Many refugees have been victims of severe violence that has profoundly affected their physical, psychological, and spiritual lives. During the past 31 years, the Intercultural Psychiatric Program at Oregon Health & Science University in Portland, has treated thousands of refugees who have been subjected to such violence in many war-torn countries. Having begun with refugees from Indochina (Vietnam, Cambodia, and Laos), patient groups at the clinic now include Bos-nians, Somalis, Ethiopians, Kurds, Iranians, Afghanis, Guatemalans, and Iraqis. Most patients in our clinic have been tortured and have had violence inflicted on them, either directly by combatants in war or during the chaos following civil disturbances and “ethnic cleansing.”
These refugees have sustained multiple losses, including family, country, social position, social network, language, and status. After being in refugee camps for long periods—in some cases as long as 15 years—many ultimately find themselves living in the United States. These patients bear the emotional toll of the violence they have experienced and of their refugee status.1
CASE VIGNETTES
Adil is a middle-aged man from Bosnia. During the Bosnian war, Serbs captured him and took him to a concentration camp. Many people in the camp were tortured and some killed; Adil himself was beaten and knocked unconscious. Some of the prisoners were taken away, never to return. Adil describes incidents in which inebriated Serbs would randomly shoot prisoners working in the fields. Adil was starved and became “skin and bones.” He finally escaped, and stayed with his in-laws, hiding outside during the day. After he left, he learned that both his in-laws had been killed.
Berko is a young African man from West Africa. He had been imprisoned because of his ethnicity and because his captors thought he was a member of a minority group that was plotting to overthrow the government. Berko was imprisoned for a month, during which time he watched many people being killed—including a friend. Berko himself was repeatedly beaten and made to crawl on his hands and knees over sharp objects. At one point, he was beaten so severely that he remained unconscious for 2 days. He was hospitalized and expected to die. After recovering, he managed to escape and eventually moved to the United States, where he had applied for asylum.
Cambro is an elderly woman from Somalia. She had been married at the age of 13 to a man who beat and verbally abused her. During the civil war in Somalia, rebels robbed everything in her home. They took her sons, lined them up outside, and shot them, and then savagely raped her. When she resisted, she was burned with cigarettes. She buried her sons and ran away with only her clothes to wrap around herself. She finally found safety at a refugee camp in Kenya.
How the clinical model works
We have used the same clinical model since the inception of our clinic. When a patient calls the clinic, he or she is assigned to a faculty psychiatrist and an ethnic case manager/ counselor who is fluent in the patient’s language and who is familiar with the patient’s culture. The case manager serves as an evaluator for the original assessment, helps with social needs, leads group therapy sessions and, most important, is the interpreter for the psychiatrist during psychiatric sessions. He or she also serves as a “cultural broker” when the patient and the psychiatrist have different concepts of psychiatric treatment. The patient receives excellent continuity of care because he has the same psychiatrist and case manager for the duration of treatment. No other clinicians are involved (ie, there are no intake workers or separate group therapists).
Currently, the clinic treats about 1300 patients and can accommodate people who speak one or several of 18 different languages. All the members of the department of psychiatry’s clinical staff are board-certified.
Signs and symptoms
The clinical symptoms displayed by refugees who are victims of violence are quite similar—regardless of their cultural background. There is much evidence that posttraumatic stress disorder (PTSD) is a major disorder among refugees.2 Major depressive disorder (MDD) is a common diagnosis as well and is comorbid with PTSD about 60% to 80% of the time. PTSD is almost always the result of torture and trauma, and MDD is often associated with the losses that the refugees have endured. About 20% of the patients have psychotic symptoms. A number of patients have schizophrenia. Some have chronic brain damage from head trauma. Most of the patients in our clinic are Buddhist or Muslim, and many are quite devout. They attribute life’s difficulties to Karma or they leave it “up to Allah.” There is little need for or expression of vengeance, and there is a remarkable acceptance of the events that have befallen them.
The ability of refugees to adjust to American life is, in large part, a function of their educational level before the trauma and disruption. For example, the Bosnians have a high rate of literacy (95%), and about 40% are currently employed. The Somalis, on the other hand, have only a 30% literacy rate, and only 10% are employed. Nevertheless, alcohol(Drug information on alcohol) and drug abuse, as well as suicides, are very uncommon. The cultural and religious prohibition of substance abuse exerts a powerful effect on first-generation refugees. There is an increase in drug abuse among second- and third-generation family members of refugees, however—probably because of the secondary effects of disruption, refugee status, war, and perhaps their parents’ psychopathology.
