Family Consequences of Refugee Trauma

STEVAN WEINEw NERINA MUZUROVICz YASMINA KULAUZOVICw SANELA BESICw ALMA LEZICw AIDA MUJAGIC JASMINA MUZUROVICw DZEMILA SPAHOVICw SUZANNE FEETHAM NORMA WARE# KATHLEEN KNAFLww IVAN PAVKOVICw

Objective: To construct a model on the consequences of political violence for refugee families based upon a qualitative investigation. Methods: This study used a groundedtheory approach to analyze qualitative evidence from the CAFES multi-family support and education groups with Bosnian refugee families in Chicago. Textual coding and analysis was conducted using ATLAS/ti for Windows. Results: A grounded-theory model of Family Consequences of Refugee Trauma (FAMCORT) was constructed that describes Displaced Families of War across four realms of family life: (1) changes in family roles and obligations, (2) changes in family memories and communications, (3) changes in family relationships with other family members; and (4) changes in family connections with the ethnic community and nation state. In each realm, the model also species family strategies, called Families Rebuilding Lives, for managing those consequences. Conclusions: Political violence leads to changes in multiple dimensions of family life and also to strategies for managing those changes. Qualitative family research is useful in better understanding refugee families and in helping them through family-oriented mental health services. Fam Proc 43:147160, 2004
wInternational Center on Responses to Catastrophes, Department of Psychiatry, College of Medicine, University of Illinois at Chicago. zUniversity of Chicago, Chicago, IL. College of Nursing, University of Illinois at Chicago, Chicago, IL. #Department of Social Medicine, Harvard University, Boston, MA. wwCollege of Nursing, Yale University, New Haven, CT.

Correspondence conerning this article should be addressed to Stevan Weine, M.D., University of Illinois at Chicago, Department of Psychiatry, Fifth Floor, 1601 W. Taylor Street (MC 912), Chicago, IL 60612. E-mail: smweine@uic.edu The work described in this text has been supported by the National Institute of Mental Health (K01 MH0204801 and RO1 MH59573-01). It has been presented in part at the International Society for Traumatic Stress Studies. 147

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BACKGROUND
Services research on refugee families is concerned with developing and implementing innovative mental health services that address the particular needs and strengths of families. However, this approach is limited by the lack of professional and scientic tools in the refugee mental health eld that focus on the family. There are no family-focused theories concerning refugees, and there is little research on the refugee family. This includes qualitative research that is especially well suited to understanding how families assess and manage changes (Kna & Deatrick, 1986; Kna & Gillis, 2002). How does the experience of refugee trauma look from a family perspective? What do family members see when they look through a family lens at what political violence has done to them? It is important that investigations of family change are not restricted to clinical populations and that they do not only focus on suffering and decits. Rather, investigations should also include nonclinical populations and be informed by family strength and resilience approaches (Rolland, 1994; Walsh, 1998). The professional literature on immigrant families provides another helpful resource that includes more inquiry into family dimensions (Suarez-Orozco, 1995; Portes & Rumbaut, 2001; Zhou & Bankston, 1998). Issues such as family obligation and transgenerational transmission of values and memories are the explicit foci of conceptualizations, investigations, and interventions.

CAFES Intervention and Proposed Model

As part of a program of research concerning family-focused mental health services interventions with refugee families, our university/community collaborative services research group has been conducting the intervention called CAFES (Coffee and Family Education and Support) since 1998. It is a multifamily education and support group that has been manualized and conducted with Bosnian refugee families in Chicago. The CAFES group intervention was designed collaboratively by a group of Americans and Bosnians on the basis of more than 5 years shared experience doing clinical, research, and advocacy work with Bosnian refugees. The overall aim was to devise a way of helping refugees that could t better with the family-oriented behaviors and culture of the refugees than did clinical trauma mental health. What concerned us was the gap between the posttraumatic stress disorder (PTSD) approach to refugees and the lived experiences of refugee families. There is good evidence from clinical and epidemiological research that many refugees, including Bosnian refugees, have the symptoms of PTSD (Weine et al., 1995). However, we found little evidence that most Bosnian refugees were framing their experiences in the terms outlined by PTSD or a clinical mental health model of trauma and recovery. This model is represented in Figure 1. We observed that family members tend to perceive the consequences of political violence through a family lens (Weine, Vojvoda, Hartman, & Hyman, 1997). This is not surprising given that family is at the center of Bosnian culture (Bringa, 1995; Weine, 1999). A common belief among Bosnians is that families have played a necessary and strong role in helping people to cope with massive social pressures in the former Yugoslavia. Our impression was that for those who became refugees and whose homes and communities were destroyed, the family was the most important remaining social
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Political Violence Person Symptoms, Disorder
TRAUMA

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Clinical Treatment Clinical Improvement

RECOVERY

FIGURE 1 Clinical Mental Health Model of Trauma and Recovery

institution. Thus, as an alternative to the clinical trauma mental health model, we proposed a Family Consequences of Refugee Trauma (FAMCORT) model. The FAMCORT model regards the family, more so than the individual, as the focal point. It envisions the multiple changes that war brings to the lives of the family and its members, rather than concentrating on discrete traumatic events linked with traumatic memories and their mental health consequences. It recognizes that families regard a wide range of changes as a part of refugee trauma, including changes related both to political violence and to the experience of displacement, and including both destructive and benecial changes. To further develop this model through empirical study, we turned to CAFES. The CAFES groups created an environment that families recognized as a familyfriendly space. The groups were conducted in community settings near where the refugees lived and facilitated by Bosnian refugees who were laypersons trained and supervised by our university/community team. Each meeting began with casual conversation between families, and then the facilitators introduced a topic with a 15-minute didactic talk, which was followed by a 1-hour family discussion. Topics included: families in transition, family beliefs, and family communication. Throughout 3 years of groups, participant-observers recorded qualitative evidence on the insider points of view of the families concerning their experiences as refugee families. The groups offered a way of gathering more data that could corroborate, specify, and elaborate the FAMCORT model. Of course, we recognized the possibility that some persons may echo some of what the CAFES group leaders had said, but believed that the creation of a family-friendly environment would encourage CAFES groups members to go further in sharing how they were making sense of their worlds, particularly in the family discussions. In order to systematically manage and analyze the qualitative data, this investigation used computer software and a grounded-theory method of analysis (Muhr, 1997; Strauss & Corbin, 1988). The specic aims of the

Violence, Loss Migration, Adjustment

Multiple dimensions of adverse changes to family and family members Multiple dimensions of helpful responses for family and family members

Family & its members

Displaced Families of War

Families Rebuilding Lives

FIGURE 2 Family Consequences of Refugee Trauma Model

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analysis were: (1) to document family perspectives of family consequences of refugee trauma; (2) to analyze the family processes for managing changes associated with refugee trauma; and (3) to discuss implications for family-oriented mental health services for refugees.

METHODS

Sources of Qualitative Evidence

This study analyzed qualitative material from CAFES group meetings, consisting of transcriptions of eld notes from group meetings of 15 groups of nine sessions each. The meetings were conducted between December 1998 and February 2001 with a total of more than 125 families. The CAFES groups consisted of 7 or 8 families of Bosnian refugees (mostly Bosnian Muslim, some mixed) who endured traumatic events of ethnic cleansing and war in Bosnia-Herzegovina, had a family member who met symptom criteria for PTSD diagnosis by research assessment, and were living in a household as part of a Bosnian family. These families were recruited through three community-based organizations and were not receiving mental health services. At each meeting, one facilitator (who was not coleading the group) was asked to take detailed notes in the Bosnian language of what family members said in the group. Most of the meetings were either videotaped or audiotaped, and the tapes were reviewed to ensure the accuracy of the written notes. All written materials were transcribed, reviewed by the CAFES group facilitators for accuracy, and then entered into ATLAS/ti for Windows in the Bosnian language.

Analytic Procedures
Textual coding and analysis was conducted using ATLAS/ti in accordance with standard procedures of qualitative research (Miles & Huberman, 1994; Strauss & Corbin, 1998). A start list of 42 descriptive codes was created on the basis of ongoing community immersion and eldwork, as well as the perspectives of family beliefs and the Prevention and Access Intervention Framework that was used to develop the CAFES groups. Texts were coded using only these codes, supplementing them with memos for any items of interest that did not match the code list. To establish smaller sets, themes and constructs (Creswell, 1998; Miles & Huberman, 1994), pattern coding was conducted through the use of ATLAS/tis query tool (Muhr, 1997). Pattern coding examines the relationship between codes. For example, when the query tool searched for quotations that included either the codes for war and communication or family, seven quotations were found. Next, to describe and analyze the pattern coding concisely, memoing was performed. Memoing involves writing short descriptive statements based on the quotations identied through the pattern coding to summarize the meanings. A grounded-theory model depicted family consequences of political violence for this group of 125 participating CAFES families and was constructed by scanning and sorting those descriptive statements into clusters and categories in the manner recommended by Miles and Huberman (1994) and Strauss and Corbin (1998). Next, the organized groupings of descriptive statements were interpreted from the vantage point of key concepts either intuitively derived or from the aforementioned scientic and professional literatures. Lastly, to check for other explanations and contrary evidence, the analysis was reviewed again by the CAFES research team.
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RESULTS
The grounded-theory model that was derived through this investigation of Bosnian refugee families for understanding FAMCORT is depicted in Table 1. It species the family consequences that CAFES participants see when they consider their experiences of refugee trauma. Through reviewing all characteristics, two major dimensions were identied and labeled. The rst is Displaced Families of War, and it represents families views of the adverse changes to the family caused by war and its aftermath. The second is Families Rebuilding Lives, which refers to families thoughts about the helpful ways that families can manage those adverse changes. Detailed analysis of all of the coded statements demonstrated that family members represented each of these two dimensions across a wide range of experiences of family life. Analysis revealed four different realms of family life: (1) family roles and obligations, (2) family memories and communications, (3) family relationships with other family members, and (4) family connections with ethnic community and nation state. Within each of these realms, multiple adverse consequences and helpful family responses were specied. The analysis found that overall, family members consistently related helpful family strategies to the adverse changes caused by genocide and war. Thus, the detailed
TABLE 1 Family Consequences of Refugee Trauma

Realms of Family Life Family Roles and Obligations

Displaced Families of War  Living through children  Less family time  Challenges to patriarchalism  Memories bring pain  Adults want to forget  Children dont talk about past  Have fear of burdening others  Family back in home country  Family scattered in the Diaspora  Living with vulnerable family members  Single mothers in a new country  Losing touch with our way of life  Children dont speak our language  Children become Americanized

Families Rebuilding Lives  Hope provided by children  Flexibility, tolerance, and trust  Family togetherness  Grandparent parenting     Sharing good memories Talking with children Expressing emotions Building trust through sharing

Family Memories and Communications

Family Relationships with Other Family Members

 Planning a return  Planning for reunication  Maintaining a larger family constellation despite distance  Sending money

Family Connections with Ethnic Community and Nation

 Teaching children our history  Teaching children our language  Returning to religion  Strengthening our identity

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presentation of results that follows has been organized in terms of those four realms of family life. Each section presents a realm of family life, provides examples of what family members said about adverse changes and helpful responses, and species how they are interpreted through the FAMCORT model.

Family Roles and Obligations

Family members report changes in their family roles and obligations. Through the analysis, four categories of changes were described. Depending on children. Youth recognize that their parents and grandparents are now highly dependent upon them. One boy said, My brother and I feel that my mother is like a small child. She relies on me and my brother for everything. Parents nd little sense of purpose or meaning in their own lives compared to their hopes for their children. Youth often experience this as an enormous burden, but they also accept it as a new family obligation. Less family time. Family members report that there is too little time to spend together as a family. Here I do not get to see my children for a few days because I keep working all day long, someone complained. Another reported, In Bosnia we had more time. One has no time for oneself, let alone for children. Because families feel enormous pressures to seek economic opportunities, most of their time is spent at work, and it is made worse because they often have multiple jobs and conicting schedules. Challenges to patriarchalism. Family members speak of new factors that challenge the patriarchal family. One man confessed, Before I used to have a greater control over my wife and children. Now when I want to give advice to my children, they just ignore me. They tell me that my beliefs are old-fashioned and that I should change and become more modern. With women and teens also working, men have been displaced from their prominent roles as the sole breadwinners, eroding their power. Girls and women are learning, by observing women in American society, that they can have more voice and agency than they would have in Bosnia-Herzegovina. These changes often leave family members feeling as if the family world has been turned upside down, but they have found ways to manage the changes in family roles and obligations. The analysis found these four strategies. Children provide hope. One of the most commonly observed comments in the entire analysis was that children are seen as the exclusive source of hope for a better life in the future by their families. These quotes from three parents are typical: Young people bring hope for us; Maybe I lost in the war. But if I see my children doing well, I will be well, too. When I was ill they gave me the strength to persevere and get up; My life is not important but I would be very happy to see them succeed. The strength derived from children appears tremendously restorative for parents. However, there is a built-in fragility because if parents see that their children are having difculties, their letdown can be equally tremendous. Flexibility, tolerance, and trust. Family members state that healthy and successful family living requires exibility, tolerance, and trust within the family. We cannot lock up our children at home. We have to have some trust in them, reported one
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parent. Another shared, I am making the best effort to guide my children in the right direction. This can only be helped through open communication. Some families respond to the cultural and economic challenges to patriarchalism by transforming family processes in a more open and egalitarian direction. It helps them see that they are able to adapt to the circumstances of this new life. Family togetherness. There is an understanding that it is better for family togetherness to be kept high. One family stated, We hang out together. In the past, the neighbor came rst, and then the family. Now everythings different. But the family is much stronger than it used to be. Another family noted, We resolve all our problems together, without offending one another. We get together, discuss things. Bosnian families togetherness is a very important cultural value. When families behaviors reect togetherness, it serves as an afrmation of their ethnocultural identity because they are doing what they believe Bosnian families have long done. Grandparents parenting. In response to parents decreased availability because of work obligations, there is an increase in grandparents parenting. I enjoy the presence of the children. We help one another, said one grandparent who cares for grandchildren. The children are at work and I take care of my grandchildren. Everyone is doing well, noted another. This strategy keeps grandparents from being socially isolated, helps parents work, prevents children from being alone, and promotes communication and sharing across generational lines.

Changes in Family Memories and Communication

All families experienced genocide and war and live with memories linked to those experiences. This has had a substantial impact on family communication. Analysis of family members statements identied multiple areas of change. Memories bring pain. Adults report that talking about memories causes both physical and emotional pain in their families. One said, I cannot talk about it because Ill get sick. Another said, I am afraid to talk to my husband and my son. I dont know if they will understand my suffering. It will just hurt more. Another reported, My wife suffered more and because of her I get up immediately and leave the place where they talk about it. I do not want to hurt her. The pain linked to memories affects many aspects of individual and family life, but it is not regarded as a problem of mental health per se. Adults want to forget. Adults say that they most often prefer not to talk about war. Many made comments like these three persons: Difcult memories make me sad and angry. I dont want to talk about that; I dont like to talk about the war and the losses. It is important to me to forget them; and We try not to talk about our traumas. One must have hope for a nicer and much better future. They believe that in order to carry on, they must pay the cost of keeping away from those memories or even erasing them. Children dont talk about the past. Family members convey that children do not want to talk about war memories, either their parents or their own. One said, Our children do not like to talk about their traumas. We want to talk about the war but our
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children do not let us. Another noted, My children would like us parents to put tape on our mouths and remain quiet. Children seem overwhelmed by the memories and often reject engaging with such horrifying and burdening experiences to which they are asked to listen again and again. They are more preoccupied with their own lives in America than they are with what happened in Bosnia-Herzegovina, and wish that their parents would be too. Fear of burdening others. Family members express concerns over burdening other family members with their troubles. Sometimes, I wish to isolate myself, to nd my peace, and not burden my family, said one man. A woman said, I call my friend to talk to her about my suffering. I do not tell my sister things I tell her. Family members believe that to protect the well-being of others, it is necessary to avoid talking about painful memories. The analysis revealed several ways that the families are managing these difculties of communication through four processes. Sharing good memories. When there are so many bad memories associated with Bosnia circulating, it can be reassuring to recall good memories, and doing so with family members can be especially gratifying. One said, It helps to be reminded of good experiences in Bosnia. Another said, It is nice to reminisce about past from the youth days onward. When I was little, there used to be thrashing of corn, making of preserves, cooking of chestnuts, music, dances, horse races. Talking with children. Talking with children helps family members refocus on positive dimensions of life. Sometimes I feel more comfortable talking to my children rather than my husband. I can always rely on them, especially in the most difcult moments. My children tell me dont worry Mom, everything will be alright, said one. When looking at their kids lives, parents try to nd positive experiences and outcomes that would take their minds off their memories of trauma and loss. The problem is that when they encounter the problems that their children are having dealing with urban America (i.e., gang violence), it again reminds them of the traumas. Expressing emotions. Family members nd that expressing emotions helps them to feel better. One said, Its easier for me when I talk about my feelings. I feel better after talking to someone. Another said, Unburdening oneself is helpful. A third claimed, I like this CAFES group because I can talk about what I am feeling, and thats most important. The experience of opening oneself up to one another, and doing so in an emotionally expressive way, appears to help both as a cathartic release and as a deepening of interpersonal connectedness. Building trust through sharing. Families note the importance of sharing experiences among family members. If you do not share your problems with your family the family cannot make progress. It is very important to talk about problems openly with family members, said one parent. Another claimed, One needs to talk to other people but also with ones family members. They believe that the recovery of trust begins in the family. Sharing experiences tests the existence of trust and afrms that one is able to trust again.
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Changes in Familys Relationship with Other Family Members

Families have had to face extraordinary challenges to the integrity of family structures. The analysis demonstrated several categories of change. We have family in our home country. Nearly all families report that they have multiple family members still living in Bosnia. Not all families were able to emigrate or even wanted to. Extended families left some people to rebuild and maintain the family house. Often, elderly people chose not to move. Families often speak on the telephone, but they can afford to visit one another only every few years. One woman spoke of how having her husband in Bosnia during the war greatly complicated family life: I was in Croatia with children. I felt an enormous guilt over that separation. My children were blaming me constantly for leaving their father behind in Bosnia. One day I decided to go back to Bosnia. When I returned, my husband was no longer the same person. Our family is scattered in the Diaspora. A signicant proportion of families are spread worldwide in the Bosnian Diaspora. Many tell stories like these two families: My one daughter returned to Bosnia. The other one is married and living in Germany; I came here ve months ago. My three sisters are in Holland. During and after the war, families often had to accept whatever chance was offered to them to leave. Typically, one sibling may be in the United States, another in Western Europe, and another in Australia. Separations are taking huge emotional tolls on family members. Living with vulnerable family members. Many families have someone with special physical or emotional needs who must be cared for (e.g., elderly, war-related physical or mental disabilities). One person said, My parents lost their memory. It is hard for me to see them that way. I cannot send them off to a nursing home. My husband helps out a lot. They had to come live with us. A son with an emotionally ill mother said, If my mother comes here it will be much easier for all of us. She could take care of the children. She will also have it better here. She will have three sons to take care of her. Single mothers in a new country. Families headed by single parents, especially widows who lost their husbands in the war, are living with their children in a new country. One woman said, I have been around the world for seven years now. I gave birth in the war. My husband died before he saw his son. My father died before, and my mother died in the war. Another reported, I am afraid I have three children . . . My world crumbled when my husband died . . . I lost my memory. I was on medication for some time. I was killing my children with my behavior. These families face enormous difculties coping with daily life in exile and with the loss of parents and spouses. The analysis found that refugee families respond to these changes through several strategies that help maintain a sense of connectedness with the larger family and its members. Planning a return. Family members, especially the older generations, express the desire to acquire property in Bosnia-Herzegovina, to live there someday, and to be buried in Bosnia. These comments from different families are typical: I am here
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because of my daughter and my grandchild. But that does not mean that I wont go back one day; We worked very hard and invested all our money in repairing our destroyed house in Bosnia; My future plan is to buy a house and return to Bosnia; and I dont plan to leave my bones here. It may come to pass that many will return to Bosnia eventually. Merely the intention to move back can be sustaining. Planning reunication. Families also convey the importance of being reunited with other family members living abroad. Our home is where our children are, reported parents who moved. Others reported, We were in Denmark. We had excellent social security benets and many Bosnian friends. The Bosnian community was big. We left all that behind to come here and join our son and his family. It is not as nice here as it was in Denmark. We are very lonely. However, the family is together and thats whats most important. Families often want to be together and will gure out what location will make that possible, given the obstacles of immigration, employment, and language. Maintaining a larger family constellation despite distance. The sense of staying connected to a larger family network is extremely important to single parents. My relatives are very important. Since I lost my husband, I have to rely on them. They help me out with children. My children are what keeps me alive, said one. Single parents try to reconstitute some kind of supportive family network with grandparents, siblings, and cousins. Sending money. Family members living in Diaspora send money to family members living in Bosnia-Herzegovina. One said, I was in a concentration camp in Bosnia. Then I came to the U.S. I need to earn money and send some to my parents in Bosnia. Because of the grim economic circumstances in Bosnia-Herzegovina, it is extremely difcult to make money there. When family members send money home, it helps their relatives to survive and perhaps also to rebuild the family home, and it also helps those in the United States to remain connected and to feel less guilt for being in exile.

Changes in Families Connections with the Ethnic Community and Nation State
Family members are concerned about changes in their connections with the ethnic community and nation state. The analysis revealed four types of changes. Losing touch with our way of life. Parents expressed concerns that their family is losing touch with Bosnian life as a consequence of their immersion in the American lifestyle and culture. One said, The longer were here, the more distanced we become. Another stated, We are Bosnian inside, but outside were American. A third said, In this new environment and with the new rules of behavior, our tradition can easily be lost. It is vitally important to most parents that the children do not forget Bosnia-Herzegovina and that they are Bosnian, but so difcult to achieve given all of the pressures on the family to Americanize. Children dont speak our language. Parents are concerned about their children losing the ability to speak the Bosnian language. One father said, It is sad that we are losing our identity, our children especially. Our grandchild does not know any Bosnian. Children learn English instead of Bosnian. A mother said, My children are whats
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most important, but I am sorry that they will forget our language. Losing the language is regarded as a threat to ethnic and national identity and is seen as a continuation of the genocide against Bosnian Muslims. Children become Americanized. Parents claim that their children adapt to their environments with ease because they are very eager to accept the American ways of life. A parent stated, Children arent the same anymore. Another claimed, My daughter does not want to go back now. She is working and going to college. Parents want their children to adjust successfully to this new life but worry that in embracing the American way of life, they are losing touch with Bosnian tradition. To cope with these changes in their connection with the ethnic community and nation state, family members have adopted several strategies. Teaching children our history. Parents believe that teaching children the history of Bosnia-Herzegovina will allow them to maintain an understanding of their Bosnian heritage and a sense of belonging to their ethnic group. A parent with older children said, I try to talk to my children about Bosnian history. Another said, We need a Bosnian school here because our heritage is very important. Some try to teach it in their homes, and others want to do this but dont know how under their circumstances. Teaching children our language. Parents nd that it is their responsibility to actively enforce Bosnian language learning at home. One said, Our tradition is extremely important. I always keep pushing my children to read and study Bosnian. It is very important for them to know their heritage. Another said, Do not allow our children to forget our culture and language, which are most important. Many parents speak Bosnian at home, ask their kids to read Bosnian books or newspapers, and encourage kids to go online to Bosnian Web sites. Returning to religion. Parents talk to their children about religion and send them to the mosque. One adult said, Because of the war, we were awakened from our disbeliefs. We returned to our religion, our faith. In the most difcult moments, one should return to family and Koran. Another claimed, We usually go back to religion when we are afraid. Now that we lost our house and the war started, we returned to religion. A teenager said, I try to preserve my identity. I never go to bed without having recited the prayers. Returning to religion is a way to maintain a relationship with God, and also with ones cultural tradition and with the community of other Bosnians and Muslims. It also maintains family togetherness and hierarchy through the teaching of family-oriented values and behaviors. Strengthening our identity. Parents believe that a strong awareness of their cultural heritage will allow their families to preserve their ties to Bosnia-Herzegovina as they adjust to life in America. One father said, I would like my family to retain its Bosnian identity. I am Bosnian and somewhat American as well, said a parent, and another reported, I am not renouncing my culture and that is my strength. They do not believe that they or their children must choose between being Bosnian and American.
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DISCUSSION
The ndings of this study corroborated, specied, and elaborated the FAMCORT model proposed as an alternative to the clinical trauma mental health approach to refugees. It specied and illustrated Displaced Families of War through 14 processes by which refugee trauma causes adverse changes to families. These processes are not limited to symptomatic consequences of discrete traumatic events, but represent multiple changes that war brings to the lives of families and their members. They indicate that the meaning of refugee trauma for these families encompasses both changes that are more directly related to the genocide and war itself (e.g., loss of a family member) and those that are more related to the experience of being displaced families (e.g., children become Americanized). The model represents that families respond with a multiplicity of strategies to being Displaced Families of War under the rubric of Families Rebuilding Lives. They look to changes in the fabric of their lives that can somehow ameliorate the life problems that they associate with being Displaced Families of War. Of 16 strategies specied, some represent behaviors or beliefs that they knew and used previously (e.g., family togetherness). Sometimes familiar strategies take on new meanings as ways to survive the adversities brought by genocide, war, and displacement. Other strategies (e.g., returning to religion) represent largely new beliefs and behaviors that have emerged strongly in the postwar milieu and that now are seen (by some but not by all) as necessary measures for survival. This studys ndings also suggest that making refugee services more family oriented means making interventions that are both aligned with family perspectives on the consequences of political violence and supportive of family members ways of managing those changes. Several specic examples will be discussed. This study documents that in refugee families, parents regard children as vitally necessary resources for their own survival. The extraordinary intensity that is carried by the parent-child relationship in refugee families is often not matched by existing interventions in refugee trauma, which focus primarily on mental health consequences for either adults or children, and far less on the parent-child relationship. These ndings suggest the need for interventions that focus primarily on the parentchild relationship, and include addressing areas of concern regarding school, cultural transition, parental monitoring, and high-risk behaviors. This study also documents that refugee families often regard themselves as belonging to an extended transnational family that has family members in America, in the home country, and in other points of the Diaspora. This prospect of conceiving of the family across great geographic, state, and cultural differences brings forth a very different set of difculties and calls for a very different set of strategies than those captured by the term acculturation, which has guided cross-cultural mental health work with refugees for the past several decades (Berry, Kim, & Mide, 1987). Familyfocused interventions could be directed at better helping families to address the problems of being transnational families in support of their overall goal of promoting family togetherness among conditions of geographic disbursement (Bauman, 1999). This study found that when refugee families live with memories of traumas and losses, the family itself becomes a very important context for narrating memories. The study identied points of potential difculty that could be addressed in family
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interventions, such as helping parents and children to share memories in ways that are developmentally timed and build trust. This study demonstrates several additional important benets of qualitative family research: it facilitates looking through a family lens at issues that tend to be approached through an individual lens; it may identify novel family constructs not derivable through existing theories or measures; and it transmits the voices of persons who would otherwise likely not be heard. This has study multiple limitations. Because the sample consists of families who chose to attend the intervention, it is not a representative sample of all Bosnian families, let alone all families who suffered refugee trauma. Nonetheless, this is a demographically heterogeneous group of families. It is important to consider that family members statements were inuenced by the CAFES context and the conceptual framings that it presented. However, the family members statements seem consistent with other ethnographic and clinical observations, and with life experience of the Bosnian members of the research team. Coding reliabilities were not calculated. The possibilities for researcher biases in coding were lessened given that this coding scheme was devised by SW and NM based on 10 years of experience, and that NM and SW reviewed all coded documents for consensus. Lastly, one limitation of the grounded-theory approach is that the sense of an individual family and how members manage the processes of change is missing. Thus, it is important to conduct additional research to further analyze these ndings, including with other populations. REFERENCES
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Weine, S.M., Vojvoda, D., Hartman, S., & Hyman, L. (1997). A family survives genocide. Psychiatry, 60, 2439. Weine, S.M., Becker, D.F., McGlashan, T.H., Laub, D., Lazrove, S., & Vojvoda, D. et al. (1995). Psychiatric consequences of ethnic cleansing: Clinical assessments and trauma testimonies of newly resettled Bosnian refugees. American Journal of Psychiatry, 152(4), 536542. Zhou, M., & Bankston, C.L. (1998). Growing up American: How Vietnamese children adapt to life in the United States. New York: Russell Sage Foundation.

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