Mental Health Care With Refugee Families: A Transnational Collectivist Approach

Abstract

With more than 25 million refugees around the globe and forced displacement an intractable issue, how can social workers provide mental health services that account for refugee families’ complex displacement narratives and needs? In this article, we argue for a global perspective on mental health, seeking to go beyond the immediate, local context which is too often bounded by the nation-state, and for going beyond the individual level to consider family, community, and culture as sources of strength and connections. Specifically, this article introduces a transnational collectivist approach (TCA) to mental health service delivery with refugee families. This approach acknowledges that even after resettlement in the United States, refugees continue to engage with and support members of their immediate and/or extended family in their country of origin and in other host countries, including those in refugee campus. Furthermore, this approach also builds on the insight that family, extended family members, and cultural communities may have shared experiences of both trauma and healing. Our article defines a TCA framework and concludes with practical elements and recommendations for mental health practitioners and clinicians to consider when working with refugee families.

Keywords

transnational collectivist mental health refugee families

Introduction

Forced migration is a phenomenon experienced by 82.4 million people globally, 26.4 million of whom are refugees (UNHCR, 2021). Refugees and other displaced people living in camp settings experience myriad challenges as they contend with trauma, safety problems, issues of belonging, limited or lack of freedom to work and travel, dependence upon international organizations for basic needs (i.e., food, housing), and protracted, precarious, unstable living situations. Less than 1% of the world’s refugees are resettled each year. Even after resettlement, refugees’ challenges evolve as they transition to different stressors in their new country and as they aim to rebuild their lives. While there is relatively more safety and permanence, resettlement yields a different set of challenges, including difficulties in adjusting to new conditions at workplaces and schools, language problems, poverty, racism, and continued trauma and mental health issues. Resettlement services are crucial in assisting and guiding refugees through their transition period and a new set of challenges. Such resettlement services, including those in the United States, encompass newcomer orientation and assistance with housing, food, health care, and education.

A central part of resettlement services is mental health for refugees, a subject that has been tackled by a rich body of scholarship. Mental health services for refugees are often rooted in a Western notion of mental health (Bracken et al., 1997; Tempany, 2009). This perspective emphasizes an individual-level, solution-focused approach, often taking as secondary the family unit and the community and how they may yield supports as well as impact outcomes. However, such an approach is often insufficient and ineffective when applied to refugees, whose experiences of persecution, violence, displacement, and resettlement often set them apart in terms of mental health needs (Bracken et al., 1997; Fennig & Denov, 2019; Westoby & Ingamells, 2010). Indeed, mental health scholars have problematized conventional mental health models and have long examined concepts of globality and diversity, such as cultural competence, in practice with refugees as well as other marginalized groups (Bracken et al., 1997; Fennig & Denov, 2019; Summerfield, 1999; Westoby & Ingamells, 2010).

Aiming to contribute to such lines of inquiry and drawing from our own practice and research with refugees, our own histories of migration, and upon relevant scholarship, we argue in this article for a global perspective on mental health. Specifically, this article introduces a transnational collectivist approach (TCA) to mental health services with refugees, calling for going beyond the immediate, local context which is too often bounded by the nation-state, and for going beyond the individual level which often overlooks family, community, and culture as sources of strength and connections.

Refugees’ Transnational Ties

Transnational practices have been studied by scholars over the last decade (Al-Ali, 2002; Fouron & Schiller, 2001; Gangamma & Shipman, 2018; Li, 2016; Pannetier et al., 2017; Portes et al., 1999). A key definition of transnationalism by Portes and colleagues (1999) is the maintenance of occupations and activities that necessarily require social contacts over time across national borders and across cultures (Portes et al., 1999). More recent definitions have emphasized an advanced concept of transnationalism as a constant movement developed and sustained by immigrants who build extensive networks linking the new country and the country of origin (Fouron & Schiller, 2001). For some refugee communities, transnational ties are heavily formed through everyday routinized practices that characterize family hierarchies and gender relations (Al-Ali, 2002a).

In thinking about transnational ties, it is critical to note how family separation cases with refugees may play a detrimental role in the health and well-being of refugees (Choummanivong et al., 2014; Löbel & Jacobsen, 2021; Löbel, 2020; Shah et al., 2019). The process of family reunification has always been arduous and it has become ever more challenging with heightened nationalism, restrictive policies, and the increase of displaced populations globally. Given these circumstances, family members who have resettled in third countries are more likely to offer economic support (via remittances) and emotional support to their families in precarious situations in their homeland, refugee camps, or host societies. The transnational activities of refugees are widely influenced by conditions in the sending country and structural constraints in the receiving country (Şimşek, 2019).

The transnational experiences and activities of refugees may vary across contexts, cultures, and regions and encompass social, economic, and ethno-cultural dimensions. In terms of the social dimension of transnationalism for refugee families who have resettled, the feeling of “home” is often connected not only to the physical, geographic location in neighborhoods, and cities in resettlement countries, but also to the presence of extended family, peer social networks, and helpful relationships across distances in their home countries (Al-Ali et al., 2001; Pannetier et al., 2017; Şimşek, 2019; Simich, 2010). Forced migration and resettlement have yielded complexities of change in family structures of refugees, and a most crucial change is the spatial separation of families and the often-abrupt severing of crucial social and familial supports, due to war, persecution, and other forms of violence (Al-Ali, 2002b; Al-Ali et al., 2001). Family members depend on each other for both practical and social support; however, during times of war, these patterns become fragmented (Muller, 2010; Sundvall et al., 2021; Van Willigen, 2011). In some instances, when there is a loss of employment, survival is linked to receiving remittances from their families and friends abroad (Al-Ali, 2002b; Şimşek, 2019).

Transnational ties have a material or economic component for refugees and the migration of adults is often related to the dire need for work to support the education and living needs of children and family members in the homeland (Foner, 2001). In addition to social and economic connections discussed above, transnational family ties are also critical to the ethno-cultural identity of refugees (Muller, 2010; Pannetier et al., 2017; Van Willigen, 2011). An insightful empirical study illustrates that the stronger the transnational ties for families, the stronger their ethnic identity and sense of connection (Lim, 2009). Transnational connections, with families and friends as well as media and other communications, can help facilitate refugees’ mental well-being, linguistic competencies, and cultural pride, which are particularly important over time (Shah et al., 2019).

Transnational Ties and Mental Health Outcomes

Transnational ties that allow and facilitate social, economic, and cultural support of family members and communities across global distances are important to the mental health and general well-being of refugees (Löbel, 2020; Muller, 2010; Treitler, 2001; Van Willigen, 2011). In some cases, the size of a nuclear family structure may impact their mental health (Löbel, 2020). It is also important to note that separation from family members has proven to have negative mental health effects on refugees (Loebel et al., 2020; Miller et al., 2018; Rousseau et al., 2001). The presence or absence of these transnational relationships is particularly impactful in the early stages of resettlement. Refugees may miss their family members and be concerned about family members they have left behind (Savic et al., 2013). Some mental health outcomes resulting from family separation include post-traumatic stress disorder symptoms and emotional distress (Miller et al., 2018).

Many scholars have demonstrated the importance of transnational ties to economic outcomes, and economic hardship has been a determinant of poor mental health (Gangamma & Shipman, 2018; Li, 2016; Pannetier et al., 2017; Simich et al., 2006). Furthermore, economic conditions in refugees’ place of resettlement can contribute to many stressors over their lifetimes (Pannetier et al., 2017). Weakened transnational ties negatively impacting ethno-cultural identity can lead to acculturative stress often experienced by many refugees. Having strong cultural ties may also contribute to the mental health of refugees (Foner, 2001).

Refugees’ Collectivist Backgrounds

Kim (1995) defines collectivistic cultures to include those that “stress ‘we’ consciousness, collective identity, emotional dependence, group solidarity, sharing, duties and obligations, need for stable and predetermined friendship, group decision, and particularism” (p. 4). Unlike individualism, a concept more commonly found in Western societies which places emphasis on the self, collectivist societies place value and high rank to relationships with family, community, and society (Ismail, 2020). For some refugee families, mental health challenges are never experienced alone. This is especially true for families that come from collectivist cultures. In our practice and research, we found that family and community networks play a significant role in the lives of refugee individuals (Gonzalez Benson & Burnett, 2021; Gonzalez Benson et al., 2022; Magan & Padgett, 2021; Magan et al., 2022). Family members may include not only immediate family members—those within close location and proximity to each other—but also members who reside in other countries.

Many refugee individuals grew up with collectivist cultures in their home countries, which thus may lead to a collective experience of trauma (Schlaudt et al., 2020). Indeed, the very violence against and persecution of refugees—grounds for forced migration—are fundamentally and profoundly tied to shared cultures and ethnicities.

A collectivist approach to trauma extends beyond the individual, personal experience of mental health as commonly understood in Western notions of psychology and counseling. Collective trauma is not only about personal experience of trauma, but also the witnessing of trauma, and being part of a group that experienced trauma yields mental health impacts. Research shows that refugees who have witnessed trauma may be at higher risk for mental health challenges than those who have experienced the trauma firsthand (Schlaudt et al., 2020). This secondhand exposure to trauma can lead refugees to develop survivors’ guilt (Hutson et al., 2015).

For refugees coming from collectivistic societies, it is not merely surviving war but it is also about keeping the memory of those who were left behind or those who did not survive. This connection to loved ones and those who were not able to make it out of harmful situations affects the mental health and well-being of survivors (Schlaudt et al., 2020). Thus, as trauma is experienced collectively, grief and implications of the trauma are also connected to the collective. Furthermore, individuals from collectivist cultures may be less likely to seek out mental health care due to fear of social stigma that may exist in larger family and community (Bettmann et al., 2015; Kirmayer, 1989; Papadopoulos et al., 2013; Shannon et al., 2015). In some cases, the negative beliefs that may be associated with seeking help may be more salient for individuals from collectivist cultures than negative beliefs associated with experiencing mental health challenges (Nickerson et al., 2020).

Critical Reflexivity

For this article, we have employed critical reflexivity as a method to better understand how transnationalism and collectivism play a role in the mental health and well-being of immigrant and refugee families. Critical reflexivity as a research method not only acknowledges practice experiences as a source of knowledge, but it argues against hierarchical research models that often negate the importance of practitioner research (Freshwater & Rolfe, 2001). We, as authors, have all had diverse practice experiences working alongside immigrant and refugee populations in the United States, Middle East, Asia, and Africa. We all identify as women of color scholars who have emigrated to the United States as adolescents.

The first author (I.M.M.) identifies as a Black Muslim woman who arrived in the United States with her family as a refugee adolescent. Since 2006, I.M.M. has been working with refugee and migrant families and children in the United States and globally on various advocacy and community-engaged practice and research topics including mental health. I.M.M. coined the concept used in this article, “transnational collectivist approach” for practitioners and researchers to take into account when working with refugee families in mental health care. The second author (O.G.B.) identifies as a Filipino woman who emigrated with her family as an adolescent and has diverse global experiences. O.G.B. has nearly a decade of research experience with refugee and migrant communities in the United States and globally (Philippines and Tunisia), and years of social work practice, including work with families and children in mental health services. The third author (M.B.) identifies as a Black woman who arrived in the United States as an adolescent after fleeing her country of Sierra Leone due to conflict. Since then, M.B. has spent 12 years working with young African girls and their families in diverse West African communities including Ghana, Liberia, and Sierra Leone. As authors, we have merged our own individual experience with migration and forced displacement with our years of practice and community organizing work with diverse and global communities. In our own practice experiences, we have witnessed the role of transnationalism and collectivist cultures in shaping the health and well-being. We have come to understand that collectivism is not merely about family members and communities within a particular geographical location, but that this concept expands and links to transnational ties including families and communities in the diaspora.

Employing TCA: Definition, Key Elements, and Recommendation for Mental Health Providers

TCA is a practice, as well as a research tool, that emphasizes the relevance of transnational ties and collectivist cultures in shaping mental health services and interventions with refugees. TCA aligns with person-in-environment as a social work framework for mental health services, but extends the person to the collective and extends the environment from the local and national to the transnational. There are three major key elements to consider when employing a TCA:

Transnational View of the Family and Experiences Beyond Nation-State Boundaries

During clinical intake processes, it is vital that practitioners ask how individuals define the family unit rather than assuming a nuclear family model. Relevant understandings of the family unit may include members who are in the homeland, refugee camps, elsewhere in the host society, or other countries of resettlement. Mental health interventions and service delivery must also account for the diversity of family experiences and how the well-being and safety of those left behind is interlinked to the well-being of those who survived. We recommend that practitioners acknowledge these aforementioned points as early as during the first intake and ensure that an expansive definition of family and family networks is incorporated into the service plan.

Second, therapeutic interventions such as transnational therapy management (i.e., health-related advice and resources) reinforce affective ties and create a sense of belonging between migrants and their home-country relatives (Sargent & Larchanché, 2016). It is critical to keep in mind the family ties and networks beyond resettlement as refugees often have family members and communities in their homeland and across the diaspora.

Third, a transnational lens in mental health services would prioritize not only current challenges in the place of resettlement, but also premigration mental health and contexts (Li, 2016; Pannetier et al., 2017). For clinicians, it is critical to understand the premigration experiences of mental health as not separate from post-resettlement mental health experiences. Rather, viewing post-resettlement mental health experiences as an extension of and interconnected with premigration mental health experiences is vital to gaining a holistic understanding of mental health experiences not exclusive to one particular geographical locale.

Collectivist Perspective to Trauma and Mental Health Experience

For refugee and immigrant families who come from collectivist societies, it is key to acknowledge how collectivism shapes their mental health experience, and importantly, their ability to seek help and care. As discussed above, trauma and traumatic experiences resulting from war and violence are never experienced alone.

First, a collectivist approach accounts for the ways in which healing must be understood beyond the individual. Given the closeness of family members within collectivist cultures, it is also important to note that caregiving for individuals experiencing mental health challenges is seldom done alone and that different family members become caregivers. As such, it is important to acknowledge not only how trauma and mental health challenges impact individuals but also how they shape the well-being of the entire family and at times community.

Second, given the shared experiences of trauma and displacement, we recommend that mental health practitioners pay close attention to the potential development of “survivors’ guilt” among resettled refugees. Thus, it is critical to acknowledge how, on one hand, family may be a protective factor and a source of comfort and healing but, on the other hand, family can present additional challenges and stressors. In some cases, both cases can be true where family is linked to sources of both comfort and stress. Therefore, it is critical for mental health practitioners to gain an understanding of the family dynamics and not draw conclusions without factoring in the diversity of perspectives refugees may have about their familial experiences and connections.

Equally important, practitioners must recognize the adverse impact of family separation on refugee families’ mental health, as research has shown (Liddell et al., 2021; Löbel, 2020; Miller et al., 2018). For many refugee families that are separated in the premigration stage, reunification efforts are a top concern once resettled. Furthermore, family reunification may take several years, which prolongs mental health stressors (Liddell et al., 2021; Löbel, 2020; Miller et al., 2018). In understanding the impact of family separation on refugee mental health, it is critical for practitioners to understand who is in the resettlement stage, where the rest of the family members are, and how long they have been separated. Practitioners should be cautious in exploring these questions as it may cause further traumatization and stress for participants to recall memories of being separated from their family members.

Third, because faith and culture are shared and often central to the development of the collective sense of self (Magan & Padgett, 2021), mental health services should take into account the role of faith and culture. Studies have shown that a holistic approach to mental health interventions and services for refugee populations cannot be employed without centering the role of faith and culture (Chaze et al., 2015; Magan et al., 2022). Faith and culture are often used interchangeably, but may also correspond to completely different concepts for some communities. For example, Muslim refugee populations rely heavily on their Islamic faith and draw strengths from elements of Islam in dealing with mental and emotional health challenges (Magan & Elkhaoudi, 2022). While acknowledging the role of faith in the lives of Muslim refugees, it is also critical for practitioners to understand the differences between major Islamic sects (e.g., Sunni and Shia) as well as the diversity in national, ethnic, and racial backgrounds. Our recommendation is that practitioners understand the role faith plays in participants’ lives and use that information to better implement programs that are in line with their faith. Integrating this practice recommendation may entail, as an example, understanding the role of faith in processing past traumatic memories, how faith helps participants deal with their current reality, and/or how various faith-based practices impact participants’ lives and mental health services. We believe that integrating faith may look different depending on the relationship between mental health providers and participants. For practitioners with different cultures, we recommend an approach of cultural humility in both seeking to understand the importance of faith in a participant’s life and letting participants direct what the process of integrating faith may look like. Some participants may feel more comfortable not bringing up their faith, whereas others may feel it is important for their providers to know. Our recommendation is for clinicians to ask the questions relevant to understanding the importance of faith in a participant’s life and then allow the participant to guide how, if at all, they would like their faith to be centered in the practice. Our recommendation is more about awareness and less about direct integration by clinicians.

Fourth, in designing mental health programming and interventions for individuals who come from collectivistic cultures, it is imperative to rely on not only formal sources of help but also informal avenues that may consist of family, friends, and social networks that refugees may rely on as a source of support and help (Drummond et al., 2011; Markova & Sandal, 2016; Nickerson et al., 2020; Slewa-Younan et al., 2014; Yaser et al., 2016). Understanding these informal avenues of support is critical to integrating a collective approach to mental health care.

Intersectional, Trauma-Informed Lens

A transnational, collectivist approach is further strengthened by incorporating an intersectional, trauma-informed lens, which allows practitioners to ask the questions not only about “what happened” but also about concepts such as race, gender-identity, religion, language accessibility, ableism, and class, which impact the mental health experiences of refugee families and individuals. Mental health is considered with the myriad identities and contexts that interact with power structures and influence in the lives of refugees (Gangamma & Shipman, 2015). The intersectional lens (Crenshaw, 1989) allows for practitioners to utilize a critical eye in the transnational contexts within which refugees live (Falicov, 1995; Hardy, 1989; Knudson-Martin et al., 2015; McDowell & Fang, 2007; McGoldrick & Hardy, 2008). In the context of forced migration due to war, a therapist may validate the struggles the individual has gone through by employing this framework to unpack the dynamics of race, class, gender, ethnicity, nationality, and refugee status in helping the client retell their stories (Gangamma & Shipman, 2018). An intersectional, trauma-informed lens considers how diversity contributes to the experiences of past and present traumas and mental health challenges. For example, in family reunification cases, it is imperative for practitioners to understand how some policies may impact refugees from a particular faith, national origin, gender, and so on (Magan, 2020). As such, practitioners must be aware of how policies such as the “Muslim travel ban” under the previous U.S. presidential administration may have affected the mental health and well-being of refugee families from those countries. The policy had a direct impact on refugee families with pending reunification applications and even delayed reunification for those who had already received approval. Intersectional, trauma-related work may allow mental health practitioners to advocate for mental health resources and services, and call attention to systematic and structural barriers in our current mental health care system.

Conclusion

Transnationalism and collectivism are two concepts discussed together in this article, aiming to raise questions and open new lines of inquiry. Mental health practice and research with refugees has grappled with challenges concerning cultural competence, cultural humility, community mental health, and intersectionality. We posit a TCA as a concept that warrant further examination both empirically and theoretically. Moving transnationally beyond the national scale and toward a collectivist sense of the individual self poses challenges for mental health practitioners, as it may warrant new skills and practice modalities, unconventional ways of thinking, and critical reflexivity. However, doing so also yields promise in integrating the spatial, temporal, and personal dimensions of refugee mental health care.

Footnotes

Disposition co-editors: Robin E. Gearing, Fang-pei Chen, Messay Gebremariam, Andrea Kenya Sánchez Zepeda, and Sondra J. Fogel

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ifrah Mahamud Magan

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