Enhancing Evidence-Based Interventions for Refugees

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By: Sara L. Buckingham, MA and Melissa Paiva-Salisbury, MA

Sara Buckingham, MA

Numerous refugees from diverse nations have resettled in Vermont. New England Survivors of Torture and Trauma (NESTT) provides comprehensive mental health, social work, and legal services to refugees. As doctoral clinical psychology interns, we provide culturally-informed, linguistically-appropriate, evidence-based intervention services. In this article, we detail how efficacious interventions for torture and trauma have been adapted for refugee populations and integrated into multidisciplinary care.

 

Displacement and Resettlement

Melissa Paiva-Salisbury, MA

Approximately 65.3 million people worldwide have been forcibly displaced (UNHCR, 2015). Asylum-seekers flee their countries and live as unauthorized residents while navigating the asylum process; refugees are designated by the United Nations and often placed in temporary camps. During this period, refugees and asylum-seekers are not authorized to work and largely live in impoverished, unsafe conditions. In 2016, fewer than 1% of the world’s refugees were resettled (UNHCR, 2017). A person spends an average of 17 years in a camp prior to resettlement and 2–6 years in the U.S. as an unauthorized resident after seeking asylum (American Immigration Council, 2016). Approximately 44% of refugees and asylum-seekers in the U.S. are survivors of torture (Higson-Smith, 2015).

Since the 1980s, Vermont has resettled over 7,500 refugees from over 25 countries. Many new Vermonters are refugees from Bhutan. Beginning in the 1970s, the Bhutanese government attempted to create a uniform Drukpa ethnic culture by politically, economically, and culturally excluding the ethnically Nepali community (UNHCR, 2011). Nepali-Bhutanese people were driven out; those who protested were imprisoned and tortured. The government ran effective public relations campaigns to delegitimize claims of expulsion, leading many countries, including the U.S., to not resettle Nepali-Bhutanese refugees until 2008. Through public and private funds, U.S. Committee for Refugees and Immigrants (USCRI) organizations financially support refugees for their first six months post-resettlement. After that time, refugees are expected to be self-sufficient, despite language barriers, transportation challenges, and education and skill differences, compounded with the possibility of having significant trauma histories.

            Mental Health Treatment with Refugees

Connecting Cultures is a specialty psychological services program through NESTT, housed in a community-based clinic at the University of Vermont’s Department of Psychological Science. Connecting Cultures provides intervention services to refugee and asylum-seeking children, adults, and families. Clients present with diverse concerns, including impairing reactions to prolonged trauma related to war, persecution, torture, adverse camp conditions, and resettlement. Evidence-based treatments for trauma include prolonged exposure (Foa, Hembree, & Rothbaum, 2007), cognitive processing therapy (Resick & Schnicke, 1996), trauma-focused cognitive behavioral therapy (Cohen & Mannarino, 2008) and narrative exposure therapy (designed for refugees; Schauer, Neuner, & Elbert, 2005). Many treatments include exposure to traumatic events, which allows clients to learn alternative responses to recalling events and theoretically facilitates extinction of fear reactions and associations. While efficacious, many exposure-based treatments have limitations in their applicability to refugees, given the chronic and ongoing nature of trauma and resettlement stress, and diverse cultural norms and expectations related to mental health.

At Connecting Cultures, we use the Chronic Traumatic Stress (CTS; Fondacaro & Mazzulla, under review) treatment framework to adapt evidenced-based techniques for the populations we serve. Refugees frequently experience trauma after resettlement, as their families often remain in areas of active war or impoverished, dangerous camps. Additionally, refugees experience post-migration/resettlement stressors, such as unemployment, poverty, discrimination, transportation difficulties, and acculturative stress, which may intensify the effects of trauma (e.g., Schweitzer, Brough, Vromans, & Asic-Kobe, 2011). Moreover, daily stressors impact functioning. Therefore, the CTS treatment framework seeks to unify trauma treatments while supplementing with acceptance and commitment modalities, distress tolerance, mindfulness, grounding, and active coping techniques that are client-centered and culturally-consistent. For example, we flexibly utilize Image Rehearsal Therapy (IRT; Krakow et al., 2011) to target nightmares by allowing clients to adapt nightmares in culturally relevant ways, and we incorporate clients’ indigenous coping strategies, such as prayer, meditation, and singing.

Expanding Beyond Individual Mental Health Treatment

Because clients have diverse needs and circumstances impacting their mental health, NESTT coordinates psychological, social work, psychiatric, and legal services. In addition to psychological treatment, each client has social work services available to address basic needs, such as assistance with housing, employment, transportation, and language barriers. Therapists receive psychiatric consultation from University of Vermont Medical Center psychiatrists to ensure that clients receive appropriate referrals. The legal arm of NESTT provides refugees access to pro-bono legal services (e.g., asylum, citizenship, family reunification).

We have recognized the necessity of not only serving clients through multidisciplinary teams, but also situating ourselves in the community and partnering with trusted organizations. We literally meet clients “where they are” – in community centers, homes, and schools. For example, Connecting Cultures has a satellite office in a trusted and frequented community center, The Association of Africans Living in Vermont (AALV). We collaborate with and work alongside key stakeholders, allowing relationships to form naturally and building on each organization’s strengths. By learning from community partners, positioning ourselves as a resource, and continually conducting informal needs assessments, we are responsive to the community. For example, we created an “alumni group” to help survivors of torture step down from individualized mental health care. However, as clients told of friends who could benefit from the group but were not previously connected with NESTT services, we soon transitioned to a “community engagement” group. Facilitated by doctoral psychology interns with a refugee co-facilitator who also serves as a cultural consultant, this group uses principles of behavioral activation (Lewinsohn, 1975) and sense of community (McMillan & Chavis, 1986) to help isolated members engage with their communities and form connections post-resettlement.

Case Example

 K is a 56-year-old Nepali-Bhutanese man invited by his neighbor, a former Connecting Cultures client, to attend a community engagement group at AALV. After several groups, K approached the cultural consultant co-facilitator regarding individual mental health treatment. The co-facilitator enabled communication between K and an intern to set up a Connecting Cultures intake.

At his intake, through an in-person interpreter, K reported that he rarely leaves the house, cannot work, and is unable to cook for himself. K described being forced to leave Bhutan when he was 22 with his wife and child. Although illegal to work in Nepal, K reported it was necessary for survival over his 18 years in the refugee camp. On multiple occasions, K was caught by police and beaten severely for leaving camp boundaries for work. While K experienced symptoms consistent with posttraumatic stress, his primary concerns were loneliness, isolation, fears of the community, and dysphoria. Because he was considered an elder, he was not expected to work, cook, or travel alone. During the first therapy sessions, one of K’s daughters accompanied him.

Assessment of K’s needs revealed limited access to transportation, resulting in an immediate referral to in-clinic social work services. The social worker aided K in qualifying for ride assistance to medical appointments, ensuring he could attend therapy. Further, the social worker assisted K in learning bus schedules, facilitating his attendance of English classes.

Treatment began by establishing K’s sense of safety and identifying some indigenous coping tools. K highlighted the importance of Hinduism, which was incorporated into the CTS framework by including religious practices into his valued activities. Further, as Hinduism employs meditation, K incorporated his own understanding of and relationship to mindfulness as central treatment components. He began mindfully breathing, and coupled with psychoeducation around sleep hygiene, he reported sleep improvements. Additionally, K utilized IRT by changing threatening men in his dream into docile dancers. Throughout treatment, K attended the community engagement group and reported increased connections, ease with leaving home, and participation in valued activities.

As treatment progressed, K expressed interest in processing past traumas. Through a visual life-path activity, K shared moments of his life that brought joy and those that brought pain and fear. Following psychoeducation and development of a hierarchy, K chose to narrate several events in detail, which were used as guides for subsequent imaginal exposures. Throughout exposures, K was prompted to use relaxation and grounding strategies. K maintained control over the timing and intensity of exposures. His symptoms decreased, his functioning improved, and he increased value-driven actions. K was subsequently discharged from individual mental health services, though he still attended the community engagement group and participated in cooking classes. Later, he sought legal services regarding challenges applying for citizenship.

Conclusion

Our work as Connecting Cultures therapists through NESTT highlighted unique considerations in trauma treatment with refugees. As psychologists-in-training, we desire to strengthen skills in delivering culturally-informed, evidence-based treatment. However, basic needs are pressing for our clientele, impacting emotional instability; thus, involving social workers is crucial. Even with effective interventions, the chronicity of war trauma and resettlement stress is challenging. It is not uncommon to have a client ready to discharge only to hear that her child recently ‘disappeared’, that a grandchild was murdered, or that reunification of family members has stalled yet again. This begs the question, when does treatment end? We believe it is important to be present in the community, collaborating with organizations to meet pressing needs while not duplicating existing services. Finally, adapting evidence-based treatments to incorporate culturally-consistent strategies is key to serving diverse community members.

References

American Immigration Council (2016). Asylum in the United States. Retrieved from https://www.americanimmigrationcouncil.org/research/asylum-united-states

Cohen, J., & Mannarino, A. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child & Adolescent Mental Health, 13, 158–162.

Foa, E. B., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide (treatments that work). New York, NY: Oxford University Press.

Higson-Smith, C. (2015). Updating the estimate of refugees resettled in the United States who have suffered torture. The Center for Victims of Torture. Retrieved from http://www.cvt.org/what-we-do/research

Fondacaro, K. M., & Mazzula, E. C. (under review). Moving beyond PTSD for refugees and survivors of torture: The applicability of the Chronic Traumatic Stress framework.

Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T., & … Koss, M. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA: Journal of the American Medical Association, 286, 537–545.

Lewinsohn, P.M. (1975). The behavioral study and treatment of depression. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavioral modification (Vol. 1, pp. 19–65). New York, NY: Academic Press.

McMillan, D. W., & Chavis, D. M. (1986). Sense of community: A definition and theory. Journal of Community Psychology, 14, 6–23. doi:10.1002/1520-6629(198601)

Resick, P. A., & Schnicke, M. (1996). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage Publications.

Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative Exposure Therapy: A short-term intervention for traumatic stress disorders after war, terror, or torture. Cambridge/Göttingen: Hogrefe & Huber Publications.

Schweitzer, R. D., Brough, M., Vromans, L., & Asic-Kobe, M. (2011). Mental health of newly arrived Burmese refugees in Australia: Contributions of pre-migration and post-migration experience. Australian & New Zealand Journal of Psychiatry, 45, 299–307.

UNHCR (2011). Power and politics in resettlement: A case study of Bhutanese refugees in the USA. Retrieved from http://www.refworld.org/docid/4e55f6242.html

UNHCR (2015). United Nations High Commissioner for Refugees (UNHCR) refugee resettlement trends 2015. Retrieved from http://www.unhcr.org/en-us/559ce97f9

UNHCR (2017). United Nations High Commissioner for Refugees (UNHCR) resettlement. Retrieved from http://www.unhcr.org/en-us/resettlement.html

 

Sara Buckingham completed her Ph.D. in Clinical and Community & Applied Social Psychology in the Human Services Psychology Program at the University of Maryland, Baltimore County. Her program of research examines how immigrants and their new communities shape the acculturation process and influence wellbeing. At the time of this writing, Sara Buckingham was completing her APA-accredited internship at the University of Vermont, where she specialized in strengths-based, culturally-informed clinical services for survivors of torture, refugees, and asylum-seekers. Sara Buckingham is extending this line of research and practice as an Assistant Professor at the University of Alaska, Anchorage this coming fall.

Melissa Paiva-Salisbury completed her Ph.D. in Clinical Psychology from the University of Vermont, and a Master’s of Arts in Forensic Psychology from Roger Williams University.  At the time of this writing, Melissa Paiva-Salisbury was completing her APA-accredited internship at the University of Vermont.  Through the Connecting Cultures program at UVM, she incorporated Acceptance and Commitment Therapeutic frameworks into evidenced-based behavioral based approaches for survivors of torture, refugees, and asylum-seekers.   Clinically, she is keenly interested in forensic assessment, the dissemination of evidenced based approaches, and the incorporation of mindfulness into evidenced based approaches.  Her current research interests include the heterogeneity within psychopathy, callous-unemotional traits, and the exploration of construct measurement. Melissa Paiva-Salisbury is joining the Psychology Department at Coastal Carolina University in the Fall of this year.