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
