Chapter 29: Mental Health

Learning Objectives

  • Learn from the national and global perspectives of mental health among immigrants and refugees.
  • Recognizing that the world is constantly and rapidly changing.
  • Recognizing that Global/national/international events can have an impact on individuals, families, groups, organizations, and communities.
  • Global implications dictate that we foster international relationships and opportunities to address international concerns, needs, problems, and actions to improve the well-being of not only U.S. citizens, but global citizens.

29.1 Introduction

“After all, when a stone is dropped into a pond, the water continues quivering even after the stone has sunk to the bottom.”

–Arthur Golden, Memoirs of a Geisha, 1999, p. 265.

Immigrant and refugee journeys are often idealized in literature, art, and historical accounts. Their experiences are repeatedly distilled into tales of extreme adventure where rugged courage and the intense desire for a better life overshadow all other experiences. Individuals and families become characters in larger than life stories, archetypes of human heroism and determination. As observers, we are often drawn in by the rich stories of survival, pain, and loss where people flee oppression and sacrifice to find unparalleled freedom and endless opportunity. These are the stories that incite respect, shock, and awe. However, immigrants and refugees are more than stories, more than the romanticized inspiring tales. They are real people who have suffered the loss of loved ones, homes, and communities. The multilayered impact of displacement is frequently manifest in one’s mental health and felt for multiple generations.

Leaving home, by choice or by force, is a disorienting experience. Through migration or via displacement and resettlement, immigrants and refugees are often confronted with a new world, new language, and new social norms. They face culture shock in everyday life events experienced as foreign. Immigrants and refugees experience disruption in their sense of self, often having to give up previous occupations, privilege, and social status. They lose community and established systems of social support. In addition to expected adjustment difficulties, immigrants and refugees may face additional challenges wrought by poor physical and mental health resulting from exposure to multiple traumatic events and extensive histories of loss. They may experience severe and long-lasting psychological struggles including depression, anxiety, posttraumatic stress symptoms, and adjustment problems. Compounding these difficulties can be logistical complexities such as a lack of jobs, affordable housing, culturally and linguistically appropriate health and mental health services, financial resources, and social support.

In spite of the myriad of obstacles, struggles, and daily stressors, most immigrants and refugees demonstrate tremendous resilience as they persist in finding ways to work around, cope with, or overcome displacement related challenges. Some, especially highly skilled immigrants with means, might not experience a great deal of negative stress. Unfortunately, this represents a small segment of the total immigrant population. Refugees and undocumented immigrants come with inherent risk factors and many other immigrants share experiences of loss and traumatic stress, including multiple exposures to traumatic events.

This chapter reviews some of the shared and unique experiences of immigrant and refugee populations with particular focus on mental health implications and relational risk factors associated with exposure to traumatic stress. Mental health treatments and emerging directions for future prevention and intervention research are also discussed.

Dr. Carrie Hanson-Bradley (Family Social Science Alumna, University of Minnesota) and Dr. Liz Wieling (Family Social Science, University of Minnesota)

29.2 Different Shared Experiences

“While every refugee’s story is different and their anguish personal, they all share a common thread of uncommon courage – the courage not only to survive, but to persevere and rebuild their shattered lives.”

–Antonio Guterres, UN High Commissioner for Refugees (UNHCR, 2005).

Families immigrate to the United States for various reasons. Some voluntary immigrants may choose to leave their country of origin in search of better opportunities, while others are forced to flee due to war, political oppression, or safety issues. Some families manage to stay together over the course of their journey, but many are divided or separated through the migration process. This is particularly true of refugee families whose migration is involuntary, hasty, and traumatic in nature (Rousseau, Mekki-Berrada, & Moreau, 2001). Refugees in particular may have survived traumatic events and violence including war, torture, multiple relocations, and temporary resettlements in refugee camps (Glick, 2010; Jamil, Hakim-Larson, Farrag, Kafaji, & Jamil, 2002; Keys & Kane, 2004; Steel et al., 2009). The destructive nature of war “involves an entire reorganization of family and society around a long-lasting traumatic situation” (Rousseau, Drapeau, & Platt, 1999, p. 1264) and individuals and families may continue to experience traumatic stress related to family left behind and stressful living conditions long after they have resettled.

When it comes to mental and physical health, refugees are a part of an especially vulnerable population. While some adjust to life in the United States without significant problems, studies have documented the negative impact of a trauma history on the psychological wellbeing of refugees (Keller et al., 2006; Birman & Tran, 2008). Pre-migration experiences may precipitate refugee mental health concerns, particularly in the early stages of resettlement (Beiser, 2006; Birman & Tran, 2008). These experiences may include witnessing and experiencing violence, fleeing from a family home located in a city or village that is being destroyed, and walking to find refuge and safety for days or weeks with limited food, water, and resources. Post-migration conditions, such as adapting to living in an overcrowded refugee camp or trying to rebuild life in a foreign country, as well as structural stressors, such as going through the legal process of obtaining asylum or legal documentation, may also precipitate a cascade of individual mental health and family relational issues. The pre- and post-migration experiences and stressors of refugees may compound and create a “cumulative effect on their ability to cope” (Lacroix & Sabbah, 2011). Spending weeks, months, or even years managing stressful and traumatic experiences may weaken an individual or family’s ability to cope with continued change and the multiple stressors of resettlement.

While it is reported that refugees are at risk for higher rates of psychiatric disorders such as posttraumatic stress disorder (PTSD), depression, anxiety, complicated grief, psychosis, and suicide (Akinsulure-Smith & O’Hara, 2012; Birman & Tran, 2008; Jamil et al., 2002; Jensen, 1996; Kandula, Kersey, & Lurie, 2004; Steel et al., 2009), immigrants are also at risk for these mental health complications, especially if they have been exposed to multiple traumatic events. However, when working with immigrants and refugees, it is important to remember that one cannot assume that all members of an affected population are psychologically traumatized and will have the same mental health symptoms (Shannon, Wieling, Simmelink, & Becher, 2014; Silove, 1999). Further, mental health symptomatology is expressed in a variety of culturally sanctioned ways. For example, somatic complaints such as headaches, dizziness, palpitations, and fatigue might be a way to avoid stigma and shame often associated admitting to mental health problems (Shannon, Wieling, Im, Becher, & Simmelink, 2014).

We know that the mental health of an individual does not exist in isolation; the experiences of one person in a family or community affect others. Unfortunately, the majority of the literature about immigrant and refugee mental health focuses on mental health as an individual process; the systemic ramifications are understudied and underrepresented in academic literature (Landau, Mittal, & Wieling, 2008; Nickerson et al., 2011).

29.3 Mental Health Challenges

“Just because you leave war, war does not leave you. And for me in America, it came back in my nightmares, it came back in the low kick of a car’s engine, it came back in the loud roar of a plane, it came back in a mother’s hum, in a father’s song.”

–Loung Ung, Cambodian American Author and Human-Rights Activist, full speech available at https://www.youtube.com/watch?v=6odKrFRfqkI&feature=youtu.be.

 

Much of the literature on immigrant and refugee mental health focuses on loss and trauma, as well as the depression and anxiety that frequently accompanies them. The interconnectedness of loss, trauma, depression, and anxiety can make it difficult to distinguish what is the presenting problem. When looking at one, others are likely to be present. Those who work with immigrants and refugees must be aware of how loss, trauma, depression, and anxiety may each affect an immigrant or refugee’s mental health as well as family health and functioning.

Loss

In every story of immigration or refugee resettlement, a common thread of loss is present. Some losses are obvious, like the loss of home and community or the severance from family and friends who have been left behind or killed. Loss does not end with resettlement; new losses are experienced and revealed over time, some of which can be obscure, like the loss of identity, social status, language, and cultural norms and values.

The grief response that comes with loss can manifest as physical, emotional, and psychological responses including crying, anger, numbness, confusion, anxiety, agitation, fatigue, and guilt. The loss of surroundings, possessions, ideas, and beliefs such as those experienced by immigrants and refugees can trigger a grief response similar to those experienced with the death of someone close (Casado, Hong, & Harrington, 2010).

Some losses and the accompanying grief are considered normative in United States culture. For instance, the death of a loved one or child is a recognized loss and the manifestations of grief associated with that type of loss are understood by most people. However, some losses and the accompanying grief are disenfranchised, meaning that grief occurs when a loss is experienced but is not recognized by others as loss. For example, Kurdish families who resettled in the United States while Saadam Hussein was president may have found that people in the United States did not understand why they would miss living in Iraq. Migratory grief is considered a disenfranchised grief (Casado et al., 2010) and is often dismissed in the immigrant and refugee adjustment experience. As a result, people with disenfranchised grief are unable to express feelings, and grief-related emotions are not recognized or accepted by others.

Another way to think about grief and loss experienced by immigrants and refugees is to understand the ambiguous nature of their loss experiences. There are two types of ambiguous loss (Boss, 2004). The first occurs when a loved one is physically absent but emotionally present because there is no proof of death. A kidnapped child, soldiers missing in action, family separation during war, deportation, and natural disasters can all result in this type of ambiguous loss. The second type of ambiguous loss occurs when a loved one is physically present but emotionally absent. Dementia, brain injuries, depression, PTSD, and homesickness can all result in individuals being physically present but emotionally or cognitively they have “gone to another place and time” (Boss, 2004, p 238). Family members who experience ambiguous loss describe physical and mental pain as a result (Robins, 2010). The lack of clarity associated with ambiguous loss can lead to boundary ambiguity expressed in conflict and ambivalence in the new roles family members take after resettlement. Ambiguous loss is also often characterized by frozen grief, represented by the immobilization of individuals and relational systems stuck between the old and new worlds (Boss, 2004). Although ambiguous loss is a common experience for immigrants and refugees, limited research has been conducted with this population (Rousseau, Rufagari, Bagilishya, & Measham, 2004).

Most people experience grief reactions to a mild or moderate degree and then return to pre-loss levels of functioning without the need for clinical intervention. However, some suffer a more complicated grief reaction (Bonanno et al., 2007). Complicated grief occurs when acute grief becomes a chronic debilitating condition (Shear et al., 2011). It may be incorrectly labeled as depression (Adams, Gardiner, & Assefi, 2004). However, research indicates that complicated grief is distinguishable from depression and other trauma-related psychological disorders. Intense longing for the object of loss, preoccupation with sorrow, extreme focus on the loss, and problems accepting the death or loss are all symptoms of complicated grief. Complicated grief can exacerbate psychiatric disorders and influence the relationship between loss, symptoms of posttraumatic stress and depression (Nickerson et al., 2011). In one study with Bosnian refugees, for example, complicated grief was a better predictor of refugee general mental health than was PTSD (Craig, Sossou, Schnak, & Essek, 2008).

Anxiety and Depression

The literature on immigrants’ and refugees’ experiences with anxiety and depression is often intermingled with that of loss and trauma. Comorbidity can make it difficult to measure and separate one symptom cluster from the other but the two comprise different psychological diagnoses. Anxiety is characterized as a normal human emotion that we all experience at one time or another. Symptoms include feelings of fear and panic, uncontrollable and obsessive thoughts, problems sleeping, shortness of breath, and an inability to be still and clam. Anxiety disorders are serious and sufferers are often burdened by constant fear and worry further exacerbating comorbidity of PTSD symptoms. The literature on anxiety prevalence of immigrant and refugee populations is limited but expected to be highly correlated with that of PTSD and depression. Depression, described as feelings of sadness, unhappiness, or feeling down, is a normative reaction and can be felt in varying degrees. However, clinical depression is a mood disorder in which the feelings of sadness interfere with everyday life for weeks or longer. Immigrants and refugees are at high risk for clinical depression due to their extensive histories of loss, potential trauma, and resettlement. Studies have also shown that depression among immigrants is related to the process of adapting to the host culture (Roosa et al., 2009). Depression is known to cause long-term psychosocial dysfunction in refugees who have experienced violence and loss (such as in Bosnian refugees resettled in Australia; Momartin et al, 2004). It should not be seen as a marginal issue when compared to PTSD and other trauma-related diagnoses (Weine, Henderson, & Kuc, 2005). Depression is a common clinical problem with successful available treatments. Weine et al. (2008) argue that it should be a target of intervention and focus of health education with immigrant and refugee populations.

Traumatic Stress

Many immigrants and most refugees have experienced or been exposed to traumatic events such as witnessing or experiencing violence, torture, loss, or separation. Psychological trauma is most often not limited to a single traumatic event but includes direct and indirect events over the course of a person’s life (Jamil et al., 2002). Traumatic stress affects how people see the world, how they find meaning in their lives, daily functioning and family relationships. Several studies have documented the effects of traumatic stress related to war violence on refugee health. Steel et al. (2009) conducted a meta-analysis with over 80,000 refugees and reported a weighted prevalence rate of PTSD ranging between 13% and 25%. In one critical review, torture and cumulative exposure to traumatic events were the strongest factors associated with PTSD, with some refugee communities experiencing PTSD prevalence rates as high as 86% (Hollifield et al., 2002). A study of symptom severity of PTSD and depression with 688 refugees in the Netherlands supported these findings, reporting that a lack of refugee status and accumulation of traumatic events were associated with PTSD and depression (Knipscheer, Sleijpen, Mooren, ter Heide, & van der Aa, 2015). Studies have also established the enduring effects of pre-migration traumatic stress even years after resettlement (Marshall, Schell, Elliott, Berthold, & Chun, 2005) as well as the long-term physical health effects of refugee trauma, including hypertension, vascular disease, coronary, metabolic syndrome, and diabetes (Crosby, 2013).

For immigrants and refugees, it is possible that entire families will have been exposed to similar traumatic events and losses that disrupt family and social networks (Nickerson et al., 2011). This is especially true for those who have experienced war or interpersonal violence. War is characterized as an attack on civilian populations where citizens are targeted, dislocated, and displaced (Lacroix & Sabbath, 2011). According to Sideris (2003), war unravels the social fabric of a community as the “social arrangements and relationships which provide people with inner security, a sense of stability, and human dignity are broken down” (p. 715). For instance, people may experience a sense of helplessness, damaged trust, shame, and/or humiliation associated with traumatic experiences such as rape, physical violence, witnessing death, being forced to violently turn on one another, and having to flee homes.

The harmful effects of traumatic stress on mental health and functioning have been well documented in refugee populations (de Jong et al., 2001; Hebebrand et al., 2016; Nickerson et al, 2011). Research in the United States shows that PTSD is higher for refugees who spent time in refugee camps affected by war and forced migration than for other resettled communities (LaCroix & Sabbath, 2011). Common trauma-related diagnoses are PTSD and Acute Stress Disorder (ASD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), PTSD and ASD correspond to a situation in which a person experiences or witnesses threatened or actual death, serious injury, or sexual violence and continues to bear the mark of the experience after the event has ceased. PTSD and ASD are characterized by a cluster of symptoms that cause symptom-related stress or functional impairment (e.g., difficulty in work or home life). Symptoms that are present between three days and one month after the traumatic event are classified as ASD, symptoms that last more than one month are classified as PTSD. Both adults and children can have PTSD and ASD. Symptoms fall into four categories: (a) persistently re-experiencing through intrusive thoughts or nightmares; (b) avoiding trauma-related reminders such as people, places, or situation; (c) negative alterations in mood or cognitions such as the inability to recall key features of the traumatic event, negative beliefs about and expectations about oneself and the world (e.g., “I am bad,” “the world is completely unsafe”), diminished interest in pre-traumatic activities, and persistent negative trauma-related emotions (e.g., fear, horror, anger, or shame); and (d) alterations in arousal and reactivity that worsen after the traumatic event such as increased irritable or aggressive behavior, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, problems concentrating, and sleep disturbance.

Traumatic Stress and Family Relationships

Family consequences of exposure to traumatic stress include financial strain, abuse, neglect, poverty, chronic illness, and increased family stress (Weine et al., 2004), as well as a decreased ability to parent (Gewirtz, Forgatch, & Wieling, 2008). Individuals with PTSD, for example, are likely to be more reactive, more violent, and more withdrawn in relationships with a spouse or children (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010; Nickerson et al. 2011).

Floods in Sahrawi refugee camps in southwest Algeria
Floods in Sahrawi refugee camps in southwest Algeria. Wikimedia Commons – CC BY-SA 2.0.

The literature shows that family attachment and support can have a protective effect on those who have experienced traumatic stress, while separation from family can exacerbate symptoms (Rousseau et al., 2001). This makes family mental health and functioning particularly important when there has been loss and exposure to traumatic stress (Nickerson et al., 2011).

Research shows that parental PTSD can significantly affect the parent-child relationship. Parental PTSD is associated with an increase in self-reported aggressive parenting, indifference and neglect (Stover, Hall, McMahon, & Easton, 2012), lower parenting satisfaction (Samper, Taft, King, & King, 2004), an increase in family violence (Jordan et al., 1992), an increase in challenges with couple adjustment and parenting (Gewirtz et al., 2010), and lower perceived relationship quality with children (Lauterbach et al., 2007; Ruscio, Weathers, King, & King, 2002). Having a parent with PTSD has been linked to an increase in children’s behavior problems (Caselli & Motta, 1995; Jordan et al., 1992), trauma-related symptoms (Kilic, Kilic, & Aydin, 2011; Polusny et al., 2011), anxiety and stress (Brand, Schechter, Hammen, Brocque, & Brennan, 2011), and depression (Harpaz-Rotem, Rosenheck, & Desai, 2009). A recent study in Northern Uganda also found that exposure to trauma was associated with family violence (Saile, Neuner, Ertl, & Catani, 2013). In the same study, children reported that their worst traumatic experiences were related to family violence, not exposure to war violence. Similarly, Catani, Jacob, Schauer, Kohila, and Neuner (2008) found that following war and the tsunami in Sri Lanka, 14% of children reported an experience of family violence as the most distressing experience of their lives. A later study with by the same research group (Sriskandarajah, Neuner, & Catani, 2015) found that children listed their worst experiences of family violence immediately after war experiences, but reported that parental care significantly moderated the relationship between mass trauma and internalizing behavior problems. This literature documents the ubiquitous impact of traumatic stress on family relationships and underscores the need for prevention and intervention treatment modalities targeting individual and relational family systems for populations commonly exposed to multiple traumatic events (Catani, 2010).

Videos

Paul Orieny, Sr. Clinical Advisor for Mental Health at the Center for Victims of Torture (CVT), discusses post-traumatic stress and family adjustment issues (1:03-4:55).

Ruben Parra-Cardona, Ph.D., LMFT discusses intergenerational trauma and power in the context of parenting (12:00-13:40).

Child Mental Health

Children are not immune to the deleterious effects of the immigrant and refugee experience. Children who flee adversity to seek refuge in a foreign land often endure physical and mental challenges during a turbulent and uncertain journey (Fazel, Reed, Panter-Brick, & Stein, 2012). They may experience traumatic experiences in their homelands (war, torture, terrorism, natural disasters, famine), lose or become separated from family and caregivers, and endure traumatic journeys to a host country (crossing rivers and large bodies of water, experiencing hunger, lacking shelter; Pumariega, Rothe, & Pumariega, 2005). Children may feel relief once they resettle, but resettlement can bring additional challenges including financial stressors, difficulties finding adequate housing and employment, a lack of community support, new family roles and responsibilities that often transcend developmental age, acculturation stressors such as generational conflict between children and parents, and a struggle to form a cultural identity in the resettled country.

Abed (15) fled Syria to escape the war and was separated from his parents along the way
Abed (15) fled Syria to escape the war and was separated from his parents along the way. Trocaire – DSC_1009 – CC BY 2.0.

The cumulative effects of being exposed to traumatic events and/or stressors pre- and post-migration may overwhelm the coping ability and resilience of children, leading to an accumulation of stressors that may have profound and lasting effects on children’s ability to meet developmental milestones and optimally function on a day-to-day basis. This is especially true for children who experience post-migration detention or enter a host country unaccompanied (Hodes, Jagdev, Chandra, & Cunniff, 2008; Rijneveld, Boer, Bean, & Korfker, 2005). Immigrant and refugee children may continue to suffer from similar conditions as adults, such as anxiety disorders, depression, and PTSD (Fox, Burns, Popovich, Belknap, & Frank-Stromborg, 2004). Studies have shown that the prevalence of PTSD and depression among resettled refugee children in the United States is significantly higher than for children in the general population (Bronstein & Montgomery, 2011; Merikangas et al., 2010). A community-based participatory study conducted by Betancourt, Frounfelker, Mishra, Hussein, and Falzarano, (2015) with Somali Bantu and Bhutanese youth in the United States found that these communities also identified areas of distress corresponding to Western concepts of conduct disorders, depression, and anxiety.

Age Specific Effects of Trauma

See the National Child Traumatic Stress Network’s list of age-specific effects of trauma at: https://www.nctsn.org/resources/age-related-reactions-traumatic-event.

29.4 Mental Health Treatments

“We don’t heal in isolation, but in community.”

—S. Kelley Harrell, Gift of the Dreamtime: Awakening to the divinity of trauma, Reader’s Companion (2014).

Addressing the mental health needs of immigrants and refugees can be a complex challenge for providers. Research has shown that immigrants and refugees underutilize mental health services. This can be for a variety of reasons including the stigma associated with mental health in many cultures, the inability to properly diagnose because of cultural and linguistic barriers, less access to health insurance, lack of financial resources, and the propensity to seek help from traditional healers or providers before seeking Western mental health services (Betancourt et al., 2015; Kandula et al., 2004).

Treating immigrants and refugees within the United States offers unique opportunities and challenges. The refugee experience should be considered multidimensional and multifaceted, and the therapeutic perspective should be sensitive to each family member’s experience (Lacroix & Sabbath, 2011). However, many westernized treatments and interventions do not accommodate for such complexities. Using westernized treatments without proper cultural tailoring and testing may not be ideal or even ethical for those who come from other countries. Many immigrants and refugees come from collectivistic cultures that prioritize interpersonal relationships and social networks above the needs of the individual. The Western concept of psychotherapy as an individualized treatment modality that involves talking with a stranger might not fit with their more collectivist worldview. Many of the native cultures of immigrants and refugees take a holistic approach to mental health and are likely to seek assistance from religious leaders, community elders, or family members (Akinsulure-Smith, 2009; Bemak & Chung, 2008; Fabri, 2001). In a new country, they may be separated from family and indigenous leaders and may not know where to turn for help.

Another challenge is the inadequacy of Western psychiatric categories’ ability to describe refugees’ problems (Adams et al., 2004). Some critics question the validity of applying Western-based trauma models to diverse cultures and societies and believe that the PTSD diagnosis may not fully capture the complexities of the psychological responses that arise from individuals who have experienced human rights violations (Marsela, 2010; Silove, 1999).

Available treatments may also be limited in their abilities to treat immigrants and refugees. Many Western treatments are individually based, which may be appropriate for PTSD and other intrapsychic diagnoses but have not proven effective or sufficient to address the relational and systemic consequences of trauma and displacement-related stressors. In contrast, community connections offer protective factors that can buffer mental health and relational functioning of immigrants and refugees. Studies show that living in communities high in same-ethnic neighbors may contribute to lower levels of depression amongst immigrants and refugees (Ostir, Eshbach, Markides, & Goodwin, 2003). Practitioners can incorporate the positive influence of community support in treatment approaches. Traditional healers can be used to help immigrants and refugees in culturally relevant and acceptable ways, and family-level interventions can improve psychological symptoms and access to services (Weine et al., 2008; Nickerson et al., 2011). When possible, the incorporation of families in the treatment process is paramount. Families bring with them knowledge, competence, and values that can be used during the intervention process to facilitate healing and foster resilience (Lacroix & Sabbath, 2011).

In mental health treatment for children, it is particularly important to engage the child’s support system. Studies suggest that higher levels of family, community, and school support are related to fewer psychological symptoms among children who have experienced war (Betancourt & Khan, 2008). Family-based interventions may target improving the emotional functioning of the family, identifying family patterns of coping, and making meaning of the family’s experience. Schools offer a secure and predictable environment in which immigrant and refugee children struggling with anxiety, depression, and PTSD can be identified and receive supportive services.

Despite the protective factors associated with community and family connections, caution must be taken to acknowledge the potential complexities of a particular cultural community and to develop a deep understanding of contextual and relational dynamics of the group. Many refugee communities share a complex history involving conflict between groups from similar or same ethnic backgrounds that can problematize healing and community building.

PTSD Treatments

A variety of Western therapies have demonstrated efficacy and/or effectiveness for treating PTSD in children and adults. They commonly use various levels of exposure therapy to address one or more traumatic memories in an effort to reduce PTSD symptomatology. Evidence-based exposure therapies include Prolonged Exposure (PE), Trauma-Focused Cognitive Behavior Therapy (TF-CBT), Eye Movement Desensitization and Reprocessing (EMDR), and Narrative Exposure Therapy (NET; KIDNET for children). NET (Schauer, Neuner, & Elbert, 2011) is the only model specifically developed for treating immigrant and refugee populations in post-conflict, low-income contexts and has been extensively researched with refugee populations (Robjant & Fazel, 2010; Crumlish & O’Rourke, 2010). NET integrates elements of cognitive behavior therapy and testimony therapy and is specially targeted for individuals who have been exposed to multiple traumatic events in their lifetime (see Schauer, Neuner, & Elbert, 2011 for a full description of the treatment model). A recent study conducted by Slobodin and de Jong (2015a) reviewed the literature on the efficacy of treatments for asylum seekers and refugees, including trauma focused interventions, group therapies, multidisciplinary interventions and pharmacological treatments. They reported that the majority of studies had positive outcomes for reducing trauma-related symptoms. However, the evidence mostly supports NET and CBT as the recommended treatment modalities for refugees.

Parenting and Family Interventions for Trauma-Affected Immigrants and Refugees

The effects of traumatic stress related to war, violence, and subsequent displacement have far-reaching implications for parent-child relationships. There is a small but developing literature documenting the importance of parenting interventions for populations affected by traumatic stress, as parents are the most proximal resources to effectively intervene and affect child outcomes (Gewirtz et al., 2008; Siegel, 2013). Persistent intergenerational transmission of family violence accompanied by harsh parenting practices and low positive involvement between parents and children is one dimension of a complex set of consequences related to traumatic stress that affect family and community functioning. Although resilience is readily seen in displaced communities, the lasting negative effects of traumatic stress on individual and family health is ubiquitous across multiple generations. The sequelae of maladaptive coping that often includes mental health disturbances, substance abuse and intimate partner violence, are further exacerbated by poverty and social disparities that place these families on a delicate faultline. There are currently no evidence-based parent or family-level treatments for traumatic stress. A review of the literature on family-based interventions for traumatized immigrants and refugees conducted by Slobodin and de Jong (2015b) found only six experimental studies, four school-based and two multifamily support groups. They validated that the shortage of research in this area currently does not allow for effectiveness claims to be made about family-based interventions with these populations.

However, a small number of researchers worldwide have been advancing systemic treatments with promise. One such team is comprised of vivo International (vivo; www.vivo.org) researchers who have collaborated with post-conflict communities for over a decade, primarily providing treatment for PTSD. One of these communities is in Northern Uganda, the setting of a brutal civil war that lasted nearly two decades through 2006. Involvement in this community revealed a critical need for parent and family-level interventions in addition to PTSD treatment. Wieling and colleagues adapted an evidence-based intervention called Parent Management Training, Oregon model (PMTO; Patterson, 2005) which includes core components of encouragement, positive involvement, setting limits, monitoring, and problem-solving to the context of traumatic stress. Additional content areas included the individual and relational effects of traumatic stress, intergenerational transmission of violence, substance abuse, and other risk-taking behaviors. Multi-method data collection approaches and the parenting intervention were carefully tailored to fit the cultural characteristics of Northern Uganda and the models was successfully tested for feasibility of implementation in 2012 with much promise (see Wieling et al., 2015a; 2015b). The research team is currently adapting and testing a similar model with the Karen refugee community in the United States and hope to further test and implement it with other immigrant and refugee groups in the United States. Another approach that specifically targets the family and broader community level to rebuild societies after conflict or resettlement is called the Linking Human Systems or Link Approach (Landau, Mittal, & Wieling, 2008). Link is a specific method of engaging with individuals, families, and communities after trauma and disaster. It suggests that clinicians assess 1) individual, family, and community resources, 2) how resources balance against stressors, and 3) strengths and themes of resilience, including connection to stories of resilience within the family and community-facing past adversities. The Link approach identifies specific intervention strategies to target the individual, family, and community levels. At each level, service providers work collaboratively with the individual, family, or community to identify goals and mobilize resources. This approach demonstrates an ecologically based, culturally informed, and multilevel intervention that holds promise for immigrant and refugee groups affected by trauma and disaster.

 

Videos

Integrating Mental Health Therapy with Traditional Forms of Healing

Rebecca Ratcliff, MD introduces herself and background on the Peruvian and Mayan healing modalities (5:35-9:10).

Melissa Schebloom, MSW, LICSW discusses self-talk with clients with complex trauma (12:21-13:33).

 

 

29.5 Emerging Directions

The challenges of working with immigrant and refugee families are many and the need to improve our theoretical and methodological approaches is critical. First, there is a need for more in-depth and clinically-based research with families. While the body of knowledge about individuals is vast, family interventions remain understudied. There is also a need for more culturally sensitive research methods and interventions that go beyond typical Westernized ideas and methods and that move to incorporate indigenous strengths and cultural-specific practices. Third, we need trained, culturally sensitive practitioners who are willing to grapple with the complexities of working with immigrants and refugees to effectively intervene and achieve positive outcomes. Last, we need an appropriate resettlement infrastructure (e.g., school, medical, legal, economic, political) to support the healthy transition and integration of immigrant and refugee communities. As the number of refugees in the world continues to grow, we need stronger and proactive policies and programs to support their resettlement process. For example, a more comprehensive infrastructure for promoting successful refugee resettlement would involve screening and assessing for mental health, in addition to the required physical health examinations conducted within months of arrival, and building provider capacity across resettlement states for treating individual and relational levels of mental health functioning. At a broader level, a host of legal, human rights and policy level changes will need to be achieved nationally and globally to reduce the punitive stressors associated with undocumented immigrant status, which impact the daily lives of millions in this country.

29.6 End-of-Chapter Summary

Case Study

“Big trucks remind him of the tanks…they shot his friends.”

Ari was a bright-eyed, precocious child with big brown eyes. At the young age of 5 he was full of creative ideas and imaginative scenarios. “I’m stronger than Superman!” he said with unbending confidence while whizzing around the living room of his family’s first floor apartment.

“He is obsessed with superheroes,” His older brother Amed responded.

Ari climbed on the back of the couch, put his fisted hands on his hips, puffed out his chest and with a steely smile ripped open his buttoned shirt revealing a blue t-shirt with the iconic Superman S emblazoned across the chest. “I AM STRONGER THAN SUPERMAN!” he yelled as he threw one arm in the air and jumped off the couch. He continued to run around the room, making whooshing noises and stopping every few seconds to flex his tiny arm muscles.

“We didn’t have superheroes in Kurdistan,” Amed said. “At least I don’t remember them.”

“How old were you when you left Kurdistan?” I asked.

“I was 7, Ari was 3.”

“And how long have you been in the United States?” I asked.

“A little over a year,” he replied.

At that moment Ari and Amed’s mom entered the room with a large warm disk of flatbread wrapped in towel.

“For you,” she said, handing me the bread.

Ari rushed over to grab a piece but was swatted away by his mother’s hand. She began talking to him in Arabic.

“She is telling him to act like a good boy and to stop running around,” Ahmed translated.

Ahmed was 9. He was tall for his age, slender, and very soft spoken. He and his father were the only two in the house who spoke English fluently. This meant Ahmed was often tasked with translating for the family. Sometimes he appeared to enjoy this. At other times he looked burdened.

I smiled. “Little boys are full of energy,” I said while watching Ari flex his muscles at his mother.

At that moment the loud grumbling sound of the garbage truck came in through the open window. The heavy machine wheeled in front of the house, its hydraulics let out a violent gush of air as it thrust its iron teeth into the large dumpster. The dumpster was effortlessly thrown up in the air, its content dumping into the back of the truck. hen with a whoosh and a gush it was slammed back down to earth with a loud bang.

Ari froze. The rigidness in his body was instantaneous. All super hero powers melted away. His eyes grew large and glazed over. His face contorted into that of horror. He screamed uncontrollably. The gregarious little boy was gone, and in his place the embodiment of terror.

“What is wrong?” I asked.

His mother grabbed him. Ari flailed. She pulled his head into her chest and started singing.

“Big trucks remind him of the tanks,” Ahmed said nonchalantly.

“The tanks?  I asked, “What tanks?”

“He was on the playground back home when the tanks came. The soldiers shot his friends.”

Unsure of how to respond, a quiet “oh” slipped from my lips.

“They shot his friends?” I asked.

“Yes, they shot everyone. They didn’t care. They killed children. I saw lots of kids die.” Ahmed spoke with authority but without emotion.

Ari continued screaming for several more minutes as his mother sang and rocked him. The garbage truck finished emptying the dumpsters and drove away. Its loud hum resonating throughout the complex as it left. After it was gone and the usual sounds of the apartment complex returned Ari slowly calmed down.

“Bread. Eat.” His mother smiled and motioned to me and the bread she had handed me minutes before.

“She wants you to eat the bread,” Ahmed said.

“Oh yes. The bread.” I looked down at my hands. “This is the best bread.” I said looking up, half smiling. My eyes moved to Ari. The boy stronger than Superman slowly crept back to life. His eyes unglazed. He yawned, and his mother kissed the top of his head. I pointed to the S on his t-shirt. He looked down at his chest and then instinctively flexed his tiny arm in a show of power before shyly burying his head in his mother’s arm.

Discussion Questions

  1. What are some mental health challenges that may arise in this family? How might an educator, social worker, therapist, religious/spiritual leader, employer, etc. support them?
  2. What types of treatments might be helpful for this family system?
  3. What do you believe are the challenges and opportunities in helping this family successfully resettle in the United States?
  4. What do you see as the role of United States’ communities in immigrant and refugee resettlement – whose responsibility is it to support these families?

Helpful Links

The National Child Traumatic Stress Network (NCTSN)

  • http://www.nctsn.org/
  • NCTSN’s mission is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. Their website contains information for parents and caregivers, school personnel, and professionals.

The Center for Victims of Torture (CVT)

Bridging Refugee Youth and Children’s Services (BRYCS)

  • http://www.brycs.org
  • BRYCS maintains the nation’s largest online collection of resources related to refugee immigrant children and families.

Vivo International

  • (http://www.vivo.org/en/)
  • vivo (victim’s voice) is an alliance of professionals experienced in the fields of psychotraumatology, international health, humanitarian aid, scientific laboratory and field research, sustainable development and human rights advocacy.

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Attribution

Adapted from Chapters 1 through 9 from Immigrant and Refugee Families, 2nd Ed. by Jaime Ballard, Elizabeth Wieling, Catherine Solheim, and Lekie Dwanyen under the Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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