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Social Justice Brief CONTRIBUTORS: Elizabeth Ringler-Jayanthan, LSW Dawn Brubaker, DSW Isabelle Darling, MSW Mel Wilson, MBA, LCSW Senior Policy Consultant National Association of Social Workers

Challenges of Refugee Resettlement Policy and Psychosocial Factors

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This social justice brief will discuss, analyze, and make policy recommendations about the process for obtaining refugee status and resettlement in the United States. We will also discuss the significant changes in the United States’ immigration and refugee policies that have adversely affected our nation’s commitment to providing a safe haven for the world’s displaced populations. Background There have always been migrants and refugees worldwide. However, the number of persons who are displaced, both internally and to another country, is currently at a historic high. Environmental, geothermal, and human conflict factors all contribute to the rise of migration. Each of these factors alone can cause migration; when combined they

increase abnormal migration. For example, environmental factors cause displacement and movement of people.2 Crop failure, for instance, can result in food scarcity, causing people to migrate to other countries for survivable living conditions. It is no surprise that human conflicts and violence are the main reasons for mass migration. At the end of 2014, war, violence, and persecution led to one in every 122 humans in the world becoming a refugee, becoming displaced, or seeking asylum.3 As reported by the United Nations refugee agency (UNHCR),4 the level of worldwide displacement has never been higher—with a record 59.5 million people having migrated from their homes at the end of 2014.

Challenges of Refugee Resettlement Policy and Psychosocial Factors

The issue of immigration is complex and includes many legal, social justice, and

psychosocial considerations. However, relatively little attention is paid to the

plight of refugees. A refugee is someone who has left his or her country

because of a well-founded fear of persecution, due to race, religion, nationality,

political opinion, or membership in a particular social group.1 In the United

States, to enter through the refugee resettlement program, one must be deemed

a refugee by the host country’s government, by the United Nations High

Commissioner for Refugees (UNHCR), or by both, before being given the

opportunity to be resettled in the United States.

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Additionally, in 2014 there were: » 19.5 million refugees, more than half of

them children » 38.2 million internally displaced people » 1.8 million asylum seekers.

Historically, the United States had always been a world leader in welcoming refugees. The Refugee Act of 1980 provided a formal process to actively bring refugees to the country when repatriation to the nation of origin was not possible.5 The resettlement process in the United States is managed by the U.S. Department of State’s Bureau of Population, Refugees, and Migration. The refugee resettlement program has historically had bipartisan support and at its core is a humanitarian program. During the start of the formal Refugee Resettlement and Placement program, the United States resettled refugees from Southeast Asia affected by the Vietnam War, as well as refugees from the Soviet Union and Eastern Europe. In more recent years, refugees from other parts of the world including Burma (Myanmar), Bhutan, Burundi, Sudan, Somalia, the Democratic Republic of the Congo, as well as Iraq, Syria, Afghanistan, Cuba, and Colombia have been resettled in the United States. The common goal of the resettlement program is to affirm America’s commitment to human rights. The overall hope underscoring the program is that those who are granted refugee status use their freedoms to demonstrate their appreciation for being granted refugee status by contributing to the economy and enriching the fabric of the community by bringing their cultural heritage and experiences to the United States.6

Definition of Refugee Resettlement Terms Refugee Resettlement Agency: Refugees are resettled across the United States by affiliate offices of the national resettlement agencies (also called voluntary agencies) that are contracted by the federal government to resettle refugees. At the affiliate level, case managers assist newly arrived refugees with service connection to adjust to their new communities and promote self-sufficiency. There are nine national agencies that facilitate the refugee resettlement process. Asylum Seeker: An asylum seeker is an individual who has left her or his country because of a well-founded fear of persecution, due to race, religion, nationality, political opinion, or membership of a particular social group, but has not been granted asylum status in the United States. People seeking asylum must go through the immigration court system before they can be considered for asylum, whereas refugees already have legal status when they arrive in the United States. Asylee: An asylee is an individual who has left her or his country because of a well-founded fear of persecution, due to race, religion, nationality, political opinion, or membership of a particular social group, and has been granted asylum to stay in the United States by an immigration court judge. Special Immigrant Visa (SIV) Holders: Iraqi and Afghan translators and interpreters working for the U.S. military and who meet certain requirements can qualify for the SIV program and receive refugee benefits in the United States.

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Cultural, Religious, and Ethnic Diversity of Refugee Migration As previously mentioned, for a variety of reasons there has been a significant increase in migration and refugees internationally. However, even in the face of a worldwide increase of displaced migrants, the United States has steadily decreased the number of refugees it accepts.

In 2018, 22,491 individuals arrived in the United States as refugees,7 according to data from the State Department’s Worldwide Refugee Admissions Processing System. What is important about those data is that this represents a 58 percent decrease from the 53,716 admitted in 2017. The 2018 refugee number is also about half of the 45,000 admissions that were allotted for 2018. In 2019, Refugee Council USA is reporting that 26,345 have been resettled.8

To that point, about three-quarters of the refugees admitted in the first seven months of fiscal year 2019 were from Africa and East Asia,9 with refugees from the Democratic Republic of Congo and Burma (also known as Myanmar) being the top two demographic groups admitted thus far in 2019. It should be noted that Congolese refugees are fleeing many years of armed internal strife that has

killed more civilians than any war since World War II. With respect to Myanmar, tens of thousands of the ethnic Chin, Karen, and Muslim Rohingya have fled persecution by the government of Myanmar. These religious and ethnic groups have been allowed to resettle in the United States. Religious Factors in Admitting Refugees to the United States

The United States has admitted far more Christian refugees than Muslim refugees since fiscal year 2017.10 Refugees who identify as being Christians comprised 74 percent of refugees admitted to the United States thus far in 2019. During the first eight months of 2019, the United States admitted close to 22,300 Christians. This is compared with nearly 4,600 Muslims for the same period. These statistics warrant scrutiny because they indicate a marked reversal from previous years. For example, in 2016, Muslim refugees were admitted into the United States at a historic rate.11 In fact, in 2016, 38,900 Muslim refugees were resettled in this country, compared with about 37,500 Christian refugee admissions.

Refugees from conflict in the eastern Democratic Republic of the Congo leave the Nyakabande transit camp in Uganda. (Photo: Andy Wheatley/DFID)

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Emergence of Anti-Immigration Policies & Their Impact on Refugees It would be a mistake to understate the degree to which national immigration and refugee polices can affect the emotional and social stabilization of migrant populations. As alluded to in the background section, the international commitment to nations to accept and resettle refugees for humanitarian reasons had been a universal value. However, over the past three to five years, there has been a worldwide shift toward xenophobic anti-refugee policies often fueled by racial and religious intolerance. For instance, in 2015, the influx of refugees arriving in Europe sparked anger that created divisions across the continent.12 When Germany initiated a refugee program in 2015 that allowed more than one million migrants to claim asylum, there were domestic tensions from Germans who were adamantly anti-refugee. The United States has not been immune to international anti-refugee fervor. In fact, early in the Trump administration, key administrators advocated for anti-immigrant and anti-refugee polices. These policies have included those that severely limit immigrants’ ability to claim asylum in the United States, meant to deter and reduce asylum seekers in general, but specifically those from Central America claiming asylum, and to severely harshen conditions for those seeking asylum through inhumane conditions in detention centers. In addition, the administration has moved to end temporary protected status for 300,000 individuals from 10 countries (with the largest groups from El Salvador, Honduras, and Haiti), is attempting to end the DACA (Deferred Action for Childhood Arrivals) program and has ramped up Immigrations and Customs Enforcement raids nationwide.

Severe Reductions in Accepting Refugees in the United States

President Trump is also seeking to enact new rules designed to block refugees from reuniting with family members and to grind the resettlement process to a halt.13 Via an executive order,14 the administration will reduce the annual number of refugees admitted to the United States to 18,000 in the coming fiscal year. This policy move follows an administration trend of cutting refugee levels every year since 2016. In actuality, the administration considered dropping the cap to zero15 but backed away from that draconian reduction because of political pressure from Democrats and Republicans alike. This change will require the State Department to develop new procedures for refugee resettlement. Of concern to many refugee advocacy organizations is the fact that the order will require consent from states and localities before refugees can be resettled in their jurisdictions. Many refugee advocacy organizations16 find the explicit state and local consent requirement to be unnecessary. This is because current resettlement policies

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already ensure strong, active partnerships between state and local communities and resettlement agencies. The policy to cut refugee levels intersects with asylum-seeking families trying to reach the United States southern border. A recent Supreme Court ruling allowed the Trump administration to proceed with a broad ban on asylum seekers who travel through another country to get to the U.S.–Mexico border.17 The ruling will severely restrict access for tens of thousands of migrant families traveling north from Guatemala, El Salvador, and Honduras. The Trump administration has argued that asylum seekers (who apply from inside the United States or at the border) and refugees (who apply from abroad) draw from the same pool of federal resources.18 The administration has used that rationale to justify cutting refugee admissions in recent years as resources have been redirected to processing asylum requests. The Trump administration’s fiscal year 2019 refugee admissions ceiling is devastating for the refugee community in the United States and abroad. Since its first days in office, the Trump administration has taken calculated steps to severely restrict and weaken the U.S. refugee admissions program, the largest resettlement program in the world.19 Under the guise of strengthening national security, the administration first ordered a temporary 120-day ban on all refugees traveling to the United States,20 followed by a 90-day ban on refugees coming from 11 countries, including Syria and Somalia. The overt refugee admissions ban from all “high-risk” countries was lifted in early 2018, with the condition that refugees go through

additional security on top of the multiple— and highly effective—levels of screenings that have long been in place. Policies stifling the resettlement program are contrary to the beliefs of many national security experts who argue that strengthening the refugee system is in the national interest. Four decades of refugee admissions data from the U.S. Department of State Bureau of Population, Refugees, and Migration illustrate the extent of the reduction in refugee arrivals as well as the inordinately low admissions ceiling set by the Trump administration.21 For example, the refugee admissions ceiling was set at an average of 76,000 slots from fiscal years 1999 through 2016. In 2019, it was slashed to 30,000, a 64 percent reduction compared with 2016. In October 2019, President Trump issued a proclamation barring immigrants who do not have health insurance and cannot afford to pay medical care costs from getting visas (of almost any kind) to enter the United States.22 As mandated in the executive order, immigrants must be able to verify that they will obtain health insurance within 30 days of their arrival in this country or must prove that they will be able to pay for any medical expenses they incur once they enter the United States. The executive order lacks clear processes and procedures for determining whether immigrants meet these requirements. It appears that each individual consular officer will be responsible for evaluating visa applications by using loose criteria. The executive order seems to include most visa categories.23 For example, visa applicants who are parents and spouses of U.S. citizens and immediate family members

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of lawful permanent residents are also subject to the health insurance requirement. To justify the proclamation, Trump invoked the president’s power under the Immigration and Nationality Act,24 which allows the executive to “suspend the entry of all aliens or any class of aliens…or to impose on the entry of aliens any restrictions he may deem to be appropriate.” The Architects of Anti-Immigrant and Anti-Refugee Polices To many, the salient question is, why is the United States denying assistance to those who may be fleeing humanitarian disasters or are at imminent risk of violence?25. As a 2017 New Yorker report details,26 this hardline approach to immigration policy is reflective of the influence of Trump’s senior immigration adviser, Stephen Miller. The background about how the administration’s anti-immigration policies evolved is tied to a philosophical relationship between Stephen Miller and former attorney general Jeff Sessions, when the two became close allies on immigration policies, which pre-dates their joining the Trump presidential campaign. Sessions has long been a critic of undocumented immigrants and has pushed to curtail immigration to the United States.27 He spent much of his career in Congress fighting against immigration reform bills. In 2009, Stephen Miller joined Sessions as an adviser and assisted him in his anti-immigration efforts. For instance, when a major bipartisan immigration reform bill was introduced in 2013, Sessions was active in trying to kill it. When the bill passed the Senate, Miller wrote a 23-page handbook for House of Representatives members on

how to fight the bipartisan immigration reform deal.28 Soon after being elected, the Trump administration began to explore anti- immigration initiatives. In August 2017, a group of officials at the Department of Homeland Security gathered to brainstorm new ways to toughen immigration enforcement. Among those leading the discussion was an official who was a former aide to Jeff Sessions, then the attorney general. This individual was also a close associate of Stephen Miller, who by then had become Trump’s senior immigration adviser. – “Zero tolerance” emerged as the centerpiece immigration policy after that meeting, and the administration’s family separation policy was soon to follow.29 The Muslim Travel Ban As if zero tolerance and subsequent family separation policies were not enough, Miller became the lead architect and advocate for policies that banned individuals from designated countries from being admitted to the United States as refugees. Because most of the designated countries were primarily Muslim, the policy became known as the Muslim travel ban.30 Though implementing the ban became an unmitigated disaster, it set the stage for the Trump administration’s more aggressive efforts to greatly reduce the caps for refugee resettlement in the United States. The security threat narrative is based on a misunderstanding or willful misrepresentation of the refugee screening process. “Extreme vetting” already existed in that potential refugees to the United States go through a 20-step process that includes three fingerprint screenings, two background checks, and three extensive interviews, first by the UN

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Refugee Agency, then by the State Department, and finally by the Department of Homeland Security.31 This would explain why, of the more than three million refugees admitted to the United States from 1975 to 2015, only three have committed terrorist acts,32 with a total of three deaths. There has always been a screening process in place with an extreme vetting process beginning in 2011. None of the major mass shootings or terrorist acts in the United States in recent years—at San Bernardino, Boston, Orlando, and Las Vegas or on September 11—were carried out by refugees. In addition to this, the administration has attacked the formal refugee resettlement program administrated by the federal government. Under the Barack Obama administration, the “refugee ceiling,” or maximum number of refugees to be resettled for the year, was set at 110,000. Since then the ceiling has been drastically reduced each year, from 50,000 in 2017, to 45,000 in 2018 and in 2019 down to just 30,000. In January 2017, the Trump administration suspended refugee admissions for 90 days and enacted the “Muslim ban,” which halted refugee resettlement from 11 countries: Egypt, Iran, Iraq, Libya, Mali, North Korea, Somalia, South Sudan, Sudan, Syria, and Yemen. The ban has been referred to as a “Muslim ban” due to Islam being the majority religion practiced in these countries. In June 2018 the courts upheld this decision.

Positive Contribution of Resettled Refugees The downward trends in accepting refugees fly in the face of academic research that shows refugees having a net positive impact on public budgets. A National Bureau of Economic Research working paper finds that, on average, refugees to the United States pay $20,000 more per person in taxes than they receive in benefits.33 After being established in the country, they are more likely than equally educated U.S.-born citizens to be employed and less likely to be on welfare. Consider the following: » The average workforce participation rate

of refugees is 81.8 percent, well above the national rate of 62 percent.

» Refugees are more than twice as likely as U.S.-born workers to hold jobs in general or “other services”—a sector that includes a variety of service roles such as dry cleaning, housekeeping, and machine repair.

» Several industries rely heavily on refugee workers to support their economic stability. Refugees revitalize industries, and low rates of refugee arrivals significantly impair economic growth.

Unfortunately, recent policies34 imply that despite the added benefit that refugees bring to America (and other nations in the world), the seeds of anti-refugee and migrant sentiment have been sown internationally and domestically.

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Impact of Anti-Immigrant and Anti-Refugee Policies The impact of these policies is stark. Some individuals who were scheduled to be resettled in the United States may need to wait indefinitely for resettlement, and many will face continued hardship, possible violence, and even death. These individuals may have already been vetted by the United States and have been waiting for resettlement and now will need to wait indefinitely. There are families that are now split up, with one or more family members already resettled in the United States and others waiting to come. In addition, employers that frequently hire refugees have been unable to fill positions due to the low arrival numbers; landlords that frequently rent to newly arriving refugee families have also been affected.

Finally, professionals who work in the field of refugee resettlement have been hit hard by closures of programs due to low arrival numbers, losing technical experience that those professionals have in administering these programs. Therefore, it is not surprising that refugee resettlement is an emotionally stressful process, especially for the new arrivals. Mental Health Impact of Migration and Resettlement When stress precipitated by ill-advised policies is coupled with the enormous amount of anxiety and apprehension caused by relocation, there is an increased probability of diagnosed mental health disorders within refugee communities.

In talking about the emotional and mental health toll that refugee resettlement creates for individuals, families, and children, we are

referring to two factors: (1) the adjustments to culture and language that refugees are required to make once they are admitted into the United States; and (2) the fear and uncertainty that national policies such as the Muslim travel ban and the severe reduction in refugee admissions lead to in newly arriving refugees, making them feel unwanted and even despised. According to an analysis published in World Psychiatry, mental health practitioners work in an increasingly multicultural world, shaped by the migrations of people of many different cultural, racial, and ethnic backgrounds.35 People migrate for many reasons, whether political, socioeconomic, or educational. The richness of this diversity of cultures, ethnicity, races, and reasons for migration can make understanding experiences and diagnosis of illness challenging in people whose background and experience differ significantly from that of the clinician. Culture has an important role in the presentation of illness, and cultural differences have an impact on the diagnosis and treatment of migrant populations in part due to linguistic, religious, and social variations from the clinician providing care. In addition, it appears that the incidence and prevalence of psychiatric disorders varies among people of different cultural backgrounds due to an interplay of biological, psychological, and social factors. The provision of health care is necessarily influenced by the demands of people of many different cultures but relies on economic, social, and political factors, and it is important that cultural differences be appreciated and understood to arrive at a correct diagnostic impression and treatment plan.

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The migration process itself can be stressful, depending on the type and cause of migration, and can affect the mental health of migrating individuals and their families. Issues of cultural bereavement and identity occur with increased frequency among migrants and their families. Below we review these concepts and how they impinge on mental health and psychiatric care and, by so doing, help the clinician to identify these issues in a culturally sensitive way. Migration as a Precipitating Factor of Emotional Stress The process of migration has been described as occurring in broadly three stages.36 The first stage is pre-migration, involving the decision and preparation to move. The second stage, migration, is the physical relocation of individuals from one place to another. The third stage, post-migration, is defined as the “absorption of the immigrant within the social and cultural framework of the new society.”37 One hopes that social and cultural rules and new roles may be learned at this stage. The initial stage of migration may have comparatively lower rates of mental illness and health problems than the latter stages, due to the migrant’s younger age at the initial stage of migration. Problems with acculturation and the potential discrepancy between attainment of goals and actual achievement in the latter stages can lead to emotional problems. Many experts suggest that social adjustment and the prevalence of mental illness in migrants may be influenced by: » duration of the relocation » similarity or dissimilarity between the

culture of origin and the culture of settlement

» language and social support systems » acceptance by the majority culture » access to and acceptance by the

expatriate community » employment » housing

If individuals and families feel isolated from their culture, unaccepted by the majority culture, and lacking in social support, a consequent sense of rejection, alienation, and poor self-esteem may occur. Mental Health We must remember that migrants leave their countries of origin for traumatic reasons that often involve long and hazardous journeys. That, along with the process of resettlement in a new country and culture, increases the risk to a variety of mental health issues.38 Unfortunately, identification and treatment of mental health problems has lagged far behind screening for physical health problems. Exacerbating this gap in services is the general lack of evidence-based mental health treatment and interventions. The more common mental health diagnoses associated with refugee populations include: » post-traumatic stress disorder (PTSD) » major depression » generalized anxiety » panic attacks » adjustment disorder » somatization (a chronic feeling that one

has a physical ailment) Children and adolescents often have higher levels of diagnoses, with various studies revealing rates of PTSD from 50 to 90 percent and major depression from 6 to 40 percent.39 Risk factors for the development of mental

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health problems include the number of traumas, delayed asylum application process, detention, and the loss of culture and support systems. The resettlement process includes challenges such as the loss of culture, community, and language as well as the need to adapt to a new and foreign environment. Children are often caught between the old and new cultures because they learn new languages and acquire cultural norms more quickly than their older relatives. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Much work remains to be done to develop culturally competent means of screening refugees for mental health issues and then implementing evidence-based interventions, both at an individual and community level, for these common and frequently debilitating diagnoses.” Cultural Bereavement The loss of one’s social structure and culture can cause a grief reaction. Migration involves the loss of the familiar, including language (especially colloquial and dialect), attitudes, values, social structures, and support networks. Grieving for this loss can be viewed as a healthy reaction and a natural consequence of migration; however, if the symptoms cause significant distress or impairment and last for a specified period, psychiatric intervention may be warranted. Cultural bereavement is defined as the grief experience of the uprooted person—or group—resulting from loss of social structures, cultural values and self-identity. The person—or group—continues to live in the past, is visited by supernatural forces from the past while asleep or awake, suffers feelings of guilt over abandoning culture and homeland,

feels pain if memories of the past begin to fade, but finds constant images of the past (including traumatic images) intruding into daily life, yearns to complete obligations to the dead, and feels stricken by anxieties, morbid thoughts, and anger that mar the ability to get on with daily life.40 Such bereavement is triggered by many factors, but mainly by social, cultural, and economic issues. An example of manifested cultural bereavement is the reported case of an Ethiopian female refugee. Her symptoms of grief included her inability to perform her culturally sanctioned purification rituals because of her relocation and resettlement.41 The woman was regularly misdiagnosed because of the use of Western diagnostic criteria by clinicians who failed to consider that cultural displacement could be a major cause of her grief and depression. Such examples of misdiagnosis inform the SAMHSA recommendations about the need for culturally appropriate mental health interventions. Recommendations for Reforming the Resettlement Program Increasing the Ceiling for Admissions First and foremost, the refugee admissions ceiling must be restored to previous levels, and processing of those in the pipelines must resume. This is particularly necessary for those refugee groups who have been excluded due to the Muslim ban, which has effectively stopped all refugees from countries in need of help. Lengthening the Reception and Placement Period The reception and placement program are meant to provide a “soft landing” for newly arriving refugees. The program is limited to just the first three months after arrival and thus

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has faced some criticism for not giving refugees support for a long enough period while they adjust. Extending this time period can provide additional resources to clients to ensure self-sufficiency and connect clients with services. Inclusion of Mandatory Mental Health Screenings Refugee resettlement in the United States has mandatory social service programming that is offered to refugees upon their arrival. With most services being delivered within the first 90 days, new refugee clients are enrolled in a series of essential services, including English-language classes, cultural orientation, public transportation, job-readiness training, medical screening, school enrollment for school-age children, housing assistance, and social security. Even with the shared and well-known knowledge that refugees have likely been exposed to traumatizing events prior to arriving to the United States, mental health services are not on the list of mandated support offered to refugees. Although many case managers, agency directors, state health coordinators, medical providers, and English-language educators incorporate topics of mental health into their services for refugees, there is no national standard, protocol, or even agreed upon mental health assessment tool to aid providers in strengthening the mental health of refugee clients. Need for Data Collection and Evaluation Although the United States has been the leading nation in receiving and supporting refugees for generations, research around refugee mental health is limited. Researchers are still in the beginning stages of collecting data, identifying best practices, creating standardized procedures, and overcoming stigma for refugee mental health. With the

recent threat to protective and supportive policies and programming for refugees, social workers across fields of research, case managers, and policy makers are stunted in our work. The progress we are attempting to make is forced to the margins as we now focus on dismantling incorrect and dangerous stereotypes about refugees, demanding basic human decency, and generally attempting to honor the immigrant and refugee story of the United States. While exposure to trauma has occurred prior to arriving in the United States, it is important to note that resettlement is also an extremely vulnerable phase of seeking safety but is essential to strengthening refugees’ abilities to move through the impact of past traumas. Psychosocial stressors such as discrimination, lack of economic opportunity, and significant social isolation, which some refugees experience after resettlement, may more strongly predict emotional distress than exposure to trauma before or during flight.42 Exposure to Trauma and Emotional Health Risk Due to Existing Policies The chart entitled “The Triple Trauma Paradigm”43 highlights the tremendous challenges refugees have endured. It also exposes that the current proposed US policies threaten the safety and belonging of refugee community members is mirroring the first stage of the “triple-trauma paradigm.” The policies being created today are not only impacting the mental health of refugees but are destroying founding principles of the United States. Amidst all the current challenges there is hope. Although mental health is currently not a mandated priority for refugee-serving agencies, communities are coming together to provide

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mental health services. Among the many areas and fields of service that refugees, and immigrants bring great success, former refugees are becoming social workers, medical providers, and community leaders who are aiding in breaking down obstacles for refugee mental health. The resiliency within the refugee narrative represents the essence of the American spirit, and policies that threaten refugees’ ability to have access to safety and achieve personal goals dismantle what America has always advertised, as the land of the free. The national cap for refugee arrivals has dropped to an extreme low. According to the Trump Administration there should be no surprise because the proposed arrival numbers under the Trump administration were always the “ceiling and not the floor.”44 When it comes to protecting refugees and strengthening their mental health, we have hit rock bottom as a country. Using the principles of social work, we have a chance to use our field not only to

aid refugees to access mental health services, overcome obstacles, and build better research and approaches to refugee mental health, but for our country as a whole to continue toward our foundational tenets of life, liberty, and the pursuit of happiness. There is research that examines the propensity for refugees being resettled and experiencing family separation to develop symptoms of mental illness. For example, a recent international conference presentation, “Mechanisms Underlying the Impact of Family Separation on the Mental Health of Refugees,” provides an informative overview of this concern.45 Trauma and Mental Health Assessment The Refugee Health Technical Assistance Center has prioritized responding to trauma and mental health disorders in various refugee and asylum-seeking communities.46 The following is a series of assessment tools

Source: Center for Victims of Torture. Working with torture survivor: core competencies (www.cvt.org/sites/default/files/u11/Healing_the_Hurt_Ch3.pdf)

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that are recommended to clinicians in providing behavioral health services to refugees during resettlement: » The Harvard Trauma Questionnaire is a

self-report questionnaire with four parts. The purpose of part 1 is to measure 17 war-related traumatic experiences. The purpose of the Post Migration Living Difficulties Scale is to assess current life stressors of asylum seekers.

» The 32-item Resettlement Stressor Scale, developed with Cambodian adolescents, is intended to measure stress due to resettlement.

» The War Trauma Scale consists of 42 items in both an interview and self-report format, measuring traumatic experiences inflicted by the Pol Pot regime.

» The purpose of the Comprehensive Trauma Inventory–104 was to capture the broad range of events experienced by Vietnamese and Kurdish refugees living in the United States. These combined methods identified over 200 traumatic events experienced by refugees in these two groups.

» The Vietnamese Depression Scale, a self-report questionnaire developed to screen Vietnamese refugees for depression, was developed using a well-described rational, consensus approach from extensive clinical experience. Culturally appropriate terms were added to existing Western symptoms of depression.

» The New Mexico Refugee Symptom Checklist–121 was developed from a community sample of Vietnamese and Kurdish refugees by using qualitative and quantitative methods. Refugees identified 121 symptom items, and factor and reliability analyses showed that these symptoms clustered into 12 subscales: PTSD and Depression, Musculoskeletal,

Sensory, Cardiopulmonary, Gastrointestinal, Anxiety, Urinary, Posttraumatic Vulnerability, Neurological and Bleeding, Skin Sensation, Menstrual, and Constitutional. Symptoms were highly correlated with both war trauma and impairment

» The Refugee Health Screener–15 (RHS-15) is an efficient instrument to screen for distress, anxiety, and depression in refugees. The RHS-15 is valid for predicting diagnostic level anxiety, depression, and PTSD in at least three refugee groups. It has been translated into eleven languages.

» Other instruments that have been used in general populations have been adapted for use with refugees. The Hopkins Symptom Checklist–25, a self-administered questionnaire originally designed to measure change in 15 anxiety and 10 depression symptoms in psychotherapy, has been validated in the general U.S. population and used in many refugee studies.

Role of Social Work in Migrant and Refugee Policy Reforms Immigrant and refugee rights have long been an issue of critical importance for social workers in the United States.47 Therefore, immigration policies are important for social workers to understand. As we have made clear in this social justice brief, the complexities and barriers associated with the legal and social statuses of migrants significantly affect the provision of biopsychosocial social services. As articulated in a 2015 NASW policy statement: “Often, social workers’ capacity to assist clients is constrained by immigration policies, especially policies that limit family visitation and family reunification. Immigration policies intervene in social work

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practice when family offenses become grounds for deportation and thereby impede willingness to report.”48 Advocating for refugees is clearly aligned with the NASW Code of Ethics and should be an issue area of priority to social work professionals. Social justice is a core value of the profession, and social workers must work to challenge social injustice in all forms. As a result of our mission to advocate for vulnerable populations, and as an agency that promotes social justice and human rights, it is our responsibility to fight xenophobia, racism, and injustice in the form of national policy as well as to fight structural inequalities that exist within systems. Social workers are at the intersection of social service organizations, government agencies, law enforcement, school systems, and the health care field and are positioned to provide services or design policies that can have an impact on refugee populations in all these settings. As a result, social workers can be the voice of change in these settings by implementing the following:

Recommendations » Ensuring agencies are providing culturally

and linguistically appropriate services, including interpretation and translation services.

» Encouraging agencies to hire former refugees for positions within their agencies.

» Providing education to agency staff on offering services to refugee clients and the benefits they are entitled to.

» Organizing local NASW chapters to sponsor awareness-raising events on refugee programs and why it is important for social workers to be engaged on this issue, including reaching out to elected officials and supporting the Grace Act,49

which proposes restoring the refugee ceiling back to 95,000.

» Volunteering with local resettlement agencies and organizing drives for needed supplies, such as diapers, food, clothing, and furniture donations.

» Establishing partnerships between schools of social work and local resettlement agencies for field placement sites at these agencies, thus giving students exposure to working with refugee clients.

» Ensuring an NASW presence at local World Refugee Day events. Guidelines for Mental Health Screening during the Domestic Medical Examination for Newly Arrived Refugees

» Recommendations for refugee mental health screening50

» Health clinics providing screening should have a good working relationship with refugee resettlement agencies.

» Though psychiatric emergencies such as suicidal and homicidal are infrequent, clinical facilities should have a mechanism in place for expedited referral for psychiatric evaluation in urgent situations.

» Clinicians performing the mental health evaluations should attempt to gather as much information about the history and cultural beliefs of the refugee populations they serve as possible.

» Medically trained interpreters should be used during patient interviews whenever possible.

» Refugees may not volunteer or admit symptoms at initial screening, Therefore, follow-up primary care referral for on-going health care is imperative.

» Clinicians should be aware that some refugees may present with stress-related somatic symptoms. Therefore, clinicians should consider mental health referrals

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for refugees with unexplained physical symptoms such as headaches, stomachaches, or back pain.

» Encourage immigration and refugee reform advocates to become politically active to help reverse anti-immigrant policies and regulations

Conclusion The plight of refugees and migrants is a global problem with no country, including the United States being exempt from moral and human rights implications of responding to the existential needs of the many millions of refugee individuals and families. The emotional and traumatic shock of suddenly being displaced and separated from one’s homeland cannot be underestimated. Nor can we ignore the fact that – while armed conflicts and severe food shortages are major causes of mass migration- immigration and refugee policies of countries around the world also greatly contribute to emotional trauma of those seeking to resettle in a foreign land. The challenge for behavioral health practitioners who work with immigrant and refugee individuals and families is to become fully trained in the unique cultural and psychosocial needs of displace persons who are resettling in this country. Relatedly, organizations that advocate for reforms that eliminate anti-immigrant/refugee policy and legislative must remain vigilant and active in reform such harmful governmental actions. Resources Resettlement Agencies Church World Service (CWS) Ethiopian Community Development Council (ECDC) Episcopal Migration Ministries (EMM) Hebrew Immigrant Aid Society (HIAS) International Rescue Committee (IRC)

US Committee for Refugees and Immigrants (USCRI) Lutheran Immigration and Refugee Services (LIRS) United States Conference of Catholic Bishops (USCCB) World Relief Corporation (WR) Additional Resources

Refugee Council USA Center for Victims of Torture Harvard Program in Refugee Trauma Switchboard: Connecting Resettlement Experts Cultural Orientation Resources Center 1 UNHCR: The UN Refugee Agency. Who Is a Refugee? n.d. Retrieved from www.unrefugees.org/refugee-facts/ what-is-a-refugee/ 2 Justice for Immigrants. Root Causes of Migration. n.d. Retrieved from https://justiceforimmigrants.org/what-we- are-working-on/immigration/root-causes-of-migration/ 3 Sam Jones. One in Every 122 People Is Displaced by War, Violence and Persecution, Says UN. Guardian, June 18, 2015. Retrieved from www.theguardian.com/ global-development/2015/jun/18/59m-people-displace d-war-violence-persecution-says-un 4 UNHCR. UNHCR Chief Applauds Zambia’ s Openness to Refugees.2019 October 21. Retrieved from www.unhcr.ca/news/unhcr-chief-applauds-zambia-openn ess-refugees 5 GovTrack. S. 2471 (115th): GRACE Act. n.d. Retrieved from www.govtrack.us/congress/bills/115/s2471 6 American Immigration Council. An Overview of U.S. Refugee Policy and Law. June 18, 2019. www.americanimmigrationcouncil.org/research/overvie w-us-refugee-law-and-policy 7 Brittany Blizzard and Jeanne Batalova. Refugees and Asylees in the United States. Migration Policy Institute, June 13, 2019. Retrieved from www.migrationpolicy.org/article/refugees-and-asylees-un ited-states#Refugee_Arrivals_and_Countries_of_Origin 8 Refugee Council USA. RCUSA Bi-Weekly Arrivals Tracker Holds Administration Accountable for Refugee Admissions. Refugee Council USA, October 30, 2019. Retrieved from www.rcusa.org/ 9 Ibid. 10 Jens Manuel Krogstad. Key Facts about Refugees to the U.S. Pew Research Center, October 7, 2019. Retrieved from www.pewresearch.org/fact-tank/2019/10/07/ key-facts-about-refugees-to-the-u-s/

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11 Ibid. 12 Global Citizen. How Far Will Anti-Refugee Rhetoric Spread in Europe? February 2016. Retrieved from www.globalcitizen.org/en/content/is-europe-witnessing- a-shift-to-the-right/ 13 Yehaneh Torbati and Mica Rosenberg. Trump Administration Considers Pausing U.S. Refugee Family Reunification Program. Reuters, October 20, 2017. Retrieved from www.reuters.com/article/us-usa-immigration- refugees/trump-administration-considers-pausing-u-s-refug ee-family-reunification-program-idUSKBN1CP2U4 14 Ted Hesson. Trump Officials Pressing to Slash Refugee Admissions to Zero Next Year. Politico, July 18, 2019. Retrieved from www.politico.com/story/2019/07/18/ trump-officials-refugee-zero-1603503 15 Ibid. 16 Refugee Council USA. RCUSA Responds to the News that Administration May Zero out Refugee Program in 2020. July 8, 2019. Retrieved from www.rcusa.org/blog/rcusa-responds-to-news-that-adminis tration-may-zero-out-refugee-program-in-2020 17 Josh Gerstein and Ted Hesson. Supreme Court Hands Trump a Victory on Asylum Restriction. Politico, September 11, 2019. Retrieved from www.politico.com/story/2019/09/11/supreme-court-as ylum-trump-restriction-1727124 18 Ted Hesson. Trump Administration Nearly Halves Refugee Camp for Coming Year. Politico, September 26, 2019. Retrieved from www.politico.com/news/2019/09/26/trump-administra tion-cuts-refugee-cap-to-18-000-for-coming-year-003885 19 Center for American Progress. Do Family Separation and Detention Deter Immigration? July 2018. Retrieved from www.americanprogress.org/issues/immigration/ reports/2018/07/24/453660/family-separation-detenti on-deter-immigration/ 20 Center for American Progress. Refugees Thrive in America. November 2018. Retrieved from www.americanprogress.org/issues/immigration/reports/ 2018/11/19/461147/refugees-thrive-america/#fn-461 147-11 21 Ibid. 22 Nicole Narea. The Trump Administration Will Deny Visas to Uninsured, Low-Income Immigrants. Vox, October 5, 2019. Retrieved from www.msn.com/en-us/news/politics/the-trump-administrat ion-will-deny-visas-to-uninsured-low-income-immigrants/ar- AAIiZ6Q

23 Ibid. 24 U.S. Citizenship and Immigration Service. Immigration and Nationality Act. Retrieved from www.uscis.gov/ legal-resources/immigration-and-nationality-act 25 Michael Paarlberg. Who Will Stop Stephen Miller, the Man behind America’s Anti-Refugee Policy? Guardian, October 25, 2017. Retrieved from www.theguardian.com/commentisfree/2017/oct/25/st ephen-miller-refugee-policy-trump 26 Jonathan Blitzer. How Stephen Miller Single-Handedly Got the U.S. to Accept Fewer Refugees. New Yorker, October 13, 2017. Retrieved from www.newyorker.com/news/news-desk/how-stephen-mill er-single-handedly-got-the-us-to-accept-fewer-refugees 27 Burgess Everett. The VP Hopeful Who Was Trump before Trump. Politico, July 13, 2016. Retrieved from www.politico.com/story/2016/07/jeff-sesssions-donald-t rump-vp-alabama-225439 28 Julia Ioffe. The Believer. Politico Magazine, June 27, 2016. Retrieved from www.politico.com/magazine/ story/2016/06/stephen-miller-donald-trump-2016-policy- adviser-jeff-sessions-213992 29 Tom K. Wong. Do Family Separation and Detention Deter Immigration? Center for American Progress, July 24, 2018. Retrieved from www.americanprogress.org/ issues/immigration/reports/2018/07/24/453660/fam ily-separation-detention-deter-immigration/ 30 Amrit Cheng. The Muslim Ban: What Just Happened? American Civil Liberties Union, December 6, 2017. Retrieved from www.aclu.org/blog/immigrants-rights/ muslim-ban-what-just-happened 31 Arden Farhi. The White House Explains Trump’s “Extreme Vetting” Executive Order. CBS News, January 30, 2017. Retrieved from www.cbsnews.com/news/the- white-house-explains-trumps-extreme-vetting-executive-order/ 32 Alex Nowrasteh. Terrorism and Immigration: A Risk Analysis. Cato Institute, September 13, 2016. Retrieved from www.cato.org/publications/policy-analysis/ terrorism-immigration-risk-analysis 33 William N. Evans and Daniel Fitzgerald. The Economic and Social Outcomes of Refugees in the United States: Evidence from the ACS. National Bureau of Economic Research Working Paper No. 23496, June 2017. Retrieved from www.nber.org/papers/w23498?utm_ campaign=ntw&utm_medium=email&utm_source=ntw 34 The Economist.How America’s refugee policy is damaging to the world and to itself. n.d. Retrieved from www.economist.com/open-future/2018/06/19/how-am ericas-refugee-policy-is-damaging-to-the-world-and-to-itself

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35 Dinesh Bhugra and Matthew A. Becker. 2005. Migration, Cultural Bereavement and Cultural Identity. World Psychiatry 4: 18–24. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC1414713/ 36 Ibid. 37 Ibid. 38 US National Library of Medicine National Institutes of Health. CMAJ-JAMC. Common mental health problems in immigrants and refugees: general approach in primary care. 2011 September 6. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC3168672/ 39 Refugee Health. Mental Health. n. d. Retrieved from https://refugeehealthta.org/physical-mental-health/ment al-health/ 40 Dinesh Bhugra and Matthew A. Becker. 2005. Migration, Cultural Bereavement and Cultural Identity. World Psychiatry 4: 18–24. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC1414713/ 41 Ibid. 42 K. E. Miller and A. Rasmussen. The Mental Health of Civilians Displaced by Armed Conflict: An Ecological Model of Refugee Distress. Epidemiology and Psychiatric Sciences, 2016. Retrieved from www.psychologytoday. com/sites/default/files/Mental%20Health%20of%20Civi lians%20Displaced%20by%20Armed%20Conflict.pdf 43 The Daily-Work.com. Triple Trauma Paradigm. 2019 April. Retrieved from http://daily-work.org/wordpress/ wp-content/uploads/2019/04/Handout-CVT-Triple-Trau ma-Paradigm-1.pdf

44 Politico. Trump officials pressing to slash refugee admissions to zero next year.2019 July 8. Retrieved from www.politico.com/story/2019/07/18/trump-officials-ref ugee-zero-1603503 45 Belinda Liddle. Mechanisms Underlying the Impact of Family Separation on the Mental Health of Refugees. Child, Migration and Right to Health Conference, 2019. Retrieved from https://sydney.edu.au/content/dam/ corporate/documents/sydney-law-school/news/day2bre akout2-2liddell.pdf 46 Refugee Health Technical Assistance Center. Assessment for Trauma and Mental Health in Refugees. n.d. Retrieved from https://refugeehealthta.org/physical- mental-health/mental-health/adult-mental-health/assessm ents-for-trauma-and-mental-health-in-refugees/ 47 University of Chicago School of Social Service Administration. Social Workers and the Protection of Immigrant and Refugee Rights. n.d. Retrieved from http://ssa.uchicago.edu/social-workers-and-protection-im migrant-and-refugee-rights 48 Ibid. 49 GovTrack. S. 2471 (115th): GRACE Act. n.d. Retrieved from www.govtrack.us/congress/bills/115/ s2471 50 Center for Disease Control and Prevention. Guidelines for mental health screening during the domestic Medical examination for newly arrived refugees. n.d. Retrieved from www.cdc.gov/immigrantrefugeehealth/guidelines/ domestic/mental-health-screening-guidelines.html

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