Journal of Contemporary Psychotherapy

, Volume 29, Issue 4, pp 283–306 | Cite as

Rethinking a Familiar Model: Psychotherapy and the Mental Health of Refugees

  • Kenneth E. Miller


This paper examines with a somewhat critical eye the primary role that psychotherapy and other clinic-based services currently play in addressing the mental health needs of political refugees in the industrialized countries. Two factors are considered which suggest that refugee mental health needs might be better served by complementing clinic-based treatments with a variety of community-based interventions. The first factor concerns the pervasiveness of psychological distress within refugee communities, coupled with the reluctance of many refugees to utilize formal psychological and psychiatric services. This calls into question both the adequacy and appropriateness of clinical-based services as cornerstones of our response to the mental health needs of refugees. More precisely, it suggests the need to complement such services with a variety of culturally grounded, community-based strategies that do not require attendance in formal mental health settings. Second, recent findings have shown consistently that a considerable amount of the distress reported by refugees is related not to prior exposure to violent events, but to a constellation of exile-related stressors such as the loss of one's community and social network, the loss of important life projects, changes in socioeconomic status and related concerns about economic survival, the loss of meaningful structure and activity in daily life, and the loss of meaningful social roles. It is suggested that while psychotherapy can play an important adjunctive role in helping people confront these exile-related stressors, they may most effectively be addressed through targeted community-based interventions. Examples of such community-based approaches are briefly described, and suggestions are offered for community-level strategies that might be explored. The paper concludes by emphasizing the complementary nature of clinical and community-based programs, and by suggesting that psychotherapy might best be conceptualized as one component of a more comprehensive approach to addressing the mental health needs of refugee communities.

refugees psychotherapy community 


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  1. Allden, K., Poole, C., Chantavanich, S., & Khin, O. (1996). Burmese political dissidents in Thailand: Trauma and survival among young adults in exile. American Journal of Public Health, 86, 1561–1569.Google Scholar
  2. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4 th Edition), Washington, DC: American Psychiatric Association.Google Scholar
  3. Anderson, R. (1976). Peer facilitation: history and issues. Elementary School Guidance and Counseling, 11, 16–23.Google Scholar
  4. Aron, A. (1992). Testimonio: A bridge between psychotherapy and sociotherapy. Women in Therapy, 173–189.Google Scholar
  5. Arroyo, W., & Eth, S. (1986). Children traumatized by Central American Warfare. In R. Pynoos & S. Eth (Eds.), Post-traumatic Stress Disorder in Children (pp. 101–120). Washington, DC: American Psychiatric Press.Google Scholar
  6. Bouhoutsos, J. (1990). Treating victims of torture: psychology's challenge. In P. Suedfeld (Ed.), Psychology and Torture.Google Scholar
  7. Brown, G., & Harris, T. (1978). Social Origins of Depression: A Study of Psychiatric Disorder in Women. New York: Free Press.Google Scholar
  8. Banyard, V., & Miller, K. (1998). The powerful potential of qualitative research in community psychology. American Journal of Community Psychology, 24, 485–505.Google Scholar
  9. Barrerra, M. (1986). Distinctions between social support concepts, measures, and models. American Journal of Community Psychology, 14, 413–445.Google Scholar
  10. Beach, S., Arias, I., & O'Leary, K. (1986). The relationship of marital satisfaction and social support to depressive symptomatology. Journal of Psychopathology and Behavior Assessment, 8, 305–316.Google Scholar
  11. Beiser, M., Johnson, P., & Turner, J. (1993). Unemployment, underemployment and depressive affect among Southeast Asian refugees. Psychological Medicine, 23, 731–743.Google Scholar
  12. Bennett, J., & Detzner, D. (1997). Loneliness in cultural context: A look at the life-history narratives of older Southeast Asian refugee women. In Lieblich, A. & J. Ruthellen (Eds.), The Narrative Study of Lives (pp. 113–146). Thousand Oaks, CA: Sage Publications, Inc.Google Scholar
  13. Billings, D., & Saenz, I. (In press). Mental health work with Guatemalan refugee women in Mexico City and the camps of Southern Mexico.Google Scholar
  14. Boothby, N. (1994). Trauma and violence among refugee children. In Marsella, A., T. Bornemann, S. Ekblad, & J. Orley (Eds.), (1994). Amidst Pain and Peril: The Mental Health and Well-Being of the World's Refugees (pp. 239–259). Washington, DC: American Psychological Association.Google Scholar
  15. Chesney, M., & Darbes, L. (1998). Social support and heart disease in women: Implications for intervention. In Orth-Gomer, K. & M. Chesney, M. (Eds.), Women, Stress, and Heart Disease (pp. 165–182). Mahwah, NJ: Lawrence Erlbaum Associates, Inc., Publishers.Google Scholar
  16. Cienfuegos, A., & Monelli, C. (1983). The testimony of political repression as a therapeutic instrument. American Journal of Orthopsychiatry, 53, 43–51.Google Scholar
  17. Clarke, G., Sack, W., & Goff, B. (1993). Three forms of stress in Cambodian adolescent refugees. Journal of Abnormal Child Psychology, 21, 65–77.Google Scholar
  18. Cohen, S., & Wills, T. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310–357.Google Scholar
  19. D'Augelli, A. (1983). Social support networks in mental health. In Whitaker, J. & J. Garbarino (Eds.), Social Support Networks: Informal Helping in the Human Services. Hawthorne, NY: Aldine.Google Scholar
  20. Dragons, J. (1984). Dilemmas and choices in cross-cultural counseling: The universal versus the culturally distinctive. In P. Pedersen, J. Draguns, W. Lonner, & J. Trimble (Eds.), Counseling Across Cultures (pp. 3–21). Honolulu: University of Hawaii Press.Google Scholar
  21. Drozdek, B. (1997). Follow-up study of concentration camp survivors from Bosnia-Herzegovina: Three years later. Journal of Nervous and Mental Disease, 185, 690–694.Google Scholar
  22. Egolf, B., Lasker, J., Wolf, S., & Potvin, L. (1992). The Rosero effect: A fifty year comparison of mortality rates. American Journal of Public Health, 82, 1089–1092.Google Scholar
  23. Eisenbruch, M. (1994). La sobreviviencia de la cultura a traves del curandero tradicional. In P. Farias and R. Miranda (Eds.), Experiencias del Refugio Centroamericano: Perspectivas de salud mental y psicosocial. San Cristobal de las Casas, Mexico: Centro de Investigaciones en Salud de Comitan.Google Scholar
  24. Eisenbruch, M. (1988). Can Homesickness kill? In Abbott, M. (Ed.), Refugee Settlement and Wellbeing (pp. 101–117). Auckland, New Zealand: Mental Health Foundation of New Zealand.Google Scholar
  25. Ensign, J. (1995). Traditional healing in the Hmong refugee community of the California central valley. Unpublished dissertation.Google Scholar
  26. Farias, P. (1994). Central and South American refugees: Some mental health challenges. In A. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst Pain and Peril: The Mental Health and Well-Being of the World's Refugees (pp. 101–114). Washington, DC: American Psychological Association.Google Scholar
  27. Gonsalves, C. (1990). The psychological effects of political repression on Chilean exiles in the US. American Journal of Orthopsychiatry, 60, 143–153.Google Scholar
  28. Gorst-Unsworth, C, & Goldenberg, E. (1998). Psychological sequelae of torture and organized violence suffered by refugees from Iraq: Trauma-related factors compared with social factors in exile. British Journal of Psychiatry, 172, 90–94.Google Scholar
  29. Heller, K. (1993). Prevention activities for older adults: Social structures and personal competencies that maintain useful social roles. Journal of Counseling & Development, 72, 124–130.Google Scholar
  30. Hiegel, J.P. (1994). Use of indigenous concepts and healers in the care of refugees: Some experiences from the Thai border camps. In A. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst Pain and Peril: The Mental Health and Well-Being of the World's Refugees (pp. 293–310). Washington, DC: American Psychological Association.Google Scholar
  31. Hinton, L., Tiet, Q., Tran, C., & Chesney, M. (1997). Predictors of depression among refugees from Viet Nam: A longitudinal study of new arrivals. Journal of Nervous and Mental Disease, 185, 39–45.Google Scholar
  32. Hitchcox, L. (1990). Vietnamese Refugees in Southeast Asian Refugee Camps. Hampshire, England: MacMillan Academic and Professional, Ltd.Google Scholar
  33. Hoff, L., & Miller, N. (1987). Programs for People in Crisis: Guide for Educators, Administrators, and Clinical Trainers. Boston: Northeastern University Custom Book Program.Google Scholar
  34. Kelly, J. (1991). Changing contexts and the field of community psychology. American Journal of Community Psychology, 18, 769–792.Google Scholar
  35. Kessler, R., Price, R., & Wortman, C. (1985). Social factors in psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 36, 531–572.Google Scholar
  36. Kinzie, J.D. (1986). The establishment of outpatient mental health services for Southeast Asian refugees. In C. Williams & J. Westermeyer (Eds.), Refugee Mental Health in Resettlement Countries (pp. 217–231). Washington, DC: Hemisphere Publishing Corporation.Google Scholar
  37. Kinzie, J., Sack, W., Angell, R., Manson, S., & Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children: I. The children. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 370–376.Google Scholar
  38. Kinzie, J., Sack, W., Angell, R., Clark, G., & Ben, R. (1989). A three year follow-up of Cambodian young people traumatized as children. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 501–504.Google Scholar
  39. Kivalae, S. (1997). Depression and physical and social functioning in old age. Acta Psychiatrica Scandinavica, 89, 73–76.Google Scholar
  40. Lavik, N., Hauff, E., Skrondal, A., & Solberg, O. (1996). Mental disorder among refugees and the impact of persecution and exile: Some findings from an out-patient population. British Journal of Psychiatry, 169, 726–732.Google Scholar
  41. Light, D. (1992). Healing their wounds: Guatemalan refugee women as activists. Women In Therapy. 297–308.Google Scholar
  42. Lum, R. (1985). A community-based outpatient mental health service to Southeast Asian refugees. In B. Bliatout, K. Lin, W. Liu, T. Nguyen, & H. Wong (Eds.), Southeast Asian Mental Health: Treatment, Prevention, Services, Training, and Research (pp. 283–306). Washington DC: Department of Health and Human Services.Google Scholar
  43. Lundgren, R., & Lang, R. (1989). There is no sea, only fish: The effects of United States policy on the health of the displaced in El Salvador. Social Science and Medicine, 28, 697–706.Google Scholar
  44. Lykes, B., Maciel, R., Iborra, M., Suardi, L., & Costa, E. (1991). Jugando a recrear nuestra historia. Talleres creativos integrales para niños. Una experiencia en Argentina y Guatemala. In E. Garcia Mendez & M. del Carmen Bianchi (Eds.), Ser Niño en America Latina (pp. 369–374). Buenos Aires: Editorial Galerna.Google Scholar
  45. Marsella, A., T. Bornemann, S. Ekblad, & J. Orley (Eds.), (1994). Amidst Pain and Peril: The Mental Health and Well-Being of the World's Refugees Washington, DC: American Psychological Association.Google Scholar
  46. Martín Baró, I. (1989). Political violence and war as causes of psychosocial trauma in El Salvador. International Journal of Mental Health, 18, 3–20.Google Scholar
  47. McLoyd, V. (1990). The impact of economic hardship on Black families and children: Psychological distress, parenting, and socioemotional development. Child Development, 61, 311–346.Google Scholar
  48. McGoldrick, M. (1982). Ethinicity and Family Therapy. New York: Guilford Press.Google Scholar
  49. McSharry, S., & Kinney, R. (1992). Prevalence of psychiatric disorders in Cambodian refugees: A Community Random Sample. Unpublished manuscript, Social Research Institute, Graduate School of Social Work, University of Utah, Salt Lake City, Utah.Google Scholar
  50. Metraux, (1990). El Niño, la Familia, y la Comunidad. Managua: Editorial Ciencias Sociales.Google Scholar
  51. Miller, K., & Worthington, G. Older refugees and the crisis of exile. Manuscript under preparation.Google Scholar
  52. Miller, K., Weine, S., Razzano, L., Worthington, G., Ramic, A., Birkic, N., Boskailo, E., Djuric-Bijeidc, Z., & Smajkic, A. (1999). The relative contribution of social isolation, daily activities, and war experiences to levels of PTSD and depression in Bosnian refugees. Paper presented at the 15th Annual Meeting of the International Society for Traumatic Stress Studies, Miami, FL.Google Scholar
  53. Miller, K. (1996). The effects of state terrorism and exile on indigenous Guatemalan refugee children: A mental health assessment and an analysis of children's narratives. Child Development, 67, 89–106.Google Scholar
  54. Miller, K. (1994). Growing up in exile: Mental health and meaning-making among indigenous Guatemalan refugee children. Unpublished dissertation, University of Michigan, Ann Arbor, Michigan.Google Scholar
  55. Michultka, D., Blanchard, E., & Kalous, T. (1998). Responses to civilian war experiences: Predictors of psychological functioning and coping. Journal of Traumatic Stress, 11, 571–577.Google Scholar
  56. Mollica, R., McInnes, K., Pham, T., Fawzi, M., Smith, C., Murphy, E., & Lin, L. (1998). The dose-effect relationships between torture and psychiatric symptoms in Vietnamese expolitical detainees and a comparison group. Journal of Nervous & Mental Disease, 186, 543–553.Google Scholar
  57. Paltiel, F. (1987). Is being poor a mental health hazard? Women and Health, 12, 189–211.Google Scholar
  58. Paul, M. (1986). Primary prevention and the Promotion of Mental health in the ESL Classroom. New York: American Council for Nationalities Service.Google Scholar
  59. Peltzer, K. (1998). Ethnocultural construction of post-traumatic stress symptoms in African contexts. Journal of Psychology in Africa, South of the Sahara, and the Caribbean & Afro-Latin Americal, 17–30.Google Scholar
  60. Peltzer, K. (1997). Journal of Transpersonal Psychology, 29, 13–29.Google Scholar
  61. Pappas, E., & Bilanakis, N. (1997). War refugees in concentration camps: Impact of the war on mental health. Psychiatriki, 8, 109–118.Google Scholar
  62. Pernice, R., & Brook, J. (1996). Refugees' and immigrants' mental health: Association of demographic and post-migration factors. Journal of Social Psychology, 136, 511–519.Google Scholar
  63. Rappaport, J. (1977). Community Psychology: Values, Research, and Action, New York: Holt, Rinehart, & Winston.Google Scholar
  64. Reker, G. (1997). Personal meaning, optimism, and choice: Existential predictors of depression in community and institutional elderly. Gerentologist, 37, 709–716.Google Scholar
  65. Rousseau, C., Drapeau, A., & Corin, E. (1997). The influence of culture and context on the pre-and post-migration experience of school-aged refugees from Central America and Southeast Asia in Canada. Social Science and Medicine, 44, 1115–1127.Google Scholar
  66. Ryff, C., & Singer, B. (1998). The role of purpose of in life and personal growth in positive human health. In P. Wong & P. Fry (Eds.), The Human Quest for Meaning (pp. 213–235). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.Google Scholar
  67. Saenz, I. (1994). Un Modelo Para el Apoyo de la Salud Mental de los Refugiados Guatemaltecos en el Sureste de México a través de la Capacitacion de los Promotores de la Comunidad. Unpublished dissertation, Department of Psychology, National Autonomous University of Mexico.Google Scholar
  68. Saul, J. (1999). Working with survivors of torture and political violence in New York City. Zeitschrift für Politische Psychologie, 7, 221–232.Google Scholar
  69. Servan-Schreiber, D., Lin, B., & Birmaher, B. (1998). Prevalence of post-traumatic stress-disorder and major depressive disorder in Tibetan refugee children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 874–879.Google Scholar
  70. Silove, D., Sinnerbrink, I., Field, A., & Manicavasagar, V. (1997). Anxiety, depression, and PTSD in asylum-seekers: Associations with pre-migration trauma and post-migration stressors. British Journal of Psychiatry, 170, 351–357.Google Scholar
  71. Silverman (1988). Widow to Widow: A mutual help program for the widowed. In R. Price, E. Cowen, R. Lorion, & J. Ramos-McKay (Eds.), 14 Ounces of Prevention (pp. 53–65). Washington, DC: American Psychological Association.Google Scholar
  72. Sinnerbrink, I., Silove, D., Field, A., Steel, Z., Manicavasagar, V. (1997). Compounding of pre-immigration trauma and post-migration stress in asylum seekers. Journal of Psychology, 131 463–470.Google Scholar
  73. Singer, K. (1976). Cross-cultural dynamics of psychotherapy in social psychiatry. In J. Masserman (Ed.), The Range of Normal in Human Behavior. New York: Grune & Stratton.Google Scholar
  74. Smajkic, A. (1999). Relapse of PTSD and depression in a treatment of refugees, survivors of war and genocide. Paper presented at the 15th Annual Meeting of the International Society for Traumatic Stress Studies, Miami, FL.Google Scholar
  75. Strober, S. (1994). Social work interventions to alleviate Cambodian refugee distress. International Social Work, 37, 23–35.Google Scholar
  76. Sue, S., & McKinley, H. (1975). Asian Americans in the community mental health care system. American Journal of Orthopsychiatry, 45, 111–118.Google Scholar
  77. Tribe, R., & De Silva, P. (1999). Psychological intervention with displaced widows in Sri Lanka. International Review of Psychiatry, 11, 184–190.Google Scholar
  78. Trickett, E. (1984). Toward a distinctive community psychology: An ecological metaphor for the conduct of community research and the nature of training. American Journal of Community Psychology, 12, 264–279.Google Scholar
  79. United Nations High Commissioner for Refugees (UNHCR). (1997). The State of the World's Refugees. Oxford, England: Oxford University Press.Google Scholar
  80. van der Kolk, B., & McFarlane, A. (1996). The black hole of trauma. In van der Kolk, B., A. McFarlane, & L. Weisaeth (Eds.), Traumatic Stress (pp. 3–23). New York: Guilford Press.Google Scholar
  81. Von Buchwald, U. (1994). Refugee dependency: Origins and consequences. In Marsella, A., T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst Pain and Peril: The Mental Health and Well-Being of the World's Refugees (pp. 229–238). Washington, DC: American Psychological Association.Google Scholar
  82. Weine, S., Vojvoda, D., Becker, D., McGlashan, T., Hodzic, E., Laub, D., Hyman, L., Sawyer, M., Lazrove, S. (1998). PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. American Journal of Psychiatry, 155, 562–564.Google Scholar
  83. Weine, S. M. (1998). A Prevention and Access Intervention for Survivor Families. National Institute of Mental Health (ROI MH59573-01).Google Scholar
  84. Weine, S., Razzano, L., Miller, K., Ramic, A., Brkic, N., Smajkic, A., & Bijedic, Z. Comparing the Clinical Profiles of Bosnian Refugees Who Have Presented for Mental Health Services Verses Those Who Have Not. Manuscript under review.Google Scholar
  85. Werner, D., & Bower, B. (1990). Aprendiendo a Promover la Salud. Palo Alto, CA: Hesperian Foundation.Google Scholar
  86. Wessells, M. & Monteiro, C. (In press). Healing the wounds following protracted conflict in Angola: A Community-based approach to assisting war-affected children.Google Scholar
  87. Westermeyer, J., & Williams, C. (1986). Planning mental health services for refugees. In C. Williams & J. Westermeyer (Eds.), Refugee Mental Health in Resettlement Countries (pp. 235–245). Washington, DC: Hemisphere Publishing Corporation.Google Scholar
  88. Williams, C. (1986). Mental health assessment with refugees. In C. Williams & J. Westermeyer (Eds.), Refugee Mental Health in Resettlement Countries (pp. 175–188). Washington, DC: Hemisphere Publishing Corporation.Google Scholar
  89. Worthington, G. (November, 1999). Treating Bosnian refugees through shared rural culture and nonverbal accompaniment. Paper presented at the 15th Annual Meeting of the International Society for Traumatic Stress Studies, Miami, FL.Google Scholar
  90. Yamamoto, J. (1978). Therapy for Asian Americans. American National Medical Association, 70, 267–270.Google Scholar

Copyright information

© Human Sciences Press, Inc. 1999

Authors and Affiliations

  • Kenneth E. Miller
    • 1
  1. 1.Department of PsychologySan Francisco State UniversitySan Francisco

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