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Strange is our situation here on earth. Each of us comes for a short visit, not knowing why, yet sometimes seeming to divine purpose. From the standpoint of daily life, however, there is one thing we do know: That we are here for the sake of humanity . . . for the countless unknown souls with whose fate we are connected by a bond of sympathy. Many times a day I realize how my own outer and inner life is built upon the labors of my fellow human beings, both living and dead, and how earnestly I must exert myself in order to give in return as much as I have received and am still receiving.

Albert Einstein, quoted in Pediatrics. 100(5), 878.

Many refugees are at high risk for mental health problems as a direct result of the refugee experience. Primary factors leading to this increased risk are war/trauma experience and displacement. Many refugees also experience psychosocial and environmental problems in the host country that negatively affect their mental health. It should be remembered that in addition to these factors, refugees are subject to the same mental health problems as any other population. Here we will examine only mental health issues specific to refugees.

War/Trauma Experience

War is a brutal experience, and to those who have not experienced it, is simply unimaginable. Even a brief contact with war or war-like circumstances has a lasting effect on many people. Rescue workers and survivors at the Oklahoma City Federal Building bombing, for example, are, and in some cases will always be haunted by what happened there. Compare that one-time event to the multiple bombings, artillery attacks, and other sustained violence of war. Caught in the middle and burdened by family and possessions, refugees often experience far greater brutality than combatants. Common to all such experiences are a shattered illusion of safety and a penetrating awareness of vulnerability. Traumatic experiences of refugees may include experiencing or witnessing the following (1):

Imprisonment is common and being held in isolation tends to be more traumatic. In contrast to imprisonment in more lawful circumstances, imprisonment for refugees often includes not knowing the fate of loved ones. Visitors and news are seldom allowed in refugee prison circumstances.

Rape and other assaults are far more common than generally reported and torture is also common. Common forms of physical torture are beating, electric shock Bed Frame Used for Torture (Cambodia)(increasingly used because no signs are left), burning, asphyxiation, stretching, genital trauma and rape. The bed frame at the right was used to torture prisoners at Tuol Sleng Prison in Cambodia. Common forms of psychological torture are threats, isolation, mock execution, forced witnessing of torture or execution, and sleep deprivation. See links below. In some cases, e.g., Serbia and Burma (Myanmar), rape is an institutionalized weapon of war.

Combat atrocities; including bombing, explosions, and other means of mass killing are very common. Refugees may witness multiple killings extending over time. Executions may be witnessed and some refugees have been subjected to mock executions.

THE SECURITY REGULATIONS (Tuol Sleng Prison)

1. YOU MUST ANSWER ACCORDINGLY TO MY QUESTIONS. DON'T TURN THEM AWAY.
2. DON'T TRY TO HIDE THE FACTS BY MAKING PRETEXTS THIS AND THAT. YOU ARE STRICTLY PROHIBITED TO CONTEST ME.
3. DON'T BE A FOOL FOR YOU ARE A CHAP WHO DARE TO THWART THE REVOLUTION.
4. YOU MUST IMMEDIATELY ANSWER MY QUESTIONS WITHOUT WASTING TIME TO REFLECT.
5. DON'T TELL ME EITHER ABOUT YOUR IMMORALITIES OR THE ESSENCE OF THE REVOLUTION.
6. WHILE GETTING LASHES OR ELECTRIFICATION YOU MUST NOT CRY AT ALL. WHEN I ASK YOU TO DO SOMETHING, YOU MUST DO IT RIGHT AWAY WITHOUT PROTESTING.
7. DO NOTHING. SIT STILL AND WAIT FOR MY ORDERS. IF THERE IS NO ORDER, KEEP QUIET.
8. DON'T MAKE PRETEXTS ABOUT KAMPUCHEA KROM IN ORDER TO HIDE YOUR JAW OF TRAITOR.
9. IF YOU DON'T FOLLOW ALL THE ABOVE RULES, YOU WILL GET MANY LASHES OF ELECTRIC WIRE.
10. IF YOU DISOBEY ANY POINT OF MY REGULATIONS YOU WILL GET EITHER TEN LASHES OR FIVE SHOCKS OF ELECTRIC DISCHARGE.

Home and possessions are destroyed or left behind. Any valuables retained at the beginning of the refugee process may be stolen by soldiers, bandits, or refugee camp guards; or traded for food or medicine. The majority of refugees come to countries of second asylum with nothing but clothes and perhaps one or two momentos of their former life.

Family members are separated, wounded, or killed. During fighting or while fleeing, separation of family may occur; and for various reasons, some members may be left behind. In our years of work with refugees, we have heard countless stories of parents, grandparents, or others left behind and never again seen. This is a source of chronic unresolved grief for many survivors.

How I Came to America (Anonymous)

It was very difficult to leave Cambodia. There was very little food, even though people were made to work very hard. Pol Pot's soldiers killed many people. The Vietnamese came and fought with Pol Pot's army.

I remember being happy in Cambodia when I was little. I remember helping my Grandfather and Grandmother make clothes to sell. They let me fold and help cut material. Then they would sew the material to make clothes.

I remember playing games, fresh coconuts, and the temple Angkor Wat.

I remember many things that make me very sad. I will tell you about them.

We rode the train from Phnom Penh to Battambang. From Battambang we started walking to Thailand. We had to leave. My father, my mother, brother, sister, grandfather and grandmother all went together. We were walking through the forest. The trees bent back and forth, the leaves fell to the ground like raindrops, but there were no clouds in the sky. The Vietnamese and Pol Pot's soldiers captured us. They did some terrible things I will never forget. They tied my mother and father to trees. My mother was going to have a baby but she was very skinny. They took a sword and cut her stomach opened and cut the baby out and killed it and cut her again. She screamed and screamed! Many days I put my head on my desk and still hear her screaming. They shot my father in the head. They dug a big hole and put my grandfather and grandmother in it and other people too. They threw grenades into it and blew all the bodies apart. This soldier helped us try to get away with my aunt. They shot at us. They threw a grenade. They shot my toes and part of the grenade hit me in the back. I almost died.

The Vietnamese came and made Pol Pot's soldiers leave. The Vietnamese doctor came and gave me a shot and took me to a hospital in a tent. I got better. My aunt carried me to Thailand.

I went to school 4 days in Thailand. I came to America on June 25, 1981.

Hunger is widespread. Food (or its lack) is a classic and effective weapon of war, and civilians, of course, are the last priority for receiving food and the first to have it taken away. Children are at the greatest risk for malnutrition. Contrary to the common images of starving children, malnutrition is most often manifested by decreased activity and delayed development in children whose bodies range from thin to appearing normal.

Health is compromised. Risk factors include nutritional deficiencies, shortages of medicine, shortages of health personnel, and lack of facilities. Health problems are discussed in a later section.

Life in a refugee camp, especially in countries of first asylum, is usually difficult. Conditions in most camps are primitive and dangerous, with some camps similar to third-world prisons.

These and other factors lead to a high incidence of (a) anxiety disorders, especially posttraumatic stress disorder (PTSD) or combat stress reaction (CSR) and to a lesser extent (b) depressive disorders. Grief is a major factor in the lives of many refugees and grief therapy is a helpful model in counseling refugees with PTSD and other distress.

Displacement

"When we came to America we were so scared. Somehow we just lost. Maybe our souls. We don't know."

Refugees leave their homeland and culture with little hope of return. "Culture shock" is thus overwhelming and for older generations with less ability to adapt, unrelenting. A lifetime of memories, familiarity, and accomplishment is abandoned and a completely new and often incomprehensible and hostile world is entered. Language, customs, and values of the new world are not only different from those of the refugee, but also are perceived by some refugees and some people in the country of refuge as superior to the language, customs, and values of the refugee. Adjustment to the culture in the new home is often more difficult for refugees than for immigrants; and is most difficult for older refugees.

Some refugees experience displacement worse than what follows, some experience better, and some are displaced several times. To understand the power of displacement, it is helpful to follow a relatively typical process in a person becoming a refugee.

Displacement usually begins with war. A few people decide to leave early, but most are reluctant to leave their homes and thus wait until there is no choice. Events may suddenly occur, e.g., a successful offensive, and families forced to leave with only what they can immediately pick up and carry. Somewhere along in the process of leaving ñ before, during, after, or throughout ñ there is usually brutality. The brutality may be impersonal like bombs or artillery or may be very personal like assaults or torture. In either case, displacement is often accompanied by physical and/or psychological trauma. Even without the accompanying trauma, displacement is a wrenching event.

To the displaced person, whether rich, middle-class, or poor, displacement is much like it would be for you or me to walk away from home, career, culture ñ everything familiar and everything attained ñ and never return.

Constructs such as "social displacement syndrome" and "survivor syndrome" applied to refugees give a relatively consistent picture of responses to displacement. Although presented as "stages" here, these are better thought of as a process of common states of mind/response(s) often experienced by refugees, especially those who have had traumatic displacement experiences (2).

The first phase of displacement is the wartime and/or repression that lead to the necessity of leaving. This is discussed in the section on war/trauma experience.

The barbed wire phase (a term from holocaust literature) represents time spent in refugee, austerity, or even concentration camps. This phase also includes time living under hostile totalitarian governments as in phase one. This phase is characterized by suppression or repression of feelings and normal responses to circumstances. The genesis of chronic post-traumatic stress disorder is found in this and other phases, when normal responses to stress are not allowed or experienced.

The liberation and following year phase may begin with life in the country of first asylum if living and other conditions are positive. If living conditions in the country of first asylum are difficult (e.g., Kurdish refugees in some Turkish camps, Burmese refugees in Thai border camps, etc.), liberation may not be felt to begin until the country of second asylum is reached. This phase is characterized by some euphoria, and a degree of cognitive or emotional disorganization related in some cases to separation of family members.

The early after-effects phase occurs when a refugee reaches stable and relatively safe refuge, e.g., the country of second asylum. Ambivalence in thought and behavior are characteristic of this phase as the refugee reorganizes patterns of living and perception to deal with life in the new land. New and effective behaviors may be in conflict with old and more deeply held values. It is at this time that the refugee may begin to confront behaviors that resulted in survival but conflict with the ego ideal, e.g., fleeing for survival while others may have stayed to fight. The conflict between reorganized patterns of living vs. older values + the unresolved issues of displacement may result in chronic anxiety, flattened emotions, loss of self-esteem, depression, and recurrent nightmares. Problems may be well masked.

The delayed after-effects phase is characterized by withdrawal and exacerbation of the above problems masked in many cases by frequent alcohol use. Family conflict may worsen and be exacerbated by young peopleís embrace of the new cultureís values and rejection of the past.

A recovery phase with some degree of assimilation and acceptance of the new circumstances is, hopefully, the last phase.

In some cases, displacement is a desired and much anticipated event. Many Cubans, for example, have planned their escape for years and leave willingly. Even in these circumstances, there often comes a time when the old place seems far more desirable that the new place.

The Consequences of War/Trauma Experience and Displacement

The most common negative outcome of war/trauma experience and displacement is posttraumatic stress disorder (PTSD) or some variation on PTSD (3-7). These and other mental health problems are compounded by great difficulty accessing and obtaining, on a consistent basis, any sort of effective health care and an almost complete inability to access mental health services.

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV) (8) identifies "psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders" (page 29). These problems fit ñto a startling extent ñ the circumstances of many refugees. They include:

  • Problems with the primary support group, such as the death of a family member, family disruption, and abuse.
  • Problems related to the social environment, such as death or loss of a friend, inadequate social support, acculturation problems, and discrimination.
  • Educational problems, including illiteracy and academic problems.
  • Occupational problems, including unemployment and stress at work.
  • Housing problems, such as inadequate housing, unsafe neighborhood, or problems with neighbors.
  • Economic problems.
  • Problems with access to health services (and we would add, staying in the health care system).
  • Problems related to the legal system.
  • Other psychosocial and environmental problems, including exposure to disaster or war and unavailable social services.

All these (except problems related to the legal system - usually) fit the circumstances of virtually all refugees, especially early in the refugee process. The cumulative negative effects of these factors contributes to the development, exacerbation, and difficulty resolving the mental and other health problems of many refugees.

Posttraumatic Stress Disorder

Anxiety disorders such as posttraumatic stress disorder (PTSD) and/or combat stress reaction (CSR) are common responses to war and related or similar trauma. Symptoms of PTSD or PTSD-like disorders are often accompanied by depressive symptoms. The focus in this article is on PTSD because most studies on refugees have identified PTSD as a primary problem rather than CSR. Diagnostic criteria (or assessment parameters) of PTSD as defined in the DSM IV include:

  • Exposure to a traumatic event involving (a) actual or threatened death or serious injury to self or others and (b) a response of intense fear, helplessness, or horror. Note that children may respond with agitation or disorganized behavior.
  • Persistent and distressing reexperiencing of the traumatic event in one or more of the following ways: (a) intrusive recollections, (b) dreams of the event, (c) reliving the event such as in flashbacks, (d) intense psychological distress from exposure to external or internal cues to the event, (e) physiological activity (increased heart rate, chest pain, difficulty breathing, diaphoresis, etc.) from exposure to external or internal cues to the event. Note that children may express or experience these differently than adults.
  • Persistent avoidance of stimuli related to the trauma and "numbing of general responsiveness (not present before the trauma)" such as (a) attempts to avoid stimuli such as thoughts, feelings, places, or people related to the trauma, (b) inability to remember key aspects of the trauma, (c) decreased interest or participation in activities, (d) feeling detached or estranged from others, (e) decreased affect such as inability to feel love, and/or (f) decreased sense of future.
  • Persistent "increased arousal (not present before the trauma)" such as (a) difficulty sleeping, (b) irritability or anger, (c) difficulty concentrating, (d) hypervigilance, and/or (e) increased startle response.
  • Symptoms last more than one month.
  • Distress results in significant symptoms or impairment.

PTSD is classified as acute if symptoms last less than three months, chronic if symptoms last more than three months, and delayed onset if onset is at least six months after the traumatic event. Most refugees with PTSD in countries of second asylum would thus have chronic (and often delayed onset and chronic) PTSD.

The incidence of PTSD as defined by the DSM IV among adult and child refugees from war zones ranges from 25%-94% (3-7). The incidence and severity of PTSD are often directly related to the frequency and severity of trauma. Other factors influencing or acting as protective factors in PTSD include:

  • Preparedness for trauma, with persons prepared for trauma, e.g., political activists, faring better than those unprepared, e.g., civilians or other non-activists (9).
  • The existence or absence of spirituality in the person experiencing trauma, with spirituality playing a protective role.
  • Both the preceding may be seen as related to the presence or absence of meaning, identified by Victor Frankl after World War II as an important factor in survival in concentration camps.

In the case of refugees, a common exacerbating factor in developing PTSD or confounding factor in treating it is that there is neither time nor resources available after the trauma(s) for dealing with or integrating the trauma. War-time presents little opportunity for dealing with anxiety; some totalitarian regimes do not allow expression of feelings; living as an asylum-seeker in the country of first asylum adds to the uncertainty and stress; and living in the country of second asylum may mean an absence of culturally, linguistically, and/or spiritually appropriate means of addressing psychological/emotional pain. In countries of second asylum many refugees also work extraordinarily hard, hence have little energy for dealing with problems. Conversely, many refugees are unemployed and unable to mobilize themselves for life itself, much less, addressing psychological problems.

The incidence or severity of PTSD or PTSD-related disorders tends to decrease with time after the stressful event(s). Although healing is slower in more traumatized persons and groups, there is a reduction in symptoms and decline in distress. A common pattern is alternating responses of intrusion and avoidance that changes as an individual works through or adapts to the trauma. Intrusion gradually shifts more into avoidance as time passes (10).

The refugee affected with PTSD is not an isolated individual, but a part of a family and community hence the consequences of distress touch others. Indeed, in some cases, PTSD is related across parent-child generations (5).

Grief

Grief is the normal response to loss and must be considered in an attempt to understand the mental health of refugees. Responses to trauma often resemble or can be described in terms of grief reaction or delayed grief reaction. Through displacement and war, refugees lose their home, possessions, and often, loved ones or sense of self. Any one of these losses might result in severe grief. Other losses that may be less obvious include:

  • The unconditional loss of a war, i.e., complete dominance by a hostile force, may be a shattering blow to individual and community esteem.
  • Decisions made during war or flight from war may come to haunt refugees as they shift from circumstances of war to those of peace. What seemed necessary, if not right at one time may later be perceived as wrong and perhaps unnecessary.
  • Old ways of life are seldom valued in the new life. The respected family or village elder becomes irrelevant, impotent, or even an object of ridicule. Relations within families or groups undergo irrevocable change. Rituals, ceremonies, and perhaps religions are out of synch with the mainstream culture and may thus lose at least some of their power. Adjustment to the new culture, for which many refugees strive, means losing the old while never quite gaining the new. These losses are complicated by difficulty in articulating them to others.
  • Loss of future is a subtle and little-understood phenomenon. For many refugees the future seems at best uncertain. Once safety is reached, there is a sense of great relief. However, the relief is often followed by persistent and well-founded uncertainty and anxiety about the future.
  • As is true with PTSD, grief may affect individuals, their families, communities, or even be seen in terms of cultural grief and bereavement (5).

Dysfunctional or complicated grief is grief that lasts longer and is characterized by greater disability or dysfunctional patterns than is usual among persons of a particular culture. Assessment parameters include (a) the loss of something important (see above) and (b) responses including prolonged, disabling changes in life patterns, e.g., sleep, dreams, libido, concentration; excessive anger, crying, sadness, guilt; difficulty expressing or denial of the loss; repetitive reliving of experiences related to the loss and/or ineffective attempts to address the loss or replace the lost object; and verbal expression of lasting distress over the loss.

Suicide

Persons who are bereaved or have PTSD are at risk for suicide. Factors that increase risk of attempting suicide include physical and especially advanced physical illness, poorly managed mental or physical symptoms, disorientation, exhaustion, little social support, alcoholism, history of depression or current depression, history of suicide attempt(s), and unresolved grief. Unrecognized physical and/or mental problems further increase risk. Talking or hinting about suicide is the primary indication that a person is at risk for suicide. Retrospective examination of suicide or suicide attempt usually shows that the person made statements indicating despair and plans to resolve the despair by suicide. Risk is increased by specific and lethal plans. A person who says when and how he or she will commit suicide is at very high risk; threats to kill self with a gun are at highest risk.

In many cases, suicidal ideation or the method of suicide is related to the stressful event(s), especially torture. When the method of torture is blunt force, e.g., beatings, the choice of suicide method tends to be jumping from a height or otherwise inflicting blunt trauma; when the method of torture is water immersion, the method of suicide tends to be drowning; and when torture is inflicted with a sharp instrument, the method of suicide tends to involve cutting (11).

Refugee workers who encounter a person who is suicidal should get help from a suicide crisis center or other source of specialized services. Helping a person who is suicidal is (a) not to be delayed and (b) not a matter for an individual.

Addressing Mental Health Problems of Refugees

Treatment of problems related to war, trauma, and torture is an enormous challenge. The literature has numerous studies demonstrating incidence and severity of PTSD, etc., but less on treatment of refugees experiencing distress. The most common documented means of treatment seems to be through programs focusing on torture victims. There are few of these programs, they are often poorly funded, and in some cases focus efforts only on a particular group of refugees. Typical services include initial evaluation and referral, medication management, referral for medical treatment, and individual and group counseling (limited by language). Please see links for connection to specialized services.

Ideally, dedicated multidisciplinary services, including a mental health component would be available for refugees. Such is not the case in most communities or for most refugees. Here we will offer some suggestions for addressing mental health problems of refugees ñ especially problems related to war, trauma, and torture. These suggestions are not intended as a substitute for therapy provided by a counselor with expertise in the field. However, they will be helpful in many cases.

Assessment

Determining whether a problem exists is, of course, the first step. Assessment is confounded by language and cultural differences, time available for assessment, financial resources, and the shame many refugees feel about having experienced torture or related trauma. Probably the most common expression of psychological distress is vague somatic complaints, e.g., complaints of headache, abdominal pain, joint pain, muscular pain ñ often occurring at the same time, not attributable to organic causes, and not responsive to symptomatic or other treatment. Answers to direct questions about traumatic event(s) may be positively or negatively influenced by:

  • Trust or mistrust of the health care provider,
  • Trust or mistrust of the translator,
  • Sameness or difference in gender of the patient and the translator and/or health care provider,
  • Perception by the patient that something can or cannot be done about the problem,
  • Other cultural, language, and interpersonal factors.

Our experience has been that many refugees will readily discuss some traumatic experiences related to war such as fighting, bombing, and people killed; but are reluctant to discuss rape and torture unless these is (a) a trusting relationship and (b) great personal distress. In general, the whole story comes slowly and in stages.

The diagnostic criteria for PTSD and characteristics of dysfunctional grief listed above provide assessment guidelines for determining the likelihood of PTSD and/or dysfunctional grief. In most cases, there is not the opportunity for a definitive diagnosis and competent culturally appropriate treatment of PTSD. Physical sequelae of torture are, of course, important to assess and treat.

Along with PTSD and/or grief assessment, one should also look at the presence or absence of spiritual support and met or unmet spiritual needs. Basic spiritual needs include meaning, hope, relatedness, forgiveness or acceptance, and transcendence. The presence or absence of any of these has a profound influence on all aspects of life.

Interventions

The following is offered as a means of addressing psychological, emotional, or spiritual distress related to PTSD and/or grief among refugees who are distressed, but not suicidal or psychotic. First, physical problems should be addressed. When possible a same-gender provider for physical, psychological, and spiritual care (when culturally appropriate) should be used and the same person should provide the care. Along with addressing physical health problems, the psychosocial and environmental problems noted above should be addressed. Staff can help solve problems and/or mobilize resources to resolve problems with: the primary support group, the social environment, education, occupation, housing, economics, access to health services, the legal system, and other influencing problems.

As physical, psychosocial and environmental problems are resolved, the following interventions may be used for individuals and families depending on staff ability and client situation:

Identify a staff member with primary responsibility for care. The staff member should (a) have or obtain understanding of the type of trauma the client has experienced (See links), (b) have or obtain understanding of the processes of PTSD, grief, and related problems, and (c) work to stay aware of her or his own internal and external responses to trauma and its sequelae. In most cases (in all cases of rape), the staff member should be the same gender as the client. If possible, as time passes, other staff may be introduced to the care, but the primary staff person should remain the same.

Clients who have been traumatized are likely to have difficulty with trust, acceptance, and authority figures. Therefore, staff must show themselves to be completely reliable, accepting of the client and others in similar situations, and operate from an I-Thou and respectful rather than an authority perspective. Staff presence that manifests both an inner and outer respect for the client is essential to an effective therapeutic relationship. As with any therapeutic relationship, it is important to remember that the clientís issues are the issue, not staff issues ñ even when staff are justifiably outraged.

As in any therapeutic relationship, staff should set and maintain limits. It also is important for clients to set their own boundaries and for staff to respect those limits, whether psychological or physical. Clients who have been tortured, raped, imprisoned, or suffered similar trauma need always to be free to leave a counseling session or other closed-in situation. Counseling settings should have as little institutional flavor as possible.

Staff may find themselves pushed to their emotional and spiritual limits and be at significant risk of burnout. Some may also be tempted to share their deep feelings of outrage with clients. Staff stress should be addressed organizationally with support activities and organizational awareness of the stress. On a personal level, staff will be well advised to find sources of spiritual and other support.

Client substance abuse should be assessed and if present, treated.

Anxiolytic or antipsychotic medications may be indicated. Staff and clients should understand that (a) medications are often used on a short-term basis to get through especially painful times and (b) their use does not mean the client is mentally ill. It is best when a psychiatrist is available to prescribe such medications, but they are available from general practitioners and some can be prescribed by nurse practitioners. Medications are not the answer ñ but they may be a vital part of the answer.

Exploring and expressing feelings about the trauma and/or loss and events and feelings leading to the trauma/loss is vital to recovery. The client takes the lead in deciding what is appropriate for discussion and when she or he is ready to deal with trauma. The "tasks of bereavement" provide a useful framework for this exploration (12). Completion or progress toward completion of these tasks usually results in decreased distress and progress toward healing (though complete healing may never be achieved). Please note that these tasks are not completed and then discarded one by one, as a person might strike items from a to-do list!

The Tasks of Bereavement Applied to Refugees

The tasks of bereavement are:

  • Telling the story of the loss or trauma: The story usually needs to be told repeatedly. The client may need help in sequencing events, clarifying details, and separating what is real from what is not.
  • Expressing and accepting the sadness and pain: Many people fear an emotional catastrophe if the sadness and related feelings are let out. There also are cultural, gender, and other issues in expressing or controlling feelings. Catharsis is one of the processes involved here.
  • Expressing and accepting guilt, anger, and other negatively perceived feelings: Denied or hidden guilt and/or anger are common defenses. As with addressing sadness and pain, there are cultural, gender, and other issues related to guilt, anger, and other feelings. Catharsis is a powerful and sometimes frightening process in this step. Group work may be especially helpful here. Because guilt is almost universal, it should be directly addressed, including working with the client to help her or him reach the conclusion that neither the trauma nor the response is the victimís fault. Forgiveness of self can be a powerful experience.
  • Reviewing the relationship with what was lost, e.g., loved ones, culture, sense of self, trust, dignity, and so on: This step is obviously valuable when grief is the primary issue, but is also part of dealing with the losses related to trauma, including torture.
  • Understanding common processes and problems in responses to trauma: Although the pain is not lessened, it is highly beneficial to know that responses (such as described earlier) are normal and even common. Like other people in distress, refugees often feel that nobody else has experienced what they have experienced nor responded as they have responded. Some feel that their responses indicate mental illness. Understanding common processes helps decrease the sense of shame and isolation. Therapeutic/information groups are a helpful means of increasing understanding and decreasing isolation.
  • Being understood or accepted by others: Isolation is common and functions to exacerbate problems among refugees. Understanding and acceptance are healing factors.
  • Exploring possibilities in the new life: From the ashes of pain and destruction may rise a new and sometimes stronger life. Some losses are never regained and some wounds are never healed. Even so, through a process of grieving for the old life, setting achievable goals for the new, and successfully solving problems; and with the social and spiritual support discussed throughout this article, the client can go forward.

Working on, and to some extent, through these tasks decreases distress and moves the client toward healing. However, recovery from the trauma of torture and some war experiences is a long process and periods of regression may occur, as may emergency situations involving violence toward others or self. Intermittent emergency and/or long-term support is often required (10).

Much of the western literature on trauma focuses on the use of psychotherapeutic or professional counseling intervention in the treatment of persons who have been tortured or otherwise traumatized. Clearly, trauma such as torture clearly inflicts spiritual as well as physical and psychological injury. Consideration should thus also be given to the spiritual component in the response to or treatment of trauma. Traditional treatments and ceremonies often have a spiritual component and may be an effective recourse for traumatized and/or grieving clients. If clients are referred to a source of spiritual care, the referring party should ensure that the source of care is aware of the realities and consequences of war-related trauma.

And finally, we must recognize that not all wounds heal; and be still in the face of more than we can understand.

Follow Me

 

To Hell

Links

Survivors International: Highly recommended. Gives specific information on torture and treatment of victims

RAINN: is a 24-hour-a-day, 7-day-a-week national hotline for victims of sexual assault. The toll-free hotline is: 1-800-656-HOPE. The WebSite has other information.

Thoughtful links and more on sexual assault

Canadian Center for Victims of torture

World Organization Against Torture

Torture survivors Network

Physicians for Human Rights

The Holocaust History Project Learn more about the pretty woman (above) and a lot else you didn't want to think about.

 

References

Kemp, C. E. (1993). Health services for refugees in Countries of second asylum. International Nursing Review. 40(1), 21-24.

Phillips, S., Baker, R., & Pearson, R. (1982). A critical review of terminology and psychosocial issues related to the survival of refugees who have experience the threat of genocide. Proceedings of the International Conference on the Holocaust and Genocide. Tel Aviv.

Silove, D., Sinnerbrink, I. Field, A., Manicavasagar, V., Steel, Z. (1997). Anxiety, depression, and PTSD in asylum-seekers:Associations with pre-migration trauma and post-migration stressors. British Journal of Psychiatry. 170(4), 351-357.

Goldstein, R. D., Wampler, N. S., & Wise, P. H. (1997). War experiences and distress symptoms of Bosnian children. Pediatrics. 100(5), 873-878.

Weine, S. M., Becker, D. F., McGlashan, T. H., Laub, D., Lazrove, S., Vojvoda, D., & Hyman, L. (1995). Psychiatric consequences of "ethnic cleansing": Clinical assessments and trauma testimonies of newly resettled Bosnian refugees. American Journal of Psychiatry. 152(4), 536-542.

Sack, W. H., Seeley, J. R., & Clarke, G. N. (1997). Does PTSD transcend cultural barriers? A study from the Khmer adolescent refugee project. Journal of the American Academy of Child and Adolescent Psychiatry. 36(1), 49-54.

Holtz, T. H. (1998). Refugee trauma versus torture trauma: A retrospective controlled cohort study of Tibetan refugees. The Journal of Nervous and Mental Disease. 186(1), 24-34.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Edition). Washington, DC: Author.

Basoglu, M., Mineka, S., Paker, M., Aker, T., Livanou, M., & Gok, S. (1997) Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine. 27(6), 1421-1433.

Solomon, Z. (1993). Combat Stress Reaction: The Enduring Toll of War. Plenum Press: New York.

Ferrada,-Noli, M., Asberg, M., & Ormstad, K. (1998). Suicidal behavior after severe trauma. Part 2: The association between methods of torture and of suicidal ideation in posttraumatic stress disorder. Journal of Traumatic Stress. 11(1), 113-124.

Kemp, C. E. (1995). Terminal Illness: A Guide to Nursing Care. J. B. Lippincott: Philadelphia.

 

Author: Charles Kemp, R.N., CRNH

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