Project 'Levensboek': development of a method for older refugees, war victims and veterans with depressive symptoms.

There is a high incidence of mental complaints among older refugees, war
victims and veterans.
Because of war and violence, older refugees were forced to migrate. After
arriving in the Netherlands they were kept in a state of suspense for a long
time and often stayed in refugee centers for years. After a few years, people
acquired a residence permit and finally were able to start building an new
life. By then, people discovered that certificates obtained in their own
country didn*t gain access to the Dutch labour market. Older refugees often
have a low socio-economic status, have great difficulty with the Dutch language
and often lead an isolated existence. 43.7% of the older refugees have
depressive symptoms. In addition, a large number of this group suffers from
anxiety disorders and post-traumatic stress disorders (Laban, 2004).
Older war victims and veterans often have been through traumatic events, which
makes them vulnerable when they get older. Approximately 3.1% of people with
the age of 75 and older suffer from a traumatic disorder which they attribute
to the war. 10% of them try to avoid memories of the war (Bramsen, 1999).
Besides the traumatic experiences, the lack of recognition after the war and
the confusion over offender-victim plays a part (Begman, 2001, Piersma, 2001,
Captain, 2002; Kristel and Piersma, 2005; Malauw and Lilipaly-de Voogt, 1997).

In all three groups the past (flight, war), getting older and their place
within the Dutch society plays an important role. So far, there are no specific
methods developed for older refugees, war victims and veterans with depressive
symptoms. The existing methods cannot be used without modifications these
groups. Because of language and cultural differences and specific events in the
lives of refugees, war victims and veterans makes it necessary to adapt the
existing methods.
To support older refugees, veterans and war victims with the life review we
will develop a course. They get the opportunity to make a book about different
themes in their life.

Goal of this project is to develop and evaluate the course "Levensboek" for
older refugees, war victims and veterans with depressive symptoms.

This study consists of:
1. Development and adaptation of the methodology of the course 'Levensboek'
2. Implementation of the course
3. Evaluation (process and effect)

The main goal in this project is the development of a method and not an effect
study. However, we will use several questionnaires to have a first impression
of the possible effect on older refugees, war victims and veterans.

A manual has been written for course supervisors. The draft will be presented
to an expert panel. The manual will be adapted based on the results of the
evaluation-study and afterwards we will consult the expert panel again.

We will try out the course with older refugees, war victims and veterans in
three institutions.

The effect study follows a pre-post test design with a questionnaire the week
before the course starts and a questionnaire the week after the end of the
course. In the pre- and posttest the effect of the course on depressive
symptoms, locus of control, quality of life and psychological wellbeing will be
measured.

A process evaluation will be conducted to verify if the developed methodology
is feasible an acceptable for the target groups. At the end of each session a
short questionnaire will be completed by the counselors and participants. After
the course all participants will complete a satisfaction questionnaire. Four
participants and counselors from the four groups will be interviewed after the
course using a semi-structured interview.

The standardized intervention in this study consists of the course
'Levensboek', a course for older refugees, war victims and veterans about their
own life story.
For participants, the intervention consists of a course of eight meetings of
two hours in a group of 8 persons with the same background. Each meeting
handles a different theme. During the course, there is a lot of attention for
making a book, the so-called Life Book. In between meetings, the participants
can fill the book up.
The course is based on the course "Searching for meaning of life", an
intervention for older people with depressive symptoms developed by the
Trimbos-institute. This intervention used the reminiscence and life review
method. The structure of the group intervention is based on exercises.

After inclusion to the study, the participant will be sent a questionnaire
twice. One before and one after the course. Completing the questionnaire takes
about an half hour. Following the course will cost the participant 8 meetings
of two hours. The total time is 16 hours in 16 weeks. The participants are free
to work on their book in between meetings.

We expect that the intervention (course) will improve the wellbeing of the
participants. Also, we expect that the participants are willing to participate
in the course because of the few interventions available for this target group.

Variants of this method has been used and studied in other older target groups.
These versions have no side effects or adverse consequences.

Facing unpleasant memories can be an extra burden on the participants. For
this reason the course supervisors need to have experience with these target
groups. They are capable of recognizing problems and if necessary they can
refer the participant to an appropriate practitioner. Moreover, participation
have the right to withdraw from the study any time.