On December 10, 2009, The Center for Health and Health Care in Schools hosted a webinar, Treating Traumatized Immigrant and Refugee Youth.  Our presenters for this webinar were Drs. Heidi Ellis and Judith Cohen.  As promised, we have posted the questions submitted by our audience.  Drs. Ellis and Cohen have provided the responses to the questions.  We look forward to your comments and thoughts on our webinar and the questions and answers posted in this blog.

Dr Heidi Ellis:

What strategies have you found successful in reaching and effectively engaging the fathers in working on child-related issues as this tends to fall mostly to the women in most refugee cultures I've worked with?

The three levels of care (parent outreach, school-based groups for youth, and individualized Trauma Systems Therapy treatment) are tightly integrated.  One of the keys to this is our weekly interdisciplinary treatment team meeting. In this meeting our parent outreach coordinator, cultural brokers,clinicians, and school liaison are all present.  This kind of regular communication is critical to making sure that cultural, clinical, and school factors are all considered in the program.  Programmatically the groups allow our clinicians to get to know the children and more readily identify those who need a higher level of care. We have found that home-based visits are essential to engaging parents. 

Dr Heidi Ellis:

Some schools have done this successfully with some immigrant communities (see http://www.healthinschools.org/Immigrant-and-Refugee-Children/Caring-Across-Communities/LA-Bienestar.aspx for a description of a program through the LA Unified School District that screens).  For the Somali community I am not sure this approach would be successful.  We have found that it is important to build connections with the community and families before discussing trauma or identified mental health problems.  Also, if you conduct a widespread screening it is important that you have services available for those youth who are identified as in need.

Dr Heidi Ellis:

We didn’t measure this specifically in our study; we used an instrument called Every Day Discrimination by David Williams.  This instrument has 9 items that ask about different situations in which someone might have been treated unfairly (e.g. was treated with less respect, was called names or harassed).  Participants were asked to say whether this had occurred to them, and if so to rate how frequently.  We then added a question asking what they think the primary reason for discrimination was.  The most common answers were due to being Somali or Muslim.  Please note that in our study the youth were fluent in English (and had been resettled at least one year).  Experiences of discrimination may be quite different for recent arrivals who are not fluent in English.

Dr Heidi Ellis:

Our program has an active parent advisory board.  In addition, one of the agencies we collaborated with one of our partners (the Refugee and Immigrant Assistance Center) who sponsored leadership training for youth in the community, including graduates from our program.

Dr Heidi Ellis:

The face of refugee communities is constantly changing, requiring different language capacity and cultural knowledge.  However, the process of building culturally-sensitive mental health programs remains the same.  Although there are no easy answers I recommend starting with the community and identifying leaders or groups within the community that can work closely with existing mental health service systems.  Partnerships are key to leveraging existing resources in a world where there are never enough.

Dr Heidi Ellis:

Please see a later question about bringing resources to new communities.  The best way to manage high need in times of low resources is through building partnerships and leveraging existing resources.  If you are able to bring together three agencies that serve refugees and create a common approach and goal then duplicate services can be eliminated and the goals and focus can be streamlined greatly.  I also recommend you visit the website www.traumasystemstherapy.com.  One of the goals of this treatment model is to explore existing resources so that they can be coordinated and a more integrated, comprehensive treatment plan can be provided in place of the more typical fractured system of care.

Dr Heidi Ellis:

We interviewed 144 adolescent-parent dyads, so 144 adolescents and another 144 caregivers.

Dr Heidi Ellis:

We have two models of addressing linguistic barriers in our mental health care.  First, we have cultural brokers who are part of our clinical team and help with interpretation during sessions when needed, attend all home visits with clinicians, and are part of our clinical team to make sure cultural issues are well understood.  Second, we have a partnership with the Boston University School of Social Work which has a program to support the training of social workers from refugee communities (see the BRIDGE program through BUSSW).  Through this partnership two Somali individuals are being trained as social workers and have been conducting their internships with our program.  Thus about half of our clinical work is done by Somalis in training to be mental health professionals, and about half is done by non-Somalis who work with cultural brokers. 

Dr Heidi Ellis:

We work with the whole school system.  Typically our focus is working with teachers and staff to help them manage problems that may arise in the classroom.  Sometimes we have found a specific issue needs to be addressed.  An example of this is during a time when there was particular tension between Somali and Latino students we convened a school ‘dance’ where the students could get to know each other.  We also made a point of having Somali and Latino teachers present at the dance so that youth could see positive models of relating across cultural barriers.  This intervention seemed to greatly reduce the level of tension between the groups.

Dr Heidi Ellis:

This is a big question, and the answer will be different depending on many factors including which service system you are working in.  Our Center for Refugee Trauma and Resilience, a partner in the National Child Traumatic Stress Network, is working on developing a ‘Refugee Services Toolkit’ which will help guide people and service systems who work with refugees through the process of identifying level and areas of need and accessing appropriate resources.  Please see our website and check back in the coming months for the launch of our toolkit.

Dr Heidi Ellis:

Dr Heidi Ellis:

Unfortunately although school based services are one of the best ways of increasing access for immigrant and refugee students the process of setting up services in a school can be complicated.  Issues such as billing/reimbursement, space, parent involvement, and access to students during the school day will need to be worked out.  That said I encourage you to begin conversations between service agencies (such as CVT) and schools to see if it could be done.  It may be helpful to keep in mind how such a partnership could help both agencies; when done right school-based services can solve problems faced by service agencies (the no-show rate drops way off) and schools (students are able to learn better when their mental health problems are being addressed).

Dr Judith Cohen:

Only licensed and appropriately trained mental health professionals should provide psychotherapy. In particular the use exposure therapy techniques such as creating a trauma narrative and in vivo exposure with children who have significant trauma symptoms should not be undertaken by individuals who do not have these qualifications. In appropriate provision of these interventions can lead to worsening of trauma symptoms.  However adults have many other venues through which to provide support to traumatized children other than as psychotherapists. Parents, teachers, and other adults can support resilience building skills including those described in this presentation (psychoeducation about the impact of trauma; relaxation; affect expression and modulation; and cognitive coping) in a multitude of ways that are consistent with what was described here without providing formal psychotherapy.

Dr Judith Cohen:

Some resources are available on the National Child Traumatic Stress Network website at www.nctsn.org including information about different treatment approaches that may be helpful for refugee and immigrant children, a white paper that describes the many challenges facing these children, and information about various other types of traumas that they may have experienced. You may also receive information about trauma specialty providers in your area.

Dr Judith Cohen:

Absolutely, we often use creative activities including music, art,dance, and/or drama to implement the components that were described during this presentation. Not only are these activities fun, but creative activities are different on many levels from thinking and talking so itis possible that engaging in both types of activities are helpful in therapy.

Dr Judith Cohen:

KidNET is Narrative Exposure Therapy for Children and Adolescents. More information about this treatment approach is available at  http://www.vivofoundation.net/eng_narrative_exposure_therapy

Dr Judith Cohen:

Youth like Amina seem to be doing very well in our program. More than 80% generally recover within 12-20 sessions with drop outs and need for additional services also being similar to other children seen in our program.

On May 21st, the Center for Health and Health Care in Schools sponsored a webinar: Understanding the Rise in Suicide Attempts in Latina Teens by Dr Luis Zayas.  There were over 400 participants and many excellent questions were submitted to Dr Zayas.  He will be working on his responses and we will be adding them to this blog as they are completed.  Please feel free to post additional questions and/or comments for Dr Zayas and we look forward to hearing from you.