Mental Health of Refugees and Asylum Seekers: Assessment and Intervention

Family and Systemic Approach

Individual patients should be assessed in the context of their family, community, and larger social milieu. This follows an “ecological framework” that attends to microsystems (attachment, social support, caregiver mental health), mesosystems (schools, neighbourhoods), and macrosystems (political policies, regional host culture). ^{9 , 13} Including family members in the assessment can help facilitate the development of a trusting relationship with the clinician, and is especially crucial as war and other forms of organized violence tend to implicate the entire family, rather than just one individual. ¹⁴ The identified patient may therefore represent only one face of the family’s difficulties, and, further, enforcing ties between family members may be protective to vulnerable family members. ¹⁵ When family members are present for interviews, the clinician should be mindful of confidentiality in general and within the family’s specific ethno-cultural community. ¹⁴

Separation from family members during migration causes suffering both because of loss but also because of fear for the safety of the absent family members if they remain in peril in the country of origin. ¹⁵ As one study showed, ¹⁶ children separated from their parents for over 2 years had greater rates of depression and anxiety than non-separated children. Diagnostically, attending to family separation is also important, as fear for a family member’s safety may aggravate mental health problems, especially PSTD, where threat is perceived as ongoing.

At the systemic level, post-migratory stressors are strongly linked with poor psychological outcomes (see Hynie, in this issue). A significant body of research has examined how factors within the host country, such as socioeconomic stress, social and interpersonal difficulties, and the challenges inherent in the immigration process, contribute to poor mental health. ^{7 –9 , 17} Refugees with access to housing, for example, have better mental health outcomes than those without access. ¹⁸ While several factors were correlated to changes in PTSD symptoms, a recent study examining a cohort of 195 adult trauma-affected refugees in Denmark showed that secure employment was particularly associated with improvements in PTSD. ¹⁹ Regarding the immigration process, Canadian research has shown an increase in psychiatric disorders among detained asylum seekers as compared with an equivalent group of refugee claimants living in the community. ²⁰ In both children and adults, having precarious status is associated with PTSD. ^{3 , 8, 21 –23} A recent review suggests that 94% of unaccompanied refugee minors experienced traumatic or stressful events during migration or during the resettlement processes. ²⁴ The level and amount of emotional support received after resettlement predicts the course of depressive symptoms, post-traumatic stress symptoms, and anxiety level, as does the warmth of the host country. ²⁴ It is therefore critical that clinicians attend to these post-migratory determinants of refugee mental health, particularly because patients may feel these fundamental stressors are not appropriate to speak about with physicians. ^{14 , 25}

Interpreters and Cultural Brokers

A systematic review ²⁶ found improved clinical care when interpreters were used for all patients speaking a non-dominant language. Other research has suggested that interpreters can increase the level of disclosure in clinical encounters. ²⁷ Canadian guidelines recommend that lay interpreters and family members should not be used. ¹⁴ Although many hospitals may rely on allied health professionals to interpret, there is a risk that, in trying to be helpful to their colleague, these interpreters may gloss over patient’s hesitations or organize content which may be relevant to the mental status exam. When children are used as interpreters, parents may not disclose traumatic material or, inversely, children could be exposed to traumatic content. A practical approach to working effectively with interpreters has been outlined in the Canadian Guidelines for Immigrant Health ¹⁴ and Leanza et al have developed guidelines for clinicians as well as institutions. ²⁸ When institutions fail to provide access to professional interpreters, refugee patients are at risk of receiving substandard care. ²⁹

Cultural brokers can also be useful in the clinical evaluation of refugees. Their role is to facilitate the interpretation and negotiation of non-linguistic cultural content and differences. ^{28 , 30}

Screening

Refugees with trauma-related disorders, including depression and anxiety, often differ from other populations with PTSD. Some of the differences include a history of multiple traumatic events, the impossibility of returning home to safety, being identified as a racialized minority, socioeconomic stress, or fractured communities and social networks. ³¹ Diagnostic assessment and screening therefore requires a specialized approach. Canadian guidelines emphasize the imperative to avoid over-diagnosis and medicalization of suffering, ^{32 , 33} and thus recommend against routine screening in the primary care setting to avoid false positives. ³⁴

Whereas refugees typically experience high rates of pre-migratory trauma, mental health professionals should avoid urging disclosure of trauma, especially in the preliminary encounter, because of the risk of inducing trauma, stigma, and the impact of such disclosure on families and communities. ³³ When trauma is disclosed, practitioners should take an empathic and supportive stance, ¹⁵ especially given that refugees may face incredulity in other contexts, such as at the refugee hearing. ³⁵

Diagnosis

Refugees who are referred to mental health services from the community may be more likely to have psychiatric disorders than those in primary care settings; however, clinicians should remain cognizant that reactions to traumatic disclosures may incite referrals, rather than signs of a disorder itself. In other words, there may be various reasons why refugees find themselves in specialized mental health settings, and distress and social suffering—individual and collective suffering resulting from socially generated ills ³⁶ —should be distinguished from disorder. ³⁷

Diagnosis is further complicated by research evidence that stress-related disorders in refugees may present with unique symptomatology not necessarily captured in ICD-10 or DSM-5 criteria. ^{31, 6} For example, a Swiss study of severely traumatised refugees and asylum seekers suggests that the severity of PTSD symptoms is predicted by somatisation and anger. ¹⁷ There is much research to support the notion that distress may be expressed through physical symptoms. ¹⁴ Dissociation, brief reactive psychoses, psychotic depression, and conversion symptoms, though rare, could also be associated with PTSD or a post-traumatic presentation. ¹⁵

Culture can influence all aspects of the illness experience and the expression of distress. It is therefore important to consider the patient’s culturally specific explanatory models for their difficulties to promote cultural safety and to ensure that interventions will address the true concerns of the patient. ^{14 , 32 , 38} The Cultural Formulation Interview (CFI), included in the DSM-5, may help to elicit refugees’ cultural identity, their illness narrative(s), cultural elements of their psychosocial environment, and mechanisms for coping and adaptation. ^{39 , 40} Patients may be reticent to discuss their ethnocultural background with clinicians, especially if they have been previously persecuted or stigmatized based on identity. Thus, clinicians should communicate how such information can be supportive of assessment and treatment. ⁴¹

Special Considerations in the Assessment of Refugee Children

The assessment of refugee children and youths should follow the ecological approach described above, attending to the child as an individual, and within the contexts of family, community, and the broader sociocultural system. Likewise, as in adult populations, clinicians should avoid medicalization of difficulties, given that, despite significant adversity, some research shows that refugee children may have better mental health outcomes than host country children. ^{13 , 42 , 43}

Cumulative traumatic exposure may increase the risk of psychopathology, ¹³ and post-migratory stressors are associated with an increased risk, ⁹ with some evidence that, in youths, exposure to post-migratory stress is a stronger predictor of psychological problems than pre-migratory trauma. ⁴⁴ Being a recipient of an attack or observing violence towards others, specifically witnessing a mother’s torture or experiencing the violent death of a family member were shown to be predictors of PTSD in young resettled refugees. ³ The challenges of reunification after long absence from family members should be explored, because such family transformations come with the redefinition of family roles, that pose challenges and conflict. ¹⁵ There is also research with refugee children confirming that parental psychopathology increases the risk of child psychiatric problems, ⁴³ and thus care or treatment for parents is often a central part of a child’s intervention.

Children may present with concerning symptoms, such as sleep disturbance, nightmares, grief reactions, inattention, withdrawal, somatization, and disruptive behaviours yet not meet the criteria for PTSD. ¹³ All these symptoms should alert mental health professionals to a possible disorder, although assessment must consider the level of impairment and distress. ¹⁵

Types of Interventions

Children and Youth

With children, as with adults, a pyramidal and phased approach is recommended. ^{13 , 45 , 46} Research has emphasized that schools, primary care physicians, and community workers are at the front line in providing support to asylum-seeking and refugee children and, as such, should be provided with resources and training. ¹³ Clinical models of service have been developed to help provide a multi-layered, multi-disciplinary, collaborative care that allows community-based professionals (for example, teachers, family doctors, social workers) to be linked with specialized mental health clinicians to guide interventions or intervene with a smaller percentage of children and families. ^{13 , 61 , 62}

Vicarious Traumatization and Vicarious Post-Traumatic Growth in the Clinician

While traumatology has historically focused on the risks of vicarious traumatization to the clinician, there is increasing research on more complex and bi-directional processes between patient and practitioner. Vicarious traumatization refers to the risk that therapists may become traumatized themselves through exposure to trauma narratives. ⁶⁵ Researchers have acknowledged that the transmission of trauma also confers the possibility of post-traumatic growth and resilience to the clinician ⁶⁵ and that, through bearing witness, the care provider is not just a recipient of vicarious harm but also the receiver of a “precious gift.” ³⁵ There is also clinicians’ potential retaliation in the context of the transmission of trauma. Rousseau and Foxen ³⁵ have documented this phenomenon in the setting of the refugee determination process, in which adjudicators respond to narratives of trauma with subtle forms of retaliation, such as avoidance or denial. Clinicians working with refugees should be aware of these possible reactions in themselves, recognizing both the opportunities for vicarious growth and the risks of unwitting participation in aggression toward our patients. ⁶⁶