The world faces an unprecedented displacement crisis, with millions fleeing their homes worldwide due to conflict, persecution, and human rights violations. As these individuals navigate the complex resettlement process, their mental health is shaped not only by past trauma but also by the stressors of current environments. Heightened political tension, shifting immigration policies, and public discourse around refugees and asylum seekers can compound feelings of uncertainty, fear, and alienation. Restrictive policies, prolonged asylum procedures, and the threat of deportation often create a sense of instability that undermines recovery and healing. Therapists must be aware of how sociopolitical contexts can retraumatize refugees or exacerbate mental health symptoms—and respond with culturally sensitive, trauma-informed care that acknowledges these ongoing systemic pressures.

Grasping the unique experiences and needs of refugee clients is vital for providing effective, culturally-responsive care. Refugees often carry the weight of profound trauma, grief, and dislocation, while also demonstrating remarkable resilience. Therapists must possess the knowledge and skills to address the complex interplay of trauma, loss, and resilience that defines the refugee experience. When clinicians adopt a trauma-informed, culturally-sensitive approach, they can help refugee clients heal from past wounds, manage the emotional impact of current stressors, and build hope for the future.

In this article, we explore the mental health implications of forced displacement and the key considerations for therapists working with refugee clients. We examine the common challenges refugees face throughout the migration journey and discuss best practices for providing culturally-responsive, trauma-informed care. Join us as we look at the significant role mental health professionals play in supporting refugees on their path to healing and integration.

The Refugee Experience: A Triple Trauma Paradigm

Refugees often endure multiple, compounding traumas across the migration continuum, conceptualized as the Triple Trauma Paradigm. Pre-migration trauma may involve exposure to war, persecution, violence, and the loss of home and loved ones. The migration journey itself often includes life-threatening dangers, detention, and family separation. Post-migration, refugees face ongoing stressors such as legal limbo, poverty, racism, and the challenges of acculturation. This cumulative trauma exposure can lead to complex clinical presentations that require nuanced understanding and intervention.

Common Mental Health Presentations in Refugee Clients

Refugee clients often show a complex mix of mental health concerns, reflecting the impact of their experiences. PTSD, including Complex PTSD are among the most common diagnoses, marked by intrusive memories, avoidance, negative changes in cognition and mood, and hyperarousal. Depression and prolonged grief disorder are also common conditions related to refugee mental health as refugees deal with deep losses, uncertainty, and a sense of powerlessness.

Anxiety disorders and somatization also appear frequently in refugee populations. Panic attacks, generalized anxiety, and physical reports of distress, like headaches and gastrointestinal problems, may be the main concerns. Identity disruption and survivor's guilt are also significant issues, as refugees face the challenges of adapting to a new culture while processing past traumas.

In order to provide culturally responsive care, therapists need to recognize symptoms and expressions of distress that are culturally specific when working with refugee clients. These may include:

• Spiritual or supernatural explanations: Refugees may interpret their distress through cultural or religious beliefs, such as spirit possession or divine punishment.
• Physical complaints: Emotional pain might be expressed through physical symptoms, such as "heart weakness" or "thinking too much."
• Relational or social issues: Distress may be expressed in terms of interpersonal problems or disruptions in social roles and responsibilities.

Clinicians should approach refugee mental health with cultural sensitivity and humility, aiming to understand how each client experiences and communicates distress within their cultural context. Working with cultural brokers, like interpreters or community leaders, can help connect Western diagnostic frameworks with the lived realities of refugee clients.

Barriers to Accessing and Engaging in Therapy

Refugee clients encounter many hurdles when trying to access and participate in mental health treatment. Language differences are among the most significant challenges, as they can obstruct effective communication and understanding between therapists and clients. While working with interpreters adds complexity to the therapeutic process, it is often essential—requiring clinicians to thoughtfully navigate issues of confidentiality, trust, and cultural nuance to ensure safe and effective care.Cultural stigma surrounding mental illness can also deter refugees from seeking help. Mental health concerns may be viewed as personal weaknesses, moral failing, or spiritual imbalance within their communities, leading to shame and reluctance to engage in treatment. These beliefs often discourage individuals from discussing mental health openly or turning to professionals outside the family or cultural group. In addition, Western models of diagnosis and treatment may not resonate with refugees’ own understandings of suffering and healing, further complicating engagement in therapy. When cultural norms discourage emotional disclosure or prioritize collective coping over individual expression, clinicians must tread carefully, respecting these frameworks while gently building trust and offering support.  

Refugees often have a deep distrust of institutions and authority figures due to past experiences of persecution, discrimination, and trauma. This distrust can extend to healthcare systems, making it difficult for refugees to open up and engage in therapy. The fear of re-traumatization or being misunderstood by providers who lack cultural sensitivity can further hinder treatment engagement.

Practical barriers, such as lack of insurance, transportation difficulties, limited childcare, and housing instability, also pose significant challenges for refugee clients accessing support. These issues can make it hard for refugees to prioritize mental health care amidst competing survival needs. Important considerations for addressing these barriers include:

• Collaborating with interpreters: Therapists must learn to work effectively with language interpreters, ensuring clear communication while maintaining therapeutic rapport and confidentiality.
• Promoting cultural humility: Clinicians should approach refugee clients with openness, respect, and a willingness to learn about their cultural beliefs and experiences.
• Building trust through community engagement: Partnering with refugee community organizations and leaders can help build trust and increase access to mental health services.
• Addressing practical needs: Connecting refugee clients with resources for insurance, transportation, childcare, and housing can help reduce practical barriers to treatment engagement.

Culturally-Responsive, Trauma-Informed Care Approaches

Providing effective mental health care for refugee clients involves a culturally-responsive, trauma-informed approach that recognizes their unique experiences and strengths. Therapists need to adopt a perspective that acknowledges the resilience and resourcefulness of refugees in the face of adversity. This perspective shifts the focus from deficits to the inherent capacities of individuals and communities to heal and thrive.

Cultural humility plays a key role when working with refugee populations. Instead of aiming for cultural competence, which suggests a finite set of knowledge and skills, cultural humility involves a lifelong commitment to self-reflection, learning, and partnership with clients as the expert of their cultural context. Therapists must be aware of their own biases and limitations, actively seeking to understand each client's cultural background and lived experience.

Collaborating with interpreters is important for providing culturally-responsive care for refugee clients. Key considerations include:

• Briefing and debriefing: Prepare interpreters for sessions and debrief afterward to ensure clear communication and emotional support.
• Maintaining therapeutic rapport: Speak directly to the client, rather than looking at or addressing the interpreter, and use the first person to maintain a direct connection.
• Attending to nonverbal cues: Pay attention to the client's body language and emotional expressions, as these may convey important information beyond the interpreted words.
• Seating arrangements: Arrange seating so that the client and therapist can see each other clearly, with the interpreter slightly off to the side. This helps reinforce the therapeutic alliance between therapist and client while still allowing effective interpretation.

Adapting evidence-based treatment modalities is also important for meeting the needs of refugee clients.  Parenting interventions, eye movement desensitization and reprocessing (EMDR), group therapy, and self-help plus, which is derived from acceptance and commitment therapy (ACT) have shown promise in treating refugee trauma. However, these approaches should be modified to incorporate culturally relevant concepts, metaphors, and practices that are specific to the client’s experience.

Safety planning and boundary-setting are vital when working with high-need refugee clients. Therapists must assess for suicidality, self-harm, and other safety concerns, developing clear crisis response plans in partnership with clients and their support systems. Maintaining appropriate boundaries is also necessary to prevent burnout and vicarious trauma among clinicians doing this demanding work.

Vicarious Trauma and the Clinician's Inner Work

Working with refugee clients who have experienced significant trauma can take a profound emotional toll on therapists. Vicarious trauma, also known as secondary traumatic stress, refers to the cumulative psychological impact of empathetically engaging with trauma survivors. Clinicians may experience symptoms similar to PTSD, such as intrusive thoughts, hyperarousal, and emotional numbing. Recognizing the signs of vicarious trauma is important for maintaining the well-being of both therapists and their clients.

Countertransference, a common challenge in trauma work, involves the therapist's emotional reactions to the client's experiences. Therapists may feel overwhelmed by feelings of helplessness, anger, or despair when confronted with the injustices and atrocities their clients have faced. —and continue to face amid current political tensions, shifting federal policies, and global instability. Moral injury can also arise when clinicians feel unable to provide adequate support or witness systemic barriers to refugee well-being. These ongoing realities can heighten both client distress and clinician emotional burden, underscoring the need for support, supervision, and systemic awareness in this work.

To manage vicarious trauma and maintain emotional resilience, therapists must prioritize their own self-care and professional support. Key strategies include:

• Engaging in regular self-care activities: Maintain work-life balance, practice relaxation techniques, and nurture physical and emotional health.
• Seeking consultation: Work with  consultants, including cultural brokers and clinicians experienced with refugee populations, who can provide guidance, validation, and perspective on challenging cases.
• Participating in peer support and consultation groups: Connect with colleagues to share experiences, process emotions, and learn from others in the field.
• Engaging in reflective practice: Regularly examine one's own emotional responses, biases, and cultural countertransference to maintain self-awareness and empathy.

Organizational support is also important for mitigating vicarious trauma among clinicians working with refugees. Agencies should provide ongoing training, resources, and accommodations to help therapists manage the emotional impact of their work. Cultivating a workplace culture that values self-care, open communication, and shared responsibility for client well-being can help prevent burnout and compassion fatigue.

Systemic Advocacy and Interdisciplinary Collaboration

Therapists working with refugee clients play a vital role in advocating for their needs beyond the therapy room. Collaborating with professionals from various fields greatly enhances the support provided. Key partners in this work include:

• Legal services: Therapists can assist refugee clients by connecting them with attorneys who specialize in immigration and asylum law. Providing psychological evaluations and testifying in court can strengthen clients' legal cases.
• Social services: Working with social workers and case managers ensures that refugee clients have access to important resources like housing, employment, and language classes. Therapists can offer insights into clients' mental health needs and advocate for suitable accommodations.
• Schools and educational programs: Partnering with schools and teachers supports refugee children and families. Therapists can guide the creation of trauma-informed classrooms and address the unique learning needs of refugee students.
• Refugee resettlement agencies: Collaborating with resettlement agencies allows therapists to connect clients with a variety of services, from cultural orientation to job training. Therapists can also provide training to agency staff on recognizing and responding to mental health concerns.

Advocating for systemic change is another important aspect of supporting refugee mental health. Therapists can use their expertise to educate policymakers and community leaders about the impacts of trauma and the need for culturally-responsive care. Key advocacy efforts may include:

• Promoting trauma-informed policies in schools, healthcare systems, and social service agencies
• Advocating for increased funding for refugee mental health services and research
• Challenging policies that lead to discrimination and marginalization of refugee communities
• Raising awareness about the resilience and contributions of refugees in society

Engaging in interdisciplinary collaboration and systemic advocacy requires therapists to step outside their traditional roles and work towards broader social change. This work can be demanding, but it is necessary for creating a more just and equitable society that supports the well-being of all refugees.

Conclusion: Holding Hope and Building Belonging

Therapists working with refugee clients have the unique privilege and responsibility of fostering hope, dignity, and growth despite the immense adversity they face. The therapeutic relationship can act as a significant force for healing, as refugees navigate the complex journey of rebuilding their lives in a new context. Clinicians must approach this work with profound respect for the resilience and agency of their clients, recognizing that refugees are the true experts of their own experiences.

Healing for refugee clients rarely follows a straightforward path. Therapists must honor the complexity of each individual's journey, recognizing that progress may be slow and setbacks are common. The aim is not to "fix" refugees but to walk alongside them as they face the ongoing challenges of resettlement and integration. This requires a deep commitment to cultural humility, as therapists continue to learn from and adapt to the diverse needs of their clients.

As mental health professionals, we play an important role in advocating for the well-being of refugee communities. This work extends beyond the therapy room, urging us to be active allies in the fight for social justice and equity. Ongoing education, cultural awareness, and collaboration with refugee-led organizations are crucial for providing effective, responsive care.

Supporting refugee mental health is both challenging and deeply rewarding. Therapists who engage in this work have the chance to witness incredible resilience and transformation in the face of unimaginable adversity. May we approach this important task with humility, compassion, and a steadfast commitment to holding hope for a better future.