Trauma Systems Therapy for Refugee Children and Families

  • Molly A. BensonEmail author
  • Saida M. Abdi
  • Alisa B. Miller
  • B. Heidi Ellis


Trauma Systems Therapy for Refugees (TST-R) is an innovative, trauma-informed multi-tiered approach to mental health prevention and intervention with refugee children and their families. TST-R was developed as an adaptation of Trauma Systems Therapy (TST), which is an organizational and clinical model that focuses on both a child’s dysregulation and the social environmental context that may be contributing to ongoing symptoms in the aftermath of trauma. TST-R adaptations address multiple barriers to care for refugees and their families through innovative mental health service delivery including multi-tiered approaches to community engagement and stigma reduction, embedding of services in the school setting, partnership building, and the integration of cultural brokering throughout all tiers of intervention to provide cultural knowledge, engagement, and attention to the primacy of resettlement stressors. TST-R has been shown to be effective in engaging refugee youth in services and reducing symptoms of PTSD and depression.


Refugee Children and adolescents Trauma Cultural brokering Trauma systems therapy 


  1. Abdi, S. & Nisewaner, A. (2009). Group work with Somali youth manual. Unpublished manual.Google Scholar
  2. American Psychological Association. (2010). Resilience & recovery after war: Refugee children and families in the United States. Retrieved from
  3. Barr, D. A. (2014). Health disparities in the United States: Social class, race, ethnicity, and health. Baltimore, MD: Johns Hopkins University Press.Google Scholar
  4. Behrens, D. (2015). Financing Strategies for TST-R Project. Unpublished internal document, George Washington University.Google Scholar
  5. Betancourt, T. S., & Khan, K. T. (2008). The mental health of children affected by armed conflict: Protective processes and pathways to resilience. International Review of Psychiatry, 20(3), 317–328. CrossRefGoogle Scholar
  6. Bogic, M., Njoku, A., & Priebe, S. (2015). Long-term mental health of war-refugees: A systematic literature review. BMC International Health and Human Rights, 15(1), 29. CrossRefPubMedPubMedCentralGoogle Scholar
  7. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748–766. CrossRefGoogle Scholar
  8. Brown, A., McCauley, D., Navalta, K., & Saxe, C. (2013). Trauma systems therapy in residential settings: Improving emotion regulation and the social environment of traumatized children and youth in congregate care. Journal of Family Violence, 28(7), 693–703. CrossRefPubMedPubMedCentralGoogle Scholar
  9. Bureau of Population, Refugees, and Migration. (2017). Fact sheet: Fiscal year 2016 refugee admissions. Retrieved from:
  10. Carpenter-Song, E., Whitley, R., Lawson, W., Quimby, E., & Drake, R. E. (2011). Reducing disparities in mental health care: Suggestions from the Dartmouth–Howard collaboration. Community Mental Health Journal, 47(1), 1–13. CrossRefPubMedPubMedCentralGoogle Scholar
  11. Catani, C., Jacob, N., Schauer, E., Kohila, M., & Neuner, F. (2008). Family violence, war, and natural disasters: A study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry, 8(1), 33. CrossRefPubMedPubMedCentralGoogle Scholar
  12. Dixon, L., Lewis-Fernandez, R., Goldman, H., Interian, A., Michaels, A., & Kiley, M. C. (2011). Adherence disparities in mental health: Opportunities and challenges. The Journal of Nervous and Mental Disease, 199(10), 815–820. CrossRefPubMedPubMedCentralGoogle Scholar
  13. Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L. (2010). Mental health service utilization of Somali adolescents: Religion, community, and school as gateways to healing. Transcultural Psychiatry, 47(5), 789–811. CrossRefGoogle Scholar
  14. Ellis, B. H., MacDonald, H. Z., Lincoln, A. K., & Cabral, H. J. (2008). Mental health of Somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting and Clinical Psychology, 76(2), 184–193. CrossRefPubMedPubMedCentralGoogle Scholar
  15. Ellis, B. H., Miller, A. B., Abdi, S., Barrett, C., Blood, E. A., & Betancourt, T. S. (2013). Multi-tier mental health program for refugee youth. Journal of Consulting and Clinical Psychology, 81(1), 129–140. CrossRefGoogle Scholar
  16. Ellis, B. H., Miller, A. B., Baldwin, H., & Abdi, S. (2011). New directions in refugee youth mental health services: Overcoming barriers to engagement. Journal of Child & Adolescent Trauma, 4(1), 69–85. CrossRefGoogle Scholar
  17. Fazel, M., & Stein, A. (2002). The mental health of refugee children. Archives of Disease in Childhood, 87(5), 366–370. CrossRefPubMedPubMedCentralGoogle Scholar
  18. Goode, T. D., Sockalingam, S., & Snyder, L. L. (2004). Bridging the cultural divide in health care settings: The essential role of cultural broker programs. Washington, DC: National Center for Cultural Competence.Google Scholar
  19. Hidalgo, J., Maravić, M., Milet, C., & Beck, R. (2016). Promoting collaborative relationships in residential care of vulnerable and traumatized youth: A playfulness approach integrated with trauma systems therapy. Journal of Child & Adolescent Trauma, 9(1), 17–28. CrossRefGoogle Scholar
  20. Huang, Z., Yu, S., & Ledsky, R. (2006). Health status and health service access and use among children in U.S. immigrant families. American Journal of Public Health, 96(4), 634–640. CrossRefPubMedPubMedCentralGoogle Scholar
  21. Jezewski, M. A. (1990). Culture brokering in migrant farm worker health care. Western Journal of Nursing Research, 12(4), 497–513. CrossRefPubMedGoogle Scholar
  22. Kaczorowski, J. A., Williams, A. S., Smith, T. F., Fallah, N., Mendez, J. L., & Nelson–Gray, R. (2011). Adapting clinical services to accommodate needs of refugee populations. Professional Psychology: Research and Practice, 42(5), 361–367. CrossRefGoogle Scholar
  23. Khawaja, N. G., White, K. M., Schweitzer, R., & Greenslade, J. (2008). Difficulties and coping strategies of Sudanese refugees: A qualitative approach. Transcultural Psychiatry, 45(3), 489–512. CrossRefGoogle Scholar
  24. Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., et al. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Medical Association Journal, 183(12), E959–E967. CrossRefGoogle Scholar
  25. Kohn-Wood, L. P., & Hooper, L. M. (2014). Cultural competency, culturally tailored care, and the primary care setting: Possible solutions to reduce racial/ethnic disparities in mental health care. Journal of Mental Health Counseling, 36(2), 173–188. CrossRefGoogle Scholar
  26. Lustig, S. L., Kia-Keating, M., Knight, W. G., Geltman, P., Ellis, H., Kinzie, J. D., … Saxe, G. N. (2004). Review of child and adolescent refugee mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 43(1), 24–36. CrossRefGoogle Scholar
  27. Moore, K. A., Redd, Z., Beltz, M., Malm, K., Murphy, K., Schusterman, G., & Sticklor, L. (2016). KVC’s bridging the way home: An innovative approach to the application of trauma system therapy in shild welfare.. Lexington, KY: KVC Health Systems.Google Scholar
  28. Munroe-Blum, H., Boyle, M., Offord, D., & Kates, N. (1989). Immigrant children: Psychiatric disorder, school performance, and service utilization. American Journal of Orthopsychiatry, 59(4), 510–519. CrossRefGoogle Scholar
  29. Nisewaner, A., & Abdi, S. M. (2010, June). Challenges, strategies and rewards of an adaptation of trauma systems therapy for newly arriving refugee youth: School-based group work with Somali adolescent boys. In V. Roy, G. Berteau, & S. Genest-Dufault (Eds.), Strengthening Social Solidarity through Group Work: Research and Creative Practice. Paper presented at the Proceeding of the XXXII International Symposium on Social Work with Groups, Montreal, June 3–6, (pp.129–147). London, UK: Whiting & Birch.Google Scholar
  30. Office of Refugee Resettlement. (2016). Unaccompanied children released to sponsors by state. Retrieved from:
  31. Reed, R. V., Fazel, M., Jones, L., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. The Lancet, 379(9812), 250–265. CrossRefGoogle Scholar
  32. Saxe, G. N., Ellis, B. H., & Brown, A. D. (2015). Trauma systems therapy for children and teens (2nd ed.). New York, NY: Guilford.Google Scholar
  33. Saxe, G. N., Ellis, B. H., Fogler, J., Hansen, S., & Sorkin, B. (2005). Comprehensive care for traumatized children: An open trial examines treatment—Using trauma systems therapy. Psychiatric Annals, 35(5), 443–448. CrossRefGoogle Scholar
  34. Saxe, G. N., Ellis, B. H., & Kaplow, J. (2006). Collaborative care for traumatized teens and children: A trauma systems therapy approach. New York, NY: Guilford.Google Scholar
  35. Saxe, G. N., Ellis, H. B., Fogler, J., & Navalta, C. P. (2012). Innovations in practice: Preliminary evidence for effective family engagement in treatment for child traumatic stress–trauma systems therapy approach to preventing dropout. Child and Adolescent Mental Health, 17(1), 58–61. CrossRefGoogle Scholar
  36. Sundquist, J., Bayard-Burfield, L., Johansson, L. M., & Johansson, S. E. (2000). Impact of ethnicity, violence and acculturation on displaced migrants: Psychological distress and psychosomatic complaints among refugees in Sweden. The Journal of Nervous and Mental Disease, 188(6), 357–365. CrossRefPubMedPubMedCentralGoogle Scholar
  37. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. CrossRefPubMedPubMedCentralGoogle Scholar
  38. United Nations High Commissioner for Refugees. (2015). UNHCR global trends 2015: Forced displacement in 2015. Retrieved from:
  39. United Nations High Commissioner for Refugees. (2016). Facts and figures about refugees. Retrieved from:
  40. Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science & Medicine, 52(11), 1709–1718. CrossRefGoogle Scholar
  41. Wong, E. C., Marshall, G. N., Schell, T. L., Elliott, M. N., Hambarsoomians, K., Chun, C. A., & Berthold, S. M. (2006). Barriers to mental health care utilization for US Cambodian refugees. Journal of Consulting and Clinical Psychology, 74(6), 1116–1120. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Molly A. Benson
    • 1
    Email author
  • Saida M. Abdi
    • 2
  • Alisa B. Miller
    • 1
  • B. Heidi Ellis
    • 1
  1. 1.Department of PsychiatryBoston Children’s Hospital/Harvard Medical SchoolBostonUSA
  2. 2.Boston Children’s HospitalBostonUSA

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