Applied Psychology OPUS

Psychological Well-being of Refugees Throughout the Relocation Process

Mila Hall

Because of the continuing conflicts in war-torn areas such as the Gaza Strip and Syria, refugee well-being is quickly becoming an inescapable reality. A refugee is someone who has fled his or her country of origin to escape extremely adverse situations, seeking asylum, or trying to reach a safer environment to live in. For example, people who fled Europe during World War II would be considered refugees. There are currently millions of refugees worldwide, many of whom are affected by mental illness (Fazel, Wheeler, & Danesh, 2005). Due to the recent conflicts in the Middle East and all over the world, these numbers are steadily rising. Many counseling services fail to acknowledge that the potentially traumatic situations in their countries of origin are not the only sources of stress refugees face. Daily obstacles, such as language difficulties and discrimination stemming from xenophobia, also influence the well-being of refugees throughout the arduous relocation process (Betancourt et al., 2015; Miller & Rasmussen, 2010; Nickerson, Bryant, Steel, Silove, & Brooks, 2010). 

Asylum can be sought in a variety of ways, including migrant smuggling or traveling to refugee camps in neighboring countries (Sirin & Rogers-Sirin, 2015). Migrant smuggling is an illegal practice wherein asylum-seekers pay large sums of money to be transported from their countries of origin to other countries (United Nations Office on Drugs and Crime [UNODC], n.d.) through smuggling routes, such as crossing the Mediterranean on rafts (Brown, 2008). Others spend years in overcrowded refugee camps, where they can submit applications to enter countries such as Germany, Sweden, or Denmark and wait to be processed (Sandhu et al., 2013). Because there are many avenues to seeking asylum, refugees’ experiences vary greatly and have different different effects on their mental health (Miller & Rasmussen, 2010). This paper will discuss the psychological impact of obstacles that refugees commonly encounter throughout the stages of relocation.

Safety-Related Obstacles

Lack of safety plays an integral role in how refugees experience relocation, as well as their subsequent mental health. Often, refugees escape their countries of origin because of overwhelming violence (Brown, 2008). Refugees are distinctly different from voluntary immigrants because their migration is involuntary and often prompted by the outbreak of violent wars (Brown, 2008). Exposure to potentially traumatic and violent incidents in refugees’ often unsafe countries of origin is therefore very likely (Quosh, Eloul, & Ajlani, 2013). However, their exposure to violence and unsafe environments occurs throughout the relocation process, beyond their countries of origin. Violence, often due to excessive drinking, is a common occurrence in refugee camps (Meyer, Murray, Puffer, Larsen, & Bolton, 2013; Tanaka, 2013). If traveling through illegal migrant smuggling routes, methods of transportation often lead to physical injury (Gushulak & MacPherson, 2000). Refugees report significantly higher levels of post-traumatic stress and symptoms of distress than non-refugee immigrants (Arnetz, Rofa, Arnetz, Ventimiglia, & Jamil, 2013). This implies that the unsafe and dangerous conditions that led to their migration have a significant impact on their mental health. Though it is not the only psychological stressor influencing the mental well-being of refugees, this kind of exposure has a profound, long-lasting impact on them (Montgomery, 2008). Due to the likelihood of exposure to multiple violent events, refugees are particularly vulnerable to the psychological aftereffects of experiencing violence, which include the development of PTSD, anxiety, psychosis, and schizophrenia (Arnetz et al., 2013; Levine et al., 2015; Rhodes, Parrett, & Mason, 2016; Tay, Rees, Chen, Kareth & Silove, 2015).

Migrant smuggling often leads to financial exploitation of those being smuggled who are often additionally dealing with poverty (Gushulak & MacPherson, 2000). Research about the mental health and overall well-being of refugees who have been smuggled is very limited. Most assertions about this hard-to-reach demographic have been made through news headlines (Gushulak & MacPherson, 2000). For example, in certain cases, smuggled refugees endure barely livable conditions to be transported, including enduring physical injuries, limited access to food, and even low levels of oxygen (“Six Die In Spanish Ship’s Hold,” 1999; Veronneau, Mohler, Pennybaker, Wilcox, & Sahiar, 1996). These conditions are sometimes accompanied by physical violence, perpetrated by the smugglers, in an effort to assert power (“Five Arrested In Teens’ Deaths,” 1999). Another possible effect of migrant smuggling is facing deportation or incarceration, due to the illegal nature of their transportation (Gushulak & MacPherson, 2000).

Often, refugees are unable to bring their whole family with them. Leaving family members behind and advancing through the stages of relocation alone leads to intense anxiety for the safety of those left behind (Nickerson et al., 2010). Fear for family contributes more to current distress than traumatic memories, especially once refugees have arrived in their country of final relocation (Nickerson et al., 2010). These family-based concerns are often complicated by whether or not the refugee is accompanied or not. Many underage refugees are sent abroad to get jobs and send money back to their family (Zwi & Mares, 2015). This fact, alongside the prolonged experiences in unsafe environments, can have an impact on how children develop later in life.

Developmental Obstacles

Refugees and their families are affected by the destruction of their communities and much of their local infrastructure, including schools. The general safety of refugees and their children is in jeopardy on a daily basis in refugees’ countries of origin. In times of unrest, children’s education is therefore often disrupted, especially in contexts of heavy military activity (Palosaari, Punamäki, Peltonen, Diab, & Qouta, 2015; Robertson & Hoffman, 2014). This is reflected in the low school attendance rates in Syria as, in the last academic year, 50% of Syrian children did not attend school (Sirin & Rogers-Sirin, 2015). If traveling as a family, the children of refugees often stop attending school to help earn money to financially support the family (Betancourt et al., 2015). Additionally, some children living in refugee camps were susceptible to the development of Callous-Unemotional traits, a common precursor for Antisocial Personality Disorder, due to their desensitization to chaos and violence over time (Latzman, Malikina, Hecht, Lilienfeld, & Chan, 2016). 

In refugee camps, children face obstacles related to their education, as well. In one sample, 65% of children currently in a refugee camp had experienced interruption in their education (Mace, Mulheron, Jones, & Cherion, 2014). This is a common experience in the lives of refugee children, who additionally ranked lower than average on diverse measures of development, observing motor, social, and language development in particular (Muennig, Boulmier-Darden, Khouzam, Zhu, & Hancock, 2015). Both children and adults in camps reported education as one of the top three concerns faced by kids in refugee camps, indicating that this is a salient, self-identified problem among camp inhabitants (Meyer et al., 2013). The previously mentioned measures of development were positively influenced by mother’s literacy levels, indicating that educational programs may be helpful for adult refugees as well (Muennig et al., 2015).

Occasionally, unaccompanied children arriving in the United States are detained in mandatory detention centers, which look like prisons, for long periods of time and where they are unable to access age-appropriate educational activities (Zwi & Mares, 2015). This causes the refugee children to fall even further behind on their already disrupted education (Sirin & Rogers-Sirin, 2015). In some refugee camps, nursery schools have been introduced, providing a safe environment for the children to spend time away from common stressors. Such stressors include adults’ alcohol and drug abuse, physical abuse, and neglect, which are often the result of the accumulation of financial, social, and psychological pressures (Meyer et al., 2013; Tanaka, 2013). These set negative examples for the young, developing children (Meyer et al., 2013). Often, children will fall into similar, destructive drinking patterns, which further exacerbate symptoms of PTSD across refugee children’s lifespans (Meyer et al., 2013; Tanaka, 2013). Communication between children and their parents about their traumatic experiences can have a significant impact on development as well, with unfiltered, non-age appropriate communication leading to the development of insecure attachment styles in the children (Dalgaard, Todd, Daniel, & Montgomery, 2016).

Political & Bureaucratic Obstacles

Throughout relocation, refugees face multiple political and bureaucratic barriers, such as their refugee status applications, time spent in camps and mandatory detention centers, as well as living with undocumented status (Campbell, Klei, Hodges, Fisman, & Kitto, 2014; Steel et al., 2011; Zwi & Mares, 2015). Refugees’ extended stays in overcrowded refugee camps is not voluntary, but necessary. In order to move to their preferred countries of final relocation, refugees must first complete the refugee status application and vetting process. The United States’ vetting process can take between 18 to 24 months to complete, and can include spending time in mandatory detention centers (Richter, 2014). The longer refugees stay in temporary locations, such as camps and detention centers, the greater their overall psychological distress becomes (Uribe Guajardo, Slewa-Younan, Smith, Eagar, & Stone, 2016). As a result of their traumatic experiences, as well as the fact that they are required to stay in prison-like settings thereafter, can lead to the presentation of symptoms of PTSD, anxiety, depression, and even psychosis (Zwi & Mares, 2015).

Temporary and Permanent Protection Visas (TPVs and PPVs), and other similar visas, are granted by governments around the world after refugee status is confirmed by the United Nations. As their names suggest, TPVs are valid for a limited amount of time, while PPVs do not expire. Despite the fact that refugees with either of these kinds of visas are allowed to enter a country for more permanent relocation, the fact that TPV-holders had limited time there, had a profound influence on their well-being. Those who were granted TPVs scored higher on measures of PTSD, depression, and anxiety than those with PPVs. Additionally, TPV-holders were less socially engaged than those granted PPVs. Over time, PPV-holders experienced greater improvements in their overall mental health, while the well-being of TPV-holders remained stagnant at undesirably low levels (Steel et al., 2011). 

Similar sentiments of anxiety, due to fear of deportation, occur with undocumented refugees. Undocumented refugees are likely to have been smuggled. In addition to anxiety related to possible deportation, undocumented people often live in poverty, and are therefore at higher risk for depression, lower levels of cognitive functioning, and often have to work jobs with very little income stability (Campbell et al., 2014; Tampubolon, 2015). Despite the fact that they face enormous amounts of stress, undocumented refugees frequently do not seek out psychological services they might benefit from (Brown, 2008; Campbell et al., 2014). Gaining access to working rights and subsidized health care decreased the symptoms of mental illness in refugees as they settled into a novel environment (Hocking, Kennedy, & Sundram, 2015).

Cultural Obstacles

Moving to an unfamiliar environment, often of a completely different culture, significantly predicted depression in refugee populations, more so than exposure to war in their countries of origin did (Miller & Rasmussen, 2010). Unfortunately, these effects are exacerbated by intolerance and xenophobia among the local population. Other barriers to joining new communities, or acculturation, include not being able to speak the local language, struggling to find employment, and systematic discrimination (Miller & Rasmussen, 2010; Betancourt et al., 2015). In 2010, the American Psychiatric Association denounced xenophobia against immigrants because of its overwhelmingly negative effects on mental health and overall well-being.

Acculturation helps to ease refugees’ psychological distress (Salo & Birman, 2015). When refugees are able to acculturate, they are more likely to seek help for their mental health concerns, often stemming from exposure to trauma (Thikeo, Florin, & Ng, 2015). After refugees began to self-identify their overall health, including mental health, as good, they became more socially integrated in their new communities (Lee, Choi, Proulx, & Cornwell, 2015). Learning to speak the local language, particularly in English-speaking countries, greatly facilitated social integration and therefore also lead to reductions in overall stress (Lee et al., 2015).

Conclusion

Refugees’ experiences with relocation are incredibly diverse and shape their futures once they arrive at their final destination (Betancourt et al., 2015; Miller & Rasmussen, 2010; Steel et al., 2011). If two refugees of the same nationality decide to flee the same conflict but take different routes towards relocation, their experiences would be vastly different. The refugee who endures migrant smuggling might experience stressors such as anxiety related to being undocumented. The other, who relocates to a neighboring country’s refugee camp, would encounter challenges such as local people’s intolerance and discrimination.

Considering how varied refugees’ experiences are based on their stage of and path to relocation, it should not be surprising that developing successful, large-scale interventions has been difficult. The interventions that do exist have largely been developed to address refugees’ traumatic pasts instead of integrating their past, present, and future (Nickerson, Bryant, Silove, & Steel, 2011). An example of a form of treatment commonly used with refugees is narrative exposure therapy. Refugees are exposed to multiple major life events, which are integrated into an extensive narrative that focuses in great detail on their traumatic memories (Neuner et al., 2008). Repeated exposure leads to the refugees’ desensitization to it over time. This form of treatment has been relatively successful, but fails to account for stressors that may have occurred after the original trauma and throughout the relocation process.

Multidisciplinary interventions use a combination of various treatments to account for stressors that may have occurred after the original trauma. Depending on the needs of those being treated, a multi-faceted program is created (Carlsson, Mortensen, & Kastrup, 2005; Palic & Elklit, 2011). However, due to the fact that refugees at different stages of the relocation process cannot predict how long they will be in one place, long-term participation in these complex treatments has been rare. The success rates of multidisciplinary interventions have therefore been inconsistent.

Data collection in the context of overcrowded refugee camps and other stages of relocation is incredibly difficult (Quosh, 2013), which partially explains why such research is limited. Future research should focus on possible moderators that could affect the relation between the stages of relocation and overall well-being. Establishing the biggest area of risk across various stages of relocation is essential to developing more effective short-term interventions. In order to implement successful multidisciplinary interventions for refugees, research should evaluate specific experiences within refugee populations that go beyond their exposure to trauma in their countries of origin.

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