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Nearly 1% of the world’s population is now forcibly displaced as a result of conflict and persecution and most remain subject to sustained vulnerability and uncertainty. The psychological impact of persecution, war and displacement is substantial, with research indicating that rates of psychological disorders amongst refugees are significantly higher than those seen in the populations of host countries (Bogic et al., 2015; Henkelmann et al., 2020; Posselt et al., 2019; Steel et al., 2009). Despite this some refugees have been observed to cope considerably better than others despite the same exposure to environmental and psychological trauma. We were interested in understanding why this might be the case.
The authors work in a mix of direct practice field work and clinical research. Together we were interested in understanding which factors could be leveraged to best promote coping in contexts of sustained vulnerability. The aim in coming together on this topic was to inform the development of an intervention approach that would better harness the unique strengths and capabilities of an individual whilst also reducing environmental stress factors to ultimately lead to a better state of wellbeing. 
A review of the literature revealed that the impact of both psychological and environmental factors was already well understood in relation to post-trauma psychopathology, however there appeared to be limited consideration of the interactive nature of these factors. This led us to propose that psychological and environmental factors may be best understood as two intersecting axes in a quadrant, as opposed to being linearly related. Therefore, the PIE Matrix model was formulated to provide a mechanism for understanding this interaction and to inform intervention responses.


The model seeks to demonstrate the impact of high or low levels of internal and external stress factors on individual wellbeing and psychopathology. It proposes that clinical and non-clinical interventions should focus on building internal psychological and cognitive functioning whilst simultaneously seeking to minimise the level of environmental stress. By understanding this interaction, practitioners and clinicians alike can develop a more nuanced and complimentary intervention approach that we hypothesise will lead to reduced incidence of psychological distress. 
This paper seeks to formulate arguments for a new way of approaching trauma intervention in populations facing sustained vulnerability such as those who are forcibly displaced. More research is needed to test this approach and its application to inform interventions and to determine causal factors in a longitudinal context.

Reference Article

Kashyap, S., Keegan, D., Liddell, B. J., Thomson, T., & Nickerson, A. (2020, Dec 12). An Interaction Model of Environmental and Psychological Factors Influencing Refugee Mental HealthJ Trauma Stresshttps://doi.org/10.1002/jts.22636

Discussion Questions

  1. How could the PIE matrix model be applied in other settings or population groups?
  2. How could clinicians or practitioners tailor their intervention approach according to the PIE matrix model?
  3. How might the PIE matrix model encourage critical reflection among clinicians/practitioners about how different people manage stress in different environments?

About the Authors

David Keegan
is the Founder and CEO of HOST International, an NGO empowering communities to create localised solutions to displacement in the Asia Pacific region. He is a qualified Social Worker and holds a Masters in Community Management as well as a Certificate in Migration Management. He is a member of the UN Network on Migration working group for alternatives to detention and was formerly an executive leader for a large refugee resettlement program in Australia. Twitter: keegandj

Ted Thomson
is co-founder of HOST International, Ted was Country Manager of Nauru and then appointed chief operating officer in April 2018. His area of expertise is in non-profit management, case management and client services, strategic planning, and leadership. Ted’s background includes 30 years in housing and homelessness, child protection and out of home care, youth sector work, refugee settlement, international capacity development and humanitarian work. Prior to working at HOST, Ted has held management positions with Connect Settlement Service, Settlement Services International, Marist Youth Care and Southern Youth and Family Servicesd. Ted holds an Associate Diploma in social sciences

Shraddha Kashyap
completed her Masters and PhD in Clinical Psychology at the University of Western Australia (UWA). She was awarded a Fulbright Scholarship to study factors affecting mental health among people with refugee backgrounds living in New York City, at the Bellevue/NYU Program for Survivors of Torture, and then worked as a Postdoctoral Research Fellow at the Refugee Trauma and Recovery Program at the University of New South Wales, Sydney.  Shraddha currently splits her time between working as a clinician and a researcher.  She is a Clinical Psychology Registrar at a private practice in Perth; and a Postdoctoral Research Associate at the UWA School of Indigenous Studies, working on a project which aims to improve the cultural safety of mental health services accessed by Aboriginal and Torres Strait Islander peoples. 
Belinda Liddell
is a Senior Research Fellow and Deputy Director of the Refugee Trauma and Recovery Program in the School of Psychology, University of New South Wales Sydney. Her research focuses on understanding the impact of human rights violations on the brain, and investigating the psychological, social and cultural factors that influence refugee trauma recovery and settlement pathways to inform policy and practice. Belinda completed her PhD at the University of Sydney in cognitive neuroscience, and has previously worked for Unicef in Cambodia on evidence-based policy development and directed a longitudinal mental health research project in Timor-Leste. Twitter: Bellidell
Angela Nickerson
is Professor at the School of Psychology at UNSW Sydney, and Director of the Refugee Trauma and Recovery Program. Her research focuses on understanding the psychological mechanisms underpinning refugee and post-conflict mental health, and developing effective interventions for traumatic stress reactions in refugees. She is also interested in the impact of policy on refugee mental health, and cross-cultural considerations in psychological processes. She has worked with refugee and post-conflict populations in Australia, Indonesia, Timor-Leste, Switzerland, and the United States. Twitter: A_Nickerson36


Bogic, M., Njoku, A., & Priebe, S. (2015). Long-term mental health of war-refugees: a systematic literature review. BMC Int Health Hum Rights, 15, 29. https://doi.org/10.1186/s12914-015-0064-9

Henkelmann, J. R., de Best, S., Deckers, C., Jensen, K., Shahab, M., Elzinga, B., & Molendijk, M. (2020). Anxiety, depression and post-traumatic stress disorder in refugees resettling in high-income countries: systematic review and meta-analysis. BJPsych Open, 6(4), e68. https://doi.org/10.1192/bjo.2020.54

Posselt, M., Eaton, H., Ferguson, M., Keegan, D., & Procter, N. (2019). Enablers of psychological well-being for refugees and asylum seekers living in transitional countries: A systematic review. Health Soc Care Community, 27(4), 808-823. https://doi.org/10.1111/hsc.12680

Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537-549. https://doi.org/302/5/537 [pii]