Mental health issues of refugees
Some refugees are at risk for developing mental health issues. Some do not develop mental health issues, but may require some form of psychosocial support. As a physician/health care worker, whether you work as a general practitioner or as an emergency room physician, you are bound to encounter these problems at some point. This module of the e-learning course will offer you:
- Insights in the background and origin of refugees’ mental health problems and the associated risk factors;
- The specific mental health issues you can encounter such as grief, depression and somatic expressions of distress;
- Screening and treatments for mental health problems and other forms of psychosocial support;
- Tools and instruments that you could use in assessing the needs and helping the problems of affected persons.
Parts of this chapter are based on EUR HUMAN
2.1 Origin and associated risk factors of refugees’ mental health problems
About 59.5 million people are forcibly displaced due to conflict, persecution and/or human rights abuse. Among these people are 19.5 million refugees. After being exposed to these distressing events, refugees are at risk of developing a mental health issues. Prevalence of mental disorders varies tremendously (rates between 75% and less then 5% for the prevalence of PTSD in refugees have been reported; Gerritsen et al., 2006; Mann & Fazil, 2006; Fazel, Wheeler & Danesh, 2005). Systematic reviews of studies that included both children and adults show that children fare better psychologically than adults. Further, a review based on a large number of studies revealed that for 30% of adults depression and post-traumatic stress disorder coincided (Reed, Fazel, Jones, Panter-Brick & Stein, 2012). Although these figures show that refugees are at risk of developing a mental health illness, it is important to note that most will not. However, after being exposed to distressing events, some refugees will be in need of some form of psychosocial support.
This module will specifically address three of the most important causes of psychosocial distress amongst refugees, i.e. potential traumatic events in the country of origin, potential traumatic events during the course of the flight, and stressful conditions in the country of arrival.
2.1.1 Traumatic events in the country of origin
Refugees often leave their country of origin after having been exposed to distressing events, such as war conflicts and state-induced violence. Before they leave their homes, refugees often witness changes in politics and economics (Bala, Mooren& Kramer, 2014). In addition to this, they might be exposed to life-threatening situations, to imprisonment or the loss of loved ones. Refugees can be exposed to persecution and oppression because of their ethnicity, religion or sexuality. In some countries, gender based violence may also include female genital mutilation (Thomas, Nafees & Bhugra, 2004). After experiencing these distressing events, refugees are at risk of developing symptoms such as avoidance, intrusion, hyperarousal and a depressive mood (Slobodin & de Jong, 2015; Murray, Davidson & Schweitzer, 2010). In addition to mental health symptoms, refugees might find that their beliefs and assumptions about the world and their self-worth are shattered (Janoff-Bulman, 1992).
An unaccompanied child said: “I came because of the war. The government had killed my father, and captured my mother and my little sisters. I didn’t have any kind of support anymore. Furthermore, what happened to my family would have happened to me as well” (Thomas et al., 2004, p. 117)
2.1.2 Traumatic events during the flight
After fleeing their country, refugees often experience a dangerous flight period. While dealing with their pre-migration experiences and losses and their current situation, refugees face an insecure future and might worry about reaching their location of resettlement. In addition to this, refugees might be separated from their loved ones and are often deprived of their basic needs (Lustig et al., 2004). Young children may go through important phases of their development in an extremely insecure and turbulent environment. Children are at times separated from their caregivers, putting them at greater risk of developing mental health issues. Some refugees go through refugee camps, described as “total institutions, places where … the inhabitants are depersonalized and where people become numbers without names” (Lustig et al., 2004, p. 26). Refugees in refugee-camps are likely to witness more potentially traumatic events and dreadful conditions (Rothe, Castillo-Matos, Busquets & Martinez, 2002). Additionally, refugees are at risk of human trafficking. Human trafficking entails recruiting and/or transporting persons, in order to exploit them. It is a rapidly growing crime, where especially women and children are sold like drugs and weapons. It is also linked to high levels of physical and sexual violence (Shelley, 2010).
2.1.3 Stressful circumstances in the country of arrival
Though there are opportunities and changes for a better life as well, when reaching the country of resettlement, refugees can be faced with several problems that can affect their mental wellbeing. First and foremost this has to do with:
- Insecurity about long and enduring asylum procedures;
- Dreadful living conditions as they are likely to live in small rooms and faced with constant relocation;
- Exposure to violence whilst living in the asylum-seeker centre;
- Post-migration stressors such as a poor social support system, a lack of employment and -education possibilities and financial insecurities (Laban, Gernaat, Komproe, Schreuders& De Jong, 2004; Laban, Gernaat, Komproe, van der Tweel and De Jong, 2005; Murray et al., 2010; Burnett & Peel, 2001; Slobodin& de Jong, 2015).
Often it can be seen that not only the previously experienced traumatic events, but also, and sometimes even to a greater extent, the current insecure life situation can cause emotional suffering. In addition to this, asylum-seekers and refugees can be exposed to extreme discrimination due to misrepresentation in the media and in political statements; therein asylum-seekers and refugees might be dehumanized, demonized and portrayed as “enemies at the gate” who aim to invade Europe, US and Australia, as well as a threat to economic security (Esses, Medianu& Lawson, 2013).
2.2 Psychosocial support
Although some refugees might develop a mental health illness, many will not. Most signs of distress are considered a normal reaction to the abnormal events that refugees have been exposed to. Therefore it is of importance to note that although most refugees will show signs of distress, such as crying, sadness, nightmares and headaches, this does not necessarily mean that they are in need of mental health care. In many cases, the signs of distress will naturally recover over time. However, some refugees might develop symptoms or a mental health disorder that affects their daily life functioning.
In order to guide refugees to proper assessment and training, it is important to execute some form of triage. This is important whether you are in emergency or chaotic situations, or in a more stable environment, such as arrival countries. The intervention should start with triaging the most psychologically severely affected individuals (“the psychological casualties”) (Mollica et al, 2004). By definition, triage includes sorting, screening, and prioritizing affected people in a resource-constrained environment. Triage of serious health issues, including MH, is essential, high-priority response that should be implemented as soon as possible in an emergency. In this early response, triage is not intended for diagnostic purposes but rather to identify those individuals who require immediate attention, primarily for being at risk to themselves or other people. The model of triage can be found in figure 1. In terms of mental health issues, we define immediate risk as threat to personal safety of the affected people, or threat to safety of people around them. These severe mental health problems need direct specialist attention. However, identifying such individuals is challenging. In addressing asylum-seekers and refugees, consider involving trained non-specialist health personnel and allied staff and trained volunteers.
2.3.1 Recognizing signs of distress
Although people react differently to stressful events [LINK to idioms of distress in Module 4.2], there are some physical signs that indicate severe distress in majority of people. In a group of refugees and migrants, care providers should look for signs of being disoriented or overwhelmed (Table 1). Care providers should approach directly people showing any of these signs and engage in interaction. Psychological First Aid (PFA) will be discussed elaborately in chapter 2 of this module.
Table 1 Physical/behavioural and emotional/cognitive signs of severe distress (Ajdukovic & Bakic, 2016)
|Looking glassy eyed and vacant, unable to find direction||Exhibiting strong emotional responses, uncontrollable crying|
|Unresponsive to verbal questions or commands||Feeling incapacitated by worry|
|Disorientation (engaging in aimless disorganized behaviour, not knowing their own name, where they are, or what is happening)||Unable to care for themselves or their children|
|Rocking or regressive behaviour||Unable to make simple decisions|
|Hyperventilation||Feeling anxious or fearful, overwhelmed by sadness, confused|
|Experiencing uncontrollable physical reactions (shaking, trembling)||Physically/verbally aggressive|
|Exhibiting frantic searching behaviour||Feeling shocked, numb|
|Self-destructive or violent behaviour||Guilt, shame (for having survived, for not helping or saving others)|
Figure 1 Triage procedures (Ajdukovic & Bakic, 2016)
2.4 Specific mental health problems
2.4.1 Symptoms of anxiety and distress
After being exposed to a distressing event, it is normal to feel anxious or distressed. Somatic symptoms of anxiety and distress include nausea, sweating, an increased heart rate and gasping for air. Some people will still experience distress and anxiety when the distressing experience is no longer there. For example, they might experience symptoms of anxiety and distress when they are exposed to something that reminds them of the event, such as hearing fireworks or other loud noises, or seeing images of wounded people. Anxiety and distress can cause people to avoid situations that remind them of the event or situations where they are surrounded by other people. In this way, anxiety and distress can affect their daily life functioning. There are different forms of anxiety disorders, such as Panic Disorder, Social Phobia and Generalized Anxiety Disorder. Overall it is important to note that if the anxiety is considered excessive and affects the behaviour of the patient, for example when the patient engages in avoidance behaviour, the symptoms might meet the criteria for a disorder and it is advisable to refer him or her to an institution that offers psychological treatments (https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml).
Feelings that can be developed after a distressing event, such as helplessness, shame and guilt, can lead to feelings of sadness. If this feeling continues after the distressing event, it can affect someone’s daily life. Individuals suffering from depression might experience a depressed mood, numbness, loss in interest, loss of energy and suicidal thoughts. Moreover, depressive symptoms impair functioning on a social, occupational and educational level and are associated with worrying, feeling tense, being withdrawn in relationships and social isolation. To be diagnosed with depression, the symptoms must be present for at least two weeks. In this case, it is advisable to refer the patient to an institution that offers treatment for depression. Refugees and asylum-seekers have an increased risk of developing symptoms of depression, for example after losing a loved one or experiencing war conflicts (https://www.nimh.nih.gov/health/topics/depression/index.shtml).
2.4.3 Physical expressions of distress
Research indicated that people who have experienced distressing events can develop somatic complaints, such as fatigue, muscle aches, lower back pain and nausea. These complaints often do not have a physical cause, but are related to the distressing experiences. These complaints are described as unexplained somatic complaints. For example, somatic symptoms that are associated with depression are changes in appetite, lack of energy, sleeping difficulties and pains such as headaches, abdominal aches and backaches. Somatic complaints can affect someone’s daily life, for example causing someone to avoid social contact, as they do not have energy for it (Roelofs & Spinhoven, 2006).
Everybody deals with the loss of a loved one in a different manner, resulting in different pathways of reactions. For example, grief can include feelings of guilt, thinking about death and a decrease in joy and pleasure. Although there is no grief diagnosis in the diagnostic and statistical manual of mental disorders V, grief is noted as a possible stressor that can possibly lead to mental health issues, such as depression. The majority of people who are exposed to losing a loved one experience some disruptions in their daily life, which are considered a normal reaction to loss (www.centrum45.nl). If the grief does not reduce after a year and the missing of the loved one continues, it may be a case of complicated grief, which very likely requires professional help. However, it is important to assess whether or not the reactions are outside someone’s cultural norm. How people experience and express grief, differs across cultures and is often related to customs, rituals and religion. For example, grief might be expressed louder or for a longer period in some cultures than in others (for more information on grief, see Parkes & Prigerson, 2013).
2.4.5 Substance abuse
If someone is suffering from symptoms such as re-experiences, sleeping difficulties and feelings of sadness, they might try out different ways to cope. Some people try to cope by substance use, for example by drinking alcohol. A risk of alcohol is that large quantities are needed to decrease negative feelings. In addition to alcohol, people can use soft drugs or hard drugs as a way to cope. Drugs can have several negative effects, such as symptoms of anxiety and depression. Substance abuse can affect someone’s daily life and can lead to health issues, financial difficulties and addiction.
Find more information on: https://www.jellinek.nl/english/
2.4.6 Post-traumatic stress disorder (PTSD)
PTSD is an anxiety disorder that can be developed after being exposed to a traumatic event where an individual was directly exposed, witnessed, or was indirectly exposed to actual or threatened death, serious injury or violence. PTS-symptoms can be divided into symptoms of intrusion, avoidance, negative changes in cognitions and mood and changes in arousal. Symptoms of intrusion can be recurrent and intrusive memories of the events, traumatic nightmares and flashbacks. Avoidance might present itself through avoiding thoughts and feelings about the traumatic events, as well as avoiding persons, places, situations that remind the individual about the traumatic events. Negative changes in cognitions and mood include memory issues and negative ideas about the self and the world. Arousal symptoms can be irritable behaviours and difficulties concentrating. Additionally, individuals suffering from PTSD might have dissociative symptoms, described as periods of feeling detached from oneself or experiencing a distortion of experiences. If the symptoms last for at least one month and affect the daily life functioning, the symptoms might meet the clinical criteria for a disorder. In this case, someone is likely in need of professional help (American Psychiatric Association, 2013).
- For an elaborate description of mental health psychosocial support and first aid for refugees, rapid assessment of mental health and psychosocial needs of refugees, see
- For a free e-learning course concerning mainly the mental health problems of Syrian refugees and interventions for their mental health and psychosocial wellbeing, see Refugee Care[e]Education: http://www.healthefoundation.eu/get/7100/444/refugee-care-e-education-online-
- NICE guideline PTSD: https://www.nice.org.uk/guidance/CG26/chapter/1-Guidance
- Articles on trauma: http://www.ejpt.net/index.php/ejpt/pages/view/theme
- Psychological First Aid: http://www.nctsn.org/content/psychological-first-aid
- Victims of torture: http://www.centroexil.org/actualidad/categoria/3/id/88
- Mental health and psychosocial support: https://data.unhcr.org/mediterranean/download.php?id=280
2.5 Screening, treatments and tools
2.5.1 Screening and assessment
Refugees are at an increased risk of developing mental health issues. Nevertheless, mental health screening is the least frequent component of medical screening in newly arrived refugees and asylum-seekers. However, it is of great importance that refugees in need of psychosocial- or mental health care are identified and offered the help they need. In order to screen for those in need of immediate psychosocial help, you can start by identifying refugees who seem disoriented or overwhelmed (see triage). After identifying a distressed person, try to approach them calmly and engage with them. In this way, try to establish a basic trustful relationship. The purpose of engaging in a conversation with a distressed person is to assess the risk they pose to themselves and others, to calm them down and to offer practical assistance if needed. You can also offer to do a grounding exercise with them. Both engaging in conversation and grounding exercises will be discussed in more detail in the second section of this module. In addition, it is important to identify available resources, so that immediate practical assistance can focus on strengthening them. These elements of assessment are shown in Table 3, while in the text below, we give practical guidance in conducting this conversation.
Once the initial triage is conducted and no visible signs of distress are identified, some form of mental health screening can be conducted.
Figure 2 Screening procedures (Ajdukovic & Bakic, 2016)
Table 2 Rapid assessment during triage (assessed by caregiver) (Ajdukovic & Bakic, 2016)
|Distress level||0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10|
|Personal safety or safety of other people endangered||No Yes|
|Resources (note up to 3 most important resources)||1.
Example of a grounding exercise:
“Sit in your chair, and have your feet firm on the ground. Feel the back of the chair against your back. Feel the way you sit on the chair, focus on that.”
“(as a next step:) Notice that when the stress increases, your breathing goes faster. In fact, there is a difference – the way you breathe is from your breast – the higher part of your rump. In order to feel more relaxed, less tense, you’ll need to breathe from your stomach. Let’s try: do like me: take a deep breathe through your nose, hold it, and while counting to 7 (slowly, show) you breathe out through your mouth. Repeat this.”
“Look around in this room, and list out loud all the things you see that are coloured blue (or any colour).”
“Be aware: this is […Diemen, the Netherlands, May 27th]. You came here by train, you are in the room of the doctor. … etc.”
In order to screen for symptom intensity, you can use the RHS-13, a screening tool assessing symptoms of PTSD, anxiety and depression. This instrument was specifically designed for and validated on newly arrived refugees and migrants with items derived from existing and valid instruments used on similar populations. Link: http://www.lcsnw.org/pathways/
When a refugee has developed a mental health disorder as a result of being exposed to distressing events, he or she is possibly in need of a trauma-focused treatment by a trained psychologist, psychotherapist or psychiatrist. Trauma Focused Cognitive Behaviour Therapy (TF-CBT) is a treatment that has been proven effective in treating trauma-related symptoms, such as symptoms of PTSD. It focuses on the traumatic memories, the negative thoughts and the behaviour that has resulted from the traumatic experience. Three key components of TF-CBT are psycho-education, recognizing and changing distortions in cognitions and behaviour and exposure to the traumatic memories. In TF-CBT exposure is often used, for example by letting the patient recall memories of the traumatic event. The patient can also be exposed in vivo, which entails that the patient is directly exposed to something or a situation that he or she is afraid of (Hinton, Rivera, Hofmann, Barlow & Otto, 2012).
One treatment that can be offered to refugees is Eye Movement Desensitization and Reprocessing (EMDR). EMDR is an individual treatment that focuses on the processing of traumatic experiences. EMDR requires the client to think about their traumatic memory, including images, thoughts and feelings related to the memory. When the client has a memory in mind, he or she is exposed to a distracting stimulus. This stimulus might be a hand or a light-bar moving from side to side. After a short period of exposure to the distracting stimulus, the client is asked what comes to mind: this can be thoughts, images, feelings or bodily sensations. For a description of EMDR, see: http://www.emdr.com/what-is-emdr/
Another treatment that can be offered to refugees after witnessing potentially traumatic events is the Brief Eclectic Psychotherapy for PTSD (BEPP). BEPP focuses on processing the traumatic experiences and allowing and accepting painful feelings and thoughts related to the event. The first session of BEPP focuses on the traumatic experiences. The subsequent sessions entail a relaxation exercise and retelling the experiences in detail. In this way, the client can use an object that reminds him or her of the distressing experience. As homework the client writes a letter to someone or an institute he or she finds responsible for the trauma or the consequences of the trauma. This letter is written in order to express anger and is not send in reality. The letter can also be used as a way to say goodbye to someone. For a description of BEPP, see http://www.traumatreatment.eu/assets/uploaded/68-contentofbepp.pdf
A third treatment is Narrative Exposure Therapy (NET). This treatment also focuses on processing the potentially traumatic events. NET starts with placing flowers and stones along a string. The flowers represent the beautiful moments in one’s life. The stones represent the distressing or traumatic moments. After this, the client names the flowers and stones. In subsequent sessions, the stones and flowers will be discussed in detail chronologically, exposing the client to the traumatic experiences. For a description of NET, see: http://media.psychology.tools/worksheets/english_us/narrative_exposure_therapy_en-us.pdf
2.5.3 Diversity and cultural sensitivity
Geographical distance and having roots in different parts of the world do make a difference on held-beliefs about one-self, the social environment, disease and health and professionals. The word ‘acculturation’ is used to refer to a dynamic process that starts when people from different cultural backgrounds meet. It is not to say that the arriving minority 100% adapts to the dominant majority; some traditions will be lost, others will be kept. Moreover, there is a generational difference: children tend to have a different speed in adjusting to the new surroundings, because of quicker use of local language and schooling.
In the literature on cultural diversity, cultural sensitivity is emphasized. Cultural sensitivity refers to a general attitude of being respectful, interested in the other – the norms, values and other believes and last but not least – being aware of one’s own believes derived from a cultural heritage. Because culture is never static and always changing and dynamic, this attitude is found to be crucial for effective communication.
- Refugees often face issues pre-flight, during their flight and during resettlement
- These issues can lead to mental health problems
- Most distress symptoms are normal reactions to an abnormal situation
- Try to identify those in immediate need of help by screening