Mental Health Issues of Resettled Refugees
Mental Health Care Needs of the Refugee After Relocation
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.
-Friskila Damaris Silitonga, SKEP, NS, MPH
-Friskila Damaris Silitonga, SKEP, NS, MPH
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