IMMIGRANT INTEGRATION LAB
 
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BOSTON COLLEGE SCHOOL OF SOCIAL WORK
When I began refugee resettlement work, a disturbing truth confronted me almost daily. Our clients were traumatized. There was a deep, pervasive grief that empathetic nerve endings could not ignore. BUT, in the world of immigrant services, neither federal contracts nor local philanthropy could begin to address the evident and prevalent pain. 

Drawing on lessons learned in doing hospice work in my past, I began to think about the relevance of stages of grief. When meeting new refugees I realized they were often at a stop on a long journey, not from Kabul or Ho Chi Minh City, but from soul wrenching loss. In days or years past, all that was familiar was left behind, all those who were supportive were separated, all those buried could not be revisited and all those places of old sanctuary, of solace, were beyond reach.  To the general sense of loss was added painful, and often invisible, wounds of betrayal, abuse, violence, disloyalty, cruelty, degradation and sometimes loss of virtue, identity, hope and faith, robbing the sojourner of everything they held of value about their life.  Grief prevailed. 

Within caring for newcomers should be this simple recognition - 'All that is' has behind it 'all that is lost.'  But wherever the sojourner is in recovery, rebuilding their life, we can play a role. To me it seemed overwhelming to address all the wounds, all the trauma, all the grief and so we turned to others who taught us that self-healing is a natural process (Mollica, 2017) and that where we are wounded we can become our strongest. 

The caring profession's response is critical. Compassionate understanding of loss and intellectual commitment to accompaniment and support can be powerful tools.  Even the simple recognition of the terrible, horrible loneliness each of us feels in the face of tragic loss or traumatic events can be a bridge between people.  We can validate the experience and the psychological consequence.  Within a strengths-based approach is a concept that each of us has a force working for our good, finding a way forward and developing the necessary coping mechanisms.  From outside we cannot take away any of the facts - the experience - but we can provide a safe place for disclosure (if wanted), we can listen without judgement and acknowledge the pain, and we can move alongside and perhaps help to discover a path forward that has always been there.
I think of TS Eliot's in Four Quartets that only through time can we accept  our past and future.
"Time past and time future
Allow but a little consciousness.
To be conscious is not to be in time
But only in time can the moment in the rose-garden,
The moment in the arbour where the rain beat,
The moment in the draughty church at smokefall
Be remembered; involved with past and future.
Only through time time is conquered." - T.S. Eliot

In remembering, we might see again our life and our ability to make good decisions, to cope with pressure, to discover through altruistic endeavor our own worth.  We recognize that bereavement is not depression, that the grieving process is its own truth.  When one finds a way to participate in action beyond themselves, or finds that  spiritual root that gives hope or breathes life into a newly found faith, or enters into productive work, the elements of self-healing are flowing.  What no one can do for the individual, the individual can do for themselves.

Kubler-Ross, Rodebaugh, Stroebe and Schut (1999) discuss many stages of grief. Understanding these stages help us to accompany others wisely. However, the stages of grief are even more complicated for immigrants whose grief processes may be interrupted by an inability to return to their country of origin to mourn with their family due to poverty, travel documents, or the political situation. Furthermore, stages of grief many not always be linear for immigrants who often experience ambiguous losses related to family separation, deportation, or loss of identity and sense of self in  addition to more traditionally-understood losses related to death of loved ones.  Grief processes for immigrants are also complicated as immigrants and refugees attempting to create a new life in America continue to experience the death of multiple loved ones due to ongoing war and violent crime, or deadly migration journeys.  Even as I write this, bombs are dropping and famine increasing, creating shock-waves of grief that impact new Americans   whose countries of origin are affected. Thus, it stands to reason that we should be doing justice work to help reduce the violence of the world while we walk patiently, accompanying those journeying toward integrating loss within a new-found life. 

Immigrant integration is too often perceived as some political reality. At the core of immigrant integration are individuals who are coping and hoping while  new identities in a new land emerge. A serious loss after migrating can throw the process into reverse; however, the caring community sustains hope, creating the possibility of once again beginning to find a life defined not by grief but by surprising spring awakening.
For practitioners, knowing that we do not have answers or the power to take away the grief, we find the privilege in seeing what is yet to be and welcome the wounded, the tempest tossed, into a place of possibility.
  
Image Source: Marti, F. (2017).

Westy Egmont, Director
BCSSW, Immigrant Integration Lab

Marti, F. (2017). También caerá,  this too shall fall. JustSeeds. Retrieved from: http://justseeds.org/product/this-too-shall-fall-tambien-caera/

Mollica, R.F. (2017). Healing invisible wounds: Helping our patients find hope and recovery in a violent world.  Refugee Services National Partnership for Community Training. Retrieved from: http://gulfcoastjewishfamilyandcommunityservices.org 

Stroebe, M. & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description.  Death Study, 23(3), 197-224.

Agency AGENCY FOCUS

Wediko Children's Services, based in Boston, New Hampshire, and New York, provides children and families with the necessary resources and treatments to reinforce supportive home and social environments. Wediko currently provides a wide range of behavioral and mental health services for children and families with the desire to increase safety, strength, and resiliency. Many of the children served by Wediko encounter a variety of repeated obstacles in their young lives, including depression, anxiety, trauma, and loss. These struggles often result in children developing difficulties in school, relationships, and within families. Wediko's  Living with Loss  school based support group  constructs age-based support groups for children, teens, and family members who have experienced loss from a variety of circumstances, including death, incarceration, foster care, trauma, and abandonment. Due to its age-based nature, Living with Loss creates a sense of community, trust, and connection, for individuals to explore their experiences, and work on developing coping skills within the context of a support group. The group also focuses on the concept of ambiguous loss, described by Wediko as, "someone who is physically present but psychologically absent, or someone who is psychologically present but physically absent" (Wediko, 2017). Due to the complex nature of trauma and loss experienced by immigrant and refugee children, Living with Loss provides a space for individuals to work through the experiences of both ambiguous and traditional loss, and to validate this loss as real, and important.
 
Based in Tucson, Arizona,  is a nonprofit family advocacy center with a mission to end migrant death and suffering on the U.S.-Mexico border. The Colibrí Center combines forces with families, forensic scientists, and humanitarians to approach the border crisis through a human rights perspective, with the goal of preventing future deaths and suffering. Colibrí focuses its efforts through three main programs, The Missing Migrant Project, aimed at bridging the data gap which exists between the families and the medical examiners of those missing; the DNA Program, which assists families in the identification of those individuals who remain unidentified after passing while crossing the border; and the  Red de Familiares (Family Network) , which provides a space for connection and support for the relatives of individuals who have died or gone missing while risking everything to cross the U.S.-Mexico border. Colibrí also supports  Historias y Recuerdos,  a project aimed at sharing stories of loved ones lost on the U.S.-Mexico border in order to give families the space and opportunity to remember, reflect, and honor their loved ones.
 
The Refugee Trauma and Resilience Center (RTRC) at Boston Children's Hospital is committed to understanding the healthy adjustment of refugee children and adolescents settling into the United States. RTRC is in partnership with other local refugee communities and agencies working together to provide prevention and intervention programs, as well as conduct research and develop adequate resources for refugee families and the agencies serving them. RTRC incorporates  Prevention and Intervention methods into its practice, including Trauma Systems Therapy, and Trauma Systems Therapy adapted for Refugees (TST-R). Additionally, RTRC focuses on delivering research to the larger community, including the  Somali Youth Risk and Resilience Project, and  Intervention Research regarding TST-R. As a model program for other agencies providing support to refugee families, RTRC also provides accessible resources for  Training and Resource Development. This development includes the  Refugee Services Toolkit (TST), wherein providers can understand the intersectional experiences of refugee children and families, and learn how to connect them with adequate interventions and resources.
 
The National Child Traumatic Stress Network  (NCTSN) was established in order to increase access to care, treatment, and services for children who have experienced trauma. The NCTSN aims to improve the accessibility to services for traumatized children through raising public awareness regarding the range of impact of child traumatic stress, advancing the range of effective interventions provided by agencies, and fostering a community dedicated to increasing collaboration between providers and the NCTSN. The NCTSN was established in 2000 by the U.S. Congress, as a section of the Children's Health Act, and has since grown to form a network of 150+ centers affiliated with the NCTSN located across the nation.  The NCTSN includes research and resources for many different types of trauma, including Complex, Domestic, Early Childhood, Medical, and Refugee. The NCTSN provides an in depth guide for  Refugee Trauma , with informational resources, clarifications for care providers, refugee rights, and tools & training.

Current CURRENT RESEARCH 
McLellan, J. (2014). 
Journal of Loss and Trauma 20(2), pp. 131-138.
Resettled refugees have experienced multiple losses, which may include loss of culture, skills, knowledge, beliefs, languages, life goals, status, social roles, finances, homes, property, dignity, self-esteem, and hope. Refugees have also often experienced traumatic events, family and social devastation, powerlessness, and other hardships. These experiences can lead to longer bereavement and complicated grief. Complicated grief has been recognized as a depressive and adjustment disorder with intrusive symptoms, social isolation, and failure to adapt. The complex problems brought on by prolonged bereavement, complicated grief, and multiple losses have serious ramifications for refugees' adaptive capabilities upon resettlement. Western psychological treatments of prolonged and complicated grief and bereavement can be enhanced by religious beliefs and practices and communal engagement. This is particularly significant given that most refugees currently come from non-Western backgrounds and hold a variety of religious beliefs. A case example of Cambodian refugees in Canada reveals how Buddhist practices helped many deal with traumatic events, multiple losses, and complicated grief.
Bravo, V. (2017).
Mortality22(1), pp. 33-44.
Undocumented immigrants living abroad experience grief differently when family members or loved ones pass away in their countries of origin. Many undocumented immigrants choose not to leave their host country because of uncertainties about being able to return, particularly if they have built families of their own in the United States and do not want to risk never seeing them again. The advancement of technology has created applications such as Skype and Whatsapp which have allowed undocumented immigrants to virtually participate in funerals and communicate with loved ones who are aging, sick, or in hospice care. Findings from the study show that when these events occur, communication intensifies among undocumented immigrants and their family members as a way of providing comfort and managing emotions. Although many may still experience guilt and sadness for not being with a loved one physically during an emotional event, many find solace and support knowing that digital mediums have made it easier to communicate with family members.
Ambiguous loss experienced by transnational Mexican immigrant families.
Solheim, C., Zaid, S., & Ballard, J. (2016). 
Family Frocess, 55(2), pp. 338-353.
When immigrants leave their countries of origin, they experience a sense of ambiguous loss related to family, culture, and language. Similarly, family members back in their countries of origin experience a parallel loss due to immigration. An ambiguous loss framework defines ambiguous loss as resulting from instances where a family member is either physically absent, such as working abroad, but is psychologically present or instances where a family member is physically present but psychologically absent, dealing with depression or trauma.  This study examines the experiences of immigrant workers from Mexico living in Minnesota and their family members back home. Findings show that uncertainties surrounding a family member's return can deter people from making necessary adjustments, creating boundary ambiguities in determining who will take responsibilities for certain roles. Family members in countries of origin cope and find support through communicating with one another, daily family visits and gatherings, and in particular instances, silence. Immigrants working in the U.S. find support through extended family members in the U.S., co-workers, community members, and the church.

Dombo, E.A. & Ahearn, F.L. (2017).
Illness, Crisis, & Loss, 25(2), pp. 107-126.
Natural and man-made disasters are traumatic events that displace individuals, families, and communities. Trauma, which is subjective, is associated with displacement as well as flight, persecution, oppression, torture, and war. Loss is related to both loss of life such as of family members, as well as loss of property, purpose, and identity, and is deeply intertwined with grief and the bereavement process. Separation is a form of displacement and can result in multiple negative emotional outcomes, and stress caused by displacement is also associated with a variety of physical and emotional symptoms. These variables of loss, separation, and stress interact with one another; however, their negative physical and psychological effects can be mediated through social supports and coping behaviors, which includes acknowledging and assessing the individual's inherent strengths and resiliency. The authors' explanatory model shows the effects of trauma, loss, stress, and separation on behavioral outcomes and helps to inform the choice of intervention. Given the extensive needs of displaced individuals, interventions must involve both clinical and community strategies. A case example of Cuban refugees in the U.S. is given to illustrate the use of a multilevel public health prevention model.

ReviewsREVIEWS
 
Detained and deported: Stories of immigrant families under fire. 
By Regan, M. 
Beacon Press (2015)
This journalist's account of several undocumented immigrant families on both sides of the U.S.-Mexico border poignantly illustrates the grief and loss that families experience when detention and deportation processes push them apart. As parents, children, and spouses are separated, often forcibly, all involved must learn how to cope with the physical absence yet emotional presence of their loved ones. Both the family members left behind and those who are removed by the state's immigration enforcement apparatus must grapple with the emotional upheaval of ambiguous loss. In this volume, Reagan shares numerous stories of the immigrant families who are attempting to do just that.

Death and the migrant: Bodies, borders, and care. 
By Gunaratnam, Y.
Bloomsbury (2013)
A sociological investigation relying on oral history and ethnographic observations, this volume explores the transnational experience of death and loss. The author carefully collects testimony from immigrants and migrants in the United Kingdom regarding their experiences with both care taking and dying. Particular attention is paid to the external social, economic, and cultural factors that influence the individual's experience of the "migrant deathbed." By providing a fresh understanding of the ways in which national borders affect the end-of-life process, Gunaratnam offers an addition to the scholarship on migrants' unique experiences of grief and loss.

Ambiguous  loss: Learning to live with unresolved grief. 
By Boss, P. 
Harvard University Press (2000)
Loss and grief are not always simple or straightforward experiences. Unlike death, which marks both the end of a human life and the relationship between two individuals, the grief resulting from ambiguous loss can be difficult to resolve. In this work, Boss draws on clinical work and research knowledge to examine multiple examples of unresolved loss, including physical separation due to borders and migration. In addition to providing the narrative experiences of those who have experienced ambiguous loss due to immigration, this volume also provides a discussion of coping strategies and guidance on how to mourn and celebrate for those who are suffering from the pain of unresolved grief.
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RESOURCES
  
Gulf Coast Jewish Family and Community Services (2017)
This webinar is the third in a series on suicidality in refugee populations. This webinar helps to identify symptoms of grief as well as coping mechanisms in certain refugee communities and discusses effective approaches for education of groups and communities. 

Case Study: Loss and Healing
Gulf Coast Jewish Family and Community Services (2017)
An accompaniment to JFCS's webinar on grief, this clinical case study and perspective identifies specific, effective modalities to facilitate healing from grief and loss.

Community Impact: Effective Messaging and Trauma Informed Care Approaches
ACEs Connection (2017)
This webinar focuses on trauma informed practices as well as relevant topics in refugee mental health.

Training: Helping Patients Find Hope and Recovery: A Guide to Self-Healing
Gulf Coast Jewish Family and Community Services (2017)
A guide to self-healing in refugee communities created by Dr. Richard Mollica, Director of Harvard Program in Refugee Trauma.

Harvard Program in Refugee Trauma (2017)
A comic book set in Cambodia during the Khmer Rouge with characters who embark on a spiritual journey and examine what they have had to leave behind and endure.

Pulse Films (2014)
A documentary highlighting the stories of migrants who died attempting to cross the U.S.-Mexico border. The website for the documentary provides learning tools, resources, and curriculum material for those wishing to use the film educationally.
Follow Professor Egmont on  Twitter @wegmont
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EDITORS: E. Camacho (managing editor), F. Crutchfield-Stoker, W. Egmont, B. Schmid, E. Siskind, A. Spratley, M. Tepper, & D. Maglalang