1	Ethnocultural Aspects of Refugees and Survivors of Torture Ricardo Restrepo, M.D Michael A. Grodin, M.D Boston Center for Refugee Health and Human Rights Boston University Schools of Medicine and Public Health
2	Definitions Refugee Internally displaced people Uprooted people Systematic Violence Crimes Against Humanity Genocide Disappeared person Returnee “Torture”
3	“Our Secret” by Isabel Allende
4	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
5	World Refugee Survey 2001
6	Refugee Worldwide
7	Internally Displaced
8	Internally Displaced Worldwide
9	Uprooted People
10	Uprooted People
11	Uprooted People Worldwide
12	Leading Sources of Uprooted People
13	World View of Uprooted Population 57 Countries are Sources of Significant Uprooted Population
14	World Refugee 94 Countries are Either Producing or Hosting Significant Numbers of Uprooted People.
15	An Example: Africa
16	Systematic Violence All human rights violations: torture, ill treatment, genocide, crimes against humanity Carried out purposefully and regularly Governments, state sanction groups or individuals Against political, religious, or ethnic groups Affecting well-being of individuals
17	Crimes Against Humanity Law No. 10 International Military Tribunal Atrocities and offenses against civilian population including but not limited to - Murder, extermination, enslavement, deportation, imprisonment, torture, and rape Whether or not in violation of domestic laws
18	Genocide Any act with the intend to destroy (in whole or in part) a national, ethnic, racial, or religious group Killing Bodily or mental harm Conditions to bring physical destruction Measures to prevent births Forcibly transferring children
19	Disappeared Person Any person arrested, detained, abducted or otherwise deprived of liberty Refusal to disclose the fate or whereabouts of the person Placing that person outside the protection of the law
20	Returnee Any refugee, internally displaced person, asylum recipient/seeker Able to return to place of residence
21	Torture UN Convention Against Torture, 1984 Any act, physical or mental, intentionally inflicted Purposes: information, confession, punishing, intimating, coercing, discrimination WHO: Declaration of Tokyo, 1975 Deliberate, systematic, or wanton Physical or mental suffering Information, confession, any other reason
22	Common Methods of Torture
23	Outline Definitions The Refugee Today Epidemiology People at Risk Treatment Options Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
24	Epidemiology
25	Epidemiology Women and children represent 90% of refugees and Internally displaced people Currently 30 armed conflicts Civilians now represent 90% of casualties
26	Epidemiology Prevalence of Torture
27	People at Risk
28	Treatment options Specific interventions primary medical care psychotherapy social services spiritual resources medications physical therapy/ massage
29	Factors Needed in The Refugee Assessment
30	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
31	Stages in The Refugee Experience
32	Stages in The Refugee Experience
33	Trauma in Cultural Perspective
34	Trauma in Cultural Perspective
35	Trauma in Cultural Perspective
36	Important Cultural Factors
37	Individual’s Aspects
38	Medicalization of Trauma
39	Survival Mechanisms
40	Expressions of Vulnerability after Trauma
41	Resilience
42	Cultural Manifestation of Trauma
43	Expression of Trauma
44	The Black Box in Somatization
45	The Black Box in Somatization
46
47	Somatization
48	Cross Cultural Considerations in Mental Health
49	Cross Cultural Considerations in Mental Health
50	Cross Cultural Considerations in Mental Health
51	Cross Cultural Considerations in Mental Health
52	Cross Cultural Considerations in Mental Health
53	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
54	Interviewing the Patient Boston Center for Refugee Health and Human Rights The setting The process Interpreters Education
55	Geographical origin
56	Gender
57	Types of Torture
58	Prevalence of Health Problems
59	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
60	Interview – The Setting
61	Interview – The Process
62	Interview – Interpreters & Education
63	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
64	Guidelines to Respond to Cultural Diversity Assess the importance of ethnicity to patients and families Validate and strengthen ethnic identity Be aware of and use the patient’s support systems Serve as a “culture broker” Be aware of “cultural camouflage” Know that there are advantages and disadvantages in being of the same group as your patient
65	Guidelines to Respond to Cultural Diversity Do not feel that you have to “know everything” about your patient To avoid polarization, always try to think in categories that allow for at least three possibilities
66	Outline Definitions The Refugee Today Cultural Perspective Interviewing the Patient Final Recommendations Vicarious Traumatization
67	Vicarious Traumatization Accumulates over time and across clients Different from effect of therapy work in general Produces symptoms of Post Traumatic Stress Changes view of oneself and the world
68	Vicarious Traumatization Generalized anxiety Numbing Overwhelmed Poor coping Anger Intrusive thoughts Nightmares Irrational fears Addictions Sleep disturbances Dissociative reactions Intrusive images
69	Vicarious Traumatization Loss of sense of safety Loss of trust Loss of connection with others Despair Cynicism Disillusionment Incapacity for intimacy Poor self-esteem Loss of sense of control
70	Thanks!!