Historical Roots and Contemporary Perspectives: Mental Health Considerations with Refugee and Asylum Seeking  Children, Youth and their Families

In this special journal issue, we focus on the mental health needs of children, adolescents, and families who have been forced to flee their homes due to extreme, catastrophic conditions resulting from war, religious and ethnic persecution, violence, and human rights violations.

Tragically, we continue in the twenty-first century to confront the mental health consequences of these devastating experiences impacting children, youth, and families worldwide. In recent years, persons in South Sudan, Somalia, Ethiopia, Afghanistan, Syria, Myanmar, the Northern triangle of Central America (NOTC), and Venezuela are among those reported to be most significantly impacted, many fleeing their former homelands, and arriving in Turkey, other countries in the Middle East, Europe, Australia, the United States and Canada seeking asylum and resettlement. (For further demographics based on United Nations reports, see Kaplin, D., 2019). Though the countries of origin may differ from those of earlier years, the consequences are sadly familiar. Few of us can fail to be moved by the photos of children trapped and/or fleeing war-torn and violence-ridden areas. We are devastated at the sight of youngsters escaping bombs, small children confined behind barbed wire or fences, and the bodies of asylum-seeking children washed ashore on the beaches of countries in various locations worldwide. The diversity of needs presented by those effected compel us to continue to grow in our understanding of international policy, psycho-social impact and recent approaches to assessment and treatment interventions at various stages of the forced migration experience. Articles in this special issue present the thinking and personal reflections of contemporary clinicians involved currently with these populations. Some are newer voices, others more seasoned contributors to these efforts. We also wish to acknowledge a long history of the contributions of mental professionals on whose shoulders many stand as they develop our contemporary perspectives. Acutely aware of the lifelong ramifications of early and enduring trauma, the potential for intergenerational transmission of the traumas sustained, and the complexity of the bio-psycho-social needs of this highly vulnerable population, mental health clinicians from a variety of helping professions and theoretical perspectives, have for decades been contributing to and integrating a burgeoning literature on trauma and crisis intervention as they consider interventions for refugees and asylum seekers (Apfel & Simon, 1996; Garbarino, Kostelny, & Dubrow, 1991).

The work of early child psychoanalysts  in Great Britain  during the second world war (Freud & Burlingham, 1943; Kennedy, 2009; Bowlby, 1988a; Winnicott, 1939a; Klein, 1984) and  the evolution  of child psychoanalysis  was  itself  intimately intertwined with war. Psychoanalytic theory and its practitioners had in fact been embedded in a social context much influenced by the first world war (Newcomb and Lerner, 1982, re-printed 2016; Roper, 2016) and the forced migration of  many of its most prominent theoreticians from both wars as well (Bragin, 2019b; Hollander, 1997). Integrating a growing understanding of the impact of violence, traumatic separation and loss as an aspect of the refugee experience, contemporary psychoanalysts, have continued to make impressive contributions, bringing a  psychoanalytic sensibility and evolving developmental perspective into clinical interventions around the globe. What distinguishes several of the articles in this issue, are their rootedness in this psychoanalytic heritage. We note themes of meaning-making and the destructive influence of trauma on the capacity to think and symbolize. We note an awareness of the individual uniqueness  of emotional experience, the importance of the inner world and fantasy, the importance to identity formation of formulating a coherent narrative of one’s life experience and the significance to their future development of attachment relationships between children, caregivers and all who work with them. As psychoanalytic theory has evolved, so too has our understanding of the impact of forced migration upon the emotional development of young people, bringing some newer conceptualizations and integrations.  Specific cultural considerations have come to be deemed of paramount importance in conceptualization, assessment, and intervention, as European and American perspectives on mental  health assessment and intervention, are now understood to not always be easily generalizable or acceptable to populations from areas of the world with vastly different cultural perspectives (Bragin, 2019b; Clauss-Ehlers, 2019; Kaplin, Parente, & Santacroce, 2019).

We begin this issue with an article by our Guest co-editor, Daniel Kaplin (2019) “Framing the Issue: An Introduction to Various Types of International Migrants, Latest Figures, and The Central Role of the United Nations.”

Daniel Kaplin presents in stark demographic detail the magnitude of the refugee crisis confronting the world today. Providing, as well, a variety of important definitions and international policies promulgated by the United Nations, he contextualizes the current child refugee situation and creates a framework for understanding the plight of forced migrants within the broader world migration process.

Martha Bragin (2019b) beginning with a poetic evocation of the centuries-old plight of refugees worldwide, deftly introduces us to a psychoanalytic perspective on the personal and culturally rooted experience of refugees, and the impact of trauma on the unique functioning of each individual. Bringing a psychoanalytic sensibility to her work, born of years of experience with children and adolescents exposed to violence in various parts of the world, (inclusive of non-European, non-American cultures as well as Western cultures), she demonstrates the sensitivity required to hear and permit each individual’s unique story to unfold. Her examples of clinical work with adolescents resettled in the United States demonstrate an alertness to aspects of the adolescent’s history which have for multiple reasons been disconnected from their current personal narratives. Her knowledge of the impact of trauma on the ability to think, make meaning, and to create personal narratives, leads us to a clear understanding of what she believes is necessary to occur in a well-conducted psychotherapy with an adolescent refugee. She shares with us her integration of the works of Wilfred Bion (1957, 1961), Donald Winnicott (1939b), Jacques Lacan (1948), John Bowlby (1988, 1973) among others, as she approaches the complexities of clinical diagnosis and treatment. Deftly woven into her article is a reminder that in addition to the Freud’s, Anna and Sigmund, many significant contributors to the development of psychoanalysis were themselves refugees from War torn Europe, intimately tying the history of theory and practice of psychoanalysis to the very issue we are studying today.

We then continue with Clauss- Ehlers (this issue, 2019) culturally sensitive and clinically relevant discussion of the multiple steps migrants go through on the safety-seeking journey. Beginning with a definition of Forced Migration, she introduces the concept of “Trilateral Migration Trauma”, as a new model for understanding the complex experience of those seeking asylum. Using the refugee crises in Venezuela and Central America as illustrative of the problems facing forced migrants, she describes the experiences of children, youth and families from Venezuela and the northern triangle of Central America (Honduras, El Salvador, and Guatemala), at each stage of the migration process. Suggesting each stage of the process has implications for the other, she further expresses nuanced perspectives on both the cultural differences and premigration circumstances of refugees from each country and the clinical implications and needs of children undergoing this process.

Three articles in this issue present recommendations for intervention at refugee resettlement centers in international locations.

Virginia Fernandez (this issue, 2019) has worked as a clinician/therapist with child and adolescent refugees in resettlement centers in both the United States and Spain. Bringing to her work her relational psychodynamic sensibility, and her experience as a family therapist trained to work with traumatized people, she reflects upon the lack of the experience of safety as a critical issue in the lives of her young patients, and indeed at every level of the system, impacting providers as well as all who interact with the refugees. Reflecting upon her experience as a first-line mental health provider working with child refugees from the Northern Triangle of Central America and Venezuela, she explores the impact of a lack of safety, so crucial to growth in any form of psychotherapy, on any attempt to provide psychotherapeutic interventions in settings holding separated child and unaccompanied minors. Bringing her article alive with clinical snapshots, she describes the intense anxiety, hopelessness and the experience of deep uncertainty which pervades the entire experience at all levels of the system. She presents her use of Diana Fosha’s Accelerated Experiential Dynamic Psychotherapy (Fosha, 2000), a clinical model from which she conceptualizes her work, and which she feels helped mitigate a sense of futility about what she has to offer in her sometimes brief encounters of uncertain length.

Judith Kuriansky (2019, this issue) presents her model for Psychosocial Support Training during a Medical Mission for Syrian Refugee Children in Jordan. This article describes a model of a training workshop for volunteers that was implemented as part of a program for child refugees. The goal,  as the author states, “is rooted in similar crisis intervention models used elsewhere, to build for the children, three aspects of personal, interpersonal and social growth: (a) empowerment, (b) resilience, and (c) connection with others”. She reports the intervention is consistent with the Interagency Standing Committee’s Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007), which outline stages of interventions from the most basic to the most intensive provision of services for those affected. In addition to concrete recommendations derived from her extensive experience working in crisis conditions, she presents the above policy recommendations represented visually as a pyramid for planning and coordinating recovery and rehabilitation interventions for the mental health and well-being of persons in emergency situations.

Further contributing to our consideration of primary intervention is the work of Geoff Goodman and Valeda Dent (2019a, this issue). They present a novel intervention program which they hope will improve school readiness skills of preschool children ravaged by war, dislocation, and poverty. They express the hope that this proposal, designed initially for work with Syrian refugee children and caregivers who have fled to Turkey, will serve as a template to be implemented in other regions experiencing an influx of refugee families who need immediate psychological service. Stressing the importance of working with both parents and children, they propose a two-generation intervention program that addresses the socioemotional needs of caregivers and their preschool children under international protection. They describe a caregiver intervention, which consists of trauma-sensitive yoga; and a child intervention, which consists of a storytelling and story-acting activity. They also discuss how to assess the effectiveness of this two-generation intervention program. The storytelling and story-acting activity has been used elsewhere, including an intervention the authors, have initiated in Rural Uganda which has shown promising results in the development of Theory of mind, emergent literacy and receptive vocabulary (Goodman & Dent, 2019b).

The following articles focus specifically on the mental health clinician’s role in assessing persons who are seeking asylum.

Phyllis Cohen, Robert Bartlett, Barbara Eisold, Sharon Kozberg, Lisa Lyons, and Zina Steinberg (this issue, 2019) present their work as members of the New York University Postdoctoral Program Immigration and Human Rights Workgroup. This group of psychoanalysts describes in experience-near terms, both the content and process of performing the evaluations of each member of an asylum-seeking family. Presenting rich clinical vignettes, the authors describe a focus on the trauma suffered and its apparent impact on the children and adolescents involved, as well as the complex process of gaining information necessary to support individual affidavits for members of an asylum-seeking family. They also reflect on their own experience and process as they gain experience with this new role which involves interacting with translators, as well as attorneys involved in pro bono representation of the asylum seekers.

William Salton and Carl Auerbach (2019) describe the development of a university-based program to train graduate students in clinical psychology in the process of assessing asylum seekers. Believing in the necessity of training their students to develop this new competency, they explore the early resistances of the university, the process and some content of the curriculum, and the emotional issues raised for students and faculty as they began to learn more about and become involved with those who are seeking asylum. Students learn through first-hand experience about the lives of the refugees they are interviewing and the systems with which asylum seekers must interact. They also wrestle with the different interviewing skills required for asylum assessment and those they have been taught in conducting psychotherapy. The training involves assessment of actual refugees, the development of legal affidavits, and collaboration with attorneys representing the clients. The authors describe the obstacles they face, and the sometimes painful experiences students and faculty need to work through as they interview persons actually applying for asylum.

Anna Dobretsova and Elizabeth Batista Pinto Wiese (2019, this issue), each having resided, studied and/or worked for extensive periods of time in more than one country, with different cultural heritages, bring an exquisite multi-cultural sensitivity to their research. Anna Dobretsova, born in Saint Petersburg, is a Russian/Dutch graduate student from University College Roosevelt, Utrecht University, who became fascinated with the Sandplay method, inspired by the research of her supervisor, Dr. E. Wiese. Dr. Wiese has worked for many years as a psychotherapist with children, adolescents, and families at the International Center for Victims of War, Trauma and Political Violence, in the Netherlands, in parallel with a long career as a university professor in Brazil, France, and the Netherlands. Thus, her expertise in work with traumatized refugees adds a powerful dimension to this article. In this work, they explore the use of Sandplay to identify signs suggesting psychotrauma in scenarios of unaccompanied asylum-seeking adolescent refugees of African origin. They present the importance of research and the difficulty in assessment of psychological trauma and its dynamics for those with severe trauma, who arrive unaccompanied from other cultures. They describe both the Sandplay methodology and the dearth of research on its use for assessment and treatment with this particular population. After providing important data about the prevalence of unaccompanied adolescents in the Netherlands, and concerns about the psychological and behavioral sequelae of the traumatic circumstances of these youth who are alone in a foreign culture, they present an important literature review, inclusive of detailed information about the application of Sandplay (Kalff, 2003) as a method for psychological assessment and intervention which had to date been devoid of research with respect to this particular population. They provide a particularly rich description of the Sandplay methodology and their findings. They conclude that their research, despite its stated limitations, suggests the Sandplay method can bring knowledge about the mental functioning of the client and his/her traumatic experiences, which in the long term can positively contribute to the therapeutic process. Thus, this research actually serves as a bridge to the next article which reflects a current multi-tiered model for intervention with those in resettlement situations (temporarily or permanently, living in the community, in countries with vastly different dominant cultures.

Daniel Kaplin, Kristen Parente, and Francesca Santacroce (2019, this issue) bring us the final article in this special issue. They present a review of a treatment model “Trauma Systems Treatment for Refugees” (Ellis, Miller, Baldwin, & Abdi (2011), designed to address the multi-faceted needs of refugee children adolescents and their families after resettlement in the community of the host country, in this case, the United States. The model has been developed and used within the United States, with Somali, Somali-Bantu, and Bhutanese children, adolescents, and their families and has now begun to be extended to other refugee communities within the United States. To date, it has not been significantly assessed for its generalizability abroad.

Recognizing that refugee children and their families can face adverse experience at varying points in the immigration process, the TST-R approach addresses four core stressors conceptualized as traumatic, acculturative, isolative and resettlement stress. Treatment teams include home-based clinicians, an outpatient clinician, school-based clinician, a clinical supervisor, an organizational support person and a “cultural broker” (National Child Traumatic Stress Network [NCTSN], 2016). Interventions may occur at any or potentially several levels of a multi-tiered model). In this model, there is an emphasis on community and parent engagement (Tier 1), school-based skills groups (Tier 2), intensive individual therapy (Tier 3), and home-based/family therapy (Tier 4), with significant interventions occurring in the school, family residence or other community-based locations such as an outpatient mental health clinic. The use of Cultural brokers, who have significant knowledge of the culture of the community from which the refugees migrated, is an important and integral part of the success of all interventions.

The Multi-tiered Model is described in substantial detail in this review article, with strengths and weaknesses reviewed and its rootedness in the bioecological model embraced by many contemporary trauma therapists extensively described. It is a fitting final article for this issue.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Disclosure statement

No potential conflict of interest was reported by the author.