Introduction to Refugee Mental Health

  • 122.26 million people are forcibly displaced from their homes due to war & persecution

  • 72.1M internally displaced persons (IDP)

  • 43.7 M refugees

  • 8 M asylum seekers

What is a Refugee

  • flee their country of origin due to well-founded fear of persecution for reasons of

    • race

    • religion

    • nationality

    • political opinion

    • social group

  • persecution must be at the hands of the govt or a third party that the government is unable or unwilling to control

What is an Asylum Seeker

  • flee their country of origin due to well-founded fear of persecution for reasons of race, religion, nationality, political opinion, social group

  • request protection after arriving to the US

  • when their asylum claim is approved → asylees

Public Benefits

  • refugees are eligible for employment & public benefits on Day 1

  • asylum seekers are eligible for employment after 180 days but do not qualify for public benefits

  • some asylum seekers that are “parolees” can qualify for the same benefits as refugees

  • asylees became eligible for public benefits

Post Migration Stressors

  • socio-economic - finances, housing security, and stable employment

  • social & interpersonal - family separation, social isolation or exclusion, discrimination, loss of social identity, & change in social roles

  • asylum process & immigration policy - more restrictive policies, detention, extended processing time, insecure visa status, complex legal procedures, and temporary versus permanent protections

Overview

  • refugees & asylum seekers have 15x higher rate of PTSD and a 14x higher rate of depression than the general population

  • exposure to torture and other potentially traumatic events (PTEs) is the greatest risk factor for development of PTSD and Depression

  • post-migration stressors are associated with worse mental health outcomes

The Asylum Process

  • uncertainty during the asylum process may contribute to feelings of resignation and fatalism that impair health seeking behaviors

  • lots and lots of waiting, never know when you will get called

Additional Mental Health Concerns

  • identity-based discrimination

  • acculturation difficulties

  • somatization/physical health problems

  • substance use

  • grief and loss

    • loss of life

    • loss of way of life

    • loss of significance

Processing of Unaccompanied Children

  • Unaccompanied Child (UC)

    • under the age of 18

    • without lawful status

    • without accompanying parent or legal adult

  • Unaccompanied Refugee Minor (URM)

    • identified by the state department as URM

    • eligible for resettlement in the US but do not have a parent or adult sponsor

Youth Mental Health Concerns

  • Pre-Migration/Migration

    • Anxiety, depression, and/or post-traumatic stress symptoms experienced

    • Those that migrate without a family member present (such as UCs) are at a higher risk for mental health challenges following the loss of contact with family members during the journey. (Mcleod, 2016)

  • Post- Migration

    • UCs face increased discrimination due to their immigration status, ethnicity, language, and/or appearance (Mcleod, 2016)

    • Challenges with family reunification

    • UCs’ undocumented status can make them further vulnerable to exploitation and abuse post-migration as they fear reaching out for help when needed (Diaz-Strong, 2020)

    • Educational struggles due in part to educational gaps and/or the quality of education received in their home country (Hallson III et al., 2019)

    • Symptoms of distress can impede developing a social network

Clinical Considerations

  • Emphasize safety, trustworthiness, and predictability

  • Support somatic awareness

  • Prioritize grounding and emotional regulation to help clients connect with the present moment

  • De-emphasize trauma processing early on

  • Focus on stabilization and survival in the here and now

  • Instill hope

    • Connect to case management and community-based support

  • Appropriate use of interpretation

Different Ways Trauma can Present

  • Somatic complaints

  • Withdrawal

  • Potential minimization of symptoms

    • Avoidance

    • Shame and fear of being a burden

    • Reflect a genuine improvement in symptoms but masking severity of distress

Additional Cultural Considerations

  • effective integration of interpreters in sessions

  • understand diverse expressions of distress - symptoms may be communicated through physical complaints, silence, or spiritual frameworks

  • avoid pathologizing culturally rooted beliefs (e.g., spirits, dreams, ancestral communication)

Clinical Approaches w Refugee Adults

  • include but not limited to

    • narrative exposure therapy (NET)

    • EMDR

    • TF-CBT

What is a Forensic Evaluation?

  • objective, independent evaluation documenting

    • harm that someone has experienced

    • the impact of that harm

    • coping skills, protective factors, and aspirations

    • treatment recommendations & prognosis

    • factors that may impact legal testimony or engagement with legal process