Addressing the Mental Health Needs of Deaf Refugees: A Comprehensive Literature Review ()
1. Introduction
Operational Definition of Deaf Refugee:
For this review, “deaf refugee” refers to an individual who has fled their home country due to conflict, persecution, or environmental crisis and is either deaf, hard of hearing, deafblind or deafdisabled. This includes pre-lingual (deafened before language acquisition) and post-lingual (deafened after acquiring language) individuals, as well as those who use sign language as their primary means of communication. The definition delimits the scope to those for whom sign language and deaf culture significantly influence mental health and service accessibility.
The refugee crisis has been one of the world’s challenges, especially with the influence of global climate change, conflicts, and overhauling of immigration laws. This has seen an upsurge in refugee and migration status worldwide, and more so in the United States of America (USA). In particular, the state of refugees’ mental health has emerged as one of the issues of concern because they frequently have post-traumatic stress disorder; moreover, refugees remain vulnerable to such structural and cultural racism. In the deaf community, there has been an increase in the number of deaf refugees and immigrant populations in the USA. However, there is still scarce information on some of the particularities concerning their mental health and the kind of traumas, worries, and other problems they come across.
It is essential to focus on the group of deaf refugees as they have extra issues that affect the general situation, which is already very hard for all refugees. Deaf refugees face challenges such as communication issues, restricted access to information and materials, and language, as well as cultural differences. These challenges can significantly affect the mental health status and the utilization of mental health care services that these individuals need. There seems to be a lack of research and appreciation for the need to address the mental health of deaf refugees despite the understanding of the fact that refugees require support in this aspect. Collaboration with mental health care support and deaf community support is crucial to delivering the necessary and adequate services for this population. However, research in this area is still lacking, and even studies on the psychological well-being of deaf refugees are scarce.
Thus, the present literature review aims to identify, compare, and discuss the current conceptualizations of refugees’ mental health care in the USA and the mental health care needs of deaf refugees in particular. Specifically, based on the types of studies conducted on the mental health of refugees, this paper will be able to assess whether specific research on the need for mental health support for deaf refugees would duly offer helpful information and meet a current research gap.
2. Theoretical Perspectives on Mental Health and Refugee Experiences
2.1. Ecological Systems Theory
The ecological systems theory developed by Bronfenbrenner (1979) is a theory that explains the relations of developmental and environmental processes that affect an individual. This theory is instrumental when discussing the mental health of refugees as it addresses the people’s psychological endowment, the role of the family and the community, as well as cultural and societal factors (Phillmore, 2010). These systems are subsumed in other systems; researchers and practitioners can obtain information regarding what impacts the refugees’ well-being. For the deaf refugees, this theory has given an insight and an understanding of their situations and their families’ body language, there being support from the deaf community and culture which was discovered, and also the attitude of the community towards deafness and disability (Kusters et al., 2017). Still, theorists like Roy (2018) are quite right to point out that since the ecological systems theory covers a broader perspective and context of human development, it does not necessarily shed enough light on how oppression in its various forms intertwines and accumulates.
2.2. Acculturative Stress Model
According to the acculturative stress model, Berry (2005) argues that acculturation is a direct cause of stress and, hence, can be a cause of mental health problems. This model may also help understand the refugees as their process of acculturation is quite complicated since they have to cope with language use, cultural and language barriers, and prejudice, according to Kuo (2014). Deaf refugees may, therefore, have a more difficult time acculturating since the individual has to adapt to the new cultural norms while assimilating into the hearing and speaking culture. The acculturative stress model helps consider the psychological and sociocultural stress that deaf refugees may experience and how this stress leads to mental health problems, including depression, anxiety, and identity crises. As Chirkov (2009) points out, the outlined model might underestimate the specific and ever-changing nature of acculturation processes and resilience factors.
2.3. Trauma-Informed Care
Trauma-informed care is imperative for providing mental health care for refugees because many of them have encountered trauma before, during, and after becoming refugees (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). This appreciates the pervasiveness of trauma in bodily, psychological, and relational aspects of existence and seeks to help those affected ensure physical, social, and psychological safety for survival and optimal functioning (Muskett, 2014). It is essential for deaf refugees; the mentioned group can go through different traumatic situations connected with a lack of information and isolation, which deaf people experience in the countries where they have to live. There is also literature that provides guidelines on trauma-informed care for deaf refugees in mental health services, including the principles of safety, trustworthiness, peer support, and cultural humility, and thus helps counsel deaf refugees (SAMHSA, 2014). Some scholars have, however, criticized trauma-informed care practice as exaggerating priority results by generalizing the experiences of individuals, which are diverse in occurrences, as pointed out by Becker-Blease (2017).
2.4. Intersectionality Theory
Intersectionality theory makes it easier to understand various problems of people with multiple cultural identities and lower status, for example, deaf refugees (Wickenden, 2023). This theory acknowledges that the dynamics of various social categories, such as race, ethnicity, gender, disability, and immigration, among others, forge people’s practical consciousness. Linguistic and cultural minorities, along with their refugee status, can intensify deaf refugees’ exclusion and present specific challenges to engaging them in mental health care services (Kusters et al., 2017). By embracing an intersectional lens, it becomes possible to understand the various overlapping needs and barriers that deaf refugees experience and effectively recommend the appropriate intervention strategies to support the deprived population. However, critics such as Nash (2008) have some valid points, asserting that intersectionality theory may essentialize and generalize the mosaic of individual experiences and fail to address the dynamic and contextual construction of identity.
2.5. Framework and Rationale
These four frameworks were chosen because they collectively illustrate how deaf refugees’ mental health is shaped by individual, social, and structural dynamics. Ecological Systems Theory situates the refugee within nested social contexts; the Acculturative Stress Model highlights adaptation challenges; Trauma-Informed Care emphasizes safety and recovery; and Intersectionality reveals how overlapping identities intensify vulnerability. Together, they guide a multidimensional analysis of deaf refugee experiences.
3. Mental Health Challenges Faced by Refugees
3.1. Prevalence of Mental Health Issues among Refugees
Thus, refugees are vulnerable to various mental health concerns resulting from traumatic experiences and numerous difficulties that refugees can face during and after the process of resettlement (Turrini et al., 2019). Among all the psychological disorders, refugees are commonly diagnosed with Post-Traumatic Stress Disorder (PTSD). PTSD is an anxiety disorder that may be diagnosed in a person who has been through traumatic events such as rape, war, or being detained, which are not rare occurrences in refugees (Nickerson et al., 2011). It was found that PTSD prevalence rates among refugees varied significantly from 9% to 83% depending on factors, including the studied refugee group, the assessment tools, and the time since refugee arrival in the host country (Tinghög et al., 2017). Although comparison across studies is complicated by significant variability in prevalence rates, the existing studies indicate that PTSD should be regarded as a substantial problem for refugees.
Besides PTSD, refugees also have a higher prevalence of depression and anxiety disorders than the general population (Tinghög et al., 2017). The refugees suffer from depression and anxiety based on factors such as traumatic past events, bereavement, loss of social support structures, and migration challenges within a new and different culture and language (Bustamante et al., 2017). It was revealed that 20% - 40% of refugees experience depression and anxiety (Bogic et al., 2015). These mental health issues can, therefore, significantly affect the refugee’s quality of life, activity level, and adjustment to the new world. Even though PTSD, depression, and anxiety are among the most prevalent mental health issues researched among refugees, refugees can also be experiencing other mental health issues, including adjustment disorders, somatization disorders, and substance dependence. Common psychological disorders presented by refugees are, therefore, not superficial or a single-event phenomenon but complex, which mirrors the social determinants of their experiences both before, during, and post-forced migration.
However, it is essential to highlight that the figures available in the literature may not accurately reflect the actual degree of mental health dilemmas among refugees since there are various constraints to accessing and utilizing mental health services, such as cultural prejudices, lack of interpreter services, and scarcity of appropriate cultural comprehensiveness (Colucci et al., 2015). In addition, some authors have labelled the Western bias of diagnostic classification and measurement instruments applied in studies, claiming that they may fail to recognize the cultural manifestation and experience of mental health and illness (Thakker & Ward, 1998). This paper focuses on the prevalent mental health issues among refugees and supports the necessity for extensive and culturally appropriate mental health care and treatment. In the future, more attention should be paid to the mentioned shortcomings and constraints, including the lack of information about specific segments of refugees with physical and mental impairments and the need for the utilization of more diverse, intersectional approaches to the investigation of the mental health needs of refugees.
3.2. Risk Factors and Vulnerabilities
The refugees are mostly exposed to numerous risk factors and are vulnerable to the development or worsening of mental health problems. These risk factors can be categorized into three main phases: According to Kirmayer et al. (2011), people experience three phases of migratory stress, namely the pre-migratory phase, the migratory phase, and the post-migratory phase. Family disruption, war trauma, poverty, and malnutrition before migration are some factors that affect an individual’s psychological and socio-emotional well-being (Fazel et al., 2012). Refugees have been exposed to one form of trauma or another, including but not limited to torture, sexual assault, and viewing of horror, which in turn may lead to PTSD, depression, or other psychiatric illnesses. Additionally, prior mental health treatment needs or genetic predisposition to mental health disorders may be further worsened by forced displacement.
Refugees go through many stressors and challenges during their migration journey; during the trip, they may lose contact with their families, not get adequate and proper food, water, or shelter, or even face life-threatening situations (Bustamante et al., 2017). These experiences, in turn, can aggravate mental health or cause different disorders in a person. Furthermore, due to the randomness and the correlated lack of control over migration, there can be feelings of anger and anxiety (Kirmayer et al., 2011). In the post-migration period, several stressors related to migration have been labeled as stress, including acculturative stress, language barrier stress, xenophobic stress, and economic stress (Tinghög et al., 2017). A new culture can be challenging and provoke feelings of loneliness, blurred perceptions of self-identity, and psychological disorders (Colucci et al., 2015). Discrimination, Social exclusion, and inadequate access to resources may also aggravate an episode of mental illness and hinder integration (Khawaja & Hebbani, 2017).
However, it is essential to note that these risk factors and vulnerabilities perpetuate each other and, as a combination, are a set of intertwined challenges that affect refugees’ mental well-being and life satisfaction. Thus, specific populations of refugees, including women, children, and people with disabilities or those with chronic diseases, may experience new forms of exclusion or require adjusted approaches to mental health services (Papadopoulos, 2007). Although many studies have given detailed information on the risk factors and the various forms of vulnerability faced by refugees, some researchers have noted that the writings in this field have been narrowly focused on the problems. They call for positive change, focusing on refugees’ strengths, stressors, coping strategies, protective factors such as social support, cultural practices, and community engagement and involvement in enhancing their mental health and well-being.
Thus, it is essential to appreciate how risk factors and vulnerabilities interact within the context of the refugees’ pre-migration, during migration, and post-migration stages so that quality mental health care and support services can be provided to the refugee populace. By targeting these risk factors and enhancing protective factors, mental health workers and service providers could improve the mental health of refugees and, thus, strengthen their post-resettlement integration processes.
4. Mental Health Needs of Deaf Refugees
4.1. Unique Challenges Faced by Deaf Refugees
Deaf refugees are in a worse-off state than ordinary refugees because their challenges are worse than those of general refugees. Another challenge is a result of communication difficulties since deaf people rarely get a qualified sign language interpreter or service providers who can sign fluently (Kuenburg et al., 2015). This communication barrier is an issue that deaf refugees might face when it comes to explaining their needs, recounting their experiences, or understanding different information related to reintegration, immigration status, and the help to which they are entitled. There is another problem: a deaf person becomes a refugee, and there is little information and help they can get. The essential papers, such as the guidelines on resettlement, health, and legal documents, are rarely available in formats sensitive to deaf or hard-of-hearing clients. This can lead to powerlessness, victimization, and even anger among deaf refugees since they can feel left out of many decisions and are not well informed about their rights or the assistance that is available to them (Kusters et al., 2017).
Also, deaf refugees could experience more barriers towards culture and language since they may not search for people with the same language and culture. This can significantly impact their psychological and emotional well-being as social adjustment and cultural identification are significant sources of improvement among refugee groups (Puvimanasinghe et al., 2014). They also experience loneliness and isolation through being cut off from deaf-related services and support in refugee-hosting countries (Kusters et al., 2017). Despite these drawbacks, the literature has paid much attention to these challenges. In this regard, Bauman and Murray (2010) observed that there is a danger of concentrating on the disabilities of the Deaf people and what they cannot do rather than on what they can do. Some critics have pointed out that there should be a comprehension of other categories of people who are deaf or hard of hearing who live as refugees since it remains a very diverse group that should be considered from the standpoint of ethnicity, gender, and status (Kusters et al., 2017).
Hence, integrated and appropriate responses are needed to address the needs of deaf refugees and, in the process, recognize their language and cultural rights due to their perceived disability, language, and social isolation. Mitigating these challenges and raising awareness on the issues mentioned will go a long way toward enhancing access to and delivery of mental healthcare services for the refugees and, in general, improving their well-being and resettlement in their new host countries.
4.2. Intersection of Deafness and Refugee Experiences
Having both the identity of a deaf person and a refugee would mean coping with mental health issues twice as much. Deaf refugees have other types of exclusion and chaos because they are deaf and refugees, and these factors can worsen their conditions and increase the likelihood of having mental health disorders like depression, anxiety, and PTSD. Challenges such as communication barriers, cultural and linguistic isolation, and limited communication with the hearing community result in restricted access to information and resources that are crucial to overcoming the traumatic experiences that many deaf refugees go through during the refugee journey, as noted by Kusters et al. (2017).
In addition, combining deafness and refugee status complicates the process of obtaining and receiving adequate mental health treatment and intervention. Unfortunately, only a few mental health professionals are prepared to deal with people who are deaf or hard of hearing. Cohen noted that due to a lack of interpreters for sign language and culturally sensitive mental health services, deaf refugees cannot express their experiences, issues, or needs, which, in one way or another, limits their treatment. For instance, there was a suggestion that deaf refugees may experience some barriers when seeking mental health help since most services out there are shaped through the hearing lens. A lack of readily understandable information, misconceptions of deaf culture in connection with mental illnesses, and overall unfamiliarity with the distinct requirements of a deaf refugee may ultimately prevent particular individuals from seeking out help or utilizing the services provided (Minas et al., 2013).
The lack of received care for deaf refugees has been documented in the literature as being exacerbated by the intersection of deafness and refugee status, underscoring all the challenges faced by this population. The existing literature discusses how these populations are often constructed in a deficit framework, which has also been critiqued by Puvimanasinghe et al. (2014). Some have called for a better positivist and intersectional approach where deaf refugee resiliencies and coping mechanisms will be acknowledged, alongside the heterogeneity in their experience as deaf refugees (Puvimanasinghe et al., 2014). Hence, with the combined aspects of deafness and refugee concerns, there is a need to have researchers conduct more culturally sensitive and linguistically appropriate mental health services for the identified population. When the impact is cumulative on mental health and restrictive access to such a service is done away with, it will be possible for mental health professionals and service providers to enhance the well-being of deaf refugees as well as facilitate their integration into the new country.
4.3. Existing Literature on the Mental Health of Deaf Refugees
Unfortunately, while the importance of addressing the mental health needs of people who are deaf or hard of hearing and their refugee counterparts continues to gain attention in the literature, there is still comparatively very little research available to guide interventions. A particular gap that can be identified is a lack of research focusing on deaf refugees, especially in terms of their mental health. To the best of the author’s knowledge, there is a lack of empirical research in the literature on the trauma narratives of deaf refugees. However, there is one qualitative study by Elder (2023) that explored the trauma narratives of deaf refugees resettled in the United States. The author of the study revealed that deaf refugees experienced repeated trauma by being exposed to violence, displacement, and social isolation resulting from disability and refugee status. Furthermore, the study revealed that communication gaps, restricted information literacy, and cultural and linguistic marginalization were some of the stress factors that compounded such mental health issues as PTSD, anxiety, and depression among the refugees’ deaf community.
Another study by Emery and Iyer (2021) discussed how a deaf identity combined with language deprivation and trauma impacted deaf refugees and displaced people. The authors pointed out that the combination of these identities and stories affected mental state and psychological well-being and urged the need for both accessibility and ethnic sensitivity in responding to this group. These papers share essential information regarding deaf refugees and their psychological issues. Still, at the same time, they also reveal the need for related research and flaws in present research studies. However, there is a lack of research focusing on deaf refugees, and limited literature is one of the main challenges because the mental health of deaf refugees is an uncharted realm in the existing literature on refugee mental health (Kusters et al., 2017).
Moreover, the existing research itself is confined to examining a specific subset of deaf refugees or in a particular geographical area in the world. Thus, the results cannot be generalized to the other various disabled refugees worldwide or even cross-culturally. In addition, when using qualitative interviews and case study methodology to investigate mental health problems in the samples of deaf refugees, the issues identified might not encompass the entire problem area and its frequency (Kuenburg et al., 2015). Some scholars have also criticized such a representation as a way of perceiving deaf individuals only as a group of people with so many deficits, which they have to live with instead of focusing on their abilities and their capacity to persevere. For a positive approach, they focused on assets recognizing deaf refugees’ heterogeneity and multi-faceted status.
5. Implications and Recommendations
5.1. Culturally and Linguistically Appropriate Mental Health Services
This aligns with Kuenburg et al. (2015) and Lau & Rodgers (2021), who stress linguistic accessibility and cultural competence in refugee mental health programs. Therefore, to ensure deaf refugees get appropriate mental health services, it will be essential to provide culturally and linguistically appropriate services with deaf-specific experiences. This is combined with specialized deaf-friendly treatments that can be expressed non-verbally or with the help of sign language or an interpreter. Also, it is crucial to note that access to interpreting and communication is critical in promoting mental health services among deaf refugees (Kuenburg et al., 2015). It means sign language interpreting, captioning, or any other means to communicate with care providers during therapy sessions or using assistive technologies to communicate with mental health care workers. Furthermore, community participation may be viewed as having a more significant role in improving the mental health of deaf refugees (Kusters et al., 2017). Such affiliation with local deaf communities or organizations can help build positivity, relatedness, and purpose, essential for coping and healing (Puvimanasinghe et al., 2014). However, some people still believe that relying on community-based support can be questionable, as deaf refugees might experience particular difficulties in acquiring and applying these services.
5.2. Integrated Care Approach
Supported by SAMHSA (2014) and Emery & Iyer (2021), integrated models facilitate collaboration among interpreters, deaf service providers, and clinicians to improve treatment outcomes. For such reasons and others, care coordination is paramount when handling deaf refugees since they come with fluctuating and complex needs. This requires the collaboration of counselors or therapists, sign language English interpreters, deaf and hard-of-hearing service providers, and other stakeholders (Kusters et al., 2017). In this way, these interdisciplinary teams can offer all-inclusive and well-rounded care that encompasses mental health issues, communication barriers, and cultural peculiarities for deaf refugees. In this case, mental health professionals can recommend various mental disorders that may affect the deaf individual and the best way to attend to them. In contrast, deaf service providers can provide information about the deaf culture, experiences, challenges, and the right intervention services. Professional interpreters are essential to linguistic access and the integration of deaf refugees to receive the complete benefits of the integrated care model. Nevertheless, Lau and Rodgers (2021) have argued that the norms of these interdisciplinary teams may lead to potential power imbalances and cultural biases that again neglect the viewpoints and values of the deaf refugees and their communities. They have called for more involvement of deaf refugees in the service delivery process by integrating their care, effectively attaining better outcomes.
5.3. Advocacy and Policy Considerations
Wickenden (2023) emphasizes that intersectional policy reform is crucial to reducing systemic barriers and improving service access for marginalized deaf refugees. It is, therefore, essential to advocate for linguistic and cultural competence in mental health service delivery, promote models of care for integrated mental health care, and engage in policy dialogues that would address the needs of deaf refugees. Educating people and encouraging them to understand more about the issue are ways for authorities to acknowledge the presence and contributions of deaf refugees (Kusters et al., 2017). This might include working with the deaf communities, refugee groups, and policymakers to design educational initiatives, awareness-raising programs, and policy changes to accept and support deaf refugees’ multiple selves and marginalizations (Emery & Iyer, 2021). However, some scholars warn about the deficit approach and despair that dominates the representation of deaf refugees, promoting instead the strengths-based perspective in which deaf refugees are seen as active agents who can transform their lives for the better (Hutchinson & Dorsett, 2012). More importantly, such problems should be first tackled at the structural and systemic levels as they relate to a lack of access to mental health services and support for deaf refugees. This may include lobbying for increased access to communication aids, eliminating language and culture-related barriers in service delivery, and enhancing collaboration between appropriate stakeholders (Kusters et al., 2017).
5.4. Limitations of the Evidence Base
The evidence on deaf refugee mental health remains scarce; fewer than ten empirical studies directly address this topic. Most research is qualitative and geographically limited, reducing generalizability. The paucity of longitudinal data and cross-cultural comparisons constrains firm conclusions and underscores the need for further study.
5.5. Future Research Directions
The literature review also reveals deficits and limitations in existing literature on the mental health of deaf refugees that should be rectified in future research. As mentioned in the literature review, there is a lack of research specifically targeting this population; most of the studies include any refugee population or deaf people without considering the addition of these aspects (Kusters et al., 2017). Further studies should also attempt to make comparisons across different cultures and languages with deaf refugee populations and different migration scenarios, such as asylum seekers and internally displaced populations. On the same note, future longitudinal studies could reveal more information about the long-term mental health trajectories and coping mechanisms that deaf refugees exhibit when adjusting to the resettlement process.
Analytically, a blend of qualitative and quantitative research paradigms could provide a broader insight into mental health issues among deaf refugees. In addition to the described extent of mental health issues, it is also necessary to focus on the cultural and linguistic features of deaf refugees and their own experiences, which can be achieved through interviews and observations, while quantitative tools include questionnaires and tests (Kuenburg et al., 2015; Puvimanasinghe et al., 2014). Lastly, to integrate deaf refugees in future research, it is crucial to improve the visibility and include their communities in quantitative studies by adopting strength-based and community-engaged approaches to embrace and empower deaf refugee subjects as stakeholders in the research.
6. Conclusion
This literature review has sought to unveil the currently prevailing perception and categorization of mental health care among refugees in the United States, especially deaf refugees. The review has brought out the fact that refugee populations suffer from different degrees of mental health problems, such as PTSD, depression, and anxiety, among others, and how various risk factors interact across the pre-migration, migration, and post-migration phases. In addition, the review has highlighted specific complications experienced by deaf refugees, including communication difficulties, general lack of information and resources, and cultural/linguistic isolation, which exacerbates the PTSD and mental health problems that they undergo. The literature is scant regarding the mental health of deaf refugees. Still, existing research has enlightened the imperative of deafness and refugees on mental health and the challenges of accessibility to adequate care.
Mental health concerns of deaf refugees cannot be overemphasized; this is because this group of people is challenged by several forms of oppression and disadvantage that may negatively affect their mental health and effective resettlement. Mental health services that are culturally and linguistically sensitive, interdisciplinary models of care, advocacy, and future studies are the following steps to ensure deaf refugees acquire the necessary support and treatment. Looking ahead, there is a need to keep on increasing advocacy for disabled persons, especially deaf refugees, while calling for a strengths-based and participatory approach to focus on the capacities of the refugees and engage them in the decision-making arena concerning the designed services and support systems that meet their needs. In doing so, we can expand the mental health professionals and policies’ awareness of more deaf people, including deaf refugees, and improve the deaf mental health services cooperation between mental health professionals, deaf service providers, and deaf refugees.