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Home > Public Resources > Trauma Blog > 2016 - April > Global Perspectives: The Mass Refugee Movement - Better Reframed as Mental Health Crisis?

Global Perspectives: The Mass Refugee Movement - Better Reframed as Mental Health Crisis?

April 2, 2016

The world is witnessing an unprecedented number of uprooted people. Current estimates exceed all previous records, with more than 60 million on the run. Nearly one out of every 100 persons world-wide is being forced to flee their homes (UNHCR, Dec 18, 2015). 

Humans are experiencing wars that target primarily civilians and mass recruitment and armament of men is increasing around the globe; there is an eruption in the number of individuals turning to extremism, driven by an appeal for violence (Elbert et al., 2016; Weierstall et al., 2013); and thus there is a dramatic increase in the number of people having to survive under inhumane conditions (Kaldor, 2013). 

Aggression and deprivation have destructive impacts on mental health, resulting in a psychiatric emergency of pandemic proportions. We argue that the psychological impact of this is not only devastating for the individual, but also is a factor in perpetuating both, conflicts and mental ill-health. 

More than 20 percent of the world’s population is living in extreme poverty with limited access to nutrition, education and other basic services, under circumstances of social discrimination and exclusion, and lacking the income and resources to ensure a sustainable livelihood and participate in collective decision-making (UN Sustainable Development, Dec 2015). This takes a heavy toll on human lives. 

When caregivers are chronically stressed in a violent environment, it has long-term effects on the offspring who develop higher rates of psychological and behavioral disorders (Betts et al., 2015; Spyridou et al., 2014; Mueller-Bamouh et al., 2016) and are more likely to have a child with epigenetic alterations in their HPA-axis (Radtke et al., 2011). In other words, women living under stressful circumstances reprogram the major stress defense system of their children. Moreover, the altered stress response leads to altered parenting, predicting the risk for psychopathology (Teicher et al., 2006). There is a positive correlation between increased stress of the parent and child maltreatment as well as inconsistent discipline, hostility against the child and physical punishment (Schauer & Schauer, 2010; Ruf-Leuschner et al., 2014; Savage et al., 2014; van Ee et al., 2012; Leen-Feldner et al., 2011). 

Different childhood adversities, including poverty, organized and family violence, or poor mental health of caregivers are independently associated with a low socioeconomic status (Currie & Widom, 2014) and a wide range of poor physical, mental, behavioral, and familial outcomes later in life (Chapman et al., 2007; Teicher et al., 2003; Elbert & Schauer, 2014; Shonkoff et al., 2009; Hackman et al., 2010; Luby et al., 2013). Survivors of parental and community stressors have a higher risk of developing somatic illness, bodily pains and disabilities (Springer et al., 2007; Kestilä et al., 2006; Tosevski & Milovancevic, 2006). 

For children today – who are the parents of the next generation - the effects of violence, emotional, physical or sexual abuse and neglect, continue long after the maltreatment ends (Widom & Wilson, 2015; Champagne, 2008) and correlate with adult victimization (Desai et al., 2002; Whitfield et al., 2003). The consequences of chronic and traumatic stressors reach beyond individual mental and physical dysfunction, affecting family, work, education and social integration capacity, which in turn compounds psychological problems, making spontaneous recovery less likely (Catani et al., 2010, Elbert et al., 2009; Kolassa et al., 2010). 

The flare up of conflicts is not surprising in communities where the prevalence of trauma-related disorders is as high as 20-50 percent (Karunakara et al., 2004; Schaal & Elbert, 2006; Nandi et al., 2015; Gäbel et al., 2006; Odenwald et al., 2007; Priebe et al., 2010; Bronstein et al., 2012). A cycle of trauma and violence means that survivors of hardship, misery, and poverty, and their burdened parents living in migrant communities with high trauma rates (Miller et al., 2005; Silove et al., 1997; Bronstein & Montgomery, 2011; Hollifield et al., 2013; Slewa-Younan, 2015; Bogic et al., 2015) and violent environments, are the most likely victims of further trauma and mental health problems (Hecker et al., 2012; Bojahr et al., 2016; Stafford et al., 2007; Schauer & Elbert, 2010; Catani et al., 2008; Elbert et al., 2013). 

These adversities have reached a critical point of hopelessness and intolerability that has set a mass migration movement in motion, to “flee a miserable life without a future in the home country, hoping to grant a better life for our children” (personal statement of a refugee in an EU shelter). The perilous journey often over many months adds trauma exposure, which contributes to psychological and physical health problems (Schauer & Elbert, 2010; Ruf et al., 2010). 

Although uprooted people from different backgrounds (e.g., low-socioeconomic status vs. (post-) war scenarios) both show high prevalence rates for psychological problems. The probability of being granted support and asylum depends mainly on the verification of a personal persecution history, which is defined as “severe violation of basic human rights” (EU Convention on Human Rights). Refugees of other types of violence and abuse who do not meet this requirement cannot automatically migrate to such a ‘better life.’ As the German Federal Office for Migration and Refugees (02/2016) states: “Emergencies such as familial violence, poverty, civil wars, natural disasters or missing (economic) prospects are excluded as reasons for being granted asylum.” This is in spite of the fact that there is ample evidence that war and the social environment interact and that childhood abuse and neglect, together with social exclusion, and formal education drives poverty and cycles of trauma ad violence. 

This in turn fuels aggression and conflicts and leads to the uprooting of people trying to leave social disadvantage and ‘failed states’ (fragile state index: http://fsi.fundforpeace.org), reaching out for more desirable living environments and creating a market for human traffickers and people smugglers; again a source of severe traumatization adding to a challenged capacity for integration in a new context. 

The mental health consequences of familial, community and organized violence on our minds, bodies and social fabric do not heal on their own; they reinforce each other and render ‘home’ unlivable. Given the enormous impact of trauma spectrum disorders on populations, considering the inclusion of trauma-focused treatment modules is an indispensable component within task shifting (WHO, 2016) ‘screen and treat’ cascade models of care (Schauer & Schauer, 2010; Ruf & Schauer, 2012): 
  1. sound epidemiologic data collection and community-wide screening
  2. community-based cascade-model structures (screeners identify traumatized individuals and bring them into contact with psychosocial assistants, who offer support for less severe cases and refer diagnosed cases to psychotherapists).
  3. trauma-focused treatment modules
  4. development of local (lay) capacity through training
  5. implementation structures based on ‘natural communities’
  6. public awareness raising for population, care-takers, decision makers
  7. human/child/woman’s rights at the core of counseling and therapy
  8. evidence-based project evaluation
Understanding the root causes of migration and flight, as well as dealing with their consequences, requires an evidence-based mental health perspective with a particular emphasis on trauma-focused guiding principles in contexts of adversity and refuge.

About the Author

Maggie Schauer, PhD, Director of the Center of Excellence for Psychotraumatology (Psychological research- and outpatient Clinic for Refugees) at the University of Konstanz, Germany, has received acclaim in both research and clinical settings for her work with survivors of severe traumatic stress. Dr. Schauer is both a founding member and current board member of vivo international (www.vivo.org), an alliance that works to overcome and prevent traumatic stress and its consequences within the individual, the family, and the community, safeguarding the rights and dignity of people affected by violence and conflict. 

References

Betts, K. S., Williams, G. M., Najman, J. M., & Alati, R. (2015). The relationship between maternal depressive, anxious, and stress symptoms during pregnancy and adult offspring behavioral and emotional problems. Depression and Anxiety32, 82-90.

Bogic, M., Njoku, A., & Priebe, S. (2015). Long-term mental health of war-refugees: a systematic literature review. BMC International Health and Human Rights15(1), 1.

Bronstein, I., & Montgomery, P. (2011). Psychological distress in refugee children: a systematic review. Clinical Child and Family Psychology Review14(1), 44-56.

Catani, C., Gewirtz, A. H., Wieling, E., Schauer, E., Elbert, T., & Neuner, F. (2010).Tsunami, war, and cumulative risk in the lives of Sri Lankan schoolchildren. Child Development81(4), 1176-1191.

Catani, C., Schauer, E., & Neuner, F. (2008). Beyond individual war trauma: domestic violence against children in Afghanistan and Sri Lanka. Journal of Marital and Family Therapy34(2), 165-176.

Chapman, D. P., Dube, S. R., & Anda, R. F. (2007). Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals37(5).

Champagne, F. A. (2008). Epigenetic mechanisms and the transgenerational effects of maternal care. Frontiers in neuroendocrinology29(3), 386-397.

Currie, J., & Widom, C.S. (2010). Long-term consequences of child abuse and neglect on adult economic well-being. Child Maltreatment15, 111–120.

Desai, S., Arias, I., Thompson, M. P., & Basile, K. C. (2002). Childhood victimization and subsequent adult revictimization assessed in a nationally representative sample of women and men. Violence Vict17(6), 639-653.

Elbert T, Moran, J, Schauer M (2016). Appetitive Aggression. In: Bushman BJ (ed.) Aggression and Violence. New York: Taylor & Francis/Routledge

Elbert T., Hinkel H., Maedl A.,, Hermenau K, Hecker T, Schauer, M., Riedke, H., Winkler, N., Lancaster, P. (2013). Sexual and gender-based violence in the Kivu provinces of the DRC (Democratic Republic of Congo): Insights from Former Combatants Washington DC: The International Bank for Reconstruction and Development. The World Bank. www.logica-wb.net.

Elbert, T., & Schauer, M. (2014). Epigenetic, neural and cognitive memories of traumatic stress and violence. In: Psychology Serving Humanity: Proceedings of the 30th International Congress of Psychology: Volume 2: Western Psychology (Vol. 2, p. 215). Psychology Press.

Elbert, T., Schauer, M., Schauer, E., Huschka, B., Hirth, M., & Neuner, F. (2009). Trauma-related impairment in children—A survey in Sri Lankan provinces affected by armed conflict. Child Abuse & Neglect33(4), 238-246.

Gäbel, U., Ruf, M., Schauer, M., Odenwald, M., & Neuner, F. (2006). Prävalenz der posttraumatischen Belastungsstörung (PTSD) und Möglichkeiten der Ermittlung in der Asylverfahrenspraxis. Zeitschrift für klinische Psychologie und Psychotherapie, 35(1), 12-20.

Hackman, D. A., Farah, M. J., & Meaney, M. J. (2010). Socioeconomic status and the brain: mechanistic insights from human and animal research. Nature Reviews Neuroscience11(9), 651-659.

Hecker, T., Hermenau, K., Maedl, A., Elbert, T., & Schauer, M. (2012). Appetitive aggression in former combatants—Derived from the ongoing conflict in DR Congo. International Journal of Law and Psychiatry35(3), 244-249.

Hollifield, M., Verbillis-Kolp, S., Farmer, B., Toolson, E. C., Woldehaimanot, T., Yamazaki, J., ... & SooHoo, J. (2013). The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. General hospital psychiatry, 35(2), 202-209.

Kaldor, M. (2013). New and old wars: Organized violence in a global era. John Wiley & Sons.

Karunakara, U. K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., & Burnham, G. (2004). Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. African health sciences, 4(2), 83-93.

Kolassa, I. T., Ertl, V., Eckart, C., Kolassa, S., Onyut, L. P., & Elbert, T. (2010). Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychological Trauma: Theory, Research, Practice, and Policy2(3), 169.

Leen-Feldner, E. W., Feldner, M. T., Bunaciu, L., & Blumenthal, H. (2011). Associations between parental posttraumatic stress disorder and both offspring internalizing problems and parental aggression within the National Comorbidity Survey-Replication. Journal of Anxiety Disorders25(2), 169-175.

Luby, J., Belden, A., Botteron, K., Marrus, N., Harms, M. P., Babb, C, et al. (2013). The effects of poverty on childhood brain development: the mediating effect of caregiving and stressful life events. JAMA Pediatrics167(12), 1135-1142.

Miller, G. A., Elbert, T., & Rockstroh, B. (2005). Judging psychiatric disorders in refugees. The Lancet366(9497), 1604-1605.

Müller-Bamouh, V., Ruf-Leuschner, M., Dohrmann, K., Schauer, M., & Elbert, T. (2016). Are experiences of family and of organized violence predictors of aggression and violent behavior? A study with unaccompanied refugee minors. European Journal of Psychotraumatology, 7.

Nandi, C., Crombach, A., Bambonye, M., Elbert, T., & Weierstall, R. (2015). Predictors of posttraumatic stress and appetitive aggression in active soldiers and former combatants. European Journal of Psychotraumatology6.

Odenwald, M., Lingenfelder, B., Schauer, M., Neuner, F., Rockstroh, B., Hinkel, H., & Elbert, T. (2007). Screening for Posttraumatic Stress Disorder among Somali ex-combatants: A validation study. Conflict and Health, 1(1), 1.

Priebe, S., Bogic, M., Ajdukovic, D., Franciskovic, T., Galeazzi, G. M., Kucukalic, A., & Schützwohl, M. (2010). Mental disorders following war in the Balkans: a study in 5 countries. Archives of General Psychiatry, 67(5), 518-528.

Radtke, K.M., Ruf, M., Gunter, H.M., Dohrmann, K., Schauer, M., A Meyer , Elbert, T. (2011). Transgenerational impact of intimate partner violence on methylation in the promoter of the glucocorticoid receptor. Transl PsychiatryVol 1.

Ruf, M., & Schauer, M. (2012). Facing childhood trauma: narrative exposure therapy within a cascade model of care. Exposure Therapy: New Developments. New York: Nova Science Publishers, 229-261.

Ruf-Leuschner, M., Roth, M. & Schauer, M. (2014). Traumatisierte Mütter - traumatisierte Kinder? Eine Untersuchung des transgenerationalen Zusammenhangs von Gewalterfahrungen und Traumafolgestörungen in Flüchtlingsfamilien, Zeitschrift für Klinische Psychologie und Psychotherapie, 43 (1), 1 – 16.

Savage, J. (2014). The association between attachment, parental bonds and physically aggressive and violent behavior: A comprehensive review. Aggression and Violent Behavior19(2), 164-178.

Schaal, S., & Elbert, T. (2006). Ten years after the genocide: Trauma confrontation and posttraumatic stress in Rwandan adolescents. Journal of Traumatic Stress19(1), 95-105.

Schauer M, Schauer E (2010) Trauma-Focused Public Mental-Health Interventions: A Paradigm Shift in Humanitarian Assistance and Aid Work. In E. Martz (ed): Trauma Rehabilitation After War and Conflict, Springer: New York, pp. 361-430.

Schauer, E., & Elbert, T. (2010). The psychological impact of child soldiering. In: Trauma rehabilitation after war and conflict (pp. 311-360). Springer New York.

Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy: A short-term treatment for traumatic stress disorders. Hogrefe Publishing.

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA301(21), 2252-2259.

Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors. The British Journal of Psychiatry, 170(4), 351-357.

Slewa-Younan, S., Guajardo, M. G. U., Heriseanu, A., & Hasan, T. (2015). A systematic review of post-traumatic stress disorder and depression amongst Iraqi refugees located in Western Countries. Journal of Immigrant and Minority Health, 17(4), 1231-1239.

Springer, K. W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse & Neglect31(5), 517-530.

Spyridou, A., Schauer, M., & Ruf-Leuschner, M. (2014). Obstetric care providers assessing psychosocial risk factors during pregnancy: validation of a short screening tool–the KINDEX Spanish Version. Child and Adolescent Psychiatry and Mental Health8(1), 1-15.

Stafford, M., Chandola, T., & Marmot, M. (2007). Association between fear of crime and mental health and physical functioning. American Journal of Public Health97(11), 2076-2081.

Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., Navalta, C. P., & Kim, D. M. (2003). The neurobiological consequences of early stress and childhood maltreatment. Neuroscience & Biobehavioral Reviews27(1), 33-44.

Teicher, M. H., Samson, J. A., Polcari, A., & McGreenery, C. E. (2006). Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. American Journal of Psychiatry163(6), 993-1000.

Tosevski, D. L., & Milovancevic, M. P. (2006). Stressful life events and physical health. Current Opinion in Psychiatry19(2), 184-189.

van Ee, E., Kleber, R. J., & Mooren, T. (2012). War trauma lingers on: Associations between maternal posttraumatic stress disorder, parent–child interaction, and child development. Infant Mental Health Journal33(5), 459-468.

Weierstall, R., Schauer, M., Elbert, T. (2013). An Appetite for Aggression. Scientific American Mind, 24 (2), 46-49.

Widom, C. S., & Wilson, H. W. (2015). Intergenerational Transmission of Violence. In J. Lindert & I. Levav (Eds.), Violence and Mental Health (pp. 27-45): Springer Netherlands.

Whitfield, C. L., Anda, R. F., Dube, S. R., & Felitti, V. J. (2003). Violent childhood experiences and the risk of intimate partner violence in adults - Assessment in a large health maintenance organization. Journal of Interpersonal Violence, 18(2), 166-185.