Civil wars and intra-state conflicts as well as political violence and extreme repression are traumatising experiences that impact on refugees and lead to pushing them out of their countries often leaving behind everything of value to them. Our era is replete with the litany of dislocated people forced to desperately flee their homes in search for security and prospects following upheavals with tragic consequences in their homelands (George, 2012). The recent history of conflicts in Eritrea, the genocide in Rwanda, the wars in Afghanistan, Kosovo, Darfur, and Syria, retell the same unfortunate story of devastation caused by displacement, which is often far greater than the total number of those killed and injured (Kidane, 2021). Moreover, as the nature of many conflicts become such that they tend to rage longer, the refugee crises that ensue also tend to drag for tens of years, leaving many victims traumatised and without an opportunity for a permanent home (Salehyan, 2007, Braithwaite, Salehyan, Savun, 2019).
Despite the clear correlation between conflicts, trauma, and refugee outflows, there remains a significant gap in our understanding, particularly regarding the long-term prospects of refugees. Unfortunately, trauma support is rarely offered to refugees upon their initial arrival, as highlighted by Murray (2014). This knowledge gap persists despite ongoing discussions about refugee flows for many years, as seen in works by Teitelbaum (1984) and Grandi (2022). Mental health support is often not prioritized in disaster response efforts, with some considering it impractical or too expensive to implement (Gelbach and Davis, 2007). Consequently, the provision of integrated mental health support in post-disaster scenarios remains an underdeveloped area of service, as noted by Everly (2021).
The absence of this crucial therapeutic support forces traumatised refugees to continue to live with overwhelmed mental status and feel unsafe as a result and this might cause them to embark on dangerous (and more traumatic) secondary migration in search of safety (Luci, 2020). Meanwhile conflict-induced migration of refugees is often discussed through the prisms of economic consequences, including poverty, inequality, economic restructuring and pressures on development, these are often assumed to be the ‘root causes’ of such migration (Hamilton & Chinchilla, 1991, Fofack, Akendung 2020) rather than traumatisation and traumatic stress. The situation leads to a total failure of developing and delivering effective support for the individuals and groups suffering from traumatic stress and presenting with symptoms of PTSD hampering their recovery and rehabilitation (Gelbach and Davis, 2007, Rodriguez & Grumbine, 2021) including their efforts to rebuild the resources they lost.
Even in areas where mental health services have been made available there are challenges emanated from the fact that the provision is not contextualised to account for the historical and socio-cultural context of the population the intervention is targeting (Stammel, 2019). This can become harmful practice that exacerbates the problem, such inappropriate services in emergency contexts have been shown to result in detrimental impacts. Wessells (2009) outlined how a group of Kosovar survivors of gender-based violence in Albania were made to publicly disclose their predicament resulting in honour killings. In Sri Lanka women participants of a therapeutic programs experienced ostracization (Argenti-Pillen 2013). Therefore, exploring capacity to develop and deliver a culturally appropriate trauma support at crucial points during the refugee trajectory such as refugee camps and Internally Displaced People’s (IDP) Centres should be a pertinent area that transcends policy development as well as service provision.
This research focused on trauma in recognition of the fact that the devastation that triggers the refugee-making process, the individual experiences of harassment, extreme persecution, torture, violence and inhuman treatment as well as collective experiences such as terrorism and mass killings, are known to cause persistent symptoms that damage victims in many ways including damaging their self-esteem, and ability to trust others, often resulting in changes to their identity (Barudy, 198, Muldoon, 2021 ). Baingana, (2003) found high prevalence of depression and post-traumatic stress disorder (PTSD) in refugee communities affecting 40 to 70% of the refugee population in consideration. Systematic searches by De Silva et al. (2021) identified 15 studies, of which 10 examined treatment-seeking samples and remaining five focusing on wider population samples. Complex Post Traumatic Stress Disorder (CPTSD) prevalence was between 16 and 38, and between 2.2 and 9.3% for the two sample groups respectively. The analysis also revealed that a fifth of the people under consideration reported a much higher estimate (50.9%). This review highlighted the high prevalence of CPTSD in refugee and asylum-seeking populations in line with previous findings (e.g. Silove, Ekblad & Mollica, 2000), that identified, how war and political violence cause mental illnesses such as PTSD, with debilitating effects for the refugees that flee them.
In addition to the impacts on the lives of individual victims the above experiences have affect the wider community causing collective traumatisation. Collective trauma affects whole communities in the form of maladaptation with long term and even intergenerational consequences (Salinas & Salinas, 2021). Boehnlein et al., (2004) conducted a study in post conflict Cambodia, after the civil war of the 1960s that led to the Khmer Rouge rule, that decimated the social fabric of the society. The study found a high prevalence of psychiatric symptoms in refugees, 10 years following the events. Similar results were reported in earlier research too; a survey of 993 adult participants from the largest Cambodian IDP camp on the Thailand-Cambodia border, identified that 80% of the participants felt depressed, and suffered with somatic complaints (Mollica et al., 1999). In a Mayan village in Guatemala, among a population that suffered a genocidal campaign from 1981 to 1983, which resulted in the massacre of 600 people, Manz (2002) found that everyone suffered an overwhelming sense of guilt with a number of psychological difficulties including extreme fear, symptoms of depression, feelings of loss, abandonment and despair as well as a sense of humiliation, anger and solitude. In addition to psychological symptoms many participants experienced a shattering of their faith in God (Manz, 2002).
One of the inevitabilities of the refugee making process is the loss of home with all its resources; conservation of resources (COR) theory (Hobfoll 1998), details how the loss of resources can be more stressful than the efforts entailed in gaining resources. Accordingly, PTSD is thought to occur when there is drastic, major, and irreparable loss of valuable personal, social, or material resources crucial to survival, and social attachments (Hobfoll, 2020). Here resources are defined as things that are valued by individuals including objects, states, and conditions (Halbesleben et al., 2014). Stress, is thus, conceptualised as occurring when individuals fail to gain resources despite investment or when resources are threatened and lost. Consequently, traumatic stress is said to occur when there is an unexpected and rapid loss of resources that attacks people’s basic values, as well as the resource mobilisation strategies they are accustomed to, thus leaving a powerful imprint on their consciousness, that can get triggered easily by cues associated with the event (Hobfoll 1991). In this sense trauma healing and building resilience in refugees can be closely related to the ability to rebuild capacity to regain social and economic resources in addition to alleviating collective and individual symptoms related to the mental imprint and triggers thereof. This understanding of the prevalence of PTSD and other disabling psychological disorders will have implications for the development of policies and services suitable for vulnerable refugees. (De Silva 2021).
This research is concerned with the delivery of cost-effective trauma support, that is culturally and linguistically appropriate for the target community of highly traumatised refugees in emergency situations in refugee camps. Specifically, the research considered the delivery of trauma support to Eritrean refugees in a refugee camp in Ethiopia. The fate of Eritrean refugees, particularly the large numbers leaving the small country as well as the enormous risks they have been taking in the process have been the subject of discussion for several years now (Malk, 2019; Poole& Riggan 2022). The traumatic violence being perpetrated in Eritrea has been fully outlined in a UN Human Rights Commission report, that investigated human rights violations and concluded that, these crimes potentially amounted to ‘crimes against humanity’ (UN Human Rights Council, 2015).
The report called for accountability on behalf of the millions of Eritrean victims and their families who have suffered atrocities that were hitherto untold. Systematic use of extrajudicial killing, extensive torture, heinous rape, and the situation of indefinite national service and forced labour were outlined in extensive detail, concluding that “It is not law that rules Eritreans – it is fear” (UN Human Rights Council, 2015). Reading through the hefty document cataloguing violations committed against groups and individuals in Eritrea, it is not difficult to expect the devastative traumatic impact on victims.
According to the report the regime of President Isaias Afwerki perpetrated violations, including forced disappearances and extrajudicial imprisonments that are “on a scope and scale seldom witnessed elsewhere” (UN ND 2015 p. 1). In addition, the inquiry also found evidence of extreme surveillance and censorship aimed at curbing any form of descent. The extreme measures even extended to the level of thought resulting in a culture of traumatic fear affecting the entire population. The situation led the Commission to conclude that, due to constant spying and surveillance Eritreans were forced to live in perpetual fear of detention, arbitrary arrest, disappearances, torture, and even death. This surveillance culture has also resulted in a toxic atmosphere of mistrust and self-censorship dividing communities and even families (UN Human Rights Council, 2015).
The Eritrean national service which has become indefinite forced military conscription has also trapped an entire generation of men and women and is subjecting their families to become destitute as result (Kibreab 2009 & 2017). The UN report highlighted this situation as causing Eritreans including many underage children to flee their country in fear. In addition, at the various military installations, women were said to be facing gender-based violence: “Sexual violence against women and girls is widespread and indeed notorious in military training camps. […] Furthermore, the enforced domestic service of women and girls who are also sexually abused in these camps amounts to sexual slavery” (UN Human Rights Council, 2015, p. 13). The report also identified the prevalence of an atmosphere where Eritrean officials frequently use beatings and rape, inflicting physical and psychological pain, to extract confessions or information, or as a punishment, for defiance or to intimidate or coerce detainees and conscripts into compliance.
Linking these traumatic events to the mass exodus of refugees, the COI report states: “Faced with a seemingly hopeless situation they [Eritreans] feel powerless to change, hundreds of thousands of Eritreans are fleeing their country”, despite the fact that “Eritreans who attempt to leave the country are seen as traitors”, and that “the government has implemented a shoot-to-kill policy at border areas to prevent people from fleeing” (ibid., p. 6). Indeed, the situation has led tens of thousands of Eritreans to leave Eritrea taking enormous risks along the various routes to destinations they consider ‘safe’ (Van Reisen, Estefanos & Rijken, 2012, 2014; Connel, 2012; Hotline for Migrant Workers, 2011). Many of these young refugees are fleeing the abusive, national service, either deserting after they were forcefully recruited or to avoid impending conscription (Kibreab, 2009; Van Reisen, Saba & Smits, 2019). This situation in Eritrea has been ongoing for three decades since the country gained its independence from Ethiopia in 1993. The government’s extreme intolerance of any form of dissent (Connel, 2012) has had an impact on the whole society and not just those who have become targeted for their activities or views, everyone knows someone in prison, often being tortured, or suffering rape or sexually assault (Human Rights Watch, 2009 & Hepner, 2009), leading Eritreans to live in an atmosphere of total uncertainty, extreme repression, and hopelessness (Kidane, 2015).
The difficulties are reflected in the number of Eritreans who flee their country placing Eritrea among the ranks of top refugee producing nations (Dyvik, 2023). the United Nations Refugee Agency, UNHCR, reports for 2014 show that at the peak of the refugee crisis, the numbers arriving in Europe nearly tripled, from 13,000 the previous year to 37,000 (UNHCR, 2014). In 2014 and 2015, roughly 40,000 Eritreans embarked on the extremely hazardous journey across the Mediterranean to arrive in Italy (Lanni, 2016). Every month some 5,000 Eritreans fled their country, this a figure represents a seismic population movement for a small country of 6 million. In 2016 UNHCR reported that, 52,000 Eritreans escaped their country and, by 2018, about 12% of the total population of Eritrea had been pushed out (Human Rights Watch, 2018).
Those who flee include separated children, vulnerable women with their young children and many vulnerable young men often first fleeing to the nearest refugee camp but many end up moving further, arriving to Europe by boats having faced extremely traumatic experiences including many ship-wreck disasters (Connell, 2015; UNHCR, 2014; Hotline for Migrant Workers, 2011). The situation has been a cause of many discussions and reports with the central question being: why so many Eritreans are on such a move? (e.g., BBC, 2015; Kingsley, 2015; O’Brien, 2015; Economist, 2013). Those who are familiar with the country’s history lament Eritrea’s decline and the fate of Eritreans (Babu, Babu & Wilson, 2002; Kibreab, 2009; Kibreab, 2015; Brhane, 2016).
The experiences mentioned above pose psychological risks (Modvig & Jaranson, 2004) including the risk of threat to the integrity of the self (Chapman & Garvin, 1999; Zepinic, 2016). Many people exposed to such levels of traumatic stress go on to experience stress responses typical to PTSD, including avoidance, sleep disturbances, hyperarousal, and hypervigilance they may also engage in behaviour typical of those who anticipate further risks (Chrousos & Gold, 1992; Nuttman-Shwartz, & Shoval-Zuckerman, 2016) Tsigos & Chrousos, 2002; Stout et al. 2021). Constant activation of the stress response or allostatic load (McEwen, 2003), in post-traumatic stress, creates a state of hopelessness, fear, and horror including the risk of suicide (Yehuda, 2002; Lehrner, & Yehuda, 2018). A study of Eritrean refugees in an Ethiopian refugee camp found that there was a high prevalence of suicide ideation with previous history of trauma and traumatic stress disorder among the risk factors (Gebremeskel, et al., 2022). In a recent report Haynes (2022) was able to confirm, via Freedom of Information requests, that between 2018 and 2022 five Eritrean Unaccompanied Asylum-Seeking Children (UASC), aged 14 to 25 committed suicide in the UK. Four out of the five were from the same friendship network of young Eritrean refugees (Taylor, 2019). Despite indicators of deteriorating mental health among the young people this deterioration was, unfortunately not matched by access services (Gal-dem, 2022).
When considering traumatisation in refugees or refugee communities one should exercise caution prior to conclusions regarding PTSD, to account for confounding set of variables in the chain of events resulting in disorders and suicides, painful and vivid past memories, can fall within the range that can be considered a normal responses to such adverse contexts (Summerfield 1995, 1996, Abraham et al., 2018 ) nonetheless, we need to be mindful of all the evidence linking exposure of experiences resulting from conflict and atrocities and mental ill health including PTSD (Pederson, 2002; Musisi, & Kinyanda, 2020)). The reality for many refugees is a lack of adequate mental health support, both in initial displacement camps and in their final destinations. This deficiency goes beyond mere policy or resource constraints but extends to issues encompassing challenges in comprehending the context of trauma that drives refugees from their homes. When working with traumatised refugees, understanding historical context is vital, alongside linguistic, and cultural adaptations crucial for tailoring therapeutic approaches (Dixon, Ahles & Marques, 2016; Bass et al., 2013). As highlighted earlier, collective approach to conceptualising refugee trauma is an essential consideration. In addressing trauma healing for refugees, interventions must be contextualised at the collective level to acknowledge the potential for both individual and collective trauma resulting from experiences leading to refugee flight (Kidane and Van Reisen, 2017). Moreover, many refugee cultures are collectivistic (Suh and Lee, 2020), necessitating adaptation beyond language and cultural considerations. This departure from the Eurocentric model of PTSD treatment, primarily focused on individual trauma, questions the applicability of universally developed psychological interventions, especially in non-Western contexts (Kidane, 2021). Therefore, trauma healing efforts should encompass not only addressing individual trauma and PTSD symptoms but also rehabilitating survivors and processing collective memories.
The challenges in providing adequate trauma support for refugees are multifaceted and extend beyond merely having a trained workforce and resources. Even in well-resourced settings, the availability of appropriately trained professionals who can deliver therapy in accessible languages while understanding the cultural, social, and political contexts remains limited (Kidane, 2021). Furthermore, delivering effective trauma support is hindered by practicalities such as the refugees' legal status and the transient nature of their settlements. Many refugees are constantly on the move due to safety concerns, contributing to a sense of instability and making it difficult to access traditional trauma support modalities that often require settled living conditions (Gruner et al., 2000). Paradoxically, the lack of access to trauma support exacerbates refugees' feelings of insecurity, prompting them to continue seeking safety elsewhere. Despite advancements in practice, research, and policies, the complex needs of traumatised refugees often go unmet due to limited resources and the challenges inherent in providing appropriate care (Silove, Ventevogel & Rees, 2017). Considering the high levels of trauma among refugees and their mobility, the societal challenge, particularly for advocates of equity, lies in effectively delivering the much-needed assistance within the realistic constraints of available resources.
Recognising the challenges of resource scarcity in providing trauma therapy to refugees, organizations like the World Health Organization (WHO) have explored alternative, less resource-intensive approaches, such as self-help interventions. WHO developed Self-Help Plus (SH+), a self-help guide based on third-wave cognitive behavioural therapy, specifically Acceptance and Commitment Therapy (ACT), aiming to address the shortage of adequately trained professionals to deliver trauma support to refugees (Epping-Jordan et al., 2016). SH + consists of audio recordings of adapted ACT sessions accompanied by a manual. Trials conducted with Ugandan refugees in South Sudan revealed the intervention's efficacy in reducing psychological distress (Hayes, Luoma, Bond, Masuda & Lillis, 2006).
While self-help guides like SH + hold promise in addressing the human resource challenges in trauma therapy delivery to refugees, concerns persist regarding the high mobility of the target population. Despite the adaptability of delivering interventions through analogue audio, this method still falls short in matching the mobility of the target communities. To mitigate these challenges, leveraging information and communication technology (ICT) can enhance intervention effectiveness. This approach is particularly appealing given the widespread use of smartphones among refugees, including Eritrean refugees who utilize these devices to access valuable information from fellow refugees and official sources such as media outlets (Kidane, 2016).
This research focuses on the development and implementation of trauma support for refugees, specifically emphasising the delivery of such support via mobile phones, which have become essential tools in the lives of many refugees. As detailed in Kidane (2021), a six-session self-help trauma support program, named Trauma Recovery Understanding Self-Help Therapy (TRUST), was developed to address the expertise and logistical challenges in delivering trauma support to refugees. TRUST, designed to address both individual and collective trauma concurrently, draws from self-help techniques derived from Eye Movement Desensitization and Reprocessing therapy (EMDR), which has been noted for its effectiveness in integrating traumatic memories in survivors of traumatic experiences, including refugees (Shapiro, 1989; Mooren, De Jong, Kleber & Ruvic, 2003). Recognizing EMDR's efficacy, the World Health Organization (WHO) has endorsed it as a top-level evidence-based therapy (WHO, 2013).
The initial two sessions of TRUST focus on psychoeducation, providing participants with a comprehensive understanding of trauma and its effects on brain functioning. This is followed by three sessions aimed at equipping participants with coping skills to manage traumatic stress symptoms. Additionally, participants are provided with opportunities for reintegration and encouraged to contribute to addressing trauma within their communities. TRUST's framework is adapted from Shapiro's (2012) self-help book, which is organized into similar categories, with the incorporation of collective healing sessions to address the significance of collective trauma and healing. Notably, TRUST is delivered through information and communication technology (ICT) to overcome challenges associated with the high mobility of the target community and the scarcity of qualified therapists proficient in the refugees' language. Each session is facilitated through pre-recorded videos featuring a therapist who provides guidance on session content and demonstrates techniques. These videos are uploaded to a password-protected platform, accessible only to registered participants who follow the sessions sequentially. Participants also have the opportunity to submit text-based questions and remarks.
This paper aims to investigate the effectiveness of TRUST in reducing levels of traumatic stress and collective trauma among Eritrean refugees residing in refugee camps in Tigray, Northern Ethiopia.
The study aims to test the effectiveness of the TRUST program delivered via ICT by comparing the shorter version (focusing on psychoeducation) with the full program. The hypotheses to be tested are as follows:
Hypothesis 1
Results will reveal a negative correlation between post-traumatic stress (measured using IES-Short) and the following components:
-
Social and economic resilience (excluding worriedness, as higher values indicate more worry)
-
Social capital (measured by ISCS scores, both online and offline)
Hypothesis 2
The full TRUST program will yield superior outcomes compared to the shorter version focusing solely on psychoeducation. Specifically, the full program is expected to result in:
-
Reductions in post-traumatic stress
-
Increase in scores for social and economic resilience
-
Increase in social capital (both online and offline)
Hypothesis 3
Participation in livelihood support activities will lead to the following outcomes:
-
Decreased levels of post-traumatic stress
-
Increased social and economic resilience (excluding worriedness)
-
Increased components of social capital (both online and offline)