A Diverse Refugee Population Requires Complex Solutions

Oct 01, 2003

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.

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.

Cultural Influences on PTSD

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 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.


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