Mental Health

Many refugees and asylum seekers experience emotional distress before, during and after resettlement. Often these are natural reactions to adverse and traumatic events related to conflict, war and displacement. It is therefore important to not “pathologize” the entire refugee population and label refugees indiscriminately as “traumatized” or “mentally ill”. In fact, many refugees show remarkable resilience and can overcome emotional challenges once given opportunities and resources and many lead healthy and emotionally fulfilling lives in receiving societies.

However, for some, common mental health symptoms may severely impact their day-to-day functioning and an important subset of refugees suffer from clinically significant mental health conditions. The World Health Organization (WHO) estimates that around one in five persons living in areas affected by conflict have a mental health condition. This is twice or thrice the prevalence of such issues in non-conflict-affected populations. Data show markedly elevated prevalence of mental health conditions among refugees although estimations vary widely based on methodological issues. Most studies find that at least one out of three asylum seekers and refugees meet diagnostic criteria for depression, anxiety, and post-traumatic stress disorders (PTSD). Up to 44% report surviving torture in some resettlement countries. While most refugees and asylum seekers with PTSD and depression show a reduction over time, particularly if resettlement stressors are low, others experience long-term symptoms that do not subside.

Key terms

• Mental health: A state of mental well-being that enables people to cope with the stresses of life, to realize their abilities, to learn well and work well, and to contribute to their communities. Mental health is an integral component of health and well-being and is more than the absence of mental disorder.
• Mental health condition: A broad term covering mental disorders and psychosocial disabilities. It also covers other mental states associated with significant distress, impairment in functioning, or risk of self-harm.
• Mental Health and Psychosocial Support (MHPSS): The term “mental health and psychosocial support” is used to describe any support that aims to protect or promote psychosocial well-being and/or prevent or treat a mental health condition.
• Psychosocial Support (PSS): Psychosocial support includes all processes and actions that promote the holistic well-being of people in their social world. It includes support provided by family, friends, and the wider community. It can be used to describe what people (individuals, families, and communities) do themselves to protect their psychosocial well-being, and to describe the interventions by outsiders to serve the psychological, social, emotional and practical needs of individuals, families, and communities, with the goal of protecting, promoting and improving psychosocial well-being. In humanitarian settings, the term is often used conjointly with term “mental health”.
• Resilience: The ability of individuals and communities to anticipate, withstand and recover from adversity. It refers to both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being, and to the capacity of individuals and groups to negotiate for these resources to be provided and experienced in culturally meaningful ways.
• Toxic Stress: When children experience strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This can produce a prolonged activation of the stress response systems which can lead to further cognitive or health related concerns.
• Trauma: The lasting emotional response that often results from living through a distressing event. Experiencing a traumatic event can harm a person’s sense of safety, sense of self, and ability to regulate emotions and navigate relationships. Long after the traumatic event occurs, people with trauma can often feel shame, helplessness, powerlessness, and intense fear.

How experiences of adversity, loss and trauma may impact resettlement

Recognizing symptoms of distress
Resettlement workers should be trained in recognizing distress symptoms, and how to best respond by offering compassionate care and connection to available care. Common responses to or signs of emotional distress include:

• abrupt changes in mood
• aggression
• apathy
• change of sleep or eating patterns (e.g., eating/sleeping too much or too little)
• crying easily or for long timeframes
• difficulty to concentrate
• feeling forgetful
• lack of energy—too much or too little 
• lack of being able to care for oneself or others 
• loss of self-esteem and self-confidence
• poor personal hygiene
• social isolation

Many of these responses are natural reactions to unusual and adverse situations, and often diminish over time. However, some people may experience more intense and long-lasting reactions that could result in harm, affect daily functioning and lead to maladaptive coping mechanisms such as substance use and/or self-harm. Particularly people who have experienced rape, torture, trafficking, or other potentially traumatic situations may experience more distressing symptoms, that can be exacerbated in the case of previous or pre-existing mental health conditions.

A supportive and stable environment can help prevent the development or worsening of mental health conditions in refugees, while post-resettlement stressors such as lack of basic needs, housing, finances, and overall security negatively influence mental health. Refugees often encounter barriers to accessing care, and only a minority receive the mental health services they need.

Integration programmes should be provided in a participatory manner and holistically support the health and well-being of refugees. Early intervention and health promotion are essential and can be best drawn upon strengths-based approaches, fostering the capacities of refugee communities.

Resettlement workers may assist by collaborating with local community structures and talking about emotional health as connected to elements in the social environment. They can also actively promote access to culturally relevant recovery supports. This requires a capacity to properly identify and refer those with more severe significant problems to available care.

While many refugees are relieved to be resettled, they may find resettlement, adjustment, and integration challenging. The aim of trauma-informed care within resettlement and integration is to help refugee service providers understand how traumatic experience may impact refugees’ emotions, behaviour, and functioning, and utilize psychosocial skills to facilitate the process of integration.

Review this checklist to find out what you should think about when taking MHPSS concerns into account during integration.

Services for MHPSS can best be conceptualized as a system of overlapping layers. The MHPSS pyramid developed by the Inter-Agency Standing Committee is widely used in humanitarian contexts and forms the basis of UNHCR’s work on MHPSS in refugee contexts in low- and middle-income countries. The MHPSS pyramid is also a useful tool to conceptualize MHPSS services to refugees and asylum seekers who are integrating in new societies. The pyramid illustrates that many may need and benefit from universal sensitization and promotional support while smaller numbers will need more specialized and targeted services.

On each level, there are factors affecting one another. For example, supportive family strengthening and group support can develop a sense of connectedness, minimize isolation, and foster increased resilience, thus contributing to improved mental health. There is also a great body of evidence around the use of community-led, and peer-delivered services to support refugees’ mental health and well-being.  Persons with more complex or severe issues can receive ongoing emotional support that promotes daily functioning, improves stress management and adaptive coping. Such interventions can be provided by specialized mental health workers or others who are trained and supervised by mental health professionals as well as people without professional training in mental health care, including community workers, peers, and other lay helpers.

Essential MHPSS principles include:
 

1. do no harm;
2. avoid pathologizing and re-traumatization or assuming that everyone is traumatized;
3. deploy listening skills and psychosocial responses (e.g., using Psychological first aid (PFA)); 
4. do not minimize newcomers’ experiences;
5. follow refugees lead, and pace therapeutic, healing support as needed;
6. work across stakeholders, building capacity and referral pathways;
7. trust in people’s inherent capacity to recover and heal in culturally relevant ways;
8. acknowledge and strengthen the agency of refugee’s wisdom and build on their capacities.

Considerations for mental health and psychosocial support throughout resettlement and integration

Organize resettlement process so as to protect the dignity, safety, and security of all people, providing appropriate information, using participatory approaches, and considering basic needs and safety. Resources and support include shelter, food, clothing, etc.

Strengthen community and family support through psychosocial promotional activities (community support groups, wellness groups, health education, family interventions, and peer support groups, after-school activities etc.) that foster social cohesion and strengthen community-based mechanisms to protect and support individuals.

Provide focused psychosocial support through individual, family or group interventions, often more specialized in nature. Such interventions can be delivered by professionals in social work, by general health workers and by workers in schools but also by refugees themselves after training and with ongoing supervision.

Provide access to specialised clinical mental health and psychosocial services. Adaptions in service delivery (working with interpreters, cultural mediators, cultural awareness training for service providers) and practical/ financial support for transport, etc.  may be needed.

This chapter features examples and strategies related to the four layers of the IASC (2007)  pyramid through a systems-based approach, with case examples and other frameworks offered between each tier. While many layer 1 and 2 activities are already integrated throughout the Handbook, specific psychosocial strategies and approaches during integration are showcased here.

Many integration sites have developed MHPSS-oriented programming and responses which include:

• educational, promotional and awareness raising activities, documenting best practice resources for health and human service workers who resettle refugees to assist them in identifying and referring those requiring more intensive support;
• professional development engagements aimed to raise awareness of the psychological consequences of migration, the influencing factors of daily stressors, and impart ways in which workers can contribute to culturally relevant healing, growth, and recovery;
• information dissemination on torture rehabilitation, needs of all types of survivors (including early identification, assessment, and timely referrals), trauma-informed care, documentation procedures according to the Istanbul Protocol;
• systems for case consultation, expert testimonial and support for helping professionals;
• creation of cross-sector partnerships with other services to enable MHPSS support in the context of other activities (e.g., art and music groups) or settings (e.g., schools, health care centres, neighbourhood settlements, etc.);
• engagement in referral coordination, resource sharing, networking, and technical expert workgroups.

Mapping MHPSS services and referral pathways 

Integration workers should have a good understanding of mental health and psychosocial services within their resettlement community. This can help plan for service provision, capturing existing referral pathways and both formal and informal resources, ranging from clinical services to community-based social non-clinical services, sexual assault response services, emergency care, and other focused care relevant to resettled refugees. Such a list of services should be updated at least every six months. Specific community focal points can be utilized for prevention and outreach to the broader refugee and immigrant community.

Multi-layered interventions and supports

To operationalize different approaches and strategies during integration, the four layers of the MHPSS Pyramid serve as a framework.

Layer 1: Social and psychological considerations in resettlement and integration

This layer relates to providing equitable access to resources and services, in ways that respect and advance the safety, security and dignity of refugees. Using participatory and strengths-based approaches resettlement workers and other stakeholders may empower refugees and asylum seekers to choose interventions provided in a respectful and culturally relevant manner. It is important to consult with refugees  about the best ways to involve them. Consider creative methods of engagement, such as working with faith groups, shops, hairdressers and barbers, schools, festivals, sports events, and social media to engage with traditionally excluded groups. Countries have different legal frameworks which may promote or restrict access of refugees to basic needs and services.

For example, in 2022, many countries granted temporary residency to Ukrainians fleeing the Russian invasion offering access to employment, social welfare, and housing for up to three years, while people fleeing from other countries have different legal status and must undergo lengthy asylum processes.

The provision of basic needs-oriented care typically includes case management by resettlement workers to ensure basic needs and rights are preserved. Models for volunteer/community sponsorship to support refugee well-being have been developed in several countries. The relationships between refugees and sponsors often include emotional support; facilitation of access to basic services; assistance overcoming barriers to integration (e.g., language and cultural knowledge); strengthening of intergroup relationships; development of social connections. Community sponsorship often prioritizes elements like cultural dimensions, community engagement and wider social networking.

Assessing emotional well-being and mental health should be part of post-arrival health screening. Concerns related to distress may be chronic in nature or develop over time for a forcibly displaced person during resettlement. Trained health care providers or resettlement workers  are best suited to offer screening and referral to care. This may happen during intake, assessment, or other phases by primary care or resettlement casework. Workers should always consider more acute risks such as suicide, as well as impairment that may manifest as cognitive, or behavioural difficulties, or neurodevelopmental impacts that may impair overall functionality.

Over the last decade, advances in screening for emotional distress and early intervention support for refugees during resettlement have occurred. Some noteworthy culturally validated and normed mental health screening instruments are the Refugee Health Screener 15, and the Minnesota Wellness Check Screening tool. When screening, health providers should provide refugees with psychoeducation, ensure privacy, and reduce known barriers to service uptake (e.g., transportation, language access).

All resettlement workers benefit from developing basic psychosocial skills and learn how to best respond to someone experiencing more distressing signs or symptoms (see below in the chapter). Training on cultural competence, cultural humility, and trauma-aware services helps worker to respond in ways that encourage and support psychosocial resilience.

For more information on health, please refer to the health section of the Handbook.

Layer 2: Strengthening community and family support

Social connections between refugees and host community play an important role in integration by:

• creating emotional support;
• creating a sense of belonging to and trust in the host community;
• enhancing the sense of life satisfaction; and
• facilitating access to basic services and job opportunities.

Where social integration is weak or reduced, refugees may experience greater marginalization or stigma and may be perceived by their host communities as being problematic, or too demanding. Key to improving mental health and psychosocial wellbeing of refugees is therefore to strengthen and facilitate community support, peer support or afterschool groups. This is not so much providing services for refugees but enabling refugees and hosting communities to provide mutual support themselves. Building social networks and establishing connections are pivotal to support refugees’ emotional and social well-being. This can be done by creating space to process common challenges during post-arrival related to resettlement, adjustment, or the asylum process. This also includes facilitating community engagement, celebrating multiculturalism, honouring traditions, and rituals.

Strategies that enhance family strengthening and building social networks can develop a sense of connectedness and belonging, while minimizing isolation and fostering increased resilience and improved mental health. Integration specialists can assist in making the environment less difficult by normalizing mental health, connect people to social networks, and work to decrease risk factors while promoting well-being. Community-based support groups can disseminate information on accessing social services, community resources, and develop strategies for navigating different health and human services systems, provide psychoeducation, stress management and wellness promotion.

Creating a sense of belonging and providing mental health care for refugees should be done in partnership with the other social, cultural, and family support around the individual. Such an approach highlights the influence of environment on an individuals’ mental well-being across their lifespan. Emotional well-being is also embedded in the broader social and processes of acculturation, integration, and social inclusion.

The use of cultural traditions such as music, singing or dancing, art, natural and tactile therapies, peer support groups, or other traditional healing approaches (e.g., engaging faith healers) may be amplified in consultation with refugee communities. Psychological support may also be more acceptable if provided in the context of activities, such as craft, recreational or other social networks or cultural groups. This may involve partnership arrangements between psychological support professionals, other service providers and members of ethnic community-based organizations or faith centres. The use of trained bi-cultural focused counsellors, peer navigators or cultural mediators and others with similar lived experiences can improve the provision of basic psychosocial support.

Layer 3: Focused non-specialized psychosocial support

These strategies and interventions include more focused supports such as problem solving, skill building education and support, specialized case management, etc. Such services can be provided by case workers (such as social workers or integration workers). Despite being focused, they do not have to be provided by specialized mental health workers or professionals with advanced clinical mental health training. Many of such services can also be delivered by refugees themselves. The WHO has developed a series of brief “scalable psychological interventions” (5-8 sessions) that can be delivered by non-specialized staff after a short training and with supportive clinical supervision by a mental health professional.

Layer 4: Clinical mental health services

Clinical mental health services include psychotherapy, pharmacotherapy and treatment or hospitalization to stabilize an individual suffering from moderate to severe mental health conditions. While refugees have high mental health needs, they less frequently utilize such services. Many come from countries with limited mental health infrastructure or countries where mental health services may have been a source of persecution and oppression and conditions in psychiatric facilities may involve human right violations.  In order to facilitate equal access, a range of measures may be needed (See box below and here).

While refugees may suffer from any mental health condition, specific attention is needed in the case of mental health conditions related to the refugee experiences, especially PTSD and prolonged grief disorder. Widely used trauma-focused therapeutic approaches include Narrative Exposure Therapy (NET), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and Eye Movement Desensitization and Reprocessing (EMDR) all of whom have been shown to be effective with refugees. Many resettlement countries have established services for survivors of trauma and torture which usually provide intensive wrap-around case management, trauma recovery and rehabilitation. The services are designed to stabilize an individual or community and to support healing.
 

Concepts around mental health and well-being have different meanings across cultures, affecting where and how people seek help. Words commonly used in Western contexts for depression, anxiety, and trauma may have little or no meaning in other languages and cultures. In addition, what is appropriate or what is considered “normal behaviour” may vary considerably amongst cultures. Resettlement workers and mental health providers working with refugees should cultivate cultural humility and flexibility and attempt to learn about the specific coping practices and healing approaches that refugees have used and may rely upon. The best way to do this is by engaging in an open dialogue with refugee communities and learn from them. To assist refugees, resettlement workers and MHPSS specialists can benefit from actively acquiring a basic understanding of ethnic, religious and cultural systems, and learn to recognize common explanatory models for mental health conditions, afflictions and emotional distress. Engaging with local illness concepts and idioms of distress will facilitate communication and can be used as therapeutic levers in interventions designed to strengthen individual and collective resilience.

Service providers, volunteers, trusted community leaders, professional interpreters, sponsorship circles, or cultural mediators may be utilized to facilitate outreach and meaningful engagement to build rapport and improve connection with refugee populations during resettlement. These people can encourage communication, facilitate understanding among refugees and create a supportive environment increasing comfort in sharing information, and in promoting newcomers’ health and well-being. Combining cultural humility and trauma-informed processes can assist settlement workers as they work to optimize and promote emotional health and well-being of forcibly displaced persons.

While the demand for support may be met to some extent by specialist or professional services, most countries also recognize the importance of building the capacity of local communities of other refugees, as well as existing mental health providers to care for forcibly displaced persons more effectively. This can be achieved by:

• convening interdisciplinary teams, and developing networks of professionals prepared to offer free or affordable services to forcibly displaced persons (e.g., psychiatrists, psychologists, counsellors, community health workers, peer support specialists and others);
• adopting building capacity strategies for professionals in publicly funded primary health care services, such as counsellors and general practitioners, to provide psychological support to forcibly displaced persons;
• adopting strategies to build the capacity of paraprofessionals, cultural mediators or professional interpreters to offer bridging, language and cultural expertise supporting teams as they provide psychological support to forcibly displaced persons;
• offering telehealth services, which may reach more persons with focused clinical support; resettlement sites may devise registries of linguistically diverse telehealth providers through referral pathways mapping: this may help increase forcibly displaced persons to access mental health services;
• training and supporting paraprofessionals or non-specialists and those who provide language access in MHPSS strategies, principles, and specific low-intensity interventions, like Psychological First Aid (PFA) or peer support.
   

Effective capacity building usually requires a lead agency with appropriate professional and technical skills. In some resettlement countries, specialist services for trauma and torture survivors have been established for this purpose. Focused mental health providers, and integration workers can serve as advocates by linking refugees with psychosocial support to assist with housing, legal aid, access to health care, education, and employment. Importantly, the number of licensed mental health providers who speak a particular language may be small or non-existent in many countries. Therefore, interpreters play a critical role in mental health delivery.

Certain groups of refugees have specific MHPSS issues and face specific issues to access services, as reported below.

Changing family dynamics during resettlement

Families undergo significant changes prior and after resettlement. Gender roles may shift, placing additional stress on families. Children and their caregivers may experience the adjustment process differently; this can lead to power differences and a generational gap between parents and children, in turn producing challenges in the household. Children often learn the new language more quickly than parents or caregivers and may at times assume roles in the family unit that are related to decision making. These rapid changes can cause undue stress and pressure on youth and may also lead to parents feeling ineffective as their role is diminished or that their family is suffering. Younger refugees often take on additional family responsibilities such as finding a job or assisting family members with childcare or other household tasks. Younger refugees may feel stress and anger at the pressure to support their families, while older adults can develop low self-esteem and a sense of not belonging to the community or feel frustrated. Conversely, these changes in dynamics may stimulate members of the younger generation, leading them to be proactive in learning new skills needed in the household, flexible and adaptative to changes.

Parents or caregivers may struggle with how to support their child in a new cultural setting and tensions may arise regarding expectations of traditional roles, values, and behaviours of their home country. Parents or caregiver may experience a perceived loss of parental control as a sense of betrayal. This may cause dysfunction, conflict, or disharmony in family or household.

Refugee children and youth

Some refugee children and youth have endured chronic and pervasive exposure to interpersonal and community violence, violent loss of loved ones, and an insecure environment, which may lead to profound mental health issues. Protective family and community support can mitigate such experiences to some extent. Youth may feel like they don’t quite belong to either the culture of their parents or to the culture of peer in their new country, and struggle with identity issues and feelings of isolation. Children and youth who need mental health support should be referred to providers trained in working with children from diverse cultural backgrounds.

Gender and gender-based violence 

Refugee women, girls and LGBTQI+ persons may have experienced gender-based violence in countries of origin, during flight and during resettlement. This can have negative and often long-lasting effects on their mental and psychosocial wellbeing. Refugees with Gender-Based Violence (GBV) experiences will be more inclined to seek help when supportive structures are in place that mitigate the risk of stigmatization. This can be done by establishing (group) psychosocial activities within Women and Girls’ Safe Spaces (WGSS) with a focus on women and girls’ empowerment. These activities can also serve as non-stigmatizing entry points to case management for GBV survivors. If survivors wish, resettlement workers can facilitate referral to trained providers of evidence-based psychotherapies for survivors who are not functioning well because of mental health conditions such as depression and stress-related conditions. It is important that mental health-care providers have received appropriate training in the provision of mental healthcare to refugee survivors of GBV.

LGBTIQ+ refugees

Lesbian, gay, bisexual, transgender, intersex, and queer/questioning (LGBTIQ+) people face distinct challenges. Lack of family and social support can lead to complex mental health problems, and further challenges may continue throughout resettlement as service providers may not know how to create welcoming and inclusive environments. Many LGBTIQ+ refugees may be reluctant to connect with people from their community, becoming more isolated.

Older people

Adjusting to a new environment can be particularly hard for older people. It may be harder for them to accept support such as counselling or psychotropic medication because of unfamiliarity with these methods or because of stigma around mental health. Regular support groups, congregant meals, and planned excursions are ways to reduce isolation and depression in older refugees while increasing feelings of connection. Older refugees depend on their families and communities to carry out many activities; medical appointments due to language barriers, grocery shopping, even meeting friends due to transportation.

People with disabilities

Refugees living with disabilities, including psychosocial, cognitive and/or intellectual disabilities, may experience psychological distress, marginalization, discrimination, exclusion, violence, and neglect. They may come from countries where disability services and mental health systems were not community-based or recovery- and human rights-oriented. Therefore, careful engagement and information sharing about available services and support is important. This is best done in partnership with Refugee-Led Organizations (RLOs) to support design and implementation of disability-inclusive MHPSS programming, and support capacity building of integration staff. This may entail adapting programs and information to increase accessibility (e.g., transport, communication). It is important to invest in strong relationships with legal and other social service programmes to access available support and create environments where persons can seek additional psychosocial care.

Survivors of torture

Conducting assessment and early settlement support provides opportunities for early identification of emotional issues related to experiences of torture. This can be done through psychological assessment and by providing information for self-identification and self- referral. In some countries, a formal mental health assessment is routinely offered coupled with options for more intensive psychological assistance and social support. It is important to maximize opportunities for early intervention in the reception period. However, this is also a time when symptoms may be masked by the effects of the “honeymoon” phase. It is not uncommon for emotional health challenges to become accelerated by the stresses associated with ongoing adjustment to the new context.

Caring for persons who have experienced trauma or extreme adversity can take a toll on the emotional health and well-being of any resettlement worker. During resettlement and integration, forcibly displaced persons’ experiences of forced migration and adjustment challenges may evoke emotional reactions in workers, which may influence the provision of appropriate support as well as lead to occupational hazards and different types of stress.

People working with forcibly displaced persons are better able to deal with this stress if they have opportunities to receive supportive supervision, peer support and benefit from organizational practices that preserve worker resilience and well-being. Bearing witness to another person’s traumatic history can lead to secondary trauma, especially for workers who have similar backgrounds and histories as the individuals they are serving. Adequate self-care and organizational support must be in place to prevent and mitigate mental health impacts on personnel. Self-care and stress management strategies should be regularly reviewed and affirmed among resettlement workers on an ongoing basis to be effective. All integration personnel benefit from being supported in practicing self-care suited to their needs, cultural practices, and individual preferences.

• Individual self-care is an intentional practice that reduces stress levels and allows one to maintain and restore a sense of balance in all aspects of one’s life (both professionally and personally). Self-care begins with awareness, and entails sustaining wellness practices through action planning and reassessing overall well-being.
• Organizational resilience is an intentional response to managing stress. It may entail work related components such as normalizing staff resilience in the organizational culture by promoting wellness practices.

Mental health and psychosocial well-being are important values in themselves, but apart from that are also essential to the resettlement process. This requires collective multi-sectoral action with important roles for mental health specialist, resettlement workers and refugee and host communities. This chapter illustrated this through the four layers of MHPSS intervention pyramid.

• Organize resettlement process so as to protect the dignity, safety, and security of all people, providing appropriate information, using participatory approaches, and considering basic needs and safety.
• Strengthen community and family support through psychosocial promotional activities (community support groups, wellness groups, health education, family interventions, and peer support groups, after-school activities etc.) that foster social cohesion and strengthen community-based mechanisms to protect and support individuals.
• Provide focused psychosocial support through individual, family or group interventions, often more specialized in nature.
• Provide access to specialised clinical mental health and psychosocial services and promote adaptions to service delivery to make them optimally relevant to refugees.