Immigrant Justice Interest Group

On a crisp Saturday in January 2019, mental health practitioners and affiliates gathered for the first Working Alongside Refugees in Mental Health (WARM) full-day workshop in Anchorage, Alaska. Representing various mental health professions and levels of training – psychologists, counselors, social workers, and graduate students – all workshop attendees had a unified purpose: To understand more of refugees’ experiences and cultural and contextual considerations when providing mental health care. Jointly developed between Alaska’s refugee resettlement program, Catholic Social Services Refugee Assistance and Immigration Services (RAIS) and a faculty member in the Clinical-Community Psychology PhD Program at the University of Alaska Anchorage (UAA) and her students, the ultimate goal of WARM is to increase the availability of culturally-relevant, linguistically-appropriate, evidence-based mental health treatment for refugee community members in Alaska. And so, the cold morning had an air of excitement surrounding the start of a new network that could meet a significant community need. Below we discuss reflections on WARM, including its rationale, our partnership, the first workshop, preliminary evaluation, and future directions.

Background                                         

We are currently experiencing an international refugee crisis, with the highest levels of displacement on record. The United Nations High Commissioner for Refugees estimates that in 2017 there were 25.4 million refugees around the world with only 102,800 (less than 1%) having been resettled (UNHCR, 2018). Refugee status is legally defined under the 1951 Refugee Convention as someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country; or ... is unwilling to return to it.” Historically, RAIS has supported the resettlement of 130 refugees in Alaska annually, primarily to the Anchorage area. Currently, RAIS serves almost 600 refugees and asylees from 33 countries, providing reception and placement, case management, education, employment, and health promotion services.

Refugees are exposed to a host of pre-flight, flight, and resettlement stressors, including war trauma, persecution and discrimination, under-resourced communities, and post-migration living difficulties. These stressors are related to adverse mental health outcomes (Bogic, Njoku, & Priebe, 2015; Steel et al., 2009). Although refugees demonstrate remarkable resilience, as a whole they experience higher rates of posttraumatic stress, major depression, generalized anxiety, panic, and adjustment disorder, and are more likely to experience somatic symptoms of mental distress (Bogic et al., 2015; Steel et al., 2009). Yet, when refugees are resettled to new communities, they face numerous barriers to accessing mental health services including a lack of available and affordable practitioners who can provide culturally-informed, linguistically-appropriate, evidence-based care (Fondacaro & Harder, 2014; Vrana, Campbell, & Clay, 2013). A local needs assessment in Anchorage found that while mental health practitioners expressed interest in working with refugees, they faced many barriers, including a lack of training in working cross-culturally and with interpreters (Robinson, 2015).

WARM

Consequently, in 2018, the director of RAIS (Issa Spatrisano) and a faculty member at UAA (Sara Buckingham) began to discuss ways of addressing these barriers to mental health care. Modeled in part after the Intercultural Counseling Connection in Baltimore, Maryland (http://www.interculturalcounseling.org/), we aimed to develop a series of workshops that would provide specialized training in matters relevant to refugee mental health. A team of students, including a doctoral intern (Jordan Snyder), doctoral student (Dale Golden), master’s student (Samantha Skirko), and undergraduate student (Nyabony Gat) joined to support the development and implementation of WARM.

The goal of the initial WARM workshop was to provide practitioners foundational knowledge relevant to mental health services for refugees. In the first part of the workshop, Issa described diverse migration pathways and differentiated refugee resettlement from asylum and immigration, with a particular focus on refugees’ pre-flight, flight, displacement, and resettlement experiences. In the second portion of the workshop, Sara considered the many stressors and strengths associated with refugees’ experiences and how they may lead to, exacerbate, and/or ameliorate common mental health concerns among refugee clients. We described, modeled, and discussed specific strength-based, culturally-responsive, and evidence-based psychotherapy approaches for clients who are refugees. Licensed attendees were eligible to receive seven free Continued Education credits provided by RAIS through a partnership with our state psychological association. 

Preliminary Evaluation

Of the 29 people who attended the initial training, 14 participated in both a pre- and post-training survey to measure the impact of the training on knowledge, confidence, and intentions to provide mental health services to refugee clients. Data results are limited as only half of the attendees responded to both surveys; however, the data has demonstrated important insight into the initial impact of our first training. We found that practitioners’ knowledge of matters related to refugee mental health significantly increased and their barriers to working with refugees due to a lack of knowledge significantly decreased after the training. We also found that practitioners’ confidence working with refugees significantly increased after the training. However, while trending in a positive direction, we found that practitioners’ intentions, abilities, and commitment to working with refugees did not significantly change over time. We conclude that our first training provided foundational knowledge in refugee mental health that increased practitioners’ confidence working with refugee clients, but that many practitioners likely need additional training to feel ready to serve refugee clients. We expect that with additional trainings and ongoing consultation, we will likely see practitioners’ intentions, ability, and commitment to work with refugees increase. 

The Future of WARM

There is a strong interest among practitioners in Anchorage to provide mental health services to refugees. Through our ongoing partnership, we are working to make our foundational workshop available online so that practitioners outside of Anchorage can access it. With the evaluation data from the first workshop, RAIS has submitted a grant to conduct additional specialized trainings, such as: working with interpreters; conducting evaluations for asylum and citizenship exam waivers; working with children, youth, and families; group treatment; and, vicarious traumatization, resilience, and self-care. With this ongoing partnership, we hope to develop sustainable capacity for working with refugees in mental health in Alaska. Eventually, we would like to develop these workshops into a maintainable community of practice using opportunities including consultation groups to foster continued learning among practitioners.

In the cold of the Alaska winter, WARM is an opportunity to build sustainable mental health capacity for working with refugees. We are excited to continue to work with RAIS and local practitioners to build local capacity so that refugees in Alaska have access to culturally-responsive, linguistically-appropriate, and evidence-based psychotherapy approaches. Fostering and sustaining strong community-based partnerships is critical to building sustainable mental health capacity. WARM may be one method of building capacity that could be replicated in other communities outside of Alaska. 

References

Bogic, M., Njoku, A., & Priebe, S. (2015). Long-term mental health of war-refugees: A systematic literature review. BMC International Health and Human Rights, 15,1–41. doi:10.1186/s12914-015-0064-9

Fondacaro, K. M., & Harder, V. S. (2015). Connecting cultures: A training model promoting evidence-based psychological services for refugees. Training and Education in Professional Psychology, 8, 320–327. doi:10.1037/tep0000071

Robinson, R. V. (2015). Alaska refugee needs assessment. Anchorage, AK: University of Alaska Anchorage.

Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & Van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302, 537–549. doi:10.1001/jama.2009.1132

United Nations High Commissioner for Refugees (UNHCR). (2018). Global Trends: Forced Displacement in 2017. Geneva, Switzerland: UNHCR. Retrieved from https://www.unhcr.org/5b27be547.pdf

Vrana, S. R., Campbell, T. A., & Clay, R. (2013). Survey of national consortium of torture treatment program therapists about the assessment, diagnosis, and treatment of the psychological sequelae of torture. Traumatology, 19, 144–153. doi:10.1177/1534765612455226