Dr. Suzan Song is a humanitarian psychiatrist and leading expert in trauma-informed clinical care, research, and public health policy for vulnerable populations, including unaccompanied children. She is the Director of Global Child and Family Mental Health at Harvard/Boston Children’s Hospital.
This Mental Health Awareness Month, KIND spoke to Dr. Song to discuss her work with unaccompanied children, culture in relation to mental health treatment, and how we can best support the mental health and overall well-being of unaccompanied children.
Could you tell us how you started working with unaccompanied children?
In 2008, I started working at an immigrant clinic in California where we saw many refugees and asylum seekers, including children and families. A cohort of unaccompanied children came through the clinic, mostly kids from El Salvador, Guatemala, and Honduras. I started to do asylum evaluations with them and provide some clinical care. I was so struck by the inner resources of those kids.
Since then, in my work in the global humanitarian space, I’ve worked with unaccompanied kids in refugee camps. The stories I hear across different populations of unaccompanied children are very similar. Whether with Syrian kids in Jordan or Central American children in the United States, when I ask them how they got there, they say “my parents told me to just make it over the border.” A parent only does that in extremely dire situations where they believe the child’s life is in danger. That’s the only reason why a parent would ever tell a child to separate from them and take such a journey alone.
I was doing a lot of international work when the 2016 elections happened. There were all of these people here in the United States—refugees, immigrants, asylum seekers and unaccompanied kids—that were suddenly bombarded by inhumane policies. So, I shut down all my global work and moved all of my work to the U.S.
In your work as a global health practitioner, you talk about the importance of culture and context. Could you share some of your ideas about culture and mental health treatment?
One thing that bothers me about discussions around cultural issues in mental health treatment is that it’s always so much about the other culture. That’s important of course. But often missing is any reflection on what our own cultural paradigm is. The assumption is that this culture, i.e., the dominant U.S. culture, is the normative one and we’re trying to figure out the others.
Culturally, here in the United States and within the mental health field, our approach to mental health and trauma is very cognitive and individualized. And this comes through in a lot of the treatment. For example, for unaccompanied kids, we’ve very focused on individual trauma focused cognitive behavior therapy. In many ways, this perpetuates the stigma and this isolation of, “this is a problem I need to focus on myself.” This takes away from the relational aspects of trauma. Individualized therapy can be more effective when accompanied by more social-relational attention and an embodiment approach.
Also, just because someone is an unaccompanied child doesn’t mean that they’re necessarily having serious mental health issues. I’ve seen unaccompanied kids who were then reunified with their families after five years and were doing just fine. Yes, being unaccompanied or separated comes with traumas of migration and the pre-migration. But it doesn’t define these children. That is just one experience that these kids have had, but they are a whole human being outside of any traumatic experience. Especially for those kids who are doing okay for the most part, I think these kids would benefit from more communal ways of healing.
Discussion around the mental health of unaccompanied kids is often focused on PTSD (post-traumatic stress disorder), depression, and anxiety and those of course are very important and relevant. But it’s also very common for children to have other struggles, for example, not knowing where they’re going to live for the next month, like detained kids in the immigration facilities. How do you support the kids in those settings? Instead of solely depression, anxiety, and PTSD, I think the focus needs to be on helping kids manage uncertainty. Uncertainty of their future and about their families. These kids experience ambiguous loss of loved ones. If their family members are still in their home country, they don’t have access to communication with them. They don’t know if they’re alive or in danger. It’s that kind of ambiguous loss of loved ones that creates the depression or the anxiety or worsens the PTSD. And we don’t focus on that context enough. We focus so much on the depression symptoms, but we need to look at what is causing that.
At the end of the day, all kids want to feel a sense of belonging. And when they’re separated from their loved ones or from a guardian, it’s very hard for them to feel that sense of belonging. One security blanket is gone, and if we’re not replacing it with something, we’re just leaving kids open and terrified and confused. Helping kids build a sense of community and a sense of belonging and a safe place is key.
How can we best support unaccompanied children and their mental health?
We need to focus on the social ecology of an unaccompanied child first, meaning policies and upholding human rights for kids. A lot of times we are worsening the mental health of unaccompanied children because of some of the policies and the way that we care for them in immigration custody and the processes that we make them go through in immigration court, whether or not they have a lawyer, all of that. That all affects the mental health of unaccompanied kids. I would start there. If you imagine there are these concentric circles around a kid, this is the outer circle. I would start there, from the outside in.
Often when we focus on individual children, the question is: what sort of psychotherapy intervention can we do? I would actually start from the outside in. To support the health and well-being of unaccompanied kids we also need to think about the people surrounding that kid, the people influencing their everyday life and make sure those people are not doing more harm to kids. Everyone—from the CBP officers to the asylum interviewer officers—they all should be trained in trauma-informed approaches—and they aren’t. And that just worsens the mental health of these kids.
These kids are responding appropriately to difficult circumstances. If they’re having outbursts or are withdrawn, they’re supposed to be because they’re in these confines that we’ve placed them in. They have just fled their country, been separated from their parent. That’s a normal response to a very abnormal situation. The problem is not within that child, the problem is within the system and the cultures that we’re forcing these children into. To address the mental health of unaccompanied children, we need to start with that system. On a basic level, what that means is we uphold humanitarian law, the policies for unaccompanied children and the way that kids are treated when they arrive at the border are so focused on the enforcing of laws, which we need, but there’s a softer way of enforcing that focuses on protecting the mental health and well-being of kids.