11. Challenges and Critical Issues1
11
Innovations, Challenges,
and Critical Issues in the Development
of Ecological Mental Health
Interventions With Refugees
______
Lisa M. Rasco and Kenneth E. Miller
The projects outlined in this volume represent some of the most creative and challenging mental health and psychosocial intervention work with refugees today. The contributing authors describe a wide range of ecological interventions designed to promote the psychological well-being of refugees in a diversity of settings—from refugee camps within or along the tenuous borders of developing countries to more permanent resettlement communities in nations such as the United States. Although the methodologies and theoretical underpinnings of the interventions vary, all of the projects are guided by a community-based, ecological model, which emphasizes drawing on community strengths and resources and involving community members as stakeholders and active collaborators in the development and implementation of psychosocial interventions.
In this chapter, we step back and offer reflections on a number of critical issues that arose as common themes across this body of work. We first note the innovations, strengths, and ways the various projects exemplify the principles of ecological interventions discussed in chapter 1 (see summary in Box 11.1). Yet, even as we look to the work of the contributors for inspiration and guidance, their candid discussions of obstacles they’ve encountered make it clear that the field is not without challenges. Therefore, we next outline some common difficulties researchers and practitioners face when conducting ecologically oriented intervention work with refugees. We hope that highlighting these critical issues will help lay the groundwork for the development and sharing of constructive solutions. Toward these ends, we discuss the importance of developing well-elaborated models of risk and protection to guide intervention work, and offer a broad organizational frame to aid this endeavor. Next, we discuss the need for better conceptualizations of distress and well-being at the family and community levels, as well as the need for a clear articulation of intervention goals and the difficulties involved in choosing these goals when a wide range of material and psychosocial needs exist. We also consider the importance of clearly articulating linkages between models of risk and the design of psychosocial interventions, as well as the challenges involved in program evaluation. Finally, we discuss conceptual and practical impediments to creating culturally sensitive interventions that blend Western and local approaches to healing, and offer ideas about how to address these obstacles.
Although this chapter is not meant to cover all of the critical issues facing the field of ecological approaches to refugee mental health and well-being, our intention is to organize and frame a number of key issues as important foci for ongoing discussion and to stimulate critical reflection on how these challenges might be addressed in the diverse settings in which they arise.
Strengths and innovations
Although the theoretical foundations and methodologies of the projects in this volume vary, all of the interventions adhere in important ways to the basic tenets of an ecological approach to intervention (see Box 11.1). For example, in accordance with the first ecological principle, a number of the interventions involve the creation or alteration of community settings to support and build local capacity and enhance people’s ability to adapt to existing settings. Goodkind, Hang, and Yang (chap. 9) describe how their “learning circles” intervention for Hmong refugees built local capacity by bringing together resources from the University and Hmong communities to strengthen the skills of, and empower, all community participants. Tribe and colleagues (chap. 5) describe the training of women, all of whom had participated in empowerment programs for war widows in Sri Lanka, to work at local extension offices and become “be-frienders” to other women in their communities—thereby extending the reach of their psychosocial intervention. Weine and colleagues (chap. 8) describe the success of a family-oriented, psychosocial support and resource intervention, which helped ease the transition of Bosnian and Kosovar refugees to their new lives in the United States. These projects not only created settings for group learning, empowerment, and psychological support, but also enhanced participants’ ability to adapt to their new settings by providing crucial information and education about services, resources, and rights in their communities.
In addition, true to the second ecological principle, all of the projects involved active collaboration between project developers, staff, and community members in intervention design and implementation. Rather than imposing a ready-made agenda on refugee communities, a number of project teams drew on methods that prioritized communities’ self-identified needs. For example, Tribe and colleagues (chap. 5) conducted “fact-finding missions”, during which each community’s specific needs were identified by local community members and service organizations working in various Sri Lankan refugee camps, prior to the development of empowerment groups for war widows living in those camps. The results of these inquiries significantly shaped the agendas for the various women’s empowerment groups. Similarly, other chapter authors describe the employment of needs assessments, focus groups, meetings with community elders, and so forth to establish the needs of communities and elicit the support of key community members to help design and implement mental health interventions to address those needs.
As Ecological Principle 3 states, an ecological approach to intervention prioritizes prevention over treatment, and accordingly, the projects in this volume aimed to build local capacity to address difficulties and decrease the probability of long-term, chronic suffering among community members impacted by the stresses of forced displacement. Rather than primarily directing resources to set up Western-style, expert run clinics for the treatment of psychopathology, many projects promoted the reestablishment of local healing and psychosocial support networks, as well as community activities and meeting places to provide safe, supportive, and predictable environments to promote community healing. However, it is clear that many refugees and displaced persons do experience high levels of war-related and displacement-related distress, and contributors such as Hubbard and Pearson (chap. 3) and van de Put and Eisenbruch (chap. 4) illustrate innovative ways in which treatment-focused interventions can be culturally appropriate, utilize community resources, and strive to empower communities by helping them develop greater capacity to address their own mental health needs. Stated otherwise, while the ecological model prioritizes prevention over treatment, it in no way negates the importance of treatment for individuals experiencing significant distress. The challenge is to develop treatment-focused interventions that are contextually grounded, empowering in nature, and that utilize local resources rather than rely on scarce outside professionals.
Along these lines, several projects incorporated local approaches to healing (Ecological Principle 4), a topic we discuss in some detail in the final section of this chapter. Also, to increase the likelihood of program utilization and sustainability, many projects were integrated into familiar and nonstigmatized community settings (Ecological Principle 5), such as schools (Kostelny and Wessells, chap. 6), homes (van de Put and Eisenbruch, chap. 4) neighborhood community centers (Weine et al., chap. 8) and various community meeting places within or adjacent to refugee camps or zones of conflict (Buitrago Cuéllar, chap. 7; Hubbard and Pearson, chap. 3; Tribe and colleagues, chap. 5; and Wessells and Monteiro, chap. 2).
Finally, the interventions in this volume focused on strengthening the capacity of communities to cope with and heal from displacement-related stressors, as well as the effects of violence and war-related loss (Ecological Principle 6). For example, Hubbard and Pearson (chap. 3) described the training of local psychosocial agents to address the mental health needs of psychologically distressed Sierra Leonean refugees unable to take advantage of relief services, and Wessells and Monteiro (chap. 2) described how community members and local service providers were trained to facilitate normalizing and healing activities for thousands of internally displaced children and youth in Angola, and how a mobile unit of intensively trained local staff traveled to various communities to provide ongoing supervision and support for psychosocial interventions. In a similar vein, the staff of Corporación AVRE (chap. 7) trained local community members to work as Popular Therapists and Multipliers of Psychosocial Actions with a broad range of distressed communities affected by violent conflict and displacement in Columbia. While initially providing on-going supervision to the local staff doing the front-line work, the goal of these projects has been to train local staff who do not rely heavily on outside mental health experts, thereby building local capacity to manage necessary psychosocial intervention work. Indeed, Hubbard and Pearson describe how local psychosocial agents (PSAs) continued to provide assistance to distressed Sierra Leonean refugees even after a rebel attack forced them to relocate and necessitated the temporary withdrawal of expatriate project staff providing supervision and training. They also note that the PSAs began to train other community members to provide psychosocial assistance (spontaneously “training trainers”) and were eager to continue a new phase of their work during the process of repatriation. These chapters provide promising examples of how trained community members can provide ongoing, dependable psychosocial support to their communities even under very difficult circumstances.
Clearly, the field is rich with dedicated and creative individuals coordinating innovative programs true to the principles of an ecological approach to mental health intervention. Yet, it is also clear from the contributors’ descriptions of their projects that there remain notable challenges facing the field—and in the following sections, we elaborate a number of these critical issues in the hopes of stimulating discussion and ideas about how to address some of the challenges involved in designing, implementing, and evaluating ecological interventions for and with refugee communities.
Challenges and future directions
The Need for Elaborated Risk Models
An important endeavor in the field of refugee mental health, as in any field of health-related research and intervention, is the development and elaboration of risk models[1] that guide the design, implementation, and evaluation of psychosocial interventions. As Kostelny and Wessells (chap. 6) suggest, we can look to risk and resilience theory from the fields of public health and developmental psychopathology to inform the development of risk models, which organize our understanding of how risk factors[2]—such as the multiple stressors commonly associated with the refugee experience—in the presence or absence of protective factors, translate into psychosocial outcomes at the individual, family, and community levels. A number of pre- and post-migration risk factors—such as loss of or separation from family members, lack of shelter, torture, imprisonment, poverty, discrimination, exposure to combat, sexual assault, and so forth—have been associated empirically with increased psychosocial distress in a range of refugee populations (de Jong, 2002; Steel & Silove, 2000). Research and theory indicate that the greater the number, severity, and chronicity of risk factors experienced by individuals or communities, the greater the probability of the expression and severity of adverse psychosocial outcomes associated with those risk factors (Coie et al., 1993; Garbarino & Kostelny, 1996; Rutter, 1979; Rutter & Garmezy, 1983).
A well-articulated risk model, based on empirical data or sound theory, offers a theoretical “roadmap” outlining paths between risks and psychosocial outcomes of interest, and, ideally, delineating specific mechanisms (including mediating or moderating variables) linking risk to outcome. In the design of interventions, these models help us make predictions, visualize potential intervention points along the path from risk to outcome, and—during the evaluation phase—allow us to pinpoint what is or is not working in our interventions by drawing attention to discrepancies between predictions from the model and actual outcome data. Well-elaborated risk models, therefore, advance the science of prevention and intervention by helping us continually hone and correct our guiding models, improve the design of interventions, and even design models to guide the extension of successful interventions to new populations. In a nutshell, risk models identify clearly which problems need to be addressed; specify the factors that increase the likelihood of people developing particular problems; specify the pathways by which risk factors impact people’s well-being; and ideally, specify variables that either increase or reduce people’s vulnerability to developing the target problems in the face of the risk factors.
A comprehensive risk model for understanding the impact of trauma, loss, and displacement-related stressors on refugee mental health and well-being would account for the mental health and psychosocial difficulties—ranging from symptoms of PTSD and depression to broad social problems, such as the breakdown of support networks—that are commonly observed and documented in refugee populations. Well-elaborated risk models take into consideration both (1) risk factors, associated with various negative outcomes, that might be prevented or ameliorated and (2) protective factors[3] that moderate the impact of risk and might be harnessed to foster well-being and decrease the likelihood of maladaptive psychosocial outcomes in the presence of unavoidable stressors (e.g., de Jong, 2002). For our specific purposes, a risk model relevant to refugee mental health would outline how exposure to political violence, migration, social upheaval, and displacement-related stressors are thought to place refugees at risk for a number of adverse psychosocial outcomes—including symptoms of trauma, anxiety, and/or depression in individuals, distress and tension among families, and social disruptions in communities.
A Broad Framework for the
Development of Risk Models
The authors in this volume have drawn on a range of theoretical models—from theories of trauma to theories of political and social empowerment—to ground and guide their intervention work with refugees and displaced persons. In reflecting on these theoretical foundations and on the empirical literature summarized in chapter 1, we have constructed a general, global risk model that may be useful across the diverse settings in which refugees are found (Fig. 11.1). The model we have sketched is not meant to represent all of the underlying mechanisms involved in the translation of risk to psychosocial and mental health outcomes—but is meant to offer a guiding framework for mapping the potential impact of common war and displacement-related stressors (i.e., risk factors) on the psychosocial well-being of refugees.
A number of risk factors associated with the refugee experience are outlined on the left-hand side of Figure 11.1. Although risk factors associated with negative psychosocial outcomes are often conceptualized as occurring either within individuals (physiologic vulnerability to stress, poor coping skills), families (single-parent household, marital discord), or communities (high poverty, few mental health resources), risk also might be viewed as the result of a poor fit between individuals, families, or communities and their environments. For instance, a particular coping style may only be “poor” or “maladaptive” in a particular setting. From this perspective, we would not speak of at-risk individuals or groups, but consider at-risk contexts or person–environment transactions. In our model, most of the displacement related stressors—such as discrimination, lack of environmental mastery, loss of familiar social roles and support networks—might be conceptualized as person–environment mismatches that lead to adverse psychosocial outcomes. When risk is viewed in this ecologically contextualized manner, we would argue that risk factors are best targeted with ecologically grounded interventions that take into account person–environment transactions (Barrera, 2000; Felner, Felner, & Silverman, 2000; Kelly, 1987; Vincent & Trickett, 1983). For example, although it might be difficult to alter an individual’s physiological reactivity or previous exposure to stress, it is possible to develop community resources and adapt current environments to support resilience and protect or buffer individuals—who may be highly reactive to stress or who have experienced high levels of trauma exposure—from negative psychosocial outcomes.
It is important to note that risk factors for various forms of psychosocial distress often vary across populations (Coie et al., 1993; de Jong, 2002; Steel & Silove, 2000), and the risk factors included in Fig. 11.1 should not be assumed to be exhaustive or relevant for all refugee groups, or linked to psychosocial distress in the exact same manner across populations. However, the model provides a general schema outlining the types of stressors that commonly impact the lives of refugees in adverse ways—and provides an illustrative list of factors to take into consideration when building and testing risk models for the populations with whom we work.
Although we have stressed the importance of protective factors when creating models of risk and resilience, we did not include them in the general risk model pictured in Figure 11.1. However, the inverse of any of the risk factors outlined on the right of the diagram could be considered a protective factor. For example, the stress of losing supportive social networks in its inverse would be the maintenance or development of crucial social ties—an important protective factor thought to mitigate the stress of displacement for refugees (e.g., Gorst-Unsworth & Goldenberg, 1998; Kinzie et al., 1986; Miller et al., 2002). Other important protective factors not specifically implied by our model, but that might be harnessed and fostered in community-based interventions, include involvement in recreational activities (sports, dances, concerts) and empowering organizations such as workers unions and human rights groups, living in safe neighborhoods or smaller sized camps, access to good schools and jobs, and the maintenance of religious or political ties and activities that provide comfort and meaning in trying circumstances (de Jong, 2002; Steele & Silove, 2000). From an ecological perspective, effective interventions are likely to be those that identify and strengthen protective factors—such as the often overlooked resources present in refugee communities—while minimizing the salience of risk factors that may compromise people’s well-being.