‍Introduction and Background

There is a dire need to facilitate aid and assistance for millions of refugees and asylum seekers. It is a complex process that is impacting numerous locations around the world. This situation is made more difficult by diverse attitudes in many countries, including racialized or negative sentiments that can have an ongoing impact on the experience of the resettlement process for refugees. Displacement is the transfer of negative feelings from one person or thing to another. The theory is that a person deals with the tension or anxiety associated with negative feelings, such as fear or anger, by releasing them on a non-threatening target. Refugees, asylum seekers and irregular migrants are of special concern and need protection and support. There were an estimated 272 million international migrants in 2019 (1). Migrants and refugees can be exposed to various stress factors affecting their mental health and well-being before and during their migration journey, settlement, and integration. The prevalence of common mental disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) tends to be higher among migrants exposed to adversity and refugees than among host populations. Many migrants and refugees lack access to mental health services or experience barriers to accessing these. They also face disruptions in the continuity of care.

In studying forced or involuntary migration, sometimes referred to as forced or involuntary displacement — a distinction is often made between conflict-induced and disaster-induced displacement. 

Displacement induced by conflict is typically referred to as caused by humans, whereas natural causes typically underlay displacement caused by disasters. The definitions of these concepts are useful, but the lines between them may be blurred in practice because conflicts may arise due to disputes over natural resources, and human activity may trigger natural disasters such as landslides.

According to IOM, forced migration is “a migratory movement which, although the drivers can be diverse, involves force, compulsion, or coercion.”1
The definition includes a note that clarifies that “While not an international legal concept, this term has been used to describe the movements of refugees, displaced persons (including those displaced by disasters or development projects), and, in some instances, victims of trafficking. At the international level, the use of this term is debated because of the widespread recognition that a continuum of agency exists rather than a voluntary/forced dichotomy and that it might undermine the existing legal international protection regime.” (IOM Glossary on Migration, 2019).

According to the 1951 United Nations Convention relating to the Status of Refugees and its 1967 Protocol, refugees are persons who flee their country due to "well-founded fear" of persecution due to reasons of race, religion, nationality, membership of a particular social group or political opinion, and who are outside of their country of nationality or permanent residence and due to this fear are unable or unwilling to return to it. UNHCR includes “individuals recognized under the 1951 Convention relating to the Status of Refugees, its 1967 Protocol, the 1969 Organization of African Unity (OAU) Convention Governing the Specific Aspects of Refugee Problems in Africa, those recognized by the UNHCR Statute, individuals granted complementary forms of protection, and those enjoying temporary protection. The refugee population also includes people in refugee-like situations." (UNHCR, 2017).

Persons in a refugee-like situation include “groups of persons who are outside their country or territory of origin and who face protection risks similar to those of refugees, but for whom refugee status has, for practical or other reasons, not been ascertained.” (UNHCR, 2013).

According to UNHCR, asylum-seekers are “individuals who have sought international protection and whose claims for refugee status have not yet been determined” (2017, 56).

Internally displaced persons (IDPs) are defined as “persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border.” (Guiding Principles on Internal Displacement, E/CN.4/1998/53/Add.2.).

Mixed movement (also called mixed migration or mixed flow) is “a movement in which a number of people are travelling together, generally in an irregular manner, using the same routes and means of transport, but for different reasons. People travelling as part of mixed movements have varying needs and profiles and may include asylum seekers, refugees, trafficked persons, unaccompanied/separated children, and migrants in an irregular situation.” (IOM Glossary on Migration, 2019).

Disaster-induced migration is the displacement of people as a result of “a serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses or impacts, which exceeds the ability of the affected community or society to cope using its own resources.” (UN Office for Disaster Risk Reduction, 2009).

According to IOM, resettlement is the “transfer of refugees from the country in which they have sought protection to another State that has agreed to admit them — as refugees — with permanent residence status.” (IOM Glossary on Migration, 2019). Resettlement programmes are carried out by both IOM and UNHCR.

Countries faced with forced displacement — induced by humans or nature — collect data on displaced populations. Such data are typically collected through a combination of population censuses, household surveys, border counts, administrative records and beneficiary registers.

At the international level, data on forced migration are collected and/or compiled by various intergovernmental organizations (IGOs), such as the Office of the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM), as well as non-governmental organizations (NGOs), such as the Internal Displacement Monitoring Centre (IDMC).

Forced displacement due to persecution, conflict, violence, and human rights violations or events seriously disturbing public order

According to UNHCR, the number of forcibly displaced people both within countries and across borders as a result of persecution, conflict, generalized violence, human rights violations, or events seriously disturbing public order was more than double the number a decade ago; there were 42.7 million forcibly displaced people as of the end of 2012, and the figure was 89.3 million by the end of 2021. This represents the highest number available on record (UNHCR, 2022).

Refugees (27.1 million) and asylum-seekers (4.6 million) made up slightly more than 35 percent of the 89.3 million people forcibly displaced due to persecution, war, conflict, generalized violence, human rights violations or events seriously disturbing public order. 53.2 million internally displaced people and 4.4 million Venezuelans displaced abroad accounted for the remaining 60 percent and 5 percent, respectively (ibid.). Such figures show it is important to keep in mind that forcibly displaced persons are not only comprised of refugees and asylum seekers who seek protection in other countries but also, and indeed mainly, of individuals who have been displaced within the borders of their own countries. 

The drastic increase in total forced displacement — both within countries and across borders —  as of the end of 2021  compared to the end of 2012 was mainly due to several crises —  some already existed, some were new, and some resurfaced after years. The number of countries affected by conflict has also doubled in the last decade (ibid.).

Refugee Resettlement

In 2021, UNHCR submitted 63,200 refugee applications for resettlement, and according to government statistics, 57,500 people were resettled (UNHCR, 2022). Though this is 67 percent more than the number resettled in 2020, numbers are significantly lower than pre-pandemic numbers in 2019 (107,700) (ibid.). In 2020, refugee resettlement plummeted to its lowest level in almost two decades as a result of travel restrictions related to the COVID-19 pandemic and temporary suspensions of resettlement programmes from mid-March to mid-June 2020 (UNHCR, 2021). Eighty-six percent of the cases submitted by UNHCR in 2021 were for survivors of torture and/ or violence, people with legal and physical protection needs, and particularly vulnerable women and girls. Fifty-two percent of the total resettlement submissions were for children (UNHCR, 2022.).

In 2020, the COVID-19 pandemic posed considerable challenges to return migration because of lockdowns, travel restrictions, limited consular services, and other containment measures, and had a decelerating effect on return activities. In 2021, many countries lifted travel restrictions and different types of migration, including return migration, resumed but not to pre-pandemic levels. The number of beneficiaries of IOM’s Assisted Voluntary Return and Reintegration (AVRR) in 2021 increased by 17 percent (from 37,043 in 2020 to 43,428 in 2021) (IOM, 2022). The number of voluntary humanitarian return beneficiaries increased by 57 percent, from 4,038 in 2020 to 6,367 in 2021. The top 5 host/transit countries for AVRR in 2021 were Niger (10,573), Germany (6,785), Libya (4,332), Greece (2,736), and Morocco (2,372) (ibid.).

Forced displacement within countries due to conflict and disasters

By the end of 2022, 71.1 million people were living in internal displacement as a result of conflict, violence, and disasters (the stock of internal displacements) (IDMC, 2023). Of this total, 62.5 million people in 65 countries and territories were internally displaced by conflict and violence, and at least 8.7 million people in 88 countries and territories were internally displaced by disasters (ibid.). It is important to note that displacement by conflict and displacement by disaster cannot always be reliably distinguished because many people can be displaced for one reason and then get displaced for a second or even third time by a different reason.

In 2022, there were 60.9 million new internal displacements, the highest figure recorded and an increase of 60 percent from 2021 (ibid.). Disasters triggered more than 53 percent (32.6 million) of the new displacements recorded; the rest, about 28.3 million, were prompted by conflict and violence (ibid.).

Most of the new displacements triggered by conflict and violence (about 60%) were in Ukraine (ibid.). The five countries with the highest number of new internal displacements in 2022 due to conflict and violence  were Ukraine (16.9 million), the Democratic Republic of Congo (4 million), Ethiopia (2 million), Myanmar (1 million) and Somalia (621,000) (ibid.)

98 percent of the 32.6 million new disaster displacements in 2022 were the result of weather-related hazards such as storms, floods and droughts (ibid.). Floods surpassed storms for the first time since 2016, triggering 6 out of 10 internal displacements due to disasters in 2022, with monsoon flooding in Pakistan causing 25 percent of internal displacements due to disasters globally that year (ibid.). Somalia experienced its worst drought in 40 years and recorded 1.1 million movements. In Tonga, 2 percent of the population had to relocate following a very rare volcanic eruption (ibid.). The five countries with the highest number of new internal displacements in 2022 due to disasters were Pakistan (8.2 million), the Philippines (5.4 million), China (3.6 million), India (2.5 million) and Nigeria (2.4 million) (ibid.)

What Have Refugee Families Experienced?

Many refugees, especially children, have experienced trauma related to war or persecution that may affect their mental and physical health long after the events have occurred. These traumatic events may occur while the refugees are in their country of origin, during displacement from their country of origin, or in the resettlement process here in the US.

While in their country of origin, refugee children may have experienced traumatic events or hardships, including:

1. Violence (as witnesses, victims, and/or perpetrators)
2. War
3. Lack of food, water, and shelter
4. Physical injuries, infections, and diseases
5. Torture
6. Forced labour
7. Sexual assault
8. Lack of medical care
9. Loss of loved ones
10. Disruption in or lack of access to schooling

During displacement, refugee children often face many of the same types of traumatic events or hardships that they faced in their country of origin, as well as new experiences such as:

1. Living in refugee camps
2. Separation from family
3. Loss of community
4. Uncertainty about the future
5. Harassment by local authorities
6. Travelling long distances on foot
7. Detention

Refugee Core Stressors

Refugee children may feel relieved when they are resettled in the US. However, the difficulties they face do not end upon their arrival. Once resettled in the US, refugees may face stressors in four major categories: Traumatic Stress, Acculturation Stress, Resettlement Stress, and Isolation.

Traumatic Stress: Occurs when a child experiences an intense event that threatens or causes harm to his or her emotional and physical well-being. Refugees can experience traumatic stress related to:

1. War and persecution
2. Displacement from their home
3. Flight and migration
4. Poverty
5. Family/community violence

Resettlement Stress: Refugee children and families experience stress as they try to make a new life for themselves. Examples include:

1. Financial stressors
2. Difficulties finding adequate housing.
3. Difficulties finding employment.
4. Loss of community support
5. Lack of access to resources
6. Transportation difficulties

Acculturation Stress: Stress that refugee children and families experience as they try to navigate between their new culture and their culture of origin. Examples include:

1. Conflicts between children and parents over new and old cultural views
2. Conflicts with peers related to cultural misunderstandings.
3. The necessity to translate for family members who are not fluent in English.
4. Problems trying to fit in at school.
5. They struggle to form an integrated identity, including elements of their new culture and culture of origin.

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Isolation Stress: Stressors that refugee children and families experience as minorities in a new country. Examples include:

1. Feelings of loneliness and loss of social support network
2. Discrimination
3. Experiences of harassment from peers, adults, or law enforcement
4.            Experiences with others who do not trust the refugee child and family.
5. Feelings of not fitting in with others
6. Loss of social status

Some of the most common mental health conditions refugees and IDPs may face include:

1. Post-Traumatic Stress Disorder. PTSD is one of the most common disorders experienced by refugees
2. Anxiety and Depression
3. Obsessive Compulsive Disorder
4. Substance Use Disorder
5. Grief
6. Alienation
7. Chronic Stress

Addressing Barriers to Receiving Mental Health Care

Addressing barriers to receiving mental health care should include:

1. Provision of clear information on mental health care entitlements and how to receive services (e.g., through reception centres, community outreach, schools, and religious or cultural settings).
2. Outreach to at-risk groups (e.g., unaccompanied minors, persons with disabilities, and persons who identify as LGBTIQ+).
3. Facilitation of affordable and non-discriminatory access to care regardless of legal status, ensuring financial coverage of mental health services and care provided.
4. Facilitation of communication (e.g., through engaging interpreters and cultural mediators);
5. Providing person-centred care that is respectful of cultural differences and
6. Facilitating the engagement of multiple sectors and systems (e.g., law enforcement, protection, social services and education) to integrate mental health considerations and support and ensure referral and access to mental health services.

Integrating Mental Health in Primary Health Care

Making mental health care available through general health care can help identify migrants and refugees with mental health conditions and can make care more accessible and cost-effective (e.g. see WHO mhGAP intervention guides mhGAP-HIG and mhGAP-IG). The delivery of interventions may require adaptation to migrant and refugee populations to consider language and cultural considerations. Interventions provided should be consistent with the national guidelines and policies on the mental health of the host country.

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Ensuring continuity of care: When providing mental health care, an important consideration is related to the length of stay of the migrant or refugee in the host country. The continuity and quality of mental health care of migrants and refugees on the move can be improved by creating international protocols for assuring continuity of care, improving communication among different social and mental health service providers and providing key written information tailored to the needs that migrants and refugees can take with them and share with different providers.

Addressing social determinants and promoting social integration and inclusion: Migration management policies and stresses that have proved to harm the mental well-being of migrants (e.g. separation of families and children) should be avoided. The social integration of migrants and refugees can be facilitated by equal access to employment opportunities and decent work, vocational training, financial support, social protection services, legal and law enforcement agencies, mental health care, and psychosocial support. The recognition of skills and qualifications acquired pre-migration can also help their integration into the employment sector. Activities and events that promote the social inclusion of migrants and refugees include community forums or peer-mentorship programs organized by members of the same refugee or migrant group who are already well-integrated into the local community. Special attention is required to support asylum seekers.

Conclusion

Displacement and refugees can be traumatic experiences that can have long-lasting effects on mental health. The mental health needs of migrants and refugees should be addressed by organizing inclusive and accessible promotion and prevention programs, strengthening mental health as part of general health services, and ensuring timely diagnosis, treatment, and rehabilitation. Access to employment, basic services, and social support can all help counter the trauma and stress experienced by migrants, as can family reunification and learning the language of the host country. Access to education is important for children, as are feelings of safety.

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