Title of the module: Theories and Models of Stress. Measuring Stress among refugees

Organisation: KAINOTOMIA

This module provides a framework for understanding how individuals respond to stressors, particularly in challenging environments. The models mentioned focus on the physiological and psychological impacts of stress on the body. Regarding refugees and migrants, who often face prolonged exposure to severe stressors like displacement trauma, uncertainty and resettling in the host countries, it is crucial to measure stress. Understanding how stress affects this vulnerable population can guide interventions aimed at improving mental and physical health, ensuring that refugees and migrants receive the support they need to adapt and recover in their new environments.

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Learning goals of the module:

After completing this module, the learner will be able to:

• Understand and differentiate between key theories and models of stress
• Identify the physiological and psychological responses to stress
• Assess the unique stressors faced by refugees, migrants and asylum seekers
• Apply the appropriate methods for measuring stress in vulnerable populations
• Develop and implement interventions to support refugees’ adaptation

Understanding stress is crucial for effective refugee and migrant support, who often face unique challenges such as displacement, trauma and uncertainty. Refugees face stressors such as security threats, economic instability, social isolation and bureaucratic issues in host countries. This chapter presents some key theories of stress that provide insights into how stress affects individuals, particularly refugees and migrants.

Hans Selye's General Adaptation Syndrome (GAS) is a fundamental theory of stress that describes how the human body reacts to any kind of stress, positive or negative, indicating three stages through which the body goes through in response to stress: alarm (the body's immediate response), resistance (attempting to adapt to the stressor) and exhaustion (prolonged stress depletes the body's resources, leading to burnout, illness or mental health problems).

For refugees, the ongoing stress of violence, displacement and loss can lead to prolonged resistance, wearing down their ability to cope. This eventually leads to exhaustion, manifesting as anxiety, depression, and other health issues. Understanding this progression helps healthcare providers intervene before refugees reach the exhaustion stage (Selye, 1950, 1956). GAS explains how continuous stressors like threats and financial problems can push refugees into prolonged resistance, eventually leading to exhaustion and health issues.

According to McEwen's Allostasis and Allostatic Load, allostasis refers to the process of achieving stability through physiological and behavioural changes in response to stressors. Allostatic load represents the accumulative load of long-term stress as a result of failed adaptation (McEwen & Stellar, 1993).

Refugees often experience high allostatic load because of the continuous stress and the constant state of adaptation, making them vulnerable to various physical health issues like cardiovascular disease and mental health disorders like PTSD.

Roy’s Adaptation Model (RAM) (1964). This perspective sees each person as adaptable, especially when facing stress, by drawing on physical, emotional, and social resources. Refugees, for example, encounter different types of stressors: immediate needs like finding safety and shelter; ongoing challenges like financial uncertainty or fear of violence; and deeper, often hidden effects from past traumas that continue to shape their emotions and behaviours. To cope, people rely on two key responses: an automatic regulator that manages physical reactions, like calming the body when stressed, and a “cognator” that helps with understanding, planning, and decision-making. Together, these responses enable individuals to adjust, find resilience, and move forward even in the face of difficult circumstances.

RAM helps explain how refugees must adapt to multiple stressors simultaneously and highlights the role of healthcare systems in supporting adaptation and fostering resilience.

The Psychophysiological Stress Model (PSM) focuses on the relationship between psychological and physiological stress responses. Developed by Toth (1984), it examines how various stressors, psychological, environmental, or social factors, influence physical reactions such as the release of stress hormones or changes in heart rate. These reactions can worsen existing physical health conditions.

These stress theories provide a comprehensive understanding of how refugees respond to the numerous stressors they face. By understanding how stress can affect both mental and physical health, facilitators can adopt more effective approaches and strategies to support refugees in adapting to their new realities. Effective interventions must address both the immediate stressors and the long-term challenges that refugees face, helping them regain stability and well-being in their lives.

Resources

McEwen, B.S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to disease. Archives of Internal Medicine, 153(18), 2093–2101. https://doi.org/10.1001/archinte.1993.00410180039004

Roy, C., & Andrews, H.A. (1991). The Roy adaptation model: The definitive statement. Norwalk, CT: Appleton & Lange.

Selye, H. (1950). Stress and the general adaptation syndrome. British Medical Journal, 1(4667), 1383–1392. https://doi.org/10.1136/bmj.1.4667.1383

Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.

Toth, M. (1984). Stress and its role in the pathogenesis of cardiovascular disease. Journal of Human Hypertension, 1, 19-24.

Measuring stress accurately is important for providing appropriate support to refugees. This chapter reviews key tools and techniques used to measure stress within refugee and migrant populations.

The Perceived Stress Scale (PSS)*, developed by Cohen et al. (1983), is one of the most widely used tools for measuring stress. It assesses the degree to which individuals perceive situations in their lives as stressful. It is based on the idea that stress is largely determined by an individual's subjective interpretation of events rather than the events themselves. It consists of 10, 14, or 4 questions, depending on the version used, with questions addressing how often a person has felt unable to cope with or has been overwhelmed by life situations over the past month.

For refugees, the PSS is especially valuable because it accounts for individual perceptions of stress, which can vary depending on cultural, personal, and situational factors. Many refugees may experience similar external stressors, but their subjective experiences of stress can differ based on coping resources, past trauma, and social support. For example, refugees might report high levels of perceived stress due to uncertainty about their legal status or difficulty adapting to a new culture. Recognizing these stressors allows for targeted interventions, such as providing legal assistance or mental health support.

The Social Readjustment Rating Scale (SRRS)* is a tool that measures stress by quantifying life changes. Developed by Holmes and Rahe in 1967, the SRRS assigns numerical values to major life events, with higher scores indicating greater stress. The scale includes events such as the death of a loved one, divorce, and personal injury, which are commonly experienced by refugees. This can be useful for assessing stress caused by life-changing events such as migration, separation from family and adapting to a new country.

Qualitative Methods: Qualitative methods such as in-depth interviews and focus groups can provide deeper insights into the stress experiences of refugees. These approaches allow facilitators to explore how refugees make sense of their stress, the coping strategies they use, and the social and cultural factors that shape their experiences. Qualitative data can complement quantitative measures, providing a fuller picture of refugee stress and guiding the development of more culturally sensitive interventions.

Case Studies and Practical Applications Several case studies demonstrate the effective use of these tools in refugee settings:

• In a study with Syrian refugees in Turkey, the PSS was used to measure the impact of ongoing displacement on perceived stress levels. Results showed that refugees living in temporary housing experienced higher stress levels compared to those in more stable accommodations, emphasizing the importance of long-term housing solutions (Kirmayer et al., 2011).
• Another study with Rohingya refugees in Bangladesh used the SRRS to assess cumulative life stress. Findings revealed that refugees with higher SRRS scores were more likely to report symptoms of anxiety and depression, underscoring the link between cumulative stress and mental health (Riley et al., 2017).
• The MindSpring project, founded by the Danish Refugee Council in 2007, is a psychosocial group program supporting refugees and ethnic minorities in adapting to life in a new country. It aims to raise awareness, build coping skills, prevent psychological issues, and foster social networks through structured peer-to-peer sessions. The program is tailored for various age groups, with materials available in multiple languages, promoting empowerment, resilience, and community integration (Best Practices Handbook, M4I).

These examples highlight the importance of using a combination of stress measurement tools to gain a comprehensive understanding of refugee stress. By combining subjective and objective methods, facilitators can identify both the psychological and physical impacts of stress.

*Disclaimer: These tools are intended to be used by professionals and should not be used for self-diagnosis. Only trained professionals should administer these assessments to ensure accurate interpretation and appropriate intervention when needed.

Resources

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. https://doi.org/10.2307/2136404

Holmes, T.H., & Rahe, R.H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11(2), 213-218. https://doi.org/10.1016/0022-3999(67)90010-4

Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., Hassan, G., Rousseau, C., & Pottie, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Medical Association Journal, 183(12), E959–E967. https://doi.org/10.1503/cmaj.090292

Riley, A., Varner, A., Ventevogel, P., Taimur Hasan, M.M., & Welton-Mitchell, C. (2017). Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcultural Psychiatry, 54(3), 304–331. https://doi.org/10.1177/1363461517705571

While understanding the theories and models of stress is crucial, it is equally important to detect stress on offline interventions to alleviate the negative effects of it and engage participation.

Facilitators who work with refugees, even without being mental health professionals or experts in stress diagnosis, can play a significant role in recognizing signs of stress and helping individuals feel included. Refugees may not always openly express their distress, so you need to be alert to both verbal and non-verbal cues.

Recognizing stress early can help facilitators provide the necessary support to reduce stress and improve engagement.

Signs of stress:

• Physical symptoms: Refugees may exhibit physical signs of stress, such as fatigue, tiredness, headaches, stomachaches without any medical cause and sleeping struggles including insomnia or nightmares.
• Emotional and behavioural symptoms: Signs include irritability, mood swings, or sudden outbursts, avoidance of social interaction or isolation, difficulty concentrating and forgetfulness, and hypervigilance, which includes being overly alert.

Creating a Safe and Welcoming Environment

It is important to create a welcoming environment where refugees feel safe and supported. For this reason, facilitators should outline that the space is confidential and non-judgmental. This helps to build trust, making it easier for participants to open up about their experiences. Adopting a trauma-informed approach by recognizing that participants may have vulnerabilities stemming from past traumas and challenging experiences, that can make them particularly sensitive to certain topics. More information about the trauma-informed care approach can be found on our Best Practices Handbook.

As many refugees might face language barriers, facilitators should make sure to use clear and simple language and incorporate images or videos for more complex ideas. If translation is needed, interpreters or translated materials should be provided. It is also important to frequently check for understanding by asking simple questions to encourage feedback and clarification.

Encouraging Participation

To encourage participation, facilitators may find it useful to start with smaller groups, as refugees may feel overwhelmed by bigger settings. This allows for more personalized interaction and fosters a sense of comfort.

Facilitators should also introduce flexible activities that don’t include speaking in front of others such as writing or drawing that are not so intimidating. Offering a variety of choices ensures that everyone feels important and included.

Active Listening and Empathy

Some of the most important tools to consider as a facilitator are to offer support by paying attention, actively listening, maintaining eye contact, nodding, and summarizing what they’ve said to show understanding. Facilitators should also provide plenty of time for refugees to express themselves without interrupting them. Using empathy to understand and recognize their feelings and not pity their situation also offers support without judgment.

Cultural Sensitivity

Facilitators should keep in mind that refugees come from diverse backgrounds and their experiences of stress, trauma, and coping mechanisms vary significantly. For example, in some cultures, expressing emotional distress openly may be discouraged, while in others, communal sharing of feelings might be more common.

Peer Support

Opportunities for participants to support each other should be given to foster a sense of community among refugees, helping them cope with stress. Peer support allows refugees to share their experiences, challenges, and coping strategies with others who have been through similar situations. This shared understanding fosters a sense of community and solidarity, which can reduce feelings of isolation and helplessness. Peer support groups, facilitated by trained professionals or community leaders, create a space where refugees can openly discuss their experiences and learn from one another (Niemi et al., 2013).

Resources

Niemi, M., Manhica, H., Gunnarsson, D., Evans, M., & Ghazinour, M. (2013). A systematic review of peer-support programs for refugee mental health in resettlement countries. International Journal of Mental Health Systems, 7, 23. https://doi.org/10.1186/1752-4458-7-23