Do not forget culture when implementing mental health interventions for violence survivors

Armed conflict has positioned Colombia as the country with the second highest internal displacement of citizens. This situation has forced government projects and international cooperation agencies to intervene to mitigate the impact of violence; however, the coping strategies implemented by the country's minorities are still unknown. The study objective is to describe the coping strategies and their relation with mental health within Afro-descendant culture in Colombia and the effects that armed conflict has on these coping mechanisms, through a phenomenological study involving focus groups and interviews with experts. Rituals and orality have a healing function that allow Afro-Colombian communities to express their pain and support each other, enabling them to cope with loss. Since the forced displacement, these traditions have been in jeopardy. Armed conflict prevents groups from mourning, generating a form of latent pain. Afro-Colombians require community interventions that create similar spaces for emotional support for the bereaved persons in the pre-conflict period. Thus, it is essential to understand the impact of this spiritual and ritualistic approach on mental health issues and the relevance of narrative and community interventions for survivors.


Introduction
Colombian armed conflict has been causing internal displacement and systematic massacres of civilians, predominantly affecting rural areas where confrontations among military forces, guerrillas, and post-demobilization armed groups have been occurring for nearly 60 years.The Pacific region of Colombia, besides being geopolitically isolated, allows the transit of legal and illegal goods to the countries of Central America.As a result, this context has promoted the existence of illegally armed groups who are disputing area resources, fighting for control of territory, and drug trafficking, causing the escalation and intensification of violence [1][2][3] .
Colombia's Pacific coast is a historical settlement of its Afro-Colombian population, concentrating the highest percentage of afro population in the country.Therefore, most victims in this region are Afro-descendants who were displaced to Buenaventura and Quibdó urban areas, the two main cities in the region 4 .In 2012, Pacific municipalities received more than 92,000 forced displacement victims, and the Afro-Colombian community presently accounts for approximately 36% of internal displacement persons (IDPs) in Colombia 1 .
Afro-Colombian victims of armed conflict suffer human, material, economic, and cultural losses leaving the victims with physical and emotional scars that affect their quality of life.Afro-Colombian survivors of violence, besides being forced to run away and leave their territories and properties, are also forced to leave their communities destroying their social ties, supporting networks, and community cohesion.These results represent a serious challenge; not only are the links severed between Afro-Colombians and their communities, but they must also adapt to new territories and living situations 5 .
These situations get worse because of the lack of access to mental health services or healing alternatives as part of efforts to reduce symptoms.That along with the constant violence exposure increases the number of victims with disabling mental health symptoms 2 .
Afro-Colombian communities throughout history have looked for traditional ways to respond to situations that affect them, such as family, friendship and religion; those were the first resources that they had for relief and healing.Nowadays, these supporting networks are still maintained as lay-therapeutic approaches, with a combination of rituals, religion and art for heal-ing 6 .Displacement and other types of violence have resulted in a loss of confidence and traditional practices among members of displaced groups.It is essential to understand each person as a member of the community with individual and societal factors outlined by their own worldview.An understanding of these cultural factors should complement interventions for each ethnic group and culture.
Strategies to promote psycho-emotional recovery of violence victims are necessary.Within these strategies, it is essential to consider traditional forms of healing and popular wisdom in order to design complementary methods to primary care and in-patient treatment 6 .
Due to the effects of violence in Afro-Colombian populations, we seek to understand the meaning, experiences, and strategies that Afro-descendants apply to cope with loss and grief.Furthermore, we aim to strengthen new intervention strategies and to promote the implementation of initiatives focused on victims' mental health in Colombia.

Methodology Design and Study Population
A phenomenological research study based on focus groups and expert interviews was conducted, whose methodology allows us to understand how people make sense of, and find meaning in their experiences, and how they apply strategies to cope with loss and grief before and after violence and displacement.The study aims to make visible the features of their customs and coping systems, starting from common features of that experience.The Afro-Colombian culture is characterized by being rich in knowledge and ancestral customs, hence the importance of such methodological approach.Lay Psychosocial Community Workers (LPCW) of the ACOPLE project, and an expert in Afro-Colombian culture were assessed to identify their perspectives about the impacts of violence in the Afro-Colombian culture and mourning process.
For this study, convenience sampling was used.Selected participants were LPCW, all afro-Colombian adults regardless of their gender, who had knowledge of the ways of coping in afro-Colombian culture and the effect of armed conflict.They were chosen due to the fact that they were involved in a trial of two mental health interventions (Common Elements Treatment Approach, CETA, and Narrative Community-Based Group Therapy, NCGT) 7 .Additionally, an Afro-descendent expert on the subject, who is also an activist for pacific culture identity and a researcher at the Center for Intercultural Studies at the Javeriana University, Cali, was also interviewed.
These individuals are community leaders that have been displaced because of violence.They demonstrate a high degree of sensitivity and have knowledge about the effects of violence on Afro-Colombian culture.Focus groups included 11 participants from Buenaventura (7 women and 4 men) and 10 participants from Quibdó (9 women and 1 man), with mean ages of 40 ± 9.2 and 35.8 ± 10.8, respectively.
The selected sample ensured the relevance and sufficiency of data, which ultimately guaranteed the significance of information and confirmed that it was representative of the culture.

Procedures
After a literature review, inquiry shafts and guiding questions were designed for the focus groups, and an expert that we interviewed.A cognitive interview with a different subject from the sample was conducted, in order to make adjustments.To facilitate the interview process we used a language that was adapted to the culture.
Two focus groups and an interview were carried out between November 2014 and January 2015; the sessions were recorded and transcribed.Observations of participants' behaviors were collected in field diaries.The information obtained was contrasted with literature reviews.Meetings were held in comfortable, safe, and reliable environments to encourage accurate information retrieval.Information was stored and guarded; its confidentiality and anonymity was guaranteed.
Coding and thematic content analysis were conducted using Open Code Software® Version 4.0.Search, review, definition, and the denomination of topics were articulated, looking especially for recurring patterns.The result was the identification and development of several core categories under a summary review, verification, and confirmation (Figure 1).Data analysis involved three analysts (GVOC, SGPQ, and GSR).In addition, a data triangulation and validation was performed using a peer-reviewers' process with the other co-authors team.

Ethical Aspects
This research is considered to be risk-free, and verbal consent was obtained from all participants.This study is part of the project "Community-Based Treatment Services for Afro-Colombian Victims of Conflict and Torture" (ACOPLE) and was approved by the Institutional Review Board for Human Ethics of the Universidad del Valle, Colombia.

Rituals and Traditions
Rituals in Afrodescendant culture are considered spaces for interaction and strengthening of ties between community members.Orality  in Afro-descendant culture is present in everyday spaces and has been the basis for these rituals.For them, mourning rituals have a healing function because people can express their pain in solidarity with their community, seeking to deal with loss.Also, these activities aim to encourage mourners to return to daily activities when a ritual ends -they are reminded of issues like their support network, belongings, and daily responsibilities.
In cases where there is no body to bury, the deceased is made present through anecdotes that recall moments within the community.Communities conduct "novenario", which consists of songs and prayers over a period of nine nights; community members collaborate in ritual mourning preparations that include food and liquor.On "última noche" (in English: the last night) they prepare traditional crowns and graves; this includes lamentation songs and messages that seek to encourage mourners until the dawn of the next day, thus ending the ritual.After this, community members go back to their duties, accepting and facing the death of a community member.
Death is assumed by community members to be a painful event, but it also is seen as an opportunity to create new lines of communication, promote union, and teach the traditions and rituals to the new generations.

Meaning of community within the Afro-Colombian population
Interviewees define community as a group of people who, despite not sharing blood ties, are united by ethnic ties: brotherhood, solidarity, empathy, trust, and friendship.They also consider community as the main mechanism for transmitting customs, union, and identity to the new generations, and work to prevent its disappearance or modification.
Community ties are considered stronger than family ties; therefore, the community is essentially a large family that shares practices, reciprocity relationships, and social organization, seeking the common good.These social ties are constructed through activities such as education, feeding, childcare, housing, construction, surviving economic crises and illness, and mourning the death of its members.

Post-conflict losses and difficulties
Participants reported the existence of a pre-conflict phase characterized by customs and ancestral wisdom, and a post-conflict phase in which the continuity of these traditions are limited.In the first phase, losses were mainly family members due to illness, injuries, or another event.However, with displacement, losses include territories, property, lifestyle, and community support, with the last one being crucial for Afro-descendants wellbeing.
The adaptation process was identified as the major difficulty, since the community has to move to a different territory where they do not know anyone; they lack livelihoods and do not have support from the community.Accordingly, confronting problems individually is less effective because the economic, social, and emotional burden would squander their resources.
Also, there was a perception of discrimination in Buenaventura by the host community towards survivors of violence, which created problems of social stereotyping and effectively isolated members of the same ethnicity.In Quibdó, regardless of place of origin and reasons for moving, the culture is identified as being a caring community with survivors, in response to cultural and ethnic identity.

Coping Systems
Mourning, in Afro-descendant culture represents a loss that heals through its own customs.Grief is necessary for them; if they do not grieve, they judge themselves, worry, and feel emptiness and restlessness.According to their beliefs, the person who has died will feel the same.
Before displacement, community, family, traditions, and rituals persist in effective coping systems.Participants did not previously require mental health professionals; their needs were instead solved with their ancestral wisdom.They had the opportunity to talk about their pain or about the event at any time, allowing the time and opportunity for healing to occur.
Given the forced displacement, these traditions have declined, but some still remain.There is a greater loss of customers in urban areas compared to rural areas.Some possible reasons for this are mentioned, including the prohibition by health institutions to ensure death at home, retaliation against family members or friends of the deceased, uprooting of community ties, and the presence of different religious currents, mainly in Buenaventura.
Because of conflict and the decline of rituals and ceremonies, other coping systems appear, including the Catholic or Christian religion as one of the most important, among others such as: recognition of rights and empowerment, the consolidation of social organizations, the support between survivors, and the implementation of intervention strategies for emotional support.
Regarding the implementation of intervention strategies for emotional support, participants recognize the need to listen to violence survivors; for them, group community therapies are similar to the support that community offered during the pre-conflict period, hence its importance.
According to participants, the dynamics of armed conflict limited survivors' grief, which generated a latent pain.Violence survivors require spaces such as a Narrative Community-based Group Therapy in which they can express themselves, be accompanied by others, and create support networks.
According to interviewees, these spaces are propitious to recover rituals and traditions that were lost when they were displaced into cities.For them, it is important to incorporate those "alabaos" or other traditional songs, dances, food, cooking, crafts, stories, anecdotes, poems, and customs mainly directed towards the adult population as distracting activities.Participants indicated that having these spaces allows them to express the pain that cannot be easily externalized in other social spaces.

Discussion
There is limited evidence of similarities in mortuary rituals in Afro-descendant communities worldwide, however, shared cultural elements such as orality are highlighted and these are essential to daily life, especially in the rituals of Afro-descendant culture.Orality is a tool for overcoming losses, and for the transmission of traditions to new generations.Furthermore, rituals, artistic and cultural expressions, music, handycrafts, spirituality, games and dancing, are a crucial part of their culture 8 , and allow them to recover the individual and collective memory.The absence of these practices leads to a loss of ancestral knowledge and wisdom that form the foundation of Afro-descendant culture 3,9 .
According to findings, mourning rituals of the Afro-Colombian community facilitate grieving and overcoming loss through collective activities.It has been shown that this ritual acts as an opportunity for communities to express their cultural identity and create unity.This plays an important role in overcoming pain and promoting the return to daily activities 10,11 , because historically there has been a sense of belonging in Afro-descendant communities as a result of the struggle with slavery 9,12,13 .
Community ties are strong because they consider themselves an extended family where each member contributes to the collective good.It has been described that feelings of identification and solidarity with other community members comes from the historical, racial, social, and economic conditions they shared 13,14 .This social tissue contributes to collective coping problems and crises in communities, as described by the interviewees.
In addition, community is the transmitting mechanism of knowledge to new generations.This wisdom promotes collective memory in Afro-Colombian communities, and strengthens the organizational processes that underlie them.It has been reported that strengthening these ties between community members, family, and friends may also have a protective effect against anxiety disorders in Afro-descendants 9,15 .
Afro-descendant communities of Buenaventura and Quibdó have addressed their mental health needs using ancestral wisdom and traditions.Evidence has shown that cultural beliefs, behaviors, and practices of Afro-descendants are positive in the adaptation against risk and adversity [16][17][18] .These factors reduce the risk of stress, and the literature has indicated how specific cultural factors contribute significantly to the prediction of the quality of life beyond the factors' effects (also significant) of traditional coping (active, avoidance, distraction, and seeking support) in African Americans 17 .
Resources of internal and external coping born from centuries of discrimination and oppression have encouraged strong religious and / or spiritual beliefs, social support networks, and emotional expressiveness 17,19 .Afro-descendants' preference for group coping strategies (family, community, kinship networks) are derived from a model based on an African cultural values system which prioritizes collective interest above individual interests 17,20 .This may explain the tendencies of Afro-descendants from the Colombi-an Pacific to adopt group strategies as a means to deal with adversity.
The literature describes coping strategies that are not exclusive to Afro-descendents, but reflect the cultural framework which many of them share 21 .Among these are spiritual, collective, and ritual coping 17 ; ritual coping has been most prominent in pre-conflict findings.
While spiritual coping is present before displacement, it intensifies after the violent event, declining because of the loss of support networks, and collective and ritual coping strategies.This became more visible in Buenaventura as opposed to Quibdó.It has been demonstrated that religious or spiritual coping may increase optimism and provide a cognitive framework for understanding stressful situations and confronting adversity 21 .
Community coping moderates the association between adverse events and anxiety, but shows a negative result (increased anxiety) at high levels of discrimination and stress 16 .While it provides an explanation for re-experiencing discriminatory or co-rumination stressors, findings in Buenaventura and Quibdó confirm a positive effect and a need for the recovery of these coping strategies in Afro-Colombian communities 22 .
As for interventions, it has been reported that resistance exists to mental health services from those who have experienced major cultural alignment with traditional beliefs 23 .Therefore, it is important to promote interventions based on the recognition of multiculturalism in Colombia.It is essential to recognize the forms of ethnic identification of the population, but also, to work in agreement with the Constitutional recognition of national diversity when designing interventions and treatments.That is why strategies such as a Narrative Community-Based Group Therapy in mental health could be important as interventions for Afro-Colombian populations.In this therapy, participants use teaching and their own language to develop solutions to problems.Based on their life histories, communities show their view of the world and their relationships with others, establishing culturally accepted roles that help re-categorize beliefs and emotions 24,25 .
These results are consistent mainly in adults, since the development of meta-cognitive skills and the maturation of coping skills occur during childhood and early adolescence 16,26 .This may highlight a major need for culturally relevant coping systems, addressed to adult populations.
The study provides an enhanced understanding of resilience in displaced Afro-Colombian populations.Furthermore, it helps determine cultural factors as necessary elements in quality of life and mental health, enriching intervention strategies for surviving populations of armed conflict in Colombia, and seeking real and symbolic spaces for the practice of everyday life, feelings, and experience of their history.
A limitation of this study is that results cannot be generalized to other populations, but can guide actions in contexts with similar populations.More research is needed to accurately understand mechanisms of how culture is a protective factor against adversity in Afro-Colombian populations; this study, however, provides a basis for further research.
In conclusion, the importance of cultural coping strategies for Afro-Colombian violence victims have been highlighted, including the main components of community, spiritual, and ritual approaches.Therefore, it is essential to understand the impact of this approach in mental health and the importance of narrative interventions in afro-descendants when planning victims' repairing processes.

Collaborations
FJ Bonilla-Escobar participated in the study design, supervised the research process, offered critical input on the manuscript and approved the final version of the same.GV Osorio-Cuellar, SG Pacihana-Quinayaz and G Sánchez-Rentería worked in the study design, data collection and the drafting process of the manuscript.A Fandiño-Losada and MI Gutierrez-Martinez participated in the study design, critical reading of the manuscript and approved the final version.

Figure
Figure 1.Qualitative Analysis Categories.