Gillian Singleton, Debbie Hocking, Joanne Gardiner, Georgia Paxton
Note: Parts of this section have been adapted from Promoting Refugee Health.21 For further information see Management of psychological effects of torture or other traumatic events
- An assessment of emotional wellbeing and mental health should be part of post-arrival health screening, although concerns in these domains may only emerge over time, as trust and rapport develop.
- It is generally not advisable to ask specifically about people’s experience of torture and trauma, especially in the first visits, however the potential impacts on psychological health should be assessed.
- Consider suicide risk assessment in people where mental health concerns are evident or suspected.
- Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children, or the impact of parents’ mental health status on child wellbeing.
Many adults and children from refugee-like backgrounds have experienced trauma, conflict, family separation and significant human rights violations, including torture and physical and sexual violence. A meta-analysis found the population prevalence of reported torture was 21% in refugee adults,372 and available Australian data suggest a high proportion of asylum seekers in detention disclose a history of trauma and torture.373 Unaccompanied and separated children are recognised as having specific risks and vulnerabilities.374–378
While pre-arrival trauma is well recognised in refugee populations, settlement may also contribute to mental illness, and is often associated with multiple stressors. Navigating life in a new country, language barriers, housing and financial instability, difficulty accessing employment, changes in family roles, and loss of community, country and cultural connections can have additive impacts in terms of risk for mental health. A meta-analysis of risk factors affecting mental health outcomes in refugee groups379 found poorer outcomes were associated with institutional or temporary housing after settlement, restricted economic opportunity after settlement, ongoing conflict in the country of origin, higher education level and higher socioeconomic status pre-arrival, and coming from a rural area. Child and adolescent refugees had relatively better mental health outcomes than adults in this analysis, although parent mental health has a strong influence on child wellbeing.
Asylum seekers may face additional stressors related to their asylum experience – through perilous journeys, time in immigration detention, and living in a state of prolonged uncertainty. There is clear evidence that Australian immigration detention, especially long-term detention, is detrimental to health and mental health at all ages, in the short and long term.380–400 Additionally, Australian temporary protection visas have been shown to be associated with worse mental health status when compared to permanent protection visas,387,392,401–404 due to restrictions on family reunion, access to employment and/or Medicare, and exposure to ongoing uncertainty.404
Widely variable rates of mental health issues are reported in refugee children (reviewed in,405 also406,407 and adults,372,391,408–412) although there is more information available on the prevalence of Post Traumatic Stress Disorder (PTSD), depression, and anxiety than other mental health diagnoses, and findings are typically specific to cohorts, conflicts and countries of settlement. Like any population, people from refugee-like backgrounds may have conditions such as schizophrenia or bipolar disorder; although, there is little evidence to suggest that these diagnoses are more frequent in refugee-like populations.
The validity of mental health screening in refugee groups has been questioned.413 Existing assessment tools, diagnostic approaches and psychological interventions may have limited applicability to refugees and asylum seekers, and caution is required with mental health diagnoses; however, evidence suggests that therapy is beneficial in these groups.414–416
We advise clinical screening for emotional wellbeing and mental disorders as part of the post-arrival screening, and ongoing review for stressors related to the refugee and resettlement experience over time.
Available evidence suggests that both refugees405,417–423 and asylum seekers424–427 face significant barriers to accessing health and mental health services. A comprehensive post-arrival health assessment offers an opportunity to build trust and rapport, consider risk and resilience, and raise awareness of mental health and supports in Australia. Understanding mental health is also essential to address other health problems, and support adherence to medication and management.
History and Examination
A complete history and examination is outlined in Promoting Refugee Health.21
Health consultations and discussion about mental health may be a source of significant anxiety for some individuals. Past experiences influence people’s understanding and access to healthcare, and it is important to recognise that people may not had prior experience of mental health care. Furthermore, in some source countries, authority figures, including health professionals, may have been complicit in torture or other form/s of persecution. It is also important to consider the presence of family members in the room, and issues specific to working with interpreters.
The following areas are useful to explore during initial consultations:
- Migration history. Some useful general (and sensitive) questions include:
- When did you leave your country?
- Were you forced to leave?
- What was the situation that led you to leave?
- What countries were you in before you came to Australia?
- What were conditions like in those countries?
- Have you spent time in a refugee camp or a detention centre?
- Migration status (asylum seekers). Asylum seekers in Australia experience prolonged delays (i.e. years) in processing their claims for refugee status, which includes frequent changes to immigration policies that directly impact on their day-to-day lives. An insecure and temporary visa status is associated with feelings of powerlessness and inability to plan for the future,401,403 with the additional burden of stringent code of conduct requirements,428 denial of work rights429 and/or Medicare, and restrictions on family reunion.430
- Family composition. Useful questions include: ‘Who is in your family in Australia?’ and ‘Who is in your family overseas?’ rather than trying to construct a genogram. Concern for remaining family overseas may be overwhelming, with significant effects on settlement and wellbeing.
- Settlement experience, social connections, resources and support.
- Current functioning. It is often useful to ask about appetite, energy, daily activities, memory and concentration, sleep and plans for the future as an entry to more specific mental health symptoms. Asking about approaches to stress management, and coping strategies can also be useful, as it can indicate the extent of the person’s (internal and external) resources, and utilisation of these resources.
- Trauma screening. It is rarely necessary to ask in detail about a client’s trauma and torture history, and it is important to consider the potential for triggering a trauma response. Useful screening questions include:
- Terrible things have often happened to people who have been forced to leave their countries. I do not need to know the details about what you have been through, but is there anything that has happened that might be affecting you now?
- Do you think a lot about these things that you’ve been through?
- Is it hard to concentrate on other things in your life, or is it hard to get to sleep because of these memories or thoughts, or because of bad dreams or nightmares?
- Do you worry about going crazy or ‘losing your mind’?
- More specific mental health symptoms. Enquire about symptoms such as current mood, irritability or anger, sadness, hopelessness, guilt and worthlessness, loss of interest in (previously) enjoyable activities, social withdrawal, anxiety symptoms, panic symptoms/panic attacks, rumination, and intrusive thoughts.
- Self-harm/suicide risk assessment. Suicidality can occur independently of mental illness,431 and hopelessness has been found to be a stronger predictor of suicidal ideation than a diagnosis of depression.432–434 Furthermore, suicidality may present differently in those from diverse refugee-like backgrounds.435,436 Religious beliefs and a strong sense of responsibility to one’s family can be particularly potent protective factors, which often precludes intentional and planned acts of self-harm. It is worth noting that asylum seekers are likely to be at greater risk of suicide after a negative refugee determination decision.437,438 Therefore in addition to the usual risk assessment questions (i.e., Does the individual have thoughts of harming themselves? Do they have intent, a plan and means to do so?), the following questions may also be useful: ‘Do you ever wish you were dead?’; ‘How often do you have these thoughts… and how long have you been having them? Have they increased or lessened over time?’; ‘Do you worry that you might hurt yourself impulsively, without planning to (e.g. walking in front of a car or train)?’ ‘Do you sometimes find yourself doing things that put you at risk without realising, such as walking across the road without checking to see if there is traffic?’.
Other common presentations in adults include:
- Somatization of psychological symptoms including chronic and regional pain syndromes. Pain syndromes, particularly neuropathic pain, can also be the consequence of previous torture and thus should be comprehensively assessed.
- Concerns about memory and concentration.
- Complicated grief,439–441 prolonged grief/bereavement,439,442 and traumatic grief.443 Common – even adaptive – traumatic/complicated grief reactions in this population may be mistaken for psychotic symptoms, such as visual or auditory hallucinations,444,445 and must be considered and assessed carefully within this context.
- Relationship difficulties (including family violence, parenting issues). Refer to Women’s health for further exploration of family violence identification and management.
- Disorders of addiction, including gambling or substance abuse.
Culture, mental health literacy, education, language proficiency, education and perceptions of stigma also have profound effects on presentation and access to mental health services.
The Cultural Assessment Tool446 is a useful framework that encourages a narrative approach to exploring people’s beliefs and cultural interpretation of illness. Questions from this tool include:
- Why do you think the problem started when it did?
- What do you think your illness does to you?
- What are the main problems it has caused for you?
- How severe is your illness?
- What do you most fear about it?
- What kind of treatment/help do you think you should receive?
- Within your own culture how would your illness be treated?
- How is your community helping you?
- What have you been doing so far?
- What are the most important results you hope to get from treatment?
Management and Referral
Patients with mental health issues related to torture and trauma should be referred to a specialised torture and trauma service.
Where there is no torture or trauma history, referral to mainstream mental health services may be more appropriate. There are a number of ways to provide assistance while people await review. These include:
- Regular review and providing support to reduce feelings of isolation.
- Exploring and identifying strengths and evidence of resilience.
- Advice regarding regular exercise and good nutrition.
- Advice on sleep hygiene and relaxation strategies.
- Psycho-education about common mental health symptoms and conditions (e.g. social withdrawal, anhedonia, and disturbance of mood, sleep, appetite for depression; intrusive symptoms, avoidance and hyper-arousal for PTSD; physiological responses during panic attacks; transient cognitive difficulties due to anxiety/depression/chronic stress). Normalising symptoms can help to de-stigmatise perceptions of mental illness, and individuals may prefer to manage symptoms themselves unless, or, until, significant psychosocial functional impairment and/or subjective suffering is encountered.
- Explaining what is meant by counselling, which may increase the likelihood of the individual accepting a referral in the future. Counselling may be normalised by framing it as a way to help problem-solving processes and increase coping strategies, in addition to it being a confidential space to release ‘emotional pressure’ independent of family and community relationships.
- Introducing the concept of talking with others – e.g. friends, religious figures, or a counsellor as a way to releasing pent up emotions and stress. Useful analogies can be to get things ‘off one’s chest’ or a pressure cooker valve ‘letting off steam’, rather than ‘bottling things up’. Explaining that counselling may not suit everyone, but that it may help provide strategies to reduce further build up of emotional stress, strengthen emotion regulation, and increase social connectivity, can be a useful strategy.
- Teaching structured problem-solving, and identifying and challenging negative core beliefs using simple cognitive behavioural therapy strategies. Technology such as mobile phone applications may be useful. Whilst most applications are in English, there is at least one (‘New Roots’) that has been translated. (Refer to Links at the end of this chapter).
- Excluding possible medical contributors to mental health symptoms where relevant (e.g. low B12, thyroid dysfunction).
A list of services for each state and territory is available in the Foundation House Promoting Refugee Health Guideline.21
The methods of documenting (and managing) physical and psychological findings of torture and trauma are outside the scope of these guidelines. Please refer to the Istanbul protocol for further details.
Considerations in Pregnancy and the Perinatal Period
The sense of disconnection and loss relating to separation from key family members, supports and culture can be exacerbated during pregnancy and the perinatal period. It is common for women to be distressed by differences between mainstream ante and perinatal care and their traditional cultural practices during this time. Many women of refugee-like background are from cultures where supporting a new mother and raising children is a shared responsibility. Pregnancy and the post-partum period are often times where the sense of loss related to absence of friends and relatives is heightened and thus there is a higher risk of anxiety and postnatal depression.368 This risk appears to be extreme for women who are pregnant and give birth while they are in immigration detention.
Women who have experienced FGM/C face specific physical and psychological risks in pregnancy, which need to be recognised early and addressed (see Women’s Health).
Pregnancy is a time where women at risk of family violence may be particularly vulnerable to harm. Women of refugee-like background are not immune to these risks and thus this needs to be considered and sensitively managed355,369 (see Women’s Health).
Recognition of the risks which women of a refugee like background face during this vulnerable time is important, to enable appropriate screening, to facilitate access to care with early referral to culturally and linguistically appropriate services, to enhance social supports and enable access to appropriate health promotion and education resources to optimise outcomes.352
Considerations for Children and Adolescents
Children and young people of refugee-like background are likely to have been exposed to significant trauma prior to their arrival in Australia, and may have additive risk for mental health and developmental concerns through parent mental illness, disrupted family functioning, periods of separation, and the timing of trauma in relation to developmental milestones. Unaccompanied and separated minors have specific vulnerabilities, including increased risk of experiencing violence, sexual abuse or sexual violence, and they may have cumulative risk for mental illness. Children and adolescents experience a similar range of psychological reactions to trauma to adults; however, their clinical presentation reflects their age and development.
Parent mental health influences child mental health, and the impacts of parental distress and/or mental illness on children are significant. For asylum seeker children and adolescents, Australian immigration detention has been found to have profound negative impact on parenting and family functioning,209,390,391,395,447,448 and children frequently witness adult distress, mental illness and self-harm in detention.449 Children and adolescents in detention are at high risk of mental health problems, including PTSD, anxiety and depression, sleep and behavioural disturbances, and enuresis. Infants born in detention may have severe attachment issues in association with maternal postnatal depression.
Parental well-being is also identified as a key factor in optimising a child’s ability to recover from adversity.450 Children and adolescents experience settlement through their family circumstances, but also through their interaction with peers, community and education in their new country, and there is increasing recognition of the role of education and schools in supporting child wellbeing.451–454
In addition to the areas of history suggested in the earlier section, other points to consider in children and adolescents include:455
- Attachment to parents/caregivers.
- Behavioural difficulties, including irritability or aggression.
- Play and peer relationships, including emergent themes in games or drawing, any difficulties making friends, engaging in play, or joining group activities.
- Difficulties with attention or concentration, hyperactive behaviour, learning difficulties.
- Withdrawal or lack of interest in normal activities; retreating into screen-based play is common.
- Separation issues, including school refusal, watchfulness, and co-sleeping.
- Sleep-related symptoms, including nightmares, intrusive worries or thoughts, disordered sleep routine and fatigue.
- Enuresis and encopresis.
- Difficulties with self-esteem.
- Developmental delay, lack of expected developmental progress or regression.
- Sexualised behaviour, which may indicate that a child or young person has witnessed or been exposed to sexual abuse. Seek advice on child protection concerns and consider reporting requirements.
- Risk taking behaviour in adolescents.
Self-harm or suicidality are extremely rare in younger children, but require urgent review if present at any age.
Consider use of a screening tool for children such as the Strengths and Difficulties Questionnaire (SDQ). HEADSSS screening is useful to elicit key aspects of psychosocial history in adolescents. See below for links.
Management and referral (children and adolescents)
Management and referral of children with mental health concerns follows similar principles to adults. Where mental health difficulties relate to torture/trauma experience, a torture trauma service is an appropriate referral, and in most states and territories these services will provide services for children. Seek specialist paediatric advice early; referral to generalist mental health services may also be appropriate. Also consider (and screen where relevant) for treatable conditions that may cause or exacerbate mental health or behavioural problems, including hypothyroidism, vitamin B12 deficiency and iron deficiency.
General principles of managing children/adolescents experiencing trauma reactions and/or other mental concerns include:
- Addressing mental health issues in the whole family.
- Supporting primary attachments with significant people.
- Maintaining routine and preparing for changes, reassuring children about the future.
- Addressing sleep issues, and maintaining a healthy age-appropriate sleep routine, and limiting screen time.
- Encouraging play in younger children (between children, and between parents and children) and enjoyable activities in older children/adolescents, including sport and exercise.
- Encouraging them to express emotions and asking what they are thinking/feeling.
- Setting realistic goals for behaviour and avoiding overreacting to difficult behaviour during transition periods.
- Promoting engagement with school and community, and also promoting maintenance of first language alongside English language learning.
A brief assessment of developmental milestones should be included as part of a comprehensive assessment in children of refugee-like background, specifically eliciting parent concern, excluding sensory impairment (vision and hearing), and ensuring children are linked with age-appropriate services such as Maternal and Child Health Nursing and kindergartens early in the settlement period. Assessment of children with developmental delays or disability will usually require specialist child health input, by paediatricians or through paediatric allied health professionals.
There are limited prevalence data on developmental issues or disability in children of refugee- like background, although they may have multiple risk factors for developmental concerns, and the aetiology of developmental issues is typically multifactorial. Routine neonatal, early childhood, vision and hearing screening are unlikely to have been completed, and children may arrive with significant developmental delays or disability.
Psychological and developmental assessment can be complex, requiring an understanding of second (or later) language acquisition, language transitions in relation to development, relevant medical conditions, the impact of forced migration, trauma, and settlement, and support services available. There are specific challenges with the use of developmental screening tools, language assessments and cognitive assessments for children with English as an Additional Language (EAL). Developmental assessments take time and require close liaison with families and the help of a skilled interpreter. They are usually completed in the specialist child health setting, after referral from primary care. Service guidelines are available.456
Adolescence is a developmental stage, for which milestones include emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescents of a refugee background face all these transitions in addition to the transitions of resettlement. They are faced with balancing the values/expectations of their parents/cultural background with those of their new peers, while developing their own identity and learning a new language in a new schooling and social system. Adolescents may also make new meaning from past trauma, and present with mental health concerns in relation to trauma in early childhood.
Children and young people
Transcultural Mental Health Centre & NSW Centre for the Advancement of Adolescent Health. Adolescent Health: Enhancing the skills in caring for young people from culturally diverse backgrounds. 2nd edn. 2008