Humanitarian crises around the world have displaced more people than the Second World War. By the end of 2016, over 65 million individuals and families were affected by violence. The United States admitted over 3 million refugees since 1975 but a recent shift in policy contradict its commitment to human rights. With an unprecedented number of people displaced from their homes, the terms refugee
are often used interchangeably. But their differences have important legal implications. And while refugees and immigrants share aspects of resettlement, such as the pressure to assimilate to Western expectations, over 50% of refugees experienced one or more traumatic event. Refugees also experience considerable prejudice and discrimination that exacerbate existing vulnerabilities. Psychotherapy with a marriage and family therapist (MFT) is helpful in not only addressing the individual and relational effects of displacement but also contextual (i.e., resettlement) challenges.
Differences Between “Refugees” and “Immigrants”
Despite being used interchangeably, there are important legal differences between refugees and immigrants. A refugee
is someone who has been- or is in risk of- being persecuted in his or her country without an option to return. Grounds of persecution include: race, religion, nationality, and membership of a particular social group or political opinion. By extension, an asylum-seeker
or asylee is a person who has left his or her country but not yet obtained refugee status. An immigrant
, also referred to as a permanent resident alien
, is a person who left his or her country voluntarily and entered another country (e.g., United States) legally for a better life or to join family.
Arrival to the United States
Refugees escape their country because of persecution and are unable or unwilling to return given the aforementioned grounds. Immigrants, on the other hand, leave their country voluntarily and are not under threat of persecution. They apply for an immigrant visa category (i.e., family or employer sponsored) that enables them to live and work in the United States. These are critical distinctions because they determine whether a person is removable (i.e., can be deported) or eligible to stay under asylum. To better understand the refugee experience, it is important to become familiar with the stages of resettlement: pre-resettlement, resettlement /migration, and post-resettlement/adjustment.
Stages of Resettlement
Refugees make necessary preparations for leaving during pre-resettlement. Hopelessness, rising costs of living or poverty, decreasing opportunities, and absence of safety are reasons people leave their country. They physically relocate from one country – to a second and often third country – during resettlement/migration. People may also spend time in refugee camps, which exacerbates existing physical and psychological problems given sub-desperate living conditions. Dependence on insufficient humanitarian aid and exposure to the elements, as a result of makeshift shelters, are additional sources of suffering. During post-resettlement/ adjustment, people have reached their destination (e.g., United States). Those sponsored by the United Nations High Commissioner (UNHCR) for Refugees and approved by the United States Refugee Admission Program (USRAP) are considered refugees. Others are considered asylum-seekers and have to apply for asylum either at the airport or within one year of arrival. Failure to apply before this deadline starts removal (i.e., deportation) proceedings. Refugees apply for permanent residency (i.e., green card) status after another year.
They become eligible to apply for naturalization, the process of becoming a citizen, five years after obtaining permanent residency.
Impact of Displacement and Resettlement
Adjustment is an ongoing process that changes different parts of a person’s life (e.g., cultural and ethnic identity, values, and attitudes). Both refugees and immigrants may feel pressure to assimilate to Western expectations upon arrival. They may also be afraid of losing parts of themselves (i.e., their identity). At the same time, it is important to recognize that there are considerably more differences than similarities between refugees and immigrants.
Refugees often do not speak English because they never anticipated leaving their country. Immigrants do not experience language barriers to the same extent insofar as employment or family ties are their motivation for resettlement. Refugees also often struggle securing employment after their time-limited (i.e., 30-90 days) government assistance ends. Since qualifications and skills generally do not transfer in the United States, they are required to work as unskilled laborers. It is not uncommon for physicians to become taxi drivers or grocery baggers. Immigrants are frequently ineligible for government assistance as a condition of their visa. The individual and relational effects of exposure to traumatic events are also unique to refugees. Individual effects include physical (e.g., chronic back pain) and psychological problems (i.e., severe and persistent depression) from torture. An inability to form and maintain interpersonal relationships are relational effects.
Discrimination and Prejudice
Sociopolitical instability, fueled by violence and persecution, contributes to rising anti-refugee sentiment around the world. Discrimination is attribution of incorrect beliefs and attitudes to a person or group of people. Prejudice, on the other hand, is acting on these beliefs and attitudes. Research suggests that both are associated with inadequate living conditions and limited opportunities. Islamophobia (i.e., fear of- and hatred towards- Islam) has increased both in frequency and intensity over the past ten years in the United States. Simple religious acts, such as wearing a hijab or growing a beard, are misconstrued. This leads to identity confusion and exhaustion with assimilating to mainstream cultural values.
Instability and Uncertainty
In contrast to immigrants, asylum-seekers experience considerable instability and uncertainty from waiting for approval of their application. They may not feel comfortable resuming their life in the United States without certainty of not being deported. This sentiment is not unique to asylum-seekers. Refugees are uncomfortable because growing nationalism, combined with a recent shift in policy, threatens their presence.
Clinical Treatment for Refugees and Immigrants
Legal differences between refugees and immigrants have important implications for clinical treatment. MFTs embrace a holistic treatment approach and view people separately from their problem(s). To that end, they broker interdisciplinary collaboration between physicians, attorneys, and social workers. Research suggests that an integrative approach is the most appropriate when working with refugees and immigrants.
Physicians treat the physical and, if necessary, psychological effects of torture. Their input and documentation is important to filing for asylum. Attorneys guide people through the asylum process and other legal matters, such as obtaining employment authorization or filing for family reunification. Social workers help refugees, along with immigrants, obtain basic needs (i.e., food, shelter, and clothing).
MFTs provide psychotherapy to address presenting problems, such as the effects of trauma, while leveraging people’s strengths and rebuilding their capacity to trust others. During assessment, they take into account people’s cultural values, beliefs, and attitudes. MFTs also evaluate how contextual factors (e.g., sociopolitical climate) worsen the effects of trauma. As for treatment models, cognitive behavioral therapy (CBT) and narrative exposure therapy (NET) are valuable in the individual context. Structural family therapy (SFT) is useful in the relational context. CBT helps people identify and correct biased thinking that contributes to maladaptive behaviors. NET draws from other behavioral models and assists people in re-constructing their narrative or story to achieve a coherent identity. With a strong social justice component, SFT views structure and boundaries as critical components of functioning. It empowers couples and families to restructure their thoughts, behaviors, and interactions. MFTs are in a unique position to help refugees and immigrants overcome insurmountable obstacles. They are trained to not only embrace complexity but also instability and uncertainty.
Written by Damir S. Utržan, Ph.D., M.S., LMFT
The American Association for Marriage and Family Therapy (AAMFT) is the professional association for the field of marriage and family therapy representing the professional interests of more than 25,000 marriage and family therapists throughout the United States, Canada and abroad.
The American Academy of Pediatrics (AAP) is the professional organization of 66,000 pediatricians and allied professionals in the United States dedicated to helping all infants, children, adolescents, and young adults attain optimal functioning.
The Advocates for Human Rights (AHR) is a non-profit organization that investigates and exposes human rights violations, represents immigrants and refugees seeking asylum, trains and helps groups protecting human rights, engages the public, and pushes policy-makers for legal reform.
The Center for Victims of Torture (CVT) is an independent non-governmental organization committed to advancing human rights through research, training, advocacy, and direct services to survivors of politically-sanctioned torture.
Vivo International is an interdisciplinary alliance of professionals in the fields of traumatology, international health, humanitarian aid, scientific research, sustainable development, and human rights advocacy that developed narrative exposure therapy.