Mental Health Toolkit

Due to conflict or crisis, many people forcibly displaced have spent periods of time in locations where food is inadequate, there is little or no clean drinking water, violence is endemic, and conditions bleak. Certain diseases, malnutrition, and the consequences of some injuries can sometimes look like mental health symptoms.

Consider referring to a medical health provider to rule out a medical cause, especially if the client is new to the U.S., has non-specific symptoms like body pain or extreme fatigue, or has a history of 1) injuries due to violence or conflict, 2) food deprivation, or 3) significant illness.

U.S. mental health is primarily understood through a bio/psycho/social lens. Other countries and cultures may have a different understanding of mental health, including body humors, spirits, curses, religious tests, and karma. In addition, mental health service provision in the U.S. is mainly based on a Western worldview that puts individuals at the center and views time as linear. It prioritizes things like facts, structure and hierarchy. Other countries and cultures may have different worldviews that put groups or communities at the center, view time as non-linear or cyclical, and prioritize things like spirituality and connectedness.

Consider referring to the community based, non-specialized services when it is safe and appropriate to do so as these are most likely to be culturally congruent and linguistically accessible. If highly specialized services are needed, try to find an agency or provider that has familiarity working with people and communities with various belief systems and is able to integrate these belief systems into care. 
 

Many countries in the world lack mental health infrastructures. For example, Afghanistan has one mental health hospital where patients are commonly heavily sedated or chained. The Democratic Republic of Congo has just one inpatient hospital and one outpatient mental health clinic. People new to the U.S. from countries with little or no mental health infrastructure may be unfamiliar with effective and humane treatment.

Consider utilizing a referral script that provides elements of psychoeducation, de-stigmatization and normalization. For example, “Based on what you have told me, it sounds like having more support might be helpful. This is common for many people who are new to the U.S. and who have been through the types of things you have been through. In the U.S. people often find mental health counseling helpful. In some countries, mental health means the same as “crazy.” That is not true in the U.S. In the U.S., mental health has to do with how you feel emotionally, think, and act. For all of us, how we think, feel, and act is influenced by what has happened to us and what is happening in our lives now. A counselor or therapist is a professional who helps support people when they have difficult life challenges or are trying to heal from the past. Is this something you think might be helpful to you?”

In some countries, psychiatry has been used as a political tool of oppression on dissidents, those who identify as LGBTQIA+, people with certain religious beliefs, and more. This can make members of certain communities or groups particularly fearful of mental health services.

Consider doing research on countries who have or continue to use psychiatry as a political tool of oppression. Clients from those countries may need to be approached with particular care. Encouraging these clients to talk to a trusted medical provider can often be a safe entry point. 

Language access is critical to appropriate care and support. Still, even with accurate interpretation and translation, it is essential to note that certain words and expressions may have different meanings or simply not exist in other cultures. For example, there is no direct translation for the word “depression’ in Khmer or anxiety in Gujarati. Idioms like “feeling blue” or “feeling down” may be completely unknown in other cultures.

Consider using specific and simple words when talking and avoid idioms of expression. For example, say, “I notice that you are crying a lot and often seem sad” instead of “you seem depressed” or “worrying a lot” instead of “anxiety.” Ask people how they might describe something in their language. For example, “Can you describe what that looks like?” and “What is the word or expression for that in your language?”

In many countries, confidentiality when receiving medical or mental health services is not guaranteed and people may fear that their most sensitive concerns and issues will be spread in the community, especially if an interpreter is present.

Consider explaining and emphasizing confidentiality in all referrals, especially if an interpreter is present. For example, “In the U.S., all medical and mental health services are confidential. Providers cannot talk about a patient or client without their permission. This includes interpreters. This law is taken very seriously. Medical providers, counselors, interpreters, and other people who provide care can get in trouble and even possibly lose their jobs if they disclose things without a client or patient’s permission. The only exceptions to this are if someone is a danger to - themselves or others.”

Counseling may ask people to discuss and process difficult events and feelings. People who have been forcibly displaced may have lived in survival mode for decades. Being vulnerable enough to “feel” can be a liability in an environment in which staying alive requires suppressing one’s emotions and maintaining toughness. In addition, many forcibly displaced people, especially if they are new to the U.S., are facing daily pressures and struggles to find a job, pay their bills, learn English, and much more. They may have family and friends who are in harm’s way and may be receiving bad news frequently about people they know and care about. “Talk therapy” can seem useless and impractical.

Consider referring clients to services and support that meet their basic needs, or making a referral to a clinic or provider that will integrate case management into service provision. In addition, make sure that agencies and providers are willing to go at the client’s pace and take into account their level of stability and competing demands when delivering services.