Isidro Maya Jariego: Redes Sociales - LRPC (Laboratorio de Redes Personales. y Comunidades)

• Maya Jariego, I. (2005). Book Review of The Mental Health of Refugees. Ecological Approaches to Healing and Adaptation, edited by Kenneth E. Miller & L. M. Rasco. The Community Psychologist, 38 (1) 5-6.

Some refugee treatment centers in Spain are residences for applicants seeking permanent resident status such as asylum or refugee. These residences provide the applicant with social, medical and psychological attention, as well as meet other basic needs. Most of the temporary residents in these centers will not get refugee status and the majority are asylum seekers who have enough information and social resources to arrive in Europe from poor countries.

In this context, the preventive and promoting roles of these centers are fairly limited. The residence provides a minimum network for the integration of individuals and families. But the model of the center is similar to the residences for the elderly and for people with disabilities. Although refugee families may function autonomously, these programs are designed for people – old and/ or impaired – who demand professional attention in their everyday activities and who usually live as permanent residents in the center. Psychologists and social workers act on a case by case basis, giving an almost exclusive preference to the individual level of intervention, and inspired by the clinic-based mental health model (Maya Jariego, 2003).

As a consequence, the process of “institutionalization” is often observed in the residents, and the program shows problems of social, cultural and psychological pertinence. According to Miller & Rasco, in the intervention with refugees this is the mainstream approach. The book The Mental Health of Refugees tries to address precisely the problems of the clinic-based model programs that we have illustrated with Spanish refugee treatment centers. The same problems are found worldwide in interventions with refugees. As an alternative, an ecological approach to collaboration with the community is offered.

The first chapter of the book includes a brief but excellent review of the psychiatric literature pertaining to refugees. There are several consistent findings within this population, including the exposure to political violence is associated with acute and chronic post-traumatic stress reactions. This has been the primary topic of research on the mental health of displaced people. Most of the studies with refugees find a high prevalence of Post Traumatic Stress Disorder (PTSD). This problem tends to persist over considerable periods of time, and is systematically observed in different cultural groups and in different settings. On the other hand, it seems that the level of symptoms depends on the degree of exposure to violent acts.

However, this clinic-based approach has important limitations both for diagnosis and treatment. Miller & Rasco point out that the PTSD diagnosis (a) “medicalizes a set of normal reactions to profoundly abnormal social conditions”, (b) overlooks important cultural variations in the experience of stress, and (c) “individualizes the effects of political violence… while ignoring its effects on communities and on society as a whole (p. 50-51).” At the same time, clinic-based models of mental health intervention produce services that are often underutilized and do not adequately address the everyday problems that refugees face. Sometimes these services are not available in the countries where refugees reside, and in other cases the services are available, but are not culturally sensitive and, as a consequence, are underutilized as well.

Miller and Rasco’s book may be seen as an alternative approach to these issues. There are three parts in the book: (a) an introductory chapter that presents the benefits of adopting an ecological model of intervention with refugees; (b) eight chapters highlighting ecological mental health programs recently applied in Africa, Asia, South America, and North America; and (c) two concluding chapters that analyze the evaluation of these interventions and summarize what is state-of-the-art about this approach to the healing of refugees.

With six “ecological principles” and eight selected programs, the characteristics of this intervention are well described. The ecological approach emphasizes interventions that are integrated into existing community settings and depend on the collaboration of community members. This enables strategies that are sensitive to the social priorities and the cultural patterns of the groups of refugees to be put into practice. Under the label of “ecological” we find programs that enhance participation, stress prevention over treatment, and are oriented to capacity-building. The comparison among several projects -in so many different contexts such as Angola, Guinea, Columbia and the United States, among others- is one of the significant contributions of this volume. It is a collection that may be useful for theoretical, professional and training purposes.

Reviewing these experiences with refugee communities, there are several strategies that are very often put into practice within the ecological approach. This book emphasizes four strategies:

• A multilevel intervention approach. For instance, Wessells & Monteiro describe a program focused on internally displaced children in Angola (Chapter 2). The activities are not exclusively focused on children, but the program provides training for adults to address the needs of vulnerable children. It gives importance to the traditional leadership institution, and gives instruction to other institution members in the skills for positive conflict resolution, among other community-oriented activities.
• The integration of local ideas and practices of healing into the program. An interesting example is the combination of counselling and self-help groups with the participation of traditional healers in Cambodia (Van de Put & Eisenbruch, Chapter 4). This seems to be particularly useful when – as is the case with Cambodian refugees – the understanding of mental health refers to the community as a whole, and not only to the individual.
• The participation of paraprofessionals. An intervention in Guinea consisted of training some members of the collective of Sierra Leonean refugees to work as mental health paraprofessionals (Chapter 3, by Hubbard & Pearson). Sometimes this is applied with a “cascade model”, in which the paraprofessionals disseminate the knowledge and skills to other members of the community (see, for instance, the rational of the intervention in Sri Lanka described in the Chapter 5).
• The application of the program in community settings and the collaboration with the community. For instance, in an intervention with Bosnians and Kosovars in the United States, the activities of the program were facilitated by members of the communities themselves, and the meetings were also organized either at homes or centers of the refugee communities (Chapter 8).

In sum, the book edited by Miller & Rasco demonstrates through a combination of theory and practical examples, how to put into practice an ecological conception of mental health. This is a pertinent endeavour, as community level interventions are still a marginal approach in mental health services. This effort of translating ecological principles into practice makes an important contribution to the development of this approach. But, in the concluding chapter, the editors themselves recognize that more research and theoretical work is needed to gain presence in mental health services; for instance, “it is not entirely clear how to operationalize and assess community-level well-being, distress, or dysfunction (p.391).”

This is the case with the “general risk model” that opens and closes the book in Chapters 1 and 11 (p. 26 and 384). Paradoxically, although the book emphasizes resilience and protective factors, these are not included in the general risk model (p.385). It is a framework that organizes the stressors that may have an impact on the psychological functioning of refugees. Thus, the “general risk model” is a sort of meta-model that selects and classifies important factors to take into account when designing mental health programs with refugees. It is a useful guide for research and intervention. But it seems that more research is needed to describe the ecological transition that leads to forced migrants. To understand what it means to be a refugee in ecological terms, we need to pay more attention to the changes in social and personal networks, and develop models regarding the relocation of families and communities into different social and cultural contexts.

Ecological interventions need more theoretical and methodological strength to be an alternative to clinic-based mental health services for refugees (to support this idea, see, for instance, Miller, 2004). This is one of the reasons that I find this to be a useful book. The volume provides an excellent description of the ecological approach, and makes a contribution in that it identifies key strategies to promote the adaptation of refugees.

References

Maya Jariego, I. (2003). Estudio de caso de un Centro de Acogida a Refugiados. En Loscertales, F. & Núñez, T., Comunicación e Intervención. Módulo 10: Intervención Social. CD Interactivo. Universidad de Sevilla.

Miller, K. E. (2004). Beyond the Frontstage: Trust, access, and the Relational Context in Research With Refugee Communities. American Journal of Community Psychology, 33 (3/4), 217-227.