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Abstract of the thesis entitled
A Critical Exploration of Forces Impacting Mental Health and Psychosocial
Wellbeing of Conflict-Induced Displaced Persons in Hong Kong
Submitted by
Malabika Das
for the Degree of Doctor of Philosophy
at The University of Hong Kong
in September, 2015
Refugees, asylum seekers, and survivors of torture and cruel, inhuman, degrading
treatment or punishment (persons of concern (PoC)) in Hong Kong are extremely
resilient people. Many however, are challenged with conflict displacement traumas
that often go unaddressed. To compound matters, they have little livelihood options
and live in an uncertain state while their protection claims are slowly processed; there
is little chance of success. On a daily basis, their bio-psycho-social-spiritual wellbeing
intertwines with and is impacted by services and policy within the ecological system
in Hong Kong. This doctoral dissertation study uses an ecological systems
framework, critical paradigm and social justice perspective to explore how PoC
mental health and psychosocial (MHPS) wellbeing are interconnected to systemic and
environmental forces. Three phases of narrative inquiry with PoC participants and
service providers illuminate PoC lived experiences and provider insight and
suggestions at the micro, mezzo and macrosystem of the ecological environment.
Inductive and deductive interpretive thematic analysis generates theoretical
contributions. The deterioration of mental and overall health were linked to
oppressive policy and services such as protection screening retraumatization,
inadequate healthcare and inability to work. Traumatic uncertainty negatively affected
their lives and was primary linked to their overall deterioration. All systems presented
different levels of boundary openness and permeability across ecological interactions.
Ultimately, there was systemic empathic failure within the sub-systems of the
ecological environment. An array of physical, mental and behavioral health issues
have manifested for PoC and often become prolonged due to several systemic
barriers. While there is empathic failure in some of the sub-systems, there is also
systemic empathic attunement in other areas. Human interaction through empathy
could enable more openness in the whole system. Empathic growth pathways to
multi-level, trauma-informed services and care are provided and based on the research
findings and global MHPSS recommendations. Empathic growth can transform
empathic failure into empathic attunement. As the ecological system in Hong Kong
enhances its empathy for PoC, positive holistic health and wellbeing for PoC can be
realized. While being confronted with extreme levels of gross human rights violations
and severe social injustice created by oppressive systems and structures, social work
is in a prime position to advocate for change and for the betterment of this resilient
yet vulnerable community. Awareness of the ecological connection is essential in
work with conflict-induced forced migrants. Also, using an integrated approach can
be useful in therapeutic work. Overall strengths based services informed by
community, tailored to the context, using advocacy lens can be essential for
community empowerment and holistic and trauma-informed health promotion. There
is a valuable place for the social work profession to be at the forefront of advocacy,
multi-level services, healing and therapy, and research and education within this
rapidly evolving practice area.
A word count of 452
A Critical Exploration of Forces Impacting Mental Health and
Psychosocial Wellbeing of Conflict-Induced Displaced Persons in
Hong Kong
by
Malabika Misty Das, MSW
A thesis submitted in partial fulfillment of the requirements for
the Degree of Doctor of Philosophy
at The University of Hong Kong
September, 2015
Dedication
To my babies near and far: Thank you for being part of this journey no matter how long
I had with you, all three of you are special and you will always be loved.
To my husband: Thank you for supporting my endeavors and loving me for who I am
and continue to evolve into.
To my parents: Thank you for always enabling my wings to grow stronger and
supporting me in the directions I was determined to fly. Thank you for your great
sacrifices and journey to provide me with enriching opportunities.
To everyone who has supported me: Thank you for your love and faith.
To the Universe: Thank you for manifesting this journey for me. I am grateful for all of
the experiences, even the most challenging ones.
To all the survivors of human rights violations, displacement and torture: Thank you for
your courageous spirit and sacrifices, which teaches the world many important lessons.
You inspire me with your healing capacities. I will continue to learn from you and
promise to continue my efforts in enabling social justice and healing spaces filled with
love and empathy.
There is shade not only in mountain
But in small hut of town too.
I don’t have love with money
But with my life.
I am guitar with broken string
You can play, if you can fix
I am plant with broken root
You can save me, if you can
Research Participant
“By embracing our biologically based precondition for empathy and by operationalizing
personal actions and policies based upon empathophilia and the creation of beauty in our
healing environments we can stop the deleterious effects of human violence and create
truly therapeutic healing environments. This Manifesto is a call to action for each and
every person.” Dr. Richard Mollica (Mollica, 2013, p. 39)
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DECLARATION
I declare that this thesis represents my own work, except where due
acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a degree,
diploma or other qualifications.
Signed……………………………………………………..
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Acknowledgements
I am extremely grateful for this enriching journey of academics and life. I would
like to thank the University of Hong Kong and Department of Social Work and Social
Administration for this incredible opportunity to further my knowledge and capacities as
a social work academic, researcher and practitioner
I would like to thank my primary supervisor, Dr. Cecilia Lai Wan Chan. Ceci,
words simply cannot do justice to how much I am enamored by your incredible energies.
I am humbled to have your guidance, and experience your selflessness, insight,
thoughtfulness, and fierceness! So, thank you for unwavering faith and encouragement
through it all. I would like to thank my co-supervisor Dr. Sui Man Ng, for his insight and
guidance during this process, I truly appreciate your support.
I thank all the staff and colleagues at the Centre on Behavioral Health and the
Department of Social Work and Social Administration at the University of Hong Kong
Thank you for your empathic care. I will forever be grateful for this support.
I thank all the PoC research participants and service providers who were integral
in the production of this research. Because of you, this research study is special and
valuable. Your unwavering commitment to improve the wellbeing of forcibly displaced
persons in Hong Kong is inspiring and commendable. You have taught me so much
about trauma and healing and I am changed forever for the better because of the
experience of knowing and working with you.
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About the Author
The academic and professional background of Ms. Das entails both a macro and
micro foundation in the helping professions. She holds Bachelors in Urban and Regional
Planning from the University of Illinois at Urbana Champaign. This enabled a solid
macro level, community development experience. She then gained valuable human rights
and social justice experience in her roles serving ethnic minority groups in New York
City. She further obtained her master in Social Work at Columbia University, with a
focus on clinical and international work. As a psychiatric social worker in a community
mental health agency in Queens, New York, she was a psychotherapist for families in
crisis around a variety of issues propagated by domestic violence, sexual abuse, and
various psychiatric disorders.
She also engaged in trainings in integrated approaches to trauma healing and
holistic health, such as Acudetox, the use of auricular acupuncture for trauma, disasters,
substance use and overall stress reduction. She is a strong proponent of integrative
approaches to trauma work and healing such as the Integrative Body-Mind-Sprit Approach to
trauma healing, which combines the Eastern and Western modalities and philosophies of
healing. She is an avid yoga and energy therapy practitioner and when appropriate can
combine these modalities into work with clients.
In 2014, she trained at Harvard Program for Refugee Trauma’s Global Mental
Health Trauma and Recovery Certificate Training Program, a nine-month program where a
network of global service providers and experts serving traumatized communities
worked together through a residential and online learning community. Here, she
advanced her knowledge and skills in working with traumatized persons seeking
protection from conflict-induced displacement. She works as a researcher, practitioner,
and advocate. On the regional level, she is an individual member of the Asia Pacific
Refugee Rights Network and is assisting in their Right to Health Working Group.
Conference Presentations:
Global Social Work and Social Development: Stockholm, Sweden, 2012
Global Social Work and Social Development: Melbourne, Australia, 2014
Research Post-graduate Conference: Hong Kong, 2014
Regional Congress, World Federation for Mental Health, Singapore, 2015
Publications:
Das, M. M., & Chan, C. L. W. (2013). Uplifting Social Support for Refugees and Asylum
Seekers. In S. Chen (Ed.), Social Support and Health Theory, Research, and Practice with
Diverse Populations (pp. 79-92). New York: Nova Publishers.
Das, M. M., Chui, C. H.-K., & Chan, C. L. W. (2013). Advocacy. In B. A. Thyer, C. N.
Dulmus, & K. M. Sowers (Eds.), Developing Evidence-Based Generalist Practice Skills.
USA: John Wiley & Sons.
In Progress:
Das, M.M. (2016). Emerging I-BMS Approaches for Conflict Displacement Trauma. In
Lee, M.Y, Chan, C., Chan, C.L.W. & Leung, P (Eds.), Integrative Body-Mind-Spirit
Social Work: An Empirically-based Approach to Assessment and Treatment (Second
Edition). Oxford University Press
Das, M.M. (2016). Enabling a Bio-Psycho-Social-Spiritual Worldview: Spirituality and
Emerging Integrative Therapeutic Approaches for Conflict Displacement
Trauma. In Crisp, B (Ed.), Routledge Handbook of Religion, Spirituality and Social Work
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Detailed Table of Contents
DECLARATION …………………………………………………………………….,i
Acknowledgements………………………………………………………………….…ii
About the Author……………………………………………………………….…..…iii
Detailed Table of Contents………………………………………………………….…iv
List of Figures…………………………………………………………………………..x
List of Tables……………………………………………………………………….….xi
Key Abbreviations & Acronyms…………………...………………………………..…xii
Chapter 1: Introduction………………………………………………………………1
1.0. Overview……………………………………………………………………….......1
1.1. General Background……………………………………………………….……….3
1.1.1. Definitions of Migratory Groups…………………………………………3
1.1.2. Global Statistics……………………………………………………….….5
1.1.3. Trend of Deterrence & Responsibility Abandonment…………………….6!
1.2. Conflict-Induced Displacement & Trauma…………………………………………8
1.2.1. Conflict-Induced Displacement Phases……………………….…………..8
1.2.2. Trauma & Holistic Health Impact……………………………………...…9
1.3. Mental Health & Psychosocial Wellbeing…………………………………………11
1.3.1. Relevant Terms & Definitions…………………………………………..11
1.3.2. Prioritizing MHPSS in Conflict-Induced Displacement…………………11
1.3.3. Mental Health & Human Rights………………………………………....12
1.4. Hong Kong Situational Context…………………………………………………..13
1.4.1. Historical Deterrence Attitude & Policy………………………………....13
1.5. Problem Statement………………………………………………………………..17
1.6. Research Design Overview………………………………………………………..17
1.6.1. Rationale………………………………………………………………...18
1.7.1. Research Objectives……………………………………………………..19
1.7.2. Overarching Research Questions……………………………………..…19
1.7.3. Methodology Summary……………………………………………….…20
1.8. Chapters Organization…………………………………………………………….21
1.9. Closing Reflexive Remarks………………………………………………………..23
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Chapter 2: Selective Literature Review…………………………………………….24
2.0. Overview…………………………………………………………………………24
2.1. Part 1: Hong Kong PoC Discourse Highlights……………………………………25
2.1.1. China Migration Flow…………………………………………………...27
2.1.2. Vietnamese Boat People Era…………………………………………….28
2.1.3. Contemporary Legal & Protection Context…………………………..….30
2.1.4. Contemporary PoC Literature……………………………………..…….32
2.1.5. Part 1 Summary & Remarks………………………………………..……35
2.2. Part 2: Evolution of Conflict Displacement Trauma Research & Practice ………...36
2.2.1. Trauma Research………………………………………………..………36
2.2.2. Refugee Trauma & MHPS Practice & Treatment………………..………39
2.2.3. Refugee MHPSS & Policy…………………………………………….…43
2.2.4. MHPSS Intersection with Legal Systems & Protection…………….……44
2.2.5. Converging Refugee MHPSS Practice & Research …………………...…50
2.2.6. Part 2 Summary & Remarks…………………………………………..…52
2.3. Dissertation Research Positioning…………………………………………...….…54
2.4. Closing Reflexive Remarks……………………………………………………..…55
Chapter 3: Research Design & Methodology……………………………………...57
3.0. Overview………………………………………………………………………….57
3.1. Theoretical Framework……………………………………………………...……60
3.1.1. Ecological Systems Framework ………………...………………………60
3.1.2. Critical Paradigm…………………………………………………...……64
3.1.3. Social Justice Perspective……………………………………..…………65
3.2. Concatenated Exploration Process……………………………………………..…66
3.2.1. Narrative Inquiry………………………………………………………..………68
3.3. Phase 1: Mezzosystem MHPSS Exploration ……………………………………...69
3.3.1. Background …………………………………………………………….69
3.3.2. Methods………………………………………………………….……...71
3.4. Phase 2: Microsystems MHPS Exploration……………………………….……….71
3.4.1. Study 2: Refugee Health Screening, Services & Strengths Inquiry…….…71
3.4.2. Study 3: In-Depth Multiple Case Study Inquiry………………….………73
3.5. Phase 3: Macrosystems MHPS Exploration…………………………………….…75
3.5.1. Background…………………………………………………………..…75
3.5.2. Methods…………………………………………………….………...…76
3.6. Thematic Analysis……………………………………………………………....…76
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3.7. Trustworthiness …………………………………………………………………..79
3.7.1. Concatenated Exploration & Data Triangulation Outcomes…………….79
3.7.2. Narrative Meaning & Member Checking Validation…………………..…79
3.7.3. Researcher Involvement……………………………………………....…80
3.8. Ethical Considerations……………………………………………………….……80
3.8.1. Privacy & Confidentiality ………………………………………….……81
3.8.2. Psychosocial Growth Promotion……………………………………..…81
3.8.3. Participant Benefits ………………………………………………….….82
3.8.4. Information Sharing ……………………………………………………82
3.9. Closing Reflexive Remarks……………………………………………..…………83
Chapter 4: PoC MHPS Landscape Exploration Findings………………………...85
4.0. Overview……………………………………………………………………….…85
4.1. Part 1: MHPSS Capacity Building Inquiry …………………………………..…….85
4.1.1. Staff Service Provision & Lived Experiences……………………………87
4.1.2. PoC Trauma Factors……………………………………………………88
4.1.3. Trauma Impact on Staff………………………………………………....89
4.1.4. Volunteer Counselor Service Provision Experiences………………….....90
4.1.5. Knowledge & Skills Building Needs…………………………………..…92
4.2. Part 2: MHPSS Capacity Building Intervention………………………………....…93
4.2.1. Strengthening Partnerships…………………………………………...…94
4.2.2. Volunteer Counselor Targeted Outreach………………………….….…95
4.2.3. Peer Consultation Group …………………………………………….…95
4.2.4. Family Case Consultations …………………………………………...…95
4.2.5. Strengthened Systems & Process……………………………….….…….95
4.3. Study 1 Closing Reflexive Remarks………………………………………………..96
4.3.1. Critical Paradigm Elements…………………………………………..….96
4.3.2. Ecological System Elements…………………………………………….96
4.3.3. Social Justice Elements………………………………………………….97
4.4. Part 1: Refugee Health Screening…………………………………………………97
4.4.1. RHS-15 Results…………………………………………………………98
4.4.2. Researcher Observation & Feedback……………………………………99
4.5. Part 2: Refugee Participant Inquiry …………………………………...…………101
4.5.1. Displacement Challenges ……………………………………………...101
4.5.2. Strengths & Coping in Hong Kong ………………………………...…103
4.6. Study 2 Closing Reflexive Remarks ………………………………………….…105
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4.6.1. Critical Paradigm Elements…………………………………………….105
4.6.2. Ecological Systems Elements ………………………………………….106
4.6.3. Social Justice Elements………………………………………………...106
Chapter 5: In-depth Multiple Case Study Findings………………………………107
5.0. Overview…………………………………………………………………….…..107
5.1. Mr. V Introduction………………………………………………………………110
5.2. Pre-Migration Trauma ……………………………………………………..……112
5.2.1. Extreme Violence & Persecution………………………………………112
5.2.2. Forced Displacement………………………………………………..…114
5.3. Mrs. R Introduction……………………………………………………………...117
5.4. Post-Migration Challenges…………………………………………………….…118
5.4.1. Acculturation Stress……………………………………………………118
5.4.2. Protection Claims Process……………………………………………...119
5.4.3. Enforced Dependency…………………………………………………120
5.4.4. Joblessness……………………………………………………………..122
5.4.5. Traumatic Uncertainty…………………………………………….....…123
5.5. Mr. M Introduction…………………………………………………………....…126
5.6. Coping & Strengths………………………………………………………...……127
5.6.1. Intrinsic & Calming……………………………………………………127
5.6.2. Expressive & Creative……………………………………………….…129
5.6.3. Physical & Active………………………………………………………129
5.6.4. Spirituality……………………………………………………………...131
5.6.5. Social Support…………………………………………………….……131
5.6.6. Solution & Change Based…………………………………...……….…132
5.7. Mr. P Introduction………………………………………………………………134
5.8. Holistic Health Impact, Service & Care………………………………………….135
5.8.1. Service Provision Experience………………………………………..…135
5.8.2. Holistic Health Sequelae……………………………………………….136
5.8.3. Kaida: A Therapeutic Case Example………………………………..….138
5.9. Study 3 Summary………………………………………………………………..143
5.9.1. Critical Paradigm Elements……………………………………………143
5.9.2. Ecological System Elements………………………………………...…144
5.9.3. Closing Reflexive Remarks………………………………………….…144
Chapter 6: Service Provider Participant Findings………………………………..149
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6.0. Overview……………………………………………………………………...…149
6.1. Pre-Migration Conditions……………………………………………..…………149
6.1.1. Situational Conditions………………………………………….………149
6.1.2. Physical Health Conditions……………………………………….……150
6.1.3. Mental Health & Psychosocial (MHPS) Conditions……………………151
6.2. Post-Migration Challenges & Strengths……………………………………….…152
6.2.1. Acculturation Stress……………………………………………………153
6.2.2. Public Sentiment……………………………………………………….153
6.2.3. Enforced Dependency…………………………………………………154
6.2.4. Lack of Work or Volunteerism ………………………………………..155
6.2.5. Social Support ………………………………………………………....156
6.2.6. Faith-based Support……………………………………………...…….157
6.3. Protection Screening Concerns……………………………………………….….159
6.3.1. Rejection Culture………………………………………………………160
6.3.2. Health & Mental Health Evaluations………………………………..….161
6.3.3. Other Inadequate Standards ………………………………………..….163
6.3.4. Retraumatization ……………………………………………………....165
6.3.5. Uncertainty & Waiting Time …………………………………..………167
6.4. Holistic Health Impact & Services……………………………………………….169
6.4.1. Physical, Mental & Behavioral Health Sequelae………………………...169
6.4.2. Healthcare Service Barriers ……………………………………………171
6.4.3. MHPSS Service Barriers………………………………………………..174
6.4.4. Critical Pro Bono Services…………………………………………...…176
6.5. Enhancing MHPSS & Capacity………………………………………………..…177
6.5.1. Improve Quality of Protection Claims System ……………...…….……178
6.5.2. Incorporate Medical & Psychological Evaluations…………………...…179
6.5.3. Prevent Retraumatization ……………………………………………...182
6.5.4. Build Mental Health-Psychosocial Support Capacity………………...…184
6.6. Study 4 Summary ……………………………………………………………..…186
6.6.1. Critical Paradigm Elements…………………………………………….186
6.6.2. Ecological Systems Framework Elements…………………………...…186
6.6.3. Social Justice Elements……………………………………………....…187
Chapter 7: Analysis & Discussion…………………………………………………188
7.0. Overview…………………………………………………………...……………188
7.1. Theoretical Implications…………………………………………………………189
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7.1.1. Ecological System Boundaries & Permeability ……………...………….189
7.2. Building Inductive Theory for Practice…………………………….……….……194
7.2.1. The Essential Role of Empathy…………………………...……………195
7.2.2. Systemic Empathic Failure……………………………………..………197
7.2.3. Empathic Growth Pathways for PoC MHPS Wellbeing……………..…198
7.3. Macrosystem Empathic Failures…………………………………………………202
7.3.1. Ineffective Protection Claims Policy…………………………….…...…202
7.3.2. Perilous Livelihood Policy……………………………………………...205
7.4. Macrosystem Empathic Attunement……………………………………..………207
7.5. Macrosystem Empathic Growth…………………………………………...…… 208
7.5.1. Protection Policy Empathic Growth Opportunities………………..…..208
7.5.2. Livelihood & Health Policy Empathic Growth Opportunities..………...212
7.6. Mezzosystems Empathic Failure……………………………………………....…214
7.6.1. Broken Health & MHPS Care……………………………………….…215
7.6.2. Inadequate Welfare Provision & Services………………………………220
7.7. Mezzosystems Empathic Attunement……………………………………....……221
7.8. Mezzosystem Empathic Growth………………………………………….…..… 222
7.8.1. Health & MHPS Services Empathic Growth Opportunities………...…223
7.8.2. Social Welfare Services Empathic Growth Opportunities……………...226
7.9. Microsystem Coping & Strengths………………………………………….…… 227
7.9.1. Faith………………………………………………………...…………229
7.9.2. Gratitude………………………………………………………………229
Chapter 8: Conclusion……………………………………………………………..230
8.0. Overview……………………………………………………………………...…230
8.1. Significance & Limitations………………………………………….……………233
8.2. Theoretical Contributions………………………………………………..………234
8.2.1. Holistic MHPS Exploration……………………………………………235
8.2.2. Increased PoC Empirical Research……………………………….……235
8.2.3. Theory for Practice & Social Justice……………………………………236
8.3. Social Work Research & Practice Implications……………………………..…….236
8.3.1. Multi-Modal Therapeutic Approach……………………………..….… 237
8.3.2. Establish Trust & Safety………………………………………………238
8.3.3. Strengths Based Approach…………………………………………..…238
8.3.4. Therapeutic Partnership……………………………………………..…239
8.3.5. Advocacy Lens………………………………………………………....240
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8.3.6. Vicarious Trauma……………………………………………………....241
8.4. Current Context & Next Steps………………………………………..…………242
8.5. Final Thoughts………………………………………………………..…………242
References…………………………………………………………………………..245
Appendices…………………………………………………………………………260
Appendix A: Ethical Approval Letters……………………………………………….260
Appendix B: Partnership Letter……………………………………………………....262
Appendix C: Study 1: Workshop Evaluation Consolidated Summary………………...264
List of Figures!
Figure 1: Timeline of Key Hong Kong PoC Events………………………...…………26
Figure 2: IASC Intervention Pyramid Components…………………………...……….40
Figure 3: Conceptual Research Design Map……………………………………...……59
Figure 4: Theoretical Framework Key Components ……………….……………….…60
Figure 5: Ecological Systems Framework………………………………………..…….64
Figure 6: Concatenated Exploration Summary……………………………………...…67
Figure 7: SP Lingual Diversity ……………………………………………………..…86
Figure 8: MHPSS Capacity Building Intervention………………………………..….…93
Figure 9: Case Studies Thematic Map………………………………………...………109
Figure 10: Expressions of Gratitude…………………………………………...…..…128
Figure 11: Faith as Coping………………………………………………...……….…131
Figure 12: Combined Mental Illness Symptomology……………………………….....137
Figure 13: Interconnected Holistic Health Sequelae…………………………… .…140
Figure 14: Service Provider Thematic Map…………………………………………...148
Figure 15: Inability to Work or Volunteer Impact……………………..……………...156
Figure 16: Lack of Professional Capacity…………………………………………..…162
Figure 17: Refugee Resettlement Factors…………………………………………..…168
Figure 18: Post-Migration Mental Decline……………………………………………170
Figure 19: Psycho-Socio-Cultural Counseling Barriers……………………………..…174
Figure 20: Critical Pro Bono Services……………………………………………...…176
Figure 21: Systematizing Evaluation Services…………………………………...…….181
Figure 22: Value of Skills Building………………………………………………...… 185
Figure 23: Ecological System Boundaries……………………………….……………190
Figure 24: Systemic Empathic Growth Process………………………..……………..199
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Figure 25: Empathic Growth Pathways to MHPS Wellbeing……………………...….201
Figure 26: Macrosystem Empathic Failures…………………………………………..202
Figure 27: Macrosystem Empathic Growth Pathways…………………….………….208
Figure 28: Protection Knowledge Building Topics……………………………..…….210
Figure 29: Hong Kong MHPSS Task Force………………………………………….214
Figure 30: Mezzosystem Empathic Failures……………………………….…………215
Figure 31: Interconnected PoC Health Sequelae…………………………...…………218
Figure 32: Mezzosystem Empathic Growth Pathways……………………..…………222
Figure 33: MHPSS Intervention Pyramid in Hong Kong ……………………………228
Figure 34: Coping Mechanisms in the Ecological System……………………………226
Figure 35: Micro-Macrosystems Holistic Health Interconnection……………………232
Figure 36: Multi-Modal Therapeutic Approach………………………………………238
List of Tables
Table 1: Bio-Psycho-Social-Spiritual Wellbeing Components………………….………42
Table 2: Interdisciplinary Torture Treatment, MLR & Health Services Notable Models.49
Table 3: Case Study Contact Summary…………………………………….…………..75
Table 4: Thematic Analysis Application…………………………………………….…78
Table 5: PoC Service Provision Highlights (Staff) ……………………………….……88
Table 6: PoC Emotional States & Trauma Examples……………….…………………89
Table 7: PoC Trauma Impact on Staff………………………………….………..……90
Table 8: PoC Service Provision Attributes (Counselor) ………….……………………91
Table 9: Impact of Traumatic Uncertainty…………………………….……...………102
Table 10: Impact of Social Support…………………………….…………….………104
Table 11: Spiritual Strengths………………………………………………………… 105
Table 12: Pre-Migration Trauma……………………………………………...………112
Table 13: Post-Migration Challenges…………………………………………………118
Table 14: Coping & Strengths………………………………………………..………127
Table 15: Holistic Health Impact, Service & Care……………………………………135
Table 15: Pre-Migration Conditions……………………………………….…………149
Table 16: Post-Migration Challenges & Strengths……………….……………………152
Table 17: Protection Screening Concerns…………………………….………………159
Table 18: Holistic Health Impact & Services…………………………………………169
Table 19: Enhancing MHPSS & Capacity…………………………….………………177
Table 20: Ecological Systems Delineations…………………………...………………190
Table 21: Empathic Growth Practical Steps………………………………………… 200
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Key Abbreviations & Acronyms
CS: Case Study or Case Study(s)
CSP: Case Study Participants
CIDTP: Cruel, Inhuman or Degrading Treatment or Punishment
HKID: Hong Kong Immigration Department
HKSAR: Hong Kong Special Administrative Region
IASC Inter-agency Standing Committee
INGO: International Nongovernmental Organization
IRCT: International Rehabilitation Council for Torture Victims
MHPS: Mental Health and Psychosocial
MHPSS: Mental Health and Psychosocial Support
NGO: Nongovernmental Organization
POC: Persons of Concern
PRC: People’s Republic of China
SGBV: Sexual and Gender Based Violence
UNCAT: United Nations Convention against Torture and Other Cruel, Inhuman
or Degrading Treatment or Punishment
UNHCR: United Nations High Commissioner for Refugees
UNHCR-HK United Nations High Commissioner for Refugees Hong Kong Branch
USM: Unified Screening Mechanism
WHO: World Health Organization
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Chapter 1: Introduction
1.0. Overview
The world is currently experiencing an unprecedented crisis of conflict-induced
displacement. Conflict-induced displacement occurs when people are forced to flee their
homes due to armed conflict for any of the following reasons: civil war; generalized
violence; and persecution on the grounds of nationality, race, religion, political opinion
or social group; and where the state authorities are unable or unwilling to protect them
(FMO, 2012). Around 59 million people are currently displaced worldwide for these
reasons (UNHCR, 2015b).
Heartbreaking stories about people fleeing their countries due to war and conflict
have become all too commonplace in the media, such as people risking death on unsafe
boats journeys. In 2015, more than 300,000 refugees and migrants used the
Mediterranean sea route and around 2,500 are estimated to have died or gone missing
trying to reach Europe; many are from Syria, Iraq and Afghanistan, places affected by
violence and conflict (Fleming, 2015). This exemplifies the extent of the current crisis
and the degree of desperation of people attempting to escape conflict, persecution and
human rights violations to reach safety.
Consequently, the impact of conflict-induced displacement can be significantly
traumatic for individuals, families, groups and communities and can affect holistic health.
“Trauma results from an event, series of events, or set of circumstances that is
experienced by an individual as physically or emotionally harmful or threatening and that
has lasting adverse effects on the individual’s functioning and physical, social, emotional,
or spiritual well-being” (SAMHSA, 2012, p. 2 as cited in SAMHSA, 2014, p. 7). Without
addressing the trauma resulting from conflict (hereafter conflict displacement trauma) and its
intersection with mental, psychosocial and holistic health and wellbeing, we are in danger
of (or already are) embarking on a severe global health crisis.
As conflict continues to run rampant, so are the numbers of people seeking
safety all over the world. Hong Kong, a Special Administrative Region (Hong Kong) of the
People’s Republic of China (PRC), is not immune to this global crisis. Hong Kong has,
and continues to be a refuge for people seeking protection. Hong Kong serves as a
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temporary place for conflict-induced displaced persons who largely fall into the
categories of: refugees, asylum seekers, and claimants of torture and cruel, inhuman, or
degrading treatment or punishment (hereafter persons of concern (PoC)). PoC can seek
safety and protection by filing a non-refoulement claim under the Unified Screening
Mechanism (USM) administered by the Hong Kong Immigration Department (HKID)
(HKID, 2014).
As of February 2015, there were 9,533 outstanding non-refoulement claims, with
the majority of claimants coming from Bangladesh, India, Pakistan, Vietnam, Indonesia,
as well as people from Nepal, The Philippines, Sri Lanka, Nigeria, and other places not
specified (HKID, 2015a). As PoC wait for their non-refoulement claim to be processed
and/or resolved, they often face a myriad of barriers and their resilience is tested daily.
How these experiences as well as experiences from their overall displacement journey
impact their mental health and psychosocial (MHPS) wellbeing is a severely under-researched
area in Hong Kong.
This Social Work Doctoral Dissertation Research (Dissertation) critically
explores the factors that impact MHPS wellbeing of PoC in Hong Kong. Using an
ecological system framework, this research aims to bring forth a deeper understanding of
the connection of PoC within the many levels of their environment. Critical inquiries
bring forth a deeper understanding from the voices and lived experiences of PoC and
service providers. It explores how larger environmental structures interact and potentially
dominate this community; for example how macro level policies can impact micro level
wellbeing. This research also embodies a social justice mission and provides remedies for
increasing PoC MHPS wellbeing as well as contributions to theory and practice.
Chapter 1 presents the overview and background to the research topic. It
includes 1) relevant definitions and terminology, 2) the shocking global statistics, 3) the
role of trauma and impact on MHPS wellbeing, 4) the concerning Hong Kong PoC
situational context and 5) the problem statement. It further presents the research design
and methodology overview including 1) rationale, 2) objectives and questions and 3)
approaches. It concludes with the information about chapter organization and highlights
the important role of social work within this rapidly evolving area of practice.
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1.1. General Background
The Office of the United Nations High Commissioner for Refugees (UNHCR) is the
primary global refugee protection agency. Started in 1950, the purpose of the agency is to
lead and coordinate actions in safeguarding refugee rights and to resolve global refugee
issues (UNHCR, 2015a). The 1951 Convention on Refugees and/or its 1967 Protocol (hereafter
Refugee Convention & Protocol) is the primary globally recognized international refugee
protection instrument. As signatories, States are committed to abide by the international
statute set forth within the convention and usually have systems to evaluate claims for
asylum, also known as refugee status determination (RSD) for international protection from
non-refoulement. Amnesty International (2005) explains about non-refoulement:
The non-refoulement principle not only prohibits states from sending
people back to a country where they may face serious human rights
violations, but also prohibits indirect or chain refoulement, which occurs
when one country forcibly sends refugees to another country that
subsequently sends them to a third country where they risk serious harm.
(p. 12)
1.1.1. Definitions of Migratory Groups
The term refugee applies to someone who has a:
…well-founded fear of being persecuted for reasons of race, religion,
nationality, membership of a particular social group or political opinion,
is outside the country of his nationality and is unable or, owing to such
fear, is unwilling to avail himself of the protection of that country; or
who, not having a nationality and being outside the country of his former
habitual residence as a result of such events, is unable or, owing to such
fear, is unwilling to return to it. (UNHCR, 1951 & 1967, p. 16)
The terms “asylum seeker” and “refugee” are sometimes interchangeable,
particularly by persons seeking protection or the general pubic. However, an asylum seeker
is someone who may refer to himself or herself as a refugee, but whose claim has not
been substantiated (UNHCR, 2001). UNHCR notes that in cases of mass movements
such as in instances of armed conflict or generalized violence (as opposed to individual
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persecution), the capacity for individual RSD is unavailable and not needed since it is
obvious why mass movements of people are crossing borders; these groups are declared
prima facie refugees (UNHCR, 2001)
Other groups such as Internally Displaced Persons (IDPs) (displaced within their
own country’s borders) and Stateless people (no nationality of any country) are also
communities of concern to UNHCR (UNHCR, 2001). Furthermore, within the
complexity of international migration and forced displacement (also referred to as forced
migration), the misunderstanding of terms and categories for migratory persons can
occur. It is important to note that a “migrant” and “refugee” are different categories or
groups. Furthermore, there are various categorical distinctions of the term “migrant” as
noted by Amnesty International, AI (2015a):
A migrant is a person who moves from one country to another to live and
usually to work, either temporarily or permanently, or to be reunited with
family members. Regular migrants are foreign nationals who, under
domestic law, are entitled to stay in the country. Irregular migrants are
foreign nationals whose migration status does not comply with the
requirements of domestic immigration legislation and rules. They are also
called “undocumented migrants”. The term ‘irregular’ refers only to a person’s
entry or stay. (p. 4)
Migrants choose to move usually for economic, educational or familial reasons
and can choose to return home and continue to receive their government’s protection-
unlike a refugee, who needs certain legal protections and are unable to return home and
receive their government’s protection (Edwards, 2015). Word choice matters, since
blurring of the two terms can undermine legal protection and public support for refugees
and could have serious consequences to their safety (Edwards, 2015).
Furthermore, many refugees and persons seeking protection have additionally
also survived torture and/or cruel, inhuman, or degrading treatment or punishment
(CIDTP). Some may only identify as a torture or CIDTP survivor. Article 1 of the
Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment (UNCAT) defines torture as:
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…any act by which severe pain or suffering, whether physical or mental,
is intentionally inflicted on a person for such purposes as obtaining from
him or a third person information or a confession, punishing him for an
act he or a third person has committed or is suspected of having
committed, or intimidating or coercing him or a third person, or for any
reason based on discrimination of any kind, when such pain or suffering
is inflicted by or at the instigation of or with the consent or acquiescence
of a public official or other person acting in an official
capacity…(UNCAT, 1984, p. 1)
1.1.2. Global Statistics
Current global statistics around conflict-induced displacement are staggering with
levels not seen since World War II (Faiola, 2015, April 15). Because of conflict, human
rights violations, violence, and persecution, 59.5 million people are currently forcibly
displaced globally with 8.3 million people displaced in 2014 alone- the highest annual
increase on record (UNHCR, 2015b). Of that, the majority, 38.2 million, were IDP’s.
14.4 million refugees were under UNHCR’s mandate, and the United Nations Relief and
Works Agency (UNRWA) registered 5.1 million Palestinian refugees. 1.8 million people
were seeking asylum to gain refugee status (UNHCR, 2015b).
“For the first time, Turkey became the largest refugee-hosting country worldwide,
with 1.59 million refugees. Turkey was followed by Pakistan (1.51 million), Lebanon
(1.15 million)” (UNHCR, 2015b, p. 2). The top refugee-origin countries were Syria (3.88
million), followed by Afghanistan (2.59 million) and then Somalia (1.11 million)
(UNHCR, 2015b). There are also long running refugee-origin countries in Africa, where
people are fleeing conflict and persecution. This includes South Sudan, the Central
African Republic (CAR), Nigeria, Burundi, Somalia, Ethiopia, Sudan and the Democratic
Republic of Congo (DRC) (AI, 2015b). “There are an estimated three million refugees in
sub-Saharan Africa. Kenya is home to Dadaab-the world’s largest refugee camp, set up in
1991” (AI, 2015b, p. 5).
Surprisingly, the UNHCR budget is only around $7 billion (Tufekci, 2015,
August 13). This is well under-resourced considering their mandated responsibility and
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the scope of current global conflict-induced displacement. For example, currently we are
witnessing the continuous mass exodus of Syrians fleeing from armed conflict, which
began in 2011. More than half of Syria’s population is displaced and around four million
people have fled Syria, the majority of which have sought safety in neighboring countries
like Jordan and Lebanon (AI, 2015b). Two million are in Turkey and one million are in
Lebanon (Tufekci, 2015, August 13).
“The UN’s humanitarian appeal for Syrian refugees was only 23% funded as of
the 3 June 2015” (AI, 2015b, p. 5). The neighboring countries are now overwhelmed
with refugees due to the lack of international resettlement shouldering, humanitarian
assistance and funding (AI, 2015a). Subsequently, tighter refugee level controls by
neighboring countries and the fueling of Syria’s continuous armed conflict has led to a
surge of Syrian refugees fleeing to Europe.
1.1.3. Trend of Deterrence & Responsibility Abandonment
The Syrian refugee crisis illustrates how the political will of the international
community plays a large role in refugee movements. If European countries had originally
sought serious solutions to the Syrian conflict, and had committed appropriate
humanitarian resources and assistance to the countries who had originally shouldered the
refugee crisis, Europe would currently not be facing an inpouring of refugees (Barnard,
2015). Furthermore, there has been increased criticism of the Arab countries and their
shocking lack of engagement in the crisis considering the resources at their disposal and
the relatively close proximity of the crisis to them (Tharoor, 2015, September 4). Qatar,
United Arab Emirates, Saudi Arabia, Kuwait, Oman and Bahrain, have offered zero
places for Syrian refugee resettlement (Amnesty International as cited in Tharoor, 2015,
September 4).
The current trends of governments to relinquish their responsibilities by not
acting to help or instating deterrence policies, has significantly compounded the situation
for persons fleeing conflict, persecution and human rights violations. “The global refugee
crisis may be fuelled by conflict and persecution but it is compounded by the neglect of
the international community in the face of this human suffering” (AI, 2015b, p. 6). This
has increased preventable deaths and fueled holistic health deterioration, self-harm and
suicide. An example of this was with the Rohingya people in the May 2015 when
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Thailand, Malaysia and Indonesia pushed overcrowded and unsafe fishing boats filled
with Myanmar and Bangladeshi refugees and migrants back to sea (AI, 2015b). For one
week they suffered at sea without food, water and medical care; finally the Philippines
offered to take them in, followed by the Indonesia and Malaysia (AI, 2015b).
Deterrence polices aim to “push back” people seeking protection either literally,
such as by intercepting boats and turning them away or through other polices that
tighten up the ability to seek protection in their country. “World leaders have abdicated
their responsibility for this unlucky population, around half of whom are children”
(Tufekci, 2015, August 13). Australia’s current policies such as offshore processing on
Nauru and subsequent Cambodia deal, serve as prime examples of deterrence and
responsibility abandonment.
In Nauru, where asylum seekers were largely kept in detention facilities, there
were reports of sexual exploitation of children, abuse, unmet human rights, medical
negligence, and animal-like treatment (Lloyd, 2015, June 29). Harsher deterrence
measures in Australia are failing and does not resolve the underlying issues; instead safe
protection pathways and processes are needed (Webb, 2014). Australia currently hosts
0.3% of the world’s refugees; they can and should take more (Webb, 2014).
This disastrous reality of the global refugee crisis exemplifies how millions of
people are unable to be protected by their own State governments, need to flee from
their homes due to violence, desperately seek refuge and safety elsewhere and also face
deterrence from other countries. It truly is often incomprehensible how horrific this
human created disaster is and the degree to which it has elevated to. Unfortunately, there
seems to be no end in sight of armed conflict or the displacement of people as the result.
Consequently, the people affected by violence and conflict is exponentially growing. “It
is estimated that more than one billion people have been affected by extreme violence,
embodied in the experience of war, ethnic conflict, torture and terrorism” (HPRT, 2011,
p. 19).
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1.2. Conflict-Induced Displacement & Trauma
The journey of conflict-induced displacement has generally been distinguished
into various migration phases. Trauma can be prevalent throughout the overall
displacement experience. The challenges within each phase can also overlap into
subsequent phases, resulting in traumatic and /or cumulative traumatic experiences.
“Studies have shown that refugees and individuals affected by war and gross human
rights violations experience a wide range and high number of traumatic events, with
studies reporting a mean of between 7 and 15 traumatic events experienced per person”
(Marshall et al., 2005; Mollica, et al., 1998; Mollica et al., 1999 as cited in Carswell,
Blackburn, & Barker, 2011, p. 107).
Trauma can include single or multiple events, and continuous or long lasting
events; it can be subtle, deceptive or destructive and impacts people differently
(SAMHSA, 2014). “How an event affects an individual depends on many factors,
including characteristics of the individual, the type and characteristics of the event(s),
developmental processes, the meaning of the trauma, and sociocultural factors”
(SAMHSA, 2014, p. 59). Traumatization considers the entire range of physical and
emotional reactions and processes occurring during and long after the traumatic
experience (Bloemen, 2005 as cited in Bloemen, 2006).
The trauma and trauma reactions from conflict-induced displacement are often
referred to as “refugee trauma”. However, for the purposes of this Dissertation, will be
referred to as conflict displacement trauma. This is in part because the term “refugee” can be
convoluted, politically charged, and may not officially encompass all categories of
conflict-induced displaced persons. The next section describes the intersection of trauma
within the phases of conflict-induced displacement and the potential consequences to
health and mental health wellbeing.
1.2.1. Conflict-Induced Displacement Phases
The Pre-Migration (or pre-flight) phase occurs before a person is forced to
migrate. It can last a day or generations and can be filled with an isolated event or series
of events involving persecution, human rights violations and violence (LCSN, 2015).
“War victims endure multiple traumas: physical privation, injury, torture, incarceration,
witnessing torture or massacres, and the death of close family members” (Summerfield,
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1991, p. 161). It is a difficult decision as people leave everything they know for an
uncertain future; and can experience loss around employment, land and possessions, and
family and friends (LCSN, 2015).
The Flight phase is the period when someone leaves home to find safety; they can
flee in different ways, such as by foot, plane, car, or boat; for many, safety is not assured
until after crossing international borders (LCSN, 2015). This phase can last days or years,
and people are often separated from family, robbed, and endure harsh conditions
(RHTAC, 2015). To severely compound matters, during this vulnerable period, people
are at high risk for human trafficking, as demonstrated in the case of the Rohingya
people fleeing from Myanmar (Smith, 2015, July 20). They can also be duped or
abandoned by smugglers and left to die, such as the case of Syrian refugees found dead
in the back of an abandoned truck in Austria (Jones, 2015, August 27).
The Displacement (or post-migration) phase is where persons experience
displacement into camps or other areas including urban cities like Hong Kong. Here, the
duration, experiences and conditions of the displacement setting can all impact
individuals and families (LCSN, 2015). They can face illegal work exploitation, barriers to
healthcare and education, and the fear of deportation or prison (LCSN, 2015). This
phase can last indefinitely. (In this Dissertation the terms displacement and post-migration are
used interchangeably.) In the Resettlement phase, a person may voluntarily be repatriated
back to their country of origin, gain refugee status and resettlement in a third country, or
stay in the camp (displacement) setting (Lloyd, 2015, June 29).
Resettlement in a third country can incur a new set of stressors such as limited
livelihood options and social support networks, barriers to health and social welfare
services, and acculturation issues such as learning about a new systems, culture and
language (LCSN, 2015). Throughout the displacement phases, traumatic experiences
related to human rights violations, persecution, harrowing flight journeys, multiple losses,
and discrimination and acculturation in new settings can occur. “In examining the risk
factors for mental health problems, it is clear that trauma occurs at all stages of the
refugee situation” (HPRT, 2001, p. 6). Subsequently, conflict displacement trauma can
result in various degrees of traumatization and subsequent impacts on holistic health.
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1.2.2. Trauma & Holistic Health Impact
Trauma can impact all aspects of health and wellbeing leading to deterioration of
physical, mental and behavioral health. The massive psychological and physiological
impact of conflict displacement trauma can vary widely and can include: loss, grief,
worry, sadness, betrayal, dissociation, nightmares, irregular sleep patterns, sense of
foreshortened future, intrusive thoughts, anger, numbness or disconnection to others,
diminished memory and/or focus, hyperarousal, mistrust, hopelessness, weakness,
fatigue, suspicion, shame, guilt, chest tightness, headaches, and chronic pain (LCSN,
2015).
Also, enduring betrayal by their own people, government, other forces and their
political circumstances, can have significant health and trust implications (RHTAC,
2015). In the displacement and resettlement phases, the loss of agency, role, self-efficacy,
and energy as well as feelings of helplessness and worthlessness could also be
experienced. “A meta-analysis of 181 research surveys from 1980 to 2009 of 81,866
refugees and other survivors of extreme violence in 40 countries, for example, reveal an
overall mental health impact of 30.6% and 30.8% for PTSD and depression,
respectively” (UNHCR, 2008 as cited in HPRT, 2011, p. 19).
Many persons displaced by conflict are also survivors of torture. Globally, it is
estimated that there could be up to one hundred million survivors of torture (Chelidze et
al., 2015). Common psychiatric diagnoses found in torture survivors include depression,
post-traumatic stress disorder (PTSD), and comorbidity rates ranging between 14-74
percent (Kinzie, Jaranson and Kroupin, 2007 as cited in Einhorn and Berthold, 2015).
High suicide rates have been found in both torture survivors and refugees, particularly
those having PTSD (Einhorn & Berthold, 2015).
While mental disorders alone have significant impact, when interacting with
physical health, the accumulation of both conditions overtime can cause major disability
and reduction in quality of life (Dudley, Silove, & Gale, 2012). Untreated mental health
problems may advance into significant health issues such as diabetes, cardiovascular
disease, hypertension and cancer (HPRT, 2011). Furthermore, trauma and torture can
have a significant impact on someone’s spirit. Inflicting torture can result in physical
pain, social degradation, humiliation and the distress of soul around meaning, purpose,
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nature of reality, good and evil, and God and man (Tuskan, 2009). If not appropriately
addressed, the result of conflict displacement trauma can mean the deterioration of body,
mind and sprit.
1.3. Mental Health & Psychosocial Wellbeing
Good or positive mental health is an intrinsic part of a person’s wellbeing, overall
heath and all aspects of life. When viewed holistically, mental health is not a separate
dimension but an important facet to a person’s overall health; thus health is not complete
without mental health (WHO, 2014). Positive mental health and psychosocial wellbeing and
outcomes cannot exist without good behavioral, spiritual, and physical health. These
overall health components are interconnected, interdependent, inseparable, and dynamic.
1.3.1. Relevant Terms & Definitions
The World Health Organization (WHO) defines health as “a state of complete
physical, mental and social well-being and not merely the absence of disease or
infirmity”; they define mental health as “a state of well-being in which the individual
realizes his or her own abilities, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to his or her community”
(WHO, 2004, p. 1). The term psychosocial refers to the person in the environment,
focusing on how environmental factors influence individual level matters (UNHCR,
2013a). Mental health and psychosocial support (MHPSS) describes a range of services and
actions addressing social, psychological and psychiatric problems already existing or
resulting from emergencies and is carried out in a range of diverse settings by various
professionals and organizations (WHO-UNHCR, 2012).
1.3.2. Prioritizing MHPSS in Conflict-Induced Displacement
MHPSS services are often placed with a lesser priority or as an afterthought
within the complexity of displacement, as is the case in Hong Kong. In settings where
resources are limited, often the human and financial capacity for these services are rare,
limited, or simply do not meet the needs of the community in various ways. While
humanitarian and legal services should be prioritized, increasing MHPSS access and
mechanisms within overall systems can improve a person’s overall situation, increase
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resilience in difficult life circumstances and assist someone in successfully navigating the
complex journey.
An individual’s adverse and resilient reactions as well as coping abilities can
significantly vary and can increase MHPS risk or protection (UNHCR, 2013a). The kind,
size and cumulative nature of the traumatic experience as well as personal attributes such
as cultural, political and social contexts, past traumatization, coping styles, and genetic
fear predispositions are all influencing factors in deterioration caused by trauma
(Bloemen, Vloeberghs, & Smits, 2006).
Conflict-induced displacement can place significant psychosocial strain and stress
for individuals, families and communities, however, most people experience normative
trauma reactions that can be overcome (UNHCR, 2013b). The availability of a
supportive environment consisting of family and community increases the refugees’
abilities to cope with difficulties and to build resilience (UNHCR, 2013b). Furthermore,
when in place, trauma-informed protective systems can significantly prevent further
deterioration and retraumatization. Therefore, placing MHPSS as a priority within
services for conflict-induced displaced persons is an integral aspect to health and
wellbeing.
1.3.3. Mental Health & Human Rights
Protection of conflict-induced displaced persons is a human rights issue, and this is
inclusive of health and mental health. In addition to the clinical aspect, mental health “is
also related to social capital, human rights and economic development” (HPRT, 2011, p.
20). Human rights and mental health converge through research and practice and
intersect in various ways, and a key element of shared concern is the burden of mental
health sequelae related to war and conflict (Dudley et al., 2012). This rights-based approach
can ensure access and security for this community and establish an environment in which
basic civil, economic, social, political and cultural rights are respected. It can safeguard
overall health and increase resilience and coping, particularly in situations of uncertainty
and distress.
The instruments established through the United Nations (UN) act as guides in
designing, implementing and monitoring mental health polices, legislation and programs.
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For example, both the Universal Declaration of Human Rights (UN, 1948) and the
International Covenant on Economic, Social and Cultural Rights (ICESCR) (UN, 1966)
aim to ensure that rights to adequate food, housing and living standards as well as health
and wellbeing for all people are protected. Using a human right framework can be an
effective way to prioritize mental health services by developing mental health policies for
conflict-induced displaced persons. Mental health can be promoted and viewed as a
fundamental aspect of basic human rights.
1.4. Hong Kong Situational Context
Historically, Hong Kong has been a refuge for various communities of people,
including Mainland Chinese, Russian, Vietnamese, South Asian, African and more
recently, Middle Eastern and Latin American. PoC (refugees, asylum seekers, and
claimants of torture and cruel, inhuman, or degrading treatment or punishment) in Hong
Kong reside in a largely complex and uncertain state in what is a displacement or post-
migration environment, but a transitional space. Their resilience is heavily tested while
living within this uncertainty, which can be traumatic (hereafter traumatic uncertainty). They
face daily challenges impacted by pre- and post-migration conditions and stressors. Key
historical influences, policy barriers, legal advocacy and humanitarian services shape the
contemporary PoC discourse and heavily influence the situational context and systems in
which they reside.
1.4.1. Historical Deterrence Attitude & Policy
The Hong Kong government (HKSAR) policy towards PoC has been lukewarm
at best-despite having a long history as a refuge for persecuted persons. Historically, the
HKSAR has not hidden their unwelcoming attitude towards person seeking non-
refoulement protection. Not extending the Refugee Convention and Protocol in Hong
Kong is the primary and fundamental example of refugee deterrence. Also, there is a
significant fear of the “magnet affect” or “pull factors” of economic migrants to Hong
Kong. In part, the government's stance could be due to its experience in dealing with the
25 year saga of Vietnamese refugee influxes which amounted to more than HK $1.6
billion to process (Choi, 2014, May 21). While public perception is gradually evolving
through school and public outreach and media opinion pieces by local service providers
and advocates, the public’s attitude towards refugees seems largely unenthusiastic:
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Although asylum seekers and refugees have long been one of the
minority groups in Hong Kong, most of their grievances remain virtually
unheard. Very little people in Hong Kong know or are interested to know
where asylum seekers and refugees live, what they do to sustain their lives
in Hong Kong, or their original reasons of coming to Hong Kong. They
are often being neglected by the general public in Hong Kong. (Leung,
Ng, Wong, Yiu, & Yuen, 2013, p. 2)
A discussion of the legal backdrop, current rhetoric and social welfare provisions
illuminates how advocates have fought HKSAR deterrence attitudes and policy.
1.4.1.1. Legal Backdrop
Most PoC are facing slim chances of protection claim success since the overall
recognition rates for asylum and torture cases have been shockingly low with extensive
inefficiencies. From 1992 till February 2015, there have been less than 30 recognized
successful torture claims, setting an extremely low recognition rate of less than 1%
(JCHK, 2015). This has impacted the limbo-like state for PoC - they can be stranded in
Hong Kong for a few months to sometimes ten years or longer. Until recently, a dual
protection claims system existed in Hong Kong because the HKSAR has not signed the
Refugee Convention and Protocol but has signed onto the United Nations Convention
on Torture and CIDTP (UNCAT), (further elaborated in Chapter 2).
Legal and faith-based advocates, NGO’s and academics have long been
supporting the creation of a unified protection claims system administered by HKSAR.
This was realized in 2013 following key landmark rulings in the C and Umabaka cases in
the Hong Kong Court of Final Appeals (Daly, 2015). Beginning in 2014, all protection
claims related to persecution, torture and CIDTP are filed with the Hong Kong
Immigration Department (HKID) under the new Unified Screening Mechanism (USM)
and are considered non-refoulement claims. However, the HKID (2015b) recently stated:
The objective of USM is to decide whether an illegal immigrant may (and
should) be removed immediately, or whether removal action should be
temporarily withheld until his claimed risks cease to exist. The illegal
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immigrant status of non-refoulement claimants will not change because
of their non-refoulement claim, regardless of its result. (p. 2)
The emphasis on “screening out illegal immigrants” illustrates the prevalent
deterrence attitude and dangerous rhetoric towards PoC protection and screening. In
using the term “illegal immigrants” the Hong Kong government abandons responsibility
towards them, deliberately propagates public perception of suspicion, fuels negative
portrayal, intolerance and stereotyping, and suppresses the truth of their complex
displacement journey and need for protection (McLaughlin, 2015, June 19). Any
sentiment of Hong Kong being a haven for those fleeing persecution has been gone-
however there always remains a flicker of hope.
1.4.1.2. Social Welfare Provisions
In Hong Kong, “structural constrains, insufficient financial support, high cost of
rent, discrimination and the deprivation of rights force refugees to apply different
survival strategies” (Schum, 2011, p. 17). The HKSAR has been generally slow to address
PoC needs, however the Hong Kong Social Welfare Department (HKSWD) has
contracted the International Social Service (ISS-HK) to provide in-kind assistance services
since 2006. “It was only shortly before the judicial review hearing in February 2006 that
the system was created, and ISS was contracted only in April 2006 despite knowledge of
the problem long before then” (Daly, 2009, p. 29).
The humanitarian assistance budget was $203 million Hong Kong Dollar (HKD)
in 2013-2014. In 2014, the Hong Kong Security Bureau and HKSWD announced
enhancements to the welfare package (HKSWD, 2014). Per PoC, primary enhancements
included the following:
1. Rental deposits: $3,000 HKD or an amount equivalent to two months rent
2. Property agent fees: $750 HKD or an amount equivalent to half a month’s rent
3. Rent allowance: Adjusted from $1,200 to $1,500 HKD (around $200 USD).
4. Food budget: Adjusted from $1,060 to $1,200 HKD (around $40 USD). Food
can be collected three or six times in a month.
5. Utilities: Adjusted from around $260 to $300 HKD (HKSWD, 2014).
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The irony of these low provisions is that Hong Kong is one of the most
developed and lucrative economies in the world. PoC and advocates are critical of the
social welfare services, food and housing quality and assistance levels; several protests
have been enacted because of this (Choi, 2014, February 12). Through advocacy, social
welfare provisions were recently enhanced. A notable development was the introduction
of a government issued food voucher system for use at a local supermarket chain, which
has been a welcome breakthrough for PoC and advocates (Lee, 2015, June 21).
1.4.2. PoC Service Providers, Groups & Collectives
A small network of key PoC legal advocates, NGO’s, humanitarian and faith-
based service providers’ assist PoC with basic humanitarian services such as food and
shelter, as well as advocacy on legal, casework and MHPS needs. These services have
been integral to the care and the fight for rights of this severely marginalized group.
Traditionally, many available services were fragmented or compartmentalized to each
service provider. However, increased network collaborations and open dialogue have
been increasingly visible in recent years, such as the Refugee Concern Network (RCN)
and the monthly service provider meetings.
Faith-based groups have been integral to the support of PoC, incorporating faith
as a strength and resilience factor. A few mutual aid, community-initiated, and PoC-led
groups have also emerged. They are organized around ethnic, cultural, and group
similarity, arts inspired empowerment and protection and rights advocacy. While recent
on the scene, these groups exemplify a rights-based and empowerment model based on
PoC interests, skill development, rights and protection advocacy and meaningful use of
time. Without the majority of these organizations, the state of affairs for PoC individuals
and families would be far worse off.
1.4.3. Health & Mental Health Services
Until recently, there had been a glaring gap in health and MHPS services. Health
services are largely provided through the public hospital system of Hospital Authority
(HA). One clinic and some individual providers offer valuable pro bono services. Mental
health services are even more rare for PoC to access. Pro bono services around different
aspects of advocacy are increasing. While mental health and counseling services now
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exist through a PoC service provider (MHPSS-PoC), it is estimated that many who have
needed services in the past and present still do not have access.
Not all individuals may need ongoing or specialized mental health services,
however many may have experienced conflict-induced displacement and could use
support. A further barrier is that many local mental health providers and counselors do
not have the specialized training and experience to work with PoC. However, this is
beginning to change as service providers develop capacity and are increasingly partnering
and collaborating. If health and mental health are not prioritized within service provision
settings to promote individual, family and community support, PoC vulnerabilities will
be exacerbated as their human rights are placed on the back burner (Das, 2013).
1.5. Problem Statement
Discourse, services and advocacy for PoC in Hong Kong have largely focused on
a variety of concerns. However, there is a dearth of information regarding bio-psycho-
social-spiritual wellbeing in general or from the voices of PoC themselves. In the past
several years, NGO’s, legal advocates, civil society actors, academics and the media have
illuminated the need for improvement of social welfare provisions and protection claims
system transparency. However, there is little empirical evidence on how systemic and
structural conditions such as the protection claim process, current policies, and health,
social and welfare services impact PoC MHPS wellbeing. Moreover, little is known about
protective factors such as strength and coping strategies for gaining a deeper
understanding of factors promoting MHPS and holistic wellbeing.
1.6. Research Design Overview
As conflict-induced forced displacement continues to accelerate and become
more complex in scope, social workers have an integral responsibility to respond to this
global crisis. Social work research can be an instrument to illuminate the lived
experiences of violence and displacement and social justice advocacy can be a tool to
effect change. This next section summarizes this Dissertation’s research rationale,
objectives, and methodology.
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1.6.1. Rationale
The research rationale is based on 1) researcher social justice aspirations and
therapeutic commitments, 2) the significant gap in existing PoC MHPS knowledge and
empirical studies, and 3) alignment with the recommended MHPSS global research
priorities for displaced communities. My involvement as a volunteer counselor and
organizational consultant with the frontline MHPSS-PoC service provider enabled a
deeper understanding of the complexities of PoC situational context. I began volunteer
counseling with several PoC clients and rapidly built trust and engagement with them. As
I conducted psychotherapy and other holistic healing techniques with them, I
experienced how their MHPS needs were obviously connected to and exacerbated by
their pre- and post-migration trauma and stressors.
1.6.1.1. Researcher Social Justice & Therapeutic Commitments
I quickly discovered how PoC micro clinical and mental health needs were
closely intertwined with the mezzo systems and the macro level policies they found
themselves facing in Hong Kong. I found myself advocating for their various needs,
particularly their health and legal needs. My interest and passion in exploring factors of
PoC trauma and MHPS wellbeing deepened. This initiated deeper exploration through
the research platform. I wanted to bring to light their lived experiences. I had aspirations
to change oppressive conditions and improve the current situational context for PoC.
Furthermore, by being able to relate my own experiences as a therapist, a deeper level of
understanding and the interplay between structural factors on mental health and
wellbeing is enabled. In working with this community, I felt a deep commitment to
facilitate a process of healing and advocacy as both a counselor and researcher.
1.6.1.2. Significant Gap in MHPS Empirical Knowledge & Studies
Another aspect of the research rationale is that there is a significant gap in
empirical knowledge around Poc MHPS factors in Hong Kong. Much of the current
available academic literature (further elaborated in Chapter 2) encompasses 1) the
historical context of refugee and migration flow across the Mainland Chinese border
with Hong Kong, 2) the Vietnamese Boat People era, and 3) the contemporary legal and
policy contexts. These areas are extremely valuable for understanding PoC discourse in
Hong Kong. However, there is little empirical data around PoC trauma and MHPS
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wellbeing and the factors that impact it. Through this Dissertation research, I hope to
contribute towards the reduction in this gap and offer further insight into the area.
1.6.1.3. Alignment with Global MHPS Research Trends & Priorities
Finally, this research is aligned with current MHPSS global research priorities
(Tol, Barbui, et al., 2011), (Tol, Patel, et al., 2011), and a human rights and social justice
paradigm. A review of literature demonstrates how health and MHPS research with
refugees has evolved into 1) qualitative and narrative approaches exploring experiences
and strengths and 2) a holistic and inclusive exploration promoting social justice and
psychosocial growth elements, aims and goals. I strongly believe in these principles,
ethics and value of this approach, hence, this Dissertation research situates itself within
this paradigm.
1.7.1. Research Objectives
The following overarching objectives guide the Dissertation research and aims to:
1. Explore how environmental, structural forces and policies impact bio-psycho-
social-spiritual wellbeing of PoC
2. Explore PoC trauma and coping strategies
3. Identify solution-focused pathways to change and wellness
4. Contribute to theory, conflict-induced displacement and social work research and
practice
1.7.2. Overarching Research Questions
The following overarching research questions guide the Dissertation research:
Microsystem:
1. How does trauma manifest and impact PoC physical, mental and behavioral
health and wellbeing?
2. How do the factors of body, mind and spirit interconnect?
3. What challenges do they face in their lives in Hong Kong?
4. How do PoC cope and garner strength to face daily challenges in Hong Kong?
Mezzosystem:
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5. What are service providers experience with PoC trauma, coping and MHPS
factors?
6. What types of barriers do PoC face in the healthcare, legal and protection and
social welfare systems?
7. Are PoC retraumatized in Hong Kong?
8. How can PoC systems including MHPSS infrastructure be strengthened?
Macrosystem:
9. What are the historical underpinnings of current PoC policies?
10. How do current policies intersect with PoC MHPS wellbeing?
11. How has trauma and wellbeing manifested throughout PoC environment?
12. What are globally recommended MHPSS practices and approaches for PoC
wellbeing?
Overarching:
13. How do these various systems (PoC environment) interact and impact human
development (PoC wellbeing)?
14. How open are the sub-system boundaries?
15. What are ways to increase openness in the PoC ecological system?
1.7.3. Methodology Summary
This Dissertation is grounded in an ecological systems framework
(Bronfenbrenner, 1994) in which I explore how the micro, mezzo and macro “levels” or
“systems” connect and interact (Brough, Schweitzer, Shakespeare-Finch, Vromans, &
King, 2012), (Watters, 2001) to impact PoC MHPS wellbeing. Since human rights are
essential to the process, a critical (Fook, 2003) and social justice research paradigm was
enacted in the research design and process. Social justice research can enable a process
whereby research entails a platform for illuminating the lived experiences of often-
marginalized voices, as well as assist in promoting change. I wanted to deeply explore
PoC life, trauma and coping mechanisms while they lived in uncertainty in Hong Kong. I
also wanted to advocate (Silove et al., 2002) with PoC and other service providers to
enable a holistic framework of care for their various needs.
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Since little empirical research exists around this topic, this research is exploratory.
A process of concatenated exploration was used to link fieldwork exploration within the
research process with an inductive aim to generate new concepts and generalizations that
can consist of an array of explanations, facts, and beliefs leading to the emergent theory
grounded in the data (Stebbins, 2001). A researcher who is passionate and enthusiastic
about a topic usually conducts concatenated exploration alone, and the explorative
nature of the process begins in the chain but can be significant throughout (Stebbins,
2001).
Using exploratory narrative inquiry and thematic analysis, three phases of inquiry
were conducted with a total of ten PoC participants and twenty PoC service providers,
n=30. Data collection from a variety of key stakeholders aimed to ensure an inclusive
and reliable approach to research exploration (WHO-UNHCR, 2012). Thematic analysis
(Braun & Clarke, 2006) was used to code and analyze emerging themes and relate them
to the larger literature. Additionally, using ethical approaches applicable to refugee
research (Hugman, Pittaway, & Bartolomei, 2011) was imperative. Finally, my experience
working with PoC also informs the findings. Ethical approval for all phases was obtained
from the University of Hong Kong Ethics Board (Appendix A: University of Hong Kong
Ethics Approval Letters).
1.8. Chapters Organization
This Dissertation is comprised of eight chapters. Chapter 2 provides a review of
selective literature based upon key concepts related to the research topic. This includes 1)
historical highlights of the refugee context in Hong Kong, 2) the evolvement of trauma-
focused research and practice to a more holistic approach, and 3) the interconnectivity of
MHPS and legal and protection contexts of conflict-induced displaced persons.
Chapter 3 presents the research design and methodology. Information includes:
1) the theoretical framework: ecological system framework, critical paradigm and social
justice perspective, 2) the use of concatenated exploratory research, narrative inquiry and
thematic analysis, and 3) ethical concerns, trustworthiness of findings and the generation
of theory based on the ecological system and current conditions faced by PoC.
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Chapter 4 provides the Study 1 and Study 2 key MHPS findings segmented into
summarized tables of MHPS themes and anecdotal examples. Key areas of Study 1
covered included Part 1: PoC service provision attributes, PoC trauma impact, MHPS
skills, knowledge and capacity building needs; and Part 2: the MHPS capacity building
intervention. The Study 2 inquiry involved substantiated refugees involving Part 1: a
screening for metal health distress which revealed high levels of distress; and Part 2: an
inquiry focusing on strengths, challenges and service provision
Chapter 5 provides the Study 3: In-depth Case Study Findings of four PoC case
studies. Finings are segmented into tables of themes, subthemes and anecdotal examples.
A unique therapeutic case example highlights the complex work and healing partnership
between a case study participant and myself. The use of a multi-modal systemic
integrative Body-Mind-Spirit approach to therapeutic work is encouraged.
Chapter 6 provides the Study 4: Service Provider Findings, segmented into tables
of themes, subthemes and anecdotal examples. All findings chapters discuss 1) the
interconnection between sub-systems of the whole PoC ecological system and 2) how
structural impediments in the environment and failures of the sub-systems can impact
the deterioration of PoC MHPS and holistic health.
Chapter 7 presents a deeper deductive and inductive interpretive analysis that is
grounded in the research. The analysis is connects the research findings to the larger
related literature. It then provides suggestions on MHPS pathways to wellness, entitled
Empathic Growth Pathways. Chapter 8 concludes the Dissertation and offers a summarized
caption of key takeaways. It then discusses the research limitations and significance,
theoretical contributions and conflict-induced displacement and social work research and
practice implications. Next steps and final thoughts are also noted.
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1.9. Closing Reflexive Remarks
Conflict-induced displacement is prevalent around the globe and Hong Kong is
not immune. Social work researchers and practitioners can be proactive to take action
and provide platforms for empowerment and support. Through my work as a volunteer
at the MHPSS-PoC, I experienced the oppressive environmental systems and structures
that are just barely meeting PoC basic needs. My research rationale was based on this
experience, as well as my commitment to improve the situation through my roles as a
researcher, practitioner and advocate.
Ultimately, I believe we have an ethical obligation to assist the many vulnerable
yet resilient conflict-induced displaced persons in their complex journeys to safety, good
health and a future filled with hope. While this research takes on a complex subject, it is
exploratory in nature. I hope to illuminate important aspects of MHPS forces impacting
PoC, in hopes of creating further opportunities for change in this important, but often
less prioritized practice and research area.
Chapter 2 presents a selective literature review of key historical PoC events,
MHPS refugee research and practice and the interconnection of protection claims and
trauma.
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Chapter 2: Selective Literature Review
2.0. Overview
Chapter 2 presents a review of related literature on the primary conceptual
themes and key inquiry components of this Dissertation research. The purpose of
Chapter 2 is to offer key information that could be influential on the current conditions
and context of Hong Kong’s PoC situational context. This information also informs the
Dissertation research methodology.
Part 1: Hong Kong PoC Discourse Highlights provides a general overview of Hong
Kong’s refugee historical and contemporary situational context and ultimately
demonstrates the constant struggle for the rights and care of this vulnerable but resilient
PoC community versus the needs and perceptions of the host local Hong Kong community.
The historical context covering the China Migration Flow and Vietnamese People Boat Era
offer significant context in how polices and deterrence of PoC emerged in Hong Kong.
The Contemporary Legal and Protection Context illustrates key judicial rulings influencing the
evolving of PoC protection screening process. Other PoC studies and literature
demonstrate how structures and systems are largely oppressive for PoC. There is little
information for PoC MHPS context. The context of this backstory is heavily
interconnected with current PoC MHPS factors as will be demonstrated in following
chapters.
Part 2: Evolution of Refugee MHPS Research & Practice provides a general summary
of refugee trauma research illustrating its evolution from the medical model into a
holistic, ecological and integrated approach. The inclusion of and promotion of spirituality
as a key component of overall health and trauma recovery is a noteworthy concept. This
section also describes the current global best practice approaches for mental health and
trauma recovery and psychosocial support including the use of policy and establishment
of a Mental Health Action Plan (HPRT, 2004). Furthermore, tailoring and applying the
IASC Intervention Pyramid (IASC, 2007) and the MHPSS approach (UNHCR, 2013b) can be
useful for communities to provide holistic care for displaced persons. This is because the
levels of care address the multi-faceted needs of displaced persons.
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Information of how trauma and MHPS wellbeing intersects within the legal and
protection processes is provided. Navigating the protection screening process can often
be a harrowing experience for a survivor of trauma and torture. Unfortunately, rarely do
protection-screening systems go out of their way to minimize harm or make screenings
comfortable. Several important issues are highlighted such as the importance of using the
Istanbul Protocol (PHR, 1999) in identifying trauma and torture experienced by persons
displaced by conflict.
2.1. Part 1: Hong Kong PoC Discourse Highlights
This section provides a general overview of refugee migration from Mainland
China, and the Vietnamese Boat People (VBP) era offer key factors and a foundational
understanding of historical events influencing current conditions of PoC policy and
public sentiment. The legal related information offers information on key judicial rulings
that have shaped the face of contemporary PoC protection discourse in Hong Kong.
Figure 1: Timeline of Key Hong Kong PoC Events offers a chronological summary of key PoC
events. It is adapted from information from (UNHCR-HK, 2014), (Choi, 2014, May 21)
and (Scherr, 2011).
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Figure 1: Timeline of Key Hong Kong PoC Events
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2.1.1. China Migration Flow
Hong Kong’s history with Mainland China and the Chinese government (PRC)
offers rich information about initial migration and refugee contexts of persons fleeing
Mainland China to Hong Kong, as well as Western influence. The politicization of PRC
and HKSAR migration flows and border controls, the unextending of the Refugee
Convention & Protocol, the UNHCR and international involvement and deterrence
policies largely contribute to Hong Kong’s PoC discourse. Historically, pre-PRC
founding, Hong Kong and Mainland China borders were largely open. UNHCR (2000)
notes how Hong Kong had long been a place for Mainland Chinese to seek refuge at
times of unrest. Population increases are noted during the 1850’s Taiping Rebellion, the
1900’s Boxer Rebellion, the 1912 revolution in the forming of the Republic of China,
and the Sino-Japanese War of 1937-45 (UNHCR, 2000).
In 1945, Hong Kong was returned to British rule following Japanese defeat and
China was immersed in civil war (Peterson, 2012). As the Chinese communist rule and
the Cold War era began around 1949, large numbers of Mainland Chinese sought refuge
in Hong Kong. In 1946, Hong Kong’s population was approximately 1.6 million and by
1956, it had reached 2.5 million with 1/3 of the population being refugees (Peterson,
2012). Throughout this time, Hong Kong’s colonial leaders began placing stricter
immigration controls in the face of the overwhelming flow of people and also, to secure
Hong Kong as a sovereign space.
This led to the militarization of borders which reduced the capacity for Mainland
Chinese migrants to be considered refugees during a period in which failed liberalization
campaigns resulted in widespread political persecution and economic oppression in
China (MacFarquhar 1960; Berge`re 2002 as cited in Modorado, 2012). This militarized
border control and new rhetoric, created divisions about legality perceptions; this
subsequently profoundly impact a migrant’s ability to be viewed as a refugee (Madokoro,
2012). Furthermore, geopolitical sensitivity involving Taiwan and China further
complicated the situation and relations between Hong Kong’s British colonial
government, Great Britain, PRC, Taiwan, and the United States of America (USA). By
1967, the possibility for refugee-hood was virtually gone, accounting for the limited
capacity for Chinese migrants to seek asylum during this post war period (Madokoro,
2012).
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Simultaneously, the living and welfare conditions of Hong Kong refugees gained
international attention through a 1952 UNHCR report which revealed clusters of
squatters poorly constructed housing and unhygienic conditions all over the city (UK
National Archives 1952-54 as cited in Peterson, 2012). By 1954, there was almost
600,000 refugees if refugee dependents were included, which was almost 30% of the HK
population (Peterson, 2012).
Waves of thousands of Russian refugees had also fled from China to Hong Kong
following the Soviet occupation of Manchuria and further complexity in China (Scherr,
2011). Their resettlement in the West was difficult as they waited in Hong Kong in
uncertainty for almost two decades (Scherr, 2011). From 1952 to 1969, UNHCR
successfully resettled almost 20,000 European refugees and cited that the logistical and
political challenges involved were some of their greatest, despite the relatively small
numbers (UNHCR, 2000).
2.1.2. Vietnamese Boat People Era
The next major wave of refugees came about in the mid 1970’s to late 1990’s and
is commonly referred to as the Vietnamese Boat People (VBP) era. Hong Kong’s refugee
policy transformation can broadly be attributed within the VBP era, and divided into
four policy phases: Open Camp: 1975-1982, Closed Camp: 1982-1988, Screening and
Repatriation: 1988-1998 and Recognizance since 1992 (Ngai, 2012). In 1975, following
the end of the war between the USA and Vietnam; the fall of Saigon and rise of
communism led to a mass exodus of Southern Vietnamese to their Southeast Asian
neighbors including Malaysia, Thailand and Hong Kong. These places were set up as
countries of “first asylum” following the Geneva Conference in 1979 (Hau, 1997).
During the Open Camp Policy, Hong Kong had a liberal, humanitarian based
approach, which was largely influenced by their British colonial leaders. Great Britain
was a signatory to the Refugee Convention & Protocol and also had alliances to the
USA. However, Great Britain failed to extend the Refugee Convention to Hong Kong,
largely due to its sensitive relationship with the PRC and complexity around Taiwan.
However, this was a time of openness towards the VBP. The Open Camp Policy enabled
VBP medical check ups on arrival, provided open camp shelter, and even encouraged
them to seek legal employment until resettlement (Hau, 1997).
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The influx of VBP continued after 1979 and lasted for more than a decade. In
1979 there were 74483 new arrivals and figures indicate more than 11,000 new arrivals in
1980 and 1981; while resettlement rates were around 80% (HKSAR, 1994 as cited in
Ngai, 2012). Over time, Western resettlement countries began tightening their policies;
the public and local Hong Kong legislator sentiment began to shift as they became
dissatisfied with the government’s open door policy (Hau, 1997).
Domestic pressures mounted as worries about resource and economic strains
increased, population density surged, and possibly the most salient, was the belief that
many so-called refugees were actually economic migrants trying to escape the dismal
economic realities back in Vietnam (Hau, 1997). Hong Kong’s refugee policy also
became increasingly hardline as they implemented closed camp policies in which refugees
were unable to leave the camp (Hau, 1997) or gain legal employment (Ngai, 2012).
Ngai (2012) notes that within the course of policy succession, there are hurdles to
and resistance due to conflict of interests of the groups involved; benefit receivers
arguable resist change to retain befits, and policymakers attempt to win votes when
addressing problems through new policies. However, for the HKSAR, their new closed
camp policy, while attending to public and legislator dissatisfaction, also increased
tremendous costs shouldered by the government. More than 8.7 Billion HKD was spent
by the HKSAR during the 1980’s following the record high numbers of VBP arrivals
(Legislative Council, HKSAR, 2006 as cited in Schum, 2011). Also, widely criticized
inhumane conditions were reported in these camps which were administered by the
Correctional Services Department; they incorporated prison rules (Ngai, 2012).!!
Hau (1997) notes increased deterrence policies were influenced by HKSAR
having little international support in handing the situation, increased regional hardline
approaches, commitment to the British government as a first asylum port, deteriorating
economic conditions in Vietnam propagating migration and reduction of resettlement
rates. To address these complexities, a screening and repatriation policy was ultimately
enacted to largely screen out potential economic migrants and suppress the refugee
population (Ngai, 2012). This policy was also party enacted to deter more from arriving.
Arriving VBP would have to be screened and would not be given automatic refugee
status; others were repatriated back to Vietnam, at first voluntarily, but forcible return
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was also enacted. Additionally, HKSAR worked with the Hong Kong Branch of
UNHCR (UNHCR-HK) around screening and organizing the repatriation program for
screened out cases. Eventually, only a few thousand VBP remained in Hong Kong and
were integrated into the local community under a local resettlement program (Ngai,
2012).
In 1992, a policy of Recognizance was enacted subsequent to HKSAR’s signing
of the Convention against Torture. Refugees arrived each month, mostly from the South
Asian countries of Pakistan, Nepal and Sri Lanka (Ngai, 2012). A recognizance paper
entitled PoC some form of legitimacy to remain without arrest or detention. Prior to this
Recognizance Policy, a number of asylum seekers had been arrested or detained,
including one who was even pregnant (Shamdasani, 2005, September 20). With the
introduction of recognizance papers, HKSAR allowed them to stay in Hong Kong until
their cases were settled, either under the process of UNHCR’s Hong Kong sub-office
(UNHCR-HK) for asylum screening or the HKID for torture claims screening, as
explained in the next section.
For further information about the historical refugee backdrop, several locally
based masters and doctoral level dissertations address various aspects of the topic: such
as focusing on refugee camps (Lan, 2006) and (C.-s. Lee, S., 1992), policy analysis (Hau,
1997) and (Ngai, 2012), VBP and psychosocial factors (Ng, 1991), comparative studies
(Haynes, 1993), NGO role (P.-l. Lee, A, 1992), youth programs (Lo, 1983), and
integration (Lulla, 2007). Several recent books (Guthrie, 2015) and (Law, 2014) are also
available depicting stories about this era.
2.1.3. Contemporary Legal & Protection Context
Following the VBP era, a fascinating legal backdrop changed the landscape for
protection for PoC in Hong Kong. Until recently (February 2014), a dual protection
claims system existed in Hong Kong because the HKSAR is not a signatory to the
Refugee Convention and Protocol. Due to this, the UNHCR-HK was delegated the
responsibility to conduct RSD, which was also largely viewed as having a low recognition
rate for successful cases. In the Justice Centre Hong Kong’s (JCHK) experience, the
UNHCR-HK recognition rate in 2011 hovered around 10%, compared to the global
UNHCR recognition rate of around 80% (JCHK, 2015). Furthermore, UNHCR-HK’s
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standards of fairness in RSD have been implied as being inadequate for Hong Kong
Courts and Judiciary (Daly, 2015). Moreover, NGOs and lawyers claim that the methods
of discerning between real and false claims has been inefficient, costly and opaque (Choi,
2014, May 21).
HKSAR has signed onto the United Nations Convention on Torture and CIDTP
(UNCAT) in 1992 (UNHCR-HK, 2014). The case of Prabakar proved to be monumental
in granting non-refoulement protection under this Convention for a survivor of torture
who was had originally been rejected from UNHCR-HK protection (Daly, 2009). “As a
result of Prabakar, the Hong Kong administration implemented ‘discretionary’, ‘non-
statutory’ screening procedures for CAT claimants” (Daly, 2009, p. 19). The CAT
screening system was enacted and administered by the Hong Kong Immigration
Department (HKID).
Further legal challenges through the case of FB found that the torture screening
that was set up needed enhancement, particularly addressing unfair assessment practices;
the system was then administratively enhanced in 2009 enabling claimants to obtain legal
assistance under the Duty Lawyer Service (DLS) (Daly, 2009). However, despite any
enhancements, from 1992, when UNCAT was enacted till February 2015, there have
been less than 30 recognized successful torture claims, setting an extremely low
recognition rate of less than 1% (JCHK, 2015).
2.1.3.1. USM Introduction
A unified protection claims system administered by HKSAR was realized in 2013
following key landmark rulings in the C and Umabaka cases in the Hong Kong Court of
Final Appeals (Daly, 2015). Beginning in March 2014, all protection claims related to
persecution, torture and CIDTP are considered non-refoulement claims and are filed
with the HKID under the new Unified Screening Mechanism (USM). UNHCR-HK
would provide capacity building support to the HKID around non-refoulement claims
screening as well as monitor USM progress (UNHCR, 2015).
Following fact finding missions and surveying PoC about their USM experiences,
the commencement of the USM was criticized for its lack of information sharing, clarity
on how to apply, and overall transparency (JCHK, 2014). Furthermore, other concerns
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raised included the lack of consultation with lawyers, publication of decision making to
public, transparency on the medical examination/procedures and practices, and training
of decision makers in assessing non-refoulement protection claims (Daly, 2015).
Successful asylum claims would result in someone gaining protection status on
the grounds of persecution. “Given Hong Kong’s general policy not to grant asylum it is
apparent that little attempt is made to integrate refugees into society” (Ramsden &
Marsh, 2013, p. 578). Mandated refugees could be resettled in another country
(resettlement is not guaranteed) through UNHCR-HK, who will fulfill their original
mandate of protection and providing durable solutions for substantiated persecution
claims (UNHCR-HK, 2015). However, no durable solutions for substantiated CIDTP
and torture claims were available and additionally, there was no guarantee to local
integration such as residency permission, the right to work and vocational training
(JCHK, 2015).
For more information about this area, several legal advocates, academics and
researchers discuss legal and policy contexts around: building the legal PoC infrastructure
and updates on key PoC judicial rulings (Daly, 2009), (Daly, 2012), and (Ramsden &
Marsh, 2013); customary international law and the principle of non-refoulement (Jones,
2009), (Rice, 2011), and (Loper, 2010); the monitoring of and adherence to human rights
conventions (JCHK, 2015), and protection advocacy and USM implementation (JCHK,
2014) and (Daly, 2015).
2.1.4. Contemporary PoC Literature
While most academic literature around the refugee context has focused on the
legal and policy contexts, other academics and researchers intersect this context into
various relevant areas that affect PoC in Hong Kong such as the socio-economic
experiences, livelihood, networks and transnational spaces that PoC access and interact
in (Schum, 2011), (Mathews, 2007), and (Vecchio, 2015). Additionally, the advocacy of
NGO and Poc-led groups exposed the Ping Che dilapidated housing. This garnered local
and international media attention to the plight and living conditions of PoC (Chan, 2013,
July 18) and (Lai & Tjhung, 2013, June). A PoC-led protest was conducted around the
inadequacies of the social welfare system (Solomon, 2014, April 25) and (Choi, 2014,
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February 12). Finally, there has been limited discourse and literature around the PoC
right to work, public perception, health and mental health.
2.1.4.1. The Right to Work
The right to work is an important topic for PoC. Currently, during the protection
screening process, applicants are not allowed to work and rely on government handouts
to avoid creating a "magnet effect" for others seeking refuge (Read, 2014, January 16).
Not having the right to work and depending on low levels of social welfare can leave
PoC destitute (JCHK, 2015). HKSAR policy prohibits refugees from working unless they
demonstrate ‘exceptional circumstances’ and is influenced by the threat of drawing more
immigrants to the territory; the policy’s reasonableness and claim assessment mechanism
is questionable (Ramsden & Marsh, 2013).
In the case of MA v Director of Immigration, four mandated refugees and one
screened-in torture claimant (who resided in Hong Kong for around a decade without
the ability to work) challenged the legality of this policy. The Hong Kong’s court
unanimously dismissed the appeal (Chen, 2014, February 18). Since then, the HKID
reported that from November 2014 till April 2015, four substantiated torture claims and
mandated refugees applicants have applied and two applicants were granted the
permission to work (HKID, 2015).
I. L. Leung, Ng, Wong, Yiu, and Yuen (2013) inquired about the public’s
perception (n= 944) on permission for refugees and asylum seeker legal employment and
found the majority of their respondents did not support this idea or didn’t answer;
except for many with higher education levels, who indicated their support. The authors
suggest that respondents could be afraid that refugees and asylum seekers would take job
opportunities or reduce overall salaries in the labor market (I. L. Leung et al., 2013).
Also, more than 40% of respondents between ages 26 and 35 misbelieved that refugees
and asylum seekers could legally work in Hong Kong; 418 respondents also misbelieved
that refugees and asylum seekers could maintain their daily life by their own savings (I. L.
Leung et al., 2013).
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2.1.4.2. Public Perception
Two other key findings in the same pubic perception survey by I. L. Leung et al.
(2013) found that 70% of the right of abode respondents refused to provide free
education to refugees and asylum seekers (the authors speculate reluctance for resource
sharing with taxpayer funds). Also, more than 98% responded that they knew who a
‘refugee’ was, however most failed to distinguish between refugees from asylum seekers in
subsequent questions or did not answer at all; except those with higher education levels
could more accurately distinguish between the two categories (I. L. Leung et al., 2013).
2.1.4.3. Medical Care Access
There is a dearth of academic literature regarding healthcare barriers. However,
Health in Action conducted a survey of 139 asylum seekers revealing several health and
dental barriers (Khoe, 2014). Medical care barriers included 1) Not knowing how to seek
help, 2) Complicated phone appointment booking and registration procedures, 3) Lack
of information about the local medical system, and 4) Language barriers. Dental care
barriers included 1) Limited opening hours of dental emergency care, 2) Limited services
of tooth extractions and pain medications, and 3) Access to the needed medical waivers
(Khoe, 2014).
2.1.4.4. MHPS Care
There is also very little literature around PoC MHPS wellbeing in the
contemporary context. One notable study assessed PTSD and oral health among a group
of 87 asylum-seekers in Hong Kong. Cheung et al. (2010) found that most had untreated,
decayed teeth and approximately a third (31.0%) had PTSD. Of those with PTSD, 50%
reported experiencing dental trauma, such as from assaults and beatings to the head,
which consequently showed a significant association between reported dental trauma and
psychological distress. Cheung et al. (2010) found a correlation between the highest
PTSD scores and durations of stay in Hong Kong of five years or more, implying
chronic psychological disturbances persisted over time. Furthermore, 60% experienced
dental problems after arrival to Hong Kong, but only 25% sought treatment due to the
lack of information on where to go and financial concerns (Cheung et al., 2010).
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2.1.5. Part 1 Summary & Remarks
Part 1 offers a general backdrop into how conflict-induced displacement and
migration patterns from China and Vietnam alongside various HKSAR geopolitical
sensitivities and domestic pressures, subsequently shaped public perception, deterrence
policies, legal discourse and overall conditions for PoC in Hong Kong. Key judicial
rulings have offered a degree of protection, however has little influence on successful
recognition rates, which indicate there are larger fundamental problems with the system
itself. While the backstory to PoC discourse in Hong Kong is indeed fascinating, what is
not, however, is how PoC have suffered in varying degrees throughout this history.
The commencement of the USM was a welcome development. Yet, if it is going
to be administered in similar ways as previous asylum and torture claim systems, this
would not be welcomed and could further deteriorate PoC holistic health conditions.
Part 2 of this literature review illustrates how refugee research and practice evolved
towards a holistic framework of care. It posits the obvious link into necessary
components of a fair, effective and just system for PoC protection and holistic wellbeing
in Hong Kong.
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2.2. Part 2: Evolution of Conflict Displacement Trauma
Research & Practice
This section provides an overview of how refugee MHPS research and practice
have evolved over the past three decades from the trauma model to an ecological model
to a holistic, integrated and trauma “informed model”. This section is important for two
primary reasons. First, it is necessary to emphasize how the trend towards holistic,
integrated and trauma-informed services is crucial in serving PoC. This model can be
valuable in enhancing the protection system in Hong Kong. Second, it is important to
demonstrate how the chosen research methodology for this Dissertation is positioned
within the larger refugee mental health and psychosocial research arena.
2.2.1. Trauma Research
This section relates a general overview on how refugee trauma and mental health
research evolved. It covers key areas that impact this growth including the 1) Trauma
Model, 2) Displacement & Post-Migration Stressors, and 3) Resilience, Social Support &
Coping.
2.2.1.1. Trauma Model
The trauma model of refugee health research (also referred to as the medical
model, deficit model or the trauma-focused model) evolved in the 1980’s. “This model
was ushered in with the inclusion of Post-Traumatic Stress Disorder (PTSD) in the
American Psychiatric Association’s DSM III, in part, influenced by the return of US
Vietnam Veterans having mental difficulties upon return after war exposure (Schweitzer
& Steel, 2008). The trauma model relied heavily upon standardized instruments
(Schweitzer & Steel, 2008). Researchers identified the relevancy of the PTSD criteria in
Southeast Asian refugee groups (Mollica et al. 1987; Kinzie et al. 1984 as cited in HPRT,
2001).
The trauma model was critical in developing and validating measures to identify
mental health disorders in refugee populations. This importantly enabled a reliable
measure for trauma outcomes and a critical function in documenting human rights
abuses (HPRT, 2001). However, based upon a Westernized concept of psychiatric
assessment and treatment, there was much variance in the prevalence of trauma
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outcomes, specifically prevalence of PTSD (Silove, 1999). This outcome of trauma-
focused research indicated that a sole reliance on this model was not adequate (Miller &
Rasmussen, 2010).
Over time, the focus on the trauma model was questioned and critiqued by
several academics, practitioners and researchers citing its limitations. Schweitzer and Steel
(2008) emphasized that being a refugee is a derivative of social and political situations,
which could have a mental health impact. Miller and Rasco (2004) cited how it did not
address the scarcity of mental health services in the original country, the communities’
culturally specific way of addressing psychological stressors, and lacked attention to
environmental, acculturation and displacement stressors. Importantly, however, the
trauma model established a strong link between stressors related to conflict, torture, and
persecution.
2.2.1.2. Displacement & Post-Migration Stressors
Eventually, an inclusion to refugee research was that of displacement stressors
and post-migration challenges resulting in significant findings. For instance, in a study of
Sudanese refugees, post-migration challenges of unemployment and family separation
were associated with depression and anxiety symptoms (Schweitzer, Melville, Steel, &
Lacherez, 2006). In other studies, “…post-migration stressors accounted for equal or
greater variance in symptomatology relative to pre-migration war exposure. Post-
migration stressors have been consistently stronger predictors than war exposure of
depression, while war exposure has tended to be more strongly related than post-
migration stressors to PTSD” (Ellis, MacDonald, Lincoln, & Cabral, 2008; Gorst-
Unsworth & Goldenberg, 1998; Miller et al., 2002; Montgomery, 2008; Steel et al., 1999
as cited in Miller & Rasmussen, 2010, p. 11). Due to the chronic nature of daily stressors
which eroded coping and wellbeing, social support and services were crucial in the post-
migration environment.
2.2.1.3. Resilience, Social Support & Coping
“The strong focus on trauma and posttraumatic stress reactions means that
limited attention has been directed towards understanding positive adaptation in
refugees” (Schweitzer, Greenslade, & Kagee, 2007, p. 4). However, following the
establishment that being a refugee was more than a psychological issue, there was a need
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to explore other research methodologies that were more exploratory and inductive in
nature to understand refugee experiences (Schweitzer & Steel, 2008). Qualitative and
ethnographic approaches could provide richer understanding of the complexity of the
experiences of refugees (Hinchman and Hinchman 1997 as cited in Schweitzer & Steel,
2008).
The “salience of resilience variables may differ depending on the individual’s
coping style, which present implications for clinical practice with torture survivors”
(Hooberman, Rosenfeld, Rasmussen, & Keller, 2010, p. 557). De Haene, Grietens, and
Verschueren (2010) cited the turn in refugee health research from psychosocial harm
minimization towards psychosocial growth. “This increasingly prevalent paradigm, which
provides a more balanced approach to understanding survivors of trauma, has risen in
tandem with recent developments that promote a broadened perspective on human
experience to include affirmative aspects” (Park & Ai, 2006, p. 390).
Social support was found to be an important coping mechanism in the post-
migration environment. For instance, inadequate social support can negatively impact
mental health wellbeing (Gorst-Unsworth & Goldenberg, 1998), (Simich, Beiser, Stewart,
& Mwakarimba, 2005), and (Ahern et al., 2004), while informal social support networks
positively correlated with mental health wellbeing (Stewart et al., 2008) and (Schweitzer
et al., 2007).
Key studies and findings around refugee coping and positive mental health
included the impact of empathic experiences and help reciprocity (Keyes & Kane, 2004),
hope and post-traumatic growth (Ai, Tice, Whitsett, Ishisaka, & Chim, 2007), the role of
religion and spirituality (Whittaker, Hardy, Lewis, & Buchan, 2005), the intersection of
liminality, self-support, and hope (Baird & Boyle, 2012), Buddhist philosophy and
practices, community bonding and support, strength and resilience inspirations (Hussain
& Bhushan, 2011), meaning-making, acculturation engagement, strategic identity
representation (Clarke & Borders, 2014), and focusing on the future and reframing
negative situations (Khawaja, White, Schweitzer, & Greenslade, 2008).
The trauma model also served as an extremely valuable foundation for refugee
trauma practice and treatment. It enabled an increase in trauma treatment and torture
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39
rehabilitation centers in developed countries over the past three decades (Cunningham &
Silove 1993; Basoglu 2006 as cited in Schweitzer & Steel, 2008). It also had “the
advantage of presenting victims as survivors who are in need of specialized care and
support” (Schweitzer & Steel, 2008, p. 7). Moving beyond a trauma-focused model of
practice, a shift towards ecological and integrated models of treatment and practice
occurred with the important acknowledgement of facilitating empowerment and shifting
the locus of control towards refugees.
2.2.2. Refugee Trauma & MHPS Practice & Treatment
This section relates information around how trauma and mental health practice
for refugees has evolved and covers key areas that impact this growth including the 1)
Ecological Model, 2) IASC Intervention Pyramid, 3) H5 Model of Trauma Recovery, and
4) Bio-Psycho-Social-Spiritual Clinical View.
2.2.2.1. Ecological Model
Miller and Rasco (2004) suggest how implementing services through an
ecological collaborative and community empowerment model was effective. While not a
traditional way to approach refugee mental health work, Miller and Rasco (2004) argued
that the strong link between mental health and someone’s capacity to manage
displacement challenges clearly fell into the domain of mental health work. The
interconnectivity of micro services should be addressed to intersect at the mezzo and
macro levels (Watters, 2001).
Key principles of Miller and Rasco (2004) ecological model included: 1)
developing collaborative relationships and approaches with community members set in a
community setting rather than mental health clinics; 2) respecting local values and beliefs
regarding psychosocial wellbeing and distress; 3) tailoring spaces for community needs
and capacities; 4) reflecting and addressing problems, community values, and beliefs
regarding MHPS wellbeing and distress identified by community members within
culturally appropriate community-based interventions and 5) prioritizing prevention over
treatment to avoid the development of issues (Miller & Rasco, 2004). Consulting with
refugees themselves is an important way to identify service needs, priorities and unique
strategies for implementation (Watters, 2001).
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2.2.2.2. IASC Intervention Pyramid
Summerfield (1995) recommended using a human rights framework to address
trauma and suggested that while some require specialized services, a majority could cope
using social support assistance. Along this notion, in 2007, the Inter-Agency Standing
Committee (IASC), a forum of key global heads of humanitarian agencies, developed
guidelines on MHPSS in emergencies (IASC, 2007). The UNHCR (2013a) described the
development of Intervention Pyramid as an influential component of the guidelines since it
recommended the layering of coordinated MHPSS services and offered supports for
affected communities. The MHPSS framework embodied principles that enhanced the
integration of services and quality of care (IASC, 2007, p. 13). Figure 2: IASC Intervention
Pyramid Components is adapted from IASC Intervention Pyramid (IASC, 2007, p. 13).
Figure 2: IASC Intervention Pyramid Components
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Adapted from IASC Intervention Pyramid (IASC, 2007, p. 13)
2.2.2.3. H5 Model of Trauma Recovery
The H5 Model of Trauma Recovery is aligned with trauma-informed and culturally
competent care for refugee and other traumatized populations. Central to holistic care
and the core of the model is the trauma story; it includes the brutal facts, cultural meaning
of trauma, revelation from looking behind the curtain and the storyteller and listener
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relationship (Mollica, 2014). The overlapping elements around the trauma story aiding
trauma recovery are: human rights, humiliation, self-healing, health promotion and habitat. Mollica
(2014) notes how safety and security is a foundation of refugee care and as it’s restored,
the person’s trauma story needs to be acknowledged as a form of justice restoration. Care
and services should empathically understand how humiliation, shame and disgrace
impact survivors of violence, restore agency, power and validate that any violence is
wrong and unjustified (Mollica, 2014).
Mental health work should aim to alleviate or manage trauma symptoms and
enhance the capacity of refugee communities to effectively cope with the daily
displacement stressors they are confronted with (Miller & Rasco, 2004). “In the context
of a holistic approach, clinicians will function less as detectives trying to uncover the
‘‘real’’ causes of the presentation of physical symptoms, but will instead be open and
receptive to the explanations given by patients as to the causes of their distress” (Watters,
2001, p. 1714).
Positive social behaviors such as altruism, work, and spirituality enhance health
promotion and reduce stress reactions and isolation (Mollica, 2014). Trauma survivors
often have poorer behavioral health outcomes, such as increased substance use, which
contribute to further chronic illness; therefore an emphasis on health promotion is
needed. Habitat emphasizes the total surrounding and living environment.
2.2.2.4. Bio-Psycho-Social-Spiritual Clinical View
Trauma treatment approaches have focused on the medical model but further
incorporated ecological and psychosocial approaches. Working with traumatized
individuals through a holistic model or a bio-psycho-social-spiritual model should be the
new clinical worldview (Mollica, 2008). An awareness of the mind-body connection and
its association with trauma has increased. Rothschild (2000) noted how the body stores
trauma from the autonomic state of fight, flight or freeze resulting in traumatic stress.
Bodywork in the form of yoga, appropriate massage, and movement therapies can be
helpful to release these pent up, maladaptive energies. A more recent movement towards
holistic trauma care incorporating spirituality has been an important addition to trauma
work.
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Table 1: Bio-Psycho-Social-Spiritual Wellbeing Components is adapted from Das and
Chan (2013) and provides examples of bio-psycho-social-spiritual wellbeing components
that support PoC. Adapting a bio-psycho-social-spiritual wellbeing model can be tailored
in work with a PoC trauma survivor using a strengths based approach. “Trauma work”
includes targeted work including necessary medication.
Table 1: Bio-Psycho-Social-Spiritual Wellbeing Components
Bio
Psycho
Social
Spiritual
Comprehensive
Health Check
Up
Strength & Coping
Build Community, Social,
Cultural Networks and
Capacity
Natural
Healing
Exercise
Mental Health
Screening
Traditional and Indigenous
Values, Strengths and Coping
Nature /
Universality
Yoga
Trauma Work
Facilitating Leadership,
Education and Skills
Faith / Belief
System
Sensitive
Torture
Screening
Meaning
Reconstruction
Build Community, Social,
Cultural Networks and
Capacity
Religious
Group
Bodywork
Expressive Arts
Meaningful Activities and
Employment:
Higher
Power
Energy
Psychoeducation
Safety, Food and Shelter
Rituals
Nutrition
Empowerment, Control and
Awareness
Spirituality has steadily emerged in the literature around trauma and healing.
Spirituality and the power of the human spirit in healing can connect people to their self-
healing abilities and strengths. Particularly for survivors of trauma and torture, their
spirituality or belief system can play a large part in their resilience. Agger, Igreja, Kiehle,
and Polatin (2012) noted how spiritual practices enable a connection to the bigger picture
and the ability to confront upsetting feelings and memories. Also, through breathing,
movement and spiritual practice such as mindfulness, observation is engaged and
physiological arousal is regulated (Agger et al., 2012). Protective effects of spirituality
throughout time may be a complex operational process (Ai & Park, 2005).
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Promising and emerging spiritual practices and interventions include narrative
and storytelling work, social and community support, advocacy and activism (McKinney,
2011). McKinney (2009), Piwowarczyk (2005) and Tuskan (2009) offer guidance and
insight into spirituality practice and assessment for trauma and torture survivors.
Lee, Ng, Leung, and Chan (2009) present an innovative and Integrative Body-
Mind-Spirit Approach, that views the three components as inter-connected entities.
“There is an increasing interest in approaches that utilize physical, cognitive, emotional
and spiritual components in assessment and treatment” (P. Leung, Chan, Ng, & Lee,
2009, p. 303). This approach combines elements of evidence based Western approaches
with Eastern modalities of healing and philosophies. “The increased attention to spiritual
issues holds great promise to enrich research and practice in interpersonal violence and
trauma, particularly in the effects of spirituality in recovering from trauma and the effects
of trauma on spirituality” (Ai & Park, 2005, p. 247).
2.2.3. Refugee MHPSS & Policy
Policies can ensure safety and support and also reduce risks to wellbeing.
Unfortunately, policy planners can propagate further deterioration of mental health with
policies that undermine human rights such as economic and forced dependency where
self-sufficiency cannot be achieved (HPRT, 2011). Creating a rights-based approach to
PoC mental health policy can help to reduce post-migration problems and subsequent
MHPS impact (Carswell, Blackburn, & Barker, 2011).
“It is recognized that for such a policy to exist, and to be effective, there is a need
for political commitment to such processes and ongoing advocacy at both national and local
levels” (HPRT, 2011, p. 90). The emphasis on mental health promotion as a broader
social policy can be more substantial than a stand-alone policy and should be organized
into values and objectives for mental health improvement and reduction of mental
disorder burden (WHO, 2004). Often before policy can be improved, advocacy needs to
occur and alliances and collaborations between stakeholder groups can increase mental
health promotion.
Through their work with PoC communities for the past three decades, the
Harvard Program for Refugee Trauma (HPRT) recommended addressing the domains of
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human suffering associated with physical and mental health from the perspective of the
patient, community, and provider. This holistic approach inclusive of policy can be
realized through a Global Mental Health Action Plan (GMHAP) (HPRT, 2004) for
traumatized communities. It is a comprehensive approach to mental health recovery that
can be tailored and adjusted to the needs of any context encompassing survivors of
trauma from political violence or disasters.
The components are: 1) Mental Health Policy & Legislation, 2) Financing of
Mental Health Recovery, 3) Science-Based Mental Health Services, 4) Building an
Ongoing Program of Mental Health Education, 5) Coordination of International
Agencies, 6) Mental Health Linkages to Economic Development, 7) Mental Health
Linkages to Human Rights, and 8) Mental Health Evaluation, Research and Ethics
(HPRT, 2004).
2.2.4. MHPSS Intersection with Legal Systems & Protection
There has been a global recognition of the connection of trauma and mental
health wellbeing to the protection systems that PoC like communities face around the
world. Discourse around the concern of retelling stories in the legal and adjudication
environments, fair screenings, trauma awareness and the need for increased
interdisciplinary advocacy has been relevant in work with trauma and torture survivors.
The next section discusses key aspects to this discourse including 1) Istanbul Protocol-
Informed Medical & Psychological Support, 2) Trauma, Memory & Credibility, 3)
Retraumatization & Interdisciplinary Advocacy, and 4) Notable Practices in Medico-
Legal Reports & Comprehensive Care.
2.2.4.1. Istanbul Protocol-Informed Medical & Psychological Support
International protection claims systems often vary from place to place. However,
it is important that there is a minimum standard for evidentiary support. Medical
affidavits acting as legal documents (also known as medico-legal reports or MLR’s)
evidencing physical and psychological evidence of torture have emerged as a
fundamental component of asylum claims (Chelidze et al., 2015). In order to
comprehensively document torture and its impact, the Manual on the Effective
Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading
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Treatment or Punishment otherwise known as the Istanbul Protocol (IP) was adopted in
1999 (PHR, 1999).
UN Special Rapporteur on Torture adopted the IP as authoritative, international
bodies have affirmed its use, and sets forth the domestic legal obligations for
incorporation; now incorporated into domestic law in several countries (IRCT, 2009). It
is useful for fact finding for evidentiary support since proof of torture is highly obscure,
as traces have often disappeared by the time of medical care.
Often health care professionals are not properly trained to detect traces of
torture, since tortured use methods that don’t leave physical evidence (IRCT, 2009). The
IP tool can equip both health and mental health professionals to conduct an objective
evaluation inclusive of investigation, assessment and report of torture. It could be
fundamental support in addressing the challenges to prove torture (IRCT, 2009).
Article 12 of UNCAT mandates States to perform a timely and neutral
investigation on torture committed on their territory but offers nothing more about
torture investigation in asylum proceedings. The Istanbul Protocol could be a useful
supplement for this. Within the fact-finding process of assessing an asylum claim, MLR’s
play a supportive role since forensic knowledge such as examination of scars and other
torture sequelae contributes to better quality asylum decisions (Battjes, 2006).
2.2.4.2. Trauma, Memory & Credibility
During the protection claims determination process, trauma survivors can be
challenged an perplexed to relay their stories, trust authorities and discuss past trauma,
usually due to shame, cultural reasons, and mental health issues. “Asylum applicants who
demonstrate partial or intermittent memory loss in court may be perceived by
adjudicators to be lying and deemed not credible, unless it is understood by the
adjudicator as evidence of the applicants symptoms of post-traumatic distress” (Einhorn
& Berthold, 2015, p. 37).
More often than not, the ability to tell a coherent and consistent story is the
foundation of credibility, and it strongly influences the outcome of the adjudication
process. Compounding this is the screening in a system that is more interested in
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deterrence than protection. For instance, Kirmayer (2003) describes how within a system
aimed at catching fake cases, the applicant is questioned to clarify unclear or
contradictory details to obtain a satisfactory answer, but the goal is often to catch the
applicant in a more obvious inconsistency or contradiction. This is then used as evidence
to accuse the applicant of lying in order to take advantage of the benefits of that society.
Bloemen, Vloeberghs, and Smits (2006) noted that memories are complex
representations of interpretations that have been transformed into life histories and
positioned into the socio-cultural contexts. When reconstructed they are transformed by
the continuous remembering and forgetting process; traumatization can influence the
storing and retrieving of memories. A complete verbal narrative of the trauma may be
difficult to provide and can often “consist of fragments of sensory impressions, such as
smells, tactile sensations, emotional states, sounds, and or images of the trauma event
(Einhorn & Berthold, 2015, p. 38).
Also, traumatized individuals can split from the experience to protect themselves
from the intense feelings it may bring, which can serve as a maladaptive protection
mechanism. It also could be something they inevitably did at the time of torture or
trauma. Dissociation shuts off the person’s senses until they no longer feel what is going
to happen; following this, their emotions may unravel as they are unable to recall what
happened (Bloemen et al., 2006). Dissociation is one of the most classic and mysterious
symptoms of trauma and is common in repeatedly traumatized persons (Levine, 1997).
Without psychosocial care, this dissociation may continue long after the trauma.
Traumatized persons, even without meeting the criteria for mental health
disorders, can still be compromised by challenges of concentrating and symptoms of
distress and shame, which can contribute to being judged as not credible or reliable
(Einhorn & Berthold, 2015). Furthermore, even in the absence of trauma, one’s ability to
recall details about all aspects of their life experiences tends to be compromised over
time (Gyulai et al 2013 as cited in Einhorn & Berthold, 2015).
Obstruction is often unavoidable when associated with trauma and health
problems, thus the asylum seeker should not be blamed for being unable to reconstruct
their experiences adequately (Bloemen et al., 2006). Adjudicators often have a different
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impression about what and how someone should say and act, i.e. what is important to be
recounted as a person’s experience. Thus, “an adjudicator may easily come to an
erroneous conclusion about the applicant’s credibility if they rely on their low benchmark
regarding what is central or reasonable to recall be trauma survivors” (Einhorn &
Berthold, 2015, p. 39). Trauma awareness in adjudicators is crucial and MLR’s can be
useful in explaining the applicant’s behavior and emotional and cognitive functioning.
2.2.4.3. Retraumatization & Interdisciplinary Advocacy
Applying for asylum can be a harrowing experience as well as could retraumatize
a trauma survivor. Recalling past trauma incurs the possibility of retraumatization and
further deterioration of a person’s health. Recalling trauma may exacerbate or increase
trauma symptoms and “compromises the functioning of asylum applicants in their
asylum interviews or court testimonies (Herlihy 2012 as cited in Einhorn & Berthold,
2015, p. 34). It can contribute to the further breakdown of holistic health throughout the
protection screening process, often initially with legal providers, then with other
interviewers and adjudicators.
Also, being interviewed by legal providers and adjudicators who are culturally
insensitive and not trauma-informed is not uncommon. It can worsen the experience
when they are made to recall trauma, particularly if they have mistrust towards
government authorities and officials due to their past persecution experiences; this can
implant more fear and deteriorated functioning in the process (Berthold and Gray, 2011
as cited in Einhorn and Berthold, 2015).
The effects of recalling trauma in the absence of treatment or other support
should be evaluated. Legal needs may be at odds with the individual’s needs (Kinzie &
Jaranson, 2001). Some lawyers may push for the story or simply are unaware of how to
recognize trauma signs. “The lawyer may have little or no training in recognizing or
responding to indicators that the process of preparing the asylum proceeding is
retraumatizing the client” (Marton, 2015, p. 110). Interdisciplinary training and
partnerships with mental health providers can equip the lawyer with trauma awareness,
ability to assess risks, interview skills and methods to assist the client’s response (Marton,
2015).
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Watters (2001) highlights the connection of refugee mental health services and
the broader social contexts encompassing refugees and overall refugee services.
Interdisciplinary approaches are recommended as a strategy to address the complex
needs of refugees, which often span a variety of service needs and modalities. A team
that includes a mental health provider or at a minimum, access to a mental health
referral, can be useful for conducting evaluations as well as providing mental health
support in relaying past trauma. Enlisting a mental health professional that can offer
support and encourage coping through the process and even having them present during
tough interviews and conversations is helpful (Marton, 2015). This can assist in
minimizing retraumatization and mental health deterioration. It can also increase the
strength and resilience needed to navigate the intense protection screening process.
2.2.4.4. Notable Practices in Medico-Legal Reports & Comprehensive Care
Protection screening procedures and screening systems should systematically
include MLR’s for fact-finding and support of an applicant’s health condition since many
applicants have been physically and mentally traumatized and are in need of support.
However, the sad reality is, even States with more advanced protection screening systems
still have a long way to go in 1) recognizing how physical and mental trauma is related to
experiences of violence and torture, and 2) implementing a systemic use of the Istanbul
Protocol. “Given the gravity and difficulties in some cases of asylum determinations, it is
vital that the court be knowledgeable or educated about these issues” (Einhorn &
Berthold, 2015, p. 37).
Various initiatives have been taken to remedy this situation. For example, the
CARE FULL initiative was launched in Europe to improve RSD procedures for torture
and trauma survivors. The aim is to promote the Istanbul Protocol and to discuss the
usefulness of medico-legal reports in providing supportive evidence in asylum claims
(Bruin, Reneman, & Bloemen, 2008). It emphasizes the need for consideration of holistic
health and socio-cultural factors preventing the narration of a coherent historical account
of past experience.
Other pioneering and outstanding organizations that have been notable in
providing MLR’s as well as newer clinics and programs to assist torture survivors and
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asylum seekers have emerged throughout the USA and are summarized in Table 2:
Interdisciplinary Torture Treatment, MLR & Health Services Notable Models.
Table 2: Interdisciplinary Torture Treatment, MLR & Health
Services Notable Models
Group/Model
Description
Components
The Asylum
Network
Physicians for
Human Rights
(PHR) (PHR,
2015)
• Volunteers trained identifying
and documenting evidence of
human rights abuses.
• Evaluations become affidavits
in court and often a
determining factor when
asylum seekers are granted
asylum or other protection
• Members are volunteer physicians,
psychologists, and licensed clinical
social workers
• Evaluate vulnerable populations
The Human
Rights Clinic
Health Right
International in
New York City
(HRI, 2015).
• Trained medical and mental
health professionals meet
detained asylum seekers
• Sensitively conduct medical
and psychological assessments
• Become affidavits in their
asylum proceedings
• Bridges the medical,
psychosocial and legal needs of
asylum seekers
• 1500 physicians and mental health
professionals to provide forensic
evaluations
• Document signs of torture in
survivors seeking asylum and other
protections in the United States.
• Have provided more than 5,500
pro-bono forensic evaluations to
over 4,700 torture and human rights
abuse survivors from 130 countries
The Program for
Survivors of
Torture (PSOT)
(PSOT, 2015).
Bellevue
Hospital & New
York University
• Hospital-based clinic with
University partnership
• Programs increase capacity and
also for evaluations and care of
torture survivors and asylum
seekers
• Comprehensive,
interdisciplinary therapeutic
approach
• Comprehensive health, mental
health, social and legal services have
been provided to almost 3,500
survivors
• Therapeutic multi-disciplinary team:
practicing doctors, nurses,
psychologists, psychiatrists, social
workers, administrative staff,
community liaisons, and volunteers
• Health professionals in training
Weill Cornell
Center for Human
Rights (WCCHR)
(WCCHR, 2015)
• University-based clinic is the
unique example of a human
rights clinic
• Run by medical students
providing forensic evaluations
to asylum seekers in the USA
• While students run the clinic,
the faculty supervises them,
resulting in a mentored
partnership
• Human rights education is included
in the medical school curriculum
• Medical graduate becomes a part of
a workforce committed to bridging
health and human rights
• Psychologists, psychiatrists and
licensed clinical social workers
provide psychological evaluations
(Chelidze et al., 2015)
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2.2.5. Converging Refugee MHPSS Practice & Research
There has been an increased recognition of the need for evaluation of commonly
used MHPSS interventions, the design of MHPS inquiry based on global research
priorities tailored to the local context and understanding how the macro and micro
forces converge in a survivor’s world. These issues are presented in the next section
including 1) Linking Research & Practice in the Micro-Macro Nexus, 2) Assessing
MHPSS Factors, Interventions & Services, and 3) Global MHPSS Research Priorities &
Suggestions.
2.2.5.1. Linking Research & Practice in the Micro-Macro Nexus
Trauma research and practice with refugees have evolved to importantly
understand how factors beyond individual pathology influence someone’s wellbeing,
including environmental forces. Holistic MHPS analysis and services can be achieved by
examining the interconnection of the micro to macro nexus (Brough, Schweitzer,
Shakespeare-Finch, Vromans,