Exploring the Role of Mental Health Stigma In Treatment Engagement Among Refugees and Asylum-Seekers

Background & Purpose: Refugees and asylum-seekers experience multiple stressors throughout their displacement journey and during adjustment to life in the United States (U.S.). Previous studies have shown these stressors to be associated with high risk of psychological distress, even though treatment engagement remains low. Among non-refugee populations, mental health stigma has been associated with low treatment engagement. Our paper explores mental health stigma and treatment engagement among refugees and asylum seekers, an understudied population.

Methods: We interviewed mental health service providers (N=10) and key stakeholders (N=5) who provide mental health treatment to refugees and asylum-seekers. Most participants were former refugees or came from a similar culture as those they served. Key stakeholders were community leaders, mental health managers, and field experts. Participants were recruited via flyers/emails through behavioral health and resettlement agencies located in Northeastern U.S. In-depth interviews were completed via Zoom between July-Aug 2024. Interview topics were related to mental health and barriers/facilitators to treatment. Multiple coders analyzed interview data using line-by-line open coding and grounded theory techniques.

Results: Participants, on average, worked as a mental health service provider or key stakeholder for 11.3 years (Range 1-30, SD=6.8). Participants were from Bhutan, Congo, Haiti, Iraq, North Africa, Rwanda, Somalia, and Sudan. Four major themes surrounding mental health stigma emerged: 1) fear of being labeled “crazy”, 2) mental health internalized as a character flaw, 3) being “othered” by community members, and 4) treatment that is non-holistic.

Participants reported some refugees and asylum seekers were reluctant to seek mental health treatment or disclose symptoms as it would label them as “crazy”; a person who presents with severe symptomology, or one who has completely lost control of their mind (e.g., “nobody talks about it [mental health]... and if you try... the response will be ‘are you calling me crazy?’”). They also reported the perception of mental health was internalized as a character flaw, a personal bodily defect or weakness, or potentially a consequence of a bad deed earlier in life.

Additionally, mental health stigma included fear of being talked about negatively in their community, especially among collectivist communities, where stigma is not only attributed to the individual, but associated to family unit as well (e.g., “they will talk a lot about the person in the community... to prevent people from talking... I don’t want to be exposed”). Lastly, participants reported that mental health treatment was too “Western”, in that holistic understanding of wellness that include spiritual and cultural practices was not incorporated into healing practices.

Conclusion & Implications: Like non-refugee populations, refugees and asylum-seekers experience stigma surrounding mental health and treatment engagement. Although participants reported stigma, they also report that over time, their community has become more understanding and accepting of mental health. Cultural brokers, an individual who shares both the U.S. culture and the refugee culture, are seen as a potential bridge to mitigate mental health stigma. Cultural brokers have an intimate knowledge of mental health in both cultures, and may reduce stigma by providing psychoeducation and facilitating culturally appropriate treatment.