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Briefing Paper: Trauma and Mental Health in Forcibly Displaced Populations

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Angela Nickerson, PhD
University of New South Wales, Australia
 
Belinda Liddell, PhD
University of New South Wales, Australia
 
Anu Asnaani, PhD
University of Pennsylvania, United States
 
Jessica Carlsson, MD, PhD
Competence Centre for Transcultural Psychiatry, Denmark
 
Mina Fazel, DM, MRC Psych
University of Oxford, United Kingdom
 
Christine Knaevelsrud, PhD
Free University of Berlin, Germany
 
Naser Morina, PhD
Zurich University Hospital, Switzerland
 
Frank Neuner, PhD
Bielefeld University, Germany
 
Elizabeth Newnham, PhD
Curtin University, Australia
 
Andrew Rasmussen, PhD
Fordham University, United States
 
We gratefully acknowledge the valuable contribution of Dr. Peter Ventevogel, Senior Mental Health Officer at the United Nations High Commissioner for Refugees in Geneva, Switzerland. We also greatly appreciate the input of Dr. Ulrich Schnyder, Dr. Stuart Turner, and the ISTSS Public Health and Policy Committee. In addition, we thank Savannah Minihan and Shraddha Kashyap for their assistance in the preparation of this document.

Key Points

  • Adult and child refugees and asylum-seekers evidence elevated rates of psychological disorders including posttraumatic stress disorder (PTSD) and depression.
  • Exposure to traumatic events and daily stressors contribute substantially to psychopathology in refugees and asylum-seekers.
  • Trauma-focused interventions have the strongest evidence base to reduce PTSD symptoms in adult and child refugees and asylum-seekers.
  • Culture impacts on conceptualization, expression and treatment of psychological distress in refugees and asylum-seekers.
  • There exist numerous logistical, cultural and situational barriers to accessing treatment for psychological disorders for refugees and asylum-seekers.
  • There is promising evidence regarding scalable interventions for refugees and asylum-seekers that overcome barriers to accessing treatment for psychological symptoms, however these require further evaluation.
Recommendations
  • Evidence-based interventions should be made available for, and implemented where possible with, refugees with psychological disorders.
  • Settlement policy and mental health and psychosocial support (MHPSS) programming should facilitate positive mental health outcomes amongst refugees via the provision of resources, enhancing the capacity of the individual for resilience, and strengthening family and community supports. Settlement policy should consider the potentially negative effects of restrictive immigration policies on mental health.
  • Clinicians and support workers should take into account contextual factors (i.e., cultural background, daily stressors, living, family and school environments) when working with refugees and asylum-seekers.
  • High-quality research should be undertaken in collaboration with refugee communities to increase understanding and treatment of psychological disorders amongst refugees and asylum-seekers. More research should be conducted in LMICs to enhance knowledge about the mental health needs of those in sustained displacement.
  • Professional organizations can play an important role in facilitating, promoting and disseminating research on refugee mental health.

Executive Summary

As of the end of 2016, there were over 65 million people forcibly displaced worldwide as a result of conflict and persecution. The experiences of conflict, persecution and forced displacement have a pervasive negative impact on the mental health of refugees and asylum-seekers. There is global recognition of a growing need to understand and meet the mental health needs of refugees and asylum-seekers worldwide. The International Society for Traumatic Stress Studies (ISTSS) commissioned this briefing paper to inform its membership, policymakers and global stakeholders about the mental health impact of the refugee experience. This paper outlines the research evidence regarding (1) commonly-experienced traumatic events and daily stressors, (2) mental disorders experienced by adult and child refugees, (3) psychological and pharmacological interventions, (4) the role of culture in influencing mental health and (5) barriers to treatment following forcible displacement. Recommendations are also made across the areas of public health, immigration, settlement and mental health and psychosocial support (MHPSS) policy, and clinical practice and research.

Refugees are typically exposed to multiple types of traumatic events in their countries of origin and during displacement. These events are often repeated, prolonged and interpersonal in nature, and have been demonstrated to have a deleterious effect on mental health. Child and adolescent refugees may be especially vulnerable to exploitation during migration, leading to poor mental health outcomes. In addition, refugees face numerous daily challenges in their home countries and during displacement, as well as in the post-migration environment, including those related to lack of resources, family separation, social isolation and discrimination, socioeconomic factors, and immigration and refugee policies. These stressors negatively impact mental health over and above the traumatic events experienced in the context of persecution. Accordingly, refugees and asylum-seekers experience elevated rates of psychological disorders compared to the broader community in host countries, with the majority of research to date focusing on posttraumatic stress disorder (PTSD) and depression. For child and adolescent refugees, factors related to the family of origin (i.e., loss of a parent or poor parental mental health) may have an especially pervasive impact on wellbeing.

There is a growing evidence base relating to psychological treatment for trauma-related disorders amongst refugees and asylum-seekers. Evidence to date points to trauma-focused interventions being the most efficacious in reducing PTSD symptoms amongst adult and child refugees. In contrast, there has been relatively little rigorous research investigating other approaches such as multimodal and pharmacological interventions. In recognition of the barriers to accessing evidence-based interventions for refugees in both high and low-resource settings, there is increasing evaluation of scalable approaches to addressing mental disorders in refugees, including low-intensity interventions, task-shifting approaches, school-based interventions and the online delivery of treatments. Promising findings are emerging from these studies, however more research is required to determine the feasibility and efficacy of these approaches amongst refugees and asylum-seekers.

Refugees often originate from cultural groups that are outside the western context where psychiatric nosologies have been developed. Culture has a profound impact on the conceptualization, expression and treatment of psychological distress. Knowledge regarding cultural constructs of distress can aid the understanding of mental health symptoms amongst trauma-affected refugees, however few studies have systematically investigated these. Similarly, few interventions are specifically developed around cultural content, with treatments often relying on clinicians’ cultural competence in delivery.

There are numerous barriers to the treatment of psychological symptoms amongst refugees and asylum-seekers, including lack of access to specialized care, the high cost of traditional clinical treatments, lack of financial and practical resources, and lack of access to interpreters. In addition, divergent conceptualizations of mental distress, lack of knowledge regarding mental health care in the host country, stigma related to mental illness and lack of trust arising from persecutory experiences may hamper the uptake of available treatment. Practical concerns may also overshadow the salience of psychological symptoms leading to de-prioritizing psychological treatments amongst forcibly displaced groups.

We recommend a number of actions to improve knowledge regarding refugee mental health, and to better address the mental health needs of those affected by persecution and displacement.

Public Health Policy. Evidence-based psychological therapies should be made available to refugees and asylum-seekers in need of treatment. To facilitate this, the following steps could be taken:

  • Provision of evidence-based treatment at no cost (with interpreters if required)
  • Increased competence in the culturally-informed delivery of evidence-based interventions in the healthcare systems of host countries
  • The creation of complementary treatment, training and research facilities for refugees and asylum-seekers in settlement countries
  • The involvement of individuals from a refugee background in mental health programming and implementation
  • Provision of stigma-reduction programs.
Immigration, Settlement and MHPSS Policy. Immigration, settlement and MHPSS policy should:
  • Provide critical resources to facilitate positive adaptation in refugees and asylum-seekers, including enhancing individual capacity for resilience and strengthening family and community supports
  • Consider the negative mental health effects of restrictive immigration policy and how psychological symptoms may impact on legal processes related to immigration status resolution
  • Prioritize the reunification of families to protect vulnerable children and adolescents.
Clinical Practice. Those providing treatment to forcibly-displaced groups should 
  • Implement evidence-based treatments (such as trauma-focused interventions for PTSD) where possible and via a trained interpreter if required
  • Consider how the cultural background of the client, the context in which the client is living (i.e., refugee camp, settlement country) and daily stressors impact on psychopathology, and how clinical practice can be adapted to accommodate these factors
  • Consider family and school contexts when working with forcibly displaced children and adolescents.
Research. Research studies should
  • Implement community participatory designs and be conducted in collaboration with service providers, clinicians and policymakers where possible
  • Investigate the full breadth of psychological disorders and symptoms in refugees, focusing on cultural conceptions of distress
  • Implement longitudinal, experimental, biological and neuroscience methods to identify mechanisms underlying refugee mental health and determine the temporal causal relationship between refugee experiences, mental health and other outcomes
  • Be conducted in low- and middle- income countries (LMICs), to increase knowledge regarding the mental health of refugees in sustained displacement.
Further, treatment studies should
  • Implement rigorous randomized controlled trial designs
  • Investigate the efficacy of interventions in reducing psychological symptoms beyond PTSD and improving broader outcomes (e.g., functional impairment, quality of life)
  • Evaluate interventions that improve access to mental health care (i.e., stepped care and on-line treatments) and have a broader community and societal focus
  • Evaluate the efficacy of early intervention/ prevention programs, including Psychological First Aid
  • Investigate treatment moderators to identify individuals who fail to benefit from best-practice interventions
  • Include the development and evaluation of programs that support parental care and parenting practices in refugee families.
Professional Organizations. Relevant professional organizations should adopt an increased focus on refugee and asylum-seeker mental health.