Mental Health of Forced Migrants

Medicalizing mental health issues by relying solely on the effectiveness of medicine was a controversial risk factor that negatively affected the daily life activities of refugees and reduced their willingness for seeking professional mental health services. Empowering vulnerable minorities by giving them back their power and agency to be able to speak for themselves and raise voices of trauma and recovery was the missing protective factor for sustainable mental health practice. The benefits of group-based interventions were highlighted in which communities and individuals address mental health issues as well as isolation through building collective identities and support networks. Information and communication technologies (ICTs) can add more strength to any kind of mental health intervention. Finally, the benefits of applying an ecological perspective for the study of the mental health of refugees, and its implications for a sustainable intercultural practice, were discussed. Social workers in this model are the representatives of at-risk groups and thus require more agency and creativity in reflecting client’s concrete needs. 

mental health;risk factor;protective factor;refugee;asylum-seeker;sustainable intervention

1. Introduction

Across Europe and internationally there is a pressing need for the development of culturally appropriate mental health services for socially excluded and marginalized populations (Mölsä et al. 2019 Mölsä et al. 2019 ). Approaches to mental healthcare have undergone significant reforms around mental health intervention and immigrants’ health policies, wherein social scientists have realized that mental health and well-being are influenced by various social determinants (Hynie 2018 Hynie 2018 ; Marmot 2020Marmot 2020 ). Through efforts to acquire holistic approaches towards mental health, social scientists have concluded that the social, cultural, and historical diversity of refugees adds to the complexity of mental health service delivery but also presents opportunities for reform (Murray et al. 2010 Murray et al. 2010 ; Hutchinson and Dorsett 2012Hutchinson and Dorsett 2012 ).

At present, most of the research in the field of migration is reproduced through the same dominant top-down patterns, confined to pathology and diagnosis and highlighting only prevalence rates of the mental health issues. Thus, voices, interests, and expectations of the immigrant communities are ignored. However, with the continued migration of refugees, there is increased attention to how to address the ongoing needs of refugees, resulting in greater demands for services appropriate to their needs.

Other studies on utilizing mental health services by refugees show that despite higher prevalence rates of mental health issues being documented, there still exists an underutilization of Western mental health treatment by refugee populations, the reasons given include both structural and cultural barriers (Moreno et al. 2006 Moreno et al. 2006 ; Lamkaddem et al. 2014Lamkaddem et al. 2014 ; Agrawal and Venkatesh 2016Agrawal and Venkatesh 2016 ). Thus, existing research on mental health service barriers has identified issues of stigma, distrust of services and social and cultural problems that impact on “how problems are understood” and the question about whether help should be sought and if so, how” (de Anstiss et al. 2009 de Anstiss et al. 2009 ; Colucci et al. 2015Colucci et al. 2015 ; Brown et al. 2016Brown et al. 2016 ). It is therefore important for social workers to understand the barriers and reasons why underutilization exists and how to better support this vulnerable population (Lamkaddem et al. 2014 Lamkaddem et al. 2014 ; Rankopo Rankopo and Osei-Hwedie 2011and Osei-Hwedie 2011 ).

It is evident from the literature review the mental health of forced migrants is a multidimensional phenomenon. It not only needs quick responses but also requires receiving constant feedback from the field. In other words, research must go beyond diagnosis and medical responses to the mental health needs of the forced migrants. Through identification of the commonly recognized risks and protective factors in this systematic review, we try to offer an alternative approach that guarantees the sustainability of mental health practice, which values forced migrant’s viewpoints as active agents, capable of trauma growth and resilience.

2. Rationale for the Study

The primary aim of the study is to systematically review the literature on the protective and risk factors for the mental health of forced migrants. Secondly, it focuses on providing an alternative approach to the mental health issues of the forced migrants that transcends from the usual pathologizing and medicalizing perspectives, highlighting the resilience, strength, and capability of these vulnerable minorities. The need to explore this area is supported by the fact that the cultural diversity of forced migrants calls for more in-depth practice research. Practice research is therefore the base for sustainable mental health intervention. This highlights the critical role of social workers who deal directly with forced migrants, grounded for a more preventive approach in mental health care than diagnosis.

3. Analysis of Findings

The evidence presented in this systematic review supports the findings of previous studies that mental health issues of vulnerable populations are multidimensional, and widely measured outcomes of health issues are of great concern. However, the measures and perspectives that attempted to explain mental health issues especially in the included quantitative studies in this systematic review were top-down, and less of them by nature were supported to really explain refugees’ points of view. This fact became more evident after comparing the quality and the depth of the findings in terms of the identified risks and protective factors in each of the included articles.

Socio-demographic factors in this literature review appeared to reflect the findings of previous research. Women were at greater risk of developing poorer mental health than men and poor mental health was associated with having more children (Poole et al. 2018 Poole et al. 2018 ; Segal et al. 2018Segal et al. 2018 ). Due to the possibility of adapting to a new environment and behavioral resilience, young refugees found the adjustment to a new culture easier compared to the older age refugees (Georgiadou et al. 2018 Georgiadou et al. 2018 ). The country of origin and the reasons for migration appeared to be positively associated with mental health, post-traumatic stress disorder, and depression symptoms (Pandya 2018 Pandya 2018 ). Low socioeconomic and educational levels were strongly associated with mental health outcomes, as poorly educated refugees with lower incomes were at greater risks of developing adverse mental health outcomes (Im et al. 2017 Im et al. 2017 ; Şimşek et al. Şimşek et al. 20182018 ; Dietrich et al. 2019 Dietrich et al. 2019). However, it is proven that recently resettled refugees with higher education and socioeconomic backgrounds were at greater risks of developing mental health issues during the period leading up to the outcome of their asylum application (Carswell et al. 2011 Carswell et al. 2011 ).

Infrequent contact and interaction with relatives and friends were found to be associated with poorer mental health outcomes (Chung et al. 2018 Chung et al. 2018 ). DThe development of new social networks in host countries was found to be an offsetting element (Şimşek et al. 2018 Şimşek et al. 2018 ). Distrust of western mental health practice, and dissatisfaction with the centrality of the medicine in the treatment of the mental health issues, were controversial risk factors calling for more in-depth research (Omar et al. 2017 Omar et al. 2017 ; Savic et al. 2016Savic et al. 2016 ; Yassin et al. 2018Yassin et al. 2018 ). The importance of language acquisition for social interaction was highlighted. Involvement in social activities and community networks requires acceptable knowledge of language skills (Campbell et al. 2018 Campbell et al. 2018 ). Without linguistic skills, no connection, and consequently, no integration is possible. This problem was mostly common amongst older refugees. The potential for learning a new language decreases as age raises (Beiser and Hou 2001 Beiser and Hou 2001 ). Thus, social isolation, due to not having enough language skills, was strongly associated with negative mental health issues.

Selected qualitative studies in the current review provided a more in-depth view of the risks and protective factors for mental health issues. In terms of protective factors, community support and social networks of refugees seemed to play a crucial role in dealing with mental health issues (Alemi et al. 2017 Alemi et al. 2017 ; Im et al. 2017Im et al. 2017 ; Omar et al. 2017Omar et al. 2017 ; Poudel-Tandukar et al. 2019Poudel-Tandukar et al. 2019 ; Valtonen 2008Valtonen 2008 ). According to the findings of Affleck et al. community representatives of Sri Lankan Tamil, refugees were actively screening the mental health of each member of the community and, in doing so, those who were recognized sas suffering from various mental health issues were closely taken care of and treated according to the traditional practices (Affleck et al. 2018 Affleck et al. 2018 ). This can be a good example ofor a sustainable mental health program that shows how to use community potentials to manage its members’ well-being and health.

4. Current Insights

Pre-migration conditions, movement difficulties, and resettlement challenges are interwoven periods in forced migration that can have adverse mental health effects lasting for years or even generations (Ceri et al. 2017). However, a review of the literature proved that involving forced migrants, and using community potentials in research and further in mental health intervention plans can yield positive, sustainable effects (Affleck et al. 2018; Shawyer et al. 2017; Slewa-Younan et al. 2017; Lillee et al. 2015; Rizkalla and Segal 2018; Acarturk et al. 2018; Pandya 2018).
Some of the important pre-migration risk factors identified in the included studies were experiencing discrimination, constant fear, abrupt separation from family, leaving close kin behind, and witnessing the death of family members or relatives (Alemi et al. 2016; Savic et al. 2016). These risk factors clearly call for providing quick access to mental health services upon arrival of the forced migrants in host communities (Yassin et al. 2018; Yu et al. 2018; Campbell et al. 2018; Şimşek et al. 2018; Segal et al. 2018). However, culturally sensitive mental health services are missing protective factors that positively impact willingness in seeking sustainable services in forced migrants (Şimşek et al. 2018; Shawyer et al. 2017; Lillee et al. 2015; Rizkalla and Segal 2018; Pandya 2018).
Movement difficulties commonly occurred in the migration phase through borders and usually associate with human rights violations, migrants smuggling, and systematic discrimination in transit countries (Yu et al. 2018; Shawyer et al. 2017). Traumatic experiences of movement periods usually remain forever and need attention as soon as possible but, it is the duty of the international organizations such as UNHCR or IOM to hold transit countries accountable, encouraging them to legally recognize forced migrants’ human rights (Perrin 2010). As for the resettlement phase in the host countries, we found structural factors that could negatively associate with the mental health of forced migrants. Some of those identified factors included un/under employment, neighborhood disadvantages, the prolonged asylum application process, the short length of residence permits, stigmatization, isolation, impossibility of reunion with the rest of the family members, and cultural encounters (Vitale and Ryde 2016; Hocking and Sundram 2015; Georgiadou et al. 2018; Grupp et al. 2018; Kandemir et al. 2018; Shawyer et al. 2017; Lillee et al. 2015; Leiler et al. 2019; Rizkalla and Segal 2018). These structural level issues could be dealt with in the host countries by actively revising, and updating policies towards forced migrants’ wellbeing (Hagelund 2020).