Responding to migration and upheaval
Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice
Published online: 12 June 2012
� Springer Science+Business Media, LLC 2012
Abstract Each step of the refugee migratory journey has
its own unique characteristics and mental health conse-
quences, which require much attention from social work
service providers. In an effort to provide quality service
delivery for refugees, their premigration, migration and
post-migration traumatic experiences need to be examined
and understood beyond current narrow formulations. Inte-
grating the concepts derived from refugee trauma and
psychological distress literature, the author presents in this
paper group-based interventions grounded in cultural
competency, spirituality and strengths which will enable
social workers to provide efficient service delivery and
adopt a leadership role among service providers as advo-
cates for refugees.
Keywords Refugee trauma � Social work practice with refugees � Group-based interventions with refugees � Cultural competence � Spirituality
In order to provide quality service delivery for refugees,
social workers must deepen and broaden their compre-
hension of refugees’ traumatic migration experiences
beyond narrow formulations. To achieve this, a clear pic-
ture of the life journey taken by refugees needs to be
captured as they interact with their new environment. It is
essential that the voices of refugees be heard so that cli-
nicians can better understand refugee perspectives and
needs and thereby provide efficient intervention, particu-
larly as it pertains to trauma. The goal of this paper is to
provide social work practitioners with an in-depth under-
standing of refugees’ migration journey in order to make
the most appropriate decisions regarding refugee service
Migration Traumatic Experiences
A refugee is a person who has been forced from his or her
home and has crossed an international border for safety
(U. S. Department of State 2009). Since the end of World
War II, an estimated 42 million refugees in the world have
been forcibly uprooted from their country of origin due to
fear of persecution in their native country on account of
race, religion, nationality, membership in a particular
social group, or political opinion (UNHCR 2011). The
effects of refugees’ traumatic migration experiences are
immeasurable, long lasting, and shattering to both their
inner and outer selves (Steel et al. 2006). Three areas of
inquiry are germane to the discussion of refugee migration
traumatic experiences: pre-migration, migration and post-
migration. Knowledge of these areas will provide the
necessary understanding for social work practitioners
working with refugees.
Analysis of pre-migration literature from different
regions of the world revealed one constant thread: coloni-
zation. Colonizers brought with them their own social,
political and economic values and practices that trans-
formed the colonies into places they could understand.
Colonial imperialism replaced the native systems to the
point where it became increasingly difficult for natives to
survive in their own land. Colonization left countries
with social, political, cultural, economic and environmen-
tal chaos and oppression, with no organizational struc-
ture to intervene in the inter-racial, inter-ethnic and/or
M. George (&) School of Social Work, Virginia Commonwealth University,
P. O. Box 842027, Richmond, VA 23284, USA
Clin Soc Work J (2012) 40:429–437
inter-religious conflicts left behind, which were originally
created by colonizers as a means of control (Askeland and
Payne 2006; Hyndman 2000; George 2009; Mollica 2001;
White 2004). Economic inequality combined with demo-
graphic pressures and environmental crises have generated
ethnic conflict, civil war, terrorist threat and forced
migration (Richmond 2002). Refugees are forced to leave
home to escape danger with no destination in mind (Collins
During the migration period, refugees often move
between different countries and different refugee camps.
By this time, they are typically separated from their fam-
ilies and friends, creating intense anxiety and depression as
they realize all they have lost (Mollica 2006). Refugees’
lives remain in limbo until their legal challenges are sorted
out. During this time, refugees must confront the losses in
their life, as well as develop a new sense of hope for the
future (Hunt 2004). They are simultaneously required to
pass through the asylum-seeking process, which is inten-
sely re-traumatizing (Quiroga 2004).
Until refugees receive their status in the host country,
their lives are controlled by the United Nations, govern-
ments, refugee boards and non-profit agencies. Only after
recognition of their protection needs by the host govern-
ment are they entitled to refugee status, which carries
certain rights and obligations according to the legislation of
the receiving country (Crepeau et al. 2007; Steel et al.
2004). According to Steel et al. (2004), many countries
such as Australia have instituted mandatory detention for
all persons arriving without valid entry documents. Con-
sequently, a significant number of refugees and their chil-
dren have been held in detention for considerable periods
of time (Steel et al. 2004). Many cannot even think about
settling into society due to their ongoing legal battles for
permanent resident status (Burgess 2004). Refugee claim-
ants who do not have adequate identity documents to prove
their claim must face continuous interrogation by immi-
gration and naturalization authorities (Burgess 2004).
A study of psychological distress and migration trauma
among South Asian refugee claimants in Indian refugee
camps and in Canada (George 2009; 2012) found that those
refugee claimants in Canada, had higher scores for psy-
chological distress and trauma, likely due to the greater
degree of interrogation by immigration officials. Moreover,
this study revealed that refugee claimants experienced
re-traumatization each time they were exposed to interro-
gation by immigration boards in the host country. Fong and
Mokuau (1994) claim that the terms used with respect to
forced migrants—such as refugee claimants, asylum seek-
ers, and displaced persons—exemplify the complexity of
the immigration systems’ ascribing of status and conditions
of treatment. Furthermore, these statuses reflect the variety
of migration experiences and affect the ways in which
refugees settle into their new country.
Crepeau et al. (2007) and Steel et al. (2004) examined
the lack of tolerance in many of the refugee policies in host
countries. Numerous refugees are subjected to additional
traumatic experiences by policies which involve third party
agreement; for example, Canada will not grant refugee
status to persons who have been denied acceptance by a
country with which Canada has an agreement. Traumatic
experiences are also heightened by the burden of proof
policy whereby during the process of determining eligi-
bility, the onus is on the claimant to provide a medical
certificate to prove their claims of having been physically,
mentally or sexually abused. Often refugee review board
members’ lack of knowledge of international refugee law,
ambivalence toward traumatization, ignorance regarding
trauma and lack of understanding of refugees’ historical,
social, cultural and political backgrounds adversely affect
the decision-making process (Crepeau et al. 2007). Many
host country policies are highly Eurocentric and not
applicable to the diverse social, cultural and political nature
of individuals. These policies need to be expanded and
negotiated in order to provide meaning to human experi-
ences. Only after all these legal struggles are status-awar-
ded refugees eligible to receive settlement services, which
include language training, housing and securing identity
documents (Valtonen 2004).
Refugee-host relationships can create an atmosphere
that either aids or hinders the post-migration experiences of
refugees (George 2003). Refugees who have already sur-
vived pre-migration traumatic experiences in their country
of origin often experience particular difficulties, including
feelings of not being safe, during the resettlement period.
After the difficult experience of migration, refugees
approach the new land with mixed feelings (Cummings
et al. 2011; Finklestein and Solomon 2009).
During the initial post-migration period, refugees are
confronted by the loss of their culture—their identity, their
habits and their place. Every action that used to be routine
will require careful examination and consideration (White
2004). Culture shock will particularly affect those refugees
who did not think about, intend, or prepare for exodus, and
who were caught up in panic, hysteria or even adventure
(Mollica 2006; Mollica 2000). When refugees learn the
difficult realities about settlement services, their anxiety
and feelings of exclusion from their host country greatly
increases (George 2003). Nostalgia, isolation, depression,
anxiety, guilt, anger and frustration are so severe that many
refugees may want to go back to their country of origin
even though they fear the violent consequences (Mollica
2000). These factors tend to increase psychological prob-
lems (Ehntholt and Yule 2006; Mollica 2006; White 2004).
430 Clin Soc Work J (2012) 40:429–437
Most host countries’ refugee service agencies are funded
by the government and managed by non-profit and/or faith-
based organizations. Lack of coordination among refugee
settlement support systems often increases the difficulty
refugees face during the settlement process (Keung 2006).
An example from the Canadian system is the lack of
communication between the Immigration and Refugee
Board, which is under the federal government of Canada,
and the Ontario Health Insurance Program, which is under
the provincial government. To make things worse, refugees
are often not sure what help-seeking behavior is appro-
priate in the host country (Collins 1996). It is a general
observation that whatever behavior they put forward will
be assumed to be due to cultural difference. The tension
between culture as a basis of universal human experience
and culture as the primary basis of difference has important
social and political implications for social work practice
A phenomenon of particular importance with respect to
refugee behavior during resettlement is many refugees’
strong belief that they are owed something by someone
(Hyndman 2000). People from developing nations and/or
formerly colonized nations may have the impression that
Western governments provide social and economic ser-
vices to their citizens without any obligation (Reese 2004;
White 2004; Hyndman 2000). Since their persecutors are
unavailable, many refugees shift their demands to the host
government and the helping agencies. They may continu-
ally complain of not receiving enough (Hyndman 2000).
This discontent can create a feeling among refugees of
being controlled by agencies (Crosby 2006), causing them
to become aggressive and demanding of more and more
resources. At the same time, refugees are often stigmatized
by their own refugee cultural communities, as well as by
society in general, for utilizing social welfare services.
Compounding these issues, refugees may find themselves
isolated from the mainstream community due the inter-
section of racism, classism and sexism (White 2004; Fung
and Wong 2007; Levine et al. 2007). The toll of the
stressors refugees must face during the pre-migration,
migration, an post-migration periods on their physical and
mental wellbeing can be quite devastating.
Being a refugee is clearly a category of risk for physical
and psychological distress, because, surrounded within this
state is often-unspeakable violence (Keller et al. 2006).
Therefore, refugee health care issues can be complex and
wide-ranging. Many refugees have experienced torture in
their home land, which inflicts severe long-term physical
and psychological pain. The first interaction a new arrival
encounters with the host country health care system is a
refugee medical assessment conducted by health depart-
ments (Garrett 2006). Most often this medical evaluation is
the only health assessment completed after a refugee’s
exposure to torture (Miller 2004). The reason for this
assessment is to screen for health-related issues before
granting refugee status. Refugees typically inform health
care providers about their severe headaches, abdominal
pain and anxiety. In-depth investigations result in a
detailed report on their physical and psychological chal-
lenges. Injuries to the skin and muscular-skeletal system
from blunt trauma, burns and electrical shock, severe
internal bleeding due to rupture of the liver and spleen,
head trauma due to brain haemorrhage, and contraction of
the HIV virus are widespread physical conditions among
refugees (Quiroga 2004). Refugee women are especially at
risk for sexually transmitted diseases (STD’s) because of
the sexual violence that may have occurred during their
flight (LaFraniere 2005).
Torture survivors have significantly higher rates of
trauma symptomatology than other groups of traumatized
individuals (Mollica 2006; Porter and Haslam 2005). Many
volumes of research have been completed on refugee
trauma (Mollica et al. 1993, 2007; Mollica 2006; George
2009; Porter and Haslam 2005; Steel et al. 2004, 2006;
Schweitzer et al. 2011; White 2004). A systematic review
by Fazel et al. (2005) of 7,000 refugees showed that those
resettling in Western countries could be approximately ten
times more likely to have Post-Traumatic Stress Disorder
(PTSD) than age-matched general populations in those
countries. PTSD can result from undergoing or witnessing
torture, combat or violent personal assault as well as
structural barriers (Schweitzer et al. 2011; Westoby and
Ingamells 2010). Unique psychosocial problems such as
loss of social role and social networks, loss of property,
acculturation stress, anger, language problems and socio-
political factors can complicate the diagnosis of PTSD
In examining refugee mental health, one can clearly see
a difference of opinion among researchers and clinicians
regarding the effects of trauma. Some researchers state
unequivocally that there are traits in refugees that produce
specific symptoms in addition to migration stress, and that
these individuals are likely candidates to experience mental
health problems (Mollica 2006). Others believe that the
almost universal similarity of problems in refugees indi-
cates that severe trauma in and of itself is the cause of the
symptoms (Stein 1998). The controversy boils down to
situational response tendencies based on Refugee Theory.
Only a few studies have examined the considerable inter-
action between Refugee Theory and psychological distress.
A 2009 study provides an alternative perspective on
refugees’ pre-migration experiences and host country
Clin Soc Work J (2012) 40:429–437 431
settlement distress (George 2009). Using a refugee theo-
retical perspective as proposed by Kunz and Paludan, the
study on Sri Lankan Tamil refugees examined the inter-
action between typology of refugee (acute versus antici-
patory), typology of refugee settlement (new versus
traditional) and psychological distress. Acute refugees who
left their home country within a few days or hours of
disaster had a higher levels of psychological distress than
anticipatory refugees (George 2009). Silove et al.’s quan-
titative study (2007) showed that 85 % of refugees fleeing
from war-torn Vietnam during the 1970s made the decision
to leave their homeland 2 days to 2 hours before their
departure. Acute refugees may not have any resources or
any support from anyone, and must seek help more fre-
quently. However, due to their direct experience with
trauma, they may avoid contact with strangers out of fear
of re-traumatization, despite their need for immediate help
(Mollica 2006). Keller (1975) strongly argues that the
trauma of flight produces residual psychological states in
refugees that will affect their health for years to come.
Refugees who are late to flee usually endure the greatest
hardship and loss, and are therefore likely to come out of
the experience with residual characteristics of guilt, vul-
nerability and aggressiveness. There may be a perception
of loss of direction, role or purpose, leading to feelings of
pointlessness. These feelings lower a person’s self-esteem,
which, when coupled with social isolation or a feeling of
‘‘uniqueness,’’ can create a sense of alienation, existential
distress and severe demoralization (Briggs 2011). Antici-
patory refugees, on the other hand, are those who leave
their home country prior to the disaster, most often with
their families and personal resources intact. They tend to
seek less help than acute refugees (George 2009).
Another factor in the refugee experience that deserves
more attention from researchers is the typology of refugee
settlement—new and traditional. The key differences
between new and traditional refugees are that new refugees
are culturally, racially and ethnically vastly different from
their hosts, and are likely to lack kin or potential support
groups in their country of resettlement, whereas traditional
refugees are culturally and ethnically similar to their host,
and are likely to be welcomed and assisted by family and
friends who speak their language and can cushion their
adjustment (George 2009). It can be argued that new
country settlement will increase the psychological distress
of refugees, and therefore, an acute refugee in a new set-
tlement will experience an even higher level of psycho-
logical distress because of the pressure to adapt to a new
culture, new language and new social practices while also
dealing with their direct traumatic migration experiences
(George 2009). These specific circumstances should be
taken into account during practice interventions with ref-
ugees. In all situations, the challenge for the health care
professional is to approach refugee distress in a scientifi-
cally sound and systematic manner, providing the basis for
incorporating each refugee’s unique background into the
assessment, as well as in the interventions.
An important concept that is often missed or underes-
timated in refugee mental health research is resiliency. A
refugee’s life is most often marked by pain and oppression.
Martin et al. (2000) postulate that refugee mental health
challenges may be better understood within the context of
refugee resilience and coping capacity. Refugee resiliency
serves to counter the social construction of forced migrants
as victims without agency, and enables refugees, despite
their traumatic experiences, to succeed in the new society.
After the initial period of struggle, many refugees display
an impressive drive to rebuild their lives (Pipher 2001).
The key factor for refugee resiliency is the refugee expe-
rience itself, which may make them more aggressive and
innovative (Stein 1998; Gronseth 2006). The strength
gained from their traumatic migration journey enables
them to learn the new language and culture, and to achieve
a certain level of stability (George and Tsang 2000; Stein
1998; Weaver 2005; White 2004). A considerable degree
of integration occurs simply because life must go on. The
recovery of lost status continues, even though the pace may
be slow. Interventions should include a resiliency per-
spective that lends meaning to refugee suffering and places
a focus on their strengths and experiences. There may be
other factors that impact refugee psychological distress that
have yet to be uncovered. More research is needed in order
to better understand this issue and provide the most
effective treatments and services for the refugee
Implications for Social Work Practice
The social work profession has been changing continuously
to adapt to international influences. Social workers play a
central role on the team of professionals (medical, legal,
judicial) that collaboratively respond to refugee needs.
Social workers often initiate all other types of support
received by refugees. Analysis of the literature on this topic
leads to the conclusion that refugee interventions need
more coordination and consolidated attention from social
work practitioners. The best way to accomplish this is by
incorporating various interventions models. This researcher
proposes a group practice model of integrated under-
standing of refugee trauma to enable service providers to
respond productively to refugees’ needs. This represents a
departure from the fully medical model that has guided
most trauma research and interventions with refugees that
emphasizes provision of services such as psychotherapy
and psychiatric medication by highly trained professionals
432 Clin Soc Work J (2012) 40:429–437
(Mollica 2006). Group-based interventions grounded in
cultural competency and spirituality could more effectively
provide support to refugees.
Cultural competence is necessary for the provision of
care to clients with diverse values and beliefs, and of varied
race and ethnicity, as well for tailoring service delivery
to meet clients’ social, cultural and linguistic needs
(Betancourt et al. 2002). The relevance of understanding
race, ethnicity and culture in therapeutic interventions
cannot be underestimated. Gaining awareness of differ-
ences in cultural identity is hindered by viewing individ-
uals as singular and unitary. Recognition and awareness of
one’s own culture, gender, race, class and ethnicity in
relation to that of refugee clients is crucial for the effective
treatment of this client population (Campinha-Bacote
1999). Social workers’ knowledge on their own biases,
prejudices and subjective interpretations of others that are
borne from different life experiences helps to prevent any
transference or counter-transference. The degree to which
the social worker can have a multicultural perspective will
affect the degree to which he or she can understand refugee
clients’ points of view, barriers, and strengths and incor-
porate effective interventions.
Being culturally competent also requires that the social
worker recognize the power dynamic between himself/
herself and the refugee client. The quality of attitude and
engagement a social worker brings to clinician-client
interactions is as important as cross-cultural knowledge in
facilitating culturally sensitive and culturally comprehen-
sive care (Wheat 2005). In today’s post-colonial society,
some social workers use information and resource control,
expertise or perception of expertise, and/or structural
legitimacy as a way to exert power within the helping
profession. When working with refugees, social workers
should use appropriate relationship strategies for inter-
vention negotiation, rather than using persuasion,
exchange, reinforcement, consultatioin, pressure, or coali-
tion. Until recently, the explicit objective of intervention
techniques has been the imposing of the cultural norms of
the dominant society on minority clients (Sodowsky et al.
1997). By using intervention negotiation instead, social
workers can combine mainstream and cultural interven-
tions. In addition, intervention negotiation also fosters
empowerment, an artificial factor in intervention with
historically oppressed refugees. In this way, the social
worker can work together with the client and become more
Social workers should also be able to address discrep-
ancies in the physical appearance of refugees and under-
stand the importance of providing interventions at an early
stage. Refugees may physically appear to be healthy, yet
there may be unobservable daily stressors. Service models
should be developed to not only deal with refugee trauma
and refugee settlement needs, but also to emphasize the
major contextual issues affecting the daily stressors of
refugees. Due to refugees’ diverse backgrounds and expe-
riences, they may be either hesitant to seek help or not be
given the opportunity to express their concerns. As men-
tioned earlier, refugees often demand resources based on
their belief that they are owed support by the host country.
In addition, refugees may also be confused about how to go
about seeking help in the new country. As a result, social
workers need to consider refugees’ contextual informa-
tion—including whether they are acute/anticipatory
(Kunz 1981), traditional/new (Paludan 1981), and their
host country status—when analyzing their help seeking
Service models should include non-Western interven-
tion methods consistent with the values and traditions of
refugee communities (Lacroix and Sabbah 2011). Under-
standing refugees requires an iterative process involving
dialogue between social work practitioner and refugee
clients. Social workers need to address the oppression
faced by refugees, which is caused by society norms and
invisible pressures. One way of implementing direct social
work practice is through group interventions. Loewy et al.
(2002) contend that traditional one-on-one counseling
conducted from a Western perspective view is not suffi-
cient for working with refugees. When working with ref-
ugees in group intervention, an appreciation for traditional
ceremonies within the cultural context of the group, along
with an understanding of main stream societal interven-
tions, can enhance the therapeutic process and build rap-
port. The ability to understand the way the world works
from the clients’ point of view enables the group leader to
develop trust and connect with group members (Loewy
et al. 2002). Asner-Seif and Feyissa (2002) state that the
benefit of using group counseling is that it can alleviate
the sense of isolation many refugee clients feel during the
acculturation process, and offer a support network within
the group. This creates a safe place for refugees to explore
experiences, creates universality amongst them, and gives
them a sense that they are not alone. In addition, social
workers using group counseling with refugees should
incorporate rituals that come from the refugees’ culture,
use a combination of intervention techniques that are cul-
turally appropriate, and educate the refugees about their
experiences by discussing issues such as trauma, women
and trauma, and psychological distress (Asner-Seif and
Feyissa 2002; Loewy et al. 2002; Norsworthy and
Khuankaew 2004; Stepakoff et al. 2006; Weine et al.
In addressing the needs of refugee clients, social
workers may be unsure about the right clinical intervention
for addressing differences in values, beliefs, race, culture
and expectations. Regardless of the approach ultimately
Clin Soc Work J (2012) 40:429–437 433
pursued, it is often accompanied by doubt that it may lead
to miscommunication, and thus they struggle to find the
language that will most effectively speak to issues of
oppression and stigma faced by mentally ill refugees. In
this situation, the incorporation of spirituality and strengths
perspectives may lend insight into the refugee client-social
worker interaction and help overcome the differences
between clinicians and clients.
A strengths perspective on mental illness serves to
counter social constructions and advances the success of
individuals with mental illness in society. It is closely tied
to the concept of resiliency. The lives of mentally ill
individuals are often filled with pain and suffering, yet one
of their major strengths is their resiliency (George 2009).
Refugees gain durability from the experiences they
undergo before resettling (Gronseth 2006). As Harter
(1996) suggests, overestimating one’s abilities (within
reason) is associated with positive mental health. However,
recognizing refugees’ internal strengths should not lead to
underestimating the difficulties they continue to face in
their new country. Nevertheless, it is important for social
workers to realize the necessity of maximizing the resil-
iency power of each refugee. Research by Finklestein and
Solomon (2009) with Ethiopian refugees found that the
challenge is to identify factors and mechanisms that sup-
port resiliency and prevent vulnerability. These factors
could inform the development of intervention programs
and promote successful absorption, as well as increase the
well-being of refugees (Finklestein and Solomon 2009).
Most traditional intervention strategies focus on problem
identification rather than simultaneously recognizing the
strengths of these individuals in overcoming their pre-
migration traumatic events. Instead of only addressing
acculturation issues, poverty, unemployment, racism and
mental illness, it is equally important that interventions
deal with pre-migration traumatic experiences and the
strength gained from these experiences to deal with hard-
ships and successfully settle in the new host country
(Gronseth 2006; George 2009).
The courage and strength of refugee clients to seek help
for their mental illness and to integrate into society, despite
the stigma they may experience from their own commu-
nity, needs to be recognized. Rapp (1998) views the
community as an oasis of resources. For refugees with
distress, community resources include family and friends
from their country of origin, the collective insight and
independence gained during their migration journeys, and
the different meanings and inspirations brought with them.
Family involvement is common in many refugee commu-
nities, and often proves valuable to social workers in times
of crisis. Some view it as over-protection, while others see
it as continuing care and support by families. During social
work intervention with refugees and their families, it is
crucial that service models emphasize the importance of
social, historical, cultural and political awareness. Fur-
thermore, a strengths-based approach must focus on the
complex interplay of risks and strengths among individual
family members, the family as a unit, and the broader
neighborhood and environment. This will empower clients
to take ownership of their treatment, interactions with
family members, and connections to social supports.
It would be misleading to restrict spirituality to a precise
definition. Rather, it may best be described through a cluster
of related themes. Spirituality is the soul of the total process
of human life. It is the wholeness of being human. Spiritu-
ality helps social workers realize there are many different
experiences that shape one’s life, and the greater this
awareness, the more tolerant they will become of differences
and diversity (Langer and Moldoveanu 2000). Spirituality
relates to a person’s search for a sense of meaning and ful-
filling moral relationships between self, others and the uni-
verse. This critical self-reflection enables social workers to
listen more carefully to clients’ distress, recognize their own
errors, refine their technical approach, arrive at evidence-
based decisions and clarify their values, and enhance their
practice with compassion, competence, presence and insight
(Epstein 1999). Spirituality-based social work practice
promotes interconnectedness with clients. Refugee clients
who feel the presence of the social worker during clinical
interactions are more likely to feel connected and thus per-
haps more willing to disclose symptoms or interpretations
not obviously evident (Wheat 2005). Inherent within each
client are diverse experiences. In the case of refugee clients,
they include pre-migration, migration and post-migration
struggles, including unemployment, acculturation, adjust-
ment and culture shock. These experiences, however, will
affect each client differently. Spirituality aids social workers
in accepting and looking beyond the differences between
self and client by focusing on how and why each feels as they
do, their underlying needs and their desired outcome,
thereby enhancing the client’s feeling that the social worker
is totally present for them. Broadening the clinical scope to
incorporate spirituality may help social workers realize the
diversity of refugees, the complexities of their individual
experiences, and the influence of varied issues on their
mental health (Dominelli, 1988). By focusing attention on
the present moment of client interaction and reserving
judgment on clients’ diverse culture, race, experiences,
practices, beliefs and values, clinicians can cultivate a longer
lasting interconnection with their immigrant clientele.
Addressing spirituality in group counseling can help the
refugee client not only relate to the social worker, but also
to other refugees. Incorporating spirituality into group
counseling can help clients ‘‘connect with the other group
members at a deeper and more satisfying level’’ (Cornish
and Wade 2010). In groups with refugees from various
434 Clin Soc Work J (2012) 40:429–437
places, cultures, and experiences, discussing spirituality
may give some clients a safe way to explore how religion
and/or spirituality affected the conflict that forced them to
leave their homes, the migration process, and acculturation
in their host country. At the same time, exploring spiritu-
ality in group counseling can also help to identify and
highlight the ways that spirituality is a source of strength
and resilience for some clients. By addressing spirituality,
therapists might help clients to access the beneficial ele-
ments afforded by their spiritual beliefs, and practices.
Furthermore, it might help clients to apply these strengths
to their present concerns in a way that facilitates healing
and growth (Cornish and Wade 2010).
Cornish and Wade (2010) assert that ‘‘the use of ritual or
ceremony could be a particularly powerful spiritual tool
when working with counseling groups composed of a
specific cultural group. Practitioners leading such groups
could survey members to identify common spiritual rituals
or ceremonies that could be incorporated in the group
process. Being able to engage in a shared practice could
serve to strengthen the bond among members.’’ Loewy
et al. (2002) used an African coffee ceremony during group
counseling with Ethiopian and Eritrean female refugees,
calling it the ‘‘Kafa Intervention’’. This coffee ceremony is
an indigenous form of spiritual and psychological healing
that has been part of East African culture for over
3,000 years (Loewy et al. 2002). The Kafa Intervention
uses this ceremony to help the women practice altruism,
serving and helping each other by listening and offering
support. This process helps to clarify, paraphrase, sum-
marize, and reflect back to the members of the group both
their personal stories and the common themes emerging in
the group. Group counseling incorporating cultural cere-
monies allows the group members to feel heard and
understood. In general, a culturally grounded group coun-
seling process will help group members to express them-
selves and to disclose intimate details about their lives.
A study by Weine et al. (2008) used a similar Coffee and
Family Education and Support (CAFES) intervention to
‘‘analyze the effect of a multiple-family group on increasing
access to mental health services for refugees with PTSD. In
order to further bridge cultural gaps, they utilized facilitators
who were all Bosnian refugees themselves, were fluent in
Bosnian and English, were members of the Chicago Bosnian
community, and had experiences doing group work (e.g., as
teacher, nurse, organizer). In this study, subjects were
encouraged to invite any family members over 17 years old
to participate in the intervention, empowering clients to
interact with family members and foster their support sys-
tem. This family support approach gives families a place and
space to discuss and explore issues pertaining to being a
refugee, which can be especially helpful in addressing
intergenerational migration stress.
The Weine et al. (2008) study also emphasized the
importance of working with families, and specifically
children. In some instances, social workers should work
with adults and children separately. The social worker may
choose to meet with the family as a whole for one or two
sessions to build rapport and to assess the family as unit.
However, separating the children from the adults may help
the social worker to address multigenerational transmission
issues that affect the family as a whole, but particularly the
children. The definition of child can be different for each
refugee community. Thus, it is important that the social
worker be culturally competent to know what constitutes
childhood in a particular family’s culture. The National
Technical Assistance and Evaluation Center for Systems of
Care (NTAECSC) believes that it is critical to incorporate a
strengths perspective in order to increase the safety, per-
manency, and well-being of children and their families
(2008). This approach acknowledges each child’s and
family’s unique set of strengths and challenges, and
engages the family as a partner in developing and imple-
menting the service plan (NTAECSC 2008). Instead of
focusing on what is wrong with refugee children, a
strengths perspective emphasizes each child’s strengths—
for example, the ability to act as a cultural interpreter
between family members and institutions.
One way in which social workers can work effectively
with refugee children is through art-based therapy. An
example of this would be the Hope Project, a qualitative
study incorporating an after-school program in Canada to
provide a strengths-based program for refugee children
between ages 6 and 18 deemed to be in high-risk, multiple-
barrier communities (Yohani 2008). The refugee children
participated once a week for 10 weeks in a variety of
psychosocial activities with the goal of creating a safe and
comforting environment in order to support healing,
growth and adjustment to Canada (Yohani 2008). The
project utilized photography as a form of expression,
allowing the children to step away from the parameters of
traditional interventions and explore hope in the various
contexts of their lives. The children’s photographs depicted
how they see hope in themselves, other people, and the
environment. The pictures told the stories of the children’s
lives. Projects combining strengths- and art-based therapy
are very useful in addressing refugee issues, and particu-
larly those of children; in doing so, they help bring to the
surface the resiliency these children have developed
through their refugee experiences.
This paper lays the foundation for informing social workers
on complex refugee migration experiences, and possible
Clin Soc Work J (2012) 40:429–437 435
group-based intervention strategies. Developing group-
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social workers’ ability to continuously learn about different
human experiences from their refugee clients, as well as
from themselves. As we move towards an increasingly
pluralistic and multicultural society, social workers are
among those best equipped to deliver the needed care and
to empower people from all backgrounds to lead con-
nected, healthy lives.
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Dr. Miriam George is an Assistant Professor at the School of Social Work, Virginia Commonwealth University. Dr. George has fifteen
years of clinical social work practice experience in different mental
health settings. Dr. George’s research interests include refugee trauma,
clients with severe mental illness, and international social work.
Clin Soc Work J (2012) 40:429–437 437
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- Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice
- Migration Traumatic Experiences
- Psychological Distress
- Implications for Social Work Practice
- Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice