Patricia J. Shannon

Screening for War Trauma, Torture, and Mental Health Symptoms Among Newly Arrived Refugees: A National Survey of U.S. Refugee Health Coordinators

A total of 44 state refugee health coordinators returned a survey assessing mental health screening practices and barriers to screening. Results show that less than half the states ask refugees about a history of war trauma or torture. Of the 25 states that provide mental health screening, 17 (70.8%) utilize informal conversation rather than standardized measures. Screening practices are highly associated with the number of refugees and community discretionary grants and with the presence of a Services for Survivors of Torture Program. Refugee health coordinators identified the need for short, culturally appropriate mental health screening tools to identify refugees who need assessment and treatment services.

Beyond Stigma: Barriers to Discussing Mental Health in Refugee Populations

Mental health stigma remains one of the most commonly cited reason for why refugees fail to access mental health services. This study looks beyond stigma to explore refugees’ perspectives on why it is difficult to discuss mental health. Ethnocultural methodologies informed 13 focus groups with 111 refugees from Burma, Bhutan, Somali, and Ethiopia. Findings describing reasons why it is difficult to discuss mental health include a history of political repression, fear, the belief that talking does not help, lack of knowledge about mental health, avoidance of symptoms, shame, and culture. Recommendations for empowering and educating refugees are discussed.

Exploring the Mental Health Effects of Political Trauma With Newly Arrived Refugees

We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culture-bound disorders and idioms of distress.

Refugees' advice to physicians: how to ask about mental health

BACKGROUND About 45.2 million people were displaced from their homes in 2012 due to persecution, political conflict, generalized violence and human rights violations. Refugees who endure violence are at increased risk of developing chronic psychiatric disorders such as posttraumatic stress disorder and major depression. The primary care visit may be the first opportunity to detect the devastating psychological effects of trauma. Physicians and refugees have identified communication barriers that inhibit discussions about mental health. OBJECTIVES In this study, refugees offer advice to physicians about how to assess the mental health effects of trauma. METHODS Ethnocultural methodology informed 13 focus groups with 111 refugees from Burma, Bhutan, Somali and Ethiopia. Refugees responded to questions concerning how physicians should ask about mental health in acceptable ways. Focus groups were recorded, transcribed and analyzed using thematic categorization informed by Spradleys Developmental Research Sequence. RESULTS Refugees recommended that physicians should take the time to make refugees comfortable, initiate direct conversations about mental health, inquire about the historical context of symptoms and provide psychoeducation about mental health and healing. CONCLUSIONS Physicians may require specialized training to learn how to initiate conversations about mental health and provide direct education and appropriate mental health referrals in a brief medical appointment. To assist with making appropriate referrals, physicians may also benefit from education about evidence-based practices for treating symptoms of refugee trauma.

Characteristics of Successful and Unsuccessful Mental Health Referrals of Refugees

In this community based participatory research study, we explored key characteristics of mental health referrals of refugees using stories of providers collected through an on-line survey. Ten coders sorted 60 stories of successful referrals and 34 stories of unsuccessful referrals into domains using the critical incident technique. Principal components analysis yielded categories of successful referrals that included: active care coordination, establishing trust, proactive resolution of barriers, and culturally responsive care. Unsuccessful referrals were characterized by cultural barriers, lack of care coordination, refusal to see refugees, and system and language barriers. Recommendations for training and policy are discussed.

Torture, War Trauma, and Mental Health Symptoms of Newly Arrived Karen Refugees

This article documents frequencies of torture, war trauma, and associations with mental health distress reported by Karen refugees during their initial public health screening in the United States. A total of 179 Karen refugees completed a demographic questionnaire and 25-item mental health screening tool scored on a 4-point Likert scale. Frequencies of primary and secondary torture were 27.4% and 51.4%, respectively. War trauma was reported by 86% of the participants. Torture, older age, and female gender were significantly associated with increased total distress, posttraumatic stress, depression, and somatic complaints. Recommendations are reviewed for discussing mental health symptoms with Karen refugees.

Developing self-care practices in a trauma treatment course

This article describes the development of self-care practices of social work students who were part of a larger study of students’ experiences in a graduate course on the treatment of trauma. Consensual qualitative research methods were used to analyze 17 participant journals submitted at 4 times during the course. Findings indicated that students benefited from being introduced to evidence-based practices for mediating the stress of trauma education, including journaling and mindfulness-based stress reduction. Although students reported struggling with developing effective self-care practices, they demonstrated an ability to integrate self-care into their professional practice behaviors. The authors review recommendations for research and pedagogy of self-care practices in courses on trauma treatment.

War trauma and torture experiences reported during public health screening of newly resettled Karen refugees: a qualitative study

BackgroundKaren refugees have suffered traumatic experiences that affect their physical and mental health in resettlement. The United States Centers for Disease Control and Prevention recommends assessing traumatic histories and mental health symptoms during initial public health screening. This article reports the traumatic experiences that Karen refugees were able to describe during a short screening and contributes knowledge to existing human rights documentation systems.MethodsFour semi-structured and open-ended items asked about lifetime experiences of war trauma and torture. Interviews were completed with adult, Karen refugees during their initial public health screening. Experiences of war trauma and torture were coded using the extensive Human Rights Information and Documentation (HURIDOCS) Micro-thesauri coding system. Additional codes were created to describe experiences not captured by existing codes.ResultsOver 85% of 179 Karen people interviewed experienced life-threatening war trauma. All participants who reported war trauma or torture stories were able to describe at least one event. New war trauma codes proposed include: widespread community fear, systematic destruction/burning of house or village, exposure to dead bodies, orphaned in the context of war, injury caused by a landmine, fear of Thai police or deportation from Thailand, and harm or killings in the context of war. New torture codes include: forced portering; forced to be a human landmine sweep; forced to be a soldier, including child soldier; forced contact with a dead body; and removal of the eyes.ConclusionKaren refugees were able to report traumatic experiences in the context of a brief health screening. The findings confirm existing reports of human rights violations against Karen people and suggest that additional codes be added to the HURIDOCS Micro-thesauri system that is used by torture treatment centers. Understanding the nature of traumatic experiences of this group is important for health providers working with resettled Karen refugees in their countries of resettlement. Health providers may need specialized training to understand the traumatic histories of this new refugee group, learn how to initiate conversations about trauma and its impact on health, and make appropriate mental health referrals in the context of a brief public health screening.

Experiences of Stress in a Trauma Treatment Course

This study explores the reactions of social work students in a course on trauma treatment and how those reactions changed over time. Consensual qualitative research methods were used to analyze 17 participant journals submitted at 4 times during the course. Findings indicate that students experienced a range of responses to traumatic material, including both positive and negative emotional, cognitive, behavioral, physical, and relational reactions. Student survivors of trauma reported reactions related to their own trauma. Although student reactions became less acute over time during the course, recommendations for the pedagogy of trauma are offered, including curriculum related to the management of vicarious and secondary trauma reactions as well as the development of evidence-based practices for self-care.

Validation of a brief mental health screener for Karen refugees in primary care

BACKGROUND Karen refugees from Burma are one of the largest refugee groups currently resettling in the USA. Karen people have endured decades of civil war and human rights violations, leaving them more likely to develop serious mental health disorders. There is a noted lack of brief, culturally validated tools present in primary care settings for detecting posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) in Karen refugees. OBJECTIVE To create the Karen Mental Health Screener, a five-question screening tool used to identify depression and PTSD and to validate it against a clinical reference standard. METHODS This validation study was conducted during a primary care visit. Participants completed a 20-item questionnaire using a 4-point visual aid and the PTSD and MDD portions of the Structured Clinical Interview for DSM Disorders (SCID-CV for DSM-IV) as the reference standard. Both the questionnaire and the relevant sections of the SCID-IV were rigorously translated and administered by trained researchers along with a trained Karen interpreter. RESULTS Logistic regression models and receiver operating characteristic curve analyses were used to determine a subset of items that could be used to construct a screener to identify Karen patients who were most likely to have PTSD and/or MDD. A final five-question screener was created with very strong performance characteristics. With a clinical cut score of 4, these items displayed very strong performance characteristics with sensitivity = 0.96, specificity = 0.97, positive predicted value = 0.83 and negative predicted value = 0.99. CONCLUSION The Karen Mental Health Screener is a valid measure for detecting PTSD and major depression in Karen people from refugee backgrounds presenting in a primary care setting.