The second type of Somali patients we see are young men, ages 20 to 30, with florid psychoses that are hard to locate neatly into a DSM diagnostic category. They are delusional, hallucinatory and confused; the clinical picture resembles somewhat the French notion of bouffees delirantes (Ey et al., 1974). This might be considered schizoaffective disorder in our present nosology, but such a designation seems unsatisfactory and does not convey the confusion and perplexity of the acute state. Following recovery of sorts, there is usually interpersonal intactness and warmth and a relative lack of negative schizophrenic symptoms. Some of these young men most likely have bipolar disorder, but again we would stress the atypicality of the presentation. Khat, a plant leaf containing an amphetamine-like compound, is a culturally accepted recreational drug, but has been implicated in only a few of our patients. The relationship of the Somali Civil War to this group of young men with acute psychosis is problematic, partially because they are often reluctant to discuss the traumas of their childhood and teen-age years and partially because they are too disorganized to provide a coherent history. When recovered sufficiently to give a more coherent trauma history, these young men are usually quite resistant and evasive in disclosing their civil war experiences.The Experience of Demoralization
There is one important feature worth noting about the refugee clinical population. Much more striking in the Southeast Asian families who are approaching 15 to 20 years in the United States, it is the gradual transition over the years from acute depression and posttraumatic stress disorder to a picture of demoralization among those who are not doing well in their assimilation. Demoralization fits the learned helplessness paradigm rather than the medical condition of depression. In this model, a person generalizes from observations and personal experiences from which outcomes are uncontrollable, to chronic motivational, cognitive and emotional deficits (Abramson et al., 1978). New coping skills are not developed, and the few attempts at adaptation and positive change are spectacularly unsuccessful, further reinforcing the learned helplessness response. Frank (1961) considered demoralization a common central feature of those seeking psychiatric, especially psychotherapeutic, care. It has been long contended that many of the psychiatric screening scales since World War II actually measure demoralization rather than clinical disorders (Dohrenwend et al., 1980; Link and Dohrenwend, 1980). The case for the central role of demoralization in understanding depression in Native American populations has been cogently made by Hodge and Kipnis (1996). The very recent restructuring of the clinical scales of the Minnesota Multiphasic Personality Inventory (MMPI) pulls out 29 items to form a new demoralization scale (Tellegen et al., 2003). In previous MMPI interpretations, these items contributed to the high correlation between depressive, somatization and anxiety disorders.
We have singled out the centrality of demoralization because it exemplifies the types of problems that are prevalent in working with a traumatized refugee population (Chung and Bemak, 1996; Sundquist et al., 2000). A certain number of patients can be relatively neatly fitted into a DSM-IV diagnostic model (e.g., endogenous depression, manic-depressive illnesses, schizophrenia and a variety of neurological conditions related to head trauma). However, the majority of chronic patients show a complex picture of residual PTSD and depressive symptoms that become relatively quiescent until some new misfortune or stress develops (e.g., medical illnesses; loss of or inability to find a job; or delinquent, disrespectful adolescent children). Coupled with the waxing and waning PTSD symptoms are issues surrounding the permanent grieving for dead family members through battle, assaults or sickness, as well as grieving for a culture that appears irretrievably lost. The DSM-IV defines grieving that lasts beyond two months as a depressive illness, but this temporal criterion must refer to the norm of a civilian population at peace. Surely there are losses, especially multiple ones, from which a person never recovers. Prigerson et al. (2000) referred to this type of chronic grief as traumatic bereavement, a construct that requires further clinical and philosophical investigation.Therapeutic Programs
The approach at CUHCC incorporates a traditional medical/psychiatric model including diagnostic evaluation and psychopharmacological treatment as one line of approach. We use antidepressant and mood-stabilizing medications, supplemented by low-dose atypical antipsychotic medications, for a variety of non-psychotic mixed pictures. The challenge with any refugee population involves ongoing patient education, especially about side effects and time lines; bargaining about dosage, frequency and number of medications; frequent follow-up appointments to ensure better compliance; and awareness of how different cultures view the role of medications. If a medication can give a patient five to six hours of sleep rather than one or two hours and can partially reduce anxiety and intrusive imagery without establishing dependency, we are ahead with that patient.
We inquire about patients' use of traditional (Chinese) herbal medications. A small percentage of patients take these traditional medications intermittently, but because the herbal preparations usually come in small cellophane packets, we are rarely able to identify them. We also see some chronic opium users, since opium was often the only effective medicinal for rural populations in parts of Southeast Asia. The clinic does not employ shamans, but does encourage families to seek diagnosis and treatment from shamans and other indigenous healers.
The CUHCC mental health program is staffed with three part-time psychiatrists (two adult, one child) who are University of Minnesota faculty members, four nurse clinical specialists, three psychologists, social workers and several bilingual case workers (with or without formal Western education) for each ethnic group. Relationships between professionals and bilingual staff have to be flexible and mutually respectful, since neither group can work well without the other. Western professionals must remain sensitive to the fact that, often, the bilingual worker has shared the same trauma experiences as the patients. Outside group facilitators meet with the staff several times per year to work on cultural sensitivity awareness and responsiveness.
Complementing our pharmacological approach is a variety of group treatments and rich advocacy and outreach programs. There are day treatment groups run for each ethnic group (Hmong, Lao, Latino, Cambodian, Vietnamese and Somali) with a focus geared to meet specific needs (Table 2). There are educational components built into each of these groups, including discussion about the proper use of medication for a variety of illnesses (including diabetes and hypertension), an understanding of medication side effects, importance of citizenship, job training options and raising children in the United States. In addition, CUHCC case workers assist patients directly with citizenship applications, immigration problems, disability filings, housing problems, job training, transportation problems and parenting troubles. Family sessions are convened when deemed appropriate. A legal firm offers on-site pro bono legal services for noncriminal matters to our patients.
Providing medical and psychiatric services to refugees with diverse civilian and military traumas and the panoply of problems attendant upon the uprooting and forced migration of entire ethnic groups is a daunting challenge. Balancing out this diversity is a simultaneous awareness that humans have many similarities by virtue of their common humanity. The refugee mental health programs at CUHCC have endeavored to provide a combination of both generic and specific programs to meet the changing needs of these refugee groups.