stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
conduct their work during the year, and then come back at the end and show what
they have done. We provide a great deal of assistance along the way, a little bit of
training in the beginning and a listserv with access to experts and data that can help
them work more effectively. We currently have an external review of that program
to look at its effectiveness, but so far we have been pleased with and are proud of it.
Bob Ursano asked us to acknowledge the lenses through which we are making
our remarks. I will give you several of mine. One is public policy. The recommendations
around mitigation that I will talk about will likely have much more of a policy
flavor than a clinical flavor because that is what we do at the Carter Center and that
is what I have done for the last portion of my career. The second lens through which
I am looking involves disaster work that I did for 12 to 14 years of a very different
type. That is through the lens of refugee mental health.
We underwent some major migration events during the 1980s, several of which
were unplanned and chaotic and caused a tremendous amount of social disruption
in certain parts of the country. Some of those who migrated had preexisting mental
disorders. Those people taught me a great deal about the kinds of needs that people
of other cultures have. Culture was mentioned earlier. I think Paul Hammer was the
first one to bring it up. I think culture is vitally important.
The third lens I am looking through is cultures within cultures. I thought about
my remarks more from the military standpoint since I am a veteran. As a member
of the military, not only do you have thoughts and ideas from the greater culture
that we are all part of, but you have a military culture that is very steeped in norms
and values. The military culture, unlike other subcultures in our society, talks a great
deal about norms and values and reminds the members of that culture that they are
expected to live by those norms and values. That sets an expectation that is fairly
high. Those of us who are not involved in those types of organizations are not asked
on a routine basis to reexamine our values and our adherence to those values. In
some ways there is a higher standard.
I want to return to the larger culture for a moment. In working with refugee
populations, I realized that my formal education prepared me in no way for that
work. All of a sudden we were faced with people from vastly different countries
who think about the world very differently than we do, populations that may not
have labels for things like depression. Some cultures do not have a word for depression
in their language. We initially thought we could take western principles that
are very much couched in our own cultures and our own ways of seeing the world
and apply them to people of vastly different backgrounds. It was a learning curve
for me and my colleagues. It was a very sharp learning curve because as we went to
look for knowledge and information to inform our work, there was none. This work
generally involves a new migrating group, applying treatment to 15 or 20 people,
and reporting on that treatment, and it gets no further than that.
It is difficult to get mainstream refugee research funded. But it taught me the
importance of things like community, tribe, and family. Family was vital. When I was
trained, family was the potential perpetrator so you had to hold them suspect. In
the refugee world, if you do not legitimize yourself with the family and community
they will not come. It was important to understand that the role of family is very
different than we think about it in most cultures in the world.
What I came to understand, and this is not a criticism, is that we are much more
individually focused than most people in the world. America is the outlier in many
of the ways we conceptualize care, and the way in which we provide, organize, and