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Abstract. More people than ever in history are being displaced and becoming refugees due to political conflict, climate change, and persecution, among others. Meeting the mental health care needs of refugees has become a global priority. This population’s needs are unique due to the multiple traumatic experiences of refugees, their difficulties in navigating various systemic barriers, and the minimal specialized cultural training in refugee care. In order to improve the health of refugees, it is important to examine how care is delivered and the provider and systemic factors that perpetuate inequities and cultural misunderstandings in providing care. Most of the refugee literature focuses on refugee factors that limit access to care but falls short on discussing providers’ lack of training in refugee care. In the following paper, we present refugee mental health training considerations for providers. These considerations are based on the lessons learned from direct clinical work in a refugee clinic located in a major public academic hospital in the New England area (United States of America). The authors discuss the particular context of caring for refugee populations, the skills needed to work with this population, and considerations for navigating provider and systemic barriers that arise in refugee care. We believe that training mental health providers can have significant implications for refugee mental health care utilization, patient improved treatment outcomes, and on refugees’ increased sense of self-determination.

In recent years, multiple global crises have contributed to increasing human displacement. Currently, there are approximately 84 million displaced people around the world. Many suffer from mental health problems. However, the mental health service delivery system is not fully prepared to meet the complex needs of refugees. Refugees experience multiple barriers, both individual and systemic, to accessing and engaging in mental health treatment. The following article provides an overview of some of the challenges faced by refugees worldwide and avenues forward. The authors also examine contextual factors that impact refugee resettlement and discuss barriers to culturally responsive, trauma-informed, and ethical care. Finally, the authors review advocacy efforts and discuss future directions to improve refugee mental health care delivery.

In this commentary, the authors argue that discriminatory US immigration institutions and policies have a direct negative impact on immigrant and refugee mental health. A close examination of these polices reveal a pattern of systematized racism and discrimination in the handling of immigrant arrivals to the US. The authors further argue that a comprehensive and culturally responsive approach towards the psychological care of immigrant individuals in the US must incorporate the traumatic effects of experiences of post-migration discrimination and racism, not only pre-migration traumas. Finally, a case is made for training mental health care workers to reflect on and examine how institutions and policies, as well as current health care approaches, may result in moral injury and institutional betrayal which can further exacerbate symptoms of PTSD, and experiences of discrimination, health inequities, and social isolation.

The popularity of complementary and integrative health (also complementary integrated health; CIH) approaches has significantly increased in recent years. According to the National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health, about 1 in 3 adults and 1 in 9 children used CIH approaches to healing. Some reports estimate that the use of CIH approaches will continue to increase (Clarke et al., 2015) as these therapies are cost effective and also due to the difficulties in finding trained mental health professionals (Simon et al., 2020). For the purpose of this special issue, we use the NCCIH's definition of CIH as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine" (Barnes et al., 2004, p. v). However, the integration of these therapies into the health system has not followed the same pattern despite the fact that patients report the need to discuss CIH therapies with their doctors or are actually using them (de Jonge et al., 2018; Jou & Johnson, 2016; Stapleton et al., 2015). This inability to keep up with the demand or patients' preference is possibly due to providers' lack of understanding and/or knowledge of these therapies, as well as scientific skepticism (Ali & Katz, 2015; Fletcher et al., 2017). Using data from the 2012 National Health Interview Survey, Jou & Johnson (2016) identified patterns of CIH use in the United States and reasons for patients' nondisclosure of the use of these therapies. Patients' fear of disclosure due to perceived skepticism or disapproval from their provider was frequently attributed as a cause of patients' nondisclosures to providers about the use of these therapies (Eisenberg et al., 2001; Jou & Johnson, 2016; Thomson et al., 2012). The arrival of patient-centered care models is beginning to shift the ways we understand the patient's role in treatment engagement. Patient-centered approaches often emphasize the use of preventative and holistic wellness models that go beyond the use of evidence-based treatments. This approach also seeks to be culturally responsive, which is a key factor in addressing health disparities in the United States (American Psychological Association [APA], 2019). The Institute of Medicine, in its report on CIH therapies, highlighted the importance of engaging patients in their own care, including having a decision about therapeutic options (Bondurant et al., 2005). Likewise, the Race and Ethnicity Guidelines in Psychology (APA, 2019) recommend psychologists engage the patient's cultural beliefs, or what Kleinman called the "explanatory belief model" (Kleinman, 1978)- for example, by "aim[ing] to understand and encourage indigenous/ ethnocultural sources of healing within professional practice" (APA, 2019, p. 24). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The arrival of the pandemic known as COVID-19 has resulted in an emergency appraisal of the way mental health services are delivered to refugee and asylum-seeker populations at the Boston Medical Center in Massachusetts. The following commentary summarizes some of the main approaches used to address the unique needs of this vulnerable population under lockdown. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The efficacy of evidence-based practices with underprivileged groups and non-Western cultures has been a subject of controversy in the trauma psychology and disaster mental health literature. There has been a debate as to whether evidence based assessments and interventions work equally well for diverse populations. Resolving this controversy has been difficult in part because of the methodological challenges involved in the study of cultural mediation of psychological phenomena. The authors argue that adding qualitative research to the evidence base supporting trauma treatments, as a matter of standard practice, can fill this need. Qualitative research can provide a rigorous research basis for the identification of cultural factors to be accounted for in quantitative outcome studies, as well as a rigorous means of understanding the real-world meaning of quantitative outcome findings. This would address Evidence-based practices (EBP) advocates’ concerns about the unscientific nature of the multicultural literature’s critique, and multiculturalism advocate’s concerns about the lack of contextualism in EBP outcome studies of trauma treatments.

The fields of trauma psychology and cultural psychology have rarely crossed paths within the context of mainstream psychology and psychiatry. Although clinical trauma psychology has acknowledged relevance of the ethical principle of respect for differences in trauma treatment, this has not so far motivated a systematic effort to improve our understanding of how culture is intertwined with our cognitive and emotional responses to trauma. As the field of disaster mental health has come to greater prominence in recent years, it has confronted trauma psychology with how profoundly the forms of both trauma and resilience are, as well as how ineffective traditional paradigms are in transcultural work. The author reviews some of the barriers in cultural considerations in trauma psychology and provides practical suggestions toward developing cultural competence benchmarks for trauma psychology education, training, and research.

“We want our children to become world citizens.” These words were uttered by my Lebanese immigrant parents when I (Sandra) was an early teenager struggling with issues of identity in Venezuela, my native country. Little did I know that those words would have a significant impact on my life’s journey as an immigrant in the United States a journey that was very much tied to my family’s particular circumstances, but also to the cultural, historical and sociopolitical context of the countries that represent my family’s journey. An analysis of the complex intersection between psychosocial adjustment and acculturation embedded in all these factors is necessary to understand the way my daughter (Maria Teresa) is growing up and acculturating in the US. Otherwise, the migration story is only half-told.