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Well-being, strategic design, transition, & policy : a case for the federal settlement platform Shahban, Shenaz A. H. 2019

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 WELL-BEING, STRATEGIC DESIGN, TRANSITION, & POLICY:  A CASE FOR THE FEDERAL SETTLEMENT PLATFORM  by  Shenaz A. H. Shahban  B.A., The University of British Columbia, 2009 M.A., The City University of Seattle, 2012  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies) [Public Policy, Psychiatry]  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   January 2019  © Shenaz A. H. Shahban, 2019  ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: Well-Being, Strategic Design, Transition, & Policy: A Case for The Federal Settlement Platform  submitted by Shenaz A. H. Shahban in partial fulfillment of the requirements for the degree of Doctor Of Philosophy  in The School of Public Policy and the Faculty of Medicine Department of Psychiatry Examining Committee: Moura Quayle Supervisor  Soma Ganesan Supervisory Committee Member  Ishu Ishiyama Supervisory Committee Member Dr. Marvni Westwood University Examiner Dr. Samson Nashon University Examiner  Additional Supervisory Committee Members:  Supervisory Committee Member  Supervisory Committee Member   iii  Abstract  The importance of refugee well-being research is on the rise as increasing numbers of refugees are finding sanctuary in Vancouver. In 2015 and 2016, the federal Operation Syrian Refugee program oversaw the arrival of 25,000 refugees to 250 communities across Canada. In 2016 the Immigrant Services Society of British Columbia (ISS of BC) investigated the well-being of these government-assisted refugees in A Roadmap to Integration and Citizenship. That study revealed that 30% refugee participants reported low well-being and were “sad” or “depressed”. As mental health services (e.g., counselling) are widely known to support well-being, the purpose of this interdisciplinary research was to investigate what formal and informal mental health services were offered to government-assisted refugee men, women, and families during the period of 2015-2016 in Vancouver. The study participants included key informants (public servants, mental health professionals, and settlement professionals) and data was collected using service journey maps and interviews. This study found that there were no formal settlement-informed mental health care services available to government-assisted refugees and very few informal mental health services. Thematic findings accompanied by quantitative frequency computational analysis revealed that improvements are needed for refugee mental health care. The four main needs for refugee mental health care are: (i) the need to be seen as a priority, (ii) the need to be provided to all [refugees], (iii) the need to be trauma and settlement-informed, and (iv) the need to be collaborative. Further analysis of the findings led to the development of the proposed policy recommendations for the Federal Settlement Platform (FSP). The intention for the development of this platform is for refugees, settlement agencies, and stakeholders to access one unifying web-experience to coordinate, coalesce, and organize not only mental health resources but all settlement-related information. Analysis of the data makes clear the necessity for the FSP by highlighting the consequences of a lack of refugee mental health services which are growing rates of cognitive disorders like depression.   iv  Lay Summary  The Immigrant Services Society of British Columbia investigated the well-being of government-assisted refugees in Vancouver. That study revealed that 30% of participants were “sad” or “depressed.” This research investigated the mental health services offered at that time. The study participants included public servants, mental health professionals, and settlement professionals. This research found there were no appropriate mental health care services available to government-assisted refugees and very few informal mental health services. Other findings revealed a need for refugee mental health care services to be seen as a priority, to be provided to all refugees, to be trauma and settlement-informed, and to be collaborative. These revelations led to the proposal of a policy recommendation to create the Federal Settlement Platform (FSP). The FSP would be a federally supported platform for newcomers and settlement professionals to access one unifying web-experience to coordinate, coalesce, and organize mental health resources as well as all settlement-related information.  v  Preface  As of the date of this dissertation, no part of my research has been partly or wholly published. The action research studies were approved by UBC’s Behavioural Research Ethics Board and identified by Ethics Certificate Number #H16-032199. The author was the lead investigator for the document analysis and interview research studies described in Chapters 3 and 4. Similarly the author was responsible for all areas of research design, data collection and analysis, as well as the author for the entire manuscript and all the framework visualizations. This dissertation is original, unpublished, and independent work by the author, Shenaz A. H. Shahban. vi  Table of Contents  Abstract .................................................................................................................................... iii!Lay Summary .......................................................................................................................... iv!Preface ....................................................................................................................................... v!Table of Contents ..................................................................................................................... vi!List of Tables.......................................................................................................................... xiii!List of Figures ........................................................................................................................ xiv!Glossary .................................................................................................................................. xv!Acknowledgements ............................................................................................................... xvii!Dedication ............................................................................................................................ xviii!Chapter 1: Introduction ........................................................................................................... 1!1.1! Defining a Refugee...................................................................................................... 3!1.2! Theory of Refuge & Stages of Adaptation ................................................................... 3!1.3! Humanitarian & Refugee Crisis of 2014 ...................................................................... 7!1.4! Anthropological Considerations .................................................................................. 8!1.5! Migration to Neighbouring Countries & Canada ........................................................ 11!1.6! The Importance of Well-Being of Refugees in Vancouver: A Roadmap to Integration and Citizenship Study ........................................................................................................... 13!1.7! Rationale and Research Questions ............................................................................. 14!1.8! Contribution .............................................................................................................. 18!1.9! Theoretical Framework and Methodology ................................................................. 20!1.10! Dissertation Chapters ................................................................................................ 21!vii  Chapter 2: Relevant Literature .............................................................................................. 23!2.1! Well-being Literature ................................................................................................ 23!2.2! Well-being Framework .............................................................................................. 26!2.2.1! PERMA: Positive Emotions. .............................................................................. 26!2.2.2! PERMA: Engagement. ...................................................................................... 28!2.2.3! PERMA: Relationships. ..................................................................................... 28!2.2.4! PERMA: Meaning. ............................................................................................ 29!2.2.5! PERMA: Achievement. ..................................................................................... 30!2.3! Understanding Refugee Experiences and Risks to Well-being with PERMA ............. 31!2.3.1! Emotions ........................................................................................................... 31!2.3.2! Engagement ....................................................................................................... 32!2.3.3! Relationships ..................................................................................................... 33!2.3.4! Meaning ............................................................................................................ 34!2.3.5! Achievement ..................................................................................................... 35!2.4! Mental Health Services.............................................................................................. 37!2.4.1! Formal ............................................................................................................... 37!2.4.2! Informal ............................................................................................................ 39!2.5! Strategic Design Theory ............................................................................................ 40!2.6! Summary ................................................................................................................... 43!Chapter 3: Methodology ......................................................................................................... 46!3.1! Introduction ............................................................................................................... 46!3.2! Qualitative Study with Frequency Computational Analysis ....................................... 47!3.3! Participants ............................................................................................................... 49!viii  3.3.1! Key Informant Participants ................................................................................ 49!3.3.2! Inclusion Criteria ............................................................................................... 51!3.3.3! Exclusion Criteria .............................................................................................. 52!3.3.4! Recruitment ....................................................................................................... 52!3.4! Data Collection Methods ........................................................................................... 55!3.4.1! Consent Form .................................................................................................... 55!3.4.2! Service Journey Map ......................................................................................... 55!3.4.3! Interviews .......................................................................................................... 59!! Interview Questions ....................................................................................... 59!! Interview Procedure ....................................................................................... 60!! Interview Setting ........................................................................................... 62!3.5! Data Analysis Methodologies .................................................................................... 62!3.5.1! Computational Frequency Analysis ................................................................... 62!3.5.2! Qualitative Analysis .......................................................................................... 63!3.6! Methodology of Development of Policy Recommendations....................................... 66!3.7! Researcher Bias ......................................................................................................... 67!3.7.1! Ethical Considerations ....................................................................................... 67!3.8! Summary ................................................................................................................... 70!Chapter 4: Findings ................................................................................................................ 71!4.1! The Available Mental Health Services During Arrivals ............................................. 71!4.2! Data Collected ........................................................................................................... 79!4.3! Quantitative Frequency Computation Analysis .......................................................... 80!4.3.1! Policy and Education Category .......................................................................... 82!ix  4.3.2! Communities, Refugees, and Families Category ................................................ 85!4.3.3! Primary Health and Mental Health Category ...................................................... 87!4.4! Qualitative Findings .................................................................................................. 90!4.4.1! Theme 1: Mental Health Services Should be Seen as a Priority .......................... 90!4.4.2! Theme 2: Mental Health Services for All Refugees ............................................ 92!4.4.3! Theme 3: Mental Health Services Should be Trauma & Settlement-Informed .... 94!4.4.4! Theme 4: Mental Health Collaboration .............................................................. 96!4.4.5! Summary ........................................................................................................... 98!4.5! Ethnographic Findings .............................................................................................. 99!4.5.1! High Informant Engagement .............................................................................. 99!4.5.2! Carefully Chosen Words to Explain Issues ...................................................... 100!4.5.3! Refugee Guilt in Asking for Help/Assistance ................................................... 100!4.5.4! Importance of Cross-Cultural and Trauma-Informed Competencies ................. 101!4.5.5! The Research Context ...................................................................................... 102!4.5.6! Importance of Asking Questions with Sensitivity ............................................. 102!4.6! Summary ................................................................................................................. 103!Chapter 5: Policy Recommendations ................................................................................... 104!5.1! Policy to Action ...................................................................................................... 105!5.2! Policy Recommendations ........................................................................................ 106!5.2.1! Policy Recommendation 1: Create a Federally Supported Settlement Platform 107!! Defining the Problem: .................................................................................. 107!! Proposed Policy Recommendation: .............................................................. 108!! Housing: ................................................................................................ 110!x! English Classes: ..................................................................................... 110!! Health & Mental Health: ........................................................................ 111!! Community Integration: ......................................................................... 111!! Identification:......................................................................................... 112!! Financial: ............................................................................................... 112!! Education and Employment: .................................................................. 112!! Information: ................................................................................................. 113!! Projected Outcomes: .................................................................................... 113!! Tradeoffs: .................................................................................................... 114!5.2.2! Policy Recommendation 2: Allow Counsellors to Consult as Mental Health Clinicians ........................................................................................................................ 114!! Defining the Problem: .................................................................................. 114!! Proposed Policy Recommendation: .............................................................. 115!! Information: ................................................................................................. 115!! Projected Outcomes: .................................................................................... 116!! Tradeoffs: .................................................................................................... 116!5.2.3! Policy Recommendation 3: Up-skill Current Practicing & Licensed Mental Health Clinicians ........................................................................................................................ 117!! Defining the Problem: .................................................................................. 117!! Proposed Policy Recommendation: .............................................................. 117!! Projected Outcomes: .................................................................................... 118!! Tradeoffs: .................................................................................................... 118!xi  5.2.4! Policy Recommendation 4: Create Trauma and Settlement-Informed Curriculum for Students in Mental Health Clinical Training Programs............................................... 119!! Defining the Problem: .................................................................................. 119!! Proposed Policy Recommendation: .............................................................. 119!! Projected Outcomes: .................................................................................... 120!! Tradeoffs: .................................................................................................... 120!5.2.5! Policy Recommendation 5: Increase Federal Support from One to Two Years . 120!! Defining the Problem: .................................................................................. 120!! Proposed Policy Recommendation: .............................................................. 121!! Global Precedents: ....................................................................................... 121!! Projected Outcomes: .................................................................................... 121!! Tradeoffs: .................................................................................................... 122!5.2.6! Policy Recommendation 6: Offer Incentives to Community Partners ............... 122!! Defining the Problem: .................................................................................. 122!! Proposed Policy Recommendation: .............................................................. 122!! Global Policy Precedents: ............................................................................ 123!! Projected Outcomes: .................................................................................... 123!! Tradeoffs: .................................................................................................... 124!5.2.7! Summary: ........................................................................................................ 124!Chapter 6: Critical Reflections ............................................................................................ 128!6.1! Operation Syrian Refugee ....................................................................................... 129!6.2! Service Journey Mapping ........................................................................................ 130!6.3! LGBTQ+ ................................................................................................................. 132!xii  6.4! Key Informant Methodology ................................................................................... 133!6.5! Media & Discrimination .......................................................................................... 133!6.6! Summary ................................................................................................................. 135!Chapter 7: Conclusion .......................................................................................................... 136!7.1! Research Contextualization ..................................................................................... 136!7.2! Research Methods ................................................................................................... 136!7.3! Research Findings ................................................................................................... 137!7.4! Research Implications and Contributions ................................................................. 137!7.5! Research Critique and Limitations ........................................................................... 139!7.6! Directions for Future Research ................................................................................ 140!7.7! Research Conclusions.............................................................................................. 141!Bibliography ......................................................................................................................... 143! xiii  List of Tables  Table 3-1 Key Informant Participants ....................................................................................... 52!Table 3-2 Interview Questions Breakdown ............................................................................... 60!Table 4-1 Key Informant Sector Content Frequency Analysis by Word Category ..................... 81!Table 4-2 Key Informant Quotes for Theme 1: Mental Health Services as a Priority ................. 92!Table 4-3 Key Informant Quotes for Theme 2: Mental Health Services for all Refugees ........... 94!Table 4-4 Key Informant Quotes for Theme 3: Mental Health Services Should be Trauma & Settlement-informed ................................................................................................................. 96!Table 4-5 Key Informant Quotes for Theme 4: Mental Health Collaboration ............................ 98!Table 5-1 Policy Recommendations Summary Table .............................................................. 125! xiv  List of Figures  Figure 3-1 Methodology Map for Well-being, Strategic Design, Transition & Policy: A Case for the Federal Settlement Platform ................................................................................................ 46!Figure 3-2 Key Informants ........................................................................................................ 53!Figure 3-3 Key Informants by Sector ........................................................................................ 54!Figure 3-4 Service Journey Map ............................................................................................... 58!Figure 3-5 The Policy Design Studio Canvas 2.0 (2017) ........................................................... 67!Figure 4-1 Service Journey Map & Interview Data Fields ......................................................... 80!Figure 4-2 Policy & Education Concept Usage Per Interview ................................................... 82!Figure 4-3 Policy and Education Frequency Data by Sector ...................................................... 84!Figure 4-4 Community, Family & Refugee Concept Usage Per Interview ................................. 86!Figure 4-5 Community, Family & Refugee Concept Frequency by Sector ................................ 87!Figure 4-6 Mental Health Care & Primary Health Care Concept Usage Per Interview ............... 88!Figure 4-7 Mental Health Care & Primary Health Care Concept Usage by Sector ..................... 89!Figure 5-1 Federal Settlement Platform (FSP) ......................................................................... 109! xv  Glossary  Family: For this proposed study, a family will be defined as two or more people who are related    by blood, marriage or adoption.   Forced Displacement: A situation in which a person or group of people who are forced to  leave or flee their homes due to conflict, violence and/or human rights violations.  GAR: government-assisted refugee Lived experiences: The first-hand accounts and impressions of living through experiences just  as we find it in our own (past) experience (van Manen, 2014)  Mental health professionals and Support Staff: (e.g., psychiatrists, psychiatric nurses,  psychologists, counsellors, social workers and others) as well as non-specialized health    care staff (e.g. general physicians, midwives and nurses).  PSR: privately sponsored refugee  Phenomenology: The study of lived experiences regarding a particular phenomenon    described with awareness about the phenomenon such as that made available by the  pre-reflective consciousness (van Manen, 2014). Positive Psychology: the branch of psychology focusing on what is working well in  individual’s lives, which foster well-being and happiness (Seligman, 2009).  Pre-reflective consciousness: The pre-reflective consciousness is explained as “an  awareness we have before we do any reflecting on our experience” and “an implicit  awareness [rather than an explicit or higher-order form] of self-consciousness”    (Gallagher & Zahavi, 2005, p. 2). xvi  Protective Factors: A protective factor, an aspect of resilience, is defined as conditions under    which risk-factors are not associated with negative outcomes (Masten, 2009). Psychological Well-being: According to Seligman (2012) comprises of: positive emotions,    engagement, relationships, meaning and accomplishments. However, during the    interviews, each participant will be asked to define what “psychological well-being”    means to them.  Refugee: A refugee is defined as anyone "owing to a well-founded fear of being persecuted for   reasons of race, religion, nationality, membership of a particular social group or   political opinion, is outside the country of his nationality, and is unable to, or owing to   such fear, is unwilling to avail himself of the protection of that country” (Article 1A(2),   Convention relating to the Status of Refugees, 1951). Resilience: “the capacity of a dynamic system (individual, family, school, community, society)    to withstand or recover from significant challenges that threaten its stability, viability,      or development” (Masten, 2011, p. 494).  xvii  Acknowledgements  Enduring gratitude is offered to the research participants and faculty, staff, and fellow students at UBC, who have inspired the work in this field. I thank my committee Dr. Soma Genesan and Dr. Ishu Ishiyama. I also extend gratitude to mentors who have guided me endlessly and readers and supporters of this work who have invested in its preparation.  I owe particular thanks to Moura Quayle. A supervisor, mentor, and guide whose penetrating questions taught me to reflect more deeply and who provided a vision and coherence not only to this journey but endless questions. A visionary without whom the completion of this project would not have been possible.  Special thanks are owed to my family, for their unending support and patience. xviii  Dedication       To those on a journey.  1 Chapter 1:!Introduction    There is a need to better understand how to support refugees’ mental health in culturally sensitive ways and to encourage those who are suffering from mental illness to seek assistance. The Committee agrees… that creating mental health “footholds, steppingstones and safety nets for the individuals at risk is an important investment that Canada needs to make” to ensure that new arrivals integrate into Canadian society and to avoid problems in future generations. While healthcare is largely a matter of provincial jurisdiction, through such programs as the IFHP and settlement funding, the Government of Canada can play an important part in improving Canada’s approach to mental health in refugee populations.      -Hon. Jim Munson, Salma Ataullahjan  Report of the Standing Senate Committee on Human Rights  When a photograph of what appeared to be a face-down doll on a Turkish beach was identified as the lifeless body of three-year-old Alan Kurdi, the world awoke to the largest humanitarian crisis of our time (UNHCR, 2015). Nilüfer Demir’s September 2, 2015 photograph caused the mobilization of civilians from countries across the globe urging their governments to take action as some half-million Syrians were displaced during the civil war prompted in 2009. Canadians were no exception to this global mobilization.    In November 2015, the Canadian Liberal Party re-claimed Ottawa just weeks after announcing a platform promise of welcoming 25,000 refugees who were fleeing war. With the Liberal administration in place, the first arrivals of the 25,000 refugees entered Canada between November 2015 and March 2016 (CIC, 2015). Of the government-assisted refugees (GAR’s) arriving in Canada, 4,400 came to British Columbia making it the largest re-settled cohort since the 1980s.    Through an Immigration, Refugees, and Citizenship Canada (IRCC) subcontracting agreement, GARs receive initial reception and orientation support through the Immigrant Services Society (ISS of BC) located in Vancouver. With the unprecedented arrival of Syrian GARs to BC, ISS of BC took the opportunity to mark their first year in Canada by systematically probing some of their early settlement experiences and outcomes in A Roadmap to Integration and Citizenship study. This study investigated  2 key constructs relevant to well-being, including income security, education, housing, primary and dental health, language acquisition, acculturation, and mental health. The study revealed that 30% of GARs self-identified as “sad” or “depressed” in their first-year post-resettlement in Vancouver (ISS, 2016, p. 16). This result may be expected considering the plight of the study’s population. However, without the access to adequate mental health services in host communities, these “sad” or “depressed” GARs have the potential to develop long-lasting conditions.     This research and subsequent dissertation is a follow-up to the aforementioned ISS of BC study findings. The Well-being, Strategic Design, Transition, & Policy: A Case for the Federal Settlement Platform research project applied an interdisciplinary approach. Data was collected using service journey maps (Kimbell, 2014) and interviews (Schensul & LeCompte, 2013). Study participants included key informants (public servants, mental health professionals, and settlement professionals). All data was analyzed using frequency computational analysis (Stemler, 2001) and thematic analysis (Braun & Clarke, 2006). Findings were further analyzed and applied to develop the results into policy recommendations for the Federal Settlement Plan (FSP) (Bardach, 2000; UBC School of Public Policy, 2017).    Before these steps were undertaken, a wealth of background information was researched in order to prepare for the study. Presented below is information on: (i) what a refugee is, (ii) a theory of refuge and stages of refuge, (iii) the refugee crisis, anthropological considerations and the cultural concept of refugee (iv) the influx of refugees to Canada and other countries, (v) threats to the well-being of refugees, (vi) why the well-being of refugees in Vancouver is important, (vii) the rationale for this research and the research questions, (viii) the anticipated contributions of this research to the field, and the (ix) the overarching theoretical framework underpinning this research. This chapter is bookended by a list of the subsequent chapters of this dissertation.   3 1.1! Defining a Refugee  The 1951 Refugee Convention is a United Nations (UN) document pertaining to refugees’ rights as well as the legal obligation of states (Fitzpatrick, 2010; UNCHR, 2016). According to the Convention, a refugee is anyone who: Owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country, (Article 1A(2), Convention relating to the Status of Refugees, 1951).    The United Nations High Commissioner on Refugees (UNHCR) and many United Nations (UN) member nations alike use this broad definition to determine refugee status (Bordignon & Moriconi, 2017). Being classified as a Convention Refugee is contingent on individuals reaching a UNHCR deployment station or a member states border in order to claim convention status. Many individuals and families who are fleeing war, however, may never have the opportunity to register with the UNHCR. As such, there are countless people living the reality of a convention refugee, such as those who are internally displaced but remain undocumented as a refugee by the UN High Commissioner on Refugees (UNHCR, 2016).   1.2! Theory of Refuge & Stages of Adaptation  According to the Kunz Kinetic Model (1973) refugees are a result of a push from their country of origin, not a pull from a resettlement country for opportunities and a new life (as is commonly mis-portrayed). In fact, Kunz, states that if faced with the choice most individuals would choose not to leave their home country. Just as populations within peaceful countries can be high functioning and successful, most refugees bring with them an educational background and years of professional work experience (Hundstorfer, 2016). The reluctant decision to flee their homes, jobs- and communities is wholly based on  4 protecting themselves and their families from the suffering imposed by their host country. Suffering may be caused by one or more of: Violent death of a parent, injury, torture towards a family member(s), witness of murder, massacre, terrorist attack(s), child-soldier activity, bombardments and shelling, detention, beatings and/or physical injury, disability inflicted by violence, sexual assault, disappearance of family members/friends, witness of parental fear and panic, famine, forcible eviction, separation and forced migration, (Burnett & Peel, 2001, p 486 in Davies & Webb, 2000, p 542).   After fleeing from the above-mentioned security threats and reaching a UNHCR post, individuals may register with the UNHCR deployment station as a convention refugee. Registration to become a convention refugee comes with its own hurdles. Firstly, one seeking refugee status must recognize that they have the right to do so. This legal entitlement may not be obvious to an individual whose host country is actively trying to keep their civilians within their borders. Secondly, there must be a UNHCR office or registry representing the High Commissioner on Refugees in their community. Often refugee status seekers must travel far distances, into neighbouring provinces or even countries, facing many life-threatening situations to reach a UNHCR office that suffices this requisite. Once the appropriate office is reached with the necessary documentation the individual is accepted into the registry and can be matched with a host country. It should be noted that each host country accepts refugees within its own established process and requirements.    Once an individual or a family’s paperwork and refugee claim are accepted by a host country the process of adaptation begins. A refugee’s adaptation during resettlement has been represented by the U-Curve model (Lysgaard, 1955). This is one of the most widely used adaptation theories in displacement discussions and research (ISS of BC, 2016; Martin & Nakayama, 2012; UNHCR, 2014; Ward, 1998). Many theories describe how people adapt to new cultural environments. The pattern of adaptation varies depending on the circumstances and the migrant, but some commonalities exist. The U-Curve Model is the most common theory of adaptation. A theory of cultural adaptation positing that migrants go through fairly  5 predictable phases—excitement/ anticipation, shock/disorientation, adjustment in adapting to a new cultural situation (Martin & Nakayama, 2012, p. 327).  Lysgaard, a sociologist, studied Norwegians in the United States. Findings revealed by his research concluded that all three of his experimental groups of Norwegians in the United States showed increased adjustment before and after the six-month mark of resettling in the States (Lysgaard, 1955). Hence the “U” shape in the culture shock model. Adjustment as a process over time seem[ed] to follow a U-shaped curve: adjustment [was] felt to be easy and successful to begin with; then follow[ed] a ‘crisis’ in which one [felt] less well-adjusted, somewhat lonely and unhappy; finally one [began] to feel better adjusted again, becoming more integrated into the foreign community (Lysgaard, 1955: p. 50).  The U-Curve model attempts to explain individuals adaptation to the host-society using the Culture Shock Curve (Lysgaard, 1955). Several studies over the decades have supported this model with populations from foreigners in the United States, (Morris, 1960); Scandinavians (Sewell & Davidsen, 1961) and Turks in the United States (Davis, 1963). Other published academic works have studied this model and adjusted it (creating and supporting their own frameworks) (Adler, 1975; Black, J. S., & Mendenhall, 1991; Brown, 1980; Chien, 2016; Gullahorn & Gullahorn, 1963; Mohamed, 1997; Oberg, 1960; Torbiörn, 1994;). In other cases, this model has been shown to have weaknesses (Anderson, 1994; Furnham and Bochner, 1986). The use of cross-sectional rather than longitudinal designs and other definitional inquiries have been the bases of inquiry (Chien, 2016). Still, its applications are high in academic and community research (Immigrant Services Society, 2016).   The Culture Shock Curve is divided into four stages. The first stage is known as the Honeymoon Period. For most, it is characterized by an initial reaction of enthusiasm, fascination, admiration, and cordial relationships. An individual can be “…enthusiastic about all of the new sights and ways of life. Things are easy and exciting” (Croucher, 2017, p. 232). Generally, individuals are grateful and are feeling  6 relief in the newfound safety of their host society. There are cases, however, where positive affect is not experienced as acutely. Individuals may be grateful for safety but find the separation from their culture and countries of origin difficult. The disappointment of not being matched with a chosen host country near their country of origin can also lead to difficulties. Many individuals prefer to stay in proximity to their country of origin until conditions are safe for return. In these cases, Canada may not be the desired match for some individuals leading to less enthusiasm (ISS, 2016; Martin & Nakayama, 2012, p. 327).    The second stage is known as Challenge and Crisis. For many individuals this stage is marked by a decrease in positive affect. Differences surface around language, cultural norms, and values between newcomers and their host country (Miller & Rasmussen, 2010). For example, there may be differences around emotional belonging and problem-solving (e.g., methods of verbally or physically greeting neighbours, the visible presence of religiosity and faith-based vernacular, and practices in how daily problems are solved). There may also be differences around social connection, family proximity, and cohesion (e.g., the social atmosphere in residential communities, gender roles inside and outside the home, and previous close-knit communities with proximal neighbours). Additionally, there may be cultural differences with expectations around finances and transportation (e.g., costs of meal preparation, the time it takes to travel a distance to purchase groceries, the financial cost of groceries, potential lack of garden space in host societies, and the distance between housing and major sites such as school and jobs). While many individuals usually overcome these situational differences with time and practice to others it may seem incompatible and invoke a desire to leave the host country. The discord can lead to emotional and psychological distress (Chien, 2016; Porter & Haslam, 2005). Many times, the burden is significant enough to lead to feelings of inadequacy, frustration, anxiety, and anger until they are resolved (Robjant, Hassan, & Katona, 2009).   The third stage, Reconstruction and Recovery, is marked by moments when the crisis may seem to be resolved as individuals become familiar with the language and culture of the host country. During this  7 stage the individual’s identities (from that of the previous and that of the new host culture) begin to integrate. Previous normative cultural practices can also inform the adoption of new practices. Learning the language can help to build social connections, cultural fluency, employment, and aid in problem-solving, thus creating more independence (Bordignon & Moriconi, 2017). Increased social connectedness can build self-esteem and promote pro-social experiences of belonging. This stage is also marked by increased familiarity with costs of living in host societies and distances to and from places of necessity such as markets, banks, and schools.   Finally, in stage four Adjustment / Adaptation newcomers begin to work in and enjoy the new culture. While there may be some instances of anxiety and strain, individuals are better able to manage these emotions (Martin & Nakayama, 2012, p. 327). The major issues of (i) belonging and problem-solving, (ii) social connectedness and cohesion, and (iii) expectations around distance and finances become reconciled. Individuals are able to appreciate the differences and similarities between their host society and previous communities they had to leave due to war or other crises.   1.3! Humanitarian & Refugee Crisis of 2014  In 2014, the UNHCR declared the Syrian displacement the worst humanitarian crisis ever faced globally. Since 2009, the Syrian civil war caused the internal and external displacement of over 14.5 million people (UNHCR, 2015). Nearly half of the Syrian population was displaced since March 2011. Of that number, more than half were under 24 years of age (UNHCR, 2015). Thousands died, 14 million people lost their homes or were internally displaced persons (IDPs), and the number of registered refugees were also in the millions (UNHCR, 2014; Verme et al., 2016). More than four million individuals fled to neighbouring countries (UNHCR 2014; UNHCR, 2015b). It is because of this particular crisis the UNHCR has taken the position on resettlement to relocate individuals close to home so they can return as soon as it is safe:  8 A durable solution is achieved when internally displaced persons no longer have any specific assistance and protection needs that are linked to their displacement and can enjoy their human rights without discrimination on account of their displacement. (Inter-Agency Standing Committee, 2010, p 5).   The UNHCR has three durable solutions to resettle refugees (ISS of BC, 2016). The first is voluntary repatriation (which allows refugees to return to their country of origin). The local integration option is one where refugees are in proximal communities (so individuals can live in dignity and peace until conditions are safe for return). The final durable solution is resettlement to a third country made possible by host countries.    The UNHCR has long understood that by developing a strong understanding of the culture, history, and anthropology of the places inflicted by war (which produce large numbers of refugees) the better they are able to support these individuals (UNHCR, 2014). This is discussed further in the upcoming section.  1.4! Anthropological Considerations  Consistent with the UNHCRs position on understanding human factors which differentiate large cohorts of refugees this section will outline the anthropological considerations of the newcomers who arrived under Operation Syrian Refugee. The UNHCR has published several reports on the anthropological features of this population during the refugee crisis (UNHCR, 2014; 2015a; 2015b). This includes information on cultural, historical, gendered, and faith-based orientations of the Syrian peoples. This attention to the nuances of this culture immediately helps to personify the other and helps to create bridges of understanding between refugees and their host societies.   The war conditions in Syria following the Arab Spring of 2009 threatened the decade-old Assad regime, who inherited his position from his father after the death of his older brother. The Arab Spring caused an uprising of several rebel groups who were, until recently, marginalized for holding extremist  9 views. A detailed account of these political events is beyond the scope of this paper. However, a brief review is necessary to lay the foundations for the present discussion (Henderson, & Knight, 2012). Rebel groups were abetted when they were sold arms by the United States perpetuating violence in Syria over the course of the civil war. Andrew Pierre an American foreign affairs author, in his book Global Politics of Arms Sales, writes, “The US sold arms…to many critics, th[is] arms sales policy…had gone out of control. Indeed it often seemed as if there was no coherent arms transfer policy at all (Pierre, 2014, p. 46). The American Antiterrorism and Effective Death Penalty Act of 1996 states that “This act requires the [American] President to withhold aid to… countries that provide assistance (Section 325) or lethal military equipment (Section 326) to countries… but allows the [American] President to waive this provision on grounds of national interest”, (p. 15). According to this Act (1996), the US’s continued arms sales to Syrian rebels despite the ongoing civil war and refugee crisis is acceptable due to the American government’s national interests.   The result of this external national interest in Syria (mentioned above) has several ramifications to Syrian refugees’ well-being. The widespread destruction of historic cities and architecture, institutions of schools, faith-based institutions, and the scarring of a generation born in war has left them with tattered traces of their identity. The death of mothers, fathers, and children is traumatizing to the psychological well-being of the survivors. Further, many children born in war become accustomed to the sounds of explosions, buildings collapsing, blood-curdling screams, and gunshots all of which are a constant backdrop in a life of war. Friends and family going missing and waiting to see who survived the night become the norm. Physical and psychological wounds, running from site to site seeking shelter, and lack of food and clean water are all common experiences of war life. Since many of us in North America are distanced from war, we can become instantly intimated with such experiences when asylum seekers and refugees are resettled in our communities. While the traumas posed to an individual seeking refuge from their country of provenance aggregates every day they do have traditional sources of help that originate from their historical geography, culture, and religious beliefs.   10   Narratives about migration to safety and peace have significant cultural and traditional roots in the Middle East stemming from the dominant Abrahamic faith groups in the area: Judaism, Christianity, and Islam. Stories of the migration of prophets such as Abraham, Moses, Jesus, and Mohammed are used as examples for making life-decisions and establishing ways of life (UNHCR, 2012). This migration came to symbolize the movement of people from lands of oppression to those of peace and submission to God’s will (UNHCR, 2012). The journeys and experiences of the prophets and leaders are used as examples for natives residing in the traditional lands where these stories are believed to have taken place.    Migration for the purpose of saving lives and preserving families in search of peace and submission to the will of God holds traditional meanings to those aligned with Abrahamic Faiths. Thus, leaning on the examples of their religious leaders who dealt with displacement and conflict can give guidance and solace to refugees seeking help. In this way, migration for well-being is part of the fabric of tradition, culture, and identity of people in the middle east and is key to understanding the dominant culture of this population.   The formal Islamic migration law of Syria and outlying areas is also an essential component to understanding the context of the Syrian refugee crisis since that is the dominant framework practiced there. The law secures any individual’s (Muslim and non-Muslim’s rights) to seek and be granted asylum in any Islamic state. According to this law, it is the duty of Muslim countries to accept and protect any refugee for as long as they seek protection. In the source of Sharia Law, the Qur’an, there are several references to justice and upholding the rights of the poor and needy through safeguards such as zakat (the mandatory annual donation to charity of 2.5% of accumulated wealth).    According to the UNCHR (2012), the Qur’an provides (i) instructions for refugees and migrant situations, (ii) praises those who assist others in distress, (iii) requires the faithful to protect refugees  11 (Surah 9: 100 and 117), (iv) qualifies refugees and internally displaced persons to rights and to humane treatment (Surah 8: 72-75, 16: 41), (v) condemns people whose actions prompt mass migration, viewing them as lacking faith in God’s words (2: 84-86), and (vi) outlines methods of additional support to those considered more vulnerable women, children and the elderly (4: 2, 9, 36, 75, 98, 127, 17: 34), (UNCHR, 2012, p. 2). Despite these traditional roots, this is in stark contrast to the reception of Syrian refugees in parts of the Arab world today.    The lack of acceptance of Syrian refugees in several Islamic Gulf states causes confusion as millions of refugees suffer across international borders (Bordignon & Moriconi, 2017). Very wealthy Gulf countries have the least accepting refugee policies. The disregard of asylum guides by Gulf countries, that guarantee refugee rights and upon which the refugees rely, can be traumatizing and cause feelings of abandonment for refugees. Three poorer nation states (Lebanon, Turkey, and Jordan) in the region have accepted millions of Syrian refugees while wealthier countries have a no-refugee stance that contradicts their faith-based declaration, thus, leaving many Syrian refugees feeling abandoned and unwanted in certain Gulf nations in the Arab world. A discussion of Syrian refugees’ asylum in neighbouring countries follows.  1.5!  Migration to Neighbouring Countries & Canada  Among Syria’s three neighbouring countries receiving the majority of Syrian refugees, the processing and living arrangements of refugees vary widely. Lebanon, Turkey, and Jordan have processed nearly 3 million Syrian refugees combined (Samari, 2015). In Lebanon, the asylum process is highly integrative (Refaat & Mohanna, 2013). Of the nearly three-thousand refugees entering Lebanon daily, and the total 1,176,971 arrived by 2015 (which is over one-quarter of the Lebanon population), almost none live in camps (Coutts, Fouad, & Batniji, 2013). In Turkey, there are twenty-two government-run camps across ten provinces sheltering nearly 1 million refugees with another 300,000 living in urban areas  12 outside of camps (Ozden, 2013). Turkey is taking a lead role in the refugee situation, spending $3.5 billion internally, since refusing interference from outside sources such as the UNCHR (UNCHR, 2014; Ozden, 2013). In Jordan, over three quarters of nearly 1 million Syrian refugees live in host communities. The Za’atari camp hosts over 120,000 refugees making it one of Jordan’s most populated cities (Murshidi, Hijjawi, Jeriesat, & Eltom, 2013). Contrastingly, countries with soaring growth domestic products (GDPs) such as Qatar, UAE, and Saudi Arabia have taken in a total of zero Syrian refugees and continue to hold a no-refugee stance, causing Syrian Refugees to feel unwanted by a large Arab population in the Middle East. This is in contradiction of the countries’ faith which requires open reception to refugees in Islamic states, as mentioned above (UNHCR, 2012).    While a few neighbouring countries have hosted the majority of people (over 4 million) who have been displaced since the beginning of the Syrian civil war, it was not until 2015 that Canada took visible action in the Syrian resettlement. Under the Trudeau government, the Immigration, Refugee and Citizenship Canada (IRCC) Minister Hon. John McCallum announced the admission of 25,000 refugees over the course of 4 months, from November 4, 2015 to February 28, 2016. By the end of March 2016, over 27,000 refugee applications were processed (LPC, 2016). Among these were nuclear and extended family units that fled Syria due to political persecution, conflict, generalized violence, or human rights violations stemming from the Arab Spring civil war.    In Canada under the humanitarian immigration stream, there are 4 refugee-related streams including the government resettlement scheme for government assisted refugees (GARs). GARs are invited to resettle to Canada under permanent residence status and provided up to 12 months of income support. With permanent residence, GARS are eligible for all federally funded language, employment and settlement supports (ISS of BC, 2016).   13  The large-scale displacement of Syrians presents a unique opportunity to explore well-being as a dynamic and complex structure in the face of novel stressors faced in communities in Canada. Currently, approximately 5.4 million Canadians, or 18.4% of the total population, were born outside of the country. Enriching this demographic picture, a large proportion of recent arrivals (within the last ten years) come from “non-traditional” European source countries (Kirmayer et al., 2011). Before 1960, over 90% of immigrants to Canada came from Europe, whereas 58% of the 1.8 million of those who arrived between 1990 and 2001 have come from Asia, the Middle East, and Africa. However, the health and well-being policies and funding budgets may not have adapted to reflect that size and speed of recent wave of refugee admittances. During refugee crises, governments and organizations use history to inform decisions around policy.    The assertion in this dissertation is that by investigating mental health services available during the 2015/2016 resettlement this study may become a part of the literature needed to inform policy and service recommendations and would also help settlement organizations plan for future resettlements. Due to the rapid arrival of this newcomer population it is crucial to ensure their successful integration and well-being as they adjust to Canadian communities. Focusing on well-being is crucial as research reveals high rates of mental distress developing into depression, anxieties, and possible post-traumatic symptoms if untreated in host communities (Fazel, Wheeler, & Danesh, 2005; Lie, 2002; Mollica, 2011; Roth, Ekblad, & Agren, 2006; Samari, 2015; UNHCR, 2015). The importance of refugee well-being is discussed further in the following section.  1.6! The Importance of Well-Being of Refugees in Vancouver: A Roadmap to Integration and Citizenship Study   The Immigrant Services Society of BC (ISS of BC) is the main resettlement hub in Vancouver. It oversaw or subcontracted the settlement of every single refugee that arrived in Vancouver and British  14 Columbia. With unprecedented levels of arrivals over 2015 and 2016, the ISS of BC undertook a study to systematically probe into their settlement experiences and outcomes. The study was conducted under two separate consultation initiatives. Over three hundred telephone interviews were held with head of households who arrived during November 4, 2015 and February 28, 2016. Sixty youth were also included in this study. A major finding of this study was that 30% of this group were dealing with mental distress (16% depression and 14% sadness). These findings offer important and valuable insights into newcomer well-being.   The study however, did not further examine the reasons why distress statistics were at 30% or for how long. The study also did not examine further the factors that lead to one-third of individuals experiencing mental distress. Similarly, while it could also be beyond the study’s goals it did not examine any factors that could be improved in order to help shrink the high number of individuals experiencing distress. As such, the ISS of BC findings have inspired the undertaking of the present study to investigate deeper into the nuances that produced this statistic of 30% of newcomers experiencing mental distress.    It is in the best interest of Vancouverites and our new neighbors to investigate the causal factors of mental distress amongst GARs and to generate their potential solutions. Hence the research position to investigate the mental health services provided (if any) and what the gaps were in order to improve those services. Then using those findings to produce policy recommendations that could help improve newcomer well-being in Vancouver.  1.7! Rationale and Research Questions  Doctors Without Borders (2016) reports that refugees cross dangerous foot, train, and boat routes due to the lack of safe routes. Every day, over 5,000 adults are displaced with a vast number growing up and spending their entire adult lives in refugee camps (UNHCR, 2014). The longer individuals spend in  15 temporary settlements or refugee camps, the harder it is to recover to pre-trauma and pre-displacement levels of well-being (Fazel, Wheeler, & Danesh, 2005). Similarly, the greater time spent in refugee camps awaiting decisions about placement poses a greater risk for mental health concerns (Fazel, Reed, Panter-Brick, & Stein, 2012; Wilkinson, 2002). This is critical as every day nearly 3,000 families are displaced with a vast number growing up and spending their entire family lives in refugee camps (UNHCR, 2014). Repeated displacements have been a striking feature of the Syrian conflict as front lines keep shifting and former safe zones become embroiled in conflict (Hassan, et al, 2016).    Both internally and externally displaced Syrians have suffered significant war crimes, rights violations, and abuses (Samari, 2015). These violations of international law and basic human rights include individual and mass executions, torture, hostage-taking, disappearance, rape and sexual violence, as well as recruiting and using children in hostile situations (Hassan, et al., 2016). Increased levels of poverty, loss of livelihood, soaring unemployment and limited access to food, water, sanitation, housing, healthcare, and education have had devastating impacts on the population putting them at further risk of multiple forms of exploitation and forcing them to leave their country (Norwegian Refugee Council, 2014; UNHCR, 2014) (see Impact of Syria Crisis Report, 2014; Syrian Centre for Policy Research , 2014). The unique resilience factors that accompany refugee cohorts, such as peer support and a sense of community may assist in helping them survive and partially prevent exacerbation of psychosocial concerns throughout the migration process (Daud, af Klinteberg, & Rydelius, 2008). Researchers increasingly hold the viewpoint that it is important to view refugees’ experiences through a lens of resilience and hope for recovery (Masten, 2012) because focusing on risk alone paints an incomplete picture of refugee experiences (Pieloch, 2016). Thus, considering the potential for traumatic experiences of each individual GAR multiplied by that of the entire cohort it is unsurprising that the ISS of BC found that 30% of GARs were afflicted with mental distress (ISS of BC, 2016, p 16).   16  Based on the risks to psychological well-being faced by refugees cited above, the literature is ripe with examples of the trauma and psychological distress accompanying displacement. What is unknown is how resettlement sites, specifically in Vancouver, helped newcomers manage and cope with their mental and psychological distresses during resettlement. There is also an absence of research in the literature on how this wave of refugees’ mental health was supported to recover their well-being during resettlement.    It is critical to understand how the mental health of refugees is supported as they enter host societies since their level of well-being is directly linked to the pace and success of assimilation. (O’Toole, Corcoran, & Todd, 2015; Fozdar & Torezani, 2008; Thomas & Lu, 2001). With 30% of newcomers reporting low well-being it is essential to advise mental health and psychosocial support staff (e.g., psychiatrists, and social workers), non-specialized healthcare staff (e.g., general physicians, midwives, and nurses) and policymakers on issues related to mental health. Since the successful implementation of well-being support for refugees branches into three major categories, it is essential that each branch is well informed and congruent on the refugee experiences, potential traumas, and sources for help. To reach this level of informed practice and congruencies, we must first recognize what is available currently in Vancouver, what can be improved upon and what is needed in psychosocial well-being resources for newcomers in Vancouver (Hassan et al., 2016; Ventevogel et al., 2015). The research answering these questions is both crucial for refugees as well as Canadians and currently deficient on a local and federal scale.    The benefits of supporting well-being for newly landed populations range from helping them with integration to removing emotions of isolation and loneliness. However, less perceptible advantages are those to the host-communities like Vancouver. By having accessible resources for refugees to be able to get help with adjusting to Canadian perspectives and social conventions there is less feeling of “us and them” on both sides (newcomer and host community). Both sides feel less threatened by the others’ foreign way of life and usually conclude that each population is more alike than dissimilar.  17 Commonalities quickly become apparent since many Canadians and the refugees allowed entrance into Canada are both high functioning, educated, or employed professionals. A refugee with higher degrees of well-being will also integrate into Canadian society smoothly and quickly than their “depressed” counterparts which lead to faster financial independence thus, weaning refugees off tax-payer supported resources faster.    A recent study by the National Bureau of Economic Research in the United States conducted by, William Evans and Daniel Fitzgerald (2017), shows that refugees have a positive effect on the host country’s economy in the long-term. The study reveals that while refugees initially draw on publicly funded resources to help their integration, they end up contributing more economically in the long-term than they used in the short term (Evans & Fitzgerald, 2017). Evan and Fitzgerald calculated that the U.S. spends a mean total of $15,148 USD in relocation and $92,217 USD in social benefit costs across an adult refugee’s initial two decades in the United States. On the contrary, over the same span of time the average refugee adult pays $128,689 USD in taxes. The difference between financial resources contributed and consumed by a refugee is a total of $21,324 USD. This research depicts how a well-adjusted refugee can prove to be a lucrative investment for host countries and how providing mental health resources and aid not only benefits the newcomer but also the entire host nation.    While the above-mentioned research shows the benefits of mentally healthy refugees to host communities there is also research that shows untreated psychological traumas and distresses can lead to prolonged and long-term mental health illnesses that hinder their successful integration. (e.g., post-traumatic stress disorder, anxiety, nightmares, insomnia, phono phobia, exaggerated fear responses) (Fazel, Wheeler, & Danesh, 2005; Lie, 2002; Mollica, 2011; Roth, Ekblad, & Agren, 2006). There is also evidence to suggest that the treatment of these psychological traumas and distresses (and their consequences) can be improved with mental health services (Bogic, Njoku, & Priebe, 2015; Hebebrand et  18 al., 2016; Lincoln et al., 2016; Shannon et al. 2015; Slobodin & de Jong, 2015). However, given the gap in the literature on how mental health of this particular arrival of refugees was supported in Vancouver this study sought to investigate: (1)! What formal and informal mental health services were offered to support government-assisted refugees (GAR) men and women, and families during their first year in Vancouver?  (2)! What gaps were present in formal and informal mental health services offered to government-assisted refugees (GAR) women, men, and families during their first year in Vancouver?  (3)!  What policy recommendations can be made to three levels of government to help improve government-assisted refugees (GAR) mental well-being?  1.8!  Contribution  This research aims to generate and contribute new knowledge by combining well-being discourse around mental health services in host sites in order to construct a better understanding of services available during Operation Syrian Refugee. Accomplishing this aim requires the critical understanding of how mental health and well-being was promoted during the settlement process. Researching refugee well-being requires interdisciplinary and diplomatic approaches and is essential to ensure post-migration psychological well-being (Fozdar & Torezani, 2008). An interdisciplinary research team at the University of British Columbia announced, “refugees entering Canada represent a potentially vulnerable and understudied group” and that collectively we know little about newcomer determinants of health and well-being (HELP, 2016, p 2). The lack of knowledge of refugee well-being sources is highlighted by a professor of political science who argued “Despite tens of millions of refugees in this century, refugee research is sporadic, unsystematic, isolated, and cursory” (Stein, 1980, p. 6). Stein also calls for more substantial research exploring refugee family well-being is needed:  19 Although the refugee problem has existed for a long time and has created great suffering for refugees and major difficulties for those who have tried to assist refugees, there has been little refugee research--research which might relieve the suffering of the refugees and assist those who try to aid the refugees, (Stein, 1986, p. 6).   Informed by Stein’s observations this research aims to contribute new knowledge that is critical to demystify experiences, within a mental health landscape, for refugees in Vancouver. The necessity of the research is not only in the generated data but also in its timing. Considering the current crisis where millions of refugees are being displaced from their countries, change makers urgently need relevant and comprehensive information. The earlier policymakers and people of influence receive the data the faster they can make changes in mental health services to refugees. The need for immediate current data on the well-being of newcomers during resettlement is further highlighted with persistent academic searches yielding minimal results. Among the research that has been conducted their outcomes are rarely investigated; thus, this study will seek to decrease that gap by investigating the outcome of the ISS of BC study (2016) with the intent of contributing to improved policies circling refugee mental health.    First, this research will be used to better understand what mental health services were available to GARs during the most recent refugee movement to Canada in order to address the ISS of BC (2016) finding that 30% of GARs are self-reporting as sad or depressed. It is important to evaluate what mental health and well-being services were available to GARs. It is equally pertinent to evaluate what aspects or factors of these processes did not contribute to the well-being of newcomers. This information will catalyze and inform new mental health services and programming in Vancouver. Second, this study can offer information about what mental health services key informants consider useful for newcomer populations’ during their first year of resettlement (key informants are experts in refugee settlement in Vancouver and had first-hand experience with the 2015/6 arrivals see Chapter 3) Third, this study can offer an integration of findings into federal policy recommendations for health and well-being for GARs. These recommendations can help with planning, budgeting, program implementation, and increased  20 awareness of mental health concerns for refugees in Vancouver. Consequently, more mental health-focused services can offer ways to enhance well-being for GARs resulting in potential ripple effects on how they integrate into Vancouver and the broader community. Finally, information from this study can also inform local grassroots movements with mental health professionals in areas with high refugee populations as well as humanitarian agencies.    Overall, this research aims to generate new knowledge about Vancouver refugee mental health and contribute potential options for improving mental health policies for GARs. The following section will outline the theoretical framework for this research.  1.9! Theoretical Framework and Methodology  The interdisciplinary theoretical frameworks informing this dissertation integrate well-being theory (Seligman, 2012) and design theory (Helsinki Design Lab, 2013; Simon, 1969). They include Martin Seligman’s (2012) well-being framework incorporating the PERMA model and design theory model derived from Herbert Simon’s (1969) interdisciplinary framework which emphasizes solutions-focused problem-solving.   Informed by this interdisciplinary theoretical framework, this research is qualitative in nature and hosts frequency computational analysis to enhance the qualitative data. It will explore key informants’ knowledge of GAR mental health services in Vancouver. The term explore suggests a constructivist study, seeking to gain understanding (Schensul & LeCompte, 2013) and offer potential solutions. The two main activities in this research include inviting key informants to complete the service journey map for GARs’ mental health services (Kimbell, 2014) and conducting interviews with the key informants to develop an understanding of GAR mental health services from key informant experiences (Elliott & Timulak, 2005; Braun & Clarke, 2006). The service journey maps are a visual aid that allows for deeper  21 understanding of services. This method can help to identify service gaps and issues in order to suggest and develop improvements and solutions using pain points. Pain points are troublesome aspects of a service that can cause inconveniences, disruptions, or challenges in delivering a service. By identifying pain points this can be a way to create improvements in the services. This method lends itself to producing rich qualitative data. The second data collection method is qualitative interviewing. Interviewing will allow for increased lucidity of the information provided on the service journey maps and provide richness to data collected in order to develop qualitative data themes (Elliott & Timulak, 2005; Braun & Clarke, 2006). By combining service journey maps and interviewing, this dissertation will provide qualitative findings combined with frequency computational analysis. Some guiding assumptions of this dissertation include: 1.! Well-being can be improved  2.! Formal and informal mental health services can improve well-being 3.! Identifying gaps can help to inform solutions 4.! Interdisciplinary research may provide a broader view of the issue 5.! A qualitative study with frequency computational analysis components may lead to deeper insights that will contribute to the existing literature.    1.10! Dissertation Chapters The dissertation is organized into the following chapters:  Chapter 1: Introduces the problem and the research questions associated with key informant interviews to understand formal and informal mental health services available to GARs in Vancouver during their first year of arrival. Chapter 2: Provides a literature review of the most influential well-being theories interfaced with displacement and strategic design theory. Chapter 3: Outlines the study methodology involving key informant interviews and service journey map.  22 Chapter 4: Provides qualitative findings accompanied by frequency computational analysis from the key informant interviews and service journey maps. Chapter 5: Offers policy recommendations for the Federal Settlement Plan (FSP). Chapter 6: Offers a critique of concepts used in this dissertation (e.g., PERMA and Service journey map) and a researcher reflection. Chapter 7: Provides a summary and concluding remarks with an outline of directions for future research as well as implications, and contributions of the study.   This chapter included information on: (i) the definition of a refugee as described by the UNHCR (ii) a theory of refuge and stages of refuge, (iii) the refugee crisis, anthropological considerations and the cultural concept of refuge (iv) influx of refugees to Canada and other countries, (v) threats to well-being of refugees, (vi) why well-being of refugees in Vancouver is important, (vii) the rationale for this research and the research questions, (viii) the anticipated contributions of this research to the field, the (ix) the theoretical framework underpinning this research, and (x) the outline of chapters in this dissertation. The following chapter includes a literature review which lays out relevant background information to this study.   23 Chapter 2:!Relevant Literature The dissertation addresses the issue that one-third of refugees arriving in Vancouver who participated in the ISS of BC (2016) study reported low well-being. In order to address this research gap, the literature reviewed in this chapter includes a broad well-being corpus that discusses well-being and human experience during displacement. This chapter provides information on: (i) the well-being literature and provides a summary of the history of well-being theory, (ii) the well-being framework used in this dissertation, (iii) risks to well-being for refugees presented in the PERMA framework including why well-being needs to be a focus in host societies, (iv) informal and formal mental health services, and (v) strategic design theory. This chapter also provides the theoretical frameworks for the research methodology and findings outlined in Chapters 3 and 4 respectively.  2.1! Well-being Literature  Well-being has been discussed since antiquity (Fletcher, 2015; Henderson & Knight, 2012). In ancient Greece, pre-Socratic philosopher Democritus (460- 370 BCE), mentioned eudaimonia in his treatise On Happiness. To him, well-being (eu-esto) and authenticity (daimon), lead to well-being (peace and lack of worry), also known as epicureanism; defined, by the Athenian philosopher Epicurus, as a special state of well-being without passion, achieved through practicing philosophy (Deiner, 2009; Delle Fave, Massimini, & Bassi, 2011). To Epicurus, well-being came from spiritual development through wisdom and inner peace which could be honed through nurturing friendships and gaining knowledge (Waterman, 2008). Socrates (470- 399 BCE) in the Republic was portrayed to believe that well-being was the pursuit of all people while learning about the self by engaging in discussion and dialogue (Delle Fave, Massimini & Bassi, 2011). Further, Socrates proposed that living in well-being was to live with both pleasure and discomfort, making it a virtuous activity (Fletcher, 2015; Reeve, 2004). In his Nicomachean Ethics, Aristotle (384-322 BCE) similarly suggested that happiness or well-being was the pursuit of all  24 humans. However, happiness and well-being, to Aristotle, could emerge only upon living a life of contemplation and developing high-level ethical standards to live by.    In the West, a shift in thinking about well-being occurred in the middle ages during the time of St. Augustine (354-430). To the Christians of this time, suffering became a gateway to happiness and well-being. Christianity also supported overcoming worldly desires to ensure union with the Divine after death. The enlightenment era, however, brought with it alternative notions about well-being such as the right to well-being and freedom to have well-being, since well-being was no longer considered to be at the mercy of the Divine. This sparked research and inquisition into the area of well-being in psychology through medicine and by the twentieth century, years of western research has developed strong theories of well-being and caused it to become a popular topic in psychology (Lyubomirsky & Lepper, 1999). However, it was only until the last four decades that psychology research took a pause from exploring the absence of well-being. Until this, pathology and negative states research were published seventeen times more frequently than positive research on well-being (Deiner, Suh, Lucas & Smith, 1999).   In 1946, the definition of well-being was altered, yet again, by the World Health Organization (WHO, 1997). The amended WHO’s, Constitution of Health, suggests that health is the absence of mental illness alongside the well-being of individuals (WHO, 1997). The shift to positive outlooks of well-being was followed by the arrival of the Humanist theorists. For example, Maslow and Rogers suggested self-actualization through challenging work and goal achievement to answer the meaning of life and other existential questions. Modern positive psychologists describe well-being as being a component of two common factors: (1) hedonism, pleasure-seeking and satisfying the psychoanalytic pleasure-seeking segment of the ego called the id (Henderson & Knight, 2012). Second, eudaimonia, the idea that well-being lies beyond physical or immediate gratification.    25  By the second half of the twentieth century a large body of research studies including theories of well-being emerged. Ryff, a prominent psychologist, studied psychological well-being in three hundred and twenty-one men and women, divided by age (young, middle-aged, and older adults) (Ryff, 1989; 1995). The self-report measures from her study supported her six-factor psychological well-being model: autonomy, environmental mastery, personal growth, positive relations, purpose in life, and self-acceptance. Ryan and Deci’s (2000) study of Self-Determination Theory (SDT) point to three innate psychological needs: competence, autonomy, and relatedness, which when met, are proposed to enhance well-being. Deiner and Deiner (2006) delineate the well-being of sixty-seven homeless men and women in their study using the Satisfaction with Life Scale which uses self-assessments to rate life: conditions, satisfaction, important aspects, and aspects to improve.   In the 1980s, Martin Seligman, at the University of Pennsylvania began to explore positive psychology. Seligman’s departure from the traditional study of psychology was characterized by focusing on what works well in a thriving individual’s life. This was a shift from the traditional medical-model method of psychology commonly referred to as being deficit-driven, practiced by Sigmund Freud, the Behaviourists, and the Cognitivists (Bretherton, 2006; Seligman 2000). Seligman’s aim was to discover the factors contribute to fostering psychological well-being and happiness (Huppert & So, 2013). Seligman, (2012) used positive psychology to focus on operationalizing components of mental health. He has taken his research to schools, workplaces, and the military to apply his research on practices of: gratitude, cognitive re-framing and shifts towards positive thinking.    The addition of Seligman’s theory to the psychology literature launched a shift in psychological practice and the encouragement of several spiritual and religiously inclined topics for research on happiness such as gratitude, hope, and optimism (Aspinwall & Staudinger, 2003; Linley & Joseph, 2004; Peterson & Seligman, 2004). In doing so, he arrived at five core principles, which lead to increased mental health, which he termed PERMA an acronym for positive emotions, engagement, relationships,  26 meaning and achievement. Decades of his studies were amalgamated in his book, Flourish (2012) which focuses on well-being as relayed in the PERMA model.    In this way, Seligman’s body of research in PERMA has re-opened an entrance for culturally diverse beliefs to merge with positive psychology to explain mental health and well-being. Due to this well-being theory encompassing cultural diversity and interdisciplinary thinking, PERMA is theoretically supportive of interdisciplinary research. Thus, this research operationalizes PERMA as a representative model for well-being in order to support the research goals of this study and is discussed further in the upcoming section.  2.2! Well-being Framework  This section discusses the PERMA well-being theory as it relates to refugee experiences and its suitability within this research.  2.2.1! PERMA: Positive Emotions.  As mentioned above the P in the PERMA model stands for positive emotions. Positive emotions are defined by first differentiating between Aristotelian concepts of hedonistic pleasure and eudaimonic enjoyment (Seligman, 2011). The model states that pleasure of the senses is synonymous with hedonism. Where pleasure is sought to satiate tactile, sensuous, or physical appetite pleasure which relate to immediate gratification and do not lead to long-term happiness (Forgeard & Seligman, 2012). Contrastingly, long-term eudaimonic enjoyment can be achieved through intellectual stimulation and creativity that require applied effort and concentration to achieve a goal. Accordingly, eudaimonic enjoyment can lead to longer-term happiness because the positive emotional effects far outlast the effects of hedonistic pleasure.    27  It is well known that positive emotions can “engender successful outcomes, as well as behaviours that parallel success” (Khaw & Kern, 2014, p 12). Within positive psychology, one well-researched example of a positive emotion is optimism (Forgeard & Seligman, 2012; Seligman, 1990, 2006). First, there is dispositional optimism. This is characterized by consistent behaviours that increase a positive outlook (Schueller & Parks, 2006). Next, there is optimistic explanatory style. This is defined as “the manner in which you habitually explain to yourself why events happen” that is the self-talk that explains events (Seligman, 2006, p. 15).    Optimism is commonly described by several English idioms such as: looking on the bright side, finding the silver lining or tomorrow is another day. These idioms capture the general sense of a person who is able to identify the positives in a situation or looks forward to better outcomes. However, researchers aiming to decipher the markers and protective factors of optimism must find ways to operationalize optimism (Forgeard & Seligman, 2012; Seligman, 1990, 2006). This operationalization will allow researchers to more accurately group, correlate and attribute research results to specific components of well-being (Seligman, 2011, 2012; Seligman & Csikszentmihalyi, 2000; Seligman et al., 2009).   One emotion optimism helps to avoid is helplessness. Helplessness is like despair, a fear-based response activated when individuals feel like they have a decreased sense of control (Seligman, 2006, p. 15). This is important in the refugee experience since refugees are marked by their resilience and hope of surviving dangerous journeys to reach safety. Along with emotions, the refugee experience is marked by mental concentration or engagement which is covered in the next sub-section.   28 2.2.2! PERMA: Engagement.   In PERMA, the E is for engagement. It is defined as the moments where individuals experience extreme concentration or flow. This is described by occasions when people are engaged in an activity and time is experienced as though it is paused (Schueller, & Parks, 2006; Seligman & Csikszentmihalyi, 2000). For many, this may be felt in activities such as reading, art, building, and in those pursuits from which it is hard to be pulled away. Flow is described to require concentration and effort that stretches intellectual, emotional endurance, and survival (Seligman & Csikszentmihalyi, 2000).   Engagement in enjoyable and challenging activities increases people’s proclivities towards increased persistence and searching deeper for creative solutions to challenges. This search for creative solutions to problems have parallels in the refugee experience. When one tool or item must serve multiple purposes or when danger is around the corner and a new route must be sought.    During times of strife, there is an elevated level of concentration and creative thinking that is required to survive life-threatening situations. Along with engagement or concentration, relationships are also important in the refugee experience and are discussed in the next sub-section.  2.2.3! PERMA: Relationships.  Studies show that intimate and supportive relationships are linked to many positive constructs such as happiness, pro-sociality, success, achievement, better emotional health, and psychological well-being (Hawkley & Cacioppo, 2010; Perissinotto, Cenzer, & Covinsky, 2012). A major finding is also that “People supported by close friendships, family, and support groups have higher well-being, and are found to be less vulnerable to sickness and premature death, while loneliness has been found to be an important risk factor for poor health outcomes and functional decline” (Khaw & Kern, 2014, p 11). Relationships are beneficial because “one important function of social networks, is that they can spread happiness, cheer  29 and laughter like wildfire” (Go Strengths, 2015, p. 13). This is important for problem-solving measures, garnering support, sharing ideas, and belonging for individuals (Seligman, & Csikszentmihalyi, 2000).     During the refugee experience, many children and parents were separated due to the numbers of individuals allowed in immediate departures for underground border crossings. People were packed into crates, hidden in fruit trucks, while others hid beneath moving trucks across far distances (Fazel et al., 2005). These immediate departure experiences may not allow parents and children the same routes to safety. In other cases, adults travel with others’ children acting as the children’s temporary protector or guardian. The importance of relationships can be the motivation for someone to keep fighting, to keep walking, and to survive in order to arrive at their host country for hopes of reunification with loved ones. The threats to purpose and meaning for refugees is explored further in the next section.  2.2.4! PERMA: Meaning.   The M in PERMA stands for meaning. Meaning as explained by the PERMA model refers to connection or devotion to a purpose larger than the self (Khaw & Kern, 2014; Seligman, 2012). Seligman’s body of research out of the University of Pennsylvania suggests that meaning can also be described as creating a guiding framework to explain the world or the purpose of one’s life. Some purposes may include “loving”, where one can be loved and one can give love. Religion, spirituality, and volunteerism are also mechanisms within which individuals can find deeper meaning in life, according to Seligman (2011). Through attaching to a larger idea than themselves, individuals can confer meaning to their daily activities (Baumeister, et al., 2013).    Meaning-making activities like volunteering at a shelter or place of worship help to dedicate oneself with passion and action. These activities help to encourage the manifestation of meaningful action  30 towards something greater than the self. In the refugee experience this could be committing the self to the right to safety. Meaning is followed by achievement in the PERMA model.  2.2.5! PERMA: Achievement.  To Seligman, setting attainable and explicit goals daily helps individuals identify clear achievable outcomes and gives individuals something to accomplish and to be proud of each day (Seligman, 2012; Seligman, & Csikszentmihalyi, 2000). By making a goal, individuals are inherently saying that they are making an effort to achieve something (such as survival) and more effort leads to more satisfaction (if they could survive one day, then they could survive another). The more satisfaction individuals possess, the more they can use their self-beliefs to foster self-esteem, empathy, planning, and optimism (Seligman, 2012). Having daily, weekly and more long-term goals encourage effort, diligence, discipline, patience and gratitude in individuals (Duckworth, Steen, & Seligman, 2005). Discipline, sacrifice, and patience are not unfamiliar to the resilient and survival experiences of refugees. Surviving another day of the escape, waking up alive the next morning and keeping families together are survival goals for individuals who must flee in the middle of the night.    The PERMA model, as can be seen by the breakdown of each of each of its factors, has the capacity to be applied flexibly to diverse human experiences. Thus, making it a preferred well-being model to understand the well-being of refugees. This model is used to describe how well-being is understood in this dissertation. The following section discusses threats to well-being for refugees using the PERMA framework. It reviews the empirical research base from the past 40 years on well-being among refugee youth to highlight the field’s current understanding of well-being among people who are forcefully displaced.   31 2.3! Understanding Refugee Experiences and Risks to Well-being with PERMA   The following section will use the PERMA framework to contextualize on refugee experiences and risks to well-being. The sub-sections include: (i) emotions (positive emotions), (ii) engagement, (iii) relationships, (iv) meaning, and (v) achievement in order to discuss experiences of seeking refuge which can impede well-being.   2.3.1! Emotions The twenty-first century has been called an urgent time for well-being policy for GARs; it has been named one of the most pressing challenges by Canadian primary health care policymakers and practitioners (Kirmayer, 2011). Central issues in armed conflict settings are loss and grief, whether for missing or deceased family members or for other emotional, relational, and material losses (Carlson, & Rosser-Hogan, 1994). For Sudanese refugee women, well-being decreases when they are unable to communicate with health professionals. This is worsened when dependents’ health is involved (Simich, 2009; Zanchetta at al., 2012). The largest psychiatric hospital in Lebanon has seen an increase in admissions of Syrians over the past few years, with severe psychopathology and suicidal tendencies. The International Medical Corps has treated more than 6000 people in their centers in the region, of whom almost 700 were diagnosed with psychotic disorders (Hijazi & Weissbecker, 2015).   Feelings of estrangement, yearning for the lost homeland and loss of identity run high as displaced Syrians struggle to adapt to life as refugees within a foreign country (Care Jordan, 2013; Moussa, 2014). As can be expected on the basis of fear of persecution by one’s home country elevated rates of post-traumatic stress disorder (PTSD) in refugees have been documented (Teodorescu et al., 2012). Psychological and social distress among refugees from Syria and people who are forcefully displaced in Syria manifests in a wide range of emotional, cognitive, physical, and behavioural and social problems (De Jong et al. 2003; Mollica et al. 2004; Momartin et al. 2004; Pérez-Sales, 2012; El Masri et  32 al. 2013; IMC and JHAD, 2013; IRC, 2013; IMC and UNICEF, 2014; Vukcevic et al. 2014; Wells, 2014a, b). Emotional manifestations include sadness, grief, fear, frustration, anxiety, anger, and despair.   Cognitive manifestations include loss of control, helplessness, worry, ruminating, boredom, and hopelessness as well as physical symptoms such as fatigue, problems sleeping, loss of appetite and medically unexplained physical complaints. As with other populations affected by collective violence and displacement, the most prevalent and clinically significant problems among Syrians are symptoms of emotional distress related to depression, prolonged grief disorder, post-traumatic stress disorder, and various forms of anxiety disorders (De Jong et al. 2003; Mollica et al. 2004; Momartin et al. 2004). Reinforcing this idea are summations citing members of nuclear families during war had better overall well-being and decreased pathology after war including fewer psychiatric diagnoses (Arroyo & Eth, 1996).  2.3.2! Engagement  GARs are among the group of refugees along with other ethno-racialized minorities, to have the poorest mental health and experience greatest cognitive risks to well-being (Hansson, Tuck, Lurie, McKenzie, 2009). Cognitive stressors can fall broadly within three periods: pre-migration (e.g., trauma experienced while in their country of origin), migration (e.g., hostility encountered while traveling before reaching their host country), and post-migration periods (e.g., separation from family after migration) (Pacione, Measham, & Rousseau, 2013). A study with refugees from China and Sudan showed that people feared further abuse from their families if they already had a mental illness or suffered from low well-being (Donnelly et al., 2011). Moreover, previous studies found that displaced people without refugee status experienced more traumatic life events when compared to displaced people with refugee status.    33  PTSD symptom severity has also been predicted by a lack of refugee status (vs. asylum seeking or claimant status) and the most common fear identified in people who are displaced is being sent back to their country of origin. While on the other hand, they also fear being unable to return home in case of emergencies (e.g., death of a loved one). In other words, the cause of PTSD in asylum seekers and convention refugees may have begun with the conflict in their native country, however, stress experienced as a result of the process of becoming a refugee and seeking asylum in a foreign country has been shown to evoke further psychological disturbance (Pacione, Measham, & Rousseau, 2013).    Symptoms related to past traumatic experiences have also been widely documented, such as nightmares, intrusive memories, flashbacks, avoidance behavior, and hyper-arousal (Vukcevic et al. 2014; Acarturk et al. 2015). Sack et al. (1991) report that re-settled refugee parents who report higher mental health, can care for their children to meet their needs. Similarly, survivors of torture, terrorism or war can have post-trauma symptoms which may hinder their ability to care for their children.  2.3.3! Relationships Several resettlement stressors have been known to exacerbate mental health concerns. In post-migration, gender-role reversal can be expected in marital relationships since women were more likely to secure work (Pessar & Mahler, 2003; Murray, Davidson & Schweitzer, 2010). Men’s lack of ability to secure employment as quickly as their female counterparts contributes to their post-settlement stress because they could not fulfill their traditional gender roles (Hyndman & Walton-Roberts, 1999).  In displacement settings, the social fabric of society is often severely disrupted, hence many refugee families become isolated from larger support structures (Mollica et al, 2001; Miller et al, 2002; Thorleifsson, 2014). In a clinical review titled, the “Canadian Collaboration for Immigrant and Refugee Health”, Pottie et al. (2011) wrote about findings that showed refugee women’s well-being was impacted  34 by social isolation, and lack of social support. These problems can amount to a mental disorder if they include elevated levels of suffering and functional impairment while not all psychosocial problems or emotional distress in themselves necessarily imply that the person has a mental disorder (Bou Khalil, 2013; Almoshmosh, 2015).   Many studies focus on individual adult or individual child and youth experiences; however, few have looked at family experiences of displacement and resettlement together (Nelson, Hess, 2015). Social and behavioural manifestations of trauma-related issues include withdrawal, aggression, and interpersonal difficulties. In eastern collectivist cultures, families and their interdependent members are key sources for culture, traditions, and well-being especially in times of strife (Papageorgiou et al., 2000; Sack et al., 1994).  Research has shown that parents’ well-being and absence of stress was positively correlated with similar experiences in children (Sack, Clarke and Seeley, 1995). Garbarino et al., (1991) further suggest that if relations are strained in family units this can hinder mental health for each member and the family, especially if there is marital strain between parents. Green et al., (1991) showed exactly this when children’s resilience and mental health after war is greatly reliant on the family unit, especially if other family members are missing or deceased. However, studies that have explored collectivist refugee families have been able to discern that family relationships transcend time and place of displacement (Napolitano 2002; Rouse 1995), and that, “family collectivity and cohesion” may give rise to well-being during migration (Boehm, 2011, p. 11). This supports the idea that family well-being and relationships are a vital component during high stress and war especially within collectivists cultures.  2.3.4! Meaning  One’s sense of life meaning and purpose can be shaken by forced displacement. Academic, professional, or financial goals may be suspended during displacements and in host communities due to  35 slow or no hiring based on cultural or religious discrimination, slow credential recognition, and new economic systems (Beiser & Hou, 2001; Murray, Davidson & Schweitzer, 2010). Many refugee women and girls feel particularly isolated and may rarely leave their homes to attend school due to concerns over safety or lack of opportunities (International Rescue Committee, 2014; Boswall & Al Akash, 2015). Further decreases in meaning and purpose can occur for women and children who may be vulnerable to forced marriage, survival sex, and child labour in camps and other temporary settlements (IRC, 2013). Research on life after resettlement also showed that female refugee and asylum seekers were ten times more likely to live alone, fall victim to abuse, and have increased rates of pregnancy with cesarean births than Canadian born women (Pottie et al., 2011). This same sense of isolation can affect boys, with some refugee boys rarely leaving their homes (UN Women, 2013).   Further distance from one’s meaning and purpose can occur during displacement which can lead to demoralization and hopelessness, which may be related to profound and persistent existential concerns of safety, trust, coherence of identity, social role and society (El Sarraj et al. 1996; Ellsberg et al. 2008; IRC, 2012; Parker, 2015; Usta & Masterson, 2015). Refugees from Sudan (n=220) across Ontario showed that maintaining a sense of purpose towards collectivist roles were essential for well-being (Donnelly et al., 2011). Overall, many mental health researchers recommend interventions that include family and community members in services to help invoke a sense of meaning and purpose for clients (Weine, 2011). Involving families in treatment can provide an opportunity for facilitating effective parenting practices, increasing family cohesion and support, and giving clinicians context for understanding broader cultural values that support a sense of meaning and purpose (Weine, 2011).  2.3.5! Achievement  Although the literature on refugees is saturated with examples of risk for many types of mental health and educational challenges associated with each period of migration (Fazel et al., 2012),  36 researchers increasingly hold that it is also important to recognize their experiences of recovery and resilience (Masten, 2012). This is because focusing on risk alone paints an incomplete picture of their lives. As Ann Masten (2009) claims, well-being or resilience achievement can be “ordinary”. Meaning basic but effective changes can be implemented to a lifestyle to enhance well-being. With the resilience and stories of survival that mark refugee experiences, there are also dangerous aspects of fleeing that may potentially cause long-lasting mental health issues and risks to well-being. Race, gender, class, and traditional gender normative roles all contribute to the post-settlement well-being. People who are suffering risks and barriers to well-being do not typically have the power or access to change the system. This is particularly challenging because every level of government is responsible for Canada’s new citizens (Beiser, 2005; Hansson, Tuck, Lurie, & McKenzie, 2009).    Conflict-affected Syrians may experience a range of mental health complications including exacerbations of pre-existing mental disorders, disorders caused by conflict-related violence and displacement, and issues in adaptation related to the post-emergency context (for example, living conditions in the countries of refuge which can affect resilience). In some countries, discrimination toward refugees and social tensions also contribute to feelings of stress and isolation. Thus, care must begin before refugees enter their host country in order to be able to fully aid this population and to have the positive long-term effects of their migration be felt within host communities.    In the current protracted crisis, with no end in sight, a pervasive sense of hopelessness is setting in for many Syrians (Al Akash & Boswall, 2014; International Rescue Committee, 2014). The number of Syrians with psychotic symptoms will have increased given the escalation of risk factors, such as potentially traumatic events, forced migration, and the breakdown of social support. Research exploring refugees of Chinese, Hmong and Yemeni families show that both parents and children experience being a refugee very differently (Suarez-Orozco, 2000; Boehm et al., 2011). In refugee families resettled in asylum countries, parents who were torture victims were more likely to have children who had  37 somatization symptoms such as a headache or stomach aches as supported by Lukman and Bach-Mortensen (1995). Further, they add, parents’ can act as a protective factor to children’s resilience and this, in turn, can be a buffer to their own development of psychopathology (Sack et al., 1986).  As can be seen, many of the research projects mentioned herein are either inter- and intranational. There is no BC based research data on the large refugee cohort that came to this province across 2015 and 2016 other than the ISS study. While Vancouver has a strong history for advocating for the well-being for newcomers, the production for local research on the most recent wave of refugees is very low. For example, in the 1980s a national task force of mental health experts was struck in Vancouver to provide policy recommendations on how to improve the well-being of newcomers from Vietnam (Ganesan, Fine, & Lin, 1989). However, since then no major cross-sector and interdisciplinary publications have been produced in Vancouver. Building upon the work of this task-force and other initiatives like it, this dissertation hopes to add to this critical body of knowledge to help improve mental health and well-being of newcomers through a series if policy recommendations. In addition, involving people that are often the first point of contact for refugees (e.g., school personnel, primary care providers, and community workers) is fundamental to offer services and programs that promote well-being of newcomers. Services are typically categorized by formal and informal services discussed in the following section.  2.4! Mental Health Services 2.4.1! Formal  Formal mental health services include sessions with psychiatrists, psychologists, career and psychotherapy counsellors to ensure access to appropriate and timely mental health care. Regardless of culture, a practitioner’s familiarity and openness to working with diverse cultural backgrounds have shown to be important in refugee studies as well as how individuals speak about and understand mental health and well-being. Well-being can be experienced differently across cultures. For example, Rousseau,  38 Drapeau, and Corin, (1997) have shown that culture can have a complex effect on refugees’ well-being, post-traumatic stress, and the mental health service they receive. Cultural norms and traditions are said to influence refugee mental health as well (Rousseau et al., 1997; Arroyo & Eth, 1996).    In formal mental health services the combination of the therapeutic style of mental health service providers and their interventions need to be flexible in accordance with clients’ changing therapeutic needs. Interventions must be applied with regards to the level of experienced trauma pre, during, and post-flight and they must be evaluated with the clients’ own life expertise and cultural and other belief systems. Different interventions and approaches may have varying success depending on the stage of resettlement (Murray, Davidson & Schweitzer, 2010). Although Judith Herman, is a Psychiatrist for Harvard Medical School in the United States, her work has been integrated into mental health care in countries across the world including Australia which is where Kazemipur & Halli, (2001) advocate for trauma-informed settlement services in their work below: There has been a growing recognition of the mental health needs of refugees in countries of settlement, as many are survivors of torture and other traumatic events experienced in countries of origin, during flight, and in places of temporary refuge. The challenges in providing access to services and quality mental health care arise not only from the fact that refugees generally come from cultures very different to the societies in which they settle and are not proficient in the languages of their new homes. In response to the challenges, specialist agencies have developed ways of providing services that are trauma-informed, culture-informed, and holistic (Kazemipur & Halli, 2001, p 1159).   This growing genre of formal mental health services acknowledges the emotional and possibly traumatic experiences and cultural background of the newcomers. This type of practice combining the emotional and settlement experiences is known as trauma-informed settlement services (Herman, 1992).   39 2.4.2! Informal  It is common for newcomers to Canada to rely on informal networks for social support (Statistics Canada, 2004). Informal supports can be friends, family, settlement workers, volunteers, and community members who do not have mental health training or license for practicing mental health care. During transitional periods familiar ethnic communities, faces, and food can help foster a sense of belonging which is imperative to grow networks and build bridges in new communities and society at large (Beiser, 2005). Almqvist and Broberg (1991) have shown with qualitative interviews that family cohesion before becoming refugees is a strong predictor of well-being success post-resettlement as was seen with one hundred and eighteen Khmer refugee youth and parents who were interviewed for symptoms of post-traumatic stress.  Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations, (Kirmayer, 2011, p 959).   Kirmayer et al., (2011) suggest that “trained interpreters and cultural brokers, meetings with families, and consultation with community organizations” are key informal services that support integration for newcomers. The most significant support for getting mental health help to refugees from China and Sudan was social support and written and translated information (Donnelly et al., 2011). For new GARs life in host countries revolve around cultural and language brokering, and access to care (Mitschke, Aguirre, and Sharma, 2013). Another settlement study revealed informal informational and emotional support was key to well-being post-settlement (Kawachi & Berkman, 2001; Simich, Beiser and Mawani, 2003). While common among refugees, many symptoms of stress do not necessarily indicate mental disorders which must be assessed on the basis of configurations of symptoms and associated  40 functional impairment. Most people who are forcefully displaced are tremendously resilient and informal support and community liaisons can successfully cultivate the conditions that promote such resiliency.   2.5! Strategic Design Theory  As mentioned above, well-being is a dynamic construct that can be improved and preserved based upon the needs of an individual. Focusing on opportunities to improve peoples’ well-being can be seen as a solution orientation (Frankel & Racine, 2010; Helsinki Design Lab, 2013; Tschimmel, 2012). This approach of seeing opportunities for improvement through solutions is characteristic of strategic design (Helsinki Design Lab, 2013; Simon, 1969). Strategic design is an approach that originated out of design fields, which was mentioned in chapter one, as a creativity and solutions-focused discipline for solving problems (Rosenbaum, Otalora, & Ramírez, 2017). Finland based, Helsinki Design Lab (2013), practiced strategic design with government leaders to research and solve challenges with a big picture perspective to consider multiple sides of a problem for more complete solutions. They differentiated design and strategic design in the following way: Traditional definitions of design often focus on creating discrete solutions—be it a product, a building, or a service. Strategic design applies some of the principles of traditional design to "big picture" systemic challenges like health care, education, and climate change. It redefines how problems are approached, identifies opportunities for action, and helps deliver more complete and resilient solutions. Strategic design is about crafting decision-making (Helsinki Design Lab, 2013p 1)   The Helsinki Design Lab reported that there are three core components to strategic design. First, there is integration. Key decision makers may “only see the parts rather than the whole of a problem” due to their unique positions, roles, or responsibilities. However, the naturally integrative approach of strategic design could help illuminate the complex web of relationships— between people, organizations, and things—to provide a holistic view of the problem. Hence, the approach of this study to bring together  41 key informants from three sectors (settlement, mental health, and public). Additionally, “by working across different areas of expertise strategic design outlines the architecture of the problem” in order to signpost key opportunities for the problem and its potential solutions. Second, the Helsinki Design Lab proposed that “an important and iterative means of communicating complex, even contradictory, relationships—… would be difficult or impossible to explain in text and numbers alone”. For example, the potentially contradictory relationships between the settlement key informants and the public sector key informants who are partial funders and donors of settlement organizations. The third component the Helsinki Design Lab wrote about is stewardship, where “good ideas are easy to come by: implementing the right ones is not. But successful design is not only about creative thinking. It also involves implementation and ensuring that key ideas maintain their integrity during that process”. They also noted that strategic designing occurs across time during the change processes, where expertise and feedback identify, test, and deliver durable solutions as a repetitive or continuous process.   In Chapter one of his book, Michael Luchs describes strategic design as a “systematic and collaborative approach for identifying and creativity solving problems, includes two major phases: identifying problems and solving problems” (Luchs, Griffin, & Swan, 2015, p 4). Further into his work he  references “wicked problems”. They are described as problems “which are complex and consist of many interconnected issues (Luchs, Griffin, & Swan, 2015). Wicked problems are those which are ill-defined and are usually owned by many (Rittel & Webber, 1973).   Social and policy issues according to Rittel commonly fall into the category of wicked problems. As such, Rittel argues further that they may not be problems which can be solved easily. Instead, a wicked problem is “re-solved” with iterations and improvements (Rittel & Webber, 1973, p 136). It also means that it is a problem that is difficult to define and will require several voices to help understand. Hence, the use of key informants from three sectors in this study. The wicked problem of this study is that 30% of newcomers reported being sad and depressed after resettling in Vancouver because this problem  42 doesn't only belong to the government, or to Immigrant Services Society or to newcomers. This is a wicked problem which has many stakeholders. The application of strategic design on the concept of a “wicked problem” can develop an understanding of problems from the customer’s perspective, considering all the details while retaining the “bigger picture” (Luchs, Griffin, & Swan, 2015, p 228).    In the book In Studio: Recipes for Systemic Change: Helsinki Design (2011), designers from the Helsinki Design Lab suggest there are recipes to advance social change in order to address wicked problems. The recipe includes: (i) convening the right group of people, (ii) framing a problem carefully, (iii) the crafting of a solution within an open-ended process (Boyer, Cook, & Steinberg, 2011). The combination of these three ingredients would lead to iterative improvements that could lead to systemic change.   There is evidence that before the turn of the century universal design methods were the main object of strategic design research (Cross et al., 1992). Decades later design became the object of study for creativity and the cognitive process of designers and strategies when improving a service (Cross, Dorst & Roozenburg, 1992). This paved the way for strategic design to become focused on how to improve the cognitive abilities of designers (Eastman, McCracken & Newstetter, 2001). Since then strategic design has grown as a field for service development across sectors (Brown, 2009; Martin, 2009; Lockwood, 2010; Cross, 2011; Liedtka & Ogilvie, 2011) and has even been paired theoretically with psychology (Dasu & Chase, 2010). Its rise can be attributed to its versatility as a way to lead to transformation and improvements in service design (Tschimmel, 2012).   In his seminal work The Sciences of the Artificial (1969), Simon also promotes solution-focused thinking through identifying and investigating complex problems in designing constructive options for improvement. Generally, strategic design is characterized by solutions that are iterative in nature (Dasu & Chase, 2010). Simon suggests “you only learn about the interior structure of an artifact when it fails to  43 respond to the environment properly” (Simon, 1996, p 114). For example, mental health services for GARs may not have been further investigated had 30% of GARs not reported low well-being. Simon’s work fits within this dissertation because design is “concerned with how things ought to be, with devising artifacts (or practices) to attain goals” (Simon, 1996, p112). Using this logic, by examining gaps and shortcomings in the current mental health services and aggregating the findings with GAR suggestions comprehensive improvements can be made to mental health services. Further, Simon suggests solutions are “a process by which we devise courses of action aimed at changing existing situations into preferred ones” (Simon, 1996, p111). Which means that the burden of improving mental health services can be reduced over time and solutions can be built upon each other such that refinements can be made upon improvements.    In this way, design theory can lend itself to this dissertation with a focus on a solutions orientation with regards to opportunities to improve GAR well-being by investigating where the informal and formal mental health services available fell short to preserve or enhance their well-being. The wicked problem of this study would be that 30% of newcomers reported being sad and depressed after resettling in Vancouver. In this dissertation, a solution orientation would see the 30% of GARs who are “sad” or “depressed” as an opportunity to improve their well-being. The mental health services available to GARs can be improved to better support GARs well-being in the future. Inspired by design theory, service journey mapping is an important technique for mapping experiences which will be discussed in the methods chapter.  2.6! Summary   This chapter highlighted relevant theories informing this study including those of well-being and strategic design. This chapter also provided relevant literature on refugee-specific risks to well-being contextualized within the PERMA framework.   44  The literature examined, however, points to a gap in knowledge about the recent refugee arrivals in Vancouver. While this chapter provided an in depth exploration of refugee research in cities across the world, the research for this dissertation is critical because no other research like this has been conducted on this settlement movement in Vancouver.   Although the Syrian refugee crisis is at the forefront of current global concern, studies have yet to be published on the mental health services for Syrian GARs in Vancouver. It will likely take some time for more recent refugee populations to be involved in research, and this might not occur until after they are settled for a longer period. For example, the “Lost Boys” of Sudan were fleeing their homes and living in refugee camps throughout the 1980s and 1990s, and most were not resettled until the early 2000s; however, most of the research with this population was not published until the 2010s. Perhaps in ten to twenty years a surge of research published on mental health needs of Syrian GARs will emerge. Until then, it is of great interest for the present study to examine the mental health services provided to GARs during the 2015-2016 arrivals.   This research aims to be of use across Canadian host communities where the recent arrivals of GARs from Syria have resettled by sharing findings with relevant government bodies and policymakers. Due to the substantial growth in human displacement and increasing resettlement in Vancouver there is an urgency to identify factors that are associated with how to promote mental health for those who are resettling in this region. As this chapter detailed many individuals who are forcefully displaced can experience numerous stressors and traumatic events because of their migration, resettlement, and acculturation experiences. This chapter also highlighted that they are able to overcome these challenges with appropriate help and assistance (Diener et al., 1999; Lyubomirsky & Lepper, 1999; Masten, 2009; Seligman, 2012).    45  Overall, this chapter has shown how interdisciplinary research is needed to bring a new perspective on well-being integrated with a solutions-focused lens (design theory) for improvements in mental health care for GARs in Vancouver (Helsinki Design Lab, 2013). This research is crucial as it takes an approach that explores the experiences of expert key informants who help support the mental health of Syrian GARs in their first year of settlement. This research aims to build on the studies included in this chapter and both generate and contribute new knowledge by combining well-being discourse with settlement in Vancouver. A such, the next chapter discusses the research methodology.    46 Chapter 3:!Methodology  3.1!  Introduction   Chapter one discussed the Immigrant Services Society (2016) study which revealed that 30% of government-assisted individuals were “sad” or “depressed” one year post-resettlement in Vancouver and the potential risks of prolonged psychological distress (see Rationale). Chapter two discussed major well-being theories, the importance of well-being for newcomers, and the specific displacement related risks to well-being. This chapter describes the methodologies that were applied in conducting this research including: the (a) discussion of qualitative approach combined with a frequency computational techniques, (b) purposive sampling, (c) key informant methodology, (d) data collection, (e) qualitative data analysis and frequency computational analysis, and (f) the development of policy recommendations. Figure 3-1 shows the methodology map for the Well-being, Strategic Design, Transition & Policy: A Case for the Federal Settlement Platform study.  Figure 3-1 Methodology Map for Well-being, Strategic Design, Transition & Policy: A Case for the Federal Settlement Platform Research Questions:InterdisciplinaryTheoretical ApproachInterdisciplinary DataCollectionCombined MethodsData AnalysisDevelopment of PolicyRecommendationsWell-being TheoryStrategic Design TheoryService Journey MapQualitative InterviewingThematic AnalysisComputationalFrequency AnalysisUBC Public Policy CanvasBardach Policy Guide 47 3.2!  Qualitative Study with Frequency Computational Analysis  This interdisciplinary study is qualitative in nature and employs frequency computational analysis to enhance the qualitative data. This combined approach was employed in the current study for the following reasons. First, qualitative research interprets non-numerical data and quantitative research analyses numerical data. Traditionally, the fundamental difference between the two kinds of research gave researchers an impression of incompatibility between the two research approaches. Increasingly, however, researchers argue for a combined approach allowing for one methodology to be enhanced by the other (Whitley, 2007). The combination of qualitative analyses with additional quantitative computations offers researchers “the best of both worlds” to address complex research problems (Helsinki Design Lab, 2013; Whitley, 2007). For example, the research questions which this study sought to investigate are: •! What formal and informal mental health services were offered to re-settled government-assisted refugee (GAR) men and women, and families during their first year in Vancouver?  •! What gaps were present in formal and informal mental health services offered to re-settled government-assisted refugee (GAR) women, men, and families during their first year in Vancouver?  •!  What policy recommendations can be made to the federal government to help improve government-assisted refugee (GAR) well-being?   In Qualitative Data Analysis: An Expanded Sourcebook, Miles and Huberman (1994) wrote that “both types of data can be productive for descriptive, reconnoitering, exploratory, inductive, opening up purposes. And both can be productive for explanatory, confirmatory, hypothesis-testing purposes” (Miles & Huberman, 1994, p 42). Further, Miles and Huberman (1994) stated, “The careful measurement, generalizable samples, experimental control, and statistical tools of good quantitative studies are precious assets. When they are combined with the up-close, deep, credible understanding of complex real-world  48 contexts that characterize good qualitative studies, we have a very powerful mix” (Miles & Huberman, 1994, p 42).   Combining qualitative approaches with quantitative frequency computations is understandably growing in popularity and use. The features of this approach are increasingly defined to help researchers locate their work in this paradigm (Leech & Onwuegbuzie, 2009). For example, features such as the levels of combining of approaches (partially vs. fully) allow for whether qualitative and quantitative approaches were integrated before or after independent collection and analyses. The time orientation (concurrent vs. sequential) indicates whether qualitative and quantitative findings were collected at the same time or one after another. The emphasis of approach (equal vs. dominant) indicates whether the qualitative and quantitative approaches are weighed equally in addressing the research problem.    Based on the above defining features this research was conducted partially via combined methods (the qualitative and frequency computational analysis findings were combined after analyses rather than before). A concurrent method was also used in that both qualitative and frequency computational approaches were applied in parallel rather than sequentially. Furthermore, this research would not be considered equally combined methods as it is dominantly qualitative in nature and hosts frequency computational analysis (to enhance the qualitative data). Both approaches yielded valuable information that comprise the findings in chapter four. The rationale for employing frequency computational analysis for this dominantly qualitative study is that such analysis maximizes the research contribution towards increasing well-being of GARs by creating deeper meaning, evaluation, and applications for the findings (see section 3.5 Data Analysis). Often the use of both qualitative and quantitative analyses is applied in order to understand the relationships between constructs while exploring an issue in depth, and to confirm findings from multiple sources (Creswell, 2003).    49  The following sections cover the study’s step-by-step procedures which included: (i) requesting that key informants complete the service journey map in advance of the interview (Kimbell, 2014), (ii) conducting interviews with key informants using the service journey map as an investigative and visual tool (Schensul & LeCompte, 2013), (iii) analyzing findings using qualitative analysis along with frequency computational analysis, (iv) integrating the frequency computational analysis and qualitative findings to provide a better understanding of the research problem (Creswell, 2013), and (v) using all of the above to develop policy recommendations.   3.3! Participants  The following section discusses key informants, inclusion and exclusion criteria, recruitment, and data collection methods.  3.3.1! Key Informant Participants  The key informant technique is broadly used across the social sciences and interdisciplinary research (Kumar, Stern, & Anderson, 1993). The use of key informants is an ethnographic research sampling approach where experts are sought out to share their unique, specialized, and rare combination of experiences and knowledge with researchers (Marshall, 1996; Tremblay, 1957). The ideal key informant should have four qualities. First, they should have a role in community which exposes them to the information sought out by the research. Second, they should have accessed and meaningfully integrated that knowledge. Third, they should be willing to cooperate to advance the research to the best of their ability. Fourth, the key informant should be highly communicable and able to convey their insights in a meaningful way to the researcher (Tremblay, 1957). Key informants, who meet these criteria, are able to provide rich, detailed, and meaningful information required in research. Further, key informants usually hold positions of “influence” and “responsibility” (Marshall, 1996, p 92). Additional benefits associated with the application of this approach are outlined in this quote:  50 Key informants, as a result of their personal skills, or position within a society, are able to provide more information and a deeper insight into what is going on around them. The principle advantages of the key informant technique relate to the quality of data that can be obtained in a relatively short period of time. To obtain the same amount of information and insight from in-depth interviews with other members of a community can be prohibitively time-consuming and expensive. Key informants, as a result of their personal skills, or position within a society, are able to provide more information and a deeper insight into what is going on around them (Marshall, 1996, p 92).   As seen in the above quotation by Marshall (1996) key informants can offer a wealth of information (relevant to any topic of study) with insight and familiarity with the constructs being investigated. They are leaders in society who have a host of unique and specialized experiences, knowledge, and expertise in a particular field thus positioning them as effective and efficient participants for research purposes.   While the research goals and complexity often determine sample size, a large sample size of key informants is not required since a small sample of experts is sufficient to provide rich and detailed information. Similarly, due to the unique, specialized, and rare combination of experiences and knowledge required to be a key informant very few individuals in a society or community will meet this criteria. Some qualitative interviewing approaches recommend 10 to 25 interviews (Anderson 2004; Bentley et al., 2004, Dolisca et al., 2007; Tongco, 2007; UCLA, 2014), while some other interview approaches suggest a range between 2 to 15 interviews (Tongco, 2007; Belcher et al., 2004; Hamza et al., 2006; University of Washington, 2006; Lewis & Sheppard 2006).   The key informant technique was appropriate for this study due to the efficiency with which a large amount of data was collected. It was particularly useful for this study as there are multiple individuals and organizations involved in the periphery of the refugee resettlement but only a few individuals who were in decision-making roles. These few individuals observed what the needs were, oversaw program  51 implementation, and witnessed the policy and funding mandates that were present during that time, therefore, making them appropriately resourced to be key informants for this study.  3.3.2! Inclusion Criteria  The inclusion criteria for the key informants for this study were as follows. The participant recruitment list was developed from the Canadian Council of Refugees Vancouver membership. All Vancouver refugee-facing organizations were contacted to take part in the study. Individuals with management and leadership experience were sought to participate as key informants. This included, expertise in resettlement, refugees and integration in Vancouver during 2015-2016. Recruiting participants with these specific features, provided the study with rich and detailed data relevant to the particular issues this study sought to investigate. This type of sampling is known as purposive sampling which is further discussed in the Recruitment section of this chapter (Tongco, 2007).   Since this study focuses on mental health services available to GARs who entered Canada between the Fall of 2015 and the Spring of 2016, the key informants were required to be in a leadership role at a refugee agency during the time of the ISS of BC study population entered Canada (November 4, 2015 and April 28, 2016). This was because in order to satisfy the requisites of being a key informant, participants had to hold critical information about mental health services available to GARs within their first year of resettlement. To offer triangulation of findings collected, three relevant sectors of staff were invited to take part in the study. The sectors included: refugee resettlement organizations, mental health organizations, and government. All key informants were assured their participation, organization and all data collected would be kept confidential. A communicable level of English was required to complete the service journey map and to partake in the interviews.   52 3.3.3! Exclusion Criteria  Exclusion criteria was based on the inclusion criteria being unmet. However, due to the purposive nature of participant selection of the key informants no potential participants were refused. There was no need to exclude organizations or key informants since they were recruited based on meeting the criteria during purposive sampling. However, as mentioned above three key informants were not included due to lack of engagement.  3.3.4!  Recruitment  Recruiting participants from member organizations of the Canadian Council for Refugees allowed for the sample to meet specific inclusion criteria required to participate. The Canadian Council for Refugees is a national non-profit umbrella organization committed to the protection of rights and settlement of refugees in Canada. There were important reasons for choosing participants from the Canadian Council for Refugees Vancouver members list (see 3.3.2 Inclusion Criteria). Table 3-1 shows the participant pool. The identities of the member organizations are intentionally concealed as to uphold the integrity of the confidentiality promised to key informants. Table 3-1 Key Informant Participants   A purposive sampling technique was used in the recruitment of this research. Purposive sampling is an intentional type of sampling that can lead to participants with more specific experiences relevant to the research being conducted offering critical information about relevant research constructs (Tongco, 2007). For example: Table 3.1 Participants ListCCR Member Organizations Pool Key Informants ParticipantsKey Informants Never RepliedKey Informants Refused 16 (100%) 13 (81%) 3 (18%) 0.0  (0%) 53 The purposive sampling technique is a type of non-probability sampling that is most effective when one needs to study a certain cultural domain with knowledgeable experts within. Purposive sampling may also be used with both qualitative and quantitative research techniques. The inherent bias of the method contributes to its efficiency, and the method stays robust even when tested against random probability sampling (Tongco, 2007, p 151)   Of the Canadian Council for Refugees Vancouver membership, 40% were refugee-settlement agencies. Sixteen of which were organizations that worked directly with refugees (n=16) and were contacted to participate in the study. Invitations were also extended to municipal, provincial, and federal level bodies involved with refugee resettlement and mental health care; see Fig. 3-2 below. The upper level management who served in leadership roles during the time of the Syrian refugee resettlement were also invited to provide a broader knowledge base of mental health care for refugees.   Figure 3-2 Key Informants   These key informants were aware of over arching and systemic functions on the ground and policy level that inform refugee mental health advocacy, funding and structural needs, and program Canadian Council forRefugees MemberOrganizations16 Refugee FacingOrganizations Invited13 Key InformantsParticipants3 Lack of Response 54 implementation. There were a total of sixteen invitations to participate as key informants in the current study. Of those sixteen invites, thirteen participated (81%) and three were not included due to lack of engagement (18%).    Figure 3-3 below shows the key informants by sector from the Canadian Council of Refugees member organizations and decision-makers for programming during the time of the first wave of newcomers to Vancouver. The colour codes (green for mental health key informants, red for public sector key informants, and blue for resettlement sector) are used to indicate qualitative and quantitative frequency computational analysis findings in chapter four. Due to the small refugee resettlement industry in Vancouver, the identities of all the key informants from each of the three sectors are intentionally protected.   Figure 3-3 Key Informants by Sector  The following section discusses data collection methods.   Mental Health SectorSettlement SectorPublic SectorKey Informant #1: MaleKey Informant #2:FemaleKey Informant #3:FemaleKey Informant #4: MaleKey Informant #9: MaleKey Informant #5: MaleKey Informant #6:FemaleKey Informant #7:FemaleKey Informant #8:FemaleKey Informant #10:Male Key Informant #11:MaleKey Informant #12:MaleKey Informant #13:Male 55 3.4!  Data Collection Methods   Once initial interest to participate in the study was expressed the participants were sent the following: (a) the consent form describing study details, (b) instructions for filling out two service journey maps (discussed further below) and, (c) request for interview time. Interviews followed completion of the service journey map in order to get detailed data from each key informant’s experience.  3.4.1! Consent Form  The consent forms invited key informants to complete the service journey map. The consent form included: (i) the purpose of the study, (ii) what participation in the study entailed, (iii) contact details, (iv) that no harm would come to participants from participation or withdrawal of participation, (v) that participants would be fully informed of the study activities, (vi) that privacy and confidentiality would be maintained with all interviews and information obtained with secure handling and dissemination of findings, and finally, (vii) that participants would not be obligated or coerced to participate.   3.4.2! Service Journey Map  Within the discipline of strategic design there are several tools for human-centric and solution-focused problem-solving. One such tool is the service journey map that is frequently used in business development to improve user experiences with products or services (Nixon, 2016; Lee, E., & Karahasanovic, 2013; Bitner, Ostrom & Morgan, 2008). The capacity of the service journey map to improve user experience speaks directly to the intention of this research which is to improve refugee experiences with services provided by settlement and mental health organizations and governments in host communities.    A service journey map is a simple and useful idea: a visual “canvas” that illustrates how users engage with services (Richardson, 2010). In this study it would be a visual recording of mental health  56 services available to GARs during their first year of settlement in Vancouver. The use of a service journey map “is of particular importance for services and requires a good understanding of interactions among the stakeholders involved in service provision and [use]” (Lee, E., & Karahasanovic, 2013, p 579). Further, service journey maps are used to develop services with the users in mind: On the other hand, visualizations of customer journeys for the purpose of conceptualization of new services have been successfully used in the area of service design… presenting the customer journey through a service might be useful for aligning business processes of service providers with customers' needs and, in turn, contribute to the delivery of better services (Lee, E., & Karahasanovic, 2013, p 579).   The service journey map originates in the field of strategic design and as such it is a new methodology to the mental health field. Rationale for use of the service journey map in this research along with the evidence presented above is that it allows for a considerable amount of information about services to be collected at one time to improve existing services. As the map is visual, the information can be shared and discussed easily between key informant participants and the interviewer. Specific questions can be asked about the map and it can be continually updated and added to. It can map a service from the beginning to the end of a time period and collect information about the service’s features. For example, the service journey map used in this study mapped data about mental health services that were available to GARs across time (from November 2015-November 2016) and across population (men, women and children; however not initially used, LGBTQ+ are referred to in Chapter six).   Service journey maps make services visible and tangible and allow for perspectives through several “point(s) of view” (Kimbell, 2009, p. 1). Service journey mapping is described as: A shared understanding of the complex world of people, things and organizations that make up services. The method provides a way to map existing resources and connections (see How to do it v1), or to suggest new collaborations or configurations (How to do it v2). It also highlights the material and digital touch-points that are part of day-to-day life, rather than ignoring them, (Kimbell & Julier, 2012, p 4).  57   As mentioned above in Kimbel and Julier’s Service Innovation Handbook (2012), service journey mapping can show complex features of services. To make use of this, two service journey maps were used in this study. In the first service journey map, key informants were invited to list and describe all services available to the GAR cohort arriving upon the federal government’s announcement to accept 25,000 new refugees in 2015. In the second service journey map, key informants were invited to get creative and fill in services that could have or should have been available (and why) to the cohort of arriving GARs during their first year of arrival. It also provides red stars to mark where there are pain points, or positions in GAR mental health services that are problematic. Finally, it provides red circles to add urgently needed mental health services, programming and initiatives for GARs. See Figure 3-4 for example of the service journey map used in this study.   58  Figure 3-4 Service Journey Map   As can be seen, the service journey map uses a visual technique intended to gather detailed information across time and population demographics (Rosenbaum, Otalora, & Ramírez, 2017). The time or X axis is divided by four columns of three-month increments. The population or Y axis is divided by three rows: men, women, and families. Each population division on the Y axis has a sub-section further divided into two rows to distinguish between service type (formal and informal mental health care services). Formal services were those services offered by licensed mental health practitioners, such as psychologists, psychiatrists, and clinical counsellors. Informal services were those offered by settlement professionals, volunteers, or anyone who is not considered part of the mental health professional category (See Chapter 2). When combined, both service journey maps lead to a considerable amount of data  59 collection. The data collected via the service journey maps is supplemented by the data gathered through the participant interviews which is discussed in the section below.   3.4.3! Interviews  The next step was the qualitative interview which covered the completed service journey map in order to acquire nuanced data from each key informant’s experience. This section will provide information on the interview questions, procedure and settings.! Interview Questions  The interview consisted of twenty-seven open-ended questions (Q1-27,100%) depicted in Table 3-2. There were four questions about the key informant (14%) including, How long have you worked with your organization? How long have you worked in re-settlement? There were five questions about the service journey maps (18.54%). There were three questions (11%) on definitions such as, what is distinct about refugee mental health services compared to other mental health services? There were five questions on service delivery (18.54%) including: How do you know what programs are needed? and How do you decide on programs that will be chosen for implementation? There were five questions about program participants and how participant feedback was used (18.54%) including: How do you invite participants? and How do you assess efficacy or outcomes? The final five questions were on possibilities (18.54%) including: What can we learn from peers in the field? and Are there specific changes you would like to recommend to the refugee mental health service field?  60 Table 3-2 Interview Questions Breakdown! Interview Procedure  As a researcher, prior to each interview, I clarified the objective and purpose of the research in order to stay ethically accountable to the participants and to the research questions (Elliott & Timulak 2005, Warren, 2012). At the outset each interview required a tone of friendliness and curiosity when reviewing consent and framing what was to follow in the interviews covering the service journey maps. I also practiced dialogical openness, meaning that I was ready to allow the participants to speak at anytime during the interview and to be ready to listen (Manen, 2014). The order of interview questions after the completion of the service journey map was essential to building rapport. Starting broad then getting more specific as the interview progressed helped for the interview questions to build both complexity and depth. As Kvale (2008) mentions, introductory questions help to set the tone and give an idea of the interview and be attuned to the participants (Josselson, 2013). By slowly moving into clarifying and exploratory questions, this step-by-step approach helped to build rapport and trust during the interviews. Table 3.2 Interview QuestionsType of Question Frequency Percentage (%)Defining Questions 3 11%Service Journey Map 5 18.5%Demographic 4 14%Service Delivery 5 18.5%Participants & Assessments 5 18.5%Possibility Questions 5 18.5% 61 Questions were worded carefully so as to be as open, never assume, lead, or limit responses (Seidman, 2013).    This intentional wording also prevented interviewing errors such as conveying various different meanings of certain words. Each question was asked with the whole dissertation in mind so that the interview was relevant to the research goals and ethics. Certain interview practices can restrict participants from answering freely. Those include what Schensul & LeCompte (2013) refer to as: finishing the participants’ thoughts, taking tentative ideas as fact, failing to clarify certain ambiguous or unclear slang or other referents, and asking questions insensitively. They also suggest that interviewers should avoid making any strong judgements during interviews, whether they are positive or negative because such reactions can influence the respondents (Schensul & LeCompte, 2013).   Interviews were carried out in English and in a solutions-focused format using positive affirmations and questions to explore key informant experiences with GAR mental health services in Vancouver (Seidman, 2013). Essentially, participants were collaborators with the study by sharing their perspectives to advance the goals of the study (Kvale, 2008). Sharing perspectives, Warren (2012) suggests may cause discomfort (e.g., desire for therapy, negative consequences), and reflexivity must be applied to post-interview conversations using both verbal and non-verbal techniques to close the interview time together.   After the completion of the interviews, they were transcribed and read to get a sense of the whole before any analysis was conducted (Braun & Clarke, 2006). Each key informants’ experience highlighted important and unique details for mental health services available to GARs during this time period. This is why each participant was asked to give their own explanations for their responses to the service journey map as well as participating in the interview. This, eliminated opportunities for assumptions and ambiguity and allowing for more reliable and valid data.   62! Interview Setting  The interviews were carried out in each key informant’s office, there was also an option to book a private meeting space at the Immigrant Services Society to help interviewees feel comfortable in case they did not want to meet where they work. The preferred timing for interviews was within regular business hours and all interviews were scheduled into that timeframe. To allow for the busy schedules of the key informants the option to interview during day hours on the weekends was also offered. Both voice-recorded and written, field notes were used during and after interviews to help build on the thick description of data. This also aided in recollection of the interviews afterwards (LeCompte & Schensul, 1999; Warren & Karner, 2010).  3.5! Data Analysis Methodologies  As mentioned above, clinicians and researchers are increasingly moving toward investigating refugee experiences using qualitative and quantitative approaches to collect and analyze data. This approach, however, generally leads to multiple steps in data analysis. The data analysis used in this research began with descriptive quantitative frequency computational analysis. Which led to over-arching qualitative thematic analysis leading to identifying thematic properties of the findings presented in chapter four (Murray et al.,2010). Both of these analyses are discussed in this section.  3.5.1! Computational Frequency Analysis  Generally, the basis of any quantitative analysis is descriptive statistics. Descriptive statistics allow for a large volume of text to be analyzed to support a meaningful secondary analysis (e.g., qualitative thematic analyses discussed below) (Hsieh, & Shannon, 2005). Arguably, one of the most objective and unambiguous descriptive statistics techniques is the computational frequency analysis technique (Curtis et al., 2001). The computational frequency analysis technique is described as:  63 In a summative approach to quantitative content analysis, frequency analysis begins with searches for occurrences of the identified words by hand or by computer. Word frequency counts for each identified term are calculated, with source or speaker also identified (Hsieh, & Shannon, 2005, p 1285).   In this dissertation the large volume of data was systematically analyzed, scrutinizing the text for concept frequency usage (i.e., quantitative frequency computational analysis). The quantitative frequency computational analysis was completed using Voicebase software. This software, computed frequency counts on identified terms (Kondracki & Wellman, 2002). Then systematically computed frequencies were grouped into a list of themed word-cluster categories. The categories then lend itself to the development of the qualitative thematic findings. In this way the foundational level of analysis is systematically improved locating the more important or latent structures within the data, (i.e., the themes).    As mentioned above (see section 3.2), a two-level combined data analyses approach was employed in this study. After the descriptive frequency computational analysis was carried out then qualitative analysis was conducted. The combination of the frequency computational analysis followed by qualitative methodology allowed for a systematic analysis of the large volume of data in a measurable and concrete two-level process for increased validity of the data findings presented in chapter 4. The next section will discuss how the qualitative analysis was carried out.  3.5.2! Qualitative Analysis  As mentioned earlier, the qualitative and quantitative approach to the research in this dissertation combined qualitative thematic analysis and computational frequency analysis methods to decipher data, provide empirical findings, and “a confluence of evidence that breeds credibility” (Eisner, 1991, p 110). Inviting key informants to complete the service journey map for GARs mental health services and then discussing the service journey maps allowed understanding of GAR mental health services in great detail from the key informants’ experiences (Elliott & Timulak, 2005; Braun & Clarke, 2006). The follow-up  64 interviews with key informants allowed for increased depth, clarity, and richness of data collection (Elliott & Timulak, 2005; Braun & Clarke, 2006).   Within combined approaches, the rationale behind selecting thematic analysis as the qualitative analysis method is that it proves an effective way to draw on multiple sources of interview data. It is a systematic approach to review, evaluate, and interpret large volumes of interview data in order to develop understanding, meaning, and empirical knowledge. When combined with frequency analysis as mentioned above it allows for confirming, converging, and corroborating patterns of observations and insights (Creswell, 2013; Roulston, 2010). Further rationale for qualitative analysis includes allowing for acknowledgement of complexities, attending to nuances, deeper analysis, and taking a holistic view of the settlement context (Murray et al.,2010). Additionally, the use of qualitative approaches in this study builds upon the appreciation of cultural differences and experiences. These culturally informed qualitative approaches can foster improved methods of coping and responding to adversity in host sites with greater information about mental health services in general (von Peter, 2008).   The first step in the thematic analysis of the large volume of data was familiarization. All transcripts were thoroughly read, examined, and scrutinized. Any impressions during review of the data were noted at each systematic review of the transcribed data (see figure 3.3). Substantive statements, which were those that delve deeper into the subject matter relating to the research questions were further reviewed and defined in order to be analyzed and categorized. The review and emergent themes were examined with the research questions framing all analysis: •! What formal and informal mental health services were offered to re-settled GAR men and women, and families during their first year in Vancouver?  •! What gaps were present in formal and informal mental health services offered to re-settled GAR women, men, and families during their first year in Vancouver?   65 •!  What policy recommendations can be made to three levels of government to help improve GAR well-being?   The subsequent steps required noting emergent themes which include: basic themes, organizing themes, and global themes. Due to the sheer amount of data collected a thematic analysis was conducted coinciding with Roulston (2010): The data generated provide in-depth knowledge, and understanding concerning the beliefs, perceptions, experiences and opinions of the authentic self of the interview subject. The data are co-constructed by the interviewer and interviewee, and the interviewer may contribute his/her own views to the conversation in order to heighten rapport. Data may be coded and categorized to produce thematic accounts; or subject to various narrative analytic methods to produce evocative narrative accounts concerning the participants' lifeworlds. Research may draw on psychosocial theories. (Roulston, 2010, p 57).   Thematic accounts of the interview data allow for deciphering and grouping data into manageable pieces that allow for enhanced review and understanding to elicit themes (Braun & Clarke, 2006). Interviews were transcribed verbatim using Voicebase Software. The analysis of transcripts allowed for “organization of key themes into larger units of abstraction to make sense of the data” (Creswell, 2013, p. 187).   This section discussed how the qualitative thematic analysis was conducted. The following section discusses the methodology for developing policy recommendations.   66 3.6! Methodology of Development of Policy Recommendations  The interdisciplinary data collected from the study was used to develop policy recommendations with the assistance of The Policy Design Canvas 2.0 (“the canvas”) see Figure 3-5 (April 2017). The canvas was created at the Policy Studio at The University of British Columbia’s new School of Public Policy and Global Affairs to assist with the design and development of policies using the visual canvas inspired by the Business Model Generation Canvas created by Alex Osteralder (Osterwalder et al., 2014). The Policy Design Canvas was used to develop the policy recommendations based on the findings of the service journey mapping and interview methodologies. The canvas is divided into seven segments to help consider the multiple factors any new policy must consider. This provides researchers and professionals a design-centered way of thinking about research-based policy recommendations. Bardach’s (2000) Practical Guide for Policy Analysis also informed the development of the policy recommendations of Chapter 5.   Over many decades, the field of resettlement, refugee mental health, and other related fields have seen numerous experts who have worked tirelessly in policy reform. As such, this research acknowledges the effort and work put in across the country and would like to add the information generated from this study in support of their decades of important and meaningful work in policy reform.    67  Figure 3-5 The Policy Design Studio Canvas 2.0 (2017) 3.7! Researcher Bias  All logistics of the data collection were managed single-handedly. From inviting potential participants, to introducing the study, conducting interviews, and conducting qualitative analysis and frequency computational analysis. Within these many tasks and roles, there were ethical considerations which are discussed in the following sub-sections.   3.7.1! Ethical Considerations  This research is a response to the Immigrant Services Society (ISS) study that was conducted with the refugee population who entered between 2015 and 2016. The response of this research to the ISS study is pertinent and relevant today, when nearly thirty-thousand refugees have landed in Canada and 30% of the respondents in Vancouver self-reported as sad or depressed. The selection of this research also reveals the researcher’s intention to privilege and acknowledge this particular issue facing new Vancouver residents (Tuck, 2009).  68   Second, due to the arrival of many refugees from a seven-year civil war, many may be suffering post-traumatic symptoms and would be considered a vulnerable research population. Research in vulnerable populations runs the risk of causing more harm (DeVault & Gross, 2012). This dilemma was curtailed by alternatively using the key informant population that is adjacent to the vulnerable population for whom mental health services are being investigated. As a means of preventative care attention was paid to ensure little or no harm could come from the carefully selected interview questions, that participant rights and risks were outlined in the consent form upon careful explanation, and the contact to a free counselling helpline was provided in case the interviewees required immediate assistance.   The third ethical issue recognized was the power dynamics which can occur in research, as mentioned by DeVault & Gross (2012). This power issue may come up during interviews as there is a potential for the interviewee to feel as if the interviewer has increased power in their dynamic. These feelings of inferiority of the interviewee can colour their thinking of the interviewer and can lead them to feel as if the interviewer has “one-up” position over the interviewee. (Tammivaara & Enright, 1986, p 224). Gathering information and exploring a topic could risk key informants feeling marginalized, subjugated, and powerless in the interview.   By asking questions, the researcher ultimately decides the direction of interviews and can risk reifying experiences of powerlessness. This research study sought to address this concern by emphasizing that participants were doing the researcher a favor by sharing their lived experiences to fulfil the requirements of a PhD. Asking respectful open-ended questions and allowing the interviewee to decide the depth and details of their responses were also intended to increase key informant agency during interviews. Ethical reflexivity was applied by attending to processes and power dynamics when making difficult choices in uncertain circumstances such as inviting the interviewee to take a break when they  69 were emotionally disturbed, which would in itself also require relational reflexivity (i.e. attending to the interpersonal) (Finlay, 2012).   The fourth issue was whether a Canadian born researcher, who has never been a refugee, can adequately interpret the mental health services needs or gaps through key informant interview responses and service journey mapping as an outsider. This was mediated by understanding the limitations of interpretations and reflecting on the interview process as both science and art. By recognizing interview research as an art, it lent itself to processes of learning and improving upon which can cyclically inform how the researcher elicited and interpreted data and aided in contextual and discursive reflexivity (Finlay, 2012). Then recognizing it as a science is important to use all of the skills and necessary measures described above (see Interview subsection) that should take place in successful interviews (DeVault & Gross, 2012).   The fifth ethical issue was that of reporting and disseminating interview responses and framing them as results. It could have seemed unfitting that key informants’ experiences, could be ethically de-contextualized into something as robotic as the “results” section in a dissertation (Van Manen, 2014). Instead Chapter Four is entitled “Findings”. This was because key informant interviews were used to understand the immediate experiences of resettled people. Information about experiences could not be separated from the key informant who experienced them and the researcher who elicited them in the interview process because they are both inherently connected to the co-creation of the findings. The researcher is positioned as a facilitator and elicitor of experiences (Devault & Gross, 2012), it was helpful to be reminded of this using contextual-discursive reflexivity as written by Finlay (2012).    70 3.8! Summary  Aligned with the above research methodologies this study focused on building knowledge around improving well-being using a qualitative approach combined with computational frequency analysis to explore key informants’ knowledge of GAR mental health services in Vancouver. Two research methods were employed to investigate mental health services available to GARs re-settlement in Vancouver. As mentioned above, the first method used was service journey mapping which initially invited key informants to complete the service journey map for GAR mental health services. The subsequent discussion of the completed service journey map informed by the key informants’ experiences allowed for increased understanding of GAR mental health services (Elliott & Timulak, 2005; Braun & Clarke, 2006).    The second method was conducting follow-up interviews with key informants. Interviewing allowed for increased depth, clarity, and richness of data collection (Elliott & Timulak, 2005; Braun & Clarke, 2006). The aims of the qualitative analyses and frequency computational analysis were to observe and generate findings from the key informant interviews. Conducting the interviews and becoming intimated with the interview process assisted in the generating of detailed and full data transcripts. This systematic review of interview data provided important and valuable information from expert sources, upon which the findings in Chapter 4 are based. The approach employing qualitative data analyses accompanied by frequency computational analysis assisted in aligning the data analysis consistently with the research questions in order to inform the policy recommendations in Chapter 5.     71 Chapter 4:!Findings  This chapter will address the first two research questions: (i) What formal and informal mental health services were offered to re-settled GAR men, women, and families during their first year in Vancouver? and (ii) What gaps were present in formal and informal mental health services offered to re-settled GAR men, women, and families during their first year in Vancouver?    This chapter includes findings collated from the service journey maps and interviews. The findings are organized by: (i) presenting quantitative findings from the frequency computational analysis, (ii) presenting qualitative findings from the thematic findings, and (iii) presenting additional ethnographic findings.  4.1! The Available Mental Health Services During Arrivals  The service journey map and interview research both elicited important findings with regards to the first research question. It was revealed by all key informant participants that during the 2015-2016 arrivals there were no trauma- and settlement-informed formal mental health services (services provided by licensed clinicians) for men, women, or families during their first year in Vancouver linked to settlement services.    This discovery proves crucial and unsettling since the mental stress of migrants leaving a war-torn country for a foreign nation requires mental health supports as stated in research (Bogic, Njoku, & Priebe, 2015; Hebebrand et al., 2016; Lincoln et al 2016; Shannon et al. 2015; Slobodin & de Jong, 2015). Moreover, several longitudinal studies have found mental health risks can persist even after resettlement (Lie, 2002; Mollica, 2011; Roth, Ekblad, & Agren, 2006). These risks can lead to potentially high prevalence rates of depression 80 % (Carlson, & Rosser-Hogan, 1994) and post-traumatic stress disorder 86% (Carlson, & Rosser-Hogan, 1994). These statistics coincide with the findings of the Immigrant  72 Services Society Study that newcomers in Vancouver are suffering mental distress. To reiterate, there were no formal settlement- and trauma-informed resources available for GARs who are fleeing war crimes and arriving to a foreign nation with a myriad of barriers to overcome, such as language and culture.    There is an abundance of research outlining the importance of why trauma-informed mental health services should have been available during these arrivals. Mental health services for refugees have been shown to improve mental distress with clinically significant improvements in symptoms (Bradley, Greene, Russ, Dutra, & Westen, 2005). Specific improvements include promoting resilience (Lambert & Alhassoon, 2015), increasing adaptation and lowering risks (Hebebrand et al., 2016), and providing a foundation for strengths-based interventions (Lambert & Alhassoon, 2015). Mental health services have also been known to treat trauma-related symptoms such as sleep disturbance, nightmares, and flashbacks (Slobodin, O., & de Jong, J. T. (2015). Similarly, mental health support has been seen to support unspecified anxiety disorders and resulting stresses (Bogic, Njoku, & Priebe, 2015). Mental health services have also been shown to improve symptoms of depression including low affect, low energy, sadness, and sleep and appetite disturbances (Fazel, Wheeler, Danesh, 2005). Further Pottie et al., (2016) recommend that “Empathy, reassurance and advocacy are key clinical elements of the recovery process for refugees” for host communities to offer to reduce the severity of symptoms of posttraumatic stress disorder or depression caused by displacement (Pottie et al., 2016 p 206).Lambert & Alhassoon (in their meta-analyses) also suggest that “Given the potentially debilitating effects of these disorders and the likelihood that symptoms interfere with successful adaptation following migration, it is important to determine existing trauma-focused therapies for treating this population” (Lambert & Alhassoon, 2015, p 2).   73  While there were no specific formal trauma and settlement-informed mental health services available to refugees in Vancouver during the first year of these arrivals key informants did reveal that there were two options that newcomers could access outside of their settlement service providers. The first of these is The Cross Cultural Psychiatry Clinic housed within the Vancouver General Hospital Psychiatry Department. Individuals are either referred by several community professionals or can make a self-referral for services. The second service option is available through Interim Federal Health, the medical coverage provided to refugees during their first year of arrival. Vancouver’s Interim Federal Health providers list shows only two Arabic speakers. One provider is located on the North Shore, a forty-five-minute drive or an hour and a half bus ride from the Immigrant Services Society site in Vancouver where government-assisted refugees are first processed. Also, based on their specialty profiles neither of the Arabic speaking practitioners indicate a trauma or settlement-informed practice. While these services are available neither were trauma- and settlement-informed formal mental health services linked to settlement services.    A prominent issue with this is having a mental health care worker who is not trained in refugee care and settlement issues causing larger capacity and efficacy issues. While the counselling of a displaced person may seem adjacent to that of one who has not been displaced how they operate and their respective issues require specialized knowledge. Just as the specialized knowledge of one stream of medicine is not necessarily transferrable to another aspect of medicine (e.g., surgery and endocrinology), mental health care of one population cannot necessarily be transferred onto another.    Refugees can bring with them unimaginable anguish caused by a long list of niche traumas (see Chapter 2). Being victims of torture, traveling dangerous terrain over months to find safety, and living in refugee camps requires specialized care and needs to be effectively treated. Not only is it vital for the refugee to work with an informed clinician but it is important for the well-being of the clinician as well.    74  Trauma-informed clinicians are equipped with skills to help trauma patients as well as manage their own self-care as clinicians. As mentioned in earlier chapters Judith Herman’s (1994) research states says that no matter what the experiences of a patient are, those experiences cannot hurt or vicariously traumatize a well-trained and prepared practitioner. Thus, having uninformed refugee mental health care is not only ineffective for the treatment of a GAR but poses direct risks to the practitioner themselves. This begs the question of whether uninformed care can even be considered as mental health services available to GARS.    Investing in trauma and settlement-informed mental health care is beneficial for improving distress, post-traumatic stress, depression, and somatic complaints (Shannon et al. 2015) as well as “caring for needy refugees, contributing to the productivity of future citizens and building the capacity of refugee settlers” (Bordignon & Moriconi, 2017, p 98). Thus, having no formal mental health services available for government-assisted refugees is converse to supporting refugee well-being in Vancouver. As 30% of government-assisted refugees are self-disclosing as sad or depressed, this statistic could have been lowered by planning for mental health services to be trauma and settlement-informed. Investing in refugees is directly investing in the Canadian communities they will integrate into. The more emotionally and mentally stable refugees are, the more efficaciously they can contribute back to their host communities.    Research shows that “The increase in refugee demand raises host-country incomes and spending, which in turn, generates additional rounds of spending impacts in the local economy” due to “income spillovers resulting from market interactions between refugees and host-country businesses and households” (Taylor et al., 2016, p 7451). For example, when refugees were given money rather than goods-in-kind, they could choose what they want to spend their money on. This creates an effect of injecting money back into the economy rather than the goods consumption (Taylor et al., 2016). Research also shows refugees contribute not only as entrepreneurs with small businesses (Heilbrunn & Iannone,  75 2017), but also pay taxes (Bizri, 2017), and participate in the labour market (Sak et al., 2017). In Canada the Lebanese community in Halifax created 3.6 jobs for each immigrant (Vancity, 2016). This may be attributed to the fact that newcomers are 30% more likely to become entrepreneurs than their native-born counterparts (Bizri, 2017; Vancity, 2016). A similar finding showed that when refugees were able to purchase and re-sell goods they were creating their own micro-economies around refugee camps in host-countries. Further, when reporting on the 2015-2016 refugee arrivals Vancouver based Vancity Bank reported that “over the next 20 years, these refugees will have contributed an estimated minimum of $563 million in local economic activity” (Vancity, 2016 p 1). These findings highlight the positive impact refugees can have in host economies and communities once integrated.    However, when refugees are not invested in through integration supports such as mental health care there is a cost to their host communities. By avoiding front-end financial costs of integration (i.e., failing to provide mental health services) many newcomers are put at risk for further marginalization in host communities further delaying their integration and eventual contribution (Miller & Rasmussen, 2010; Porter & Haslam, 2005; Robjant, Hassan, & Katona, 2009). Thus, other systems must make up for the lack of integration. These can include the employment, housing, and financial assistance sectors in the host community.   The key informants also revealed that there were very few distinct informal refugee mental health services provided during that time. According to them, available informal services included three key service areas: English language training, employment services, and first language settlement supports. Services under first language settlement support included women’s, youth, after school, senior and other programming for individuals and groups in the native language of the GAR. Here resettlement workers, volunteers and other settlement professionals provided group activities that may have acted as informal mental health groups (Murray et al., 2014; Patel, 2009; Patel, Chowdhary, Rahman, & Verdeli, 2011). Cooking groups for women, men’s employment groups, and youth groups were available during the time  76 of the Syrian refugee arrivals through settlement agencies. Another key informant offered an example of a “training-to-work” program which helped to encourage men to return to the work force by providing them with tools and techniques for labour and construction jobs. Informal resources are another important avenue for GARs to organically integrate into a new society and use less fiscal resources to operate.    These informal groups are generally cost-effective and cause less strain on already strained non-profit budgets (Murray et al., 2014; Patel, 2009; Patel, Chowdhary, Rahman, & Verdeli, 2011). Four major reasons for the reduced cost of implementing informal services are that clinical mental health staff are not required, training may not be provided during these groups, low-cost brochures and pamphlets may be provided instead, and multiple individuals can be in the group at the same time. The cost efficiency of informal well-being support allows for a variety of services and programs to be available to GARS.    Informal groups can have a rolling start date as needs arise. This is because informal groups can be run by any of the resettlement agency staff and they do not need to wait for budgetary approval (as is required by many formal services). In some circumstances, portions of agency funds can only be used for certain activities which meet certain funding requirements (i.e. certain funds are designated for specific programming). The informal groups can also be created for any topic the resettlement agency and their staff believe would benefit the newcomer population. Key informants explained that the implementation of informal groups were based on settlement workers’ suggestions centered around ideas from their clients. Informal services are also bound by fewer restrictions than their formal service counterparts because informal programming (e.g., cooking, sewing, trades, or culture groups) has fewer protocols. Informal supports for well-being are easy to institute since they are cost-effective, can have flexible start dates, and are bound by fewer restrictions and conditions.   77   Key informants explained that informal groups become a way for resettlement and community services to creatively engage with newcomer populations. They provide benefits such as building networking opportunities by bringing together individuals who are new to the country and may have limited connections to the host community (Miller & Rasmussen, 2010; Porter & Haslam, 2005; Robjant, Hassan, & Katona, 2009). They play an integral part in building a sense of community for newcomers. These groups can also strengthen social ties by providing a regular time, setting, and space for individuals to meet (Neuner et al., 2008). Informal groups can also provide opportunities for increased English practice during the commute to the site, at the informal group site, and the commute home. The groups are also a reminder to refugees that they are not alone in their experience. Normalizing the experience of fleeing, relocating, resettlement, language acquisition, loss of identity and employment, and loss of a prosperous and adapted life are experienced by others in the group. This can help reduce feelings of isolation, loneliness, and being misunderstood (Neuner et al., 2008).   While there are many benefits to informal groups they cannot replace the psychotherapeutic benefits of formal mental health supports. For example, formal supports provide a level of confidentiality that informal groups sessions cannot. Formally trained mental health practitioners are extensively trained in the area of maintaining confidentiality. This means that anything shared during the therapeutic process is kept secret except under certain circumstances such as: (i) the risk of safety to someone in a vulnerable sector (elderly or children), (ii) the risk for or presence of suicidal ideation, or (iii) a court subpoena. Formal psychotherapeutic settings also allow for the treatment for mental illnesses and experiences that if not treated specifically can cause dysfunction such as trauma (Bogic, Njoku, & Priebe, 2015; Hebebrand et al., 2016). Furthermore, formal services also provide support for grief and loss issues (Lincoln et al 2016; Shannon et al. 2015; Slobodin & de Jong, 2015).    While informal resources have benefits to the well-being of a refugee they may be ill-equipped when faced with certain GAR experiences. An example of how formal resources can probe deeper and  78 thus treat GAR related trauma more effectively is the psychotherapeutic approach mentioned in chapter two. This approach is Judith Herman’s practice of combining the mental and emotional realm with settlement experiences known as trauma-informed settlement services (Herman, 1992). Herman focuses on how trauma is the rupture of safety. All key informants referenced trauma-informed competencies for newcomer mental health services. This psychotherapeutic approach uses techniques which: removes the blame from the survivor, acknowledges systemic forms of trauma and violence, and allows for healing for the survivor. Formal psychotherapeutic focus on being trauma-informed (focusing on mental health as well as refugee resettlement context) is important so that services can incorporate re-integration with attention to emotional needs of repairing trauma while also avoiding practices that can re-traumatize people in host societies (Herman, 1992).    Specialized trauma- and settlement-informed techniques that trained mental health clinicians use can ameliorate the consequences and further worsening of the following mental challenges and barriers to optimal mental health. Traumatic experiences can lead to hypertension, nightmares, irrational fears, anxiety, and depression (Hollifield et al., 2002; Keller et al., 2006; Steel et al., 2009). Grief over the death of loved ones can be difficult to manage with increased stressors of resettlement (Porter & Haslam, 2005). Loss of a successful career or educational goals, and a familiar community with ancestral roots is also stress inducing (Robjant, Hassan, & Katona, 2009). Fear from living in war zones and the insecurity that arises with lack of regular food, water, and shelter can cause long-term fear responses in individuals which could be treated in psychotherapy (Lie, 2002; Mollica, 2011; Roth, Ekblad, & Agren, 2006). These fears can be compounded by stresses of resettling in a foreign place, learning the language, and learning the customs in order to integrate into host communities. Evidence for the need of formal treatments for these social stressors have also been seen with cognitive-behavioral therapy (CBT) and narrative exposure therapy (NET) in certain populations of refugees (Lambert & Alhassoon, 2015; Schauer, Neuner, & Elbert, 2011; Slobodin & de Jong, 2014).   79  Overall, key informants wanted to see more emphasis on trauma and settlement- informed mental health care for all newcomers. They also saw a need for well-being resources to not only be available by categorization of gender and age but also by LGBTQ+ identifications held by the GAR. They underscored the importance of mental health care to be settlement and trauma-informed. Finally, key informants wanted to emphasize the need for cross-cultural responsiveness and relevant sensitivity in formal and informal mental health care.  4.2! Data Collected  The service journey map and interview research methodologies allowed for a large volume of data to be collected. The service journey map elicited this sizeable volume of data due to 24 data fields available for data entry. For example, there were two types of services (formal and informal), three types of population (women, men, and families) and four time intervals (each consisting of three months). Combined, the service journey map led to a total of twenty-four data fields (2 x 3 x 4 = 24). The interview included 27 questions (see Table 3-2 Breakdown of Interview Questions). There were thirteen key informants. Thus, the service journey map and interview research combined with the thirteen key informants produced 561 data fields (24 + 27 x 13= 561). Finding from the computation frequency analysis is presented followed by qualitative findings in the following sub-section.   Figure 4-1 below depicts the volume of data collected in the service journey map fields and the interview. Both methods of collecting data yielded a large amount of data and when combined yield an even more substantial amount of information.  80  Figure 4-1 Service Journey Map & Interview Data Fields  4.3! Quantitative Frequency Computation Analysis  The following section details findings elicited from the second research question: What gaps were present in formal and informal mental health services offered to re-settled GAR men, women, and families during their first year in Vancouver? It will describe the whole data collected and discuss quantitative frequency computational analysis findings and qualitative findings from the thematic analysis.    As mentioned in Chapter Three, during computational frequency, data was mined for usage of certain words and their frequency. This quantitative frequency computational analysis technique can be used to determine what the focus of key informants is with regards to refugee mental health. In some cases, frequency analysis can also be used as an indicator of what people are looking for in a service (Stemler, 2001). The proportionally high degree of usage of certain words can lead to a better understanding of what is important to key informant participants. These types of observations are interesting and valuable as refugee numbers increase globally as are the number of refugee admittances in Vancouver. As computational frequency analysis can be somewhat mechanical it is one technical way to  81 compare content among key informants. As such, this analysis was used in combination with the qualitative thematic analysis discussed below.   The method of computational frequency analysis provided a way to slice into a large volume of content to see the way software might evaluate it yielding valuable and unforeseen insights. Table 4.1 depicts the frequency of the most common concepts appearing in the key informant interviews and service journey maps combined. The identified frequency concepts were computed and grouped into three categories: (i) policy and education, (ii) communities, refugees, and families, and (iii) primary health and mental health. Table 4-1 depicts the summative frequency analysis scores by key informant sector and identified categories of content frequency analysis.   Table 4-1 Key Informant Sector Content Frequency Analysis by Word Category    This is an important initial glimpse into the large volume of data collected. Table 4-1 shows that settlement sector key informants had the highest frequency of recurring groups of matched words. They used 934 words related to communities, refugee, and families. The fewest frequency of matching words were of mental health professionals speaking about policy and education. These are initial insights that are discussed further in each frequency word category below. The following sub-sections depict the usage of the most frequently repeated words grouped into three categories: (i) policy and education, (ii) communities, refugees, and families, and (iii) primary health and mental health. Sector Policy & Education Communities, Refugee & FamiliesPrimary Health & Mental HealthPublic 292 682 505Settlement 486 934 719Mental health 229 606 456 82  4.3.1! Policy and Education Category  The words in the policy and education category included: IRCC (acronym for Immigration, Refugees, and Citizenship Canada), government, federal, provincial, language classes, student, learning, free education, and school. See figure 4-2 to view frequency of policy and education category words per key informant interview.   Figure 4-2 Policy & Education Concept Usage Per Interview    The least variance among sectors is within the government sector key informants. One reason for less variance could be that the government sector highly monitors its staff and training programs across the country. Due to the frequency of government staff asked to comment on community issues and research participation they may be better prepared to respond diplomatically leading to a less diverse response frequency count in that sector. A second reason for similarities among key informants could be education level. For example, many government jobs may require at least an undergraduate degree (the mental health sector requires a graduate degree). While there are many settlement workers with undergraduate and graduate degrees, the settlement field does not require it (as there is no professional regulating body for settlement workers).   83  Per key informant interview the most variance in interviews is seen within the settlement sector. This is interesting for a number of reasons. First, the fact that training in this sector is budget and time dependent. Meaning that not all settlement staff receive the same training. According to one key informant, an additional key reason for training posing an issue is lack of time. The last arrivals happened so quickly in such a short period there simply wasn’t enough time to train everyone. Normally thorough training and on-boarding of settlement staff takes place, but during these arrivals there was simply insufficient time to do so. Additionally, there is no regulated training programs in the settlement field. Lastly, many staff in the resettlement sector are immigrants or refugees themselves and the quality of training or language supports they may have received upon their arrival may have influenced the heterogeneity in responses. The variance may also be attributed to a lack of coherence among settlement agencies on what political and educational needs are present during refugee crises both for staff and newcomers.  This computational frequency category group included matched words with a broad scope (policy, government, and education). These words may also be considered political in nature. It could also point to issues (policy and education) that broadly concern many people and issues that involve several professional and interested stakeholders (Bardach, 2000). For example, education could involve training newcomers in language, trades, and upgrading or recognizing foreign professional credentials. Additionally, education and training could be for the settlement staff, policymakers, and mental health professionals who will be on the servicing side for the newcomers.  When the key informant interviews are grouped together by sector another pattern emerges. According to Figure 4-3, the settlement sector used almost the same frequency of policy and education related concepts compared to the government and mental health sectors combined.  84  Figure 4-3 Policy and Education Frequency Data by Sector    This is interesting as many key informants in the resettlement sector consider themselves advocates for the industry of resettling newcomers. With their leadership experience and expert knowledge gained from their roles of responsibility they can come to see the broader scope of change that is needed in their industry. As such, policy and education become ways to garner this improvement and ameliorate processes relevant to their industry. For example, education is a large component of their advocacy work in terms of providing newcomers with language classes, professional training, and foreign skills recognition. Many conversations with key informants revolved around the education of newcomers and how language classes for newcomers had wait lists from a few months to up to one year. Language learning delays and lack of childcare are stressors, which are impediments to successful settlement.    According to key informants federal systems provide free language classes, however, due to the influx and lack of adequate resourcing many newcomers failed to receive the language education promised to them. Key informants in the resettlement sector were also speaking to the education and training of staff working with newcomers. These staff include teachers, policymakers, cultural brokers, interpreters, bankers, police officers, social workers, and border patrol officers. These sectors require a superior understanding of the plight and situation of newcomers. According to key informants, training  85 and education for professional groups that work with refugees during their initial stages of adaptation in Vancouver can have a significant impact on how integration unfolds for these groups. Key informants also stated that building bridges of understanding through education and training of these professions can help to create improved communication and assistance while also creating separation from potentially sensationalized, racist or demonizing stories presented by the media about newcomer populations. Key informants also made references to education and policy as ways to integrate newcomers in order to provide the optimal experiences to support successful integration (Alix-Garcia J, Saah D 2009; Alloush et al., 2017; Taylor et al., 2016). This is something communities at large benefit from when all members of a community are prospering.  4.3.2!  Communities, Refugees, and Families Category   The words in the communities, refugees, and families category included: war, migrants, immigrants, refugee, persecution, torture, peace, children, child care, mother, parenting, resettlement, and society. Figure 4-4 shows the frequency of communities, refugees, and families category words per key informant interview. All sector key informants appear to be relatively similar in frequency usage of terms within this category. There was one specific interview with a public sector key informant who was particularly involved in engaging community partners for refugee well-being and integration in the community. This could be due to being in government and being more responsible for GARs as a result of this arrival of refugees.  86  Figure 4-4 Community, Family & Refugee Concept Usage Per Interview   All key informants stressed the importance of community and family in their interviews. Importance of community was emphasized for the newcomer’s community of origin, residence prior to displacement, and their host community. The importance of family and family integration was evidenced for newcomers in host societies like Vancouver. According to Maslow (1971), belonging is a basic need for humans (which was a key issue the informants raised). Key informants raised the importance of family as a basis of the community to which individuals belong. A strong sense of family acts as a buffer ameliorating displacement stressors, resettlement stressors, and mental health stressors (Hebebrand et al., 2016).    According to Figure 4-5, all three sectors (government, settlement, and mental health) share higher usage of community, family & refugee concepts. This is especially true if the frequency was divided by participants in each sector. This high-frequency use could be due to all three sectors advocating for family reunification of newcomers and community-based practices such as community kitchens and classes for newcomers.  87  Figure 4-5 Community, Family & Refugee Concept Frequency by Sector   Key informants from all three sectors have interests in communities and families according to the frequency computations. The government sector key informants described how important family units are to functioning communities. This is especially true for children in school. Happy homes lead to well-functioning students in classrooms. This is also evidenced when whole families are resettled in Vancouver rather than having the family split up upon arrival or arriving at different times. Similarly, the settlement sector advocated for family reunification. They described the integration barriers that can arise when families are split. Mental health sector informants reported that when families are reunited there are also fewer risks to mental health. Worry and stress around family members cause undue strain and guilt. This issue is also raised under 4.6 Ethnographic Findings sub-section later on in this chapter.  4.3.3! Primary Health and Mental Health Category  The words in the primary health and mental health category included: health, diabetes, clinic, patient, grief counseling, suffering, psychologist, IFH (an, acronym for Interim Federal Health), trauma, social worker, RAP worker, cross-cultural, trauma-informed, and hope.   Figure 4.6 depicts the frequency of primary health and mental health concept usage per key informant interview. Overall, in the interview figures 4-2, 4-4 and 4-6 except for one anomaly in figure  88 4.4, there is generally more consistency with concept usage frequency. This could be due in part to the language training, programmatic language, and public relations training that government officials may have compared to mental health or settlement sector key informants.   Figure 4-6 Mental Health Care & Primary Health Care Concept Usage Per Interview   Refugee healthcare is provided under a federal system called Interim Federal Health Care. However in British Columbia, all health services are provided by provincial health care (which has been further separated into regional health care) (British Columbia, 1991). According to key informants, the effects of this shift to regionalization are still being felt today. One key informant explained the persistent confusion with “who” was supposed to provide mental health care to refugees. Unsurprisingly, there is still confusion over a federal mandate under which refugees are provided for in provinces where healthcare is regionalized and cities have no jurisdiction for the healthcare of their citizens. One such consequence of this confusion was emphasized in the closing of the Bridge Clinic. This was a medical clinic for refugees housed in East Vancouver (also where the Immigrant Services Society is located). The Bridge Clinic, unfortunately, closed within the year after the refugee arrivals. This is one of a series of refugee services impacted both by the regionalized medical services and the previous federal government before 2015.    Key informants strongly advocated that healthcare and mental health care services must be provided with a trauma and settlement-informed lens. There may be issues where loss of family, distance  89 from family, or other traumatic experiences can cause medical and mental ailments. According to key informants, these issues must be seen and treated within a system of health services that are provided under a trauma-informed mental health service lens. Trauma-informed settlement care education can be provided to GARs in as little as three sessions (Lambert & Alhassoon, 2015). Over the course of these sessions, therapists provide trauma, recovery, resilience, and psycho-educational information and activities in session with the newcomers as a part of therapy. Through these sessions clinicians help clients develop a cohesive narrative of their entire life, incorporating both positive and negative events (Lambert & Alhassoon, 2015). Lastly, at the end of therapy participants are provided with a complete written autobiography. If they so choose, this autobiography can be used as documentation of human rights abuses (Lambert & Alhassoon, 2015; Schauer et al., 2011). Below, Figure 4-7 also depicts a more even distribution of mental health care and primary health care concept usage by sector.   Figure 4-7 Mental Health Care & Primary Health Care Concept Usage by Sector    This even distribution could be due to the fact that all three sector key informants were participating in this study about mental health services. This also shows that there are like minds across sectors working with and for newcomers. The slight increase in settlement key informants could be because they observe firsthand the service gaps and solutions. This also is evidence for potential cross- 90 disciplinary and inter-disciplinary collaboration since there is leadership in all three sectors who are talking about, sharing experiences of, and advocating for mental health services for newcomers.   Overall, as mentioned above, the computational frequency analysis mines data for usage of certain words and their frequency. This quantitative frequency computational analysis technique was used to determine the key informants’ focus regarding refugee mental health and indicated what key informants were looking for in mental health services for GARs. The proportionally high degree of usage of certain words leads to a better understanding of what was important to key informants. These observations are interesting and valuable, especially when paired with the qualitative findings discussed next. 4.4! Qualitative Findings  The following section details thematic qualitative findings elicited from the key informant interviews. This section is important because it highlights not only what we can learn from the research but also what we can potentially use with future resettlement populations. The research suggested six prominent themes that help explain what is needed in mental health services during re-settlement projects. These themes help develop well-being for those re-settled and promote integration and wellness according to key informants in Vancouver.  4.4.1! Theme 1: Mental Health Services Should be Seen as a Priority   This emergent theme from key informant interviews highlights a growing sentiment that mental health needs to be a priority for all members of the community. According to these experts, all too often mental health care suffers budget cuts as needs in other areas soar. Furthermore, the key informants explained that there were mental health services (including language classes) that were eliminated due to budget cuts and repatriation of services from provincial to federal mandates. Immigration, Refugees, and Citizenship Canada provides funding to each province on the basis of newcomer landings. This shift of resources has continued since the final year of the Conservative government. Had these services still been  91 present during the invitation of some 25,000 refugees over 2015 and 2016, the mental health and integration landscape would have been different and could have potentially decreased the statistic showing 30% of newcomers feeling sad or depressed during their first year.    These statistics are meaningful and important facts calling for the reinstatement of these services that existed until very recently. One key informant reported that while the province added 1 million dollars via the Ministry of Tourism and Jobs for settlement workers, mental health services were still not developed and completely left behind. There were no existing or additional dollars injected into this area for newcomer populations even with a large body of research supporting mental hath care services ability to support integration in host communities. Thus, settlement agencies were forced to become creative with what resources were transmitted from the ministry of employment and tourism. Under the Province, ISS of BC was able to access funding for formal mental health services although such services were ineligible under Immigration, Refugees, and Citizenship Canada. When the BC-Canada agreement was repatriated by Immigrants, Refugees, and Citizenship Canada (IRCC), funding was no longer permitted for such services. The province maintained some funding, but only for refugee claimants through Vancouver Association for Survivors of Torture. Table 4-2 includes key informant quotes related to how mental health care for refugees must be seen as a priority.  92 Table 4-2 Key Informant Quotes for Theme 1: Mental Health Services as a Priority   4.4.2! Theme 2: Mental Health Services for All Refugees  Repeatedly key informants raised the issue that during the entry of 25,000 Syrian GARs to Canada within a six month period there were increasing barriers for access to services. Some services mentioned in the interviews include federal language classes, resident cards, the transfer from federal onto provincial financial services, and mental health care. Within the key informant interviews, 100% of participants referred to one key mental health resource and organization for refugees called The Vancouver Association for Survivors of Torture (VAST). This organization provides experienced, specialized Key Informant Quotes for Theme 1, Mental Health Services as a Priority  Public Sector There’s need to fund through national settlement budget…to allocate specific resources for development of specialized settlement informed trauma treatment interventions in all of the resettlement assistance across Canada this is what some other countries have been doing across decades, not funded by each state or city but by the federal government.Mental Health SectorWe have learned and transferred knowledge elsewhere and integrated [it] as new practices, formal mental health program trauma informed, it ran for five years, where we had registered psychologists and other specialized resources working with refugees. It was essential. It ended because of change in government policy…the change was that when IRCC repatriated because of the Canada agreement on immigration took back all of the funding given to the provincial BC government…they discontinued the funding, that was in 2014 under the Conservative government. The federal provided funding to the province to administer set language programs and mental health services because each province could decide, but under Harper government the 2 evolved agreements BC and Canada Manitoba both repatriated back to the federal government. So we were left with no funding and no programming for this large influx. We had to make do. Resettlement SectorTrauma can surface late in first year or early in second year by extending mental health supports and coverage this would by and large address vast majority of critical clinical supports needed for refugees.There is no IFH funding. We’re stuck. Coverage is currently only provided to refugees for period of one year in case of mental health or trauma survivors of torture the IFH program particularly for mental health should be extended to 3 years because issue is most refugee trauma only begins to surface at the end of first year or second year when there is no IFH coverage. 93 therapy and boasts both a trauma-informed lens and a settlement-informed lens. However, during the arrival of the newcomers in 2015 and 2016 due to budget and mandate restrictions, they were only funded to support refugee claimants (those who arrived in Canada and who were waiting for status or had precarious status). All other classifications of refugees were effectively turned away (including the group in 2015 and 2016). This is one example of how host societies can inadvertently minimize (one group can receive services but not the other group) and marginalize (asylum-seeking refugees offered services but not convention refugees) refugee experiences. Key informants explained that this could also further marginalize newcomers because they have refugee experiences that unfortunately do not meet certain criteria for services. Their circumstances further prevent them from integration (Miller & Rasmussen, 2010). This can also lead to further newcomer stigmatization and feelings of hopelessness within host communities (Porter & Haslam, 2005; Robjant, Hassan, & Katona, 2009). Table 4-3 includes key informant quotes supportive of the theme that refuge mental health care should be available to all refugees.    94 Table 4-3 Key Informant Quotes for Theme 2: Mental Health Services for all Refugees  4.4.3! Theme 3: Mental Health Services Should be Trauma & Settlement-Informed   The third theme that emerged from key informant interviews was that of mental health services being trauma-informed and settlement-informed with an emphasis on cross-cultural competencies An example being becoming familiar with clients backgrounds as it relates to gender norms, professional, and Key Informant Quotes for Theme 2, Mental Health Services For AllPublic Sector There are seriously no mental health supports, there is VAST, but their funding got cut I think they only work with claimants. This group of refugees is definitely in need of support, they got sort of a short end of the stick. But many systems don’t know how to handle it. Is it IFH? is it the province? mental health is definitely not in the municipal budget.Mental Health SectorWe need a mutli-pronged approach… need info piece …who’s coming to province theres ministry of health…we need to respond in a number of different ways around provincial refugee health program, in this province there has been provincial health program for LGBTQ + but no time given to dispersement of refugee services… we need a provincial health strategy like they have for LGBTQ [this] would call on need for better access to interpretation services training for practitioners, addition targeted resources, to help support the settlement process.Well for example the provincial government through set funding to ISS has sub contracted services to VAST to support mental health of claimants but there isn’t any services in place to the degree that its needed for GARS , provincially funded clients are only eligible for that, VAST and ISS are currently running short term pilots related to formal mental health interventions those pilots and the funding associated with them target small numbers of individual where the need is far greater. Mental health is ignored. Not funded and not supported. We do the best we can. These people need help.Resettlement SectorYouth was our biggest group, they need attention. We need to figure out through the youth and changing youth capacity with technology how we can use technology to provide more support for refugees prior to arrival to Canada and get them more access to support before they arrive.So if Canada keeps bringing refugees with special needs and treatment then IFH should be banded to 3 years in order for them to insure they get treatment, not only for people in their first year, its not enough. 95 educational norms. As shown by several studies in chapter 2, mental health reinforcements can lead to improved well-being for newcomers (Bradley, Greene, Russ, Dutra, & Westen, 2005).   According to key informants, mental health services for this group should be centered around the specific needs of this population. Special focus is required on being trauma-informed (focusing on the mental health as well as the refugee resettlement context). Key informants insist this is important so that services can incorporate re-integration with attention to emotional needs of repairing trauma and also avoiding practices that can re-traumatize people, such as forcing appointments, forcing local practices, or ignoring social, historical, and cultural sensitivities that any client may have, regardless of where they are coming from (Herman, 1992).    Key informants explained that paying attention to how clients present and ask questions can help avoid making assumptions about what clients need. Furthermore, key informants say this is a key tenet of trauma-informed practice as well as re-joining meanings of community and broken emotional bonds. When attending to particularities of this experience and viewing it through a trauma-informed lens more context, possibilities, and temporality become apparent to those involved (e.g., clinicians, policymakers, funders, and stakeholders) in the service delivery. When combined with a settlement-informed lens, key informants explain there is a more embodied therapeutic practice that can lead to increased connection and hope for the client leading to them having improved well-being. Table 4-4 shows key informant quotes that support that refugee mental health care should be trauma and settlement-informed.   96 Table 4-4 Key Informant Quotes for Theme 3: Mental Health Services Should be Trauma & Settlement-informed     4.4.4! Theme 4: Mental Health Collaboration  Key informants reported that during the time of the arrivals service providers were scrambling to connect with each other, with funders, and to link with resources to find out which agencies were providing which services. Key informants described how thousands of newcomers were stranded in hotels because of the housing shortage in Vancouver. Although housing shortages were an issue, the bigger issue was that there was no time to plan for three times the GAR arrivals of one year arriving within a few Key informant Quotes for Theme 3: Mental Health Services Should be Trauma & Settlement InformedPublic Sector Other unique factors that contribute towards differing mental health needs could be settlement informed trauma work, mental health linked to the settlement process, the starting point that is unique and greatest distinction in the settlement process, and the notion of rebuilding ones life.Mental Health SectorRefugees by definition are the only new comer population that is invited to come to Canada, versus  immigrants who choose to come to Canada. Refugees fled their homes due to a well founded fear of persecution based on a number of factors, and have significant and unique migration experience. Some unique services provided to them because of migration especially, could include service specific to those that are survivors of torture, that have witnessed excessive violence that have survived war related violence rape, but also for example for children and youth with disruption of education system and their life in protracted camps.All refugees don’t need mental health, however 15-20% of refugees will require formal support by trained mental health professionals.Resettlement SectorThe issue is that Canada continues to select refugees on vulnerability criteria and we have increasing number of special populations however we do not have a pan-Canadian national settlement-informed, trauma-informed trauma treatment program. 97 months. While many of the arrivals included large families of four to eight people there were many people in the mix trying to navigate the storm of information, mandates, processes, and procedure. While the federal government has been applauded by many of its citizens for inviting refugees under humanitarian stream, at the same time, there could have been smoother processes for information transmission as well as clearer guidelines for services across sectors from resettlement, health care, education, and employment.    The key informant interview quotations below reveal that many people were not familiar with the settlement procedure during this wave of arrivals. There was so much happening at this time that the systems simply could not keep up. These systems include housing, health care, employment, language classes, child care, and education (elementary, high-school, and post-secondary). One unfortunate reality was that school-age children were in the hotel for months because they were not admitted into the school system due to lack of a permanent address.    Usually, during regular arrivals, all refugee children (regardless of legal status) are eligible to attend school. The issue in this case was the time to move children into permanent housing. The Vancouver School Board was not going to provide schooling on a temporary basis for those children living in Vancouver hotels. This is an example of further marginalization of refugees due to the speed with which they arrived in a short period of time. Their own experiences of being a refugee were further crippling them from integrating into their host society due to lack of systemic collaboration and innovative or creative problem-solving. Table 4-5 outlines key informant quotes that were supportive of refugee mental health care being more collaborative.  98 Table 4-5 Key Informant Quotes for Theme 4: Mental Health Collaboration  4.4.5! Summary  This section provided findings from the key informant interview data. It included four major themes. Themes were centralized around mental health and well-being services for newcomers. The first theme was to prioritize mental health services so as to avoid funding and budget cuts. The second theme was to declare mental health services a vital component of well-being for all people regardless of status so Key Informant Quotes for Theme  4:  Mental  Health CollaborationPublic Sector …Such a hard such a complex piece, better training is the thing that I would say. …better training for people working with refugees in terms of understanding, connections cross sectoral connections work less independent and working together not silos and silos…work together, finding ways to do more collaborative work and looking at different approaches, more understanding more community based approaches not maybe “medicalizing” it so much.it was too fast and too big, kids were out of school for months because they had no permanent address…Mental Health SectorResources, financial, right staff, trained, and also philosophically looking at the stuff…Ive sat around people who have a broader understanding… that they work collaboratively, not independent (overlap, unrecognized) it all happened so quickly, and services were rolling out slowly, I understand there were political decisions around that but I think if you talk to service providers, have more conversations before hand, not having housing people in hotel in 3 monthsResettlement SectorA pre-arrival strength based assessment would be completed online then all stakeholder agencies could go into the system and put name into system where we have notification of arrival transmission and be able to obtain competed inform by IOM staff and upload into our system so as to make a more robust refugee plan …prior to their arrival of entrance into Canada. If they were part of orchestra in Damascus we could connect them with Vancouver orchestra VSO for example, if we knew in advance that they were entrepreneurs we could immediately arrange for them to access entrepreneurial training.More wrap around care, IFH and RCCs  and specialized funding for settlement informed trauma treatment intervention…lots of supports to ensure refugees able to access the RCCs not only about providing the resources for RCC to work with refugees but wrap around support so that there is non english speaking refugee reminders, bus tickets from BC transit, child care, they have supports to help them ensure they can access specialized resources made available to them. 99 no one is left behind. The third theme was to recognize professionals trained in counselling and to match them up efficiently and effectively with whomever requires their services. The fourth theme was to support multi-sectoral collaboration. The upcoming section outlines additional ethnographic findings.  4.5! Ethnographic Findings  There were additional important and meaningful findings that emerged throughout the research process. These additional findings developed over a span of several months during and post-data collection when comparing and collating: (1) reflexive researcher notes, (2) notes post-key informant interviews, (3) notes post-service journey mapping, (4) qualitative and frequency computational analysis data analysis notes, and (5) the researcher notebook.  4.5.1! High Informant Engagement  In general, key informants were eager to participate in this research even though they led key organizations carrying out important work and as such had incredibly busy schedules. They were widely experienced and deeply knowledgeable giving clear and authentic information about settlement in Vancouver. Key informants wanted to debunk inaccuracies and misleading information that surrounded settlement in Vancouver.   There was a surprising level of eagerness to participate by key informants. In fact, this was the case in each sector -public, mental health and resettlement. Their portfolios were marked by obligations to donors and stakeholders, their staff, their leadership and of course to the public or clientele they serve. Of the participants, almost all were eager. There was some reservation from one mental health organization because their patient lists were so long that as much as they wanted to participate in the interview spending time on this project came into conflict with their portfolio and client management. This was also the case in one public sector office. The refugee resettlement sector in Vancouver is very small with the workload carried out by a small group of people.  100 4.5.2! Carefully Chosen Words to Explain Issues  Upon being posed certain questions, key informants became slightly hesitant and careful of word choice. This was particularly prevalent around questions that referred to feedback surrounding civic, municipal, and federal level governments. One reason for this could be that these government bodies are direct and indirect funders of the organizations contacted for this study.   There was one case in particular from a key informant in the mental health sector where this was particularly noteworthy. When asked about recommendations to government bodies, her speech became slow and she became reflective. She has been working in the refugee resettlement sector for over a decade and could have been reminiscing on past years of recommendations which may have been unmet, refused, or cut back. It seemed as if she did not want to offend or say anything that could be seen as unappreciative. The key informant was reminded that data would be kept confidential and that it would not be connected back to any agency or staff member. This was important and noteworthy as it relates to collection of data in order to answer the research questions. 4.5.3! Refugee Guilt in Asking for Help/Assistance  There was a common theme (explained by key informants) that refugees express and exhibit guilt for asking questions about the process, services, and for being in Canada. The marked reason for this was because many of their loved ones were still back home, injured, or deceased.   Most key informants referred to how refugees could or could not access information, and how a large portion of information transmitted to refugees through informal networks was inaccurate. However, this is a difficult process as many refugees do not ask very many questions due to their enormous sense of appreciation and indebtedness towards Canada.   They feel grateful since they arrived in Canada (a safe haven), yet also experience the guilt of knowing they have loved ones back home suffering. Many refugees may not want to seem ungrateful for  101 their opportunity at a new life and starting fresh in a safe country even though many aspects of the culture and language are new and foreign. They silently suffer through feelings of guilt, depression and desperation yet still express gratitude for their current situation. Refugee empowerment and refugee voices can be important here. This information may not have surfaced without the keen observations and open sharing of the key informants. 4.5.4! Importance of Cross-Cultural and Trauma-Informed Competencies  The key informants consistently refer to cross-cultural and trauma-informed competencies. This did not mean that all settlement professionals are required to speak multiple languages and have research backgrounds in multiple cultures. Rather it was a suggestion to train settlement professionals to work in culturally sensitive ways. Asking questions about what is needed, what their expectations are, and how the client would like to be supported are all examples of working with cultural sensitivity. Across the mental health, settlement and public sector the references were made to cross-cultural competency and trauma-informed competencies in settlement professionals.   Judith Herman’s 1992 work set the tone in the mental health field for working with trauma. She focuses on how trauma is the rupture of a safe relationship such as relationships with loved ones, caregivers, a home, or land. Anything a person had a deep relationship with that developed a sense of belonging and safety for an individual. This approach is strengths-based, removes the blame from the survivor, acknowledges systemic forms of trauma and violence and allows for healing for the survivor in a holistic and person centric way. The term cross-cultural competencies are used immensely in the mental health and resettlement sectors. This work style is informed by an anthropological lens where professionals do not have to be experts in all cultures and speak many languages but instead to be informed in appreciating the collaboration that can come from acknowledging similarities and differences in cultures without admonishing them.  102 4.5.5! The Research Context  Within the literature, there were patterns based on what was published at certain time periods or words that were used during certain decades. For example, certain time periods had more information and research on certain topics. This may reflect what was happening in the research world at the time of the publication. For example, as one wades deeper in the well-being literature topics like culture, family, collectivist cultures begin to emerge and offer more information. This could be a reflection of values in the research world such as the direction of funding. Certain topics are funded more, and others have more invitations for grants to conduct research and as a result the topics which receive more funding experience were more carefully or frequently researched.  This was important and meaningful to acknowledge in the literature. As much as knowledge transcends time it can also succumb to trends. This is especially important as independent research is fewer and substantial funding is awarded based on previous awards, university affiliation, discipline, and topic. Conducting research requires several resources and much more as the scope and measures advance. It can be argued that the literature reflects only funded studies which can conduct elaborate data schemes and presentations or knowledge. Due to this, some strong research ideas may not have the opportunity to be made available in the literature to the same extent if adequate dollars are not received. The literature used in this dissertation could be seen to have been favored and privileged by researchers and funding organizations that publish literature in order to be broadcasted to the larger public. 4.5.6! Importance of Asking Questions with Sensitivity  The interview questions were developed from a strengths-based collaborative approach. They were exploratory and open-ended, brief and concise, and aimed to get all around the topic in order to develop a whole and round picture using the interview questions. In some cases, questions were misunderstood, or questions seemed to receive portions of repeated answers. This could be a limitation of my questions or it  103 could be pointing to a need for more training in this sector, or further emphasis on a lack of training of immigrants and refugees as many acquire their first employment in this sector.  There are several examples of the key informants from all sectors being either a refugee or an immigrant. They all offered profound experiences for which I could base this study on. I am immensely grateful for their donation of time, their sharing of experiences, and their motivation to advance this research. As such, I am significantly aware of their contribution and this study would not be possible without them. However, increased regular training for refugees and migrants is something the governments local and provincial and federal should be paying attention to. Excellent people are working hard to help their communities and they deserve adequate support and training to reinforce their important work. 4.6! Summary   This chapter provided findings from computational frequency analysis, qualitative thematic analysis, and additional ethnographic findings. The computational frequency analysis categories included policy and education, communities, refugees, and families, and primary health and mental health. The qualitative thematic analysis revealed four themes. The first theme was to prioritize mental health. The second theme was to make mental health services available to all people regardless of status. The third theme was for mental health services to be trauma- and settlement-informed. The fourth theme was to create and support multi-sectoral collaboration. Finally, there were additional ethnographic findings presented. These findings are the foundation for the development of the policy recommendations presented in the next chapter.    104 Chapter 5:!Policy Recommendations   Before policy recommendations are designed there are three major factors that influence the process. Professor and director of the undergraduate public affairs program at the Maxwell School of Citizenship and Public Affairs at Syracuse University in New York, William D. Coplin (2002) reports these major factors as domestic politics, economic condition, and international context.    Within domestic politics, he claims there are “policy influencers” who are actors that assert their influence on decision-making processes within policy reform. For example, at the time of Canada’s acceptance of 25,000 refugees, there were several civilian protests across the country to encourage the government to admit the refugees. The Immigration, Refugees, and Citizenship Canada Minister Ahmed Hussen, announced his intention to improve and modify several policies regarding refugees and their optimal well-being and integration in Canada. This could suggest that the domestic politics of Canada could be an environment ready to host new policy recommendations on refugees.   Coplin’s second factor, economic condition, is reflective of the fact that the Canadian economy could support 25,000 refugees in 2015. At that time Canada was ranked as the tenth of 195 countries listed for growth domestic product (GDP) (at the time worth 1, 550, 537 U.S. dollars) (The World Bank, 2016). Since the arrival of the refugees and after the dip of GDP during the final year of the Conservative Government, Canada has seen incremental growth in its GDP. In 2015 Canada saw a .942% increase in GDP, a 1.4% increase in 2016, a 2.05% increase in 2017, and a 1.94% increase in 2018 (The World Bank, 2018). For the year 2019, The World Bank projects Canada’s GDP growth to be 1.94%.    The final influence on policies which nation-states use to accept refugees, as argued by Coplin (2002), is the international context. Coplin contends nation states behave in ways that reflect the position that promotes the country’s national identity or as a perception the country wants to hold in the  105 international context. In 2015, during the acceptance of the refugee wave, Canada was facing media attention due to the lack of response and acceptance of refugees during the Conservative federal administration (Dwiharianto, 2017). After the acceptance of 25,000 refugees Canada’s image as a world leader in humanitarian resettlement was somewhat restored. In 2018 the number of refugees and displaced people globally was the highest number seen in decades (UNHCR, 2018). Due to multiple global conflicts and war over borders, oil, and other financial and national interests refugee numbers are projected to grow and Canada will be seeing more refugee applications. This is why there is an urgent need for updated policy shifts under the Immigration, Refugees, and Citizenship Canada portfolio. The following section outlines process policy recommendations that could allow Canada to become more actionable.  5.1! Policy to Action  After policy recommendations have been influenced by the above mentioned three dynamic factors (domestic politics, economic condition, and international context) they pass through an additional three stages in order to become legislation (Dwiharianto, 2017). The parliament report titled The Legislative Process: From Government Policy to Proclamation Andre Barnes (2009) discusses these stages. First, Cabinet discussions around topical items, civilian needs, and upcoming decisions form the basis of deliberations. This could be the breeding ground for new ideas in the cabinet and/or ideas brought in from civilians. Of the ideas discussed in cabinet, one is selected for further consultation with other departments in order to be drafted into a new document. The inter-departmental consultations lead to revisions to the document leading into the second stage which begins when the sponsoring department drafts a Memorandum of Cabinet for the Department of Justice to authorize. The final report is then taken back to the Cabinet for voting. Once passed, legislative drafters prepare a bill for approval by the House Leader. The Governor General will need to approve any bills requiring public dollars. The third stage takes place in Parliament where the bill is presented to the House of Commons and the Senate where debate and  106 contestations of legitimacy occur. Once approved in both bodies it enters the final stage of coming into force and establishing the date the act can be implemented (Dwiharianto, 2017).    This process of how policy becomes actionable is crucial to understand because new policies will inevitably be proposed for refugee resettlement due to increasing global conflict, war, and the corresponding growth in refugee numbers (UNHCR, 2018). Thus, Canada will be seeing more refugee applications and new policies will be made to respond to these persistent global displacements. This is why there is also an urgent need for updated policy shifts under the Immigration, Refugees, and Citizenship Canada portfolio. The following section outlines some proposed policy recommendations based on the Immigrant Services Society (2016) and the research conducted for this dissertation.  5.2! Policy Recommendations  The analysis of the research in this dissertation included operational frequency computational analysis of a large data set and a further systematic refinement and collating of the data leading to qualitative findings which communicate four latent themes. The findings were then developed into six key federal level policy recommendations. This section and the recommendations which follow herein have been developed using the University of British Columbia’s School of Public Policy, Policy Design Canvas 2.0 (April 2017). The policy design canvas uses key questions to elicit important information in order to design policy recommendations that are viable, useful, and appropriate for implementation. This section was also developed using Bardach’s (2000) A Practical Guide for Policy Analysis. This information adds to the extant body of literature and may be useful to those who may have wider mandates, responsibilities, and agendas as stakeholders in refugee resettlement. While a detailed policy brief is beyond the scope of this chapter it is necessary to provide a broad overview to lay the foundations for the present discussion.   107 5.2.1! Policy Recommendation 1: Create a Federally Supported Settlement Platform Policy Recommendation  1: Create a Federal Support Platform (FSP) for newcomers, settlement agencies, and stakeholders to access one unifying web-experience to coordinate, coalesce, and organize settlement-related information.! Defining the Problem:   Key informants revealed that there were many shortcomings during the arrival of refugees across 2015 and 2016. During this time, refugee housing shortages saw families housed in hotels for nearly six months. Many were unable to get their school-aged children into schools because they did not have a permanent address. Children were unable to attend school with no planned child-care, so instead, they would spend months on end in a hotel room. Since the children had no alternative supervision other than their parents this in-turn caused many parents to miss vital opportunities for their own integration into the community. During interviews, key informants recalled that countless parents or guardians would miss English classes and opportunities for training and jobs because of child-care issues due to lack of settlement programming.    This cohort experienced many issues merely because of its size and the speed at which it arrived. Firstly, there was extreme pressure put on the housing market to host refugee beds. Secondly, due to the speed of the influx, there was all around confusion amongst the government, settlement, and mental health sectors regarding which agencies were providing what services and under which mandate. Thirdly, due to the refugee influx, there was an insufficient amount of time to prepare additional English classes. This meant that the class times, childcare, and hiring of new language support workers were never organized. Similarly, key informants reported that the large flow of newcomers and lack of collaboration among agencies resulted in mental health supports being completely forgotten about in the resettlement process. There was not one trauma and settlement-informed mental health system in place during the arrival of refugees in Vancouver.  108! Proposed Policy Recommendation:  The proposed policy recommendation here is to create a Federal Support Platform (FSP). An FSP would be a federally organized platform for newcomers, settlement agencies, mental health agencies, and stakeholders to access one unifying web-experience to coordinate, coalesce, and organize settlement-related information.   This is a specific proposed action for the IRCC to fund out of the national settlement budgets, a pan Canadian settlement-informed trauma support program for refugees. The platform would be made accessible (via weblink) to newcomers with their package of acceptance to Canada. Here they would be able to access both general information and information specific to an individual refugee. Examples of specific information include the name of their settlement worker, proposed housing accommodations, and other essential information. This could kick-start the process of integration before they even arrive in Canada. In order to access this specific information, each refugee will be sent a login and password with their package of acceptance to Canada. As of now, access to this sort of information is found across different outlets and becomes available at different times throughout the process. By consolidating this data onto one platform refugees can find all the vital information pertaining to their migration in one place. Key informants repeatedly described how most refugees were equipped with cell phones and data plans. Cell phones could be used as a means to access the platform. The website would be designed with the compatibility to be translated into several languages.   The relevant settlement features of this platform would host the currently offered federal programming along with additional features to enhance resettlement including: (i) housing, (ii) English classes, (iii) mental health, (iv) community integration, (v) identifications, (vi) financial, and (vii) education and employment. Figure 5-1 depicts the layout of the proposed FSP.  109  Figure 5-1 Federal Settlement Platform (FSP)  Federal Settlement Platform(FSP)Housing English Classes Mental Health Community +IntegrationIdentificationFinancial Education +Employment*Policy Recommendation:to extend from 1 to 2years*Policy Recommendation:to offer trauma informedsettlement care module topracticing and licensedmental health clinicians*Policy Recommendation:to offer trauma informedsettlement care module tocounselling, psychology,psychiatry, and social workclinical training*Policy Recommendation:to offer registered clinicalcounsellors (RCCs) towork as consultants forInterim Federal HealthCare*Policy Recommendation:to offer incentives andgrants to special interestgroupsHealth 110   With this platform, agencies abroad can begin the processes of connecting newcomers with their settlement agencies. The settlement agency, in turn, can be better prepared to view profiles of the newcomers, who they will be arriving with, as well as any special needs right from the very beginning of acceptance into Canada.! Housing:   The newcomers can be connected to the housing that fits with their family needs. Interviews with key informants revealed that there were families of two parents with greater than two kids, however, only four people were allowed in one hotel room. This lead to many families being split up upon their arrival. Cases like this can be avoided if the size of the family can be determined beforehand and necessary housing accommodations are made. It can also be used to connect accommodating apartment buildings with vacancies with newcomers. Key informants revealed how this was the case during the large influx of 2015.! English Classes:  English classes could be assigned and registered for all online. Many of the Syrian refugees’ arrivals came to Canada with cellphones and data plans giving them access to the internet (allowing for easy access to registration). For those without data plans the internet can be accessed via a public library or internet café. Online registration proves to be optimal as newcomers, settlement professionals, and English-language professionals can see who is registered in their classes and who is yet to register. For increased accessibility classes can be made available online. Thus, alleviating the pressure of finding childcare, transportation, and lack of access for those situated in rural areas.    111! Health & Mental Health:  The health and mental health category would help to organize all health-related documents and paperwork. According to key informants, upon acceptance, the refugee organizers from the host country send health checkup documents to refugees. These documents are often lost during travel. These documents are also sent to resettlement agencies which are oftentimes mishandled, misplaced, or never arrive. The FSP can be used as an efficient streamlining tool by having all documents available on the federal settlement platform. This page would be login protected so only the immediate care team of the newcomer and the newcomer could access this information, thus, complying with privacy and health informant acts within Canada. As many resettlement workers perform a diagnostic mental health check-up in the cases where additional mental health support is needed these files could be flagged for further evaluation of supports required. Mental health clinicians working under IFH could also access their client files on this platform.! Community Integration:  According to key informants, during the initial reception phase the focus is for the orientation to be within six weeks of GAR’s arrival and securing permanent housing within two to three weeks. These timelines are part of the service goals for the national humanitarian program for GARs which carries out the resettlement assistance program.    Oftentimes refugees were rarely seen as more than someone needing housing for a long time upon arrival in Vancouver. This leads to delayed integration, a delayed sense of belonging, and delayed contribution to the community. Community partners such as religious affiliates, language groups, cultural or national groups, sports clubs, sporting and recreational arenas, food banks, interest groups (such as the orchestra or improv), peer to peer refugee groups, libraries, transport through Translink, mobi and other interest groups could set up pages for connection  112 with newcomers (provided they have digital literacy). This would be a way for newcomers to connect with groups they may have been a part of before they had to leave everything behind. For example, a refugee with musical inclinations could be connected with the Vancouver Symphony Orchestra. This could help integration from abroad and allow for these groups to have new members.! Identification:  During the arrivals key informants reported it was difficult to process refugees who had little or no paperwork. It created difficulties in many different areas such as employment, housing, and financials. This area of the platform could indicate to settlement workers which newcomers have paperwork. Any information gaps can be addressed as soon as possible (through mechanisms to start some of these processes abroad) or upon arrival.! Financial:  During their first year of arrival, newcomers are provided with a stipend. While key informants unanimously reported that the amount is very small and usually well below the poverty line, its process and tracking is very important and could be managed online by the newcomer. This could also alleviate the stress and confusion that occurs when newcomers shift from federal to provincial support. This would also streamline the process when newcomers transfer funds from their country of origin to local institutions.! Education and Employment:  According to key informants, the missed and interrupted schooling during displacement left many children, youth, and adults feeling left behind. On the FSP each newcomer could outline the level of education they received prior to displacement. This would help to encourage school  113 systems to appropriately recommend at which level the newcomer should enter the education system in Canada. For adults, it could help with foreign skills and training recognition. Graduate degrees and professional skills belonging to roles like doctors, nurses, engineers could be integrated into the job roles they would have held prior to displacement. Local employers or organizations needing volunteers could also post-calls to newcomers to gauge their interest and/or start a job application.! Information:  Successful examples of federal settlement platform-like web experiences exist in Europe. For example, newcomers in Sweden have dedicated newcomer profiles to outline their individual characteristics that can help host communities match their education skills, hobbies, and work experience with employment and other connections (Bordignon & Moriconi, 2017). Similarly, an early intervention protocol has been designed and piloted in Germany were newcomers’ skills and professional capacities were assessed using their declared work experiences and samples of work products (Bordignon & Moriconi, 2017).! Projected Outcomes:  There are several projected outcomes of the Federal Settlement Platform (FSP). First, this could give resettlement agencies ample time to organize their staff, programs, and process to during an influx. Second, it also preserves the dignity and agency of newcomers over starting their new life in a foreign country. Third, it allows for several sectors to be connected over the resettlement and integration of newcomers to foster the collaboration that was absent during the last influx. Fourth, it builds a framework for contribution to local organizations to assist during influxes. Fifth, it fosters coherence for the settlement process in that most resettlement resources, necessary paperwork and information can be found all in one place creating an easy flow of information. Sixth, it provides a concrete way for Immigration,  114 Refugees and Citizenship Canada to offer and measure successful integration. Seventh, it allows for newcomers to receive attention in a holistic method to their resettlement.! Tradeoffs:  If extra resources such as web servers, staff, time, and dollars are invested into the development of the Federal Settlement Platform (FSP) this would increase the capacity of newcomers, settlement agencies and stakeholders to access one unifying web-experience to manage all settlement-related information, steps, and services. The increase of the organization of all resettlement-related information would lead to the early and coordinated integration of newcomers allowing them to contribute to the economy and communities faster (Bordignon & Moriconi, 2017).  5.2.2! Policy Recommendation 2: Allow Counsellors to Consult as Mental Health Clinicians   Policy Recommendation  2: Allow and encourage clinical counsellors (RCCs, referring to those licensed by the British Columbia Association of Clinical Counselors) to apply to work as consultants under Interim Federal Health Care to provide settlement-informed counselling to refugees.!  Defining the Problem:  According to key informants currently under the Interim Federal Health (IFH) policy managed by the office of Immigration, Refugees, Citizenship Canada (IRCC) newcomers are under the purview of the federal government. As such, their health care needs fall under this federal system of heath care. It covers, physicians, dentists, specialists, para-medical practitioners (psychiatrists and psychologists). However, the clinicians registered under the Medavie Blue Cross system may not be specialized in trauma-informed or cross-cultural competencies (Newbold & Mckeary, 2018).    115  Key informants reported that due to the small numbers of providers there are long wait lists. The absence of mental health practitioners who are able and willing to provide trauma-informed settlement services due to federal regulations is costly to the communities and the newcomers. With high rates of psychological distress, depression, anxiety, and traumatic symptoms newcomers are at risk for delayed integration, sense of belonging, and contributing to their host societies. The major operative of IFH is to provide intermediary health provisions to newcomers before falling under provincial jurisdictions of health care. During this initial entry into a host country there are specific challenges the newcomers are dealing with related to trauma and displacement. It is critical to have mental health clinicians who are able and willing to help the ability to offer services under IFH. One key informant stated “There’s need to fund through national settlement budget to allocate specific resources for the development of specialized settlement-informed trauma treatment interventions in all of the resettlement assistance across Canada.”! Proposed Policy Recommendation:  The policy recommendation proposed alternative is to allow individual registered clinical counsellors (RCCs) with refugee and trauma and settlement-informed training to enlist under the Interim Federal Health system as consultants. Individual RCCs who have expertise that is needed by IFH can apply to be enlisted under IFH’s mental health practitioner or professional category.! Information:   There are nearly 4,000 registered clinicians in British Columbia. A large portion of whom have trauma-informed skills, cross-cultural competencies, know multiple languages, are accessible and available, and want to work with the refugee community. This recommendation is rooted in both the quantitative frequency computational analysis findings and qualitative analysis findings. The quantitative frequency computational analysis themes including: 1) policy and education; 2) community, families, and refugees; and 3) mental health care and primary health care, support this recommendation. Further, this  116 recommendation also represents the four qualitative themes that mental health services should be a priority, that mental health services should be available to all refugees, that mental health services should be trauma & settlement-informed, and that mental health services should be collaborative.! Projected Outcomes:   The policy recommendation that graduate level educated counselors should be able to offer newcomers mental health services under IFH has many beneficial projected outcomes. The benefits are critically important for planning mental health services in the post-flight context, be it resettlement, returning home, or living indefinitely in another country. The individuals impacted include stakeholders such as: resettlement agencies who can then focus on resettlement instead of pseudo-psychology services and newcomers can receive professional settlement and trauma-informed support. The key collaborators would be IFH and resettlement agencies across the country. The sponsors would include IFH and RCCs who would provide the service. IFH support informal mental health care and can make this happen with increased intentional budgeting for mental health. The potential challenges could be the service providers currently funded under IFH that may need to give up some resources to accommodate for increased practitioners. This idea may be piloted with newcomers for a temporary amount of time with RCCs who specialize in resettlement and trauma-informed care. The proposed policy recommendation would have a positive effect on newcomer mental health, integration, and well-being.! Tradeoffs:   By recognizing RCCs as mental health consultants and allowing those who wish to practice under federally supported mental health care there would be a marked increase in the number of available mental health professionals while also lowering costs spent on (higher paid) psychiatrists and psychologists. The increase in well-trained service providers would allow for newcomers to access services regularly and promote healthy integration of newcomers.  117  5.2.3! Policy Recommendation 3: Up-skill Current Practicing & Licensed Mental Health Clinicians  Policy Recommendation  3: Up-skill current practicing and licensed mental health clinicians by creating a federally supported training module for trauma- and settlement-informed mental health care.! Defining the Problem:  During key informant interviews, it became clear that currently there are health professionals registered under Interim Federal Health (IFH) who do not have experience or training in trauma-informed settlement care. Under the IFH registered professionals list there were two Arabic speaking professionals. However, neither of those professionals listed exhibited refugee or displacement specializations in their profiles. There is a critical need to build capacity within the current fraternity of mental health clinicians to work with refugees as professionals listed under IFH.! Proposed Policy Recommendation:  The proposed policy recommendation is a 5-lesson research-supported, evidence-informed, and experiential module focusing on trauma and settlement-informed mental health care for seasoned clinicians. The module would cover: (i) diversity training, (ii) trauma, (iii) displacement, (iv) rights and legal processes, and (v) resettlement. These are five foundational topics that are crucial for mental health clinicians to understand when working with refugee populations. It can be used to up-skill practicing medical, psychology, psychiatric, counseling, and social workers who seek to work and provide refugee mental health care under IFH. It can be held at the Immigrant Services Society location in Vancouver and other similar resettlement hubs across the country.   118! Projected Outcomes:  The obvious and immediate benefit of implementing a training module for clinicians would be the marked increase in qualified professionals available. This would also allow current practitioners to up-skill their aptitudes when working with refugees. Communities will also benefit by having more well trained and skills-equipped clinicians available to provide mental-healthcare. Perhaps the most important benefit of one unilateral training module to up-skill clinicians is that it creates uniformity across the clinical treatments offered to refugees. A homogeneous approach to treatment allows for easier evaluations of symptoms and progress amongst patient populations. Uniformity in care also allows a refugee to receive care from a different clinician with minimal disruption in treatment if the need arises such as in the case of relocation.    There would be increased support for newcomers in group settings, private clinic settings, and within the settlement arena. The outcome would be better integration and mental health supports in host communities. It could also lead to better English learning and language acquisition and better overall integration in the community. The policy recommendation reinforces the idea that since GARs are selected based on vulnerability criteria the government should resettle individuals with the help of informed professionals to best support refugee transition and settlement.! Tradeoffs:   If extra resources such as staff, time, and dollars are invested into the up-skilling of practicing mental health clinicians this would increase the capacity of current mental health professionals registered under IFH. The increase of capacity in current mental health professionals would lead to more adequately trained clinicians to support newcomers’ early integration in host communities.    119 5.2.4! Policy Recommendation 4: Create Trauma and Settlement-Informed Curriculum for Students in Mental Health Clinical Training Programs  Policy Recommendation 4: To develop curriculum in trauma- and settlement-informed mental health care to students in medical, psychology, psychiatric, counseling, and social work within clinical training programs.! Defining the Problem:  During key informant interviews, it became clear that students in health professions do not receive adequate experience or training in trauma-informed settlement care. The problem is also ongoing as the current curriculum for new clinicians does not include trauma-informed settlement care. There is a critical need to build capacity for the future of various mental health clinicians to work with refugees as professionals listed under IFH.! Proposed Policy Recommendation:  The proposed policy recommendation is a five-lesson research supported, evidence-based, and experiential module focusing on trauma and settlement-informed mental health care for students. The module would cover: (i) diversity training, (ii) trauma, (iii) displacement, (iv) rights and legal processes, and (v) resettlement. These are five foundational topics that are crucial for students of mental health professions to understand when working with refugee populations. It can be taught within core programming for medical, psychology, psychiatric, counseling, and social work training programs. It can be held at the Immigrant Services Society location in Vancouver and at other similar resettlement hubs across the country.   120! Projected Outcomes:  There would be many beneficial outcomes including having students well prepared in their mental health professional course work. By having well trained, skills-equipped, and prepared students communities will benefit at large by improving integration and settlement to newcomers in host communities. The policy recommendation reifies that since GARs are selected based on vulnerability criteria the government should resettle individuals with professionals to best support their transition and settlement.! Tradeoffs:   If extra resources such as time and money are invested in students of mental health professions (psychologists, psychiatrists, registered clinical counsellors, and social workers) this would increase the capacity of future registered professionals. The increase of trauma- and settlement-informed capacity in IFH providers would lead to the integration of newcomers allowing them to contribute to the economy and communities faster and could potentially provide a return on investment of $23,000 per newcomer (Vancity, 2016).  5.2.5! Policy Recommendation 5: Increase Federal Support from One to Two Years  Policy Recommendation  5: Increase specific federal programs for refugees including English classes, and Interim Federal Health Coverage to be extended from one year to two years for refugees.! Defining the Problem:  According to key informant interviews, there were half to one full year-long waitlists for federally provided English language classes. These wait times impact how long it takes newcomers to apply to education programs, apply for jobs, and enter the workforce. This ultimately delays the newcomers’  121 contribution to the community and local economy. Key informants also described how health care needs for refugees may be blurred under anxieties of displacement and relocating and health needs can surface later on.! Proposed Policy Recommendation:  The proposed policy recommendation is that federal coverage and language assistance programs be extended from one year to two years. This would be under the new Federal Settlement Plan (FSP). The additional coverage for newcomers would allow a safety net during cognitively distressing times. It would also allow for follow up visits for treatments and services that have long waitlists, thus, allowing for more complete health care.! Global Precedents:  A successful example of this exists in Norway. The Norwegian government facilitates the delivery of up to 250 hours of language classes and training to refugees who are awaiting longer-term accommodations and are still in reception centers (Bordignon & Moriconi, 2017). This is an example of sufficient time invested into newcomers as a method of early interventions. Early interventions are likely to be effective to expedite integration especially for those looking to enter the labour market (Vancity, 2016).! Projected Outcomes:  All aspects can be coordinated and managed online allowing newcomers to submit paperwork and book necessary appointments. Healthcare clinicians providing immediate care could access paperwork, appointment bookings, and treatment care. English language class teachers and coordinators could manage class lists, course offerings, and student profiles all on the platform. Finally, the financial aspect would also be managed all online through the FSP.  122! Tradeoffs:  If IFH federal supports for newcomers are increased to two years (under FSP) this would increase the ability of newcomers to access services in case of large arrivals. The increased ability of newcomers to access federal supports would help to ensure that newcomers are supported during their first stages of arrival in host communities.  5.2.6! Policy Recommendation 6: Offer Incentives to Community Partners  Policy Recommendation  6: Offer incentive programs and grants under Immigration, Refugees, Citizenship Canada to community and integration partners for inclusive programming.! Defining the Problem:  There is currently no way of finding out additional information about newcomer hobbies or interests to support integration and settlement prior to arrival in Canada. Key informants reported that it takes weeks and months to collect data about newcomer hobbies and/or activities prior to displacement. Many newcomers fail to realize that many of the interests they partook in prior to displacement may be prevalent in their host city. Similarly, newcomers may not know how to facilitate a connection with such interest groups. Alleviating this problem could prevent newcomer issues such as: isolation, absence of belonging, possible marginalization, and risks to integration and settlement.! Proposed Policy Recommendation:  The proposed policy recommendation is to allow community partners such as: religious congregations, language groups, cultural or national affiliations, sports clubs, sporting and recreational  123 arenas, food banks, interest groups (such as the orchestra or improv), peer to peer refugee groups, libraries, transport through Translink, mobi (bicycle share)and other interest groups to receive incentives or grants by setting up pages for connection with newcomers on the Federal Settlement Platform (FSP). As part of pre-arrival programming, there could be a refugee strength- based assessment tool that captures previous education, special skills, and employment (including self-employment) history. Settlement agencies would use this information to develop more advanced and comprehensive settlement action plans. This would be a way to encourage these interest groups to engage newcomers to connect with groups they may have interests they had to leave behind. For example, a refugee could be connected with the Vancouver Symphony Orchestra or with a library and, in turn, these groups could receive support for their programming.! Global Policy Precedents:  Research shows that Sweden is one of the best performers when it comes to policies that integrate and engage newcomers without risking further isolation, segregation, and marginalization (Bordignon & Moriconi, 2017). Along similar lines, the Danish ‘Step-model’ policy gradually leads new arrivals and longer-term immigrants into regular employment via intensive language training, an introduction to the workplace and subsidized initial employment, which can be combined with further on-the-job language training and up-skilling.! Projected Outcomes:  Implementing the Federal Settlement Platform (FSP) and incentivizing various community partners (see Community Partners) to engage newcomers through the integration boards there can lead to positive effects on newcomer integration, sense of belonging, and contribution to host societies. The various interest groups would also have a sense of purpose to give back to their community and engage newcomers. Government incentives via subsidies and grants have many desirable effects on activities of  124 organizations most common of which is stimulating engagement. These financial incentives can also play a role in the site of relationships between governments and nonprofits or other organizations (Bardach, 2000). Subsidies and grants can also be a mechanism to transfer wealth from one end of a system to another in order to make recipients create more transactions with their clients or with the community (Bardach, 2000).! Tradeoffs:  If extra resources are allocated to enlist and incentivize special interest groups to engage with newcomers, this would increase the ways these groups can create programming and reach out to newcomers. The increased connection between special interest groups and newcomers would lead to faster and more meaningful ways for newcomers to integrate into the community and rebuild their lives and identities in host communities.  5.2.7! Summary:  Overall, the findings produced in the research of this dissertation were analyzed and incorporated to develop six key federal policy recommendations using the University of British Columbia’s School of Public Policy, Policy Design Canvas 2.0 (April 2017) and Bardach’s (2000) A Practical Guide for Policy Analysis see Table 5.1 Policy Recommendations Summary below.     125  Table 5-1 Policy Recommendations Summary Table Policy Recommendation # Wording Problem Defined Proposed Alternative Policy Recommendation 1   Create a Federally Supported Settlement Platform Create a Federal Support Platform (FSP) for newcomers, settlement agencies, and stakeholders to access one unifying web-experience to coordinate, coalesce, and organize settlement-related information. Key informants reported lack of collaboration and organization among agencies, mental health supports, childcare, and government supports. The proposed alternative is a platform for newcomers and settlement stakeholders to kick- start the process of integration before arrival. The settlement agency can be better prepared to view profiles of the newcomers as well as any special needs right from the very beginning of acceptance into Canada.     Policy Recommendation 2   Allow Clinical Counsellors to Offer Trauma- and Settlement-informed Counselling as Federal Health Consultants Allow and encourage registered clinical counsellors (RCCs) to apply to work as consultants under Interim Federal Health Care to provide settlement-informed counselling to refugees. Key informants reported that due to the small numbers of providers there are long wait lists. The absence of mental health practitioners who are able and willing to provide trauma-informed settlement services due to federal regulations is costly to the communities and the newcomers. The proposed alternative is to allow individual registered clinical counselors (RCCs) referring to those licensed with the British Columbia Association of Clinical Counsellors, to enlist under the Interim Federal Health system as consultants. Individual RCCs who have expertise that is needed by IFH can apply to be enlisted under IFH’s mental health practitioner or professional category     Policy Recommendation 3   Up-skill Current Practicing and Licensed Mental Health clinicians  Create a federally supported training module for trauma-informed settlement mental health care to up-skill current practicing and licensed mental health clinicians registered under Interim Federal Health (IFH) Key informants reported that currently there are seasoned health professionals registered under Interim Federal Health (IFH) who do not have experiences or training in trauma-informed settlement care  The proposed alternative is to up-skill practicing medical, psychology, psychiatric, counseling, and social workers who seek to work and provide refugee mental health care under IFH.      126 Policy Recommendation 4   Create Trauma- and Settlement-informed Curriculum for Students in Mental Health Clinical training programs  To offer a federally supported new clinician training for trauma-informed settlement mental health care in medical, psychology, psychiatric, counselling, and social work within clinical training programs. Key informants reported that currently there is a gap in health professionals training around building capacity in trauma-informed settlement care.  The proposed alternative is to train new clinicians during their clinical training including: (i) diversity training, (ii) trauma, (iii) displacement, (iv) rights and legal processes, and (v) resettlement. These are five foundational topics that are crucial for mental health clinicians to understand when working with refugee populations.     Policy Recommendation 5   Increase Federal Settlement Supports from One to Two Years  Increase specific federal programs for refugees including English classes, and Interim Federal Health Coverage to be extended from one year to two years for refugees. Key informants reported there were half to one full year long waitlists for federally provided English language classes. These wait times impact how long it takes newcomers to apply to education programs, apply for jobs and enter the work force. This ultimately delays the newcomers’ contribution to the community and local economy.  The proposed alternative is that federal coverage of English language classes, medical coverage and financial support be extended from one year to two years. Policy Recommendation 6   Offer Incentives to Community Engagement Partners  Offer incentive programs and grants under Immigration, Refugees, Citizenship Canada to community and integration partners for inclusive programming. Great idea! Key informant reported there was currently no way of finding out additional information about newcomer hobbies or interests to support integration and settlement prior to arrival in Canada. Similarly, newcomers may not know how to contact or facilitation a connection with such interest groups leading to isolation, the absence of belonging, possibly marginalization and risks to integration and settlement. To allow community partners such as: religious congregations, language groups, cultural or national affiliations, sports clubs, sporting and recreational arenas, food banks, interest groups (such as the orchestra or improv), peer to peer refugee groups, libraries, transport through Translink, mobi and other interest groups to receive incentives or grants by setting up pages for connection with newcomers on the Federal Settlement Platform (FSP).    This information adds to the extant body of literature and may be useful to those who have wider mandates, responsibilities, and agendas as stakeholders in refugee resettlement. According to key informants, many last-minute adjustments during the influx were made through budgetary allowances from various ministries. For example, one key informant reported that funds were acquired through the  127 Ministry of Tourism to provide settlement services. As such, there may be funding for these programs in various unused budgets to support the much needed Federal Settlement Platform (FSP).    128 Chapter 6:!Critical Reflections  This dissertation culminates four years of research, study, and reflection on the topic of refugee well-being. Countless hours were spent in reading topic related literature. Books, periodicals, reports, and journal articles were studied in order to become proficient in the fields of well-being, refugees, strategic design, and settlement in Vancouver. The research in this dissertation included various systematic components of research and their resultant findings. First, the research in this dissertation revealed the lack of mental health services that were available to GARs during their first year of arrival. This research also highlighted the gaps in services available during that time period represented in thematic findings. Finally, all findings were systematically evaluated in order to develop federal level policy recommendations. Now, with this dissertation being finished the key latent reflections that developed over the course of this journey are becoming increasingly lucid. These discoveries include a reflective critique of the topics of this research.   A critique can be described as a systematic method of reporting both strengths and weaknesses of a topic rather than focusing on negatives alone (Valente, 2003). A discussion based on limitations alone can paint an incomplete picture of research factors (Coughlan, Cronin, & Ryan, 2007). Since this study takes a strategic design approach any critical observation can be used to improve an iteration of a design, delivery, or application of the research factors discussed below. Any comments or observations in this chapter are relevant to the construct and are not aimed at individuals who are directly or indirectly linked to them. Generally, critiques are meant to be objective and efforts are made to aspire to this especially with attention to presenting both strengths and limitations. Linking observations to evidence in research can further support objectivity. Further, the observations are not presented to be disparaging but instead inspire discussion and further thought on elements that contributed to the research.     129 6.1! Operation Syrian Refugee  Operation Syrian refugees was an unusual movement and at the time it was unlike any previous refugee admittance programs in Canada. When the arrivals came to Vancouver, key informants described hastily devised top-down directions from the federal government seemingly without any strategic planning. Hundreds of families who were invited to Canada through federal government assistance programs were forced to stay in hotels as no accommodations had been planned for them.    While this study looks to contribute to knowledge that can help improve the overall well-being of GARs via mental health services, the global conditions that give rise to refugees and that are the cause of much of their traumas are still rampant. One such global condition is war. It is widely known that lucrative military contracts worth billions are made between Canada and countries that have been charged with human rights violations (Jansen, 2018). Research from the University of Victoria explains that it is confusing and saddening that Canada condemns violence, acts to advocate human rights, and welcomes refugees while concurrently selling thousands of armoured trucks to war-torn countries (Jansen, 2018). Perhaps more can be done to investigate and research how to halt the social, geopolitical, and economic systemic forces that create refugees across the world. For example, there could be increased transparency on how countries which seem to value democracy and peacefulness can oftentimes benefit from dictator led wars in other countries (Dwiharianto, 2017; Pierre, 2014).   Further, along with national and global transparencies, more can be done to make asylum seeking less burdensome to an already stressful and usually life-threatening situation. It can be a difficult process for many individuals and families who are displaced to seek out a UNHCR office to register as a refugee (Rousseau et al, 2002). The necessary processes of seeking refuge can be stress-inducing as is the case with registering as a convention refugee. These processes can be streamlined and modernized in response to the growing number of individuals experiencing displacement in the world. One example of a modern  130 tool that can streamline refugee resettlement is the proposed Federal Settlement Plan (FSP) (see Chapter 5), which could be used to help newcomers begin a smooth integration process prior to landing in host communities.   Easing into host communities could be vital to integration as each major wave of refugees arriving in Vancouver may witness discrimination. Even though the face of refugee waves shift across generations, each refugee wave suffers discrimination. Sometimes, the rhetoric of who came here first can lead to the false impression of legitimacy to the issue of belonging in Canada. Human nature inherently supports a short memory that overlooks the glaring fact that all populations who are not, in fact, indigenous are immigrants or refugees from other parts of the world.    Research often reminds readers that during its first hundred years, the Confederation of Canada was made up of refugee and immigrant populations from various European countries. Since then there has been a shift towards more newcomers arriving from Asia, Africa and Central and South America (Kirmayer et al., 2011). Large movements from Vietnam, Hungary, Italy, and Uganda have increased Canada’s multicultural landscape as well as its economic stability.   A similar reminder to use person-first language such as “people with refugee experience” would help to remind us that refugees are human beings first and that their experiences do not have to define them or follow them indefinitely.  6.2! Service Journey Mapping  As a developer and proponent of the service journey map methodology, Kimbell (2014) proposes service journey mapping as being effective across disciplines and within cross-sector applications. In the present study, however the service journey maps took more steps than expected to complete. For example,  131 all service journey maps were emailed to key informants prior to the interview. This was both to increase familiarity with research documents relating to the study and to also to aid in the completion of the service journey map. However, every service journey map had to be filled out during the interview as no key informants completed it beforehand. As a result, potential researcher effects may have influenced how the service journey map was completed. Upon a replication of this study, it may be of value to note any differences if service journey maps are instead filled out by key informants without the presence of the researcher.    An additional research effect could be attributed to the lack of familiarity with the tool due to this research method being used with limited applications in the psychology field and more so in design and business. It could also be attributed to the explanation of how to complete it, or perhaps the cumbersome appearance of twenty-four data points to fill out. The service journey map did, however, help to create a context for conversations that were important and meaningful to this research. For example, having the service journey map divided across time in three-month increments allowed key informants to break up the first year when the large wave of newcomers arrived. This was helpful to enable key informants to remember events and experiences in certain months and stages across the first year. Even though there were no formal services, it reminded key informants of other anecdotal but important information. One example of this pertained to housing.    The service journey maps’ temporal demarcations did, however, help to signify when the younger school-aged newcomers should have been in school. For example, since many newcomers arrived during the middle of the school year, many children and youth were not registered in elementary or secondary school. As mentioned earlier, there was also a reported reluctance from the school boards to accept new students without permanent addresses.    132  The service journey map sparked these conversations and allowed for them to be nuanced by both the temporal and population features it represented. Another further conversation that the service journey map initiated surrounded the population’s subgroups including men, women, and families. Conversations led to a variety of recommendations for variations of the service journey map that could have been more inclusive. For example, there could be an unnamed segment on the Y-axis for the population. In this manner, the key informants were able to indicate if their agencies offered mental health services to a group that was not one of the groups (eg. women, families, men) represented in the service journey map.  6.3! LGBTQ+  As mentioned above, the service journey map included services to men, women, and families. It did not include any additional or unnamed categories that could be filled out by the key informants (i.e., LGBTQ+). The rationale for this was to avoid any undue misrepresentation or misinformation about the group without adequate experience with this population. This is a body of research that is growing and still needs more attention in mental health and specifically mental health of refugee individuals (Hopkinson et al., 2017). In Vancouver, there is an organization that helps individuals who suffer persecution due to their gender, sexuality, and other issues called Rainbow Refugee. While in North America and other parts of the world there has been a growing shift toward acceptance and inclusivity of those who identify as LGBTQ+, some governments still “stigmatize, criminalize, and legitimize abuse” of this population (Messih, 2016, p 5). The Weill Cornell Medical College has done extensive work in this area focusing on the psychological impact of anti-LGBT persecution that causes individuals to seek refuge across the world (Hopkinson et al., 2017; Shidlo, & Ahola, 2013). The LGBTQ+ forced migrants are distinct from other migrant groups since their families of origin may also be the source of abuse (Shidlo, & Ahola, 2013). When compared with their non-LGBTQ+ counterparts from the same countries, LGBTQ+ refugees had higher incidents of emotional, physical, sexual, and verbal violence, corrective rape, isolation, and denigration (Hopkinson et al., 2017). These experiences of persecution that cause  133 LGBTQ+ individuals to fear for their safety can produce a “history of multiple traumatic events across their lifespan” (Shidlo, & Ahola, 2013, p. 9).  6.4! Key Informant Methodology  The spread of the key informant methodology ascribes its use across disciplines in the social sciences. While the key informant methodology worked well in this study, there could be some research effects unaccounted for simply based on the design of this method. For example, due to their expertise in the field, the key informant responses may be coloured by the organization they represent. In other cases, key informants may be in a particular professional role for other motivations or life experiences, whose effects are difficult to account for in research. Biases due to length of experience in the field could also host undue research effects.  6.5! Media & Discrimination  The influence of the media on humanitarian issues is multi-faceted and complex (Buchanan, et al. 2017). These influences are often credited with having the power to sway public feeling and emotions about world events. The photo of deceased three year old Alan Kurdi (see Chapter 1) created a shift in global perception of the refugee crisis by reminding people that there are countless humans in “distant suffering” due to war (Höijer, 2004, p 513). This begs the question as to why other refugee populations fail to receive the same media coverage and why it took so long for the media to bring light to the effects of the Syrian war that had be raging for years before Kurdi’s photo.    Mainstream media arguably has the monopoly on what is or is not worthy of talking about through story coverage (Höijer, 2004). There are obviously cases of dark-skinned refugees across cultures who get stranded or pass away on their journey to find refuge who do not make it to the front page of a newspaper. Yet, there is a disproportionate representation of lighter skin-coloured and lighter eye-coloured refugees  134 covered by media including magazines. Further this issue of covering lighter skinned refugees may stem from popular media where research shows that only 9% of magazines covers feature people of colour (Office for National Statistics, 2017). This has led to newspaper, blog, and other popular media outlets and speakers to question the favour for media coverage of light-skinned refugees.    There have been repeated instances of an Anglo bias and preference on the part of the media. For example, the infamous 1985 issue of National Geographic which featured a young green-eyed female the media named “the Afghan Girl” on its cover (Braun, 2003). The photographer (a white American male) selected this photo “out of hundreds” shot the same day. His choice of that photo for the cover has been noted as the major contributing factor for the West to learn more about refugee camps in Pakistan which have been hosting thousands of Afghans for decades (Braun, 2003).    To address this pattern (of choosing refugees with Caucasian aesthetics as the faces of media covered refugee stories), a question can be formulated around whether there is a tendency for the western media to “internalize white racial norms” when covering migrant stories. Another interesting inquisition would be into whether the lightness or darkness of refugees affects how much media attention, humanitarian assistance, and aid they receive (Balgopal, 2000, p 86).    The media also influences beliefs about newcomers with vague or insinuating stories linking criminality with newcomers. This linkage can occur without directly saying it or without presenting evidence but by merely positioning the two unrelated stories (ie. a story about refugee settlement and another story about an increase in crime) either adjacent to each other or in sequence to one another (Höijer, 2004). This type of story positioning can be suggestive that one causes the other.   Taking into consideration the power and influence of the media, there needs to be more transparency and fluency in the decision-making process of the media in regard to their coverage of  135 refugees. A call for more research on how the media chooses which refugee stories go to print would aid in answering many of the questions of researchers presented in this section.  6.6! Summary  The process of researching and writing this document has led to critical reflections surrounding possible solutions, reform, and has the capacity to add to meaningful and actionable change in the implementation of refugee centric mental health care. This section reinforced the obvious importance of creating positive change in settlement and trauma-informed mental health care and surrounding disciplines like media. While the forging of perspectives and notions from different arenas has the capacity to result in the conception of novel problem-solving solutions it must also recognize and critically reflect on questioning norms. Such critical reflection can help to see the nuances and multi-dimensions of not only the research effects of the sampling technique and data collection tools but also the societal norms which can cause barriers to integration. Well-being is a human right. Geographies, politics, education, and economic and other systemic features can both be the reason and the solution for this work and research.      136 Chapter 7:!Conclusion   This chapter concludes this dissertation by summarizing the research context, methodologies, findings, implications and contributions, limitation and closes with concluding remarks.   7.1! Research Contextualization  Research has shown the need for refugee mental health care in host communities (Fozdar &Torezani, 2008; HELP, 2016; O’Toole, Corcoran, & Todd, 2015; Thomas & Lu, 2001). However, evaluation of refugee mental health care services in host communities exists to a lesser extent in the literature. In Vancouver, there was no available research on the mental health services provided to government-assisted refugees during the large admittance in 2015 and 2016. Vancouver based Immigrant Services Society also showed that 30% of government-assisted refugees were experiencing mental distress during that same time. As a consequence this research examined the available mental health care services to government-assisted refugees during the large arrival in 2015 and 2016 and what improvements could be made to those services (see Chapter 1 and 2).  7.2! Research Methods  A thorough review of relevant literature on well-being, the refugee crisis of 2014, strategic design, and the research methodology used in this study was presented. This study applied a key informant methodology to design and conduct interviews about refugee mental health care services in Vancouver. The key informant study participants included (public servants, mental health professionals, and settlement professionals) and used service journey map and interview techniques to collect data. The data analysis combined the use of qualitative data analysis and quantitative frequency computational analysis (see Chapter 3). The analyses of the findings were further developed into policy recommendations using the UBC Policy Schools Policy Design Canvas and Bardach’s Guide to Policy Analysis.  137 7.3! Research Findings  This study found there were no formal trauma- and settlement-informed mental health care services available to government-assisted refugees and very few informal mental health services. Thematic findings accompanied by quantitative frequency computational analysis revealed improvements are needed for refugee mental health care. The four main needs for refugee mental health found were: (i) the need to be seen as a priority, (ii) the need to be provided and accessible to all refugees, (iii) the need to be trauma- and settlement-informed, and (iv) the need to be collaborative. The politics surrounding mental health care were also found to be nebulous due to confusion about health care jurisdictions for refugees (see Chapter 4).  7.4! Research Implications and Contributions  The principal purpose of this study was to determine what mental health services were available to GARs, what gaps may have been present in those services, and how these findings could be developed into policy recommendations to improve refugee well-being in host communities. These three research questions were explicitly answered using the interdisciplinary research data collection methods, findings and policy recommendations (Chapter 5).   The implications for the study lie in replication, education, potential policy reform, and future research on refugee populations in Canada in order to develop best practices. This study’s methodology can be replicated in other refugee host-communities to examine their mental health care for refugees. The use of key informants provides useful, deep, rich sources of data with years of specialized experiences that can offer a large volume of data targeted specifically to answering the research questions. The combined use of the service journey map with interviewing increases interdisciplinary cross-pollination of research methodologies and data collection techniques. The combination of qualitative analysis and computational frequency analyses also adds dimension and deeper understanding of the collected data.   138   This research can be used for the further education in host communities that may be welcoming refugees. It can also be used to emphasize the need for trauma and settlement-informed training for mental health clinicians. This research can be used to train teachers, language educators, border officers, and others who work directly with refugees the importance of a trauma- and settlement-informed lens. This approach could also be helpful to inform policymakers whose decisions influence and impact refugees entering host communities. This research is useful to emphasize the need for trauma- and settlement-informed training for existing and future mental health clinicians. By educating these members of important refugee-facing sectors about the data collected from expert key informants they could be better prepared to do their work with refugees.   Additionally, the implications of this research could lie in policy reform. Added to the volume of research on settlement in Canada, this research could be used for formal federal policy recommendations. Polices could impact settlement agencies who provide care to refugees, to health care bodies and agencies, and could be added to the volume of research used to lobby the federal support systems to provide improved refugee mental health care to GARs. One such example was the proposal for the Federal Settlement Platform (FSP). The FSP is proposed to be a federally supported online platform for newcomers, settlement agencies, and stakeholders to access all necessary settlement-related information and documentation on one unifying web experience. The intention for the development of the platform was to help in GAR resettlement procedures, integration, accessibility to necessary information and for settlement workers to be able to keep track on the progress of their assigned refugee to kick-start the process of integration even before they arrive in Canada (see Chapter 5).    A final implication of this study and its recommendations could be used for further research. For example, the FSP could be used to garner important demographic information such as where newcomers are settling, how many people there are in each family, what are their age ranges and gender, and what  139 their annual income and tax contribution is. The information from the FSP could also be used for more sophisticated analysis such as what courses refugees are enrolled in, which courses are completed faster, what jobs are refugees able to acquire based on the courses they enrolled in, and how their past education and professional skills are helping them enter the workforce. This type of information can help to equip settlement agencies and the IRCC learn from refugees about what works for them in order to develop best practices in refugee settlement. Learning best practices reifies the strategic design alignment of this research (a major tenet of which is to build upon solutions with iterations of improvements). The development of best practices can lead to further dissemination of information across Canadian communities and transnationally to other communities welcoming refugees in order to improve the well-being of newcomers in host communities.  7.5! Research Critique and Limitations   Research critique and limitations included aspects that could be improved upon during replication of this study. First was the novel use of service journey mapping technique regarding mental health services. This was a strategic design research technique used in mental health and was new to all key informants causing unfamiliarity with this data collection tool. While service journey mapping yielded a large amount of information it could have been enhanced with more explanation. Second, the interview questions did not include LGBTQ+ populations which could be included in further replication to get a broader view of services offered to this marginalized group. Finally, while this research aimed to understand mental health services available to newcomer refugee populations (men, women, and families) it’s scope was limited by not including recommendations for age-specific therapies i.e. children and youth (see Chapter 6).   140 7.6! Directions for Future Research  The research was conducted by studying books, periodicals, journals, and articles that comprise the literature upon which this dissertation is based. The research pursuit of well-being reflects the work of hundreds of like-minded researchers. It also reveals that there are still many questions remaining surrounding refugee well-being and mental health. The community of researchers studying well-being has a broad reach and the capability to disseminate and share knowledge. The knowledge gained from this research could be applied to inform new settlement services, to show how communities support newcomers, to justify how existing services can be improved; and to recommend policies to governments.   This dissertation brings light to the deliberate and creative efforts of the leaders of refugee-serving agencies (i.e., key informants). These leaders strive to provide care with shrinking budgets, short notification surrounding the arrival of waves of newcomers, and shallow pools of information. This research dissertation elicited insightful recommendations to improve upon refugee centered well-being resources and policies with the informed experiences and knowledge of these leaders. These invaluable suggestions can be formally compiled and offered as official recommendations to elected officials in making difficult budgetary, planning, and strategic decisions towards mental health care services to improve the well-being refugees.   Opportunities for future research lie in several areas. Many newcomers arrive severely distressed, malnourished, terrorized and in shock (Murray, Davidson & Schweitzer, 2010). Research in this area of refugee arrival focuses initially on rebuilding feelings of safety and treating stress-related trauma (Ehntholt & Yule, 2006). More data showing which settlement-informed health services should be immediately available upon refugee treatments upon arrival could prove useful. Immediate care may be instrumental in stopping the progression of a current ailment and preventing new mental health issues from arising. Thus, it would be favorable to ascertain what resources and/or services should be accessible  141 to newcomers right away. Research can be carried out for evidence-based best practices when working with refugees (Kirmayer, Guzder, & Rousseau, 2014). An example of this would be a cumulative repertoire of trauma and settlement-informed tools which could be beneficial in several ways. Best practices could be formed and may assist in service provision. Training for mental health staff working in this area could be based on this research. It could also inform policymakers in focusing on certain areas to develop funding and greater service provision. It is crucial for this sort of research that seeks to answer what host countries can do to help the resettlement process and the well-being of refugees to be undertaken and it is equally imperative that more data be available on the cultural and ethnic make-up of refugee groups. Finally, research on current mental health service practices should be assessed to ensure compatibility with trauma settlement-informed practices.   7.7! Research Conclusions  Overall, this research contributes to the domain of well-being, refugee mental health, strategic design, and settlement policy with an overarching aim to help improve the well-being of refugee newcomers in host communities. This research contributed to a better understanding of the mental health care services provided to government-assisted refugees during the significant admittance in 2015 and 2016 in Vancouver. Previous research has emphasized the need for refugee mental health care, however, no research had been conducted on Vancouver’s refugee mental health scene to examine its efficacy. In particular, little emphasis was placed on learning from experts in the field of resettlement and using their specialized knowledge to not only understand the supports that were offered but further understand how they could be improved. With the instrumental support from cross-sector key informant collaborators, this research was able to ascertain a broad view of what the needs were and what changes could be made. Including learning that investing in refugees is directly investing in the Canadian communities they will integrate into. The more emotionally and mentally stable refugees are, the more efficaciously they can contribute back to their host communities. 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