Refugee mental health and human rights: A challenge for global mental health

Abstract

This article introduces a thematic issue of Transcultural Psychiatry that presents recent work that deepens our understanding of the refugee experience—from the forces of displacement, through the trajectory of migration, to the challenges of resettlement. Mental health research on refugees and asylum seekers has burgeoned over the past two decades with epidemiological studies, accounts of the lived experience, new conceptual frameworks, and advances in understanding of effective treatment and intervention. However, there are substantial gaps in available research, and important ethical and methodological challenges. These include: the need to adopt decolonizing, participatory methods that amplify refugee voices; the further development of frameworks for studying the broad impacts of forced migration that go beyond posttraumatic stress disorder; and more translational research informed by longitudinal studies of the course of refugee adaptation. Keeping a human rights advocacy perspective front and center will allow researchers to work in collaborative ways with both refugee communities and receiving societies to develop innovative mental health policy and practice to meet the urgent need for a global response to the challenge of forced migration, which is likely to grow dramatically in the coming years as a result of the impacts of climate change.

Keywords

advocacy cultural psychiatry human rights refugee mental health

This year marks the 70th anniversary of the 1951 Geneva Convention relating to the Status of Refugees, which enshrined in international law the obligation to protect those fleeing war and persecution. Yet despite the right to protection, the global response to the growing “migration crisis,” as it is often termed, vacillates between measured humanism and outright hostility. The rise of powerful forms of xenophobic populism (nativism, white supremacy) and the urgency of COVID-19 preventative measures are powerful forces that have led to sealed borders. These challenges demand renewed commitment, understanding, and strategies to ensure the protection of refugee mental health and human rights.

This issue of Transcultural Psychiatry presents recent work that deepens our understanding of the refugee experience—from the forces of displacement, through the trajectory of migration, to the challenges of resettlement. In 2017, we published a thematic issue organized by the Transcultural Section of the World Psychiatric Association, with a call for humanitarian action on refugee policy and mental health (Bäärnhielm et al., 2017). Since that time, the world has continued to witness dramatic levels of forced migration greater than what followed World War II. More than 100 million people have been displaced this past decade (UNHCR, 2020), though the reality that low- and middle-income countries host the vast majority remains unchanged. A decade earlier, nearly 10 million displaced people found a way to return to their countries of origin, but due to protracted wars and social conflict, in the past decade fewer people in exile have been able to return home. More people are seeking protection than ever before, but their options for rebuilding a secure life are increasingly limited, a trend exacerbated by the COVID-19 pandemic.

Refugee rights in an era of populism and polarization

The Refugee Convention recognizes the need to preserve territorial sovereignty and the responsibility of nations to protect the stateless (Benhabib, 2020). The ambivalent reception that refugees receive in host countries reflects the inherent tension between these two goals. Since the construction of refugee as a category in human rights discourse 70 years ago, many nations have welcomed displaced peoples and immigrants, as was the case right after the adoption of the Convention when those seeking safety were primarily of European origin (Silove et al., 2017). In later decades, however, with larger influxes of racialized, non-European displaced persons, and rises in unemployment in high-income countries, hostility toward migrants has increasingly prevailed over hospitality (Fassin, 2012; Silove et al., 2017) The criminalization and restriction of immigration gained further impetus in the wake of the attacks of 9/11 (Rousseau et al., 2015), and continues with public rhetoric insisting on the need to protect and preserve the rights and resources of the majority, who perceive themselves to be threatened by migration (Kronick & Rousseau, 2015). This rhetoric frames refugees as dangerous and burdensome to the host society, undermining the legitimacy of their claims to asylum as a basic human right (Jarvis, 2020). Nationalist populist discourse and practice have moved from the margins to center stage, as seen with the Brexit movement in the UK as well as the polarized and ‘isolationist’ politics in the United States (Inglehart & Norris, 2016). This 21st-century version of populism—which has been theorized as emerging from economic disparities and as a form of cultural backlash against progressive values, including ‘multiculturalism’ (Inglehart & Norris, 2016)—too often leaves the human rights of migrants as a privilege bestowed entirely at the discretion of host nations (Crépeau, 2018).

In the current climate, as human rights and international law are increasingly sidelined in public discourse, we see illness and vulnerability, as well as childhood, emphasized as central features of refugeehood in an effort to garner empathy, compassion, and more humane responses. The image of the innocent refugee child who elicits compassion stands in sharp contrast to the criminalized, racialized migrant adult inciting calls for border walls. In the US, these tensions culminated in the catastrophic policy of the Trump administration to separate refugee children from their parents at the border (Maclean et al., 2019). While the policy was reversed in response to international public outcry, over 1,000 children remain separated in the United States (Jordon 2021), and similar human rights abuses continue to be enacted, albeit on smaller scales, in many places (e.g., Bureau, 2020).

The efforts to control borders and protect dominant groups promote representations of migrants as dangerous, illegitimate interlopers, who deserve rapid deportation without due process. These representations trivialize, minimize, or make invisible the experiences of refugees, and thus undermine their claims to protection as well as blocking avenues to self-advocacy and participation in justice movements (Boochani & Tofighian, 2018). The arguments for restricting asylum reflect a failure of empathy and a zero-sum logic, “rooted in a deficit/surplus dichotomy in which refugees are contrasted with citizens” (Boochani & Tofighian, 2018, p. 389). The dilemma this poses for mental health practitioners has been well documented: if the medicalization of social suffering renders a refugee’s claim legitimate (symbolically and legally), then professionals called on to certify the reality of the psychic scars may inadvertently downplay refugee resilience, self-efficacy, and power (Fassin, 2012; Kirmayer, 2002; Ticktin, 2011). Caught between polarizing pro- and anti-refugee sentiments, care providers, psychiatric services, and mental research enter terrain in which “the domains of psychiatry and politics become thoroughly entangled” (Kirmayer, 2002, p. 728). Charting a course toward effective care and advocacy requires careful analysis of the politics of identity, power, and privilege, which reflect structural and systemic racism, and concerted efforts to articulate a vision of global civil society founded on social justice, equity, and diversity (Jammermann, 2020; Shachar, 2020).

Shutting the door on the contaminated other

Metaphors of the infectious foreigner are pervasive in recent public discourse, in which refugees and immigrants are often represented as invasive ‘swarms’ (Ticktin, 2017). As the global COVID-19 pandemic continues to unfold, the power of these metaphors is evident: they are treated as literal truth, despite the lack of evidence that refugees are responsible for the spread of infectious disease and robust evidence that migrants do not represent a burden to host country health care systems (Aldridge et al., 2018; World Health Organization, 2021). Asylum seekers and refugees are now regularly turned away at borders, in violation of international principals of non-refoulement (Kluge et al., 2020). Asylum seekers barred from entering Canada have faced detention in the U.S. and, in some cases, deportation without an asylum hearing (Coletta, 2020). The Trump regime in the U.S. mobilized xenophobic fears to legitimize the ‘Remain in Mexico’ program, leaving more than 69,000 asylum seekers—including children of all ages—in peril in a setting where reports of murder, exploitation, kidnapping, and sexual assault are common (Human Rights Watch, 2021). While in February 2020 a federal appeals court found that the U.S. policy caused “extreme and irreversible harm,” COVID-19 postponed hearings, leaving tens of thousands of involuntary migrants stranded (Human Rights Watch, 2021). From March 2020—and justified by COVID-19 border closure—US Immigration and Customs Officials summarily expelled asylum seekers without entry documents, robbing them of their right to an asylum claim (Blue et al., 2021). In Greece, Human Rights Watch has reported the beating and expulsion of Lebanese and Syrian asylum seekers (Human Rights Watch, 2020b), while unaccompanied children, adult asylum seekers, and families have been trapped in squalid refugee camps where COVID-19 outbreaks are common (Human Rights Watch, 2020a). The Moria camp, which hosted four times the number of people it was built for, was ravaged by fire this in September 2020, leaving over 10,000 asylum seekers temporarily homeless (Khamoosh, 2020; Lowen, 2020; UN News, 2020). Of course, the circumvention of international obligations to protect refugees did not begin with COVID-19 (Benhabib, 2020), but the pandemic has aggravated the situation. State and structural violence produce and target migrants—the vast majority of whom are from racialized groups—and this demands a collective reckoning and response (Fox et al., 2012; Garner, 2007; Maneri, 2021; Olmos, 2019; Silverstein, 2005).

Involuntary migration is not expected to slow in the coming decade. Indeed, climate change will force massive population displacements—especially in low- and middle-income countries—due to rising sea levels, floods, fires, hurricanes, and other natural disasters, while also exacerbating global inequalities through drought, poverty, and food insecurity. In 2019, 135 million people were estimated to be experiencing acute food insecurity. This dire situation will almost certainly get worse. Resource scarcity and loss of territory will in turn drive increased conflict. With no provisions in the current Refugee Convention for those fleeing the widespread impacts of climate change, the global community will face an unprecedented humanitarian crisis in the coming years (Berchin et al., 2017; Docherty & Giannini, 2009; Hayes et al., 2018; Shultz et al., 2019).

Research challenges

Mental health research on refugees and asylum seekers has burgeoned over the past two decades (Silove et al., 2017) to pursue a number of important lines of inquiry. These include: epidemiological studies (Morina et al., 2018); accounts of the lived experience of migrants in diverse social-political contexts (Bosworth, 2014; Jenkins, 2008; Valibhoy et al., 2017); the development of conceptual frameworks that go beyond PTSD to consider other impacts of refugee trauma, forced migration, and resettlement (Hynie, 2018; Kirmayer et al., 2018; Silove, 2013; Tay & Silove, 2017; Tuomisto & Roche, 2018); and advances in the understanding of effective treatment and intervention (Almoshmosh et al., 2019; De Haene & Rousseau, 2020; Kronick, 2018; Silove et al., 2017). Despite this growing literature, there are substantial gaps in available research, and important ethical and methodological challenges to engaging in rigorous, trustworthy studies informed by a decolonizing perspective (Lawrence & Hirsch, 2020). Here we outline three particular dilemmas and directions that warrant further study.

Research in the field has to this point been primarily about refugees and migrants. Less research has been done with refugee communities—with important exceptions (e.g., Dantas & Gower, 2020; de Smet et al., 2020; Müller-Funk, 2020). While participatory methodologies may be ideal (see Wood & Kallestrup, 2021), there are real ethical and pragmatic challenges to including migrants as partners in research teams. As the former UN Special Rapporteur on the Human Rights of Migrants, Professor François Crépeau, has pointed out:

Migrants constantly exercise agency, often have considerable underground support networks and make life-altering decisions on a regular basis. However, migrants rarely publicly protest, contest, organize, unionize, mobilize or go to court. Sticking their neck out may mean being detected by the authorities as undocumented, or identified by the employer as a troublemaker, the consequence of which may be detention and deportation. Repression creates fear, which is a key part of the political strategy. (Crépeau, 2018)

Given that silence is often a survival strategy (De Haene et al., 2018; Rousseau et al., 2001), the question of when and how to amplify migrant voices requires careful ethical reflection and consideration of the relative power and privilege of ‘non-displaced’ researchers. The call for ‘nothing about us without us’ demands a shift in our methodological approaches and consistent effort on the part of researchers to avoid repeating the exploitation and exclusion that result in epistemic injustice (Fricker, 2007).

An ongoing challenge in transcultural mental health research with migrants is advancing conceptualizations of health and illness that are multilevel and systemic (Silove et al., 2017). This calls for an ecosocial perspective that integrates neurobiology, psychology, and individual experience with broader social and cultural contexts across time (Kirmayer & Gómez-Carrillo, 2019a). With more integrative models, we can better capture the complex interactions between neurobiological, social, and political processes and forms of agency mobilized by individuals facing intractable situations (Kirmayer & Gómez-Carrillo, 2019b). For refugees and migrants, as in other marginalized communities:

there is a patterning of conditions of social danger that make events of trauma all but routine … Comprehending this problem […] requires a clear recognition of a social-historical pattern of structural violence … that conduces to a reciprocal shaping of subjective experience and social structural relations. This reciprocal shaping can create inarguably tangible forms of psychic anguish as a bodily matter of lived experience. (Jenkins, 2015, p. 216)

Over the next decade, the research agenda must develop more integrative frameworks to anchor epidemiological, clinical, and social studies of refugee mental health. This is one reason that interdisciplinarity is essential to the field of refugee mental health studies.

Finally, researchers and clinicians committed to the care of refugees and migrants face the important challenge of translating research into practice. Several obstacles impede this translation. One of these is the dearth of longitudinal epidemiological studies clarifying the temporal course of distress, psychopathology, adaptation, and recovery (Silove et al., 2017). Very few refugees remain symptomatic over time, but among those who do, what are individual, communal, and ecosocial factors that determine their outcomes? How can mental health services be tailored to support refugees at various points in their migration trajectory? A second barrier to knowledge translation is the stark reality that in resource-scarce settings where large communities are affected by mass conflict, professionalized mental health care is simply unavailable (Silove et al., 2017). Indeed, even many resource-rich nations lack adequate community and mental health support. Providing such community services demands a re-imagining of integrated, multi-tiered, ecosocial, mental health services (Inter-Agency Standing Committee, 2007) that include asylum seekers and refugees as collaborators and facilitators of peer-led intervention.

New research in this issue

The articles in this issue address three broad themes: the experience of displacement, models of refugee mental health that go beyond the focus on PTSD, and the experience of resettlement.

Displacement and seeking asylum

Four articles address the experiences of the displaced, grappling with their embodied distress, the prevalence of mental disorder, predictors of resilience, and the possibilities of participatory research approaches with this population.

Murphy and colleagues (2021) used semi-structured narrative interviews with African asylum seekers in Ireland to reveal the multidimensional nature of their distress, liberated from the confines of psychiatric diagnosis, providing an intimate portrait of what is most at stake for asylum seekers. The authors identify four overarching themes: relentless rumination, shame and self-loathing, anger and mistrust, as well as demoralization and hopelessness. Their findings reveal the prolonged suffering that asylum seekers face over the course of migration, including frequent self-harm and struggles to establish a new footing that are exacerbated by the harsh conditions they encounter.

Selmo and colleagues (2021) examined the mental health consequences of the civil war in Syria, through a cross-sectional survey of the general population. They found that being from an active war zone, older, and female all conferred a higher risk of psychological disorders like posttraumatic stress (nearly 50%), moderate to severe depression (43%), and somatization (nearly all respondents). Interestingly, they found a complex relationship between religiosity and distress, while social support and recognition of victim status were associated with less risk of PTSD. They note that online interventions show promise, especially for vulnerable groups like women and the elderly, because online delivery may circumvent barriers to access and reduce the stigma associated with service use.

A growing number of studies focus on resilience among refugees (Atallah, 2017; Panter-Brick et al., 2018; Simich & Andermann, 2014). Wilson and colleagues (2021) employ cross-sectional mixed methods to evaluate resilience factors in Palestinian children, including supportive relationships, education, and social participation in an environment with an overall lack of resources. The authors draw attention to the balance between gaining access to resources while limiting the associated risks; for example, curtailing education to work at a young age just to survive, or being loyal to friends even if this means risking trouble with Israeli soldiers. Sex differences in resilience point to the importance of family relationships for girls and of friends for boys.

Wood and Kallestrup (2021) review the benefits and challenges of implementing participatory approaches in community-based mental health and psychosocial support in displaced populations. Key considerations include resolving the divide between community-based and evidence-based approaches, attending to local versus standardized outcome measures, making room for local idioms in diagnostic categories, and taking into account local power structures and how they may be impacted by programs and interventions. Despite these dilemmas, the authors conclude that participatory community-based mental health psychosocial support is essential to understanding displacement as a context-laden human experience.

Refugee trauma and beyond

Refugees face violence, loss, disruption to the fabric of social life, prolonged uncertainty about their future, and myriad challenges adapting to new environments, whether the ‘temporary’ conditions of camps or the long-term process of resettlement. Although refugee research has given much weight to the impact of trauma exposure through the construct of PTSD, this diagnostic category captures little of what is distinct about the refugee experience. Accordingly, there is a great need for work that widens the view to examine other dimensions of distress.

Sleep quality is a sensitive but non-specific indicator of emotional distress, health, and wellbeing. Bruck and colleagues (2021) survey sleep disturbances among South Sudanese refugees in Australia. Sleep difficulties were associated with memories and dreams of past trauma, and gradually improved over time. The authors argue for the importance of sleep quality as a target for intervention, which has its own clinical challenges (Sandahl et al., 2017).

Nyarko and Punamäki (2021) conducted life history interviews with Liberian refugees living in a refugee camp in Ghana to explore their experiences of trauma and resilience following their forced migration as adolescents. Participants recounted terrible privations associated with the war but also describe positive impacts on their lives related to increased empathy and compassion for others and appreciation of the beauty of life. Their narratives thus fit the typical description of intrusive symptoms of PTSD but also reflect the processes of post-traumatic growth and resilience.

Symptom network analysis is a novel method for analyzing the mutual reinforcing effects of symptoms that can yield insight into cross-cultural variation in syndromes (Borsboom & Cramer, 2013). Yuval and colleagues (2021) present a network analysis of data from Sudanese and Eritrean asylum seekers who completed the Harvard Trauma Questionnaire. They found evidence for a trauma syndrome broadly related to DSM-IV-TR criteria for PTSD. However, symptoms formed clusters not adequately distinguished by the PTSD construct, including: Diurnal Re-Experiencing; Nocturnal Re-Experiencing & Anxious Arousal; Avoidance & Emotion Dysregulation; Depression Cognitive Impairment; and Interpersonal Fear-Withdrawal. The prominence of specific clusters varies across individuals and they interact with each other to give rise to particular syndromes. Decomposing symptom clusters in this way may lead to better understanding of underlying mechanisms which may not involve core characteristics of a disorder but interactions between multiple functional symptoms which are configured not only by neurobiology but also by cultural models and interpersonal interactions (Borsboom et al., 2019; Kirmayer et al., 2017).

Resettlement

The prolonged uncertainty while awaiting determination of refugee status can force people to put their lives ‘on hold.’ This can have profoundly damaging effects on mental health because it creates a sense of loss of control or powerlessness and limits the ability to invest in future-oriented action. Even after acceptance, however, refugees face many stresses related to rebuilding their lives in a new land. This can be exacerbated by racism, xenophobia, and other forms of marginalization and discrimination, which are fueled by local and global politics (Kirmayer, 2019).

Hocking (2021) studied the experience of asylum seekers awaiting determination of their refugee status in Australia. Based on interviews with 187 claimants, her qualitative findings illuminate the “ubiquitous insecurity and uncertainty experienced by asylum seekers,” and how their social suffering often resists a psychiatric framing, requiring what Hocking calls a “psycho-social-political lens” to understand it. As one participant puts it, “I’m just a lonely person. It’s something that a counsellor doesn’t help because they can’t bring my wife.” Hocking discusses the central importance of inclusive social policy in promoting asylum seekers’ wellbeing in the face of social suffering.

Also working in Australia, Copolov and Knowles (2020) conducted interviews with young Hazara refugees using the lens of Silove’s (2013) ADAPT framework as well as Erikson’s developmental stages to examine adaptation about seven years after resettlement. Discrimination, racism, and a sense of injustice emerged as important factors disrupting participants’ sense of security. The authors also point to significant gender differences in identity development during resettlement.

Further addressing gender differences in refugee experience, Vromans and colleagues (2019) report findings from a prospective cohort study of ‘at-risk’ refugee women in Australia that examined the contributions to psychological distress of trauma events, loss events, level of post-migration problems, and lack of trust in community members. Although losses and trauma exposure were significant determinants of distress, post-migration problems were the most robust determinant of psychological distress. This points to the vital importance of the overall societal attitude toward refugees as well as the availability of post-migration support to address emerging problems.

Mond and colleagues (2021) explore the relationship between resettled Iraqi refugees’ awareness of their own PTSD symptoms and their attitudes toward help-seeking. Those who recognized PTSD symptoms were, unsurprisingly, more likely to seek mental health care. The authors discuss how an individual’s understanding of mental health may be central to service use, while also raising questions about the validity and meaning of PTSD as a diagnostic category. Their research demonstrates that there is a need for better understanding of how refugees’ illness experiences and help-seeking propensity influence key outcomes including quality of life, functioning, and symptoms.

The final article in this issue by Salami and colleagues (2021) does not directly address refugees but considers related issues, outlining an ecological approach to the treatment of foreign-born victims of human trafficking (some of whom become asylum seekers despite legal barriers; Moser, 2018). The authors guide clinicians through the levels of individual, interpersonal, community, and societal considerations relevant to the care of trafficked immigrants, focussing on the U.S., highlighting resources and clinical approaches. The ecological approach they outline can be applied to the assessment of refugees as well, by taking into consideration the kinds of specific challenges uncovered by the research presented in many of the other studies presented here.

Conclusion

The papers in this issue of Transcultural Psychiatry offer a vivid portrait of the symptoms and suffering endured by refugees as well as their resilience in diverse contexts. This work has many lessons for policy makers seeking to devise humane and effective processes of reception and social integration, for public health programs and community organizations aimed at mental health promotion, as well as for clinicians providing mental health care. What is clear is that the context of resettlement plays a crucial role in refugee mental health (Beiser & Hou, 2017; Hynie, 2018). Policy and practice must recognize the persistent effects of trauma and displacement and the ongoing challenges of building a new life in societies marked by structural inequities.

Refugees constitute a heterogeneous group defined by a common social and political situation of forced migration. In studying refugee mental health, then, we face the methodological challenge of distinguishing aspects of illness experience that are due to differences in individual psychology, life history, cultural background, migration trajectory, or the context of resettlement. Comparative studies of specific groups in different settings can help clarify some of these contributors to illness and resilience. Comparisons of countries or regions with differing migration policies and practices can highlight the benefits of particular approaches.

At a time of unprecedented levels of displacement, as many countries have sought to turn back refugees seeking safety (UNHCR, 2021), we are faced with the ever more urgent moral and legal imperative to protect the human rights and health of migrants. What are the roles of researchers, educators, and clinicians engaged in mental health care for refugees in addressing these human rights issues, given the global, structural, and political dimensions of the task? Research, including first-person perspectives, can support advocacy by producing knowledge that can inform sound policy development in the domains of health and immigration. For clinicians focussed on person-centered care for the individual, the duty to ‘do no harm,’ central to medical ethics, requires that we confront the structural violence embedded in our own health care institutions, policies, and practices. Bearing witness to the refugee patient’s experience leads naturally to advocacy for individuals but can also mobilize larger efforts to challenge injustice (Lennon, 2017). The growing interdisciplinarity of research in the field—represented by some of the work in this issue—is critical for enhancing the mental health of asylum seekers and refugees because it can enlarge our awareness of their predicament, increase our capacity for critical reflection, and energize collective action.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Rachel Kronick is a clinician-scientist based at the Sherpa and Lady Davis Research Institutes. She is an Assistant Professor affiliated with the Division of Social and Transcultural Psychiatry of McGill University. Her clinical work as a child and adolescent psychiatrist is based at the Centre for Child Development and Mental Health at the Jewish General Hospital. Her research has looked at immigration policy and its consequences for children and families, with a specific focus on immigration detention. Currently her research interest is participatory-action research with asylum seeking communities to develop and implement ecosocial mental health interventions.

G. Eric Jarvis, MD, MSc is Associate Professor of psychiatry at McGill University & Director of the Cultural Consultation Service and the First Episode Psychosis Program at the Jewish General Hospital. His clinical work involves the psychiatric evaluation and treatment of immigrants and refugees in addition to patients with early psychosis. His current research interests include the relation between psychosis and culture, the process of cultural consultation, and language barrier to mental health services. Dr. Jarvis also writes about the history of psychiatry.

Laurence J. Kirmayer is James McGill Professor and Director of the Division of Social and Transcultural Psychiatry at McGill University and Editor-in-Chief of Transcultural Psychiatry. He directs the Culture and Mental Health Research Unit at the Jewish General Hospital, where he conducts research on culturally responsive mental health services, the mental health of indigenous peoples, and the anthropology of psychiatry.

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