Mental Health of Refugee and Conflict-Affected Populations: Theory, Research and Clinical Practice

395 Pages·2018·5.09 MB·English

by  Nexhmedin Morina

Nexhmedin Morina
Angela Nickerson Editors
Mental Health
of Refugee and
Confl ict-Aff ected
Populations
Theory, Research
and Clinical Practice
Mental Health of Refugee and Conflict-Affected
Populations
Nexhmedin Morina • Angela Nickerson
Editors
Mental Health of Refugee
and Conflict-Affected
Populations
Theory, Research and Clinical Practice
Editors
Nexhmedin Morina Angela Nickerson
Department of Clinical Psychology School of Psychology
and Psychotherapy University of New South Wales
University of Münster Sydney, NSW, Australia
Münster, Germany
ISBN 978-3-319-97045-5 ISBN 978-3-319-97046-2 (eBook)
https://doi.org/10.1007/978-3-319-97046-2
Library of Congress Control Number: 2018957833
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Dedicated to individuals and families
affected by violence, persecution, and
displacement worldwide
Foreword
This timely volume brings together the accumulated experience of clinical scientists
who are determined to improve our approach to improving the mental health of
refugees and individuals in conflict-affected settings. The challenge is enormous
given the millions of refugees and internally displaced people, half of whom are
children, as well as the multitude of regions in the world in a state of war. Their
needs are complex and ever changing.
Traditionally, refugees and conflict-affected groups were offered help by NGOs.
Some excellent work was developed, often incorporating a human rights perspec-
tive within a humanitarian framework. However, as is discussed, the various proj-
ects were rarely scientifically evaluated. In contrast, mental health responders seized
on the then recently described posttraumatic stress disorder and introduced training
which was evaluated. A major problem was that often other mental health needs –
notably depression, anxiety and bereavement reactions – were ignored. Over the
past 20 years or so, there have been strenuous efforts to blend these two contrasting
approaches. Contributors discuss how this can be developed.
As reflected in the chapters, there have been many examples of interventions
being adapted and applied to groups of refugees and conflict-affected populations.
The trouble is that all too often studies are of small number of participants and
rarely have follow-ups of more than 2–3 months. In addition, more thought needs to
be given as to what measures are developed and applied in order to judge the effects.
Understandably, when responding to a crisis, well-meaning people want to get
going quickly and so use whatever materials they are familiar with. A strong mes-
sage from this text is that we should think through beforehand what may be needed,
how it should be implemented and how it will be evaluated. The intervention litera-
ture is full of examples that “show promise”, but that rarely deters their authors from
then implementing their approach without further development.
Many NGOs still eschew the use of concepts of trauma, depression and so on,
believing that this medicalises normal human reactions and that such labelling can
be harmful. They talk of using “psychosocial” approaches to avoid such terminol-
ogy. But this does not absolve them from properly evaluating what they do. For
example, providing child friendly spaces is welcomed, but unless active interven-
vii
viii Foreword
tions are included, there is little evidence that they have a beneficial effect on chil-
dren’s adjustment. Similarly, ensuring access to education is a matter of right and of
urgency, but unless some attention is paid to children’s stress reactions, opportuni-
ties will be wasted.
Overall, the book moves on from seeing mental health needs solely in terms of
individual treatment for specific diagnostic entities to how best to support people at
many points throughout their lengthy journeys. Indeed, one radical suggestion is
that it may be better to concentrate on providing skills so as to sustain everyday liv-
ing. Social context is important and can bolster resilience. One recent technological
development has been the wide-scale use of smartphones and Wi-Fi-enabled
devices. Refugees are no longer totally separated from their families of origin and
keep in contact, at times checking back home that advice being given is
acceptable.
People can and will join online support groups just as they will access the inter-
net. Not all will be moderated by mental health professionals. Whilst partially
empowering individuals affected by war and persecution, it means professionals
will have to learn new ways of interacting with them.
Lest it be thought that the book is debunking all that is currently undertaken in
the name of improving the mental health of refugees, far from it. The argument is
that much broader issues have to be tackled simultaneously and across time. CBT-
based interventions remain the most powerful currently in use. However, there is a
strong move towards more transdiagnostic approaches looking at underlying psy-
chological processes such as emotional regulation and memory. A far better under-
standing of the effects of stress on recall is needed to avoid some of the injustices
encountered in the judicial processes when apparent contradictions in providing
testimony are taken as evidence of lying.
The need to provide some help to as many people as possible has led to the call
for low-intensity interventions. Certainly it would be good to see more of these
developed and evaluated. But it should not be forgotten that group interventions,
often of only a few sessions, can encourage relevant skills that in turn ensure access
to community resources. For some, there will still be a need for very long-term sup-
port. The question is: who should be responsible for providing all these desirable
activities. Different countries have different ways of funding mental health treat-
ment. Whatever protection is theoretically available under international human
rights legislation, services can still be overwhelmed unless properly planned and
funded. This book is full of up-to-date information that will make for huge improve-
ments in the way societies respond to the needs of refugees and conflict-affected
groups.
London, UK William Yule
February 2018
Preface
Millions of individuals around the globe carry physical and psychological scars fol-
lowing exposure to mass violence. Mass violence violates the basic psychological
needs of humans, damaging both the physical and mental integrity of the individual.
Survivors of war and other forms of systematic oppression often endure multiple
and varying traumatic experiences, such as assaults, injuries, torture, rape, and lack
of food and water. In addition, many have witnessed violence toward, and even the
murder of, family members, friends, or strangers. These experiences typically occur
in the context of the destruction of property and infrastructure and may erode the
basic values that underpin societal cohesion. Even after enduring such experiences,
survivors of war and persecution may be forced to leave their homes and face the
perils of flight into the unknown, as well as the prospect of starting a new life far
from home.
Such experiences are likely to significantly affect the well-being of survivors of
mass violence. On the individual level, the individual must come to terms with his
or her own physical and mental injuries, potential loss of family members and
friends, or loss of faith in societal norms and solidarity. Additionally, he or she is
likely to live in an environment characterized by daily hardship, either in a postwar
society or as a refugee in a host country. Many survivors of organized violence suf-
fer from psychological problems that arise from their experiences of systematic
violence, as well as the daily hardships they endure. On the societal level, organized
violence may have diminished trust in others and led to the dismantling of infra-
structure necessary for successful societal functioning. Evidently, wars and other
forms of mass violence represent a major global challenge to well-being. The mag-
nitude of the problems resulting from mass violence becomes clear when one con-
siders the fact that, since the end of the Cold War in 1989, more than half of the
countries in the world have been affected by armed conflicts (Marshall & Cole, 2014),
ix
x Preface
with about 68 million people currently forcibly displaced worldwide (UNHCR,
2017). Hence, mass violence has led to enormous suffering among millions of indi-
viduals and has caused destruction of social, educational, economic, and health-
related structures among many societies.
During the last two decades, increasing efforts have been made to bring mental
health to the forefront of the global health agenda. A growing body of research has
investigated the factors underlying mental health in refugee and other conflict-
affected populations and evaluated treatments to reduce psychological distress in
these groups. At the same time, several initiatives by different organizations or
groups of individuals have promoted greater collaboration in humanitarian mental
health. Global efforts in this regard are urgently needed since most countries with a
recent history of mass conflict lack effective mental health services as a conse-
quence of the destruction of infrastructure during conflict.
In developing this book, we aimed to create a comprehensive and up-to-date
resource on the mental health of refugee and other conflict-affected populations.
The overarching goal of this book was to offer a review of theoretical, empirical,
and clinical conceptualizations on mental health following exposure to mass vio-
lence. The first part of the book includes a review of current research on the mental
health of refugee and conflict-affected populations. Here, prevalences of mental
disorders, stressors experienced during and after mass conflict, and psychological
interventions implemented with war-affected populations are reviewed (chapters
“Mental Health Among Adult Survivors of War in Low- and Middle-Income
Countries: Epidemiology and Treatment Outcome”, “Mental Health, Pre-migratory
Trauma and Post-migratory Stressors Among Adult Refugees”, and “Child Mental
Health in the Context of War: An Overview of Risk Factors and Interventions for
Refugee and War-Affected Youth”). The second part of the book provides a histori-
cal analysis of military violence that offers an important context in which the mental
health of survivors of organized violence can be understood (chapter “Variations of
Military Violence: Structures, Interests, and Experiences of War from the Nineteenth
to the Twenty-First Century”). This part further offers psychological, neurobiologi-
cal, and psychosocial frameworks that can guide the investigation and treatment of
psychological symptoms and disorders in refugee and post-conflict populations
(chapters “Pathways to Recovery: Psychological Mechanisms Underlying Refugee
Mental Health”, “Drive to Thrive: A Theory of Resilience Following Loss”, “A
Neurobiological Perspective of Mental Health Following Torture Trauma”, and
“Interventions for Mental Health and Psychosocial Support in Complex
Humanitarian Emergencies: Moving Towards Consensus in Policy and Action?”).
The third part of the book outlines prominent psychological and psychosocial inter-
ventions for refugees and other conflict-a ffected groups (chapters “Narrative
Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-
conflict Populations”, “Culturally Sensitive CBT for Refugees: Key Dimensions”,
“Alcohol and Drug Misuse Interventions in Conflict-Affected Populations”,
“Trauma Systems Therapy for Refugee Children and Families”, and “Supporting
Children Affected by War: Towards an Evidence Based Care System”). In addition,
this part presents relevant clinical, ethical, and legal considerations for practitioners
Preface xi
working with refugees and other conflict-affected groups (chapters “Clinical
Considerations in the Psychological Treatment of Refugees”, and “Legal and Ethical
Considerations Related to the Asylum Process”). The final part details important
considerations in conducting research with refugees and war-affected populations
in terms of measurement of mental health status (chapter “Conceptualization and
Measurement of Traumatic Events among Refugees and Other War-Affected
Populations”), evaluation of psychosocial interventions (chapter “Development and
Evaluation of Mental Health Interventions for Common Mental Disorders in Post-
conflict Settings”), enhancement of feasibility and dissemination of interventions
via low-intensity treatments (chapter “Low Intensity Interventions for Psychological
Symptoms Following Mass Trauma”), and application of technology to assist psy-
chosocial interventions (chapter “Development and Evaluation of Mental Health
Interventions for Common Mental Disorders in Post-conflict Settings”).
We were fortunate to have internationally renowned clinicians and researchers
contribute to this text and share their research and clinical insights derived from
years of experience working with refugee and conflict-affected populations. We
hope that this book will be informative to academics, researchers, clinicians, stu-
dents, community workers, human rights advocates, journalists, public policymak-
ers, and others throughout the globe who work to support individuals exposed to
systematic violence.
Münster, Germany Nexhmedin Morina
Sydney, NSW, Australia Angela Nickerson
References
Marshall, M. G., & Cole, B. R. (2014). Global report 2014: Conflict, governance, and state fragil-
ity. Vienna, VA: Center for Systemic Peace.
UNHCR. (2017). Global trends: Forced displacement in 2017. Geneva: UNHCR.