Allen S. Keller

Mental health of detained asylum seekers

Asylum seekers arriving in the USA are likely to be held in detention for months or years pending adjudication of their asylum claims. We interviewed 70 asylum seekers detained in New York, New Jersey, and Pennsylvania. We used self-report questionnaires to assess symptoms of anxiety, depression, and post-traumatic stress disorder. At baseline, 54 (77%) participants had clinically significant symptoms of anxiety, 60 (86%) of depression, and 35 (50%) of post-traumatic stress disorder; all symptoms were significantly correlated with length of detention (p=0.004, 0.017, and 0.019, respectively). At follow-up, participants who had been released had marked reductions in all psychological symptoms, but those still detained were more distressed than at baseline. Our findings suggest detention of asylum seekers exacerbates psychological symptoms.

Traumatic Experiences and Psychological Distress in an Urban Refugee Population Seeking Treatment Services

While a growing literature has addressed the psychological consequences of torture and refugee trauma, most studies have focused on homogeneous samples drawn from a single region. Thus, relatively little research has attempted to identify demographic or experiential factors that might help explain different levels of distress in these individuals. We measured depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms in a convenience sample of refugees and survivors of torture seeking treatment in a torture treatment program (N = 325). We found 81.1% of patients had clinically significant anxiety, 84.5% had clinically significant depressive symptoms, and 45.7% had significant PTSD symptoms. Regression analyses revealed that anxiety and depressive symptom were significant higher among women (β = .08, p = 0.02 and β = .22, p = 0.0001 for anxiety and depression respectively) and those who reported death threats as part of their traumatic experiences (β= .10, p = 0.033 and β = .12, p = 0.036 respectively). Symptoms of PTSD were also predicted by death threats (β = .22, p = 0.03), but were also influenced by the experience of rape (β = .33, p < 0.001), family torture experiences (β = .23, p = 0.022), religion (β= .21, p = 0.03), and age (β = –.18, p = 0.004). The clinical implications of these results are discussed.

Entering exile: Trauma, mental health, and coping among Tibetan refugees arriving in Dharamsala, India

Each year thousands of Tibetans escape Chinese-controlled Tibet. The authors present findings on the experiences, coping strategies, and psychological distress (depression, anxiety, somatization, and posttraumatic stress disorder) of 769 Tibetan refugees arriving in Dharamsala, India (2003-2004). Distress increased significantly with greater trauma exposure. However, despite a high prevalence of potentially traumatizing events, levels of psychological distress were extremely low. Coping activity (primarily religious) and subjective appraisals of trauma severity appeared to mediate the psychological effects of trauma exposure. The potential impact of other variables, including culturally determined attitudes about trauma and timing of assessment, are discussed.

Resilience in trauma-exposed refugees: the moderating effect of coping style on resilience variables.

Research with survivors of torture has generated considerable variability in prevalence rates of posttraumatic stress disorder (PTSD). Multiple risk and resilience factors may affect this variability, increasing or decreasing the likelihood of experiencing psychological distress. This study sought to investigate the effect of several such resilience factors, coping style, social support, cognitive appraisals, and social comparisons on PTSD symptom severity. Furthermore, this study examined whether coping style moderated the relationship between resilience variables and PTSD symptoms. Seventy-five torture survivors completed an intake interview and several self-report measures upon entry into a treatment program for survivors of torture. Results indicated that emotion-focused coping styles significantly moderated the relationship between cognitive appraisal and social comparison variables and PTSD, and usually increased the likelihood of developing severe symptoms. These results indicate that the salience of resilience variables may differ depending on the individuals coping style, which present implications for clinical practice with torture survivors.

Promoting Professionalism through an Online Professional Development Portfolio: Successes, Joys, and Frustrations

Medical educators strive to promote the development of a sound professional identity in learners, yet it is challenging to design, implement, and sustain fair and meaningful assessments of professionalism to accomplish this goal. The authors developed and implemented a program built around a Web-based Professional Development Portfolio (PDP) to assess and document professional development in medical students at New York University School of Medicine. This program requires students to regularly document their professional development through written reflections on curricular activities spanning preclinical and clinical years. Students post reflections, along with other documents that chronicle their professional growth, to their online PDP. Students meet annually with a faculty mentor to review their portfolios, assess their professional development based on predetermined criteria, and establish goals for the coming year. In this article, the authors describe the development of the PDP and share four years of experience with its implementation. We describe the experiences and attitudes of the first students to participate in this program as reported in an annual student survey. Students’ experiences of and satisfaction with the PDP was varied. The PDP has been a catalyst for honest and lively debate concerning the meaning and behavioral manifestations of professionalism. A Web-based PDP promoted self-regulation on an individual level because it facilitated narrative reflection, self-assessment, and goal setting, and it structured mentorship. Therefore, the PDP may prepare students for the self-regulation of the medical profession—a privilege and obligation under the physician’s social contract with society.

The subjective experience of trauma and subsequent PTSD in a sample of undocumented immigrants

Although a subjective component of trauma is commonly recognized in diagnosing posttraumatic stress disorder (PTSD), there are few studies that specifically address Criterion A2, and none addressing this issue among undocumented immigrants. We assessed 212 arriving undocumented immigrants with diverse trauma histories to investigate concordance between objective and subjective factors of trauma (Criteria A1 and A2) and across different types of trauma and PTSD. Concordance between Criteria A1 and A2 varied, with highest rates found for political violence. Interpersonal violence in general was associated with higher rates of PTSD. We identified a dose-response effect for PTSD, but this was not dependent on other events (i.e., other doses) meeting Criterion A2. Discussion focuses on Criterion A within the phenomenology of PTSD and the need to gauge subjective interpretations of trauma events among this population.

Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun

Although psychosocial programming is seen as essential to the humanitarian response to the Darfur conflict, aid groups lack culturally-appropriate assessment instruments for monitoring and evaluation. The current study used an emic-etic integrated approach to: (i) create a culturally-appropriate measure of distress (Study 1), and (ii) test the measure in structured interviews of 848 Darfuris living in two refugee camps in Chad (Study 2). Traditional healers identified two trauma-related idioms, hozun and majnun, which shared features with but were not identical to posttraumatic stress disorder and depression. Measures of these constructs were reliable and correlated with trauma, loss, and functional impairment. Exploratory factor analysis resulted in empirical symptom clusters conceptually parallel to general Western psychiatric constructs. Findings are discussed in terms of their implications for psychosocial programming.

A Population-Based Assessment of Human Rights Abuses Committed Against Ethnic Albanian Refugees From Kosovo

OBJECTIVES This study assessed patterns of displacement and human rights abuses among Kosovar refugees in Macedonia and Albania. METHODS Between April 19 and May 3, 1999, 1180 ethnic Albanian refugees living in 31 refugee camps and collective centers in Macedonia and Albania were interviewed. RESULTS The majority (68%) of participants reported that their families were directly expelled from their homes by Serb forces. Overall, 50% of participants saw Serb police or soldiers burning the houses of others, 16% saw Serb police or soldiers burn their own home, and 14% witnessed Serb police or soldiers killing someone. Large percentages of participants saw destroyed mosques, schools, or medical facilities. Thirty-one percent of respondents reported human rights abuses committed against their household members, including beatings, killings, torture, forced separation and disappearances, gunshot wounds, and sexual assault. CONCLUSIONS The present findings confirm that Serb forces engaged in a systematic and brutal campaign to forcibly expel the ethnic Albanian population of Kosovo. In the course of these mass deportations, Serb forces committed widespread abuses of human rights against ethnic Albanians.

The effects of torture-related injuries on long-term psychological distress in a Punjabi Sikh sample.

Torture survivors often report chronic debilitating physical and psychological distress. Prior research on the relationship between physical and psychological trauma suggests that the 2 are not independent. Injury sustained during torture may increase the likelihood of subsequent distress as either a moderator or mediator. For long-term psychopathology in a sample of Punjabi Sikh survivors of human rights violations (N = 116), chronic injuries mediated the path between torture and posttraumatic stress disorder, specifically the severity of numbing symptoms. Although injuries were associated with major depression, torture was not, and injuries did not moderate the relationship between major depression and torture. Chronic injuries may represent trauma severity or persistent traumatic cues. These findings emphasize connections between physical and psychological trauma and the importance of an interdisciplinary approach to torture treatment.

Effects of Post-migration Factors on PTSD Outcomes Among Immigrant Survivors of Political Violence

This study examined the predictors of posttraumatic stress disorder (PTSD) in a clinical sample of 875 immigrant survivors of political violence resettled in the United States, with a specific aim of comparing the relative predictive power of pre-migration and post-migration experiences. Results from a hierarchical OLS regression indicated that pre-migration experiences such as rape/sexual assault were significantly associated with worse PTSD outcomes, as were post-migration factors such as measures of financial and legal insecurity. Post-migration variables, which included immigration status in the US, explained significantly more variance in PTSD outcomes than premigration variables alone. Discussion focused on the importance of looking at postmigration living conditions when treating trauma in this population.