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Mental Health Issues of Resettled Refugees

Author(s): Richard Ater, RN, University of Washington
Date Authored: November 18, 1998

Introduction

A refugee is someone who has crossed international borders fleeing war or persecution for reasons of race, religion, nationality, or membership in particular social and political groups and are protected by several international conventions (Toole & Waldman, 1993). The number of refugees and internally displaced persons in need of protection and assistance has increased from 30 million in 1990 to more than 43 million today. War and civil strife have been largely responsible for this epidemic of mass migration that has affected almost every region of the planet (Toole & Waldman, 1993). Refugees are a particularly vulnerable population that is at risk for mental health problems for a variety of reasons: traumatic experiences in and escapes from their countries of origin, difficult camp or transit experiences, culture conflict, and adjustment problems in the country of resettlement, and multiple losses-- family members, country, and way of life (Lipson, 1993).

Mental Health Care Needs of the Refugee After Relocation

Nowhere are the health care needs of refugees more pronounced than in the realm of mental health. Refugees are vulnerable to psychological distress due to uprooting and adjustment difficulties in the resettlement country, such as language, occupational problems, and cultural conflict. Uprooting creates culture shock, a stress response to a new situation in which former patterns of behavior are ineffective and basic cues for social intercourse are absent (Lipson, 1993).

The clinical and research literature shows a significant degree of psychological stress among refugees with relatively high levels of physical and psychological dysfunction during the first two years of resettlement; after three years, there was some improvement and increased adaptability, but there was still serious and pervasive adjustment problems affecting some sectors of the refugee population, such as high levels of somatization, depression, and post traumatic stress disorder. These symptoms have even been noted five years after resettlement (Lipson, 1993 & Chung & Kagawa-Singer, 1993).

The Importance of the Family

Studies have shown that much of the depression and anxiety of refugees can be alleviated if they can keep family ties somewhat intact and can develop social networks with others from their culture (Beiser, et. al, 1989, Beiser, et. al., 1993, Allden, et. al., 1996, Buchwald, et.al., 1993, Baker, et. al., 1994, & Carlisle, 1995). Other studies, however, have shown that while family can be a valuable source of emotional support, immigrant families can also be too overwhelmed by their own immigration demands to provide support or can generate additional stress for their members (Aroian, et. al., 1996).

Initial Assessment

Mental health providers should elicit their refugee client's immigration history: length of time in the country, circumstances of flight and first asylum, and who and what was lost. This information is critical for understanding client's adjustment and problems, such as identifying post- traumatic stress disorder (PTSD). It is important to assess for specific symptoms of PTSD and whether they are being confused with other symptoms, such as grieving, losses of family, country, and lifestyle, depression associated with downward social status and inability to find work (Lipson, 1993).

Torture

A major issue in treating the refugee population is the subject of torture. Many refugees come from parts of the world where torture is still prevalent. This population suffers from significant problems besides those that effect other refugees. Torture survivors suffer from high levels of depression and anxiety with "existential" aspects that are not a part of the traditional schemata; these may be reflective of a more subtle and specific aspect of psychopathology or may be part of a more pervasive problem of "complex PTSD." Psychotic symptoms and suicide attempts are relatively frequent; these constitute severe problems which led to psychiatric assessment and treatment. Domestic violence, aggression, alcohol problems, and psychological disorders among the children of survivors are also frequent concomitants of formal psychiatric disorders in torture victims (McGorry, 1995 & Silove, et. al., 1993). These symptoms have been found to be consistent across cultural and gender lines (Fornazzari & Freire, 1990 & Petersen, et. al., 1994). Another significant aspect of the symptomatology of torture victims is that the effects are more pronounced in those who become refugees than in those who stay in their own country (Kantemir, 1994).

Traditional psychiatric approaches such as individual insight or supportive psychotherapy with psychoactive medications have had a limited success; however support groups for such refugees composed of others from their background and experience appear to be helpful (Lipson, 1993).

The Role of Culture

Finally, the role of culture cannot be emphasized enough. Culture may not only be the glue that holds a group together, it can also be their chief stressor in trying to adapt to new surroundings without losing their own identity or sense of self worth (Hattar & Meleis, 1995).

It is incumbent on health care agencies that will be treating a refugee population to employ members of the refugee community and to look to them for guidance in their approach to the community. The use of traditional healers from the refugee's home culture can assist the refugee in getting access to health care in a culturally acceptable and meaningful way. Traditional healers, in conjunction with western trained health care providers can bridge the gap between cultures and make the transition from cultures smoother (Hiegel, 1983).

In conjunction with the refugee community it is advisable to develop a cultural competence check list. This will assist in maintaining an approach to the community that is culturally sensitive while allowing for the community's health care needs to be met (Dana & Matheson, 1992). It is also necessary to learn to work with and through interpreters. This will require adequate training of interpreter staff. Fluency in the languages of the host country and refugee group is not enough. The interpreter must be knowledgeable of the nuances of both languages and cultures. S/he must also be knowledgeable of the common medical terms and psychiatric terms that will be used and how best to accurately translate them. The health care worker must, on the other hand, not treat the interpreter as a mere "mouthpiece", but as a respected colleague who is to be consulted with (Westermeyer, 1990).

The Cultural Consultant

A relatively new concept is that of the cultural consultant in medicine and psychiatry. In a sense the cultural consultant serves as a bridge between the medical model and the refugee's world view. Ideally, the cultural consultant should have experience and training in health care and should be bicultural and bilingual. Awareness of one's own identity, behavior, and biases is also important. These characteristics can be enhanced by training, e.g., workshops in clarification of values or cross-cultural communication and working with and systematic observation of a good role model. Ultimately the cultural consultant's chief task is to answer the question: "Is this behavior normal?" This question lies at the heart of cross-cultural psychiatry, which must determine normality in its cultural context (Budman, et. al., 1992 & Bulle, 1987).

Conclusion

In conclusion the influx of refugees does not appear to be abating at any time soon. The generalist-trained health care provider is in a unique position to aid the refugee; both in the camps and in resettlement. By establishing a hierarchy of needs and building from a base of meeting the refugee's biological needs and leading to the refugee's psychological needs, the provider can assist the refugee to make the transition to a new homeland while alleviating much of the stress involved. These tasks are daunting, but with compassion, knowledge, and the will to be flexible they can be accomplished.

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