Prolonged wars in Syria, Iraq, and Afghanistan have contributed heavily to a global refugee crisis. The number of refugees today, estimated at 65 million, is the highest it’s been in 20 years. Populist rhetoric has fanned an international wave of anti-refugee sentiment, leading to growing calls to stem the flow of refugees into the United States and Europe. Meanwhile, local and international organizations are working to meet refugees’ basic needs, and to address the high levels of psychological distress commonly found among them.
To respond effectively to the mental health needs of refugees, it’s helpful to first dispel several myths and let the intriguing findings of recent studies guide our efforts.
Myth: Psychological distress among refugees is primarily the result of war-related violence and loss.
Fact: Distress among refugees is related just as powerfully to life in exile as it is the violence and destruction of war.
It’s understandable to assume that the elevated levels of trauma, anxiety, and depression we see among refugees from war zones like Syria, Afghanistan, and Iraq are the result of the violence and loss they’ve experienced prior to becoming displaced. That’s what a lot of Western researchers and clinicians assumed when they were confronted with thousands of refugees from Southeast Asia and Central America in the late 1970s and 1980s. They shared horrible stories of massacres, detention and torture, the destruction of their homes and possessions, the disappearance of loved ones, and living in a constant state of fear. It was natural to assume that their distress was the result of these terrible experiences. And that assumption naturally led to a widespread focus on healing the effects of war-related trauma.
The focus on healing war trauma wasn’t wholly misplaced, by any means. Living through war can be devastating, and may threaten people’s mental health in powerful and lasting ways.
However, research in the past 15 years has shown something quite striking. In study after study, it turns out that distress among refugees is related as strongly to so-called “post-migration stressors” as it is to experiences of war-related violence and loss. What happens to people after they become refugees affects their mental health just as powerfully as whatever they experienced during the war. It’s counter-intuitive, but true, and a consistent finding across studies of refugees from numerous war zones living in diverse settings.
For refugees in camps, life entails continuous exposure to overcrowded and inadequate housing, a lack of access to adequate nutrition and medical care, unemployment and severe poverty, heightened family violence, sexual assault in and around the camps, separation from relatives left behind, and a chronic sense of uncertainty regarding the future—life on indefinite hold. These stressful conditions are powerfully linked to depression, anxiety, and trauma. They also deplete people’s psychological resources for coping with war-related traumatic experiences. It’s a lot tougher to heal from the violence and loss of war when confronted with high levels of chronic stress and uncertainty.
And what about refugees living in more highly developed Western nations? The findings are surprisingly similar to those for refugees in camps. In a recent review paper, my colleague Andrew Rasmussen and I identified a consistent set of post-migration stressors that threaten refugees’ mental health and undermine their resilience and capacity to heal from experiences of war-related trauma and loss. Social isolation, discrimination, heightened family violence, poverty, the loss of social networks, and especially indefinite detention while their applications for asylum are pending, all take a powerful toll on mental health. Although war-related violence clearly contributes to distress among refugees, a narrow focus on war trauma can lead us to overlook current stressors that may account for much of the distress we are seeing.
Fact: While clinical services can play a useful role for distressed refugees, most refugees don’t have access to psychotherapy, and among those do, cultural and linguistic barriers lead to widespread underutilization. Moreover, clinical services aren't generally well-suited to addressing post-migration stressors shown to have a powerful effect on refugees’ mental health.
Fortunately, there are many ways of fostering psychological wellbeing among refugees. Improving the social and material conditions of everyday life can have a powerful and lasting impact, by reducing toxic stressors and fostering resilience and recovery from war-related violence and loss. These range from cash transfer programs that help impoverished people meet their basic needs while increasing spending in local businesses; training language teachers to address and incorporate mental health issues into the refugee classroom; helping refugees create new social networks through communal spaces and activities, in order to reduce isolation and increase social support; and advocating for a reduction in the use of detention centers for asylum seekers, who've committed no crime yet are often treated as criminals, locked away with uncertainty for prolonged periods of time while their applications for asylum are pending (not surprisingly, rates of depression and suicidal behavior escalate dramatically in such centers).
Some of these approaches are promising, while others already have good data to back them up. Psychiatrist Allen Keller and colleagues found that being granted asylum and gaining release from detention markedly reduced depression among asylum seekers in the U.S. Psychologist Jessica Goodkind and her colleagues have shown that helping refugees develop new social networks can significantly improve their psychological wellbeing and reduce emotional distress. And researchers at the International Rescue Committee have shown through a randomized controlled trial that a community-based intervention was able to significantly reduce harsh and abusive parenting in refugee families, a key source of toxic stress affecting children that often spikes among refugees as a result of chronically heightened parental stress.
Even in clinical settings, innovative community approaches can be adopted to empower refugee clients. Some years ago, when I was working at a clinic for Bosnian refugees in Chicago, an intern was working with an elderly woman whose severe depression did not respond to either therapy or anti-depressant medication. She was widowed, and lived in a small apartment with her son and daughter-in-law, both of whom worked during the day. Unable to speak English and afraid of the public transportation system, she spent her days alone, ruminating about the war and the wonderful life it had stolen from her. Her profound isolation only worsened her symptoms of trauma, ramping up the volume and intensity of her painful memories. One day, her therapist decided to take a novel approach. He accompanied her on the subway and bus, and each week they rode together to different parts of the city. With his assistance, she learned to read the transportation map, and within a month was attending social events and visiting new friends in their homes. Her depression lifted along with her sense of empowerment, and her trauma symptoms gradually abated. She was no longer imprisoned in a small and lonely apartment.
Myth: Most refugees are severely traumatized by their war experiences.
Fact: Only a minority of refugees experience enduring psychological trauma. For that minority, however, trauma is real, painful, and severely under-treated.
Rates of Posttraumatic Stress Disorder (PTSD) vary markedly across studies, but systematic reviews have shown that only a minority of refugees show persistent signs of trauma. Particularly vulnerable groups include survivors of torture and sexual assault, among whom PTSD rates tend to be higher. Unfortunately, refugees in the West, as I noted earlier, generally underutilize mental health services even when they are available. And in the developing world, where mental health professionals are comparatively scarce, trauma-focused interventions have shown promise using trained community members as lay therapists; however, no such programs have yet been brought to scale, and their promising effects have largely been demonstrated in resource-intensive, highly controlled efficacy studies. Effectiveness studies, which examine the effects of interventions under real-world conditions, are sorely needed to assess how programs may need to be adapted in order to be helpful in the low resource conditions in which most community-based organizations function.
It’s important to bear in mind that trauma among refugees may be the result of on-going traumatic stressors such as family violence, in which case establishing safety is critical before engaging in any sort of trauma treatment. In fact, family violence, including both spouse abuse and child maltreatment, often increases in refugee communities as a result of chronic stress. It’s important to never assume that the trauma we’re seeing is the result whatever war people have escaped from.
And finally, two myths about refugees that are not specifically related to mental health, but that impede the provision of supportive responses that can help refugees adapt successfully and integrate into their new environment.
Myth: Refugees, especially from Syria, are flocking to the United States in great numbers to take advantage of job opportunities, social services, and other benefits.
Fact: Refugees seldom wish to leave their world behind. When people become refugees, they lose their homes, possessions, communities, and livelihoods. The decision to flee is agonizingly painful, a last desperate resort when armed conflict poses too great a threat to people’s lives.
Although the number of refugees who make it to Western countries may seem great, it pales in comparison to the number living in refugee camps and informal settlements in countries adjacent to their embattled homeland. Turkey is host to more than 2.7 million Syrians, Lebanon to more than one million, and Jordan to 655,000. By comparison, the United States resettled just 1,682 Syrians in 2015, and another 12,600 by the end of 2016.
Myth: Refugees cause a rise in crime in their host society.
Fact: Despite fear mongering from right wing politicians, studies suggest that refugees are statistically less likely to engage criminal behavior than native-born members of their host society.
Germany, which has taken in more refugees than any other European country, has studied this issue extensively. In fact, native-born Germans are more likely to be involved in crime than refugees, especially refugees from Syria, Iraq, and Afghanistan. In fact, refugees may have more to fear than their hosts; by the end of 2014, attacks in Germany against shelters for asylum seekers had tripled. Studies on crime among refugees and crime in the US show a similar pattern to that found in Germany.
Goodkind JR, Hess JM, Isakson B, LaNoue M, Githinji A, Roche N…Parker DP (2013). Reducing Refugee Mental Health Disparities: A Community-Based Intervention to Address Postmigration Stressors With African Adults. Psychological Services. Advance online publication. DOI: 10.1037/a0035081
Keller AS, Rosenfeld B, Trinh-Shevrin C, Meserve C, Sachs E, Leviss J…Ford D. (2003). Mental health of detained asylum seekers. The Lancet 362, 1721-1723. DOI: 10.1016/S0140-6736(03)14846-5
Sim, A. (2014). Building happy families. New York: International Rescue Committee. Retrieved from http://www.rescue.org/sites/default/files/resource-file/HappyFamilies_report_FINAL_18Nov14.pdf
Miller, K.E., & Rasmussen, A. (2016). The mental health of populations displaced by armed conflict: An ecological model of refugee distress. Epidemiology and Psychiatric Sciences. DOI: 10.1017/S2045796016000172