The more common mental health diagnoses associated with refugee populations include post-traumatic stress disorder (PTSD), major depression, generalized anxiety, panic attacks, adjustment disorder, and somatization. The incidence of diagnoses varies with different populations and their experiences. Different studies have shown rates of PTSD and major depression in settled refugees to range from 10-40% and 5-15%, respectively. Children and adolescents often have higher levels with various investigations revealing rates of PTSD from 50-90% and major depression from 6-40%. Risk factors for the development of mental health problems include the number of traumas, delayed asylum application process, detention, and the loss of culture and support systems.

Traditionally the refugee experience is divided into three categories: preflight, flight, and resettlement. The preflight phase may include, for example, physical and emotional trauma to the individual or family, the witnessing of murder, and social upheaval. Adolescents may also have participated in violence, voluntarily or not, as child soldiers or militants. Flight involves an uncertain journey from the host country to the resettlement site and may involve arduous travel, refugee camps, and/or detention centers. Children and adolescents are often separated from their families and at the mercy of others for care and protection. The resettlement process includes challenges such as the loss of culture, community, and language as well as the need to adapt to a new and foreign environment. Children often straddle the old and new cultures as they learn new languages and cultural norms more quickly than their elders. All of these experiences may play a role in the acquisition of, or protection from mental health conditions in each individual within a refugee population.

(RHTAC, https://refugeehealthta.org/physical-mental-health/mental-health/)

Although we are not going to be diagnosing any individuals, having a good look at some of the common emotional, behavioral and mental health concerns will help shape our conversation and care. These include depression, fear and anxiety, grief and loss, suffering and trauma.

Depression

Depression generally comes in two broad forms, “reactive depression” which is depression resulting from external sources and “endogenous depression” which generally has a biological root or medical cause, or predisposition. Sadness which is the God-given reaction to loss to help with grieving, is different than depression. The symptoms of depression include decreased energy, inability to concentrate, withdrawal, and suicidal thoughts. If you suspect a person is struggling with depression, always ask them about self-harm or attempted suicide, and refer for help immediately. Additional questions include “How long have you felt depressed? What has happened up to this point in your life that has made you feel depressed? Do you have a family or personal history with depression?” Listen without judgement, show genuine acceptance and gentleness. This is a great time to show the compassion of Christ! Fear, guilt and unrepentant sin are leading causes, asking “Are you dealing with guilt or fear about anything?” which may open up opportunity to pray for and encourage with the word of God (Anxiety in the heart of man causes depression, but a good word makes it glad.” Prov. 12:25). Further, hope is an excellent deterrent to depression, asking something like “what do you see in your future? How do you think you will beat depression?” may open up discussion for Hope in Christ!

Psalm 42:5 “Why are you cast down, O my soul? And why are you disquieted within me? Hope in God, for I shall yet praise Him for the help of His countenance. 

Isaiah 61:3 “To console those who mourn in Zion, to give them beauty for ashes, the oil of joy for mourning, the garment of praise for the spirit of heaviness; that they may be called trees of righteousness, the planting of the Lord that He may be glorified. 

Fear and Anxiety

“Fear” is the emotion that triggers automatic response, draws a person into a self-protective (survival) mode. It is the God given “engine” to out “fight or flight” responses. Fear is related to what a person perceives as a threat to their own safety/security. Four common fears include: failure, rejection, abandonment, and fear of death or dying. “Anxiety” is the constant fearful state, unrest, dread or worry. Caused by external sources, physical wellbeing, past or present trauma. Often has a physical symptom (increased heart rate, jumpiness). May lead to “panic attack” which is a sudden and overwhelming reaction, usually without any warning or known cause. Good conversation starters, or questions include: “When are you afraid or anxious? What causes the most distress?” When they answer, listen. Do not “downplay” or “rationalize”, just listen. Fear is a good thing, but fearful people have an irrational belief system. Gain understanding of what lies or deception contribute to their fear or anxiety. “What do you do to cope? When do your feelings of fear or anxiety go away?” Make a big deal about positive things, especially things which may lead them to a closer relationship with God! 

Psalm 91:3-6 “Surely He shall deliver you from the snare of the fowler and from the perilous pestilence. He shall cover you with His feathers, and under His wings you shall take refuge; His truth shall be your shield and buckler. You shall not be afraid of the terror by night, nor of the arrow that flies by day, nor of the pestilence that walks in darkness, nor of the destruction that lays waste at noonday.”

Proverbs 3:5-6 “Trust in the Lord with all your heart, and lean not on your own understanding; in all your ways acknowledge Him, and He shall direct your paths.”

Grief and Loss

Grief is intense emotional suffering caused by loss, which may be cumulative (awakens earlier losses never fully grieved) and reactive (intensified with certain reminders, anniversaries). There are 5 basic stages of grief (Kubler-Ross) (1) Denial/Shock (2) Anger towards others/God (3) Bargaining (4) Depression/Disconnection (5) Acceptance/New Normal. These are not sequential, more of a “cycle”. The goal is to help the individual find “new normal”. We hope that they find their new normal in Christ, who makes all things, including loss, good. When asking, “What are you going through? What has happened?“ Allow them to process the “facts” and “debrief their grief”. Don’t worry about “digging in to deep”. Don’t be afraid to cry with them, or just let them cry. Feel their pain, share their emotion, and normalize it with them. Everyone grieves! Asking, “How are you functioning now? What are you best times? Worst times?” gives us time to listen. Point their success to God, Praise Him. Redirect “if onlys” to signs of healing “now I am doing XYZ”. Finally, asking “Who is supporting you emotionally, spiritually?” provides opportunity to pray with them and share scripture. 

Isaiah 53:3-4 “He is despised and rejected by men, a Man of sorrows and acquainted with grief. And we hid, as it were, our faces from Him; He was despised, and we did not esteem Him. Surely He has borne our griefs and carried our sorrows; yet we esteemed Him stricken, smitten by God, and afflicted.”

Revelation 21:4 “And God will wipe away every tear from their eyes; there shall be no more death, nor sorrow, nor crying. There shall be no more pain, for the former things have passed away”

Suffering

Suffering has many causes and may be resulting from personal sin and failure, other peoples sin and failures, forces outside of our control and even because of personal faith/conviction. Many times those who suffer feel like they are one trial, or did something to deserve it. A basic “Theology of suffering” explains suffering is common to all, it is not removed by the presence of the Holy Spirit. Christians, non Chrisitians, Wealthy, Poor, Americans and Refugees… Everyone suffers. God uses suffering, and promises He will not abandon us. Suffering can be purposeful (2 Tim. 4:6-8) and is easier when you can see the end (Rom. 8:22-23). But It is not holy to simply endure pain for sufferings sake. First asking, “What is going on in your life? How can I help you?” provides time to try to gain understanding and provide empathy. Listen and offer to pray for them. Often suffering people are more open to intercessory prayer, because they feel God doesn’t hear them anymore or they are tired of praying for themselves. We need to attempt to help them gain “spiritual” clarity and recognize how God has sustained or helped them, instead of how they see Him “punishing” them. “How do you understand your situation? When did this start? How long have you been suffering? Have you made progress? Hows your faith?” Are all good ways to start to show them they need to trust God and to see what He’s teaching and what He’s doing. When staring at the “big picture” we can encourage them to take small steps forward. 

Psalm 66:10 “For You, O God, have tested us; You have refined us as silver is refined”

Trauma

Traumas can be defined as a life event that causes pain that goes deep and lasts a long time. They “go to the core” of the individual by overwhelming their normal adapting or coping mechanisms. Invasive trauma occurs when something happens to a person that creates damage (emotional invasion = verbal/nonverbal abuse, physical and sexual invasion = abuse/sodomy/rape, and spiritual invasion = oppressive cultic fear based/unworthy/shamed). Abandonment trauma occurs when something that should have happened, did not (emotional abandonment = no love/care, physical abandonment = missing basic needs, sexual abandonment = lack of modeled/taught healthy sexuality, spiritual abandonment = no healthy spiritual instruction). These “traumas” often overlap. Healing from the effects of trauma is possible. These individuals need to know they are experiencing a normal reaction to trauma, they need to be heard. Discuss what has happened, and do so gently. Honesty is key, don’t allow “denial”. If trauma goes on without being addressed it gives birth to more symptoms, namely “post traumatic stress”. This is different than PTSD. A disorder is clinically categorized by psychologists as the continued symptoms of PTS for more than a month, occurring more than a month after the event. This symptoms often include: Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares. Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma. Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered. Many individuals who do not get help with post-traumatic stress become to identify as being “broken, sick, mentally ill”. It is important to remember these people are looking for their identity. We should help them see their identity in Christ, as Sons of the King. As Co-heirs! They do not need to be defined by their past experience, or their current symptoms.  

There is a great podcast available here: https://ibcd.org/demystifying-ptsd/

I would encourage you to go to the website and listen to the podcast, while completing the notes (also available on the same website). This will give you great insight into PTS and caring for individuals with the word of God and Prayer. 

Lastly, the following text is adapted from Dr. Wrights book on Crisis and Trauma:

Remember what trauma is and does. Trauma is a thief. It steals from a person. It takes away their sense of wellbeing, security, predictability and safety

1. Make the Person Feel Safe The first step is to help the person feel safe. You must build the relationship first, so begin by building an atmosphere of safety, trust and exploration to ensure stability for the person before going any further. Just talking and listening with your eyes and ears is more important than techniques. Ask everyone, “Tell me your story.” 
2. Match the Person’s Thinking and Speaking If you honor the person’s way of thinking and speaking by matching his or her style of thinking and speaking, you will establish a connection. The more similar you appear, the greater comfort the person will experience. Connecting is vital. The principal to follow is “commonalities create comfort: differences produce distance.”
3. Know the Nature of the Trauma It is vital for you to know the nature of the trauma to this individual: how it is being perceived, how it is felt, and how it is being acted out. There is no effective way to know the impact of the trauma without going inside the individual to find out how the trauma has made its mark. 
4. Give Reasons for Symptoms When you work with traumatized people, giving them reasons for their symptoms and normalizing them can provide some of the relief they are looking for. By understanding that the way they react now is tied to changes in their brain, people can realize that what they’re experiencing now does not mean they’re in danger. It’s still upsetting, but not as upsetting as the actual event. 
5. Explore Trauma Memories with the Person You can explore trauma memories and associated responses with the person. People are often unable to process trauma because they are afraid of their thoughts. Trauma doesn’t fit what happened in reality; it goes against their belief or reality. The memories that come up of what happened makes them scared, so they try to push it out of their brain, but it just comes up even more. Intense or charged negative emotions seem to be “stuck” in the right hemisphere, split off from the more logical left hemisphere. As a result, trauma material remains fragmented, emotionally charged, nonverbal and unstable. At this point, relatively harmless triggers can cause trauma memories or memory fragments to flood the person’s awareness. The material is emotionally distressing and doesn’t make sense. 
6. Additional Items to Consider 

Here are some additional facts for you to be aware of as you help a traumatized person:

 • Intrusive thoughts represent the brain’s attempt to assimilate the experience—to make sense of the experience. The brain is not just letting the experience go, but attempting to make sense of it in some way. Flashbacks/nightmares are actually access routes to memory; it’s the brain attempting to heal itself and make sense of what happened. 

• Denial/numbing are ways the mind takes a “time out” as a way of “dosing” or of “pacing” itself so that it only has to deal with so much stress at one time. 

• Dissociation occurs when the body is present but the mind is somewhere else. In trauma it is a potentially useful skill, as the mind creates an emotional and mental escape when physical escape isn’t possible. 

Here are a few additional steps to take with someone who has gone through a traumatic event: 

• Convey that the survival skills the person once used and adapted to fit his or her situation may no longer be appropriate. 

• It often helps to commend the individual for being distressed. You could say something such as, “Given what you have been through, you should have [use individual’s symptoms—stressful reactions, depression, a short fuse at times, tendency to dwell on what happened]

• Tell the person that it is possible the symptoms will get worse before they get better as you begin to refocus on the trauma and work through what happened and why.

 • Finally, encourage the person that there might be unforeseen benefits for going through the traumatic situation. You could share, “Although this may be difficult for you to believe right now, you may find that there will be some positive benefits as a result of the experiences you have had and your willingness to face them and work through them.”

Adapted from: Wright, H. Norman. The Complete Guide to Crisis & Trauma Counseling