Magazine article Forced Migration Review

Psychiatric Treatment with People Displaced in or from Fragile States

Magazine article Forced Migration Review

Psychiatric Treatment with People Displaced in or from Fragile States

Article excerpt

A fragile state is not an ideal environment for any professional to work within - psychiatric, medical or otherwise. Psychiatrists working to assess psychological distress and mental health in fragile states, or with refugees from fragile states, need to adopt flexible approaches.

The instability and uncertainty usually found in fragile states create a breeding ground for psychological problems and mental health issues, as well as risk of physical harm. Individuals that live in such environments are more likely to experience trauma on a scale not otherwise known by the rest of the world. When deciding how best to adjust practice and treatment when working with those from fragile states, the psychiatric community must be able to examine many aspects of the environment surrounding that particular social group.

The circumstances under which the psychiatrist is operating may well dictate what work can be delivered. Teams of researchers and psychiatrists often descend to determine the levels of psychological distress and look at mental health issues and can be faced with a range of restrictions including general health treatment limitations, inability to adopt a multidisciplinary approach and reduced access to psychotropic medication and other drugs. Traditional methodologies therefore need to be adjusted in this environment, first of all by taking into consideration which treatment plans can realistically be considered.

Within refugee camps or safety zones with basic living conditions and little apparent governance or control, violence can occur without warning, services may be attacked or cut off from outside assistance, political and economic disruption may occur and governmental policy could change at any time. Although short-term and intensive cognitive behavioural therapy sessions - usually used once the immediate distress of the patient has been alleviated - have been successful within Western and refugee populations, it is unknown whether the same success rates can be repeated elsewhere. In spite of this, short-term interventions may be the best way forward as they will empower the individual and give them tools to help themselves if psychiatrists are no longer present.

Many attempts have been made to design psychiatric assessment questionnaires and scales that are sensitive to different cultures and that include colloquial terminology and phrasing. Unfortunately, when a team is dispatched in an emergency situation, the likelihood of obtaining an already validated set of assessment tools is low. This is a considerable barrier for psychiatric professionals to overcome. Bringing an additional person into the assessment or treatment stages to act as translator may cause confidentiality issues but alternative options are limited. The use of local bilingual professionals and volunteers may help psychiatrists assess which diagnostic tools will be efficient, and they may even be involved in the treatment process.

Every psychiatrist must be able to provide care that is free from discrimination of any kind; the psychiatric community may, however, hold preconceptions about certain social groups. It has been noted, for example, that the role of women during times of conflict has been described almost exclusively in relation to victim status. Although women are at a higher risk of being the targets of persecution and acts of violence, the psychiatrist could be at risk of viewing all female patients as victims, and not, as was the case during the 1994 Rwandan genocide for example, as perpetrators, instigators or bystanders.

Cultural interpretation and understanding

Psychiatrists may not be able to view such vulnerable groups outside their own, traditional and often Western points of view. The structure of family units, gender roles and class systems differ with every culture, and are also more likely to be going through a state of flux within fragile states. All these factors may lead psychiatrists to misinterpret symptoms or make incorrect assumptions regarding their causes. …

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