Abstract This paper argues for a re-examination of mental health responses to refugee youth seeking asylum in high-income countries. Reviewing international literature related to mental health and social care services for refugee children and youth and drawing upon Foucault’s concepts of power, truth and discourse, we explore and question the predominance of the bio-medical model in responding to refugee children’s distress. We demonstrate that, despite notable initiatives and developments in social work theory and practice, the bio-medical model has, in many ways, become a ‘regime of truth’, with the power to define refugees’ problems and thus shape the policies and services that affect their lives. While not denying that many refugee youth and their families may benefit from such therapeutic interventions, it is our contention that working with this population requires a significant expansion, diversification and transformation of the current paradigm informing social work practice to incorporate the multiple and unique cultures and contexts of this population. We conclude with a discussion of promising practices and interventions with refugee youth and families. Refugees, children and adolescents, mental health, bio-medical model, social work practice Introduction It seems to me that the real political task in a society such as ours is to criticize the workings of institutions, which appear to be both neutral and independent; to criticize and attack them in such a manner that the political violence which has always exercised itself obscurely through them will be unmasked, so that one can fight against them (Foucault, in Chomsky and Foucault, 2006, p. 41). In recent years, the psychological distress of refugee youth seeking asylum in high-income countries1 has taken centre stage in service provision and immigration policy. This, in turn, has led to a prolific amount of research, policies and services focused on the study and treatment of Post-Traumatic Stress Disorder (PTSD) assumed to stem primarily from war exposure (Pacione et al., 2013). These studies and interventions have been largely rooted in a bio-medical model of mental health that focuses on ‘pathological conditions, the diagnosis of disorders, epidemiological studies and the treatment of symptoms through pharmacological or psychotherapeutic interventions’ (Ryan et al., 2008, p. 2). The social work profession has been a key player within this trend, too often uncritically importing theories of Western psychology and psychiatry into its disciplinary toolkit (Lacroix and Sabbah, 2011; Masocha and Simpson, 2012). While not denying that many refugee youth and their families may benefit from such therapeutic interventions, scholars have called into question the universality of the bio-medical approach, and its ability to effectively respond to the psycho-social pain of war-related violence, torture, discrimination and loss (Miller and Rasmussen, 2016). Authors have underscored the pressing need for social work to develop discipline-specific models of refugee mental health—ones that incorporate the knowledge of the multiple and interacting factors at each level of refugee youth’s socio-ecological system, whether family, school, peer group, surrounding culture or resettlement environment (Allan, 2015). This paper reviews international literature related to mental health and social care services for refugee children and youth to understand the continuing dominance of the bio-medical model in social work practices, as well as its implications on the lived realities of refugee youth. Drawing upon Michel Foucault’s seminal work on the relationship between power and knowledge, we argue that what is often considered a ‘neutral’, agenda-free approach to refugee mental health is—in reality—a site of tension, power and dominance (Foucault, 1980). We do not deny the important contributions of the bio-medical model to the refugee mental health field—it provides us with a framework to understand emotional distress, criteria to define diagnosis, epidemiological data and, most importantly, a common language to communicate with other professionals. However, it is our contention that working with this population requires a significant expansion, diversification and transformation of the current bio-medical paradigm informing social work practice to incorporate the multiple and unique cultures and contexts of refugee youth. We provide case examples from northern Uganda and Australia to demonstrate how, through the medicalisation of refugee youth’s distress, social workers may not only miss the boat on appropriate methods of healing and intervention, but may also unwittingly divert attention away from problematic social policies and structural inequalities, ultimately promoting a culture of passive conformity to problematic state refugee policies. We conclude with a discussion of promising practices and interventions with refugee youth and families. Mental health social work with refugees: trends in theory, practice, policy and education Around the world, more than 28 million children have been forcibly displaced due to war and extreme forms of violence. While a majority of these children are hosted in regions where they were born, a significant number seek shelter in high-income countries (UNICEF, 2016). Upon their arrival in host countries, refugee and asylum-seeking children may face additional threats to their well-being including separation from family, detention, discrimination and poverty. However, protective factors in the resettlement country (rapid resolution of asylum decisions, accessible and adequate services, accepting and safe environment) may decrease the chance of a child experiencing mental health difficulties (Fazel et al., 2012). Although social work practice in host countries has been largely shaped and restricted by national contexts and policies, social workers have been at the forefront of the international response to the humanitarian crisis, providing a range of services including material assistance, individualised casework, trauma counselling, services pertaining to resettlement and interventions targeted to community building and policy promotion (International Federation of Social Workers, 2016). At the same time, however, the profession has been slow to develop discipline-specific theories and conceptual frameworks on the topic of migration. As Cox and Geisen (2014) note in their cross-national systematic review, ‘the social world is being transformed by migration and social work is playing catch-up’ (p. 162). Some scholars suggest that this notable void in our professional arsenal has led many social workers to draw on bio-medical theories of mental health practice when working with refugee youth in host countries. They argue that the mental health difficulties experienced by refugees cannot be understood solely based on biologic aetiology (Masocha and Simpson, 2012). These developments can been seen as part of wider scholarly and public discussions on the role the medical model has played in mental health social work. Authors such as Weinstein (2014) and Gomory et al. (2011) argue that, in the search for professionalisation and survival, clinical social work has become over-reliant on psychiatric and psychological theories and epistemologies that often have competing foundational visions and core values. Scholars have pointed to the heavy emphasis on DSM diagnosis in social work assessment and training, and the neglect of social, environmental and economic factors that lead to emotional distress (Lacasse and Gomory, 2003; Robbins, 2014). Moreover, social work scholars have cautioned against the central role the trauma model plays when responding to refugees’ complex needs (Lacroix and Sabbah, 2011). Westoby and Ingamells (2010) describe how, in Australia, funding bodies’ demands for evidence-based practice and the increasingly managerialist ethos in public-sector organisations have led trauma-focused services to become a highly legitimised form of social work practice, leading social workers to prioritise trauma work with war-affected populations. In the realm of social work policy and advocacy, Chantler (2012) and Humphries (2004) have highlighted the absence of a critical debate on the mental health impacts of oppressive refugee policy and legislation in statutory mental health social work. Focusing on the context of the UK, they argue that the dominance of the medical model in social work practice has led to an emphasis on providing clinical services to address disorders rather than a more fundamental critique of harmful policies such as enforced poverty, dispersal and detention. Similarly, scholars warn that social workers who do not challenge the status quo ‘risk being complicit in maintaining the tragedy of the asylum system, and being viewed as collaborators’ (Maylea and Hirsch, 2017, p. 5). It is important to note, however, that there have been significant practice, policy and educational challenges to these trends and to the unilateral focus on the bio-medical model. Researchers and practitioners have begun to shift the emphasis away from experiences of war-related violence and symptoms of post-traumatic stress towards understanding the psycho-social impact of stressors in the resettlement environment (Miller and Jordans, 2016; Mitschke et al., 2017). Accordingly, scholars such as Westoby and Ingamells (2010), Doucet and Denov (2012) and Dubus (2015) have offered important practice and intervention alternatives, underscoring the need to capitalise on the capacity and wisdom inherent in refugee communities. In addition, there are multiple incidents where social workers have attempted to defy and resist restrictive governmental policies. Many social workers have served as outspoken advocates for refugee rights through their professional associations, which have issued official statements and inquiries denouncing unjust immigration policies (International Federation of Social Workers, 2016). Others have exercised discretionary power to provide services that otherwise would have been denied (Robinson and Masocha, 2017). Within the realm of social work education, in the last few decades, the profession has taken upon itself to improve its members’ ability to work with culturally and ethnically diverse clients (Council on Social Work Education, 2008; National Association of Social Workers, 2007). This is reflected in the Education and Accreditation policies, as well as in the Code of Ethics adopted by Social Work Associations in countries like Canada, the USA and Australia. Yet, a recent literature review of social work scholarship on international immigration found a clear omission of cultural factors related to social work practice with migrants and refugees (Shier et al., 2011). So, while there appear to be important pockets of professional critique, debate and resistance, the predominance of the bio-medical remains entrenched. To understand this entrenchment, we rely on the work of Michel Foucault, particularly in relation to his notions of power, truth and discourse. Understanding the dominance of the bio-medical model in mental health care for refugee youth When attempting to understand the dominance of the bio-medical model in the field of mental health care for refugee youth, we turn to Foucault’s extensive writing on the role of truth and power in mental health. In his book, Madness and Civilization, Foucault traces the evolution of the concept of madness demonstrating the social forces that shape the meaning of, and responses to, the deviant ‘other’ (Foucault, 1965). For Foucault, both Western psychology and psychiatry emerged from the power base resulting from the seventeenth-century ‘great confinement’, in which large numbers of people considered ‘mad’ were institutionalised under the supervision of medical doctors. According to Foucault, the purpose of declaring them mentally ill was, in fact, to reinforce that their deviance from established social norms was abnormal and inadvisable. Ultimately, through a process of what Foucault terms ‘normalization’, these understandings were standardised, and what we now call the ‘bio-medical model of mental illness’ became the most popular model for understanding problems individuals have with regard to their feelings, behaviours and beliefs (Foucault, 1965). Thus, from a Foucauldian perspective, the Western bio-medical model did not emerge from a ‘neutral space’ that is disconnected from culture, time and political environment. Rather, it should be understood as a ‘discourse’ that has emerged from ‘a whole range of institutions, economic requirements, and political issues of social regulation’ (Foucault, 1980, p. 91). Furthermore, this discourse—built up and created over time—is itself an expression of power relations, not only assuring knowledge in a particular disciplinary area, but also establishing who has a claim on that knowledge. Foucault notes that the discourse becomes a means through which power relations are established and maintained—ultimately empowering some (those who have control over the discourse), while subordinating others (those who do not). From a Foucauldian lens, the bio-medical model is, in fact, one of many valid systems of understanding human suffering, and is no less socially constructed than any other. Adopting Foucault’s concept of discursive power, the slow but steady dominance of the bio-medical model in social work over the past several decades can be regarded as a creation of a ‘regime of truth’, which holds hegemonic control in understanding and responding to human distress. Foucault describes the regime of truth: Each society has its regimes of truth, its ‘general politics’ of truth: that is the types of discourse which it accepts and makes function as true; the mechanisms and instances which enable one to distinguish true from false statements, the means by which each is sanctioned; the techniques and procedures accorded value in the acquisition of truth; the status of those who are charged as saying what counts as true (Foucault, 1980, p. 131). Despite the well-intended motives of social work practitioners, the assumption that the mental illness construct is universally applicable may create an unquestioned and authoritarian consensus that ultimately denies the legitimacy of alternative conceptualisations of mental health and healing (Clark, 2014). Indeed, the growing awareness of the role of culture and context in mental health has led scholars to criticise the assumption that psychiatric categories and diagnoses developed from one culture can be carried over to another culture, calling it a category fallacy (Kleinman, 1988). A strong focus on PTSD has shaped research and practice with refugee youth (Nadeau et al., 2017). Yet, while scholars have widely acknowledged the devastating mental health consequences of war, flight and displacement (Fazel et al., 2012), researchers have argued that simply applying a Western psychiatric diagnosis such as PTSD to refugee youth suffering from emotional distress from severe trauma is inappropriate, as it risks pathologising what can otherwise be understood as a normal reaction to devastating adverse events (Pacione et al., 2013). Scholars have also highlighted that, for war-affected populations, ‘daily stressors’ in the present life of resettled youth (poverty, family conflict, impaired parenting due to parental distress, and lack of access to housing and education) are key factors in barriers to achieving post-war well-being. They note that the tendency of post-war interventions to treat PTSD among children, while neglecting to address resource deficits in their families and broader social environments, is unlikely to show significant or lasting effects (Miller and Jordans, 2016). The role of culture and context in refugee youth mental health practice and policy: case studies from Uganda and Australia In relation to social work practice, in the following section, we highlight two case studies relating to the mental health of youth affected by war, violence and abuse in northern Uganda and Australia. By drawing upon these two case studies, we seek to highlight the potential iatrogenic effects of imposing a bio-medical model. Understanding cultural concepts of distress: Cen in northern Uganda One of the central limitations of the bio-medical model in addressing war-affected children’s distress is its little emphasis on refugees’ own experiences and cultural explanations of symptoms, favouring instead a ‘one size fits all’ approach. However, today, there is a wide recognition that all forms of emotional distress are locally shaped (American Psychiatric Association, 2013). When children flee their countries of birth and arrive in high-income states, their cultural beliefs and traditional knowledge, combined with the broad social, economic and political context in which they find themselves, shape the ways in which they experience and express distress (Pacione et al., 2013). These local conceptualisations have been termed in DSM-5 ‘cultural concepts of distress’ and have been defined as ‘ways cultural groups experience, understand, and communicate suffering, behavioural problems, or troubling thoughts and emotions’ (American Psychiatric Association, 2013, p. 758). Studies have shown that, when providing mental health services to refugee children, accounting for cultural concepts of distress is extremely important, since they affect their coping strategies, expectations from treatment and their pathways to help seeking (Kirmayer et al., 2011). The following case study presents the cultural concepts of distress held by war-affected youth from northern Uganda. This case study was chosen because of its ability to illustrate the important role of local context and cultural beliefs in explaining and experiencing distress as well as the potential harm of applying a Western diagnosis. It should be noted that past attempts to describe ‘folk illnesses’ and ‘culturally bound syndromes’ have sometimes resulted in an exoticised, paternalistic and rigid view of local mental health problems (Nichter, 2010). We therefore urge readers not to understand these culture-based concepts as stagnant and frozen in time, but instead as ‘tied to culturally salient types of interaction that make sense in context’ (Nichter, 2010, p. 407). The Acholi of northern Uganda traditionally believe in two types of disease—the ‘normal’ disease and ‘spirit’-related disease (Bilotta, 2016). ‘Normal’ diseases represent physical ailments such as old age, malaria and fungal infections, which tend to be treated with herbs, natural medicines or visits to health units/hospitals (Harlacher, 2009). ‘Spirit-related’ illnesses originate from ancestors sending mild illness as a response to the misconduct of clan or family members and require Acholi rituals and ceremonies performed by local clan leaders in order to be healed (Bilotta, 2016). In northern Uganda, children’s traumatic distress resulting from war is often manifested as spirit possession—a dissociative phenomenon that involves ‘experiences of being under the control of a powerful entity, such as a god, a demon, a devil or a ghost’ (Neuner et al., 2012, p. 548). It is said to be especially common among former child soldiers who were abducted by the rebel Lord’s Resistance Army and forced to kill (Neuner et al., 2012). In the post-war context, children complain of being haunted by spirits of people who have been killed during the war, referred to as Cen (Akello et al., 2010). Cen has been described as the revenging of spirits of those who were killed during the war and not given a proper burial. It manifests by haunting the sufferer (usually the perpetrator of the killing) as well as his or her family, via nightmares, disturbing visuals, sickness and physical pain (Akello et al., 2010). If not explored via a locally specific contextual framework, practitioners may identify symptoms of Cen as those of PTSD—given that children haunted by Cen suffer from nightmares, sleeplessness, headaches, hearing voices, images of violent men and disturbing recollections of witnessed violence (Bilotta, 2016). However, while Cen requires specific cultural rituals and ceremonies, PTSD is often treated by Western-based behavioural practices and possibly medication. The above-noted case example highlights the importance of addressing cultural idioms of suffering, distress and well-being—and their social, relational, cultural and historical meaning and implications for affected populations. Failure to do so may wittingly or unwittingly create and perpetuate dominant bio-medical paradigms and ‘ways of knowing’ that may marginalise or silence local sources of knowledge and indigenous forms of practice that are, in fact, more meaningful and effective for affected youth (Denov and Akesson, 2017). The impact of state policy on refugee youth mental health in Australia: self-harm and suicide In the realm of policy, it is often assumed that macro-level policies are largely divorced from individual mental health. However, in this section, we illustrate the ways in which state policies—which in many ways reflect and perpetuate the regime of truth—can be harmful and detrimental to the mental health of refugee youth, sometimes worsening individual expressions of trauma and distress. The following case study focuses on the mental health of war-affected youth detained in Australia. This case study was chosen because it demonstrates not only the direct impact of policy on refugee health, but also highlights the importance of advocating on a systemic level as well as addressing the post-migration context when designing services. Although post-migration detention of refugees is common in many countries, Australia has been unique in establishing a harsh policy of mandatory detention since 1992, and—since 2001—legislation allowing unlimited detention in onshore and offshore facilities (Isaacs, 2015). While Australia’s Migration Act affirms that children shall only be detained as a measure of last resort, in practice, the provisions of the Migration Act relating to mandatory detention apply equally to adults and children and the particular vulnerabilities of asylum-seeker children are not addressed (Australian Human Rights Commission, 2017). In 2013, the number of children in closed detention facilities reached a peak of 1,992. Since then, it has gradually declined and currently almost all children and families have been released on temporary protection visas or to community detention centres (Australian Human Rights Commission, 2017). However, according to the UN Special Rapporteur on the human rights of migrants, these centres ‘resemble military barracks, are fenced, are guarded by security officers, and their inhabitants have to sign in and sign out each time they leave or enter the camp’ (United Nations, 2017, p. 14). These policy approaches have significantly shaped children’s expression of distress and its damaging effects have been shown to persist even after release (Fazel et al., 2012). Although governmental restriction has limited systemic health surveys within detention centres, the Australian Department of Immigration and Border Protection recorded that, between January 2013 and March 2014, there have been ‘128 incidents of self-harm in children aged 12–17 years; 171 incidents of threatened self-harm in children; 105 children monitored after being assessed as being at “high-imminent” or “moderate” risk of suicide or self-harm’ (Paxton et al., 2015, p. 366). Leaked documents from 2016 revealed that threats of, attempts at and instances of self-harm among children in the Naru detention centre occur consistently, sometimes daily (Farrel et al., 2016). International human rights organisations have termed the phenomenon ‘an epidemic of self-harm’ (Amnesty International, 2016) and the former director and chief psychiatrist of mental health services at the International Health and Mental Services (IHMS) described the treatment of refugees in detention facilities as ‘akin to torture’ (Isaacs, 2015, p. 354). Social workers employed within the Australian asylum-seeker processing system have been accused of collaborating with ‘the systemic abuse of men, women and children who seek asylum in Australia’ (Maylea and Hirsch, 2017, p. 1). Indeed, whether effective mental health care can be provided in the context of detention has been a matter of fierce debate, raising numerous ethical dilemmas. While some mental health professionals and researchers have found the scientific documentation of mental health distress to be a vital tool in fighting the current policy (Silove et al., 2007), others have raised concerns that treating children in extreme distress is ineffective, as it does not change the underlying structural problem (Isaacs, 2015). The implications of the regime of truth on refugee youth mental health: medicalisation, depoliticisation and (dis)empowerment The presence of a regime of truth whereby privileging a bio-medical model, alongside harsh policies that determine and declare who are ‘insiders’ and ‘outsiders’, continues to hold a firm grip and hegemonic control over social work practice and policy with refugee youth. This regime of truth has multiple and far-reaching implications. Unilaterally employing a bio-medical model may sustain the social order by medicalising and de-politicising refugee youth’s challenges and struggles. Medicalisation is defined as a ‘process whereby human problems are framed as medical problems, and are treated as such’ (Clark, 2014, p. 1). In this process, social workers may ‘biologise’ refugees’ psychological distress and complex political and social problems are ignored. The reframing of the suffering of war, migration and resettlement as a medical problem risks reinforcing social workers to adopt neo-liberal individualistic solutions such as psychotherapeutic methods, thus diverting public attention away from problematic social policies, structural inequalities and, ultimately, promoting a culture of acceptance and de-politicising refugees’ distress. Drawing on Foucault’s concept of disciplinary societies, fundamental questions that arise are: who has the power to define a problem and why is it defined as such? Power, from a Foucauldian perspective, is productive rather than repressive. Efforts to control and define refugee problems actually produce and enable elements such as clinics, interventions, research, specialists and fields of study. The justification underlying these services and policies are not in and of themselves always negative: they do not seek to punish refugees, but rather aim to heal, to reintegrate and to prepare refugees to be productive members of society. However, according to Foucault, it is the so-designated social work ‘experts’ who ultimately control the production of knowledge and services (Foucault, 1980). Indeed, refugee children’s perspectives are rarely included in research and they have had little to no influence in the design of their own service provision (Watters, 2001). Given a refugee’s relatively powerless position within that encounter, alongside possible experiences of racism and oppression, they may find it difficult or dangerous to articulate their own point of view, especially when it conflicts with social workers’ framework and may hamper their chances of receiving crucial benefits and services. Kohli (2006) highlights that unaccompanied refugee minors often choose to remain silent in the social work encounter and, when they do talk, they often give ‘a restricted view of their lives’ (p. 710). While trust is an essential component of a successful therapeutic relationship, the silences and fragmented narratives of refugees have sometimes led social workers to feel suspicious and sceptical of their clients, discrediting the stories they share (Robinson and Masocha, 2017). Without a ‘voice’ in decision making or an opportunity to articulate their challenges in their own terms, services may fail to respond to refugees’ diverse mental health needs. In addition, discourses rooted in the bio-medical model of mental health play a pivotal role in shaping refugees’ life worlds. Through ‘technologies of domination’, social workers may draw upon prescribed parameters within which refugees’ identities can be formed (Foucault, 1979). By classifying refugees in binary categories (sick/healthy, mad/normal, traumatised/resilient), they both constitute and limit refugees’ narratives. Indeed, studies have shown that receiving a mental health diagnosis can have significant implications for refugees’ sense of self, both positive and negative. A diagnostic label may help validate their suffering. It can normalise their feelings and behaviours, provide a shared vocabulary from which to express their experiences, and mobilise services and support from their community (Kleinman, 1988). However, studies have shown that solely considering refugees in terms of ‘passive victims suffering from mental health problems’ can have a damaging impact on their sense of self and well-being (Watters, 2001, p. 1709). Refugees may internalise these labels and see themselves primarily as helpless victims (Bracken et al., 1997). As Stubbs notes: The ways in which psycho-social needs are addressed do little to empower survivors of flight, violence and destruction and, instead … when people become cases, when expressions of hurt become symptoms, and when processes of healing becomes treatment, I worry it is professional definers who are empowered rather than the people we work with (Stubbs, 1995, p. 64). Importantly, and perhaps in response to the above-noted implications, recent studies have shifted away from vulnerability and pathology and highlighted instead refugees’ strength and resilience (Pacione et al., 2013). Rather than focusing on deficits, scholars and practitioners have adopted a perspective that emphasises the resilience, coping mechanisms and protective factors of war-affected individuals. However, there is a real danger of dichotomising complex human experience into simple traumatic/resilience categories. Whether the focus is on the positive or negative outcomes of exile, both perspectives can lead to an essentialisation and generalisation of refugees’ experience (Denov and Akesson, 2017). Discussion Drawing upon Foucault’s concepts of power, truth and discourse, we have sought to explore and question the predominance of the bio-medical model in responding to refugee children’s distress. We have demonstrated that, despite notable initiatives and development in social work theory and practice, the bio-medical model has, in many ways, become a ‘regime of truth’ in social work practice, with the power to define refugees’ problems and thus shape the policies and services that affect their lives. Foucault’s critique of the epistemological assumptions at the root of the bio-medical model challenges social work practitioners and researchers to develop more reflexive and critical practices that consider refugees’ unique understandings and conceptualisations of distress. Such consideration implies a shift from predominantly focusing on post-migration trauma and individualised clinic-based forms of intervention to employing socio-ecological models that target refugee wide-ranging needs and include an array of actors, institutions and services such as housing, family, culture, community, legal advice, advocacy, food and education (Miller and Rasmussen, 2016). Perhaps the most well known ecological model is that of Bronfenbrenner (1977), which includes five systems—the microsystem, mesosystem, exosystem, macrosystem and chronosystem—that affect and are affected by individual behaviour. The model assumes that human development is shaped not only by intra-personal factors, but also by inter-personal and political ones. Bronfbrenner’s model and other socio-ecological models of refugee distress (Allan, 2015; Miller and Rasmussen, 2016) enable us to examine how larger social systems in which children are embedded impact their mental health and well-being. Interventions based on this model would include ‘the utilization of existing healing resources within a child’s ecosystem in addition to or as part of whatever therapeutic methods are used directly with children’ (Miller and Jordans, 2016, p. 3). Three factors are considered to explain the rationale for this much-needed shift. First, as demonstrated in the case studies presented, the vast majority of refugee children and their families do not understand their distress as ‘disorders’ with a bio-medical causation, but rather conceptualise and express their distress in culturally salient ways. Furthermore, for many children and adolescents who resettle in high-income countries, stressors encountered after resettlement have a powerful negative impact on their mental health and well-being. Studies have demonstrated that the contribution of these stressors to children’s levels of distress ‘has consistently equaled or exceeded that of direct war exposure’ (Miller and Jordans, 2016, p. 1). Socio-ecological models encourage social workers to work collaboratively with multiple agencies and with refugee community members to develop culturally appropriate services rooted in the culture, community and context they live in. This may require linking interventions to a spiritual, religious and social perspective as well as engaging with existing healing resources within a child’s ecosystem (e.g. family, peers and teachers) (Miller and Jordans, 2016). This call is in line with best-practice guidelines that emphasise the need for inter-agency and inter-sectoral collaboration when working with war-affected populations (Inter-Agency Standing Committee, 2007; Social Care Institute for Excellence, 2015). Second, the unequal power relations within the therapeutic encounter may disempower and silence refugee children and families. Socio-ecological models of psycho-social service delivery, with their emphasis on community-led interventions, can help overcome this barrier (Miller and Rasmussen, 2016). This involves respecting children and young people’s capacity and creating spaces for them to be actively involved in service design and provision. In many countries, this is already happening organically with the growth of refugee community organisations (RCOs) and other informal networks that are addressing important gaps in resettlement services (Lacroix et al., 2015). However, there remain various opportunities for social workers to further leverage community resources and wisdom. Emerging research is showing the benefits of involving paraprofessionals, who are refugees themselves, in mental health services (Mitschke et al., 2017). One example is the Coffee and Family Education and Support (CAFES) intervention, which aims to ‘devise a way of helping refugees that could fit better with the family-oriented behaviors and culture of the refugees than did clinical trauma mental health’ (Weine et al., 2004, p. 148). The intervention involves multiple-family support groups that are facilitated by community members trained and supervised by a university/community team (Weine et al., 2004). Third, as noted, the bio-medical model may medicalise and depoliticise refugee youth’s challenges and struggles. In light of the entrenchment of bio-medical models, there is a compelling call in social work to return to its social justice and advocacy roots (Humphries, 2004). This call is driven by the understanding that a considerable amount of refugees’ distress is related not to past trauma, but rather to a constellation of stressors in the host country, including oppressive systems and policies. Greater emphasis on social justice frameworks in social work education is therefore urgently needed, with a particular focus on the link and direct application between theory and direct practice. The socio-ecological approach encourages social workers to engage in macro-level interventions, which can significantly improve refugees’ mental health but are not traditionally perceived as psychotherapeutic. These may include political advocacy for eliminating refugee detention or advocating for simpler and shorter asylum application processes (Miller and Rasmussen, 2016). An example of a social justice initiative in which social workers have played a dominant part in its leadership is the ongoing anti-racist movement in Greece. This movement comprises tens of grassroots organisations spread across the country that are seeking to combat anti-immigration policies through political advocacy (public education, demonstrations, coalition building) as well as providing services that meet refugees’ immediate needs (medical care and psychological services, legal support and advice, shelter and housing). Often working voluntarily and risking serious sanctions, social workers operating in this space are defying the profession’s tradition of ‘neutrality’ and ‘gate-keeping’ (Teloni and Adam, 2016). Several limitations of this review should be highlighted. It is important to note that the suggestions of the present study are based on a review of international literature and, despite a comprehensive search strategy, we did not conduct a systematic review, nor did we undertake international or national surveys of social workers’ attitudes and practices. Additionally, the studies were varied in their environment, target population and scope. While this approach allowed us to open up a broad dialogue on the social work profession’s role in the refugee mental health field, it also limited in the conclusions that can be drawn on what is most effective for these settings. It is important to emphasise that we are not suggesting that the socio-ecological model should replace bio-medical diagnosis; rather, it should be understood as an additional perspective on refugee children’s mental health. A key future challenge for social work theory and practice is to unpack and address the ‘tension between establishing universal principles ... through international collaboration in research and practice, while respecting indigenous uniqueness, distinct local traditions and cultural strength’ (Link and Ramanathan, 2010, p. 10). It is essential that, as a profession, social workers continue to analyse existing theories and practice assumptions with a critical eye, highlighting their strengths and limitations and illuminating any potential blind spots, silences and ensuring voices from the margins. While there remains significant work to be done in terms of research, practice and policy, social workers are in a unique and important position to make a distinctive contribution to the refugee mental health field and to promote a more contextualised and holistic understanding of refugee youth’s experiences, opportunities and challenges. Conflict of interest statement. None declared. 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The British Journal of Social Work – Oxford University Press
Published: Jun 2, 2018
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