A grounded theory investigation into the experiences of African women refugees: effects on resilience and identity and implications for service provision.
Article Type: Report
Subject: Women refugees (Psychological aspects)
Resilience (Personality trait) (Methods)
Coping (Psychology) (Methods)
Women in war (Psychological aspects)
Authors: Sherwood, Katie
Liebling-Kalifani, Helen
Pub Date: 03/01/2012
Publication: Name: Journal of International Women's Studies Publisher: Bridgewater State College Audience: Academic; General Format: Magazine/Journal Subject: Sociology and social work; Women's issues/gender studies Copyright: COPYRIGHT 2012 Bridgewater State College ISSN: 1539-8706
Issue: Date: March 1, 2012 Source Volume: 13 Source Issue: 1
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 289359833
Full Text: Abstract

The current study aims to explore African women's experiences of violence during conflict. The research was undertaken in 2009 in part fulfilment for a Doctorate degree in Clinical Psychology. Previous research on women refugees' experiences has focused on the negative impact on psychological functioning despite indications that they show great strength and resilience. Using qualitative methods the study sought to identify the impact of violence on mental health as well as develop a greater understanding of the roles of resilience, coping and identity. Women from Somalia and Zimbabwe who attended a refugee centre in the UK were interviewed; analysis of the results identified a relationship between resilience, access to rights and support and identity. It also recognised cultural and societal influences and experiences in the United Kingdom as contributing factors. Findings support the move toward a more holistic model of understanding refugee women's experiences. However, the study also reveals the importance of support and treatment assisting women to utilise their resilience in reconstructing their identities from traumatic events and recovery process.

Keywords: Women, Refugees, Trauma, Africa, Gender Based Violence

Introduction

Although this research was primarily written from a psychological perspective, research articles included in the study were systematically reviewed from a number of disciplinary backgrounds including international women's studies, sociology, refugee studies as well as feminist and critical psychology.

The current article begins with a general background to the literature highlighting key themes; namely a move away from a traditional medical model of understanding trauma and recovery and more towards a holistic one encompassing social, religious and cultural factors as well as addressing human rights, identity and empowerment. The research goes on to explore these concepts further by carrying out an in-depth exploration of women refugees' experiences of war and conflict and develops a model for understanding specific methods of coping in this particular group of women. The current investigation aims to enhance understanding on what assists women to recover from traumatic events. Women interviewed were residing in Coventry, England and attending a local refugee centre, for this reason the research therefore focuses on the UK.

Background and Context

Critical psychiatrist Derek Summerfield reports that there have been an estimated 150 wars in the developing world since 1945 which has left 22 million people dead (Summerfield, 1995). Despite this, relatively little is known about the patterns of distress and recovery following violence during conflict.

Some people remain in their native countries during and following war, however many others are forced to flee the violence and seek asylum in other parts of the world. There are currently around 32.9 million refugees worldwide known to the United High Commissioner for Refugees (UNHCR) a 56% increase since 2005 (UNHCR, 2007). There are an estimated ten million refugees and a further twenty five million people internally displaced, half of whom are not recognised by international laws.

Britain, as a signatory to the 1951 Geneva Convention has traditionally offered asylum to those fleeing from persecution and violence. Under the terms of the convention, a refugee is defined as any person who;

Owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or owing to such fear is unwilling to return

United Nations (1951, p. 16).

A report published by UNHCR in March 2009 stated that 30,500 applications for asylum were received in the United Kingdom in 2008, an increase of 8% from the previous year. This is however a reduction since its peak in 2002 when 103,000 people requested refugee status. 2008 saw a surge of applications made by refugees from African countries making it currently the second highest continent of origin for refugees entering the UK. This reflects the ongoing conflict within these countries (UNHCR, 2009).

Literature on the mental health of refugees has explored psychological distress immediately following war (Johnson et al., 2008; Rehn & Sirleaf, 2002; Jansen, 2006), however recent research has also drawn attention to the emotional distress experienced during migration periods (Schweitzer, Greenslade & Kagee, 2007; Khawaja, White, Schweitzer & Greenslade, 2008). Schweitzer, Melville, Steel & Lacharez (2006) found that post-migration difficulties such as unemployment and family separation were associated with symptoms of depression and anxiety in 63 resettled Sudanese refugees.

Studies have highlighted the effects of war on physical and social wellbeing and have demonstrated how these effects are intrinsically bound up in psychological distress (Isis-WICCE, 2001a; 2002a; Liebling-Kalifani, 2007; Liebling-Kalifani, 2009). Historically these effects have often been understood by a model of post traumatic stress disorder (PTSD). However the strong focus on posttraumatic stress reactions, particularly within a biomedical model means that limited attention has been directed towards understanding positive adaptation following war. This theoretical conceptualisation cannot explain the relatively low rates of psychiatric symptomatology in post-war societies (Silove, 2001). For example, Steel, Silove, Phan & Bauman (2002) found that only 3% of a sample of Vietnamese refugees living in Australia developed PTSD. These findings support other studies in Sudan and Uganda (Schweitzer et al., 2006; Isis-WICCE, 2006a) and suggest that the majority of refugees successfully adapt to stress and trauma. Another concern with research based on the biomedical model arises from its general reliance on quantitative methodologies (Silove, 2001). Recognition of these limitations has spurred a shift towards the use of more qualitative approaches (Miller, Worthington, Muzurovic, Tipping & Goldman, 2002)

Resilience and Recovery in Refugees

As previously mentioned and as argued by Linley & Joseph (2004), a substantial amount of research tends to focus on the negative sequellae of trauma and adversity. In recent years a number of psychologists have turned their attention to positive human functioning and the question of how health professionals can help achieve a more optimal level of well being. Positive psychology approaches recognise that large numbers of people manage to endure the temporary upheaval of loss or potentially traumatic events remarkably well, with no apparent disruption in their ability to function at work or in close relationships (Bonanno, 2004).

Relatively few studies have addressed resilience and growth in war survivors and even fewer studies have addressed resilience in people from developing countries where support and opportunities for growth are limited. Although under researched, it is important that research begins to focus more on these areas; it empowers women by focusing on strengths rather than pathologising their experiences and therefore makes a contribution towards women's health policy, and activism which is worthy of further theoretical development.

Social and family support and cohesiveness has been reported to be a protective factor for refugees (Gorman, Brough and Ramirez, 2003). McMichael & Manderson (2004) found that social support from family members as well as the wider community can be associated with increased psychological wellbeing in refugees. This is supported by Schweitzer et al., (2006) and Jasinskaja-Lahti, Liebkind, Jaakkola & Reuter (2006). Similarly Almedom, Tesfamichael, Saeed, Mascie-Taylor & Alemu (2007) administered a sense of coherence scale to explore resilience among internally displaced and non-internally displaced Eritrean men and women. They found that displacement particularly in women war survivors compromised their resilience.

Religious beliefs and practices have also been shown to strengthen resilience particularly in African populations. For instance Halcon et al., (2004) found that between 50% and 75% of a sample of Somalian and Ethiopian refugee youths used prayer to relieve their sadness. Eisenbruch (1991) described what he termed 'culturally bereaved' Cambodians living in the United States who felt guilty about abandoning their homeland and about unfilled obligations to the dead. Haunted by painful memories they were unable to concentrate on tasks facing them in an alien society. He compares this group of refugees with young Cambodians living in Australia who were under less pressure to conform and were given a chance to practice some traditional ceremonies; these refugees coped better than those in the United States. Religion and cultural beliefs can provide a meaningful framework in which to structure their suffering and continue to live their lives. Colic-Peisker & Tilbury (2003) propose that religious beliefs can in some cultures advocate a form of 'endurance' of current adversities with the belief that they will be rewarded with a better future.

Other forms of resilience and methods of coping among refugees lie in cognitive processes in the form of interpretations and perceptions of themselves and their situation (Khawaja et al., 2008). Such 'inner resources' include taking a positive approach, identifying strengths, reinforcing the determination to cope and self perception as a survivor rather than a victim (Gorman, et al., 2003). Goodman (2004) similarly highlights adaptive cognitive processing in refugee youths from Sudan such as giving new meaning to difficulties and talking about experiences, as well as emerging from hopelessness to hope and having aspirations for the future as a way of overcoming psychological problems.

Literature has highlighted how refugees, particularly women can be silenced due to huge stigma about their experiences during war and conflict. Consequently research has shown that giving women the opportunity to speak out about their experiences empowers them and strengthens their capacities to cope. Liebling-Kalifani (2009) found that women war survivors in Uganda who were speaking for the first time about their experiences of sexual violence found it helpful to narrate what had happened to them. Similarly Summerfield (1995) recognised that non-western cultures have little place for the revelation of intimate and personal material outside the close family circle. He advocates the chance to be heard and believed in a safe place where expression of emotions and regeneration of hope fall on sympathetic ears.

Much of the research recognises the importance of human rights and working towards social justice and empowerment, as part of the recovery process for war survivors. Liebling-Kalifani et al., (2007) argued that human rights are an essential precondition for physical and mental health. In their paper looking at women's experiences during the war in Luwero District, Uganda they recommended that to be successful:

Integrated health interventions for war torture survivors need to be combined with the further collective legal, social and political empowerment of women and address the health inequalities and discriminations that exist (Liebling-Kalifani et al., 2007, p.2).

Non-governmental organisations in some developing countries, aim to help men and women war survivors to rebuild their lives and empower them by becoming involved in income generating schemes and legal aid programmes. For example in Uganda, Liebling-Kalifani (2005) worked in collaboration with a non-governmental organisation called Isis Women's International Cross Cultural Exchange (Isis-WICCE) to promote women's roles in peace processes, which has assisted in their further empowerment and knowledge of their rights to be in a better position to take action against some of the atrocities they experienced during the war.

Rationale for current study

Research has suggested that refugees who have experienced violence show resilience, and are able to reconstruct their identities and continue to live their lives (Burnett, 2002; Liebling-Kalifani, 2007). The idea that people who have survived atrocities during wars are 'survivors' rather than 'victims' is now being considered more carefully (Bracken, 1997) and the use of a solely medical model is increasingly challenged.

Recently, authors have argued for a more 'ecological' view of resilience and coping in refugees which accounts for the direct and indirect influences of social and psychological factors (Harvey, 1996; Radan, 2007). This regards community values, beliefs, and traditions as pivotal influences on individual responses to and recovery from violence, abuse, and other traumatic events (Pratyusha, 2007; Haeri, 2007). Mukta (2005) states that in order to build up resources of hope, we need to build on all ways in which people make sense of the violence, and the ways in which they reconstitute and reconstruct the fabric of their lives.

There is limited existing research exploring the resilience and coping strategies of refugees. Much of the literature has adopted quantitative methods, which rely on a priori assumptions about the range of relevant variables to be assessed. These assumptions can be problematic in this under-researched area.

As highlighted in the literature most refugees in the world are women and children (UNHCR, 2009). They are vulnerable to gender-based discrimination, exploitation, and violence, and are at risk not only in the communities from which they are fleeing, but also in their adopted homelands and while en route from one to the other. Women also endure the added difficulties of remaining responsible for the survival of their children and other members of their families, and for the preservation of their cultural heritage (Brautigan, 1996). They are often unable to call for help, press charges, or seek justice. Indeed, women can be killed if they try to resist or look to others for support. Thus, during war women face an ongoing catastrophe. The aims of the study are in four thematic areas:

1. To explore the experiences of violence during conflict for African women refugees residing in the UK

2. To provide an understanding of the impact of violence on the mental health of African refugee women

3. To develop a greater understanding of the roles of resilience, coping and identity in African refugee women

4. To understand African refugee women's experiences in the UK and how this knowledge might be utilised to improve health service provision

The reader should be aware that interviews were carried out with women from two countries of Africa and whilst the study was open to African women from all countries, women who volunteered to take part in the study were from Somalia and Zimbabwe and therefore the focus is primarily on cultural influences and frameworks from Christian and Muslim faiths. It is important to be mindful that cultural context varies considerably and therefore results from this study should not be generalised across the African population.

In order to fully understand the resilience refugee women demonstrate in dealing with hardship it is essential to understand the context and individual experiences.

Method

This explorative, qualitative study was chosen to allow for an in-depth exploration of women's experiences to gain a greater understanding of the impact of war on their mental health and resilience. A grounded theory was used which allowed participants to be viewed as active agents constructing meaning from their own perspectives (Hood, Mayall & Oliver, 1999). By using grounded theory it was intended that this would more effectively illuminate the richness and diversity of their subjective experiences and allow the researcher to develop a model based on analysis of this (Glaser & Strauss, 1967).

The researchers are from a clinical psychology discipline, ethical approval was granted by Coventry University Ethics Committee. Informed consent was obtained from the participants. Ethical conduct and confidentiality procedures were adhered to in accordance with the guidelines outlined by The British Psychological Society (2006).

Hollway (1989) advocates the importance of subjectivity in the research process. The researcher is from a clinical psychology background and at the time of the research was working as a volunteer caseworker at the refugee centre. Whilst every effort was made to ensure the theory developed and analyses undertaken closely matched the data from the interviews, it was importance to be mindful of this position and how any potential pre-existing assumptions may have influenced the interpretation of the data. In addition it was important to acknowledge the position of being from a different culture and how a lack of understanding of African cultures may have also impacted on the process; being an 'outsider' to the centre may have impacted on the rapport developed between the researcher and participant.

Participants

The study comprised of a group of women African war survivors attending a refugee centre in the West Midlands, UK. A purposeful sample of six volunteer participants were interviewed aged between 24-46 years. The length of time the women had been residing in the UK ranged from four to six years and all women had been given at least five years leave to remain. Five of the women were from Zimbabwe and one woman was from Somalia. The women from Zimbabwe followed a Christian faith and the woman from Somalia was Muslim. Women were approached and recruited through the refugee centre either individually or through a women's group. Leaflets were handed out to women detailing the study and asked to contact the researcher if they were interested in taking part.

Interview Schedule

A semi-structured interview schedule was utilised to elicit participant's experiences based on the research aims. Through the use of open ended questions the researcher was able to ask questions that functioned as 'prompts' in order to encourage the participant to narrate their experiences and views. When devising the questions it was important that the researcher was familiar with the participants' cultural milieu so that the interview could be carried out in a culturally sensitive manner. Participant's views were also addressed through pilot interviews which were also included in the analysis.

Although all participants were able to conduct the interviews at the refugee centre in English, interpreters at the Refugee Centre were available. Following the interview participants were de-briefed and given the opportunity to ask questions or discuss any concerns. Interviews were transcribed verbatim.

Analysis

The interviews were analysed using the procedures of grounded theory as outlined by Strauss and Corbin (1990) and Giles (2002) with the aid of Atlas Ti, a computer software package. In the initial stages of the analysis Open Coding was used followed by Axial Coding (4). Open Coding involved analysing each transcript and developing descriptive themes. Charmaz (2000) refers to this as 'line by line coding' although not every line necessarily suggested a code. Once the initial sets of codes were generated, these were integrated into broader conceptual categories.

Axial Coding was then carried out, which involved reducing the initial set of categories to an explanatory framework of 'higher order' categories by establishing links between them. Saturation of the codes was achieved when coding and categorizing of emerging themes reached a stage whereby no further evidence or contributions to the research could be made. The theory developed from the research was emergent directly from the interview data analysed through Selective Coding (5).

Theoretical memos were kept by the researcher to ensure the theory was grounded in the data. Validity checking was carried out between a research group of clinical psychology trainees who were familiar with the grounded theory.

Results

Following initial line by line coding, thirty three lower order categories were identified. These lower order categories were then grouped into broader conceptual categories producing seven higher order categories providing an explanatory framework for the emerging data (See table 1). Once no further codes were obtained and saturation of the data was reached, selective coding then enabled the development of a theory, which is represented visually in figure 1. This aims to aid understanding of the research findings and illustrate the relationship between categories.

[FIGURE 1 OMITTED]

Figure one is a diagrammatic representation of a model which was developed to show the interrelationship of women's experiences of war violence in Africa, their resilience and identities.

For all participants interviewed, cultural and societal influences affected all aspects of their lives both in their native countries in Africa and in the UK. All of the women I interviewed had witnessed or experienced violent traumatic events during conflict, which impacted on their identities, resilience and ability to access support and rights. There appeared to be a complex interaction between their experiences and these three concepts. Notably, although resilient, women also described traumatic psychological effects which also impacted on their multiple identities, resilience and access to support and rights. The model indicates how cultural and societal influences, experiences of war/conflict, psychological effects and experiences in the UK all influence resilience and that these interact with a woman's ability to build on her own strengths, reconstruct new identities following war and violence and increase her ability to access knowledge and support that allows her to begin to recover from her experiences.

It is important to note that this is a preliminary model which needs to be further explored by future research; it represents the findings of this particular sample of women in their particular contexts.

Cultural/Societal Influences

All of the women interviewed described powerful societal and cultural influences which appeared to have an overall influence on women's experiences and their capacity to be resilient. Women described an 'inferior' position in society in relation to men, who were culturally regarded as being 'in control' of their women. One woman said:

Cos they have that you know that um.... I don't know ... that idea that they are better than a woman they are always better than a woman everything you're supposed to do.... they have the last say and woman are just supposed to be underdogs (Participant 3, lines 293-295).

Men's patriarchal roles often prevented women from seeking help as they were fearful of disclosing their experiences. One woman spoke of her experiences of domestic violence and how her family knew but chose to ignore what was going on telling her she should respect him regardless.

Nobody would come and try to stop him from doing what he's doing, that's how he was. You know they (parents) called me to say if you are in that sort of domestic, someone you respect, if someone comes you stop, just with that respect (Participant 6, lines 416-419).

The strong cultural traditions of marriage and expectations of the family meant this woman was unable to leave the relationship leaving her feeling powerless and unable to speak out about her experiences and seek support.

Women who had witnessed sexual violence described it as being a 'taboo' subject which meant that they were afraid to disclose their experiences for fear of being shunned by their family or community. One woman who had witnessed her sister being raped described her torment at being sworn to secrecy, she told me:

You don't have to show any sign that something happened because if daddy knows it's not good. I said, okay, and she said promise you'll say nothing (Participant 2, lines 282-284).

Furthermore, one woman who had been diagnosed as HIV positive described feeling blamed by members of the community:

.... in Africa it's not custom to say something like that you know in Africa when you say HIV they think maybe you're selling your body something like that'. (Participant 5, lines 195-196).

There appeared to be an inner struggle for women interviewed of wanting to seek help for their experiences yet fearing being shunned by their family or communities. This constant struggle meant that women felt 'trapped' which further decreased their capacity to cope rendering women isolated and psychologically affected. Those who did speak out were often accused of going against their culture and 'disrespecting their men' as Participant 3 explained:

It was like.... you want to know too much, you're going against your culture. You're supposed to respect ... you know ... the men. (Participant 3, lines 275-276).

Experiences

All of the women interviewed described witnessing violence, sexual violence or death of a close relative as a result of conflict. One woman described as a child being forced to watch her sister being raped by soldiers in the field where she was working, she said:

.... and my sister was just not answering and they slapped her, and she was bleeding in her mouth because they slapped and they shoved her, they pin her down. I was just standing there. They told me to stand there. Next to me there was another soldier standing next to me. My sister was crying and one of them, the one who was smacking her, put his hand on my sister's mouth. I didn't know what sex was, I didn't know then. But, yes, he raped my sister in front of me. (Participant 2, lines 254-258).

Another woman described the torture that women she knew endured:

Um ... I witnessed women being beaten up and ... one time we did like a story of this woman erm.... in the villages it was worse in the villages she was beaten up like you say ... the other party.... she was beaten up and she was raped and tortured and they put like erm.... you know plastics when you bum plastics.. Yeah yeah ... It was like burning ... then they put it like on her breast. (Participant 3, lines 181-183).

Other women reported their own personal experiences of violence. One woman who was a member of an opposing political party described being kicked and beaten by police. She said:

Him and two others were in this room and the guy was like ... grabbing my hair and he was smoking and blowing it in my face and I'm asthmatic and he was blowing smoke in my face and all this it was horrible. You know for the first time you know you really you are really thinking right this is it. (Participant 6, lines 34-37).

Although not all of the women had experienced violence directly, all women reported witnessing the death of at least one family member or loved one which, as one women said felt like it was happening to her:

It happened to me like.... the same because my mum and dad are like me ... it didn't happen to me you know but ... It's happened in my blood. (Participant 1, line 59).

Psychological Effects

Women described a multitude of psychological effects following exposure to violence. Often the women felt they did not have access to support and were unable to discuss their feelings with anyone. Women described traumatic following violence for example one woman said:

Sometimes when I'm sleeping I'm shocked and wake up crying I was sure it's happening to me. I was shocked and sitting and crying and shouting then I sleep and there's nobody in here. Then I go back to sleep again. (Participant 1, lines 151-154).

Women described the emotional trauma of witnessing death and violence:

You could see dead bodies everything ... yeah and then just seeing somebody being shot honestly ... I don't know how long it took me yeah I was just so quiet speaking ... not.... 'Coz I was really shocked. (Participant 4, lines 254-255).

Those women who had no means of support often found that they turned their anger inwards and blamed themselves for what had happened, Women reported feeling shame as this woman describes:

If I saw someone I knew from Zimbabwe I couldn't look them in the face. (Participant 6, line 7).

Another woman reported feelings of anger and guilt about the murder of her parents, which reflected her powerlessness to seek justice or have any control over the situation:

I feel horrible, because.... I feel horrible because, if you saw bleeding your mum ... and people coming with no reason to kill, and you can't help them and its very horrible.... say if at the time I got the gun ... I will kill them back.... you feel like that because you feel guilty for your mum and your dad. Innocent ... they don't do anything and it's killing straight-away with no reason to kill.... you feel angry. I say you want be bigger or get something? (Revenge) ... do that guy, who do it to your mum and your Dad.... get him back ... sometimes I feel guilty myself and crying you know. (Participant 1, lines 176-183).

One woman even felt that dying would have been better than surviving her trauma:

You know, I used to feel like I don't care if I die. I think I'll have peace because from time to time I used to see it (Murder) happening again and again and again. (Participant 2, lines 326-327).

Psychological feelings were further exacerbated by the lack of support for women in Africa and gave them a sense of hopelessness.

United Kingdom Experiences

The focus of the interview was on how women dealt with their violent experiences. They frequently reported how being in the UK served to increase or decrease their strength and resilience and capacity to cope. Fear of being sent back to their country of origin and uncertainties about their future in the UK were mentioned by all women as well as being unable to work whilst waiting for asylum applications to process. One woman told me:

I'd heard of asylum and stuff but you're just so afraid. My biggest thing was fear to apply ... I thought if I could claim ... what if they send me back? And then I'm really really going to be in trouble coz failed asylum seekers when you go back.... I know a family.... friends of family that have family that have gone back been deported back and nobody has seen them. (Participant 6, lines 45-48).

However, women generally reported having a better life in the UK once their security was established. They valued the 'freedom of being a human being' (Participant 4, line 133) and being treated as an equal which further reconstructed their identities. One woman explained:

Hmm it's like since I have come over here.... and I have realized the changes ... the difference between where I came from and where I am now really there are so many you know organizations that are helping out that are helping you know women ... as we are doing alright now.... yeah that just speak out. (Participant 4, lines 203-205).

Another woman said:

... because my life has changed you know what I am saying now because I am in this country. (Participant 5, line 191).

In contrast, one woman experienced the 'flip side of the coin' (Participant 6, lines 73-74): her negative experiences in the UK resulted in her losing a sense of who she was. She reported feeling that she was unable to talk to anyone and felt depressed. She said:

My life has been a very big secret in the UK and that's not who I was.... back in Africa. (Participant 6, line 79).

Resilience

Women were able to report a number of coping strategies that served to increase their inner strength and resilience. Women adopted positive thinking and self-talk as a way of managing their distress by thinking of a positive future. One woman said:

There is a day ... although you don't know when that better day is going to come but there is always hope that there's going to be a better day and my life is going to be a little bit better than how it is now. (Participant 2, lines 26-28).

Another woman said:

....my head, and I know it's coming like that. I was so young, and I say, look, if you think too much. You can be crazy. You can be having anything. And now you've lost all your family. If you loosen your mind there is problem. More problems ... be strong, and have a good life, and then you stay alive you know? (Participant 1, lines 49-53).

Other women described taking positive action by problem solving:

I'll sit in that spot for bit and I'm like right now Okay what do I do now ... this problem.... what am I going to do.... how am I going to.... you know rather than dwelling on it ... I jump out of the box. (Participant 6, lines 201-203).

All of the women valued religion immensely, and felt their faith was a major factor in their resilience, for instance one woman said:

... but who was I going to let it out to I didn't want people to know what I was going through or my situation so I go to God in prayer and that's where my strength came from. (Participant 6, lines 143-144).

Their firm beliefs allowed them to make sense of what was happening to them and to normalise their experiences:

You know if Jesus went through all that, if he had the power to stop it and he didn't just to show me how difficult life is, who am I to quiz? Who am I to quiz? With that I said, okay, I changed the whole situation. (Participant 2, lines 362-364).

Women described feeling empowered having come through their experiences and all had strong hopes for the future:

But I hope that one day things will be okay.... coz I've managed to pull it right through from back there and I am still hoping I will end up getting whatever I want. (Participant 4, lines 187-188).

Access to Rights and Support

Women reported feeling stronger and more resilient when they felt supported in rebuilding their lives. External agencies and practical help were valued although all the women reported that this help was only available to them since being in the UK.

In this sense, support from families and friends were of particular value to the women living in Africa. One woman when asked if she felt family were a source of support she replied:

Very very very much so I mean if you look here you have a brother a sister they all go out to fend for themselves if they can't they'll probably go to the Government. But in Africa you have only got your family to lean on. (Participant 6, lines 174-175).

Equally, women described how they felt they got their strength from women members of their families. One woman spoke about her mother and said:

She was never negative always positive, even if we tell her that this thing you know is not right. But she is always putting us on the horizon. (Participant 4, lines 175-176).

Another woman described how talking to her family helped:

The only support you can have is like if you can talk to your sister or to your auntie about it, how you feel, that's the only counselling, you know. (Participant 2, lines 504-505).

Women felt that access to equal rights and justice was an important aspect of becoming more resilient and empowered, and some of the women hoped to take legal action in the future. One woman told me:

Yeah, because the people live who killed my family ... they are still alive walking the streets I haven't passed them but they are still walking the streets. You feel guilty yourself. But if this person is in prison your heart will be alright. Yeah in prison now he doesn't walk the streets. (Participant 1, lines 40-44).

Opportunities such as employment and education equally served to strengthen resilience and enable women to feel they had 'choice' and 'control' over their lives. As participant one described:

I want to be a nurse, but my dreams (in Africa) were broken and it didn't come true. Education is very very.... it starts life ... a person starts life. ....it's very powerful you can do whatever you want.... my dream is being in school I liked school. (Participant 1, lines 69-73).

Identity

Some women described feeling like they didn't have a sense of identity when living in Africa. Some of their experiences meant that they were forced to take on different roles and they described not knowing who they were stating for instance 'the real me was lost'. (Participant 6, line 144).

One woman felt she was forced to adopt the identity of the opposing government party:

They say that if you don't have a Zapu-pf card which means we are not Zimbabwean.... they were forcing us to be Zapu-pf. (Participant 5, lines 137-138).

Women valued their identity as a 'mother' and 'provider' reporting that it helped them to be strong and many reported staying resilient for the sake of their children. A woman who was in a violent relationship with a soldier reported:

I did my role as a mother. I didn't want to fail. If I fail not only I fail myself, I fail the baby. (Participant 2, line 428).

This woman continued on to say:

... yes, being a mother, that identity thing, it's so important and you don't want a stained identity, would you? Like to be known because you are a murderer. You just want to be known as--in a positive way, not in a negative way. (Participant 2, lines 720-722).

Having 'choice' and 'independence' served as a protective factor. Women described this in the context of being able to work and gain an education, which appeared to give them a sense of purpose, one woman said:

Work and education are very important because I won't just stay home, look after all the children being a housewife not helping out. What if anything happens to the bread winner? (Participant 4, lines 366-367).

Discussion

This research aimed to explore the unique perspectives of African women refugees living in the United Kingdom who have experienced violence in the context of war. It also sought to gain an understanding of the impact of these experiences on mental health and understand the roles of resilience in African women and its relationship to identity. Figure one illustrates the model developed from grounded theory analysis of the interviews.

In summary, data analysis of the interviews revealed that the concepts of resilience, access to rights and support and identities were inter-related and were directly influenced by cultural and societal influences, experiences of war, and the psychological effects of these experiences. The analysis suggests that women in this sample were striving to reconstruct new identities which certainly appeared to strengthen their resilience to take action to access support if required to rebuild their lives.

The current research contributes to an understanding of the experiences of African women refugees in the context of war. The use of a qualitative methodology allowed women to identify some of the difficulties and coping strategies and their impact on resilience. Analysis revealed that societal and cultural influences have a strong impact on women's ability to cope. Traditional and societal views of women and the stigma attached to sexual violence in Africa served to silence women, which often prevented them from accessing other forms of support (Liebling-Kalifani, in press). This broadly supports the findings of McMichael and Manderson (2004) who found that refugees who used established social networks were better able to access social and material support and tended to suffer less psychological distress.

Women described a number of psychological effects which could be understood as symptoms of complex post traumatic stress disorder. However, data analysis revealed that although African women interviewed in this study reported psychological effects of trauma, a diagnosis of complex post traumatic stress disorder cannot fully account for understanding the impact of war on these African women refugees. It does not take sufficient accounts of their culture, context, gender and resilience and identity, as others have also argued in the context of Uganda and Mozambique (Liebling-Kalifani et al., 2008; Liebling-Kalifani, 2009; Sideris, 2003). Women were able to deal with their symptoms on their own and this appeared to be helped by accessing practical support to rebuild their lives. It is important to note however that none of the women in this study had disclosed torture or sexual violence themselves, and therefore interpretations of this data should be treated with caution.

A number of salient coping strategies were employed by women in the current study such as accessing social networks, talking to close family/friends, seeking practical help and legal action for human rights abuses they endured. Equally women displayed remarkable inner strength such as cognitive appraisals e.g. positive self talk and positive thinking, as well as hopes for the future and religion/faith. These findings support the existing literature, for example Khawaja et al., (2008) found similar coping strategies in Sudanese refugees during pre-transit and post migration periods. Goodman (2004) equally illustrated the progression from helplessness to hope as well as positive thinking in Sudanese youth, a finding also supported by the current study.

Religion formed a major component of women's resilience in this study. Halcon et al., (2004) highlights this as a common form of coping used by refugees from Africa and the results from this study are consistent with previous research findings (Gorman et al., 2003). Women described how they believed their fate was in God's hands and that a strong faith would bring them a better future.

Existing literature does not address the impact of identity on resilience and effects on the psychological health of African women. The current research however suggests a complex interaction between resilience, coping and identity and proposes a 'resilience mechanism' to illustrate their interdependent relationship. Liebling-Kalifani (2007) identified how women are able to reconstruct their identities following violence however its link to resiliency is not addressed in depth.

The current study identified how resilience appeared to fluctuate with women's sense of self. They valued their identities as mothers, providers and as women. If they felt these roles were in some way compromised, this devalued their sense of self and decreased their resilience and capacity to cope. These findings are important in terms of implications for service needs as women need to feel they have a sense of purpose or identity. This also reflects a need for women to be helped in terms of access to opportunities such as employment and education so that they can provide for their families and gain a sense of empowerment.

Interestingly analysis in the current research identifies the importance of women's experiences in the UK and its impact on maintaining resilience. This is also identified in the literature by Khawaja et al., (2008) as the 'post-migration phase'.

Findings of the current study suggest that there are a number of difficulties that serve to hinder women's ability to rebuild their lives in the UK, for example access to practical support and advice, education, housing and employment. The salience of these factors has previously been reported by Miller et al., (2002) in their study on exile-related stressors among Bosnian refugees. All of the women interviewed in this study expressed a desire to access education as they felt this would improve their future. This contradicts findings by Miller et al., who found that many refugees felt a sense of hopelessness and felt it was too late to start new meaningful life projects. However this may reflect cultural differences in aspirations of refugees.

Difficulties during the asylum seeking process in the UK served to decrease resiliency and coping, largely due to the fact that women were unable to access these services until permission had been given to remain. Women reported not knowing who they were during this process which instilled feelings of uncertainty about the future and fear of being sent back which women felt affected their ability to cope and increased psychological distress.

Literature has highlighted the negative impact of refugees not being able to practice their religion in post-migration environments (Eisenbruch, 1991). However in the current study women did not discuss any difficulties in being able to practice their religion, this may be because the predominant religion in Zimbabwe is Christianity and women may have felt more able to practice their religion in the UK as Christianity is adopted by many British citizens. This may also contribute to explanations about the amount of resilience displayed by women in the current study, it may be that the culture in Zimbabwe is not too dissimilar to that of the UK and may have eased the transition into UK life.

Although a number of findings support the existing literature there are a number of new and important issues to emerge from this study, in particular the links between identity and resilience and its importance in recovery from traumatic experiences. The current study also identifies important factors in maintaining the resilience of African women and suggests building on women's sense of empowerment by providing equal opportunities that serve to reconstruct women's identity and allow a smooth transition into life in the UK.

Methodological Limitations of the Study

The study employed just six participants; this not only highlights the sensitive nature of the study but also the difficulties for refugee women to talk about their experiences and the importance of creating a good rapport. Similarly, all but one of the women interviewed were from the same African country. The results of the study therefore need to be interpreted with caution as they cannot be generalised to other African populations of refugees in the UK. All women interviewed had been given leave to remain, which may have influenced their perceptions of their resilience and health. Future studies would benefit from utilising a more culturally varied sample to increase the validity and reliability of results.

Despite the researcher's attempts to build rapport with the women prior to interview, participants may have shared only general experiences. None of the women disclosed personal experiences of rape or sexual violence and only two reported personal experiences of physical violence. Psychological effects may have been more severe in women survivors of gender-based violence and torture and this might have had a greater impact on resilience and identity.

Implications for Clinical Practice and Future Research

he current study contributes to an ongoing shift from the medical model of trauma toward a more holistic model of understanding African women's experiences, which is culturally and gender sensitive. Future research could usefully test the model developed on a larger scale with different cultural groups.

The study findings have implications for responding to the mental health needs of refugees. Mental health services need to recognise and build on women's resilience in order to assist them to access their rights to health, service provision and justice. Health services should be provided which support women's further empowerment and utilise a rights approach (Grown, Rao Gupta and Pande 2005). This study also recommends that services for African women refugees needs to adopt a multi-agency approach. Equally a culturally sensitive approach would build on women's unique abilities to rebuild their lives and the role of the wider community in their recovery. As other researchers have found (Liebling-Kalifani et al., 2007) therapeutic groups may have an important place for refugee women seeking support in the UK. Future research could therefore evaluate therapeutic and support groups women war survivors.

The women interviewed in this study often referred to the 'stigma' of sexual violence. Literature exploring stigma is scarce however it remains a huge problem for refugees and often deters them from accessing mental health services in western countries. Therefore it is also recommended that research continues to understand stigma and its effects and how this can be addressed more effectively within services.

References

Almedom, A.M., Tesfamichael, B., Mohammed, Z., Mascie-Taylor, N., Alemu, Z. (2007). Use of 'Sense of Coherence (SOC)' Scale to Measure Resilience in Eritrea: Interrogating both the data and the scale. Journal of Biosocial Science, 39, 91-107.

Bonanno, G.A. (2004). Loss, Trauma, and Human Resilience: Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events? American Psychologist, 59, 20-28.

Bracken, P., Giller, J. and Summerfield, D. (1995) Psychological Responses to War and Atrocity: The Limitations of Current Concepts, Social Science and Medicine, 40, 1073-1082.

Bracken, P., Giller, J.E. & Summerfield, D. (1997). Rethinking Mental Health Work with Survivors of Wartime Violence and Refugees. Journal of Refugee Studies, 10, 431-442

Brautigan, C. A. (1996). Traumatized women: Overcoming Victimization through Equality and Non-discrimination. In Y. Danieli, N. S. Rodley,& L. Weisaeth. (Eds.). International responses to traumatic stress: Humanitarian, human rights, justice, peace and development contributions, collaborative actions and future initiatives (pp. 347-365). New York: Baywood Publishing Co.

British Psychological Society. (2006). Code of Ethics and Conduct. Retrieved August 23, 2008,fromwww.bps.uk/the-society/code-of-conduct/codeofconduct_home.cfm

Burnett, A. (2002). Guide to Health Workers Providing Care for asylum Seekers and Refugees. Medical Foundation for the Care of Victims of Torture. Retrieved on 22, March 2009 from http://www.torturecare.org.uk/files/Bum_1.rtf

Charmaz, C. (2000). Grounded Theory: Objectivist and Constructivist Methods. In Denzin, N. & Lincoln, Y. (Eds.). Handbook of Qualitative Research. 2nd Ed. London:Sage.

Colic-Peisker, V., & Tilbury, F. (2003). "Active" and "Passive" Resettlement: The Influence of Support Services and Refugees' own Resources on Resettlement Style. International Migration, 41 (5), 61-91.

Eisenbruch, M. (1991). From Post-traumatic Stress Disorder to Cultural Bereavement: diagnosis of Southeast Asian refugees. Social Science and Medicine, 33,673-680.

Giles, D. C. (2002). Advanced Research Methods in Psychology. Hove: Routledge.

Glaser, B. G., & Strauss, A. L. (1967). The Discovery of Grounded Theory. Chicago: Aldine.

Goodman, J. H. (2004). Coping With Trauma and Hardship among Unaccompanied Refugee Youths from Sudan. Qualitative Health Research, 14, 1177-1196.

Gorman, D., Brough, M., & Ramirez, E. (2003). How Young People from culturally and Linguistically Diverse Backgrounds Experience Mental Health: Some insights for mental health nurses. International Journal of Mental Health Nursing, 12, 194-202.

Grown, C., Rao Gupta, G., and Pande, R. (2005). Taking Action to Improve Women's Health through Gender Equality and Women's Empowerment. The Lancet, 365, 541-43.

Haeri, S. (2007). Resilience and Posttraumatic Recovery in Cultural and Political Context: Two Pakistani women's strategies for survival. Journal of Aggression, Maltreatment & Trauma, 14 (1/2), 287-304.

Halcon, L.L., Robertson, C.L., Savik, K., Johnson, D.R., Spring, M.A., Butcher, J.N., Westermeyer, J.J., & Jaranson, J. M. (2004). Trauma and Coping in Somali and Oromo Refugee Youth. Journal of Adolescent Health, 35, 17-25.

Hanson, R.F., Kilpatrick, D.G., Freedy, J.R. & Saunders, B.E. (1995). Los Angeles County after the 1992 Civil Disturbance: Degree of exposure and impact on mental health. Journal of Consulting and Clinical Psychology, 63,987-996.

Harvey, M. R. (2007). Towards an Ecological Understanding of Resilience in Trauma Survivors: Implications for theory, research, and practice. Journal of Aggression, Maltreatment & Trauma, 14 (1), 9-32.

Hollway, W. (1989). Subjectivity and Method in Psychology: Gender, meaning and science. Sage Publications Ltd. London.

Hood, S., Mayall, B., & Oliver, S. (1999). Critical Issues in Social Research Power and Prejudice. Open University Press.

Isis-WICCE. (2001a). Women's Experiences of Armed Conflict in Uganda, Gulu District, 1986-1999 Part One. An Isis-WICCE research report, Kampala, Uganda.

Isis-WICCE. (2002a). Documentation of Teso Women's experiences of Armed Conflict 1987-2001. Part One. An Isis-WICCE Research Report. Isis-WICCE, Kampala, Uganda.

Isis-WICCE. (2006a). Medical Interventional Study of War Affected Kitgum District, Uganda: An Isis-WICCE Report with financial support from Medica Mondiale. Isis-WICCE, Kampala, Uganda.

Jansen, G. G. (2006). Gender and War: The Effects of Armed Conflict on Women's Health and Mental Health. Affilia, 21 (2), 134-145.

Jasinskaja-Lahti, J., Liebkind, K., Jaakkola, M. & Reuter, A. (2006). Perceived Discrimination, Social Support Networks, and Psychological Well-being among Three Immigrant Groups. Journal of Cross-Cultural Psychology, 37, 293-311.

Johnson, K., Asher, J., Rosborough, S., Raja, A., Panjabi, R., Beadling, C., Lawry, L. (2008). Association of Combatant Status and Sexual Violence with Health and Mental Health Outcomes in Post-conflict Liberia. Journal of the American Medical Association, 300 (6), 676-690.

Khawaja, N. G., White, K., Schweitzer, R., & Greenslade, J. (2008). Difficulties and Coping Strategies of Sudanese Refugees: A Qualitative Approach. Transcultural Psychiatry, 45 (3), 489-512.

Liebling-Kalifani, H, (2009). A Gendered Analysis of the Experiences of Ugandan Women War Survivors. VDM Verlag Dr. Muller.

Liebling-Kalifani, H. (in press). Research and Intervention with Women War Survivors in Uganda: Resilience and Suffering as the Consequences of War. In H. Bradby & G. Lewando-Hundt. (Eds.). War, Medicine and Gender: The Sociology and Anthropology of Structural Suffering. A collection of papers presented at a One Day Conference at Warwick University entitled, 'Intended and Unintended Suffering: The Legacy of Meg Stacey's Ideas and Work. Ashgate Books.

Liebling-Kalifani, H., Marshall, A., Ojiambo-Ochieng, R. and Nassozi, M. (2009). Experiences of Women War-Torture Survivors in Uganda: Implications for Health and Human Rights. In S.K. Multani. (Ed.) Women and Armed Conflicts: Consequences and Coping Mechanisms. The Icfai University Press. India.

Liebling-Kalifani, H., Marshall, A., Ojiambo-Ochieng, R., and Nassozi, M. (2007). Experiences of Women War-Torture Survivors in Uganda: Implications for Health and Human Rights. Journal of International Women's Studies, 8 (4), 1-17.

Linley, P. A. & Joseph, S. (2004). Positive Change Following Trauma and Adversity: A Review. Journal of Traumatic Stress, 17 (1), 11-21.

McMichael, C., & Manderson, L. (2004). Somali Women and Well-Being: Social Networks and Social Capital among Immigrant Women in Australia. Human Organization, 63 (1), 88-99.

Miller, K. E., Worthington, G. J., Muzurovic, J., Tipping, S., & Goldman, A. (2002). Bosnian Refugees and the Stressors of Exile: A Narrative Study. American Journal of Orthopsychiatry, 72 (3), 341-354.

Mukta, P. (2005). Research and Intervention with Women War Survivors in Uganda: The Health Consequences of War. Meg Stacy Annual Memorial Lecture. One-Day Colloquium: Intended and unintended Suffering: The Legacy of Meg Stacey's Idea and work, Institute of Health, University of Warwick, 28th June 2005.

Pratyusha, T. (2007). Conceptualizing Trauma and Resilience Across Diverse Contexts. Journal of Aggression, Maltreatment & Trauma, 14 (1), 33-53

Radan, A. (2007). Exposure to Violence and Expressions of Resilience in Central American Women Survivors of War. Journal of Aggression, Maltreatment & Trauma, 14 (1), 147-164

Rehn, E., & Sirleaf, E. J. (2002). Women, War and Peace: The independent expert's assessment on the impact of armed conflict on women and women's role in peace-building. New York: UN Development Fund for Women.

Schweitzer, R., Greenslade, J. H., & Kagee, A. (2007). Coping and Resilience in Refugees from the Sudan: A narrative account. Australian and New Zealand Journal of Psychiatry, 41 (3), 282-288.

Schweitzer, R., Melville, F., Steel, Z & Lacherez, P. (2006). Trauma, Post Migration Living Difficulties and Social Support as Predictors of Psychological Adjustment in Resettled Sudanese Refugees. Australian and New Zealand Journal of Psychiatry, 40, 179-187.

Sideris, T. (2003). War, Gender and Culture: Mozambican women refugees. Social Science and Medicine, 56, 713-724.

Silove, D. (2001). A Conceptual Framework for Mass Trauma: Implications for adaptation, intervention and de briefing. In B. Raphael & J. Wilson (Eds.), Psychological debriefing: Theory, Practice and Evidence (pp. 337-350). Cambridge, UK: Cambridge University Press.

Steel, Z., Silove, D., Phan, T., & Bauman, A. (2002). Long-term Effect of Psychological Trauma on the Mental Health of Vietnamese Refugees Resettled in Australia: A population-based Study. Lancet, 360, 1056-62.

Strauss, A. & Corbin, J. (1990). Basics of Qualitative Research: Grounded Theory Procedures and Techniques. London: Sage Publications.

Summerfield, D. (1995). Addressing Human Response to War and Atrocity: Major Challenges in Research and Practices and the Limitations of Western Psychiatric Models. In R. J. Kleber., C. R. Figley., & B.P.R. Gersons. (Eds.). Beyond Trauma. New York: Plenum Press.

UNHCR. (2007). Global Trends: Refugees, Asylum-seekers, Returnees, Internally Displaced and Stateless Persons. Division of Operational Services. Field Information and Coordination Support Section. Retrieved on 12, February 2009 from http://www.unhcr.org/statistics/STATISTIC S/4676a71d4.pdf

UNHCR. (2009). Asylum Levels and Trends in Industrialised Countries 2008: Statistical Overview of Asylum Applications Lodged in Europe and selected Non-European Countries. Retrievedon 9,April2009 from: http://www.unhcr.org/statistics/STATISTICS/49c796572.pdf

UNHCR. (2009). Statistical Yearbook 2007. Retrieved on February 21, 2009 from http://www.unhcr.org./cgibin/texis/vtx/home/ opendoc.pdf?id=4981c3252&tb1=STATISTICS

United Nations. (1951). United Nations Convention Relating to the Status of Refugees of 28th July 1951. Geneva. Retrieved on 11, August 2008 from www.unhcr.org/protect/PROTECTION/3b66c2aa10._pdf

Willig, C. (2001). Introducing Qualitative Research in Psychology: Adventures in Theory and Method. Buckingham: Open University Press.

Katie Sherwood (2) and Helen Liebling-Kalifani (3)

(1) Acknowledgements: The authors would like to acknowledge all of those participants and personnel Who contributed to and participated in this study.

(2) Katie Sherwood is a Clinical Psychologist, working in Child & Family Services in the National Health Service, Worcestershire. The current research was submitted as partial fulfilment of the requirements of the Degree of Doctor of Clinical Psychology. Katie hopes to go on to carry out further research in Africa with war survivors.

(3) Helen Liebling-Kalifani is a Lecturer-Practitioner in Clinical Psychology, Coventry University. She is a member of African Psycare Research Organisation, Uganda, and helped to establish and run the clinical psychology masters course at Makerere University, Uganda. Together with Isis-WICCE and APRO, she has been working with war-torture survivors since 1998. Her PhD followed up earlier intervention work in Luwero and is now published as a book. She has been awarded ESRC funding, the Phil Strong Research Prize, an Applied Research Fellowship, Royal Society and British Academy funding for her ongoing research with war survivors.

(4) Axial Coding axial is the development and linking of concepts into conceptual families.

(5) Selective coding is the formalising of these relationships into theoretical frameworks
Table 1: Lower and Higher Order Categories

Higher Order Categories         Lower Order Categories

Experiences of War/Conflict     Witnessing violence/death
                                Personal experiences of violence
                                Loss of family member

Psychological Effects           Trauma symptoms
                                Self Blame
                                Anger
                                Suicidal thoughts/behaviour

Cultural/Societal Influences    Going against culture
                                Patriarchy of men
                                Women's roles
                                'Inner struggle'
                                Silenced

Resilience                      Religion/faith
                                Positive thinking
                                Positive self talk
                                Hope
                                Problem solving

Access and Rights and Support   Justice
                                Empowerment
                                Practical help
                                Opportunity
                                Family/friends support
                                Talking

Identity                        Reconstruction/deconstruction
                                Identity as a women
                                Identity as a mother
                                Independence
                                Choice

Experiences in United Kingdom   Opportunity
                                Choice
                                Unfamiliarity
                                Future
                                Uncertainty
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