“It comes down to just how human someone can be”: A qualitative study with young people from refugee backgrounds about their experiences of Australian mental health services

Abstract

While much literature documents the mental health needs of young people from refugee backgrounds, and the barriers they face in accessing mental health services, researchers have yet to document the perspectives of service users from this population about their contacts with clinicians and services. We therefore individually interviewed 16 young people (aged 18–25 years) who were refugees about their experiences of seeing mental health professionals. Participants were born in 9 different countries and had lived in Australia for an average of 5.2 years. They placed most emphasis on in-session factors, and particularly on interpersonal considerations. Among the main themes identified via thematic analysis were the practitioner's sensitivity to the young person's cultural background and to the stressors affecting him or her, including traumatic refugee experiences, and the therapeutic relationship—especially the qualities of trust, understanding, respect, and a caring connection. The participants had diverse reactions to treatment strategies. They emphasised the role of their preconceptions around mental health services, and called for systematic mental health awareness-raising for young people from refugee backgrounds. Implications for research, policy, and practice are discussed with a focus on findings that may guide efforts to improve service acceptability, accessibility, and effectiveness. In particular, there is a need for practitioners to attend to their clients' experiences of sessions, to adopt an attuned, contextualised, systemic approach, and especially to take a nuanced approach to cultural sensitivity.

Keywords

counselling mental health refugee service user perspective service utilisation therapy youth

Studies capturing mental health service users' voices have been growing in number (e.g., Binder, Holgersen, & Nielsen, 2009; Lee et al., 2006), reflecting the recognition that clients' perspectives on services and counselling form an important component of the evidence base for mental health practice (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). However, one growing group of service users whose voices have gone unheard in the research literature is that of young people who have been refugees.

Although a heterogeneous group, young people with refugee backgrounds typically have in common experiences of being subjected to human rights violations and forced migration, and having to adapt to a culturally and linguistically different environment. Mental health practitioners in host countries therefore require awareness of young refugee clients' diverse journeys, the violence they may have experienced, and the stresses of settling into the new environment, as well as skills for intervening cross-culturally. Some guidance for practitioners can be found in descriptions of interventions modified for young people from refugee backgrounds (e.g., Ellis, Miller, Baldwin, & Abdi, 2011; National Child Traumatic Stress Network, 2005; Watters, 2008), in principles of working transculturally (e.g., Kirmayer, 2012; Kirmayer et al., 2012), and in research conducted with experienced service providers about how best to engage refugee youth (Colucci, Minas, Szwarc, Guerra, & Paxton, 2015).

Within refugee mental health research, a few qualitative studies have explored the perspectives of clients about services and therapy (e.g., Donnelly et al., 2011; Kramer, 2005; Mirdal, Ryding, & Sondej, 2012), however none of these studies focused on youth. Services are underutilised by young people from refugee backgrounds with mental health needs (e.g., Bean, Eurelings-Bontekoe, Mooijaart, & Spinhoven, 2006; Ziaian, de Anstiss, Antoniou, Baghurst, & Sawyer, 2013), due to barriers such as stigma, language, cultural differences, unfamiliarity with services, multiple competing practical needs, distrust, and underresourced services (Colucci, Szwarc, Minas, Paxton, & Guerra, 2012; de Anstiss & Ziaian, 2010; de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009). There is a need to complement these findings about barriers with research that captures the perspectives of young refugees who have actually accessed mental health services, in particular, their views about what helps or hinders their engagement and recovery.

The present study, conducted by staff of the Victorian Foundation for Survivors of Torture (also known as Foundation House) aimed to help fill that gap in the literature by asking young people with refugee experiences how they accessed mental health services, their feelings about disclosing personal problems, what promoted and what discouraged engagement with services and practitioners, what assisted them, and what they recommended to improve services. We define mental health service users (or clients or consumers) broadly, as those who have had contact with mental health professionals, defined as practitioners whose role includes assessment, treatment, and support for people with mental health problems, including alcohol/substance use problems. Thus we use the term “practitioners” to include counsellors, therapists, psychologists, psychiatrists, mental health social workers, and so forth.

Method

Design

Qualitative in-depth individual interviews were chosen to suit our aims. We designed a guide interview schedule with topics to raise with each participant (demographics; experiences of verbalising emotions and personal problems; pathways to service use; barriers and facilitators; access and engagement; experiences of cultural, religious, and linguistic considerations; therapeutic relationship; perceived efficacy; satisfaction; and recommendations).

Sampling, recruitment, and participants

Eligible participants included 18–25 year olds from refugee backgrounds who had ever received services in Australia from a mental health professional. The upper age limit was chosen to be consistent with contemporary definitions of “young person” (e.g., Colucci et al., 2015; French, Reardon, & Smith, 2003), and the lower limit to avoid too broad a developmental range. Because this small population is “hard to reach,” we expected recruitment would be a gradual process, requiring a multifaceted approach. Anecdotally, the barriers that refugee youth face to mental health service utilisation, especially stigma and language, also appeared to pose barriers to research participation.

We disseminated the call for participants across multiple sectors (e.g., health, education, welfare, and recreation), using multiple modalities (e.g., project flyer distribution via noticeboards, mail-outs and electronic sources, presentations to professionals and to groups of youth from refugee backgrounds). We aimed to sample purposively (e.g., to balance characteristics such as gender), and this balance occurred naturally without necessitating exclusions. Recruitment continued until saturation (Guest, Bunce, & Johnson, 2006). We did not include current asylum seekers, however, some participants had arrived as asylum seekers before being granted refugee status. The resulting sample came from ethno-specific/cultural diversity services, nongovernment specialist services, public and community mental health services, a government support service, an education support service, an Internet site, volunteers, word-of-mouth, and snowballing.

Nine women and seven men aged 18–25 years were interviewed. Participants were born in Iraq, Iran, Afghanistan, Sudan, DR Congo, Ethiopia, Tanzania, Côte d'Ivoire, and Pakistan. They had lived in Australia for an average of 5.2 years (range: 1 year 6 months to 12 years 3 months). All were bilingual or multilingual, with varying degrees of literacy in first languages. Six were of Christian background, and 10 of Muslim background. Six participants were employed, 13 were students, and two were neither working nor studying. One participant lived alone, four lived with unrelated others, and 11 lived with various family constellations (only two with both parents). All participants were unmarried. One was a single parent.

Data collection

Between March 2012 and January 2013, the first author individually interviewed participants. Interviews were 1 to 2 hours in duration, and were conducted at Foundation House (13), a library meeting room (one), home (one), and over Skype (one). Three participants were recruited and interviewed with prebriefed, qualified interpreters. Three participants did not wish to be audio-recorded but gave consent for detailed note-taking. Participants were given the option to self-select their pseudonym.

Ethical considerations

Careful attention was paid to ethical considerations given the sensitivities of conducting research with refugees and with young mental health clients. We used a multistage informed consent process, allowing time for consideration before scheduling an interview. We assumed no prior understanding of what research participation involves, or concepts such as voluntariness and confidentiality. To minimise risk of distress, interview questions did not initiate discussion of traumatic experiences or mental health symptoms (Marlowe, 2009; Perren, Godfrey, & Rowland, 2009). The Victorian Foundation for Survivors of Torture Institutional Ethics Committee granted approval. Recruitment through one of the agencies approached required additional approval, granted by the Melbourne Health Human Research Ethics Committee.

Analysis

Thematic analysis was conducted on verbatim interview transcripts and interview notes (guided by Braun & Clarke, 2006). A coding framework document was developed iteratively, which defined and named the key themes and subthemes that encompassed the data. NVivo10 was used for data management. Additionally, a random selection of 25% of the transcripts were blind cross-coded at the key theme level by a colleague (a clinical psychologist and refugee researcher), who was briefed on the coding framework. Consensus was reached via discussion (Olszewski, Macey, & Lindstrom, 2006). Field notes aided in the interpretation of findings, to avoid a focus on abstract, decontextualised themes.

Results

We first summarise data on participants' service utilisation, and then describe the six key themes that encompassed their comments: contextual influences on service utilisation; service systems' responsiveness; practitioners' cultural sensitivity; psychosocial and traumatic stressors; experiences of treatment strategies; and the therapeutic relationship.

Service use

Most participants had attended multiple practitioners/services, ranging from one participant who had experienced only one session, to one who had seen more than 10 different practitioners. Eight participants were current clients, and eight were former clients. More than 20 service types had been utilised across the public, private, nonprofit, and education sectors. Eight participants had attended Foundation House, of whom five had also attended other services. One described having been a psychiatric inpatient, and three others described hospitalisations where mental health was a consideration. Two described attending mental health practitioners before arrival in Australia. Several were prescribed psychotropic medication. Broadly categorised, three participants had only negative experiences with services and practitioners to report, while a few recounted only positive experiences of practitioners/services, and the majority of participants described mixed experiences.

Participants were not asked overtly about diagnoses or presenting problems, but all gave some indication of this. Six conveyed that risk of suicide was a reason for referral. Other reasons were sleep disturbance, depression, stress, anxiety, loss, posttraumatic stress, feeling overwhelmed, adjustment issues, alcohol abuse, conduct disturbance, interpersonal difficulties, excessive nail-biting, obsessive hand-washing, low appetite and digestive issues, and talking to oneself.

Understanding contextual influences on service utilisation

Service utilisation was influenced by participants' preconceptions regarding what mental health clients are like, what mental health practitioners are like, and what constitutes a treatment-worthy psychological problem. Participants' expectations reflected their sociocultural contexts, particularly the predominance of stigmatising attitudes. Their experience of professional help was also influenced by their level of comfort with verbalising emotions and personal problems, and by family and friends' help-seeking attitudes and help-seeking experiences.

Participants' preconceptions about what it means to be a mental health client were typically highly stigmatising. As Sara explained, “it's deeply rooted in our society that if you see a psychologist you're crazy.” Consequently, being referred often caused fear or offense. Not all preconceptions were negative, as Daniel exemplified, “we're not born yesterday, we're not from the village … We have these things in Iran, psychologists and all this kind of stuff, so we know it can do some good.” Media representations also influenced preconceptions:

[Y]ou get most of your ideas from the media … The idea of you sitting down, you're laying down on a bed and there is a person who just sits there like a statue recording what you say … I came in—with those ideas about mental health—and how it just seems like a very silly profession that would not help you at all. (Stamma)

An initial obstacle for several participants was feeling unaccustomed to verbalising personal experiences and emotions. For example, in Betoto's upbringing, “if you were freely open and you start talking, then [community members are] gonna label you as bad and disrespectful, if you're talking a lot or trying to show your feelings.” Consequently, she described her first session as “weird”:

I was like, “am I supposed to tell you, I don't want to tell you, can I tell you, is it okay?” … [in my] community … it's not okay for you to just blurt out whatever your problem is … So I was like “okay nothing, like nothing is wrong, whatever” … Then the lady's like, “you can tell” … so I told her … It felt very different, and very um, unusual for me because I'm not used to showing and telling my feelings.

Many participants indicated that personal problems were expected to be kept “in-house.” Yet there was often silence surrounding such issues within families, in some cases to protect loved ones, as Aisha explained: “It's hard to say everything to people around you. Especially my family; I don’t want to make them upset.” According to Jay, disclosing previously unshared issues to someone unrelated would feel “like you broke the rule … what you can’t mention in the family, how could you mention outside?” Similarly, Lionel questioned himself, “Did I do the right thing about telling … but family says ‘we should be the ones’ … did I do something against my cultural norms, standards, and obligations?”

Family and friends’ various attitudes toward mental health professionals, and in several cases, their direct experiences of services, held considerable sway over the young people. Several participants had been encouraged to access services by a loved one with positive experiences. In contrast, some participants did not tell family members about being a client because they anticipated negative reactions. In Majok’s experience, friends were discouraging (“someone else told me like, ‘nah, don’t go to her, she’s gonna talk a lot’ … My friend told me, ‘don’t go to this guy, this guy maybe he’s crazy guy’”) while family acted as facilitators (“Family … they want you badly to go … The families know better than you, they care”).

Acceptance of services often changed over time, most commonly from negative preconceptions to positive appraisals. The converse shift was also described by some, as well as examples of positive or negative experiences of services being consistent with prior expectations. To give one example, Aisha recalled:

At first I was afraid and in shock, and like “why I go to the counsellor” because, you know, in my country just the crazies went [laughing] … I was asking myself, “did I crazy, am I crazy?!” … I was un-believe that I will talk! … When I talk to her I feel confident, directly, at the first day. And I've been talking, talking for 2 hours without stop, like I'm booming, booming … Booming like a boom! … Actually it was really good, because I find someone to listen.

Several participants recommended de-stigmatising public awareness-raising initiatives (e.g., through English language classes) about mental health problems and services:

[T]ell everybody that, like let them know there is help … I know two people or three people that had suicided … because of what's happened, and they are from refugees and they're young boys … And I get hurt because I know that I could've gone to that level but I know that I had help. (Betoto)

Accessible and responsive services

Many participants raised considerations beyond the control of individual practitioners, such as location and colocation of services, and outreach availability. Participants wished for welcoming services to respond promptly and appropriately to their needs. Adequate session frequency, session length, and flexibility around scheduling were important to participants.

A few participants mentioned complex referral processes and eligibility criteria. For example, Betoto recounted, “doctors at [A] they suggested [B]. I contacted [B] and then they couldn't do help much. Then I was transferred to [C] and from there to [D]. So it's like a little tour.” Rumi recalled, “I'm feeling suffering and they can't provide the service because of some reason and some formality.” Waitlists were criticised:

[I]t's not good for young people to let them wait … Speak to them directly without put them in the waiting list … they need the help at that time … some crazy people like they do hurt themselves … the period [of waitlist], it getting worse and worse and worse … Have many, have other counsellors, to help until the waiting list come through. (Aisha)

Several participants mentioned continuity of care issues:

The more I repeat the same thing that they ask me I get more depressed, because I'm bringing out the same thing again and again, and it's making me more emotional. So every time I went or somebody new came I would not talk. (Betoto)

While favourable comments were made about interpreters, concerns were raised about interpreters omitting material, interpreting inaccurately, hampering interpersonal dynamics, inserting opinions, or passing judgment on the client, for instance:

In our community I honestly don't trust them … feelings are a joke in our community … they'd keep watching their watch … they need to be picked … the interpreter would leave out some things … they're kind of judging you. (Sara)

A nuanced approach to cultural sensitivity

This theme captures accounts of how practitioners handled participants' cultural backgrounds, identity and acculturation levels, linguistic and communication needs, and religiosity. No participants described seeing a practitioner “matched” to their ethnic background, although one participant had specifically sought out a same-faith practitioner and one a same-language practitioner.

Participants conveyed the importance of practitioners having a broad understanding of their cultural background, yet avoiding assumptions and learning from the client as an individual. For example, Rumi commented, “the psychologist, he was a good man, but, but still he didn’t got much understanding of the different history or culture or something, he sort of struggled.” Maryam commented, “she was really clever, you know, she was waiting for me to talk and she always mention, ‘this is in Australia; is that in your culture as well?’”

Majok said his practitioner knew he was African but not from which country, commenting “they think it's one country.” He added that he had encountered racist comments in public, such as “where you from, you not from here,” but that he recommended well-intentioned practitioners to ask about country of birth. He reasoned, “maybe I will act different, so I make them understand who I am exactly, what I've been through … I feel interesting to them so I tell them my story … they become like closer to me.”

Participants wanted practitioners to be ready to learn about and accommodate nuances in ethnic and religious identities. To illustrate, Daniel appreciated that his practitioner “really wanted to learn, ‘cause I was even gonna tell her you have to come to Iran for a visit, but you have to put a scarf on … she tried to learn some of the words, Farsi words.” He identified more strongly with his culture than his faith, which featured less in sessions: “I’m not really religious. I’m a Muslim but I don’t really practice. God is in my heart, so as long as you respect people, you can be anything.” Regarding some people’s preference for religious healers to health practitioners, he said, “why you want to go to the mullah instead of going to the doctor [laughing]. If I have a religious problem, then I’ll go to them.” In contrast, though Tania minimised her association with her Hazara Afghani ethnic community, raising issues around treatment of women and judgmental attitudes, she sought out a Muslim practitioner she felt understood by, who integrated standard approaches such as relaxation with recommendations for prayers and Qur’anic readings. The fluidity and unpredictable trajectories of cultural identities postmigration was conveyed by several participants:

[Y]ou have the mix, but some people completely avoid adapting to the new culture and keep to themselves, the horrible things about our culture. And then others do the complete opposite thing, become completely westernised and completely forget good values in our culture. (Sara)

While participants wanted to be viewed as individuals and not stereotyped, they still wanted to be seen in context—for the influence of past and present sociocultural environments to be recognised:

It was this idea of not really understanding that family union is different when you have a different cultural background … She was surprised that I still lived at home and why I cared so much for [my family]. So it was a bit hard to get through. (Stamma)

Overall, practitioners' level of cultural sensitivity contributed to participants' broader sense of feeling understood or misunderstood. The challenges of understanding cultures, acculturation, history, and religiosity were captured by Ahmed, who had experienced practitioners who missed the mark:

She always ask me, “do you know any mosque, where to go, and the Hazara community?” I said, “no, I'm not really interested!” … They understand lots of things and they don't understand lots of things as well … Australian culture or European culture is quite similar, but ours is very different … I might change here … I don't really, yeah, follow my own culture lots. I follow, but not all. People are changing.

Recognising the impact of psychosocial and trauma-related stressors

Although interview questions did not initiate discussion about prearrival experiences, participants commonly mentioned devastating effects of violence and persecution. As well as losing loved ones, participants spoke of losing homes, possessions, educational opportunities, hope, trust, meaning in life, and social status. The young people were now safer, but leaving family behind in danger caused ongoing distress for many, as Rebecca expressed: “all this year I was worried about my brother and with my sister still there.”

Life in Australia often presented a language barrier, multiple practical demands, and social exclusion alongside the general stressors faced by young people of any background. Participants mentioned a wide range of issues regarding housing, education, employment, financial strain, gender roles, racism, unfamiliar systems, visa applications for family, coping without missing loved ones, and intergenerational tensions:

There was nowhere to live and I was worried, really worried about where to live, and job, and then Centrelink [social security] they didn’t increase my pay … and I was out, nowhere to be … I told [caseworker] I have no-one, no-one around me to help … my mum is not here so what the point of living is there because I have no-one … ‘cause I was doing VCE [Victorian Certificate of Education—final 2 years] and VCE is very pressure. (Angelina)

Participants typically conveyed the importance of practitioners being mindful of their experiences as refugees, as Christina said:

You can't take someone like refugee and someone Australian … as counsellor, just say, “this is gonna help you”— no. There's some Australian they just grow up here—they have everything, they doesn't see fighting, they doesn't sleep no eating … [refugees] eat, like a brick, you know, you eat like something because you need like your stomach to come to feel like you have something to eat. They're suffering … fighting is still there … yesterday there are people dying there.

Yet while Christina appreciated the recognition of the ongoing distress caused by her experiences, she found it too painful to repeatedly detail them in counselling:

If I have a counsellor, I have to talk the problem I have. And then if I talk my problem … it remind me the thing the past. And then if I'm reminding I'm gonna be sick, because I just wanna come go home and thinking and then it just give me headache, then I just wanna remember everything.

Christina expressed feeling helpless because of fear for family members remaining in danger and concurrent issues related to poverty, discrimination, education, and employment. She felt she could not be helped by talking with practitioners about the violence that affected her and her family, but commented that under better circumstances, at a later stage, she might find counselling for past events helpful. Other participants advocated talking earlier, as expressed by Aisha: “young people need, need to talk. Yeah. And especially the new arrival people.” Overall, participants expressed diverse preferences regarding whether and when to talk through traumatic events with practitioners, as Ahmed captures:

Sometimes they were asking very like personal questions that I didn't like … The journey that we had, like how many days were you in the boat, and I never want to think about it … [later] People are different, like we have saying; “jungle has dry and wet—some trees are alive, some trees are dead, and they are different.” And people are the same; some people like to talk about their selves, their families, and some people want to keep a secret.

Betoto described a knowledgeable approach to revisiting a refugee past as helpful:

He knows the whole refugee deal … He knew where I was coming from, he knew what was happening. So it was really helpful, he understood everything … we went back to what I remember from Africa, so it's like the smell that I remember from Africa started coming back to me while I was talking … they needed to go back that far for them to help.

Appropriate treatment strategies

Participants had encountered diverse treatment methods, and reported very different reactions to specific techniques. For instance, both favourable and unfavourable comments were made about sleep-related strategies, as illustrated by the contrasting accounts of Daniel (“it did improve a lot, because every time I came and saw her, she was obviously teaching me new ways about getting some sleep”) and Ahmed:

She said, “when you go to bed, don't drink coffee,” or, I never, [pause] [laughs] I knew that sort of thing already. They really don't understand us, about our journey, about the life we had, so even if you don't drink or if you don't play with the electronic things, still we can't sleep.

Ahmed ceased attending, explaining, “I saw her because of my sleeping problems and I didn't see any much help.” Directives relating to exercise, relaxation, socialising, concentration strategies, and strategies to distract oneself from worries about family were each mentioned as helpful by some participants and as inappropriate or invalidating by others. For example, when Rebecca was worried about family in danger overseas, she valued being told, “you have to think about other things and your life, don't think all your mind put it just worries about your brother.” Karim found similar advice simplistic, and felt that recommendations to exercise, socialise, and distract himself from fears for family indicated that the practitioner could not begin to understand what occupied his mind. Similarly, Christina conveyed with intensity:

Seriously, they say “go home take water, and sleeping, they're gonna help you. Don't worry, don't think too much,” and touching [motioning patting shoulders] … How am I gonna drink water? Is it gonna help me? … My sister is dying here, I was crying, crying, crying, no one to help me … Me actually, I never see the help from counsellor, seriously … one told me I have to go to the shop to look the clothes … Do I have money to buy clothes?

A few participants who experienced specific recommendations as ill-fitting discontinued treatment. Other participants recounted beneficial effects from specific directives. For instance, Tania was advised in initial sessions to improve her nutrition, exercise, and sleep patterns, and stop isolating herself and the resulting improvements in her mood dispelled her initial reservations about practitioners.

Participants spoke appreciatively of practitioners whose approach encompassed responding to multiple needs (e.g., material and psychosocial needs), either directly or by referral. Some practitioners were described as not open to hearing about practical problems. To illustrate, Rumi appreciated his practitioners connecting him with activities that provided him a sense of purpose, and dealing with practical sources of distress:

If I need some help regarding my accommodation or other things … they also give me some advice on this, like they don't mind if I ask them something which will be otherwise look silly to someone else, like other doctors.

In a related comment, Daniel recommended, “If you really want to help the youth you have to try to find them a job.”

Generally, participants expressed a preference for broad parameters in their sessions, wanting to be able to ask questions freely, raise topics that mattered to them, and seek advice. For example, Maryam recommended practitioners avoid narrowness and “try to answer people if they ask you questions,” commenting, “the counsellor is not giving you advice. And I don't like this. I think they should.” She laughed, “I can talk with myself at home.”

Although not prominent in participants' narratives, medication was a treatment strategy experienced by several. Discourse around medication was typically matter-of-fact, neither highly positive nor negative. Of note, four participants had explicitly or implicitly indicated that without professional intervention, they could have become acutely suicidal, and each of these four had been prescribed medication as well as “talking” treatments.

The therapeutic relationship

Participants strongly emphasised the relationship with their practitioner as key to their experiences of services; in particular, they noted the importance of trust, the sense of a caring connection, recognition, and respect.

Many participants spoke at length about trust. In the words of Daniel, “you just have to be able somehow to gain the trust and build relationship … [Young people are] hotheaded and they're very prideful … deal with them good from the beginning to be able to win them across.” He observed increased mistrust amongst former immigration detainees, saying, “the policy of the camp is for the counsellors to just see people are eating and drinking … They would drug them up.” According to Daniel, trust develops gradually: “it just takes time to um, basically see if you can trust the person.” However, for Betoto, trustworthiness could be sensed immediately: “for me to even say the words and things like that, I have to feel this—I don't know how to say it—connection with the person, to know that they can understand me.” She commented, “I actually look at that before I even say anything—whether they're gonna help me or not—like I can feel it.” Factors that enhanced or hindered trust were discussed, for instance, Jay raised intrusiveness—“this person is forcing me to, you know, to tell what I don't like to tell at the moment”—and Stamma linked genuine care with heightened trust: “the fact that they're showing that they care about you makes you trust them.”

A caring connection in which the young person felt heard, known, recognised and understood often seemed to be central to the discourse of those participants who were satisfied with the service. In the words of Sara, “it comes down to just how human someone can be.” For Rumi, what was “most important” was knowing “someone cares for you.” His comments highlight the role practitioners can play in countering degrading experiences, for example, he considered feeling recognised and valued to be particularly important,

[F]or those peoples … who have been tortured or something like that, because the torturer, they, they show you your life valueless … like you have no value, they do it in a very organised way. It happens to me that's why I'm telling you.

Aisha emphasised the strength of her connection with the practitioner, saying, “all the week I’m waiting to see her to talk and to share.” She added, “actually we’ve been friends from the first time.” Indeed, participants commonly characterised the relationship as one of friendship or kinship, with some describing the professional as like a substitute family member. For example, Daniel commented, “I was very comfortable with her, she’s just like my sister … I would like to continue to come and talk to someone about all the issues, ‘cause we don’t have a family.” Similarly, Betoto said her father was, “happy there’s somebody there to help, ‘cause he’s not there, you know, he’s not here to help, or Mum.”

Some participants recounted the absence of a sense of connection and negative feelings towards practitioners. Lionel felt “they were just doing their job.” Stamma commented,

He was very stubborn and it was obvious he was doing it for the money. Like it wasn't enough time … I just hated his guts and I couldn't see why I had to go and suffer … He was just not helpful or he was just not getting us … I felt he was being disrespectful … We were new to the country and … we had to travel by train then take a tram and sometimes we might be a bit late, but he wasn't understanding one bit.

As conveyed above, the importance of respect and responsiveness was emphasised. For instance, Tania recalled thinking, “she doesn’t want to hear my feelings; what’s the point” when her practitioner smiled in response to her outpouring of distress. Tania changed the topic to her hobbies and after that session switched practitioners. She commented that her new practitioner, “knows my feelings, my insides,” helps her “let it all out,” and shows sadness on her face in empathy with Tania’s suffering. Some young people sometimes felt practitioners were disrespectfully invasive, leading Ahmed to suggest, “psychologist should ask the client first, ‘what you like to talk, and about what you don’t like to talk?’ Don’t just ask whatever they like!”

Many participants stressed the need to be well listened to and responded to, as Jay explained: “it would be better if like a counsellor listened and like, you know, not just to sit back and open their ears … to respond back, to show that they're in a mood of listening to the stories.” Similarly, Betoto commented,

They say it all the time, and most of the counsellors do: ‘yes, I understand, yes, dah, dah, dah, I get what you’re saying, dah, dah, dah.’ Okay, I think that doesn’t help at all … because your feeling is different to what they’re saying. I think that they should listen more, and then talk after they observe what you’re saying. And also the information that they give you, some of them don’t give you enough information, so you feel like you’re just still lost … But with the ones that you know you’re gonna click … they do a lot more talking to help you, not just you talking the whole session and then it’s finished, ‘oh yeah we’ll wrap it up.’

Discussion

This study captured a wide range of experiences of mental health services expressed by a diverse group of 16 young people from refugee backgrounds. Participants' agency came across strongly; they were not passive recipients of care. Most participants described improvements in their presenting problems and functioning, and alleviation of distress. Many of the findings overlap with the views of young service users from the general population. For instance, participants' concerns relating to the structuring and resourcing of the service system have been raised by other young service users (French et al., 2003; McCann & Lubman, 2012), and their stigmatising preconceptions—albeit more severe—echo those found in population-based research with youth (Rickwood, Deane, & Wilson, 2007). It is likely that many migrants, especially youth undergoing acculturation, share the views that participants in the present study expressed on cultural sensitivity. The theme that captured content most distinctive to refugees was that of psychosocial and traumatic stressors.

Participants described how their sociocultural contexts influenced their use of services, for instance, how close others—family and friends—could enable or inhibit the young person's engagement. Many participants recounted that opening up to a practitioner felt uncomfortable because they came from a family and community in which verbal emotional self-expression was more tightly bounded, experiences of violence were considered unspeakable, and mental health services were highly stigmatised (consistent with Goodman, 2004; Guerin, Guerin, Diiriye, & Yates, 2004; Whittaker, Hardy, Lewis, & Buchan, 2005). The fact that some participants were brought up with boundaries of the shared and the private self that differed from the host society norms in general, and from the norms of psychotherapy in particular (Kirmayer, 2007), caused some initial disquiet in sessions.

Participants' preconceptions were consistent with past findings about young refugees' mental health help-seeking attitudes, including distrust of and low familiarity with services, stigmatising attitudes towards service users, concerns about breaching family privacy, and a high threshold for determining need of mental health intervention (de Anstiss & Ziaian, 2010), although a small minority did approach services with favourable expectations. Of note, mental health professionals are scarce in the current study participants' homelands; for example Afghanistan has 0.1 psychiatrists per one million people (World Health Organization, 2011). Thus, many participants had arrived in Australia holding impressions of mental health service users based on extremely severe cases.

Service-level responsiveness mattered greatly to participants, who wanted services to treat them with sensitivity and promptly provide them a practitioner for the duration required. Waiting lists, ineligibility criteria, and continuity of care issues, including referrals from service to service, were described as distressing. Concerns were raised about the suitability of interpreters engaged by services. Many participants valued long-term interventions; outreach; flexibility and regularity of contacts; and multilevel forms of assistance to meet their needs (consistent with Colucci et al., 2015; Watters, 2008).

Cultural responsiveness was also very important to participants, and evidently often a challenge for practitioners. Participants portrayed culture as a complex interplay of ethnic, religious, linguistic, political, historical, and geographic factors, rather than a simple or static concept. Most were in the dynamic process of constructing a multifaceted cultural identity during their acculturation to the host society, as is commonly observed in refugee youth research (e.g., Whittaker et al., 2005), reflecting their exposure to varied environments and ways of life during their refugee journeys at critical developmental stages.

As Kleinman and Benson (2006) note, standard approaches to cultural competency can be particularly limited for clients who are “between worlds.” Several participants encountered practitioners who made incorrect assumptions about the level of salience of their background culture and religion. While stereotyping was considered problematic, so too was an individualised, decontextualised view which ignored local environments, sociopolitical considerations, and health inequalities (Jenks, 2011; Kirmayer, 2012; Kleinman & Benson, 2006). Participants conveyed that they felt understood by practitioners who recognised what mattered to them and the multiplicity of factors affecting them. Thus a nuanced approach to cultural sensitivity seems fitting, in which the practitioner views individuals in the context of the interpersonal and sociocultural worlds that they have been exposed to, and considers how they have reacted, positioned themselves, and constructed their own individual preferences.

Participants also wanted practitioners to recognise their life context in terms of the impact of psychosocial and traumatic stressors, both present and past. While “refugee” can be an unwanted identity label for some, and a term that obscures enormous diversity, participants did wish for practitioners to be mindful of their experiences as refugees over time. In particular, they wanted practitioners to recognise the history of violence and hardship affecting their communities, and that in many cases, leaving loved ones overseas in violent areas caused continuing anxiety. Because of the effects of fear for family in danger overseas on mental health (Nickerson, Bryant, Steel, Silove, & Brooks, 2010), practitioners need to think about the impact of trauma in an ongoing way (Brough, Gorman, Ramirez, & Westoby, 2003; Kaplan, 2013). Understanding of a range of psychosocial stressors, from social exclusion to educational issues, and from navigating relationships to coping with financial strain, was also desired of practitioners (Correa-Velez, Gifford, & Barnett, 2010; McFarlane, Kaplan, & Lawrence, 2011; Montgomery, 2011).

Some participants considered it important for clients to talk through traumatic experiences with practitioners, while some thought otherwise. This echoes the ambivalence about disclosure expressed by asylum seeker clients reporting on their subjective experiences of the exposure component of trauma-focused cognitive behavioural therapy (Vincent, Jenkins, Larkin, & Clohessy, 2013). Present study findings suggested that practitioners need to consider if, how, and at what point in time, a refugee client would benefit from disclosing and talking through traumatic experiences, which accords with the recommendations of Rousseau, Measham, & Nadeau (2013).

Treatment strategies seemed most likely to be helpful when they targeted issues considered relevant by the young person, particularly when delivered within a strong, empathically attuned therapeutic relationship. Some young people disengaged after feeling that the practitioner gave simplistic directives that conveyed a limited understanding of their suffering and its sources. Participants valued practitioners who showed openness to a range of causes of distress, answered questions and gave advice willingly, and assisted them directly or via referral with their multiple pressing needs. This is consistent with other refugee mental health literature highlighting the value placed on advice (Copping, Shakespeare-Finch, & Paton, 2010; Kramer, 2005), using advocacy to attend to the priorities of the person (Colucci et al., 2015), observing and addressing the interrelationship of practical problems and deeper psychological needs (Allan & Hess, 2010), and holistic practice combining health and social care (Watters, 2001).

Participants strongly emphasised the therapeutic relationship, in particular the importance of feeling understood, a close connection, trust, and attunement. They valued practitioners putting them at ease; genuinely listening; being nonjudgmental; and showing warmth, respect, responsiveness, compassion, and sensitivity. They seemed to be looking for a human encounter more than a traditionally “clinical” encounter. Like young clients from the general population (e.g., Buston, 2002; Cohen, Medlow, Kelk, Hickie, & Whitwell, 2009; Lee et al., 2006), the participants wanted to feel heard, understood, recognised, and cared for. Some participants called for attentiveness to client feedback, which is indeed associated with highly effective therapists (Duncan, Miller, Wampold, & Hubble, 2010). In recent research exploring therapy experiences of adult refugee clients, their therapists and interpreters, a close and compassionate therapeutic relationship was also a key theme (Mirdal et al., 2012).

In the present study, when participants described therapeutic relationships as good, they frequently characterised practitioners as friends or like family members. Although not unique to clients with refugee backgrounds (Hamilton, Bichara, Roper, & Easton, 2012), and clearly relating to the literature on transference, this phenomenon might be more pronounced among refugee clients. Young refugees may feel an increased need for a substitute attachment figure, because of loss, isolation, and family members being separated by war or less emotionally available due to traumatisation; or they may have no cultural reference point for the role of a mental health professional (Allan & Hess, 2010). Consistent with the findings of Mirdal et al. (2012), none of these participants characterised their practitioner as crossing boundaries; rather, they spoke favourably of these strong attachments.

When participants discussed poor therapeutic relationships, they described experiencing professional help as uncomfortable, insensitive, unhelpful, or retraumatising, and feeling misunderstood or invalidated. Participants seemed to be particularly sensitive to the experience of recognition—to being heard, acknowledged, and held in mind by the practitioner. Recognition is of particular importance to refugees on an interpersonal as well as legal level (Thomas, Roberts, Luitel, Upadhaya, & Tol, 2011). Perhaps because of experiences such as membership in a persecuted ethnic group, membership in a family with fractured attachments or that was forcibly separated, and residence in a new society often hostile to refugees, participants valued therapeutic relationships which countered lack of recognition in other spheres. In this vein, Kirmayer has argued that in pluralistic societies the politics of recognition enter the health practitioner–patient relationship, and that “through the expression of attentiveness, concern and commitment to appropriate and effective helpful action, the clinical encounter provides a site of recognition of the other” (2011, p. 412).

Conclusion

This study addressed a gap in our knowledge by focusing on the voices of young people from refugee backgrounds about their experiences as clients of mental health services. Participants valued accessible practitioners who combined content expertise with interpersonal qualities to make clients feel listened to openly, responded to aptly, and recognised as individuals affected by their circumstances (including cultural influences as well as past and present stressors). Participants' perspectives on good mental health practice broadly agree with systemic approaches to working with young refugees (Watters, 2008), and suggest that program delivery needs to integrate both trauma-informed approaches and systems-focused approaches (Kaplan, 2013). Within refugee youth research, a “systemic” perspective has been defined as conceptualising forced migration “as a multicausal and multidimensional process and addresses the interplay between internal and external factors in promoting distress or resilience in refugee children … as an individual, familial, social, cultural, and political reality ” (De Haene, Grietens, & Verschueren, 2007, p. 241). Overall, the emphasis placed by participants on the multiplicity of relevant factors and on the relational aspects of their experiences with services calls for practitioners to work with this population using a contextualised and systemic approach that is attuned to the individual's experience. For practitioners to work in this way, the services and systems they work within need to enable them to prioritise empathic therapeutic relationships, to be trained about this population, modify assessment processes and interventions, and address clients' practical needs directly or by referral.

Many of the study implications have long been called for in the broader field of youth mental health in terms of a shift towards person-centred, culturally safe, recovery-oriented, systemic, and holistic care (Rosenberg & Hickie, 2013). Participants wanted practitioners to heed their views. They wanted to be understood as affected by interplaying, dynamic factors, both current and historical, and to be seen in their richness and complexity—as would most clients. In the lives of the participants, these factors were particularly wide-ranging (e.g., from fear for loved ones overseas to study-related stress), and often life-changing (e.g., traumatic loss, loss of home, and forced migration). A key implication for practitioners is that it may be helpful to seek layers of knowledge relating to refugees, including homeland histories, the impacts of traumas, host society conditions, cultural influences on concepts of mental health, and acculturation trajectories. In applying this knowledge, practitioners need to consider its relevance to any one individual, thus practitioners need to couple knowledge with qualities such as openness to being guided by the client as to what matters to him or her. This quality is closely related to that of empathic attunement, which is often called for in the general trauma literature. Professional development for practitioners therefore needs to address knowledge, skills, attitudes, and relational qualities. The finding that many participants characterised their relationship to their practitioner in terms of friendship or kinship—which may be a heightened propensity in this population—requires further research, for example, regarding to what extent it complicates boundaries for practitioners.

Several participants called for raising awareness among young refugees about when and how to access mental health assistance. Services in turn need to be equipped to respond appropriately to meet the needs of these clients to avoid an off-putting first encounter that might negatively influence their help-seeking attitudes for years to come. Broader implications include recognition of the need for well-located, accessible, flexible, and adequately trained and resourced services that have “no wrong doors” for new clients. Ideally, young refugees should be genuinely involved in the planning and evaluation of service delivery (Watters, 2008). Services need to create the conditions for strong therapeutic relationships; to support practitioners to think critically about the applicability, acceptability, and efficacy of treatment approaches for this population; and to support practitioners to address their clients' practical needs directly or via referral.

The major limitation of this study was the small and unrepresentative sample. Underrepresented categories included new arrivals, group therapy clients, marginalised “at-risk” youth disengaged from all societal institutions, and young people with severe mental illness. The breadth of the interview was a strength but meant that some areas could not be covered in detail. Research on this topic could be extended by interviewing youth both during their time as clients and afterwards, by triangulating interviews with focus groups and anonymous written feedback, by interviewing their practitioners and analysing files, by interviewing family members, by asking participants more about their own mental health history and concepts of mechanisms of change, and by including young refugee clients or former clients as part of the research team to further the coproduction of findings. As research progresses beyond the exploratory phase, different study designs could enable comparison between subgroups (e.g., type of service received, type of presenting problems, acculturation levels, years in host country), and delineation of predictors of when clients will experience an intervention as satisfactory.

Footnotes

Acknowledgements

We thank the young people who shared their experiences, thus making this study possible. We acknowledge all those who assisted with recruitment and contributed ideas to the study, especially the group of advisors, with particular thanks to Susannah Tipping for cross-coding during data analysis, and to Andrea Polari of Orygen Youth Health. We are also grateful to Lauren Ban and to Liz Alexander for their comments on an earlier draft of this article.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded as part of a grant from the Sidney Myer Fund and the William Buckland Foundation.

Madeleine Valibhoy, BA (Hons), DipCA, Dpsych (Clin), is a clinical psychologist. In her capacity as a Research Fellow at the Victorian Foundation for Survivors of Torture (Foundation House), she has been the Principal Investigator for Project TYRES (Talking with Young Refugees about Experiences of Services). She has also worked for several years as a counsellor/advocate at Foundation House with children, youth, and families who have been refugees. Her main areas of interest are child, adolescent, and family clinical psychology, and refugee mental health; and more specifically, conceptualisations of mental ill-health across cultures, and service user experiences amongst young people from refugee backgrounds. She has worked as a psychologist in schools.

Ida Kaplan, BSc (Hons), MSc, PhD, is Direct Services Manager at the Victorian Foundation for Survivors of Torture and an Honorary Research Fellow in the School of Psychological Sciences, University of Melbourne. Dr Kaplan researches the development and use of computer-assisted interviews for assessing well-being in refugee children and young adults and the impact of immigration detention on asylum seekers; she is a Co-Chief Investigator of a study on children living in out-of-home care. She has extensive experience, locally and internationally, in training professionals in the provision of interventions for survivors of torture and other traumatic events and has a long-standing policy, practice, and research interest in the intersection of mental health, social justice, and human rights issues.

Josef Szwarc, BA (Hons), is Manager of Research and Policy at the Victorian Foundation for Survivors of Torture. He has worked in governmental and civil society agencies on a range of domestic and international social policy and human rights issues, and is a member of the Board of the Equal Opportunity and Human Rights Commission of the state of Victoria, Australia. His recent publications focus on the accessibility of mental health services for young people from refugee backgrounds, the accessibility of maternity and maternal and child health services for refugee families, and the role of interpreters in psychotherapy.

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