Toward healing-centered engagement to address mental well-being among young Bhutanese-Nepali Refugee women in the United States: Findings from the cultural leadership project

ABSTRACT

Our study provides findings from cultural leadership project based on healing-centered engagement strategies using a transformative convergent mixed methods research design to address mental well-being among young Bhutanese-Nepali refugee women(N = 36). Using a participatory approach, data were collected to explore the feasibility and acceptability of a culturally responsive healing-centered intervention. While quantitative scores showed a significant decrease in anxiety and depression, qualitative findings revealed increased leadership skills, self-esteem, social support, and resilience after the intervention. We discuss the need to promote a holistic view of healing from collective trauma and offer a culturally grounded asset-driven approach to promote hope and healing among refugees.

KEYWORDS:

• Bhutanese refugee youth
• hope and healing
• healing-centered engagement
• collective trauma
• cultural leadership
• intergenerational trauma
• mental well-being
• transformative research

Trauma-informed care (TIC) aimed at youth well-being has recently received wide attention across different settings around the globe. TIC – social, behavioral, and mental health services that account for the possibility that clients may have experienced some form of past trauma (Knight, 2019) – is an evolving organizational approach to recognizing and responding to the impact of trauma on people (LeBel & Kelly, 2014). It incorporates an understanding of the frequency and effects of early adversity on psychosocial functioning across the lifespan (Substance Abuse and Mental Health Services Administration, 2014). The primary goal of TIC is not to address past trauma but to view the presenting problems in the context of past traumatic experiences (Brown et al., 2012). Schools, juvenile justice departments, mental health programs, and human service agencies in the United States have been increasingly advocating for TIC practices as a way to improve health outcomes (S.A. Ginwright, 2018). In social work, TIC principles also have been gaining ground across social work settings, from public or nonprofit agencies to private practice, including clinical, case management, or advocacy roles (Levenson, 2017).

Although the TIC approach, which builds on the core characteristics of trust, safety, choice, collaboration, and empowerment (Knight, 2019), has certain benefits, such as avoiding re-traumatization and increasing engagement, practices that only recognize the impact of trauma on mental, physical, and emotional health have significant limitations in acknowledging the collective view of trauma, especially across interdependent and collective cultures. Postcolonial scholars have long asserted that there is a need to devise new models for understanding and interpreting trauma that includes more differentiated culturally and historically specific notions beyond a Western view of trauma (Visser, 2015). TIC practices steeped in the Western culture of individualism often fail to acknowledge the collective experience of trauma, which is vital in addressing the root causes of trauma (Pulla, 2016; Maleku et al., 2021b). As a result, these practices focus on coping and symptom management rather than on healing (S.A. Ginwright, 2018). Arguably, these strategies ignore the environmental context that caused the harm by focusing only on reducing negative emotions and behavior. They also run the risk of focusing on the treatment of pathology rather than on fostering the possibility of well-being (S.A. Ginwright, 2018). This narrow focus often limits the scope of TIC in fostering overall well-being. Addtionally, it fails to engage individuals and communities whose beliefs, customs, and values do not align with traditional trauma-informed models (Seligman, 2011).

Therefore, alternative models of care, such as healing-centered engagement (HCE), have been evolving as a way to fill in the gaps in traditional TIC models through the construction of healing spaces where participants convene to navigate how to collectively address trauma through a multitude of practices and to begin to heal (Chavez-Diaz & Lee, 2015). Although HCE is promising, there are persistent gaps in how it can be translated into a pragmatic and mainstream option to address trauma. This is particularly true among refugee youth, for whom traditional TIC provides little insight into the root cause of trauma within their neighborhoods, families, and places of employment, failing to situate current hardships within a historical context (Maleku et al., 2021b). Immigrant and refugee youth face challenges in negotiating educational curricula and culture and often lack supportive and safe spaces in US society (Maira, 2009).

Further, experiences of racism faced by immigrant and refugee youth either remain hidden or go unnoticed because of persistent racial erasure in US society (Subedi & Maleku, 2021). There is also a dearth of literature that explores the racialized and gendered experiences of young refugee women (Subedi & Maleku, 2021). Discussions of HCE strategies and practices that focus on healing, especially among refugee youth, and particularly among young refugee women, are extremely limited or nonexistent. Therefore, there is a critical need to build knowledge around HCE strategies targeted at diverse refugee youth beyond TIC models. Based on the findings of a 12-month cultural leadership project conducted among young Bhutanese-Nepali refugee young women in a Midwestern US region, our study offers insights into using HCE strategies targeted to refugee youth, with a focus on education, empowerment, and the identification of cultural assets in the community that serve as protective factors to promote increased mental well-being and ignite hope and collective healing among the community. Our study aimed: (1) to examine the impact of the cultural leadership project on the mental health outcomes of Bhutanese-Nepali young women and (2) to explore the feasibility and acceptability of a group-based, culturally responsive, healing-centered intervention for the Bhutanese refugee population. We begin with an overview of the Bhutanese refugee population and of the trauma-informed care models, with a particular focus on Bhutanese refugee youth, to set the context of our study.

Bhutanese refugee population in the United States

Bhutanese refugees, an ethnically and linguistically Nepali minority group, were forced to flee Bhutan in the early 1990s (Evans, 2010; Hutt, 2003). For more than 20 years, most have settled in refugee camps established by the United Nations High Commissioner for Refugees in Nepal, where, despite the group’s cultural and historical ties to the country, they have never received citizenship (Chase & Sapkota, 2017). In 2007, a large-scale third-country resettlement campaign was launched, and today the majority of Bhutanese refugees have resettled in Europe, North America, New Zealand, and Australia (Shrestha, 2015). More than 86,000 Bhutanese refugees have been resettled in the United States (U.S. Department of State, 2017). The Midwestern US region, the setting of this study, is home to 23,500 Bhutanese refugees, and that number is expected to increase in the next five years (Adhikari et al., 2015). A recent study in the region suggested alarming rates of anxiety symptoms, posttraumatic stress disorder (PTSD), depression, suicide, and substance misuse among resettled Bhutanese refugees in the region (Adhikari et al., 2015). Given the increasing demographic shifts in the region, mental health services are highly uneven, and human services organizations face persistent challenges in providing culturally responsive services (Maleku et al., 2020, 2018).

Once resettled in the United States, Bhutanese refugees have been documented to face myriad hardships in addition to the adjustment to a new environment. These include employment barriers, lack of reliable social services, language and cultural incongruences with the larger society, and other psychosocial stressors (Ellis et al., 2016). Recent studies conducted by the Centers for Disease Control and Prevention (Cochran et al., 2013); and the Mental Health and Addiction Services suggest alarming rates of anxiety symptoms, PTSD, depression, suicide, and prevalence of substance misuse. Specifically, Bhutanese refugees experience various mental health problems, including PTSD, as well as an elevated risk of somatoform pain disorders, anxiety, and other mental health problems (Mills et al., 2008; Van Ommeren et al., 2001).

Although the critical need for behavioral health interventions through culturally and linguistically appropriate services has been continually highlighted for this population (Adhikari et al., 2015), mental health concerns remain a huge stigma within the community, and mental health is often unaddressed and unrecognized due to gaps in service delivery and utilization (Soukenik et al., 2022). Further, most of the literature on Bhutanese refugee populations within the United States tends to focus extensively on adult samples, particularly on their maladjustment issues, such as acculturative stress, suicide rates, and other health issues (Moinolmolki, 2020). Studies exploring mental health challenges across demographic subgroups, especially Bhutanese refugee youth, and more specifically, young Bhutanese refugee women, are either very limited or nonexistent (Betancourt et al., 2019; Subedi & Maleku, 2021).

Bhutanese refugee youth

Many youths from the Bhutanese refugee community were born either in the refugee camps in Nepal or the United States itself and have never been to Bhutan (Chao, 2019). As such, the Bhutanese-Nepali identity has been found to be very strong among Bhutanese refugee youth, especially young Bhutanese women (Subedi & Maleku, 2021). Similar to other refugee youth, Bhutanese refugee youth, who often take on parentified roles as cultural navigators and interpreters, have found language to be a crucial part of their identity (Chao, 2019). Language barrier frustrations were found to prevent Bhutanese youth from socializing outside their community and expanding their network (Chao, 2019). Language barriers also were found to be a key stressor for Bhutanese youth, leading to both academic and ongoing social problems (Betancourt et al., 2015).

Further, the most frequently reported behavioral and emotional issues faced by Bhutanese youth were fighting, loneliness, depression, and being scared (Betancourt et al., 2015). While Bhutanese youth were more aware and open about mental health issues in the community (Maleku et al., 2021b), they expressed difficulties in developing academic and social skills as they handled multiple responsibilities as breadwinners and caregivers while also trying to integrate themselves into a new environment (Poudel-Tandukar et al., 2019). Additional stressors faced by Bhutanese youth included role reversals and intergenerational conflict arising from alteration of family dynamics (Poudel-Tandukar et al., 2019). More importantly, Bhutanese youth’s experience of everyday racial othering, which impacts their already fragile sense of identity and belonging, negatively affected their mental health (Subedi & Maleku, 2021).

Studies among the Bhutanese population affirm that the younger generation has expressed the need for guidance and support to increase their ability to cope with postmigration stressors, learn about stress-management skills, and increase their personal competence in navigating the new environment (Poudel-Tandukar et al., 2019). Although recognition and acceptance of mental health are more widespread among Bhutanese youth compared to older generations (Maleku et al., 2021), there still are persistent gaps in formal support systems that provide assistance in culturally and linguistically appropriate ways (Maleku et al., 2018). Emerging studies on Bhutanese youth show that given the gaps in formal service systems, they were starting to organize and create peer support structures, such as by using digital technology applications as a coping mechanism to find collective healing (Maleku et al., 2021). Literature posits that barriers experienced by refugee youth, however, can have a lower level of burden when strong social networks are in place to enable refugee youth to feel that they have support from peers, mentors, or community members (Rossiter et al., 2015).

Refugee youth and trauma-informed care interventions

The experience of historical trauma in a population has been identified as a potential cause of long-term distress and substance abuse within communities (Ehlers et al., 2013). Collective histories of trauma shared by refugee communities could have cumulative emotional and psychological impacts that linger across generations (Maleku et al., 2021). However, the intergenerational trauma – emotional and psychological wounding transmitted across generations – resulting from collective histories and experiences among refugee populations is little understood (Sangalang & Vang, 2017). Current paradigms within the field are constrained by their focus on individual risk factors at the expense of cultural, structural, and historical context (Cerdeña et al., 2021). Therefore, there is a critical need to explore the collective trauma experienced by refugee youth across groups and communities (Maleku et al., 2021).

Among refugee youth, the frequency, severity, and variation of traumas experienced, in combination with developmental and gender-based challenges, indicate the importance of treatment modalities that are either developed or adapted for this specific population (Ehntholt & Yule, 2006). Refugee families are often served by multiple and frequently disconnected systems of services, from health, mental health, education, and child welfare services to the criminal justice system. Unfortunately, awareness about the effects of trauma, and consequently the presence, type, and quality of trauma-informed services provided, vary widely across both systems and individual providers (Ko et al., 2008). Likewise, screening for trauma and its effects greatly depends on the perceptions of the service system and provider, which may be influenced by the lack of validated screening tools for specific issues and populations (Gadeberg et al., 2017). Moreover, there are significant limitations within the research assessing the effectiveness of interventions for trauma-impacted youth, particularly those experiencing psychosomatic, internalizing, and PTSD symptoms (Duckles et al., 2018; Isakson et al., 2015).

In addition to discontinuity and limited effectiveness of appropriate services, treatment access barriers, such as distrust of authority, mental health stigma, language, and cultural differences, present another important challenge for trauma-impacted refugee youth (Ellis et al., 2011). Recently, novel interventions have been developed specifically for trauma-exposed refugee youth, including narrative exposure therapy and International Family, Adult, and Child Enhancement Services (Birman et al., 2008; Ruf et al., 2010). While preliminary findings have been promising, such services warrant further investigation to determine how they can be effectively implemented in various systems and settings.

What is critical is that Western interventions that focus on trauma have been deemed incongruent with Bhutanese cultural perspectives (Pulla, 2016). Studies emphasize that strengths and resilience factors may be more effective in finding solutions to complex challenges faced by refugee communities (Papadopoulos, 2007). Effective community interventions, such as community gardening or group-focused interventions, have been found to be better than traditional therapeutic services at reducing psychological distress among Bhutanese refugees (Mitschke et al., 2013; Reiffers et al., 2013). It is clear, however, that a traditional approach to mental health treatment, such as providing mental health therapy in a traditional office setting, might not be effective due to the lack of attention to stressors such as poverty, transportation, and language and literacy barriers that impact the refugee population in the resettlement context (Praetorius et al., 2016). Recent studies highlight that mental health service access and utilization among this population may be fostered by community-generated solutions such as case management approaches, community-level awareness and empowerment, peer-led information sharing by Bhutanese leaders, capacity building in local Bhutanese community-based ethnic organizations (CBEOs), diversifying the mental health workforce, disaggregating subgroup needs, and multisectoral collaboration (Soukenik et al., 2022).

Nonetheless, interventions that holistically build on the community’s existing support systems and promising cultural capital to address the collective trauma experienced by Bhutanese refugee youth are either sparse or nonexistent. Studies exploring nuanced gender structures and how these impacts young refugee women in patriarchal cultures like the Bhutanese remain fragmented. For instance, while local resettlement programs offer citizenship classes to learn English or to gain basic knowledge about the United States and may offer minimal measures to facilitate the obtaining of US citizenship, culturally responsive programs focused on the collective experiences of young Bhutanese women and targeted toward collective healing and transformations that positively affect mental well-being are nonexistent in local contexts. Given the paucity of programs grounded in culturally responsive techniques to directly support the collective experiences of Bhutanese-Nepali women, our cultural leadership project was piloted as a strategy to begin to address collective trauma in the migration context and instill hope and healing among this understudied population.

Our healing-centered cultural leadership project

The literature has established that culture is a significant coping mechanism that builds resilience. Cultural ways of coping are crucial protective factors that can minimize risk factors for the overall psychosocial well-being of Bhutanese refugees (Pulla, 2016). Building on prior literature on the Bhutanese refugee population and addressing the gaps therein, particularly in the literature related to Bhutanese youth (Betancourt et al., 2015; Maleku et al., 2021; Poudel-Tandukar et al., 2019), our cultural leadership project, built on the consideration of cultural identity, was guided by two major concepts: hope and healing. Despite the wide agreement on the dynamic role of hope in social work practice, the concept of hope has received less attention in social work research. S. Ginwright (2015) calls for the use of hope to ignite radical healing among youth through healing-centered engagement. HCE is a mechanism to facilitate hope by acknowledging individual and collective trauma and developing a space for healing. Using a strengths-based collective view of healing, HCE repositions culture as a central feature of well-being and highlights the intersecting nature of identities (S.A. Ginwright, 2018). S. Ginwright (2015) argues for three types of hope that create spaces of opportunity: relational hope, or changing conditions in communities based on trust and relationship; restorative hope, or creating conditions and opportunities for communities to prosper and thrive; and political hope, or engaging in political decisions in everyday lives to articulate opportunities to flourish.

Foregrounding our conceptual framework on S. Ginwright’s (2015) radical healing approach, we theorized healing among young Bhutanese-Nepali women as the dynamic process of self-discovery and transformation rooted in family, community, and cultural identity that would promote increased self-awareness, collective belonging, and inclusion in new spaces, ultimately improving their overall health and well-being. As such, we viewed cultural leadership as a core element of the healing-centered engagement project that engaged young Bhutanese-Nepali women as cultural ambassadors (Figure 1). Using a group-based approach inherent in a collectivist culture, the project focused on increasing financial, political, legal, and school systems and health literacy; identifying community assets and cultural resources that can serve as protective factors to challenge gender norms and ease transition into new spaces; and practicing mindfulness to reverse long-term collective traumatic stress and supplant it with a sense of confidence and self-efficacy. Together, these cultural leadership elements would promote collective healing and resilience among the young Bhutanese-Nepali women.

Figure 1. Theory of Change for Healing-Centered Cultural Leadership Project for Young Bhutanese-Nepali Women.

Note: Only variables in colored boxes were measured quantitatively in the study.

Through a co-ethnic, group-based, peer learning circle that utilized various techniques, such as group discussions, eco mapping, arts-based work, free-listing exercises, photovoice techniques, and listening sessions, the project aimed to restore and improve personal and interpersonal relationships with oneself and others, to support interpersonal abilities to articulate collective refugee experience, to ameliorate experiences of marginalization and othering in different spaces such as school or workplaces, and to promote positive health behaviors such as help-seeking. These positive shifts in participant capacity and conditions, based on relationships with family, community, and collective cultural identity, would facilitate the beginning of the healing process, which was then assessed quantitatively and qualitatively by assessing cultural awareness, self-efficacy and resilience, help-seeking behavior, a sense of safety and belonging, interpersonal connectedness, and collective trust.

The basis for the conceptual underpinning of the healing domains was the National Institutes of Health measure Healing Experience of All Life Stressors, or NIH-HEALS (Ameli et al., 2018), a 42-item self-report questionnaire that focuses on psychological, social, religious, and spiritual healing experiences during life-threatening challenges, which we adapted to the refugee youth context, particularly focusing on their mental well-being. Concrete, measurable outcomes included a decrease in somatic symptoms and increased positive physical health, a decrease in mental health symptoms, and an increase in social adjustment and social support. For this study, we focused only on mental well-being outcomes measured quantitatively by a decrease in acculturative stress, anxiety, and depression and an increase in resilience, as shown in Figure 1.

Methods

Research approach and design

Because participatory approaches promote engagement and human agency, these approaches can provide pragmatic strategies to infuse hope in social work research and practice across diverse ethnic communities (Maleku, 2019). We used the transformative convergent mixed methods design, encased within the community-based participatory research approach, for our study. A convergent mixed methods design was appropriate, given the intent to obtain complementary data to best understand the research topic (Creswell & Plano Clark, 2018). The use of a transformative framework in mixed methods research, which focuses on unique cultural situations, a participatory approach, and transformative principles of enrichment of social justice, promotion of human rights, and valuing cultural norms (Mertens, 2010), is especially relevant in research with minoritized groups, given the strong social justice focus (Maleku et al., 2021).

We thus used community-based participatory research – a holistic approach to public health, with the potential to illuminate local barriers to care while simultaneously empowering the community through participation and advocacy (Wallerstein et al., 2018) – as the transformative framework in this study (Maleku et al., 2021a). The cultural leadership project was conducted in collaboration with a local community-based ethnic organization serving the Bhutanese community, which was the key recruitment site for data collection. Partnership with the Bhutanese CBEO throughout the research process, from conceptualization to implementation, presented pragmatic research advantages by providing access to otherwise understudied groups (Bonevski et al., 2014). The convergent mixed methods design included a one-group pretest-posttest design – a pre-experimental design that establishes both correlation and time order and has more value for pilot studies (Rubin & Babbie, 2011) – in which quantitative data was collected before and after the cultural leadership project and qualitative data were collected throughout the duration of the project. The university’s Office of Responsible Research Practices provided approval at the study site. All assent and consent forms were collected before participants engaged in the project.

Participants and procedures

We critically documented the experiences and perspectives of young Bhutanese women (N = 36) during a 12-month cultural leadership project conducted in two cycles. Participants in each cycle attended four-hour sessions every two weeks for 6 months (12 weeks). As an incentive, participants received a gift card of $100 at the completion of the project. Sample participants were recruited with assistance from the Bhutanese CBEO. The CBEO also provided transportation for the participants. Although 40 participants were initially recruited for the study, only 36 consistently attended the sessions, with an attrition rate of 11.11% throughout the project period. This attrition rate is relatively lower than the generally accepted standard of 20% per year (Rivers, 1985).

The participants’ ages ranged from 11 to 24 years old, and the average age of the participants was 15.97 (SD = 2.91). In terms of length of stay, 52.7% of respondents reported having been in the United States since birth (Table 1). In the sample, 94.3% reported living at home with family. Most participants spoke both English and Nepali at home (52.8%) versus speaking only Nepali at home (47.2%). As far as education level, 85.7% reported being a high school student or below. Respondents reported that both parents were employed (50.0%), both parents were unemployed (16.7%), or only one parent was employed (33.3%).

Table 1. Sample Characteristics (N = 36).

Variable	% (n)	M (SD)
Age		15.97 (2.91)
Length of stay in the United States
Up to 3 years	16.7 (6)
Up to 4 years	16.7 (6)
More than 5 years	13.9 (5)
Since I was born	52.7 (19)
Household
Live with family	94.3 (33)
Other	5.7 (2)
Education
High school or below	85.7 (30)
College	14.3 (5)
Language spoken at home
Nepali	47.2 (17)
English and Nepali	52.8 (19)
Parent’s employment
Both parents are employed	50.0 (18)
Both parents are unemployed	16.7 (6)
Only one parent employed	33.3 (12)

Note. Actual n varies based on missing values

The project sessions focused on five key areas: political literacy, economic/financial literacy, legal literacy, health literacy, and school system literacy. Eight modules covered these five key areas across the 12-week period, including modules on cultural leadership and identity (week 1); Bhutanese culture, such as gender norms, family, and community values (weeks 2 and 3); refugee experience, discrimination, and mental health (weeks 4 and 5); body, mind, spirit, and stress regulation (week 6); support networks to understand systems and structures in the United States (weeks 7 and 8); a sense of belonging and inclusion (week 9); community engagement and civic action (week 10), and Bhutanese youth aspirations, collective healing, and resilience (weeks 11 and 12).

All sessions were held at the Bhutanese CBEO space and were cofacilitated by the first and second authors, in collaboration with the last author, who represented the Bhutanese CBEO and identified as a member of the Bhutanese community with lived refugee experience. It is noteworthy to briefly mention the positionality of the first and second authors, who identified as a cisgender female and a cisgender male Nepali immigrant, spoke Nepali, and were affiliated with an academic institution but lacked the lived experience of displacement and refugee status. The collaboration with the Bhutanese CBEO during the research process contributed to the much-needed reflexivity of the refugee experience. We also opened the sessions to volunteers from the university’s Bhutanese American student organization and to a social work intern at the Bhutanese organization, who assisted with the project. Guest speakers from both inside and outside the Bhutanese community, also were used at the sessions on a regular basis.

Data collection and measures

Quantitative data

Pretest and posttest data were collected to quantitatively assess changes in acculturative stress, mental well-being, and resilience levels before and after the cultural leadership project.

Acculturative stress

The modified Index of Life Stress (ILS) measure was used for acculturative stress. The original ILS, developed by Yang and Clum (1995); is a 31-item self-report scale for measuring particular aspects of stress experienced by Asian international students on F-1 visas. The ILS has shown robust psychometric properties among both Korean and non-Asian international students (Yang & Clum, 1995). The ILS uses a four-point Likert scale ranging from 0 (never) to 3 (often) to measure the frequency of certain stressful events. Higher scores indicate higher levels of acculturative stress. Examples of stressful events include “My English embarrasses me when I talk to people” and “People are biased against me.” The current study used a 15-item modified ILS, previously used in Kim and Cronley (2020); consisting of five domains of stressful events: financial concerns, language difficulties, perceived discrimination, cultural adjustment, and academic pressure. The Cronbach’s alpha coefficient in the current study was strong for both pretest (α = .857) and posttest (α = .889).

Depression and anxiety

In this study, mental well-being was determined through measures of anxiety and depression, the mental health issues most commonly experienced by refugee populations. Disturbances of mental well-being were operationalized using the GAD-7, which is a seven-item scale measuring generalized anxiety disorder (Spitzer et al., 2006), and the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001). Both have been widely used as screening tools to measure anxiety (GAD-7) and depression (PHQ-9) across refugee populations (Bjärtå et al., 2018).

The GAD-7 is a self-administered questionnaire designed to assess the frequency of anxiety symptoms. The seven items are measured on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). Scores of 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression, respectively. A cut point of 10 or higher indicates clinically significant symptoms of anxiety (Spitzer et al., 2006). Following the prompt, examples of GAD-7 responses include “Trouble relaxing” and “Becoming easily annoyed or irritable.” GAD-7 has been widely used in low-middle-income countries in the South Asian region and among the Nepali-speaking population in other recent studies (Gupta et al., 2020). The Cronbach’s alpha coefficient for the pretest (α = .841) and posttest (α = .823) for the measure in this study was strong.

The PHQ-9 is a nine-item self-administered questionnaire to assess depressive symptom severity (Kroenke et al., 2001). The items are measured on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). Scores can range from zero to 27, with scores from zero to 4 indicating minimal severity, 5 to 9 indicating mild severity, 10 to 14 indicating moderate severity, 15 to 19 indicating moderately severe, and 20 to 27 indicating severe depression. A cutoff of 10 or higher indicates a possible diagnosis of major depression, with a sensitivity of 88%. Following the prompt, response statements include “Feeling down, depressed, or hopeless” and “Thoughts that I would be better off dead or hurting myself in some way.” The PHQ-9 also has been adapted and validated with the Nepali-speaking population by Kohrt et al. (2016), with high reliability (Cronbach’s α = 0.84), moderate internal consistency (0.54–0.86), and high sensitivity and diagnostic odds (OR =  62.55). In the current study, Cronbach’s alpha coefficient for the pretest (α = 0.703) and posttest (α = 0.702) were within acceptable reliability standards.

Resilience

The modified Resilience Scale for Adults (RSA) was used to measure resilience. The RSA is a 31-item scale designed to measure a set of protective factors and has been cross-culturally validated with samples in different languages, including Persian, Norwegian, and French (Hjemdal et al., 2011, 2006; Jowkar et al., 2010). The RSA is measured on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The possible score range is 31 to 165, with higher scores indicating higher levels of protective resilience factors. Examples of protective factors include “No matter what happens, I always find a solution” and “There is a strong bond in my family.” This study used a 20-item modified RSA, as used in Kim and Cronley (2020). The modified RSA consists of six domains: positive perceptions of self, positive perception of the future, social competence, structured style, family cohesion, and social resources. In this study, the Cronbach’s alpha coefficient was strong for both the pretest (α = .872) and the posttest (α = .915).

Qualitative data

Qualitative data were gathered throughout the project, using small- and large-group discussions, free-listing exercises, handwritten notes, ecomaps, and arts-based methods on identity, belonging, acculturative stress, gender, mental health, and resilience factors. For the purpose of this study, qualitative data that focused on the efficacy of the project, which was gathered at the end of the project through small- and large-group discussions and handwritten notes, have been used. Questions around experience with the project, the project’s impact on the participants’ daily lives, major takeaways, and lessons learned were discussed.

Data analysis and results

We report data analysis and the results of our mixed methods project using a contiguous approach to mixed methods integration, which involves the presentation of findings within a single report, but the qualitative and quantitative findings are reported in different sections (Fetters et al., 2013).

Quantitative data analysis and results

List-wise deletion was employed to address any missing data in which all variables under 14% of missing cases ranged from age (zero) to resilience (14%). To foster unbiased estimates, cases with missing data on key study variables were excluded from the analyses. A paired sample t-test was used to determine whether there was a statistical mean difference between pre- and postintervention. Further, effect size (Cohen’s d) was calculated (Cohen, 1988) to describe the results in terms of measures of magnitude beyond statistical significance. All analyses were considered statistically significant, considered at p < .1. Paired samples t-test results (Table 2) indicated that the observed decrease in anxiety for the refugee youth participants was significant (t = 3.91, p < .001); the observed decrease in depression was also significant (t = 1.78, p =.084).

Table 2. Paired Samples t-test Results (N = 36).

Measure	Pretest M (SD)	Posttest M (SD)	Paired Differences
			M	SD	Standard error mean	95% CI		t	df	p
						Lower	Upper
Acculturative stress	11.21 (7.44)	10.62 (8.60)	.59	6.76	1.25	−1.99	3.16	.47	28	.644
Anxiety	6.66 (4.35)	4.32 (3.47)	2.34	3.49	.60	1.12	3.56	3.91*	33	.000
Depression	4.64 (3.67)	3.68 (3.20)	.97	3.18	.54	−.14	2.08	1.78**	33	.084
Resilience	108.69 (17.78)	111.46 (16.71)	−2.77	12.08	2.37	−7.65	2.11	−1.17	25	.253

* p < 0.01, ** p < 0.1

Although the observed decrease in acculturative stress (t = 0.47, p = .644) and the observed increase in resilience were not statistically significant (t = −1.17, p = .253), changes in effect sizes (d) showed that there were changes in anxiety, depression, and resilience. Changes in anxiety and depression demonstrated a medium effect size, and changes in resilience showed a small effect size (Table 3).

Table 3. Effect Sizes for Measures.

Measures for effect	Effect size (d)
Acculturative stress	0.09
Anxiety	0.67**
Depression	0.31*
Resilience	0.23*

Note. *Small effect (0.2 − 0.49), **medium effect (0.5 − 0.79), ***large effect (> 0.8)

Qualitative data analysis and results

For the qualitative data analysis, we first used the rapid and rigorous qualitative data analysis technique – an individual and team-based approach to coding and qualitative data analysis – to develop data reduction tables in Excel (Watkins, 2017). The tables, which included multiple rows and columns of transcribed focus group discussions, formed the basis for coding and analysis. We then followed a five-step process for data analysis (Nowell et al., 2017): (1) data triangulation with field notes and reflection; (2) generation of thematic initial codes through line-by-line coding; (3) generation of thematic connections based on relationships between codes, frequencies, and meaning across codes, resulting in four interrelated thematic patterns; (4) review of themes and interrelated subthemes, with the researchers vetting the themes by testing for referential adequacy and returning to the raw data; and (5) reevaluation of the data analysis by all authors to generate consensus on the overarching themes and subthemes.

In order to maintain methodological rigor in the data analysis, the first and fourth authors coded the data independently, generated tables with initial and focused codes, and translated the codes into categories, themes, and subthemes. We ran kappa analysis (Cohen’s k) to determine the level of intercoder agreement (McHugh, 2012); the results determined substantial agreement in data coding and analysis (k = 0.692, p = .001). All authors then reevaluated the data analysis, unanimously agreed on the study’s themes and subthemes, and finalized the translation of the themes table (Table 4).

Table 4. Translation of qualitative themes (N = 36).

Extracted original codes	Categories	Overarching themes
Political empowerment; citizenship; political rights and advocacy; increased knowledge [politics]; citizenship rights; advocacy	Citizenship; political empowerment; rights	Theme 1. The role of citizenship in belonging
Community identity; cultural identity; self-exploration; increased knowledge of culture and community; pushing gender and cultural norms; awareness of community issues; desire to be mentor/role-model within community; increased knowledge about United States; learned to be more open-minded	Increased awareness of US culture and community’s culture; building cultural and personal identity; becoming active member of their community	Theme 2. Cultural exploration as a mechanism for healing
Positive experience; sense of community with group members; sense of encouragement from peers; increased belief in oneself; platform to speak up; more confidence in public speaking; social connection and support; life changing experience; felt they were a part of something; changes in perception of social environment; women’s empowerment and rights; self-discovery; self-confidence; empowerment	Empowerment; concrete skill building; intrapersonal skills; peer support; confidence; self-exploration	Theme 3. The genesis of empowerment: personal growth, peer engagement, and finding voice

Three interrelated thematic patterns emerged from the qualitative data, centered on the development of cultural leadership rooted in family, community, and cultural identity. The three themes – the role of citizenship and belonging; cultural exploration as a mechanism for healing; and the genesis of empowerment: personal growth, peer engagement, and finding a voice – stem from the opportunity to engage in a culturally curated program, which created space for the young women to explore their identity, build relationships with their peers, and expand their role as cultural ambassadors both within and outside their communities. Issues of identity, patriarchy, and gender norms emerged as a strong cross-cutting element throughout the three themes. The themes discussed here, with verbatim examples, holistically represent the impact of the cultural leadership project among young Bhutanese-Nepali women.

Theme 1. the role of citizenship and belonging

Citizenship within a country is integral to building a sense of belonging and identity within a new space (Pulla & Rai, 2016). Though citizenship is often simplified into a binary construct representative of legal status, critics argue that citizenship and belonging extend beyond the bureaucratic classification system and include personal identification and emotional ties to a space (Yuval-Davis, 2007). The history of Bhutanese refugees is fraught with stories of egregious human rights violations, including neither Bhutan nor Nepal recognizing the refugees as citizens. Now resettled in the United States, they are again tasked with navigating the socially constructed concept of citizenship, used to determine who “belongs” in the United States and what rights and resources one is eligible to claim. In part, older Bhutanese refugees participated in third-country resettlement with the hopes that the younger generation would not be without citizenship and would be afforded the chance to reconstruct the idea of a home in a new space (Pulla & Rai, 2016). Therefore, the role of political literacy and engagement is of great importance among many refugee communities.

The young Bhutanese women identified with these sentiments, noting the value of knowing one’s rights, voting, and political advocacy:

I learned that even though I’m just one person, I can make a big difference. I learned how important it is to vote.

All the sessions have helped me a lot. It made my thoughts better, and now I know so much about my community and my new country. Thank you for giving me the opportunity to believe [in myself].

Beyond the binary view of legal status, citizenship can be cultivated by creating multicultural spaces where differing identities, religions, or cultural practices are expressed freely (Johns et al., 2015). Yuval-Davis (2007) argues that citizenship embodies the relationship between a person and various political communities for which they feel responsible, such as religious, ethnic, or transnational spaces where they play a role in shaping group processes and outcomes. Due to the intersecting minoritized identities that refugees possess, they are more likely than those from dominant groups to be “citizens” of multiple entities comprising places and people beyond political borders (Yuval-Davis, 2007). These more humane depictions of citizenship are at odds with the traditional conception rooted in white nationalism and allegiance to the dominant identity of a nation-state (Subedi & Maleku, 2021). Recognizing these expanded views of citizenship is important among refugee youth, who often are excluded from civic engagement but fill an integral role in school, at work, in their ethnic or cultural community, and in their religious community.

Theme 2. cultural exploration as a mechanism for healing

The young women learned more about Bhutan, Nepal, and Bhutanese-Nepali culture during the cultural leadership project. Migrant children are often caught in the balance of multiple cultures that are simultaneously embedded in their daily lives and on the periphery. Young migrants may have only vague memories of their country of origin or may have been born in places of resettlement and bypassed the firsthand experiences of exclusion and forced migration. On the other hand, they often experience microaggressions and discrimination in new spaces, such as school and work, where they are “othered,” resulting in feelings of exclusion (Subedi & Maleku, 2021).

The historical context that led to resettlement shapes subsequent generations through myriad pathways, making it important for refugee youth to foster a sense of belonging both within their community and within the place of resettlement (Correa-Velez et al., 2010). This endeavor involves learning about their culture, country of origin, and collective experiences of older generations. The young women also expressed the importance of acting as a resource and mentor for younger generations within their community and of showing other youth the workings of their community and culture. There was a sense of pride in learning about their culture and being able to pass their knowledge on:

It’s been an amazing experience. It has been an uplifting and encouraging event. I feel like I’ve grown to understand my community and community problems. The sessions have made me feel like a leader and I feel like I can bring changes in our community.

Attending these sessions have made me more open minded, I have learned so much about the issues in my community. Before, I never had thought about it, but now I want to set an example for “bhai and buinee” [younger brothers and sisters] in my community. I also want to bring issues that are in our community to the surface and help resolve it.

It helped me understand things happening in our community, especially with women. I have learned to be a role model to youngsters.

These sentiments are also reflections of hope, as the young women discussed visions of themselves as leaders and change-makers who are equipped to take on the challenge of tackling issues both within and outside their community.

Theme 3. the genesis of empowerment: personal growth, peer engagement, and finding a voice

Dissent is a form of identity building. When youth learn to use their voice, they are signaling that they belong in a space (Subedi & Maleku, 2021). This is particularly important among young Bhutanese women, who often experience the burden of being silenced by society and also within their community, as their male counterparts are seen as the primary leaders (Pulla & Rai, 2016). The young women stressed the importance of feeling more confident in using their voices and learning to engage in tough conversations with their community:

I can’t appreciate enough and how grateful I am to be a part of this leadership group. I learned how to discuss openly about anything that bothers me with my family and others from the community. Most of all, I gained confidence about public speaking and now I can speak in large groups.

This project has helped me have self-confidence and get to know myself better.

The young women experienced personal growth characterized by intrapersonal shifts in their view of themselves, by the fostering of strong interpersonal bonds with each other, and by acquiring concrete skills. These myriad forms of maturation contribute to the participants becoming emerging cultural leaders. Intrapersonal growth to them centered on an increase in confidence, self-efficacy, and self-discovery. The women also expressed close ties with each other and the importance of peer engagement:

Being part of this project has truly been a life-changing experience for me. Not only do I get to learn new things every time, but I get to form a connection with everyone on a personal level. I love how talented all the girls are. I get to learn about my culture and tradition even more. We all love the experience and knowledge we gain from the project. For some of us, this project is the only experience we can get outside of our house and school. To add to that, this project gives voice to everyone. All the girls in the group grew up being told that girls cannot speak up and must stay silent. Therefore, this project is a platform for all of us to express our opinions.

It has helped me a lot when I do presentations in school. I feel like I can now talk in front of everyone. And it has helped me to get some ideas about many problems in our community, [such as], young children and drug issues. I can tell my friends and convince them about [going to school] and getting an education.

Pragmatic result: ormation of women of knowledge and excellence

Also noteworthy is the pragmatic impact of the cultural leadership project, which helped form a peer support group initiated by project participants. Based on academic–community partnership, this support group morphed into an organized Women of Knowledge and Excellence (WOKE) project geared toward promoting women’s reproductive health engagement. Using a peer-led group-based model, WOKE intends to mitigate teen pregnancy and intimate partner violence and to create pathways for open communication around sexual health. The peer-led model, led by the participants of the cultural leadership project, is designed to facilitate a sense of community among participants, to empower young women to speak up about their sexual health, and to guide them to engage in more positive communication around this sensitive topic. The WOKE project is currently in its second round of funding from a local foundation. It has continued to broaden its reach among young Bhutanese women, even after the culmination of the cultural leadership project.

Discussion and implications

The culturally grounded leadership project provided a platform for the young Bhutanese-Nepali women to create a healing-centered environment that extended beyond group therapeutic modalities to encompass the restoration of identity and curate a sense of belonging. The young women were supported and engaged in the space, allowing them to explore their identities, discuss community challenges, and speak up about issues important to them, leading to an increase in self-confidence. Though the young women learned about various facets of transitioning into adulthood, such as health and well-being, their responses focused on the value of self-discovery, political rights, and viewing themselves as having an integral role in their community. These attributes will be indispensable as the young women assume the role of cultural ambassadors, both within and outside their cultural community, and transition into adulthood.

Findings showed a decrease in anxiety and depression symptoms and an increase in resilience after the pilot intervention. Through education, empowerment, and identification of cultural assets in the community that serve as protective factors, the project helped increase positive mental well-being outcomes. In the Bhutanese community, family members, friends, and neighbors tend to be intimately involved in recognizing and managing individual distress, often responding proactively to perceived vulnerability rather than reactively to help-seeking (Chase & Sapkota, 2017). However, this reduced help-seeking and underutilization of mental health services are not indicative of a lack of need. The influence of community stigma on mental health utilization, and the lack of culturally appropriate mental health interventions, continue to represent challenges in culturally sensitive prevention and intervention efforts (Augsberger et al., 2015). Between the cultural barriers and the service environment, a lack of cultural sensitivity is an obstacle to service utilization and delivery, caused not just by language barriers but also by a conflict between cultural outlook on life and values, making provider–patient communication difficult (Maleku & Aguirre, 2014).

Findings from the cultural leadership project showed that the participatory nature of the intervention project provided the young women with the opportunity to expand their social network, increasing their access to spaces that often are inaccessible for minoritized youth (Subedi & Maleku, 2021). Historically, youth have not been viewed as vital to knowledge generation in academia or as proponents within their community who can meaningfully engage in participatory research practices (Martinez et al., 2018). The findings from this study dispel those myths and call for social science research, especially social work, which engages extensively with families, to recognize the power of youths’ voices and capabilities in research. Instead of constructing youth experiences through the eyes of adults in their lives, youth voices themselves should be at the forefront (Martinez et al., 2018). The young Bhutanese-Nepali women in this project echoed this sentiment. They highlighted the importance of their involvement in the group for their personal growth, fostering relationships with their peers, and becoming advocates for their community. Moreover, through the academic–community partnership with the local university, the young women could expand their loosely formed support group into a formally organized one. Thus, the multisectoral collaboration strategies utilized in the project were advantageous to knowledge sharing and afforded the young women the opportunity to expand their health and political literacy. This is important for human service organizations, especially those serving the refugee population, who have been found to work in silos and foster an atmosphere of competition over cooperation with peer agencies (Maleku et al., 2020).

The findings of our study showed that HCE projects such as the cultural leadership project have the potential to promote a holistic view of healing from traumatic experiences and environments, offer an asset-driven approach aimed at the holistic restoration of young people’s well-being, are culturally grounded, and view healing as the restoration of identity. This approach is particularly important among minoritized youth, who often are excluded from spaces they occupy and endure discrimination and marginalization from peers, adults, and the larger society (Subedi & Maleku, 2021), contributing to disparate mental health outcomes. Within the context of social work practice, findings from our study call for interventions to extend beyond Western trauma models, which have failed to serve historically marginalized populations.

The idea of healing-centered engagement grew out of communities’ needs to heal from systemic injustices that have intentionally excluded and harmed entire populations, often legally and with support from the larger society. Communities on the receiving end of collective trauma require communal healing fostered through meaningful connection and recognition of their lived experiences. Their lived experiences extend beyond isolated incidents of harm or trauma that may be best remedied with Western therapeutic approaches or current evidence-based practices. Social workers must invest in empowering communities to identify their own solutions and then support their endeavors to dismantle repeated harm and engage in healing.

Through this project, the young women identified important issues to discuss among their peers and within their community. They were able to engage in collective healing through the recognition of their past experiences in the presence of others who shared similar identities and stories, thus fostering inclusion and connection. The project’s findings also contribute to understanding the complexity of cultural capital in migration and mental health research and practice. Study findings contribute to designing culturally responsive programs that recognize refugee youth’s transition into a new social system and increase their access to various forms of mental health and human service resources. This will inform policymakers, program developers, nonprofit agencies, researchers, and practitioners as they expand their understanding of cultural resources and environmental structures’ complex intersections as an integral component of achieving health equity. Using innovative methodology grounded in the Bhutanese culture, this study will contribute to improving mental health services among the Bhutanese refugees, foster a sense of belonging and collective healing, and provide pathways for translational research, which can be translated and replicated among other immigrant and refugee populations as well as other ethnic minoritized groups.

The young women’s voices are at the center of this study and illuminate the need for culturally appropriate spaces where healing and empowerment can flourish through community-engaged participatory research approaches. Quantitative and qualitative results reveal the feasibility and acceptability of a group-based culturally responsive HCE intervention to address collective trauma among refugee youth. Developing and testing strategies for the multisectoral delivery of healing-centered mental health and psychosocial support may serve as a model for integration across various humanitarian sectors to improve refugee youths’ mental, physical, and social well-being. Additionally, the study process and findings also inform the beginning of multidimensional, culturally responsive healing measures that can be applied and replicated across different settings.

Limitations

The findings of our project should be interpreted with caution. The generalizability of study findings might be limited due to the small sample size and study setting in a Midwestern US region. Although our project captured firsthand experiences of young Bhutanese-Nepali women, some contextual and culturally heterogeneous nuances may have been obfuscated by grouping participants based only on gender. Exploring subgroup differences and examining intersections of gender with other demographic variables was beyond the scope of the study. Further, we could not disaggregate the findings based on participants’ length of stay in the United States, which could impact resettlement experiences. While we justify using standard mental health measures such as PHQ-9 and GAD-7, we also recognize the limited scope of the general scales used in the study. Future studies should consider using targeted scales such as Hopkins Symptom Checklist. Although qualitative data conducted in Nepali were recorded, transcribed verbatim, and translated into English in collaboration with our Bhutanese community partner organization, original meanings might have been misinterpreted or lost in translation. Despite these limitations, our study contributes to the existing knowledge base on healing-centered mental health research in the resettlement context.

Conclusion

Our cultural leadership project is distinct in its efforts to examine the cultural nuances of mental health risk and resilience among young Bhutanese-Nepali refugee women. Using collective healing as an innovative tool, the project helped identify the cultural strengths and resources, efficiencies, and links among symbolic cultural patterns, practices, common aspirations, and values through the community members themselves. Using HCE strategies, findings showed promising measurable shifts in participant capacity and conditions. Our pilot project contributes to the development of culturally responsive HCE intervention that can be replicable across other refugee populations and builds the framework for large-scale testing of HCE strategies across refugee youth. Further, infusing participatory approaches that focus on community engagement and human agency into research and practice, as demonstrated by our project, has the potential to promote hope and collective healing across diverse communities.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Funding for this study was provided by The Columbus Foundation, United Way of Central Ohio, and The Ohio State University through the Connect and Collaborate Grant Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.