Understanding the mental health and help-seeking behaviours of refugees
Ana-Marija Tomasi, Shameran Slewa-Younan, Renu Narchal, Pilar Rioseco
For a range of reasons relating to past-trauma and settlement challenges, humanitarian migrants (sometimes referred to as refugees) in Australia are vulnerable to psychological distress and overall poor emotional health. However, help seeking – especially for mental health challenges – is low and/or problematic. This is largely attributable to poor mental health literacy, mixed cultural understandings of mental illness and associated stigmas. Practitioners can be unaware of this combination of issues, their invisible nature and the impacts they can have in the longer term.
Refugees show high levels of mental health problems, including post-traumatic stress disorder.
Despite the high levels of symptoms, professional mental health help seeking is low in this population.
Community-based programs have shown promising results but there are still several barriers to help seeking that need to be addressed, including stigma, cultural competency and cost.
Globally, refugees are often exposed to highly traumatic events in their home country and during their migration journey. This results in higher rates of poor mental health than in the general population. The impact of refugee trauma often extends beyond the symptoms of individuals to have a broader impact on families and communities (Silove, Ventevogel, & Rees, 2017).
It is estimated that around half of refugees internationally experience post-traumatic stress disorder (PTSD) (48.7%) (Hamrah et al., 2020), anxiety and psychological distress (40–50%) and that one-sixth have severe mental illness (16%) (Chen, Hall, Ling, & Renzaho, 2017; Guajardo et al., 2018; Taylor et al., 2014). Despite this, research in Australia suggests only around one-fifth seek help – either professional or informal (19%) (Slewa-Younan et al., 2015). When help is sought, it is more often from family members, friends or other informal sources (Nguyen et al., 2018; van der Boor & White, 2019). The use of specialist trauma and torture mental health services is low, with less than one in 10 refugees in Australia with PTSD symptoms using these services (4.6%–10%) (Slewa-Younan et al., 2017).
This short article identifies the factors affecting help-seeking behaviours among refugee families and outlines how practitioners can better support this vulnerable group during the resettlement process.
What affects the help-seeking behaviour of refugees?
Help-seeking amongst refugees is affected by socio-demographic factors; specifically, older adults, females and those with better English language proficiency are more likely to seek professional help (Byrow, Pajak, Specker, & Nickerson, 2020). Further structural barriers to seeking professional help include poor mental health literacy, limited understanding of new health care systems, financial difficulties, limited transport, challenges obtaining appointments and long waiting periods, and difficulties securing child care. Other factors that influence the help-seeking behaviours of refugees include the severity of mental health symptoms, low levels of trust in the health care system and fears surrounding confidentiality (Byrow et al., 2020; Slewa-Younan et al., 2017).
Evidence also suggests the stigma of mental illness, and cultural interpretations of symptoms, inhibit help-seeking behaviours (Byrow et al., 2020). However, acculturation has been found to positively affect help-seeking behaviours: a longer time spent in the host country is associated with higher levels of professional help seeking (Markova, Sandal, & Pallesen, 2020).
What works to support refugees with mental health challenges?
Factors that facilitate uptake of services include having services close to where participants live to minimise travel costs; soft entry points, where referrals from trusted organisations/community groups create a sense of confidence and trust; and child-minding services. The recent addition of telehealth items to Medicare may help with access to mental health services not previously available. Additionally psycho-education and training for cultural leaders has been shown to ease some of the negative attitudes associated with poor mental health and increase promotion of professional mental health services amongst refugee groups (Slewa-Younan et al., 2020). Bulk-billed mental health care options for refugees facing financial hardship is also likely to reduce barriers to access, as is support from community organisations to cover these costs1. Information about these services needs to be provided to refugee communities and individuals who may need them.
The cultural competence2 of a practitioner is also an essential component of providing effective mental health treatment to refugees. This goes beyond providing interpreters or offering programs in the participant’s language to providing culturally informed services. These services provide effective and appropriate care to individuals with diverse values, beliefs, linguistic needs and cultural practices. This could be implemented by providing multicultural practitioners, speaking to cultural leaders and asking clients about their culture and incorporating this information into treatment planning (Betancourt, Green, & Carrillo, 2002).
Finally, targeted services during the resettlement period could also assist refugees to better integrate into the host country (UNHCR, 2002). These services could include community-based psychosocial programs created to address the trauma and resettlement stressors experienced by refugees (Slewa-Younan, Blignault, Renzaho, & Doherty, 2018). Community-based programs are those in which the community is actively involved in highlighting and addressing the issues that are most important to them (Van Bibber, 1997). Five categories of psychosocial programs that have been shown to have positive effects on refugees’ mental health and wellbeing include:
- trauma-informed psychotherapy programs delivered with a group component
- community-based psychoeducation and/or health programs
- physical activity and sports-based programs
- peer support and/or mentoring programs
- targeted school-based programs.
Community-based psychosocial programs for refugees have been recommended to address the impact of trauma and resettlement stressors on the individual, family unit and their community, and existing research shows promising results. However, further high-quality evaluation studies are still required to strengthen the evidence for these programs (Slewa-Younan et al., 2018).
Refugees often have higher rates of poor mental health compared to the general population. However, they are less likely to seek professional help. This significantly impacts their ability to integrate into a new country and can cause cycles of intergenerational trauma (Sangalang & Vang, 2016). Promoting culturally informed professional mental health services is essential to improve the wellbeing of this population.
Resources and organisations
- Asylum Seeker Resource Centre Services
The Asylum Seeker Resource Centre provides services such as food and material aid, support services, health care, legal aid, education and training, empowerment pathways, advocating from lived experience, and employment pathways to refugees and people seeking asylum.
- AMES Australia
AMES Australia supports culturally and linguistically diverse communities by providing end-to-end settlement services including English language and vocational training and employment and accommodation services.
- Working with culturally and linguistically diverse (CALD) adolescents | Child Family Community Australia
This Practitioner Resource highlights the issues commonly experienced by CALD adolescents and provides links to evidence-based reports, resources and practice examples for hands-on application when working with CALD young people.
- Australian Red Cross
The Red Cross provides help and support for refugees, people seeking asylum, people in immigration detention and other migrants in Australia.
- Children of Parents with a Mental Illness (COPMI)
COPMI promotes better outcomes for children of parents with mental illness.
- Embrace Multicultural Mental Health
Embrace provides a national platform for Australian mental health services and multicultural communities to access resources, services and information in culturally accessible formats.
- Foundation House
Foundation House is a specialist refugee trauma agency supporting survivors of torture and other traumatic events.
- In Touch Multicultural Centre Against Family Violence
The In Touch Multicultural Centre Against Family Violence addresses the needs of refugee and migrant women and children with services such as prevention, early intervention, post-crisis intervention, and recovery from family violence. Information and training is provided for professionals and women experiencing family violence.
- Multicultural Centre for Women's Health (MCWH)
The MCWH increases migrant and refugee women’s opportunities for health and wellbeing in Australia through education, advocacy and leadership.
- NSW Refugee Health Service (RHS)
Website created by the NSW Department of Health to provide information, policy, resources and available services related to refugee mental health.
- NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)
STARTTS is a not-for-profit organisation providing culturally informed psychological treatment, support and community intervention to refugees in Australia. STARTTS also provides training to services and advocacy for refugees.
- Refugee Health Program
The Refugee Health Program (formerly the Refugee Health Nurse Program) operates in 17 local government areas of Victoria. The program is delivered by community health services, and employs community health nurses, allied health professionals and assistants, and bicultural workers. The nurses and other health professionals have expertise in working with culturally and linguistically diverse and marginalised communities.
- Services Australia
The Australian Government department responsible for social, health and child support services and payments. For example, payments and services are available for newly arrived refugees, humanitarian entrants and asylum seekers.
- Settlement Services International (SSI)
SSI help support refugees and asylum seekers with settlement services in metro and regional Queensland, NSW and Victoria.
- The Orange Door
The Orange Door is a free service for Victorian adults, children and young people who are experiencing or have experienced family violence and families who need extra support with the care of children. Help and support is provided to migrants, refugees and those who do not have permanent residency.
- Victorian Refuge Health Network
The Victorian Refuge Health Network works to develop responsive health service systems that meet the needs of people from refugee backgrounds, including asylum seekers.
- Victorian Transcultural Mental Health
Victorian Transcultural Mental Health (VTMH) advocates strongly for cultural safety and supports the examination of societal structures, service systems and institutional factors. Promotes equity and social justice in mental health practice, policy, governance and the allocation of public resources.
- Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002, October). Cultural competence in health care: Emerging frameworks and practical approaches (No. 576). Commonwealth Fund. Retrieved from www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf
- Byrow, Y., Pajak, R., Specker, P., & Nickerson, A. (2020). Perceptions of mental health and perceived barriers to mental health help-seeking amongst refugees: A systematic review. Clinical Psychology Review, 75, 101812. doi:10.1016/j.cpr.2019.101812
- Chen, W., Hall, B. J., Ling, L., & Renzaho, A. M. (2017). Pre-migration and post-migration factors associated with mental health in humanitarian migrants in Australia and the moderation effect of post-migration stressors: Findings from the first wave data of the BNLA cohort study. The Lancet: Psychiatry, 4(3), 218–229. doi:10.1016/S2215-0366(17)30032-9
- Deardorff, D. K. (2009). The Sage handbook of intercultural competence. Thousand Oaks, Cal.: Sage Publications.
- Guajardo, M. G. U., Slewa-Younan, S., Kitchener, B. A., Mannan, H., Mohammad, Y., & Jorm, A. F. (2018). Improving the capacity of community-based workers in Australia to provide initial assistance to Iraqi refugees with mental health problems: An uncontrolled evaluation of a mental health literacy course. International Journal of Mental Health Systems, 12(1), 1–13. doi:10.1186/s13033-018-0180-8
- Hamrah, M. S., Hoang, H., Mond, J., Pahlavanzade, B., Charkazi, A., & Auckland, S. (2020). The prevalence and correlates of symptoms of post-traumatic stress disorder (PTSD) among resettled Afghan refugees in a regional area of Australia. Journal of Mental Health, 1–7. doi:10.1080/09638237.2020.1739247
- Markova, V., Sandal, G. M., & Pallesen, S. (2020). Immigration, acculturation, and preferred help-seeking sources for depression: Comparison of five ethnic groups. BMC Health Services Research, 20(1), 1–11. doi:10.1186/s12913-020-05478-x
- Nguyen, P. V., Corona, R., DeCarlo, M. P., Yaros, A., Le, A. T., & Compton, K. (2018). Do Asian American young adults differ in their help seeking compared to older adults? Help seeking patterns and predictors. Journal of Ethnic and Cultural Studies, 5(2), 1–15.
- Sangalang, C. C., & Vang, C. (2016). Intergenerational trauma in refugee families: A systematic review. Journal of Immigrant and Minority Health, 19(3), 745–754. doi.org/10.1007/s10903-016-0499-7
- Shuang, L. (2014). Becoming intercultural: Exposure to foreign cultures and intercultural competence. China Media Research, 10(3), 7–15.
- Silove, D., Ventevogel, P., & Rees, S. (2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry, 16(2), 130–139. doi:10.1002/wps.20438
- Slewa-Younan, S., Blignault, I., Renzaho, A., & Doherty, M. (2018). Community-based mental health and wellbeing support for refugees: An evidence check rapid review brokered by the Sax Institute for the NSW Ministry of Health. Canberra: Sax Institute. Retrieved from www.saxinstitute.org.au/publications/community-based-mental-health-wellbeing-support-refugees
- Slewa-Younan, S., Guajardo, M. G. U., Mohammad, Y., Lim, H., Martinez, G., Saleh, R., & Sapucci, M. (2020). An evaluation of a mental health literacy course for Arabic speaking religious and community leaders in Australia: Effects on posttraumatic stress disorder related knowledge, attitudes and help-seeking. International Journal of Mental Health Systems, 14(1), 1–11. doi.org/doi:10.1186/s13033-020-00401-7
- Slewa-Younan, S., Mond, J. M., Bussion, E., Melkonian, M., Mohammad, Y., Dover, H. et al. (2015). Psychological trauma and help seeking behaviour amongst resettled Iraqi refugees in attending English tuition classes in Australia. International Journal of Mental Health Systems, 9(1), 1–6. doi:10.1007/s12134-015-0441-1
- Slewa-Younan, S., Yaser, A., Guajardo, M. G. U., Mannan, H., Smith, C. A., & Mond, J. M. (2017). The mental health and help-seeking behaviour of resettled Afghan refugees in Australia. International Journal of Mental Health Systems, 11(1), 1–8. doi:10.1186/s13033-017-0157-z
- Taylor, E. M., Yanni, E. A., Guterbock, M., Pezzi, C., Rothney, E., Harton, E. et al. (2014). Physical and mental health status of Iraqi refugees resettled in the United States. Journal of Immigrant and Minority Health, 16(6), 1130–1137. doi:10.1007/s10903-013-9893-6
- UN High Commissioner for Refugees (UNHCR). (2002, September). Refugee resettlement: An international handbook to guide reception and integration. Geneva: UNHCR. Retrieved from www.refworld.org/docid/405189284.html
- Van Bibber, M. (1997). It takes a community: A resource manual for community-based prevention of Fetal Alcohol Syndrome and Fetal Alcohol Effects. Toronto, ON: Aboriginal Nurses Association of Canada.
- van der Boor, C. F., & White, R. (2019). Barriers to accessing and negotiating mental health services in asylum seeking and refugee populations: The application of the candidacy framework. Journal of Immigrant and Minority Health, 22(1), 156–174. doi:10.1007/s10903-019-00929-y
1. For example, WentWest assist in paying for services for individuals in Western Sydney. Additionally, some organisations such as ‘Startts’ and the Transcultural Mental Health Centre in NSW provide psychological services free of charge.
2. Cultural competence is defined as the cognitive, emotive and behavioural skills required to communicate with individuals from other cultures appropriately and effectively (Deardorff, 2009; Shaung, 2014).