Key factors impacting on the mental health and well-being of refugees and asylum seekers in the resettlement context.
Luke Fullagar
RMIT University
Both refugees and asylum seekers in the resettlement context encounter a complex array of pre- and post-displacement factors that coalesce to affect their mental health and well-being (Porter & Haslam, 2005; Fernando, Miller & Berger, 2010). Contemporary psychological research has sought to integrate an understanding of the range of crisis-related and daily stressors refugees and asylum seekers encounter at each stage in their journey toward safe and just living conditions (Miller & Rassmussen, 2010), and to study both the direct of these stressors as well as their unique interaction effects (Fernando, Miller & Berger, 2010).
Early trauma-focused research assumed refugee psychopathology to directly result from pre-displacement exposure to pervasive, organised violence and persecution (Porter & Haslam, 2005). While accounting for a significant proportion of psychopathology and diminished well-being in a swathe of studies (e.g. Fox & Tang, 2000; Lopes Cardozo, et al., 2004; Neuner, Karunakara & Elbert, 2004), this direct-effects model has nevertheless been challenged by large variances in the degree to which disaster-related exposure accounts for PTSD symptom levels (3% to 99%) and depression symptom levels (3% to 86%) (Silove, 2009). While it is clear that pre-migration stress and trauma makes an important contribution to diminished mental health and well-being in refugee and asylum seeker populations, these results have prompted critiques that the direct-effects trauma-focussed model fails to adequately account for all dimensions of the refugee experience, typified by a diversity of persistent events across manifold dimensions of experience and which accumulate over pre-flight, flight, exile and resettlement situations (Porter & Haslam, 2005; Martin, 1994).
Counterbalancing the direct-effects model, psychosocial frameworks have sought to additionally offer perspectives on the contribution of 'daily' stressors that endure post-displacement (Miller & Rassmussen, 2010). These stressors include: in the pre-arrival phase; dangerous flight (e.g. dangerous terrain in unroadworthy vehicles or unseaworthy vessels), unsanitary temporary settlements, exposure to disease and poor access to healthcare, and the absence of privacy; and in the post-arrival phase; marginalisation, racism, socioeconomic disparity and disadvantage, inadequate housing, restrictions to labour market participation and access to capital, acculturation challenges including language inadequacies, loss of social and cultural supports, family disruption, isolation and separation anxieties, diminished social status, and cultural bereavement for loss of one's identified culture of origin (Eisenbruch, 1991; Porter & Haslam, 2005; Coffey, Kaplan, Sampson & Tucci, 2010; Sztompka, 2000; Silove, 1999; Birman et al., 2005). In the Australian setting, these 'daily' stressors can also accumulate in long-term immigration detention – a situation which has been shown to participate in inducing and exacerbating extant distress, including depression, anxiety, demoralisation, low-concentration and memory disturbances (Coffey, Kaplan, Sampson & Tucci, 2010).
Contemporary studies which have added these post-displacement concerns to pre-displacement trauma-exposure have repeatedly found that post-migration stressors account for equal, and at times greater, variance in depression; and significant, yet typically lesser, variance in PTSD symptoms (Ellis, MacDonald, Lincoln & Cabral, 2008; Gorst-Unsworth & Goldenberg, 1998; Montgomery, 2008; Miller & Rassumssen, 2010; cf Panter-Brick, et al., 2008). Moreover, these effects have been shown to interact – for example, in a study of Darfur refugees residing in Chad (Rassmussen et al., 2010), daily stressors of lacking basic needs and safety fully mediated the relationship between crisis-exposure and PTSD, and perceived safety mediated the relationship between crisis-exposure and functional impairment. In a study of internally displaced Sri-Lankans, (Fernando, Miller & Berger, 2010), evidence for a three-way mediation model was advanced – demonstrating direct effects of crisis-trauma on psychopathology, partial mediation whereby acute 'daily' stressors implicated in psychopathogy were exacerbated by crises, and further, a direct effect of daily stressors unrelated to the relevant crisis – together suggesting a complex arrangement of direct and interactional effects between crises and daily stressors which demand a multimodal treatment approach.
Taken together, the above trauma-focussed and psychosocial results also suggest that post-traumatic stress, while to be taken seriously, is not in all cases a predominant, or perhaps even inevitable, consequence of acute exposure to humanitarian crises, and that material and psychosocial support to remediate acute daily stressors may significantly assist resilient individuals regain psychological equilibrium in due course (Foa & Rothbaum, 2001; Bonanno, 2004; Miller & Rassumssen, 2010). This has been used to inform integrated psychological therapies, and should inform future research in both repatriation and resettlement contexts (Miller & Rassumssen, 2010). Moreover, the role of material support, from government or private-sector social programs should not be underestimated in the design of integrated social policies complimenting these contemporary therapies. Indeed, Porter & Haslam's (2005) meta-analysis highlighted that in addition to personal factors, post-displacement material conditions moderated mental health outcomes, and that materially secure conditions, exemplified by permanent individual accommodation and economic opportunities, were significantly positively associated with enhanced psychological outcomes. Trans-disciplinary research into the psychological correlates of these sociological issues will remain a fruitful line of inquiry into key factors impacting refugees and asylum seeker mental health and well-being.
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