Approximately 8 million people have left Ukraine for other European countries in 2022 following Russia’s invasion that February, as the continent sees its largest and fastest displacement since World War II. As we have seen in the headlines, peoples’ lives were literally upended overnight and many refugees have experienced violence, family separation, and/or stressful journeys to a safer place. Such stressful situations are why mental health and psychosocial support are an essential component of humanitarian interventions – and why they should also be a key part of integration approaches, in this and other displacement contexts. Meanwhile, as the war continues, receiving countries are thinking more and more about the integration of newcomers from Ukraine.

Refugee integration and mental health

By definition, refugees are compelled to leave their homes due to dangerous and stressful circumstances. But it is not just the situation in countries of origin that impacts their mental health and well-being: Experiences during and after displacement also play an important role. Post-arrival experiences and conditions can shape refugees’ mental health and well-being and impact their resilience, or ability to cope with adversity new and old. While data suggest that refugees have similar rates of mental disorders as general destination-country populations (although there is considerable variation across studies), they are more likely to suffer from post-traumatic stress disorder (PTSD). Additionally, five years after resettlement, the rates of anxiety and depression are higher among refugees — illustrating the potential persistence of mental health challenges and indicating connections to integration contexts and trajectories.

As the research base grows, so does our understanding of the connections between refugee mental health and integration and the important role that integration stakeholders stand to play in supporting both. What have we learned so far, and how can integration actors strengthen their response?

The importance of the destination-country context

Post-migration stressors are now thought to be just as influential as experiences prompting forced migration. These include challenges related to the asylum procedure as well as those that come with settling in.

The asylum procedure is characterised by a high degree of uncertainty and it often entails a considerable wait. During this time, many asylum seekers live in reception facilities, which vary in setting type and quality but may be overcrowded, unsanitary, lack privacy, and/or have insufficient measures in place to ensure women’s security.

Even after a protection status is granted (or a refugee is directly resettled from a third country), refugees must contend with a range of changes when adjusting to life in a new country, including navigating a different culture and often a new language, as well as unfamiliar systems and institutions. Most immediately, they may face challenges in finding housing and employment and meeting other basic needs. At the same time, refugees may be dealing with other difficulties such as a loss of social networks, poverty, a decrease in social status, a rise in domestic violence, and/or discrimination and social exclusion.

Thus, even after arrival to a ‘safe’ country, the post-migration context in which refugees live can bring about new sources of stress – and may determine whether refugees can cope with pre-migration trauma. Additionally, the COVID-19 pandemic has presented new mental health challenges for refugees and exacerbated pre-existing ones.

The relationship between mental health and integration

Research shows that integration supports mental health, both in helping to address ongoing mental health challenges and protecting against new ones. Studies have found, for example, that active social participation serves as a protective factor, and that local language proficiency generally supports mental health. Studies of unaccompanied refugee minors have found that children’s post-migration social support network, such as peers and mentors, serve as a protective factor, and that having fewer post-migration daily challenges translates to a higher likelihood of resilience. By contrast, being isolated, unemployed, unable to speak the local language, or unsatisfied with housing has been found to worsen refugee mental health. The evidence base thus illustrates that the level of ease, or difficulty, in settling in – in other words, integration contexts and trajectories – can shape refugee mental health outcomes. For this reason, the World Health Organization has identified integration measures as an area for intervention to promote refugee mental health.

Meanwhile, available evidence, while more limited, suggests that the impacts of trauma and post-migration stress make language learning, health, employment, and other facets of life in a new country more challenging. A 2022 study of refugees in Australia, for instance, found that poorer mental health had a negative impact on a range of indicators related to labour market integration, including the chances of employment and likelihood of being in the labour force in the first place, as well as income and job quality. This indicates that mental health interventions can help promote positive integration outcomes for refugees. It also suggests that the relationship between refugee integration and mental health is bidirectional – in other words, that each affects the other. Mental health support can help increase the ability of refugees to benefit from the integration services provided and improve integration outcomes, while supporting refugees’ socio-economic integration can also serve to support their mental health.

Soon after Russia’s invasion of Ukraine, the European Union activated the Temporary Protection Directive for those displaced, thereby extending quick access to medical care, social welfare, housing, education, and the labour market. Also important, they are allowed to move within the EU to link up with their networks. This approach has been instrumental in supporting the integration and well-being of people fleeing Ukraine. In addition, initiatives to help newcomers learn the local language, build their networks, and take up jobs commensurate with their qualifications are also important in this respect. At the same time, challenges remain with regard to accessing mental health care – and, even if the Directive is implemented fully, ongoing stressors like uncertainty due to the continuing war and family separation all fall outside the scope of integration policies and programmes, meaning that mental health support will remain crucial.

An important and complementary role for non-clinical support

Many destination countries lack sufficient capacity to meet the mental health needs of their general populations, and it is often difficult to quickly provide specialised services that are culturally and linguistically responsive to all refugees who may need them. In the case of displacement from Ukraine, several of the main destination countries have relatively little prior experience receiving refugees, while mental health care systems were already under pressure prior to the Russian invasion, illustrating that mental health services must be strengthened generally and for refugees particularly. In Poland, for instance, temporary protection beneficiaries are entitled to free psychological assistance provided by municipalities, but a shortage of specialists remains a key barrier to access, as does the limited availability of Ukrainian- and Russian-speaking staff (although their number is growing). Even if mental health care is available, several factors might keep refugees from actually using them, including lack of awareness about available services, language barriers, transportation challenges, stigma, different or negative conceptions of mental health, and competing priorities (such as employment).

While specialised, clinical mental health care services remain an important tool for addressing refugee mental health needs, a broader approach involving other settings and sectors is beneficial, particularly given the role of post-migration stressors in influencing refugee mental health. Schools, early childhood programmes, community-based organisations, religious organisations, and sport and creative arts programmes are all examples of actors that can actively support refugee mental health and integration. Non-clinical approaches can reach larger numbers of beneficiaries, which is important in light of access and utilization barriers as well as migration dynamics. Broader approaches may lead to more focused interventions for some.

What does this mean for integration actors?

When it comes to post-migration stressors, policymakers and programmes have significant room to intervene. A bidirectional relationship between refugee integration and mental health suggests that both areas should be addressed simultaneously and that collaboration between the mental health and integration fields should be promoted. Mental health should be seen as an important component and outcome of integration programming (when it comes to humanitarian contexts, the importance of mental health and psychosocial support, MHPSS, is already accepted as a key part of displacement responses). This means that integration actors, including those in the housing, education, employment, social services, and health sectors, all stand to play an important role in supporting refugee integration and mental health. They can do this by:

• Working to improve public attitudes towards refugees among the public to foster a welcoming environment.

• Raising awareness about refugees and their experiences among service providers interacting with this population.

• Helping refugees to strengthen their networks in their new communities to reduce isolation and increase access to social support.

• Targeting refugee sub-groups that are especially at risk of mental health challenges for outreach and support, including unaccompanied children, women and girls, older adults, those with particularly severe trauma, and those facing a larger drop in socio-economic status.

• Offering non-clinical programming at schools and community-based organisations aimed at boosting mental health.

• Identifying symptoms of trauma as early as possible and referring people in need to specialised mental health services.

• Hiring mental health and integration staff from among refugee populations, as they bring important language and cultural knowledge as well as lived experience that will support efforts to reach out to and serve refugees.

The research base on the refugee integration-mental health nexus is growing. With evidence increasingly suggesting a bidirectional relationship between these two areas, it becomes clear that integration actors can play an important role in supporting both refugee integration and refugee mental health. Integration services can not only make daily life in a new country easier, but they can also boost mental health outcomes for refugees. Recognising the connection between integration and mental health and incorporating mental health considerations into integration policies and services, including by increasing support to reduce post-migration stressors, are critical areas for action.

This article is based on Katsiaficas, C. (2022), Refugee Integration and Mental Health: A Two-way Street?, Institute for European, Russian, and Eurasian Studies (IERES), George Washington University.

Caitlin Katsiaficas is a policy analyst at the International Centre for Migration Policy Development (ICMPD) and a former visiting scholar at IERES.

The opinions expressed in this article are those of the author and do not necessarily reflect the views of ICMPD.