Mental health policy and practice across Europe: an overview

364 Mental health policy and practice
for refugees (Silove et al. 2000a, 2001). Furthermore, there is evidence that
even small-scale mental health programmes for refugees can have a significant
impact. Drawing on an evaluation of the impact of the introduction of a community
psychiatric nurse in a large refugee camp, Kamau and colleagues have
argued that even a small amount of mental health care can have a dramatic
impact on the mental well-being of refugees (Kamau 2004).
Further research on the mental health of refugees focuses on the impact of
‘stressors’ arising from external events such as displacement and resettlement
and ‘stresses’, the latter referring to subjective reactions to these events (Ahearn
2000). The effect of stressors can be ameliorated through coping strategies and
external support. The impact of these has been the subject of extensive research
activity focusing, for example, on work on the impact of religious faith, on
social networks and material support. These factors have been mapped onto a
chronological sequencing of the refugee’s experience in which the stressors
relating to the pre-flight, flight, post-migration and resettlement environments
are identified (Ager 1993). The pre-flight environment is associated with a combination
of stressful factors that commonly include economic hardship, social
disruption, political oppression and physical violence. A common feature of
‘social disruption’ is the loss of family and friends either through them having
been killed or through becoming separated in the chaotic circumstances of refugee
migration. McCallin (1992), for example, observed that out of a sample of
109 Mozambican women who fled to Zambia, 24 per cent had been separated
from their children. According to Beiser (1999), the loss of family members
frequently results in long-term emotional problems that make the process of
readjustment and integration into a new society more difficult.
The impact of the process of flight on the mental health of refugees has been
given relatively little attention in the literature. According to one authority, this
is regrettable because ‘flight from one’s homeland represents a major life event
which – even if accomplished swiftly and in safety – is likely to prompt major
emotional and cognitive turmoil, with concomitant risk to mental health’ (Ager
1993: 9). Refugees may be particularly vulnerable, during the process of flight, to
violence and sexual and economic exploitation. Besides these external factors
they may experience subjective stresses arising from the recent loss of family,
friends and homelands. Eisenbruch (1991) has argued that the profound sense
of loss should be more clearly recognized in the mental health field and has
proposed the establishment of a specific psychiatric category of ‘cultural
bereavement’ that, he argues, may more accurately encapsulate refugees’
experience than current western psychiatric categories. He cites, for example,
the case of a Cambodian patient who is possessed by spirits, ‘troubled by visitations
of ghosts from the homeland, hears voices commanding him to make
merit on behalf of his ancestors, and feels that he is being punished for having
survived’ (p. 675). In these instances the person is suffering from culturally
normal signs of bereavement that may be misinterpreted as PTSD in a western
psychiatric context.
While the emphasis on mental health research on refugees has been, until
recently, on the impact of ‘stressors’ arising in the pre-migration environment
on mental health, over the past decade there has been a considerable growth in
literature on the impact of post-migration factors. This emphasis has reflected