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Post-resettlement challenges and mental health of Southeast Asian refugees in the United States.

Existing research and practice with the refugee population has focused primarily on traumatic experiences, perhaps due to common history with wars or interethnic violence in the country of origin prior to arrival in the United States (Beiser & Wickrama, 2004; Hsu, Davies, & Hansen, 2004; Kinzie et al., 1990). However, successful refugee resettlement depends not only on the characteristics of the refugees and tangible resources they have brought in with them, but also and perhaps more importantly, on the willingness and resourcefulness of the host countries to respond to their various needs (Davidson, Murray, & Schweitzer, 2008; Murray, Davidson, & Schweitzer, 2010; Potocky-Tripodi, 2002; Watters, 2001). Thus, consideration of the mental health needs of Southeast Asian refugees ought to go beyond a discussion of the factors related to the usual premigration conflicts and traumatic events or lack of resources and focus on post-resettlement structural and social forces that affect their overall mental health.

For researchers and practitioners working with the Southeast Asian refugee population, the social determinants of mental health (SDMH) framework (Galea & Steenland, 2011; Solar & Irwin, 2007) is a useful tool for understanding how structural and social factors contribute to various behavioral health outcomes and can shed important light on readjustment challenges in a new and unfamiliar socio-cultural environment. This article will utilize the SDMH framework to highlight post-resettlement factors that shape the experiences of Southeast Asian refugees in the United States and contribute to their long-term mental health outcomes.

Brief History of Southeast Asian Refugees in the United States

Refugees are defined as people who are forced to live outside of their home country and who are unable or unwilling to return to their country of origin because of a well-founded fear of persecution due to their race, religion, nationality, political opinion, or membership in a particular social group (Potocky-Tripodi, 2002; UN General Assembly 1951). Geopolitical conflicts and human rights violations resulting in a massive displacement of people have been the main force behind Southeast Asians fleeing their homelands. These Southeast Asian refugees are generally those who were forced to flee from the southeast region of Asia including Cambodians, Laotians, Vietnamese, and more recently, ethnic groups from Burma (also known as Myanmar). On a macro level, geopolitical circumstances, such as genocide (Cambodia), communism (Vietnam), or an authoritarian military junta (Burma), have largely dictated the grand narrative for these Southeast Asian groups. In addition, many ethnic groups in the Southeast Asia region have been involved in this seemingly never-ending violence and uncertainty.

Since the fall of Saigon in 1975, Southeast Asian refugees have been continuously arriving in the United States. By 2010, more than one million refugees from Southeast Asia were reported to have resettled in the United States (Southeast Asia Resource Action Center, 2011). As a result of the recent political turmoil in Burma, the locus of the major incoming refugee populations to the United States has shifted from three Southeast Asian countries (Cambodia, Laos, and Vietnam) to ethnic groups from Burma, such as the Burman, the Karen, the Karenni, and the Chin. Approximately 121,100 refugees from Burma entered the United States between 2002 and 2013 (Office of Refugee Resettlement, 2012a; Refugee Processing Center, 2014), making them the largest refugee group resettled in recent U.S. history. In addition, more than half a million people, mainly of Karen ethnicity, currently live in designated refugee camps along the western Thailand border (Barron et al., 2007).

Southeast Asian refugees are considered to be at greater risk for various behavioral health problems, primarily because of traumatic events associated with ongoing war and ethno-political conflict, life-threatening situations faced while escaping from their homelands, and subsequently harrowing experiences endured while surviving in refugee camps as well as lack of resources (O'Hare & Tran, 1998; Tran & Ferullo, 1997). It is critical to recognize that traumatic events have affected the lives of many Southeast Asian refugees. However, these events alone cannot and often do not define and dictate their present lives in the United States because each individual has different experiences and capacity to deal with these potentially traumatic events. In addition, despite sharing seemingly common experiences and challenges, the types and severity of traumatic events to which refugees were exposed vary significantly across Southeast Asian ethnic groups, as do the mental health outcomes linked to those experiences (Kim, 2007). Their current environments may also be of greater importance to them because present social, cultural, and individual circumstances shape and influence their adjustment patterns in a new environment and may ultimately predict their mental health outcomes. In order to take into account the significance of present circumstances (i.e., structural components), the SDMH framework will be used to explicate factors affecting Southeast Asian refugees in their post-resettlement period.

Core Values of the SDMH Approach

One of the unique aspects of the SDMH framework is that it couples the issue of mental health equity, which promotes mental health across all peoples regardless of their background, with a human rights perspective. The United Nations places a high emphasis on the rights of refugees and on every nation's obligations to protect their human rights (Office of the High Commissioner for Human Rights, n.d.). Therefore, access to adequate resources for maintaining optimal mental health, a right that has a firm basis in legal and moral principles for all humans (Solar & Irwin, 2007), should be accepted as an inalienable right for Southeast Asian refugees. Consequently, any impediment that imposes significant compromises and barriers on the ability to provide basic rights must be identified, examined, and eventually eliminated for the overall well-being of Southeast Asian refugees.

As initially proposed by the Commission on Social Determinants of Health (2008), established under the World Health Organization, attending to structural and social factors must be the priority for undoing social injustices that determine and contribute to health disparities. Physical and mental health are intricately and critically related (Prince et al., 2007); therefore, applying the social determinants of health framework to describe and examine factors relevant to mental health seems appropriate (Galea & Steenland, 2011; Kim, Chen, & Spencer, 2012).

Structural Determinants of Mental Health

Structural determinants of mental health (i.e., income, education, occupation, social class, gender, race/ethnicity, and nativity status) essentially govern the socioeconomic positions of individuals through a social stratification process. Social stratification emerges as a consequence of social and economic policies in a society that are persistently biased toward the majority group, which holds power. As a result, social stratification puts those with less power and resources at risk for differential exposure, vulnerability, and consequences of health and mental health problems (Solar & Irwin, 2007). In general, lower socioeconomic status, measured in income or education, predicts worse physical and mental health outcomes (Pappas, Queen, Hadden, & Fisher, 1993). Systematic biases in historical and current social and economic policies, such as racial and gender discrimination that grants unearned privileges and advantages to majority group members, are examples of social stratification (Kim et al., 2012).

Historically, Asian Americans, including Southeast Asian refugees, have been perceived and treated as perpetual foreigners, which suggests that Asian Americans in general will always be seen as incapable of being assimilated and as other (Huynh, Devos, & Smalarz, 2011; Lee, Wong, & Alvarez, 2009). Thus, Southeast Asian refugees constantly face language, ethnic, and cultural discrimination (Ng, Lee, & Pak, 2007; Noh, Beiser, Kaspar, Hou, & Rummens, 1999). For Southeast Asian refugees to be broadly placed in a perpetually foreign group may have reverberating consequences that manifest negatively in various dimensions of the social/intermediary determinants of mental health.

However, this perpetual foreigner stereotype may not affect the mental health of all Southeast Asian refugees equally. Given the importance of nativity status in association with behavioral health outcomes (John, de Castro, Martin, Duran, & Takeuchi, 2012; Takeuchi et al., 2007), it is possible that the perpetual foreigner stereotype may differentially affect Southeast Asian refugees based on their nativity. For example, foreign-born Southeast Asian refugees may acknowledge that they are indeed foreigners because they were not born in the United States, and this would not necessarily imply psychological distress. In comparison, U.S.-born Southeast Asian Americans may recognize the disparity between their understanding of themselves as Americans and others' tendency to perceive them as foreigners. Indeed, a number of studies examining the impact of nativity on substance use and misuse highlight the finding that Southeast Asian adolescents born in the United States are more susceptible to problem drinking and drug misuse (Lee, Battle, Antin, & Lipton, 2008; Wong et al., 2007).

Social/Intermediary Determinants of Mental Health

Recognizing the impact of structural determinants is difficult due to their abstract, hidden nature. However, the consequences of these structural forces can be examined through social/intermediary determinants. By definition, social/ intermediary determinants are processes through which structural determinants operate (Commission on Social Determinants of Health, 2008; Solar & Irwin, 2007). These processes highlight potential differences in exposure and vulnerability to conditions that lead to mental health disparities (Campbell, 2012; Chapman, 2010). Material circumstances (e.g., housing and neighborhood environment), psychosocial stressors (e.g., negative life events, degrees of social support, and coping styles), behavioral and biological factors (e.g., exercise, diet, drinking, and smoking), and health system issues (e.g., access to health care) are examples of intermediary determinants (Kim et al., 2012; Solar & Irwin, 2007).

Material Circumstances

Material circumstances are factors that shape the individual's physical environment, including housing, consumption potential, and physical working and neighborhood environments (Solar & Irwin, 2007). Southeast Asian refugees resettling throughout the United States by and large assume their position at a lower social stratum. This is because whatever social, cultural, and political resources they had maintained and were able to capitalize on in their country of origin were invariably diminished during their flight. The few resources that they managed to retain often do not transfer over to the host country. For all refugees who are not eligible for federal cash assistance (e.g., temporary assistance to needy families or Supplemental Security Income) and/or medical assistance (i.e., Medicaid), the Office of Refugee Resettlement (2012b) guarantees financial and medical assistance during the initial eight months after their arrival in the United States. Thus, the basic benefit level available to arriving refugees is comparable and tied to federal- and state-level benefits for the poor. Because most refugees tend to have spent years or decades in refugee camps without much opportunity to build or learn life skills, such as how to seek employment or to speak English, eight months is not nearly enough time to acclimate to a foreign environment.

Furthermore, if the refugees ever decide to make a secondary migration (i.e., to join family or friends in another city or state, which happens relatively frequently), they forfeit ancillary services, such as case management, associated with their benefits from the Office of Refugee Resettlement, because services are allocated and locked into resettlement agencies, not assigned to the refugees themselves. Thus, guaranteed benefits do not go far enough, and most refugees are left with an impending significant reduction in financial and other resources.

Southeast Asian refugee communities also struggle with economic and academic advancements (DeNavas-Walt, Proctor, & Smith, 2011; Grieco et al., 2012; Hune & Takeuchi, 2008). For example, Vietnamese Americans, who are relatively more established in the Southeast Asian community, have a much higher prevalence of poverty (27.1%) than Chinese (20.9%) or Filipino Americans (12.3%), based on representative national data of Asian Americans (Kim et al., 2012). This may be partly because, along with their lack of social and cultural capital, most refugees are placed in urban areas with high poverty and poverty-related problems, such as low-quality education, unstable neighborhoods, and high amounts of violence in the neighborhoods (Singer & Wilson, 2006). To make matters worse, Southeast Asian refugees are from a region with a mild/subtropical climate, but many of the more recent refugees have tended to settle in states with a much colder climate, such as Minnesota or New York. On all accounts, they are simply ill prepared to deal with, if not unaware of, the cold reality of their host society.

Psychosocial Circumstances

Psychosocial circumstances reflect stressors borne out of social stratifications that place individuals in various disadvantaged socioeconomic positions. These psychosocial circumstances consist of adverse life events, job stress, financial difficulties, and limited social support and coping resources (Kim et al., 2012). For example, compared with other Asian ethnic groups in the United States, Vietnamese Americans have the highest poverty rate, lowest health insurance coverage, and fewest college graduates (Cho, Kim, & Velez-Ortiz, 2014; Kim et al., 2012), putting them at a higher risk for job and financial difficulties.

Furthermore, a supportive social network within a new refugee community takes time to establish (Tran & Wright Jr., 1986). The conservation of resources theory (Hobfoll, 1989) posits that the loss of sociocultural resources (e.g., social status, employment, and social support) that many Southeast Asian refugees experience during their pre-resettlement period continues to hamper their recovery during the resettlement period. Therefore, the precarious socioeconomic positions of the post-resettlement process may engender greater strain on coping resources, which in turn negatively affect mental health outcomes.

Adaptation to U.S. society by Asian American refugees is also hindered by additional challenges that most Asian Americans or immigrants face in the United States. Southeast Asian refugees are subsumed under the pan-Asian racial group, which is mythologized as being a model minority in the United States. The model minority myth characterizes every Asian as quiet, hard working, and successful (Chou & Feagin, 2008; Wu, 2014). In addition to general post-resettlement challenges, such as cultural and linguistic barriers, Southeast Asian refugees face additional challenges unique to being labeled as Asian Americans. Namely, being identified and recognized as Asian in America carries with it a tenuous position along the racial hierarchy (Kim, 1999). Belonging to the Asian American category automatically places Southeast Asian refugees in a model minority status. Thus, generic Asians are praised for their hard work ethic, but are never accepted as true Americans.

Since William Pettersen's New York Times Magazine article "Success Story, Japanese-American Style" (1966), which introduced the idea of a model minority for an Asian ethnic group, popular media and anecdotal narratives have reinforced and stereotyped all Asians as having a strong work ethic, enduring family support, and personal discipline--characteristics that will lead to eventual economic and academic success despite a multitude of challenges. Many Asian American scholars and communities object to the model minority label because it fails to recognize the heterogeneity of Asian Americans or the fact that they have to contend with serious economic and social challenges (Hartlep, 2013; S. Lee et al., 2009; Ng et al., 2007; Zhang, 2010).

Despite what the model minority myth suggests, it takes more than just a strong work ethic and traditional values to survive in the United States as a refugee from Southeast Asia (Thrupkaew, 2002). As Maslow's hierarchy of needs illustrates, one's basic physical and psychosocial needs must be met before one's mental health needs can be addressed. Being broadly labeled as a model minority takes away an opportunity to receive the help and governmental support needed to stay competitive in a society where resources are unequally and prejudicially allocated. This lack of opportunity is directly related to a persistent lack of provision for adequate behavioral health services for Southeast Asian refugees (D'avanzo, 1997; O'Hare & Tran, 1998), which can exacerbate their already fragile mental health status.

Behavioral and Biological Factors

Behavioral factors refer to a variety of behaviors in which individuals engage. Such behaviors--the use of tobacco, alcohol, and/or other substances; diet patterns; and physical exercise or the lack thereof--are associated with an individual's socioeconomic position (Galea, Nandi, & Vlahov, 2004). There is evidence for comorbidity between substance use disorders and mood and anxiety disorders in the general population (Merikangas et al., 1998). Concerns for serious mental health problems among Southeast Asian refugees suggest that they may be at a higher risk for the misuse of alcohol and other drugs than other Asian ethnic groups (D'avanzo, 199 7; O'Hare & Tran, 1998; Wong et al., 2007; Yee & Thu, 1987). Recent studies of Southeast Asians in the San Francisco Bay Area (Lee et al., 2008) and in Washington, DC (Wong et al., 2007) have reported different rates of problem drinking across different Southeast Asian ethnic groups; the problem drinking prevalence was found to be comparable to that of the general U.S. population. On the other hand, a recent representative study of Cambodian refugees in California (D'Amico, Hambarsoomians, Marshall, & Schell, 2007) found that their rates of alcohol consumption and problematic drinking were much lower than popularly believed.

Southeast Asian refugees may also be at a greater risk for pathological gambling. In a small community-based study (N = 96) of Cambodian, Laotian, and Vietnamese refugees in Connecticut, it was found that 59 percent of the sample met the criteria for a lifetime prevalence of pathological gambling (Petry, Armentano, Kuoch, Norinth, & Smith, 2003). Another study done with a representative sample of the Cambodian refugee community in California (N = 127) found a much lower prevalence rate (13.9%) of lifetime disordered gambling (Marshall, Elliott, & Schell, 2009). The differential findings in these studies may highlight heterogeneity among Southeast Asian ethnic groups. Due to a limited number of existing studies, it is difficult to conclude whether pathological gambling is a problem among Southeast Asian refugees or to what extent. However, because much lower problem gambling rates have been found among the general U.S. population (lifetime: 3.9%, 12-month: 1.9%; Shaffer, Hall, & Vander Bilt, 1999), these initial inquiries warrant further examination of this topic and its relation with mental health among Southeast Asians.

Biological factors refer to genetic factors that make individuals susceptible to mental illness and substance-related problems. Within the SDMH framework, sex and age are generally considered to be two defining biological factors that closely interact with individuals' socioeconomic positions, as well as with structural and institutional determinants. As in the case of behavioral factors, more research is needed to address the biological determinants of mental health for Southeast Asian refugees.

Mental Health Services/System

Availability of and access to mental health services (MHS) for Southeast Asian refugees are critical to their behavioral health outcomes. Due to the model minority myth, Southeast Asian refugees as a group receive little funding in such areas as government and educational assistance programs and access to health and mental health services (Wong & Halgin, 2006). The unsubstantiated assumption that they do not need such services needs to be examined empirically. Refugees in general have reported low mental health system use (Boehnlein, 1987; Colucci, Szwarc, Minas, Paxton, & Guerra, 2012; Dhooper & Tran, 1998), although there is an indication that U.S. Cambodian refugees are reporting relatively high rates of mental-health-related services (Berthold et al., 2007; Marshall et al., 2006). In either case, there have been a number of barriers to mental health services identified for Southeast Asian refugees, such as differences in cultural orientation, the stigma of being labeled with mental disorders, financial cost, and a lack of transportation and interpretation services (Boehnlein, 1987; Gong-Guy, Cravens, & Patterson, 1991; Williams, 1985; Wong et al., 2006). In short, additional research is needed to further examine the rates of mental health system utilization and the degree of effectiveness of mental health services delivered among Southeast Asian refugees (Colucci et al., 2012).

Implications for Best Practices of the SDMH Framework among Southeast Asian Refugees

One approach that reflects the tenets of the SDMH framework is a three-dimensional (i.e., treatment, service, and institutional) model of mental health interventions for refugees (Watters, 2001). The three-dimensional model aims to highlight the importance of a broader social policy context that ultimately determines the treatment and outcome of refugees' mental health. The treatment encounter often starts in the context of a visit with a general practitioner. Watters argues that practicing professionals recognize that mental health problems and treatment approaches for refugees are often framed in epistemology that is based on the Western conception of mental health and with not nearly enough input from refugees themselves. Thus, by offering to solicit and respond to the refugees' own explanations of the origins and resolution of their mental health problems, helping professionals may learn that many Southeast Asian refugees will indicate that their mental health problems arise from their current social, political, and economic circumstances and the symptoms of these circumstances. One appropriate response to learning of this alternative explanation may be to focus on helping these refugees with basic needs, such as welfare benefits, accommodations, and education and vocational training, in order to eliminate as many socioeconomic barriers as possible before referring them to specialized mental health services.

At the service level, working across traditional professional boundaries is important for fostering improved interprofessional communications among primary health care providers, special mental health teams, social services, and voluntary organizations to best identify current gaps in services to Southeast Asian refugees. Rather than focusing on the utilization of interpreter services within various service settings, service providers might collectively provide training in the mental health needs of Southeast Asian refugees. In order to offer this training in culturally responsive ways, the views and need for mental health services of Southeast Asian refugees must be included through empirical data (Watters, 2001). Another way to promote effective service level provision is to establish service programs run by Southeast Asian refugees to respond to the particular mental health needs of this population. Developing services or agencies for specific refugee communities may foster natural relationships of trust between the service providers and their clients, one of the essential factors in making mental health treatment effective. Furthermore, creating an infrastructure within the community helps to develop the community's capacity to educate, train, and build future leaders within and beyond the refugee community.

Finally, in order to influence institutional-level mental health resources for the Southeast Asian refugee community, we must get involved in a grassroots advocacy effort within the refugee community. Establishing adequate capacity for institutional advocacy requires systematic and persistent willingness and coalition building from all those who work with the Southeast Asian refugee communities, including policy makers, service providers, and the refugees themselves. Although mental health policy makers must consider inviting refugees to inform their decision making, it is the Southeast Asian refugees who must ready themselves to advocate for their needs and provide meaningful consultation in the policymaking process. A number of Southeast Asian organizations, such as the Southeast Asian Resource Action Center (http://www.searac.org), already exist. Such organizations represent the interests of Southeast Asians by creating and maintaining a visible presence in the policy and advocacy arena, which can translate into leadership development and community capacity building.

For many Southeast Asian refugees who have resettled in western countries, posttraumatic stress disorder (PTSD) and its symptoms have been the primary focus of their mental health treatment (Nickerson, Bryant, Silove, & Steel, 2011; Palic & Elklit, 2011). A blanket assumption that associates PTSD with Southeast Asians has caused other equally dire needs to be overlooked. There are growing concerns that interpreting refugee experiences through Western psychiatric nomenclature may be inappropriate without careful consideration of the social, political, and economic factors that play pivotal roles in refugees' overall well-being during the post-resettlement process (Watters, 2001). Thus, it may be important for mental health clinicians to avoid such common mistakes by reexamining their preexisting assumptions. First, clinicians must refrain from assuming that all refugees have traumatic symptoms and develop PTSD and that treatment of PTSD symptoms surpasses all other needs. Likewise, clinicians must refrain from assuming that their traumatic experiences are the main reason why Southeast Asian refugees struggle throughout their resettlement in the United States. Failure to avoid these assumptions may mean unnecessarily involving refugees in protracted clinical interventions in foreign settings, which further pathologizes their suffering.

It may be most helpful to implement services that can address immediate and long-term psychological, social, and economic factors related to post-resettlement concerns (Murray et al., 2010; Watters, 2001) while simultaneously considering refugees' intrapsychic resilience as evidenced by their individual developmental processes, culture, history, and experiences before and after the trauma (Alayarian, 2007; Hsu et al., 2004). Attending to post-resettlement factors may be critical in furthering our understanding of the influences of these factors on mental health outcomes among Southeast Asian refugees (Hsu et al., 2004).

Fortunately, an emerging SDMH framework has provided researchers and practitioners with a new vocabulary to reshape their understanding of mental health practices beyond the walls of traditional clinical treatment settings. Indeed, the most common approach to mental health treatment for refugees has been multimodal intervention, which includes a variety of wraparound services (i.e., resettlement assistance and medical care) and formal psychotherapeutic intervention if and when the specialized treatment is warranted (Nickerson et al., 2011). In summary, what may work best in successfully attending to the mental health problems of Southeast Asian refugees is to first provide sufficient macro level structural and institutional support that will stabilize their position in the community and to then develop culturally responsive mental health intervention strategies that can be tailored to their needs. Throughout this process, a close collaboration must be maintained between mental health professionals and the Southeast Asian refugee communities, incorporating traditional cultural and/or religious practices.

Isok Kim, PhD, LCSW, is assistant professor of social work at the University at Buffalo, the State University of New York. Wooksoo Kim, PhD, MSW, is associate professor of social work and codirector of the Immigrant and Refugee Research Institute at the University at Buffalo.

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Author:Kim, Isok; Kim, Wooksoo
Publication:Best Practices in Mental Health
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Date:Oct 1, 2014
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