and Honduras with 34% and 21%, respectively (ORR, 2016).

Unfortunately, because of recent anti-immigration rhetoric in the United States, the general public is often misinformed of the experiences of unaccompanied minors (Androff, 2016). In 2014, at the height of the surge of unaccompanied minors, various anti-immigration protests occurred in the United States against children and youth from Central America (Androff, 2016; Knake, 2014). In a protest organized in Michigan by the Michiganders for Immigration Control and Enforcement, some protesters carried rifles and handguns along with signs that read “seal the border,” “it’s law—deport,” and “no illegals” (Knake, 2014, para. 12). A major misconception is that unaccompanied minors are immigrants. However, the unaccompanied children and youth from the Northern Triangle of Central America are refugees fleeing impoverished living conditions, extreme violence from gangs and organized crime, and political instability (Androff, 2016; Chishti & Hipsman, 2015; Jani, Underwood, & Ranweiler, 2016; Sawyer & Márquez, 2017). DHS Secretary Jeh Johnson reported that over the last 15 years “far fewer Mexicans and single adults are attempting to cross the border without authorization, but more families and unaccompanied children are fleeing poverty and violence in Central America” (DHS, 2016, para. 1).

Reasons for the Increase of Unaccompanied Minors

The poverty and violence experienced by those living in the Northern Triangle of Central America have been well documented (Chishti & Hipsman, 2015; Gonzalez-Barrera et al., 2014; Jani et al., 2016; Sawyer & Márquez, 2017; Women’s Refugee Commission, 2012). Impoverished living conditions and gang violence are the major factors leading unaccompanied minors to leave Central America. Even though the journey to the United States is filled with grave danger, children are fleeing Central America because of their dire living situations.

Poverty and the Lack of Economic Opportunities

Societal inequalities and natural disasters have negatively impacted this region (International Organization for Migration [IOM], 2016; Seelke, 2016). These inequalities have led those living in the Northern Triangle to experience high rates of poverty and limited economic opportunities. Since 2012, El Salvador, Guatemala, and Honduras have been impacted by prolonged drought (IOM, 2016). This has caused immense food insecurity and has negatively affected agricultural labor. For instance, nearly 50% of the Guatemalan population has experienced chronic undernutrition (IOM, 2016). Furthermore, over half of the population in Honduras and Guatemala live in poverty: 63% and 59%, respectively (Seelke, 2016), and 40% in El Salvador (Padgett, 2014). The Northern Triangle also has high rates of youth unemployment. In El Salvador and Honduras, over 25% of youth ages 15–24 have never worked or studied (De Hoyos, Rogers, & Székely, 2016).

Violence by Gangs and Organized Crime

According to the Council on Foreign Relations, “El Salvador, Guatemala, and Honduras consistently rank among the most violent countries in the world” (Renwick, 2016, para. 4). In 2015, El Salvador’s homicide rate was the highest in the world, with 105 murders per 100,000 inhabitants (Watts, 2015). Moreover, this makes El Salvador almost 20 times more deadly than the United States (Watts, 2015). It is important to note that from 2011 to 2015, San Pedro Sula, Honduras, was identified as the most violent city in the world outside a war zone (O’Connor, 2012). From 2005 to 2010, the murder rate in Honduras more than doubled (United Nations Office on Drugs and Crime, 2011). Guatemala City also has consistently ranked as one of the most violent cities. The U.S. Department of State’s Overseas Security Advisory Council (2016) stated that “Guatemala’s homicide rate is one of the highest in the Western Hemisphere,” with 91 murders per week in 2015 (para. 2).

The high murder rates in the Northern Triangle of Central America are attributed to the maras, or gangs, in that region (Chishti & Hipsman, 2015; Jani et al., 2016; Sawyer & Márquez, 2017; Watts, 2015). The violence and murders are because of the rivalry of two prominent gangs: the Mara Salvatrucha, also known as MS-13, and Barrio 18 (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). These gangs were able to flourish in the Northern Triangle because of weak government and political instability in the region (Sawyer & Márquez, 2017). From the 1980s into the early 1990s, there was a deadly civil war in El Salvador between the government and the Martí National Liberation Front, a Salvadorian political party (Sawyer & Márquez, 2017). From 1960 to 1996, Guatemala suffered from a 36-year civil war between civilian farmers who lost land and voting rights and government military forces (Sawyer & Márquez, 2017). Furthermore, Honduras experienced a military coup in 2009, which led the government to suspend freedom of assembly and the press and authorize excessive force to silence opposition (Sawyer & Márquez, 2017). As the countries began to rebuild after these periods of political unrest, gangs in this region were able to go unchecked.

Gangs in Central America were able to gain control in part because of the drug demands of the United States. These gangs assist in the transportation of cocaine and marijuana moving from South America into Mexico, and eventually the United States (Sawyer & Márquez, 2017; Seelke, 2016; Watts, 2015). However, the Central American gangs are not the major narco-cartel suppliers, so they have relied on robbery, extortion, kidnapping, human trafficking, and weapons smuggling for additional sources of income (Seelke, 2016; Watts, 2015). The extortions have impacted residents, bus and taxi drivers, and general business owners (Seelke, 2016; Watts, 2015). For instance, in the El Salvadorian city of San Salvador, gangs demand residents pay “war taxes,” and those that do not pay face harassment and violence (Ribando, 2007, p. 4).

The gangs actively target children and youth as young as 7 or 8 years old for recruitment (Sawyer & Márquez, 2017). Moreover, the gangs use coercive and violent means, such as kidnapping, extortion, and murder, to force families to “give up their children” (Jani et al., 2016, p. 1196). In El Salvador, gangs have even targeted children at schools, resulting in low school attendance rates (Women’s Refugee Commission, 2012). On the other end, some youth become susceptible to gang recruitment because of high unemployment and absence of family influences (Farah, 2016). Nevertheless, the violence and intimidation perpetuated by gangs are major push factors leading children and youth to flee Central America. The exposure to violence also can have an impact on the mental health of unaccompanied minors.

Mental Health Needs of Unaccompanied Refugees

Although there is a limited understanding of the mental health needs of unaccompanied minors from the Northern Triangle of Central America, researchers have documented the common mental health needs of refugees. Because many refugees have been exposed to traumatic events and violence in their countries of origin, they experience higher rates of mental health issues, such as post-traumatic stress disorder (PTSD), depression, and emotional and behavioral problems (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011). Mental health needs do not solely stem from the trauma exposure experienced by refugees pre-migration. Many refugees also experience trauma and uncertainties during their migration and post-migration resettlement that negatively impact their mental health (Bronstein & Montgomery, 2011; Karaman & Ricard, 2016; Kirmayer et al., 2011).

According to a recent study conducted by Keller, Joscelyne, Granski, and Rosenfeld (2017), Central American refugees from El Salvador, Honduras, and Guatemala have “significant mental health symptoms” because of the violence they experienced (p. 1). Of their sample of 234 participants, 204 experienced trauma in their countries of origin, 182 fled because of violence concerns, and 166 were afraid to return home. Moreover, rates of depression and PTSD were high among those from the Northern Triangle: 32% reported clinically significant PTSD symptoms and 24% had major depressive disorder symptoms (Keller et al., 2017). Similar findings were echoed in a study that examined the mental health needs of Guatemalan refugees living in Mexico (Sabin, Lopes Cardozo, Nackerud, Kaiser, & Varese, 2003). The researchers surveyed 170 participants, and all reported at least one traumatic event, with a total of 1,230 reported traumatic events (e.g., being close to death, friend or family member massacred, witnessing the disappearance of others; Sabin et al., 2003). From these participants, 11.8% met symptom criteria for PTSD, 54.4% had anxiety symptoms, and 38.8% revealed depression symptoms (Sabin et al., 2003).

Further research is needed on the mental health needs of unaccompanied minors from the Northern Triangle of Central America. The purpose of this study was to gain awareness of the journey experienced by unaccompanied minors from their countries of origin to the United States and to provide implications for counselors. Therefore, the following research question guided the study: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America?


Thematic analysis, a qualitative methodological approach, was utilized because the researchers were analyzing written narratives. Thematic analysis, unlike content analysis, provides a rich and detailed description of the data (Vaismoradi, Turunen, & Bondas, 2013). This research study was approved by the researchers’ institutional review board.


The researchers analyzed the narratives of 16 participants. All the participants entered the United States as unaccompanied minors from the Northern Triangle of Central America (i.e., El Salvador, Honduras, and Guatemala) and were receiving assistance through a shelter in the Southern region of the United States. Part of the assistance included counseling services offered by a counseling graduate program affiliated with the researchers. After gaining signed consent forms, the participants and their appointed legal guardians received individual counseling sessions in Spanish with bilingual counselors-in-training (CITs). Three of the participants were female, and 13 were male. Ten of the participants were from Honduras, three were from Guatemala, and three were from El Salvador. Participants’ ages ranged from 10 to 23. Although some of the participants were over 18 years of age at the time of the study, they arrived in the United States as unaccompanied minors.

Data Collection

The data was collected during the counseling process. The CITs involved had at least one semester of supervised counseling experience. They also had completed all foundational counseling courses in their degree plan, including counseling theories, multicultural counseling, assessment, diagnosis, human growth and development, crisis intervention, counseling skills, and group counseling. At the time of the study, the CITs were enrolled in a bilingual counseling course and received information on the counseling needs of unaccompanied refugee minors.

Each CIT was assigned a participant and completed three to 18 hours of individual counseling sessions. The hours varied depending on the participants’ availability. Because the participants were exposed to violence in their countries of origin and the journey to the United States, CITs utilized basic relaxation skills, trauma-focused cognitive behavioral therapy (TF-CBT), and expressive counseling techniques to help the participants process their experiences. Upon conclusion of the counseling sessions, each participant organized a digital storybook that illustrated and discussed their journey to the United States. The storybooks were created on iPads using Microsoft PowerPoint. The participants received assistance from their CITs on utilizing the iPad and writing the content for each page of their book. The books ranged from five to 26 pages. After eliminating all identifying information, the content of the books was provided to the researchers by the CITs. The content was then translated from Spanish to English, and two external auditors provided language translation verification.

Data Analysis

The data were analyzed using the thematic analysis approach outlined by Braun and Clarke (2006). First, the researchers familiarized themselves with the data by reading and re-reading each participant’s book content. Key ideas were documented during this time. Next, a systematic approach was taken in reviewing the data and identifying codes. In particular, a “data-driven” approach was used to code instead of a “theory-driven” approach (Braun & Clarke, 2006, p. 88). These codes were then grouped into potential themes based on shared meanings. The researchers also reviewed and discussed the themes to ensure they represented the data. This process allowed for the refining of each specific theme. External auditors then reviewed the themes and reported that the themes reflected the participants’ experiences. The participants discussed their journey from their countries of origin to the United States. Therefore, the themes reflect what occurred on their journey. Based on these themes, the researchers provide implications for counselors and discuss mental health issues.


Based on the analysis of the participants’ narratives, the researchers identified three primary themes and 11 subthemes. The primary themes were: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States. Each theme is described in the following section. Pseudonyms were selected for each participant to protect their privacy.

Reasons for Leaving Central America

All the participants discussed factors that contributed to them fleeing their countries of origin. Three subthemes fell under the primary theme of what led the participants to leave Central America: (a) to financially help family, (b) to escape gang violence and death, and (c) powerlessness. It is important to note that these subthemes are closely related. The gangs in the Northern Triangle of Central America were a result of the extreme poverty in that region, and they also contributed to the poverty experienced by the participants.

Financially help family. Many of the participants experienced extreme poverty in their home countries. Enrique shared how he grew up in a “house made out of sticks, mud, and rocks” and how his family “melted fat in order to eat.” When he was 10 years old, his father was killed by a gang, and he stopped attending school to provide for his family. He left for the United States with the support of his mother because it was difficult to find a job and the country’s economy was unstable because of the gangs. Many of the participants echoed these sentiments. For instance, Federico also shared that “poverty, delinquency, and lack of work opportunities” led him to leave his native country for “a more promising future for myself and my family.”

Escape violence and death. All the participants fled their home countries in order to escape violence and death. Federico provided a detailed account of how the maras, or gangs, in his native country recruited children as new members. If someone did not join, the gang members would kidnap, rape, or kill his or her family members. This led Federico and many of the participants to flee their countries; they felt there was no other option to escape the violence.

Some participants left their native countries because gang members threatened to kill them. Brenda lost her parents because of gang violence and was living with her aunt and uncle. Brenda fled to the United States shortly after this incident: “My aunt received a phone call from somebody who said that my sister and I were easy targets. . . . And if they were not paid a certain amount, we [participant and her sister] would be hurt.”

Powerlessness. Another subtheme that emerged was powerlessness. Some of the participants were homeless because of the extreme poverty and violence. Additionally, they felt alone and had no family ties left in their home countries. These participants felt powerlessness regarding what occurred in their lives and fled to the United States to gain a sense of control. Armando shared feeling powerless after his mother died from a heart attack when he was 14 years old. Afterward, he lived with his brothers for 2 years, but they did not support him. Armando’s friend then encouraged him to flee to the United States because he was on his own.

Journey to the United States

In their narrative books, the participants discussed what occurred on their journeys to the United States. The subthemes that fell under this primary theme were: (a) mode of journey, (b) physical pain, (c) emotional pain, and (d) help from others.

Mode of journey. Participants either arrived by riding above trains or through the assistance of a smuggler, also known as a coyote. Carlos tried multiple times to come to the United States and primarily used the train. His first attempt was at 6 years old, but he was unable to complete the journey. The second time Carlos fled Central America, he “came aboard the train of death.” The train was often referred to by participants as la bestia, or the beast. Several participants shared these experiences. For instance, Enrique made three attempts to leave Central America starting at 11 years old. His journey took him 8 months to arrive in the United States. Other participants arrived in the United States through smugglers. Cristobal described how his parents saved money so they could pay a coyote to bring him to the United States.

Physical pain. The participants provided various accounts of physical and emotional trauma experienced on their journey to the United States. Several of the participants reported being beaten and robbed in Mexico when their trains would stop at various points. To find food, the refugees had to get off the train. Federico discussed how traveling alone led one to be vulnerable to “food, water, and clothes predators.”

Some participants described not knowing what to expect on their path to the United States; they were not prepared for what lay ahead while on the train or by foot. Federico wrote: “We knew nothing about the journey, knew no landmarks, and knew nothing about the path that could help us plan ahead.” Damian wrote about the freezing temperatures he was not prepared for when the train reached mountainous terrain. He was traveling with two other boys, and they were only wearing t-shirts and pants. He described how he felt immense pain from the freezing weather and worried that he was “dying from the cold.” Damian felt fortunate that he was traveling with someone who told him they needed to take off their clothes and use their body heat to keep warm.

Other participants provided accounts of being physically injured on their journey because of days of walking in desert terrain. Brenda recalled the injuries and pain caused to her feet: “It took us 8 days to get to our stopping point. I remember that my shoes had peeled the soles of my feet, and my toenails had fallen off.” Feet being severely damaged from walking was a common experience shared by the participants.

Fernando began his journey at 10 years old and recounted the injuries he received from the train and walking nonstop for 2 days as he approached the Mexico–United States boarder: “My arms were bandaged from having been hurt on the train. . . . I saw the body of a man floating in the river. I wondered if it was the body of my father.” Fernando’s accounts illustrate the nature of the physical and emotional pain the participants experienced. Not only was Fernando physically hurt on his journey, but he also carried the emotional or psychological wounds of witnessing death at a young age. In his book, Fernando also wrote about seeing a man’s body being dismembered after accidentally falling from the train.

Emotional pain. All the participants were exposed to and witnessed trauma on their journey to the United States. They were exposed to physical and sexual assaults and death. For instance, riding above the train was very dangerous. Participants provided accounts of people being sucked under the train as they tried to jump on. Enrique wrote about seeing a girl die trying to get on the train. Federico stated that the following events impacted him the most on his journey: “(I) witnessed a person being shot to death, the raping of women while family members were forced to witness this, witnessing a person being cut to pieces by the train, and seeing pieces of human bodies alongside the railroads.” These were not isolated events; all the participants reported at least one such traumatic situation.

Damian wrote how he “felt frustrated and powerless” after seeing a girl being raped by a gang of three or four men; the girl’s brother was forced to watch the sexual assault. He met the girl and her brother a few days before the sexual assault occurred. Damian was told by his cousin not to intervene or confront the rapists because he would most likely be killed or severely assaulted by the gang. Many of the participants, like Damian, noted that these memories were reoccurring, and how they often think about those whom they saw injured and sexually assaulted. Damian wrote how he wants to find the girl who was raped and explain to her why he did not intervene and that he wants to apologize. In his book, Damian listed her name and the city she was planning to arrive to in the United States.

Help from others. The last subtheme that emerged from the participants’ narratives was receiving help from others. Even though the participants experienced physical and emotional trauma on their journey to the United States, they met individuals along the way that provided assistance. Many of the participants reported struggling to find food. Ismael wrote: “I also remember good people throwing food at us because they knew we were hungry.” Damian shared how he met a “good-hearted lady” that gave him advice on evading possible harm. She told Damian to be careful about motorcycles because they were involved with “kidnapping migrants and asking their families for ransom.” Although this information caused “more real fear” in Damian, it helped him on his journey. There were several accounts of priests in Mexico helping refugees find local shelter. Enrique shared that he received help from a priest who took him to a “house of immigrants” to receive food, clothes, and shelter. These instances of support helped the refugee children and youth continue on their journey.



Life in the United States

The last primary theme related to the participants’ life in the United States. Four subthemes emerged from the participants’ narratives: (a) faith, (b) worries about the future, (c) help from others, and (d) view of self after the journey.

Faith. Some of the participants discussed how they felt God “guided” them on their journey to the United States. When they faced obstacles and harm, God protected them and provided guidance. As a result, they felt God would be present in their life in the United States. Even though they are continuing to face challenges in the United States (e.g., court hearings, financial instability), they believed God would continue to provide support. In her book, Delmy wrote that “although there might be darkness in life, there is light that always breaks through the darkness.” She then stated that her faith provides her the “light” to keep moving forward in the United States.

Worries about the future. The refugee children and young adults in the study described various worries about their future. Some participants shared worries about providing for their family. Robert echoed these sentiments; he had two jobs to help his family back home. Other participants were worried about their family’s safety in Central America. Damian described how he is worried because his “mother is sad.” She even told him that “she doesn’t want to live anymore” because of the dire situation in Central America. Damian also was worried about the safety of his younger sister.

There were worries expressed about the participants’ safety in the United States. Delmy expressed feeling alone at the detention center and “fears” that people want to harm her. Moreover, several participants expressed worries about their immigration status in the United States and being judged by American society. Jesus stated: “I hope that one day I can be accepted by the American society. I can only pray that I am not judged too harshly. I plan on continuing to help my family to have a better life.” Tomas, like many of the participants, was waiting on his court hearing. He described the uncertainty and worries of his future: “My future is uncertain. . . . I will either be deported back to my country where there is a high possibility that I can be killed, or my immigration status will become legalized in the near future.” For those that fled gang violence, being sent back to their countries of origin could be a death sentence. For Carlos, who recently gained legal status, there was worry about discrimination he might face in the United States: “Some people judge me without knowing me, even more so in this country where there is so much discrimination against immigrants. And even though I am legal, it does not mean that other people will not judge me.”

Help from others. Participants noted receiving help from individuals in the United States. The help they received provided them with hope and guidance to keep moving forward in a positive direction. In his book, Armando expressed how he allowed himself to be picked up by immigration authorities. He felt alone and did not know how he was going to survive in the United States. Armando shared that once he was detained, he received help from his assigned lawyer. She gave Armando hope that he could stay in the United States, attend school, and have a positive future. Now, Armando wants to give back to his community and help other unaccompanied minors from Central America. Damian expressed similar sentiments; he wants to help others because of the support he received from the director of a children’s shelter. The director has become a father figure to Damian and has helped him realize that he has a future.

View of self after the journey. The participants’ views of themselves after their journey was another subtheme that emerged from the participants’ narratives. For some participants, they felt their life was going nowhere—there was no hope. Tomas expressed these sentiments: “My American dream has become my nightmare. My journey here was not pleasant plus I feel helpless here because I cannot help my family in Central America. . . . I feel my life has no meaning.” Not only was Tomas’s journey filled with trauma and pain, his life in the United States was uncertain. Furthermore, he was separated from his family and unable to help them financially or provide for their safety. Other participants viewed themselves as “survivors.” Carlos finished his book with the following: “This book does not show all the pain and sacrifice that I have endured, but it is a reminder that I am a survivor.”



This study examined the narratives of 16 refugees from El Salvador, Honduras, and Guatemala who arrived to the United States as unaccompanied minors. The data set was gathered to answer the research question: What are the experiences of unaccompanied refugee minors from the Northern Triangle of Central America? From the participants’ narratives, three primary themes emerged: (a) reasons for leaving Central America, (b) journey to the United States, and (c) life in the United States.

There were three prominent reasons that led participants to flee their home countries in Central America. Some participants described living in poverty and leaving for the United States to financially help the family. Also, all participants discussed fleeing to escape gang violence and death. Previous literature on unaccompanied refugees from the Northern Triangle has discussed how poverty (Gonzalez-Barrera et al., 2014; IOM, 2016) and gang violence (Jani et al., 2016; Sawyer & Márquez, 2017; Seelke, 2016) are major push factors. However, participants in this study also reported feelings of powerlessness that led them to leave their home countries. Participants described feeling they did not have control of what was occurring in their lives and fleeing to the United States was a way to take hold of their future. These pre-migration worries and stressors could impact the mental health of the participants. Unaccompanied refugee minors have more traumatic stress reactions than accompanied children and non-immigrants (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007).

This study also provided some insight into the experiences of unaccompanied refugee minors on their journey to the United States. The participants described their mode of journey, which fell into two categories: using a coyote, or smuggler, and riding above trains. These findings were consistent with what has been documented in the literature (Sawyer & Márquez, 2017; Uehling, 2008) regarding unaccompanied refugees from Central America. Previous literature (Keller et al., 2017; Sawyer & Márquez, 2017) has focused on the living conditions of refugee minors in their home countries, which represent the push factor present in their lives in El Salvador, Honduras, and Guatemala. The participants in this research study shared the physical and emotional pain that was part of the journey to the United States. They provided detailed accounts of how they were physically assaulted, faced various injuries to their bodies because of long days of walking, and lacked the proper clothing to endure the various terrains they encountered. Furthermore, the participants also shared the emotional pain they experienced on their journey: reoccurring images from witnessing physical and sexual assaults and seeing dead bodies. These types of physical and emotional pain place unaccompanied refugee minors at greater risk of mental health problems. The exposure to trauma and stressors can lead refugees to develop depressive and anxiety disorders including PTSD (Keller et al., 2017; Sabin et al., 2003; Vervliet at al., 2014). For minors, mental health issues can significantly impair their functioning (e.g., academics; Fox, Burns, Popovich, Belknap, & Frank-Stromborg, 2004).


In the literature on unaccompanied refugees from the Northern Triangle, there was limited understanding of their experience once they arrived in the United States. The participants in this study provided some insight into these experiences. Faith was a prominent theme that emerged and has not been discussed in the literature. For many of the participants, their faith and religious views were sources of strength as they transitioned to life in the United States. Participants also gained a sense of empowerment from the help they received from various sources in the United States. Emotional support from lawyers or mentors in the community gave the participants hope to continue moving forward in a positive direction. However, many of the participants shared worries about their future. These worries were about their family members who were left back at home, their safety in the United States, and the uncertainty of their legal status. Many of the participants also were aware of the discrimination they would face in the United States.


Discrimination and prejudice have been documented as post-migration stressors for immigrants in the United States (Pumariega, Rothe, & Pumariega, 2005). Discrimination can have a negative impact on the mental health of refugees (Montgomery & Foldspang, 2008). Those who experience discrimination may exhibit stress and depressive symptoms (Stuber, Galea, Ahern, Blaney, & Fuller, 2003). The participants wondered whether discrimination would impact their ability to stay in the United States or cause them to be deported. For these participants, deportation meant being sent back to a death sentence. All of these worries and uncertainties about their future led some participants to feel they had no hope for their futures.


Along with the exposure to trauma experienced by unaccompanied minors pre-migration, they experience additional stressors post-migration in the United States. In a study conducted with unaccompanied refugee minors in Europe, there were high rates of anxiety, depression, and PTSD symptoms (Vervliet et al., 2014). In particular, high scores were rated (self-report measures: Hopkins Symptoms Checklist-37A, Stressful Life Events, Reactions of Adolescents to Traumatic Stress, and Harvard Trauma Questionnaire) for these symptoms shortly after the unaccompanied minors arrived at their host countries (Vervliet et al., 2014). Their findings dispute previous research that suggests that there is a “honeymoon” phase experienced after arrival in the host country (Tousignant, 1992; Ward, Okura, Kennedy, & Kojima, 1998). This study helps shed some light into the additional stressors experienced by unaccompanied refugee minors post-migration: worries about their future such as safety, immigration status, and being judged. Constant uncertainty about their future, coupled with the exposure of trauma in their past, might increase the anxiety, depression, and PTSD symptoms experienced by unaccompanied refugees. Obviously, counselors can play an important role in addressing the mental health needs of unaccompanied refugee minors.


Implications for Counselors

Unaccompanied refugees from Central America experience various forms of trauma in their countries of origin and on the journey to the United States (Keller et al., 2017; Sawyer & Márquez, 2017). As a result, these children and adolescents are at risk of developing PTSD and major depressive disorder symptoms (Keller et al., 2017; Sawyer & Márquez, 2017). Therefore, it is crucial that counselors working with unaccompanied refugees be informed of trauma counseling theories and interventions such as trauma-informed care (Substance Abuse and Mental Health Services Administration, 2014).


Additionally, counselors must practice multiculturally competent counseling services with this population and create a safe space for clients to process their trauma (Sawyer & Márquez, 2017). Building rapport is crucial when counseling refugees. Clients might be anxious about sharing personal information because of past experiences of mistrust (Tribe, 2002). Moreover, unaccompanied refugee minors might have culture-bound expressions of mental health symptoms (Pumariega et al., 2005). This means counselors must have an awareness of their client’s cultural upbringing. Counselors can work with “cultural consultants” who have connections with refugee communities and can assist in facilitating accurate mental health assessments (Pumariega et al., 2005, p. 591). Culturally competent counselors also need to be aware of factors that can affect the therapeutic relationship such as stigma, location, language barriers, and documentation (Pumariega et al., 2005).


Incorporating the client’s cultural values in session can assist refugees in “maintaining their equilibrium” (Tribe, 2002, p. 243). For many refugees, their sense of identity may have been threatened in their countries of origin (Tribe, 2002). For the participants in this study, arriving in the United States also meant encountering additional stressors to their sense of identity. For instance, many of the participants worried about their safety in the United States, immigration status, and judgments and discrimination from others. This study provides insight into cultural values that counselors can incorporate to help unaccompanied minors find some personal balance in the United States. Some participants shared how their faith and helping others brought personal meaning and hope for the future. Other participants held to the notion that they were survivors and that they have the skills to face struggles they will encounter in the future.


It is important for counselors working with unaccompanied refugees to understand the impact of vicarious trauma and the importance of self-care. The process of listening to the stories of refugees who have experienced trauma can in itself be very painful and cause the counselor to experience vicarious trauma. Before a counselor can begin to help a refugee client to open up about painful experiences, the counselor must consider: “Do I have the skills needed to help the client contend with the intense emotions that arise in the counseling process? Do I have the debriefing resources necessary to help myself contend with conflicting emotions?”


Although the CITs in this project had considerable experience working with refugee children as teachers and were intensely prepped for the possibility of hearing their clients discuss graphic content, they still related that the counseling process was emotionally stressful and draining. In order to help the CITs address any vicarious trauma they may have experienced from counseling unaccompanied refugees, they were debriefed after every session by their site supervisors. Many of the CITs involved in this process reported that by discussing their sessions with supervisors and with one another, they felt better able to deal with what they heard. Therefore, counselors providing services to unaccompanied refugees should regularly meet for individual or group supervision to debrief. It is important for counselors to understand the characteristics of vicarious trauma, such as cognitive distortions and changes in core beliefs (Bell, Kulkarni, & Dalton, 2003), intrusive thoughts or nightmares (Hernandez-Wolfe, Killian, Engstrom, & Gangsei, 2015), and decreased self-efficacy (Sartor, 2016). Clinical supervisors can play an important role in helping counselors to recognize and decrease symptoms of vicarious trauma (Lonn & Haiyasoso, 2016).


Engaging in self-care activities can help counselors who are providing services to clients who have experienced trauma (Lonn & Haiyasoso, 2016; Williams, Helm, & Clemens, 2012). Counselors can develop a wellness plan to help maintain self-care (Williams et al., 2012), such as participating in “spiritual or religious renewal” (e.g., prayer, meditation, yoga) or spending time in nature (e.g, camping, walking, hiking; Lonn & Haiyasoso, 2016, p. 4). Self-care activities also can include connecting with other counselors who provide services to unaccompanied refugees.


Limitations and Future Research

There were four limitations in this study. First, the study was comprised of more male than female participants. However, the sample is reflective of the population of unaccompanied minors who enter the United States in that males are more likely to enter the United States unauthorized than females (ORR, 2016). Second, the participants were asked to document their experiences in a digital storybook with the assistance of their CIT. The structure of the books could have limited what the participants shared about their experiences. Third, the digital storybooks were created after participants completed counseling. Participant reports could have been impacted by counseling. Lastly, as a result of the researchers utilizing a qualitative methodology, the findings have limited generalizability. Nevertheless, there were participants representing all three countries (i.e., El Salvador, Honduras, and Guatemala), which helps support limited transferability of the findings (Yardley, 2008).


The findings and limitations of this study provide areas for future research. The qualitative nature of the study and the findings around the emotional pain experienced by the participants opens up opportunities for conducting quantitative studies. This includes assessing if there are trauma-related diagnoses or depression and the degree to which it is experienced by unaccompanied refugees from the Northern Triangle. Moreover, the effectiveness of particular trauma-focused therapies with this population is an area that needs further exploration. For instance, TF-CBT is considered an evidence-based treatment approach with children and adolescents who have experienced trauma (Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011; Silverman et al., 2008). However, there is limited understanding of TF-CBT’s effectiveness with unaccompanied refugees from Central America. Also, examining culturally competent strategies of implementing TF-CBT with this population is warranted.




The treacherous journey unaccompanied minors must undertake to arrive in the United States is not a deterring factor. Secretary Jeh Johnson from the United States DHS reported: “Border security alone cannot overcome the powerful push factors of poverty and violence that exist in Central America. Walls alone cannot prevent illegal migration” (DHS, 2016, para. 4). Even though these children and adolescents walk thousands of miles and face hostile situations on their journey to the United States, they choose this path instead of the alternative, which for many, if they stay in their home country, is certain death (United Nations Children’s Fund, 2016; Women’s Refugee Commission, 2012). Ultimately, counselors and other helping professionals must consider the instinctive nature of self-preservation, especially in children. Child and adolescent refugees will continue to come to the United States seeking food, shelter, and asylum until their home situation becomes bearable. Until then, counselors and those supporting unaccompanied minors must understand the strengths, stresses, and struggles of refugees to develop effective practices for helping these children to be successful in their receiving country.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.





Androff, D. (2016). The human rights of unaccompanied minors in the USA from Central America. Journal of Human Rights and Social Work, 1(2), 71–77. doi:10.1007/s41134-016-0011-2

Bean, T., Derluyn, I., Eurelings-Bontekoe, E., Broekaert, E., & Spinhoven, P. (2007). Comparing psychological distress, traumatic stress reactions, and experiences of unaccompanied refugee minors with experiences of adolescents accompanied by parents. Journal of Nervous and Mental Disease, 195, 288–297. doi:10.1097/01.nmd.0000243751.49499.93

Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society: The Journal of Contemporary Human Services, 84, 463–470. doi:10.1606/1044-3894.131

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.

Bronstein, I., & Montgomery, P. (2011). Psychological distress in refugee children: A systematic review. Clinical Child and Family Psychology Review, 14, 44–56. doi:10.1007/s10567-010-0081-0

Chen, A., & Gill, J. (2015). Unaccompanied children and the U.S. immigration system: Challenges and reforms. Journal of International Affairs, 68, 115–133.

Chishti, M., & Hipsman, F. (2015). The child and family migration surge of summer 2014: A short-lived crisis with a lasting impact. Journal of International Affairs, 68, 95–114.

De Hoyos, R., Rogers, H., & Székely, M. (2016). Out of school and out of work: Risk and opportunities for Latin America’s Ninis. Retrieved from

Department of Homeland Security. (2016). Statement by Secretary Johnson on southwest border security. Retrieved from

Farah, D. (2016). Central America’s gangs are all grown up. Foreign Policy. Retrieved from

Fox, P. G., Burns, K. R., Popovich, J. M., Belknap, R. A., & Frank-Stromborg, M. (2004). Southeast Asian refugee children: Self-esteem as a predictor of depression and scholastic achievements in the U.S. The International Journal of Psychiatric Nursing Research, 9, 1063–1072.

Gonzalez-Barrera, A., Krogstad, J. M., & Lopez, M. H. (2014, July 1). DHS: Violence, poverty, is driving children to flee Central America to U.S. Pew Research Center. Retrieved from

Hernandez-Wolfe, P., Killian, K., Engstrom, D., & Gangsei, D. (2015). Vicarious resilience, vicarious trauma,

and awareness of equity in trauma work. Journal of Humanistic Psychology, 55, 153–172. doi:10.1177/0022167814534322

International Organization for Migration. (2016). Hunger without borders: The hidden links between food insecurity,

            violence and migration in the Northern Triangle of Central America. Retrieved from https://environmental


Jani, J., Underwood, D., & Ranweiler, J. (2016). Hope as a crucial factor in integration among unaccompanied immigrant youth in the USA: A pilot project. Journal of International Migration and Integration, 17, 1195–1209. doi:10.1007/s12134-015-0457-6

Karaman, M. A., & Ricard, R. J. (2016). Meeting the mental health needs of Syrian refugees in Turkey. The Professional Counselor, 6, 318–327. doi:10.15241/mk.6.4.318

Keller, A., Joscelyne, A., Granski, M., & Rosenfeld, B. (2017). Pre-migration trauma exposure and mental health functioning among Central American migrants arriving at the US border. PLOS One, 12, 1–11.


Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., . . . Pottie, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Mental Health Association Journal, 183, 959–967. doi:10.1503/cmaj.090292

Knake, L. (2014, July 14). Protesters carry AR rifles, flags in march against Central American teens coming to Vassar. Mlive. Retrieved from


Krogstad, J. M., Gonzalez-Barrera, A., & Lopez, M. H. (2014). Children 12 and under are fastest growing group of unaccompanied minors at U.S. border. Retrieved from


Lonn, M. R., & Haiyasoso, M. (2016). Helping counselors “stay in their chair”: Addressing vicarious trauma in supervision. VISTAS 2016. Retrieved from

Montgomery, E., & Foldspang, A. (2008). Discrimination, mental problems and social adaptation in young refugees. European Journal of Public Health, 18, 156–161. doi:10.1093/eurpub/ckm073

O’Connor, E. (2012, October 15). Mexico’s Ciudad Juárez is no longer the most violent city in the world. Time. Retrieved from

Office of Refugee Resettlement. (2016). Facts and data. Retrieved from


Overseas Security Advisory Council. (2016). Guatemala 2016 crime & safety report. Retrieved from

Padgett, T. (2014, March 19). El Salvador’s new president faces gangs, poverty and instability. NPR: Parallels. Retrieved from

Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community Mental Health Journal, 41, 581–597. doi:10.1007/s10597-005-6363-1

Renwick, D. (2016, January 19). Central America’s violent Northern Triangle. Council on Foreign Relations. Retrieved from

Ribando, C. M. (2007). Gangs in Central America (CRS RL34112). Retrieved from the U.S. Department of Justice website:

Sabin, M., Lopes Cardozo, B., Nackerud, L., Kaiser, R., & Varese, L. (2003). Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. Journal of the American Medical Association, 290, 635–642. doi:10.1001/jama.290.5.635

Sartor, T. A. (2016). Vicarious trauma and its influence on self-efficacy. VISTAS Online 2016. Retrieved from


Sawyer, C. B., & Márquez, J. (2017). Senseless violence against Central American unaccompanied minors: Historical background and call for help. The Journal of Psychology, 151, 69–75.

Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three- through six year-old children: A randomized clinical trial. The Journal of Child Psychology and Psychiatry, 52, 853–860. doi:10.1111/j.1469-7610.2010.02354.x

Seelke, C. R. (2016). Gangs in Central America (CRS RL34112). Retrieved from


Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., & Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology, 37, 156–183. doi:10.1080/15374410701818293

Stinchcomb, D., & Hershberg, E. (2014). Unaccompanied migrant children from Central America: Context, causes, and responses (CLALS Working Paper Series No. 7). Retrieved from

Stuber, J., Galea, S., Ahern, J., Blaney, S., & Fuller, C. (2003). The association between multiple domains of discrimination and self-assessed health: A multilevel analysis of Latinos and Blacks in four low-income New York City neighborhoods. Health Services Research, 38, 1735–1759.


Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services (HHS Publication No. SMA 13-4801). Rockville, MD: Author.

Tousignant, M. (1992). Migration and mental health—some prevention guidelines. International Migration, 30, 167–177. doi:10.1111/j.1468-2435.1992.tb00782.x

Tribe, R. (2002). Mental health of refugees and asylum-seekers. Advances in Psychiatric Treatment, 8, 240–247. doi:10.1192/apt.8.4.240

Uehling, G. L. (2008). The international smuggling of children: Coyotes, snakeheads, and the politics of compassion. Anthropological Quarterly, 81, 833–871. doi:10.1353/anq.0.0031

United Nations Children’s Fund. (2016). Broken dreams: Central American children’s dangerous journey to the United States. Retrieved from


United Nations High Commissioner for Refugees. (2015). Global trends: Forced displacement in 2015. Retrieved from

United Nations Office on Drugs and Crime. (2011). Global study on homicide. Retrieved from http://www.unodc.


Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405.


Vervliet, M., Meyer Demott, M. A., Jakobsen, M., Broekaert, E., Heir, T., & Derluyn, I. (2014). The mental health of unaccompanied refugee minors on arrival in the host country. Scandinavian Journal of Psychology, 55, 33–37. doi:10.1111/sjop.12094

Ward, C., Okura, Y., Kennedy, A., & Kojima, T. (1998). The U-curve on trial: A longitudinal study of psychological and sociocultural adjustment during cross-cultural transition. International Journal of Intercultural Relations, 22, 277–291. doi:10.1016/S0147-1767(98)00008-X

Watts, J. (2015, August 22). One murder every hour: How El Salvador became the homicide capital of the world. The Guardian. Retrieved from

Williams, A., Helm, H. M., & Clemens, E. V. (2012). The effect of childhood trauma, personal wellness, supervisory working alliance, and organizational factors on vicarious traumatization. Journal of Mental Health Counseling, 34, 133–153. doi:10.17744/mehc.34.2.j3l62k872325h583

Women’s Refugee Commission. (2012). Forced from home: The lost boys and girls of Central America. New York, NY: Author.

Yardley, L. (2008). Demonstrating validity in qualitative psychology. In J. A. Smith (Ed.), Qualitative psychology:
A practical guide to research methods
(2nd ed., pp. 235–251). Thousand Oaks, CA: Sage.




Angelica M. Tello, NCC, is an assistant professor at the University of Houston-Clear Lake. Nancy E. Castellon is a doctoral student at the University of Texas at San Antonio. Alejandra Aguilar is a doctoral student at the University of Houston-Clear Lake. Cheryl B. Sawyer is a professor at the University of Houston-Clear Lake. Correspondence can be addressed to Angelica Tello, 2700 Bay Area Blvd, Houston, Texas, 77058-1002,



Counseling People Displaced by War: Experiences of Refugees from the Former Yugoslavia

Branis Knezevic, Seth Olson

The purpose of this qualitative study was to explore the lived experiences of refugees from the former Yugoslavia who migrated to the United States as a result of the civil wars in the 1990s. The present research utilized a phenomenological method, in which the researchers collected data using in-depth interviews with 10 participants; analyzed the data themes relating to the pre- and post-migration experiences; and documented high rates of exposure to war-related violence and the presence of multiple stressors during resettlement. The study offers an integration of the collective essence and meaning of refugees’ experiences. Findings suggested that being a refugee and resettling in a new country constitute a complex and life-changing process. Overall, the results indicated that the migration process for refugees from the former Yugoslavia was modulated by stressors during the war, migration and resettlement. The study concludes with a discussion of implications for counseling practice and counselor education.


Keywords: civil wars, refugees, migration, Yugoslavia, resettlement, stressors


Violent conflicts throughout the world have left millions of people displaced, some within their own country (the internally displaced) and some across international borders (refugees). The United Nations High Commissioner for Refugees (UNHCR) reported that in 2010, 43.7 million people from over 125 countries were forcibly displaced from their homes by civil or interstate war (2011), and that the expense of meeting needs was nearly $2 billion. The psychological impact of war has been widely acknowledged and well documented (Miller & Rasco, 2004; Miller, Weine, et al., 2002; Mollica, 2006; Murthy & Lakshminarayana, 2006; Porter & Haslam, 2001; Summerfield, 2003; van den Heuvel, 1998).


The most frequently reported consequence of war exposure is post-traumatic stress disorder (PTSD), followed by depression, recurrent nightmares, insomnia, chronic hyperarousal, impaired concentration and irritability (Miller & Rasco, 2004). It has been estimated that 50% of refugees experienced higher levels of PTSD, depression and other psychiatric problems (de Jong, Scholte, Koeter, & Hart, 2000), with the lifetime prevalence of PTSD among specific groups of trauma survivors ranging from 15%–24%, compared to 8% in the general United States population (de Jong et al., 2001). PTSD is associated with long-term physical health problems, higher mortality rates and heart disease (Hamblen & Schnurr, 2007).


One country in particular, the former Socialist Federative Republic of Yugoslavia, experienced similar issues. The breakup of Yugoslavia in the 1990s produced an estimated 992,200 refugees and 1,203,000 internally displaced people, which constituted 3% of the total population (U.S. Department of Health & Human Services [USDHHS], 1999). From 1983–1999, the United States accepted an estimated 200,000 refugees from the former Yugoslavia (USDHHS, 1999). Furthermore, in 1998 and 1999, refugees from the former Yugoslavia were the largest refugee group admitted into the United States, representing 36% of all arrivals (USDHHS, 1999).


Consistent with other wars, the hardships in the former Yugoslavia were particularly acute for women, children and the elderly (Weiss & Pasic, 1998). Thousands of people suffered through war trauma, persecution, torture, abrupt and sometimes repeated displacements, physical violence against themselves or their family, rape and other forms of sexual violence. As a result of this exposure, refugees from the former Yugoslavia have reported high rates of depressive symptoms, PTSD and other trauma-related issues (Porter & Haslam, 2001; Vojvoda, Weine, McGlashan, Becker, & Southwick, 2008; Weine et al., 1998).


Purpose of Study


Resettling in the United States is not an easy process, and many refugees experience numerous problems in their new host country. Some of these problems include “poverty, illiteracy, prolonged dependence on government aid, cultural differences, social isolation, the language barrier, and loss of status” (Carlson & Rosser-Hogan, 1993, p. 224). Humanitarian organizations have primarily been concerned with the material and medical needs of refugees, largely ignoring mental health needs (Mollica, Cui, McInnes, & Massagli, 2002). Mollica (2006) noted that it is worrisome that psychological support for victims of war has been so limited and often nonexistent.


Miller and Rasco (2004) stated that there is a substantial need to collect and explore the stories of forced displacement from refugees themselves. They stated that in much of the research on refugees, “the voices of refugees are largely absent” (p. 343), noting that researchers have underutilized qualitative methods, such as semi-structured interviews, which are more effective in deepening understanding of the range of stressors, challenges and experiences that refugees commonly face. Miller, Worthington, Muzurovic, Tipping, and Goldman (2002) explained that in order to understand people’s life in exile, it is necessary to first understand their central reference point, which is their life before the forced migration. Although psychological assessments and quantitative methods can specify patterns of distress, Miller, Worthington, et al. (2002) suggested capturing the historical aspects of refugee experiences by utilizing thick descriptions and phenomenological exploration. Furthermore, many studies in the literature support the assertion that pre- and post-migration experiences can have an impact on the mental health of refugees (Mollica, 2006; Mollica et al., 2002; Silove, 1999). The primary purpose of this study was to achieve better understanding of the experiences, attitudes, perceptions and mental health needs of refugees as they coped with their traumatic war past and challenges in adjusting to United States society. Secondarily, the results provide counselor educators, school counselors and mental health counselors with the education, suggestions and strategies necessary to work with refugees displaced by war.





Participants were 10 refugees from the former Yugoslavia, resettled in the Midwestern United States. There were six female and four male participants. Their ages ranged from 38–63 years, with a mean of 49.5 years. Eight participants originated from Bosnia, one from Serbia, and one from Croatia. All 10 participants had lived in another country (e.g., Germany) before coming to the United States; therefore, participants had experienced displacement multiple times. The number of years that participants had been in the United States ranged from 8–20, with a mean of 12.7 years. Educational backgrounds ranged from vocational training to graduate professional degrees. Nine participants were employed at the time of the interviews and one was retired. All of the participants were married; nine had children and two had grandchildren.


Primary Researcher’s Background

     Qualitative research is personal in nature, and the identity and experiences of the researcher influence the results that are produced (McLeod, 2002). The first author was born and raised in Belgrade, the capital of the former Yugoslavia. The researcher left the former Yugoslavia in 1988, several years before the war began. Based on personal experiences and acquired knowledge, her assumptions included the following: (a) participants were resilient despite the traumatic events and stressors they were exposed to; (b) most participants did not seek professional help (e.g., counseling services), but engaged in talking with friends and family members; and (c) participants were likely to miss their home country, old friends and culture.



A convenience and snowball sampling method was used in two communities in the Midwest. The inclusion criteria were as follows: (a) participants were older than 25 years of age (in order to remember their pre-migration experiences); (b) participants were Yugoslav citizens who had lived in the former Yugoslavia; and (c) participants had relocated to the United States as a direct result of the 1991–1995 civil wars. The first author scheduled a personal meeting with each individual who expressed interest in participating, in order to explain the nature of the study and discuss issues of confidentiality, informed consent and freedom to terminate participation at any time. This meeting included a detailed review of the consent form, ensuring that potential participants fully understood the purpose of this study and agreed to take part. The authors provided consent forms in English and in Serbian/Bosnian/Croatian, depending on the participant’s language of choice; the authors also explained confidentiality and privacy throughout the research process.


Upon obtaining consent, the authors asked participants to fill out a demographic questionnaire, and then collected data through semi-structured interviews, which were recorded, transcribed verbatim and translated. Nine interviews were conducted in Serbian/Bosnian/Croatian and one in English. The first author translated the transcripts, and her husband verified the translations for accuracy. (The first author’s husband is fluent in English and Serbian/Bosnian/Croatian, and is not connected to this research project.) As a prerequisite of conducting translation verification services, the author’s husband took part in institutional review board (IRB) training and became familiar with the tenets of qualitative research interviewing. The first author conducted interviews in private homes—some in the participants’ homes and some in mutual acquaintances’ homes. Interviews lasted from 1–2 hours, depending on the amount of information provided. In qualitative research there is no fixed number of participants. Creswell (2007) suggested interviewing 5–25 individuals through single in-depth interviews or multiple interviews, until saturation of data is achieved. After careful consideration, the first author conducted in-depth interviews with 10 participants, which allowed her to reach the point of saturation. She asked participants at the end of the interviews and during the verification process whether they wanted to add anything to their story.


The present study was part of a doctoral dissertation, and the university’s IRB and dissertation research committee approved the protocol. To ensure confidentiality, the authors locked all notes, tapes and flash drives in a file cabinet, and did not identify participants by their first or last names or with any other information (the names that appear in this paper are fictitious).


The research questions for this study were as follows:


  1. What are the key themes, contexts and processes in the integration of pre-migration experiences for refugees from the former Yugoslavia?
  2. What are the key themes, contexts and processes in the integration of post-migration experiences for refugees from the former Yugoslavia?


This study sought to explore what it means to be a refugee from the former Yugoslavia by understanding the thoughts, beliefs and feelings that the participants have about their displacement and forced migration. In order to gain a deeper awareness of the participants’ experiences, the first author asked open-ended, culturally sensitive questions, utilizing an informal, conversational tone. The interviews explored topics and issues that included pre-migration, arrival, reception in the United States and post-migration, following the chronological stages of migration. The authors pretested the questions and protocol with two practice interviews in order to assess how effectively the questions would work and whether they would obtain the type of information they sought (Berg, 2007). The purpose of the pilot study was to determine whether the questions were easily understood and culturally appropriate, and whether the research protocol was adequate. The author asked pilot study participants to give their feedback about the interview process and identify any modifications that needed to be made. The Appendix provides a complete list of interview questions, which the authors used only as a general structure for gathering information and not as a script. The authors modified questions during the interviews, depending on what appeared comfortable and what a participant shared spontaneously.


Data Analysis

In phenomenological research, the transcriptions are reduced into emerging themes, which are linked thematically until a full description is derived (Moustakas, 1994). The qualitative software used in this research was ATLAS.ti 6.2. After coding all transcripts, the authors identified emerging themes by grouping and classifying similar answers, and then used the themes to construct the narrative describing what the experience meant to the participants. In order to ensure trustworthiness, the authors used three strategies (Creswell, 2007). First, the participants verified the findings for accuracy of interpretation. Second, the authors shared the findings with committee members. Third, the authors asked a peer reviewer to look over the material and react to the themes that emerged. The authors then incorporated the feedback from participants, committee members, and the peer reviewer into the themes. The results are categorized by research question: experiences during pre-migration and experiences during post-migration.




Experiences During Pre-Migration

Participants’ responses were organized into three major categories: (1) living well, (2) tensions building, and (3) the war experience and its effects (Table 1).


Table 1

Pre-Migration Perspectives


Code and Major Categories Code and Theme Code and Subtheme
1. Living well 1.1 Multinational society
1.2 Normal, good life
2. Tensions building
3. War experiences and their effects 3.1 Hardship 3.1.1 Displacement
3.1.2 Severe living conditions
3.1.3 Loss of freedom
3.2 Trauma conditions 3.2.1 Fear
3.2.2 Other mental health stress
3.3 The experience of loss
3.4 Escape

Note. Code indicates thematic hierarchy.


     Living well. Living well incorporated the participants’ perceptions of life before the war. All the participants described their lives as normal and stable, consisting of raising families, completing their education or finding employment. All the participants characterized the former Yugoslavia as a society in which people of all ethnicities lived in peace and harmony. Nikola described the multinational society (1.1) of the country as follows: “This country was a very special combination of religions and nationalities.” Participants talked about the normal, good lives (1.2) they lived, with an emphasis on personal goals. Mira stated that their parents gave them a “comfortable life, and a safe home in which we didn’t lack in anything.”


     Tensions building. This category emerged to describe the deteriorating situation in the country that created tension between different ethnic groups. Even when the war started in Slovenia in 1991, many participants did not believe that it would spread to the rest of the country (e.g., Bosnia, Serbia, Croatia); it seemed so distant. The situation was rapidly deteriorating, as Nina described:


Everything started changing; I could feel that there would be a war, first you could feel it at work, and you had to watch what you said because ethnic groups started talking against each other. We all knew and felt that something will happen.


     The war experience and its effects. This category contained descriptions of what life was like during the war. The data were grouped into four themes: hardship (3.1), trauma conditions (3.2), the experience of loss (3.3) and escape (3.4).


Hardship (3.1). During the war, the civilian population experienced various forms of hardship. Participants described their hardship as displacement (3.1.1), severe living conditions (3.1.2) and loss of freedom (3.1.3). The following excerpt from Mira captures her experience when she was displaced from her home:

We didn’t have anywhere to go nor did we know anybody there. With our bags in our hands and more bags over our shoulders, with three small kids in our arms, we were on the street. We were standing on the street like that and we looked around in all directions, wondering what to do.

Kristina described severe living conditions after being displaced from their home:

We would lie down next to each other, my husband, then my father, and then my mother,            we all lined up like that in a line to sleep outside. The rest of the people were next to us, they lined up also. My children were between me and my mother, to shelter them and keep warm; we had no blankets to cover them with. That’s how we slept for a week.


Life during the war was disrupted and difficult. Participants had to deal with many shortages of supplies, such as food, gasoline, water and electricity. After being left without work, participants did not have any real source of income. They experienced financial hardship, as explained by Daniel, who was forced into random, odd jobs:

I worked as a laborer at the local farms; I didn’t have any other job. One day I would work with one farmer, the next with another. Some paid me and some didn’t. I couldn’t do anything about it, if they gave me some money, I was very pleased. But if they didn’t I would move on.

According to the data, males and females experienced loss of freedom differently. Women and children often encountered loss of freedom as an inability to leave the area or an inability to move freely around the city or the rest of the former Yugoslavia. Men often experienced loss of freedom as being subjected to forced mobilization, which was the case for two participants.


Trauma conditions (3.2). The overall experience of war directly resulted in conditions that led people to experience trauma and emotional suffering. The sense that one’s life was in constant danger created conditions for participants to experience fear (3.2.1) and other mental health stress (3.2.2). Several participants talked about fear of mobilization, and the female participants were fearful for their husbands, brothers and fathers. Fear for their lives and the lives of their loved ones was constant and overpowering. There was an overwhelming sense of the danger and risk that occurred in war situations as participants grasped the seriousness of their circumstances. Emma explained: “But maybe somebody will come and kill me, I can’t tell you what the people were talking about around us.” Living under the constant threat of death produced many different feelings for the participants: hopelessness, anger, guilt, shame, self-pity, deep sorrow, despair, anxiety and depression.


The experience of loss (3.3). The participants experienced loss throughout the displacement: family separations as well as loss of possessions, income, support, dreams, security and opportunity. Mira talked about losing everything: “All our material possessions were lost. That is not important any more, the only thing that was left worth fighting for were our lives.” Participants also described the loss of hope, friends and country, as Mira stated:

We realized that the country we lived in just doesn’t exist anymore and that was very difficult. We could not patch it up anymore. It was all lost and there is no going back. It was very difficult to accept that fact. We understood with great sorrow that we can’t continue this way. We didn’t know what to do.


Escape (3.4). As a result of participants escaping at different times during the conflict, their difficulties ranged from buying an airplane ticket to crossing the border in the middle of the night. Many participants escaped abruptly because of the war. Five participants talked about having to walk long distances with small children, without any food or shelter. During their escape, their lives continued to be in danger.


Experiences During Post-Migration

     The categories that emerged in the post-migration phase were the following: (1) cultural shock, (2) resettlement support and (3) coping with challenges (Table 2).



Table 2

Post-Migration Perspectives


Code and Major Category Code and Theme Code and Subtheme
1. Cultural shock
2. Resettlement support 2.1 Aid organizations
2.2 Relatives and family
3. Coping with challenges 3.1 Learning English
3.2 Becoming employed
3.3 Cultural connections 3.3.1 Religion


Note. Code indicates thematic hierarchy.


     Cultural shock. All 10 participants stated that their expectations did not match the realities of life in the United States. Sava had formed his expectations through Hollywood movies: “Basically now when I look back at the America I knew, it was the America that presented itself through movies. And real American people are not like the movies.” The participants’ emotional reactions in the early period of migration were varied. Kristina described her experience as follows:

When we first came here, it was terrible, it was a catastrophe. My husband and I were crying on our balcony every day. We cried because we didn’t know anything here, like we fell out of the sky. One moment we were thinking of taking our bags and packing to go back home. We thought there is no life for us here, this is not for us. We wanted to go anywhere but here.


     Resettlement support. Individuals who came to the United States and were granted refugee status were eligible for certain short-term benefits, services and aid in the resettlement process. Most participants came to the United States with little money and few possessions, and therefore many depended on aid programs for financial assistance, housing and basic needs. Nina explained the help of aid organizations (2.1) as follows:


They helped us so much, three churches were helping us, they were so good to us. It was wonderful. The third day after our arrival they found us an apartment and they asked if we like[d] it, and we said we liked it very much.


Some participants had relatives (2.2) who had come to the United States earlier and were willing to help them. Mira explained:


They took us into their warm house and we spent almost a month with them; they helped us to figure things out, to find our own apartment, to start school and orientation, to get our social security numbers, and all of those initial things we completed with their help.


     Coping with challenges. Participants reported varying challenges as they arrived and settled in the United States. They managed these difficulties by using effective coping strategies, such as learning English (3.1), becoming employed (3.2) and getting involved with the Yugoslavian community (3.3). The most common theme that emerged regarding post-migration difficulty was the language barrier. English language competence (3.1) was considered a survival skill. Without speaking English fluently, the participants experienced challenges in daily living, isolation and a lack of support. They relied heavily on interpreters and did not feel independent. Nina stated, “We came and we didn’t know even one word of English; even today I don’t know English very well, but back then I didn’t even know one word. We were not prepared at all.”


Based on the findings of this study, all the participants stated that getting a job (3.2) was very important in their adaptation process. All the participants who received aid wanted to become independent as quickly as possible and obtain a job that would provide an income for their basic needs. Working gave participants a sense of control over their lives, which made them feel better about themselves. In addition to emphasizing employment, the participants also indicated the importance of remaining connected to members of their cultural group (3.3). The impact of community on the participants’ adaptation in the United States was salient across the narratives. Bane said:


We always have big parties at my house; we have a great community here. I like it when everybody comes to my house. My house is small and the basement isn’t anything fancy, but the best parties and celebrations are at my house.


Five participants talked about religion (3.3.1) and spirituality. Ana described her experience: “We have a church, at the time when we came the priest was this wonderful man, he was so kind, so we went often while he was there.” Zoran reported strongly that being a member of the cultural community gives his life meaning and satisfaction. Several participants added that the community was a source of frustration for them, with divisions along ethnic lines.




Many studies in the literature support the idea that pre- and post-migration experiences can have an impact on the mental health of refugees (Mollica, 2006; Mollica et al., 2002; Silove, 1999). The purpose of this study was to achieve better understanding of the experiences, attitudes and perceptions of refugees as they coped with their traumatic war past and challenges in adjustment to United States society.


Pre-Migration Perspectives

The first research question addressed the experiences of the participants in the former Yugoslavia before their forced migration. In the literature about refugees, it has been well recognized that experiencing war is difficult and traumatizing (Miller, Weine, et al., 2002; Porter & Haslam, 2001; Silove, 1999; Weine et al., 1998). The results of this qualitative study are consistent with similar research on refugee populations who have been displaced from their countries because of war. This study also provides new information specific to the within-context perspective of trauma and violence that took place in the former Yugoslavia. The adversity that the participants faced reflected a broader political and socioeconomic conflict; yet this study focused on a phenomenological view. Two things are unique to this population. First, most participants were surprised by the onset of war and were caught unprepared to deal with the daily hardships. Participants described the transition from a peaceful life to the war period as a time in which tension and danger were increasing and the threshold between peace and war was reached. Second, the male participants who were drafted into joining the war did not believe in the cause and were forced to fight against different ethnic groups.


Numerous research studies have established that refugees experience the first set of stressors in pre-migration prior to forced exile (Miller & Rasco, 2004; Pumariega, Rothe, & Pumariega, 2005). Silove (1999) developed the conceptual framework for understanding pre-migration experiences. The refugee experience contains an accumulation of stressors until a decision is reached to flee, which Silove (1999) referred to as the continuum of stress. As the participants in the present study stated, life-threatening events were a part of their daily lives in the war-torn country. The results indicated that the pre-migration experiences included exposure to war, sudden displacement, and loss of personal safety and security. The participants lived in fear, which they experienced as fear of mobilization and fear for their lives and the lives of their loved ones.


As supported in the literature, participants voiced that the pre-migration phase was marked by major losses (Ryan, Dooley, & Benson, 2008; Silove, 1999), such as loss of freedom, employment, home, stability and security. The participants experienced considerable material deprivation and were able to take only a few documents with them before their escape. Many of their houses and other material belongings were totally destroyed. Participants in this study specifically discussed the loss of jobs, which represented the disappearance of their primary source of income and created financial hardship as they experienced “an ongoing accumulation of losses, challenges, [and] life changes” (Porter & Haslam, 2001, p. 818).


Traumas that occur in pre-migration have captivated the attention of researchers. Some researchers described refugee experiences from different regions around the world (Ager & Young, 2001) and some described experiences from the former Yugoslavia (Miller, Worthington, et al., 2002; van den Heuvel, 1998). There are many similarities between experiences, yet each refugee story is unique. Refugees who have experienced war may be coping with emotional traumas resulting from witnessing bombardments and destruction, family separation and life in poverty conditions (Neuner et al., 2008). The participants in this study faced destruction of homes and communities, life-threatening events, danger, and forced participation in combat. These traumatic conditions caused emotional suffering, constituting the first set of stressors that have a negative impact on the mental health of refugees (Miller & Rasco, 2004). It is noted in the literature that some refugees from war-torn countries have lived under the constant threat and fear of death (Miller & Rasco, 2004); this finding is consistent with the results in this study. Some of the other mental health stress reactions that participants experienced were hopelessness, anger, guilt, shame, self-pity, despair, anxiety and depression.


In addition to mental health consequences, the participants in this study faced daily problems with safety, security and limited freedom of movement. The participants experienced loss of freedom, which manifested differently for men than for women and children. According to Weiss and Pasic (1998), the hardships in the former Yugoslavia were particularly acute for women, children and the elderly. This finding was supported by the experiences of the participants in this study. Due to constant bombardment, women and children were trapped in shelters, basements or abandoned houses. Men were forced to fight in the war and were separated from their families. Two of the four male participants in this study were forced into combat and did not have any other choice but to follow orders. They did not know who they were fighting against because friends and neighbors faced each other on the front lines. The other two male participants in this study were able to flee the country before they could be forced to fight in the war.


As reported in other studies (Ager & Young, 2001; Miller, Worthington, et al., 2002; van den Heuvel, 1998), refugees from the former Yugoslavia experienced serious challenges during the war. The present study confirmed this finding, as all 10 participants were affected by the war in the pre-migration phase. Participants lived in unstable and unsafe situations, with daily bombardment of their villages and cities. They experienced economic hardship, social disruption, violence, hiding from military forces, and the trauma of sudden or multiple displacements.


Post-Migration Perspectives

The second research question for this study explored post-migration experiences. Refugees who had survived traumatic experiences while living in a war zone now faced a new set of stressors, compounded by migration to a new and different environment (Ager, Malcolm, Sadollah, & O’May, 2002; Mosselson, 2009). Migration involves events that can be highly stressful, such as separation from familiar surroundings and being placed in a new and alien culture (Carballo & Nerukar, 2001). Based on the findings of this study, the experiences of the participants during the post-migration period included cultural shock, resettlement support, coping with challenges and cultural connections.


Refugees often face challenges in the post-migration phase of their refugee experiences (Davidson, Murray, & Schweitzer, 2008; Miller, Worthington, et al., 2002). The results of this study suggested that participants were inadequately informed or prepared for migration to the United States. This study found that the participants’ early adjustment experiences were highly stressful, resulting in cultural shock. Cultural shock can precipitate feelings of helplessness and disorientation (Bemak, Chung, & Bornemann, 1996). The participants’ first impressions of the United States were mostly negative, and they experienced difficulty operating in a new culture. The findings are consistent with the literature suggesting that refugees who depart from traditional routines and established social networks often suffer from social isolation and loss of social and occupational roles (Ager et al., 2002; Carballo & Nerukar, 2001). Many participants were disappointed when they first arrived in the United States, and all 10 participants stated that their first impressions did not match the realities of life in the United States.


Coming to the United States was a second or third migration for some participants. While they were safe from immediate danger, experiences in the country of first or second asylum are often very stressful (Ager & Young, 2001). Participants in this study did not want to come to the United States, but the war forced them out of their homes and they were not able to settle anywhere else. There is a fundamental difference between immigrants who voluntarily leave their country and refugees who are forced to leave. This loss of control over the decision-making process regarding geographic location is an important factor in the adaptation process for a refugee (Bemak, Chung, & Bornemann, 1996).


The participants in this study experienced difficulties that were grouped into the theme coping with challenges. One of the primary challenges in the participants’ resettlement was learning English. Knowledge of English is seen in the literature as a prerequisite for successful integration and an important aspect of adjustment (Djuretic, Crawford, & Weaver, 2007). One participant in this study was fluent in English upon arrival in the United States, but the other nine participants stated that they spoke little or no English when they resettled. The inability to read and write English made daily life very difficult. Participants relied on interpreters to take them to the doctor, fill out forms or open a bank account, and consequently they faced isolation and a lack of independence. Participants claimed that learning English was the most difficult challenge in their resettlement. The findings of this study demonstrate a need for programs that can help refugees learn English, which will help them find higher-paying jobs and decrease financial dependency on aid organizations.


Consistent with the literature, this study further uncovered strategies used for survival in a new system (Djuretic et al., 2007). These findings support Mollica’s (2006) core psychological dimension of self-healing, in which the individual demonstrates a will to survive and recover. Opportunities to practice traditions from the home country, to participate in social activities and to work all have a positive impact on the body and mind. All participants became employed soon after resettlement, which was mostly due to the aid organizations. Participants stated that they were placed in jobs soon after arrival in order to decrease their dependency on financial aid. It seemed that immediate employment was the key objective for the aid organizations, and participants were relieved to become employed and self-sufficient, which provided stability for their families and allowed them to feel better about themselves. Participants stated that their goal was not to depend on aid organizations, but to build a new life, and to once again feel in charge of their destiny. Through working, participants were able to build new relationships and become socially involved in their new country. Becoming financially stable allowed two participants to send money to relatives in the former Yugoslavia; several participants tried to sponsor others to come to the United States.


The need to balance cultural connections with the home country and the host community can be stressful (Gray & Elliott, 2001). The literature suggests that from a psychological standpoint, cultural connections positively impacted the participants’ adjustment to the new environment (Mollica, 2006). Refugees rely on social support during times of transition and resettlement (Simich, 2003). Isolation from natural support systems often leads to emotional vulnerability. The literature also suggests that access to co-ethnic and co-linguistic communities may have established better adjustment (Ager et al., 2002; Mollica, 2006).


Consistent with other research, the study participants identified social support as a key influence in their post-migration life. Porter and Haslam (2001) stated that refugees “are forced to reevaluate assumptions about their social roles, lives, and core identities” (p. 818). Participants in this study talked about the benefits of being connected with the Yugoslavian community, and they often turned to each other for friendship, information and help during the stressful time of resettlement. This community not only offered familiarity and continuity of traditions, religion and language, but also served as a source of advice, emotional support and exchange of resources built on mutual recognition. Several participants invested money, time and effort in building a church and cultural center. Within the cultural community, individuals shared their pre-migration experiences and celebrated cultural traditions through holidays, food, music and dance. Support from family and friends with similar cultural backgrounds is vital for refugees to close the gap between two cultures (Simich, 2003). These cultural relationships provided social support and helped participants navigate the United States system.


Participants discussed the importance of maintaining cultural connections with the community from the former Yugoslavia. According to the data, some participants saw this community as a source of frustration and claimed that different groups from the former Yugoslavia could not get along in the United States as well, creating divisions along ethnic and religious lines. They encountered different groups from the former Yugoslavia in their workplaces and neighborhoods. The irony for the refugees was that people on all sides of the conflict that forced them to emigrate were now living as neighbors in the United States. Most passionate were Nikola and Daneil, who stated that the co-national social networks were a problem rather than an asset. Ethnic affiliation was difficult for participants with spouses from another ethnic group or parents from different ethnic backgrounds.


Limitations of the Study


This study has several limitations. First, the time that has elapsed since the experience of war and the participants’ telling of their stories may be 15–20 years. Second, findings were limited by the small sample of participants and the geographical location of the study. This study used a purposive sample and not a random sample of refugees from the former Yugoslavia. Particular experiences of the participants may not be reflective of the larger immigrant and refugee population from the former Yugoslavia or of refugees from different parts of the world. Third, the composition of the sample may have been impacted by the researcher’s social network in the Yugoslavian community. Fourth, the participants were given the choice of conducting interviews in their first language (Serbian/Bosnian/Croatian) or English. Describing events in their first language provided richer details and descriptions, although translation errors were possible, which could have contributed to misinterpretation or loss of meaning of the data. Fifth, in qualitative research there is a lack of anonymity during the interview process, which in itself may introduce some limitations. Since the first author is from the former Yugoslavia, the participants may have chosen to share perceptions, thoughts and feelings that would be most helpful to the researcher. The researcher’s personal biases and assumptions based on experiences of immigration may have been a limitation in the interpretation of themes and the coding process.


In phenomenological research, the inquiry is autobiographical (Moustakas, 1994). This article is a reflection of the authors’ interpretations, which are based on our cultural, social, class and gender beliefs (Creswell, 2007). Thus, the first author’s own experiences with migration issues and the collapse of Yugoslavia framed the research and interpretive process.


Suggestions for Counselor Educators and Counseling Professionals

It is essential for counselor educators to develop their understanding of refugee populations so that counselors-in-training can improve their cultural proficiency. Counselor educators could benefit from (a) developing courses with a focus on the experiences of refugees or infusing refugee topics into existing courses, (b) inviting speakers with refugee experiences, and (c) generating lists of community resources, with training on how to investigate these resources. Counselor educators can become leaders in educating other professionals who work with refugees and immigrants, such as law-enforcement personnel, social workers and health professionals.


It is recommended that a course on refugee and immigrant issues become an integral part of any counselor training program, in order to prepare new counselors to work in a complex and multicultural world. While a separate course related to refugee, immigrant and wartime experiences would be ideal, it may not be possible for counselor education programs. In a more practical way, educators and counselor education programs would be well served to add these elements to existing courses. For example, counselor educators could add special topics to diversity courses on the causes of international migration, the history of immigration in the United States and refugee policies worldwide. In addition, it is recommended that through continuing education and workshops, practicing counselors should learn about topics that include general refugee and immigrant issues, such as acculturation and strategies for preventing discrimination. Counselors must actively advocate for social justice in their communities and places of employment. Multiculturalism and social justice should be a salient topic in every counselor’s professional development (Stadler, Suh, Cobia, Middleton, & Carney, 2006; Midgette & Meggert, 1991).


Guest speakers with refugee or immigrant backgrounds could help future counselors gain new perspectives about the experiences of resettlement and adaptation. Participants in this study were pleasantly surprised when they encountered individuals who knew facts about the former Yugoslavia or were familiar with some of the names of the new countries that were established. To increase familiarity with issues around the world, international student and community organizations could be used to gain access to guest speakers. Individuals with multicultural backgrounds can promote cross-cultural understanding, new perspectives and interactions based on mutual trust and understanding.


Counselors also can help by assisting refugees with accurate information about services available to them. Participants in this study often depended on aid organizations to provide them with information about accessible services in their new community. With their knowledge of community resources, counselors can provide referrals that help refugees navigate unfamiliar and complicated systems, including information about immigration policies, such as reunification or asylum-seeking requirements (Keel & Drew, 2004).


Mental health professionals who are meeting the needs of displaced people must have the knowledge and skills necessary to effectively work with them. This is a challenge because refugees have specific mental health problems which are often inadequately understood by professionals who work with them (Silove, 2004). Given that the refugee crisis continues to be a worldwide problem (Murthy & Lakshminarayana, 2006), it is important for counselors to increase their understanding of pre- and post-migration issues, which can help them work more effectively with refugees. Roysircar (2004) explained: “Understanding the statements of clients and placing their life events in their trauma contexts enable the therapist to begin to appreciate the worldview of clients rather than making harsh judgments about them” (p. 173).


This research study provided several directions for treatment conceptualization and is further organized into (a) relationship building, (b) culturally appropriate trauma interventions, (c) advocacy-service connections and (d) strength finding.


Relationship building. Building relationships is an important implication of this study—specifically, building relationships with counselors, cultural community members and individuals from the host culture (Birman & Tran, 2008; Weine, 2011). The participants in this study did not utilize any counseling services and indicated that they were not familiar with the counseling profession or services that were available in their communities. In clinical practice, it is recommended that counselors utilize person-centered approaches to explore the client’s story and establish a strong therapeutic relationship to enhance trust and understanding. An understanding of cultural kinship could be an important first step in providing help (Keel & Drew, 2004). The results of this study indicated that fostering cultural connections may bring out natural strengths and support in the refugee community.


Culturally appropriate trauma interventions. As counselors encounter refugees who have lived through war trauma, they will need to provide the necessary interventions to facilitate change. Interventions such as finding meaning, fulfillment and purpose may be used to address the losses endured and improve the mental health conditions of refugees in the new environment (Miller, Worthington, et al., 2002). It is suggested that treatment goals not avoid physical, psychological and emotional loss topics, but address those influences directly.


Advocacy-service connections. In order to enhance mental health services that are accessible to everyone, counselors can take an active leadership role in promoting available services. Counselors can develop multilingual pamphlets explaining the counseling process, and conduct brief community outreach presentations, workshops and psychoeducational groups. However, counselors should not assume that war trauma necessarily results in mental health problems (Miller & Rasco, 2004); refugees in this study wanted to be in charge of their lives and pursue their own goals and ambitions. Counselors can organize and implement volunteer programs in communities so that soon after arrival to the United States, refugees can access volunteers’ skills and knowledge. School counselors can be helpful in providing information to refugees about the United States education system, building networks and finding information about further educational opportunities.


     Finding strength. Several participants talked about discovering strength and ingenuity that they did not know they possessed. As a result, several participants felt much stronger and had a sense that they could handle anything that came their way. Participants demonstrated resilience to stress and became active agents in determining their future. Based on the responses in this study, it is recommended that counselors acknowledge refugee strengths in meeting adversity. Counselors can do this by reinforcing a sense of normalcy in their clients’ current lives, embracing their sense of hope and safety, and recognizing their rich ethnic history and the complexity of their experiences. Some participants indicated that they were living productive and fulfilling lives despite the trauma they lived through.




This study demonstrated the depth of the trauma experiences that the 10 participants suffered in their homeland, which is consistent with previous literature that has focused on refugees from the former Yugoslavia and from other regions. The first set of stressors they experienced in their native country was compounded by a second set of stressors in their adaptation to the United States. The participants faced many difficulties in their adjustment to United States society and utilized a variety of strategies to overcome these hardships.


In conclusion, mental health services should be part of the resettlement support that refugees receive immediately upon arrival in the United States. The findings of this study indicated that the mental health needs of this population were unmet. It is imperative that counselor education programs provide students with training in refugee issues. Practitioners need training in culturally sensitive approaches that will enable them to provide culturally sensitive interventions with this very specific population. It is hoped that such therapeutic services will allow refugees to live a life free of fear, anxiety and post-traumatic stress. After enduring traumatic experiences in their homeland, these refugees can move forward in their future as productive American citizens and permanent residents.






Ager, A., Malcolm, M., Sadollah, S., & O’May, F. (2002). Community contact and mental health amongst socially isolated refugees in Edinburgh. Journal of Refugee Studies, 15, 71–80. doi:10.1093/jrs/15.1.71

Ager, A., & Young, M. (2001). Cultivating the psychosocial health of refugees. In M. MacLachlan (Ed.), Cultivating health: Cultural perspectives on promoting health (pp. 177–197). Chichester, England: Wiley & Sons.

Bemak, F., Chung, R. C.-Y., & Bornemann, T. H. (1996). Counseling and psychotherapy with refugees. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (4th ed., pp. 243–265). Thousand Oaks, CA: Sage.

Berg, B., L. (2007). Qualitative research methods for the social sciences (6thed.). Boston, MA: Allyn & Bacon.

Birman, D., & Tran, N. (2008). Psychological distress and adjustment of Vietnamese refugees in the United States: Association with pre- and postmigration factors. American Journal of Orthopsychiatry, 78, 109–120. doi:10.1037/0002-9432.78.1.109

Carballo, M., & Nerukar, A. (2001). Migration, refugees, and health risks. Emerging Infectious Diseases, 7, 556–560.

Carlson, E. B., & Rosser-Hogan, R. (1993). Mental health status of Cambodian refugees ten years after leaving their homes. American Journal of Orthopsychiatry, 63, 223–231.

Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five traditions (2nd ed.). Thousand Oaks, CA: Sage.

Davidson, G. R., Murray, K. E., & Schweitzer, R. (2008). Review of refugee mental health and wellbeing: Australian perspectives. Australian Psychologist, 43, 160–174. doi:10.1080/00050060802163041

de Jong, J. P., Scholte, W. F., Koeter, M. W. J., & Hart, A. A. M. (2000). The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiatrica Scandinavica, 102, 171–177. doi:10.1034/j.1600-0447.2000.102003171.x

de Jong, J. T. V. M., Komproe, I. H., Van Ommeren, M., El Masri, M., Araya, M., Khaled, N., . . . Somasundaram, D. (2001). Lifetime events and posttraumatic stress disorder in 4 postconflict settings. The Journal of the American Medical Association, 286, 555–562.

Djuretic, T., Crawford, M. J., & Weaver, T. D. (2007). Role of qualitative research to inform design of epidemiological studies: A cohort study of mental health of migrants from the former Yugoslavia. Journal of Mental Health, 16, 743–755.

Gray, A., & Elliott, S. (2001). Refugee resettlement research project ‘Refugee Voices’: Literature Review. New Zealand Immigration Service. Retrieved from

Hamblen, J., & Schnurr, P. (2007). Mental health aspects of prolonged combat stress in civilians. National Center for PTSD. Retrieved from

Keel, M. R., & Drew, N. M. (2004). The settlement experiences of refugees from the former Yugoslavia. Community, Work & Family, 7, 95–115. doi:10.1080/1366880042000200316

McLeod, J. (2002). Qualitative research in counselling and psychotherapy. London, England: Sage.

Midgette, T. E., & Meggert, S. S. (1991). Multicultural counseling instruction: A challenge for faculties in the 21st century. Journal of Counseling & Development, 70, 136–141. doi:10.1002/j.1556-6676.1991.tb01574.x

Miller, K. E., & Rasco, L. M. (2004). An ecological framework for addressing the mental health needs of refugee communities. In K. E. Miller & L. M. Rasco (Eds.), The mental health of refugees: Ecological approaches to healing and adaptation (pp. 1–66). Mahwah, NJ: Erlbaum.

Miller, K. E., Weine, S. M., Ramic, A., Brkic, N., Bjedic, Z. D., Smajkic, A., . . . Worthington, G. (2002). The relative contribution of war experiences and exile-related stressors to levels of psychological distress among Bosnian refugees. Journal of Traumatic Stress, 15, 377–387. doi:10.1023/A:1020181124118

Miller, K. E., Worthington, G. J., Muzurovic, J., Tipping, S., & Goldman, A. (2002). Bosnian refugees and the stressors of exile: A narrative study. American Journal of Orthopsychiatry, 72, 341–354. doi:10.1037/0002-9432.72.3.341

Mollica, R. F. (2006). Healing invisible wounds: Paths to hope and recovery in a violent world. Orlando, FL: Harcourt.

Mollica, R. F., Cui, X., McInnes, K., & Massagli, M. P. (2002). Science-based policy for psychological interventions in refugee camps: A Cambodian example. The Journal of Nervous and Mental Disease, 190, 158–166.

Mosselson, J. (2009). From the margins to the center: A critical examination of the identity constructions of Bosnian adolescent refugees in New York City. Diaspora, Indigenous, and Minority Education: Studies of Migration, Integration, Equity, and Cultural Survival, 3, 260–275. doi:10.1080/15595690903227772

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.

Murthy, R. S., & Lakshminarayana, R. (2006). Mental health consequences of war: A brief review of research findings. World Psychiatry, 5, 25–30.

Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 686–694. doi:10.1037/0022-006X.76.4.686

Porter, M., & Haslam, N. (2001). Forced displacement in Yugoslavia: A meta-analysis of psychological consequences and their moderators. Journal of Traumatic Stress, 14, 817–834. doi:10.1023/A:1013054524810

Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community Mental Health Journal, 41, 581–597. doi:10.1007/s10597-005-6363-1

Roysircar, G. (2004). Child survivor of war: A case study. Journal of Multicultural Counseling and Development, 32, 168–179. doi:10.1002/j.2161-1912.2004.tb00369.x

Ryan, D., Dooley, B., & Benson, C. (2008). Theoretical perspectives on post-migration adaptation and psychological well-being among refugees: Towards a resource-based model. Journal of Refugee Studies, 21, 1–18. doi:10.1093/jrs/fem047

Silove, D. (1999). The psychosocial effects of torture, mass human rights violations, and     refugee trauma: Toward an Integrated Conceptual Framework. Journal of Nervous and Mental Disease, 187, 200–207.

Silove, D. (2004). The challenges facing mental health programs for post-conflict and refugee communities. Prehospital and Disaster Medicine, 19, 90–96.

Simich, L. (2003). Negotiating boundaries of refugee resettlement: A study of settlement patterns and social support. Canadian Review of Sociology & Anthropology, 40, 575–591.

Stadler, H. A., Suh, S., Cobia, D. C., Middleton, R. A., & Carney, J. S. (2006). Reimagining counselor education with diversity as a core value. Counselor Education & Supervision, 45, 193–206. doi:10.1002/j.1556-6978.2006.tb00142.x

Summerfield, D. (2003). War, exile, moral knowledge and the limits of psychiatric understanding: A clinical case study of a Bosnian refugee in London. International Journal of Social Psychiatry, 49, 264–268. doi:10.1177/0020764003494004

United Nations High Commissioner for Refugees. (2011). 60 years and still counting: UNHCR Global Trends 2010. Retrieved from http:/

U.S. Department of Health & Human Services, Administration for Children and Families, Office of Refugee Resettlement. (1999). Making a Difference: FY 1999 Annual Report to the Congress. Retrieved from

van den Heuvel, W. J. A. (1998). Health status of refugees from former Yugoslavia: Descriptive study of the refugees in the Netherlands. Croatian Medical Journal, 39, 356–360.

Vojvoda, D., Weine, S. M., McGlashan, T., Becker, D. F., & Southwick, S. M. (2008). Posttraumatic stress disorder symptoms in Bosnian refugees 3 1/2 years after resettlement. Journal of Rehabilitation Research & Development, 45, 421–426. doi:10.1682/JRRD.2007.06.0083

Weine, S. M. (2011). Developing preventive mental health interventions for refugee families in resettlement. Family Process, 50, 410–430. doi:10.1111/j.1545-5300.2011.01366.x

Weine, S. M., Becker, D. F., Vojvoda, D., Hodzic, E., Sawyer. M., Hyman, L., . . . McGlashan, T. H. (1998). Individual change after genocide in Bosnian survivors of “ethnic cleansing”: Assessing personality dysfunction. Journal of Traumatic Stress, 11, 147–153. doi:10.1023/A:1024469418811

Weiss, T. G., & Pasic, A. (1998). Dealing with the displacement and suffering caused by Yugoslavia’s wars. In R. Cohen & F. M. Deng (Eds.), The forsaken people: Case studies of the internally displaced (pp. 175–231). Washington, DC: Brookings Institution Press.







Interview Questions


  1. As we begin our conversation about your experiences, what would be helpful for me to know about you?
  2. Could you tell me about your life in Yugoslavia before the war?
  3. How were you and your family affected by the war?
  4. What were your experiences during the war?
  5. What do you remember as being the most difficult during that time?
  6. Please describe your journey to the United States.
  7. Describe some of your earliest experiences when you first arrived in the United States.
  8. How prepared were you to deal with resettlement in the United States?
  9. What helped you in the resettlement process?
  10. What is life like for you now?
  11. How has this experience changed you?
  12. How have your attitudes and values changed in the adaptation process?
  13. What has surprised you about how you have coped with resettlement?
  14. What has been helpful and what has been difficult while living in America?
  15. What have you learned about yourself during these years?



Branis Knezevic, NCC, is an Assistant Professor at Wayne State College. Seth Olson, NCC, is an Associate Professor at the University of South Dakota. Correspondence can be addressed to Branis Knezevic, 1111 Main Street, Wayne, NE 68787,