Trauma and resettlement: lessons learned from a mental health screening and treatment programme for Syrian refugees in the UK

Abstract

Resettlement schemes can offer refugees an opportunity to rebuild their lives and to heal from loss and trauma. Mental health services in host countries may have an important role to play in aiding refugees in this journey to recovery. However, facilitating the process of healing for refugees raises challenges for mental health services working within Western medicalised settings. Recovery and wellbeing for resettled refugees also depends upon an interaction of variables at a wider systemic level, that go beyond the direct remit of mental health services. Based on the experience of delivering a mental health screening and treatment programme for resettled Syrian refugees in the UK over a 5-year period, this paper reflects on these challenges and suggests that future resettlement schemes in the UK be designed in accordance with the principles of trauma-informed care. This means putting safety, trust, choice, collaboration, empowerment and respect for inclusion and diversity at the core of the services provided for resettled refugees.

Keywords:

• Syrian
• trauma-informed
• resettlement
• refugee
• mental health

Introduction

The Vulnerable Persons Resettlement Scheme (VPRS) was launched in 2014 to relocate to the United Kingdom (UK), some of the most vulnerable families and individuals displaced by the Syrian civil war, residing in Jordan, Lebanon, Turkey, Iraq and Egypt (Bolt, 2020). Refugees relocated under this scheme were granted 4-year humanitarian protection or refugee status on arrival in the UK and a resettlement assistance package, including healthcare provided by the UK’s National Health Service (NHS). Our trauma service was commissioned to provide mental health screening, support and signposting to refugees relocated under this scheme within two London boroughs. Community organisations were also funded to help with other aspects of resettlement, including access to healthcare, housing, welfare and education. This paper presents a critical perspective on the successes and challenges of the scheme and of our intervention in facilitating healing and recovery for this cohort of refugees.

The refugees arrived over the period 2015–2020. Most originated from Damascus or Aleppo, but many also came from more rural areas in Syria. A majority had fled to Lebanon or Turkey after the start of the Syrian civil war in 2011. Of the 77 adults relocated to our boroughs, 61 (79%) were seen by our service. Children made up a large part of the group, but we report here only on our work with the adults or the families as a whole. The majority of the people we screened reported multiple symptoms and difficulties, relating to a spectrum of mental health conditions, but also critically to a variety of psychosocial stressors and challenges associated with adjusting to life in the UK. Systematic reviews and meta-analyses of conflict-affected and refugee populations suggest elevated rates of Post-Traumatic Stress Disorder (PTSD), depression, anxiety disorders, chronic pain and other somatic complaints compared to global mean prevalence or prevalence in host populations (Charlson et al., 2019; Kirmayer et al., 2011). Whilst some have argued that the cross-cultural validity of diagnostic categories in mental health should be questioned (Summerfield, 2008; Tribe, 2013), particularly in crisis-affected populations, our experience is consistent with these trends. 62% (38 out of 61) of the individuals who we screened met the criteria for a diagnosis of PTSD, and 54% (33 out of 61) met the criteria for moderate to severe depression at initial screening. Adults reporting symptoms of PTSD were offered phase-based psychological treatment (Robertson et al., 2013), at our clinic, these three phases are: stabilisation, trauma-focussed treatment, and support with reclaiming life. Those clients who reported primarily symptoms of depression or anxiety were referred to other local psychology or intercultural counselling services. Of the clients who met the criteria for PTSD, 68% (26 out of 38) chose to attend symptom management and psychoeducation interventions (i.e. stabilisation) at our clinic, and 42% (16 out of 38) also opted to engage in trauma-focussed treatment with our clinicians.

Whilst these numbers indicate that we were able to support many of the refugees, in practice we found that the systems within which we worked could have gone further in meeting the needs of this vulnerable population, and in harnessing and building on their strengths. This paper reflects on these challenges and suggests that strategies to support the post-migration well-being and mental health of refugees in the UK would be enhanced if implemented at a broader systemic and service level and in accordance with the principles of trauma-informed care. Trauma-informed care is offered within a strengths-based framework that emphasises physical, psychological, and emotional safety and creates opportunities for individuals to rebuild a sense of control and empowerment. It understands “symptoms” and behaviours displayed by clients not as indications of pathology, but as manifestations of ways in which they have had to cope with adversity and traumatic experiences. The key question to ask of individuals is not “What is wrong with you?”, but rather “What has happened to you?” (Johnstone et al., 2018; Kezelman & Stavropoulos, 2020; Substance Abuse and Mental Health Services Administration (SAMHSA), 2014).

In addition, we highlight that explanatory models and treatment protocols used by healthcare professionals should be adaptable to cultural diversity and difference if these services are to build trusting relationships with refugee communities and succeed in delivering effective interventions. The Syrian people make up a mosaic of different cultural, ethnic and religious groups, in various states of transition in the face of war and displacement, as well as globalisation and modernisation (Hassan et al., 2015). This precludes simplifying assumptions of the “Syrian refugee,” and instead calls for mental health services to demonstrate maximal flexibility and diversity with regards to interventions offered. It also demands an ability to work at times within different explanatory paradigms and to be aware of the limitations of individualised psychotherapeutic treatment practices and Western concepts of personhood (Kirmayer, 2007), that may or may not align with different cultural beliefs and family norms present in Arabic cultures (Fakhr El-Islam, 2008).

Close to 20,000 refugees have been relocated to the UK under the VPRS scheme at the time of writing. A recent review of the UK’s VPRS programme suggested that healthcare has been one of the least discussed aspects of the scheme and emphasised the importance of providing good mental healthcare (Gilbert, 2017). In sharing our experiences, we hope to contribute to this discussion, with the aim of improving the services provided to refugees relocated to the UK in subsequent resettlement programmes. We first present some of the key challenges we faced in delivering a trauma-informed service to the VPRS refugees. We go on to suggest what might have been done differently to best engage and meet the particular needs of this population, including changes to the broader design of the resettlement scheme itself. Designing resettlement packages in line with trauma-informed principles means putting safety, trust, choice, collaboration, empowerment, and insight into the impact of an individual’s history, culture and gender on their experiences, at the core of all clinical and non-clinical services provided for resettled refugees in the UK.

Challenges

We faced a number of challenges in delivering the service we had been commissioned to provide. These related to variable relationships with community agencies, overcoming the stigma associated with “mental health,” ongoing psychosocial challenges the refugees faced while settling in to life in the UK, difficulties with funding constraints and overcoming language barriers.

Outreach and reliance on partnership agencies

Community agencies were tasked with providing initial support to the VPRS refugees upon arrival in the UK, including arranging appropriate housing, facilitating access to healthcare, and registering for education and training. Due to the practical and essential nature of the support they offered, these organisations mostly developed trusting relationships with many of the families. The program was initially structured with a psychologist as part of these community teams who conducted a mental health screening for each client as part of an assessment of their overall needs. Subsequent signposting into our clinic for trauma-focussed treatment for PTSD was then made if required. Joint home visits and coffee mornings carried out with a member of the community organisation also helped to gain the trust of the VPRS community. In both cases, the psychologist benefitted from the “halo effect” of being with a trusted community worker. The BPS Guidance for Psychologists on Working in Partnership with Community Organisations provides a range of examples and suggestions on working in collaboration with community organisations.

The relationships between our mental health service and the community organisations however also came with complications, particularly as organisations held different beliefs about how best to integrate with mental health services. In cases where organisations opted not to invite our psychologists to join their initial meetings with the families, VPRS refugees were instead directed to contact our service independently. In these instances, the community organisations then found themselves in a position of having to “sell” the benefits of engaging with our service, which was not clearly within their remit or domain of expertise. This resulted in decreased engagement from the VPRS community which put a strain on the relationship between all parties. For example, one organisation was concerned about being perceived to be trying to “persuade” clients to engage with mental health services, and worried that this could damage the trusting relationships they had with the families. Our attempts to arrange contact with the refugees independently were somewhat successful, but were resource intensive. We were fortunate in having an experienced Arabic speaking psychologist within our service who was able to phone these clients, and explain to them in a culturally sensitive way what our service could offer them and answer any questions or concerns they might have prior to their first appointment.

Stigma

Shame and stigma surround the labelling of distress as “psychological” or “psychiatric,” including in Syrian culture (Hassan et al., 2015). Mental health services in Syria are not widely available, and most are based within in-patient institutions rather than community settings. Proactively reaching out to the refugee community in cooperation with the community agencies, and introducing our service in a non-pathologising manner, was very important in overcoming these barriers. This was particularly the case given our physical location on the grounds of a psychiatric in-patient hospital, rather than being co-located with other agencies in the community. We made sure to emphasise that our service was not for people who are “crazy,” but rather to support recovery following exposure to repeated stressful situations, and help with adaptation and integration. For example, our clinic facilitated sessions in which members of the VPRS community came together to discuss shared experiences of war and displacement, which received positive feedback. However, despite these successes, we also noted rumours circulating within the refugee community that “mental health services” were separating children from their families, reflecting a failure of services to establish trust with the refugee community.

Safety and integration

The perception of current ongoing threat is a core feature of the distress associated with PTSD (Ehlers & Clark, 2000), as is the rupture of the individual’s previously held identity (Herman, 1997). Re-establishing safety is part of the process of healing, as is re-claiming lost roles and identities. This is a task that goes beyond the clinic and is codetermined by the fabric of the society within which clients live, thus shaping clients’ readiness to engage in trauma-focussed treatment. The ongoing nature of the conflict in Syria meant that many clients continued to live the war at a distance, preoccupied with the safety of family and friends in Syria. Whilst this was unavoidable, unfortunately many of the Syrians we screened also reported a sense of disillusionment and uncertainty about their new lives in the UK, citing various challenges. For some, difficulties learning English were compounded by poor concentration, memory and sleep. For others, it was hard to find jobs in which their existing skills were recognised, and only a minority of the refugees were able to secure employment. Some families were housed in noisy or deprived areas where they reported feeling unsafe. Many also reported significant distress at learning that welfare benefits and housing were only guaranteed for the first year after arrival. Others described feeling isolated and unwelcome and a small number of the refugees reported experiencing hate crimes and taunting in their communities. Significantly, the women’s role in looking after the children and liaising with schools offered them opportunities for building social networks. Many men on the other hand, unemployed and stripped of their valued “provider” role struggled to rebuild social networks or meaningful identities. This interacted with and compounded the fact that there was a higher incidence of PTSD among the men in our cohort, perhaps due to higher risk of imprisonment and torture and direct exposure to the armed conflict whilst in Syria.

In addition, the structure of the UK benefits system created much insecurity and financial hardship for these newly arrived Syrian families. In line with our phased approach which initially focuses on helping people establish a sense of safety in their lives, we assisted these families in applying for the benefits to which they were entitled. We shared our knowledge about the welfare system and signposted individuals to welfare advisors who could support them. Through this form of practical support, we often established strong and trusting relationships but we were disappointed to discover how little training and employment support was available to these individuals. This was unfortunate given the many skills that the refugees brought with them, and their willingness to re-train and get back to work. In a few cases it seemed that the narrative of “If I am unwell, I will be supported” reinforced a “sick role” and may have reduced the clients’ motivation to recover, whilst creating a precarious dependence on the welfare system.

Short-term funding and timing of trauma-focussed treatment

Trauma-focussed therapy usually requires that the client be willing and able to talk about their traumatic experiences, and tolerate an increase in intrusive PTSD symptoms in the early stages of treatment and to talk about distressing events in detail which they typically avoid (Ehlers & Clark, 2000). As noted above, this capacity is often contingent on an individual’s sense of safety and stability in other domains of their life. While psychological treatment was available to all those arriving on the VPRS scheme on the NHS, one of the boroughs opted to fund a “fast-track” treatment service within the first year of arrival, allowing the refugees to circumvent long NHS waiting lists, but with funding available only during the first year. While VPRS clients for the most part were able to engage with the stabilisation aspects of our treatment model, many did not feel ready to engage with trauma-processing treatment until after funding had expired. Rather, their focus in the first year was justifiably on integration and on meeting basic needs. Some clients also presented with only mild symptoms of PTSD, anxiety and depression upon arrival, whilst more severe psychological symptoms emerged later on. This may have been a feature of a “survival mode” mindset in which they were initially consumed by the pragmatic demands of settling into their new lives, as well as initial optimism about a new start.

Working with interpreters

The majority of the VPRS refugees (93%) referred to the clinic or contacted for screening through outreach stated that they required the support of an Arabic-speaking interpreter. Guidelines for psychologists on working with interpreters recommend that the interpreter be considered an active part of the working relationship and that factors such as gender, religion and politics be considered in their selection (BPS, 2017). The complexity of the religious and political situation in Syria, and limited availability of trained Levantine-Arabic speaking interpreters, posed challenges in meeting these recommendations. Furthermore, given the ongoing Syrian conflict, we had to remain mindful of the risk of vicarious traumatisation to the interpreters, due to them having had similar experiences or fears over the safety of their family in Syria. Therapists made sure to regularly check-in with the interpreter at the end of sessions. These interpreters became an essential and integral part of the team and we relied on them not only for interpreting during assessment and therapy sessions, but also as cultural consultants and for translating our written communications to clients.

Recommendations: towards a trauma-informed vprs programme

In order to address the challenges noted above, we recommend that any programme working with refugees needs to be delivered according to the principles of trauma-informed care, namely: safety, trust, choice, collaboration, empowerment and respect for inclusion and diversity based on an understanding of people’s history, culture and gender (Kezelman & Stavropoulos, 2020; SAMHSA, 2014). We elaborate on these principles below, in relation to our findings and experience. Our recommendations echo those made by other professionals working in a trauma-informed manner with refugee populations in emphasising the importance of social integration, education, housing and employment, as well as cultural adaptations and coordination amongst services, including outreach and mental health services (Almoshmosh et al., 2019; Hassan et al., 2015; Priebe et al., 2016).

Safety

The principle of safety relates to both physical and emotional safety. VPRS clients were almost consistently derailed and distressed by limitations placed on welfare support, guaranteed only for the first year after arrival. Many clients were extremely concerned about their longer-term financial security and the continued housing of their families, without any clear pathway for achieving financial independence in the short time-period expected. Resettlement packages that do not guarantee suitable long-term housing and financial security packages with no clear prospects for employment or independence, raise challenges and place a burden on refugees that may generate a damaging degree of insecurity.

Critically, programmes must also consider the importance of keeping families together, including the resettlement of adult children, siblings and elderly parents, rather than only nuclear family units. We suggest that the sense of safety achieved by allowing for entire extended families to resettle in the same host country would go a long way towards easing distress and facilitating integration into new communities without the obstacles of guilt and worry about family members left behind.

In addition, VPRS clients seemed to feel physically and emotionally safer and more confident to engage with mental health services when these were community-based and workers could, at least during the initial engagement phase, visit them in their homes. We suggest that stigma is reduced and accessibility and engagement enhanced, when mental health services are physically co-located and better integrated within other support and resettlement services. It also circumvents problems we encountered in having to rely on community agencies to reach clients.

Trustworthiness

The principle of trustworthiness demands sensitivity and reliability in responding to client needs. Practically speaking, all providers working within the VPRS scheme need to be consistent in their commitment and their messaging to clients. Simply put, this means following through on what they say they are going to do. Effective integration among the different services working with the refugees is vital to ensuring this consistency, beginning with pre-departure support, to the first points of contact in the UK, the allocated community support organisations and the services providing mental and physical health care. Through collaboration and multi-disciplinary consultation, clients’ needs can be thoroughly assessed, and agreed plans followed-through. Trustworthiness also involves conveying assurances around confidentiality to clients, especially when professionals are visibly working with several people in the same cohort who may come from the same community. This is particularly important in a community where discomfort and shame about experiencing mental health problems and adjustment difficulties is prevalent.

Choice

Services should provide choice to clients at all possible levels. As noted above, one of the community organisations we worked with interpreted this as meaning that the refugees should not be encouraged to make contact with mental health services. We argue however that choice is only possible where someone is presented with full information, and that working in a culturally competent manner involves proactive action to build trust and share information with communities that might otherwise be suspicious or misinformed about services. In our experience most refugees had not had direct experience with mental health services previously and had only heard of these in a stigmatised manner as places for “mad” people. Meeting the refugees informally face to face in the first instance was necessary to demystify and normalise our service, before they could in effect make an informed choice about whether they wanted to engage with mental health services or not. In a similar vein, a review of the VPRS programme by the Centre for Social Justice concluded that psychosocial assessments should be conducted routinely during a refugee’s first primary care consultation in the UK, to ensure that all vulnerable individuals are given the opportunity to access support (Gilbert, 2017).

Choice is also critical when it comes to engaging specifically in trauma-focussed PTSD treatment. The “fast-track” funding model assumed that refugees would be ready to engage in trauma therapy soon after they arrived. This was not our experience. Initially most of our clients were in “survival mode” and focussed on basic needs and crises. Having initially declined treatment, a number of these same clients asked to access treatment many months later, when designated funding had unfortunately expired. The time limit also put pressure on clients to engage with treatment when it was being offered as a “fast-track” option, when they might otherwise have preferred to wait until they felt more secure. As such, we strongly recommend the longer-term funding of services so that there is greater flexibility in the provision of trauma-focussed treatment to clients, such that it can be offered at the times when they are in a better place to engage with and tolerate this. This could lead to better use of clinical resources and improved treatment outcomes.

Collaboration

The principle of collaboration requires consistently communicating a sense of “doing with” rather than “doing to” or “doing for” clients. Our clinicians routinely provided supporting letters for housing and benefits in an attempt to secure ongoing support for the refugees and help establish a sense of safety, which appeared to hasten the process of building trust and collaborative relationships. However, whilst support with housing and benefits helped our clinicians to build relationships with the refugees, it also created an incentive at times for the refugees not to initially state their true preferences about receiving psychological treatment, for risk of losing other practical support. Given the lack of other sources of practical and systemic support, this was understandable and a functional strategy. If all involved services had formed collaborative working relationships from the start with a shared trauma-informed and holistic perspective on the critical elements which the refugees needed in order to settle into their new lives, then the resettlement might have progressed more rapidly and smoothly for all.

Finally, future resettlement programmes would do well to request feedback and expertise from service-user representatives from previous refugee cohorts to inform the design of the support package, and to identify key areas of challenge and potential disappointment. Indeed, one example of a request made by the refugee cohort came from some of the women who said that they would like to meet with other Syrian women in a safe space to discuss their shared experiences of resettlement. This was seen as preferable in some cases to meeting individually with our psychologists. Our clinicians brought these requests to the local municipality and refugee support organisations and advocated for funding so that these meetings could be facilitated. This example demonstrated the willingness of the refugee community to engage in shaping the resettlement program itself, and how working more collaboratively with the refugee community could facilitate more needs-based interventions.

Empowerment

The management of “mental health” by psychological and psychiatric therapies alone in resettled populations can be disempowering, pathologising and inefficient if delivered without the supporting frame of a robust resettlement package that properly addresses important psychosocial needs. These include individualised and well-thought through provision of language learning, education and employment initiatives, as well as opportunities for civic participation and the enhancement of family life.

Research supports the idea that when refugees have security, social support, hope for the future, and are meaningfully occupied through employment and education, symptoms of PTSD, depression and anxiety reduce (Carswell et al., 2011; Priebe et al., 2016). An independent inspection of the UK resettlement schemes also highlighted access to employment as crucial to integration and improved mental health, but noted that refugees have found this hard to access due to language barriers, lack of formal education, and poor mental health (Bolt, 2020). On these grounds and based on our experience, we argue that resettlement packages should harness refugees’ existing strengths and occupational capabilities. This could include refugees being matched with opportunities and training in relevant occupations, whilst accommodating their lack of English skills.

Supporting English language development is also vital, as this has bearing upon employment and integration prospects, which is significant for longer term mental health outcomes in refugees (Kirmayer et al., 2011). While enrolment in English language courses was included in the resettlement package, some refugees with poor sleep and concentration struggled to attend and benefit from the more formal college classes. The funding of alternatives, such as mentoring and befriending schemes, may allow for a more informal learning environment as well as offering opportunities for social integration. Finally, clients are less likely to feel empowered to advocate for themselves when they are unable to communicate effectively or understand aspects of their care and support. Unfortunately, clients frequently reported that interpreters were not provided at their hospital, GP and welfare benefits appointments, or that the interpreters provided were inappropriate (for example, male interpreters for gynaecological appointments). On this basis, we argue that there must be training and funding for all services so that VPRS clients are provided with appropriate interpreters.

Diversity and inclusion

Finally, a central trauma-informed principle to consider with this client group is respect for and awareness of diversity and inclusion. This means an understanding that trauma may be experienced differently according to cultural, gender, religious and other factors and identities. These dimensions will in turn affect peoples’ experiences of services and what they will need in order to recover and to settle. A process of learning and engagement with Syrian history, culture and politics, and the existing Syrian refugee community in the UK, was undertaken by our clinicians, and was vital in informing our work. This involved reading literature, watching films and documentaries, participating in conferences with Syrian activists and human rights organisations, as well as attending Syrian refugee community meetings, which were particularly informative in thinking about shared experiences amongst the Syrian refugee community, and difficulties navigating cultural differences in the UK. Our clinicians also engaged our Arabic speaking clinician as a “cultural consultant” on several occasions, as well as our Syrian interpreter and Arabic speaking workers in the community organisations. This process of learning and consultation informed our approach to engaging the Syrian refugee community in culturally appropriate ways. For example, asking about and respecting gender preferences in the first instance was one simple but important adaptation, which in many cases involved our male clinician speaking first with the father in the family, and our female clinicians and interpreters meeting separately with the female family members. Our clinicians also adapted their usual outreach strategies and met with many of the Syrian families in their homes, where they could drink tea together and build rapport in a non-clinical environment.

An ongoing process of cultural consultation also closely informed our clinical formulations and treatment. As just one illustrative example, our Syrian interpreter was invaluable in helping one clinician to formulate the difficulties experienced by one of our Syrian clients who had lost her daughter in Syria in a bombing and was presenting with unprocessed traumatic grief. In this particular case, the presence of unexpressed anger and devastation at the loss of her daughter was notable to our clinicians, as was the importance of the client’s Muslim faith in making sense of her loss. Our interpreter, who was also a Syrian Muslim, hypothesised that this client had an assumption that showing anger or upset would be a sign that she lacked faith and trust in God’s will. Indeed, trust and surrender to God’s will in the face of loss is understood to be a normative response to bereavement in Muslim culture in Syria, in which adversity is seen as an opportunity for spiritual growth (Hassan et al., 2015). An incorporation of this into the formulation was a turning point in the therapy, and our clinician and interpreter worked with the client to consider the strong evidence demonstrating her faith in God’s will, to normalise her grief reaction, and to weaken her assumption that feeling sad and angry about the loss of her daughter would lead to a rupture in her relationship with God. Upon reflection this client noted that this had been the most valuable part of the therapeutic process. This was just one of many instances in which working closely within a multicultural team with some knowledge of the beliefs and norms that exist in Syrian culture facilitated a meaningful therapeutic outcome.

Given how critical this cultural consultation and bridging was to engaging the refugee community, it was still felt that the wider system of care around the Syrian clients would benefit from the recruitment of more Arabic speaking and Syrian mental health and other professionals. Ensuring cultural and linguistic diversity of professionals, as well as culturally humble and reflective practitioners, should be emphasised as a central feature of the planning and delivery of future resettlement programs for refugees. There is also a need for the recruitment of service user representatives to guide decision making for future work.

Future directions

Placing the principles of trauma-informed care at the centre of any intervention for resettled and trauma-affected populations echoes what has been suggested by a multitude of services, professionals and researchers. What is at stake for the UK in heeding these recommendations is the provision of a resettlement programme that offers refugees a chance of thriving in their new communities, the opportunity to heal from loss and trauma, and the chance to regain a sense of peace, security and belonging. Whilst our specific recommendations are based on our clinical and practical experiences, more robust evidence-based improvements would require closer consultation with a range of service providers, and crucially with the refugee communities themselves. Given the number of variables that can be expected to determine wellbeing in refugee populations, evidence-based improvements would also require a more systematic collection of data on a variety of longer-term post-resettlement variables, including integration difficulties, social isolation, education and employment, that goes beyond the routine data collection of psychiatric symptomatology in NHS services.

Disclosure statement

No potential conflict of interest was reported by the author(s).