Migration Traumatic Experiences and Refugee Distress

ORIGINAL PAPER

Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice

Miriam George

Published online: 12 June 2012

� Springer Science+Business Media, LLC 2012

Abstract Each step of the refugee migratory journey has

its own unique characteristics and mental health conse-

quences, which require much attention from social work

service providers. In an effort to provide quality service

delivery for refugees, their premigration, migration and

post-migration traumatic experiences need to be examined

and understood beyond current narrow formulations. Inte-

grating the concepts derived from refugee trauma and

psychological distress literature, the author presents in this

paper group-based interventions grounded in cultural

competency, spirituality and strengths which will enable

social workers to provide efficient service delivery and

adopt a leadership role among service providers as advo-

cates for refugees.

Keywords Refugee trauma � Social work practice with refugees � Group-based interventions with refugees � Cultural competence � Spirituality

In order to provide quality service delivery for refugees,

social workers must deepen and broaden their compre-

hension of refugees’ traumatic migration experiences

beyond narrow formulations. To achieve this, a clear pic-

ture of the life journey taken by refugees needs to be

captured as they interact with their new environment. It is

essential that the voices of refugees be heard so that cli-

nicians can better understand refugee perspectives and

needs and thereby provide efficient intervention, particu-

larly as it pertains to trauma. The goal of this paper is to

provide social work practitioners with an in-depth under-

standing of refugees’ migration journey in order to make

the most appropriate decisions regarding refugee service

delivery.

Migration Traumatic Experiences

A refugee is a person who has been forced from his or her

home and has crossed an international border for safety

(U. S. Department of State 2009). Since the end of World

War II, an estimated 42 million refugees in the world have

been forcibly uprooted from their country of origin due to

fear of persecution in their native country on account of

race, religion, nationality, membership in a particular

social group, or political opinion (UNHCR 2011). The

effects of refugees’ traumatic migration experiences are

immeasurable, long lasting, and shattering to both their

inner and outer selves (Steel et al. 2006). Three areas of

inquiry are germane to the discussion of refugee migration

traumatic experiences: pre-migration, migration and post-

migration. Knowledge of these areas will provide the

necessary understanding for social work practitioners

working with refugees.

Analysis of pre-migration literature from different

regions of the world revealed one constant thread: coloni-

zation. Colonizers brought with them their own social,

political and economic values and practices that trans-

formed the colonies into places they could understand.

Colonial imperialism replaced the native systems to the

point where it became increasingly difficult for natives to

survive in their own land. Colonization left countries

with social, political, cultural, economic and environmen-

tal chaos and oppression, with no organizational struc-

ture to intervene in the inter-racial, inter-ethnic and/or

M. George (&) School of Social Work, Virginia Commonwealth University,

P. O. Box 842027, Richmond, VA 23284, USA

e-mail: mgeorge@vcu.edu

123

Clin Soc Work J (2012) 40:429–437

DOI 10.1007/s10615-012-0397-y

inter-religious conflicts left behind, which were originally

created by colonizers as a means of control (Askeland and

Payne 2006; Hyndman 2000; George 2009; Mollica 2001;

White 2004). Economic inequality combined with demo-

graphic pressures and environmental crises have generated

ethnic conflict, civil war, terrorist threat and forced

migration (Richmond 2002). Refugees are forced to leave

home to escape danger with no destination in mind (Collins

1996).

During the migration period, refugees often move

between different countries and different refugee camps.

By this time, they are typically separated from their fam-

ilies and friends, creating intense anxiety and depression as

they realize all they have lost (Mollica 2006). Refugees’

lives remain in limbo until their legal challenges are sorted

out. During this time, refugees must confront the losses in

their life, as well as develop a new sense of hope for the

future (Hunt 2004). They are simultaneously required to

pass through the asylum-seeking process, which is inten-

sely re-traumatizing (Quiroga 2004).

Until refugees receive their status in the host country,

their lives are controlled by the United Nations, govern-

ments, refugee boards and non-profit agencies. Only after

recognition of their protection needs by the host govern-

ment are they entitled to refugee status, which carries

certain rights and obligations according to the legislation of

the receiving country (Crepeau et al. 2007; Steel et al.

2004). According to Steel et al. (2004), many countries

such as Australia have instituted mandatory detention for

all persons arriving without valid entry documents. Con-

sequently, a significant number of refugees and their chil-

dren have been held in detention for considerable periods

of time (Steel et al. 2004). Many cannot even think about

settling into society due to their ongoing legal battles for

permanent resident status (Burgess 2004). Refugee claim-

ants who do not have adequate identity documents to prove

their claim must face continuous interrogation by immi-

gration and naturalization authorities (Burgess 2004).

A study of psychological distress and migration trauma

among South Asian refugee claimants in Indian refugee

camps and in Canada (George 2009; 2012) found that those

refugee claimants in Canada, had higher scores for psy-

chological distress and trauma, likely due to the greater

degree of interrogation by immigration officials. Moreover,

this study revealed that refugee claimants experienced

re-traumatization each time they were exposed to interro-

gation by immigration boards in the host country. Fong and

Mokuau (1994) claim that the terms used with respect to

forced migrants—such as refugee claimants, asylum seek-

ers, and displaced persons—exemplify the complexity of

the immigration systems’ ascribing of status and conditions

of treatment. Furthermore, these statuses reflect the variety

of migration experiences and affect the ways in which

refugees settle into their new country.

Crepeau et al. (2007) and Steel et al. (2004) examined

the lack of tolerance in many of the refugee policies in host

countries. Numerous refugees are subjected to additional

traumatic experiences by policies which involve third party

agreement; for example, Canada will not grant refugee

status to persons who have been denied acceptance by a

country with which Canada has an agreement. Traumatic

experiences are also heightened by the burden of proof

policy whereby during the process of determining eligi-

bility, the onus is on the claimant to provide a medical

certificate to prove their claims of having been physically,

mentally or sexually abused. Often refugee review board

members’ lack of knowledge of international refugee law,

ambivalence toward traumatization, ignorance regarding

trauma and lack of understanding of refugees’ historical,

social, cultural and political backgrounds adversely affect

the decision-making process (Crepeau et al. 2007). Many

host country policies are highly Eurocentric and not

applicable to the diverse social, cultural and political nature

of individuals. These policies need to be expanded and

negotiated in order to provide meaning to human experi-

ences. Only after all these legal struggles are status-awar-

ded refugees eligible to receive settlement services, which

include language training, housing and securing identity

documents (Valtonen 2004).

Refugee-host relationships can create an atmosphere

that either aids or hinders the post-migration experiences of

refugees (George 2003). Refugees who have already sur-

vived pre-migration traumatic experiences in their country

of origin often experience particular difficulties, including

feelings of not being safe, during the resettlement period.

After the difficult experience of migration, refugees

approach the new land with mixed feelings (Cummings

et al. 2011; Finklestein and Solomon 2009).

During the initial post-migration period, refugees are

confronted by the loss of their culture—their identity, their

habits and their place. Every action that used to be routine

will require careful examination and consideration (White

2004). Culture shock will particularly affect those refugees

who did not think about, intend, or prepare for exodus, and

who were caught up in panic, hysteria or even adventure

(Mollica 2006; Mollica 2000). When refugees learn the

difficult realities about settlement services, their anxiety

and feelings of exclusion from their host country greatly

increases (George 2003). Nostalgia, isolation, depression,

anxiety, guilt, anger and frustration are so severe that many

refugees may want to go back to their country of origin

even though they fear the violent consequences (Mollica

2000). These factors tend to increase psychological prob-

lems (Ehntholt and Yule 2006; Mollica 2006; White 2004).

430 Clin Soc Work J (2012) 40:429–437

123

Most host countries’ refugee service agencies are funded

by the government and managed by non-profit and/or faith-

based organizations. Lack of coordination among refugee

settlement support systems often increases the difficulty

refugees face during the settlement process (Keung 2006).

An example from the Canadian system is the lack of

communication between the Immigration and Refugee

Board, which is under the federal government of Canada,

and the Ontario Health Insurance Program, which is under

the provincial government. To make things worse, refugees

are often not sure what help-seeking behavior is appro-

priate in the host country (Collins 1996). It is a general

observation that whatever behavior they put forward will

be assumed to be due to cultural difference. The tension

between culture as a basis of universal human experience

and culture as the primary basis of difference has important

social and political implications for social work practice

(Hyndman 2000).

A phenomenon of particular importance with respect to

refugee behavior during resettlement is many refugees’

strong belief that they are owed something by someone

(Hyndman 2000). People from developing nations and/or

formerly colonized nations may have the impression that

Western governments provide social and economic ser-

vices to their citizens without any obligation (Reese 2004;

White 2004; Hyndman 2000). Since their persecutors are

unavailable, many refugees shift their demands to the host

government and the helping agencies. They may continu-

ally complain of not receiving enough (Hyndman 2000).

This discontent can create a feeling among refugees of

being controlled by agencies (Crosby 2006), causing them

to become aggressive and demanding of more and more

resources. At the same time, refugees are often stigmatized

by their own refugee cultural communities, as well as by

society in general, for utilizing social welfare services.

Compounding these issues, refugees may find themselves

isolated from the mainstream community due the inter-

section of racism, classism and sexism (White 2004; Fung

and Wong 2007; Levine et al. 2007). The toll of the

stressors refugees must face during the pre-migration,

migration, an post-migration periods on their physical and

mental wellbeing can be quite devastating.

Psychological Distress

Being a refugee is clearly a category of risk for physical

and psychological distress, because, surrounded within this

state is often-unspeakable violence (Keller et al. 2006).

Therefore, refugee health care issues can be complex and

wide-ranging. Many refugees have experienced torture in

their home land, which inflicts severe long-term physical

and psychological pain. The first interaction a new arrival

encounters with the host country health care system is a

refugee medical assessment conducted by health depart-

ments (Garrett 2006). Most often this medical evaluation is

the only health assessment completed after a refugee’s

exposure to torture (Miller 2004). The reason for this

assessment is to screen for health-related issues before

granting refugee status. Refugees typically inform health

care providers about their severe headaches, abdominal

pain and anxiety. In-depth investigations result in a

detailed report on their physical and psychological chal-

lenges. Injuries to the skin and muscular-skeletal system

from blunt trauma, burns and electrical shock, severe

internal bleeding due to rupture of the liver and spleen,

head trauma due to brain haemorrhage, and contraction of

the HIV virus are widespread physical conditions among

refugees (Quiroga 2004). Refugee women are especially at

risk for sexually transmitted diseases (STD’s) because of

the sexual violence that may have occurred during their

flight (LaFraniere 2005).

Torture survivors have significantly higher rates of

trauma symptomatology than other groups of traumatized

individuals (Mollica 2006; Porter and Haslam 2005). Many

volumes of research have been completed on refugee

trauma (Mollica et al. 1993, 2007; Mollica 2006; George

2009; Porter and Haslam 2005; Steel et al. 2004, 2006;

Schweitzer et al. 2011; White 2004). A systematic review

by Fazel et al. (2005) of 7,000 refugees showed that those

resettling in Western countries could be approximately ten

times more likely to have Post-Traumatic Stress Disorder

(PTSD) than age-matched general populations in those

countries. PTSD can result from undergoing or witnessing

torture, combat or violent personal assault as well as

structural barriers (Schweitzer et al. 2011; Westoby and

Ingamells 2010). Unique psychosocial problems such as