A Model for Treating Refugees Traumatized by Violence

July 10, 2009
J. David Kinzie, MD
Volume 26, Issue 7

Many refugees have been victims of severe violence that has profoundly affected their physical, psychological, and spiritual lives.

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 Bosnians, 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 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.

As evidenced by our patients, PTSD and MDD usually run a chronic course, and treatment is of long duration. Therapy generally affords a rapid reduction in the most obvious symptoms (such as nightmares and startle reaction); nevertheless, patients remain highly vulnerable to stress.3 Stress secondary to news of renewed fighting in their homeland and worry about relatives left behind typically exacerbates symptoms in almost all patients. Many refugees were greatly disturbed by the events of 9/11. Like many Americans, these patients believed they were safe in the United States; after the attacks, they felt that the horror they had experienced had followed them here.4

There is a high rate of hypertension (44%) and diabetes (15%) among all the refugee populations who attend our clinic. This finding does not seem to be related to trauma as much as to obesity.5 In addition, the high incidence of these disorders is not related to ethnicity (rates are the same across all ethnic and racial groups). Because combined medical and psychiatric care is necessary, we have started to screen for these 2 disorders and have a primary care physician available in our clinic to attend to immediate problems.

Treatment approaches
Treatment of refugees who have survived violence and torture is complicated and not formula-bound (Table). Therapy must address the interface of psychiatric disorders related to trauma with an understanding of cross-cultural needs. Cultural sensitivity and awareness of the effects of massive trauma are crucial. One of the most important aspects of our approach has been the consistent relationship of the counselor, psychiatrist, and patient over the long period needed for treatment. Stress reduction is also essential and is achieved by ensuring that patients have housing, a social network, and adequate food, and by providing continuity of care in the community and alleviating symptoms with medication.

Psychotherapy is of a supportive-dynamic type: the clinicians listen to the patient’s story and stay with the patient through the difficult process of coming to terms with the trauma and adjusting to life in the United States. Educational reframing (ie, defining the symptoms as the body’s response to massive trauma) provides a cognitive frame of reference to all patient groups. However, highly specific techniques, such as cognitive-behavioral therapy or exposure therapy, may be culturally inappropriate, or may seem like “tricks” to those who have suffered severe interpersonal losses or existential crises.

Clearly, many of the problems can­not be fixed. Family members cannot be brought back; cultures will never be the same; and (for some) status, position, and income will be forever lost. There is no easy solution, but relieving the symptoms and staying with the patients through the ups and downs of their lives has been very valuable. Many patients have never had a chance to tell their story before, nor have they had someone listen with compassion.6

Group therapy of a socialization type has been very helpful. Sessions are used to educate the patient about the symptoms associated with the disorder; to promote the patient’s culture and holidays; and to bring together people of different cultures for American celebrations, such as Thanksgiving. Group sessions also give patients the opportunity to share their experiences and challenges in adjusting to life in this country. (Many of our middle-aged parents are having difficulty in raising their children in the United States.) More than half of our patients attend socialization groups.7

Medicines have been particularly helpful. Antidepressant medicines, both SSRIs and tricyclics, are very useful for the depressive symptoms. The tricyclics, such as imipramine and doxepin, help with insomnia- a common problem among this patient population. There is strong evidence that prazosin and clonidine help reduce nightmares and, to some extent, startle reactions.8 Occasionally, when aggressive behavior must be addressed, risperidone has been useful.

The usual antipsychotic medications, both first- and second-generation, have been useful for patients with chronic mental illness. Because adherence has been a problem, most of our patients with schizophrenia are treated with long-acting injectable medicines, such as fluphenazine, haloperidol, or risperidone.

Outcomes
We believe our program is a successful one, but we have not yet statistically evaluated patient outcomes. Perhaps unique for a minority mental health clinic, 90% of our patients keep their appointments for physician visits. We have, however, followed responses to treatment with the Sheehan Disability Scale, which indicates diminished impairment in social functioning and family/home life. With a sample of 70 Somali, Ethiopian, and Kurdish patients over 1 year, the Sheehan Social Disruption scale average went from 8.0 to 5.8 (x2 < .0001) and Family Disruption went from 7.6 to 5.8 (x2 < .001). Nevertheless, some of our severely traumatized patients have symptoms even after 25 years of treatment.

We are beginning a project to determine the effects of treatment on quality of life, the effects of social and family impairment, as well as the effects of symptoms reduction in a prospective manner to evaluate this very traumatized group.

Conclusions
Those of us who treat this population find some of the countertransference issues difficult. It can be challenging to maintain the right therapeutic balance between over-involvement and emotional distance. Treatment is difficult and takes a toll on providers. Our medical staff and counselors find peer interaction and support necessary to maintain our emotional balance.

Despite the difficulties in treating survivors of violence and tragedy, the work is ultimately rewarding and fulfilling. Physicians cannot stop all the violence in the world, but we can comfort the suffering survivors and be compassionate witnesses to their pain.

Disclosures:

Drugs Mentioned in This Article
Clonidine (Catapres)
Doxepin (Adapin, Sinequan)
Fluphenazine (Prolixin decanoate)
Haloperidol (Haldol)
Imipramine (Tofranil)
Prazosin (Minipress)
Risperidone (Risperdal)

References:

1. Boehnlein JK, Kinzie JD. Refugee trauma. Transcultural Psychiatry. 1995;32:223-252.
2. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005;365:1309-1314.
3. Boehnlein JK, Kinzie JD, Sekiya U, et al. A ten-year treatment outcome study of traumatized Cambodian refugees. J Nerv Ment Dis. 2004;192:658-663.
4. Kinzie JD, Boehnlein JK, Riley C, Sparr L. The effects of September 11 on traumatized refugees: reactivation of posttraumatic stress disorder. J Nerv Ment Dis. 2002;190:437-441.
5. Kinzie JD, Riley C, McFarland B, et al. High prevalence rates of diabetes and hypertension among refugee psychiatric patients. J Nerv Ment Dis. 2008; 196:108-112.
6. Kinzie JD. Psychotherapy for massively traumatized refugees: the therapist variable. Am J Psychother. 2001;55:475-490.
7. Kinzie JD, Leung P, Bui A, et al. Group therapy with Southeast Asian refugees. Community Ment Health J. 1988;24:157-166.
8. Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract. 2007;13: 72-78.
Evidence-Based References
Boehnlein JK, Kinzie JD. Pharmacologic reduction of CNS noradrenergic activity in PTSD: the case for clonidine and prazosin. J Psychiatr Pract. 2007;13:72-78. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet. 2005; 365:1309-1314.