“Just because you leave war, war does not leave you. And for me in America, it came back in my nightmares, it came back in the low kick of a car’s engine, it came back in the loud roar of a plane, it came back in a mother’s hum, in a father’s song.”–Loung Ung, Cambodian American Author and Human-Rights Activist, full speech available at: https://www.youtube.com/watch?v=6odKrFRfqkI&feature=youtu.be.
Much of the literature on immigrant and refugee mental health focuses on loss and trauma, as well as the depression and anxiety that frequently accompanies them. The interconnectedness of loss, trauma, depression, and anxiety can make it difficult to distinguish what is the presenting problem. When looking at one, others are likely to be present. Those who work with immigrants and refugees must be aware of how loss, trauma, depression, and anxiety may each affect an immigrant or refugee’s mental health as well as family health and functioning.
In every story of immigration or refugee resettlement, a common thread of loss is present. Some losses are obvious, like the loss of home and community or the severance from family and friends who have been left behind or killed. Loss does not end with resettlement; new losses are experienced and revealed over time, some of which can be obscure, like the loss of identity, social status, language, and cultural norms and values.
The grief response that comes with loss can manifest as physical, emotional, and psychological responses including crying, anger, numbness, confusion, anxiety, agitation, fatigue, and guilt. The loss of surroundings, possessions, ideas, and beliefs such as those experienced by immigrants and refugees can trigger a grief response similar to those experienced with the death of someone close (Casado, Hong, & Harrington, 2010).
Some losses and the accompanying grief are considered normative in United States culture. For instance, the death of a loved one or child is a recognized loss and the manifestations of grief associated with that type of loss are understood by most people. However, some losses and the accompanying grief are disenfranchised, meaning that grief occurs when a loss is experienced but is not recognized by others as loss. For example, Kurdish families who resettled in the United States while Saadam Hussein was president may have found that people in the United States did not understand why they would miss living in Iraq. Migratory grief is considered a disenfranchised grief (Casado et al., 2010) and is often dismissed in the immigrant and refugee adjustment experience. As a result, people with disenfranchised grief are unable to express feelings, and grief-related emotions are not recognized or accepted by others.
Another way to think about grief and loss experienced by immigrants and refugees is to understand the ambiguous nature of their loss experiences. There are two types of ambiguous loss (Boss, 2004). The first occurs when a loved one is physically absent but emotionally present because there is no proof of death. A kidnapped child, soldiers missing in action, family separation during war, deportation, and natural disasters can all result in this type of ambiguous loss. The second type of ambiguous loss occurs when a loved one is physically present but emotionally absent. Dementia, brain injuries, depression, PTSD, and homesickness can all result in individuals being physically present but emotionally or cognitively they have “gone to another place and time” (Boss, 2004, p 238). Family members who experience ambiguous loss describe physical and mental pain as a result (Robins, 2010). The lack of clarity associated with ambiguous loss can lead to boundary ambiguity expressed in conflict and ambivalence in the new roles family members take after resettlement. Ambiguous loss is also often characterized by frozen grief, represented by the immobilization of individuals and relational systems stuck between the old and new worlds (Boss, 2004). Although ambiguous loss is a common experience for immigrants and refugees, limited research has been conducted with this population (Rousseau, Rufagari, Bagilishya, & Measham, 2004).
Most people experience grief reactions to a mild or moderate degree and then return to pre-loss levels of functioning without the need for clinical intervention. However, some suffer a more complicated grief reaction (Bonanno et al., 2007). Complicated grief occurs when acute grief becomes a chronic debilitating condition (Shear et al., 2011). It may be incorrectly labeled as depression (Adams, Gardiner, & Assefi, 2004). However, research indicates that complicated grief is distinguishable from depression and other trauma-related psychological disorders. Intense longing for the object of loss, preoccupation with sorrow, extreme focus on the loss, and problems accepting the death or loss are all symptoms of complicated grief. Complicated grief can exacerbate psychiatric disorders and influence the relationship between loss, symptoms of posttraumatic stress and depression (Nickerson et al., 2011). In one study with Bosnian refugees, for example, complicated grief was a better predictor of refugee general mental health than was PTSD (Craig, Sossou, Schnak, & Essek, 2008).
Anxiety and Depression
The literature on immigrants’ and refugees’ experiences with anxiety and depression is often intermingled with that of loss and trauma. Comorbidity can make it difficult to measure and separate one symptom cluster from the other but the two comprise different psychological diagnoses. Anxiety is characterized as a normal human emotion that we all experience at one time or another. Symptoms include feelings of fear and panic, uncontrollable and obsessive thoughts, problems sleeping, shortness of breath, and an inability to be still and clam. Anxiety disorders are serious and sufferers are often burdened by constant fear and worry further exacerbating comorbidity of PTSD symptoms. The literature on anxiety prevalence of immigrant and refugee populations is limited but expected to be highly correlated with that of PTSD and depression. Depression, described as feelings of sadness, unhappiness, or feeling down, is a normative reaction and can be felt in varying degrees. However, clinical depression is a mood disorder in which the feelings of sadness interfere with everyday life for weeks or longer. Immigrants and refugees are at high risk for clinical depression due to their extensive histories of loss, potential trauma, and resettlement. Studies have also shown that depression among immigrants is related to the process of adapting to the host culture (Roosa et al., 2009). Depression is known to cause long-term psychosocial dysfunction in refugees who have experienced violence and loss (such as in Bosnian refugees resettled in Australia; Momartin et al, 2004). It should not be seen as a marginal issue when compared to PTSD and other trauma related diagnoses (Weine, Henderson, & Kuc, 2005). Depression is a common clinical problem with successful available treatments. Weine et al. (2008) argue that it should be a target of intervention and focus of health education with immigrant and refugee populations.
Many immigrants and most refugees have experienced or been exposed to traumatic events such as witnessing or experiencing violence, torture, loss, or separation. Psychological trauma is most often not limited to a single traumatic event but includes direct and indirect events over the course of a person’s life (Jamil et al., 2002). Traumatic stress affects how people see the world, how they find meaning in their lives, daily functioning and family relationships. Several studies have documented the effects of traumatic stress related to war violence on refugee health. Steel et al. (2009) conducted a meta-analysis with over 80,000 refugees and reported a weighted prevalence rate of PTSD ranging between 13% and 25%. In one critical review, torture and cumulative exposure to traumatic events were the strongest factors associated with PTSD, with some refugee communities experiencing PTSD prevalence rates as high as 86% (Hollifield et al., 2002). A study of symptom severity of PTSD and depression with 688 refugees in the Netherlands supported these findings, reporting that a lack of refugee status and accumulation of traumatic events were associated with PTSD and depression (Knipscheer, Sleijpen, Mooren, ter Heide, & van der Aa, 2015). Studies have also established the enduring effects of pre-migration traumatic stress even years after resettlement (Marshall, Schell, Elliott, Berthold, & Chun, 2005) as well as the long-term physical health effects of refugee trauma, including hypertension, vascular disease, coronary, metabolic syndrome, and diabetes (Crosby, 2013).
For immigrants and refugees, it is possible that entire families will have been exposed to similar traumatic events and losses that disrupt family and social networks (Nickerson et al., 2011). This is especially true for those who have experienced war or interpersonal violence. War is characterized as an attack on civilian populations where citizens are targeted, dislocated, and displaced (Lacroix & Sabbath, 2011). According to Sideris (2003), war unravels the social fabric of a community as the “social arrangements and relationships which provide people with inner security, a sense of stability, and human dignity are broken down” (p. 715). For instance, people may experience a sense of helplessness, damaged trust, shame, and/or humiliation associated with traumatic experiences such as rape, physical violence, witnessing death, being forced to violently turn on one another, and having to flee homes.
The harmful effects of traumatic stress on mental health and functioning have been well documented in refugee populations (de Jong et al., 2001; Hebebrand et al., 2016; Nickerson et al, 2011). Research in the United States shows that PTSD is higher for refugees who spent time in refugee camps affected by war and forced migration than for other resettled communities (LaCroix & Sabbath, 2011). Common trauma-related diagnoses are PTSD and Acute Stress Disorder (ASD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), PTSD and ASD correspond to a situation in which a person experiences or witnesses threatened or actual death, serious injury, or sexual violence and continues to bear the mark of the experience after the event has ceased. PTSD and ASD are characterized by a cluster of symptoms that cause symptom-related stress or functional impairment (e.g., difficulty in work or home life). Symptoms that are present between three days and one month after the traumatic event are classified as ASD, symptoms that last more than one month are classified as PTSD. Both adults and children can have PTSD and ASD. Symptoms fall into four categories: (a) persistently re-experiencing through intrusive thoughts or nightmares; (b) avoiding trauma-related reminders such as people, places, or situation; (c) negative alterations in mood or cognitions such as the inability to recall key features of the traumatic event, negative beliefs about and expectations about oneself and the world (e.g., “I am bad,” “the world is completely unsafe”), diminished interest in pre-traumatic activities, and persistent negative trauma-related emotions (e.g., fear, horror, anger, or shame); and (d) alterations in arousal and reactivity that worsen after the traumatic event such as increased irritable or aggressive behavior, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, problems concentrating, and sleep disturbance.
Traumatic Stress and Family Relationships
Family consequences of exposure to traumatic stress include financial strain, abuse, neglect, poverty, chronic illness, and increased family stress (Weine et al., 2004), as well as a decreased ability to parent (Gewirtz, Forgatch, & Wieling, 2008). Individuals with PTSD, for example, are likely to be more reactive, more violent, and more withdrawn in relationships with a spouse or children (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010; Nickerson et al. 2011).
Floods in Sahrawi refugee camps in southwest Algeria.
Wikimedia Commons – CC BY-SA 2.0.
The literature shows that family attachment and support can have a protective effect on those who have experienced traumatic stress, while separation from family can exacerbate symptoms (Rousseau et al., 2001). This makes family mental health and functioning particularly important when there has been loss and exposure to traumatic stress (Nickerson et al., 2011).
Research shows that parental PTSD can significantly affect the parent-child relationship. Parental PTSD is associated with an increase in self-reported aggressive parenting, indifference and neglect (Stover, Hall, McMahon, & Easton, 2012), lower parenting satisfaction (Samper, Taft, King, & King, 2004), an increase in family violence (Jordan et al., 1992), an increase in challenges with couple adjustment and parenting (Gewirtz et al., 2010), and lower perceived relationship quality with children (Lauterbach et al., 2007; Ruscio, Weathers, King, & King, 2002). Having a parent with PTSD has been linked to an increase in children’s behavior problems (Caselli & Motta, 1995; Jordan et al., 1992), trauma-related symptoms (Kilic, Kilic, & Aydin, 2011; Polusny et al., 2011), anxiety and stress (Brand, Schechter, Hammen, Brocque, & Brennan, 2011), and depression (Harpaz-Rotem, Rosenheck, & Desai, 2009). A recent study in Northern Uganda also found that exposure to trauma was associated with family violence (Saile, Neuner, Ertl, & Catani, 2013). In the same study, children reported that their worst traumatic experiences were related to family violence, not exposure to war violence. Similarly, Catani, Jacob, Schauer, Kohila, and Neuner (2008) found that following war and the tsunami in Sri Lanka, 14% of children reported an experience of family violence as the most distressing experience of their lives. A later study with by the same research group (Sriskandarajah, Neuner, & Catani, 2015) found that children listed their worst experiences of family violence immediately after war experiences, but reported that parental care significantly moderated the relationship between mass trauma and internalizing behavior problems. This literature documents the ubiquitous impact of traumatic stress on family relationships and underscores the need for prevention and intervention treatment modalities targeting individual and relational family systems for populations commonly exposed to multiple traumatic events (Catani, 2010).
Child Mental Health
Children are not immune to the deleterious effects of the immigrant and refugee experience. Children who flee adversity to seek refuge in a foreign land often endure physical and mental challenges during a turbulent and uncertain journey (Fazel, Reed, Panter-Brick, & Stein, 2012). They may experience traumatic experiences in their homelands (war, torture, terrorism, natural disasters, famine), lose or become separated from family and caregivers, and endure traumatic journeys to a host country (crossing rivers and large bodies of water, experiencing hunger, lacking shelter; Pumariega, Rothe, & Pumariega, 2005). Children may feel relief once they resettle, but resettlement can bring additional challenges including financial stressors, difficulties finding adequate housing and employment, a lack of community support, new family roles and responsibilities that often transcend developmental age, acculturation stressors such as generational conflict between children and parents, and a struggle to form a cultural identity in the resettled country.
Abed (15) fled Syria to escape the war and was separated from his parents along the way.
Trocaire – DSC_1009 – CC BY 2.0.
The cumulative effects of being exposed to traumatic events and/or stressors pre- and post-migration may overwhelm the coping ability and resilience of children, leading to an accumulation of stressors that may have profound and lasting effects on children’s ability to meet developmental milestones and optimally function on a day-to-day basis. This is especially true for children who experience post-migration detention or enter a host country unaccompanied (Hodes, Jagdev, Chandra, & Cunniff, 2008; Rijneveld, Boer, Bean, & Korfker, 2005). Immigrant and refugee children may continue to suffer from similar conditions as adults, such as anxiety disorders, depression, and PTSD (Fox, Burns, Popovich, Belknap, & Frank-Stromborg, 2004). Studies have shown that the prevalence of PTSD and depression among resettled refugee children in the United States is significantly higher than for children in the general population (Bronstein & Montgomery, 2011; Merikangas et al., 2010). A community-based participatory study conducted by Betancourt, Frounfelker, Mishra, Hussein, and Falzarano, (2015) with Somali Bantu and Bhutanese youth in the United States found that these communities also identified areas of distress corresponding to Western concepts of conduct disorders, depression, and anxiety.
Age Specific Effects of Trauma
See the National Child Traumatic Stress Network’s list of age-specific effects of trauma at: http://learn.nctsn.org/mod/book/view.php?id=4518&chapterid=38.