Program relies on cultural sensitivity to treat refugees

Before she started working with new Americans and refugees, Karen Fondacaro, Ph.D., a University of Vermont clinical psychology professor and director of its Behavior Therapy and Psychotherapy Center, never brought religion into treatment services.

But these clients have taught Fondacaro that religion and spirituality can enhance treatment.

“Sometimes we end up praying in sessions. We end groups with prayer,” Fondacaro said. “We just have to be much more open-minded and curious than judgmental.”

Fondacaro directs Connecting Cultures, a mental health program for refugees from about 25 countries who have resettled in Vermont, many of whom have experienced torture and trauma. Licensed psychologists and pre-doctoral clinicians completing training with the supervision of the clinical psychology faculty staff the program for children and adults, working in schools and an outpatient clinic on the university’s Burlington campus.

Research has shown high rates of mental health problems among post-conflict populations relocated to different countries because of traumatic experiences in their countries of origin and in camps or transit. Adjustment problems, cultural conflicts, language barriers and loss of family members, country, occupation and way of life can lead to somatization, depression and posttraumatic stress disorder.

Nearly 7,000 refugees have come to Vermont since 1989 with between 325 and 350 new arrivals each year, according to Amila Merdzanovic, director of the Vermont Resettlement Program in Colchester, a field office for the U.S. Committee for Refugees and Immigrants. The state’s refugee population has primarily resettled in the cities of Burlington and Winooski.

Among the ethnic groups are those from Bosnia and Herzegovina who came in the 1990s and more recent arrivals like Somali Bantu and Bhutanese refugees from Nepal.

Fondacaro founded Connecting Cultures in 2007 in response to growing numbers of refugees going to hospital emergency rooms with mental health problems.

“I was getting information from all these people in the state that we have all these refugees. They have all these needs, but they don’t view mental health in the same way that we do and nobody’s going to come to a clinic,” she said.

“So we started some outreach groups with various cultures and talked to them about what did they think mental health was and primarily the answers we got were more along the severe psychotic end of how they were perceiving mental health needs.”

It took a couple of years to build trust and establish a relationship with the refugee community, Fondacaro said. “I think we do have a reputation in the community that we can be helpful and we’re not going to pathologize and call them crazy.”

In early February, there was a three-month waiting list for a new client seeking to be evaluated and receive services.

Estimates of how many refugees have suffered torture range from 10 to 30 percent, even higher for asylum seekers. Connecting Cultures has established New England Survivors of Torture and Trauma (NESTT), part of the National Consortium of Torture Treatment Programs, providing and coordinating psychological, legal and social work services.
Refugees who come to the clinic seem to be evenly divided between men and women, Fondacaro said. A focus of ongoing research is to assess gender differences in the prevalence of mental health problems.

In addition to accepting prayer, cultural sensitivity has staff members learning to count from zero to 10 in various languages when using the Subjective Units of Distress Scale to connect with clients.

“They absolutely love that we’re trying to learn their language,” Fondacaro said. “They appreciate that you’re taking their culture seriously.”

Clinicians also need to be open to modifying empirically validated techniques. Emily Mazzulla, Ph.D., associate director in charge of operations for NESTT, said cultural consultants, community elders and interpreters review assessment measures to avoid misunderstandings. For instance, “I feel blue” became “I feel sad” on one assessment for anxiety and mood.

“There’s an idea in some Bhutanese communities that being attacked by a ghost or a spirit might be a true physical-emotional symptom and so that’s something that we added,” Mazzulla said.

A specialty area has been in the development of a narrative-based intervention model for torture survivors that is “based on giving clients control over the timing of their story and whether they want to tell it,” Fondacaro said.

“If you hear the types of torture that happens in these countries, it’s pretty severe. It could be anything from severe beating, from murdering family members in front of people, burning, electrocution, rape,” Fondacaro added.

She is developing trauma-informed practice for physical therapists. “They have all kinds of interesting instruments that could be really scary to a survivor of torture,” she said.