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

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.

Another contrasting message is being sent by those professionals who argue that it is wrong, and perhaps harmful, to take a crime and make it into a disorder. They say, do not engage in the "privatization" of the "public" by putting the emphasis upon individual diagnosis. Instead, focus on the fact that refugees are victims of gross violations of human rights and work towards social justice.

There is truth in both perspectives, but what neither sufficiently acknowledges is the place of the family in the lives of refugees. Just because refugee families have a victimized or vulnerable member does not mean that they stopped thinking and working together as a family. Because survival and suffering are not regarded in the context of families, though, we do not have sufficient answers to help refugee families gain access to services, prevent the need for services, or have services address their other central concerns. Refugee parents, for example, tell us that what concerns them most of all is helping their children to grow and learn. This is not at all surprising, but why don't America's helping efforts reflect it?

The trauma perspective in American mental health has tended to look away from interventions that focus on helping strengthen families. This is understandable, given that trauma in the American context often implicates family. Many trauma mental health professionals are far more used to thinking of family as the source of traumas--as in childhood incest or abuse, or domestic violence. Some object to a family approach because, they think that, if we support families, we are maintaining conditions that work against girls and women. It can be extraordinarily difficult to reconcile our own views of family with those of another culture, especially concerning gender issues. These concerns regarding how families can do harm must be addressed, but they are insufficient reasons to justify not helping families through focusing on their strengths.

There are several compelling scholarly critiques of mental health, such as those by philosopher Ian Hacking and anthropologist Allen Young, but they focus on what is wrong with PTSD and do not really get at the issue of family. Someone who does call for greater reliance upon families is conservative psychiatrist Sally Satel, who berates psychiatry for creating a nation of victims for its "grief industry." However, her pro-family position seems more an expression of political ideology than a clear commitment to a new path for professional helping efforts for refugees or other trauma survivors.

What is needed more than political ideology is to build a family-centered approach to refugee mental health. That means promoting a theoretical understanding of families and their strengths and needs in the context of actual realities. It must include developing interventions aimed at family support, education, and prevention. Also needed is good family-focused science in refugee mental health, especially science that will help to develop new services and advocate for new policies.

Looking through a family lens

Sometimes you find extraordinary families who have engaged with providers and made those systems work for them. They know what kind of help their family needs and are good at seeking it out. There are also many providers in refugee services who intuitively know how to connect with families. They take the time to speak with family members and are committed to thinking at the level of the family and how best to support families. Each can make wonders happen for refugee families and their members.

The shortcoming is that this is a matter of individuals in systems that are basically oriented in directions other than family. This happens when helpers don't sit and share with family members, and, just as important, seem not to believe that the family and its strengths are important as a value or a methodology in their work. Yet, our experience and research tells us that, among refugees, there is a large proportion of families where there is substantial suffering and needs. Again and again, these families tell us that they have neither the "information" nor the "trust" about how to engage with services that could be of benefit to their family.

The result is that many do not ever access services and that services do not learn how to be oriented better towards family needs and strengths. This must be a concern not only for professionals, but those moved enough by the images and stories to believe that we have an obligation to provide effective services for refugees.

There are some current examples of innovative services that show what can be done when we look through a family lens. One is happening in Chicago, where collaborations between families and professionals from Bosnia-Herzegovina, Kosovo, and the U.S. led to organizing the groups for Bosnian families that are called CAFES--Coffee and Family Education and Support--and also TAFES with Kosovars, because what they drink is tea. These are multifamily groups in community settings that are run by refugees and focused on providing support and education. The National Institute of Mental Health is funding our group at the University of Illinois at Chicago to study the effectiveness of these interventions and take steps towards the development of other family-focused interventions for refugees.

Another innovation is happening in Prishtina, where Kosovar psychiatric leader Fetid Agani and his colleagues recognized that to build a mental health system for Kosovo, they must draw upon the roles and values embodied in the traditional Kosovar extended family. So, they engaged in a collaboration with family-focused mental health professionals from America to form the Kosovar Family Professional Education Collaborative. This is enabling them to bring a family focus into all dimensions of their professional work, including direct service to families in clinical and preventive services, health and mental health services, and the design and implementation of a new mental health system of care.

What has made both of these innovations possible is a commitment to the core value of family and to collaborative dialogue and interaction concerning cultural issues that are part and parcel of globalization. The latter is important because it often seems that the trauma mental health profession finds itself in the throes of a globalization it neither recognizes nor understands. When engaging internationally, especially with peoples of the underdeveloped world, its efforts are at risk of being undermined by some of the more problematic aspects of this globalization.

Rather than focusing primarily on diagnosing and treating individuals with disorders, we must learn to start from their own perspective on what their needs and resources are. What we have found is that this means putting the family and its strengths first. Furthermore, we believe that this kind of family-focused approach has the potential for helping the field of refugee mental health to respond better to the mental health and public health challenge for the 21st century.

One starting point is to reflect on the pictures and words concerning refugees that have moved people the most. Many American have seen Gilles Peress' photographic exhibit, "Farewell to Bosnia," which is an extraordinary testimonial document of the human drama of ethnic cleansing and siege that played out in Bosnia-Herzegovina in the late 20th century. Peress, reflecting on one image of hands pressed on a bus window to try to make contact with a parting loved one, identifies the family as central: "One of the things that always moves me the most is when I arrive on a scene and I see those family albums lying on the floor. And there's always a picture of a child from a better time. And you really wonder what's happened to that family, to that child.... And the reality is that it's families like your family, my family, that are being totally affected."

I, too, find that the images and stories that get to me so often involve families being tom or broken. Yet, even amidst the anguish of family separations and losses in a historical nightmare, still alive is a sense of the centrality and goodness of the family. That is what we must endeavor to nurture and build upon in our helping efforts.

If you were to sit with some of those refugee families, listening to their voices would make you further realize that this is not yet another thing for America to do for the poor refugees of the world. Rather, concerning refugees, family is the real deal, and we should be making family-focused approaches our main way of helping.

Stevan M. Weine, associate professor of psychiatry, University of Illinois at Chicago, is co-director of the university's Project on Genocide, Psychiatry, and Witnessing, and author of When History Is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina.
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Author:Weine, Stevan M.
Publication:USA Today (Magazine)
Geographic Code:1USA
Date:Jan 1, 2002
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