The Mental Health of Children Impacted by Armed Conflict: Supporting Parenting & Wellbeing

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In this podcast, we are joined by Professor Kenneth E. Miller, Edith Lando Professor in Counselling for Refugee and Immigrant Youth and Families at the University of British Columbia in Vancouver. Ken is also the author of the book War Torn, Stories of Courage, Love and Resilience. He’s director of the film Unholy Ground about the impact on war on a frontline village in Sri Lanka. And he writes a blog for Psychology Today called The Refugee Experience.

Today we’ll be focusing on Ken’s work with refugees, and some of his research, including his recent JCPP paper ‘Supporting parenting among Syrian refugees in Lebanon: a randomized controlled trial of the caregiver support intervention’ (doi.org/10.1111/jcpp.13668).

To set the scene, Ken shares how he came to work in refugee camps and what drove him to pursue an interest in refugee mental health right at the onset of his career.

Ken provides insight into what the conditions are like for children and young people living in areas of armed conflict and comments on, from his experience and research, what kinds of interventions make the most difference for refugee children and their families.

Turning to his research, Ken provides an overview of his recent JCPP paper, and a companion article published in another journal, and comments on the outcomes from introducing caregiver support interventions, plus shares how he defines harsh parenting in his paper.

Furthermore, Ken shares his message for CAMH professions who work with refugee and immigrant youth, plus discusses what his message is to policy makers; before turning to comment on how optimistic he is that healing is possible for children and young people who find themselves displaced or at the center of unrest.

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Kenneth E. Miller
Professor Kenneth E. Miller

Kenneth E. Miller is the Edith Lando Professor in Counselling for Refugee and Immigrant Youth and Families at the University of British Columbia in Vancouver. Since 1991, Dr. Miller has worked with diverse communities affected by armed conflict and forced migration, as a researcher, clinician, organizational consultant, and documentary filmmaker. His research has examined the multiple sources of stress impacting war-affected communities, and he has led the development and evaluation of mental health interventions aimed at strengthening resilience among refugee families. the book The Mental Health of Refugees. His book War Torn explores resilience and its limits in six war-affected communities, and his edited book The Mental Health of Refugees is widely used in graduate courses and other training programs. He also writes a blog on PsychologyToday.com, The Refugee Experience.

Transcript

[00:00:09.540] Jo Carlowe: Hello. Welcome to the In Conversation podcast series with the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in Psychology. Today I’m interviewing psychologist and writer Ken Miller, Edith Lando Professor in Counselling for Refugee and Immigrant Youth and Families at the University of British Columbia in Vancouver.

Ken is also the author of the book War Torn, Stories of Courage, Love and Resilience. He’s director of the film Unholy Ground about the impact on war on a frontline village in Sri Lanka. And he writes a blog for Psychology Today called The Refugee Experience.

Today we’ll be focusing on Ken’s work with refugees, and some of his recent research. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review. And do share with friends and colleagues. Ken, welcome. Nice to meet you. You have a very full career. Can you start with an introduction about who you are and what you do?

[00:01:13.845] Professor Ken Miller: I’m a clinical psychologist by training. I got my degree at the University of Michigan eons ago. And then I did a two-year postdoctoral training in community psychology prevention science, which gave me a very, very different perspective. Ended up having a kind of a profound impact on shifting my thinking from understanding mental health problems as something wrong inside of the person, to a broader view of looking at mental health as a reflection of the fit between people and the settings that they live in. And that shift has guided a lot of my work, most of my work over the years.

My pathway has been a bit unusual, I suppose. I started out in graduate school. I spent about two years living in Central America, working initially in Guatemala. I had gone to Guatemala to study the impact of state terror on genocide, on Indigenous Mayan children. And I spent six months volunteering with an Indian Health Organization. But it was– at the time it was still the tail end of the genocide. And the danger was quite great. Not so much to me as being from the US, but to anyone in any of the villages that I spoke with. Every village had an [INAUDIBLE], an ear, a spy. And my partner at the time, she was– she was getting a degree in sociology and studying Mayan women. We decided that we would put too many people in danger. And so, after six months in Guatemala, we moved across the border to the refugee camps in Southern Mexico where we worked with– there was about 130,000 Guatemalans living in exile in the camps. And that’s where we had the freedom to do the work we wanted to do.

And that ended up setting me on this trajectory that I’ve been on ever since working with refugees, working with conflict affected people. I directed a clinic for Bosnian refugees in Chicago for two years before I decided that I wanted to follow an academic path because it would give me the freedom to think a little bit more outside the box than I was able to in a traditional mental health clinic. And so, I worked, for a lot of years, as a professor of psychology in California, and then ended up moving to Amsterdam for quite a while. And I was a senior researcher at a Dutch non-profit called War Child. And that’s where I spent the last several years developing and evaluating mental health interventions primarily for Syrian refugees in Lebanon. And then just recently joined the faculty again here in Vancouver.

[00:03:53.620] Jo Carlowe: Can I ask you to take a step back and ask you how you came to be working in refugee camps? As in what drove you for that to be your interest right at the onset of your career?

[00:04:07.570] Professor Ken Miller: It’s funny because in my book War Torn I tell the story. And I think I’ve abbreviated it from the original draft. But it was one of those very fortuitous moments. I studied political science at university as an undergrad. And was very interested in social change and the psychology of social change. Very committed to social justice issues, particularly in Latin America. At the time the Nicaraguan revolution had happened. And I was deeply, deeply moved by what I saw happening in Nicaragua. And deeply troubled by the impact of the US intrusion into the country.

I left my activism aside for a bit after I graduated and joined the University of Michigan clinical psychology program which at the time was a very conservative program. I was studying adolescent suicide, which is, by definition, a rather depressing topic anyway. But I remember being one New Year’s Eve, my second year, and I had a stack of books on teen suicide on my shelf. And I was sitting there looking at it, thinking, this is something fundamentally wrong with my life right now that this is what I’m looking at. It was really depressing.

And I had helped organize a visit of these two psychologists from Central America to talk about a project they were doing in rural Guatemala. It was a Friday night, I remember, and I was just sort of, kind of down about what I was doing. And I wasn’t even motivated to go to this talk I’d helped organize. And I sat down on the couch. And then at last minute I thought, you should go hear that talk. You helped organized it. And I walked over to the Student Union. And it was love at first sight. I heard these two psychologists talking about using creative and expressive arts in these Mayan Indian communities that had endured the genocide to help people heal from the trauma. And it was political, and it was social justice and it was mental health. And it was a marriage of things that it all just came together and saw it. By the end of the weekend I signed up to go down to volunteer with them for six months. I went down and I studied Spanish in Nicaragua and Guatemala, and never looked back. But it was one of those moments where the last 11th hour moment decision to go down and hear that talk ended up transforming the whole path that my life was on. And I left the teen suicide stuff behind and ended up carving out this interest on the mental health of armed conflict. It’s primarily focused on refugees, but not exclusively.

[00:06:35.730] Jo Carlowe: I’m wondering if you can give us more insight for those of us that witness armed conflict, the situation of refugees, from afar. What are the conditions like for children and young people at the sharp end?

[00:06:49.825] Professor Ken Miller: It’s terrifying. It’s terrifying to live with the constant bombarding, the vulnerability, the sense of a world that is extraordinarily dangerous. Now, war zones really vary enormously. We think of it only as bombs and bullets and rockets. And depending on where you live, you can be– and Sri Lanka is a perfect case. During the Civil War there, I did some work in Sri Lanka. You could be in the South, in the East, and walking along the beach and have no idea that there’s a pretty brutal armed conflict North of you.

In other places like Afghanistan, you just know that there’s a low level and at times high level war happening, or in Syria. Although even within Syria there are places you can be somewhat outside of the war. And in other places like Aleppo, if you’re a child living in Aleppo during the bombing, your entire world is just falling down around you. The biggest thing I would say about understanding the experience of children in armed conflict, though, is we focus a great deal on their exposure to the violence of war per se.

But what we’ve learned over the last, I’d say 15 or 20 years, that’s been so important– and this is especially true in refugee communities– is that children’s well-being, their mental health is very much a response not only to the outer world, but to its impact on their parents or caregivers, whoever is taking care of them. And, in fact, one of the great, I think, well intended mistakes that a lot of humanitarian organizations made for a lot of years was they would work with refugee kids in refugee camps. And they would provide an hour and a half or two hours of really fun activities, and then send the kids home but provide no support to the families, or the parents. And what we now know is that what war does to parents is that it not only leaves a significant number with trauma and grief that they’re dealing with from whatever they endured directly in conflict or from all that they’ve left behind, it confronts them with a host of what my colleague Andie Rasmussen and I have written a lot about as daily stressors.

This is poverty, overcrowded housing, lack of work, lack of access to the most basic necessities of life, loss of social support networks, isolation, loneliness. And these are things researchers weren’t talking about for the longest time. And humanitarian organizations weren’t seeing their impact. And now we understand that when parents are coping with chronically high levels of stress, it impacts– it compromises their parent. Not always and not for everyone by any means.

So then to take a kid out of the home, provide a couple of hours of supportive play activity, expressive arts activity, normality, is a wonderful thing. But if you send a child back to a high stress environment without also supporting parents, you’re undermining your own best efforts. And that’s– I think if I have one message for people working with kids in settings of armed conflict it’s don’t just focus on the child, focus on the family as a whole, and not just the child and the parents or caregivers.

[00:09:59.185] Jo Carlowe: Can you say more about this? I mean, from your experience and from your research, what kinds of interventions make the most difference for refugee children and their families?

[00:10:10.240] Professor Ken Miller: I have to say we are still trying to figure that out as a field, as the sort of constellation of mental health fields, psychiatry, psychology, social work. It’s been clear that our interventions are effective for adults affected by war and displacement. The data on kids is a lot less encouraging. But I suspect that one of the big reasons– my colleague Mark Jordans in Amsterdam and I have– we’ve written about this. He’s been a real pioneer in working with kids affected by armed conflict. So much of the work with kids to date has been focusing on kids without also addressing the larger context in which they live, the communities, the family. The assumption has been that kids are distressed. And we know that refugee kids, war affected kids have higher levels of stress and distress, depression, anxiety, trauma, than kids growing up in healthy environments.

But the assumption has largely been that their distress is a product of what they endured in their country of origin or the violence they’ve been exposed to. And it’s only recently that we’ve come to see the role of family and community environments. And that those need to be targeted too. And I think this is why our interventions with kids have been less effective. Where we are beginning to see some effects is when you not only work with kids, but also work with their families, with their parents in particular, you begin to see an impact, a downstream impact on children. As you help parents manage their own stress and their own distress so that they feel better, surprisingly– not surprisingly, they parent better.

Now, the interesting trend that humanitarian organizations have been working with refugee parents for some years now, but the traditional model. Once there is in response to the growing recognition that we need to work with parents as well, not just kids, a number of organizations began to do that. But interestingly, for reasons that still befuddle me, the primary focus was on teaching parents how to parent. And so, you would see these 10 session interventions where most of the focus was on teaching parents evidence-based parenting skills and accepted knowledge, and very little to do with parents’ own well-being. I think one of the best known interventions had a half session on caregiver stress. And so implicit in that was this really interesting assumption that the reason parents were using more harsh parenting and less warm and responsive parenting was they didn’t know better. And that’s a very silly assumption, without any basis in any kind of data.

And so, the new shift that I’m very excited about is recognizing that actually when parents, even the best parents, are highly stressed perpetually for a long time, their parenting is impacted. And that rather than assuming that the increased harsh parenting or the decrease in warm or responsive parenting– which is what kids thrive on– rather than assuming that’s due to a lack of knowledge and skill, let’s start with the assumption that people have a lot of skill and knowledge. But it’s the chronic stress and distress that’s compromising their ability to use what they know.

So, in the intervention that we did for the last– we developed and have been testing for the last several years, we started it in Gaza, and then moved it over to– expanded it to Lebanon where we did a lot of research on it called the Caregiver Support Intervention or the CSI. It’s a mindfulness-based intervention that is nine sessions, it’s group, separate for women and men. And the first four sessions, we don’t even talk about kids, it’s for parents. First four sessions are just about their own well-being. And although we do introduce evidence-based parenting stuff in the last half of the program– because we think all parents can benefit from that– the emphasis on mindfulness continues to occupy about 25% of the time of every session, even in the parenting sessions. And there’s home practice where parents really develop mindfulness, stress management kinds of techniques, anger management stuff, to help them. Other organizations are using similar kinds of approaches now. It’s something I’m very excited about.

[00:14:24.720] Jo Carlowe: All right. I want to ask you more about the outcomes from those interventions. But before I do, I should mention you’re referring to here to one of a recent paper that you’ve written. So, you’re the first author of the paper Supporting parenting among Syrian refugees in Lebanon: a randomized controlled trial of the caregiver support intervention. And that was recently published in the Journal of Child Psychology and Psychiatry, which is one of ACAMH’s three journals.

You’ve also written a companion article with the title “Worlds of Pain, A Process Evaluation of Caregiver Support Intervention with Syrian Refugees in Lebanon.” Can you say anything about the outcomes from introducing these interventions?

[00:15:07.310] Professor Ken Miller: There’s two interesting things about, I think, those papers. They’re both open access. So, if people want to see them, you can just Google them online and they’ll take you to the journal and–the journals. And Social Science and Medicine Mental Health published the process of evaluation, which was focus groups, with participants in the trial and in the big study.

We did a pilot randomized controlled trial, smaller study. And I think we had about 100 and– I don’t remember exactly– about 150 parents, two from each family. Which was exciting, we got men involved. In every family we had both male and female caregiver. I say that rather than mother and father because in some cases it was grandparents who were watching the kids, so we term care givers more broadly.

And in the pilot study what we found, we found that in the CSI groups, after nine weeks, on everything we studied, every measure, parents improved substantially with effect sizes that were medium to large. Meaning there was really significant improvement in lower distress, lower stress, better stress management, increased warm and responsive parenting, decrease in harsh parenting, and improve child mental health. So, we saw improvements across the board. And in the control group we saw no change at all. So, we were super encouraged. And at the time I remember thinking, of all the places I’ve done research, Lebanon was the easiest. It was pretty peaceful. The majority of Syrians lived in poverty, but they were managing to make ends meet one way or another.

So then we decided it was time to do a full randomized controlled trial, 480 caregivers from 240 families. Big sample divided into two ways. We were very excited. We got grant money to run this, and we thought we have the statistical power to really run this well. Just as we were starting the trial, Lebanon entered– the World Bank has called it the third worst economic crisis since the mid-1800s in terms of human impact. The economy imploded. It devastated Lebanese families. But for Syrians, 60% to 70% of whom were already living in poverty, it subjected them to extreme poverty. So suddenly you had this situation where people were being threatened with– Syrians with being threatened with eviction, they couldn’t pay the rent. This increased acts of hostility, discrimination against Syrians by their Lebanese hosts.

There are about one and 1/2 million Syrians living in Lebanon, which is 20% to 25% of the population. Lebanon has generously allowed a lot of Syrians in, but the welcome was growing increasingly thin already, and this exacerbated that. Issues of food scarcity, hunger, basic survival, access to health care, all of these became enormous once the economic collapse hit.

[00:18:00.660] Jo Carlowe: So how on earth do you conduct research in that type of environment?

[00:18:04.968] Professor Ken Miller: Well, so there’s two questions. How do you conduct research? And then what is the role of a mental health intervention, essentially, in a context where people are mostly focused on the fact that they can’t feed their children.

[00:18:17.610] Jo Carlowe: Survival.

[00:18:18.715] Professor Ken Miller: Survival. Right, and that became– the level of stress just went through the charts at that point. And we’re teaching a stress management workshop. But we all know from our own lives that whatever stress management techniques we use tend to lose some of their power when stress reaches a certain point, it just overwhelms us. We didn’t know how bad it would get. I mean, the currency became almost worthless.

Lebanese were often getting paid in dollars, depending on the kind of work that they did. But Syrians, actually due to a US law, meant to keep money from getting to the Syrian regime, Syrians in Lebanon were often getting paid in the local currency. And what it meant was that their money was monopoly money, it was worth [INAUDIBLE].

Anyway, we started the intervention. We thought, well, we’ve got the grant money, we’ve got the team ready to go, let’s do it. And we recruited our 480 people. We were very excited. Again, we got men involved as we hope to– which really challenged a lot of the conventional wisdom that men won’t get involved in parent-focused interventions. But they will, and we had. We made a number of adjustments. We got a lot of feedback from them during the formative research, the early research on some changes we needed to make to the intervention to make it more suitable to them. We scheduled it at times that didn’t conflict with their income generation opportunities. So, we worked on– we work to make it work for them, and they responded well to that.

And we ran the study. Now, we had so many people that we divided it into two waves. We finished the first wave. Midway through the second wave of COVID-19 reached Lebanon. Now we’re running this randomized controlled trial in a condition of absolute poverty and also social unrest. Protests had broken out throughout Lebanon in response to what’s– this perceived government corruption, and that’s caused this economic collapse, and now there’s lots of violence. And you have to remember for Syrians is that they fled Syria in response to what began as peaceful protests against the government, and ended up being met with extraordinary violence.

In the same way peaceful protests in Lebanon were initially responded to peacefully, and then no longer peacefully. The government became violent again. So, Syrians it was deja vu, they were very frightened by that. And then COVID-19 hit. And the government moved fairly rapidly to a series of lockdowns. And that brought all field activities to a complete stop. So, we had finished wave one implementation. We had, I guess, 120 families were done. We’d done baseline data, and we were at session six of the nine sessions in wave two. And we had– and we had to stop the intervention.

[00:21:04.210] [INTERPOSING VOICES]

[00:21:06.090] Professor Ken Miller: So, they didn’t get a third of the intervention, half the participants. And we didn’t know what to do. We waited a couple of weeks to see if the lockdowns would end, and it was clear they were not going to end. So, we switched to a telephone data collection system. It was an amazing. We did it all by cell phone. And we were able to complete all the data collection. We just did it at six weeks instead of nine weeks for wave two.

And then we waited three months as planned for both groups, and we did follow up data collection. So, we gathered data in this context of extreme poverty, of prolonged lockdowns, of social unrest. And we evaluated the intervention under those conditions. Now, we did show– despite all of this extraordinary stress and distress on our questionnaire data, which is what was published in Journal of Child Psychology and Psychiatry– we did show a reduction in harsh parenting in the intervention group, relative to the control group, we– and improvement in child mental health as well. And we also showed a significant reduction in parents distress. And what was really important was that the reduction in harsh parenting was partly explained by this improvement in parental mental health. That if parents became less distressed, they were less likely to engage in harsh parenting.

[00:22:30.470] Jo Carlowe: It might seem obvious, but can you define harsh parenting. What–

[00:22:34.730] Professor Ken Miller: Yeah, so– no, no, it’s fine. It’s a really great question. So for us we define harsh parenting as anything from yelling at children, speaking to them very harshly, to actually physically hurting a child. What we found was that as parents felt better, as they felt less distressed, they were less likely to engage in harsh parenting. And that really was exciting for us because that lends support to this model that we were proposing, which was that the harsh parenting or the lack of warm and responsive parenting wasn’t so much a– it certainly wasn’t just a lack of knowledge and skills about parenting, it was a product of parents’ own stress and distress.

Now, it’s important to also acknowledge that we didn’t find intervention effects on a number of other things. That in the pilot study, we found medium to large effects. And we didn’t see an impact on parental warmth and responsiveness. We didn’t see lowered stress. We didn’t see improved stress management in that study. And those were things we had seen big effects or medium to big effects on in the pilot study.

Now, I attribute that primarily to just the extraordinarily stressful conditions under which the trial was conducted, and the fact that half our participants didn’t get the full intervention. So, then I expect to see less effects across the board. What I’m puzzled by and intrigued by is that we did focus groups with almost 60% of the participants in the intervention. And of the folks that we did focus groups, six to seven months following the intervention when the lockdown finally stopped, we could go back into the field, and we asked them about the impact of adversity of the stress on their lives. We asked them about the benefits– any benefits they had experienced from the intervention. And then about the impact of all of the stress on the intervention. How helpful was it given the stress? And how much did the effects last?

And what we found in the qualitative data, in the focus group data was actually much more encouraging than what we found in the questionnaire data. And where truth lies is a tough call, but for me it underscores the power of what in research we call triangulating, which is using different types of data to get at the same questions. So, what we found in the focus group– and this is in the worlds of pain paper, the process evaluation paper– is a lot of parents in the intervention described a marked reduction in stress despite all this adversity as a result of the mindfulness activities. And they were very clear about some of the breathwork, that counting the breath, the lowering arousal.

Parents describe this pathway from using these techniques, to feeling calmer, and to becoming much more patient and less likely to engage in the harsh parenting. Which they– most of them recognized was unhelpful and not a kind of parenting that they wanted to engage in, but they felt– they had felt unable to stop it. Now they felt there was a little space where because they felt better, they felt calmer [INAUDBILE] they were less likely to get triggered. But if they did get triggered, they were able to use some of the techniques that we taught, also some of the anger and frustration management techniques to lower their arousal before responding.

So, they described, in fairly detailed examples, becoming more patient, less angry. They quoted their children as describing them as becoming different, nicer, kinder. Whenever they would lose their temper, the kids would say, hey, go do the CSI, go to another session. You need more of the sessions. Women describe these really striking transformations of their husbands. I remember one man who said, when I would come home, my kids used to run and hide in their bedroom. They were so frightened of me. Now they come running out, and I give them kisses. And they want me to tell them stories. We didn’t get that stress reduction, that improved ability to manage stress. We didn’t get this increased warmth and responsiveness from parents in our questionnaire data.

Now, where does truth lie? I mean, I can’t– I believe the focus group data are real. I believe the questionnaire data are real. Where I’m struggling is how we reconcile those two. Now, mind you, not all the parents describe this benefit. There were some parents who didn’t describe it. And one of the problems with the way randomized controlled trials are done is we typically look for an overall group difference is there an effect for one group, the intervention group, compared to the control group?

I think what we probably have is a much more nuanced experience where there are some folks in the intervention group who got the CSI, who really benefited from the experience. And then other folks who did not. And there’s a growing literature now, there’s a really interesting approach where people are looking at how, in fact, this is actually normative. This is really more the norm than the exception. That even when you find a group effect, any kind of intervention, whether it’s a medication or a behavioural intervention, only a portion of your intervention group, only some often a minority of that group actually shows that real benefit, and many others don’t. But it’s enough to show an overall group effect compared to a control group.

And so one of the interesting directions that is being advocated for randomized controlled trials is to begin looking not just at overall group effects, but at for whom within an intervention group is an intervention actually most helpful, and for whom does it not seem to be most helpful. That allows us to really target those folks who are most likely to benefit. We do that in medicine. We know, for example, that some medications for cancer only help 5% of people with a particular type of cancer. And then we really target those folks with that medication, and try and figure out what will be helpful to other folks.

In psychological interventions, we were still working in a more crude way. Does this help everyone in the intervention group? Is there an overall mean difference, average difference compared to a control group? And it’s a somewhat crude approach. And I think we need to get more nuanced and ask for whom is this beneficial and why from the program. Now, over time a lot of folks described a gradual deterioration of those benefits, not everyone. I would say about half the people who benefited described a gradual deterioration. And they were very clear about why. They said, over time, these methods of stress management are no match for the chronic lockdowns. Seven people locked in a basement apartment.

One woman described feeding a mixture– a spice mix that is common in Syrian cuisine to her kids. They had no food. She said, I pick up bread from the ground to bring home to feed my kids, she says. Another woman said, we don’t have electricity. We live in darkness, we use candles. They don’t have medication. A father described his agony at being unable to get medication for his kids or his wife who were quite sick. And under those conditions, it becomes clear that you can’t provide psychosocial interventions, mental health interventions without complementing them with interventions that target basic needs. People need nutrition. They need health care. They need housing. Of course, the CSI was never meant to be implemented in isolation. That’s simply how we studied it. But in this context, it really underscored for us that if you’re trying to lower stress, it’s fine to teach people these kind of methods and techniques. But they need to feed their kids. They need to know that if somebody gets sick, they can afford medication. And we couldn’t provide that.

[00:30:43.155] Jo Carlowe: What’s going to happen with these interventions? Are they being rolled out elsewhere or are you working on new projects?

[00:30:50.460] Professor Ken Miller: Well, right now, yeah. I mean, the CSI continues to be implemented in Gaza. We have a wonderful team there. The Lebanon team is well trained in the CSI so they have it in their toolkit for their work with Syrians, and they were using it with Lebanese families. There was a massive explosion some years ago in the Port of Beirut. These storage containers that had massive amounts of explosive material, it just blew. And it destroyed hospitals, thousands of homes. People were devastated by it. And so, the Lebanon team from workshop was using the CSI with Lebanese families as well in that case.

We recently rolled it out in Jordan. So, really, throughout the Middle East now this is being scaled up. I’m really intrigued. I recently arrived in Canada, so I’m in Vancouver now. And I’ve just arrived so I’m still kind of getting a sense of the landscape here. But one of my– the things I’m excited about is to adapt the CSI for use here in Canada with refugees. Traditionally interventions and knowledge in mental health and psychosocial work have gone from the high-income world to the low and middle income world. It’s been critiqued for having a certain colonialist, if you will, direction.

And I’m very excited about taking an intervention that was really developed in what was a middle-income country, Lebanon, and very much a low income country now. And also developed in its earliest stages in Gaza, in Palestine. And bringing that to a high-income country, Canada, and seeing what sort of adaptations do we make to take this evidence-based intervention and make it evidence-based here in this context.

[00:32:32.370] Jo Carlowe: I’m wondering then what message you have for CAMH professionals who work with refugee and immigrant youth. What would be helpful for them to take from your experiences?

[00:32:43.932] Professor Ken Miller: Yeah. And here I think I would make a distinction then between the children and youth, as you just did. As you’re thinking about kids, younger kids who are much more dependent on their families and their parents in particular, the message would be don’t just intervene to support the kids, really think more broadly about the kinds of support that families need. Because children spend an enormous amount of time with their families. And particularly younger children are very powerfully impacted by the well-being of their parents and the parenting, of course.

The more we can support the needs of parents and other caregivers of children, the more we are going to be supporting kids. Now, a lot depends on where you’re working. If kids have access to schools, schools are a wonderful venue for supporting kids as well, and particularly older kids who are in schools.

One of the most important things, we know that discrimination against refugee kids is one of the biggest sources of stress, and anguish, depression that refugee kids experience. So, interventions need to not just target the refugee kids themselves, but the school environment, to make it more welcoming and supportive. Teachers and counsellors, they want to be supportive to their refugee students, but they often lack the background to understand how to do that. I think intervening at the level of schools, and, again, not just targeting the refugee kids themselves at the level of the school environment can be very helpful.

And then with older kids, with youth, the other thing I would say is a lot of refugee youth have experienced a profound sense of disempowerment. Control has been ripped out of their lives. And one of the most interesting approaches to working with refugee youth has been adopting an empowerment approach.

They can benefit from mental health care, no question. And I saw that when I was the director of a clinic for Bosnian refugees. There is a place for that, of course. But for a lot of youth what’s enormously helpful is empowerment-focused programs that give voice to refugee youth, that start with the assumption that they can articulate what’s hard for them, what the challenges are, they can organize to partner with the host country youth, develop different kind of school environments. They can do photo projects to document their lives and the thing– that the resources that matter to them, the things that get them excited. And they can articulate what it is that they hope to achieve in the future, what their dreams are. And then work on projects to help figure out what are the steps to get from where they are now to where they’d like to get to.

They can develop community projects, if they’re in refugee camps, to help improve the community, and develop goals and projects and social support for girls, teenage girls. I mean, programs around– and this is very sensitive in some communities, of course, but around reproductive health, sexual health. Programs around gender-based violence can be very helpful too, particularly in refugee camps where adolescent girls are particularly at risk of harassment or assault.

[00:35:50.630] Jo Carlowe: All of this takes resources and training. I’m wondering what your message is to policy makers.

[00:35:56.780] Professor Ken Miller: One of my messages is that preventive interventions are an enormously cost-effective investment. We can pay to prevent problems from arising and to strengthen well-being in refugee communities in war affected communities, or we can pay downstream for treatment, which is far more expensive and less effective. The other message that is exciting is for policy makers, but it’s also for the field itself. One of the most exciting developments in the field is we’ve learned that you can implement highly impactful mental health interventions by training local community members to do the implementing that you do not need people with master’s degrees and PhDs and medical degrees to do.

And I’m talking not just about activity groups with kids, I’m talking about real clinical interventions, I’m talking about all manner of mental health treatment and preventive interventions can be effectively implemented by training local folks, providing them with the support and supervision that they need. So, for policymakers who are willing to invest in these kinds of interventions, we can dramatically expand our reach in areas where there aren’t a lot of mental health professionals.

We can still have an enormous impact if policymakers are willing to invest in it. And then finally, of course, the last message is the most obvious, war is bad for living beings. And if we want to stop the trauma of war and the dislocation and all the pain it gives rise to, we need to stop the violence. And we need to create empowering refugee settings while we’re working on stopping violence.

One of the most horrific policies that a lot of countries abide by or have in place for refugees is they don’t allow them to work. What that does is that generates structurally imposed poverty, it creates dependence on outside aid, it causes a deep sense of shame and dependence among refugees, at least to all kinds of exploitation when refugees seek black market work. And all of this impacts the mental health of those who are involved. And it leads to heightened stress, heightened depression, heightened substance abuse, which is a risk factor for family violence. So, what I would say is one of the biggest policy changes we can make while we’re working to end wars is let’s find ways to get refugees gainfully employed, and we will have so many downstream mental health benefits from that.

[00:38:24.650] Jo Carlowe: And how optimistic are you that healing is possible for children and young people who find themselves displaced or at the center of unrest?

[00:38:34.655] Professor Ken Miller: I’m actually very hopeful. I think the problem is not so much that the pain and the distress of refugee kids is untreatable or unhealable, it’s not that at all. I think the problem has been more that the mental health disciplines psychiatry, social work, psychology, it’s taken us a while to figure out what are the factors that are contributing to the kids’ distress as we’ve adopted a more ecological or systems level view. And we’ve come to see that kids’ well-being is impacted not just by what they’ve been through in the country of origin by direct exposure to armed conflict and violence, but also by the family environment, the stresses in the community, in the school. We’ve begun to adopt a much more holistic systems level approach to intervention. As we do that, I’m actually quite confident that we’re going to have a much bigger impact on kids’ well-being than we’ve had to date.

[00:39:31.360] Jo Carlowe: Where can listeners go for more information or for helpful resources on the issues we’ve talked about today?

[00:39:38.625] Professor Ken Miller: There’s a lot of places to go. I think one of the most helpful places, the World Health Organization. If you just go to the WHO website, they’ve made a lot of their resources available online, then any of the big non-profits. You can look at whether it’s Save the Children, or War Child Holland where I worked. There’s a host of NGOs that have all kinds of information on their website in plain kind of non-jargon, easy to understand language.

I have a blog on Psychology Today called The Refugee Experience. And my goal in that blog is really to translate a lot of what we know about war and displacement on the mental health of kids and families and adults into everyday speak. And so, The Refugee Experience is a nice resource. I also a lot of what I’ve talked about today, I’ve talked about– I don’t mean this to overly self-promoting, but in my book War Torn, that’s based on my work in six war affected populations. And that’s a book of creative non-fiction. And the goal is to really bring stories to life for people about a lot of the themes that we’ve talked about today in a way that are very accessible, Afghanistan, Iraq, Sri Lanka, Guatemala, Mexico.

[00:40:52.867] Jo Carlowe: Before we finish, is there anything else in the pipeline that you’d like to mention?

[00:40:57.045] Professor Ken Miller: Well, as I say, I’m relatively new in Canada so I’m really just scoping out the landscape here and trying to figure out what would be helpful to refugees here in British Columbia where I’m living, and more broadly, in Canada. As I say, one of the things that I’m most interested in at this point is seeing whether there’s an adaptation of the Caregiver Support Intervention, the CSI, that might be useful to refugees settled here in this higher income, higher resourced country. So that’s something that I’m going to be focusing on and that I’m very excited about.

[00:41:27.846] Jo Carlowe: And, finally, Ken, what is your take home message for our listeners?

[00:41:32.250] Professor Ken Miller: We can do a whole lot to help refugee kids, and youth adapt successfully to whatever setting they’re living in, but we need to view their well-being in context. It’s not just about working directly with them, but it’s about creating schools and communities that are welcoming. It’s about supporting parents who are struggling to survive, and to help their families survive. And it is adopting this holistic or ecological approach that will help people thrive in their new environment. And I firmly believe we can do that, but it takes a real commitment. And this is a tough political climate these days for creating welcoming environments for refugees.

[00:42:15.570] Jo Carlowe: Ken, thank you so much. For more details on Professor Ken Miller, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed a podcast with a rating or review. And do share with friends and colleagues.

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