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DOI: 10.1177/0020872816648256
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Listening to refugees:
How traditional mental health
interventions may miss the mark
Diane B Mitschke
University of Texas at Arlington, USA
Regina T Praetorius
University of Texas at Arlington, USA
Don R Kelly
University of Texas at Arlington, USA
Eusebius Small
University of Texas at Arlington, USA
Youn K Kim
University of Texas at Arlington, USA
Abstract
Understanding the dynamics of mental health of recently resettled refugees is an essential
component of any comprehensive resettlement program, yet establishing the components
of a successful and acceptable mental health intervention is an elusive task. Semi-structured
interviews were conducted with 30 resettled refugees from five countries who had received
treatment for depression, post-traumatic stress symptoms, or anxiety. Themes generated from
the interviews emphasized the need for strong group-based social support as well as a focus on
practical needs such as acquiring and maintaining employment, language and literacy training,
and access to care.
Keywords
Maslows hierarchy of needs, mental health, needs, refugees, resettlement
Corresponding author:
Regina T Praetorius, University of Texas at Arlington, 211 S. Cooper, Box 19129, Arlington, TX 76019, USA.
Email: rtpraetorius@uta.edu
648256ISW0010.1177/0020872816648256International Social WorkMitschke et al.
research-article2016
Article
2 International Social Work
Background
From 2000 through 2014, the United States has given refugee status to 945,970 refugees from over
200 countries (Office of Refugee Resettlement, 2014). On average, 1 in 10 adult refugees resettled
in Western countries suffers from post-traumatic stress disorder (PTSD), 1 in 20 suffers from major
depression, and 1 in 25 suffer from generalized anxiety disorder (Brady et al., 2000). Thus, the
purpose of this qualitative study was to assess the mental health needs of refugees from Burundi,
Burma, Congo, Rwanda, and Bhutan1 recently resettled in a large, metropolitan city in the
Southwestern United States.
Rates of mental illness vary by ethnic group; however, most mental health research with reset-
tled refugees has garnered rates of mental illness that are much higher than those in the general
population across the world. For example, Steel et al. (2002) found that Vietnamese refugees in
Australia who experienced more than three traumatic events had a heightened risk of mental illness
even 10 years post-resettlement compared with people with no trauma exposure. Similarly, Pernice
and Brook (1994) found high levels of anxiety and depression in their study of recently arrived
refugees in New Zealand. Allan (2014) indicates that there are high levels of depression, anxiety,
and guilt among refugee populations in Australia as well.
Many studies indicate that PTSD most often complicates refugee transition. Sack et al. (1994)
found that 44 percent of Cambodian refugees in their study suffered from PTSD. In a study of
Kosovan Albanians, Turner et al. (2003) found that 38 percent of refugees suffered from PTSD.
Fazel et al. (2005) posit that approximately 50,000 refugees in the United States may have PTSD
or experience post-traumatic stress symptoms.
Favaro et al. (1999) found a combination of PTSD and anxiety disorders among many
Yugoslavian refugees in Italy Mghir et al. (1995) found 13 of 24 refugees from Afghanistan relo-
cated to Washington had PTSD, major depression, or both. Weine et al. (2000) found that 70 per-
cent of Bosnian refugees not seeking mental health services met symptom criteria for PTSD and
displayed symptoms of depression.
The mental health needs of resettled refugees are well documented, with symptoms of anxiety,
post-traumatic stress, and depression stemming from both pre-resettlement trauma and post-
resettlement stressors (e.g. Fazel et al., 2005; Mitschke, Aguirre and Sharma, 2013; Steel et al.,
2009). Carswell et al. (2011) concluded that post-migration stress is related to poorer mental health
upon arrival in the host country. Many refugees arrive in their host countries with mental health
issues as a result of trauma experienced pre-arrival. Post-arrival stressors, especially the vast
differences in culture between home and host countries, can exacerbate the symptoms. For example,
Peisker and Tilbury (2003) found that refugees suffer from considerable acculturation stress,
making them vulnerable to mental illness. Teodorescu et al. (2012) found that post-migration
stressors such as having a weak social network and a weak social integration into the ethnic
community were significantly associated with more mental illness and symptom severity.
Intervention research
When discussing applicable interventions for mental health treatment among resettled refugees,
one must consider the general mode of delivery, type of intervention, and purported effective-
ness. Regarding mode of delivery, newly arriving refugees are among the most vulnerable of
populations due to language barriers and a lack of exposure to US practices (Office of Refugee
Resettlement, 2014). Gong-Guy et al. (1991) state that the vast majority of refugees seeking
mental health services in the United States encounter barriers such as language that preclude
easy access to services. Murray et al.’s (2010) meta-analysis concluded that programs targeting
Mitschke et al. 3
culturally homogeneous client groups were four times more effective than those targeting cul-
turally heterogeneous client groups. In addition, the study found programs providing interven-
tions in the refugee’s original language were twice as effective as those delivered in a second
or other language (Murray et al., 2010).
Various challenges in addition to language exist, though language may be the primary barrier
given that it is an impediment to refugees’ willingness and ability to report mental health issues.
According to the Refugee Health Technical Assistance Center (2011), cultural barriers, biases
(whether of the refugee or of the provider), culturally competent screening, and treatment strategy
efficacy are challenges that influence treatment. Simich et al. (2004) found that many interventions
are deficient in cultural sensitivity and language proficiency, and some interventions fail to utilize
social networks in the community. This is accentuated through recent studies showing that empha-
sis on practical needs such as employment, healthcare, transportation, finances, language, educa-
tion, and security usually attained through networks can aid in reducing mental health matters.
Allan (2014) posits that there is a need for ‘deep interrelationship between psychological well-
being and structural inequalities’ (p. 3). According to Murray et al. (2010), interventions should
focus on psychosocial models promoting positive personal change. Peisker and Tilbury (2003)
assert that social inclusion approaches that focus on social adaptation and integration building of
social capital are effective in successful refugee resettlement, which they defined as ‘re-establish-
ing feelings of control and that life is “back to normal” – the state which the WHO identifies as
being “mentally healthy”’ (p. 78).
Murray et al.’s (2010) meta-analysis examined intervention practices such as cognitive behav-
ioral therapy (CBT), eye-movement desensitization and reprocessing (EMDR), pharmacotherapy,
expressive therapy, testimonial therapies, multifamily and empowerment mutual learning groups;
individualized therapy, and psychoanalytical orientations therapy; however, their results indicate
that the mode of delivery is far more influential on effectiveness than the type of intervention
delivered. Some research has shown that narrative exposure therapy can be effective in treating
the effects of trauma in refugees (Gwozdziewycz and Mehl-Madrona, 2013; Neuner et al., 2004).
Narrative exposure therapy involves the participant’s construction of a chronological narrative of
traumatic experiences, characterized by the therapist’s employment of empathic understanding,
active listening, congruence and unconditional positive regard (Gwozdziewycz and Mehl-
Madrona, 2013). In a study comparing narrative exposure therapy, supportive counseling, and
psycho-education, refugee participants receiving narrative exposure therapy reported significant
declines in post-traumatic stress symptoms as compared to the refugees receiving counseling or
psycho-education.
However, given Maslow’s (1954) hierarchy of needs, it is possible that mental health interven-
tions should be preceded by interventions focused on engendering belongingness. Acculturation
models posit high contact participation (interaction with those of one’s own culture) and contact
maintenance (contact with the dominant culture) are keys to acculturating in a dominant society
(Berry, 2001). Psychosocial and acculturation models help empower refugees and their communi-
ties, encourage actively approaching acculturation and integration, and embolden refugees to seek
social inclusion in the host society (Peisker and Tilbury, 2003). In one intervention study,
Vongkhamphra et al., 2011) found that refugees experienced a decline in self-reported stress after
participating in a program that combined social service provision and psychosocial integration
(Vongkhamphra et al., 2011).
Emerging research is showing that the needs such as language education, financial literacy,
employment training, provision of transportation, access to affordable health care, and security
should be part of any intervention program. Interventions catering to the cultural and language
needs of refugees have expanded over time to include services designed and delivered by
4 International Social Work
paraprofessionals who are refugees themselves working in a collaborative team approach with
mental health providers (Abrahamsson et al., 2009; Shaw, 2014; Yohani, 2013). Stewart et al.
(2012) found that refugee participants reported a greater ability to cope with resettlement after
participating in an intervention utilizing peer facilitators who had experienced life as a new refugee
and helped other refugees overcome settlement challenges. Miller and Rasco (2004) report favora-
ble outcomes training refugees to become peer-counselors and mental health resources in their own
communities. Wollersheim et al. (2013) developed a program using mobile phones to create posi-
tive psychosocial outcomes through communication interconnectedness by removing the geo-
graphical distance between refugees and trained peer supporters.
While integration programs are meeting the physical needs of refugees, more is needed to
ensure mental health stability. Emerging research is showing that attention to these needs through
peer programs that are culturally competent and sympathetic to cultural sensitivities have success-
ful outcomes. This in turn appears to shorten the transition period and help to make the transition
less traumatic. This study provides qualitative data supporting the need for transition programs that
are peer-centered and culturally competent.
Method
The purpose of this study was to assess the mental health needs of recently resettled refugees from
Burundi, Burma, Congo, Rwanda, and Bhutan.2 Specifically, these refugees were resettled in a
large, metropolitan city in the Southwest United States that annually resettles roughly 10 percent of
refugees sent to the United States. This qualitative study is a follow-up to a larger quantitative
study. In the quantitative study, all participants began in the project with first attending community-
based psycho-educational group meetings, which were open and available to all refugees in the
community. These meetings were led by Cultural Ambassadors – natural leaders and refugees
themselves – who lived in the same apartment complexes with their group members. Cultural
Ambassadors were trained and employed by the resettlement agency to conduct these group meet-
ings, which were held weekly and covered topics such as general awareness about mental health
and access to resources in the community. The Cultural Ambassadors facilitated the group meet-
ings and oversaw the consenting process that was conducted in the participants’ native languages.
To be eligible to participate in this study, participants had to be over 18 years, able to consent to
participate in either English or one of the five included languages mentioned previously, have at
least a moderate mental health concern per one of the mental health measures used at baseline (see
Note 2), and be of refugee status from the five ethnic groups settled in the Southwestern United
States. Eligible participants were randomly assigned to one of the three modes of mental health
intervention for 8 weeks of intervention. The three types of interventions were the community-
based psycho-educational group meetings, office-based counseling, and home-based counseling.
Office- and home-based counseling were conducted by licensed mental health professionals using
a trauma-informed approach. After the 8-week intervention, participants completed post-test
assessments identical to the baseline assessments. Each participant received a US$10 gift card at
completion of the 8-week intervention for use at a national retailer. Upon initial analysis of the
quantitative results, we embarked on this qualitative study to capture the participants’ perceptions
of mental health intervention.
Data collection
Qualitative interviews were conducted with a subset of participants from the larger study following
the study’s completion. This required a separate consent process, facilitated by CAs (cultural
Mitschke et al. 5
ambassadors). Interviews were conducted by CAs in the refugees’ native languages, and those who
agreed to be interviewed received an additional US$10 gift card at completion of the interview for
use at a national retailer. A total of 30 refugees were interviewed: 10 Bhutanese (conducted in
Nepalese), 10 Burmese (conducted in Karen and Karenni), and 10 from Burundi, Congo, and
Rwanda (conducted in Swahili). Demographic information is provided in Table 1. Interviews were
recorded with digital recorders and later transcribed and translated, and back-translated by a certi-
fied translation service. Interview questions were as follows:
1. Why did you agree to participate in this study?
2. In what ways has participating in Mental Health Support Group helped you?
3. How could the Mental Health Support Group be improved?
4. In what ways participating in counseling helped you?
5. How could the counseling be improved?
6. Before you started going to the support group or receiving counseling, what things did you
need help with?
7. What things do you need more help with now?
Data analysis
The first three authors (D.B.M., R.T.P., and D.R.K.) each independently analyzed the data using the
grounded theory technique of line by line open coding. Open coding encompasses the researchers’
initial ideas, thoughts, and perceptions of the data (Creswell, 2007). D.B.M., R.T.P., and D.R.K. then
met for axial coding using a constant comparative approach; axial coding involves the organization
of open codes into broader themes or categories (Creswell, 2007). Axial codes were discussed and
deliberated until agreement was reached in each instance. The last two authors (E.S. and Y.K.K.)
then reviewed coding, checking for signs of bias in the process. Once consensus was established and
final codes developed, the authors then collated the axial codes into the final themes.
Table 1. Demographic characteristics of three groups.
All (N = 30a) Nepali group (n = 10) Swahili group (n = 10) Karen group (n = 10)
M (SD)
Age (years) 51.23 (14.7) 60.40 (5.81) 48.1 (19.09) 49.15 (9.85)
n (%)
Marital status
Married 22 (78.6) 8 (80) 6 (60) 8 (80)
Others 8 (21.4) 2 (20) 4 (40) 2 (20)
Gender
Male 12 (41.4) 5 (55.6) 5 (50) 2 (20)
Female 17 (58.6) 4 (44.4) 5 (50) 8 (80)
Education
No education 13 (44.8) 9 (100) 2 (20) 2 (20)
Primary 14 (48.3) 0 (0) 6 (60) 8 (80)
Higher education 2 (6.9) 0 (0) 2 (20) 0 (0)
Employment
Employed 3 (10.7) 2 (22.2) 1 (11) 0 (0)
Unemployed 25 (89.3) 7 (77.8) 8 (88.9) 10 (100)
aNs vary due to missing data.
6 International Social Work
Results
Two major themes and two minor themes were extracted from the interviews, each related to char-
acteristics of an effective mental health intervention designed to address the needs of recently
resettled refugees experiencing mental health issues such as symptoms of depression and anxiety.
The identified major themes were group program structure and program content, and the two minor
themes were program duration and program location. Each of these themes and their subthemes
will be described in detail with supporting evidence provided.
Major theme: Group program structure
Participants felt that a mental health intervention should have a group focus, rather than an indi-
vidual focus. They appreciated the camaraderie that developed out of a shared sense of purpose in
the mental health support group meetings and felt that this was a missing component in individual
meetings with their mental health counselors.
Subtheme: Social support. Several participants explained that participating in the mental health sup-
port group with their peers helped to reduce feelings of social isolation. One participant shared,
‘Being in the group was helpful because we are making friends and learning many new things from
others as we exchange ideas and helping each other’. Others appreciated the group structure as
providing them with a sense of belonging and helping to combat negative feeling associated with
seclusion. Another participant explained, ‘In group, it helped us to join others. We meet, we gather,
and we exchange ideas’. And still another interviewee agreed, ‘It helped me very much because
sometimes I feel lonely, but when I am in group I don’t feel alone’.
Subtheme: Mutual aid. Another common idea shared by a number of interviewees was the assertion
that the group program structure was an effective mechanism to create a sense of shared responsi-
bility and obligation to one’s fellow community members. Participants expressed a strong desire to
provide assistance in various forms to one another within their communities, and they viewed the
mental health support group as an important facet of this commitment to one another. Several
interviewees explained this sense of community responsibility as an important feature of the cul-
ture and traditions in their home countries. One participant explained,
The first thing for these groups, which made me happy, was that they said that we will be helping our
neighbors and friends who have some conflicts … This is how we grow in our country; we were advising
and helping our friends and neighbors with their conflicts.
Interviewees emphasized the importance of the reciprocity that developed in the groups and
described this process as an ongoing exchange of knowledge and ideas. A participant shared, ‘The
group helped me in the way that I tried to learn, and have knowledge of how I can help others who
have concerns, and also help me to know other people’. The reciprocity and shared responsibility
were not limited to knowledge and ideas, however. As one participant explained,
The groups can be improved by helping refugees who are especially vulnerable and who don’t have work
or refugees who are sick and don’t have transportation to the hospital. That’s why I liked this group,
because we help each other.
So, being a part of the mental health group was seen not only as an opportunity to share ideas and
knowledge with other refugees but also served as a place to receive and exchange practical help
from others, as in this example, transportation to the hospital.
Mitschke et al. 7
Subtheme: Empowerment. Some of the participants saw value in what they deemed as power
through group membership. They expressed a sense of authority or privilege that they felt simply
by being a member of the mental health support group. These feeling persisted despite the open
nature of the group – anyone could join the group at any time without a formal entry procedure in
place. Some participants expressed a desire for a formal recognition of group membership. As one
interviewee explained,
First of all, they told us that we will be peer group, but they didn’t give us anything such as a badge to show
who we are, even when police officers come we cannot show anything to identify who we are. So they
need to give us something showing that we are peer group.
Major theme: Program content
In addition to group program structure, the second major theme focused on the program content, in
both a substantive sense and a more general sense of providing overarching direction in the devel-
opment of a mental health support program. In a broad sense, participants expounded on the impor-
tance of addressing the specific needs of refugees at a single point in time. They explained that
while some refugees may be able and ready to talk about their mental health concerns, others may
be focused on other needs such as transportation or employment. Several interviewees emphasized
the necessity of accommodating these varying needs. Much of the content suggested by partici-
pants is not specific to mental health, but instead speaks more broadly to the numerous other needs
that may affect ongoing mental health adjustment among recently resettled refugees.
Participants stressed the need for a participatory model of program development and expressed
a strong desire to be involved in the creation and delivery of program content. In this regard, par-
ticipants had many ideas about the content that should be included in an effective mental health
group intervention, many of which centered around adjustment to life in the United States as a
newly resettled refugee.
Subtheme: System navigation. A number of participants expressed a need for assistance in navigating
the health and social services landscape in the United States. Of particular concern were skills and
knowledge related to accessing health and medical services. Participants experienced difficulty
managing ongoing mental and physical health care needs due to barriers associated with language,
cost, scheduling of appointments, and arranging appropriate transportation. Some participants also
expressed frustration with financial illiteracy, specifically as this relates to understanding medical
bills, insurance premiums and co-pays, and Medicaid renewal applications.
Subtheme: Literacy and language. Even more pressing than financial literacy concerns was the need
for English language literacy assistance. Many participants expressed frustration with their inabil-
ity to understand English and felt that this was a primary reason that they experienced many of the
challenges they faced in adjusting to life in the United States. Interviewees requested assistance
reading their mail and explained that it was difficult for them to sift through ‘junk’ mail and bills
that needed to be paid without an ability to read English. Some participants expressed strong opin-
ions about how English language and literacy education should be delivered to refugees, and sev-
eral noted the need for bilingual teachers who could communicate in both English and the language
spoken by refugees. As one participant explained,
… some offices are trying to teach English to refugees but I think that the people who are teaching English
to refugees suffering method of teaching refugees. They don’t know how to attract refugees in English
lesson, [and] they don’t know how to interest refugees in the study. I think that the best thing would be …
8 International Social Work
[to] ask the people who speak the language of refugees [to teach English classes] because sometime[s]
they can … interpret English word[s] in other language[s]. The level[s] of study for refugees are different
– some people did not go to school, and others … only [went to] elementary school. If English lesson is
give[n] by who know the African language … [it will] be easy.
Also related to literacy and language learning was the desire for programming that would provide
assistance attaining US citizenship. Many participants expressed anxiety about their inability to speak
and read English as impeding their desire to pass the US Citizenship Exam. For a number of partici-
pants, the need to learn English in order to pass the citizenship test superseded other reasons such as
attaining employment, communicating with service providers, and navigating the health sector.
Subtheme: Sense of place. Another theme that relates to the program content involved recognizing
the importance of a sense of place. Several participants expounded on the natural beauty of their
homeland and discuss how much they missed the sense of connection to the beauty of the land fol-
lowing resettlement. As one Bhutanese interviewee explained,
We came from the Himalaya Kingdom. Our country has its natural scenic beauty. Our mind would have been
satisfied if we could get chance to visit such places here in the United States occasionally. But, the geographical
features of the United States are different from our country. Therefore, to improve our mind from being
strange and lonely, the Mental Health Support Group could surely provide relief to our contracted mind, by
taking us in such places timely manner where there are similar geographical features in the United States.
Another participant expressed a similar sentiment, establishing a connection between the effec-
tiveness of mental health intervention and connecting to the surrounding physical environment.
The participant shared, ‘Counseling be improved when we refugee people are getting opportunity
to visit green sceneries in the United States in timely manner’.
Subtheme: Advocacy. Several participants spoke about the need for advocacy on their behalf,
especially related to interactions with employers and medical or social service settings. Partici-
pants viewed themselves as vulnerable to individuals who were in positions of power and felt
they were at risk of being taken advantage of by others. As one interviewee explained, ‘Some
office[s] here in America have dishonest people especially when they know that you are refugee
you don’t know very well English, we don’t know how to get to the office it very hard because
of the language knowledge’.
Subtheme: Counseling. While much of the feedback related to program content involved factors
external to mental health, several key ideas specific to mental health and counseling were noted by
interviewees. Participants noted the importance of building the relationship between the individual
client and the counselor as an essential component of establishing trust and honesty in a mental
health intervention. A number of participants discussed the need for assistance from a mental health
professional in helping to prioritize problems and needs. As one interviewee explained, ‘It helped
me because I had too many things in my mind. So this counseling helped me handle it. It helped
me not to have a lot of thoughts and just focusing on my family’. Others discussed the value of the
counselor in providing advice and encouragement in the face of difficulties related to employment
and overall adjustment to life in the United States. Several interviewees also mentioned the coun-
selors’ assistance with managing feelings of stress and coping with insecurity.
Subtheme: Ethnic-specific differences. While the program content areas mentioned previously were
distributed across each of the refugee groups represented in the study, the topic of law enforcement
Mitschke et al. 9
was noted by several African interviewees, but not mentioned at all by the Bhutanese or refugees
from Burma. Interviewees from each of the three African nations expressed concerns about the role
of law enforcement in their communities. Several expressed interest in learning more about US
laws, and still others expressed concerns about their personal safety and the safety of their com-
munities. A minority of African interviewees also expressed a desire for conflict resolution and
mediation training as a distinct component of a mental health curriculum; again, these concerns
were expressed only by representatives of this community.
Minor themes: Frequency/duration and location
While the major themes of program structure and program content were well-defined and exten-
sive, minor themes related to the frequency of group meetings, the duration of the intervention, and
the location of meetings were also revealed. Participants expressed a desire to attend at least two,
and often three or more group meetings each week in order to have their needs met. Many partici-
pants felt that the program duration should extend longer than 8 weeks and should include a long-
term follow-up component a number of months after the regular meetings had concluded. Finally,
interviewees emphasized the importance of holding meetings in an easily accessible location. For
many, the apartment ‘clubhouse’ was suggested as a location that would be accessible to all with
minimal transportation arrangements required to facilitate attendance.
Discussion
While the mental health intervention in question in this study included both individual and group
structure, the overall consensus of participants who reflected on the program’s efficacy appreciated
the group structure over the individual counseling model. Stewart et al. (2012) found similar results
in a multi-method participatory study of a social support intervention for refugees from Sudan and
Somalia. In the study, both trained peer helpers and professional counselors provided support in a
group setting, and the authors noted a significant decline in self-reported loneliness and increases
in perceived support and social integration. These findings are also consistent with Behnia’s (2004)
exploratory study comparing community peer groups and traditional counseling, which indicated
that perceptions about formal mental health services included distrust, stigma, and uncertainty.
While the stigmatization of formal counseling was not evident in this study, the refugee partici-
pants in this study, like the participants in previous research conducted with resettled refugees,
favor a peer-led support group model in general when compared with formal, individualized coun-
seling services. These findings provide further support to research that has found merit in the
effectiveness of a supportive network of family, friends, caring professionals, and community
members to serve as a protective buffer for mental illness and to ease adjustment of recently reset-
tled refugees in a host country (Behnia, 2004).
The cultural ambassadors in this study served a multi-faceted role in this study – as paraprofes-
sional mental health educators, as liaisons and brokers, and finally as community organizers. These
roles mirror the functions of many former refugees working as resettlement caseworkers in reset-
tlement programs in the United States (Shaw, 2014) and provide support to the notion that peer-led
group support can have a positive impact on overall well-being. The importance of the develop-
ment and maintenance of a strong social support network has been well documented (Beiser, 1999;
Davies and Bath, 2001; Hernandez-Plaza et al., 2006; Stewart et al., 2012). Refugees establish a
sense of belonging when they spend time in established groups of others facing similar stressors
related to adjustment in a new society. Furthermore, having a shared sense of purpose and past can
increase feelings of social belonging among resettled refugees (Stewart et al., 2008). In contrast,
10 International Social Work
research with African refugees indicates that the loss of social support can have a negative impact
on adjustment and coping (Simich et al., 2004).
Participants in this study extolled the virtues of the exchange of ideas and reciprocal helpfulness
that was facilitated by group membership. It may be that having the opportunity to share, learn, and
grow together allows refugees to develop a sense of usefulness in an environment in which they are
often reminded of their lack of power. Even refugees who had resettled within the few months prior
to group membership might have something to share with others in the group. Stewart et al. (2012)
found that participating in group discussions with other refugees served as a way to empower an
individual to attempt a new task or take on a new challenge that had previously seemed insur-
mountable. Refugees’ shared experience as victims of oppressive regimes may result in an una-
voidable loss of a sense of autonomy that is further ingrained by the resettlement process. Group
membership and shared decision-making, as is the nature of a peer support group, may provide an
opportunity for individuals to regain a sense of lost power and autonomy.
This sense of collective responsibility and communal reciprocity may be a healthy and essential
outgrowth of rediscovered cultural tradition for many refugees. To this point, the fact that partici-
pants emphasized the need for a participatory model of program development suggests that refu-
gees value having a role in the development and delivery of program content. Like the participants
in Behnia’s (2004) study, the refugees in this study indicated that practical advice, advocacy, and
assistance dealing with the numerous stressful life events they faced took precedence over a need
for formal counseling that would focus on the provision of emotional support.
To this end, participants expressed a number of challenges related to language and literacy,
access to health care and social services, and the need for advocacy as it relates to employment.
This recognition of Maslow’s (1954) hierarchy of needs is an important one for determining how
to best address the mental health issues faced by recently resettled refugees; in this study, as in
previous studies, refugees’ mental health needs were circumvented by more practical issues such
as access to employment, housing, and other basic necessities. The need for language and literacy
education rose to the surface as a primary concern, as participants viewed their inability to com-
municate in English to be a major detriment to their ability to succeed in the United States. It is
interesting to note participants’ ideas about how and by whom English language should be taught
to refugees. Of particular interest was the assertion that refugees might be most receptive to learn-
ing English when it is taught to them by bilingual speakers who are also able to speak a common
language. This notion provides support to the idea that refugees can teach and learn from each
other in a reciprocal way that empowers the refugee community as a whole.
Participants in the study appear to possess a number of misconceptions around the subject of
attaining US citizenship. Many interviewees lamented about their inability to speak and read
English as a major source of stress as it relates their inability to take and pass the US citizenship
test. In order to become a US citizen, among other basic requirements, a refugee must have a basic
knowledge of US government and history (measured by a written assessment) and have a basic
ability to read and speak English, measured by both a brief oral exchange and a spoken oath.
While attaining citizenship is a sensible path toward long-term acculturation and integration into
US society, it should be noted that refugees who are not yet citizens, as legal permanent residents
of the country, benefit from most of the same basic privileges as citizens. For many participants
in the study, however, fears related to possible deportation or other unspoken concerns seemed to
play a major role in the pressure they place on themselves to learn English in order to pass the citi-
zenship test. The roots of these misconceptions surrounding citizenship are unclear and deserve
further examination.
A number of participants in this study discussed the meaning of place, geography, and topogra-
phy and expressed a need for a connection to the land or place to be addressed in mental health
Mitschke et al. 11
interventions for refugees. Relocation and forced abandonment of home, country, and lifestyle can
be disorienting and acceptance of a new, often strange, and very different built environment can by
jarring (Dam and Eyles, 2012). Home, and by extension, one’s sense of place, may change and be
redefined over time as a result of the migration experience. According to Chaitlin et al. (2009),
one’s sense of place and feelings of home are constructed and reconstructed as individuals and
groups change and relocate. In Dam and Eyles’ (2012) study of the meaning of place among reset-
tled Vietnamese refugees, the authors found that their sense of place derived from geography as
well as family ties and memories of past places lived. The participants in this study also possess a
multi-faceted conceptualization of place. In response, it seems logical that a mental health inter-
vention designed for refugees would also include components related to geography and topography
to allow participants to develop new connections with the land and built environment. Because
refugees were in a sense rejected by their country of origin, helping them to develop sense of place
and connection to the land may be an important part of adjustment and belonging.
Conclusion
Social workers and other mental health professionals embrace a client-centered approach to mental
health care. This approach can be articulated in any number of ways, but perhaps most common is the
oft-touted ‘meeting clients where they are’ (Falk-Rafael, 2001). The results of this study inform where
refugee clients are in relation to effective mental health intervention. Specifically, our typical concep-
tualization of the client-counselor dyad does not seem as good a fit for resettled refugee clients as
compared to a group intervention where there are opportunities for group support and psycho-educa-
tion related to their needs. Specifically, refugees voiced needs related to needs lower on Maslow’s
hierarchy. This should give social workers pause in considering when to introduce therapy for mental
health issues. In other words, true to Maslow’s hierarchy, interventions should first stabilize refugees
by helping them meet their basic needs. As (Mitschke et al., 2013) found, simply introducing financial
literacy classes in a group setting taught in the refugees’ native language produced significant relief of
mental health struggles including depression, anxiety, and post-traumatic stress. Thus, we encourage
social work practitioners working with refugees to develop and implement interventions in a group
setting that address needs in Maslow’s (1954) hierarchy from bottom to top.
Funding
Regina Praetorius, Diane Mitschke and Eusebius Small were funded by the UT Arlington School of Social
Work innovative Community-Academic Partnership (iCAP) (2012–2013) for the project Refugee Mental
Health: A Comparison of Three Treatments.
Notes
1. The intervention impacts were measured and reported separately in Small et al., 2015.
2. The intervention impacts were measured and reported separately in Small et al., 2015.
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Author biographies
Regina T Praetorius is a licensed social worker and Associate Professor of social work at UT Arlington. She
is the Director of the Bachelor of Social Work Program. Her research focus is the interconnectedness of
trauma and suicide.
Diane B Mitschke is an Associate Professor of social work at UT Arlington. She is the Director of the Master
of Social Work Program. Her research research interests focus on exploring the intersection of health and
mental health among vulnerable communities.
Eusebius Small is an Assistant Professor of social work at UT Arlington. His research interests focus on reduc-
ing incidents of sexually transmitted infections among vulnerable populations of youths with a particular
emphasis on sub-Saharan Africa.
Youn K Kim is a recent graduate of the UT Arlington social work doctoral program. In the fall of 2016, she
will begin work as an Assistant Professor of social work at Louisiana State University.
Don R Kelly is a licensed social worker and is a social work doctoral student at UT Arlington. His research
interests include conflict resolution, restorative justice, conflict coaching, leadership, law, and child
advocacy.
