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Eye on Psi Chi: Spring 2019

Eye on Psi Chi

Spring 2019 | Volume 23 | Issue 3


Bhutanese Refugees Coping With Acculturation Challenges

Gabriela Heermans,
University of Vermont

View this issue in Digital and PDF formats.

In the early 1990s, more than 100,000 ethnic Nepalis in Bhutan were expelled or fled from Bhutan when their language, customs, and rights were repressed in order to prevent them from potentially shifting the country’s political powers. After living 20 long years in camps in eastern Nepal, Burma, and Thailand, the majority of these refugees have finally been resettled in countries including the United States, Canada, and some European countries, while others are still stateless and struggling in the camps to this day.

Post-traumatic stress disorder (PTSD) is a common diagnosis found among Bhutanese refugees; Elise Nelson (2012) has found that there are high rates of suicide among Bhutanese refugee communities, and Gerber et al. (2017) found that Bhutanese refugees are 10 times more likely to be experiencing PTSD symptoms than those citizens who are age-matched in their home countries. The focus of this article is to explore how refugees cope with stresses in the aftermath of being stateless and acculturating in the United States, and to challenge the commonly used model of Western medicine to approach dealing with mental health issues in Bhutanese refugees.

Through participant observation and select interviews, I asked Bhutanese refugees about their life experiences and culture, noticing an emerging pattern that illustrated the importance of religion and traditional activities in their lives. Here I ask whether ensuring the continuation of traditional celebrations could even possibly be a more desired approach to healing mental health issues in refugee communities. I look at the connection between karma and mental illness, and why the topic of mental illness is often stigmatized in Bhutanese-Nepali culture. I found that having enough programs to help the refugees maintain traditional cultural practices is a vital aspect of ensuring Bhutanese refugees feel at home in the United States.

"There is an apparent difference in the understanding of trauma-related idioms and perceptions, and also how to deal with trauma, between Western and Eastern cultures. It is important to understand the various terminologies of Eastern cultures and how seriously a respective family may take them."

Effects of Citizenship

Kingston and Stam (2015) pointed out that citizenship serves as a divider because noncitizens are denied economic rights, freedom of movement, and participation in the government. Their studies involved 30 formerly stateless refugees resettled in the United States and interviews with 15 Bhutanese-Nepalese, all members of the Karen ethnic minority (from Burma and Thailand). In their findings, positive change in experience occurred when refugees went from lack of status to legal recognition; having citizenship granted access to basic things that made living a self-sufficient life possible.

Bhutanese refugees have been stripped of their rights, which promotes discrimination from citizens; one of these cruel discriminatory resentments was, “You have no rights. Our dogs have rights, our cats have rights. You do not” (Kingston and Stam, 2015).

Ethical Dilemmas Around Treating Mental Illness

Since the 1980s, mental health researchers have been using the PTSD label when working with Southeast Asian Refugees. The Centers for Disease Control and Prevention (CDC) studies PTSD in Bosnia, Pakistan, Afghanistan, Burma, and Thailand.

However, Kohrt and Hruschka (2010) have raised some questions about the ethical dilemmas pertaining to diagnosing Bhutanese refugees with PTSD. Humanitarian workers have diagnosed a high 53% of internally displaced Bhutanese refugees with PTSD, and 60% of torture victims have also been diagnosed. This raises ethical concerns for the thousands of Lhotsampa refugees who have been dispersed into Western cultures all around the world, the majority to the United States where PTSD is a diagnosis commonly used (Nelson, 2012). However, the cultural idioms used to explain mental illness in Eastern countries do not hold the same meaning as PTSD, neither in symptoms nor sociological relation to the illness (Kohrt & Hruschka, 2010). For this reason, the U.S Office of Refugee Resettlement and volunteer agencies that facilitate the process of resettlement have had difficulty addressing the mental health needs of the Bhutanese population (Gerber et al., 2017).

Nowhere in the PTSD definition does it include ethnopsychological and ethnophysiological frameworks that are a part of the idioms of mind–body relations which describe the effects of trauma in Nepalese and Bhutanese culture. There is, in fact, no word for “trauma” in any of the Bhutanese-Nepalese dialects.

According to some of these idioms, the self is considered to be made up by man, or heart-mind, dimaag, brain-mind, saarir, corporeal body, atma, spirit or soul, and ijjat, social status; all of these are compositions of samaaj, the social world. Within this ethnophysiological framework, afflictions of the brain-mind are highly stigmatized. “Soul loss” is another idiom that is commonly used by Eastern cultures to describe symptoms of mental illness. Even in other cultures such as Ethiopian and West African cultures, depression and trauma are conceptualized as symptoms of an issue with the heart (Kohrt & Hruschka, 2010).

There is an apparent difference in the understanding of trauma-related idioms and perceptions, and also how to deal with trauma, between Western and Eastern cultures. It is important to understand the various terminologies of Eastern cultures and how seriously a respective family may take them.

Alternatives to Traditional Western Approach

The structure of the Bhutanese communities, the way community ethics are determined, and their life cycle rituals for spiritual rebirth are all shown by their caste system, belief in karma, and family life respectively. Newly resettled refugees are more likely to rely solely on their own ethnic community and not take advantage of support offered by the host community’s services. This suggests that more services to help devout Hindu-Bhutanese with the acculturation process are needed (Benson, Sun, Hodge, & Androff, 2012). Vonnahme, Lankau, Ao, Shetty, and Cardozo’s (2015) findings have also found an affiliation between depression and problems with maintaining religious or cultural traditions.

The Bhutanese Refugee Community of Burlington Vermont

In my interview with Jass, a Bhutanese-Nepali refugee, he said that people might sometimes use the concept of karma to blame refugees for their own problems, insinuating that the experience of displacement is something that was deserved. He says that there is not a lot of stigma against mental illness, and even in Bhutan, some Bhutanese would see a doctor if they had a mental illness.

It is apparent that more studies on karma and mental illness must be done, and researchers must be careful of this concept of blaming victims for their troubles. Jass said that religion was very important to him, but he does not relate mental illness with karma or see becoming a refugee as a punishment for something he did.

It’s important to consider religion when looking at what factors impact Eastern culture’s mental health, especially when it plays as big of a role as it does as in the Bhutanese culture. Although it is important to be sensitive to those refugees from Hindu sects and the beliefs they may hold about karma and the stigmatization surrounding mental illness, we must also keep in mind that it may not be the case that all Hindu refugees accept karma as something that stigmatizes mental illness.

What Jass said about his religion, Hinduism, in his interview helped me better understand how Vonnahme et al.’s (2015) findings could be a reality. Jass considers the practice of Hinduism a very important aspect of his life, though when he first came to Vermont there was not a very large number of Hindu Bhutanese refugees like himself, and he was unable to attend a temple to worship as he normally does. He said that, when more refugees arrived, the Hindu Bhutanese community grew and the need for a place of worship was apparent.

Eventually, a place for Hindu worship was established, but up until one became available, Jass was a refugee who believed in a religion that was in the minority relative to the people around him. He spoke of how there are two main festivals celebrated in Hindu religion twice a year, something he was not celebrating with other Hindus until the place allocated for the Hindu community members to pray was established.

To explore the issue of how engaging in cultural events impacts the well-being of Bhutanese refugees in Vermont, I also interviewed Sang, a man who founded a Bhutanese dancing circle in Burlington. The circle meets biweekly and consists of a group of Bhutanese girls. Sang created the gathering for a traditional festival held annually to ask their Gods for a successful harvest in 2016; this event has now been put on successfully two times. When asked about what the gathering means to him, he says that he is grateful and finds it meaningful to be able to honor their culture’s tradition with this event, which goes along with Gerber et al.’s (2017) findings in their study on the importance of offering refugee community’s communal activities that are engaging for them.

Strategies to Support Bhutanese Refugees

In a study designed to pinpoint the factors affiliated with mental illness in Bhutanese refugees, Vonnahme et al. (2015) found a correlation between two factors: strength of religion and level of happiness. Religion and cultural practices were one of the five principal categories that was found to be most impactful on mental health in Bhutanese refugees.

Gerber et al.’s (2017) findings on positive influences in Bhutanese refugees’ communities show that creating activities such as community gardening to address the need to engage with each other is an effective way of dealing with this problem. The community garden is useful because it allows the refugees to engage in a community activity where language barriers do not get in the way. Findings also suggest that acculturation may be a smoother process if refugees have a support system that includes their own ethnic circle as well as the host community’s social services (Benson et al., 2012), something supported in my research by the fact that Saang’s Bhutnanese dancing circle and the annual festival receives aid from the Vermont Folklife Center.

It was apparent that the interviewees underwent many challenges when repatriating in the United States, a country completely different from their homelands. Language was a significant barrier for them when they first arrived, but so was religion and not practicing cultural events. Gatherings help refugees feel connected to their culture and to lessen any shame that comes with being in the minority engaging in different cultural practices.

Bhutanese refugees’ differing opinions about Western medicine did bring up some interesting issues that could be addressed in future research. For example, my interview with Jass proved that there are Hindu Bhutanese who do not hold strongly to the concept of karma and perceives mental illness as something that he and Bhutanese-Nepalese like himself could go see a doctor for. There are perhaps some communities more open to the idea of seeking “professional” help for mental health issues than others.

Whether or not the stigmatization of mental illness is an issue that pertains more specifically to the Bhutanese population than it does for the general U.S population is another issue that could be further explored. Does stigmatization of mental health vary among Bhutanese refugee communities, and how does this differ pre- and post- settlement? How does mental health stigmatization of refugees vary from the culture surrounding them?

Continued efforts must be made by citizens, government programs, and communities of refugees if we are to ensure that refugees receive the humanitarian rights they deserve. We must also make sure that Western psychiatrists, hospitals, and psychologists are aware of what real cultural competency looks like if we are going to deliver the most effective and meaningful treatment to Bhutanese refugees. Promoting cultural community gatherings that include the host country community members may show that unique cultural traditions are accepted in the host country, and offer encouragement to those refugees who are strongly affiliated with their religion.


Benson, G. O., Sun, F., Hodge, D. R., & Androff, D. K. (2012). Religious coping and acculturation stress among Hindu Bhutanese: A study of newlyresettled refugees in the United States. International Social Work, 55, 538–553.

Gerber, M. M., Callahan, J. L., Moyer, D. N., Connally, M. L., Holtz, P. M., & Janis, B. M. (2017). Nepali Bhutanese refugees reap support through community gardening. International Perspectives in Psychology: Research, Practice, Consultation, 6, 17–31.

Kingston, L. N., & Stam, K. R. (2015). Recovering from statelessness: Resettled Bhutanese-Nepali and Karen refugees reflect on the lack of legal nationality. Journal of Human Rights, 12, 389–406.

Kohrt, B. A., & Hruschka, D. J. (2010). Nepali concepts of psychological trauma: The role of idioms of distress, ethnopsychology, and ethnophysiology in alleviating suffering and preventing stigma. Culture, Medicine, and Psychiatry, 34, 322–352.

Nelson, E. J. (2012). Examining the psychosocial context of mental health: Bhutanese refugees and their story of resettlement (Order No. 1509966). Retrieved from ProQuest Dissertations & Theses A&I. (1015014238).

Vonnahme, L. A., Lankau, E. W., A, T., Shetty, S., & Cardozo, B. L. (2015). Factors associated with symptoms of depression among Bhutanese refugees in the United States. Journal of Immigrant and Minority Health, 17, 1705–1714.

Gabriela Heermans received a bachelor's degree in psychology from the University of Vermont with minors in anthropology and global studies. She pursued research on cultural perspectives of post-traumatic stress disorder within Bhutanese refugee populations in Burlington, Vermont. Inspired by previous years spent in a variety of African countries, Gabriela has pursued a track that she hopes will allow her to work in a developing country one day. After receiving her degree, she volunteered briefly with the Connecting Cultures lab at the University of Vermont and helped design culturally sensitive questionnaires for refugees experiencing PTSD. She is currently pursuing a master’s degree through the Erasmus Mundus Global Mobility, Inclusion, and Diversity in Society (Global-MINDS) programme, which will allow her to study in a series of European countries over the course of two years. After completing the programme, Gabriela will hold a MA in social psychology, which she hopes will enable her to work in a field with refugees in the future.

Copyright 2019 (Vol. 23, Iss. 3) Psi Chi, the International Honor Society in Psychology

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