Barry N. Stein
link to Prof. Stein's homepage
Carolyn Williams and Joseph Westermeyer, editors
Refugees and Mental Health
A draft of this chapter was presented at a conference on "The Refugee Experience" sponsored by the Royal Anthropological Institute and the Minority Rights Group in London, England in February 1980. Portions of this chapter appeared in the International Migration Review, vol. 15, No. 1, under the title "The Refugee Experience: Defining the Parameters of a Field of Study."
The refugee problem is worldwide: today no region or continent lacks refugees--people caught between danger at home and loss of identity in a strange land. Fear of persecution has led millions to flee their homes and seek safety in strange societies where they may be isolated, different, and often impoverished. Although the refugee problem has existed for a long time and has created great suffering for refugees and major difficulties for those who have tried to assist refugees, there has been little refugee research--research which might relieve the suffering of the refugees and assist those who try to aid the refugees. Despite tens of millions of refugees in this century, refugee research is sporadic, unsystematic, isolated, and cursory.
Superficially, when viewing refugees one is struck by diversity, a large number of refugee groups from distinct cultures forced to flee due to a wide variety of historical circumstances. However, scientifically, it is possible to develop a perspective which sees certain consistencies in the refugee experience and refugee behavior. The basic premise with which this chapter approaches refugee research is that there is a refugee experience and that this experience produces what we can call refugee behavior (David, 1969; Kunz, 1973; Liu, 1979). Refugees should be seen as a social psychological type whose behavior is socially patterned. Refugee problems should be analyzed from a general, historical, and comparative perspective which views them as recurring phenomena with identifiable and often identical patterns of behavior and sets of causalities. Specific refugee situations should not be treated as unique, atypical, individual historical events but rather as part of a general subject; refugee behavior, problems, and situations that recur in many contexts, times and regions.
Unfortunately this viewpoint is not widely accepted by many scholars or by most governments. In most cases this is not due to rejection: most people have never even considered this approach. Refugee problems are usually seen as isolated, deviant, and non-recurring. The consequence of this view is a failure to learn the lessons of the past, a failure to develop an institutional memory, and a constant need in connection with each new situation, to re-invent the wheel. And the wheel that is reinvented is not perfectly round. When we re-learn the lessons of the past we repeat the mistakes, blunder into the same crises, and use the same erroneous ideas that caused needless human waste, suffering, and hardship in earlier refugee programs.
The scholarly inattention to the refugee problem is understandable because of the nature of the problems themselves. Refugee research does not fit neatly into disciplinary categories. Some aspects of refugee research appear to fit fairly easily into a disciplinary or area studies framework, such as refugee mental health or refugees in Africa, but most of the research is inter-disciplinary and would benefit from cooperation between scholars with different skills. The breadth of the problems and subject demands an inter-, cross-, multi- disciplinary approach. Sociology, psychology, anthropology, law, political science, linguistics, medicine, social work, history, and of course, area or regional subdivisions of these disciplines all impinge on refugee studies.
The lack of an easy disciplinary fit combined with the common view that refugee problems are unique, atypical, and non- recurring problems has produced scholarly neglect of refugee research possibilities. For most disciplinary specialists or area experts refugee problems are too isolated, atypical, and unpromising to distract their interest from normal, mainstream research topics. Refugee research is not a ready-made field of study. It lacks standards textbooks, a theoretical structure, a systematic body of data, and even a firm definition of the subject of the field. The researchers must be prepared to wander over neighboring fields, borrowing and modifying ideas, concepts, and theories from analogous situations.
The 1951 Convention Relating to the Status of Refugees defines a refugee as any person who:
owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.
This definition does not include displaced persons who have not crossed an international boundary nor does it include those who fled, internally or externally, to get out of the way of war or civil strife. Laws and treaties limit the refugee experience or behavior these legal distinctions are relatively unimportant. For social scientists the refugee category is defined by the trauma and stresses, persecution and danger, losses and isolation, uprooting and change of the refugee experience.
Disciplinary or area studies specialists are likely to notice the refugee problem only when it forcibly intrudes in their field of view. The occasional spectacular refugee movement which commands widespread interest may be seen as an opportunity for research. But even during such episodes most of these opportunities will be used not to do research on refugees but rather to use the refugee problems as a means to research other ends. They are studying their ethnic groups, albeit in a new location; or the mental health problems of Asians, minority groups, or immigrants; or race relations; or the usage of public assistance by different client groups.
Research using refugee subjects done this way often adds little to our knowledge of the problems of refugees. Area specialists could contribute much to refugee research but often their effort lacks the perspective and analytical tools needed to understand their special group after that group has been torn from its milieu and rudely transplanted to a vastly different environment.
Many people dealing with refugees don't even know who or what they are studying. They can't define or immigrant and have no idea of how profoundly different the background and behavior of refugees is from under-privileged minorities. All too often one needs to say to other scholars or government officers, "Don't call them immigrants," or "Refugees are not poor people. They are successful individuals temporarily without funds and opportunities.
Many researchers are simply unaware of refugee research already done or of the possibilities of using a general approach. When they embark on a refugee study it seems, to judge from footnotes and bibliographies, that they never visit their library catalog and check for references marked "refugee." The result is not only "original" scholarship that fails to build on the efforts of the past but also one-shot scholarship. Because they research the current refugee movement as a non- recurring event, their work ignores available general theories that are as valid for religious refugees of biblical times as well as for ideological refugees of modern times.
The core problem that results from scholarly inattention to refugee problems is a failure to learn from past experiences. Few institutional records and analyses of concluded programs are developed. This is a problem in both the private and the public sectors.
Government agencies do not always write after action reports. Private agencies are too busy with the next crisis and fail to analyze what they did in the last crisis. Expertise exists but it is in the minds and experience of the old hands. It passes by word of mouth, example trial and error. Often while one agency is befuddled by a problem another is successfully coping with it. Sometimes the answer to your problem is in one of your own branch offices but unwritten, without analysis or evaluation, the answer is lost or unavailable.
Until recently, this lack of institutional memory required each new refugee wave to be treated on an ad hoc emergency basis. During each refugee emergency there is a quick start-up with almost no pre-planning; programs are temporary and designed to respond to the specific needs of individual refugees. Coordinated efforts with built-in research components are rare. Experiences with alternative strategies of intervention and assistance and with systematic approaches to the matching of resources with needs often go unreported and are lost for the future. And, of course, there are few experimental programs to test alternatives and develop standards, mechanisms, and guidance.
In part this lack of institutional memory and failure to coordinate and experiment is due to the erroneous belief that the refugee problem of the moment is temporary and unique. If all will be finished in a year or two then there is no time to evaluate, measure, or modify; or to undertake research, learn from the past and prepare for the next wave. However refugee movements rarely take the form of a single burst exodus, rather they tend to be ongoing irregular flows from persecution to safety. The first group of refugees in a new situation does not represent the scale or limits of the problems, more likely they are harbingers, with friends.
The occasional spectacular refugee movement or series of large movements can bring enough scholars into the field -- to cause a break away from the temporary and unique perspective (Stein, 1980). For example, after World War II the massive refugee problems of Europe led to many excellent refugees problems of Europe led to many excellent refugee studies there and in the countries of resettlement. Interest waned, however, the problems receded from view and many of the studies then gathered dust for a quarter of a century. Recently a new body of refugee studies -- this book is an example -- has developed in response to large refugee crises involving many regions and refugee groups (IRIRC, 1982 a, b, c, d). Although during the last five years there have been large resettlement programs involving Cuban, Haitian, and Soviet Jewish refugees and major relief efforts in Kampuchea, Somalia, Pakistan and Central America, the catalytic event generating increased refugee studies was the refugee crisis in Indochina, beginning in 1975, land the subsequent resettlement of approximately one million Indochinese refugees. That program particularly the resettlement component, is now greatly reduced from its peak in 1979 and 1980. It remains to be seen whether the interest in, and support of, refugee studies will continue if refugee problems enter a quiet period.
While there is a great need for useful, practical, applied research on refugees, there is also a need for academic research. Even in this relatively enlightened period people continue to disparage "academic" refugee research -- "in order to avoid that such studies become academic and thus remain without consequences for practical refugee work (German Foundation for International Development, 1982)." Academic research, however, has the ability to anticipate, to develop answers or alternatives before the practitioners or policy makers even know there is a question. .
Thus far this chapter has been a lament of unfulfilled refugee research opportunities and needs. It is better, however, to note how much good, even excellent, work has been done. Much of this work is sadly underutilized. the remainder of this chapter will describe some approaches to refugee research and some key resources. In making this survey it will try to follow the stages of the refugee experience that Stephen Keller outlined in Uprooting and Social Change (1975). These stages are perception of a threat; deciding to flee; the period of extreme danger and flight; reaching safety; camp behavior; repatriation; settlement or resettlement; the early and late stages of resettlement; adjustment and acculturation; and finally, residual stages and changes in behavior caused by the experience.]
Edna Bonacich (1973), writing about middle-man minorities, has described a group that might be considered in jeopardy around the world. It consists of sojourners in a land- -aliens who come to seek their fortune and plan to return home once they have accumulated a pot of gold. Of course, many never return home, but this home orientation, combined with the desire to accumulate money, leads to an isolation from the host culture and to a concentration in certain occupations and business. As an alien element in a somewhat abrasive economic position such groups are particularly vulnerable during periods of nationalist ferment in their host society. The ethnic Chinese expelled from Vietnam (Stein, 1978), the Asians expelled from Uganda (Mamdani, 1973), and many other groups that have been persecuted or expelled fit in this category.
Another fine work is E.F. Kunz's Kinetic model (1973) of the refugee in flight. It is a partial and abstract model, limited to flight, but it has many useful ideas and classifications. In a later and valuable work (1981) Kunz explored theoretical concerns for the periods before and after flight.
The key to Kunz's model of flight is the idea of push. In the language of migration theory, it is common to think of the immigrant as pulled to his new land - attracted by opportunity and a new life. The refugee is not pulled out; he is pushed out. Given the choice, he would stay. Most refugees are not poor people. They have not failed within their homeland; almost all were functional and independent, a great many were successful, prominent, well-integrated individuals who flee because of fear of persecution. (Expellees may be an exception to this generalization. The characteristics of an expellee cohort will be determined by the expelling authority.)
Kunz sees the flight and settlement pattern of most refugees as conforming to two kinetic types - anticipatory refugee movements and acute refugee movements. The anticipatory refugee senses the danger early, before a crisis makes orderly departure impossible. Superficially the anticipatory refugee resembles the voluntary migrant. The whole family moves, brings resources with them, and has made preparations for a new life. The difference between the immigrant and the refugee comes in the unhappy vindication given the refugee's anticipatory move by later events. Another difference is also that any destination will do for the refugee while the immigrant has a preferred destination. The anticipatory refugee wants to leave and will leave as soon as he finds a country willing to take him. The pattern is push-permit. Anticipatory refugees are normally educated, well to do, and alert.
Acute refugee movements result from an overwhelming push. War of political crisis or government policy places the emphasis on immediate escape. The acute movement may be a mass flight which includes many who actually have little to fear but who flee because of the atmosphere of panic or hysteria. Or, if escape is restricted, only small groups or individuals may get out. In an acute movement the refugees leave their homeland on a moment's notice. They have not planned or prepared for the journey; they are not looking at their future; they are simply trying to get out of harm's way. One study of the Vietnamese refugees has found that 85% of the refugees surveyed made their decision to flee their homeland two days to two hours before their departure (Liu, 1979).
Because the acute refugee makes the decision within a short time span, little thought will be given to the consequences of flight. Not until the place of asylum is reached, often in a state of shock, in a condition Kunz calls "midway to nowhere," will the refugee ponder the three classic choices that face refugees: to return home, to remain in the place or first asylum or to accept a distant resettlement opportunity in a strange land. At this point the kinetic factor will be one of pressure from the country of asylum and the international aid agencies to force the refugee and others to make a choice. (Refugees rarely get to choose from the full range of potions. Pressure is used because all of the available options may be more or less unsatisfactory.)
In addition to these kinetic forces, Kunz has described refugee associative patterns in a useful way. There is a tendency to see all refugees from a given country or region as a homogenous group, to label them Cubans or Indochinese and not to look beyond the label. Most refugee groups however, are subdivided into many waves and vintages that may differ greatly, have different experiences, and may even be hostile to one another. Refugee "vintages" (Kunz's term) refer to the fact that those who leave a country at different points in time are fleeing from different pressures and have different backgrounds. As policies and conditions within the persecuting land shift, different refugee groups, or vintages, will flee. As Cuba moved from Batista to communist rule, approximately fifteen different vintages came out in the first thirty months (Fagen and Brody, 1968), and many of those in the later vintages had served in Castro's guerilla forces.
Just as departure from one's homeland may mark a refugee, so the arrival in "waves" in the new land may be of importance. Some 1975 Indochinese refugees found themselves in America in a span of days. Others who at the same time languished for years in refugee camps before being admitted for resettlement. Beyond the impact that the camp experience will have on the refugee, it is clear that the Indochinese refugee wave that arrived in the United States in 1980 did not have the same refugee experience as those who, in 1975, were the first wave to be resettled in this country.
Further, in an ongoing refugee flow, the earlier vintages tend to consist disproportionately of the upper educational and occupational levels of the old society (Stein, 1979). The later vintages are likely to leaven this profile somewhat but overall, refugee groups are normally not representative of their homeland. The total flow is strongly biased in the direction of higher skills, education and occupation as well as being more youthful. (Selection criteria used by different resettlement countries are likely to make particular resettled segments of a refugee group unrepresentative of the total exodus.)
Another aspect of flight explored by Kunz (1981) is that of the majority-identified and events-alienated refugees. The first category refers to refugees who identify with their nation, with their homeland and its people but who have fled from the current government or from a foreign oppressor. Events- alienated refugees normally are from marginal or minority groups who have tried to identify with their country but who have been alienated by its rejection or persecution. The majority- identified refugee will tend to delay flight until danger is paramount and will long and hope to return home. The alienated refugee will often seek opportunities to escape and will eagerly seek a new identity. Acculturation is likely to be much more difficult for the majority-identified refugees.
A particularly interesting question is the refugees' perception of threat and danger. The anticipatory refugee perceives peril early, whereas some acute refugees begin to flee only when the bombs start to burst about them. Similarly, even at this point of clear and present danger there are some who refuse to leave. Jensen (1966) suggests that those refugees who flee emotionally, join the mob, who have an inadequate tolerance of frustration, "whose flight was an almost spontaneous so- called hedonistic reaction to stress" will be most likely to show maladaptive behavior in refugee camps and during resettlement. (f.n. Jensen's research is based on one of the more neglected refugee subjects -- the repeatedly rejected refugee. Currently, there are large numbers of Khmer and Hmong refugees in Thailand who have been in camps for years and who have been repeatedly rejected by resettlement missions.)
There is some information regarding those who make the decision to leave, but much more research is needed. Stephen Keller (1975), using general theoretical aspects first developed by disaster researchers, has explored the reaction to threats and the impact of stress and trauma on behavior. Keller strongly argues that the trauma of flight produces residual psychological states in the refugee that will affect behavior for years to come. Because they usually endure the greatest hardship and loss, those who are late to flee are likely to come out of the experience with residual characteristics; guilt, invulnerability, and aggressiveness. Guilt for the loved ones lost because the refugee delayed flight or failed to protect them during attack. The feeling of invulnerability develops because the refugee has been through the worst and has survived. The aggressiveness is seen by Keller as an outgrowth of the other two states: a displacement of the guilt onto others and a willingness to take risks because one is invulnerable. This new aggressiveness may be displayed in the form of increased violence, crime and suicide, or, as Keller found in the Punjab, in an increased willingness to innovate, to take risks, to make the effort bo build a new life. If Keller is right then he has identified as a refugee characteristic that should be taken account of and advantage of in the design of refugee programs. More important, in pinpointing the effect of the refugee experience on subsequent behavior, Keller has identified an area needing more research.
Scudder and Colson (1982) suggest that active risk taking by refugees does not occur immediately. At first refugees react in a conservative security-oriented fashion "clinging to the familiar and changing no more than is necessary." Later on, often after a period of several years, after reconstituting their lives, the refugees make a transition to a stage "characterized by increased initiative and risk taking and the emergence of a dynamic and increasingly open- ended society."
The next stage in the refugee experience, refugee camps, has received relatively little analysis. A fair amount of descriptive material exists, and a few scholars have examined the impact of the camp experience on behavior, but there is no system of classification of camps nor models of the crucial elements of the camp experience.
The most useful description and analysis of refugee camps is a brief essay by H.B.M. Murphy (1955). Murphy notes that although the physical conditions of camps may vary widely, from hell to hotels, the effects tend to be uniform. The most important characteristics of the camps are: segregation from the host population, the need to share facilities, a lack of privacy, plus overcrowding and a limited, restricted area within which the whole compass of daily life is to be conducted. This gives the refugees a sense of dependency, and the clear signal that they have a special and limited status, and are being controlled.
Murphy and his colleagues (Bakis, 1955; Stern, 1955) find that it is during the camp experience that the enormity of what has happened finally strikes home to the refugee. The focus is on what has been lost. Besides the suffering, trauma, and persecution already endured, and the loss of loved ones, the refugee must now face up to the loss of homeland, identity, and his former life. A new life in a strange land awaits. Anxiety, fear, frustration, and emotional disturbance appear, and often the refugee regresses to a more infantile state, loses his willpower, and becomes apathetic, helpless, or manic and aggressive. The refugee loses structure, the ability to coordinate, predict and expect, and his basic feelings of competence. Bakis writing in 1952 spoke of "D.P. Apathy" to describe camp conditions after World War II. In many of the camps in Pakistan, Southeast Asia and the Horn of Africa the behavior of today's refugees are only too reminiscent of that period.
Maria Pfister-Ammende (1973) writing shortly after World War II noted that refugee camps had a "deeply pathological" effect on mental health. It is possible to mitigate this effect by shortening the stay, reducing camp size so that there is a sense of community, providing dwellings that are bright and private rather than gloomy warehouses, allowing contact with the outside world, and by reducing dependency through participation. In the quarter century since this advice was given it has been only sporadically followed.
Refugee camps are a major feature of today's refugee scene. Roughly one-half of the approximately ten million refugees are in some type of camp situation. The three million Afghan refugees in camps in Pakistan are one of the largest long term refugee encampments in history. Smaller camp populations, only hundreds of thousands each, are in the Middle East, the Horn of Africa, Southeast Asia, and Central America. Most are at least three years old--the Palestinian camps are three decades and four generations old--with no solution in sight. In addition, twice in the last decade there have been major refugee camps for several months in the United States, in 1975 for Indochinese refugees and in 1980 for Cuban refugees.
Despite this potentially fertile research ground almost no research has emerged from the above camp situations. Most of the research has focused on refugee health care (Simmonds and Gabaudan, 1982), with a bit of research on mental health (Morrison and Moos, 1982; Harding and Looney, 1977; Liu, 1979) and very little on life inside the camps (Christensen, 1982). It is understandable that research has not been done in short- lived camps, such as the U.S. resettlement camps, given the difficulties of developing a research design and getting funding and permission in a very brief time. It is less understandable, perhaps even irresponsible, in camps that have been semi- permanent fixtures since the mid or late seventies or even since the late forties. Lewis and Wisner (1981) several years ago issued a call for research on Somali refugee camps that for the most part is still unanswered.
Little is actually known about the origins and background or the refugees, or about the actual problems and workings of the camp. There is an economic and social life in these camps which workers are not aware of, knowledge of which may be very important in order to plan rationally and to avoid egregious errors. It is our strong impression that a short period of direct observation and participation in camp life by a social scientist can pay considerable dividends.
The next stage is departure from the camps. There are three classic durable solutions (lingering in refugee camps is the classic non-solution): the refugees can go home-- repatriation--the solution that gets the least study; can get permission to stay--settlement or integration--in their land of first asylum; or can be sent to a third country, usually distant, for resettlement. Basically these three choices present an increasing order of difficulty for the refugee. Going home involves only the most minor cultural adjustment problems although the longer gone the greater the difficulties. The flight to asylum is normally short, across the nearest "friendly" border, where there may be ethnic kin or the reluctant host may be different but not completely strange or unknown. Resettlement, on the other hand, often overseas and distant from home, means leaving not only one's native culture but its wider zone of influence. Today some resettled refugees move from non-European to European-based cultures, from least developed countries to the space age (Paludan, 1974).
Approximately ninety percent of the world's ten million plus refugees are from developing countries and over ninety percent of these refugees will stay in developing countries, either settling in their countries of first asylum, being repatriated to their homelands, or remaining in semi-permanent relief camps. An overwhelming proportion of these refugees are from rural areas in their homelands and they stay in the rural areas in their less developed sanctuaries. These refugees have been the subject of very few studies (Keller, 1975; Saskena, 1961; Keely, 1981; Stein, 1981; Kibreab, 1983; Hansen, 1977; Aga Khan, 1981; Mutiso, 1979)--particularly research concerned with their characteristics and behavior. Most of the refugee literature deals with that minority of all refugees who are resettled. Traditional Refugees and "New" Refugees
Another factor that needs to be included in the resettlement research, particularly mental health research, is the emergence of what Anne Paludan (1974) calls the "New Refugees." Until the 1960s resettlement was focused on the traditional refugees, Europeans, primarily eastern Europeans, who were products of the Cold War. Now the weight of concern and interest is shifting to the new refugees from Africa, Asia, and Latin America. The new element is not the presence of refugees in those regions. It is the great increase in their numbers and the fact that they are no longer solely dealt with within those regions but in Europe and North America.
The key differences between the traditional and new refugees are that the new refugees are culturally, racially and ethnically vastly different from their hosts, they come from less-developed countries, at a greatly different stage of development that the host, and they are likely to lack kin, potential support groups, in their country of resettlement. Traditional refugees, on the contrary, are culturally and ethnically similar to their host, come from societies whose levels of development are similar, and are likely to ve welcomed and assisted by well-established kinfolk who know their language and can cushion their adjustment.
The new refugee is typified in the extreme by those among the Indochinese refugees whose backgrounds are most different from their host society. The Hmong refugees are mountain tribesmen from Laos, most lack any formal education, and they used to practice slash and burn agriculture. The behavioral and material aspects of Western culture are strange and alien to them. Their only ethnic kin in the United States are those of their community who arrived in the last few years (Downing and Olney, 1982). Many of the refugees have levels of skill and education that produced prominence or success in their less developed homelands but which will not transfer well to an urban technological society.
The patterns of adjustment and resettlement behavior described below are applicable to the new refugees but in many cases the stresses and problems are greatly magnified. Resettlement
Resettlement, adjustment and assimilation is a complex and multifaceted process. There is a large volume of material on different aspects of the process so that, in contrast to the other stages of the refugee experience, here we can do some picking and choosing. Nonetheless, there are some significant gaps in our knowledge about resettlement.
The studies of the adjustment process tend to fall into two sizable groups. First are those studies which focus on the refugees: their mental health, occupational adjustment, language, residence and community patterns, culture and identity problems, health, reactions to stress, relationships with natives, the problems of the women and children and various measures of their progress and adjustment. The second set of studies focuses on the programs themselves: the mix of services and assistance; which policies and programs and which agencies provide the most effective aid to the refugees.
In examining the refugee experience during resettlement in is important to take a split-screen view of what is happening. One side is what research indicates happens to most refugees, what they should actually expect regarding life in a new and strange land. On the other side we have the refugee's expectations, often romantic and unrealistic, which are quite different from what we know they should expect. The refugees' expectations will have a large impact on their behavior during resettlement. The Pattern of Adjustment
The general pattern of refugee adjustment over time can be analyzed in four stages: 1) the initial arrival period of the first few months; 2) the first and second years; 3) after four to five years; 4) a decade or more later. This discussion is limited to just a few key points. Across the spectrum of occupational and economic adjustment, social adjustment, cultural adjustment and mental health, the patterns develop as follows.
In the initial period, the refugees will be confronted by the reality of what has been lost. From a high occupational and social status at home they will plunge downward in their new land-from professional to menial, from elite to an impoverished minority (Weiermair, 1971; Rogg, 1974). "A highly educated person with professional competence becomes a non-entity overnight (Doheny, 1981)." They will confront the loss of their culture--their identity, their habits. Every action that used to be habitual or routine will require careful examination and consideration (Eitinger, 1960; Ex, 1966). "Refugees suddenly find themselves virtual islands in a strange and sometimes hostile sea (Mutiso, 1979)." Strains will appear at home because the husband can't provide, the women must work and the children don't respect the old ways. Because they acquire the new culture more rapidly, the children socialize the parents (Hoff, 1968; Rees, 1960). Nostalgia, depression, anxiety, guilt, anger and frustration are so severe that many refugees toy with the idea of going home even though they fear the consequences (Zwingmann and Pfister-Ammende, 1973).
During the period of one or two years the refugees display an impressive drive to recover what has been lost, to rebuild their lives (Keller, 1975; Paikert, 1962). Some of the factors which caused the refugees' initial downward mobility can be ameliorated by time, acculturation, language improvement, retraining programs, hard work and determination. There are two key factors present here. First, many of the refugees were successful and prominent at home, and those qualities that led to their earlier success can facilitate upward mobility in the new land (Kent, 1953; Davie, 1947; Stein, 1979; Rogg, 1974). Second, the refugee experience may make them more aggressive and innovative (Keller, 1975).
In this period many of the refugees will change jobs, go to school and move from their initial placement to an area of refugee concentration. They will also experience increased problems within the family, and the level of mental dysfunction is likely to shift and increase (Ex, 1966; Lin, et al., 1979; Cohon, 1977).
After four or five years the refugee has completed the major part of adjustment (Weirmair, 1971; Stein, 1979; Ex, 1966). Less change occurs after this point. The refugee has acquired the language and the culture, been retrained and worked hard. If the goal is not near or at hand now, the refugee is likely to abandon the effort. Skills are getting stale, the refugee is older, the family and the routines of living demand attention. Drive and determination wane, discouragement sets in, and the refugee is resigned to the changes in his or her life and status. By this point many refugees talk of their exodus as having been for the sake of the children; hopes are transferred to the next generation (Soskis, 1967).
Resignation, of course, does not necessarily mean happiness. Many will be embittered and alienated. Many will be just surviving, acculturated enough to function but far from assimilated or integrated (Department of Health, Education and Welfare, 1979).
After ten years the refugee group will have achieved a certain stability. The recovery of lost status will have continued but at a much slower pace. The sum total after the first decade is one of decline. Despite the drive and determination, the effect of exodus is to produce lower status. Resettlement Behavior
After all the trauma and suffering, after the refugee camp, a refugee approaches the new land with mixed feelings. The refugee left home to escape danger; there was no destination in mind, no "positive original motivation to settle elsewhere" (Kunz, 1973). The country of resettlement is often chosen against or despite his wishes; the refugee is taking a "plunge" into the unknown.
On his way to the country offering him asylum, the refugee experienced ...his liberation from the troubles and cares which has driven him from his fatherland; the oppression of the uncertain arrival which he was to face; the sorrow on account of all that was dear to him and left behind. Against the background of his...experiences...he fostered undifferentiated and rosy-colored expectations about things awaiting him in the country lying ahead (Ex, 1966).
Refugees have high expectations about their new life, especially regarding their economic and occupational adjustment. They do not expect to lost anything because of their migration. The refugees want to recover their lost status and are resistant to accepting jobs that represent underemployment. "Americans who provide support should recognize the former positions of the Hmong people (Lao Family Community, 1981)."
A phenomenon of particular importance regarding refugee behavior during resettlement is the refugees' strong belief that they are owed something by someone. Since their persecutors are unavailable, the refugees shift their demands to the government and the helping agencies.
Refugees often have difficulties with agencies set up to help them... Many agencies report that the refugees studied tended to be very demanding, displaying an attitude that they should be compensated for their unjust suffering and fortitude. They continually complained of not receiving enough (Rogg, 1974).
Neither the government nor the agencies are able to satisfy all of the refugees' demands. As their requests are frustrated the refugees become suspicious and bitter. Denied what they believe is owed them, feeling that the agencies seek to control them, the refugees suspect "counterfeit-nurturance", that is, aid given to humiliate and subjugate the refugees rather than from motives of genuine charity (Keller, 1974; DeVoe, 1981). A vicious spiral can set in: refugees are helped because they are helpless; they must display their need and helplessness; the caseworker cannot accede to all who are needy and must shield himself from emotional involvement; the cool attitude of the caseworker conveys suspicion to the refugee about his truthfulness; if they won't believe the truth the refugee inflates it; hearing exaggerated stories the caseworker becomes suspicious (Keller, 1975).
The immigrant tends to se the resettlement agency as a hostile bureaucracy. This may cause the immigrant to become aggressive, demanding of resources and to measure his initial success in the United States by how much he can get from the agency (Taylor and Nathan, 1980).
A last point regarding refugee resettlement behavior: the refugee is searching his way through a strange and frightening society. The patterns of behavior that sustained life at home are no longer sufficient. The refugee is uncertain about how to mobilize his resources to succeed in his new home.
Loss of patterns of conduct is intensified by the uncertainty of what kind of behavior is acceptable or nonacceptable in their new environment.....(they) may exhibit restlessness, aimless bustling about, constantly searching for something to do (Taylor and Nathan, 1980).
Without clear guidance from the host the refugee does not know what to do. This need for guidance is greatest in the initial stages of resettlement.
(He)...is experiencing crisis and is often placed in ambiguous situations without clear definitions of behavioral expectations... tries to redefine his life situation and to adopt strategies for dealing with the crisis; he begins to discover that their prior life experiences have not adequately prepared him for a life in this different culture (Taylor and Nathan, 1980).
The split-screen view of resettlement reveals a tension in resettlement that must be dealt with if refugees are to integrate successfully into society. The resettlement agencies and the refugees have different views of the same situation. In pursuing their rose-colored expectations of their ability to recover what they have lost, refugees can become aggressive, demanding and suspicious. Behind these behaviors, though, is confusion, uncertainty and a need for guidance.
What is portrayed is somewhat bleak but it reflects the realities. There is a tendency to dwell on refugee success stories which are not representative of the experiences of the group. Such stories set a standard of expectations that add to the refugee's frustrations and to those of the host. In reality, lives torn apart are not easily repaired. The refugee pays a high price for flight. Remember, though, that the refugee fled for safety and freedom, not for economic or social values and opportunities.
In examining the overall process of assimilation the most useful works are those of S.N. Eisenstadt (1954), who deals with the Israeli experience, and Milton Gordon (1964), who analyzes assimilation in American life. Since he deals with the American experience this section tends to rely more heavily on Gordon while incorporating some of Eisenstadt's ideas.
There are three basic elements in the analysis of refugee assimilation: the assimilation model itself; the role of the refugee community or ethnic group, and the nature of the process of assimilation. Different authors, such as Gordon (1964) and Berry (see chapter ) tend to use such terms as assimilation and acculturation in similar but not identical fashions. Generally assimilation is seen as "relinquishing cultural identity and moving into the larger society (Berry)" while acculturation represents a learning of the culture and behavior of the dominant society. Depending on one's viewpoint assimilation may be seen as the result of a process of total acculturation or acculturation may be seen a stage in the process of assimilation.
Gordon notes three models of assimilation: 1) Anglo- conformity or, in more universal terms, host-conformity--the refugee must become like the native, completely accepting the dominant culture; 2) the Melting Pot, a romantic American idea that probably never existed (Gordon, 1964; Haavio-Mannila and Stenias, 1965), it sees both the native and the refugee being changed, merged into a new and supposedly better alloy; and 3) cultural pluralism, the refugee will acculturate to the dominant pattern particularly for politics, play, education and work, but will preserve his communal life and much of his culture. These three models are the ones confronting most refugees. They differ greatly in the demands they place on the refugees and in their attitude toward the refugee's culture.
The ethnic community eases the shock of adjustment and transition for the refugees. It lessens the danger of social and personality disorganization, and it provides a group identity and a network of relationships, associations and institutions. It allows the refugee to function while gradually assimilating (Pfister-Ammende, 1960; Gordon, 1964; Rogg, 1974). In a society that prizes the conformity model, however, the ethnic group may be seen as dysfunctional, as a barrier that keeps the refugee in an ambivalent position--midway to nowhere between the lost homeland and the new society (Ex, 1966).
The role of the ethnic community is illustrated by the resettlement experiences of the Indochinese refugees. In 1975 Indochinese refugees were dispersed across the United States in order to avoid impacting any one community. This diaspora -- reflecting the melting pot model rather than cultural pluralism -- "effectively hampered and even crippled the refugees' struggle to survive and adapt (Nguyen et al., 1980)." The refugees' response was secondary migration to form ethnic clusters. Later, in 1981, Khmer refugees were deliberately clustered by the government in a few areas in order to create new viable communities that would slow the growth of the older clusters, and to promote more effective resettlement (Granville Corp., 1982).
Although different authors conceptualize a different number of stages in the absorption process, basically they agree on the nature of the process. Eisenstadt (1954) sees four stages: first, the acquisition of language, norms, roles, customs; second, learning to perform a host of new roles and hence to handle the many new situations that will occur; third, development of a new identity and status-image, new values about oneself--a basic personal adjustment; and fourth, movement from participation in the institutions of the new ethnic group to participation in the institutions of the host society.
Gordon (1964) considers these first three phases to constitute behavioral assimilation or acculturation--learning the cultural patterns of the new country--and finds this to be compatible with the long-term existence of ethnic subsocieties. The fourth phase--Gordon calls it structural assimilation--is entry into the primary group life of the new land-- intermarriage, joining clubs, acquiring their identity, an absence of prejudice or discrimination, a lack of power of value conflicts between natives and refugees. This structural assimilation is the precondition to total ideal assimilation--a complete merging of the refugee into the native society, and it is likely to take several generations, if it occurs at all.
Most of the research on refugees focuses on Eisenstadt's first three phases--Gordon's behavioral assimilation or acculturation. Rather than attempt to deal with each of the many facets of resettlement the remaining discussion is confined to refugee mental health during resettlement.
To the stresses and traumas inflicted on refugees before escape, during flight, and in refugee camps, one must add the difficulties and fears that face the refugees during resettlement. Acculturation, loss of status, identity confusion, language difficulties, poverty, concern for separated or lost family members, guilt, isolation, host hostility, and countless other factors add to the pressures on the refugee in a strange land.
These pressures don't remain constant over time, they change as the refugee goes through the process of adjustment. Most studies have focused on the early years of resettlement, and most recognize the stages already described. The first few months, roughly equivalent to Eisenstadt's first phase of acquiring skills, are stressful to almost all refugees, but many problems ease as acculturation occurs and some language ability is acquired. The first and second years, Eisenstadt's second stage, involve learning new roles and coming to grips with one's drastically changed statuses. A considerable degree of adjustment occurs simply because life must go on. After four years most refugees have made a personal adjustment and have accepted their situation. However, delayed reaction to earlier traumas and reactions to the situations accepted often emerge now. The later periods have received the least study, and we particularly lack longitudinal studies.
In examining refugee mental health one finds a controversy among researchers and clinicians regarding the effect of trauma (Cohon, 1977, 1981). Some state unequivocally that there are predispositions or traits in individuals that produce specific symptoms secondary to the stress of migration (Eitinger, 1960) and that those already experiencing difficulties or marginality in their home societies are likely candidates to experience mental health problems due to the stresses they are experiencing as refugees (Prins, 1955; Jensen, 1966). Others believe that the similarity of problems in refugees almost everywhere indicates that severe trauma in and of itself is the cause of the symptoms (Keller, 1975; Pedersen, 1949). The controversy boils down to situational response tendencies versus characterlogical responses.
The most frequent problems diagnosed among refugees fall within three areas with considerable overlap among them. They are paranoidal reactions with common delusions that the food is poisoned, that they are being followed or talked about, or that their mind is being read (Kino, 1951); forms of depression include, suicide, emotional outbursts of anger and crying, restlessness, withdrawal, confusion, pity, grief, despair, and psychosomatic symptoms (Garza-Guerrero, 1974); and nostalgic reactions involving homesickness, glorification of the past, criticism of the new land, regressive behavior, and an over- dependency on existing affective objects such as family and children (Zwingmann, 1978).
More interesting is the agreement on the factors promoting or hindering adjustment and thus contributing to mental health problems; Several clusters of factors either beneficial to adjustment or tending toward an increase in mental problems have been identified. These clusters are: loneliness or isolation; status changes, particularly in occupational- vocational status; inter-generational conflict; host-refugee relationships; and culture shock. Of course the boundaries between these clusters of factors are ill defined and there is considerable interaction among them.
Single refugees, those from separated families, divorced or widowed women as household heads, refugees in rural areas, and other refugees in a lonely, isolated situation lacking company, community, and support have all been identified as at high risk (Ex, 1966; Rogg, 1974; Gordon, 1964). Those with an intact family, their own home, young children (still respectful of authority), and other aspects of community and support tend to do well. Torn from one's homeland, one can adjust more easily in the company of others who have shared the experiences. We can see the refugees' need for one another, particularly family members, in their guilt feelings regarding their own safety and material comfort while relatives are still over there, in their moving within the host land to be near other refugees, in the volume of letters and telephone calls to trace friends and relatives, and in their eagerness for news from home.
Unemployed refugees, those on welfare, refugees with untransferable occupational skills, older refugees whose roles have been altered (e.g., women providing income, men who cannot) and those whose standard of living is markedly lower than it was at home form the high risk group (Stein, 1979; Portes, 1969). On the other hand, success in the new land, the achievement of material conditions either higher than at home or higher than one's initial expectations, tends to facilitate adjustment. Particularly for middle aged male refugees who are suffering from status inconsistency or a loss of traditional roles and statuses there is a tendency toward marital conflicts, depression, and homesickness.
Inter-generational conflicts are particularly frustrating and common for the refugee. As noted, many come to see the exodus as having been for the sake of the children. But how do the objects of these transferred hopes behave? Not firmly rooted in their home culture, facile and flexible, strongly desiring peer approval, the young tend to acculturate rapidly. However, the parent may take an ambivalent attitude toward the child's progress--dependent on the child as a guide to the new land, proud of the child's scholastic achievements, yet angered at the lack of respect shown to both the parents and to the old ways.
Of less significance but still creating an atmosphere that can either aid or hinder personal adjustment is the tone and character of refugee--host relationships. Some refugee groups are received warmly, some are tolerated with indifference, and others are the object of scorn and hostility. And for their part some refugees, often in defense of their identities, are highly critical of the host culture, whereas other refugees may fees, either individually or collectively, inferior to the natives. An additional complication will be ethnic or racial differences which can add permanence to the refugees minority position.
The host-refugee relationship is not an easy one. In the U.S. despite the use of the sponsorship technique, few personal friendships are formed. The refugee is aided out of duty, to serve one's own needs, and rarely is seen as a fellow or friend. A weak or inadequate relationship can hinder the refugee's willingness to open up and seek available assistance. Lastly some sponsors fail to recognize the refugee's growing independence and do not know when to let go. This can create difficulties in the relationship akin to a teenager's transition to adult status.
The last cluster, culture shock, (Garza-Guerrero, 1974), really encompasses all the others to a degree. Its main elements are the test it puts to the refugees personality and stability when he is placed in a strange and unpredictable environment; the lost culture--desocialization and resocialization; lost friends, family, food, values; the loss of all that is familiar may represent a threat to one's identity, and can lead to the mourning, grief, despair and nostalgia the refugee feels for his gigantic loss. Culture shock will particularly affect those refugees who did not think about, intend, or prepare for exodus, who were caught up in panic, hysteria, or even adventure.
Baskauskas (1981) and Loizos (1981) both separately modifying the ideas of Marris (1975) have noted that one means of refugee adjustment to great loss may be through the process of grief. In the process of grieving refugees pass through three stages: conservatism, a defensive element to maintain continuity and hold on to the past; bereavement, mourning, emotion and anger but an acknowledgment of the irretrievable loss; and, innovation, moving beyond one's loss to develop new pasterns of life. The second and most important of these stages, bereavement, can be difficult for refugees to enter because it may be unclear for a long time that the homeland is forever lost (Murphy, 1955), or, because the refugees are so majority-identified (Kunz, 1981), with their nation not its government, that they cling to hopes of return. Hope can delay the refugees psychological arrival, interrupt the process of grief and inhibit adjustment.
The new refugees represent a difficult challenge to those interested in providing mental health services, or any services to refugees. Western mental health professionals and "mainstream" services often have little understanding of the new refugees beliefs, practices, culture, and perspectives regarding mental health. The new refugees culturally defined ways of seeking help may mean they are reluctant to use Western mental health facilities, and may have significantly different expectations about types of help and treatment (Moon and Tashima, 1982).
There has been much discussion regarding the provision of mental health services to Indochinese refugees, or rather to each of the specific ethnic groups who came from Indochina (Egawa and Tashima, 1982; Sanders, 1980; Nguyen et al., 1980; Cohon, 1977, 1981). In Indochina each of the ethnic groups served their mental health needs through the family, community and traditional indigenous healers. Some feel that in exile it might be best not to intervene and try to treat mental health problems, but rather to strengthen these traditional cultural institutions so they may aid the new refugees. Others believe that the family and community have been too severely weakened, have too many problems of their own, and are unavailable to many geographically isolated refugees, so that some intervention by the American mental health system is needed. The passage of time has strengthened many of the exiles' cultural institutions, and secondary migration has created some large ethnic communities but it is unlikely that one method of treatment, whether traditional or Western, can suffice in all cases. In examining the stages of the refugee experience the purpose has been to suggest some of the research that needs to be done. In closing, there are two key points to emphasize regarding refugee research. First, it is important how the research is approached, with a general comparative perspective which sees certain consistencies and patterns in the refugee experience. And, lastly, this is needed research which might relieve the suffering of the refugees and assist those who try to aid the refugees.
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