Ani Kalayjian & Andrew Dolinear

Section Editor: Claire J. Starrs

The Association of Trauma Outreach and Prevention (ATOP) MeaningfulWorld is an international non-governmental organization affiliated with the United Nation’s Department of Global Communication. MeaningfulWorld offers mental health education programs and workshops focusing on empowerment, stress management, time management, creating a healthy workplace, preventing burnouts, mindfulness, resolving conflicts peacefully, emotional intelligence, and meaning making. In addition, our humanitarian outreach teams have implemented rehabilitation programs for survivors of traumatic events in over 48 countries and 26 American states. Over the last three decades, MeaningfulWorld has conducted humanitarian missions in 50 countries aimed at transforming trauma caused by human-made and natural disasters. Although the primary aim of such missions is to facilitate healing and post-traumatic growth in affected individuals and groups, the utilization of surveys, workshops and other engagement efforts has provided insight into the individual and institutional factors that influence the ways in which traumatic events are integrated, processed, discussed, and passed on, in various cultural contexts.

Horizontal Violence (HV), also known as lateral violence, is defined as internalizing the aggression of a perpetrator and displacing it onto others within one’s own group (Hastie, 2002). HV has been shown to emerge from oppression, discrimination, and colonization (Embree & White, 2010). The resulting preference for the oppressor’s kind (e.g., their race, religion, color, gender, etc.), leads to oppressed people making negative assumptions about themselves and their own kind. Therefore, in-group individuals may start behaving as the aggressor, feeling entitled and putting other group members down. This may include attitudes and behaviors such as envy, jealousy, distrust, one-upmanship, negativity, denigration and displacement of frustrations and anger. Instances of HV have been described in several communities that MeaningfulWorld has served. In the African American community in the Southern United States, this process is called the “Crab in a Bucket” syndrome, where in a bucket full of crabs, when one tries to climb out, another will pull it back down, and as the cycle endlessly repeats, it leaves all the crabs stuck in the bottom of the bucket. Thus, in a fitting allegory for the process of HV, members of the oppressed group, stuck in the proverbial bucket, preclude other members from overcoming their condition.

Brief Literature Review

HV has primarily been examined in studies focusing on workplace dynamics, particularly among nurses in hospital settings. Much of this research was conducted in response to instances of hostility observed among nurses despite ostensibly sharing similar experiences, goals, and workplace status. Studies point to HV prevalence rates among US nurses ranging from 25.3% (Sellers et al., 2012) to as high as 85% (Wilson et al., 2011). In their 2002 study in this population, Hastie (2002) described examples of gossip, verbal abuse, intimidation, sarcasm, elitist attitudes, and body language such as eye rolling, folding arms, and disinterest. Furthermore, nurses report experiences of HV as both the victim (25.5%) and the witness (29.8%) (Sellers et al., 2012).

Embree and White (2010) identify various antecedents to HV, such as organizational imbalance of power, personal oppression, lack of empowerment, and a professionally dysfunctional culture. Moreover, Bent suggests that, due to their difficult working conditions, nurses are being oppressed, as the nursing profession is marked by a continual struggle for autonomy, accountability, and control over the profession (Bent, 1993). Nurses

may, therefore, be responding to a sense of powerlessness associated with restricted autonomy and autocratic leadership, and feelings of powerlessness and insecurity may manifest as aggression either turned inward or outward in the form of HV.

Until now, the HV model has seldom been applied to understand intragroup conflict and hostility outside of the realm of nursing. One exception is within the Indigenous community, where such concepts as internalized racism and internalized colonialism leading to HV, have been examined (e.g., Canada, Bombay et al., 2014; Australia, Whyman et al., 2021). Indeed, Bailey (2019), examined lateral violence in Indigenous post-secondary students in Canada. Using open-ended interviews, Bailey found that in addition to the complex burden of historical trauma due to colonization and colonized institutions, Indigenous students reported experiencing acts of HV. Despite recent efforts by the government to address historic oppression, these acts, Bailey contends, continue to negatively impact attainment of community, power, and resources. Other studies on HV in Indigenous communities also argue this process affects well-being and sense of identity (Whyman et. al., 2021).

Of note, other groups for whom bullying within the workplace, including from peers, has been explored, such as amongst the military (for review see Stuart & Szeszeran, 2021), first-responders (for review see Walker & Stones, 2020), and academics (see Goodboy et al, 2020 for discussion), do not fit within an HV framework, as these are not groups that experience overall oppression and discrimination.

Horizontal Violence in the Field

As we have learned through three decades of humanitarian work, the HV framework can shed light on both individual behavior and attitudes, and intragroup dynamics in far reaching contexts. Indeed, it provides a useful structure to map the relationships between institutional or cultural prejudice, and oppressed groups. Throughout our missions, we have identified several ways in which HV is expressed, including:

• Minimizing positive behavior, and lack of validation
• Fear and avoidance of reporting HV behavior
• Isolation from others
• Lack of respect and support
• Organizational chaos
• Personal and professional bullying
• Distrust, envy, jealousy, and gossip
• Discrediting success
• Undermining strengths
• Division and conflict instead of collaboration and mediation

We have observed these dynamics in more than a dozen missions, including to the countries of Haiti, Sierra Leone, and Armenia. Although these countries have unique histories and cultures, they have each experienced periods of armed conflict, genocide and collective violence, leading to intergenerational trauma, which is compounded by continued societal injustices. As such, these events have had similar effects on intragroup cohesion and HV in these three locations.

In 2022, during our last mission to Armenia, many Armenians expressed a degree of hopelessness. For example, one individual, when taught the concept of HV, immediately recognized it in her own community and culture, and said to the first author that she believed it could not be changed, and that our intervention efforts on the ground were in vain. Examples of HV in Armenia that we observed included distrust, envy, gossip, jealousy, putting others down, disregarding others’ achievements, finding faults in others, and making disparaging public announcements about others without any corroborating evidence. Additionally, given the complex political situation in the Middle East, thousands of Armenians have been forced to migrate from Iraq and Syria back to Armenia, and we noted instances of HV expressed against these new immigrants who were competing for already limited resources.

Throughout numerous missions to Haiti, volunteers with MeaningfulWorld have observed the previously identified signs of HV daily. For instance, in a capacity building effort, we worked to connect local organizations working on peace-building, with the objective of ensuring a continuation of these efforts after our mission’s conclusion. However, local organizers often refused or failed to cooperate with one another due to a lack of trust and comradery. Instead, they reported wishing to continue working with our organization, despite our mission lasting only a few weeks. When first discussing signs of HV in workshops, many people dismissed the idea that such actions and attitudes could be indicative of a greater issue; however, after describing HV in detail, they generally laughed and told us “This is a Haitian disease, we all are infected by it.”

Intervention Utilized

According to the literature on HV, the first step in addressing it is to increase awareness of its prevalence, followed by proactively addressing its multiple components within each specific environment (Lewis & Malecha, 2011). In various contexts where we have encountered HV, MeaningfulWorld has utilized the 7-step Integrative Healing Model (Kalayjian, 2017; Kalayjian, & Diakonova-Curtis, 2019), in which various aspects of emotions are assessed, identified, explored, expressed, processed, validated, and finally re-integrated.

• Step 1: Assess Levels of Distress, Disagreement, or Conflict. Participants are given a written questionnaire that helps them define the kind of trauma, distress, or dispute they are working on.
• Step 2: Encourage Expression of Feelings. Each participant in the group is encouraged to describe their feelings about the trauma, or conflict from their own perspective and express feelings in the “here and now.”
• Step 3: Provide Empathy and Validation. Each participant’s feelings are validated by the mediator, group facilitator, and group members. Emphasis is placed on understanding others and putting one’s feet in the opponent’s shoes.
• Step 4: Encourage Discovery and Expression of Meaning. Participants are asked, “What lessons, meaning, or positive associations did you discover about yourself as a result of this dispute?”
• Step 5: Provide Information. Practical tools and information are shared on how to gradually integrate the conflict resolution information that has been provided, and care for oneself as a caregiver/mediator.
• Step 6: Nurturing Mother Earth. Participants are provided with practical tools for connecting with nature (Mother Earth) and ways to care for one’s environment.
• Step 7: Breath Work and Meditation. Participants are guided on how to use breathing, to create peace within, and to foster gratitude, compassion, faith, strength, and forgiveness in response to conflicts, with the objective of increasing self-empowerment.

This 7-step model is an integrative approach that incorporates modalities from multiple schools, including psychodynamic, interpersonal, existential, humanistic, and learning-theory, as well as third-wave approaches that encompass mind-body-ecological-spiritual practices. This model has been useful in addressing the behaviors associated with HV, by focusing on group-based exercises in developing emotional intelligence through empathy, while also treating the causes through forgiveness, mindfulness and meaning making. This intervention model has been utilized to address HV in multiple countries (Kalayjian, 2017; Kalayjian, & Diakonova-Curtis, 2019). However, research specifically examining the efficacy of the various components of this intervention, would greatly benefit future humanitarian missions in this area.

In sum, the prevalence of HV observed in numerous culturally distinct groups suggests the possible benefits of utilizing this framework in future research on collective trauma, intragroup conflict, and community building in oppressed groups. We believe such an analytic lens has the potential to better identify problematic behaviors and attitudes, as well as address their causes in individual and group settings.

ANI KALAYJIAN, EdD, President of Meaningfulworld, and Adjunct Professor of Psychology at Teachers College, Columbia University, John Jay College of Criminal Justice, multicultural and multilingual Psychotherapist, Genocide Prevention Scholar, International Humanitarian Outreach Administrator, Integrative Healer, author, and United Nations Representative. She was awarded Outstanding Psychologist of the Year Award by the American Psychological Association (2016, Trauma Division), a Humanitarian Award from the University of Missouri-Columbia (2014), the 2010 American Nurses Association Honorary Human Rights Award, and an Honorary Doctor of Science degree from Long Island University (2001) recognizing 30 years as a pioneering clinical researcher, professor, humanitarian outreach administrator, community organizer and psycho-spiritual facilitator around the globe and at the United Nations. In 2007 she was awarded Columbia University, Teacher College’s Distinguished Alumni of the Year. She has over 100 published articles in international journals, books, and is an author of Disaster & Mass Trauma, Chief Editor of Forgiveness & Reconciliation: Psychological Pathways to Conflict Transformation and Peace Building (Springer, 2010), Chief Editor of two volumes on Mass Trauma & Emotional Healing around the World: Rituals and Practices for Resilience and Meaning- on Mass Trauma & Emotional Healing around the World: Rituals and Practices for Resilience and Meaning-MakingMaking (Praeger, ABC-CLIO 2010), author of Amazon Bestseller Forget Me Not: 7 steps for Healing our Body, Mind, Spirit, and Mother Earth (2018), A Journey of Empowerment, Healing, and Transformation (2023), and a meditation CD called “From War To Peace” transforming generational trauma into healing and meaning-making.

ANDREW DOLINAR holds a MA Human Rights Studies from Columbia University and a BA in Sociology from The University of Illinois at Urbana-Champaign. He has worked on crisis response and conflict monitoring at Human Rights Watch in New York, and sentencing reform at Penal Reform International in Tbilisi, Georgia. Much of his career has focused on human rights issues in Eastern Europe and the Caucuses, in particular LGBTQ+ rights, transnational organizing, and conflict intervention. He currently serves as the Vice President of the Association for Trauma Outreach and Prevention at MeaningfulWorld.

Citation: Kalayjian, A., & Dolinar, A. (2023). Transforming horizontal violence globally. Trauma Psychology News, 18(1), 22-27. https://traumapsychnews.com

Phoebe Lewis
Section Editor: Antonella Bariani
Peer Reviewers: Molly Becker

The United Nations High Commissioner for Refugees (UNHCR, 2023) estimates that, as of mid-2022, 32.5 million people were of refugee status. According to the Immigration and Nationality Act (INA), a person meets the legal definition of refugee if they are “unable or unwilling to return to their country or nationality” due to fears or experience of persecution based on religion, political affiliation, social membership, race, nationality, or religion (INA, section 101(a)(42)). To be granted refugee status, people must apply from outside the desired country, and, according to United States criteria, must not be “firmly resettled” in another country (U.S. Citizenship and Immigration Services [USCIS], 2022). Those seeking asylum must meet the same legal definition as those seeking refugee status; however, they apply from inside the new country. People of refugee status and those seeking asylum are often the most vulnerable members of their new society (UNHCR, 2021). As the number of displaced people around the world rises, it is vital to support the expansion of literature and knowledge concerning this population.

Displaced and resettled populations are vulnerable to post-migration living difficulties (PMLD; Silove, 1998). PMLD refers to daily stressors that resettled people may face, such as language barriers, cultural differences, new legal and bureaucratic systems, loneliness, and boredom (Teodorescu et al., 2012). A growing body of research has identified the role of PMLD in refugee mental health, and, relevant to this paper, its relationship with suicidality (Aisik-Reebs et al., 2022). This paper examines the function of PMLD from the IPTS framework. It asserts that expanding our knowledge of the role of PMLD in the emergence of suicidality could support risk assessment, and thus appropriate intervention planning, with displaced populations.

PMLD in Context

The experience of forced displacement is stressful and traumatic and often follows war, persecution, and significant loss. Refugees have been found to frequently meet higher rates of post-traumatic stress disorder (PTSD) and mood disorders (Malm, 2020). A significant element of the refugee experience is post-migration, a liminal time between places as some people may spend decades in camps that have poor infrastructure and security (Devictor & Do, 2017). Post-migration stressors have been identified as a factor in suicidality in refugee populations, yet there is relatively limited research on this topic; this may be due to difficulties researching transient groups, as well as the cultural, ethnic, and racial heterogeneity of refugee communities (Cogo et al., 2022).

“Double Trauma”

PMLD has been described as a “double trauma,” in that compounding stress inherent to resettlement may exacerbate pre-existing psychological distress (Teodorescu et al., 2012). Difficulties associated with adapting to and navigating a new country may be experienced as equally – or even more – stressful than experiences associated with the initial dislocation (Schick et al., 2018). In a three-year longitudinal study, PMLD was found to mediate rates of anxiety and depression more than previous trauma histories; this finding prompted the authors to call for interventions directly addressing these sources of PMLD (Schick et al., 2018). In another study of the Rohingya of Myanmar, daily stressors in the environment and demographic factors, more so than trauma histories, were found to predict symptoms of depression. These environmental stressors – which could be considered PMLD though the study took place in a post-emergency setting –partially mediated the relationship between trauma history and symptoms of PTSD (Riley et al., 2017).

PMLD has also been found to play a role in suicidal ideation and behavior in refugee and asylum-seeking populations and has been identified as a risk factor for suicide in these populations (Schick et al., 2018). In a study concerning refugees resettled in unstable urban environments, Aisik-Reebs et al. (2022) found strong associations between PMLD, PTSD, and mood disorders, as well as their co- and multi-morbidity, with the severity of suicidal ideation. The findings are significant for an emphasis on the compounding nature of acculturative environmental stressors. Further, the additive stress of chronic racism, poverty, cultural isolation, and a slow-moving immigration bureaucracy have all been identified as risk factors for suicidal behavior in ethnic and immigrant groups (Silove, 1998). Some have contested this directionality of relationships, suggesting that psychological distress associated with the refugee experience, in general, may contribute to post-migration living difficulties (Hynie, 2018). However, for this paper, the etiology of PMLD is of less concern than its role in overall psychological functioning.

PMLD + Perceived Burdensomeness

The IPTS posits that a contributing factor to the development of suicidal behavior is “perceived burdensomeness,” (PB) or the sense of being a burden to loved ones and that one’s death could bring relief to one’s family and community (Joiner et al., 2009). IPTS argues that the desire for suicide emerges when the concepts of PB and “thwarted belongingness” (TB) – or a sense of social alienation – are present. When the capacity to access and act upon this desire is present, the interaction of those three constructs (PB, TB, and capacity) can contribute to, and indicate, imminent risk (Joiner et al., 2006).

PB has been proposed to be particularly salient to the post-migration experience (Chu et al., 2018). In a study of suicidality in Bhutanese refugee populations placed in America, PB was more strongly associated with suicidal ideation more than TB (Meyerhoff, 2021). The proposed relationship between PB and PMLD, and the contributions of PMLD to the development of PB, is compelling when considering that becoming a refugee involves the loss of professional, familial, and cultural identity and a shift in self-concept. Overnight, people may find themselves experiencing an “unmet need for social competence” in which the skills and knowledge they developed in their home country are less useful, impactful, or respected in the new environment (Van Orden et al., 2010, p. 2). PMLD may challenge hierarchies within a family structure, forcing parents to rely on younger generations for support (Fondacaro, 2014; Schick et al., 2018). Considering their 2021 qualitative study of suicidality in Bhutanese refugees resettled in New England, Meyerhoff (2021) even suggested that PB be included as an individual risk factor for refugee populations. While research in this model concerning PMLD remains relatively nascent, the concept of PB appears culturally and environmentally salient to the refugee experience (Chu et al., 2018).

Hidden Ideators

A better understanding of the relationship between PMLD and suicidality in refugee populations may help guide effective risk assessment. People of refugee status and those belonging to ethnic minority groups may be more likely to endorse the desire to be dead, rather than an active wish to harm or kill themselves (Dadfar et al., 2017). Passive ideation may be more difficult to detect initially, but when it is detected, it is more frequently associated with active attempts (Bommersbach et al., 2022). One hypothesis to explain this association is that refugees are more likely to progress along the suicide continuum undetected, thus receiving reactive, rather than preventative, interventions (Han et al., 2014). Recognizing the significant role of PMLD in the emergence of risk constructs may provide useful insight for clinicians attempting to adapt risk assessment protocols to minority clients.

The use of risk measures is a critical element of suicide prevention, detection, and intervention (Bernet & Roberts, 2012). However, many measures were developed with WEIRD samples and clinicians must consider the cultural, racial, ethnic, and linguistic complexities inherent to working with refugee populations. Some available measures were developed with culturally diverse populations, such as the Cultural Assessment of Risk for Suicide scale (CARS-S; Chu et al., 2013), and others, such as the Wish to be Dead scale (Lester, 2013), assess specifically passive ideation which as noted is often found in refugee and ethnic minority groups. Another tool currently available to clinicians that could be adapted for use in refugee populations is the Interpersonal Needs Questionnaire INQ) which includes subscales measuring PB and “thwarted belongingness” (Van Orden, 2012).

The Post-Migration Living Difficulties checklist, (Silove et al., 1998) assesses the severity of sources of PMLD common to refugee populations. These include but are not limited to access to healthcare, delays in processing immigrant applications, discrimination, communication barriers, poverty, loneliness, restricted access to traditional foods, and adjusting to the weather (Silove et al., 1998). Given growing research connecting PMLD and suicidality in refugee samples, it is important to consider how PMLD could be conceptualized as a specific risk factor to guide clinical decision-making. Specifically, assessing the psychological experience of PB as measured by the subjective severity of PMLD may help clinicians consider how environmental factors manifest in clients’ lives, self-concepts, and histories.

PHOEBE LEWIS, M.S., is a Psy.D. candidate at Antioch University New England. She has trained in pediatric neuropsychology at Dartmouth-Hitchcock Medical Center and in trauma-focused therapies with refugee, asylee, and survivor of torture populations through the University of Vermont’s Connecting Cultures specialty service. Currently, Phoebe conducts research and forensic asylum evaluations through the Connecting Cultures clinic and is a graduate clinician at the University of Vermont Counseling and Psychiatric Services (CAPS). Phoebe lives in Burlington, Vermont where she plans to practice upon graduation.

Citation: Lewis, P. (2023). Double trauma: Post-migration living distress and refugee suicidality. Trauma Psychology News, 18(3), 26-29. https://traumapsychnews.com

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.