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Meeting the mental health needs of refugees and asylum seekers
Abstract
Mental health provision for diverse refugee populations is faced with a number of challenges, and requires the development and evaluation of flexible service models that maximise capacity and utilise existing non-specialist resources. Emerging therapeutic approaches should be applied in real settings, adapted to cultural needs and integrated with the other agencies involved.
... Migration challenges both home, transit and host countries at many levels, in their willingness to help and give protection or reversely by showing disinterest or even hostility towards the migrant population, an example being through appropriate adaptation of healthcare systems to meet specific needs (Bogic, Nook & Priebe, 2015), (Vostanis, 2014). ...
... This phase is usually long-lasting, charged with specific stress factors that can have a cumulative effect on previous life events and traumas (Bhugra & Wojcik, 2010). Many authors highlight the importance to limit and reduce the postmigration phase stressors as much as possible, to prevent the development or the aggravation of mental health problems in this population (Harris, 2007, p. 93), (Herrman, Kaplan & Szwarc, 2010, p. 55), (Vostanis, 2014). ...
... Scholars in this field underline the fact that mental heath care for migrants is a complex issue to address, especially due to cultural aspects to be considered and to severity of traumatic experiences that are frequently presented to the clinician (Alayarian, 2007-a, p. 141-159), (Craig, 2010, p. 9-19). Mental health problems that are commonly encountered in this population are post-traumatic stress syndrome (PTSD), depression and anxiety disorders, and less frequently other disturbs as dissociative states, paranoid schizophrenia, psychosomatic symptoms, suicidal thinking and difficulty in the regulation of emotional state (Alayarian, 2007-a, p. 141), (Bogic et al., 2015), (Butler, Warfa, Khatib & Bhui, 2015), (Vostanis, 2014). ...
This qualitative research presents the results of an investigation conducted in Italy on a group of psychologists working in mental healthcare for migrant population. These professionals addressed problems characterized by complexity, in particular related to high level of trauma encountered among migrants and to intercultural aspects to consider in the clinical practice. The author, a physiotherapist specialized in mental healthcare, was
interested in the investigation of facets related to psychologists’ distress, secondary reactions, coping strategies and resilience, with a particular focus on the bodily reactions. The findings confirmed the presence of various phenomena of both positive and negative character, that could be linked to existing constructs described in scientific literature. The negative phenomena showed to be in relation to both objective stressors and subjective factors. The positive ones revealed the link between psychologists exposition to stressors and their growth at personal and professional level. Original themes that further emerged from the analysis were that of the body as a work-tool and that of re-humanization. The latter could be seen as the essence of psychologists’ intervention, in responding to the extreme de-humanization which they frequently witnessed in migrant population. The theme of the body as a work-tool appeared to be strictly related to the constructs of
body-awareness and embodiment. Besides the qualitative investigation by means of interviews, also a supplementary observation of body patterns was conducted that confirmed a remarkable level of physical affliction, evidenced in deviations from posture and respiration patterns. Thus, the results underpinned the relevance of the subject of interest, stimulating further investigations. Building on these findings, new research
should override the limitations of this study that did not explore subjective characteristics and traits that also could have an influence on coping mechanisms and resilience of psychologists. By exploring the relationship between body phenomena, body awareness and resilience in clinicians, a possible goal of further research could be the contribution to the development of a prognostic tool and of a therapeutic concept, to be used with
supportive function for the psychologists. The contribution of a body-oriented approach like that of Norwegian Psychomotor Physiotherapy could be worthy and should be considered.
... The asylum-seeking process with the associated feelings of uncertainty about the future, is an additional stress factor with further mental health implications [3]. Therefore, it is not surprising that trauma-related problems such as post-traumatic stress disorder (PTSD) are particularly common among refugee children [4][5][6]. For instance, a recent study on 307 URMs in Norway and Belgium [7] showed that 53% reported high levels of PTSD symptoms. ...
... respectively (see Figure 1 for the full list of the items). Each item is rated on a 4-point scale: not at all (0), rarely (1), sometimes (3) and often (5). A total score is obtained by summing up all the eight items (ranging between 0 and 40). ...
... CFA was conducted in R (version 3.2.4) using the lavaan package (version 0. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. All other analyses were performed using SPSS-23. ...
Aims:
The dramatic increase in the number of refugees in Europe presents a major public health challenge. The limited existing evidence indicates that the mental health needs of refugees are significant; unaccompanied refugee minors (URMs) constitute a particularly vulnerable group. In this study, we aimed to investigate whether a short questionnaire (Children's Revised Impact of Event Scale; CRIES-8) could be used as a screening tool for PTSD symptoms in URMs, 8-18 years old, during their routine health check-up.
Methods:
Data were collected at the healthcare centre for asylum-seekers in Uppsala, Sweden. In total, 208 URMs completed the CRIES-8 during their health assessment.
Results:
The CRIES-8 was feasible to use, showed good internal consistency and its factor structure was confirmed. Children with less than four years of education often had difficulties completing the questionnaire by themselves and needed help reading the questions. Almost all the respondents were male (98%), aged 9-18 years. The majority (81%) came from Afghanistan. About 76% scored above the cut-off and therefore were considered to be at risk of PTSD. The proportion of children who screened positive did not differ based on age, country of origin or current living arrangements.
Conclusions:
The CRIES-8 is a useful tool in clinical settings, however, children should be provided with reading support and instructions about how to complete the questionnaire. The high number of children who screened positive for PTSD symptoms indicates the need for a more thorough mental health assessment, and early prevention/intervention programmes to address URMs' mental health issues.
... The literature relates to both the traumatic events that forced them to leave their homes or occurred during their journey, the search for an asylum, and post-migration living difficulties in the country in which they currently reside. Past traumas thus include the traumas that led them to leave their home countries, such as civil wars, persecution, or natural disasters, as well as traumas experienced during their escape, such as being shot by soldiers, serious physical injury due to violence, kidnapping, slavery, etc. (Tonsing & Vungkhanching, 2020;Vostanis, 2014). Post-migration living difficulties in the receiving countries include issues of legal status, the threat of being deported, economic hardship, limited ...
... As noted above, living difficulties are problems that asylum seekers and refugees face in their new country, such as issues of legal status, the threat of being deported, economic hardship, limited access to healthcare and welfare services, worries about their families at home, social distance from the local population, and low occupational opportunities (Kalnisky & Levy, 2021;Li et al., 2016;Tonsing & Vungkhanching, 2020;Vostanis, 2014). Studies indicate that these difficulties impair the psychological wellbeing and mental health of refugees and asylum seekers (Li et al., 2016;Wicki et al., 2021). ...
The living difficulties of asylum seekers in receiving countries may impair their mental health. Based on the Social Capital Theory, the current study sought to identify social factors that might reduce their psychological distress and improve their wellbeing. A sample of 227 Darfuri asylum seekers in Israel aged 19–58 completed a questionnaire assessing the outcomes of psychological distress and wellbeing, and the predictors of post-migration living difficulties, number of asylum seeker and Israeli friends, perceived social support, and volunteering in community activity for asylum seekers. The findings show that whereas perceived social support was associated with reduced psychological distress and increased wellbeing (and the latter also associated with number of Israeli friends), the number of asylum seeker friends was associated with increased psychological distress and reduced wellbeing. Moreover, both factors moderated the association between living difficulties and psychological distress, that is, it was significant only at higher levels of these factors. Volunteering in community activity also moderated this association. The results suggest that having friends is not enough to improve wellbeing and may even have the opposite effect when friends share similar adversities. However, friends who are available to offer support can contribute to improved wellbeing. Similarly, volunteering in community activity may reduce the individual’s own welfare, as it exposes them to the adversities of others. Thus, while some social capital indicators are beneficial, others might have a detrimental effect. The results indicate the need to strengthen the social contacts of asylum seekers while paying attention to the potential cost.
... Migration within or across countries has thus placed humanitarian, welfare, and health care systems under a strain to meet the complex needs of this vulnerable population. A large body of research has focused on mental and physical health conditions and has consistently established high prevalence rates of a range of disorders (Frost et al., 2019;Vostanis, 2014). These include posttraumatic stress, anxiety, depression, and somatization disorders, often with high levels of comorbidity and secondary impairments (Frost et al., 2019;Vostanis, 2014). ...
... A large body of research has focused on mental and physical health conditions and has consistently established high prevalence rates of a range of disorders (Frost et al., 2019;Vostanis, 2014). These include posttraumatic stress, anxiety, depression, and somatization disorders, often with high levels of comorbidity and secondary impairments (Frost et al., 2019;Vostanis, 2014). Research regarding the physical health of refugees has also shown a high prevalence of diseases such as hypertension, vision impairment, arthritis, back pain, musculoskeletal pain, and urinary tract infections, particularly in refugees aged 60 years and older (Frost et al., 2019). ...
To date, research on refugee mental health has mainly focused
on understanding the absence of psychopathology rather than
on their well-being and associated positive aspects. The aim of
this study was to examine the role of resilience, hope, belongingness, and social support in predicting satisfaction with life
and flourishing among 361 minority Syrian refugees living
in Iraq (age range = 18–60years, mean = 32.57, SD=10.05).
Participants completed the Brief Resilience Scale, Adult Hope
Scale, Multidimensional Scale of Perceived Social Support Scale,
General Belongingness Scale, Satisfaction With Life Scale, and
Flourishing Scale. Males reported significantly higher levels of
resilience, belongingness, and flourishing compared to females.
Demographic variables (age, gender, and economic level), resilience, hope, belongingness, and social support were correlated
with life satisfaction and flourishing scores. While controlling
for sociodemographic characteristics, resilience and hope were
associated with life satisfaction and flourishing scores. However,
belongingness and social support were only associated with
flourishing scores. The findings suggest that equipping refugees
with positive psychological resources could promote increased
levels of life satisfaction and flourishing and thus enhance
preventive psychosocial programs.
... Adolescent refugees are at particular risk of developing mental-health problems [4,5]. ...
... This exposure included the experience of bombs falling and damaging one's neighborhood and surroundings, as well as harm suffered by acquaintances [13]. Such experiences may increase the risk of PTSD and other internalizing problems, especially during the first stage of migration [3,5,11,12]. Studies of the effects of cumulative exposure to violent political events have yielded inconclusive findings [3,11,14]. ...
Background:
Against the backdrop of 10 years of civil war in Syria, with millions of refugees, this study aimed to explore sense of community coherence and the acculturation strategies of integration and competition as factors that might explain mental-health problems among adolescent Syrian refugees in Greece. Methods: Data were gathered from 173 adolescents aged 13–18 (M = 15.85; SD = 1.49); female adolescents accounted for 60.7% of the sample. Participants filled out a self-reported questionnaire regarding internalizing and externalizing problems, as well as posttraumatic stress disorder (PTSD). They were also asked about their sense of community coherence, their use of different acculturation strategies, and sociodemographic factors (i.e., gender, age, amount of time spent in the camp, and parents’ education), as well as contextual factors such as exposure to war events, appraisal of danger, and whether they had received aid from various organizations. Results: The female adolescents reported a stronger sense of community coherence and that they had received more aid from organizations than the male adolescents reported receiving. The male adolescents reported more externalizing problems. Exposure and appraisal of danger, as well as sense of community coherence and the use of the acculturation strategies of separation and competition all significantly explained the various mental-health problems. Conclusions: This article underscores the significance of gender, community coherence, and acculturation strategies in the prediction of mental health. It presents the results of this research in the context of the salutogenic and acculturation models.
Keywords: Community coherence; Refugees; Mental health; Acculturation
... Bean et al. [10] and Khamis [69] state in their studies on refugee adolescents that a significant relationship exists between stressful life events and psychiatric disorders. Anxiety is one of the most common psychiatric disorders observed in these adolescents [21,55,57,58,135]. Many researchers in the literature, both in Turkey and in different countries, have conducted studies on Syrian refugee adolescents and have noted that at least half of these adolescents exhibit symptoms of anxiety [25,52,64,66]. ...
Prior studies comparing Syrian refugee adolescents to their native peers in the same region have found higher anxiety and lower life satisfaction. Therefore, identifying regulatory variables is crucial for implementing support programs. This study examined the mediating effect of peer relationships and the moderating effect of being a refugee or native adolescent on the relationship between adolescent anxiety and life satisfaction across different samples. Participants and setting: The study included 2,336 adolescents aged 11–19 (M = 14.79, SD = 1.04). Participants completed the Screen for Child Anxiety Related Disorders, Satisfaction with Life Scale, and Strengths and Difficulties Questionnaire. The mediation and moderation effects were analyzed with the path analysis codes written on Mplus 8.3. SPSS 26 was used for descriptive statistics and group comparisons. The findings showed that peer relationships mediate adolescent anxiety and life satisfaction, and this relationship is moderated according to whether the participants are native adolescents or refugee adolescents. This study highlights the significant associations between peer relationships, adolescent anxiety, and life satisfaction and the moderating role of the participant identity. The findings may inform psychological interventions to improve Syrian refugee adolescents' mental health and well-being. These findings may also have implications for policies and programs aimed at supporting the integration of Syrian refugee adolescents in host communities.
... 14 Research also shows, however, that non-clinical settings can facilitate effective resilience-enhancing interventions that deliver evidence-based programming at accessible venues (eg, school, religious institution), often via trained lay workers, a strategy that simultaneously addresses language and fiscal barriers. [14][15][16][17][18][19][20] Yet, the best approaches to mitigate childhood adversities and develop resilience in forcibly displaced children remain unclear. Most research has focused on psychopathology rather than factors linked to improved resilience outcomes in children. ...
Background
Children represent nearly 40% of forcibly displaced populations and are subject to stressors that affect well-being. Little is known about the effects of interventions to enhance psychological resilience in these children, outside clinical settings.
Methods
We conducted a systematic review, following Cochrane methods. Eligible studies tested resilience-enhancing interventions outside clinical settings in forcibly displaced children/adolescents. We included longitudinal quantitative studies with comparator conditions irrespective of geographical scope or language. We searched articles published between January 2010 and April 2020 in PubMed, Embase, Cochrane Library, Web of Science, PsycINFO and the WHO’s Global Index Medicus. To standardise effect sizes across the different reported outcomes, we transformed reported mean differences to standardised mean differences using Hedge’s g statistic with associated 95% CI. We pooled data for meta-analysis where appropriate. We used Cochrane tools to assess study risk of bias and used Grading of Recommendations Assessment, Development and Evaluation to determine evidence quality for meta-analysed outcomes.
Results
Searches yielded 4829 results. Twenty-three studies met inclusion criteria. Studies reported 18 outcomes measured by 48 different scales; only 1 study explicitly measured resilience. Eight studies were randomised controlled trials; the rest were non-randomised pre–post studies. Interventions were diverse and typically implemented in group settings. Studies reported significant improvement in outcomes pertinent to behavioural problems, coping mechanisms and general well-being but not to caregiver support or psychiatric symptoms. In meta-analysis, resilience was improved (g av =0.194, 95% CI 0.018 to 0.369), but anxiety symptoms and quality of life were not (g av =−0.326, 95% CI −0.782 to 0.131 and g av =0.325, 95% CI −0.027 to 0.678, respectively). Risk of bias varied. Quality of evidence for most graded outcomes was very low.
Conclusions
The multiplicity of study designs, intervention types, outcomes and measures incumbered quantifying intervention effectiveness. Future resilience research in this population should use rigorous methods and follow reporting guidelines.
PROSPERO registration number
CRD42020177069.
... The culturally adapted intervention also has the potential to bridge the gap between mental health needs and services [77]. Help-seeking in the Philippines was seen as being very different to that in the UK because there are more mental health resources in the latter [78]. ...
Purpose
This pilot study of a culturally adapted online mental health literacy (MHL) program called ‘Tara, Usap Tayo!’ (C’mon, Let’s Talk) aims to assess the acceptability, appropriateness, feasibility, and potential effectiveness in improving the help-seeking behavior of Filipino migrant domestic workers in the United Kingdom (UK).
Methods
Using mixed methods, we conducted a non-randomized single-group study of the online MHL program with 21 participants. The development of this intervention was guided by the Medical Research Council Framework for developing complex interventions and utilized Heim & Kohrt’s (2019) framework for cultural adaptation. Content materials from the WHO Mental Health Gap Action Program (mhGAP), WHO Problem Management Plus (PM +) and Adult Improving Access to Psychological Therapies (IAPT) were modified and translated into the Filipino language. The MHL program was delivered online in three sessions for two hours each session. Data were collected at three time points: (T1) pretest; (T2) posttest; and (3) follow-up test. Quantitative data on participants’ attitudes towards help-seeking and level of mental health literacy as outcome measures of potential intervention effectiveness were collected at T1, T2 and T3, while focus group discussions (FGDs) to assess participants’ feedback on the acceptability, feasibility, and appropriateness of the online MHL program were conducted immediately at T2. Data analysis was done using a thematic approach for qualitative data from the FGDs and descriptive statistics and repeated-measures ANOVA were used to assess the difference in the T1, T2, and T3 tests . Both quantitative and qualitative results were then integrated and triangulated to answer the research questions.
Results
The online MHL program is generally acceptable, appropriate, and feasible for use among Filipino migrant domestic workers. Preliminary findings lend support for its possible effectiveness in improving mental health literacy and help-seeking propensity. The cultural adaptation made in the content, form, and delivery methods of the intervention was acceptable and feasible for this target subcultural group.
Conclusion
By improving their mental health literacy and help-seeking propensity, this online MHL program has the potential to provide support to the mental health and well-being of Filipino migrant domestic workers in the UK. Further feasibility study or large-scale randomized controlled trial is needed to confirm the preliminary findings of this study.
... 28 Although the existing evidence is consistent on the association between trauma exposure and a range of child mental health problems, more is needed to understand the mechanisms in relation to refugee parents. 29 A mixed method study among conflict-affected families in Timor-Leste suggested that parental explosive anger was related to women's traumatic experiences, and this had an impact on women's parenting. 30 The relationship between parenting style and child behaviour is likely bi-directional: recent investigation of coping among displaced Syrian refugee families revealed that problems increased in parenting style as children develop increasingly problematic behaviours. ...
Background
This research examined the mental health of a cohort of asylum-seeking children, adolescents and their primary caregiver affected by insecure residency while living in the community, compared to refugees and immigrants.
Methods
The project investigated the prevalence of psychosocial problems among Iranian and Afghani asylum seeker, refugee and immigrant children and adolescents, and their caregivers who arrived in Australia from 2010. In total, n=196 children and adolescents aged 5–18 years, and their primary caregiver were asked about family visa status, country of origin, level of education, parent symptoms of posttraumatic stress disorder (Harvard Trauma Questionnaire) and child wellbeing (Strengths and Difficulties Questionnaire). An additional n=362 Farsi and Dari speaking children, recruited through the Building a New Life in Australia (BNLA) study, a national comparison sample of families with permanent refugee visas, were included.
Findings
Asylum seeker children and adolescents displayed significantly more psychosocial problems compared to those with full refugee protection and immigrant background within the current sample and when benchmarked against a national sample of Farsi-Dari speaking refugee children. Higher parental posttraumatic stress disorder symptoms was associated with poorer child and adolescent psychosocial functioning. This effect was more marked in families with insecure residency.
Interpretation
Insecure visa status is associated with higher rates of children's mental health problems and a stronger association with parental PTSD symptoms compared to children with secure residency. This raises important questions about Australia's restrictive immigration policies.
Funding
This project was supported by an Australian Rotary Health Research Fund / Mental Health of Young Australians Research Grant and by the Australian Research Council (DP160104378).
... post-migratoires (Silove, Steel, McGorry et Mohan, 1998). À Genève, comme dans différents pays, l'accent est mis sur une approche holistique des soins psychiatriques (Watters, 2001) tenant compte à la fois du vécu traumatique de cette population mais aussi de l'atteinte à la personne « sociale » que peuvent occasionner la combinaison de l'isolement socioprofessionnel et de l'insécurité liée au statut administratif (Vostanis, 2014). Ce second aspect des soins implique une collaboration étroite avec le monde associatif, acteur essentiel dans le travail en réseau auprès de cette population. ...
... There were encouraging results for Middle Eastern and South Asian people, although again this was based on a limited number of studies. Given the concerns that have been raised about the care received by refugees and asylum seekers (Satinsky, Fuhr, Woodward, Sondorp, & Roberts, 2019;Vostanis, 2014), it is particularly reassuring that interventions for these groups appear to be effective. The most frequent minority groups for which interventions were adapted were East Asian, and Latinx people, with fewer studies for South Asians, religious minorities, or people from the Middle East. ...
This review assessed the efficacy of adapted psychological interventions for Black and minority ethnic (BME) groups. A conceptual typology was developed based on adaptations reported in the literature, drawing on the common factors model, competence frameworks and distinctions between types of cultural adaptations. These distinctions were used to explore the efficacy of different adaptations in improving symptoms of a range of mental health problems for minority groups. Bibliographic searches of MEDLINE, Embase, PsycINFO, HMIC, ASSIA, CENTRAL, CDSR and CINAHL spanned the period from 1965 to December 2020. Adaptations to interventions were categorised: i) treatment specific: therapist-related, ii) treatment-specific: content-related and iii) organisation-specific. Meta-analyses of RCTs found a significant effect on symptom reduction when adapted interventions were compared to non-adapted active treatments (K = 30, Hedge's g = -0.43 [95% CI: -0.61, -0.25], p < .001). Studies often incorporated multiple adaptations, limiting the exploration of the comparative effectiveness of different adaptation types, although inclusion of organisation-specific adaptations may be associated with greater benefits. Future research, practitioner training and treatment and service development pertaining to adapted care for minority groups may benefit from adopting the conceptual typology described.
... As well as needing food, clothing, shelter and security, the migrant community could present with a range of medical needs, including stress related illness and mental health problems such as Post-Traumatic Stress Disorder [1,10]. Furthermore, health problems could be acute, chronic, or acute and chronic, whether for newly arrived asylum seekers or for those living in settlements for longer periods of time [11]. ...
While the health care needs of refugees can be considered a human right, asserting obligations to satisfy that right is a necessary but not sufficient step to ensure that they are met, and in addition to political will and social commitment, a well-trained workforce is also needed. All displaced persons have health care needs, and it is important for health care professionals to have the skills to be able to treat this vulnerable, diverse, growing population. When developing an overview of global health problems associated with the health care needs of refugees, it is important to be mindful of ethical and human rights considerations. Given the nature and scale of this problem, there is a moral case for making refugee health a key component in global health education programs, for instance, as part of nurses’ continuing education and professional development. To this end, a set of twelve intended learning outcomes are offered, which could be adapted, as needed, and incorporated into new or existing programs.
Keywords: Global health, Education, Health care professionals, Ethics, Human rights, Refugees
... A collaborative model for refugee engagement requires cross-disciplinary and interfaith relationships (Vostanis, 2014). We encourage therapists to reach out to and meet with area refugee resettlement offices, nongovernment and social service agencies, and houses of worship. ...
... The effects of trauma exposure have widely been studied in the child mental health literature. Although the existing evidence is broadly consistent on the association between trauma exposure and a range of child mental health problems, the underpinning mechanisms involving different factors, especially in relation to refugee parents, remain relatively scarce [58]. This study found that, whilst trauma exposure was, as hypothesized, associated with post-traumatic stress symptoms, both parental psychopathology and parenting-related stress were associated with general mental health problems (total SDQ, emotional and/or conduct scores) but not with PTSS. ...
Although there has been increasing attention on the impact of risk and resilience factors on refugee children’s mental health, there has been limited evidence on the role of parental factors to inform interventions, and this predominantly relies on adult reports. The aim was to investigate the relationship between perceived parenting styles and attachment relationships and child mental health, as reported by 322 Syrian refugee minors aged between 8 and 17 years in Turkey. Child-rated scales included the Children Revised Impact of Event Scale–8 (CRIES-8), Strengths and Difficulties Questionnaire (SDQ), Security Scale and Egna Minnen Betraffande Uppfostran for Children (EMBU-C), and were used as measures of post-traumatic stress disorder (PTSD), general mental health problems, attachment relationships and perceived parenting styles, respectively. Children with secure maternal and paternal attachment perceived their parents as less rejecting, while children with secure paternal attachment also reported their parents as emotionally warmer. Attachment relationships significantly contributed in predicting PTSD after controlling for age and gender, while conduct problems were predicted by lack of emotional warmth, rejection and over-protection by both parents, in addition to insecure attachment relationships. Refugee children’s views are essential in establishing their needs and planning interventions. These should address both the impact of trauma and current family relationships.
... Exposure to war events refers to the individuals' experience of bombs falling and damaging their neighborhoods and surroundings, as well as harm caused to their acquaintances as a result of the war [8]. This type of exposure to violence is likely to increase the risk of psychological problems such as anxiety, depression, and somatization, especially during the first stage of migration [9]. However, results of studies regarding the cumulative exposure to violent political events are inconclusive [10]. ...
The present study aimed to explore the coping resources and mental health of women who have fled Syria to a neighboring European country. To that end, we examined the roles of sociodemographic factors, situational factors, and personal and community sense of coherence (SOC and ComSOC, respectively) in mental-health outcomes. One hundred and eleven refugee women aged 19-70 filled out self-reported questionnaires during August 2018 in a refugee camp in Greece. The questionnaires asked the participants for demographic information (i.e., age, level of education level, and time spent in the camp) and also addressed the situational factors of having received aid from various organizations, appraisal of danger during the war in Syria, and exposure to war experiences, as well as the coping resources of SOC and ComSOC. The results show that time spent in the camp, appraisal of danger, SOC, and ComSOC all play significant roles in predicting the variance of various mental-health outcomes. Together, those factors predict 56% of anxiety, 53% of depression, and 58% of somatization. SOC was also found to mediate the relationships between time spent in the camp and outcome variables, as well as the relationships between the appraisal of danger and the outcome variables. This indicates that SOC is crucial for good adaptation. These results will be discussed in light of the salutogenic theory.
... Mental health practitioners also have an increasing range of therapeutic approaches and emerging evidence to draw from. Although the methodological quality of evaluation varies, with some programmes being less structured or validated, overall there are positive findings of symptom reduction through cognitive-behavioural, expressive, exposure, testimonial, creative, interpersonal and eye-movement desensitisation and reprocessing (EMDR) therapies (Ngo et al., 2008;Ruf et al., 2010;Vostanis, 2014). These use different techniques and underpinning theories to help the child re-frame the complex relationship between traumatic memories, cognitions and/or emotions, and current symptoms (predominantly PTSD). ...
Background
Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.
Methods
We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.
Results
Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high‐income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder‐specific therapies will be required.
Conclusions
Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.
... Our findings, further, highlight the need for culturally relevant targeted strategies addressing the needs of these groups, which should also take into consideration key stages of the migration trajectory and children's exposure to stressors in their countries of origin, during the migration trajectory, and following arrival. Such stressors may include exposure to trauma (e.g., violence, conflict, and sexual abuse), which is often prolonged and repeated, or migration-related factors such as insecure legal or residential status, social exclusion, discrimination, and acculturation stressors [3,14,16]. ...
One in four asylum applicants in Europe are children, and 23% of whom are unaccompanied and may be at increased risk of mental illness. This study contributes to the limited evidence base by comparing the incidence of psychiatric disorders among unaccompanied and accompanied refugee children. We linked a cohort of refugee children who obtained right of residency in Denmark between 01 January 1993 and 31 December 2010 to the Danish Psychiatric Central Register, and calculated incidence rates per 100,000 person years and incidence rate ratios of overall psychiatric disorder, psychotic disorders, affective disorders, and neurotic disorders for accompanied and unaccompanied minors using Poisson regression. We adjusted the analyses for sex, age at residency, and age at arrival (aIRR). Stratified analyses were conducted by nationality. Unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 1.38, 95% CI 1.14-1.68) and neurotic disorders (aIRR: 1.67, 95% CI 1.32-2.13) than accompanied minors. Among children from Afghanistan, unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 2.23, 95% CI 1.26-3.93) and neurotic disorders (aIRR: 3.50, 95% CI 1.72-7.11). Among children from Iraq, unaccompanied minors had higher rates of any psychiatric disorder (aIRR: 2.02, 95% CI 1.18-3.45), affective disorders (aIRR: 6.04, 95% CI 2.17-16.8), and neurotic disorders (aIRR: 3.04, 95% CI 1.62-5.70). Unaccompanied children were found to experience a higher incidence of any psychiatric disorder and neurotic disorders. Strategies are needed to address the specific mental health and social needs of unaccompanied minors.
... post-migratoires (Silove, Steel, McGorry et Mohan, 1998). À Genève, comme dans différents pays, l'accent est mis sur une approche holistique des soins psychiatriques (Watters, 2001) tenant compte à la fois du vécu traumatique de cette population mais aussi de l'atteinte à la personne « sociale » que peuvent occasionner la combinaison de l'isolement socioprofessionnel et de l'insécurité liée au statut administratif (Vostanis, 2014). Ce second aspect des soins implique une collaboration étroite avec le monde associatif, acteur essentiel dans le travail en réseau auprès de cette population. ...
La multiplication et l’intensification des flux migratoires des dernières années ont conduit à un afflux parfois soudain de nouvelles populations venant frapper à nos portes pour demander asile. Si le parcours migratoire de ces personnes peut se ressembler, leur histoire, leurs trajectoires et de ce fait leurs besoins varient et viennent par là-même interroger notre système de soins et ses capacités d’adaptation. L’hétérogénéité des tableaux cliniques rencontrés nous oblige dès lors à proposer différentes modalités de réponses institutionnelles à la souffrance psychique de cette population, qui tiennent compte à la fois de ses références culturelles, de la clinique du trauma dont elle peut être porteuses, mais aussi de la part de souffrance liée à la violence des conditions d’accueil qu’elle peut rencontrer.
... The effects of trauma exposure have widely been studied in the child mental health literature. Although the existing evidence is broadly consistent on the association between trauma exposure and a range of child mental health problems, the underpinning mechanisms involving different factors, especially in relation to refugee parents, remain relatively scarce [58]. This study found that, whilst trauma exposure was, as hypothesized, associated with post-traumatic stress symptoms, both parental psychopathology and parenting-related stress were associated with general mental health problems (total SDQ, emotional, and/or conduct scores) but not with PTSS. ...
War-torn children are particularly vulnerable through direct trauma exposure as well through their parents’ responses. This study thus investigated the association between trauma exposure and children’s mental health, and the contribution of parent-related factors in this association. A cross-sectional study with 263 Syrian refugee children-parent dyads was conducted in Turkey. The Stressful Life Events Questionnaire (SLE), General Health Questionnaire, Parenting Stress Inventory (PSI-SF), Impact of Events Scale for Children (CRIES-8), and Strengths and Difficulties Questionnaire were used to measure trauma exposure, parental psychopathology, parenting-related stress, children’s post-traumatic stress symptoms (PTSS), and mental health problems, respectively. Trauma exposure significantly accounted for unique variance in children’s PTSS scores. Parental psychopathology significantly contributed in predicting children’s general mental health, as well as emotional and conduct problems, after controlling for trauma variables. Interventions need to be tailored to refugee families’ mental health needs. Trauma-focused interventions should be applied with children with PTSD; whilst family-based approaches targeting parents’ mental health and parenting-related stress should be used in conjunction with individual interventions to improve children’s comorbid emotional and behavioural problems.
... This may hinder their ability to empathise and could influence the effectiveness of the therapeutic process ( Blackwell, 2005). Accordingly, lots of research has been focused on the issue of culturally sensitive psychotherapeutic interventions ( American Psychological Association., 2003;Murray, Schweitzer, & Davidson, 2010;Vostanis, 2014). The interventions of mental health workers who specialise in and have trained for multicultural populations seem to have greater effectiveness than others ( Ardenne, Capuzzo, Ruaro, & Priebe, 2005;Blackwell, 2005;Tribe & Patel, 2007;Karaman & Ricard, 2016;Psarros et al., 2016). ...
... Importantly the refugees had been removed from the violence within Syria for many months and, while living in refugee camps is challenging, were some time past severely traumatic events. 20 As elsewhere, mental ill health carries considerable stigma in Syria and discussion about such issues is only likely to occur after trust has been established-inevitably this takes some time. In turn general practice staff, while alert to the possibility of mental illness, would be handicapped in its detection by working through an interpreter and not having any knowledge of the families. ...
Background:
During 2015 and 2016 a group of Syrian refugees were resettled in Edinburgh, Scotland under the United Kingdom Government Syrian Vulnerable Person Resettlement Programme. We evaluate the strengths and weaknesses of the settling in arrangements for these refugees.
Methods:
Semi-structured interviews were conducted with five Arabic interpreters who had worked extensively with these refugees. Interviews sought their impressions about what went well or was not successful. Interviews were transcribed and key themes extracted and analysed.
Results:
Six themes emerged: 'first impressions', language skills, different healthcare systems, health of the refugees, relationships between the interpreters and refugees and support for the interpreters.
Conclusions:
The welcoming arrangements went well and exceeded refugees' and interpreters' expectations. There was perhaps too much information given immediately and reinforcing details about various public services and facilities after a first few months would be worthwhile. The Syrians were unfamiliar with NHS structures and found lack of direct specialist access surprising. Problems were amplified by low English levels. A need for Arabic literacy classes was also identified. Interpreters were often used informally out-of-hours and a better system with first contact in Arabic should be established. Interpreters find this work particularly stressful and the provision of psychological support for them should be prioritized.
... A child-specific systematic review by Jordans, Tol, Komproe, and De Jong (2009) identified a shift from specialist to primary care and community settings for an increasing number of interventions of variable theoretical approaches and often not rigorous designs. The most reported frameworks are cognitive behavioural, exposure, narrative, testimonial, interpersonal, reprocessing, eye movement desensitisation and creative therapies, mostly aiming at the reconstruction of traumatic experiences (Ehntholot & Yule, 2006;Vostanis, 2014aVostanis, , 2014b. ...
Background:
Child mental health services and related agencies are faced with an increasing challenge in responding to the influx of refugee children around the world. There is strong evidence on the prevalence and complexity of these children's mental health problems and broader needs.
Aims:
To review the research literature on risk and protective factors, and associated mental health interventions for refugee children.
Methods:
Peer-reviewed studies were included for the period 2004-2017; if they included refugee, asylum-seeking or internally displaced children under 18 years; and adopted a quantitative design. Vulnerability and protective factors for refugee children were considered in this context, followed by the respective types of interventions at pre-, peri- and postmigration stage, and across high- and low-/middle-income countries. Eighty-two peer-reviewed studies fulfilled the selection criteria.
Results:
The existing body of literature is largely based on identifying risk factors among children with mental health problems and predominantly designing trauma-focused interventions to reduce their symptomatic distress. Recent research and services have gradually shifted to a broader and dynamic resilience-building approach based on ecological theory, that is at child, family, school, community and societal level. There is increasing evidence for the implementation and effectiveness of multimodal interventions targeting all these levels, despite the methodological constraints in their evaluation.
Conclusions:
In high-income countries, child mental health services need to collaborate with all agencies in contact with refugee children, establish joint care pathways, and integrate trauma-focused interventions with family and community approaches. In low- and middle-income countries, where specialist resources are sparse, resilience-building should aim at maximising and upskilling existing capacity. A six-dimensional psychosocial model that applies to other children who experience complex trauma is proposed.
... In low-income countries, where there is little access to specialist services, the focus should be more on building capacity (Patel et al, 2006), along with training of professional staff and consultation with voluntary organisations. In high-income countries, though there could be a hostile political climate, the same issues apply, although there is the additional need to adapt the usual model of service (Vostanis, 2014). ...
Global events like wars and natural disasters have led to the refugee population reaching numbers not seen since the Second World War. Attitudes to asylum have hardened, with the potential to compromise the mental health needs of asylum seekers and refugees. The challenges in providing mental healthcare for asylum seekers and refugees include working with the uncertainties of immigration status and cultural differences. Ways to meet the challenges include cultural competency training, availability of interpreters and cultural brokers as well as appropriately adapting modes of therapy. Service delivery should support adjustment to life in a foreign country. Never has the need been greater for psychiatrists to play a leadership role in the area.
... For interventions to be optimally successful, public health, population-based interventions, community supports, and family and individual mental health services are required. 275 There is a need gap, even in more highly resourced host countries. ...
This article is a companion to the March 23, 2018, Quinnipiac Law Review symposium of the same title. Both article and symposium assess epigenetic inheritance in the context of the refugee experience and posit legal, social, and clinical responses to this potentially multi-generational crisis. Part I of this article contextualizes the worldwide refugee crisis. Part II assesses the legal challenges facing refugee children. Part III discusses the neurological challenges facing refugee children and the potential for epigenetic inheritance. Part IV discusses the mental health needs of refugee children and suggests clinical Interventions for the children and families. Part V offers concluding observations.
... Research investigating predictors of mental health outcomes in refugees has predominantly focused on the negative impact of factors, such as trauma exposure on mental health outcomes. Studies indicate not only that refugees are typically exposed to numerous and different types of potentially traumatic experiences in their home countries and during displacement, but also that these experiences are often repeated and prolonged in nature [15]. Overall, there is a significant dose effect of refugee trauma on mental health, whereby greater exposure to trauma is associated with higher severity of psychiatric symptoms, including PTSD [16]. ...
In recent years there has been a progressive rise in the number of asylum seekers and refugees displaced from their country of origin, with significant social, economic, humanitarian and public health implications. The aim of this study is to describe the frequency and correlates of psychological distress and psychiatric disorders in asylum seekers and refugees resettled in an Italian catchment area. In the catchment area of Verona, all male asylum seekers and refugees aged 18 or above included in the Italian protection system for asylum seekers and refugees during a period of 1 year were screened for psychological distress and psychiatric disorders using validated questionnaires. During the study period, 109 asylum seekers or refugees were recruited. The frequency of traumatic events experienced was very high. More than one-third of the participants (36%) showed clinically relevant psychological distress, and one-fourth (25%), met the criteria for a psychiatric diagnosis, mainly PTSD and depressive disorders. In multivariate analyses, time after departure, length of stay in the host country and number of traumatic events were independent factors associated with psychological distress and psychiatric disorders. In an unselected sample of male asylum seekers and refugees, after around 1 year of resettlement in an Italian catchment area, the frequency of psychological distress and psychiatric disorders was substantial and clinically relevant. Health care systems should include a mental health component to recognise and effectively treat mental health conditions.
... T he social, 1 health, 2 and medical 3 needs of refugee populations are unique. Refugees are more likely to have experienced combat and domestic violence; 4 political instability and political warfare; death of family and friends; and culture shock. 5 The combination of these adverse events before, during, or after migration frequently manifest as physical and mental health issues, predominantly post-traumatic stress disorder, generalized anxiety disorder, and depression. ...
Refugees face considerable challenges upon seeking asylum in Canada, and accessing health care services remains a prominent issue. Recurrent themes in the literature outlining barriers to health-services accessibility include geographic, economic, and cultural barriers. Drawing on the experiences of service providers in Hamilton, Ontario, we explored the efficacy of telemedicine services in bridging the gap between refugee health and health-services accessibility. Research methodology included structured interviews with clinicians who provide health-care services to refugees, complemented by a scoping literature review. The results of this exploratory study demonstrate the efficacy of telemedicine in encouraging dialogue and policy change in the greater health-care setting, and its potential to increase access to specialist health-care services.
... There are multiple stressors of adjustment for anyone forced to leave their homeland, but the high levels of potentially traumatic events experienced and accumulated by these migrants before and during their journey put their mental health at risk [32]. A European working group has referred to forced migration itself as a process of grief reactions due to multiple losses, whereby the individual experiences loss of certainty and solid parameters such as a personal, social and cultural structure [33]. ...
Background
In 2015, Italy was the second most common point of entry for asylum seekers into Europe after Greece. The vast majority embarked from war-torn Libya; 80,000 people claimed asylum that year. Their medical conditions were assessed on arrival but their mental health needs were not addressed in any way, despite the likelihood of serious trauma before and during migration. Médecins sans Frontières (MSF), in agreement with the Italian Ministry of Health, provided mental health (MH) assessment and care for recently-landed asylum seekers in Sicily. This study documents mental health conditions, potentially traumatic events and post-migratory living difficulties experienced by asylum seekers in the MSF programme in 2014–15.
Methods
All asylum seekers transiting the 15 MSF-supported centres were invited to a psycho-educational session. A team of psychologists and cultural mediators then provided assessment and care for those identified with MH conditions. Potentially traumatic events experienced before and during the journey, as well as post-migratory living difficulties, were recorded. All those diagnosed with MH conditions from October 2014 to December 2015 were included in the study.
Results
Among 385 individuals who presented themselves for a MH screening during the study period, 193 (50%) were identified and diagnosed with MH conditions. Most were young, West African males who had left their home-countries more than a year prior to arrival. The most common MH conditions were post traumatic stress disorder (31%) and depression (20%). Potentially traumatic events were experienced frequently in the home country (60%) and during migration (89%). Being in a combat situation or at risk of death, having witnessed violence or death and having been in detention were the main traumas. Lack of activities, worries about home, loneliness and fear of being sent home were the main difficulties at the AS centres.
Conclusion
MH conditions, potentially traumatic events and post-migratory living difficulties are commonly experienced by recently-arrived ASs, this study suggests that mental health and psychosocial support and improved living circumstances should be integrated into European medical and social services provided by authorities in order to fulfil their humanitarian responsibility and reduce the burden of assimilation on receiving countries.
This paper presents our reflections on organising and running an asylum seeker wellbeing group, within the context of an NHS mental health Trust.
Parental Psychiatric Disorder presents an innovative approach to thinking about and working with families where a parent has a mental illness. With 30 new chapters from an internationally renowned author team, this new edition presents the current state of knowledge in this critically important field. Issues around prevalence, stigma and systems theory provide a foundation for the book, which offers new paradigms for understanding mental illness in families. The impact of various parental psychiatric disorders on children and family relationships are summarized, including coverage of schizophrenia, depression, anxiety, substance abuse disorders, eating disorders, personality disorders and trauma. Multiple innovative interventions are outlined, targeting children, parents and families, as well as strategies that foster workforce and organisational development. Incorporating different theoretical frameworks, the book enhances understanding of the dimensions of psychiatric disorders from a multigenerational perspective, making this an invaluable text for students, researchers and clinicians from many mental health disciplines.
Background: The mental health needs of refugees and asylum seekers are often unmet. Many screening methods for mental health problems in refugees and asylum seekers have been suggested, but the optimal method for identifying those at risk has not been determined. The PROTECT questionnaire and the Patient Health Questionnaire 4 (PHQ4) are two tools currently being used to identify refugees and asylum seekers at risk of mental health problems in Ireland, but there is limited data on the prevalence of positive scores or risk factors for these to inform health service planning.
Methods: Cross sectional analysis was conducted of anonymous data of all adult asylum seekers or refugees who completed a PHQ4 and PROTECT questionnaire during their nurse conducted arrival health assessment within a one-year period. Data collected include: gender, age category, marital status, family unit, country of origin, refugee/asylum status, medical conditions, mental health conditions, exposure to violence, PROTECT score, PHQ4 score and outcome of GP mental health review. Statistical analysis was completed using R.
Results: 440 people completed a PROTECT and PHQ4 questionnaire. 198 people had a GP review based on either a positive PROTECT or PHQ4 score. Among all participants, 9.1% (n=40) were diagnosed with depression, 15.0% (n=66) were diagnosed with PTSD, and 7.3% (n=32) had another mental health condition. There was a positive correlation between PHQ-4 score and PROTECT score, (rs= .738, p < .001) although the PROTECT score identified more cases of PTSD and depression. Being female (aOR: 2.47 95% CI: 1.59-3.86) and country of origin Zimbabwe (aOR: 3.19 95% CI: 1.56-6.53) was associated with a positive PROTECT score. Country of origin was negatively associated with PROTECT score for Syria (aOR: 0.32 95% CI: 0.15-0.65). There were similar findings for PHQ4.
Conclusions: Rates of depression, anxiety and PTSD were similar to other studies. There was a strong correlation between PHQ4 scores and PROTECT but with PROTECT ultimately identifying more cases of depression and PTSD, suggesting it may be reasonable to use it alone. Whichever screening tool is used, adequate healthcare resources need to be available for further assessment and treatment. Participants from Syria were less likely to have a positive score compared to others and further research is required to understand the reasons for this.
Note:
Funding Information: Funding for this study was provided by Safetynet Primary Care. The funder was involved in developing the research question and employees of the funder carried out the new arrival health assessments. The funder was not involved in data analysis or interpretation of results.
Declaration of Interests: Dr Fiona O’Reilly is CEO of Safetynet Primary Care, a charity that provides new arrival health assessments for refugees and asylum seekers. No other authors have any competing interests to declare.
Ethics Approval Statement: The study is reported according to the STROBE reporting guidelines. Ethical approval was granted by the Irish College of General Practitioners Research Ethics Committee. All attendees for new arrival health assessments are consented to do the health assessment, for the processing of their data in order to do this and informed that anonymous data is used for research and reports.
Keywords: Mental health, International protection, PTSD, psychological distress, trauma
The number of refugees is increasing (UNHCR, 2019). The experiences of refugees are linked to impaired mental health yet, this population faces barriers to accessing mental health support (Shannon et al., 2016). Digital mental health interventions are increasingly recognised as an avenue for overcoming these barriers (WHO, 2017). The present paper begins by introducing the area of digital approaches to mental health and developments in this area targeted at refugee populations specifically. We then take a step back to look at the wider picture of refugee mental health and technology. Drawing on Toyama’s Law of Amplification (2011; 2015) - that successful technical interventions amplify the intent and the capacity of the people involved - we discuss the importance of context, exploring the assumptions, possibilities and potential pitfalls in the use of digital technologies for addressing refugee mental health. We conclude that by collaborating with refugee populations, placing them at the centre of the design process for digital mental health interventions, we stand the greatest chance of creating the most useful tools.
The current study aims at investigating the experience of Greek NGOs' mental health workers who work with refugees and asylum seekers (RaAS). An Interpretative Phenomenological Analysis was used, to create a deep understanding of practitioners' emotions and meaning-making regarding their struggles and the ways they cope as professionals and as human beings. The data-collection was accomplished via a semi-structured interview of five practitioners who worked at an NGO in Greece. The analysis brought to light four major themes: the first theme relates to the cultural gap between clients and practitioners, the second theme highlights the importance of being person-centred, the third theme relates to the practitioners' psychological impact as a result of counter-transference and the final theme highlights the importance of setting boundaries in order to avoid burnout. Findings revealed the existence of human-istic values in NGOs' mental health workers who work with RaASs in general, and the importance of a person-centred approach to bolster the effectiveness in the therapeutic context with RaAS clients.
“Anxiety disorders” (ADs) are a broad category of psychiatric disorders characterized by excessive fear, worry, or anxiety which cause significant distress or impairment in everyday life. They are among the most common psychiatric disorders, affecting over a quarter of people during their lifetime (Kessler et al., 2005). This chapter reviews the evidence concerning the psychological mechanisms by which ADs affect parenting and adjustment in children and young people, in order to guide further research in this area and inform clinical practice. Most research in this field has focused on the impact of maternal ADs on parenting and Children's development, largely because women are at higher risk of ADs than men (Kessler et al., 2005) and tend to be the primary caregivers of children in Western cultures. Nevertheless, recent studies including fathers with ADs have found similar associations between parenting and child adjustment to those found with mothers with ADs (Aktar et al., 2013, 2014). Thus, in the absence of evidence to the contrary, it would be prudent to assume that studies of “mothers” may well provide evidence relating to “parents”. However, we also consider potential gender-specific associations with parenting and child adjustment when appropriate. Outcomes for children of parents with Ads Offspring of parents with ADs are at increased risk of psychiatric disorders (e.g., Beidel and Turner, 1997; Merikangas et al., 1999). Specifically, these offspring have a fourfold higher risk of AD than offspring of parents with no psychiatric diagnoses, and a twofold higher risk than offspring of parents with other psychiatric (nonanxiety) disorders (Micco et al., 2009). Offspring of parents with AD may also be at somewhat increased risk of mood disorders, particularly where parents have comorbid mood disorders (Micco et al., 2009).
This literature review aims to critically appraise and evaluate qualitative papers exploring the experiences of asylum seekers and refugees relating to their engagement in activity following forced migration. Forced migrants are at risk of occupational deprivation, however providing opportunities to engage in meaningful and familiar occupations can improve displaced people’s health and wellbeing. The seven papers reviewed were appraised for methodological quality using the Critical Appraisal Skills Programme for qualitative research. The papers were deemed to range from relatively poor to good quality, however useful insights were drawn from all. The findings suggest that engagement in meaningful activities in host countries can generate positive experiences for forced migrants regarding opportunities to reinforce or develop identity, a sense of wellbeing, and a sense of connection on both personal and community levels. Occupational therapists can promote health and well-being through creating opportunities to engage in meaningful occupations.
Adopting a children's rights perspective, a critique and analysis underpinned by documentary research methodology was undertaken in order to assess the extent to which the government's Green Paper (Department of Health and Social Care and Department of Education, 2017. Transforming children and young people's mental health provision: a green paper. Available at: https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper (accessed 7 December 2017)) addresses the mental health and well-being needs of refugee children and young people in England and Wales, identifying strengths, limitations and challenges for future policy and practice. Findings suggest that there is much of potential benefit to refugee children and young people's future mental health and well-being. However, a paradigm shift, explicit in implications, scale and time frame, will be required, if the Green Paper is to achieve those changes in attitudes, practice and service delivery which it anticipates. We argue that this Green Paper's overarching challenge is that it is premised on Western-centric models in its understanding of the experiences of refugee children and young people, and management of trauma and mental health. It fails to recognize the meanings and significance of culture, and of diversity and difference, and the need to invest in all communities in facilitating engagement and support for children and young people's mental health issues.
Hope for Children of Trauma: An International Perspective synthesizes all the existing evidence, policy and practice from around the world for children and youth who have experienced different forms of complex trauma-such as abuse, neglect and war violence and also presents a real advance in the literature, by covering new material from the author’s extensive visits and collaborations in low and middle-income countries in Asia, Africa and Latin America.The book covers a historical and research overview of developments in trauma and child mental health, global policy and evidence on the impact of trauma on child mental health. In particular, this book communicates real experiences through narratives and supporting photographic material from children in slum areas, orphanages or on the streets, and explores the application of therapeutic approaches by frontline practitioners, therapeutic interventions, service development and training programmes.Integrating testimonies, observations, therapeutic interventions and research findings, Hope for Children of Trauma shows how these problems can be addressed, and will be thought-provoking reading for child and adolescent mental health practitioners, NGOs and policy-makers.
Accepted for publication in Social Psychological and Personality Science (ISSN 1948-5506).
The effects of intergroup contact on prejudice are well established. However, its effects on minority group well-being have been rarely studied. We hypothesised that contact with members of the majority culture will be related to better well-being, and that this is facilitated by majority language proficiency. We tested this hypothesis in a three-wave longitudinal study of refugees over two years (N = 180). Cross-lagged path modelling confirmed that intergroup contact at earlier time points was associated with increased well-being at later time points; the reverse associations (from earlier well-being to later contact) were not reliable. Self-rated earlier English language competence was positively associated with later intergroup contact (but not the reverse), suggesting that improving majority language proficiency might be the key to better well-being of refugees, with intergroup contact being the mediator between language and well-being.
Parental Psychiatric Disorder presents an innovative approach to thinking about and working with families where a parent has a mental illness. With 30 new chapters from an internationally renowned author team, this new edition presents the current state of knowledge in this critically important field. Issues around prevalence, stigma and systems theory provide a foundation for the book, which offers new paradigms for understanding mental illness in families. The impact of various parental psychiatric disorders on children and family relationships are summarized, including coverage of schizophrenia, depression, anxiety, substance abuse disorders, eating disorders, personality disorders and trauma. Multiple innovative interventions are outlined, targeting children, parents and families, as well as strategies that foster workforce and organisational development. Incorporating different theoretical frameworks, the book enhances understanding of the dimensions of psychiatric disorders from a multigenerational perspective, making this an invaluable text for students, researchers and clinicians from many mental health disciplines.
The purpose of this chapter is to outline the impact of trauma and migration on the mentalhealth of parents in refugee families, and to conclude with service recommendations. The published and gray literature on asylum seeking in the UK over the last ten years (2005–14) were reviewed and integrated with the author's own clinical experience. Asylum seekers who are parents flee their home countries mainly because of fear for the survival of their children: Fear of physical attack, chemical warfare, rape, torture, and ethnic cleansing, all of which are considered normal means of war in many parts of the world. Persecutors know that attacking children is the surest way to inflict pain on parents. In seeking refuge, personal possessions, familiar surroundings, and the lives of loved ones are lost, and, as a consequence, such parents develop a variety of medical and psychological disorders (Pfortmueller et al., 2013). This is probably especially true for mothers, themselves the targets of sexual violence and torture (Keygnaert et al., 2014), and witnesses to the murder of family members. The UN High Commissioner for Refugees (UNHCR) reports that, in 2010, 47% of the world's 15.4 million refugees were women and girls (UNHCR, 2011). Who is a refugee? Refugees arriving in a host country differ from immigrants in that they have not been able to plan their displacement ahead of time, often leaving behind aging parents, children, or domestic partners. Refugees do not choose where to go. Host countries vary in their willingness to accept refugees and in their desirability as refugee destinations (Table 18.1). There are no specific statistics on asylum seekers who are parents; however, there is information on dependants, by age, for 2012 in the UK (Refugee Council, 2012). That year, there was a total of 4,128 asylum seekers between 5 and 17 years old, with no indication of how many came alone or accompanied by a parent.
Parental Psychiatric Disorder presents an innovative approach to thinking about and working with families where a parent has a mental illness. With 30 new chapters from an internationally renowned author team, this new edition presents the current state of knowledge in this critically important field. Issues around prevalence, stigma and systems theory provide a foundation for the book, which offers new paradigms for understanding mental illness in families. The impact of various parental psychiatric disorders on children and family relationships are summarized, including coverage of schizophrenia, depression, anxiety, substance abuse disorders, eating disorders, personality disorders and trauma. Multiple innovative interventions are outlined, targeting children, parents and families, as well as strategies that foster workforce and organisational development. Incorporating different theoretical frameworks, the book enhances understanding of the dimensions of psychiatric disorders from a multigenerational perspective, making this an invaluable text for students, researchers and clinicians from many mental health disciplines.
Parental Psychiatric Disorder presents an innovative approach to thinking about and working with families where a parent has a mental illness. With 30 new chapters from an internationally renowned author team, this new edition presents the current state of knowledge in this critically important field. Issues around prevalence, stigma and systems theory provide a foundation for the book, which offers new paradigms for understanding mental illness in families. The impact of various parental psychiatric disorders on children and family relationships are summarized, including coverage of schizophrenia, depression, anxiety, substance abuse disorders, eating disorders, personality disorders and trauma. Multiple innovative interventions are outlined, targeting children, parents and families, as well as strategies that foster workforce and organisational development. Incorporating different theoretical frameworks, the book enhances understanding of the dimensions of psychiatric disorders from a multigenerational perspective, making this an invaluable text for students, researchers and clinicians from many mental health disciplines.
Parental Psychiatric Disorder presents an innovative approach to thinking about and working with families where a parent has a mental illness. With 30 new chapters from an internationally renowned author team, this new edition presents the current state of knowledge in this critically important field. Issues around prevalence, stigma and systems theory provide a foundation for the book, which offers new paradigms for understanding mental illness in families. The impact of various parental psychiatric disorders on children and family relationships are summarized, including coverage of schizophrenia, depression, anxiety, substance abuse disorders, eating disorders, personality disorders and trauma. Multiple innovative interventions are outlined, targeting children, parents and families, as well as strategies that foster workforce and organisational development. Incorporating different theoretical frameworks, the book enhances understanding of the dimensions of psychiatric disorders from a multigenerational perspective, making this an invaluable text for students, researchers and clinicians from many mental health disciplines.
This book has been written for practitioners who work with children, parents, and families as well as for those who design and conduct applied research in the area of parental mental illness. The first and second editions chronicled the development of research, policy, and practice in this field across various countries. The third edition is completely rewritten, reflecting recent research developments as well as policy and practice changes. These reflect the greater specificity we now know in terms of what, when, and how family life is impacted by parental mental illness. Additionally, recently developed programs and interventions for children, parents, and families are showcased in this edition. These interventions provide the latest research evidence and concrete guidance to practitioners in terms of formal and informal approaches for different family members. What is especially heartening are the various workforce approaches to professional development as well as collaborative models for intervention.
In order to ensure the optimal care of children, this chapter presents a framework for assessing capacity for effective parenting in the context of mental illness. The chapter will (1) outline the principles of ethical assessment practice, (2) provide a multidimensional and practical template for a comprehensive assessment, and (3) offer an example of a functional formulation following from a parenting assessment. The term “parent” may refer to anyone functioning in a parenting role.There are wide regional disparities in the conduct of family assessments that depend on available resources, predominant philosophies, tradition and culture, and service structure. We will outline practice principles relevant to practitioners from diverse contexts. This is important because a good clinical formulation of a parent provides the essential foundation for all subsequent treatment interventions, be they with the parent, child, or family (Diggins, 2011). In most resource-rich countries, assessments are multidisciplinary, with Children's social workers retaining responsibility for coordinating multiagency perspectives and ensuring child safety. All mental health professionals have responsibility for developing meaningful mental health formulations that address the needs of all family members, and this includes highlighting potential risks. Principles of ethical assessment practice Health service cultures worldwide have adopted the four Hippocratic principles of beneficence, nonmaleficence, autonomy, and fairness. We have tried to adapt them here for the practice of parenting assessment, which fundamentally involves the responsibility for the welfare of child and parent. Ethically, this means that the needs of family members should not be assessed unless a service to meet such need can be provided. Commitment to the parental role and the parent–child relationship. The literature focuses on the needs of and risks to the child because children are more vulnerable than adults. But mentally ill parents are vulnerable as well. The separation of child and adult services makes it hard to simultaneously encompass the needs of both. In some countries, policies have been developed to help overcome this dilemma; for example, in the UK, guidance on this issue is now available from the Social Care Institute of Excellence (Diggins, 2011). However, in most contexts, services are not designed nor are professionals trained to address the mental health needs of both parent and child.
Children and young people want professionals to listen to them and to talk to them; above all, they want to be recognized as important to the parent they live with. Barnardos Action with Young Carers (AWYC) is located in Liverpool and supports young caregivers who reside in that city. Barnardos is a children's charity that has services and projects across the UK and internationally. All of the statements reported in this chapter are from Liverpool young people. In November 1999 a small group of young people involved with Barnardos AWYC were invited to take part in a conference launching the report Keeping the Family in Mind (Göpfert et al., 1999). This project, like other AWYC projects, provides a service for children and young people who live with someone with a mental health problem, and many of whom take on caring roles and responsibilities. All of the young people who participated care for a parent with mental ill health and receive support from staff at the AWYC project. We know from research and consultations with children and young people that they value being listened to and drawing upon their own experiences.They have some very important messages for professionals and policymakers.
The Family Options psychiatric rehabilitation intervention targets families where a parent is living with or in recovery from a serious mental illness (e.g., major depression, bipolar disorder, schizophrenia and other psychotic disorders). The Family Options intervention grew out of the efforts of providers, researchers, and parents themselves to provide supports to parents and their family members at Employment Options, Inc., a community-based, recovery-oriented agency located in Marlborough, Massachusetts, USA. The aim of the intervention is to support family members in achieving their desired level of well-being and functioning, and to enhance their social supports and resources, both formal and informal. This chapter will provide (1) our rationale for intervention development; (2) an overview of the Family Options model; (3) a description of services provided; (4) a perspective on the roles of key players, including parent peers, in meeting families' needs; (5) steps in the intervention; and (6) preliminary data regarding outcomes. We conclude with a discussion of the implications of this work for providers, administrators, and policymakers.
Some clinicians consider children whose parents have a mental illness to be a relatively homogeneous group, with the same needs and issues (Steer et al., 2011). The consequence of such an assumption is that youth are then grouped together and provided with the same intervention, such as peer support groups (Reupert et al., 2012). Grouping children together for the purposes of intervention may or may not be appropriate. However, we know that the risk exposure for children is not uniform; instead there are multiple influences that affect children’s developmental outcomes, influences from within them, and from their parents, their family, and the community in which they live and the services they have access to. This chapter will consider whether, and in what way, a parent’s mental illness diagnosis may affect children’s well-being and mental health. Such information is important to identify the children at greatest risk of adverse outcomes, ensure that intervention goals meet the needs of participants, and ensure that appropriate participants are selected for different interventions. Moreover, such information may also allow us to consider whether a public health approach is needed for all children whose parents have a mental illness and whether specific programs are needed for different groups of children, using a specific eligibility criterion such as their parent’s mental illness diagnosis
It can be challenging to talk to children about a sensitive topic such as their parent's mental health difficulties. Nonetheless, it is essential that children be informed about their parent's mental illness and given the opportunity to express how their parent's health issues might be affecting them. This chapter will explore some of the issues related to having conversations with rather than to young people and, similarly, to “opening up” a discussion rather than “imposing” information. In this chapter, the term “children” refers to the offspring of those with a mental difficulty, illness, or disorder, and includes adolescents as well as younger children. It is our belief that supporting parents to hold conversations about their mental illness with their children, in an age-appropriate and sensitive manner, can empower parents by acknowledging their critical role within the family setting (Marston et al., 2014). In this way, parents are reinstated as the experts in their children's lives, often at times when they are feeling disempowered by the course of the illness and treatments. Acquiring and applying these skills is not necessarily easy, however. Within this context, it might be helpful to consider what it is like for parents to discuss with their children other sensitive or personal topics such as sex, divorce, death, or a physical illness and the skills that parents might need to do this, and issues or problems parents and children might encounter during and after such discussions. Thus, the skills used to discuss parental mental illness could well be generalized into other family conversations. A parent's mental illness is often the “elephant in the room” or the shameful secret that everyone knows is there but no one talks about. Mental illness is likely to affect the parent's behavior, which the child might notice but not always understand. Within these families' systems, children need to be provided with a framework for understanding what is happening in their family and given permission to talk and ask questions. Moreover, strategies are required to counterbalance the pervasive negative stereotypes and stigma often associated with mental illness within and outside the family.
Background: The protective role of parenting factors on the mental well-being of children exposed to war trauma remains an under-researched area. Aim: To establish the relationship between perceived positive parenting support and PTSD symptoms in children exposed to war trauma. Methods: A random sample of 412 children aged 12–16 years was selected from the Gaza Strip and was assessed using the Gaza Traumatic Events Checklist (GTEC), the SCID (DSM-IV) and the Perceived Parenting Support Scale (PPSS). Results: Palestinian children were exposed to different types of war-traumatic events. The number of exposed traumatic events was independently associated with the severity of post-traumatic symptoms scores or the diagnosis of PTSD, while perceived parenting support was found to act as a protective factor in this association. Conclusions: Interventions in war zones need to ensure the minimal possible disruption to communities and family units, and to involve parents in preventive or treatment programmes for children exposed to trauma.
Studies have shown high levels of distress and mental disorder among people living in refugee camps, yet none has confirmed diagnosis through clinical reappraisal.
To estimate the prevalence of mental disorders, related disability and treatment gap in adult refugees living in the Burj el-Barajneh camp.
Randomly selected participants were screened by household representative (n = 748) and individual (n = 315) interviews; clinical reappraisal was performed on a subset (n = 194) of 326 selected participants. Weighted prevalence estimates and 95% confidence intervals were calculated.
The prevalence of current mental disorders was 19.4% (95% CI 12.6-26.2); depression was the most common diagnosis (8.3%, 95% CI 4.4-12.2) and multiple diagnoses were common (42%) among the 88 persons with mental disorder. Lifetime prevalence of psychosis was 3.3% (95% CI 1.0-5.5). Mental disorders were associated with moderate to severe dysfunction (odds ratio = 8.8, 95% CI 4.5-17.4). The treatment gap was 96% (95% CI 92-100).
A range of mental disorders and associated disability are common in this long-term refugee setting. Combined with an important treatment gap, findings support the current consensus-based policy to prioritise availability of mental health treatment in refugee camps, especially for the most severe and disabling conditions.
This article describes the implementation of a psychoeducational group treatment with students with a history of refugee trauma, war, and human rights abuses who were further traumatized by the 9/11 attacks in New York City. The rationale for group intervention and specific techniques utilized to promote emotional and behavioral stabilization and relief, including trauma education and stress management, are discussed. In addition, group-related issues, themes, and challenges are considered. This psychoeducational treatment modality provides an example of the usefulness of group intervention with a re-traumatized population.
Objective:
We sought to establish that refugee youths who receive a multi-tiered approach to services, Project SHIFA, would show high levels of engagement in treatment appropriate to their level of mental health distress, improvements in mental health symptoms, and a decrease in resource hardships.
Method:
Study participants were 30 Somali and Somali Bantu refugee youths in the English language learner classroom in a middle school in New England. Project SHIFA is a multi-tiered program including prevention and community resilience building for the community at large, school-based early intervention groups for at-risk students, and direct intervention using an established trauma model (trauma systems therapy) for those with significant psychological distress. Data were collected from students at time of enrollment, 6-month follow-up, and 12-month follow-up. Measures used were the War Trauma Screening Scale, Adolescent Post-War Adversities Scale-Somali version, UCLA PTSD Reaction Index for DSM-IV (Revision 1), and the Depression Self-Rating Scale.
Results:
Students across all tiers of the program demonstrated improvements in mental health and resources. Resource hardships were significantly associated with symptoms of posttraumatic stress disorder over time, and the stabilization of resource hardships coincided with significant improvements in symptoms of depression and posttraumatic stress disorder for the top tier of participants.
Conclusions:
Project SHIFA is a promising model of treatment for young refugees.
With large numbers of refugee arrivals and numerous barriers to accessing services it is especially important that resources are efficiently and effectively directed to address the health needs of refugees. Ten databases were utilised to conduct the review, returning 156 titles which were assessed for validity based on specified criteria. The 14 critically appraised articles included in this review consist of experimental research and discussions on best practice. Articles consistently demonstrated the benefit of community-based mental health service in improving mental health outcomes. Themes of cultural awareness, language, setting, and post-migration stressors emerged across the articles. In addition, the studies also point to the gaps in research of a longitudinal nature and ones that deal with scattered populations post migration. Community-based interventions proved valuable for improving the mental health of refugees. However, additional interventions and evaluations are required to draw consistent and conclusive judgments on best practice in dealing with refugee mental health issues.
There are increasing numbers of refugees worldwide, with approximately 16 million refugees in 2007 and over 2.5 million refugees resettled in the United States since the start of its humanitarian program. Psychologists and other health professionals who deliver mental health services for individuals from refugee backgrounds need to have confidence that the therapeutic interventions they employ are appropriate and effective for the clients with whom they work. The current review briefly surveys refugee research, examines empirical evaluations of therapeutic interventions in resettlement contexts, and provides recommendations for best practices and future directions in resettlement countries. The resettlement interventions found to be most effective typically target culturally homogeneous client samples and demonstrate moderate to large outcome effects on aspects of traumatic stress and anxiety reduction. Further evaluations of the array of psychotherapeutic, psychosocial, pharmacological, and other therapeutic approaches, including psychoeducational and community-based interventions that facilitate personal and community growth and change, are encouraged. There is a need for increased awareness, training and funding to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement.
This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.
The protective role of parenting factors on the mental well-being of children exposed to war trauma remains an under-researched area.
To establish the relationship between perceived positive parenting support and post-traumatic stress disorder (PTSD) symptoms in children exposed to war trauma.
A random sample of 412 children aged 12-16 years was selected from the Gaza Strip and was assessed using the Gaza Traumatic Events Checklist (GTEC), the SCID (DSM-IV) and the Perceived Parenting Support Scale (PPSS).
Palestinian children were exposed to different types of war-traumatic events. The number of exposed traumatic events was independently associated with the severity of post-traumatic symptoms scores or the diagnosis of PTSD, while perceived parenting support was found to act as a protective factor in this association.
Interventions in war zones need to ensure the minimal possible disruption to communities and family units, and to involve parents in preventive or treatment programmes for children exposed to trauma.
Mental Health of Refugees and Asylum Seekers presents both the theoretical and practical aspects of the mental health needs of refugees and asylum seekers. It looks at the impact of migration on mental health and adjustment, collective trauma, individual identity, and diagnostic fallacies. A practical section highlights cultural factors, ethno-psychopharmacology, therapeutic interaction, therapeutic expectation and psychotherapy. The final part focuses on special problems - such as bereavement, sexual violence, and post-traumatic stress disorders, as well as considering mental health problems in special groups, such as child refugees.
Parenting support and PTSD in children of a war zone
- A A Thabet
- A Ibraheem
- R Shivram
- E Van Milligen
- P Vostanis
Thabet AA, Ibraheem A, Shivram R, Van Milligen E, Vostanis P. Parenting
support and PTSD in children of a war zone. Int J Soc Psychiatry 2009; 55:
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Multi-tier mental health program for refugee youth
- H Ellis
- A Miller
- S Abdi
- C Barrett
- E Blood
- T Betancourt
Ellis H, Miller A, Abdi S, Barrett C, Blood E, Betancourt T. Multi-tier mental
health program for refugee youth. J Consult Clin Psychol 2013; 81: 129-40.
10.1192/bjp.bp.113.134742