Mental Health of Older Adults with a Refugee Life Experience

Rochelle L. Frounfelker & Tej Mishra

Section Editor:
Claire J. Starrs
Opinions expressed by the authors are their own and not necessarily those of APA, Division 56, or any member of the editorial board.

Mental Health of Older Refugees

The most recent data from the United Nations High Commissioner for Refugees (UNHCR) indicates that the number of civilians forcibly displaced from their homes due to war and political violence reached over 117 million in 2023 (UNHCR, 2024). A subset of forcibly displaced individuals is considered refugees. UNHCR defines a refugee as someone who is unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion (UNHCR, 1951). Forced displacement due to conflict and persecution has been shown to have negative effects on mental health. For example, compared to the general population, refugees have higher rates of depression, anxiety, and PTSD (Blackmore et al., 2020; Morina et al., 2018). Researchers have identified individual, family, community and macro level pre- and post-resettlement factors that contribute to the poor mental health outcomes of displaced populations (Fazel, 2018; Gleeson et al., 2020; Mesa-Vieira et al., 2022; Porter & Haslam, 2005; Scharpf et al., 2021).

The majority of research on the mental health of refugees has studied effects of displacement in youth and younger adults, and little is known about the mental health trajectories of aging refugees. This is important, as older individuals may be disproportionately vulnerable to adverse mental health outcomes in the context of past exposure to war and political conflict (Porter & Haslam, 2005). Processes of migration and aging are conceptualized as entwined trajectories that heighten vulnerability to adverse mental health outcomes (King et al., 2019). For instance, there are experiences that are common among the majority of older adults, regardless of migration status, including concerns over maintaining functional capability, quality of life, and access to care, that may negatively impact mental health (WHO, 2018). In addition, older refugees are disproportionately burdened by historical traumas experienced before and during flight from country of origin and displacement, as well as post-resettlement socioeconomic stressors, both of which impact current mental health among war-affected populations (Miller & Rasmussen, 2017).

Older refugees often receive limited attention from national and international aid providers (Ridout, 2016; UNHCR, 2016), even though they are more likely to experience physical and psychological distress compared to younger refugees (Bazzi & Chemali, 2016; Strong et al., 2015). Studies on the impact of forced migration on the elderly have found both pre- and post-migration experiences contribute to negative mental health outcomes (Lor et al., 2022; Mistry et al., 2021; Mölsä et al., 2017; Virgincar et al., 2016; Yang & Mutchler, 2020). Critiques of psychosocial services for older refugees include a lack of cultural specificity and failure to consider the age-specific needs of the population. Typically, services are an extension of those provided to general adult refugees, and do not address age-related accessibility barriers, such as physical limitations, language skills, or intergenerational struggles (Ahmadinejad-Naseh & Burke, 2017; Ridout, 2016; Virgincar et al., 2016). Interventions are frequently based upon and promote more Western-oriented coping strategies that may be more suitable, familiar, and comfortable for older American-born populations (Chenoweth & Burdick, 2001).

Bhutanese with a Refugee Life Experience

In the mid-1980s, the Bhutanese government stripped citizenship from ethnic-Nepali Bhutanese and deprived them of various basic rights including land ownership and access to education (Rizal, 2004). Pressure to leave the country intensified, with Bhutanese authorities threatening violence and carrying out rape, murder, and torture of the ethnic-Nepali (Giri, 2005; Hutt, 1996). This persecution culminated in the forced displacement of over 100,000 ethnic-Nepali into Nepal in the early 1990s (Hutt, 1996). UNHCR provided relief to Bhutanese refugees in Nepal starting in 1991 (Hutt, 2005), where they lived in refugee camps until third-country resettlement commenced in 2008 (Reiffers et al., 2013). In the past 15 years, over 90,000 ethnic-Nepali Bhutanese refugees have relocated to the US (Embassy, 2016). Ethnic-Nepali Bhutanese were exposed to a range of traumas and stressors in Bhutan and Nepal. They were incarcerated and tortured by government authorities as a way to pressure individuals, families, and entire communities to leave the country (Van Ommeren et al., 2001). Once in Nepal, the refugees suffered hardships that significantly impacted their wellbeing (Martin et al., 1994). Over a decade after forced expulsion, UNHCR reported overall poor quality of health programs and services in camps, including concerns over a lack of qualified health care personnel and coordination of services for survivors of interpersonal violence (Unit, 2005). Post resettlement has increased attention to the mental health of Bhutanese refugees given the disproportionally high rate of suicide in this group, which is roughly double the rate in the US (Brown et al., 2019; Cochran et al., 2013; Meyerhoff et al., 2018). Research indicates that Bhutanese also face resettlement challenges and stressors related to language barriers, cultural loss, lack of social support, and economic strain (Brown et al., 2019; Im & Neff, 2020; Meyerhoff et al., 2018).

Project Bhalakushari

In 2017, a Bhutanese community in the Northeast US began collaborating with researchers to explore the mental health of older adults. In the spirit of building a community partnership, we named this research to Project Bhalakushari, based on the Nepali term bhalakushari meaning a casual conversation. The goal of the project was to learn about the older adults’ past experiences in Bhutan and Nepal, and their current lives in North America. Project Bhalakushari is a mixed methods study that aims to understand the impact of forced displacement and immigration on the long-term mental health of older Bhutanese, and, ultimately, to inform downstream multi-level interventions that address their psychosocial functioning. We adopted a community-based participatory research approach (CBPR) as outlined by Israel and colleagues (Israel et al., 2018), in which community partners are actively involved in all aspects of the research process. Community members partnered with researchers to develop research proposals and secure funding, participate in data collection and data analysis, and disseminate study findings to the community and relevant stakeholders. To date, several additional Bhutanese communities have collaborated, including in Springfield, Massachusetts, Ottawa, Ontario, and recently in central Pennsylvania through the Bhutanese Community in Harrisburg (BCH), a self-help community organization. Since 2017, academic partners have included researchers at Harvard T.H. Chan School of Public Health, McGill University, Boston College’s Research Program on Children and Adversity, and, most recently, Lehigh University’s College of Health. The study has received funding from the Harvard T.H. Chan School of Public Health, the Research Institute of the McGill University Health Centre, the Canadian Institute for Health Research, and is currently supported by the National Institute on Aging (1R01AG089038-01). The current NIA-funded objective is to explore the longitudinal mental health outcomes in this population over three waves of data collection.

Project Bhalakushari was motivated by concerns from within the Bhutanese community for the psychosocial wellbeing of older adults. In their country of origin, the Bhutanese lived in remote villages with communal farming, which promoted strong social bonds with relatives and neighbors. After displacement to refugee camps in Nepal, this culture of togetherness was maintained through time spent mingling and helping each other during times of distress and disasters. However, this highly interconnected lifestyle deteriorated after US resettlement, especially for the more elderly individuals of the community who no longer worked outside the home. Furthermore, in combination with the American cultural ideal of independence, elderly community members had fewer opportunities to engage in social interaction with their peers.

Resettled Bhutanese families generally live in multi-generational homes, often with three generations living together. Elderly individuals report feeling that there is a deterioration in the fabric of the family and of their own value within the family, primarily due to spending most of their time home alone or solely with a spouse while the bread earners, typically sons and daughter in-laws, go out to work (Prasai et al., 2024). The role of the elders in the family has changed dramatically, from being the provider and head of the family in Bhutan and Nepal, to being in the back seat in the US, due to language and other barriers such as lack of transportation (not being able to drive) and challenges in obtaining employment (Frounfelker et al., 2020; Prasai et al., 2024). Their adult children, who are adapting to the American way of life, are dealing with their own stressors including adjusting to American society (workplace, school, etc.), managing the perceived and expected responsibilities of preserving ethnic-Nepali culture and tradition, and taking care of young children brought to the US or born as US citizen. The elder generation is strongly impacted by these changes, in part because they don’t have the opportunity to spend time outside of the home (Prasai et al., 2024). Understanding how current social and family dynamics, as well as past experiences, shape the current mental health of resettled elderly Bhutanese is important for both researchers and health care providers to identify and adapt evidence-based mental health interventions that will effectively address their needs and be culturally relevant.

To date, our research highlights the relationship between pre-resettlement trauma, current stressors, and mental health. Past traumas, including imprisonment and torture in Bhutan and threats to physical wellbeing in Nepal, have been shown to have a lasting negative impact on symptoms of depression and anxiety in older Bhutanese, both directly and via mediating pathways such as current physical health and economic stressors (Frounfelker et al., 2021). We have found that individuals with higher exposure to pre- and post-resettlement trauma and stress, as well as those who experienced deprivation and loss in refugee camps in Nepal, show more severe symptoms of PTSD than those with less past and current trauma and stress (Frounfelker et al., 2023). Furthermore, social support has been shown to be an important moderator of the relationship between trauma, stress, and mental health outcomes (Frounfelker et al., 2021). Qualitative findings highlight the importance of social support and meaning-making as coping mechanisms with pre- and post-resettlement experiences by older Bhutanese to overcome challenges and stressors throughout their refugee life experience (Frounfelker et al., 2020; Prasai et al., 2024). Our findings reveal that the elderly long for social time and interaction, to share their joy as well as their pir (sorrow) with their friends.

Culturally-informed Research and Services

Culturally-informed care is increasingly recognized as an important component of effective mental health services and treatment for refugees (Baarnhielm, 2016; Greene et al., 2017; Im et al., 2021; Reis et al., 2020; Wylie et al., 2018). Developing culturally-informed services requires detailed investigation into how specific populations conceptualize mental health and the mechanisms that promote psychosocial wellbeing and healing (Kirmayer et al., 2014; Raghavan & Sandanapitchai, 2020; Ungar, 2014). Thoughtful attention has been given to understanding the ethnopsychology of ethnic-Nepali Bhutanese and how this informs adjustment and coping for this population in refugee camps and post-resettlement (Chase, 2012; Chase et al., 2013; Kohrt & Harper, 2008; Kohrt & Hruschka, 2010). Nepali words such as dukha (sadness), chinta (worry/anxiety), dar (fear) and pir (sorrow/anguish) are commonly used when describing emotional responses to trauma (Kohrt & Hruschka, 2010). A common idiom of distress is that of tanaab (tension/stress), and the concept of coping in Nepali is best translated by tannab samaadhaan garnu (solving tension) (Chase et al., 2013).

Our work builds on this by exploring culturally-specific protective processes related to social support among older resettled Bhutanese. There is a well-established association between social support, social connectedness, and mental health outcomes in aging adults (De Main et al., 2023; Gabarrell-Pascuet et al., 2022; Newman & Zainal, 2020; Santini et al., 2020; Schwarzbach et al., 2014; Turner et al., 2022; Xiao et al., 2022). This evidence extends to some immigrant and refugee populations (Brown et al., 2009; Ekoh et al., 2023; Hawkins et al., 2022; Kim et al., 2020; Lee et al., 1996; Miyawaki, Liu, et al., 2022; Park & Roh, 2013; Wong et al., 2007). Among refugee populations, family, religious, ethnic/cultural, and host community networks may all play a pivotal role in providing support and promoting resilience of individuals in this age group (Tippens et al., 2023). At the same time, the circumstances of forced migration can lead to a reduction in social networks and social supports among older adults (Ekoh et al., 2023), suggesting that mental health interventions should prioritize promoting social connectedness. However, there is considerable cultural variation in expectations about social relationships, forms of social support, sources of social support, and appraisals of social interactions (Kim et al., 2008; Makwarimba et al., 2013; Miller et al., 2017; Mojaverian & Kim, 2013; Stewart et al., 2008). As such, it is critical to understand culturally-relevant pathways and mechanisms by which social support promotes or diminishes mental health among distinct aging refugee groups. With the support of NIA funding, we plan to qualitatively investigate how older resettled Bhutanese, their caregivers, and health care providers understand social support and its role in promoting the psychosocial wellbeing of aging adults.

In addition to geographic isolation, the limited availability of healthcare services in rural Specific to resettled Bhutanese of all ages, there are established relationships between social support (concrete and emotional) and refugee wellbeing, for example, social support from family and friends has been shown to play an important role in protecting against negative mental health (Ao et al., 2016; Chase & Sapkota, 2017). Interpersonal support (both familial and community) is critical for older Bhutanese to cope with past traumas and current stressors, acting as a moderator in the relationship between exposures and depression and anxiety (Frounfelker et al., 2021; Frounfelker et al., 2020). This idea of interpersonal support becomes even more culturally relevant within the context of intergenerational families and normative support mechanisms in Nepali culture. In Nepal, over 80% of older adults reside with family members (Chalise, 2021; Joshi, 2019; Singh et al., 2021). Culturally, caring for elderly parents is regarded as the responsibility of children, with primary caretaking assigned to sons and daughters-in-law (Khanal & Chalise, 2020; Kharel, 2023; Shrestha et al., 2021). To our knowledge, there is currently no data published on patterns of family caregiving arrangements among ethnic-Nepali Bhutanese in the US. However, we believe that, with rare exceptions, older Bhutanese in the US also live in multi-generational households, with family members acting as primary caregivers. This is important in terms of understanding the relationship between family caregivers and older adults with a refugee life experience. There is a robust body of literature highlighting the mental and physical health needs of individuals who are caretakers to older adults (Schulz et al., 2020; Schulz et al., 2016). Evidence suggests that witnessing the physical and psychological suffering of a relative can increase caregiver risk for psychological and physical morbidity (Monin & Schulz, 2009; Schulz et al., 2017). Recently, there has been increased attention on mental health of caregiver/care receiver dyads (Jiang et al., 2021; Liu et al., 2023; Meyer et al., 2021; Monin et al., 2023). In longitudinal studies, caregiver symptoms of depression were associated with care recipient mental health and cognitive functioning (Jiang et al., 2021; Liu et al., 2023); in one study, this relationship was reciprocal (Monin et al., 2023). However, currently there is limited information on these dynamics among immigrant and refugee populations (Miyawaki, Meyer, et al., 2022). This is a significant shortcoming, as family members play an important role in providing care for older immigrant adults, particularly among some minority groups, such as Asians Americans (Knight & Sayegh, 2010; Miyawaki, 2016; Raj et al., 2021; Weng & Ngyuen, 2011). Foreign-born Americans and Asian populations are more likely than US born Americans and Whites to live in multigenerational households (Cohn & Passel, 2018), prompting a call to include Asian Americans in family caregiving aging research (Yellow Horse & Patterson, 2022). The current phase of our research in Project Bhalakushari will include enrolling dyads of older Bhutanese and a loved one/caregiver to track longitudinal mental health outcomes and identify the relationship between older adult and caregiver mental well-being over time.

Conclusion
Our ultimate goal is to develop a preventive, community-based psychosocial intervention for older ethnic-Nepali Bhutanese that leverages both family and community-level resources to promote resilience (Weine, 2011). This population experienced and survived expulsion from Bhutan, refugee camps in Nepal, and third country resettlement. It is critical that this generation not be left behind and forgotten as a casualty of the refugee life experience. Furthermore, we encourage other researchers, mental health providers, and policy-makers to address the dearth of research and evidence-based services for aging refugees more broadly, given the high level of need in this population.

Rochelle Frounfelker, ScD, MPH, MSSW is an Assistant Professor in the College of Health, Lehigh University, PA. She is a social epidemiologist with her doctorate in Social and Behavioral Sciences from Harvard T.H. Chan School of Public Health. Her primary area of research is addressing mental health disparities among refugees and other war-affected populations. She conducts community-based participatory research with refugees that address mental health throughout the lifespan, ranging from preventing mental health problems among children and youth to promoting the psychosocial wellbeing of aging adults. A focus of her work is on adapting and implementing interventions that incorporate and privilege local understandings of mental health and wellness and leverage culturally relevant strategies for coping and healing.

Tej Mishra, MPH is the Executive Director of Bhutanese Community in Harrisburg (BCH), a community based non-profit organization serving Nepali speaking former Bhutanese Refugees. As the Executive Director, Tej has led important initiatives such as fostering and improving community relationship with law enforcement, research collaborations with universities to address public health issues of the community, and led the organization to become a refugee resettlement affiliate of one of the national Refugee Resettlement Agencies. Tej has a master’s degree in public health from BU and has worked as a Surveillance Epidemiologist for the Massachusetts Department of Health, and later for the District of Columbia Department of Health. His experiences also include mental health research, notably in the Community-Based Participatory Research (CBPR) framework. He’s collaborated on CBPR projects as a research staffer at Harvard University, and later as a CBPR research consultant at Boston College, McGill University, and more recently as a community partner through BCH with Lehigh University.