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Mental Health Awareness Month: Innovative Solutions to Increase Access to Mental Health Services for Migrants & Refugees

By USCRI May 20, 2024

Written by: Rosalind Ghafar Rogers, PhD, LMHC, Clinical Behavioral Health Subject Matter Expert

with USCRI’s Refugee Health Services in Arlington, VA

In recognition of Mental Health Awareness Month during the month of May, it is important to recognize the sizable gap that exists globally and domestically between individuals who need mental health care and those who receive it. In 2022, approximately 59 million U.S. adults (23% of all adults in the U.S.) had a mental illness, however nearly half of them did not receive treatment (Health Resources & Services Administration, 2023). In addition to commonly cited barriers to accessing mental health care, such as high out-of-pocket costs, coverage gaps, and excessive wait times, there is a major shortage of mental health providers in the U.S. which was exacerbated by the COVID-19 pandemic. As of December 2023, more than half of the U.S. population (169 million) lives in a Mental Health Professional Shortage Area (MH PSA; Health Resources & Services Administration, 2023). For example, consider the following:

 

  • More than 1 in 5 Americans live with mental illness and 46% of Americans will meet the criteria for a mental health condition at some point in their lives, however 55% of adults with a mental health condition did not receive treatment in between 2019 and 2020 (Reinert et al., 2022).
  • The national average wait time for mental health services in the U.S. is 48 days (Health Resources & Services Administration, 2023).
  • 6 in 10 U.S. psychologists are not accepting new clients (Health Resources & Services Administration, 2023).
  • Among mental health professionals in the U.S., 65% report increased client caseloads, 93% have experienced burnout, and 62% report suffering from moderate to severe levels of burnout (National Council for Mental Wellbeing, 2023).
  • The estimated shortage is about 10,000 to 20,000 psychiatrists across the U.S. (Mongelli et al., 2020).
  • By 2036, there will be an estimated shortage of 87,630 addiction counselors, 69,610 mental health counselors, and 62,490 psychologists in the U.S. (Health Resources & Services Administration, 2023).
  • Only 25% of primary care practices have onsite mental health specialists of any sort (Mongelli et al., 2020).
  • Medicaid is the single largest payer of mental health services in the U.S., however mental health providers that accept Medicaid are extremely low because of low reimbursement rates, with only 36% of psychiatrists accepting new Medicaid patients (Haseltine, 2023)

 

Refugees and other forcibly displaced people are at a higher risk for common mental health conditions and psychosocial problems compared to the general U.S. population, however they face additional barriers to accessing services, such as language and literacy issues, stigma, different explanatory models of wellbeing and illness, adjustment and integration challenges, difficulty navigating multiple complex systems, and a lack of linguistically and culturally appropriate services. The Bureau of Labor Statistics found that in 2023, close to 70% of social workers and 76% of mental health counselors in the U.S. are White. The American Psychological Association (APA) estimated that in 2021, only 10% of health service psychologists provided services in languages other than English (Refugee Advocacy Lab, 2024). Most mental health professionals in the U.S. identify as female, non-Hispanic White, and English-speaking only. These demographics do not reflect the population at large and may not be representative of the communities being served, all of which severely limit the ability of migrants and refugees to receive linguistically and culturally appropriate mental health care.

 

Exacerbated by the lack of funding and poor reimbursement rates for mental health services, the U.S. refugee resettlement program lacks a consistent and cohesive mental health strategy to fill the gaps in the provision of mental health care for refugees and other forcibly displaced people (Refugee Advocacy Lab, 2024). Innovative solutions and increased funding are needed to fill these gaps, address the mental health workforce shortage, and advance mental health equity in the U.S. Discussed below are some recommendations of innovative solutions to increase mental health service access, reduce barriers, address mental health workforce shortages, and ensure that mental health support is linguistically and culturally appropriate and tailored to the unique needs of refugees and other forcibly displace populations.

 

Capacity Building and Alternative Pathways to Growing a Diverse Mental Health Workforce

 

To address the existing shortage of mental health professionals and improve the linguistic and cultural diversity of the mental health workforce, we need investments in training and workforce development programs, the creation of pathways to licensure for foreign-born professionals, and the elimination of barriers to interstate practice. By developing accessible pathways to licensure for migrants and refugees who were trained in their home countries, the cultural and linguistic diversity of the U.S. mental health workforce would improve, and migrants and refugees would have greater opportunities to practice within their professions upon resettlement. Although it falls short of resolving the shortage of mental health professionals, reducing the restrictive barriers that prevent mental health professionals from practicing across state lines is another way to expand the geographical reach of linguistically and culturally responsive services for migrants and refugees (Refugee Advocacy Lab, 2024). Currently, mechanisms are underway that would allow for interstate practice, such as the PsyPact that permits psychologists to practice across 39 states, and the forthcoming Counseling Compact that would permit professionals counselors to practice across state lines.

 

Additionally, it is crucial to invest in comprehensive training programs that emphasize cultural responsiveness and trauma-informed care and strengthen the capacity of general health providers and resettlement workers to identify, screen, and effectively respond to common mental health conditions. These strategies can improve mental health outcomes and increase mental health service access and utilization among migrants and refugees.

 

Leveraging a Task-Sharing Approach

 

As a promising strategy for addressing the mental health workforce shortage, a task sharing approach involves the formalized redistribution of care and duties typically provided by those with specialized training (e.g., psychiatrists, psychologists, mental health counselors) to individuals in the community, or non-specialists, with little or no formal training (Belz et al., 2024; Le et al., 2022). Task sharing in mental health services can be developed through the training and supervision of non-specialized lay workers from within refugee communities who lack prior professional education and training in delivering key mental health interventions. This non-specialist role has been referred to as lay health worker, lay provider, community health worker, indigenous paraprofessional, cultural navigator, peer support specialist, and peer volunteer, but for ease of reading, this role will be referred to as community health worker (CHW) going forward. Using a task sharing approach, CHWs could serve as a bridge between the community and care providers by conducting community outreach and providing cultural and linguistic consultation to providers; CHWs could provide auxiliary support of the delivery of mental health treatment through case management, promoting client adherence to treatment, and screening to identify refugees in need of mental health services; CHWs can provide lower levels of care to clients with less intensive mental health needs while referring clients with more severe symptoms to mental health specialists to provide a higher level of care; and lastly, CHWs can serve as the sole service provider of mental health and psychosocial support services (Barnett et al., 2018).

 

A task-sharing approach in mental health services has the potential to increase access to mental health services by requiring less resources and specialist skills than traditional therapeutic approaches that are provided by mental health professionals and strengthen and scale-up a mental health system that is sustainable. Additional benefits of task sharing include:

  • As intermediaries between individual refugees, refugee communities, and healthcare/social service providers, CHWs build peer-to-peer relationships, facilitate trust, increase engagement with mental health services, bridge cultural healing support, inform communities of preventative care and mental health resources, address social determinants of health, reduce the cost of care, and improve health outcomes (Health Resources & Services Administration, 2023; Verbillis-Kolp et al., 2024).
  • As individuals with similar lived experience as the refugees being served, CHWs/peer support specialists can both increase the acceptability of interventions for refugee clients and help them navigate and reduce the impact of stigma.
  • Refugees gain a sense of belonging and connection to others who have gone through similar challenges. Peer-led group-based support has been shown as effective in reducing social isolation and supporting community healing responses. (Le et al., 2022)
  • CHWs have been shown to be effective in improving outcomes for depression, post-traumatic stress disorder (PTSD), and alcohol use disorder. (Barnett et al., 2018), enhancing coping strategies, and reducing symptoms associated with physical ailments (Verbillis-Kolp et al., 2024).
  • Training and relational communication between CHWs/peer support specialists and service providers promoted empowerment, built social capital and community capacities, and developed leadership and self-efficacy within CHWs/peer support specialists, as well as the refugees receiving support (Verbillis-Kolp et al., 2024).

 

Community-Based Approaches & Collaborative & Integrated Care Models

 

Due to structural and cultural barriers, the most commonly reported points of access to health care for refugees and other forcibly displaced people are via primary health care settings and in their communities in the country of resettlement (Iqbal et al., 2022; Lu et al., 2020). Community-based approaches and collaborative and integrated care models are additional solutions that avoid stigma, include minority cultural perspectives, increase mental health service access, reduce utilization barriers, and address the shortage of mental health professionals.

 

Community-based mental health care involves multisectoral partnerships and the active involvement and leadership of refugees and other forcibly displaced people in defining and implementing services and initiatives that are integrated with other services commonly accessed by refugees and other forcibly displaced populations in their respective communities. By creating opportunities that enable and encourage the participation of refugees and other forcibly displaced people in the design, planning, and implementation of mental health and psychosocial support services, bi-directional learning is fostered between refugees and providers and services are likely to be linguistically appropriate, culturally responsive, and sustainable. Mental health prevention initiatives, such as information campaigns aimed at reducing stigma and increasing mental health literacy, or mental health interventions such as psychoeducation, coping skills, and emotion regulation strategies for adults and children should be integrated into community and neighborhood settings, such as home-based care, resettlement agencies, mutual aid organizations, religious institutions, and schools. Community-based approaches to mental health and psychosocial support for refugees have been shown to increase access to care, promote emotional well-being and coping, interpersonal functioning, social support, and community empowerment, (Im et al., 2023; Mongelli et al., 2020).

 

Collaborative and integrated care models are systemic, multidisciplinary team-based approaches to the management of mental health conditions by integrating mental health services into primary care settings. In collaborative and integrated care approaches, a multidisciplinary team of primary care providers, mental health specialists, as well as CHWs or cultural navigators work together to address the medical and mental health needs of refugees concurrently in a culturally responsive manner (Lu et al., 2020). In collaborative and integrated care approaches, refugee clients can access mental health services through self-scheduling, provider-to-provider consultations during primary care appointments, warm handoffs during primary care visits or referrals to follow-up care (Daniel et al., 2023).

 

The Department of Health and Human Services (HHS) highlighted the critical role of integrated care in addressing the national behavioral health crisis by improving access to affordable and high-quality care that was culturally and linguistically appropriate (Health Resources & Services Administration, 2023). Integrated care has also been shown to promote early access to mental health services for refugees by reducing stigma, fostering alignment of cultural factors in clients’ illness experience, and improving the therapeutic alliance and client satisfaction (Daniel et al., 2023; Versteele et al., 2024).

Technology-Based Mental Health & Psychosocial Support           

 

E-mental health can be defined as “the use of information and communication technology—in particular the many technologies related to the internet—when these technologies are used to support and improve mental health conditions and mental health care, including care for people with substance use and comorbid disorders” (Riper et al., 2010, p. 1). Technology-based interventions can be developed and implemented to improve mental health outcomes among refugees and other forcibly displaced populations via online tools and apps, online counseling or telehealth platforms, and digital integration, such as Zoom and WhatsApp. Technology-based mental health and psychosocial support interventions should be linguistically adapted and culturally responsive and should provide self-help resources that focus on normalizing symptoms, enhancing mental health literacy, building coping strategies and social support, and informing refugees of local support services and resources.

 

Advancements in technology-based mental health and psychosocial support have broken down barriers, such as digital and mental health literacy and geographical constraints, enhanced accessibility, confidentiality, and inclusivity, and promoted sustainable, community-engaged services that are responsive to the complex needs of refugees and other forcibly displaced populations (Im et al., 2023). Although more conclusive evidence is needed, technology-based mental health innovations have shown positive non-clinical (i.e., perceived flexibility, cultural sensitivity, and time saving) and clinical outcomes (i.e., reduced mental health symptoms) among immigrants and refugees (Woodward et al., 2023).

 

Innovative solutions are needed to address the widespread shortage of mental health professionals, especially those with linguistic and cultural competence, who can sufficiently meet the extensive mental health and psychosocial needs of a diverse immigrant and refugee population in the U.S. Prioritizing funding and resources to strengthen the infrastructure of refugee resettlement programs and culturally responsive mental health services is critical. Capacity-building, creating alternative pathways to licensure and improving the diversity of the mental health workforce, community-based approaches, collaborative and integrated care models, and technology-based mental health tools and platforms are just a few examples of innovative approaches that address the growing mental health demands of an increasingly diversified population. By embracing and advocating for these innovative solutions, we can expand access to mental health support that is culturally sensitive and tailored to the unique needs of refugees.

 

 

For resources or more information about USCRI’s Refugee Health Services program for resettled Afghans, please visit: https://refugees.org/the-behavioral-health-support-program-for-afghans/

 

If you or someone you know is thinking about suicide or would like emotional support, call or text 988, the Suicide and Crisis Lifeline that is available 24/7. If you or someone you know is having a life-threatening emergency, please call 911 or go to your nearest hospital emergency room.

 

 

References

Barnett, M. L., Gonzalez, A., Miranda, J., Chavira, D. A., & Lau, A. S. (2018). Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review. Administration and Policy in Mental Health, 45(2), 195–211. https://doi.org/10.1007/s10488-017-0815-0

Belz, F. F., Vega Potler, N. J., Johnson, I. N. S., & Wolthusen, R. P. F. (2024). Lessons from low- and middle-income countries: Alleviating the behavioral health workforce shortage in the United States. Psychiatric Services, 0(0). https://doi.org/10.1176/appi.ps.20230348

Daniel, K. E., Blackstone, S. R., Tan, J. S., Merkel, R. L., Hauck, F. R., & Allen, C. W. (2023). Integrated model of primary and mental healthcare for the refugee population served by an academic medical centre. Family Medicine and Community Health, 11, e002038. https://doi.org/10.1136/fmch-2022-002038

Health Resources & Services Administration. (2023). Behavioral Health Workforce, 2023. Department of Health & Human Services. Retrieved from https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/Behavioral-Health-Workforce-Brief-2023.pdf

Im, H., Verbillis-Kolp, S., Atiyeh, S., Bonz, A. G., Eadeh, S., George, N., & Wadu, A. M. (2023). Implementation evaluation of community-based mental health and psychosocial support intervention for refugee newcomers in the United States. Health & Social Care in the Community, 6696415.  https://doi.org/10.1155/2023/6696415

Le, P. D., Eschliman, E. L., Grivel, M. M., Tang, J., Cho, Y. G., Yang, X., Tay, C., et al. (2022). Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks. Implementation Science, 17, 4. https://doi.org/10.1186/s13012-021-01179-z

Lu, J., Jamani, S., Benjamen, J., Agbata, E., Magwood, O., & Pottie, K. (2020). Global mental health and services for migrants in primary care settings in high-income countries: a scoping review. International Journal of Environmental Research and Public Health, 17(22), 8627. https://doi.org/10.3390/ijerph17228627

Mongelli, F., Georgakopoulos, P., & Pato, M. T. (2020). Challenges and opportunities to meet the mental health needs of underserved and disenfranchised populations in the United States. Focus, 18(1), 16-24. https://doi.org/10.1176/appi.focus.20190028

National Council for Mental Wellbeing. (2023). New study: Behavioral health workforce shortage will negatively impact society. Retrieved from https://www.thenationalcouncil.org/news/help-wanted/

Reinert, M., Fritze, D., & Nguyen, T. (2022). The State of Mental Health in America 2023. Mental Health America. Retrieved from https://www.mhanational.org/sites/default/files/2023-State-of-Mental-Health-in-America-Report.pdf

Riper, H., Andersson, G., Christensen, H., Cuijpers, P., Lange, A., & Eysenbach, G. (2010). Theme issue on e-mental health: a growing field in internet research. Journal of Medical Internet Research, 12(5), e74. https://doi.org/10.2196/jmir.1713

Versteele, J., Rousseau, C., Danckaerts, M., & De Haene, L. (2024). Developing a collaborative approach to support access and acceptability of mental health care for refugee youth: an exploratory case study with young Afghan refugees. International Journal of Environmental Research and Public Health, 21(3), 292. https://doi.org/10.3390/ijerph21030292


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