Unaccompanied asylum-seeking and refugee minors (URMs) are children and youth who have fled their home-country without the company of any adult legal caretaker [1]. They seek asylum in a foreign country, after being exposed to accumulated negative and traumatic life events, such as experiences of war, extensive social and economic hardship, unnatural death or disappearance of family members, ethnicity-related conflicts, forced recruitment or sexual violence [2]. In their destination country, they are faced with postmigration stressors related to asylum-seeking and acculturation processes [3, 4]. They report more mental health problems than other refugee and non-refugee youth [5], and a review study reported a prevalence between 17 and 85% for post-traumatic stress disorder (PTSD), and 12.7–76% for depression [6]. Despite the frequent mental health problems URMs are burdened with, they underuse specialized mental health services, either because they themselves are unwilling to be referred to such, or because of a lack of capacity and competence within the services [7,8,9]. Thus, there is a need for alternative, low-threshold interventions that can alleviate their mental distress, that are more acceptable to the youth, and that can reach many URMs in relative short time.

“Teaching Recovery Techniques” (TRT) was developed by the Children and War Foundation [10] to mitigate symptoms of PTSD among children exposed to war and disaster in low resource contexts [11]. However, it is also of importance to get knowledge about the potential of TRT to impact the subjective wellbeing of URMs, such as their life satisfaction. There is a general lack of evidence-based knowledge about life satisfaction among refugees and URMs, particularly about interventions that can enhance this aspect of their wellbeing [12]. Hence, the overall aim of this study is to explore if TRT, an intervention developed to reduce distressing trauma-reactions, may have an additional positive effect by enhancing the life satisfaction of URMs.

Life satisfaction

Good health and wellbeing for everyone is an overall aim for the United Nations, and is one of the 17 sustainable development goals (goal nr 3) [13]. There are many dimensions of wellbeing, but less clear definitions [14]. According to Diener and Suh [15], “subjective wellbeing consists of three interrelated components: life satisfaction, pleasant affect, and unpleasant affect. Affect refers to pleasant and unpleasant moods and emotions, whereas life satisfaction refers to a cognitive sense of satisfaction with life. Both affect and satisfaction judgments represent people’s evaluations of their lives and circumstances” (p. 200).

In cross-national studies, younger adolescents (11 years) reported better life satisfaction than older adolescents (15 years). This decline with age seemed to be stronger for girls than for boys [16]. Studies of the adult refugee populations also showed that older age was associated with lower quality of life, a more comprehensive indicator of wellbeing, but these studies differed in relation to gender variation [12, 17, 18]. In a study of Iranian refugees in Sweden, males reported lower quality of life compared to women [17], whereas Syrian males reported higher quality of life than their female counterparts [18]. Compared to the general population, refugees reported lower quality of life [18, 19]. In a study from Nigeria, the refugees reported lower quality of life than the non-refugees, however, the protective effect of quality of life on mental illness was the same [19]. In contrast, a Norwegian study found no significant differences comparing levels of life satisfaction among URMs with that of ethnic majority and minority youth, implying that the URMs were satisfied with life, despite higher levels of depression and daily hassles than the two other youth groups [20]. Consequently, better mental health and psychosocial functioning can be some of the benefits of improving wellbeing among asylum-seekers and refugees [19, 21]. Nevertheless, there is a lack of studies evaluating the effect of interventions on wellbeing in these groups [12].

Teaching recovery techniques (TRT)

TRT is a manualized, group-based intervention based on principles from trauma-focused cognitive behavioral therapy (TF-CBT). In addition to effectiveness studies from low-income countries of war and disaster [22,23,24], the intervention has been implemented and evaluated among asylum-seeking and refugee children in England [25] and among URMs in Sweden and Norway [9, 26]. Most studies that have evaluated TRT have focused on its effectiveness in reducing symptoms of PTSD and depression [22, 25].

TRT was designed to be relevant for children (> 8 years old) in low-income countries, who are suffering from clinical levels of symptoms of PTSD after having experienced war- and disaster-related traumatic events. The program can be delivered by individuals without a professional psychiatric or psychological background. The TRT comprises five modules. The participants meet in groups (5–15 participants) for one to two hours once a week over five weeks, with two facilitators who have been trained to deliver the intervention in accordance with the manual. In each of the five meetings, the participants are taught and practice various techniques aimed at alleviating the distress associated with the three main PTSD-symptoms groups: hyperarousal, avoidance, and intrusive memories. They are also encouraged to practice the techniques between sessions. The following elements of TF-CBT are included: psychoeducation, relation skills, affective modulation skills, cognitive coping and processing, trauma narrative, in vivo mastery of trauma reminders and enhancing future safety and development.

Many of the proposed change mechanisms of the TRT to alleviate mental distress, may also be related to better wellbeing, e.g., increased coping and perception of control, better understanding of trauma reactions, and enhanced social support from peers and adults affiliated with each TRT-group. These positive adaptations, such as coping and social support, are predictive of life satisfaction and other aspects of positive mental health [17, 20]. Hence, to expand on the current knowledge about the effectiveness of the TRT in reducing mental health problems, we focus on wellbeing outcomes in terms of life satisfaction. This is in line with the dual-continua model, which recognizes that mental illness and positive mental health are related, but distinct dimensions of mental health [27].

Intervention compliance

The process of transferring an intervention program into the real world consists of several phases, such as the implementation phase, which must be carefully studied to ensure the validity of an intervention [28]. Better implementation leads to better program outcomes, nevertheless, many studies do not include or document implementation indices [28, 29]. Implementation can be studied through facilitator behavior, such as fidelity, the quality of delivery and adaptation of the program, and through participant behavior, such as responsiveness and enthusiasm. These aspects jointly affect the outcome [30]. Previous research on preventive programs has shown that the number of sessions attended and program engagement were associated with better program outcomes [29, 31, 32].

The impact of the techniques and coping strategies that the participants are taught in TRT, are likely to depend on how many of the five TRT sessions they attend, how much they practice the techniques between sessions, as well as their overall contentment with the TRT. We refer to these indices as intervention compliance, reflecting the participants’ responsiveness to the intervention. By including indices of intervention compliance, we gain a deeper knowledge about how TRT was received by the participants, and in what ways their engagement with the intervention is related to outcome.

Asylum status

Most participants in the present study arrived during the so-called 2015 European refugee crisis, characterized by a considerable increase in refugees and migrants coming to Europe, including URMs [33]. This challenged the capacity of the asylum-processing apparatus in many European countries, including Norway, and changed the countries’ immigration policies in direction of more restrictive laws, regulations and practices. In Norway, some of the measures of the new policies contributed to elaborated stress and worries among the asylum-seeking URMs, because many, especially from Afghanistan, were granted a temporary residence permit, which was a permission to stay until the youth reached the age of majority (18 years).

In an intervention study with URMs in Germany, lack of permanent asylum status negatively affected the outcome of TF-CBT by impairing the participants’ feelings of safety [34]. In another study of URMs in Germany, coming from Afghanistan predicted poorer treatment response to a trauma-focused intervention, compared to URMs from African countries [35]. The authors discussed that this was because it was not possible to provide them a safe place for relieving trauma symptoms because of the threat of deportation to Afghanistan [35].

To expand on the discussion from these studies, we speculate if asylum-stress and other strains can take a toll on the motivation to participate in these programs. On the other hand, TRT-participants in the Swedish study, emphasized normalization of trauma reactions and making sense of their past as important aspects of TRT. They also highlighted that they gained a sense of manageability and strategies to cope with their symptoms, and appreciated the social support within the group [26]. As the effect of TRT in different groups of URMs (asylum-seekers and refugees) remains inconclusive, more information is needed about potential variation in the effect of TRT related to the URMs’ context. Asylum-seekers include those who initially launched their claim, those who have their claim rejected and have appealed, and those who have been granted temporary residence permit until they reach the age of majority (18 years). If the asylum claim is approved, the youth is granted residence and are then referred to as a refugee.

The Norwegian URM context

The care and support for URMs in Norway are structured by governmental laws and regulations and carried out by local public services. All URMs are entitled the same public health care as Norwegian children and youth. However, there are variations in the services provided, especially the mental health services [8]. This was partly explained by professional and organizational variations and disagreement related to the responsibility for URMs’ mental health, and in shortages in capacity to deal with the mental health problems of URMs.

While they are awaiting their asylum interview, which is the basis for processing of their asylum claims, URMs live in special asylum centers located all over the country, separated from ordinary asylum centers for asylum-seeking families and adults. They continue staying in the asylum center during the time it takes to handle their asylum application, and a potential appeal of a rejected claim. As a result of the high numbers of URMs that came to Norway during the European refugee crisis, Norwegian authorities established many new asylum centers on short notice in 2015, but many of these were discontinued already in 2017, due to the more restrictive policies [8].

Resettlement of the URMs who have been granted asylum is regulated by the Directorate of Integration and Diversity, based on available residence places in local municipalities nationwide, where Child Welfare or Refugee services oversee their support. The majority of resettled URMs live in group homes with varying degrees of adult supervision. Only a small proportion of the youngest children are placed in foster homes [36].

The present study

The present study is part of the Coping among Asylum-Seeking and Refugee Minors-project (CASaRM). CASaRM was commissioned and funded by three governmental directorates responsible for URM asylum centers and resettlement: The Norwegian Directorate for Child, Youth and Family Affairs, the Norwegian Directorate of Immigration, and the Directorate of Integration and Diversity. The Children and War Foundation trained social workers of the asylum centers and resettlement municipalities together with the local health nurses to deliver TRT in accordance with the manual. We established a group of refugee advisors, consisting of three URMs. The group contributed to developing and piloting measures and advised us on recruiting participants to the study.

The overall aim of the present study is to examine if participation in TRT can increase life satisfaction among URMs with war- and trauma-related PTSD symptoms. The more specific objectives are to investigate if

a)

TRT increases life satisfaction among URMs,

b)

indices of intervention compliance, such as course evaluation, how often they practice the techniques, and the number of times attending TRT are associated with changes in life satisfaction,

c)

life satisfaction trajectories following the TRT differ between youth who were granted and not granted residence.