Culturally-Sensitive Mental Health Services for Immigrant and Refugee Populations

Samantha Allweiss, LCSWSamer Hussein, BA

Professional Development TrainingKansas City

November 15th, 2018| 9am-11:00 a.m.

© 2017 RefugeeOne. All Rights Reserved. Materials cannot be reproduced without advance permission.

Presentation Agenda

• Overview – Facts and figure, populations served

• Defining mental health – The universal themes of migration trauma

• Mental health trends in the immigrant/refugee community – The prevalence of adverse mental health symptoms

• Practice Strategies– A quick intervention guide for community-based workers & strategies for working with interpreters (Samer Hussein)

• Final remarks with Q & A session

Department of StateOffice of Admissions – Refugee Processing CenterRefugee Admissions by RegionFY 1975 through 31 – Jan 2017

Refugee Processing Centers Admissions Data http://www.wrapsnet.org/admissions-and-arrivals/

Refugee Admissions

Refugee AdmissionsNumber of Refugees Resettled

Country FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 FY 18 Totals

1 Afghanistan 9 19 2 1 16 16 49 74 5 191 3%

2 Angola 1 1 0%

3 Bhutan 38 43 12 23 5 9 8 3 141 3%

4 Bosnia 7 7 0%

5 Burma 2 35 132 98 153 140 73 140 91 109 66 17 18 1,074 19%

6 Burundi 17 35 3 20 12 0 87 2%

7 C A R 2 3 7 7 11 1 0 31 1%

8 Congo 1 14 10 6 52 71 118 174 100 108 654 12%

9 Cuba 45 83 25 31 68 84 59 24 13 57 23 3 1 516 9%

10 Eritrea 5 14 6 1 16 10 23 1 76 1%

11 Ethiopia 2 4 1 7 2 1 1 14 7 3 42 1%

12 Ivory Coast 6 6 0%

13 Iran 11 21 2 3 6 1 0 44 1%

14 Iraq 5 2 53 113 95 54 82 61 45 62 41 43 5 661 12%

15 Liberia 44 27 4 2 8 1 1 87 2%

16 Mauritania 1 9 7 5 22 0%

17 Pakistan 4 1 5 10 0%

18 Russia 1 6 18 25 0%

19 Sierra Leone 1 1 0%

20 Somalia 80 23 38 103 61 144 107 90 70 121 140 109 105 87 6 1,284 23%

21 Somali Bantu 56 71 10 9 146 3%

22 Sudan 75 24 31 6 1 13 8 4 1 14 44 8 22 37 1 289 5%

23 Togo 2 2 0%

24 Uganda 1 1 0%

25 Ukraine 2 9 10 21 0%

26 Rwanda 5 5 0%

27 Vietnam 7 18 13 23 2 63 1%

28 Syria 85 28 113 2%

29 CAM 1 1 0%

TOTAL 326 272 138 243 400 492 468 370 309 479 480 459 589 415 161 5,601 100%

cumulative 326 598 736 979 1379 1871 2339 2709 3018 3497 3977 4436 5025 5440 5601

Refugee Populations

Migration Experiences Matter

• The adjustment process and mental health problems for any new immigrant is directly influenced by the three elements of their migration journey:• Pre-migration experiences

• Experiences in transit

• Post-migration / resettlement experiences

Life in a Refugee Camp

• Sleeping accommodations• Medical facilities• Hygiene facilities• Food distribution centers• Education/common areas• Security check-points• Daily activities

View Salam Neighbor on Netflix

Life in an Urban Camp

• Overcrowded apartments in urban settings

• Status similar to undocumented immigrant without authorization to work despite UNHCR Protection Letter

• Minimal access to education or medical care

• Easily harassed and bribed with threat of arrest. Violations of human rights common

Experiences in Transit

• Great uncertainty of what comes next and excitementabout the future.

• Most refugees typically sell/give away all their items when they are approved for travel, and travel a great distance to get their port of exit.

• While some may have a route planned, some refugees do not know their receiving city until their day of travel.

• The Executive Order signed Jan. 28, 2017 has left a great deal of fear and disbelief for many immigrants and refugees.

Post-migration Experiences: New Arrivals in the U.S.

• What are the most important things a refugee living in the US should know?

Adjustment to a New Country is Tough

• Surviving winter.• The rights of a U.S. citizen.• Public benefits and using U.S. currency. • Grocery shopping.• English – reading and writing.• Finding a job.• Riding public transportation.• Getting children/adults enrolled in school.• Finding a doctor, dentist, or other medical

professionals.• Living in an apartment and using all the

appliances.• Riding in an elevator or using a revolving door.

Universal Themes Surrounding theImmigrant/Refugee Experience and Trauma• Refugees come with their unique and

collective trauma narrative• History of fear and uncertainty• Need for safety• Loss of homeland, loved ones and

cultural underpinnings• Worry about the future• Feelings of guilt for families left behind

or for personal safety• Feelings of loneliness, homesickness &

isolation• Cumulative impact of migration

experiences on mental health.

What is Mental Health?

Definition -- Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood (mentalhealth.gov)

Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected.

Many factors contribute to mental health problems, including:• Biological factors, such as genes or brain chemistry• Life experiences, such as trauma or abuse• Family history of mental health problems

How do Immigrants and Refugees Define Mental Health?

• The term “mental health” has a negative connotation in many cultures.

• Mental health is sometimes correlated with “being crazy” or a product of moral failing. Conversely, mental illness can be seenas a gift or curse, or something unspoken (“it just is”).

• It is only understood through physical health symptoms.

• Many cultures see mental health as a private matter that is not to be discussed.

• Some cultures do not realize that poor mental health symptoms are a problem; it is part of the collective group experience and seen as normal.

Prevalence of Adverse Mental Health Symptoms for Adults

• Common symptoms:• Prolonged sadness with poor coping skills• Increased anxiety and frustration levels• Poor sleep patterns and appetite• Difficulty concentrating• Suicide risk• Intimate Partner/Family Violence• Substance abuse• Severe mental illness: Schizophrenia,

Bipolar I, Major Depressive Disorder , PTSD

Somatic Symptoms

• In many cultures, mental health problems present in physical ailments including:• Chronic pain and headaches• Tingling/burning sensations in their extremities• Chest pain / rapid heart beat • Persistent coughs and sores• Persistent fever with chronic fatigue (flu-like

symptoms)

üEvaluations are needed to rule-out a medical condition.

üEducation is necessary to help clients understand the nature of their symptoms in terms that are safe and accessible.

Mental Health Trends among Refugees

*Based on data collected 2011-2016 from the RefugeeOne Wellness Program

Country of Origin Language Common Symptoms

Mode of Treatment

Iraq Arabic MDD, PTSDGeneralized AnxietySomatic symptoms

Individual + Psychiatric*education-levels signif.

Syria Arabic MDD, PTSDSomatic symptoms

Individual + PsychiatricGroup

Bhutan Nepali Generalized Anxiety,DV (local/national)

GroupPsychoeducation

Burmese Karen, Burmese, Rohingya

Generalized AnxietySubstance Abuse, DV (local/national)

GroupPsychoeducation

Democratic Republic of Congo

Swahili, Kinyarwanda

Somatic symptomsMDD

GroupPsychoeducation

Columbia Spanish MDD, Generalized Anxiety

Individual + Psychiatric

© 2015 RefugeeOne. All Rights Reserved.

The Two-Generational Model of Trauma

• Trauma has the ability to freeze the relationship between parent and child.

• Excess stress disrupts the architecture of the brain in a young child.

Poor Mental Health in Children: What Does it Look Like? (Resource: NCTSN)

Birth 0-2 years Age 3-6 years

• Cognitive: Poor verbal skills, memory problems

• Behavioral: Excessive temper*, attention-seeking (+/- behaviors)*, regressive/aggressive behaviors*, cries excessively, easily startled*, separation anxiety*, irritability*, sadness*, withdrawn*

•Physiological: poor appetite, low weight, poor sleep*, sleep difficulties*

• Cognitive: Difficulty learning, poor skill development

•Behavioral: Acts out, imitates traumatic events, verbally abusive, unable to trust and make friends, believes they are to blame, anxious, fearful, avoidant, lack self-confidence

•Physiological: Experiences stomachaches/headaches, regressive traits including bed-wetting

The Effects of the Current AdministrationImmigrant arrests soar under Trump –

ABC News – 5/17/17With Ally in Oval Office, Immigration Hard-

liners Ascent to Power – NYT 4/24/17

Texas lawmakers pass bill allowing police to ask about immigration status – USA Today 5/3/2017

Indian detained at Atlanta airport diesin custody – Times of India 5/19/2017

ICE activity in Virginia spikes under Trump –Inside NoVA 5/4/17

Judge blocks Trump effort to withhold money from sanctuary cities – NYT 4/26/17

Homeland Security unveils sweeping plan to deport undocumented immigrants – USA Today 2/21/17

Speaker: Samer Hussein• Clinical Interpreter &

Outreach Worker• Coordinates clinical and

psychiatric appointments• Completes mental health

assessments• Provides medical case

management • Assists in SSI applications• Primary interpreter for Arabic

speaking individual, group and psychiatric services

• Refugee from Iraq• Born in Kuwait • Threatened in Iraq• Fled Iraq for Jordan in 2001• Lived for 13 years without legal

documentation • Received refugee status in 2012

and moved to Chicago in 2013

Central Themes of Culturally Appropriate Interventions

There are three themes you will encounter: 1. Priority of resettlement needs

2. Pre-migration, transit, post-migration stressors

3. Experiences of profound loss and trauma

© 2017 Aimee Hilado. All Rights Reserved – see Hilado (2017). Practice with Individuals on Resource slide

Trauma Informed Practice Strategieso Provide psycho-education to staff and clients about traumao Screen and assess for trauma o Create a safe and comfortable environmento Teach and practice safety planning and harm reductiono Identify and build support systemso Listen and be present to clients’ stories: not just therapistso Validate emotions even if you don’t understand themo Remind clients that recovery is possible & they deserve to feel better

Application: The Value of Psycho-Education

Topics:• How to support physical & mental

healtho Diabetes, hypertension & medication

management

o Trauma, stress management & healthy relationships

o Identifying the signs of depression

o Mental Health 101

• Combating domestic violence & family violence

• Positive parenting & importance of early development

Format of Psycho-Education Sessions

• Length: 1 hour (with interpretation)• Frequency: 3-part series run over 3 weeks• Format: Language specific groups, gender-

specific as appropriate

PURPOSE:

1. Normalizing, Informing, & Connecting to Resources

2. Holistic: Mind/Body Connection

3. Delivery: Can be non-clinical/clinical staff, interns & Staff Interpreters

Application: The Value of Group Therapy

• The group modality is often inline with the cultural norms of the immigrant and refugee cultures served.

• It fosters a sense of community through shared experiences and can be less threatening than individual sessions.

• It is an effective vehicles for contextualizing mental health symptoms and providing education that normalizes therapy services.

Application: Working with Congolese Clients

• Traumatic experiences will be shared without hesitation or with an atypical affect (normalization of trauma)

• Discomfort is tempered with laughter

• Self-reflective and goal-setting process is novel

• Poor functioning described in health (somatic) and adjustment terms

• Less likely to take medication or request therapy

• Useful tips: Psychoeducation/CM integrated

• Useful approaches: Expressive Communication Therapies in group settings (e.g., art therapy)

Application: Working with Burmese Clients

• Very little disclosure of trauma

• Many have had prolonged stays in their displaced countries. Focus is primarily on moving forward and the children.

• Poor functioning described in health (somatic) and adjustment terms. Similar to Congolese, the are less likely to take medication or request therapy but requests are more tied to adjustment

• Useful tips: Psycho-education/CM integrated

• Useful approaches: Solutions-focused, community approaches, somatic-based approaches with mindfulness techniques, and home-based services for families with young children and sessions in group settings

Working with Interpreters/Cultural Brokers

In-Person Interpretation Phone Interpretation• Pros:

• Consistent access for the client

• Potential for greater disclosure

due to anonymity

• Cons:

• Non-verbal cues can be missed

• Challenges in feeling

comfortable with the technology

• Cost-prohibitive

• Pros:

• Stronger level of connection

• Focus on verbal and non-verbal

communication possible

• Cultural broker available

• Cons:

• Concerns about privacy and

confidentiality

• Requires more coordination of

schedules

• Issues with dual-roles

Practice strategy: The interpreter should not alter what is being said, interprets

using 1st person language and reflects the tone, volume, and inflection of

the speaker.

Common Denominators of Effective Interventions

First and foremost….Relationships matters!

• It is built on cultural understanding, attention to basic/resettlement needs, and flexible yet consistent support.

• The “vehicle’ includes:• Providing relevant information

(psychoeducation)• Demonstrating personal investment in the client

through critical consciousness (learning about culture and adjusting treatment methods)

• Cultural humility through acknowledging the role of family, religion and culture in practice

The Impact of Secondary Traumatic Stress on Effective Practice

STS refers to the presence of PTSD symptoms caused by at least one indirect exposure.

Other related terms:• Compassion fatigue – used interchangeably with STS• Vicarious trauma – changes in the inner experiences of the therapist resulting in

disturbances in the professional’s cognitive frame of reference in the areas of trust, safety, control, esteem, and intimacy.

• Burnout – characterized by emotional exhaustion, depersonalization, and a reduced feeling of personal accomplishment.

• Compassion satisfaction – the positive feelings derived form competent performance as a trauma professional.

üTo do this work well, recognize the signs of STS and any of the other related terms.

üEarly identification and thoughtful intervention will aid the process.

Resources

• Hilado, A. (2017). Practice with individuals. In A. Hilado & M. Lundy (Eds). Models for Practice with Immigrants and Refugees: Collaboration, Cultural Awareness and Integrative Theory. Sage Publications. Thousand Oaks, CA.

• Hilado, A., & Lundy, M. (2017). Maintaining critical thinking and self-awareness skills: The common denominator. In A. Hilado & M. Lundy (Eds). Models for Practice with Immigrants and Refugees: Collaboration, Cultural Awareness and Integrative Theory. Sage Publications. Thousand Oaks, CA.

• United Nations High Commission for Refugees (www.unhcr.org)

• U.S. State Department Website (www.state.gov)

• Refugee Processing Centers Admissions Data http://www.wrapsnet.org/admissions-and-arrivals/

Contact Information

Samantha Allweiss, LCSW

Manager of Clinical Operations:The Wellness ProgramThe Wellness Program at RefugeeOne

Email: sallweiss@refugeeone.org

Founding member of theIllinois Refugee Mental Health Task Force

www.ilrmh.org