The present refugee crisis will likely be one of the defining features of the current era. By the end of 2015, worldwide refugee numbers exceeded 65 million and growing, surpassing displacement numbers seen at the end of World War II. At present, nearly one out of every hundred people on earth are refugees; men, women, and children torn from their homes by war and violence. In the course of becoming refugees, many of these people have experienced traumatic events, which may carry heavy psychological consequences. Dr Ulrich Schnyder has devoted his career to understanding the psychological burdens of civilian trauma survivors, with hopes of improving the psychological wellbeing of refugees.

Over the past decade war and terror attacks have loomed over the general consciousness of most of the world. The stress of these events may stretch across nations, but none feel it more acutely than those living in war zones. Researchers, such as Dr Ulrich Schnyder, are working to understand the effects of this severe traumatic stress on the most vulnerable populations, refugees who have fled their violent homelands.

Psychological Consequences of War

Since its addition to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, post-traumatic stress disorder (PTSD) has made the journey from a poorly understood phenomenon to household name. In the past decade, public awareness of PTSD has risen dramatically and diagnosis and interventions for this potentially debilitating psychological disorder have improved. PTSD is a mental disorder that may develop following the experience of a highly traumatic event that threatens a person’s life or the life of those they care about. Symptoms often include flashbacks, nightmares, distressing memories, strong psychological and physical reactions to things that remind the sufferer of the event, and long-term alterations in thought processes and emotional responses. While PTSD is often associated with soldiers returning from war, civilians can also develop the disorder following traumatic events such as sexual assault, witnessing a murder, terrorist attacks, or natural disasters.

Refugees often experience a multitude of traumatic events while living in and escaping from their violent homelands, placing them at high risk for PTSD and other trauma related mental disorders. Dr Ulrich Schnyder, a professor of psychiatry and psychotherapy at Zurich University, and head of department at the University Hospital Zurich, has been studying traumatic stress for over 25 years. In 2010, he recognised that the unique needs of refugees were poorly understood and often inadequately treated, and embarked on a research program to improve our comprehension of the psychological consequences of war and other state-organised forms of violence such as persecution and torture on civilians. He recalls, ‘I realised that there is a need to study this population scientifically in order to better understand their particular situation, to take into account the cultural dimension, and ultimately to develop interventions that are tailored to the specific needs of severely traumatised refugees.’

Refugees are more likely to experience PTSD, along with a host of other mental disorders, including depression, anxiety, obsessive-compulsive disorder, outbursts of anger, and trust issues. The number and severity of traumas experienced are tied to the likelihood of developing a disorder, and many refugees have survived multiple traumas. These experiences are often compounded by the ongoing stress of displacement, due to factors such as homelessness, unemployment, separation from family, insecure visa status, and discrimination against refugees. Dr Schnyder and his colleagues hope that by illuminating the dysfunctional psychological processes caused by these stressors, they can develop effective individual as well as public health interventions that improve the lives of refugees and help them move past the traumas of war and violence to build new lives.

‘There is a need to study this population scientifically in order to better understand their particular situation, to take into account the cultural dimension, and ultimately to develop interventions that are tailored to the specific needs of severely traumatised refugees’

Unique Perspectives on Trauma & PTSD

The DSM is revised roughly every 10 years to accommodate advances in research and understanding of psychological disorders. Original DSM-IV standards for PTSD contained seven diagnostic criteria, generally: exposure to a traumatic event, persistent re-experiencing of the trauma in the form of intrusive thoughts or distress when exposed to reminders of the event, avoidance of things that remind the sufferer of the trauma, and higher reactivity and anxious energy following the event, with all symptoms creating distress, lasting more than a month, and not being due to other causes. When the DSM was revised to the DSM-5 in 2013 it added an additional cluster to the PTSD diagnostic – negative changes in thought patterns (cognitions) and mood following the event. While research in other populations had found relatively little difference in diagnosis levels with the new criteria, Dr Schnyder compared the PTSD diagnostic criteria of the DSM-IV to the DSM-5 in a group of refugees. He found that fewer refugees (49.3% to 60.4%) met the diagnostic criteria for PTSD with the new scale. This was surprising, but may provide important insight into diagnosis and treatment of refugee populations in the future. Negative changes in cognitions and mood could be more predictive of emotional dysregulation and need for treatment in people that have experienced multiple traumatic events, while other PTSD criteria, such as thoughts about the traumas, might be more expected and less indicative of a disorder when a person has been through so much.

Military PTSD treatments focus heavily on reducing the fear related responses typical to PTSD, but Dr Schnyder and his colleagues recognised that the traumas experienced by civilians are often different in nature than those experienced by soldiers. Civilian war survivors certainly experience situations that provoke a life-threatening fear response, but beyond that, refugees often also witness events that run opposite to their deeply held moral principles and beliefs about the world. These types of experiences, such as witnessing a murder or being forced, under torture, to betray a friend, can cause ‘moral injury’, a long lasting psychological response to having one’s beliefs about humanity and morality shattered during a traumatic experience. Dr Schnyder notes, ‘The majority of refugees we are studying had been exposed to torture, and all of them had experienced a multitude of additional traumatic events.’ To understand the role of moral injury in the mental disorders that often follow trauma, Dr Schnyder’s research group studied a group of refugees seeking asylum in Switzerland, who were suffering from conditions including PTSD, depression, and angry outbursts. After controlling for other factors, such as number of traumas and additional stressors, they found that moral injury largely predicted whether or not a refugee would suffer from PTSD. This holds important implications for treating PTSD in refugees. Rather than focusing on extinguishing fear responses, individuals that have suffered moral injury may benefit more from cognitive therapies that help realign and repair their view of humanity.

Perhaps unsurprising, PTSD is not the only mental disorder likely to plague refugees, and those experiencing PTSD are also more likely to suffer from additional conditions, both psychological and somatic. Studies of refugees across many cultures have indicated that nearly a third may experience PTSD, while over half are likely to suffer from depression. Of those with PTSD, up to 75% have at least one additional psychiatric condition. Dr Schnyder and colleagues have worked to deepen the understanding of conditions that are likely to be comorbid with PTSD in refugees. They found that survivors with more severe PTSD symptoms are more likely to experience obsessive-compulsive disorder, chronic pain, difficulties with anger regulation, and problems adjusting to new living conditions following migration. Surprisingly, the number of traumas experienced was not always predictive of the severity of symptoms and comorbid disorders. In order to understand this, Dr Schnyder and colleagues sought to understand what factors might influence whether or not the experience of a trauma led to a disorder. They found that difficulties with certain aspects of emotion regulation predicted which individuals were more likely to have psychological disorders following a trauma. Specifically, trouble with goal-directed behaviour (‘When I’m upset I have difficulty concentrating’) and lack of emotional clarity (‘I am confused about how I feel’) were associated with severity of PTSD symptoms. These findings provide further direction for developing effective psychological interventions for refugees.

Moving Forward in an Uncertain World

Beyond the mental burden of past traumas, refugees often face additional psychological hurdles even after they have managed to escape their dangerous homeland. Those that have resettled in unfamiliar host countries are often expected to integrate quickly, despite language and cultural differences, visa uncertainty, lack of employment, potential discrimination, and possible psychological impairment. Those suffering from a trauma-induced mental disorder may have difficulty finding psychiatric treatment in their language or that is sensitive to their cultural nuances, while those settled in countries with less public health infrastructure may struggle to find treatment at all. To further compound the issue, Dr Schnyder and colleagues have found that survivors of severe traumas, particularly torture, often become distrusting of others and avoidant of forming new interpersonal relationships. These avoidant tendencies may inadvertently work to maintain poor psychological health, as the emotional support, understanding, and stability afforded by close relationships can be a powerful force for healing in trauma survivors. Cognitive treatments that help to restore trust and support the formation of healthy interpersonal attachments may further benefit refugees attempting to integrate into new societies.

Dr Schnyder and his colleagues are working to understand and address the psychological factors that hinder refugees from integrating their new host countries. In a study of over 100 psychiatric-treatment seeking refugees resettled in Switzerland, they found that difficulties with integration were strongly associated with the number of trauma related symptoms a patient displayed. Factors expected to help with integration, such as high levels of education and stable visa status, made relatively little difference in the face of unresolved psychological trauma, even in individuals that had been residing in Switzerland for over 10 years. This suggests that early and effective psychological treatments for refugees could dramatically improve integration into their host societies, with the long-term effect of increasing their overall wellbeing and contributions to their new communities.

To facilitate integration success for refugees, Dr Schnyder champions the necessity for culturally sensitive treatments for trauma survivors. Psychological healthcare providers can partner with members of the refugee community to gain valuable insights into cultural differences that may present roadblocks to standard treatment strategies. When traditional talk therapy isn’t working, patients may benefit from the use of other mediums, such as art or dance, to access and work through traumatic memories. Recognising that not all countries have the public health funding and infrastructure to provide expensive mental health treatment, Dr Schnyder, in collaboration with a large research consortium, is currently embarking on a large-scale study to bring mental health to present victims of the refugee crisis. The EU (Horizon 2020) funded STRENGTHS project aims to provide innovative, low intensity mental health treatment to large numbers of Syrian refugees who had been lucky enough to make it to Europe, as well as in refugee camps in Jordan, and Turkey. These treatments are tailored to the unique needs of refugees, designed to be easy to implement and capable of improving mental health across a wide spectrum of traumarelated disorders. Moreover, the research group in Zurich also hopes to develop new treatment approaches for treatment-seeking, severely traumatised refugees: ‘We are currently developing so-called miniinterventions, i.e., short psychotherapeutic interventions that address a specific, circumscribed problem such as the traumatised refugees’ lack of perceived self-efficacy,’ Dr Schnyder explains.

Dr Ulrich Schnyder is a professor of psychiatry and psychotherapy at University of Zurich, and head of department at the University Hospital Zurich in Switzerland. His current research revolves around trauma in civilian survivors of war, and he is dedicated to improving the psychological health of these individuals.

E: ulrich.schnyder@access.uzh.ch

T: (+41) 44 255 5251

Dr Naser Morina, PhD, is a licensed clinical psychologist and psychotherapist at the University Hospital Zurich, specialising in traumatic stress. His specific research expertise focuses on aspects of traumatic stress research in migrants, refugees and civilian war survivors. His research theme on trauma-related disorders in refugees and post-war affected people is wideranging. In addition, he is Co-Director of the Clinical Psychology and Psychotherapy Training in Kosovo (CPPK). He is senior research assistant and psychotherapist at the Outpatient Unit for Victims of Torture and War.

E: naser.morina@usz.ch

T: (+41) 44 255 5280

Dr Matthis Schick, MD, is a licensed psychiatrist and psychotherapist and holds a Master of Advanced Studies in Psychotraumatology from University of Zurich. Since 2010, he has headed a treatment centre for victims of torture and war at the University Hospital of Zurich. His research interests cover various aspects of refugee mental health, including post-traumatic and post-migration stress, family mental health, and public policy. One of his roles is to ensure the integration and mutual stimulation of clinical and research activities within the team.

E: matthis.schick@usz.ch

T: (+41) 44 255 5280

Dr Monique Pfaltz received her PhD in 2008 from the University of Basel, Switzerland. She currently works as Assistant Professor of clinical and experimental psychophysiology at the University of Zurich. Dr Pfaltz’s research focuses on emotion regulation and emotion recognition in healthy individuals and in clinical populations.

E: monique.pfaltz@usz.ch

T: (+41) 44 255 5280

Tobias Raphael Spiller is currently a final year medicine student at the University of Zurich. During his studies, he developed a special interest in psychotraumatology with a focus on refugees. He had the opportunity to work as a guest researcher at the University of New South Wales in Sydney and as a research assistant at the University of Zurich. His scientific interests include comorbidity of Post-Traumatic Stress Disorder (PTSD), anger, somatisation and new methods like network analysis.

E: tob_spiller@hotmail.com

T: (+41) 44 255 5280

Professor Richard Bryant AC is Scientia Professor of Psychology, University of New South Wales, NHMRC Senior Principal Research Fellow, and Director of the UNSW Traumatic Stress Clinic. He has published over 460 journal articles on trauma, anxiety, and treatment. He has authored the leading text on acute stress disorder and served on both the DSM-5 and ICD-11 committees rewriting the new diagnoses for PTSD. He is conducting largescale mental health evaluation programs in Europe and the Middle East, as well co-ordinating studies into neural and psychological mechanisms of refugee adjustment.

E: r.bryant@unsw.edu.au

T: (+61) 2 938 3640

Dr Angela Nickerson completed a Masters/PhD in Clinical Psychology at UNSW Australia in 2009. Following this, she conducted postdoctoral research at Harvard University, Boston University and UNSW Australia, supported by research fellowships from the American Australian Association and the Australian National Health and Medical Research Council. Dr Nickerson is Senior Lecturer in the School of Psychology, UNSW Australia, and Director of the UNSW Refugee Trauma and Recovery Program. Her research focuses on understanding mechanisms underlying refugee mental health, with the goal of informing treatment development, service provision and policy for refugees and asylum-seekers.

E: anickerson@psy.unsw.edu.au

T: (+61) 2 9385 0538

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