On the Outskirts of Two Societies: Addressing Alcohol Use Disorder in Refugees Resettled in Western Countries

Introduction

Everyone has the inalienable right to the highest standard of life. However, the crises afflicting the millions of refugees, asylum seekers, stateless, and displaced persons worldwide prove this vision has not yet been realized. The United Nations defines a refugee as someone who has “fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or owing to such fear, is unwilling to avail himself of the protection of that country” (Robila, 2018). As of early-2023, the number of forcibly displaced persons has reached an all-time high of 103 million, with no signs of subsiding (UNHCR, 2023). In addition to experiencing trauma after fleeing their homeland, many refugees must deal with post-migration and acculturative stressors in a new host country, such as language acquisition, economic hardships, and discrimination. These stressors, in addition to complex traumatic events, are directly correlated to psychological distress and substance use, especially alcohol (Keyser, 2015). Unfortunately, the lack of funding for mental health services and culturally competent clinicians perpetuate these issues,  leaving this population even more disenfranchised from the outside looking in. 

Mental Illness and Substance Use

Refugees resettled in Western nations are especially vulnerable, given their additional case complexities from fleeing trauma and assimilating into a new culture. Consequently,  they experience five times the level of mental health disorders than the general population. To diagnose refugees’ mental well-being, researchers use multi-dimensional instruments like the Refugee Post-Migratory Stress Scale, Hopkins Symptom Checklist (HSCL-25), Harvard Trauma Questionnaire (HTQ), and Well-being Index (WHO-5) (Solberg, 2020). The most common mental illnesses seen in this population include depression (67.9%), Post-Traumatic Stress Disorder (PTSD) (60.7%), and anxiety (59.3%) (Solberg, 2020). Psychiatric disorders like these are often highly comorbid with alcohol misuse (Keyser, 2015). Since alcohol is one of the most used and abused substances globally, there is significantly less stigma associated with excess drinking (Grant, 2015). For example, while the rates for alcohol misuse among refugees in Sweden are notably higher compared to those in their home country, resettled refugees still have a “48%-54%” lower chance of developing this substance disorder in contrast to the Swedish population (Harris, 2019). Therefore, there may be hesitation in seeking treatment, as it is not viewed as problematic in their new host country, worsening their conditions. Trauma and Alcohol Use Disorder symptoms are further exacerbated by the belief that alcohol dependency revolves around the brain disease model, which views addiction as a chronic relapsing illness (Volkow, 2016). This perspective is harmful as it ignores critical factors, such as acculturation, racism, neighborhood characteristics, and employment, that maintain drug use and continue social injustice (Hart, 2017). 

Post-Migratory Stressors

Acculturation is considered the most fundamental factor in mental health suffering and alcohol misuse among resettled refugees (Robila, 2018). Acculturation is defined as a “two-dimensional process” that addresses the “cultural maintenance of the culture of origin” and “contact and participation” with the host culture (Robila, 2018). Kuo (2014) asserts that knowledge and proficiency with the host language, in particular, are significant protective factors against the stress associated with assimilation (Kuo, 2014). Lacking such language skills creates substantial “psychological and social barriers”, leading to segregation, discrimination, poor daily functioning, higher unemployment, lower job satisfaction, and higher alcohol misuse (Alexander et al., 2021). Language fluency also affects the effectiveness of treatment outcomes because it “shapes understandings and expressions of distress and mental health symptomatology” (Alkemade et al., 2018). Since most of the instruments used to detect psychological distress and substance use rely on Western concepts of psychopathology, refugees coming from more traditional and family-oriented societies may interpret questions such as “How often do you feel excluded or isolated in Swedish society?” or “Do you ever feel guilty after drinking?” differently from the cultural expectations of the host country (Alexander et al., 2021). Such intrusive questions may retraumatize or shame individuals too (Malm, 2020), intensifying stigma and perpetuating the discourse that addiction is a “moral failing” (Broyles, 2014). Language, in essence, frames what society believes about minority communities, alcohol misuse, and recovery, in addition to how victims think about their ability to change. 

Economic hardship is a second mediating factor affecting refugees’ mental health and alcohol use. Syrian male refugees appear to be particularly adversely affected by the loss of their professional status. This could be attributed to traditional gender norms, which assign the responsibility of financial provisions to men (Alexander et al., 2021). Employment is critical for assimilating because it builds confidence and fiscal responsibility, and encourages social interactions (Robila, 2018). Refugees who enter the workforce in a new host country gain valuable resources and improve their quality of life (Kuo, 2014). Unfortunately, many refugees’ qualifications or occupational skills are not officially recognized by employers in the host countries, leaving these once highly respected professionals underemployed and struggling with feelings of status inconsistency. This loss of occupational prestige frequently leads to depressive symptoms and substance misuse (Mulia, 2012). Further, economic hardship isolates and ghettoizes minority communities into the outskirts of society. This is problematic given that neighborhood socioeconomic status (NSES) influences alcohol use patterns, such as persistent binge drinking, alcohol misuse, and alcohol dependence. Those living in disadvantaged neighborhoods in wealthy host countries are especially susceptible, having over “double the elevated risk” of monthly drunkenness, risk drinking, and psychological distress (Mulia, 2012). 

Lastly, perceived discrimination magnifies PTSD, depression, and Alcohol Use Disorder symptoms for resettled refugees (Starck, 2020). Discrimination manifests overtly as verbal and physical attacks and covertly as interpersonal and institutional prejudice. In Ziersch’s study assessing refugee discrimination in Australia, 22% of refugees, especially those from the Middle East or Africa, said that they experienced discrimination within the last year, and “90% of those felt that discrimination” had negatively impacted their health and alcohol use (Ziersch, 2020). Unfortunately, racist and xenophobic narratives are frequently voiced in the media, and perpetuated by politicians, public officials, and mental health professionals in host countries, alluding to the sentiment that refugees are lazy and “draining” on the state’s welfare system (Rabo, 2021, p. 6). Such discrimination and bigotry generate feelings of hopelessness, loss of control, and low levels of trust and belonging (Ziersch, 2020), increasing isolation, demotivation, and risk of substance misuse within these communities (Lutterbach, 2021). 

Limitations

Although current literature surrounding the mediating factors of post-migratory stress has many strengths, there are significant limitations and shortcomings. Firstly, longitudinal studies are far more efficacious at assisting refugees throughout their various stages of resettlement. However, there is a heavy dependency on “short-term, targeted, purpose-specific” practices instead, such as the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach (Alkemade et al., 2018). While SBIRT focuses on early intervention to alleviate emotional suffering and severe substance use, it is time limited and does not evaluate the long-term and associative effects between a community’s environment and alcohol misuse (Babor, 2007). 

Secondly, there is a paucity of literature addressing the mental health of refugee subgroups, such as gender, age, country of origin, and length of time spent in the host country (Alexander et al., 2021). For example, almost 50% of all refugees are 17 years or younger and yet most research focuses on adults aged 18-40 years old (Robila, 2018). Adults and youth have vastly different needs and without recognizing or adhering to their demands, half of this population will not receive adequate services. Regarding one’s country of origin, another study reported that Cambodian refugees who had resettled in the United States showed a positive correlation between their length of stay in the US and psychological distress. After 20 years in the country, the rate of refugees who met the criteria for PTSD and depression had increased to 62% and 51%, respectively, suggesting that trauma and substance use related disorders may worsen post-resettlement for certain populations (Guajardo, 2016). To reiterate, various groups have specific requirements. Therefore, modifying approaches and practices is crucial if clinicians, researchers, and policymakers are to uphold and respect the human rights of these vulnerable populations. 

Thirdly, many interventions are not culturally adapted to each patient and, instead, rely on Western methodologies outside the clients’ ideologies, such as individualism. Most of these refugees come from interdependent cultures that profoundly depend on family systems. Additionally, the familial environment is one of the essential components of sustained drug use; therefore, family involvement should be a key component in recovery. In several Western societies, it is standard practice to isolate a patient with Alcohol Use Disorder, which is antagonistic to certain refugees’ belief systems and hinders them from utilizing a vital source of support (Lutterbach, 2021). 

A final shortcoming in refugee mental health research is that individual refugee experiences are not centered in the treatment process. Although pharmacotherapy, Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy for Substance Use Disorders (DBT-SUD), and psychotherapy for alcohol use, PTSD, depression, and anxiety are effective, these prescriptions have all been written by academics and clinicians (Robila, 2018). Furthermore, Syrians, the largest group of displaced persons, are the focal point of many of these studies, which is understandable given that refugees are such a hard to reach population (Malm, 2020). However, this lack of multi-ethnic and multi-national data makes it challenging to attribute findings to other refugee populations or cohorts, preventing clinicians from accurately designing informed treatment plans. Additionally, many researchers resort to self reports and convenience sampling, rather than randomized clinical trials (Alexander et al., 2021). This may result in response rates as low as “20-30%” (Malm, 2020). A possible risk for an overreliance on self reports and convenience sampling is selection bias, where non-respondents might exhibit significantly worse mental health outcomes and alcohol misuse from the sample size. Another risk includes recall bias, where participants overestimate or under-report mental health and addiction symptoms (Harris, 2019). 

Recommendations

To begin, governments must establish community resources and multiethnic organizations that provide free language courses and services related to resettlement, legal rights, and integration. Scandinavian countries, for example, have created comprehensive state-sponsored employment assistance programs in their refugee policies, like the Step-In job and Fast Track programs (Robila, 2018). Job training, skill development, streamlined procedures for work permits, pro-bono legal services, and free educational opportunities should be mandated, in order to promote social integration and assimilation. Further, governments have an obligation to address the harms of prejudice by banning the use of inflammatory, xenophobic language and removing discriminatory policies that bar refugees from housing, education, and employment activities. This would allow refugees to regain a sense of agency, confidence, normality, purpose, and contribution to the country that they are in. 

Secondly, education, cultural humility and diversity training, transparency, and community-oriented approaches should be standard treatment practices in this field, in order to increase access to quality mental health services.  Additionally, culturally adapting interventions like Evidence Based Practices (EBPs), as well as matching clients and providers based on language and cultural background, ensuring language proficiency, and increasing treatment access, develop trust and rapport between the client and clinician and ultimately, improve addiction treatment completion (Guerrero et al., 2017).  This was exemplified in March 2017, when Medecins Sans Frontieres hired refugees as mental health counselors to orchestrate group therapy. In therapy, refugees shared their suffering, mental health struggles, and experiences with one another, while the counselors provided techniques and coping skills to help deal with alcohol use, stress, anxiety, and depression. This experiment reported a marked increase in participation rates and a decrease in depressive and substance use symptoms at the end of the study (Sandalio, 2018). A similar policy or approach would help increase the number of refugees obtaining treatment. 

Thirdly, treatment would be easier if signing up for healthcare was streamlined and accessible language was mandated for patients to understand the consequences and benefits of their insurance. However, as seen with the Affordable Care Act, while coverage may have increased for Black and Brown communities, treatment rates for substance use disorders remained the same (Creedon, 2016). This suggests that insurance coverage alone does not promote meaningful reductions in mental health treatment disparities. Instead, primary care for mental health and alcohol misuse should be helpful, concise, “comprehensive, patient-centered, accessible, and quality driven”, which decreases the drivers that create racial/ethnic disparities in substance use healthcare (Jones, 2016, p. 1440). Systems approaches must focus their attention on increasing accessibility to treatment, in addition to the unique access barriers that racial and ethnic minorities face, such as stigma, prejudice, and a lack of culturally-sensitive clinicians (Creedon, 2016). 

Fourthly, regarding psychotherapeutic interventions for this population, an integrated care and family based approach such as Family Behavior Therapy (FBT), is recommended. FBT merges both contingency management and behavioral treatment, in order to address the physical, behavioral, and social factors underlying alcohol misuse and other behavioral problems. By itself, contingency management has already proven to be effective in addiction recovery and helpful in enhancing clients' self-efficacy in resisting future drug use. It uses immediate and tangible low cost incentives for positive behaviors and coping strategies, which in turn, weakens the reinforcement derived from using drugs and substitutes it with the reinforcement developed from healthier habits and drug abstinence (Petry, 2017). In FBT, this reconditioning is integrated with behavioral goals, designed by family members, to reduce risk behaviors and foster an environment highly conducive to positive change (Petry, 2017). Incorporating case management and Cognitive Behavioral Therapy (CBT) alongside FBT would also be beneficial. Case management holistically addresses the patient and focuses on individualized goals in each session (Sullivan, 2015). Since there is no one size fits all approach, tailoring objectives is critical. Refugees should collaborate with mental health professionals to design their own treatment plans, given that they are the experts on their own trauma, problems, and psychological distress (Gruenewald, 2014). CBT also aids in recovery, as it explores the positives and negatives of maintaining alcohol use and teaches patients how to regulate feelings, thoughts, and cues that may incite substance use (Guenewald, 2014) By encouraging healthy coping mechanisms and cognitive reframing, clients learn to not rely nor become overly dependent on drugs. Instead, they master behavioral and cognitive techniques that allow them to handle the emotional distress and cravings associated with drug use (Guerrero et al., 2017). 

Beyond these standard psychotherapeutic protocols for Alcohol Use Disorder, exciting new research indicates that psychedelics may become the new status quo, after exhibiting tremendous long term outcomes in treating PTSD, depression, anxiety, and Alcohol and Substance Use Disorders, among others. Psychedelics are psychoactive substances that change or enhance sensory perception, cognitive processes, and positive moods (Nichols, 2016) such as increased feelings of intimacy, compassion, and empathy for oneself and others (Sessa, 2017). The most commonly used psychedelics and psychedelic-like substances include LSD, psilocybin, MDMA, and ketamine. The powerful effects of these drugs have been shown to decrease the fear response and facilitate the release of oxytocin, allowing patients to better retrieve, tolerate, reconsolidate, and unlearn traumatic and maladaptive reward memories, reducing harmful drinking behaviors (Das, 2019). A phase 3 clinical trial at the Multidisciplinary Association for Psychedelic Studies (MAPS) recently reported that after three 8-hour MDMA-assisted therapy (MDMA-AT) sessions, 88% of clients no longer met the clinical criteria for PTSD nor Alcohol Use Disorder, versus 60% in the Placebo + Therapy group. Moreover, there was no increased risk for illicit substance use following treatment (Nicholas, 2022). Other studies have shown that two doses of psilocybin combined with 12 weeks of Motivational Enhancement Therapy (MET) resulted in an 83% decrease in heavy drinking among participants. The control group saw a 51% decline in their alcohol consumption (Jacobs, 2022). Additionally, 82% of patients who received a single infusion of ketamine combined with behavioral therapy, remained abstinent at the end of the three-week trial, compared to 65% who received psychotherapy alone (Dawkwar, 2019). At follow-up one year later, 66% of those in the ketamine group remained abstinent, compared to 24% in the control group (Sessa, 2017). It is important to note that recreational drugs are not the same as those used in clinical trials. Further, “pure” psychedelics in conjunction with psychotherapy produce the most efficacious results, rather than the drug or talk therapy alone. Fortunately, with the persistent work of organizations such as MAPS and recent FDA approval, psychedelic-assisted psychotherapies may soon become a new addition to the repertoire for addressing trauma and substance use disorders in refugee populations (Ducharme, 2023). 

Conclusion

 Acculturation, economic instability, and discrimination continue to be significant post-migratory stressors on the mental health and alcohol misuse of refugees. Providing culturally-sensitive, immediate, and ongoing mental health services not only alleviates psychological distress and addiction related symptoms for these individuals, it also benefits the host country socially and economically. However, limited funds and access to care hinder their needs from being sufficiently met. Therefore, NGOs should not serve as the principal resource for addressing refugee trauma. Rich, Western nations must allocate more resources towards refugee services and develop trauma-informed policies and culturally-appropriate psychoeducational treatment plans to help mitigate post-migration stressors and promote positive mental health, social integration, and recovery from substance misuse. It is vital to look at refugees and asylum seekers as an asset rather than a deficit and remember that host countries can often find tremendous value in engaging refugee communities in society.

 

 

 

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