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Understanding psychological responses to trauma among refugees: The importance of measurement validity in cross-cultural settings

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Abstract

Refugees from the current conflict in Syria have been exposed to a variety of stressors known to increase the risk of mental distress. These may include witnessing atrocities as well as dealing with the challenges of surviving in the displacement context. As a vast array of organisations rush to address mental health outcomes among Syrians, the scientific and conceptual validity of psychological tools used to assess and treat mental health difficulties becomes of paramount importance. Many psychological tools for assessing trauma have been validated in western contexts, but not among Syrians. This paper outlines three errors of reasoning which undermine the validity of psychological methods in cross-cultural contexts, including assuming that western psychiatric categories are universal constructs which can be applied in any context and failing to take contextual factors into account. Qualitative research may help us to better understand culturally specific conceptions of mental health. It is only once we have a solid understanding of how mental distress is understood and expressed among Syrian refugees that we can support effective interventions to alleviate it. The strengthening of indigenous health systems can help promote culturally appropriate mental health care.
Journal and Proceedings of the Royal Society of New South Wales, vol. 148, nos. 455 & 456, pp. 60-69.
ISSN 0035-9173/15/010060-10
60
Understanding Psychological Responses to Trauma among
Refugees: the Importance of Measurement Validity in
Cross-cultural Settings
Ruth Wells* 1, David Wells2, Catalina Lawsin1
1 Department of Psychology, University of Sydney, Sydney, Australia
2 Department of Biology, Macquarie University, Sydney, Australia
* Corresponding author.
Ruth Wells
E-mail: wruthw@gmail.com
Abstract
Refugees from the current conflict in Syria have been exposed to a variety of stressors known to increase
the risk of mental distress. These may include witnessing atrocities as well as dealing with the challenges of
surviving in the displacement context. As a vast array of organisations rush to address mental health
outcomes among Syrians, the scientific and conceptual validity of psychological tools used to assess and
treat mental health difficulties becomes of paramount importance. Many psychological tools for assessing
trauma have been validated in western contexts, but not among Syrians. This paper outlines three errors of
reasoning which undermine the validity of psychological methods in cross-cultural contexts, including
assuming that western psychiatric categories are universal constructs which can be applied in any context
and failing to take contextual factors into account. Qualitative research may help us to better understand
culturally specific conceptions of mental health. It is only once we have a solid understanding of how
mental distress is understood and expressed among Syrian refugees that we can support effective
interventions to alleviate it. The strengthening of indigenous health systems can help promote culturally
appropriate mental health care.
Keywords: Syria, Refugee, Psychosocial, Cultural, Assessment, Validity.
Introduction
The current conflict in Syria has led to the
deaths of over 200,000 people (IAS, 2014).
There are currently approximately 3.7 million
registered refugees in surrounding countries
(UNHCR, 2015). Many Syrians have been
subjected to human rights violations as a
result of the conflict (Hassan et al., 2014;
Ouyang, 2013). Displaced Syrian’s face these
challenges in the context of living conditions
in which it may be difficult to satisfy their
basic needs, and where they are isolated from
support structures (Taleb et al., 2015).
In this context, a myriad of international
actors are seeking to address the
psychological needs of Syrians. However, in
a rapidly changing environment, how can we
be sure that the tools we use to measure and
alleviate distress are appropriate? In order to
do no harm, we must work to validate our
tools. While there is pressure to act
immediately in a crisis, ensuring the efficacy
of action must remain paramount.
The following is a discussion of factors which
affect the validity of psychological
JOURNAL AND PROCEEDINGS OF THE ROYAL SOCIETY OF NEW SOUTH WALES
Wells et al. Responses to Trauma among Refugees
61
measurement tools in humanitarian settings.
This discussion is part of an ongoing PhD
research program exploring factors affecting
uptake and implementation of mental health
services among Syrian refugees living in
Jordan and Turkey. Our preliminary
qualitative research has explored community
readiness to address mental health difficulties,
cultural factors which influence care seeking
behaviour and culturally specific explanatory
models used to understand mental health
problems among Syrians living in Jordan.
The next phase of our research will build on
these foundational concepts with a Train the
Trainer approach to build the capacity of a
Syrian founded mental health organisation
serving the refugee community in Turkey.
Scientific Validity
Most of the tools used to measure
psychological disorders have been developed
among western populations (Kleinman,
1988). In fact, most of the categories
employed to understand what constitutes
normal and abnormal behaviour may
represent culture bound constructs which
cannot be meaningfully applied in diverse
cultural settings (Summerfield, 1999). This
calls into question both the conceptual
framework and scientific validity of research
into psychological health among refugees.
In the field of clinical psychology, establishing
the validity of psychological categories and
how we measure them can be a complicated
process. Firstly, we must define what
constitutes psychological disorder. Most
experiences associated with psychological
disorder exist on a continuum within a
population. If we take the example of
depression, most people experience sadness
at some time in their life. However, some
people experience such intense feelings of
sadness that they find it difficult to cope.
They can no longer go to work or participate
in healthy relationships. It is a clinician’s job
to determine whether a given individual’s
level of sadness is so severe that it may be the
product of a pathological process, understand
what this process might be and help the
person overcome it. Traditionally,
psychologists have sought to define
psychological pathology by measuring
reported experiences and behaviour within a
given population, in order to determine what
may be considered normal. Experiences which
fall at the extreme ends of a given continuum
are then defined as abnormal. As such, the
definition of pathology in the field of
psychology is a normative exercise, reflecting
the values of the culture in which it operates
(De Vos, 2011). The category of psychological
disorder labels individuals as falling within or
without a range which has been classified as
normal (Plante, 2013).
The purpose of defining and measuring
normality is so that we can learn more about
the underlying processes which contribute to
distress. Through the generation of
psychological measures, psychologists can
discover what kinds of processes are related
to psychological disorder. For example,
repetitive negative thinking is often associated
with depression (Papageorgiou and Wells,
2004), a process for which we now have
efficacious, evidence-based treatments
(Kenny and Williams, 2007), thereby helping
people to overcome depression. The ability
of this scientific research to uncover useful
constructs relies on the use of valid measures
to identify relationships between variables.
Establishing the validity of measures is
integral to interpreting empirical data in any
discipline. For example, if a biochemist
wanted to measure the amount of a certain
protein within a sample of tissue, she would
require a special tool. She could chose to
label the protein with a fluorescent tag which
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Wells et al. Responses to Trauma among Refugees
62
would light up, enabling her to identify and
count the protein. She would first need to
ensure that this given tag accurately identifies
the protein she is measuring. That is, that her
measure is valid. In her field, her data would
not be accepted as indicating the presence of
the protein unless she used a validated
measure. Similarly, in order to be confident
that measurement in the field of psychology is
accurate, validated measures are required.
However, in the case of cross-cultural
research, validated measures may not be
readily available (Hassan et al., 2014).
Psychological Consequences of
War and Displacement
War and displacement can lead to a complex
array of negative psychological outcomes
(Mollica, 2008) yet mental health among
refugees is not clearly understood (Nickerson
et al., 2011b; Tol et al., 2011) as psychological
research into the effects of trauma is primarily
focused on non-refugee western populations
(Murray et al., 2010). Estimates of the
prevalence of psychological disorder in
humanitarian settings have ranged between 0-
99% (Steel, 2009). Accurate measurement of
prevalence has been hampered by
methodological constraints including sample
size, sampling procedure (Silove, 1999), and
heterogeneous refugee populations (Murray
et al., 2010) as well as difficulties in
conducting research in crisis situations.
Research comparing displaced, war-affected
populations to non-refugees indicates
elevated levels of psychopathology (Porter
and Haslam, 2005), yet there is no
psychological treatment for refugees which is
firmly supported by a strong evidence base
(Crumlish and O'Rourke, 2010; Palic and
Elklit, 2011). Research has tended to focus
on posttraumatic stress disorder (PTSD).
PTSD is a reaction to traumatic experiences
characterised by intrusive symptoms, such as
re-experiencing the event or nightmares;
avoidance of trauma reminders; cognitive and
mood alterations, such as memory
disturbance, anger, guilt and estrangement;
and physiological arousal (APA, 2013).
Trauma leads to a wide variety of sequelae,
including effects on brain development (Bellis
et al., 2002); cognitive function (Koenen et al.,
2003); depression (Cardozo et al., 2004);
uncontrollable anger (Brooks et al., 2011); and
guilt (Gorman, 2001). In the case of
individuals who have experienced ongoing
and extreme rights abuses, PTSD may not
adequately capture the experience of
survivors (Gorst-Unsworth et al., 1993);
Herman, 1992). In addition, there is limited
research which explores individuals’ capacities
for resilience during the refugee experience
(Hijazi et al., 2014). Conflict related trauma
occurs in a context of disruptions to a variety
of social, personal, cultural and political
systems which normally promote health.
Clinical frameworks for understanding
refugee mental health need to take into
account impacts on cognitive, interpersonal,
social and existential functioning (Nickerson
et al., 2011a). A greater focus on a wider
range of adaptive functions following trauma
may help to ensure that research and
treatment accurately address the subjective
experience of survivors (Silove, 1999).
Logical Fallacies in the International
Application of Western Psychiatric
Categories in Diverse Settings
When epidemiologists measure the
prevalence of categories like PTSD in
humanitarian settings, the interpretation of
findings is constrained by the validity of the
measures used. In order to arrive at the
conclusion that these individuals suffer from
the same discrete disease entity as that
described in western populations, a number
of logical fallacies may have been committed.
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Arthur Kleinman (1988) identified the
category fallacy, the assumption that the
identification of symptoms in a different
cultural context carries the same significance
as they do in western culture. For example,
hopelessness in an affluent society in which
people have the opportunity to exercise their
rights, may be a sign of psychological
disorder. However, in a context of
continuing loss where “powerlessness is not a
cognitive distortion but an accurate mapping
of one’s place in an oppressive social system”
(Kleinman, 1988, pg. 15), hopelessness may
be a normal reaction.
Kleinman argued that culturally specific
norms inform the way that emotional,
cognitive and behavioural phenomena are
interpreted, contributing to understandings of
what constitutes normal and abnormal within
a given society. Each society has its own
understanding of the factors which cause
distress and psychological pathology. These
are explanatory models. These conceptions
will, in turn, determine the ways in which
distress is expressed. Therefore, each culture
will have specific idioms of distress, of which
western psychiatric categories are an example.
Since distress may be expressed in a different
manner in different cultural contexts,
psychological measures which have been
validated in one context, may not be valid in
another, as items lack cultural relevance and
do not include local idioms of distress (Velde
et al., 2009). For example, the Beck
Depression Inventory (BDI) is a measure of
depression which has been validated in
numerous western samples (Beck et al., 1988).
However, when Nicolas and Whitt (2012)
compared qualitative responses of Haitian
women to scores on the BDI, they found that
these women did not identify with the
symptoms on this checklist. That is, the
identified symptoms did not carry meaning as
expressions of distress within their cultural
framework.
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The assumption that the identification of
symptoms associated with PTSD means that
individuals have PTSD, may be an example
of the fallacy affirming the consequent. This error
in reasoning takes the form:
If you have PTSD, then you have these
symptoms.
You have these symptoms.
Therefore you have PTSD.
Although having PTSD entails having
particular symptoms, those symptoms may be
the result of causal conditions other than
PTSD. For example, recurrent memories and
re-experiencing of traumatic incidents may be
normative responses in the immediate
aftermath of a traumatic event and may in
fact be adaptive, as they aid in processing the
experience (Gorman, 2001).
Researchers who go into diverse cultural
settings and use measurement scales to
identify cases of PTSD may be committing
this fallacy. The scientifically valid procedure
is to first assess the scale for criterion validity
in the local context. Criterion validity is
established by examining the relationship
between scores on the checklist and some
external criterion (Van Ommeren, 2003). For
example, diagnostic cut-offs for a given
checklist are established by comparing scores
on the checklist to diagnosis following an in-
depth clinical assessment.
Establishing criterion validity in a given
community is vital to understanding the
contextual factors associated with the
identification of a given set of symptoms, and
whether or not these symptoms constitute an
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abnormal reaction within that society. The
blanket use of unvalidated symptom
checklists in humanitarian settings may
pathologise reactions to stress, for how are
we to determine what a normal reaction to an
extreme situation is (Eisenbruch, 1991)?
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Another logical problem arises when the
identification of symptoms associated with
PTSD is taken as evidence to support the
conclusion that PTSD is a cross-cultural
phenomenon. This may take the form of
begging the question, a form of logical fallacy in
which truth of the conclusion is assumed in
the premise. That is, the person making the
argument has assumed that the conclusion
they are attempting to prove is self-evident,
using it as an axiom to support their
argument (Garner, 2001). It is a form of
circular reasoning (not to be confused with its
incorrect usage to mean “raises the
question”). In this case, researchers who
employ western derived measurement
instruments to measure PTSD symptoms in
diverse cultures and take this as evidence that
PSTD is a universal phenomenon, have
actually assumed this by applying western
categories as if there were self-evident
(Summerfield, 1999).
Ethnographic Research can help
validate Assessment Tools
It is circular to apply culture-bound western
psychiatric categories (Kirmayer, 2006) as first
principles in cross-cultural research.
Ethnographic and qualitative research can
help us to understand what constitute
concepts of “mental” and “health” in local
taxonomies. Through this process we can
validate the basic assumptions upon which
assessment instruments are based (Kleinman,
1988). It is only once we have taken these
initial steps that the prevalence of mental
disorder in a given context can be established.
A psychiatric ethnography would hope to
make clear local conceptions of health and
disease from the perspective of daily practices
and coping strategies. Bolton and Tang
(2004) seek to do this by applying
ethnographic methods in a rapid assessment
participatory model for use in humanitarian
settings. They trained local health workers in
ethnographic techniques as a primary step to
epidemiology and intervention planning.
Participants’ unconstrained listing of concerns
generated a prioritised list of local problems
which identified the most pressing
psychosocial issues to be discussed in in-
depth key informant interviews. The
outcomes of this qualitative analysis were
used to develop a modification to the
Hopkins Symptom Checklist (HSCL) which
could measure the prevalence of locally
described idioms of distress consistent with
depression. In a large randomly selected
sample they further found that scores on this
checklist were associated with both locally
defined measures of functional impairment
and western defined criteria for depression
(Bolton and Ndogoni, 2000).
The Importance of Identifying
Distress
Despite the theoretical limitations raised
above, many clinicians seek to apply
psychiatric theory in diverse cultures with the
aim of achieving practical outcomes
(Kirmayer, 2006). The link between
traumatic events, such as torture, mental
health disorder, such as PTSD or depression
has been demonstrated across a wide range of
countries (Steel et al., 2009). Whether or not
these categories are always valid, they may
often indicate an increased level of distress.
Many survivors of trauma do not require
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65
psychological treatment, however it is
imperative that treatments are available for
people who do (Garcia-Moreno and van
Ommeren, 2012). Hopefully, work which
seeks to gain a deeper understanding of local
healing norms (for example the work of Al-
Krenawi and Graham (2000), Hinton et al.
(2009), Mollica et al. (1993)) can assist in
identifying individuals in need of assistance.
Some argue that, while valid, these theoretical
issues have led to polarisations which risk
obscuring practical realities for the severely
mentally ill (Kirmayer, 2006; Silove et al.,
2000). However mental disorder is classified,
the fact remains that across cultures, a subset
of people suffer marked functional and social
impairment as a result of mental health
difficulties (Kleinman, 1988), most notably
among those with severe problems such as
psychosis, neurological disorder and epilepsy
(Silove et al., 2000). The mentally ill are at
increased risk in crisis situations. For
example, when a psychiatric hospital in
Aleppo, Syria, was bombed in 2012, patients
had to flee and were left without support.
There is evidence that some of these patients
were subsequently killed by sniper fire while
wandering the streets (Abou-Saleh and
Mobayed, 2013).
Identifying Distress Among Syrians
In order to appropriately diagnose and treat
mental health issues among Syrian refugees, it
is necessary to understand how they perceive
and describe mental health problems (Tol et
al., 2011). There are, however, no standard
clinical instruments for assessing trauma
which have been validated in Syrian
populations (Hassan et al., 2014). In fact,
psychiatric services have historically not been
widely available in Syria. For example, in
2012 there were <0.5 psychiatrists, 0
psychologists and 0.5 psychiatric nurses per
100,000 population in Syria (Okasha et al.,
2012). Prior to 2011, available services were
generally residential and restricted to major
cities (1,200 beds) (Abou-Saleh and Mobayed,
2013). In addition, public health systems
have come under attack in Syria and are no
longer fully functional (Kherallah et al., 2015).
In addition to having limited practical access
to treatment options, stigma may prevent
individuals from seeking help. There is
limited research on the impact of stigma
among Syrians in particular, however, a
review of 22 publications of psychological
interventions adapted for Arabic speaking
patients reported that a high number of
papers identified fear of stigma as a barrier to
care (Gearing et al., 2013). Arabic speaking
people interviewed in Sydney reported that
having a heritable disease (such as
schizophrenia) may be considered
appropriate grounds for divorce and 51% said
that isolating people with mental health
disorders was considered normal (Youssef
and Deane, 2006). Fear of social
consequences may lead to disclosure of
somatic symptoms only (Weiss et al., 2001)
and patients may be unlikely to attend
dedicated mental health clinics for fear that
they will be observed. Provision of mental
health services in the primary health care
context may help to overcome this (Nasir and
Al-Qutob, 2005).
While it is important to ensure that
professional help is available to those who
would like it, Syrians may have alternative
ways of coping with distress with which they
identify more strongly. For example, Syrian
refugees in southern Turkey reported reasons
for not seeking care, including only needing
God, preferring to speak to family or friends
and stating that their emotional reaction to
the circumstance is normal, so they do not
require specialised treatment (Jefee-Bahloul et
al., 2014). It is possible that members of the
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Wells et al. Responses to Trauma among Refugees
66
Syrian refugee community are best placed to
understand the mental health needs of their
compatriots. In which case, interventions
which work to strengthen indigenous coping
systems may be an effective means to
overcome validity concerns in translating
cultural conceptions of distress.
Rebuilding Community Structures
Silove and colleagues (Silove, 1999) identify
how the breakdown of systems of social
networks, justice and other support structures
in post-conflict settings undermine
community structures which might otherwise
provide support to individuals. Programs
which help to rebuild these structures can
promote healing at the community and
individual level. For example, greater trust in
the community and a sense of community
cohesion has been associated with better
social support and reductions in mental health
difficulties, in a longitudinal study of
displaced children in Burundi, indicating that
programs which build a sense of community
may help children to marshal social resources
in order to improve health (Hall et al., 2014).
Situations of dependency associated with
living in refugee camps, or lack of recognition
of previous roles and qualifications in
resettlement countries leads to major
disruptions to individuals’ identity (Silove,
1999). Involvement in meaningful action
leading to recognition as a valuable member
of the community has been identified by
refugees as contributing to recovery from
PTSD following conflict and displacement
(Ajdukovic et al., 2013).
Conclusions
For humanitarian organisations, mental health
practitioners and scientific researchers
working in conflict and post-conflict settings,
questions of validity cannot be overlooked
when applying empirically based methods to
provide care to individuals who have
experienced considerable adversity.
However, there are limited opportunities to
establish validity in the context of
humanitarian crises. One solution to this
problem may be to employ measurement
methods which have been validated in
different contexts, and hope that they
produce meaningful data. An arguably
superior solution is to take advantage of the
skill and understanding of people within the
local community. The detailed cultural
knowledge of these individuals enables them
to make valid assessments of distress,
whether conducting clinical assessments or
research. While some members of refugee
communities will be in need of assistance in
coping with the experiences of war and
displacement, others are likely to be resilient.
These individuals may be in a position to play
a leadership role in rebuilding community
support systems. All humanitarian
organisations are in a position to support
these leaders to facilitate the generation of
culturally appropriate psychosocial programs.
Respecting their knowledge engenders respect
and human dignity.
References
Abou-Saleh, M. & Mobayed, M. (2013) Mental
Health in Syria, International Psychiatry, 10, 3, 58-
60.
Ajdukovic, D., Ajdukovic, D., Bogic, M.,
Franciskovic, T., Galeazzi, G. M., Kucukalic, A.,
Lecic-Tosevski, D., Schützwohl, M. & Priebe, S.
(2013) Recovery from Posttraumatic Stress
Symptoms: A Qualitative Study of Attributions
in Survivors of War, PLoS ONE, 8, 8.
Al-Krenawi, A. & Graham, J. R. (2000) Culturally
Sensitive Social work Practice With Arab Clients
in Mental Health Settings, Health & Social Work,
25, 1, 9-22.
APA (2013) The Diagnostic and Statistical Manual of
Mental Disorders: DSM 5, bookpointUS.
JOURNAL AND PROCEEDINGS OF THE ROYAL SOCIETY OF NEW SOUTH WALES
Wells et al. Responses to Trauma among Refugees
67
Beck, A. T., Steer, R. A. & Carbin, M. G. (1988)
Psychometric properties of the Beck Depression
Inventory: Twenty-five years of evaluation,
Clinical Psychology Review, 8, 1, 77-100.
Bellis, M. D. D., Keshavan, M. S., Shifflett, H.,
Iyengar, S., Beers, S. R., Hall, J. & Moritz, G.
(2002) Brain Structures in Pediatric
Maltreatment-Related Posttraumatic Stress
Disorder : A Sociodemographically Matched
Study, Biological Psychiatry, 52(11), 1066-1078 .
Bolton, P. & Ndogoni, L., (2000) Cross-Cultural
Assessment Of Trauma-Related Mental Illness,
CERTI, 71-71.
Bolton, P. & Tang, A. M. (2004) Using
ethnographic methods in the selection of post-
disaster, mental health interventions, Prehospital
and disaster medicine : the official journal of the National
Association of EMS Physicians and the World
Association for Emergency and Disaster Medicine in
association with the Acute Care Foundation, 19,
March, 97-101.
Brooks, R., Silove, D., Steel, Z., Steel, C. B. &
Rees, S. (2011) Explosive anger in postconflict
Timor Leste: interaction of socio-economic
disadvantage and past human rights-related
trauma, Journal of affective disorders, 131, 1-3, 268-
76.
Cardozo, B. L., Bilukha, O. O., Crawford, C. a. G.,
Shaikh, I., Wolfe, M. I., Gerber, M. L. &
Anderson, M. (2004) Mental health, social
functioning, and disability in postwar
Afghanistan, JAMA, 292, 5, 575-84.
Crumlish, N. & O'Rourke, K. (2010) A systematic
review of treatments for post-traumatic stress
disorder among refugees and asylum-seekers,
The Journal of Nervous and Mental Disease, 198, 4,
237-251.
De Vos, J. (2011) The psychologization of
humanitarian aid: skimming the battlefield and
the disaster zone, History of the Human Sciences, 24,
103-122.
Eisenbruch, M. (1991) From post-traumatic stress
disorder to cultural bereavement: Diagnosis of
Southeast Asian refugees, Social Science &amp;
Medicine, 33, 6, 673-680.
Garcia-Moreno, C. & van Ommeren, M. (2012)
Mental health and psychosocial support for
conflict-related sexual violence : 10 myths, World
Health Organisation, 2.
Garner, B. A. (2001) A Dictionary of Modern Legal
Usage, Oxford University Press.
Gearing, R. E., Schwalbe, C. S., MacKenzie, M. J.,
Brewer, K. B., Ibrahim, R. W., Olimat, H. S., Al-
Makhamreh, S. S., Mian, I. & Al-Krenawi, A.
(2013) Adaptation and translation of mental
health interventions in Middle Eastern Arab
countries: a systematic review of barriers to and
strategies for effective treatment
implementation, The International journal of social
psychiatry, 59, 7, 671-81.
Gorman, W. (2001) Refugee Survivors of Torture:
Trauma and Treatment, Professional Psychology:
Research and Practice, 32, 5, 443-451.
Gorst-Unsworth, C., Van Velsen, C. & Turner, S.
(1993) Prospective Pilot Study of Survivors of
Torture and Organized Violence: Examining the
Existential Dilemma, The Journal of Nervous and
Mental Disease, 181, 4, 263-264.
Hall, B., Tol, W., Jordans, M., Bass, J. & de Jong, J.
(2014) Understanding resilience in armed
conflict: Social resources and mental health of
children in Burundi, Social Science and Medicine,
114, 121-128.
Hassan, G., Quosh, C., Mekki-berrada, A.,
Youssef, A., Coutts, A. & Kirmayer, L. (2014)
Culture and Mental Health of Syrians A primer for
mental health professionals working with Syrian refugees
and displaced people, UNHCR.
Herman, J. L. (1997) Trauma and Recovery,
BasicBooks.
Herman, J. L. (1992) Complex PTSD: A
syndrome in survivors of prolonged and
repeated trauma, Journal of Traumatic Stress, 5, 3,
377-391.
Hijazi, A. M., Lumley, M. A., Ziadni, M. S.,
Haddad, L., Rapport, L. J. & Arnetz, B. B.
(2014) Brief Narrative Exposure Therapy for
Posttraumatic Stress in Iraqi Refugees : A
Preliminary Randomized Clinical Trial, Journal of
Traumatic Stress, 27(3), 314-322.
Hinton, D. E., Hofmann, S. G., Pollack, M. H. &
Otto, M. W. (2009) Mechanisms of Efficacy of
CBT for Cambodian Refugees with PTSD:
Improvement in Emotion Regulation and
Orthostatic Blood Pressure Response, CNS
Neuroscience & Therapeutics, 15, 3, 255-263.
IAS (2014), I am Syria, www.iamsyria.org/daily-
death-count.html.
JOURNAL AND PROCEEDINGS OF THE ROYAL SOCIETY OF NEW SOUTH WALES
Wells et al. Responses to Trauma among Refugees
68
Jefee-Bahloul, H., Moustafa, M. K., Shebl, F. M. &
Barkil-Oteo, A. (2014) Pilot assessment and
survey of syrian refugees' psychological stress
and openness to referral for telepsychiatry
(PASSPORT Study), Telemedicine journal and e-
health : the official journal of the American Telemedicine
Association, 20, 10, 977-9.
Kenny, M. a. & Williams, J. M. G. (2007)
Treatment-resistant depressed patients show a
good response to Mindfulness-based Cognitive
Therapy, Behaviour research and therapy, 45, 617-
625.
Kherallah, M., Alahfez, T., Sahloul, Z., Eddin, K.
D. & Jamil, G. (2015) Health care in Syria before
and during the crisis, Avicenna Journal of Medicine,
2(3), 51.
Kirmayer, L. J. (2006) Beyond the 'new cross-
cultural psychiatry': cultural biology, discursive
psychology and the ironies of globalization,
Transcultural Psychiatry, 43, March, 126-144.
Kleinman, A. (1988). Rethinking psychiatry: From
cultural category to personal experience. Simon and
Schuster.
Koenen, K. C., Moffitt, T. E., Caspi, A., Taylor, A.
& Purcell, S. (2003) Domestic violence is
associated with environmental suppression of
IQ in young children, 15, 297-311, Development
and psychopathology, 15(02), 297-311.
Mollica, R. F. (2008) Healing Invisible Wounds: Paths
to Hope and Recovery in a Violent World, Vanderbilt
University Press.
Mollica, R. F., Donelan, K., Tor, S., Lavelle, J.,
Elias, C., Frankel, M. & Blendon, R. J. (1993)
The effect of trauma and confinement on
functional health and mental health status of
Cambodians living in Thailand-Cambodia
border camps, JAMA : the journal of the American
Medical Association, 270, 581-586.
Murray, K. E., Davidson, G. R. & Schweitzer, R.
D. (2010) Review of refugee mental health
interventions following resettlement: best
practices and recommendations, American Journal
of Orthopsychiatry, 80, 4, 576-85.
Nasir, L. S. & Al-Qutob, R. (2005) Barriers to the
diagnosis and treatment of depression in Jordan.
A nationwide qualitative study, The Journal of the
American Board of Family Practice, 18, 2, 125-131.
Nickerson, A., Bryant, R. A., Brooks, R., Steel, Z.,
Silove, D. & Chen, J. (2011a) The familial
influence of loss and trauma on refugee mental
health: a multilevel path analysis, Journal of
Traumatic Stress, 24, 1, 25-33.
Nickerson, A., Bryant, R. A., Silove, D. & Steel, Z.
(2011b) A critical review of psychological
treatments of posttraumatic stress disorder in
refugees, Clinical Psychology Review, 31, 3, 399-417.
Nicolas, G. & Whitt, C. L. (2012) "Conducting
qualitative research with a Black immigrant
sample: Understanding depression among
Haitian immigrant women.", in Nagata, D.,
Kohn-wood, L. & Suzuki, L. A. (eds.) Qualitative
Strategies for Ethnocultural Research, American
Psychological Association, Washington, 199-217.
Okasha, A., Karam, E. & Okasha, T. (2012)
Mental health services in the Arab world, World
Psychiatry, 11, 1, 52-54.
Ouyang, H. (2013) Syrian refugees and sexual
violence, The Lancet, 381, 9884, 2165-2166.
Palic, S. & Elklit, A. (2011) Psychosocial treatment
of posttraumatic stress disorder in adult refugees:
A systematic review of prospective treatment
outcome studies and a critique, Journal of Affective
Disorders, 131, 1-3, 8-23.
Papageorgiou, C. & Wells, A. (2004) Depressive
rumination, Nature, Theory and Treatment.
Plante, T. (2013) Abnormal Psychology Across the Ages,
ABC-CLIO.
Porter, M. & Haslam, N. (2005) Predisplacement
and postdisplacement factors associated with
mental health of refugees and internally
displaced persons: a meta-analysis, JAMA, 294,
5, 602-12.
Silove, D. (1999) The Psychosocial Effects of
Torture, Mass Human Rights Violations, and
Refugee Trauma: Toward an Integrated
Conceptual Framework, The Journal of Nervous and
Mental Disease, 187, 4, 200-207.
Silove, D., Ekblad, S. & Mollica, R. (2000) The
rights of the severely mentally ill in post-conflict
societies, Lancet, 355, 1548-1549.
Steel, Z., Chey, T., Marnane, C., Bryant, R. A. &
Ommeren, M. V. (2009) Association of Torture
and Other Potentially Traumatic Event with
Mental Health OUtcomes Among Populations
Exposed to Mass Conflict and Displacement. A
Systematic Review and Meta-analysis, Journal of
the American Medical Association, 302, 5, 537-549.
Steel Z, C. T. S. D. M. C. B. R. A. v. O. M. (2009)
Association of torture and other potentially
traumatic events with mental health outcomes
JOURNAL AND PROCEEDINGS OF THE ROYAL SOCIETY OF NEW SOUTH WALES
Wells et al. Responses to Trauma among Refugees
69
among populations exposed to mass conflict and
displacement: A systematic review and meta-
analysis, JAMA: The Journal of the American Medical
Association, 302, 5, 537-549.
Summerfield, D. (1999) A critique of seven
assumptions behind psychological trauma
programmes in war-affected areas, Social Science
& Medicine, 48(10), 1449-1462.
Taleb, Z. B., Bahelah, R., Fouad, F. M., Coutts, A.,
Wilcox, M. & Maziak, W. (2015) Syria: health in
a country undergoing tragic transition,
International journal of public health, 60 Suppl 1, 63-
72.
Tol, W. A., Patel, V., Tomlinson, M., Baingana, F.,
Galappatti, A., Panter-Brick, C., Silove, D.,
Sondorp, E., Wessells, M. & van Ommeren, M.
(2011) Research Priorities for Mental Health and
Psychosocial Support in Humanitarian Settings,
PLoS Med, 8, 9, e1001096.
UNHCR (2015) Syria Regional Response Plan,
UNHCR.
Van Ommeren, M. (2003) Validity issues in
transcultural epidemiology, British Journal of
Psychiatry, 182, 376-378.
Velde, J. V. D., Williamson, D. L. & Ogilvie, L. D.
(2009) Participatory Action Research: Practical
Strategies for Actively Engaging and Maintaining
Participation in Immigrant and Refugee
Communities, Qualitative Health Research, 19(9),
1293-1302..
Weiss, M. G., Jadhav, S., Raguram, R., Vounatsou,
P. & Littlewood, R. (2001) Psychiatric stigma
across cultures: Local validation in Bangalore
and London, Anthropology & Medicine, 8, 1, 71-87.
Youssef, J. & Deane, F. P. (2006) Factors
influencing mental-health help-seeking in
Arabic-speaking communities in Sydney,
Australia, Mental Health, Religion & Culture, 9, 1,
43-66.
Ruth Wells is a PhD candidate at the University of Sydney. She was a recipient of a Royal Society
of New South Wales Scholarship for 2014, awarded to acknowledge and support outstanding
achievement by early-career researchers working towards higher degrees in science-related fields.
Received: 3, April 2015 Accepted: 21, May 2015
... Stressors and mental health of SRAs have been predominantly assessed through nomothetic measurements -often developed and validated in western contexts [20]. Studies have shown that standard instruments often fail to encompass all aspects of distress in cross-cultural settings, and that it is a fallacy to assume that symptoms in different cultural contexts carry the same significance across cultures [21][22][23]. Client-generated outcome measurements are person-centred by definition and unlike standardized measures, they seek to encompass the individuals' phenomenological experiences as well as their priorities, local values, perspectives and expectations [22,24,25]. Individuals' social circumstances and culture are at the core of the WHO global strategy on personcentred care, which suggests that care should address physical, socioeconomic, mental and emotional wellbeing [26]. ...
... A person-centred approach is appropriate for understanding the stressors and needs of SRAs because they emigrate to diverse cultural, social, political and religious contexts. Furthermore, despite general cultural commonalities among SRAs, there is also great diversity among Syrians and their individual experiences [21,27]. This approach also accords with the UNHCR mental health and psychosocial support (MHPSS) programs. ...
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... However, despite PTSD being a prominent diagnosis associated with forced migration, depression and anxiety are equally common in refugees and contribute to limitations in quality of life (Ghazinour, Richter, & Eisemann, 2004). Moreover, Western psychiatric categories and constructs may fail to cover the problems and needs of refugees with other cultural backgrounds (Wells, Wells, & Lawsin, 2015). The investigation of the effectiveness of mental health service should thus not only rely on predefined psychiatric conditions but also consider subjective perspectives on health (Drescher et al., 2021). ...
... A study that reviewed 183 studies concerning the mental health of refugees found that over 50% did not validate the instruments used (Hollifield et al., 2002). To accurately measure the magnitude of mental illness, it is essential to choose an instrument that is rigorously designed to capture the cultural aspects of the specific population studied (Ali et al., 2016;Wells et al., 2015). ...
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Background: Refugee mothers are at a significantly increased risk of suffering from perinatal depression. However, available tools to screen for it often use a western paradigm of mental health, may not be culturally appropriate, and may not account for the background stress experienced by refugees. The objective of this study is to test and validate RHS-13, which was developed by consultation with refugees from different backgrounds, among a group of Syrian refugee mothers living in Beka’s valley in Lebanon. Methodology: The tool was tested on a sample of 103 women. Internal consistency of the items for each subscale was assessed using Cronbach’s alpha. An interitem correlation was performed to examine the most correlated items on the scale. Pearson correlation coefficient was calculated between each subscale and its diagnostic proxy. To find the best fit cut-point between sensitivity and specificity, ROC curves were used. Results: RHS-13 is a reliable and valid tool to detect depression and anxiety among perinatal Syrian mothers (Internal consistency 0.803) (correlation with PHQ: 0.63), (correlation with GAD-7: 0.73). The best fit cut-points were 12, 15, and 25 indicating the severity of symptoms from mild to severe, respectively. Conclusion: RHS-13 is a valid tool among perinatal refugees in Lebanon and can be used by primary care physicians, mental health providers, social workers working with refugees from the Middle East to screen mothers for depression and anxiety.
... However, measuring mental health with standard tools across contexts is particularly challenging. These challenges stem from cultural differences in epistemology, cross-contextual equivalence, the vast, deep and diverse issues of stigma around poor mental health, translocation, and differences in training and implementation of mental health services (49,50). Especially for mental health, many measures rely on nosological distinctions and clinical assessment, which may be too narrow to capture myriad intersectoral and interdisciplinary outcomes that we now consider important. ...
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... In addition, the way that cultural beliefs shape illness experience is fluid and in constant interaction with changing social conditions (Lewis-Fernandez and Kirmayer 2019), such as those brought about by conflict and displacement. Elsewhere we have documented how community attitudes to mental health concerns have become increasingly differentiated in response to displacement, with increased exposure to different kinds of mental health concerns resulting from conflict (Wells et al. 2015). ...
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... In addition to the obvious practical advantage of abbreviating psychological assessment and containing its cost, the VAS has the advantage of placing a lower demand on the examinee's cognitive skills (reading/ numeracy) and mental stamina (Lichtenstein et al., 2017), as well as the assessor's time spent on calculating and norm-referencing test scores (Huang, Kohler, & Kampfen, 2020). Thus, it has the potential to make symptom report accessible for patients with conditions that make instruments with high verbal mediation challenging, like aphasia (Berg, Lonnqvist, Palomaki, Kaste, 2009;Bodner, Merten, & Benke, 2019;Townend, Brady, & McLaughlan, 2007), limited English proficiency, or low levels of acculturation (Boone et al., 2007;Coffey, Marmol, Schock, & Adams, 2005;Merten & Rogers, 2017;Schroeder & Marshall, 2010;Stevens, Bahlo, Licha, & Liske, 2016;Wells, Wells, & Lawsin, 2015). At the same time, Erdodi et al. (2020) has pointed out that, despite significantly lower verbal mediation compared to traditional symptom report inventories, the anchor words on VASs still need semantic decoding (May & Pridmore, 2020). ...
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... A person-centred approach is appropriate for understanding the stressors and needs of SRAs because they emigrate to diverse cultural, social, political and religious contexts. Furthermore, despite general cultural commonalities among SRAs, there is also great diversity among Syrians and their individual experiences (Hassan et al., 2015;Wells et al., 2015). This approach also accords with the UNHCR mental health and psychosocial support (MHPSS) programs. ...
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... Prevalence of post-traumatic stress disorder (PTSD) among Syrians is reported at over 80% (Vukcevic et al. 2014;Acarturk et al. 2018), although some studies have lower estimates (Chung et al. 2018) likely due to variability in survey tools (Steel et al. 2009) and inadequate translation practice leading to a lack of scientific and conceptual validity (Wells et al. 2015). ...
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... Wells et al. point out that what is valid in one cultural context may not be valid in another. Symptoms might not carry the same significance in different cultures: hopelessness experienced by a healthy, young, upper-middle class individual has a very different significance than the hopelessness experienced by an individual in the grip of an oppressive system that denies all personal freedom (Wells et al., 2015). Hassan et al. emphasize the importance of cultural competency in offering mental health and psychosocial support (MHPSS) to individuals from non-western cultural backgrounds. ...
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