Research on Refugees in AJO 

Shaw, S. A., Ward, K. P., Pillai, V., & Hinton, D. E. (2018). A group mental health randomized controlled trial for female refugees in Malaysia. American Journal of Orthopsychiatry. Advance online publication.

Abstract 

Forcibly displaced persons confront multiple stressors while awaiting permanent asylum or resettlement and often experience high levels of emotional distress. This study assessed an 8-week somatic-focused culturally adapted cognitive–behavioral therapy (CBT) group intervention with 39 female refugees from Afghanistan living in Kuala Lumpur, Malaysia. Twenty-nine participants were randomly assigned to treatment conditions, resulting in 20 participants in two separate treatment groups and 9 in a waitlist control group. An additional 10 participants were not randomly assigned and therefore were treated as an additional treatment group and analyzed separately. A three-group piecewise linear growth model was specified in Mplus using Bayesian estimation. Dependent variables included emotional distress, anxiety, depression, posttraumatic stress, and social support. From baseline to posttreatment assessments, initial intervention participants experienced significant declines in emotional distress (b = −16.90, p < .001), anxiety (b = −.80, p < .001), depression (b = −.59, p < .001), and posttraumatic stress (b = −.24, p < .05). Gains were maintained three months posttreatment, with similar trends observed among nonrandomized participants. Subsequent to receiving treatment, the waitlist control participants also showed significant declines in emotional distress (b = −20.88, p < .001), anxiety (b = −1.10, p < .001), depression (b = −.79, p < .001), and posttraumatic stress scores (b = −.82, p < .001). Comparing the treatment groups to the waitlist control group revealed large effect sizes: Cohen’s d was 2.14 for emotional distress, 2.31 for anxiety, 2.42 for depression, and 2.07 for posttraumatic stress. Relevant public health findings include low drop out, group format, and facilitation by a trained community member.

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Chase, L. E., & Rousseau, C. (2018). Ethnographic case study of a community day center for asylum seekers as early stage mental health intervention. American Journal of Orthopsychiatry, 88(1), 48-58.

Abstract 

Clinical guidelines in refugee mental health increasingly advocate phased approaches to intervention that foreground the provision of pragmatic and social support in contexts of ongoing instability. However, the impact of such interventions has rarely been explored from the perspective of refugees themselves. We conducted ethnographic research on the experiences and perceptions of users of an intervention embodying this approach: a community Day Center for asylum seekers in Montreal. Data comprising 15 interviews and field notes from 50 participant observation visits were analyzed using an established theoretical framework to identify mechanisms supporting self-perceived wellbeing among users in the domains of safety, social networks, justice, identity/roles, and existential meaning. Results shed light on how this nonspecific buffering intervention responds to the threats and pressures asylum seekers themselves identify as most salient in the immediate postflight context. These findings are discussed in relation to emerging theoretical frameworks in refugee mental health that emphasize agency, justice, and the role of local ecologies. We conclude that the Day Center shows significant promise as an innovative early stage mental health intervention for precarious status migrants and merits further research and evaluation.

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Miller, A., Hess, J. M., Bybee, D., & Goodkind, J. R. (2018). Understanding the mental health consequences of family separation for refugees: Implications for policy and practice. American Journal of Orthopsychiatry, 88(1), 26-37.

Abstract 

Consistent evidence documents the negative impacts of family separation on refugee mental health and concerns for the welfare of distant family members and desire to reunite with family members as priorities for refugees postmigration. Less is known about refugees’ emic perspectives on their experiences of family separation. Using mixed methods data from a community-based mental health intervention study, we found that family separation was a major source of distress for refugees and that it was experienced in a range of ways: as fear for family still in harm’s way, as a feeling of helplessness, as cultural disruption, as the greatest source of distress since resettlement, and contributing to mixed emotions around resettlement. In addition to these qualitative findings, we used quantitative data to test the relative contribution of family separation to refugees’ depression/anxiety symptoms, posttraumatic stress disorder (PTSD) symptoms, and psychological quality of life. Separation from a family member was significantly related to all 3 measures of mental health, and it explained significant additional variance in all 3 measures even after accounting for participants’ overall level of trauma exposure. Relative to 26 other types of trauma exposure, family separation was 1 of only 2 traumatic experiences that explained additional variance in all 3 measures of mental health. Given the current global refugee crisis and the need for policies to address this large and growing issue, this research highlights the importance of considering the ways in which family separation impacts refugee mental health and policies and practices that could help ameliorate this ongoing stressor.

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LeMaster, J. W., Broadbridge, C. L., Lumley, M. A., Arnetz, J. E., Arfken, C., Fetters, M. D., . . . Arnetz, B. B. (2018). Acculturation and post-migration psychological symptoms among Iraqi refugees: A path analysis. American Journal of Orthopsychiatry, 88(1), 38-47.

Abstract 

Refugees frequently experience symptoms of posttraumatic stress and depression, which impede their acculturation in the new host country where they are resettling. There are few longitudinal studies investigating predictors of mental health and acculturation during the early postmigration period. We conducted a longitudinal study of 298 Iraqi refugees, assessing them upon arrival to the U.S. and 1 year after migration. Premigration trauma was associated with increased PTSD and depressive symptoms at baseline, and with decreased acculturation 1 year later. Resilience was associated with depressive symptoms at 1-year follow-up, but not with other resettlement outcomes (PTSD symptoms, English-language skills, or acculturation). PTSD and depressive symptoms at baseline predicted the same symptoms at 1-year follow-up, but not any other resettlement outcomes. The number of chronic diseases at baseline predicted worse PTSD and depressive symptoms, acculturation, and English language skills at 1-year follow up. Postmigratory exposure to daily stressors and less social support predicted worse 1-year outcomes. Results suggest that interventions that aim to improve mental health and promote acculturation among refugees should assess their history of trauma, chronic disorders, and psychological symptoms soon after migration, and promptly provide opportunities for social support.

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Ellis, B. H., Abdi, S. M., Lazarevic, V., White, M. T., Lincoln, A. K., Stern, J. E., & Horgan, J. G. (2016). Relation of psychosocial factors to diverse behaviors and attitudes among Somali refugees. American Journal of Orthopsychiatry, 86(4), 393-408.

Abstract 

Refugee studies have examined both resilience and adverse outcomes, but no research has examined how different outcomes co-occur or are distinct, and the social-contextual factors that give rise to these diverse outcomes. The current study begins to address this gap by using latent profile analysis to examine the ways in which delinquency, gang involvement, civic engagement, political engagement, and openness to violent extremism cluster among Somali refugees. We then use multivariable regression analyses to examine how adversity (e.g., discrimination, trauma, and marginalization) is associated with the identified latent classes. Data were collected from 374 Somali refugee young adults (Mage = 21.30 years, SD = 2.90, range 18–30, 38% female) from 4 different North American communities. Participants completed a structured survey assessing their experiences of adversity, delinquent and/or violent attitudes and behaviors (e.g., attitudes toward violent extremism, participation in delinquent behaviors, involvement in gangs), and positive outcomes (e.g., civic and political engagement). Our findings indicate that participants fall into 5 distinct groups, and that social-contextual and individual factors are uniquely related to those groups. Specifically, strong social bonds seem to be associated with positive outcomes. These findings point to the need to further examine both positive and negative outcomes, paying special attention to social–contextual factors. 

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Pejic, V.; Hess, R.; Miller, G.; & Wille, A. (2016). Family first: Community-based supports for refugees. American Journal of Orthopsychiatry 86(4):409-414. 

Abstract

This article presents a community-based approach that targets family interventions and services through a preventive, family systems ecological framework. A public health approach is used to emphasize the need for a tiered model of family support that builds on the strengths of refugee families while recognizing their specific needs and challenges. The rationale for a family systems ecological perspective is presented to highlight the critical features of effective family support programs for refugee families, followed by a discussion regarding the transitions and adaptation faced by refugee families when entering the United States. Finally, a public-health problem solving model is employed to promote a comprehensive vision for how more effective support can be developed to best serve the mental health needs of refugee families. An integrated case example highlighting the Somali Parent Program, a family-focused intervention, is also provided.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2016-32685-005


Ellis, B.; Abdi, S.; Lazarevich, V.; White, M.; Lincoln, A.; Stern, J.; & Horgan, J. (2016). Relation of psychosocial factors to diverse behaviors and attitudes among Somali refugees. American Journal of Orthopsychiatry 86(4):393-408. 

Abstract

Refugee studies have examined both resilience and adverse outcomes, but no research has examined how different outcomes co-occur or are distinct, and the social-contextual factors that give rise to these diverse outcomes. The current study begins to address this gap by using latent profile analysis to examine the ways in which delinquency, gang involvement, civic engagement, political engagement, and openness to violent extremism cluster among Somalirefugees. We then use multivariable regression analyses to examine how adversity (e.g., discrimination, trauma, and marginalization) is associated with the identified latent classes. Data were collected from 374 Somali refugee young adults (Mage = 21.30 years, SD = 2.90, range 18–30, 38% female) from 4 different North American communities. Participants completed a structured survey assessing their experiences of adversity, delinquent and/or violent attitudes and behaviors (e.g., attitudes toward violent extremism, participation in delinquent behaviors, involvement in gangs), and positive outcomes (e.g., civic and political engagement). Our findings indicate that participants fall into 5 distinct groups, and that social-contextual and individual factors are uniquely related to those groups. Specifically, strong social bonds seem to be associated with positive outcomes. These findings point to the need to further examine both positive and negative outcomes, paying special attention to social–contextual factors.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2015-54041-001


Tay, A.; Rees, S.; Kareth, M.; & Silove, D. (2016). Associations of adult separation anxiety disorder with conflict-related trauma, ongoing adversity, and the psychosocial disruptions of mass conflict among West Papuan refugees. American Journal of Orthopsychiatry 86(2):224-235. 

Abstract

Refugees commonly experience traumatic events that threaten the self and close others, suggesting the possibility that they may experience overlapping symptoms of posttraumatic stress disorder (PTSD) and separation anxietydisorder (SAD). We examine this possibility among West Papua refugees (n = 230) displaced to Port Moresby, Papua New Guinea. We also examine associations between the combined PTSD−SAD construct and indices of past trauma exposure, ongoing adversity, and the psychosocial disruptions caused by mass conflict and displacement. We applied culturally adapted interview modules to assess symptoms of PTSD, SAD, traumatic events (TEs), ongoing adversity, and 5 psychosocial dimensions. Latent class analysis identified a PTSD class (23%), a posttraumatic (PT) SAD class (22%), and a low-symptom class (55%). Compared with the low-symptom class, both the PTSD and PT−SAD classes endorsed higher levels of exposure to all domains of TEs (conflict -related trauma, witnessing murder, childhood related adversities, traumatic losses, and health stress) and ongoing adversity (access to health care, displacement/separation, safety in the community, and access to basic needs), but the 2 comorbid groups did not differ on these indices. The PT−SAD class alone scored higher than the low-symptom reference class in relation to disruptions to the psychosocial domains (safety/security, bonds/network, access to justice, roles/identities, existential meaning) and higher than the PTSD class on safety/security, justice and roles/identities. Our findings suggest that the PT−SAD pattern may represent a response to the most severe forms of psychosocialdisruptions of mass conflict among refugees. A focus on separation anxiety may enhance psychotherapies designed to treat PTSD in refugees.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2016-00301-001


McGregor, L.; Melvin, G.; & Louise, K. (2015). Differential accounts of refugee and resettlement experiences in youth with high and low levels of post traumatic stress disorder (PTSD) symptomatology: A mixed-methods investigation. American Journal of Orthopsychiatry 85(4):371-381. 

Abstract

In recent years there has been increased debate and critique of the focus on psychopathology in general, and posttraumatic stress disorder (PTSD) in particular, as a predominant consequence of the refugee experience. This study was conducted to broaden the conceptualization and examination of the outcomes of the refugee experience by jointly examining how adaptive processes, psychosocial factors, and psychopathology are implicated. A mixed-methods approach was used to specifically examine whether adolescents’ (N = 10) accounts of their refugee and resettlement experiences differed according to their level, “high” or “low,” of PTSD symptomatology. The superordinate themes of cultural belongingness and identification, psychological functioning, family unit functioning and relationships, and friendships and interpersonal processes, were identified as having particular relevance for the study’s participants and in distinguishing between participants with high and low levels of PTSD symptomatology. Findings were characterized by marked differences between adolescents’ accounts according to their symptomatology levels, and may thereby inform important avenues for future research as well as clinical prevention and intervention programs with refugee youth.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2015-30991-003


Ellis, B.; Lankau, E.; Ao, T.; Benson, M.; Miller, A.; Shetty, S.; Lopes Cardozo, B.; Geldmann, P.; & Cochran, J. (2015). Understanding Bhutanese refugee suicide through the interpersonal-psychological theory of suicidal behavior. American Journal of Orthopsychiatry 85(1):43-55. 

Abstract

Attention has been drawn to high rates of suicide among refugees after resettlement and in particular among the Bhutanese refugees. This study sought to understand the apparent high rates of suicide among resettled Bhutaneserefugees in the context of the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS). Expanding on a larger investigation of suicide in a randomly selected sample of Bhutanese men and women resettled in Arizona, Georgia, New York, and Texas (Ao et al., 2012), the current study focused on 2 factors, thwarted belongingness and perceived burdensomeness, examined individual and postmigration variables associated with these factors, and explored how they differed by gender. Overall, factors such as poor health were associated with perceived burdensomeness and thwarted belongingness. For men, stressors related to employment and providing for their families were related to feeling burdensome and/or alienated from family and friends, whereas for women, stressors such as illiteracy, family conflict, and being separated from family members were more associated. IPTS holds promise in understandingsuicide in the resettled Bhutanese community.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2015-03458-003


Afifi, W.; Afifi, T.; Robbins, S.; & Nimah, N. (2013). The relative impacts of uncertainty and mothers' communication on hopelessness among Palestinian refugee youth. American Journal of Orthopsychiatry 83(4):495-504. 

Abstract

The life of adolescent refugees has been described as uncertainty laden. Yet no quantitative data exist to elucidate that experience of uncertainty, investigate its implications in that population, or explore potential moderators. This study applies the Entropy Model of Uncertainty (Hirsh, Mar, & Peterson, 2012) and the stress‐buffering hypothesis (for review, see Hegelson, 2003) to examine the experience of uncertainty among adolescent Palestinians living in refugee camps in Lebanon. It then tests the role of mothers' uncertainty‐related communication for adolescent hopelessness. One hundred and sixty‐two adolescents across 2 refugee camps in Lebanon participated in the study. Results support the existence of elevated levels of uncertainty about both personal and macrosecurity, show an association between uncertainty regarding personal security and levels of hopelessness, and suggest that uncertainty's negative impact may overwhelm the role of mothers' supportive communication as a buffer against hopelessness. Interestingly, the data also suggest surprisingly little hopelessness in this population.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2013-38014-006


Field, N.; Muong, S.; & Sochanvimean, V. (2013). Parental styles in the intergenerational transmission of trauma stemming from the Khmer Rouge regime in Cambodia. American Journal of Orthopsychiatry 83(4):483-494. 

Abstract

The impact of parental styles in intergenerational transmission of trauma among mothers who survived the KhmerRouge regime in Cambodia, in power from 1975 to 1979, and their teenaged children was examined in 2 studies. In Study 1, 46 Cambodian female high school students and their mothers were recruited. Each daughter completed anxiety and depression measures as well as assessment of her mother's role‐reversing, overprotective, and rejecting parental styles, whereas the mothers completed measures of their trauma exposure during the Khmer Rouge regimeand PTSD symptoms. In support of trauma transmission, the mother's PTSD symptoms were predictive of her daughter's anxiety. Moreover, the mother's role‐reversing parental style was shown to mediate the relationship between her own and her daughter's symptoms. In support of their generalizability, the results were replicated in Study 2 in a Cambodian‐American refugee sample comparing 15 mental health treatment‐seeking mothers and their teenaged children with 17 nontreatment‐seeking mother–child pairs. The implications of the findings within the larger literature on intergenerational trauma transmission stemming from genocide are discussed.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2013-38014-005


Perera, S.; Gavian, M.; Frazier, P.; Johnson, D.; Spring, M.; Westermeyer, J.; Butcher, J.; Halcon, L.; Robertson, C.; Savik, K.; & Jaranson, J. (2013). A longitudinal study of demographic factors associated with stressors and symptoms in African refugees. American Journal of Orthopsychiatry 83(4):472-482. 

Abstract

The objectives of this study were to assess differences in premigration, transit, and resettlement stressor exposure and post traumatic stress disorder (PTSD) symptoms as a function of demographic characteristics (i.e., gender, ethnicity, age, time in United States) and to examine the concurrent and longitudinal relations between stressor exposure and PTSD symptoms. The sample consisted of adult (18–78 years) Somali and Oromo refugee men and women (N = 437). Qualitative data regarding participants’ self‐nominated worst stressors collected at Time 2 (T2) informed the development of quantitative scales assessing premigration, transit, and resettlement stress created using items collected at Time 1 (T1). PTSD symptoms were measured at both T1 and T2. Quantitative analyses showed that levels of stressor exposure and PTSD symptoms differed as a function of refugee demographic characteristics. For example, Oromo, more recent, women, and older refugees reported more premigration and resettlement stressors. Oromo refugees and refugee men reported more PTSD symptoms in regression analyses with other factors controlled. Premigration, transit, and resettlement stressor exposure generally was associated with higher PTSD symptom levels. Results underscore the importance of assessing stress exposure comprehensively throughout the refugee experience and caution against overgeneralizing between and within refugee groups.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2013-38014-004


Ellis, B.; MacDonald, H.; Klunk-Gillis, J.; Lincoln, A.; Strunin, L.; & Cabral, H. (2010). Discrimination and mental health among Somali refugee adolescents: The role of acculturation and gender. American Journal of Orthopsychiatry 80(4):564-575. 

Abstract

This study examines the role of social identity (acculturation and gender) in moderating the association between discrimination and Somali adolescent refugees’ mental health. Participants were English‐speaking Somali adolescent refugees between the ages of 11 and 20 (N = 135). Perceived discrimination, trauma history, posttraumatic stress disorder (PTSD), depressive symptoms, and behavioral acculturation were assessed in structured interviews. Fourteen in‐depth qualitative interviews and 3 focus groups were also conducted. Results indicated that discrimination was common and associated with worse mental health. For girls, greater Somali acculturation was associated with better mental health. Also, the association between discrimination and PTSD was less strong for girls who showed higher levels of Somali acculturation. For boys, greater American acculturation was associated with better mental health, and the association between discrimination and depression was less strong for boys with higher levels of American acculturation.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2011-25070-015 


Murray, K.; Davidson, G.; & Schweitzer, R. (2010) Review of refugee mental health interventions following resettlement: best practices and recommendations. American Journal of Orthopsychiatry 80(4):576-85. 

Abstract

There are increasing numbers of refugees worldwide, with approximately 16 million refugees in 2007 and over 2.5 million refugees resettled in the United States since the start of its humanitarian program. Psychologists and other health professionals who deliver mental health services for individuals from refugee backgrounds need to have confidence that the therapeutic interventions they employ are appropriate and effective for the clients with whom they work. The current review briefly surveys refugee research, examines empirical evaluations of therapeutic interventions in resettlement contexts, and provides recommendations for best practices and future directions in resettlement countries. The resettlement interventions found to be most effective typically target culturally homogeneous client samples and demonstrate moderate to large outcome effects on aspects of traumatic stress and anxiety reduction. Further evaluations of the array of psychotherapeutic, psychosocial, pharmacological, and other therapeutic approaches, including psychoeducational and community‐based interventions that facilitate personal and community growth and change, are encouraged. There is a need for increased awareness, training and funding to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement. 
http://psycnet.apa.org/?fa=buy.optionToBuy&id=2011-25070-016&searchId=D890013D-D549-111F-5B59-95E834669C16&uid=2011-25070-016&db=PA