Trauma, Collective Trauma and Refugee Trajectories in the Digital Era: Development of the Trauma Recovery Understanding SelfHelp Therapy (TRUST)

S. Kidane

Research output: ThesisDoctoral Thesis

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Trauma, Collective Trauma and Refugee Trajectories in the Digital Era
Development of the Trauma Recovery Understanding SelfHelp Therapy (TRUST)

This study investigates the effectiveness of the Trauma Recovery Understanding Self-Help Therapy (TRUST). The intervention was specifically developed to treat Traumatic Stress in highly traumatised populations, residing in settings where there are few resources and limited, if any, mental health support provisions. The study found that the intervention is highly effective and can be used in remote settings with little cost.

The background to the study was the observation that Eritrean refugees take very high risks, often life threatening, during their search for a safe heaven. This raised the question whether PTSD symptoms could impair decision-making in refugees causing them to make risky. Another question that was raised was whether the Eritrean refugees were engaging maladaptive behaviours as coping strategies. Underpinning these questions was the fact that hypervigilance, which is a symptom of PTSD, causes people to become oversensitive to the presence of risk and danger and can cause an exaggerated response. The question therefore was whether Eritrean refugees, did suffer from high levels of post-traumatic stress disorder (PTSD), and if so, whether resilience could be enhanced by an intervention, adapted to the context, to treat PTSD.

The research consists of three phases: (i) an exploration to understand the prevalence of PTSD among Eritrean refugees and an investigation of the occurrence of collective trauma and how traumatic stories are communicated; (ii) a design of a pilot of an intervention (TRUST) to treat PTSD and (iii) the test of the intervention among Eritrean refugees in a real-life setting.

The research was conducted among Eritrean refugees residing in different locations. A pilot of TRUST was carried out in North Uganda. The prevalence of PTSD was measured using the Impact of Events Scale-Revised (IES-R). It was found that almost without exception, the scores indicated high levels of PTSD. The extensive prevalence of PTSD also indicated collective trauma, which was researched by investigating the narration of traumatising memories on digital channels, such as Facebook. It was found that social media platforms were important communication channels, despite the fact that traumatic memories were also shared through these mediums causing high levels of collective trauma.

As a subsequent step, an intervention was designed. This therapy took into account the nature of the context and utilising the available communication channels – such as the mobile phones, that were in high use and trusted. The utilisation of these communication channels was intended to overcome the challenge of the unavailability of mental health workers to provide support. Based on techniques from Eye Movement Desensitisation and Reprocessing (EMDR), TRUST was designed with the objective of offering self-help techniques. Instructions were adapted taking the cultural and linguistic context into account. The program consists of three parts: understanding of the cause and symptoms of traumatic stress, the provision of techniques to cope with the symptoms of trauma and a social reintegration program.

Following its development, TRUST was first tested as a pilot in Northern Uganda among female returnees after the civil war. Selfperceived resilience was measured using the Social and Economic Resilience Scale (SER). SER is a self-reporting questionnaire with five constructs: social, income, empowerment, access to justice and capacity. In addition IES-R was used to measure levels of traumatic stress. The study was conducted in a real-life setting in a controlled pre-test post-test experimental design. TRUST was administered alongside an intervention of a social protection program, in the form of cash transfers and in-kind support packages. This allowed us to isolate and measure the various factors affecting resilience as well as compare their effect.

Prior to the implementation of TRUST the impact of other psychosocial support methods was tested. In this first phase, 471 women participated and were divided into four groups in a postexperimental design. The results compared the impact of the various interventions on socio-economic resilience. The groups that had psycho-social support for trauma scored significantly higher on socio-economic resilience than the groups that only participated in social protection interventions. The group that received a combination of income support interventions for social protection and psycho-social support scored the highest for improvements on socio-economic resilience.

We then compared the psycho-social support received in phase one with TRUST. In this phase, 356 participants were divided into eight groups and were given different combinations of interventions. TRUST was, contextualised to the culture and was offered in local languages through an audio program, recorded by trusted and familiar local radio presenters. Findings indicated a significant impact of TRUST on socio- economic resilience, with varying implications for the different constructs of resilience. Moreover, the results of the study pointed to the relevance of collective trauma in addition to individual traumatic stress.

Subsequently, the intervention was adapted and implemented in two refugee camps in Ethiopia (Hitsats and Shimelba camps in the Tigray region) with 103 young, Eritrean participants. TRUST was made available via videos on mobile phones. This had been proven to be a familiar and trusted communication channel for refugee youth in the camps.

The study in Ethiopia implemented TRUST within the framework of livelihood support programmes, which allowed the isolation of several variables that influence resilience. Participants were divided into four groups, with the trauma intervention being administered in two ways: group 1 received only the first stage of the intervention, group 2 completed the entire intervention. The research was a pre test-post test-experimental study with repeated measurements. Both IES-R and SER were shortened, taking into account the high mobility of participants. Additionally, in this research the collective nature of trauma was investigated as an independent variable and measured using the Internet Social Capital Scale (ISCS).

The results of this study are similar to the previous results from Uganda: the participants who completed the TRUST intervention scored significantly higher on the Socio-Economic Resilience Scale. Interestingly the availability of livelihood support packages had no influence on the socio-economic resilience of the respondents, indicating that the improvements are caused by psychological rather that material support. The intervention also dramatically decreased the score on the IES-R, indicating that it may decrease the symptoms of PTSD. It was also found that collective trauma decreased as a result of the TRUST treatment and that the decrease negatively correlated with enhanced socio-economic resilience.

The three experimental studies confirm the hypothesis that trauma affects perceived social and economic resilience and that psychosocial support alleviates the situation and contributes to enhanced socio-economic resilience (SER scores). The study further finds that the treatment TRUST, designed as a low-cost self-help intervention, has significant impact on socio-economic resilience and more so than social protection support in the form of cash transfers, in-kind support or livelihood support. Additionally, the study points to the relevance of collective trauma as a factor in improving socioeconomic resilience.

The study concludes that high levels of traumatic stress can be a factor that influences refugee decision-making. High levels of PTSD are not conducive for refugees settling down; in fact, they may keep fleeing to avert the trauma-induced danger that haunts them, taking their trauma along with them. Current policies developed to discourage refugees to move away from the first point of safety that they flee to, can exacerbate the stress of traumatised refugees. To understand the risky behaviours of refugees and to develop approaches that generate more resilience, greater attention is needed for the treatment of Post-Traumatic Stress in refugee communities. Based on the findings in this study, it may be postulated that it would be more prudent to improve the mental health state of refugees with PTSD symptoms, by treating trauma and thus increasing their resilience, rather than instituting preventive measures restricting their movement and enhancing their feelings of insecurity. TRUST offers a viable option to help address trauma, decrease risky decision-making and increase the socioeconomic resilience of refugees and their communities.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Tilburg University
  • van Reisen, Mirjam, Promotor
  • Kroon, Sjaak, Promotor
  • Stokmans, Mia, Co-promotor
  • Ashaba, S., Member PhD commission, External person
  • Braakman, Mario H., Member PhD commission
  • Dekker, M., Member PhD commission, External person
  • Mooren, G.T.M., Member PhD commission, External person
  • Rijken, Conny, Member PhD commission
Thesis sponsors
Award date5 Nov 2021
Place of PublicationBamenda, Cameroon
Publication statusPublished - 2021


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