Mental health policy and practice across Europe: an overview

Care of asylum seekers and refugees 363
environment; research into mental health service provision; and research on
the socio-legal context of mental health care.
Much of the debate on refugees and mental health has, in recent years,
focused on post-traumatic stress disorder (PTSD) (Silove et al. 2000b). PTSD is
widely regarded as one of the major mental health problems experienced by
refugees. Most frequently it refers to the impact of a traumatic event in the
refugee’s country of origin, for example the direct or indirect experiencing of
torture, beatings, killings or rape. These distressing experiences are then relived
with intrusive flashbacks or vivid memories and the afflicted person may seek to
avoid circumstances and locations that they associate with the original trauma
(Goldberg et al. 1994). PTSD is a relatively recent addition to the psychiatric
canon, having only been recognized as a distinct psychiatric category in 1980
and entered into the Diagnostic and Statistical Manual of the American Psychiatric
Association. Vietnam War veterans and those who lobbied the health
insurance industries on their behalf crucially influenced the recognition of
PTSD (Young 1995). Since then there has been considerable clinical and academic
interest in the extent to which refugee populations suffer from PTSD. A
range of epidemiological studies has been undertaken on diverse refugee populations
to seek to determine the prevalence of the illness. For example, Mollica
et al. (1999) found that 15 per cent of Cambodian residents in a refugee camp on
the Thai border suffered from PTSD while a study of Bosnian refugees in treatment
indicated that between 18 per cent and 53 per cent suffer from PTSD.
Silove et al. (2000b) have argued that, in general, only a minority of those
exposed to mass violence suffer from PTSD, with numbers normally varying
between 4 and 20 per cent. Silove has drawn attention to the context of research
and pointed to the significant sampling bias that may exist between the findings
of community studies and those focused on clinic populations, with the former
studies recording consistently lower rates of PTSD (Silove 1999).
The past decade has seen significant challenges to the application of the PTSD
diagnosis to refugee populations. There has been a sociological critique of the
way in which the numbers of ‘victims’ of PTSD may be inflated to support the
programmes of humanitarian aid organizations. Drawing on work in the former
Yugoslavia, Stubbs (2004), for example, has challenged the epidemiological
underpinnings for a process he describes as ‘talking up the numbers’ in which
rash statements such as that ‘more than 700,000 people in Bosnia Herzegovina
. . . suffer from severe psychic trauma’ are made. Summerfield (1999) provides a
wide-ranging and sustained critique of the widespread application of the PTSD
diagnosis. Drawing on the work of Allan Young, he points to the relatively
recent ‘discovery’ of PTSD and contrasts its historical contingency with its
widespread association with the problems of various refugee and non-western
populations. A central concern of Summerfield’s is what he sees as a form of
psychiatric imperialism whereby large numbers of those suffering from the
effects of war are categorized as mentally ill and as needing mental health
interventions regardless of the sufferers’ own views of their condition or what
would alleviate it. While acknowledging that, on occasions, exaggerated statements
have been made regarding the incidence of PTSD in post-conflict and
refugee populations, authors have argued that an unforeseen consequence of
this critique may be to undermine much-needed mental health programmes