Chapter 3: Migration-Related Trauma and Refugee Mental Health in the Canadian Resettlement Sector
What is Migration-Related Trauma?
According to the Centre for Addiction and Mental Health (CAMH) in Toronto, “Trauma is the lasting emotional response that often results from living through a distressing event” (CAMH, n.d.). The CAMH definition goes on to explain that
“[e]xperiencing a traumatic event can harm a person’s sense of safety, sense of self, and ability to regulate emotions and navigate relationships. Long after the traumatic event occurs, people with trauma can often feel shame, helplessness, powerlessness, and intense fear” (CAMH, n.d.).
Migration-related trauma, at first glance, is what is sounds like—the trauma that a person may experience in relation to migration. There are common experiences found in forced migration stories. Yaylaci (2018, pp. 2–3) lists a number of events and factors linked to trauma common in forced migration experiences:
- Exposure to war-related events
- Unknown fate of missing family members
- Exposure to multiple traumatic events
- Perception of the degree of personal threat
- Level of personal involvement in the event
- Pre-existing individual vulnerability
- Poor mental health of family members
- Incarceration or political persecution of family members
- Fleeing alone without accompanying family members
- Low social support in the country of asylum or post-migration country
- Financial difficulties
- Social isolation
- Language problems
- Difficult asylum procedures
People who experience migration-related trauma can suffer from anger, depression, anxiety, the inability to set and pursue goals, and PTSD. Nickerson et al. (2014) argue that many of the symptoms associated with psychological disorders are mediated by emotional dysregulation, or emotional expression that is different from or outside of the socially accepted range of expression. Post-migration stressors in the country of asylum and/or resettlement are also understood to further influence a person’s response to trauma. Steel et al. (2017) state that “[c]hronic stress after arriving in the host country associated with resettlement leads to poorer quality of life and health (p. 524).
Trauma and migration-related trauma are specific terms that can determine what official immigration paths migrants are eligible for and what support services they may receive both during and post-migration. Schouler-Ocak (2015) explains that studies on trauma and migration
“report on the multiple and highly complex stressors with which refugees are often faced … [which] might be experiences of traumatization before, during, and after the actual journey of migration. If they succeed in leaving the crisis area, this journey is often a long and tortuous one during which they may be exposed to other traumatic events” (p. 4).
To more fully understand how and when experiences might be classified as traumatic, it is important to understand the term “trauma” and how it is used in relation to migration, as well as protective factors that may influence how a trauma is experienced. Pedersen (2015) examines the history of the term “trauma” and how it was originally a term that referred to purely physical phenomena. Then, over time, the term became used in relation to psychological and emotional experiences related to physical trauma and violence. Now the term is also used to refer to purely psychological experiences.
Throughout the historical transformation in the use of the term “trauma,” how trauma is recognized and classified also evolved. Pedersen (2015) notes that trauma can now be understood as a cultural and individual experience. That is,
“It is now generally accepted that victims react to the experience of trauma according to the meaning that this represents for them, and therefore not all reactions should be regarded as necessarily pathological, or abnormal. In fact, it can be argued that many of the reactions to trauma are ‘normal’ and represent a rather healthy response from which defence mechanisms evolve and healing processes are constructed” (p. 12).
This perspective that the experience of trauma is cultural extends from the individual experience to a societal level. Pedersen goes on to explain how societal perspectives and responses can mediate how a person experiences a traumatic event:
“[S]ociety and culture assign significance and attach meanings to the traumatic event, which can give to and make sense of the traumatic experience, so that in turn it could somehow mitigate, reduce, or even amplify its impact” (p. 12).
Trauma is a concept mediated by a number of factors, including physical and psychological phenomena, violence, migration experiences, culture, and society. Protective factors can be individual, cultural, and social. They can help a person adapt to stressors and trauma. We need to understand trauma to understand how it can affect measures of mental health in migrants who have experienced it.
Determinants of Migrant Mental Health
Mental health is another concept that has become common to everyday language. The World Health Organization (WHO) in the Social Determinants of Mental Health (2014) defines mental health as
“a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (p. 12).
You will notice that this definition includes the capabilities that a person would have with good mental health and includes stated action. Although there are many definitions and frameworks for mental health, for the purposes of this chapter, we will be using this one.
Because trauma may be culturally framed, the definition of mental health may be as well. As you continue through this chapter, consider the strengths and complications that might come from a particular definition. Although we need definitions and classifications to direct our actions and help us collaborate to promote and support health and well-being, mental health is not an end state, but rather exists on a spectrum, from greater to poorer mental health. People fluctuate along this continuum throughout their lives. Migration is one of many important factors influencing a person’s mental health.
The IOM model of the social determinants of mental health uses the Social Determinants of Health (SDOH) framework crosscut by situations in forced migration. The SDOH framework builds on the idea that the determinants of mental health are social in nature.
The International Organization for Migration (IOM) captured the Social Determinants of Health in a graphic that includes details on the situational effects of the forced migration journey. To view this graphic, please go to the Social Determinants of Migrant Health.
Social determinants of mental health include “gender, age, ethnicity, income, education, or geographic area of residence” (WHO, 2014, p. 16). McKenzie et al. (2014) outlines how those social determinants may exist as pre- and post-migration factors and their impact on an individual’s mental health:
“Among the pre-displacement characteristics, region of origin, higher levels of education, higher age, higher socioeconomic status, being from a rural area, and, to a lesser extent, female gender were associated with lower levels of mental health. The factors showing lower levels of mental health after flight and displacement were low levels of economic opportunity (work permit, access to employment, retaining socioeconomic status), living in institutional or temporary private accommodations, being internally displaced, being repatriated, and coming from a region with an ongoing conflict” (p. 36).
Here, pre-displacement refers to pre-migration. You will note that Aichberger also expands on the idea of “geographic area of residence” to include type of accommodation and ongoing conflict as characteristics of that residence.
While trying to understand what migration experiences or factors affect migrant mental health, researchers have examined whether the timing or the type of trauma has the strongest impact on mental health. Many studies look at the effects of trauma that occur before people are forced to move from their homes or while they are migrating. Other studies look at the effects of the post-migration context, or what life is like for migrants who have the chance to resettle in a new country.
Although migrants who experienced traumatic events pre-migration “were more likely to suffer mental health problems in their resettlement country” (Chen et al., 2017, p. 6), “resettlement-related post-migration stressors were the most important correlates of humanitarian migrants’ mental health” (Chen et al. 2017, p. 9).
Chen et al. (2017) looked at humanitarian migrants who resettled in Australia. The study found that the two factors that moderated migrants’ post-migration mental health were “loneliness” and “social integration or isolation” (p. 10). Migrants who experienced pre-migration trauma, and then also experienced loneliness and social isolation in their resettlement country, reported lower levels of mental health. This begs the question, what about migrants who experience pre-migration trauma and then experience social integration and support in their resettlement country?
Learning Activity 2 : Matching Migration-Related Trauma and Factors with SDOH Categories
Resilience and the “Resilient Migrant”
In the field of psychology, resilience may describe a person’s ability or set of resources that allow them to adapt and cope with a highly stressful situation. Resilience can come from individual characteristics as well as socio-demographic factors such as social network, the stability that comes from enduring relationships. However, the “resilient migrant” has become a characterization of a migrant whom receiving countries might deem an asset to the economy. Although both uses of “resilience” appear positive, as with other terms, it is critical to examine how the definition can be used to evaluate a migrant’s story when they make a refugee claim and the potential consequences of that evaluation.
In Gatt et al. (2019), “[r]esilience is a dynamic process of positive adaptation to significant adversity.” McKenzie et al. (2014) describe some refugees as people who “use their own resources and coping strategies to deal with the difficulties encountered in their country of origin, during migration, in their new host country, and in the asylum process. They are resilient people” (p. 183). In a study of unaccompanied refugee minors (URMs) in the United States, Carlson et al. (2012) looked at “sources of resilience among URMs that have allowed them to adapt and even thrive in a vastly different cultural environment despite exposure to multiple risks” (p. 1). Carlson also warns that we may not be able to see a person’s resilience if their trauma story is pathologized.
An American Psychology Association report (2009) published as an update for mental health professionals discusses the dangers of the Western medical model and pathologizing trauma:
“[T]he Western medical model frames adversity and suffering in terms of psychopathology rather than as a legitimate response to stress and upheaval. A clinician may experience pressure to emphasize vulnerability and victimization over resilience in the clinical formulation of a refugee client’s condition in order to request other services or support an application for asylum. This kind of emphasis then suggests that the individual’s reaction to war and organized violence is abnormal rather than an expected response to severe trauma” (p. 10).
Over the past decade, more studies have considered what types of responses to trauma are natural psychological coping mechanisms. One long-term study by Beiser (2014) on Southeast Asian and Sri Lankan Tamil refugees in Canada found that “[s]uppression of traumatic memory may be an effective coping strategy in the short and medium term aftermath of trauma” (p. 79). The study went on to describe how time and social resources were potential sources of resilience for refugees who had experienced migration-related trauma. Challenge and the risk of mental disorder came when individuals began to remember traumatic experiences. In some cases, this remembering did not begin to occur until after a decade in Canada (pp. 79–80). Social networks that included “like-ethnic community,” spouses, and non-kin relationships such as community organization staff or work colleagues provided potential sources of resilience through relationships. Prolonged relationships appeared as a highly effective protective factor (p. 81).
These examples of resilience take into account that individuals may have different experiences of trauma, different migration stories, and different potential sources of resilience. In contrast, a new characterization of the “resilient migrant” has emerged based on a stereotypical image. Although the characterization may certainly have some basis in examples of individuals, Faist (2020) notes that “[i]t is the resilient migrant who has emerged in policy discourse as the ideal-typical figure … who adapts”(p. 249). Faist continues that characterizing a resilient migrant as the ideal can mean that countries create policies that expect migrants to show resilience rather than creating structures or programs that recognize the trauma that is so often part of the forced migration experience (p. 250). Additionally, the problem with the resilient migrant ideal-type is that it may be based on the short- and mid-term responses that migrants can have to trauma when they might be using strategies such as suppressing memories. This ideal-type may not be informed by the longer-term mental health responses people have had to trauma.
Learning Activity 3: Case Study – Fatima
Fatima: Potential Trauma During Migration
Fatima is a single mother with two children, a seven-year-old son, Ahmed, and a 10-year-old daughter, Aysha. The family does not know where Mohamed, Fatima’s husband is; he went missing in their home country during a night of violence in their area. Fatima and the children fled when the fighting and violence overtook their city and their neighbourhood.
Fatima and the children fled with very little planning or preparation. They took a local bus to the land border of a nearby country. They each took one small suitcase, then walked across the border, registering with authorities at the crossing. They walked to a UNHCR refugee camp that was 12 kilometres inside the country of asylum border. Fatima and the children stayed in the refugee camp for two months. When Fatima received her official permit to work and education permission for her children, the three of them moved to a nearby town. They moved into an apartment with another single mother with three children who were also from Fatima’s home country and had fled the violence.
Fatima started working informally as a seamstress. She has no official position despite having formal permission to work. She goes to a small textile workshop, and each morning they tell her whether they have work for her or not. Aysha and Ahmed go to the local public school but do not yet speak the national language. There are some very recently appointed language support teachers in the school to help children like Aysha and Ahmed; however, all classes are delivered in the national language.
Local people in the apartment building and neighbourhood have little to no experience with foreigners and often cluster and whisper to one another as Fatima or the children walk in or out of the building. Fatima is polite and smiles and nods slightly when she sees people in the building lobby, but she is not able to greet them. Like her children, Fatima does not speak the language of the country of asylum.
There is a local medical clinic that has a doctor and nurses who specialize in refugee health issues; however, they only speak the local language. A few people in the community can provide translation support, but Fatima and her children have not accessed the health clinic or translation supports because they do not know anything about the translators and are concerned about sharing very personal information with strangers.
Case Study Questions
Use the questions below to consider how traumatic events may be viewed differently by a person depending on their individual character, social circumstances, and sources of resilience. Discuss your responses with others working through this chapter.
- Do you think Fatima and her children may have experienced trauma?
- What parts of their migration story may have included traumatic experiences?
- What elements of Fatima’s current situation might act as prolonged stressors?
- Knowing that trauma can be determined by the perspective of the person experiencing it, what thoughts or perspectives might Fatima have that would make her migration experiences seem less traumatic to her?
- In what ways do you think Fatima and her children may have shown resilience along their journey and in their current situation in the country of asylum?
- Do Fatima and the children have any potential social resources that may increase their resilience?