Primary Prevention of Acculturative Stress among Refugees: Application of Psychological Theory and Practice.

By: Carolyn L. Williams
Division of Epidemiology, University of Minnesota;
J. W. Berry
Queen's University at Kingston, Kingston, Ontario, Canada

Acknowledgement:

International migration in the 20th century has been distinguished by refugee movements (Rose, 1984). Refugees are a subset of immigrants who flee their homes because of fear of persecution for their beliefs, politics, or ethnicity. If given the choice, most refugees would prefer to stay in their countries and not seek shelter in strange foreign lands, where they can be isolated, ostracized, and impoverished. Despite diverse cultural, ethnic, and historical backgrounds of today's refugees, Stein (1986) indicated that refugees should be considered a distinct “social psychological type whose behavior is socially patterned” (p. 5). Social and behavioral scientists document commonalities underlying refugee behavior across diverse groups (e.g., Berry, in press; Boehnlein, 1987; Owan et al., 1985; Stein, 1981; Westermeyer, 1989; Westermeyer, Williams, & Nguyen, in press; Williams, 1987; Williams & Westermeyer, 1986).

Many of the characteristics of the refugee experience and behavior are directly related to psychological theory, research, and practice. Given the typical experiences of refugees before, during, and after flight from their homes, many are highly stressed and traumatized (Ben-Porath, in press). It is not unreasonable to hypothesize that these tremendous stressors account for, in part, the elevated symptoms and mental disorders frequently observed in refugee populations (e.g., Boehnlein, 1987; Garcia-Peltoneimi, in press-a, in press-b; Lin, 1986; Westermeyer, 1986, 1989). This article blends information from clinical, health, and cross-cultural psychology to focus on primary prevention of mental disorders, with the goal of stimulating others to consider the special needs of refugees adapting to resettlement in the United States, Canada, and other Western countries.

Primary prevention has its roots in public health, which adopts a communitywide perspective for addressing health concerns. A public health approach differs from the clinical-psychology/medicine emphasis on one-on-one curative care, its hallmark being community action (Turshen, 1989). Public health's closest counterpart for the mental disorders is the community mental health movement. Goldston (1986a) traced recent interest in prevention to the mid 1970s, with the release of two government reports, one from Canada and the other from the United States. Both reports reached similar conclusions about the importance of prevention for health planning in the two nations (Lalonde, 1975; U.S. Department of Health, Education, and Welfare, 1974).

Given research suggestive of higher rates of symptoms and mental disorders in refugees, compared with the general population, refugees should be considered an at-risk population suitable for public health interventions. However, with little public health planning, the mental health needs of refugees have been neglected (Boehnlein, 1987; Westermeyer, 1987; Williams, 1989, 1991, in press). Boehnlein (1987) suggested that the lack of planning and foresight on the part of the U.S. government, particularly at the federal level, is a major contributor to the problem, although mental health professionals also contribute to this neglect. Part of the difficulties stems from the definitional problems that plague the general field of primary prevention of mental disorders. Another contributing factor is that some psychologists have been hesitant to work with such culturally different populations as those represented by the recent refugee groups to the United States and Canada. In the remainder of this article, we will address some of these definitional problems, present models that can be used for developing primary prevention programs for refugees, and describe several definitions of stress and acculturative stress, providing a model of acculturative stress that also can be used to develop prevention programs. Application of these genral principles will be illustrated with case examples at the three levels at which prevention programming for refugees can be implemented (i.e., the local community level, the national level, and the international level). We will conclude with suggestions about how psychology can respond to the mental health needs of this underserved population.

Definitions and Models of Prevention

We indicated earlier the need for developing prevention programs for refugees using a systematic approach (Williams, 1989, 1991, in press). Others (e.g., Owan, 1985) also recognized the importance of primary prevention as a meaningful mental health alternative for refugees, and recommended that the following three structural requirements for primary prevention—first proposed by Cowen (1982)—be used in developing primary prevention programs for refugees:

1. A primary prevention program must be group or population based, rather than individually focused as in traditional clinical interventions.
2. Groups or populations that are not maladaptive or disordered are targeted for primary prevention. Groups at risk for disorders are especially appropriate.
3. Primary prevention programs must be developed from previous research or theory about improving psychological health or preventing maladaptation.

By adopting Cowen's (1982) structural requirements for prevention programming for refugees, we are limiting this discussion to primary prevention. This distinction merits further attention because it is quite common for mental health practitioners to refer to secondary and tertiary prevention. These terms, however, represent the relabeling of treatment services as prevention, which trivializes the concept of prevention (Goldston, 1986b). We refer our colleagues who are interested in more traditional mental health services for refugees to the article that follows (Gong-Guy, Cravens, & Patterson, 1991).

Bloom's (1982) stressful life-events model is another helpful approach for conceptualizing primary prevention that is relevant for refugee mental health. The following three components are a part of Bloom's model:

1. Select a stressful life event(s) appearing to have undesirable consequences associated with it (them). Develop reliable identification procedures to determine who has experienced this (these) event(s).
2. Using research methods including epidemiology, study the outcomes of these events in order to develop hypotheses about how to reduce or eliminate their negative outcomes.
3. Develop and evaluate experimental prevention interventions based upon your hypotheses.

The first two components of Bloom's (1982) model have already been applied to refugee mental health (Williams, 1989, 1991, in press). The stressful life events surrounding refugee movements are well documented in the literature (e.g., Williams, 1987), and clear definitions exist about who is a refugee. Furthermore, as we will see in the next section, research on the refugee experience, acculturation, and stress provide hypotheses on which to develop primary prevention interventions for refugees. It is the third area, implementation and evaluation, in which further work is needed (Williams, 1989, 1991, in press).

Definitions and Model of Acculturation and Adaptation
Definitions

The concept of acculturation is now widely used to refer to the changes that groups and individuals undergo when they come into contact with another culture. Group-level acculturation entails a variety of changes, such as economic, technological, social, cultural, and political transformations (Redfield, Linton, & Herskovits, 1936). Individual-level acculturation (called “psychological acculturation” by Graves, 1967) entails changes in behavior, values and attitudes, and identity. Cross-cultural psychologists are now working at both levels, so that the general acculturative situation experienced by the individual, and the various personal outcomes, can be understood as part of a larger psychocultural system (Berry, 1989). Separate concepts and measures are usually required when working at the two levels, in part because they are different phenomena, rooted in different disciplines (anthropology and psychology), and in part because there is much current interest in studying individual differences in acculturative outcomes, and linking them to features of the general acculturative situation (Berry, Trimble, & Olmeda, 1986).

Three points require emphasis in this preliminary examination of acculturation. One is that the study of acculturation phenomena requires the adoption of a cross-cultural perspective, including understanding and accepting the culture of the acculturating group on its own terms (rather than treating it as a “minority” group). A second is the need to recognize that many of the acculturation phenomena arise as a result of the interaction between the two groups in contact (rather than residing solely in the acculturating group). The third is that, as psychologists, we need to be aware that not every individual enters into, deals with, or reacts to the acculturative situation in the same way; we must expect wide individual differences in psychological acculturative outcomes in terms of variation in acculturative experiences.

Within this general acculturation perspective, the notion of acculturative stress has been proposed (see Berry, Kim, Minde, & Mok, 1987) to account for the variable mental health outcomes that have been observed among refugees. This notion is rooted in the contemporary literature on stress, particularly as developed by Lazarus and Folkman (1984); it is an alternative to the more popular notion of culture shock (Furnham & Bochner, 1986), but encompassing the same general phenomena of psychological turmoil and maladaptive behavior.

Acculturative Stress

One of the most obvious and frequently reported consequences of acculturation is societal disintegration, which can result in personal crisis. The old social order and cultural norms often disappear, and individuals may be disturbed by the change. At the group level, previous patterns of authority, civility, and welfare no longer operate, and at the individual level, hostility, uncertainty, identity confusion, and depression may set in. Taken together, these changes constitute the negative side of acculturation, which is frequently, but not inevitably, present. The opposite, that of successful adaptation, may also take place. The outcome appears to vary as a function of a complex set of cultural and psychological variables, in which personal and situational factors interact to produce a particular level of adaptation.

The concept of acculturative stress refers to one kind of stress, that in which the stressors are identified as having their source in the process of acculturation, often resulting in a particular set of stress behaviors that include anxiety, depression, feelings of marginality and alienation, heightened psychosomatic symptoms, and identity confusion. Acculturative stress is thus a phenomenon that may underlie a reduction in the health status of individuals (including physical, psychological, and social health).

Model of Acculturative Stress

In a review and integration of the literature, Berry and Kim (1988) attempted to identify the cultural and psychological factors that govern the relationship between acculturation and mental health. They concluded that although mental health problems often do arise during acculturation, these problems are not inevitable. That is, acculturation may enhance one's life chances and mental health or virtually destroy one's ability to carry on, depending on a variety of group and individual characteristics that enter into the acculturation process.

This conception is illustrated in Figure 1. On the left of the figure, acculturation occurs in a particular situation, and individuals participate in and experience these changes to varying degrees. In the middle, stressors may result from this varying experience of acculturation; for some people, acculturative changes may all be in the form of negative stressors, whereas for others, they may be benign or even serve as opportunities. On the right, varying levels of acculturative stress may become manifest as a result of acculturation experience and stressors. Individual differences in each of these three phenomena are indicated by the vertical arrows within each of the components.

The first crucial point to note is that relationships among these three concepts (indicated by the solid horizontal arrows) are probabilistic, rather than deterministic; the relationships all depend upon a number of moderating factors (indicated in the lower box), including the mode and phase of acculturation, the nature of the larger society, the type of acculturating group, and a number of demographic, social, and psychological characteristics of the group and individual members. In particular, one's appraisal of the acculturation experience and one's coping skills in dealing with the stressors can affect the level of acculturative stress experienced. That is, each of these factors can influence the degree and direction of the relationships between the three variables at the top of Figure 1. This influence is indicated by the broken vertical arrows between this set of moderating factors and the horizontal arrows.

Factors Affecting Acculturative Stress

Results of studies of acculturative stress have varied widely in the level of difficulties found among members of acculturating groups. Early views were that acculturation inevitably led to stress; however, current views are that stress is linked to acculturation in a probabilistic way, and the level of stress experienced will depend on the factors noted in Figure 1. One important factor is mode of acculturation (Berry, 1984): Those who feel marginalized tend to be highly stressed, and those who seek to remain separate are also highly stressed; in contrast, those who pursue integration are minimally stressed, and assimilation leads to intermediate levels of stress (Berry et al., 1987).

The phase of acculturation is also a factor. In many studies (reviewed by Berry, 1985) there have been attempts to link levels of acculturative stress to a particular phase of acculturation (using an inverted U function). Evidence to support such a simple relationship with length of acculturation is slight, probably because acculturative stress is also influenced by so many other factors. Although those in first contact and those who have achieved some stable adaptation tend to be minimally stressed, those in the intermediate phases may or may not exhibit stress, depending on the numerous other factors outlined in Figure 1.

Another factor is the way in which the larger society exerts its acculturative infleunces. One important distinction is the degree of pluralism extant (Murphy, 1965). Culturally plural soceities, in contrast to culturally monistic ones, are likely to be characterized by two important factors: One is the availability of a network of social and cultural groups that may provide support for those entering into the experience of acculturation (i.e., provide a protective cocoon), and the other is a greater tolerance for or acceptance of cultural diversity (called “multicultural ideology” by Berry, Kalin, & Taylor, 1977). One might reasonably expect the stress of persons experiencing acculturation in plural soceities to be less than those in assimilationist societies who pursue a policy of forced inclusion. A related factor, paradoxically, is the existence of policies that are designed to exclude acculturating groups from full participation in the larger society; to the extent that acculturating people wish to participate in the desirable features of the larger society (such as adequate housing, medical care, political rights), the denial of these (by a policy of segregation) may be cause for increased levels of acculturative stress.

There are also many social and cultural qualities of the acculturating groups that may affect the degree to which acculturative stress is experienced. The list of possible factors identified in the literature (Berry & Kim, 1988) is extremely long; thus, we attempt here only a selective overview. Socioeconomic status is a factor. One's entry status into the larger society is often lower than one's departure status from the home society. This relative loss of status may result in stress. In addition, some specific features of status, such as education and employment, provide one with resources to deal with the larger society, and these likely affect one's ability to function effectively in new circumstances.

Perhaps the most comprehensive variable in the literature is that of social support; this refers to the presence of social and cultural institutions for the support of the acculturating individual. Included here are such factors as ethnic associations (national or local), residential ethnic enclaves, extended families, availability of one's original group, and more formal institutions such as agencies and clinics devoted to providing support.

A final set of social variables refers to the acceptance or prestige of one's group in the acculturation setting. Some groups are more acceptable on grounds of ethnicity, race, or religion than others; those less acceptable run into barriers (prejudice, discrimination, exclusion) that may lead to marginalization of the group and greater stress. The point is that even in plural societies (those societies that may be generally more tolerant of differences), there are still relative degrees of social acceptability of the various acculturating groups.

Beyond these social factors, numerous psychological variables may play a role in the mental health of persons experiencing acculturation. Here a distinction is useful between those characteristics that were present prior to contact and those that developed during acculturation. Precontact variables include certain experiences that may predispose one to function more or less effectively under acculturative pressures. These include prior knowledge of the new language and culture, prior intercultural encounters of any kind, motives for the contact (voluntary vs. involuntary contact), and attitudes toward acculturation (positive or negative). Other prior attributes that have been suggested in the literature are one's level of education and employment, values, and self-esteem.

Contact experiences may also account for variations in acculturative stress. Whether one has a lot of contacts with the larger society (or few of them); whether they are pleasant (or unpleasant); whether they meet the current needs of the individual (or not); and in particular, whether the first encounters are viewed positively (or not) may set the stage for all subsequent ones, and ultimately affect mental health. A recurring finding is that the congruity between contact expectations and actualities will affect mental health. Individuals for whom there is a discrepancy—so that they aspire to or expect more than they actually obtain during acculturation—usually have greater acculturative stress than those who achieve some reasonable match between them.

A key psychological variable in dealing with acculturative stressors is that of coping (Taft, 1977). Not all individuals deal with these pressures in the same way, leading to highly variable stress outcomes. When confronted by two cultures, individuals develop attitudes and coping strategies that lead to varying personal adaptations. Another variable is the appraisal that one makes of the acculturation experience. The sense of cognitive control that an individual has over the acculturation process also seems to play a role; those who perceive the changes as opportunities that they can manage may have better mental health than those who feel overwhelmed by them. In essence, then, the attitudinal and cognitive perspectives espoused here suggest that it is not the acculturative changes themselves that are important, but how one sees them and what one makes of them.

An important lesson to take from this research is that although refugees are at risk from numerous factors, many of these factors can be controlled or their impact moderated. This fact provides a point of entry for those involved in prevention work, illustrated in the next section.

Case Illustrations of Primary Prevention at Three Levels

Prevention programs can be implemented at three broad levels: local community, national, or international. Each of these levels has its own distinctive features. Most mental health professionals have limited training or experience working at the broader national and international levels, although actions at these levels have direct mental health consequences that can eventually come to the attention of mental health professionals (e.g., Garcia-Peltoniemi, Jaranson, & Teter, 1989; Punamaki, 1989; Westermeyer, 1987).

War, torture, political repression, human rights violations, and other experiences closely associated with refugee flight typically are out of the realm of study of psychologists and mental health professionals. However, the few behavioral scientists who conduct research in these areas document the relevance of these horrific events to human behavior. Lifton (1986), studying Nazi doctors' participation in the Holocaust, concluded that these doctors were not demons, but ordinary human beings, and this fact justified his study of their behavior. Findings such as Lifton's support our contention that trauma-producing events like concentration camp experiences and torture are the result of human action, and in principle, can be subject to human counteraction or prevention (Berry, in press).

Work at the national and international levels brings special challenges to psychologists and other mental health professionals, and goes beyond the provision of traditional mental health services. Professionals frequently become one of many voices, often with conflicting and competing messages. It can be frustrating becasue not all experts bring uniform recommendations, and the political needs of governments and other large entities often assume greater importance than the mental health, or even basic survival, needs of the refugees (e.g., Reynell, 1989). Given all of this, implementation of recommendations and actions at these levels can be quite slow.

When working at the local community level, it may be more difficult to ignore secondary and tertiary needs of those refugees already exhibiting mental disorders. For example, it can be harder for psychologists at the local level to devote time to broader community-level problems, rather than arranging services for an individual suicidal patient. On the positive side, although prevention requires an interdisciplinary approach at all three levels, local-level prevention efforts are more likely to be confined among the mental health, social services, and health disciplines, where there are more likely to be already established working relationships and understanding of the other professionals' discipline and point of view. Finally, more immediate action or implementation of ideas is possible in local communities, perhaps because of the fewer players and less complexity involved, as compared with national or international arenas. In the remainder of this section, we will provide case illustrations of primary prevention efforts at the three levels.

Prevention at the Community Level

Primary prevention for traumatized Khmer children

Duncan and Kang (1985) developed a mental health promotion program to facilitate the resettlement of Khmer refugee children served by the Catholic Community Services of Tacoma, Washington. These children survived the Pol Pot atrocities in Cambodia, often were forcibly separated from family and friends, and arrived unaccompanied in Tacoma. Duncan and Kang's (1985) program development followed Bloom's (1982) stressful life-events model and was developed for all the children being resettled by this agency, regardless of their current psychiatric status (Williams, 1991). Duncan and Kang developed a series of hypotheses centering on the massive trauma and loss experienced by the Khmer unaccompanied minors. Their losses included separation from family members under circumstances that did not allow for resolution of grief and loss. Duncan and Kang also recognized the tremendous acculturative stress these young people were likely to experience given their migration to Tacoma. The behaviors of the children on arrival supported Duncan and Kang's hypotheses: All reported sleep disturbances, frequently characterized by dreams or nightmares of lost family members, and many reported disturbing visits of spirits, including parents and grandparents.

The main components of Duncan and Kang's (1985) primary prevention program included three Theravada Buddhist ceremonies and rituals honoring the children's dead family (Ban Skol—a memorial for absent family members; Pratchun Ban—an annual family reunion of living and deceased relatives held yearly in Tacoma; and religious observances for absent family members held during the annual Khmer New Year's celebration), as well as consultation with Khmer Buddhist spiritual leaders. Also included in the program were foster placements in ethnically similar homes, suggested as optimal in circumstances like these (Ressler, Boothby, & Steinbock, 1988).

The Ban Skol ceremony, representative of all three practices, was a joint effort of the child's foster parents and the Catholic Community Services staff. It was performed in the child's foster home, preferably within a few months of the child's arrival in the United States (Duncan & Kang, 1985; Williams, 1991). Special food, prepared by the foster family, was offered to the monks in attendance and also provided a festive meal for the family, guests, and agency staff in attendance. A list of the family members, prepared in advance by the child, was burned and its ashes slowly doused with water in a ceremony symbolic of cremation. This was particularly meaningful for those children who witnessed family members' bodies left to rot in mass graves or who were fearful of such a fate for their loved ones.

The unaccompanied refugee minor was the central figure in the Ban Skol ceremony. Rituals like these have been hypothesized to serve protective functions (e.g., Dubreuil & Wittkower, 1976) in times of loss and grief. Through the process of this ceremony, the child was able to begin seeing the foster family, their friends, and the agency's caseworkers as sources of support. These preventive interventions reinforced the integration mode of acculturation by retaining important Buddhist values and traditions within a Catholic resettlement agency's program.

Duncan and Kang (1985) provided anecdotal reports from 47 Khmer children who participated in this program. During the Ban Skol ceremony, many of the children withdrew or were overcome with grief. They were consoled by the foster family and guests, and eventually participated in the festivities that usually occurred during the meal. There were some reports after the ceremony of grief resolution, decreased sleep disturbances and spirit visits, and increased bonding with the foster family. However, as Duncan and Kang indicated, much more systematic evaluation, including follow-up, is needed.

It is only with evaluation that Duncan and Kang's (1985) program can meet all of the structural requirements of primary prevention. Evaluation is critical to eliminate potential iatrogenic effects of this and other potential preventive interventions (Williams, 1989, in press). It is particularly important when interventions deal with such highly traumatic and emotionally charged experiences. As Levine and Perkins (1987) indicated, the potential harmful effects of psychological interventions have long been recognized in psychotherapy outcome studies, and they are of even greater ethical concern in primary prevention, with its focus on healthy individuals who may or may not be aware of the preventive intervention.

Attitude change and prejudice reduction in the schools

Because one of the identified risk factors resides in the negative attitudes held by the dominant group toward acculturating groups, an important strategy is to prevent the development of such attitudes, or reduce them once they are developed. Much of the focus has been on children (e.g., Aboud, 1988), and there are numerous examples of successful attitude change programs during the primary school years. For example, Ijaz (1984) used a multidimensional approach to changing children's attitudes toward people with origins in India. It was hypothesized that by emphasizing similarities, a reduction in contrast effects and stereotypical views can be achieved; by teaching children to take the perspective and role of the other, a reduction in antipathy is likely; and by providing cultural information, a decrease in ignorance of the other group will result. These three elements were built into an instructional program for primary school students in Toronto, and were conveyed by a dancer/teacher from India. Students participated in these activities and were encouraged to literally step into the shoes of a child from India and to sense and express their feelings and thoughts. Using a pretest–posttest design, significant changes in attitudes were found immediately after, and again three months after, the completion of the program. Such a school-based demonstration of attitude change is encouraging for those who seek to prevent psychological problems from arising for acculturating groups and individuals that result from their experience of negative attitudes, prejudice, and discrimination.

Prevention at the National Level

Canadian task force

In 1986 the Ministry of Multiculturalism and the Ministry of Health and Welfare of the Federal Government of Canada established a national Taskforce on Mental Health Issues Affecting Immigrants and Refugees. The task force report (Beiser et al., 1988) presents information gained through a review of the literature and extensive public hearings in all parts of Canada, and concluded with 27 recommendations. It outlines the immigrant and refugee situation in Canada, and contains sections on prevention (dealing with attitudes in Canadian society, settlement and social support, language education, and employment), remedial measures (formal mental health care, community mental health care, training for service providers and ethnic practitioners), and groups with special needs (children and youth, women, seniors, and victims of catastrophic stress).

The main theoretical orientation of the report is that

While moving from one country and culture to another inevitably entails stress, it does not necessarily threaten mental health. The mental health of immigrants and refugees becomes a concern primarily when additional risk factors combine with the stress of migration. (Beiser et al., 1988, p. 1)

These additional risk factors are identified as (a) negative public attitudes toward immigrants and refugees generally, and toward some groups specifically, (b) separation from family and community, (c) inability to speak French or English, (d) unemployment (and underemployment, compared with one's level of training or education), (e) being adolescent or elderly at the time of migration, (f) and being a woman from cultures in which gender roles and values differ from those in Canada.

With respect to prevention, a number of specific recommendations were made. These included (a) premigration orientation in refugee camps, (b) broadening the definition of family for purposes of admission in order to increase the available social support system, (c) improving core or basic funding for ethnocultural settlement service agencies, particularly for those serving youth, seniors, and women, (d) developing school curricula that promote multicultural and multiracial understanding and tolerance, (e) public education to increase the knowledge and acceptance of the benefits of pluralism to a society, and of the contribution of newcomers to the cultural and economic life of the country, (f) increasing public awareness of the possible difficulties faced by newcomers, and the effects of prejudice on both victim and perpetrator, and (g) improving access to English and French courses, and to trades and professions for those educated outside Canada.

More generally, it was recommended that research and teaching centers dealing with immigrant and refugee mental health be established, and that a national information center be created to collect, coordinate, and disseminate information about research, evaluation, and application in the area of immigrant and refugee mental health. Both of the aforementioned ministries responded favorably to the report and its recommendations, as have many cultural and professional organizations.

U.S. Refugee Assistance Program–Mental Health

Ten years after the first large Southeast Asian refugee exodus to the United States, the federal government, at the urging of local community organizations, established the Refugee Assistance Program–Mental Health (RAP–MH) through funding from the Office of Refugee Resettlement (ORR) in collaboration with the National Institute of Mental Health (NIMH; Cravens & Bornemann, 1987). The purpose of this three-year project was to enable the 12 funded states with large refugee populations to upgrade mental health services for refugees living within their boundaries, with the eventual goal of integrating these services into the states' existing mental health systems. The RAP–MH program was developed after the realization that mental health problems were increasing in the refugee groups in the United States, that mental health problems contributed to difficulties with refugee resettlement, that there was a significant federal investment in refugee resettlement and social service programs, and that a lack of a coordinated federal mental health effort was contributing to the problem (Williams, 1989, in press).

The University of Minnesota was funded as the Technical Assistance Center (TAC) for the RAP–MH program. A monograph summarizing the TAC-produced documents is soon to be available (Westermeyer et al., in press). The present authors developed the TAC documents concerning prevention (Berry, in press; Williams, in press) for mental health practitioners from the 12 states. Unfortunately, though, throughout the three years of funding, no primary prevention programs were identified. Rather, this work was best characterized as being at the hypothesis-generating stage, inasmuch as no funding was forth-coming from ORR or NIMH for actual program development, implementation, or evaluation.

Shortly after the RAP–MH program, plans for the resettlement of two new refugee groups in the United States were formulated at the national level. Because of the unique characteristics of these two groups—which included possible trauma, in addition to acculturative stress—they were considered to be at even greater risk for mental disorders. One group was the Amerasian children of U.S. servicemen stationed in Vietnam. The Amerasian group included mostly adolescents and young adults who had lived in Vietnam since the end of the U.S. involvement in the war. Their probable trauma, in addition to acculturative stress, included racial discrimination, family breakdown, and in many cases, erroneous expectations of joyful reunions with their American fathers. The other group, whose resettlement is occurring at the present time, are the “re-education camp detainees” from Vietnam. These men are former South Vietnamese government officials or servicemen, and it is probable that their last 15 years in re-education camps in Vietnam could be characterized as highly stressful and traumatic.

Although progress was made during the RAP–MH program through the development of models or strategies to follow for primary prevention program development, this progress has not led to a federal initiative in this area for the two most recent traumatized groups being admitted to the United States. The Office of Refugee Resettlement, the lead federal agency on refugee matters, has no plans for the development, implementation, and evaluation of primary prevention programs for Amerasian young people or re-education camp detainees. The sense of frustration about slow action that can occur in work at the national level, described earlier, is illustrated in this case.

Prevention at the International Level

Many international organizations, agencies, and governmental bodies are actively involved in refugee work. Vernez (1991, this issue) provides detailed descriptions of these efforts. Most refugee relief efforts in human and health services are at the remedial, rather than the preventive, level of intervention. Very few efforts are directed toward mental health issues. However, a recent World Health Organization (WHO) Mental Health Mission to the Khmer border camps in Thailand included public health and prevention recommendations and serves as an illustration of what can be accomplished at this level (Bastiansen, de Girolamo, Diekstra, Top, & Williams, 1989).

These Khmer border camps provide one of the best examples of the need for a primary prevention intervention based on political action and social change. Because of national policies of several countries including the United States, Thailand, and the People's Republic of China, the Khmer, although fleeing from persecution and war in Cambodia, are denied refugee status and its accompanying internationally guaranteed protection and legal rights. International relief, however, has been provided to the Khmer since 1979 (Reynell, 1989).

The situation along the Thai–Cambodian border is very complex and ever changing. The border is an active war zone, which contributes to its chaos. More than 300,000 Khmer civilians, of whom nearly 30% are under the age of four years, are sequestered in about eight United Nations Border Relief Operations (UNBRO) assisted camps (Reynell, 1989). Each of these camps is associated with one of the several Khmer military factions, who have records of human rights violations (e.g., the Khmer Rouge, responsible for the Cambodia genocide between 1975 and 1979, control several camps) that contribute to high levels of trauma and associated stress in the camps.

Because of shelling and other military activities, the camps frequently are evacuated or moved, which requires considerable effort. The largest, Site 2, has a population base of about 160,000–175,000. Contributing to the difficulty of life in Site 2 is its location in a barren, desolate area with no electricity or natural source of water. For one decade, basic supplies like food and water have been set at temporary, emergency survival levels, another contributory factor to poor conditions in the camps (Reynell, 1989). Supplies have to be brought in daily, although deliveries are suspended in times of increasing military activity.

Not surprisingly, conditions in the UNBRO camps have deteriorated into a major mental health crisis (Mollica, Lavelle, Tor, & Elias, 1989), characterized by high rates of suicide attempts, domestic violence, apathy, hopelessness, depression, anxiety, somatization, insomnia, physical and sexual abuse, and learning problems in children. Others have more broadly portrayed their problems as a “humanitarian crisis of international proportions” (Jackson, 1987, p. 24). A number of mental health site visits have been conducted on behalf of several government agencies and nongovernmental organizations (e.g., Cravens, 1988; Diekstra, 1988; Eisenbruch, 1988; Mollica et al., 1989). Psychopathology and social problems are so readily apparent in the UNBRO camps that professionals from other disciplines document them as well (e.g., Jackson, 1987; Reynell, 1989).

In 1988, because of requests from field relief workers for assistance in dealing with increasing mental health problems, UNBRO asked the Mental Health Division of WHO to assess both the magnitude of the mental health problems and their likely contributing factors, and to recommend possible interventions. Diekstra (1988) provided some short-term suggestions, but also recommended that a WHO mission of five international experts be sent to the camps as soon as possible for additional assessment and the development of mental health interventions. This mission spent three weeks on the border in three of the largest camps.

Because there were no existing mental health services included in UNBRO's well-established system of health care in the camps, the WHO mission's report provided a blueprint for developing a system of mental health services in the camps (Bastiansen et al., 1989). One result of the WHO report was an UNBRO search for an expert to fill the newly created position of Mental Health Co-ordinator for the camps. In addition to the recommendations about developing a system of mental health care along the border, the WHO report also took a broader public health perspective suggesting several needed political solutions to the mental health crisis. Included among the preventive interventions were the following:

1. Informing the international community, donor countries (the U.S. is the largest donor country), and the Royal Thai government about the tremendous psychological, social, and family problems occurring in the camps because of current international policies.
2. Granting refugee status to Khmer civilians seeking it, and removing these vulnerable refugees from the active war zone.
3. Working toward a political solution that will allow for voluntary repatriation to Cambodia.
4. Creating as safe an environment as possible for women and children by providing 24-hour supervision by UNBRO security in all refugee camps, including those controlled by the Khmer Rouge.
5. Improving the basic physical aspects of the camps (i.e., more acceptable amounts of water, more varied diets, and decreased overcrowding).
6. Allowing for adequate employment of adults in the camps.
7. Improving the education programs for children of all ages.
8. Providing adequate interpreter services, not only for mental health consultation, but also for community development and organization. This should enhance UNBRO's ability to meet their goal of Khmer self-management.
9. Providing acceptable birth control methods to the Khmer women in order to reduce the extraordinarily high birth rates in the camps.
10. Providing stress management programs for the international refugee relief workers based on the border. Many of these WHO recommendations are consistent with those proposed by others (e.g., Eisenbruch, 1988; Jackson, 1987; Mollica et al., 1989; Reynell, 1989), yet many remain to be enacted.

Psychology's Potential in Refugee Mental Health

There are several ways psychologists can contribute to refugee mental health. The first is recognition of the mental health needs of this underserved population. Next, is the acquisition of skills to provide psychological services to refugees and to address this field's important research questions. As in other areas of psychological practice and research, knowledge acquisition can be obtained through formal training offered at universities; continuing education workshops and meetings; and supervision, consultation, and collaboration with experts in refugee mental health. Cross-cultural presentations and topics could be introduced in case conferences and presentations as part of ongoing supervision and training. An advisory board, made up of members of the refugee groups to be served, can be used to educate other mental health providers about the special needs of refugee communities. This advisory board could also provide a forum for the sharing of ideas and approaches to refugee mental health.

Refugee mental health requires a cross-cultural perspective rooted in a full understanding of the groups in contact (i.e., that of the larger society, as well as the numerous refugee groups). Lessons from anthropology and cross-cultural psychology tell us about the importance of time spent “in the field.” In any cross-cultural work, psychologists have to fight against the tendency toward professional distancing by leaving their offices and clinics and spending time with refugees in their environment.

For example, valuable experience can be obtained through home, school, or work-site visits with individual clients; guest lectures in English-as-a-second-language classes; participation in training sessions for paraprofessional refugee interpreters; or mentoring students from refugee groups. However, informal contact like attendance at ethnic New Year's celebrations or other festivities or the establishment of a mutual friendship with a member of a particular ethnic group also enhances a psychologist's understanding of the refugee's cultural background. For those interested in primary prevention, greater experience with the refugees' culture and society becomes even more important because our work takes place in their communities. Active collaboration with members of the ethnic community is a requirement for such an approach. If this perspective is not taken, psychologists will add the further risks of ethnocentrism and victim-blaming to those already being experienced.

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