Mental health issues in the refugee community.

1. Refugee Children & Families:
The Emotional Impact of Resettlement
and Treatment Strategies
1

2. Presenters:
Beth Farmer, MSW
Junko Yamazaki, LICSW
Souchinda Khampradith, MSW
2

3. The Refugee Experience
 Varies not only among refugee groups, but also among
individuals.
 Complex and almost always contains numerous traumas and
stressors.
 Approximately 5-10% of refugees in the United States have
experienced a form of torture, including electric shocks,
beatings, caning of the soles of the feet, rape, and forced
witnessing of torture of executions.
 Many refugees experience loss of contact with family members,
repeated exposure to violent acts, and extreme fear situations.
 All refugees have experienced a loss of home, loss of livelihood,
and relocation stress.
 Research supports the relationship between trauma and mental
health issues.
3

4.  Numerous studies demonstrate that refugees are a
particularly vulnerable population when it comes to mental
health issues.
 Common diagnoses include Post-Traumatic Stress Disorder,
Major Depressive Disorder, and Anxiety or Adjustment
Disorder.
 Refugees have been found to have ten times the rate of
Post-Traumatic Stress Disorder [PTSD] as compared to the
general population.
 Refugees have higher rates of mental disorders in general.
4

5. Migration and its Impact on
Mental Health
The refugee
experience is
multifaceted and
contains
elements of
trauma and/or
stress during all
its migration
stages:
5

6. Stage 1: Forced Migration
 Includes events both before “flight” and during “flight.”
 Before being forced to flee, refugees may experience
imprisonment, torture, loss of property, malnutrition, physical
assault, extreme fear, loss of livelihood, being forced to inflict
pain or kill, witness torture or killing, and/or the loss of close
family members or friends.
 The flight process can last days or years.
 During flight, refugees are frequently separated from family
members, robbed, have little or no food, become ill, assaulted
and/or raped, witness physical assault and/or rape, witness
others being beaten or killed, and endure extremely harsh
environmental conditions. Because of its “dramatic” nature this
is often of most interest to clinicians, but is rarely cited as having
extensive bearing on emotional health by resettled refugees.
6

7. Stage 2: Camp Residency
 Not all refugees live in camps.
 Refugee camps differ in size (some containing a few thousand
while others contain well over 100,000 people) and physical
attributes (some having schools, hospitals, roads, and sanitation
while others consist of quickly constructed tents).
 Although refugee camps are considered temporary, in reality,
many are long-term settlements where refugees can remain for
decades.
 Refugees may be barred from agricultural pursuits or from
working. And results in a lack of meaningful activity and
demoralization.
 A time of incredible uncertainty – repatriation, integration,
resettlement.
 Violence is often a feature of camps.
 Food inadequacy, micro-nutrient deficiencies.
7

8. Stage 3: Resettlement –
“Resettlement is a life crisis.”
 Refugees move to a new country with a different
language and culture leaving behind family and
friends – usually do not have choice of location.
 The resettlement period = 90 –180 day period of
assistance by Volags.
 Their initial financial situation is extremely limited.
($450 per person + travel loan)
 Opportunities for employment may be few due to a
lack of education or language skills, or conversely,
their previous education and training may be useless
in the US.
8

9.  Feelings of isolation can also emerge due to a lack of
language skills, extended support network, and
transportation.
 Refugees may feel their values conflict with the
culture in which they reside.
 They may become targets of discrimination or
oppression.
 Refugees cite resettlement factors as the most critical
to their mental health.
 “Post-migration stressors such as unemployment and
family separations have a more powerful effect on
refugee mental health than pre-migration stressors
during the first few years of resettlement” (Hyman,
Vu, & Beiser., 2000).
9

10. Resettlement and Mental Health
 Stages of Resettlement –
 1) Excitement and Gratitude
 2) Overwhelmed and Numb
 3) Loss of illusion and Expectation
 4) Depression
 5) Acceptance
 6) Greater Integration and Acculturation
– The initial period of resettlement is followed by what may be the most
critical phase in the post-migration process, it is during this phase that
refugees can be “most vulnerable and most in need of comprehensive
support services” (NAMMH, n.d., p. 18).
– If they are able to get adequate support they are more likely proceed
towards successful psychological and cultural integration into their new
society. If these supports are absent, the stressful demands of
resettlement, along with past trauma and separation from family and
friends, can put refugees at high risk for mental health issues, alienation,
and marginalization. 10

11. Resettlement Challenges
 Economic - Housing
– Example: Seattle has one of the highest costs of living in the
US.
 Isolation
– Lack of transit options in suburbs.
– Less refugee density.
– Less “walkability.”
– Fewer accessible community centers and other close
options for gathering.
 Lag in Cultural Competency
– Services – schools, hospitals, etc. – less experience with
refugees and providing services to refugees.
 All INCREASES stress
11

12. How to Approach the Topic of
Mental Health/Illness
1. Meaning of mental illness
2. Cross-cultural factors affecting mental
health
3. Cultural view of schizophrenia
4. Before the client walks through the
door
5. Talking to the patient about symptoms
12

13. What do we mean by
“Mental Illness?”
 In the western world “mental illness” refers to
a wide range of emotional distress.
 In many other cultures, mental illness means
“crazy.”
 The difference in the meaning of “mental
illness” is a major barrier to service access.
13

14. Cross-Cultural Factors Affecting
Refugee Mental Health
 Culture frames how one expresses
emotions and processes emotions:
– In many refugees’ worldview there is no dichotomy between
physical complaints and mental, spiritual, and social distress
(Watters, 2001; Nadeau & Measham, 2006). This often
leads to a high degree of “somatization.”
– In many cultures, it is considered a sign of immaturity to
speak of past trauma or emotional reactions to it.
– The western paradigm of psychodynamic counseling is
foreign to most cultures, who find it vague and not
particularly useful.
14

15. Connecting to Refugee Clients
• Attain Knowledge of Client Background
- Resources: Ethnomed/ Interpreters/ Literature/
Colleagues
• Learn the Landscape of the Individual
• Use of mental health terms vs. Use of somatic
symptoms/descriptive terms to delineate the
problem (sleep, sadness, worry)
• Checking with interpreter to see what your words
may mean to client
15

16. Know the Landscape
Ask the Individual
– Age
– Class
– Education
– Religion
– Language
– Family
16

17. Eight questions by Dr. A. Kleinman
Are there Comparable MH Questions?
1. What do you think caused your problem?
2. Why do you think it started when it did?
3. What does your sickness do to you? How does it
work?
4. How severe is your sickness? How long do you
expect it to last?
5. What problems has your sickness caused you?
6. What do you fear about your sickness?
7. What kind of treatment do you think you should
receive?
8. What are the most important results you hope to
receive from this treatment?
17

18. Connecting
“…..there is no substitute for deep, empathic, open-
minded listening to people. It is, of course, very
important to have some knowledge of the culture,
values, attitudes, even gestures of people from
cultures different from ours. But even with this very
useful knowledge, when we work directly with people,
we must listen to them with a minimum of
assumptions, with genuine interest, caring and
curiosity, as well as a desire to truly know their
thinking and feelings. We need to balance the truth
that people are very much products of their cultures
with the truth that, at the core, we are all equally
human.”
Bernard Kempler, PhD
18

19. Working with Refugee
Children and Youth
19

20. Third Culture Youth:
 Youth with 1st generation immigrant/refugee
parents and whose peers are American born.
 They are a critical subset of the immigrant and
refugee community.
 They often do not identify with their parents’
culture or their adopted American culture.
 Cultural identity conflict adds an additional
element of stress to both the youth’s and their
parents’ lives as they try to cope with the usual
tensions of adolescence.
20

21. Common Issues
 Loss and Grief
 Depression and Anxiety
 Guilt and Shame
 Trauma and PTSD
 Adjustment: depends on the age of resettlement,
level of literacy, whether resettling with family &
relatives or unaccompanied minor, trauma & the
experience before, during & after resettlement
 Other issues: parent/child conflict, peer and
school issues, CD/SA, DV/SA, involvement with
gang and violence, problem gambling and
normal developmental issues such as dating.
21

22. Treatment Strategies -
PARENTS
 Always include Parents/Foster Parents/Care Givers
in development of Tx Plan if possible. Work them
through the issues and Tx process. Provide culturally
tailored explanation.
 Build trust and credibility by working on tangible
needs first– translate letters from child’s school, find
doctor, connect with housing, etc.
 Many come from single parents household/multi-
generational household/mixed family household.
Find out who has decision making power.
22

23. Treatment Strategies -
PARENTS
 Be a cultural navigator/broker for the family and
youth. Family members’ unfamiliarity and lack of
knowledge of US systems (legal, educational,
health, mental health) hinders help-seeking.
 Mistrust of the government and their past
experiences with authority figures hinder help-
seeking. Take your time to build trust and explain
to decrease their anxiety.
 Build partnership and alliance.
23

24. Treatment Strategies -
PARENTS
 Find out parents’ understanding of child’s issues;
what they have tried; what worked and what did not
work.
 If possible always match culture, language and
gender of counselor to youth and their family.
 Have trained interpreter available. Make sure that
culture/language/gender and age of interpreter is
appropriate.
24

25. Treatment Strategies -
PARENTS
 Pay attention to family’s understanding of causality of
mental illness. The Western mental health symptoms
may not be looked upon as mental illness, but rather
“gifts,” “special powers” and “ black magic.”
 Pay attention to their spiritual belief system.
 Develop culturally responsive Tx Plan.
 Understand and incorporate indigenous healing
practices -- rituals with shamans and monks,
sacrificing chickens, etc.
25

26. Treatment Strategies -
PARENTS
 Many parents and adult caregivers are
dealing with their own issues that affect
their ability to support the child. Such as:
-- PTSD
-- Loss & Grief
-- Chemical Dependency/Problem Gambling
-- Sexual Abuse/Domestic Violence
-- Unemployment/Underemployment
-- Substandard Housing
 Offer them resources and connect them to
culturally appropriate services.
26

27. Treatment Strategies –
CHILDREN AND YOUTH
– Refugee youth develop differently than the
mainstream youth. Western developmental
assessment tools do not work well with this
population.
• Emotional Development
• Sense of Self/Identity Formation
• Social Development
• Sexual Identity Development
• Family Relationship
27

28. Treatment Strategies –
CHILDREN AND YOUTH
 Encourage them to have their parents involved but
assure confidentiality.
 Establish trust and credibility -- work with tangible
needs first. Assign staff who has similar refugee and
cultural experience.
 Understand issues at home -- who lives at home,
who is raising them, who makes decisions.
 Understand their unique refugee experience -- years
in camp, age of resettlement, literacy in their own
language, trauma, loss, etc.
28

29. Treatment Strategies –
CHILDREN AND YOUTH
 Understand youth’s cultural norms and
traditions.
 Assess the level of acculturation of both
youth and parents. Level of English
proficiency.
 Assess CD/SA, DV/SA, problem gambling,
health and mental health issues with youth
and family members.
29
 Assess readiness to accept services.

30. Treatment Strategies –
CHILDREN AND YOUTH
 Address:
 School and Academic Development
 Social and Peer Life
 Identity -- cultural/ethnic/sexual
 Developmental Stage
 Health Issues -- make sure youth has a medical
provider.
 Connect to Resources in the Community -- after
school programs, sports, cultural groups, and other
fun activities.
 AND Empower them, nurture Hopes and Dreams!!!
30

31. Resources
– Bridging Refugee Youth and Children’s
Services
www.brycs.org
– Cultural Orientation Resource Center
www.cal.org/co/publications/profiles.html
31

32. Thank you!
Beth Farmer, MSW
Bfarmer@lcsnw.org
Junko Yamazaki, LICSW
Junkoy@acrs.org
Souchinda Khampradith, MSW
Souchindak@acrs.org
32