mental health issues in tamil refugees and displaced persons. counselling implications

Patient Education and Counseling 42 (2001) 15–24www.elsevier.com/ locate /pateducou

Mental health issues in Tamil refugees and displaced persons.Counselling implications

*Jolanda De Vries

Department of Psychology, Tilburg University; Research Institute Psychology & Health, LE Tilburg, The Netherlands

Received 18 December 1998; received in revised form 13 October 1999; accepted 21 November 1999

Abstract

Fifty-one Sri Lankan Tamil refugees /displaced persons living in South India completed the Hopkins SymptomChecklist-58. In addition, in interviews they answered open-ended questions about personal loss, personal traumaticexperiences, negative feelings, living in camps, and the availability of support. The health of the respondents was poor.Moreover, experiences such as watching the killing of family members and being wounded were mentioned as reasons toflee. Many respondents said they experienced negative feelings. Social support was reasonably available although familymembers were often not situated in the same camp. 2001 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Mental health; Refugees; Displaced persons; Social support

1. Introduction Relating to the Status of Refugees and its 1967Protocol, refugees are people who, because of a

Worldwide the number of refugees still increases. well-founded fear of being persecuted for reasons ofIn the early 1990s, there were approximately 15 race, religion, nationality, membership of a particularmillion refugees [1] while in 1994 the total number social group, or political opinion, are outside theirhad increased to 25 million [2]. Only a small country of origin and are unable or, because of suchproportion of the refugees seek asylum in Western fear, unwilling to avail themselves of the protectioncountries. Most refugees just flee to neighbouring of that country. This definition, which is used incountries. For instance, during the problems in Western countries, excludes, among others, peopleMozambique, over 1 000 000 people fled to Malawi who are displaced by violence or warfare and who[3]. have not been singled out for individual persecution.

According to the 1951 United Nations Convention However, some governments, for instance, in mostcountries of Africa and Central America, recognizepeople as refugees whenever they have sufferedviolence, strife, war, and similar politically generated*Tel.: 1 31-13-466-2705; fax: 1 31-13-466-2370.

E-mail address: [email protected] (J. De Vries). disasters that affect whole groups rather than in-

0738-3991/01/$ – see front matter 2001 Elsevier Science Ireland Ltd. All rights reserved.PI I : S0738-3991( 99 )00120-2

16 J. De Vries / Patient Education and Counseling 42 (2001) 15 –24

dividuals. The majority of the refugees under the and revealed that these children had suffered inordi-United Nations High Commissioner for Refugees nate and sometimes irreparable physical and psycho-(UNHCR) mandate are persons who meet the latter logical damage. Finally, Miller [33] examined 58definition of refugees [4]. Guatemalan children living in camps in Mexico. The

Refugees and displaced people are very vulnerable mental health and psychosocial development of the[5,6]. They are commonly not protected by a govern- children appeared to be related to the physical andment and they are often victims of violence in the mental health status of their mothers.country they fled to. Furthermore, they are seldom The conflict in Sri Lanka started when the Britisheconomically secure. unified the Sinhalese low country and the Tamil

The events that refugees and displaced people areas in the North-eastern part of the island into onefaced in their home country, play a role in problems state. The Tamils strive for autonomy, especiallythey experience when in another country. The litera- when Tamil is abolished as an official language inture on refugees living in Western countries is mainly 1956. After a number of conflicts between thecentred around health-related problems such as post- Sinhalese – the majority of the population – and thetraumatic stress-disorder (PTSD), trauma, psycho- Tamils about the rights of the Tamils, a civil warsocial problems, psychological distress, depression, starts which concentrates in the North-eastern part ofand somatic symptoms e.g. [7–15], stressors like Sri Lanka. As a result, many Tamils leave that areaassimilation, immigration, and culture shock e.g. and flee to India or other parts of Sri Lanka. Most[16–18], substance abuse e.g. [19–21], and therapy Tamils who left Sri Lanka are living in camps ine.g. [22–27]. South India. The aim of the present study was to

There are only a few studies into the mental health examine the events that led to fleeing to India andof refugees and displaced persons who have fled to the mental health (including post-traumatic stressneighbouring countries. For instance, research in a disorder) and psychosocial problems of Tamils livingCambodian refugee camp revealed that more than in refugee camps in South India for a long time.85% of the refugees /displaced persons suffered fromPTSD following an intensely traumatic event [28].Furthermore, it was shown that psychosomatic symp-toms related to depression coincided with PTSD, and 2. Methodthat these effects could extend over a long period oftime. A study among Khmer adults revealed that 2.1. SubjectsPTSD was positively associated with the number oftraumatic events experienced [29]. In the latter study, Fifty-one Sri Lankan Tamil refugees, all living inpatients with a diagnosis of PTSD reported twice as South India, participated in this study; 23 men andmany traumatic events as those with other psychiat- 28 women with ages ranging from 16 to 67 years. Ofric diagnoses. PTSD is a delayed and/or protracted them, 47 were living in refugee camps that areresponse to a stressful event or situation of an spread all over Tamil Nadu, where the language isexceptionally threatening or catastrophic nature Tamil as in Sri Lanka. They all fled from the ethnicwhich is likely to cause pervasive distress in almost conflict in their home country. Nearly all participantsanyone. In the case of refugees the stressful events had been in India for at least four years. Allare mostly ‘witnessing the violent death of others’ participants were recruited by the Organisation forand ‘being the victim of torture and/or terrorism’ Eelam Refugee Rehabilitation (OfERR), an organisa-[30]. Mollica and colleagues [31] studied 182 tion founded by refugees living outside the campsCambodian adolescents living in a refugee camp on with the purpose of trying to improve the livingthe Thai–Cambodian border. The most frequently conditions and health of the refugees living in thereported symptoms were somatic complaints, social camps. This organization arranged meeting pointswithdrawal, attentional problems, anxiety, and de- with refugees for the interviews because the inter-pression. Others [32] studied children from Rwanda views all had to take place outside the refugee

J. De Vries / Patient Education and Counseling 42 (2001) 15 –24 17

camps. Refugees were interviewed by an Indian indicated not to have experienced such losses (t 5

psychiatrist (in Tamil). 2 2.57; P 5 0.015).

2.2. Questionnaires 2.3. Translation methodology

All respondents were interviewed in Tamil using Items were translated using a forward–backwardopen-ended questions concerning the social support methodology. This methodology consisted of thethey received in the camps, personal traumatic following steps. First, a bilingual person translatedexperiences, loss suffered in Sri Lanka, and problems the original questionnaire from English to Tamil.within the camps. The interviewer, who also spook Subsequently, a second person translated the TamilEnglish fluently, typed reports of each interview. version back to English. Then, a third person com-

Furthermore, one questionnaire was administered. pared the two English versions of the questionnaireWhen possible, the refugees completed this ques- to establish semantic equivalence between the ver-tionnaire themselves. In the case of persons who sions. Finally, when items were not semanticallycould not read or write, the questionnaire was identical, the Tamil version was adapted and againadministered in the form of a structured interview. translated into English. This iterative process ended

Health was measured by the Hopkins Symptom when the back-translated version was semanticallyChecklist [34]. This instrument was selected because identical to the original.the 25 item version had proven to be useful instudies with refugees from other Asian countries[29,35]. The response scale used was a five-point 3. ResultsLikert type scale derived from the HSCL-90 [36] inorder to get more differentiation in the responses. 3.1. Mental health issuesThe HSCL-58 measures somatization, obsessive-compulsive behaviour, interpersonal sensitivity, de- A substantial number of respondents scored highpression, and anxiety. In the present study, Cronbach ( . 5 3; possible range 1–5) on the subscales of hetalphas for the scales ranged from 0.61 to 0.87. In a HSCL-58. More than 10% (11.9) had somatic com-normative US sample average scores on the HSCL- plaints like headaches, faintness or dizziness, pains58 were between 1.12 and 1.16 (SD’s 0.24–0.28). in the heart or chest, and feeling low in energy orAverage normative scores for depressed neurotic slowed down. Looking at obsessive-compulsive be-persons ranged from 1.89 to 2.62 [34]. In order to haviour, more than one-quarter of the respondentsmeasure the extent of PTSD a scale was developed (27.5) scored high on the respective scale. Inter-consisting of items and scales from the HSCL-58 and personal sensitivity, which focusses on a person’sthe COPE. These items and scales were selected on feelings of inadequacy and inferiority with respect tothe basis of the diagnostic criteria for PTSD as communicating with others, was substantially presentmentioned in the ICD-10 [30]. The selected scales in 19.7% of the refugees. Finally, 15.8% scored highwere the Depression and Anxiety scales from the on the Depression scale and nearly one in five (19.7)HSCL-58 and the Substances scale from the COPE reported to be anxious. When one takes a somewhat[37,38], and several items from the HSCL-58 that are wider perspective by looking at the number ofrelevant for PTSD but are no part of the Depression respondents that scored 2 or more on the subscalesor Anxiety scales (items 7, 9, 24, 28, 44, 47, 52, 55). (answering positive on all questions within a sub-The internal consistency of this PTSD scale was scale, irrespective of severity), an even more seriousreasonably good (Cronbach’s alpha 5 0.75). The picture emerges. More than 40% (41.4) indicated todiscriminant validity of the scale was supported by suffer from somatic complaints. For the other phe-the finding that respondents who had experienced nomena, the percentages were 66.7% for obsessive-personal loss (other than material loss) scored sig- compulsive behaviour, 59% for interpersonal con-nificantly higher on the scale than persons who had flict, 58.8% for depression, and 43.2% for anxiety.


No gender differences appeared for any of the scales. had worked in a hospital in Jaffna had witnessedThese figures indicate that the health status of both how his colleagues were shot, because they weremale and female refugees was poor. suspected of giving treatment to members of the

Freedom Fighters. Five others had witnessed serious3.2. Post-traumatic stress disorder (PTSD) bombing by the Sri Lankan army. For example,

someone had seen how the house in which more thanGeneral population studies have shown that life- 50 of his relatives were present at that moment, was

time prevalence of PTSD is about 10% [39]. In the bombed to pieces. As a result, someone mentionedpresent study, 12% of het respondents scored high still getting into a panic when hearing the sound of a( . 5 3; range 1–5). This percentage was even 46 helicopter. For example, one woman recollected thatwhen a score of 2 or above (meaning ‘a little bit to she and her nephew had been captured by a group ofextremely’) was used as the norm. There was no Freedom Fighters. This group told her that they haddifference between men and women. A detailed to run for their lives. When they did, the Freedominquiry into the kind of traumas that the refugees had Fighters started to shoot at them. The woman gotexperienced in their home country was made by two away, but her nephew, in total panic, ran towards theopen-ended questions concerning personal loss and shooting militants. She assumed that the boy waspersonal traumatic experiences (see Table 1). shot dead. Another refugee told the following. ATwenty-two respondents had experienced any per- Freedom Fighter group suspected him of working forsonal loss, of which nine mentioned loss of property the government; so they captured him. Subsequently,like a house. he was lined up with others in an execution line. The

With regard to personal traumatic experiences, person next to him was shot in the head whichone-fourth of the refugees reported a critical event. A caused his brains to come out. Just at the momentfew of them had witnessed the killing of relatives. that the narrator would be shot, the army came.For instance, one woman told that she saw how her Apart from such events, a few respondents gener-oldest daughter was killed by a bomb. A person who ated general fears which had made them decide to

Table 1aEvents happened in Sri Lanka (N 5 51)

Event Number of times eventwas mentioned

Personal lossDeath / injury of relatives 8Material loss 9Husband vanished 2

Personal traumatic experienceDeath / injury of relatives 5Shot at 1Tortured 1Wounded 4Threatened 1Forced to join a freedom group 1

General fearsEthnic conflict 20Suspected of being a Freedom Fighter 1Fear of brainwashing by Freedom Fighters 1Threatened with removing child / relative 1Massive rape in nearby village 1

a Note: Respondents could mention more than one event.


leave Sri Lanka. For instance, one person mentioned he preferred dying in Sri Lanka above staying in ahearing about a nearby village where many women refugee camp in India. Whereas five persons saidhad been raped. Consequently, her father decided to they felt guilty either about having left friendsgo to India. In addition, many respondents indicated behind in Sri Lanka or because they were not able tothat the fighting between Freedom Fighters and the pay the funeral honours to a relative who died in SriSri Lankan army, the bombing, the random violence Lanka.on civilians, threats and the subsequent general fearand feelings of not being safe, all summed under the 3.4. Problems within the campsheading ‘ethnic conflict’, were reasons for leavingtheir home country. Furthermore, one fourth of the According to the respondents, a number of prob-respondents mentioned the death of relatives. lems that began within the camps also attributed to

their negative feelings. A sizeable number of persons3.3. Negative feelings mentioned alcoholism as a problem that affected

camp life. Other issues raised were the gossip byApart from telling about past experiences, the women and all sorts of illegal or immoral activities.

refugees also talked about how they felt around the In general, these problems were attributed to livingtime of the interview. The negative feelings men- in camps which changed the social structure of life.tioned are presented in Table 2. Feelings of depres- In addition, the refugees were not allowed to worksion, guilt, worrying, hopelessness, and helplessness which led to a lack of money (n 5 20) which in turnwere mentioned most frequently. These extreme caused anguish because they could not buy thingsnegative feelings, assessed by the Depression scale such as food and medication. The fact that childrenof the HSCL-58, were connected with experiences of were not allowed to follow higher education was apersonal loss and traumas. major concern for many (former) students and their

Quite a number of respondents mentioned that parents (n 5 16) because in their culture education isthey worried about their relatives and friends who considered very important. The whole camp situationwere still in Sri Lanka and about family members changed social roles.who lived in other refugee camps. Two persons did Finally, the circumstances within the camps leftnot know the whereabouts of their partner and/or much to be desired. Most camps were overcrowded.relatives. This led to worrying about them. Another For instance, the camps that are situated in cyclonecause of worrying was the future. One-fifth said they shelters housed at least 100 families. Each familyfelt depressed. One refugee even explicitly said that had some four square metres, separated from the

Table 2Negative feelings mentioned by respondents (N 5 51)

Feelings Number of respondents

Worrying 17Being depressed 11Guilt 5Being hopeless 3Feeling helpless 2Weeping 2Suicide thoughts 2Memories about the past 2Upset during festival seasons 2Distressed about events that happened in Sri Lanka 1Not able to cope with continuing stress 1Anxious when hearing a helicopter /plane 1Feeling worthless 1Fear of freedom group 1


space of other families by cotton cloth, to cook and lived in another camp, which led to changes in socialsleep in. This housing situation was ‘solved’ by roles.building straw huts outside the cyclone building.However, in the raining season, all families lived in 3.6. Practice implicationsthe building making it even more crowded. This ledto health problems. Furthermore, police harassment This study shows that refugees and displacedwas mentioned by 11.8% of the persons, not all persons have severe mental health problems. Theseliving in the same camp. This entailed that the police problems may last years after fleeing the country ofcame into the camps at night demanding everyone to origin. Considering the traumas that refugees haveshow their identification card in order to verify experienced, this population needs special mentalwhether everyone who should be in the camp was care, even when problems emerged years after theyreally there. If persons were not present, their food fled. It is important that clinicians are aware of therations were cancelled. This harassment had started things that refugee clients might have experiencedafter the assassination of Rajiv Gandhi by a Tamil and be sensitive to problems. Usually no or hardlyFreedom Fighter. any attention is paid to the refugees’ mental health

Despite their problems in India, most people only problems because they present with all kinds ofwanted to go back to Sri Lanka when the fighting has physical problems. These physical problems are thenstopped. Until then, they expected not to be safe in usually the focus of treatment. Traumas should betheir home country. Because of the bombing and treated in stead of downplayed or disregarded asfighting and due to the fact that innocent people were causes for present problems simply because theystill harassed by either the Freedom Fighters or the happened a long time ago.Sri Lankan army. In spite of this, some refugees, (Prolonged) PTSD symptoms should initially bealthough they said that they would not be safe in Sri treated in the same way as other refugee populationsLanka, had voluntarily registered to go back. They with intense trauma. Such treatments should enhancewere doing this because they felt unhappy, helpless, feelings of control and counteracting patterns ofdepressed, and worried about relatives who had to learned helplessness [40]. Psycho-education andstay in Sri Lanka. psycho-social activities are effective tools to alleviate

traumatic stress responses. Other components of3.5. Social support treatment can be psychological structuring of ex-

periences, working on control, reconnecting ownRespondents were asked from which persons they experiences to emotions, working on integration and

got emotional support. Sixteen persons (31.4%) future perspective, and self-help techniques [40].answered that they got support from friends and/or Relaxation, guided meditation, communication, sys-neighbours; one got support from elderly persons. tematic desensitization, and behaviour prescriptionFamily members gave support to 17.6% of the are possible intervention techniques [40]. In generalrespondents. It should be mentioned that some it is important that counselling centres are easilyrespondents received emotional support from accessible and counsellors have the same culturalfriends /neighbours and family members. Eight per- background as the refugees.sons (15.7%) said not to get any social support; forsome this was by own choice. Financial help wasgiven to 25.5% of the refugees /displaced persons; 4. Discussionsome of them received money from relatives livingabroad. In a number of cases, families were sepa- The mental health of the Tamil refugees /displacedrated by the Indian government. To keep in contact persons within the present study was poor. Theywith relatives living in other camps was difficult, showed all kinds of symptoms and a considerablecausing problems in the family. Sometimes daugh- percentage suffered from PTSD. They had witnessedters lived separately from her parents, who were not or experienced physical threat, personal loss, or hadable to watch over her. In other instances the father just been terrified.


Living in the camps had for the most part resolved own gender, this was not always possible. However,their fears for being harmed. However, they suffered women who were interviewed by a female inter-from survival guilt, grief, loss of dignity, shame, viewer also did not mention sexual harassment. Still,uncertainty, and other negative feelings which are an influence of gender may not be excluded.known problems in refugees [5]. In addition, circum- Fleeing to a Western country seems to add prob-stances did not permit a normal life. They were not lems related to assimilation, culture shock, andallowed to work or to follow higher education. The language problems [5,6]. In addition, the refugeesphysical situation within the camps was poor. The that do flee and get asylum in Western countries aresocial structure changed due to lack of normal family often persons with severe personal trauma, becauselife caused by separation of families. Fortunately, these countries apply the strict definition of a re-most persons got emotional and/or material support fugee. However, whether the problems in refugeeswhich were mostly provided by family, friends, who fled to a Western country are really worse stillneighbours, or elderly persons. needs to be examined. The present study also

It is difficult to compare the present results with showed that respondents who had experienced per-other studies because different instruments were sonal trauma scored higher on PTSD. From the fewused, the recruitment of subjects was organized in studies conducted among adults who lived in refugeedifferent ways, and participating refugees had ex- camps, a grim picture emerges. For instance, re-perienced different traumas in their country of origin. search in a Cambodian refugee camp revealed thatHowever, in accordance with present results, in more than 85% of the refugees suffered from PTSDgeneral it appears that PTSD, depression, anxiety, following an intense trauma. Furthermore, it wasfear of repatriation, barriers to work, and hopeless- shown that psychosomatic symptoms related toness are major problems for refugees [5,28,29,41– depression coincided with PTSD, and that these45]. Mollica and coworkers found about the same effects could extend over a long period of time [28].percentage of PTSD but a much higher percentage of In general, 40 to 50% of the refugees suffer fromdepression among a large group of Khmer adults PTSD [41]. Rangaraj [46] concluded that refugees[29]. These problems are worse when refugees have who stay in a camp for a long time seem to dieexperienced personal traumatic experiences such as internally: outwardly, they have lost everything;being tortured, witnessing murders, and lives being inwardly, they are listless, dispirited, and despon-threatened e.g. [30,39,41]. A study in Sri Lanka dent. The results from the present study also indicaterevealed the same picture for persons who had major problems for the Tamil refugees, from whomexperienced war stresses but had not left their most lived in a refugee camp for more than fourcountry [42]. years.

Women did not mention sexual harassment as a The fact that most respondents in the present studycamp problem. However, respondents mentioned that already lived in a refugee camp for several years is achildren married and had sex at an earlier age than difficulty in diagnosing PTSD. According to thewas custom in Sri Lanka. This was against the ICD-10 definition of PTSD, the onset must be withinwishes of their parents. The parents blamed the six months of the traumatic event(s). However, in thehousing facilities that caused families to live together present study this could not be verified. One effectin a small space where privacy was extremely that this might have is that the disorder is under-limited. This problem was not labelled by the women reported in the sense that a higher percentage ofas sexual harassment. This may have several reasons. respondents might have fulfilled the PTSD criteria inFirst, the interviewers did not specifically ask about the period of six months following their arrival insexual harassment. Second, women might have been India. A number of refugees /displaced personsafraid to mention sexual harassment if this was a might have worked through their trauma in thecontinuing problem in the camps. Another reason period thereafter. However, the present interest wasmight be that not all refugee women were inter- in mental health problems. Persons meeting all otherviewed by an interviewer of their own gender. criteria of PTSD have mental health problems andAlthough interviewers tried to talk to persons of their therefore are of interest in this study.


Another restriction to this study is that the group tioned that before the execution the Indian govern-of respondents is a selected group. The Tamil ment had been much more helpful and less restrictiveorganization asked persons within the camps to to them. In addition, the Indian population had beencooperate in the study. Because the Indian Govern- more kind in earlier times. The more negativement nor any other official institute was involved in attitude of the Indian population also was attributedthe study, recruitment for this study had to be done to the growing of the population which led to lack ofcarefully and low profile, making the best of it. water and food. In this sense the Tamil refugees areTherefore, the results might not be representative for a political problem.the total Tamil population living in refugee camps in In general it is important that counselling centresSouth India. Consequently, whether the present are easily accessible and counsellors have the sameresults actually underestimate or overestimate exist- cultural background as the refugees. It is known thating problems can not be determined. However, psycho-education and psycho-social activities arerespondents came from many different camps and in effective tools to alleviate traumatic stress responsesgeneral the information about camp life and the [40]. In addition, treatment elements such as psycho-problems in Sri Lanka formed a coherent story. logical structuring of experiences, working on con-

Other methodological shortcomings of the present trol, reconnecting own experiences to emotions,study concern a lack of a comparison group and a working on integration and future perspective, andvalidity check. Because it was impossible to go to self-help techniques are known to be effective inthe North-Western part of Sri Lanka to interview refugees who have recently experienced (war) traumaTamils, no comparison group was used in the present [40]. However, the effectiveness of these techniquesstudy. Other potential comparison groups, for in- in refugee populations with prolonged PTSD symp-stance, Indians living in the areas of the refugee toms remains to be studied.camps, were inadequate due to a different culturalbackground, different living conditions, and a lack ofrecent civil war experiences. The absence of a

Acknowledgementscomparison group has some obvious methodologicaldown-sides such as an impossibility to place the

The author thanks Prof. Dr. S. Rajkumar and Dr.present results in perspective. The lack of a validityNakkeerar for their role in the study and Prof. Dr.check of the questionnaires was mainly due to theG.L. van Heck for his comments on an earlier draftsample size, a lack of existing norm for inhabitantsof this manuscript.of Sri Lanka, and the fact that the study population

was difficult to contact. In fact, most restrictions inthe present study were caused by the fact that therespondents were a convenience sample. Unfortuna- Referencestely, this is inherent to this type of studies.

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mental health issues in tamil refugees and displaced persons. counselling implications

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