Listening to refugees: How traditional mental health interventions may miss the mark

Abstract

Understanding the dynamics of mental health of recently resettled refugees is an essential component of any comprehensive resettlement program, yet establishing the components of a successful and acceptable mental health intervention is an elusive task. Semi-structured interviews were conducted with 30 resettled refugees from five countries who had received treatment for depression, post-traumatic stress symptoms, or anxiety. Themes generated from the interviews emphasized the need for strong group-based social support as well as a focus on practical needs such as acquiring and maintaining employment, language and literacy training, and access to care.

Keywords

Maslows hierarchy of needs mental health needs refugees resettlement

Background

From 2000 through 2014, the United States has given refugee status to 945,970 refugees from over 200 countries (Office of Refugee Resettlement, 2014). On average, 1 in 10 adult refugees resettled in Western countries suffers from post-traumatic stress disorder (PTSD), 1 in 20 suffers from major depression, and 1 in 25 suffer from generalized anxiety disorder (Brady et al., 2000). Thus, the purpose of this qualitative study was to assess the mental health needs of refugees from Burundi, Burma, Congo, Rwanda, and Bhutan¹ recently resettled in a large, metropolitan city in the Southwestern United States.

Rates of mental illness vary by ethnic group; however, most mental health research with resettled refugees has garnered rates of mental illness that are much higher than those in the general population across the world. For example, Steel et al. (2002) found that Vietnamese refugees in Australia who experienced more than three traumatic events had a heightened risk of mental illness even 10 years post-resettlement compared with people with no trauma exposure. Similarly, Pernice and Brook (1994) found high levels of anxiety and depression in their study of recently arrived refugees in New Zealand. Allan (2014) indicates that there are high levels of depression, anxiety, and guilt among refugee populations in Australia as well.

Many studies indicate that PTSD most often complicates refugee transition. Sack et al. (1994) found that 44 percent of Cambodian refugees in their study suffered from PTSD. In a study of Kosovan Albanians, Turner et al. (2003) found that 38 percent of refugees suffered from PTSD. Fazel et al. (2005) posit that approximately 50,000 refugees in the United States may have PTSD or experience post-traumatic stress symptoms.

Favaro et al. (1999) found a combination of PTSD and anxiety disorders among many Yugoslavian refugees in Italy Mghir et al. (1995) found 13 of 24 refugees from Afghanistan relocated to Washington had PTSD, major depression, or both. Weine et al. (2000) found that 70 percent of Bosnian refugees not seeking mental health services met symptom criteria for PTSD and displayed symptoms of depression.

The mental health needs of resettled refugees are well documented, with symptoms of anxiety, post-traumatic stress, and depression stemming from both pre-resettlement trauma and post-resettlement stressors (e.g. Fazel et al., 2005; Mitschke, Aguirre and Sharma, 2013; Steel et al., 2009). Carswell et al. (2011) concluded that post-migration stress is related to poorer mental health upon arrival in the host country. Many refugees arrive in their host countries with mental health issues as a result of trauma experienced pre-arrival. Post-arrival stressors, especially the vast differences in culture between home and host countries, can exacerbate the symptoms. For example, Peisker and Tilbury (2003) found that refugees suffer from considerable acculturation stress, making them vulnerable to mental illness. Teodorescu et al. (2012) found that post-migration stressors such as having a weak social network and a weak social integration into the ethnic community were significantly associated with more mental illness and symptom severity.

Intervention research

When discussing applicable interventions for mental health treatment among resettled refugees, one must consider the general mode of delivery, type of intervention, and purported effectiveness. Regarding mode of delivery, newly arriving refugees are among the most vulnerable of populations due to language barriers and a lack of exposure to US practices (Office of Refugee Resettlement, 2014). Gong-Guy et al. (1991) state that the vast majority of refugees seeking mental health services in the United States encounter barriers such as language that preclude easy access to services. Murray et al.’s (2010) meta-analysis concluded that programs targeting culturally homogeneous client groups were four times more effective than those targeting culturally heterogeneous client groups. In addition, the study found programs providing interventions in the refugee’s original language were twice as effective as those delivered in a second or other language (Murray et al., 2010).

Various challenges in addition to language exist, though language may be the primary barrier given that it is an impediment to refugees’ willingness and ability to report mental health issues. According to the Refugee Health Technical Assistance Center (2011), cultural barriers, biases (whether of the refugee or of the provider), culturally competent screening, and treatment strategy efficacy are challenges that influence treatment. Simich et al. (2004) found that many interventions are deficient in cultural sensitivity and language proficiency, and some interventions fail to utilize social networks in the community. This is accentuated through recent studies showing that emphasis on practical needs such as employment, healthcare, transportation, finances, language, education, and security usually attained through networks can aid in reducing mental health matters. Allan (2014) posits that there is a need for ‘deep interrelationship between psychological well-being and structural inequalities’ (p. 3). According to Murray et al. (2010), interventions should focus on psychosocial models promoting positive personal change. Peisker and Tilbury (2003) assert that social inclusion approaches that focus on social adaptation and integration building of social capital are effective in successful refugee resettlement, which they defined as ‘re-establishing feelings of control and that life is “back to normal” – the state which the WHO identifies as being “mentally healthy”’ (p. 78).

Murray et al.’s (2010) meta-analysis examined intervention practices such as cognitive behavioral therapy (CBT), eye-movement desensitization and reprocessing (EMDR), pharmacotherapy, expressive therapy, testimonial therapies, multifamily and empowerment mutual learning groups; individualized therapy, and psychoanalytical orientations therapy; however, their results indicate that the mode of delivery is far more influential on effectiveness than the type of intervention delivered. Some research has shown that narrative exposure therapy can be effective in treating the effects of trauma in refugees (Gwozdziewycz and Mehl-Madrona, 2013; Neuner et al., 2004). Narrative exposure therapy involves the participant’s construction of a chronological narrative of traumatic experiences, characterized by the therapist’s employment of empathic understanding, active listening, congruence and unconditional positive regard (Gwozdziewycz and Mehl-Madrona, 2013). In a study comparing narrative exposure therapy, supportive counseling, and psycho-education, refugee participants receiving narrative exposure therapy reported significant declines in post-traumatic stress symptoms as compared to the refugees receiving counseling or psycho-education.

However, given Maslow’s (1954) hierarchy of needs, it is possible that mental health interventions should be preceded by interventions focused on engendering belongingness. Acculturation models posit high contact participation (interaction with those of one’s own culture) and contact maintenance (contact with the dominant culture) are keys to acculturating in a dominant society (Berry, 2001). Psychosocial and acculturation models help empower refugees and their communities, encourage actively approaching acculturation and integration, and embolden refugees to seek social inclusion in the host society (Peisker and Tilbury, 2003). In one intervention study, Vongkhamphra et al., 2011) found that refugees experienced a decline in self-reported stress after participating in a program that combined social service provision and psychosocial integration (Vongkhamphra et al., 2011).

Emerging research is showing that the needs such as language education, financial literacy, employment training, provision of transportation, access to affordable health care, and security should be part of any intervention program. Interventions catering to the cultural and language needs of refugees have expanded over time to include services designed and delivered by paraprofessionals who are refugees themselves working in a collaborative team approach with mental health providers (Abrahamsson et al., 2009; Shaw, 2014; Yohani, 2013). Stewart et al. (2012) found that refugee participants reported a greater ability to cope with resettlement after participating in an intervention utilizing peer facilitators who had experienced life as a new refugee and helped other refugees overcome settlement challenges. Miller and Rasco (2004) report favorable outcomes training refugees to become peer-counselors and mental health resources in their own communities. Wollersheim et al. (2013) developed a program using mobile phones to create positive psychosocial outcomes through communication interconnectedness by removing the geographical distance between refugees and trained peer supporters.

While integration programs are meeting the physical needs of refugees, more is needed to ensure mental health stability. Emerging research is showing that attention to these needs through peer programs that are culturally competent and sympathetic to cultural sensitivities have successful outcomes. This in turn appears to shorten the transition period and help to make the transition less traumatic. This study provides qualitative data supporting the need for transition programs that are peer-centered and culturally competent.

Method

The purpose of this study was to assess the mental health needs of recently resettled refugees from Burundi, Burma, Congo, Rwanda, and Bhutan.² Specifically, these refugees were resettled in a large, metropolitan city in the Southwest United States that annually resettles roughly 10 percent of refugees sent to the United States. This qualitative study is a follow-up to a larger quantitative study. In the quantitative study, all participants began in the project with first attending community-based psycho-educational group meetings, which were open and available to all refugees in the community. These meetings were led by Cultural Ambassadors – natural leaders and refugees themselves – who lived in the same apartment complexes with their group members. Cultural Ambassadors were trained and employed by the resettlement agency to conduct these group meetings, which were held weekly and covered topics such as general awareness about mental health and access to resources in the community. The Cultural Ambassadors facilitated the group meetings and oversaw the consenting process that was conducted in the participants’ native languages. To be eligible to participate in this study, participants had to be over 18 years, able to consent to participate in either English or one of the five included languages mentioned previously, have at least a moderate mental health concern per one of the mental health measures used at baseline (see Note 2), and be of refugee status from the five ethnic groups settled in the Southwestern United States. Eligible participants were randomly assigned to one of the three modes of mental health intervention for 8 weeks of intervention. The three types of interventions were the community-based psycho-educational group meetings, office-based counseling, and home-based counseling. Office- and home-based counseling were conducted by licensed mental health professionals using a trauma-informed approach. After the 8-week intervention, participants completed post-test assessments identical to the baseline assessments. Each participant received a US$10 gift card at completion of the 8-week intervention for use at a national retailer. Upon initial analysis of the quantitative results, we embarked on this qualitative study to capture the participants’ perceptions of mental health intervention.

Data collection

Qualitative interviews were conducted with a subset of participants from the larger study following the study’s completion. This required a separate consent process, facilitated by CAs (cultural ambassadors). Interviews were conducted by CAs in the refugees’ native languages, and those who agreed to be interviewed received an additional US$10 gift card at completion of the interview for use at a national retailer. A total of 30 refugees were interviewed: 10 Bhutanese (conducted in Nepalese), 10 Burmese (conducted in Karen and Karenni), and 10 from Burundi, Congo, and Rwanda (conducted in Swahili). Demographic information is provided in Table 1. Interviews were recorded with digital recorders and later transcribed and translated, and back-translated by a certified translation service. Interview questions were as follows:

Why did you agree to participate in this study?

In what ways has participating in Mental Health Support Group helped you?

How could the Mental Health Support Group be improved?

In what ways participating in counseling helped you?

How could the counseling be improved?

Before you started going to the support group or receiving counseling, what things did you need help with?

What things do you need more help with now?

Table 1.

Demographic characteristics of three groups.

	All (N = 30^a)	Nepali group (n = 10)	Swahili group (n = 10)	Karen group (n = 10)
M (SD)
Age (years)	51.23 (14.7)	60.40 (5.81)	48.1 (19.09)	49.15 (9.85)
n (%)
Marital status
Married	22 (78.6)	8 (80)	6 (60)	8 (80)
Others	8 (21.4)	2 (20)	4 (40)	2 (20)
Gender
Male	12 (41.4)	5 (55.6)	5 (50)	2 (20)
Female	17 (58.6)	4 (44.4)	5 (50)	8 (80)
Education
No education	13 (44.8)	9 (100)	2 (20)	2 (20)
Primary	14 (48.3)	0 (0)	6 (60)	8 (80)
Higher education	2 (6.9)	0 (0)	2 (20)	0 (0)
Employment
Employed	3 (10.7)	2 (22.2)	1 (11)	0 (0)
Unemployed	25 (89.3)	7 (77.8)	8 (88.9)	10 (100)

Ns vary due to missing data.

Data analysis

The first three authors (D.B.M., R.T.P., and D.R.K.) each independently analyzed the data using the grounded theory technique of line by line open coding. Open coding encompasses the researchers’ initial ideas, thoughts, and perceptions of the data (Creswell, 2007). D.B.M., R.T.P., and D.R.K. then met for axial coding using a constant comparative approach; axial coding involves the organization of open codes into broader themes or categories (Creswell, 2007). Axial codes were discussed and deliberated until agreement was reached in each instance. The last two authors (E.S. and Y.K.K.) then reviewed coding, checking for signs of bias in the process. Once consensus was established and final codes developed, the authors then collated the axial codes into the final themes.

Results

Two major themes and two minor themes were extracted from the interviews, each related to characteristics of an effective mental health intervention designed to address the needs of recently resettled refugees experiencing mental health issues such as symptoms of depression and anxiety. The identified major themes were group program structure and program content, and the two minor themes were program duration and program location. Each of these themes and their subthemes will be described in detail with supporting evidence provided.

Major theme: Group program structure

Participants felt that a mental health intervention should have a group focus, rather than an individual focus. They appreciated the camaraderie that developed out of a shared sense of purpose in the mental health support group meetings and felt that this was a missing component in individual meetings with their mental health counselors.

Subtheme: Social support

Several participants explained that participating in the mental health support group with their peers helped to reduce feelings of social isolation. One participant shared, ‘Being in the group was helpful because we are making friends and learning many new things from others as we exchange ideas and helping each other’. Others appreciated the group structure as providing them with a sense of belonging and helping to combat negative feeling associated with seclusion. Another participant explained, ‘In group, it helped us to join others. We meet, we gather, and we exchange ideas’. And still another interviewee agreed, ‘It helped me very much because sometimes I feel lonely, but when I am in group I don’t feel alone’.

Subtheme: Mutual aid

Another common idea shared by a number of interviewees was the assertion that the group program structure was an effective mechanism to create a sense of shared responsibility and obligation to one’s fellow community members. Participants expressed a strong desire to provide assistance in various forms to one another within their communities, and they viewed the mental health support group as an important facet of this commitment to one another. Several interviewees explained this sense of community responsibility as an important feature of the culture and traditions in their home countries. One participant explained,

The first thing for these groups, which made me happy, was that they said that we will be helping our neighbors and friends who have some conflicts … This is how we grow in our country; we were advising and helping our friends and neighbors with their conflicts.

Interviewees emphasized the importance of the reciprocity that developed in the groups and described this process as an ongoing exchange of knowledge and ideas. A participant shared, ‘The group helped me in the way that I tried to learn, and have knowledge of how I can help others who have concerns, and also help me to know other people’. The reciprocity and shared responsibility were not limited to knowledge and ideas, however. As one participant explained,

The groups can be improved by helping refugees who are especially vulnerable and who don’t have work or refugees who are sick and don’t have transportation to the hospital. That’s why I liked this group, because we help each other.

So, being a part of the mental health group was seen not only as an opportunity to share ideas and knowledge with other refugees but also served as a place to receive and exchange practical help from others, as in this example, transportation to the hospital.

Subtheme: Empowerment

Some of the participants saw value in what they deemed as power through group membership. They expressed a sense of authority or privilege that they felt simply by being a member of the mental health support group. These feeling persisted despite the open nature of the group – anyone could join the group at any time without a formal entry procedure in place. Some participants expressed a desire for a formal recognition of group membership. As one interviewee explained,

First of all, they told us that we will be peer group, but they didn’t give us anything such as a badge to show who we are, even when police officers come we cannot show anything to identify who we are. So they need to give us something showing that we are peer group.

Major theme: Program content

In addition to group program structure, the second major theme focused on the program content, in both a substantive sense and a more general sense of providing overarching direction in the development of a mental health support program. In a broad sense, participants expounded on the importance of addressing the specific needs of refugees at a single point in time. They explained that while some refugees may be able and ready to talk about their mental health concerns, others may be focused on other needs such as transportation or employment. Several interviewees emphasized the necessity of accommodating these varying needs. Much of the content suggested by participants is not specific to mental health, but instead speaks more broadly to the numerous other needs that may affect ongoing mental health adjustment among recently resettled refugees.

Participants stressed the need for a participatory model of program development and expressed a strong desire to be involved in the creation and delivery of program content. In this regard, participants had many ideas about the content that should be included in an effective mental health group intervention, many of which centered around adjustment to life in the United States as a newly resettled refugee.

Subtheme: System navigation

A number of participants expressed a need for assistance in navigating the health and social services landscape in the United States. Of particular concern were skills and knowledge related to accessing health and medical services. Participants experienced difficulty managing ongoing mental and physical health care needs due to barriers associated with language, cost, scheduling of appointments, and arranging appropriate transportation. Some participants also expressed frustration with financial illiteracy, specifically as this relates to understanding medical bills, insurance premiums and co-pays, and Medicaid renewal applications.

Subtheme: Literacy and language

Even more pressing than financial literacy concerns was the need for English language literacy assistance. Many participants expressed frustration with their inability to understand English and felt that this was a primary reason that they experienced many of the challenges they faced in adjusting to life in the United States. Interviewees requested assistance reading their mail and explained that it was difficult for them to sift through ‘junk’ mail and bills that needed to be paid without an ability to read English. Some participants expressed strong opinions about how English language and literacy education should be delivered to refugees, and several noted the need for bilingual teachers who could communicate in both English and the language spoken by refugees. As one participant explained,

… some offices are trying to teach English to refugees but I think that the people who are teaching English to refugees suffering method of teaching refugees. They don’t know how to attract refugees in English lesson, [and] they don’t know how to interest refugees in the study. I think that the best thing would be … [to] ask the people who speak the language of refugees [to teach English classes] because sometime[s] they can … interpret English word[s] in other language[s]. The level[s] of study for refugees are different – some people did not go to school, and others … only [went to] elementary school. If English lesson is give[n] by who know the African language … [it will] be easy.

Also related to literacy and language learning was the desire for programming that would provide assistance attaining US citizenship. Many participants expressed anxiety about their inability to speak and read English as impeding their desire to pass the US Citizenship Exam. For a number of participants, the need to learn English in order to pass the citizenship test superseded other reasons such as attaining employment, communicating with service providers, and navigating the health sector.

Subtheme: Sense of place

Another theme that relates to the program content involved recognizing the importance of a sense of place. Several participants expounded on the natural beauty of their homeland and discuss how much they missed the sense of connection to the beauty of the land following resettlement. As one Bhutanese interviewee explained,

We came from the Himalaya Kingdom. Our country has its natural scenic beauty. Our mind would have been satisfied if we could get chance to visit such places here in the United States occasionally. But, the geographical features of the United States are different from our country. Therefore, to improve our mind from being strange and lonely, the Mental Health Support Group could surely provide relief to our contracted mind, by taking us in such places timely manner where there are similar geographical features in the United States.

Another participant expressed a similar sentiment, establishing a connection between the effectiveness of mental health intervention and connecting to the surrounding physical environment. The participant shared, ‘Counseling be improved when we refugee people are getting opportunity to visit green sceneries in the United States in timely manner’.

Subtheme: Advocacy

Several participants spoke about the need for advocacy on their behalf, especially related to interactions with employers and medical or social service settings. Participants viewed themselves as vulnerable to individuals who were in positions of power and felt they were at risk of being taken advantage of by others. As one interviewee explained, ‘Some office[s] here in America have dishonest people especially when they know that you are refugee you don’t know very well English, we don’t know how to get to the office it very hard because of the language knowledge’.

Subtheme: Counseling

While much of the feedback related to program content involved factors external to mental health, several key ideas specific to mental health and counseling were noted by interviewees. Participants noted the importance of building the relationship between the individual client and the counselor as an essential component of establishing trust and honesty in a mental health intervention. A number of participants discussed the need for assistance from a mental health professional in helping to prioritize problems and needs. As one interviewee explained, ‘It helped me because I had too many things in my mind. So this counseling helped me handle it. It helped me not to have a lot of thoughts and just focusing on my family’. Others discussed the value of the counselor in providing advice and encouragement in the face of difficulties related to employment and overall adjustment to life in the United States. Several interviewees also mentioned the counselors’ assistance with managing feelings of stress and coping with insecurity.

Subtheme: Ethnic-specific differences

While the program content areas mentioned previously were distributed across each of the refugee groups represented in the study, the topic of law enforcement was noted by several African interviewees, but not mentioned at all by the Bhutanese or refugees from Burma. Interviewees from each of the three African nations expressed concerns about the role of law enforcement in their communities. Several expressed interest in learning more about US laws, and still others expressed concerns about their personal safety and the safety of their communities. A minority of African interviewees also expressed a desire for conflict resolution and mediation training as a distinct component of a mental health curriculum; again, these concerns were expressed only by representatives of this community.

Minor themes: Frequency/duration and location

While the major themes of program structure and program content were well-defined and extensive, minor themes related to the frequency of group meetings, the duration of the intervention, and the location of meetings were also revealed. Participants expressed a desire to attend at least two, and often three or more group meetings each week in order to have their needs met. Many participants felt that the program duration should extend longer than 8 weeks and should include a long-term follow-up component a number of months after the regular meetings had concluded. Finally, interviewees emphasized the importance of holding meetings in an easily accessible location. For many, the apartment ‘clubhouse’ was suggested as a location that would be accessible to all with minimal transportation arrangements required to facilitate attendance.

Discussion

While the mental health intervention in question in this study included both individual and group structure, the overall consensus of participants who reflected on the program’s efficacy appreciated the group structure over the individual counseling model. Stewart et al. (2012) found similar results in a multi-method participatory study of a social support intervention for refugees from Sudan and Somalia. In the study, both trained peer helpers and professional counselors provided support in a group setting, and the authors noted a significant decline in self-reported loneliness and increases in perceived support and social integration. These findings are also consistent with Behnia’s (2004) exploratory study comparing community peer groups and traditional counseling, which indicated that perceptions about formal mental health services included distrust, stigma, and uncertainty. While the stigmatization of formal counseling was not evident in this study, the refugee participants in this study, like the participants in previous research conducted with resettled refugees, favor a peer-led support group model in general when compared with formal, individualized counseling services. These findings provide further support to research that has found merit in the effectiveness of a supportive network of family, friends, caring professionals, and community members to serve as a protective buffer for mental illness and to ease adjustment of recently resettled refugees in a host country (Behnia, 2004).

The cultural ambassadors in this study served a multi-faceted role in this study – as paraprofessional mental health educators, as liaisons and brokers, and finally as community organizers. These roles mirror the functions of many former refugees working as resettlement caseworkers in resettlement programs in the United States (Shaw, 2014) and provide support to the notion that peer-led group support can have a positive impact on overall well-being. The importance of the development and maintenance of a strong social support network has been well documented (Beiser, 1999; Davies and Bath, 2001; Hernandez-Plaza et al., 2006; Stewart et al., 2012). Refugees establish a sense of belonging when they spend time in established groups of others facing similar stressors related to adjustment in a new society. Furthermore, having a shared sense of purpose and past can increase feelings of social belonging among resettled refugees (Stewart et al., 2008). In contrast, research with African refugees indicates that the loss of social support can have a negative impact on adjustment and coping (Simich et al., 2004).

Participants in this study extolled the virtues of the exchange of ideas and reciprocal helpfulness that was facilitated by group membership. It may be that having the opportunity to share, learn, and grow together allows refugees to develop a sense of usefulness in an environment in which they are often reminded of their lack of power. Even refugees who had resettled within the few months prior to group membership might have something to share with others in the group. Stewart et al. (2012) found that participating in group discussions with other refugees served as a way to empower an individual to attempt a new task or take on a new challenge that had previously seemed insurmountable. Refugees’ shared experience as victims of oppressive regimes may result in an unavoidable loss of a sense of autonomy that is further ingrained by the resettlement process. Group membership and shared decision-making, as is the nature of a peer support group, may provide an opportunity for individuals to regain a sense of lost power and autonomy.

This sense of collective responsibility and communal reciprocity may be a healthy and essential outgrowth of rediscovered cultural tradition for many refugees. To this point, the fact that participants emphasized the need for a participatory model of program development suggests that refugees value having a role in the development and delivery of program content. Like the participants in Behnia’s (2004) study, the refugees in this study indicated that practical advice, advocacy, and assistance dealing with the numerous stressful life events they faced took precedence over a need for formal counseling that would focus on the provision of emotional support.

To this end, participants expressed a number of challenges related to language and literacy, access to health care and social services, and the need for advocacy as it relates to employment. This recognition of Maslow’s (1954) hierarchy of needs is an important one for determining how to best address the mental health issues faced by recently resettled refugees; in this study, as in previous studies, refugees’ mental health needs were circumvented by more practical issues such as access to employment, housing, and other basic necessities. The need for language and literacy education rose to the surface as a primary concern, as participants viewed their inability to communicate in English to be a major detriment to their ability to succeed in the United States. It is interesting to note participants’ ideas about how and by whom English language should be taught to refugees. Of particular interest was the assertion that refugees might be most receptive to learning English when it is taught to them by bilingual speakers who are also able to speak a common language. This notion provides support to the idea that refugees can teach and learn from each other in a reciprocal way that empowers the refugee community as a whole.

Participants in the study appear to possess a number of misconceptions around the subject of attaining US citizenship. Many interviewees lamented about their inability to speak and read English as a major source of stress as it relates their inability to take and pass the US citizenship test. In order to become a US citizen, among other basic requirements, a refugee must have a basic knowledge of US government and history (measured by a written assessment) and have a basic ability to read and speak English, measured by both a brief oral exchange and a spoken oath. While attaining citizenship is a sensible path toward long-term acculturation and integration into US society, it should be noted that refugees who are not yet citizens, as legal permanent residents of the country, benefit from most of the same basic privileges as citizens. For many participants in the study, however, fears related to possible deportation or other unspoken concerns seemed to play a major role in the pressure they place on themselves to learn English in order to pass the citizenship test. The roots of these misconceptions surrounding citizenship are unclear and deserve further examination.

A number of participants in this study discussed the meaning of place, geography, and topography and expressed a need for a connection to the land or place to be addressed in mental health interventions for refugees. Relocation and forced abandonment of home, country, and lifestyle can be disorienting and acceptance of a new, often strange, and very different built environment can by jarring (Dam and Eyles, 2012). Home, and by extension, one’s sense of place, may change and be redefined over time as a result of the migration experience. According to Chaitlin et al. (2009), one’s sense of place and feelings of home are constructed and reconstructed as individuals and groups change and relocate. In Dam and Eyles’ (2012) study of the meaning of place among resettled Vietnamese refugees, the authors found that their sense of place derived from geography as well as family ties and memories of past places lived. The participants in this study also possess a multi-faceted conceptualization of place. In response, it seems logical that a mental health intervention designed for refugees would also include components related to geography and topography to allow participants to develop new connections with the land and built environment. Because refugees were in a sense rejected by their country of origin, helping them to develop sense of place and connection to the land may be an important part of adjustment and belonging.

Conclusion

Social workers and other mental health professionals embrace a client-centered approach to mental health care. This approach can be articulated in any number of ways, but perhaps most common is the oft-touted ‘meeting clients where they are’ (Falk-Rafael, 2001). The results of this study inform where refugee clients are in relation to effective mental health intervention. Specifically, our typical conceptualization of the client-counselor dyad does not seem as good a fit for resettled refugee clients as compared to a group intervention where there are opportunities for group support and psycho-education related to their needs. Specifically, refugees voiced needs related to needs lower on Maslow’s hierarchy. This should give social workers pause in considering when to introduce therapy for mental health issues. In other words, true to Maslow’s hierarchy, interventions should first stabilize refugees by helping them meet their basic needs. As (Mitschke et al., 2013) found, simply introducing financial literacy classes in a group setting taught in the refugees’ native language produced significant relief of mental health struggles including depression, anxiety, and post-traumatic stress. Thus, we encourage social work practitioners working with refugees to develop and implement interventions in a group setting that address needs in Maslow’s (1954) hierarchy from bottom to top.

Footnotes

Funding

Regina Praetorius, Diane Mitschke and Eusebius Small were funded by the UT Arlington School of Social Work innovative Community-Academic Partnership (iCAP) (2012–2013) for the project Refugee Mental Health: A Comparison of Three Treatments.

Notes

Author biographies

Regina T Praetorius is a licensed social worker and Associate Professor of social work at UT Arlington. She is the Director of the Bachelor of Social Work Program. Her research focus is the interconnectedness of trauma and suicide.

Diane B Mitschke is an Associate Professor of social work at UT Arlington. She is the Director of the Master of Social Work Program. Her research research interests focus on exploring the intersection of health and mental health among vulnerable communities.

Eusebius Small is an Assistant Professor of social work at UT Arlington. His research interests focus on reducing incidents of sexually transmitted infections among vulnerable populations of youths with a particular emphasis on sub-Saharan Africa.

Youn K Kim is a recent graduate of the UT Arlington social work doctoral program. In the fall of 2016, she will begin work as an Assistant Professor of social work at Louisiana State University.

Don R Kelly is a licensed social worker and is a social work doctoral student at UT Arlington. His research interests include conflict resolution, restorative justice, conflict coaching, leadership, law, and child advocacy.

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