Mental health in forcibly displaced adults in Germany: Access and barriers to mental health service utilization, the impact of an insecure asylum status, and the moderating effect of perceived social support

Böttcher V. Mental health in forcibly displaced adults in Germany: Access and barriers to mental health service utilization, the impact of an insecure asylum status, and the moderating effect of perceived social support. Bielefeld: Universität Bielefeld; 2023.Background. In May 2022, the United Nations High Commissioner for Refugees (UNHCR) published a new record with 100 million people being forcibly displaced worldwide (UNHCR, 2022). Compared to populations that were not forced to leave their home country, prevalence rates of mental disorders are comparably high in populations of forcibly displaced people (Bozorgmehr et al., 2016; Gäbel et al., 2006). Even though research in this area is growing, numbers and data vary widely across studies. In addition, although a significant portion of the literature has addressed mental distress in forcibly displaced populations, comparably little is known about mental health care utilization among these groups, including perceived barriers. The mental distress experienced by forcibly displaced persons is not limited only to the potentially high trauma load accrued before, during, and after flight. Challenges may also stem from different factors associated with the country of reception. These so-called postmigration living difficulties (PMLD) include potentially distressing factors refugees may confront in the country of reception. For example, forcibly displaced persons may be faced with an insecure asylum status, and the insecurity and perceived lack of control associated with such status uncertainty, a known factor associated with mental distress in refugees (Heeren et al., 2016; Müller et al., 2018; Newnham et al., 2019). Perceived social support is another factor that has been associated with refugees’ mental health, and serves as a possible target for intervention and support. Perceived social support is thought to provide a buffering effect that protects forcibly displaced persons from the negative influence of the stress they experience, promoting better outcomes (Mels et al., 2008; Sierau et al., 2019). Throughout their experience of displacement, however, most forcibly displaced people report the loss of close family members or other important persons which represents a significant threat to their social connections (Chen et al., 2017). Objectives. Drawing from the literature on mental health in forcibly displaced persons, the research presented in this dissertation thesis presents three different topics within the area of refugee research. The approach utilized in the present dissertation thesis utilizes a multi-step process to better understand the experience of refugees. In the first study, the goal was to investigate the current context of forcibly displaced persons’ mental health and mental health care utilization. This step creates a firm foundation of understanding on which the next studies are established. After establishing an overview of refugees’ mental health status as well as their perceptions and utilization of mental health care, the second study evaluated the influence of an insecure asylum status on mental distress as one of the most significant postmigration living difficulties. Time since arrival in Germany was added to this analysis as well to account for differences in experiences over time. Last, perceived social support was investigated as a possible protective factor for forcibly displaced people in Germany. As the majority of those forcibly displaced arriving in Germany experienced the loss or absence of close friends and family members, the moderating effect of perceived social support was investigated to get a better understanding of the role of social support for forcibly displaced people. More precisely, the feeling of having the opportunity to confide in someone was analyzed as a specific aspect of perceived social support. In addition, different social contexts were considered in exploratory analyses. Methods. Data was collected during two phases of data collection (February 2018–August 2018 and August 2018–March 2019, respectively) by means of face-to-face interviews. Participants were accessed through contact with social workers working in the selected area in the north-east of North Rhine-Westphalia. Prior to any data collection, informational events were conducted to inform potential participants about the aim and procedure of the research. For the first data collection, phase interviews were conducted by trained paraprofessional interviewers in Arabic, Kurmancî, Farsi, English, or German. The final unselected convenience sample included 177 interviews (20.3% female). Participants were an average 33.03 years old (SD = 11.21). Instruments used included an event checklist, the Refugee Health Screener-15 (RHS-15; Hollifield et al., 2013) to assess mental distress, questions regarding participants’ asylum status, and a self-developed questionnaire to assess health service utilization, barriers to mental health service utilization, and perceived need for psychotherapeutic treatment. Following the first wave of data collection, attempts were made to contact participants who had provided their written consent with the opportunity to participate in the second round of interviews. Here, the majority of interviews were conducted by the lead researcher (V. S. Boettcher), with a master’s student in psychology also conducting several interviews. Trained interpreters were present during all interviews and translated when necessary. In total, 65 participants completed interviews (20.0% female). Participants in this wave of data collection were, on average, 34.50 years old (SD = 12.13). The semi-structured interviews included questions regarding asylum status, opportunity to confide in others, potentially traumatic event types, and posttraumatic stress disorder (PTSD) symptoms using the German version of the PTSD checklist for DSM-5 (PCL-5; Krüger-Gottschalk et al., 2017). In the first study presented here, data of the first data collection phase was analyzed. For the second study both samples were included in the analyses. Regarding the last study, the second data collection was in the center of attention. Results. More than half of the participants (54.8%) scored above the RHS-15 cutoff indicating a high amount of mental distress in the majority of participants. Despite the high number of mentally distressed participants, only 19.8% (n = 35) participants reported a need for psychotherapeutic support. However, none of the mentally stressed individuals received evidence-based psychotherapeutic treatment as recommended in the German S3-Leitlinien. Common perceived barriers to accessing care were language difficulties and missing information regarding German mental health care system. Within the scope of the second study, multiple hierarchical regression analyses were calculated to determine the impact of an insecure asylum status on mental health. In both samples an insecure asylum status explained an additional significant amount of variance of mental distress above and beyond the influence of the number of reported potentially traumatic events (i.e., their trauma load) and time since arrival in Germany (Sample A: F(5, 161) = 7.82, p < .001, explained variance: 19.5%; Sample B: F(5, 58) = 9.64, p < .001, explained variance: 45.4%). Last, a multiple hierarchical regression analysis was used to investigate the possible moderating effect of the perceived opportunity to confide to someone on the association of potentially traumatic events on PTSD symptomatology. Results revealed that the association of potentially traumatic event types and PTSD symptomatology was moderated by the opportunity to confide (F(4, 59) = 6.05, p < .001). The final model accounted for 29.1% of the total variance in PTSD symptoms captured by the PCL-5. Conclusion. In summary, the forcibly displaced people interviewed within the scope of this research reported their exposure to a significant number of traumatic events and stressors, as well as high levels of mental distress symptomatology. The high load of mental distress revealed by the present research is in line with previous research and is not surprising when keeping in mind the numbers of reported traumatic event types. Risk of chronification (BPtK–Bundespsychotherapeutenkammer, 2015) and the increasing burdens on the refugees’ mental health, the mental health care system, and the financial resources of both (Bühring & Gießelmann, 2019) underscore the urgency of the current situation. One of the postmigration stressors further increasing the risk of mental distress is an insecure asylum status. However, this factor is a stressor created by the country of reception and, therefore, is malleable to change and amelioration. Indeed, a systemic understanding of the plight of forcibly displaced populations indicates the importance of rethinking existing regulations to better support refugees. Perceived social support, as measured by assessing the refugees’ perceived opportunity to confide in another, can have a positive influence on an individual’s level of distress. However, perceived social support alone is not sufficient to address the challenges facing forcibly displaced persons in the country of reception. Targeted mental health care services are required, as levels of psychological distress are high even in the subgroup of participants who reported a perceived opportunity to confide in someone. In addition, on average, a high trauma load was associated with high symptom levels. Mental health care services need to match target population in order to provide appropriate care and barriers to access need to be addressed. Facing a rapidly changing context for mental health provision, the field must, by necessity, re-evaluate existing models of care provision in order to sufficiently address the needs of all members of society. A stepped care approach as well as the task shifting approach are two concepts that can complement traditional psychotherapeutic care to better support those who might benefit from accessing mental health care