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i-counseling.net Refugee Mental Health

Refugee Mental Health:Issues for the New Millennium

Edited by the Center for Credentialing & Education

CE Hours: 2

Course Introduction

Many refugees leave their homes to escape life-threatening situations such as natural and man-made disasters, persecution, and human rights violations. Escaping these experiences might involve even further trauma. Refugees are at particular risk to resist treatment and are likely to not obtain services. Among refugees from group-oriented cultures, group-type interventions might be the treatment of choice. However, traumatized refugees may be reluctant to tell their stories due to shame, lack of trust, and fear. There is a pressing need for practitioners to be able to assist these people. This course summarizes the literature on refugee mental health.

Learning Objectives

Upon completion of this course, you will learn:

• Aboutissuesandtrendsinforcedmigration

• AspectsofU.S.policyregardingresettlementandasylum

• Abouttheimplicationsforrefugeementalhealthservices

• Culturalissuesrelatedtorefugeementalhealth

• Aboutopportunitiesforrefugeementalhealthandresearchpriorities

Course Content

Article: Refugee Mental Health: Issures for the New MillenniumJaranson,J.,Martin,S.F.,andEkblad,S.(2002).Refugeementalhealth:Issuesofthemillennium.InR.W.Manderscheid&M.J.Henderson(Eds).Mental Health, United States, 2002 (pp.120-133).DHHSPub.No.(SMA)01-3537.Washington,DC:Supt.ofDocs.,U.S.Govt.Print.Off.,2001.

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Refugee Mental Health:Issues for the New Millennium

JamesJaranson,M.D.,M.A.,M.P.H.;

*SusanForbesMartin,Ph.D.;*andSolvigEkblad,D.M.Sc.*

*University of Minnesota; Center for Victims of Torture; Regions Hospital/HealthPartners; * Institute for the Study of International Migration, Georgetown University;* National Institute for Psychosocial Factors and Health

TenyearsafterexuberanceabouttheendoftheColdWarpromptedtheUnitedNations(U.N.)HighCommissionerforRefugees(UNHCR)todeclarea“decadeofvoluntaryrepatriation,”theinternationalcommunityisfacedwithasignificantnumberofcomplexemergenciesinvolvingtheforcedmovementsofmillionsofpersons.Forcedmigrationhasmanycausesandtakesmanyforms.Peopleleavebecauseofpersecution,humanrightsviolations,repression,torture,conflict,andnaturalandhuman-madedisasters.Manydepartontheirowninitiativetoescapetheselife-threateningsituations;although,inagrowingnumberofcases,people are driven from their homes by governments and insurgent groups intent on depopulating or shifting the ethnic,religious,orothercompositionofanarea.Somemanagetoescapetheircountriesandfindtemporaryor permanent refuge abroad, while an alarmingly large number remain trapped inside or are forced to repatriate beforethehomecountryconditionschangeinanysignificantmanner.

Forcedmigrantsoftenshareatraumaticpast,including“exposuretowar-relatedviolence,sexualassault,torture,incarceration,genocideandthethreatofpersonalinjuryandannihilation”(Friedman&Jaranson,1994).Escaping these experiences may involve still further trauma, including the physical danger of crossing borders, prolonged periods in refugee and displaced persons camps, malnutrition and disease, armed attacks, and sexual andotherviolence.ManyforcedmigrantswhoreachtheUnitedStatesandothersupposedlysafecountriesenterwithout authorization and continue to risk removal to their home countries. Even those who secure a legal status that permits them to remain may face chronic unemployment, poverty, racial discrimination, lack of access to medicalcare,difficultiesinfindingsafeandaffordablehousing,highlevelsofcrime,andanabsenceoffamilyand community networks. Their adopted country, in some cases, may have supported the repressive regime that causedtheiroriginaltrauma(Quiroga&Gurr,1998).

TheeventsofWorldWarIIproducedanumberofclassicstudiesofrefugeementalhealth,withparticularfocusonconcentrationcampsurvivors(Eitinger,1959;Krupinski,Stoller,&Wallace,1973).Ashumanitariancrisesmultipliedandgrewinseverityinthe1980’s,newinterestinrefugeementalhealthemerged,creatinganewliteratureonthesubject.GenocideinRwanda;ethniccleansinginBosnia,Kosovo,andeastTimor;savageconflictsinLiberia,SierraLeone,andChechnya—alloftheseeventshaveshownthepressingneedforevenmoreattentiontothetraumasfacedbythesurvivorsofthesecalamities.FollowingareviewofinternationalandU.S.trendsrelatingtoforcedmigration,thisarticlesummarizesthescientificliteratureonrefugeementalhealth, discusses challenges to address in improving responses, and presents recommendations for future research.

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International Trends in Forced Migration

TheU.S.CommitteeforRefugees’1999WorldRefugeeSurveyestimatesthattherewere13.5millionrefugeesatthebeginningoftheyear,downfromalmost17millionatthebeginningofthedecade.Refugeeshaveaspecialstatusininternationallaw(USCR,1999).The1951U.N.ConventionRelatingtotheStatusofRefugeesdefinesarefugeeas“apersonwho,owingtowell-foundedfearofbeingpersecutedforreasonsofrace,religion,nationality, membership of a particular social group or political opinion, is outside the country of his nationality andisunableor,owingtosuchfear,isunwillingtoavailhimselfoftheprotectionofthatcountry.”Refugeestatus has been applied more broadly, however, to include other persons who are outside their country of origin becauseofarmedconflict,generalizedviolence,foreignaggression,orothercircumstancesthathaveseriouslydisturbed public order, and who, therefore, require international protection.

ThelargestnumberofrefugeeswereintheMiddleEast(almost6million),followedbyAfrica(3million),EuropeandSouthAsia(1.7millioneach),theAmericas(750,000),andeastAsiaandthePacific(500,000).Eachofthefollowingcountriesoriginatedmorethan250,000personswhowerestilldisplacedin1999:Afghanistan,theformerYugoslavia,Iraq,Somalia,Burundi,Liberia,Sudan,SierraLeone,andVietnam.Inaddition,morethan3millionPalestiniansremaineddisplacedandeligibleforaidfromtheU.N.ReliefandWorksAdministration.Insomeofthesecases,therefugeeshadbeenuprootedfordecades,whereasinothersthey had become refugees more recently.

Thatthenumberofrefugees—thatis,personsoutsideoftheirhomecountry—isatitslowestlevelinyearsdoes not mean that the number of persons in need of humanitarian aid and protection has reduced. There are growingnumbersofconflictsinwhichciviliansaretargetsofmilitaryactivityaswellaswarcrimesandcrimesagainsthumanity.Fartoooften,nationalismhasturnedrabidwithethnicgrouppittedagainstethnicgroupindeterminingthenationalidentity(e.g.,RwandaortheformerYugoslavia).Incertainextremecases,sovereigntyitselfhasbeencompromisedasnogroupcanamassthestrengthorlegitimacytomaintainorder(e.g.,LiberiaorSomalia).Intensefightingerupts,withtargetedattacksoncivilians,massivepopulationdisplacements,“ethniccleansing”ofopposingnationalities,andevengenocide.

Increasingly,peopleintheselife-threateningsituationsarefindingavenuesofescapeclosedtothem.Evenwhentheyareabletoleave,anincreasingnumberfindnocountrywillingtoacceptthemasrefugees.Asaresult,therehasbeenalargeincreaseinthenumberofinternallydisplacedpersonswhointhelate1990’soutnumberrefugeesbyasmuchastwotoone.The1999World Refugee Survey listsmorethan17millioninternallydisplacedpersons,butitwarnsthatthetotalnumbermaybemuchhigher.Sudanleadsthelistwithanestimated4millioninternallydisplacedpersons.AngolaandColombiaareestimatedtohaveasmanyas1.5millioninternallydisplacedpersonseach,andIraq,Afghanistan,Burma,andTurkeyhaveasmanyas1millioneach.

Thedecreaseinthenumberofrefugeesreflectsasecondphenomenonaswell:therepatriationofmillionsofrefugeestotheirhomecountries.Duringthe1990’s,large-scalereturnoccurredtoawiderangeofcountries.InAfricaalone,repatriationoccurredinAngola,Burundi,Eritrea,Ethiopia,Liberia,Mali,Mozambique,Namibia,Rwanda,andSomalia.OtherprominentrepatriationdestinationswereCambodia,Afghanistan,ElSalvador,Nicaragua,Guatemala,andBosnia-HerzegovinaandKosovo.

Insomecases,returnisvoluntarybecausehostilitieshavetrulyendedandwithpeacecouldcomerepatriationand reintegration. Too often during the decade, though, refugees along with their internally displaced cousins returnedtocommunitiesstillwrackedbywarfareandconflict.Arangeoffactorsinducessuchreturn.Countriesof asylum may be weary from having hosted the refugees and place pressure on them to repatriate prematurely.

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Donorsmayalsoreducetheirassistanceintheexpectationthatreturnwillsoontakeplace.Therefugeesthemselves may wish to restake their claim to residences and businesses before others take them, or they may wishtoreturnintimetoparticipateinelections.Familiessplitbyhostilitiesmaybeeagerforreunification.Prematurereturn,particularlywhenforced,istroublingfortworeasons:(1)suchrepatriationcanendangertherefugeeswhomaymovefromoneinsecuresituationintoanother;and(2)forcedreturnunderminestheentireconceptofasylum,thatis,aplacewhererefugeescanfindprotectionfromdangerandpersecution.

Inthepost-ColdWarera,theopportunitiestorespondtohumanitariantragediesaregreaterthaneverbefore,thoughstilldifficulttoseize.WhiletheinternationalcommunitycouldprovideaidandsometimesprotectiontothosewholefttheircountriesinthedecadesafterWorldWarII,addressingrootcausesorbringingaidtovictims still inside their countries was limited. Many humanitarian emergencies were triggered by surrogate ColdWarconflicts,complicatingmatters.Attheheightofsuperpowerrivalry,interveningintheinternalaffairsofacountryalliedwitheithertheUnitedStatesortheSovietUnioncouldhaveprovokedamassivemilitaryresponsefromtheother.ItwasunlikelythattheSecurityCouncilwouldauthorizesuchactions.

Today,humanitarianinterventionhastakenplaceincountriesasdiverseastheSudan,Iraq,Bosnia,Somalia,Haiti,andnowKosovoandEastTimor.Theformsofinterventionrangefromairliftedfooddropstooutrightmilitary action. The results have been mixed. Aid reached otherwise inaccessible people in many of these cases, and,insomecases,peacesettlementslessenedtheimmediatereasonsforflightandpermittedsomerepatriationto take place. The root causes of displacement have not generally been addressed, however, and internally displaced populations often still remain out of reach. And, safe havens established to protect civilians have too often been vulnerable to attack, leaving civilians still victimized by those committing war crimes and crimes against humanity.

U.S. Policies

Victimsofpersecution,humanrightsviolations,andconflictcometotheUnitedStatesinnumerousways,withandwithoutauthorizationfromtheGovernment.TheUnitedStatesoffersresettlementtorefugeeswhoareprocessedabroad,aswellasasylumtothosearrivingdirectly.UndertheRefugeeActof1980,thesestatusesapply only to individuals who have been persecuted or demonstrate a well-founded fear of future persecution. Personsadmittedthroughtheresettlementsystemorgrantedasylummayadjusttopermanentresidentstatusafter1year,whichputsthemontheroadtocitizenship.

ThenumberofrefugeesresettledintheUnitedStatesvarieseachyear,determinedannuallybythePresidentin consultation with Congress. Resettlement is available for refugees who are of special humanitarian concern totheUnitedStates.Intheearlyyearsoftherefugeeprogram,resettlementgenerallywasofferedtorefugeesfleeingCommunistcountries,reflectingU.S.foreignpolicy.SincetheendoftheColdWar,however,theprogram reaches a broader segment of the refugee population, with an emphasis on protecting refugees at risk andprovidingdurablesolutionsforthosewithnootheralternatives.Forfiscalyear(FY)2000,thePresidentauthorizedadmissionofupto90,000refugees:47,000fromEurope,dividedamongnationalsoftheformerYugoslaviaandtheformerSovietUnion;18,000fromAfrica;8,000fromeastAsia;8,000fromtheneareast/southAsia;3,000fromLatinAmerica/Caribbean;and6,000geographicallyunallocated.ActualadmissionsinFY1999numbered85,000,includinghumanitarianevacueesfromKosovo.

AsylumapplicantsmayapplydirectlythroughaffirmativeapplicationstotheImmigrationandNaturalizationService(INS)orthroughdefensiveapplicationsduringaremovalhearinginimmigrationcourtwhenapprehendedataportofentryorintheinterioroftheUnitedStates.Inaffirmativecases,INSmaygrantasylumor refer the case to an immigration judge for further adjudication. Although there are no limits on the number

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ofpersonswhocanobtainasylum(withtheexceptionofthoseapplyingunderaspecialprogramforChineseprotestingChina’scoercivepopulationcontrolpolicies),theUnitedStatespermitsamaximumof10,000asyleestoadjusttopermanentresidentseachyear.PreliminarystatisticsforFY1999indicatethatabout40,000asylumcaseswerefiledwithINSasaffirmativecases.INSapprovedabout38percentofthecasesthatreachedfinaldecisionsinFY1999.Duringthesameperiod,theimmigrationcourtreceivedalmost50,000cases,somereferredbytheINSasylumoffice,andothersapplyingasaresultofapprehension.Theimmigrationcourtapprovedalmost30percentofallofthecasesinwhichitmadeafinaldeterminationonthemerits,grantingasyluminabout6,500cases.

Individualsfleeingconflictsandotherlife-threateningsituations,butwhohavenotbeengrantedasylum,mayreceiveTemporaryProtectedStatus(TPS),permittingthemtoremainwithintheUnitedStatesuntilconditionschangeintheircountryoforigin.TPSisnowavailabletopersonsfleeingconflictsandnaturaldisastersinsuchcountries/areasasNicaragua,Honduras,Kosovo,Sudan,SierraLeone,andBurundi.Victimsoftorturewhodonotqualifyforoneoftheseotherstatuses(forexample,becausetheyhavecommittedacrime)mayapplyforrelief from removal if they would risk future torture. The process for obtaining such relief is relatively recent, adoptedwhentheUnitedStatespassedlegislationimplementingcommitmentsundertheU.N.Conventionagainst Torture.

PersonsresettledintheUnitedStatesorgrantedasylumhaveworkauthorizationfromthetimeoftheiradmission/grant.Bycontrast,asylumapplicantsmaynotworklegallyunlessthegovernmentfailstomakeaninitialdeterminationwithin6monthsofapplication.Theyarealsoineligibleforpublicassistance.Mostrelyonfamilies,communitymembers,ornonprofitagencies,ortheyworkwithoutauthorization.ThosegrantedTPSreceive work authorization, but they are ineligible for public cash or medical assistance.

Refugees and asylees are eligible for time-limited cash and medical assistance as well as social services aimed atassistingtheminadjustingtotheirnewhomes.FundedbytheOfficeofRefugeeResettlement(ORR)intheDepartmentofHealthandHumanServices,theseservicesincludeEnglishlanguagetraining,employmentservices,andjobtraining.Assistanceandservicesareprovidedbystaterefugeeoffices,privateresettlementagencies, and mutual assistance associations organized by refugees themselves.

Inrecognitionofthetraumasexperiencedbymanyrefugeesandasylees,ORRhasanintraagencyagreementwiththeRefugeeMentalHealthProgramintheSubstanceAbuseandMentalHealthServicesAdministrationtoproviderefugeementalhealthconsultation;adviceandguidancetotherefugeeresettlementnetwork,Stategovernments,andresettlementagencies;andtoserveasthefocalpoint,intheFederalGovernment,onmentalhealth issues and services for refugees and torture survivors.

Inadditiontotheseprograms,theUnitedStatesplaysanimportantroleinternationallyinassistingandprotectingforcedmigrants.TheUnitedStatesisoneoftheprincipaldonorstotheinternationalhumanitarianaidprogram,throughitscontributionstosuchagenciesastheU.N.HighCommissionerforRefugeesandtheU.N.VoluntaryFundforTortureVictims,aswellasitssupporttotheInternationalCommitteeoftheRedCrossandothernongovernmentalorganizationsprovidingrelieftothevictimsofhumanitariancrises.Inaddition,theU.S.militaryhasbeenactivelyinvolvedindeliveringassistanceandparticipatinginhumanitarianinterventionsinsuchplacesasnorthernIraq,Somalia,Haiti,Bosnia,andKosovo.Regrettably,theUnitedStateshasnotyetsignedtheU.N.ConventionontheRightsoftheChild,whichincludessignificantprovisionsthatenhanceprotectionofchildrencaughtinconflictsituations.

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Refugees and Mental Illness

Refugees are at particular risk not only for developing mental disorders but also for failing to receive treatment fortheseillnesses.Premigration,migration,andpostmigrationexperiencesallcontributetotherisk.Stressorsincludeacculturationpressures,financialandemploymentdisadvantages,dissonancebetweentraditionalsocioculturalvaluesandthehostcountry,intergenerationalstresses,andsocialisolation.LegalstatuscanaffecttherealityofremaininginrelativesafetyintheUnitedStates.Oftenthelossoffamilymembersorseparationfrom them can affect mental well-being.

Jablenskyetal.(1994)havenotedthefollowingriskfactorsfordeterminantsofpoormentalhealth,andthesefactors occur throughout all phases of the refugee resettlement process. These factors are marginalization and minority factors, socioeconomic disadvantage, poor physical health, starvation and malnutrition, head trauma andinjuries,collapseofsocialsupports,mentaltrauma,andadaptationtohostcultures.Psychologicaldistressandimpairmentinpsychosocialfunctionareinfluencedbyindividual,family,cultural,andsocialvariables(Ekblad,Ginsburg,Jansson,&Levi,1994).

Itisusefultoconsiderthemajorpsychosocialsystemsthatareaffectedbytherefugeeexperience,bothwithintheindividualandacrossthecommunityasawhole.EkbladandSilove(1998)suggestthefollowingsimplifiedframeworkinwhichfivefundamentalsystemsarethreatenedordisrupted:(1)Theattachmentsystem:manyrefugeesareaffectedbytraumaticlossesandseparationsfromcloseattachmentfigures.(2)Thesecuritysystem: it is common for refugees to have witnessed or encountered successive threats to the physical safety andsecurityofthemselvesandthoseclosetothem.(3)Theidentity/rolesystem:therefugeeexperienceposesamajorthreattothesenseofidentityoftheindividualandthegroupasawhole.Lossofland,possessions,andprofessionsdivestindividualsofasenseofpurposeandstatusinsociety.(4)Thehumanrightssystem:almostall refugees have been confronted with major challenges to their human rights. These include arbitrary and unjusttreatment,persecution,brutality,and,insomeinstances,torture.(5)Theexistential-meaningsystem:therefugee experience poses a major threat to the sense of coherence and meaning that stable civilian life usually provides for most communities.

AccordingtoJablenskyetal.(1994),themostcommonsymptomsandsignsthatappearinrefugeesacrossdifferentculturesincludeanxietydisorders(i.e.,highlevelsoffear,tension,irritability,andpanic),depressivedisorders(i.e.,sadness,anergia,anhedonia,withdrawal,apathy,guilt,andirritability),suicidalideationandattempts,anger,aggressionandviolentbehavior(whichoftenfindsexpressioninactsofspouseandchildabuse),drugandalcoholabuse,paranoia,suspicionanddistrust,somatizationandhysteria,andsleeplessness.

BoehnleinandKinzie(1995)havereviewedbiological,psychological,andsocioculturalmodelsforrecognizing,conceptualizing,andtreatingthepsychiatricproblemsoftraumatizedrefugees.AfterWorldWarII,a“concentrationcampsyndrome,”characterizedbyfatigue,irritability,restlessness,anxiety,anddepression,wasdescribedinJewishvictimsoftheNaziconcentrationcamps(Krupinskietal.,1973).Higherratesofschizophreniawerealsofound(Eitinger,1959;Krupinskietal.,1973).

Since1975,withtheescapeofSoutheastAsianrefugeestotheUnitedStatesfromVietnamattheendoftheVietnamWarandfromthekillingfieldsofPolPotinCambodia(1975–1979),theeffectsofseveretraumawerestudiedinthesepopulations.Themostfrequentpsychiatricdiagnoseshavebeenidentifiedasposttraumaticstressdisorder(PTSD)andmajordepression(Boehnlein,Kinzie,Rath,&Fleck,1985;Kinzieetal.,1990;Kinzie,Fredrickson,Rath,&Fleck,1984;Kinzie&Jaranson,1998;Kinzie,Sack,Angell,&Clarke,1989;Kinzie,Sack,Angell,&Manson,1986;Kinzie,Tran,Breckenridge,&Bloom,1980;Krupinskietal.,1973).

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InastudyofVietnameserefugees,severityofPTSDandrelatedsymptomswasdirectlycorrelatedwiththenumberoftraumaticevents(Smith-Fawzietal.,1997).AlthoughcognitiveimpairmentsaresubjectivelydistressingandmaybesymptomsofPTSD,theincreasedfrequencyofheadinjuryamongvictimsoftorturecouldaccountforsomeofthisimpairment(Goldfeld,Mollica,Pesavento,&Farone,1988).Severalotherdisorders and symptom complexes are common among refugees in general and especially prevalent among torturevictims.Oneoftheseistheexpressionofemotionaldistressinpsychologicalterms,orsomatization(Turner&Goest-Unsworth,1990;Westermeyer,Bouafuely,&Neider,1989).

AlthoughPTSDisclassifiedasananxietydisorderintheU.S.andinternationaldiagnosticmanuals,manyclinicians do not consider torture survivors and other traumatized refugees as true psychiatric patients because theymaybeexperiencinganormalreactiontoanabnormalstressor.Labelingtorturesymptomsasamentaldisorderisseenasamedicalizationofasociopoliticalproblem.Fromanotherperspective,onecouldspeculatethatthebiologicalchangesoccurringinposttraumaticstressoverridethisargument(Friedman&Jaranson,1994).Thesechangesincludeabnormalsleeppatterns,increasedarousalofthenervoussystem,elevatedlevelsofadrenaline(asinthefight-or-flightresponse),decreasedlevelsofserotonin(asindepression),lowercortisollevels(althoughtheyarehigherindepression),andshrinkageofpartofthebrain,thehippocampus(Shalev&Yehuda,1998).

Among refugees seeking psychiatric care, damage to the central nervous system has been the most common typeofbiomedicalcondition(Begovacetal.,1992;Lunde,Rasmussen,Wagner,&Lindholm,1981).Causesofbiomedicalillnessesincludewoundsandotherphysicalassault;prolongedmalnutrition;exposuretotheelements;lackofmedicalcareforinfectiousdiseasesuchastuberculosis,HIV/AIDS,andothermaladies;injuryduringrefugeeflight;andcombatwounds(Walker&Jaranson,1999).Malnutritionplusuntreatedmedicalconditionscanbeespeciallydamaging(Thygesen,Herman,&Willanger,1970).

Refugeewomen,whowiththeirchildrenaccountforasmuchas80percentoftherefugeepopulation,mayexperienceadditionaltraumas(Martin,1991).Whilemenareusuallytheactiveparticipantsinwar,womenareoftenlefttorespondtotheincreasingchaosandthebreakdownsintheirfamiliesandcommunities(Farhood,Zurayk,Chaya,Meshefedjian,&Sidani,1993;Jensen,1994;Kaler,1997;Lifschitz,1975;Lyons,1979;Murphy,1977).Inwarzones,womencontinuetoberesponsibleforprocuringandpreparingfoodandforcaring for children, the elderly, and the ill. They face survival issues every day with massive unemployment, dramaticpriceincreases,lackoffuel,foodshortages,shelling,andsniping(Ashford&Huet-Vaughn,1997;Mann,Drucker,Tarantola,&McCabe,1994).Afterwomenbecomerefugees,theyoftenliveinpovertyandfeelpowerlesstoreducethestressintheirfamilies(D’Avanzo,Frye,&Froman,1994;Mollica,Wyshak,&Lavelle,1987).Bothwomenlivinginwarandrefugeewomenareoftenlefttowonderiftheirhusbandsorchildrenarealiveordead,leavingtheminalivinglimbo(Agger&Jensen,1996;Boss,1999).

War-relatedstress,environmentalfactors,persistentgrief,mourning,loneliness,andisolationtendtopredisposewomenlivinginwarandrefugeewomentosustainedstressthatleadstodepression(Bryce,Walker,Ghorayeb,&Kanj,1989;Bryce,Walker,&Peterson,1989;Farhoodetal.,1993;Fox,Cowell,&Johnson,1995;Lipson,1993).Thisisparticularlyrelevantbecausemothers’depressionandtheirchildren’sadjustmentareintrinsicallylinked(Downey,1990;Field,1995;Fieldetal.,1988;Field,Healy,Goldstein,&Guthertz,1990;Murray,Kempton,Woolgar,&Hooper,1993).Thereisevidencethatchildren’sreactionstostressmirrortheirfamily’sresponses.Symptomsrelatedtotraumainmotherscontributetochildren’svulnerability,andthemother’slevelofdepressionhasbeenshowntobethemostimportantpredictorofchildmorbidity(Apetkar&Boore,1990;Chimienti&AbuNasr,1992–1993;Greenetal.,1991;Punamaki,1987).

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RapehasaveryhighrateofacutePTSDandcanleadtohighratesofchronicPTSD,especiallyifleftuntreated(Foa,Rothbaum,Riggs,&Murdock,1991).Femalerelativesofpersecutedmenarealsoatriskforpsychologicalandhealthproblems(Khamis,1998).Childrenandadolescentsalsofacespecialproblems.They may be torture victims, either as a means of demeaning and demoralizing the children themselves or as a meansoftorturingtheirparents(Carlin,1979;Krupinski&Burrows,1986;Lonigan,Shannon,Taylor,Finch,&Sallee,1994;consequences,despitehavingneverbeentorturedthemselves(Carlin,1979;Danieli,1998;Krupinski&Burrows,1986;Loniganetal.,1994;Solkoff,1992;Westermeyer&Wahmanholm,1996;Williams&Westermeyer,1984).

Prevalence of Mental Illnesses Among Refugees

SinceWorldWarII,epidemiologicalstudiesandtheoreticalmodelsofrefugeetraumabasedonbiomedical,sociopolitical, and ethnographic perspectives have been conducted in a variety of cultural and ethnic groups. Nonetheless,despiteanincreaseofknowledgeaboutthementalhealthproblemsandmethodsofintervention,themagnitudeoftheproblemsisnotknown.RecentepidemiologicalevidenceindicatesthatPTSDcanbeidentifiedacrosscultures,butitoccursinonlyaminorityofpersonsexposedtomassconflict;prevalenceratesvarybetween4and20percent,withhigherratesamongwomen(Silove,1999).Previousstudiesinrefugeeclinicpopulations(Kinzieetal.,1986,1989)andinrefugeecamps(Mollicaetal.,1993)foundarelativelyhighprevalenceofPTSD(greaterthan50percent).

Morerecently,studiesamongnon-treatment-seekingpopulationshaveproliferated;however,theyhavecontinued to focus on symptoms rather than diagnoses or have not employed rigorous population-based samplingmethodology.Acontrolledstudycomparing526BhutaneserefugeesurvivorsoftortureinNepalwithmatchedcontrolsfoundthattorturesurvivorshadmorePTSDsymptomsandhadhigheranxietyanddepressionscores(Shresthaetal.,1998).Inaretrospectivecohortstudy,35refugeeTibetannunsandlaystudentstorturedinTibetwerecomparedwithcontrols(Holtz,1998).Torturesurvivorsagainhadsignificantlyhigheranxietyscoresthandidthenontorturedcohort.SimilarincreasedsymptomrateswerefoundintorturedBurmesepoliticaldissidentsinThailand(Alldenetal.,1996).AcommunitysampleofAfghanrefugeeadolescentsandyoungadultslivingintheUnitedStatesfoundhighratesofdepression(45percent)andPTSD(13percent)(Mghir,Freed,Raskin,&Katon,1995).

AmnestyInternationalhasestimatedthatover150countriesaroundtheworldpracticegovernment-sponsoredtortureagainsttheircitizens.AccordingtoBaker(1992),between5percentand35percentofrefugeeshavebeentortured.Ithasbeenestimatedthatasmanyas400,000torturesurvivorsliveintheUnitedStates.TheactualnumberofrefugeesintheUnitedStateswhohavebeentorturedorterrorizedbytheirformergovernmentsisnotknown(Petersen,1988),althoughitisclearfromclinicalreportsandsmallsurveysthatthenumbersareappreciable(Allodi&Stiasny,1990;Eitinger,1959;Westermeyer,1989a).Intheabsenceofadequate data, it is not possible to state with accuracy the total numbers of torture survivors or whether their needs are met.

Coping and Resiliency

Refugee mental health challenges may also be understood within the context of refugee resilience and coping capacity. The opportunity to freely practice traditions, beliefs, and customs and to recreate social institutions canserveasprotectionfactors.Thefollowingprotectivefactorshavebeenidentified(Jablenskyetal.,1994):(1)availabilityofextendedfamily;(2)accesstoemployment;(3)participationinself-helpgroups;and(4)situational transcendence, or the ability of individuals and groups to frame their status and problems in terms

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thattranscendtheimmediatesituationandgiveitmeaning(e.g.,ethnicidentity,culturalhistory).Preexistingdemographicandpersonalityfactorscanalsoaffecteventualfunctioningandmentalhealth(McKelvey,Webb,&Mao,1993).

Mental health programs should stimulate these mechanisms of adaptation and foster self-help to minimize helplessness.Programsshouldhelprefugeesdevelopcopingmechanismstoreplaceorrestorethelostprotectivefactors offered by social networks, religion, and culture. Although it is important to initiate mental health programs during the emergency phase of the refugee crisis, this rarely happens.

Cultural Issues

AccordingtoMorris&Silove(1992),nosingletheorycanadequatelyencompassthephenomenonofrefugeetrauma.AccordingtoWestermeyer(1987),understandingthelargersocioculturalmilieuinwhichthepatientfunctionsiscrucialindistinguishingpsychopathologyfromculture-boundresponses.Inassessmentandtreatment, excessive reliance on models of cultural determinism would be as unproductive, however, as totally disregarding cultural factors.

Although survivors of traumatic life events have similar symptoms, cultures differ in the meaning ascribed to thekeyconceptsoftraumaandtorture.Insomecultures,thereisreluctancetoexpressemotionsortorevealtraumatic experiences, including sexual torture, until trust has been established. Consequently, forcing refugees totelltheirstorymaybecounterproductive.Insuchsituations,indirectmethodsmaybemoreuseful(Mollica,1988).Culturalattitudestowardsufferingalsoplayanimportantroleinhelp-seekingandtreatmentresponse(Boehnlein&Kinzie,1995).Forinstance,beliefsthatsufferingisinevitableorthatone’slifeispredeterminedmaydeter,forexample,someMuslimsorBuddhistsfromseekinghealthcare.

Culturestraditionallymayusemedicationsorreligious/traditionalceremoniesfortreatmentandbelessfamiliarwithWesternmentalhealthinterventions.Westernapproachestendtoemphasizetheindividualandminimizetheimportanceofthesocioculturalcontextandsocialnetworks.OftheWesternapproaches,theauthoritativeviewofthedoctorismoreactiveordirectiveandoftenmoreacceptable(Jaranson,1991).Ingroup-orientedcultures,intervention-basedgroupactivitiesmaybemorerelevantthanindividualtherapies.Symbolicinterventions are particularly relevant, such as supporting the grieving process for lost family members when burialisimpossible.Illnesses,tension,andconflictsareresolvedintraditionalsocietiesthroughexistinginbuiltculturalprocesses.Interventionsthatdonotrecognizethesefactorscouldbedetrimental(Chakraborty,1991).Socialcohesionandsolidarityactasprotectiveforces.Establishingaspecializedcentermayunderminelocalindividual and community responses, except for those survivors who do not receive the social support they need.

Overthepastseveraldecades,considerableattentionhasbeendevotedtomattersoftranslation,includingdenotation,connotation,andsemantic/technical/psychometricequivalence.ThisworkbeganwithSapirandotherlinguistsandanthropologistsduringthe1930’sto1950’s(Hall,1959),wascontinuedbyculturalpsychologistsinthe1970’sand1980’s(Brislin,1970;Butcher&Garcia,1978;Hulin,1987)andbypsychiatristsdoingcross-culturalwork(Bravo,Woodbury,Canino,&Rubio-Stipec,1993;Flahertyetal.,1988;Kinzieetal.,1982;Robinsetal.,1988;Sabin,1975;Westermeyer,1990),andwasdevelopedfurtherby psychiatric epidemiologists concerned with measuring and comparing psychiatric conditions in various populationsduringthe1980’sand1990’s(Bravo,Woodbury,Canino,&Rubio-Stepic,1993;Sartorius,1989;Westermeyer&Janca,1997).

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Implications for Assessment and Treatment

Mainstreamprofessionalsoftendonotwishtoknowtheanswersto,ordonotknowhowtoask,thedifficultquestions. Therapists, especially those who have been traumatized themselves, need skilled supervision to help them deal with their own issues that arise while trying to help others. The sensitive personalities of people motivatedtohelptraumatizedrefugees,especiallytorturesurvivors,canfindthepainandsufferingdistressing.This is also true for interpreters, many of whom have been traumatized themselves as refugees.

Sinceatrustingrelationshipmustbedevelopedforprogresstobemade,thishasthehighestprioritybeyonddiagnosis or telling the trauma story. Cultural understanding is essential in choosing the methodology of the assessment.AstandardWesternpsychiatricinterviewcanbetoxic(Mollica,1989;Quiroga&Gurr,1998).However, using structured interviews and diagnostic instruments as part of the assessment process can have several advantages, such as systematically recording symptoms in a way that elicits more than would otherwisebevolunteeredbysurvivors.Somecanbeself-administratedoradministratedbyevenbrieflytrainednon-professionals to make reasonably accurate diagnoses and to provide information for research purposes. However, there are still problems with diagnostic assessment tools, as has been shown with minor changes leadingtomajorvariationsinprevalenceinepidemiologicalsurveys(Quiroga&Gurr,1998;Regieretal.,1998),andthishasimportantimplicationsforassessingtheneedforservices.

Sensitivityalsoisrequiredinthephysicalmedicalexamination,assomesurvivorscanfindmedicalproceduresreminiscentoftortureexperienceandbecomehighlyanxiousandfrightened(Jaranson,1995).Theindividual’slarger life experiences, personal values, current life situation, family situation, and external social supports are of equal importance to the medical assessments. There are problems if either the medical or the social assessment and actions dominate, as the diversity of the needs of survivors means that some will have medical treatment priorities, some psychological treatment priorities, and others practical assistance priorities.

The best psychiatric care considers the multiple health and social service needs of refugees, as well as their otherspecialneeds(Kinzie&Jaranson,1998).InterventionsmayincludenotonlystandardWesterntreatmentssuch as pharmacotherapy and psychotherapy, but also community approaches and traditional healing, such as cultural, religious, and political dimensions important to the refugee. Traumatized refugees may be reluctant to tell their stories due to shame, lack of trust, or fear of symptom exacerbation, and they should be allowed to revealinformationatapacethatiscomfortableforthem(Jaranson,1998;Jaransonetal.,1998).Inadditionto a complete mental status examination and symptom inventory, prior and postmigration experiences, adjustment,anddisordersmustbeassessed(Westermeyer,1989b).Judicioususeofpsychotropicmedicationscan reduce symptoms, further the development of trust in the care-providers, and allow further assessment and psychotherapytoproceed(Jaranson,1991).Inmanycultures,themedicalmodelismoreacceptedorbetterunderstoodthanpsychotherapy.EducationaboutPTSD,depression,andpsychotropicmedicationsisimportant.A consistent, supportive, nonjudgmental, and culturally competent clinical approach is essential.

Sincethesymptomsandothereffectsoftortureandseveretraumaaremodulatedbybio-psychosocialfactorsrelated to the individual, a comprehensive treatment and rehabilitative approach should provide long-term flexibleinvolvementinordertocopewithrelapses(Kinzie&Jaranson,1998;Quiroga&Gurr,1998;Shalev,Bonne,&Eth,1996).Forinstance,thereisevidenceofachronicfluctuatingcourseinPTSD,whichcanlastalifetimeifuntreated(Basoglu,1993;Basoglu,Jaranson,Mollica,&Kastrup,1998).Therearefluctuationsintherevelationof,andreactionto,thetraumaexperiences,asthesurvivor’slevelofpsychologicalsecurityfluctuateswithlifeeventsandlifestages.Psychologicaltreatmentisveryimportantforthemoreseverelyaffected survivors, and evidence exists that social support may not be of much help unless the survivor is

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psychologicallyhealthyenoughtoaccessanduseit(Basoglu,1993;Kinzie&Jaranson,1998;Quiroga&Gurr,1998).Thefamilyisintimatelyinvolvedandmayneedasmuchassistanceforindirecttraumaandfordealingwith the survivor.

Inorderforrefugeementalhealthcaretobeeffective,itisessentialthatprimaryhealthcareserveasthemainhealth service infrastructure. The challenge is to orient and train primary health care workers in mental health skills and services, including diagnosis and therapy. Mental health services should be closely coordinated with general health services, psychosocial services, and other relevant rehabilitation, social, educational, occupational, cultural, and recreational activities. Mental health services should be community based, and, wherever possible, focus on early intervention at the primary, secondary, and tertiary levels of prevention. Mental health services should be sensitive to gender and cultural issues and the needs of particular demographic groups, as well as to high-risk groups such as the physically injured and disabled, the severely mentally disabled,andsurvivorsofextremetrauma,torture,andsexualabuse.Inaddition,thedoctormustbesensitivetothe differing ethnic responses to psychotropic medications in metabolism, nutritional status, age, smoking, and drug interactions.

AccordingtoShalev,Bonne,andEth(1996),themainoutcomegoalfortherapyisincreasedfunctionalityto achieve personal goals, rather than symptom reduction. However, symptom reduction may also be a goal, particularlyforhighlevelsofthepositivesymptomsofPTSD,majordepression,orotherdisordersthatrespondto medication. These disorders require a combination of medical, psychological, social, and legal intervention.

However,therealityisthatmostrefugeesdonotgetformalhelp.Itisimportanttotraincommunitymemberstorecognize signs of torture and trauma and to inform torture survivors that they are not alone, that their reactions and symptoms are not unusual. The advantages of this approach, conducted by members of the community, include minimizing linguistic or cultural barriers and providing better capacity to screen people needing services.Disadvantagesincludetheneedforsupervisionandlimitedcapacityfordiagnosisorprovisionofpsychotherapy.

Challenges and Opportunities

Despitethegrowthinexpertise,experience,andknowledgeaboutmentalhealthissuesaffectingforcedmigrants, there are many barriers to use of this information to improve policy and programmatic responses. Inpart,thebarriersreflectfailuresofcommunicationbetweenscientists,serviceproviders,andpolicymakers.Research is not necessarily formulated or packaged in a manner that translates readily into new program designs orpolicyapproaches.Serviceprovidersandpolicymakers,oftenmovingquicklyfromonecrisistoanother,have little time to review the research literature to assess its implications for programs or policies. Moreover, issuesraisedbytherefugeementalhealthliteraturecrossmanyfieldsofexpertise,butthereisconsiderablefragmentationofresponsibilityforforcedmigrationwithintheUnitedStatesand,evenmoreso,withintheinternational community.

Thebarriersalsoreflectbasicrealitiesinthedeliveryofservicestoforcedmigrants.Refugeeandotherforcedmovementstendtobedefinedasemergenciesrequiringemergencyresponses.Theseresponsestend,inturn,tobedefinedinlogisticalterms:howmanytentsandhowmanytonsoffood,clothing,andmedicinescanbedeliveredintheshortesttimepossible.Failuretorespondquicklyandefficientlytotheseimmediateneedsmayresultinthousandsofdeaths.Theemergencyparadigmmakessenseinsomecases—forexample,therapidexodusandthenrepatriationofKosovars—butmanyrefugeesituationswouldbedescribedmoreproperlyasprotracted crises, with displacement continuing for years.

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Even in developed countries with the resources and expertise to respond to emergencies, large-scale forced migrationpresentslogisticalchallenges.Inmanycases,themigrantsarrivewithoutauthorizationandareunwilling to present themselves to the authorities for fear of return to their home countries. Humanitarian evacuations,suchasoccurredfromSoutheastAsiainthelate1970’sandMacedoniaduringtheheightoftheKosovocrisis,presentparticularchallengesasrefugeesarrive,havinghadlittleopportunityforplanningorpreparation.

Oftenoverlookedinrespondingtotheemergencyaretheactualpeoplewhoareinflight.Theirnon-materialneedsaremuchmoredifficulttoquantify.Theafter-effectsofrapeandwitnessingmurderarefarmoredifficulttoaddressthanaretheafter-effectsofanemptystomach.Foodandsheltermayservethemostimmediateneedsof the small child separated from his or her parents, but the emotional and psychological effects of this loss also require attention.

Even with the best will in the world to tackle these nonmaterial needs, budgets constrain options for services. In2000,theUnitedNationsissuedaconsolidatedappealfor17complexemergencies,requestingalmost$3billioninassistance.TheappealcoversalloftheU.N.agenciesthatassistthevictimsofhumanitariancrises—refugees,internallydisplacedpersons,andotherwar-affectedpopulations.Itdoesnotincluderesourcesfornewemergenciesthatmayoccurduringthecourseoftheyear.Generally,contributionsfallshortoftherequestedamount.UNHCRreportedashortfallof$185millioninits1999budgetof$1.2billion(whichincludesfundsbeyondwhatwererequestedintheconsolidatedappealsprocess).Thesituationislikelytobenobetterin2000.IntheUnitedStates,forexample,Congressappropriated$625milliontosupportoverseasrefugeeassistanceprogramsaswellasresettlementofrefugees,$52.5millionlessthanthePresidentrequested.

Inabudgetaryclimateinwhichitisdifficulttoraisefundsforbasicfood,shelter,andsecurityneeds,providingfundingformentalhealthservicesmayappearfoolhardy.Fromapolicymaker’spointofview,theliteratureonthe psychosocial needs of refugees and other forced migrants presents a daunting picture. The prevalence of experiences that could trigger mental health problems appears staggeringly high. The potential client base for any programs could number in the millions.

Furthercomplicatingtheproblemisaccesstothoseneedingservices.Manyofthemostvulnerableforcedmigrantsareinternallydisplaced,oftentrappedinconflictzonesandoutofreachbytheinternationalcommunity. Refugees and displaced persons who reach relative safety may be able to avail themselves of services, but life remains highly insecure for them as well. Tending to basic needs, particularly for refugee womenwhoareoftenresponsibleforwater,food,andfirewoodcollectioninadditiontootherhouseholdandchildcare duties, often precludes participation in programs.

Even after reaching resettlement countries, refugees engage in survival activities that may mask their need for psychosocial services while restricting their ability to access programs that are available to them. Resettled refugees, in fact, have a much wider array of services available than do other forced migrants arriving in the UnitedStateshavinghadsimilarexperiences.Asdiscussedabove,theFederalGovernmentprovidessocialservicegrantstoprivateagenciesandStategovernmentsandhasanofficespecificallyresponsibleforrefugeemental health issues.

Bycontrast,forcedmigrantswhoarriveintheUnitedStatesotherthanthroughtheresettlementprogramhaveaccesstofewservices.TheU.S.CommitteeforRefugees(1999)hassaid:

Psychologicalsupportforasylumseekersandsurvivorsoftorturewhodonotarriveunderanorganized resettlement program is particularly tenuous. Asylum seekers face legal uncertainty

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and lack access to the social services afforded to resettled refugees, factors that compound problems associated with their lack of psychological support.

Asylum seekers often require access to such services, not only to address their mental health problems but also to underscore the credibility of their asylum claims. Mental health professionals are often asked to certify the likelihood that an applicant experienced the torture or persecution alleged in the application.

Improvingresponsesrequiresactionsatseveraldifferentlevels.Themosteffectiveresponseswould,ofcourse,addressthecausesofforcedmigrationthroughpreventionstrategiesthatprotecthumanrights,avertconflicts,and improve economic development. Clearly, reducing the traumas that force people to migrate for safety will reducetheneedforrefugeementalhealthprograms.Sincesuchstrategiesrequireinterventionsfarbeyondthecapacitiesofprofessionalsworkingintherefugeeormentalhealthfields,practicalstepsmustbetakenintheinterim to increase access to appropriate services.

Training and preparation of all staff with responsibilities for refugee assistance and protection will be necessary ifsignificantimprovementistobemadeinaddressingthepsychosocialneedsofrefugeesandotherforcedmigrants.Sincealldecisionsmadeinrefugeeemergenciesholdthepotentialforincreasingorreducingtrauma,itisimportantthatthementalhealthimplicationsofdecisionsbetakenintoaccount.Forexample,humanrights monitors who interview refugees to document war crimes may trigger posttraumatic stress responses astherefugeestelloftheirpersonalexperiences.Inaddition,acadreofspecialistsmaybeneededforquickresponses, people who can get out at the start of an emergency to interview refugees, get an index of what the problemsare,designlow-costresponses,andtrainfieldstaffasneeded.Trainingofrefugeesthemselvestotakeresponsibility for problems as they arise is also a key element of a more effective response.

Improvingrefugeementalhealthprogramswillalsorequirechangesinorganizationalrolesandthedeploymentof institutional resources. At the international level, greater attention needs to be paid to determining which agencies among those responsible for refugees and forced migrants should take the lead regarding mental health issues.InadditiontotheUNHCR,theWorldHealthOrganizationandUNICEF(U.N.InternationalChildren’sEmergencyFund)havemandatesinthisarea.Ultimately,addressingmorebroadlythementalhealthandpsychosocialneedsofrefugeeswillrequirefinancialresources.Throughtheconsolidatedappealprocess,theU.N.agenciesshoulddeterminewhatadditionalfundingwillbeneededtorespondmoreeffectively.

WithintheUnitedStates,mostprogramsdesignedtocarefornewAmericanshavefacedoverwhelmingobstaclestosurvival.AlthoughFederallawrequireshealthcareorganizationstoprovideinterpretersfornon-English-speakingpatients,enforcementhasbeeninconsistent.Interpretationincreasesthecomplexityandcostofprovidinghealthcareservices.Fewprogramshavesurvivedbydependingsolelyuponthird-partyreimbursement,andlocal,State,Federal,orprivatefoundationfundingisusuallyrequiredforsustainability.Realizingtheseobstacles,theU.S.CongresspassedtheTortureVictimsReliefActinOctober1998,providingfundingfortorturerehabilitationprogramsbothintheUnitedStatesandabroad.However,nocomparableFederallegislationtocareforrefugeesandasylumseekerstraumatizedinotherwayshasbeenpassed.

Research Priorities

AccordingtoRosenheckandFontana(1999),researchonthedeliveryofhealthcareservicesforPTSDcanbethought of as addressing the following three goals:

• Severity/BurdenofDisease.Serviceuse,alongwithepidemiologicaldataondiseaseprevalence,isanindicatoroftheburdenofdiseaseonthegeneralpopulationanditseconomicconsequences.Kessleret

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al.(1999),intheNationalComorbiditySurvey,showsthatPTSDisassociatedwithnearlythehighestrate of service use, and, by implication, the highest per-capita cost of any mental health disorder. This showsthecentralimportanceofPTSDforthepublic’smentalhealth.RosenheckandFontanaalsoconcludethatPTSDisalsoassociatedwithhighlevelsofuseofnon-mentalhealthservices.

• Access to Care. Studiesofserviceutilizationprovideinformationontheaccessibilityofservices(i.e.,thesuccessorfailureofthehealthcaresystemtoaddresstheneedsofitstargetpopulation).RosenheckandFontanafoundthatsurvivorsofhuman-madedisasterswerereluctanttousementalhealthservicesbecause of the fear that painful memories would be aroused.

• Outcome, Cost, and Value. Studiesofserviceutilizationareimportanttosimultaneouslyevaluatetheeffectivenessandcostofservices(i.e.,theirultimatevaluetothepublic).Althoughmedicalcarehastraditionally focused its research efforts on individual patients and illnesses, new research methods and perspectivesareincreasinglyoperationalizedtocorrectthesedeficiencies.

Beforestartingastudy,itisofcrucialimportancetoconsidertheoreticaldilemmas(i.e.emiceticperspectivesregardingbothdiagnosticandoutcomemeasuresfollowingseverebutdifferenttraumaticlifeevents).Researchersshouldalsoclarifythedefinitionsofkeyconceptssuchasrefugeeversusimmigrant;differencesinethnic,educational,religious,andsocioeconomicbackgrounds;andreasonsforimmigration.

Itmustalsobekeptinmindthatresearchconductedwithrefugeesfromcountrieswhereethnicconflictsarestillactivecaneasilybeaffectedbysuchconflicts.Further,fromanethicalpointofviewitisimportantthattherefugee who is to be interviewed does not have the feeling of being investigated by the police or courts. Time shouldbeallowedforthenecessarytrusttodevelop.Beforestarting,theresponsibilityforvariouspartsoftheworkshouldbeclarified.Thestudysiteshouldbelocatedclosetotheresearchers,andafrequentdialogueof training and supervision take place between the researchers and practitioners, minimizing the need for gatekeepers.

The cultural and language competence of the interviewer is important in the contact with the interviewees, butthiscompetenceiseasilytransformedintodifficultieswhentransference/countertransferenceprocessesoccur. Transcultural validity, the concept of equivalence, and appropriate methods, with their limitations, are of concern. An integration of quantitative and qualitative methods provides the best possibility for understanding the complex issues affecting the mental health of refugees. The study of methods to avoid burnout or vicarious traumatization among mental health providers is also relevant.

Sincefundingisscarce,identifyingeffectiverehabilitationmodelsisessential.Controlledrandomizedclinicaltrialsareneededinordertodevelopbriefandcost-effectivementalhealthprogramsforrefugees.Ofpressingimportanceareclinicaloutcomestudies,fewofwhichexist(Mollicaetal.,1990)becauseofthelackofcontrolgroups,definitionsofdiagnosticcriteria,validationofassessmentinstruments,andmanyotherobstacles.Asetofstandardsandmeasuresofoutcomeshouldbeincludedinresearchdesigns.Internationalcollaborativecross-cultural studies would facilitate research on policy studies, methodological issues, technical issues in refugee healthcare,andthegenericandculture-specificriskandresilienceresponsestotraumaticlifeeventsandPTSD.

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