Refugees, resettlement experiences and mental health: a systematic review of case studies

Bulik, Karin Juliane Duvoisin; Colucci, Erminia

doi:10.1590/0047-2085000000235

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LITERATURE REVIEW • J. bras. psiquiatr. 68 (2) • Apr-Jun 2019 • https://doi.org/10.1590/0047-2085000000235 copy

Refugees, resettlement experiences and mental health: a systematic review of case studies

Refugiados, experiências de reassentamento e saúde mental: uma revisão sistemática de estudos de caso

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

In 2017 the number of refugees around the world reached 25.4 million. These people make up one of the most vulnerable populations globally. This study aims to understand the strategies refugees used to cope with the impact on their mental health by the difficult pre- and post-resettlement circumstances they encountered.

Methods

A systematic review of articles reporting case studies concerning adult refugees’ experiences in the hosting country. The electronic databases searched were: PubMed, The Cochrane Library, PsycINFO, Embase, Scopus and Web of Science. Eligible manuscripts were examined through a narrative synthesis.

Results

Twenty-two articles fitted the inclusion criteria and four main themes were highlighted: reasons for fleeing; the impact of negative experiences on mental health; supportive experiences and coping strategies; and experiences of mental health treatment.

Conclusions

Refugees present a significant impact on mental health due to pre- and post-migration experiences. The approach offered to this group and reported as the most effective to deal with such an impact was the multidimensional approach that, besides caring for the psychic aspects, contemplated the cultural context of each one, assisted in housing, employment, financial aid, support with learning the new language and social activities.

Refugees; resettlement experiences; mental health; case studies; trauma

Study (Authors, year)	Score CASP (/10)	Date of collecting data	Objective of study	Subject info	Flew from – to (year)
1. Deljo²⁵	9	Late 1990s	Case study of a refugee who had to deal with the legal justice system in Australia, to present how police conduct can adversely affect the mental health of a traumatised refugee.	Ali, around 30y, male, from the Horn of Africa, a devout Muslim, with his wife and 3 children, tortured in his country and in the first asylum country, was now unable to work due to mental health problems.	Horn of Africa – a neighbouring country (when he was 18y and where he spent 9 years) – Australia (in the early 1990s)
2. Becker et al.⁴	9	Before 2000	Ethnographic study to explore how Cambodian refugees with chronic illnesses respond to the welfare reform, cutting government support, usually the only income they have to live in the USA.	Mr. K, 58y, Khmer, male, married, with children (only one living with them), was a teacher in Cambodia and now his only income is from Supplemental Social Assistance (SSI).	Cambodia – Refugee camp – USA (in the early 1980s)
3. Rechtman²⁶	9	Before September, 2000	Clinical case study to highlight the importance of focusing on the singular experience of the individual presenting mental health symptoms, rather than taking only the cultural explanation for interpreting it.	Miss V, Khmer female, 22y, living with her father, stepmother and three half-siblings. She was helping at home and working for free with her father.	Cambodia – Paris, France (when 22 years old/before year 2000)
4. Fitzpatrick⁶	9	1998	Case study with Bosnian refugees to assess the use of art therapy as a mental health intervention with refugees.	Nina, 38y, Bosnian female, married with two children. She was a bank manager in Bosnia.	Bosnia – Perth, Western Australia (15 months before 1998)
5. Summerfield²⁷	7.5	May, 1997 to September, 2000	Clinical case study that illustrates the lack of validity of psychiatric diagnoses to understand the effects of surviving war and ethnic expulsion.	Samir, male, 45y, married, with an 8y daughter, a truck driver for family business in home country, assaulted but not seriously injured.	Zvornik, Bosnia – Refugee camp – London, UK (1996)
6. Phan et al.⁵	7	2004	Review historical influences on the identity development of Vietnamese refugee women and how it affects their resilience and coping mechanisms. A clinical case is presented to illustrate it.	Thuy, 32y, Vietnamese female, single, with parents and 7 siblings. Social worker.	Saigon, Vietnam – USA (26th of April, 1975)
7. Hrycak and Jakubec²⁸	7	Before June, 2006 and after the 1990s	Case analysis of a refugee woman to highlight the importance of listening to every personal history to improve access to and experience with health care.	Elena, female, middle-aged, married, with two young adult children, suffered torture and rape.	Latin America country – neighbouring country – Canada (1990s)
8. Grønseth²⁹	9	Between 1996 and 2000	Investigate how health and sickness are related to cultural values and social life of Tamil refugees in a fishing village in Norway.	Raji, Tamil female, married with two children, working as a cutter in the fishing industry.	Sri-Lanka – Arctic Harbour, Northern Norway (before 1996)
9. Schulz et al.¹⁴	9	2000 (for 9 months)	Case study demonstrating the course of cognitive-behavioural therapy for PTSD with a Bosnian refugee woman who had suffered rape.	Marina, 64y, Bosnian Muslim refugee woman, living alone, raped and physically assaulted in her country, never attended school but acquired some literacy in Serbo-Croatian.	Former Yugoslavia (current Bosnia) – Germany (1999, following a refugee rescue mission) – St. Louis, USA (1999)
10. Rosenbaum and Varvin¹⁵	9	Before 2007, started when the patient was in his mid-thirties and lasted for 6 years	Case study and psychoanalytic research to present how traumatic experiences affect different dimensions of mind and its ability to regulate emotions.	Hassan, male, from Middle-East, in his mid-thirties at the beginning of treatment, alone, living in a hostel. In his country, he was from a minority group and was the designated leader of his clan, tortured and imprisoned.	A Middle-East country – a desert refugee camp in a neighbouring country (when he was in his twenties and where he spent 4 years) – a Nordic country (in his thirties)
11. Hinton et al.³⁰	8	From 1999 to 2001	Compare the rate and severity of orthostatic panic attacks among Vietnamese refugees a month before and a month after September 11, 2001. A case study is reported to illustrate the role of this type of response to trauma.	Trung, 61y (in 1999), male Vietnamese married, 4 children (but only two sons with him in the USA), a lieutenant chief of police before being arrested, probably not working in the USA, severely tortured.	Vietnam – the USA (1993)
12. Hinton et al.²⁴	8	From 1999 to 2001	Present orthostatic panic attack as a cultural expression of traumatic experiences among Vietnamese refugees attending a psychiatric clinic. Authors present case examples to demonstrate its phenomenology.	Thach, 57y (in 1999), female, widowed, four children, living with her daughter, suffered from war, famine and a violent husband.	Saigon, Vietnam – Malaysia (1983) Malaysia – New York, USA (1984)
13. Charlés³¹	8.5	Before 2009, after 1 year patient was living in the USA.	Case study of home-based therapy with a female refugee to illustrate how a therapist can work in the context of the client’s home.	Veronique, 28y, Liberian woman, with 2 children and her sister (her husband was still in the camp), in disability benefits because she was shot in both legs, but willing to work.	Liberia – “Peace (refugee) Camp”, Ivory Coast (when she was 12y) – eastern city in the USA (when she was 27y)
14. Franco-Paredes³²	8	Before May, 2009 – 16 months after patient had arrived in the USA	Clinical case to present an unusual expression of PTSD in a Sudanese refugee.	Mr. A, Sudanese male, alone, last 20 years before arriving in the USA spent in refugee camps, unable to work due to stabbing pain.	Southern Sudan – Refugee camps of Southern Sudan, Kenya, Egypt and Ethiopia (where he lived for 20 years) – USA (16 months prior medical treatment)
15. Langellier³³	9.5	Summer of 2006	Narrative analysis of a young refugee living in Lewiston, Maine, to examine how a Somali woman deals with her identity.	Caaliya, 22y, Somali Muslim woman, working in the service sector and attending college in Lewiston.	Somalia – Kenya (1996, when she was 12y) – West Coast of the USA – Lewiston, Maine, USA (2004, when she was 20y)
16. Vongkhamphra et al.³⁴	8	March, 2008	Report a case study of the resettlement process of a Somali Bantu refugee in the USA to highlight some of the refugees’ needs and how to meet them.	Ms. X, born in the late 70s, Somali Bantu woman, divorced twice, with 5 children (4, 6, 10, 12 and 14y), not working due to kidney failure.	Southern Somalia – Dadaab, a refugee camp in Kenya (when she was a young teenager, where she spent 1 year and moved to another camp in Kenya) – Kakuma refugee camp – Nashville, Tennessee, USA (2006, after living 14 years in refugee camps)
17. Pedersen³⁵	7	During 15 months between 2004-2005	Fieldwork among Iraqi observant Muslim refugee women to explore how social class relations, ethnicity and gender affect the integration of well-educated women in Danish society. A case study is presented as an example of what these women experience.	Umm Zainap, 49y, Iraqi observant Shiite Muslim woman, married, with 3 children, with a technical university degree, teaches Arabic to children at the mosque and has a temporary job in an Arab school.	Baghdad, Iraq – Copenhagen, Denmark (1992, when she was 37y)
18. Quackenbush and Krasner³⁶	10	Before 2012	Present a case report to examine elements of psychotherapy carried in the ‘Second Life’ virtual environment.	Ranndy, male, 34y, alone, engineering degree.	Libya – ‘a large city in a more developed Arab country in the Middle East’ (before 2012)
19. Green³⁷	9	2010	Present a clinical case study of a Congolese refugee woman who suffered violent xenophobia in South Africa and to explore the relationship with the therapist.	Gabrielle, 35y, Congolese woman, married, working at home, making cushions, suffered many violent attacks including rape.	Democratic Republic of Congo (DRC) – Kenya (1998) – Cape Town, South Africa (2001)
20. Smith et al.³⁸	9	Before October, 2011 and after 2008	Case study demonstrating the value of engagement in meaningful occupation (weaving) as an important component of resettlement.	Paw Law Eh, female, in her 40s (born in 1965), married, with four children, a school-teacher in her home country and in refugee camps and weaving teacher in the USA.	Karen State of Burma – Thailand (1977) Burma - Umpiem Mai refugee Camp in Thai-Burma border (where she lived for 24 years) – United States (2008)
21. Jensen³⁹	9	Before December, 2012 and after 1993	Case report to evidence the application of exposure therapy treatment in a tortured refugee in need of an interpreter.	Zaid*, 60y, male, married, with children, tortured.	Iraq – Denmark (1993)
22. Medeiros et al.⁴⁰	7.5	From December, 2010 to September, 2013	Case report to present successful multidisciplinary treatment with a traumatised refugee from the Democratic Republic of Congo.	Djo*, 23y, male, alone, tortured.	Democratic Republic of Congo – Brazil (2010)

Subject	Symptoms of mental health problems (MHP)	Triggers of MHP before immigration	Triggers of MHP in hosting country
MEN
Ali²⁵	PTSD and Major Depressive Disorder symptoms: anxiety, sweating, heart palpitations, insomnia, nightmares, socially-withdrawn, paranoid thoughts.	Persecution, detention and torture.	His home was raided by the police with all his family witnessing it; he was aggressively taken to interrogation; policemen were disrespectful to him and did not give him the right to have a lawyer.
Mr. K⁴	Withdrawn, isolation.	Health problem developed from forced labour in harsh conditions.	Living in an area without people from his country, unable to work (due to health problems) and language barriers.
Samir²⁷	PTSD and Major Depressive Disorder symptoms: sleeping disturbance, chain smoking, tension, sadness, withdrawn, dysfunctional and speechless.	Ethnic cleansing, assault, loss of belongings, especially his house, and freedom of the perpetrators, who were unpunished.	The news of the death of his aunt in Bosnia and the crisis in Kosovo.
Hassan¹⁵	PTSD symptoms: anxiety, fear, difficulties in trusting people, withdrawn, nightmares and paranoid thoughts.	Loss of family and friends. Witnessing death. Persecution, detention and torture. Bodily injury (due to a shot in his arm).	Isolation from family and ashamed for not being able to become the leader of his clan, as expected.
Trung³⁰	PTSD symptoms: orthostatic panic attack, dizziness, fear, flashbacks, tachycardia, tinnitus, tension, tightness in the chest and difficulty breathing.	Loss of family and friends. Witnessing death. Persecution, detention and torture for a long period. Starvation and maltreatment.	Being mugged and beaten on the street once. The news of the attack on the World Trade Centre (both worsened already present symptoms).
Mr. A³²	Unusual PTSD symptoms: abdominal and lower back stabbing pain, nightmares.	Witnessing death and war.	-
Ranndy³⁶	Major Depressive Disorder symptoms: socially withdrawn, loneliness, ashamed due to unemployment, a phobia about driving, sexually risky behaviour.	Insecurity due to turmoil in his country. Educated to hide emotion.	The loss of his job. Isolation. General prejudice against his ethnic origin.
Zaid³⁹	PTSD and Major Depressive Disorder symptoms: nightmares, anxiety, distress with torture reminders, sleeping disturbance, anger outbursts, startle responses, difficulty in concentrating.	Persecution, detention and torture.	Seeing people from his ethnic origin and other torture reminders.
Djo⁴⁰	PTSD and Major Depressive Disorder symptoms.	Loss of friends and family. Witnessing death. Raped and physically assaulted.	Language and social barriers, lack of friends, family, employment and housing.
WOMEN
Miss V²⁶	Headaches, anxiety, nightmares, withdrawn behaviour, sleeping disturbance and sadness.	Her father’s abandonment of her and her mother. Fear of being separated from her mother by the Khmer Rouge regime.	Conflicting emotions when she moved to Paris to live with her father, step-mother and siblings and left her mother in Cambodia.
Nina⁶	Anxiety, unable to deal with emotions and talk about the past.	Loss of friends, family and personal belongings.	Language barriers and difficulties in making new friends.
Thuy⁵	Anxiety, sleeping disturbance and guilt feelings.	-	Conflicting emotions when she decided to marry and have an American wedding instead of a Vietnamese one, which upset her parents.
Elena²⁸	Major Depressive Disorder and somatic symptoms: unexplained pain and anxiety.	Loss of family, had to leave her children with her mother. Persecution, detention, torture and rape.	Difficulties with health professionals and health system. Traumatic experience at the hospital after a surgery. Language and cultural barriers.
Raji²⁹	Dizziness, pain in her jaws and shoulders, vomiting and without appetite.	-	The loss of her father and having a violent husband. General prejudice against her ethnic origins.
Marina¹⁴	PTSD and Major Depressive Disorder symptoms: nightmares, blaming herself for being raped, anxiety, angry, not trusting people and fear of men in general.	Loss of family and friends. Witnessing death and war. Impossibility of providing a funeral for her husband. Raped and assaulted by a family friend who was unpunished.	The news that her assailant was living in her house in her homeland. Being alone with men or having to walk alone on the streets.
Thach²⁴	PTSD symptoms: orthostatic panic attack, dizziness, tinnitus, nightmares, sleeping disturbance and paralysis, difficulty breathing, hand cramp, flashbacks, tachycardia, tension.	Loss of family and friends. Witnessing death and war. Starvation. Violent family members (stepmother, mother-in-law and husband, who was also unfaithful).	Arguments with her husband and his affair with her half-sister. Being robbed in her flat. Imprisonment of her son. The news of the attack to the World Trade Centre. All events worsened already present symptoms.
Veronique³¹	Nightmares, sadness, missing dead mother and sister and frustration at her mobility problems.	Loss of family and friends. Witnessing death and war. Bodily injury (due to being shot in both her legs).	Staying at home all the time and being inactive. A recent loss of a cousin.
Gabrielle³⁷	Emotional unbalance, fearful, withdrawn, isolation, guilt feelings, rage for men.	History of violent attacks.	Gang-raped twice and physically attacked five times due to xenophobia. General prejudice against her ethnic origin. The death of her mother after telling her about the rape episodes. Retraumatized by an invasive gynaecological examination.

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[1] Address for correspondence: Karin Juliane Duvoisin Bulik. Centro Universitário Facex, Departamento de Psicologia Rua Orlando Silva, 2896, Capim Macio 59080-020 – Natal, RN, Brazil Telephone: +55 (84) 99974-9394 E-mail: karin_bulik@yahoo.com.br