Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and Treatment : The Importance of Culturally Sensitive Screening, Diagnosis, and Treatment [1 ed.] 9781617283161, 9781616687465

Citation preview

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

POST-TRAUMATIC STRESS DISORDER IN REFUGEE COMMUNITIES: THE IMPORTANCE OF CULTURALLY SENSITIVE SCREENING, DIAGNOSIS, AND TREATMENT

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS Additional books in this series can be found on Nova’s website under the Series tab.

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Additional E-books in this series can be found on Nova’s website under the E-book tab.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

POST-TRAUMATIC STRESS DISORDER IN REFUGEE COMMUNITIES: THE IMPORTANCE OF CULTURALLY SENSITIVE SCREENING, DIAGNOSIS, AND TREATMENT THEODORE W. MCDONALD AND

JAIME N. SAND

——————————————

Nova Science Publishers, Inc. New York

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS.

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA McDonald, Theodore W. Post-traumatic stress disorder in refugee communities : the importance of culturally sensitive screening, diagnosis, and treatment / Theodore W. McDonald and Jaime N. Sand. p. ; cm. Includes bibliographical references and index. ISBN HERRN 1. Post-traumatic stress disorder. 2. Refugees--Mental health. 3. Psychiatry, Transcultural. I. Sand, Jaime N. II. Title. [DNLM: 1. Stress Disorders, Post-Traumatic--diagnosis. 2. Cultural Competency. 3. Refugees-psychology. 4. Stress Disorders, Post-Traumatic--therapy. WM 170 M478p 2010] RC552.P67M384 2010 616.85'21--dc22 2010016080

Published by Nova Science Publishers, Inc. † New York

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

CONTENTS vii 

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Preface Chapter 1

Introduction

1 

Chapter 2

Refugees and PTSD

3 

Chapter 3

Screening and Diagnosis of PTSD in Refugees

11 

Chapter 4

Treatment

21 

Chapter 5

Conclusion

35 

References

37 

Index

51 

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

PREFACE In the past several decades, millions of refugees fleeing conflicts across the globe have been resettled in other countries, including industrialized Western nations such as the United States, Canada, Australia, and Sweden. Many of these refugees have been exposed to severe—and often repeated— trauma in conflict zones, including combat, torture, sexual violence, and destruction of property. Sadly, countries receiving refugees are often unprepared for the magnitude of mental health problems these refugees bring with them. Post-traumatic stress disorder (PTSD), perhaps not surprisingly, seems to be a particularly prevalent condition among these refugees. Research on repeated waves of refugees from Southeast Asia, the former republics of Yugoslavia, as well as Africa, Southwest Asia, and the Middle East confirms that refugees experience PTSD symptomatology to an alarming degree. In this volume, we discuss how PTSD manifests itself, sometimes differentially, in refugees, and present some best practices on how to screen for and diagnose it, as well as treat it in a culturally sensitive fashion. We present some standardized assessment inventories, such as the Harvard Trauma Questionnaire, that were deliberately created for use with refugees, and summarize some steps that refugee researchers can use to create their own culturally sensitive screening and diagnostic tools. Then, we introduce some empirically supported treatments used to alleviate PTSD symptomatology in refugees, including Cognitive Behavior Therapy (CBT), Narrative Exposure Therapy (NET), and testimony therapy. Ultimately, we argue that Western mental health practitioners can, through timely triage and provision of mental health services, dramatically improve the quality of refugees’ lives and decrease the disease burden incurred by untreated mental health problems in their host countries.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Chapter 1

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

INTRODUCTION Post-traumatic stress disorder (PTSD) is a pervasive mental health condition that is highly troubling and debilitating for those who suffer from it. Characterized by a variety of symptoms including recurrent and disturbing thoughts and dreams of a traumatic event, avoidance of people or places associated with the event, feelings of numbness or restricted emotions, and heightened arousal (American Psychiatric Association, 2000), PTSD has been conservatively estimated to affect 6.8% of all Americans during their lifetimes (Kessler et al., 2005). Using this estimate, we can conclude that approximately 21 million of the nearly 308 million Americans alive in mid-September 2009 (U.S. Census Bureau, 2009) either have suffered from, currently suffer from, or will at some point in their lives suffer from PTSD. A variety of different traumas can lead to the development of PTSD symptoms, and as a result, many seemingly different types of people suffer from the disorder. Research suggests that PTSD frequently affects such diverse persons as combat veterans (e.g., Blake et al., 1990; Hoge et al., 2004), sexual assault victims (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992; Ullman, Filipas, Townsend, & Starzynski, 2007), persons injured in motor vehicle accidents (e.g., Blanchard & Hickling, 2003; Irish et al., 2008), survivors of natural and human-caused disasters (Galea et al., 2007; Neria, Nandi, & Galea, 2008), and emergency responders, including firefighters, police officers, emergency medical technicians, humanitarian workers, and others (e.g., Benedek, Fullerton, & Ursano, 2007; Kates, 1999; Perrin et al., 2007). One group that seems to have a particularly high rate of PTSD—reportedly about 10 times higher than the general population—consists of refugees who have been resettled from wartorn countries in the United States and a number of other nations (e.g., Fazel,

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

2

Theodore W. McDonald and Jaime N. Sand

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Wheeler, & Danesh, 2005; Gong-Guy, Cravens, & Patterson, 1991; Keller et al., 2006; Vojvoda, Weine, McGlashan, Becker, & Southwick, 2008). The purpose of this volume is to discuss PTSD in the context of the refugee experience, as well as to share information on how service providers can screen for, diagnose, and treat PTSD in refugees in a culturally sensitive and effective manner.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Chapter 2

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

REFUGEES AND PTSD It is difficult to document historical rates of displacement, as verifiable international records have only been kept for the past half-century or so. However, the records that do exist suggest that the number of refugees worldwide has skyrocketed in the last four decades. For example, several researchers have maintained that whereas there were fewer than three million refugees in 1970, there were between 30 and 40 million refugees by the early 21st century (Colic-Peisker & Walker, 2003; Pumariega, Rothe, & Pumariega, 2006). The United Nations High Commissioner for Refugees (UNHCR, n.d.) supports that an extremely high number of refugees exist, reporting that U.N. workers monitor 34 million international refugees and internally displaced persons in 110 countries around the world. Many refugees settle temporarily in camps in countries neighboring their own (this is particularly true in Africa, the Middle East, and southwest Asia; UNHCR, 2008), however, a number are resettled permanently in industrialized Western countries. When refugees settle in such developed nations, there may be an expectation that public health systems—including community mental health systems—are in place to help remediate health-related concerns associated with their displacement and resettlement. As we will discuss in this volume, many community mental health researchers have found that nations may underestimate the psychological trauma experienced by refugees and be unprepared (or at least underprepared) to respond to mental health problems—most notably PTSD— associated with this trauma. Some of the earliest research documenting PTSD in refugees was focused on the experiences of persons fleeing violence and persecution in Southeast Asia. Prior to the end of the war in Vietnam, there were relatively few people

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

4

Theodore W. McDonald and Jaime N. Sand

from Southeast Asia living in the United States or other western nations (Uba, 1992). However, with the communist takeovers in South Vietnam, Laos, and Cambodia, massive numbers of refugees fled, often by boat, to countries such as Thailand, Malaysia, and the Philippines, before being resettled in nations such as the United States, Canada, and Australia (Gong-Guy et al., 1991; Silove, Steel, Bauman, Chey, & McFarlane, 2007). Almost immediately, public health workers in the receiving countries began documenting a host of medical problems, many of which were not problems routinely experienced in those countries such as tuberculosis, malaria, cholera, and anemia (Muecke, 1983; Uba, 1992). It was somewhat later that focus was extended to mental health problems (perhaps due to the fact that screening for medical conditions potentially communicable to the host population is emphasized more during the refugee intake process than is screening for non-communicable mental health problems). However, within just a few years, researchers began to document mental health problems, most notably PTSD (but also depression and a host of other anxiety problems) in Southeast Asian refugees. Mollica, Wyshak, and Lavelle (1987) were among the first to systematically study levels of exposure to traumatic wartime events and psychological and physical morbidity in Southeast Asian refugees. Noting that over 700,000 refugees from Southeast Asia had settled in the U.S. since 1975, Mollica et al. (1987) reported that many such refugees likely suffered from psychological distress due to their high levels of exposure to trauma both before and during escape from their home countries (violence during escape has also been reported by other authors such as Gong-Guy et al. [1991] and Lee & Lu [1989], who reported that over 80% of boats fleeing Southeast Asia were boarded by pirates and that “boat people” were frequently attacked, beaten, and raped by these and other predatory persons during transit). They also maintained that the scope of psychological distress in Southeast Asian refugees was largely unknown due to the fact that, well into the 1980s, there were almost no specialized mental health services available to these refugees. Mollica et al. (1987) described their specialized treatment study—one of the first of its kind—and documented levels of trauma and psychopathology among 52 refugees from Cambodia, Laos, and Vietnam. They found, perhaps not surprisingly, that levels of trauma exposure were high, with the refugees reporting, on average, nearly 10 trauma experiences and two torture experiences each. They found that fully half of the refugees met the diagnostic criteria for PTSD (and that sizable percentages of the refugees also met the diagnostic criteria for other mental health conditions, most notably major affective disorder), and that those who were diagnosed with PTSD had

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Refugees and PTSD

5

experienced many more traumatic events than those who did not meet the diagnostic criteria. In short, they found that the Southeast Asian refugees in their sample were highly traumatized, and suffered psychological distress at a much higher level than one would expect in the general population. They also reported that the refugees had experienced marked difficulties adjusting to life in the U.S., with nearly all reporting having difficulties with language, and majorities reporting difficulties accessing employment and housing. Other researchers working with the same population of Southeast Asian refugees reported similar findings. For example, in another early study, GongGuy (1987; cited in Hsu, Davies, & Hansen, 2004), conducting a mental health needs assessment for the state of California, reported that Southeast Asian refugees from a variety of subgroups (including Cambodians, the Hmong people from highland Laos, Laotians, and Vietnamese) experienced high rates of reported trauma, and that approximately 10% of all refugees suffered from PTSD. Finding a much higher prevalence rate of PTSD, Kinzie et al. (1990) reported that 70% of the 322 Southeast Asian refugees seeking treatment at a mental health center met the diagnostic criteria for PTSD, with rates as high as 93% for certain subgroups (the Mien people from the hill country of Laos). Sadly, the evidence exists that PTSD symptomatology may persist for Southeast Asian refugees long after resettlement. For example, Marshall, Schell, Elliot, Berthold, and Chun (2005) examined the prevalence of PTSD in Cambodian refugees who had been in the United States for over a decade and found that more than 60% of formerly traumatized refugees continued to meet the diagnostic criteria for PTSD. Although they found that premigration trauma (such as near-starvation, combat exposure, and forced labor) was most strongly associated with the prevalence of PTSD, they also found that postmigration trauma (such as exposure to community violence or crime victimization) also increased the likelihood of refugees developing PTSD. In sum, it became clear in this first wave of research on Southeast Asian refugees with PTSD that these refugees were highly traumatized by experiences in their home countries (and in some cases, in their host countries as well), that PTSD levels among refugees are typically much higher than in other host country residents, and that symptomatology may persist long after the initial trauma. The next major wave of research on the mental health of refugees included refugees fleeing war in the former Yugoslavia. Much of this research focused on refugees from the former Yugoslavian republic of Bosnia, which from 1992-1995 played host to some of the most brutal warfare and genocide (often referred to as “ethnic cleansing”) documented since the Second World War (Begic & McDonald, 2006); an estimated 250,000 people were killed in less

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

6

Theodore W. McDonald and Jaime N. Sand

than four years (Becker, Weine, Vojvoda, & McGlashan, 1999; Craig, Sossou, Schnak, & Essex, 2008). According to UNHCR (2006), some 2.2 million Bosnians were displaced at some point during the war there, and many settled in a variety of Western countries, including the United States (Vojvoda et al., 2008). One of the earliest studies on PTSD in Bosnian refugees was conducted by Weine and his colleagues (Weine et al., 1995), who documented the trauma experienced by 20 survivors of ethnic cleansing operations in Bosnia. They found that 65% of the refugees, all of whom completed clinical interviews, met the criteria for diagnosis with PTSD, and that the severity of the PTSD symptoms was positively correlated with the number of trauma experiences the refugees reported. Other authors (e.g., Begic & McDonald, 2006; Craig, et al., 2008; Durakovic-Bello, Kulenovic, & Dapic, 2003; Papageorgiou et al., 2000; Thulesius & Hakansson, 1999) have confirmed that PTSD is highly prevalent in Bosnian refugees (generally occurring at much higher rates than in non-refugees and host country citizens), and is strongly correlated with traumatic exposure. Several researchers have also reported that certain subgroups of Bosnian refugees seem particularly vulnerable to experiencing PTSD, including women (e.g., Begic & McDonald, 2006) and older persons (e.g., Begic & McDonald, 2006; Craig et al., 2008; Mollica et al., 1999) In this second major wave of refugee research, stronger attempts seem to have been made to study the prevalence of PTSD longitudinally. Weine and his colleagues have been particularly active in attempting to track PTSD symptoms in Bosnian refugees in the years after resettlement. For example, Weine et al. (1998) assessed the presence of PTSD symptomatology in 34 Bosnian refugees at resettlement and at one year post-resettlement. At the first assessment, 25 of the 34 refugees (all of whom were ethnic Muslims and all but one of whom reported exposure to traumatic experiences), or 65% of the total, met the diagnostic criteria for PTSD. At the follow-up assessment, PTSD diagnoses were made for 15 (or 44%) of the refugees. A longer-term assessment was later conducted by Vojvoda, Weine, and their colleagues (Vojvoda et al., 2008); in this assessment, PTSD symptoms were assessed in Bosnian refugees 3.5 years after resettlement. Forty-five Bosnian refugees were tested for PTSD at baseline, when they were resettled in the U.S. All of these again were ethnic Muslims who reported various levels of exposure to trauma during the war in Bosnia. Of the 45 refugees, 34 were available for the one-year follow-up, and 21 were available for the 3.5 year follow-up. All longitudinal prevalence rates were calculated out of those 21 who were available for all three assessments. The results paint an interesting story about how PTSD evolves in refugees over time. Whereas 76% of the refugees (16 of

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Refugees and PTSD

7

21) met the criteria for a PTSD diagnosis at baseline (i.e., when resettled), seven (33%) met the criteria at one year, and five (24%) met the criteria at 3.5 years. Although these numbers show that the percentage of refugees with PTSD decreased over 50% from baseline to one year, and by over two-thirds from baseline to 3.5 years, they also show that nearly one in four refugees continued to suffer from clinically diagnosable PTSD long after resettlement. The third major wave of research has cast a much wider net than the previous two described here. In this third wave, researchers have studied the prevalence of PTSD in refugees from regions and countries throughout the world. Many of these studies have focused on refugees fleeing conflicts in the Middle East, such as those in Iraq (e.g., Jamil et al., 2005; Lindencrona, Ekblad, & Hauff, 2008; Sondergaard, Ekblad, & Theorell, 2001), Israel/Palestine (e.g., Laufer & Solomon, 2006; Lavi & Solomon, 2005; Qouta, Punamaki, & El Sarraj, 2004), and Lebanon (Macksoud & Aber, 1996); in Africa, such as those in Congo (e.g., Mels, Derluyn, Broekaert, & Rosseel, 2009), Rwanda (e.g., Onyut et al., 2009; Pham, Weinstein, & Longman, 2004), and Somalia (Bhui et al., 2006; Onyut et al., 2009); and in Southwest and Central Asia, such as Afghanistan (Malekzai et al., 1996; Mghir, Freed, Raskin, & Katon, 1995; Renner & Salem, 2009), Chechnya (de Jong et al., 2007; Renner & Salem, 2009), and Sri Lanka (e.g., Somasundaram, 2007; Steel, Silove, Bird, McGorry, & Mohan, 1999). Several studies in this third wave are particularly interesting because they focused on refugees from more than one country, allowing for a broader assessment of PTSD as a universal phenomenon rather than simply a pattern of response to wartime trauma experienced by members of specific cultures. Lindencrona and his colleagues (2008), for example, studied the prevalence of PTSD in a sample of refugees from several different Middle Eastern countries (although the majority were from Iraq) who had resettled in Sweden. They found that over 75% of their sample of refugees exhibited the “core symptoms of post-traumatic stress” (p. 125), and reported that preresettlement trauma (and torture in particular) was the strongest predictor of post-traumatic stress. High rates of PTSD were also found in a study by Lamaro et al. (2009) in a recent study of Rwandese and Somali refugees living in a large camp in Uganda. This study was particularly interesting because it compared two disparate types of refugees (for example, nearly all of the Somalis were Muslim and a plurality of them had been unemployed prior to displacement; the overwhelming majority of Rwandese were Christian and were largely displaced farmers). Both groups had high levels of trauma exposure, and over 48% of the Somalis and 32% of the Rwandese met the

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

8

Theodore W. McDonald and Jaime N. Sand

clinical criteria for PTSD. Similarly, a study by de Jong and his colleagues (2002) on the mental health of refugees and other displaced persons in Chechnya and Ingushetia showed high levels of trauma exposure (only 2% of the refugees in Ingushetia and 6% of the refugees in Chechnya had not been exposed to violent events, and the vast majority of refugees in both samples had lost their homes as well as all their possessions), as well as high levels of somatic and mental health complaints. Overall, each of these studies showed refugees tend to be highly traumatized, and that levels of trauma are related to levels of PTSD. Although most studies related to PTSD in refugees have focused on how pre- and post-displacement trauma affect refugee mental health in only one or two ethnic groups, several have focused on the extent to which PTSD is a common pattern of responses to trauma across many groups of refugees. For example, Porter and Haslam (2005) conducted a meta-analytic review of 56 reports that focused on the association between different types of traumatic events and mental health problems in refugees; each of these 56 studies included at least one comparison between refugees and non-refugees, and together featured data from over 67,000 participants. The refugees covered in these studies previously resided throughout the world; 18 of the studies focused on refugees from Europe, and 14, 12, 10, and three of the studies focused on refugees from Asia, the Middle East, Latin America, and Africa, respectively. Consistent with other research reported here, levels of mental distress were high in refugees, and refugees scored higher on mental distress than non-refugees; the magnitude of the difference between the two groups was reported to be “medium-sized” (p. 609). Also consistent with other research, mental health outcomes tended to be poorer for older refugees than younger ones, and for women than men. In another recent meta-analysis, Steel and his colleagues (2009) reviewed 161 articles in which nearly 82,000 refugees had been surveyed on levels of trauma, and PTSD and/or depression; this collective body of articles covered refugees from Africa, the Middle East, Europe, and Asia (in decreasing order of representation). They reported the weighted prevalence rate of PTSD across all refugees tested for it to be 30.6%. Although Fazel, Wheeler, and Danesh (2005), in a smaller review of nearly 7,000 refugees in several Western nations (primarily the U.S. and Australia), reported the overall prevalence rate of PTSD to be lower at nearly 10%, and some researchers have maintained that the prevalence of PTSD among refugees may be inflated (Silove [1999], for example, maintained that high PTSD prevalence rates are reported because researchers usually assess refugees from psychiatric rather than epidemiologic samples; Stubbs [1999],

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Refugees and PTSD

9

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

as cited in Watters [2001], maintained that refugee advocacy groups may deliberately overstate the prevalence of mental health problems in refugees to further their own agendas), the large scale studies by Porter and Haslam (2005) and Steel et al. (2009) suggest that PTSD is indeed prevalent in refugees across the world, and that these refugees would be well served by appropriate screening, diagnosis, and treatment.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Chapter 3

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

SCREENING AND DIAGNOSIS OF PTSD IN REFUGEES Although, as will be discussed shortly, there are some well validated and culturally sensitive measures already established for the assessment and diagnosis of PTSD in refugees, as well as some relatively new and innovative ones, a number of researchers maintain that caution must be used when attempting to screen for and diagnose a Western-defined disorder such as PTSD in refugees. For example, Summerfield (1999) has been extremely critical of the effort by Western mental health professionals to attempt to diagnose and treat PTSD in refugees and other potentially traumatized people in non-Western countries. In short, he has argued that PTSD is a Western concept that may not even be applicable to people in the non-Western world; he further argued that Western mental health professionals, in part through their emphasis on PTSD, essentially ignore indigenous peoples’ own constructions and interpretations of distress and impose a foreign concept upon them (Summerfield, 1999). Others seem to take a more balanced approach, but still question the validity of the PTSD concept across cultures. In his 2001 review, Watters provided a valuable overview of arguments about the validity of PTSD for members of this population. The theme connecting these arguments was that when attempting to study PTSD in refugees, Western mental health professionals may be “pigeonholing” refugees’ responses to stress—some of which may actually be adaptive, at least within certain cultures—into Western concepts of psychopathology (a good example of this tendency is also described by Zur, 1996). In doing so, they may be failing to recognize important elements in refugees’ experiences and coping responses while searching for evidence of a condition that may not exist. In a similar

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

12

Theodore W. McDonald and Jaime N. Sand

vein, Bracken (2001; Bracken, Giller, & Summerfield, 1995) has argued that PTSD as a disorder may be a time- and context-specific phenomenon (i.e., a manifestation of psychopathology in the Western world in the contemporary period), and questioned whether the concept is appropriate for study of refugees from developing countries. Despite these criticisms, it seems it would be a mistake for mental health professionals to conclude that PTSD is not a valid and measurable construct in refugees. Although PTSD as a mental health condition is certainly based on Western concepts, the fact that its symptoms have been found in refugees from every inhabited continent (e.g., Fazel et al., 2005; Porter & Haslam, 2005; Steel et al., 2009) lends support to the universal nature of the condition in most, if not all, cultures. Furthermore, researchers such as Campbell (2007) and Nutt and Malizia (2004) have noted that there are biological similarities in how people respond to traumatic events; Campbell (2007) states that “Underlying biological responses may indicate that there is a common mechanism for PTSD cross-culturally” (p. 636). Nicholl and Thompson (2004), echoing other researchers (e.g., Campbell, 2007; Friedman & Jaranson, 1994; Zur, 1996), sagely recommend shying away from discussions of how universal PTSD might be, and instead attempting to assess, diagnose, and treat it in the most culturally sensitive and informed ways possible. The remainder of this volume provides guidelines on how to do this. Typically, the PTSD assessment process involves two distinct subprocesses: Screening for PTSD and (when appropriate) making a diagnosis. As was noted earlier, there are a number of assessment inventories that have been validated for use with refugees who have experienced trauma. Several of these have been created primarily to measure trauma, and are intended to be used in conjunction with other measures to explicitly assess whether PTSD or related mental health conditions exist. One of the most widely used measures to assess trauma is the Harvard Trauma Questionnaire (HTQ). The HTQ was developed during the first wave of refugee research described earlier; it was originally used by researchers associated with the Harvard Program on Refugee Trauma (HPRT; n.d.a.) in studies of mental health problems in refugees from Southeast Asia. Although it is beyond the scope of this volume to describe the HTQ (or any other assessment measure) completely, it is important to understand at least some of its key features, because it is considered one of the best assessment measures to use with traumatized refugees. The HTQ, although it exists in modified forms for use with different types of refugee populations, has some fundamental similarities across versions (HPRT, n.d.b.). It consists of four parts. The first part consists of a number of

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Screening and Diagnosis of PTSD in Refugees

13

questions intended to assess the frequency and magnitude of trauma experienced by refugees. These questions ask, using a dichotomous “Yes” or “No” response format, whether the refugees have experienced a wide range of trauma experiences, including material deprivation (such as not having access to food or water), exposure to war-like conditions (such as combat or sniper fire), bodily injury (such as being beaten or raped), forced confinement (such as imprisonment in a camp), and disappearance or loss of a loved one (such as the kidnapping or death of a family member), among others. Cumulative responses from this part (i.e., the number of traumatic events experienced) are most often quantified in studies on the effect of trauma exposure on mental health problems in refugees. The second includes some open-ended questions designed to allow refugees to comment on their trauma experiences in their own words. The third part asks several questions to assess experiences related to traumatic brain injury (for example, whether refugees have been beaten or suffocated to unconsciousness). The fourth part consists of several dozen items intended to assess whether refugees may be experiencing PTSD and the extent to which they are able to function well in everyday life (HPRT, n.d.b.). The HTQ has several characteristics that make it ideal for use with refugees. First, it is one of the few measures that were deliberately created to study refugee trauma rather than traumatic life events in general (general trauma measures used in other PTSD research include the Trauma Questionnaire and the Stressful Life Events Screening Questionnaire [SLESQ]; see Connor, Foa, & Davidson [2006] for a review). Second, it has been translated (using a meticulous process involving native language speakers) into a number of different languages, and in some cases, into different vernaculars of the same language (HPRT, n.d.b.). Third, versions of the HTQ often ask questions about particular types of trauma experiences that are relatively unique to different wars or conflict situations. Fourth, versions of the HTQ are tested rigorously to ensure high levels of reliability and consistency. For this reason, some researchers consider the HTQ to be a “gold standard” for the assessment of trauma, mental health, and functioning in refugees, and it likely can be used as a stand-alone assessment tool. More often, however, researchers have used it or another trauma assessment measure with an additional measure that was explicitly created to assess PTSD and/or other mental health conditions. Some of the more commonly used PTSD assessment tools include the Hopkins Symptom Checklist-25 (HSCL-25; Hesbacher, Rickels, Morris, Newman, & Rosenfeld, 1980; HPRT, n.d.c.; the HSCL-25 is the PTSD screening tool most often used in conjunction with the HTQ [Campbell,

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

14

Theodore W. McDonald and Jaime N. Sand

2007]), the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995: a concise overview of the CAPS is offered by the United States Department of Veterans Affairs [2007]), the Composite International Diagnostic Interview (CIDI; Robins, Wing, Wittchen, & Helzer, 1988), the Structured Clinical Interview for DSM (SCID-I; Spitzer, Williams, Gibbon, & First, 1992; Werner, 2001), the Impact of Event Scale-Revised (IES-R; Miller et al., 2009; Weiss, 2007; Weiss & Marmar, 1997) the General Health Questionnaire (GHQ; Goldberg, 1978; Sondergaard et al., 2003), the PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993; Paunovic & Ost, 2001) the Anxiety Sensitivity Index (ASI; Hinton et al., 2004; Otto et al., 2003) and the Structured Interview for PTSD (SIP; Al-Saffar & Borga, 2006; Davidson, Malik, & Travers, 1998) (see Connor et al. [2006] for a review of several of these measures). Although assessment tools such as these are usually created in the English language, a number of them have been translated into other languages—making them useful elements in the provision of culturally sensitive mental health care. Although using standardized tests that are translated into foreign languages (and often also have items that are specific for members of certain cultural groups) seems a very successful method for most researchers working with refugee populations, the development of tools specifically for certain refugee groups is a viable and culturally sensitive alternative. Several researchers have particularly distinguished themselves in terms of their ability to understand how PTSD symptoms manifest themselves differently in people from unique cultural backgrounds, and how PTSD can be meaningfully measured in members of different cultural groups. Hinton and his colleagues (e.g., Hinton, Hofmann, Pollack, & Otto, 2009; Hinton & Otto, 2006; Hinton, Pich, Chhean, Safren, & Pollack, 2006; Hinton, Safren, Pollack, & Tran, 2006), for example, have been very active in studying how PTSD symptoms uniquely manifest themselves in refugees from Southeast Asia. Noting that PTSD and PTSD-generated panic attack symptoms manifest themselves differently among people of different cultures, Hinton and Otto (2006) maintain that somatic symptoms are particularly prominent in members of non-Western cultures and caution that sensitivity to somatic complaints is important in screening for and diagnosing PTSD in such people. Summarizing work on PTSD symptoms in Cambodian refugees in particular, Hinton and Otto (2006) describe that patient complaints of dizziness, a “weak heart”, neck pain, and disruption of “inner air” or Wind (khyal) may be indicators of PTSD in Cambodians; a Western-trained health professional unfamiliar with traditional Cambodian health-related beliefs likely might not recognize this.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Screening and Diagnosis of PTSD in Refugees

15

Hinton et al. (2006) provide a particularly interesting discussion of how Western therapists who have been trained to identify heart-focused panic symptoms in Western clients might not correctly identify PTSD-related panic disorder in Cambodians, as symptoms are focused on the neck, rather than the heart. Thus, it is quite clear that an understanding of how symptoms manifest themselves differently in different cultures is critical to correctly screening for and diagnosing PTSD in refugees. A recent example of the development of measures to assess PTSD in nonWestern refugees was provided by Miller and his colleagues (e.g., Miller et al., 2006; Miller et al., 2009). In their 2006 study, Miller et al. describe the processes they used to develop the Afghan Symptom Checklist (ASCL) and articulate what they believe to be “an easily implemented methodology for learning about the ways that psychological well-being and distress are understood and expressed in specific cultural settings” (p. 424). The eight steps described by Miller et al. (2006) seem an excellent strategy to use for researchers interested in developing their own culturally sensitive assessment tools (rather than relying on one of the established ones described above), and therefore merit some discussion here. It is noteworthy that all steps in the process involved not only a traditional academic researcher, but also personnel “on the ground” and embedded in the community in Afghanistan; this type of cross-cultural collaboration seems a hallmark of culturally sensitive instrument development. 1. Identifying indicators of well-being and distress. In the first step of their procedure, Miller et al. (2006) identified, through narratives and interviews of men and women in Kabul (the Afghan capital), emotional states and/or behaviors Afghans associated with well-being or distress. Through asking the interviewees to describe people they knew who had experienced “difficult life experiences,” the interviewers took notes on specific indicators of well-being and distress, and through a content-analysis procedure, identified three themes (namely, “behavior within the community”, “behavior within the family”, and a “person’s internal state”; p. 425). 2. Selecting indicators of distress. Specific indicators of distress and poor mental health were identified within each theme, and these indicators were woven into items for use on the ASCL. Some of the indicators were similar to those found on Western PTSD inventories (e.g., nightmares, intrusive and unwanted memories, irritability, and being easily startled), but others seemed specific to the Afghan

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Theodore W. McDonald and Jaime N. Sand

16

3.

4.

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

5.

6.

7.

culture. Examples of the latter included becoming jigar khun (a manifestation of intense sadness after a loss of a loved one or an extremely painful event), fishar payin (an internal state of low motivation or energy), beating oneself, and “thinking too much”. Translation and back-translation. The initial version of the ASCL was constructed in English, however because it was intended for use with Afghans, it required translation into Dari (the language commonly spoken by Afghans living in Kabul). The translation was performed by a bilingual Dari-speaking consultant. Then, a second bilingual Dari-speaking consultant back-translated the Dari version into English. When discrepancies were found between the original version and the back-translated version, the two consultants reconciled them. New items were added as appropriate to more accurately represent the constructs identified in the narratives. Through this process, construct validity was strengthened. Review of appropriateness and ease of comprehension. The research team and Dari language translators reviewed all items to ensure that they were appropriate for the ASCL and easy to comprehend. Modification of items was made as necessary. Pilot testing. Pilot testing was conducted to ensure internal consistency reliability and confirm that each item was related to the ASCL (internal consistency was excellent at α = .93, and all items were highly correlated with the scale as a whole, so no items had to be removed). A novel response scale depicting five glasses containing various levels of liquid was created for the ASCL, as it was used with a population with “very limited literacy skills” (Miller et al., 2006, p. 426); the utility of this response scale was also validated. Administration of the survey. The survey was administered through an interview format to over 300 adults in Kabul. The internal consistency of the ASCL, as well as the item-to-scale correlations of each of its items, was again found to be excellent. Assessing validity. To further assess construct validity, scores on the ASCL were assessed in relationship to a culturally validated measure of war trauma in Afghans (the Afghan War Experiences Scale [AWES]; this scale was created based on the War Experiences Scale [WES] created by Weine et al. [2000] for use with Bosnian refugees). The scores on the two scales were highly and significantly correlated (r = .70, p < .001), indicating that, as others (e.g., Begic & McDonald,

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Screening and Diagnosis of PTSD in Refugees

17

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

2006; Craig et al., 2008) have found repeatedly, a greater number of trauma experiences is associated with higher levels of distress. 8. Examining factor structure. The final step in the process was to examine the factor structure of the ASCL to determine whether conceptually distinct subsets of items existed in the measure as a whole. Three reliable factors were identified, including: 1) Sadness with social withdrawal and somatic distress; 2) Ruminative sadness without social withdrawal or somatic distress; and 3) Stress-induced reactivity (Miller et al., 2006). To this point in this section, we have presented some standardized PTSD assessment tools that have been translated into different languages for use with refugee groups, described the importance of mental health professionals understanding how PTSD symptoms may differentially manifest themselves among people with different cultural backgrounds, and discussed a model by which researchers and therapists might create culturally sensitive assessment tools of their own. Thus, we hope that we have provided some information to assist PTSD screening and diagnosis activities with refugees. We would be remiss, however, if we did not articulate some reasons for concern about PTSD assessment in refugees, and provide an overview of some of the barriers other researchers have identified in such assessment work. These concerns and barriers are discussed below. One area of concern with respect to screening for and diagnosing PTSD in refugees is that the disorder—which for a number of reasons is not easy to diagnose in members of the general public—is particularly difficult to diagnose in refugees (e.g., Kinzie, et al., 1990; Pfefferbaum, 1997). This is partly true because even people in developed countries are hesitant to initiate or remain in treatment due to the stigma surrounding mental health (e.g., Corrigan, 2004; Wahl, 1999), and this is likely even more true for refugees fleeing problems in less developed nations (e.g., Gold, 1992; Marshall et al., 2006). This is also partly true because refugees suffering from PTSD may be even less inclined to want to consciously recall their traumatic memories than host country PTSD sufferers, due to the fact that the nature of their traumatic memories may be particularly humiliating (Connor et al., 2006; Cunningham & Cunningham, 1997; Foa, 1997). In sum, cultural stigmas about mental health and the humiliating nature of some of their traumatic experiences may combine to make it even more difficult to screen and diagnose refugees than other PTSD sufferers.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

18

Theodore W. McDonald and Jaime N. Sand

A second area for concern is that due to delays in screening and diagnosis, refugees’ PTSD symptoms might become quite advanced prior to the initiation of treatment, leading to greater subsequent problems. Sadly, it has been welldocumented (e.g., Fowler et al., 2005; Nicholl & Thompson, 2004; Onyut et al., 2004; Weine & Henderson, 2005) that humanitarian and relocation personnel who work with refugees during the transition and resettlement processes are often overwhelmed by the sheer magnitude of refugees’ needs, and often screening for mental health problems is not performed or occurs in a cursory or haphazard fashion. This certainly need not be the case, as procedures to provide mental health triage are both feasible—even for use in relatively brief screening interviews—and desirable (Begic & McDonald, 2006; Connor et al., 2006; Savin, Seymour, Littleford, Bettridge, & Giese, 2005). Connor et al. (2006), in their review of PTSD screening and diagnostic assessments, discuss several short instruments, including the 10-item Trauma Screening Questionnaire (TSQ; Brewin et al., 2002) and the four-item SPAN (Melzer-Brody, Churchill, & Davidson, 1999), that can be used in a rapid screening (i.e., triage) environment. Other research suggests that simply knowing that a refugee has experienced a great deal of trauma, particularly if that trauma involved torture, should indicate that he or he likely suffers from PTSD and is in need of mental health services (Basoglu, Paker, Ozmdn, Tasdemir, & Sahin, 1994; Campbell, 2007; Steel et al., 2009; Weine et al., 1995). In other words, it is not difficult to screen for and diagnose mental health problems in refugees, even in the early stages of resettlement (see Savin et al., 2005 for a description of a successful early detection mental health screening program in Colorado), and successful early screening and diagnosis may help facilitate long-term function and well-being. A final area for concern is that, for a variety of reasons, some Western mental health professionals may know very little about refugees’ cultures and the nature of traumatic experiences in their former countries prior to their involvement in screening and diagnosis procedures (Nicholl & Thompson, 2004). As noted earlier, if therapists are not aware of culturally specific manifestations of PTSD symptoms, they might not know, for example, that neck-focused somatic complaints in Cambodian refugees may be a symptom of panic-related PTSD (Hinton et al., 2006). Thus, it may be important for such therapists to learn more about the culturally specific manifestations of PTSD symptomatology (Miller et al., 2006); familiarity with these will not only help practitioners correctly diagnose PTSD in refugees, but also “communicate effectively with distressed community members and to develop mental health interventions that are likely to be perceived as responsive to

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Screening and Diagnosis of PTSD in Refugees

19

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

local beliefs and values” (Miller et al., 2006, p. 424). Campbell (2007) suggests that therapists “working with refugees should make every effort to learn about the refugee’s home culture prior to treatment, and should also make an effort to determine where the refugee was living” (p. 635) to understand the nature of refugees’ trauma experiences and to begin to develop cultural sensitivity. Thankfully, in the modern era, access to the Internet can help such therapists learn a good deal about refugees’ native cultures and the traumas occurring in their home countries; Campbell (2007) recommends web sites hosted by Amnesty International, Global Security, and the Central Intelligence Agency as being potentially valuable in this regard. With knowledge about culturally specific manifestations of PTSD and about the traumatic experiences refugees have likely survived, mental health professionals should be much better equipped to screen for and diagnosis PTSD in refugees, as well as to provide culturally sensitive treatment.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Chapter 4

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

TREATMENT To this point in this volume, we have reviewed the prevalence of PTSD in refugees and discussed ways that mental health professionals can screen for and diagnose the disorder in a culturally sensitive manner. Of course, it is not enough to know that PTSD is prevalent among refugees, or to understand how to screen for and diagnose it. Ultimately, if we are interested in improving the mental health and functioning of refugees suffering from PTSD, it becomes imperative to treat the disorder in the most efficacious fashion possible. In this chapter, treatment will be our focus. First, we will discuss some cultural considerations, particularly in the context of providing treatment (as opposed to screening and diagnosis, which was discussed earlier). Embedded in this discussion will be a focus on the role of language and communication in refugee mental health services, and an exploration of cultural factors that influence refugees’ understandings of mental health and mental health treatment. Then, several treatment approaches that seem particularly efficacious or highly promising for serving refugees are presented. These include cognitive behavior therapy (CBT), narrative exposure therapy (NET), and several innovative community-based treatments.

CULTURAL CONSIDERATIONS As discussed in the previous chapter, it is very unlikely that mental health professionals will be successful when working with refugees if they do not understand important issues related to the refugees’ culture. Even if a therapist understands how PTSD symptoms manifest differently in members of

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

22

Theodore W. McDonald and Jaime N. Sand

different cultural groups, he or she is not likely to be successful in providing care if unable to treat refugees in a culturally sensitive fashion. Thus, developing what is often referred to as ‘cultural competence’ is important. Although some might characterize cultural competence in different ways, or use different terms to connote the same type of cultural sensitivity in practice, there is general agreement that a culturally competent treatment provider is one who has an awareness and acceptance of his/her own culture as well as other cultures, who recognizes and attempts to control for potential biases, who values intercultural communication, and who is willing and able to adapt treatment to accommodate different belief systems and meet the needs of the client (Brune et al., 2002; Pumariega, Rogers, & Rothe, 2005; Raphael, Delaney, & Bonner, 2007). Cultural competence does not develop on its own, of course, and training in it is often needed (see Dana, 2007 for a discussion of issues related to training therapists for PTSD work with refugees), however, it is invaluable and essential in practice when working with refugees. It is a culturally competent therapist, for example, who would recognize that neck pain might be a symptom of PTSD-related panic in a Cambodian refugee (e.g., Hinton et al., 2006). It is also a culturally competent therapist who would consider seemingly unorthodox adjuncts to therapy in order to meet the cultural needs of a patient or client. For example, Hinton et al. (2006) discuss treating ‘survivor guilt’, a common PTSD symptom in Cambodians who survived the genocidal rule of Pol Pot and the communist Khmer Rouge (Red Khmer), by encouraging a Buddhist client to conduct “merit making”—a type of religious activity designed to foster a good rebirth for a deceased person, as well as good luck for the person who performs the activity—as a part of the therapeutic process. In a similar vein, Nicholl and Thompson (2004) suggest allowing patients time during therapy to perform important cultural rituals, particularly grief rituals. In short, cultural competence entails the ability to address cultural considerations in treatment ranging from obvious host country-refugee group differences such as language to the lesser recognized differences in attitudes towards mental health, child development, understanding of the self and identity, autobiographical memory, and in the interpretation of events.

LANGUAGE Language barriers often present an immediate problem in treatment of refugees suffering from PTSD. As noted by Miller et al. (Miller, Martell,

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Treatment

23

Pazdirek, Caruth, & Lopez, 2005), a third-party interpreter is often required in therapy, which alters the traditional treatment setting and may change the dynamic of the therapist/client relationship. On one hand, interpreters may act as a cultural guide to therapists, may ease the stigma of mental health for the client, and often develop significant relationships with the client, which can affect treatment and may lead the interpreter to become the client’s trusted source in times of crisis (Miller et al., 2005). On the other, use of an interpreter may slow the pace of therapy, increase cost, raise concerns about confidentiality and/or misdiagnosis and treatment errors, and the sharing of such traumatic events may have an effect on both client and interpreter (although Miller et al. [2005] concluded the distress for the interpreter was often temporary and minimal) (Miller et al., 2005; Nicholl & Thompson, 2004; Schulz, Resick, Huber, & Griffin, 2006). Thus, special consideration and training should be provided for both the interpreter and the therapist (Miller et al., 2005; Nicholl & Thompson, 2004; Westermeyer, 1990). According to Miller et al. (2005), effective interpreters may be refugees themselves, and should be empathic, self-aware, comfortable with their own traumatic experiences, supportive of psychotherapy as a treatment option, and have an adequate support system. The client may not be able to understand the diagnosis of PTSD, the therapist, or the treatment plan, which can cause frustration and embarrassment, and a competent interpreter may be able to ameliorate these problems. The client may also not be understood by the therapist, and may make language-related errors when reflecting on previous traumatic events or trying to communicate emotions. These problems too may be reduced through the use of a competent interpreter (Miller et al., 2005).

CULTURAL INFLUENCES ON MENTAL HEALTH An understanding of cultural influences on and perceptions of mental health is essential in the treatment of refugees with PTSD. Beliefs about physical and mental illness are often culturally determined, which influence refugees’ access to and participation in treatment, causing them to label and interpret symptoms and emotional experiences differently (Pumariega et al., 2005). For example, Cambodians view flashbacks as a weakness of the mind, resulting from the soul leaving the body and returning to Cambodia, causing those involved to re-experience the trauma, and potentially leading to death from physical dysfunction (Hinton et al., 2005). Coping behaviors may also vary, such as internalization of emotions, humor, rituals, or artistic expression

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

24

Theodore W. McDonald and Jaime N. Sand

(Pumariega et al., 2005). Therapists should be aware of the client’s culturally valued roles of family, primary care givers, and healers, learning about the client’s home culture, where the client was living, and if possible, where the traumatic events took place (Campbell, 2007; Pumariega et al., 2005). Having this background can help the therapist establish rapport with the client, building the trust that is essential to treatment (Campbell, 2007). Part of PTSD treatment often involves recalling traumatic events, and cultural interpretations of these events can be very different. For example, there are differences in the meaning of torture across cultures. The Cambodian word for torture is a derivative of the Buddhist term for karma, causing Cambodians to view torture in terms of fate or as retaliation for another equally terrible behavior they themselves may have committed (Campbell, 2007; McKelvey, 1994). Such culturally determined understandings obviously must be addressed in the context of therapy in order for a successful resolution of psychological distress.

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

CULTURAL INFLUENCES ON SENSE OF SELF AND IDENTITY As noted earlier, screening and diagnostic inventories that were created for use with members of Western cultures may need to be adapted for use with members of refugee groups. Adaptation of treatment practices may similarly be necessary. For example, many of the standard PTSD treatment protocols, such as cognitive behavior therapy (CBT), focus on the individual and the expression of traumatic events with associated feelings and emotions, potentially altering autobiographical memory (e.g., Brewin, 1996). There is a major difference, however, among cultures with respect to sense of self and identity. As Jobson (2009) notes, in individualistic cultures, including those in most Western and North American countries, individuals are seen independently from one another and are considered stable as a unique unit. Thoughts and emotions are considered private and attributes are internalized, leading to an individual identity. The focus is on self-evaluation, using others as a comparison, and pursuing individual goals as personal achievements. Success is measured independently and a lack of personal control contributes to self-esteem and wellness issues. Many Western theories of psychology focus on this individual identity, and Western therapies often involve questioning clients about their personal feelings, thoughts, and goals. Thus, in

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Treatment

25

individualistic cultures, it is relatively easy for an acculturated client to be focused on the self, opening up emotionally and creating an elaborate life story with him/herself as the focus. Jobson (2009) notes that in contrast, in collectivistic cultures (including most non-Western cultures), individuals are seen as interdependent with others. The self is viewed in terms of societal roles and relationships with a focus on fitting in and meeting social responsibilities, clearly basing identity on those other than the individual. Activities are focused on the collective, valuing social interactions and events over a unique life story. Individuals are not typically the focus of achievements or failures, but rather fate, adjustment to situations, and the individual role in the social environment (Jobson, 2009). A therapist without an understanding of these different perspectives on the self might have difficulty providing quality care to a refugee with PTSD. For example, a Western therapist might mistakenly perceive a refugee from a non-Western culture who accepts exposure to trauma and subsequent suffering as fate to be avoiding or “giving up” on treatment instead of adapting as expected in his or her culture (McKelvey, 1994). Refugees from non-Western cultures may very well perceive the use of a Western approach to treatment as immature or arrogant (Jobson, 2009), which could obviously affect treatment compliance and a successful resolution of PTSD symptoms. Members of many collectivist cultures, such as the Vietnamese, place high value on the family and place family interests above their own (McKelvey, 1994). This family extends beyond the Western nuclear family, to include multiple generations and extended family. Family is typically the first resource for treatment and assistance as it provides a safe environment for sharing. For this reason, it can be very challenging for a Western-trained therapist to compel a Vietnamese refugee to “open up” and share intimate emotions, as the therapist would likely be viewed as a stranger outside of that family (McKelvey, 1994). Because level of comfort speaking to therapists, and the resulting degree of self-disclosure, will vary by culture (Pumariega et al., 2005), it is incumbent on mental health professionals to create the safest therapeutic environment possible. This may include being open to some alterations to the traditional therapy environment, including the involvement of family members or other trusted persons in treatment sessions (Weine et al., 2005).

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

26

Theodore W. McDonald and Jaime N. Sand

TREATMENT OPTIONS Although more extensive research on treatment options for refugees with PTSD is needed, there have been a number of studies that have identified some empirically supported treatment (EST; other terms for the same construct include “best practice,” “evidence-based practice” and “evidence-based intervention”) approaches for use with refugee populations. These approaches, which are typically trauma-focused rather than symptom-focused (Neuner, 2008), have often been reported to be preferable to pharmacological treatment (although, as Kinzie [2007] notes, they can be effectively combined with pharmacological treatment), and include cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), narrative exposure therapy (NET), testimony therapy, and a number of community-based population-specific adapted treatments. Some coverage of these approaches is provided in the remainder of this chapter.

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

COGNITIVE BEHAVIORAL THERAPY (CBT) CBT is a form of psychotherapy that includes a variety of treatment protocols and focuses on internal thoughts and feelings (Association for Behavioral and Cognitive Therapies, n.d.). It is a relatively brief therapy—at least in treatment terms—based on a collaborative effort between therapist and client in which the therapist guides the client through exploring and modifying maladaptive patterns of behavior and thought, creating goals and encouraging questions. CBT is used to treat a variety of different mental health problems, including PTSD. When CBT is used for persons suffering from PTSD, the focus is often placed on how the previously traumatized client interprets thoughts related to the trauma in a catastrophic fashion (Paunovic & Ost, 2001), and how catastrophic thinking may reinforce the avoidance behaviors characteristic of PTSD sufferers. As Paunovic and Ost (2001) note, CBT is frequently used in the treatment of PTSD because it is believed to target both the catastrophic thinking and the avoidance behaviors that sufferers experience. In an oft-cited study that helped establish CBT as an EST for use with refugees, Paunovic and Ost (2001) compared CBT with exposure therapy (another common treatment for PTSD) to determine their relative effectiveness in reducing PTSD symptoms in 16 refugee patients during 16-20 weekly

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Treatment

27

sessions. The CBT treatment component involved identifying the catastrophic interpretations that stemmed from intrusive thoughts about traumatic events, challenging the patterns of faulty thinking that sustain the catastrophic interpretations, and the development of alternate interpretations of the intrusive recollections that were not catastrophic in nature. Finally, the alternate explanations were tested through the degree to which stimuli associated with the traumatic event continued to generate fear. Paunovic and Ost (2001) found CBT to be similarly effective to exposure therapy, leading to marked reductions in PTSD symptoms; CBT reduced symptomatology by 53%, compared to 48% for exposure therapy. Perhaps more importantly, the positive results of CBT (and exposure therapy as well) were maintained six months after the completion of the therapy. Otto and his colleagues (2003) also examined the effectiveness of CBT in the treatment of refugees in a study of 10 Cambodian outpatients who had not responded well to medication alone. In their study, they paired CBT (with a particular focus on cognitive restructuring) with sertaline (trade name Zoloft; Mayo Clinic, 2009) for one group of refugees, and treated the other with sertaline alone. The CBT-sertaline combination therapy led to significantly greater decreases in PTSD symptomatology (with effect sizes ranging from medium to very large) than sertaline therapy alone, with particularly larger reductions on symptoms as measured by the CAPS reexperiencing and avoidance/numbing items and the ASI and ASI-Khmer (Cambodian-specific) items. Between 2004 and 2006 Hinton and his colleagues (e.g., Hinton et al., 2005; Hinton et al., 2004; Hinton et al., 2006) published several articles exploring the effectiveness of CBT in treating PTSD in refugees from Southeast Asia. The studies described in these articles yielded results that commented very favorably on the efficacy of CBT in treating PTSD. For example, in a pilot study of the effectiveness of CBT in reducing PTSD symptoms in Vietnamese refugees, Hinton et al. (2004) found that the treatment, which included such CBT hallmarks as providing objective information about PTSD symptoms, relaxation training, and cognitive restructuring, led to dramatic and statistically significant reductions in symptomatology as measured by the HTQ, ASI, and HSCL-25 anxiety and depression subscales; these results were all the more impressive in that the patients selected for the study had been identified as highly treatment-resistant. Hinton and his colleagues (Hinton et al., 2005) conducted another study of treatment-resistant refugees, this time Cambodian, and reported similar results. As in their earlier study, Hinton et al. (2005) utilized a sound methodological

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

28

Theodore W. McDonald and Jaime N. Sand

approach (a randomized controlled trial using a cross-over design), and found that CBT led to large and statistically significant reductions in PTSD symptoms as measured by the ASI, CAPS, and Symptom Checklist-90. These results certainly support the notion that CBT is an EST for serving refugees suffering from PTSD. In their 2006 article, Schulz and her colleagues describe the use of cognitive processing therapy (CPT), a therapeutic approach closely related to CBT, in the treatment of refugees from Afghanistan and former Yugoslavia. CPT involves many of the same cognitive therapy elements characteristic of CBT, and also includes a written exposure component; it was designed to be administered during 12 treatment sessions lasting one hour each. Treatment was provided, often with the assistance of trained interpreters, to 53 individuals who had been highly traumatized (and in most cases, tortured) during conflicts in their former countries. The PSS was used to measure PTSD symptomatology. An examination of pretest and posttest PSS scores showed that the CPT resulted in highly significant reductions in PTSD symptoms across the sample (regardless of whether or not the treatment was delivered through an interpreter), with a very large effect size. Thus, although CPT is not identical to CBT, it can safely be concluded that the cognitive therapy components shared by both lead to marked improvement in PTSD outcomes, across a variety of different groups of refugees and as measured by a number of different PTSD instruments.

NARRATIVE EXPOSURE THERAPY (NET) Narrative exposure therapy (NET) is another treatment approach that has been utilized with some frequency with refugees suffering from PTSD. NET differs from some other approaches used to treat PTSD in refugees in that most other approaches were developed for other purposes (for example, to treat anxiety or depression) with members of non-refugee populations, whereas NET was created deliberately for work with victims of war trauma, torture, and political detention (Campbell, 2007). As Campbell (2007) notes, NET was developed from a model of testimony used by torture victims of Augusto Pinochet’s regime in Chile in the 1970s, in part from the recognition that revisiting traumatic events and exposing them publicly can have a cathartic effect on survivors (see also Cienfuegos & Monelli, 1983; Schauer, Neuner, & Elbert, 2005). A relatively short-term treatment strategy (usually involving 10 or fewer sessions), NET involves survivors of trauma telling their

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Treatment

29

stories, which are typically then written and reviewed. The written reports are kept by the patients as records. The goal of this therapy is to help patients overcome the symptoms of PTSD through repeated activation of traumatic experiences and habituation to them. The discussion of and re-experience of traumatic events and emotions is believed to lead to a reorganization of patients’ autobiographical memories (Campbell, 2007; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004; Schauer et al., 2005). Neuner and his colleagues (2004) provide an excellent example of the use of NET in their study of three different therapies for treating PTSD in refugees in Africa. In this study, the researchers compared the effectiveness of NET with supportive counseling and psychoeducation. The psychoeducation approach involved teaching traumatized refugees about PTSD (what it is, what the symptoms are, and so forth), and explaining how it is a common condition in survivors of trauma. The supportive counseling approach included psychoeducation, with additional counseling intended to address current problems and strengthen refugees’ individual and social resources. The NET component involved the refugees, working with therapists, creating cohesive biographical narratives chronicling the refugees’ lives, with particular focus on their exposure to traumatic events. As is always the case with NET, psychological and physiological responses were documented as the traumatic events were recalled or relived, and therapy was not concluded until the refugees had habituated to the discussion of these events. The refugees in the NET condition showed the greatest improvement (significantly greater than refugees in both of the other two groups), with 71% of them no longer meeting the DSM-IV PTSD criteria one year after therapy (in contrast, 79% and 80% of those in the supportive counseling and psychoeducation conditions continued to meet the DSM-IV criteria a year after therapy). What is particularly remarkable about this improvement is that only four NET sessions were conducted for the refugees, so even very short-term NET led to dramatic improvements. In 2008, Neuner et al. conducted a follow-up study, using a randomized controlled trial to investigate whether trained lay counselors could effectively administer NET treatment for PTSD to traumatized Rwandese and Somali refugees in a Ugandan camp. In the trial, 277 refugees were randomly assigned to a NET condition, a trauma counseling condition (which involved relating current problems with prior traumatic events, the development of coping skills, and interventions focused on grief), or a no-treatment control group. Laypersons trained in a six-week counseling course (in which they learned NET as well as general and trauma counseling skills) administered both the

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

30

Theodore W. McDonald and Jaime N. Sand

NET and trauma counseling; six treatment sessions were provided, regardless of the type of therapy. Once again, the refugees in the NET group showed the greatest level of improvement with nearly 70% no longer meeting the DSM-IV criteria for PTSD after therapy; the refugees in the trauma counseling group also showed marked improvement (slightly over 65% of refugees in this group also no longer met the PTSD diagnostic criteria after treatment). Both treatment groups showed significantly greater improvement compared to the control group (63% of control group refugees continued to meet the PTSD criteria after the treatment period). Again NET, even when administered in a brief (i.e., six session) format demonstrated itself to be highly efficacious for reducing PTSD symptomatology in traumatized refugees. A type of therapy derived from NET is testimony therapy, which has also been used to some effect in helping refugees suffering from PTSD. Developed in large part on the work of Agger and Jensen (e.g., Agger & Jensen, 1990), testimony therapy involves the therapist and client working together in compiling and documenting the client’s story—and then exploring ways to share that story with others. As Weine, Kulenovic, Pavkovic, and Gibbons (1998) noted, modern testimony therapy is not unlike the work completed by survivors of the Holocaust. The goal of testimony therapy is not only to document clients’ stories, however; it is also intended to obtain some therapeutic benefits for clients and help facilitate their recovery from trauma. Furthermore, it is intended to allow clients to feel personal accomplishment by contributing to a body of literature that may ultimately be used to promote peace and human rights. The first known effort to systematically study the potential therapeutic benefits of testimony therapy was conducted by Weine and his colleagues in 1998. Working with 20 refugees from Bosnia, Weine et al. (1998) documented how testimony therapy was conducted, in the Bosnian language, on a weekly or biweekly basis for an average of six sessions (each of which lasted approximately 90 minutes in length). In these sessions, the clients focused on their life histories, family histories, trauma stories, life experiences as refugees, and current and future living conditions. All clients completed the PSS, Beck Depression Inventory, and Global Assessment of Functioning Scale both prior to and after therapy. The clients compiled their testimonies with guidance from therapists, and at the conclusion of their work, were given a copy of the testimonial report (another was archived at the Project on Genocide, Psychiatry, and Witnessing at the University of Illinois-Chicago). The results demonstrated decreases in rate of PTSD diagnosis; whereas 100% of the clients met the diagnostic criteria for PTSD pretestimony, only 75% met

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Treatment

31

the same criteria posttestimony. Interestingly, the benefits of testimony therapy seem to have accrued over time, with 70% of the former clients continuing to meet PTSD criteria at a two-month follow-up, and 53% continuing to meet the criteria at a six-month follow-up (thus, 47% of the sample no longer suffered from clinically diagnosable PTSD six months after testimony therapy began). Mean scores on all inventories also improved dramatically from pretestimony to six-month follow-up (for example, mean ASI symptom severity scores dropped from 31.2 pretestimony to 7.7 at the sixmonth follow-up, and mean Global Assessment of Functioning Scale score improved from 63.0 pretestimony to 87.0 at the six-month follow-up).

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

COMMUNITY-BASED TREATMENTS Whereas CBT and NET are therapeutic approaches that have been used to treat PTSD in traumatized refugees from a number of countries and in a number of locales, several innovative therapies have been created specifically for particular groups of refugees in unique community settings. One of the elements that makes these therapies so innovative and attractive is that they have been deliberately created to move away from the standard Western treatment protocols that may feel foreign to refugees (such as having a dyadic therapist/client relationship that focuses solely on the individual) and adapted to be more congruent with refugee beliefs and practices (such as involving the family or friends in the therapeutic environment). It is likely that these adaptations may lead to increased motivation for refugees to seek treatment, and lead to more durable, sustainable treatment programs overall. An excellent example of a family-based treatment intervention is provided by Weine and his colleagues (2003). Noting that the family is a very important unit for ethnic Albanians recently relocated from Kosova (known as Kosovars), Weine and other researchers in the greater Chicago area created a multifamily group intervention called the Tea and Families Education and Support (TAFES) program. The TAFES program was created as a true community-based service initiative, in which Kosovar immigrants, all mental health laypersons, were trained to conduct a support and education intervention with up to six families per group, for six sessions over eight weeks. Sixty-one families were visited by TAFES workers and invited to participate, with 86 individuals choosing to participate in the program. In the TAFES program, the multifamily groups discussed ways to strengthen families, identified family needs and explored how to better communicate

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

32

Theodore W. McDonald and Jaime N. Sand

within the family and the community, and learned about resources outside of the family, including mental health resources available in the community (this last component seems particularly valuable in that, as Weine et al. [2003] note, mental health services were generally denied to Kosovars in their home country due to discrimination). The TAFES intervention lasted six sessions, after which participants (“engagers”) were compared to Kosovars who chose not to participate (“nonengagers”). Weine et al. (2003) reported that after TAFES participation, engagers, compared to nonengagers, had significantly higher levels of social support, hardier families, greater knowledge about mental health conditions such as PTSD, and were more willing to access psychiatric services. Although Weine et al. (2003) recognized limitations in their design (for example, the lack of randomization or the use of a true control group) and characterized their research as a “feasibility study,” the results clearly suggested that a local, community-based multifamily intervention could be very successful in achieving a number of desirable outcomes. Weine and his colleagues (Weine et al., 2005; Weine et al., 2008) also developed a multifamily group intervention for Bosnian refugees in the greater Chicago area. Similar to the TAFES program created for Kosovar refugees, the Coffee and Family Education and Support (CAFES) program was developed in the late 1990s. The CAFES program was predicated on a similar notion: Bosnian culture (like Kosovar culture) is centered around the family, and any interventions designed to improve the mental health and functioning of Bosnian refugees would only be successful if they involved the family in a meaningful way. The CAFES program, similar to TAFES, was designed to build on and further develop existing family strengths. It involved nine treatment sessions offered in community settings by other Bosnian refugees who were trained laypersons. In their 2005 article, Weine et al. reported that participation in CAFES was higher for Bosnian refugees who experienced a greater number of problems transitioning to life in America, greater disruptions in social networks caused by their experiences as refugees, and greater PTSD symptomatology. These findings suggest that an intervention such as CAFES may be particularly attractive to refugees most in need of help. In their 2008 article, Weine et al. focused explicitly on determining the extent to which participation in CAFES affected mental health services access and several other variables. They reported that Bosnian refugees who participated in CAFES, relative to randomly assigned controls, more often accessed mental health services, and that families participating in CAFES were more likely to have members access mental health services for PTSD treatment if family members felt comfortable discussing trauma-related mental health with each

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Treatment

33

other. Thus, CAFES, like TAFES, appears successful in achieving several of its key goals. Although both programs were created for use with specific populations (Bosnian and Kosovar refugees, respectively), it is important to note that Weine et al. (2005) maintain that the basic principles behind both— focusing on building strengths and fostering access to services in multifamily groups—can be successfully applied with other groups of refugees in other types of settings. Another innovative effort to develop a community-based program for families was described in a recent report by Birman and her colleagues (Birman et al., 2008). This program, titled International Family, Adult, and Child Enhancement Services (FACES), was created specifically to treat refugee children suffering from mental health problems. Noting that posttraumatic stress symptoms are highly prevalent in refugee children, and that refugee children are likely even more underserved in terms of mental health than host country children, Birman et al. (2008) worked with a local service agency to develop a program that provides comprehensive services to children and their families. Featuring a team approach to providing case management services, FACES uses multi-ethnic teams and is explicitly sensitive to cultural issues. Trained health care interpreters are utilized and treatment is provided at locations designed to be easily accessible and comfortable for clients, including homes, community centers, and schools. Treatment consisted of individual and group therapy, family therapy, and art, dance, and occupational therapy. Consultation between FACES staff and other key personnel (e.g., teachers, other social service workers) was reported as a fundamental component to ensure continuity of care. Using reliable instruments such as the Child and Adolescent Functional Assessment Scale (CAFAS; Functional Assessment Systems, 2009; Hodges, 2000) and the HTQ, Birman et al. (2008) documented the effect of FACES participation on 97 children and adolescents, who spoke 26 different languages and were primarily refugees from Africa, Central or Eastern Europe, and Latin America. They reported that nearly 27% of the children suffered from PTSD (many also suffered from adjustment disorders or major depressive disorder). The results of the study showed that the mental health and functioning of the children improved as a result of program participation, although Birman et al. (2008) were careful to note that these improvements were not related to the “dosage” or quantity of services received. Throughout this chapter, we have reviewed a number of different approaches to providing treatment to refugees suffering from PTSD. We have attempted to focus on therapeutic approaches which meet several key criteria,

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

34

Theodore W. McDonald and Jaime N. Sand

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

including those whose efficacy is supported by outcome data, that are either explicitly culturally sensitive or can be easily adapted to be so, and that have been used specifically with refugees. We acknowledge that there are other treatment approaches that are likely to be efficacious as well, and a number certainly seem promising (an example is Hanscom’s [2001] HEARTS model, which incorporates the key elements of an excellent intervention, but for which no outcome data seem available). Those summarized here then, although not comprehensive, provide good examples of treatments that could be used by other mental health professionals working with refugees in the future.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Chapter 5

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

CONCLUSION In this volume, we have attempted to accomplish several goals. First, we have maintained that PTSD symptomatology is highly prevalent among refugees who are resettled from war-torn countries. We have demonstrated that in each major wave, refugees—whether they have come from Southeast Asia, the former republics of Yugoslavia, or elsewhere in the world— experience some common PTSD symptoms. Although different studies, using different methodologies with different groups of refugees, have reported varying PTSD prevalence rates, it seems quite clear that the prevalence of PTSD is much higher in refugees than it is in the general populations of most host countries. Because we understand PTSD to be very distressful and highly debilitating, it seems incumbent on Western mental health professionals to be aware that refugees entering a new country, particularly when they come from a nation or region wracked by war or related trauma (e.g., mass imprisonment, relocation), will likely suffer at least some of the symptoms of PTSD, and to ensure that appropriate and culturally sensitive mental health and other services are available to them. Second, we have shown that although PTSD may be a construct developed by Western mental health professionals, it is a phenomenon that affects people of many cultures—and many refugees in particular. We have maintained that although screening and diagnostic inventories developed strictly for use with host country citizens are not likely to be helpful when used with refugees, modified versions of them—which are well translated into refugees’ native languages and include items addressing culture-specific manifestations of PTSD symptoms—can be very useful in measuring PTSD in refugees. We have summarized, at least briefly, a number of different PTSD inventories that

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

36

Theodore W. McDonald and Jaime N. Sand

have been successful in measuring distress in refugee populations, and have also provided some examples of how mental health professionals have developed and validated their own instruments. We have also made some recommendations for how and when screening and diagnosis should occur when refugees are resettled to new countries. Finally, we have shown that a number of empirically supported approaches exist for treating PTSD in refugees. Although several of them (particularly those involving the use of CBT) were based on principles supporting treatments for Western clients, they have been modified for use with refugees, and research supports that they work well with members of refugee groups. We have also covered some treatments that were designed specifically for treating PTSD (and related mental health problems) in refugees, and discussed how these treatments are culturally sensitive and often have benefits that extend well beyond what is typically quantified as mental health improvement (such as addressing human rights concerns, strengthening families, and building community resources and supports). Although it is clear to us, as it is to other mental health professionals, that greater service capacity is needed to treat PTSD in refugees, we believe that there are exciting advances in this area and that more successful approaches can be developed in the future. Sadly, we recognize that war, population displacement, torture, and other types of trauma are likely to continue to be worldwide realities, at least in the near future. It seems certain that people will continue to flee the prospects of death, injury, imprisonment, and oppression in the coming years, and that many of these people will become refugees who resettle in Western countries. We hope that continued improvements will be made in early screening and diagnosis of mental health of refugees; indeed, we hope that mental health problems will be given the same level of priority as communicable diseases when refugees initially arrive in a host country. When mental health problems such as PTSD are identified at initial resettlement, Western mental health professionals will be much more able to work closely with refugees to ensure that they receive the care they need as early as possible. By providing this care in the culturally sensitive ways highlighted in this volume, these professionals can help ensure more healthy and complete adjustment for refugees and their families, and help host countries avoid the disease burden and other social problems that stem from untreated mental health disorders.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

.

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

REFERENCES Agger, I., & Jensen, S. (1990). Testimony as ritual and evidence in psychotherapy for political refugees. Journal of Traumatic Stress, 3, 115130. Al-Saffar, S., & Borga, P. (2006). Focusing on trauma and PTSD in general psychiatric services: Could outcome be improved? In G. D. Kume (Ed.) Posttraumatic stress disorder: New research (pp. 147-166). NY: Nova Science. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders IV-TR (4th ed., text revision). Washington, DC: American Psychiatric Association. Association for Behavioral and Cognitive Therapies. (n.d.). What is cognitive behavior therapy? Retrieved October 23, 2009, from http://www.abct.org/ dMental/?m=mMental&fa=WhatIsCBT. Basoglu, M., Paker, M., Tasdemir, O., Ozmen, E. & Sahin, D. (1994). Factors related to long-term traumatic stress responses in survivors of torture in Turkey. Journal of the American Medical Association, 272, 357-363. Becker, D. F., Weine, S. M., Vojvoda, D., & McGlashan, T. H. (1999). Case series: PTSD symptoms in adolescent survivors of “ethnic cleansing”: Results from 1-year follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 775-781. Begic, S., & McDonald, T. W. (2006). The psychological effects of exposure to wartime trauma in Bosnian residents and refugees: Implications for treatment and service provision. International Journal of Mental Health and Addiction, 4, 319-329. Benedek, D. M., Fullerton, C., & Ursano, R. J. (2007). First responders: Mental health consequences of natural and human-made disasters for

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

38

Theodore W. McDonald and Jaime N. Sand

public health and public safety workers. Annual Review of Public Health, 28, 55-68. Bhui, K., Craig, T., Mohamud, S., Warfa, N., Stansfeld, S. A., Thornicroft, G., et al. (2006). Mental disorders among Somali refugees. Social Psychiatry and Psychiatric Epidemiology, 41, 400-408. Birman, D., Beehler, S., Harris, E. M., Everson, M. L., Batia, K., Liautaud, J. et al. (2008). International family, adult, and child enhancement services (FACES): A community-based comprehensive services model for refugee children in resettlement. American Journal of Orthopsychiatry, 78, 121132. Blake, D. D., Keane, T. M., Wine, P. R., Mora, C., Taylor, K. L., & Lyons, J. A. (1990). Prevalence of PTSD symptoms in combat veterans seeking medical treatment. Journal of Traumatic Stress, 3, 15-27. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75-90. Blanchard, E. B., & Hickling, E. J. (2003). After the crash: Psychological assessment and treatment of survivors of motor vehicle accidents (2nd ed.). Washington, DC: American Psychological Association. Bracken, P. J. (2001). Post-modernity and post-traumatic stress disorder. Social Science & Medicine, 53, 733-743. Bracken, P. J., Giller, J. E., & Summerfield, D. (1995). Psychological responses to war and atrocity: The limitations of current concepts. Social Science & Medicine, 40, 1073-1082. Brewin, C. R. (1996). Theoretical foundations of Cognitive-Behavior Therapy for anxiety and depression. Annual Review of Psychology, 47, 33-57. Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., & McEvedy, C. (2002). Brief screening instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181, 158-162. Brune, M., Haasen, C., Krausz, M., Yagdiran, O., Bustos, E., & Eisenman, D. (2002). Belief systems as coping factors for traumatized refugees: A pilot study. European Psychiatry 17, 451-458. Campbell, T. A. (2007). Psychological assessment, diagnosis, and treatment of torture survivors: A review. Clinical Psychology Review, 27, 628-641. Cienfuegos, A. J., & Monelli, C. (1983). The testimony of political repression as a therapeutic instrument. American Journal of Orthopsychiatry, 53, 4351.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

References

39

Colic-Peisker, V., & Walker, I. (2003). Human capital, acculturation, and social identity: Bosnian refugees in Australia. Journal of Community & Applied Social Psychology, 13, 337-360. Conner, K. M., Foa, E. B., & Davidson, J. R. T. (2006). Practical assessment and evaluation of mental health problems following a mass disaster. Journal of Clinical Psychiatry, 67, 26-33. Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614-625. Craig, C. D., Sossou, M. A., Schnak, M., & Essex, H. (2008). Complicated grief and its relationship to mental health and well-being among Bosnian refugees after resettlement in the United States: Implications for practice, policy, and research. Traumatology, 14, 103-115. Cunningham, M., & Cunningham, J. D. (1997). Patterns of symptomatology and patterns of torture and trauma experiences in resettled refugees. Australian and New Zealand Journal of Psychiatry, 31, 555-565. Dana, R. H. (2007). Refugee assessment practices and cultural competency training. In J. P. Wilson & C. S. Tang (Eds.) Cross-cultural assessment of psychological trauma and PTSD (pp. 91-112). New York: Springer. Davidson, J. R. T., Malik, M. A., & Travers, J. (1998). Structured interview for PTSD (SIP): Psychometric validation for DSM-IV criteria. Depression and Anxiety, 5, 127-129. De Jong, K., van der Kam, S., Ford, N., Hargreaves, S., van Oosten, R., Cunningham, D., et al. (2007). The trauma of ongoing conflict and displacement in Chechnya: Quantitative assessment of living conditions, and psychosocial and general health status among war displaced in Chechnya and Ingushetia. Conflict and Health, 1. Retrieved October 3, 2009 from http://conflictandhealth.com/content/1/1/4 Durakovic-Bello, E., Kulenovic, A., & Dapic, R. (2003). Determinants of posttraumatic adjustment in adolescents from Sarajevo who experienced war. Journal of Clinical Psychology, 59, 21-40. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees settled in western countries: A systematic review. Lancet, 365, 1309-1314. Foa, E. B. (1997). Psychological processes related to recovery from a trauma and an effective treatment for PTSD. Annals of the New York Academy of Sciences, 821, 410-424. Foa, E. B., Riggs, D. S., Dancu, D. B., & Rothbaum, B. O. (1993). Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, 459-473.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

40

Theodore W. McDonald and Jaime N. Sand

Fowler, N., Redwood-Campbell, L., Molinaro, E., Howard, M., Kaczorowski, J., Jafapour, M., Robinson, S. (2005). The 1999 international emergency humanitarian evacuation of the Kosovars to Canada: A qualitative study of service providers’ perspectives at the international, national, and local levels. International Journal for Equity in Health. Retrieved March 28, 2006 from http://www.equityhealthj.com/content/4/1/1 Friedman, M., & Jaranson, J. (1994). The applicability of the Posttraumatic Stress Disorder concept to refugees. In A. J. Marsella, T. Bornemann, S. Ekbland, & J. Orley (Eds.) Amidst peril and pain: The mental health and well-being of the world’s refugees. Washington, DC: American Psychological Association. Functional Assessment Systems (2009). Child and Adolescent Functional Assessment Scale-CAFAS overview. Retrieved November 3, 2009 from http://www.fasoutcomes.com/Content.aspx?ContentID=12 Galea, S., Brewin, C. R., Gruber, M., Jones, R. T., King, D. W., King, L. A., et al. (2007). Exposure to hurricane-related stressors and mental illness after Hurricane Katrina. Archives of General Psychiatry, 64, 1434-1434. Gold, S. J. (1992). Mental health and illness in Vietnamese refugees. Western Journal of Medicine, 157, 290-294. Goldberg, D. (1978). Manual of the General Health Questionnaire. Windsor, UK: National Foundation for Educational Research. Gong-Guy, E. (1987). The California Southeast Asian mental health needs assessment. Sacramento, CA: California State Department of Mental Health (Contract No. 85-76282A-2). Gong-Guy, E., Cravens, R. B., & Patterson, T. E. (1991). Clinical issues in mental health service delivery to refugees. American Psychologist, 46, 642-648. Hanscom, K. L. (2001). Treating survivors of war trauma and torture. American Psychologist, 56, 1032-1039. Harvard Program in Refugee Trauma. (n.d.a.). Harvard Program in Refugee Trauma. Retrieved October 11, 2009 from http://www.hprt-cambridge. org/ Harvard Program in Refugee Trauma. (n.d.b.). Harvard Trauma Questionnaire. Retrieved October 11, 2009 from http://www.hprtcambridge. org/ Harvard Program in Refugee Trauma. (n.d.c.). Hopkins Symptom Checklist-25 (HSCL-25). Retrieved October 11, 2009 from http://www.hprtcambridge.org/

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

References

41

Hesbacher, P. T., Rickels, R., Morris, R. J., Newman, H., & Rosenfeld, M. D. (1980). Psychiatric illness in family practice. Journal of Clinical Psychiatry, 41, 6-10. Hinton, D. E., Chhean, D., Pich, V., Safren, S. A., Hofmann, S. G., & Pollack, M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18, 617-629. Hinton, D. E., & Otto, M. (2006). Symptom presentation and symptom meaning among traumatized Cambodian refugees: Relevance to a somatically focused Cognitive-Behavior Therapy. Cognitive and Behavioral Practice, 13, 249-260. Hinton, D. E., Hofmann, S. G., Pollack, M. H., & Otto, M. W. (2009). Mechanisms of efficacy for CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS Neuroscience & Therapeutics, 15, 255-263. Hinton, D. E., Pham, T., Tran, M., Safren, S. A., Otto, M. W., & Pollack, M. H. (2004). CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: A pilot study. Journal of Traumatic Stress 17, 429-433. Hinton, D. E., Pich, V., Chhean, D., Safren, S. A., & Pollack, M. H. (2006). Somatic-focused therapy for traumatized refugees: Treating posttraumatic stress disorder and comorbid neck-focused panic attacks among Cambodian refugees. Psychotherapy: Theory, Research, Practice, and Training, 43, 491-505. Hinton, D. E., Safren, S. A., Pollack, M. H., & Tran, M. (2006). CognitiveBehavior Therapy for Vietnamese refugees with PTSD and comorbid panic attacks. Cognitive and Behavioral Practice, 13, 271-281. Hodges, K. (2000). Child and Adolescent Functional Assessment Scale (2nd rev.). Ypsylanti, MI: Eastern Michigan University. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22. Hsu, E., Davies, C. A., & Hansen, D. J. (2004). Understanding mental health needs of Southeast Asian refugees: Historical, cultural, and contextual factors. Clinical Psychology Review, 24, 193-213. Irish, L., Ostrowski, S. A., Fallon, W., Spoonster, E., van Dulmen, M., Sledjeski, E. M., et al. (2008). Trauma history characteristics and subsequent PTSD symptoms in motor vehicle accident victims. Journal of Traumatic Stress, 21, 377-384.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

42

Theodore W. McDonald and Jaime N. Sand

Jamil, H., Hakim-Larson, J., Farrag, M., Kafaji, T., Jamil, L. H., & Hammad, A. (2005). Medical complaints among Iraqi American refugees with mental disorders. Journal of Immigrant Health, 7, 145-152. Jobson, L. (2009). Drawing current posttraumatic stress disorder models into the cultural sphere: The development of the ‘threat to conceptual self’ model. Clinical Psychology Review, 29, 368-381. Kates, A. R. (1999). Cop shock: Surviving posttraumatic stress disorder (PTSD). Cortaro, AZ: Holbrook Street Press. Keller, A., Lhewa, D., Rosenfeld, B., Sachs, B., Aladjem, A., Cohen, I., et al. (2006). Traumatic experiences and psychological distress in an urban population seeking treatment services. Journal of Nervous and Mental Disease, 194, 188-194. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. Kinzie, J. D. (2007). Combined psychosocial and pharmacological treatment of traumatized refugees. In J. P. Wilson & C. S. Tang (Eds.) Crosscultural assessment of psychological trauma and PTSD (pp. 359-370). New York: Springer. Kinzie, J. D., Boehnlein, J. K., Leung, P. K., Moore, L. J., Riley, C., & Smith, D. (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147, 913-917. Laufer, A., & Solomon, Z. (2006). Posttraumatic symptoms and posttraumatic growth among Israeli youth exposed to terror incidents. Journal of Social and Clinical Psychology, 25, 429-447. Lavi, T., & Solomon, Z. (2005). Palestinian youth of the Intifada: PTSD and future orientation. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1176-1183. Lee, E., & Lu, F. (1989). Assessment and treatment of Asian-American survivors of mass violence. Journal of Traumatic Stress, 2, 93-120. Lindencrona, F., Ekblad, S., & Hauff, E. (2008). Mental health of recently resettled refugees from the Middle East in Sweden: The impact of preresettlement trauma, resettlement stress and capacity to handle stress. Social Psychiatry & Psychiatric Epidemiology, 43, 121-131. Macksoud, M. S., & Aber, J. L. (1996). The war experiences and psychosocial development of children in Lebanon. Child Development, 67, 70-88.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

References

43

Malekzai, A. S. B., Niazi, J. M., Paige, S. R., Hendricks, S. E., Fitzpatrick, D., Leuschen, et al. (1996). Modification of CAPS-1 for diagnosis of PTSD in Afghan refugees. Journal of Traumatic Stress, 9, 891-898. Marshall, G. N., Berthold, S. M., Schell, T. L., Elliot, M. N., Chun, C. A., & Hambarsoomians, K. (2006). Rates and correlates of seeking mental health services among Cambodian refugees. American Journal of Public Health, 96, 1829-1835. Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. A. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association, 294, 571-579. Mayo Clinic (2009). Sertaline (oral route). Retrieved November 11, 2009 from http://www.mayoclinic.com/health/drug-information/DR601237 McKelvey, R. S. (1994). Refugee patients and the practice of deception. American Journal of Orthopsychiatry, 64, 368-375. Mels, C., Derluyn, I., Broekaert, E., & Rosseel, Y. (2009). Screening for traumatic exposure and posttraumatic stress symptoms in adolescents in the war-affected Eastern Democratic Republic of Congo. Archives of Pediatrics & Adolescent Medicine, 163, 525-530. Melzer-Brody, Churchill, E., & Davidson, J. R. (1999). Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatry Research, 88, 63-70. Mghir, R., Freed, W., Raskin, A., & Katon, W. (1995). Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. Journal of Nervous and Mental Disease, 183, 24-30. Miller, K. E., Martell, Z. L., Pazdirek, L., Caruth, M., & Lopez, D. (2005). The role of interpreters in psychotherapy with refugees: An exploratory study. American Journal of Orthopsychiatry, 75, 27-39. Miller, K. E., Omidian, P., Kulkarni, M. Yaqubi, A., Daudzai, H., & Rasmussen, A. (2009). The validity and cultural utility of post-traumatic stress disorder in Afghanistan. Transcultural Psychiatry, 46, 219-237. Miller, K. E., Omidian, P., Quraishy, A. S., Quraishy, N., Nasiry, M. N., Nasiry, S., et al. (2006). The Afghan Symptom Checklist: A culturally grounded approach to mental health assessment in a conflict zone. American Journal of Orthopsychiatry, 76, 423-433. Mollica, R. F., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M. P. (1999). Disability associated with psychiatric comorbidity and

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

44

Theodore W. McDonald and Jaime N. Sand

health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 282, 433-439. Mollica, R. F., Wyshak, G., & Lavelle, J. (1987). The psychosocial impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572. Muecke, M. A. (1983). Caring for Southeast Asian refugee patients in the USA. American Journal of Public Health, 73, 431-438. Neria, Y., Nandi, A., & Galea, S. (2008). Post-traumatic stress disorder following disasters: A systematic review. Psychological Medicine, 38, 467-480. Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 686-694. Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004). A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72, 579-587. Nicholl, C., & Thompson, A. (2004). The psychological treatment of Post Traumatic Stress Disorder (PTSD) in adult refugees: A review of the current state of psychological therapies. Journal of Mental Health, 13, 351-362. Nutt, D., & Malizia, A. (2004). Structural and function brain changes in Posttraumatic Stress Disorder. Journal of Clinical Psychiatry, 65, 11-17. Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., & Elbert, T. (2009). Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement: An epidemiological study. Conflict and Health, 3. Retrieved October 2, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2695430 Onyut, L. P., Neuner, F., Schauer, E., Ertl, V., Ogenwald, M., Schauer, M., & Elbert, T. (2004). The Nakivale Camp Mental Health Project: Building local competency for psychological assistance to traumatized refugees. Intervention: International Journal of Mental Health, Psychosocial Work & Counseling in Areas of Armed Conflict, 2, 90-107. Otto, M. W., Hinton, D., Korbly, N. B., Chea, A., Ba, P., Gershuny, B.S., et al. (2003). Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: A pilot study of combination

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

References

45

treatment with cognitive-behavior therapy vs sertraline alone. Behaviour Research and Therapy, 41, 1271-1276. Papageorgiou, V., Frangou-Garunovic, A., Iordanidou, R., Yule, W., Smith, P., & Vostanis, P. (2000). War trauma and psychopathology in Bosnian refugee children. European Child & Adolescent Psychiatry, 9, 84-90. Paunovic, N., & Ost, L. (2001). Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behaviour Research and Therapy, 39, 1183-1197. Perrin, M. A., DiGrande, L., Wheeler, K., Thorpe, L., Farfel, M., & Brackbill, R. (2007). Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. American Journal of Psychiatry, 164, 1385-1394. Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1503-1511. Pham, P. N., Weinstein, H. M., & Longman, T. (2004). Trauma and PTSD symptoms in Rwanda: Implications for attitudes toward justice and reconciliation. Journal of the American Medical Association, 292, 602612. Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. Journal of the American Medical Association, 294, 602-612. Pumariega, A. J., Rogers, K., & Rothe, E. (2005). Culturally competent systems of care for children's mental health: Advances and challenges. Community Mental Health Journal, 41, 539-555. Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community Mental Health Journal, 41, 581597. Qouta, S., Punamaki, R. L., & El Sarraj, E. (2004). Prevalence and determinants of PTSD among Palestinian children exposed to military violence. European Child and Adolescent Psychiatry, 12, 265-272. Raphael, B., Delaney, P., & Bonner, D. (2007). Assessment of trauma for aboriginal people. In J. P. Wilson & C. S. Tang (Eds.) Cross-cultural assessment of psychological trauma and PTSD (pp. 337-358). New York: Springer. Renner, W., & Salem, I. (2009). Post-traumatic stress in asylum seekers and refugees from Chechnya, Afghanistan, and West Africa: Differences in

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

46

Theodore W. McDonald and Jaime N. Sand

symptomatology and coping. International Journal of Social Psychiatry, 55, 99-108. Robins, L. N., Wing, J., Wittchen, H. U., & Helzer, J. E. (1988). The Composite International Diagnostic Interview: An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry, 45, 1069-1077. Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., & Walsh, W. (1992). A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455-475. Savin, D., Seymour, D. J., Littleford, L. N., Bettridge, J., & Giese, A. (2005). Findings from mental health screening of newly arrived refugees in Colorado. Public Health Reports, 120, 224-229. Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative Exposure Therapy: A short-term intervention for traumatic stress disorders after war, terror, or torture. Hogrefe Publishing: Cambridge, MA. Schulz, P. M., Resick, P. A., Huber, L. C., & Griffin, M. G. (2006). The effectiveness of cognitive processing therapy for PTSD with refugees in a community setting. Cognitive and Behavioral Practice, 13, 322-331. Silove, D. (1999). The psychosocial effects of torture, mass human rights violations, and refugee trauma: Toward an integrated conceptual framework. Journal of Nervous and Mental Disease, 187, 200-207. Silove, D., Steel, Z., Bauman, A., Chey, T., & McFarlane, A. (2007). Trauma, PTSD and the longer-term mental health burden amongst Vietnamese refugees: A comparison with the Australian-born population. Social Psychiatry & Psychiatric Epidemiology, 42, 467-476. Somasundaram, D. (2007). Collective trauma in northern Sri Lanka: A qualitative psychosocial-ecological study. International Journal of Mental Health Systems, 1. Retrieved October 2, 2009 from http://www.pubmed central. nih.gov/articlerender.fcgi?artid=2241836 Sondergaard, H. P., Ekblad, S., & Theorell, T. (2001). Self-reported life event patterns and their relation to health among recently resettled Iraqi and Kurdish refugees in Sweden. Journal of Nervous and Mental Disease, 189, 838-845. Sondergaard, H. P., Ekblad, S., & Theorell, T. (2003). Screening for posttraumatic stress disorder among refugees in Stockholm. Nordic Journal of Psychiatry, 57, 185-189.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

References

47

Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49, 624-629. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302, 537-549. Steel, Z., Silove, D., Bird, K., McGorry, P., & Mohan, P. (1999). Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants. Journal of Traumatic Stress, 12, 421435. Stubbs, P. (1999). Transforming local and global discourses: Reassessing the PTSD movement in Bosnia and Croatia. Paper presented at a symposium on The Mental Health Care of Refugees in Utrecht, Netherlands. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science & Medicine, 48, 1449-1462. Thulesius, H., & Hakansson, A. (1999). Screening for posttraumatic stress disorder symptoms in Bosnian refugees. Journal of Traumatic Stress, 12, 167-174. Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public Health Reports, 107, 544-548. Ullman, S. E., Filipas, H. H., Townsend, S. M., & Starzynski, L. L. (2007). Psychosocial correlates of PTSD symptom severity in sexual assault survivors. Journal of Traumatic Stress, 20, 821-831. United Nations High Commissioner for Refugees (2008). 2007 global trends: Refugees, asylum-seekers, returnees, internally displaced and stateless persons. Retrieved September 21, 2009 from http://www.unhcr.org/ statistics/STATISTICS/4852366f2.pdf United Nations High Commissioner for Refugees (2006). Displaced person and refugee returns within/to Bosnia-Herzegovina. Retrieved September 29, 2009 from http://www.unhcr.ba/press/state%20of%20annex7.htm United Nations High Commissioner for Refugees (n.d.). UN High Commissioner for Refugees Antonio Guterres. Retrieved September 20, 2009 from http://www.unhcr.org/pages/49c3646c8.html? gclid= CM_ k1N36gJ0CFRlcagodU2IxZw

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

48

Theodore W. McDonald and Jaime N. Sand

United States Department of Veterans Affairs (2007). Clinician-Administered PTSD Scale (CAPS). Retrieved October 11, 2009 from http://ncptsd.va. gov/ ncmain/ncdocs/assmnts/clinicianadministered_ptsd_scale_caps.html U.S. Census Bureau (2009). U.S. and world population clocks. Retrieved September 18, 2009 from http://www.census.gov/main/www/popclock Vojvoda, D., Weine, S. M., McGlashan, T., Becker, D. E., & Southwick, S. M. (2008). Posttraumatic stress disorder symptoms in Bosnian refugees 3 1/2 years after resettlement. Journal of Rehabilitation Research & Development, 45, 421-426. Wahl, O. F. (1999). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25, 467-478. Watters, C. (2001). Emerging paradigms in the mental health care of refugees. Social Science and Medicine, 52, 1709-1718. Weine, S. M., Becker, D. F., McGlashan, T. H., Laub, D., Lazrove, S. Vojvoda, D., et al. (1995). Psychiatric consequences of “ethnic cleansing”: Clinical assessment and trauma testimonies of newly resettled Bosnian refugees. American Journal of Psychiatry, 152, 536-542. Weine, S. M., & Henderson, S. W. (2005). Rethinking the role of posttraumatic stress disorder in refugee mental health services. In T. A. Corales (Ed.) Trends in posttraumatic stress disorder research (pp. 157183). Hauppauge, NY: Nova Science Publishers. Weine, S., Knafl, K., Feetham, S., Kulauzovic, Y., Klebic, A., Sclove, S., et al. (2005). A mixed method study of refugee families engaging in multiplefamily groups. Family Relations, 54, 558-568. Weine, S., Kulauzovic, Y., Klebic, A., Besic, S., Mujagic, A., Muzurovic, J., et al. (2008). Evaluating a multiple-family group access intervention for refugees with PTSD. Journal of Marital and Family Therapy, 34, 149164. Weine, S. M., Kulenovic, A.D., Pavkovic, I., & Gibbons, R. (1998). Testimony psychotherapy in Bosnian refugees: A pilot study. The American Journal of Psychiatry 155, 1720-1726. Weine, S. M., Raina, D., Zhubi, M., Delesi, M., Huseni, D., Feetham, S., et al. (2003). The TAFES multi-family group intervention for Kosovar refugees. The Journal of Nervous and Mental Disease 191, 100-107. Weine, S., Razzano, L., Ramic, A., Brkic, N., Miller, K., Smajkic, A., et al. (2000). Comparing the clinical profiles of Bosnian refugees who have presented for mental health services with those who have not. Journal of Nervous and Mental Disease, 188, 416-421.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

References

49

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

Weine, S. M., Vojvoda, D., Becker, D. F., McGlashan, T. H., Hodzic, E., Laub, D., et al. (1998). PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. American Journal of Psychiatry, 155, 562-564. Weiss, D. S. (2007). The Impact of Event Scale: Revised. In J. P. Wilson & C. S. Tang (Eds.) Cross-cultural assessment of psychological trauma and PTSD (pp. 219-238). New York: Springer. Weiss, D., & Marmar, C. (1997). The Impact of Events Scale-Revised. In J. Wilson & T. Keane (Eds.) Assessing psychological trauma and PTSD: A handbook for practitioners (pp. 399-411). New York: Guilford Press. Werner, P. D. (2001). Structured Clinical Interview for DSM-IV Axis 1 Disorders: Clinician Version. In B. S. Plake & J. C. Impara (Eds.) The fourteenth mental measurements yearbook (pp. 1123-1125). Lincoln: NE: Buros Institute of Mental Measurements. Westermeyer, J. (1990). Working with an interpreter in psychiatric assessment and treatment. Journal of Nervous and Mental Disease, 178, 745-749. Zur, J. (1996). From PTSD to voices in context from an “experience-far” to an “experience-near” understanding of responses to war and atrocity across cultures. International Journal of Social Psychiatry, 42, 305-317.

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

INDEX

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

A access, 13, 19, 23, 32, 48 acculturation, 39 adaptations, 31 adjustment, 25, 33, 36, 39 adolescents, 33, 39, 43 advocacy, 9 affective disorder, 4 Afghanistan, 7, 15, 28, 41, 43, 45 Africa, vii, 3, 7, 8, 29, 33 age, 42 alters, 23 American Psychiatric Association, 1, 37 American Psychological Association, 38, 40 anemia, 4 anxiety, 4, 27, 28, 38 arousal, 1 ASI, 14, 27, 31 Asia, vii, 3, 4, 8 assault, 1, 47 assessment, vii, 5, 6, 7, 11, 12, 13, 15, 17, 38, 39, 40, 42, 43, 45, 48, 49 assessment tools, 13, 15, 17 assumptions, 47 asylum, 45, 47 attitudes, 22, 45 Australia, vii, 4, 8, 39 authors, 4, 6 autobiographical memory, 22, 24

avoidance, 1, 26, 27 avoidance behavior, 26 awareness, 22

B background, 24 barriers, 17, 22, 41, 47 Beck Depression Inventory, 30 behavior, 15, 21, 24, 26, 37, 41, 45 behavior therapy, 21, 24, 37, 41, 45 behaviors, 15, 23, 26 belief systems, 22 beliefs, 14, 19, 31 biological responses, 12 blood, 41 blood pressure, 41 boat people, 4 Bosnia, 5, 6, 30, 47 Bosnia-Herzegovina, 47 Bosnians, 6 brain, 44

C Cambodia, 4, 23 Canada, vii, 4, 40 cast, 7 Census, 1, 48 Central Asia, 7

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Index

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

52

challenges, 45 child development, 22 children, 33, 38, 42, 45 Chile, 28 cholera, 4 clients, 15, 24, 30, 33, 36 CNS, 41 cognitive process, 26, 28, 46 cognitive processing, 26, 28, 46 cognitive therapy, 28 collaboration, 15 combination therapy, 27 communication, 21, 22 community, 3, 5, 15, 18, 21, 26, 31, 32, 33, 36, 38, 43, 46 comorbidity, 43 competence, 22 competency, 39, 44 compliance, 25 components, 28 comprehension, 16 confidentiality, 23 confinement, 13 conflict, vii, 13, 39, 43, 47 Congress, iv construct validity, 16 consultants, 16 consumers, 48 continuity, 33 control, 22, 29, 32 control group, 29, 32 Copyright, iv correlations, 16 counseling, 29, 44 crime, 5 Croatia, 44, 47 cultural influence, 23 culture, 16, 21, 25, 32, 35

D damages, iv dance, 33 death, 13, 23, 36 delivery, 40

Democratic Republic of Congo, 43 depression, 4, 8, 27, 28, 38 deprivation, 13 destruction, vii detection, 18 detention, 28 developed countries, 17 developed nations, 3, 17 developing countries, 12 Diagnostic and Statistical Manual of Mental Disorders, 37 diagnostic criteria, 4, 5, 6, 30 disaster, 39, 45 disclosure, 25 discrimination, 32 diseases, 36 disorder, vii, 1, 11, 17, 21, 37, 39, 41, 42, 43, 44, 45, 47, 48 displaced persons, 3, 8, 45 displacement, 3, 7, 8, 36, 39, 47 distress, 4, 8, 11, 15, 17, 23, 36 dizziness, 14 dosage, 33 dreams, 1 DSM, 14, 29, 30, 39, 42, 47, 49 DSM-II, 47 DSM-III, 47 DSM-IV, 29, 30, 39, 42, 49

E Eastern Europe, 33 echoing, 12 Education, 31, 32 emotion, 41 emotion regulation, 41 emotional experience, 23 emotional state, 15 emotions, 1, 23, 24, 25, 29 employment, 5 energy, 16 environment, 18, 25, 31 EST, 26, 28 ethnic groups, 8 Europe, 8

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Index evacuation, 40 exposure, 4, 5, 6, 7, 13, 21, 25, 26, 28, 29, 37, 43, 44, 45

F family, 13, 15, 24, 25, 30, 31, 32, 33, 38, 41, 48 family members, 25, 32 family therapy, 33 farmers, 7 fear, 27 feelings, 1, 24, 26 flashbacks, 23 focusing, 33 food, 13 Ford, 39 foreign language, 14 foundations, 38 frustration, 23 future orientation, 42

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

G General Health Questionnaire, 14, 40 genocide, 5 GHQ, 14 glasses, 16 goals, 24, 26, 33, 35 gold, 13 grief, 22, 29, 39 group therapy, 33 groups, 7, 8, 14, 22, 28, 29, 30, 31, 33, 35, 48 growth, 42 guidance, 30 guidelines, 12 guilt, 22

H

53

health, vii, 3, 4, 5, 8, 11, 12, 13, 14, 17, 18, 21, 22, 32, 33, 35, 36, 37, 39, 40, 42, 43, 44, 45, 46, 47, 48 health care, 33, 47 health problems, vii, 3, 4, 8, 12, 18, 36 health services, vii, 18, 21, 32 health status, 39, 44 Hmong, 5 home culture, 19, 24 host, vii, 4, 5, 17, 22, 33, 35, 36 host population, 4 housing, 5 human rights, 30, 36, 46 Hurricane Katrina, 40

I ideal, 13 identity, 22, 24 immigrants, 31, 45, 47 imprisonment, 13, 35, 36 indicators, 14, 15 indigenous, 11 indigenous peoples, 11 Ingushetia, 8, 39 initiation, 18 injury, iv, 13, 36 instruments, 18, 28, 33, 36 interactions, 25 internal consistency, 16 internalization, 23 intervention, 26, 31, 32, 34, 46, 48 interview, 16, 39 Iraq, 7, 41 irritability, 15 Israel, 7

J justice, 45

K

habituation, 29 kidnapping, 13

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Index

54

L labor, 5 language, 5, 13, 14, 16, 21, 22, 23, 30 languages, 13, 14, 17, 33, 35 Laos, 4, 5 Latin America, 8, 33 learning, 15, 24 Lebanon, 7, 42 life experiences, 15, 30 likelihood, 5 literacy, 16 living conditions, 30, 39

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

M major depressive disorder, 33 majority, 7 malaria, 4 Malaysia, 4 management, 33 measures, 11, 12, 13, 14, 15 medication, 27 men, 8, 15 mental disorder, 39, 42 mental health, vii, 1, 3, 4, 5, 8, 11, 12, 13, 14, 15, 17, 18, 21, 23, 25, 26, 31, 32, 33, 34, 35, 36, 39, 40, 41, 43, 44, 45, 46, 47, 48 mental health professionals, 11, 12, 17, 18, 21, 25, 34, 35, 36 mental illness, 23, 40 meta-analysis, 8, 45, 47 methodology, 15 Middle East, vii, 3, 7, 8, 42 military, 45 model, 17, 28, 34, 38, 42 models, 42 modernity, 38 morbidity, 4 motivation, 16, 31 movement, 47 multi-ethnic, 33 Muslims, 6

N narratives, 15, 16, 29 nation, 35 Netherlands, 47 New England, 41 New Zealand, 39 nightmares, 15 North America, 24 nuclear family, 25

O occupational therapy, 33 oppression, 36 order, 8, 22, 24 outpatients, 27

P pain, 14, 22, 40 panic attack, 14, 41 panic disorder, 15 panic symptoms, 15 perceptions, 23 permission, iv personal accomplishment, 30 personal achievements, 24 personal control, 24 pharmacological treatment, 26, 42 pharmacotherapy, 44 Philippines, 4 pilot study, 27, 38, 41, 44, 48 police, 1 political refugees, 37 poor, 15 population, 1, 5, 11, 16, 26, 36, 46, 48 posttraumatic stress, 33, 39, 41, 42, 43, 44, 47, 48 post-traumatic stress disorder, 38, 43, 46 poverty, 44 program, 18, 31, 32, 33 psychological distress, 4, 24, 42 psychological well-being, 15

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Index psychology, 24 psychopathology, 4, 11, 45 psychosocial development, 42 psychotherapy, 23, 26, 37, 43, 48 PTSD, vii, 1, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 17, 18, 21-33, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 46, 47, 48, 49 public health, 3, 4, 38 public safety, 38

Q questioning, 24

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

R range, 13 rape, 46 reactivity, 17 reason, 13, 25 recall, 17 recalling, 24 recognition, 28 recommendations, iv, 36 reconciliation, 45 recovery, 30, 39, 45 refugee group, 14, 17, 22, 24, 36 region, 35 relationship, 16, 23, 31, 39 relaxation, 27 reliability, 13, 16 repression, 38 resettlement, 3, 5, 6, 7, 18, 36, 38, 39, 42, 43, 48, 49 resolution, 24, 25 resources, 32, 36 respect, 17, 24 response format, 13 restructuring, 27 retaliation, 24 returns, 47 rights, iv risk, 45 risk factors, 45

55

Rwanda, 7, 45

S sadness, 16, 17 Sarajevo, 39 school, 33 scores, 16, 28, 31 searching, 11 Second World, 5 self-esteem, 24 sensitivity, 14, 19, 22 sertraline, 45 service provider, 2, 40 severity, 6, 31, 47 sexual violence, vii sharing, 23, 25 shock, 42 skills, 16, 29 social environment, 25 social identity, 39 social network, 32 social problems, 36 social resources, 29 social support, 32 social withdrawal, 17 Somalia, 7 Southeast Asia, vii, 3, 4, 5, 12, 14, 27, 35, 40, 41, 42, 44, 47 Sri Lanka, 7, 46 starvation, 5 statistics, 47 stigma, 17, 23, 39, 48 strategy, 15, 28 stress, vii, 1, 7, 11, 37, 42, 44, 45, 46, 48 stressors, 40 subgroups, 5, 6 survivors, 1, 6, 28, 29, 30, 37, 38, 40, 42, 47 Sweden, vii, 7, 42, 46 symptom, 18, 22, 26, 31, 41, 47 symptoms, 1, 6, 7, 12, 14, 17, 18, 21, 23, 25-29, 33, 35, 37, 38, 41-49

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and

Index

56

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

T teachers, 33 teaching, 29 testing, 16 Thailand, 4 therapeutic approaches, 31, 33 therapeutic benefits, 30 therapeutic process, 22 therapists, 15, 17, 18, 22, 23, 25, 29, 30 therapy, vii, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 41, 44, 45, 46 thinking, 16, 26, 27 thoughts, 1, 24, 26, 27 threat, 42 torture, vii, 4, 7, 18, 24, 28, 36, 37, 38, 39, 40, 44, 46, 47 trade, 27 training, 22, 23, 27, 39 transition, 18 translation, 16 trauma, vii, 3, 4, 5, 6, 7, 8, 12, 13, 16, 18, 19, 23, 25, 26, 28, 29, 30, 32, 35, 36, 37, 39, 40, 42, 44, 45, 46, 47, 48, 49 traumatic brain injury, 13 traumatic events, 5, 8, 12, 13, 23, 24, 27, 28, 29, 47 traumatic experiences, 6, 17, 18, 23, 29 trends, 47 trial, 28, 29, 41, 44 trust, 24 tuberculosis, 4 Turkey, 37

United States, vii, 1, 4, 5, 6, 14, 39, 43, 48, 49 urban population, 42

V validation, 39 variables, 32 vein, 12, 22 victimization, 5 victims, 1, 28, 41, 46 Vietnam, 3, 4 violence, 3, 4, 5, 42, 45

W war, 1, 3, 5, 6, 13, 16, 28, 35, 36, 38, 39, 40, 42, 43, 44, 46, 47, 49 weakness, 23 web, 19 web sites, 19 well-being, 15, 18, 39, 40 wellness, 24 West Africa, 45 Western countries, 3, 6, 11, 36 withdrawal, 17 women, 6, 8, 15 workers, 1, 3, 4, 31, 33, 38, 45 World Trade Center, 45

Y Yugoslavia, vii, 5, 28, 35

U UNHCR, 3, 6 United Nations, 3, 47 United Nations High Commissioner for Refugees, 3, 47

Z Zoloft, 27

Post-Traumatic Stress Disorder in Refugee Communities: The Importance of Culturally Sensitive Screening, Diagnosis, and