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Mon. Feb. 16, 2009
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Family > Your Society
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The Mentally Ill from War-Torn Societies
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By Joanne Mcewan
As war is perhaps a society's greatest atrocity, it becomes almost unbearable to think about the terror and abuses experienced by a people who must live in its midst. And post-war events can create similar or even worse anguish - although with different manifestations - for a nation already weighted with trauma.
The problems of adaptation faced by a community following war is complicated by the incidence of mental illness among its members. The struggle faced by the mentally ill is ongoing, as they typically exist on the fringes of society where indigenous systems of care have been rendered defunct by war and international humanitarian agencies are not providing service.
In this discussion, we will take a look at the two categories of mental illness to be found in the aftermath of war: those suffering from mental illness previous to war, and those who have been affected psychologically by war and, subsequently, by mental illness.
Concerning the latter category, some would imply that entire populations exposed to war are mentally "traumatized." Conditions such as post-traumatic stress disorder (PSTD), depression, drug and alcohol addiction, somatization, psychosis and anxiety are psychiatric outcomes of war. But just how many people they affect is unclear.
PTSD can be identified in most cultures, but its incidence varies between 4 and 20 %. Some academics would explain this as an "either/or fallacy," and warn that blanket statements citing mass mental illness should be taken with circumspection as what some aid agencies and other organizations consider mental illness may very well be normative social responses to trauma.
There is little evidence to prove that displacement and the horrors of war affect the mental state of victims. Although research on the mental and psychological effects of war has been carried out since the American Civil War, with the exception of studies inNorthern Ireland, few have focused on civilian populations. Over the past 30 years, these studies have found little evidence of a significant impact on mental health (as indicated by referrals) due to the "troubles" that country has experienced.
As for treating post-trauma displaced persons, psychiatric medication is often prescribed immediately, but one wonders about the consequences of rushed diagnoses and labeling as mentally ill. Often, "normal" reactions to war and feelings of loss expressed to aid workers are misunderstood due to cultural differences between clients and caregivers.
Symptoms of psychological distress have been detected in asylum seekers in the West; however, many of these manifestations of mental illness have been known to develop after seeking refuge in the host country. For example, some Iraqi asylum seekers in London suffering from depression only developed it after leaving Iraq. The reasons for this are closely linked to the lack of social cohesion and support mechanisms, isolation, racial discrimination, poverty, and dependence often experienced by asylum seekers and refugees. An "asylum seekers bill" probably only exacerbated the problem by creating even more restrictions on entering Britain, and partly replacing social security payments with food vouchers. In addition, on an international level, intolerant diatribe and political rhetoric charred with racist overtones further threatens the dignity and security of an already vulnerable people.
The mentally ill who were diagnosed as suffering from psychiatric disorders
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pre-war are one of the most vulnerable groups of displaced people. Very often during war, psychiatric hospitals are evacuated, and remain so afterwards. Patients who have been institutionalized most of their lives as well as those who are in hospitals for the short term treatment of acute psychiatric disorders have found themselves left to survive in environments that they hardly know and are little capable of coping with during times of peace, let alone war.
The severely mentally ill in war-torn societies are exposed to neglect, hunger, illness, and the risk of trauma from epilepsy, etc. Their safety is often further threatened by situations of abuse, stigma, ostracism, rape, violence, and abandonment. Sometimes, bizarre behavior can be triggered in the mentally ill by situations as simple as withdrawal from (or simply not taking) medication. In London last year, a Kurdish man wielding a knife laid siege to an immigration appeal court following an undesirable verdict in his case for asylum. Holding the knife to his throat, he threatened to kill himself. Over zealous police reaction resulted in armed officers and a riot squad appearing at the court where the man was peacefully disarmed. Apparently, he had not taken his medication that morning.
International assistance to war-torn regions rarely acknowledges previously existing systems of mental health care; their budgets are normally set to care for the physically needy. This does not mean that they ignore mental conditions. For example, in the Balkans, 180 of the aid organizations were known to offer psychosocial support and counseling to at-risk clients, although mainly to those who were free of any signs of mental illness pre-war. But indigenous, existing systems were ignored throughout the humanitarian crisis, and the aid agencies that came all had short-term goals that coincided with their short-term contracts. In Bosnia and Croatia, the densely populated psychiatric and psycho-geriatric hospitals received little attention. Now, funding is proving to be increasingly difficult to obtain with the proliferation in crises within the Balkans (Kosova) and worldwide.
As well, many academics are questioning the success and appropriateness of the therapies and treatments being used by these emergency aid organizations. Often, there are no resident psychiatrists on their teams, and diagnoses of mental illness as well as the prescription of anti-depressants, anti-psychotic drugs, and tranquilizers are often made without due reason.
Counseling (which, according to the Western model, is new even for Westerners) and psychotherapy are being questioned for their cultural validity - they often do not take into account the huge differences that occur between diverse cultures. For example, for Mozambicans, forgetting is the method by which they cope with difficult circumstances. In Ethiopia, it is called "active forgetting." And although many displaced persons do want to talk about their experiences, the setting or the manner in which they are asked to do so can be problematic. How counseling actually takes place is now being discussed.
Part of the aim of post-war social and community reconstruction is to restore cohesion and a sense of community - even when it has changed dramatically. Some suggest that promoting indigenous healing methods and utilizing the social, cultural and religious traditions of a society can greatly serve to rebuild the lives of the mentally ill. Often, a combination of medication and supportive community follow-up are successful in helping the mentally ill gain normality and dignity. For example, in Cambodia, a man suffering from psychosis who had been chained to a tree by his family for eight months was found working in paddy fields three weeks after getting on medication. With the support of his family and appropriate treatment, he was able to return to work.
The practice of Islam played an important role for the Bosnians, both during and after the Bosnian war, as it nourished their souls - even when their minds and physical bodies were not at ease.
In conclusion, the mentally ill in their war-torn societies and those who have found refuge in other countries are in need of special care. In particular, they need to be understood and dealt with patiently.
Sources:
Black, M. and Tosiac, O. "Mental Health of Refugees from Kosovo," The Lancet, 10 July 1999.
Guardian Unlimited, 18 April 2000.
Hargreaves, S. "Policy and People," The Lancet, 23 December 2000.
Silove, Ekblad, and Mollica. "Health and Human Rights," The Lancet, 29 April 2000.
Summerfield. BMJ, 22 July 2000.
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