Overcoming the Mental Health Stigma and Facilitating Cultural Integration for Refugee Youth by Providing Counseling Services at School

Ralitsa Rano, PhD, LCSW

Coordinator of International KidSuccess, Jewish Family Service of Colorado

rrano@jewishfamilyservice.org

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Abstract: Refugee youth come from all over the world: Africa, Asia and Middle East—and all experience culture shock as they adjust to their new home in the United States. Along with “carrying the baggage” of numerous losses and past experiences of trauma they are expected to adjust quickly to a different culture and get acquainted with the American school system while learning a new language. Parents who are the usual source of support are often struggling themselves, not just to adapt to the new society but also to be able to provide for their children. All these situations can be very overwhelming for refugee youth. Jewish Family Service of Colorado’s International KidSuccess counseling services play a key role in supporting refugee children and adolescents in their cultural adjustment journey so that they can be successful at school and have a better life and future in their new country.This article will focus on the cultural adjustment process and the challenges refugee youth encounter throughout its four stages. Refugees’ views about clinical services and overcoming the stigma associated with mental health will also be explored.

Key Words: International KidSuccess program, refugee youth, counseling services, cultural adjustment process and challenges, stages of cultural adjustment, cultural adjustment groups, refugees’ views about clinical services, mental health stigma.

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Introduction

Refugees flee their country of origin because of war, persecution, or a well-founded fear of persecution based on their race, ethnicity, religion, nationality, membership in a particular social group, or political opinion. No matter what is the reason behind their escape from danger and how much they have hoped for safety and better future, their adjustment to a different culture and life in their host country is difficult and stressful. Everyone entering a new country experiences some mixed feelings of sadness, excitement, worry, and confusion. All these emotions are normal and are part of the cultural adjustment process. Cultural adjustment does not happen overnight; it is a long process through which some challenges will be encountered. Some difficulties are anticipated, but most refugees have underestimated the degree of difficulty in cultural adjustment.

Stages of Cultural Adjustment

There are four common stages of the cultural adjustment process: arrival, reality, negotiation/alienation and the integration/marginalization phase. In the arrival phase, also known as the “honeymoon”, most refugees feel elated that they have come to a safe place where they have a chance to rebuild their lives (Hunt, 2002). They might also feel worried and confused about how exactly this will happen. For refugee youth this would be the time that they are enrolled in school; for some the first time in their life. Refugee youth are excited about being in school, learning, and making friends. However, adjusting to a new school system, learning a new language, so different from their native languages, understanding school rules or making friends in a different culture are some of the many challenges they face.

N. S. is a refugee from an Asian country. She was 12 years old when she came to the United States and was enrolled in a high school due to a mistake in her age. She was 6 years old when her family escaped war in her country of origin. N.S. had lived for six years in a refugee camp before being resettled in the United States. The hardest part for her and her family about moving to the United States was not knowing anyone in their host country and not speaking any English. In school she wanted to ask her teachers for help, but she did not speak the language, so she could not ask questions. She cried every day after school because she felt helpless.

E.B. is a refugee from an African country. He was 12 years old when he had to flee his country of origin due to turmoil and persecution. E.B. and his family had to walk through the jungle at night to find safety in a neighboring country. He feels lucky to go to high school in the United States because he could not go to school back in his country of origin. The hardest thing for him at the beginning was not speaking any English and being confused about what was going on in class and what was expected of him. On his first day of school he did not even know how to get lunch and other students laughed at him.

R.B. is a refugee from an Asian country. She was 16 years old when she came to the United States. Her family had to flee their country of origin because they belonged to an ethnic group persecuted by the ruling military junta. She spent many years in a refugee camp in a neighboring country before being resettled in the United States. In school she got in trouble for always looking down because her teachers thought that she was not listening. However, in her culture looking down is a sign of showing modesty and respect toward others.

A.H. is a 16 year old refugee from a war-torn African country. His father had been a victim of torture and A.H. himself witnessed chaos and violence. His best friend was killed right in front of him and A.H. had to run for his life. After two years in a refugee camp he was resettled in the United States. He had a hard time trusting his teachers and difficulties forming relationship with peers due to the past trauma. He still carries the scars of the war, but he can see a future for himself in America.

These are but a few examples of the difficult issues facing refugee youth in the United States schools. Refugee youth are very resilient and appreciative of the opportunity to get education in the United States. At the beginning, “honeymoon” stage, despite the difficulties they come to school every day with hope to learn English, make friends and make their families proud. But after a few months the initial enthusiasm naturally wears off and the reality sets in. The reality stage, also known as “culture shock”, marks the realization that building a new life in their host country is harder than they had imagined. For refugee youth, this is the time when they feel really tired of all their efforts to adjust to the new school setting, learn the new language, and understand their teachers’ expectations. This would be the time when refugee youth might perceive being different from their peers as a huge burden and an obstacle for making friends. Feelings of loneliness, isolation, discouragement, and even hostility, towards the host culture could be experienced. In this stage students need as much support as possible at school since their parents are unfamiliar with the educational system in their new country and might be struggling themselves, not only adapting to the new society, but also providing for their children. If adequate support is provided in this phase, refugees will take steps and change attitudes that will prepare them for cultural and psychological integration (Hunt, 2002). Signs of moving towards successful integration are: having some friends at school from different cultures, understanding what is expected from them in class and confidence in their problem solving skills. During integration there is progress learning the new language, as well as understanding that this is time consuming process, not an overnight event. Some stability in the family is also a factor. At least one parent might be employed and the family is not struggling with survival. There is a sense of hope that things would be better in future. However, if the support is not available, the stresses of their current life situation combined with their past resettlement experiences and trauma will affect their moving towards independence and might lead to alienation.

The fourth stage of cultural integration or marginalizationdepends again on the direction taken at the previous stages. (Hunt, 2002) This last stage of cultural integration is a beginning of a unique, lifelong journey for refugees. It characterizes with feelings of comfort in the host culture and an acceptance of their cultural background as an integral part of their identity. Even though being different is still difficult at times, at this cultural adjustment phase refugees could see it more as an asset than as a burden. Conflict between the two cultures is resolved by adopting many aspects of the host culture while retaining cultural values and religious beliefs from their past. Refugees at this point of their journey perceive themselves as bicultural and bilingual. How long a refugee would stay in each stage of the cultural adjustment process depends on many factors, such as stability of their life prior to becoming refugees, level of trauma experienced, developmental level, skills possessed, personality characteristics, resources and support available for them and their families after resettlement. Schools could smooth and facilitate the process of cultural adjustment by providing programs and services addressing the needs of refugee youth (British Columbia Ministry of Education, 2009).

International KidSuccess’ Cultural Adjustment Groups for Refugee Youth

The importance of assisting refugee students with cultural adjustment and emotional difficulties that may arise as a result of resettlement cannot be underestimated. Jewish Family Service of Colorado’s International KidSuccess program provides culturally sensitive individual and group counseling services to refugee youth at school. An overarching goal of the program is to support refugee youth through the major life transition of resettlement so that they are better able to focus on and succeed in school. The program also provides training and consultation about cultural adjustment, trauma, and other mental health issues to educators and other professionals working with refugees throughout the state of Colorado.

The International KidSuccess Program began providing cultural adjustment groups for refugee and immigrant students in 2000 to a culturally diverse group of students at Denver South High School. This school has served as a magnet school for refugee and immigrant students for many years and has a strong English Language Acquisition (ELA) program. South High School students who take part in the ELA program come from more than 60 countries. Currently, the largest groups of refugee students are from Burma, Bhutan, Eritrea, Iraq, the Democratic Republic of the Congo (DRC), and Somalia. Over time, the International KidSuccess Program grew, and based on the needs identified by students and school staff, additional school-based counseling services were developed.

“Being part of the group is like being in a family for a while.”

-High School Student

“This group is a safe place for me. We talk about our countries, cultures, and how you feel…”

-Middle School Student

“We are all the same even if we look and act differently. We all have been through things that make us different in a way, but we can help each other feel good about ourselves.”

-High School Student

“Thank you for focusing on relationship building and the human aspect of this work. It is crucial to be a human first — I hope more people adapt to that philosophy.

-Teacher

“Thank you so much for coming and increasing my awareness about the needs of refugees. You really made the topic come alive and gave it a voice. Thank you for serving our community in this way.”

– Counselor

Among variety of group interventions, International KidSuccess’ cultural adjustment groups play a key role in helping refugee youth recognize that they are not alone in their past experiences and current cultural adjustment struggles. For some refugee students, these groups are their most empowering experience since coming to the United States. They are the place where, for the first time, students are able to overcome the common fear of speaking in English and making mistakes. The groups also foster a sense of belonging to a school community of youth sharing a unique, but also similar journey. During those groups an International KidSuccess therapist might be the first person who validates refugee youth feelings of confusion, anger, sadness, discouragement, and normalizes experiences that were not even anticipated. Since not all students are at the same stage of cultural adjustment the International KidSuccess’ groups are helpful in different ways for different students: for those who are still in the “honeymoon” stage, it is helpful to hear that although there will be some ups and downs on the road ahead, this is a normal process that everyone goes through when moving to a new country and culture. For refugee students who are feeling depressed, the opportunity to acknowledge and process their feelings could be the first step toward the next negotiation phase (Adkins, Birman, and Sample 1999). In addition, students who have passed the “culture shock” phase can give hope to those who are still struggling with cultural adjustment. International KidSuccess’ cultural adjustment groups and a cycle of ten group activities are described in a publication called the R.E.S.P.E.C.T. Guide: Refugee Education and Schools Promoting Empowerment and Culture of Tolerance (Jewish Family Service of Colorado’s International KidSuccess, 2012).

Overcoming Mental Health Stigma

The major advantages of providing counseling services at school is that students can easily access them and the mental health stigma, so common in many cultures and refugee communities, can be overcome. In addition, schools are the setting where many of the acculturative struggles of refugee children and youth unfold (National Child Traumatic Stress Network 2003).

Y. K. is an 18 year old refugee from a Middle Eastern country. She was rushed to a local hospital with a panic attack. Y.K. had presented with somatic symptoms and her family felt that she needs medical help. She was referred to therapy for addressing her depressive and anxiety symptoms. Family was not interested in outpatient services due to transportation issues and stigma that only “crazy” people have therapy. Having counseling at school was the only way for this student to get help. International KidSuccess therapist had helped with many school related issues and had earned the family’s trust.

H.M. is a 17 year old refugee student from an African country. He had been involved in the U.S. legal system for stealing and his family was very concerned. During a parent meeting to discuss appropriate outpatient referral mother was skeptical about the benefits of therapy outside of school. She felt that the school needs to help her son. The only culturally appropriate solution she saw was summarized in the words: “We need to pray more”.

A.Y. is a 15 year old refugee from a Middle Eastern country. He was referred to International KidSuccess school-based counseling due to behavior concerns and issues with authority figures. The student was interested to talk, but worried to share personal experiences with therapist without his father’s approval. In conversation with father confidentiality of counseling services was assured and its limits were explained. Father not only signed the necessary paperwork, but gave verbal permission to son to share with therapist some disturbing experiences that happened to him back in their country of origin.

It is essential to note that mental health is a new concept for many refugees coming from countries or other places (refugee camps, rural areas, etc.) where mental health counseling has not been available or accessible for everyone. Due to the fragmented and limited mental health staff resources in refugee camps, those refugee who were judged to be at high risk—such as victims of violence, unaccompanied minors, single young women and men, and elderly people—were given priority (Gong-Guy, Cravens, and Patterson 1991).

Even when refugees have some understanding of the mental health concept, they are typically not familiar with the different services provided in the United States and how to access them. Emotional distress is expressed in different ways throughout cultures. Some cultural groups would rather talk about their physical state and present with somatic complaints (headache, trouble sleeping, fatigue, stomachache, etc.) that are better addressed first by a physician. In some cases, refugees may even request or seek out treatments that do not address the mental roots of their symptoms (Peng 2008). Often, for newcomer refugees, mental health will not be their primary concern because they might struggle with inadequate housing, unemployment, transportation issues, language difficulties, and so on. But even when refugees are ready to seek help, accessibility of services and language may still be obstacles.

The stigma associated with mental health is another barrier for seeking and accessing services. It represents a terrible burden that a person has to carry, in addition to all other difficulties related to the emotional distress (Sartorius 2006). The Canadian sociologist Erving Goffman(1963) defines stigma in two ways: the public one, which includes the reaction of society toward individuals with mental illness, and self-stigma, or the feelings that people with emotional distress have about themselves and their relation to “normals.” The negative effects of the public and private stigma are enhanced by the normal experience of feeling different, which refugees already have through their initial encounters with the host country and culture. Stigma about mental health can be manifested in different ways.

For some cultural groups, it might not be appropriate to talk about psychological and emotional difficulties with someone outside of their family or from a different culture, religion, ethnicity, gender, and so forth. In other cultures, the expression of pain is not encouraged, and the appearance of strength is preferred over weakness (Menon et al. 2002). Shame could be associated with mental illness, and therefore people sometimes prefer to suffer in secrecy. For example, in the Arab culture, honor, or “saraf,” plays an important protective role in many families and therefore mental health issues might be considered shameful and could be ignored or hidden (Jule 2007). Asian cultures tend to stigmatize mental disorders by valuing silence, modesty, and saving honor (Peng 2008). In addition, refugees from Southeastern Asia might associate mental health treatment only with severe pathology requiring institutionalization, and therefore avoid it at any price (Gong-Guy, Cravens, and Patterson 1991). Mental illnesses generally carried a strong negative stigma in the former Soviet Union, as well as many Eastern European countries where serious mental health problems were often treated by forced institutionalization (Center for Health Disparities, n.d.). “In addition, in some countries, mental health professionals were part of the system used to control and oppress political dissidents” (Menon et al. 2002, p. 40), and therefore refugees might find it difficult to trust therapists here. Also “depending on the culture, male therapists may be viewed with more suspicion than female therapists or female therapists may not have the power in that culture to be effective” (Menon et al. 2002, p. 40). In some countries and cultures, there is a different explanatory model of mental health issues. For example, in Somalia, beliefs in the causes of mental health problems are predominately spiritual. Mental health illness comes from God or evil spirits called “jinn.” It can also be brought on through another person by curses or as a result of one’s bad behavior (Schuchman and McDonald 2004). Therefore, seeking assistance outside of the community (religious leaders or healers) for those types of problems is seen as ineffective.

Considering all of the previously mentioned reasons, the cultural adjustment difficulties newly-arrived refugees normally face are often not addressed initially. Therefore, providing counseling services at school by International KidSuccess program has been a huge advantage in overcoming those barriers, as well as the stigma associated with mental health.

References

Adkins, M.A., D. Birman, and B. Sample. 1999. Cultural Adjustment and Mental Health: The

Role of the ESL Teacher. Part V: ESL Activities to Address Mental Health Issues. Spring

Institute for International Studies. Culture Shock pp. 29–30.

British Columbia Ministry of Education (2009). Students from Refugee Backgrounds: a Guide for Teachers and Schools. Available: http://www.bced.gov.bc.ca/esl/refugees_teachers_guide.pdf

Center for Health Disparities. n.d. Russians and Other Immigrants from the Former Soviet Union. University of Northern Iowa. Available: www.iowahealthdisparities.org/ documents/russian.pdf.

Gong-Guy, E., R.B. Cravens, and T.E. Patterson. 1991. Clinical issues in mental health service delivery to refugees. American Psychologist 46(6):642–648.

Hunt, D. 2002. Part III: Refugee adaptation in the resettlement process. In Lessons from the Field: Issues and Resources in Refugee Mental Health. The National Alliance for Multicultural Mental Health. pp. 17–26. Available: http://www.uscrirefugees.org/2010Website/5_Resources/5_1_For_Refugees_Immigrants/5_1_1_Health/5_1_1_3_Mental_Health/Lessons_from_the_Field.pdf

Jewish Family Service of Colorado’s International KidSuccess (2012)R.E.S.P.E.C.T. Guide, Refugee Education and Schools Promoting Empowerment and Culture of Tolerance,for School Social Workers, Counselors, Psychologists and Educators. Avaulable: www.jewishfamilyservice.org/respect

Jule, J.S. 2007. Culture and mental health: eliciting the big picture. PowerPoint slide in Crisis Intervention Training, Mental Health Transformation Project, Unit 12. p. 262. Available: www.dshs.wa.gov/pdf/dbhr/mhtg/CITResourceManual.pdf.

Menon, Sh., R. Mueller, J. Okawa, and S. Shoaee. 2002. Part V: Working effectively with refugees. In Lessons from the Field: Issues and Resources in Refugee MentalHealth. The National Alliance for Multicultural Mental Health. pp.36-43. Available: http://www.uscrirefugees.org/2010Website/5_Resources/5_1_For_Refugees_Immigrants/5_1_1_Health/5_1_1_3_Mental_Health/Lessons_from_the_Field.pdf

Peng, T. 2008. East mind, west mind. Newsweek August 11. Available: www.newsweek.com/2008/08/11/east-mind-west-mind.html.

Sartorius, N. 2006. The centrifugal tendencies of the stigma attached to mental illness. Neuropsychiatric Disease and Treatment 2(1):1–2. Available: www.ncbi.nlm.nih.gov/pmc/articles/PMC2671734/.

Schuchman, D. and C. McDonald. 2004. Somali mental health. Originally published in Bildhaan—An International Journal of Somali Studies. Available: http:// ethnomed.org/clinical/mental-health/Somali-mental-health.pdf.

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This article was published on June 20th: World Refugee Day in Global Education Magazine.

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