Helping Refugee Adults Critical to Helping Kids: Q&A With Katherine Yun, MD, MHS

Katherine Yun, MD, MHS, discusses PTSD treatment for resettled refugee adults in the U.S.

Editor’s note: Posttraumatic stress disorder (PTSD), a mental health condition that is triggered by a traumatic event, affects nearly 1 in 10 resettled refugee adults in the United States. Effectively treating these adults and improving their health is essential for the well-being of their children, according to Katherine Yun MD, MHS, faculty at PolicyLab and attending physician in the Division of General Pediatrics and the Refugee Health Program at Children’s Hospital of Philadelphia. Her practice and research are centered on the welfare of children in refugee and immigrant families in the United States.

Dr. Yun, who is also on faculty in the Perelman School of Medicine at the University of Pennsylvania, sat down with Cornerstone to explain her work of creating a brief, provider-oriented summary of “Psychological and Pharmacological Treatments for Adults with Posttraumatic Stress Disorder,” a comprehensive systematic review outlining the evidence base for PTSD treatment produced by the Patient-Centered Outcomes Research Institute (PCORI). Her summary addresses the specific evidence for refugees and includes direction to clinicians on how to present treatment options to adults with limited English proficiency.

Dr. Yun, as you’ve noted in your research, PTSD affects nearly 1 in 10 resettled refugee adults in the U.S. Please tell us about some of the robust evidence that you and other researchers have gathered that shows untreated PTSD among refugee parents has profound adverse impacts on child health, behavior, and development.

We know PTSD is common among resettled refugee adults, and when we think about that 1 in 10 statistic, that includes individuals who have been here for many, many years. So when we look at communities such as some of our newly arrived families from Syria or Iraq who have recently been in a war zone, the number of people with PTSD can be even higher. What we know, not just from immigrant and refugee health, but also from all kinds of child health research, is that for many children, their most important therapeutic environment is their home. And their most important influence in terms of their emotional well-being, behavior, and development is their parents and caregivers.

When we are seeing children who are experiencing emotional distress related to either traumatic experiences overseas or challenges related to migration to the United States, it’s much harder for the parents to help the child learn to cope with their own emotions and to help that child heal when the parent has PTSD that hasn’t been treated. Helping parents is absolutely critical to helping kids.

What are the goals of your project titled “Effective Treatment for Refugee Adults with Posttraumatic Stress Disorder (PTSD): A Summary of Practice Recommendations for Clinicians”?

Thanks to the PCORI systematic literature review, we know there are many effective PTSD treatments, that these treatments can be delivered in collaboration with an interpreter, and that they have been shown to be effective for adults from different cultures and who have experienced difference kinds of trauma. However, we also know that most adults with PTSD do not get treatment. Our experience clinically shows that if you have a language barrier, it is even harder to access effective treatment, and the data from our research supports this.

The rationale for this project is to bridge the gap between what is known and what is done. We want to provide clear, succinct information for clinicians who might be referring an individual for PTSD treatment and also to those who provide PTSD treatment. We’re hoping that if people have greater awareness of how effective treatment can be and have more confidence in treatment for our refugee communities, they will be more likely to recommend it, and more parents of the kids we see in our practices will actually get the care they need.

How do you plan to disseminate this information and to whom will this information go? How will you reach these refugees and communicate it to them, considering many refugees will have limited English proficiency?

We’re focusing our dissemination in Pennsylvania by collaborating with the PA Refugee Resettlement Program and the Multi-Cultural Health Evaluation Delivery System Inc. They have existing relationships with clinicians, social service providers, and others all over Pennsylvania.

We’re also acknowledging the fact that talking about PTSD across language and cultural differences can be challenging. So in addition to summarizing this evidence in a way that makes sense for healthcare providers serving refugee communities, we’re also hoping to provide them with a practical tool that we’re calling a lexicon. It’s a list of 41 words that are important when talking about PTSD treatment, like the word “flashback,” or the word “coping,” or even the word “trauma.”

We’re working with teams of individuals who speak Arabic, Sgaw Karen, Nepali, and Swahili, and have in-depth experience with refugee and immigrant communities who speak these languages to think about each of the words in the lexicon and consider how to communicate that concept to someone who speaks the other language.

For instance, I have a colleague who worked so hard to get a family into mental healthcare. But when the family finally arrived at a behavioral health provider, one of the words that was used to communicate the nature of that facility to the family was a very stigmatizing word that is used to mean “crazy” in a pejorative sense. That one communication turned the family off from the idea of continuing with behavioral healthcare. I’m sure the word was used inadvertently, but it was loaded with stigma, and that is a preventable problem.

Words that we take for granted, that we think must be so easy to say and comprehend, are actually sometimes really hard to convey in other languages. We’re hoping that by creating lexicons that have this combination of expert language and cultural guidance, clinical providers who are communicating with refugees will be able to build more trust with their patients.

Similarly, we’re hoping this is a tool that will be helpful for medical interpreters. Some interpreters are very experienced in a mental health space, but many are working all over the health system, so they might not have had the time to grapple with how to communicate these concepts.

Why is the timing right for conducting this project to have a powerful effect on refugee communities and their leaders and clinician partners?

The timing is right because the language groups we’re focusing on are living in relatively large communities within the state of Pennsylvania. We believe there’s a need there.

We know that refugee communities have incredible internal assets. These assets include leaders who other people often turn to for guidance when they need access to health care. The more refugee leaders know and understand about PTSD, the easier it’s going to be for them, in turn, to provide good information to community members. We hope this will be an educational tool to support refugee community leaders in the incredibly important work that they’re already doing.

What do you see as the most exciting potential contribution of this project to improve the health of refugee families?

Many people are working hard to improve refugees’ access to needed care, and we want to be a part of that. Seeing that change — the increase in accessibility, the improvement in communication, and the increased trust — is very meaningful and important. By strengthening providers’ knowledge of PTSD treatment for refugees and by doing outreach directly to communities, our hope is that all refugees will have the opportunity to live a healthy life not only for themselves, but also for their children.