Contemporary Refugees: Issues,Challenges,and a Culturally Responsive Intervention Model for Effective Practice ψ

Premigration Experiences

Critical to effective culturally responsive clinical interventions with refugees is the need to be aware, acknowledge, and understand premigration experiences and its impact on adjustment during resettlement (Bemak & Chung, 2017b; Chung & Kagawa-Singer, 1993). Fleeing from danger may expose refugees to atrocities, such as, rape, killing, and other inhumane acts, that may result in unresolved psychological challenges during resettlement (Atari-Khan et al., 2021; Bemak & Chung, 2017a; Jorgenson & Nilsson, 2021; Maung et al., 2021). As Nilsson and Jorgenson (2021) explain, refugees are at higher risk for developing serious mental health problems (American Psychological Association [APA], 2010; Bemak & Chung, 2016; Kinzie, 2005). Refugees experience greater degrees of generalized anxiety, posttraumatic stress disorder (PTSD), psychosis, depression, dissociation, and higher rates of psychopathology as compared to the general population (APA, 2010; Hollander et al., 2016; Vickers, 2005). Subgroups of refugees are at even greater risks for mental health problems. These groups include unaccompanied children (Brannan et al., 2016; Unterhitzenberger & Rosner, 2016); the elderly (Strong et al., 2015); single young men under 21 years of age (Bemak & Chung, 2016); women and girls who witnessed or experienced sexual assault and rape; and women whose husbands were killed (Chung & Bemak, 2002a; Morash et al., 2007; Shakil, 2016).

Postmigration Transition and Resettlement

Following the premigration period there is an adjustment to a new life. Nilsson and Jorgenson (2021) describe the importance of overcoming barriers such as language, unemployment, and discrimination. In addition, Atari-Khan et al.’s (2021) study of Syrian refugees finds that concerns about loved ones and the loss of social supports, relationships, and cultural identity contributes to postmigration stressors. Similarly, Maung et al.’s (2021) findings on Burmese refugees and Jorgenson and Nilsson’s (2021) Somali refugee study note additional postmigration stressors of economic disadvantages, marginalization, and shifting gender roles. These postmigration challenges in building a new life and gaining familiarity, security, and safety in a new culture are significant, especially after fleeing from dangerous life threatening situations.

Issues of adjustment and adaptation were noted in all three studies and the introductory article of this Major Contribution, particularly highlighting cultural competency and Berry’s (2003) model in the article on Somali refugees. Closely correlated to culturally competent postmigration challenges and psychological well-being are the phases of the acculturation process (assimilation, integration/biculturalism, rejection, deculturation) outlined by Berry (2003). Berry notes that integration/biculturalism constitute the healthiest period of acculturation that combines adjustment to a new country while concurrently integrating traditional beliefs and values. We highlight several other factors that further add to the complexity of acculturation and adjustment including: the absence of extended family and community to assist with the support and healing and subsequent changes in family dynamics (Bemak & Chung, 2016); racism and xenophobia that is being popularized in some host countries (Bemak & Chung, 2021); survivor’s guilt that is underscored by access to technology that allows regular communication with friends and family in their home country (Bemak & Chung, 2017a); and unresolved premigration trauma as well as PTSD and depression (LeMaster et al., 2018).

Politics and the Culture of Fear: Racism and Xenophobia

Similar to the findings in the Somali study (Jorgenson & Nilsson, 2021) we believe that an important added factor in refugee mental health is the current political climate that has fostered hatred, fear, racism, discrimination, and xenophobia. It is our belief that modern day politics has created a culture of fear of refugees (Chung et al., 2008) and thus negative experiences for refugees. This was seen in the Somali (Jorgenson & Nilsson, 2021) study where the longer Somali refugees remained in the United States the less they felt American. These results may be tied to such events as U.S. President Donald J. Trump signing an Executive Order travel ban in January 2017 banning refugees from seven Muslim countries including Syria, with the exception of Syrian religious minorities (Christians; De Luce & Ainsley, 2018). The President explained, “To be clear, this is not a Muslim ban. . . . this is not about religion—this is about terror and keeping our country safe” (British Broadcasting Corporation, 2017). Politicians such as the U.S. Secretary of Housing and Urban Development, Ben Carson, instigate fear about job security, terrorism, and threats to personal safety with comments such as “[terrorists] sneak into the country as refugees” (Scott, 2015). Compounding the issue, the media’s promotion of refugee xenophobia reinforces political ideas that refugees will not only perpetrate violence and terrorism, but will also take away limited resources, opportunities, and jobs (Bemak & Chung, 2017a). Politics and the instigation of a culture of fear and xenophobia intensify further intolerance, racism, and xenophobia towards refugees (Bemak & Chung, 2017a, 2017b; Chung et al., 2008). Consequently, the U.N. Secretary-General Ban Ki-moon commented that, “Xenophobic and racist responses to refugees and migrants seem to be reaching new levels of stridency, frequency, and public acceptance” (Wulfhorst, 2016). However, what is not commonly known is that these xenophobic messages and amplifications of a culture of fear are in direct contradiction to the projections by the U.S. Department of Health and Human Services that refugees will contribute $63 billion more in government revenue than what it will cost to resettle them (Tharoor, 2018).

Political Countertransference

The perpetuation of the culture of fear along with xenophobic and discriminatory views of refugees creates new issues that may inhibit effective clinical practice. One issue that we have identified to be a significant addition to issues refugees face during postmigration is what we have termed political countertransference (Chung et al., 2008). The bombardment of myths and stereotypes through social media and political rhetoric that refugees take jobs, cost inordinate amounts of money that could be utilized elsewhere, and are involved in crime, may have a tremendous impact on mental health professionals. Given the political intensity and exposure of these messages, it is critical that mental health professionals are aware of the effect of this barrage of propaganda on the therapeutic process (Chung et al., 2008). We believe there is danger in internalizing these antirefugee messages of safety concerns and fear, leading to political countertransference that may affect clinical work (Bemak & Chung, 2017a; Chung et al., 2008).

Modern-Day Techfugees

The Atari-Khan et al. (2021) study found that Syrian refugees experienced significant distress worrying about loved ones back home, and Maung et al.’s (2021) study on Burmese refugees highlighted the importance of social support networks. Our experience supports these findings. Subsequently, we would add another key aspect to postmigration stressors that underscore and focus on the dependence and use of technology to connect with loved ones and social support networks. Today’s refugees have been labeled “techfugees” based on their heavy reliance on technology, such as the high utilization of the internet, social media venues, and smart technological devices throughout their displacement, escape, and migration (Bemak & Chung, 2017b; Graham, 2015; Murphy et al., 2016). Given substantial use and dependence on technology during all phases of their refugee experience, we believe it is important to provide more details about techfugees so that mental health professionals are aware of the relationship between technology and refugee mental health. Techfugees utilize google apps to navigate their dangerous escape to host countries, alert others to dangers during their precarious journey, maintain ongoing contact with loved ones still living in their homelands, keep minute-to-minute communication with others escaping perilous situations, and share updates with other refugees regarding postmigration challenges (Bemak & Chung, 2017b). Demonstrating the high usage of technology, Ram (2015) found that 85% of Syrian youth housed in refugee camps used smartphones. As a result of refugees’ reliance on technology, major international organizations also use technology as a means of communication. For instance, the Red Cross helps refugees upload photos to find missing people and the UNHCR circulates information on how to open a bank account, access resources, and register with local authorities, through text and short messaging services (Bemak & Chung, 2017b). Despite the availability and use of technology, techfugees and refugees who do not have access to technology encounter similar pre- and postmigration challenges. The following section briefly discusses these issues.

Phase I: Mental Health Education

Generally, refugees have not been exposed to Western mental health practices. Given the paucity of information regarding psychological interventions, coupled with the stigma and negative stereotypes surrounding mental illness, Phase I: Mental Health Education is an important first step in establishing the therapeutic relationship in a culturally responsive manner. During Phase I, therapists explain how the therapeutic relationship works, describing what to expect, what happens, what kinds of questions and feedback will be offered, and what the roles of the client and the therapists are during therapy. We have found this to be an important starting point when working with refugees, who oftentimes experience traumatic events, harbor concerns about safety, and are distrustful of officials and sharing personal information or details (Majumder et al., 2015; Ní Raghallaigh, 2014). It is during Phase I that the therapist shares issues such as time boundaries, confidentiality, the role of the bilingual interpreter, and expectations, helping to establish clear norms and understanding of the therapeutic encounter. Sharing this information provides clarity for refugee clients and assists in creating a foundation of trust and empathy (Bemak & Chung, 2016; Chung & Bemak, 2002b; Kruse et al., 2009). Simultaneously, Phase I can help inform therapists about cultural constructs and refugees’ perspectives on expectations for treatment, help-seeking behavior, symptom expression, and their conceptualization of problems, as well as answer any questions and dispel myths and stereotypes that refugee clients may have about the therapeutic process (Chung & Kagawa-Singer, 1995; Chung & Lin, 1994). If refugee clients have any additional questions that need clarification about the therapeutic process, Phase I may be revisited throughout the other four phases as needed.

Phase II: Individual, Group, and/or Family Psychotherapy

Phase II: Individual, Group, and/or Family Psychotherapy utilizes culturally responsive individual, group, and family therapy interventions. The MPM focus on group and family interventions is underscored by Maung et al.’s (2021) findings with Burmese refugees, where interpersonal relationships were a major theme as refugees shared money, information, encouragement, and food. Similarly, in the Atari-Khan et al. (2021) study on Syrian refugees, community and family support played a major role in developing resilience. As mentioned in Phase I, given social and cultural stigmas and premigration trauma, refugees may be reluctant to disclose painful experiences and deeply personal thoughts and feelings. As evident in the articles on Burmese, Somali, and Syrian refugees, many refugees traditionally relied on families, elders, religious, spiritual, and community leaders for healing, in contrast to Western psychotherapy that stresses independence, autonomy, and self-reliance (Bemak & Chung, 2016, 2021; Hong & Domokos-Cheng Ham, 2001). Maung et al. (2021) pointed out deficits in Western diagnoses to categorize the refugee experience, reflective of the complexity of shifting from interdependent to independent cultures (Bemak & Chung, 2016, 2017a, 2021; Kinzie et al., 1988). Similar to the use of photography, art, music, storytelling, reconnecting with nature, and metaphor in the Maung et al. (2021) study, in the MPM, we have found effective interventions to include a wide range of strategies that can be employed in a culturally responsive manner, including critical incident stress debriefing, cognitive restructuring therapy, metaphor, psychological first aid, role playing, storytelling, dream work, narrative therapy, existential psychotherapy, psychodrama, projective drawing, mythology, critical incident stress management, trauma-focused cognitive-behavioral therapy, relaxation techniques, gestalt therapy, imagery, play therapy, and interpersonal group therapy (Bemak & Chung, 2016, 2017a, 2021; Duarté-Vélez et al., 2010; Parthasarthi et al., 2004; Schottelkorb et al., 2012). It is important to point out that these intervention strategies are underscored by strength-based approaches that focus on resiliency, especially given refugees’ history of trauma and loss compounded by the designation of refugee status (Coulter, 2014; Hughes, 2014; Smith, 2006b). Strengths emerged in the findings of the three studies in this Major Contribution, noting growth in personal development, coping skills, stronger interdependent relationships with others, trusting one’s instincts, stronger religious and spiritual convictions, taking risks, greater persistence, cultural competency, less fear, and enhanced pride. A strength-based approach is important in developing hope, empowerment, and healing, making these findings vital to consider when working with refugee populations. Thus, Phase II’s focus is on healing utilizing various culturally responsive therapeutic interventions, strategies, and techniques that focus on strength and resiliency, rather than an emphasis on pathology (Smith 2006a), as is highlighted throughout this Major Contribution.

There are three key factors to consider when implementing the MPM, Phase II (Bemak & Chung, 2021). First, refugees originate primarily from cultures that are collectivistic and value social connectivity, cooperation, and group identity (Bemak & Chung, 2021; Hofstede, 2001; Triandis, 2001). Subsequently, social context, interdependence, and social support are important constructs underlying social connectivity that are conducive to effective treatment modalities within refugee populations (e.g., Akinsulure-Smith, 2009; Chung & Bemak, 2012; Ehntholt et al., 2005; Goodkind et al., 2011; Lacroix & Sabbah, 2011). Second, providing efficacious mental health services for refugees requires a clear understanding of the effect of premigration on postmigration adjustment, as well as historical, sociopolitical, and economic factors that affect the therapeutic process. Given histories of escape, trauma, and psychological and physical abuse noted in the four other articles in this special issue, many refugees are distrustful and have an aversion to discussing or sharing private information (Bemak & Chung, 2016). A third key factor in using the MPM with refugees is to keep in mind five critical issues for being culturally responsive. These issues include: (a) awareness of somatization symptomology, as pointed out in Atari-Khan et al. (2021); (b) attention to nonverbal context of cross-cultural communication; (c) sensitivity and appreciation of the quality and nature of cross-cultural verbal interactions between the therapist and refugee client; (d) a deliberate and conscious cultural interpretation of refugees’ feelings, thoughts, behaviors, and experiences; and (e) utilizing culturally responsive healing approaches as described throughout this Major Contribution.

Phase III: Cultural Empowerment via Social and Navigational Capital

Cultural empowerment for refugees correlates with mastering the environment and the promotion of psychological well-being (Bemak, 1989). Solomon (1976) initially identified cultural empowerment in relationship to self-advocacy and power to traverse cultural barriers for African American clients. Similarly, it is essential for refugees who face formidable barriers in adaptation, to cultivate and acquire information and skills to establish social and navigational capital that leads to cultural empowerment. The MPM embeds cultural mastery as a critical phase that helps resolve everyday adjustment problems such as daily monetary transactions, transportation, housing, language obstacles, social services, education, employment, and medical care (Chung & Bemak, 2012). Findings from the three studies in this issue were consistent in identifying environmental mastery as important during acculturation: Maung et al. (2021) pointed to the importance of handling everyday life challenges; Jorgenson and Nilsson (2021) highlighted the need for mastering language and employment challenges; and Atari-Khan et al. (2021) noted the critical need for developing resilience through the acquisition of new coping skills such as language acquisition and employment. In some cases, refugees may be underemployed or unemployed prior to postdisplacement, adding a more complex challenge in attaining cultural and environmental mastery. Therapists must be mindful of these situations that differ from person to person. To cultivate cultural mastery, Phase III requires therapists to incorporate case-management type support for refugees to familiarize and equip them with social and navigational capital knowledge and skills (Bemak & Chung, 2017a, 2017b). Utilizing Phase III happens during different phases of the MPM, when developmentally there are different needed skills. For example, as refugees are more acclimated, they may become more aware of discrimination (Dietz, 2010) and may need to prepare for employment interviews or better understand policies at their worksites (Bemak & Chung, 2021). The importance of cultural empowerment and cultural mastery was evident in this Major Contribution.

Phase IV: Indigenous Healing

Phase IV: Indigenous Healing takes into account traditional healing practices from the refugees’ home countries, including faith-based practices. Chung and Lin (1994) found that refugees from Southeast Asia utilized both Western mainstream mental health services and their traditional healing methods concurrently. Similarly, the World Health Organization (2013) reported continued use of a combination of traditional and Western healing practices. Traditional healing practices are now more widely accepted, leading to some countries reinstating these practices into the basic health insurance and expanding coverage in comprehensive health care systems. Subsequently, Phase IV necessitates that therapists expand beyond Western psychological practices to integrate culturally and faith based healing practices. It is noteworthy that Maung et al. (2021) found that Burmese women relied on religious and spiritual leaders for guidance, and Atari-Khan et al. (2021) found Syrian refugees relied on religious practices and faith for comfort, pride, and strength. Phase IV is consistent with clinical recommendations in the Maung et al. (2021) article that encouraged collaboration with stakeholders to support refugee parents. This alliance requires educating stakeholders about both mainstream mental health services and traditional healing practices so they will be able to effectively support refugees in navigating and accessing a balance of services.

Phase V: Social Justice and Human Rights

The articles in this Major Contribution describe the plight of refugees and their escape from dangerous circumstances in their home countries. Historically, refugees have experienced human rights violations during both pre- and postmigration. The injustices and violations that refugees face during resettlement are important to address for their psychological well-being. Thus, Phase V: Social Justice and Human Rights is an important component of the MPM that is incorporated in the intervention model and delineates how therapists can include human rights and social justice in treatment. Phase V may also be utilized during any of the other MPM phases. Human rights matters for refugees may include issues such as housing access, educational and legal discrimination, language training, employment opportunities, educational and job training access, voting rights, healthcare, access of support services, and job discrimination and exploitation, many of which were raised in the articles in this Major Contribution. Our experience has demonstrated that addressing these social justice and human rights violations is essential for refugees’ mental health (Chung & Bemak, 2012). To effectively attend to social justice issues, it requires therapists, at times, to assume a case manager role to provide information and support for refugee clients (Bemak & Chung, 2021; Chung & Bemak 2012). The following are five key areas where therapists may employ Phase V during treatment: (a) educate refugee clients about their rights; (b) educate colleagues, other professionals, and stakeholders about the historical, economic, psychological, sociopolitical, and cultural influences impacting refugees’ acclimation; (c) participate in changing public policy through speaking at public forums, writing to public policy makers, and researching, publishing and disseminating findings in various forums and publication outlets (APA, 2017); (d) support refugee clients, families, and communities through advocacy for equal and equitable access, opportunities, resources, and treatment; and (e) incorporate human rights and social justice work as a fundamental element in the mental health treatment of refugees (Bemak & Chung, 2021).