“Translating Socio-Cognitive Models of Agency into Migration and Mental Health: A Framework for Individual and Community Empowerment” by Adam Brown and Evan Henritze

This is part of our special feature on forced migration, Narration on the Move.

 

The potential negative mental health consequences of forced migration is becoming increasingly recognized as an urgent issue in the context of international public health. Recent estimates show forcibly displaced people to be approximately 71 million worldwide. This crisis not only impacts those directly affected by forced migration, but also subsequent generations as well as non-immigrant populations of host countries whose health is closely associated with immigration policy (Bakhtiari, 2019). Historically it was believed that those who were able to navigate the challenges of migration were healthier than the general population. Given the physical and emotional demands of the journey, however, there are now many studies showing high levels of mental health issues among those who are displaced and seeking asylum in countries throughout Europe. Many factors contribute to mental health issues, but it appears that stressors and traumas before, during, and after migration all increase vulnerability to issues such as anxiety, depression, PTSD, and substance abuse. Despite the increased risk, there are dire gaps in the accessibility of appropriate treatments and services for migrants residing in countries throughout Europe.

How can researchers and policymakers address the mental health dimensions of forced migration? We recommend considering the following points when developing new methods and systems of care. First, mental health is inextricably linked with circumstances before, during, and after migration, and symptoms are closely related to an individual’s migration history. Second, accessible treatments must be culturally appropriate and presented in non-stigmatizing languages. Third, effective prevention and treatments must be guided by research appropriate for the context in which they are being delivered and informed by the intended recipients of such interventions. Finally, resources are scarce and thus any intervention must be scalable and easily accessible. The field of mental health practice and research has long been wedded primarily to medical models in which the investigations of cause and treatment focus primarily on the individual. Despite this, great strides have been made over the past decade by those working in “Global Mental Health” to emphasize the importance of social determinants. This latter approach can better elucidate why a person may be suffering from mental health issues, and it can guide the process of delivering support in partnership with migrant communities. In this frame, the distinction between “expert” and “patient” is reconfigured in such a way that the approaches used may also be more engaging and effective as they reflect more closely the lived experiences of individuals that have been forcibly displaced.

Across many subfields of mental health work (i.e. social work, clinical psychology) there has been a surge to create and disseminate community-based and peer-to-peer interventions. Other, more “traditional,” treatments grounded in theories such as cognitive behavioral therapy are also showing positive effects in the treatment of individuals experiencing distress associated with forced migration. Moreover, the World Health Organization (WHO) and other organisations recently developed a series of interventions, such as Problem Management Plus and Self-Help Plu.  These interventions are intended to be delivered by non-experts who can be trained in a relatively short period to participate in the mental health care of those in their communities. The method of delivering mental health interventions through less specialized health workers is known as “task-shifting.” Interventions based on this method of dissemination appear to be quite promising and have since received considerable support for treating Syrian refugees across Europe.

Although current task-shifting approaches show promise, they would be better able to meet the complex needs for researching and treating migrant mental health if they incorporated the construct of efficacy. Cognitive and social psychologist Albert Bandura’s framework of efficacy explains how an individual’s belief system plays an important role in their reactions to stress and the quality of coping in threatening situations (Bandura, 1997). Since first proposed in the 1970s, efficacy has been demonstrated to be an underlying cognitive mechanism predicting a range of mental health outcomes. Beliefs associated with efficacy refer to the perceived capacity to control one’s environments, thoughts, emotions, and actions to manage personal and group functioning and to achieve desired goals. The same event may seem benign to one person and potentially threatening to another person. Those who believe they can exercise control over challenging circumstances do not ruminate over potential calamities. In contrast, those who perceive threats as unmanageable view the environment as dangerous and focus on their limits to successfully cope. The concepts of self and collective efficacy are central to understanding the mental health impacts of forced migration. For many, forced migration may be defined, in part, by a lack of control.

Forcibly displaced individuals face an extensive range of potentially distressing circumstances before migration, during migration, and after resettlement in a host country in which many of the decisions being made are outside of their input (Priebe, Giacco, & El-Nagib, 2016). Even after a person removes her or himself from immediate danger or poverty- applying for asylum is a highly stressful process that involves language barriers as well as incomplete information about legal processes and documentation challenges. Such stressors, directly and indirectly, lead to mental health issues. People differ, however, in the way that they respond psychologically to events beyond their control: some may feel hopeless or despondent years after exposure to life-altering events and others may experience few to no negative mental health consequences (Buckley, Blanchard, & Neill, 2000; Foa, 1997). Individual differences in self-efficacy can predict susceptibility to trauma-related disorders such as PTSD (Benight & Bandura, 2004).

The importance of considering efficacy in mental health interventions for forced migration converges with years of experimental studies that have demonstrated that self-efficacy can be enhanced and doing so buffers the negative impacts of stress. For example, in a series of lab-based studies with clinical and non-clinical populations, our lab found that perceptions of self-efficacy (beliefs about one’s ability to cope with adversity and stress) can be temporarily enhanced, and this enhancement has a number of clinically-relevant downstream consequences. That is, as people experience themselves as being more self-efficacious, they subsequently exhibit better performance on tasks associated with emotion regulation, problem-solving, and memory. Recent work has also interestingly shown that increasing self-efficacy beliefs also correspond to differences in activation in the prefrontal cortex- a part of the brain highly involved in adapting to stress (Titcombe-Parekh et al., 2018). A recent study by psychologist Naser Morina and colleagues found that asking torture survivors to recall memories of self-efficacy experiences subsequently led to better performance on tasks related to regulation of emotions (Morina et al., 2018).

While individual self-efficacy is an integrated component of collective-efficacy, it is important that clinicians, researchers, and policymakers clearly distinguish collective-efficacy approaches as particularly appropriate for the migrant experience. The concept of efficacy might otherwise  be misconstrued as a promotion of individualism and an inattention to social circumstances. Explanations centered on self-efficacy without a discourse of the collective can risk promoting notions of “self-reliance” which deemphasize the crucial need for resource distribution via public and private refugee-assisting agencies. Current approaches to “self-reliance en masse” ignore individual ability differences and thus enact neoliberal tenets that uphold individual responsibility and put marginalized people (e.g. women, ethnic minorities, and disabled peoples) at increased risk (Easton-Calabria & Omata, 2018). We believe that a focus on personal agency need not be confused with an atomized view of mental health and can instead be a humane way of promoting collective psychological and political resilience among migrant populations.

By proposing collective-efficacy as a psychological framework for the promotion of migrant wellbeing, our interest is in human enablement and avoiding discourses of victimization. This framework also encourages the importance of partnerships between clinicians, researchers, activists, and policymakers to consider the role of civic and political engagement within the therapeutic context. It recognizes that perceptions of efficacy, both self and collective, are profoundly shaped by access to power and participation. Mental health interventions developed within communities and designed to promote a shared understanding of how efficacy beliefs are formed would support asylum seekers to be political-engaged actors. By working towards collective attainment of goals, this intervention model promotes powerful and lasting effects on wellbeing that are not often achieved or addressed in “traditional” individual therapy.

Migrants’ shared beliefs in their collective power to enact and move towards desired outcomes are key ingredients of collective efficacy. This group-level property of efficacy is not simply the sum of individual members’ personal beliefs but is instead determined by the interaction and coordination of how those beliefs are shared, modeled, and transmitted within communities. People act in coordination with sets of shared beliefs that influence the types of futures they seek, as well as their willingness to commit to difficult shared goals (e.g. political sovereignty and human rights).  These are goals that will likely not manifest quickly but will require persistence, patience, and skill in the face of potential opposition. Measures of efficacy have a distinct advantage over many mental health screenings since they avoid stigmatizing language associated with pathology and can be assessed by simple questions. Collective-efficacy research would shed light on the interpersonal transmission of efficacy and allow an insight into which particular members of communities (e.g. local leaders) have the greatest impact on other members.

The efficacy framework also raises critical questions about what constitutes a mental health intervention. Wellbeing is intimately connected to basic needs and economic security. Whereas traditional forms of individual counseling may effectively address some mental health issues, we urge those involved in social entrepreneurship and related sectors to consider developing strong partnerships with mental health researchers and policy makers to consider studying and supporting the potential long-term benefits of non-mental health interventions that will likely improve wellbeing. Some such interventions are already happening in lower-to-middle-income countries (LMICs) around economic empowerment, access to micro-loans, and providing easy access to sports, but there is much more work to be done in this area—especially for those seeking asylum in Europe. Entrepreneurship development programs offer another avenue for improving mental health outcomes by specifically addressing self and collective efficacy beliefs amongst migrants.

We know from decades of research that stripping people of agency has negative impacts on their lives. A psychology of efficacy begins with the premise that empowerment and agency are central to individual and community wellbeing. A forcibly displaced migrant’s sense of personal controllability influences their capacity to shape the very same social circumstances from which their pathology arose. How and what kinds of interventions will be used to enhance perceptions of control will benefit from diverse participation in the design and delivery of new forms of care. A diversity of perspectives in the design and delivery of new forms of care will determine how and what kinds of interventions will be used to enhance perceptions of control. While the experience of forced migration disconnects people from their power as agents, our personal and political systems would benefit from a body of research and associated interventions focused on collective-efficacy.

 

Evan Henritze is a Ph.D. candidate in Clinical Psychology at the New School for Social Research.

 

Adam Brown is a clinical psychologist and Associate Professor at The New School for Social Research, where he directs the Trauma and Global Mental Health Lab. His research focuses primarily on studying the impact of trauma on mental health and creating international multi-disciplinary partnerships to aid in the identification of mental health risk factors and increasing access to care. 

 

 

 

References:

Bakhtiari, E. (2019). Immigration Policy is Health Policy. Retrieved September 3, 2019, from Europe Now website: https://www.europenowjournal.org/2019/06/10/immigration-policy-is-health-policy/

Bandura, A. (1997). Self-efficacy: The exercise of control. Macmillan.

Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42(10), 1129–1148. https://doi.org/10.1016/j.brat.2003.08.008

Buckley, T. C., Blanchard, E. B., & Neill, W. T. (2000). Information processing and PTSD: A review of the empirical literature. Clinical Psychology Review, 20(8), 1041–1065.

Easton-Calabria, E., & Omata, N. (2018). Panacea for the refugee crisis? Rethinking the promotion of ‘self-reliance’ for refugees. Third World Quarterly, 39(8), 1458–1474. https://doi.org/10.1080/01436597.2018.1458301

Foa, E. B. (1997). Psychological processes related to recovery from a trauma and an effective treatment for PTSD.

Morina, N., Bryant, R. A., Doolan, E. L., Martin-Sölch, C., Plichta, M. M., Pfaltz, M. C., … Nickerson, A. (2018). The impact of enhancing perceived self-efficacy in torture survivors. Depression and Anxiety, 35(1), 58–64.

Priebe, S., Giacco, D., & El-Nagib, R. (2016). Public health aspects of mental health among migrants and refugees: A review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region. World Health Organization. Regional Office for Europe.

Titcombe-Parekh, R. F., Chen, J., Rahman, N., Kouri, N., Qian, M., Li, M., … Brown, A. D. (2018). Neural circuitry changes associated with increasing self-efficacy in Posttraumatic Stress Disorder. Journal of Psychiatric Research, 104, 58–64. https://doi.org/10.1016/j.jpsychires.2018.06.009

Bakhtiari, E. (2019). Immigration Policy is Health Policy. Retrieved September 3, 2019, from Europe Now website: https://www.europenowjournal.org/2019/06/10/immigration-policy-is-health-policy/

Bandura, A. (1997). Self-efficacy: The exercise of control. Macmillan.

Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42(10), 1129–1148. https://doi.org/10.1016/j.brat.2003.08.008

Buckley, T. C., Blanchard, E. B., & Neill, W. T. (2000). Information processing and PTSD: A review of the empirical literature. Clinical Psychology Review, 20(8), 1041–1065.

Easton-Calabria, E., & Omata, N. (2018). Panacea for the refugee crisis? Rethinking the promotion of ‘self-reliance’ for refugees. Third World Quarterly, 39(8), 1458–1474. https://doi.org/10.1080/01436597.2018.1458301

Foa, E. B. (1997). Psychological processes related to recovery from a trauma and an effective treatment for PTSD.

Morina, N., Bryant, R. A., Doolan, E. L., Martin-Sölch, C., Plichta, M. M., Pfaltz, M. C., … Nickerson, A. (2018). The impact of enhancing perceived self-efficacy in torture survivors. Depression and Anxiety, 35(1), 58–64.

Priebe, S., Giacco, D., & El-Nagib, R. (2016). Public health aspects of mental health among migrants and refugees: A review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European Region. World Health Organization. Regional Office for Europe.

Titcombe-Parekh, R. F., Chen, J., Rahman, N., Kouri, N., Qian, M., Li, M., … Brown, A. D. (2018). Neural circuitry changes associated with increasing self-efficacy in Posttraumatic Stress Disorder. Journal of Psychiatric Research, 104, 58–64. https://doi.org/10.1016/j.jpsychires.2018.06.009

 

 

 

 

Photo: Chain of people figurines connected by white lines | Shutterstock

Published on October 29, 2019.

 

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