Training Refugee Mental Health Providers: Ethnography as a Bridge to Multicultural Practice

Human Organization, Summer 2004 by Gozdziak, Elzbieta M

As the number of forced migrants increases, so does the number of programs established to provide psychological help to refugees and victims of wartime violence. The expansion of such programs both in the West and in nonwestern countries indicates the prominence of mental health professionals in the refugee field. There is a widespread assumption that armed conflict and civil strife constitute mental health emergencies and all refugees and victims of wartime violence need to have an immediate access to psychological counseling and trauma programs. The role of mental health interventions in addressing refugee suffering begs the question whether existing training programs adequately prepare mental health professionals to serve diverse refugee populations. This article attempts to answer this question by analyzing the tenets of Western training programs for the helping professions. It also explores the contributions that anthropology can make to the field of refugee mental health.

Key words: refugees, mental health, biomedical training

As the number of refugees and internally displaced continues to increase, so does the number of programs established to provide psychological help for refugees and victims of wartime violence (Bracken, Giller, and Summerfield 1997). The expansion of such programs in the West and the considerable zeal with which they are exported to nonwestern countries indicate the prominence of mental health professionals in the refugee field. This prominence is based on the premise that ethnic cleansing, war, and civil strife constitute mental health emergencies. The ever-increasing role of mental health interventions in addressing refugee suffering begs the question whether mental health professionals are adequately prepared to serve ethnically, culturally, and religiously heterogeneous refugee populations. I attempt to answer this question by critiquing the growing importance of psychological trauma programs and counseling services in refugee relief operations and resettlement programs; by discussing the tenets of Western training programs for the helping professions, based primarily upon a biomedical model and Western diagnostic categories; and by exploring the contributions that anthropology can make to the field of refugee mental health.

The Growing Prominence of Refugee Mental Health Programs

Recent years have seen a tremendous increase in the number of programs addressing "post-traumatic stress" and providing counseling services to refugees (Bracken, Giller, and Summerfield 1997; Summerfield 1999). Indeed, trauma projects are becoming progressively more attractive for Western donors.

In February 1995 the European Community Humanitarian Office (ECHO) was providing financial support to 15 international NGOs from six European Union member states for psychological work in former Yugoslavia. A European Community Task Force (ECTF) review noted 185 such projects being implemented by 117 organizations. There were 10 times more projects in Croatia than in Bosnia-Herzegovina, the reason given being the state of the war. 63% of projects were offering direct psychological services and 54% ran psychologically oriented groups, mostly self-help. 33% ran psychiatric services and 63% had staff training programmes including topics like war trauma (Summerfield 1999:1452).

The expansion of such programs in the West-as documented by van Ewijk and Grifhorst (1997) in the Netherlands, Muecke (1992) in the United States, and Watters (2001) in Britain-and their export to nonwestern countries-as shown by Foster and Skinner (1990) in South Africa, Gibbs (1994) in Mozambique, and Boyden and Gibbs (1996) in Cambodia-are directly related to what Kleinman (1997) calls "medicalization of human suffering" and Hughes (1994) labels "culture of victimhood." Bracken and colleagues relate the proliferation of specialized centers for the care of refugees and torture victims to the "modernist responsibility to act" and "control the disorder provoked by suffering and loss through instituting programs of analysis and therapy" (Bracken, Giller, and Summerfield 1997:434) "that may eschew critical analysis in favor of pragmatism that proliferates, and adds credence, to bio-medical taxonomies" (Watters 2001:1710). They argue that the tendency to establish such centers and programs results from the "spectacular growth within Western culture in the power of medical and psychological explanations for the world, and in the pronouncements of mental health professionals" (Bracken, Giller, and Summerfield 1997:436-437).

Undeniably, mental health professionals and trauma programs have acquired a new prominence in the refugee field. Shortly after the genocide in Rwanda in 1994: "there was a stampede by humanitarian agencies in the region. The first flows of destitute Tutsi refugees had scarcely abated when from afar a surprising number of agencies, many with little knowledge of the country, mobilized projects to address what they saw as mass traumatization" (Summerfield 1999:1452). In the mid-1990s, the United Nations Children's Fund (UNICEF) established a National Trauma Program in Rwanda (UNICEF 1996). The National Trauma Center, headquartered in Kigali, provided intensive therapy to traumatized children and their families. By 1996, more than 6,000 "trauma advisors" had been trained in basic trauma alleviation methods. They reportedly assisted approximately 144,000 children (Summerfield 1999:1451). Similar efforts to train mental health staff were undertaken by the United Nations High Commissioner for Refugees (UNHCR) and the World Health Organization (WHO) in Bosnia and Croatia (Summerfield 1999).