Jerome Kroll, MD

[[{"type":"media","view_mode":"media_crop","fid":"17393","attributes":{"alt":"Mental health treatment for refugees","class":"media-image media-image-right","height":"245","id":"media_crop_7533685177284","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"947","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"","typeof":"foaf:Image","width":"174"}}]]This article will present the major patterns of psychiatric morbidity in the Somali community of Minnesota, assessing several features of medical and social importance that are somewhat unique to this refugee community because of Somalia’s history, culture, characteristics, and longevity of its Civil War.

 in January 1991, a significant portion of the Somali population has become displaced persons either within Somalia and the Horn of Africa, or more widespread to Europe and North America. At the present time, there are sizable groups of Somali persons living in Minneapolis, Columbus (Ohio), Nashville, Atlanta, Boston, and Seattle. Minnesota hosts over 50,000 Somalis, constituting one of the largest concentrations of Somalis outside of the Horn of Africa.

Several features of Somali history and culture that impact uniquely upon psychiatric syndromes are that the population has been (1) overwhelmingly ethnic Somali, and therefore not subject to the ethnic violence of other civil wars, and (2) overwhelmingly Sunni Muslim, and therefore not torn apart by religious sectarianism and terrorism. The violence and inability to form a stable government have been based upon clan and caste mistrust and animosity, rather than on religious ideological differences. One additional feature unique to Somali refugees that has psychiatric import has been the accepted custom, especially among men, of chewing khat, an indigenous plant that contains cathinone compounds having stimulant properties milder than, but closely akin to, amphetamines.

, we saw patients with interconnected problems of PTSD, depression, grief, and demoralization that is the common burden of 

 The clinical picture of combined PTSD/depression was considerably more common in women than in men, especially in women age 30 years and older. Compounding the violence incurred during the early months of the Civil War within Mogadishu and adjacent regions in the south of the country was the experience of chronic exposure to daily threats and aggression in overcrowded refugee camps in Kenya and, to a lesser extent, in Ethiopia. There, the refugee population-composed primarily of women and young children-were 

 to raids by hostile local tribesmen, as well as by predatory male teenagers living within the camps themselves.

In our clinic, self-reports of rape and other forms of violence were initially under-reported in the refugee population, both for reasons of personal and social shame and because of the religious sense that complaining about hardships in the life that “God has written for you” borders upon blasphemy. We also saw a very high percentage (80%) of men under age 30 years with psychotic illnesses of acute, stormy, confused, and violent presentations, far in excess of what we had seen in other refugee groups.

 Risk factors leading to these acute psychoses appear to be childhood head injury, early childhood starvation, early and uncontrolled khat use in adolescents far in excess of that permitted in pre-Civil War Somali society, and the overall differential effects upon young boys and girls of early violence and social disruption.

Role expectations of manliness-loyalty to the clan and protection of the homestead-may have brought pressures unique to young males raised in this patriarchal society. Employing a mythical lineage identity, the clan would organize in groups to expand or defend its power base, depending upon whom one is hearing. Through this process, men of each clan forced an armed confrontation with those of other clans. Consequently, boys who were not yet of fighting age (early adolescence and even late childhood) took part in the horrors of civil violence and were scarred for life. The psychological effects of such a burden, it seems, later matured into psychotic illnesses. The weight of clan responsibility had doubled the dangers they were exposed to, as the young men were taught to defend their clan, to defend their mothers and sisters from rape; and to defend their fathers, brothers, and cousins as well as defending themselves and their honor. Yet death, rape, and destruction all arrived, regardless. Now the great grief that resulted brought about irreconcilable psychological scars that might breed a cluster of psychoses in Somali men who came of age in the Civil War and its immediate aftermath.

The other major risk factor unique to refugees from the Horn of Africa is the use of khat.

 Khat is a psychoactive alkaloid derived from the Catha edulis plant. Khat chewing is a legal and socially accepted recreational activity in the Horn of Africa countries and parts of the Middle East. Leaves of the plant are chewed slowly over the course of 3- to 4-hour khat sessions, usually restricted to men, in which a mild euphoria, accompanied by expansive plans and endless possibilities, are nourished, only to fade by the next morning.

Pharmacological and physiological effects

 are similar to amphetamines, but a slight alteration in chemical structure results in a much milder stimulant effect.

 Khat use is ordinarily socially regulated, but the breakdown of social and family structures in Somalia after 1991 allowed its use among young adolescents in amounts and frequency that previously never had been permitted. As with early and excess use of marijuana, there appears to be a correlation with onset of psychoses in early adulthood.

Pre- and post-natal malnutrition is a prominent risk factor for failure to thrive and for pathological neurological and psychological development. There was a drought and subsequent famine in 2002-2004 following the Civil War, with an estimated childhood death rate of 30% to 40%.7 Prenatal malnutrition has been linked to development of psychotic illnesses in young adults. Vitamin D deficiency is endemic in African refugees living in northern Europe and North America. Several researchers have linked 

Attaining citizenship is a source of great stress for many Somali persons with a mental illness that interferes with learning of new material, including the English language and the facts of US history and civics. Failure to obtain citizenship places a disabled person at risk of losing all federal benefits (ie, health insurance, medical insurance, housing assistance), as well as losing the legal protection given to US citizens. Loss of disability benefits often means that the Somali individual is unable to send money back to relatives in refugee camps or in Somali, a failure that involves loss of face at both personal and clan levels of expectations. The psychiatrist is often called upon to provide a lengthy N-648 waiver form for a patient, attesting that the patient’s disability is severe enough to make learning English impossible. Small discrepancies among various documents can lead to suspicions on the part of the government of dishonesty or malingering, deadly for a citizenship applicant. For young men, minor drug charges or domestic assault charges might lead to a felony conviction with subsequent deportation, now that the US recognizes the provisional Somali government.

The psychiatrists and community health centers that 

 should appreciate that an essential and integral component of care involves considerable effort in helping patients in many social and legal spheres. These involve obtaining medical benefits; assisting with the entire panoply of housing, day programs, special medical clinics, and vocational programs; and immigration issues, such as assistance in applying for citizenship or sponsorship of relatives in Africa who wish to join the patient in the US. In addition, as with many refugee populations, Somali individuals suffer from underdiagnosed and undertreated chronic medical illnesses, primarily 

, as well as excessive tobacco use in males. Stress from these many issues contribute to the illness burden of the refugee patient, and confront the psychiatrist with redefining the role and boundaries of the community psychiatrist.

 in Minneapolis and Professor of Psychiatry Emeritus at the University of Minnesota Medical School. Mr Yusuf is Case Manager at 

, University of Minnesota Medical School, Minneapolis, Minn.

Psychosis, PTSD, and depression in Somali refugees in Minnesota

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Articles

This article highlights several features of medical and social importance that are somewhat unique to the Somali refugee community in the US.

Psychiatric Issues in the Somali Refugee Population

The role of no-suicide contracts is but a small tactical piece of the larger strategic approach to the assessment and prevention of suicide. Its many obvious limitations-to some degree in assessment, but primarily in suicide prevention-should have driven serious discussion of no-suicide contracts out of consideration as a practical measure in clinical practice and a legal talking point in the courtroom. Yet the construct, practice, and surrounding discussions of no-suicide contracts survive despite all their many weaknesses and seemingly terminal status. Why? What keeps them alive?

It may be that in the microcosm of suicide prevention, where all rational strategies and predictions dissolve before the impulsiveness, determination, cleverness, and persistence that are the hallmarks of seriously suicidal persons, and where the differentiation between the seriously and imminently suicidal person and the neurotically opportunistic parasuicidal person with hidden agenda is often impossible to divine, the no-suicide contract seems to offer an arena where personal connection and human relatedness make a difference. The no-suicide contract seems to hold the promise that the strength of a relationship of a particular patient to a particular clinician will make the critical difference in keeping a person from taking the final steps in a long chain of visualized and possibly rehearsed scenarios of self-destruction.

Paradoxically, clinicians, especially in those frequent situations in which a strong relationship with the suicidal patient does not exist, instead bank on a peculiar social assumption about human behavior that has its roots in childhood and possibly even in our genes, that promises, commitments, and contracts are binding on each individual even in the face of inconvenience, even when contrary to our strongest urges. It is as if "promises are to be kept" is the 11th commandment by which we guide our lives.

What are the limitations of the no-suicide contract? They are vast. If we first examine its use in suicide assessment, it is sometimes said that refusal to commit oneself to a no-suicide contract conveys to the clinician that the person is seriously contemplating suicide and does not want the moral encumbrance of a promise to act as a brake.

 The assumption is that the scruples of the person, however suicidal, would actually interfere with agreeing to a no-suicide contract. Such is the assumed power of keeping one's word, no matter what. Deception is worse than death.

Optimistically, refusal to agree to a no-suicide contract may be intended by the suicidal person as a communication of serious intent in order to give the clinician an opportunity to intervene. In such a case, the clinician would be insensitive and even negligent in not acting on this cue to safeguard the patient. This is the best that can be said about a no-suicide contract as an assessment tool. The problem is, as can readily be appreciated, that refusal to agree to a no-suicide contract can have many other meanings, centered around motives and personality styles of struggle, hostile or dependent engagement, victimization mentality, testing of a relationship, and the need to raise the stakes and create excitement in one's life. Reciprocally, agreement to a no-suicide contract may be a disingenuous attempt to avoid interference with one's serious suicidal intent. The upshot is that agreement with a no-suicide contract does not help in assessment of suicide and refusal of a no-suicide contract still leaves the clinician guessing about the meaning and importance of the refusal.

Furthermore, the attempt during an initial evaluation, especially in situations of high stress and preoccupation with suicide, to obtain a no-suicide promise from a patient whom one has just met has the strong potential to backfire because it lends itself to the perception that the clinician is more interested in legalistic self-protection than in understanding the patient's desperate situation. This again raises the question of whether the no-suicide contract has relevance and benefit only in situations in which some sort of therapeutic relationship already exists. The psychiatric literature is in agreement that a no-suicide contract, if it is employed, cannot substitute for the careful and detailed assessment of suicide risk.

In the arena of suicide prevention, the issues are muddier and more complex rather than simpler. First of all, characteristics of the patient under evaluation, the context and location of the interaction, and the nature of the relationship between patient and clinician are very important. It makes no sense to indiscriminately endorse no-suicide contracts generically as is often done at the time of admission to an inpatient unit. However, collaborating on an initial treatment plan by spelling out what the ideal expectations of patient and clinician are and communicating genuine concern for the patient at both a professional and personal level, even at a first meeting, needs to be distinguished from the formalistic procedure of extracting a promise to forswear suicidal and other self-injurious behaviors.

Some inpatient services include a no-suicide contract in the documents that a patient initials or signs on admission: laundry list, HIPAA confidentiality regulations, personal belongings put into storage, insurance information, smoking policy, and meal schedule. In effect, a tool that might be useful in a family setting in which there is an ongoing relationship with the patient is being used during a nursing evaluation and management of risk of the patient, in a setting in which the parties to the "contract" are essentially strangers to each other.

Given that the average length of inpatient stay has been reduced in the past few decades to 3 to 7 days and that criteria for admission have been constricted to imminent risk of suicide, homicide, or total failure of outpatient treatment programs, clinicians must safeguard and treat an increasingly high-risk, impulsive, often drug-addicted population with strategies that do not allow much development of a therapeutic relationship.

 found that patients who had no-suicide contracts were more likely to engage in self-harm, although it is possible that negotiation of a contract reflects staff assessment of high risk. Hospitalization is no longer a process that emphasizes daily involvement with a psychiatrist and a close working relationship with nursing staff. As a corollary, keeping suicidal patients safe on a ward requires well-defined algorithms and protocols for assessing suicidality and implementing whatever procedures, including increased nursing time spent with a patient, are required, with no place for perfunctorily signed no-suicide contracts.

In an outpatient situation, all the standard limitations of no-suicide contracts apply. Investigators agree that there is no empirical evidence that use of these contracts reduces risk of suicide; there are few studies and no controlled studies. In response to hearing about a clinical psychologist who was censured by the Minnesota Board of Psychology for not obtaining a no-suicide contract with a borderline patient who threatened but did not make a suicide attempt, and curious about the psychology board's rationale for this disciplinary action, I undertook a postcard survey of 514 psychiatrists in Minnesota inquiring about no-suicide contract practices.

Of the 267 respondents, 152 (57%) used no-suicide contracts. Within this group, 62 (41%) psychiatrists reported that they had patients who had committed suicide or made a serious attempt after entering into a no-suicide contract. There was an inverse relationship between the use of no-suicide contracts and years out of residency training. The reason more experienced psychiatrists are less likely to use no-suicide contracts are not entirely clear, but it may in part relate to the seasoned judgement that if a therapeutic relationship is already present, then a formal contract has no moral claim on a patient. It may also be that psychiatrists recently out of training are more accustomed to using formal assessment instruments and legalistic forms than are older practi- tioners. Although experienced psychiatrists used no-suicide contracts less frequently, a higher percentage of ex- perienced psychiatrists reported serious or completed suicide attempts in their practices. It is assumed that this finding reflects the greater number of years at risk for having suicidal patients in one's practice.

There were 2 goals to this study. The first was to inquire whether there was a standard of care among psychiatric practitioners about the use of no-suicide contracts. The answer was clearly no; slightly more than half of the respondents used it. The second goal was to obtain a rough measure of the effectiveness of no-suicide contracts. The limitations of the study are many, including lack of a control group, self-reported data, and sample bias in who responds to a postcard survey. Nevertheless, it is clear that no-suicide contracts are of little assistance, on average, in preventing serious suicidal behavior; although, there undoubtedly are cases in which a no-suicide contract as part of a richer therapeutic relationship between patient and clinician is effective.

There are situations in which rote adherence to a no-suicide contract policy interferes with effective treatment.

 The policy at a rural mental health program that operated a crisis hotline was that with suicide calls, the telephone counselor could not disengage until a no- suicide contract or promise was extracted from the caller. A patient with borderline personality disorder (BPD) came to appreciate the opportunity this policy afforded and began telephoning the crisis line 3 or 4 evenings per week, keeping the counselor on the line for an hour or two before reluctantly agreeing to a no-suicide pledge. This patient had never posed a serious threat for suicidal behavior, but the policy, until modified, did not allow for common-sense contingencies, such as limiting the telephone calls to 10 minutes per evening, or scheduling the patient to call in each evening for a brief status report.

If we consider the diagnostic spectrum, it appears that no-suicide contracts, in and of themselves, are untrustworthy in patients with schizophrenia whose suicidality may be psychotically driven, with alcoholic patients who are impulse-driven and cognitively and conatively incompetent when intoxicated, and with patients who have BPD for whom requests for a promise are overladen with too many control, manipulation, and relationship issues. It is also likely that a no-suicide contract would have different meaning and usefulness to adolescent, middle-aged, and elderly patients, but this too is an unexplored arena.

Is it time to dispense with the no-suicide contract?

Recently, writers on this topic have concluded that the no-suicide contract is a construct that has outlived its usefulness. It sets up the clinician for a nasty court battle in cases of completed suicide and suicide attempts that result in serious injury to the patient and provides little or no advantage overall. In its place, most investigators advocate careful suicide assessment and documentation and a suicide prevention plan that is one piece of a larger therapeutic contract, however construed. The decision to have a formal contract versus an informal therapeutic understanding appears to have as much to do with the clinician's personality and theoretical approach as it does to an evidence-based decision.

 working from a cognitive-behavioral model, have written an interesting piece criticizing the conceptual basis and practical use of no-suicide contracts. In its place, they advocate an individualized commitment-to-treatment statement that is drafted and handwritten by both patient and therapist. This statement encompasses many areas of commitment to a broadly conceived therapeutic relationship, including such housekeeping topics as attendance at sessions, setting goals, completing homework assignments, and voicing opinions honestly. Included in the commitment-to-treatment statement is a crisis response plan that again is tailored to a specific patient and, by agreement, is time-limited. If advisable, family members' roles are incorporated into the steps of the crisis plan for when self-management fails.

The notion of a broad commitment-to-treatment statement that includes a crisis response component makes much sense; however, it cannot be applied to all patients in an outpatient practice, nor would it fit in with different styles of psychiatric and psychological care. Although its virtues cannot be questioned, it may be too rational and too formal and not fit some psychiatrists' style of interaction with patients. Perhaps it is best suited for a cognitive-behavioral psychotherapy practice.

An alternative approach is to openly discuss suicide risk and available responses to suicidality, including many of the elements mentioned by Rudd and colleagues,

 and to convey to patients concern about their safety and survival without extracting a no-harm pledge from a patient. As stressed by most articles in the psychiatric literature on suicide prevention, it is imperative to document assessment of risk and the response options discussed with the patient. Lee and Bartlett

 present an extended discussion of suicide prevention without the use of a no-suicide contract that includes thorough assessment, creation of an appropriate management plan, involvement of family and significant others, consultation with other professionals, and implementation of a plan that assumes professional responsibility.

It is hazardous to develop absolute dictums in psychiatric practice beyond the general understandings against exploitation of patients. Assuming that the therapist's intentions toward a patient are professionally benevolent, questions still remain about what is best for a particular patient in specific circumstances. In the absence of evidence-based practice guidelines-and most daily psychotherapeutic interactions fall into this category-it is impossible to say that a no-suicide contract should never be used. This modesty of imperatives keeps the notion of no-suicide contracts as one of the viable options that the clinician may consider in working with patients at risk for self-harm. There is no good statistical evidence that no-suicide contracts do more benefit than harm, but the possibility that such negotiations may be helpful for some clinicians in some situations precludes any absolute recommendation against their use.

Recent psychiatric literature on the topic advises against routine use of no-suicide contracts as a suicide assessment or prevention tool or as a method of providing some legal protection in the advent of suicide completion and serious attempts.

 This is especially the case when a no-suicide contract is expediently substituted for a careful assessment of risk and a thoughtful and collaborative development of a suicide prevention plan.

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 Kennedy SP, Baraff LJ, Suddath RL, Asarnow JR. Emergency department management of suicidal adolescents. 

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 Lee JB, Bartlett ML. Suicide prevention: critical elements for managing suicidal clients and counselor liability without the use of a no-suicide contract. 

The role of no-suicide contracts is but a small tactical piece of the larger strategic approach to the assessment and prevention of suicide. Its many obvious limitations-to some degree in assessment, but primarily in suicide prevention-should have driven serious discussion of no-suicide contracts out of consideration as a practical measure in clinical practice and a legal talking point in the courtroom.

No-Suicide Contracts as a Suicide Prevention Strategy

During the past two decades, the Twin Cities experienced an unprecedented increase in refugees from Southeast Asia, the Horn of Africa and Latin America. Most of these immigrants were political and war-zone refugees who arrived in the United States with a broad range of trauma-related injuries in addition to the problems attendant upon dislocation from one's homeland and traditional culture. The Community-University Health Care Clinic (CUHCC), in a poverty-line neighborhood in Minneapolis, was designated as the major primary health care facility to develop medical, psychiatric and outreach services for these refugee populations. The CUHCC represents a joint academic and community enterprise committed to providing care for a traditionally underserved urban neighborhood. The clinic is funded by a variety of federal, state, county and private foundation grants.

The life experiences encountered by most disaster-zone refugees can be divided into several phases of varying duration and duress (Table 1). The last phase (demoralization) occurs among the less successfully assimilated families as the early hopefulness of the refugee family and the generosity and patience of the host country wane.

In thinking about refugee health problems and planning and implementing various types of services, there is a dynamic interaction between the commonality of all refugees by virtue of their humanness and their exposure to invasion, occupation, violence, lawlessness, persecution and loss and the differences between the refugee groups in terms of national, ethnic and cultural history and customs; vastly different trauma and escape experiences; and different degrees of preparedness for the accommodations necessary to survive and flourish in the United States (Kroll et al., 1989). Finally, there are individual differences among human beings in constitution, life experience, personality and resilience, as well as cohort differences such as in the case of Southeast Asian refugees whether one emigrated to the United States in the first waves in the early 1980s or came belatedly 15 to 20 years after these initial groups (Bowman, 1999; Brewin et al., 2000; Westermeyer, 1987).

This article will present the clinical experience of the different ethnic and national refugee groups at CUHCC. Our experience with Latin American refugees is very limited; therefore, this group will not be discussed. The only caveat to bear in mind is the inherent problem in making generalizations about national characteristics and experiences; however, generalizations are as necessary as individualization to clinical research and work.

Despite our awareness that the countries of Europe are very different from each other, Americans might have thought of the peoples of Indochina as essentially homogeneous prior to the Vietnam War. On the contrary, the prewar culture and the experience of the war were vastly different for each of the ethnic groups comprising Southeast Asia. There were differences between the Cambodian four-year experience of the Khmer Rouge killing fields; the Hmong experience of (from their point of view) working for the Central Intelligence Agency and the U.S. government until they were abandoned in 1975 and thereafter moving from village to village in the jungle under Communist attack; the Lao experience of ground warfare against the Communists alternating with heavy aerial bombardment from U.S. forces; and the Vietnamese experience of heavy ground warfare against a very disciplined army while contending with a demoralized home front. In addition, surviving Lao and Vietnamese military officers and government officials were sent to Communist re-education camps in wilderness areas for many years to clear jungles and build irrigation systems. The families of the men interned at these camps faced economic and social persecution.

An obvious, but often overlooked, individual difference between refugees is their age at the time of each phase of the war and at the time of escape. For example, a cohort of Cambodians born between 1972 and 1978, now in young adulthood, experienced fetal and childhood starvation conditions. While studies just from the Hunger Winter (1944-1945) in the Netherlands suggested increased morbidity of psychiatric illness of those in gestation during this famine (Brown et al., 2000), we have seen almost no Hmong with schizophrenia in our 25 years at the clinic. We would welcome comments and feedback from other clinical centers about this observation.

The Somali experience of the Civil War of 1991 and its aftermath is vastly different from the Southeast Asian wars. There was sporadic violence and lawlessness and a repressive regime in Somalia prior to 1991. Then, with the sudden collapse of all government authority, the country erupted into anarchy and unchecked internecine slaughter between clans. Somali patients seen at the clinic fall into two very different categories. The majority of Somali patients are middle-aged women whose experience, if it were not so horrific, sounds very stereotypical. A band of marauders break into a house, shoot and kill the menfolk in front of the women, and then beat and rape the women sometimes literally next to the dead male bodies. This may be a hit-and-run assault or the marauders may stay for hours to days, with repeated sexual assaults. Occasionally, the younger women are abducted when the bandits leave, usually not to be seen again. The surviving family members, usually women and children, flee by whatever means possible, often without the opportunity to bury their dead.

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 

 (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.

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 

 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 

 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.

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.

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The chief psychiatrist of the Community-University Health Care Clinic in Minneapolis reflects on what he's learned caring for refugees from Southeast Asia and Somalia. His experiences can educate others caring for immigrants and refugees.

Jerome Kroll, MD

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