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Key points
- Interventions should target stressors in the here-and-now, and not focus solely on healing war trauma.
- Mental health interventions for refugees can be effectively implemented by trained community members.
- To support the well-being of refugee children, it’s essential to support their parents and schools.
The global refugee crisis has heightened awareness of the impact that war and forced migration have on people’s mental health. Refugee crises are ultimately political problems that require political solutions (e.g., an end to the violence and persecution from which refugees have fled, integration of refugees into their host societies, etc.). However, they are also humanitarian crises requiring urgent responses to the material and psychosocial needs of people who have endured extreme violence and left everything behind to find safety in a foreign land.
Although a minority—currently about 25%—of refugees live in high-income countries, the great majority live perilous lives in refugee camps, informal settlements, and cities in low- and middle-income countries with limited resources (and often limited will) to support impoverished refugee communities. Consequently, we see a reliance on international aid, restrictions on employment to prevent refugees from taking local jobs, and a transformation from an initially warm welcome, to growing resentment and hostility by the host society if refugees overstay their welcome or are not effectively integrated into their new country.
Not surprisingly, rates of psychological distress among refugees are significantly higher than those found in populations not impacted by war and displacement. Although a majority of refugees show remarkable resilience given all they have endured, elevated rates of depression, anxiety, PTSD, and culturally specific forms of distress reflect the enduring toll of traumatic war experiences and the stressful nature of everyday life in exile.
Fortunately, we have learned a lot in the last 25 years about how (and how not) to support the healing and adaptation of refugees so that they can manage successfully, and even thrive, in their new environment.
Lesson 1: The mental health of refugees is affected at least as powerfully by their current life circumstances as it is by the violence and loss from which they have fled. The most effective interventions target the conditions of life in the here-and-now, as well as the effects of war-related violence and loss.
In the wake of massive refugee influxes from Southeast Asia and Latin America into North America, Europe, and Australia in the 1970s and 1980s, mental health professionals prioritized the assessment and treatment of PTSD, a newly established diagnosis that seemed to fit the picture of distress seen among many refugees. It was assumed that most of their suffering reflected the enduring psychological harm caused by the violence they had endured in their homeland.
This assumption was by no means entirely wrong. But it reflected a flawed and incomplete analysis. One of the most powerful findings from research in the past 25 years is the discovery that distress among refugees is caused at least as much by the everyday conditions of their lives in exile as it is by anything they experienced before leaving their homeland. Poverty, discrimination, restrictions on work, the loss of social support networks, a lack of access to healthcare and education, and chronic uncertainty about the future can take a terrible toll on mental health. These chronic stressors can also increase family violence, which is toxic for mental health.
Fortunately, conditions in the here-and-now can be changed. For example, community centers and religious settings can foster new social support networks and reduce isolation, while offering training in locally valued skill sets (e.g., language classes, new livelihood skills). Cash transfer programs and changes in labor restrictions can reduce poverty and lead to income generation. Innovative education programs, often using tablets and smartphone technologies, can make education available even in remote settings, and school personnel can be trained to recognize and support the particular needs of refugee students and parents.
This isn’t to suggest we should discount the reality of war trauma among refugees or fail to treat it. There will always be a need for effective methods of healing the enduring trauma of war among refugees. The point is simply that the distress we see among refugees is deeply influenced by the conditions of their lives in here-and-now. And importantly, those stressful conditions may impede people’s natural ability to recover from the trauma of war.
Lesson 2: In our earlier focus on war trauma, we overlooked the centrality of loss and the grief to which it gives rise.
In its overly narrow focus on PTSD, the mental health field overlooked the pervasive nature of loss among refugees, and the grief to which it gives rise. Not all refugees have experienced the violence of war firsthand; some are able to escape before the war reaches their village or city. But all refugees have left their worlds behind—loved ones and possessions and a deeply rooted sense of place and belonging. Although most refugees gradually overcome their grief, a significant minority remain stuck in what we now call traumatic grief, which can be healed through interventions but otherwise may persist for years. (To learn more, see my post “What Do Refugees Leave Behind?”)
Lesson 3: Mental health interventions for distressed refugees can be effectively implemented by trained community members with no formal education in mental health.
Well-trained community members, with no formal training in mental health, can effectively implement a mental health intervention with refugees. We now know that this model, commonly called task shifting, shows great promise and has become a widely used approach to implementing mental health interventions in low-resource settings where mental health professionals are scarce. It’s even been shown to be an effective way of closing the treatment gap in high-income countries, where the demand for mental health treatment among refugees far exceeds the availability of trained professionals. Task-shifting is a game-changing approach, because it means we can dramatically increase the reach of mental health interventions.
Lesson 4: To support the well-being of refugee children, it’s essential to support their parents and teachers.
In contrast to mental health interventions for adult refugees, which have shown promising results, interventions for refugee children have been comparatively disappointing. This isn’t because children’s distress is more persistent or severe; instead, the most compelling explanation is that children are continually impacted by the two primary settings in which they spend much of their days: home and school. We know that refugee parents experience high levels of stress, and may struggle with trauma, depression, or anxiety. This increases the risk of harsh parenting, and makes it harder to provide their children with the sort of loving, nurturing interactions they need in order to thrive. No surprise then, that mental health interventions that only target children, while ignoring the stressful home environments to which they may be returning each day, show limited effects.
Likewise with schools: we now know that discrimination by non-refugee peers is a major source of distress among refugee children; consequently, trying to ameliorate their distress without targeting the discrimination that is contributing to it, is a poor recipe for success. Moreover, teachers in refugee communities are often struggling with the same types of stressors as the parents of their students, making it even more difficult for them to teach effectively in conditions of ongoing adversity.
Fortunately, there are empirically supported interventions that have been shown to improve refugee children’s well-being by strengthening the well-being and parenting of their parents. There are also innovative approaches to making schools more welcoming to refugee pupils, with several demonstrating highly encouraging outcomes. The Dutch non-governmental organization (NGO) War Child (where I worked for six years) has developed a promising approach to supporting teachers' own well-being in refugee and other conflict-affected communities, called CORE.
This isn’t to say there’s no need for mental health interventions that work directly with refugee children. Rather, the point is to underscore the reality that children live within a social ecology that includes their family, school, and community—settings that can be sources of stress and distress, or that can foster resilience and help refugee children adapt and thrive.
Lesson 5: Supporting the dignity of refugees as fellow human beings who are fleeing nightmarish situations is essential to supporting their mental health.
The media tend to portray refugees in heartbreaking snapshots of despair: clinging to the side of an overcrowded boat, standing aside the rubble of their bombed-out home, or shivering inside tents in impoverished refugee camps. The images reflect a certain reality, of course, but what they don’t convey are the complex and meaningful lives people lived before they were forced into exile. We don’t see the skilled physician a woman used to be, the gifted teacher a man once was, the star basketball player a teenager was before war or persecution forced them into the nowhere-land of a refugee camp and reduced their identity, in the eyes of the world, to “refugee”. It’s not a status anyone desires, and can feel like a source of shame, particularly when all of one’s previously valued social and professional roles are wiped away or made invisible.
One of the simplest ways to begin healing the pain of the refugee experience is to meet refugees person to person, human to human, asking about and recognizing the many roles and identities hidden beneath the label of refugee. When we reduce refugees to vulnerable and psychologically wounded recipients of aid and charity, we deny their dignity and their capacity to collaborate in the creation of new and meaningful lives in whatever setting has become their de facto new home.
