Occupational Therapy for Burmese Refugees
According to the World Federation of Occupational Therapists (WFOT), “all persons, including displaced people, by virtue of being human, have the right to occupational opportunities necessary to meet human needs, access human rights, and maintain health” (2014, p. 1). Forced migration is disruptive to the identity, health, roles, and opportunities of individuals and communities who experience displacement. The scope of occupational therapy and its emphasis on health and wellbeing make occupational therapy practitioners well suited to meet the needs of refugee populations and enable participation in valued occupations (Huot, Kelly, & Park, 2014; Trimboli & Taylor, 2016). However, despite identifying the role of occupational therapy in working with displaced people, there are limited resources for and about occupational therapists working in this emerging area of practice.
This blog post aims to share my experience as an occupational therapist working at an outpatient mental health clinic in Minnesota with Karen (pronounced Kah-ren) and Karenni refugees from Burma and shed light on the supports and barriers to daily occupations faced by recently resettled refugees.
Background
Burma, also known as Myanmar, is a country located in Southeast Asia that borders Thailand to the southeast. It is populated by numerous ethnic minorities, each with their own culture, language, and history including the Rohingya, Chin, Kachin, Mon, Karen, and Karenni to name a few. Burma has a long and complicated history, one that cannot be adequately summarized in a single blog post. However, understanding the historical contexts, even an oversimplified version like this one, is essential in order to understand the occupational experience of refugees from Burma.
In essence, efforts by ethnic minorities to form an independent state have been met with repressive rule and violence. In 1989, the military coup that seized power changed the country’s name from Burma to Myanmar. However, many activists, organizations, and nations continue to refer to it as Burma as a small act of protest and a refusal to give legitimacy to the military regime whose history is stained by human rights violations and ethnic cleansing operations spanning decades. Displacement of ethnic minorities, burning of villages, forced labor, and extrajudicial killings, along with a long-standing civil war have existed since Burma gained its independence from British rule in 1948. As a result, ethnic minorities have been driven out of their homes where many reside in refugee camps across Burma’s borders in places like Thailand and Bangladesh. Beginning in the mid-2000’s refugees from Burma became eligible for resettlement in the United States with a large concentration of Karen refugees settling in Minnesota (Harkins, 2012).
While refugee camps are designed to meet the immediate and emergent needs of displaced people, they are not suitable for permanent or long-term residence. However, the average length of time Karen refugees spend in these camps is 14 years (Fuertes, 2010). One group of Karen refugees in Mae La Camp in Thailand developed the following metaphor, a powerful illustration of the occupational deprivation, disempowerment, and loss of identify associated with life in a refugee camp.
“Karen refugees are birds inside a cage that get fed on a regular basis but are not able to fly. When the owner comes and opens the cage and lets them go, chances are that most of the birds cannot fly anymore because they did not have the opportunity to learn or practice how to fly for a very long time now. Many do not even know what it means to fly” .
(Fuertes, 2010, p. 20).
Current Events
In the last decade, Burma had made small steps towards democracy. However, in recent weeks, Burma has made headlines for the detainment of elected officials and the reinstatement of military rule. Peaceful citizen protests have been met with violence and the military regime has limited internet and phone access and imposed restrictions and curfews to limit gatherings. The international community has viewed these events as a step backwards in Burma’s progress towards democracy. Members of the Karen and Karenni refugee community that I interact with have been greatly impacted by these recent events, reporting exacerbated PTSD symptoms as they witness events similar to what they had experienced.
Trauma and Mental Health
The trauma histories of Karen and Karenni refugees are unfathomable. Many clients I work with present with amputations, blindness, hearing loss, and joint deformities – stark physical signs of the trauma they have endured. These physical barriers are compounded by challenges to daily life including inaccessibility of healthcare, lack of transportation, food insecurity, and unaddressed chronic health conditions and mental health symptoms.
One study of resettled Karen refugees found that 27.4% experienced primary torture, 51.4% experienced secondary torture, and 86% experienced war trauma (Shannon, Vinson, Wieling, Cook, & Letts, 2014). Refugees experience higher rates of mental health diagnoses than the general population and have less access to mental health treatment (Bernardi, Dahiya & Jobson, 2019). Further challenges to addressing the mental health needs of refugees is the stigma and lack of knowledge surrounding mental health within the refugee community. Terms that we’re familiar with like “anxiety”, “PTSD” and “depression” aren’t easily translated and don’t exist in the Karen and Karenni languages.
Considerations for Occupational Therapy
The goal of occupational therapy is to address the functional impact and barriers to everyday life caused by mental health or physical health symptoms. While the following considerations are important for all occupational therapy practice, they are particularly relevant when working with a refugee population who face unique barriers to daily life.
Facilitate culturally responsive interventions. Many of the clients I work with used to be farmers or have experience weaving clothing or baskets. By incorporating activities related to these occupations into OT interventions, we not only ensure that interventions are occupation-based but can also work to restore lost occupations that are meaningful to our clients.
Utilize principles of trauma-informed care. Some of our clients openly share their trauma histories without requiring prompting while others remain guarded. As occupational therapy practitioners, our role isn’t to process past trauma but to find strategies to overcome the functional limitations that exist as a result of their experiences and current health condition. For clients who don’t openly share their trauma histories, it is important to not press for details. We can look at the historical context and what has been reported in the literature and assume that our clients may have experienced primary or secondary torture and war trauma and can work to maintain an environment in which clients feel safe. A specific example of using trauma-informed care is that we avoid pointing infrared thermometers at our client’s foreheads as some models of infrared thermometers bear resemblance to a weapon. Instead, we always check temperatures on the medial wrist.
Work towards social justice. It is impossible to provide services without addressing the social justice concerns and inequities that exist for marginalized communities. Many of our client’s experience food insecurity, lack basic necessities and have insufficient finances to meet their needs. In response to these challenges, we have taken on additional responsibilities beyond our scope as occupational therapists in order to connect our clients with the resources they need. In a broader context, it is also essential to use our voice to speak up and engage in advocacy efforts at the local, state, and national level in an effort to build more equitable systems.
Prioritize empowerment. It is important to facilitate an empowering and supportive environment in which clients can make choices and advocate for themselves. Therefore, occupational therapy interventions should work to disrupt the cycle of disempowerment and facilitate development of positive self-identity and adaptive habits and routines. One way to facilitate empowerment is by incorporating simple choice making and promoting a collaborative therapeutic relationship.
I consider myself so lucky to be able to spend my days working with Karen and Karenni refugees – they are resilient and kind. They fill my days with joy and make my community brighter. They call my colleagues and I “theramu”, which means teacher, a title held in the highest regard. But what they don’t realize is that they’ve taught me far more than I ever could teach them.
-Jenny Fried, OTD, OTR/L
References
Bernardi, J., Dahiya, M., & Jobson, L. (2019). Culturally modified cognitive processing therapy for Karen refugees with posttraumatic stress disorder: A pilot study. Clinical Psychology & Psychotherapy, 26(5), 531-539. doi:10.1002/cpp.2373
Fuertes, A. (2010). Birds inside cages: A metaphor for Karen refugees. Social Alternatives, 29(1), 20-24.
Huot, S., Kelly, E., & Park, S. J. (2016). Occupational experiences of forced migrants: A scoping review. Australian Occupational Therapy Journal, 63(3), 186-205. doi:10.111/1440-1630.12261
Trimboli, C. & Taylor, J. (2016). Addressing the occupational needs of refugees and asylum seekers. Australian Occupational Therapy Journal, 63(6), 434-437. doi:10.1111/1440-1630.12349World Federation of Occupational Therapists (WFOT). (2014). Position Paper on Human Displacement. Retrieved from: http://www.wfot.org/ResourceCentre.aspx
About the Author
Jenny is an occupational therapist at an outpatient occupational therapy clinic in St. Paul, Minnesota that specializes in addressing mental health and other chronic conditions. She is a recent graduate from the University of South Dakota.
For correspondence: jenny@prcmn.com
