Culturally Responsive Trauma Assessment for African Refugee Youth in New Hampshire

1. Community Dialogue and Needs Assessment for Addressing Traumatic Stress among Resettled African Refugee Youth in New Hampshire Directors/Investigators Michelle V. Porche, EdD Wellesley Centers for Women, Wellesley College Lisa R. Fortuna, MD, MPH University of Massachusetts Medical School Stanley D. Rosenberg, PhD Dartmouth Medical School, PATT Funding Support and Partners New Hampshire Endowment for Health National Child Traumatic Stress Network Wellesley Centers for Women University of Massachusetts Medical Center New Hampshire Charitable Foundation http://www.wcwonline.org/nhrefugee

2. Traumatic Stress (Becker, et al., 2003) • In traumatic stress we tend to focus on the event and not the individual response, but it is the nature of the response that is most important in understanding the effects of trauma on an individual's immediate and subsequent psychological functioning. • Individuals and communities can experience severe and difficult events, it is the subjective psychological experience that is the crucial aspect of psychic trauma. In this sense, it could perhaps be said that trauma is in the eye of the beholder; trauma exerts its effects through the prism of meaning. Environments and supports can be implemented to be responsive to psychic trauma and promote relief and even healing.

3. Aims of this Needs Assessment • Extension of New Hampshire Project for Adolescent Trauma Treatment (PATT), with primary focus on African resettled youth and families. • Create trauma-informed and responsive systems within New Hampshire by: • strengthening awareness of treatment gaps for refugee youth • understanding the intersection of immigration, culture and trauma in services needs • identifying next steps for addressing traumatic stress among resettled refugee youth.

5. General and Mental Health Care Concerns • Limited period covered by health insurance • 8 months • Language Barriers: increased access to interpretation services, greater variety of interpreters in order to maintain privacy of those needing mental health services • Stigma and cultural differences in understanding emotional health and understanding trauma • Competing demands: basic needs need to be met first

6. Trauma Specifics • Need to define trauma in the context of refugee experiences • Multiple trauma—compounded with loss • Intergenerational—shared and differing trauma between parents and youth • Gender role stress—affecting men and women differently • Stressors of acculturation, economic stability and adjustment following political violence and the refugee camp experience • Is a community vs. an individual approach to intervention more helpful here? • Alcohol abuse and addiction as co-morbid occurrences

7. Sources of Resiliency • Parents hopeful and invested in the prosperity of youth • Youth often aspire to higher education and/or economic prosperity • Religious practices and customs • Family is a central source of support • New Hampshire has dedicated ethnic leaders • Traditions and the importance of respecting elders

8. Provider Requests for Interventions:Cultural Competency Training Cultural competency training that includes increased understanding of differences related to countries of origin as well as tribal differences within specific countries religious practices and customs gender roles and expectations trauma in families and communities

9. Cultural Competence in Interpreting Social Cues • A classic example that you always hear from people in authority is, you know, when you talk with a kid or a young person, you want them to look you in the eye. And we read something into it if they don’t look you in the eye. Well, in some cultures, as you know, you would never look an adult in the eye. Particularly if you’re being reprimanded! So that’s just one very concrete example in terms of why we have to do more in terms of cultural competency and cultural effectiveness training, so people can kind of understand the various dynamics.

10. Suggested Interventions:Trauma Training Cultural and developmental understanding of trauma Increased understanding of the secondary effects of trauma on children whose parents experienced direct trauma Increased understanding of the effect of long-term stays in refugee camps Understanding what mental health means for the refugee community

11. Secondary Effects of Trauma on Children • There was a mother who seemed to be struggling with substance abuse issues, a single mom, and I believe she had four children. She spoke English, but she also wanted to make sure that she understood everything so she had an interpreter. But what ultimately happened in her case was that it sounded as if she became neglectful. She was starting to just go out and wander out and leave her children, sometimes leaving them with strangers. And then there was a question if she was struggling with her own mental illness issues. But what ultimately happened is DCYF came and removed the children.

12. Cultural Understanding of Mental Health • I was just talking to somebody actually last week from the World Health Organization in Geneva, who had just come back from Burundi. And he said, “There’s two psychiatrists for fifteen million people.” So there’s really no mental health system there to speak of. And then culturally, a lot of people still believe in spirits and have different beliefs about why somebody’s ill. And so bridging that sort of divide about our understanding clinically of mental health issues and trauma with somebody’s cultural beliefs and faith is a challenge.

13. Follow Through with Services • We found that often times a family would be referred for care for a child, but the family didn’t follow up on it. And when the health agency followed up with the family, they said, “Hm, my kid’s okay now.” They might have come into either a sick-care visit or a well-child visit saying, “They’re not sleeping. They’re angry. They seem, you know, withdrawn.” But when it actually came time to make that next step, even with a facilitated referral they said, “You know what? They’re okay.” And that’s something we haven’t quite gotten our hands around, going what’s happening in between that time?

14. Suggested Interventions:School Programs Accommodation strategies for working with students who have behavioral problems related to trauma Information for teachers regarding strategies for working with traumatized students, help them to understand boundaries of involvement with clear directions for referrals Funding that would allow mental health to partner with schools: consultation around how to set up a classroom, appreciation of culture, training about trauma and its meaning for youth, psychotherapy sessions or a group in the school. Cultural liaison person within the schools Family orientation nights at the children’s schools, with interpreter assistance

15. Strengths and Barriers to Learning We discovered a need for some of our children that have had in their early years no educational experience and extended periods in a camp and a lot of war trauma and their families experiencing that stress a long time. A strength of all the families is that they’re very motivated to learn. Education is highly valued. But they just have so many barriers to overcome in terms of not having skills that can be used readily in a new culture.

16. Adjustment to School Parents are trying to learn English, get some job-training skills, find a secure place to live, pay their bills, take care of their children, and then begin the process of settling and acclimating into the community. So the children have to come to school. But it’s their first educational experience. And a lot of them enjoy learning but maybe exhibit some behaviors that are difficult in school -- a very difficult time sitting and attending for long periods of time, which is very natural.

17. Culturally Defined Expectations of Parent Involvement • And my role is to support and encourage families that might not otherwise come. So we look for barriers like transportation or understanding. In Africa, when you turn your children over to the school, then they become the parent. And so you only go to school if there’s a severe problem. And something that we had to learn to understand, because it was scary for parents to come, and it didn’t make sense to them. They’re very respectful of educators. Which is a very positive thing in many ways, but also can be a problem if they might have concerns and worries, because they don’t know that they can be a partner in their child’s education.

18. Educators’ Need for Trauma Training • Educators are hungry for information. There are sort of different levels. I think that just understanding cultures is a really important piece of the training. God Grew Tired Of Us, about the Sudanese boys, was presented and a lot of our staff went to that. But to understand that it’s a truly different experience for kids. You know, we all feel at a loss with some of the behaviors. So we do a lot of trial and error. So it would be nice if someone that’s had some good success with trauma could train us. Tell us about good research showing how to teach kids who’ve experienced trauma.

19. Suggested Interventions: Adaptation of Evidence-Based Treatment Adaptation of interventions so that they are responsive to trauma but focused on communities rather than individual families. Group work rather than individual therapy Training of community leaders to be mental health workers School-Based groups/narrative therapy/CBT groups Parental empowerment and outreach by culturally competent liaison A medical home: integrated mental health, medical and social services from providers skilled at working with the refugee and immigrant population, and with adolescents and people in poverty Home visits by providers to see families where they are most comfortable

20. Suggested Interventions:Post-Resettlement Programs Short-term resettlement support and educational workshops that might start once the “honeymoon period” is over, so that individuals know what to expect and better understand feelings of distress, rather than feeling isolated Women-centered groups and educational advancement of girls and women Literacy projects for parents ESL classes that fit work schedule better Train the trainer model of ESL so that individuals learn English from African community leaders who share the same ethnic background Medical and mental health literacy for parents Employment training and opportunity Culturally competent interventions to respond to domestic violence

21. Suggested Interventions:Cultural Brokers and Mentors Newcomer groups providing access to information about nuts and bolts of daily living in NH, school systems, social service agencies, local and US culture Reverse mainstreaming [in schools], where the other youth can come in and work together with refugee/resettled youth, so that they develop peer relationships

22. Next Steps Recruitment of an advisory group to guide the development of community selected pilot interventions including seeking appropriate funding Inform the development of trainings responsive to the need of mental health providers, schools, communities, ethnic leaders and families Cultural competence Refugee and cross-cultural mental health Child and adolescent trauma intervention/treatment Dissemination of results across community sectors, for policy makers and the greater mental health field