Responding to migration and upheaval

Responding to migration and upheaval


Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice

Miriam George

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

DOI 10.1007/s10615-012-0397-y



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

(Hyndman 2000).

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.

Psychological Distress

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

(Mollica 2000).

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

culturally competent.

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-

based interventions grounded in cultural competency,

spirituality and strengths-based practice encourages social

workers to seek to understand, accept, and respect different

cultures and values, and to recognize how they relate to

their clients’ needs. Successful service delivery depends on

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.


Askeland, G. A., & Payne, M. (2006). Social work education’s

cultural hegemony. International Social Work, 49(6), 731–743. Asner-Seif, K., & Feyissa, A. (2002). The use of poetry in

psychoeducational groups with multicultural-multilingual cli-

ents. Journal for Specialists in Group Work, 27(2), 136–160. Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural

competence in health care: Emerging frameworks and practical

approaches. The Commonwealth Fund. Briggs, L. (2011). Demoralization among refugees: From research to

practice. Social Work in Mental Health, 9(5), 336–345. Burgess, A. (2004). Health challenges of refugees and immigrants.

Refugee Research, 2, 3–4. Campinha-Bacote, J. (1999). A model and instrument for addressing

cultural competence in health care. Journal of Nursing Educa- tion, 38(5), 203–207.

Collins, J. (1996). An analysis of the voluntariness in refugee repatriation in Africa. University of Manitoba Press.

Cornish, M., & Wade, N. (2010). Spirituality and religion in group

counseling: A literature review with practice guidelines. Pro- fessional Psychology: Research and Practice, 41(5), 398–404. doi:10.1037/a0020179.

Crepeau, F., Nakache, D., & Atak, I. (2007). International migration:

Security concerns and human rights standards. Transcultural Psychiatry, 44(3), 311–337.

Crosby, A. (2006). The boundaries of belonging: Reflections on

migration policies into the 21st century. Inter Pares Occasional Paper, 7, 14–16.

Cummings, S., Sull, L., Davis, C., & Worley, N. (2011). Correlates of

depression of older Kurdish refugees. Social Work, 56(2), 159–168.

Dominelli, L. (1988): Anti-racist social work (2nd ed. in 1997; 3rd ed. in 2007). London: Macmillan.

Ehntholt, K., & Yule, W. (2006). Assessment and treatment of

refugee children and adolescents who have experienced war-

related trauma. Journal of Child Psychology and Psychiatry and Allied Disciplines, 47(12), 1197–1210.

Epstein, R. M. (1999). Mindful practice. Journal of American Medical Association, 282(9), 833–839.

Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious

mental disorder in 7000 refugees resettled in western countries:

A systematic review. The Lancet, 365, 1309–1314. Finklestein, M., & Solomon, Z. (2009). Cumulative trauma, PTSD

and dissociation among Ethiopian refugees in Israel. Journal of Trauma and Dissociation, 10(1), 38–56.

Fung, K., & Wong, Y. R. (2007). Factors influencing attitudes toward

seeking professional help among east and southeast Asian

immigrant and refugee women. International Journal of Social Psychiatry, 53(3), 216–231.

Fong, R., & Mokuau, N. (1994). Not simply ‘‘Asian Americans’’:

Periodical literature reviewon Asians and Pacific Islanders.

Social Work, 39(3), 298–307. Garrett, K. (2006). Living in America: Challenges facing new immigrants

and refugees. Retrieved from cations/other/Immigration_Report.pdf.

George, U. (2003). A needs based model for settlement service

delivery for newcomers to Canada. International Social Work, 45(4), 465–480.

George, M. (2009). Sri Lankan Tamil diaspora: Contextualizing pre- migration and post-migration traumatic events and psycholog- ical distress. Toronto: University of Toronto Press.

George, M. (2012). Sri Lankan Tamil refugee migration experiences:

A qualitative analysis. International Journal of Culture and Mental Health. doi:10.1080/17542863.2012.681669.

George, U., & Tsang, A. K. T. (2000). Newcomers to Canada from

former Yugoslavia—Settlement issues. International Social Work, 43(3), 381–393.

Gronseth, A. S. (2006) Experiences of tensions in re-orienting selves:

Tamil refugees in Northern Norway seeking medical advice.

Anthropology & Medicine, 13(1), 77–98. Harter, S. (1996). Historical roots of contemporary issues involving

self-concept—handbook of self-concept. New York, NY: Wiley. Hunt, N. (2004). Public health or human rights? International Journal

of Drug Policy, 16(1), 231–237. Hyndman, J. (2000). Managing differences: Gender and culture in

humanitarian emergencies. In J. Hyndman (Ed.), Managing displacement: Refugees and the politics of humanitarianism. Minneapolis, MN: University of Minnesota Press.

Keller, A., Lhewa, D., Rosenfield, B., Sachs, E., Aladjem, A., Cohen, I.,

et al. (2006). Traumatic experiences and psychological distress in

an urban refugee population seeking treatment services. Journal of Nervous and Mental Disease, 194(3), 188–194.

Keller, S. L. (1975). Uprooting and social change: The role of refugees in development. Delhi: Manohar Book Service.

Keung, N. (2006). Board endorses ‘don’t ask, don’t tell’. Toronto Star, May 26. Accessed from: node/405.

Kunz, E. (1981). Exile and resettlement: Refugee theory. Interna- tional Migration Review, 15, 42–51.

Lacroix, M., & Sabbah, C. (2011). Posttraumatic psychological distress

and resettlement: The need for a different practice in assisting

refugee families. Journal of Family Social Work Journal, 14(1), 43–53.

LaFraniere, S. (2005). AIDS now compels Africa to challenge

‘‘widows’ cleansing’’. New York Times, November.

Langer, E. J., & Moldoveanu, M. (2000). The construct of mindful-

ness. Journal of Social Issues, 56(1), 1–9. Levine, J., Esnard, A., & Sapat, A. (2007). Population displacement

and housing dilemmas due to catastrophic disasters. Journal of Planning Literature, 22(1), 3–15.

Loewy, M. I., Williams, D. T., & Keleta, A. (2002). Group counseling

with traumatized East African refugee women in the United

States: Using the Kaffa ceremony intervention. Journal for Specialists in Group Work, 27(2), 173–191.

Martin, S., Jaranson, J., & Ekblad, S. (2000). Refugee mental health:

Issues for the new millennium. Centre for Mental health

Services. Washington, DC: Supt. of Documents, U.S. Govern-

ment Printing Office.

Miller, A. (2004). Sexuality, violence against women, and human

rights: Women make demands and ladies get protection. Health and Human Rights, 7(2), 16–47.

436 Clin Soc Work J (2012) 40:429–437




Mollica, R. F. (2000). Responding to migration and upheaval’. In G.

Thornicroft & G. Szmukler (Eds.), Textbook of community psychology 37 (pp. 439–551). Oxford: Oxford University Press.

Mollica, R.F. (2001). Assessment of trauma in primary care. Journal of the American Medical Association, 285(9), 1213.

Mollica, R.F. (2006). Healing invisible wounds: Paths to hope and recovery in a violent world. San Diego, CA: Harcourt Books.

Mollica, R.F., Donlan, K., Tor, S., Lavelle, E.C., Frankel, M., &

Blendon, R.J. (1993). The effects of trauma and confinement on

functional health and mental health status of Cambodians living

in Thailand-Cambodia border camps. Journal of the American Medical Association, 270, 581–586.

Mollica, R.F., Shoeb, M., Weinstein, H. (2007). ‘The Harvard Trauma

Questionnaire: Adapting a cross-cultural instrument for measur-

ing torture, trauma and posttraumatic stress disorder in Iraqi

refugees’. International Journal of Social Psychiatry, 53(5), 447–463.

National Technical Assistance and Evaluation Center for Systems of

Care. (2008). A closer look: An individual, strengths-based approach in public child welfare driven systems of care. VA: Fairfax.

Norsworthy, K. L., & Khuankaew, O. (2004). Women of Burma

speak out: Workshops to deconstruct gender-based violence and

build systems of peace and justice. Journal for Specialists in Group Work, 29(3), 259–283.

Paludan, A. (1981). Refugees in Europe. International Migration Review, 15(1/2), 69–73.

Pipher, M. (2001). A lesson from the world’s refugees. Monitor on Psychology, 32(11), 15.

Porter, M., & Haslam, N. (2005). Predisplacement and postdisplace-

ment factors associated with mental health of refugees and

internally displaced persons. Journal of the American Medical Association, 294(5), 646.

Quiroga, B. (2004). Health challenges of refugees and immigrants.

Refugee Reports, 25(2), 1–20. Rapp, C. A. (1998). The strengths model: Case management with

people suffering from severe and persistent mental illness. New York, NY: Oxford University Press.

Reese, L. (2004). Cross-generational and transnational perspectives

on schooling in Mexican immigrant families’ narratives. The Journal of Latino-Latin American Studies, 1(2), 93–112.

Richmond, A. H. (2002). Globalization: Implications for immigrants

and refugees. Ethnic and Racial Studies, 25(5), 707–727. Schweitzer, R., Brough, M., Vromans, L., & Asic-Kobe, M. (2011).

Mental health of newly arrived Burmese refugees in Australia:

Contributions of pre-migration and post-migration experience.

The Royal Australian and New Zealand College of Psychiatrists, 45(4), 299–307.

Sodowsky, G. R., & Lai, E. W. M. (1997). Asian immigrant variables

and structural models of cross-cultural distress. In A. Booth

(Ed.), International migration and family change: The experi- ence of U.S. immigrants (pp. 211–234). NJ: Erlbaum.

Steel, Z., Momartin, C., Bateman, A., Hafshejani, D. M., Silove, D.,

& Everson, N. (2004). Psychiatric status of asylum seeker

families held for a protracted period in a remote detention centre

in Australia. Australian and New Zealand Journal of Public Health, 28(6), 527–536.

Steel, Z., Silove, D., Brooks, R., Momartin, S., Alzuhairi, B., &

Susljik, I. (2006). Impact of immigration detention and tempo-

rary protection on the mental health of refugees. British Journal of Psychiatry, 188, 58–64.

Stein, B. (1998). The refugee experience: Defining the parameters of a

field of study. International Migration Review, 15(1–2), . Stepakoff, S., Hubbard, J., Katoh, M., Falk, E., Mikulu, J., Nkhoma,

P., et al. (2006). Trauma healing in refugee camps in Guinea: A

psychosocial program for Liberian and Sierra Leonean survivors

of torture and war. American Psychologist, 61(8), 921–932. U. S. Department of State. (2009). Bureau of population, refugees,

and migration. Retrieved from UNHCR. (2011). Total population of concern to UNHCR. Retrieved


Valtonen, K. (2004). From the margin to the mainstream: Concep-

tualizing refugee settlement processes. Journal of Refugee Studies, 17(1), 70–96.

Weaver, H. (2005). Reexamining what we think we know: A lesson

learned from Tamil refugees. Affilia, 20(2), 238–245. Weine, S., Kulauzovic, Y., Klebic, A., Besic, S., Mujagic, A.,Muz-

urovic, J. et al. (2008). Evaluating a multiple-family group

access intervention for refugees with PTSD. Journal of Marital and Family Therapy, 34(2), 149–64.

Westoby, P., & Ingamells, A. (2010). A critically informed perspec-

tive of working with resettling refugee groups in Australia.

British Journal of Social Work, 40, 1759–1776. doi:10.1093/ bjsw/bcp084.

Wheat, P. (2005). Mindfulness meditation: promoting cultural

competency. In S. C. Culfield (Ed.), Spectrum (pp. 35–37). Massachusetts: Chickering Group.

White, J. (2004). Post-traumatic stress disorder: The lived experience of immigrant, refugee and visible minority Women. Canada: Prairie Women’s Health Centre of Excellence.

Yohani, S. C. (2008). Creating an ecology of hope: Arts-based

interventions with refugee children. Child & Adolescent Social Work Journal, 25(4), 309–323.

Author Biography

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




Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.


  • c.10615_2012_Article_397.pdf
    • Migration Traumatic Experiences and Refugee Distress: Implications for Social Work Practice
      • Abstract
      • Migration Traumatic Experiences
      • Psychological Distress
      • Implications for Social Work Practice
      • Conclusion
      • References

"Is this question part of your assignment? We can help"