Surendra Bir Adhikari, Ph.D. MedSoc, MA, Mental Health Administrator; PI-Health Disparities & Equity

Behavioral health (trauma, suicidal ideation) and substance abuse issues that refugees experience (e.g., Bhutanese refugees); and Need for Cultural sensitivities and culturally competent interventions to enable refugee s effective resilience and integration. Policy implications for making informed and culturally competent decisions as appropriate and relevant. Trauma Informed Care for Survivors of Torture Hana Khaled, BS, MS Pharmacology Applied lessons of experience drawn from a federally funded program in Ohio that serves refugees who were survivors of trauma (SOT). 1

CAMH (2009) IRER: 12 SDOHs: 1. Income and Social Status 2. Social Support Networks 3. Education and Literacy 4. Employment/Working Conditions 5. Social Environments 6. Physical Environments 7. Personal Health Practices and Coping Skills 8. Healthy Child Development 9. Health Services 10. Gender 11. Culture DRAFT!!!

Suggested citation: National Academies of Sciences, Engineering, and Medicine. (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. 10/29/2018 Washington, DC: The National Academies Press. doi: 10.17226/23442.o peer specialized 4 services in health services systems.

Source: Eckstein, Barbara. 2011. Primary Care for Refugees. Available at: https://www.aafp.org/afp/2011/0215/p429.pdf (accessed October 28, 2018). 5

Trauma in Immigrants/Refugees Immigrants: Individuals may express psychological distress in different ways; traumatic stressors may be different for different people. Bhutanese refugees: Dramatically high incidence of mental illness including depression, anxiety and PTSD; and incidence of torture as a possible contributor to the illnesses. Karenni (Burmese) refugees: Psychosocial risk factors for poorer mental health and social functioning outcomes included insufficient food, higher number of trauma events, and previous mental illness. Iraqi/Syrian refugees: vulnerable to the burden of neuropsychiatric disorders. Possible interventions could include stroke risk factor reduction and medication for multiple sclerosis, epilepsy, and schizophrenia. Somali patients: among <30 years and younger, 80% were diagnosed with psychoses; older male, and the majority of Somali female patients predominantly showed depressive and PTSD symptomatology. Literature VA, Accessed, 6/20/18) Mills et al. (2008) Cardozo et al. (2004). McKenzie et al. (2015). Jerome et al. (2011). 6

People of Nepali origin living in Bhutan since 19 th Century. Ethnic cleansing(?): Bhutanization in early 90s, 1/6 th of the Bhutanese fled Bhutan and resettled in Nepal. UNHCR 2013 report estimated 108,000 Bhutanese refugees in Nepali refugee camps. Bhutanese Refugee Camps/Nepal [Courtesy: CDC] U.S. commitment for 82,000 Bhutanese refugees. States like Ohio have much higher number than official resettlement numbers due to secondary migration (outstretched resources). 7

Unmet Physical and/or Behavioral Health Need Bhutanese Nepalis: post-resettlement psychosocial issues; prevalence of physical (chronic diseases), behavioral health issues (mental health disorders, anxiety, depression, PTSD); cooccurring behaviors; other physical health manifestations. Barriers in terms of referrals to a psychiatry or other clinical specialty/practice; help-seeking behavior. Disparities in access to care and utilization. Community-Based Participatory Research: OhioMHAS, BNCC, and CRIS Epidemiological Study of MH, Suicide and PTSD among Bhutanese Refugees in Ohio, 2014 8

Drug Use/Alcohol: Current Alcohol Use: Yes, 20% (n=39) Standard drinks of alcohol daily (n=39): One, 34%; 2-3, 37%; 4-5, 12%, >5, 2.4% Current smokers, 25% (n=50): N=200 Smokeless tobacco use every day, 23% (n=44): N=192 Dual tobacco use: About 28% smoke cigarettes and chew tobacco. Figure 1: Dual Tobacco Use Behavior, Bhutanese Refugees, 2014 Current Smoker (Yes) Curent Smoker (No) Total No. of Respondents 27 26 53 Current Smoker also Chewing Tobacco (Dual User) 21 118 139 Current Smoker not Chewing Tobacco 48 144 Total 192 Smoking and Smokeless Tobacco Use 9

[N=199]: 13% were told by a doctor/mh professional that they have a MH condition. Someone in family diagnosed with MH condition: Yes, 21.4%. 25 Questions [Hopkins System Checklist-25] [HSCL25 has 10 statements to measure anxiety & 15 to measure depression statements] [N=195]: 30% (n=58) suffer from anxiety symptoms. [N=192]: 26% (n=49) reported depression. [N=200]: 9% (n=17) have posttraumatic stress disorder symptoms. ****Multi-layered/Cumulative Trauma/Stressors: Displacement/Torture; Harsh Camp Life; Post-Resettlement Navigational Challenges/Hardships/Barriers. CDC Data Source: Ao, T., Suicide and suicidal ideation among Bhutanese refugees United States, 2009-2012. MMWR. 2013;62(26):553-6] 10

6.2% (n=12) of 195 respondents were seriously thinking about committing suicide. Of 11 respondents who answered a question about suicide attempts, 3 (27%) reported attempting suicide. 38% of 114 respondents knew well a close friend or neighbor who ever committed suicide. Of 145 respondents who personally knew people who have taken their own life: 18% knew at least one such person; 26% knew 2-4 persons; and 5% knew 5 or more person. Knew People who Took Own Life in Past 12 Months [N=145] 26%, 38 5%; 7 None Know at least one person Know 2-4 persons 18%, 26 51%, 74 Know 5 or more persons 12 11

Pre-Displacement: Most common traumatic events experienced in Bhutan were (those with high responses): [N=200] Harvard Trauma Questionnaire (HTQ) 22 questions lack of nationality or citizenship (80%; n=160); having to flee suddenly (72%; n=144); lost property or belongings, including seizures by the government (Bhutanese) (68%; n=136); and religious or cultural persecution (being forced to speak the national language or wear the national dress) (49%; n=98). # HTQ-22 were used to analyze traumatic events experienced in Bhutan before being settled in refugee camps of Nepal. Source: Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992;180:111 6.] 12

Symptoms of PTSD, depression, anxiety, as well as somatic complaints The survivors had higher lifetime and 12-month rates of ICD-10 psychiatric disorder. Men--more likely to report torture; tortured women--more likely to report certain disorders. The tortured Bhutanese refugees, as a group, suffered more and had higher anxiety and depression scores than non-tortured refugees. Number of PTSD symptoms, independent of depression and anxiety, predicted both number of reported somatic complaints and number of organ systems involving such complaints. Dramatically high incidence of mental illness including depression, anxiety and PTSD; and incidence of torture as a possible contributor to the illnesses. Nepali-Bhutanese syndrome? A form of depression that doesn t fit clearly into any defined mental health disorder. It progresses from them having aches and pains all over their bodies, to burning. and, in extreme situations, not doing anything [Ken Thompson, a psychiatrist working with Bhutanese refugees in Pittsburgh] Literature Ommeren et al. (2001) Nirakar et. al (1998) Ommeren et. al (2005) Mills et al. (2008) Fusion (2016) 13

Coping methods (5 components)#: Withdrawal [N=196]: 24% respondents avoided being with people in general. Turning to friends or self-focused problem solving [N=196]: 45% went to a friend to help them feel better about the problem. Entertainment/leisure activities [N=196]: 8% watched TV. Religion and/or culture [N=196]: 42% visited a temple or church; and 38% (n=74) participated in singing Hindu devotional songs. Community support [N=195]: 48% talked with community leaders; and 43% (n=84) joined community support groups. # Adapted from: Vonnahme, Lankau, Ao, Shetty, and Cardozo. 2014. Factors Associated with Symptoms of Depression among Bhutanese Refugees in the United States. Journal of Immigrant and Minority Health. Published online: 28 October 2014] 14

National Center for Cultural Competence in 2001 defined culture as a dynamic pattern of language, beliefs, values, rituals, and customs that characterize specific racial, ethnic, religious or social groups...a trauma-informed approach to the delivery of behavioral health services...involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.. [SAMHSA TIP #57] The landscape of trauma informed care is grown more diverse in recent times across race/ethnicities, special populations, new immigrants and refugees hence the need to be culturally informed and competent. There has been increasing support more so in recent years for embracing cultural humility and enhancing communities resiliency in trauma-related health care. Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 15

Beal 2003; The Commonwealth Fund

https://store.samhsa.gov/shin/content//sma14-4849/sma14-4849.pdf 18

Characteristics Cultural and Acculturation Issues: Navigational challenges (learnings about the society); parent-child acculturation discrepancies. Need to negotiate the educational system, acquire language proficiency, and seek employment. Cultural Strengths: Strengthen the diversity; positive social, political, and cultural contributions to U.S. society; significant loyalty, ingenuity, and strong work ethic; collectivistic orientation. Pre-migration (past persecution; torture) trauma and PTSD among refugees: Exacerbated by the new challenges of adjustment; feeling estranged and isolated; mistrust with service providers. Counseling Implications Multiple roles: Counselor (recognizing that they face multiple stressors); educator (providing information on services and education about their rights and responsibilities); and advocate (helping them to navigate health care, education, and employment systems). Barriers to seeking Tx: Communication difficulties due to language differences (or LEP); lack of knowledge of mainstream service delivery; cultural factors (privacy; stigma; deportation fears); lack of resources (SDOH; transportation..) Effort toward a strong therapeutic relationship with traumatized refugees by (a) establishing trust; and (b) considering the cultural perspective of refugees concerning mental and physical disorders (and assess how these are different from those of the dominant culture). Compiled and adapted from Sue and Sue. 2016. Counseling the Culturally Diverse: Theory and Practice.

http://www.nctsn.org/sites/default/files/assets/pdfs/culture_and_trauma_brief.pdf 20

Need to focus on posttraumatic stress disorder to address family-level processes, such as family relationship, communication, and resilience. [Ortal & de Jong, 2015] Physicians may require specialized training to learn how to initiate conversations about mental health and provide appropriate mental health referrals. [Shannon, 2014] Physicians need to screen for PTSD when survivors of extreme stressors present nonspecific somatic complaints. [Ommeren et al. 2005] Modifications in refugee policy may improve social functioning, and innovative mental health and psychosocial programs need to be implemented, monitored, and evaluated for efficacy. [Cardozo, 2004] Clinical guidelines should continue to refine the assessment of immigrants presenting mental health problems. (Foster, 2001] From SAMHSA s perspective, it is critical to promote the linkage to recovery and resilience for those individuals and families impacted by trauma. [SAMHSA, Accessed on October 28, 2018] 21

http://healthpolicy.ucla.edu/publications/documents/pdf/2015/i mmigrantreport-apr2015.pdf 22

Community trauma is not just the aggregate of individuals in a neighborhood who have experienced trauma from exposures to violence. There are manifestations, or symptoms, of community trauma at the community level. The symptoms are present in the socialcultural environment, the physical/built environment and the economic environment. https://www.preventioninstitute.org/sites/default/files/publications/adverse%20community%20experiences%20and 23 %20Resilience.pdf

https://www.healthcaretoolbox.org/culturalconsiderations/culturally-sensitive-trauma-informedcare.html 24

http://www.theannainstitute.org/refugeetraumapaperjuly212008.pdf 25

John R. Kasich, Governor Tracy J. Plouck, Director (614) 752-6462 Surendra.Adhikari@mha.ohio.gov THANK YOU! 26

Trauma Informed Care for Refugees and Survivors of Torture From Harm to Healing Hana Khaled, BS, MS Parmacology SOT case manager US Together, Columbus, Ohio

Figures at a Glance According to the UNHCR there are 68,500,000 forcibly displaced people worldwide 40 million are internally displaced 25.4 million externally displaced and only 1 percent are resettled worldwide 3.1 million asylum seekers 44,500 persons per day leave their homes and seek protection elsewhere 2

Defining Torture... 'torture' means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions. Article 1 of the United Nations Convention Against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment 3

Who are the Perpetrators? Prison officers/detention staff Police officers Military personnel Paramilitary forces State-controlled contra-guerilla forces Health professionals Legal professionals Co-detainees acting with the approval or on the orders of public officials Death squads/opposition forces/rebels Source: www.irct.org 4

Who are the Victims? Ethnic minorities Human rights advocates Political figures Union leaders Student leaders Journalists Religious figures Health professionals Women and children Poor and disadvantaged Source: www.irct.org 5

The Prevalence of Torture Documented to occur in 141 countries (Amnesty International) Up to 45% of refugees and asylum seekers are torture survivors (ORR; CVT, 2015) 1.3 million refugee torture survivors currently reside in the U.S. (CVT, 2015) 99% of Syrian refugees in 2013 were survivors of violence and torture (UNHCR, 2015) 6

Common Methods of Torture: Physical Beating, whipping, caning Concussive trauma is almost universal A third to half of survivors report beatings on the feet (J Fam Pract. 2012;61(4):E1-E5) Rape or witnessing rape, or the threat of rape Extreme deprivation: Restriction of food, water, and sanitation Extreme temperatures Submersion, water boarding, suffocation Electric shock, burning, mutilation by cutting Forced inhalations Pharmacological torture Forced postures, stress positions, stretching Hooding and blindfolding 7

Common Methods of Torture: Psychological Forced, prolonged isolation and imprisonment Harassment, intimidation, and deprivation of human rights Repeated and systematic threats Forced witnessing of torture, death squads or mass murder Mock executions Sleep deprivation Sensory deprivation or sensory overload Capture of love ones, colleagues, community members 8

A Story

Diverse Group of Clients in SOT 220 clients served in our Columbus, Toledo, Cleveland offices since 2015 21 different countries of origin 25 ethnicities 7 religions 18 languages Ages 0-81 years Different education levels Different physical and mental abilities Different immigration statuses 10

Where do most Refugees and SOTs Come From? Bhutanese Nepali Former Soviet Union Iraq Afghanistan Eritrea Burma Burundi Rwanda Ethiopia Sudan Somalia Vietnam Democratic Republic of Congo Syria 11

Immigration Statuses Parolee Immigrant Asylum Seeker/ Asylee Refugee Undocumented Immigrant US Citizen 12

Comprehensive Services Trauma Story Biomedical Psychological Social Spiritual Legal Best Practices Outcomes

AT HOME Trauma Informed Care Model AT HOME is an acronym for A=Accessible T=Timely H=Holistic O=Oriented M=Multi- Disciplinary E= Education and Empowerment 14

Now I can finally feel safe and able to sleep when I put my head down on my pillow. You have a very hard job, because it is your job to put the soul back in the body. -Survivors of Torture 15

Often it isn t the initiating trauma that creates seemingly insurmountable pain, but the lack of support after. We don t heal in isolation, but in community - S. Kelly Harrell, Gift of the Dreamtime-Reader s Companion 16