Counseling Newcomers and Refugees: Children and Adolescents

The Context of Human Migration

Human migration is permanent or semi-permanent movement from one geographical location to another (United Nations High Commissioner for Refugees [UNHCR], 2017). This process may occur either internationally or domestically and is often categorized as voluntary or involuntary. Voluntary migration is understood as a choice to migrate for the betterment of social and economic standing. Examples of voluntary migration have included relocating for a job or moving for educational purposes. Involuntary migration is often understood as a forced movement as a result of political conflict and persecution, man-made or natural disasters, and development-induced projects (e.g., hydro-electric,mining, and irrigation development projects). Examples of involuntary migration include refugees seeking asylum as a result of war-time conflict and victims of Hurricane Katrina who were forced to vacate their homes and neighborhoods. It is crucial to recognize that labels and distinctions between forced and voluntary migration exist to ease political and public discourse around the process of migration. Instead, approaching migration as one that exists on a forced-voluntary continuum allows for a more nuanced understanding of a migrant’s experience.

Research on migration has repeatedly evidenced numerous commonalities across migrant populations, including but not limited to, internally-displaced individuals, international students, refugees, and undocumented immigrants. Overlaps in experiences generally fall under pre-migration or post-migration stressors. Pre-migration stressors often include exposure to trauma or trauma-related incidents that occurred throughout the migration process. Post-migration stressors include difficulties that arise in the cross-cultural transition after migration. For instance, researchers have linked acculturative stress as a result of migration to higher rates of depression and anxiety (Miller, 2012). Additionally, migration raises the likelihood of experiencing depression, facing communication challenges due to a language barrier, and experiencing anxiety (Jefferies, 2014). These barriers may contribute to a lower rate of high school graduation and low academic performance for children and adolescents (U.S. Department of Education, 2016). In recognizing that pre-migration and post-migration stressors can affect all migrants, this practice brief will focus mainly on the unique experiences faced by refugees in general, and refugee children and adolescents in particular. Also, we will discuss assessment and intervention strategies for migrants (newcomers) and refugee clients, while keeping in mind the complex needs and experiences migrants on the continuum face.

Description and Implications of Immigration

The term refugee is used to refer collectively to all people forced by political violence to flee their homes and communities (Department of Homeland Security [DHS], 2018). There are currently over 21.3 million refugees worldwide, with over half being under the age of 18 years (UNHCR, 2017). In 2017, the United States granted 1,127,167 permanent resident statuses and 53,716 refugee statuses. Fifty-two percent of refugees in the United States are children (DHS, 2018), which mirrors worldwide statistics of the general refugee population. The majority of refugees are civilians who have lived in regions of violent conflict or belong to a particular ethno-cultural group subjected to oppression and persecution, extending in some cases to the extremity of genocide. It is important to note that some migrants flee their countries under refugee circumstances but may not obtain refugee status. Instead, they may be documented or undocumented immigrants with refugee experiences and needs.

Much of the research on refugee populations focuses on mental health implications directly tied to war- related violence. Countless studies on refugee populations from numerous countries of origins, cultures, and ethnicities have concluded with similar results. Exposure to political violence historically has been associated with an increased risk of both acute and chronic post-traumatic stress reactions (Basma & Kronick, 2016). Most commonly, symptoms of traumatic stress among refugees have been assessed using the diagnostic criteria of post-traumatic stress disorder (PTSD), which was initially developed based on research with American veterans of the Vietnam War (Miller & Rasmussen, 2010). 

While a significant portion of research on refugees focused heavily on the impact that war-related trauma had on their mental health and wellbeing, other research has focused on psychosocial and displacement stressors, indicating that these stressors can have an equally significant impact on wellness. Many even argue that distress is heavily rooted in the daily stressors faced, especially when exacerbated by war-related events (Miller & Ramussen, 2010). For example, many refugee populations struggle with the process of acculturation to their new host cultures (Jamil, Nassar-McMillan & Lambert, 2007). Often, barriers are a result of post-migration stressors exacerbated by numerous losses during the process of the migration and challenges of adapting to new and unfamiliar settings (Miller & Ramussen). Specific variables that exacerbate stressors include loss of social support, lack of a new social network, feelings of isolation and alienation from the new host culture, feelings of marginalization by the host culture, perceived discrimination from the host culture, financial disparities and struggles to attain financial sufficiency, dramatic shifts in both familial and social roles, and lack of access to healthcare and educational resources (Basma & Kronick, 2016).

Given that over half of the refugees in the United States and worldwide are children, it is necessary to recognize the developmental implications of migration. Refugee children and adolescents have an increased risk of being separated from their families (Xu & Brabeck, 2012). Parent-child separation effects on the well-being of children and adolescents include the development of depressive symptoms (Gaytan, Carhill, & Suarez-Orozco, 2007), anxiety, guilt, and dysregulation of eating and sleeping (Chaudry et al., 2010). Lack of language proficiency also presents another barrier. Parents’ inability to speak the host culture’s primary language leads to high rates of unemployment and low wages. Therefore, these families have a higher probability of living in poverty and a higher level of financial stress (Stromquist, 2012).

Children and adolescents who are somewhat host culture language-proficient often act as translators for their parents and extended family. Rong, Dávila, and Hilburn (2011) observed that the role of the translator has both positive and negative consequences. While this role helps the child cultivate communication and leadership skills, it can also cause intergenerational clashes due to a confusion in the hierarchy of roles within the family.

Identification/Assessment Strategies

Research on culturally-specific assessments for refugee and newcomer populations is limited. This limitation is exacerbated by the fact that this population is heterogeneous in their cultural backgrounds and languages. For instance, there are currently 25.4 million refugees worldwide, coming from approximately 138 different countries (UNHCR, 2017); a truly culturally-specific assessment would have to account for the varying cultural and national groups that exist within this broader population.

Therefore, when contemplating using an assessment strategy, counselors must take into consideration cultural, developmental, and language appropriateness of the assessment. The following assessments were designed for culturally-sensitive use with refugees and newcomers and might be helpful in identifying mental health concerns in need of attention.

Trauma Assessment

A trauma assessment instrument specifically developed to be used and adapted across cultures is the Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992). Systematic reviews of tools used to assess the health of refugees found that the HTQ was quite extensively used by researchers to assess trauma and its sequelae (Gagnon, Tuck, & Barkun, 2004; Hollifield et al., 2002). Among the various PTSD instruments evaluated in these reviews, the HTQ was described as being a particularly robust measure because of the procedures used in its development and its psychometric properties. In addition, the HTQ was recommended by other experts in the field of trauma assessment such as Keane, Silberbogen, and Weierich (2008) and Nakeyar and Frewen (2016). Currently, there are six different language versions of the HTQ. The Vietnamese, Cambodian, and Laotian versions of the HTQ were written for use with Southeast Asian refugees. The Japanese version was written for survivors of the 1995 Kobe earthquake. The Croatian Veterans’ Version was written for soldiers who survived the wars in the Balkans, while the Bosnian version was written for civilian survivors of that conflict.

Resources:

To purchase this instrument or for more information, visit

http://hprt-cambridge.org/screening/measuring-trauma-measuring-torture/

Acculturation Models

Acculturation is the process of cultural and psychological change that takes place as a result of contact between two or more cultural groups and their individual members (Berry, 1997). The cross cultural transition can result in acculturation stress, and varies in intensity depending on the similarities and dissimilarities between the host culture and culture of origin. Acculturation models can be used to assess clients’ acculturation levels and stress, and assist clients in connecting with their communities and cultural environments. A widely used acculturation model is Berry’s acculturation framework. Berry’s model includes four acculturation strategies; assimilation, separation, integration, and marginalization. Each category assesses the level of integration or rejection of a host culture. On one end of the spectrum is assimilation, which refers to the discarding of culture of origin for the host culture. Marginalization, on the other hand, is a complete rejection of the host culture. While Berry’s acculturation framework has been widely used, some researchers argued that the framework places too much emphasis on migration demands (Ryan, Dooley, & Benson, 2008) or oversimplifies the acculturation process (Schwartz, Unger, Zamboanga, & Szapocznik, 2010). Other models have been introduced to address such concerns, such as the resource-based acculturation model (Ryan et al., 2008) and the multidimensional individual difference acculturation (MIDA) model (Safdar, Lay, & Struthers, 2003). Some acculturation models have been developed to work with specific refugee and newcomer populations such as Middle Eastern refugees (e.g., Fathi, El-Awad, Reinelt, & Petermann, 2018), Vietnamese refugees (e.g., Salo & Birman, 2015), Jewish refugees (e.g., Persky & Birman, 2005), and Latinx newcomers (e.g., Cuéllar, Arnold, & Maldonado, 1995; Norris, Ford, & Bova, 1996). 

The use of acculturation models has been controversial due to the over- or under-emphasis of culture and cultural identity (Schwartz et al., 2010), which can exacerbate clients’ acculturative stress and disconnec- tion (Sue & Sue, 2016). Counselors can use acculturation models to inform their practice and assist clients in finding a connection to their cultural identities. However, counselors should use acculturation models with caution and avoid “one size fits all” approaches (Schwartz et al., 2010).

Resources:

Immigrant Youth in Cultural Transition:

https://www.amazon.com/Immigrant-Youth-Cultural-Transition-Acculturation/dp/0415648432 Toolkit for “A Case for Acculturation”:

https://www.tolerance.org/magazine/summer-2017/toolkit-for-a-case-for-acculturation

Intervention Strategies

Multi-tiered interventions work best in a population with layered and complex needs (Basma & Kronick, 2016). When working with newcomers and refugees, especially children and adolescents, it is essential to implement interventions on the individual, family, school and community levels. Also, counselors should embed advocacy and multicultural aspects in any intervention strategy.

Individual Counseling

When working with newcomer and refugee clients, individual counseling interventions must take into consideration trauma, migratory grief, displacement, systemic barriers, and socio-political and cultural contexts (Bernal & Sáez-Santiago, 2006). Most classic theoretical interventions could be used as long as counselors remain flexible and aware of the complex needs of this population. Several specific individual counseling interventions not only address the complex issues that this population presents, but also promote cultural competency and self-awareness in counselors: multiphase model of psychotherapy (Bemak & Chung, 2017), culturally adapted cognitive behavior therapy (CA-CBT; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012), and narrative therapy (White, 1995).

The multiphase model of psychotherapy addresses trauma and migratory grief, and uses the Multicultural and Social Justice Counseling Competencies (Ratts, Singh, Nassar-McMillan, Butler & McCollough, 2016) to provide a framework to address the socio-political and cultural implications that arise with counseling newcomers and refugees (Bemak & Chung, 2017). CA-CBT was designed using the basic tenets of

CBT, with added considerations for underrepresented and refugee populations (Hinton et al., 2012). Considerations of CA-CBT included lack of language proficiency, somatic complaints, culturally-specific syndromes, and reduced tolerance to traditional exposure-based trauma treatments. Lastly, postmodern approaches that directly integrate cultural awareness and cultural competence, such as narrative therapy, are often used with newcomers and refugees (Oliver, Flamez, & McNichols, 2011). Narrative therapy aims to empower clients and foster awareness, and does not pathologize or label behaviors, including culturally-specific syndromes (White, 1995).

Resources:

American School Counselor Association:

https://www.schoolcounselor.org/school-counselors/professional-development/learn-more/refugee-issues Counselling and Therapy with Refugees and Victims of Trauma: Psychological Problems of Victims of War, Torture and Repression: https://www.wiley.com/en-us/Counselling+and+Therapy+with+Ref- ugees+and+Victims+of+Trauma%3A+Psychological+Problems+of+Victims+of+War%2C+Tor- ture+and+Repression%2C+2nd+Edition-p-9780471982272

Narrative Theory: A Culturally Sensitive Counseling and Research Framework: https://www.counseling.org/resources/library/Selected%20Topics/Multiculturalism/Narrative_Theory.htm

Family Therapy

Families are a protective factor for newcomers and refugees if the family values, culture, and traditions are aligned with all family members (Paat, 2013). However, alignment is not guaranteed. Newcomer and refugee children and adolescents often are more connected to their host culture than their parents, creating different values between the children and their parents. Lack of cultural alignment can result in feelings of disconnection, isolation, and conflict within the family and community (Paat, 2013; Waters, Tran, Kasinitz, & Mollenkopf, 2010). Family therapy can help with family conflicts and disconnection (Paat, 2013), including multigenerational family therapy (Bowen, 1985), structural family therapy (Minuchin, 1974), strategic family therapy (Madanes, 1991), and narrative family therapy (White, 1995)

Resources:

The Bowen Center: https://thebowencenter.org

The Minuchin Center for the Family: http://www.minuchincenter.org/structural_family_therapy Narrative Therapy Initiative: https://www.narrativetherapyinitiative.org

School Interventions for Children and Adolescents

Schools remain the primary provider of mental health services for children and adolescents; as such, it comes as no surprise that many of the interventions for working with refugee children can be used within the school building. Children are forced to negotiate a wide array of challenges in a host country that include grasping the culture of the new school and environment while also learning a new language (Basma & Kronick, 2016). Mental health workers, teachers, and staff within the school need to be aware and mindful of the context in which those students were placed in the schools in order to facilitate early identification of interventions needed. Usually it is not necessary to engage in traditional talk therapy with the children, as that may not be the best vehicle to assess their needs. Expressive approaches to counseling as manifested in play, drama, art, or writing can provide a space the children may require to process the pre- and post-migration stressors. Counseling may also provide an environment that would ease the process of acculturation. Expressive approaches can be incorporated in the classroom or encouraged in the afterschool program. Teachers and staff can also use the support system the children form in the classroom to solidify the child’s feelings of belonging and acceptance.

Resources:

U.S. Department of Education on educational resources available for newcomers: https://www2.ed.gov/policy/rights/guid/unaccompanied-children.html

The Center for Health and Health Care in Schools: http://healthinschools.org/immigrant-children-unaccompanied-minors/#sthash.piYkXu4i.dpbs 

Bridging Refugee Youth and Children’s Services: https://brycs.org/publications/schools-toolkit.cfm

Integration of Community Resources

The integration of community resources can increase community connection and acculturation (Waters et al., 2010). Counselors should use a combination of individual, family, and community services and identify strengths, resources, and resiliency in each area. Community locations such as schools are often the first point of contact with newcomer and refugee children, adolescents, and their parents (Xu & Brabeck, 2012). Counselors need to be informed about the barriers that newcomer and refugee families face with school attendance, academic achievement, and financial instability and assist in connecting them with resources that aid their needs.

Counselors in all settings can use tools such as 411 to identify potential resources or partner with local refugee and immigration organizations for appropriate community resources. Social support and community connection also aid in cultural identity development and promote a sense of belongingness in newcomers and refugees (Paat, 2013). Social supports include, but are not limited to, friends, coworkers, neighbors, family members, and churches. Counselors should advocate for clients to use their social support systems when issues of disconnection and isolation arise (Xu & Brabeck, 2012).

Resources:

Contact information: http://www.411.com

Office of Refugee Resettlement Resources: https://www.acf.hhs.gov/orr/resources

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