Working With Refugees in the U.S.: Trauma-Informed and Structurally Competent Social Work Approaches

Jason Ostrander, Alysse Melville, S. Megan Berthold


Social workers, government, and non-governmental organizations in the United States have been inadequately prepared to address the impact of trauma faced by refugees fleeing persecution. Compounding their initial trauma experiences, refugees often undergo further traumatic migration experiences and challenges after resettlement that can have long-lasting effects on their health and mental health. Micro and macro social work practitioners must understand the impact of these experiences in order to promote policies, social work training, and clinical practice that further the health and well-being of refugees and society. Social workers are in a unique position to provide multi-dimensional, structurally competent care and advocacy for diverse refugee populations. The experiences of Cambodian refugees will be used to examine these issues. We will explore the benefits of an ecological perspective in guiding interventions that support refugees, and will apply the framework of structural competence to highlight multidimensional implications for social work with refugee populations.


Refugees; trauma; ecological perspective; structural competence

Full Text:



Agbényiga, D., & Huang, L. (2012). Gendered immigration: Implications and impact on social work education. Advances in Social Work, 13(2), 291-305.

Agrawal, P., & Venkatesh, A. (2016). Refugee resettlement patterns and state-level health care insurance access in the United States. American Journal of Public Health, 106(4), 662-663. doi:

Berthold, M. (2000). The effects of exposure to community violence on Khmer refugee adolescents. Journal of Traumatic Stress Studies, 12(3), 455-471. doi:

Berthold, M. (2015). Human rights-based approaches to clinical social work practice. New York: Springer.

Berthold, M., Kong, S., Mollica, R. F., Kuoch, T., Scully, M., & Franke, T. (2014). Comorbid mental and physical health and health access in Cambodian refugees in the US. Journal of Community Health, 39(6), 1045-1052. doi:

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.

Catolico, O. (2013). Seeking life balance: The perceptions of health of Cambodian women in resettlement. Journal of Transcultural Nursing, 24(3), 236-245. doi:

Council on Social Work Education [CSWE]. (2015). Educational Policy and Accreditation Standards for baccalaureate and master’s social work programs. Retrieved from

Dawson-Hahn, E., Pak-Gorstein, S., Hoopes, H., & Matheson, J. (2016). Comparison of the nutritional status of overseas refugee children with low-income children in Washington state. PLoS ONE, 11(1), 1-13. doi:

Dharod, J., Xin, H., Morrison, S., Young, A., & Nsonwu, M. (2013). Lifestyle and food-related challenges refugee groups face upon resettlement: Do we have to move beyond job and language training program? Journal of Hunger & Environmental Nutrition, 8(2), 187-199. doi:

George, M. (2012). Migration traumatic experience and refugee distress: Implications for social work practice. Clinical Social Work Journal, 40, 429-437. doi:

Grigg-Saito, D., Och, S., Liang, S., Toof, R., & Silka, L. (2008). Building on the strengths of a Cambodian refugee community through community-based outreach. Health Promotion Practice, 9(4), 415-425. doi:

Grigg-Saito, D., Toof, R., Silka, L., Liang, S., Sou, L., Najarian, L., Och, S. (2010). Long-term development of a “whole community” best practice model to address health disparities in the Cambodian refugee and immigrant community of Lowell, Massachusetts. American Journal of Public Health, 100(11), 2026-2029. doi:

Healy, L., & Wairire, G. (2014). Educating for the Global Agenda: Internationally relevant conceptual frameworks and knowledge for social work education. International Social Work, 57(3), 235-247. doi:

Hepworth, D., Rooney, R., Rooney, G., Strom-Gottfried, K., & Larsen, J. (2010). Direct social work practice: Theory and skills (8th ed.). Belmont, CA: Brooks/Cole.

Higson-Smith, C. (2015). Updating the estimate of refugees resettled in the United States who have suffered torture. St. Paul, MN: Center for Victims of Torture.

Hooberman, J., Rosenfeld, B., Lhewa, D., Rasmussen, A., & Keller, A. (2007). Classifying the torture experiences of refugees living in the United States. Journal of Interpersonal Violence, 22(1), 108-123. doi:

International Federation of Social Workers [IFSW]. (2012). Refugees. Retrieved from

Janmyr, M. (2014). Attributing wrongful conduct of implementing partners to UNHCR. Journal of International Humanitarian Legal Studies, 5, 42-69. doi:

Kiernan, B. (2008). The Pol Pot regime: Race, power, and genocide in Cambodia under the Khmer Rouge, 1975-79 (3rd ed.). New Haven, CT: Yale University Press.

Ku, L., & Matani, S. (2001). Left out: Immigrants’ access to health care and insurance. Health Affairs, 20(1), 1247-1256. doi:

Kula, S., & Paik, S. (2016). A historical analysis of Southeast Asian refugee communities: Post-war acculturation and education in the U.S. Journal of Southeast Asian American Education and Advancement, 11(1), 1-23. doi:

Lewis, D. (2010). Cambodian refugee families in the United States: “Bending the tree” to fit the environment. Journal of Intergenerational Relationships, 8(1), 5-20. doi:

Lu, J. (2016). Validating visibility and voice: A community-based participatory research study to address the health access of Cambodian Americans (Doctoral dissertation). Retrieved from Digital Commons@UConn.

Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. (2005). Mental health of Cambodian refugees two decades after resettlement in the United States. JAMA, 294(5), 571-579. doi:

Marshall, G. N., Schell, T. L., Wong, E. C., Berthold, S. M., Hambarsoomian, K., Elliott, M.N., & Gregg, E. W. (2016). Diabetes and cardiovascular disease risk in Cambodian refugees. Journal of Immigrant and Minority Health, 18(1), 110-117. doi:

Metzl, J., & Hansen, H. (2014.) Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126-133. doi:

Mollica, R., Brooks, R., Tor, S., Lopes-Cardozo, B., & Silove, D. (2014). The enduring mental health impact of mass violence: A community comparison study of Cambodian civilians living in Cambodia and Thailand. International Journal of Social Psychiatry, 60(1), 6-20. doi:

Mollica, R., Cui, X., McInnes, K., & Massagli, M. (2002). Science-based policy for psychosocial interventions in refugee camps: A Cambodian example. The Journal of Nervous and Mental Disease, 190(3), 158-166. doi:

Mollica, R., Donelan, K., Tor, S., Lavelle, J., Elias, C., Frankel, M., & Blendon, R. (1993). The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. Journal of the American Medical Association, 270(5), 581-586. doi:

Morantz, G., Rousseau, C., Banerji, A., Martin, C., & Heymann, J. (2013). Resettlement challenges faced by refugee claimant families in Montreal: Lack of access to child care. Child & Family Social Work, 18, 318-328. doi:

National Association of Social Workers [NASW]. (2009). Code of ethics. Retrieved from

NASW. (2015). Immigration and refugees. In D. Wheeler & A. McClain (Eds.), Social work speaks: National Association of Social Workers policy statements, 2015-2017 (pp. 176-181). Washington, DC: NASW Press.

NASW. (2016). NASW Standards for Social Work Practice in Health Care Settings. Retrieved from

National Cambodian American Health Initiative [NCAHI]. (2007). Health emergency [Report]. West Hartford, CT: Author.

National Consortium of Torture Treatment Programs [NCTTP]. (2015). Descriptive, inferential, functional outcome data on 9,025 torture survivors over six years in the United States. Torture, 25, 34-60.

Office of Refugee Resettlement [ORR]. (2016). Refugees. Retrieved from

Peterman, J. N., Wilde, P., Silka, L., Bermudez, O., & Rogers, B. (2013). Food insecurity among Cambodian refugee women two decades post resettlement. Journal of Immigrant and Minority Health, 15(2), 372-380. doi:

Porter, M., & Haslam, N. (2005). Pre-displacement and post-displacement factors associated with mental health of refugees and internally displaced persons. JAMA, 294(5), 602-612. doi:

Rotabi, K. (2007). Ecological theory origin from natural to social science or vice versa? A brief conceptual history for social work. Advances in Social Work, 8(1), 113-129.

Shannon, P., Im, H., Becher, E., Simmelink, J., Wieling, E., & O’Fallon, A. (2012). Screening for war trauma, torture, and mental health symptoms among newly arrived refugees: A national survey of U.S. refugee health coordinators. Journal of Immigrant & Refugee Studies, 10, 380-394. doi:

Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA, 302(5), 537-549. doi:

Substance Abuse and Mental Health Services Administration [SAMHSA]. (2014). Trauma-informed care in behavioral health services: A treatment protocol (TIP), Series 57. HHS Publication No. (SMA) 14–4816. Rockville, MD: SAMHSA

Tasker, R. (1993). Empty dreams: Thais about to close last Cambodian refugee camp. Far Eastern Economic Review, 156(13), 22.

Torture Victims Relief Act (TVRA) of 1998, 22 U.S.C. §§ 1-7 (2016).

United Nations Committee on Economic, Social and Cultural Rights [UNCESCR]. (2000, August). General comment number 14: The right to the highest attainable standard of health (Art. 12 of the Covenant). Retrieved from

United Nations General Assembly. (1951, July). Convention relating to the status of refugees. Retrieved from

United Nations High Commissioner for Refugees [UNHCR]. (2016). Figures at a glance. Retrieved from

United States Census Bureau (USCB). (201. Selected population profile in the United States (SQ201): Cambodian alone or in any combination (405-409) or 300, A01-Z99) or (400-999) (2014). Retrieved from

Wagner, J., Berthold, S. M., Buckley, T. E., Kuoch, T., & Scully, M. (2015). Diabetes among refugee populations: What newly arriving refugees can learn from resettled Cambodian Americans. Current Diabetes Reports, 15(8), 56. Advance online publication. doi:

Willard, C., Rabin, M., & Lawless, M. (2014). The prevalence of torture and associated symptoms in United States Iraqi refugees. Journal of Immigrant and Minority Health, 16(6), 1069-1076. doi:

Wong, E., Marshall, G., Schell, T., Elliott, M., Babey, S., & Hambarsoomian, K. (2011). The unusually poor physical health status of Cambodian refugees two decades after resettlement. Journal of Immigrant and Minority Health, 13(5), 876-882. doi:

Yoshida, H., Henkin, N., & Lehrman, P. (2013). Strengthening intergenerational bonds in immigrant and refugee communities. Philadelphia, PA: The Intergenerational Center at Temple University. Retrieved from


Copyright (c) 2017 Jason Ostrander


Indiana University School of Social Work
902 West New York Street
Indianapolis, Indiana, USA, 46202
Voice: 317.274.6705
FAX: 317.274.8630
TDD/TTY: 317.278-2050