Exposure to trauma, mental health and community engagement among refugees

Refugees and asylum seekers are more susceptible to mental disorders and psychological complaints after experiencing forced displacement, war, persecution and trauma.

However, little is known about the cognitive mechanisms underlying the development of mental disorders in refugees, hampering the development of cognitive interventions for this population group.

What do we already know?

Interpersonal trauma

• Interpersonal trauma is common among refugees and can lead to negative beliefs about others
• Negative beliefs about others have been found to be associated with worse symptoms of PTSD and depression
• A stronger belief in people’s goodwill is likely to lead to greater social involvement.

Self-sustainability

• Self-efficacy refers to an individual’s beliefs about his or her ability to perform a task
• Preliminary evidence suggests that increasing self-efficacy is associated with better psychological outcomes.
• Interventions aimed at improving the self-confidence of refugees may be associated with fewer psychological complaints.

What do we want to find out?

It is important to understand the relationship between self- and other-beliefs and psychological outcomes in refugees. Findings from previous cross-sectional studies examining the relationship between self- and other-beliefs and psychological outcomes can be problematic because the outcomes may precede exposures, which may not allow for the observation of effects over time. Furthermore, the outcomes measured by previous studies may be limited because most of them focused only on psychological symptoms, while the effect of beliefs can be projected not only from the psychological but also from the social perspective.

What is the long-term relationship between exposure to trauma, own and others’ beliefs, and social and psychological outcomes in refugee communities?

Methods

In order to gain valuable insights into the lives of refugees and asylum seekers, this study used a longitudinal design, which allowed researchers to follow participants over a longer period of time.

The participants formed a diverse sample of 1,079 Farsi, Tamil or English speaking refugees or asylum seekers who live in AustraliaResearchers chose to study these languages ​​because they represented half of successful applications for refugee status in Australia between 2012 and 2015. Participants were recruited through social media platforms, advertisements displayed in refugee support services, and by asking participants for contact details of family members and friends who might be interested in participating.

The following outcomes were measured in questionnaires/scales: PTSD symptoms, depressive symptoms, self-efficacy, beliefs about trusting and relating to others in the community, traumatic events, common refugee stressors, feelings of anger, and levels of social engagement. To ensure the cultural appropriateness of the questionnaires, the researchers translated them into Arabic, Farsi, and Tamil, and then back-translated them into the original language to compare any inconsistencies. They then piloted the questionnaires with refugee populations to ensure that the measures were culturally appropriate.

Data collection occurred at two time points: First, between April 2015 and January 2018, and then 6 months later. Remarkably, 1,007 of the original 1,079 individuals participated at Time 2, providing a wealth of information for analysis. Participants were given an online questionnaire or a paper version by mail if they did not have access to the internet, allowing for inclusivity.

Results

Exposure to potentially traumatic events (PTEs)

• Negatively linked to self-confidence and positive beliefs about others
• The higher the PTEs at Time 1, the lower the self-confidence and positive beliefs about others at Time 2 (6 months later).

Self-sustainability

• Greater self-reliance at time 1 is associated with lower levels of depression and anger at time 2
• Greater self-confidence at time 1 is associated with increased positive perceptions of others.

Positive beliefs about others

• Greater positive belief in others at time 1 is associated with higher levels of self-reliance at time 2
• Greater positive belief in others at time 1 is associated with higher levels of depression at time 2.

Psychological symptoms and social involvement

• More severe PTSD symptoms at Time 1 were associated with lower self-efficacy at Time 2
• Greater depression at time 1 is associated with higher levels of positive beliefs about others at time 2
• Lower anger at time 1 is associated with higher levels of positive beliefs about others at time 2.
• Greater social engagement at Time 1 predicted more positive opinions of others at Time 2.

Greater exposure to traumatic events was associated with lower self-esteem and less positive views of others.

Conclusions

This is the first study to longitudinally examine the relationship between beliefs about self and others and important psychological and social outcomes for refugees. Cognitive variables are important for the maintenance of psychological symptoms over time. Targeted cognitively focused interventions promote positive posttraumatic mental health by supporting disrupted, persecuted, or conflict-affected populations.

Cognitive mechanisms have a major influence on the maintenance of psychological outcomes in displaced persons.

Strong and weak points

This study has certain limitations. The findings may not be generalisable to wider refugee communities as this sample overrepresents highly educated refugee participants. In reality, the vast majority of refugees seeking asylum in the UK and other Western countries do not have a higher education background and are often prevented from pursuing further education during their asylum process, with UNHCR reporting that over 50% of refugee children are not in school. Further concerns are raised about the cross-cultural validity of the findings as the majority of constructs in the study were drawn from a Western context. Dichotomous items in the questionnaire about the beliefs of others may limit the ability of participants to assess the outcome appropriately and affect its validity. It is also important to note that questionnaires and standardised measures often do not reflect the ethno-cultural experience of refugee communities from the Global South.

Future studies examining the temporal association between complex PTSD and self- and other-related cognitive appraisals could be conducted qualitatively to better capture the psychological processes underlying complex PTSD and guide intervention development.

The sample may not be representative of the entire refugee population or of refugees with a lower educational background.

Implications for practice

The findings can inform the approach taken by frontline clinicians working with refugee and asylum seeker communities, both at the assessment and treatment stages. At the point of entry into mental health services, clinicians can explore and identify the cognitive processes of their service users through semi-structured interviews. Taking into account the finding highlighting that refugees with higher exposure to traumatic events may not have positive views of others, this can inform the way clinicians approach the therapeutic relationship and rapport.

When done well, psychological assessments can build trust between the client and clinician and help them reach a joint decision about which psychological intervention would be most beneficial.

During treatment, clinicians can work in an integrative manner, using different psychological models, without neglecting the importance of addressing cognitive beliefs and supporting people in deconstructing negative thoughts about themselves and others, while anchoring positive events and encouraging post-traumatic growth.

Clinical counselors working with refugees can help them break down and challenge negative beliefs about themselves and others, thereby promoting resilience and recovery.

Declaration of interests

There are no conflicts of interest to report.

Staff

Thanks to MSc Mental Health UCL students who wrote this blog from Rowe A student group: Demetra Christodoulou, Owen Ho Hin Chu, Dimitris Santorinaios, Zhixing Yang, Sheila Greenan, Clover Zhang and Rameezah Asad.

UCL MSc in Mental Health Studies

This blog was written by a group of students at the Clinical Mental Health Sciences MSc at University College London. A full list of blogs from UCL MSc students can be found here , and you can follow the Mental Health Studies MSc team on Twitter.

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Links

Primary paper

Nickerson, A., Byrow, Y., O’Donnell, M., Bryant, R. A., Mau, V., McMahon, T., & Liddell, B. J. (2022). Cognitive mechanisms underlying the association between trauma exposure, mental health, and social engagement in refugees: A longitudinal study. Journal of Affective Disorders307, 20-28. https://doi.org/10.1016/j.jad.2022.03.057