This chapter is designed to examine the impacts of disaster on displaced populations and refugees of multiple trauma events. The aims therefore are to highlight the processes of psychological triage, identify at-risk groups, and suggest treatment approaches that enhance the adjustment processes and well-being of victims and survivors. The focus is particularly on those victims who have witnessed traumatic events and experienced considerable loss.
It is hoped that this work will also answer a few important questions on how displaced populations, including children, women, and other adult family members, may react to the traumatic refugee experience, how they adjust and cope in the host culture, and what their mental health problems are. The answers provided to these questions are important to a number of professionals and emergency field workers, including emergency staff and rapid response team members, doctors, nurses, policy makers, researchers, psychiatrists, psychologists, social workers, and other mental health professionals.
The scale of refugee population movements in the world today is becoming alarming, with approximately 51.2 million people across the globe considered to be “of concern” to the United Nations High Commissioner of Refugees (UNHCR). In 2013 the UNHCR suggested the reasons for large-scale refugee movements are numerous, including persecution, conflict and wars, generalized violence, and human rights abuse and violation. The same report of the UNHCR noted that 16.7 million of these displaced people were refugees in foreign host nations, whereas 33.3 million individuals became internally displaced persons (IDPs) within their own countries, and 1.2 million of the reported figures became asylum seekers. This particular report also noted that the year 2013 alone witnessed the displacement of 10.7 million individuals, of which 8.2 million were internally displaced and 2.5 million later became refugees. That is with an estimate of 32,200 individuals who leave their home daily and seek protection elsewhere. It is worth noting that the majority of these displaced populations are children and women. Children below 18 years old represented 50% of the displaced population. Meanwhile the group between 18 and 50 years old represented 46% of displaced figures; individuals more than 60 years old were only 4% of the population. The majority of these displaced individuals seem to be currently living in developing countries. Major sources of countries of refugees include Afghanistan, Syria Arab Republic, Somalia, Sudan, Democratic Republic of Congo, Myanmar, Iraq, Colombia, Vietnam, and Eritrea.
The 2011 civil war in Syria has contributed to one third of its population fleeing and becoming displaced in what could be described as the worst humanitarian disaster in modern times. It has also created the worst refugee crisis in the Middle East. It is estimated that 2.5 million Syrians have fled abroad and another 6.5 million have been internally displaced. Most Syrian refugees are currently living in poor conditions in tents and in neighboring countries, such as Turkey, Iraq, Jordan, and Lebanon.
As will be seen throughout this chapter, victims of war and oppression usually flee in large numbers, arriving in poor, underdeveloped countries without appropriate care or education for the young individuals. Most of these host developing countries lack the appropriate infrastructure needed to facilitate massive humanitarian needs. Similarly Iraq continues to face a long-standing, large-scale population displacement and pressing humanitarian needs for its own population, particularly in the north and west of the country. Terrorist organization attacks (Islamic State of Iraq and the Levant [ISIL]) on Mosul have forced hundreds of thousands of people of various Iraqi ethnic backgrounds to seek shelter elsewhere in Iraq. However, the services remain inadequate, overcrowded, and unsustainable.
Focusing on the literature in this area, apart from some very limited publications, it has been suggested there is very little attention paid to the links between reactions, losses, and adjustment of displaced populations and refugees living in a host nation. Published research that links both adjustment and preflight problems, particularly among those refugees who have escaped civil strife and wars and suffered multiple traumas or displacement, is very limited. An interesting study, which was funded by the King’s Fund (United Kingdom), on the health needs assessment of the Iraqi community in London, suggested that 53% of the adult population studied had a wide range of mental health problems, 49% had heart diseases, and 24% suffered from various types of cancers. These findings confirm results reported by similar studies. , The former examined the importance of social factors in exile among 84 Iraqi refugees and found depression in 44% of the sample. This particular study suggests that many of the most important factors in continuing morbidity can be modified in the country of exile. It has also highlighted the importance of the preflight experience and family reunion in which the survivor is separated from close relatives, including spouses and children. Meanwhile another study found that 46.6% of patients included in their study had a posttraumatic stress disorder (PTSD) according to the criteria of the Diagnostic and Statistical Manual— Fourth Edition (DSM-IV). Age, gender, unemployment, and torture emerged as important predictors of emotional withdrawal in this study. Both of the above-mentioned studies seem to place emphasis on the multifactorial nature of risk factors in the psychological health of refugees and the need for integrated rehabilitation efforts as well as professional help to improve the social environment and the need to provide appropriate activities and support to the refugee population.
Postmigration and adjustment of traumatized refugees in host nations
Certain research has reported that reactions to direct exposure and living through war conditions may contribute to promoting negative outcomes among newly arrived refugees, including high levels of PTSD symptoms in children and adults who have survived war. This particular study further added that traumatic stressors in war are commonly multiple, diverse, chronic, and repeated. Other research in this area , has focused on parental adjustment and children’s reactions to traumatic events. In fact some of these studies, , which were conducted in former conflict regions, such as Bosnia, Lebanon, Iraq, and South Africa, have found that adults and parental mental health, particularly that of mothers in times of conflict, was a significant predictor of children’s adjustment and morbidity. Baker and those of similar work , support the above-mentioned findings and add “tortured individuals are less likely to function as parents, spouses or employees. Tortured survivors can have difficulty in establishing relationship and trust with their spouse and children and are therefore more likely to transmit their problem to their offspring.”
Sourander looked at the extent of damage on separated refugee minors waiting for placement in an asylum center in Finland and reported that approximately half of the minors were functioning within clinical or borderline range when evaluated with the Child Behavior Checklist. This study also claimed that very young and unaccompanied refugee minors are more vulnerable to emotional distress than older children. Hauff and Vaglium suggested that the availability of a close confidante, such as a spouse, children, or close relatives, in periods of psychosocial transition has been shown to have a protective effect against psychiatric disorders. This research also noted that married refugees separated from their spouses by the flight were more emotionally distressed than other refugees on arrival. Allodi indicated that emotional distress in children was related to previous traumatization of the parents and the current coping styles. Weile and colleagues stated that children of traumatized refugee families were fragile, vulnerable, and had more psychosomatic problems than age-matched native school children.
Level of exposure to violence and human disaster versus vulnerabilities of displacement
It is worth noting here that the extent of vulnerability depends on the impact of premigration exposure to violence and postmigration experience on individuals and community. This may include, before migration, witnessing the death and injury of a parent or sibling and perhaps persistent exposure to death, destruction, and ultimately children separated from parents. Researchers , regard separation from family support, siblings, and friends as more stressful than exposure to bombing and injury. Hence the most vulnerable time appears to be the preschool years and early adolescence. , Other risk factors may include sudden and unanticipated death of parents or siblings during disaster, consequent radical change in family circumstances, and poor access to family support, followed by an unstable, inconsistent host environment in the dissimilar host culture. It would be fair to suggest here that rapidly changing environments with little stability as well as parental psychopathology and lack of security or protection have implications on the physical health and mental well-being of the refugee population.
Further research in this area has looked at the factors that help children to cope with severe and stressful life events. This work indicates that a lack of immediate support, disintegration of family, and the more risk factors a child is exposed to are more likely to make children vulnerable to psychiatric or mental health problems. Williamson, Ahearn, and Athey have summarized the plight of refugees and the extent of their vulnerability and suggested “at any point in time, half of the refugees in the world are children. Most large-scale flights involve children, young adults, and women. These children often experience malnutrition, lack of a balanced diet for normal growth, infectious diseases during the flights, exposure to crowded conditions, and poor sanitation. Many children also may lose siblings because of infectious diseases, experience separation, experience death of parents, become victims of violence, be beaten and suffer injuries, and are more likely to assume an adult role when the family structure changes through the death of parents and during illness.” ,
While writing on the legacies of war, atrocities, and refugees, Summerfield noted that there had been at the time an estimated 160 wars and armed conflicts in the developing world since 1945, with 22 million deaths and 3 times as many injured. He quoted United Nations Children’s Fund (UNICEF) figures for 1986 and suggested “in the First World War, 5% of all casualties were civilians, 50% in the Second World War, over 80% in the U.S. war in Vietnam and in present conflicts over 90%.” He went further to add that 80% of all war refugees are in developing countries, many among the poorest on earth. In parts of Central America, he claimed 50% of households are headed by a woman and these are much more likely to be poor. Mortality rates during the acute phase of displacement by war are up to 60 times those of expected rates. Those at extra risk are households headed by an unprotected woman (often widowed), those without a community or marginalized in an alien culture, those at serious socioeconomic disadvantage or in severe poverty, and those with poor physical health or a disability. The emotional well-being of children remains reasonably intact for as long as their parents (or other significant figures) can absorb the continuing pressure of the situation. Once parents can no longer cope with day-to-day living, children’s well-being deteriorates rapidly and infant mortality rates rise.
Disaster and mental health triage of refugees and suggested therapeutic approaches
In a comprehensive review Westermeyer suggested that assessment and treatment should take into consideration a wider range of past experience and current life situations as well as medical history, family illnesses, and social background. This should include physical examination, developmental data, prenatal and postnatal problems, social and emotional development, preflight stressors, losses, length of stay in refugee camps, and early resettlement experience. That is to say premigration, transmigration, and postmigration experiences are frequently traumatic and must be assessed.
Treatment, however, should resemble that offered to indigenous populations and should include counseling, cognitive and behavioral therapy, and pharmacotherapy, if necessary. Compliance problems and complaints regarding side effects may occur more often among refugees who are not familiar with long-term medications. These can be reduced through education and reeducation of the parents and children. Refugee problems are too complex to rely on medication to solve mental health and psychiatric problems. Doctors and therapists therefore should direct patients to counseling, social activities, play, group work, stress management, education, and recommendation of other psychotherapies available to deal with stressful and long-term problems.
Jones worked with adolescent refugees in Bosnia who experienced uprooting and various losses (i.e., losses of family, home, school, town, friends, and relatives) and suggested that greater flexibility over boundaries is required, particularly regarding time and setting. In addition, therapists working in a human rights or refugee camp context should be prepared to acknowledge their own impartiality and subjectivity and allow the discussion of political and social issues within the group. It is also suggested that such support can be of use through providing a space for expressing feelings, problem-solving, and rebuilding of social ties. Eisenbruch uses the term cultural bereavement to describe the losses and sees this as a condition that can affect both physical and mental health. Jones and Eisenbruch both agreed on the fundamental task of first rebuilding the social networks, engaging in community support, facilitating the development of problem-solving skills, and addressing the collective experience of loss rather than focusing entirely on the psychopathological impact of trauma on the individual. , It has been claimed that the most important task to accomplish during debriefing is to educate the victims and survivors about the psychological sequela frequently experienced by most refugees. This normalization of stress through debriefing can reduce people’s responses to the inevitable symptoms of stress, depression, guilt, sleep disturbance, etc. The sociocultural background of the survivor may be an important consideration in the screening process. Some survivors may be from certain cultures or from certain parts of a particular country where psychotherapy is not recognized as a form of treatment. In such cases an offer of psychotherapy may be rejected by the client or, even when accepted, premature termination of treatment is always a possibility.
In refugee camps and on arrival, physical needs, such as food, water, clothes, shelter, sanitation, immunization, and care for infectious diseases should be a priority. Psychological and social needs should follow and must include reduction in uncertainty, improved education, and links with religious groups, expatriate groups, and other social agencies. Moreover, screening for problems of mental health and social adjustment should occur in school, through the social services, and perhaps through primary care clinics and hospitals. Staff in these locations should be sensitive to the special needs and problems of refugees. Woodhead summarized the needs of refugees as follows, “refugees arrive from different countries—with different historical, age, gender and cultural backgrounds—seeking safety, accommodation and security. Some arrive in considerable distress, are victims of war and torture and may have complex physical and mental health needs. However, food and a safe environment (home) is likely to be their first priority. Those who arrive from war-torn regions tend to show signs of PTSD alongside other psychiatric and health problems such as anxiety, depression, insomnia, malnutrition, intestinal problems, skin complaints, stigma, poor self esteem.”
Overall, refugee assessments demand special sensitivity to anxiety, fear, shyness, reassurance, clarity, and understanding. Refugees are individuals with a well-founded fear arising from one of a number of causes, including witnessing malicious violence and losses to being subject to interrogation, imprisonment, and oppression. Turner stated “despite the resilience of many refugees coming to the United Kingdom, there was a substantial proportion who have evidence of serious psychological difficulties. Newly arrived refugees not only need community support but also many will have significant mental health problems and will need access to effective mental health treatment.”
Prevalence studies of refugee reactions to disaster and PTSD have revealed that approximately 25% to 30% of individuals who witness a traumatic event may develop chronic PTSD symptoms and/or other forms of mental disorders, such as depression. Preexisting psychopathology, degree of horror, duration, frequency and level of exposure, gender, age, suddenness, controllability, inflicted damage and intensity of the disaster, perceived threat at the time, early separation from family, and availability of support would all be risk factors that determine PTSD development in both children and adults. In summary the prevalence of symptoms is related to a variety of factors, including the nature of trauma and the child’s own experience, age, sex, past psychiatric illnesses, and the degree of social support received from parents at home. It should be noted, however, that a high prevalence of some forms of mental health problems is a characteristic of studies of refugee communities. For example, Brent and Harrow’s survey indicated that self-reported mental health problems were more than 5 times higher in a refugee sample than in the general population sample. Furthermore, other research also reported that approximately 30% of refugee children are in a severe state of mental discomfort and are in urgent need of child psychiatric or psychosocial rehabilitation.
Finally Stimpson and co-workers confirmed the above findings and indicated that psychiatric disorder is common, disabling, and a burdensome source of disability after war. Treatment approaches and rehabilitation of trauma must include the whole family (spouses, children) and the whole social network of the victims. However, working with refugee families and their children who may have witnessed displacement, exile, torture, atrocity, or separation is at best difficult. The stress levels suffered by such traumatized patients are chronic and sometimes severe. It is advisable to use a combination of approaches (e.g., debriefing, counseling, cognitive therapy, drugs, and other psychotherapeutic approaches) to treat the problems of decrease of social interest, isolation, chronic depression, nightmares, poor concentration, and irrational and avoidance behaviors. Dedicated professionals with the necessary energy and expertise may be able to provide specialized treatments that recognize the role of current stresses, relieving some symptoms by medication and also helping traumatized individuals to get the social, emotional, and financial support that they require. Jumaian, Hosin, and Rahmatallh touched on this issue by suggesting that the treatment approach for survivors of traumatic events often begins with debriefing. Other studies suggested that there is a wide range of effective strategies, including group therapy, behavior and cognitive approaches, desensitization, flooding techniques, as well as relaxation training used for tension, anxiety, and intrusive thoughts. Most of these techniques can help sufferers to enhance their coping skills. Sleep problems and nightmares are other aspects of PTSD symptoms among children who have witnessed disasters. Halliday found that relaxation and music before bedtime could be useful techniques for alleviating the recurrence of nightmares. Other reactions that need careful intervention and therapy include depression, guilt feelings, pessimism, irritability, and anger.
Furthermore, whatever approach is used, establishing a supportive, trusted relationship and being in a safe environment are essential elements in therapy. Finally Levin indicated that professionals should consider the following aspects while assessing or offering rehabilitation programs to traumatized refugees: the type of trauma, difficult life events before the flight, experience in refugee camps, cultural and ethnic background, gender perspectives, language difficulties, and life in exile.
Unaccompanied children, women, and displaced refugee families
It is understood that most of the industrial world in the past has received and still receives asylum applications from unaccompanied children. Some of these children arrive completely alone, whereas others are with relatives or nongovernmental organizations. Their parents could be dead, ill, imprisoned, or simply did not have the money to flee as well. It has been suggested that most unaccompanied children and refugees come from war-torn regions, such as Syria, Iraq, Afghanistan, Somalia, Eritrea, and Ethiopia. However, more than half (53%) of all refugees worldwide come now from just three main countries: Afghanistan, the Syrian Arab Republic, and Somalia.
These studies add that refugee women and their children are extremely vulnerable, as are the elderly. Rape is a common element in the pattern of persecution, terror, and ethnic cleansing that uproots refugee families from their homes and communities. The UNHCR also reports that from Somalia to Bosnia refugee families frequently cite rape or the fear of rape as a key factor in their decision to leave.
It has been estimated that 20% to 30% of refugees up to 1990 have been tortured. , , , In a study of 104 torture survivors Domovitch observed the following mental symptoms in descending order of frequency: anxiety, insomnia, nightmares, depression, withdrawal, irritability, loss of concentration, sexual dysfunction, memory disturbance, fatigue, aggressiveness, impulsiveness, and hypersensitivity to noise. Similarly Somnier and Genefke reported that the most common symptoms were sleep disturbances, nightmares, headaches, impaired memory, poor concentration, fatigue, fear and anxiety, and social withdrawal. It should be emphasized here that refugee populations cannot be regarded as a homogeneous group. Although they share the experience of forced uprooting, their reactions to trauma are not necessarily similar or totally predictable. Some refugees have highly developed occupational skills, whereas others are educated and have various abilities which enable them to resettle and perhaps make a useful contribution to the new host country. Some become depressed or lack the skills to adapt quickly to a new culture. Because of their near-death experiences and exposure to violence either before or during the flight, many adults are unable to function adequately as parents, spouses, employees, or citizens and they are likely to experience a series of strained relationships as a result. In addition, their mental health problems are significantly higher when compared with the general nonrefugee population.
Good psychological adjustment among refugee families and children is more likely to manifest itself when parents are psychologically healthy and less distressed. As well as parental health, variables, such as the duration and number of years spent in the host country, the group’s background, current level of social contact and support, numbers of family members sharing the household, and the nature of the traumatic experience before their flight, have been investigated. The prior-mentioned outcomes were expected and discussed within the frameworks of acculturation, culture-learning theory, U-curve theory, and the multidimensional model on acculturation discussed below. , It was claimed that such problems can be attributed to problems before displacement, the new demands of the host culture, daily stresses, unmet expectations, isolation, and perhaps lack of skills and social support in the new and unfamiliar culture. , On the other hand, the manifestation of social, emotional, and behavioral problems among children was related to their home surroundings, isolation, and lack of care provided by the suffering and traumatized parents. This research has also suggested that emotional and adjustment problems manifested among children will not disappear without proper intervention programs, and proper consideration of all risk factors, including family circumstances and previous parental psychopathology.
Indeed the challenge of learning a new language, internalizing different social norms, and finding new employment are great challenges for even the most able and creative refugees. Westermeyer, Hauff, and Vaglum confirm the above and pointed out that upon assessment it is important to take into account the conditions during exile and premigration experience, the traumatization in the host country (i.e., the acculturation stress and the pressure of assimilation during the first years of resettlement), and other predisposing factors that are not related to their experience. , , In other words, research on the mental health of refugees should take into account the complexity of their holistic situation. That is to say the quality of life and the health situation of the refugee population demand considerable attention, including the delivery of services, which should be available, effective, and aimed at reducing stress. However, lack of social support and isolation appears to be a much stronger predictor of poor mental health and depression in the long term than severity of trauma. Indeed an early period of adjustment to a new environment and coming to terms with posttraumatic experiences need a much more sensitive approach, particularly for the most vulnerable refugees, such as victims of torture and rape, and for unaccompanied children. It should also be remembered that while refugee experiences can generate a number of mental health problems, some refugees are reluctant to seek help, and their tendency to somaticize emotional problems is particularly common because they come from societies that stigmatize mental illnesses.
Almqvist and Hwang addressed the importance of parental coping and parental functioning and stated that young children will continue to cope with difficult environments as long as their parents are not pushed beyond the stress threshold level capacity. This research also added that parents who are hopeful and optimistic are more likely to influence children’s adjustment in the host culture. Freud and Burlingham identified the importance of the family as a buffer for stress and separation from the family as a major stress crisis period.
Various writers claim that successful adjustment in an unfamiliar culture is greatly dependent on not only the individual but also on other situational factors and reasons for the exposure to the host culture (i.e., reasons for the contact), length of the stay, and culture norms and policies. Furthermore, other researchers maintain that both assimilation policies and integration are facilitative strategies for adjusting into the new culture as compared with separation. , Some researchers argue that the least stress occurs during the early stage of contact with the host culture, whereas the most stress occurs during the intermediate phase of acculturation processes. , The latter relates adjustment to the duration and stages of time spent in a host culture. It involves an initial stage of optimism, which Lysgaard describes as the honeymoon period, followed by a culture shock and the process of improvement of adjustment in the host society. In fact others associate an individual’s reactions to the nature of the displacement to complex factors, such as personality, temperament, the extent of social support, cultural similarity, prior knowledge of the language, reasons for contact, and perceived cognitive control over the experience. Using the stress model, researchers suggest that any new move to a new place creates stressful demands, and a major task confronting individuals in stressful situations is a cognitive one. , This implies the interpretation of the situation and the activation of the coping response could maximize a sense of control over the situation. Similarly others claim that an individual who possesses positive cognitive control and views the changes resulting from the acculturating experience as being constructive adapts better to the host culture. , As can be seen now, there is a somewhat complex interplay among a variety of factors that influences the extent to which successful adjustment can be made in the host culture. Having discussed all of the possible factors which may contribute to the poor psychological well-being of the refugee population, a good understanding of this complexity and the relationship between migration and mental health is essential for any assessment or rehabilitation program.