Every day, nearly 34,000 people are forcibly displaced as a result of war, conflict or persecution. Globally, more than 65 million people have been forced from their homes and about 21 million of these are refugees, over half of whom are under the age of 18. About 80% of these refugees, over 16 million, are under UNHCR (the UN Refugee Agency) mandate, and fully 5.2 million Palestinians are refugees registered by UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East). Approximately 10 million persons are stateless and denied access to basic rights such as education, healthcare, employment and freedom of movement. Currently, more than half of the world’s refugees are from three countries: Syria, Afghanistan, and Somalia (UNHCR, 2017). The major receiving countries are Turkey, Pakistan, Lebanon, Iran, Ethiopia, and Jordan. Despite all of the popular media attention to waves of refugees, only 17% of those displaced reach Europe; 56% remain in Africa and the Middle East.
Behind every number in the UNHCR statistics there is an individual story of someone forced to uproot and move due to war, conflict, persecution, and hardship—and, for many, this situation has led to persistent displacement and uncertainty in “temporary” situations that now span generations. We know that being an asylum seeker, refugee, or forcibly displaced has a profound impact on mental health, with an increased risk of developing common psychiatric disorders, such as, depression, anxiety, post-traumatic stress disorder (PTSD), psychotic disorders as well as disabling symptoms of psychosocial stress (Hassan, et al., 2015; 2016). In addition, there is often poor access to mental health care and a lack of funding for mental health promotion strategies addressing the special needs of asylum seekers, refugees, and other displaced persons.
The number of people seeking refugee status in Europe has soared over recent years with a peak in 2015.Waves of refugees continue to search desperately for sanctuary by crossing the Mediterranean, a perilous journey that already has cost thousands of lives. European countries have responded with joint efforts which increasingly aim to close their borders to refugees—with the notable exception of Germany, which as of late 2017 is still receiving large numbers of asylum seekers. With blocked borders to much of Europe, many refugees are stuck in countries like Greece and Italy. Recent reports from the European Union Agency for Fundamental Rights (2017) note that living conditions in the EU reception centers remain poor. In addition to unfair treatment at border zones in some places, practical and legal barriers to receiving health care, poorly resourced child protection services, and fragile relationships with local communities are aggravated by incidents of racism and discrimination. In parallel to the social strains in European countries marked by the rise of populist and protectionist policies and hostility towards refugees, there have been major efforts within several countries, communities, and the civil sector to promote a humanitarian response to people seeking protection from war and persecution. While 18 European countries currently fund and promote health education and staff training on cultural awareness (Priebe et al., 2016), at present, there are no routine systems in place on a regional or national basis for documenting the mental health care services used by refugees, asylum seekers, and irregular migrants.
In an effort to discourage irregular migration, Australia has implemented policies of prolonged detention with disastrous effects on mental health (Silove, Austin, & Steel, 2007); for those arriving by boat, this has involved indefinite incarceration under harsh conditions in “regional processing centres” maintained in neighbouring countries (Pryor, 2017). In the U.S., there has been a dramatic rise in right-wing politics and demagoguery that uses populist sentiments and xenophobia to argue against immigration in general as well as against providing safe haven for some of the most vulnerable refugees coming from war-torn areas. The current liberal government in Canada has taken a different path, with efforts to increase the intake of refugees and offer faster paths to social integration and citizenship. Although a source of positive collective identity for Canadians, these policies of openness and solidarity are viewed with some ambivalence in the general population and may be endangered in the context of continuing global anxieties about security.
The refugee situation calls for urgent humanitarian responses including access to mental health care for persons in need, adaptation of mental health care systems, and implementation of culturally informed methods to support resilience and inclusion in the new host societies. The development of an adequate response to the needs of these ‘people on the move’ must address the attitudes and perceptions of receiving countries and communities and the ways in which these views impact on health, education and other institutions and professionals. Transcultural psychiatric research and expertise can make important contributions at multiple levels in this humanitarian response.
For refugees coming from areas of war, conflict and poverty there is a risk not only of poor access to mental health care but also of misunderstandings when encountering the psychiatric services. Health care clinicians may fail to fully comprehend the enormity of patients’ loss and cultural differences in self-presentation, self-understanding, memory and identity (Kirmayer, 2003). In treating victims of severe trauma, restoring relationships and a sense of community is central for restoring the well-being of the person (van der Kolk, 2015).
Innovative Research
This thematic issue of TP, prepared by the Section on Transcultural Psychiatry of the World Psychiatric Association, presents studies related to the mental health of refugees and asylum seekers. Papers address a wide range of issues including: migration-related predictors of health, impact of post-migration resettlement, social integration and language learning, changes in belief systems, factors predicting academic achievement among refugee minors, screening for psychological distress, access and barriers to care, interaction of childhood abuse experiences of adults with war-related trauma, and the role of cultural idioms of distress in clinical assessment and treatment. Reflecting the diverse experience of receiving countries, there are studies from Australia, Canada, Germany, Israel, Denmark, The Netherlands, Norway, South Africa, the U.K., and the U.S.
A substantial body of research documents elevated rates of mental disorders among refugees, including trauma-related disorders and depression (Kirmayer et al., 2011). Adversity occurring before, during, and after migration contributes to these elevated rates and influences the long-term outcome of forced migration (Bogic, Njoku, & Priebe, 2015; Porter, 2007; Porter & Haslam, 2005). Several papers in this issue add to the evidence for this increased burden of illness and clarify some of its culturally shaped modes of expression with implications for assessment and treatment.
Kiat, Youngmann and Lurie (2017) add to the body of evidence on the high rates of psychological distress among asylum seekers. They compared groups of asylum seekers in Israel accessing help from outpatient general medical and psychiatric services and found comparably high levels of distress in both groups but significantly more stressful life events in the group attending the psychiatric service. The group attending the psychiatric service also made more use of medical and other services suggesting their difficulties in finding effective help. Emotional distress appeared to be under-recognized and under-treated by mental health practitioners in the medical clinic. Although PTSD is often the focus in discussions of psychiatric disorders among refugees, it usually accompanied by other forms of distress. Belz and colleagues (2017) document the high levels of comorbidity of PTSD and depression among distressed refugees at a reception centre in Germany; fully 94% of patients who had PTSD also had depression. Refugees suffered the gamut of PTSD symptoms, especially symptoms of intrusions, hyperarousal, avoidance, and dissociation, some of which appeared to be related to more recent or acute exposures before, during, or after migration. There is evidence that co-existing severe depression is associated with poor response to treatment for PTSD (Haagen, et al. 2017). Refugees thus may need interventions that address depression along with PTSD as well as more acute trauma-related symptoms and syndromes.
Identifying psychological distress among refugees can be challenging because of language differences and cultural variations in the ways of expressing distress. Jakobsen, DeMott and Heir (2017) provide evidence for the feasibility and acceptability of using a touch screen computer to deliver two of the most widely used screening tools in refugee care, the Hopkins Symptoms Check List (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). The scales had modest sensitivity and low specificity, but this was comparable to results with paper-and-pencil administration. The method of computer administration might also lend itself readily to modifications to improve cross-cultural validity (e.g. use of audio, linguistic glosses of terms, additional items to explore idioms of distress, visual analogue scales, etc.)
Based on focus groups with mental health professionals and community members, Im, Ferguson and Hunter (2017) present some common cultural concepts of distress among Somali refugees. They note the distinction made in DSM-5 between cultural syndromes, idioms of distress, explanatory models and folk diagnoses (American Psychiatric Association, 2013; Lewis-Fernández, Kirmayer, Guarnaccia, & Ruiz, 2017). Some of the terms in common use function as idioms of distress but others clearly convey the notion of an extreme state of distress and are associated with social stigma. Becoming aware of cultural idioms is crucial to clinicians’ ability to respond to patient and family concerns as well as for community outreach and health systems planning to improve access, acceptability of services, and reduce the risk of stigmatization.
The asylum adjudication process varies substantially across countries and is far from consistent or reliable within any jurisdiction. Receiving the news that one’s application for asylum has been rejected can be profoundly challenging and, at times, catastrophic. Morgan, Melluish and Welham (2017) compared the prevalence and correlates of distress in a sample of asylum seekers and those refused asylum in the U.K. While level of anxiety and depression was associated with pre-migration stressors, the failure to gain asylum was the strongest predictor of depression in multivariate models.
While the very definition of refugee points to the traumatic situations that drive people to seek asylum, among the most powerful determinants of mental health are post-resettlement factors. In particular, discrimination, social marginalization, and exclusion after migration play important roles in refugee mental health and adaptation. Beiser and Hou (2017) present data from a large general population survey in Canada that allowed the comparison of the mental health of immigrants and refugees. Overall, refugees had lower levels of positive mental health than other migrants. This difference was related to perceived discrimination for women but not men, while a sense of belonging to Canada was protective.
Similar findings on the importance of post-migration context are presented in two studies from Durban South Africa report on the experience of migrants and refugees within Africa. Labys, Dreyer and Burns (2017) report a qualitative study of refugees in Durban, South Africa, from Zimbabwe and the Democratic Republic of Congo. Participants reported many distressing feelings associated with barriers to social integration including problems finding work, racism and xenophobia, and other structural adversity. In a quantitative study of 335 migrants, Thela and colleagues (2017) report on post-migration factors associated with distress. Family separation and experiences of discrimination were important determinants of mental health.
Salvo and Williams (2017) present a qualitative study of the experiences of refugees in the UK trying to learn English. While language skill was crucial for social integration, self-esteem and autonomy, refugees encountered multiple obstacles to linguistic competence. Feelings of shame and embarrassment impeded their engagement in the kinds of social exchanges and settings where they could advance their language learning. Focusing social support on language learning may yield big dividends for refugees’ social integration and psychological well-being.
School plays a critical role in the adaption and integration of refugee children and adolescents. Wong and Schweitzer (2017) present the results of a systematic literature review that identified factors contributing to academic success among adolescent refugees and they propose a multilevel model of factors contributing to post-resettlement academic trajectories. They draw from Bronfenbrenner’s (2005) bio-ecological model of development and Silove’s (2013) multidimensional model of trauma response and emphasize the importance of social support from family and peers and school connectedness to mediate resilience processes at the the levels of individual, family and community.
The U.S. government is currently trying to implement policies to limit immigration from certain Muslim countries and making strong efforts to reduce the influx of irregular migrants from Mexico, as well as refugees from many countries. Paat and Green (2017) describe the multiple challenges faced by migrants from Mexico seeking legal services in Texas. Their examples show how the distinction between voluntary migrants and refugees may be blurred for people facing severe economic pressures and endemic violence. Undocumented migrants and those with other forms of precarious status face many of the same challenges to social integration as refugees.
Basic care for refugees follows the same principles as mental health in primary care and psychiatry, but unfamiliarity with the predicament of refugees may make clinicians hesitant or uncertain about how to proceed (Kirmayer, 2003). Guidelines for primary care mental health and psychiatry are available (Kirmayer et al., 2011; Bhugra et al., 2014). Refining these guidelines requires research that develops and evaluates interventions for specific types of problems, as well as strategies for cultural adaptation to improve their fit (Hinton, et al., 2012).
Sleep disturbances are among the most common symptoms experienced by refugees and may aggravate other disorders and impair functioning. In a study of a clinical sample attending a specialized centre in the Denmark, Sandahl, Vindbjerg and Carlsson (2017) found that almost all reported sleep disturbances and recurrent nightmares. They also conducted a systematic review of the literature on the treatment of sleep disturbances among refugees but found it so sparse that it was not possible to make specific recommendations.
The experience of war, massive human rights violations, and forced displacement can have profound effects on the ways that survivors view the world. This impact goes well beyond the construct of PTSD. In a study examining overall cognitive assumptions about the world, ter Heide, Sleijpen, and van der Aa (2017) found that refugees had relatively low scores on sense of benevolence of the world and benevolence of people. Sense of self was less severely affected. They point toward the need to address attitudes toward the social world, especially loss of trust, in the assessment and treatment of refugees. Work on refugee resilience could lead to cognitive, behavioural, interpersonal and social interventions to mitigate this loss of trust, which could improve the adaptation of vulnerable individuals.
The construct of PTSD was originally framed around the notion that a discrete trauma of sufficient severity would result in psychopathology among many or most people. However, prospective research on the effects of trauma exposure has shown that pre-existing mental health problems are predictive of the emergence of PTSD and other trauma-related disorders. Then too, the kinds of situations that force migration often involved multiple, repeated, and prolonged exposures to threat and violence. The construct of complex PTSD has been put forward to capture some of the varied effects of such cumulative trauma. In a qualitative study of refugees with PTSD, Riber (2017) documented the high prevalence of childhood physical and emotional abuse and neglect. Some of these forms of childhood adversity reflected situations of protracted war, violence, and disruption in their countries of origin that affected the functioning of families and quality of parenting. These early experiences affected subsequent development, the response to traumatic events directly related to migration, and trajectories of adaptation after migration. This points to the need for clinicians to address the interplay between the more proximal traumas associated with migration and the background of developmental challenges and family dysfunction that renders individuals vulnerable and impedes resilience and recovery.
Most of the papers discuss the need to go beyond the focus on trauma and PTSD to understand the refugee’s predicament, including the major pre- and post-migratory determinants of mental health and the priorities for clinical intervention, promotion of social integration, and prevention of problems of adaptation. Fostering positive public attitudes to refugees in receiving countries is crucial for well-being and social integration (Esses, Hamilton, & Gaucher, 2017). Many of the papers point toward the importance of involving refugees in policy, planning, design and delivery of their own care.
Finally, it is important to acknowledge that most research on refugees comes from high income receiving countries that can provide relatively high levels of support and opportunities for integration—though this potential is not always or often realized. However, the majority of people enduring forced migration are internally displaced—and the majority of refugees live in low-income countries adjoining the regions from which they have fled. The difficulties in survival and, especially, in forming and carrying out some future-oriented plan make their situation especially challenging for mental health. Providing refuge needs to be coupled with interventions in global mental health to mitigate the factors that force migration and improve the situation of those enduring prolonged regional or internal displacement.
Conclusion
Ten years ago, this journal published a thematic issue on refugees that responded to the new strictures on migration emerging in an era of increased securitization and anxiety about terrorism that branded the refugee as a potential dangerous vector of violence (Kirmayer, 2007). In the last decade, the situation has worsened substantially, with dramatic increases in populations displaced and forced to migrate by the upheavals of war and natural catastrophes. In parallel, there has been a rise in populism and protectionist policies with new hostility to providing safe haven to those most in need. International recognition of the right to seek asylum grew out of the failure of nations to prevent the atrocities of World War II, but it now seems that historical memory and collective commitment to human rights have a short half-life and are rapidly decaying.
According to the Universal Declaration of Universal Human Rights “Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services” (United Nations, 1948). These human rights of refugees extend to asylum seekers and people viewed as irregular migrants. As health professionals, our work is governed by ethical guidelines that require we respect and respond to these human rights agendas. The World Medical Association (2015) states that one principal right is that every person has the right to medical care of good quality and is entitled without discrimination to appropriate medical care. Further, physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights.
Work on refugee resilience highlights the fact that refugees have agency and adaptability and cope with an enormous range of obstacles and challenges (Simich & Andermann, 2014). Refugees constitute culturally diverse and heterogeneous populations. What makes their mental health care distinctive is not only exposure to trauma, multiple losses, and prolonged uncertainty about their future, but also variations in their reception in host societies. Mental health care for refugees, and other displaced persons must be person-centered, based on people’s current needs, easily accessible, and organized and delivered in a culturally safe, sensitive and responsive way that strengthens resilience and supports each individual’s social inclusion and participation in the host society. Providing culturally safe care requires careful reflection on the values, attitudes and practices of the host society and concerted efforts to promote a sense of mutual recognition, respect, and belonging.
Migration policy poses many conundrums, with challenging ethical, political, and practical questions that deserve ongoing discussion and debate (Betts & Collier, 2017; Miller, 2016). Given the likelihood of dramatically increased pressure for migration with climate change, political instability, and other global factors, it is essential that there be continuing research to evaluate effective social integration and mental health practices. Our response to the predicament of refugees is a marker of our basic humanity. A recent discussion paper prepared by the Transcultural Psychiatry Section of the World Psychiatry Association (2016) calls for a global humanitarian agenda to support the needs of refugees, asylum seekers, and forcibly displaced persons through mental health promotion and the provision of appropriate care. We hope this special issue about research on asylum seekers and refugees will stimulate further research, the development of culturally responsive clinical services, and effective policy and practice.