This cumulative dissertation brings together two quantitative and two qualitative studies to explore the relationship between mental health and integration among refugees who arrived in Germany between 2013 and 2018. It is widely recognized in research and policy that refugees face a particular risk of experiencing mental health problems as sequelae of pre-, peri-, and post-migration traumatic experiences and stressors – despite demonstrating enormous resilience through resettlement itself. It is also increasingly recognized among policymakers that although their stays in receiving societies may be of a temporary nature, at least initially, integration as a process and aim does apply and should be seen as applying to refugee arrivals. The theoretical starting point of this dissertation is the hypothesis that mental health and integration are interrelated such that mental health is vital for integration and integration is vital for mental health.
The first chapter fulfills an introductory function. It provides background information on global forced migration and on the increased arrival of asylum seekers to Germany since around 2013. Second, it presents the concept of integration, including background theory and major frameworks, as well as key facts about integration processes in the German context. Third, it includes an overview of mental health concepts and factors linked to mental health among refugees. A fourth introductory section presents the idea of a bidirectional relationship between mental health and integration, into which resilience also figures, and raises motivations for bringing these concepts together. It also argues that assessing the prevalence of mental health problems among refugee populations is key to receiving societies fulfilling their responsibilities within integration as well as to understanding the overall significance of potential mental health and integration associations. Furthermore, this fourth section summarizes previous findings on associations between mental health and areas of integration, on resilience among refugees, and on estimates of prevalence of mental illnesses in refugee populations. A final introductory section outlines research gaps as well as the aims of this dissertation project.
The second chapter provides an in-depth look at the research design and methods of the four research studies at the heart of this dissertation with a focus on how they relate to the overall dissertation project as well as on the benefits of using both qualitative and quantitative methods. Studies I and II, which are presented in chapters 3 and 4, are quantitative investigations based on two different waves of the IAB-BAMF-SOEP refugee survey, a large-scale panel study on refugees and asylum seekers who arrived in Germany between 2013 and 2016. Study I identifies associations between the severity of core symptoms of depression and anxiety and several integration-related factors: less secure legal status, seeking family reunification, residing in a refugee housing facility, being unemployed, low German language ability, and limited contact to German nationals. It also identifies several interaction effects between sociodemographic factors as well as the number of flight reasons and circumstances of integration in relation to psychological distress as an outcome.
Study II estimates the prevalence of mild to severe psychological distress comprising symptoms of depression, anxiety, and post-traumatic stress disorder among the population of refugees who arrived in Germany between 2013 and 2016 using nationally representative data, showing that roughly four in ten refugees show symptom levels indicative of a need for further assessment, mental healthcare, or even urgent and comprehensive care. Women, older adults, and Afghan nationals show particularly high rates of distress. The relationship between several contextual factors and screening positive for psychological distress was also assessed, revealing associations between having the least secure legal status, being a single male, and residing in a refugee housing facility and screening positive for distress. Those who were distressed were also found to be less likely to be employed or to have participated in integration courses if they are male and less likely to be in education if they are female.
Studies III and IV, which are presented in chapters 5 and 6, are both based on data from 54 qualitative interviews with adult refugees who arrived in Germany between 2013 and 2018. Study III examines the relationship between mental health and integration, providing rich detail on the association between mental health and the motivation as well as the capacity to participate generally, mental health and the asylum procedure, the process of trying to build a new life with regard to work and other meaningful activities, language learning and bureaucratic tasks, and social connections and experiences with longer-term members of the receiving society as well as with fellow refugees.
Study IV examines resilience among refugees – both manifestations of strength in the process of facing adversities and factors that appear to relate to this strength. Themes address cognitive and behavioral coping strategies, resilience as a personal capacity, the links between volunteering and activism and resilience, the importance of social support, the benefits of being a young adult and being a parent, as well as how experiencing migration as an opportunity in various ways may protect mental well-being and overall functioning. In doing so, Study IV provides indirect insights into the relationship between mental health and integration: it shows how refugees protect their mental health against adversities faced within integration as well as how the protection of mental health may facilitate integration.
The seventh and final chapter represents an Integrative Discussion of the four studies. It brings together results from the studies, comparatively discussing these and using qualitative results to complement and illustrate potential mechanisms underlying quantitative results. First, results on the prevalence of psychological distress as well as risk factors are discussed, bringing in insights from the qualitative studies. Second, and centrally, different domains of integration are discussed in turn with regard to their relationship to mental health. The dissertation closes with conclusions, strengths and limitations of the research conducted within this dissertation project, and a research outlook.
This dissertation shows that a large proportion of refugees who arrived in Germany at the height of new arrivals between 2013 and 2016 exhibits significant levels of symptoms of depression, anxiety, and post-traumatic stress disorder, and that women, older individuals, and Afghans are particularly affected. These results have the potential to inform Germany’s efforts to fulfill its receiving society responsibility of providing adequate and needs-tailored mental healthcare within integration. They also demonstrate the scale at which potentially diagnosable mental health problems may be interacting with integration.
Centrally, this dissertation shows how multiply and deeply different aspects of the integration process and mental health are intertwined among refugees. Various and often seemingly bidirectional links between mental health and integration were identified within each of the following areas: asylum procedure and legal status, housing, participation in the labor market, education, and integration courses, bureaucratic tasks within integration, German language learning, social bridges to Germans and experiences of xenophobia from Germans, and social bonds within refugee communities – including experiences of family connections and separation. These findings suggest that the role of mental health should be considered in integration policy and that the importance integration should be considered in the conception of mental health interventions and programs.
