Young refugees talk about well-being: a qualitative analysis of refugee youth mental health from three states.
The only fact of our immediate experience is what has been called 'the specious' present, a sort of saddle-back of time with a certain length of its own, on which we sit perched, and from which we look in two directions into time. (William James, 1892) Within given limits, 'now' is always transcended. (Agnes Heller, 1982)
As James suggested at a psychological level and Heller at an historical level, it can be difficult to neatly separate past, present and future. Although we cannot avoid such separations, we also know at a deeper level that the past inextricably reaches into our present and future. By definition, refugees hold with them a past involving persecution or fear of persecution. Yet refugees also embody hope for a brighter future. Refugees perhaps more than any other group confront the challenges of the present and future in the context of a tumultuous past. For young people from a refugee background, the desire for better futures is more poignant as they seek to establish secure futures not only in a new social, cultural and geographical space but also in a new adult space as well.
Refugees arriving in Australia face not only the stresses of migration related to sudden changes in language and culture, but they must also contend with a past that is often filled with extremely traumatic experiences. It is not surprising then, that the health literature concerning refugees tends to focus on the stress of adapting to new environments as well as the additional stress of dealing with past events. Yet in the West, mental health status is often understood in terms of acculturation stress and post-traumatic stress disorder. Whilst both of these areas are clearly extremely important, they can focus attention on refugees in a manner which limits our understanding of them as whole people with lives that stretch beyond the label of refugee. Our gaze can be restricted to transitions in lives rather than whole lives, to victims rather than survivors, to illness rather than health. Moreover, biomedical dominance tends to direct our attention toward the clinical level of treatment rather than a broader population health perspective.
Langer (1990:69) has commented that to understand the experience of refugees we must have a 'clear sense of refugee trauma as having its origins in the intersection of history, social structure and biography--an intersection that does not cease when refugees leave their homeland.' When we talk of 'refugee youth' we are creating a construct, which at times can mask the diverse ways in which a young person from a refugee background experiences the world. A young refugee might experience the world primarily as a young black person, or a young woman--issues of gender, race, discrimination, inequality, poverty could provide some of the primary prisms through which the world is experienced. Trauma emerges as the past mixes with both the painful experiences of the present and anxieties about the future. The outbreak of war again in the country of origin will often trigger experiences that link to the past--a complex nexus of individual emotion and broader social and political forces.
Wyn and White (1997:25) reminds us that the experience of young people is best understood as a 'relational concept', one that enables us to 'take into account the diverse ways in which young people are constructed through social institutions, and the ways in which they negotiate their transitions'. It is essential then, that we do not make assumptions about who refugees are and what problems they face. The only way we can achieve this is by listening to refugees themselves, and attempt to understand their issues within their frame of reference. This paper presents the voices of young people who have recently settled in Australia as refugees. We argue that rather than being fearful of the subjectivities of refugees and the scientific 'bias' this may bring we need to engage directly in the experiential world (2). We do this in order to describe mental health issues that exist not only within social contexts, but also as a means to challenging prevailing assumptions embedded within related biomedical research.
Research in the area of immigrant youth mental health suggests a complex relationship between migration and health. Some studies suggest higher rates of psychiatric morbidity, some lower and some no difference when compared to the general population (Bevan, 2000). In part, this reflects the diversity of different population groups as well as the use of different measurement tools. Some authors have suggested that part of the problem with many studies of psychiatric morbidity is that they focus on only a narrow spectrum of issues, and that the range of issues spans from risk factors common to all adolescents through to very specific factors relevant to specific groups (Klimidis et al. 1994). This focus emphasizes individual pathology over broader social questions.
Yet, as Moore (1997) has suggested in her application of public health principles to youth mental health, optimal mental well-being is produced through a balance between the young person's personal characteristics and the environmental pressures she or he encounters. This can be a major challenge for refugee young people who must seek out a community to which they can belong. They may feel guilt or anxiety for 'betraying' their culture of origin, yet suffer isolation from the broader community if they do not embrace the dominant culture.
Much of the literature on acculturation stress implies a conservative understanding of change, in which the challenge for migrant populations is related to adaption to new environments. However, as O'Neil (1986:250) argues, much of the distress impacting on migrant and other 'acculturating' communities has 'less to do with change per se and more to do with the political and economic structures which constrain individual and community attempts to construct meaningful and rewarding social environments'. This has important implications for how mental health status is conceptualised among migrant and refugee populations. Much of the research literature concerns itself with finding correlations between level of acculturation and mental health status, with some literature suggesting low levels of acculturation produce greater risk of psychological illness. Yet, elsewhere higher levels of acculturation are thought to produce higher levels of psychological illness (Klimidis, 1995:93). Rogler et al. (1991) suggests a bicultural position is best. The overall evidence seems unclear with one review of the literature showing 12 studies supported a positive relationship, 13 negative, 3 curvilinear, 2 either, depending on measurement variables (Klimidis, 1995:94).
Although it is clearly important that acculturation research provides a focus on the capacity of refugees to adapt to a new environment; from a broader population health perspective, we also need to understand the importance of adapting environments to suit the needs of refugees. Within this approach we need to acknowledge the broader social determinants of health (including mental health) (Promotion, Prevention and Early Intervention for Mental Health, 2000). Without a commitment to providing supportive environments for refugees, there is the real danger of placing both blame and burden on already compromised individuals.
Muecke (1992:520) has argued biomedicine can objectify refugees as medical phenomenon particularly through the category Post Traumatic Stress Disorder (PTSD) which highlights only one aspect of the suffering that refugees experience, and diverts attention away from the 'stigma, isolation and rejection of being irretrievably out of phase with the host society and its values, and with one's parents' generation and with the generation of one's children'. Similarly, Sharpe's (1998) discussion of Iraqi refugee men in Australia argues the need to understand refugee mental health circumstances beyond the 'panacea' of PTSD. Allotey's (1998) analysis of Latin American women refugees in Australia also suggests the need to describe the entire 'baggage' carried by refugee women.
These aforementioned critiques of biomedical dominance all try to locate refugees within a broader social context (see also Farias, 1991). They do not suggest that there are no substantial issues of pathology surrounding refugees, rather they show how these medical categories do not capture the full array of challenges to refugees. As Sharpe (1998) argues, early assessment of issues like PTSD are valuable if used in conjunction with models of practice and policy which empower refugees 'rather than interventions driven by pathological considerations'.
Guus van der Veer (1999:9) has suggested:
.... there are signs that may indicate a change in paradigm, at least in countries outside Western Europe and North America. In Third World countries that suffer the after effects of armed conflict, a new generation of mental health workers has become active, and they do not seem too impressed by Western views on trauma counselling. These people say that rebuilding their shattered communities and mobilizing its resources are much more important and much more effective than individual treatment, although individual treatment may be useful in some cases.
Furthermore Guus van der Veer argues from his experience of working with trauma survivors in the Netherlands that 'traumatized refugees are often people who do not have a social network. The primary objective of professional help is therefore, by means of therapeutic contact, to help refugees to build up a social network...." (1999:51)
The data used in this paper is derived from a larger study of the social and emotional well-being of young people from culturally and linguistically diverse backgrounds (Selvamanickam et al, 2001) which involved in-depth interviews with 123 young people from Queensland, South Australia and Western Australia and included 10 different ethnic communities. A purposive sampling strategy was adopted in which participants aged 16-24 who identified themselves as having experienced depression, anxiety or stress were recruited by bi-lingual interviewers in each of the participating ethnic communities. Using both formal and informal networks interviewers were able to recruit participants for the study.
Of the total 123 interviews, 70 had been accepted to Australia as refugees. Those interviewed came from Somalia (17), Sudan (11), Former Yugoslavia (26), Cambodia (10), El Salvadore and Columbia (6). A further 6 Chinese young people were identified in the interviews as having met the definition for refugee status, although they had migrated under non-refugee programs.
These 76 interviews were extracted from the total data set and re-coded to ensure themes specific to refugee issues were appropriately acknowledged and analysed. The data was then analysed using standard qualitative thematic interpretation utilising NUDIST software to organise and assist in the process.
Results and discussion
Most of the young people interviewed had left their home countries with their immediate families as a result of war and or other major political disturbances. The circumstances under which people were forced to leave their homes were often traumatic in the extreme. Some had personally experienced torture, rape and imprisonment. Many others lived in fear of such possibilities for several years, having lost friends and family. Some did not know the fate of loved ones, sometimes being rewarded with the sudden return of a missing family member, whilst others were to have to contend with the confirmation of their worst fears. Although each story is different the common theme is one of trauma and chaos. A young person (19) from the former Yugoslavia vividly described her own chaotic experience:
The war was raging on, grenades were flying everywhere and the snipers were on every corner. Eventually I got over being scared of the explosions, those days it was just a normal part of life. If it hits you there was no way out, you just die. But the scariest part was when it was quiet, because when it is quiet that's when something big is really going on, which meant the enemy is occupying people's homes and killing them in cold blood. So one day without a shell being fired the army barged into our home and took mother, father and grandfather away ... I was left with my grandmother and we were both screaming and crying. With the guns that they pointed at us, they said they would blow our brains out if we don't shut up. So we did ... For four months I didn't know anything about my parents or about my grandfather and meanwhile my grandmother and I were moving from one home to another. We were told we had to do that to save our lives. After four months my parents came back but without my grandfather.
The journey into refugee status represented a chaotic period of life in which the young people interviewed described further trauma and insecurity. Many were forced to travel long distances, with few or no belongings, crossing borders into refugee camps, finding the administration of refugees to be often long and confusing. Sometimes both the escape journey as well as life inside camps were to contain further traumas, both physical and emotional. Many were assisted by the United Nations High Commissioner for Refugees (UNHCR) to gain entrance to Australia. The most common reason for selecting Australia was that it was seen as peaceful. For others the decision was more pragmatic, selecting whatever country would take them at the time.
The first few months
For most of the young people, the early months after settlement in Australia were the most difficult. Many expressed a sense of emotional shock upon first arriving. A young woman (17) from the former Yugoslavia stated:
Soon after arrival I was so stressed and I cried every single day. Everything was so stupid. I missed my home, house, my friends. I wanted to go back immediately when I realised the emotional state I was in........ advice was not helpful for me because they kept saying 'you will get used to it, do not worry!', but I was in terrible pain. They said there is nothing we can do about it.
Another young woman from the former Yugoslavia who had been having trouble communicating at school described the sensation as surreal:
I had a feeling that my body and mind were separating. I was walking but in front of me were pictures of my town, my friends and relatives. Shortly I think that I am falling apart.
A young Chinese woman (17) described her first experience of Australia:
When I came, I was 10 year old. I could not understand and speak English well. It was very stressful for me. No one understood me and I understood no one. People laughed at me.
Having 'survived' the initial period of settlement, most of the young people described some improvement in their situation. Not surprisingly, the discovery of their own cultural community within Australia, for most proved a source of great comfort. Most reported that it was not too difficult to continue to retain their own culture within Australia. There was a genuine appreciation of cultural diversity within Australia. Indeed many young people as well as their parents cited multiculturalism along with freedom and peace as the things they liked most about Australia. Multiculturalism was almost universally praised by the young people. Though for a few it was also perplexing for them to then discern exactly what constituted 'Australian' culture. The nexus between ethnic division and war was a profound experience from which people were glad to be freed. A young man (22) from the former Yugoslavia described why he valued Australian multiculturalism:
My main problem was living in a society, which was divided on ethnic/nationalistic basis. It led to terrible war later. I was experiencing fear and anxiety.
Young people frequently spoke of appreciating the freedom of Australian life. For some though, this freedom was not always easy to enjoy, particularly among young women. As one young Cambodian woman (16) put it:
... there is so much freedom. People can do whatever they want. Like, kids my age can go out wherever they want to whereas its very hard for me to do that. Because as a girl being in a Cambodian culture I'm not allowed to go out really. The most difficult is wanting to go out to movies and parties with my Australian friends but I'm never allowed so I sneak out.
Parents were more likely to see freedom in the Australian lifestyle as a negative. Australian families were often seen as not being as close and allowing their children too much freedom. The disjunction between life in Australia and home for some caused family rifts which left young people finding themselves in a position of independence before they felt ready. A young Somali man (21) described his situation in this way:
I wasn't feel happy at the beginning because of too much control, uncomfortable style of life. Then I decided to leave them [family] --too much restriction. That is when I started having stress and depression because I was new in this country and too young to handle a problem.
Finding a place in multicultural Australia was for some a challenging prospect involving questions about their own identity. A young woman (19) from Hong Kong described her situation:
The problem of identity crisis, a sense of belonging. Difficult to tell which group I belonged to, local Australian or people from Chinese community. I did not feel happy ... Even international students, like students from Hong Kong, felt easier to identify themselves ... But I'm a permanent resident. I had the feeling of being 'left out' by either of the groups.
Despite the enjoyment of Australian multiculturalism, young people were nevertheless very aware of racism. A young Cambodian woman (20) cited racism as a major stumbling block to forming relationships with Australians:
And the most difficult to practice is when I am trying to socialise with the Australian people because we are not Australians and I don't know whether or not they are racist. Also trying to get a job is difficult because they look at you 'funny' because most of the managers or whatever are white.
Most commonly, racism was spoken about in relation to school. It included verbal and physical abuse and caused some young people to carefully monitor places they decided as safe or not safe. A young Cambodian woman (16) described racism at school as her biggest problem:
When I'm at school there were a few who were racist towards me. And some place that I went or even now go to. I'm pretty hesitant of going by myself because of these types of people.
Racist violence was particularly catastrophic for young people and their families who had escaped violence in their past. In one incident involving a racist attack in a public place, two young people from El Salvador were set upon by three adults. The emotional consequences of this attack were profound leading to depression and social withdrawal. One of the young people locked himself in his room for several weeks. The mother of the young people described the worst consequence as triggering 'memories of mistrust, where I couldn't trust my own shadow.' The mother was to later attempt suicide.
The Traumatic Continuum
Various stressors described by the young people were of an ongoing nature having been problems in their home country and not going away upon settlement in Australia. This ability for stressors to 'travel' with refugees makes the notion of 'post'-trauma problematic. Anxiety about family and friends still living in their home country amidst sometimes ongoing human rights violations caused considerable stress. As a young man (22) from Somalia put it:
People get killed everyday. They do not have any government protection. Every time I call them, I wonder if they are going to tell me someone in the family died. There is nothing I can do for them as I am yet in school and do not have the necessary powers to better their conditions of life.
Education had often been severely disrupted in their countries of origin as a product of war or other upheavals, hence the challenges of education in Australia were often seen as a continuance of disruption rather than a new challenge in their lives. One young man (18) from Sudan had already changed education systems twice before settling in Australia:
The depression that I had is because how I feel about the gap in my education. I started my schooling in English in Southern Sudan but due to war, I fled to Northern Sudan where I found the education there in Arabic language. I found it difficult to cope with that and it effected my educational progress. Then, I left for Cairo. I thought the situation would change but I found the same problem. Most of the government schools is in the Arabic language.
It is a well known phenomenon for young people from CALD (culturally and linguistically diverse) backgrounds to find themselves in positions of great family responsibility upon settlement in a new country. For some though this was not an entirely new role and began in their country of origin. Parents suffering major reactions to traumatic events sometimes needed the support of their children as much as their children needed the parents support. Hence, some young people find themselves trying to cope with helping parents suffering from major emotional disorders. One young woman (23) from the former Yugoslavia described her situation:
The major problem I had (and still have) is living and dealing with my mother's disorder [post-traumatic stress disorder] ... This makes it difficult to cope, because I attend school, trying to get things done around the house to make it easier for her. However it is not that easy; it is very stressful to see her almost destroy herself (she eats only once a day), and also trying to help her through her nervous episodes and her not giving us (my brother and me) any support.
Moreover relationship problems, family conflict and domestic violence which had their beginnings in the country of origin travelled with the family. Some relationships already stressed at home reached breaking point in Australia. Men who had abused their partners in the home country, continued to abuse in Australia. The strain of such disharmony was multiplied for many families who continued to stay together because they feared additional isolation on top of an already isolated existence. For others, where separations did occur, the associated grief and loss on top of other traumas often convened to crisis situations. The meaning and depth of anxiety related to family break-ups was for many young people multiplied several fold by their personal histories involving already substantial loss and grief.
Sometimes the social context of a stressor was almost as important as the stressor itself. A young woman (16) from El Salvadore described how the thing she valued most about El Salvadorean culture was family closeness and that the break-up of her mother and father was devastating because her father returned to El Salvadore. She explained:
It interfered with my friends because they didn't understand. A lot of them (Anglo-Australians) had their parents divorced and for them it wasn't a big deal ... I was so depressed, cried to sleep in my room and felt like crying all the time ...
For many young people trying to manage a bi-cultural identity was a major challenge. Most wanted some of each culture, seeing positives and negatives in each. But their views about this did not always line up with their family or community's expectations. A common problem for young people was in forming relationships outside of their own cultural community. Many young refugees described a particular 'turning point' in their feelings about Australia and their country of origin. It was the point when they fully realised that they were not going back. For some this point was based on a commitment to making Australia 'home', for others it was an awareness that going home was simply not possible. Whatever the reason, there seemed a profound sense of mixed emotions for young people when they reached this point. A young woman(19) from the former Yugoslavia described her feelings:
Migration experience--expecting to find something better here. Financial/educational expectations of improvement. Does it compensate for family and friends you left behind? Not sure if it was the right decision. I was really depressed when NATO bombed Serbia. That created a real distance between us here and people left behind. When that happened I knew we couldn't go back. Being helpless, feelings of certain guilt, you had a chance to escape and they didn't.
Coping and Resilience
Young refugees used a variety of strategies to deal with stress and anxiety including talking with friends, family, counsellors, medical practitioners to playing sport, listening to music, and participating in community activities. Some wanted help to deal with their problems but were not sure to whom they should talk. Others felt they should deal with problems by themselves. Many felt that they needed to be strong because others in their family were dealing with so much that they felt too guilty adding to the level of burden. This background level of high stress appeared to be very common, not only making it difficult for young people to feel comfortable about exposing their personal issues to others scrutiny, but also meant that additional stressors accumulated very quickly.
Social interaction of various kinds was by far the most commonly cited activity which young people found helpful. One young man (22) from the former Yugoslavia with severe traumatic reactions described the limitations of drug therapy he had experienced:
Migration, leaving my country because of the war. When I arrived here I was highly stressed, nervous, full of anxiety, sweaty palms. I couldn't sleep properly, had lots of bad dreams. And felt bad all the time. I was taken to a doctor, he gave me 12 tablets to take a day. I had lots of tests and examinations to find out what was wrong with me. I felt numb each time I saw the doctor. For 3 months, I felt this way, then I made some friends and the symptoms seemed to reduce and then go away.
Many of the young people interviewed straggled to imagine that anyone would be suitable to talk to about their problems. A young Chinese woman (17) mapped out her options thus:
My mum was aware of my problem, but I didn't want to show her too much ... I didn't want to burden her even more. One of my teachers noticed and asked me, but I didn't tell her. To me teacher is someone who teaches, and it didn't occur to me that I could speak to a teacher ... I didn't confide in my friend because I couldn't express them in English well at that time, so I didn't know how to tell.
Although some young people did eventually find people they could talk too, many simply kept their problems to themselves. A young man from the former Yugoslavia (19) bluntly described his situation:
I could not get any family support because of the circumstances that I have described earlier. I have kept my problems in me and I do not think that I will talk about it in details with anybody ... Thinking about the past and bringing back bad memories was not helpful at all (makes me feeling worse).
Strength in community was commonly cited by young people as an important positive in their life. For example consider the following two quotes, the first from an El Salvadorian, the second from a Bosnian:
I feel comfortable and proud to be from El Salvadore and being associated with everything over there. I like to talk about it. I'm not sure about many things but what I feel about being from El Salvadore is very positive. The most helpful things for me were my social activities with the friends of mine from Bosnia. While we were together we were able to discuss openly about nearly everything, even intimate things. I have hard feelings of belongings to some group of people. I felt safe!
This did not mean that young people did not value time with young people from the broader community. Sometimes very special friendships could emerge which were extremely valued as lines of support. For others, friendships outside of their cultural community were seen as 'escapist', providing opportunities not to have to talk about their problems.
Despite all of the challenges facing young refugees, perhaps the most inspiring part of their psychological outlook was that of their optimism for the future. Almost all of the young people interviewed spoke positively about the future. They had endured so much already, they felt sure they could make good futures for themselves. Considering that all of the young people interviewed had identified themselves as someone who had experienced significant anxiety or depression, this view of the future demonstrates enormous courage and conviction.
The data reported here suggests that the refugee experience of migration and resettlement is more complex than simply a series of discrete events. At least in terms of mental health and well-being, the refugee experience lingers well beyond the flight from chaos. In this sense, trauma and the consequent emotional instability is better conceptualised within a life continuum rather than a series of discrete events.
Young people's experience of the present is very much mediated by their past. This is not only true of present reactions to past catastrophic traumas, but also to other past traumas related to family break-down, illness, educational disruption, job losses, family and friendship disruption. The past mingles with the present too in terms of the meanings and interpretations young people give to life events as they unfurl. Sense of success or failure, notions of freedom and independence, identity and physical and emotional security may be played out in the present, but contain salient meanings generated by the past. Among the young people interviewed here, it is difficult to discern neat boundaries between a past traumatic event and a state of 'post' trauma. Rather than conceptualise their lives in terms of illness boundaries, young people were far more likely to talk of their degree of connectedness within their family, their own ethnic community, their friends, and within Australian society at large. This exemplifies the importance of promoting supportive social environments within public health approaches to refugee health. Biomedical dominance tends to highlight individual dysfunction in our understanding of health. Whilst this has a place, it is essential we also attempt to look at the larger picture. Community development strategies which connect young people to communities and communities to young people are of critical importance.
Of course, past experiences impact on all people, but they have special relevance to young people due their occurrence at a time of rapid emotional development. The ability of the individual to negotiate this period of their life can have an impact on their future mental wellbeing suggesting a heightened risk of later mental illness. One of the positive things to come out of this study was the evidence of resilience amongst the participants that has perhaps been underrated in the past. Considering the difficulties that they had experienced, there was evidence of an inner strength to keep moving forward in the hope of better things to come. This strong desire to construct positive and productive futures is one we should be careful to harness not hinder.
To the young people who had the courage to share their stories for the Non-English Speaking Background Youth Mental Health Needs Assessment Project, the data from which this paper is based on, we sincerely thank. Thanks are also due to Rita Prasad-Ildes for her thoughtful direction during the initial discussion of the paper. Finally we acknowledge the support provided by the partnership between the Queensland Transcultural Mental Health Centre and the Youth Affairs Network of Queensland Inc, without whom this work could never have been undertaken.
(2) See recent paper by Sultan and O'Sullivan (2001) as well as subsequent letters to the editor by Ruddock (2002) and Graves (2002).
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Mark Brough, Don Gorman, Elvia Ramirez and Peter Westoby (1)
(1) Dr Mark Brough, Medical Anthropologist, School of Population Health, University of Queensland. Mark's research interests are concerned with the social determinants of health and include particular emphasis on Indigenous health, migrant and refugee health, youth health, drug and alcohol use and social capital.
Prof Don Gorman is Associate Professor of Mental Health Nursing at the University of Southern Queensland. His major area of research is in cross-cultural health care and education.
Elvia Ramirez is Mental Health Promotion Coordinator at the Queensland Transcultural Mental Health Centre. Elvia is a psychologist from El Salvador who migrated to Australia under the Special Humanitarian Program. She has been working in multicultural health promotion over the last twelve years and completed a masters degree in health promotion.
Peter Westoby is Team Leader of Community Connections/Youth Team: Queensland Program of Assistance to Survivors of Torture & Trauma. Peter has spent the past 5 years working as part of the youth team at QPASTT with young people from a refugee background. He also lectures in youth work practice at Griffith University. Prior to this he spent 4 years involved in youth worker training and national youth initiatives in South Africa; and with CEDPA--an International NGO working on adolescent girl empowerment projects. Peter's background is in sociology, community development and peace & conflict studies.