Understanding Refugee Mental Health and Employment Issues: Implications for Social Work Practice

Journal of Social Work in the Global Community 2020, Volume 5, Issue 1, Pages 19–30 DOI: 10.5590/JSWGC.2020.05.1.02 © The Author(s) Original Research Understanding Refugee Mental Health and Employment Issues: Implications for Social Work Practice Lindsey Disney, PhD, LCSW University at Albany, SUNY, Albany, New York, United States Jane McPherson PhD, MPH, LCSW University of Georgia, Athens, Georgia, United States Contact: Abstract Resettled refugees have high rates of some mental health disorders, such as PTSD and MDD, largely due to trauma histories and current resettlement stressors. Resettled refugees also have employment struggles that are unique to their status as refugees. This article provides overviews of refugee mental health and refugee employment issues with a specific focus on how these factors are interrelated in U.S. resettled refugee populations. The article describes prevalence rates of mental health disorders among refugees, barriers that limit refugees’ access to mental health treatment, and evidence-based mental health. Additionally, prevalence rates of refugee unemployment and underemployment are reported, along with barriers to adequate refugee employment. The article concludes with recommendations for social work professionals in their practices with resettled refugees in multiple settings: clinical practice, refugee resettlement, policy work, and research. Keywords: refugee; mental health; employment; unemployment; underemployment; clinical social work; resettlement; community-based interventions Date Submitted: March 20, 2020 | Date Published: September 9, 2020 Recommended Citation Disney, L., & McPherson, J. (2020). Understanding refugee mental health and employment issues: Implications for social work practice. Journal of Social Work in the Global Community, 5, 19–30. https://doi.org/10.5590/JSWGC.2020.5.1.02 Introduction Social workers practicing with refugee communities resettled in the U.S. have historically needed to choose between (1) clinical or trauma-focused practice and (2) case management or social adjustment-focused practice (Miller & Rasmussen, 2010, 2014). However, more recently, scholars are arguing that refugee populations require a more holistic approach that combines individual mental health treatment and the case management services that support successful resettlement (Engstrom & Okamura, 2004; Nazzal, 2014; Miller & Rasmussen, 2010, 2014). This shift in thinking can be traced to Miller and Rasmussen’s (2010) “War exposures, daily stressors, and mental health” conceptual model, which sought to expand upon the traumafocused models that conceptualized war traumas as the sole predicator of poor mental health by including “daily stressors” as a concurrent predictor. While Miller and Rasmussen were clearly not the first researchers to consider the negative effects of long-term, cumulative stress on mental health, their model provided an Disney & McPherson, 2020 integrative approach to understanding the interplay between trauma histories, current daily stressors, and mental health for refugee populations. Numerous post-migration resettlement stressors have been linked to poor mental health in refugees (Teodorescu et al., 2012). However, perhaps no other resettlement stressor has more effects on a refugee family than unemployment. Unemployment, or underemployment, can negatively impact refugee families in multiple areas, such as income, housing, social interaction, and social status. Additionally, employment issues are associated both with the existence of a mental health diagnosis and with symptom severity (Teodorescu et al.). This article provides an overview of refugee mental health, refugee employment issues, and the interplay between these forces. It also examines the social work practice recommendations that concurrently address refugee mental health and refugee employment issues, from literature published after Miller and Rasmussen introduced the “daily stressors” conceptual model in 2010. This article is intended to serve as a guide for social workers who want to increase their clinical, cultural, and social understanding of refugees and who want to incorporate evidence-informed recommendations into their practice with refugees. An Overview of Refugee Mental Health Refugees, by definition, have experienced extreme stress by the time they reach the United States for resettlement. A refugee, according to Article 1 of the 1951 Convention Relating to the Status of Refugees, is an individual, who, owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, unwilling to return to it. As is suggested by the definition, before fleeing their countries of origin, refugees may well have experienced human rights violations, including war, mass violence, persecution, family separation, torture, and rape. Certainly, the experience of persecution—and/or the fear of it—underlies the refugee experience. Also, before being resettled in the US (or in any of the resettlement countries), refugees are required to have taken up residence in a second country (often in a refugee camp) where they requested, waited for, and ultimately received their refugee papers from the United Nations. Their experiences in that second country may also have been traumatic, as violence, especially against women and children, are serious concerns in refugee camps (Lischer, 2015). When experts conceptualize refugee mental health, they think of the continuum of the refugee’s experience: pre-migration in the home country; migration as the refugee fled home and sought initial refuge in a second country; and post-migration in the resettlement country (Bhugra & Jones, 2001). Mental health concerns may originate in any of these stages (Kirmayer et al., 2011). Prevalence of Mental Health Disorders in Refugee Populations Given their histories of trauma and dislocation, it is unsurprising that refugees have high rates of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), complicated grief, and somatic disorders (Craig et al., 2008; Fazel et al., 2005; Hocking et al., 2015). In a systematic review of psychiatric research on nearly 7,000 refugees living in Western countries, the prevalence of PTSD among refugees was found to be nearly ten times as high as that in non-refugee populations (Fazel et al., 2005). And in a study of 126 Bosnian refugees resettled in the United States prevalence rates of PTSD were 66.6%, complicated grief was 54%, anxiety was 40%, and depression was 31% (Craig et al., 2008). All these rates are higher than the relevant rates in the U.S. (...truncated)