https://docs.google.com/document/d/1j8dpputOjIX4ZraGtS8lJETowCQte_uILi_gZB2UwHo/edit
The number of displaced people worldwide due to war or violence was over 19 million in 2018 (Hameed et al., 2018). Consequently, there is a greater global need for safe spaces for the resettlement of refugees and asylum seekers. The United States defines a refugee as a person outside of their country who “is unwilling or unable to return because of persecution or a well-founded fear of persecution” due to race, religion, nationality, membership in a social group, or political views. Asylees are defined similarly, except they are already within the US or seeking entry into the US (Department of Homeland Security). It is necessary to investigate the mental health of refugees and asylum seekers because there is a deficit between the support that is needed, and the support they receive (Song & Teichholtz, 2018). The government agencies in charge of processing and resettling these people, legislators writing policy affecting refugees and asylees, the host communities, and health care providers all have a stake in the plight of refugees and asylees. This paper will investigate the pre-migration, peri-migration, and post-migration contributors to refugee and asylee mental health, and what mechanisms can support them.
Exposure to war, violence, and associated traumas can be linked to increased vulnerability to mental health disorders (Hameed et al., 2018). Many of the characteristics specific to refugee populations, such as trauma prior to migration, staying in refugee camps, having a death in the family, and lacking basic living resources are associated with depression. Refugees are also more vulnerable to psychotic symptoms of Post Traumatic Stress Disorder (PTSD), which are the most severe form of symptoms associated with PTSD (Lindley et al., 2000). Refugees who experience one traumatic event may experience increased PTSD symptoms after another trauma or significant life event, which is of particular significance since the migration and resettlement processes can also be considered traumatic life events. The increased severity of symptoms associated with mental health disorders may be due to increased duration or number of traumatic events and lack of support systems that refugees often endure (Hameed et al., 2018). Therefore, people who are categorized as refugees are already at a higher risk of developing mental health disorders as a result of circumstances that forcibly displace them (Hameed et al., 2018).
Similarly, a study investigating the mental health status of Central American asylum seekers in McAllen, Texas showed a strong association between previous traumatic experience and negative mental health outcomes. Interviews of 234 adults revealed 83% fled their homes due to violence, and 90% said they were afraid to return home due to murder, kidnapping, sexual assault, extortion, and fear of retaliation for reporting violence. In terms of mental health status, 32% of the interviewees met the criteria for PTSD, and 24% met the criteria for Major Depressive Disorder. These people experienced high levels of trauma, and exhibited high rates of psychological symptoms of PTSD and depression–demonstrating the importance of mental health considerations in asylum seekers (Keller et al., 2017).
It is clear that pre-displacement factors, namely exposure to violence and the resulting trauma, have significant mental health impacts on refugees and asylees (Hameed et al., 2018). There are also numerous factors arising during the displacement process that affect the mental health of those in the process of resettlement or seeking asylum. One such factor includes having to live in refugee camps, or being held in detention centers. In fact, multiple studies have shown that the length of stay is associated with more negative mental health outcomes (Keller, 2003 and Keller 2017). One Lancet article found that in a group of 70 asylees detained in the northeastern United States, 77% had symptoms of anxiety, 86% of depression, and 50% of PTSD when initially surveyed. Each of these categories of symptoms was significantly correlated with length in detention centers. After following up with the same people later, they found that asylees who had been released exhibited reduced symptoms, while those still in detention had increased severity compared to the initial results. Based on this, it seems the asylum process itself contributes to negative mental health outcomes (Keller et al., 2003).
The lack of control over one’s future, constant uncertainty, restrictive rules, and lack of basic resources have been identified as contributing factors to these outcomes (Hameed et al., 2018). ICE detention centers have been expanding in the US since 2017, and an ACLU report found that they were largely lacking in medical and mental health services (Cho & Cullen, 2020). They also reported that people in these detention centers are subject to violence and threats of violence from detention officers themselves, lack access to adequate legal representation, and are denied asylum 90% of the time (Cho & Cullen, 2020). While the relationship between memory and PTSD has not yet been well defined, sometimes people living with PTSD can have difficulty accurately remembering certain events, which can greatly impact the credibility of claims made by asylum seekers in the stressful environment of an interview or hearing (Sandalio, 2018).
The COVID-19 global pandemic has compounded some of these issues in 2020, as the International Rescue Committee reported that displaced people are more vulnerable to the disease (Chotiner, 2020). An ICE detention center in Houston was reported to have 1 in 5 immigrants test positive (Tallet, 2020), and the US closing its borders to asylum seekers has facilitated the spread of COVID in border towns. This has not only forced thousands of people to live in unsafe and unsanitary conditions (Washington Office on Latin America, 2020), but also increased feelings of anxiety and uncertainty as many asylum hearings have been delayed, some even until 2021 (Aguilera, 2020).
The policies enacted by host countries necessarily impact the lives and mental health of refugees and asylees. Specifically, policies of deterrence have increased the restrictions and criminalization of asylees and refugees through several means such as detention, enforced dispersal, more strict refugee determination and caps, and restricted access to work, education, and housing (Silove et al., 2020). Other policies such as the Migrant Protection Protocols, which requires tens of thousands of asylees to wait for their hearings in unsafe conditions in Mexico even after passing the credible fear screening, contribute to feelings of uncertainty and add to the trauma experienced by asylum seekers (Aguilera, 2020). Family separation is another potential form of deterrence, as reports have surfaced that asylees who were separated from their families were given the choice to reunify if they would drop their asylum claims (Isacson et al., 2018). Policies that may fall under this category typically induce conditions for refugees and asylees that compound their trauma and further increase their risk of developing and long term mental health problems.
Family separation also acts as an important factor in the mental health of refugees and asylees. A study looking at refugees after resettlement in the US showed that separation from family was significantly related to symptoms of depression/anxiety, PTSD, and overall psychological quality of life. The refugee participants identified family separation as a “major, ongoing stressor” (Miller et al., 2017). These are not the only effects: medical professionals have stated that family separation constitutes an “extremely stressful experience that can cause irreparable harm”, increases the risk of chronic mental and physical conditions, and affects brain development (Isacson et al., 2018). A documentary depicting family separation at the US-Mexico border highlights the damage caused, as one child returned to his mother after a month of separation was traumatized to the point of believing his mother did not love him anymore (Raff, 2018). Although the family separation policy was officially discontinued in 2018, it still occurs in 2020 and has lasting effects on thousands of families (Vinson, 2020).
After the evaluation of 7,000 refugees and asylees resettled in western countries, a 2018 study concludes that refugees and asylees are ten times more likely to be diagnosed with PTSD when compared to the general population. Acculturative stress, which is stress associated with having to assimilate to a new culture, can also contribute to symptoms of PTSD (Hameed et al., 2018). The very act of resettlement requires acculturation to host country culture as refugees and asylees face the difficulties of housing, visa uncertainty, literacy, employment concerns, hostility, discrimination, and the lack of belonging (Hameed et al., 2018). Housing can be detrimental to mental health as one study indicates that asylee and refugee populations who lived in institutional accommodations were “consistently linked with worse psychological outcomes” in comparison to permanent private housing. Conversely, improvements in PTSD were associated with the presence of stable housing (Kashyap et al., 2018). Improvements in psychological distress were also associated with certainty of immigration status for asylees (Kashyap et al., 2018). Overall, a study of 2,399 refugees resettled in Australia demonstrates that these post-migration resettlement stressors are the “strongest correlates of mental health problems,” making them imperative to address (Chen et al., 2017).
According to the Center for Immigration Studies, of the two million immigrants that come to the United States each year, half lack proficient English language skills. Although these non-U.S. born adults only make up 15% of the total population, they “comprise 34% of the population with low English literacy skills” (U.S. Department of Education, 2014). Specifically in America, 72% of refugees arrive functionally illiterate in English (Richwine, 2017). The existence of these low literacy skills has several implications. First, language barriers cause stress, as depicted through the Bosnian refugees who experienced “significantly more stress” when living in Australia in comparison to Bosnian refugees living in Austria. Second, literacy permeates every aspect of life, having a negative ripple effect on both poverty and health care.
The National Institute for Literacy denotes that higher literacy rates correlate to higher earnings; lower literacy levels correlate to lower wages and higher unemployment rates. In fact, 43% of the adults living with the lowest literacy levels in the United States are also living in poverty. This correlation between low literacy and poverty is detrimental for the mental health of asylees and refugees. 70% of epidemiological studies in a systematic review reported “positive associations between a variety of poverty measures and common mental disorders,” and referenced the cycle this association creates in the lives of those who experience it (Allen et al., 2014). For refugees and asylees, lower post-migration socioeconomic conditions are correlated to poor psychological functioning (Kashyap, 2018).
Refugees and asylees experience many limitations when seeking access to health care and mental health accommodations. Specifically, a scoping review of 26 articles demonstrates that cultural communication barriers, lack of psychological support, difficulties with health care payments, and perceived discrimination from health care professionals present issues for general health care access (Mangrio & Forss, 2017). These barriers only increase when accessing mental health treatment. A comprehensive study with interviews of eight refugees indicate that stigma, fear, cultural differences, language barriers, practical barriers, lack of education, and spiritual barriers all prevent refugees and asylees from accessing proper mental health accommodations (Fitzgerald, 2017).. Many in the community did not seek mental health treatment because of the stigma against it, its association with unfaithfulness, and the fear that they could lose their children as well. All depicted language barriers and literacy as significant problems in health care interactions. According to the American Journal of Public Health, an excess of $230 billion per year is incurred because of the difficulty in understanding important health information. This disproportionately impacts those with lower literacy levels, as they pay six times more in health care costs per year than those with higher literacy levels (ProLiteracy, 2019).