“While exposure to persecution, war and displacement is associated with high rates of psychological disorders, such as PTSD and depression, remarkably the majority of refugees, despite having gone through very difficult experiences, don’t go on to develop a psychological disorder,” says Prof. Nickerson, Director of the Refugee Trauma and Recovery Program at UNSW’s School of Psychology.

Despite this, previous research has focused on trying to understand factors that predict psychopathology or psychological distress, rather than factors that predict wellbeing or resilience.

“More recently, however, there has been a movement towards a strengths-based approach in mental health, particularly in the refugee space, and we wanted to look at what research was out there,” says Prof. Nickerson.

The paper, out this week in Nature Mental Health, is the first to focus on factors contributing to better mental health in refugees.

To conduct the review, researchers searched four databases for relevant studies. They screened thousands of studies, 174 of which met the study criteria. 81% of the included papers were undertaken in refugees living in high-income countries (HICs) and 19% in lower-and-middle income countries (LMICs).

“The lack of research looking at predictors of good mental health highlighted the deficit focus of so much research into refugee mental health,” says Prof. Nickerson. She also noted that though 75% of the world’s refugees live in LMICs, most of the research took place in HICs.

“It underscores a real gap in refugee research,” says Prof. Nickerson.

What were the researchers looking for?

“Our systematic review covered studies investigating the mental health of refugees or asylum seekers, and we looked at factors that we called either protective or promotive of mental health. Protective factors are associated with reduced poor mental health outcomes, and promotive factors are associated with increased good mental health outcomes,” says Prof. Nickerson.

The researchers wanted to understand how to enhance the strengths of an individual or community to alleviate or even prevent distress.

“We were interested in everything from demographic and social factors to environmental and psychological factors,” Prof. Nickerson says.

“We wanted to be able to speak to a range of different implications and recommendations in the field of refugee mental health — from what psychologists or social workers might do with a client in a room, and also more broadly what kinds of conditions policy-makers should be creating in countries that host refuges to help people thrive and move forward after traumatic experiences.”

Study findings

The refugee experience is characterised by protracted exposure to danger and uncertainty. The review highlighted factors related to stability and predictability as having some of the strongest associations with good mental health in refugees.

“It makes a lot of sense that, if people who’ve been through very difficult experiences are going to overcome those and thrive, we need to create conditions where their basic needs for safety are met,” says Prof. Nickerson.

The study found a secure visa status, employment, income, good housing conditions and control over environmental circumstances were associated with good mental health outcomes in both HICs and/or LMICs.

Individuals vary in their capacity to cope with difficult circumstances, with resilience reflecting the extent to which an individual can recover or maintain good mental health in the context of adversity.

The review found that psychological factors such as cognitive strategies, self-efficacy and a sense of control were protective and promotive of wellbeing.

Building individual skills and capabilities to cope and thrive represents an important goal to promote good mental health in refugees.

“When we’re trying to understand how best to support people, we often look at the things that are going wrong, and that means our interventions are focused on those things. This study speaks to the importance of harnessing interventions that are associated with resilience, self-efficacy and psychological flexibility,” says Prof. Nickerson.

But experiences such as war, persecution and displacement occur at a societal level, and so approaches to promoting good mental health in their aftermath must extend beyond the individual.

“There is a consistent link between social engagement and support and good mental health outcomes among refugees, particularly for those in high-income countries,” Prof. Nickerson says.

“The ability to communicate in the host language, social support, and social engagement with both the refugees’ own community and the host community, along with religious coping strategies, were all linked with increased wellbeing.”

The way ahead

This review puts forward a clear research agenda, with at least three important pathways to progressing our understanding of refugee mental-health wellbeing, Prof. Nickerson says.

“One is to purposefully study factors associated with wellbeing and positive mental health outcomes, rather than just looking at factors that contribute to psychological distress. Refugee communities are remarkably resilient, and we have a lot to learn from people who have overcome adversity to thrive in their new country.

“Two is to fill the research gap in low-and-middle-income countries. The majority of refugees live in transit settings outside high-income countries. If we are going to provide effective supports, we need to understand factors that promote wellbeing in these contexts

“And finally it’s important to take a cross-disciplinary research approach. By bringing together researchers, psychologists, social workers and policy-makers, we can gain a more nuanced understanding of protective and promotive factors. Having refugee voices at the centre of this process is critical to help us understand priority areas for research and using these findings effectively. This will pave the way for developing policies and interventions that support refugee communities to thrive.”

This research was supported by funding from the Social Policy Group.