Identifying resilience-promoting factors for refugee survivors of torture


  • Phyu Pannu Khin
  • Keith Burt
  • Karen Fondacaro



refugee resilience, mental health, psychological flexibility


Introduction: There are 1.3 million refugee survivors of torture currently living in the United States today. While a substantial body of research has been growing on refugee mental health, few studies have focused on refugee resilience.

Objective: The current study focuses on a clinical sample of refugee survivors of torture to examine resilience-promoting factors, including community engagement, employment, English fluency, and psychological flexibility. Specifically, our study conducted moderation and mediation analyses to better understand how these resilience-promoting factors impact the torture-mental health relationship.

Results: Findings showed that torture severity was significantly and positively associated with all mental health symptoms, and psychological flexibility was significantly and negatively associated with all mental health symptoms, including PTSD, depression, and anxiety. Psychological flexibility also emerged as a significant mediator of the torture-mental health relationship, such that individuals with a history of greater torture severity reported higher mental health symptoms via lower psychological flexibility. Additionally, English fluency and employment, but not community engagement, showed significant negative correlations with mental health symptoms. However, resilience-promoting factors did not interact with torture severity to predict mental health symptoms.

Conclusion: The findings from this study identified variables that may have a meaningful impact on the mental health of refugee survivors of torture and provide insights and implications in treating this population from resilience-oriented clinical frameworks.    



Allden, K., Poole, C., Chantavanich, S., Ohmar, K., Aung, N. N., & Mollica, R. F. (1996). Burmese political dissidents in Thailand: Trauma and survival among young adults in exile. American Journal of Public Health, 86(11), 1561–1569. doi: 10.2105/ajph.86.11.1561.

American Psychiatric Association.(2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed). doi: 10.1176/9780890423349.

Amnesty International. (2014). Torture in 2014: 30 years of broken promises. Retrieved from

Arnetz, B. B., Broadbridge, C. L., Jamil, H., Lumley, M. A., Pole, N., Barkho, E., & Arnetz, J. E. (2014). Specific trauma subtypes improve the predictive validity of the Harvard Trauma Questionnaire in Iraqi refugees. Journal of Immigrant and Minority Health, 16(6), 1055–1061. doi: 10.1007/s10903‐014‐9995‐9.

Bemak, F., Chung, R. C-Y., & Pedersen, P. (2002). Counseling refugees: A psychosocial approach to innovative multicultural interventions. Westport, CT: Greenwood.

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. doi:10.1016/j.beth.2011.03.007.

Center for Victims of Torture. (2015). U.S. home to far more refugee torture survivors than previously believed. Retrieved from more-refugee-torture-survivors-previously-believed.

Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L.(1974). The Hopkins Symptom Checklist (HSCL): A self‐ report symptom inventory. Behavioral Science, 19(1), 1–15. doi:10.1002/bs.3830190102.

Edward, K.L., & Warelow, P. (2005). Resilience: When coping is emotionally intelligent. Journal of the American Psychiatric Nurses Association, 11, 101-102. doi: 10.1177/1078390305277526.

Elklit, A., Kjær, K. O., Lasgaard, M., & Palic, S. (2012). Social support, coping and posttraumatic stress symptoms in young refugees, torture, 22, 11–23.

Fazel, M., Reed, R. V., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. The Lancet, 379(9812), 266-282. doi: 10.1016/S0140-6736(11)60051-2.

Fondacaro, K., & Mazzulla, E. (2018). The chronic traumatic stress framework: A conceptual model to guide empirical investigation of comprehensive treatments for refugees and survivors of torture. Torture, 28(1), 58–69. doi: 10.1016/j.cpr.2007.01.017.

Gagnon, A. J., Tuck, J., & Barkun, L. (2004). A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International, 25, 111- 149. doi: 10.1080/07399330490267503.

Gray, B., Dewey, L., & Fondacaro, K. (2020). Torture, psychological inflexibility, and mental health outcomes among resettled refugees in the United States. Journal of Refugee Studies. doi:

Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.

Hayes, S.C., Strosahl, K., & Wilson, K.G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. Guilford Press, New York, NY, USA.

Higson-Smith, C. (2015). Updating the estimate of refugees resettled in the United States who have suffered torture. Center for Victims of Torture. Retrieved from

IBM Corp. (2017). IBM SPSS Statistics for Macintosh, Version 25.0. Armonk, NY: Author.

Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical psychology review, 30(7), 865–878.

Kaaya, S.F. (2002). Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania. Acta Psychiatrica Scandinavica, 106(1), 9-19. doi:10.1034/j.1600-0447.2002.01205.x.

Kira, I. A., Amer, M. M., & Wrobel, N. H. (2014). Arab refugees: Trauma, resilience, and recovery. In S.C. Nassar-McMillian, K.J. Ajrouch, & J. Hakim-Larson (Eds.), Biopsychosocial Perspectives on Arab Americans: Culture, Development, and Health, (pp. 175-195). New York: Springer. doi:10.1007/978-1-4614-8238-3_9.

Lewis, S. (2013). Trauma and the making of flexible minds in the Tibetan exile community. Ethos, 41(3), 313–336. doi: 10.1111/etho.12024.

Masten, A. S. (2011). Resilience in children threatened by extreme adversity: Frameworks for research, practice, and translational synergy. Development and Psychopathology, 23(2), 141–154. doi: 10.1017/S0954579411000198.

Mollica, R. F., Caspi‐Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard Trauma Questionnaire: Validating a cross‐cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease, 180(2), 111–116. doi:10.1097/00005053‐199202000‐ 00008.

Mollica, R. F. (2008). Healing invisible wounds: Paths to hope and recovery in a violent world. Nashville, TN: Vanderbilt University Press.

Mollica, R. F., Wyshak, G., de Marneffe, D., Khuon, F., & Lavelle, J. (1987). Indochinese versions of the Hopkins Symptom Checklist-25: A screening instrument for the psychiatric care of refugees. The American Journal of Psychiatry, 144(4), 497-500. doi: 10.1176/ajp.144.4.497.

Murray, K. E., Davidson, G. R., & Schweitzer, R. D. (2010). Review of refugee mental health interventions following resettlement: best practices and recommendations. The American journal of orthopsychiatry, 80(4), 576–585.

Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community mental health journal, 41(5), 581–597.

Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA, 294(5), 602–612.

Quiroga, J., & Jaranson, J. (2005). Politically-motivated torture and its survivors: A desk study review of the literature. Quarterly Journal on Rehabilitation of Torture Victims and Prevention of Torture, 15(2), 1-111.

Shrestha, N. M., Sharma, B., Van Ommeren, M., Regmi, S., Makaju, R., Komproe, I., Shrestha, G. B., & De Jong, J. T. (1998). Impact of torture on refugees displaced within the developing world: Symptomatology among Bhutanese refugees in Nepal. The Journal of the American Medical Association, 280, 443–448. doi:10.1001/jama.280.5.443.

Sonn, C.C., & Fisher, A.T. (1998). Sense of community: Community resilient responses to oppression and change. Journal of Community Psychology, 26(5), 457–472. doi: 10.1002/(SICI)1520-6629(199809).

Steel, Z., Silove, D., & Brooks, R.(2006). Impact of immigration detention and temporary protection on the mental health of refugees. British Journal of Psychiatry, 188, 58-64. doi: 10.1192/bjp.bp.104.007864.

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. The Journal of the American Medical Association, 302, 537–549. doi:10.1001/jama.2009.1132

Substance Abuse and Mental Health Administration (SAMHSA). (2013). Trauma-informed care in behavioral health services, part 3: A review of the literature. Treatment Improvement Protocol (TIP) series, 57. Rockville, MD.

Tol, W.A., Leku, M.R., Lakin, D., …& Carswell, K. (2020). Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trial. The Lancet. Global Health. 8. e254-e263. 10.1016/S2214-109X(19)30504-2.

UNGA/United Nations General Assembly.(1984). Convention against torture and other cruel, inhuman or degrading treatment or punishment. United Nations Treaty Series, 1465, Retrieved from

United Nations High Commissioner for Refugees. (2018). Global trends: Forced displacement in 2017. Retrieved from

Wanna, C. P., Seehuus, M., Mazzulla, E., & Fondacaro, K. (2019). A house is not a home: Modeling the effects of social support and connection within resettled refugee populations. Journal of Community Psychology, 47(7), 1629-1644. doi:10.1002/jcop.22218.

Wood, N., Charlwood, G., Zecchin, C., Hansen, V., Douglas, M., & Pit, S.W. (2019). Qualitative exploration of the impact of employment and volunteering upon the health and wellbeing of African refugees settled in regional Australia: A refugee perspective. Biomedical Central Public Health, 19(1), 143. doi:10.1186/s12889-018-6328-2.




How to Cite

Phyu Pannu, Burt, K., & Fondacaro, K. (2022). Identifying resilience-promoting factors for refugee survivors of torture. Torture Journal, 32(3), 31–48.