There has been an ongoing debate among refugee mental health workers about the applicability of Western diagnostic criteria to non-Western populations. (25) In addition, many humanitarian aid workers believe that the human suffering associated with refugee trauma is a normal human response to the refugee's experience and that the refugee should not be further stigmatized by receiving a psychiatric diagnosis and treatment. Both arguments have frequently supported an anti-mental-health attitude among international relief workers. There are a number of methodological problems in refugee research that have to be overcome in order to determine the validity of the above statements.
Cross-cultural research suggests that assessments of psychiatric illness should begin with phenomenological descriptions of folk diagnoses or culture-specific syndromes.(26) To date, not a single culture-specific illness associated with the mass violence and torture experienced by refugees has been defined. (27) On the contrary, the criteria for the two major diagnoses associated with violence in Western society, i.e. major depression and PTSD, have been successfully applied to refugees from many parts of the world. While epidemiological evidence suggests that high rates of pTsd, for example, are experienced by both refugee patients and non-patients, it is not known whether there are other culture-specific symptoms not part of the DSM-IV criteria that have greater clinical relevance and meaning to a specific refugee group. A general principle demonstrated by the World Health Organization cross-cultural study of depression, (28) i.e. that while some depressive symptoms may be present across cultures, they may not be the symptoms most strongly endorsed by the patient, may also apply to PTSD. Figure.2 provides an illustration which can help to address the problem of psychiatric diagnoses in refugee patients. This figure suggests that, until further research is forthcoming, the psychiatric provider needs to determine clinically whether the refugee patient is presenting with scenario A, B, or C.
The high prevalence of psychiatric symptoms associated with trauma in refugee populations does not either affirm or negate the 'normalization' of these symptoms. A narrow medical viewpoint could create a psychiatric redefinition of refugee mental health problems that would place the majority of refugees in a 'mentally ill' box without any access to individual psychiatric care; on the other hand, the hostility of many humanitarian aid workers toward psychiatry has denied the seriously mentally ill refugee legitimate access to psychiatric treatment. There will probably be a compromise at the intersection of public health objectives and the protection goals of humanitarian aid workers. In the future, the presence of chronic and severe disability in refugee survivors will be the gold standard which drives the psychiatric and humanitarian rehabilitation of refugee survivors. (29,,39
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