The Role of Community Leadership in Refugee Suicide Prevention
By Ashika Dhaurali
Though Bhutanese refugees have resettled in the United States for over a decade, culturally competent mental health infrastructure has yet to adequately meet their needs. Suicide is a leading cause of death among certain populations. Bhutanese refugees who have been resettled in the United States between 2009 and 2012 have an age-adjusted suicide rate of 24.4 per 100,000 (Ao et al., 2012) compared to a 12.6 per 100,000 U.S. national average in 2012. The first Bhutanese refugees arrived in the United States in early 2008. Since then, the community has struggled with isolation and cultural dissonance. Most recently, in a press conference, Governor Josh Shapiro of Pennsylvania mentioned that there are 70,000 Bhutanese people in Pennsylvania (abc27 News, 2025). Yet, mental health programs remain inaccessible to them due to the program’s fundamental cultural misalignment. So, to prevent suicide among Bhutanese refugees in Harrisburg, local organizations need to implement culturally-rooted, trauma-informed, community-led initiatives.
The Bhutanese community has a long history of displacement and statelessness. In 1989, the Bhutanese government enforced a One Nation, One People policy, which promoted the norms of the dominant Ngalong community (Human Rights Watch, 2003). The Nepali-speaking Bhutanese population spoke out against the policy. Still, due to the Tsa-Wa-Sum law, which states that you cannot speak against the King or country, the community was labeled as terrorists, anti-nationals, and illegal immigrants. Over 100,000 Nepali-speaking Bhutanese people were ethnically cleansed and permanently exiled from Bhutan. They found a new home in the rural village of Maidhar, Nepal, where they were allowed to set up temporary refugee camps until the United Nations intervened. They were confined to refugee camps in Nepal for nearly two decades. This prolonged statelessness created material hardship, but also deep psychological trauma. Due to the circumstances, any children born in the refugee camps of Nepal were deemed stateless, as Nepal does not have a birthright citizenship policy. This caused deep intergenerational psychological scars.
Beginning in 2007, the United States participated in a multilateral third-country resettlement program coordinated by the UNHCR (United Nations High Commissioner for Refugees). States such as Ohio, Pennsylvania, New York, Georgia, Texas, North Carolina, Utah, Missouri, Arizona, and Illinois became relocation hubs for the Bhutanese community.
Upon resettlement, Bhutanese refugees were suddenly expected to integrate into an unfamiliar system. Most refugees were not used to physical healthcare, let alone mental healthcare. Mental health was a new and stigmatized concept. This was worsened by the language barrier, intergenerational disconnect, and the Western clinical model’s limitations in incorporating cultural practices. MacDowell’s study (2019) reveals that over 70% of Bhutanese refugees in the U.S. believe others would look down on them for seeking mental health help, and nearly one-third reported difficulties accessing mental health care. As a result, the community’s mental health needs went undetected for several years.
To address this issue, Bhutanese community leaders need to be empowered to complete trauma-informed training and serve as culturally fluent mental health ambassadors. A pilot program of Mental Health First Aid (MHFA) instructor training for Bhutanese leaders was highlighted in the International Journal of Mental Health Systems. The pilot program increased their mental health literacy and willingness to refer others to services (Subedi et al., 2015). These leaders delivered preventive intervention trainings in Nepali and culturally contextualized mental health.
Structures that are centered around culture and storytelling are critical for the Bhutanese community. Pyakurel (2024) details practices like family engagement workshops, intergenerational dialogue circles, and culturally familiar metaphors for emotional well-being. These models help Bhutanese people reconnect with their history and roots. They also help validate their lived experiences and offer strength in their identity. Community-led storytelling initiatives can offer therapeutic release in ways that sterile clinics often cannot.
The common argument against such models is that Western clinicians tend to offer more reliable care and that community-led efforts lack professional oversight. While it is true that licensed professionals are critical, institutional systems must evolve not only to accommodate but also to actively co-create solutions with community stakeholders. Co-leadership models where mental health professionals partner with culturally competent community leaders ensure and empower grassroots care. These hybrid models have shown outcomes in diverse refugee communities (Subedi et al., 2015).
As Pyakurel (2024) highlights, the Bhutanese community in the United States has faced repeated marginalization within mental health systems because it prefers individualistic, talk-based therapies. This approach fails to address the collective trauma of refugee identity. The community’s pain is intergenerational and political—it cannot be confined to cognitive behavioral therapy alone. Instead, care must address language access and community education. Organizations should direct funding toward local Bhutanese nonprofits and invest in training programs for refugee youth to enter the mental health field. In doing so, it builds long-term community leadership and mental wellness infrastructure. One example of a culturally grounded approach in practice is Project Pathway to Hope, an initiative based in Harrisburg and designed in response to the Bhutanese community’s urgent mental health needs. The program delivers regular QPR (Question, Persuade, Refer) suicide prevention trainings and hosts town hall–style discussions that normalize conversations around mental health in accessible formats. It also works to train local providers—including law enforcement officers, school personnel, and healthcare workers—on culturally responsive care. In the coming months, the initiative plans to expand its offerings to include Youth Mental Health First Aid (YMHFA), Teen Mental Health First Aid (TMHFA), and Adult Mental Health First Aid (AMHFA) sessions for community leaders, parents, and young people. Programs like this help bridge the gap between Western clinical models and culturally relevant, preventative care.
As someone deeply connected to this issue, I have witnessed how silence can take lives. I’ve attended funerals where families try to navigate loss while fearing shame. But I’ve also seen what happens when community members feel seen. For example, when a workshop is led in Nepali and storytelling is promoted, or when mental health is discussed over tea in a neighbor’s home, and when someone says, “you are not weak for struggling internally.” These moments of connection are powerful because it is rare. Real change does not start with institutions, it starts internally.
Suicide prevention in the Bhutanese refugee community requires changing the perspective of mental health as an isolated medical issue to understanding it as a culturally entangled experience of displacement, survival, and healing. By empowering community leaders with trauma-informed tools and investing in cultural programming, Harrisburg can become a model for refugee mental health innovation.
References
abc27 News. (2025, April 21). Ten Bhutanese refugees, four from PA, deported; four back in India. abc27 News. https://www.abc27.com/local-news/ten-bhutanese-refugees-four-from-pa-deported-four-back-in-india/
Hagaman, A. K., Sivilli, T. I., Ao, T., Blanton, C., Ellis, H., Lopes Cardozo, B., & Shetty, S. (2016). An Investigation into Suicides Among Bhutanese Refugees Resettled in the United States Between 2008 and 2011. Journal of immigrant and minority health, 18(4), 819–827. https://doi.org/10.1007/s10903-015-0326-6
Human Rights Watch. (2003, May). History of the Bhutanese refugee situation in Nepal. https://www.hrw.org/legacy/backgrounder/wrd/refugees/3.htm
MacDowell, H., Pyakurel, S., Acharya, J., Morrison-Beedy, D., & Kue, J. (2019). Perceptions Toward Mental Illness and Seeking Psychological Help among Bhutanese Refugees Resettled in the U.S. Issues in Mental Health Nursing, 41(3), 243–250. https://pubmed.ncbi.nlm.nih.gov/31599662/
Pyakurel, S. (2024, June 22). Transforming mental health care for resettled Bhutanese refugees: A call for cultural sensitivity and community integration. New Americans Magazine. https://thenewamericansmag.com/2024/06/22/transforming-mental-health-care-for-resettled-bhutanese-refugees-a-call-for-cultural-sensitivity-and-community-integration/
Subedi, P., Li, C., Gurung, A. et al. (2015). Mental health first aid training for the Bhutanese refugee community in the United States. International Journal of Mental Health Systems, 9, 20. https://ijmhs.biomedcentral.com/articles/10.1186/s13033-015-0012-z
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Ashika Dhaurali is a Suicide Prevention Project Coordinator for the Bhutanese Community in Harrisburg (BCH). She is certified in QPR and Mental Health First Aid and leads community-based mental health initiatives for refugee and immigrant populations. Her work centers on culturally grounded care and advocacy for stateless and displaced communities.