Story, Science,

and Self-Care in a
Refugee Community:
Initial Impact of The Field Guide for Barefoot Psychology

RESEARCH BRIEF | OCTOBER 2020

Vivian Khedari DePierro, PhD

Table of Contents

03 About

04 Acknowledgements

05 Introduction

09 Research Questions and Study Design

13 Findings

27 Discussion

29 Limitations & Future Directions

30 Conclusion

31 References

33 Appendix A

Initial Impact of The Field Guide for Barefoot Psychology 2/33

About The Field Guide for
Barefoot Psychology

The Field Guide for Barefoot Psychology is an The Field Guide’s content was designed jointly
educational and psychosocial support program by neuroscientists, trauma recovery professionals
for communities affected by stress and trauma. and refugees in Jordan. It was designed to be
The Guide, implemented through a participatory accessible and sensitive to the social, cultural,
community engagement strategy, aims to clarify and religious context of the MENA region, using
why and how adverse experiences can affect culturally-relevant metaphor, story, and exercises.
the brain, body, and social behavior, and to
provide specific information and exercises to
ameliorate the effects of stress and trauma, ABOUT BEYOND CONFLICT
improve emotion regulation, and build resilience.
For nearly 30 years, Beyond Conflict has created
powerful and innovative frameworks to open path-
The Field Guide first uses storytelling, art, and
ways for progress in peace talks, transitions to de-
accessible scientific explanations to explore
mocracy and national reconciliation in the aftermath
various biological and psychological experiences
of division and violence in over 75 countries. Build-
associated with forced displacement, including
ing on this body of experience, we have partnered
trauma, stress, guilt, shame, hopelessness,
with cognitive and behavioral scientists to create
resilience, and post-traumatic growth. These
a new framework at the intersection of behavioral
issues are not only commonly stigmatized, but
sciences and real-world experience. Beyond Conflict
affect a wide range of impulses, behaviors, and
aims to apply brain science to design and promote
social interactions.
new tools that understand and address conflict in
the United States and abroad. Beyond Conflict is
Second, the Guide features a library of self-
a non-partisan, evidence-based, global non-profit
care exercises with easy-to-use practices from
focused on tackling an array of social challenges, in-
various fields, including somatic experiencing,
cluding the impact of displacement on the psycho-
mindfulness, and cognitive behavior therapy
logical well-being of refugee populations.
specifically targeting emotion regulation as a
key component of trauma recovery, resilience,
and improved interpersonal behavioral health. beyondconflictint.org
Users of the Guide have access to all content
@BeyondConflictInt
via a membership-only online community and
mobile app for Android and iOS devices. @Beyond_Conflict

Initial Impact of The Field Guide for Barefoot Psychology 3/33

 Acknowledgements
The Field Guide reflects a unique collaboration between Beyond Conflict and
Questscope to address the emotional and psychological burdens associated
with forced displacement, trauma, and violence.

Beyond Conflict would like to acknowledge the contribution of its many

partners in making this impact assessment possible. As any global mental
health initiative, this project would not have been possible without the
leadership of local partners - including the men and women who drew from their
own experiences as refugees and their first-hand knowledge of life in Za’atri
to thoughtfully plan and coordinate data collection and recruitment efforts
- Zakaria Al-Kareem, Abdulkareem Al-Hassan, Ahmad Abu Nimreh, Zaher Al-
Deiri and Ziad Jazzazi; and to facilitate The Field Guide workshops - Abdallah
Khasawneh, Mohanad Al-Hiraki, Mohammad Al-Rajabi, Mohamad Al-Ahmad,
Shireen Al-Hiraki, Merfat Al-Hamad, Kafa Eweijan, and Zad Al-Kheir Al-Zoubi.

We would also like to thank Dr. Wendy D’Andrea & Sarah Beranbaum - The New
School, New York - and Elizabeth Herman - University of California, Berkeley -
for their contributions to the impact assessment’s design; and Maiada Qazaq,
Mawadda Al-Akkad, Amani Zughbar, Mohammad Kheir Refai, Sahem Al-Nimr,
Hamza Al-Nimr, and Ahmad Joukhan for their contribution to data collection.

Initial Impact of The Field Guide for Barefoot Psychology 4/33

Introduction

Many factors including exposure to war, violence, There is emerging evidence in favor of
persecution, displacement and the stressful psychoeducational interventions for refugees, such
challenges of resettlement and integration place as the World Health Organization’s Self-Health
refugees at higher risk for poor mental health.1 Plus package (SH+) which consists of pre-recorded
Refugees burdened by psychological distress sessions accompanied by a book that illustrates
often have significant functional impairments, concepts with minimal text.8 SH+ is described
worse health outcomes, and a reduced ability to as a low-intensity psychological intervention
care for or protect themselves.2-3 A systematic that reduces reliance on specialists, making it
review of the prevalence of post-traumatic stress more easily-scalable. However, lack of access to
disorder (PTSD) and depression in refugees care providers is not the only barrier to mental
estimates rates for PTSD and depression at 30%4 health care in refugees. As interventions shift
-- nearly ten times higher than the overall global towards models that rely more on participant’s
prevalence of PTSD and depression.5 willingness to engage and interact with a given
book or didactic material, attention must be
This is an increasingly important problem as the given to additional factors that contribute to
United Nations High Commissioner for Refugees lack of engagement with mental health services.
(UNHCR) recently reported that of the 70.8 million These include mental health stigma and attitudes
forcibly displaced people worldwide, 25.9 million towards dominant culturally-determined models of
of them are refugees.6 This number is projected to mental health.9 Self-paced or community-managed
continue trending upwards, with the majority of mental health interventions can only be successful
refugees residing in developing countries often in if they address stigma as a barrier to care and are
proximity to or involved in armed conflicts. Further, culturally relevant to their audience.10
the increase in the number of refugees worldwide
has not been accompanied by a proportionate The present document summarizes the design and
increase in available personnel and resources to main findings of a randomized controlled trial (RCT)
tackle their mental health needs. for a novel intervention designed to address the
need for scalable and culturally appropriate mental
Therefore, there is a pressing need for health interventions for forcibly displaced people
mental health interventions designed called The Field Guide for Barefoot Psychology
(The Field Guide). The study was carried out in
for large-scale implementation in low-
the Za’atri Refugee Camp in Jordan with a Syrian
resource settings.7
refugee population with a well-documented high
degree of mental health stigma.11-12

Initial Impact of The Field Guide for Barefoot Psychology 5/33

The Field Guide is a psychoeducation intervention The Field Guide is a psychoeducation intervention
that utilizes culturally relevant storytelling and that utilizes culturally relevant storytelling and
metaphors to provide a basic and accessible metaphors to provide a basic and accessible
curriculum on the psychological and biological curriculum on the psychological and biological
impact of forced migration. The psychoeducation impact of forced migration. The psychoeducation
content is paired with self-taught, evidence- content is paired with self-taught, evidence-
based exercises meant to improve emotion based exercises meant to improve emotion
regulation skills. It has a series of innovative regulation skills. It has a series of innovative
characteristics that make it uniquely equipped to characteristics that make it uniquely equipped to
function as either a standalone or complementary function as either a standalone or complementary
effective intervention and has the potential effective intervention and has the potential
to normalize the experience of mental health to normalize the experience of mental health
symptoms and increase engagement in self-care symptoms and increase engagement in self-care
and mental health-promoting activities. and mental health-promoting activities.

The Field Guide is a unique

model among existing global
mental health interventions,
insofar as:
It complements rather than replaces existing
narratives about mental health: The Field Guide
does not challenge expressions of distress –
culturally sanctioned or not – but instead provides
the reader with a new narrative that can explain
the origin of the distress and the many ways we
express it.

The Field Guide taps into what is universal about

psychology: opening with an introduction in which
the reader learns how the brain is like an airport
control tower that plans, coordinates and adapts
to a myriad of changing circumstances. The Field
Guide’s curriculum walks the reader through the
biological processes and structures that we all make
Example of visual storytelling present in the Field Guide use of to adapt to threatening situations and that
Illustration by Haya Halawah
contribute to mental illness under extreme stress.

6/33
It is accessible: The Field Guide uses carefully It sets an empowering and optimistic tone:
curated graphics, metaphors, and lay language to Prior biologically-based psychoeducation
explain the biological concepts it introduces to its interventions have had the unintended effect of
audiences in such a way that no prior knowledge of creating the expectation of permanent pathology
psychology or biology is required to learn from it. in their target audiences, increasing rather than
decreasing psychological distress.13 The Field
We found that 90.7% of the RCT sample agrees or Guide is careful to maintain a tone that highlights
strongly agrees with the statement: “I feel I now brain plasticity and the possibility of recovery as
have a better understanding of how the body and well as a here-and-now approach to well-being
mind are affected after forced migration than I did through self-care exercises.
before reading the Guide.”
From the Field Guide: “Suffering has been around
much longer than medicine and psychologists,
It is relatable: The Field Guide makes use
and people have found ways to survive. And when
of engaging storytelling inspired by the real-
it comes to mental health and psychological
life experiences of representatives from the
well being, humans already possess many core
target audiences, tying the biological concepts
abilities that help us confront the past and the
it introduces to relevant aspects of the story
present to chart a new, healthier course forward.”
narrative. This way, it avoids using a “textbook” or
“lecture” tone, facilitating audience engagement.
It is practical: The Field Guide offers an
We found that 86% of participants endorsed extensive menu of science-based and proven self-
moderate to strong agreement with finding the care exercises, carefully explained and modeled
characters relatable, an indicator that correlated, through video in which the instructors are
at 3-month follow-up, to lower mental health representatives of the target audience.
stigma, perceived utility of the intervention,
continued reading, and engagement with the At follow-up the majority of the sample continued
intervention materials after workshop ending, and to report engagement with the self-care
to closeness to other Syrians. exercises. Frequency of practice appeared to
follow exercise complexity, with simple exercises
like deep breathing or belly breathing being
practiced daily by at least 46% of the sample.

It is easily scalable: The Field Guide content is

delivered either in a group-format by Field Guide
trained community facilitators or individually
through written materials with illustrations and
video clips modeling the exercises.

We found that from a group of 160 individuals

only a small proportion (12%) withdrew from the
study. Further, an incidental finding hints at the
spread of the intervention by word of mouth from
active participants to people in the study waitlist.

Initial Impact of The Field Guide for Barefoot Psychology 7/33

As an intervention, The Field Guide aims to increase scientific knowledge about mental health and self-
care, resulting in a reduction of mental health stigma and an increased engagement with mental health-
promoting activities. These outcomes combine over time in increased emotion regulation and decreased
trauma-related distress symptoms. This theory of change is summarized below:

INCREASED SCIENTIFIC KNOWLEDGE SELECTION AND APPLICATION OF

ABOUT SELF (PSYCHOEDUCATION) SELF-CARE EXERCISES

Learning about the physiological and psy- Readers can assess and try a wide variety
chological processes that accompany forced of validated exercises, practice and repeat
migration experience on themselves

STIGMA REDUCTION, USE OF EXERCISES,

AND SYMPTOM IMPROVEMENT

Based on this theory of change, a randomized It also addressed the potential of stigma as a
controlled trial was conducted to gather evidence barrier to entry, inviting participation of those
of the psychological impact of The Field Guide who, for various reasons, do not report existing
among users in Za’atri Refugee Camp. Like the symptoms. This decision was in close alignment
intervention itself, the approach on the study with the Beyond Conflict mission to make
design was innovative in that (1) recruitment was scientific research widely accessible.
not limited to the presence of a psychological
diagnosis or symptoms of distress, and (2) the Second, this study evaluates The Field Guide’s
study was carried out in a naturalistic setting. impact on refugee mental health within
communities affected by the Syrian refugee
First, the present study did not deliberately crisis in a low-resource, low-control, non-Western
recruit participants with specific symptoms or setting that more appropriately represents
illness as per standard psychiatric diagnostic the settings in which the majority of forcibly
frameworks. Recruitment was focused on displaced people live, addressing gaps in the
offering a psychoeducational intervention for any existing literature wherein mental health RCTs
interested community members who met eligibility for refugees are often conducted in Western
criteria. This open enrollment approach increased resettlement settings.14
generalizability of study findings, and increased the
reach of the study to individuals with symptoms
that do not meet the criteria for a formal diagnosis.

Initial Impact of The Field Guide for Barefoot Psychology 8/33

Research Questions
and Study Design
Between April and October 2019, a team of researchers from Beyond Conflict
in partnership with Questscope, The New School for Social Research and the
University of California, Berkeley carried out a randomized controlled trial
of The Field Guide in Jordan’s Za’atri Refugee Camp. The research sought to
test the Field Guide’s theory of change in a naturalistic, low-resource setting
with reported high levels of conflict-related distress. The scope of the present
report is to highlight the mental health impact of the intervention. Key research
questions included, but were not limited to:

1 Is The Field Guide for Barefoot Psychology effective in

reducing mental health stigma?

2 Is The Field Guide for Barefoot Psychology effective in

increasing emotion regulation?

3 Is The Field Guide for Barefoot Psychology effective in

reducing trauma-related symptoms and distress?

4 Are the effects of The Field Guide due to its method of

delivery (group vs. individual), or to its design and content?

Initial Impact of The Field Guide for Barefoot Psychology 9/33

Summary of
Study Design

SAMPLE STUDY CONDITIONS

Recruited participants were 160 Syrians living in The evaluation consisted of a three-arm ran-
the Za’atri Refugee Camp in Jordan. There were domized controlled trial (RCT). Participants were
no mental health symptom-specific exclusion randomized into the following groups: (i) self-di-
criteria enforced during recruitment. Any person rected, individual use of The Field Guide (Reading
interested in enrolling in the intervention was in- at Home condition), (ii) guided reading of The Field
vited to do so provided they were 18 years of age Guide in a facilitated group (Workshop condition),
or older; able to speak, read and write in Arabic; (iii) waitlist group that received the intervention as
had access to a smartphone, tablet or laptop; a workshop 8 weeks later than the other treatment
and were not pregnant at the time of recruitment. groups (Waitlist + condition).
Before any analyses, 19 participants who officially
withdrew from the study and 13 with less than From the final sample, 43 participants were in the
50% attendance to intervention activities were ex- Reading at Home condition (46.5% female), 36 were
cluded from the sample. The final sample consist- in the Workshop condition (52.8% female), and 49
ed of 128 participants (65 men and 63 women). were in the Waitlist + condition (49% female).

ASSESSMENT SCHEDULE

All participants were assessed three times: at baseline before the intervention (T0), immediately post-in-
tervention (T1), and in a follow-up three months after the conclusion of the intervention (T2). For individ-
uals in the Waitlist + condition, the third assessment was their only post-intervention assessment.

Wave 1 intervention | 8 weeks Wave 2 intervention | 8 weeks

T0 (groups + at home) T1 (groups) T2

APRIL 2019 JULY 2019 OCTOBER 2019

Initial Impact of The Field Guide for Barefoot Psychology 10/33

MEASURED VARIABLE INTERVENTION PROCEDURE

• Demographic information Workshop Group. The first treatment group

consist-ed of 50 participants who received the
• Measures of stressors and trauma exposure:
Field Guide in a group format over (16) 120-minute
potential traumatic exposure (RTHC)15; ongoing
sessions provided in the camp twice weekly for 8
stressors (Human Security Index)16
weeks. Four sex-segregated groups were run of
• Measures of mental health and emotion 12-14 mem-bers each and led by paired facilitators.
regulation: trauma-related symptoms, including The basic structure of the guided sessions included
Post-Traumatic Stress Disorder (PTSD) and collective reading, Q&A, explanations of the major
Complex-PTSD (C-PTSD) (ITQ)17; psychological concepts, group discussion, and guided instruction
distress (Kessler-10)18; resilience (BRS)20, of the self-care exercises.
emotional awareness and self-regulation
(MAIA & DERS)21-22 Reading at Home Group. In the second separate
treatment group, 50 participants were provided
• Measure of stigma: mental health stigma (ISMI)23 with The Field Guide text and accompanying exer-
cise instruction video materials to review on their
• Social measures: loneliness (Three-Item
own at home on a weekly basis. Participants in the
Loneliness Scale)19; closeness (IOS)24
reading at home group also received twice-weekly
SMS text reminders about engaging with content
and coming to the research site to collect the next
week’s materials.

Waitlist + Group. The third group consisted of 60

participants in the Waitlist + condition who did
not receive any study intervention within the first
8 weeks and then received the in-person workshop
utilizing the same procedures as described above.

ASSESSMENT PROCEDURE

Participants were matched with same-sex enu-

merators who collected in-person data at each
scheduled interval in a specifically designated area.
Enumerators were undergraduate or graduate-level
students studying psychology or related disciplines
Scientific illustration present in the Field Guide recruited via local university partnerships.

The primary aim of the research was to test the hypothesis that participating in The Field Guide for
Barefoot Psychology intervention results in a reduction of mental health stigma, an increase in emotion
regulation, and a decrease in trauma related symptoms. We hypothesized that these effects would be
due to the contents of the intervention and engagement with the self care exercises and not a secondary
benefit to group interaction in the workshop conditions.

Initial Impact of The Field Guide for Barefoot Psychology 11/33

Data Analysis

We set out to compare short and medium-term particularly effective facilitator group instead of
intervention impact on three study conditions: the shared aspects of the intervention, we used
intervention delivered individually, intervention two partially nested mixed linear models (MLM) in
delivered as workshops and the Waitlist + group. our analysis. The MLM were set with Compound
However, for workshop delivery participants were Symmetry covariance structure for the random effects
separated into four facilitator groups. In order of group and participants and an autoregressive
to control for potential facilitator group effects, AR(1) structure for the repeated measurements of
wherein positive outcomes might be due to one participant or participant within groups.

Main outcome MLM: our primary model was used to determine if the intervention
resulted in statistically significant changes in outcome measures. For this model, a
significant time x condition interaction indicated that scores for participants were
significantly different from baseline to post-intervention or follow up (time effect) and
that these changes were significantly different by study condition (Workshop group
vs. Reading group vs. Waitlist + group). Bonferroni comparisons were used to detail
the direction of these changes in outcome score for each study condition.

Replication MLM: in addition, we compared the first Workshop group to the second
Workshop group. For this model, a significant effect of time but not of condition would
indicate that the intervention had an impact on participants (time effect) and that the
impact was the same on both workshops (no condition effect). Pearson’s correlations
and T-tests are reported to further detail trends in the data.

Initial Impact of The Field Guide for Barefoot Psychology 12/33

Findings

1 The Field Guide for Barefoot Psychology is effective in

reducing mental health stigma.

At the time of the follow-up assessment, all study participants had received
the intervention either on the first Workshop, the reading at home condition,
or the second Workshop. As a whole, The Field Guide for Barefoot Psychology
intervention resulted in a decrease in the perceptions of mental health stigma. In
line with the intervention’s theory of change, the decrease in stigma was related
to improvements in mental health, specifically to improvements in Complex
PTSD, and improvements in emotion regulation. Consistent with the decrease in
stigma, after the intervention the majority of participants endorsed an increased
likelihood of speaking to family or doctors about their mental health.

1 - How was mental health stigma measured?

Seven statements adapted from the “Stereotype Endorsement”
subscale of the Internalized Stigma of Mental Illness Scale (ISMI)
were used to assess mental health stigma. Participants reported their
degree of agreement with the statements using a four-point Likert
scale and sum scores were calculated. Sum scores could range from 7
(strong disagreement with every statement) to 28 (strong agreement
with every statement). Internal consistency of the instrument was
deemed acceptable (T0 α =.66; T1 α = .70; T2 = α = .77.)

Initial Impact of The Field Guide for Barefoot Psychology 13/33

 2 - How did stigma relate to other measured variables at baseline?
At baseline, the sample’s mean mental health stigma score was 16.1 (SD = 2.9), indicative of moderate
levels of stigma, and there were no significant differences among treatment groups (F [2, 120] = .449,
p = .639). There were no gender or age-related differences in baseline scores. Mental health stigma
scores at baseline were positively correlated with the Negative Self Concept subscale of the ITQ,
r(123) = .180, p = .046 and negatively correlated to reported closeness to family members r(123) =
-.212, p = .019. These correlations suggest that participants with higher mental health stigma tended
to endorse negative views about themselves (e.g., “I feel like a failure) more strongly, and to feel more
distant from their families. The table below summarizes participants’ responses at baseline:

STRONGLY STRONGLY
STEREOTYPICAL STATEMENT DISAGREE DISAGREE AGREE AGREE

Mentally ill people tend to be violent. 14 (11%) 41 (32%) 63 (49%) 9 (7%)

Mentally ill people shouldn’t get married. 23 (18%) 71 (55.5%) 28 (22%) 5 (3.9%)

People with mental illness cannot live

17 (13%) 64 (50%) 40 (31%) 6 (4.7%)
a good, rewarding life.

People can tell that somebody has a mental

25 (20%) 64 (50%) 35 (27%) 3 (2%)
illness by the way they look.

People with mental illness need others to make

9 (7%) 36 (28%) 66 (52%) 16 (13%)
most decisions for them.

People with mental illness can’t contribute

30 (23%) 78 (61%) 15 (12%) 4 (3%)
anything to society.

Stereotypes about the mentally ill apply to

11 (9%) 53 (41%) 59 (46%) 4 (3%)
people I know.

RESPONSE FREQUENCY 129 407 306 47

3 - What evidence is there of the intervention’s impact on stigma?

3.1 - MLM yielded a significant time x condition interaction (F [4, 184.5] = 3.4, p = .018)
indicating that the intervention had a significant impact on stigma scores. Specifically:

A) The Reading group had significant short-term improvements in stigma from T0 to

T1 (Mdiff = 1.07, p = .03, d = 0.32) that lost their statistical significance at T2.

Initial Impact of The Field Guide for Barefoot Psychology 14/33

 B) The Workshop group had significant long-term improvements. Their stigma score
improved between T0 and T1 without reaching statistical significance, a trend which was
maintained and reached statistical significance at T2 (Mdiff = 1.14, p = .034, d = 0.39).

C) As expected, The Waitlist + group showed no significant changes between T0 and

T1. Once they received the intervention, the second workshop group replicated the
intervention findings, as indicated by the significant effect of time (F [1, 80.7] = 9.76,
p = .002) and lack of condition effect (F [1, 0.46] = 0.30, p = .743).

D) In addition to MLM findings supporting the intervention’s favorable impact on

stigma, we found that the sample’s mean stigma score across treatment conditions at
the time of the last assessment was significantly lower than it was at baseline (Mdiff
= - .772, p = .001, d = 0.26). When focusing only on participants with relatively high
stigma at baseline (N = 58 participants above the baseline mean), the effect size of this
comparison increases considerably (Mdiff = - 1.9, p < .001, d = 0.86).

Reading Workshop Waitlist/Workshop 2

17.00

16.50
MEAN STIGMA

16.00

15.50

15.00

14.50

Baseline Post-Intervention Follow-Up

TIME

Initial Impact of The Field Guide for Barefoot Psychology 15/33

 3.2 - The fact that trends towards a lower stigma score only began after the
intervention for participants in the Waitlist + condition stands as evidence that the
decrease in stigma was due to the intervention and not an effect of time.

3.3 - At follow-up assessment:

Percentage of participants agreed or strongly agreed with the statement:

“I am more accepting of people with mental illness than I was before

77.4% reading the guide.”

“I am more afraid of being perceived as mentally ill by others than I was

22.6% before reading the guide.”

“I feel more comfortable talking to family or friends about my feelings

83.9% about forced migration than I was before reading the guide.”

“I feel more comfortable talking to family or friends about any fear or

79% anxiety I might experience than I was before reading the guide."

“I feel more comfortable talking to a doctor or health service provider about

74.1% my feelings about forced migration than I was before reading the guide.”

“I feel more comfortable talking to a doctor or health service provider about

79.9% any fear or anxiety I might experience than I was before reading the guide.”

4 - How was the decrease in stigma related to other outcome variables?

Across treatment conditions, the decrease in mental health stigma between baseline and
last assessment was moderately correlated to decreases in Complex PTSD symptoms, r(122)
= .25, p = .004 and increases in emotion regulation, r(117) = -.31, p =.005.

5 - Was any key intervention component associated with stigma improvement?

For participant’s with relatively high stigma at baseline (N = 58 participants with baseline
scores above the mean), decrease in mental health stigma between baseline and last
assessment was correlated to how much participants felt they could relate to the characters
in The Field Guide’s stories r(54) = -.38, p = .004.

Initial Impact of The Field Guide for Barefoot Psychology 16/33

 2 The Field Guide for Barefoot Psychology is effective in increasing
emotion regulation.
The Field Guide for Barefoot Psychology intervention resulted in an increase in
emotion regulation - the ability to manage unpleasant or intense emotions by
refocusing attention. In line with the intervention’s theory of change, the increase
was related to improvements in mental health, specifically, in C-PTSD, loneliness
and psychological distress and improvements in stigma.

1 - How was emotion regulation measured?

The emotion regulation scale from the Multidimensional Assessment of
Interoceptive Awareness Version 2 (MAIA) was used to assess interoceptive skills
related to emotion regulation (4 items; e.g., “I can use my breath to reduce tension).
The MAIA uses 6 scale points for symptom endorsement ranging from 0- “never” to
5- “always”. Mean scores were calculated. Internal consistency was acceptable
(T0 α =.80, T1 α = .80, T2 α = .91).

2 - How did emotion regulation relate to other measured variables at baseline?

There were no significant differences at baseline among treatment groups
(F [2, 123] = 1.46, p = .236). Baseline scores were positively correlated with
closeness to others ( r = .19, p = .038) and resilience ( r = .36, p < .001) and
negatively correlated to Lack of Emotional Awareness (DERS; r = -.24, p = .007);
psychological distress (K-10; r = -.37, p < .001); and Complex PTSD ( r = -.27, p =
.003). These correlations suggest that participants with lower emotion regulation
reported feeling less close to others and less resilient as well as having higher
psychological distress, C-PTSD symptoms and difficulties with emotional awareness.

3 - What evidence is there of the intervention’s impact on emotion regulation?

3.1 - MLM yielded a significant time x condition interaction (F [3, 180.05] = 6.93, p
< .001) indicating that the intervention had a significant impact on MAIA emotion
regulation scores. Specifically:

A) The Reading group had a significant short-term increase in emotion

regulation between T0 and T1 (Mdiff = - .387, p = .049, d = .4) that lost its
statistical significance at T2.

B) The Workshop group had significant short and long-term increases in

emotion regulation when comparing T0 to T1 (Mdiff = - 1.026, p <.001, d = .91) and
T2 (Mdiff = - .813, p <.001, d = .68).

C) As expected, The Waitlist + group showed no significant changes between

T0 and T1. Once they received the intervention, the second workshop group
replicated the intervention findings, as indicated by the significant effect of time
(F [1, 81.71] = 24.8, p <.001) and lack of condition effect (F [1, 7.06] = 0.351, p = .572).

Initial Impact of The Field Guide for Barefoot Psychology 17/33

 D) In addition to MLM findings supporting the intervention’s favorable impact
on emotion regulation, we found that the sample’s mean score across treatment
conditions at the time of the last assessment was significantly higher than it was at
baseline (Mdiff = - .445, p < .001, d = 0.41).

EMOTION REGULATION

4.5
4.19
3.93
4.0 3.92
3.67
3.54 3.49
3.5 3.37
3.26 3.26
3.0

2.5

2.0

1.5

1.0

0.5

0.0

Reading at home* Workshop * ; ** Waitlist/Workshop **

* = significant T0-T1 difference

Baseline Post Follow-up
** = significant T0-T2 difference

3.2 - The fact that gains in emotion regulation were significant on the Waitlist +
group only after the intervention stands as evidence that the decrease in emotion
regulation was due to the intervention and not an effect of time.

4 - How was the increase in emotion regulation related to other outcome variables?
When looking at change scores from baseline to last assessment, the sample’s
increase in emotion regulation score across treatment conditions was correlated to
increases in resilience (r(111) = .37, p < .001) as well as decreases in mental health
stigma, r(117) = -.32, p < .001; C-PTSD, r(119) = -.29, p = .002; loneliness, r(114) = -.19,
p = .038, and psychological distress, r(118) = -.23, p = .001.

Initial Impact of The Field Guide for Barefoot Psychology 18/33

 5 - Was any key intervention component associated with emotion regulation gains?
At follow-up assessment, those participants who reported higher frequency of
engagement with The Field Guide’s self-care exercises also reported higher emotion
regulation scores, r(128) = .41, p < .001.

Additionally, across conditions, including controls, there was a trend towards higher
emotion regulation between baseline and post-intervention assessments. While the
increase seen in the control group was small and not statistically significant, it is
important to highlight that for participants in the control condition emotion-regulation
scores at the post-intervention assessment were significantly correlated to how much
they reported having heard about the intervention while on the waitlist, r(49) = .35,
p = .014. This incidental finding hints at the possible spread of The Field Guide by
word of mouth within the refugee camp setting.

3 The Field Guide for Barefoot Psychology is effective in reducing

trauma-related symptoms.
As expected given the studied population, the sample reported significant exposure
to potentially traumatic events (PTE) and contextual stressors. Exposure to
potentially traumatic events was related to PTSD, and in the subset of the sample
with high PTE, the intervention resulted in significant symptom improvement in
both PTSD and C-PTSD. Contextual stressors were related to C-PTSD and controlled
for in the analysis.

1 - How were trauma, stress and mental health symptoms measured?

The present study did not focus on the effects of The Field Guide on a specific clinical
sample and did not recruit for symptoms. However, given the high potential for
trauma exposure and contextual stressors inherent to the experience of forced
displacement, we expected to encounter sufficient clinical subgroups in our study
sample of 160 refugees, through which to gather preliminary information about the
intervention’s impact on specific clinical groups. We assessed for psychological trauma,
stress, and mental health symptoms through the following self-report measures:

1.1 - Potential trauma exposure (PTE): A modified 12-item version of the Refugee
Trauma History Checklist (RTHC) was used to measure potential trauma history.
The modified measure consists of 6 items. The original RTHC comprises eight items,
however the torture and sexual violence items were intentionally omitted in this
study for administrative reasons.

1.2 - Contextual stressors: In order to quantify current stressors experienced in a

refugee camp, we used 7 items from a 10-item measure constructed by Ziadni et
al. (2004) to measure levels of human insecurity in post-war situations. Responses
range from 1 (least insecure) to 5 (most insecure) resulting in a maximum potential

Initial Impact of The Field Guide for Barefoot Psychology 19/33

 total score of 35. Throughout the study, internal consistency of the Human Security
Index (HSI) was acceptable (T0 α = .76, T1 α = .81, T2 α = .83).

1.3 - Trauma-related symptoms: The International Trauma Questionnaire was used

to assess for trauma-related symptoms as conceptualized in the ICD-11. ICD-11
distinguishes classic post-traumatic stress disorder (PTSD) (symptoms of re-
experiencing, avoidance, and sense of threat following a traumatic event) from
Complex PTSD (symptoms of affective dysregulation, negative self-concept, and
disturbed relationships in addition to classic PTSD symptoms following repeated
exposure to traumatic events). Internal consistency for the scale was acceptable (T0
α =. 82; T1 α = .82; T2 α = .85). Classic PTSD symptoms are generally caused by acute
traumatic experiences; C-PTSD symptoms, however, are generally caused by pervasive
or accumulated stressors and trauma instead of acute, isolated incidents.

Studies on refugee samples tend to use only measures of classic PTSD, which can
fall short of properly documenting the consequences of the sustained periods of
stress that are typical of the refugee experience.

2 - How did trauma, stress, and trauma-related symptoms relate to other measured
variables at baseline?

2.1 - Potential trauma exposure: There were no significant differences in PTE exposure
among study groups. Baseline trauma exposure scores were positively correlated with
total PTSD symptoms, r(123) = .23, p = .009; and perceived contextual stressors,
r(126) = .18, p = .045. Trauma exposure was negatively correlated to closeness to others,
r(122) = -.20, p = .029. Trauma exposure was controlled for in MLM for all study outcomes.

REFUGEE TRAUMA STUDY CONDITION

HISTORY CHECKLIST ENTIRE SAMPLE READING WORKSHOP WAITLIST+

Number of people in the sample endorsing experience (%)

War at close quarters 106 (82.8%) 37 (86%) 29 (80%) 40 (81.6%)

Forced separation from family and friends 93 (72.7%) 28 (65.1%) 31 (86.1%) 34 (69.4%)

Loss or disappearance of family or loved one 74 (57.8%) 21 (48.8%) 26 (72.2%) 27 (455.1%)

Physical violence or assault 12 (9.4%) 5 (11.6%) 3 (8.3%) 4 (8.2%)

Witnessing physical violence or assault 41 (32%) 17 (39.5%) 11 (30.6%) 13 (26.5%)

Other frightening / life-threatening situation 104 (81.3%) 36 (83.7%) 28 (77.8%) 40 (81.6%)

Mean number of endorse experiences (SD)

TOTAL PTE EXPOSURE 5.8 (2.5%) 5.7 (2.7%) 6.3 (2.3%) 5.4 (2.3%)

Initial Impact of The Field Guide for Barefoot Psychology 20/33

 2.2 - Contextual stressors: There were no significant differences in perceived
contextual stressors among study groups at baseline. In addition to PTE, HSI was
positively correlated to total Complex PTSD symptoms, r(125) = .29, p = .001; Lack of
emotional clarity, r(125) = .41, p < .001; psychological distress (K-10), r(122) = .50,
p <.001; and loneliness, r(119)= .33. It was negatively correlated to resilience,
r(123) = - 0.32, p < .001; and closeness to others, r(120) =- .204, p = .025. HSI was
controlled for in MLM for all study outcomes.

STUDY CONDITION
HUMAN SECURITY INDEX ENTIRE SAMPLE READING WORKSHOP WAITLIST+

In the past month how often did you fear

3.1 (1.3) 3.2 (1.4) 3.0 (1.3) 3.2 (1.2)
for yourself in your daily life?

In the past month how often did you fear

3.8 (1.2) 3.8 (1.2) 3.8 (1.2) 3.9 (1.3)
for your family in your daily life?

In the past month how often did you fear

not being able to provide your family with 3.2 (1.4) 3.0 (1.1) 3.5 (1.5) 3.2 (1.5)
daily necessities?

In the past month how often did you worry

about losing your source of income or your 3.2 (1.3) 3.0 (1.3) 3.4 (1.3) 3.3 (1.4)
family’s source of income?

In the past month how often did you worry

2.3 (1.5) 2.2 (1.4) 2.6 (1.6) 2.3 (1.5)
about losing your house?

In the past month how often did you fear

2.9 (1.5) 2.4 (1.4) 3.4 (1.4) 3.0 (1.6)
displacement or uprooting?

In the past month how often did you worry

4.0 (1.3) 37 (1.4) 4.0 (1.3) 4.4 (1.0)
for your future or your family’s future?

SUM SCORE 15.9 (6.3) 14.6 (6.3) 16.8 (6.6) 16.5 (5.9)

Initial Impact of The Field Guide for Barefoot Psychology 21/33

 Scientific illustrations present in the Field Guide

2.3 - Trauma-related symptoms: There were no significant baseline differences among

treatment groups in baseline C-PTSD (F [2, 123] = 0.623, p = .538) or PTSD (F [2, 22.8]
= 1.179, p = .311). From the entire sample 10 participants met established criteria for
C-PTSD and 39 for PTSD at baseline.

• In regards to relation with other variables, at baseline C-PTSD was positively

correlated to psychological distress, r = .51, p < .001; and negatively correlated to
resilience, r = -.365, p < .001. This was also the case for PTSD (K-10, r = .271, p =
.003; Resilience, r = -.182, p = .047).
• Complex PTSD, which includes a component of relationship difficulties and
blunted affect, fittingly correlated with measures of emotional dysregulation
(MAIA Emotional Self-Regulation, r = -.279, p = .002; DERS Lack of Emotional
Clarity, r = .300, p = .001) and loneliness (r = .275, p = .002). For its part, PTSD’s
correlation to MAIA Noticing ( r = .222, p = .016) is fitting given that this scale
measures awareness of negative body sensations such as tension or discomfort
typical of the hyperarousal seen in PTSD. The different correlations obtained with
each subscale gives validity to the use of this diagnostic distinction when
intervening on mental health with Syrian refugees.
• As expected, PTSD was correlated with trauma exposure ( r = .187, p = .038).
C-PTSD was positively correlated with the Human Insecurity Index (r = .288,
p = .001), but not with trauma exposure as measured by the RHTC. This baseline
finding gives validity to the conceptual distinction between C-PTSD and PTSD
in general, and the importance of using measures that accurately capture the
breadth and duration of distress refugees face.

Initial Impact of The Field Guide for Barefoot Psychology 22/33

 3 - What evidence is there of the intervention’s impact on trauma-related symptoms?
In order to assess the intervention’s impact in a clinically relevant group, we focused the MLM
analysis on participants with high trauma exposure (n = 92 participants endorsing three or more
types of trauma on the RTHC screener).

3.1 - MLM yielded a significant condition x time interaction for C-PTSD (F [3, 143.0] = 3.3,
p = .020) and PTSD (F [3, 137.6] = 3.54, p = .016) indicating that the intervention had a
significant impact on PTSD and CPTSD scores. The Workshop condition drove this effect, as
their score changes were the only ones to reach statistical significance. Specifically, for C-PTSD:

A) The Reading group had no significant change in C-PTSD from T0 to T1 (Mdiff = .44)
or T0 to T2 (Mdiff = -.06).

B) The Workshop group had statistically significant short and long term
improvement in C-PTSD when comparing T0 to T1 (Mdiff = 3.44, p = .014, d = 0.33)
or T1 to T2 (Mdiff = 4.96, p = .002, d = 0.47).

C) As expected, The Waitlist + group showed no significant changes between T0 and

T1. Once they received the intervention, the second workshop group replicated
the intervention findings, as indicated by the significant effect of time (F [1, 57.61] =
11.84, p =.001) and lack of condition effect (F [1, 7.06] = 0.351, p = .572).

Reading Workshop Waitlist/Workshop 2

MEAN COMPLEX PTSD SYMPTOM SCORE

18.00

17.00

16.00

15.00

14.00

13.00

Baseline Post-Intervention Follow-Up

TIME

Initial Impact of The Field Guide for Barefoot Psychology 23/33

 In comparison, for PTSD:

A) The Reading group had no significant change in PTSD from T0 to T1 (Mdiff = -1.11)
or T0 to T2 (Mdiff = -1.03).

B) The Workshop group only had statistically significant long-term - not short
term- improvements in PTSD (Mdiff = - 1.98 , p = .033, d = 0.58). This finding
suggests a delayed effect of the intervention on PTSD, but not C-PTSD symptom
reduction.

C) As expected, The Waitlist + group showed no significant changes between T0 and

T1. Once they received the intervention, the second workshop group replicated the
intervention findings, as indicated by the lack of significant effect of both, time
(F [1, 60.02] = 3.33, p =.073) and condition (F [1, 60.65] = 0.140, p = .710).

Reading Workshop Waitlist/Workshop 2

12.00

11.00
MEAN PTSD

10.00

9.00

8.00

Baseline Post-Intervention Follow-Up

TIME

In addition to MLM findings on key sample members, overall and regardless of prior trauma
exposure or baseline symptom level, the study sample presented a significant decrease
between baseline and last assessment on both C-PTSD symptoms (Mdiff = - 2.37, p < .001,
d = 0.3) and PTSD symptoms (Mdiff = - 1.25, p = .003, d =.28).

Initial Impact of The Field Guide for Barefoot Psychology 24/33

 3.2 - The fact that trends towards a lower C-PTSD or PTSD scores only began after
the intervention stands as evidence of changes being due to the intervention and
not an effect of time.

4 - How was the improvement in trauma-related symptoms related to other

outcome variables?
• The sample’s decrease in C-PTSD symptom score across treatment conditions was
correlated to decreases in stigma r(127) = .198, p = .026; loneliness, r(120) = .234,
p = .010; and psychological distress, r(123) = .404, p < .001; as well as increases in
emotional awareness, r(120) = -.193, p < .034; emotion regulation, r(119) = -.287,
p < .002; and resilience, r(117) = -.268, p = .003.
• The sample’s decrease in PTSD symptom score across treatment conditions was
correlated to decreases in psychological distress, r(120) = .187, p = .040 and
increases in emotional awareness, r(116) = -.197, p = .034.

5 - Was any key intervention component associated with ITQ symptom improvement?
Improvement on C-PTSD symptoms was related to how much participants reported
enjoying reading the chapters, r(62) = .374, p = .003; whereas improvement in PTSD
was related to chapter enjoyment, r(63) = .421, p = .001 as well as exercise engagement
frequency at follow-up, r(63) = .271, p = .032.

The different ways in which the intervention affected C-PTSD and PTSD were aligned with
intervention components and its theory of change:

By participating in the intervention, we expect individuals to have the opportunity to

increase their knowledge about mental health consequences of forced displacement and
also to relate to the story’s characters in a validating way. This experience can have an
immediate impact on attitudes towards mental health, meaning-making, and sense of
isolation - which can be reflected in decreased scores on mental health stigma measures
as well as Complex PTSD subscales such as negative self-concept and disturbances in
relationships. We would not, however, expect acquired knowledge to have an immediate
impact on the classic PTSD symptoms of sense of threat, re-experiencing, and avoidance.
That said, continued engagement with self-care exercises can have a long term effect in
classic PTSD symptom reduction.

Initial Impact of The Field Guide for Barefoot Psychology 25/33

 Scientific illustration
present in the Field Guide

4 The effects of The Field Guide are due to its design and content,
not to its method of delivery.

This report has detailed only key findings from a comprehensive list of outcome
variables. It also makes sense to question whether the effects of The Field Guide
are due to its method of delivery (group vs. individual) or due to its design and
content. Appendix A summarizes mean differences obtained in each group from
baseline to post-intervention and final assessment.

The choice to deliver The Field Guide as both a group workshop and individual
reading at home was to assess the unique roles of context versus content in driving
positive outcomes. The table above highlights how the Workshop condition
yielded significant results on more outcome measures than the Reading at
Home condition, and furthermore results in the Workshop condition often had
larger effect size and were longer-lasting. The present findings suggest that
while the impacts were greater in the workshop condition, the intervention and not
group proximity itself led to the observed gains. This is evidenced by the fact that
while the group had some effect, we saw no increases in closeness or decreases in
loneliness in the workshop groups even after participation.

The larger impact of the Workshop condition might be due to intervention dosage
effects, that is, higher experimental control over how much of the intervention
content’s participants received as measured by their attendance to the group
sessions. For participants in the reading at home condition, experimenters could
only control participant’s picking up of intervention contents at designated times,
which does not allow for accurate conclusions about how much of the material was
read and practiced to be drawn. Estimates of exercise engagement or chapters
read were assessed entirely through self report, a question that was potentially
highly susceptible to social desirability effects, as people are unlikely to want to
report not having engaged in the intervention. The trend towards lower effect sizes
and smaller change magnitude at follow up is also evidence of dosage effect, as are
the reported correlations between continued self-care exercises after intervention
completion and long-term symptom improvement.

Initial Impact of The Field Guide for Barefoot Psychology 26/33

 Discussion
The increase in displaced persons across countries in the Middle East
presents a challenge to mental health professionals, not only due to the
elevated mental health symptom burden but also the substantial stigma
around mental illness within these communities and its potential long term
effects on social cohesion and conflict. Individual-level interventions may be
efficacious in reducing symptoms, but they are often not scalable due to the
shortage of mental health professions in refugee settings and the extreme
level of need. Additionally, pervasive mental health stigma may affect
willingness to engage with materials in non-clinical community programs.

The presented study consisted of a randomized controlled trial (RCT) of a

psychoeducational tool, The Field Guide for Barefoot Psychology, with 160
adult Syrian refugees residing in the Za’atri Refugee Camp in Jordan. The
Field Guide is novel in that it incorporates personal stories from Syrian
refugees and grounds the psychological effects of forced migration in
accessible neurobiological language throughout the text to reduce mental
health stigma and promote engagement with a menu of self-care exercises.
Syrian refugees randomized to receive The Field Guide in a workshop format
were compared with another group who received the materials to read at
home, while a third group were initially on a waitlist (and then received the
group intervention eight weeks later).

Initial Impact of The Field Guide for Barefoot Psychology 27/33

The results of our statistical analysis of outcome While we attempted to control for ongoing
measures confirmed that The Field Guide sources of stress by using the Human Insecurity
intervention resulted in a reduction of mental Measure, it was difficult to isolate how news from
health stigma and trauma-related symptoms, Syria (e.g., the United States pulling their troops
as well as increased emotional awareness and at the time of the third assessment round; inflation
regulation for individuals who attended the of the Syrian Pound) might have heightened
workshops. Improvements were also seen on anxiety among residents of Za’atri Camp and
some measures for individuals reading from affected the outcome variables under study.
home. Analysis further showed that intervention However, we are not discouraged by this lack of
gains were due The Field Guides’ use of an experimental control, and instead consider that
optimistic tone, relatable narratives, and both the findings obtained despite these limitations
psychosocial and neurobiological explanations speak to the effectiveness of the intervention
for mental health symptoms along with provision when implemented in the complex environment
of self-care exercises and not due to the effect where it is needed most: the refugee camp.
of being in contact with peers during workshops.

Given that this RCT was carried out in a

The Field Guide intervention
naturalistic setting (the Za’atri Refugee Camp)
where the sample was exposed to ongoing
resulted in a reduction of mental
stressors with limited possibility for experimental health stigma and trauma-
control, the evidence of statistically significant related symptoms, as well as
gains in stigma reduction, emotion regulation,
increased emotional awareness
emotion noticing, PTSD and CPTSD support The
Field Guide’s potential to favorably impact a and regulation for individuals
wide range of targeted populations. who attended the workshops.

Initial Impact of The Field Guide for Barefoot Psychology 28/33

Limitations &
Future Directions

There was insufficient data on participants’ engagement with the materials

(e.g., attentiveness to the assigned chapter readings), particularly in the
Reading at Home group. Future studies could utilize cutting-edge strategies
to monitor ongoing engagement with The Field Guide. Moving the material
towards digital platforms such as smartphone apps or websites might
enable the tracking of when a participant uses the material and why,
furthering our understanding and ability to provide effective resources.

Only participant’s intention to speak to doctors about their mental health was
Moving the measured. In order to track actual help-seeking behaviors, future work should
material towards measure utilization of specialized mental health care at follow-up intervals.
digital platforms
will further our The present study only did an 8 week follow-up on the intervention sample.
Longer-term follow-ups (e.g. six months post-intervention), would allow for
understanding
continued assessment of engagement with the distributed material, which
and ability to could highlight the cost-effectiveness of this scalable intervention.
provide effective
resources. The present study did not assess the individual impact of distinct intervention
components on outcomes. Follow up studies should have a dismantling
component, where aspects of the intervention are presented in isolation
in order to evaluate their individual impact. As an example, presenting
The Field Guide’s self-care exercises with and without the psychoeducation
component would enable researchers to test the hypothesis that deeper
knowledge of the scientific evidence in favor of specific self-care exercises
leads to more favorable ratings of their effectiveness and increased exercise
engagement, which would ultimately result in symptom improvement.

Initial Impact of The Field Guide for Barefoot Psychology 29/33

Conclusion

This research highlights key findings obtained from a randomized controlled

trial of The Field Guide for Barefoot Psychology’s in a refugee camp. The
Field Guide was designed with the guiding principle that individuals and
communities that have been affected by stress and trauma have a right to
the most recent scientific knowledge on how their experiences impact their
mental health and bodies, and with increased understanding, people are better
equipped to explore steps towards caring for themselves and others in their
community. The intervention sought to use storytelling and accessible language
to deliver a scientific curriculum on the psychobiological consequences of
stress and trauma with the intention to normalize these experiences and
highlight the body’s resourcefulness and innate coping mechanisms meant to
facilitate healing.

The study hypothesis was that the accessible delivery of the curriculum and
choice of optimistic, non-clinical tone would result in a decreased mental
health stigma and increased engagement with self-care exercises offered
in The Field Guide. Results showed that the intervention was successful in
achieving its aims: across intervention modalities (workshop vs. reading at
home) and regardless of initial symptom burden or trauma experiences, the
entire sample’s average mental health stigma decreased, as did trauma related
symptoms. Emotion regulation - the aspired outcome of engagement with the
self-care exercises - also improved.

The results highlight how The Field Guide for Barefoot Psychology can be an
effective mental-health intervention in a high-stress setting with a population
that has been documented to have high-stigma towards mental illness. The
findings suggest that The Field Guide offers a promising way forward to inspire
self-help and community-led mental health interventions in low-resource
settings. Furthermore, the results lay the foundation for future iterations of The
Field Guide, where the stories and examples are adapted to deliver the content
to other populations in need. As the population assessed in this study grows
around the world, the need for scalable interventions that offer accessible
information and self-care informed by research is more important than ever.

Initial Impact of The Field Guide for Barefoot Psychology 30/33

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Appendix A

Mean differences in study variables on post-intervention and follow-up by group

READING WORKSHOP WORKSHOP 2

VARIABLE T0 - T1 T0 - T2 T0 - T1 T0 - T2 T1 - T2

Stigma 1.07 0.195 .911 1.11 1.02

C-PTSD 1.023 1.74 2.85 3.72 1.48

PTSD -0.26 0.146 1.14 2.2 1.93

Emotion Regulation -.353 0.012 -1.02 -.812 -.575

Emotion Noticing -.298 -.426 -.515 -.303 -.395

Emotional Awareness -0.185 0.029 -.3 0.034 -.106

Kessler 10 0.023 0.428 2.38 0.314 0.553

Resilience 0.019 0.036 -.185 -.058 0.038

Loneliness -0.976 0 0.117 0 0.446

Closeness 0.47 1.3 -1 1.3 -.11

LEGEND = Change in hypothesized direction. Not statistically significant.

= Statistically significant change in hypothesized direction.
= Change not in hypothesized direction. Not statistically significant.
= Statistically significant change, not in hypothesized direction.

Initial Impact of The Field Guide for Barefoot Psychology 33/33