Year 2 Customers Sales ($000) January 215 265 February 259 388 March 325 298 April 354 260 May 258 263 June 199 402 July 254 320 August 299 310 September 264 307 October 198 302 November 223 225 December 261 361 Refugee Youth: A Review of Mental Health Counselling Issues and Practices E. Anne Marshall, Kathryn Butler, Tricia Roche, Jessica Cumming, and Joelle T. Taknint University of Victoria A global migration crisis has resulted in unprecedented numbers of refugees coming to Canada and other countries. A third of these refugees are youth, arriving with family members or alone. Although specific circumstances differ widely, refugee youth need support with language learning, education, and adjusting to a new country; a significant number also need mental health services. For this review paper, we focused on mental health issues and challenges refugee youth face, as well as counselling practices that have been found to be effective with these youth. There has been very little research specifically focused on refugee-youth mental health in Canada; however, the studies cited come from Canada, the United States, Australia, and European countries that have much similarity in their approaches to mental health counselling and psychotherapy. An overview of the refugee-youth context is presented first, followed by a description of refugee mental health issues and challenges, a discussion of barriers to engagement with mental health services, and suggestions for effective mental health counselling practices for this population. The paper concludes with a summary of key findings from the literature and suggestions for future research to address the gaps in knowledge. Given the adversities many young refugees experience premigration, during migration, and after resettlement, it is not surprising that they experience mental health problems. Despite difficulties, young refugees demonstrate adaptability, perseverance, and resil- ience; having mental health professionals acknowledge their strengths and abilities will help them on their healing path and support them to adapt positively to a new home. Keywords: refugee youth mental health, review of refugee youth mental health, refugee youth mental health issues, counselling for refugee youth, mental health practices with refugee youth “Being a young refugee involves growing up in contexts of violence and uncertainty, experiencing the trauma of loss, and attempting to create a future in an uncertain world.” (Correa-Velez, Gifford, & Barnett, 2010, p. 1399). The world is experiencing a global refugee crisis. According to the United Nations High Commission for Refugees (UNHCR), there are close to 14 million refugees worldwide; the level of human displacement has increased by 50% since 2011 (United Nations High Commission for Refugees [UNHCR], 2016b). The Syrian refugee situation has received a great deal of attention recently; the Government of Canada (2016) has reported that a total of 26,921 refugees.

1. Year 2
Customers
Sales ($000)
January
215
265
February
259
388
March
325
298
April
354
260
May
258
263
June
199
402
July
254
320
August
299
310
September
264
307
October
198
302

2. November
223
225
December
261
361
Refugee Youth: A Review of Mental Health Counselling
Issues and Practices
E. Anne Marshall, Kathryn Butler, Tricia Roche, Jessica
Cumming, and Joelle T. Taknint
University of Victoria
A global migration crisis has resulted in unprecedented numbers
of refugees coming to Canada and other
countries. A third of these refugees are youth, arriving with
family members or alone. Although specific
circumstances differ widely, refugee youth need support with
language learning, education, and adjusting
to a new country; a significant number also need mental health
services. For this review paper, we
focused on mental health issues and challenges refugee youth
face, as well as counselling practices that
have been found to be effective with these youth. There has
been very little research specifically focused
on refugee-youth mental health in Canada; however, the studies
cited come from Canada, the United
States, Australia, and European countries that have much
similarity in their approaches to mental health
counselling and psychotherapy. An overview of the refugee-
youth context is presented first, followed by

3. a description of refugee mental health issues and challenges, a
discussion of barriers to engagement with
mental health services, and suggestions for effective mental
health counselling practices for this
population. The paper concludes with a summary of key
findings from the literature and suggestions for
future research to address the gaps in knowledge. Given the
adversities many young refugees experience
premigration, during migration, and after resettlement, it is not
surprising that they experience mental
health problems. Despite difficulties, young refugees
demonstrate adaptability, perseverance, and resil-
ience; having mental health professionals acknowledge their
strengths and abilities will help them on
their healing path and support them to adapt positively to a new
home.
Keywords: refugee youth mental health, review of refugee youth
mental health, refugee youth mental
health issues, counselling for refugee youth, mental health
practices with refugee youth
“Being a young refugee involves growing up in contexts of
violence
and uncertainty, experiencing the trauma of loss, and attempting
to
create a future in an uncertain world.” (Correa-Velez, Gifford,
&
Barnett, 2010, p. 1399).
The world is experiencing a global refugee crisis. According to
the United Nations High Commission for Refugees (UNHCR),
there are close to 14 million refugees worldwide; the level of
human displacement has increased by 50% since 2011 (United
Nations High Commission for Refugees [UNHCR], 2016b). The
Syrian refugee situation has received a great deal of attention

4. recently; the Government of Canada (2016) has reported that a
total of 26,921 refugees have arrived in Canada from Syria
since
November 2015. Syria is one of the top 10 countries from which
refugees have fled to Canada, the other nine being China,
Hungary,
Pakistan, Nigeria, Colombia, Iraq, Libya, Somalia, and Afghani-
stan (Citizenship & Immigration Canada, 2016b). Together
these
countries accounted for almost half of the total refugee claims
in
Canada in 2015. Citizenship and Immigration Canada (CIC) has
reported that just over 32,000 refugees became permanent resi-
dents of Canada in 2015 (CIC, 2016a), contributing to a total of
149,163 refugees of all statuses living in Canada; 51% of these
refugees are children and youth under the age of 25 (UNHCR,
2016a). In this paper youth typically includes ages 15 to 24
years
because this age range is used for this population in most of the
literature and institutional reports.
Young refugees are a particularly vulnerable group. Although
many figures pertaining to refugees in general are approximate
because of their chaotic conditions, the reported numbers of
refu-
gee children and youth, in particular, are incomplete (Evans, Lo
Forte, & McAslan Fraser, 2013). Evans et al. (2013) referred to
refugee youth as an “invisible” population (p. 15). They noted
that
a third of the global population of displaced people is thought
to be
between the ages of 10 and 24, with almost half (47%) being
under
18. In Canada in 2012, youth between the ages of 15 and 24
comprised 21% of the population of refugees admitted (Guruge

5. &
Butt, 2015). A disturbing number of these refugee youth are
orphans or travelling alone, either by choice or after separation
from parents or caregivers; they are extremely vulnerable to ex-
ploitation (UNHCR, 2016a).
Newcomers who have been forced to flee their home countries
experience a number of difficulties and barriers after arriving in
their new host country. About 80% of refugee families receive
some social assistance in their first year living in Canada,
dropping
to 50 – 60% in the second year (Statistics Canada, 2015b). In
2013,
about half (52%) the government-assisted refugee youth (GARs)
under 24 were employed; privately sponsored refugees fared
bet-
E. Anne Marshall, Educational Psychology and Leadership
Studies
and Centre for Youth & Society, University of Victoria;
Kathryn Butler
and Tricia Roche, Centre for Youth & Society, University of
Victoria;
Jessica Cumming, Educational Psychology & Leadership
Studies, Uni-
versity of Victoria; Joelle T. Taknint, Department of
Psychology,
University of Victoria.
Correspondence concerning this article should be addressed to
E. Anne
Marshall, Educational Psychology and Leadership Studies,
University of
Victoria, PO Box 1700, Victoria, BC, Canada, V8W 2Y2. E-
mail:
[email protected]

6. Canadian Psychology / Psychologie canadienne © 2016
Canadian Psychological Association
2016, Vol. 57, No. 4, 308 –319 0708-5591/16/$12.00
http://dx.doi.org/10.1037/cap0000068
308
mailto:[email protected]
http://dx.doi.org/10.1037/cap0000068
ter, with an employment rate of 69% (Statistics Canada, 2015a).
Even with the support available from all levels of government
and
private sponsors, many refugee youth and their families
experience
challenges in language learning, housing, employment,
education,
social relationships, and health, including mental health.
For this review paper, we focused on mental health issues and
challenges that refugee youth face and on good practices that
have
been found to be effective with these youth. Working with
young
refugees presents a distinct set of circumstances for counselling
psychologists and mental health therapists. Given the
adversities
that these young people experience premigration, during migra-
tion, and after resettlement, it is not surprising that they exhibit
symptoms of posttraumatic stress disorder (PTSD) and other
men-
tal health disorders (Fazel, Wheeler, & Danesh, 2005). Yet,
despite
these circumstances, young refugees also demonstrate
adaptability,

7. perseverance, and resilience; they possess strengths and
attributes
that can help them adjust positively to a new home (Correa-
Velez
et al., 2010; Mawani, 2014). It is vital that mental health practi-
tioners acknowledge and build upon the assets and potential
these
refugee youth possess.
McKenzie, Tuck, and Agic (2014) observed that the Govern-
ment of Canada Mental Health Commission’s strategy of 2012
acknowledged the need for improving services for refugees, but
did not provide specific recommendations for designing and im-
plementing such services. In their recent scoping review,
Guruge and
Butt (2015) pointed out that there has been very little research
spe-
cifically focused on refugee-youth mental health in Canada; the
stud-
ies cited in this paper come from Canada, the United States,
Australia,
and European countries that have much similarity in their
approaches
to mental health counselling and psychotherapy. The paper
begins
with a brief overview of key considerations related to refugee
youth
in general. Next, research and scholarly literature is presented,
de-
scribing the mental health challenges refugee youth may
experience
as well as factors that have been found to increase their levels
of risk.
Barriers to engagement in mental health services are then
discussed,
along with strategies to address those barriers. The fourth

8. section
outlines several concepts and practices for effective mental
health
counselling with refugee youth. The paper concludes with a
summary
of key points related to youth-refugee mental health and
suggestions
for future directions.
Key Considerations Related to Refugee Youth
Because of the different situations affecting individual refugees
and families, there are very few general principles that can be
applied. One principle is priority or primacy of needs—similar
to
the hierarchy of needs concept articulated by Abraham Maslow
(1943). Though refugee youth may have experienced severe psy-
chological trauma before or during migration, safety and
survival
needs, such as shelter, food, and basic physical health must be
addressed first. Beyond basic safety and survival needs, other
key
areas for supporting refugees include language, economic and
family situation, education, and gender, discussed briefly
below.
Language
Language is a key factor in resettlement because it affects all
aspects of life in a new country. Refugees who have some
knowl-
edge of the host-country language are at a distinct advantage
(Woods, 2009). Refugees are generally highly motivated to
learn
the language of their new location (Iversen, Sveaass, & Morken,

9. 2014); however, their schooling histories, experiences of
trauma,
and migration difficulties can present challenges to this
acquisition
(McBrien, 2005; Woods, 2009). In a short period of time,
refugees
have to catch up to peers in a new school (or study language at
night if they are working), acquire functional and digital
literacy,
and learn to navigate a new culture, including its institutions,
history, expectations, and norms. Because children and youth
learn
new languages more quickly than their parents, they are often
called on to act as interpreters, or language brokers (Umaña-
Taylor, 2003). This can result in young people having the
respon-
sibility to translate in situations that may be inappropriate for
their
developmental level or familial role. There is a high need for
trained translators; resettlement assistance programs designed to
meet other needs are increasingly being called upon to provide
translation services, as these are not available elsewhere in the
community (Citizenship & Immigration Canada, 2011).
Refugee students have particular language-learning needs that
require specialized curriculum and effective ways of integrating
second-language learning and content learning (McBrien, 2005).
Bilingual strategies that build on and validate students’ existing
knowledge are effective but costly. Woods (2009) called for re-
search on ways to incorporate language-learning technology in
the
classroom and to develop tools for use outside the classroom
(e.g.,
through TV and Internet), particularly for refugee youth who
are
no longer in school. Providing accurate information in the

10. school
curriculum and encouraging constructive and open-minded
discus-
sion of refugee issues in the classroom is important for
combatting
negative attitudes and stereotypes toward refugees in their new
communities (MacNevin, 2012). Community programming can
provide opportunities to explore nontraditional language-
learning
methods, such as arts-based instruction, as well as to foster
social
development, cultural awareness, acceptance, and integration
among residents and new arrivals (Mawani, 2014; Taylor &
Sidhu,
2012).
Economic and Family Situations
Older refugee youth may need to contribute economically to
family survival; almost two thirds (63%) of refugees in Canada
under the age of 24 are employed (Statistics Canada, 2015a).
Young refugee women with small children may suddenly find
themselves the head of a household and needing to work
(UNHCR,
2006). Citizenship and Immigration Canada (2011) reports that
women head most single parent refugee families. This can mean
a
heavy responsibility for young refugee mothers who are often
under 20 years old, an age when many in a host country such as
Canada are relatively carefree and pursuing postsecondary
educa-
tion (Hatoss & Huijser, 2010; Mawani, 2014). Adding to the
stress
of forced migration, economic and family responsibilities can
constitute a burden for refugee youth that erodes their mental
health and coping abilities. Counsellors and therapists who

11. serve
new refugees attest to the urgency of assisting them to deal with
multiple and serious living-situation difficulties and to access
necessary community support (Murray, Davidson, & Schweitzer,
2010; Nadeau & Measham, 2005).
309REFUGEE-YOUTH MENTAL HEALTH
Education
Another key area for supporting refugee youth is education and
training. Some refugee children and adolescents have spent
most if
not all of their young lives in refugee camps or other living
situations that have disrupted the normal education process
(Guruge & Butt, 2015; MacNevin, 2012; Taylor & Sidhu, 2012).
Thus, some refugee youth have low literacy skills in their own
native language and no knowledge of their host country’s
language
(Woods, 2009). If they are of school age, they may face a
daunting
amount of work to catch up to their age mates. If they are past
secondary school age, they may not meet requirements for post-
secondary schools or training institutions and they may be pres-
sured to take low-paying jobs to support family members and
other
dependents (Woods, 2009). Young refugees’ credentials or work
experience may not be recognised in their host country
(McBrien,
2005). This can be very stressful and, when added to the ordeal
of
forced migration, ensuing mental health problems are not
surpris-
ing (Iversen et al., 2014).

12. Gender
Mental health clinicians and other professionals in European
and North American countries may not be familiar with the par-
ticular gender-role expectations and cultural norms among many
refugee populations (Tastsoglou, Abidi, Bigham, & Lange,
2014).
Furthermore, refugee girls and women have distinct needs and
abilities that often go unrecognized because settlement policies
and procedures were originally developed for uprooted men
(UNHCR, 2006). Such uniformity in policy does not adequately
account for the specific ways women may be affected by forced
migration. For example, many refugee men are already accus-
tomed to the role of financially providing for their families;
how-
ever, refugee women, including many who are very young, may
face a new demand to generate family income while still main-
taining their traditional child-rearing role (Tastsoglou et al.,
2014).
Often they receive little community or social support (Hatoss &
Huijser, 2010). Mental health professionals may need to
advocate
for equitable policies within their agencies to support these
young
women (Berman et al., 2009; Ellis et al., 2010). In their
Canadian
study, Tastsoglou et al. (2014) found that young refugee women
were victims of sexual violence at higher rates than men;
however,
they have often suffered from the loss of community protection
and struggled to access services for gender-based violence they
may have experienced in their home country. Refugee women
and
girls are also at risk of being victims of domestic violence in
host

13. countries but may not feel safe to report such incidents;
increasing
awareness of safe ways for these women to report abuse is nec-
essary (UNHCR, 2006). The need for culturally and gender-
appropriate counselling is great; Guruge and Butt (2015) noted
that
young female refugees overall are diagnosed with mental health
problems at higher rates than their male peers.
Addressing the issues affecting young refugee women means
developing an understanding of the intersectionality of young
women’s identities (Beck, Williams, Hope, & Park, 2001). In
this
framework, strengths, abilities, barriers, and challenges are con-
sidered through the multiple and intersecting variables of
gender,
class, race, family, language, trauma, work, and educational
back-
ground. By exploring the impact these interacting influences
have
on the experiences and identities of young refugee women,
mental
health therapists can tailor counselling to meet clients’
particular
and contextualized needs. More research is needed on gender
interactions.
Counselling and mental health professionals can take a leader-
ship role in supporting young refugee women. A perspective
shift
to identify refugee girls’ and women’s needs in the context of
their
existing abilities and strengths is critical for restoring a sense
of
agency and, ultimately, a sense of self to uprooted women.

14. Tastsoglou et al. (2014) suggested that connecting refugee
women
with opportunities to contribute their stories to public dialogues
could positively impact societal discussions of their
experiences.
Developing and adapting mental health programming to accom-
modate refugee girls’ and young women’s home and family re-
sponsibilities can promote greater access to services. Increasing
the availability and accessibility of services for young refugee
women who have experienced sexual violence could increase
their
sense of safety in their new countries (Tastsoglou et al., 2014).
Finally, mental health professionals are well positioned to advo-
cate for refugee women and girls in their local communities
(UNCHR, 2006). Advocacy can pose some challenges, however,
because of the need to balance recognition of cultural gender
roles
and acknowledgement of structural barriers that may segregate
and
devalue female refugees in schools, agencies, and community
settings. Many refugee women are dependent on family males
who
make all decisions for them and accompany them at all times;
access to mental health services can thus be limited (Tastsoglou
et
al., 2014).
Understanding Mental Health Challenges for
Refugee Youth
To understand the mental health challenges young refugees
face,
it is imperative to consider the multiple losses associated with
being forced to leave a home country compounded with the
stress
and trauma that many refugees encounter either premigration or

15. along their journey to the host country. These difficulties distin-
guish them from other immigrant populations, though the latter
also experience multiple losses and some similar challenges
(Hyndman, 2011). Guruge and Butt’s (2015) review of refugee-
youth mental health in Canada noted that refugee youth
experience
many of the same postmigration stressors as other immigrants
(e.g., institutional barriers, intergenerational conflict, and
discrim-
ination), but varying premigration hardships can influence refu-
gees’ specific reactions to these stressors. Refugees’
experiences
of trauma can include loss of family members or friends through
death, disappearance, or displacement; witnessing or
experiencing
emotional and/or physical torture, severe injury, rape,
bombings,
or other forms of violence; camp imprisonment; fear for safety;
hunger; homelessness; and loss of property (Yakushko, Watson,
&
Thompson, 2008). In addition, refugee youth may be forced to
relocate to a new country without their parents, siblings, or
other
family members. Some must integrate into school or work
systems
without speaking the dominant language, whereas others may be
held in detention centres for varying periods of time (Warr,
2010).
Refugee youth have experienced different levels of conflict and,
thus, their external experiences of trauma vary greatly. Also,
internal experiences of trauma differ among individuals (Warr,
2010). In their review of youth-refugee mental health, Guruge,
and
Butt (2015) found that personal experiences of trauma were
more

16. 310 MARSHALL, BUTLER, ROCHE, CUMMING, AND
TAKNINT
likely to lead to maladaptive symptoms than collective
experiences
such as war or staying in a refugee camp. Many refugee youth
experience symptoms of post traumatic stress disorder (PTSD)
such as emotional numbness, disturbed sleep patterns, and
flash-
backs (Teodorescu et al., 2012). Unaccompanied refugee youth
are
most at risk for mental health challenges (Bean, Derluyn,
Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007; Derluyn,
Mels, & Broekaert, 2009). Derluyn et al. (2009) reported that
unaccompanied adolescents are especially likely to be exposed
to
premigration trauma and also to show more depressive
symptoms
upon resettlement. Unaccompanied minors show higher levels of
PTSD symptoms than accompanied minors and minors from
non-
refugee populations (Huemer et al., 2009), as well as higher
levels
of anxiety (Derluyn & Broekaert, 2007). Other mental health
issues that are common among refugee youth but may be mani-
fested in unique ways are depression, low self-esteem, stress,
anxiety, and conduct disorders (Guruge & Butt, 2015).
Trauma associated with high-conflict areas such as Syria and
parts of Africa typically involves multiple losses for youth,
includ-
ing family members, friends, education, property, work opportu-
nities, and the sense of belonging. Thus, many refugees

17. experience
grief during their resettlement (Craig, Sossou, Schnak, & Essex,
2008; Nickerson et al., 2014). Although grief is an expected
response for those experiencing this magnitude of loss, some
refugees experience prolonged or complicated grief, such that
maladaptive responses to the losses persist (Prigerson et al.,
2009).
Psychologists and other mental health professionals working
with
refugee youth consistently identify a distinct theme of loss of
home, belonging, and culture that emerges in therapy sessions
(Warr, 2010).
Refugee youth often experience a disrupted sense of self or
identity that can erode self-esteem and independence (Allan,
2015). Migration can pose a significant threat to cultural
identity,
particularly if the home culture is discriminated against in
the postmigration country (Pickren, 2014). Inman, Howard,
Beaumont, and Walker (2007) found that cultural norms in a
new
country often make it difficult for refugees to maintain their
natal
culture, even when they attempt to do so. Moreover, forced mi-
gration can lead to culture shock, a deep sense of isolation or
lack
of identification with a foreign home, which can have a negative
impact on refugees’ sense of self. Ndengeyingoma, de
Montigny,
and Miron (2014) note that many refugee youth draw strength
from family and religious values; however, negotiating the
tension
between these values and those of peers in the host country can
be
a challenge. Mental health professionals can assist refugee
youth

18. by engaging them in discussions about how such value conflicts
are affecting them and their families and by helping them to
address and resolve tensions.
Factors Influencing Mental Health Outcomes for
Young Refugees
Being a refugee does not in itself cause mental health problems;
rather, a multitude of factors interact to influence individuals
and
families. Researchers have found a wide range of effects of mi-
gration on refugees’ mental health (Ellis, Miller, Baldwin, &
Abdi,
2011; Mawani, 2014). Some refugees experience mental health
problems during and after resettlement, whereas others demon-
strate positive functioning and resilience. Mawani (2014)
articu-
lates the interaction of factors.
It is important to stress that, although refugees may be more
likely to
experience certain determinants and are therefore more at risk
of
certain mental health outcomes, they may not actually
experience
those outcomes, due to a combination of individual, family and
community strengths. (p. 29)
Therapists need to consider relevant migration contexts, as well
as individual, family, and community factors, when assessing
refugee mental health and planning interventions.
Individual factors. Young refugees come to new countries
with a wide range of experiences that influence their mental
health.

19. Levels of stress, conflict, trauma, and coping are unique to each
refugee in premigration, during migration, and upon
resettlement.
Not surprisingly, researchers have found that direct and indirect
exposure to violence is associated with increased mental health
problems for young refugees (Fazel, 2012; Yakushko et al.,
2008).
In their review, Fazel, Reed, Panter-Brick, and Stein (2012) also
noted that personal injury sustained during premigration events
was related to increased mental health concerns. Beyond these
traumatic experiences associated with migration and
resettlement,
Joly (2011) has found that premigration mental health
difficulties
such as anxiety, depression, and exposure to nontraumatic but
stressful life events impact refugees’ postmigration mental
health.
Family factors. Family history and disruptions to the family
unit have an impact on young refugees’ mental health outcomes
(Fazel et al., 2012). For example, children who are separated
from
their families pre- or postmigration are at increased risk of psy-
chological problems (Bean et al., 2007; Hodes, Jagdev,
Chandra,
& Cunniff, 2008). Likewise, there is increased mental health
risk
for young refugees whose parents are missing, imprisoned, or
cannot be contacted (Hjern, Angel, & Jeppson, 1998). Family
support and cohesion are related to better mental health for
young
refugees (Kovacev & Shute, 2004; Rousseau, Drapeau, & Platt,
2004), as is parental mental health (Hjern et al., 1998).
Economic
circumstances within the family can also influence mental
health

20. outcomes. Sujoldzić, Peternel, Kulenović, and Terzić (2006)
found
that parental worries about financial problems, a common
occur-
rence upon resettlement, can have an adverse effect on
children’s
mental health. Therapists who are counselling refugee youth
need
to have some understanding of family context and history to
establish priorities in therapy.
Community and societal level factors. It is important that
refugee youth find positive connections and develop
relationships
in places where they feel welcome, such as in school and in
their
host communities. The extent to which refugees perceive them-
selves as accepted or discriminated against within host
countries is
related to mental well-being (Fazel et al., 2012). Oppression
and
discrimination based on race, ethnicity, sex, religion, poverty,
and
employment status have a negative impact for these young
people
(Marsella & Ring, 2003; Yakushko et al., 2008). Research has
identified a relationship between peer discrimination and low
self-esteem, depression, and PTSD among young refugees
(Sujoldzić et al., 2006). In contrast, perceived positive social
support is related to improved psychological functioning
(Kovacev
& Shute, 2004). Therapists can help refugee youth establish
rela-
tionships in which they experience the sense of belonging that
has

21. 311REFUGEE-YOUTH MENTAL HEALTH
been found to protect against anxiety and depression (Fazel et
al.,
2012).
Addressing Barriers to Engagement in Mental
Health Services
Despite experiencing disproportionately more mental health
challenges than their host-country peers, refugee youth make
sig-
nificantly less use of mental health services than do nonrefugees
and many who are in need go without support (Huang, Yu, &
Ledsky, 2006). It is important that community and mental health
referrals be aware of barriers to service faced by refugee youth
and
their families to develop strategies to overcome these
challenges
(Craig et al., 2008). The main barriers identified in the
literature
include distrust of authority, stigma, language and cultural
differ-
ences, and having other priorities.
Distrust of Authority
Interventions for refugee youth and their families must be de-
veloped and delivered with attention to individuals’
experiences,
together with their more general cultural history (Allan, 2015).
Many refugees develop distrust of authorities after being
victim-
ized by governmental systems and other establishments. Some-

22. times the very organisations that were in place ostensibly to
provide support and safety were, in fact, responsible for
inflicting
trauma (Ellis et al., 2011). Some refugees might be hesitant
with
helping professionals due to perceived power imbalances.
Because
of such potential for distrust, it is recommended that therapists
devote increased time and effort to develop rapport and a sense
of
safety with refugee clients (Ehntholt & Yule, 2006; Hundley &
Lambie, 2007).
Ellis et al. (2011) suggest that enlisting input and help from
other refugee families and the broader community to develop
and
deliver appropriate mental health services can assist in
establishing
trust. Young people may feel more comfortable if their families
and/or community members are involved in mental health
discus-
sions and program planning. Although this type of collaboration
may be rare, Ellis and colleagues (2011) argue that parent
groups
and outreach programs that commonly seek input from refugee
families could be extremely valuable in creating effective,
appro-
priate, and trustworthy services.
Stigma
Refugee youth and their families may hesitate to seek counsel-
ling services because of the stigma surrounding mental illness
and
those who seek this form of help (Osterman & de Jong, 2007;
Palmer, 2006). For some families, help-seeking stigma could be

23. perceived as worse than enduring mental health problems with
no
support (Ellis et al., 2011). Some refugee cultures may not
define
mental illnesses in the same way they are conceptualised in host
countries and some languages may not have the words to convey
the adjustment difficulties young refugees experience (Ellis et
al.,
2011). Kira et al. (2014) found that internalized stigma
surround-
ing mental illness can exacerbate the negative impact of mental
health problems; thus, the need for counsellors to address this
issue
with refugees who may be struggling is paramount.
Rousseau et al. (2004) suggest that one strategy to diminish the
stigma associated with mental illness is to embed mental health
services in other acceptable forms of support. An example is the
counselling services that are available in secondary and postsec-
ondary educational settings (Guruge & Butt, 2015; Rousseau &
Guzder, 2008). Refugee youth can receive support from a
mental
health professional while at school, rather than having an addi-
tional commitment solely for the purpose of mental health. Fam-
ilies may be more likely to view support from professionals in
an
educational setting in a positive light, compared with services
from
a mental health organisation. Community cultural organisations
and outreach programs are other examples of support services
that
can include mental health information and promotional
activities
in their programming (Correa-Velez et al., 2010). Trusted com-
munity leaders and members can also assist by emphasising the

24. importance of positive mental health and encouraging families
to
seek help when difficulties persist.
Linguistic and Cultural Differences
Language differences can constitute a considerable barrier be-
tween refugees and host country mental health professionals.
As-
sessment and therapy sessions are often one-on-one encounters
that require good language skills. Refugee youth may acquire a
new language relatively quickly; their parents, however, who
may
need mental health services themselves or who have to provide
consent for youth counselling, may not. This forms part of a
larger
pattern in which gaps exist between parents and children’s level
of
acculturation to the host country, which may lead to stress and
conflict within the family (Hynie, Guruge, & Shakya, 2012).
Services are rarely available in the language in which these
fam-
ilies are fluent and the refugee demographic changes constantly;
counsellors need to be sensitive to refugees’ language
proficiency
and take time to ensure that they and their clients understand
one
another (Ellis et al., 2011).
In their study of refugee families’ use of mental health services
in Canada, Nadeau and Measham (2005) found that using inter-
preters could address the need for both linguistic and cultural
relevance in treatment. Translation can help facilitate communi-
cation in therapy, however, having an extra person present
affects
the therapeutic relationship and can compromise confidentiality.

25. Moreover, given the wide diversity within and among refugee
groups, it cannot be assumed that an interpreter will have a full
cultural understanding of a refugee’s background, (Nadeau &
Measham, 2005). Interpretation is a necessity in cases in which
language barriers are significant, though translation of therapy
terms and client experiences is not ideal (Ellis et al., 2011).
Ellis
and colleagues (2011) recommend that including community
voices and cultural experts in the development and delivery of
mental health services and training is essential and should be a
priority in program design. Therapists can benefit from such
cul-
tural perspectives on delivering care in appropriate and relevant
ways.
Other Priorities
A significant barrier for young refugees is that other resettle-
ment needs may be seen as more urgent and pressing than
mental
health concerns (Codrington, Iqbal, & Segal, 2011). Refugees
who
seek counselling may be as much or even more concerned about
basic needs such as food, shelter, and safety (Fazel et al., 2012).
312 MARSHALL, BUTLER, ROCHE, CUMMING, AND
TAKNINT
Where possible, mental health professionals can broaden their
scope of care so that urgent resettlement needs are addressed
together with mental health concerns (Codrington et al., 2011;
Warr, 2010). Therapists can include attention to basic needs as
part
of their initial assessment and either take on an advocacy role

26. themselves or refer clients to additional services (Yule, 2002).
Having mental health services located with or close to other
health,
family, and community services can facilitate a holistic
approach
to refugee support as well as make it easier for diverse clients
to
benefit from the services available.
Another strategy to address multiple and pressing needs is to
spend a significant portion of counselling sessions on fostering
client strength and agency rather than focusing solely on premi-
gration or migration experiences and problems (Murray et al.,
2010). Psychologists and therapists need to use their
professional
judgment to establish priorities and the primacy of needs.
Codrington
et al. (2011) suggest that efforts to enhance positive social
connections
and employability may be more valuable during initial stages of
resettlement than focusing primarily on past events.
Good Practices in Counselling Refugee Youth
The range, severity, and impact of problematic and traumatic
experiences is different for each refugee youth; counselling psy-
chologists and therapists need to assess multiple and contextual-
ized dimensions of clients’ experiences and reactions (Shakya,
Khanlou, & Gonsalves, 2010; Yakushko et al., 2008).
Adjustment
to a new community and culture requires significant new
learning
in social, linguistic, educational, and vocational spheres
(Murray et
al., 2010). Research and scholarly writing have identified
several

27. recommended practices for effectively addressing short- and
long-
term mental health challenges among refugee youth: cultural
com-
petency, establishing trust and safety, recognising strengths, ex-
tending counselling to the family unit, using creative
approaches,
and making use of mobile and online environments.
Cultural Competency
A key factor to effectively address the mental health needs of
young refugees is providing culturally relevant services
(Grothaus,
McAuliffe, & Cragien, 2012; Sue, Zane, Nagayama Hall, &
Berger, 2008; Yakushko et al., 2008). Culture includes a
constel-
lation of factors, including but not limited to race, ethnicity,
gender, sexual orientation, spirituality, and socioeconomic
status
that interact to form attitudes, beliefs, and values (Harris,
Thoresen, &
Lopez, 2007). A culturally competent therapist is self-aware
and recognizes how cultural values, attitudes, and beliefs
intersect
with and influence the counselling process (Constantine, Hage,
Kindaichi, & Bryant, 2007). For instance, what may be
perceived
as a strength or asset in one culture (e.g., individualism or inde-
pendence) may be viewed as a deficit or problem in another
culture
(e.g., the collective good, or interdependence; Grothaus et al.,
2012). There are also cultures within cultures; gender
differences
are noted to be particularly salient among refugee populations
(Tastsoglou et al., 2014). Both therapists’ and clients’ cultures

28. affect the way counselling is explained and proceeds. Mental
health counsellors should be mindful of ethnocentrism and make
efforts to understand the client’s own conceptualisation of his
or
her strengths (Whalen et al., 2004). Avoiding culturally bound
views of mental health leaves space for appreciating culturally
distinct and appropriate notions of mental health and healing
that
could benefit the client (Miller, Kulkarni, & Kushner, 2006).
Cultural competency in counselling requires that counsellors
educate themselves about different worldviews (Ponterotto,
Utsey,
& Pedersen, 2006). This includes knowledge about the sociopo-
litical contexts of refugee youth, including experiences of
discrim-
ination and other oppression. It is important for counsellors to
be
able to learn (either through research, education, or direct ques-
tioning) what their clients perceive as strengths, as well as
positive
dimensions of their cultural groups, such as spirituality,
storytell-
ing, or being bilingual (Grothaus et al., 2012). Services should
be
developed with the refugees’ specific cultures in mind (Ehntholt
&
Yule, 2006). The diversity among refugees is such that
therapists
cannot be expected to know about all the particular cultures of
potential clients; a broad understanding of refugee population
issues and knowing how to access more specific information is
foundational. Community cultural centre events, professional
de-
velopment workshops, and online webinars or courses are all

29. good
resources for expanding cultural competency (Constantine et al.,
2007; Grothaus et al., 2012).
Pickren’s (2014) research found that refugees’ continued con-
nection to their cultural identity is often a source of strength
and
resilience for them individually and within the family unit.
Ther-
apists can encourage the social and emotional support among
family and community members that involves exploration of
cul-
tural, spiritual, and family beliefs, which can be a protective
factor
against mental health problems. Furthermore, counsellors can
pay
attention to whether clients begin to question or abandon their
own
cultural identity (which may be perceived as lower status in the
host country) in an effort to fit in to the dominant culture
(Yakushko et al., 2008). As families settle within their host
coun-
tries, parents may struggle to balance socializing their children
within the new environment with maintaining the connection to
their preimmigration culture (Pickren, 2014). Mental health pro-
fessionals can engage refugee youth and families in exploring
these acculturation tensions and address what it means to
maintain
connection to their cultural identity while adapting to a new
one.
Adopting a bicultural identity is often attractive to youth but of
concern to parents and older relatives, (Kovacev & Shute,
2004).
The notion of seeking psychological counselling for mental
health concerns is not necessarily accepted by all cultures (Sue

30. et
al., 2009). Some cultures may stigmatize those who express a
need
for counselling services, or they may believe the process is un-
trustworthy or incompatible with their spiritual or religious
beliefs
(Osterman & de Jong, 2007). Others may simply not understand
the purpose of counselling or the processes involved. Warr
(2010)
suggests that devoting time in session to explaining the
counselling
process can be beneficial for young refugee clients. Toporek
(2012) recommends that this conversation be collaborative
rather
than prescriptive, such that therapist and client negotiate what
will
work for both parties.
Establish Trust and Safety Within the
Therapeutic Relationship
The relationship between the client and therapist, referred to as
the therapeutic alliance, is paramount for successful outcomes
(Elvins & Green, 2008). A positive connection is particularly
313REFUGEE-YOUTH MENTAL HEALTH
important with refugee clients, because their need to feel safe is
understandably high (Guregård & Seikkula, 2014). Moreover,
refugees may face uncertainty about factors such as legal status
or
income and thus experience insecurity and a threatened sense of
safety (Van der Veer & Van Waning, 2004). To establish
effective

31. therapeutic relationships with refugees, therapists should
prioritize
building trust and rapport and recognise that more time than
usual
may be required because of trust, language, and other issues.
Warr
(2010) suggested that professionals pay particular attention to
helping refugee children and youth feel safe and secure.
With refugees who have experienced trauma and conflict, it is
important to consider emotional containment in the therapeutic
relationship (Van der Veer & Van Waning, 2004). Young
refugee
clients may share horrific stories and their emotional reactions
to
them; the safety of the therapeutic relationship requires
therapists
to attend to appropriate containment of emotional intensity and
not
become traumatized themselves (Van der Veer & Van Waning,
2004). The foundational skills of empathy and positive regard
are
also crucial in establishing a positive therapeutic relationship;
demonstrating these skills includes listening carefully to
personal
testimonies of adversity and reflecting an understanding of
these
stories (Murray et al., 2010). It is important for counsellors to
pay
close attention to the story of the referral process and assure
that
they fully understand the client’s reason for seeking
counselling; a
study by Codrington et al. (2011) suggested that a counsellor’s
lack of understanding of how a refugee family arrived in
counsel-

32. ling or who the identified client is may be a root cause of
unsuc-
cessful therapy.
Maintaining hope is valuable in the fostering of an effective and
change-producing therapeutic relationship (Codrington et al.,
2011). A counsellor’s sense of hope can affect the client’s; bal-
ancing it with realistic expectations is a goal for therapists. Un-
derstanding a refugee client’s priorities and capabilities
contribute
to fostering hope and motivation for change.
Recognise Resiliency and Strengths
All too often, well-intentioned programs oriented toward refu-
gee youth “fail to recognise and build on the considerable re-
sources these youth bring to their new country” (Correa-Velez
et
al., 2010, p. 1399). Psychologists and counselling professionals
are
encouraged to adopt a strength-based approach, focusing on
knowledge and abilities youth have acquired through previous
experiences and on the agency they have within their own lives,
leveraging such assets to help overcome problems. While
refugee
youths’ risk of mental health difficulties is significant, they also
possess resiliency and strengths that can help them adjust
success-
fully in host countries (Eide & Hjern, 2013). One study investi-
gating mental health outcomes for refugees found that almost
half
the sample did not show symptoms of complex prolonged grief
or
PTSD, but rather, recovered from their experiences of trauma
and
loss naturally over time (Nickerson et al., 2014). Yakushko and

33. colleagues (2008) described how young refugees showed resil-
ience in managing the stress of relocation. Other research has
shown that refugees demonstrate considerable well-being in
areas
of psychological, social, and economic adaptation (Coughlan &
Owens-Manley, 2006). These authors concluded that positive
ad-
aptation after very difficult experiences is prevalent;
counselling
therapists should not assume that problems with adjustment will
occur for all or even most refugee youth.
Researchers and counselling therapists increasingly call for a
shift away from emphasising experiences and symptoms of
trauma
and PTSD and more toward a positive holistic approach that
highlights the inherent strengths and coping abilities of refugees
(Murray et al., 2010; Papadopoulos, 2007). Miller et al. (2006)
suggested incorporating culturally appropriate mental health ex-
planations and interventions; imposing western definitions of
psy-
chological and psychosocial well-being and impairment can be
misleading and even harmful to refugee populations. Refugees
themselves report that it would be helpful for therapists to focus
on
family issues, social integration, and grieving (Miller et al.,
2006).
Strengths-based practices support positive growth and change
among refugee populations (Papadopoulos, 2007). Mental health
professionals can use therapy approaches and interventions that
highlight personal strengths and leadership skills as well as
com-
munity leadership and cultural wisdom (Murray et al., 2010;
Yakushko et al., 2008). As Yakushko et al. (2008) observe,
strengths-focused approaches build on refugees’ hope and opti-

34. mism as momentum for positive growth and change.
Positive youth development (PYD) is a strengths-based ap-
proach to working with young people that aims to guide youth
so
they can mature into well-adjusted adults; this approach has
been
used successfully to inform the design of programs for refugee
youth (Morland, 2007). Developed to counter deficit-focused
con-
ceptualisations of young people, PYD begins with the view that
all
youth have inner strengths and resources that supportive adults
can
capitalize on and nurture (Damon, 2004). Recommended PYD-
implementation practices to support refugee youth include
forming
partnerships with refugee communities, engaging with youths’
family members, supporting and encouraging
bicultural/bilingual
staff, strengthening ethnic and bicultural identity, encouraging
youth leadership, ensuring academic support, and fostering con-
nections with community organisations and businesses
(Morland,
2007).
Many individuals who encounter hardship, including trauma,
notice areas of growth or positive change that take place after
their
difficult experiences. Tedeschi and Calhoun (2004) refer to this
phenomenon as posttraumatic growth (PTG), defined as follows.
The experience of individuals whose development, at least in
some
areas, has surpassed what was present before the struggle with
crises

35. occurred. The individual has not only survived, but has
experienced
changes that are viewed as important, and that go beyond what
was
the previous status quo. (p. 4)
Tedeschi and Calhoun (2004) stress that this growth arises from
responses and situations in the aftermath of the trauma, not
from
the trauma itself.
The concept of positive change in the aftermath of trauma is
particularly relevant for refugee youth. Teodorescu et al. (2012)
explored the presence of PTG for individuals with a refugee
background and found that most participants reported greater
appreciation for life, positive spiritual change, and increased
per-
sonal strength since migration. Further, social support has been
found to increase refugees’ reports of PTG (Kroo & Nagy,
2011).
The notion of PTG does not suggest that refugees are better off
in
some way because of their extreme challenges, but rather, that
many can find positive things to say about how their lives have
314 MARSHALL, BUTLER, ROCHE, CUMMING, AND
TAKNINT
changed. Keeping this in mind, counsellors and mental health
therapists should look for current and previous indicators of
pos-
itive growth, and encourage their refugee clients to elaborate on
the strengths they believe they possess or are developing.

36. Extend Counselling Services to the Family Unit
Relationships within refugee families are put under stress by the
members’ migration and premigration experiences, as well as by
the ordeal of resettling in a new country. Youth may find the
normal challenges of adolescence exacerbated by trauma and
hard-
ships; for the same reasons, parents may find it difficult to
fulfill
their usual roles (Codrington et al., 2011). Because most
refugee
families have a history of shared experience, providing mental
health services to the entire family, rather than just to one
specified individual, may be beneficial. Björn, Boden, Sydsjo,
and Gustafsson (2013) suggest that even a few counselling
sessions
that include parents and siblings can be beneficial for refugee
youth who suffer from mental health problems. Young refugees
who do not necessarily demonstrate symptoms of
psychopathology
or psychological difficulties may still benefit from counselling
sessions that include their family members. Björn and
colleagues
(2013) cautioned that decisions to include family members in
therapy should be discussed collaboratively with young refugee
clients together with an exploration of expectations, cultural
norms, and possible outcomes that could affect family relation-
ships or progress in therapy.
Refugees have left behind aspects of their culture and support
systems they may have relied upon during difficult times; thus,
the
family unit becomes more important (Voulgaridou,
Papadoupoulos,
& Tomaras, 2006). Despite losses, refugee youth and their
families

37. have the ability to adapt and meet new challenges. Family
therapy can
foster strengths and build the nuclear or extended family as a
reliable
support in the new country (Hjern & Jeppson, 2005).
Use Creative and Complementary Approaches
and Interventions
Creative therapy approaches and methods appeal to young peo-
ple, enhance expression, build trust, aid communication, and
help
youth process emotions (Warr, 2010). Offering a therapeutic
pro-
cess that is flexible and creative can be beneficial for youth who
are not familiar with counselling or mental health practices.
Non-
verbal and arts-based therapies provide opportunities to explore
past or present events and trauma impacts with clients whose
host-language abilities are limited (Marshall, 2009; Rousseau &
Guzder, 2008). Two Canadian studies using expressive arts and
psychodrama found these approaches effective in assisting
refugee
youth in processing feelings and thoughts in a safe environment
(Rousseau et al., 2004; Rousseau & Guzder, 2008).
Structured interactions with peers at school and in the commu-
nity can provide opportunities for refugee youth to develop
social
skills and learn the ways of the host country, as well as their
local
contexts. Whether as a complement to therapy or by itself,
partic-
ipation in extracurricular and community activities can help in-
crease self-esteem, prevent social isolation, and build social
net-

38. works (Stewart, 2014). Programs in sports, music, dance,
cooking,
arts and theatre, as well as homework clubs, educational field
trips,
and employment support can help refugee youth build positive
relationships and a sense of community with other youth and
supportive adults (Mawani, 2014). Edge, Newbold, and
McKeary
(2014) found that refugee youth in their Canadian sample were
likely to take advantage of such opportunities if they were
offered.
School and community professionals are well-placed to
encourage
and monitor social interactions among refugees and their peers
in
these types of activities.
Sports have long been advocated as a globally recognised means
for promoting social engagement, acceptance, and acculturation
for refugee and immigrant youth (Forde, Lee, Mill, & Frisby,
2015; Oliff, 2008; Spaaij, 2013). Sports activities and programs
offer opportunities for improving refugee youths’ integration,
growth, well-being, and sense of belonging, and for providing a
sense of normalcy in their lives. At their best, sports can
promote
connections among refugee and host-country youth, families,
and
communities; critics, however, have also pointed to negative
fac-
tors that need to be addressed, such as participation barriers,
exclusion, and marginalization (Spaaij, 2015). There are mixed
views on whether sports and other activities should involve
groups
of a single ethnic background or include youth from diverse
backgrounds. Some research has revealed that having diverse

39. backgrounds fosters cross-cultural awareness and positive
relation-
ships among refugee youth and their nonrefugee peers (Oliff,
2008); other research has found that refugee youth feel more
comfortable and willing to participate when they are among
peers
from a similar background (Spaaij, 2013). Gender-role expecta-
tions and strictures are a barrier for some young refugee
women’s
participation in sports, unless all-female teams or activities are
made available (Spaaij, 2015). Choice is not always possible;
supporting adults can assist refugee youth and their families to
sensitively explore the options, benefits, and challenges of
sports
participation (Ontario Council of Agencies Serving Immigrants,
2006).
The potential mental health benefits of social and community
interactions and activities for refugee and host-country youth
needs to be underscored (Forde et al., 2015; Ontario Council,
2006). Sports and community programs also fill a mental health-
problem-prevention role by focusing on cooperation, social
devel-
opment, and leadership abilities (Forde et al., 2015; Spaaij,
2015).
More research and program evaluation are needed on the
impacts
of educational, social, and sports participation on refugee youth
mental health.
Mobile Connections and Online Counselling
As is the case among their nonrefugee peers, almost all refugee
youth regularly use mobile technologies and social networks
(Robertson, Wilding, & Gifford, 2016). Mobile communication
helps youth maintain vital connection to dispersed family

40. members
and friends; such connection is a key aspect of positive mental
health. In resettlement contexts, access to tele-mental health
ser-
vices, e-counselling, online mental health-promotion resources,
and apps offer new possibilities for a range of mental health
support that is particularly attractive to youth (Robertson et al.,
2016). Mobile technologies have the potential to improve access
to
mental health services for refugee populations, reduce stigma,
and
improve quality of health care (Mucic, Hilty, & Yellowlees,
2016).
For youth who have fled persecution and who may have other
histories that engender mistrust of government services and au-
315REFUGEE-YOUTH MENTAL HEALTH
thorities, mobile phone mental health support is an important
re-
source offering both anonymity and immediacy (Mucic et al.,
2016).
Research and evaluation of online mental health services have
become complicated by new and rapidly developing online plat-
forms, tools, and apps (Mucic et al., 2016). Although youth use
online and mobile services with great ease, some research has
suggested that outcomes are best when technology augments or
enhances in-person services (Knight & Hunter, 2013). An inter-
esting point for service providers, Knight and Hunter (2013)
iden-
tified a gap between how youth engage in mobile technologies
for
mental health support and how organisations (and youth

41. workers)
engage with and are comfortable using these same tools. Mental
health professionals are encouraged to seek training
opportunities
in the complementary use of online and mobile tools in counsel-
ling.
Summary and Future Directions
Counselling psychologists and other mental health professionals
have vital knowledge and skills that are needed to support the
healing and positive development of refugee youth. Key consid-
erations when working with this population involve assessing
need
priorities, language, and acculturation levels. Individual,
family,
and community factors will have influenced the young people’s
responses to the multiple losses and disrupted identity they
expe-
rienced before, during, and after migration. An understanding of
the youth’s economic, family, and educational situation is
impor-
tant for mental health clinicians in assessing problems to be
addressed. Gender is a particular element of potential difference
and conflicting values; the intersectionality of young refugee
women’s identities is a critical focus for therapy. Although
chal-
lenges such as fulfilling basic needs and barriers such as
mistrust,
stigma, and language/cultural differences can prevent or limit
access to mental health support and its benefits for refugee
youth,
we have identified strategies and tools through the studies in
this
review that can help refugees overcome these barriers.

42. Refugee youth come from diverse backgrounds and have par-
ticular needs linked to their situations; however, the research
findings covered in this review point to several principles and
practices that can help mental health service providers deliver
appropriate and effective support for these young people.
Cultural
competency is essential, as recognised in professional codes of
ethics and scope of practice guidelines. Establishing trust and
safety as part of the therapeutic alliance is another key aspect
when
counselling refugee youth. A number of researchers have
empha-
sised the importance of recognising strengths and resiliency
among
refugee youth while still acknowledging the incidence of PTSD,
depression, prolonged grief, and other psychological disorders
among this population. Depending on the youth’s particular
family
context, it may be advisable to extend counselling to the family
unit. Using creative therapy techniques and approaches and
making use of mobile and online environments can expand the
opportunities to engage refugee youth in mental health support
that fits their particular circumstances. Evaluation and research
are needed to assess the effectiveness of specific approaches
and interventions.
In their scoping review on youth refugee mental health, Guruge
and Butt (2015) found only 17 articles on the topic in the
previous
23 years. They recommend more research to gain a holistic
picture
of refugee youth mental health, including prevalence rates, pre-
and postmigration factors, use of mental health services, and
family dynamics. Gender-related mental health needs and inter-
ventions are also seen as a priority, as is longitudinal research

43. to
assess change over time in resettlement. School and community
programs and activities that bring refugee and host-country
youth
together show great potential for mental health support and pro-
motion; additional research could identify particular elements or
program approaches that are effective. More cross-disciplinary
studies about refugee youth mental health risk and protective
factors, coping styles, effective therapy interventions, and re-
sponses to treatment will inform research, clinical practice, and
policy spheres.
Intended for a broad audience, the goal of this review paper was
to provide an overview of youth refugee mental health issues
and
practices; space precluded in-depth discussion or application to
specific regional contexts. A further limitation, also related to
space, was a lack of research methodology detail that would
have
enabled comparison among the studies.
In summary, refugee youth arrive in host countries with expe-
riences and histories of loss, trauma, uncertainty, and upheaval.
Although their premigration context and migration journeys
may
place them at greater risk for mental health problems, they also
settle in their new homes with skills, abilities, and hope. Mental
health counsellors and therapists have a key role to play in
assist-
ing these young refugees to overcome mental health difficulties
and realise their potential in their new environments.
Résumé
La crise mondiale de la migration a donné lieu à l’arrivée d’un
nombre sans précédent de réfugiés au Canada et dans d’autres

44. pays. Un tiers de ces réfugiés sont des jeunes, qui sont
accompa-
gnés de leur famille ou qui sont seuls. Bien que les
circonstances
particulières varient énormément, ces derniers ont besoin d’aide
pour l’apprentissage de la langue, l’éducation et l’adaptation à
leur
pays d’adoption; un grand nombre d’entre eux ont aussi besoin
de
services en santé mentale. Cet article de synthèse est axé sur les
problèmes de santé mentale et les difficultés que vivent les
jeunes
réfugiés, ainsi que sur les pratiques de counseling qui se sont
révélées efficaces auprès de ce groupe. Très peu de recherches
se
sont concentrées sur la santé mentale des jeunes réfugiés au
Canada. Les études citées proviennent du Canada ainsi que des
États-Unis, d’Australie et de pays d’Europe qui présentent de
nombreuses similitudes dans leurs façons de traiter les dossiers
et
les difficultés concernant le counseling en santé mentale et la
psychothérapie. L’article fait un compte rendu de la situation
des
jeunes réfugiés, suivi d’une description des problèmes et des
difficultés en santé mentale qui leur sont propres, et d’une
discus-
sion sur les obstacles à l’engagement des services en santé men-
tale, puis des suggestions de pratiques de counseling efficaces
parmi cette population. L’article se termine par un sommaire
des
principaux résultats tirés de la littérature et par des suggestions
de
recherches futures en vue de combler les lacunes dans les
connais-
sances sur le sujet. Étant donné les nombreux obstacles que con-
naissent les jeunes réfugiés avant leur arrivée, durant leur

45. déplace-
ment et après leur installation dans un pays d’accueil, on ne
peut
s’étonner du fait qu’ils présentent des problèmes de santé
mentale.
En dépit de ces difficultés, ces jeunes gens font preuve
316 MARSHALL, BUTLER, ROCHE, CUMMING, AND
TAKNINT
d’adaptabilité, de persévérance et de résilience. L’appui de pro-
fessionnels de la santé mentale qui reconnaissent leurs forces et
leurs aptitudes contribuera à leur rétablissement et les aidera à
s’adapter positivement à leur nouveau pays.
Mots-clés : santé mentale des jeunes réfugiés, revue sur la santé
mentale des jeunes réfugiés, jeunes réfugiés ayant des
problèmes
de santé mentale, counseling pour les jeunes réfugiés, pratiques
en
santé mentale pour les jeunes réfugiés.
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319REFUGEE-YOUTH MENTAL HEALTH
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70. http://dx.doi.org/10.1080/13603110903560085
http://dx.doi.org/10.1207/s15327965pli1501_01
http://dx.doi.org/10.1186/1477-7525-10-84
http://dx.doi.org/10.1186/1477-7525-10-84
http://www.unhcr.org/45339d922.html
http://www.unhcr.org/pages/49c3646c11.html
http://www.unhcr.org/pages/49c3646c11.html
http://www.unhcr.org/pages/49e491336.html
http://dx.doi.org/10.1111/j.1467-6427.2006.00346.x
http://dx.doi.org/10.1111/j.1467-6427.2006.00346.x
http://dx.doi.org/10.1080/02643944.2010.481307
http://dx.doi.org/10.1080/15427580802679468
http://dx.doi.org/10.1007/s10447-008-9054-0
http://dx.doi.org/10.1177/153476560200800304
http://dx.doi.org/10.1177/153476560200800304Refugee Youth:
A Review of Mental Health Counselling Issues and
PracticesKey Considerations Related to Refugee
YouthLanguageEconomic and Family
SituationsEducationGenderUnderstanding Mental Health
Challenges for Refugee YouthFactors Influencing Mental Health
Outcomes for Young RefugeesIndividual factorsFamily
factorsCommunity and societal level factorsAddressing Barriers
to Engagement in Mental Health ServicesDistrust of
AuthorityStigmaLinguistic and Cultural DifferencesOther
PrioritiesGood Practices in Counselling Refugee YouthCultural
CompetencyEstablish Trust and Safety Within the Therapeutic
RelationshipRecognise Resiliency and StrengthsExtend
Counselling Services to the Family UnitUse Creative and
Complementary Approaches and InterventionsMobile
Connections and Online CounsellingSummary and Future
DirectionsReferences
OPPORTUNITIES IN REFORM: BIOETHICS AND MENTAL
HEALTH ETHICS

71. ARTHUR ROBIN WILLIAMS
Keywords
mental health ethics,
mental illness,
healthcare reform,
autonomy
ABSTRACT
Last year marks the first year of implementation for both the
Patient Pro-
tection and Affordable Care Act and the Mental Health Parity
and Addiction
Equity Act in the United States. As a result, healthcare reform
is moving in
the direction of integrating care for physical and mental illness,
nudging
clinicians to consider medical and psychiatric comorbidity as
the expecta-
tion rather than the exception. Understanding the intersections
of physical
and mental illness with autonomy and self-determination in a
system rea-
ligning its values so fundamentally therefore becomes a top
priority for

72. clinicians. Yet Bioethics has missed opportunities to help guide
clinicians
through one of medicine’s most ethically rich and challenging
fields.
Bioethics’ distancing from mental illness is perhaps best
explained by
two overarching themes: 1) An intrinsic opposition between
approaches to
personhood rooted in Bioethics’ early efforts to protect the
competent
individual from abuses in the research setting; and 2) Structural
forces,
such as deinstitutionalization, the Patient Rights Movement, and
managed
care. These two themes help explain Bioethics’ relationship to
mental
health ethics and may also guide opportunities for
rapprochement. The
potential role for Bioethics may have the greatest implications
for interna-
tional human rights if bioethicists can re-energize an
understanding of
autonomy as not only free from abusive intrusions but also with
rights to

73. treatment and other fundamental necessities for restoring
freedom of
choice and self-determination. Bioethics thus has a great
opportunity amid
healthcare reform to strengthen the important role of the
virtuous and
humanistic care provider.
INTRODUCTION
Mental illness has a tremendous impact on health
throughout American and global society. By the late
1990s, medical authorities and epidemiologists demon-
strated that mental illness accounted for the second great-
est burden of disease globally.1 In the United States, the
presence of mental illness serves to exponentially com-
pound poor outcomes and increased costs among
patients. For instance, in a comprehensive report released
April 2014 for the American Psychiatric Association,
Milliman, Inc. assessed that comorbid mental illness
(including substance use disorders) often doubles or
triples healthcare costs for patients with chronic physical
conditions such as diabetes or asthma.2 The burden of
mental illness is even greater at the margins of society.
The US Department of Justice estimates that over half of
1 C.J. Murray & A.D. Lopez. The global burden of disease: a
compre-
hensive assessment of mortality and disability from diseases,
injuries and

74. risk factors in 1990 and projected to 2020. Cambridge: Harvard
Univer-
sity Press; 1996.
2 S.P. Melek, D.T. Norris & J. Paulus. Economic Impact of
Integrated
Medical-Behavioral Healthcare, Implications for Psychiatry.
Millima,
Inc: Denver; 2014; See also C. Boyd, B. Leff, C. Weiss, et al.
Clarifying
Multimorbidity Patterns to Improve Targeting and Delivery of
Clinical
Services for Medicaid Populations. Faces of Medicaid Data
Brief,
Center for Health Care Strategies, Inc December 2010.
Address for correspondence: Arthur Robinson Williams,
Division of Substance Abuse Columbia University Department
of Psychiatry, 1051 Riverside
Drive, Unit 66, New York, NY 10032, USA. Email:
[email protected]
Conflict of interest statement: No conflicts declared
Bioethics ISSN 0269-9702 (print); 1467-8519 (online)
doi:10.1111/bioe.12210
© 2015 John Wiley & Sons Ltd
ORIGINAL ARTICLES
Bioethics ISSN 0269-9702 (print); 1467-8519 (online)
doi:10.1111/bioe.12210
Volume 30 Number 4 2016 pp 221–226
bs_bs_banner

75. prisoners have a serious mental illness3 and researchers
find that the great majority of the chronically homeless
have untreated mental illness including substance
dependence.4 Yet we are witnessing the widespread
closure of mental health clinics, psychiatric wards, and
state hospital beds at academic centers and their affiliate
institutions nationwide following decades of shrinking
budget allocations for mental health. In response, Bioeth-
ics has largely been silent.5
American healthcare reform’s great expanse offers an
opportunity to reverse this trend. Last year marked the
first year of implementation for both the Patient Protec-
tion and Affordable Care Act (PPACA or ‘Obamacare’)
and the Mental Health Parity and Addiction Equity Act
(MHPAEA or ‘Parity Act’) of 2008. These two sentinel
pieces of legislation are helping to overhaul the nation’s
healthcare system which has become better known for
spending money than improving health. Healthcare
reform as such is also moving in the much-needed direc-
tion of integrating care for physical and mental illness,
nudging clinicians to consider medical and psychiatric
comorbidity as the expectation rather than the exception.
The full implementation of integrated medical and
behavioral healthcare could save upwards of $40–50
billion annually, surpassing current total expenditures on
mental healthcare in the United States alone.6 Under-
standing the intersections of physical and mental illness
with autonomy and self-determination in a system rea-
ligning its values so fundamentally therefore becomes a
top priority for clinicians.
Yet a brief review of American Bioethics’ literature,
commentary in the media, curricula within the classroom,