Project Proposal. UNC Refugee Wellness Project. Albert Thrower. UNC School of Social Work

Running head: UNC REFUGEE WELLNESS PROJECT Project Proposal UNC Refugee Wellness Project Albert Thrower UNC School of Social Work I have neither given nor received any unauthorized assistance on this assignment. Albert Thrower

UNC REFUGEE WELLNESS PROJECT 2 Background Refugee Mental Health in America The U.S. refugee program began in 1975, to accommodate refugees from Vietnam after the fall of Saigon (National Child Traumatic Stress Network [NCTSN], 2005). At the end of 2012, 45.2 million people were currently displaced as a result of persecution, conflict, and violence, the highest level since 1994 (United Nations High Commissioner for Refugees [UNHCR], 2013). 88,600 refugees were resettled in 2012, with the United States of America taking in the highest number (66,300; UNHCR, 2013). A refugee is a person who has left his or her native country and cannot or will not return due to war, violence, or persecution (United Nations, 1951). The refugee must have a rational fear of persecution for membership in a specific social group, nationality, political opinion, race or religion. In 2012, the primary reasons for refugees fleeing their home country were ethnic and tribal conflict, religious persecution, and war violence (UNHRC, 2013). Refugees show greater levels of psychological disturbance than the general population (Fazel, Wheeler, & Danesh, 2005; Porter & Haslam, 2005). The World Health Organization estimates that approximately half of all refugees have some mental health issue as a result of traumatic experiences. Killings, material losses, torture, sexual violence, detention, displacement, life in overcrowded camps, uncertainty over the future, disruption of community and social support networks all increase the risk for psychological distress (Brundtland, 2013; Rousseau, 1995). Refugees escaping war and political persecution have an especially high rate of mental health problems (Williams & Berry, 1991). More intense traumas, such as the violent death of a family member or witnessing someone being injured, killed, or tortured, put the individual refugee at greater risk for higher levels of psychological distress (Heptinstall et al., 2004;

UNC REFUGEE WELLNESS PROJECT 3 Kuterovac, Dyregrov, & Stuvland, 1994; Smith et al., 2002). Also increasing the risk of psychological distress is the individual refugee s subjective perception of the degree to which he or she was under direct threat and his or her level of involvement during the traumatic event (Dyregrov et al., 2000; Garbarino & Kostelny, 1996; Nader et al., 1993; Smith et al., 2002). The uncertainty inherent in the disappearance of a family member robs the refugee of a proper grieving period and therefore results in higher levels of distress for those individuals as well (Quirk & Casco, 1994). The stresses for refugees do not end upon resettlement. The acculturation process refugees go through in the host country can involve stresses such as the loss of social networks, changes in work status, communicating in a new language, encountering discrimination, changes in social roles, financial difficulties, poor living conditions, and social isolation (Berry, Kim, Minde, & Mok, 1987; Mena, Padilla, & Maldondo, 1987; Williams and Berry, 1991; Colic- Peisker & Walker, 2003; Beiser & Hou, 2001; Miller et al., 2002; Mollica et al., 2001; Laban et al., 2005; Silove et al., 1997; Schweitzer, Melville, Steel, & Lacherez, 2006). Somewhat counter intuitively to what is generally thought of as a protective factor in Western mental health models, a meta-analysis by Porter and Haslam (2005) found that refugees with higher levels of education who experienced a greater decrease in their socio-economic statues had worse post-migration outcomes. Some studies even suggest that these post-migratory risk factors have a greater impact on psychological morbidity than exposure to traumatic events (Gorst-Unsworth & Goldenberg, 1998; Laban et al., 2004; Lie, 2002). Common mental health difficulties among refugees include post-traumatic stress disorder (PTSD), depression, anxiety, grief, somatic complaints, sleep problems, social withdrawal, generalized fear, and irritability (Ehntholt & Yule, 2006). The incidence of diagnoses varies

UNC REFUGEE WELLNESS PROJECT 4 between populations. Studies have found prevalence rates of PTSD and major depression in resettled refugees ranging from 10-40% and 5-15%, respectively (RHTAC, 2011). PTSD seems to be linked to pre-migration war trauma, while depression is related to post-migration difficulties such as not speaking the new local language (Sack, Clarke, & Seeley, 1996). Another meta-analysis found that increased PTSD symptoms were associated with a higher number of experienced traumas, adaptation difficulties in the host country, culture loss, and the loss of support systems (Carswell, Blackburn, & Barker, 2011; Carlson & Rosser-Hogan, 1991; Kinzie et al., 1990; Steel, Silove, Phan, & Bauman, 2002). The mental health needs of refugees are beginning to find advocates in academia, but they are still largely ignored on the ground. In a World Health Organization report, Brundtland (2013) reports that despite the scientific evidence that refugees are at enormous risk for poor mental health outcomes, resources have not been allocated to address the problem. Without the presence of accessible mental health services for refugees, these individuals traumatic experiences and stressful situations often manifest into severe mental illness (Duckworth & Shelton, 2012). Refugees in North Carolina In 2012, North Carolina had the 11 th largest grand total of refugees accepted for resettlement, down from the 9 th largest in 2011. The largest subgroups included Burma (785 persons), Bhutan (639), Iraq (148), Somalia (93), and the Democratic Republic of Congo (76; U.S. Office of Refugee Resettlement, 2013). Resettlement agencies in Charlotte, Durham, Greensboro, High Point, New Bern, and Raleigh received $11.2 million in federal funds in 2009 to resettle incoming refugees (Walker, 2011). That money is used to provide housing, case management, employment services, transportation, language classes, and other programs for

UNC REFUGEE WELLNESS PROJECT 5 refugees. From 2005 to 2011, Orange County hosted 666 resettled refugees, with 95% of those being from Burma (Community Health Assessment [CHA], 2011). Barriers to Refugee Mental Health Services Studies estimate that 40% of refugees in the United States are in need of mental health services for psychiatric disorders but cannot access those services (Ehntholt &Yule, 2006). Simmelink & Shannon (2012) posit that the reason refugee resettlement agencies do not prioritize mental health in the services they provide is because their funding from the Office of Refugee Resettlement is based heavily on the employment rate of the refugees and so most of their energy is spent making sure their clients get jobs. These agencies can also be overworked and understaffed, like many human service organizations, and taking on an additional cause could simply be beyond the agency s capacity to address. There are a number of other unique challenges to providing mental health services to refugees. These include lack of research into the cultural appropriateness of many psychological assessment techniques and treatment modalities (Bracken, 2002; Summerfield, 1999), frequent misdiagnosis (Gong-Guy, Cravens, & Patterson, 1991), the cultural competence of providers, language barriers, culture barriers, and transportation (Paniagua, 2005; Sue, Zane, Nagayama Hall, & Berger, 2008; Chang-Muy & Congress, 2009). Cultural barriers such as stigma about mental health or just being unaware of the concept of mental health can keep refugees from seeking or sticking with mental health treatment (Crowley, 2009). Unless someone reaches out to them and teaches them about Western mental health practice, they are unlikely to seek treatment. If a refugee does decide to seek treatment, though, there are a number of barriers to actually getting it. Transportation is perhaps the most fundamental of these barriers, because if an individual cannot travel to a mental health provider

UNC REFUGEE WELLNESS PROJECT 6 then the other barriers cannot be dealt with. The distances in Orange and Durham Counties are great, and without a personal vehicle getting from one place to another can be difficult. There are bus systems, but the routes can be complicated to figure out, they do not reach every corner of the counties and in Durham County the fare can be a financial burden for low-income families. Acquiring a personal vehicle can also be difficult for a refugee, primarily because of the burdensome cost it takes to register for a vehicle and the language barrier in the likely event that the driving test is not available in the individual s native language. Currently the test is offered in English, Spanish, Chinese, Japanese, Russian, German, Korean, Arabic, and Vietnamese (NC DMV, 2009). The language barrier is another barrier that presents great difficulty to refugees who need to access mental health services. While it is Federal Law under Title VI of the 1964 Civil Rights Act for mental health providers who bill Medicaid to provide interpreters for patients, it is unclear to what degree it is enforced. Anecdotal evidence suggests it is not. Using a non-trained interpreter from the community can be dangerous because he or she may omit information or confuse the boundaries and ethics of a therapeutic relationship (Chen et al., 2007). Even with an interpreter, communicating across a language gap introduces the risk of misidentifying problems and can hinder the development of the therapeutic relationship (RHTAC, 2011). In Orange and Durham counties, specifically, available interpreters are not trained in mental health interpreting and thus sometimes accidentally disrupt the therapeutic process without knowing they are doing so. Psychotherapy is a complex process, and the goals of each interaction will not be so apparent to someone not trained in psychotherapy. For instance, if the interpreter is not translating the client s words precisely, interpreters run the risk of obscuring clues of underlying schemas and

UNC REFUGEE WELLNESS PROJECT 7 cognitive distortions implicit in the client s phrasing (Beeber, Lewis, Cooper, Maxwell, & Sandelowski, 2009). Also, if the interpreter takes it upon himself to smooth over a misunderstanding between client and practitioner, she is disrupting the client-therapist relationship and thwarting an opportunity to empower a client to navigate cultural misunderstandings without having it navigated for him (Beeber et al., 2009). If a refugee manages to find transportation to a mental health appointment, and a professional interpreter has been arranged, if the mental health practitioner is not trained in psychotherapy modalities specifically designed for refugees then the refugee might not get treatment acceptable to his or her culture. Literature on psychotherapy techniques meant for refugees is limited, but there are some promising treatments, which will be discussed in the next section. Mental Health Intervention for Refugees As mentioned earlier, studies have found prevalence rates of PTSD and major depression in resettled refugees ranging from 10-40% and 5-15%, respectively (RHTAC, 2011). PTSD seems to be linked to pre-migration war trauma, while depression is related to post-migration difficulties such as not speaking the new local language (Sack, Clarke, & Seeley, 1996). It therefore seems that depressive symptoms could be mitigated (or avoided) in this population by directly addressing some of the daily stressors affecting the individual (Miller, 1999). Since PTSD is related to past trauma, however, psychotherapy will be needed. While there is a tremendous amount of literature around the use of cognitive behavioral therapy to treat PTSD in individuals who have experienced sexual assault, physical violence, or accidents (Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991; Tarrier et al., 1999), these

UNC REFUGEE WELLNESS PROJECT 8 studies have mainly been done with Western populations. The knowledge base regarding what s effective in treating PTSD in refugees is still very limited. Some studies have found success treating PTSD in refugees with CBT (Otto et al., 2003), but there are a number of concerns that suggest traditional CBT might not be the best fit for refugees. Language barriers and cultural barriers regarding the client s expectations of the treatment required hamper the application and acceptability of psychotherapy treatments to trauma in refugee populations (Stephenson, 1995; Uba, 1992). For instance, working through interpreters makes it difficult to appropriately manage and pace the presentation of trauma material (Otto & Hinton, 2006). Also, some studies suggest that traditional exposure techniques are poorly tolerated by refugee and ethnic minority clients (Lester, Resick, Young-Xu, & Artz, 2010; Markowitz, 2010), and may not even work for the complex trauma histories that many refugees have. For instance, traditional prolonged exposure in trauma-focused CBT work asks clients to recall their worst traumatic memory, and that becomes the focus of the exposure therapy. Many refugee clients, however, have experienced a long series of traumas for much of their life. Picking out a worst trauma could seem like a confusing and arbitrary request to a refugee client. And even if the client does name one and the practitioner carries through with exposure therapy focusing on that worst trauma and is successful at defanging it it s not a given that overcoming that trauma will generalize to the many other traumas in the client s life. A psychotherapy model for treating PTSD symptoms in refugees should be able to address the complex nature of refugee trauma. For a therapeutic intervention to realistically work, especially for a client who has experienced heavy complex trauma, the intervention should have the trust and buy in of the client. The foreignness of Western mental health treatment could make getting that buy in quite

UNC REFUGEE WELLNESS PROJECT 9 difficult. Many refugees are coming from cultures where psychotherapy isn t so commonplace, and seeing someone for mental health reasons carries a stigma (Crowley, 2009). Some Southeast Asian cultures believe that suffering is inevitable, which can stop them from seeking mental health care (Uba, 1992). Also, many refugee clients will have spent a considerable amount of effort locking away traumatic memories; asking them to open that Pandora s box no doubt seems like an absurd request to someone without a prior understanding of psychotherapy, let alone exposure therapy. Getting buy in from the client in this circumstance poses quite an obstacle. It is possible that psychotherapy is just too foreign a concept for some refugee populations to trust, and if alternatives are not offered then refugees will continue to be shut out of mental health services in America. Some mental health problems, such as depression and anxiety, could potentially be helped by addressing stressors in the environment, thus avoiding the foreign concept of therapy (Miller, 1999). PTSD symptoms, however, will likely require some form of therapy to alleviate. Trauma treatments designed for refugees. There are a few relatively new psychotherapy interventions for trauma that have been designed for and successfully tested with refugee populations. One of these newer models is Narrative Exposure Therapy (NET). NET is a standardized short-term treatment based on cognitive behavioral exposure therapy but specifically adapted to meet the needs of survivors of war and torture (Neuner, Schauer, Elbert, & Roth, 2002). NET was developed to address situations of complex trauma, where an individual has suffered not one major traumatic event but a long series of traumas. This is often the case with refugees, who have sometimes spent the majority of their lives in warzones and refugee camps. In NET, a client constructs a narration of his or her entire life from birth until the present moment, with emphasis

UNC REFUGEE WELLNESS PROJECT 10 on moments of trauma. Like exposure therapy, NET seeks to reduce the symptoms of PTSD by confronting the patient with memories of the event, but it also addresses the theory that PTSD symptoms are maintained by a fragmented narrative of traumatic memories (Ehlers & Clark, 2000). NET works upon this theory by stringing together all of the little traumas and threats into a consistent narrative, thereby defragmenting the memories ending the maintenance of PTSD symptoms. NET has been shown to be effective in randomized controlled trials with Sudanese refugees living in Uganda (Neuner, Schauer, Elbert, Klaschik, & Karunakara, 2004). Also quite notably, the dropout rate for the NET group in Neuner et al. s study was 0%, compared to studies of traditional exposure therapy, which have reported dropout rates of up to 28% (Foa, Rothbaum, Riggs, & Murdock, 1991). NET s exceptionally low dropout rate could be due to the fact that the treatment procedure is, at its core, storytelling, which would feel much more natural than traditional CBT exposure to many populations. There are a number of other efforts to adapt CBT specifically for use with refugees and people from other cultures. Culturally Adapted CBT (CA-CBT), for instance, is designed to be easily understood by populations with minimal education and focuses on emotion exposure (interoceptive exposure) and emotion regulation techniques such as meditation and yoga-like stretching, and promotes emotional and psychological flexibility (Hinton et al., 2012). Emotions and somatic symptoms are the key treatment targets of CA-CBT, as some evidence suggests that these are the primary outlets through which non-western cultures experience PTSD. Many people in non-western cultures unfamiliar with exposure therapy and psychotherapy in general are unwilling to relive their traumatic memories in detail. The interoceptive exposure used in

UNC REFUGEE WELLNESS PROJECT 11 CA-CBT focuses not on the details of what happened, but on the emotional experience and meaning of what happened. For this reason, individuals may be more willing to participate. Hinton et al. (2012) report that CA-CBT is intended to be further tailored for particular cultural groups. Thus far it has been shown to be effective in randomized control trials in Latino populations and with refugees from Cambodia and Vietnam (Hinton et al., 2005; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011; Hinton et al., 2004). The treatment was well accepted and efficacious in these populations. The same group that created CA-CBT performed a study with refugees from Cambodia that introduced into trauma treatment other culturally-adapted elements, which focus on skill building, discriminating trauma memories from current reality, symptom exposure, and emotional acceptance (Otto & Hinton, 2006). Instead of focusing on the normal exposure elements of TF-CBT, they sought to give individuals the skills to recognize trauma cues and change the meaning of them so that overwhelming emotions from the past were not brought up. The initial way into this was interoceptive exposure, similar to what was done with CA-CBT. This technique proved effective at decreasing individuals fears of somatic sensations and reducing re-experiencing, hyperarousal, and avoidance/numbing symptoms in a small randomized trial with distressed and treatment-resistant Cambodian refugees (Otto et al., 2003). If refugee clients are showing some resistance to relive their traumatic memories in detail, for fear that the emotions will overwhelm them, these adaptions to the CBT model could be a good option. All of these treatments seek to bridge the gap between traditional Western trauma treatment and refugees cultural beliefs about what will be helpful. These interventions are still

UNC REFUGEE WELLNESS PROJECT 12 quite young, but if they catch on they could open up the world of mental health services to millions of people who were previously underserved. The UNC Refugee Wellness Project To follow is a proposal for an expansion of what is now known as the UNC Global Transmigration Refugee Mental Health & Wellness Initiative. The current program is run by Clinical Instructor Josh Hinson and four students in the UNC School of Social Work graduate program. They receive referrals of new arrivals from Church World Service (a refugee resettlement agency), screen those individuals for a mental health need with the Refugee Health Screener 15 (RHS-15; see Appendix A), and then provide therapy, support groups, and/or psychiatric case management to those who want it. It is a time-limited pilot program operating for the 2013-14 school year. The primary aims of the initiative at this stage are to collect data on the mental health needs of Orange and Durham counties refugee populations and to test the feasibility of the operation, its acceptability to refugees, and different models of therapy / mental health intervention. By the end of Spring Semester 2014, the initiative hopes to have quantitative and qualitative data from at least 80 refugees, as well as a plan for moving forward and developing the program further. The expansion proposed here keeps the core tasks of the current initiative, but adds the following: 1) additional intervention options, 2) an expanded client capacity, 3) a recruitment program to draw in additional practitioners, 4) training programs and manuals for practitioners and interpreters. All of these will be explained in more detail below. There is a chart of the full program structure in Appendix B. Involved Parties Below is a list of the groups involved with the project.

UNC REFUGEE WELLNESS PROJECT 13 Refugee resettlement agencies. The project will continue to take new refugee referrals from Church World Service, but will also begin taking referrals from World Relief, another resettlement agency in the area. This will expand the number of incoming referrals significantly. Additionally, to fuel the Peer Mentorship program (more on that below), the project will solicit nominations from the resettlement agencies for refugees who have been in America at least 1 year to serve as mentors to new arrivals. RWP Core Team. It will be necessary to increase the project s capacity to accommodate the increased number of referrals the project will be receiving. The Core Team of the project will be Josh Hinson and students from the UNC School of Social Work who have been assigned the project as their field practicum, with the possible addition of a paid full-time staff member. Social Work students placed with RWP and interested in a direct practice field placement can perform more therapy, and students interested in a macro placement can perform more recruitment, management, and outreach tasks. The Core Team will recruit providers (called Friends) from outside the project, including from the community, UNC, and other universities in the area. The Core Team s responsibilities will include (but not be limited to): Recruiting, training, and supervising Friends Creating training manual for Friends Organizing training for Interpreters Creating simple training manual for Interpreters Scheduling Interpreters Performing intake assessments and determining appropriate services Planning community events Evaluating intervention outcomes and process

UNC REFUGEE WELLNESS PROJECT 14 Assuming some Friend roles as needed by clients / desired by Core Team Member Performing outreach to community groups and organizations and monitoring collaborations Writing grants to fund future of project Being creative and rapidly developing and deploying new strategies and interventions that address emergent needs, evaluating results The Core Team will provide training for all of these Friends and produce training manuals for each Friend role. Friends will report to a designated member of the Core Team to update them on sessions. The Core Team member will be responsible for arranging interpreters for sessions based on schedule reported by Friend. Depending on the split of interests among the Core Team, each member could be assigned specific Friend categories (i.e., Screeners, Therapists, Mentors, etc.) to supervise, or the Core Team members could divide up individual cases. When a refugee client is involved with more than one type of Friend, those Friends will be encouraged to collaborate on the case and in some cases consider meeting with the client as a team (Friend Group), to the degree that the client is comfortable with doing so. Friends. The project will have eight Friend roles that recruits can assume. A recruit can have more than one role, but some of these should not be held by the same person for the same refugee client, so as to keep boundaries as clear as possible. The available Friend roles are: Screeners Main task is to screen newly arrived refugees with the RHS-15. This role can be held by any student, but preference will be given to Psychology, Social Work, and Public Health graduate students. 4 hours/month minimum commitment.

UNC REFUGEE WELLNESS PROJECT 15 Therapists Main task is to provide psychotherapy to refugees. This role can be held by members of the Pro Bono Counseling Network, Psychology graduate students, and 2 nd year Social Work graduate students. 4 hours/month minimum commitment. Group Facilitators Main task is to facilitate Peer Support Groups. This role can be held by graduate students and members of the refugee community who have been settled for some time. 4 hours/month minimum commitment. Advocates Main task is to provide enhanced case management and advocacy for refugee clients at elevated risk for negative mental health outcomes due to psychosocial stressors that can realistically be alleviated with some assistance. Special care will be taken to not interfere with the case management strategies of the resettlement agencies, but instead to be a support to their efforts. This role can be held by graduate students and members of the refugee community who have been settled for some time and have some knowledge of community resources. 4 hours/month minimum commitment. Health Advocates Main task is to provide enhanced medical case management and advocacy for refugee clients at elevated risk for health problems. Ideally the Health Advocates would be provided through collaboration with the student-run UNC Refugee Health Initiative, but interested Social Work or Public Health graduate students will be able to request the role as well. Once assigned, we hope they will be able to dedicate 4 hours/month to the client until they are no longer needed. Mentors This role is for established members of the refugee community who would like to connect to new refugees to help them adjust, connect them to the greater community, and be a friend. 4 hours/month recommended involvement.

UNC REFUGEE WELLNESS PROJECT 16 Allies This role is for volunteers who want to be involved with the community but cannot commit to regular sessions with refugees. They will be called upon as needed by the core group to assist with certain projects (event planning, website maintenance, etc.). This role can be held by any student or community member. Interpreters. The project will continue to source interpreters through the Raleigh office of the U.S. Committee for Refugees and Immigrants. New to this relationship will be a mental health interpreter training program, based on a model designed and implemented by Beeber et al. (2009) with depressed Latino women. This model makes some adjustments to the usual interpreting models. For example, interpreters trained in this method are taught the importance of translating everyone s words exactly as they were spoken, and not adding their own beliefs and opinions. Also, so as to strengthen the client-therapist relationship, the interpreter sits out of the client s eye line so that the client speaks to the therapist rather than the interpreter. If the interpreter is asked a direct question by the client, the interpreter is to say (in both languages) why they cannot answer the question. These modifications and more all help to maintain therapeutic fidelity. The training manual will be adapted for easy digestion and provided to the agency in case some interpreters are not able to make one of the training sessions. Interventions There are seven interventions that RWP will organize and facilitate: Peer mentorship, acculturation support groups, psychotherapy, psychiatric case management, advocate partnership, connecting to community resources, and community events. Individuals scoring below the threshold on the RHS-15 will be offered peer mentorship and acculturation support groups, and informed about useful community resources and upcoming community events. Individuals scoring above the threshold will complete an intake assessment with a member of the

UNC REFUGEE WELLNESS PROJECT 17 Core Team, who will then suggest one or more of the following based on the client s needs, preferences, and presenting problems: Peer mentorship, acculturation support group, psychotherapy, psychiatric case management, advocacy partnership, community resources, community events. The variety of interventions is meant to address mental health from all angles, as individuals preferences and needs will not all be the same and focusing too narrowly on one area will leave many people without the kind of help they need. By offering psychotherapy alongside a range of community-based interventions, the RWP will be able to alleviate distress from trauma as well as from exile-related stressors such as loss of community and loss of meaningful activity in one s life (Miller, 1999). Each of the interventions is described below. Peer mentorship. A peer mentor will be offered to every refugee client. These mentors will be refugees who have been settled for more than a year. They will be an immediate friend to the newly arrived refugee and connect him to the greater community, thereby avoiding the isolation and loneliness that many newly arrived refugees feel. (Miller, 1999) Referrals for mentors will hopefully come from resettlement agencies and other community groups. They will not be required to report in to the Core Team unless they have a need to. Acculturation support group. These groups will commence once five clients from one language group express interest. The curriculum will be designed by the Core Team, possibly based on the Pathways to Wellness Community Adjustment Support Group model that is currently being piloted by the RMWHI. Groups will be ideal for clients whose mental health distress seems to be based in anxiety and depression about the common challenges of resettlement, and who are willing to share their experience and interested in hearing the

UNC REFUGEE WELLNESS PROJECT 18 experiences of others. Ideally, there will be at least one peer mentor in each group who can give his perspective looking back. Psychotherapy. Individuals with a distinct mental health need (especially trauma) will be referred to psychotherapy. The Core Team member or Friend who completed the assessment will provide some introductory psychotherapy to explain how it will work and why it will be helpful. Treatment will follow the latest literature regarding best practices. Psychiatric case management. Provided by either an Advocate or Health Advocate. Clients will be referred to psychiatric case management by their Therapist, according to the Therapist s judgment. Advocates will assist client in scheduling and attending psychiatric appointments and medication maintenance. The Core Team will arrange interpreter services for psychiatric appointments. Advocate partnership. Clients will be referred to an Advocate if they are experiencing pronounced distress, depression, or anxiety primarily because of daily stressors and challenges of resettlement that are realistic to overcome with proper enhanced case management and advocacy. Health advocacy. Same as above, except for clients whose stressors relate to a particular medical need. Ideally a student from RHI. The Health Advocate will be responsible for helping clients navigate health systems, advocating for their rights as patients, and assisting in responsible ways with any medical needs. Community referrals. Some clients may be better served by or more interested in another program or agency in the community. For example, individuals might be interested in the services of the Art Therapy Institute, or Transplanting Traditions, or additional English help through the Orange County Literacy Council.

UNC REFUGEE WELLNESS PROJECT 19 Community events. These events will be planned by the Core Team with the assistance of Allies, preferably refugee community members themselves. The goals will vary from event to event, but could include large, visible celebrations that introduce the greater community to the refugee community and vice versa. Smaller gatherings will be great for connecting new refugees with the existing community, and strengthen bonds and social supports. Conclusion This project design is meant to be a medium-term goal for the RMHWI, not a next step. The modifications proposed herein would be quite difficult to implement all at once. That being said, once all of the pieces are in place it will be a comprehensive, holistic approach to refugee mental health that works on multiple levels (individual, community, systems) and gives the refugee options about what they think will be most helpful. The project could build a unified community of refugees and Friends that becomes self-sustaining as former clients re-enter the program to be trained as mentors, advocates, and possibly therapists. If strong efforts are made to engage the refugee community in the running of the project, it s possible that in less than 10 years it could transition from being a University-based program to a standalone refugee-run nonprofit.

UNC REFUGEE WELLNESS PROJECT 20 Appendix A

UNC REFUGEE WELLNESS PROJECT 21

UNC REFUGEE WELLNESS PROJECT 22 Appendix B

UNC REFUGEE WELLNESS PROJECT 23 Annotated References Beeber, L. S., Lewis, V. S., Cooper, C., Maxwell, L., & Sandelowski, M. (2009). Meeting the ''now'' need: PMH-APRN Interpreter teams provide in-home mental health intervention for depressed Latina mothers with limited English proficiency. Journal of the American Psychiatric Nurses Association, 15. 249-259. This article explains a mental health interpreting model that is meant to maintain therapeutic intent from the therapist and empower the client by relating her exact words to the practitioner. The article describes the training process for interpreters and practitioners, as well as how the model was used for in-home therapy visits with depressed Latino mothers. The challenges of implementing this model are also well described. Hinton, D. E., Rivera, E. I., Hofmann, S. G., Barlow, D. H., & Otto, M. W. (2012). Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry, 49, 340-365. This article details culturally adapted CBT (CA-CBT). The article includes detailed descriptions and rationale for 12 key aspects of CA-CBT. In addition to the uses mentioned already in the blog post, the authors have seen some success in treating comorbid anxiety disorders and anger in refugees as well. Neuner, F., Schauer, M., Elbert, T., & Roth, W. T. (2002). A narrative exposure treatment as intervention in a refugee camp: A case report. Journal of Behavioural and Cognitive Psychotherapy, 30, 205 209. This article gives a report of the first trial of Narrative Exposure Therapy, in a Kosovar refugee living in a camp in Macedonia. It provides a description of the treatment, and details the promising results achieved with the client, including reduction in PTSD symptoms.

UNC REFUGEE WELLNESS PROJECT 24 Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public Health Reports, 107, 544 548. This article looks at the access to healthcare barriers faced by a population of Southeast Asian refugees whom have been resettled in America. The barriers identified include cultural beliefs about suffering, illness, and treatment. A lack of understanding about Western healthcare methods can also make refugees reluctant to make appointments. The other big barrier is providers lack of culturally appropriate services, especially around providing interpreters to accommodate different languages. Another major barrier is refugees not knowing what services are available and how to access them. Other References Beiser, M., & Hyman, I. (1997). Refugees time perspective and mental health. American Journal of Psychiatry, 154, 996 1002. Beiser, M., Turner, R.J., & Ganesan, S. (1989). Catastrophic stress and factors affecting its consequences among Southeast Asian refugees. Social Science and Medicine, 28, 183 195. Berry, J.W., & Annis, R.C. (1974). Acculturative stress: The role of ecology, culture, and differentiation. Journal of Cross-Cultural Psychology 5, 382-405. Berry, J.W., Kim, U., Minde, T., & Mok, D. (1987). Comparative studies of acculturative stress. International Migration Review 21, 491-511. Brewin, C.R., Andrews, B., & Valentine, J.D. (2000). Meta-analysis of risk factors for posttraumaticc stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748 766.

UNC REFUGEE WELLNESS PROJECT 25 Brundtland, G.H. (2013). Mental health of refugees, internally displaced persons and other populations affected by conflict. Retrieved from http://www.who.int/hac/techguidance/pht/ mental_health_refugees/en/ Carswell, K., Blackburn, P., & Barker, C. (2011). The relationship between trauma, postmigration problems and the psychological well-being of refugees and asylum seekers. International Journal of Social Psychiatry, 57, 107. Cathcart, R., Decker, C., Ellenson, M., Schurmann, A., Schwartz, & Sing, N. (2007). People from Burma living in Chapel Hill and Carrboro: An action-oriented community diagnosis: Findings and next steps of action. Unpublished manuscript, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina at Chapel Hill. Retreived from http://archives.hsl.unc.edu/cdpapers/orange_2007.pdf Chang-Muy, F. & Congress, E. (Eds.). (2009). Social Work with Immigrants and Refugees: Legal Issues, Clinical Skills, and Advocacy. New York, NY: Springer Publishing Company. Chen, A. et al. (2007). The legal framework for language access in healthcare settings: Title VI and beyond. Journal of General Internal Medicine, 22, 362-367. Crowley, C. (2009). The mental health needs of refugee children: a review of literature and implications for nurse practitioners. Journal of the American Academy of Nurse Practitioners, 21(6), 322-31. Duckworth, K., & Shelton, R. (2012). Depression. Retrieved from http://www.nami.org/ Template.cfm?Section=Depression&template=contentmanagement/contentdisplay.cfm& ContentID=67727

UNC REFUGEE WELLNESS PROJECT 26 Dyregrov, A., Gupta, L., Gjestad, R., & Mukanoheli, E. (2000). Trauma exposure and psychological reactions to genocide among Rwandan children. Journal of Traumatic Stress, 13, 3 21. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavioral Research and Therapy, 38, 319 345. Ehntholt, K.A., & Yule, W. (2006). Practitioner review: Assessment and treatment of refugee children and adolescents who have experienced war-related trauma. Journal of Child Psychology and Psychiatry 47:12, 1197 1210. Fazel, M. & Stein, A. (2002). Community child health, public health and epidemiology: the mental health of refugee children. Archives of Disease in Childhood, 87, 366-370. Fazel, M., Wheeler, J. & Danesh, J. (2005) Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet, 365, 1309 1314. Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67, 194 200. Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59, 715 723. Foner, N. (1997). The immigrant family: Cultural legacies and cultural changes. International Migration Review, 31, 961-974. Garbarino, J., & Kostelny, K. (1996). The effects of political violence on Palestinian children s behavior problems: A risk accumulation model. Child Development, 67, 33 45.

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UNC REFUGEE WELLNESS PROJECT 28 adapted CBT for Latino women with treatment-resistant PTSD: A pilot study comparing CA-CBT to applied muscle relaxation. Behaviour Research and Therapy, 49, 275 280. Johnson, H. & Thompson, A. (2008) The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review. Clinical Psychology Review, 28, 36 47. Kinzie, J.D., Tran, K.A., Breckenridge, A., & Bloom, J.D. (1980), An Indochinese refugee psychiatric clinic: Culturally accepted treatment approaches. American Journal of Psychiatry, 137, 1429-1432 Kuterovac, G., Dyregrov, A., & Stuvland, R. (1994). Children in war: A silent majority under stress. British Journal of Medical Psychology, 67, 363 375. Laban, C.J., Gernaat, H.B., Komproe, I.H., Schreuders, B.A. & De Jong, J.T. (2004). Impact of a long asylum procedure on the prevalence of psychiatric disorders in Iraqi asylum seekers in The Netherlands. Journal of Nervous and Mental Diseases, 192, 843 851. Laban, C.J., Gernaat, H.B., Komproe, I.H., van der Tweel, I. & De Jong, J.T.V.M. (2005). Postmigration living problems and common psychiatric disorders in Iraqi asylum seekers in the Netherlands. Journal of Nervous and Mental Diseases, 193, 825 832. Lamberg, L. (2008). Psychiatrists strive to help children heal mental wounds from war and disasters. The Journal of the American Medical Association, 300, 642-643. Lester, K., Resick, P. A., Young-Xu, Y., & Artz, C. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78(4), 480 489. Lie, B. (2002). A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatrica Scandinavica, 106, 415 425.

UNC REFUGEE WELLNESS PROJECT 29 Markowitz, J. C. (2010). IPT and PTSD. Depression and Anxiety, 27(10), 879 881. Marshall, G.N., Schell, T.L., Elliott, M.N., Berthold, S.M. & Chun, C.A. (2005) Mental health of Cambodian refugees two decades after resettlement in the United States. JAMA: Journal of the American Medical Association, 294, 571 579. Mena, F.J., Padilla, A.M., & Maldondo, M. (1987). Acculturative stress and specific coping strategies among immigrant and later generation college students. Hispanic Journal of Behavioral Sciences 9, 207-225. Miller, K. (1999). Rethinking a familiar model: Psychotherapy and the mental health of refugees. Journal of Contemporary Psychotherapy, 29, 283-306. Mollica, R.F., McInnes, K., Poole, C. & Tor, S. (1998) Dose effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482 488. Mollica, R.F., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I. & Massagli, M. P. (1999) Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA: Journal of the American Medical Association, 282, 433 439. Nader, K., Pynoos, R.S., Fairbanks, L., Al-Ajeel, M., & Al-Asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32, 407 416. National Child Traumatic Stress Network [NCTSN]. (2005). Mental Health Interventions for Refugee Children in Resettlement, White Paper II. Retrieved from http://www.nctsnet.org/nctsn_assets/ pdfs/materials_for_applicants/mh_interventions_for_refugee_children.pdf Neuner, F., Schauer, M., Elbert, T., Klaschik, C., & Karunakara, U. (2004). A comparison of

UNC REFUGEE WELLNESS PROJECT 30 narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72(4), 579 587. North Carolina Department of Motor Vehicles. (2009). Tips for Obtaining a North Carolina Driver s License. Retrieved from: www.ncdot.gov/dmv/ Orange County Health Department [OCHD]. (2011). 2011 Orange County Community Health Assessment. Retrieved from http://www.co.orange.nc.us/healthycarolinians/documents/ FINAL_2011_Orange_County_CHA_Full_Report2.pdf Otto, M. W., & Hinton, D. E. (2006). Modifying exposure-based CBT for Cambodian refugees with posttraumatic stress disorder. Cognitive and Behavioral Practice, 13(4), 261 270. Otto, M. W., Hinton, D. E., Korbly, N. B., Chea, A., Ba, P., Gershuny, B. S., et al. (2003). Treatment of pharmacotherapy-refractory post-traumatic stress disorder among Cambodian refugees: A pilot study of combination treatment with cognitive behavior therapy vs. sertraline alone. Behaviour Research and Therapy, 41, 1271 1276. Papadopoulos, R.K. (2001). Refugee families: Issues of systemic supervision. Journal of Family Therapy 23, 405-422. Pathways to Wellness (2011). Integrating Refugee Health and Well-Being: Creating Pathways for Refugee Survivors to Heal. Retrieved from: http://refugeehealthta.org/files/2012/09/ RHS15_Packet_PathwaysToWellness.pdf Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. Journal of the American Medical Association, 294, 602-612.

UNC REFUGEE WELLNESS PROJECT 31 Power, D., Moody, E., Trussell, K., O Fallon, A., Chute, S., Kyaw, M., Letts, J., Mamo, B. (2010). Caring for the Karen: A newly arrived refugee group. Minnesota Medicine. Retrieved from http://www.minnesotamedicine.com/pastissues/pastissues2010/april2010/clinical- Power-April2010.aspx Punamäki, R.L. (1996). Can ideological commitment protect children s psychosocial well-being in situations of political violence? Child Development, 67, 55 69. Quirk, G.J., & Casco, L. (1994). Stress disorders of families of the disappeared: A controlled study in Honduras. Social Science and Medicine, 39, 1675 1679. Refugee Health Technical Assistance Center [RHTAC]. (2011). Mental Health. Retrieved from http://refugeehealthta.org/physical-mental-health/mental-health/ Refugee Works: The National Center for Refugee Employment and Self-Sufficiency. (2012). Local Refugee Resettlement Agencies. Retrieved from: http://www.refugeeworks.org/about/ links_refugee_agencies_local.html. Rousseau, C. (1995). The mental health of refugee children. Transcultural Psychiatric Research Review, 32, 299 331. Sack, W.H., Clarke, G.N., & Seeley, J. (1996). Multiple forms of stress in Cambodian adolescent refugees. Child Development, 67, 107 116. Schweitzer, R., Buckley, L., & Rossi, D. (2002). The psychological treatment of refugees and asylum seekers: What does the literature tell us? Mots Pluriels, 21. Retrieved from http://motspluriels.arts.uwa.edu.au/mp2102sbr.html

UNC REFUGEE WELLNESS PROJECT 32 Schweitzer, R., Melville, F., Steel, Z. & Lacherez, P. (2006). Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian and New Zealand Journal of Psychiatry, 40, 179 187. Schibel, Y., Fazel, M., Robb, R., & Garner, P. (2002). Refugee integration: Can research synthesis inform policy? London, UK: Home Office Research Development and Statistics Directorate. Retrieved from http://library.npia.police.uk/docs/hordsolr/rdsolr1302.pdf Servan-Schreiber, D., Lin, B.L., & Birmaher, B. (1998). Prevalence of posttraumatic stress disorder in Tibetan refugee children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 874 879. Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V. & Steel, Z. (1997). Anxiety, depression and PTSD in asylum- seekers: associations with pre-migration trauma and post-migration stressors. British Journal of Psychiatry, 170, 351 357. Simmelink, J. & Shannon, P. (2012). Evaluating the mental health training needs of community-based organizations serving refugees. Advances in Social Work, 13(2), 1-15. Smith, P., Perrin, S., Yule, W., Hacam, B., & Stuvland, R. (2002). War exposure among children from Bosnia-Hercegovina: Psychological adjustment in a community sample. Journal of Traumatic Stress, 15, 147 156. Smith, P., Perrin, S., Yule, W., & Rabe-Hesketh, S. (2001). War exposure and maternal reactions in the psychological adjustment of children from Bosnia-Hercegovina. Journal of Child Psychology and Psychiatry, 42, 395 404. Steel, Z., Silove, D., Bird, K., McGorry, P. & Mohan, P. (1999) Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants. Journal of Traumatic Stress, 12, 421 435.