In honor of Mental Health Awareness Month during the month of May, USCRI recognizes the importance of fostering public education and advocating for policies that prioritize the well-being of refugees and other forcibly displaced populations affected by mental health issues and mental disorders.
Refugees and other forcibly displaced populations are at a high risk for common mental health conditions and psychosocial problems due to exposure to trauma, violence, and other extreme stressors in their home countries, during migration, and compounded by post-migration stressors during resettlement. There is growing evidence demonstrating that post-migration stressors, such as housing and food insecurity, unemployment, English language proficiency, and social exclusion, significantly influence mental health outcomes and accumulate over time (Hou et al., 2022). In fact, there is growing evidence that unfavorable everyday life experiences in the host country may have a stronger impact on the mental health of forcibly displaced populations relative to pre-migration trauma (Hou et al., 2022). Forced migration also contributes to social losses and interpersonal stressors due to family separation and disruption to family roles and community connections. In turn, these experiences often negatively affect important relationships within families and may result in the breakdown of vital social networks (Hou et al., 2022).
Despite the significant needs of refugees and other forcibly displaced population, there are major gaps and barriers in the available mental health service system and therefore mental health services are used at a lower rate compared to U.S.-born individuals. These barriers include limited availability of service providers, cultural and language barriers, lack of language support, cost of care, lack of health insurance or covered services, lack of access to transportation, encounters with discrimination, mistrust of service systems, and mental health stigma. Access to mental health care has been ranked as one of the top five issues highlighted as being a key determinant of successful integration, according to a recent report surveying forcibly displaced populations in the United States (as cited in Refugee Advocacy Lab, 2024).
Refugee resettlement agencies receive governmental funding to provide assistance with housing, employment, language training, and other basic services to refugees and other forcibly displaced people during their first 90 days. After this initial period, funding typically ends, although additional federal support may be provided for eight months for those who qualify (Refugee Advocacy Lab, 2024). Refugees and other displaced people who are admitted to the U.S. have access to health insurance through Medicaid, the Children’s Health Insurance Program (CHIP), Refugee Medical Assistance (RMA), or the Health Insurance Marketplace. In general, Medicaid, CHIP, and RMA are managed by state Medicaid programs. However, depending on the provider and state, insurance coverage may or may not include access to mental health services or coverage may only be for serious mental illnesses.
For refugees and other forcibly displaced people who do have access to mental health coverage through their insurance, access to linguistically responsive mental health services is limited and varies significantly by state. Under Title VI of the Civil Rights Act and Section 504 of the Rehab Act of 1973, providers who receive federal funds to provide Medicaid/CHIP services are supposed to make language services available to Limited English Proficient (LEP) individuals (Refugee Advocacy Lab, 2024), however language interpretation services are not considered mandatory services and there appears to be infrequent enforcement and inconsistent funding for interpreter services (Shah et al., 2020). Even when language support options are available, service providers may often find that there is a lack of well-trained professional interpreters in medical and/or mental health communication. This may lead to miscommunication, delayed treatment or misdiagnosis, mistrust on the part of refugees to disclose sensitive information or missed opportunities in identifying mental health issues. Service
providers may be unaware of the language support services that are available or the legal obligation to provide language support to refugees and other forcibly displaced people. For refugees and other forcibly displaced people, available interpretation services may be met with frustration with the interpreter’s lack of linguistic competence, knowledge of medical and mental health terminology, and cultural responsiveness. Furthermore, language support services may place an additional financial burden on providers because they indirectly increase the cost of mental health services and increase the length of visits or sessions (Shah et al., 2020).
Overcoming language barriers is vital to ensuring the equitable access to mental health services and improving outcomes for refugees and other forcible displaced people. The following are general recommendations to increase language support services:
· Pay for interpreter services whether by cost-based reimbursement, their inclusion in prospective payment models, or insurer-led contracting for remote interpreters. This will not only counter disparities in access but would also move towards pricing parity between providers who care for a majority of Medicaid patients and those with a higher proportion of commercially incurred populations.
· Greater oversight of Medicaid administrators to ensure that contracted refugee healthcare providers meet the mandate for language support services.
· Long-term and consistent investments of funding for language support services by Congress and other relevant federal agencies.
· Invest in high quality interpretation and improved language accessibility, including developing clearer guidelines on what constitutes “culturally and linguistically responsive” services (Refugee Advocacy Lab, 2024) and sponsoring free training and support for interpreters.
· Programs should be adequately funded and expanded to ensure that newly arrived refugees and other forcibly displaced people receive English language training and have access to language support services.
Language barriers are more than just an obstacle to communication for refugees and other forcibly displaced populations; they are deeply connected to mental health and successful integration. Language is a crucial tool for building and maintaining relationships, sharing one’s experiences and struggles, navigating daily life, and contributing to one’s family, local community, and society. Therefore, it is crucial for communities, service providers, and policymakers to advocate for, fund, and implement comprehensive language support services that can improve access to medical and mental health care for refugees and other displaced populations across the U.S.
References
Hou, W. K., Liu, H., Liang, L., Ho, J., Kim, H., Seong, E., Bonanno, G. A., Hobfoll, S. E., & Hall, B. J. (2020). Everyday life experiences and mental health among conflict-affected forced migrants: A meta-analysis. Journal of Affective Disorders, 264, 50–68. https://doi.org/10.1016/j.jad.2019.11.165
Refugee Advocacy Lab. (2024). Policy guide: Improving access to mental healthcare for refugees and other displaced people in the United States. https://www.refugeeadvocacylab.org/resources/mental-health-policy-guide
Shah, S. A., Velasquez, D. E., Song, Z. (2020). Reconsidering reimbursement for medical interpreters in the era of COVID-19. JAMA Health Forum, 1(10), e201240.
