The influence of traumatic experiencs : post-traumatic stress and well-being on the social resilience and integration of resettled refugees

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THE INFLUENCE OF TRAUMATIC EXPERIENCS; POST-TRAUMATIC STRESS AND MENTAL WELL-BEING ON THE SOCIAL RESILIENCE AND INTEGRATION OF

RESETTLED REFUGEES

T.S. Wallner

University of Amsterdam theresa.wallner@student.uva.nl Tel.: +31(0)617693175

Roeterstraat 11, E6.06, Amsterdam

Dr. A. A. P van Emmerik University of Amsterdam A.A.P.vanEmmerik@uva.nl Tel.: +31(0)205258604

Nieuwe Achtergracht 129, G1.41, Amsterdam

Dr. A.R. Feddes

University of Amsterdam A.R.Feddes@uva.nl Tel.: +31(0)205256116

Nieuwe Achtergracht 129, G2.30, Amsterdam

Acknowledgements

We would like to thank VluchtelingenWerk Noordwest Nederland and Oost Nederland for their cooperation and help. Dr. A. Fisher and Dr. B. Doosje for their support in the project. Special acknowledgements to Tina Shamaan, Adnan Mouheddine, Jinane Araqi and David Lips for translating the survey.

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TRAUMA, SOCIAL RESILIENCE AND INTEGRATION OF REFUGEES 2

Abstract

In 2016, more than 20.000 refugees found shelter in the Netherlands. Given the high number of traumatized refugees, this research explores the link between traumatic experiences, post-traumatic stress, mental well-being, social resilience, and intentions to integrate. An online survey collected data from 283 resettled refugees in the Netherlands. Structural equation modelling and mediation analysis suggested that traumatic experiences are related to decreased social resilience, a factor determining refugees’ intentions to integrate into society. Increased post-traumatic stress and decreased mental well-being partially mediate this link. Refugees that are socially resilient are more likely to integrate. Decreased mental well-being and post-traumatic stress can however impede the integration process, mainly through social resilience. These findings overall underscore the importance of an integrative approach to facilitate integration, including strategies to strengthen the mental- and physical health of refugees and to enhance their social resilience.

Keywords: Traumatic experiences, post-traumatic stress, social resilience, resettled refugees, integration, quality of life, mental well-being, physical well-being,

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Introduction

In 2016, there were 22.5 million refugees in the world; more than 20.000 refugees found shelter in the Netherlands (UNHCR, 2017). The former secretary General of the United Nations stated that “we are facing the biggest refugee and displacement crisis of our time. Above all, it is not just a crisis of numbers; it is a crisis of solidarity”. Two years later, one of the long-term challenges is the successful integration of refugees. Being able to integrate successfully however requires a high level of resilience, the ability to cope with and adapt to environmental and social change (Adger, Kelly, Winkels, Huy, & Locke, 2002).

Most refugees show great willingness to integrate and impressive levels of resilience (Haker, Van den Muijsenbergh, & Torensma, 2016; Fazel, Reed, Panter-Brick, & Stein, 2012). Negative social as well as psychological factors can however decrease resilience and in turn counteract the successful integration of refugees (Holder, 2012).

This study explores the influence of traumatic experiences, mental well-being and post-traumatic stress on social resilience and intentions to integrate of 283 resettled refugees in the Netherlands.

We hypothesize that traumatic experiences can lead to post–traumatic stress and decreased mental well-being; this in turn decreases the social resilience and intentions to integrate (see Figure 1). More knowledge about factors decreasing social resilience and integration could inform policies concerning mental health care and the social integration of refugees.

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Figure 1. The influence of traumatic experience on social resilience and intentions to integrate is mediated by mental well-being and post-traumatic stress

Integration of resettled refugees

Integration is a process which is often measured in terms of cultural acculturation. Berry et al. (2006) describe that immigrants successfully integrate when they maintain a degree of cultural integrity, while at the same time seek to participate as an integral part of the larger society. One determinant of whether people successfully integrate, can be summarized in the concept of social resilience.

Resilience

Resilience is described on an individual and a group level. Psychological resilience describes resilience from an individual perspective and determines the capacity to “overcome life challenges and facilitate personal development under stress” (Ungar, 2013, p. 255). When psychological resilience is decreased, people are prone to develop physical or mental problems (Friedli, 2009). Social resilience rather focuses on an interpersonal or group level; it determines the capacity to sustain positive social relationships and to endure and recover from stressors and social isolation (Adger, 2000). Decreased social resilience can manifest in acculturation difficulties, and in extreme cases, even in problematic attitudes and behaviours,

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such as involvement in crimes, violence or non-normative collective action (e.g. Weine, Henderson, Shanfield, Legha, & Post, 2013; Weenink, 2015; Mann et al. 2015; Doosje, Loseman, & Van den Bos, 2013). Since plentiful research has focused on factors related to determinants of psychological resilience (Haker, Van den Muijsenbergh, & Torensma, 2016; Engelhard, 2007; Schellingerhout, 2011), this study will mainly focus on the social aspect of resilience, further referred to as social resilience.

Components of decreased social resilience

Mann et al. (2015) suggested that determinants of resilience are interrelated but can be categorized into affective, cognitive and behavioural components. Examples of affective determinants of social resilience are trust in authorities in one’s country and the feeling of meaningfulness in one’s life. A decrease of affective determinants can result in relative deprivation, realistic in-group threat, higher perceived procedural injustice and perceived illegitimacy of authorities (Mann et al., 2015). Relative deprivation describes a feeling people get when they do not get what they perceive to deserve (Crosby, 1976; Grant & Brown, 1995). Realistic threat describes the perception of one’s group being threatened economically, such as by not having good economic opportunities in the future (Stephan et al., 2002). Perceived procedural injustice describes the feeling of being treated in an unjust matter on a procedural level (Doosje, Loseman, & Van den Bos, 2013), for example through discrimination. Illegitimacy of authorities describes the perception that the authorities in one’s country are not respectable or legitimate (Buijs, Demant, & Hamdy, 2006).

Cognitive determinants are related to the need for cognitive closure (Webster & Kruglanski, 1997), the desire to have firm answers to ambiguous questions or situations. A decrease in cognitive resilience was suggested to result in increased feelings of entrapment (Paulussen, Nijman, & Lismon, 2017) or the inability to cope with emotional uncertainty

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(Doosje, Loseman, & Van den Bos, 2013). A behavioural determinant of social resilience is, for example, multiple group memberships (Mann et al., 2015), meaning that one is flexible enough to adapt to the perspectives and norms of different groups. Decreased behavioural resilience can lead to intergroup anxiety, feeling symbolically threatened or disconnected from society (Stephan et al., 2002). Intergroup anxiety describes feeling nervous, anxious or uncomfortable when one encounters members of other groups. Symbolic threat describes the perception that one’s culture is threatened by other cultures.

Factors suggested to negatively impact social resilience are catastrophic events (Walsh, 2007), social isolation, a lack of cultural integration, uncertainty, economic inequality (Haker, Van den Muijsenbergh, & Torensma, 2016), and perceived unfairness (Mann et al., 2015; Doosje, Loseman, & Van den Bos, 2013).

Unfortunately, refugees are often exposed to situations that can undermine the development and maintenance of social resilience. Many of them experienced catastrophic events in their homelands, as well as during their flight. Once they have reached their new host country, many asylum seekers face high levels of uncertainty while waiting for the outcome of their asylum application. Even after refugees have settled down, they experience economic difficulties which foster feelings of relative deprivation (Porter & Haslam, 2005). Stigmatization, discrimination, and a lack of perspective or occupation that many asylum seekers encounter could feed into the societal disconnectedness (Montgomery, 2010) and into strong singular in-group identification among people sharing the same faith.

In sum, the social circumstances, the history and consequences of traumatic experiences of asylum seekers can potentially decrease their social resilience. Consequences of decreased resilience, as manifested in problematic behaviour, can lead to a negative image of refugees. This could in turn foster stigmatization of refugees and hence further decreasing the social resilience of refugees, ultimately leading into a vicious circle of stress by

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displacement, problematic behaviour (Kreidie & Kreidie, 2016) and impeded integration. Given the challenge to integrate high numbers of refugees, it is important to investigate factors undermining social resilience in resettled refugees.

Resilience and Integration

Social resilience influences how one deals with aversive life events. Immigrating into a new cultural context entails adversity and change. It is therefore not surprising that social resilience was suggested to relate to acculturation (Paulussen, Nijman, & Lismont, 2017). Unsuccessful acculturation in particular, has shown to relate to lacking commitment or purpose in life, feeling socially disconnected and discriminated against; in other words: it is associated to factors that describe decreased social resilience (Paulussen, Nijman, & Lismont, 2017; Mann et al., 2015; Doosje, Loseman, & Van den Bos, 2013; Haker, Van den Muijsenbergh, & Torensma, 2016).

Very few research studies have empirically tested key factors underlying social resilience and integration (Weine, Henderson, Shanfield, Legha, & Post, 2013; Adger, Kelly, Winkels, Huy, & Locke, 2002), let alone in refugees. Below, we discuss a number of important factors that are the subject of this study.

Determinants of social resilience

We hypothesized that traumatic experiences are related to decreased mental well-being and increased post-traumatic stress which decreases social resilience and intentions to integrate. In the following paragraphs, it is illustrated how these factors relate to each other.

Traumatic experiences. A traumatic experience can be defined as a deeply distressing or disturbing experience (Hornby & Wehmeier, 1995), such as witnessing or experiencing sexual violence, actual or threatened death or serious injury (American

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Psychiatric Association, 2013). Various data suggest that negative critical life events are associated with decreased social resilience (Ellis, Abdi, Horgan, Miller, Saxe, & Blood, 2015; Knapton, 2014; Bhui, Everitt, & Jones, 2014; Soufan group, 2016; Robben, 2005; Jensen & LaFree, 2016; Wiktorowicz, 2004). In a sample of Somali refugees in the United States, traumatic experiences were associated with openness to illegal activism (Ellis, Abdi, Horgan, Miller, Saxe, & Blood, 2015), one possible consequence of decreased social resilience. This relationship was however only existent in refugees who did not have strong social bonds; social bonds in turn, facilitate integration (Oppendal, Røysamb, & Sam, 2004).

Refugees’ traumatic experiences in the host country, such as being imprisoned, could, for example, increase perceptions of injustice, illegitimacy of authorities and societal disconnectedness; three components of social resilience (Mann et al., 2009) and subsequently decrease the intentions to integrate.

Since many refugees have lived through traumatic experiences, our first hypothesis explores, whether traumatic experiences are determinants of social resilience.

Mental well-being. Traumatic experiences are quite common. More than 80% of all people in the Netherlands will experience at least one traumatic event in their life (De Vries & Olff, 2009). In refugees this prevalence is even higher1 (Haker, Van den Muijsenbergh, & Torensma, 2016; Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997). However, trauma does not always have an impact on people (Bonanno, 2004) and not all people who experience trauma are unable to integrate into a new context. It can, however, make people less psychologically resilient as characterized by a decrease in mental well-being. A link between decreased mental well-being and consequences of low social resilience was suggested by various sources (Ellis, Abdi, Horgan, Miller, Saxe, & Blood, 2015; Weenink,

1

The lifetime prevalence of traumatic experiences of refugees in the Netherlands has not been published. A sample of refugees in Sweden however showed that more than 89% of resettled refugees had traumatic experiences (Steel, Dunlavy, Harding, & Theorell, 2017).

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2015; Bhui, Everitt, & Jones, 2014; Soufan group, 2016; Sinkule, 2008). Weenink (2015), for example, analyzed the police files of 140 people who got involved in non-normative collective action. His data indicated that 60% of all people had been in mental health treatment, 76% had been in child protective services, and 46% had displayed problem behaviour before engaging in non-normative collective action. Bhui, Everitt, and Jones (2014) found evidence that symptoms of depression can foster positive attitudes towards violence. Our second hypothesis is therefore that decreased mental well-being mediates the relationship between traumatic experiences and social resilience.

Post-traumatic stress. Post-traumatic stress follows the experience of a traumatic event, witnessing learning about its occurrence or repeatedly experiencing some of its aversive details (American Psychiatric Association, 2013). Symptoms are related to intrusion (e.g. flashbacks or nightmares), avoidance (e.g. feeling disconnected, emotional numbing) and hyper-arousal (e.g. hyper-vigilance, general irritability; American Psychiatric Association, 2013).

Recent empirical evidence about refugees in Lebanon suggested that not mental well-being but post-traumatic stress symptoms (PTS) specifically determine political attitudes and willingness to engage in violence (Kreidie & Kreidie, 2016). The authors argue that “continues trauma aggravated by displacement” (Kreidie & Kreidie, 2016, p. 598) affects executive brain functions, leading to low impulse control and subsequently high conflict behaviour. In their study, PTS symptoms predicted revengeful behaviour and positive attitudes towards violence; symptoms described as high conflict attitudes. Interestingly, their high conflict attitudes variable contained items related to relative deprivation, perceived procedural injustice, legitimacy of authorities and willingness to use violence (e.g. “Does social injustice exist in Syria?”); These are reversed components of what we define as social

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resilience.2 Ellis et al. (2015), found that post-traumatic stress mediated the relationship between traumatic experiences and greater openness to illegal activities. Our third hypothesis is therefore that PTS is associated with social resilience by mediating the relationship between traumatic experiences and social resilience.

Mental well-being, post-traumatic stress and integration. Various data suggested that decreased mental well-being and increased post-traumatic stress decrease the ability to integrate in refugees (Laban, Gernaat, Komproe, van der Tweel, & De Jong, 2005; Haker, Van den Muijsenbergh, & Torensma, 2016; Sinkule, 2008; Lindencrona, Ekblad, & Hauff, 2008). This is a two-sided process. While mental health problems can decrease the motivation to integrate, the inability to integrate can also negatively influence the mental health of refugees (Haker, Van den Muijsenbergh, & Torensma, 2016). Not having a daily occupation, such as having a job, has shown to decrease the mental well-being of refugees (Haker, Van den Muijsenbergh, & Torensma, 2016; Sinkule, 2008). And having a decreased mental well-being can influence refugees’ ability to find and sustain a job (e.g. Adler, McLaughlin, Rogers, Chang, Lapitsky, & Lerner, 2006).

One underlying factor of integration and mental well-being could be the ability to cope with emotional uncertainty, a component of social resilience (Doosje, Loseman, & Van den Bos, 2013). It has shown to be an underlying factor of many mood disorders (Boswell, Thompson, Hollands, Farchione, & Barlow, 2013) and could be related to integration (Berry et al., 2006) by explaining why some people develop maladaptive strategies to cope with uncertainty, such as separating oneself from society to ambiguous situations.

Our fourth and fifth hypotheses are that social resilience mediates the effect between mental well-being (Hypothesis 4), post-traumatic stress (Hypothesis 5) and intentions to

2

From a theoretical perspective, key aspects of PTS could predict factors of social resilience. Emotional numbing could lead to, for example, feeling disconnected from society and that hyperarousal could lead to a higher perception of threat.

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integrate.

Exploratory analyses

Further, the influence of trauma location (i.e., in home country, during flight or in host country), demographic- and personal factors (i.e., religiosity, education, occupation, physical well-being and social support) on the key concepts are explored.

In summary, this study examines the relationship between trauma, social resilience and lower intention to integrate in resettled refugees. We hypothesize that:

1. Traumatic experiences are associated with decreased social resilience.

2. Mental well-being mediates the relationship between traumatic experiences and social resilience. Traumatic experiences are associated with decreased mental well-being, which is in turn associated with decreased social resilience.

3. Post-traumatic stress (PTS) mediates the relationship between traumatic experiences and social resilience. Traumatic experiences are associated with increased PTS, which are in turn associated with decreased social resilience.

4. The relationship between mental well-being and intentions to integrate is mediated by social resilience. Decreased mental well-being is related to decreased social resilience and subsequently lower intentions to integrate.

5. The relationship between PTS and intentions to integrate is mediated by social resilience. Increased PTS leads to decreased social resilience and subsequently lower intentions to integrate.

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Methods

Participants

Inclusion criteria. The online survey was sent to approximately 6000 refugees. Only refugees older than 18 years old with a residence permit in the Netherlands could participate.

Participation and dropout rate. Out of the approximately 6000 approached refugees, 915 people clicked on the survey link. Subsequently 535 closed the survey without any further action and 10 did not accept the informed consent. Out of the 370 participants who agreed to the informed consent, 87 started with the study but stopped and 283 finished the survey (see Figure 2).

Figure 2. Illustrates the number of approached participants and dropout rate

Demographics. Our sample of 283 refugees who finished the study, 230 participants came from Syria (81.3%), 16 participants from Eritrea (5.7%), eight from Iraq (2.8%) and one participant came from each of the following countries: Afghanistan, Congo, Somalia, Azerbaijan, Burkina Faso, Guinea, Iran, Jamaica, Kurdistan, Kyrgyzstan, Pakistan, Palestine, Rwanda, Uganda, Vietnam and Zimbabwe. Seven participants did not specify their origin in the text entry. The age ranged from 18-67 years (M = 34.74, SD = 10.40). Out of our 51 female (18%) and 227 male participants (82%), 51.1% were college educated, 18.9% had not

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received formal education, 10% finished secondary school and 3.9% had a doctoral degree. Most participants came to the Netherlands in 2015 (21.7%). The range of the arrival in the Netherlands was however between 1998 and 2017 (M = 2013, SD = 2.55). Most of the participants were currently doing voluntary work (12%), 3.9% were doing internships and 4.1% had paid work. Only 32.1% of the participants identified themselves as religious (25.8 % Muslim, 5.9 % Christian, 0.4 % Yezidi). The frequencies of the different traumatic experiences are displayed in table 1. Additionally, 71.4% of our participants reported an additional traumatic experience.

Pilot study

The survey was pilot tested by the principal investigator to evaluate the three assessment languages English, Dutch and Arabic and to estimate how participants react to the questionnaire. The principal investigator met the seven male participants in public places. Five of them were from Syria (two did not specify their origin) and were between 20 and 45 years old (M = 32.80, SD = 11.12). Three of them had a completed college degree and two had finished high school. Six were currently in language school and occupied with the civic integration course. One participant had paid work. As predicted by experts of the Dutch Council for Refugees and a trauma expert at the University of Amsterdam, the study did not cause long lasting discomfort in participants. The participants indicated that they were reminded of their traumatic experiences, but that this did not cause long-lasting discomfort. Accordingly, unclear questions, errors in the translations and the length of the questionnaire were adapted.

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Main Study

Recruitment and ethical approval. The survey was approved by the ethical committee of the University of Amsterdam (ID: 2017-CP-7755). It was distributed via e-mail by the Dutch Council for Refugees East Netherlands (VluchtelingenWerk Oost Nederland) and The Dutch council for refugees North-West Netherlands (VluchtelingenWerk Noord-West Nederland). Since the initial response rate was below 1%, to increase the number of participants, the survey was posted in Facebook groups related to refugees in the Netherlands. Additionally, key people known to be related to a high number refugees were approached to additionally distribute the questionnaire. A reminder e-mail was sent by the Dutch Council for Refugees after two weeks, which increased the response rate by 35%.

Procedure

Participants could switch between the English, Dutch and Arabic version while doing the survey. After giving their consent to the collection of data, participants had to indicate their country or origin and subsequently proceeded to a trauma questionnaire assessing of 19 types of traumatic experiences. They could voluntarily add a traumatic experience which was not mentioned in the questionnaire. If participants indicated that they experienced or witnessed one of the 19 traumas, they had to answers more specific questions about the event, including one question about the place of the trauma, the intensity of the experience and how many times they were exposed to the trauma. If at least one trauma was indicated, participants proceeded to a following Post-Traumatic Stress Symptoms (PTS) assessment scale. Subsequently their quality of life (including the mental well-being scale), social resilience and demographics were assessed.

At the end of the questionnaire participants could leave comments about the study and click on a link to a new survey in which they could subscribe to a lottery to win one out of

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five vouchers or to receive the results of the study. They were also given the telephone number and e-mail address of the principal investigator in case that they experienced emotional difficulties after participating in the study or to revoke their permission to use the data. Participants would have been forwarded to their social worker at the Dutch Council for refugees by the principal investigator in case of experienced discomfort. However, none of the participants indicated emotional difficulties after participating.

Measures

Trauma. This variable was assessed with 12 items (Serious injuries, physical abuse, torture, accidents, natural hazards, loss or separation from family members, destruction of personal property, lack of proper food, lack of proper housing, lack of proper medical facilities, overcrowding at the place of stay, unemployment) of the Refugee Trauma Experience Inventory (Hussain & Bhushan, 2009). Additionally, six traumatic experiences that were added because of their prevalence in refugees (physical illness, airstrikes, terrorist attacks, being threatened verbally or physically, rape or sexual abuse, extreme violence, Other [please specify]). Participants had to indicate whether they had experienced, witnessed, heard about or not at all experienced the in total 19 traumatic experiences. If they indicated that they witnessed or experienced the trauma, they had to answer questions about this specific experience. We assessed the severity of the traumatic experience by measuring how many times they were exposed to the trauma (“Once, more than once”) and the subjective intensity of the experience (e.g. “Please describe the intensity of your experience”) on 5-point likert scale (1= not at all – 5= very high). The last trauma question was an open question in which participants could indicate whether they had traumatic experiences that were not mentioned before. Trauma scores were calculated by multiplying trauma intensity scores with trauma type scores (0 = no, 1 = heard about, 2 = witnessed, 3 = experienced) of

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trauma and the times of exposure (1 = once, 2 = multiple times). Subsequently, the mean score was calculated M(Trauma type 1 x Intensity Trauma 1 x Times of exposure Trauma 1)3 resulting in score that displays the overall number and intensity of traumatic experience. An example item is: “Please indicate which of the following events you have encountered and specify whether you have experienced them yourself, witnessed them happening to other people, heard about them or not encountered them at all. You can also choose multiple options: Serious injuries [Experienced, witnessed, heard about, no]”.

Quality of life. Mental health was assessed with the WHOQOL-Bref (World Health Organization Quality of Life) scale (WHOQOL group, 1995). It consists of 26 items and measures the physical- and mental health, the quality of environment, and social relationships and has a high reliability (α = .93). One of the six items for mental well-being (α = .82) was: “Do you have enough energy for everyday life?”. One of the seven items measuring physical well-being (α = .82) was: “How satisfied are you with your physical health”. One of the three items measuring social support (α = .74) was “How satisfied are you with your personal relationships?”. One of the eight items measuring the quality of environment (α = .78) was “How available to you is the information that you need for day-to day life?”. One of the two

items measuring general quality of life (r = .39, p < .01) was “How would you rate your quality of life?”. All items were measured on a measured on a 5-point likert scale (1= not at

all – 5 = completely). Validated Arabic (Ohaeri & Awadalla, 2009), Dutch (Trompenaars,

Masthoff, Van Heck, Hodiamont, & De Vries, 2005) and English (Skevington, Lotfy, & O’Connell, 2004) versions were used.

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Example: If participants experienced (1 = heard about, 2 = witnessed, 3 = experienced) physical injuries (T1), indicated that it happened multiple times (1= once, 2 = multiple times) and that they experienced it as highly intense (1= not intense at all, 7 = highly intense), then their trauma score would have been (3x2x7)= 49.

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Post-Traumatic Stress (PTS). If participants indicated to have experienced or witnessed one of the traumas as indicated above, they were asked to answer four items of the SPAN (Meltzer-Brody, Churchill, & Davidson, 1999), a short self-report PTS symptoms screen derived from the Davidson Trauma Scale (Davidson, Tharwani, & Connor, 2002). They had to respond to the event that had most impact on their life. The scale assessed the PTS symptoms startle response, being physically upset by reminders, anger, and numbness, the reliability of the scale was questionable (α = .64). An example item is: “Have you had difficulty concentrating after the adverse event? (Yes, No)”. We additionally assessed the intensity of the PTS (e.g. “Please describe the intensity of your experience”) on a 5-point likert scale (1= not at all – 5 = very high) and whether the event that had most impact on their life took place in the country of origin, during the flight or in the Netherlands (“Where have you encountered this event? (Multiple answers are possible)”; “In my country of origin, During my flight to the Netherlands, In the Netherlands, In another location”).

Integration. This variable was measured with six items of Barry’s Acculturation scale (Barry, 2001). The scale was adapted to refugees in the Netherlands and measured on a 7-point likert scale (1= strongly agree – 7 = strongly disagree). An example item is “I want to be valuable to the Dutch society.” (α = .61).

Resilience. This variable was assessed with 26 items from different scales related to resilience and adapted to the context of refugees in the Netherlands. The subscales measured symbolic and realistic in-group threat, relative deprivation, intergroup anxiety, emotional uncertainty, external entrapment, in-group identification, perceived illegitimacy of authorities, perceived ingroup superiority, societal disconnectedness, perceived procedural injustice,

Three items measured symbolic in-group threat (Stephan et al., 2002; e.g. “Dutch people think their way of life is better than my way of life.”) and two items measured realistic

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in-group threat (Stephan et al, 2002; e.g. “It is very likely that I will become a Dutch National.”); both scales measured on a 10-point likert scale (1= not at all – 10 = very much).

Two items measured relative deprivation (Doosje, Loseman, & Van den Bos, 2013; e.g. “I think I can start a good life in the Netherlands.”) on a 7-point likert scale (1= strongly agree – 7= strongly disagree). One item measured intergroup anxiety (Stephan et al, 2002; e.g. “Imagine that you would talk to a Dutch person. How would you feel?”) by assessing the degree to which people felt uncertain, worried, awkward, anxious, threatened, nervous, relaxed, calm, secure, or comfortable on a 4-point likert scale (1= not at all – 4= very much so).

Two items measured emotional uncertainty (Greco, & Roger, 2001; e.g. “I get worried when a situation is uncertain.”) on a 4-point likert scale (1= not at all – 4= very much so). Two items assessed external entrapment (Gilbert & Allan, 1998; e.g. “I can see no way out of my current situation.”) on a 5-point likert scale (1= not at all like me – 5 = extremely like me).

In-group identification was measured with one item (Doosje, Ellemers, & Spears, 1995; e.g. “Being from Chad is important to me.”) on a 5-point likert scale (1 = not at all – 5= very much). The in-group identification item participants were shown, depended on the country of origin that they indicated in the beginning of the survey (e.g. What is your country of origin?; Syria, Eritrea, Iraq, Afghanistan, Sudan, Congo, Somalia, Nigeria, Niger, Chad, Other [please specify]). Participants from an unspecified country saw the item “Being from my country of origin is important to me.”.

Perceived legitimacy of the authorities was measured with reversed items of the illegitimacy of authorities scale two items (Doosje, Loseman, & Van den Bos, 2013; e.g. “I respect institutions related to my civic integration.”) on a 5-point likert scale (1= not at all – 4 = very much).

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Perceived in-group superiority was measured with two items of the in-group superiority scale (Doosje, Loseman, & Van den Bos, 2013; e.g. “I don't think that people where I come from are better than Dutch people.”) on a 5-point likert scale (1= not at all – 5= very much).

Societal connectedness was assessed with Doosje, Loseman, and Van den Bos’ (2013) reversed societal disconnectedness scale (α = .65), with four items on a 5-point likert scale (1= strongly agree – 5 = strongly disagree). An example item is: “I feel at home in the Netherlands.” (reverse coded). Additionally, added seven Venn circles (Aron, Aron, & Smollan, 1992) that displays the distance of oneself with the Dutch society (Self, Other people in the Netherlands).

Perceived procedural injustice was assessed with four items of Moorland’s (Doosje, Loseman, & Van den Bos, 2013) reversed Perceived Procedural Injustice Measure (α = .81) on a 5-point likert scale (1= strongly agree – 5 = strongly disagree). An example item is: “I think I am treated fairly most of the time.” (reversed). The scale was very reliable (α = .83).

Lastly age (e.g. What is your year of birth? [for example, 1990]), current occupation (e.g. Are you currently working, doing an internship or voluntary work? [Multiple answers possible]), educational level (What is your highest level of education?; Primary school, Secondary school, I did not have formal education, University or College, Doctorate degree), current education in the Netherlands related to the civic integration (Are you currently in school or following an education program [e.g. Civic integration, language school]?), arrival date in the Netherlands (On which date did you arrive in the Netherlands? [for example, in 01-2015 for January 2016]), and sex (male, female) were assessed.

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Results Analysis procedures

In the preliminary analyses, the assumptions for structural equation modelling and regression analyses, descriptives and frequencies were computed.

To test our research question whether traumatic experiences are related to social resilience and integration, structural equation modelling was used to assessed the overall fit of the model (see Figure 1). The analysis was conducted with the Lavaan package (Rosseel, 2011) in the statistical software R. According to Hu, and Bentler (1999) the model fit is best assessed by examining the Standardised Root Mean Square Residual (SRMR), the Tucker-Lewis Index (TLI), the Comparative Fit Index (CFI) and the Root Mean Square Error of Approximation (RMSEA). Traditionally the Model Chi-square test (Hu & Bentler, 1999) is used in addition (Hooper, Coughlan, & Mullen, 2008).4

More specifically, mediation analyses (Baron & Kenny, 1986) with the bootstrapping method (Preacher & Hayes, 2008) were conducted for hypotheses one to five.

Preliminary analyses

Assumptions. A Cox-small test (Cox & Small, 1978) indicated violations of multivariate normality in the traumatic experiences (D(283)= .11, p = < .01), PTS (D(283)= .13, p = < .01), integration (D(283)= .09, p = < .01), and mental health (D(283)= .12, p = < .01) variables; we consequently transformed all variables into log-scores to avoid problems of normality and collinearity. There were outliers in the integration variable (Z = 4.33, 4.32, -3.22, -3.22 < -3), and in the trauma variable (Z = 3.01, 3.03, 3.13 > 3). Due to the discretion of the researcher, the outliers were not excluded because there were multiple outliers in the same range, and extreme traumatic experiences and low levels of integration are not unusual

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in the tested population. There were no influential cases in the dataset according to Cook’s Distance (Maximum D = .06 < 1).

Descriptives. In our sample, 98.1 % of the participants had experienced or witnessed

at least one traumatic experience, leaving only 1.1% of the participants who had only heard about or not had a traumatic experience in their life. The most frequent traumatic experiences were experienced physical or verbal threat, destruction of personal property, unemployment and lack of proper housing and the least frequent traumatic experiences were torture and rape or sexual abuse (see Table 1). Men had experienced significantly more traumatic experiences than women t(272) = 2.74, p = .01. Men, compared to women, scored significantly higher on destruction of personal property (M = 20.26, SD = 12.19; M = 13.58, SD = 6.85, respectively), lack of proper food (M = 21.64, SD = 11.56; M = 12.25, SD = 6.70, respectively), lack of proper medical facilities (M = 20.04, SD = 11.66; M = 12.64, SD = 7.52, respectively), and experienced traumas as significantly more intense (M = 1.73, SD = 1.01; M = 1.34, SD = .84). No significant gender differences were found for the key variables.

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Table 1.

Frequencies of traumatic events that were experienced, witnessed or heard about.

Traumatic experience Experienced

N (%) Witnessed N (%) Heard about N (%) Serious injuries 63 (22.3%) 120 (42.4%) 87 (69.3%)

Lack of proper medical facilities 99 (35.0%) 69 (24.4%) 86 (30.4%) Overcrowding in the place of stay 112 (39.6%) 92 (32.5%) 67 (23.7%)

Unemployment 143 (50.5%) 90 (31.8%) 77 (27.7%)

Physical illness 55 (19.4%) 83 (29.3%) 89 (31.4%)

Airstrikes 117 (41.3%) 110 (38.9%) 104 (36.7%)

Extreme violence 111 (39.2%) 73 (25.8%) 85 (30.0%)

Terrorist attacks 77 (27.2%) 69 (24.4%) 126 (44.5%)

Being threatened verbally or physically 161 (56.9%) 68 (24.0%) 83 (29.3%) Rape or sexual abuse 45 (15.9%) 37 (13.1%) 100 (35.3%)

Physical abuse 79 (27.9%) 81 (28.6%) 87 (30.7%)

Torture 49 (17.3%) 62 (21.9%) 126 (44.5%)

Accidents 80 (28.3%) 98 (34.6%) 90 (31.8%)

Natural hazards 81 (28.6%) 52 (18.4%) 86 (30.4%)

Loss or separation from family 123 (43.5%) 49 (17.3%) 65 (23.0%) Destruction of personal property 149 (52.7%) 79 (27.9%) 74 (26.1%) Lack of proper food 140 (49.5%) 62 (21.9%) 94 (33.2%) Lack of proper housing 140 (49.5%) 75 (26.5%) 75 (26.5%)

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Correlations. The results of a preliminary correlation analysis can be seen in table 2.

Trauma significantly correlates negatively with mental well-being (r = -.24, p < .01) and positively with PTS (r = .29, p < .01). Physical well-being is negatively correlated with trauma (r = -.24, p < .01) and PTS (r = -.47, p < .01). It was positively correlated with mental well-being (r = .73, p < .01) and social resilience (r = .45, p < .01). The degree to which people considered themselves religious or spiritual was negatively correlated with the integration (r = -.30, p < .01) and positively with social support (r = .13, p < .05). Whether participants were currently participating in an education program, such as language school or a civic integration course, was negatively associated with PTS (r = -.14, p < .05) and positively with social resilience (r = .12, p < .05).

Table 2.

Correlations between key variables of the model and demographics

1. 2. 3. 4. 5. 6. 7. 8. 1. Trauma 1 2. Mental well-being -.24** 1 3. PTS .29** -.51** 1 4. Social resilience .00 .49** -.51** 1 5. Integration .06 .01 -.01 .30** 1 6. Physical well-being -.24** .73** -.47** .45** .01 1 7. Religiosity .02 .08 -.08 .05 -.30** .04 1 8. Social support -.21** .69** -.39** .40** -.01 .61** .13* 1 9. Current education -.00 .00 -.14* .12* .05 .04 .09 .01 Note. * = p < .05, ** = p < .01

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Main analyses

To test the relationships between the variables in our model (see Figure 3) a structural equation model was computed. The model yielded a good model fit (Hooper, Coughlan, & Mullen, 2008): χ2(283) = 6.61, p = .09, CFI = .98, TLI = .93, RMSEA = .07, SRMR = .04.

Figure 3. Displays the results of the hypothesis testing

To test the first, second and third hypotheses, whether mental well-being and post-traumatic stress mediate the effect between post-traumatic experiences and social resilience, a bootstrapping mediation regression analysis with 5000 bootstrap samples (Preacher & Hayes, 2008) was conducted. Evidence for a full mediation exists if the main path, e.g. traumatic experiences to social resilience (Hypothesis 1), becomes insignificant after adding the mediators, mental well-being (Hypothesis 2) and PTS (Hypothesis 3), to the regression model (Baron & Kenny, 1986). Meditation is confirmed if zero is not within the confidence interval of the variables (Preacher & Hayes, 2008). If main path remains significant and zero lies in the confidence interval, partial mediation exists. If the main path is not significant but zero lies in the confidence interval, an indirect effect exists.

The first hypothesis whether traumatic experiences is related to social resilience was confirmed. Traumatic experiences are significantly associated with social resilience (b* = .01, t(273) = 2.74, p < .01).

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The second and third hypothesis could be partially confirmed as traumatic experiences are significantly related to decreased mental health (b* = -.02, t(273) = -4.13, p < .01) and increased PTS (b* = .04, t(273) = 5.03, p < .01). Increased mental well-being (b* = .31, t(273) = 7.12, p < .01) and decreased PTS (b* = -.10, t(273) = -2.89, p < .01) are significantly related to social resilience. A bootstrapping analysis indicated that PTS 95% CI [-.15, -.03] and mental well-being 95% CI [.22, .40] partially mediate the relationship between traumatic experiences and social resilience.

The fourth hypothesis, whether social resilience mediates the relationship between mental well-being and intentions to integrate was partly confirmed. Mental health is positively related to integration (b* = .15, t(280) = -2.75, p < .01) and positively to social resilience (b* = .35, t(280) = 5.93, p < .01). The relationship between integration and mental wellbeing stays significant when social resilience is added to the model (b* = .15, t(280) = -2.75, p < .01). Social resilience has a significant positive indirect effect on integration (b* = .44, t(280) = 5.93, p < .01), indicating that social resilience partially mediates the relationship between mental well-being and integration 95% CI [.29, .58].

The fifth hypothesis was partly confirmed. PTS is not significantly related to integration (b* = .07, t(279) = 1.91, p = .06) but negatively to social resilience (b* = -.18, t(279) = -6.42, ,p < .01); social resilience is in turn related to integration (b* = .39, t(279) = 5.56, p < .01) indicating an indirect effect as confirmed by the bootstrapping analysis 95% CI [-.11, -.04].

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Exploratory analyses

Trauma location. We additionally explored whether the location of the trauma was

related to all outcome variables. Participants who indicated that the most impacting traumatic experience happened in the Netherlands (N = 36), scored significantly lower on mental health (t(278) = -3.7, p < .01), higher on PTS (t(277) = 3.79, p < .01), lower on social resilience (t(278) = -4.78, p < .01), lower on physical health (t(278) = -3.53, p < .01), and lower intentions to integrate (t(54) = -2.07, p = .04) than participants who experienced their most impactful trauma in the country of their origin, in an unspecified location or during their flight. Participants who indicated that the most impacting traumatic experience happened during the flight to the Netherlands (N = 96), scored significantly lower on social resilience (t(278) = -2.42, p = .02), compared to participants who experienced their most impactful trauma in the country of their origin or in an unspecified location (N = 244). Such an effect could not be found for traumatic experiences in the home country or in another location. The means and standard deviations are reported in Table 3.

Table 3.

Effect of location of most impactful traumatic experience on the key variables

In the Netherlands M (SD)

During the flight M (SD) Others M (SD) Mental well-being 2.83 (.83) 3.17 (.78) 3.25 (.78) PTS 2.26 (1.34) 1.54 (1.20) 1.54 (1.12) Social resilience 4.77 (.55) 4.59 (.55) 4.72 (.57) Integration 4.90 (.51) 5.03 (.61) 5.08 (.63) Physical well-being 3.15 (.80) 3.62 (.78) 3.57 (.78) Note. Means and standard deviations for the most impactful traumatic experience in the Netherlands, during the flight and in other locations (including country of origin and other locations)

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Discussion

This online study with 283 resettles refugees in the Netherlands, explored the link between traumatic experiences, social resilience and intentions to integrate. The data suggest that traumatic experiences are related to decreased social resilience, decreased mental well-being and increased post-traumatic stress. Decreased mental well-being and increased PTS partially mediate the relationship between traumatic experiences and social resilience. While mental well-being positively relates to social resilience, PTS is negatively related to it. Social resilience is positively associated with intentions to integrate into a host society. No direct associations between traumatic experiences and integration were found. Increased mental well-being, however, relates to increased intentions to integrate. This relationship is partially mediated by social resilience. Increases in PTS only indirectly relate to decreased integration via decreased social resilience.

These findings overall suggest that traumatic experiences alone do not impede the ability to integrate; intentions to integrate only decrease when refugees experience post-traumatic stress and decreased mental well-being in combination with decreased social resilience. Social resilience therefore seems to be an important factor that determines whether refugees have high or low intentions to integrate.

Our finding that social resilience is related to traumatic experiences is in line with prior research suggesting that traumatic experiences can trigger a cognitive opening (e.g. Wiktorowicz, 2004). A cognitive opening can be a change in the perception of justice in one’s society after an aversive life event, for example. After a traumatic experience in the host country, such as experiencing lack of proper housing, refugees might lose their belief in justice in the asylum system. One of the participants reported5 “the most humiliating event that I have seen in my life was in your country, Holland. When people in the camp forced

5

Many participants described the most impactful traumatic experiences in a text entry field in which they could add additional traumatic experiences.

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people to sleep in tents outside, every tent accommodated three families [...] sometimes bad food dishes and all this humiliation, so that no one would come to the Netherlands and ask for asylum”. Perceptions of justice are in turn part of the concept of social resilience. Social resilience consists of various sub factors related to the perception of justice, perspective of the future and feeling socially connected (Doosje, Loseman, & Van den Bos, 2013) and can therefore be influenced by social factors.

The direct effect of traumatic experiences on social resilience was however quite small. This was probably due to the fact that the relationship between traumatic experiences and social resilience is partially mediated by mental well-being and post-traumatic stress. This is in line with prior research suggesting that traumatic experiences can lead to decreased social resilience by making people psychologically vulnerable, as indicated be decreases in mental well-being and increases in post-traumatic stress (e.g. Bhui, Everitt, & Jones, 2014; Soufan group, 2016; Ellis, Abdi, Horgan, Miller, Saxe, & Blood, 2015). One symptom of post-traumatic stress is hyperarousal, an overreaction to reminders of a traumatic event. Post-traumatic stress can lead to a heightened perception of threat when one is exposed to reminder of the event (Kutz & Dekel, 2006). Traumatic experiences, such as unemployment or discrimination at work, could accordingly lead to a more intense perception of realistic or symbolic threat and undermine social resilience.

The association between decreased mental well-being and decreased intentions to integrate is in line with prior research suggesting that mental- and physical health problems decrease refugees’ ability to integrate economically (e.g. Laban, Gernaat, Komproe, Van der Tweel, & De Jong, 2005; Haker, Van den Muijsenbergh, & Torensma, 2016; Sinkule, 2008).

Exploratory analyses indicated that the traumatic experiences in the Netherlands are related to lower intentions to integrate; participants who were less socially resilient, had lower mental health scores, were more likely to develop PTS, were less physically healthy

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and had a lower overall quality of life. Traumatic experiences could for example lead to higher perceived injustice and relative deprivation. Factors that could interact with mental and physical well-being and indicate decreased social resilience. This effect could on the other hand be explained by the recency of the traumatic experiences as more recent traumatic experiences seem to have a larger impact on mental well-being and post-traumatic stress by leading to higher stress levels (e.g. Schock, Böttche, Rosner, Wenk-Ansohn, & Knaevelsrud, 2016; Pinto, Henriques, Jongenelen, Carvalho, & Maia, 2015).

Independently of the cause of the effect, one should note that traumatic experiences in the host country and during the flight seem to impede social resilience and integration, which could backfire under adverse circumstances.

One participant described that “in the AZC [Asylum Seeker Centre], I was so sick I could not walk to go to the reception area for sick people. I told the nurse that I was sick but she did not believe me [..]. What she did was dropped my ears, pinched my stomach and dragged me from my room”. Other participants reported suffering most from discrimination, lack of choice, freedom and “sober” housing conditions (Holder, 2012, p. 22). Traumatic experiences of such nature are inevitable. These findings however underscore the importance of training of people working with refugees but also of expectation management of refugees and the local population, for example through framing, transparency and education. Future research should however further explore this link before conclusions can be made.

Secondly, an exploratory analysis indicated that social support is positively related to mental well-being, physical well-being, social resilience and integration. It negatively relates to trauma and PTS. This is in line with prior research (e.g. Haker, Van den Muijsenbergh, & Torensma, 2016a; King, King, Fairbank, Keane, & Adams, 1998; Cohen & Wills, 1985) and underlines the importance of factors that decrease post-traumatic stress. Post-traumatic stress

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is, both, related to coping with the aversive life experience but to related safe environments that facilitate the post-traumatic healing, rather than entailing adversity (e.g. Wilson, 2014).

Thirdly, physical well-being was related to social resilience and mental well-being. Future research could explore the effectiveness of interventions fostering physical well-being, such as communal sport activities and culturally adequate medical treatment of refugees.

A fourth explored factor was the level of religiosity or spirituality of the participants. Religion or spirituality has suggested to foster resilience in refugees (Hamlin-Glover, 2009; Ní-Raghallaigh & Gilligan, 2010). Our data however indicated that religion negatively relates to integration. Future research should explore the mechanisms behind this link. Factors, such as feeling stigmatized for one's’ religion, could potentially explain such a finding.

These findings overall suggest that, even when refugees experienced severe traumas, health related factors and societal factors ultimately determine whether people integrate into a host society. Accordingly, to facilitate integration, two kinds of practical strategies can be applied: strategies to strengthen mental- and physical well-being and strategies to strengthen social resilience.

Practical strategies. Strategies fostering mental and physical well-being should

incorporate a holistic and culturally adapted approach to the physical and mental health care of refugees. Fostering the physical- and mental health of refugees should enhance their social resilience and ultimately their ability to integrate. The association between social resilience and mental health is two sided. One of the participants described6 “I wanted to learn Dutch since I entered the shelter so that I could take advantage of my time and be able to take responsibility for my own personal requirements and be prepared to integrate into the Dutch society [...] but the laws of these centres do not allow school access to those above the legal age and I was unable to register at any school outside the centre [..] this delay of learning

6

Many participants described the most impactful traumatic experiences in a text entry field in which they could add additional traumatic experiences.

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Dutch created a mental fatigue because I always had to ask for help in translations”. This example illustrates how social factors and mental well-being influence each other. Similarly, prior research showed that being unoccupied and not having control over one’s life can impede the post traumatic healing process (Holder, 2012), further underscoring the importance of an integrative approach.

Practical strategies related to social resilience, could be fostering a shared in-group identity of refugees and non-refugees. This could lead to higher levels of societal connectedness, lower perceptions of in-group superiority between refugees and locals and foster integration (related to factors in Mann et al., 2015).

By increasing transparency during the asylum procedure, one could establish trust in the government and reduce uncertainty during the asylum procedure (e.g. Grimmelikhuijsen, Porumbescu, Hong, & Im, 2013). Similarly, relative deprivation and realistic threat both relate to the perception of not having a good future in the Netherlands (e.g. Stark, & Taylor, 1991). A lack of perspective on the job market might foster these feelings, underscoring the necessity of suitable occupation and education of refugees.

Limitations. This study was designed to explore the basic relationship between

different psycho-social factors, social resilience and integration of refugees. Unfortunately, integration scale was not very reliable. This is not surprising since integration entails one positive (adapting elements of a new culture) and one negative dimension (keeping parts of one’s culture). Additionally, integration is only one of the four acculturation styles that Barry (2001) describes. Future research could explore all four dimensions of acculturation in relation to social resilience.

One advantage of our study was that it was translated into English, Dutch and Arabic. Due to time and financial constraints, we could unfortunately not back translate the Arabic scales by native English or Dutch speakers. Future research could therefore check the

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reliability of our translated scale and further develop scales in other languages to include people who do not have sufficient levels of English, Dutch or Arabic to participate.

Another disadvantage could be that our sample might have been biased through its recruitment process. A questionnaire assessing traumatic experiences could have attracted people who wanted to anonymously share their traumatic experiences as more than 71% of the participants used the open questions to describe their experiences7. Our sample additionally deviated from the overall population of refugees in the Netherlands; our sample was highly academic as more than half of the participants were college educated and 4% even had a PHD. This might have had an effect on the outcome variables, in particular on religiosity. Only 32% of our sample identified as being religious or spiritual; one participant even indicated that he or she only believes in “reasoning and science”. Another bias could be our participants’ high willingness to integrate. One of the example items for the integration scale was “I want to be valuable to the Dutch society”. The mean score of this item was 6.51 on a 7-point likert scale. The item “I want to be valuable to my host society”, had a considerably lower mean (M = 2.73). This suggests that our survey might have attracted more people who are more willing to integrate compared to people who separate themselves from the Dutch society. Our study however focused on factors fostering social resilience rather than on determinants of problematic behaviour. We therefore believe that we could still make a valid assessment of factors fostering social resilience. Future research however needs to target individuals who are not willing to integrate.

7

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Conclusion

Our data suggest that traumatic experiences are related to social resilience. Increased post-traumatic stress and decreased mental well-being partially mediate this link. Decreased mental well-being and increased PTS independently relate to social resilience; a factor determining refugees’ intentions to integrate into society. Additionally, traumatic experiences, in the host country and during the flight, have shown to be negatively associated with integration and social resilience. These findings overall underscore the importance of an integrative approach to facilitate integration, including strategies to strengthen mental health and enhance the social circumstances that refugees are experiencing.

To summarize, the findings suggests that, even when people experience severe traumatic experiences. It is mental health, post-traumatic stress, and decreased social resilience that ultimately decrease the intentions to integrate in refugees. These findings suggest that proper mental- and physical health care for refugees would increase their social resilience and ultimately would benefit their capabilities and motivation to integrate better in the host society.

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