What Are the Roots of Distress Among Refugees?

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SOME YEARS AGO, when I worked at a clinic for Bosnian refugees in Chicago, we were treating a severely traumatized 40-year-old woman who lived with her husband and young son in a small apartment in a gritty north side neighborhood. They'd escaped the war, but not before living through the destruction of their village and the killing of loved ones by nationalist Serbs. Alma (not her real name) was seen by one of our Bosnian counselors, and was prescribed antidepressant medication as well as sleeping pills to help her get some relief from her restless and anxious nights.

None of it helped. It didn't help because we were treating the effects of the wrong war.

Every day of the previous two years, Alma's husband had been sexually assaulting her in their small studio apartment in front of their young son. He'd threatened to kill them both if she told anyone or tried to escape. The war she was still desperately trying to survive was taking place in the supposedly safe haven of her refuge in Chicago. What Alma had survived in Bosnia seemed distant, a painful memory, compared with the daily terror she and her child were still living through.

We only learned about the violence in her home when we got a call from a local hospital. Alma was in their emergency room, acutely suicidal and possibly psychotic. Could we come over? On the way over, my Bosnian colleague shared her concern that Alma might be getting beaten by her husband at home. We found her in a small locked room in the ER, terrified but not psychotic. She sat silently, until I asked whether she was getting hurt at home. That's when it all came out.

For more than six months, we'd assumed her trauma, her relentless despair, stemmed from all that she'd lived through in Bosnia. We eventually got it right, got them both safe, but not before a woman in our care was repeatedly brutalized, and her young son lost the capacity for speech.

When working with refugees, it's easy and natural to attribute their distress to whatever war they've recently escaped from. It's an understandable and parsimonious explanation, because war-related violence and loss are often so striking. And it's generally not wholly wrong. But it's seldom wholly right, either.

CURRENT LIFE STRESSORS represent powerful threats to refugees' mental health. As powerful, in fact, as prior exposure to the violence and loss of armed conflict. This is as true in refugee camps adjacent to war zones as it is among refugees resettled in cities and towns in high income countries. It's a consistent finding, and it's slowly changing how organizations are working to foster healing and resilience among civilians displaced by war.

For more than 25 years, researchers and clinicians generally assumed that war exposure was the critical determinant influencing refugees' well-being. This led to lots of studies assessing exposure to wartime violence and loss, with limited consideration of the chronic adversity experienced by refugees after leaving their homeland. On the treatment side, the war exposure model led to an overly narrow focus on treating war trauma, while overlooking current stressors that might be causing distress—in some cases, extreme distress, like that of Alma and her young son in Chicago.

What sort of current life stressors are common among refugees?

• Poverty
• Overcrowded and unsafe housing
• Unemployment, often due to employment restrictions placed on refugees by their host society
• Social isolation, as family members and friends are left behind or resettled elsewhere
  • See "What do Refugees Leave Behind"?
• Heightened family violence, as marital and family tensions rise due to chronic adversity and parents struggle with continuously high levels of stress
• Social marginalization of stigmatized groups such sexual assault survivors, people disabled by landmines or other war-related violence, and children orphaned by violence and displacement
• The loss of life projects and valued social roles
• Frequent moves, leading to a sense of perpetual homelessness, a feeling that "This place we call home could be gone tomorrow."
• Discrimination by the host society
• The detention of asylum seekers and uncertainty regarding their asylum applications

• See "What do Refugees Leave Behind"?

This isn't an exhaustive list, just a sampling of things that have been shown to predict distress and undermine resilience among refugees. As research has increasingly demonstrated the importance of addressing current life stressors such as these, practitioners have begun to broaden their approach to strengthening refugees' mental health and psychosocial well-being. In addition to traditional clinical interventions targeting war trauma, efforts are increasingly being made to help refugees adapt effectively to the challenges of life in whatever setting they are in. This can mean altering settings to make them safer and more hospitable; it can also mean helping refugees gain the knowledge, skills, and other resources they need to overcome the daily challenges they face.

In high income countries, this might mean any of the following:

• ​Linking clients in clinical settings to various community resources (housing, employment, education, language classes, domestic violence programs, etc.)
• Incorporating psychosocial support into community settings (integrating mental health and psychosocial strategies into language classes, livelihoods programs, etc., and creating refugee-sensitive schools that prioritize the integration and support of refugee students)
• The creation of community settings where new social support networks can develop and resources can be easily accessed
• Anti-discrimination campaigns as well as campaigns aimed at minimizing the use of detention for asylum seekers
• Training social and health service organizations about the mental health needs and challenges of refugees. This could mean training physicians to explore the social determinants of depression among refugee patients, and link them to helpful resources rather than simply providing medication. For example, social isolation is powerfully related to depression among refugees, so linking socially isolated and depressed individuals to community resources that can foster a sense of connection may have more enduring benefits than anti-depressant medication.

In low and middle income countries, mental health interventions were similarly guided by the war exposure model until relatively recently. As the evidence has grown regarding the power of current life stressors, however, a similar shift has begun in the ways in which organizations are working to promote resilience as well as healing among refugees. Recognizing that mental health can be strengthened not only through traditional clinical services, but also through interventions that target the stressful conditions of everyday life, we see a greater emphasis on programs focused on:

• Livelihoods
• Poverty reduction
• Gender-based violence
• Mindfulness and trauma-informed yoga classes in community settings
• Psychosocial support for highly stressed refugee parents
• Life skills training for kids and teens
• Women’s empowerment
• Community-based child protection
• Safe schools and innovative approaches to educating refugee children who lack access to conventional schools. Schools not only offer structure, but also instill a sense of hopefulness, a wonderful antidote to depression.

In programs such as these, mental health is typically a collateral benefit, not a primary outcome. A critical task for researchers is to document the mental health and psychosocial benefits of such interventions, in order to clarify how mental health may be improved and resilience enhanced by helping refugees cope effectively with the stressful and challenging environments in which they are living.

A CLOSING ANECDOTE: A 60-year-old Bosnian woman came to our clinic severely depressed and struggling with symptoms of PTSD. She'd lost her husband during the war and had escaped with her grown son and his wife, first to a refugee camp and then to Chicago. Months of therapy and medication had no impact. Focusing on her painful losses and the terror of the war simply wasn't helpful. So her therapist changed his approach. Looking through his notes, he realized how distressed she was by her social isolation, spending her days alone in a small apartment while her son and daughter-in-law were at work. Afraid to take public transportation because she didn't know how to read the bus and subway map, and unable to speak English to ask for help, she stayed at home, lonely and haunted by her painful memories.

So after months of unhelpful treatment, she joined her therapist and their interpreter in what they playfully called "bus therapy." They got on a bus or subway together and intentionally got lost. Her task, with their help, was to find their way back home. Within six weeks, she'd mastered the transportation system, and was attending a women's group at the clinic, visiting new friends in their homes, had enrolled in an English class, and was regularly visiting the community center. Her depression lifted, and her trauma symptoms abated. Her natural capacity for healing had been supported by helping her overcome her isolation and develop a sense of empowerment in her new environment.

HERE ARE the takeaways:

1. Current life stressors pose significant threats to refugees' well-being. Because they are ongoing, they represent key targets of intervention. As George Bonanno and others have noted, we are generally more resilient than we are fragile; resilience is the norm, not the exception, even among refugees. However, post-migration environments can either strengthen or undermine our resilience.
2. Current life stressors undermine recovery from war-related trauma and grief. We have evolved to recover from painful life events. However, environments can either foster or impede natural processes of recovery. For refugees with enduring war-related distress, clinical treatment can be significantly enhanced by helping clients cope effectively with the ongoing stressors they are dealing with. Conversely, a failure to address those stressors can really slow down the treatment process.
3. Not all trauma among refugees is war trauma. As I illustrated in the story I opened with, it's natural to attribute distress among refugees to whatever violence and loss they may have endured before leaving their homeland. However, there are ongoing sources of traumatic stress that may cause a similar clinical presentation, yet have profoundly different implications for intervention.

To learn more about the shift from a war exposure model to a more comprehensive view of refugees' mental health, please see Miller, K.E., & Rasmussen, A. (2016).

To hear a live reading from War Torn (Larson Publications, 2016), from which the opening story in this post was adapted, please click here.