“…this question… is very difficult for me. When you (ask) which one is the most severe … they were all severe, they were all unpleasant things…you didn’t give me a very good measurement to measure this.” -A Kurdish Woman, 2001
Refugees have experienced many extremely stressful events because of political or religious oppression, war, migration, and resettlement. It is difficult to even define all of the types of events they have suffered, because refugee trauma often precedes the primary war-related event that causes them to flee. Historically, a standard assessment of refugee trauma has been a 17-item section on the Harvard Trauma Questionnaire (HTQ),1 which assessed whether or not the particular event was experienced personally, or whether the refugee witnessed or heard about such trauma. While this has been a useful research tool, it is clear that the breadth and depth of trauma for refugees is far greater than 17 events. For example, in more recent work, sixty-seven Vietnamese and Kurdish refugees endorsed 612 war-related traumatic events on in-depth interviews during development of the Comprehensive Trauma Inventory-104 (CTI-104).2
Before being forced to flee, refugees may experience imprisonment, torture, loss of property, malnutrition, physical assault, extreme fear, rape and loss of livelihood. The flight process can last days or years. During flight, refugees are frequently separated from family members, robbed, forced to inflict pain or kill, witness torture or killing, and/or lose close family members or friends and endure extremely harsh environmental conditions. Perhaps the most significant effect from all of the experiences refugees endure is having been betrayed, either by their own people, by enemy forces, or by the politics of their world in general. Having misanthropic actions of others become a major factor controlling the lives of refugees has significant implications for health and for their ability to develop trusting interpersonal relationships, which are critical to resettlement and healing.
Torture, a severe form of trauma, varies with each historical event and group, ranging from 3% to 63%. There is no evidence for a clinical torture syndrome that is separate from the clinical consequences of severe trauma,3 yet, due to the heinous nature of torture, it continues to be reported as an independent predictor of medical and psychiatric illness in refugees of war.4 Tortured refugees have significant challenges for emotional and sometimes physical healing that must be carefully assessed and treated.
When refugees resettle to a host country, which is most often in a place that is not of the refugee’s choosing, the refugee must adapt to a new place and language under uncertain circumstances and with uncertain futures. Re-establishing a home and identity, while trying to juggle the tasks of daily living, is yet another significant challenge that the refugee must undertake. Early studies showed that post-migration stress contributed to the poor mental health of refugees.5–7 Recent work has verified that post-migration stress significantly influences the emotional well-being of refugees, and often provides a risk similar to or greater than war-related trauma.8-13 Pre- and post-migration stress may differentially predict specific kinds of symptoms and distress in both children and adults.14, 15 This information is important; it is during the period of resettlement where stress is high and the refugee may be reminded of other traumatic events of their lives, when resettlement agencies and health care workers might start to reverse the effects of trauma across the lifespan of the refugee by providing culturally sensitive care that gives the refugee support.
1. Mollica R. The Harvard Trauma Questionnaire Manual: Indochinese Versions: Harvard University; undated.
2. Hollifield M, Eckert V, Warner TD, Jenkins J, Krakow B, Ruiz J, et al. Development of an inventory for measuring war-related events in refugees. Comprehensive Psychiatry. 2005; 46(1): 67-80.
3. Hollifield M, Warner TD, Westermeyer J. Is torture reliably assessed and a valid indicator of poor mental health? J Nerv Ment Dis. 2011; 199(1): 3-10.
4. Quiroga J, Jaranson, J.M. Politically-motivated torture and its survivors: A desk study review of the literature. Torture (Thematic Issue). 2005; 15(2-3): 1-111.
5. Beiser M. Strangers at the Gate. The Boat People’s First Ten Years in Canada. Toronto: University of Toronto Press; 1999.
6. Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z. Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors. Br J Psychiatry. 1997; 170: 351-7.
7. Westermeyer J, Vang TF, Neider J. Migration and mental health among Hmong refugees. Association of pre- and postmigration factors with self-rating scales. Journal of Nervous & Mental Disease. 1983; 171(2): 92-6.
8. Lindencrona F, Ekblad S, Hauff E. Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Soc Psychiatry Psychiatr Epidemiol. 2008; 43(2): 121-31.
9. Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun C. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005; 294(5): 571-9.
10. Fenta H, Hyman I, Noh S. Determinants of depression among Ethiopian immigrants and refugees in Toronto. Journal of Nervous & Mental Disease. 2004; 192(5): 363-72.
11. Momartin S, Steel Z, Coello M, Aroche J, Silove D, Brooks R. A comparison of the mental health of refugees with temporary versus permanent protection visas. Med J Aust. 2006; 185(7): 357-61.
12. Schweitzer RD, Brough M, Vromans L, Asic-Kobe M. Mental health of newly arrived Burmese refugees in Australia: contributions of pre-migration and post-migration experience. The Australian and New Zealand Journal of Psychiatry. 2011; 45(4): 299-307.
13. Steel Z, Silove D, Bird K, McGorry P, Mohan P. Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants. J Trauma Stress. 1999; 12(3): 421-35.
14. Birman D, Tran N. Psychological distress and adjustment of Vietnamese refugees in the United States: Association with pre- and postmigration factors. The American Journal of Orthopsychiatry. 2008; 78(1): 109-20.
15. Heptinstall E, Sethna V, Taylor E. PTSD and depression in refugee children: associations with pre-migration trauma and post-migration stress. European Child & Adolescent Psychiatry. 2004; 13(6): 373-80.