Dr. Amit Bernstein’s interest in refugee mental health was piqued just over a decade ago, when forcibly displaced people—not only men and women, but young people and unaccompanied minors—started flowing into Israel from Eritrea and Sudan.
“They looked so resilient,” recalls Bernstein, a professor of clinical psychology with the School of Psychology, University of Haifa, in Israel. However, study after study showed that there was, Bernstein says, “a real public health crisis of mental health that we didn’t know about.” The refugees came from “extraordinarily, shockingly high rates of traumatic stress experiences”: torture, imprisonment, starvation, combat. Following the trauma and stress of forced migration, the refugees also struggled with post-displacement issues, including separation, grief, isolation, loneliness, fear, conflict, and no access to education or work.
A representative sample found that two-thirds of the population was struggling with PTSD, depression, and anxiety. In addition, up to one third were struggling with suicidality (up from the 3-19% for migrants who aren’t forcibly displaced).
“It’s very shocking. It’s a real crisis,” says Bernstein. “I had never seen numbers in any community with this kind of prevalence or severity of trauma and mental-health problems.”
The plight faced by refugees globally has not lessened in the intervening years. By 2050, the Institute for Economics and Peace reports, climate change and conflict could raise the number of refugees to as high as one billion. A person is forcibly displaced from their home approximately every two seconds, according to Oxfam. Or, as Bernstein puts it, “Every two seconds, some organization or person has another forcibly displaced person to care for.”
“The generational and intergenerational implications are not just frightening and destructive for the forcibly displaced communities, but also the host nations.”
Dr. Amit Berstein
Refugees experience inordinately high rates of traumatic stress, leading to a wide range of mental-health issues. “The generational and intergenerational implications are not just frightening and destructive for the forcibly displaced communities, but also the host nations,” says Bernstein.
These intersecting crises led Bernstein’s team at Observing Minds Lab, founded by Bernstein, to explore mindfulness as a possible way to help promote trauma recovery and buffer the effects of post-displacement stress. “We came to understand how potentially transformative mindfulness was, which is something we couldn’t have predicted,” says Bernstein.
A Right to Recovery
Treating refugee mental health is a complicated endeavor—the many geographic, linguistic, and sociocultural factors at play present daunting logistical challenges. “Nothing that I’ve done in the past 20 years compares to the complexity of doing this work responsibly and well,” says Bernstein. A growing body of evidence (from Israel as well as other countries around the world) led his team to the idea that mindfulness and compassion training, if tailored to the needs of forcibly displaced people, might be an important, new focus for scientific study and intervention development.
“If you had asked when we started, ‘Hey, do you think mindfulness is a good idea here?’ we probably would have laughed,” says Bernstein. “We would have thought, ‘That’s crazy.’”
But more and more research documented the psychological and biological stress-buffering effects of mindfulness training. In addition, mindfulness training can be delivered in groups, is low cost, and could theoretically be delivered in diverse settings. This kind of therapy could be scalable even in complex contexts.
“Studies show that mindfulness targets processes that transcend language and culture,” says Bernstein. “That’s a very powerful capacity for this purpose.” Could mindfulness bridge the gap between refugees worldwide, who, as he says, come from extraordinarily diverse social, cultural, linguistic, and geographical backgrounds?
“Mental health and the right to recovery following forced displacement is a human right,” said Bernstein in a keynote at the 4th International Conference on Mindfulness in July 2021. “It’s our ethical obligation to bring the most rigorous and compassionate science available to try to care for forcibly displaced persons in need.”
Allowing Moments of Refuge
Bernstein’s team at Observing Minds Lab developed Mindfulness-Based Trauma Recovery for Refugees (MBTR-R), a socioculturally adapted, trauma-sensitive, mindfulness-and compassion-based intervention for diverse, forcibly displaced people.
MBTR-R consists of nine 2.5-hour group sessions and at-home practice supported by guided meditations on YouTube. Psychoeducation focuses on the effects of stress and trauma, and loving-kindness practices are taught to cultivate compassion for the self and others. The program includes a host of trauma-sensitive adaptations to help ensure the safety of the meditation practices, and sessions are socioculturally adapted and delivered within and by the community—refugees make up 50% of the team delivering the program, as well as providing childcare and preparing meals for participants.
Initially, the team’s aspirations were relatively modest: “We wanted to see if we could use this intervention to help asylum seekers have moments of refuge in their own bodies and minds,” says Bernstein. Secretly, the team hoped that if you give people space in their consciousness and teach them different ways to relate to their stress, memories, and fears, maybe a process of healing could begin.
Put to the Test
A randomized controlled trial tested the efficacy and safety of MBTR-R among a community sample of 158 Eritrean asylum seekers in Israel with a severe history of trauma and chronic post-migration stress. The study was supported by funding from the Israel Science Foundation, the Charney Foundation, and a European Varela Fellowship.
Quickly, the researchers realized they’d hit on something valuable. They found that MBTR-R significantly reduced rates and symptom severity of PTSD, depression, and anxiety, immediately after the study’s end and at follow-up five weeks later. These therapeutic effects were not dependent on key demographics such as gender, age, trauma history severity, or post-migration living difficulties, indicating that mindfulness was broadly effective within the pool of participants. Furthermore, the positive effects researchers were monitoring didn’t appear to fade over time.
The brief intervention format, group-based delivery, and few people leaving the study indicate MBTR-R might be a feasible, acceptable, and scalable mental-health intervention for refugees and asylum seekers. “The findings were far better than we had imagined they could be,” admits Bernstein.
Clinicians around the world are trying to use mindfulness with forcibly displaced persons. But Bernstein says he’s not aware of any other standardized, trauma-sensitive, sociocultural intervention adapted or studied through a randomized control design.
Pandemic Pivot
The MBTR-R study was published in early 2020, and Observing Minds was eager to kick-start the Moments of Refuge Project: a global, multisite study that would help researchers understand more about the power of MBTR-R.
Could it be effective and safe for multiple other asylum seekers of different origins, language groups, and contexts? Could MBTR-R impact not only mental health, but also physical health, for forcibly displaced persons? “We don’t know, and it’s really important to test,” says Bernstein.
Then COVID-19 hit.
Bernstein started receiving dozens of texts and calls from asylum-seeker communities and NGOs: The pandemic had spawned an acute humanitarian crisis. Despite significant health risks, the Observing Minds team surreptitiously carried out a study in a Tel Aviv NGO during one of Israel’s lockdowns to understand whether COVID-19 was exacerbating the mental-health crisis.
All the existing stressors for refugees, of insecure residential status, housing, income, food, and healthcare access, were exacerbated by the pandemic, increasing their risk of contracting and transmitting COVID-19.
“The findings were haunting,” says Bernstein. All the existing stressors for refugees, of insecure residential status, housing, income, food, and healthcare access, were exacerbated by the pandemic, increasing their risk of contracting and transmitting COVID-19. Asylum seekers were struggling with elevated depression, anxiety, and PTSD levels. Suicidality in the community sample of women, primarily mothers, was between 50% and 60%.
Mindfulness SOS
Bernstein’s team pivoted and launched Mindfulness-SOS, a shorter, online version of Moments of Refuge, available in Arabic, English, and Tigrinya (the mother tongue of many Eritreans), focused on mitigating acute stress and related mental-health symptoms. Mindfulness-SOS offers eight audio lessons, each with guided practices teaching skills such as cultivating inner safety and peace, working with difficult thoughts and emotions, and self-compassion. Since the program was delivered online, it respected physical distancing policies while providing rigorous data, and the number of sessions and practices— known as doses—was quantifiable.
“We had quite robust results,” says Bernstein. Initial findings haven’t yet been published, but show that mindfulness and compassion trainings have protective dose-response effects. In addition, there was surprisingly high adherence (the extent to which the participants’ behavior coincided with researchers’ instructions) and engagement (extent of participants’ active involvement and feedback to the research team), as well as high rates of completion of mindfulness exercises.
With two programs on the go, Bernstein is seeking funding to re-launch the Moments of Refuge project. “At this point, we don’t even know if it will work like it did here in Israel,” says Bernstein. “Maybe it’ll work better. We don’t know.” Eventually, he hopes, this ongoing work will pave the way to “make Moments of Refuge a new reality” for forcibly displaced people around the world.
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