Moral injury related to immigration detention on Nauru: a qualitative study

Background: Immigration detention is associated with detrimental mental health outcomes but little is known about the underlying psychological processes. Moral injury, the experience of transgression of moral beliefs, may play an important role. Objective: Our aim was to explore moral injury appraisals and associated mental health outcomes related to immigration detention on Nauru. Methods: In this retrospective study, we conducted in-depth interviews with 13 individuals who had sought refuge in Australia and, due to arriving by boat, had been transferred to immigration detention on Nauru. At the time of the study, they lived in Australia following medical transfer. We used reflexive thematic analysis to develop themes from the data. Results: Major themes included 1) how participants' home country experience and the expectation to get protection led them to seek safety in Australia; 2) how they experienced deprivation, lack of agency, violence, and dehumanization after arrival, with the Australian government seen as the driving force behind these experiences; and 3) how these experiences led to feeling irreparably damaged. The participant statement 'In my country they torture your body but in Australia they kill your mind.' conveyed these three key themes in our analysis. Conclusion: Our findings suggest that moral injury may be one of the processes by which mandatory immigration detention can cause harm. Although refugees returned to Australia from offshore detention may benefit from interventions that specifically target moral injury, collective steps are needed to diminish deterioration of refugee mental health. Our results highlight the potentially deleterious mental health impact of experiencing multiple subtle and substantial transgressions of one's moral frameworks. Policy makers should incorporate moral injury considerations to prevent eroding refugee mental health. Keywords: Moral injury; Nauru; asylum seeker; immigration detention; post-migration living difficulties; refugee mental health

Mental health assessments in refugees and asylum seekers

Background Mental health problems resulting from persecution and forced migration are very common among refugees and asylum seekers and evolve into a major public health challenge in hosting societies. Language barriers often prevent timely access to appropriate health care, leading to chronic trajectories and abortive social integration. Tools for multilingual screening and assessment could be of great benefit for this particularly vulnerable population as well as for policy makers. This study aimed at testing the reliability, feasibility and usability of the Multi-Adaptive Psychological Screening Software (MAPSS), a newly developed Audio Computer-Assisted Self- Interview Software (ACASI) for touchscreen devices, for screening purposes in a clinical setting. Methods In a randomized cross-over design including both MAPSS and paper-pencil clinician-administered interviews, 30 treatment-seeking refugees completed clinical measures and a feasibility questionnaire to rate the user interface of MAPSS. Five professionals performed given tasks in MAPSS and completed usability questionnaires for the administration interface. Results Results showed no differences between the two assessment modalities with regard to symptom scores. The findings suggest good feasibility and usability of MAPSS in traumatized refugees. The administration via MAPSS was significantly shorter than the paper-pencil interview. Conclusion MAPSS may be a cost-effective, flexible and valid alternative to interpreter-based psychometric screening and assessment

Mental health assessments in refugees and asylum seekers: evaluation of a tablet-assisted screening software

BACKGROUND: Mental health problems resulting from persecution and forced migration are very common among refugees and asylum seekers and evolve into a major public health challenge in hosting societies. Language barriers often prevent timely access to appropriate health care, leading to chronic trajectories and abortive social integration. Tools for multilingual screening and assessment could be of great benefit for this particularly vulnerable population as well as for policy makers. This study aimed at testing the reliability, feasibility and usability of the Multi-Adaptive Psychological Screening Software (MAPSS), a newly developed Audio Computer-Assisted Self-Interview Software (ACASI) for touchscreen devices, for screening purposes in a clinical setting. METHODS: In a randomized cross-over design including both MAPSS and paper-pencil clinician-administered interviews, 30 treatment-seeking refugees completed clinical measures and a feasibility questionnaire to rate the user interface of MAPSS. Five professionals performed given tasks in MAPSS and completed usability questionnaires for the administration interface. RESULTS: Results showed no differences between the two assessment modalities with regard to symptom scores. The findings suggest good feasibility and usability of MAPSS in traumatized refugees. The administration via MAPSS was significantly shorter than the paper-pencil interview. CONCLUSION: MAPSS may be a cost-effective, flexible and valid alternative to interpreter-based psychometric screening and assessment

Are you angry at me? Negative interpretations of neutral facial expressions are linked to child maltreatment but not to posttraumatic stress disorder

Background: Individuals with a high prevalence of child maltreatment, e.g. those with borderline personality disorder, tend to see neutral facial expressions as negative. Objective: Our aim was to assess whether this bias is present in individuals with posttraumatic stress disorder (PTSD) and whether it is linked to child maltreatment. Methods: Thirty-nine PTSD participants, 44 traumatized and 35 non-traumatized healthy controls watched 300 one-second movies showing 30 neutral and 270 emotional facial expressions, and indicated whether they interpreted each as a neutral or as one of nine emotional expressions. Results: PTSD individuals did not perform differently than the two control groups in the recognition and interpretation of neutral facial expressions (p's < .300). Higher levels of childhood sexual and emotional abuse, and physical neglect were linked to more interpretations of neutral facial expressions as contempt (p's < .043), and (for sexual abuse and physical neglect) to more interpretations of neutral facial expressions as anger (p's < .014). Comparisons of statistical model fits suggested that childhood sexual abuse was the most relevant predictor of recognition accuracy in our sample. Alexithymia, state dissociation, interpersonal trauma, and number of experienced trauma types were not associated with deficits in the interpretation of neutral expressions. Conclusions: Child maltreatment, especially sexual abuse, may shape the interpretation of neutral facial expressions. Future research should explore whether the observed biases extend to real-life situations. If so, therapists might improve the therapeutic relationship with patients with a history of child maltreatment by paying more attention to their own non-verbal communication and their patients' responses to it. Furthermore, similarly to individuals with high depressive and high social anxiety symptoms, facial expression recognition training might counteract negativity bias in individuals with a history of childhood (sexual and emotional) abuse, and (physical) neglect

Facial mimicry, facial emotion recognition and alexithymia in post-traumatic stress disorder

Individuals with post-traumatic stress disorder (PTSD) show abnormalities in higher-order emotional processes, including emotion regulation and recognition. However, automatic facial responses to observed facial emotion (facial mimicry) has not yet been investigated in PTSD. Furthermore, whereas deficits in facial emotion recognition have been reported, little is known about contributing factors. We thus investigated facial mimicry and potential effects of alexithymia and expressive suppression on facial emotion recognition in PTSD. Thirty-eight PTSD participants, 43 traumatized and 33 non-traumatized healthy controls completed questionnaires assessing alexithymia and expressive suppression. Facial electromyography was measured from the muscles zygomaticus major and corrugator supercilii during a facial emotion recognition task. Corrugator activity was increased in response to negative emotional expressions compared to zygomaticus activity and vice versa for positive emotions, but no significant group differences emerged. Individuals with PTSD reported greater expressive suppression and alexithymia than controls, but only levels of alexithymia predicted lower recognition of negative facial expressions. While automatic facial responses to observed facial emotion seem to be intact in PTSD, alexithymia, but not expressive suppression, plays an important role in facial emotion recognition of negative emotions. If replicated, future research should evaluate whether successful interventions for alexithymia improve facial emotion recognition abilities