“There is a Mental Resistance”: Experiences of Involving Refugee Parents in a Youth Trauma Recovery Program from the Perspective of Participating Youth, Parents and Facilitators
Auteurs:
Sandra Löfving Gupta, Anna Sarkadi, Georgina Warner
Scalable light-touch programs that align with the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) approach is becoming an established intervention model for refugee youth with symptoms of post-traumatic stress. Teaching Recovery Techniques (TRT) is one example and, as TF-CBT guidelines state, parent sessions are included as the model relies on parents to provide support and instigate the techniques. In addition to traumatic stress, refugee families are often subjected to acculturative, isolation and resettlement stress. This study sought to understand how refugee parental involvement in TRT functions in practice and how it is perceived by participating youth, parents, and facilitators in Sweden. Thirty semi-structured interviews (11 youth, 8 parents, and 11 TRT facilitators) were conducted by phone or videoconference, transcribed, and analyzed using Thematic Network Analysis. A global theme ‘Parental engagement in trauma recovery requires dedicated attention’ emerged. Three organizing themes sat within this global theme: (i) Shifting roles when adapting differently to a new context; (ii) Tendency to keep parents at a distance; and (iii) Parent sessions don’t just happen. Whilst the potential for refugee parent involvement was recognized, a number of factors preventing their participation were identified. Cultural adaptations within TRT facilitators’ training are recommended, including: raising awareness about contextual factors and changes in family dynamics with regard to trauma and migration; adopting culturally responsive ways to present parental involvement to youth and parents; adding positive parenting skills; addressing parental mental health and readiness; and preparing facilitators to redirect parents to adequate services, when needed.
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By now, it is well established that refugees are subjected to traumatic events from multiple sources; be it in the country of origin, during the migration process or after resettlement. Besides traumatic stress these families may also face acculturative, isolative and resettlement stress (Gewirtz et al., 2022; Griffin, 2018; Kaplin et al., 2019). Post resettlement refugee youth also face challenges within domains of social support, security, culture and education as well as discrimination and bullying, (Beiser & Hou, 2016; Lustig et al., 2004; Nakeyar et al., 2018). Consequentially, refugee children have high rates of post-traumatic stress, depression and anxiety (Blackmore et al., 2020).
Trauma-focused cognitive behavior therapy (TF-CBT) is the treatment of choice for children and youth with post-traumatic stress (National Collaborating Centre for Mental Health (UK), 2005). A recent review of TF-CBT for refugees concludes that TF-CBT is relevant for refugee families, even though some tweaks may be needed regarding the use of interpreters and addressing cultural differences in regard to trauma treatment (Chipalo, 2021). Yet, it is an extensive treatment comprising roughly of 12-25 individual sessions, delivered by specialist mental health services. Access and utility of specialist mental health services are limited among refugees (Colucci et al., 2014; Murray et al., 2008; Satinsky et al., 2019). This gap in mental health care needs and utilization is evident in Sweden, the country in which the current study is situated and the country that received the highest number asylum seekers per capita in the European Union in 2015, predominately from countries like Syria, Afghanistan and Iraq, many of whom still remain in Sweden (Tanner, 2016). Since then, Sweden has adopted a stricter immigration policy (with the exception of Ukraine) and implemented laws that occasioned UNHCR to express concerns regarding the mental health of refugee families (UNHCR Recommendations to Sweden on Strengthening Refugee Protection, n.d.).
Teaching Recovery Techniques (TRT) is a manualized group intervention that aligns with the TF-CBT approach, which can be delivered in community settings, such as schools, by professionals after a three-day training with the purpose of preventing the onset of post-traumatic stress disorder (PTSD) among children aged 8-18 years who exhibit trauma symptoms. It comprises 5 weekly group sessions for children including the following components: psychoeducation; affective modulation skills; cognitive coping and processing; in vivo mastery of trauma reminders; guided exposure; and exploring plans and hopes for the future.
TRT includes two sessions for parents. They are recommended to be sequenced prior to the children’s sessions to prepare parents to meet the needs of the children. The first session aims to teach parents about trauma symptoms and normalize children’s reactions. Parents are encouraged to reflect how to create a safe environment for the child to talk about traumatic events through active listening as well as advantages and disadvantages of talking about traumatic events, as parents might be uncomfortable or hesitant addressing this issue. The importance of daily routines is stressed. The second session starts with asking parents to reflect on any tools they use to support themselves emotionally, followed by a brief review of the techniques taught in the children’s TRT sessions. The purpose is twofold; preparing parents to help the children practice the techniques at home as well as trying the techniques for their own benefit. Furthermore, the parents receive information on how to seek care if the child needs additional help after TRT.
TRT has been evaluated in conflict settings, with promising results, and piloted in the resettlement context including in Sweden. (I. Barron et al., 2016; I. G. Barron et al., 2013; Punamäki et al., 2014; Rondung et al., 2022; Sarkadi et al., 2018; Warner et al., 2020). The intervention was developed to meet the needs of low-resource settings, where scalability is prioritized (Ehntholt & Yule, 2006; Yule et al., 2013). Taking the TF-CBT approach into community-based delivery requires careful consideration. A recent international study focused on the experience of implementation and training of TRT facilitators in low-income settings (Heltne et al., 2023). There are also Swedish studies on how to implement and maintain TRT (Lampa et al., 2021) and the impact on lay TRT counselors given the prevalence of other psychiatric expressions among TRT participants (Löfving Gupta et al., 2021).
Parental involvement is an integral part of TF-CBT and parental factors have been stressed in models of children’s development of traumatic stress (Pynoos et al., 1999). Parents are essential in supporting the child to practice the skills outside the treatment room, as well as to facilitate family resilience rituals that may continue after treatment has ended. However, parents may also be the focus of change in their own right by developing new parental management skills or acquiring coping strategies for their own psychological problems that might contribute to the child’s difficulties (Stallard, 2006). The timing and sequencing of parental involvement is important, as not all parents are able to positively support the child and sometimes need an own intervention before being able to do so (Stallard, 2006). Studies have suggested that parental involvement may have a positive effect on the child treatment outcome (King et al., 2000; Deblinger et al., 1996; Yasinski et al., 2016), with some evidence from the refugee context (El-Khani et al., 2021). Although a recent systematic review of refugee adolescents’ mental health highlights how refugee parents’ own mental health and behavior serve as potential protective and risk factors for the child’s mental health (Scharpf et al., 2021) and parental involvement is an essential part of TF-CBT, services fail to involve refugee parents in treatment (Chipalo, 2021; Schottelkorb et al., 2012). This could be due to host countries limiting access to mental health services or lack of culturally tailored interventions. Indeed, distrust of authority, linguistic and cultural barriers, stigma regarding mental health, as well the primacy of resettlement stresses, are identified barriers to engagement in mental health services among refugees (Heidi et al., 2011). Embedding mental health programs in community settings, such as schools, is suggested to reduce some of these barriers (Murray et al., 2008). Yet, little is known about how refugee parental involvement in community-based trauma intervention functions.
The aim of this paper is to explore how parental involvement in TRT, a community-based program aligning with the TF-CBT approach, functions in practice and how is it perceived by participating refugee youth, parents, and TRT facilitators, in order to inform future TRT implementation guidance and provide lessons for the broader context of refugee parent involvement in community mental health interventions.
Methods
Research Design Overview
The study design was an explorative qualitative inquiry with an inductive approach as this allowed us to be flexible and modify research topics based on the data collected instead of being limited by preexisting theories or frameworks. Semi-structured interviews with youth, parents, and TRT facilitators were conducted as we strived for a holistic approach to the subject matter that considered the issue from multiple stakeholder perspectives.
Researcher Description
All interviews were conducted by the first author, who is a second-generation immigrant and an experienced child and adolescent psychiatrist who has personally facilitated TRT groups. This gave her insight to the practicalities of TRT and made her well fitted to conduct the interviews which sometimes dealt with sensitive topics. The second and third authors immigrated to Sweden as adults. All three authors were in various ways involved in TRT implementation in Sweden and there was a potential risk of them harboring positive bias and being invested in TRT. Prior to the study there was a notion among authors that parenting sessions did not always happen in Sweden, which lead to the research question. Issues of subjectivity, assumptions and biases were discussed openly among the authors but also in the wider research team.
Ethical Considerations
Ethical approval from the Swedish National Ethical Review Board was received prior to the study commencing (Ref. 2021-02160). The respondents were given both oral and written information about the study. Written consent was obtained for most participants; in a few cases, a recorded oral consent was obtained due to illiteracy. The interviews were recorded, transcribed verbatim and stored in a manner compatible with ethical guidelines. Careful attention was paid to ethical considerations given the sensitivity of conducting research with refugees. As it became evident that some parents were not informed that their child had participated in a TRT group, recruitment of refugee parents via participating youth was reconsidered, to protect the integrity of the participating youth.
Data Collection
The participating refugee youth and parents were recruited by snowball sampling TRT facilitators were recruited by purposive sampling through e-mail and Facebook pages.
In total, 30 semi-structured interviews were conducted by the first author with an average time of 40 min (range 15-70 min). Of these, 11 interviews were conducted with participating youth, 8 with refugee parents, and 11 with TRT facilitators either by phone or videoconference. An interpreter was present when needed. Three separate interview guides were developed (see supplementary material) with open-ended questions covering topics such as perceptions, barriers and experiences of the parent sessions as well as the youth’s perceptions of TRT sessions content, which will be analysed separately. Follow-up questions were added during the interviews. The interviews were considered rich enough for our aim. Each participant was reimbursed with a gift card valued at approximately 20 USD.
Demographics
Gender was balanced among the participating youth, with six who identified as female and five as male. Their country of origin varied: Syria (6); Palestine (2); Afghanistan (1); Kurdistan (1); Ethiopia (1). They had been in Sweden between 2-6 years (Mdn 4 years). Their age varied between 16 and 20 years (Mdn 18 years). The time lapse between participating in the intervention and conducting the interviews was up to two years in some cases.
Gender was balanced among the participating parents, with four who identified as female, and four as male. The majority originated from Syria (6), as well as Palestine (1) and Iraq (1). Time since arrival in Sweden varied between 2-6 years with an exception of one mother who had spent substantially more time in Sweden but had moved back and forth.
The majority of TRT facilitators identified as women (8/11) and were in their middle ages, although ages varied between 25 and 62 years (Mdn 45 years). They were a professional mix of school counselors (4), teachers (3), NGO personnel (2), nurse (1) and student (1) who had all undergone the three-day facilitator training. Some were experienced facilitators, having hosted more than 10 groups, and others had only facilitated one group (Mdn 3 groups). Only one facilitator had own experience of forced migration. The facilitators had conducted TRT groups in a school setting with youth from middle- and high-schools in rural and urban settings across Sweden.
Data Analysis
The interviews were analysed inductively using Thematic Network Analysis, as this qualitative method addresses both subjective experiences and underlying context and was perceived to be helpful when bringing together perspectives from multiple stakeholders (Attride-Stirling, 2001; Mano, 2017). The transcripts were read repeatedly by all authors to get a sense of the entire data. Text segments related to the research question or other salient issues emerging in the text were coded and transferred to an Excel sheet by the first author. The codes were compared and grouped to reveal patterns and similarities, and the text segments related to a group of codes were reread within the context of the classified codes. Codes with similar meaning were merged into basic themes. Standalone basic themes say very little about the text or groups of texts as a whole. Instead, the thematic network approach requires basic themes to be read within the context of the other basic themes to make sense beyond their immediate meaning (Attride-Stirling, 2001). Basic themes with similar underlying meaning where clustered into organizing themes. Organizing themes “are more abstract and more revealing of what is going on in the texts” (Attride-Stirling, 2001). An overarching theme (serving both as a summarization of the organizing themes and a metaphor of the text as a whole) was identified as a global theme. Finally, a weblike network was created to illustrate interconnectedness between themes, see Fig. 1. Throughout the analytic process the entire text was revisited and text segments compared with the codes and themes until consensus was reached among all three authors, during the process a decision trail was kept to ensure transparency. Finally, quotations were chosen to further illustrate the themes.
Fig. 1
Thematic network
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Methodological Integrity
Aspects of trustworthiness were addressed throughout the design and analysis. A research trail was kept and crucial decision points in the analysis were peer reviewed and audited by a group of external research colleagues. A professional interpreter was used with all parental interviews but one (who didn’t need an interpreter). The same interpreter was used throughout the study, and was provided with the TRT manual beforehand to enable them to familiarize with the context of the interviews. Whilst it is acknowledged that interpreters can affect the interview dynamic, our reflection was that this interpreter enabled a warm and professional atmosphere. Although, all youth were offered an interpreter, all but one declined as they took great pride in speaking Swedish. In some cases, the youth’s Swedish proficiency turned out somewhat limited, but it was decided to respect the youth’s choice of language over the cost of potential additional depth in the interview and authors deemed the depth sufficient and saturation was reached.
Researchers were aware of the potential power imbalance between the interviewer and respondents, hence, the importance of creating a safe space where participant could speak freely and confidentiality was stressed repeatedly in order for instance facilitator to speak openly about potentially “failed” attempt to engage parents. However, it was noted that the refugee parents in general were less likely to disclose parental inadequacies and issues regarding trust was discussed. To ensure rigor and validity negative cases were lifted in the analysis when appropriate.
Patient and Public Involvement (PPI)
The emerging themes, with a particular focus on the parent interview data, were discussed with a group of PPI contributors. The group was established in 2018 to advise on an effectiveness evaluation of TRT, and was composed of 3 mothers and 1 father with lived experience of forced migration. They arrived to Sweden from Syria (3) and Kurdistan (1), and have varied professions including teacher (1), driver (1) and “house wife” (2). The purpose of the process was for the PPI group to provide an extra dimension to the data analysis, by offering a lived-experience perspective on the emerging themes. The validity of interpretations was discussed, with the research team seeking to correct any misinterpretations and enhance the way the results were described. Insights from the PPI process are included in the Discussion.
Results
A global theme ‘Parental engagement in trauma recovery requires dedicated attention’ emerged (Fig.1). Three organizing themes sat within this global theme: (i) Shifting roles when adapting differently to a new context; (ii) Tendency to keep parents at a distance; and (iii) Parent sessions don’t just happen. Each organizing theme contained three basic themes.
Organizing Theme 1: Shifting Roles when Adapting Differently to a New Context
This theme relates to the role changes, disempowerment, and stressors experienced by refugees when resettling in a new country and cultural context. The basic themes that comprise this organizing theme are presented below, with illustrative quotes from Youth (Y), Parents (P) and Facilitators (F).
Being a parent to your parent
Some youth conveyed that their experience of trauma and migration had forced them to “grow up quickly” and revealed a shift in responsibility within the family since arriving in Sweden. They described adapting more quickly to Sweden compared to their parents, and being forced to handle responsibilities normally assigned to parents. They reflected that this shift in family hierarchy had led them not to rely on their parents in the same way they had before.
For example, my mother, she can’t speak Swedish. One of the children always has to follow her, yes, to where she is going, to interpret, yes./…/It’s not just my mother. Most of the people I know are like that, their children who take care of them over the language. /…/ /../We have to take care of our family. Yes, because we are … I forgot the word … alienated in society, yes. Y9
Disempowerment of refugee parents
Parents described a sense of disempowerment, not explicitly in their role as parents but rather in society. They revealed frustration over the uncertainty and stress the migration process entailed and showed signs of helplessness and hopelessness. They expressed worry about the future, regarding their own health, the health of their children as well as relatives in their country of origin. Some parents voiced concerns about their children adopting potentially risky behaviours and being associated with the “wrong crowd” since arriving in Sweden.
I’m sick, I can’t work. I can’t do anything. So, I’m just a number or I’m just … well, one that’s just over/…/It’s begging, that we’re kind of begging, that we can’t do anything/…/ So, it’s very bad in every single way. If it’s not money, then it’s residency. If it’s not residence permit, then it’s the weather. If it’s not the weather then it’s that you feel trapped here, it’s like prison.” P6
Yet, there were also refugee parents who expressed immense gratitude and felt they had adapted well and received the help and support they needed.
We are here in safety. We feel comfortable. I’m going to school myself and I’m learning to read and write and we haven’t seen any of the horrible things /…/ Thank God. We have a permanent residence permit. /…/ My daughter didn’t get this attention, or children didn’t get this involvement before, in our country, Iraq, where we come from. But when we came here, I told my daughter how children are treated in Sweden and how involved others are in their well-being. P8
Loss of orientation
The facilitators described the refugee parents’ struggle and effort to adjust to the new society and culture. They identified a loss of orientation among refugee parents and a need for help to navigate the new environment. TRT facilitators talked about parents lacking the habit of school involvement, claiming that it isn’t custom in their countries of origin. It was mentioned that this ‘non-engagement’ in school was more common when refugee families were newly arrived and subsided with time. Facilitators mentioned that there were misconceptions regarding Swedish authorities and a fear among refugee parents that the social services might separate the family. This fear was also described by the youth, but not by the refugee parents themselves. The facilitators suggested that informing parents of their rights and responsibilities would lessen the burden of refugee parents.
… it’s really important we think… or I think. That the parents are informed. But it’s difficult. We’ve also noticed that parents are incredibly worried before they know how the system works here in Sweden. That you actually can take time off and come and pick up your children if they are sick. They can miss a “Swedish for immigrants” lesson, that’s how it works, they don’t lose anything. It’s knowledge that’s the issue, I feel. Because it’s missing in society… for these parents who come… information and knowledge. F2
Organizing theme 2: Tendency to Keep Parents at a Distance
This theme relates to the tension and ambiguity surrounding parental participation in TRT sessions, shedding light on why these sessions might be difficult to implement. Some youth and facilitators harbored concerns about refugee parents’ capacity to engage in the intervention or to adequately support the youth which compromised parental involvement in the intervention.
Protecting parents from more pain
Some facilitators mentioned fear of brief parent sessions potentially exacerbating trauma symptoms that parents may harbor. The refugee youth described a need to shield and protect their parents from more suffering and pain. They suggested to the facilitators that it would be better not to be too detailed regarding the “trauma” part of the intervention when talking to their parents as this might increase parents’ worries. Some youth hadn’t told their parents they had participated in the trauma recovery program.
I didn’t want… Sorry. I didn’t want my family to know because my mom, she is sick, she has different … what is it called, diseases, different diseases, and if she … if I made her worry and cry about me, made her sad about me, maybe I’d lose her. So that’s why I didn’t tell her, or tell them, that. Y6
Youth expressed a strong sense of the family being important and something valued very highly. Some youth could not understand why other youth didn’t want to involve their parents as they experienced so much comfort and support from their parents. Even youth who had described that they were unable to talk to their parents about their own mental health or sometimes perceived them as obstacles, expressed this value of family like an entity. The importance of “putting family first” was also evident among some parents but was not present in the facilitators’ interviews.
If you live with your parents, you are a family. And a family to me is everything! For me family is everything! Family comes first and the rest I don’t give a shit about. For me, every person in my family is a part of my body. Y10
Although the refugee parents were a heterogenous group, where some reported own hardship and failing health, no one suggested that they were too vulnerable or stressed to be involved in their children’s mental health or take part in the intervention. On the contrary, there was a strong will to be included.
I have come to this country for my children. I didn’t come here for me. In other words, everything concerning my children interests me. /…/ Everything that happens for the wellbeing of my children I participate in. Once again, I want to repeat, anything that is for the good of my children, I am willing to participate in. P3
Preserving integrity and independence
The youths’ choice not to disclose mental health problems or participation in a trauma recovery group also involved protecting their own integrity and independence.
Yes, but if I tell my parents that I was part of a group that helps young people with stress, they will just ask a lot of questions. They will have lots, lots of questions… They look at me more. /…/. They won’t let me go out, hang out with friends. Things like that. That’s why I don’t want them to be there. Also, if I had told them at the beginning and … / Y7
Furthermore, the refugee youth displayed a strong sense of being self-sufficient and relying on faith or friends instead of parents. The TRT facilitators were well aware of the Swedish legislation regarding children’s right to make their own decisions when turning 15 years old, and stressed the importance of youth fully understanding that no personal information would be disclosed during the parent sessions. They valued the trust given by youth and expressed a need to protect it. This basic theme did not emerge in the parental interviews. On the contrary, one parent proposed having joint sessions with children and parents.
Concerns about parental reactions and lack of capacity
Some youth stated that they felt uncomfortable addressing trauma symptoms with their parents as they were afraid their parents were not equipped to handle the youth’s mental health state. Some youth reflected that their parents, or refugee parents in general, might not be as open-minded and knowledgeable about mental health problems as Swedish parents.
Especially “blatte” [slang for immigrant] parents, immigrants are not as open as Swedes. So that can be a disadvantage. Not everyone will understand it as well as you really want to….Yes, I think it’s upbringing … They (parents) grew up with, kind of, that you should work … well, you shouldn’t have as much emotion. Or not so, but you shouldn’t be as sensitive. They don’t understand that you can feel psychologically bad and all that. For example, if we were to have that conversation with my dad, he would just laugh about it. But my mum understands a bit more, and stuff like that. Y3
Some facilitators expressed hesitance over merely inviting refugee parents to the intervention, based on experience, perceptions and assumptions among TRT facilitators about refugee parents’ capacity. For example, they expressed that refugee parents found talking about mental health stigmatizing. There were also cases where facilitators struggled to see what the refugee parent could contribute with other than as a source of information regarding the child’s trauma. Facilitators also shared experiences of lack of parental engagement due to own mental health problems.
As I said, we haven’t had very many groups with just parents involved. I felt that there was a difference between when we met a mother who was feeling very, very bad herself, who had lost her husband and several of her children and who was obviously very preoccupied with her grief and what she had been through. It was very difficult to turn the talk and the discussion to her children and what we were doing. Whereas one of the fathers that we met in that group, he seemed to have a bit more of a stable life situation, going to Swedish lesson and employment etc. Had got some things going, and it was easier for him to participate in the discussion. F5
Organizing theme 3: Parent Sessions don’t Just Happen
This organizing them highlights logistical and professional challenges in implementing parent sessions, which are not currently addressed in the TRT manual nor training. Parents as trauma victims in their own right was acknowledged, but also perceived as challenging.
Understanding the purpose
A few TRT facilitators expressed that some refugee parents did not understand the purpose of TRT; it seemed counterintuitive for parents to bring up hurtful memories for their children.
The two mothers were a bit like that, they didn’t want to talk about what had happened, they wanted to forget. “We don’t want to bring it up, we never talk about it at home. We want the children to forget about this”. So, then we had that discussion, well, you can’t forget it because the question is have you forgotten it, what you’ve been through? “No, I haven’t”. “It comes when I sleep”. Then we have to explain that it can be helpful to process this. The trauma that your children have been through, like, so they were positive towards the end, at the beginning they were very suspicious and didn’t really understand how to bring that up and talk about it. F7
But facilitators also described situations where refugee parents claimed they understood the importance of the intervention but acted otherwise, for instance, giving priority to leisure activities instead of attending the intervention. The facilitators also dealt with skepticism from others, like other teachers not understanding the concept or siblings being critical and questioning the intervention. They explained the intervention was not fully established at their workplace and struggled to reach and recruit parents. Some facilitators voiced they themselves didn’t understand the rationale for the sessions and felt the TRT manual did not give them enough guidance. Some reflected that they subconsciously omitted the parent sessions to lessen work load and that parenting sessions were not necessary. Others bluntly stated that it is more rewarding working with children, as parents may find the topic controversial and the parent sessions are more unpredictable.
I notice this mental resistance in a lot of places. Let me think…I just have to say this thing about the carer meetings in general, it’s something that very often falls by the wayside. /…/ Which is perhaps not really evident in the way that TRT is communicated, that there is almost always an unexpected amount of work. It’s probably the part that’s talked about quite little as well… F1
However, all three groups of informants gave examples of children sharing the tools that they have learnt during intervention with their parents. Some parents reported that they had noticed a positive change in their child’s behavior after completing the intervention and described their children as more “open”. Youth reported that the intervention made communication with their parents regarding trauma and other sensitive topics easier.
It’s nice that she (mum) gets to know what we get and what we do there, and that she also learns. Even she liked it. She looked up this with yoga and something like that, and started doing it. She liked it too. My mum is not like that when it comes to such things. She encourages you to live and get better. Yes, we did one where you sit in a quiet place and imagine something positive…Y11
Also, parents expressed how the sessions had helped both themselves and their children, giving themselves a sense of empowerment. One mother said she had made new acquaintances, and that she continued to talk to the other parents at the school yard about the child’s wellbeing long after the intervention was terminated.
What it requires to make it work
The refugee parents expressed different needs regarding an optimal time for the parent sessions and how they preferred to receive the information and invitation.
Because I find it really hard to get away from home after coming home from work, so … Well, maybe some weekend then./…/I have a lot of responsibilities at home. I have five children and I work until late in the afternoon and I have to have my … I have to cook and I have to help with homework and I have things like that to do. P1
The facilitators also described refugee parents as a heterogenous group with various needs, some parents were onboard and accommodated the parent sessions well, whereas others didn’t. Some facilitators felt that it was important to have the parent sessions before they met the children, whereas others wanted to meet the youth first. The facilitators who had managed to keep the parent sessions over time described a deep sense of fulfillment and received gratitude from refugee parents.
They were very, very grateful. They said so. They still say it. You can take my daughter and go to the moon with her if you want, we trust you. They’re very grateful like that. F4
Some facilitators who described successful parent sessions also revealed initial hesitance from parents towards the intervention; however, this hesitance was overcome through dialogue and time. The facilitators also described an existing relationship with refugee parents prior to the intervention and how they could build on this existing bond when introducing the intervention. They described helping families with practical matters.
Sometimes we help out with a lot. I helped a parent book a trip. It gets a bit like that. I think a lot of parents see that you can always go to the school and get help from someone. We may not be able to do that, but we can make a call. F6
Facilitators stressed the importance of cultural liaisons (personnel working at schools who speak the same language and know the families), both when recruiting the parents and during the intervention as interpreters. All groups of informants highlighted the magic of “Swedish fika” i.e., sharing a cup of coffee or tea together. Also, the youth stressed the importance of building a relationship beyond the intervention with the refugee families.
Facilitators who had managed to keep parent sessions running over time conveyed a strong belief in the capacity of the refugee parents and perceived them as central in the role of helping the child overcome trauma.
Parents… that’s the key. I really enjoy working with parents, when they’re at the new school…. We’ve had a mother who travelled from the other side of town and twenty miles outside, by bus, along with her children to be part of this. Took about two hours on the bus, I guess. They didn’t even live in the area. F3
These facilitators didn’t find parents’ own trauma something threatening, on the contrary, they saw it as something that needed to be addressed.
Consideration of additional parental needs
All three groups of informants expressed the need for parents to receive care for their own traumas as the few tools taught at the parent sessions weren’t perceived to be sufficient.
Yes, it didn’t only affect (name of child) but it affected all of us. It may be that we are sleeping at home, then we start to hear the sound of rockets and cannons and then everyone starts to cry…Both the mother and the father, the parents, should also be able to get that help in conjunction or in co-operation with doctors and experts in order to be able to help their child. P5
Many parents also expressed a sense of isolation and difficulties getting to know and interact with “Swedish people”. They hoped the parent sessions would serve as an opportunity to form deeper relationships, for instance by placing the parent sessions at the refugee families’ houses. One mother suggested that she would like the facilitators to help her locate her relatives as part of the parent sessions as this caused her the most pain at the moment. Some parents requested joint sessions with the children.
Some youth expressed a need for the parent sessions to include not only trauma education but practical tools for parents on how to address and react when mental health problems are revealed.
To understand that young people go through many hormones and changes, and that we can go through trauma and feel bad. And that it doesn’t always have to have a huge reason. Because when I got my depression, my mum thought it was really strange, and she didn’t really understand what was happening /…/ Y3
They wanted parents to learn what parental behaviors are helpful and which ones are not.
I think you should tell them /…/ that parents shouldn’t make it stressful for the children and, you know, sit in their room if they’re sad. Because parents shouldn’t ask the child too many questions about “why are you sad? What has happened?” Maybe the child doesn’t want to say. Y8
The facilitators and youth also identified a need to individualize the sessions and the possibility for youths to identify another important adult instead of the parents.
Discussion
Summary of Results and Findings
Although the current study showed the potential of parental engagement, it also highlighted several barriers. Youth were hesitant to involve parents, facilitators were not adequately prepared to deal with practical matters and harbored concerns regarding the readiness of parents to engage in the intervention. Parents expressed willingness to take part in the intervention but for several reasons did not participate. Despite promising examples of successfully implemented parent sessions, a resistance was uncovered, with several youths having not disclosed TRT participation to their parents and resistance from facilitators to even invite parents. This meant that for many young people, their parents did not attend. While parent participation is not mandatory, meaning that young people can take part even if their parents do not, resistance to involving parents could potentially affect the impact of the intervention. The intervention logic encompasses the role of parents in creating a supportive home environment and playing an active role in supporting young people to practice techniques between sessions and after the intervention has finished.
The organizing theme “Shifting roles when adapting differently to a new context” addresses youths’ descriptions of changes in family roles, obligations, and communication., This aligns with the family beliefs framework of displaced families of war (Weine et al., 2004, 2006), which also describes how refugee families adapt and apply beliefs about youth in their new context. The framework draws connection between the trauma experienced by these families and the social, cultural, economic, familial, and psychological transitions they are going through in the host country. Our findings mirror this, and speak to the importance of recognizing the transitional processes when engaging families in trauma intervention. Although there are descriptions of resilient parents in the present study, voices from both refugee parents and facilitators also illustrates disempowerment of refugee parents, from loss of identity to loss of status, family ties, social supports, and culture, which resonates with previous findings (Betancourt et al., 2015). The changes in family hierarchy and parentification of youth may be understood in a migration context where an acculturation gap between youth and parents (with youth adapting quicker to the host country compared to may) affect family dynamics (Telzer, 2011) as well as in a trauma context where parental trauma exposure and PTSD affects family patterns and parenting (Flanagan et al., 2020; van Ee et al., 2016). The latter can be considered through the lens of intergenerational transmission of trauma (Lang & Gartstein, 2018), which explains poorer lifetime offspring outcomes both through perinatal biological processes and suboptimal parent-child interactions.
This serves as a backdrop to understand why some youth in the current study refrain from sharing mental health problems or disclosing participation in the trauma recovery program to their parent. As the organizing theme “Tendency to keep parents at a distance” reveals, youths harbor concerns about burdening and potentially aggravating parental ill-health by disclosing mental health problems and seem to assign little credence to parents’ ability to alleviate their symptoms or situation. Hesitance to disclose participation is also due to concerns that parents will react negatively for instance by diminishing symptoms, persuading the youth that mental health issues are best kept within the family or by displaying misconceptions regarding mental health.
Yet, the reluctance to inform and engage parents when seeking psychological services is not unique to the refugee youth population (Gibson et al., 2016; Neelakantan et al., 2019). Although youth in our study do address issues of integrity and autonomy, they also address important issues more specific to refugee family context. Changes in family dynamics due to gap in acculturation or cultural negotiation, intergenerational trauma, disempowerment of refugee parents and parental ill heath may act as barriers to disclosure and involvement. Although, a recent systematic review of TF-CBT (Chipalo, 2021) among refugee families identified the potential risk of youth not disclosing traumatic experience directly related to the parents, when involving parents in treatment, the other potential reasons for non-disclosure uncovered in this study are a new contribution. In order to successfully involve parents, facilitators need to be aware and adjust for these barriers when introducing parental involvement to youth.
Youth in our study raised the issues of parental mental health problems and hostile or overprotective parental behavior, both of which have been identified as risk factors for development of PTSD (Fazel et al., 2012; Williamson et al., 2017). PTSD among refugee parents often caused by traumatic experiences or postmigration stress, may contribute to a harsh parenting style (Bryant et al., 2018). However, the relationship between parental PTSD and parenting limitations is not specific to the refugee situation (van Ee et al., 2016).
Only one facilitator expressed insight that youth may refrain from disclosing participation due to parental limitations caused by migration, cultural beliefs and trauma. It is interesting to note that this facilitator also had experience of forced migration. One may only speculate if the other facilitators might have picked up on these barriers and weren’t comfortable addressing them for fear of being perceived as prejudiced or if they simply had no knowledge about this. The value of cultural competence among facilitators cannot be overstressed and matching therapists with shared cultural experiences as clients may affect the relationship and treatment engagement positively (Marsyla, 2024).
Although it is developmentally expected that “youth” rely less on parents compared to children and adolescents, it is possible that adding supportive parenting skills or direct trauma support for parents would increase the motivation for the youth to involve parents in TRT as well as impact treatment outcome.
Strikingly, only one mother revealed feeling insufficient in her parental role and expressed the need for parenting skills. Of course, this could reflect the true experience of the interviewed parents, but may also be interpreted in the Swedish context where many refugee parents are afraid to disclose any signs of deficiencies in their parental role as this may entail risk of the social services getting involved, as highlighted by the PPI group and mentioned in youth and facilitators’ interviews. This was not something the research team was aware of prior to the interviews; however, the spread of disinformation regarding social services kidnapping immigrant children became headline news a few months later (Mårtensson & Shawish, 2021).
Barriers to engage in mental health interventions mentioned in the literature, such as stigma, lack of trust in authorities and cultural barriers (Fazel & Betancourt, 2018; Hodes & Vostanis, 2019; Scharpf et al., 2021) were not mentioned by the refugee parents in this study, which could also be explained by lack of trust, or perhaps they were not as prevalent given the intervention was in a school setting.
The PPI group spoke more openly about stigma related to mental health problems and confirmed the youths and facilitators’ descriptions regarding parental avoidance of talking about traumatic events. A recent systematic review (Byrow et al., 2020) consolidates stigma as a recognized barrier for refugees to seek mental health care; disclosing mental illness may entail feelings of shame and disapproval, which can affect family unit as a whole. Parents’ avoidance of addressing trauma and encouragement of avoidant coping strategies is described in the general population too (Williamson et al., 2019), and has been associated with the severity of children’s posttraumatic stress symptoms (Claxton et al., 2021). Some TRT facilitators were not adequately prepared to tackle this avoidance and perhaps the brief TRT training in its current form isn’t sufficient to consolidate a deeper understanding of avoidance in a trauma context nor provide the tools some facilitators need to engage parents expressing avoidant behavior.
When the specific topic of youth’s right to engage with health care without parental consent after the age of 15 years was addressed among the PPI group they reacted strongly and expressed deep concerns should their child participate in a trauma recovery group in school without their knowledge. Facilitators need to be prepared to handle these situations in a culturally responsive way, adjust for a possible distrust in authorities among refugee parents, as well as acknowledge and reflect on their own biases, for instance how Sweden, in a global context, is extreme in valuating individual autonomy (Institutes for Future Studies, 2015).
Within the third organizing theme “Parents sessions don’t just happen”, facilitators addressed several barriers to engaging refugee parents in TRT including lack of purpose, rational and resources for the parenting sessions and concerns regarding the readiness of parents to incorporate the sessions, due to own trauma or resettlement stresses. Similar challenges and miscommunication between service providers and the refugee population have been described in other studies, both in Sweden and internationally, in part due to lack of cultural humility among service providers (Forrest-Bank et al., 2019; Salami et al., 2019). The current study suggests that the brief TRT training does not provide the cultural competence needed nor addresses the assumption that some facilitators may harbor about refugee parents’ capacity, which in some cases denied refugee parents the opportunity to engage in the intervention since they were not even invited.
The most prominent feature of successful engagement was having an established relationship with the parents prior to the intervention, often by the use of cultural liaison personnel at school. These liaisons personnel shared the same language and culture as the families and were able to communicate the purpose of TRT in a culturally relevant way as well as advice on resettlement hassles. These features have been identified as essential in previous studies when engaging this population (Abdi et al., 2022; Cureton, 2020; Heidi et al., 2011). Moreover, the successful sites facilitators perceived and experienced refugee parents as resourceful and expressed personal fulfillment when engaging with them. This could be added to the list of previous findings identifying network support, resource availability, careful integration of interpreter and “going to where the potential recipients are” as key features for successful TRT implementation (Lampa et al., 2021).
There seems to be a great potential in engaging parents in the intervention, as they report feelings of empowerment, relief to see improvement in their children’s mental health, use the tools for themselves and socialize with other parents, despite only attending two sessions. Parents who attended the school-based trauma intervention (CBITS) have reported similar experiences (Santiago et al., 2016). Refugee parents also identify a need to participate in TRT themselves; however, TRT needs to be adapted to the adult population (Hasha et al., 2022). Furthermore, refugee parents express the importance of having trustful relationships, a yearning to spend time with Swedish people, sharing their culture and suggest that parent sessions could be held in the home of the refugees.
Recommendations Based on Findings
A review of preventive mental health interventions for refugee children (Fazel & Betancourt, 2018) concluded that the interplay between child mental health and contextual factors is complex and needs to be addressed in a wide range of sectors, with a “continuum of care and multilevel and cross sectional intervention models” and although embedding youth trauma interventions in integrated services culturally tailored to meet the needs of refugee families would facilitate parental engagement (Heidi et al., 2011), these services are not yet always available. In lieu of this, cultural adaptations within TRT implementation are recommended.
Introducing the concept of cultural humility and reflecting on the context of refugee families including resettlement stressors and changes in family dynamics due to trauma and migration during TRT facilitator training, could address facilitators’ assumptions and also inform facilitators how to address parental involvement to participating youth. This could entail addressing difficulties talking to parents about mental health, stigma or potential worries about the parent that youth might have. Addressing these issues with youth may potentially normalize what some youth experience in their home environment. Furthermore, youth can also inform facilitators how to introduce the intervention to parents in a culturally responsive way. Communicating the intervention to parents in terms of symptoms of stress instead of emphasizing mental illness may reduce stigma (Miller et al., 2019). Recruiting future facilitators with shared cultural backgrounds as the refugee families could potentially address cultural barriers and aid parental engagement.
Enhancing the parenting sessions with reflections on family dynamics and tools on positive parenting may increase youth’s motivation to involve parents, as well as treatment outcome. Incorporating sessions for parents to discuss and reflect over negative parental practices such as overprotection has been suggested as supplement to child treatment in the extant literature (Williamson et al., 2017). Moreover, a randomized controlled trial comparing TRT with extra parenting sessions (3 extra sessions covering evidence-based parenting strategies) with TRT and waitlist in an low income setting showed significant enhancement in both parent and child mental health when parenting sessions were added (El-Khani et al., 2021).
The lack of rationale and other barriers such as “ fear of potentially aggravating trauma symptoms among refugee parents” as well as practical issues concerning different means of inviting refugee parents and sequencing of the parenting sessions, needs to be addressed during facilitators training as well as in the TRT manual. It is also important to reflect on appropriate and inclusive locations for the parenting sessions, as schools might not be the optimal place (Cureton, 2020). Offering certificate of absence, that employers or Swedish for immigrant teachers may request, may also facilitate parental engagement. Facilitators need to be prepared to redirect parents to other services in order to make them ready to receive the intervention.
Also, communicating the need for time and resources to establish relationships and trust with refugee families, to program developers as well as settings in which TRT is embedded is important for successful involvement. In the promotion and description of TRT there has, until now, been an assumption that youth want to involve their parents but, based on the findings in the current study, this can no longer be the automatic preset. Regardless of the adaptions suggested above, a dialogue is needed with the youth regarding the pros and cons of involving parents, and the youth need to be asked to identify the most suitable adult to attend the session. This person needs to be legally defined as an adult in the host country. For instance, in Sweden the person would be required to be 18 years or older.
To further the understanding and develop practical guidelines on how to invite and engage refugee parents, address parental involvement with youth as well as modifying content in parental sessions in a culturally responsive way, further participatory research with refugee youth and parents is recommended.
Strengths and Limitations
Although it is an evident strength that participating refugee youth, parents and TRT facilitators are all represented in the current study, their spread in demographics, numbers and ability to voice opinion vary. Both parents who had participated in the intervention and those who had not were represented among interview participants, which is an obvious strength. Although careful considerations were taken in selecting an appropriate interpreter, allowing more time to establish relationship and trust with the refugee parents could potentially deepen the conversations, however involvement of refugee parent public contributors strengthens the voice of parents. TRT facilitators were fairly well represented. However, the participating youth were all at least fourteen at the time of the intervention, an age when it is a natural part of development to become less dependent on parents. TRT is suitable for children aged 8 years and above, and thus the present study has not captured the full childhood perspective relevant to the intervention. Given the convenience snowballing approach to recruitment some of the youth had received TRT over two years before the interview, which could have introduced some recall bias.
Conclusions
This study acknowledged the potential of parent sessions and identified barriers. TRT is a streamlined light-touch intervention where scalability is an obvious strength. Clearly, embedding TRT with integrated services culturally tailored to meet the needs of refugee families would facilitate parental engagement; yet, this it is not always available in practice. However, adding enhancements within TRT facilitators’ training like introducing cultural humility, awareness of refugee contextual factors, changes in family dynamics, reflecting over the way parental involvement is presented to youth and how avoidance may play out in this situation, adding positive generic parenting skills, addressing parental readiness and preparing facilitators to redirect parents to adequate services when needed, could potentially make a huge difference.
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“There is a Mental Resistance”: Experiences of Involving Refugee Parents in a Youth Trauma Recovery Program from the Perspective of Participating Youth, Parents and Facilitators
