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