Mental health and refugee families: "what is needed more than political ideology is to build a family-centered approach to refugee mental health." - Psychology

USA Today (Society for the Advancement of Education), Jan, 2002 by Stevan M. Weine

IN RESPONSE TO the catastrophic escalation of refugees worldwide, there has been a corresponding growth of America's helping efforts that focus on their mental health. These range from "clinical treatments" such as psychotherapies and psychoactive medications to "psychosocial interventions" such as group and rehabilitation activities. For those refugees resettling in the U.S., these services are provided by voluntary agencies, such as the faith-based organizations championed by Pres. Bush, as well as mainstream health, mental health, and social services. For refugees in countries affected by war, the U.S. government and American nongovernmental organizations play major roles in funding, designing, monitoring, and delivering these services.

These efforts exist at all because, when presented with media images of suffering, a human response is to ask, "What can be done?" The past decade has witnessed tremendous growth in the clinical mental health approaches to survivors of catastrophes. Mental health professionals stepped forward with medications and therapies to treat refugees' post-traumatic stress disorder (PTSD) and, through their work, the suffering of many was eased.

Yet, what the actual engagements with refugees also reveal is that one size does not fit all. Medications and psychotherapy cannot possibly be for all persons from all cultures. What is more, individually focused treatments are really not the appropriate means for addressing the social suffering of public health of a population. To make good on the obligation to do something consequential for refugees, America needs for the refugee mental health field to find new ways of being helpful that can address these other dimensions. One especially important shortcoming in refugee mental health is that sufficient attention has not been paid to the refugee family.

This is reflected in a meager existing knowledge base. There is little to no theory and research concerning how refugee families recover from trauma and adjust to their new surroundings, including how they interact with mental health services. Just a small number of family-focused programs has ever been described, and there are hardly any resources for family-focused training. There is a small amount of family therapy literature on refugees, but it tends to be clinically focused and limited to addressing problematic interpersonal aspects of the survivor experience.

For too long in my work with refugees, I was blind to the world of families. What enabled me to change was having several years of intensive engagement with refugee families. What I found in Bosnia and in its Diaspora in Chicago is that family comes first. You are a father, sister, son, or wife before you are a patient, or, for that matter, a doctor, writer, or athlete. You are who you are in your family. That is true when times are good, and it is even truer when times are hard, when family may be all you can depend on.

To learn more about refugee families, we conducted a case study of one Bosnian family in their first year of resettlement. We were surprised to find that their formula for family living, which at first appeared problematic to us, was really working for them. Instead of causing psychopathology, as we would have predicted on the basis of our clinical theories, this family was taking steps that were associated with recovery from traumatization and positive adjustment to their new life situation. This family's way provided its members with enough of a margin of solidarity that each could find goodness, joy, and strength in being together as a family--no small achievement.

Being with many refugee families has forced me to confront the biases Of my profession. When we work with families, too often it means identifying what has gone wrong. I had to find a way to acknowledge what they so often say: "We are our families"; "We live for family and through family"; and "If you want to understand Bosnians, you must know their family." That means looking at families through a family lens that identifies what is right and that appreciates their strengths, hopes, and achievements.

Looking through a family lens reveals a glaring disconnect between how important family is to most refugees and how seemingly unimportant it can be to the systems that provide services to them. Having observed many of the current arrays of efforts to help, both in the Balkans and in the U.S., I find that it is very rare to discover any programs which deliberately fit either the needs or strengths of families.

The Red Cross's World Disaster Report 2000 sharply criticizes international mental health initiatives and issues the urgent call for changes. Regarding Kosovo, for example, the report states that "[it] is very much a family-oriented society and you cannot simply take short-term approaches on a one-on-one basis." Yet, too often, that is precisely what is done.

Psychiatric or political?

If there is a lack of theory, science, and training which looks through a family lens, what then is it that has been driving the current programs and policies for America's refugee mental health efforts? The American discourse on refugee mental health has been shaped by the sharply polarized views of the nature of suffering in refugees that characterize the discourse in trauma mental health. Suffering is regarded as either a psychiatric or political program. The psychiatric view considers the mental health of refugees through the lens of PTSD. It maintains that refugees suffer because they have PTSD and that we can help them by treating that disorder. It makes this claim for refugees like it has made the claim for combat veterans and victims of sexual assault.