Transcript Learn@Lunch with Associate Professor Angela Nickerson
Understanding pathways to refugee wellbeing | 13 June 2018

Welcoming remarks from Professor Emma Johnston, Dean, UNSW Science 

Welcome to Learn@Lunch. This is UNSW's bite-sized lecture series with some of our top researchers and talent. Thank you for joining us. My name is Emma Johnston. I'm the Dean of Science at the University of New South Wales.

Before I get started, I'd like to take a little moment to acknowledge the Gadigal people of the Eora Nation, the traditional owners of this land and indeed the first creators of the understanding of our beautiful harbor, which is very close to my heart as a marine scientist. The Gadigal people's territory stretched from South Head into Petersham and down to the Cooks River. Many of the cultural traditions and understandings are still alive today. I'd like to extend my respects beyond the Gadigal people of the Eora Nation to any Torres Strait and indigenous Australians who may have joined us today.

I am very privileged to be the Dean of Science at UNSW. Our researchers stretch from huge range of disciplines, but they're all working at the very edges of the unknown. Some of the examples of the breadth of research that goes on within my faculty include discovering new treatments for eye disease, for example, all the way to discovering little mammals that have been considered extinct for hundreds of years. We have people who are mapping the furthest galaxies, and the chemical signatures and DNA of 340,000 stars out in the outer world. We have people working on the tiniest microscopic animals and looking at their DNA. The scale and the breadth of the research is absolutely outstanding.

The faculty has around 900 researchers. We published more than 2,000 peer-reviewed papers every year. That's new bits of knowledge that we're contributing to the understanding of the world. We also graduate more than 100 PhD students every year. Its breadth, depth and volume is substantial. Our reputation for world-class research is substantial as well, not only within Australia but also internationally. An example of that is we host two of the Centres of Excellence that were announced in 2017. We host the Australian of the Year, Michelle Simmons, who you will have heard from an outstanding quantum computing researcher, building her own Australian company to develop the first quantum computer in Australia, but also leadership in a way that is so inspiring to students around Australia.

Hopefully, we are inspiring the next generation of students to come and join us at the university and to train themselves in Science, Technology, Engineering, Math and Medicine, which is my particular area of love. The faculty itself has the mission not only to do the great research and to introduce all this new knowledge, but also to train the next generation of scientists and inspire them to come up with their own solutions to some of the global challenges facing the nation and the global.

Enough about of me bragging about my beautiful faculty. It does make me very proud to be the dean. I do want to focus today on one of our very, very special researchers of whom I'm particularly proud, Associate Professor Angela Nickerson. She's the one that you will come to hear, not me. She's Director of UNSW's Refugee Trauma and Recovery Program. She'll be discussing her work on understanding but also developing pathways to improve psychological wellbeing amongst displaced people. Obviously, this is a huge issue for the entire globe; tens of millions of people around the world are being forcibly displaced due to conflict and due to persecution. The trauma of that displacement does put them in peril and makes them much more likely to have mental health issues up to five times more likely, in fact, than the general member of the population who hasn't been displaced.

Supporting and coordinating the research and developing new treatments for this group of people is incredibly important. We're so proud of Angela's work in this space. While the stress does take its toll, the good news is that there's great resilience amongst people who have been displaced as well. Tapping into that resilience and helping to create ways of encouraging and supporting people to recover from the trauma is part of Angela's work that we will hear about today.

Welcome, again. The presentation will go for around 40 minutes. I want to remind people that it's being recorded, and it will be available on the UNSW alumni website for you to watch again or for you to show your friends. It's also a time in which you should have your phones turned to silent because the last thing we want is a big beating sound or one of your favourite ring tones enjoyed by all. The 40 minutes of the presentation will be followed by 10 minutes of Q&A, which I will be able to host. So please join me in giving a very warm welcome to Associate Professor Angela Nickerson.

5.40 Learn@Lunch presentation by Associate Professor Angela Nickerson, UNSW Science

Thank you so much for that very lovely introduction, Emma. I'm really thrilled to be here today with such esteemed colleagues to speak to you about some of the research that we are doing at UNSW on understanding pathways to refugee mental health. I'm a clinical psychologist by training. I've been working with refugee groups for over a decade now. This is an area that's very close to my heart.

We know that there are currently over 65 million people forcibly displaced worldwide. This is the largest number of people forcibly displaced in recent history. It's estimated that over 20 million of these are refugees who, by definition, have been forced to flee their home countries because they've been persecuted on the basis of some important aspect of their identity, whether that'd be their politics, their religion, their ethnicity, their sexuality or another reason.

Now, refugees' experiences are diverse and wide ranging, but what they have in common is that they've all had to pick up sometimes with very short notice and flee their home country in efforts to keep themselves and their families safe. Refugees may have been exposed to conflict and violence in their home countries. Many have witnessed the murder of other people, loved ones or strangers. Some have been exposed to gross human rights violations like torture and sexual assault. Many refugees leave behind people that they love, whether this be their husbands, their wives, their children, their parents, their brothers and sisters. They don't know when they're going to see them again.

The journey to asylum is often highly perilous, whether it be by land, by sea or by air. People coping with lack of food, lack of water, lack of shelter, not even sure if they're gonna get to their destination safely. Many refugees are displaced for years in refugee camps like this. This is an image of Zaatari on the border of Syria and Jordan. Again, suffering from these adversities on a daily basis around shelter, food, water, medical care.

Even when refugees do make it to a country of asylum, like Australia, somewhere where they're safe, they're faced with a whole host of different challenges, accessing education and employment, accessing financial resources to take care of their families who are with them in Australia or to support those who are struggling back home. These adversities don't just stop because a refugee has reached a country of resettlement. It's important to note that refugees face all of these challenges often against the backdrop of fear. Many of them keep in touch with family and friends in the home country via social media, and they see stories of things that are happening back home, and they worry that these things are going to happen to their loved ones. They're going to get that phone call that says something terrible has happened.

From the many refugees who are in resettlement countries who don't have permanent residency, there's also this ongoing fear that they may be sent back to their country of origin or further displaced and is waiting by the phone or by the postbox, the news of what their fate is going to be.

As Emma mentioned, these experiences take that toll. We know that in the general population, rates of psychological disorders like post-traumatic stress disorder, PTSD, and depression are present in around 5% of people. When we look at refugees we see this number skyrockets to around one in three. But there's a group of people who aren't on this graph, who we have become very interested in the previous years. That's these people. What's incredible to me is not the fact that one in three refugees has a psychological disorder, but rather the fact that despite universal exposure to persecution, violence, displacement, adversity, two in three don't.

In fact, we have a great deal of evidence to tell us that refugees who resettle in countries like Australia make substantial and important contributions to society, culturally, economically in a whole variety of ways. We've been really interested at the Refugee Trauma and Recovery Program in trying to understand these people better. How is it that when two people go through similar experiences in their home country? One might end up adapting well and thriving, and another might struggle with mental health problems. Are there things that we can learn from the people who are doing well that can really help us to support those who are struggling and put them on a pathway to positive adaptation? This is a question that we are trying to answer at the Refugee Trauma and Recovery Program, where we conduct research to try to understand the psychological, social, biological and contextual factors that underlie refugee mental health.

We know that refugee experiences are associated with poor mental health and functioning, and we know that poor mental health and functioning needs to be treated by psychological interventions, and people with these experiences must access psycho social support, help them to recover. What we don't know so much about is what the mechanisms and processes are by which refugee experiences impact on mental health nor the barriers to care that might prevent someone from being able to access what they need to recover. These are the two areas I'm going to focus on today.

The first half of my talk is going to be speaking about these mechanisms and processes that we've been looking at, and the second half, the barriers to care. The overarching goal of our research, however, is not to sit in an academic journal in a library somewhere or online nowadays, but rather to inform policy and practice. The findings from these kind of studies really provide an evidence base to inform the people who are working in the front line with refugees and asylum seekers to create policies and services that are most likely to be able to help them and support them to recover.

To start with, I'm going to speak about some work we've been doing on processes influencing refugee adaptation. There are myriad of these processes. There's one, in particular, that we've been very interested in the past few years. That is understanding the impact of prolonged uncertainty. Out of these 65 million people who are forcibly displaced worldwide, we know that less than 1% of refugees worldwide were permanently resettled in 2016. This means that over 99% of refugees worldwide were living in a state of prolonged uncertainty not knowing what their future was going to hold. Despite this, the vast majority of research that has been conducted on refugee mental health has taken place in Western countries of resettlement, individuals with permanent visas.

Now, there's a growing recognition of the effect of prolonged uncertainty on adaptation and wellbeing. Some work that we've done as well as other people have suggested that asylum seeking or a temporary visa status has a negative impact on mental health. However, there's been very little research, longitudinally investigating the experience of those who don't have the sense of permanency. We really don't know much about these people and how they cope with this experience, which is absolutely critical if we're going to inform policy and service provision for this 99% of people globally.

Now, one way that we are trying to address this question is via the refugee adjustment study. This is a longitudinal study investigating changes in refugee and asylum seeker mental health over time, and it's funded by the ARC Linkage scheme. We're very fortunate to be conducting a study in collaboration with our partners, the Australian Red Cross, Settlement Services International who are really some of the key players in the settlement space in Australia. This partnership has been incredibly valuable to this project because it's allowed us to make sure that we're asking the right questions and that the findings from this work are being disseminated back to help the very people that we're aiming to support. This project is also being conducted in collaboration with Phoenix Australia, the University of Melbourne.

This is the first study globally to longitudinally follow refugees with secure and insecure visa status over a number of years. That's really exciting. In this way, it really complements some of the other work that's being done in Australia. For example, the Building a New Life in Australia project, which is following refugees predominantly with permanent visa status over a period of time.

The overarching aims of this study are to investigate changes in mental health and functioning of refugees with secure and insecure visa status over time, to better understand the factors that contribute to healthy settlement for these groups and to enhance support for refugees throughout their settlement journey.

In terms of the methodology, this study was open to refugees or asylum seekers who had arrived in Australia since January 2011, who are over 18 years of age, and they completed surveys online or in pen and paper in Farsi, Arabic, Tamil or English. In brief, participants complete the survey every six months over a period of two and a half years, five times in total. They'll receive a $25 gift voucher at each completion. We just closed our first time point in January this year. We have a sample of 1,091 refugees.

The retention rate in this study is very high, so across the five-time points to date, we've managed to retain over 85% of our participants. We're really proud of that. I think one of the reasons for this is when our participants take part in the study, they're not just taking part in a research project, and they’re joining a research community. They kept up-to-date with findings of the study and how it's going with newsletters that are translated into their own language that they can read. We keep in touch with them via thank you cards, personalized acknowledgements of the contributions that they're making, reminders via text, via email, via phone, so that they really feel part of something bigger.

This has been the feedback that we've had overwhelmingly from participants in this study. Many of them have been in situations where they feel quite powerless, and taking part in this research has enabled them to feel that they're contributing to knowledge that might help other people who are in the similar situation to them.

Who are the people? Well, the majority of the participants in this study were between ages 26 and 45. Nearly two thirds of people in this study completed in Arabic, followed by Farsi, English and then Tamil. We had it roughly even split between men and women. We ended up with a sample, which was 75% individuals with secure visas, so these are things like permanent protection visas, Australian citizenship and so on, and 25% of those with insecure visa status. Those who had temporary visas, bridging visas, expired visas and so on. We're quite proud of being able to access this 25% even though it's a relatively smaller amount because these people are a little harder to get to because they have so many other things going on in their lives.

The first thing we were interested in knowing is, are the experiences of these groups different when they're in their home country? In fact, we found that this was the case. We measured here the average number of traumatic events that were experienced by refugees with secure and insecure visas. This wasn't the number of traumas they've experienced in their life, rather it was the number of types of traumatic events they had experienced. Each may have been experienced multiple times. What we found here was that the rates of exposure to traumatic events was over double for those with insecure visas compared to those with secure visas.

We then looked at the top 10 types of traumatic events that were experienced by those with insecure visas and compare it to those with secure visas. We found, in fact, that over 50% of those with insecure visas have been close to death, forcibly separated from their family, forcibly isolated from others. Incredibly half of those with insecure (silence) and in fact, what we're seeing here is that the rates of exposure to torture amongst those with insecure visas were four times higher than those with secure visas.

Now, this speaks to some of what we might think of as the factors that cause people to leave their home country and seek asylum. We're speculating here, but one possibility is that those with insecure visas were exposed to often very severe types of traumatic events that necessitated them leaving very quickly and seeking asylum once they arrived in Australia.

We were also interested in trying to understand the post-migration environment and how it might be different for these two groups. We looked at the number of post-migration living difficulties, those with secure and insecure visas endorsed. These are things like difficulties finding employment or education, fear of being sent home to the home country, fear of being sent in offshore processing center. We found here that those with insecure visas endorsed an average of 16 types of living difficulties while those with secure visas endorsed an average of six types.

In fact, we saw this pattern across the board with different types of living difficulties, so health-related stresses, logistical stresses, social stresses, but importantly immigration-related stresses and fear for the future, fear about what was going to happen in the future were particularly different. We didn't, however, find a difference between acculturation stresses.

What does this all mean for mental health? We wanted to know how these groups differ in terms of the psychological functioning. Not surprisingly, we found that those with insecure visas had significantly higher levels of PTSD symptoms and depression symptoms as well as suicidal thought severity. Interestingly, however, we found that there was no difference between the groups in their disability. That means their ability to really function in their daily lives and do those activities that are necessary if you and I to get by.

When we looked at rates of psychological disorders, we found that 50% nearly of those with insecure visas had PTSD, 30% are those with secure visas. Depression was 27% compared to 7%. Importantly, suicidal intent, so having actually made a plan or having an intention to take one's own life was eight times higher amongst those with insecure visas.

Now, the question that came to our mind, however, is what we know that those with insecure visas are more traumatized. Maybe it's just the case they've been exposed to more trauma and this is what leads to these psychological problems. Maybe it's nothing about their visa status at all. We did a little bit more investigating. Initially, we looked at the association between trauma exposure and psychological symptoms across the whole sample. What we found is what we already know, the more types of trauma you're exposed to, the more severe your  psychological symptoms are. For every additional type, we see an increase in the severity of mental health problems.

Next, we were interested in looking at when you take trauma exposure out of the equation, when you control for that, what is the independent effective insecure visa status? Here, we found that over and above the impact of trauma exposure, insecure visa status was associated with higher PTSD symptoms, high depression symptoms, but not higher disability. It suggests that something about this insecure visa status, this uncertainty about the future that is associated with poor mental health.

Next, we wanted to look at social engagement. Maybe these people with insecure visas, they're experiencing more symptoms, maybe they're less likely to engage with the Australian population with their communities and so on. In fact, we found that, that was not the case. Compared to those with secure visas, we found that individuals with insecure visas were over three times more likely to be active members of sporting groups, three times more likely to be active members of volunteer or charity groups, twice more likely to be active members of religious group and nearly twice more likely to be an active member of a cultural and community group.

We also wanted to look at the extent to which these people access support. We found that those with insecure visas were five times more likely to receive help from someone in the Australian community, three times more likely to receive help from a volunteer group and 2.6 times more likely to receive help from an NGO. It's suggesting that these people are highly engaged in the community that they're living in. We still found that those with insecure visa status were 1.5 times less likely to report a sense of belonging in Australia. They're engaging, they're out there, they're engaging with other people, but there's still this sense of having difficulty putting down roots.

What does this tell us overall? Well, it tells us that those with insecure visas have had different experiences to those with secure visas, have had more trauma exposure and exposed to different types of traumatic events. We know that this is associated with poor mental health but not worse functioning. In fact, those with insecure visas have better social engagement. This suggests overall that those with insecure visas are likely to have different needs and that the sense of security and permanence is critically important for wellbeing. What we're in the process of doing now, looking at longitudinally is what might be some of the psychological mechanisms that are underlying this. For those with insecure visas who are coping well, what are they doing? What strategies are they using? What can we learn from them to be able to support other people who are living with this state of prolonged uncertainty?

Now, I'm going to change tack a little bit and talk about a complementary study that we have been conducting, looking at mental health and barriers to care. We know that we need to provide psychological treatment for people who have psychological difficulties to help them recover, but we wanted to know about here was what were the things that might stop that from happening. As I've already mentioned, there are very high rates of PTSD amongst refugees. The symptoms of this disorder can be highly debilitating. Many refugees are haunted by the experiences that have happened to them in their home country. They might experience nightmares or flashbacks of terrible things that have happened. They might want to make them push away these thoughts and memories and remind us and be highly vigilant for danger in the environment around them even when they're in a situation of relative safety.

Despite this, we know rates of help-seeking are extremely low amongst refugee communities. There have been several potential barriers that are being proposed that account for this. One is structural barriers. Some refugees may not have access, for example, to the financial means, to afford treatment or to get treatment or to access an interpreter so they can understand what's going in treatment. There are also barriers related to the refugee experience. We've already spoken about visa insecurity and the restrictions that might go with that. Also refugees, by definition of being exposed to persecution, this can have a profound impact on an individual's capacity to trust other people, particularly, those in authority, which might make it difficult to seek help.

Finally, there are cultural barriers, negative beliefs about mental health and help-seeking, which can come under the banner of mental health stigma. We're likely to see in certain groups that these things compound create a perfect storm. We've got people, for example, with insecure visas who may have these structural barriers, specific barriers related to their refugee experience and these cultural barriers, which might particularly strongly impact on help seeking.

Now, as a clinical psychologist, sometimes it can be difficult for me to do something about the structural barriers or the barriers related to the refugee experience. But this mental health stigma idea is idea that negative beliefs about mental health might prevent help seeking, that's something that's really important because it's malleable, something we might be able to address. Despite this, there's been no specific intervention developed to address mental health stigma in displaced populations worldwide.

This is where the Tell Your Story project came in. So Tell Your Story project is a collaboration between the Refugee Trauma and Recovery program, Settlement Services International and the Black Dog Institute at UNSW. It was funded by beyondblue with donations from Movember as part of an Australia Wide STRIDE initiative when they aimed to reduce mental health stigma amongst different groups of vulnerable men in Australia. This was a multiphase project with a focus on informing service delivery. It focused on refugee men again from Arabic, Farsi and Tamil-speaking backgrounds.

At the beginning of this project, we set up community advisory boards in each of these refugee communities to inform the project from beginning to end. The questions that we're asking, the content we were using in the intervention, and now the interpretation and dissemination of results. We started with identifying barriers to care, conducted a qualitative study with interviews with key informants from each of these communities and a literature review. We conducted a quantitative study to understand the impact of these barriers. We then developed an online intervention to reduce barriers to care, and we evaluated it using a randomized controlled trial.

Today, I'm going to be speaking about the last two phases of this study. The Tell Your Story intervention, this was an online intervention designed to reduce stigma and increase help seeking for refugee men with PTSD symptoms. There is quiet ... There's not a lot of research on mental health stigma in refugees, specifically, so we had to draw on the broader evidence base to come up with what we were going to target in the intervention. We use evidence-based strategies including psycho education to providing people with information about their symptoms; cognitive reappraisal, so helping people to challenge negative beliefs they had about mental health and help seeking; finally, the strategy with the strongest evidence-based for stigma reduction was social contact.

Now, social contact really refers to if I have a particular problem, I meet someone else with that problem, and that gives me a new insight. Imagine if I have PTSD symptoms, and I think that this means there's something wrong with me, I'm going crazy, I can't possibly speak to someone else about it. Then I meet someone else with PTSD symptoms. I think, "Hang on a second. They seemed like a pretty, nice person who's functioning well, and they had a good experience with help seeking. Maybe that might reduce my negative beliefs and lead me to speak to someone about my problems." Of course, there's a massive problem with this, right?

If you have high levels of mental health stigma, you're extremely unlikely to go seek out someone else with similar problems to speak to about this. We had to get a little bit creative around how we were doing this. The way in which we approach this was by filming videos of refugee men, two from each language group speaking about their symptoms and their positive help-seeking experiences. You can say the filming, this is the image of the filming here. This was an incredibly involved process. I have to say, I have to strongly acknowledge the incredible generosity of these men. These were not actors. This was not scripted. This was them wanting to share their experiences to help other people. Given the high levels of mental health stigma in these communities, this was very brave of them, and we're incredibly grateful to them.

This is what the intervention looked like. We built three websites, on in Arabic, one in Farsi, one in Tamil, which had its own challenges associated with that, which you can imagine. On the left, you can see here the smartphone-enabled version of the website in Tamil. On the right, you can see the Arabic version of module two. You can see 12 modules that participants worked through as they went through the program. Each of these were just bite-sized pieces, so maybe five minutes each the participants could go through and learn about these men's experiences and conduct activities to really reinforce the messages.

The first, I guess, port of call for this intervention was really to normalize these psychological symptoms to help men understand that PTSD symptoms are normal consequences of abnormal events, and that many people experience them. I'm now going to share with you one of the videos from the Arabic site where you can see Arabic men, one from Syria, one from Iraq, talking about their symptoms.

[Video segments – foreign language]

After viewing these videos, the men then went on to do activities where they identified their own psychological symptoms and got education about how these things arise from traumatic events? A major focus of this intervention was helping people to identify some of the benefits of help seeking, particularly, social benefits for their family, friends and community. I'm going to show you another video of the men speaking about the way in which help seeking affected them.

[Video segments – foreign language]

Participants then went on to do activities that really helps to consolidate the messages from these videos, which were interspersed throughout the 12 sessions. They did things like identify their own help-seeking concerns and identifying and ranking potential sources of help for them. One really great, I think, innovation of this online intervention, which drew on Black Dog's existing platform for web-based interventions is this information was then fed back to participants so that they could develop a personalized action plan about how they're going to speak about their problems, who they're going to speak to, and when and where and so on.

The intervention ended with a congratulations component, but also with a message directly from the men in the videos to the men who are using the program, encouraging them to reach out and connect, to support them through the difficulties they are experiencing.

We were very proud of this intervention, but a nice website and some beautiful videos don't necessarily mean that it's going to change things for people. We wanted to evaluate The Tell Your Story intervention using a randomized-controlled trial. Participants were randomly assigned to the Tell Your Story intervention or a wait list control group. We got 103 participants in study overall. They registered their interest, and then we screened into the study with inclusion criteria being having a refugee background, being literate in one of the study languages, having clinically significant PTSD symptoms and not currently seeing a mental health professional.

Participants were assessed at baseline post-intervention and a one month follow-up or using an online methodology. For all participants in the wait list control group, they have access to the intervention after the period of the waitlisted finished. We again had the majority of our participants being Arabic-speaking followed by Farsi. We had some difficulty recruiting Tamil participants in this study. We also had about 75, about three quarters with secure visa status and a quarter with insecure visa status.

We're interested in looking at whether compared to the waitlist control group, did the Tell Your Story intervention change negative beliefs about mental health, help-seeking behaviours and social functioning? Given the body of research that we were accumulating are suggesting that this status plays a really important role. We wanted to see whether there was differential impact according to visa security.

The first thing we looked at was negative beliefs around social inadequacy. These are things like feeling like symptoms don't allow you to contribute socially or you're a burden to others. What we found here, so looking at this graph, these are, right, for social inadequacy at pre-intervention, post-intervention and follow-up. The green bars are the Tell Your Story group and the blue bars are the waitlist control group. We found that for those with secure visas, there was a significant reduction in negative beliefs about social inadequacy for those in the Tell Your Story group, but not for those with insecure visas.

We then looked at help-seeking inhibition beliefs. These are things like feeling embarrassed that other people knew I was seeking help or not wanting people to know I wasn't coping. We found a very similar pattern here, significant reduction in these negative beliefs for those with secure visas, but no change for those with insecure visas.

Next, we're interested in looking at behaviours. When people had completed the intervention, where they're more likely to actually go out and talk to someone. We measure this at post-treatment and at follow-up. Here, we actually found the opposite pattern. There was no behaviour change for those with secure visas, but those with insecure visas who receive the Tell Your Story intervention was significantly more likely to seek help after the treatment.

Finally, we looked at social functioning difficulties. These are things like loneliness, isolation, conflict with family and friends. Here we found across all participants, there was a significant reduction in social functioning difficulties for those who received the Tell Your Story intervention. This is a puzzling picture right? We're seeing change that looks very different for those with secure versus insecure visas. We saw that the intervention was more effective at reducing mental health stigma in refugees with secure visas, but more effective at changing behaviour in refugees with insecure visas.

Now, we have a few ideas about this. These are a bit speculative, and we're looking in investigating them further. One possibility is, certainly, from our participants, we have noted that those with insecure visas actually tend to experience quite a high level of stigma around their visa status and their method of travel to Australia. They may feel that in some ways, they're not welcome in the community and embarrassed or ashamed to talk about these factors. One possibility is that there are aspects of stigma that are going on for the insecure visa group that weren't targeted by this intervention, which may have prevented the reduction in mental health stigma.

Why did we see more help-seeking behaviour in refugees with insecure visas? Well, one possibility is that the resources available to individuals with secure and insecure visas upon arrival in Australia can be quite different. People with insecure visas may receive less opportunity to seek help or less information about this after arrival. Maybe the case with the information in the program, which is very mental health specific, it was talking about who can I speak to? What does a psychologist do? What does a psychiatrist do? What does a counsellor do? How does confidentiality work? Perhaps, this information is valuable in changing behaviour. Again, we're not really sure. We need to look at this further.

Finally, I think it was very heartening to see that the intervention was associated with positive social outcomes across all participants. I have to note that we didn't set out to look at visa status in this study. It became clear as we were finishing the study that this was an important thing that was coming out of other research. We had a relatively small sample size with insecure visas.

Now, I think this partly speaks to the strength of some of the findings that we're still seeing these changes despite the small sample size, but it really needs to be replicated with a larger group of people. Again, these findings point to the differential needs of refugees with secure and insecure visas and to promote belief change and access to services. What we're hoping to do moving forward with this intervention is to create, to test it even more rigorously. To go forth and do a randomize-controlled trial. We have an active control group, and we se Tell Your Story is better than that and to properly look at the factors that might differentially impact on change for those with insecure and secure visas.

Today, I've spoken about ... Some of the research that we are doing on mechanisms and processes and barriers to care. These were just two of the studies of a whole host that we're working on at the moment. When we look at this moving forward from a broader perspective, in terms of where the field is going, I think it's important to really highlight the role of research and understanding refugee adaptation. Without good quality scientifically rigorous research, it's very difficult for us to pinpoint the factors that can really support refugees with secure and insecure visas to adapt well.

There's also been a growing interest in looking beyond epidemiology, looking beyond how many people in different refugee groups have psychological symptoms to try to understand these pathways and mechanisms that I've spoken about today. I think this is absolutely critical if we're going to build the best possible evidence base to inform national and global policy, and also to ensure gold standard practice.

The final comment that I'd like to make is the critical importance of partnerships to really guide and disseminate research. These studies would not have been possible without the import of our partners, a number of whom are here today. It helps us really try to understand what the right questions are to ask, how this question should be framed, but really importantly, make sure that at the very end of the day, when these research findings are done and dusted, that they're not just sitting in an academic journal but rather a caseworker or a clinician who's sitting down in front of the refugee client who is suffering is able to be guided by the best possible evidence to make sure they can support this person as well as possible.

I just like to finish by acknowledging and the many, many, many people who contribute to this kind of work. First and foremost, our participants who generously shared their time and stories when they have many other things going on to worry about in their life, and the refugee men who shared their experiences bravely in those videos. Also, of course, I'd like to acknowledge our partners who are here today, the Australian Red Cross and Settlement Services International and the many other people who took part in this work. Thank you very much.

46:00 Q&A with audience

Emma Johnston:     Thank you very much, Angela, for an astoundingly rigorous but also very moving talk. We have a few moments for questions from the audience. We have microphone, roving microphone. There's one question down the left here.  Very quick to get their hand up. I was going to sneak in a question, but I'll have to give way.

Speaker 1:               I'd like to raise a question of comparative analysis. My background started in the military and I became an academic, and I've been out in the real world for a while. My colleague, the ex-chief medical officer of the Navy believes that PTSD does not exist. It's a new invention. If you go back a bit on history, we've done comparative research of the Jews that came out of concentration camps into Australia and into Israel. Have you done any comparison with the military and the TPI, particularly, with the XPOWs? Finally, to what extent does religion create help or destroy your people?

Angela Nickerson:   Wow. I think that's another talk in itself, but thank you for some very thoughtful questions. I guess, in relation to the broad question or comment around whether PTSD actually exists. There's a very, very long history of people writing about these kinds of symptoms very far back throughout different wars and conflicts in history. What we know is that PTSD symptoms certainly are a normal consequence of exposure to an abnormal experience. For this reason, some people have criticized PTSD as a disorder, as medicalizing what a normal experience. In fact, as a clinical psychologist, what I always come back to is, do these symptoms cause someone distress and impairment in functioning? If that's the case, these are something that we really want to help that person address.

                                You asked the question, and I'll just briefly speak to around the military. There's been a great deal of research conducted on mental health in the military. In fact, I would say that probably the majority of PTSD research worldwide is driven by these, particularly, in the US with the Veteran Affairs and administration. Certainly, we see very similar types of symptoms in the military as we see in refugees. One aspect of the refugee experience that's quite unique is that the trauma is often personal. It's interpersonal. It's on some valued aspect of someone's identity. It's perpetrated from one human being to another human being. We're starting to understand that these kinds of experiences have a really unique and devastating impact on mental health. Of course, it's important to look broadly and consider how this research is situated amongst other trauma affected populations worldwide.

Speaker 2:               I was just wondering is it possible to interview refugee women or it's not possible?

Angela Nickerson:   Yeah. No, absolutely it is. There are a couple of reasons that we focused on refugee men in that study. One was that, that was the mandate of the funding. It was funded by Movember, and they focus on men's health. Another is that we see that rates of help seeking are even lower amongst refugee men than refugee women. One of my hopes for the next phase of this study is to expand it out. There are women suffering from mental health stigma and PTSD symptoms who are not getting the help that they need. I'd really love to see this intervention extended, so that we can address their needs as well.

Speaker 3:               I was just going to ask if you were going to send your findings to Peter Dutton.

Angela Nickerson:   Look, I think that research has a really important role to play in terms of informing policy and global debate. We're certainly working with our partners to work out the best way to disseminate these findings so they get to the people who need to hear them.

Speaker 4:               Hi, Dr Nickerson. Thank you so much. I'm from the Brain and Mind Centre at the university. My research is looking at the young adolescent brain developing the impact of trauma in relation to how that affects the impression long time. A study I'm looking at doing coming through is looking at the come ...  I guess, there's an area of transition with refugee. Researched that the transition is actually as impactful if anything. It's worse than the actual trauma of our origin itself. Do you have any pointers for me as a student? Some advice you could give me on how it could possibly measure these transition factors because that's quite difficult to do in a cross-cultural population. Thank you.

Angela Nickerson:   I think that's a really important question. I'd be happy if you wanted to get in touch via email to speak about that. Certainly, other research is telling us that the impact of the post-migration environments are transitioning from the home country to the country of settlement or the country transition is as important in contributing two mental health as the trauma that happened in the home country. I think it's a critical question to answer. We are looking at some of these factors actually, looking at some of the neuro biological mechanisms, which is being driven by. Dr Belinda Liddell who's the Deputy Director of the Refugee Trauma and Recovery program.

Speaker 5:               Thanks. Got a question whether you're able, in your study, to ask of the participants whether they ... in seeking employment, are they part of the gig economy or the ‘uber economy’ rather than less casualised work? I also have a comment regarding post-traumatic stress disorder, in that when Veteran Affairs looked at veterans returning from Afghanistan, there was one submission that suggested that perhaps part of the problem was the acronym, PTSD, could perhaps drop the D and just be called post-traumatic stress. Part of the issue is that Veteran Affairs requires the criterion from the diagnostic statistical manual, and that has the word ‘disorder’. My question really was about uber and gig economy.

Angela Nickerson:   Look, I think that's a really important point. We know that PTSD was developed as a disorder purely for that reason in the US after the Vietnam War, so people could get access to insurance. I think that's an important point. Again, I still get back to this fact that we see significant distress and impairment, and that's what differentiates people who are experiencing symptoms that really need to be looked at.

                                 In terms of employment, we don't specifically ask what people are doing in what role they're employed, but we do get information on whether it's part time, casual, full time and so on. We're going to be looking at that data in the coming months.

Speaker 6:               Thank you for very interesting talk. I may have missed at the beginning, but I just wanted, the original 1,000 people, were they all in Australia? Did you get them via the Internet?

Angela Nickerson:   Yes, they were all in Australia. We recruited them via a whole host of different ways. We advertised its services, we worked with services like our partners, SSI and Red Cross, and services like Racks were really helpful in helping us access them. We also advertise on Facebook. We basically put on net ad as widely as we can. They were all in Australia, but we're currently looking at projects where we can look at refugees in transition internationally as well.

Speaker 7:               Thank you for a very interesting talk, Professor. What could somebody like me do to help ... I'm a retired lawyer. I've had probably 18 years of doing voluntary work for the mental health of New South Wales and in fact, founded the Anxiety Disorders of the New South Wales Association. Yeah. What could somebody like me do?

Angela Nickerson:   Yeah. Thank you for your wonderful work in this area. I think the fact that we saw that insecure visa holders were so likely to be receiving help from a member of the Australian community is a really important and interesting finding in this study. This idea of helping people become socially engaged and fostering a sense of belonging in a community, where it's difficult for them to put down roots because of the restrictions placed on them is incredibly valuable. I think that can be done in a whole host of different ways depending on the person's expertise. Certainly, speaking to our participants, the connections that they make with the members of the Australian community are incredibly valuable for them.

Emma Johnston:     Well, that's just about perfect timing. We are coming to the end of the questions from the audience, but because I'm Dean I get to ask the last question, just dying to ask. Angela, wonderful talk.

                                What's the role of time in the healing process? I ask it because partly you had some really interesting time effects of your treatments that weren't observable immediately post-treatment, but were occurring a month later. In general, how much does time help or hinder with PTSD?

Angela Nickerson:   I think that's a really important question. In general, with PTSD, we see an increase in psychological symptoms immediately after the trauma. For most people, they then go down within a period of a month to three months after the trauma. Then you're left with the people with prolonged and chronic ongoing distress.

                                In terms of refugee mental health, I think it's a trickier question. People have looked at things like the amount of time in the host country. Some people have found that people are most distressed when they first arrive. There's a kind of a honeymoon effect where you're here and you're like, "Thank goodness, I'm safe," but then things start to get really hard. We haven't ... Because of a lack of longitudinal data like this, we haven't really been able to look at this systematically. That's something we're really excited to look at. In terms of the Tell Your Story findings, I wondered about that, too. I think potentially, having some time for all those lessons learned to sink in is really important for this group.

                                Yeah, that's great. Well, I think you would all like to join me in thanking Associate Professor Angela Nickerson very much for a stimulating and thoughtful talk.

Angela Nickerson:   Thank you.

Emma Johnston:     Just before I let you go, I would like to let you know that the next Learn@Lunch event will be hosted by the faculty of medicine on 11th of July. It will all be about cancer and embryos and stem cell research. So another fascinating talk to come. That's by Professor Christopher Hitchens. I hope you can all read that at the top. Thank you very much for coming along, again. Please keep connected with UNSW.