Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States
Abstract
:1. Introduction
A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.(p. 9)
2. Methods
2.1. Data Collection and Participants
2.2. Individual Interviews
- Awareness of trauma and trauma impacts (individual staffer)
- Screening or assessment of trauma or trauma-related needs
- Intervention or services to address trauma recovery or promote resilience
- Organizational culture for trauma sensitivity
- Administrative or policy-level support and strategies
- Trauma-informed workforce development (trauma-related training, supervision, etc.)
- Referrals to other resources to meet different trauma-related needs
- Interagency and intra-agency collaboration
- Evaluation or quality control/management for TIC
2.3. Data Analysis
3. Findings
3.1. Relevance of TIC to Refugees in Resettlement
3.1.1. Prevention of Retraumatization during Resettlement
Including the mental health component of intake assessment [is a part of providing trauma-informed and culturally responsive care]. I think that helps to identify the needs of the client and then helps you tailor to services that you provide so that they include the mental health component and take into consideration the past trauma of that client.
After 90 days, people have to pay their rent and live on their own. Not knowing anybody to rely on in the community, how can you manage to take care of five children, learn English, learn driving or get a ride, worry about families you left behind, send them some money if you can, and work on a minimum wage job? I can’t imagine how stressful, draining, and even traumatic it can be.
Our clients are low-income. They are in poverty. They are not making living wages. They have more than likely experienced trauma. There’s one thing to convey to staff that might change or enlighten our services is the real tangible facts. We talk about how to give better services to somebody. It’s regarding this person’s past experience of trauma and the stress that they feel. How does that stress manifest? Is it forgetfulness? I think if we understood the real, tangible, meaningful effects of suffered trauma and living in poverty, then […….] I think that might remove some of the immediate frustrations.
3.1.2. Groundwork for Trauma Recovery
3.2. Current Practice
3.2.1. Divide between Tacit Knowledge and Lacking Awareness
My job is to see client facing trauma, so a lot of times psychoeducation component could definitely be helpful because when people come into my office. Refugees or not, or immigrants or asylum seekers, a lot of them are suffering from trauma or are in the stages of crisis. [……] It’s not always the right time to tell someone ‘you might be suffering from the effects of trauma.’ But sometimes when people get out of crisis it can be helpful to just put a name on some of the things that they’re feeling.
If we have the resources to actually see the signs, we can help this person. They think this is their state of mind, just overlooking that behavior if we are not trained enough to see that this is very typical signs of trauma. If we were trained, then we will help them referred to resources that can help them.
You’re already in crisis and everyone around you reminds you that you need to come up and stand on your feet and move on. Nothing that you’ve been through even matters anymore. What matters is what you have to do from today and on.
There is a big disconnect between the idea of our organization having deadlines and a certain amount of time and money that can be spent on people. Then, at the same time, in reality, in order to serve them best, wanting to give them the time that they need to process and make decisions, knowing that you have to be patient with that process, possibly because of trauma. [……] I think one of the more frustrating aspects is having to fulfill the requirements of the job, but at the same time, wanting to give the client autonomy and time. A lot of times, it feels like if a client doesn’t fit into that timeline that it’s almost like the system punishes them for that.
3.2.2. Growing Needs, Growing Interest
Whatever we can do to help clients feel heard and feel safe. Especially right now, with this political climate. I think that there is a lot of heightened anxiety, and so prioritizing being able to welcome clients, truly, even to help them feel like humans. And just listening to their needs. I genuinely believe that that [TIC] is the top priority.
I think it’s important for everyone to at least have a superficial understanding of what to look for and how they can refer to the correct people. And I do know that we have a three-year plan for having all of the centers that provide support to families have a trauma-informed approach.
3.3. Challenges in TIC
3.3.1. Lack of Competencies for TIC
Obviously, since our goal in my program is to provide trauma informed service, we had training on trauma, but we didn’t have training specifically about refugees. We would talk about being culturally responsive, but there was no specific training on refugees. Then, I feel like after coming to this [refugee-specific TIC training], I kind of was like thinking like, ‘Gosh, I think families I’ve already been working with, I wish I had a little bit more of this [refugee-specific TIC training] before I even started.’
Capacity is, I feel like probably, just not enough. With the current [Trump] administration and climate, less people have been migrating at least in this area. I know there have been budget cuts and things of that nature, so capacity would probably be an issue.
3.3.2. Missing Culturally-Relevant Care
Having a little bit better understanding of the capacity of the agency could be good. If there was, like, maybe a meeting where all of them had a very firm understanding of what our agency is offering and here’s what we’re trying to refer out. I think that could be good. I’ve noticed some clients getting referred back and forth, which isn’t good.
Sometimes some of the organizations we work with extensively, especially in the government, they don’t really have any training. So, you can do a lot of really great work with the client, where you feel like you’re making a lot of progress, and then they can leave and go to Health and Human Services, and just have a terrible time because the employees there aren’t using the same kinds of principles, so it’s just not matching up in the same way.
3.3.3. Community Capacity and Systems for Culturally Responsive TIC
I just feel like we’re kind of set up to fail currently in many ways. If we’re not failing the clients in the service we’re providing, we’re failing to be able to fully document it because we just don’t have the time for both and that jeopardizes the future of our ability to defend the funding for it to be given. That takes an emotional toll on all of us. They want to see a certain number of clients served within a fiscal year. They want to see a certain number of units of service provided to those clients within that fiscal year.
I don’t want to blame external forces all the time because I think there are also organizational changes that can always be made, but I think the biggest barriers are probably rules implemented by other organizations or restrictions on grants or reporting things that feel like they kind of slow down the work we do or even prevent the kind of work that we would like to do.
I think beginning to identify the needs after a year is very helpful for people to make good decision versus when they are at the first month mark. […….] I think it would be helpful [for refugees to receive services for a full year] because your priority is not survival, but your priority is actually planning for your future and recovering.
3.4. Opportunities for TIC
3.4.1. Growing Interest, Growing Opportunities
My agency, maybe like a year ago, they had one workshop about mental illness. At that time, I see people from different community, even from my [refugee] community, they came and they talk about mental illness. They came to know about what is mental illness and these things [TIC]. [……] Our agency did trauma training last year, and I don’t know about this year, but yeah, it would be more I know, we’ll be glad to have more, that type of class for the community.
But there’s definitely also, in leadership, a strong advocacy for expanding the work that we do. I’m not concerned about it, but I just think that it’s going to take more education on what it means to have trauma-informed approaches on a larger scale and what it means to provide mental health and what are purview is on that.
3.4.2. Disparities in Resources for TIC
I will say we don’t [have resources], particularly our office don’t have the resources [for TIC]. We don’t have the expertise. We do need to gain that, for sure. So, we won’t be able to do it without the help of other agencies, without the help of other resources, and that’s why we won’t be able to do our work without their help.
3.5. Recommendations
3.5.1. Training to Enhance Awareness for TIC
First, training will be for these people’s [providers’] awareness. They should be aware. Then, step by step, for the future, we can have another program for others, for example, for some gathering. [……] Training is important. I think training of personnel, training of clients, training of community leaders, these are the basis for this [TIC].
For me, I have the background of working in victim services and about trauma-informed care, but they added emphasis on culture, which provided me the opportunity to strengthen my already existing skills. I think bringing this [culturally relevant TIC] to my team and my agency can strengthen my advocates and team members and peers, so they can bring it to the community as front-line impact-changers and creating it, using the same analogy of the pebble and trauma, but for the greater good and changing how our community works with our population.
3.5.2. Resources for Refugee-Specific, Culture-Informed TIC
You have to renew certain trainings and modules every year. I think that the hospital system is getting better at incorporating certain trainings. For instance, it took a very long time but we just got a human trafficking training approved for every new employee. Having something like that with trauma-informed, or in the future maybe refugee trauma in the tool house. I think it takes some time, but that would be the best way to reach everybody.
Overall, I think we could be more trauma informed. Our behavioral health department is great. Every single one of our therapists has extensive background with training and practice in providing trauma informed therapeutic services. But I don’t know that that extends across the rest of the clinic. So I think that is definitely something where we can improve on. And I think even something as simple as embedding different programs with our clinic that provides opportunity for connectedness to other folks. And that opportunity to really build communities and I think it’s somewhere we’re definitely headed.
3.5.3. Building Partnership for Care Coordination
I know there’s a consortium of providers and they’ll talk about tougher cases and try to brainstorm on how to help those families. I think the more application-based things are still important because one agency may have a resource that others don’t. Just resource-building, honestly. If I’ve learned anything it’s really about growing those relationships so that you can help the people that you serve. I think the stronger the network, the better the outcome for the client.
We’re in a position where we’re not able to spend a lot of time. So, for example, there’s like a three hour window that we can do individual work with children. We’re having a hard time finding opportunities to create a community with the families. [……] We set up some events, but then we don’t have our target population show up. So, maybe just different ways of organizing cross-culturally [can work]. Getting other refugees involved, so that they can help us build better relationships, so that the families feel comfortable with us.
We need the support and help of community, to program. For this purpose, the [refugee] community needs training, especially the leaders, those who are involved in programming and managing, need some training. They should be aware of the importance of this issue [trauma and mental health]. This is really important for them, for their family, they should know about that. Then they can be encouraged by this.
3.5.4. Community Engagement and Inputs for TIC
What would be fruitful is [……] having more opportunities to come to these realizations of how to streamline programs. I do believe that that’s only gonna happen by spending time sitting down and talking to each other more about what’s going on and what we’re doing.
There’s so many things we base off of assumption. We don’t have the means to pilot or do a full on focus group study with all of our different client groups. If there was any easier, more accessible way to get that feedback and something that could let us learn more. I think that’s a huge gap from what we do in every single program.
4. Discussion
Towards Culturally Responsive TIC
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Country of Origin | 2018 | 2019 | 2020 | Total |
---|---|---|---|---|
Afghanistan | 52 | 69 | 46 | 167 |
Benin | 3 | 3 | ||
Bhutan | 85 | 85 | ||
Burma | 443 | 462 | 214 | 1119 |
Burundi | 32 | 6 | 3 | 41 |
Cameroon | 1 | 5 | 1 | 7 |
Central African Republic | 10 | 1 | 11 | |
Colombia | 16 | 23 | 6 | 45 |
Cuba | 4 | 4 | ||
Dem. Rep. Congo | 690 | 1329 | 282 | 2301 |
El Salvador | 81 | 45 | 44 | 170 |
Eritrea | 107 | 171 | 58 | 336 |
Ethiopia | 12 | 12 | 8 | 32 |
Guatemala | 2 | 13 | 30 | 45 |
Guinea | 2 | 2 | ||
Honduras | 12 | 11 | 20 | 43 |
Iran | 10 | 33 | 38 | 81 |
Iraq | 25 | 94 | 57 | 176 |
Ivory Coast | 4 | 8 | 12 | |
Nepal | 3 | 1 | 4 | |
Pakistan | 37 | 17 | 5 | 59 |
Palestine | 5 | 3 | 8 | |
Republic of South Sudan | 5 | 5 | ||
Rwanda | 23 | 18 | 41 | |
Senegal | 1 | 1 | ||
Somalia | 9 | 18 | 1 | 28 |
Sri Lanka (Ceylon) | 1 | 2 | 3 | |
Sudan | 13 | 36 | 13 | 62 |
Syria | 1 | 39 | 40 | |
Turkey | 1 | 1 | ||
Uganda | 3 | 3 | ||
Vietnam | 25 | 24 | 8 | 57 |
Zimbabwe | 8 | 1 | 9 | |
Total | 1696 | 2458 | 902 | 5056 |
Variable | Frequency (%) | M (SD) |
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Gender | ||
Female | 49 (68.1%) | |
Male | 23 (31.9%) | |
Age (in years) | 38.51 (11.69) | |
Prior experience working with refugees | ||
Yes | 70 (89.7%) | |
No | 8 (10.3%) | |
Time working with refugees (in years) | 5.89 (5.58) | |
Profession a | ||
Mental health service provider | 13 (12.9%) | |
Healthcare provider | 8 (7.9%) | |
Refugee resettlement services | 26 (25.7%) | |
Interpretation | 12 (11.9%) | |
Medical case worker, community health worker | 8 (7.9%) | |
School coordinators, staff in school setting | 10 (9.9%) | |
Refugee program supervisor | 4 (3.9%) | |
Refugee community leader/volunteer | 8 (7.9%) | |
Community-based organizations | 8 (7.9%) | |
Other b | 4 (3.9%) |
Refugee Resettlement Services (i.g., R&P Programs) | Mental Health Services | Others (e.g., CBOs, Schools, Social Services) | Cross-Sectional Themes | |
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Im, H.; Swan, L.E.T. Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States. Behav. Sci. 2021, 11, 155. https://doi.org/10.3390/bs11110155
Im H, Swan LET. Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States. Behavioral Sciences. 2021; 11(11):155. https://doi.org/10.3390/bs11110155
Chicago/Turabian StyleIm, Hyojin, and Laura E. T. Swan. 2021. "Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States" Behavioral Sciences 11, no. 11: 155. https://doi.org/10.3390/bs11110155