July/August 2016 Issue

Treating Trauma in America's Refugees
By Kate Jackson
Social Work Today
Vol. 16 No. 4 P. 10

Today's refugees have faced horrifying brutality in the countries they've fled. Social workers are developing culturally sensitive tools to address the experiences these strong but struggling individuals have endured and continue to endure as they resettle in a new land.

Refugees land in America each day, arriving in waves from countries such as Somalia, the Democratic Republic of Congo, Myanmar, Iraq, and Bhutan. In the coming year, many more will reach American soil, some having fled the Near East and South Asia, and thousands having departed Syria. They will have left their homelands and may have torn themselves away from loved ones to escape murder, genocide, kidnapping, rape, torture, enslavement, forced labor, political and social instability, restrictions by repressive regimes, and persecution due to their religion or ethnicity.

In many cases, more than once they will have been victims of brutality and unspeakable horror, having been traumatized preflight, in transit, and during the resettlement process. While many refugees nevertheless will demonstrate remarkable resilience and adapt extraordinarily well to their new lives, others will struggle in the aftermath of resettlement, facing numerous practical challenges and battling psychological repercussions.

Today, refugees, particularly those from the Middle East, increasingly are the subjects of headlines, political campaign platforms, and sensationalized segments on talk radio, cable television, and the nightly news. The conversations sometimes focus on the need for humanitarian aid but more often pillory refugees as a scourge on the nation. The loudest, most vitriolic voices trumpet an unwelcoming message that foments fear and wariness. "The tenor of the conversation in the United States now is incredibly distressing and has negative impacts on refugees' mental health," says Beth Farmer, LICSW, who directs a trauma and torture treatment center at Lutheran Community Services Northwest that works with refugees and asylum seekers in the Pacific Northwest. Although as an American, Farmer says, she may not believe that refugees are at risk of deportation, she sees and understands their trepidation. "For people who have been expelled from their homes and have already lost one country, there's tremendous fear," alongside which, she says, is "a sense of deep injustice," both eroding refugees' perceptions of safety and permanence.

More sober voices, heard by fewer Americans, are trying to correct the narrative and quell the fear. These voices, among them dedicated social workers, speak to the need for the understanding and compassionate care that leads to healing.

The Refugee Experience
By virtue of meeting the humanitarian criteria that give them refugee status, these immigrants can't return to their countries without facing grave harm, and all have experienced violence and persecution, Farmer says. "They've all experienced the loss of their country, roles, jobs, home; their social fabric has been ripped; and they're having to build a new life in the United States," she adds. "That sense of migration stress on top of loss is universal for all refugees."

This abruption takes a heavy toll, no matter the starting point or circumstances of a refugee's emigration. "In many ways there are more commonalities than differences among the challenges refugees face, since all who qualify for refugee status have experienced or are at risk for persecution," says Hilary Weaver, MSW, DSW, a professor and associate dean for academic affairs at the University of Buffalo School of Social Work. Weaver, who's also codirector of the school's Immigrant and Refugee Research Institute, says that the commonalities among all refugee populations emerging from that risk are trauma, mental health challenges, and resilience.

"All refugees by definition have been victimized by human rights violations," says Miriam Potocky, MSW, PhD, a professor in the School of Social Work at Florida International University in Miami. "Whether those have involved the multitude of horrors of war, torture, political imprisonment, or violence or discrimination based on religion, ethnicity, political belief, or membership in a particular social group, the ultimate challenge is finding new meaning in life in the face of humanity's evil. Apart from this existential challenge are the practical tasks of economic survival; learning new skills; adjusting to a different environment including new customs, new foods, and new language; and potentially facing discrimination based on one's skin color, religion, clothing, or accent," says Potocky, an internationally recognized expert on refugee resettlement and author of Best Practices for Social Work With Refugees and Immigrants, currently under revision for a second edition.

According to Weaver, "In addition to experiencing trauma that led them to becoming refugees, many are displaced for significant periods of time before being resettled. They may live in refugee camps for years and experience additional trauma in transit. While some communities such as Buffalo, NY, have developed a strong infrastructure for resettling refugees and generally provide a welcoming context for rebuilding lives, many other communities have expressed significant xenophobia, racism, and religious intolerance." She points, for example, to pending legislation to impede resettlement or to track and fingerprint refugees as if they'd committed crimes. "Experiencing hostility once in the United States is a major issue of concern that has significant psychological consequences for people who have already experienced significant trauma."

Once they arrive here, during the resettlement process, Farmer says, refugees have on average just 90 days of case management and must get a job quickly to survive. They also need to learn the language and customs and figure out logistical issues such as transportation. On top of everything else, she says, they're almost always poor. "It's a difficult combination—that toxic stress of poverty and adjustment coupled with what's happened in the past."

According to Potocky, "Hundreds of studies of refugees from all over the world across many decades now have repeatedly found that posttraumatic disorder, depression, anxiety, panic attacks, adjustment disorder, and somatization are prevalent among these populations." Farmer also points to a large body of literature demonstrating that diagnosable mental health conditions are more prevalent among refugees than among the mainstream population. These aren't persistent severe illnesses, she says, but rather issues such PTSD, depression, and adjustment disorder. "Given that these diagnoses are often caused by exogenous forces such as stress, loss, and trauma, that makes sense."

The Obstacles to Care
With limited resources to help refugees, attention focuses on the practical aspects of resettlement while mental health issues may go unrecognized and unaddressed. "Regrettably, mental health assessment is inadequate," says Potocky, adding, "U.S. refugee resettlement policy prioritizes early employment above all other client needs; while there is recognition that client services should be holistic and client-centered, the reality is that resettlement agencies are ultimately accountable for how many clients they place into jobs; thus, mental health concerns will naturally take a back seat."

And despite the existence of some good assessment tools and increased screening, Weaver says, "We have a bigger problem once assessments are done with limited services and trauma-informed care."

Weaver says that there are good models, research, and awareness-building efforts, pointing, for example, to the June 2016 North American Refugee Health Conference, the third WNY Refugee Health Summit in Buffalo, or the symposium her school recently held to inform students and the community about the needs of refugees. "In the community, there's good grassroots work being done, but there are so many basic overwhelming needs that service providers are overwhelmed just doing the basics. More long-term trauma treatment is a luxury that rarely happens." Social workers, she adds, "have their hands full responding to xenophobia." Case in point, she notes, is pending legislation in New York that pushes service delivery in the background while emphasizing gatekeeping and "policing-type activities." The hostile climate, Weaver says, "is a major setback to the good programs and services were are working to provide."

On top of these obstacles, Potocky says, "There are cultural, linguistic, financial, and logistic barriers. Culturally, many people from around the globe do not share the same worldview of mental health that Western mental health professionals hold. For example, while a social worker may view a mental health problem as a brain disorder, a refugee client may view it as a spiritual curse. Thus, it's possible for a worker and client to experience a misunderstanding or lack of communication about this issue. Further, stigma or fear of authority may prevent a refugee from speaking to a social worker about mental health concerns. Linguistically, there's certainly a shortage of bilingual or multilingual mental health professionals as well as trained interpreters. Financially and logistically, social workers or other service providers may not be reimbursed or provided the necessary time to provide mental health screening," Potocky says.

Innovative Approaches
Despite the challenges and limitations, social workers are striving to hurdle obstacles to mental health screening and assessment and to develop resources and programs to address what Farmer calls a "lack of good, cross-cultural, linguistically accessible care."

Screening and Assessment
Resettlement, Weaver explains, "is concerned with basic needs such as housing, jobs, and language, so there isn't much in terms of assessing for trauma associated with those services. Beyond resettlement, however, there are some good assessment tools and a move toward more screening."

For example, Potocky says, "A new instrument was developed three years ago, the Refugee Health Screener-15 (RHS-15) (http://refugeehealthta.org/wp-content/uploads/2012/09/RHS15_Packet_PathwaysToWellness-1.pdf), which is a brief, valid tool for screening for depression, anxiety, and PTSD."

Developed by Michael Hollifield, MD, RHS-15 is a brainchild of Pathways to Wellness: Integrating Refugee Health and Well-Being, project of Lutheran Community Services NW, Asian Counseling and Referral Service, Public Health Seattle & King County, and Hollifield of the Pacific Institute for Research and Evaluation. Farmer and her colleagues at Lutheran Community Services Northwest and Asian Counseling and Referral Service came up with the idea for RHS-15. Both agencies had mental health programs to which refugees were coming after they'd lost benefits. They knew they needed a quick and easy-to-use tool that was effective across cultures and could be integrated with primary care. According to Farmer, the tool is embedded with the mandatory health screening for refugees in King County, Washington, so people receive early screening and referral. Across the country, more than 150 sites are using or developing the resources to use the free tool. She's quick to point out that RHS-15 can't stand alone, but is only a conduit to resources. "It allows us to look at resettlement and refugees from a more holistic standpoint than just physical health and self-sufficiency."

Another unique tool was created by Elaine P. Congress, DSW, LCSW, an associate dean and professor at Fordham University Graduate School of Social Service and coauthor of Social Work With Immigrants and Refugees: Legal issues, Clinical Skills, and Advocacy, 2nd edition. Her Culturagram is a family assessment tool social workers can use when working with individuals from other cultures to overcome the problem of overgeneralizing and stigmatizing. The idea for the tool was born when Congress worked in a mental health clinic early in her career. "In the morning I would see a Mexican family that had been here a few weeks, was undocumented, and had no money. Then in the afternoon I'd see a Puerto Rican family that had lived here for many years, the members working or in school," she recalls. "You call both families Hispanic and Latin, and although they're very different, we lump them together." The available tools at the time didn't look at the role of culture, which Congress felt was crucial in understanding a person and a family.

Her Culturagram is a pictographic representation of a family surrounded by 10 areas of assessment social workers can explore to gather information about the unique cultural views of the individuals and the family, including aspects such as health beliefs; feelings about oppression, discrimination, bias, and racism; and values about family structure, power, myths, and rules. By exploring these aspects, social workers can better assess the family members, identify needs, and plan interventions.

Treatment
Healing for mental health issues begins when individuals are able to tell their stories and reveal their needs. "One major way to overcome some of the obstacles is to take our time with clients to build trust," Potocky says. She acknowledges that lack of time is itself a barrier, but one way to break down that barrier is to make the most of all opportunities to allow refugees to express themselves. "One thing I have learned from resettlement case managers is that a lot of really meaningful conversations occur while driving clients to and from appointments and while sitting in waiting rooms. These are 'down' times that we can capitalize upon." Among the ways to profitably use that time, she says, "is by expressing empathy through reflective listening."

Potocky, among a number of social workers who employ motivational interviewing in practice, is researching its particular usefulness for refugee clients. This innovative approach is the foundation of a study she's conducting with colleague Kristen Guskovict, MS, MSW, Project MIRACLE: Motivational Interviewing for Refugee Adaptation, Coping, and Life Empowerment. "We've found that social workers and other trained helping professionals respond more empathetically to hypothetical refugee statements than do other service providers. And previous research strongly supports that empathy leads to better client engagement, which leads to better mental health outcomes."

Potocky points to other innovative care delivery approaches that are making a difference in the lives of refugees. One of her doctoral students, Mitra Ahmadinejad, for example, performed a systematic literature review on PTSD treatments published during the past five years. "She found that one of the most promising practices was imagery rescripting, in which the trauma survivor imagines the traumatic event and then imagines an intervention that changes the course of events so that a more favorable outcome is achieved." Another promising tool Ahmadinejad identified was narrative exposure therapy, one of a number of narrative therapies through which refugees tell their stories to defuse the emotional repercussions. With narrative exposure therapy, Potocky says, "The survivors narrate their life stories with a focus on the traumatic events, which the therapists then document and sign in a ritualized manner and give to the clients as a therapeutic tool."

There's no shortage of innovative approaches to health care delivery, says Farmer, who adds that there are "many people on whose shoulders we stand." She points, for example, to the World Health Organization's Mental Health Gap Action Programme; the community-based interventions of the Center for Victims of Torture, headquartered in St. Paul, MN; and the H5 model, developed by Richard Mollica, MD, MAR, a professor of psychiatry at Harvard Medical School and director of the Harvard Program in Refugee Trauma at Massachusetts General Hospital.

Social Workers Making a Difference
Social workers, Potocky says, "can best assess refugees' life experiences by using the skills that we're so well trained in: taking the time to build trust, using reflective listening skills; asking open-ended questions; respecting the client's self-determination to share or not share; using judicious self-disclosure to find common ground; and acknowledging the horrific nature of the clients' experiences without reacting either with shock or painting a rosy picture, but rather being present with the clients in their reality."

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.