Part I--the mental health impacts of migration: the law and its effects failing to understand: refugee determination and the traumatized applicant

To strive, to seek, to find, and not to yield: Narratives on the road to asylum

This study aimed to explore the ecological influences on subjective well-being identified by current and former community-dwelling asylum seekers engaged in the process of Refugee Status Determination in Australia. This article presents the qualitative component of a prospective mixed-methods study of 131 asylum seekers and refugees (T1, N = 131; T2, N = 56). The Framework Analysis method was employed to qualitatively analyse the narrative data derived from 187 semi-structured interviews documenting pre-, peri-, and post-migration experiences, and the impact of Australia's asylum policies and procedures. Four overarching themes comprising 15 sub-themes emerged: The Refugee Status Determination process (Waiting; Uncertainty; Worry); Psychosocial factors (Un/employment & gainful activity; Medicare; Accommodation; Family separation & loneliness; Loss); Health and well-being (Mental health; Physical health & somatic issues; Hopelessness; Helplessness); and Protective factors (Hope; Support & social connectivity; Religion). The complex interface between the Refugee Status Determination process, un/employment, and mental health concerns was the most salient finding. Policy implications are discussed in relation to the application of the Convention and Protocol Relating to the Status of Refugees and the Guidelines on the Judicial Approach to Expert Medical Evidence.

Finding Keys: A Systematic Review of Barriers and Facilitators for Refugee Children's Disclosure of Their Life Stories

The systematic review presented in this article aims to reveal what supports and hampers refugee children in telling their, often traumatic, life stories. This is important to ensure that migration decisions are based on reliable information about the children's needs for protection. A systematic review was conducted in academic journals, collecting all available scientific knowledge about the disclosure of life stories by refugee minors in the context of social work, guardianship, foster care, asylum procedures, mental health assessment, and therapeutic settings. The resulting 39 studies were thoroughly reviewed with reference to what factors aided or hampered the refugee children's disclosure of their life stories. The main barriers to disclosure were feelings of mistrust and self-protection from the side of the child and disrespect from the side of the host community. The facilitators for disclosing life stories were a positive and respectful attitude of the interviewer, taking time to build trust, using nonverbal methods, providing agency to the children, and involving trained interpreters. Social workers, mentors, and guardians should have time to build trust and to help a young refugee in revealing the life story before the minor is heard by the migration authorities. The lack of knowledge on how refugee children can be helped to disclose their experiences is a great concern because the decision in the migration procedure is based on the story the child is able to disclose.

'Valuable but incomplete!' A qualitative study about migrants' perspective on health examinations in Stockholm

Background

A voluntary health examination is offered to asylum seekers in Sweden with the purpose of detecting infectious diseases and identifying other health needs. This study aimed to explore the organization, content and perceived value of the health examination from the perspective of asylum seekers.

Methods

Semi-structured interviews were conducted with 18 migrants recruited from different settings in Stockholm. Data were transcribed verbatim and analysed using thematic analysis in relation to the availability, accessibility, acceptability and quality framework.

Results

Participants reported positive aspects of the health examination while raising important concerns, categorized into the following themes: availability-despite being available, the service was considered to be delayed with perceived implication for infection control; accessibility-migrants experienced no physical or economic barrier to access the health examination, especially when it was performed through a mobile clinic, however, they had limited access to information; acceptability and quality-migrants trusted the health staff, however, the examination lacked important aspects related to mental health and dental care needs, among other health needs.

Conclusion

Health examinations are valued by participants but failed to identify and address many perceived health needs. Mobile clinics seem a practical strategy to improve accessibility.

Recently arrived refugee children: The quality and outcomes of Best Interests of the Child assessments

Best Interests of the Child (BIC) assessments provide migration authorities with behavioral information about which interests of the child could be taken into account before a decision is made on the request for a residence permit. This study provides insight into the quality and outcomes of BIC assessments with 16 unaccompanied children (15-18 years) and 11 accompanied children (4-16 years) who have recently arrived in the Netherlands and requested asylum (N = 27). The results suggest that BIC assessments provide relevant information that enables assessors to determine the best interests of recently arrived refugee children. The inter-rater reliability of the BIC-Questionnaire, an instrument that evaluates the child-rearing environment and that is one of the components of the BIC assessment, was fairly good. The children in the sample had experienced a high number of stressful life events and a majority reported trauma related stress symptoms or other emotional problems. The quality of the child-rearing environment in the country of origin had protected their development insufficiently in the past and would not protect their development sufficiently in the future. The results show that in many cases forced return to the country of origin can put children's development at risk.

Knowledge of the Unknown Child: A Systematic Review of the Elements of the Best Interests of the Child Assessment for Recently Arrived Refugee Children

Decision-making regarding an asylum request of a minor requires decision-makers to determine the best interests of the child when the minor is relatively unknown. This article presents a systematic review of the existing knowledge of the situation of recently arrived refugee children in the host country. This research is based on the General Comment No. 14 of UN Committee on the Rights of the Child. It shows the importance of knowing the type and number of stressful life events a refugee child has experienced before arrival, as well as the duration and severity of these events. The most common mental health problems children face upon arrival in the host country are PTSD, depression and various anxiety disorders. The results identify the relevant elements of the best interests of the child assessment, including implications for procedural safeguards, which should promote a child rights-based decision in the asylum procedure.

"If I speak English, what am I? I am full man, me": Emotional impact and barriers for refugees and asylum seekers learning English

Lack of proficiency in the language of the host country predicts distress among refugees, but many refugees and asylum seekers in the United Kingdom have less than functional English. This study examined how learning English affected refugees' and asylum seekers' lives, particularly their emotional wellbeing, to explore what factors, particularly psychological ones, facilitated or impeded their learning English. We recruited 16 refugees and asylum seekers from an inner-city National Health Service trauma service and from a charity providing one-to-one English classes. All participants were interviewed in English. Interview data were analysed using thematic analysis from a critical realist perspective. Interviewees provided consistent accounts of their efforts to learn English, integrated into often unsettled and difficult lives. The analysis generated six themes in two domains. The impact of learning English was mainly positive, associated with autonomy, sense of achievement, and aspirations. Barriers to learning English consisted of other problems affecting refugees' capacity to learn, limited opportunities to speak English, and a sense of shame associated with perceived lack of English language competence. Findings highlight the need to provide adequate psychological support for refugees and asylum seekers learning English, recognising its importance in promoting both their integration in the UK and their individual psychological well-being.

Health Assessment and the Right to Health in Sweden: Asylum Seekers' Perspectives

BACKGROUND

Swedish law entitles asylum seekers to a voluntary health assessment and to "health care that cannot be postponed". The last expression suggests, however, restrictions on the entitlement, and what it may or may not include remains ultimately a decision for health professionals in the specific case. Indeed, the health assessment constitutes the sole active effort from Swedish authorities to fulfill this right. This study was therefore aimed at assessing how the information, procedures and services related to the health assessment are accessible and acceptable to fulfill the right to health of asylum seekers, from their own perspective.

METHODS

The study has a cross-sectional design. A questionnaire was administrated in 16 language schools for immigrants, in four counties of Sweden. Three hundred eighty-six individuals fulfilled the inclusion criteria. The frequency of their answers was tabulated to estimate how the information, procedures and services related to the health assessment correspond to the criteria for accessibility and acceptability regarding the right to health.

FINDINGS

Forty-eight (12.4%) respondents did not undergo the health assessment. Thirty-one of them did not even receive the invitation letter. They said they lost the opportunity to know their health status, to obtain treatment for or advice about their health problems. Additionally, 55.2% of those who attended the health assessment indicated that their needs were overlooked, particularly when these were of a psychological nature. Two in three participants also considered the health assessment to be a communicable disease control, rather than an effort to take care of their health needs. Nevertheless, the respondents had a positive attitude towards the health assessment as such.

CONCLUSIONS

Although being an important contribution, the health assessment does not suffice to fulfill the right to health of asylum seekers because there are shortcomings regarding the accessibility and acceptability of the information, procedures and services that it includes.

Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: results of a longitudinal study

BACKGROUND

A significant proportion of trauma survivors experience an additional critical life event in the aftermath. These renewed experiences of traumatic and stressful life events may lead to an increase in trauma-related mental health symptoms.

METHOD

In a longitudinal study, the effects of renewed experiences of a trauma or stressful life event were examined. For this purpose, refugees seeking asylum in Germany were assessed for posttraumatic stress symptoms (PTS), Posttraumatic Stress Diagnostic Scale (PDS), anxiety, and depression (Hopkins Symptom Checklist [HSCL-25]) before treatment start as well as after 6 and 12 months during treatment (N=46). Stressful life events and traumatic events were recorded monthly. If a new event happened, PDS and HSCL were additionally assessed directly afterwards. Mann-Whitney U-tests were performed to calculate the differences between the group that experienced an additional critical event (stressful vs. trauma) during treatment (n=23) and the group that did not (n=23), as well as differences within the critical event group between the stressful life event group (n=13) and the trauma group (n=10).

RESULTS

Refugees improved significantly during the 12-month period of our study, but remained severely distressed. In a comparison of refugees with a new stressful life event or trauma, significant increases in PTS, anxiety, and depressive symptoms were found directly after the experience, compared to the group without a renewed event during the 12 months of treatment. With regard to the different critical life events (stressful vs. trauma), no significant differences were found regarding overall PTS, anxiety, and depression symptoms. Only avoidance symptoms increased significantly in the group experiencing a stressful life event.

CONCLUSION

Although all clinicians should be aware of possible PTS symptom reactivation, especially those working with refugees and asylum seekers, who often experience new critical life events, should understand symptom fluctuation and address it in treatment.

Linkages between mental health need and help-seeking behavior among adolescents: Moderating role of ethnicity and cultural values

Risk of developing emotional and behavioral mental health problems increases markedly during adolescence. Despite this increasing need, most adolescents, particularly ethnic minority youth, do not seek professional help. Informed by conceptual models of health behavior, the current study examined how cultural values are related to help seeking among adolescents from 2 distinct racial/ethnic groups. Using a prospective survey design, 169 Vietnamese American and European American youth in 10th and 11th grade reported on their mental health need, as measured by emotional/behavioral mental health symptoms and stressful life events, with participants reporting on their help-seeking behavior at 6-month follow-up assessments. Multinomial logistic regression analyses indicated that mental health need interacted with cultural values and ethnicity to predict help-seeking behavior. Specifically, associations between symptoms and stressful life events, and help-seeking behavior were smaller among Vietnamese American adolescents, and among adolescents with strong family obligation values. These results underscore the complex sociocultural factors influencing adolescents' help-seeking behavior, which have important implications for engaging youth in needed mental health care.

Impact of asylum interviews on the mental health of traumatized asylum seekers

BACKGROUND

Asylum interviews within the asylum procedure are associated with psychological stress for traumatized asylum seekers. This study investigates the impact of asylum interviews on the mental health in a sample of 40 traumatized asylum seekers. The comparison group consisted of refugees (N=10) that had not been invited to an asylum interview. Additionally, the moderating effects of trial-related variables such as perceived justice of the trial, stress of giving testimony, and stress of waiting for the asylum interview were examined.

METHOD

Participants were assessed on average 10 days before (t1) and 16 days after (t2) the asylum interview. Chi-square tests for dichotomous and categorical variables were used to compare the descriptive statistics of the two groups. To investigate symptom changes from t1 to t2, paired t-tests were calculated. The magnitude of effects was measured by Cohen's effect size d within groups. Hierarchical regression analyses were conducted for demographic and trial variables predicting posttraumatic intrusions, avoidance, and hyperarousal.

RESULTS

Data showed a significant increase in posttraumatic intrusions and a significant decrease in posttraumatic avoidance and hyperarousal symptoms from t1 to t2. No significant symptom changes in the posttraumatic stress disorder subscales were found in the comparison group. The results of hierarchical regression analyses revealed perceived justice of the interview to predict the increase of intrusions and the number of experienced traumata and testimony stress to predict posttraumatic avoidance.

CONCLUSIONS

The present findings underline the stressful impact of asylum interviews on traumatized refugees. They indicate that the asylum interview might decrease posttraumatic avoidance and trigger posttraumatic intrusions, thus highlight the importance of ensuring that the already vulnerable group of traumatized refugees needs to be treated with empathy during their asylum interview.

A mixed-method study of expert psychological evidence submitted for a cohort of asylum seekers undergoing refugee status determination in Australia

The levels of exposure to conflict-related trauma and the high rates of mental health impairment amongst asylum seekers pose specific challenges for refugee decision makers who lack mental health training. We examined the use of psychological evidence amongst asylum decision makers in New South Wales, Australia, drawing on the archives of a representative cohort of 52 asylum seekers. A mixed-method approach was used to examine key mental health issues presented in psychological reports accompanying each asylum application, including key documents submitted for consideration of asylum at the primary and review levels. The findings indicated that the majority of decision makers at both levels did not refer to psychological evidence in their decision records. Those who did, particularly in the context of negative decisions, challenged the expert findings and rejected the value of such evidence. Asylum seekers exhibiting traumatic stress symptoms such as intrusive thoughts and avoidance, as well as memory impairment, experienced a lower acceptance rate than those who did not across the primary and review levels. The findings raise concern that trauma-affected asylum seekers may be consistently disadvantaged in the refugee decision-making process and underscore the need to improve the understanding and use of mental health evidence in the refugee decision-making setting. The study findings have been used to develop a set of guidelines to assist refugee decision makers, mental health professionals and legal advisers in improving the quality and use of psychological evidence within the refugee decision-making context.

Security and subjective wellbeing: the experiences of unaccompanied young people seeking asylum in the UK

This article considers the relevance of the notion of ontological security - a sense of order, stability, routine and predictability to life - to contemporary conceptualisations of wellbeing. Drawing on in-depth interviews with unaccompanied young people seeking asylum in the UK, it demonstrates how a positive sense of self and being able to visualise a place and role in the world into the future were integral to their notion of wellbeing, offering an important counter to the pervasive sense of living in limbo. The article argues that this fundamental need for a projected self is largely neglected in contemporary discussions on wellbeing. To date the idea of security as a determinant of wellbeing has been primarily constructed around the notion of protection from harm and the provision of the requirements for physical, emotional, economic and social wellbeing in the here and now. Findings from this research suggest that those providing services and support to young people who have experienced trauma need to consider how they might best nurture in them a sense of place, belonging and security into the future. Equally, they have implications for how we conceptualise and operationalise wellbeing more generally.

Trauma, exile and mental health in young refugees

OBJECTIVE

To review evidence of trauma and exile-related mental health in young refugees from the Middle East.

METHOD

A review of four empirical studies: i) a qualitative study of 11 children from torture surviving families, ii) a cohort study of 311 3-15-year-old asylum-seeking children, iii) a qualitative study of 14 members of torture surviving families and iv) a follow-up study of 131 11-23-year-old refugees.

RESULTS

The reactions of the children were not necessarily post-traumatic stress disorder specific. Seventy-seven per cent suffered from anxiety, sleep disturbance and/or depressed mood at arrival. Sleep disturbance (prevalence 34%) was primarily predicted by a family history of violence. At follow-up, 25.9% suffered from clinically relevant psychological symptoms. Traumatic experiences before arrival and stressful events in exile predicted internalizing behaviour, witnessing violence and frequent school changes in exile predicted externalizing behaviour. School participation, Danish friends, language proficiency and mother's education predicted less long-term psychological problems.

CONCLUSION

Psychological problems are frequent in refugee children, but the extents are reduced over time in exile. Traumatic experience before arrival is most important for the short-term reaction of the children while aspects of life in exile are important for the children's ability to recover from early traumatization.

Feelings of betrayal by the United Nations High Commissioner for Refugees and emotionally distressed Sudanese refugees in Cairo

Thousands of Sudanese refugees have fled to Cairo, Egypt in the wake of Sudanese civil conflicts. Sudanese refugees were evaluated with respect to symptoms of depression, post-traumatic stress disorder (PTSD) and social stress. Four respondents (22%) indicated that their interactions with the United Nations High Commissioner for Refugees (UNHCR) in Cairo, Egypt were the worst experiences since war-related atrocities. Fourteen participants (63.6%) felt 'extremely' betrayed by the UNHCR on a four point scale. Greater feelings of betrayal by the UNHCR were associated with greater avoidance and arousal symptoms of PTSD, symptoms of depression and trait anger. This is the first study of which we are aware that examines the relationship between sense of betrayal by the UNHCR and symptoms of PTSD, depression and anger among asylum seekers.

Mental health of failed asylum seekers as compared with pending and temporarily accepted asylum seekers

BACKGROUND

Asylum seekers (AS) and refugees often suffer from severe psychopathology in the form of post-traumatic stress disorder (PTSD). As PTSD impacts memory functions, and as asylum applications rely on personal accounts, AS with PTSD are at more risk of being rejected than refugees.

METHODS

We studied the mental health of failed asylum seekers (FAS, N = 40) and a matched sample of AS (N = 40). Participants were administered structured interviews on sociodemographics, flight, exile and standardized questionnaires on PTSD, anxiety, depression and pain.

RESULTS

Both samples were severely affected; >80% exhibited at least one clinically significant condition.

CONCLUSION

Given the great vulnerability of these individuals, long and unsettling asylum processes as practised in Western host countries seem problematic, as does the withdrawal of health and social welfare benefits. Finally, high rates of psychopathology amongst FAS indicate that refugee and humanitarian decision-making procedures may be failing to identify those most in need of protection.

Status and health security: an exploratory study of irregular immigrants in Toronto

BACKGROUND

This qualitative study explores experiences of living without regular immigration status and implications for health security among irregular migrants in Toronto. Irregular migrants include those who lack secure status in Canada, including visitors who overstay visas; refugee claimants awaiting status determination; and failed claimants remaining in the country without authorization, awaiting deportation or following alternative procedures when judicial appeal is impossible.

METHODS

In-depth, semi-structured interviews were conducted with irregular migrants recruited at a downtown community health centre. Interview transcripts were coded and analyzed using grounded theory and qualitative analytical techniques. The theoretical framework employed anthropological metaphors of liminality and examined psychosocial factors associated with stress.

FINDINGS

Experiences of the study sample counter popular assumptions about irregular immigrants. The majority of study participants came to Canada to escape violence as well as lack of economic opportunity in home countries in Latin America, and most have tried to follow correct immigration procedures. Most are parents working in low-paying, exploitative jobs. They have attempted to lead productive and meaningful lives, but lack social support beyond the immediate family. They showed signs of suffering from trauma, depression, chronic stress, family separation and stress-related physical illnesses. Despite expressing self-esteem and using personal coping skills effectively, many reported unmet health needs and described barriers to help-seeking. Beyond the individual, the greatest impact of living without status appeared to be on the family, especially the children.

CONCLUSIONS

More comprehensive information about this growing population is needed for health promotion, provision of mental health services and fair policy formulation.

No refuge from terror: the impact of detention on the mental health of trauma-affected refugees seeking asylum in Australia

The final decades of the twentieth century were accompanied by an upsurge in the number of persons fleeing persecution and regional wars. To stem the flow of asylum seekers, several countries in the west introduced policies of deterrence, including detention. Although many countries detain asylum seekers, Australia has been unique in establishing a policy of mandatory, indefinite detention. The impact of prolonged detention on the mental health of asylum seekers drew commentary from mental health professionals soon after the policy was introduced, but administrators and politicians disputed the assertion that detention was a factor in causing or exacerbating mental disorder. This overview examines the impact of mandatory, indefinite detention on the mental health of asylum seekers by drawing on evidence gathered during Commissions of Inquiry, from observations of health and mental health professionals who have worked in detention centres, and from the small body of systematic research undertaken among immigration detainees. The data from all sources converge in demonstrating that prolonged detention has adverse mental health and psychosocial impacts on adults, families and children. Recent studies suggest that the mental health effects may be prolonged, extending well beyond the point of release into the community. The Australian experience offers general lessons to health professionals worldwide about the importance of remaining vigilant in protecting the rights of vulnerable groups, and more specifically, to ensure that the traumas that cause mental suffering in refugees are not compounded as a consequence of immigration policy decisions in recipient countries. Documentation and research can be vital in achieving policy change in these settings.

Asylum claims and memory of trauma: sharing our knowledge

Decisions about asylum are extremely difficult because of the absence of a body of objective evidence. Psychiatrists and psychologists have a breadth of knowledge relating to the memory of trauma which could help to inform the asylum process, but we need to investigate how to apply this knowledge and how to make it accessible to decision makers.