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Shelter From the Storm

Psychiatric Diagnosis and Treatment of the Refugee Patient

Rothe, Eugenio M. MD*; Pumariega, Andres J. MD; Mihajlovic, Aida S. MD; May, Catherine MD§; Ruiz, Pedro MD; Perras, Nicole MD

Addictive Disorders & Their Treatment: September 2019 - Volume 18 - Issue 3 - p 121–133
doi: 10.1097/ADT.0000000000000164
Original Article

In the last 3 years the numbers of forcibly displaced people around the world has reached a record high. Experiences of war, persecution, violence, torture, participating in the killing of others, disruptions of attachments, and emotional losses increase the risk for psychological distress and may contribute to the risk of developing psychiatric and substance abuse disorders. The authors review the existing psychiatric literature on refugees, discuss the sociological reasons that explain the recent crisis, describe the psychiatric consequences, the risk factors and protective factors of the refugee experience, narrate the current conditions in refugee camps located in Greece and discuss the most up-to-date treatment modalities and preventive interventions to treat this patient population.

*Psychiatry and Public Health, Herbert Wertheim College of Medicine, Florida International University, Miami

Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Florida College of Medicine and UF Health, Gainesville, FL

Department of Psychiatry, University of Illinois College of Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School, Chicago, IL

§Department of Psychiatry, George Washington University School of Medicine and Life Sciences

Department of Psychiatry, MedStar Georgetown University Hospital, Washington, DC

Department of Psychiatry, Baylor College of Medicine, Houston, TX

The authors declare no conflict of interest.

Reprints: Eugenio M. Rothe, MD, Department of Psychiatry and Public Health, Herbert Wertheim College of Medicine, Florida International University, 2199 Ponce de Leon Boulevard, Suite 304, Coral Gables, FL 33134 (e-mail:

I came in from the wilderness

A creature void of form.

Come in she said, I’ll give you

Shelter from the storm.

—Bob Dylan, 1974

Refugees are people who have been forced to leave their homelands due to persecution, war, or natural disasters and who face a threat to their individual safety, or the safety of their family or community and seek who asylum in other countries.1 In addition to those who find a way to cross into other lands, there are many who cannot exit from their beleaguered countries and are known as internally displaced persons, or IDP’s. Their plight is in many ways the most precarious of all for they often remain captives of the very regimes that may have driven them from their homes and otherwise sought to oppress them through humiliation, ostracism, mass internment and, in some cases, mass murder.2 Refugee status protects a person from being returned to his or her country of origin. The term asylum seeker, describes an individual who has crossed an international border in search of safety and is trying to obtain refugee status in another country. For the purposes of this article, the term refugee will also be used to include asylum seekers.1,3 Experiences of war, persecution, violence, torture, participating in killing, disruptions of attachments and emotional losses increase the risk for psychological distress and may contribute to the risk of developing psychiatric disorders, especially in child and adolescent refugees.4–6 The mental health literature on adult and child refugees has been concentrated on the diagnosis and treatment of posttraumatic stress disorder (PTSD) and now constitutes a separate field of investigation.7,8 In spite of this, there is still a lack of accurate data on the mental health status of adult or younger refugees and there is very limited information in their help-seeking and service utilization.9–12 Moreover, some authors argue that mental health care is not among the primary needs of refugees and considerable debate exists in terms of what a refugee needs and how to provide these services,13–16 so the mental health needs of refugees is a source of ongoing controversy in which a knowledge base is still being developed. This article will present an overview of the current numbers of refugees around the world, the types of mental health issues that affect them, the diagnosis, treatment and systems of care that have been utilized to treat these refugees in Europe and the United States, and the risk factors and protective factors that may influence the mental health outcomes in this population.

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Civilian populations are very often the victims of war, violence, and persecution. The number of refugees around the world is constantly changing and developing countries were host to four-fifths of the world’s refugees. By the end of 2016, 65.6 million individuals were forcibly displaced worldwide as a result of persecution, conflict, violence, or human rights violations. That was an increase of 300,000 people over the previous year, and the world’s forcibly displaced population remained at a record high. During the year 2016, 10.3 million people were newly displaced by conflict or persecution. This included 6.9 million individuals displaced within the borders of their own countries and 3.4 million new refugees and new asylum seekers. The number of new displacements was equivalent to 20 people being forced to flee their homes every minute. Children below 18 years of age constituted about half of the refugee population in 2016, as in recent years. Children make up an estimated 31% of the total world population and the UNHCR estimated that at least 10 million people were stateless or at risk of statelessness in 2016. However, the data captured by governments and reported to UNHCR was limited to 3.2 million stateless individuals in 75 countries, so the true total numbers are estimated to be higher. Developing regions hosted 84% of the world’s refugees. The least developed countries provided asylum to a growing proportion, with 28% of the global total (4.9 million refugees). Refugees who returned to their countries of origin increased from recent years. During 2016, 552,200 refugees returned to their countries of origin, often in less than ideal conditions. The number of new asylum claims around the world remained high at 2.0 million and Germany was the world’s largest recipient of new individual applications with 722,400 such claims, followed by the United States of America (262,000), Italy (123,000), and Turkey (78,600). Lebanon continued to host the largest number of refugees relative to its national population, where 1 in 6 people was a refugee. Jordan (1 in 11) and Turkey (1 in 28) ranked second and third, respectively. More than half (55%) of all refugees worldwide came from just 3 countries: The Syrian Arab Republic (5.5 million), Afghanistan (2.5 million) and South Sudan (1.4 million). In 2016, UNHCR referred 162,600 refugees to other countries for resettlement. According to government statistics, 37 countries admitted 189,300 refugees for resettlement during the year, including those resettled with UNHCR’s assistance. The United States of America admitted the highest number (96,900). Unaccompanied or separated children, mainly Afghans and Syrians, lodged some 75,000 asylum applications in 70 countries during the year, although this figure is assumed to be an underestimate. Germany received the highest number of these applications (35,900).1 Refugees rarely have a choice in the decision to migrate, the most common cause of sudden flight is the targeting of an individual or a group due to their tribal, racial, religious, political, or ideological identity. This may result in their actual expulsion or, more often the decision to escape is due to an attempt to avoid being arrested, segregated, tortured or killed, sometimes in genocidal campaigns known as “ethnic cleansing.” Complex national and international conflicts of interests continue to perpetuate the worldwide refugee crisis.1,2,17,18

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Refugees, especially children and adolescents may demonstrate great resiliency in the face of adversity, yet before arriving in the receiving country, these refugees may undergo a series of very stressful experiences that may place them at risk for psychological distress and the development of psychiatric disorders.4 These experiences fit within the 3 phases of the refugees experience described below.19

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This phase refers to the time before the escape from the country of origin. Refugees face social upheaval and increasing chaos. Daily routines are disrupted and there is limited access to work. In the case of children, schools close down, going outside the house becomes unsafe and this results in a disruption of education and social development. Refugees often face threats to their safety and many of them witness or engage in violence. Separation from relatives, parents, and caregivers is common.

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During this period, refugees must survive displacement from their home environments and are often at the mercy of external circumstances that they cannot control. Children’s ability to self-regulate depends in large part upon the availability and the emotional state of their caretakers. One of the most common effects of war and persecution on the family is the separation of family members from each other and children from caretakers. Many young refugees lack identifiable guardians and may have travelled long distances and experienced many traumatic events without adult supervision. Political violence may sometimes render entire villages devoid of adults19 Children who come to the US without a guardian must negotiate the legal system without advocates. Children awaiting asylum hearings in the US are sometimes held up to 2 years in detention facilities or juvenile jails. Resources for refugee children are scarce and many who may have legitimate asylum claims are unaware of their legal rights.12

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The loss of the homeland, family, friends, and material possessions characterize the resettlement stage. Once refugees resettle in the new host country they need to undergo a process of acculturation which brings about inherent stressors.4 Refugees and families often need to learn a new language and have to adjust to new values, beliefs systems, social mores, family roles, which causes stress to all the members of the family. In the process of resettlement and acculturation, refugees often undergo stages similar to the type of profound mourning process that follows a massive personal loss.20 Continued psychological distress in this stage may result from delays in processing asylum applications, uncertainty about asylum status, negotiation with immigration authorities, obstacles with employment, inadequate housing, frequent moves, language problems, racial discrimination, and social isolation.3,11,21–23 For example, unfavorable living conditions, such as living in communal shelters have been found to increase psychological stress in war-exposed children.23

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A review of 29 studies involving 16,010 refugees of war found, (1) high prevalence rates of depression, PTSD, and other anxiety disorders among refugees 5 years or longer after displacement, with prevalence estimates typically in the range of ≥20%, (2) there were a number of unique risk factors for mental disorders which included higher exposure to traumatic experiences and postmigration stress, such as poor postmigration socioeconomic situation (unemployment, low income, poor host language proficiency, and lack of social support) was associated with depression, and being a female refugee was associated with higher levels of anxiety, but not PTSD.24 Other findings included, that the risk of having a serious mental disorder is substantially higher in war refugees than in the general population, even several years after refugee resettlement, that among refugees of war was 14 times higher, and the risk of developing PTSD was 15 times higher than in the general population. In the case of child and adolescent refugees, many have been exposed to experiences of persecution, violence, war, killing or torture as well as the subsequent losses, which increase the risk of psychological distress and psychiatric disorders. PTSD symptoms have been found in children exposed to persecution, war, and organized violence in many parts of the world.12,25 Depression, anxiety, and grief are also commonly found among refugees. However, the estimates of coexisting psychiatric disorders vary widely depending on the type of events experienced, the population studied and the diagnostic methods that are used. Researchers explored the effects of political trauma and torture in 111 adult refugees who arrived in the US from Bhutan, Burma, Ethiopia, and Somalia. These refugees reported, (1) experiencing mental distress defined as “craziness” in each of their native languages; (2) “too much thinking”; (3) cognitive effects such as memory loss, confusion, and difficulty with concentration; (4) physical symptoms such as headaches, stomachaches, and palpitations; (5) behavioral effects, such as abuse of substances, irritability, startle reactions, inability to sleep, talking too much or being at a loss for words, avoidance, and suicidal ideation; (6) emotional sensations and reactions such as fear, anger, sadness, depression, shame, guilt, frustration, hopelessness, and helplessness over past traumatic events, which was described as burning emotionality.26 Other commonly reported, but less well-researched problems that affect younger refugees include physical complaints, sleep problems, social problems, conduct disorder, social withdrawal, attention problems, generalized fear, overdependency, restlessness, irritability, and difficulties in peer relationships,27–31 learning difficulties and problems with school functioning32 and defiance, hyperactivity and aggression31,33 and eating disorders.34 Among child refugees there can be a loss of previously acquired skills, such as loss of bladder control with secondary bedwetting, soiling, intense separation anxiety, and nail-biting.31,35 Sadness, introversion and tiredness,36 suicidal ideation and attempted suicide,28,37 and violent self-harm38 have also been reported. The risk for developing psychosis has been found to be increased in adolescent refugees.39 A syndrome of pervasive devitalization has been described in young asylum seekers, characterized by a refusal to eat, drink, talk, walk, engage socially, or accept help.37,40

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Unaccompanied child refugees typically flee their nations alone to avoid threats of persecution or violence towards them or their families, threat of war and resulting victimization, threat of recruitment as child soldiers or enslavement, or after the death of parents or guardians during war or political strife.3 They are typically exposed to a higher number of traumatic stressors before fleeing than their accompanied counterparts. For example, in 1 study40 32% of unaccompanied child refugees reported having been raped, including some male refugees. They are not only at greater vulnerability to traumas in their home nation that prompted escape, but also during their stays in refugee camps29 and during the initial period of resettlement in host nations. The latter can include placement in group homes or foster homes with little supervision or support, victimization at the hands of caregivers or peers, as well as their isolation as a result of their separation or loss of their natural families. Uncertain legal status can also complicate their emotional adjustment, and contribute to their being further isolated in detention facilities in host nations for extended periods, interfering with their resettlement adjustment and acculturation process. Unaccompanied child refugees have been shown to have higher levels of symptoms of psychological distress than their accompanied counterparts.41,42 They may also encounter ambivalence and even ostracism and rejection by their natural family at the time of reunification as a result of their psychological/ mental health problems, which can have repercussions on the family as well. Their distress may also not be believed and validated by their natural families at the time of reunification, in part out of denial and guilt by their parents at having made the decision to allow them to emigrate alone.

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The exodus of Syrian refugees had been growing steadily since the beginning of the civil war in 2011. The escalation of conflict in the Middle-East, and the growing political and economic instability in other countries increased the flow dramatically. The subsequent closing of land routes into Europe did not stop the tide. In 2015, it is estimated that more than 1 million refugees crossed the Aegean Sea by raft from Turkey to the Greek Islands. This migratory crisis involves multiple ethnic and social groups, multiple nationalities and Syrians make up the majority, in addition to Iraqis and Afghanis. There are also economic refugees from Africa. The crossing of the Mediterranean in overloaded, underpowered rafts results in not infrequent drownings and hypothermia and in refugee camps in Turkey, many of these refugees may be exploited, raped, tortured both in the camps and by smugglers. Once in Greece, they confront an overwhelmed immigration system and multiple obstacles to their continued journey to often uncertain destinations and uncertain reception in Northern Europe. Most of the refugees travel in family groups and suppress traumatic experiences in order to be able to continue their journey. Attention to refugees is provided by Non-Governmental Organizations (NGO’s) and volunteer groups and is limited to 3 interventions: Stage I Camps, on the beach address basic physiological needs, rewarming tents and provide refugees with hypothermia blankets and dry clothes. Stage 2 Camps, reunite families and provide basic medical attention by groups such as Doctors without Borders. Stage 3 Camps, are designed for long-term stay, individuals register to obtain refugee status and initially, they stayed several days to several weeks awaiting transfer to the mainland. As the numbers have become overwhelming and resistance in the receiving communities has increased, weeks and months have now become years. Those who are allowed to leave the camps are then transferred to Athens from where they then travel to the border with Macedonia for points north. A treaty between the European Union and Turkey on March 20, 2016 has significantly reduced the number of daily arrivals, but over 60,000 refugees are currently dispersed across Greece in sites on the mainland and the islands. In the Greek island of Lesbos, a former prison with a capacity for 500 inmates now holds 5000 refugees. They struggle against demoralization awaiting an uncertain future in what has been called, A State of Infinite Uncertainty.43 Like with other refugee crises29 unattached male refugees often represent a threat to female refugees and some produced self-inflicted wounds as a manipulative attempt to advance his chances of obtaining asylum. Psychologists and psychiatrists play a role by providing some direct services to refugees, supervising humanitarian aid workers in psychological first aid and providing advice and assistance to them. Some interventions are put in place in an attempt to normalize the daily life of refugees, but these are not universally or consistently applied. Obstacles to mental health care remain significant during the refugee confinement and are not a priority to the refugee upon arriving in the host country.43,44

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Jenna, a 41-year-old Iraqi woman was born as “Israa” in a small Iraqi village. She married young and had 5 children. Jenna was not a political refugee or a victim ethnic or religious persecution. Before leaving her country of origin she spent her time caring for her children and working as a hairstylist in a beauty salon. However, Jenna was a victim of long-standing domestic violence at the hands of her husband and her home situation was unsafe. She became severely depressed and after years of abuse and subjugation, she decided to run away from her home. After detecting her plan to run away, Jenna’s family locked her in a small room. Secretly, Jenna’s sister was able to give her a key so she could escape, but in her desperation Jenna left her children behind. Jumping over rooftops she was able to find a taxi that took her to the Turkish border. After crossing over to Turkey, she found refuge in a home that paid her to work as a maid, but the family exploited her because she did not have a work permit and soon thereafter she began feeling trapped and that she was caught in a dead end. Jenna eventually made it to the United States through a series of clever maneuvers, persistence, and sacrifice. Once in the US she tried to get her children out of Iraq, but this became impossible because her husband argued in front of the authorities that she had abandoned them. Jenna was not allowed to work in the US, so her money quickly ran out and she resorted to stealing. She was caught, brutally attacked by a security guard and then arrested by the police. While in detention, she attempted suicide and was psychiatrically hospitalized. Only then was she finally diagnosed and received treatment for PTSD, depression, anxiety, and insomnia.45

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Refugee resiliency has been poorly studied, but is beginning to receive more attention. Studies on adult refugees conclude that effective social integration into the host country is associated with better mental health in men, but not in women. Women and girls are more prone to having been victims of sexual violence during war and inside the refugee camps.46 Endless waiting and uncertainty about the future while in refugee camps worsens mental health issues of refugees and leads to a sense of helplessness and catastrophic thinking.31,46,47 In contrast, thinking about the future, with dreams of furthering their education, resuming a normal life, and reuniting with loved ones improved coping. Refugees may experience great joy when reencountering peers and loved ones and reestablishing past relationships. The concept of having someone’s to share one’s thoughts with, especially someone who had shared the same experiences was found to be very healing. The concept of a person’s Sense of Coherence, which derives from the field of Positive Psychology postulates that individuals who feel empowered to make change in their lives and surroundings and see life as comprehensible, manageable, and meaningful and not as life-events being inevitable and the person being at the mercy of their fate have better mental health outcomes.48 This perspective allows the refugee to think positively and learn and grow from the experiences.29,31,47 The role of religion has also been found to foster resiliency in refugees. Having faith in God and in God’s plan for the person’s future, counting on the support from a religious community, being grateful for having survived, trusting that future difficulties will be overcome with God’s help and the soothing effects of prayer, meditation, and spirituality have been found to be of help when facing difficult circumstances. Moreover, the sense of collectivism, of feeling part of a community, including experiencing feelings of empathy, dependency, reciprocity towards other members of the group and having a sense of belonging are important in resiliency.46,49 Some of the factors that contribute to resiliency in young refugees include being of a young age at the time of the trauma, having good self-esteem, a temperament that allows to respond well and effectively to new situations, having religious faith,50,51 and strong ideological commitment to their side of the cause.52 Adaptability and cohesion within families, positive psychological well-being of caregivers, good peer group, and social supports has been found to be protective during the refugee process as well as during the resettlement period.23,51,53 A meta-analysis of refugee mental health research found that children may be less symptomatic, have better psychosocial functioning and be more resilient than adults.54

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The federal Refugee Act of 1980 entitles newly arrived refugees to a comprehensive health assessment and referral to health services and assistance or state Medicaid in their first 8 months makes it even more imperative that screening and referral for assessment and treatment takes place early in the resettlement process. There is also a growing body of literature that indicates that refugees struggle with substance use and families may be vulnerable to domestic violence both in camps and after they are resettled. A national survey on refugees who had been victims of torture55 revealed that only half of the states provide any mental health screening to newly arrived refugees. Of the states that provide screening for mental health symptoms, more than half utilize informal conversation. Further, less than half the states reported directly asking refugees about their exposure to war trauma or torture. The most frequently cited reasons for not providing mental health screening were the lack of culturally sensitive instruments and the lack of time and resources. For adult refugees, there have been various attempts at adapting the Harvard Trauma Questionnaire to diverse ethnic populations.56,57

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In the case of child and adolescents, a number of instruments have been identified, but very few have been used extensively with refugees. The majority of the diagnostic instruments have been designed and validated for Western, Caucasian, mainstream, majority populations in developed countries and may not be valid when used with peoples of other cultures. In addition, most diagnostic instruments have been designed to overidentify pathology, so the data must be interpreted with extreme caution. Kinzie8 is of the opinion that it is not appropriate to use standardized questionnaires with this population, only extensive, open-ended interviewing and assessment can be used, in order to establish a diagnosis. Ehntholt and Yule,3 based on their experience in Britain, have designed a semistructured interview for assessing child and adolescent refugees. They recommend that only when the diagnosis is not clear, or when writing legal reports, should standardized questionnaires be used. Birman and Chan58 have developed parameters to assess child and adolescent refugees in schools. They highlight that universal mental health screening of refugee children in schools is not advised, given that it may unnecessarily label and stigmatize children and may also identify more problems than the school or community can treat. They also enumerate other barriers that interfere with universal mental health screening, such as obtaining informed consent from parents and other sociocultural issues. Many of the parents may speak a language for which there are few available interpreters and sometimes may not even be literate in their own language. Sometimes parents may assume that if they are being called by the school, it is because the child “is in trouble and needs to be punished.” As refugee families are dealing with a multitude of stressors, a team approach is the most feasible. As well as a model of co-joint consultation, which includes involving prominent members of the refugee community, many of whom may themselves be former refugees or immigrants, as well as refugee and community agencies or religious institutions. A comprehensive list and description of the standardized mental health assessment questionnaires for child and adolescent refugees can be found in Birman and Chan58 and Ehntholt and Yule.3

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Access to Care

Traditional Western mental health services and treatment approaches have not been historically effective with immigrants and refugees. They often underutilize traditional mental health services as a result of numerous internal and external barriers. These include the stigma associated with mental illness and treatment in their cultures and countries of origin, usually stronger than that seen in Western nations,59 a lack of clinicians who speak the languages and understand the cultures of refugees, low priority for obtaining mental health services among more pressing human needs (food, shelter, employment, etc.), and lack of finances or insurance coverage to pay for services.3 The principles of culturally competent mental health services and community-based systems of care are most applicable to the development and delivery of mental health services for refugees.59–62 These include accounting for cultural differences that can impact diagnostic assessment; addressing factors that affect the accessibility and acceptability (such as location, stigma, linguistic barriers, documentation, and legal status); addressing traumatic and acculturation themes in psychotherapy; empowerment, psychoeducation, and collaboration with families), and integrating traditional mental health services with primary care services and natural community supports from the immigrant or refugee community (including collaboration with spiritual resources and cultural healers). Cultural consultants with knowledge of the immigrant and refugee communities have been found to be particularly effective in facilitating accurate assessment and improved services utilization and effectiveness.63 Approaches that address the need for validation, mutual support, and processing of their common migration and adaptation experiences have been found to be particularly effective.64,65 In dealing with refugee crises, sometimes the receiving community may find itself besieged by a massive arrival of refugees, which may overwhelm the available mental health infrastructure. To avoid this situation, it is advisable to compose teams of mental health professionals that take into account the particular circumstances of the refugee crisis and the particular cultural and language characteristics of the of the refugee group in question. Culturally competent professionals must compose the treatment groups and, if they are not proficient in the particular language of the members of the refugee group, translator services should then become indispensable.66 Treatment interventions should start at the level of refugee groups within camps, following the similar parameters of those of victims of natural disasters and can be divided into 3 phases: triage, debriefing, and emergency services. The first intervention involves triaging the most psychologically severely affected refugees, the psychological casualties, in order to provide the immediate necessary treatment interventions to the victims.

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Child refugees and their families often suffer cognitive disorganization as a result of the multiple stresses to which they have been subjected, and which result from the process of traumatic migrations. The process of debriefing aims to validate the traumatic and disorganizing quality of the experience, and to inform and orient the refugees about their new surrounding reality. The traumatic events and their associated emotional, behavioral, and physical reactions are revisited, analyzed and understood in the context of the surrounding circumstances. Activities are designed in order to provide structure, help organize time, and plan daily activities, including work activities, in an attempt to normalize routines. This prevents the child and the family’s cognitive disorganization and its consequences. Supporting indigenous religious practices and culturally prescribed altruistic practices among refugees also supports resiliency and recovery.29,67 Rothe47 has developed a psychotherapy model for treating child and adolescent refugees living inside refugee camps that attempts to minimize psychological trauma and to prevent dissociative memories that result from these experiences.

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Most of the treatments for adult have been designed utilizing the model pf PTSD; however, literature relating to the treatment of PTSD in refugees has been described and has been shown to be limited by methodological difficulties, including nonrandom allocation to treatment, lack of controls, nonblind outcome assessments. In a review of the psychological therapies for treatment of PTSD in adult refugees, Nicholli and Thompson68 concluded that, (1) the presentation and validity construct of PTSD is open to debate due to cultural and linguistic factors, (2) the nature of trauma experienced by refugees may differ from typical occurring Western traumas and as such may be novel for clinicians. (3) Multiple, extremely severe, and prolonged traumatic incidents may be common and require complex treatment approaches. (4) The use of standard assessment measures can be criticized as lacking in reliability and validity with this population. (5) Efficacious PTSD psychotherapeutic treatment approaches, have been developed and evaluated within Western countries, and as such these findings will not necessarily generalize to other cultures. (6) The use of an interpreter removes the traditional therapeutic dyad and may slow down the pace of therapy. Moreover, listening to trauma stories and the distress of clients is potentially overwhelming and may impact on both therapists and interpreters. (7) Refugees are often undergoing additional life-stresses such as poverty, loss of status, uncertainty of residence, discrimination and prejudice, which raises the question of when or even whether to address psychological issues, in the presence of pressing fundamental needs. (8) Clinicians will be faced with exploring cultural and religious practices that are likely to be different from their own and may stimulate strong countertransference feelings and possibly underlying prejudices. A more recent study69 compared (1) Office-based Counseling, (2) Home-based Counseling, and (3) Community-based Psychoeducational Group treatment to treat posttraumatic stress symptoms, depression, anxiety, somatization, and to provide social support for adult resettled refugees of various nationalities and found all interventions to be relatively effective. In addition, they discovered that using a practical and yet less threatening mental health intervention facilitated by community leaders and counselors can also have positive effects on serious mental health problems and should be studied further. Testimonial psychotherapy in adults has also yielded promising results.70

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In the work with refugee children and adolescents, a phased specific model approach is important, as they may be still undergoing significant turmoil in their lives. Movement back and forth between phases is common. This is especially true for children and families seeking asylum, for whom emotional states are heavily influenced by changes in asylum status and the impact these have on life circumstances.3 The 3 main phases to be considered are: (A) establishment of safety and trust. The aims during this stage are to help the child and family develop a sense of stability, safety, and trust, as well as to regain a sense of control over their lives. This may be difficult to achieve until stable asylum status is granted, so, clinicians must have an awareness of immigration law, welfare rights, and the sociopolitical situation in the home nation. Liaison work with agencies is necessary in order to ensure that basic needs and supports are addressed. Initial sessions may need to focus on solving housing and financial problems, as well as facilitating access to reputable attorneys, family tracing services, and educational, health, religious, cultural, and leisure resources. Psychoeducation with regard to symptoms and treatment models, normalizing reactions to trauma, and symptom management and coping strategies are key interventions, with trauma work not being advisable due to the family and child’s state of continued vulnerability. They are ready for the next stage only after the child and family feel some sense of safety and stability, control over their symptoms, and some level of trust. (B) Trauma-focused therapy/treatment. For children suffering from symptoms of PTSD, this phase involves working through traumatic events, at a pace that is emotionally manageable, to create a coherent and detailed narrative of past experiences that is more integrated into their life story. This should include the exploration of feelings of guilt and shame from witnessing violence or murder, reframing them within the context of political and developmental realities, and issues of loss and bereavement. The therapist bears witness and validates the traumatic experiences that the child has experienced. Depending on the young person’s current complaints, alternative interventions may be offered at this stage for a range of difficulties, including depression, anxiety, sleep problems, somatic complaints, and behavioral difficulties. (C) Reintegration. The focus during this phase is on creating future goals and aspirations and integrating into a new community and culture. Young refugees will have already begun this process on their own, with help from schools and community resources. The therapist could discuss educational plans, geographic relocation, or future employment with refugee children and families to help develop a pathway towards these goals. Child refugees and their families can also become more involved in their religious or immigrant communities, or in school extracurricular and social activities.

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The World Health Organization-WHO71 has designed a series manualized psychological interventions aimed at reducing psychological distress and improving resilience and functioning through individual, group and smart phone applications. The World Health Organization Problem Management Plus (PM+) is a module of 5 weekly sessions which can be peer-refugee directed. The interventions are symptom focused rather than diagnostic and involve developing practical skills and emphasize taking positive action with the goal of empowering the individual. They emphasize stress management, problem solving, behavioral activation, social support skills and a forward-looking focus. Numerous cell phone applications help improve access to psychosocial support. Application for Mental Health Aid for Refugees (ALMHAR)72 is an application which aims to normalize feelings through modules that encourage self-esteem and social connectedness. Smartphone-Mediated Intervention for Learning Emotional Regulation of Sadness (SMILERS)73 is another application offering cognitive behavioral therapy (CBT) for symptom relief. Infomigrants74 is a website which in addition to providing accurate information, offers refugees a chance to post their own stories of endurance and triumph.43 Evidence-based treatments for many conditions, including those affecting refugees are now also available. However, it is a challenge to provide these in catastrophic situations, such as refugee camps, underserved areas and rural areas Bolton et al,75 tested the Common Elements Treatment Approach (CETA) with Burmese refugees living in Thailand. This approach trains nonprofessional counselors to apply some necessary elements of evidence-based treatments to treat refugees residing in low-income settings who suffer from depression, anxiety, and posttraumatic stress. In a randomized controlled study they found that there was a 77% reduction in the average depression score from before the intervention to after the intervention among participants in the CETA arm, but only a 40% reduction in the depression score among participants in the control arm. Different models of types of psychotherapy have been found effective in addressing the mental health needs of refugee children and their families.3Trauma-focused CBT has demonstrated effectiveness with diverse populations and even a track record with child refugee populations. A controlled study of group CBT with refugee children from various nations demonstrated that it was effective at reducing PTSD symptoms, as well as behavioral difficulties and emotional symptoms resulting from war-related trauma.36Testimonial psychotherapy invites refugees to transcend the grief, anger, and resentment resulting from their persecution by using the resulting testimonies for purposes of education and advocacy. A pilot study with Sudanese adolescents suggested its safety and feasibility in this age group.76Narrative exposure therapy combines elements of testimonial psychotherapy with cognitive behavioral techniques and theory. One of the goals of this approach is to reduce PTSD symptoms by confronting the individual with memories of the traumatic event, but also to using a detailed narrative to correct distortion of traumatic memories. It has been recently adapted for use with refugee children with reports of positive outcomes.77Eye Movement Desensitization and reprocessing therapy is a treatment that uses bilateral stimulation when processing traumatic memories in individuals with PTSD. With this method, the person is often asked to conjure up an image of their traumatic event while the therapist simultaneously moves his or her finger in front of the person’s eyes in a rhythmic, lateral motion. The treatment involves a combination of both exposure and distraction or “dual attention” as it is most frequently referred to. A small study (N=13) reported significant improvements using Eye Movement Desensitization and reprocessing therapy with refugee children experiencing PTSD symptoms.77 Empirically tested interventions operating within community settings have been preliminarily promising. Kataoka et al78 demonstrated the effectiveness of a school-based CBT program for trauma-related depression or posttraumatic stress with Hispanic children and youth, using group and individual CBT and psychoeducational interventions for youth and parents. Layne et al79 reported on a school-based, trauma and grief-focused group psychotherapy that significantly reduced posttraumatic stress, depression, and grief symptoms among 55 war-exposed Bosnian adolescents. Pharmacotherapy has been shown to be useful in the treatment of depression and PTSD symptoms in nonrefugee children and youth, although most effective in combination with CBT.80,81 Selective serotonin reuptake inhibitors, anticonvulsants, and atypical antipsychotics have been identified as most useful, although studies with refugee children are lacking. Clonidine was shown to be effective for psychiatric symptoms among Cambodian adults with PTSD.82 There are beginning models for preventive community-based mental health services for immigrant and refugee children and their families. Rousseau and Guzder83 describe a number of promising school-based prevention programs for refugee children. The National Center for Mental Health Promotion and Youth Violence Prevention at Education Development Center84 reviews a number of promising preventive models and practices are being implemented around the United States facilitating the adaptation of immigrant and refugee children and their families, most of which are oriented around schools. These programs promote the development of adaptational skills by the child and develop family and community supports. All of these models have demonstrated considerable success with a diverse range of populations, including Latino, Bosnian, Hmong, and African immigrant and refugee communities.

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It is very likely that the numbers of refugees worldwide will continue to increase as a result of regional warfare and conflict, so it is reasonable to expect continued large numbers of refugees will continue to immigrate to the United States and other developed nations seeking safety, security, and freedom.1 Mental health and support services are most effective in the context of a refugee and immigration policy based on rational national interests rather than on reactions to crises or to xenophobia. Part of such a policy should be to actively prepare all Americans for the demographic changes resulting in increased cultural diversity, culminating in the lack of any numerical majorities by 2050. Refugees have historically been a significant proportion of the immigrant population in the United States. Our nation should develop and implement resettlement policies and practices, in human services and education that facilitate refugees in learning their new host culture while retaining the strength-based, adaptive aspects of their cultures of origin. The media and all institutions in civil society, including schools, churches, and volunteer organizations should be recruited towards this important endeavor. Such public education efforts can support enhanced efforts towards proactive refugee services, including mental health services, preventive cultural adaptation programs, and community supports for all immigrant children and their families. International exchange of treatment models and techniques that are effective in diverse cultures and with special populations is also particularly important in order to disseminate and build upon the experience developed in the field with such models.

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refugees; trauma; psychiatric diagnosis; psychiatric treatment; adults; children; adolescents

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