A 'Cultural Models' Approach to Psychotherapy for Refugees and Asylum Seekers: A Case Study from the UK

Despite the existence of significant research on the mental health care challenges of migrants, particularly refugees and asylum seekers, less attention has been paid to treatment approaches. We used a case study from the UK to look at the topic from a cultural models approach (which comes from cognitive anthropology) to analyse migrants' experiences with mental health care. Twenty-five refugees and asylum seekers living in North East England and Northern Ireland were interviewed who had used at least six sessions of talking therapy during the last three years. Our results suggested that adopting a 'cultural models' approach, which offers a new conceptual and methodological framework of migrants' experiences and their underlying schemas and expectations, would significantly contribute to building therapeutic alliances and provide relevant and appropriate treatments for migrant clients, particularly for unrecognised pre- and post-migration traumatic experiences.

Meta-synthesis of mental healthcare-seeking behavior - Perspectives of refugees and asylum seekers

The number of refugees and asylum seekers worldwide is increasing, and these populations often experience significant mental health challenges due to their difficult life experiences. This study aims to explore the perspectives of refugees and asylum seekers regarding their behavior when seeking mental healthcare. We conducted a meta-synthesis of thirteen articles published between January 2000 and January 2023. The study identified four main themes: understanding of mental health, utilization of health services, the role of society, and necessary interventions. Based on our findings, we provided recommendations for healthcare providers, governments, and researchers to improve the mental healthcare-seeking behavior of these populations in the future.

Factors Associated with Professional Mental Help-Seeking Among U.S. Immigrants: A Systematic Review

Structural and cultural barriers have led to limited access to and use of mental health services among immigrants in the United States (U.S.). This study provided a systematic review of factors associated with help-seeking attitudes, intentions, and behaviors among immigrants who are living in the U.S. This systematic review was performed using Medline, CINAHL, APA PsycInfo, Global Health, and Web of Science. Qualitative and quantitative studies examining mental help-seeking among immigrants in the U.S. were included. 954 records were identified through a search of databases. After removing duplicates and screening by title and abstract, a total of 104 articles were eligible for full-text review and a total of 19 studies were included. Immigrants are more reluctant to seek help from professional mental health services due to barriers such as stigma, cultural beliefs, lack of English language proficiency, and lack of trust in health care providers.

Investigating Outcomes of a Family Strengthening Intervention for Resettled Somali Bantu and Bhutanese Refugees: An Explanatory Sequential Mixed Methods Study

Pre- and post-migration stressors can put resettled refugee children at risk of poor mental health outcomes. The Family Strengthening Intervention for Refugees (FSI-R) is a peer-delivered preventative home visiting program for resettled refugees that aims to draw upon families' strengths to foster improved family communication, positive parenting, and caregiver-child relationships, with the ultimate goal of reducing children's risk of mental health problems. Using an explanatory sequential mixed methods design, this study draws upon qualitative interviews with caregivers (n = 19) and children (n = 17) who participated in a pilot study of the FSI-R intervention in New England, as well as interventionists (n = 4), to unpack quantitative findings on mental health and family functioning from a randomized pilot study (n = 80 families). Most patterns observed in the quantitative data as published in the pilot trial were triangulated by qualitative data. Bhutanese caregivers and children noted that children were less shy or scared to speak up after participating in the FSI-R. Somali Bantu families spoke less about child mental health and underscored feasibility challenges like language barriers between caregivers and children. Interventionists suggested that families with higher levels of education were more open to implementing behavior change. In both groups, families appreciated the intervention and found it to be feasible and acceptable, but also desired additional help in addressing broader family and community needs such as jobs and literacy programs.

Do Gender and Country of Residence Matter? A Mixed Methods Study on Lay Causal Beliefs about PTSD

Laypersons' causal beliefs about mental disorders can differ considerably from medical or psychosocial clinicians' models as they are shaped by social and cultural context and by personal experiences. This study aimed at identifying differences in causal beliefs about post-traumatic stress disorder (PTSD) by country and gender. A cross-sectional, vignette-based online survey was conducted with 737 participants from Germany, Greece, Ecuador, Mexico, and Russia. Participants were presented with a short unlabeled case vignette describing a person with symptoms of PTSD. Causal beliefs were assessed using an open-ended question asking for the three most likely causes. Answers were analyzed using thematic analysis. Afterwards, themes were transformed into categorical variables to analyze differences by country and by gender. Qualitative analyses revealed a wide range of different causal beliefs. Themes differed by gender, with women tending to mention more external causal beliefs. Themes also differed between the five countries but the differences between countries were more pronounced for women than for men. In conclusion, causal beliefs were multifaceted among laypersons and shared basic characteristics with empirically derived risk factors. The more pronounced differences for women suggest that potential gender effects should be considered in cross-cultural research.

Mental health promotion among resettled Bhutanese adults in Massachusetts: Results of a peer-led family-centred Social and Emotional Well-being (SEW) intervention study

Family-centred interventions addressing sociocultural and emotional stressors promise to prevent mental health problems among refugees in the United States. Peer-led strategies are highly valued, as they engage communities and promote the sustainability of interventions. We assessed the effects of a peer-led family-centred Social and Emotional Well-being (SEW) intervention on preventive (coping, social networking and conflict resolution) and mental health outcomes (stress, anxiety and depression) among resettled Bhutanese adults in Massachusetts. We conducted a SEW intervention with a pre-intervention versus post-intervention (7-day) and follow-up (3-month) evaluation among 103 adults (50 families). The SEW is a culturally tailored 5-weekly session program that included health education, problem-solving and mind-body exercises to increase knowledge and skills regarding stress management and conflict resolution. We measured anxiety and depression using the Hopkins Symptom Checklist-25 and stress using Cohen Perceived Stress scales. Health-promoting behaviours were measured using validated scales. We used paired t-tests for continuous and McNemar tests for categorical variables. Mean scores significantly decreased from pre-intervention to post-intervention and follow-up for stress by 15% and 13.9%, anxiety by 20.9% and 25.1% and depression by 18.7% and 20.4% (all p's < 0.01). Mean scores increased from pre-intervention to post-intervention and follow-up for coping by 10% and 17.2%, and for community networking by 28% and 36.8% (all p's < 0.01). Generalised estimating equations showed a significant reduction in stress, anxiety, depression and improved coping, self-efficacy, family and community networking scored from baseline to follow-ups (all p's < 0.01). Our peer-led family-centred SEW intervention was associated with improved preventive and mental health outcomes among Bhutanese adults.

Peer-led family-centred problem management plus for immigrants (PMP-I) for mental health promotion among immigrants in USA: protocol for a pilot, randomised controlled feasibility trial

INTRODUCTION

Research is needed to investigate preventive strategies to reduce mental health burden and assess effective implementation among immigrants. Problem management plus (PMP) is a low-intensity multicomponent psychological intervention developed by the World Health Organization (WHO) that trained laypeople can deliver. PMP has been adapted as a prevention intervention and developed as PMP for immigrants (PMP-I), including psychoeducation, problem-solving, behavioural activations and mind-body exercise, to address immigrants' multiple stressors. This pilot trial aims to assess the feasibility and acceptability of PMP-I and provide a preliminary estimate of the difference between PMP-I versus community support services pamphlets on the primary outcomes of interest (stress, anxiety and depressive symptoms) to inform the design of a large-scale intervention.

METHODS AND ANALYSIS

The feasibility and acceptability of PMP-I will be assessed by measuring recruitment, session attendance, retention rates, programme acceptability and the fidelity of intervention delivery. This pilot trial will test preliminary effects of PMP-I vs community support services pamphlets in a randomised controlled trial (N=232 participants from 116 families (2 members/family); 58 families randomised to condition intervention or control) on stress, anxiety and depressive symptoms (primary outcomes), chronic physiological stress assessed in hair cortisol (secondary outcomes), and coping, family conflict resolution, and social networking (targets), with assessment at baseline, postintervention and 3-month postintervention. Eligibility criteria for the primary study participants include Bhutanese ≥18 years resettled in Massachusetts with a score of ≤14 on the Patient Health Questionnaire-9. All family members will be invited to participate in the family-based intervention (one session/week for 5 weeks). Multilevel modelling will compare the longitudinal change in outcomes for each treatment arm.

ETHICS AND DISSEMINATION

The Institutional Review Board of the University of Massachusetts Amherst approved this study (Protocol: 1837). Written informed consent will be obtained from all participants. The study results will be used to inform the design of a large-scale intervention and will be disseminated in peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04453709.

Conceptualizing Mental Health Through Bhutanese Refugee Lens: Findings from a Mixed Methods Study

Despite the rapidly growing need to understand mental health challenges faced by refugee subpopulations, there is a dearth of literature exploring mental health conceptualization through the unique refugee lens. Guided by historical trauma theory, we gathered data using a two-phase explanatory sequential mixed-methods study (quantitative: n = 40; qualitative: n = 6) in a Midwestern U.S. region to understand mental health conceptualization from the Bhutanese refugee perspective by examining the cultural meaning and perception of mental health, describing experiences of mental health problems, and examining cultural protective factors and coping strategies. We argue that recognition of refugees' conceptualization of mental health and identification of cultural protective factors is paramount to healing. Findings emphasize the need to understand historical and cultural perspectives in cross-cultural contexts for the development and implementation of culturally responsive services. Our study also contributes to emerging knowledge on methodological rigor in research among understudied, hard-to-reach, small populations.

Social and Emotional Wellbeing (SEW) Intervention for Mental Health Promotion Among Resettled Bhutanese Adults in Massachusetts

Preventative behavioral interventions aimed at reducing mental problems among refugees are limited. We assessed the effect of a Social and Emotional Wellbeing (SEW) intervention on health-promoting behaviors (coping, social-networking, and conflict-resolution) and health-outcomes (stress, anxiety, and depression) among resettled Bhutanese adults in Western Massachusetts. The study was a community-based SEW intervention with pre-posttest evaluation among 44 Bhutanese adults in Western Massachusetts. The SEW is a culturally tailored 5-week, once-weekly health-education, problem solving, and mind-body exercise program to promote stress management skills. We used validated scales to measure outcomes. Mean scores of mental problems decreased by 5.9 for depression, 9.0 for anxiety, and 5.0 for stress post-intervention (p < 0.01). Mean scores increased by 27.3 for coping, 10.6 for social support, and 20.4 for conflict-resolution. Mean social-network scores increased by 4.6 for family, 4.7 for friends, and 1.8 for community networks (p < 0.01). Our Bhutanese participants reported improvement in their mental health after attending SEW intervention.

A Systematic Review of the Protective and Risk Factors Influencing the Mental Health of Forced Migrants: Implications for Sustainable Intercultural Mental Health Practice

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The primary aim of this research was to identify risks and protective factors for the mental health of forced migrants. The secondary aim was to suggest an alternative, more comprehensive approach in social work that surpasses usual diagnoses and intrinsically contradicts the medicalization of mental health issues of forced migrants. The search was conducted between January 2015 and January 2021. As a result, 29 studies met inclusion criteria. Medicalizing mental health issues by relying solely on the effectiveness of medicine was a controversial risk factor that negatively affected daily life activities of refugees and reduced their willingness for seeking professional mental health services. Empowering vulnerable minorities by giving them back their power and agency to be able to speak for themselves and raise voices of trauma and recovery was the missing protective factor for a sustainable mental health practice. The benefits of group-based interventions were highlighted in which communities and individuals address mental health issues as well as isolation through building collective identities and support networks. Information and communication technologies (ICTs) can add more strength to any kind of mental health interventions. Finally, the benefits of applying an ecological perspective for the study of the mental health of refugees, and its implications for a sustainable intercultural practice, were discussed. Social workers in this model are the representatives of at-risk groups, and thus require more agency and creativity in reflecting client’s concrete needs.

Risk and Protective Factors for Common Mental Disorders among Urban Somali Refugee Youth

The purpose of this study was to explore exposure to trauma as well as demographic and psychosocial factors as predictors of mental health symptoms among Somali refugees in Kenya. Participants were recruited via snowball sampling to complete a survey and included 86 Somali refugee youth, aged 15 to 34 years, who were living in Eastleigh. We measured trauma using a total traumas experienced variable as well as four trauma types categories (pre-migration/migration trauma, post-migration trauma, family trauma, and individual trauma). We measured anxiety and depression symptoms using the Hopkins Symptom Checklist-25 (HSCL-25) and PTSD using the PTSD Check List - Civilian Version (PCL-C). We ran descriptive statistics followed by multiple linear regression models with trauma exposure, education, gender, and willingness to share problems as predictors of mental health symptoms. Out of 12 possible traumatic events, most participants (83.7%) reported experiencing at least one trauma, and participants reported experiencing an average of 3.76 total traumas. The regression models predicted between 11.5% and 35.5% of the variance of the mental health symptoms. Willingness to share problems was a significant predictor of decreased mental health symptoms in most models. These findings highlight the role of trauma exposure and psychosocial factors in predicting Somali refugee mental health and indicate that implementing programs to encourage problem sharing may help address Somali refugee mental health needs. Further research is needed to explore the differential impact of trauma exposure and various psychosocial factors on Somali refugee mental health.

Navigating healthcare systems before and after resettlement: Exploring experiences and recommendations for improvement from the perspectives of a Bhutanese refugee community

Background

Though refugees often survive in refugee camps for many years, little is known about the impact of their interactions within the healthcare system during that time and how it may affect current concerns with the healthcare system after resettlement. Guiding our analysis was the Community Health Development model, which emphasizes the importance of understanding the impact of historical experiences on a community's health to identify specific current health needs, and plan solutions alongside the community to address and improve health concerns.

Objective

To better understand the healthcare system related experiences of Bhutanese refugees before and after resettlement, and describe potential solutions based on their perspectives to improve their health status.

Methods

This study used an explorative qualitative research design. Four focus group discussions were conducted with 40 female participants to examine their experiences within the healthcare system in Nepal (e.g. before resettlement) and the US (after resettlement). Focus group data were audio-recorded, translated, coded, and reported based on qualitative thematic analysis.

Results

Findings revealed that Bhutanese refugees were mistreated in the Nepalese healthcare system, often neglected from healthcare access and services because of their refugee status. Upon arrival to the United States after resettlement, study participants also reported experiencing challenges within the US health care system including cultural and linguistic barriers when interacting with medical interpreters during visits with their providers, as well as having inadequate time during the visit to fully express their concerns. Respondents’ recommendations to improve their overall health centered on their experiences with the US health care system including initiatives developing leadership skills for building community capacity towards advocating for the refuges, while increasing access to external resources.

Conclusion

The result of this study outlines an account of Bhutanese refugees’ experiences and recommendations for improving their community's health based on such past experiences and their current needs. These findings provide a starting point for future research with underserved refugee migrant groups and indicate a need for health programs to be historically and culturally sensitive in order to be more effective. Further, the understanding of refugees’ collective history should inform the development of collaborative interventions with community members in order to be effective.

Barriers and Facilitators of Mental Health Service Utilisation among Bhutanese Refugees in the USA: Findings from a Mixed-Methods Study

Although discussions regarding the need to develop culturally responsive mental health services for resettled refugee populations in the USA have been burgeoning, efforts to comprehensively understand the unique barriers and facilitators of mental health services across refugee subpopulations remain fragmented. Our study explored the barriers and facilitators of mental health services experienced by the resettled Bhutanese refugee population in a Midwestern city in the USA using a two-phased sequential explanatory mixed-methods study (N = 46). Study findings draw much needed attention to culturally grounded solutions generated by the community to reduce barriers and increase facilitators of mental health engagement. Building on community-generated solutions and expanding the capacity of local community-based ethnic organisations will be the first step in providing services that are truly responsive to the cultural needs of the Bhutanese refugee population. Recognition of refugee communities’ unique collective strengths will be much needed to holistically collaborate with these new members of the society to promote mental well-being and foster a sense of inclusion and belonging, especially in the post-coronavirus pandemic context. Our study also contributes to emerging knowledge on methodological rigor in research amongst understudied, hard-to-reach populations.

Perceptions of mental health and perceived barriers to mental health help-seeking amongst refugees: A systematic review

Despite elevated rates of psychological disorders amongst individuals from a refugee background, levels of mental health help-seeking in these populations are low. There is an urgent need to understand the key barriers that prevent refugees and asylum-seekers from accessing help for psychological symptoms. This review synthesises literature examining perceptions of mental health and barriers to mental health help-seeking in individuals from a refugee background. Our analysis, which complies with PRISMA reporting guidelines, identified 62 relevant studies. Data extraction and thematic analytic techniques were used to synthesise findings from quantitative (n = 26) and qualitative (n = 40) studies. We found that the salient barriers to help-seeking were: (a) cultural barriers, including mental health stigma and knowledge of dominant models of mental health; (b) structural barriers, including financial strain, language proficiency, unstable accommodation, and a lack of understanding of how to access services, and (c) barriers specific to the refugee experience, including immigration status, a lack of trust in authority figures and concerns about confidentiality. We discuss and contextualise these key themes and consider how these findings can inform the development of policies and programs to increase treatment uptake and ultimately reduce the mental health burden amongst refugees and asylum-seekers.

Resilience and anxiety or depression among resettled Bhutanese adults in the United States

BACKGROUND

Resilience, or an individual's positive response in managing life's adversities, is of increasing interest in addressing the mental health disparities in refugees. Although the link between stressful life events and poor mental health is established, research on the role of resilience on the mental health of refugees is limited.

AIMS

This study assessed the association between resilience and anxiety or depression in resettled Bhutanese adults in Western Massachusetts.

METHODS

A cross-sectional survey was conducted among 225 Bhutanese (men: 113, women: 112) refugees aged 20-65 residing in Massachusetts. Resilience was measured with the 25-item Wagnild and Young's Resilience Scale including two constructs as follows: a 17-item 'personal competence' that measures self-reliance, independence, determination, resourcefulness, mastery and perseverance and an 8-item 'acceptance of self and life' that measures adaptability, flexibility and a balanced perspective of life. Higher total scores indicate greater resilience. The Hopkins Symptom Checklist-25 was used to measure anxiety (10-item) and depression (15-item) with a cutoff mean score of ⩾1.75 for moderate to severe symptoms. Associations of resilience with anxiety or depression scores were assessed using multiple-linear and logistic regression analyses.

RESULTS

The proportion of participants with above threshold anxiety and depression were 34.2% and 24%, respectively. Resilience was inversely associated with both anxiety (beta for 1 unit change in resilience scores: β = -0.026; p = .037) and depression (β = -0.036, p = .041). 'Personal competence' resilience was inversely associated with both anxiety (β = -0.041 p = .017) and depression (β = -0.058, p = .019), but 'acceptance of self and life' resilience was not. Participants with the highest tertile of resilience scores had a significantly decreased risk of anxiety (ORs (95% CI): 0.13 (0.04-0.40)) and depression (0.16 (0.04-0.60)).

CONCLUSION

Higher resilience was associated with reduced anxiety and depression among Bhutanese with personal competence resilience accounting for most of the effects. These findings suggest the potential targets for mental-health intervention to improve resilience in refugees.