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Mental health care for refugees should emphasize optimism, resilience


 

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SAN DIEGO – More than 263,000 refugees lived in the United States in 2013, according to the United Nations High Commissioner of Refugees. These families often receive no mental health care or orientation to American schools, said Dr. A. John Sargent III, who is chief of the division of child and adolescent psychiatry at Tufts Medical Center in Boston.

But instead of therapy that focuses on problems and conflicts, refugees need help building confidence and resilience by focusing on strengths, cohesiveness, and connections between children and parents, Dr. Sargent and his fellow speakers said at the annual meeting of the American Association of Child and Adolescent Psychiatry.

Therapy for refugees should not center on approaches such as “tell me more about it,” or “how do you feel,” said Dr. Rama R. Gogineni, who is head of the division of child and adolescent psychiatry at Cooper University Health Care in Camden, N. J. “If we just see them as victims, we overidentify with the victim and are not able to treat them, not able to bring out their strength and resiliency.”

In therapy, refugee parents and elders need to learn to encourage their children and enjoy their success, maintain optimism through shared rituals and experiences, and foster a strong work ethic and shared aspirations, Dr. Sargent said. As with dialectical behavior therapy, refugees first need to feel safe and know that their basic needs are met before they begin processing past traumas, he emphasized. “American providers may be influenced by trauma therapy models that don’t apply here,” he said. “We want to get to the trauma right away and that can be disrupting and harmful.”

The ultimate goal of therapy for refugees is a “life worth living,” Dr. Sargent added. “Really feeling good about what you are doing and where you are.”

About 40% of refugees in the United States are children, noted Dr. Suzan Song, a psychiatrist and medical director for Asian Americans for Community Involvement in San Jose, Calif. “I have to be very sensitive, because I don’t want parents to think that they are traumatized and therefore their children will be traumatized,” she said. “I take a resiliency perspective when I speak to these children and their families. I ask parents to go internally and ask what are you proud of; what do you hope for your kids; what do you want your family to look like; what cultural values are most important to you; and what are you willing to let go?”

Mental health providers should avoid reflexively applying a single therapeutic model to all refugees, Dr. Song said. “Just because someone is a refugee doesn’t mean they would benefit from narrative therapy vs. cognitive-behavioral therapy.”Clinicians also should take care not to equate the refugee experience with that of immigrant families, the speaker said.While immigrants come to the United States voluntarily and may be more open to adopting U.S. culture, “refugees want to be home and may insist on retaining their own customs,” Dr. Song said.Refugee parents also might rely heavily on children to serve as cultural and linguistic brokers while simultaneously struggling to understand their children’s Americanized dress and behavior, Dr. Sargent said. Children, for their part, may be “disappointed in their parents” and perceive them as “weak” because of their difficulty in adapting, he said. Perhaps not surprisingly, astudy at Dr. Song’s clinic found that current family stresses were the most common presenting complaint, she said.The journey from a conflict-torn home country to resettlement in the United States involves several areas of stress and challenge, Dr. Sargent said. Torture, poverty, rape, loss, or separation from loved ones, and enslavement are all potential traumas at home, he said. In war zones, “Boy child-soldiers are there to fight,” he added. “Girl child-soldiers are there to be sex slaves.”

During their flight from home, refugee families might face the same stressors as well as hunger and exhaustion, Dr. Sargent said. Families also may split up, only to be relocated in different refugee camps without the means to find one another, he added. And camp life can be a daily struggle that includes sexual assault, impoverished conditions, hunger, exhaustion, sleep deprivation, and high noise levels, he said. “The thing about refugee camps is that people are encouraged to be passive,” Dr. Sargent added. “They do not have power over their well-being. They are encouraged to sit and wait, and they are often pawns in a political struggle.”

After arriving in the United States, refugees face a “completely new environment” as well as poverty, language struggles, limited access to services, and more potential separations from loved ones, Dr. Sargent said. “Those crossing the United States-Mexico border with ‘coyotes’ may be expected to pay with sex,” he added. “For some families, the journey is a source of resilience, and for others, it is disrupting and highly traumatic. We have to learn which is which.”

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