4.1. MENTAL HEALTH IN CONTEXT OF WAR AND FORCED MIGRATIONS.
Activity 27: Mental health of refugees
According to the World Health Organization, mental health is a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. In these sense, mental health is more than the absence of mental disorder and it is considered as integral part of health.
Mental health is determined by a range of socio-economic, biological and environmental factors and it is well documented that war and disasters have a large impact on mental health and psychological well-being. It is often thought that mental health difficulties and psychological distress of refugees primarily results from war-related violence and loss. Although destruction and violence of war present a severe mental health risk factors, life in exile and integration difficulties have just as powerful impact.
Activity 28: Mental health risk and protective factors in refugees
Every human being has its own unique set of capacities, skills, experiences developed and existing in a certain environment that present either a risk or protective factor for one’s mental health and psychological wellbeing. However, there are certain factors almost universally associated with mental health outcomes of refugees.
Factors contributing to or preventing mental health difficulties and disorders in refugees can occur prior to migration (pre-departure), during the travel and transit and after arrival (post-migration). Here are some of the risk factors in different stages:
Pre-migration risk factors:
- exposure to traumatic events
- economic hardship
- lack of social support and networks
- educational, professional and social disadvantages
- gender and age
- timing of migration (the later migration more risk and more severe)
During the travel and transit:
- duration and route of travel
- exposure to traumatic events (violence, human trafficking, life-threatening events)
- harsh living conditions (in camps, homelessness)
- disruption in family and social ties
- uncertainty of outcomes
Post-migration risk factors:
- poor living conditions
- detention and facing return
- economic hardship, unemployment, exploitation
- duration and uncertainty of status determination procedures
- social exclusion
- acculturation difficulties
There are factors that work as protective mechanism with regards to mental health of refugees and migrants, such as:
- higher educational level, usually associated with more opportunities and better social status
- availability of material and financial resources
- maintenance and/or development of family, community and social ties
- social support, employment and social inclusion
- new opportunities to flourish
- proactive attitudes and internal locus of control
- development of resilience to stressors
Activity 29: Common mental health problems in refugee population
Are there common and typical mental health difficulties and disorders of refugees?
Different studies and reviews show a very high variation regarding the commonality (prevalence) of metal health disorders in refugee and migrant population. At present, there is a consistent evidence that Post-traumatic Stress Disorder (PTSD) appears more often in refugee than in host population.
Long-term refugees (more than 5 years) tend to suffer from depression and anxiety disorders more often than the host population, and this is associated with a lack of social integration and specifically with unemployment.
4.2. TRAUMATIC EVENTS AND TRAUMA RESPONSE
Activity 31: Stress, crisis and trauma
Several psychological constructs explain relations of external / environmental occurrences and events with psychological distress and well-being.
Stress arises when individuals perceive that they cannot adequately cope with the demands being made on them or with threats to their well-being (Lazarus, R. S. (1966). Psychological stress and the coping process. New York, NY, US: McGraw-Hill). It can be viewed as imbalance between demands and coping resources and processes (Lazarus, R., & Folkman, S. (1984). Stress, Appraisal, and Coping. New York: Springer).
Stress can have substantial damaging impact on physical and mental health. Effects on the body and physical health are linked with a “fight-or-flight-response”, a combination of nerve and hormonal signals that are instigated in encounter with a perceived threat. The long-term experience of stress, such as in uncertain circumstances of forced migration and adapting to new environment, results in the fight-or-flight-response being activated continuously for a long period of time. And that overexposure to stress hormones and body and mind alert systems can disrupt almost all physical and mental processes and increase risk of numerous mental and physical health problems, including:
- Digestive problems
- Heart disease
- Sleep problems
- Weight gain
- Memory and concentration impairment
Crisis is, as Gerald Caplan defines it, a brief psychological disturbance occurring when an individual, faced with an obstacle to important life goals, finds that it is for the time being insurmountable through the utilisation of customary methods of problem solving.
Crises occur in normally in life of every person, as a part of development and maturity but can also be precipitated by unpredictable events, such as natural disasters, accidents or sudden losses.
According to Caplan (1964) most crisis reactions follow 4 distinct phases:
- Initial rise in tension from the impact of the stimulus calls forth habitual problem-solving responses;
- Lack of success and continuation of stimulus is associated with increasing upset and ineffectuality;
- Further rise in tension acts as a powerful internal stimulus and calls out emergency problem solving mechanisms – novel methods to attack the problem, trial and error, and attempts to define the problem in a new way;
- If the problem continues, tension mounts beyond a further threshold and its burden increases to breaking point. To avoid major disorganisation the person employs restitutive methods to reduce anxiety and opens up maladaptive pathways. These can lead eventually to the development of various psychiatric syndromes.
Psychological trauma is a set of emotional, physical, cognitive and behavioural responses to traumatic events that represent normal response to abnormal circumstances.
Traumatic event is such event that would be markedly distressing to almost anyone, and is outside the range of usual human experience.
Person can experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. Events may be human-made, such as war, terrorism, sexual abuse, or violence, or they can be the products of nature (e.g., flooding, earthquakes, hurricanes).
Activity 33: Trauma response – consequences of exposure to traumatic events
Most survivors exhibit immediate reactions which are normal in the sense that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Only a small percentage of trauma survivors develops symptoms that meet criteria for trauma-related stress disorders.
Post-traumatic Stress Disorder (PTSD) is a mental health condition that is triggered by traumatic event and it is characterized with symptoms getting worse with passing of time, symptoms produce significant distress and impairment and interfere with day-to-day functioning and last for a significant period of time (more than months) sometimes for years.
The DSM-5 (American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013) identifies four symptom clusters for PTSD:
- Re-experiencing the traumatic event through intrusive memories, flashbacks, nightmares, or intense mental or physical reactions when reminded of the trauma.
- Avoidance and numbing such as avoiding anything that reminds you of the trauma, being unable to remember aspects of the trauma, a loss of interest in activities and life in general, feeling emotionally numb and detached from others and feeling a sense of a limited future.
- Hyperarousal, including sleep problems, irritability, hypervigilance (on constant “red alert”), feeling jumpy or easily startled, angry outbursts, and aggressive, self-destructive, or reckless behaviour.
- Negative thought and mood changes like feeling alienated and alone, difficulty concentrating or remembering, depression and hopelessness, feeling mistrust and betrayal, and feeling guilt, shame, or self-blame.
Activity 32: Traumatic events in life of refugees (forced migrants)
Refugees can experience traumatic events in their country of origin (or initial residence), in the pre-migration stage, in transit countries (during migrations) as well as in settlement countries (post-migration). Being that refugees typically come from war-torn countries where they may have been persecuted, witnessed war violence and destruction and suffered human and material loss, majority of the traumatic events are linked to pre-migration stage.
Harvard Trauma Questionnaire (HTQ) lists 82 types of traumatic events, most of which represent the experience of refugees and survivors of war.
4.3. TRAUMA RECOVERY AND GROWTH.
Activity 35: Stages of trauma recovery
How person will react to trauma as well as a path of recovery from trauma is affected by range of unique individual experiences, the accessibility of support networks, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social support, to deal with the aftermath and effects of trauma.
Recent research indicate that it is not necessary for survivors to talk about the trauma and express associated emotions in order to come to terms with what happened and recover. Survivors have individual styles of coping and as long as it allows person to continue necessary activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts, there is no point to value some more than the other.
Some authors (Dolan, Y. (2000): Beyond Survival: Living Well is the Best Revenge. BT Press; Vigliotti, A. & Maynor, W. (2012). Victim, survivor, thriver. In C. R. Figley (Ed.), Encyclopedia of trauma: An interdisciplinary guide (pp. 787-789)) differentiate three stages of trauma recovery:
The victim stage is the beginning of healing. In this stage person faces the reality of the bad or unfortunate thing that happened. Person acknowledges the negative feelings and emotions that might be around (grief, anger, sadness, disappointment, frustration, despair, hopelessness, helplessness, etc.) and allows herself to feel these emotions and express them. Recognising that one
has been a victim of circumstances or other people serves the important purpose of allowing oneself to let go of self-blame and shame. However, the feeling of being caught in the trauma is pervasive in this stage throughout thoughts, feelings, behaviours, and sometime identity.
In the survivor stage begins when person understand (s)he has lived beyond the traumatic or experience/s. In this stage person is able to identify and appreciate the internal strengths and external resources that (s)he already possessed at the time of the trauma or developed afterwards in order to survive it, thus integrating the experience of trauma and “bridging” the experiences before and after trauma into a continuum of life. However, remaining at this stage means that survivors evaluate all events of his/her life in terms of how they resemble, differ from, mitigate or worsen the effects of the past, thus diminishing the ability to fully experience and enjoy life.
In the thriver stage person begins living not only in reference to the bad things he/she survived or even in reference to present experiences and hopes for the future, but according to the totality of who he/she really is as a person. The present and the future becomes more vivid and fulfilling than the past. Those who thrive often exhibit increased productivity, leadership skills, mental strengths, renewed faith, and/or a deeper appreciation for loved ones.
(Description of stages adapted from: Dolan, Y. (2000): Beyond Survival: Living Well is the Best Revenge. BT Press)
Activity 36: Resilience and growth
Studies suggest that trauma need not be debilitating and that most people are resilient and even grow in the wake of a trauma (Fredrike P. Bannink, 2008).
The typical pattern for even the most catastrophic experiences is resolution of symptoms and not the development of PTSD. Only a minority of the victims will go on to develop PTSD and with the passage of time the symptoms will resolve in approximately two-thirds of these’ (MacFarlane & Yehuda, 1996).
Many internal and environmental factors contribute to persons resilience. Research indicate that caring and loving relationships, that support trust and offer encouragement are primary protective factor that contributes to resilience. However, as Bannik states, resilience is not something that persons has, but all the things s/he does as s/he recovers from traumatic experience.
Posttraumatic growth (Tedeschi & Calhoun, 2004) is the experience of positive change as a result of persons struggle to overcome the pervasive impact of the trauma. Posttraumatic growth results in the interaction of individual characteristics, resilience, support, and most importantly, cognitive processing involving cognitive structures that were threatened by the traumatic events. For the most people posttraumatic growth and distress co-exist, and the growth emerges from the struggle with coping, not from the trauma itself. Trauma is not necessary for growth and it is not in any way seen as desirable.
Not all survivors grow in the aftermath of trauma, nor the absence of posttraumatic growth is seen as pathological. Although a majority does experience posttraumatic growth, there are also a significant number of people who experience little or no growth and this outcome is quite acceptable.