Summary
This webinar is targeted at mental health providers who are looking to enhance their skills in working with diverse populations and contributing to more inclusive and effective mental health services.
Webinar Overview
This webinar is targeted at mental health providers who are looking to enhance their skills in working with diverse populations and contributing to more inclusive and effective mental health services. The webinar emphasizes a strengths-oriented, systems-based approach that recognizes the resilience and cultural richness of refugee and immigrant populations. Participants will gain practical skills to enhance their cultural competency, enabling them to provide more effective and culturally responsive care. The webinar offers essential insights, as well as suggestions of standardized assessment instruments and evidence-based intervention approaches that are effective with refugee and immigrant populations.
At the end of this webinar, participants will:
- Critically analyze the intersectionality of pre-migration trauma, post-migration stressors, and structural challenges in shaping the mental health landscape of refugee and immigrant populations.
- Identify some strategies to enhance cultural competency in their professional practice when working with refugee and immigrant clients.
- Grapple with and gain insight into some of the common mental health challenges refugees and immigrants face and effective assessment and intervention strategies.
Speaker Bio:
Dr. Wanja Ogongi is an Associate Professor at the Millersville University School of Social Work in Pennsylvania, USA. Dr Ogongi graduated from the University of Nairobi, Kenya with her B.A, earned her Master of Social Work (MSW) degree at West Chester University of Pennsylvania and her PhD in Social Work at Widener University, Pennsylvania. Dr. Ogongi teaches a variety of courses in the BSW and MSW programs; and has chaired and served on dissertation committees for several doctoral students. Her areas of teaching include Human Behavior and the Social Environment (HBSE), Macro & Policy Practice and Social Work Field Education. Dr Ogongi has practiced social work professionally in the areas of International Human Rights (focus on women and children), Child Welfare, Refugees and Unaccompanied Minors, and Medical Social Work. Her areas of interest for research and presentation include Multicultural Mental Health and Issues affecting the African Diaspora in the United States.
Video – run time around 32 minutes
Transcript
Hello. My name is doctor Wanja Ogunge. I’m an associate professor of social work at the Millersville University School of Social Work, and I’m here today to talk to you briefly about refugee and immigrant mental health. I hope that the information that I share today is useful to you as a mental health provider who is providing services to this, population. I’m going to start off with a quick introduction and some background information on this population.
I’m then going to cover some of the common challenges, that this ex this population experiences that might be significantly different from the mainstream American population. And then I’m going to end this training with offering a few assessment tools and strategies that I found to be useful when looking at or working with, the refugees and immigrant. So, in terms of definition, immigrants or the term immigrant rather is usually an umbrella term that we utilize to, for people who have moved from one country of origin where they were born to and to live in another permanently. So that can encompass a lot of different populations, including refugees. But the key, thing to note here is a lot of the time when we utilize the term immigrant, we are referring to people that move voluntarily from their country and decide to move to the United States for one reason or another.
A refugee, on the other hand, is a person who is forced to move out of their country of origin because of a well-founded fear of persecution. A lot of them are usually fleeing from their country voluntarily, but rather have been forced out. From their country voluntarily, but rather have been forced out. Both of these groups, bring a lot of strengths and skills to the US, and they contribute to the diversity and beauty because we’ve had a lot of immigrants and refugees moving into the country. And in Pennsylvania specifically, the most recent statistics from 2022, by the Migration Policy Institute indicate that about 7.5 percent of Pennsylvanians, immigrants.
That’s a high number. And then about 9% of the native-born citizens living in Pennsylvania, they reported that at least one of their parents was an immigrant. So then, these numbers, therefore, highlight the growing trends of the number of immigrants that are moving into the area of Pennsylvania and also into the country in general. And, therefore, the importance of providing effective and culturally informed mental health care to cater to their needs in addition to mainstream, services. So, as you might imagine, refugees are an especially vulnerable group that is prone to, a lot of mental health challenges mostly because of the experiences that they’ve had prior to arriving to the United States and in Pennsylvania, specifically.
many, immigrants and refugees, they have faced unique challenges that may be very unique to them compared to mainstream America. For 1, many of them are displaced in terms of having to leave their country by force to go and live in another country. And when we talk about displacement, you know, many of them face very traumatic challenges prior to moving to even a refugee camp. They may have witnessed death and torture, sometimes of family members and people that they have loved and cared about. They have been separated from their families, and then they end up at a refugee camp.
And most refugees’ camps are normally not do not provide optimal services. You know, these they are usually located in places that are overcrowded and where people don’t have basic services such as water and food. And so then, and, you know, they are not even many of them are not welcome in the countries of their second of where they end up in camps. Then in addition to that, then they have to move to a third country, like the United States in Pennsylvania to live. And during those transitions, they experience a lot of distress again, in terms of loss and grief and trauma.
But even after arriving in a new country, those stressors continue. They are then now faced with the stresses of having to acclimate to a new environment, in a new culture, in a place where they have different traditions and customs that they are not familiar with. So, they face multiple losses throughout this journey, a loss of self-identity, loss of family members, the loss of home, loss of culture, as well as, a loss of their way of life. And so, therefore, many of them will exhibit, a variety of challenges as a result. In addition to all these personal challenges, there’s also structural challenges that make well-being, mental well-being child, you know, not optimal for this population.
A lot of them, once they arrive, they are faced with limited access to healthcare and specifically access to health, to mental health, services. Many the way our country’s resettlement process is structured, it is structured in that it provides excellent, services for the 1st 90 days in terms of helping refugees find housing and jobs and food and setting them up to be able to be successful in America. But then, it’s not optimal, for when it comes to things like mental health needs. So many of the refugees arrive and they are faced with employment and economic strain, housing instability. A lot of them have to share very small spaces with many of their family members.
And then there’s a variety of logistical issues that they also face in terms of learning how to drive and how to get from one place to another, how to navigate, basically, the communities in which they are settled. They also, a lot of the time, have very little family support. So, if it’s a family that is arriving, that has young kids, that those that presents a challenge in terms of access to childcare and, other amenities. And so, then there’s a variety. It’s a complex situation that they are faced with as they attempt to integrate into the American culture.
So, then the other, structural challenges is that a lot of the mainstream mental health services that are available that are great for mainstream America, sometimes are not a great fit with not only just the unique challenges that are faced by refugees and immigrants, but also their wild views and their perceptions of mental health and how they formulate mental, well-being. So, this then again adds on to this complexity of situations that mental health, that immigrants and refugees are faced with. A lot of the clinical literature, suggests that, many refugees and immigrants face psychological distress, and that these high levels of physical and psychological dysfunction, specifically during the first two years of their life in, in the United States and in Pennsylvania, as they are attempting to accrete and adjust to their new living, conditions and the demands of American life. And so then, there’s a few things that I normally like to point out to mental health providers. 1 is to say that Western paradigms of mental health and well-being are limited in that they are really kind of like crafted from one culture.
And so then when we are faced with refugees and immigrants who come in with different formulations of mental health and understandings of mental health, these paradigms might not, always fit with this population. And then, a lot of the theoretical literature that is available and the tools that we’ve learned in our programs regarding how to treat, mental health, not a good fit again, for refugees and immigrants because they neglect, like, certain cultural nuances. And we know that mental health is very culturally specific, and well, mental well-being is specific to a culture. So, we find that in terms of looking at some of the populations that, that the mental health that the some of the populations that are represented in mental health, in refugee and immigrant communities, these, theoretical tools or, tools of assessments might not work. And so then because of this, a lot of refugees and immigrants, are usually misdiagnosed.
Sometimes some of the symptoms that they present with may be misinterpreted due to cultural differences in terms of how we express distress. A lot of them are over pathologized, especially with psychosis, because some of the normal cultural expressions in certain cultures might be incorrectly labeled as psychosis. It kind of like really is such a complex, it’s a complex situation that requires a lot of depth and thought. A lot of them also terminate, services prematurely because these misunderstandings between the clients and, mental health providers. And then sometimes they can even be labeled as being resistant to treatment when the real issue really might be a lack or a misfit, between the way they formulate and understand mental health and mental well-being and healing from, the mainstream population.
So, we have to remember, though, that when we talk about culture, that there’s a variety of different cultural backgrounds. So, the people that come we come across are going to be different depending on what culture they are coming from. They are not all the same just because they are immigrants and refugees. A Congolese might be very different from a Somali, and yet they come from the same continent. So, we have to kind of, like, be careful about how we think about culture.
Even among the Congolese, you will often find that this different these differences within that particular group. So, you have to be conscious, and, careful about how you apply concepts of culture and generalizing information, across populations. But culture, basically, the concept of gives us, like, sort of, like, the wild views and paradigms about mental health and mental illness, how we express symptoms. Some cultures, we find that there’s somatization. In my culture, specifically, we have very few words or terms that we can utilize to talk about mental health.
So, you’ll not find a word for depression or anxiety or what you find, though, is description of symptoms that are usually associated with mental distress. So, people might complain about, certain physical pain, and that pain is usually really connected to their mental health. Cultures also differ in terms of health seeking behaviors and whether or not they believe that they should seek mental health. Some in some communities, there’s a lot of stigma about mental health and seeking assistance or, or, or help because of mental health, these communities that believe that that is a sign of weakness or, individual fault. And so, then that then again impacts the ability to, to seek help.
Different cultures are also going to have traditional, healing practices that they believe are the right way to address mental health and not necessarily the therapy that we normally, consider to be what is mainstream in America. Even though these traditional services these traditional practices sometimes when you scrutinize them, they really kind of like very similar to what we are providing in our practices. They just are seen differently. They present differently. And when I talk about traditional healing practices, I’m talking about spiritual and religious rituals that a culture might, believe is important to address mental health, herbal remedies, acupuncture, and many other practices that different cultures, incorporate in terms of healing or healing mental illness.
So, you know, a lot of them might try to seek help. I know that for African, African populations specifically, they tend to seek help from the traditional practices fast. So, they might go to their pastor if they are religious or if they are Christians or they are imam or, seek traditional spiritual guides, fast before they come to a mental health professional. Or sometimes they might use both. So, they might come over to an office to see, a therapist and spend time with the therapist, but then go home and utilize another practice that they believe is going to heal their mental distress.
I tell, mental health providers to be open about all or rather I encourage that you you’re open to hearing about and understanding these traditional healing practices because sometimes they can really impact your, your outcomes with a client, and they can be a big part that you can incorporate in your own, work with the client. Unless, of course, they are harmful or exploitive, then in that case, you should definitely discourage clients from utilizing them. And, in terms of, like, looking at assessment, I think this has been one of the areas that I’ve spent most time, working on. Most standardized assessments, like, when you think about the biopsychosocial assessment, for example, they have been developed again by primarily practitioners who are mainstream America and from dominant cultures. So sometimes they are not a very good fit for, refugees and refugees and immigrants.
And so then not to say that they are not useful at all, they are very, very useful because they kind of, like, give us a template or a foundation of what areas we should be looking, at the client in terms of, like, their biological presentation and any medical issues that might be present, spiritual components that might be influencing their well-being, physical presentation. So, they are these assessments are not completely useless. They give us a good foundation. But in addition to those assessments, we should be conscious about, how we incorporate other aspects of the client’s culture so that we can be able to capture a good assessment that is going to be that because assessments form the form the foundation of all of your interventions, and they can impact, your client’s outcome. So, I normally, point out that great assessments normally start with the self.
So, the individual, mental health pro provider should do their own, assessment of their culture. You know, what are your world views? What beliefs and values do you enter that space with? And, you know, self questioning and reading and educating yourself about who you are. The more you know about who you are, the easier it becomes for you to start to ask questions about others to figure out how to understand somebody else’s culture.
It’s also important to learn about diverse cultures. So educating yourself about different populations that are in the area or, different wild views, language, and terminology, and values, understanding your client’s unique identity, you know, being willing to sort of, like, ask the client who they are beyond their name. I know that in mainstream America, you know, when we identify, we put a lot of emphasis on our names. And for many cultures, identity goes beyond just the name that people call us. So, I then understanding like that client’s unique identity and what makes them who they are.
And then, we have to be conscious about our interactions with therapists. I mean, between therapists as therapists and clients and how our identities impact that alliance between us and our clients. We want to make sure that we establish a relationship that is that is based on mutual understanding and, respect for each other’s culture. In terms of specific tools or approaches that are found to be helpful, as a social worker, the strengths based strength based, orientation is important to us in terms of looking at the client’s resiliency and strengths rather than only focusing on their deficit or, the issues or problems that they bring. So, looking at their strengths and some of the components that of who they are that have helped them drive is important.
Looking at the systems, and the systems that, impact their well-being, which might include their extended families, non keen relationships that they formed in their new communities, their cultural background. Sometimes culture can be a source of pride and positive, identification, their political, understandings of their new communities, their context in terms of, like, their physical and natural environments. And then, the other approach is to utilize a variety of tools or methods to collect your data so you’re not only basing, your assessment on one tool that you’ve utilized. So using observations of the client, interviewing, the client and a variety of other people, you might want to find yourself, some cultural, some cultural con people who are from the same culture, but cultures that can be consultants and being able to get so that you can be able to get an in-depth understanding of your client and the issues that they might present. It’s also, again, also important to understand the person’s history, in their cultural context.
And when I talk about history, I’m talking about, like, certain, things that have happened historically in that client’s life that might again impact their well-being or their journey, before they get to to you as a therapist and how they locate themselves within that chronology. So, looking at, like, historical events that might be of importance to your client’s story and might be important to their well-being. And then in terms of wrapping up, once you are done collecting this information from a variety of sources, it’s usually important to provide a summary of it and your case formulation to the client. The reason why I think that this is so important again, I mentioned earlier that in some of our cultures, we do not even have the terms to, express mental distress. So, when you meet a client and they are describing all these things that may be, like, somatic or they are just giving you, like, general information about, about them.
You can tell that they are distressed, but they don’t know exactly why they are distressed. Being able to name that or give it a term like depression can become can be very freeing for the client so they know that, really, like, this there’s a term for what they are suffering from. So, I normally find that that causes quite some relief for some clients when you can formulate you can specifically tell them, oh, the reason why you’ve been feeling like this is because you’re anxious. This is what giving them that language, offering them that language can be, very relieving to some of the clients. So you might want to tell them, like, what your thoughts are about, even if it is just preliminary thoughts about what their diagnosis might be as well as some in in justifying it using some of the cyst symptoms that they’ve described and some contributing factors as well as, providing them recommendations of what you’re going to do to help them, feel better.
In terms of specific tools that I’ve utilized, so in addition to thinking about the biopsychosocial, I utilize a culturagram, which gathers, like, again, more information about the client and the client’s, experiences. This is a tool that was developed, by Elaine Congress, and I find it to be very useful when I’m dealing with, refugee and immigrant client because it gathers information from a variety if in a variety of areas that help me gain a deep understanding of the client and their symptoms. So, I would encourage that when you deal with, immigrant and refugee clients, you consider using, a culturagram or something similar that allows you to dig deeper than you would with a mainstream client that you might use just the mainstream biopsychosocial, and you are able to get the information that is needed to make your diagnosis. There are other tools that have been tested that evidence, exists that are useful to when working with client refugees and immigrants. These tools include the Harvard trauma questionnaire, the Hopkins system checklist, that looks at anxiety and depression.
This is an especially good tool because it’s validated across, many different cultures, and it’s sensitive to culturally specific expressions of distress. So, as I mentioned in earlier, every culture might formulate and express distress in different ways, utilizing different terms. And this can be a very good tool. The cultural formulation interview that you are all very familiar with, from the DSM 5. And then there’s many others.
Again, like, this is not an exhaustive list. It’s just a few of the tools that I’ve personally utilized and know that they have a good evidence based in in terms of being tested in different cultures. And this many of them have been translated to different languages, and I find them to be useful, including the brief inventory service, the migration, grief, and loss questionnaire, the refugee health skin, and the SCL 90 symptom, checklist. And then, of course, I cannot, talk about refugees and immigrants without talking about language barriers. We know that and are aware that sometimes we might experience or encounter clients whose English is not their first language.
Some of them might not even, speak English. And so then we are put in positions where we are required to utilize an interpreter. There’s some best practices that I found to be useful when, utilizing an interpreter with a client, and one is providing, or having a pre session briefing even if it is just short with, the interpreter. So during this pre session briefing, I’ll talk to the interpreter about what my goals are for the session and give them a brief overview of what my expectations are in terms of, like, what information I’m attempting to gather from the client. And then, of course, once we get together, with the client, I’ll explain confidentiality and really go into depth about discussing confidentiality and checking in with the client to see what they understand by confidentiality and making sure that they understand that what confidentiality really is because it can be a pretty new concept for some refugees and immigrants.
I usually sort of, like, say you should avoid jargon. I know that as mental health providers, we are used to throwing terms and abbreviations out there. And sometimes interpreters don’t always, understand what that is meant because interpreters can be people who are super good in the language, but sometimes they are not always very, they always don’t have any experience with the specific material itself. So, like, looking at mental health and mental health terms, they can be very specific. So, using just simple language and avoiding jargon, is important so that it kind of like gets rid of any misunderstandings that might help.
Allowing extra time for sessions because when you have somebody that you have to talk to and then that person has to talk to the client and they have to come back to you, that requires extra time. So do not rush through the session. And especially when it is the beginning sessions, when we are attempting to understand the client’s, circumstances, and you’re doing an assessment of the client, it’s important to just take your time and then address your client directly. I know that sometimes it can be it can be, easy to kind of, like, really focus on your interpreter rather than talking to the client because the interpreter is the person who is answering you. But I normally keep my eyes trained on the client because they are the person that I’m interested in.
They are the person that I’m interested in learning more about. So, the interpreter is sort of like an extra person on the side. Look at the client, address your questions to the client, listen to the client as they talk rather than focusing on the interpreter. And then, of course, stay tuned to, all, you know, both verbal and nonverbal and emotional cues that the client might display. And, of course, the one rule that I normally think is a no no, it’s the use of family members or untrained personnel unless it is really an emergency because, this can pose a lot of different, professional challenges.
In conclusion, I would, add you as mental health providers, again, to recognize the unique challenges that, refugees and immigrants face. You know, be compassionate, be understanding and empathetic about, their unique circumstances, attempt to understand the impact of their cultural and backgrounds and their mental health per perceptions on their well-being and the healing journey, collaborate with them, implement culturally responsive assessments and intervention strategies, and then just continuously, keep learning, you know, keep learning about different cultures. Keep learning about cultural humility and competency. And, you know, life, learning should be a lifelong process for a good, mental health provider. Advocate for appropriate mental health, services in your communities and in your organizations.
And just really, I encourage you to embrace a culturally, you know, responsive, culturally informed and responses practices in your work. That is all from me for today and thank you so much for listening. And, that’s it.