Out of the 69 of eligible URMs who had expressed interest in participating in TRT and their screening forms were available, nine did not start the intervention and five who started the intervention did not complete the pre-intervention measures and therefore could not be included in the analyses. An attrition analysis showed no statistically significant differences between these 14 children and the 55 who attended at least one session and completed the pre-intervention forms, with respect to age and CRIES-8 screening scores. Of the 55 children who started the intervention and completed the pre-intervention measures, nine did not complete the post-intervention forms. Again, there were no statistically significant differences between the two groups (9 without and 46 with post-intervention measures) with respect to age, CRIES-8 and MADRS-S pre-intervention scores.
The attendance rate was high for the 46 URMs included in the analyses (M = 4.20, and SD = 0.88 sessions): one URM (2.1%) attended one session only, eight (17.4%) attended three sessions, 17 (37.0%) attended four sessions and 20 (43.5%) attended all the five sessions.
The one-sample t test revealed a statistically significant reduction in both PTSD and depressive symptoms from pre- to post-intervention (Table 3).
The natural remission for PTSD symptoms in URMs was estimated to be 1.1% over the 6-week treatment period based on 10% change in the 1-year prevalence rate reported by Tam et al. . Similarly, the natural remission rate for depressive symptoms in URMs was estimated to be 0.12% over the 6-week period based on the 0.5% 6 months prevalence change reported by Vervliet et al. . The exact binomial test showed that the likelihood of improvement given the treatment was significant for both PTSD (success = 26, n = 46 trials, probability = 0.011, p < 0.001) and depression symptoms (success = 35, n = 46 trials, probability = 0.0012, p < 0.001). Doubling the remission rates as a sensitivity analysis, did not change the results.
The logistic regression analysis (Table 4) showed that for PTSD symptoms, a high level of PTSD symptoms at the commencement of the intervention was significantly related to larger symptom reduction at post-intervention (OR 1.31, 95% CI (1.13, 1.48), p = 0.003). None of the other variables, i.e. housing, program attendance and suicide ideation were significantly related to improvement of PTSD symptoms. For depressive symptoms, URMs with suicidal ideation were approximately 10 times more likely to report reduced depression symptoms following the intervention compared to URMs without suicidal ideation [OR 9.91, 95% CI (7.71, 12.11), p = 0.041]. None of the other variables were significantly related to reduced depression.
The RCI and CSC analyses showed that 22% of the participants were classified as recovered on PTSD symptoms and 33% on depression symptoms (Table 5). A few adolescents improved or deteriorated, whereas the majority were unchanged (63 and 61% for PTSD symptoms and depression, respectively) according to these indices.
A total of 62% of the youths reported negative life events during the program, most often a friend receiving refusal of asylum. However, 53% also reported positive events, such as finding new friends, moving to a better school or receiving a better placement.
The following codes resulted from the inductive analysis: supported by the group, normalisation of experiences, valuable tools for daily life, making sense of what happened, managing my feelings/having control, and finding meaning/looking to the future. These empirically derived codes were then tested against the theory-driven categories social support, normalisation, safety, comprehensibility, manageability, meaningfulness, engagement, and identity creation. The theory-driven categories safety, engagement, and identity creation were excluded as the data did not match with these. Valuable tools for daily life emerged instead as a new category. In the final stage of the analysis, merging the inductive and deductive material, the final categories were designated, according to the following. Supported by the group was converted to social support, normalisation of experiences to normalisation, making sense of what happened to comprehensibility, managing my feelings/having control to manageability, and finding meaning/looking to the future to meaningfulness. The final analysis process thus resulted in six overall categories: social support, normalisation, valuable tools, comprehensibility, manageability, and meaningfulness. Quotes were then selected to demonstrate each category, including negative case analysis where we explicitly looked for examples where the data did not match the overall direction of the category presented.
The participants expressed an appreciation for the feeling of community in the groups. Some described a trust in the group and the fact that it felt safe to open up and “ease the heart”.
“We were so comfortable in the group, we could talk to each other like a friend, like a brother. It was very nice in this group, and it was right …”
Another participant described that he felt nervous at the first group meeting, but then eased into the setting. Others mentioned that they would have liked more individual conversations with the group facilitators.
The opportunity to meet others in the same situation was described as valuable. The majority of participants described decreased loneliness to which having common experiences and resulting problems contributed substantially.
“You thought you were alone with these thoughts but then when you got into the group and saw the others, you felt, yes, but now it feels a bit easier because I’m not alone with this problem.”
Even if TRT does not explicitly encourage narratives, some of the boys told their stories to the group. A painful aspect of listening to others’ experiences was described by one of the boys:
“When you sit and listen to the others, you are reminded of your own difficult experiences so it may feel bad. But it also helps, in some way, it takes away the edge, and you become accustomed to this hard stuff.”
In general, participants expressed gratefulness for having gained access to all the techniques/tools in the program.
“These techniques we’ve learned have been good. The calmness you felt after doing these exercises, it was great to be able to feel this calm.”
Exercises such as muscle relaxation, breath control, a “safe inner place” (arousal control exercise), and tools, such as set time for thoughts/concerns and “patting the knees” while working with a difficult image (bilateral stimulation) were most appreciated.
Participants’ experiences about what has helped with regard to symptoms and techniques differed. Some young people reported having been helped with sleeping difficulties, intrusive memories, depressed thoughts, fear and irritation.
“… After doing exercises I’ve learned here, I’ve reduced sleeping pills.”
Although useful for sleep problems for some, several participants stated that the techniques did not affect their sleep. Others again described the tools becoming useful some time after the group had ended.
“Just when I joined the group, I might not have used all the methods I was taught, but afterwards, when I got into a more difficult situation, it helped me, what I learned helped.”
Making sense of their past experiences and current feelings were important elements during participation, according to the youth. Accepting that past experiences cannot be undone and relating to them as an important part of one’s personal history was apparent in the youth’s responses.
“The things that have happened to us are never forgotten. The others do not have our problems. Other people, they are more free.”
Understanding the way their past experiences affected the youth was also discussed in the interviews. They underscored that while their experiences might have been similar, there were also differences in the problems that arose for each individual.
“And so you have different problems. There is a problem, but it’s a bit different for everyone, it’s not the same.”
Finally, there was mention of how these young people with their experiences fit into the new world they had come to.
“From the first time I came to Sweden, I feel that I am a newborn, now I belong to this world as well.”
Thus, incorporating past experiences into who they are today, seeing the similarities as well as differences in the problems presented by their peers and themselves, and understanding oneself in relation to the majority culture were all important elements of comprehensibility in this study.
The term “control” was mentioned as an important factor in all of the interviews.
“When I came to this group I had no control of myself, because everything I had been through affected me and was controlling me. The group helped me to gain control over myself.”
The issue of control came up also when there was a perceived lack of it.
“I can control stress and I can control my fear, I can control that I cannot sleep, but I have difficulty controlling my anger. That’s really difficult to control.”
The participants talked eloquently about how the tools they learned helped them manage their everyday lives and symptoms.
“And one night, I had so much trouble breathing so they had to take me to the emergency room for help. And therefore, I say that these exercises help me a lot to handle my fear and anxiety. I get these attacks every night and I think if I had not done these exercises I would have been even worse.”
Thus, it was not a complete lack of symptoms, but their manageability that was the focus of the youth’s narratives.
“For me the most important thing was that when you are down or you are in a mental crisis, how to get yourself out of it, how to save yourself somehow.”
The youth struggled to find meaning in their experiences and how that might affect their lookout for the future.
“The most difficult thing one ever can do is to leave their family and move elsewhere and not be able to meet them. We have left this behind us so I think we can handle whatever happens.”
Many of the boys expressed dejection and described how, for example, current incidents in the home country really affected them. One of the young people stated that nothing can be done about the situation except to “endure”. Other useful strategies mentioned were distraction, such as listening to music, or activation, such as hanging out with friends or talking to someone they trusted.
Another participant discussed how symptoms, such as loss of appetite and insomnia were difficult to safeguard against, but could be dealt with, over time. Thus, accepting ‘what is’ and coping in face of past hurtful events and current worries was described. In addition, participants felt it was meaningful to take part in the program:
“I would really recommend other people who are in the same situation as us, as we were then, to come here and get some tools to help themselves feel better.”