Front Matter

Contributors

Acknowledgments

Foreword

Ronald Wintrob, M.D.

Preface

Daryn Reicherter, M.D.

1 Overview of Cultural and Diagnostic Issues

James Boehnlein, M.D.

2 Diagnosis and Treatment

J. David Kinzie, M.D., FACPsych, DLFAPA

3 Psychological Treatment: NARRATIVE EXPOSURE THERAPY

Linda Piwowarczyk, M.D., M.P.H.

Dhanviney Verma, M.D.

4 Psychotherapy for Postmigration Stress

J. David Kinzie, M.D., FACPsych, DLFAPA

5 Psychobiology and Psychopharmacology

J. David Kinzie, M.D., FACPsych, DLFAPA

6 The Oregon Model: THE INTERCULTURAL PSYCHIATRIC PROGRAM

J. David Kinzie, M.D., FACPsych, DLFAPA

7 Children and Adolescents

Keith Cheng, M.D.

Paria Zarrinnegar, M.D.

8 Asylum Seekers

Mark Kinzie, M.D., Ph.D.

9 Geriatric Psychiatric Problems Among Refugees

Paul Leung, M.D.

J. David Kinzie, M.D., FACPsych, DLFAPA

10 Contemporary Refugee Crisis at the United States–Mexico Border

Bernardo Ng, M.D., FAPA

Erike Apolinar, LMFT

Mario A. Martinez, M.D.

11 Training Residents to Treat Refugees

James Griffith, M.D.

Sara Teichholtz, M.D.

12 Ethical Challenges Confronting Psychiatrists in the Field of Refugee Mental Health

Derrick Silove, A.M., M.B. Ch.B. (Hons I), M.D.,

FRANZCP, FASSA

13 Overview, Perspectives, and Research Needs

George A. Keepers, M.D., FACPsych, DLFAPA

J. David Kinzie, M.D., FACPsych, DLFAPA

George A. Keepers, M.D., FACPsych, DLFAPA

Director of Psychotherapy Services, Sun Valley Behavioral and Research Centers, Imperial, California

Professor, Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

Clinical Associate Professor, Division of Child Psychiatry, Oregon Health & Science University, Portland, Oregon

Leon M. Yochelson Professor and Chair, Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C.

Carruthers Professor and Chair, Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

Professor, Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

Associate Professor, Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

Clinical Professor, Department of Psychiatry, Oregon Health & Science University, Portland, Oregon

Chief of Children and Adolescent Outpatient Services, Instituto Psiquiátrico del Estado de Baja California, Mexicali, Baja California, Mexico

Medical Director, Sun Valley Behavioral and Research Centers, Imperial, California

Boston Center for Refugee Health & Human Rights, Boston Medical Center; Assistant Professor in Psychiatry, Boston University School of Medicine, Boston, Massachusetts

Clinical Professor, Department of Psychiatry and Behavioral Sciences, Stanford University

Scientia Professor, School of Psychiatry, University of New South Wales, Kensington, Sydney, Australia

Resident, Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C.

Instructor in Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts

Past President, Society for the Study of Psychiatry and Culture

Postdoctoral Fellow, Division of Child Psychiatry, Oregon Health & Science University, Portland, Oregon

The authors appreciate the excellent logistical support from Desiree Batiste and Samantha Birk and the fine editorial corrections and additions from Crystal Riley, M.A.

Throughout its history, America has seen itself, and been seen by other nations, as a country open to and welcoming of immigrants, as symbolized by the Statue of Liberty in New York Harbor. The degree to which public sentiment and government policies have been supportive toward immigrants, refugees, and asylum seekers has fluctuated from enthusiastic welcome for those who were fleeing from discrimination, persecution, poverty, and natural disasters in their home countries, to fear and antipathy toward immigrants from specific ethnic, racial, and religious backgrounds.

Immigration numbers peaked in America in the first decades of the twentieth century, then sharply decreased from 15% of the total U.S. population in the 1920s to 5% in the 1970s, reflecting changes in public support and government policy toward immigrants. By the first decade of the twenty-first century, the proportion of immigrants in the U.S. population had once again reached 15% of the total U.S. population—equivalent to what it had been in the first decade of the twentieth century.

In recent years, fear of terrorism has merged with fear of immigrants—and especially fear of refugees and asylum seekers from countries in Asia, Africa, and Latin America suffering from protracted internal conflict, war, drought, food shortages, and both political and economic instability. These developments have been increasingly evident in Europe as well as in America, resulting in sharply increased public hostility and governmental policy restrictions—not only toward immigrants but also, in particular, toward refugees and asylum seekers viewed as a burden and as a threat to the social, cultural, economic, and political stability of the nation.

It is this context that gives even greater strength and validity to the chapters in this volume, edited by J. David Kinzie and George A. Keepers, devoted to the best practices in psychiatric assessment and treatment of refugees and drawn from the experience of the Intercultural Psychiatric Program (IPP) at the Oregon Health & Science University (OHSU) in Portland, Oregon. In existence for over 40 years, the IPP has established and maintained a clinical service for refugees and asylum seekers who have come to America seeking safety, liberty, acceptance, and opportunity during those years.

In his clearly written overview of cultural and diagnostic issues in refugees, James Boehnlein cites the 2018 report of the United Nations High Commissioner for Refugees (UNHCR) indicating that there are 66 million forcibly displaced people in the world, of whom 22 million are refugees, who are unable to return to their country of origin based on their well-founded fear of persecution due to race, religion, nationality, political opinions, or membership in a specific social group.

Since 2000, approximately 75,000 migrants have entered the United States each year as refugees. The numbers authorized in 2015 and 2016 were increased to 110,000 per year, specifically to accommodate the surge of migrants from war-torn Iraq, Syria, and Afghanistan. However, in fiscal year 2016, reflecting a government policy change marked by increasing intolerance of refugees and asylum seekers from those countries, the number of refugees admitted to the United States was less than 85,000. In 2017, that number decreased again, to 54,000, with the approval ceiling for 2018 being lower still.

Boehnlein notes that despite the conditions of persecution, deprivation, physical danger, loss of physical and financial security, and separation from and loss of family, as well as fear of and experience of abuse and violence in refugee camps prior to resettlement in United States, there currently is no clear evidence that prevalence rates of mental disorders among refugees in the initial years of resettlement are significantly higher or lower than those in the host population, with the exception of psychosis and PTSD. However, over the long term, among resettled refugees, the rates of depression and anxiety disorders seem to be higher, and rates of PTSD remain at a higher level than in the host population. Ongoing separation from family members in the country of origin has been found to be a significant risk factor for poor refugee mental health postresettlement.

In their chapter on refugee children and families, Keith Cheng and Paria Zarrinnegar cite the 2017 UNHCR report indicating that worldwide, there are approximately 10 million refugee children below the age of 18. They also point to the recent changes in American public attitudes and government policy toward immigrants and refugees that have resulted in uncoordinated—and increasingly protracted—discriminatory and deleterious treatment of refugee children and families assigned to detention centers in some southern U.S. border facilities. They emphasize that these conditions of detention and protracted screening can traumatize children, with results that are as devastating as those of armed political conflict and displacement to refugee camps prior to resettlement in the United States. The authors point to recent policy changes intended to discourage refugees seeking asylum in the United States by separating refugee children from their accompanying parents and/or other family members, and deporting parents without their children, as well as holding unaccompanied youth and even young children in facilities unequipped to handle the physical and psychological needs of such children and youth, thereby increasing their risk of long-term developmental trauma. They address the complex issue of acculturative stress for immigrant, refugee, and asylum-seeking children, youth, and families in the face of negative stereotyping, economic and educational disadvantage, and acculturative stress—referring to concepts of vertical and horizontal identity formation, as developed by the psychologist Andrew Solomon in his 2013 book Far From the Tree. Solomon relates vertical identity formation to attitudes and values held by parents, reflecting their cultural upbringing and intended to be passed on to their children, whereas horizontal identity is derived from children’s exposure to peers and the youth culture of the postmigration host community, a frequent context of intrafamilial acculturative stress in immigrant families.

In his chapter outlining the IPP at OHSU and its treatment model for refugees, David Kinzie describes a number of features characteristic of refugees, including experience of forced migration from their homeland and multiple episodes of abusive and traumatic treatment prior to, during, and postmigration—including death of family members, personal torture, starvation, and prolonged time spent living in unsafe refugee camps. In America, refugees are easily overwhelmed by the bureaucratic procedures they encounter trying to arrange for housing, medical care, and education for their children, and they are also stressed by the lack of a secure income—in addition to poor adaptation to the host culture, ghettoization, and often xenophobic reactions from the host community. Those who suffer from mental illness are even further disadvantaged by fear of family and community rejection, an inability to make decisions, and stigma. More recently, there is an additional and very real threat of arbitrary detention and deportation by immigration authorities.

For a psychiatric program to be successful, it must accommodate the language of refugees, show respect for their cultural traditions and behaviors, understand the traumas and tragedies of their life experience, and above all have empathy for refugees. Patients are treated by a team that includes a psychiatrist, as well as a counselor who is a member of their ethnic group. Most counselors have master’s degrees in counseling. Kinzie describes the counselors as “the glue that holds the patient and the program together.” Research has been another fundamental component of the IPP, leading to publication of over 100 academic articles and book chapters to date.

Details of the psychiatric assessment and the treatement—both biological and psychological—of refugee individuals and families are described in the overview chapter and subsequent chapters focusing on children, youth and families, adult patients, and elderly refugees (including the impact of dementia on patients and the ethos of families caring for their elderly members without recourse to outside help). Approaches to adapting individual, group, and family psychotherapy, including specific techniques involved, are addressed. Each chapter includes illustrative clinical case examples of diverse issues in assessment and treatment.

Several authors emphasize that working with refugees and survivors of torture is often a long-standing process that requires developing patient-physician bonds that transcend time. Grasping the emotional impact of refugees’ displacement from their homeland, family, community, and cultural traditions, in addition to confronting and coping with the categorical hatred, abuse, and violence faced by refugees in their home countries due to their ethnic and/or religious identity, requires a moral sensibility in therapists that extends beyond cultural competence. The emotional consequences of categorical hatred extend beyond symptoms of depression or PTSD. A fractured sense of identity, loss of a capacity to trust others, self-loathing, and loss of empathy for one’s own suffering can be other consequences. Individuals often suffer shame from internalized stigmatization.

It can be a profoundly humbling experience for treatment personnel to accompany patients through their process of recovery—to be witnesses to both the worst of humanity and the strength and resilience of the human spirit. The work can be very challenging, and therapists do feel overwhelmed at times by the extent of the losses and suffering their patients have had to endure. However, to see such people recover their self-esteem and be able, once again, to show trust and resilience during their recovery, and to establish independently functioning lives in their resettlement communities, inspires therapists to embrace and continue this work. Providing care for refugees and asylum seekers is a complex but gratifying experience for a psychiatrist. It can expand a psychiatrist’s repertoire of clinical skills through its focus on assessment and care for normal syndromes of distress, ethnopharmacology, family-centered care, and human rights advocacy. It encourages the development of a resilience-building approach to treatment. Providing care for a refugee becomes an opportunity not only to treat symptoms of illness but to help the person who has been disinherited regain his or her humanity—and as a result of that process, helps to validate and maintain the humanitarian instincts and integrity of therapists.

The psychiatric assessment and treatment of traumatized refugees raises a wide range of ethical issues. These issues are thoughtfully addressed in the chapter by Derrick Silove, based on the clinical and research activities of Silove and colleagues at the University of New South Wales in Sydney, Australia, over the past two decades. Silove points out that the nature of the refugee experience invariably results in a blurring between the considerations of clinical ethics, which focuses primarily on the doctor-patient relationship, and the broader human rights domain that extends to the relationship of the individual and group to the state, especially in the case of prolonged detention of asylum seekers in facilities closed to public scrutiny and intended, as government policy, to discourage and deter immigration. Under these emotionally and politically charged circumstances, currently evident in America and Europe as well as in Australia, the term refugee itself can be used in a pejorative and discriminatory manner, especially if it is affixed to the person as a permanent label—a process of reification that psychiatrists and other mental health professionals should actively discourage.

Increasingly, Silove notes, refugees and asylum seekers are being confined for indefinite periods to detention centers in prisonlike conditions, although they have not committed any crime. These facilities can be described as regimented environments that lack schooling and play facilities for children and have inadequate medical and psychiatric services. They have also been shown to expose these refugees and asylum seekers to risk of neglect, abuse, and violence, as well as confrontations with supervisory staff who lack significant training or clinical experience with physically and/or mentally ill refugees. Prolonged detention can retraumatize these people, exacerbating preestablished traumatic stress disorders. Detained asylum seekers, including children, exhibit unusually high rates of PTSD, depression, and anxiety; the stressors and traumas experienced in detention play a major role in perpetuating these symptoms, and psychiatric disturbances tend to persist in detainees for years. The tendency to label refugees and asylum seekers as illegal immigrants to justify harsh policies aimed at deterring their immigration and postmigration resettlement runs counter to the principles of international covenants such as the Universal Declaration of Human Rights and the United Nations Convention Related to the Status of Refugees, which clearly state that seeking asylum as a refuge from persecution is a right, not a crime.

Reflecting on the current unwelcoming public attitude and the negative stereotyping of refugees and asylum seekers in America and many other countries that have been the main providers of refuge and post-migration integration of immigrants for generations, and in light of the increasing hostility toward immigrants as government policy in those countries, Kinzie and Keepers lament these changes and their deleterious impact on all immigrants. They especially identify the rejection of asylum seekers; the overt prejudice toward asylum seekers from Asian, African, and Latin American countries; the specific refusal to accept asylum applicants from “Muslim countries”; and the facile characterization of immigrants as criminals and/or terrorists. They note the negative consequences of these attitudes on the human dignity, security, self-esteem, and overall stress among all categories of immigrants, not just refugees and asylum seekers. The negative implications for the mental health and cultural integration of all immigrants are clear. The various authors of this book lament the attendant rise of hate speech, of bigotry, and of overt racial, ethnic, and religious discrimination in American society. Such changes undermine the idealism and humanitarian instincts of all those who want to provide care and treatment of immigrants and are dedicated to the humanitarian ideals of cultural diversity, integration, and tolerance.

Ronald Wintrob, M.D.

I walked along a serene, rocky Greek beach after a day spent in the refugee camps meeting survivors and learning about the arduous road they traveled. The deep blue Aegean Sea quelled the blazing sun. Many of the refugees had been subjected to human rights violations. The trauma had clearly affected their minds. As a trauma psychiatrist, my role for those in the camp was to describe the mental health outcomes of their traumas. The refugee camp was filled with persons who had come from different situations, spoke different languages, and had different cultures. There are many common mental outcomes of trauma, similar despite the diversity.

I walked along the beach to clear my mind.

The islands of Greece have become a repository for waves of refugees seeking sanctuary from war, torture, and persecution from Syria, Afghanistan, and Iran. They have endured more trauma than many can imagine. In the camps in the European Union, their hopes and their dreams for a future of freedom are on hold.

Medical science has amassed a great body of knowledge in regard to trauma’s effect on mental health. There is an updated brain science of trauma, genetic science of trauma, clinical science of trauma, and population science of trauma. Psychiatrists have an art of how to contribute to the solutions for these effects. Clinical wisdom has led to an evidence base for the proactive field of trauma psychiatry. Psychiatric Evaluation and Treatment of Refugees is a cutting-edge volume of contributions that help mental health professionals better understand the outcomes and the solutions for the complicated mix of trauma and immigration with culture and worldview. Written by experts in cross-cultural psychiatry, the book holds a balance between the up-to-date science and the collective experiential wisdom of the Intercultural Psychiatric Program at the Oregon Health & Science University (OHSU). The authors have become key references for psychiatrists working in cross-cultural trauma for decades.

The authors’ ideas are foundational to how I approach cross-cultural trauma psychiatry. Their science has been in my head throughout the moments I have been in contact with Greek camps.

When one has seen enough detention centers, refugee camps, and holding areas crammed with people, these camps begin to look the same. They are unimpressive. The people’s destitute predicament draws compassion. The most remarkable aspect is always the humanity that the survivors bring to refugee camps. They adapt and personalize the deplorable conditions. They create humanity in places that otherwise would have none. But so often the traumatic experiences have taken a toll on their mental health and intervention is needed.

Their psychology is affected. They suffer. And they remember suffering. The memory of suffering is their past and their present.

If we think only in terms of diagnostic naming or in terms of statistics, the survivors become faceless numbers behind fences and barbed wire. Consideration of the science of trauma psychology in the context of real humanity is necessary to be effective in creating positive change. The editors and authors of this volume have contributed to our understanding of the blend of necessary science/evidence with compassion that gives mental health providers insight as to how to understand and treat. How else do we propose to treat without a science? How could we move forward without an evidence base? How would we practice without a guideline to the human art? This book suggests answers to these practical questions during a time when immigration is a global health concern and refugee populations are mounting. Traumatization among refugees is not a local concern; it is among the most challenging global health situations in modern times.

I continued walking along the beach. It was hot. I could not get my head straight for all the stories of flight spinning in my imagination. The sea was beautiful to look at but difficult to think about, as it is the carrier of refugee traffic by raft. And it swallows the same victims without any conscience. Yesterday’s local newspaper told the story of a woman who drowned during her family’s crossing—leaving an infant and a toddler motherless. Who will help her orphaned children? I kept walking along the beach. I could see the mainland on the horizon. The persecution happens there, and the camps are here. Between persecution and freedom is the sea—filled sometimes with hope, sometimes with despair, and often with death.

As Warsan Shire, a survivor/advocate, writes in her poem “Home,”

Imagine the state of a family’s destitution when they have come to the point where “water is safer than the land.” And they must engage danger and place their children in danger in order to escape. The land was their home. Now it has become unsafe. “No one leaves home until home is a sweaty voice in your ear / saying— /leave, / run away from me now / i dont know what I’ve become.”

I looked down at the smoothed stones that clacked together in the delicate waves. One stone was so white against the others that it insisted closer inspection. But as I examined closer, I realized that it was no stone at all. It was the polished head of a human arm bone. No mistake. Smoothed by the sea, this one fragment had been polished for a long time. The bone presumably belonged to a person who must have made the long journey and endured much, only to end in tragedy.

For the victims there is death. For the survivors there is hope. But their psychology will be forever affected.

I am grateful for the academic contributions of Drs. David Kinzie and George Keepers, and their colleagues at the OHSU. I have, for decades, been the beneficiary of their clarification of this knowledge. Their scientific additions have aided and shaped the understanding of trauma psychology in refugees and immigrants. And, their compassionate approach to patient care has created clinical wisdom that all in the field can benefit from. I am honored to call them colleagues. This book, The Psychiatric Evaluation and Treatment of Refugees, is a necessary tool for the understanding of human trauma psychology and a guide for the well-being of the survivors. This volume appears during a time when guidance toward the psychological and physical recovery of traumatized refugees is essential. This book is a key to unlock the hope of the persons who have crossed the sea. And it is the key to ensure that the refugees have found land that is safer than water.

Daryn Reicherter, M.D.