An ecological model for refugee mental health: implications for research

The paper by Ken Miller and Andrew Rasmussen presents a valuable stimulus for a discussion on research directions in the field of refugee mental health. The authors extend their earlier work on the importance of ‘daily stressors’ for populations affected by armed conflict to discuss the importance of post-migration stressors in refugee populations. While acknowledging the well-documented importance of conflict-related potentially traumatic events in the past for refugee mental health, the authors propose a model, which emphasises ongoing post-migration stressors such as poverty, unemployment, stigma and perceived discrimination, and increased family violence. The issues presented in the paper are timely, given the high number of refugees and asylum seekers worldwide, the majority of whom live in low- and middle-income countries where ongoing stressors are a daily reality. As mentioned by Miller and Rasmussen, more than 60 million people are estimated to have been forcibly displaced from their country of residence due to conflicts, human rights violations, generalised violence and persecution as of the end of 2015, including 21.3 million refugees and over 3 million asylum seekers (UNHCR, 2015). Displaced populations may encounter horrific and profoundly painful experiences and losses that – together with other chronic contextual difficulties – can form risks for severe psychological distress and a range of mental disorders through complex pathways. The consideration of this complexity is of importance for researchers in the field of global mental health, and research on mental health and psychosocial support in humanitarian settings in particular, in several ways.

First, the proposed model has much in common with proposed shifts in thinking that have been advocated for at least 15 years, in which a predominantly trauma-focused model is complemented by more holistic psychosocial (IASC, 2007) or public mental health perspectives (Silove, 1999; de Jong, 2002; Rasco & Miller, 2004). In line with psychosocial and public mental health approaches, Miller and Rasmussen's consideration of ongoing chronic stressors goes beyond a traditional biomedical (psychiatric) paradigm in which a single pathogen (e.g., conflict-related potentially traumatic events) is linked to a single mental health outcome for refugees (e.g., posttraumatic stress disorder). Rather, a focus on ongoing stressors allows an examination of social determinants of mental health in addition to violence exposure. In a public mental health approach social determinants are commonly studied through a socio-ecological lens, for example at the family, school, community and wider social levels. Family violence, unemployment, perceived discrimination and poverty are examples of social determinants of mental health, together with broader environmental factors such as unequal access to basic resources and opportunities to partake in occupational and recreational activities. Although there is considerable knowledge on the social determinants of mental health in general populations (Allen et al. 2014), relatively little of this research has focused on refugee populations. Further exploration of modifiable social determinants of refugee mental health (both protective and risk factors) is critical, as it may assist in identifying targets for socio-culturally-sensitive promotive and preventive interventions.

What Miller and Rasmussen defined in the paper as ‘daily stressors’ (i.e., all stressors, major and minor, not related to conflict) are critical both before and after migration (e.g., pre-migration childhood adversities and exposure to violence). Unfortunately, for many people in areas of armed conflict, the experience of war and violence does not represent a sudden rupture in a life previously free of adversity. Rather, conflict-related violence often takes place against a pre-existing background of chronic stressors including chronic poverty, gender-based violence and social marginalization. In conflict-affected populations, rates of intimate partner violence are often elevated (Stark & Ager, 2011). When armed conflict violence leads to violence in the home, it may set in motion transgenerational patterns of violence in a ‘cycle of violence’ model (Rees et al. 2015). These putative processes remain poorly studied, even though they would have critical implications for interventions with refugee populations.

Second, the public health model requires a developmental approach that considers the interaction between social and individual variables over age and time, with specific attention to the constellations of risk and protection at different periods of life (Eaton, 2012). Moreover, particular attention is paid to mental conditions that have their roots early in life, like prenatal exposures (including the importance of maternal mental health) and early childhood experiences. Many mental disorders identified in adulthood have antecedents that can be traced back to earlier life stages, emphasising the importance of a developmental, life-course approach (Tol et al. 2013).

Third, the model proposed by Miller and Rasmussen, and the consideration of social determinants in global mental health more broadly, requires intersectoral actions (Tol, 2015a). It is important that professionals in different humanitarian and refugee response sectors and disciplines coordinate their efforts, considering multiple potential agents that may generate psychological distress or even mental disorders. This can be done in part by governmental agencies, non-governmental organizations and communities strengthening their collaborations (Skeen et al. 2010; Brooke-Sumner et al. 2016). This is in line with the World Health Organization (WHO) ‘intersectoral action for health’ that calls for collaboration by highlighting the importance of a relationship between different health sectors and other sectors for improving health outcomes in a more effective, efficient and sustainable way (World Health Organization, 1997). As far back as 1997, the WHO stated that the intersectoral approach and the consideration of this set of determinants (including social determinants) should be considered as ‘a matter of urgency’ (World Health Organization, 1997). This is in line also with the humanitarian Inter-Agency Standing Committee principles advocating for multi-sectoral coordination in which different approaches to mental health and psychosocial support complement each other (IASC, 2007).

Fourth, a public mental health approach recalls the WHO definition of mental health as ‘a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community’ (World Health Assembly, 2006). Rather than the currently common interpretation of mental health as being synonymous with mental disorders, this definition considers psychological and social functioning as something more than simply the absence of psychopathology, with an emphasis on individual achievement and wellbeing. In this light, promotive interventions acquire particular importance since these are commonly aimed at strengthening positive aspects of psychological functioning, such as self-esteem, agency and a sense of hope (Tol, 2015a; Tol et al. 2015b). Through this lens, promoting resilience, i.e., the ability of refugees to maintain positive mental health despite adversity becomes an important goal. However, the focus in the intervention evaluation literature with conflict-affected populations is skewed towards interventions focused on particular disorders, despite the common emphasis in humanitarian practice on psychosocial interventions that have more wide-ranging goals (Tol et al. 2011; Jordans et al. 2016).

In short, despite repeated calls for a broadening of both epidemiological and intervention evaluation research to consider a wider range of predictive variables beyond conflict-related potentially traumatic events and symptoms of posttraumatic stress disorder, the published literature appears not to have caught up with these calls. For this reason, a next generation of public mental health-inspired research that strengthens knowledge on cost-effective promotion, prevention and treatment interventions for a range of mental health conditions remains an urgent priority.