Exploring the mental health effects of political trauma with newly arrived refugees.

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QHRXXX10.1177/1049732314549475Qualitative Health ResearchShannon et al.

Article

Exploring the Mental Health Effects of Political Trauma With Newly Arrived Refugees

Qualitative Health Research 2015, Vol. 25(4) 443–457 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314549475 qhr.sagepub.com

Patricia J. Shannon1, Elizabeth Wieling1, Jennifer Simmelink McCleary2, and Emily Becher1

Abstract We explored the mental health effects of war trauma and torture as described by 111 refugees newly arrived in the United States. We used ethnocultural methodologies to inform 13 culture-specific focus groups with refugees from Bhutan (34), Burma (23), Ethiopia (27), and Somalia (27). Contrary to the belief that stigma prevents refugees from discussing mental health distress, participants readily described complex conceptualizations of degrees of mental health distress informed by political context, observation of symptoms, cultural idioms, and functional impairment. Recommendations for health care providers include assessment processes that inquire about symptoms in their political context, the degree of distress as it is culturally conceptualized, and its effect on functioning. Findings confirm the cross-cultural recognition of symptoms associated with posttraumatic stress disorder; however, refugees described significant cultural variation in expressions of distress, indicating the need for more research on culturebound disorders and idioms of distress. Keywords focus groups; mental health and illness; posttraumatic stress disorder (PTSD); refugees, research, cross-cultural; trauma; war, victims of In 2012 there were 45.2 million people forcibly displaced from their homes because of persecution, political conflict, generalized violence, and human rights violations (United Nations High Commissioner for Refugees, 2012). This figure includes 15.2 million refugees, one million asylum applicants and another 23 million people who were internally displaced. The United States has become home to more than 3 million refugees since the development of its resettlement program (U.S. Department of State, U.S. Department of Homeland Security, & U.S. Department of Health and Human Services, 2013). Of the 58,236 refugees resettled to the United States in 2012, the largest groups fled protracted wars and political instability in Burma (14,020), Bhutan (15,021), Iraq (12,122), and Somalia (4,914), according to the Office of Refugee Resettlement (2013). Depending upon their political situation, between 5% and 35% of refugees endure torture, and many more refugees survive war trauma experiences (Baker, 1992; Porter & Haslam, 2005). The mental health effects of war trauma and torture can be devastating, leaving up to 30% of survivors struggling with posttraumatic stress disorder (PTSD) and major depression (Steel et al., 2009). Scholars have questioned the universality of Western concepts of mental

health and the applicability of Western measures of PTSD and depression when applied to the assessment and treatment of vastly diverse refugee populations (Marsella, 2010). A small but growing body of research has begun to report ethnocultural variation in the effects of trauma, including culture-bound disorders and local idioms of distress (de Jong & Reis, 2010; Hinton & LewisFernandez, 2010; Miller, 2009). To develop more culturally valid mental health assessment knowledge, in this article we report common and culture-specific mental health effects of war trauma from the perspectives of refugees from Bhutan, Burma, Ethiopia, and Somalia. Refugees flee their countries because of a wellfounded fear of persecution “for reasons of race, religion, nationality, membership in a particular social group, or political opinion” (Refugee Act of 1980, para. 42). Refugees might endure persecution and trauma events 1

University of Minnesota, St. Paul, Minnesota, USA Tulane University, New Orleans, Louisiana, USA

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Corresponding Author: Patricia J. Shannon, School of Social Work, University of Minnesota, 1404 Gortner Ave., St. Paul, MN 55108, USA. Email: [email protected]

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prior to leaving their home country, including economic hardships, political oppression, government-sponsored torture, detention, forced labor, and physical and sexual violence (Porter & Haslam, 2005). When fleeing their country, refugees might experience violence, separation from family, disease, and deprivation of sanitation and adequate nutrition. They might live in a refugee camp under harsh conditions for many years (Adams, 2004). Refugees who resettle to the United States face difficulties that may worsen war-related mental health symptoms, including the lack of employable skills, language and cultural barriers, unsafe housing, and social isolation (Miller & Rasmussen, 2010; Silove, 1999). In addition to experiencing war trauma, a significant percentage of refugees have been specifically targeted and tortured. Torture is defined as “an act committed by a person acting under the color of law specifically intended to inflict severe physical or mental pain or suffering upon another person within his custody or physical control” (U.S. Criminal Code, 1994, para. 1). The populations included in this study faced particularly long and violent political struggles, with whole generations growing up either internally displaced or in refugee camps outside their home countries. Somalis have been engaged in a civil war since the 1980s. The central government of Somalia collapsed in 1991, giving way to sectarian violence that has endured for more than a decade. Fighting continues between armed Islamist groups and pro-government forces, subjecting civilians to indiscriminate attacks and generalized violence. The conflict has forced over 2 million people to leave their home, and many Somalis have lived as refugees in harsh camp conditions for more than a decade (Amnesty International, 2013). Oromo refugees are the largest ethnic group living in Ethiopia. They have been engaged in a civil conflict for an independent Oromo state for several decades. Oromo refugees have reported numerous civil rights violations, including physical and psychological torture, sexual violence, extrajudicial killings, arbitrary arrests, and detention under inadequate prison conditions (Advocates for Human Rights, 2009). In a sample of 1,134 recent arrivals, Somali and Oromo refugees indicated torture prevalence rates of 36% and 55%, respectively. Oromo men reported the highest rate of torture, at 69% (Jaranson et al., 2004). Approximately 100,000 Bhutanese refugees fled Bhutan following a violent struggle resulting from Bhutan’s “one-nation” policy in 1987. They have lived in refugee camps in Nepal for almost two decades. Bhutanese refugees have been tortured in Bhutan and have faced violence in the camps (Tol et al., 2010). Bhutanese refugees began resettling to Western countries in 2007, after 17 years of negotiations broke down. By

the end of 2010, more than 40,000 Bhutanese refugees had already resettled, most to the United States (International Organization for Migration [IOM], 2010). Karen refugees are one of seven ethnic minority groups in Burma that have been severely persecuted by the military government there since the pro-democracy uprisings in the late 1980s. The Karen National Union (KNU) has been engaged in a prolonged armed conflict with government forces, and consequently, Karen refugees have lived in camps lining the Thai–Burma border for several decades (South, 2012). In a sample of 179 Karen refugees, 27% reported being tortured, 52% reported secondary torture (being a family member of a torture survivor), and 86% reported experiencing war trauma (Shannon, Wieling, Simmelink, Im, & Vinson, 2013). Schweitzer, Brough, Vromans, and Asic-Kobe (2011) found similar rates of torture in their sample in Australia. Common torture experiences for the Karen included death threats, beating, rape, and being forced to be a porter and a landmine sweep. War trauma experiences included threats, forced displacement, exposure to bombs, shooting, and burning of villages. Studies of Bhutanese refugees have reported similarly high rates of torture and associated mental health symptoms (Thapa, Van Ommeren, Sharma, de Jong, & Hauff, 2003; Tol et al., 2009). Several meta-analyses have documented the mental health effects of torture and war trauma on refugee groups (Fazel, Wheeler, & Danesh, 2005; Steel et al., 2009). Steel et al. reviewed 181 surveys of more than 80,000 refugees and found prevalence rates of 30% for PTSD and major depression. Correcting for methodological flaws in their samples, such as nonrandom samples, small sample sizes, and the use of self-report measures, they calculated a weighted prevalence rate for PTSD ranging between 13% and 25%. In their study, torture experiences and cumulative exposure to trauma were the strongest factors associated with PTSD and depression, respectively. PTSD is a debilitating condition characterized by symptoms of intrusion, avoidance, negative cognitions, and hyperarousal following traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychiatric Association, 2013), reports that the highest rates of PTSD (between one third and one half of those exposed) are reported by survivors of rape, combat, captivity, and “ethnically or politically motivated internment and genocide” (p. 276). Many researchers documenting the mental health of refugees in resettlement have historically used standardized measures that were neither developed nor validated with non-Western populations (Hollifield et al., 2013; Hollifield et al., 2002). There are only a few measures that have been developed and validated with refugee populations in mind, such as the Harvard Trauma


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Shannon et al. Questionnaire (Mollica et al., 1992). Recent critics of the use of such Western standardized measures have argued that mental health symptoms and concepts are not culturally invariant (Marsella, 2010; Summerfield, 2012). Miller (2009) accused scholars of “psychiatric essentialism” when applying Western-derived measures of mental distress to refugee populations, arguing that the experience and expression of mental health distress might be socially constructed, giving rise to cultural syndromes and idioms of distress that influence the expression of mental health and illness. Collectively, these scholars have called for more culturally grounded methods, concepts, and measurement processes for understanding cultural-specific experiences of mental health and distress. A growing body of qualitative research has begun to identify culture-specific mental health concepts and idioms of distress in refugee populations (Hinton & LewisFernandez, 2010). For example, in a small study of Somali refugees, Carroll (2004) identified several local idioms of distress associated with war, including “murug (sadness or suffering), waali (craziness due to severe trauma), and gini (craziness due to spirit possession)” (p. 119). In developing an Afghan Symptom Checklist, Miller (2009) conducted qualitative interviews to develop local understandings of mental illness and to identify local idioms of distress, such as fishar, meaning an internal state of either emotional agitation or low energy. In a recent study of the high rate of suicide among Bhutanese refugees, researchers from the International Organization for Migration used Nepali idioms of distress and conceptions of trauma identified by Van Ommeran et al. (2002) and Kohrt and Hruschka (2010) to explore families’ perceptions of the causes of suicide (Ao et al., 2012). Although research into local idioms of distress has provided a deeper and more nuanced understanding of the mental health of some refugee populations, the general finding of mental health stigma in non-Western populations remains a perceived barrier to effective cross-cultural communication about mental health. Saechao et al. (2012) conducted focus groups with Iraqi, Iranian, Cambodian, and Eastern European first-generation immigrants who described mental health stigma as a barrier, stating that consumers of mental health services would be perceived as “crazy” in their cultures. Providers also commonly cite mental health stigma as a barrier to effective communication with refugee patients (Morris, Popper, Rodwell, Brodine, & Brouwer, 2009). If stigma is a prominent barrier to communication, there remains a significant lack of knowledge about how newly arrived refugees perceive the mental health effects of political trauma. In this study, we explored common and culturally grounded conceptions of the mental health effects of political conflict through the voices of newly arrived refugees to the United States.

Method Design This qualitative study was a component of a larger participatory action research project to develop culturally grounded mental health screening tools and processes for newly arriving refugees in the United States. We used ethnocultural traditions (McCurdy, Spradley, & Shandy, 2005; Nagata, Kohn-Wood, & Suzuki, 2012) to inform the design of this exploratory study. We used focus group interviews to explore the mental health-related experiences of refugee populations from four cultural groups. Focus group interviews have been used in studies of health disparities and have been a useful way to explore community-wide understandings of mental health (Wong & Tsang, 2004). Interview questions were developed and analyzed with the aim of exploring culture-specific taxonomies related to mental health- and trauma-related distress. Study context and ideological perspective. This study was developed in response to community stakeholder requests for a better understanding of how different resettling refugees experience trauma-related symptoms and to a call for developing assessment processes and measures that are culturally grounded (Shannon et al., 2012). Cultural leaders from the Karen, Bhutanese, Oromo, and Somali communities and local scholars on refugee-related topics were consulted as part of the process of conceptualizing this study. They were also involved in supporting recruitment efforts, data collection, and cultural member checking. Participants. We conducted 13 focus groups with 111 total participants between 2009 and 2011. The sample included three focus groups with Bhutanese refugees (n = 34), three focus groups with Karen refugees (n = 23), four focus groups with Oromo refugees (n = 27), and four focus groups with Somali refugees (n = 27). Group participation ranged between 5 and 12 individuals, with a mean of 8 per group. Participants ranged in age from 18 to 78 years; the mean ages for the Bhutanese and Karen participants were 37 and 38, respectively, and the mean age for the Oromo and Somali participants was 45. The mean number of years living in the United States for each group was 8 years or less, as follows: Bhutanese, less than 1 year; Karen, 2 years; Oromo, 8.7 years; and Somalis, 6.8 years.

Procedures Following the guidance of cultural leaders, we conducted separate groups for men and women in the Somali and Oromo communities and mixed-gender groups in the Karen and Bhutanese communities. Because young adult


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refugees preferred not to be interviewed in groups with their elders, we conducted separate mixed-gender young adult groups for participants between 18 and 25 years. Focus group discussions lasted 2 hours and were conducted in easily accessible locations such as churches, community centers, and private apartments. Although this study was granted exempt status by the University of Minnesota Institutional Review Board because of the broad community-based nature of the interviews, we included a standard consent protocol. We also offered to assist participants with connecting to mental health resources if desired. If group members chose to participate, a brief demographic form was used to collect information about ethnicity, languages spoken, age, education level, current employment, and length of time in the United States. Group interpreters were trained and signed confidentiality agreements. The semistructured focus group interviews began with an effort to obtain the perspectives of all participants. The protocol addressed five areas about community responses to war: 1. Sometimes people have problems with their thoughts and feelings as a result of the war and living in a refugee camp. Do people in your community experience these things? Describe the different responses people in your community have to difficult experiences. 2. When people are suffering from these problems, how do you know that? What words do they use to describe these problems? What are acceptable ways to talk about these problems? 3. What is not said when talking about these emotions and problems? How do you know when someone is experiencing these things? 4. What do people do when they have these problems? What do they do that helps them? 5. When people who have lived through these experiences are doing well, how do you know they are doing well? We ended the focus group interviews by thanking participants, reminding them of confidentiality, and providing each with a $10 gift certificate and a copy of the consent for their records. All 13 focus group interviews were audio-recorded and transcribed by a member of the research team. A physical map of the focus group seating arrangement was drawn to identify each participant who spoke. Research assistants and interpreters were offered debriefing with the coinvestigators after every focus group interview. The role of the researchers. Shannon has more than 12 years of experience conducting research and working

clinically with refugee populations. Wieling’s research program has an international focus and is centered on addressing mental health needs of populations affected by war and organized violence. McCleary, Becher, and two additional research assistants contributing to the project have extensive experience working with refugees and advanced training in qualitative methodology. The entire research team was involved in all phases of the research project. Data analysis. The analytic procedure was informed by Spradley’s (1979) method of thematic categorization, which includes higher-to-lower orders of abstraction to hold meaning units, resulting in domain-specific taxonomies. Data were organized into domains, categories, themes, and subthemes. Transcriptions began after each interview and coding began before all focus groups were completed. Consistent with several qualitative strategies, this process allowed for initial glimpses of the emerging data and potential restructuring of questions to either verify, elaborate, or seek contrasting or divergent points of view within and across cultural groups. We first read through the interview transcripts and meeting notes of the first four focus groups to develop a sense of the whole and to further specify the coding protocol. All transcripts were then double coded by two graduate research assistants, and reconciliation meetings took place to merge meaning codes within and across transcripts while allowing new meaning units to emerge. Shannon or Wieling served as a third coder, reviewing the analytic audit trail of the research dyad and offering additional interpretation and restructuring. A protocol was developed with 10 coding domains and later expanded to 13 with several categories, themes, and subthemes included within each. After the same coding process was followed for all 13 interviews, we aggregated the data originally formatted into the 13-item domain analysis across groups and organized it according to ethnic group to assess how the domains varied or remained stable within and across refugee groups. The original organization offered a domainspecific taxonomy, whereas the within-group structure provided a picture of how refugee groups experienced each domain. Once aggregated into cultural groups, data were discussed and negotiated by the research team. These culture-specific analyses were then compared across ethnic groups. Summaries of the domains, categories, themes, and subthemes were provided to cultural leaders of each ethnic group along with the text of the transcript for member checking, to confirm, deny, or augment our interpretations of the focus group content. We held meetings with cultural leaders to discuss initial findings and interpretations based on the cultural leaders’ emic knowledge.


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Shannon et al. Verification of data. To enhance trustworthiness of the data, the credibility, transferability, dependability, and confirmability were systematically tracked (Lincoln & Guba, 1985). Cultural leaders were involved in all stages of the research process to increase the likelihood that the data being collected fit with the conceptual understanding (e.g., language, format, meanings) of the participants, and that final interpretations might also be closely aligned with what participants intended to convey. Although formal member checks were not conducted with research participants, Shannon and Wieling frequently offered summary statements during the focus group meetings aimed at obtaining confirmation or correction of initial interpretations. The strategy of involving a cultural leader at several points in the interpretation of results and specifically asking questions about whether or not findings seemed to fit their experiences of the cultural group helped to ascertain some measure of transferability. Meticulous, step-by-step strategies of data collection, note-taking, coding by independent researchers, reconciliation discussions, organization of data taxonomies from different perspectives, and checks with cultural leaders helped to verify dependability in this study. In addition to all of the analytic strategies described above as part of data interpretation, an emphasis was placed on incorporating participants’ direct words and descriptions in the reported findings.

Results Findings reported in this article are focused on the domain labeled “culturally grounded words and concepts used to describe the effects of war trauma.” First, the results describe common categories across all four refugee groups, and second, they describe concepts of mental health or illness that are unique to each refugee group. There were seven categories in common across all focus groups: (a) symptoms cannot be described separate from their political causes, (b) understanding degrees of “craziness,” (c) too much thinking, (d) cognitive effects, (e) behavioral effects, (f) physical effects, and (g) emotional effects. Concepts unique to each refugee group include words used to describe mental health and culturespecific symptoms and problems. These are reported in each of the seven categories. Symptoms cannot be described separate from their political causes. When refugees were asked to describe thoughts and feelings that resulted from war and living in a refugee camp, they immediately began discussing the political causes of those symptoms. Despite reassurances that we were familiar with the political situation in their home country and did not need to hear about the traumatic

experiences to explore mental health symptoms, participants across all four refugee groups were eager to talk about traumatic experiences. They asserted that the historical context is important to understand distress and that one cannot understand suffering without understanding the trauma that caused the suffering. Although an indepth accounting of these experiences is beyond the scope of this article, each group described common aspects of war and political oppression that caused their mental health symptoms. Somali, Bhutanese, and Karen refugees described common war experiences such as being forced from their home, imprisonment, torture, witnessing killing, rape, physical injury, separation from children, and violence in camp. Oromo refugees discussed imprisonment, torture, rape, loss of family, ongoing political struggle, violence in refugee camps, and deprivation of basic needs in refugee camps. Refugees indicated that these traumatic experiences were the cause of their mental health symptoms. One Somali woman explained: “There’s a lot of people that face thoughts and feeling issues because some people died. One of their community members or one of their sisters, a friend died in front of them, so there’s a lot of trauma.” A Somali man described mental health problems resulting from refugee camp experiences: When people go into a refugee camp they go into a life that they never imagined, and it’s one of the horrible places to be. That causes people to change. That will also cause the person’s behavior to change. Loss of memory. The person will not be happy. The person thinks and worries, and the person has a problem.

Oromo refugees stated that whenever they were talking about mental disorders, it was related to what was going on politically back home and what had happened. They expressed ongoing concern that the dominant Ethiopian government was still spying on them. Their feelings of helplessness related to politics exacerbated mental health symptoms: The majority of refugees have pain and suffering of traumas because they lost their property because of the government persecution, and their property was looted. They were forced to abandon their families and run away from the country. They experienced a difference in culture and language and a lot of economic barriers, how to live in refugee camps. So he sees a lot of pain and problems and sufferings from every refugee who comes to this country.

An Oromo man told how torture created mental health symptoms: Some of those guys have been in the main government jail and they have been in camps where they are tortured. And


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that thing is still in their mind. And they know it is in their subconscious mind. It makes them wake up, and then they cannot go to sleep.

A Karen refugee reported experiencing current symptoms related to the war: “Sometimes I still have bad dreams, like I hear gunfire, and I woke up. Oh! I am safe, now.” Another Karen refugee explained the impact on the family: Some family members were killed in action, so the family split out and came to the U.S. So that memory has stayed in their minds. Now here, if they face some trouble, they see that picture as a memory. The memory comes back because of stress here. They have fear and worry, and it’s a mental problem.

A Bhutanese refugee described symptoms related to past trauma: When we first came from Bhutan to the refugee camp those things were bothering them a lot. Back in the refugee camp for some time, there was a lot of harassment by the Maoists. Those guys that turned into communists would come and ask for donations, and they wouldn’t have any money to give for donation because the little bit of rice or rations they received, they didn’t know if they should save that for food or give them as donation. So we were really terrified by this group, and it made our thoughts worse. Those of them that experienced prison, this torture from the police, even now in their dream they see police and they are very scared: Am I in Bhutan, or am I here?

Understanding degrees of “craziness” or mental distress. All four refugee groups described a word for “crazy” in their language; however, contrary to popular beliefs that refugees refer to all mental illness as one construct called “crazy,” the participants in this study reported knowledge of a continuum of mental distress that was well recognized in their community. Somalis described a range of mental illness from mentally unstable or sick to crazy. Mentally unstable meant stressed, thinking all the time, emotionally unstable but still capable of taking care of their children. One participant added, “They know what they are doing but their mental state is not what it used to be.” They shared that sometimes such mentally unstable or sick Somalis were considered “not dead or alive.” Somalis had words to describe mental distress that is not as bad as “crazy.” By contrast, they described crazy people as not making sense, saying one thing and meaning another, being potentially violent, being unaware of what they were wearing or where they were walking, being generally unable to see themselves the way others did, and being unable to take care of themselves or their children.

Oromo refugees described a range of disabilities related to mental illness, from having difficulty doing ordinary tasks of living to being “out of control.” For example, depression was described as not wanting to do what one usually did: “You don’t want to get up, meet someone, read the Koran, or prepare your own meals.” Some people who were affected by the political instability were described as “running out of control” and in need of hospitalization. They were reported to be at risk of becoming crazy, which meant that they were “talking to themselves,” and some could “become violent and even kill someone.” Oromo refugees also talked about people who were mentally sick as giving up. This was described as “cutting hope.” Some Oromos who were systematically tortured for speaking their own language described mentally ill people as “becoming speechless,” or having no words to describe their experience. These refugees simply stopped talking, and some harbored fears that if they talked, they might have a heart attack. Oromos used the word dhukkuba to describe mental pain or sickness. Karen refugees described a range of distress and a range of phrases for distress. “Crazy” was described as being out of control: “Just a few minutes she is laughing and then after that she is crying, sometimes singing very loud when people are sleeping. Sometimes if crazy, she may take off all her clothing and walk around the camp.” Karen words for crazy included tap we ba, meaning not full, or tha tah ta ba, meaning not a clear heart or mind. Karen also described milder forms of mental distress in which people seemed abnormal. The Karen words for this milder form of distress were tha ta sah, meaning “a little bit mentally ill” or having “a heart in trouble.” They expressed that such refugees looked upset or sad, cried, or expressed worries. Karen participants believed that too much thinking and crying could lead to craziness, and if refugees kept thoughts and feelings inside, they could commit suicide. Bhutanese refugees stated that the concept of “crazy” was reserved for someone with schizophrenia or bipolar illness, and is pronounced boule or boula. They recognized degrees of mental illness and expressed sympathy toward people who lost their mind because of depression from being imprisoned. Such persons were referred to as undango, which means “living in between.” They were perceived as mentally ill because of the situation and not because of biological illness. Bhutanese reported feeling frightened by biologically based mental illness, because the person could be violent or try to kill them. They depicted these people as looking scary, with eyes wide open and not talking. Some Bhutanese also described a milder form of mental illness using the phrase ondaroo, which means “dark.” This word described a sadness that kept people from participating


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Shannon et al. in their community. They use dhukah to describe pain or suffering. Too much thinking. Refugees reported doing too much thinking about past trauma, family back home, and worries about the future. They believed such thinking led to mental health problems both mild and severe. A Somali man stated, The war caused the mind to change. This created a lot of thinking, thinking about their future and what’s next for them and thinking about the people they left behind. They will also start to think about what they faced and what they have seen.

Somali women stated that there are two kinds of thinking: worrying when something happened to someone they knew and constantly thinking about family back home: “We’re always thinking about what’s happening to them, other people that we left behind. So there’s always stress and always our mental state is not okay.” Oromo refugees stated that they were always thinking about problems back home that were still “tearing” them here. An Oromo woman explained: We are always thinking about those who are there. The problem is thinking about, worrying about them, but we are here even though we worry about them. I don’t want to talk and I don’t want to think about what’s going on back home. The person we have seen in the evening will be found outside with his neck cut off. They do whatever they want to do in the night.

Karen refugees described thinking about the past, the current Karen situation back home, and many thoughts and worries about their future. A Karen participant stated that she “kept troubles in [her] mind for a long, long time, and then after thinking about it, [she] may not be able to control [herself], and become abnormal.” In addition, others endorsed that “sometimes people can go ‘crazy’ from thinking too much.” Bhutanese refugees stated that the brain does not work when they are thinking too much about things: “Sometimes when you are thinking and thinking about things, your brain doesn’t work. Because of too many thoughts going on in your mind, you don’t get to sleep. If you go on thinking, you don’t get peace.” These participants understood that thinking interfered with concentration and sleep, and that people could have mental problems from thinking too much: “They think and think and at the end, they can’t tolerate and bust, and have mental problem. They bust and it becomes too much.” Cognitive effects. In addition to too much thinking or worrying, refugees described struggling with a number of

cognitive effects, including short- and long-term memory loss; confusion; poor concentration; perceptual confusion, such as hearing voices, disorientation, flashbacks, or nightmares; difficulty forgetting; an avoidance of talking or listening; and “forcing yourself to forget.” One Oromo medical interpreter who participated in the focus groups stated, “They cannot think, actually, beyond what they are doing right now, and most of them have shortand long-term memory problems.” They attributed these memory problems to thinking about their former home all of the time. Oromo refugees explained their difficulties with concentration similarly: Their emotion is all over. Their mind is all over about families, their worries about country, their families, and the problem they hear, so they have very little concentration. They are all English students. They’re not really focusing when they are in class. Somebody calls, they pick up the cell phone. They think something happened to the family member or whatever, so their mind is all over. They are not concentrating.

Somali refugees stated that the difficulties of camp life caused loss of memory for many. When Somalis gathered at local malls, they saw people who were hearing voices and were confused: “Sometimes he might talk to himself. And the other time, without you even doing anything to him, he will just get mad.” “He’s talking to you and then his words are not complete.” Flashbacks and nightmares were described by all groups. The Bhutanese offered a cultural story to describe their flashbacks: Even if I see police here I am terrified. There is a saying in our language. If you hit a dog with burning firewood, because the dog might have entered the house and the dog runs away, and if there is a lightening, the dog will bark because they think it’s the same incident. Once they were tortured by the police, it’s the same feeling. Once they see the police again they get terrified and they get shaky.

Many of the Bhutanese were exposed to fires in their camp in their home country, and reported flashbacks upon hearing a fire truck in the United States: “We are very scared when a fire truck comes, and have a flashback, and every time it comes I’m feeling it’s a fire. We are tortured by the fire.” They also described revisiting their torture in their dreams: “Once they experienced this torture from the police, even now in their dream they see police and they are very scared. Am I in Bhutan, or am I here?” Refugees described efforts to avoid reminders of past traumatic events by avoiding watching the news and people who might bring back memories. The Karen described forcing themselves to forget but still struggling with memories: Sometimes I still have a bad dream like I heard gunfire and I woke up ten years later. And the other one is, sometimes, I


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try to forget what I have been through in the refugee camp, but I remember. I’m so scared. So I don’t want to think about my past.

Behavioral effects. Behavioral effects described by refugees included behavioral reactions such as sleeplessness (lack of sleep, difficulty falling asleep, and staying asleep), becoming speechless or having no words to describe experiences, talking too much, startle reactions, behavioral avoidance (of people, political activity, TV reminders of distress), suicide attempts, loss of appetite, use of substances such as alcohol, crying, stopping usual activities (reading the Koran, preparing meals), and becoming argumentative or having violent outbursts. One Oromo refugee described the lack of sleep this way: Many of these people experience lack of sleep continuously. He can’t sleep because he thinks so many things from back experience and up until now, and issues that are not resolved for him and for his family. So because of this pain and long sleep deprivation, many people use medications.

This problem with falling asleep and staying asleep was common across all refugee groups and was connected to worry, thinking, difficulties with concentration and memory, and loss of appetite. All refugee groups discussed being tortured for speaking. They were tortured for speaking their language, for participating in cultural practices, and for speaking about political and human rights issues. Becoming speechless or having no words to describe atrocities was commonly expressed. Some became speechless because of their traumatic experiences and were hospitalized. One Oromo refugee described the struggle to speak this way: They were tortured and imprisoned in their own country for speaking, to have the right as a people, as a citizen. Still the pain exists because the issues that made them to be victims have not been resolved. We have ongoing pain and suffering that we can’t describe.

Many refugees talked about their efforts to avoid reminders of their traumatic experiences. The Karen described their avoidance of politics and people. One participant said, “The Karen from here, mostly we are living in quiet. We don’t want to participate or demonstrate. We will refuse political activities.” Another refugee described his mother’s avoidance of people: “She’s afraid of people. She was suffering from depression, worry, and concern. When she sees people she gets scared and thinks that she might be killed. She runs away from people.” Lack of trust or distrust was described in particular by Karen and Oromo refugees, because both communities worried about the ongoing presence of spies. An Oromo participant shared,

There are spies here. This is how the African government works sometimes. If you say bad thing about them here, they will go back and attack the rest of the family back home. If I say something openly in a meeting against the government, they will find an excuse for them to be arrested, tortured, and under surveillance. That is why most of us cannot openly express our feelings about what is happening back home.

Some refugees described the use of various substances, such as alcohol, to help with feelings and stress. One Karen man stated, “If people are stressed or have some problem, they drink until they have lost control.” Loss of control sometimes led to behavioral violence or domestic violence: “In our community, if they have a fight with the wife, they drink. It’s an excuse to drink. It’s an excuse to beat your wife.” Oromo refugees stated that the use of drugs or alcohol was not acceptable in their community, so they would not see them used openly. Somali women mentioned the use of khat for dealing with stress: “For those people that used to chew khat before when they were stressed out or worried, they chew more so they can numb their pain.” Startle was a reaction reported by many, and was described well by a Bhutanese youth who was frightened of Maoist invasions: “We all lived in fear and it was so scary that even if a pin dropped, a small noise, it was, ‘Oh my God! They have come!’ We would all wake up scared.” Physical effects. The most common physical effects (bodily sensations) described by all refugees groups were headaches and stomach aches. All groups also discussed various physical pains, including all-over body pain, pain in the heart or fear of having a heart attack, neck pain, and pain related to specific torture experiences. Somali and Oromo refugees mentioned high blood pressure. Somalis used the phrase “air in the brain” to describe their physical sensations. Oromos described emotional pain by saying that they “burn from the inside.” They also discussed feeling tight or stiff. Emotional effects. Refugee groups differed most in describing emotional words used to convey mental distress. All groups discussed fear, sadness, fright, depression, and hopelessness. A few groups added anger, pain, emotional burning, frustration, shame, and guilt. Fear. Fear was commonly described in reaction to war and political oppression. Refugees also talked about feeling afraid here for families who were still living in danger back home. One Bhutanese refugee stated, “We all feel the same fear. We have experienced it once and we feel like it again.” Bhutanese youth stated that fear was a prominent feeling in camp life because “we all


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Shannon et al. lived in fear and fear.” Karen refugees explained that when they faced stress and difficulties, it brought back the fear from the past. Sadness. Sadness was described as the main reaction that refugees had in response to losses, such as being forced out of their home and witnessing and enduring atrocities. Sadness was the word that many refugees used to explain other experiences, such as being “upset” or in “mental pain.” Oromo refugees explained that losses add up to make people sad. Karen refugees used the word sad to describe reactions to loss, such as the loss of a son. Bhutanese reported feeling sad about being unable to bury their dead properly: It feels sad to think about life in camp when those incidents happened between refugees and locals. When someone dies in the Hindi culture, we have something called death ceremonies that we couldn’t do properly because we couldn’t go out and buy anything. Can you image how hard it was to not be allowed to go out?

Karen youth reported feeling sad when seeing their parents’ sadness and the suffering of the Karen back home. Oromo young adults indicated that their parents did not share sadness because it could be perceived as a sign of weakness. They reported that instead, their parents showed anger because it was more acceptable than sadness.

adults used the word “depressed” to describe how they felt in the camp: “You know, you feel so depressed. Your parents are not with you and you heard about your other family members facing a problem and he was killed.” Bhutanese refugees used the words “sad” and “dark state of mind” to describe what prevented people from getting involved with the community. One participant said, It’s like you are sad and you’re not getting involved with the community. It’s a term like depression. The exact meaning is dark, but it’s not dark. You are quiet and you are not talking. In the community, you know this guy is not happy or something is bothering him, and he’s kind of aloof, and if you invited him to something he won’t come.

Suicide was described as a possible effect of such prolonged depression for Bhutanese and Karen refugees. Oromo refugees discussed suicidal feelings but stated that this option was outside their religious practice: “Because we are a human being and we are created by God, so we can’t waste our life. It is what we are told from childhood by our families.”

I cannot interpret that in one word. I have to go around. For example, you woke up today and you don’t want to do that. You are going and meeting somebody else, today you don’t want to do that. You are reading, even your Koran or your Bible, and today you don’t want to do that. And that is a sign of depression.

Anger. Somali, Oromo, and Bhutanese refugees discussed anger in reaction to their political situation; however, Karen refugees did not use the words angry, anger, or mad to describe their emotional reactions. When Karen talked about feeling “upset,” they defined it as being closer to sadness than anger. Refugees described anger in a variety of ways. Somali women stated that when people became angry and “mentally ill” they might start talking too much and become argumentative or violent. Somali men also stated that people became unpredictable when they were angry. Most Oromo used anger to refer to their feelings about the government back home. They stated that the trauma of colonization was hidden from the international community and was not as visible as open warfare. Oromo young adults expressed anger as a result of being confused with Ethiopians and being referred to as Ethiopians in class. For Oromo refugees, anger was described as the only acceptable feeling to express; one young adult explained: “Anger is the highest state of expression to express the highest disappointment.” The Bhutanese discussed how frightened they were to show their anger out of fear of retaliation. Their history of torture for speaking up made it difficult for them to express feelings of anger; instead, they reported keeping these feelings inside. One Karen cultural leader offered a similar explanation for why Karen did not express anger openly:

Karen refugees described depression as a combination of worry and hopelessness. Depression was described in the context of having trouble meeting needs. Karen young

People are reluctant to talk about themselves, and I don’t mean that they are nice and never get angry. Our parents and leaders taught us, the big problem make it smaller, the

Depression. All groups described sadness in connection with a functional definition that interpreters labeled as depression. A Somali woman described it this way: She loses a lot of weight and has a lot of stress. You can see that she’s going through a lot of trauma. He or she might be quiet and not talk to other people, so that’s how you tell. We call that person “not dead or alive.”

As described above, Oromo refugees described depression as being related to giving up hope or “cutting hope.” There was no one word to describe depression in Oromo; instead, the interpreter and cultural leader for the Oromo group stated it like this:


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small problem make it disappear, “problem outside of the house cover with leaves, problem inside the house cover it with clothing.” People had long suffering over the sixtyfive years of civil war. People are getting tired of fighting and living in the refugee camp for so long. Now, with resettling in the third country people try to forget the past. Most of the songs and prayers that they were saying is about forgiveness, peace, and thanks for their life. But they can only hold it for so long and they end up with alcohol abuse.

Pain. Somali and Oromo refugees were more likely to use the word “pain” even when discussing emotional or “mental pain.” For example, Oromo refugees stated that pain was difficult to express and involved the ongoing pain and suffering of millions of people, pain on top of previous pain. This pain was associated with difficulty expressing feelings: “I feel the pain everywhere but it’s hard for me to express in words. I don’t know how to express my feelings.” Oromo refugees stated that they continued to suffer here because much of their life was back home, and that they felt pain because nothing was getting better. Burning emotionally. Oromo refugees used the expression “burning emotionally” to describe the effect of keeping painful feelings inside. One participant stated, They are more burning emotionally inside so we see crying more. They are worried about their sons, daughters, brothers, and sisters that are still victimized. They are left in refugee camps. Some of them have lost their sons and daughters through war or through natural causes in refugee camps so they never see them again. All this pain is worse in women but can’t or doesn’t come out.

One Oromo woman confirmed this phrase, saying, “We burn ourselves from the inside.” Frustration. Oromo and Bhutanese refugees described feeling frustrated in response to the particular situation of oppression in their home country. Bhutanese young adults used the word “frustrated” to describe how they felt about having no identity to work outside the camps: “Some people would get so hopeless and frustrated that they would join the rebel group and they would also join gangs.” An Oromo participant stated, The frustration I was talking about adds up with the series of torture and imprisonment and loss of loved ones because of war. The other is life experience in refugee camps when they run away. By the second country, government officers come and harass or kidnap people, so every day they have to think, “Maybe I’m the next one.” And then they come to this country, they don’t have relative and they don’t speak the

language. These all add up every day to make sadness, lack of sleep, and frustration after frustration.”

Shame. Bhutanese and Oromo refugees discussed feelings of shame that women struggled with in reaction to rape and sexual assault. A Bhutanese refugee explained the complexity of shame: Sometimes a rape case took place even as small as a fiveyear-old child in the camps. It was pretty common. But mostly the victim was a refugee and the perpetrator was a local community member. Sometimes they bring it up in public. If it is an older girl, sometimes they don’t talk about it because of shame and for the future.

Oromo men stated that it was common for whole villages of women to be raped, but they suffered in silence and did not talk about it because of shame: “They’re not telling. It affects them in many ways. Because of the cultural thing, they don’t want to even discuss with the interpreter that this happened. It’s just degrading her respect and so she prefers to keep it herself.” Guilt. Bhutanese described struggling with guilt related to forced participation in the destruction of homes during war and because of being unable to provide for their family. Bhutanese young adults were described as struggling with feelings of guilt and hopelessness. A young adult stated, Especially there is a big hopeless and guilt feeling among the youth because they were thirteen or fourteen years old when they left Bhutan, and they spent the most productive age in the refugee camp. Now they are here with their older parents and they are not that resourceful like they would have been if they had been in their own country. I feel guilt and kind of hopeless that I cannot provide proper housing and proper food for my older parents. It’s hard to get adjusted here and to feel confident that I can do something. That is the general feeling of my age group.

Hopelessness. Oromo, Karen, and Bhutanese refugees referred to hopelessness. Karen and Bhutanese refugees associated hopelessness with losing their identity and being unable to work or have a future: “I lost my identity. I lost my future. It’s a bit like people get worried because of stress. It’s kind of like hopeless.” A young adult Bhutanese explained that “it was bad luck to be born in this time. I am hopeless, I can’t do anything.”

Discussion The findings we report in this study contribute to knowledge of common and culture-specific mental health


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Shannon et al. concepts in four recently arrived refugee populations, suggest directions for future research, and suggest recommendations for clinical practice. The experiences and perspectives shared by participants challenge existing ideas about conceptions of mental health among refugees; in particular, the notion that refugees prefer to avoid conversations about political trauma and mental health and tend to view all mental health problems as indications of “craziness.” We also confirm some previously reported universal and culturally grounded idioms of distress.

Acknowledging the Political Context of Trauma As Important to Healing Each refugee group asserted the importance of understanding mental health effects in a political context. Participants did not want to discuss symptoms separate from conversations about the political context of those symptoms. This finding emerged through the participatory process of our focus group interviews as refugees asserted that some of our questions and interview instructions were not valid for understanding their experiences. They effectively changed the question to, “How did what happened to your community create suffering and how do you recognize that political suffering?” They asserted that validating the political nature of their trauma was required for understanding their symptoms and required for healing. The most compelling examples of this assertion came from refugees who had been tortured for speaking their language or discussing their political beliefs or religious practices. For example, Oromo refugees asserted that the only cure for their psychological problems was political change in their home country. Refugees who have been tortured for speaking about politics need the trauma associated with self-expression recognized and their right to free speech affirmed to begin collaborating with providers in a treatment relationship. Acknowledging the dehumanizing nature of political oppression is healing in and of itself for torture survivors who have been denied free speech. Understanding and healing the symptoms of political oppression starts in the initial assessment with validating the ways that political trauma has rendered refugees “voiceless.” Listening, documenting, and witnessing individual and community stories of exposure to human rights violations is credited as an essential component of restoring human dignity. This initial finding also has implications for health care providers who administer symptom inventories to refugees in primary care, public health, and mental health clinics. General symptom inventories contain questions about depression and anxiety that lack the political context for understanding those symptoms. The brief time available for conducting health interviews has left many health care providers feeling reluctant to ask refugees

about their history because of concerns that it might lead to lengthy discussions and be retraumatizing for refugees (Eiseman, Keller, & Kim, 2000). However, simply asking questions about symptoms might risk leaving refugees feeling misunderstood and fearing that they are viewed as “crazy.” Refugees want their struggles understood in context, and they are happy to discuss political history to make their symptoms understandable. Refugee providers might benefit from training on the political histories of refugee populations and best practices for validating refugees, and for providing psychoeducation during short assessment interviews.

Mental Suffering Is More Than One Construct Called “Crazy” Scholarly writing about mental health stigma in refugee populations has indicated that refugees are reluctant to discuss their mental health symptoms because they fear being viewed as “crazy.” Contrary to those findings, the refugees in this study were eager to explain their understanding of a range of mental distress, from mild to extreme symptoms, in reaction to traumatic and life circumstances. They did not view all discussions of mental health as leading to a diagnosis of “craziness,” but instead offered complex and multifaceted conceptions of psychological distress. When refugees discussed their understanding of a continuum of mental health symptoms, they tended to explain them in a political context and in terms that described the symptom and its effect on functioning. For example, refugees who were mildly distressed might be mentally distracted by war back home but still be capable of caring for themselves and their family. Refugees suffering with reminders of past trauma have reported physical reactions such as crying, looking sad, or becoming speechless as they go about their daily activities. Such descriptions indicate that refugees conceptualize mental health through multiple lenses that include political context, outward expressions of distress, and overall effect on daily functioning. What participants reported in this study suggest that there are at least three essential domains of experience that might be useful to discuss with refugees when assessing the effects of trauma: political context, overall effects or symptoms, and effect on functioning. The refugee groups in this study also seemed to recognize a difference between “biological craziness” and mental distress caused by political trauma, even if that distress was quite serious. Some of the refugees reported using different words for similar symptoms with different causes. For example, the Bhutanese had a word for someone who loses his or her mind as a result of imprisonment. The fact that each refugee group had language that indicated contextualized dimensions of mental distress


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also indicates that they did not readily reduce mental health issues to “craziness,” nor did they label people who were suffering because of war or torture as “crazy.” For example, Bhutanese and Oromo refugees expressed great sympathy for symptoms created by imprisonment and torture. The knowledge that refugees in this study did not view all conversations about mental health as indicators of craziness has implications for health care providers as well. Attending to the language related to context and functioning that refugees use might be very helpful in overcoming stigma and obtaining accurate assessments of mental health. For example, using the case of Oromo refugees, instead of asking refugees about feeling depressed when there is no word for depression, it might be more helpful to ask them in functional terms, “Are you feeling like you don’t want to do what you usually do?”

Universal and Culture-Specific Concepts and Idioms of Distress The greatest agreement among different refugee groups was observed with regard to the cognitive and physical effects (head, stomach, and body pain) associated with war trauma. The greatest variability in culture-specific concepts and idioms was observed with regard to the emotional effects of war trauma. The most universal cognitive language used to describe the effects of war trauma was a category called “thinking too much.” Thinking too much has emerged as a category in previous refugee studies (Miller, 2009). In this study it consisted of several themes, including thinking about past trauma, worrying about family back home, and thinking about present concerns and future worries. It was believed that thinking too much could lead to more serious mental health problems such as memory loss, and eventually loss of control or “craziness.” Thinking too much appears to be a universal phrase that encompasses many cognitive effects of war trauma and might be useful in a general question to help providers begin to inquire about the severity of specific symptoms. The refugees in this study did report symptoms that are considered universal PTSD symptoms, including reexperiencing in the form of nightmares and flashbacks; avoidance, including avoidance of people, political activity, and television reminders; and hyperarousal, including startle reactions, anger, and sleep difficulties. Although refugees reported negative cognitions, often they were associated with existing political realities and ongoing trauma back home, and therefore such symptoms might need to be evaluated in context on a case-by-case basis. For example, the concern among Karen and Oromo refugees that there were spies in their local community might

have reflected the current political realities they were facing living in the United States rather than cognitive distortions. Fear, sadness, and at least a functional definition of depression were consistently reported across the four refugee groups; however, many of the emotional experiences and expressions associated with refugee trauma were culturally unique. For example, the Karen described a “heart in trouble” or an “unclear heart.” Oromo refugees described “burning from the inside,” and some Somalis described feeling “not dead or alive” and having “air in the brain.” Finding culture-specific experiences and idioms of distress is consistent with the growing body of global literature and studies on this topic among diverse populations (Hinton & Lewis-Fernandez, 2010). Recently, van Rooyen and Ngweni (2012) developed a conceptual framework to explain cultural variability in symptom expression and why the same symptoms in different cultures do not necessarily mean the same thing. They postulated that the same underlying dynamics might cause very different symptom expression related to the influence of different cultural narratives and schemas associated with distress and suffering. For health care providers, it might be very useful to inquire about both universal conceptions of PTSD and cultural variability in the expression of the emotional effects of war trauma, particularly when assessing the concept of depression. Understanding the existence of cultural variability and inquiring about it with refugees is also useful for providers who assess emotional impact or the truth of refugee accounts for the determination of legal or social service benefits. The influence of “reality” TV performances in the United States might make the overt expression of emotion seem commonplace; however, refugees who have been tortured for expressing political opinions or feelings of any kind might have great difficulty expressing feelings on demand. After years of oppression, they might have a hard time even knowing what they feel. Providers might draw the wrong conclusions about the veracity of refugee accounts or the emotional impact of traumatic experiences if they apply Western universal conceptions of mental health and suffering to vastly diverse populations.

Limitations and Recommendations This study is limited by the focus group methodology that yielded community-wide understandings of the mental health effects of trauma. Rather than providing an in-depth exploration of individual narratives related to mental health, we sought broad community-based understandings to aid the construction of culturally grounded screening processes. It is possible that a more in-depth


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Shannon et al. interview study integrating phenomenological dimensions of trauma would reveal richer and more nuanced cultural understandings of mental health and idioms of distress. Clearly, this is a direction for future research. In particular, understanding refugee recommenddations for interviewing trauma survivors and for addressing mental health issues and healing would be useful qualitative explorations. The broad scope of this study also limited our exploration of meaningful variability based on gender, age, and other demographic variables that might influence cultural expression and meaning. Although we reported some cultural language used to describe mental health distress, this language might vary based on tribe, local dialects, country locations, age, and other culture-specific variables that affect language. Our findings are relevant to the ethics of constructing or applying universal measures of mental health when interviewing refugee populations. The observation of cultural variability in terms used to describe the effects of war trauma lends support for including both universal and culture-specific terms in assessment processes. We are currently using common and culture-specific knowledge reported in this study to inform the development of culturally grounded mental health assessment tools and processes for newly arriving refugees. Based on these findings, we also question the universal recognition of mental health stigma among refugees as a reason for not inquiring about their mental health. Toward the goal of improving access to care, health care providers might require more training about how to work collaboratively with new populations of refugees to assess the mental health effects of war. Acknowledgments We thank the cultural leaders and interpreters for their invaluable assistance with this research: Amano Dube, Ehtaw Dwe, Fardous Egal, Chalthu Hassan, Saw Josiah, Parmananda Khatiwoda, Johara Mohammed, Mangala Sharma, and Wilfred Tunbaw. We thank our research assistants, Hyojin Im, Tomoko Ogasawara, and Pamela Kriege Santoso for their assistance. We thank the Center for Victims of Torture, especially Evelyn Lennon and Jon Hubbard, for their invaluable contributions.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We received partial funding support from the Blue Cross and Blue Shield Foundation of Minnesota through the Center for Victims of Torture.

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Author Biographies Patricia J. Shannon, PhD, LP, is an assistant professor at the School of Social Work, University of Minnesota, St. Paul, Minnesota, and a research associate at the Center for Victims of Torture, Minneapolis, Minnesota, USA. Elizabeth Wieling, PhD, LMFT, is an associate professor at the Department of Family Social Science, University of Minnesota, St. Paul, Minnesota, USA. Jennifer Simmelink McCleary, PhD, is an assistant professor at the Tulane University School of Social Work, New Orleans, Louisiana, USA. Emily Becher, LAMFT, is a doctoral student at the Department of Family Social Science, University of Minnesota, St. Paul, Minnesota, USA.


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