1 Trauma-Informed Care for Work with Refugees & Immigrants HYOJIN IM, PH.D. ASSISTANT PROFESSOR VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF SOCIAL WORK 2 nd Annual Symposium Center for Research on Migration & Refugee Integration (CRIMRI) University of Utah
Trauma Informed Care (TIC) 2 Trauma has the ability to affect entire communities, destroying the sense of safety in neighborhoods, community, and even broader society.
Trauma-Informed Care (TIC) 3 4 R approach Realize the widespread impact of trauma Recognize the signs and symptoms of trauma in others Respond with informed policies, procedures and practices Resist re-traumatization. (SAMHSA, 2013)
Epidemiology of Trauma 4 Adverse Childhood Studies (ACEs) study showed 59-64% of the population surveyed reported at least one ACE. Histories of trauma were reported by clients in various care systems: 98% of female offenders 96% of adolescent psychiatric inpatients 93% of homeless mothers 90% of juvenile justice-involved youth 75% of adults in substance abuse treatment 70% of children in foster care
Impact of Trauma on Health 5 Health risk behaviors Substance abuse, tabacco use, sexual behaviors, Mortality and chronic health problems Mental disorders
Refugee Trauma Events 6 Pre-Migration Exposure to war and social conflicts Torture, SGBV Numerous Human rights violations Multiple losses Witness of tragic death, Being close to death Lack of food/water Migration Forced displacement Human trafficking /smuggling Continuous losses of family and resources Separation Harsh and congested living condition Uncertainty of future Lack of protection (legal & economic) fear of deportation Post-Migration Cultural & language barriers Acculturative stress Lacking cultural orientation Loss of cultural practice & identity Social isolation Intergenerational gaps/conflicts Poverty, racism, discrimination, etc. * Photos courtesy of WFP & UNHCR
Effects of Refugee Trauma 7 Refugee communities have high risk of developing common mental disorders A review of 181 surveys showed that, among over 80,000 refugees from 40 countries (Steel et al., 2009): 30.6% reported symptoms of PTSD 30.8% reported symptoms of depression CDC-ORR Study reported 16 suicides in the Bhutanese community in the U.S. between 2009-2012 Long term studies show enduring impact of war trauma on mental health among refugees.
TIC in work with refugees/immigrants 8 Few studies have been conducted Refugee trauma studies having focused heavily on mental disorders (esp. PTSD and depression) and thus on traumaspecific interventions Refugee trauma studies started from Human Rights Movement for war-affected populations Harvard Program in Refugee Trauma in 1981 The Center for Victims of Torture in 1985 More trauma-specific program and few studies on trauma and health/wellness in refugees
Unique needs in TIC for Refugees 9 and Immigrants Role of culture in trauma Nature of trauma Barriers to systems
Trauma and Culture: Cross-cutting 10 factors Religion & spirituality Language & styles of communication Geographic location Worldview, values & traditions Heritage & history Perspectives on health, illness & healing practice Family & kinship Gender roles & sexuality Socio-economic status & education Cultural identity & degree of acculturation Immigration & migration history/patterns
High Stigma of Trauma and Mental 11 health symptoms Afraid of re-opening the wound Re-traumatization to oneself and their families Believed to bring shame to family Concept of Mental Health? Mental health = metal illness = crazy Concept of mental health services may not exist Counseling = problem-solving, consulting Little concept/utilization (or positive experience) of formal services
Trauma Event Services & 12 Healthcare One fear of living in the Thai camp was seeking medical service from hospitals. My uncle who had taken his daughter to the hospital (which was the only time you can leave camp) and brought her back dead a couple of days later. She couldn t have died. She only had a bad headache. Photo courtesy: Guardian
Dealing with Trauma Sequelae 13 Suffering in silence Self-Medication or "Self-Treatment" Internalized anger and self-harm Sending people with issues back to home country Chaining or hiding problematic persons Traditional healing Some are harmful and others empowering
Cultural Expression of Traumatic Effects 14 Various cultures may use different expressions for traumatic effects: My heart is upside down. I have too much air in the brain. Thinking too much Feeling like a stone Possessed by Jin(i) or evil spirit Feeling pain all over that can t be expressed Cultural concept of distress is useful to avoid stigma and understand culturally appropriate coping and healing methods
Example. Somali Cultural Idioms of Distress 15 Im et al. (2017). Cultural Translation of Refugee Trauma: Cultural Idioms of Distress among Somali Refugees in Displacement (Im, in Press)
Expectations unmet 16 I was one of those people who thought in the U.S there are walls where you just withdraw money. Instead of money I received an abundance of snow. (A Somali single mother, MN)
Post-Migration Trauma & Acculturative Stress 17 It is natural to compare home culture to local culture however this may lead to more stress. Changes in social status, family role change, intergenerational gap in acculturation Loss of cultural practice, identity crisis Discrimination, poverty, family separation, social isolation, etc. Traumatic stress continues
Pre-Resettlement & Post- 18 Resettlement Traumas Two decades after resettlement Cambodia refugees reported a high prevalence rate of PTSD and depression due to untreated trauma from the home country (Marshall, Schell, Elliott, Berthold, & Chun, 2005). More devastating impacts of post-migration stressors than pre-migration traumas on mental health outcomes (Bogic, Njoku & Priebe, 2015; Chu, Keller, & Rasmussen, 2013 ; Li, Liddell, & Nickerson, 2016). Each migration stage, including resettlement, has a cumulative negative effect on mental health.
Challenges in TIC for Refugees/Immigrant 19 Language and cultural barriers + transportation + lack of cultural orientation/information Limited resources or systems for adequate assessment and care of trauma-related needs, from screening to referral and to treatment and recovery Lack of awareness and capacity for culturally relevant and responsive services that are trauma-informed High stigma and lack of awareness around trauma and mental health needs in the refugee community Communication breakdown or limited interaction and trust between providers and refugees
Example of TIC for Refugee Newcomers 20 System level A multi-tiered Model of Mental Health & Psychosocial Support for Newcomers Program level A Community-Based Program (2-tier intervention): 1. Trauma-informed crosscultural training (Training) 2. Community Wellness Workshop (Intervention)
21 Severe mental illness (psychosis, schizophrenia, severe mental illness) Common mental disorders (PTSD, depression, anxiety, somatic pains) Psychosocial functioning Adjustment
Multi-Tiered Refugee Mental Health & Psychosocial Support Model 22
Tier 1 : Trauma-Informed & Culture- Sensitive Services 23 Tier 1 includes trauma-informed and culture-sensitive care integrated into existing services. Efforts in Tier 1 are to promote social adjustment and integration of refugee populations by building capacity of refugee service providers to recognize and respond to unique needs of refugees.
Tier 2: Community-Based Psychosocial Support 24 Tier 2 focuses on psychological distress and social functioning by providing community-based interventions led by competent and experienced refugee community leaders. The community-based interventions aim to increase skills to deal with acculturation stress and other psychosocial needs.
Tier 3: Trauma-Focused Treatment Tier 4: Specialized MH Care 25 Tier 3 is designed for targeted groups whose RHS-15 score is 12+. Mental health services at Tier 3 include trauma-focused treatment by mental health professionals. Tier 4 includes intense, specialized care and mental health treatment for refugees with severe mental illness. Due to the acute level of care, not many refugees are treated at VCU SSW Tier 4 level.
Ex. Trauma-Informed Wellness Program 26 Richmond (Peer-Based) Training Peer-led Intervention Selfcontained group Capacity Building Psychoeducation on Refugee trauma and MH, Cultural expressions of trauma, Mutual & cross-cultural learning Intervention Peer-led or agency-based intervention grounded to the community Sustainability Self-contained support group in the community and/or intervention embedded to existing agency program Charlottesville (Agency-based) Agencybased Intervention Interactive Training Peer-led community intervention & support Group
1. Training Trauma-informed cross-cultural training 27 Intervention Training Sustainable support Trauma-Informed Impacts of refugee trauma and migration on body, mind, spirituality, relationship, family and community Cross-Cultural Cultural understanding of mental health, cultural expectation, mutual learning between host and refugee communities Psychoeducation Psychosocial skills and competency building, coping strategies, self-care, (self-)awareness
Highlights of TIC Training 28 Mixed cohort of refugee and immigrant community leaders and professionals in health care Emerging community leaders engaged in learning about and developing strategies to address the impact of trauma and acculturation stress Increased trust and ability to partner across cultural differences to meet community needs Community members better equipped to support and educate members within their community Increased awareness of the impact of trauma, refugee mental health, and cultural adjustment within formal system of care and refugee/immigrant communities
Cross-cultural capacity building 29 Mutual learning across agencies, sectors, communities and cultures Mental health knowledge & skills Community Healing Partnership Refugee service experiences (non-mh) Cultural insights from the refugee community
2. Intervention Community Wellness Workshop 30 Training Intervention Sustainable support Body Health Healthy eating, access to healthy/cultural foods, body map, nutrition, impact of migration on health, preventive health Mind Health Body-mind linkage, acculturative stress, stress coping, breathing, mindfulness Community Building Helping others, healthy community, building community, bridging communities
Building social capital 31 Effectiveness of Peer-Led Intervention Honoring cultural practices Empowering refugee community Building community leadership Holistic and ecological perspective Individual Family - Community Importance of social capital in wellness promotion Expand intervention to include bridging social capital (linking the community to service providers) Body Mind Collective coping
Together, we learned about 32 container gardening, nutrition, & healing. Afghan & Congolese Groups Container gardening embedded to 8 sessions of Community Wellness Workshops
Wellness through empowerment 33 Critical understanding of two cultures Self-efficacy and confidence Empowerment Collective problemsolving
Charlottesvill 34 e
Resilience 35
Healing Partnership 36 Building a partnership among compassionate community stakeholders helps enhance the community s capacity to address the numerous challenges refugees/immigrants face when making a new home in the U.S. Virginia Healing Partnership
37 THANK YOU Contact: Hyojin Im (him@vcu.edu)