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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.
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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
... Eleven studies used parents as their only data source which may have resulted in over-or underestimation of children's development. Further, the use of standardized measures that may not have been culturally appropriate questions the validity of reported findings [44,64]. Confronting displaced populations with measures normed for Western contexts presupposes that understandings of psychological, behavioral or developmental phenomena and manifestations of distress can be generalized across different cultures [64]. ...
... Further, the use of standardized measures that may not have been culturally appropriate questions the validity of reported findings [44,64]. Confronting displaced populations with measures normed for Western contexts presupposes that understandings of psychological, behavioral or developmental phenomena and manifestations of distress can be generalized across different cultures [64]. Developmental tests commonly used in study settings are usually created and normed for children who already know comparable play material and assignments from educational contexts, disadvantaging displaced children without former educational experience [44]. ...
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Objectives To examine the impact of displacement experiences on 0- to 6-year-old children’s social-emotional and cognitive development, as well as influencing factors on reported outcomes. Study design We systematically searched MEDline, Psyndex, Cochrane Library, Web of Science, Elsevier, TandF, Oxford Journal of Refugee Studies, Journal of Immigrant & Refugee Studies, and Canada’s Journal on Refugees for existing literature regarding social-emotional and cognitive outcomes in children directly exposed to forced displacement due to political violence. Results were synthesized in the discussion and displayed using harvest plots. Results Our search generated 9,791 articles of which 32 were selected for review and evaluation according to NICE criteria. Included studies provided results for 6,878 forcibly displaced children. Measured outcomes were diverse and included areas such as peer relations, prosocial behavior, family functioning, play, intelligence, learning performance, and language development. Repeated exposure to adverse experiences, separation from parents, parental distress, as well as duration and quality of resettlement in the host country were reported as influencing factors in the reviewed studies. Conclusion As protective factors like secure and stable living conditions help to promote children’s development, we call for policies that enhance participation in the welcoming society for refugee families. Early integration with low-threshold access to health and educational facilities can help to mitigate the wide-ranging negative consequences of forced displacement on young children’s development.
... Several studies have addressed the negative influences of the war on the mental and psychosocial wellbeing of forced migrants from Syria. For instance, Wells et al. (2015) concluded that refugees from the conflict in Syria had been exposed to various 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. ...
... And when I return home and try to study [ . . . ] Previous studies in different countries have stressed the bad influence of the war on the mental and the psychosocial wellbeing of Syrian refugees, such as studies by Wells et al. (2015), Kliewer et al. (2021), and Gormez et al. (2017). In line with these existing results, as the data in this study show, Syrian refugees in Germany have been exposed to traumatic events in their origin country, which negatively impact their mental and psychological wellbeing, even after years of their arrival to Germany. ...
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In forced migration literature, there is a lack of studies on the impact of war trauma on interpersonal mistrust among refugees and their interpersonal trust in members of the host society. To contribute to filling this gap, the author studied the impact of war trauma on interpersonal mistrust among Syrian refugees in Germany and their interpersonal trust in Germans. The data are based on semi-structured qualitative interviews with 20 Syrian refugees and asylum-seekers conducted in 2018 and 2019. The author argues that because traumatised refugees are powerfully influenced by past traumatic events experienced in their home country, they tend to mistrust people who can be associated with the place where these traumatic experiences occurred. In contrast, they are inclined to trust people who cannot be linked to the geographical location of the traumatic experiences. The main result of this study is that similarity—that of war-traumatised refugees sharing the same socio-cultural backgrounds—leads to interpersonal mistrust, while dissimilarity leads to interpersonal trust. The author of this paper calls for considering trust-building among war traumatised refugees, which has significant importance for refugee integration.
... Similarly, there were no differences in child emotion processing or mental health measures between the children who were born in Syria compared to children who were born in Jordan (all p > .100). Child mental health scores reported by the mother were in the low range of the scales, indicating good mental health (as per cut-off scores established in non-refugee samples; Jellinek et al., 1988, although we note that mental health cut-offs established in Western non-refugee populations may not be valid for this Syrian refugee sample, e.g., Wells et al., 2015). ...
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Refugee children’s development may be affected by their parents’ war-related trauma exposure and psychopathology symptoms across a range of cognitive and affective domains, but the processes involved in this transmission are poorly understood. Here, we investigated the impact of refugee mothers’ trauma exposure and mental health on their children’s mental health and attention biases to emotional expressions. In our sample of 324 Syrian refugee mother-child dyads living in Jordan (children’s M age =6.32, SD = 1.18; 50% female), mothers reported on their symptoms of anxiety and depression, and on their children’s internalising, externalising, and attention problems. A subset of mothers reported their trauma exposure ( n = 133) and PTSD symptoms ( n = 124). We examined emotion processing in the dyads using a standard dot-probe task measuring their attention allocation to facial expressions of anger and sadness. Maternal trauma and PTSD symptoms were linked to child internalising and attention problems, while maternal anxiety and depression symptoms were associated with child internalising, externalising, and attention problems. Mothers and children were hypervigilant towards expressions of anger, but surprisingly, mother and child biases were not correlated with each other. The attentional biases to emotional faces were also not linked to psychopathology risk in the dyads. Our findings highlight the importance of refugee mothers’ trauma exposure and psychopathology on their children’s wellbeing. The results also suggest a dissociation between the mechanisms underlying mental health and those involved in attention to emotional faces, and that intergenerational transmission of mental health problems might involve mechanisms other than attentional processes relating to emotional expressions.
... While this topic has been extensively explored in other, it has not been sufficiently delved into in the Spanish context. Moreover, some studies have pointed out that Western mental health assessments can fail to recognise the needs of UMYP (von Werthern et al, 2019), since instrument translations may be available but without having been validated or culturally adapted for other specific group (Wells et al, 2015). ...
... While this topic has been extensively explored in other, it has not been sufficiently delved into in the Spanish context. Moreover, some studies have pointed out that Western mental health assessments can fail to recognise the needs of UMYP (von Werthern et al, 2019), since instrument translations may be available but without having been validated or culturally adapted for other specific group (Wells et al, 2015). ...
... Cultural competence is not the same as culturalization, which is defined as 'a process where given situations, problems or differences are interpreted and explained on the basis of generalized cultural interpretations, rather than structural and institutional mechanisms related to individual and social positions' (Rugkåsa et al. 2017, p. 1). Where cultural competence is valued, it is acknowledged that Western interventions applied are not universal (Mollah et al. 2018;Wells et al. 2015). Cultural competence promotes reflexivity of one's own stance on culture and how this impacts their attitudes, beliefs and practices, it encourages seeing value in the culture of those around them and who they work with and challenges the power imbalance of the service user-worker relationship. ...
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The question of culturally respectful and competent practice is important for human services, particularly in Australia, which is characterised by a highly culturally diverse population as a result of migration. On arrival in Australia, migrants start using local services which they anticipate to be appropriate to their culture, situations and aspirations. This study explored what culturally respectful and competent practice looks like for organisations working with migrant youth in the Illawarra region of the state of New South Wales using in-depth interviews and focus groups. Although our focus was youth, responses were more broad to reflect the day-to-day roles of participants. From the responses, themes that came out included awareness of own culture as a practitioner and understanding the cultures of service users; paying attention to service user views of the dominant culture; employing staff from refugee and migrant communities; interpreter services; supporting practitioners in addressing agency limitations; and use of a strengths-based approach. What is central to these themes is capacitating human resources with cultural knowledge and a tendency towards prioritising service users’ interpretation of their culture and addressing the disadvantage and injustice that arise from cultural differences. For the organisations, a key barrier to achieving this is inadequate financial resources. In view of these findings, we conclude that, in relation to the topic and organisations we investigated, culturally respectful and competent practice means embedding service user cultural interpretations and priorities in organisational employment practices, staff skilling and service delivery in order to achieve the best and sustainable cultural, social and economic settlement outcomes.
... Within this framework, cultural factors play an important role in the assessment of an asylum seeker, even more so in the case of women. Culture informs the emotional expression, norms, and outward manifestations of psychological distress, and numerous difficulties can arise in the assessment of an asylum seeker with a different cultural background from that of the health team [25,[100][101][102][103][104]. ...
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Asylum-seeking migrants represent a vulnerable segment of the population, and among them, women constitute an even more vulnerable group. Most of these women and girls have been exposed to threats, coercion, and violence of many kinds, including rape, forced prostitution, harassment, sexual slavery, forced marriage and pregnancy, female genital mutilation/excision, and/or other violations of their rights (e.g., deprivation of education, prohibition to work, etc.). The perpetrators of the violence from which they flee are often their own families, partners, and even institutional figures who should be in charge of their protection (such as police officers). In the process for the acceptance/rejection of an asylum application, the forensic and psychological certification can make the difference between successful and unsuccessful applications, as it can support the credibility of the asylum seeker through an assessment of the degree of compatibility between the story told and the diagnostic and forensic evidence. This is why constant and renewed reflection on the ethical, forensic, and methodological issues surrounding medico-legal and psychological certification is essential. This article aims to propose some reflections on these issues, starting from the experience of the inward healthcare service dedicated to Migrant Victims of Maltreatment, Torture, and Female Genital Mutilation operating since 2018 at
... 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. ...
... Frameworks for understanding mental health have been criticised for adopting ill-fitting models divorced from their sociocultural contexts 7 . The mental health constructs adopted may not be contextually valid, and their focus on illness and disorder may exacerbate stigma, misinterpret local idioms of distress 8 , and overemphasise the role of factors such as conflict-trauma at the expense of social determinants of mental health 9,10 . Research design can further exacerbate ethical tensions due to perceived prioritisation of care, or the rigidity of research designs [see this special issue for discussions from a previous GFRB on this topic : 11]. ...
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Background: Achieving ethical and meaningful mental health research in diverse global settings requires approaches to research design, conduct, and dissemination that prioritise a contextualised approach to impact and local relevance. Method: Through three case studies presented at the 2021 Global Forum on Bioethics in Research meeting on the ethical issues arising in research with people with mental health conditions, we consider the nuances to achieving ethical and meaningful mental health research in three diverse settings. The case studies include research with refugees Rwanda and Uganda; a neurodevelopmental cohort study in a low resource setting in India, and research with Syrian refugees displaced across the Middle East. Results: Key considerations highlighted across the case studies include how mental health is understood and experienced in diverse contexts to ensure respectful engagement with communities, and to inform the selection of contextually-appropriate and feasible research methods and tools to achieve meaningful data collection. Related to this is a need to consider how communities understand and engage with research to avoid therapeutic misconception, exacerbating stigma, or creating undue inducement for research participation, whilst also ensuring meaningful benefit for research participation. Central to achieving these is the meaningful integration of the views and perspectives of local stakeholders to inform research design, conduct, and legacy. The case studies foreground the potential tensions between meeting local community needs through the implementation of an intervention, and attaining standards of scientific rigor in research design and methods; and between adherence to procedural ethical requirements such as ethical review and documenting informed consent, and ethical practice through attention to the needs of the local research team. Conclusions: We conclude that engagement with how to achieve local relevance and social, practice, and academic impact offer productive ways for researchers to promote ethical research that prioritises values of solidarity, inclusion, and mutual respect.
Chapter
Prevalence studies provided in Syria have emphasized common mental health disorders, including depression, anxiety and post-traumatic stress disorder, with less emphasis on severe mental health presentations including self-harm and suicidal behaviour. The mortality rate due to suicide inside Syria increased from 1.5 to 2 per 100,000 between 2010 and 2019. Choice of suicide methods varies across different cultures, depending on factors such as knowledge about effective lethal ways, which are sometimes culture specific, and access to means. Psychosocial determinants of suicidal behaviour are young age, female, interpersonal conflicts, conflict with spouse, forced and early marriages, violence in the household, dowry disputes, overcrowding, poverty, hunger, illiteracy and low education, conflict with in-laws, impulsivity, affective states of hopelessness and helplessness, adjustment, depressive and trauma-related disorders, stigma associated with mental health problems and suicidality, lack of awareness and lack of mental health services. The long-lasting war, instability, chaos and significant economic problems that followed it also has a significantly negative impact. It is in the interest of public safety and proper functioning of the legal system that every case of suicide be confirmed and unambiguously differentiated from natural death, homicide or accident. The WHO’s position is that decriminalization of suicide helps combat stigma and makes it easier for suicidal persons to seek help.
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Objectives: To document the ongoing destruction as a result of the tragic events in Syria, to understand the changing health care needs and priorities of Syrians. Methods: A directed examination of the scientific literature and reports about Syria before and during the Syrian conflict, in addition to analyzing literature devoted to the relief and rebuilding efforts in crisis situations. Results: The ongoing war has had high direct war casualty, but even higher suffering due to the destruction of health system, displacement, and the breakdown of livelihood and social fabric. Millions of Syrians either became refugees or internally displaced, and about half of the population is in urgent need for help. Access to local and international aid organizations for war-affected populations is an urgent and top priority. Conclusions: Syrians continue to endure one of the biggest human tragedies in modern times. The extent of the crisis has affected all aspects of Syrians' life. Understanding the multi-faceted transition of the Syrian population and how it reflects on their health profile can guide relief and rebuilding efforts' scope and priorities.
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The study explored factors to which people traumatized by war attribute their recovery from posttraumatic symptoms and from war experiences. : In-depth interviews were conducted with two groups of participants with mental sequelae of the war in the former Yugoslavia: 26 people who had recovered from posttraumatic stress disorder (PTSD) and 17 people with ongoing symptoms of PTSD. Participants could attribute their recovery to any event, person or process in their life. The material was subjected to thematic analysis. Eight themes covered all factors to which participants attributed their recovery. Six themes described healing factors relevant for both groups of participants: social attachment and support, various strategies of coping with symptoms, personality hardiness, mental health treatment, received material support, and normalization of everyday life. In addition to the common factors, recovered participants reported community involvement as healing, and recovered refugees identified also feeling safe after resolving their civil status as helpful. Unique to the recovered group was that they maintained reciprocal relations in social attachment and support, employed future-oriented coping and emphasised their resilient personality style. The reported factors of recovery are largely consistent with models of mental health protection, models of resilience and recommended interventions in the aftermath of massive trauma. Yet, they add the importance of a strong orientation towards the future, a reciprocity in receiving and giving social support and involvement in meaningful activities that ensure social recognition as a productive and valued individual. The findings can inform psychosocial interventions to facilitate recovery from posttraumatic symptoms of people affected by war and upheaval.
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Rumination (recyclic negative thinking), is now recognised as important in the development, maintenance and relapse of recurrence of depression. For instance, rumination has been found to elevate, perpetuate and exacerbate depressed mood, predict future episodes of depression, and delay recovery during cognitive therapy. Cognitive therapy is one of the most effective treatments for depression. However, depressive relapse and recurrence following cognitive therapy continue to be a significant problem. An understanding of the psychological processes which contribute to relapse and recurrence may guide the development of more effective interventions. This is a major contribution to the study and treatment of depression which reviews a large body of research on rumination and cognitive processes, in depression and related disorders, with a focus on the implications of this knowledge for treatment and clinical management of these disorders. First book on rumination in depressive and emotional disorders. Contributors are the leaders in the field. First editor is a rising researcher and clinician with specialist interest in depression, and second editor is world renowned for his work on cognitive therapy of emotional disorders.
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Background: Given the scarcity of mental health resources available for refugees in areas of conflict, it is imperative to investigate interventions that would be accepted by the refugees. Materials and methods: In this study we surveyed 354 Syrian refugees using the HADStress screening tool and asked about their openness to referral to psychiatry and telepsychiatry. Results: Of the surveyed sample, 41.8% had scores on HADStress that correlate to posttraumatic stress disorder. However, only 34% of the whole sample reported a perceived need to see a psychiatrist, and of those only 45% were open to telepsychiatry. Conclusions: Women, those who were bilingual, and those with positive HADStress status were less likely to accept telepsychiatry; however, this finding did not reach statistical significance. This study reports a partial acceptance of Syrian refugees for telepsychiatric services despite the high prevalence of psychological stress.
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Many Iraqi refugees suffer from posttraumatic stress. Efficient, culturally sensitive interventions are needed, and so we adapted narrative exposure therapy into a brief version (brief NET) and tested its effects in a sample of traumatized Iraqi refugees. Iraqi refugees in the United States reporting elevated posttraumatic stress (N = 63) were randomized to brief NET or waitlist control conditions in a 2:1 ratio; brief NET was 3 sessions, conducted individually, in Arabic. Positive indicators (posttraumatic growth and well-being) and symptoms (posttraumatic stress, depressive, and somatic) were assessed at baseline and 2- and 4-month follow-up. Treatment participation (95.1% completion) and study retention (98.4% provided follow-up data) were very high. Significant condition by time interactions showed that those receiving brief NET had greater posttraumatic growth (d = 0.83) and well-being (d = 0.54) through 4 months than controls. Brief NET reduced symptoms of posttraumatic stress (d = -0.48) and depression (d = -0.46) more, but only at 2 months; symptoms of controls also decreased from 2 to 4 months, eliminating condition differences at 4 months. Three sessions of brief NET increased growth and well-being and led to symptom reduction in highly traumatized Iraqi refugees. This preliminary study suggests that brief NET is both acceptable and potentially efficacious in traumatized Iraqi refugees.
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Little is known about the role of cognitive social capital among war-affected youth in low- and middle-income countries. We examined the longitudinal association between cognitive social capital and mental health (depression and posttraumatic stress disorder (PTSD) symptoms), functioning, and received social support of children in Burundi. Data were obtained from face-to-face interviews with 176 children over three measurement occasions over the span of 4-months. Cognitive social capital measured the degree to which children believed their community was trustworthy and cohesive. Mental health measures included the Depression Self-Rating Scale (DSRS) (Birleson, 1981), the Child Posttraumatic Symptom Scale (Foa, Johnson, & Feeny, 2001), and a locally constructed scale of functional impairment. Children reported received social support by listing whether they received different types of social support from self-selected key individuals. Cross-lagged path analytic modeling evaluated relationships between cognitive social capital, symptoms and received support separately over baseline (T1), 6-week follow-up (T2), and 4-month follow-up (T3). Each concept was treated and analyzed as a continuous score using manifest indicators. Significant associations between study variables were unidirectional. Cognitive social capital was associated with decreased depression between T1 and T2 (B=-0.22, p<.001) and T2 and T3 (β=-0.25, p<.001), and with functional impairment between T1 and T2 (β=-0.15, p=.005) and T2 and T3 (β=-0.14, p=.005); no association was found for PTSD symptoms at either time point. Cognitive social capital was associated with increased social support between T1 and T2 (β=0.16, p=.002) and T2 and T3 (β=0.16, p=.002). In this longitudinal study, cognitive social capital was related to a declining trajectory of children’s mental health problems and increases in social support. Interventions that improve community relations in war-affected communities may alter the trajectories of resource loss and gain with conflict-affected children.