1. An Ecological Framework 51
1
An Ecological Framework for
Addressing the Mental Health Needs
of Refugee Communities
______
Kenneth E. Miller and Lisa M. Rasco[1]
This book offers a unique angle of vision from which to consider how mental health professionals can respond effectively to the psychological needs of communities displaced by war and other forms of political violence. The view represents a departure from the medical model that has guided most mental health research and intervention with refugees. That model emphasizes the provision by highly trained professionals of clinic-based services such as psychotherapy and psychiatric medication. The focus is on healing or ameliorating symptoms of psychological distress within individuals, with little attention paid to mending damaged social relations within communities, or to strengthening naturally occurring resources within families and communities that could facilitate healing and adaptation.
In allowing the medical model to so fundamentally shape our response to the mental health needs of refugees, we have—perhaps inadvertently—followed what Kaplan (1964) termed “the law of the instrument,” which dictates that when the only tool in one’s possession is a hammer, there is a tendency to see everything as a nail in need of hammering. Having seen the devastating effects of war and displacement on people’s mental health, and believing that what we have to offer in response is an array of professionally staffed, clinic-based services, we have opened the doors of our clinics to refugee clients. Specialized treatment centers have been created to serve refugees who have been tortured, and population-specific clinics have been funded to serve the mental health needs of specific refugee groups. With the very best of intentions, we have made available those services with which we are familiar, and which have historically defined the scope of our professional activities.
The extent to which clinic-based services for refugees are effective is largely unknown. Although several case studies and clinical reports have been published, few refugee treatment centers have published systematic evaluations of the services they provide. Despite the lack of empirical data, however, new clinics continue to be developed, guidelines and treatment strategies for clinical work with refugees continue to be published, and clinic-based services continue to represent the cornerstone of the mental health community’s response to the mental health needs of refugee communities.
A primary aim of this chapter is to highlight three critical factors that have been overlooked in the process of investing so much time and energy into the development of clinic-based interventions. These factors are:
1. Most refugees have little or no access to the services of mental health professionals, because such services are scarce or non-existent in those areas where the majority of the world’s refugees live, and are often difficult to access for refugees in developed countries, as well;
2. Western mental health services, when they are available, are often underutilized because they are culturally alien to most refugees, the majority of whom come from non-Western societies and bring with them culturally specific ways of understanding and responding to psychological distress;
3. Clinic-based services are of limited value in addressing the constellation of displacement-related stressors that confront refugees on a daily basis, and that represent a significant threat to their psychological well-being. Examples of displacement-related stressors include the loss of social networks and a corresponding sense of isolation and lack of social support, unemployment, the loss of previously valued social roles and role-related activities, a lack of environmental mastery (i.e., possessing the knowledge and skills needed to negotiate the local environment), and the various stressors associated with living in poverty (Beiser, Johnson, & Turner, 1993; Gorst-Unsworth & Goldenberg, 1998; Lavik, Hauff, Skrondal, & Solberg, 1996; Miller, Worthington, Muzurovic, Goldman, & Tipping, 2002; Omidian, 1996; Pernice & Brook, 1996; Silove, 1999; Silove, Sinnerbrink, Field, & Manicavasagar, 1997).[2] As we discuss below, these three factors, when taken together, raise serious questions about the value of our nearly exclusive reliance on Western, clinic-based models of mental health intervention with refugees.
Fortunately, far from holding only a metaphorical hammer in our hands, we have a great many tools available to us that we can use to promote healing and adaptation in communities displaced by political violence. All the world is not a nail, nor need it appear to be so. If we are willing to venture out of our clinics and into the communities in which refugees live; if we are willing to broaden the range of roles we play and the types of activities in which we engage; and if we are willing to learn from colleagues in other disciplines such as public health, community psychology, prevention science, and anthropology, we can have a much farther reaching impact on lowering distress and promoting well-being within refugee communities than was ever possible working exclusively under the medical model and its corresponding set of clinical services.
In short, we believe it is time for a paradigm shift for those who seek to understand and respond effectively to the mental health needs of refugee communities. The good news is that we needn’t look far to find a promising alternative to a primary or sole reliance on the medical model. The ecological paradigm of community psychology, with its roots in public health and its emphasis on collaboration and community empowerment, holds great promise as an alternative framework within which culturally appropriate mental health interventions for refugees can be developed, implemented, and evaluated. In fact, ecological interventions with refugee communities are already being conducted in various regions of the world. Such programs are still quite scarce, however, and program staff work in relative isolation, with little by way of shared experience upon which to draw. They are essentially pioneers, charting new territory as they proceed, drawing on theories and methods that have rarely been implemented in work with refugees. Psychologists, psychiatrists, and others involved in such projects have left the clinic and entered the community, and in so doing, both the rules and the roles have changed. Expert-driven services have been replaced by collaborative endeavors in which community members contribute their expertise and play essential roles in the intervention process; individual treatment has been supplemented or replaced by communal rituals and activities; and the conventional emphasis on treating psychopathology has been complemented by a new focus on identifying and developing community strengths and resources that can promote healing and adaptation.
This book represents a “taking stock” of sorts. It is a pause in the action, a chance for reflection and the sharing of experiences, both successful and problematic. It is an opportunity for those with considerable experience in the field to communicate their experiences and ideas to individuals and groups just getting started. And it is a time for serious consideration of both the possibilities and the potential limitations of ecological interventions with refugee communities. We have asked the authors of each chapter to reflect critically on the projects in which they have been involved, and to address a common set of points regarding the context, design, implementation, and evaluation of their work. There are significant differences among the projects in terms of sociopolitical and cultural contexts, populations of focus, and specific intervention goals and methods. What they have in common is an emphasis on ecological intervention strategies that maximize community participation and involve community members as respected and effective collaborators in the various phases of the intervention process.
In this chapter, we first briefly describe the scope of the world refugee situation. We then provide a short summary of research findings regarding patterns of psychological distress among refugees, and construct an empirical foundation for suggesting that clinic-based intervention strategies are fundamentally limited in their capacity to address these high rates of distress. We then turn to a discussion of the ecological model, and offer a rationale for its adoption as an alternative framework to guide mental health interventions with refugee communities. Finally, we consider some of the key issues and critical challenges inherent in doing community-based mental health work with refugees. The chapter concludes with some brief introductory comments regarding each of the projects described in the book.
The World Refugee Situation
This book makes its appearance at the start of the 21st century, a time of profound sociopolitical change and upheaval, of ultra-nationalism and widespread ethno-political violence that has resulted in the forced migration of millions of people. The majority of these are civilians whose only crime was that of living in regions of violent conflict, or belonging to a particular ethno-cultural group subjected to oppression and persecution, extending in some cases to the extremity of genocide. At the time of this writing, there are an estimated 35-38 million people displaced from their homes by civil and interstate war, as well as various forms of state sanctioned repression and persecution (Global IDP Project, 2002; UNHCR, 2002). This figure, which likely underestimates the actual total, includes approximately 13 million individuals formally recognized as refugees or asylum seekers according to the 1951 UN Convention Relating to the Status of Refugees (UNHCR, 1951). The UN Convention defines as a refugee anyone who
owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or, owing to such fear, is unwilling to avail himself of the protection of that country.
Critical to this definition is the emphasis on finding oneself outside the country of one’s nationality. In fact, however, it has become abundantly clear over the past few decades that the majority of people displaced by violence do not seek safe haven in other countries; instead, they become “internal refugees,” remaining within the boundaries of their homeland either because they cannot or will not avail themselves of protection elsewhere. Their numbers are difficult to assess accurately, for unlike “official” refugees, internally displaced persons (IDPs) do not fall under the protection or jurisdiction of any particular international organization. Outsiders often have limited access to internally displaced communities, making accurate estimates of their numbers particularly difficult. This is especially true in contexts in which repressive governments have a vested interest in denying the existence of communities displaced by the state’s own violent practices and human rights violations. Thus, the current estimate of 20-25 million internally displaced people (Global IDP Project, 2002) should be viewed as a crude approximation, with the actual number of IDP’s possibly being higher.
Throughout this introductory chapter, we break with tradition and use the term refugees to refer collectively to all people forced by political violence to flee their homes and communities, regardless of whether they enter another country or remain within the borders of their homeland. We do this partly out of semantic convenience, and partly out of a belief that the term internally displaced persons, although technically accurate, fails to capture the harsh reality experienced by the majority of people who are displaced by political violence. This reality includes a preflight period of exposure to various types of violent experiences, which may include the abduction, murder, or “disappearance” of family members or friends, witnessing or experiencing physical assault, rape and other forms of sexual violence, the destruction of one’s home and property, forced participation in acts of violence, and a persistent state of fear and vulnerability. Once the decision to flee is made, a series of profound losses and disruptions is set in motion. These include separation from family members unable or unwilling to flee, the abandonment of one’s home and other material possessions, the loss of social networks and of social and occupational roles, and the reality of leaving behind a range of
familiar and deeply valued settings, such as a parcel of land attained after years of labor, or an ancestral burial ground that represents continuity with one’s ancestors. Although we recognize that internally displaced people and “official” refugees (i.e., those outside of their homeland) often face significantly different sets of resources and challenges as they adapt to their new settings, we believe that their forced migration involves a shared set of core experiences of violence, disruption, and loss. For this reason, as well as the convenience of a somewhat simpler nomenclature, we have opted to use the term refugees inclusively, referring to all people forced by political violence to flee their homes and communities.
Research on the Mental Health of Refugees
The primary focus of research on the mental health of refugees has been on documenting patterns of psychiatric symptomatology, using questionnaires or structured clinical interviews designed to identify psychiatric syndromes such as post-traumatic stress disorder (PTSD) and major depressive disorder (MDD). Although we believe that there are significant limitations to the nearly exclusive reliance on this approach (e.g., an inattention to indigenous idioms of distress, an exclusive focus on psychopathology that fails to consider the numerous strengths and forms of resiliency within refugee communities, and an underutilization of qualitative methods that would allow refugees to identify, in their own words, critical determinants of their psychological well-being), the psychiatric/symptom-focused approach to documenting refugee distress has nonetheless yielded some compelling findings. With more than 1,000 articles and book chapters on the topic now in print, including studies using clinical and community samples, children as well as adults, and refugees living in a diverse array of settings (internal displacement near zones of ongoing conflict, refugee camps, and resettlement countries), it is now possible to draw some reasonably solid conclusions regarding the impact of political violence and displacement on people’s mental health. The following brief review first considers the psychological impact of exposure to political violence, then examines the effects ongoing stressors related to the experience of displacement.
The Traumatic Impact of Political Violence
Exposure to political violence is associated with an increased risk of both acute and chronic post-traumatic stress reactions (Arroyo & Eth, 1986; Fox & Tang, 2000; Hubbard, Realmoto, Northwood, & Masten, 1995; Kinzie, Sack, Angell, Manson, & Rath, 1986; Kinzie, Sack, Angell, Clark, & Ben, 1989; McSharry & Kinney, 1992; Michultka, Blanchard, & Kalous, 1998; Miller, Weine et al., 2002; Mollica et al., 1993, 1998; Shresta et al., 1998; Thabet & Vostanis, 2000; Weine et al., 1998). Most commonly, symptoms of traumatic stress among refugees have been assessed using the diagnostic criteria of post-traumatic stress disorder (PTSD). Although the cross-cultural validity of the PTSD construct and its appropriateness in situations of ongoing violence represent sources of ongoing controversy (a point to which we return later), the constellation of symptoms that comprise the PTSD syndrome have been documented in numerous studies of refugees representing diverse national and ethnic backgrounds. This does not mean that the PTSD construct adequately captures the totality of the trauma experience, nor does it negate the possibility that culturally specific expressions of trauma may exist that bear little resemblance to the three symptom cluster model of PTSD. Nor for that matter does it imply that psychological trauma should be understood only or primarily as an individual phenomenon. As we discuss shortly, acknowledging the presence of trauma within individuals in no ways contradicts the idea that trauma may also occur as a psychosocial phenomenon that affects entire communities and their underlying fabric of social relationships (Martín Baró, 1989; Summerfield, 1995; Wessells & Monteiro, 2001). Rather, the salience of the PTSD syndrome in a wide spectrum of refugee studies merely suggests that there exists across diverse cultures a set of highly intercorrelated symptoms of distress that develop in the wake of exposure to terrifying experiences over which people have little or no control.