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Refugee Children & Families:The Emotional Impact of Resettlement

and Treatment Strategies

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Presenters:

Beth Farmer, MSWJunko Yamazaki, LICSW Souchinda Khampradith, MSW

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The Refugee Experience Varies not only among refugee groups, but also among

individuals. Complex and almost always contains numerous traumas and

stressors. Approximately 5-10% of refugees in the United States have

experienced a form of torture, including electric shocks, beatings, caning of the soles of the feet, rape, and forced witnessing of torture of executions.

Many refugees experience loss of contact with family members, repeated exposure to violent acts, and extreme fear situations.

All refugees have experienced a loss of home, loss of livelihood, and relocation stress.

Research supports the relationship between trauma and mental health issues.

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Numerous studies demonstrate that refugees are a particularly vulnerable population when it comes to mental health issues.

Common diagnoses include Post-Traumatic Stress Disorder, Major Depressive Disorder, and Anxiety or Adjustment Disorder.

Refugees have been found to have ten times the rate of Post-Traumatic Stress Disorder [PTSD] as compared to the general population.

Refugees have higher rates of mental disorders in general.

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Migration and its Impact on Mental Health

The refugee experience is multifaceted and contains elements of trauma and/or stress during all its migration stages:

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Stage 1: Forced Migration Includes events both before “flight” and during “flight.” Before being forced to flee, refugees may experience

imprisonment, torture, loss of property, malnutrition, physical assault, extreme fear, loss of livelihood, being forced to inflict pain or kill, witness torture or killing, and/or the loss of close family members or friends.

The flight process can last days or years. During flight, refugees are frequently separated from family

members, robbed, have little or no food, become ill, assaulted and/or raped, witness physical assault and/or rape, witness others being beaten or killed, and endure extremely harsh environmental conditions. Because of its “dramatic” nature this is often of most interest to clinicians, but is rarely cited as having extensive bearing on emotional health by resettled refugees.

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Stage 2: Camp Residency Not all refugees live in camps. Refugee camps differ in size (some containing a few thousand

while others contain well over 100,000 people) and physical attributes (some having schools, hospitals, roads, and sanitation while others consist of quickly constructed tents).

Although refugee camps are considered temporary, in reality, many are long-term settlements where refugees can remain for decades.

Refugees may be barred from agricultural pursuits or from working. And results in a lack of meaningful activity and demoralization.

A time of incredible uncertainty – repatriation, integration, resettlement.

Violence is often a feature of camps. Food inadequacy, micro-nutrient deficiencies.

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Stage 3: Resettlement – “Resettlement is a life crisis.”

Refugees move to a new country with a different language and culture leaving behind family and friends – usually do not have choice of location.

The resettlement period = 90 –180 day period of assistance by Volags.

Their initial financial situation is extremely limited. ($450 per person + travel loan)

Opportunities for employment may be few due to a lack of education or language skills, or conversely, their previous education and training may be useless in the US.

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Feelings of isolation can also emerge due to a lack of language skills, extended support network, and transportation.

Refugees may feel their values conflict with the culture in which they reside.

They may become targets of discrimination or oppression.

Refugees cite resettlement factors as the most critical to their mental health.

“Post-migration stressors such as unemployment and family separations have a more powerful effect on refugee mental health than pre-migration stressors during the first few years of resettlement” (Hyman, Vu, & Beiser., 2000).

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Resettlement and Mental Health Stages of Resettlement – 1) Excitement and Gratitude 2) Overwhelmed and Numb 3) Loss of illusion and Expectation 4) Depression 5) Acceptance 6) Greater Integration and Acculturation

– The initial period of resettlement is followed by what may be the most critical phase in the post-migration process, it is during this phase that refugees can be “most vulnerable and most in need of comprehensive support services” (NAMMH, n.d., p. 18).

– If they are able to get adequate support they are more likely proceed towards successful psychological and cultural integration into their new society. If these supports are absent, the stressful demands of resettlement, along with past trauma and separation from family and friends, can put refugees at high risk for mental health issues, alienation, and marginalization.

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Resettlement Challenges

Economic - Housing– Example: Seattle has one of the highest costs of living in the

US. Isolation

– Lack of transit options in suburbs.– Less refugee density.– Less “walkability.”– Fewer accessible community centers and other close

options for gathering. Lag in Cultural Competency

– Services – schools, hospitals, etc. – less experience with refugees and providing services to refugees.

All INCREASES stress

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Questions?

Type your question into the Questions Dialogue box and press Send.

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How to Approach the Topic of Mental Health/Illness

1. Meaning of mental illness

2. Cross-cultural factors affecting mental health

3. Cultural view of schizophrenia

4. Before the client walks through the door

5. Talking to the patient about symptoms

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What do we mean by “Mental Illness?” In the western world “mental illness” refers to

a wide range of emotional distress.

In many other cultures, mental illness means “crazy.”

The difference in the meaning of “mental illness” is a major barrier to service access.

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Cross-Cultural Factors AffectingRefugee Mental Health Culture frames how one expresses

emotions and processes emotions:– In many refugees’ worldview there is no dichotomy between

physical complaints and mental, spiritual, and social distress (Watters, 2001; Nadeau & Measham, 2006). This often leads to a high degree of “somatization.”

– In many cultures, it is considered a sign of immaturity to speak of past trauma or emotional reactions to it.

– The western paradigm of psychodynamic counseling is foreign to most cultures, who find it vague and not particularly useful.

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Connecting to Refugee Clients

• Attain Knowledge of Client Background- Resources: Ethnomed/ Interpreters/ Literature/ Colleagues

• Learn the Landscape of the Individual• Use of mental health terms vs. Use of somatic

symptoms/descriptive terms to delineate the problem (sleep, sadness, worry)

• Checking with interpreter to see what your words may mean to client

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Know the LandscapeAsk the Individual

– Age

– Class

– Education

– Religion

– Language

– Family

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Eight questions by Dr. A. Kleinman Are there Comparable MH Questions?

1. What do you think caused your problem?2. Why do you think it started when it did?3. What does your sickness do to you? How does it

work?4. How severe is your sickness? How long do you

expect it to last?5. What problems has your sickness caused you?6. What do you fear about your sickness?7. What kind of treatment do you think you should

receive?8. What are the most important results you hope to

receive from this treatment?

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Connecting

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

Bernard Kempler, PhD

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Questions?

Type your question into the Questions Dialogue box and press Send.

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Working with Refugee Children and Youth

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Third Culture Youth:

Youth with 1st generation immigrant/refugee parents and whose peers are American born.

They are a critical subset of the immigrant and refugee community.

They often do not identify with their parents’ culture or their adopted American culture.

Cultural identity conflict adds an additional element of stress to both the youth’s and their parents’ lives as they try to cope with the usual tensions of adolescence.

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Common Issues Loss and Grief Depression and Anxiety Guilt and Shame Trauma and PTSD Adjustment: depends on the age of resettlement,

level of literacy, whether resettling with family & relatives or unaccompanied minor, trauma & the experience before, during & after resettlement

Other issues: parent/child conflict, peer and school issues, CD/SA, DV/SA, involvement with gang and violence, problem gambling and normal developmental issues such as dating.

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Treatment Strategies - PARENTS Always include Parents/Foster Parents/Care Givers

in development of Tx Plan if possible. Work them through the issues and Tx process. Provide culturally tailored explanation.

Build trust and credibility by working on tangible needs first– translate letters from child’s school, find doctor, connect with housing, etc.

Many come from single parents household/multi- generational household/mixed family household. Find out who has decision making power.

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Treatment Strategies - PARENTS Be a cultural navigator/broker for the family and

youth. Family members’ unfamiliarity and lack of knowledge of US systems (legal, educational, health, mental health) hinders help-seeking.

Mistrust of the government and their past experiences with authority figures hinder help- seeking. Take your time to build trust and explain to decrease their anxiety.

Build partnership and alliance.

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Treatment Strategies - PARENTS Find out parents’ understanding of child’s issues;

what they have tried; what worked and what did not work.

If possible always match culture, language and gender of counselor to youth and their family.

Have trained interpreter available. Make sure that culture/language/gender and age of interpreter is appropriate.

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Treatment Strategies - PARENTS Pay attention to family’s understanding of causality of

mental illness. The Western mental health symptoms may not be looked upon as mental illness, but rather “gifts,” “special powers” and “ black magic.”

Pay attention to their spiritual belief system.

Develop culturally responsive Tx Plan.

Understand and incorporate indigenous healing practices -- rituals with shamans and monks, sacrificing chickens, etc.

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Treatment Strategies - PARENTS Many parents and adult caregivers are

dealing with their own issues that affect their ability to support the child. Such as:-- PTSD-- Loss & Grief-- Chemical Dependency/Problem Gambling-- Sexual Abuse/Domestic Violence-- Unemployment/Underemployment

-- Substandard Housing Offer them resources and connect them to

culturally appropriate services.

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Questions?

Type your question into the Questions Dialogue box and press Send.

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Treatment Strategies –CHILDREN AND YOUTH

– Refugee youth develop differently than the mainstream youth. Western developmental assessment tools do not work well with this population.

• Emotional Development• Sense of Self/Identity Formation• Social Development• Sexual Identity Development• Family Relationship

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Treatment Strategies –CHILDREN AND YOUTH Encourage them to have their parents involved but

assure confidentiality. Establish trust and credibility -- work with tangible

needs first. Assign staff who has similar refugee and cultural experience.

Understand issues at home -- who lives at home, who is raising them, who makes decisions.

Understand their unique refugee experience -- years in camp, age of resettlement, literacy in their own language, trauma, loss, etc.

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Treatment Strategies –CHILDREN AND YOUTH Understand youth’s cultural norms and

traditions.

Assess the level of acculturation of both youth and parents. Level of English proficiency.

Assess CD/SA, DV/SA, problem gambling, health and mental health issues with youth and family members.

Assess readiness to accept services.

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Treatment Strategies –CHILDREN AND YOUTH Address: School and Academic Development Social and Peer Life Identity -- cultural/ethnic/sexual Developmental Stage Health Issues -- make sure youth has a medical

provider. Connect to Resources in the Community -- after

school programs, sports, cultural groups, and other fun activities.

AND Empower them, nurture Hopes and Dreams!!!

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Resources

– Bridging Refugee Youth and Children’s Services

www.brycs.org

– Cultural Orientation Resource Center www.cal.org/co/publications/profiles.html

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Questions?

Type your question into the Questions Dialogue box and press Send.

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Thank you!

Beth Farmer, MSWBfarmer@lcsnw.org

Junko Yamazaki, LICSW Junkoy@acrs.org

Souchinda Khampradith, MSWSouchindak@acrs.org