The Relationship between Decision-Making Agency and Mental Health for Refugees Resettled in Canada and the United States: A Critical Review

Background and Purpose: There are an estimated 120 million forcibly displaced people in the world - more than at any other time in recorded history. About a third of this population is classified as refugees, and for the past decade, the United States and Canada have consistently resettled more refugees than any other country. The experiences associated with forced displacement severely curtail refugees’ decision-making agency (DMA), or freedom to make meaningful, self-driven choices. DMA is central to wellbeing, especially for marginalized populations. Although refugees often exhibit striking levels of resilience, many also face unique mental health challenges. This critical review fills a gap by mapping current knowledge about the relationship between DMA and mental health for refugees resettled in Canada and the US, including recommendations for social work research, practice, and policy.

Methods: 463 peer-reviewed articles were retrieved from three databases (APA PsycInfo, Scopus, Sociological Abstracts); of these, 23 met inclusion criteria. Publications in English were examined with no timeframe restrictions, and Covidence software was used to conduct the review. An author-developed data extraction instrument and the JBI Critical Appraisal Checklists for Qualitative and Quantitative Quasi-Experimental Research were used to organize relevant data and assess the quality of included articles.

Results: Literature examining the relationship between DMA and mental health for refugees resettled in Canada and the US has largely emerged over the past fifteen years, with increasing attention over time. Refugees from diverse cultures, especially refugee youth, consider DMA to be an integral part of living a meaningful life. Age, life stage, mental health, and family relationships can influence how refugees conceptualize and apply DMA. Meaningful access to DMA benefits refugees’ mental health, while infringements on agency undermine mental health.

Conclusion and Implications: This review emphasizes an integrated approach to social work research, practice, and policy. The symbiotic relationship between these domains can ultimately create a strong, mutually reinforcing network of support that facilitates refugee DMA and mental health. Researchers can center DMA by offering choices around location, timing, interpreter gender, and dissemination, reinforcing the dignity of refugees and inviting them to inhabit an agentic role in the research process. Such research builds trust with refugee communities and produces actionable knowledge that can meaningfully inform practice and policy. Practitioners can center refugee DMA by prioritizing refugees’ preferences and goals, adopting asset-based approaches, and ensuring access to interpreters. By centering refugee DMA, new ideas and approaches will surface in an iterative process that improves practice, research, and policy. Policies should also preserve the rights, dignity, and agency of refugees in ways that expand their ability to improve their mental health and wellbeing. This includes prioritizing family reunification and access to culturally responsive mental healthcare. Such policies can improve the practice and research landscapes by moving these domains closer to new improvements and discoveries. Social work is well-positioned to engage in impactful research, practice, and policy work that bridges the divides of these domains and moves toward more holistic and meaningful engagement with this topic.