There is a growing acknowledgement of the importance of mental health and well-being among refugees and asylum-seekers as a result of high rates of mental distress. Most research, however, has focused on refugees and asylum-seekers who live in high-income countries, even though the vast majority (approximately 80 percent) reside in lower- and middle-income countries (LMICs). This three-paper dissertation brings attention to this research gap and examines issues surrounding the mental health of refugees and asylum-seekers living LMICs. Three different cross-sectional data sources were included in this dissertation from study participants recruited from Malaysia, Jordan, and Turkey in 2018. Additionally, three separate analyses were conducted, which include descriptive analyses and multivariable regressions. The first dissertation paper examines the scope and prevalence of mental health counseling utilization in Malaysia. Using Andersen’s Health Service Utilization as a conceptual framework, I examine how certain predisposing factors (socio-demographic characteristics), enabling factors (availability of resources), and need factors (mental health symptom severity) are associated with counseling utilization. The second dissertation paper examines suicidal behaviors among Syrian refugee women living in Jordan. Incorporating the Three-Step Theory (3ST) of suicidal behaviors, I examine how psychological pain, connectedness, and postmigration stressors are associated with suicidal behaviors. Lastly, my third dissertation paper examines the scope and prevalence of vicarious posttraumatic growth (VPTG) among service providers working with Syrian refugees in Istanbul, Turkey. Using a constructivist self- development theory, I examine how greater exposure to traumatic material, in addition to having a greater support system, and having greater years of professional experience is associated with higher levels of VPTG. Study results from Malaysia emphasize the need to understand individual and contextual determinants of mental health service use. I hypothesize that refugees and asylum seekers with certain predisposing factors (female, older age, married, higher education, lived longer in Malaysia, registered refugee), have greater enabling factors (easy access to healthcare, larger household income, do not need interpreter services, greater health literacy, and live with greater number of people in household), and have greater need factors (higher PTSD symptoms) will be more likely to attend counseling services. Almost three-quarters (71.89%) of participants surveyed had never attended mental health counseling services. The majority (71.89%) had never attended mental health counseling services, and among those who screened positive for PTSD, only a minority (16.49%) attended counseling services. My hypothesis was partially supported. Participants from Afghanistan and Myanmar were less likely to attend mental health counseling compared to Somalia and other countries (p<0.001). Not having easy access to health facility (OR:0.10, 95% CI:[0.03, 0.32]), needing interpreter services (OR:0.23, 95% CI:[0.07, 0.75]), and higher PC-PTSD scores (OR:0.69, 95% CI:[0.52, 0.91]) was associated with lower odds of counseling attendance. Other determinants of health service use such as gender, marital status, education level, years in Malaysia, registration status, household income, health literacy, and number of people in household did not show significant associations. Study results from Jordan highlight that greater research and public awareness regarding suicidal behaviors is needed among Syrian refugee women. I hypothesize that screening positive for PTSD, social isolation (have no friends or family members available to help), and greater number of postmigration stressors is associated with suicidal behaviors. Approximately one-tenth (9.86%) of participants reported suicidal behaviors (suicidal ideation and/or attempt) in the past 6-months. My hypothesis was partially supported. Screening positive for PTSD (aOR:4.02, 95% CI:[1.33, 12.15]) was associated with increased odds of suicidal behaviors, while having 1 friend or family member available to help when in need (OR:0.31, 95% CI:[0.13, 0.78]) decreased odds of suicidal behaviors. No associations between the number of postmigration stressors and suicidal behaviors were found. Lastly, results from Turkey emphasizes the importance of focusing on service providers wellbeing. I hypothesize that greater exposure to traumatic material, in addition to having a greater support system, and having greater years of professional experience is associated with higher levels of VPTG. Among service providers recruited 44.66% reported moderate-to-high levels of VPTG. My initial hypothesis was partially supported. Moderate/high/severe secondary traumatic stress (aOR:3.98, 95% CI:[1.26, 12.59]), greater social support (aOR:1.05, 95% CI:[1.00, 1.10]), and greater organizational support (OR:1.11, 95% CI:[1.02, 1.20]) was associated with moderate-to-high VPTG. Proportion of clients who disclose trauma, and years in profession did not show significant associations. Mental health utilization, suicidal behaviors, and the well-being of service providers are issues that have all been linked to the mental health and well-being of refugees and asylum-seekers. These topics have been minimally examined among forcibly displaced people living in LMICs. Clinicians and organizations must promote greater awareness of and screening for mental health conditions. Additionally, mental health and suicidal behaviors is often associated with stigma and discrimination, which means that providing basic psychoeducation surrounding mental health, its impact, as well as awareness of services available, and normalizing treatment at the individual and clinic level is essential for increasing engagement of mental health services. To further reduce global mental health disparities and provide equity in mental health care and treatment, future research and psychosocial interventions must prioritize and focus on the well-being of refugees and asylum-seekers living in LMICs.

In recent decades the ongoing rise of refugee populations around the world has provided a unique opportunity to study the impact of forced migrations on the identities of individuals and collectivities. The simultaneous emergence of the novel social phenomenon of 'refugee societies' has captured anthropological interest in the way in which 'refugee identity' is currently imagined and represented. A useful entry point for exploring representations of 'refugee' identity within a new culture of refugees is found in the recurrent notion of suffering. 'Suffering' is conceptualized here as an ideological grammar that characterizes a variety of language games contained in a broader 'language of suffering'. Focus is directed towards the 'medical dialect of suffering' and its role in articulating the identities of refugees and representing their experiences of suffering. Medical discourse, practices, and technologies can drive the transformation of the categorical 'refugee' identity into a 'medicalized' and 'traumatized' identity: revealing how medicine not only reflects cultural meanings of suffering, but can also project new cultural meanings of suffering. The relevant case of Afghan refugees illustrates how cultural identities can be conceptualized as shifting, strategic, and multiplicitous---realities that can be a blend of both coherency and contradiction.

Thesis (Ph.D. Psychology)--University of Waikato, 2007. / Title from PDF cover (viewed August 28, 2008) Includes bibliographical references (p. 312-331)

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Through conceptualizing migration as a social process, this dissertation examines the role of social support among urban migrants. Existing research examining social support is often framed in North American or European contexts and ignores its connectivity with migration or mobility. There remains critical opportunity for research to examine how social support paradigms function in Low and Middle Income Countries (LMICs) and from the perspective of urban migrants, including refugees and economic migrants. By expanding the frame of both migration and social support research, this dissertation endeavors to enrich the empirical knowledge surrounding the role of social support among urban migrants. To accomplish this, this dissertation examines the intersection of trauma, social support, and depression among two urban migrant populations. Through its integration of data from female Syrian refuges in Jordan and male economic migrants in Kazakhstan, this dissertation aims to describe social support, potentially traumatic events (PTEs), and depressive symptomology; identify the direct association of social support and depressive symptomology, and; examine the moderating role of social support on depressive symptomology related to PTEs. This dissertation is guided by the Push-Pull Theory, the Stress-Buffering Hypothesis, and van Brenda’s conceptualization of resilience. Findings from this dissertation suggest that social support plays a critical role, both directly and indirectly, in influencing outcomes of depressive symptomology. Findings have several implications for social support measurement and direct practice of mental health clinicians, as well as informing how community-based interventions and mental-health policies within LMICs can integrate social support within their resiliency frameworks.

The objective of this study is to investigate the variations in the type of trauma (post-traumatic stress disorder (PTSD) and disorder of extreme stress not otherwise specified (DESNOS) resulting first from group membership, and second from variations in socioeconomic status, and last, from exposure to physical and psychological methods of interrogation due to imprisonment. I use a diverse sample of 202 child ex-detainees who served sentences in Israeli prisons and were 17 years of age or less at the time of arrest. Various regression techniques were utilized to determine the most parsimonious way to distinguish between the three groups in their trauma responses. The key finding in this study is that child refugee ex-detainees living in refugee camps, in general, did not report PTSD or DESNOS reactions compared to their counterparts. Continuing PTSD and DESNOS symptoms were more prevalent among the group of refugees living outside the camps. However, there is at least one finding that supported what I hypothesized: refugees living in camps were more likely to experience elevated levels of alterations in attention or consciousness (DESNOS2). For refugees in camps, the DESNOS absence tells us that the volatile childhood these children experienced was not associated with severe pathological reactions or heightened sensitization to trauma. In contrast, refugees living outside camps suffer from alterations in self-perception DESNOS4 symptomology, in addition, to elevated levels of complex trauma DESNOS and they qualified for the DESNOS diagnosis more than the other two groups of children. Refugees living outside camps were the only group subjected to interpersonal stressors.

The purpose of study was to explore depression among Hmong refugees and the ways they use their coping skills to deal with stressful life events.

Introduction. Humanity is now witnessing one of the highest rates of displacement since the beginning of its history, with an unprecedented 79.5 million people around the world being forced to leave their homes; among whom are 26 million refugees. Since 2011, the protracted Syrian war has threatened the stability and well-being of all persons affected by the war. In these complex emergencies, regular access to resources, pathways to building social ties, and utilization of existing service networks (such as education, healthcare, and protection) are disrupted. Method. Nine Syrian refugees and Lebanese host currently living in Lebanon screened positive for clinical depression and receiving interpersonal psychotherapy (IPT) by Lebanese providers were recruited for the study. A novel social network assessment tool using a dynamic network framework was designed and preliminarily tested to explore social support and conflict in the sample during IPT. Changes in social support and conflict resolution were assessed pre-and post-IPT in the depressed selection. Results. To our knowledge, this is the first-of-its-kind study to adopt a dynamic, multiplex, open-system approach to identifying, classifying, and exploring temporal changes in the social network roles in both refugees and host population(s) with specific goal orientation. This is also the first to study these in the context of individuals with a mental health problem receiving IPT for depression treatment. Outcomes indicate promise of the use of the dynamic network theory’s survey approach (aka network goal analysis) among depressed participants and provides important insights about pathways through which persons activate social support and resolve conflict in a humanitarian emergency setting. Discussion. Amidst war, economic downturn, COVID-19 pandemic, and recent bomb blasts, communities have been fragmented and their social ties, severed. Increasing rates of common mental disorders have worsened peoples’ capabilities for survival. This novel dynamic network approach to the study of social support and conflict resolution brings into focus pathways and social roles among depressed individuals crucial for social support, with implications for policy makers and mental health practitioners. Keywords. Dynamic networks, Interpersonal psychotherapy, Social support, Conflict, Cohesion

D.Litt et Phil. / For over a decade, from the late 1970's to October 1992, a war raged in Mozambique that resulted in what has been described as, one of the "most terrible genocides in the history of Africa". Over 4 million people were displaced during this war. Conservative estimates put the number of Mozambicans who sought refuge in South Africa at 250 000. This study examines the trauma created by the war, and its psycho-social outcomes, from the perspective of women refugees who came to settle in villages in the Nkomazi region of Mpumalanga province, in South Africa. Posttraumatic stress disorder, the concept which dominates research in the field of trauma studies, was based on research with male war veterans in western industrial societies. Recently a body of work has emerged which questions the validity of applying posttraumatic stress disorder to contexts of massive social conflict, and its utility in cross cultural contexts. This body of work suggests that an understanding of extreme trauma and its outcomes requires careful consideration of the social and cultural dimensions of trauma. The inclusion of a cultural formulation in the latest edition of the Diagnostic and Statistical Manual for Mental Disorder, DSM-IV, reinforces a growing acknowledgement amongst mental health researchers of the influence of culture on mental health and disorder. The gaps in research on African women survivors of war and the lack of standardised assessment tools, makes this an exploratory study which uses qualitative research methods. Unstructured interviews were conducted with 30 Mozambican women refugees to explore their experiences and definitions of trauma, the psycho-social outcomes of the trauma, and coping and survival in the aftermath of the war. The magnitude of the trauma evident in the research findings called for a conceptual definition which reflects multiple risks and the interdependence of social and individual trauma. Thematic analysis and qualitative coding of the interview data revealed clinically well defined posttraumatic stress disorder symptoms and locally specific discourses of suffering framed by cultural beliefs, social practices and historical experiences. Their testimony and observations in the field, revealed that the survivors demonstrated a capacity to survive and reconstruct their lives. Their coping strategies and survival tactics were fundamentally shaped by socio-historical experiences and the limits and possibilities contained in the recovery environment. The results of this study suggest an approach to examining the complex relationship between trauma and its consequences, which abstracts neither trauma nor its victims from cultural and social-historical contexts.

Globally, an estimated one in four women have experienced intimate partner violence (IPV) in their lifetimes. IPV has enormous physical, mental, and social consequences across ecological levels of human experience. These consequences extend to the children of adult women survivors of IPV and are worsened by intersecting experiences of racism, classism, sexism, and xenophobia. Service systems purporting to help, such as child protective services (CPS) and health service systems, can either create additional harm for women and their children or offer services that women may have difficulty accessing due to cost, isolation, and other factors. These harms can be especially pronounced among (a) Black women who have used drugs, who have children, and who are in community supervision programs (CSPs) in the U.S. and (b) Syrian refugee women with children living outside camps in Jordan. These populations of women face particular challenges getting basic needs met while navigating safety for themselves and their children – both due to IPV and from systems themselves (e.g., risk of losing custody of their children, sociocultural risk of interference in family life). Yet, limited research exists on the relationship between experiencing IPV and service involvement within these two populations. The following dissertation aims to address these research gaps in three papers, using descriptive and bivariate data as well as logistic regression analyses of E-WORTH and Women ASPIRE studies, as informed by ecological theory. The first paper (E-WORTH), guided by ecological theory, aims to determine the prevalence of and test hypothesized associations between psychological, physical, and sexual IPV and CPS involvement among Black women who have used drugs, who ever had children, and who are in CSPs in New York City (N=247). I hypothesized that women who ever had children, were in CSPs, and had ever experienced psychological, physical, and/or sexual IPV by male partners would have higher odds of being involved with CPS in their lifetime than women who ever had children, were in CSPs, and had not experienced IPV by male partners. Using self-reported data from Black women who have used drugs and were recruited from CSPs in New York City, I found that 70.85% of women who ever had children and who were in CSPs reported ever experiencing psychological IPV by a male partner, 70.04% reported ever experiencing physical IPV by a male partner, 48.58% reported ever experiencing sexual IPV by a male partner, and 40.89% reported ever experiencing psychological, physical, and sexual IPV by a male partner. Further, I found that 55.87% of women reported ever having had an open case with CPS. Multivariable logistic regression analyses revealed that women who had experienced lifetime sexual IPV had significantly higher odds of ever being involved with CPS than women in the study who had never experienced sexual IPV (OR: 1.81; 95% CI: 1.09, 3.01). Similarly, women who experienced multiple forms of IPV (psychological, physical, and sexual) also had significantly higher odds of being involved with CPS (OR: 1.81; 95% CI: 1.07, 3.04). However, these associations did not hold in adjusted models. Paper 2 (Women ASPIRE) aims to (1) compare the prevalence of mental health symptomology (anxiety, depression, and PTSD) among Syrian refugee women with children under age 18 living outside camps in Jordan who have and who have not experienced physical and/or sexual IPV in the past year; and (2) examine the relationship between IPV and mental health symptomology among Syrian refugee women with children living outside camps in Jordan. Based on ecological theory as my conceptual framework, I hypothesized that Syrian refugee women with children who had experienced IPV in the past year would have significantly higher odds of meeting screening criteria for anxiety, depression, and PTSD as compared to Syrian refugee women with children who had not experienced IPV in the past year. I found high rates of IPV, anxiety, depression, and PTSD among women in the sample (N=412). Furthermore, using multivariable logistic regression models from the Women ASPIRE dataset, I found that women with children who had experienced physical and/or sexual IPV in the past year had significantly higher odds of meeting screening criteria for all three mental health conditions – anxiety (aOR: 3.68, CI: 2.28-5.94, p<0.001), depression (aOR: 3.03, CI: 1.83-4.99, p<0.001), and PTSD (aOR: 6.94, CI: 3.75-12.84, p<0.001) – than women with children who had not experienced IPV in the past year. Despite these findings, at least one-fifth of women with children reported an unmet need for mental health or protective services, and less than one-third of women were aware of the availability of these services in their local communities. The third paper (Women ASPIRE) aims to (a) examine the prevalence of physical and sexual IPV among health service-seeking Syrian refugee women with children in non-camp settings in Jordan and (b) compare the differences in health service use between women with children who had and who had not experienced IPV (N=412). Informed by experiences across levels of ecological theory, I hypothesized that women with children who had ever experienced IPV would have lower odds of using each type of health service (i.e., general, specialist, reproductive, mental health, and emergency health services) – and would have higher odds of using limited numbers of services – than women with children who had never experienced IPV. I tested my hypothesis using binary logistic regression models and an independent samples t-test. I found that nearly 60% of Syrian refugee women with children living outside camps in Jordan had ever experienced physical and/or sexual IPV by their current or most recent husband. Contrary to my hypotheses, I found that women with children who had ever experienced IPV had over three times the odds of using mental health services and were significantly more likely to use a greater variety of health services (including mental health services) than women who had not experienced IPV (aOR: 3.10, 95% CI: 1.92-5.00, p<0.001; mean 3.26 vs. 2.84 types of services respectively, t [410] = 03.71, p<0.001). Findings affirm that IPV is a serious public health issue among the affected populations and that access to needed services remains crucial to affected populations. Results fill gaps in existing literature by confirming that women with children in each study population have high odds of system involvement, particularly with CPS and mental health service systems, thereby offering social workers within those systems opportunities to intervene effectively. Thus, this dissertation can help social work practitioners and clinicians offer more responsive, accessible, and relevant services to clients within the study populations. Policymakers and administrators can fund development and testing of interventions across multiple ecological levels to promote the safety, health, and well-being of women and their children. Researchers can build on these findings through quantitative and qualitative studies on intervention effectiveness and accessibility among women engaged with system.