Educating/informing patients about the physical symptoms of and reactions to (traumatic) stress is an important first step towards control and reduction of fear, and its value has been recognised widely (Levine 1997, 2010; Van der Kolk 1996, 2006; Horowitz 2005; Rothschild 2000). Patients are offered an explanatory biological and psychological model of their symptoms to understand their own symptoms and reactions in order, subsequently, to get a grip on their own healing and resilience process. Although the effectiveness of this type of education is not yet studied (probably because it is always seen as complementary to the ‘official’ treatment), combining education and body-oriented activities in one programme appears to be essential to bring along changes in relatively fixed action patterns/routine ways of dealing with past and present stress.

Research has been done on the effectiveness of physical exercise training in the treatment of depression (Stathopoulou et al. 2006; Babyak et al. 2000; Blumenthal et al. 1999) and, to a lesser extent, of PTSD (Manger and Motta 2005). Blumenthal et al. (1999) reported significant reductions in depression scores among subjects treated with 16 weeks of aerobic exercise. The reduction was similar to sertraline or a combination of aerobic exercise and sertraline. Six months after the interventions, patients who had aerobic training had better results than patients from the other groups, especially the ones that continued to exercise at home (Babyak et al. 2000). In a meta-analysis with 11 studies, (Stathopoulou et al. 2006) concluded that physical exercise was a powerful intervention in depressive disorders. A preliminary study (Manger and Motta 2005) assessed the impact of a 12-session aerobic exercise programme on symptoms of PTSD, anxiety and depression and found positive results. Arnson et al. (2007) show that physical exercise in male patients with combat-related PTSD provides protection from future development of somatoform disorder. In an epidemiological cross-representative sample of Vietnamese living in the Mekong Delta region of Vietnam, Rees et al. (2012) found that high physical activity was significantly associated with low levels of psychological distress. Neurobiological research has shown that exercise induces expression of multiple genes known to be involved in plasticity and neurogenesis in the hippocampus (Cotman and Berchtold 2002; Elder et al. 2006).

In conclusion, educating patients on the importance of exercises, making training schedules for them and organising a guided exercise programme (by physiotherapists and movement therapists) are all means to increase positive effects of exercise on the process of resilience.

Bisson and Andrew (2007) found that stress management (SM) and trauma-focused cognitive behaviour therapy/exposure therapy (TFCBT) were equally effective in the treatment of PTSD. Stress management interventions vary widely in content and duration and may include progressive muscle relaxation (Jacobson 1965; Ehrenreich 1999). This type of SM is still widely used and considered to be a safe and accessible technique to reduce mental stress. As many traumatised patients are not aware of their bodily sensations, the technique is a nice start to connect the body and mind. Recently, meditation and mindfulness have been shown effective in reducing stress, as indicated by lowering of cortisol levels (Baer 2003). CBT mindfulness reduced the risk of a relapse of depression (Teasdale et al. 2000) and alleviated anxiety and depressive complaints (Santorelli 1992; Reibel et al. 2001). Mindfulness focuses on being completely in touch with and aware of the present moment, as well as taking a nonevaluative and non-judgmental approach to inner experiences. Although traumatised individuals tend to feel overwhelmed or deny an inner sense of themselves, elements of these techniques can readily be used: learning the difference between emotions and bodily sensations and between various emotions (anger, fear, sadness), learning techniques (breathing, movements, thoughts, etc.) on how to deal with stress, and experiencing that remembering the past does not inevitably result in overwhelming emotions. All these aspects increase the person’s ability to cope with stress, which is an important element related to resilience.

Specific aspects of pharmacotherapeutic interventions in refugee populations are described (e.g. Kinzie and Friedman 2004). However, in daily practice, in the treatment of asylum seekers and refugees, it is not always easy to find effective medication for the individual patient. Co-morbidity, a wide variety of symptoms, high sensitivity to side effects, different genotypes and compliance problems are all factors to deal with (Kortmann and Oude Voshaar 1998; Han and Liu 2005). In order to lower the resistance to using medication and to improve intake, it might be helpful to discuss medication in the context of resilience. Special focus on the most wearing symptoms (e.g. sleeping problems, nightmares, pain) and the supportive (but often non-curative) character of the medicine is important, next to adequate monitoring and explaining the working mechanism and potential side effects.

Several studies show high rates of physical diseases and complaints in asylum seekers (Laban et al. 2008; Gerritsen et al. 2006). Chronic physical health problems have a negative impact on functioning and quality of life (Laban et al. 2008). The relationship between physical complaints and depression is well established (e.g. Simon et al. 1999). PTSD appears to be a particular risk factor for several chronic diseases (Weisberg et al. 2002). These diseases are a threat to the resilience process. In order to limit their impact, adequate diagnoses and treatment of these nonpsychiatric illnesses are important.

Negative emotions narrow one’s momentary thought-action repertoire by preparing one to behave in a specific way (e.g. attack when angry, escape when afraid). In contrast, positive emotions (e.g. joy, interest, satisfaction, pride, love) broaden one’s thought-action repertoire and improve coping mechanisms such as positive reappraisal and goal-directed problem-focused coping (Folkman and Moskowitz 2000; Frederickson 2001; Tugade and Fredrickson 2004). Positive emotions also broaden one’s focus of attention in reliance to creativity, exploration and flexibility in thinking. In a study among refugees after an earthquake, Vazquez et al. (2005) interviewed 115 victims living in shelters. Surprisingly, they found that even such extraordinarily difficult circumstances, most of them revealed a consistent pattern of positive reactions and emotions. Also humour has been described as a source of resilience (Southwick et al. 2005). Humour appears to reduce the threatening nature of a situation through cognitive reappraisal (Juni and Katz 2001). Positive emotions as well as humour tend to decrease autonomic arousal. Mobbs et al. (2003) showed that humour engages a network of subcortical regions including the nucleus accumbens and the amygdalae, which plays a well-known role in fear and fear-related behaviour. Helping asylum seekers and refugees find distracting activities, areas of pride and episodes of joy might not only reduce stress but also improve coping. Examples of these activities within the reach of most mental health institutions are occupational, music and movement therapy. Otherwise, local opportunities (e.g. voluntary work, a local theatre project) can be used. Also, in all conversations with asylum seekers and refugees, the mental health worker should look for opportunities to enhance positive emotions: positive feedback, empowering remarks and something to laugh about. If children are around, this may assist in bringing about the desired emotions.

Cognitive flexibility is exemplified by positive reframing, or reappraisal, and refers to the ability to reinterpret an adverse or negative event so as to find meaning and opportunity (Yehuda et al. 2006). A recent brain imaging study has shown that cognitive reappraisal brings about decreased activation of the amygdalae (Ochsner et al. 2002). Cognitive behaviour therapy (CBT) provides an evidence-based therapy for depression, and trauma-focused CBT has been proven effective in PTSD treatment in various populations (Bradley et al. 2005). A systematic review of treatments for PTSD among refugees and asylum seekers (Crumlish and O’Rourke (2010) concluded that no treatment was firmly supported, but there was evidence for narrative exposure therapy (NET) and CBT. And the study of d’Ardenne et al. (2007) show that CBT was also applicable in these specific populations when the therapy is done with the help of an interpreter.

However, in many cases, asylum seekers and refugees do not fulfil the criteria for these therapies (e.g. safe life situation/environment) or do not have the ability to tolerate exposure. Therefore, it is necessary to find other ways to increase cognitive flexibility and reappraisal related to events in the past as well as events in the present. In our experience, several methods can be applied: analysing daily stressors individually or sharing them in a group setting creates the opportunity to learn to look at events from different angles and to reflect on the attributional styles (e.g. to place the blame where it realistically belongs). Furthermore, learning to find words for the variety of emotions and discovering the relationships between emotions, thoughts and behaviours (the basis of CBT) can be taught in a group and in an individual treatment setting. Patients can be asked to work out examples in their daily life and subsequently train themselves to change unhealthy patterns. A daily exercise is to distract yourself from negative thoughts by thinking or doing something else. All these activities are resilience oriented: they emphasise helping thoughts and behaviour.

Esteem needs of every human being are, for instance, to achieve, be competent and gain approval and recognition (Maslow 1954). Self-esteem has been defined as ‘The experience of being capable of meeting life’s challenges and being worthy of happiness’ (Reasoner 2004). Many people that are suffering from a psychiatric disorder have a low self-esteem (Silverstone and Salsali 2003). The authors suggest that there is a vicious circle: low esteem increases the risk of a psychiatric disorder and a disorder leads to a low self-esteem. Asylum seekers and refugees are at risk for a low self-esteem. Carballo et al. (2004) found in a study among Bosnian war survivors that there was an ‘overwhelming loss of perceived power and self-esteem’. Over 25 % of displaced people, for example, said they no longer felt they were able to play a useful role; even in non-displaced populations, approximately 11 % of those interviewed said that they had lost their sense of worth. The cumulative effect of the stressors during the asylum procedure may constitute an important risk for a low self-esteem. These experiences often lead to cognitive appraisals such as ‘I am not worthwhile’, etc. An overall positive therapeutic attitude is as important as more specific activities directed towards the improvement of self-esteem. Being taken seriously, being welcome in therapy, receiving positive feedback by an individual therapist or a team and being embedded in a coherent, reliable, predictable interaction can all lead to corrective emotional experiences during which self-esteem can be restored and improved. More specific treatment interventions can be working with patients to search for and set new (achievable) goals, to stop activities that decrease self-esteem, to recognise and change cognitions which undermine self-esteem (guilt, shame), to learn to be creative, to learn new things (e.g. a language, playing music), to be proud of what can be achieved in difficult situations, to find things to do for other people within or outside the family, to ask for feedback and to learn how to receive positive and negative feedback, to be assertive, to learn from experiences (instead of blaming oneself), etc. Also in the trauma-focused therapy sessions, every opportunity should be used to emphasise strength and adequate coping to correct, restore and increase self-esteem.

Coping has been defined as conscious attempts to manage internal or external stressors (Folkman et al. 1986). It can be divided into active, approach-based coping (resolving or conquering the stressor) and passive, avoidance-based coping (Moos 1995). The way an individual copes with stress is thought to mediate the possible negative influence of stress on physical and mental health. In general, resilient individuals have been described as using active coping mechanisms when dealing with stressful life situations (LeDoux and Gorman 2001). Possibly, if circumstances cannot be changed, a more passive coping style might be more adequate and healthy. Consequently, the most important ability is to be able to vary in coping styles, depending on the situation. Asylum seekers and refugees have to cope with many stressors. Working on resilience is working on coping. The difference between the two concepts is that the starting point in the resilience-oriented approach is one’s motivation, drive and personal strength rather than the more technical behaviour in the coping-oriented approach. This approach is very much in line with the documents of many survivors of adverse and horrible events. Frankl (1959) and Lindhout and Corbett (2013) learned that having a purpose in life literally keeps us alive. The resilience-oriented approach involves trying to create the conditions in which a more adequate coping can emerge and, subsequently, discussing with the patient which techniques can be used that fit the circumstances and the personal style.

Family resilience has been examined in various studies (e.g. Sossou et al. 2008). According to Walsh (2007, 2012), the resilience of families has a particular dynamic that is different from the combined resilience of separate individuals. She developed a ‘family resilience framework’ consisting of three domains: family beliefs (the extent in which a common view of reality exists), organisational patterns (the manner in which the family is organised) and communication/problem solving (the ways of communication and searching for solutions to problems). Among asylum seekers and refugees’ families, usually, problems in more than one of these domains are observed. Analysing the above-mentioned domains with the help of the ROTS model leads to questions as: Stress: what are the problems and how are these assessed by each member of the family? Vulnerability: what should be the focus to avoid problems becoming bigger? Social support: who assists in solving the problems, which members of the family receive such support and which not? Strength: how does the family try to solve the problems; what helped in the past; who helps whom in the family, what makes the family a family and what are they proud of as a family? Such an analysis also makes clear in what way a family is organised and embedded in its environment (asylum seeker centre, neighbourhood, countrymen, church, school, assistance, etc.). In resilience-oriented systemic family therapy, the resilience potential of each individual member and of the family as a whole is continuously monitored, and strengthening and healing mechanisms and activities are stimulated. In our experience, the model offers a good opening to discuss or observe all domains of Walsh’s framework. The model leaves room for including the complex social-societal context of the families. It can be tempting to forget this context and concentrate solely on solutions within the family; however, the ‘outside world’ can yield a lot of stress, which one cannot avoid. Talking about, for instance, life in the asylum seeker centre, a negative decision in the asylum procedure, discrimination or lack of money should not be seen as an interruption of the actual therapy. Family therapy with this group is often a search, in which one should take into account unexpected and sometimes unknown stressors. The joint learning on how to deal with these stressors can make this family grow.

The feeling of belongingness, being affiliated with others and being accepted and loved is one of people’s basic needs (Maslow 1954; Sandler 2001). Asylum seekers and refugees have lost many of their social contacts, and building up a new social network is difficult, for example, due to frequent moves, lack of money, language problems and cultural problems. Extensive research has been done on the influence of social support on health. The division in emotional, practical, informational and ‘esteem’ support (Schwarzer and Leppin 1999) is often used and makes sense in practice. Positive relations have been found in the general population (e.g. Schwarzer and Leppin 1999; Southwick et al. 2005) as well as in refugee populations (Gorst-Unsworth and Goldenberg 1998; Ahern et al. 2004; Stewart et al. 2011). The lack of social support, on the other hand, increases the chance of psychiatric problems (Southwick et al. 2005). In neurobiological research (Heinrichs et al. 2003), it appears that social support interacts with oxytocin (a neuropeptide affecting attachment) in lowering the cortisol levels and decreasing the response to psychological stress. Interventions should start with an analysis of the extent and nature of social support. Many patients only have a vague idea about their own wishes with regard to social support; they do not know what type of support they can get from whom and where they can access this particular type. They therefore ask or expect a particular type of support from the wrong people (e.g. practical support from a psychiatrist and emotional support from a traumatised spouse). Some patients feel ashamed to ask for help. They must learn that even though one’s own strength is always necessary, asking for support is not shameful and receiving support sometimes even is right. Other patients ask for help in an inadequate manner. Here also cultural aspects can play a role: in some cultures, you can only receive support if you act like you are completely powerless and treat the other as being superior. In the Netherlands, such an attitude will only cause irritations; your chances of being supported are larger if you tell someone what you have already tried yourself and what you would require the other to do. In conclusion, there are all sorts of possibilities for increasing (a chance on better) social support, and this is of great importance with regard to resilience.

One of the most important risk factors for a psychiatric illness among asylum seekers is worrying about not having work (Laban et al. 2005). In an earlier study among refugees and native Canadians, Beiser et al. (1993) found a significant relationship between unemployment and depression. The same connection was also found later in a longitudinal study (Beiser and Hou 2001), in which depression followed unemployment, especially among men. Unfortunately, in many countries, entering the labour market is not easy for many refugees. The unemployment rates are high and discrimination seems to be part of the problem (Nievers and Andriessen 2010). Cooperative programmes of governments, businesses and refugees agencies are needed. Asylum seekers in the Netherlands can only work a limited number of weeks per year, and because of many practical problems or limitations arising from psychological problems, only a few succeed to do that. Doing volunteer work is possible for asylum seekers; however, volunteering is an unknown phenomenon among many of them. Explanation and cooperation are thus necessary. Many mental healthcare institutions offer all sorts of activity therapy and can refer to Day Activity Centres (DAC). The value of participation in such activities should not be underestimated. People feel better being able to perform, they come in contact with others, they simply are in another environment, etc. The main purpose of this type of activity is breaking through the feelings of powerlessness and isolation and derives meaning from the activities. However, it is clear that in the end, full participation in the job market should follow on these activities. Unfortunately, there are often many obstacles to overcome and drop out, and medicalisation of social problems is a real threat.