June 20, 2014 marked the 14th Annual International Refugee Day, an event first celebrated in 2001 with the 50th anniversary of the 1951 Geneva Refugee Convention, when international guidelines for the protection of refugees were established. International Refugee Day is intended to bring attention to challenges of the millions of individuals who have fled their homes due to political violence, threat of persecution, or human rights violations.
This year the plight of those who have been forcibly displaced is particularly salient given the humanitarian crises occurring in many parts of the world. According to the recently released annual report of the United Nations High Commissioner for Refugees (UNHCR, 2014), at the end of 2013 there were 51.2 million individuals who had been forcibly displaced, including internally displaced persons (IDPs), refugees and asylum seekers. In 2013 there were an estimated 2.5 million new refugees, more than 8 million individuals displaced within their home countries, and 1.1 million individuals who filed asylum claims that had not yet been determined. These figures make 2013 the year with the greatest number of displaced persons on record (UNHCR, 2014).
Individuals who have been forcibly displaced have often been exposed to multiple potentially traumatic events and face ongoing stress associated with migration and resettlement. Hardships may include discrimination, lack of support, difficulty finding employment and challenges adapting to a new culture (Miller & Rasmussen, 2010). These and other challenges faced by IDPs and those who have sought refuge in a foreign country have increasingly been addressed in both the mental health literature and the popular media over the past several years. Some of the key issues include prevalence of trauma related distress and difficulties with adaptation, human rights concerns of individuals seeking asylum and the appropriateness and effectiveness of existing therapeutic interventions.
Precise estimates of psychological disorders have been difficult to ascertain given the heterogeneity of the population. Furthermore, questions regarding the suitability of psychological constructs and assessment measures developed with predominately Western populations have been raised (Murray, Davidson, & Schweitzer, 2010;Rasmussen, Keatley, & Joscelyne, 2014). PTSD and depression as defined in Western psychiatric nosology, however, have been the most frequently evaluated disorders in the literature to date. Results of meta-analyses suggest the proportion of refugees suffering from these disorders is between five (Fazel, Wheeler, & Danish, 2005) and 30 percent (Steel et al., 2009). Rates of psychological difficulties among those with insecure residency status are likely even higher (Kalt, Hossain, Kiss, & Zimmerman, 2013; Stenmark, Catani, Neuner, Elbert, Holen, 2013).
Whereas refugees have been granted international protection, asylum seekers have made requests for protection typically from country to which they fled, but their claims have yet to be determined. Depending on the immigration policy of the country, asylum seekers may be detained in a correctional facility or similar setting, in some cases for extended periods of time, before adjudication of their cases (Kalt et al., 2013). Personal accounts of maltreatment and traumatization while detained (Center for Victims of Torture, 2013) as well as retrospective and prospective research showing the detrimental impact of detention on mental health (see Robjant, Hassan, Katona, 2009 for meta-analysis) have contributed to controversy over such policies in high income countries where large numbers of individuals seek asylum each year including the United States, Canada, and Australia.
Documentation of high distress levels and ongoing life stressors among this population leads to the question of how to best intervene. Treatment interventions with forcibly displaced individuals in humanitarian settings and high income countries have included trauma-focused, empirically-based treatments and more broadly focused psychosocial and supportive interventions. There has been some debate over which of these approaches is most appropriate (Miller & Rassmussen, 2010); however, outcome data is primarily available for trauma-focused models (Tol et al., 2011) including variants of cognitive-behavior therapy (e.g., Hinton, Rivera, Hofmann, Barlow, & Otto, 2012) and narrative exposure therapy (Schauer, Neuner,& Elbert, 2011). Although results of research on trauma-focused therapies with this population are encouraging overall, these studies are few in number and there is significant variability in outcome that has yet to be explained (Lambert & Alhassoon, in review).
Given the growing of number individuals who have been forcibly displaced and the diversity among this population, additional research on mental health issues and treatment is clearly needed in order to develop more comprehensive guidelines for best practices. Research involving culturally-based explanations of symptoms is of particular importance to gain a more in-depth understanding of how individuals from different backgrounds understand and make meaning of their experience (Rasmussen et al., 2014; Tol et al., 2011). Studies that examine treatment process as well as outcome would also be beneficial for improving our understanding of how to best facilitate change with this population. Such research will likely hold important implications for mental health and human rights policy.
About the Author
Jessica E. Lambert, PhD, is an assistant professor in the Psychology & Child Development department at California State University, Stanislaus. Her research program is primarily focused on the long term impacts of war-related and interpersonal violence. Current projects include an investigation of risk and resiliency among traumatized Iraqi refugee families, and evaluation of factors associated with of adaptation among Tamil war widows in Sri Lanka. She teaches courses in research methods, trauma and crisis intervention, and community mental health. Clinically, she has treated survivors of torture, adult survivors of childhood abuse, as well as male and female veterans.
Center for Victims of Torture (2013). Tortured and detained: Survivor stories of US immigration detention. Retrieved from http://www.cvt.org/sites/cvt.org/files/Report_TorturedAndDetained_Nov2013.pdf
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in Western countries: A systematic review. The Lancet, 365(9467), 1309–1314. doi: 10.1016/S0140-6736(05)61027-6
Hinton, D. E., Rivera, E. I., Hofmann, S. G., Barlow, D. H., & Otto, M. W. (2012). Adapting CBT for traumatized refugees and ethnic minority patients: examples from culturally adapted CBT (CA-CBT). Transcultural psychiatry, 49(2), 340-365. doi: 10.1177/1363461512441595
Kalt, A., Hossain, M., Kiss, L., & Zimmerman, C. (2013). Asylum seekers, violence and health: A systematic review of research in high-income host countries. American Journal of Public Health, 103(3), e30-e42 doi:10.2105/AJPH.2012.301136
Lambert, J.E. & Alhassoon, O. (in review). Trauma focused therapy for refugees: Metaanalytic findings. Manuscript submitted for publication.
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine, 70(1), 7-16. doi: 10.1016/j.socscimed.2009.09.029
Murray, K. E., Davidson, G. R., & Schweitzer, R. D. (2010). Review of refugee mental health interventions following resettlement: best practices and recommendations. American Journal of Orthopsychiatry, 80(4), 576-585. doi: 10.1111/j.1939-0025.2010.01062.x
Rasmussen, A., Keatley, E., & Joscelyne, A. (2014). Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature. Social Science & Medicine, 109, 44-54. doi: 10.1016/j.socscimed.2014.03.015
Robjant, K., Hassan, R., & Katona, C. (2009). Mental health implications of detaining asylum seekers: systematic review. British Journal of Psychiatry, 194(4), 306-312. doi: 10.1192/bjp.bp.108.053223
Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy. A short term treatment for traumatic stress disorders. Cambridge, MA: Göttingen, Hogrefe & Huber.
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & Van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537-549.doi:10.1001/jama.2009.1132
Stenmark, H., Catani, C., Neuner, F., Elbert, T., & Holen, A. (2013). Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behaviour Research and Therapy, (51), 641-647. doi: 10.1016/j.brat.2013.07.002
Tol, W. A., Barbui, C., Galappatti, A., Silove, D., Betancourt, T. S., Souza, R. & Van Ommeren, M. (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. The Lancet, 378(9802), 1581-1591. doi: 10.1016/S0140-6736(11)61094-5
United Nations High Commissioner for Refugees (2014). UNHCR Global Trends 2013. Retrieved from http://www.unhcr.org/5399a14f9.html