Culturally Sensitive Psychiatric Care for Refugees: A ReassessmentBy Sara Gorman
In recent years, a welcome increase in attention to specific psychological problems among refugees has led to important new insights. Some of this research interest stems from experience with troops and veterans of the Iraqi and Afghani wars. New research has focused not only on the psychiatric effects of torture and human rights abuses, but also on the mental health consequences of victims’ subsequent forced migration. These consequences include the process of seeking asylum, isolation in a new country, and guilt and concern about leaving one’s native land.1, 2, 6
With a renewed focus on the special psychiatric needs of the refugee community, several essential areas of new research have emerged. The epidemiological research on the effects of torture and forced migration on refugee populations has proven helpful in identifying the burden of chronic mental illness on asylum seekers. But are refugees really getting the mental health care they need? Evidence from the Mental Health Commission of Canada suggests that there is a major gap between need and treatment. The report demonstrates that some of the reasons for this inadequacy are related to lack of awareness of available services and socioeconomic barriers. Yet refugees also frequently cite perceived stigma and discrimination as a major barrier to care. This discrimination may not come directly from mental health providers but may be a perceived effect of a system that ignores their special needs. The system inevitably offers poorer treatment options to persons of different cultural backgrounds, including refugees, who may feel cultural barriers particularly prominently as a result of rapid resettlement.
It is quickly becoming apparent that in order to help refugees access treatment and use it successfully, mental health care modules must be adapted to the cultural diversity of the refugee client population.3, 4 Only approaches that incorporate recognition of such diversity have the potential to overcome the low rate of help-seeking behavior among refugees and the often inadequate quality of mental health care they receive.
The language barrier is an urgent problem. Feeling misunderstood by a health care provider is a major barrier to health-seeking behaviors among refugee populations. It may end up unjustly excluding refugees from obtaining treatment. The language barrier between patient and physician causes complex problems. In the case of refugee mental health care, there is the added complication of cultural differences that inform terms for sadness, depression, anxiety, and even psychosis. Semantic equivalency can be achieved in some cases, but it may require extensive consultation with health care workers in the native country who are familiar with the illnesses and words used to describe them.
There is also the question of whether diagnostic questions proposed by the DSM-IV, and its successor, the DSM-V, are phrased in a way that is meaningful in all languages and cultures. For example, in the Somali language, what Western medicine calls PTSD is associated with a form of madness termed waali, basically meaning “madness from trauma.”5 No such sense of “madness” is conveyed by the DSM-IV diagnostic markers for PTSD, which emphasize feelings of anxiety and sadness. The result is that refugees from Somalia may have profound PTSD but may not associate it with the version of the illness presented by the DSM-IV and DSM-V. Quests for semantic equivalency should not only take into account whether a word is translated correctly, but also whether the same concept of the illness exists in the other culture. Translations of diagnostic questions should therefore be culturally, as well as linguistically, informed.
Refugees are needlessly being excluded from the mental health care they desperately need and to which they are entitled. In many cases, this exclusion is the result of unintentional misunderstanding on the part of clinicians. More research should be conducted into how accurately Western notions of PTSD, depression, and other mental illnesses translate across cultures, and how well treatments traditionally used in Western countries for these illnesses work in widespread cultural settings. Most importantly, mental health providers should always remain aware of cultural differences in order to provide the most sensitive, effective, and appropriate care to a population in great need.
The author is a PhD. candidate at Harvard University.
1. G.J. Coffey, I. Kaplan, R. C. Sampson, and M. M. Tucci, “The meaning and mental health consequences of long-term immigration detention for people seeking asylum.”Social Science & Medicine 70 (2010), pp. 2070-2079.
2. J. P. Green and K. Eager, “The health of people in Australian immigration detention centres,” Medical Journal of Australia 192 (2010), pp. 65-70.
3. K. E. Miller, M. Kulkarni, and H. Kushner, K.E. et al, “Beyond trauma-focused psychiatric epidemiology: Bridging research and practice with war-affected populations.”American Journal of Orthopsychiatry, 76 (2006), pp. 409-422.
4. A. Nickerson, R. A. Bryant, D. Silove, and Z. Steel, “A critical review of psychological treatments of posttraumatic stress disorder in refugees,” Clinical Psychology Review 31 (2011), pp. 399-417.
5. C. L. Pavlish, S. Noor, and J. Brandt, “Somali immigrant women and the American health care system: Discordant beliefs, divergent expectations, and silent worries,” Soc Sci Med 71 (2010), pp. 353-361.
6. K. Robjant, I. Robbins, and V. Senior, “Psychological distress amongst immigration detainees: A cross-sectional questionnaire study,” British Journal of Clinical Psychology 48 (2009), pp. 275-286.