Considering chronic uncertainty among Syrian refugees resettling in Europe
Authors: Charles W Cange, Calle Brunell, Ceren Acarturk, Fouad M Fouad
Journal: The Lancet Public Health (2018)

The uncertainty of the asylum-seeking process has been associated with a multitude of stressors and poor mental health outcomes.1Hynie M The social determinants of refugee mental health in the post-migration context: critical review.Can J Psychiatry. 2018; 63: 297-303Crossref PubMed Scopus (211) Google Scholar Data indicate that daily stressors mediate the effects of previous war-related trauma in shaping mental health outcomes, such as post-traumatic stress disorder symptoms.2Silove D Ventevogel P Rees S The contemporary refugee crisis: an overview of mental health challenges.World Psychiatry. 2017; 16: 130-139Crossref PubMed Scopus (306) Google Scholar Along with uncertainty, asylum seekers can experience many mixed emotions, including hope, fear, anger, distrust, and relief. Traumatic events, such as being forced to leave one's own country; being trafficked, tortured, or sexually assaulted; and facing death threats; among others, can severely damage an asylee's own sense of trust and security. Syrian asylum seekers have expressed idioms of distress to psychosocial staff, such as "I go to bed with worry and wake up with worry" or "it makes my soul go out of my body". Many of these culturally specific idioms seem to be in sharp contrast to the initial resilience expressed after the difficult journey to Europe. However, the effects of being a refugee are cumulative—eg, the longer he or she is on hold in asylum process, the less likely one is to find employment. According to a recent report from Médecins Sans Frontières, the uncertain life situation, constant fear of the future, and deportation possibilities that asylum seekers face in their destination countries is the main contributing factor to poor mental health in this population.3MSFLife in limbo: MSF's psychosocial support for asylum seekers in Sweden, report. April 9, 2018. Médecins Sans Frontières, Stockholm2018Google Scholar Specifically, asylees' uncertain situation in Sweden actually makes them feel worse.3MSFLife in limbo: MSF's psychosocial support for asylum seekers in Sweden, report. April 9, 2018. Médecins Sans Frontières, Stockholm2018Google Scholar In its most dramatic form, uncertainty expresses itself in the resignation syndrome (known as Uppgivenhetssyndrom in Swedish), as observed in asylum-seeking children in Sweden. As long as uncertainty prevails, a normal, functional life is simply not possible for many asylees and refugees. In fact, the protracted asylum-seeking process can have a stronger effect on mental health than trauma experienced before migration.4Li SS Liddell BJ Nickerson A The relationship between post-migration stress and psychological disorders in refugees and asylum seekers.Curr Psychiatry Rep. 2016; 18: 82Crossref PubMed Scopus (306) Google Scholar Postmigration factors, such as access to housing, employment and a sustainable income, language skills and social support as well as experiencing discrimination and social isolation, must also be considered to understand the psychological effects of the refugee experience.4Li SS Liddell BJ Nickerson A The relationship between post-migration stress and psychological disorders in refugees and asylum seekers.Curr Psychiatry Rep. 2016; 18: 82Crossref PubMed Scopus (306) Google Scholar The asylum system, however, is unpredictable and is characterised by its lack of transparency5Neil D Peterie M Grey networks: the contradictory dimensions of Australia's immigration detention system.Asia Pac Viewp. 2018; 59: 132-144Crossref Scopus (9) Google Scholar as well as individual control. Someone else, usually a refugee programme administrator or service provider, tells you where to live and how to fill your days.6Forrest TM Brown LA Organization-led migration, individual choice, and refugee resettlement in the US: Seeking regularities.Geogr Rev. 2014; 104: 10-32Crossref Scopus (12) Google Scholar Another person decides your fate, on grounds that are often arbitrary and hard to understand. Most asylees find it difficult to seek help and use services because of the aforementioned heightened sense of distrust and insecurity. Moreover, the operational difficulties, such as language barrier and lack of secure and safe relationships, make it more difficult to connect again to others in the new host country. Given the multitude of factors and the chronic uncertainty that refugees face, we would propose that refugee service providers be trained not only in trauma-informed care, which is already offered in some European countries,7Kazlauskas E Javakhishvilli J Meewisse M et al.Trauma treatment across Europe: where do we stand now from a perspective of seven countries.Eur J Psychotraumatol. 2016; 7: 29450Crossref PubMed Scopus (25) Google Scholar but also be trained in uncertainty-informed care. This type of care means that the provider would be able to recognise the chronic state of uncertainty in which many asylees find themselves while offering ways to minimise its effects on their daily lives and emphasise resilience. Although the provider will not have the same level of awareness or tools as a licensed clinician, this type of uncertainty-focused training could ensure a critical awareness and understanding of the asylee's situation in the host country. Furthermore, the provider can refer a client to proper psychiatric services or to a social worker who will be able to provide culturally sensitive care and treatment. We declare no competing interests.