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Barriers and enablers to mental health care for refugees and immigrants

As technical adviser to the Office of Refugee Resettlement, I conducted a webinar on 8/28/2019 on the barriers and enablers to mental health care for refugees for community-based organizations serving refugees, asylum seekers, and other immigrant populations.

Refugees and other immigrants who seek protection from violence and persecution often experience high levels of potentially traumatic events such as physical, psychological, and cultural adversities prior to arrival. These experiences, combined with the stresses of adjustment to life in a new country, all have potential to cause emotional distress. Despite the mental health needs, most refugees and other immigrants do not seek care due to individual, community, health system, and policy level barriers. Understanding the factors that enhance or inhibit the potential for individuals to access needed mental health care is a critical first step to serving this population.

Mental health burden for refugees and vulnerable immigrant populations

Many are fleeing violence and persecution, war, armed conflict, chronic, pervasive, interpersonal violence. However, the experiences for these populations are quite varied. Some have prolonged exposure with daily human rights violations (for example in the Cambodian genocide and labor camps), others have acute, intense active exposure to war (for example in the Syrian conflict). Some have prolonged migrations with lack of access to basic needs, constant threats to self and personhood. But others who have means, may travel by plane or train. Some travel alone, others with family. Some have relations, communities, and families in their resettlement state (in the US) and others have no one.

All of these populations; however, are at risk of daily life stressors in resettlement: acculturative stress, traumatic loss, cultural bereavement, and insecurity with basic needs such as food, housing, employment, and education.

About one out of three asylum seekers and refugees experience high rates of depression, anxiety, and PTSD. However, systematic reviews show that prevalence estimates of mental health disorders for this population vary widely from 20% to 80%.

While most refugees and asylum seekers with PTSD and depression show reduction over time, particularly if there are low resettlement stressors, others may experience years of PTSD. While these three disorders are commonly studied, many affected by conflict may not meet diagnostic criteria, but can experience complicated grief, complex trauma, despair, isolation, anger, and lack of trust.

Socio-ecological approach

Understanding the spheres of influence (family, peers, community, culture) around an individual helps to frame the experience of refugees as highly influenced by the social environment around them. These levels will be discussed:


§ Co-morbid mental and physical health conditions

§ Language

§ Health insurance

§ Legal status and mistrust of services

§ Perceived discrimination


§ Culture

§ Social stigma, networks, informal supports

§ Post-migration stressors

Health systems

§ Cultural sensitivity and cultural competence

§ Mental health screening and referrals

§ Health policy