Chapter 3: Migration-Related Trauma and Refugee Mental Health in the Canadian Resettlement Sector
In Canada, once a person immigrates and acquires permanent resident status, the immigration stream they came through is no longer attached to their profile or identification. This means that research and statistics on health access in Canada is not collected based on the ways in which people immigrate. So, for example, there is seldom specific information about how refugees who resettled to Canada are accessing mental health services. Academic researchers and advocacy organizations have done specific and time-limited research on newcomers accessing health services; however, those studies represent a very specific moment in time and can become outdated when there are significant changes to who is immigrating to Canada and how health care is offered and managed.
In the past 10 years, there has been more of a focus on newcomers accessing mental health supports as part of good practices for settlement, especially during the first 12 months in Canada. Although this section discusses the challenges for newcomers in accessing mental health services in Canada, internationally, Canada is known for having an excellent healthcare system. The push for improved access for newcomers is a push for equitable access to services in Canada—a striving to ensure that everyone can have quality health care.
Importance of the Post-Migration Period and Trauma
Newcomer mental health service needs are best understood through a lens of “post-migration.” In research on migration-related trauma, the post-migration period can be a time of recovery, but it can also be a time of compounding trauma. Looking again at the social determinants of health, if a newcomer has a stable socio-economic situation, social and community connections, safe housing, employment, and confidence in the health and well-being of family, then they have what the research calls “protective factors” to support their resettlement process.
By contrast, if a newcomer’s resettlement experience lacks these protective factors, post-migration stressors may compound the mental health riskw related to migration trauma. In a study of humanitarian migrants in Australia, Chen et al. (2017) found that
“resettlement-related post-migration stressors were the most important correlates of humanitarian migrants’ mental health. Specifically, economic stressors, loneliness, discrimination, family conflicts in [the resettlement country], concerns about family in [the resettlement country], and worrying about family or friends overseas were positively related to PTSD and severe mental illness” (p. 9).
Therefore, a newcomer’s post-migration access to health care and social determinants of health not only affect their resettlement experience, but also may affect how they recover from trauma experienced before and during migration.
Specific Challenges in Accessing Health Care and Mental Health Services
Although there is still no consistent data available about how newcomers with migration-related trauma experiences access mental health services in Canada, periodic studies and surveys offer useful insights. Ozcurumez et al. (2012) show that the most common barriers to newcomers’ accessing health care have included the following:
- Newcomer lack of knowledge about the healthcare system
- Location of services too far from newcomer neighbourhood
- Inappropriate fit of planned services with newcomer needs
- Health services, information, and signage not in newcomer languages
- Healthcare workers’ limited experience with migration-related trauma
These challenges are echoed by McKenzie et al. (2014) who report that “[i]n Canada, the most often cited impediments to equitable care are language, awareness of services, socioeconomic status, discrimination, and stigma” (p. 185). Regarding mental health in particular, “[i]n Canada it was … noted that many immigrants were apprehensive about using mental health services because of the stigma attached to it” (pp. 111–112).
Continuity and Gaps in the Mental Health Care System
The push for more equitable access to health care and mental health services for newcomers frames internal evaluations of health services. Wylie et al. (2020) find that
“challenges to continuity of mental health care for immigrant and refugee populations are exacerbated by the complexity of and gaps within the mental health care system. Poor coordination is a significant hindrance to the healing journey, which is a problem for all patients, particularly those dealing with trauma” (p. 75).
Then, revisiting the concept of resilience in migrants, Wylie et al. (2020) note that gaps in the health services system in Canada are being filled necessarily by the newcomers themselves:
“Personal resilience amongst patients with mental illnesses is seen as essential for their ability to cope with hardship. … system-level issues are preventing the access to timely and appropriate mental health services that could support resilience amongst those suffering mental health challenges, such as trauma” (p. 75).
It is worth remembering that some newcomers’ personal resilience comes from the support of social network resources and long-term stable relationships among family members, friends, and others (see “Resilience and the ‘Resilient Migrant'” in the section “Migration-Related Trauma”).
Cultural Competence of Healthcare Workers
One repeated policy suggestion is that Canada’s healthcare system workers need to be trained in the cultural competence (of care) in order to better assess and support the needs of resettling refugees who have experienced trauma. Sheath et al. (2020) explain that
“As a patient group, migrants are particularly susceptible to suffering as a result of a lack of cultural competence from caregivers, due to their diverse cultural backgrounds. … An area of health care where cultural competence is of huge importance is in mental health, where being able to empathize with and understand your patient is key to good diagnosis and management” (p. 2).
Cultural competence training can include learning how different mental health conditions present in different cultural ways. In addition to cultural competence training, it has also been noted that although they are trained professionals with expertise, Canada’s healthcare workers are not necessarily knowledgeable in how to support newcomers with migration-related trauma and resettlement needs. Wylie et al. (2018) found that “[m]any of the challenges of addressing the healthcare needs for this growing population of immigrants and refugees are therefore new and unfamiliar to care providers and health care organizations” (p. 3).
Role of Settlement Sector Workers in Newcomer Resilience and Mental Health
Settlement sector workers have a pivotal role in supporting the mental health of newcomers during the post-migration period. Frontline workers who are positioned as and in hubs of information exchange may help newcomers become more familiar with Canada’s healthcare system, connect newcomers with language education programs, provide connections to employment programs, and act as part of a newcomer’s professional social network. Settlement sector workers are positioned to support newcomers in almost every social determinant of health. Chadwick and Collins (2015) studied social support availability, urban centre size, and self-perceived mental health (SPMH) among recent immigrants to Canada. The study found that
“social support availability is significantly associated with SPMH [self-perceived mental health] among immigrants and found that immigrants living in small urban centres in Canada had significantly greater access to three types of social support [tangible social supports, opportunities for social interaction, emotional or informational support]. SSOs [settlement services organizations] provided immigrants with opportunities to access social support in various forms; however, provision of tangible supports appeared to be greater in the small urban centre organizations” (p. 229).
In Chadwick and Collins’ (2015) study, the small urban centre organizations were noted to be in Kingston, Ontario; Victoria, BC; and Lethbridge, Alberta. So, although referred to as small, the study’s threshold for a “small centre” referred to places with populations of approximately 100,000 to 300,000. The higher level of tangible supports mentioned in the study included training in making phone calls to arrange for transportation and direct assistance (sometimes driving) to doctor’s appointments. Although most organizations reported that tangible social supports (meal provision, doctor’s appointment accompaniment, home care during illness) were not part of their organization’s offered services, in the larger centres (Vancouver, Ottawa, Edmonton), SSOs would refer newcomers to other agencies for those services, whereas SSO staff in the smaller centres might fill gaps in services directly themselves. While this might not be a sustainable or good practice according to organizational mandates and service provision planning, the SSO staff in the smaller centres became a greater resource in newcomers’ sources of resilience.
Knowing that a newcomer’s social network supports the resilience that plays a key part in their mental health and well-being, can you think of three different people who might be a part of a newcomer’s social or community network beyond settlement workers and doctors?
Good and Promising Practices Around Newcomer Mental Health in Canada
In 2016, the Mental Health Commission of Canada (MHCC) produced a report as part of the project on “The Case for Diversity: Building the Case to Improve Mental Health Services for Immigrant, Refugee, Ethno-cultural and Racialized Populations” (McKenzie et al., 2016). As part of the project, the MHCC called for examples of promising practices designed to meet the mental health needs of immigrant, refugee, ethnocultural, and racialized (IRER) individuals or designed to address the adverse affects of social determinants of health; thirty-two examples were catalogued across Canada. The MHCC calls the examples “Canadian Practices of Interest” (McKenzie et al., 2016, p. 16) because they have not yet been evaluated to earn the title of good or best practices. Still, the project on the “Case for Diversity” offers access to information on services in BC, Alberta, Manitoba, Ontario, Quebec, and Nova Scotia.
The service programs include refugee and immigrant youth programming, family support programs, referral to multicultural therapy, language services, refugee health clinics, healthcare provider cultural awareness training, child and youth trauma services, and more. You can find the MHCC project information and links to all the “practices of interest” through The Case for Diversity – Promising Practices (MHCC, 2021).
Access to health and mental health resources produced by Immigration, Refugees and Citizenship Canada (IRCC):
- Understanding how health care works in Canada
- Newcomers to Canada: Support for Mental Health and Well-Being
- Your Mental Health and Well-Being (Video)
- Information on the Interim Federal Health Program
Learning Activity 6: Case Study – Michael
Michael is a 43-year-old mechanical engineer. He arrived in Canada seven months ago as a government-assisted refugee (GAR). Michael and his family fled their home country because of civil war. The fighting was occurring in their town. Schools had shut down, and the government department Michael worked for stopped functioning because of the violence and devastation. The group fighting that was against the government had made threats against Michael and his family, thinking he was pro-government because was working for the government. Michael, his wife, Selen, and their two children were recognized as refugees by the UNHCR.
Michael travelled to Canada a few months ahead of his family. He is fluent in English and French. Although his professional credentials have not yet been assessed, Michael has been able to find employment providing administrative support in a small engineering firm, and he reports being happy to be learning more about engineering projects in Canada.
His wife and two children just arrived last month. He has brought his wife, Selen, to the settlement agency so she can be enrolled in the Orientation program.
During Michael’s first months in Canada, whenever he came into the agency, he was smiling and positive and seemed to have a lot of energy. He was really looking forward to having his family with him in Canada. He often talked about them.
However, when Michael comes into the agency with Selen, he looks very tired and does not seem positive at all.
Case Study Questions
Use the questions below to consider how post-migration resilience and stressors can change over time. Discuss your responses with others working through this chapter.
Before you began working through this chapter, you wrote down a few details about your knowledge and expectations. Now you have a chance to revisit what you wrote to see if your ideas have changed, grown, or been reinforced. As in the beginning of the chapter, feel free to answer the following questions directly or use them as a guide for reflection.
- When you read the word “trauma,” what do you understand it to mean?
- What factors impact a person’s chances of recovering from a traumatic experience?
- What resources do you think a person needs to help them cope with a traumatic experience?
- When you read the term “resilient,” what do you understand it to mean?
- When you read the term “mental health,” what do you understand it to mean?
- What do you hope to do with the knowledge from this chapter?
- Whose “job” is it to help new immigrants to Canada?
Learn more about your local context. Search the internet or call local settlement service provider organizations for more information about the following:
- Does your community have a refugee health clinic or doctors who specialize in newcomer mental and physical health?
- Who are the local stakeholder organizations or groups that provide services to newcomers beyond the government-funded settlement services organizations?
- National organizations? NGOs?
- Community organizations, partnerships, or roundtables?
- Municipal programs for newcomers?
- Refugee health advocacy groups?
Community-based interpretation services?
- Are there any programs or organizations that advocate for newcomers in ways that may help increase newcomers’ social sources of resilience? Can you find any of the following in your local community?
- LGBTQ2S+ newcomer groups
- High-skilled employment mentorship programs
- Supports for asylum seekers yet to be recognized as refugees
- Social groups for newcomers
- Organized casual language skills practice groups or programs