Presentation by Dr Ross White at the UNESCO RILA Spring School The Arts of Integrating: Labouring and Resting May 2019

1. Addressing the mental health needs of
refugees and asylum seekers
Dr Ross White
Reader of Clinical Psychology,
Institute of Psychology Health and Science
University of Liverpool
ross.white@liverpool.ac.uk
www.rosswhiteblog.wordpress.com
@RossGWhite @CostarProject

2. A bit about me…
• Research Director, Doctorate in Clinical
Psychology programme, University of Liverpool.
• Research lead for the Mental Health in Context
research group at University of Liverpool.
• Founding Director of the MSc Global Mental
Health programme at the University of Glasgow
• Co-editor of ‘The Palgrave Handbook of
Sociocultural Perspectives on Global Mental
Health’
• Principal investigator on the COSTAR project:
https://www.liverpool.ac.uk/psychology-health-and-
society/departments/psychological-sciences/research/costar/

3. Overview
• Critically reflecting on the ‘refugee crisis’.
• Phases of the migration journey
• Process of integration
• Links between integration and mental health
• Predictors of mental health difficulties
experienced by refugees and asylum seekers
• The concepts of mental wellbeing
• Interventions for mental health and wellbeing

4. Figure showing migration patterns from 2005-2010, taken from
Abel & Sander (2014).
• Tick marks represent inflows and outflows in millions.
• Only flows of 170,000 migrants or more are shown.

5. Refugee Crisis? Migration Crisis?

6. Refugee Crisis? Migration Crisis?

7. Refugee Crisis? Migration Crisis?
Political Crisis

8. Refugee Crisis? Migration Crisis?
Political Crisis
Numbers of people seeking international protection (asylum
seekers) in Europe 1985-2015; Graph taken from Connor &
Krogstad (2016)

9. Key Definitions
• Refugee is someone who has been forced to flee his or her
country because of persecution, war or violence. A refugee
has a well-founded fear of persecution for reasons of race,
religion, nationality, political opinion or membership in a
particular social group.
• The 1951 Geneva Convention is the main international
instrument of refugee law. The Convention clearly spells
out who a refugee is and the kind of legal protection, other
assistance and social rights he or she should receive from
the countries who have signed the document.
• An internally displaced person, or IDP, is someone who has
been forced to flee their home but never cross an
international border

10. Forced Displacement
Statistics showing number of people displaced worldwide in
June 2018 (source: UNHCR, 2018)
Source: https://www.unhcr.org/figures-at-a-glance.html

11. Forced Displacement
Source: https://www.unhcr.org/figures-at-a-glance.html

12. Mental Health of Refugees
• Mental health difficulties have been shown to be
elevated in displaced and refugee populations (Fazel
et al., 2005; Lindert et al., 2009).
• Social adversity in the form of ‘daily stressors’ (such
as lack of access to basic resources, isolation, lack of
safety and security, family violence) has been
highlighted as an important determinant of CMD(Tol
et al., 2014; Whitley, 2015).
• Refugee populations have been shown to experience
elevated levels of daily stressors (Miller &
Rasmussen, 2014).

13. Factors Impacting on Mental Health
Factors associated with mental health difficulties
experienced by ASR can be classified into 3 phases of
time:
• Premigration: Experiences include exposure to war,
torture and persecution (Hollifield et al., 2002; Ryan et
al., 2008)
• Migratory journey: Exploitation, impoverishment and
lack of resources (International Migration, Health and
Human Rights, 2013)
• Post-migration: stressors found to impact MH include
perceived stigma, discrimination and the asylum
process (Laban et al., 2008; Priebe et al., 2016).

16. Factors Impacting on Mental Health
Public health aspects of mental health among migrants
and refugees: a review of the evidence on mental health
care for refugees, asylum seekers and irregular migrants
in the WHO European Region (Priebe et al., 2016):
• The prevalence of psychotic, mood and substance-use
disorders resembles that in the host populations.
• Refugees and asylum seekers have higher rates of post-
traumatic stress disorder.
• Poor socioeconomic conditions are associated with
increased rates of depression five years after
resettlement

17. Integration
Four strategies for acculturation (Berry, 1997):
1. Assimilation – when individuals do not wish to maintain
their cultural identity and seek daily interaction with other
cultures
2. Separation – holding on to ones own culture and avoid
interaction with others
3. Marginalization – when there is little cultural maintenance
or having relationships with others.
4. Integration: maintaining of one’s original culture while
engaging in daily interactions with others (Berry, 1997).
Berry (1997) views integration as a two-way process that can
only be successfully pursued by migrants when the host society
is open and inclusive in its orientation towards cultural diversity.

18. Integration
Key domains of integration are proposed related to
four overall themes (Ager & Strang, 2008):
1. Achievement & access across the sectors of
employment, housing, education and health;
2. Assumptions & practice regarding citizenship
and rights;
3. Processes of social connection within and
between groups within the community;
4. Structural barriers to such connection related to
language, culture and the local environment.

19. Integration
• A multi-dimensional concept including:
– Structural integration: socio-economic aspects of
integration referring to education, employment
– Social and cultural aspects: referring to cultural
adjustment, shared norms and social contacts of
immigrants with natives
(Vermeulen & Penninx, 2000)

20. Integration
• Good mental health is a key determinant of good
integration (UN, 2018; Schick et al., 2016).
• But, good integration is also a determinant of
good mental health (Haasen, Demiralay, &
Reimer, 2008)!
• A reciprocal link between integration and mental
health.

21. Determinants of Health
Dahlgren and Whitehead (1991)

22. Revisiting the concept of ‘Mental
Health’
Addressing mental illness is a necessary, but not sufficient aspect
of enhancing mental health:
• WHO (1947): Health is a state of complete physical, mental
and social well-being and not merely the absence of disease
or infirmity.
• WHO (2014): Mental health is defined 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.
• QoL is: ‘Individuals’ perception of their position in life in the
context of the culture and value systems in which they live
and in relation to their goals, expectations, standards and
concerns’ [WHO QoL Group, 12, p.1405].

23. Dual Continua Model
of Mental Health and
Mental Illness
(Keyes, 2002;
Westerhof & Keyes,
2010)

24. Factors Impacting on Mental Health
Van Der Boor et al., (in submission): Systematic Review of
Factors associated with Subjective Well-Being (SWB) and
Quality of Life (QoL) of Migrant Populations in High-Income
Countries
• 21 papers (19 studies) included – 5 Denmark, 5 Sweden, 4
Netherlands.
• Both positive and negative predictors of QoL were largely
dominated by social (i.e. having a good social network) and
mental health factors (i.e. experiencing depression).
• Studies on SWB mostly reported negative associations
(depression being the strongest predictor) with only one
positive association found (i.e. present life satisfaction).
• In general, the studies were of moderate methodological
quality.

25. Psychosocial Interventions
• In low- and middle-income countries, where the vast
majority of refugees reside, there is a marked absence
of highly skilled professionals available to deliver
mental health support (Mendenhall et al., 2014)
• In such settings, group-based forms of psychosocial
support that can be facilitated by community members
who receive training offer great promise.
• These approaches are socially acceptable and effective
in treating common mental disorders, whilst also
decreasing pressure on primary health care (Tol et al.,
2011; Ventevogel, 2017).

26. Psychosocial Interventions
Psychosocial interventions are based on an appreciation
that aspects of a person’s surrounding social environment
can combine with psychological factors to impact on their
physical and mental health.
The Mental Health & Psychosocial Support Network
webpage (https://mhpss.net) provides information about
various forms of psychosocial support
Guidelines have also been proposed for delivering
psychosocial support in emergency situation2 (IASC,
2007) and with refugees specifically (UNHCR, 2013;2017)

27. https://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psych
osocial_june_2007.pdf - 2007

28. Intervention
• Interventions for refugees’ mental health
problems should include: developing safety, trust,
and stabilization, providing specific therapies and
support with integration (Chang-Muy, &
Congress, 2015; Herman. 1997; Valtonen, 2008).
• It is recommended that mental health and social
care of refugees include an integrated approach,
cultural sensitivity, political awareness and
accessibility (Watters, & Ingleby, 2004).
• Support should involve multiple agencies and
may be long-term (UN, 2018).

29. https://app.mhpss.net/?get=309/unicef-cb-mhpss-guidelines1.pdf -
2018

30. https://resourcecentre.savethechildren.net/node/11929/pdf/unhcr_cbcp_and_mhpss.pdf -
2018

31. Psychosocial interventions for asylum
seekers and refugees
Turrini et al. (2019) - 26 studies included in a
meta-analysis of psychosocial interventions have
a clinically significant beneficial effect on:
• PTSD (20 studies, 1370 participants; moderate
quality evidence)
• Depression (12 studies, 844 participants;
moderate quality evidence)
• Anxiety outcomes (11 studies, 815
participants; moderate quality evidence).

32. Psychosocial interventions for asylum
seekers and refugees
Turinni et al. (2019)
• 18 studies conducted in HIC, 8 in LMIC
• Most evidence supported interventions based
on CBT with a trauma-focused component.
• There is a limited number of studies
conducted to date, with a relatively low total
number of participants.

33. Adaptation and Development after
Persecution and Trauma (ADAPT)
Silove et al. (2013) proposed a 5 core pillars:
1. Safety/Security
2. Bonds/Networks
3. Justice
4. Roles and Identities
5. Existential Meaning
Inter-dependent components of the foundations
needed to restore stability to conflict affected
societies.

34. Adaptation and Development after
Persecution and Trauma (ADAPT)
ADAPT recognises the importance of:
• Ecological/social environment to recovery
• Culturally and contextually sensitive understanding in
distinguishing between normative and pathological
reactions to stress
• Supporting a balance of interventions (psychosocial,
mental health) in a manner that provides an integrated
approach to promoting communal and individual
recovery.
• Recognising that post-traumatic growth and positive
change is possible
(Silove et al., 2013)

35. Current Projects
• PI: Community-based Sociotherapy Adapted for
Refugees (COSTAR):
https://www.liverpool.ac.uk/psychology-health-and-
society/departments/psychological-
sciences/research/costar/ @CostarProject
• Co-I: Refugee Emergency: DEFining and Implementing
Novel Evidence-based psychosocial intervention (RE-
DEFINE): http://re-defineproject.eu/
@REDEFINE_H2020
• Co-I: Feasibility study and pilot trial of an evidence-
based low intensity psychosocial intervention
delivered by lay therapists for asylum seekers and
refugees (PROSPER):
https://www.liverpool.ac.uk/psychology-health-and-
society/departments/health-services-
research/research/prosper/ @ProsperProjLiv

36. (WHO, 2017): https://apps.who.int/iris/bitstream/handle/10665/254581/WHO-MSD-
MER-17.1-eng.pdf;jsessionid=10EE8987576E8FD31BD221EFB196D12E?sequence=1

37. WHO Low-intensity Interventions
• Problem Management +:
http://apps.who.int/iris/bitstream/10665/206
417/1/WHO_MSD_MER_16.2_eng.pdf
• Thinking Healthy:
http://www.who.int/mental_health/maternal-
child/thinking_healthy/en/
• Self-Help +:
http://onlinelibrary.wiley.com/doi/10.1002/w
ps.20355/abstract

38. RE-DEFINE Project
• RE-DEFINE (Refugee Emergency: DEFining and
Implementing Novel Evidence-based psychosocial
intervention)
• EU-HORIZON-2020 project
• Evaluating the efficacy of SH+ for preventing
mental disorders in refugees and asylum seekers.
• 600 participants to be recruited across 5 different
countries – UK, Italy, Germany, Austria and
Finland.
• http://re-defineproject.eu/

39. The SH+ Package
Session Material Covered
1 Grounding: Introduces concepts of stress, how emotions can be similar to being
overwhelmed by a storm (emotional storms), and how “grounding” can help.
Grounding refers to attending to the breadth of current moment experiences.
2 Unhooking: Explains how a person can “unhook” from stress thoughts or
emotions. Unhooking is a technique for identifying difficult thoughts and emotions
and using grounding to focus on what is around you, so you may be less caught up
in struggling with thoughts or emotions.
3 Doing what matters: Explains how identifying personal values (e.g. being kind,
being a good parent) and behaving in a way that is in line with these values may
reduce stress, compared to behaving in a way that is not in line with them. It
explores how to engage in actions consistent with values.
4 Being kind: This session explains how being kind to oneself and others can help
reduce stress. It also introduces the concept of problem solving using personal
values.
5 Making room: This session reviews all the skills and techniques, finishes problem
solving and provides another technique that builds on the concept of unhooking.

40. RE-DEFINE Project
In Glasgow, UK:
• Recruiting 100 refugees and/or asylum seekers –
elevated distress/no MD
• Randomised to either SH+ or enhanced treatment as
usual
• Focusing on Arabic speaking refugees/asylum-seekers
• SH+ groups facilitated by experts by experience.
• People assessed at baseline, post-Tx, 6mths, 12mths
• Contact us: Redefine@Liverpool.ac.uk
• Whatsapp/Text/Phone: 07446771522

41. Conclusions
• The vast majority of refugees are hosted in low- and
middle-income countries.
• Refugees and asylum-seekers can experience elevated
levels of mental health difficulties.
• Events before, during and after migration are important.
• Factors that can positively impact on mental wellbeing
remain poorly understood.
• Mental health and wellbeing impacts on integration and
vice versa.
• Psychosocial support that situates the person in their social
context is key to promoting mental health and wellbeing.
• Multi-agency support is crucial.

42. Acknowledgments
• Dr Paul Bangirana
• Prof Corrado Barbui
• Carine van der Boor
• Dr Girvan Burnside
• Jane Burton
• Dr Anna Chiumento
• Prof Chris Dowrick
• Dr Rui Duarte
• Tasdik Hasan
• Dr Ruaraidh Hill
• Dr Darius Gishoma
• Dr Stefan Jansen
• Dr Rosco Kasujja
• Daniel Kagabo
• Mariana Popa
• Prof Atif Rahman
• Prof Jude Robinson
• Dr Wietse Tol
• Dr Giulia Turrini
• Peter Ventevogel