Clinical Reflection · Trauma & Migration
Beyond the Border
The Mental Health Impact of Forced Migration and What Clinicians Need to Hold in Mind
Forced migration is rarely a single event. For the refugees and newcomers we sit with in our therapy rooms, it is a long arc that begins long before the journey and continues long after resettlement papers are stamped. As clinicians, we are often introduced to people at the most disorienting point of that arc — when home is gone, the future is uncertain, and the very systems meant to help can feel like one more place where they must prove themselves worthy of safety.
Working well with this population requires more than competence in trauma. It requires us to expand our frame of reference, to interrogate our default assumptions about distress and healing, and to remain humble about what we do not — and cannot — know about another person’s world.
Understanding the Mental Health Burden
The mental health literature consistently shows that refugee and newcomer populations carry a disproportionate burden of psychological distress. Rates of post-traumatic stress disorder, depression, anxiety, and complicated grief are significantly elevated compared to the general population, and these difficulties often persist for years after arrival in a host country. Children and youth, older adults, women who have experienced gender-based violence, and people with intersecting marginalized identities are particularly vulnerable.
But naming diagnostic categories only takes us so far. The distress carried by people who have been forcibly displaced is often cumulative: pre-migration exposure to war, persecution, or political violence; the dangers and losses of the migration journey itself; and the chronic stressors of the post-migration environment. Researchers sometimes describe this as a “triple burden,” and each layer leaves its own imprint on the nervous system, the family system, and the sense of self.
For many clients, their symptoms are not signs of pathology but coherent responses to incoherent circumstances. Hypervigilance after fleeing a war zone is not disordered — it is adaptive. Numbness after losing a community is not avoidance — it is preservation.
Our clinical task is to honour those responses while gently helping the nervous system learn that the present is not the past.
Special Considerations for Clinical Practice
Cultural humility and the limits of our frameworks
Most of the assessment tools, diagnostic categories, and therapeutic models we trained in were developed within a Western, individualist, English-speaking context. They are not neutral. When a Somali grandmother describes her grief as a heaviness in her chest that her ancestors are trying to lift, we are not encountering a metaphor for depression — we are encountering her actual cosmology of suffering and healing. If we translate it too quickly into our diagnostic shorthand, we lose the very thing she came to share.
Cultural humility, as distinct from cultural competence, asks us to remain a learner in every encounter. It means asking how distress is named in a client’s first language, what role family and community play in healing, what their relationship is to spirituality or faith, and what they believe caused their suffering. It also means being willing to be corrected, to not understand, and to work alongside cultural brokers, elders, or community leaders when appropriate.
Working with language and interpreters
Language is not just a vehicle for content — it is where meaning lives. When we work through an interpreter, we are not simply translating words; we are inviting a third person into an intimate space. This requires preparation. Brief the interpreter beforehand on the nature of trauma work, agree on first-person interpretation, allow extra time, and check in with both the client and the interpreter after sessions, particularly when content is heavy. Whenever possible, work with trained mental health interpreters rather than family members, and be alert to the dynamics of gender, ethnicity, religion, and political affiliation that can make a particular interpreter feel unsafe to a particular client.
Even with skilled interpretation, some experiences will not translate. We need to be comfortable with that gap.
Trauma-informed care for collective and ongoing trauma
Much of our trauma training centres on discrete, time-limited events. Refugee trauma is often the opposite: prolonged, collective, and inseparable from loss of home, identity, social role, and community. Complex PTSD, traumatic grief, and moral injury are common presentations. Stabilization — sleep, safety, predictable routines, support for basic needs — typically must come well before any trauma processing. For some clients, particularly those still navigating immigration uncertainty, processing may not be appropriate at all in the current phase. Pacing is everything.
Trauma-informed practice also means recognizing that the therapy room itself can be triggering. Closed doors, authority figures asking probing questions, paperwork, mandatory disclosures — these can echo experiences of interrogation or institutional harm. Transparency, choice, and collaboration are not soft skills here; they are clinical necessities.
Holding the systemic and structural picture
Even the most attuned therapy cannot, on its own, undo the effects of housing precarity, family separation, racism, employment barriers, or a hostile immigration system. Post-migration stressors are robust predictors of mental health outcomes — sometimes more so than pre-migration trauma. As clinicians, this calls us to hold a wider lens. We are part of a network of supports that includes settlement workers, legal advocates, language instructors, faith communities, and primary care. Knowing those resources, making warm referrals, and advocating where appropriate is part of the work, not a distraction from it.
It also means being honest with ourselves about the systems we are part of. Mental health care in Canada, despite its strengths, is still difficult to access for many newcomers — through cost, language, wait times, or cultural mismatch. Naming those barriers with our clients, rather than pretending they do not exist, can itself be reparative.
Centring resilience without minimizing pain
Refugees are often spoken about as though they are defined by what has been done to them. They are not. The clients who walk into our rooms have already done something most of us have never had to do — they have survived, adapted, rebuilt, and very often, carried others with them. Strengths-based practice is not toxic positivity; it is the simple clinical truth that the same person carrying terrible memories is also carrying immense capacity. Asking about what has helped them survive, who they have leaned on, what they have rebuilt, and what they hope for is as clinically important as asking about symptoms. Post-traumatic growth is real, and it lives alongside, not instead of, ongoing pain.
A Note on the Clinician
Holding this work changes us. Vicarious trauma, moral distress, and burnout are real risks, particularly when we are aware that the systemic conditions causing our clients’ suffering will outlast any treatment plan we offer. Supervision, peer consultation, and our own embodied practices of rest are not luxuries — they are the conditions under which we can keep showing up with presence rather than depletion.
At ICA Counselling and Supervision, we believe that working with refugees and newcomers is some of the most meaningful, humbling, and transformative work a clinician can do. It asks us to be fully present, intellectually honest, culturally curious, and politically aware. Most of all, it asks us to remember that the people in front of us are not their stories of suffering. They are the authors still writing what comes next, and our role is to bear witness, walk alongside, and trust the deep human capacity for repair.
Ilda Caeiro-Azzam
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