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:
- What are the key themes, contexts and processes in the integration of pre-migration experiences for refugees from the former Yugoslavia?
- 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.
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).
|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|
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).
|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.
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.
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:10.1037/0002-94184.108.40.206
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 http://www.immigration.govt.nz/NR/rdonlyres/0E39C519-13CA-48C7-B024-9A551642C0AC/0/RefugeeVoicesLiteratureReview.pdf
Hamblen, J., & Schnurr, P. (2007). Mental health aspects of prolonged combat stress in civilians. National Center for PTSD. Retrieved from http://www.ptsd.va.gov/professional/trauma/war/combat-stress-civilians.asp
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:10.1037/0002-94220.127.116.111
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:/www.unhcr.org/cgi-bin/texis/vtx/home/opendocPDFViewer.html?docid=4dfa11499&query=2010%20Global%20Trends:%2060%20years%20and%20still%20counting
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 http://www.acf.hhs.gov/sites/default/files/orr/annual_orr_report_to_congress_1999.pdf
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.
- As we begin our conversation about your experiences, what would be helpful for me to know about you?
- Could you tell me about your life in Yugoslavia before the war?
- How were you and your family affected by the war?
- What were your experiences during the war?
- What do you remember as being the most difficult during that time?
- Please describe your journey to the United States.
- Describe some of your earliest experiences when you first arrived in the United States.
- How prepared were you to deal with resettlement in the United States?
- What helped you in the resettlement process?
- What is life like for you now?
- How has this experience changed you?
- How have your attitudes and values changed in the adaptation process?
- What has surprised you about how you have coped with resettlement?
- What has been helpful and what has been difficult while living in America?
- 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, firstname.lastname@example.org.