Old Stereotypes, New Realities
Refugees and Mental Health
By Richard Mollica and Laura McDonald

International research and relief organizations estimate that there are between 10 million and 11 million refugees, and 20 million and 25 million internally displaced persons (IDPs) worldwide. Scientific studies underscore the impact that horrific events - characteristic of the “refugee experience” - have on the mental health of an individual and society. An article published in Scientific American [Mollica, Richard F., “Invisible Wounds”. Scientific American, June 2000] discusses a number of discoveries revealing the varying nature and the long-term and debilitating impact of traumatic events experienced by refugees. The following illustrates the serious consequences of psychological trauma on the health of an individual and his or her society.

First, the prevalence of psychiatric disorders among survivors of war is considerable. In a study of Cambodian refugees, the prevalence rates of acute levels of depression and post-traumatic stress disorder (PTSD) were 68 per cent and 37 per cent, respectively - significantly higher than those found among the general population of 10 per cent and 3 per cent for depression and PTSD, respectively. Second, studies have also revealed the serious physical and neurological impact of trauma, showing that some potent events can indeed cause permanent organic changes in the brain. Third, research has shown that depression can lead to disability and even premature death.

Furthermore, survivors of trauma suffer from chronic fatigue and mental exhaustion. They feel as if “they are no longer capable of achieving the same level of competence in their work that they had prior to the violence”. Their claims are grounded in scientific evidence showing that “intellectual performance, especially deterioration in memory and the ability to learn new tasks and ideas, is associated with head injury (beatings to the head), starvation and the secondary cognitive sequelae of PTSD and depression”. Moreover, psychological trauma also manifests itself in physical pain through the process of somatization, whereby an individual feels pain, but examination reveals no underlying physical aetiology - a condition commonly reported among war-affected individuals. This research also underscores that the consequences of trauma leave people increasingly vulnerable to unemployment and poverty.

The unabated “trauma of war” ultimately and needlessly jeopardizes the human, economic, political and social development - each is requisite to the societal growth and rehabilitation that is the fundamental objective of development assistance. Longitudinal data and historical record are telling: the untreated wounds of war do not just go away; often they are planted in subsequent generations. Research and existing interventions have shown the positive impact of mental health assistance in these contexts. Mental health programmes in Bosnia and in Cambodia, including clinical and therapeutic interventions, have reduced physical and mental disability, and played a part in empowering individuals to pick up the pieces of their shattered lives and broken societies.

Existing evidence supports the assertion that interventions can help and are necessary. We must acknowledge that “people who face mass violence or torture cannot be expected to snap back to good mental health on their own”.

The existing paradigm for humanitarian assistance and post-conflict recovery is limited, and attention to mental health issues is inadequate. This is largely the result of a flawed model of assistance, where refugees are defined by their plight, with little regard for their identity prior to the conflict and with little consideration for the role they must play in their society’s recovery and rehabilitation. The international community is just beginning to take heed of mental health issues, which belong at the fore of recovery efforts. However, despite growing evidence of the consequences of trauma, concrete actions to address these “invisible wounds” are unexpectedly still often inadequate, if not entirely missing, from paradigms of assistance and development employed by relief and development organizations in post-conflict transition. Their absence weighs heavy on the prognosis for future peace in war-torn societies, particularly since it is precisely those individuals who have experienced the “trauma of war” who are expected to play a key role in the reconciliation, recovery, peace-building and rehabilitation process in the often tenuous aftermath.

UN Unit on Internal Displacement The United Nations has established a Unit on Internal Displacement to respond to the severe crisis of internal displacement around the world. It is estimated that some 20-25 million people have lost their homes as a result of armed conflict, and another 25 million have lost homes owing to natural disasters. These populations require the support of the international community to meet their urgent humanitarian needs and find durable solutions to their predicament. The Unit will provide a nucleus of expertise to advise and support the UN Emergency Relief Coordinator. In addition to working with United Nations humanitarian, development and human rights organizations, the Unit on Internal Displacement will liaise closely with the Red Cross/Red Crescent Movement, the International Organization for Migration and the large number of non-governmental organizations, both international and local, who are widely involved with this issue. The Unit will also maintain close links with the Representative of the Secretary-General on Internally Displaced Persons, Francis Deng, particularly in support of his advocacy function.

The international community must re-conceptualize the refugee’s plight as one phase of their experience, which begins with conflict and displacement and hopes to end in resettlement or return, and modify its assistance paradigm accordingly. And a new mental health model for refugee assistance - one that goes beyond the conventional wisdom of humanitarian assistance, e.g. protection and prevention of forced repatriation, and correlates with this re-conceptualization - is needed now more than ever. Indeed, these interventions are critical in preventing mental illness; however, there are other major environmental factors that can be employed that foster positive mental health.

Steps should be taken to provide refugees with the opportunity to work, take part in religious and spiritual activities, and participate in education or training programmes. Steps should also be taken to promote so-called altruistic behaviour in light of their limited resources. Studies of traumatized populations have revealed the efficacy of such interventions and work against a model of assistance, where refugees are treated as passive recipients of donor aid. They allow refugees to play an active role in mitigating the stress inherent to the refugee experience, allowing them to hold on to and/or restore the dignity that is essential to their recovery.

The new mental health model must be built on realities that characterize the experience of today’s refugees whose populations within refugee camps are characterized by ethnic diversity. Since studies show that the expression and experience of trauma are influenced by culture and social constructs, indigenous cultural practices that belong to the refugee communities should be fostered and promoted. Moreover, as the nature of the traumatic experiences of refugees is diverse - for example, the prevalence of rape against women in Bosnia - it is vital that those responsible for their mental health understand the indigenous system and means that will help restore them to dignity. While local health systems have been badly damaged or nearly destroyed altogether as a result of conflict, some remnants of the previously established system remain intact.

Among refugee populations, remnants of indigenous healing capacities remain, provided by elders, senior family members, traditional healers and Western primary health care practitioners. Such capacities should be strengthened and made readily available to the refugee community. Organizations should take steps to ensure that their work builds up and strengthens the local healing system, rather than imposing an alien system that is almost always discarded once the refugees return home, and that will limit the healing system’s capacity for sustainable assistance. The international community would do good to consider today’s refugees not as refugees alone, but also as individuals on their way to becoming the citizens of tomorrow, or at least the key participants in reconstructing a war-torn society and past. The primary objective of refugee assistance is to provide them with the tools necessary for the difficult tasks that lie ahead.

Richard F. Mollica is the Director of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital, and associate professor of psychiatry at Harvard Medical School. Laura McDonald is a research assistant at HPRT and a candidate for a Master’s Degree at the Fletcher School of Law and Diplomacy.