Using quantitative measures Turner et al (2003) found that about half of a sample of 842 Kosovan refugees in the UK had post-traumatic stress disorder, with substantial comorbid depressive disorder and anxiety disorder. But there is more to be reported. I was involved in having a few open-ended questions tacked on to the study, tapping subjects’ own views of their health/mental health and what they saw as their most urgent priorities for recovery. Only a tiny number saw themselves as having a mental health problem of any kind, bearing out observations by refugee workers in the reception centres housing them that there was no interest in counselling. Almost everyone nominated work, schooling and family reunion as their major concerns. This chimes with what I and others have found in clinical settings with refugees over many years. Significant psychopathology is uncommon (Summerfield, 2002).
The responses to the open-ended questions paint a picture that is a world away from that reported by Turner and colleagues; how is this contradiction to be explained? First, the question of validity. Translation/back-translation of psychiatric inventories originating in the USA and Western Europe does not by itself overcome the category fallacy to which Kleinman (1987) pointed: particular phenomena may be identified in different settings but it does not follow that they mean the same thing in each setting. Moreover, refugees in distressed and insecure circumstances may be particularly susceptible to the demand characteristics of questionnaires. Second, and fundamentally, how human beings experience an adverse event, and what they say and do about it, is primarily a function of the social meanings and understandings attached to it. No psychiatric category captures this active appraisal and meaning-making.
Quantitative methodologies serving psychiatric categorisations risk a distorting pathologisation of refugee distress, with what is social and collective being reassigned as individual and biological (Summerfield, 1999). Turner et al caution against ‘the tendency of some to reject the diagnostic paradigm in refugee populations’, but they do not make a persuasive case here that they know better than the Kosovan refugees themselves, and that many of the refugees really do need psychiatric treatment. There is simply no good evidence to back their conclusion that refugee populations anywhere are carrying a major burden of clinically significant mental ill health. As the answers to my questions demonstrated, refugees see recovery as primarily something that must happen in their social worlds, not in the space between their ears.
- © 2003 Royal College of Psychiatrists
Newly arrived refugees will often see their problems initially in terms of past experience (e.g. war-violence or torture) rather than emotional impact. They share a need for security and safety. However, it would be illogical to conclude that they are thereby free of psychopathology. It is not a case of either one state or the other. Factors operating in different domains frequently interact. This is the situation here.
Interestingly, as many as 11.1% of 522 subjects responded that they had a mental health problem and that they now wanted help (i.e. ‘ Western’ treatment). We would expect help-seeking to increase in those with persisting symptoms, in line with experience in treatment services after any major incident.
To assert that significant psychopathology is ‘uncommon’ is wrong. It implies that civil war, rape and torture do not have important psychopathological consequences in significant numbers of people. This flies in the face of the evidence. It is reminiscent of the problems that Eitinger and others had when trying to justify reparation for some concentration camp survivors on the basis of psychological injury. Surely we have moved on since then.
In this instance, we do not assert psychopathology on the basis of self-report measures. This would have been an overestimate as we demonstrated in our report. An Albanian-speaking doctor undertook semi-structured clinical interviews (in Albanian).
Summerfield refers to additional data in our survey. We wish to present a factual analysis of these. We asked an open question about respondents’ main concerns. The responses to this question are in the respondents’ own words but if anxiety, tension, nervousness, stress or trembling are grouped together as likely anxiety symptoms, these were in fact the most frequent of the first priority problems and overall were reported by 21% (of 509 respondents). Sleep disturbance was reported by 16%, depression, hopelessness, sadness, mental problems and (poor) concentration by 8%. Many reported additional somatic complaints or general health problems, probably including a significant additional burden of psychological difficulty. Surprisingly, worries about family and friends were reported by only 17%. Concerns about work/economy (6%) and school/language (3%) were infrequent.
Rather than contradict the responses to the more structured questions, answers to these open questions reinforce our more quantitative findings.