Refugees in the U.S. face the double challenge of uprooting their entire lives due to insecurity and also developing mental health conditions from these experiences. In my first article of the series, I explored how immigrants and refugees suffer from the consequences of clandestine entry and assimilation in the form of mental health struggles and Post-Traumatic Stress Disorder (PTSD). Moreover, children of immigrants and refugees are at greater risk of developing these issues due to a higher likelihood of experiencing trauma-exposures. Refugees face PTSD and related symptoms including anxiety, depression, difficulty sleeping, inattention, nightmares, and survival guilt. Although these issues are challenging to address, there are several techniques and circumstances that may actually combat some of these adverse effects.
Trauma-Informed Care
Trauma-informed care is an essential aspect of treatment for individuals who have migrated or refugees who have escaped their home country. Overall, TIC approaches care from a perspective that acknowledges the serious effect that trauma has on children’s health and development. There are a few key principles of TIC that help prevent re-traumatization. Practitioners encourage physical and psychological safety, build trusting relationships with families and patients, support and foster individual agency, and promote intersectionality. To summarize this approach, Kathleen Miller and her fellow researchers identify 10 best practices of trauma-informed care.
Three practices are particularly noteworthy for the experience of immigrants. First, individuals must recognize the impact of trauma on the developing brain, various manifestations of trauma, and screen for trauma and associated mental health conditions. Immigrant and refugee youth are less likely to access health care and preventive services in comparison to their peers. Thus, the likelihood of poor outcomes shoots upward.
In the same vein, immigrant and minority youth are less likely to be screened for depression than their native-born counterparts, highlighting the importance of quality validated tools for screening. Furthermore, practitioners should treat trauma-related disorders appropriately. It is important to consider how diagnoses of depression or anxiety could be highly stigmatizing to patients, especially in certain immigrant communities. In order to help families better understand these mental health disorders, framing depression or anxiety as a result of trauma is helpful.
Finally, it is imperative to utilize a two-generational approach to care when treating these populations. Parents and caretakers are perhaps one of the most protective factors for children and youth to survive trauma because adolescents who come from immigrant and refugee families lose the adult protection that caretakers maintained in their country of origin. This forces youth to learn a new culture and language more quickly than their parents, causing them to experience “adultification,” and risk becoming the “internal cultural brokers” of the family. Providers must acknowledge how these dynamics play into the development of anxiety in youth.
The rest of Miller's practices can be found below- A strength-based approach: Unlike a deficit-focused approach, a strengths-based approach concentrates on growth and development, acknowledging strengths that will then develop resilience and promote healing.
- Create an immigrant-friendly healthcare environment: One of the aims of TIC is to prevent re-traumatization; this task becomes more difficult when healthcare systems can be the very source of trauma, racism, and xenophobia for immigrants. Patients’ trust can be eroded right at the check-in desk, where they may feel either welcome or rejected. Miller et. al even recommends that some facilities, depending on the location, might benefit from in-house safety planning in the event of an immigration raid. For example, providers might consider what information to document regarding citizenship status.
- Promote trusting relationships within the healthcare environment: Establishing safety within the primary care setting is essential to promote healing. One of the key principles of TIC is to promote the idea that relationships present protective buffers against toxic stress. As such, primary care providers have a critical responsibility to triage a patient’s needs, allow the family to drive the agenda, and establish mutual respect.
- Ask for permission to discuss potentially difficult subjects: If youth and their families are forced to share information about traumatic events before they are ready to verbalize, there is a large risk of re-traumatization. According to therapists, there is a “window of tolerance” that describes the practice of sharing emotions within a tolerable range. Invasive physical examinations should be treated similarly.
- Know your own local resources and make sure they are trustworthy: As immigrants and their families may be hesitant to trust or engage with various services, either due to trauma or unfamiliarity with said resources, it is imperative that they are informed by healthcare providers. Healthcare providers are often the first professionals to respond to immigrants and should link systems and services with families, such as immigration law centers, community centers, etc.
- Recognize that trauma may not end after migration: This can occur in the form of racism, biases, and microaggressions. Microaggressions are subtle, yet perceivable forms of racism that can have a significant impact on an individual’s mental health and resilience mechanisms.
- Advocate for immigrants, regardless of your title: Healthcare providers aside, anyone can push for immigrant-friendly policies (see https://www.tnimmigrant.org/ for ways you can help out in TN), diversify the workforce, interact with and bring attention to these communities.
Strong Support Systems and Family Support
One of the mitigating factors of trauma in immigrant families is the very foundation of the family itself. Research has found that a strong support system, whether that be within the family or external to the immediate family, can protect both the parents and their children from exposure to trauma post-migration. Thus, the risk that both parties develop future symptoms of PTSD is low. An environment that fosters and upholds immigrants and their children can act as a buffer from the stress of the immigrant experience within the United States, and further promote resilience across immigrants’ life paths.
As Perreira and Ornelas summarize in their research, there are positive correlations between familism, or a strong connection and loyalty to the family unit, social support, and mental health. The Vancouver Association of Survivors of Torture published a guide of best practices for treating refugees who have experienced torture, emphasizing the family context and knowledge of culture.
Ambiguity of Acculturation
Acculturation is the process of assimilating to another culture–a key difficulty for immigrants across the globe. Typically, acculturation is measured in a few ways: immigrant generation, years in the US, language usage, and scales measuring adaptation to American socio-cultural norms. While acculturation does not have a causal influence in regards to exposure to trauma prior to or during migration, it may influence how immigrants might deal with exposure to traumatic events post-migration. This may then influence their risk of developing PTSD.
For those exposed prior to or during migration, years in the US may signal more time since exposure to trauma. Moreover, English language skills may allow for immigrants and refugees to heighten their capacity for accessing services and resources in the US. Lastly, adaptation to US socio-cultural norms may lead to more ease with navigating US social systems. On the other hand, time in the US might lead to greater cumulative exposure to post-migration discrimination and neighborhood disorder. Loss of native language skill might also indicate weakening protective ethno-cultural ties, as well as a decrease in access to ethnocentric resources.
In my last piece for this series, I will explore the stigma associated with mental health in immigrant families.
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