Assessment Literature Review 1
CDHS (Research Foundation) University at Buffalo, StateUniversity of New York
School of Social Work
A Framework for Assessment of Traumatic Experiences by
Southeast Asian Refugees
Steven Osterstrom, Ph.D. Student, School of Social Work,
University at BuffaloStateUniversity at New York
Hilary Weaver, DSW, Associate Professor, School of Social Work, University at Buffalo
StateUniversity at New York
Meg Brin, Child Welfare Director
Funding for this Literature Review was provided by the NYS Office of Children and Family Services, Award: 20058, Project: 1014484, Task: 1.1.2, through the Center for Development of Human Services, Research Foundation of SUNY, Buffalo State College.
Abstract
This project provides a literature review of the assessment framework used in the identification of physical and psychological sequelae of posttraumatic stress disorder and other reactions to violence experienced by refugees residing in the United States and Canada from Southeast Asian countries of origin. There is an emphasis on assessment of children and youth with an understanding the macro and micro cultural context within families and communities. There is a focus on the development of a framework for assessment practices to increase the cultural competence of practitioners in providing care to these children and families. The historical context of torture and trauma are reviewed with a detailed review of the definitions of torture, trauma, diagnostic characteristics, and implications for care. The psychological sequelae of trauma are reviewed. The Harvard Trauma Questionnaire is described by reviewing his development and adaptation to the needs of the Southeast Asian population. The work of this student in adapting the Harvard Trauma Questionnaire in assessing the Tamil’s from Sri Lanka, another Asian population, as part of a University at Buffalo research project is described.
Historical Perspective
There are reportedly about 15 million refugees in the world, many of whom have suffered violent persecution. Many have suffered from starvation, war, and severe human rights abuses including political arrest, arbitrary detention, torture, and execution (Chester & Holtan, 1994). Numerous factors must be understood to best provide for the health and well-being of these refugees. This project reviews the literature describing methods of assessment and precautions that are needed in understanding this phenomenon.
The effects of traumatic experiences are still not well understood despite the great prevalence of these events and the magnitude of their negative outcomes. Most of the knowledge available is related to the short-term effects of single-event traumas or combat trauma. No single theory has yet explained how short-term and long-term effects can result from traumatic experiences. The reason is that this field is so new. Substantial research did not begin until the 1980s in response to questions about the trauma experienced by Vietnam veterans.
Torture has been used throughout history including many accounts recorded in the Bible (Eitinger & Weisaeth, 1998). It was a generally accepted way for a king to deal with a defeated enemy, but the Church also learned it was a useful instrument for keeping people on the right path and to avoid heretical beliefs. It was used to force suspected criminals and heretics to tell the truth. This form of interrogation was accepted across the world for many centuries (Eitinger & Weisaeth, 1998). The blindness of intellectuals prior to World War II was so complete that they did not see, or were unwilling to see, that these methods were so pervasive in their own countries. The use of torture in World War II reached such heights and was so widely known that professional groups began to take an interest and sought knowledge on the subject.
The results of research conducted mostly in Denmark and Norway (Eitinger & Weisaeth, 1998) were dramatic in proving that there were long-term effects of torture. Severity of trauma was correlated with the incidence of inflicted head injuries and postwar impairment, as well as with abuse of alcohol and drugs. The use of torture had been designed to crush the resistance of those arrested and to destroy their personalities. Torture under any circumstances has severe psychiatric consequences.
It was not a medical organization but a human rights group that made the first organized attempt to understand and fight against the use of torture (Eitinger & Weisaeth, 1998). Amnesty International held a conference in 1973 to identify that torture had been occurring and how to abolish it. They traveled to countries where they suspected torture had occurred and questioned doctors for medical evidence. Those leaders who allegedly executed the torture vehemently denied its use and that any symptoms of survivors had any connection with their mistreatment. After the examination of hundreds of survivors, scientific certainty was established for the consequences of torture.
A Danish medical group associated with Amnesty International was the driving force behind the efforts to do more than research the phenomenon by helping the victims. The first Rehabilitation and ResearchCenter for Torture Victims in Copenhagen was established by the group (Eitinger & Weisaeth, 1998). They discovered knowledge about the torture perpetrators and survivors. One important piece of awareness was that medical doctors had participated in the process of torture, often conducting scientific experiments on victims. Research has shown that medical doctors were present during the administration of torture, directed the intensity, and decided when to continue or to stop. Military doctors are under pressure to conceal the activities of colleagues out of loyalty to the military profession.
The recognition of symptomatology related to torture was a phenomenon of the 1970s. At this time, there was no systematic medical literature on the subject (Genefke & Vesti, 1998). It was found that the worst sequelae of torture was psychological. It is not only “unbearable, perverse, and disgusting when it happens, but it stays with survivors and haunts them many years later” (Genefke & Vesti, 1998, p. 44).
The variability used in diverse studies through the world motivated the ResearchCenter to set up an academic, multidisciplinary consensus group in 1990 in order to define uniform terminology to be used internationally for direct comparison of data. They discovered that the most frequent torture-related signs and symptoms can be grouped under a limited number of headings without the complexity of the problem being underestimated. They decided to group the mental symptoms according to the DSM-III-R. Psychological torture was divided into “weakening procedures” and “personality-destroying procedures” (Genefke & Vesti, 1998). The former was designed to teach the victim to be helpless and to experience fatigue. The latter were characterized by the induction of guilt, fear, and loss of self-esteem. They discovered that the main aim of torture was not to obtain information but to break down the person’s personality. They destroy the person’s ability to cope with life situations in a normal way. They also discovered that they could help the victims of torture by redressing the issues. It is not hopeless as believed at an earlier time.
Demographics of Southeast Asian Refugee Children and Adolescents
The United Nations 1951 Refugee Convention defined refugees as persons outside the boundaries of their own countries who were not firmly resettled elsewhere and who maintained a well-substantiated fear of persecution based on race, religion, nationality, social class, or political opinion in their country (United Nations, 1951). The Refugee Act of 1980 utilized this definition and clarified the legal parameters for refugee status but failed to provide a continuity in provisions for refugees. Thus a thoughtful, long-range policy for meeting the needs of refugees did not evolve in the United States (Huang, 1998).
There were 806,000 Southeast Asian refugees in the United States by the end of 1986 (Huang, 1998). Vietnamese make up 63 percent of the group with 19 percent from Laos and 17 percent from Cambodia. In 1990 there were more than a million Southeast Asians in the United States with a growth rate of 150 percent between 1980 and 1990. It is a relatively young population and 55 percent male. The median age is twenty five years old. They are concentrated geographically in the West with 316,200 in California, 61,100 in Texas, and 37,00 in Washington. Although refugees reside in every state, about 85 percent are concentrated in eighteen states (Huang, 1998). The United States originally planned to disperse refugees throughout the country in order to prevent an excessive burden on any community, but secondary migration and the tendency of later refugees to join an existing enclave disrupted this plan. Employment opportunities in established ethnic communities, better welfare benefits, training opportunities, reunification with family members, and better climate were all factors in this secondary migration. Forty-one percent of sampled refugees aged sixteen and older in 1986 were in the labor force compared to 65 percent of the general population. The jobs usually differed in type and status from the jobs they previously held in their own country (Huang, 1998). In 1990, sociodemographic data indicated that Southeast Asians remained among the most economically stressed and impoverished groups in the United States. Some of the most common social and psychological problems experienced by this population have been economic strain, acculturation difficulties, and disruption in the family system and roles.
Although many well-educated and professional people entered the United States in the first wave of immigration, those who were a part of the second and third wave did not adjust as well. Their conditions and methods of flight were harsher, they had less education and skills, were rural, and had little contact with American culture prior to arriving (Huang, 1998). On arrival to this country, the refugees were entitled to government assistance for two years as a result of the 1975 Indochinese Migration and Refugee Assistance Act.
There have been few systematic research studies of the psychological or behavioral adaptation of Southeast Asian youth (Huang, 1998). In a three-phase longitudinal study of 115 Vietnamese refugees, Lin, Masuda, and Tazuma (1982) documented high levels of physical and psychological dysfunction during the early period of their resettlement. They reported a disproportional frequency of psychosomatic disorders and somatization, which may reflect a cultural expression of some disorders such as depression and anxiety. Research has shown that most of the refugees were doing well in spite of stresses such as loss of role identity and self-esteem, social isolation.
Nidorf (1985) observed in clinical work with refugee youth a high level of severe depression, hysterical conversion reactions, agitation, and antisocial and acting out behaviors among those youth who came unaccompanied by family. They were vulnerable to feelings of shame, despair, and humiliation. Certain events during their escape include traumatizing experiences such as physical and sexual assault by sea pirates. Especially females following these experiences presented as suicidal, withdrawn, not interested in social relationships and marriage. The unaccompanied group of youth were more vulnerable to maladaptive behaviors leading to “losing face” in their community and became suicidal as a result. Survival guilt often led to suicidal behavior as well.
The psychosocial assessment of Southeast Asian refugee youth must take into consideration three ecological contexts: premigration, migration, and post-migration (Huang, 1998). Within each context, both macrosystem issues and microsystem structures must be included. Huang (1998) provides a detailed description of the areas needing to be explored in each of these contexts and levels of assessment by the clinician. The understanding of torture or other traumatic experiences fits into an overall investigation of these critical issues.
With few exceptions, Southeast Asian refugees have spent a significant part of their lives under conditions of violence, experiencing great loss, fear of the unknown, prolonged periods of waiting, and discontinuities in schooling and health care. The journey was usually traumatizing and life threatening and often intensified by the interactions with their similarly traumatized parents or other caregivers (Huang, 1998). Huang recommends a complete assessment of not only the medical and legal issues involved but a thorough social history using an ecological model. Introduction to Assessment Procedures for Torture and Trauma
Health professionals must remember that the entire process of becoming a refugee is traumatic whether or not there was torture or major trauma such as rape and sexual assault. A clinic in Boston, Massachusetts reported that all its Cambodian patients had suffered one or more of 16 major traumatic events, three of which were torture as defined by the United Nations (Chester & Halton, 1994). The mind-body interaction is essential in the understanding the impact of this overall experience, especially with an Asian population. Without attention to this, patients may spend years in health care systems without finding relief from their distressing symptoms.
The diagnostic approach relies on the traditional medical and psychiatric history of the client/patient (Allodi, 1991). As the story unfolds in the words of the patient, the practitioner is developing a concept of the specific trauma, imprisonment, torture, and other characteristics. The assessment should include an understanding of the indirect traumatic events experienced by family members. An example of this would be family members who have “disappeared” at the hands of the government’s security forces. There is evidence that in adults and children the severity of trauma and fears of persecution are significantly related to the level of posttraumatic symptomatology (Allodi, 1991). The first published material on the subject in the 1970s and 1980s simply described the somatoform, affective, or cognitive symptoms experienced by the population of refugees who had been tortured. Soon there was clinical research resulting in data on personality variables involved as mediators for the effects of torture and other trauma. It was found that low scores on the Authoritarianism-Dogmatism Scale of Rokeach predicts a better outcome after trauma (Allodi, 1991). Measures of social support, social isolation, and other environmental variables have increased awareness of the effects of social context. Allodi (1991) found that it may take many months of therapy with children before they reveal what they have experienced. Approaches have been identified that help in screening of children who have experienced this type of trauma. Family interviews, play therapy, drawings, and other projective tests have been used to investigate. The Rutter scales administered by parents and teachers have been used with Vietnamese children in Toronto (Allodi, 1991).
Assessment Literature Review 1
Women generally report having suffered from sexual abuse including rape as victims of torture (Allodi, 1991). Research has shown that they experience sexual anxiety and avoidance years afterward. Allodi recommends that tactful inquiries should be made with scales specifically designed to measure sexual trauma in a group format.
Barriers to Conducting Research on Trauma
Researchers cannot control the circumstances surrounding the traumatic events in their subjects’ lives making it impossible to pre-test the individuals prior to experiencing traumatic events. It is also impossible to use experimental designs in research on human beings with the ability of manipulating different variables. Ethical considerations for effective and immediate treatment of survivors must always take precedence over answering research questions. Timing is an important aspect to consider and imposes problems for researchers. Immediately after experiencing traumatic events, most subjects are not willing to participate in research projects that may be perceived as invasive or would remind them of the trauma. They may feel they need to be protected from those memories and prefer to save their psychological resources for coping with daily life.
Traumatic events are usually not clear and discrete for research purposes. It is difficult to get detailed information about the event because it is confused with other political, social, cultural, and other complex phenomena. The survivors themselves may only be able to provide limited information about the events because of amnesia for aspects of the experience. When the event occurred in the past, the limitations of memory are even more a problem for gathering data. Archival data is difficult to find because records may not even exist for the type of incident involved.
A Conceptual Framework for Understanding Responses to Trauma
A good conceptual framework for understanding the different responses to traumatic experiences can help in conducting an accurate and efficient evaluation and in understanding the trauma-related symptoms. The framework presented by Eve Carlson (1997) addresses what makes events traumatic, what psychological responses are expected following trauma, and why symptoms persist after the experience is over. In Carlson’s framework, three elements must be present. The event must be experienced as a) sudden, b) extremely negative, and c) uncontrollable. The initial responses to the event include reexperiencing and avoidance in four modes of experience, and each of these symptoms is causally related to the traumatizing elements of the event.