Developing preventive mental health interventions for refugee families in resettlement

In refugee resettlement, positive psychosocial outcomes for youth and adults depend to a great extent on their families. Yet refugee families find few empirically based services geared toward them. Preventive mental health interventions that aim to stop, lessen, or delay possible negative individual mental health and behavioral sequelae through improving family and community protective resources in resettled refugee families are needed. This paper describes 8 characteristics that preventive mental health interventions should address to meet the needs of refugee families, including: Feasibility, Acceptability, Culturally Tailored, Multilevel, Time Focused, Prosaicness, Effectiveness, and Adaptability. To address these 8 characteristics in the complex environment of refugee resettlement requires modifying the process of developmental research through incorporating innovative mental health services research strategies, including: resilience framework, community collaboration, mixed methods with focused ethnography, and the comprehensive dynamic trial. A preventive intervention development cycle for refugee families is proposed based on a program of research on refugees and migrants using these services research strategies. Furthering preventive mental health for refugee families also requires new policy directives, multisystemic partnerships, and research training.     

Review of refugee mental health and wellbeing: Australian perspectives

This review covers refugee mental health and wellbeing within the Australian context to assist psychologists who provide services for, or who conduct research with, refugees. It provides a brief overview of the refugee movement, prior to examining evidence relating to the impacts of pre‐displacement, displacement and resettlement factors on psychological adjustment in the resettlement phase, and the systemic and sociopolitical factors that influence the process of adaptation during resettlement. Australian findings suggest that mental health and wellbeing outcomes are influenced by a complexity of pre‐displacement, displacement, resettlement and systemic factors; the detention or award of temporary residence to refugees who are already experiencing psychological distress on arrival are cases in point. Limitations of the findings are considered. More research into the combined, pathwise relations between the psychosocial pre‐determinants and psychological sequelae of the refugee experience is required. Finally, suggestions for the development of practice, training and ethical guidelines are offered.     

Primary prevention of acculturative stress among refugees. Application of psychological theory and practice

Primary prevention in refugee mental health requires information from clinical, health, and cross-cultural psychology. Primary prevention's roots are in public health, which is distinguished by a communitywide perspective for addressing mental health concerns. This article summarizes research suggesting that refugees are an at-risk population, making them especially suitable for public health interventions. Research on stress and acculturation is highlighted, given its importance to prevention in refugee mental health. The opportunities for primary prevention programs and policies at 3 levels (i.e., local community, national, and international) are illustrated with case examples from both the United States and Canada. Prevention at the international level is highlighted by a World Health Organization Mental Health Mission to camps on the Thai-Cambodian border.     

Rethinking a Familiar Model: Psychotherapy and the Mental Health of Refugees

This paper examines with a somewhat critical eye the primary role that psychotherapy and other clinic-based services currently play in addressing the mental health needs of political refugees in the industrialized countries. Two factors are considered which suggest that refugee mental health needs might be better served by complementing clinic-based treatments with a variety of community-based interventions. The first factor concerns the pervasiveness of psychological distress within refugee communities, coupled with the reluctance of many refugees to utilize formal psychological and psychiatric services. This calls into question both the adequacy and appropriateness of clinical-based services as cornerstones of our response to the mental health needs of refugees. More precisely, it suggests the need to complement such services with a variety of culturally grounded, community-based strategies that do not require attendance in formal mental health settings. Second, recent findings have shown consistently that a considerable amount of the distress reported by refugees is related not to prior exposure to violent events, but to a constellation of exile-related stressors such as the loss of one's community and social network, the loss of important life projects, changes in socioeconomic status and related concerns about economic survival, the loss of meaningful structure and activity in daily life, and the loss of meaningful social roles. It is suggested that while psychotherapy can play an important adjunctive role in helping people confront these exile-related stressors, they may most effectively be addressed through targeted community-based interventions. Examples of such community-based approaches are briefly described, and suggestions are offered for community-level strategies that might be explored. The paper concludes by emphasizing the complementary nature of clinical and community-based programs, and by suggesting that psychotherapy might best be conceptualized as one component of a more comprehensive approach to addressing the mental health needs of refugee communities.     

“It is Good to Know Now…Before it’s Too Late”: Promoting Sexual Health Literacy Amongst Resettled Young People With Refugee Backgrounds

Little is known about access to sexual health information amongst young people with refugee backgrounds living in countries of resettlement. This paper reports on a study of sexual health amongst recently arrived young people from refugee backgrounds in Melbourne, Australia. The study employed qualitative research methods to explore and describe how resettled youth access, interpret and implement sexual health information. Between August and December 2007, data was collected through 23 focus group discussions and 14 in-depth interviews involving 142 young people with refugee backgrounds. Participants were purposively selected to reflect the ethnic composition of humanitarian entrants to Australia over the past 3 years. Their countries of origin included Iraq, Afghanistan, Burma, Sudan, Liberia, and Horn of Africa countries. The findings highlight how young people with refugee backgrounds are disadvantaged in relation to access to sexual health information. Young people had little knowledge of sexual health or STIs apart from HIV/AIDS. While they are aware of potential sources of sexual health information, few of these sources are utilized. Specific barriers to learning about sexual health include concerns about confidentiality, shame and embarrassment when discussing sexual health, and the competing demands of resettlement. The paper argues for sexual health promotion to be an explicit part of early resettlement services for refugee youth, and the implications for the development of appropriate sexual health education programs are discussed.     

Mental health help‐seeking and refugee adolescents: Qualitative findings from a mixed‐methods investigation

There is general agreement in Australia and other Western resettlement countries that many refugee adolescents with social, behavioural, and mental health problems are not accessing mental health care. There is, however, a paucity of research on refugee adolescent mental health service utilisation and help‐seeking. Most research to date has centred on adolescents in the general population, and even then is still very limited. This paper presents the findings of 13 focus groups held with 85 refugee adolescents aged 13–17 years from Afghanistan, Bosnia, Iran, Iraq, Liberia, Serbia, and Sudan. The study was part of a wider investigation of mental health service utilisation by refugee parents of children aged 4–17 years, and by adolescents aged 13–17 years. With respect to adolescents, the focus group findings indicate that most are very reluctant to venture beyond their close friendship networks for help with their psychosocial problems due to a range of individual, cultural, and service‐related barriers. Implications for mental health policymakers, service planners, and service providers are discussed.     

A Comparison of Wages by Gender and Region of Origin for Newly Arrived Refugees in the USA

The resettlement model supported by the US government aims to help recently arrived refugees achieve economic self-reliance within the first 90 to 180 days of arrival. In addition to the challenges they face in adapting to their new locations, however, refugees enter a US labor market characterized by preexisting wage disparities based on race and gender. Meanwhile, recent changes in US refugee and immigration policies have infused debates over nationalism, Islamophobia, and the economics of resettlement. In this context, it is critical to assess whether refugees face wage discrimination that may affect their ability to become economically self-reliant. Drawing on the International Rescue Committee’s administrative data on refugee resettlement, we examine the extent to which starting wages for newly arrived refugees differ by region of origin and gender. The study found consistent gender pay gaps among the majority of new arrivals. The study also identified lower wages for refugees arriving from sub-Saharan Africa, Latin America, and the Caribbean compared to other regions. These trends suggest a need for more consistent agency monitoring of employment placement, and the development of strategies to ensure more equitable employment outcomes for refugees.     

Trauma healing in refugee camps in Guinea: a psychosocial program for Liberian and Sierra Leonean survivors of torture and war

From 1999 to 2005, the Minneapolis-based Center for Victims of Torture (CVT) served Liberian and Sierra Leonean survivors of torture and war living in the refugee camps of Guinea. A psychosocial program was developed with 3 main goals: (a) to provide mental health care, (b) to train local refugee counselors, and (c) to raise community awareness about war trauma and mental health. Utilizing paraprofessional counselors under the close, on-site supervision of expatriate clinicians, the treatment model blended elements of Western and indigenous healing. The core component consisted of relationship-based supportive group counseling. Clinical interventions were guided by a 3-stage model of trauma recovery (safety, mourning, reconnection), which was adapted to the realities of the refugee camp setting. Over 4,000 clients were provided with counseling, and an additional 15,000 were provided with other supportive services. Results from follow-up assessments indicated significant reductions in trauma symptoms and increases in measures of daily functioning and social support during and after participation in groups. The treatment model developed in Guinea served as the basis for CVT's ongoing work with survivors in Sierra Leone and Liberia. ((c) 2006 APA, all rights reserved).     

Post-Traumatic Stress Disorder Among Salvadoran Women:

Previous research has documented post-traumatic stress disorder among Salvadoran refugees in this country, but information on refugees living in El Salvador is not available. This study investigated the patterns of psychological distress and documented the existence of PTSD in Salvadoran refugee women in El Salvador. A team of U.S. mental health workers traveled to a refugee camp in El Salvador to interview women about their traumatic experiences and current symptoms of distress. This study provides strong evidence that many refugee women in El Salvador have developed PTSD and that many others show significant signs of distress. Data from this study also provided insight into clinical issues for Salvadoran women experiencing PTSD. In response to requests from Salvadoran mental health providers, a treatment program was developed to help Salvadoran women reduce their distress. Goals of the treatment included associating distress with the trauma as a normal reaction to a very abnormal event, reducing feelings of loss of control, reducing "survivor guilt," and lessening anxiety and high arousal level. These goals were accomplished using cognitive-behavioral and community-oriented strategies.     

The Costs of Secondary Migration: Perspectives from Local Voluntary Agencies in the USA

In recent years, as the need for global refugee assistance has increased, so have fears and concerns of the costs of refugee resettlement in Western nations. Now, seemingly more than ever, international security and regional development depend largely on the composition and distribution of the world population. In many Western nations, dispersal policies are specifically designed to manage the distribution of recently arrived refugees. Secondary migration presents a challenge to the goals of dispersal policies and raises questions regarding regional development, population pressures, job security, welfare dependency, and the future of global refugee assistance. We survey administrators and caseworkers in a series of qualitative interviews about their experiences with secondary migration. We conclude that the US refugee resettlement system is ill-equipped in handling the complications of secondary migration. These results lead us to reimagine a better strategy for achieving the goals of refugee resettlement.     

Social capital and refugee resettlement: The social networks of refugees in Canada

Survey data from a large sample of recent refugees (N=525) living in Canada are used to profile the size and structure of refugees' social networks and to highlight the value (or function) of such social capital in the resettlement process. Despite the traumas associated with becoming a refugee, most adult refugees remain part of at least some familial networks. A large minority are connected with more extented family networks, and almost half plant to build these networks by sponsoring other family members. As resettlement continues, more extensive extra-familial networks involving neighbours, co-workers and employers, other community members, and a wide range of service providers are constructed. These many formal and informal social networks are extremely valuable, providing much-needed support and assistance when refugees are faced with financial, employment, personal, or health problems. Policy challenges arising from these findings are discussed.     

Serving Clients With Hearing Loss: Best Practices in Mental Health Counseling

This article examines the risk factors and characteristics of clients with hearing loss, including inequitable access to education and mental health care services, financial barriers, communication problems, and societal discrimination. Culturally specific counseling approaches and techniques for mental health counselors serving clients with hearing loss are presented, with a focus on building counselor competency and client employment skills. The use of interpreters in therapeutic settings is also discussed.     

Critical incidents for refugee counsellors: An investigation of indigenous human resources

The mental health of refugees is increasingly being recognized as an important dimension of refugee welfare. In 1992 the Finnish Refugee Council established one of the first aid programmes to provide a therapeutic intervention to traumatized refugees. In an attempt to establish the necessary therapeutic ski& to work with this client group, we investigated the experiences of 15 refugee counsellors, using the technique of Critical Incidents Analysis. All of these counsellors were themselves refugees. Key features of their work are identified and the pros and cons of employing refugees as counsellors are discussed.     

Testimony work with Bosnian refugees: living in legal limbo

Mental health professionals working with refugees are often confronted with traumatised survivors who are living in legal limbo. Complicated asylum procedures or provisions of only 'temporary' protection trigger existential fears, reexperiencing of trauma and feelings of hopelessness and deep despair and can actively contribute to further destabilise survivors. Mental health centres have to reconceptualise their provided services for these clients. The paper introduces a testimony project for traumatised Bosnian refugees in Frankfurt, Germany, who were living in legal limbo for many years. The testimony method was used in combination with supportive therapy and informed advocacy to try to reduce the survivors' feelings of humiliation and demoralisation which for them were at the centre of their survival. By giving testimony, survivors benefited psychologically and became better able to cope with the difficult present. Feelings of self-worth and dignity could be regained and a trusting relationship between the survivor and the listener facilitated the therapeutic process. The testimony material documented human rights abuses both in the country of origin and in exile, helped us to perform informed advocacy for this group and informed a larger public on the psychological costs of refugee resettlement policies.     

Predictors of depressive symptoms among resettled unaccompanied refugee minors

This study investigated the level and predictors of depressive symptoms among unaccompanied refugee minors after resettlement in Norway. Participants (N = 414) were resettled in 26 municipalities from all regions of the country. The average length of resettlement time was 3.4 years. They originated from 33 different countries, mainly Afghanistan (n = 116), Somalia (n = 74), Sri Lanka (n = 41) and Iraq (n = 43). Participants completed a self-report questionnaire administered in groups. Findings show that unaccompanied minors are a high-risk group for mental health problems also after resettlement in a new country. A multilevel model predicting depressive symptoms from individual and contextual demographic factors indicated that, controlling for post-traumatic stress, females had more symptoms than males and Somalis had fewer symptoms than participants from other countries. Variation in symptom levels as a function of gender and ethnic background indicates that some groups may have inherent protective or vulnerability factors that need to be further studied to understand differences in psychosocial adaptation among unaccompanied minors. Further, findings imply that researchers, policy makers and mental health care workers need to expand their attention beyond the first phases of arrival of unaccompanied asylum seeking and refugee minors to the continuing experience of mental health problems after resettlement.     

A Qualitative Study of the Career Aspirations of Resettled Young Sudanese and Somali Refugees

The study documents and explicates the academic experiences, visions, hopes and desires which shape the vocational aspirations of young Sudanese and a Somali refugee who have resettled in Australia. Semi-structured interviews were conducted to examine the experiences of a sample of 14 young resettled refugees in Brisbane, Australia. Adopting a qualitative methodology, the interviews covered the aspirations of the participants across three time periods: life in the country of origin, transit and resettlement. Participants expressed high ambitions despite their experiences of school disruption pre resettlement and language difficulties post resettlement. The situation in the country of origin emerged as influential upon their aspirations in both pre and resettlement life. English language difficulties emerged as the most common consideration influencing aspirations following resettlement. A number of considerations were found that influenced their vocational aspirations before and after resettlement. Such considerations may enlighten service providers working with resettled young African refugees.     

Aetiology of Coexisting Mental Health and Alcohol and Other Drug Disorders: Perspectives of Refugee Youth and Service Providers

In the general population, people with comorbid mental health (MH) and alcohol and other drug (AOD) disorders (comorbidity) have great difficulty accessing appropriate services, and poor outcomes. Little is known about comorbidity in resettled refugees in Australia. This study was designed to identify risk factors and patterns of comorbidity development in young people from refugee backgrounds living in a disadvantaged urban region of Adelaide, South Australia. This qualitative study utilised in‐depth semi‐structured interviews (n = 30) with resettled refugee youth and workers from MH, AOD, and refugee support services. Thematic analyses were conducted to investigate the aetiology of MH and AOD disorders in young refugees. Interviews with both groups revealed how the interrelated nature of risk factors may place young people from refugee backgrounds at heightened risk of experiencing MH and AOD problems. The situations and conditions described by both groups are discussed under six main themes: pre‐migration experiences of torture and trauma; familial factors of intergenerational conflict; post‐migration adjustment difficulties in terms of language, culture, education, and employment; exposure to and availability of substances; maladaptive coping strategies and self‐medication; and access to information and services. Implications for psychologists and MH professionals are identified, emphasising the need for clinicians to understand the complexities surrounding the aetiology of comorbidity in these youth. The initial assessment needs to be comprehensive, including pre‐ and post‐settlement experiences and cultural and family dimensions of their current situation. Treatment may often need to simultaneously address multiple contributing factors and involve culturally sensitive psycho‐education.     

Randomized Controlled Trial of a Multilevel Intervention to Address Social Determinants of Refugee Mental Health

Understanding processes that support the well-being of the unprecedented numbers of forcibly displaced people throughout the world is essential. Growing evidence documents post-migration stressors related to marginalization as key social determinants of refugee mental health. The goal of this RCT was to rigorously test a social justice approach to reducing high rates of distress among refugees in the United States. The 6-month multilevel, strengths-based Refugee Well-being Project (RWP) intervention brought together university students enrolled in a 2-semester course and recently resettled refugees to engage in mutual learning and collaborative efforts to mobilize community resources and improve community and systems responsiveness to refugees. Data collected from 290 Afghan, Great Lakes African, Iraqi, and Syrian refugees at four time points over 12 months were used to test the effectiveness of RWP to reduce distress (depression and anxiety symptoms) and increase protective factors (English proficiency, social support, connection to home and American cultures). Intention-to-treat analyses using multilevel modeling revealed significant intervention effects for all hypothesized outcomes. Results provide evidence to support social justice approaches to improving refugee mental health. Findings have implications for refugees worldwide, and for other immigrant and marginalized populations who experience inequities in resources and disproportionate exposure to trauma/stress.     

The relationship between trauma and financial and physical well-being among Cambodians in the United States.

This study focused on the relationship between trauma and financial and physical well-being of Cambodian refugees in the United States. Trauma was defined by three variables: whether or not trauma had been experienced in Cambodia, the number of traumas experienced, and the number of years spent in refugee camps. It was hypothesized that these trauma variables would predict financial and physical health among Cambodians in the United States. A discriminant analysis showed significant relationships between the trauma variables and current employment status, and multiple regression analyses showed that trauma predicted income and physical health.     

The Relationship between Trauma and Financial and Physical Well-Being Among Cambodians in the United States

This study focused on the relationship between trauma and financial and physical well-being of Cambodian refugees in the United Sates. Trauma was defined by three variables: whether or not trauma had been experienced in Cambodia, the number of traumas experienced, and the number of years spent in refugee camps. It was hypothesized that these trauma variables would predict financial and physical health among Cambodians in the United States. A discriminant analysis showed significant relationships between the trauma variables and current employment status, and multiple regression analyses showed that trauma predicted income and physical health.