The New H5 Model of Refugee Trauma and Recovery

  • Richard F. MollicaEmail author
  • Robert T. Brooks
  • Solvig Ekblad
  • Laura McDonald


Refugees and internally displaced persons remain high on the international priority agenda as a result of war, inter-ethnic conflict and other forms of violent conflict. 1.5 billion people live in countries affected by violent conflict with an estimated 40 % of post-conflict societies returning to conflict within 10 years. This chapter focuses on the health and mental health impact on the refugee experience. A new model of refugee care called the H 5 Model of Refugee Trauma and Recovery is presented. The centerpiece of this model is the appreciation of the traumatic life history of refugees and their communities including past, present and threatening future traumatic life events.

The five elements of the H 5 Model taken up in detail include: (1) Human Rights; (2) Humiliation; (3) Healing (self-care); (4) Health Promotion; (5) Habitat and Housing.

The cultural and scientific evidence behind this model is presented. This chapter lays out a roadmap for the implementation of a new approach to the recovery of refugee communities worldwide.


Mental Health Traumatic Experience Refugee Camp Refugee Community Harvard Trauma Questionnaire 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Agyemang, C., Goosen, S., Anujuo, K., & Ogedegbe, G. (2011). Relationship between post-traumatic stress disorder and diabetes among 105 180 asylum seekers in the Netherlands. European Journal of Public Health, 22, 658–662.CrossRefPubMedGoogle Scholar
  2. Ahmad, A., Sofi, M. A., Sundelin-Wahlstein, V., et al. (2000). Posttraumatic stress disorder in children after the military operation “Anfal” in Iraqi Kurdistan. European Child and Adolescent Psychiatry, 9, 235–243.CrossRefPubMedGoogle Scholar
  3. Akinyemi, O. O., Owoaje, E. T., Ige, O. K., & Popoola, O. A. (2012). Comparative study of mental health and quality of life in long term refugees and host populations in Oru-Ijebu, Southwest Nigeria. BMC Research Notes, 5, 394. Scholar
  4. Al-Khatib, I., Arafat, R., & Musmar, M. (2005). Housing environment and women’s health in a Palestinian refugee camp. International Journal of Environmental Health Research, 15, 181–191.CrossRefPubMedGoogle Scholar
  5. Anda, R. (2006). The health and social impact of growing Up with adverse childhood experiences the human and economic costs of the status Quo.Google Scholar
  6. Anda, R. F., Brown, D. W., Felitti, V. J., Dube, S. R., & Giles, W. H. (2008a, June). Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC Public Health, 8.Google Scholar
  7. Anda, R. F., Brown, D. W., Dube, S. R., Bremner, J. D., Felitti, V. J., & Giles, W. H. (2008b, May). Adverse childhood experiences and chronic obstructive pulmonary disease in adults. American Journal of Preventive Medicine, 34, 396–403.Google Scholar
  8. Başoğlu, M., Livanou, M., & Crnobarić, C. (2007). Torture vs other cruel, inhuman, and degrading treatment: Is the distinction real or apparent? Archives of General Psychiatry, 64, 277–285.CrossRefPubMedGoogle Scholar
  9. Corcoran, C. B., Green, B. L., Goodman, L., & Krinsley, K. (2000). Conceptual and methodological issues in trauma history assessment. In R. Y. Shalev & A. McFarlane (Eds.), International handbook of human response to trauma. New York: Kluwer Academic/Plenum Publishers.Google Scholar
  10. Cromer, K. R., & Sachs-Ericsson, N. (2006). The association between childhood abuse, PTSD, and the occurrence of adult health problems: Moderation via current life stress. Journal of Traumatic Stress, 19, 967–971.CrossRefPubMedGoogle Scholar
  11. De Jong, J. P., Scholte, W. F., Koeter, M. W. J., & Hart, A. A. M. (2002). The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiatrica Scandinavica, 102, 171–177.CrossRefGoogle Scholar
  12. de Paardekooper, B., Jong, J. T., & Hermanns, J. M. (1999). The psychosocial impact of war and the refugee situation on South Sudanese children in refugee camps in northern Uganda: An explorative study. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 529–534.CrossRefGoogle Scholar
  13. Del Gaizo, A. L., Elhai, J. D., & Weaver, L. T. (2011). Posttraumatic stress disorder, poor physical health and substance use behaviour in a national trauma-exposed sample. Psychiatry Research, 188, 390–395.CrossRefPubMedGoogle Scholar
  14. Ekblad, S., & Silove, D. (1998, August 18). Proposals for the development of mental health and psychosocial services in refugee camps (A UNHCR and WFMH Report). Geneva: UNHCR.Google Scholar
  15. Felitti, V., Anda, R., Nordenberg, D., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258.CrossRefPubMedGoogle Scholar
  16. Fisher, J., Cabral de Mello, M., Izutsu, T., Vijayakumar, L., Belfer, M., & Omigbodun, O. (2011). Adolescent mental health in resource-constrained settings: A review of the evidence of the nature, prevalence, and determinants of common mental health problems and their management in primary health care. International Journal of Social Psychiatry, 57, v–vii: 9–116.CrossRefGoogle Scholar
  17. Frankenberger, T., & Maxwell, S. (1992). Household food security: Concepts, indicators, and measurements. UNICEF.
  18. Giacama, R., Abu-Rmeileh, N., Husseini, A., Saab, H., & Boyce, W. (2007). Humiliation: The invisible trauma of war for Palestinian youth. Journal of the Royal Institute of Public Health, 121, 563–571.Google Scholar
  19. Global Trends 2011. (2012). Geneva: UNHCR
  20. Green, B. L., & Kimerling, R. (2004). Trauma, posttraumatic stress disorder, and health status. In P. P. Schnurr & B. L. Green (Eds.), Trauma and health physical health consequences of exposure to extreme stress. Washington, DC: American Psychological Association.Google Scholar
  21. Hourani, L. L., Armenian, H. K., Zurayk, H., & Afifi, L. (1986). A population-based survey of loss and psychological distress during war. Social Science and Medicine, 23, 269–275.CrossRefPubMedGoogle Scholar
  22. Hussain, F., Anderson, M., Lopes Cardozo, B., Becknell, K., Blanton, C., Araki, D., & Kottegoda, V. E. (2011). Prevalence of war-related mental health conditions and association with displacement status in postwar Jaffna District, Sri Lanka. Journal of the American Medical Association, 306, 522–531.Google Scholar
  23. IASC Reference Group. (2010). Mental health and psychosocial support in humanitarian emergencies: What should humanitarian health actors know. Geneva: IASC.Google Scholar
  24. Janowski, K. (2012). PTSD and Physical Health. 2007
  25. Kamau, M., Silove, D., Steel, Z., Catanzaro, R., Bateman, C., & Ekblad, S. (2004). Psychiatric disorders in an African refugee camp. Intervention, 2, 84–89.Google Scholar
  26. Kim, G., Torbay, R., & Lawry, L. (2007). Basic health, women’s health and mental health among internally displaced persons in Nyala Province, South Darfur, Sudan. American Journal of Public Health, 97, 353–361.CrossRefPubMedCentralPubMedGoogle Scholar
  27. Kinzie, J. D., Riley, C., McFarland, B., et al. (2008). High prevalence of diabetes and hypertension among refugee psychiatric patients. The Journal of Nervous and Mental Disease, 196, 108–112.CrossRefPubMedGoogle Scholar
  28. Lopes Cardozo, B., Talley, L., Burton, A., & Crawford, C. (2004). Karenni refugees living in Thai-Burmese border camps: Traumatic experiences, mental health outcomes, and social functioning. Social Science & Medicine, 58, 2637–2644.CrossRefGoogle Scholar
  29. Mollica, R. F. (2000). Invisible wounds special report: Waging a new kind of war. Scientific American, 282, 54–57.CrossRefPubMedGoogle Scholar
  30. Mollica, R. F. (2006). Healing invisible wounds: Paths to hope and discovery in a violent world. Orlando: F. Harcourt Press.Google Scholar
  31. Mollica, R. F., & Jalbert, R. R. (1989, February). Community of confinement: The mental health crisis in site two (Displaced persons camps on the Thai-Kampuchean border). Committee on refugees and migrants. The World Federation for Mental Health, Washington, DC.Google Scholar
  32. Mollica, R. F., Lavelle, J., Tor, S., & Elias, C. (1989b). Turning point in Khmer mental health: Immediate steps to resolve the mental health crisis in the Khmer border camps. Alexandria: The World Federation for Mental Health.Google Scholar
  33. Mollica, R. F., Donelena, K., Tor, S., et al. (1993). The effect of trauma and confinement on functional healing and mental health status of Cambodians living in Thailand-Cambodian border camps. JAMA, 270, 581–586.CrossRefPubMedGoogle Scholar
  34. Mollica, R. F., McKinnes, K., Poole, C., et al. (1998). Does effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482–488.CrossRefPubMedGoogle Scholar
  35. Mollica, R. F., Mcinnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M. (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 282, 433–9.CrossRefPubMedGoogle Scholar
  36. Mollica, R. F., Cui, X., McKinnes, K., & Massagli, M. (2002). Science-based policy for psychosocial interventions in refugee camps. A Cambodian example. The Journal of Nervous and Mental Disease, 190, 158–166.CrossRefPubMedGoogle Scholar
  37. Mollica, R. F., Lopes Cordozo, B., Osafsky, H. J., Raphael, B., Ager, A., & Salama, P. (2004). Mental health in complex emergencies. The Lancet, 364, 2058–67.CrossRefGoogle Scholar
  38. Mollica, R. F., Lyoo, I. K., Chernoff, M. C., Bui, H. X., Yoon, S. J., et al. (2009). Brain structural abnormalities and mental health sequelae in South Vietnamese ex-political detainees who survived traumatic head injury and torture. Archives of General Psychiatry, 66, 1221–32.CrossRefPubMedGoogle Scholar
  39. Mollica, R. F., et al. (2011). Global mental health trauma and recovery: A companion guide for field and clinical care of traumatized people worldwide. Cambridge: HPRT.Google Scholar
  40. Mollica, R. F., Brooks, R., Tor, S., Lopes-Cardozo, B., & Silove, D. (2014). The enduring mental health impact of mass violence: A community comparison study of Cambodian civilians living in Cambodia and Thailand. International Journal of Social Psychiatry, 60, 6-20.Google Scholar
  41. Murthy, R. S., & Lakshminarayan, R. (2006). Mental health consequences of war: A brief review of research findings. World Psychiatry, 5, 1.Google Scholar
  42. Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., & Elbert, T. (2009). Trauma, poverty, and mental health among Somali and Rwandese refugees living in an African refugee settlement-an epidemiological study. Conflict and Health, 3, 6. doi: 10.1186/1752-1505-3-6.CrossRefPubMedCentralPubMedGoogle Scholar
  43. Petevi, M., & Kerko, H. (2011). Global mental health trauma and recovery: A companion guide for field and clinical care of traumatized people worldwide: Human rights health instruments. Cambridge: HPRT.Google Scholar
  44. Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. Journal of the American Medical Association, 294, 602–12.CrossRefPubMedGoogle Scholar
  45. Priebe, S., Bogic, M., Ajdukovic, D., Franciskovic, T., Galeazzi, G. M., Kucukalic, A., Lecic-Tosevski, D., Morina, N., Popovski, M., Wang, D., & Schutzwohl, M. (2010). Mental disorders following war in the Balkans: A study in 5 countries. Archives of General Psychiatry, 67, 518–28.CrossRefPubMedGoogle Scholar
  46. Punamaki, R. L. (1990). Relationships between political violence and psychological responses among Palestinian women. Journal of Peace Research, 27, 75–85.CrossRefGoogle Scholar
  47. Rahe, H. R., Looney, J. G., Ward, H. W., Tung, T. M., & Liu, W. (1978). Psychiatric consultation in a Vietnamese refugee camp. The American Journal of Psychiatry, 135, 185–190.CrossRefPubMedGoogle Scholar
  48. Roberts, B., Patel, P., & McKee, M. (2012). Noncommunicable disease and post-conflict countries. Bulletin World Health Organization, 90, 2–2A.CrossRefGoogle Scholar
  49. Salama, P., Spiegel, P., Talley, L., & Waldman, R. (2004). Lessons learned from complex emergencies over past decade. Lancet, 364, 1801–1813.CrossRefPubMedGoogle Scholar
  50. Sameroff, A. J., & Rosenblum, K. L. (2006). In Sci ANYA (Ed.), Psychosocial constraints on the development of resilience (Annals of the New York Academy of Sciences, Vol. 1094, pp. 116–124). New York: New York Academy of Sciences.Google Scholar
  51. Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., & Asmundson, G. J. G. (2007). Physical and mental comorbidity, disability, and suicidal behavior associate with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine, 69, 242–248.CrossRefPubMedGoogle Scholar
  52. Silove, S., & Rees, S. (2011). Global mental health trauma and recovery: A companion guide for field and clinical care of traumatized people worldwide: Planning community mental health services. Cambridge: HPRT.Google Scholar
  53. Sledjeski, E. M., Speisman, B., & Dierker, L. C. (2008). Does number of lifetime traumas explain the relationships between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). Journal of Behavioral Medicine, 31, 341–349.CrossRefPubMedCentralPubMedGoogle Scholar
  54. Sphere Project. (2011). Sphere handbooks: Standard on mental health.Google Scholar
  55. Spiegal, P. B., Checchi, F., Colombo, S., & Paik, E. (2010). Health-care needs of people affected by conflict: Future trends and changing frameworks. Lancet, 375, 341–345.CrossRefGoogle Scholar
  56. Spitzer, C., Barnow, S., Volzke, H., John, U., Freyberger, H. J., & Grabe, H. J. (2009). Trauma, posttraumatic stress disorder, and physical illness: Findings from the general population. Psychosomatic Medicine, 71, 1012–1017.CrossRefPubMedGoogle Scholar
  57. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302, 537–549.CrossRefPubMedGoogle Scholar
  58. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science & Medicine, 48, 1449–1462.CrossRefGoogle Scholar
  59. Tang, S., & Fox, S. (2001). Traumatic experiences and the mental health of Senegalese refugees. Journal of Nervous and Mental Disease, 189, 507–512.CrossRefPubMedGoogle Scholar
  60. Van Ommeren, M., Sharma, B., Sharma, G. K., Komproe, I., Cardena, E., & de Jong, J. V. M. (2002). The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: Examination of comorbidity with anxiety and depression. Journal of Traumatic Stress, 15, 415–421.CrossRefPubMedGoogle Scholar
  61. World Bank. (2012). Issues brief: Fragile and Conflict Affected Situation (CAS) Google Scholar
  62. World Health Organization, & UNHCR. (2012). Assessing mental health and psychosocial needs and resources: Toolkit for humanitarian settings. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  • Richard F. Mollica
    • 1
    Email author
  • Robert T. Brooks
    • 2
    • 3
    • 4
  • Solvig Ekblad
    • 5
    • 6
    • 7
  • Laura McDonald
    • 8
  1. 1.Harvard Program in Refugee Trauma (HRPT)Massachusetts General Hospital and Harvard Medical SchoolCambridgeUSA
  2. 2.Australian Aboriginal and TorresIslander Healing FoundationCanberraAustralia
  3. 3.School of PsychologyUniversity of New South WalesSydneyAustralia
  4. 4.Trauma and Recovery Certificate ProgramHarvard Program in Refugee (HRPT) TraumaCambridgeUSA
  5. 5.Department of Learning, Informatics, Management and Ethics (LIME)Cultural Medicine Unit, Karolinska InstitutetStockholmSweden
  6. 6.Massachusetts School of Professional PsychologyNewtonUSA
  7. 7.Harvard Program in Refugee Trauma (HRTP)CambridgeMAUSA
  8. 8.World BankUSA

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