Chapter 1. Overview Of Cultural And Diagnostic Issues
Publication: The Psychiatric Evaluation and Treatment of Refugees
Migration has been a part of the human condition since the beginning of time. People have traveled from one part of the world to another for a number of reasons. Some were looking for a better life, others wanted to see what was around the next corner, and many people over thousands of years have left their original places of habitation to escape adversity. This did not change in the twentieth century and continues in the twenty-first century. Unfortunately, conditions in various parts of the world have created difficult conditions for individuals, families, and communities because of war, persecution, or natural disasters. There are millions of migrants displaced not only within their own countries but also in various parts of the world. There currently are 66 million forcibly displaced people, of whom 22 million are refugees, more than half from Syria, Afghanistan, and South Sudan (United Nations High Commissioner for Refugees 2019). Refugees are a specific category of migrants: they are persons who are outside of their country of origin who are unable to return to that country because of a well-founded fear of persecution due to race, religion, nationality, political opinions, or membership in a specific social group (United Nations High Commissioner for Refugees 2019). Asylum seekers are different from refugees as a group; asylum seekers apply for protection after they arrive in the country in which they are seeking safety rather than being screened and approved for refugee status as refugees are. Those applications can be in refugee camps or at designated sites outside their home countries (Refugee Health Technical Assistance Center 2011).
In this chapter, I begin by describing briefly the process by which refugees are screened for resettlement in the United States. I include recent data regarding countries of origin and describe some of the conditions in those countries of origin that give rise to refugee migration. I then discuss the challenges that refugees face prior to migration, during migration, and after arrival in the host country. In addition, I provide an overview of basic medical and psychiatric screening of refugees in mental health settings and briefly describe the various approaches to treatment that are discussed in more detail in other chapters in this book.
Overview of Resettlement: Screening and Demographics
THE REFUGEE SCREENING PROCESS
The United States is a party of the 1967 United Nations Protocol Relating to the Status of Refugees that incorporated articles of the original 1951 Refugee Convention (United Nations High Commission for Refugees 2011). Because the United States is a signatory of the United Nations protocol, it is obligated to protect refugees seeking asylum from persecution. Congress legislated U.S. obligations under the United States protocol when it codified refugee protection and the procedures for asylum in the Refugee Act of 1980 (Administration for Children and Families 2012). After fleeing their own country, refugees most commonly stop at refugee camps on the border of their country or in camps in neighboring countries. If they wish to be resettled, refugees are screened by the United Nations High Commissioner for Refugees (UNHCR) to determine whether they are eligible for refugee status and qualify for UNHCR protection. The process of resettlement can often be very lengthy.
The first step in being resettled in the United States is an interview with an officer of the U.S. Citizenship and Immigration Services to determine eligibility and to arrange a required medical examination and security clearances (Refugee Health Technical Assistance Center 2011). The medical examination that occurs overseas before the refugee is accepted for resettlement in the United States screens for communicable diseases that have an impact on public health such as tuberculosis, syphilis and other sexually transmitted diseases, and leprosy. In addition, applicants are screened for drug addiction and any condition that would create conditions for harmful behaviors. If a refugee passes medical screening and security clearance overseas, he or she is granted refugee status by the U.S. Department of Homeland Security and is brought to the United States for resettlement by the U.S. Department of State. Voluntary agencies and the U.S. Department of Health and Human Services’s U.S. Office of Refugee Resettlement assist with resettlement in the United States (Administration for Children and Families 2019).
Once refugees arrive in the United States, the U.S. Department of State has cooperative agreements with resettlement agencies to provide services for refugees. The Office of Refugee Settlement is the lead agency for domestic refugee programs. These services include food, clothing, housing, employment, and medical care during the first 90 days after arrival. In reality, most refugee resettlement agencies provide longer-term support for refugees after arrival in the United States. Most refugees are also eligible for 8 months of short-term health insurance called Refugee Medical Assistance (Administration for Children and Families 2019), and the Affordable Care Act permits refugees to be eligible for medical care in states that provide funding through the marketplace exchanges.
COUNTRIES OF ORIGIN
Since the end of the Vietnam War in 1975, refugees have come to the United States from a variety of regions. From the mid-1970s through the 1980s, the vast majority of refugees settling in the United States came from Southeast Asia. The largest numbers of refugees from that region came from Vietnam, and there were also significant numbers from Cambodia and Laos. In the 1990s the greatest numbers of refugees, besides those from Southeast Asia, were from the former Soviet Union, and beginning in the 2000s the largest percentage of refugees to the United States has come from the Near East and South Asia (Refugee Processing Center 2016). Refugees from these countries included those from Afghanistan, Iraq, Iran, and Myanmar, and refugees from Bhutan who had been resettled in other parts of South Asia.
In the 2000s refugees to the United States also have come from Latin America and the Caribbean. These countries include primarily Guatemala, El Salvador, Honduras, Cuba, and Haiti. In the 2000s refugees also began coming from various parts of Central and East Africa, including the Democratic Republic of the Congo, Sudan, Ethiopia, Eritrea, and Somalia (Refugee Processing Center 2016).
Because of changes in the U.S. government’s policy toward admission of refugees, there has been a decline over the last few years in the number of refugees authorized to enter the United States. For example, in fiscal year 2016, there were approximately 85,000 refugees admitted to the United States, but in fiscal year 2017 there were only about 54,000, with the approval ceiling for 2018 being less than that number (Refugee Health Technical Assistance Center 2011). Of the refugees admitted to the United States in fiscal year 2017, the largest number were from Africa (approximately 20,000) and from the Near East and South Asia (also approximately 20,000). Refugees from Somalia and the Democratic Republic of the Congo accounted for the majority of arrivals from Africa. From the Near East and South Asia, the majority of refugees were from Iraq, Syria, and Bhutan (Refugee Processing Center 2016).
The conditions in the countries that have produced the largest number of refugees who have come to the United States in the last several years mirror the conditions that have produced refugees during the latter part of the twentieth century and the first decade of this century. There continues to be great instability in the Near East due to continued war, and these conditions show no signs of disappearing. In addition, there have been numerous civil wars in Central and East Africa, complicated by significant climate stressors such as severe drought, that have contributed to disease and malnutrition. As in so many areas of the world from which refugees come, a combination of conditions, such as war, environmental degradation, and collapse of civil society, creates very unstable conditions that lead to further violence and further shortages of food, water, and basic health care that have an impact on the population.
The significant majority of people migrating from the Central American countries of El Salvador, Guatemala, and Honduras have not been screened for official refugee status; they have come as undocumented migrants, many of whom have applied for asylum. Those applying for asylum have not been legally approved for residency in the United States. There are two routes to gaining asylum, affirmatively through the U.S. Citizenship and Immigration Services, or defensively through an immigration judge as part of a removal proceeding. The affirmative channel is open to applicants regardless of whether they have entered the country legally (De Jesús-Rentas et al. 2010). Many asylum seekers from Central America in recent years have also been unaccompanied minors fleeing violence and instability in their countries. El Salvador and Guatemala both experienced civil wars during the 1980s and 1990s, and postwar instability has continued because of gang violence, much of which is tied to the drug trade throughout the Americas. Children, particularly males, have been pressured to join gangs and to participate in horrendous violence that is part of the background of daily life in these countries. Many violent events are not reported to the police because of fear of police corruption or gang-related retaliation (Keller et al. 2017). To escape inscription into gangs, minors often leave on their own or with the encouragement of their families to seek safety in the United States. Both youth and adult migrants from these Central American countries must come through Mexico and then cross the United States–Mexican border under very difficult climatic and environmental conditions, and after being subjected to various forms of exploitation while traveling through Mexico.
ARRIVAL IN THE UNITED STATES
The cities and states where refugees are resettled frequently do not have similarities of climate or size to the areas from which they came. Resettlement is often dependent on sponsorship by nongovernmental organizations, religious communities, and other local and state agencies. After arriving in the United States, refugees and asylum seekers often migrate to various parts of the country after their initial resettlement. This secondary migration within the United States is sometimes driven by refugees wanting to join extended family in different parts of the country or to pursue job opportunities that may not be available where they originally settled.
Now that I have outlined the demographic characteristics of refugees who have resettled in the United States and described the conditions across the globe that produce refugees, I would like to summarize the epidemiological findings over the last several decades relating to mental health conditions among refugees. After summarizing these data, I then discuss current recommended approaches to assessment and treatment, which will be described in more detail in the chapters that follow.
Psychiatric Conditions Among Refugees
Because of the conditions that refugees experience during the various stages of migration, there are certain psychiatric conditions that are more prevalent than others. However, among refugee populations there are certain conditions that are encountered in any population seeking psychiatric treatment. These include a range of psychotic, mood, and anxiety disorders. As with any population, refugees are at risk for cognitive disorders such as dementia, but because of exposure to violence and traumatic brain injury, they may be more at risk for cognitive disorders as they age. A combination of biological, psychological, and social factors, in addition to the complex interplay of migration, cultural bereavement, and threats to cultural identity, plays a significant role in rates of mental illness in migrant groups (Bhugra and Becker 2005). Proper use of diagnostic methods is a key step in assessing cross-cultural factors related to epidemiology, etiology of illness, prognosis, and treatment in the context of the sociocultural milieu in which the refugee patient functions and is essential for distinguishing psychopathology from abnormal behavior (Westermeyer 1987). It is also essential that the diagnostic process allow for variations in cultural background, including sensitivity to cultural values, religious beliefs, and social structure, in conceptualizing and treating symptoms and restoring the patient to health (Boehnlein and Kinzie 1997).
Despite the conditions that refugees experience prior to resettlement, there currently is no clear evidence that the prevalence rates of mental disorders among refugees in the initial years of resettlement are significantly higher or lower than those in the host population (Giacco and Priebe 2018), with the exception of psychosis and PTSD (Kirkbride 2017). However, over the long term, among resettled refugees, the rates of depression and anxiety disorders seem to be higher than those in the host populations, while the rates of PTSD continue to be higher than those in the host populations (Bogic et al. 2015).
Torture is a particularly prominent risk factor for the development of PTSD among refugees (Steel et al. 2009), and accumulative exposure to multiple types of torture predicts anxiety and PTSD (Song et al. 2018). It is important to note that refugees cannot be regarded as a homogeneous group, so generalized statements concerning prevalence rates of mental disorders among refugees also need to be interpreted with some caution (Giacco and Priebe 2018; Hollander et al. 2016). As an example of cross-cultural variability in certain types of psychiatric conditions, even though PTSD has substantial cross-cultural validity, there can be substantial variability in the prevalence of specific symptom clusters, particularly avoidance and somatic symptoms (Hinton and Lewis-Fernández 2011).
The level of threat that a community may continue to face after resettlement, and other postmigration stressors, all make major contributions to the prevalence of disorders among refugee populations (Silove et al. 2017). Other postdisplacement factors, such as living in institutional accommodations or having restricted economic opportunities, are associated with worse outcomes (Porter and Haslam 2005). In addition, the length of time after resettlement before mental health services are accessed is an important factor associated with depression and PTSD symptoms, after adjustment for other pre- and postmigration social factors, including torture and psychosocial stress (Song et al. 2015). Another environmental condition affecting the prevalence of disorders among refugees is residing in refugee camps in low-income countries, which is associated with a high prevalence of anxiety and depression that reflects the highly stressful conditions typically encountered in refugee camps (Hynie 2018). This risk factor is related to time elapsed before mental health services are accessed (Song et al. 2018).
Besides the ongoing risks of trauma postresettlement, other factors that have been identified as being associated with poor mental health outcomes among refugees include unemployment, discrimination, and limited acquisition of language skills that are necessary for optimal functioning in the host country (Kim 2016). Conversely, stable and uncrowded housing has been found to predict lower rates of PTSD, depression, and anxiety symptoms after resettlement (Whitsett and Sherman 2017). Ongoing separation from family members in the country of origin has been found to be a significant risk factor for poor refugee mental health postresettlement (Miller et al. 2018). Family separation contributes to ill health because of ongoing fears for the safety of family members still in harm’s way in the country of origin and a feeling of powerlessness to assist those family members. Finally, demographic factors that have been shown to be consistently associated with mental ill health among refugees are gender (women at higher risk), age (elderly at higher risk), and divorced or being widowed (Tinghög et al. 2017).
Comorbidity of conditions is important in any discussion of psychiatric conditions among refugees. PTSD and depression are highly comorbid in refugee populations, and the symptoms of each cumulatively add to distress. In addition, refugees who have been exposed to violence and physical injury, particularly those who have experienced interpersonal trauma such as torture, are also at increased risk for traumatic brain injury. Comorbid traumatic brain injury and PTSD can be additive in impairing postoptimal functioning, and they commonly have overlapping symptoms. Related to risk factors for refugee mental health, as the number of trauma and torture events increases concurrently with increases in traumatic brain injury, the presence of depression and PTSD also increases (Mollica et al. 2014). Refugees with comorbid PTSD and severe depression have been found to not benefit as much from treatment for PTSD when the depression is not adequately addressed (Haagen et al. 2017). Another comorbid condition affecting outcome of depression and PTSD among refugees is chronic pain, which can be the result of injuries suffered premigration and during the migration process. This is particularly important for those who have experienced interpersonal violence and torture. Assessment of other physical health conditions is also important. For example, refugees with comorbid PTSD and depression have been found to have an increased prevalence of physical health problems, such as hypertension and diabetes, compared with those without either of those conditions (Berthold et al. 2014).
Assessment of Refugee Mental Health in the Clinical Setting
It is important that refugees referred for psychiatric assessment and treatment receive a comprehensive assessment rather than one focusing exclusively on recent events and stressors. A comprehensive assessment includes a complete developmental history of the refugee’s childhood experiences and an assessment of developmental milestones and any evidence of childhood illnesses that may affect cognitive and psychological functioning. The examiner rarely has any records from the patient’s country of origin, and frequently there is no collateral information available, but it is still important to gain as much information as possible. It is important to ask about a history of head injury, loss of consciousness, or other types of physical trauma that the person may have experienced as a child or adolescent. In addition, an assessment of the patient’s home environment, including key attachment figures, is very important, particularly because refugees have so frequently suffered numerous disruptions to important attachment figures throughout their lives, including recent separation from loved ones.
From a psychiatric perspective, it is important to connect any significant losses or disruptions of attachment experienced in childhood to psychological and emotional challenges that the patient may be facing in his or her life postmigration. Such connections are also particularly relevant to the relationship between the patient and the clinician. Many refugees have had difficult experiences with authority figures in their native countries, and, in addition, the health screening procedures prior to their resettlement may have been rushed and impersonal. Therefore, it will take time for the individual to develop some trust in the mental health assessment and treatment process because previously painful experiences of loss or disruption of trust in key attachment figures during early development or early adulthood may affect the person’s ability to develop trust. Moreover, expressing one’s painful history and emotions fully may be additionally challenging when there is an interpreter involved in the assessment process.
Besides the presence of an interpreter during the assessment, it is important for the examiner to also be aware of variations in nonverbal behavior that occur cross culturally. The examiner may falsely interpret a flat affect as being a sign of depression or disinterest, when it may actually be a sign of trepidation or hesitation on the part of the patient. Because of shame or stigma, refugee patients also may underplay the severity of their symptoms or the pain associated with their distress, and may project themselves as being healthier than they actually are. There also may be expectations within the person’s culture that discourage the sharing of intense emotions or very personal feelings associated with sadness, depression, or loss. In addition, the person may be hesitant to share frightening experiences and perceptions that may be psychotic in nature, such as hallucinations, because of fear of being labeled as mentally ill. Being aware of cultural idioms of distress is important for the clinician’s ability to respond to patient and family concerns and to reduce the risk of stigmatization (Bäärnhielm et al. 2017; Kinzie et al. 1997). Moreover, ascribing mental health symptoms to culturally acceptable terms can provide individuals with a less stigmatized way of discussing their mental health needs (Im et al. 2017).
The psychiatric assessment of a refugee patient should include all the other important standard elements of a psychiatric assessment, including the history, severity, and time course of the current symptoms. It should also include a past medical and psychiatric history and a family history of medical and psychiatric conditions. The latter is often difficult to assess because of the patient’s frequent lack of knowledge of medical and psychiatric conditions that were experienced in previous generations, particularly if certain conditions have a great deal of stigma attached to them. Because of the comorbidity of several conditions that are frequently found in refugee populations such as PTSD, depression, and traumatic brain injury, it is important to obtain a more detailed history of patterns of insomnia, headache, pain, and other frequently reported physical complaints. Stress may frequently be communicated through physical complaints such as headache, joint, and limb pain. Differential diagnosis of headache, which is a common chief complaint among refugees with PTSD and depression, is quite broad and includes tension, migraine, and posttraumatic headaches. Insomnia is a presenting symptom that can allow for an expanded discussion of important experiences that the refugee patient may have difficulty spontaneously discussing, such as previous traumatic experiences that are replayed in nightmares. Severe insomnia, often associated with recurrent nightmares, adds to the disability that is associated with depression and can contribute to significant difficulties with daytime functioning and the fulfillment of family and social responsibilities. The proper assessment of insomnia and associated nightmares can allow for early specific medication and psychotherapy treatment interventions that can significantly alleviate disabling symptoms in a short period of time, and contribute to increased functioning, enhanced trust in the provider, and optimal adherence with treatment.
The psychosocial segment of the psychiatric assessment should include a history of the patient’s premigration experiences, migratory experiences, and the stressors currently encountered in the host country. This section of the assessment can draw on important elements from the Cultural Formulation Interview Supplementary Module for Refugees (Boehnlein et al. 2015). The interviewer does not have to literally follow each question in the cultural formulation interview; rather, he or she can integrate various elements into a narrative assessment. Some questions that can be helpful include asking patients when and with whom did they leave their home country, how many family members remain, and whether they have particular concerns about family members who remain there. In addition, the examiner can ask the patient about his or her reasons for leaving the home country and ask about losses that he or she experienced before leaving, including the possible deaths of family members or close friends, and the loss of homes and property, livelihood, and education opportunities. At this point further into the interview, when the patient may be more relaxed and trusting, the examiner can ask the patient about possible experiences of violence or other trauma that he or she had experienced in the home country or during the process of migration. The examiner can also ask about the most formidable challenges the patient has faced since arriving in the host country and what types of fears and hopes the patient may have about his or her current and future life, including stability of income, housing, and employment, and prospects for education. Additionally, it is important to ask about the current family constellation and about challenges experienced within the family cross-generationally and with possible new roles for various members of the family.
Additional questions are important in a comprehensive assessment. How might cultural issues be impeding or enhancing the individual and the family’s acculturation and settlement in their new country? What are their sources of support such as other extended family, church, or friends? What are sources of meaning and hope? What strengths and talents does the person have? Finally, what is the individual’s expectations for treatment, and what difficulties or symptoms are he or she most interested in reducing during treatment? The clinician can then proceed to a differential diagnosis and formulation of the patient’s difficulties that includes a comprehensive view of biological, psychological, and social and cultural factors that have an impact on the patient’s symptom presentation, emotional suffering, and current functioning.
General Issues in the Treatment of Refugee Patients
Because of the heterogeneity of refugee populations, effective treatment requires attention to broad demographic differences and a wide range of disorders for which refugees seek care. There are barriers to access, such as language, long travel distances for care, lack of knowledge about treatment options, and lack of familiarity with the American health care system (Sijbrandij 2018). Other barriers to access include economic factors, health literacy, and various cultural factors that affect the understanding of treatment options and the perception of mental illness within refugee communities (Mangrio and Sjögren Forss 2017).
Differences in expectations between refugee communities and the American health care system involving the causes and meaning of symptoms and illness can be just as important as other barriers to care. Understanding how the mind and body function; what role various cultural healing traditions, religious systems, and social structures may be playing; how one communicates distress; and how the patient views the causes of his or her distress are key factors in designing affective treatment and optimizing adherence (Hinton and Lewis-Fernández 2011). Errors in diagnosis, of course, can have a significant impact on the choice of effective treatments. For example, in treating psychosis cross-culturally, errors can occur in clinical misunderstanding of symptoms that appear to be psychotic, such as interpreting a cultural belief as a delusion or a trance state as a hallucination. Also, the presence of multiple diagnoses, such as the coexistence of PTSD and depression commonly found in refugee populations, may require a variety of long-term interventions to address the pervasive effects of illness on the refugee’s distress, social functioning, and quality of life (Nickerson et al. 2017). The effectiveness of mental health interventions during refugee resettlement depends on not only how well those interventions alleviate symptoms of psychosis, depression, or PTSD, but also how well those interventions relate directly to educational, socioeconomic, and sociopolitical stressors that resettled refugees encounter (Murray et al. 2010). The importance of these contextual factors—and in particular exposure to significant postmigration stress—can further reinforce PTSD and depression among refugees.
Strengthening of social networks and supports, and the strengthening of other postmigration contextual factors such as employment, can provide protective effects (Beiser and Hou 2017; Paat and Green 2017). Because of the complex trauma experienced by many refugees, it is important for the treatment setting to create a trusting environment that is sensitive to difficulties that patients may have with attachment and trust (Morina et al. 2016; Riber 2017). Overall, treatment of refugees in mental health settings could be enhanced by the ADAPT model, which postulates that stable societies are built on five core psychosocial pillars disrupted by mass conflict: safety/security, bonds/networks, identity/roles, justice, and existential meaning (Silove 2013).
Most treatment studies among refugee populations have demonstrated significant improvement on at least one outcome indicator after treatment interventions. But there have been very few randomized controlled trials that have examined the efficacy of applied treatments, and they have included only small samples. This paucity of large outcome studies and randomized controlled trials among refugees is likely due to a number of factors, such as the heterogeneity of refugee populations, the difficulties of using validated treatments across cultures, the mobility of the refugee populations, and ethical issues in effectively studying traumatized populations, and applies to studies that examine psychopharmacological as well as psychotherapeutic interventions for refugees. Because there is very limited evidence available from controlled trials on the effectiveness of psychopharmacological agents in refugee populations with PTSD, clinicians depend on a combination of clinical experience and research results from trials in nonrefugee populations (Sonne et al. 2017). From the standpoint of psychotherapy, taken together, studies support the use of some form of trauma-focused cognitive-behavioral therapy (CBT) among refugees that incorporate cultural knowledge into standard CBT methods (Slobodin and de Jong 2015).
There continues to be controversy over what constitutes effective culturally adapted psychotherapy for refugee populations. For example, narrative exposure therapy, a manualized variant of CBT with a trauma focus, has been shown in meta-analyses to be the best supported intervention (Nosè et al. 2017), but the evidence is based on studies of mostly low methodological quality and small to medium effect sizes (Giacco and Priebe 2018). Culturally adapted CBT has been found to be a significantly effective treatment for PTSD and panic attacks among Vietnamese refugees (Hinton et al. 2004) and for PTSD and associated symptoms in Cambodian refugees (Otto et al. 2003). In the latter study the effectiveness of CBT was felt to be particularly effective in addressing catastrophic misinterpretations of culturally relevant symptoms.
The psychotherapeutic relationship can offer cognitive and emotional generosity to refugee patients to titrate their anxiety and to help them find coherence and trust (Kirmayer 2003). From the very beginning of treatment, it is important for clinicians to focus on relieving symptoms that will improve practical individual and interpersonal functioning. As stated earlier, these symptoms may extend to a number of diagnostic categories, such as depression, PTSD, other anxiety disorders, and psychosis. Many of the symptoms that patients initially describe that cause significant suffering and interpersonal dysfunction can also provide a window into other intense struggles that these patients may be having. As mentioned, insomnia may not only be distressing but have significant effects on daytime functioning, along with a sense of security and confidence in work and interpersonal relationships. Nightmares can provide a window into psychological struggles that the patient may be having, and this marker can be a potential marker for success of treatment. The intensity and frequency of nightmares can be reduced by prazosin or clonidine (Boehnlein and Kinzie 2007). The discussion between the survivor and the clinician of nightmare content and the accompanying emotional reactions humanizes the therapeutic encounter. And, the discussion of pain, loss, heartache, and struggle allows for a longitudinal consideration of issues vital to recovery that otherwise might be avoided by the clinician and survivor.
Education of the patient and family is vitally important, particularly in terms of being able to discuss common posttraumatic symptoms in order to reduce personal and social stigma. Reducing hyperarousal symptoms such as nightmares with effective medication can allow the person to more readily engage interpersonally and socially and also benefit more fully from psychotherapy and social intervention. Helping the survivor to process and integrate current and past trauma and interpersonal challenges can increase self-confidence and allow the person to more fully concentrate on a brighter and more promising future, further increasing the sense of well-being.
Besides various symptoms that refugees experience individually, families collectively confront numerous stressful challenges in resettlement that may alter the traditional structure of the family and may provide further challenges for acculturation. For example, after migration, older refugees may have to live with diminished status both within families and in society at large because of a lack of language proficiency, little or no formal education, and no work skills for urban developed countries. As children gain greater proficiency with the host country language, there can be a reversal of traditional generational roles as the children become facilitators of communication and culture brokers between the family and the majority of society. Even normal life-cycle separations for family members can present additional challenges for refugee families. For example, because of the extensive loss of life that many families have experienced, they may be more adversely affected by culturally expected separations in Western society, such as a child’s leaving the house for college or moving to another part of the country after marriage for greater employment opportunities.
Chronic depression and PTSD can adversely affect the stability and nurturance of family relationships. Family therapy with refugee families can help restore cultural identity that was lost or weakened during the years of trauma and migration, and also reduce the pressures of acculturation. This latter task may include helping each generation to understand and accept one another’s beliefs and roles as the family evolves through the life cycle in the new society. In addition, treatment can incorporate the strengths that allowed all members to survive individually and as a unit (Boehnlein et al. 1997). Adequately addressing trust in self, others, and the world that has been disrupted by trauma and forced migration is an essential core of treatment for refugees of all generations (Ter Heide et al. 2017). Such trust building is ideally done not just through traditional culturally sensitive mental health services, but through an array of services that include social and community interventions and special programs for vulnerable refugee groups (Silove et al. 2017). A phased approach can be especially helpful, beginning with first establishing emotional and social safety and security, followed by psychosocial interventions such as enhancing skills that optimize education and employment opportunities (Rousseau 2017). For refugee children, this would include optimizing family and parenting support, along with school-based interventions (Fazel 2018).
Case Example
In this chapter I have explored general aspects of refugee mental health assessment and treatment; details of various treatment approaches are discussed in more detail in the chapters that follow. The following case provides a clinical context for several issues discussed in this introductory chapter, and subsequent chapters, that are central to refugee mental health.
A 42-year-old widowed Guatemalan woman was referred to the clinic by her immigration attorney. Several months before her initial clinic evaluation, an extended family member was killed in Guatemala and her family there was threatened by people connected to the government during the civil war. The patient stated in the initial evaluation that she thinks about the past every day and is worried about the future. She was chronically anxious, and for years she had not been able to trust other people. Since arrival in the United States she also had felt anxious and angry when she saw military or police uniforms, thinking to herself that they were murderers just like the Guatemalan military who had killed her husband. She was sleeping only 2–3 hours at night and had chronic and recurrent nightmares that were also regularly associated with daytime intrusive trauma memories. Her nightmares centered around her husband’s murder, the exact reenactment of another murder that she witnessed in her neighborhood in Guatemala, and her sexual assault while crossing the Mexico–United States border. She also reported startle reactions and frequent headaches associated with intrusive memories and worry, and she experienced isolation, sadness, and irritability. She avoided all violence in the media and any interpersonal situations in which people were raising their voices or confronting each other.
The patient grew up in northern Guatemala in the Mayan area of the country. Her parents were farmers, and she had three brothers and two sisters. There was no violence or abuse within the family. When she was growing up, her family was frequently moving because of hostilities in their area of the country. They were constantly caught between the military and guerrillas and were frequently accused by the military of aiding the guerrillas. Food products were often withheld from the family or intercepted by the military, so there was a great deal of deprivation.
During the initial few months of treatment with an antidepressant and prazosin, her sleep improved and the frequency of her nightmares decreased to a couple of nights per week. After 4 months, her sleep returned to normal and her mood gradually improved. Six months after treatment began she was granted asylum and her nightmares decreased to a frequency of twice per month. However, during the damp winter months her nightmares temporarily increased in frequency every year, and she herself noted that it was likely related to seasonal reminders of the dampness in her native area of Guatemala, and to traumatic war memories, including the winter murder of her husband. The etiology and seasonal context of these nightmares were discussed in follow-up treatment sessions. During several years of treatment she functioned very well during most of the year, and her yearly anniversary reaction gradually decreased in intensity and duration during the course of treatment.
KEY CLINICAL POINTS
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The following are some important issues for clinicians to keep in mind when they are working with refugee patients and families:
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Validate and normalize difficulties in transition and resettlement.
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Be aware of the impact of loss and the fragility of relationships both in the host country and country of origin, particularly in patients with depression and PTSD.
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Be aware of dynamics and interactive patterns of family, cultural, and religious values/beliefs.
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Assess the degree of family cohesion, social and gender role transitions, extended family and social support networks, and strengths.
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Determine the degree of acculturation of each family member—don’t assume the degree of acculturation on the basis of age, gender, or level of education.
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Be aware of one’s own biases, blind spots, and strengths as a person and clinician.
References
Administration for Children and Families: Refugee Act of 1980. Office of Refugee Resettlement. 2012. Available at: https://www.acf.hhs.gov/orr/resource/the-refugee-act. Accessed October 7, 2019.
Administration for Children and Families: Training and technical assistance providers. 2019. Office of Refugee Resettlement. Available at: https://www.acf.hhs.gov/orr/resource/technical-assistance-providers-1. Accessed October 7, 2019.
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The Psychiatric Evaluation and Treatment of Refugees
Pages: 1 - 20
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Published in print: 28 April 2020
Published online: 5 December 2024
© American Psychiatric Association Publishing
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